Every finding on record at Fair Haven of Forest City, LLC

Based on record review and staff interviews, the facility failed to submit a request for a Level II PASRR (Preadmission Screening and Resident Review) evaluation for a resident admitted with an active diagnosis of bipolar disorder for 1 of 3 residents reviewed for PASRR evaluations (Resident #14). The findings included: Review of Resident #14's medical record revealed a PASRR level I completed prior to admission to the facility dated 03/20/18.Resident #14 was admitted on [DATE] with diagnoses which included bipolar disorder.No PASRR level II evaluation had been completed per review of Resident #14's medical record. Resident #14's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had an active diagnosis of bipolar disorder and was not currently considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. Resident #14's quarterly MDS assessment dated [DATE] revealed he was severely cognitively impaired. He had no behaviors and no signs of depression. Resident #14 was coded for an active diagnosis of bipolar disorder and received anticonvulsant and antidepressant medications daily. Resident #14's physician orders revealed the following active medication orders: mirtazapine (antidepressant medication) 15 milligrams by mouth daily at bedtime for depression and appetite; Lamictal (anticonvulsant medication used as a mood stabilizer) 25 milligrams by mouth daily for bipolar disorder. Resident #14's active care plan dated 06/17/25 revealed a focus area for antidepressant medications with indication of depression and bipolar disorder. The stated goal was that Resident #14 would remain free from side effects of the medication. Interventions included administering medications as ordered, and monitoring for adverse effects of medication. An interview with the Social Worker on 04/02/26 at 9:16 AM revealed that Resident #14 had a level I PASRR when he was admitted to the facility. The Social Worker stated that since he already had a PASRR level I evaluation completed, she did not submit a referral for a Level II PASRR evaluation and was not aware she had to. The Social Worker stated that she was aware Resident #14 had a bipolar disorder diagnosis and acknowledged she did not submit a request for a level II PASRR evaluation for Resident #14. An interview with the Administrator on 04/02/26 at 4:02 PM revealed that it was important that level II PASRR evaluations were completed for residents who met criteria so they could receive the services they needed.

Based on record review, and resident, staff, Consulting Pharmacist, Nurse Practitioner (NP) and Medical Director interviews, the facility failed to obtain consent and inform the resident or resident representative in advance of the risks and benefits of psychotropic medications prior to the initiation or increase of the medications for 3 of 5 residents reviewed for unnecessary medications ( Resident #47, Resident #67, and Resident #11). The findings included: a. Resident #47 was admitted [DATE] with diagnoses of panic disorder, depression, and anxiety disorder. Resident #47's physician's orders revealed an order dated 8/31/2024 for sertraline (antidepressant medication) 50 milligrams (mg) by mouth daily for depression. Resident #47's physician's orders revealed an order dated 10/25/2024 for alprazolam (antianxiety medication) 1 mg by mouth twice daily for anxiety. Resident #47's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #47 had intact cognition and received antianxiety and antidepressant medication during the 7-day look back period. A Nurse Practitioner (NP) note dated 10/9/2025 indicated Resident #47 reported anxiety was not well managed and had uncontrolled moderate anxiety in the afternoon, the plan indicated to increase alprazolam to three times daily. Resident #47's physician's orders revealed an order dated 10/9/2025 for alprazolam 1 mg by mouth three times daily for anxiety. An annual visit NP note dated 11/20/2025 indicated a depression screening was conducted and Resident #47 scored as moderately depressed. This note included a section for education which was left blank. Resident #47's physician's order revealed an order dated 11/20/2025 to increase sertraline to 75 mg daily. An NP note dated 12/4/2025 indicated Resident #47 reported lack of interest in activities and feeling flat in emotions. The plan included an increase of sertraline to 100 mg daily. Resident #47's physician's orders revealed an order dated 12/4/2025 for sertraline 100 mg daily for depression. Resident #47's quarterly MDS dated [DATE] revealed Resident # 47 had intact cognition and received antianxiety and antidepressant medication during the 7-day look back period. Resident #47's Medication Administration Record (MAR) from 10/9/2025 to 3/31/2026 indicated Resident #47 was administered alprazolam and sertraline as ordered by the physician. A review of Resident #47's medical record revealed no information indicating if Resident #47 was informed in advance of the risks and benefits of increasing sertraline or alprazolam. An interview with Resident #47 was conducted on 4/02/2026 at 9:06 AM. Resident #47 stated none of the providers at the facility had discussed side effects, or the risks or benefits of taking or increasing alprazolam or sertraline, but Resident #47 stated she just knew she needed the medications. b. Resident #67 was admitted on [DATE] with diagnoses of anxiety disorder and major depressive disorder. Resident #67's physicians' orders revealed an order dated 4/11/2025 for buspirone HCl (antianxiety medication) 15 mg by mouth twice daily. Resident #67's admission MDS dated [DATE] revealed Resident #67 was severely cognitively impaired. The MDS indicated Resident #67 received antianxiety medication during the 7-day look back period. Resident #67's MAR from 4/11/2025 to 3/31/2026 indicated Resident #67 was administered buspirone HCl as ordered by the physician. A review of Resident #67's medical record revealed no information indicating if Resident #67's Responsible Party was informed in advance of the risks and benefits of initiating buspirone HCl. A telephone interview on 4/2/2026 at 11:39 AM with Resident #67's Responsible Party revealed the Responsible Party did not recall a discussion with the provider or other facility staff regarding the risks and benefits of buspirone HCL when Resident # 67 was admitted to the facility. c. Resident #11 was admitted on [DATE] and readmitted on [DATE]. Diagnosis included anxiety disorder and major depressive disorder. Resident #11's physicians' orders revealed an order dated 5/09/25 for Xanax (antianxiety medication) 0.5 mg two tablets by mouth three times daily and an order dated 10/13/25 for Zoloft (antidepressant) 150 mg one tablet by mouth at bedtime. Resident #11's quarterly MDS dated [DATE] revealed Resident #11 was cognitively intact. The MDS indicated Resident #11 received antianxiety and antidepressant medication during the 7-day look back period. Resident #11's MAR from 5/09/2025 to 4/01/2026 indicated Resident #11 was administered Xanax as ordered by the physician. Resident #11's MAR from 10/13/25 to 4/01/26 indicated Resident #11 was administered Zoloft as ordered by the physician. A review of Resident #11's medical record revealed no information indicating if Resident #11's was informed in advance of the risks and benefits of initiating Xanax or Zoloft. An interview on 4/01/2026 at 10:39 AM with Resident #11 revealed she did not recall a discussion with the provider or other facility staff regarding the side effects or risks and benefits of taking Xanax and Zoloft. An interview on 4/01/2026 at 12:26 PM with the NP revealed psychotropic medication consents were handled by nursing. A telephone interview on 4/02/2026 at 8:25 AM with the Consulting Pharmacist revealed the Consulting Pharmacist did not review psychotropic consents for the facility during her monthly medication reviews. The Consulting Pharmacist verified antidepressants, and antianxiety medications were psychotropic medications and required consents when they were initiated and increased. An interview on 4/02/2026 at 10:09 AM with the Medical Director revealed he did not recall having discussions of risks and benefits with residents that were admitted on psychotropic medications prior to the medication being ordered and administered. The Medical Director stated the floor nurses and Rounding Nurse notified residents and resident representatives of medication changes. The Medical Director thought the Rounding Nurse would take care of psychotropic medication consents since the Rounding Nurse entered orders after rounding with the providers. The Medical Director indicated he expected psychotropic medication consents to be completed when psychotropic medications were initiated and increased. A telephone interview with the Rounding Nurse on 4/2/2026 at 11:59 AM revealed she was responsible for obtaining consents for residents who had orders for psychotropic medications. The Rounding Nurse stated when residents received a new order for psychotropic medication, she obtained consent from the resident or resident representative. The Rounding Nurse stated the psychotropic medication consent was only obtained for residents who started psychotropic medications after they were admitted to the facility. The Rounding Nurse explained that consents were not obtained for residents that were admitted with orders for psychotropic medications because those residents were taking the psychotropic medication prior to being admitted to the facility. The Rounding Nurse stated she did not obtain consents for residents that started or had an increased dose of antidepressants or antianxiety medications because she did not know those medications were psychotropic medications. The Rounding Nurse verified she had only obtained consents for residents who received orders for antipsychotic medications after they were admitted . An interview with the Director of Nursing (DON) on 4/2/2025 at 1:45 PM revealed the Rounding Nurse was responsible for obtaining psychotropic medication consents. The DON explained that the Rounding Nurse was the providers' nurse and worked with the providers and entered any orders. The DON verified that any order entered by the facility was a new order, including medications a resident took prior to admission to the facility. The DON stated she did not know antianxiety and antidepressants required consent to be completed when initiated and increased. The DON believed communication issues and no reeducation when the psychotropic policy was reviewed in January 2026 contributed to staff not being aware of what medications were psychotropics. She explained the policy indicated psychotropic medication consents should be completed when psychotropic medications were initiated and increased. An interview on 4/02/2026 at 3:20 PM with the Informatics Nurse revealed he had reviewed the psychotropic policy in January 2026. The Informatics Nurse stated the definition of psychotropic medications were the same as prior to the policy review and included antidepressant and antianxiety medications. The Informatics Nurse stated nurses should know what medications were considered psychotropics. The Informatics Nurse stated he was currently in the process of reviewing all of the facilities policies, then a full reeducation would be conducted. An interview with the Administrator on 4/2/2026 at 4:01 PM revealed the Administrator expected consents for psychotropic medications.

Based on record review, observation, and resident, staff, and Medical Director interviews, the facility failed to develop an individualized person-centered comprehensive care plan in the area of respiratory care (Resident #1) and anticoagulant medication use (Resident #32) for 2 of 3 residents whose comprehensive care plans were reviewed. Findings included: 1. Resident #1 was initially admitted to the facility on [DATE] with a readmission date of 02/23/26. Resident #1's diagnoses included chronic obstructive pulmonary disease (COPD, a progressive, debilitating respiratory disease), chronic respiratory failure with hypoxia (low levels of oxygen in the bodies tissues), and pneumonia due to methicillin resistant staphylococcus aureus (MRSA, a bacterial pneumonia resistant to antibiotics). A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was coded for diagnoses of respiratory failure, chronic obstructive pulmonary disease, and pneumonia. A review of Resident #1's active comprehensive care plan most recently updated on 09/30/25, did not include a care plan in place for COPD, respiratory failure, or pneumonia. A review of Resident #1's physician orders revealed that since September 2025 Resident #1 received medication daily and as needed to help with COPD and chronic respiratory symptoms and had received multiple rounds of antibiotics for pneumonia. A Physician Progress Note dated 10/23/25 revealed Resident #1 had complained of cough, congestion, and respiratory distress and that aggressive treatment for COPD would continue. A Physician Progress Note dated 11/03/25 revealed Resident #1 had been hospitalized for pneumonia on 10/29/25, had been readmitted with supplemental oxygen and to continue the current treatment for pneumonia. A Physician Progress Note dated 01/29/26 revealed Resident #1 was undergoing treatment for pneumonia, had dyspnea (shortness of breath) and to continue the current antibiotic. A review of Resident #1's Pulmonologist consult dated 03/05/26 revealed Resident #1 was seen due to a recent hospitalization for right lower lobe pneumonia. The Pulmonologist note indicated Resident #1 reported ongoing chest congestion, cough, and wheezing, and may have bronchiectasis with mucus impaction (a condition in chronic lung disease when the airway is unable to expel secretions) and recommended continuing antibiotics for 2 more weeks. An interview and observation with Resident #1 on 03/30/26 at 1:02 PM revealed she currently had a cough and reported that her respiratory issues were ongoing. Resident #1 had slightly labored breathing during the conversation but denied the need for oxygen or feeling distressed. An interview with the Medical Director on 04/02/26 at 10:59 PM revealed that Resident #1 had COPD which is a chronic lung disease. The Medical Director stated he would consider Resident #1's respiratory condition to be severe, chronic, and she required frequent monitoring and treatment of respiratory symptom management by the medical staff. An interview with the Informatics Nurse was conducted on 04/02/26 at 10:07 AM. The Informatics Nurse revealed he was temporarily in the role of the MDS Nurse and had only been in this role for a few weeks. He stated Resident #1 had a diagnosis of COPD, respiratory failure and had recurrent pneumonia. He explained that COPD should be included in Resident #1's care plan since it was a long-term issue and was unsure why one was not in place. An interview with the Director of Nursing (DON) on 04/02/25 at 12:14 AM revealed that she expected the residents' care plans to be accurate and reflect care concerns. The DON stated that Resident #1 should have a respiratory care plan in place due to her ongoing impaired respiratory status. The DON indicated the MDS Nurse who was responsible for updating care plans and had recently quit and this may have contributed to the overlooking Resident #1's respiratory care plan. An interview with the Administrator was conducted on 08/28/25 at 4:02 PM. The Administrator stated the care plans should reflect the clinical condition of the residents, including respiratory symptoms or diagnoses. 2. Resident #32 was admitted to the facility on [DATE] with diagnoses which included myocardial infarction (heart attack) and chronic atrial fibrillation. The quarterly Minimum Data Set (MDS) assessment for Resident #32 dated 01/16/2026 indicated Resident #32 was receiving an anticoagulant. The active medication orders for Resident #32 revealed an order for Apixaban (an anticoagulant medication) 2.5 milligrams (mg) by mouth twice a day for history of myocardial infarction and deep vein thrombosis (blood clot) prevention. The medication had a start date of 10/11/2025. Resident #32's active comprehensive care plan initiated on 10/17/2025 and last revised on 01/21/2026 did not reveal any care plan focus area or interventions related to Resident #32 receiving an anticoagulant medication. Review of Resident #32's Medication Administration Record (MAR) from 01/01/2026 through 03/31/2026, revealed Resident #32 received Apixaban 2.5 mgs by mouth twice a day as ordered by the physician. An interview was conducted on 04/01/2026 at 10:30 AM with the Informatics Nurse who stated the facility did not currently have an MDS Coordinator and he had been temporarily filling in for the past couple of weeks. The Informatics Nurse stated that Resident #32's quarterly MDS assessment dated [DATE] was accurately coded for anticoagulant use, but her care plan did not address the use of anticoagulant medications. He indicated anticoagulant medications were considered high-risk medications and should be care planned. An interview was conducted on 04/02/2026 at 1:45 PM with the Director of Nursing (DON). The DON stated she did not know why Resident #32's anticoagulant medication was not care planned, but she expected that all high-risk medications be care planned including anticoagulant medications. An interview was conducted with the Administrator on 04/02/2026 at 2:45 PM who stated she did not know why Resident #32's anticoagulant medication was not care planned, but she expected all resident care plans to be reflective of the resident's clinical condition including the use of anticoagulant medications. The Administrator stated that an anticoagulant care plan should have been implemented for Resident #32.

Based on record review and staff interviews the facility failed to provide a safe transfer for Resident #344. On 6/14/24 Nurse Aide (NA) #1 attempted to do a stand and pivot transfer with Resident #344 resulting in Resident #344 having to be lowered to the ground. Resident #344 was to be transferred by a mechanical lift. This deficient practice was identified for 1 of 1 resident reviewed for supervision to prevent accidents. The findings included: Resident #344 was admitted to the facility on [DATE] and was discharged on [DATE]. She was admitted to the facility with diagnoses of heart failure, lumbago with sciatica and alveolar hypoventilation (failure to breathe rapidly or deeply enough). The admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #344 had moderate cognitive impairment and was dependent for chair to bed transfer. The Comprehensive Care Plan dated 6/4/24 had a focus area stating that Resident #344 had limited physical mobility related to her medical and physical condition. One of the interventions was that Resident #344 was dependent on staff to transfer from a bed or chair to chair requiring the use of a mechanical lift. A health status note written on 6/14/24 at 6:28 AM by Nurse #1 revealed that Nurse #1 heard NA #1 yell help. Nurse #1 went to NA #1's location which was Resident #344's room. NA #1 was holding Resident #344 underneath her arms attempting to transfer her from the bed to wheelchair. Nurse #1 attempted to help and was unable to and Resident #344 was lowered to the ground without injury. NA #1 left to get the mechanical lift and sling to move Resident #344 from the floor to the wheelchair. Resident #344 denied any pain or discomfort. An accident report prepared by Nurse #1 indicated that the family representative and physician were notified on 6/14/24. On 2/12/25 at 9:50 AM a telephone interview was conducted with Nurse Aide (NA) #1. NA #1 She stated she had worked at the facility for 5 years and always worked on the rehabilitation unit for both the second and third shift. NA #1 stated that each residents' transfer status was posted on the inside of the residents' closet. NA #1 stated that if the transfer information was not there you would ask the charge nurse. If the resident was a new admission, then you would need to wait until therapy came to do a transfer evaluation. NA #1 could not remember what the transfer status was for Residents #344. NA #1 could recall the incident that happened on 6/14/24. NA #1 stated she was walking by Resident #344's room and noticed she was attempting to get out of her bed, so she went over to stop her from falling. NA #1 stated she was not trying to transfer Resident #344. NA #1 stated she yelled for assistance and Nurse #1 came and they ended up lowering Resident #344 to the floor. Afterwards Nurse #1 gave NA #1 training on proper transfer. NA #1 tried to explain to Nurse #1 that she was not transferring Resident #344. NA #1 stated that this was the first time that Resident #344 tried to transfer herself without assistance. On 2/11/25 at 7:25 PM a telephone interview was conducted with Nurse #1. She stated that early morning on 6/14/24 she heard NA #1 call out for help. Nurse #1 went to Resident #344's room and observed NA #1 trying to transfer Resident #344 from the bed to a wheelchair without using the proper equipment. NA #1 was attempting to do a stand and pivot transfer. Nurse #1 tried to help get Resident #344 into the wheelchair but was unable to do so. Both the NA #1 and Nurse #1 ended up having to lower Resident #344 to the floor. NA #1 left to go get the mechanical lift. They then used the lift and got Resident #344 into her wheelchair. Nurse #1 stated that Resident #344 did not have any injuries. Immediately after the incident Nurse #1 educated NA #1 on using the proper equipment for transfers. Nurse #1 asked NA #1 why she was attempting to transfer without a mechanical lift and NA #1 did not have an explanation. Nurse #1 stated that she informed 2 nursing supervisors of the incident. On 2/12/25 at 10:20 AM an interview was conducted with NA #2. NA #2 stated that she did work on 6/14/24 but was not assigned to Resident #344. She did not remember Resident #344, nor did she hear anything about Resident #344 that day. NA #2 stated that all residents' transfer status was posted on the inside of the closet door. If a resident was a new admission you would need to wait until therapy did their evaluation before doing a transfer. Other ways to get transfer information was from the computer or shift nurse. If staff noticed a change of condition in a resident, the staff could put in a Hey Therapy card to notify them. This would alert therapy that a resident was having a change in condition. On 2/12/25 at 11:10 AM an interview was conducted with the Therapy Manager. She stated she could not remember Resident #344 but would look back on any information regarding her. The Therapy manager was able to find two mechanical lift evaluations dated 5/6/24 and 5/21/24 and both stated that Resident #344 was a total lift for transfer. On 2/12/25 at 11:30 AM an interview was conducted with NA #3 and NA #4. Both NAs stated they had been trained on how to properly use a mechanically lift prior to working on the floor. If the NAs need to know the transfer of a resident it was on the back of the closet door or they could ask therapy or nurse supervisor. On 2/12/25 at 2:15 PM an interview was conducted with a Nursing Supervisor. She stated that Nurse #1 had reported to her about NA #1 transferring Resident #344 improperly. The Nursing Supervisor stated that Resident #344 required total assistance for her transfer and needed a mechanical lift to be used. On 2/13/25 at 2:51 PM an interview was conducted with the Director of Nursing (DON) and the Administrator. They were both aware of the 6/14/24 incident with Resident #344 and they both agreed that it would be expected that staff would follow the proper transfer.

Based on observations, record review and staff interviews, the facility failed to ensure items stored ready for use were labeled and dated and/or failed to remove expired food items in 1 of 1 pantry and 1 of 2 nourishment rooms (B Hall). These practices had the potential to affect food served to residents. Findings included: a. An initial tour of kitchen and interview with the Dietary Manager (DM) dated [DATE] at 10:15 AM revealed a cardboard box of 200 hard taco shells that was opened and not covered with the discard date of [DATE]. The DM stated she checked the pantry daily and was not aware the hard taco shells were out of date and not covered. The DM indicated dietary staff check the kitchen pantry daily and expired items should be discarded. b. An observation and joint interview conducted with Nurse Aide (NA) #1, NA #2, and NA #3 on [DATE] at 10:45 AM revealed in the nourishment room on the B Hall a tube feeding container not labeled or dated with 4 ,d+[DATE] milliliters (ML) used sitting on the counter. Observation further revealed a 4 ounce carton of orange juice with discard date [DATE], two 8 ounce nutritional vanilla shakes with discard date [DATE], and five 4 ounce cartons of lemon flavor thickened water with discard date [DATE] stored in the refrigerator. NA #1, NA #2, and NA #3 indicated they did not know why the tube feeding container was left on the counter and did not recall any expired items in the refrigerator. The NAs revealed the dietary department checked the nourishment rooms daily and was responsible for discarding outdated items. An interview conducted with the Director of Nursing (DON) on [DATE] at 12:05 PM revealed the dietary department was responsible for checking nourishment rooms daily, but nursing staff had been educated to also discard outdated items if found. The DON further revealed the tube feeding container should have been labeled, dated, discarded, and not left on the nourishment room counter.

Based on observations, record review, resident interview, and staff interviews the facility failed to secure a catheter bag to prevent the catheter bag from resting on the floor for 1 of 2 residents (Resident #36) were reviewed for urinary catheter. The findings included: Resident #36 was admitted to the facility on [DATE] with diagnoses which included urinary retention. Review of Resident #36's significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #36 was cognitively intact and required extensive assistance with a majority of activities of daily living (ADL). The MDS further revealed Resident #36 was coded for having an indwelling urinary catheter. Review of Resident #36's care plan dated 11/06/23 revealed Resident #36 had an indwelling urinary catheter there was a goal was for the resident to show no signs or symptoms of urinary infection through review date. Interventions included monitoring and documenting intake and output as per facility policy. An observation conducted on 11/14/23 at 1:25 PM revealed Resident #36 outside of the dining room in his wheelchair. It was further observed Resident #36's catheter bag to be partially full with the bag resting on the floor. Observation and interview conducted with Resident #36 and Director of Nursing (DON) on 11/14/23 at 2:45 PM revealed Resident #36's catheter bag was observed to be resting on the floor. Resident #36 indicated nursing staff hung his catheter bag daily under his wheelchair and he was not aware his catheter bag was laying on the floor. The DON stated Resident #36's catheter bag should not have been laying on the floor. Interview conducted with Nurse #2 on 11/14/23 at 4:05 PM revealed she had cared for Resident #36 on 11/14/23 and did not recall the resident's catheter bag on the floor. Nurse #2 further revealed she had been educated for it to be off the floor to avoid contamination. Interview conducted with Nurse Aide (NA) #4 on 11/13/23 at 4:15 PM revealed she had given Resident #36 a shower that morning at 6:30 AM and had hung his catheter bag on the bar below the seat on the resident's wheelchair. NA #4 further revealed she had observed Resident #36's catheter bag on the floor before. The NA indicated she hangs the resident's catheter bag on the bar under the wheelchair, but it sometimes slid to the floor. The NA stated she had been educated to place Resident #36's catheter bag off the floor. Interview conducted with NA #5 and NA #6 revealed on 11/14/23 at 4:40 PM revealed they had placed Resident #36's catheter on a bar that crosses under the resident's wheelchair seat. The NAs further revealed the bag sometimes slid and had been observed resting on the floor before. The NAs indicated they had not been educated on exact location to hang Resident #36's catheter bag to prevent it from touching the floor. An interview conducted with Nurse #3 on 11/15/23 at 2:15PM revealed she had observed Resident #36's catheter bag hanging under the resident's wheelchair and the catheter bag was hitting the floor. Nurse #3 further revealed she moved the catheter bag up and educated NAs where to hang the catheter bag. Nurse #3 indicated a residents catheter bag should kept off the floor to prevent contamination. A further interview conducted with the Director of Nursing on 11/14/23 at 3:50 PM revealed Resident #36's catheter bag was expected to be off the floor and the staff would be educated.

Based on observations and staff interviews, the facility failed to discard expired medications available for use in 2 of 3 medication carts (B hall medication cart and A hall medication cart) and 1 of 2 medication rooms (B hall medication room). The findings included: 1.a. An observation of the B hall medication cart with Nurse #2 on 6/8/22 at 2:17 PM revealed an open vial of Insulin detemir available for use in the top drawer and marked as being opened on 4/24/22 and labeled with Resident #41's name. Insulin detemir is a long-acting insulin used to treat diabetes. An interview with Nurse #2 revealed Insulin detemir expired 42 days after being opened and it should have been discarded on 6/5/22. During the interview, Nurse #2 called the pharmacy to request a refill for Resident #41's Insulin detemir and she found out that the order for Resident #41's Insulin detemir had been discontinued on 5/16/22. Further interview with Nurse #2 on 6/8/22 at 2:41 PM revealed the third shift nurses and the supervisors were supposed to check the medication carts for expired medications. Nurse #2 stated she thought the B hall medication cart had just been checked by the third shift nurse from the night before and didn't notice the discontinued insulin. Nurse #2 further stated she didn't pay attention to Resident #41's Insulin detemir because it used to be scheduled to be given only at bedtime. b. An observation of the A hall medication cart with Nurse #3 and the Assistant Director of Nursing (ADON) on 6/8/22 at 2:42 PM revealed forty 1 mg (milligram)/1 ml (milliliter) packets of [MEDICATION(S)] gel available for use in the narcotic drawer. The [MEDICATION(S)] gels were marked with an expiration date of 5/25/22 and the sticker on the plastic bag that contained the gels read: do not use after 5/26/22. [MEDICATION(S)] topical gel is currently widely used for nausea in hospice. An interview with Nurse #3 and the ADON on 6/8/22 at 2:50 PM revealed Nurse #3 last administered a [MEDICATION(S)] gel to Resident #10 on 6/8/22 at 8:00 AM but she didn't notice the expiration date on the packet. The ADON stated all the nurses were supposed to be checking the medication carts for expired medications as they administer medications. In addition, the unit managers were also responsible for checking the medication carts weekly. 2. An observation of the B hall medication room with Nurse #4 on 6/8/22 at 2:55 PM revealed an open vial of [MEDICATION(S)] dated as opened on 5/3/22 and available for use in the medication refrigerator. The box which contained the [MEDICATION(S)] vial had instructions to discard the opened vial after 30 days. [MEDICATION(S)], also known as purified protein derivative, is a combination of proteins that are used in the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with Nurse #4 on 6/8/22 at 3:00 PM revealed the opened vial of [MEDICATION(S)] was expired and it should have been discarded after 30 days of opening. Nurse #4 stated they used the [MEDICATION(S)] to perform a [MEDICATION(S)] skin test to newly admitted residents, but she wasn't sure about the last time it had been used. Nurse #4 stated the third shift nurses were supposed to be checking the medication rooms for expired medications. An interview with the Director of Nursing (DON) on 6/8/22 at 3:56 PM revealed the third shift nurses were supposed to be checking the medication carts after they check all the new orders for the day and make sure the discontinued and expired medications were pulled off the medication carts. The unit managers last checked the medication rooms the week before and they were responsible for checking them at least weekly.

Based on record review, and interviews with staff, pharmacist and Nurse Practitioner, the facility failed to discontinue a medication (Aspirin) as ordered and continued to administer the medication for 29 days after receiving the discontinue order for 1 of 5 residents reviewed for unnecessary medications (Resident #64). The findings included: Resident #64 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A document entitled, Individual Patient's Medication Review, dated 4/29/22 in Resident #64's electronic medical record indicated a recommendation by the pharmacist to consider discontinuing Aspirin due to polypharmacy, simultaneous use of multiple drugs to treat a single ailment or condition. A document entitled, Pharmacist Report, dated 5/5/22 indicated a recommendation by the pharmacist to consider discontinuing Aspirin due to polypharmacy. At the bottom of the report was a written response by the Nurse Practitioner that stated she would discontinue Aspirin. The report was signed by the Nurse Practitioner on 5/10/22. A review of Resident #64's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A phone interview with the Pharmacist on 6/8/22 at 12:31 PM revealed they had recommended to discontinue Resident #64's Aspirin due to polypharmacy which meant the regular use of at least five medications and to decrease her risk for bleeding with her age. They initially submitted this recommendation to the facility on [DATE] and again on 5/5/22. The Pharmacist stated they had not received a faxed order from the facility to discontinue Resident #64's Aspirin and were not aware that Resident #64 continued to receive Aspirin despite the discontinue order. The Pharmacist stated the facility should have sent an order to discontinue the Aspirin and the completed recommendation which was signed by the NP on 5/10/22 should have been faxed to the pharmacy. A phone interview with the Nurse Practitioner (NP) on 6/8/22 at 9:17 AM revealed she decided to agree with the pharmacy recommendation of discontinuing Resident #64's Aspirin. The NP stated she had been told at the facility that she didn't have to re-write an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The NP stated the reviewed pharmacy recommendation which she signed should be enough to serve as an order. An interview with the Director of Nursing (DON) on 6/8/22 at 4:00 PM revealed the Medical Records Director usually received the recommendations from the pharmacy and then she handed them to the rounding nurse so that the rounding nurse could give the recommendations to the medical provider whenever they came to the facility so they could review them. The DON stated the rounding nurse should have received the reviewed pharmacy recommendations after the NP had done rounds on 5/10/22. The DON further stated she should have written an order to discontinue Resident #64's Aspirin and had the NP sign it and faxed it to the pharmacy to carry out the NP's order to discontinue Resident #64's Aspirin on 5/10/22.

Based on record reviews, observations and staff interviews, the facility failed to implement their infection control policies and the Centers for Disease Control and Prevention (CDC) recommended practices when 1 of 1 staff member (Nurse #1) failed to perform hand hygiene during wound care on 1 of 2 residents (Resident #9) reviewed for wound care. The findings included: The Centers for Disease Control and Prevention (CDC) guidance entitled, Hand Hygiene Guidance, last reviewed on 1/30/20 indicated the following information: Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: immediately after glove removal. Gloves are not a substitute for hand hygiene. Change gloves and perform hand hygiene during patient care, if moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs. The facility's infection control policy entitled, Hand Hygiene, dated 3/2022 indicated the following statements: The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. An observation of wound care by Nurse #1 on Resident #9 was made on 6/8/22 at 10:10 AM. Nurse #1 was observed using hand sanitizer to both hands prior to putting gloves on to enter the room and start the procedure. Nurse #1 proceeded to remove an old dressing from Resident #9's sacrum and removed her gloves. She then put on a new pair of gloves without sanitizing her hands. She cleaned Resident #9's sacral wound with a wound cleanser-soaked gauze and then removed her gloves. She put on new gloves without sanitizing her hands first and then wiped the wound bed with a dry gauze, applied the ordered treatment to Resident #9's wound and covered it with a foam dressing. She then discarded the unused supplies on the bedside table, removed her gloves and then put on a new pair without doing hand hygiene. She helped reposition Resident #9 in the bed, exited the room, removed her gloves, and then used hand sanitizer to both hands. An interview with Nurse #1 on 6/8/22 at 3:28 PM revealed she had received education on hand hygiene during wound care which consisted of washing hands before starting procedure and making sure to change gloves after removing an old dressing and doing hand hygiene whenever gloves were removed. Nurse #1 stated she had missed the step of doing hand hygiene after removing her gloves because she was a little nervous during the wound care observation and she was distracted. She stated she should have washed her hands in the sink prior to putting on clean gloves during the procedure. An interview with the Infection Preventionist and the Director of Nursing (DON) on 6/8/22 at 3:49 PM revealed Nurse #1 should have washed her hands whenever she removed her gloves when she provided wound care to Resident #9. The DON stated they would need to do more education on hand hygiene.

Based on observations, record review, resident and staff interviews, the facility failed to provide nail care to 1 of 2 dependent residents (Resident #44) reviewed for activities of daily living (ADL). The findings included: Resident #44 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #44's annual Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact with no behaviors for rejection of care. The assessment also revealed Resident #44 required extensive assistance of 2 staff with transfers, and extensive assistance of 1 staff with dressing, toileting, personal hygiene, and bathing. Resident #44's Care Area Assessment (CAA) summary dated 05/05/22 for activities of daily living (ADL) the resident required extensive assistance with ADL including bed mobility, transfers, personal care, bathing, dressing, and toileting related to muscle weakness and [CONDITION(S)]. Resident #44 wears a splint/palm protector to her right had as indicated with passive range of motion (PROM) provided during care. She is at risk of skin breakdown related to incontinent episodes, decreased mobility, and vitamin deficiency. Weekly skin assessments completed by nursing to monitor for changes in skin integrity. Nursing to monitor for continued changes in conditions. Physician to be notified of continued changes. Resident #44's care plan dated 05/10/22 revealed a focus area for ADL self-care performance deficit related to residual effects of stroke and [CONDITION(S)]. The interventions included check nail length and trim and clean on bath day and as necessary, report any changes to the nurse, resident has contracture of the right hand so provide skin care daily to keep clean and prevent skin breakdown, staff to don right resting hand splint every day as tolerated and resident may remove, staff to apply palm protector to right hand related to contracture at bedtime and monitor skin integrity and resident may remove. Observation and interview with Resident #44 on 06/06/22 at 3:34 PM revealed her lying in bed watching TV. The resident stated she had asked 3 times to have her nails on her right contracted hand trimmed and said it still had not been done. The resident removed her covers, and her right hand was resting against a pillow with hand splint in place. Resident #44's nails were noted to be ¼ to ½ inch beyond the end of her fingers and some of the nails were jagged. Her hand was noted to be contracted inward into her palm with the nails touching the palm of her hand. The resident indicated she was concerned the nails would cause skin breakdown in her palm. Observation and interview on 06/07/22 at 12:27 PM revealed resident up in her wheelchair outside the dining room propelling back to her room. Her nails on the right hand were noted to still be long and jagged on the right hand and Resident #44 stated they had not been trimmed. Interview on 06/07/22 at 2:08 PM with Nurse Aide (NA) #1 assigned to the resident on 06/07/22 revealed she had not noticed the resident's nails on her right hand and stated she had not clipped her nails. NA #1 further stated she should have inspected Resident #44's nails especially since her hand was contracted and notified the nurse they needed to be trimmed. Observation and interview on 06/07/22 at 3:54 PM revealed Resident #44 lying in bed with her covers over her and watching TV. Resident #44 stated she had her shower today, but they did not clip her nails on her right hand and her splint was noted to be off her hand. Resident #44 further stated they had washed her hand during her shower but had not clipped the nails on her hand. Nurse #4 came into the resident's room and the surveyor asked the resident to show Nurse #4 her nails. Nurse #4 stated her nails should have been clipped after her shower and said no one had mentioned they needed clipping to her but stated she would clip them now. Interview on 06/08/22 at 3:55 PM with the Director of Nursing (DON) revealed she would have expected the resident's nails to have been trimmed after her shower on 06/07/22 without the resident asking for them to be trimmed. The DON stated she didn't know why the resident's nails were not trimmed but said they would be providing additional training to the NAs and nurses regarding trimming nails after showers were given and as needed.

Based on observations, staff interviews and record review, the facility failed to protect a resident's right to be free from abuse for 1 of 1 resident (Resident # 68). Immediate jeopardy began on 12/6/19 when three nurse aides provided personal care to a severely cognitively impaired agitated resident in a manner that resulted in the resident and staff behaviors escalating to the point of staff using foul language, threatening with fists, and imposing physical abuse to the resident, without staff intervening or discontinuing the care, or reporting the abuse to licensed staff immediately. Immediate Jeopardy was removed on 12/12/19 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee education and ensure monitoring systems in place are effective. The findings included: Resident #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #68's care plan dated 07/20/19 revealed he was care planned for combativeness and becoming resistant to staff when trying to provide care. The goal was for Resident #68 to communicate with others without swearing or being verbally abusive and allow staff to provide appropriate care through the next review date of 01/30/20. Interventions included encouraging participation in personal care, not arguing with the resident, speaking in a calm voice and reducing environmental stimuli. Resident #68's quarterly minimum data set (MDS) assessment dated [DATE] revealed he was assessed as severely cognitively impaired. He was assessed to have no behaviors or refusal of care. He required extensive assistance with bed mobility, dressing and personal hygiene. Resident #68 was totally dependent on staff for bathing and able to make his needs known. An observation of Resident #68 conducted on [DATE] at 2:39 PM revealed the resident to be in his wheelchair sitting in the hallway eating a snack. Staff were observed interacting with Resident #68 during this observation as well as another resident. A second observation of Resident #68 was conducted on 12/11/19 at 8:56 AM. Resident #68 was observed with his eyes closed resting in bed. An interview conducted on [DATE] at 1:46 PM with NA #1 revealed she had been working in the facility for 3 days on 12/06/19. She stated she was paired with NA#2 on that day for orientation. NA #1 stated a Hospice NA (NA #3) was in the facility and requested assistance with giving Resident #68 a bed bath. The interview revealed NA #2 had gotten on Resident #68's eye level and asked him if the staff could get him dressed and give him a bed bath, Resident #68 became aggressive grabbing NA#3's hand, sinking his nails into her skin, trying to kick and hit. NA #2 then stated to the resident stop, quit being a [MEDICAL CONDITION] and popped him in the right upper chest area (not hard but a small tap) which made the resident more agitated hitting and kicking resisting care. NA #3 then stated to NA #2, I don't believe smacking him helps the situation. NA #1 stated the staff continued to provide care and dress Resident #68 stating he did not become calm until he was placed in his wheelchair. Once the resident was placed in his wheelchair, he became approachable and calm. The interview revealed NA #1 did not see any red marks on Resident #68's skin from where NA #2 had popped him. NA #1 stated the incident happened on 12/06/19 at 7:30 AM. A second interview with NA #1 conducted on [DATE] at 2:48 PM revealed once the NAs began providing Resident #68 with a bed bath NA #2 was holding Resident #68's hands so NA #3 could wash his side. She stated Resident #68 got one of his hands loose from NA #2 and had grabbed NA #3's hand. NA #2 then popped him on the upper chest area to get the resident to stop fighting. On [DATE] at 1:58 PM an interview was conducted with NA #3. She stated Resident #68 would often become agitated and aggressive during a bed bath hitting, pinching and cursing at staff. NA #3 said she never gave Resident #68 a bath alone, he required someone else to assist and one of the NAs from the facility always helped her on Fridays. The interview revealed NA #3 asked NA #2 to assist her in giving Resident #68 a bed bath on 12/06/19. NA #2 was training NA #1 so all three of the staff entered the room. Once in the room she stated she was on one side of the bed, NA #2 was on the other side and NA #1 was standing at the foot of the bed observing. NA #3 stated at first Resident #68 wasn't hitting, he was holding NA #2's hands while she washed his side. Resident #68 began to become aggressive hitting at NA #2 and NA #3. NA #3 stated NA #2 began making smacking gestures with her hands in the air at Resident #68 and he was becoming more aggressive. NA #3 stated the resident had grabbed her hand and was pinching her fingers, so she turned the other way and closed her eyes. NA #3 stated she did not see nor hear NA #2's hand come into contact with Resident #68's skin. NA #3 said she told NA #2 that she was agitating him and making the situation worse which NA #2 did not acknowledge. She stated she did not hear NA #2 curse at Resident #68. She stated Resident #68 would usually become combative when she started his bed bath however if she spoke to him in a calm manner he would calm down. On [DATE] at 2:11 PM an interview was conducted with NA #2. NA #2 stated on 12/06/19 at 7:30 AM she assisted NA #3 give Resident #68 a bed bath. She also had a new employee (NA #1) in the room observing care. The interview revealed Resident #68 was very combative so she held his hands so he didn't swing or hit NA #3 and turned his body towards her so NA #3 could wash his side and back. Resident #68 started becoming combative getting one of his arms loose and digging his nails into her hand trying to hurt her and cursing at her. NA #2 stated she popped his hand with her right opened hand one time. NA #2 stated Resident #68 continued to remain agitated until he was placed in his wheelchair. On 12/12/19 at 10:33 AM an interview was conducted with the ADON. She stated on 12/06/19 she was at a function with the DON and received a text message from NA #1 to call her and she returned the call to NA#1 around 4:30 PM. The ADON was with the DON when she received the information about the incident from NA#1 and the DON took over the investigation at that time. On [DATE] at 3:03 PM an interview was conducted with the Director of Nursing (DON). She stated she had received a phone call from NA #1 on 12/06/19 at 4:30 PM regarding the incident. The DON said NA #1 reported NA #3 and NA #2 were completing a bed bath for Resident #68 earlier in the day and NA #2 had smacked Resident #68 on his arm/shoulder area. NA #1 reported to her that NA #3 had told NA #2 she was only making the situation worse. The interview revealed she had spoken with NA #2 who said she was holding Resident #68's hand to distract him while NA #3 washed his side. NA#2 had stated to the DON she had lightly popped the resident's hand to get him to let go of NA #3. The DON stated NA #2 had demonstrated to her how she had popped his hand. The DON stated she had interviewed NA #3 who said she had turned away from the incident but had seen NA #2 making a smacking motion in the air before she turned away. She stated following the incident a skin assessment was completed for Resident #68 which revealed no skin abnormalities. On 12/11/19 at 11:47 AM an follow-up interview was conducted with NA #1, NA #2 and NA #3. NA#1 and NA #3 were in the facility and NA #2 was included in the interview via phone. NA #3 stated she sees the resident twice a week and had to have help because Resident #68 was combative. The NAs on the hall would assist her giving the resident a bath. NA #1 was in training with NA#2 so she asked them for help. NA #2 asked Resident #68 if he would take a bath and he didn't respond the first time, so she asked again, and he said yes. NA #3 got the supplies together and began giving Resident #68 a bath. Resident #68 grabbed her hands and put his nails into her skin. She stated NA #1 had a better view of the situation because she was at the foot of the resident's bed. NA #2 held the resident's hands during care while she washed the resident. Then they switched sides, Resident #68 grabbed her by both hands and dug his nails into her while NA #2 was washing him. She stated she pulled her hands down and turned around. She stated she didn't hear NA #2 hit him. When she turned back NA #2 was making hand gestures at him without touching the resident. She stated to NA #2 that doesn't help the situation. NA #1 stepped up to the left side to help fasten his brief. Once the resident sat up on the side of the bed, he was calm and got into his chair. During the interview NA #1 stated when NA #3 turned her back, NA #2 was on the left side and the resident continued to flail around. NA #1 stated NA #2 popped the resident's chest area. She stated during the incident the resident had balled his fist up at NA #2 and NA #2 balled her fist up and faced them towards the resident and NA #2 stated to the resident, Do you want to fight. NA #1 stated her nerves were shot when she left the situation and that's why she didn't report that NA #2 had her fist balled at the resident initially. NA#1 was scared feeling like she was in a bad situation on her third day of training. Stated her thought if NA #2 did this with other NAs in the room what does she do when she's alone. She stated the incident was very overwhelming. During the interview NA #2 stated she lightly popped his hand because the resident had grabbed her hand and she tapped it to get him to let her hand go. She stated she lightly popped his hand and did not touch his chest area. The only time she touched his chest area was when she was putting his shirt on which was when he was sitting up on the side of the bed. She stated his hand was located near his chest area when she popped it so that is probably what NA #1 saw when she thought his chest was hit. The Administrator was notified of the Immediate Jeopardy on 12/11/19 at 2:30 PM. On 12/12/19 at 4:30 PM the facility provided the following credible allegation of Immediate Jeopardy removal. F [AGE]0 Removal Plan Identify those recipients who have suffered, or likely to suffer, a serious adverse outcome as a result of noncompliance: · On [DATE] at around 4:30 pm, NA #1 reported that during her orientation earlier that day (before breakfast), she witnessed NA#2 popped resident #68 in the right upper chest area while telling him to stop and quit being a [***] during personal care. NA #1 stated that the hospice nurse aide (NA #3) was also in the room, and she commented that will only make it worse. NA #2 was removed from the floor at 4:50 pm and an investigation started. · Around 4:50 pm, spoke with NA #3 on the phone. She stated that during care resident #68 gets combative at times. NA #2 was assisting her with his care, trying to distract him and hold his hands. NA #3 stated she witnessed NA #2 smack at his hands but did not actually see her come into contact with the resident. NA #3 felt it was inappropriate because resident #68 could see what NA #2 was doing. NA #3 stated that will not help, it will only make it worse and NA #2 did not acknowledge that she had spoken to her. · Around 5:15 pm, interviewed NA #2. Asked her to explain any interactions she had with resident #68 during her shift. She stated that during her bathing, she assisted NA #3 like she does every Friday. She stated that she was holding his hands and providing distraction to prevent him from hitting NA #3 while she washed him. Resident #68 dug his nails into her hand, and NA #2 stated she lightly popped his hand to get him to stop. She demonstrated. It was not physically painful but gave the feeling of being disciplined. · Around 6:30pm on [DATE], resident #68 was assessed, as he was in the dining room for dinner when the investigation began. A head to toe skin assessment was complete. No physical injury was noted and he did not recall the incident. He was calm with no distress noted. · The incident did not cause injury or [MEDICATION NAME] mental anguish as evidence by no redness, or bruising on physical assessment, and no recollection of the incident. NA #1 was with NA#2 throughout her shift to include breaks and did not witness any other resident at any time to be at risk of any type of abuse. · The RP was informed on Monday, December 9, 2019 of the incident. · The medical director was informed of the incident on Tuesday, December 10, 2019. · Local law enforcement notified on 1[DATE]. · NA #2 employment was terminated on Tuesday, December 10, 2019 because she admitted to lightly popping resident #68 on the hand when he was combative. She was remorseful, stated she knew the policy, and knew it was wrong. NA #2 stated she did not intend to harm the resident but was attempting to get him to let go of her hand. Fair Haven has a zero tolerance policy for abuse, warranting termination of employment. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. · All residents on NA #2's assignment, and the surrounding assignments (rooms 100-119) received skin assessments on 12/11/19. (Rooms 120-156) were completed on 12/12/19 Skin assessments were completed by the unit managers and wound nurse. No evidence of abuse on any residents. No new bruising when compared to the previous weekly skin assessments. NA #2 consistently works on the same assignment, and her last day worked prior to the alleged incident was December 1, 2019. · Alert and oriented residents from rooms 100-119 were interviewed on 12/11/19 by the social worker and assistant administrator. All residents interviewed denied abuse or mistreatment from staff. · Alert and oriented residents from rooms 120- 156 were interviewed on 12/12/19 by the social worker and assistant administrator. All residents interviewed denied abuse or mistreatment from staff. · All residents/families may file a grievance with the facility or state agency concerning resident abuse, neglect, exploitation, and misappropriation of resident property in the facility. This information is provided upon admission and is available on the resident information board. · Education began on the evening of Friday, [DATE]. This included the abuse policy, reporting abuse immediately, as well as approach with resident's with dementia/aggressive behaviors. · Education began on the evening of Friday, [DATE]. This included the abuse policy, reporting abuse immediately, as well as approach with resident's with dementia/aggressive behaviors. This education was started by the assistant administrator to the direct care staff. The education continued throughout the weekend, on all shifts, and is ongoing until it is completed by all staff employed by Fair Haven of Forest City, as well as therapy staff working at Fair Haven of Forest City. The assistant administrator, DON, ADON, and unit managers will continue the education until completion. All staff will require this education to be completed before they are allowed to work. All staff includes, nursing (nurses and CNAs), activities, dietary, housekeeping, laundry, maintenance, and therapy. · The approach education included: 10 tips for dealing with aggressive behavior in dementia 1. Be prepared with realistic expectations Reminding yourself that challenging behavior and aggressive outbursts are normal symptoms of dementia helps you respond in a calm and supportive way. · Knowing that these episodes are a common part of the disease reduces your shock and surprise when it does happen and may also make it a little easier to not take the behavior personally. 2. Try to identify the immediate cause or trigger Think about what happened just before the aggressive outburst started. Something like fear, frustration, or pain might have triggered it. · For example, your resident might start yelling at empty areas of the room and telling people to get out. Looking around, you might notice that the room is starting to get darker because it's early evening. The dim light causes shadowing in the corners of the room, making it seem like there are people in the corner. · After identifying that potential trigger, turn on the lights to get rid of the shadowy corners. That will hopefully help the resident calm down. And, in the future you'll know to turn on the lights before the room gets too dim. · In another example, you could have unintentionally approached them from behind and startled them. In a sensitive moment, that could make them feel attacked and so they lash out in what they perceive as self-defense. 3. Rule out pain as the cause of the behavior Pain and physical discomfort can trigger aggressive behavior in someone with dementia. · Many older adults with dementia aren't able to clearly communicate when something is bothering them. Instead, being in pain or discomfort could cause them to act out. · Check to see if they need pain medication for existing conditions like arthritis or gout, if their seat is comfortable, or if they need to use the toilet. 4. Use a gentle tone and reassuring touch When your older adult gets upset, take a deep breath and stay as calm as possible. If you're upset, that unintentionally continues escalating the tense emotions in the situation. · Staying calm and breathing slowly helps to reduce everyone's anger and agitation. Speak slowly and keep your voice soft, reassuring, and positive. · If appropriate, use a gentle and calming touch on the arm or shoulder to provide comfort and reassurance. 5. Validate their feelings If your resident is being aggressive and there isn't an obvious cause, it could be because they're having strong negative feelings like frustration, sadness, or loneliness and don't know how to properly express themselves. · Try to look for clues to their emotions in their behavior and speak in a calm and comforting way. Reassure them that it's ok to feel that way and that you're there to help. 6. Calm the environment A noisy or busy environment could also trigger aggressive dementia behavior. · If your older adult starts behaving aggressively, take notice of the environment to see if you can quickly calm the room. Turn down music volume, turn off the TV, and ask other people to leave the room. 7. Play their favorite music Music has an amazing effect on mood. · Sometimes, singing an old favorite song, humming a soothing tune, softly playing relaxing classical music, or playing their favorite sing-a-long tunes can quickly calm someone down. 8. Shift focus to a different activity If the current or previous activity caused agitation or frustration, it could have provoked an aggressive response. · After giving your resident a minute to vent their feelings, try to shift their attention to a different activity - something they typically enjoy. 9. Remove yourself from the room In some cases, nothing works to calm the person. · If that happens, it may be best to leave the room to give them some space and to give yourself time to calm down and regain balance. They may be able to calm themselves or might even forget that they're angry. · Before leaving, check to see that the environment is safe and that they're not likely to hurt themselves while you're gone. 10. Make sure you and your resident are safe and call for help in emergencies If your resident can't calm down and is becoming a danger to you or to themselves, you'll need help from others. · If the situation isn't extreme and there's a nearby staff member usually responds well to, call and ask them to come over to help immediately. · Always notify a supervisor if the resident is unable to be calmed, and remove yourself from the situation if you feel you are getting aggravated. · It is never acceptable to pop, smack, punch, hit, punish or inflict harm as a response to a combative resident. · Resident #68's is care planned for disruptive behaviors and combative episodes with care. The education provided for this alleged incident includes some of the approaches consistent with resident #68's care plan. However, his name was not included in the education for his privacy and protection. The 10 tips are appropriate for any disruptive / combative behaviors exhibited, and appropriate for resident #68's daily care. · Abuse education is provided to new hires, annually, and as needed throughout the year. · Dementia education is provided to new hires, annually, and as needed throughout the year. The virtual dementia tour is also provided annually. · Education will be conducted with Hospice staff before they are allowed to work in the facility. This education will be conducted by the assistant administrator, DON, and/or ADON. The hospice supervisor was informed of this requirement on December 11, 2019 at 5:45 pm. A list of all hospice staff assigned to the facility was requested to ensure completion of education before they provide care to residents in the facility. This plan has been implemented and all staff providing care has received the needed education. The administrator and DON will be responsible for continuing and maintaining the plan. The facility alleges IJ removal date of Thursday, December 12, 2019. The credible allegation for Immediate Jeopardy removal was validated on 12/12/19 at 4:30 PM, as evidenced by staff interviews, in-service record reviews and observation. The in-services included information on caring for aggressive residents with dementia, abuse and neglect policies and procedures, types of abuse and reporting incidents of abuse. Interview's were conducted with alert and oriented residents residing in rooms which NA#2 had worked regarding mistreatment from staff or abuse. None of the residents interviewed reported being abused or mistreated by NA #2 or any other staff member.

Based on record review and staff interviews, the facility failed to complete an Abnormal Involuntary Movement Scale (AIMS) assessment after an increase in dose of an antipsychotic medication on 1 of 5 residents reviewed for unnecessary medications (Resident #22). The findings included: Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #22's Medication Administration Record [REDACTED]. An AIMS assessment dated [DATE] in Resident #22's medical record indicated no abnormal involuntary movements were observed. A review of Resident #22's care plan dated 6/7/19 revealed Resident #22 was at risk of adverse effects of [MEDICAL CONDITION] medications. The approaches listed included AIMS quarterly and as needed with changes, monitoring for possible medication dosage reductions and monitoring for changes in gait or tremors. A review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #22 was moderately cognitively impaired, had no behaviors and received an antipsychotic medication routinely. A review of Resident #22's Physician order [REDACTED]. An AIMS assessment had not been completed when Resident #22's anti-psychotic medication dose had been increased on 10/18/19. The AIMS assessment was used to check for abnormal involuntary movements due to possible side effects from the use of the antipsychotic medication. On 12/12/19 at 12:57 PM, an interview conducted with Nurse #2 revealed an AIMS assessment was usually done on admission and at regular intervals by the third shift nurses. Nurse #2 stated she was not sure how often it should have been done or who kept track of when Resident #22's AIMS assessment was due. On 12/12/19 at 1:01 PM, an interview conducted with Unit Manager #1 revealed an AIMS assessment was done within 7 days of starting an antipsychotic medication and then every 6 months thereafter. Unit Manager #1 stated the third shift nurses were responsible for completing the AIMS assessment, but she was not sure who kept track of when Resident #22's AIMS assessment was due. On 12/12/19 at 1:20 PM, an interview was conducted with the Director of Nursing (DON) who stated that the facility had identified a problem regarding AIMS assessment not being completed timely. The facility did not have a designated staff member to keep up with the schedule of when AIMS assessments were due. The DON further stated that she thought the AIMS assessment was included in a group of assessments called user-defined assessments for which the unit managers were responsible for. She recently realized that it was not and agreed that an AIMS assessment should have been completed for Resident #22 when her anti-psychotic medication dose was increased on 10/18/19. The DON shared an AIMS assessment should be completed on admission or re-admission, with any changes in the anti-psychotic medication dose and every 6 months thereafter. On 12/12/19 at 3:05 PM, an interview with the Administrator revealed that he recognized that Resident #22's AIMS assessment not being completed timely was a problem and the facility was working on a plan to correct this deficiency.

Based on record review and staff interviews, the facility failed to transmit the Minimum Data Set (MDS) death in facility tracking record for 1 of 2 sampled closed records (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent transmitted MDS for Resident #1 was dated [DATE] and coded for a significant change in status assessment. No further MDS assessments had been transmitted. A review of the progress notes revealed that Resident #1 had expired (died ) in the facility on [DATE]. On [DATE] at 4:18 PM an interview was conducted with the MDS Nurse. The MDS Nurse verified that Resident #1 had expired in the facility on [DATE] and that a MDS death in the facility tracking record had not been completed. She reported that one should have been completed and transmitted, and that it was an oversight. An interview was completed with the Director of Nursing (DON) on [DATE] at 2:36 PM. The DON reported that she expected the MDS assessments to be coded and transmitted timely. In an interview with the Administrator on [DATE] at 3:06 PM he indicated that the MDS assessments should be submitted in a timely manner.

Based on observations, record reviews, resident and staff interviews, the facility failed to update a care plan for 1 of 1 resident (Resident #49) to reflect the nothing by mouth (NPO) status of the resident. Findings included: Resident #49 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. A review of Resident #49's quarterly Minimum Data Set ((MDS) dated [DATE] revealed she was cognitively intact for daily decision making and required extensive assistance of 1 staff member for eating due to her feeding tube. Resident #49 received 51% or more of her calories through tube feeding and average fluid intake of 501 cubic centimeters (cc) through her tube feedings. A review of Resident #49's care plan dated 10/09/19 revealed she had a PEG tube related to her inability to swallow food without aspirating all consistency. The resident is receiving bolus feedings and water flushes as ordered by physician. The goal was for the resident to receive feedings and flushes as indicated along with maintaining weight through the next review date of 01/09/2020. The interventions included to administer bolus feedings and flushes as prescribed by physician, administer medications via feeding tube, maintain NPO status, insure tube is inserted and secured properly for feeding purposes, secure feeding tube to prevent dislodgement, check position of tube prior to giving feeding, check for residual gastric contents prior to each feeding, Nursing to withhold feeding if residual is 200 cc or greater as ordered by physician, document and notify physician, maintain resident in upright position after each feeding as indicated, observe skin condition around insertion site and document per protocol, report increased redness, temperature at site to physician, change tube site dressing as ordered by physician, document and report any abnormalities to physician, report any significant fluid balance discrepancy to physician including decreased output, weigh resident as indicated, document and report any significant variance to physician, dietician to review resident dietary regimen and document as indicated. Further review of Resident #49's care plan dated 10/09/19 revealed she had a care plan for being edentulous with top dentures, and she was NPO related to new PEG tube placement. The goal was for the resident to be able to chew food sufficiently to swallow without difficulty through the next review of 01/09/2020. The interventions included provide dental services per protocol and as needed, dietician to evaluate per protocol, determine resident food likes/dislikes, provide oral care per protocol and as needed, monitor food intake at each meal, record and report decline in intake to physician and dietician. A review of Resident #49's physician orders [REDACTED]. Resident #49 was hospitalized from [DATE] through 11/26/19 for dyspnea, coughing, hypoxemia and aspiration pneumonia. She was treated for [REDACTED]. It was recommended the resident remain NPO (nothing by mouth) due to swallowing exam revealing all food and liquids swallowed went into the resident's lungs. Orders were written for tube feedings via Resident #49's feeding tube. A review of Resident #49's physician orders [REDACTED]. An interview with Resident #49 on 12/11/19 at 1:43 PM revealed she was not eating anything by mouth and resident stated she could not remember the last time she had something to eat. An interview on 12/11/19 at 3:50 PM with Nurse #2 revealed Resident #49 was NPO due to aspiration pneumonia. She stated the resident had just recently been hospitalized for [REDACTED]. An interview with the MDS Coordinator on 12/12/19 at 2:14 PM revealed she had not done Resident #49's Care Area Assessment (CAA) summary or care plan for nutrition but said it had been completed by the Dietary Manager. An interview with the Dietary Manager on 12/12/19 at 2:49 PM revealed he had completed the nutritional and feeding tube CAA summary and care plan for Resident #49. He stated he had not discontinued the care plan regarding her being able to chew her food and swallow because the resident had hoped she would be able to have comfort foods. The Dietary Manager stated he was aware that any food or drink the resident swallowed would go into her lungs and stated he was aware the physician had written orders for the resident to remain NPO as a result of her swallowing exam. He was not able to answer why the care plan had not been updated. An interview was conducted on 12/12/19 at 2:25 PM with the Director of Nursing (DON). She stated she would have expected Resident #49's care plan to have been updated to reflect that she could not have any food or drink by mouth. According to the DON, she would have expected if the resident was getting comfort foods interventions be in place to address the consequences of her swallowing food or drink and the family be aware of all the consequences. She stated the care plan should have been more specific to Resident #49 and address her desires versus the physician orders [REDACTED]. An interview on 12/12/19 at 3:09 PM with the Administrator revealed he would have expected Resident #49's care plan to have reflected her NPO status and interventions more specific to her and her care.

Based on observations, record review and staff interviews, the facility failed to provide supervision to a prevent a fall from occurring for 1 of 3 residents who was left leaning to one side while in bed. (Resident #31). Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly minimum data set ((MDS) dated [DATE] revealed Resident #31 was severely cognitively impaired. Resident #31 was assessed as requiring extensive assistance with bed mobility and dependent on staff members for transfers. His balance was assessed as unsteady, only able to stabilize with staff assistance. Resident #31 was assessed as having no behaviors. He had experienced two or more falls since the last assessment resulting in no injury and one fall resulting in a minor injury. The care plan dated 09/25/19 revealed a focus area for fall risk related to [MEDICAL CONDITIONS], and impaired mobility. The goal was for Resident #31 to experience no serious injuries related to falls through the next review to be completed on 01/02/20. Interventions included documenting all falls and surrounding circumstances, call light within reach, mechanical lift for all transfers, fall precautions in place, drop seat to wheelchair, concave mattress, fall mat at bedside and the bed against the wall. The resident incident report dated 09/04/19 revealed Resident #31 was on his bed and the nurse noted he was starting to lean to one side when the nurse left the room to get a nurse aide (NA) to help adjust Resident #31 in bed. When the nurse and NA returned to the room less than 30 seconds later the resident was noted to be on the floor. The note revealed Resident #31 stated he was not hurt and did not know how the fall had happened. Immediate actions taken included assessing the resident for injuries, assisting the resident back into bed using a mechanical lift. Resident #31's fall mat was in place during the incident in which the resident landed on. The bed was in low position. A follow up assessment was completed 24 hours after the fall. Resident #31 had no signs of injury related to the recent fall. The nursing note dated 09/04/19 at 10:29 PM by Nurse #1 revealed at 5:30 PM he had noticed Resident #31 leaning to one side of the bed, so he left the room to go and get a NA, 30 seconds later when the two reentered the room Resident #31 was laying in the floor. A total lift was used to place the resident back into bed and his concave mattress was adjusted to better fit the resident. The resident experienced no injuries from the fall. On 12/12/19 at 9:08 AM an interview was conducted with Nurse #1. Nurse #1 stated he usually worked on the rehabilitation hall and not the hall in which Resident #31 resided. He stated on the evening of 09/04/19 he walked into the room and saw Resident #31 laying in the bed leaning to his side near the edge of the bed. Nurse #1 stated he then left the room to find a NA to assist him reposition the resident. The interview revealed by the time the nurse and NA got back into the room Resident #31 had experienced a fall and was on the floor lying on his right side. Nurse #1 said the residents call light was in place and working however he did not think to use the call light and just walked out of the room figuring that would be the quickest way to get help because he felt like the resident was falling out of his bed. He stated looking back at the incident he would have stayed in the room to assist in preventing Resident #31 from falling. Nurse #1 stated following the fall he assessed the resident for any injuries in which he did not have any and assisted in transferring him back into the bed using a mechanical lift. He could not recall the NAs name who he went to get on 09/04/19. On 12/12/19 at 9:27 AM an interview was conducted with NA #4 who was working with Nurse #1 on 09/04/19. NA #4 stated she remembered assisting a nurse get Resident #31 out of the floor but could not recall the nurse or date of the incident. The interview revealed NA #4 did not remember any details of the incident. On 12/12/19 at 10:33 AM an interview was conducted with Nurse Manager #1. She stated she was responsible for competencies and training in the facility. The manager stated staff were trained to never leave a resident alone if they're at risk of a fall. When reviewing the incident report, she stated the nurse should have yelled for assistance or used the call light from inside of the room. The interview revealed all nurses attend yearly competency training. On 12/12/19 at 10:36 AM an interview was conducted with Nurse Manager #2. She stated she was responsible for competencies and training in the facility. She stated the staff were trained that resident safety is the number one priority and to never leave a resident alone if you felt like they might experience a fall. When reviewing the incident report, she stated the nurse should have used the call bell or yelled for assistance in repositioning the resident for safety. On 12/12/19 at 10:01 an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated she reviewed all incident reports to ensure there was enough information and follows up on falls. She stated she puts interventions in place to prevent falls from reoccurring. When reviewing the incident from 09/04/19 with Resident #31 she stated the resident was considered a special situation because he had a history of [REDACTED].#1 had done by leaving the resident. The ADON stated normally employees are told to always stay with the resident for safety and yell for assistance. She stated Resident #31's concave overlay was not secured on the bed and had to be placed back onto the bed after the fall. An observation of Resident #31 conducted on 12/09/19 at 2:37 PM revealed the resident to be laying in the middle of the bed, the bed was in a low position with a fall mat at bedside. Resident #31's concave mattress was secured to the bed at that time. A second observation of Resident #31 was conducted on 12/11/19 at 8:54 AM. Resident #31 was observed laying on his back in the middle of the bed, the bed was in a low position with a fall mat at bedside. Resident #31's concave mattress was secured to the bed at that time. On 12/12/19 at 2:36 PM an interview was conducted with the Director of Nursing (DON). The DON stated Resident #31 leaned frequently over the side of the bed and they had interventions in place such as his fall mat. She stated she was not there during the incident and could not give a definite answer of what correct actions should have taken place stating it depended on nursing judgement. On 12/12/19 at 3:14 PM an interview was conducted with the Administrator. The Administrator stated he wanted to trust the judgement in his staff and trusted his nurses. He stated resident falls were a high focus in the facility and could not say exactly what the nurse should have done because he wasn't there during the fall.

Based on observation and staff interviews, the facility failed to discard an opened and undated vial of [MEDICATION NAME] on 1 of 4 medication carts. Findings included: On 12/12/19 at 10:13 AM, an observation of Medication Cart A was conducted with Nurse #3 and revealed an opened and undated vial of [MEDICATION NAME] that was available for resident use. A pharmacy label on the vial revealed it was received by the facility on 9/5/19. On 12/12/19 at 10:15 AM, an interview was conducted with Nurse #3 who stated the [MEDICATION NAME] vial should have been dated when opened per facility policy and because the insulin had not been dated when opened there was no way to determine when the insulin had expired. Nurse #3 further stated [MEDICATION NAME] should be discarded after 28 days of being opened and the undated/opened [MEDICATION NAME] was last administered to a resident the evening prior. Nurse #3 discarded the opened and undated vial of [MEDICATION NAME]. On 12/12/19 at 10:47 AM, an interview was conducted with Unit Manager #2 who verified the [MEDICATION NAME] vial was opened and undated and was available for resident use. Unit Manager #2 stated that the [MEDICATION NAME] vial should have been dated when it was opened and was not sure how the vial was left in Medication Cart A available for resident use because the pharmacist had inspected all the medication carts the day before. She further stated the nurses were responsible for making sure all the insulin vials were dated and third shift nurses checked all the medication carts daily for outdated and expired medications. On 12/12/19 at 2:45 PM, an interview was conducted with the Director of Nursing (DON) who stated insulin should be dated when opened per facility policy. The DON shared the nurse assigned to the medication cart was responsible for making sure all insulin vials were dated but the unit managers also checked the medication carts daily. She further stated that the pharmacist had inspected all the medication carts the day before and was surprised that an undated and opened [MEDICATION NAME] vial was observed. On 12/12/19 at 3:16 PM, an interview was conducted with the Administrator who stated that staff should have followed the facility policy and dated the [MEDICATION NAME] vial when it was opened.

Based on record review, observation and staff interviews, the facility failed to develop a care plan regarding communication for 1 of 1 sampled resident for communication (Resident #14) and failed to implement a care plan intervention for monitoring the use of [MEDICAL CONDITION] medications for 1 of 5 sampled residents for unnecessary medications (Resident #22). The findings included: 1. Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was moderately cognitively impaired and had unclear speech with slurred or mumbled words. Resident #14 had difficulty communicating some words or finishing thoughts but was able to make himself understood if prompted or given time. His ability to understand others was coded as having clear comprehension. He did not have a [DIAGNOSES REDACTED].#14 had difficulty communicating in a manner that was understood. Resident #14 had constant tremors which resulted in stuttering when he attempted to speak and made his speech unclear. The CAA further indicated that the facility would proceed to care plan to address Resident #14's communication. A review of Resident #14's care plan which was last updated on 12/7/19 revealed no care plan interventions to address Resident #14's communication issues. On 12/9/19 at 4:34 PM, an observation was made, and an interview was attempted with Resident #14. When asked questions, Resident #14 just stared at the surveyor, smiled and did not answer any questions. On 12/11/19 at 8:35 AM, an interview with nurse aide (NA) #1 revealed she had assisted Resident #14 with lunch one time and was not sure if Resident #14 could talk because she had not heard him speak and Resident #14 did not talk back to her. On 12/11/19 at 4:22 PM, an interview with the MDS nurse revealed Resident #14's CAA for communication was completed by the Social Worker and after reviewing Resident #14's current care plan, the MDS nurse stated the Social Worker should have also completed a care plan addressing his communication issues. On 12/11/19 at 5:10 PM, an interview conducted with the Social Worker revealed Resident #14 had trouble communicating and stuttered sometimes. The Social Worker shared that Resident #14 should be given time to respond and sometimes he would not talk to people whom he didn't like or didn't know. The Social Worker agreed that a care plan for communication should have been developed for Resident #14 and was unsure why she missed it. The Social Worker stated she must have overlooked it and would fix Resident #14's care plan to include communication. On 12/12/19 at 2:38 PM, an interview conducted with the Director of Nursing (DON) revealed that if Resident #14 triggered for communication in his CAA, then he should have had a care plan for communication. The DON was unsure how Resident #14's care plan for communication was missed. On 12/12/19 at 3:05 PM, an interview with the Administrator revealed he agreed that communication should have been added to Resident #14's care plan after he reviewed his CAA and his current care plan. 2. Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was last re-admitted to the facility on [DATE] after hospitalization with pneumonia. A review of Resident #22's care plan dated 6/7/19 revealed Resident #22 was at risk of adverse effects of [MEDICAL CONDITION] medications. One of the approaches listed was Abnormal Involuntary Movement Scale (AIMS) quarterly and as needed with changes. Further review of Resident #22's medical record revealed an AIMS assessment dated [DATE] which indicated no abnormal involuntary movements were observed. A review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #22 was moderately cognitively impaired, had no behaviors and received a [MEDICAL CONDITION] medication routinely. On 12/12/19 at 1:01 PM, an interview conducted with Unit Manager #1 revealed an AIMS assessment was done within 7 days of starting an antipsychotic medication and then every 6 months thereafter. Unit Manager #1 stated the third shift nurses were responsible for completing the AIMS assessment, but she was not sure who kept track of when Resident #22's AIMS assessment was due. On 12/12/19 at 1:20 PM, an interview was conducted with the Director of Nursing (DON) who stated that the facility had identified a problem regarding AIMS assessment not being completed timely. The facility did not have a designated staff member to keep up with the schedule of when AIMS assessments were due. The DON further stated that she thought the AIMS assessment was included in a group of assessments called user-defined assessments for which the unit managers were responsible for. She recently realized that it was not and agreed that an AIMS assessment should have been completed for Resident #22 when she had an increase in her antipsychotic medication in October. The DON said the statement that AIMS should be done quarterly in Resident #22's care plan was inaccurate and should have read every 6 months and as needed with any changes. On 12/12/19 at 2:14 PM, an interview with the MDS Nurse revealed she had not been aware that AIMS assessments were not being done quarterly on Resident #22. The MDS Nurse shared that AIMS assessments were supposed to be done every 6 months and not quarterly as what was stated in Resident #22's care plan, and that she needed to make a correction in Resident #22's care plan. On 12/12/19 at 3:05 PM, an interview with the Administrator revealed that he recognized that Resident #22's AIMS assessment not being completed timely was a problem and the facility was working on a plan to correct this deficiency.

Based on record review, and staff interviews, Nurse Aide (NA) #1 failed to report abuse immediately after observing NA #2 impose abuse to a resident and which allowed NA #2 to continue to work the rest of her shift for 1 of 1 resident reviewed for abuse (Resident #68). Immediate jeopardy began on 12/6/19 when NA #1 observed NA #2 pop Resident #68 in the chest at 7:30 AM and did not report the incident to the Assistant Director of Nursing (ADON) until after 3:30 PM on 12/6/19, which allowed NA #2 to work the rest of the shift. Immediate Jeopardy was removed on 12/12/19 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee education and ensure monitoring systems in place are effective. The findings included: Review of the facility's Abuse Prohibition policy which was revised August 1st, 2017 included the following in part: Under protocol for reporting abuse: A. If you have reason to believe, as a reasonable person, that abuse, neglect, or misappropriation of resident property has occurred you are responsible to immediately notify a person in charge, Administrator or designee. B. Safety of the resident shall be protected at all times while the investigation is in progress. Resident #68 was admitted to the facility on [DATE]. An interview conducted on [DATE] at 1:46 PM with NA #1 revealed she had been working in the facility for 3 days on 12/06/19. She stated she was paired with NA#2 on that day for orientation. NA #1 stated a Hospice NA (NA #3) was in the facility and requested assistance with giving Resident #68 a bed bath. The interview revealed NA #2 had gotten on Resident #68's eye level and asked him if the staff could get him dressed and give him a bed bath, Resident #68 became aggressive grabbing NA#3's hand, sinking his nails into her skin, trying to kick and hit. NA #2 then stated to the resident stop, quit being a [MEDICAL CONDITION] and popped him in the right upper chest area (not hard but a small tap) which made the resident more agitated hitting and kicking resisting care. NA #3 then stated to NA #2, I don't believe smacking him helps the situation. NA #1 stated the staff continued to provide care and dress Resident #68 stating he did not become calm until he was placed in his wheelchair. Once the resident was placed in his wheelchair, he became approachable and calm. The interview revealed NA #1 did not see any red marks on Resident #68's skin from where NA #2 had popped him. NA #1 stated the incident happened on 12/06/19 at 7:30 AM and she did not report the incident to the Assistant Director of Nursing (ADON) until after 3:30 PM on 12/06/19. NA #1 said she did not report the incident immediately because she was a new staff member to the facility and was concerned to tell on NA #2. The interview revealed NA #1 had received an orientation on abuse on the Tuesday before the incident regarding how to handle an abuse situation and to report the allegation to administrative staff immediately. NA #1 stated she did not tell the nurse on duty because she had previously worked with the Assistant Director of Nursing (ADON) and felt more comfortable notifying her. On [DATE] at 1:58 PM an interview was conducted with NA #3. She stated Resident #68 would often become agitated and aggressive during a bed bath hitting, pinching and cursing at staff. NA #3 said she never gave Resident #68 a bath alone, he required someone else to assist and one of the NAs from the facility always helped her on Fridays. The interview revealed NA #3 asked NA #2 to assist her in giving Resident #68 a bed bath on 12/06/19. NA #2 was training NA #1 so all three of the staff entered the room. Once in the room she stated she was on one side of the bed, NA #2 was on the other side and NA #1 was standing at the foot of the bed observing. NA #3 stated at first Resident #68 wasn't hitting, he was holding NA #2's hands while she washed his side. Resident #68 began to become aggressive hitting at NA #2 and NA #3. NA #3 stated NA #2 began making smacking gestures with her hands in the air at Resident #68 and he was becoming more aggressive. NA #3 stated the resident had grabbed her hand and was pinching her fingers, so she turned the other way and closed her eyes. NA #3 stated she did not see nor hear NA #2's hand come into contact with Resident #68's skin. NA #3 said she told NA #2 that she was agitating him and making the situation worse which NA #2 did not acknowledge what NA #3 had told her. She stated she did not hear NA #2 curse at Resident #68. She stated Resident #68 would usually become combative when she started his bed bath however if she spoke to him in a calm manner he would calm down. NA #3 stated she reported the incident to her Hospice nurse on the afternoon of 12/06/19 and had not reported the incident to anyone in the facility. She stated the Director of Nursing (DON) had called her around 4:30 PM to receive a statement of what had happened. On [DATE] at 2:25 PM an interview was conducted with Hospice Nurse #1. She stated on 12/06/19 NA #3 reported to her she was writing a statement about something that had happened that morning while she was in the facility giving a resident a bath. Hospice Nurse #1 stated she could not recall the exact details of the incident and did not contact the facility because she knew an investigation was being completed since the DON had asked NA #3 for a statement. On [DATE] at 2:11 PM an interview was conducted with NA #2. NA #2 stated on 12/06/19 at 7:30 AM she assisted NA #3 give Resident #68 a bed bath. She also had a new employee (NA #1) in the room observing care. The interview revealed Resident #68 was very combative so she held his hands so he didn't swing or hit NA #3 and turned his body towards her so NA #3 could wash his side and back. Resident #68 started becoming combative getting one of his arms loose and digging his nails into her hand trying to hurt her and cursing at her. NA #2 stated she popped his hand with her right opened hand one time. NA #2 stated Resident #68 continued to remain agitated until he was placed in his wheelchair. NA #2 stated she did not report the incident to her nurse because it was in her opinion normal behavior for Resident #68 because he was known to hit and kick at staff while providing care. On 12/12/19 at 10:33 AM an interview was conducted with the ADON. She stated on 12/06/19 she was at a function with the DON and received a text message from NA #1 to call her and she returned the call to NA#1 around 4:30 PM. The ADON was with the DON when she received the information about the incident from NA#1 and the DON took over the investigation at that time. On [DATE] at 3:03 PM an interview was conducted with the Director of Nursing (DON). She stated she had received a phone call from NA #1 at 4:30 PM regarding the incident. The DON said NA #1 reported NA #3 and NA #2 were completing a bed bath for Resident #68 earlier in the day at 7:30 AM and NA #2 had smacked Resident #68 on his arm/shoulder area. NA #1 reported to her that NA #3 had told NA #2 she was only making the situation worse. The interview revealed she had spoken with NA #2 who said she was holding Resident #68's hand to distract him while NA #3 washed his side. NA#2 had stated to the DON she had lightly popped the resident's hand to get him to let go of NA #3. The DON stated NA #2 had demonstrated to her how she had popped his hand. The DON stated she had interviewed NA #3 who said she had turned away from the incident but had seen NA #2 making a smacking motion in the air before she turned away. She stated following the incident a skin assessment was completed for Resident #68 which revealed no skin abnormalities. The DON explained that NA #3 had told her she didn ' t report the incident immediately because she had turned away from Resident #68 and did not see NA #2 hit the resident however when she saw the smacking motion towards the resident it had made her feel uncomfortable. The interview revealed 12/06/19 made NA #1's third day working in the facility and she did not know all of the staff working in the building. She stated NAs should report to their supervisor immediately if they have a concern regarding abuse and not wait an entire shift. The DON confirmed NA #1 had received abuse training during orientation and had been told to report allegations immediately per facility policy. On 12/12/19 at 10:01 AM an interview was conducted with Nurse Manager #1. She stated she was responsible for competency training in the facility and in-servicing. Nurse Manager #1 stated staff receive abuse training upon hire, annually and as needed throughout the year. She stated staff are trained to immediately report any allegation or suspicion of abuse immediately. The Administrator was notified of the Immediate Jeopardy on 12/11/19 at 2:30 PM. On 12/12/19 at 4:30 PM the facility provided the following credible allegation of Immediate Jeopardy removal. F [AGE]7 Removal Plan Identify those recipients who have suffered, or likely to suffer, a serious adverse outcome as a result of noncompliance: · Nurse Aide (NA) #1 messaged the ADON at around 3:30pm when she had left the facility. The ADON did not receive the message and call NA #1 until around 4:30pm. NA #1 stated she was scared to report the abuse allegation earlier because she was a new and still in training. She felt the need to report it but waited until after her shift because of this fear. She stated she was more comfortable talking to the ADON because they worked together in previous years. NA #1 reported the following to the ADON: · On [DATE] at around 4:30pm, NA #1 reported that during her orientation earlier that day (before breakfast), she witnessed NA#2 popped resident #68 in the right upper chest area while telling him to stop and quit being a [***] during personal care. NA #1 stated that the hospice nurse aide (NA #3) was also in the room, and she commented that will only make it worse. This was reported to the ADON and DON at the same time. NA #2 was removed from the floor at 4:50pm. · 24-hour report was submitted on [DATE] at 5:58pm. Investigation started immediately. · Local law enforcement notified on 1[DATE]. · NA #1 was on her third day of orientation. She received abuse education upon hire. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. · Education began on the evening of Friday, [DATE]. This included the abuse policy, reporting abuse immediately, as well as approach with resident's with dementia / aggressive behaviors. This education was started by the assistant administrator to the direct care staff. The education continued throughout the weekend, on all shifts, and is ongoing until it is completed by all staff employed by Fair Haven of Forest City, as well as therapy staff working at Fair Haven of Forest City. The assistant administrator, DON, ADON, and unit managers will continue the education until completion. All staff will require this education to be completed before they are allowed to work. All staff includes, nursing (nurses and CNAs), activities, dietary, housekeeping, laundry, maintenance, and therapy. · The re-education was focused on the importance to report immediately to remove the potential threat and provide resident protection from any further potential incidents. This focus on the abuse policy will be a process improvement for education provided to new hires, annually, and as needed. · Abuse education is provided to new hires, annually, and as needed throughout the year. · Education will be conducted with Hospice staff before they are allowed to work in the facility. This education will be conducted by the assistant administrator, DON, and/or ADON. The hospice supervisor was informed of this requirement on December 11, 2019 at 5:45pm. A list of all hospice staff assigned to the facility was requested to ensure completion of education before they provide care to residents in the facility. · NA #1 will receive written discipline on December 12, 2019 due to not immediately reporting the allegation in addition to the verbal counseling and education that was completed on [DATE]. This plan has been implemented and all staff providing care has received the needed education. The administrator and DON will be responsible for continuing and maintaining the plan. The facility alleges IJ removal date of Thursday, December 12, 2019. The credible allegation for Immediate Jeopardy removal was validated on 12/12/19 at 4:30 PM, as evidenced by staff interviews and in-service record reviews. The in-services included information on caring for aggressive residents with dementia, abuse and neglect policies and procedures, types of abuse and reporting incidents of abuse.

Based on record review and staff interviews, the facility failed to complete the Nutrition Care Area Assessments that addressed the underlying causes, contributing factors and risk factors for 5 of 13 residents sampled for nutrition and/or food concerns (Residents #6, #31, #77, #84, and #85). The findings included: 1. Resident #6 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The annual Minimum (MDS) data set [DATE] coded Resident #6 as having unclear speech, being severely cognitively impaired, having no moods or behaviors, being nonambulatory and requiring extensive to total assistance with all activities of daily living skills including eating. She was also coded as having a swallowing disorder and receiving a mechanically altered diet. The Care Area Assessment (CAA) for nutrition was dated 07/18/18. This CAA consisted of a check list of indicators that affect her ability to eat, her mental status, diseases and conditions, and antipsychotic medications. Under the analysis of findings was the only narrative which stated Resident #6 is at risk for weight/nutrition issues due to puree diet and reduced ADL (activities of daily living) performance. (Resident name) is confined to wheelchair and requires extensive assistance with all activities. The information did not include Resident #6's strengths or weaknesses or any specific reason these issues posed a risk to her nutrition. Interview with the Dietary Manager, who wrote this CAA, occurred on 01/25/19 at 11:41 AM. The Dietary Manager stated he had been employed 3 years as the dietary manager at this facility. He stated he was trained by a previous MDS coordinator on what to include in a CAA. He stated that he reviewed the predetermined categories, clinical [DIAGNOSES REDACTED]. He stated that under the analysis for nutrition he was instructed to write a brief summary of the populated items on the CAA that may affect nutrition or weight which was what this CAA reflected. The Administrator was interviewed on 01/25/19 at 1:30 PM. The Administrator stated that he believed the analysis on the CAA met the Resident Assessment Instrument manual instructions and that the CAA didn't have to be detailed. 2. Resident #31 was admitted to the facility most recently on 11/08/18. Her [DIAGNOSES REDACTED]. Her admission Minimum (MDS) data set [DATE] coded her as having intact cognition, eating independently and receiving a therapeutic diet. The Care Area Assessment for nutrition dated 11/16/18 consisted of a check list with impairments that could affect her ability to eat, her having anxiety problems, and [DIAGNOSES REDACTED]. The information did not include Resident #31's strengths or weaknesses or any specific reason these issues posed a risk to her nutrition. Interview with the Dietary Manager, who wrote this CAA, occurred on 01/25/19 at 11:41 AM. The Dietary Manager stated he had been employed 3 years as the dietary manager at this facility. He stated he was trained by a previous MDS coordinator on what to include in a CAA. He stated that he reviewed the predetermined categories, clinical [DIAGNOSES REDACTED]. He stated that under the analysis for nutrition he was instructed to write a brief summary of the populated items on the CAA that may affect nutrition or weight which was what this CAA reflected. The Administrator was interviewed on 01/25/19 at 1:30 PM. The Administrator stated that he believed the analysis on the CAA met the Resident Assessment Instrument manual instructions and that the CAA didn't have to be detailed. 3. Resident #84 was admitted to the facility on [DATE] and most recently on 01/03/18. her [DIAGNOSES REDACTED]. Her annual Minimum (MDS) data set [DATE] coded her with moderately impaired cognitive skills, having no behaviors, requiring extensive assistance with eating, having a swallowing disorder and receiving a mechanically altered, therapeutic diet. The Care Area Assessment for Nutrition dated 01/02/19 consisted of a check list of impairments that may affect her ability to eat, her poor memory and anxiety problems, diseases and conditions, and she was checked as receiving antipsychotic medications. Under the analysis of findings was the only narrative which stated per her BMI (body mass index) the resident is obese, Dx (diagnoses) list items can cause issues with nutrition and weight. The information did not include Resident #84's strengths or weaknesses or any specific reason these issues posed a risk to her nutrition. Interview with the Dietary Manager, who wrote this CAA, occurred on 01/25/19 at 11:41 AM. The Dietary Manager stated he had been employed 3 years as the dietary manager at this facility. He stated he was trained by a previous MDS coordinator on what to include in a CAA. He stated that he reviewed the predetermined categories, clinical [DIAGNOSES REDACTED]. He stated that under the analysis for nutrition he was instructed to write a brief summary of the populated items on the CAA that may affect nutrition or weight which was what this CAA reflected. The Administrator was interviewed on 01/25/19 at 1:30 PM. The Administrator stated that he believed the analysis on the CAA met the Resident Assessment Instrument manual instructions and that the CAA didn't have to be detailed. 4. Resident #85 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The admission Minimum (MDS) data set [DATE] coded Resident #85 as being cognitively intact, having some mood issues including sleep and appetite concerns, requiring extensive to total assistance with all activities of daily living skills including eating, having range of motion impairments on both side upper and lower extremities and having frequently pain. He was coded as receiving a mechanically altered diet. The Care Area assessment dated [DATE] included a check list which checked some functional impairment that may affect his ability to eat, diseases and conditions, and his receipt of antipsychotic medications. The narrative located under the analysis of findings stated Reduced ADL (activities of daily living), due to paralysis, mech (mechanical) diet as of this writing. Weight and nutrition can be affected by dx list. Assisted feeding. The information did not include Resident #85's strengths or weaknesses or any specific reason these issues posed a risk to his nutrition. Interview with the Dietary Manager, who wrote this CAA, occurred on 01/25/19 at 11:41 AM. The Dietary Manager stated he had been employed 3 years as the dietary manager at this facility. He stated he was trained by a previous MDS coordinator on what to include in a CAA. He stated that he reviewed the predetermined categories, clinical [DIAGNOSES REDACTED]. He stated that under the analysis for nutrition he was instructed to write a brief summary of the populated items on the CAA that may affect nutrition or weight which was what this CAA reflected. The Administrator was interviewed on 01/25/19 at 1:30 PM. The Administrator stated that he believed the analysis on the CAA met the Resident Assessment Instrument manual instructions and that the CAA didn't have to be detailed. 5. Resident #77 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The quarterly Minimum (MDS) data set [DATE] coded Resident #77 as being severely cognitively impaired, having no moods or behaviors, and requiring extensive two- person assistance with all activities of daily living skills including eating. She was also coded to be receiving a mechanically altered diet. The Care Area Assessment (CAA) for nutrition was dated 03/27/18. This CAA consisted of a check list of indicators that affect her ability to eat, her mental status, diseases and conditions, and antipsychotic medications. Under the analysis of findings was the only narrative which stated Resident #77 had a history of [REDACTED]. The information did not include Resident #77's strengths or weaknesses or any specific reason these issues posed a risk to her nutrition. Interview with the Dietary Manager, who wrote this CAA, occurred on 01/25/19 at 11:41 AM. The Dietary Manager stated he had been employed 3 years as the dietary manager at this facility. He stated he was trained by a previous MDS coordinator on what to include in a CAA. He stated that he reviewed the predetermined categories, clinical [DIAGNOSES REDACTED]. He stated that under the analysis for nutrition he was instructed to write a brief summary of the populated items on the CAA that may affect nutrition or weight which was what this CAA reflected. The Administrator was interviewed on 01/25/19 at 1:30 PM. The Administrator stated that he believed the analysis on the CAA met the Resident Assessment Instrument manual instructions and that the CAA didn't have to be detailed.

Based on record review and staff interviews, the facility failed to complete the Minimum Data Set (MDS) accurately for 2 of 22 residents sampled for MDS accuracy. Resident #85's pressure ulcer section did not accurately reflect the number and type of pressure sores he had on admission and Resident #46's MDS did not accurately reflect weight change. The findings included: 1. Resident #85 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of the admission nursing notes dated 09/27/18 at 11:56 PM noted Resident #85 arrived to the facility around 5:45 PM on 09/27/18. The note stated he had eschar noted on the bottom of both feet, a stage 4 decubitus ulcer on the resident's sacrum, both heels were dry and he had [MEDICAL CONDITION] on both feet. He was noted to be wearing L-Nard boots (used to relieve pressure to heels) to both feet. The Wound assessment Reports noted the following 5 areas as being identified on 09/27/18: *A stage 4 was noted to the sacrum with bone exposure measuring 5.0 centimeters (cm) by 4.5 cm by 4.0 cm and noted with granulation, bone and slough. *There was an unstageable area to the right heel measuring 3.5 cm by 5.0 cm by 0.0 cm with the wound bed covered in eschar. *An unstageable area on the right plantar ball of the foot measuring 3.0 cm by 3.5 cm by 0.0 cm covered in black eschar. *On the dorsal outer ball of the left foot was an unstageable wound measuring 1.0 cm by 1.0 cm by 0.0 cm covered in black eschar. *The dorsal inner ball of the left foot was an unstageable area measuring 4.0 cm by 3.0 cm by 0.0 cm covered in black eschar. There was a wound assessment note dated 09/28/18 at 12:04 PM describing the above areas in the departmental notes of the resident record. On 10/03/18 the wound assessment reports notes these same 5 areas and new measurements including the description that the sacrum was a stage 4 pressure and the other 4 wound on the feet were unstageable. The admission Minimum Data Set (MDS), dated [DATE], coded Resident #85 as being cognitively intact, requiring extensive to total assistance with all activities of daily living, and having 1 stage 4 pressure ulcer and 1 unstageable pressure ulcer due to coverage of wound by slough and/or eschar, both present on admission. The Care Area assessment (CAA) dated 10/10/18 related to pressure ulcers included that Resident #85 was admitted to the facility with a stage 4 pressure area to his sacrum and DTI (deep tissue injury) to his heels. There was no mention of the other areas noted on his feet. An interview with the MDS Coordinator was conducted on 01/25/19 at 11:19 AM. She confirmed she completed the MDS and CAA related to pressure ulcer. She presented a report that she used which only listed the stage 4 on his sacrum and an unstageable area on the ball of one foot. Upon follow up interview with the MDS Coordinator on 01/25/19 at 12:01 PM, she stated that she did not review the wound measurements and notes which were dated 9/28/18 and 10/03/18. She stated that she did not know why all the unstageable areas did not show up on the report she used when completing the MDS. She stated that the physician's history and physical dated 10/02/18 only mentioned the sacrum stage 4 and a blister on his heel. The MDS coordinator stated the MDS was miscoded and did not include all of Resident #85's pressure ulcers. Interview with the Director of Nursing (DON) on 01/25/19 at 1:29 PM revealed that the MDS inaccurately reflected Resident #85's skin condition on admission and the MDS should be accurate. Interview with the Administrator on 01/25/19 at 1:30 PM (present with the DON) revealed the care was provided from the care plan which was what mattered. 2.Resident #46 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED].>hypertension, [MEDICAL CONDITION], non-Alzheimer's dementia. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #46 was coded for having weight loss under Section K for Nutritional Status. A review of Resident #46 recorded weight revealed a weight of 136 dated 10/10/18 and a weight of 132 dated 11/14/18. On 01/24/19 at 2:59 PM an interview was conducted with the MDS Coordinator. The interview revealed the Dietary Manager was responsible for completing Section K of the MDS assessment. The interview revealed weight loss had been coded incorrectly for Resident #46. On 01/25/19 at 8:26AM an interview was conducted with the Dietary Manger. The interview revealed weight loss had been entered in error for Resident #46. On 01/25/19 at 9:45AM an interview was conducted with the Director of Nursing (DON). The interview revealed she had reviewed the MDS for Resident #46 and had spoken to the MDS Coordinator and Dietary Manager. The interview revealed Resident #46 should have no been coded for weight loss on the 11/28/18 MDS. The interview revealed her expectations were for the MDS to be coded accurately.

Based on record reviews, staff, and physician interviews the facility failed to notify the physician after a long acting insulin had been administered with no physician's order and failed to notify the physician of a resident's low blood sugar levels for 1 of 1 sampled residents (Resident #139). Immediate Jeopardy began on 12/11/14 when Resident #139 received a long acting insulin with no physician's order and the fluctuation of low blood sugar levels without physician notification. Immediate Jeopardy was removed on 12/31/14 at 11:54 AM when the facility provided an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems are in place and the completion of employee education. The findings included: Resident #139 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 5 day admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #139 was cognitively intact and was capable of daily decision making. A review of the nurse's notes dated 12/11/14 through 12/12/14 revealed the following entries: ? 12/11/14 at 11:38 PM---Nurse #3, working the 3PM until 11PM shift, did not document in her notes that the physician had been notified that Resident #139 had been administered a long acting insulin without a physician's order. ? 12/12/14 at 12:31 AM-Nurse #2, working the 11PM to 7AM shift, documented that Resident #139's finger stick blood sugars (FSBS) was 48 and that the resident was given 8 ounces (oz.) of orange juice and peanut butter crackers. Nurse #2 documented a re-check FSBS 15 minutes later of 76 at which time she gave Resident #139 an 8 oz. cup of med pass (a fortified nutritional shake) with another re-check FSBS 30 minutes later of 88. ? 12/12/14 at 1:45 AM---Nurse #2 documented a re-check FSBS of 51 and Resident #139 was sleepy but alert and oriented to person, place, and time. Nurse #2 documented that she gave Resident #139 milk and a tangerine, at which time Resident #139 consumed the entire carton of milk and ate half of the tangerine. Nurse #2 documented a re-check FSBS 20 minutes later of 88 and again provided Resident #139 with milk, another pack of crackers, and a container of yogurt. There was no documentation in Nurse #2's notes that the physician had been notified of the fluctuation in Resident #139's low FSBS throughout her shift. ? 12/12/14 at 7:30 AM---The Unit Manager (UM) documented that she notified the physician of Resident #139's low blood sugars and that the facility's protocol was being followed. The UM documented that the physician had advised her to continue the protocol and monitor Resident #139's urine output for next 24 hours. ? 12/12/14 at 8:00 AM---Nurse #4, working the 7AM to 3PM shift, documented a FSBS of 47 and that Resident #139 was alert with confusion. Nurse #4 documented an IV (intravenous) was started and [MEDICATION NAME] 50 (D50) was pushed via the IV and a bag of fluid which contained [MEDICATION NAME] 5% (D5) & ? normal saline (NS) was hung for infusion and was set to run at 100 milliliters (ml) per hour. Nurse #4 documented a re-check FSBS 15 minutes after giving the D50 of 427. A review of a Medication Variance Report written by the UM dated 12/12/14 at 7:30 AM indicated Nurse #3 had administered the wrong medication to the wrong resident. The report noted the medication administered was [MEDICATION NAME]45 Units one time by SQ (subcutaneous) to Resident #139. ([MEDICATION NAME] is a long acting insulin which starts to work in 1 to 3 hours, with a peak in 8 to 10 hours, and lasts for 18 to 26 hours). The report indicated "error/harm: an error occurred that may have contributed to or resulted in temporary resident harm and required intervention." The variance report revealed the Physician was contacted on 12/12/14 at 7:30 AM and orders were received and the Director of Nursing (DON), the Pharmacy, the Family, and the Administrator were contacted on 12/12/14 at 8:15 AM. The report further indicated the findings/actions taken: Nurse #3 was suspended, was re-educated, and required medication administration observations. The report was signed by the DON and the Administrator on 12/12/14. During an interview on 12/29/14 at 10:45 AM the UM verified she had completed the medication variance report. She stated on the morning of 12/12/14 at 7:15 AM she overheard the 3rd shift nurse, Nurse #2, and the 1st shift nurse, Nurse #4, discussing the fluctuation of Resident #139's FSBS. She indicated at that time she went to check on the resident and Resident #139 informed her of the injection of insulin the 2nd shift nurse had administered. The UM further indicated that during the course of her investigation she "figured out" that Resident #139 was given Resident #134's insulin; Resident #134 was across the hall from Resident #139. She stated she immediately advised the DON of the error and called the physician. During a telephone interview on 12/29/14 at 11:36 AM Nurse #2 indicated she was responsible for the care of Resident #139 on 12/11/14 at 11PM until 12/12/14 at 7AM. She stated during the change of shift report at 11PM, she was not made aware of any concerns and/or problems with Resident #139. She further stated she always checked on her residents at the beginning of her shift and during her initial check that night of Resident #139, when she opened the resident's door, Resident #139 called out to her for assistance to the bathroom. At which time, Nurse #2 stated Resident #139 indicated to her that she was "feeling funny and weird" and advised her that she had been given a shot of insulin. Nurse #2 stated she checked Resident #139's blood sugar and noted it was in the 40's. She further stated she gave Resident #139 carbohydrates to eat and when she re-checked Resident #139's blood sugar it had come up into the 80's. She indicated she did not call the physician during the night because the resident was alert and talking, but she had continued to check Resident #139's blood sugar and gave her carbohydrates to eat throughout her shift. During a telephone interview on 12/29/14 at 11:51 AM Nurse #4 indicated she was responsible for the care of Resident #139 on 12/12/14 from 7AM until 3PM. She stated during the change of shift report at 7AM she was informed by Nurse #2 of Resident #139's fluctuating blood sugars throughout the night. Nurse #4 indicated after she received report, she and the UM went to assess Resident #139. Nurse #4 stated she checked Resident #139's blood sugar and noted it to be 46. She further indicated the UM called the physician and the physician gave them the orders to start an IV, administer D50, and infuse fluids of D5 ? NS at 100 ml/hour. During a telephone interview on 12/29/14 at 1:47 PM Nurse #3 indicated she was responsible for the care of Resident #139 on 12/11/14 from 3PM until 11PM. She admitted she gave Resident #139 the wrong medication on 12/11/14 around 9PM. She indicated she gave the resident [MEDICATION NAME]45 Units. She further indicated she did not use any of the resident identifiers nor did she ask the resident to state her name and/or her date of birth. She stated she told Resident #139 she was going to give her an insulin shot and the resident stated "I don't take insulin." Nurse #3 further stated she replied to Resident #139 that the insulin was ordered for her and she was supposed to have it. Nurse #3 stated she realized she had given the wrong medication when she went to back to the Medication Administration Record [REDACTED]. Nurse #3 indicated that she did not document that she had given Resident #139 the insulin and she only checked Resident #139's blood sugar 2 more times before her shift ended at 11PM. She further indicated she clocked out and left the facility without telling anyone that she had administered the long acting insulin, [MEDICATION NAME], to Resident #139. She stated she was unaware of what to do at the time she made the error. She further stated she did not talk with anyone about the medication error until the next morning when the DON called her at home and asked her about the insulin medication error. She reiterated that she did not call the physician to inform him of the medication error on 12/11/14. During an interview on 12/29/14 at 5:26 PM the physician indicated he was not the [MEDICATION NAME] physician at the time of the insulin medication error. He further indicated the physician that was contacted was no longer at the facility. He stated he was made aware of the error upon his arrival to the facility on [DATE]. He indicated he would have expected Nurse #3 to have called the physician as soon as she was aware that she had made a medication error. He stated he would have sent the resident to the hospital to be monitored due to the insulin being that of a long acting type and the large dosage amount which was administered to Resident #139. During an interview on 12/29/14 at 6:14 PM the DON stated he was not aware of the medication error until 12/12/14 at 8:15 AM. He indicated the UM told him of the medication error. He stated he expected the nurses to contact the physician anytime there was a change in a resident's condition. He further stated he would have expected Nurse #3 to have notified the physician when the insulin medication error was detected and he would have also expected Nurse #2 to have notified the physician when Resident #139's FSBS were low and fluctuating. The Administrator was informed of Immediate Jeopardy on 12/29/14 at 6:32 PM for Resident #139. A Credible Allegation of Compliance was accepted on 12/31/14 at 11:54 AM as follows: Credible Allegation of Compliance: Notification of Change 1. Residents identified to be affected: by the deficient practice. On 12/11/14, Resident #139 was administered long-acting insulin without a physician's order. The licensed nurses caring for the resident on second and third shifts on the evening of 12/11/14 failed to notify the supervisor and the physician per the facility's Diabetic Protocol of the medication error and low blood sugar level so that interventions could be put in place to provide for the resident's wellbeing. The facility identified the medication error on 12/12/14 and began an investigation into the causes of the deficient practice. The physician was notified on the morning of 12/12/14 and interventions were continued based on his direction. A Medication Variance Report was completed by the Unit Manager on 12/12/14. 2. Residents with the potential to be affected by the alleged deficient practice. Residents who have a significant change in condition related to a finger stick indicating a low blood sugar level have the potential to be affected by the alleged deficient practice. On December 29, 2014, the Director of Nursing began a detailed review of actions taken for the affected residents and audited the corresponding documentation in the medical records of these residents to insure that interventions were implemented, and nurses communicated to the physician based on the facility's Diabetic Protocol for the past 30 days. The Division Director of Clinical Services and the Director of Nursing have conducted training with licensed nurses beginning December 29, 2014 regarding notification to the physician or physician extender of changes in condition, such as symptoms of [DIAGNOSES REDACTED] which may include diaphoresis, confusion, hunger, shakiness, or blurry vision. Licensed Nurses were also educated on actively listening to residents' when they inform them of potential errors in medication administration. Licensed nursing staff will not be allowed to work until the training is completed. Licensed nursing staff will be provided this education at least annually via the Director of Nursing or Area Staff Development Manager. This education will be included in the facility's new hire orientation and newly hired licensed nursing staff will not be permitted to assume their floor responsibilities until they have completed this education. The Director of Nursing or Unit Manager will review the 24-hr Report, daily Monday through Friday, to identify changes in condition and that appropriate notification of physician and interested parties has been completed. On weekends, the RN on duty will review the 24-hour Report to identify changes in condition and notification of physician and interested parties has been completed. 3. Systemic Measures The Interdisciplinary Team (including the Director of Nursing, Administrator, Unit Manager, Unit Coordinator, Social Services Director, Activities Director, Therapy Program Manager, Dietary Manager, and Resident Care Management Director) will review on a daily basis, Monday through Friday, those residents who have exhibited acute changes in condition to assure that assessments or observations of symptoms are documented, interventions were initiated, and the attending physician was contacted as appropriate by reviewing the 24 hour reports and telephone orders. Immediate Jeopardy was removed on 12/31/14 at 11:54 AM when interviews with nurses revealed awareness of the prevention of medication errors by using the Rights of Administration which include Right Resident, Right Dose, Right Time, Right Drug, and Right Route. They verified they had received in-service training and were made aware of the importance of the notification of the physician, family, nursing supervisor, and DON, which included actively listening to the residents when they inform them of a potential error in medication administration, and the reporting process for medication variances to include a mediation variance report. The nurses further indicated the in-service training included observations of administering medications to residents in the facility, and included examples and potential factors for medication errors, such as, distraction, knowledge deficits, and what should be done if a resident questions the medications for which they are to be given.

Based on record reviews, staff, and physician interviews, the facility neglected to document a significant medication error, neglected to initiate the low blood sugar protocol, and neglected to inform another nurse, supervisor, or physician that a resident had received long acting insulin in error for 1 of 2 sampled residents (Resident #139). The facilty also failed to remove a bedpan from under a resident for 1 of 2 sampled residents (Resident #133). Immediate Jeopardy began on 12/11/14 when Resident #139 received a long acting insulin with no physician's order and the nurse failed to initiate the blood sugar monitoring protocol, and treatment, and clocked out and left the facility without informing another nurse, supervisor, Director of Nursing, or the physician of Resident #139's condition. Immediate Jeopardy was removed on 12/31/14 at 11:54 AM when the facility provided an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of G (actual harm that is not immediate jeopardy) to ensure monitoring systems are in place and the completion of employee education, and for example number two. The findings included: Review of the facility's undated document titled "Diabetic Protocol" read in part: C. Insulin is to be given as per (physician) MD's orders. D. FSBS - if lower than 80, notify MD, hold insulin until MD gives specific orders. Inform MD of any nursing interventions, such as giving sugar & orange juice. Note what the resident has eaten and general condition of the resident. E1. If resident is alert and FSBS is low give Oral Glucose Gel 15 Gm (grams), give per manufacturer's directions. E2. If consciousness is diminished or impaired in a diabetic whose FSBS is low, an IV (intravenous) of D5-1/2 NS ([MEDICATION NAME] 5% and ? Normal Saline) at 100 ml (milliliters) per hour is to be started and 1 amp ([MEDICATION NAME]) of D50 ([MEDICATION NAME] 50) is to be pushed while trying to contact the attending MD. If unable to start an IV with 1st stick, give [MEDICATION NAME] 1 mg (milligrams) IM (intramuscular). Then continue to place IV. Recheck FSBS in 15 minutes after pushing D50. Continue IV until otherwise ordered by MD, but D/C (discontinue) in 24 hours if FSBS is staying greater than 125. Resident #139 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 5 day admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #139 was cognitively intact and was capable of daily decision making. A review of the physician's orders dated 12/11/14 indicated [MEDICATION NAME] 500 milligrams (mg) one tablet by mouth three times a day for [MEDICATION NAME] related to complications of type 2 diabetes. Further review of the physician's orders indicated finger stick blood sugars (FSBS) twice daily (6:30 AM and 9:00 PM) related to diabetes. Further review revealed there was no physician's order for [MEDICATION NAME] indicated for Resident #139. ([MEDICATION NAME] is a long acting insulin which starts to work in 1 to 3 hours, with a peak in 8 to 10 hours, and lasts for 18 to 26 hours). A review of the Medication Administration Record [REDACTED]. Additional review of the MAR indicated [REDACTED]. The [MEDICATION NAME] was held on 12/12/14 due to Resident #139's low FSBS and was re-started on 12/13/14 at 9:00 AM. Further review of the MAR indicated [REDACTED]. A review of the nurse's notes dated 12/11/14 through 12/12/14 revealed the following entries: ? 12/11/14 at 11:38 PM---Nurse #3, working the 3PM until 11PM shift, documented Resident #139 was resting comfortably and medications were tolerated with no adverse effect noted. There was no documentation in Nurse #3's notes or on the Medication Administration Record [REDACTED]. Further review of the MAR indicated [REDACTED]. ? 12/12/14 at 12:31 AM-Nurse #2, working the 11PM to 7AM shift, documented that Resident #139's FSBS was 48 and that the resident was given 8 ounces (oz.) of orange juice and peanut butter crackers. Nurse #2 documented a re-check FSBS 15 minutes later of 76 at which time she gave Resident #139 an 8 oz. cup of med pass (a fortified nutritional shake) with another re-check FSBS 30 minutes later of 88. ? 12/12/14 at 1:45 AM---Nurse #2 documented a re-check FSBS of 51 and Resident #139 was sleepy but alert and oriented to person, place, and time. Nurse #2 documented that she had administered 15 grams of glucose gel by mouth to Resident #139 and gave her milk and a tangerine, at which time Resident #139 consumed the entire carton of milk and ate half of the tangerine. Nurse #2 documented a re-check FSBS 20 minutes later of 88 and again provided Resident #139 with milk, another pack of crackers, and a container of yogurt. There was no documentation in Nurse #2's notes that the physician had been notified of the fluctuation in Resident #139's low FSBS throughout her shift. ? 12/12/14 at 7:30 AM---The Unit Manager (UM) documented that she notified the physician of Resident #139's low blood sugars and that the low blood sugar protocol was being followed. The UM documented that the physician had advised her to continue the protocol and monitor Resident #139's urine output for next 24 hours. ? 12/12/14 at 8:00 AM---Nurse #4, working the 7AM to 3PM shift, documented a FSBS of 47 and that Resident #139 was alert with confusion. Nurse #4 documented an IV (intravenous) was started and [MEDICATION NAME] 50 (D50) was pushed via the IV and a bag of fluid which contained [MEDICATION NAME] 5% (D5) & ? normal saline (NS) was hung for infusion and was set to run at 100 milliliters (ml) per hour. Nurse #4 documented a re-check FSBS 15 minutes after giving the D50 of 427. A review of a Medication Variance Report written by the UM dated 12/12/14 at 7:30 AM indicated Nurse #3 had administered the wrong medication to the wrong resident. The report noted the medication administered was [MEDICATION NAME]of 45 Units one time by SQ (subcutaneous) to Resident #139. The report indicated "error/harm: an error occurred that may have contributed to or resulted in temporary resident harm and required intervention." The variance report revealed the Physician was contacted on 12/12/14 at 7:30 AM and orders were received and the Director of Nursing (DON), the Pharmacy, the Family, and the Administrator were contacted on 12/12/14 at 8:15 AM. The report further indicated the findings/actions taken: Nurse #3 was suspended, was re-educated, and required medication administration observations. The report was signed by the DON and the Administrator on 12/12/14. During an interview on 12/29/14 at 10:45 AM the UM verified she had completed the medication variance report. She stated on the morning of 12/12/14 at 7:15 AM she overheard the 3rd shift nurse, Nurse #2, and the 1st shift nurse, Nurse #4, discussing the fluctuation of Resident #139's FSBS. She indicated at that time she went to check on the resident and Resident #139 informed her of the injection of insulin the 2nd shift nurse had administered. The UM further indicated that during the course of her investigation she "figured out" that Resident #139 was given Resident #134's insulin; Resident #134 was across the hall from Resident #139. She stated she immediately advised the DON of the error and called the physician. During a telephone interview on 12/29/14 at 11:36 AM Nurse #2 indicated she was responsible for the care of Resident #139 on 12/11/14 at 11PM until 12/12/14 at 7AM. She stated during the change of shift report at 11PM, she was not made aware of any concerns and/or problems with Resident #139. She further stated she always checked on her residents at the beginning of her shift and during her initial check that night of Resident #139, when she opened the resident's door, Resident #139 called out to her for assistance to the bathroom. At which time, Nurse #2 stated Resident #139 indicated to her that she was "feeling funny and weird" and advised her that she had been given a shot of insulin. Nurse #2 stated she checked Resident #139's blood sugar and noted it was in the 40's. She further stated she gave Resident #139 carbohydrates to eat and when she re-checked Resident #139's blood sugar it had come up into the 80's. She indicated she did not call the physician during the night because the resident was alert and talking, but she had continued to check Resident #139's blood sugar and gave her carbohydrates to eat throughout her shift. During a telephone interview on 12/29/14 at 11:51 AM Nurse #4 indicated she was responsible for the care of Resident #139 on 12/12/14 from 7AM until 3PM. She stated during the change of shift report at 7AM she was informed by Nurse #2 of Resident #139's fluctuating blood sugars throughout the night. Nurse #4 indicated after she received report, she and the UM went to assess Resident #139. Nurse #4 stated she checked Resident #139's blood sugar and noted it to be 46. She further indicated the UM called the physician and the physician gave them the orders to start an IV, administer D50, and infuse fluids of D5 ? NS at 100 ml/hour. During a telephone interview on 12/29/14 at 1:47 PM Nurse #3 indicated she was responsible for the care of Resident #139 on 12/11/14 from 3PM until 11PM. She admitted she gave Resident #139 the wrong medication on 12/11/14 around 9PM. She indicated she gave the resident [MEDICATION NAME]45 Units. She further indicated she did not use any of the resident identifiers nor did she ask the resident to state her name and/or her date of birth. She stated she told Resident #139 she was going to give her an insulin shot and the resident stated "I don't take insulin." Nurse #3 further stated she replied to Resident #139 that the insulin was ordered for her and she was supposed to have it. Nurse #3 stated she realized she had given the wrong medication when she went to back to the Medication Administration Record [REDACTED]. Nurse #3 indicated that she did not document that she had given Resident #139 the insulin and she only checked Resident #139's blood sugar 2 more times before her shift ended at 11PM. She further indicated she clocked out and left the facility without telling anyone that she had administered the long acting insulin, [MEDICATION NAME] to Resident #139. She stated she was unaware of what to do at the time she made the error. She further stated she did not talk with anyone about the medication error until the next morning when the DON called her at home and asked her about the insulin medication error. She reiterated that she did not call the physician to inform him of the medication error or of Resident #139's condition prior to her clocking out and leaving the facility. She indicated on 12/15/14 she had to take a class titled "Medication Management" and was observed on 12/15/14 by the Area Staff Development Coordinator administer medications to the residents during her shift. She further indicated she was observed 2 other times to administer medications, on 12/16/14 and on 12/18/14. During an interview on 12/29/14 at 6:14 PM the DON stated he was not aware of the medication error until 12/12/14 at 8:15 AM. He indicated the UM told him of the medication error. He stated he expected the nursing staff to use at least two resident identifiers before administering any medications and he expected the nurses to contact the physician anytime there was a change in a resident's condition. He indicated he would have expected Nurse #3 and/or any of his nursing staff to have contacted him, their supervisor or the nurse on call with any questions, concerns, doubt, or any medication errors. He further indicated he expected all of the nursing staff to give a report of their resident's to another nurse before they leave the hall and especially before clocking out and leaving the facility. The Administrator was informed of Immediate Jeopardy on 12/29/14 at 6:32 PM for Resident #139. A Credible Allegation of Compliance was accepted on 12/31/14 at 11:54 AM as follows: Credible Allegation of Compliance: Staff treatment of [REDACTED]. 1. Residents identified to be affected by the deficient practice. On 12/11/14, Resident #139 was administered long-acting insulin without a physician's order. The licensed nurse failed to follow the resident identification procedures of validating the resident's identity via name or confirming the resident's identity with another nurse prior to the administration of medication. The licensed nurse also failed to acknowledge the resident's advising that she (the resident) was not on insulin. In addition, the nurse left the facility at the end of the shift without reporting the error to the Nursing Supervisor or oncoming nurse. The facility identified the medication error on 12/12/14 and began an investigation into the causes of the deficient practice. The licensed nurse was suspended on 12/12/14 pending the outcome of the investigation. One to one education regarding medication administration practices and prevention of medication errors was completed on 12/15/14 for the licensed nurse by the Area Staff Development Manager. 2. Residents with the potential to be affected by the deficient practice. Residents who require the administration of medications have the potential to be affected by the deficient practice. The Director of Nursing will complete an audit of all current residents' Medication Administration Records for the last 30 days to review for significant medication errors to be completed by 12/30/14. 3. Systemic Measures The Director of Nursing, Administrator, and Unit Managers will review on a daily basis, Monday through Friday, the 24-hour Report and Medication Variance Reports, and conduct investigations to identify that physician notification has occurred and interventions have been put in place to provide for the resident's well-being and their needs are not neglected. On weekends, the RN on duty will review the 24-hour Report and any medication variance reports to ensure physician notification has occurred and interventions have been put in place so that residents' needs are identified and provided for. The Division Director of Clinical Services and the Director of Nursing have conducted training with licensed nurses beginning December 29, 2014 regarding Abuse & Neglect Prohibition and the requirement to report medication errors to the physician and Director of Nursing or Supervisor to ensure that residents' needs are being met and not neglected, and interventions are put in place to address the error. This education included the definition of Neglect and examples were discussed. Licensed nursing staff will not be allowed to work until the training is completed. Licensed nursing staff will be provided this education at least annually via the Director of Nursing or Area Staff Development Manager. This education will be included in the facility's new hire orientation and newly hired licensed nursing staff will not be permitted to assume their floor responsibilities until they have completed this education. Beginning 12/30/14, the Director of Nursing or Social Services Director will conduct interviews with interview able residents at least three(3) times per week for four weeks, then three times per month thereafter to identify allegations of neglect related to medication administration. Investigations will be conducted, if necessary, based on interview information. Immediate Jeopardy was removed on 12/31/14 at 11:54 AM when interviews with nurses revealed awareness of the prevention of medication errors by using the Rights of Administration which include Right Resident, Right Dose, Right Time, Right Drug, and Right Route. They verified they had received in-service training and were made aware of the reporting process for medication variances to include a mediation variance report, notification of the physician, family, nursing supervisor, and DON. The nurses further indicated the in-service training included the definition of neglect and to ensure that residents' needs have been met and not neglected before leaving the facility, as well as observations of administering medications to residents in the facility, and included examples and potential factors for medication errors, such as, distraction, knowledge deficits, and what should be done if a resident questions the medications for which they are to be given. 2. Resident #133 was admitted to the facility 11/06/14 with [DIAGNOSES REDACTED]. An admission Minimum Data Set ((MDS) dated [DATE] described Resident #133's speech was clear, made herself understood, and was able to understand others. The MDS specified cognition was intact and the resident required extensive assistance of 2 staff for bed mobility, personal hygiene, and toileting. The MDS indicated the resident had an indwelling urinary catheter and was occasionally incontinent of bowel. A Care Area Assessment (CAA) specified the resident required extensive assistance with all activities of daily living and was able to make her needs known. A care plan dated 11/18/14 described Resident #133 with a self-care performance deficit for activities of daily living related to terminal illness. The care plan goal specified the resident would maintain the current level of function through the next 90 day review. Interventions included the resident required extensive assistance of 2 staff members to turn and reposition in bed on care rounds and as necessary and the resident was totally dependent on 2 staff members for toilet use. On 12/29/14 at 1:51 PM, Resident #133 was observed during a dressing change to a pressure ulcer on her sacral area. The resident was observed lying on an air mattress. When the resident was rolled to her left side, a bruise was noted from the top of the right thigh and ascending over the right buttock. Just above the sacral area, the bruise curved and extended across the resident's lower back. The bruise curved again and descended down the left buttock to the top of the left thigh. The bruise was in the shape of a thin line in width and dark red to light red in color. The bruise had the appearance and shape of the edge of a bedpan. The bruise was observed with no skin breakdown. An interview was conducted with the resident's Responsible Party (RP) on 12/29/14 at 2:49 PM. The RP stated she left the resident on 12/26/14 around 4:30 PM and the resident's buttocks showed no signs of bruising. She stated she returned to the facility on [DATE] around 11:30 AM and the resident was complaining that it hurt her to use the bedpan. The RP stated she noted bruising on the resident's buttocks when she was informed by a nurse aide the resident had been left on the bedpan through the night. The RP stated the resident had used her call light when she needed something. The RP explained the resident was declining due to her terminal illness. At times the resident used her call light if she needed care. At other times she yelled out. An interview was conducted with the Director of Nursing (DON) on 12/30/14 at 3:30 PM. The DON stated she had received a report on the morning of 12/27/14 between 5:30 AM and 6:00 AM that the night nurse found a bedpan under Resident #133. The DON added the facility was investigating this incident as neglect. She explained Resident #133 was assessed on the morning of 12/27/14 for other bruises or injuries and none were found. An interview was conducted via phone with Nurse #1 on 12/31/14 at 9:41 AM. Nurse #1 stated she worked the 11PM to 7AM shift on the evening of 12/26/14. She stated as she started her medication pass about 5:30 AM to 5:45 AM, she heard Resident #133 calling out for help. When asked, Resident #133 stated her backside was burning. Nurse #1 explained she solicited Nurse Aide (NA) #3 to assist with repositioning the resident. As they rolled the resident to her side, a bedpan was found under her. Nurse #1 stated Resident #133 had an indention where the bedpan had touched her skin. Nurse #1 explained she and NA #3 cleaned the resident and applied a moisture barrier cream to her backside. Nurse #1 stated she reported the incident to her relief nurse. An interview was conducted with NA #1 via phone on 12/31/14 at 10:09 AM. NA #1 stated she and NA #2 had worked the 3PM to 11PM shift on 12/26/14. She stated they were assigned to the end of the hall where Resident #133 resided. NA #1 stated she and NA #2 were extremely busy answering call lights and attending to residents' needs. NA #1 explained about 10:15 PM to 10:20 PM, Resident #133 turned on her call light. NA #1 responded to the light and the resident asked to be put on the bedpan. NA #1 described Resident #133 used her call light several times during the evening and NA #1 was waiting for the resident to let her know when she was ready to get off the bedpan. NA #1 stated she got very busy and did not go back to see about Resident #133. She stated since she had not heard Resident #133's call light, she assumed NA #2 had taken her off the bedpan. NA #1 stated she should have gone back to check on the resident, but she did not. NA #1 further explained before she left the facility that evening, she did not give a report to the relieving nurse aide. An interview was conducted with NA #3 via phone on 12/31/14 at 10:43 AM. NA #3 stated she had worked the 11PM to 7AM shift on the evening of 12/26/14. She stated she did not get a report from any of the nurse aides she was relieving. NA #3 stated she walked down the hall and looked into each resident's room. When she got to Resident #133's room, she saw the resident moving in bed so she walked in and asked the resident if she needed anything. NA #3 stated the resident asked for some water which she provided and then left the room. NA #3 stated she went into Resident #133's room around 2:00 AM and emptied the resident's urinary catheter bag. She asked Resident #133 if she was alright and the resident replied she was. NA #3 stated about 5:00 AM to 5:15 AM she went into Resident #133's room. The resident complained of her backside hurting. NA #3 explained Nurse #1 was nearby administering medications and came to help her. When they turned Resident #133 over, they found a bedpan under the resident. NA #3 stated Resident #133 had been using the call light until a couple of weeks ago. NA #3 stated the resident started yelling out when she needed something. NA #3 acknowledged she was unaware Resident #133 was on the bedpan. An additional interview was conducted with the DON on 12/31/14 at 12:03 PM. The DON explained she expected residents in this facility to receive the care they need and as they need it. An interview was conducted with NA #2 via phone on 12/31/14 at 12:21 PM. NA #2 stated she worked the 3PM to 11PM shift on 12/26/14 and was assigned to Resident #133's end of the hall. She stated she assisted Resident #133 with the bedpan right after supper. NA #2 stated she did not assist Resident #133 with the bedpan anymore that evening.

Based on record reviews, staff, and physician interviews the facility failed to assess, monitor closely, and consult with the physician for the continuum of care for a resident after the administration of a long acting insulin with no physician's order for 1 of 4 sampled residents (Resident #139). Immediate Jeopardy began on 12/11/14 when Resident #139 received a long acting insulin with no physician's order and the nurse failed to initiate the blood sugar monitoring protocol, and treatment, and clocked out and left the facility without informing another nurse, supervisor, Director of Nursing, or the physician of Resident #139's condition. Immediate Jeopardy was removed on 12/31/14 at 11:54 AM when the facility provided an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems are in place and the completion of employee education. The findings included: Review of the facility's undated document titled "Diabetic Protocol" read in part: C. Insulin is to be given as per (physician) MD's orders. D. FSBS - if lower than 80, notify MD, hold insulin until MD gives specific orders. Inform MD of any nursing interventions, such as giving sugar & orange juice. Note what the resident has eaten and general condition of the resident. E1. If resident is alert and FSBS is low give Oral Glucose Gel 15 Gm (grams), give per manufacturer's directions. E2. If consciousness is diminished or impaired in a diabetic whose FSBS is low, an IV (intravenous) of D5-1/2 NS ([MEDICATION NAME] 5% and ? Normal Saline) at 100 ml (milliliters) per hour is to be started and 1 amp ([MEDICATION NAME]) of D50 ([MEDICATION NAME] 50) is to be pushed while trying to contact the attending MD. If unable to start an IV with 1st stick, give [MEDICATION NAME] 1 mg (milligrams) IM (intramuscular). Then continue to place IV. Recheck FSBS in 15 minutes after pushing D50. Continue IV until otherwise ordered by MD, but D/C (discontinue) in 24 hours if FSBS is staying greater than 125. Resident #139 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 5 day admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #139 was cognitively intact and was capable of daily decision making. A review of the physician's orders dated 12/11/14 indicated [MEDICATION NAME] 500 milligrams (mg) one tablet by mouth three times a day for [MEDICATION NAME] related to complications of type 2 diabetes. Further review of the physician's orders indicated finger stick blood sugars (FSBS) twice daily (6:30 AM and 9:00 PM) related to diabetes. Further review revealed there was no physician's order for [MEDICATION NAME] indicated for Resident #139. ([MEDICATION NAME] is a long acting insulin which starts to work in 1 to 3 hours, with a peak in 8 to 10 hours, and lasts for 18 to 26 hours). A review of the nurse's notes dated 12/11/14 through 12/12/14 revealed the following entries: ? 12/11/14 at 11:38 PM---Nurse #3, working the 3PM until 11PM shift, did not document in her notes or on the Medication Administration Record [REDACTED]. ? 12/12/14 at 12:31 AM-Nurse #2, working the 11PM to 7AM shift, documented that Resident #139's FSBS was 48 and that the resident was given 8 ounces (oz.) of orange juice and peanut butter crackers. Nurse #2 documented a re-check FSBS 15 minutes later of 76 at which time she gave Resident #139 an 8 oz. cup of med pass (a fortified nutritional shake) with another re-check FSBS 30 minutes later of 88. ? 12/12/14 at 1:45 AM---Nurse #2 documented a re-check FSBS of 51 and that she gave Resident #139 milk and a tangerine, at which time Resident #139 consumed the entire carton of milk and ate half of the tangerine. Nurse #2 documented a re-check FSBS 20 minutes later of 88 and again provided Resident #139 with milk, another pack of crackers, and a container of yogurt. There was no documentation in Nurse #2's notes that the physician had been notified of the fluctuation in Resident #139's low FSBS throughout her shift. ? 12/12/14 at 7:30 AM---The Unit Manager (UM) documented that she notified the physician of Resident #139's low blood sugars and that the facility's protocol was being followed. The UM documented that the physician had advised her to continue the protocol and monitor Resident #139's urine output for next 24 hours. ? 12/12/14 at 8:00 AM---Nurse #4, working the 7AM to 3PM shift, documented a FSBS of 47 and that Resident #139 was alert and confused. Nurse #4 documented an IV (intravenous) was started and [MEDICATION NAME] 50 (D50) was pushed via the IV and a bag of fluid which contained [MEDICATION NAME] 5% (D5) & ? normal saline (NS) was hung for infusion and was set to run at 100 milliliters (ml) per hour. Nurse #4 documented a re-check FSBS 15 minutes after giving the D50 of 427. A review of a Medication Variance Report written by the UM dated 12/12/14 at 7:30 AM indicated Nurse #3 had administered the wrong medication to the wrong resident. The report noted the medication administered was [MEDICATION NAME]45 Units one time by SQ (subcutaneous) to Resident #139. The report indicated "error/harm: an error occurred that may have contributed to or resulted in temporary resident harm and required intervention." The variance report revealed the Physician was contacted on 12/12/14 at 7:30 AM and orders were received and the Director of Nursing (DON), the Pharmacy, the Family, and the Administrator were contacted on 12/12/14 at 8:15 AM. The report further indicated the findings/actions taken: Nurse #3 was suspended, was re-educated, and required medication administration observations. The report was signed by the DON and the Administrator on 12/12/14. During an interview on 12/29/14 at 10:45 AM the UM verified she had completed the medication variance report. She stated on the morning of 12/12/14 at 7:15 AM she overheard the 3rd shift nurse, Nurse #2, and the 1st shift nurse, Nurse #4, discussing the fluctuation of Resident #139's FSBS. She indicated at that time she went to check on the resident and Resident #139 informed her of the injection of insulin the 2nd shift nurse had administered. The UM further indicated that during the course of her investigation she "figured out" that Resident #139 was given Resident #134's insulin; Resident #134 was across the hall from Resident #139. She stated she immediately advised the DON of the error and called the physician. During a telephone interview on 12/29/14 at 11:36 AM Nurse #2 indicated she was responsible for the care of Resident #139 on 12/11/14 at 11PM until 12/12/14 at 7AM. She stated during the change of shift report at 11:00 PM, she was not made aware of any concerns and/or problems with Resident #139. She further stated she always checked on her residents at the beginning of her shift and during her initial check that night of Resident #139, when she opened the resident's door, Resident #139 called out to her for assistance to the bathroom. At which time, Nurse #2 stated Resident #139 indicated to her that she was "feeling funny and weird" and advised her that she had been given a shot of insulin. Nurse #2 stated she checked Resident #139's blood sugar and noted it was in the 40's. She further stated she gave Resident #139 carbohydrates to eat and when she re-checked Resident #139's blood sugar it had come up into the 80's. She indicated she did not call the physician during the night because the resident was alert and talking but that she had continued to check Resident #139's blood sugar and gave her carbohydrates to eat throughout her shift. During a telephone interview on 12/29/14 at 11:51 AM Nurse #4 indicated she was responsible for the care of Resident #139 on 12/12/14 from 7AM until 3PM. She stated during the change of shift report at 7AM she was informed by Nurse #2 of Resident #139's fluctuating blood sugars throughout the night. Nurse #4 indicated after she received report, she and the UM went to assess Resident #139. Nurse #4 stated she checked Resident #139's blood sugar and noted it to be 46. She further indicated the UM called the physician and the physician gave them the orders to start an IV, administer D50, and infuse fluids of D5 ? NS at 100 ml/hour. During a telephone interview on 12/29/14 at 1:47 PM Nurse #3 indicated she was responsible for the care of Resident #139 on 12/11/14 from 3PM until 11PM. She admitted she gave Resident #139 the wrong medication on 12/11/14 around 9PM. She indicated she gave the resident [MEDICATION NAME]45 Units. She further indicated she did not use any of the resident identifiers nor did she ask the resident to state her name and/or her date of birth. She stated she told Resident #139 she was going to give her an insulin shot and the resident stated "I don't take insulin." Nurse #3 further stated she replied to Resident #139 that the insulin was ordered for her and she was supposed to have it. Nurse #3 stated she realized she had given the wrong medication when she went to back to the Medication Administration Record [REDACTED]. Nurse #3 indicated that she did not document that she had given Resident #139 the insulin and she only checked Resident #139's blood sugar 2 more times before her shift ended at 11PM. She further indicated she clocked out and left the facility without telling anyone that she had administered the long acting insulin, [MEDICATION NAME], to Resident #139. She stated she was unaware of what to do at the time she made the error. She further stated she did not talk with anyone about the medication error until the next morning when the DON called her at home and asked her about the insulin medication error. During an interview on 12/29/14 at 5:26 PM the physician indicated he was not the [MEDICATION NAME] physician at the time of the insulin medication error. He further indicated the physician that was contacted was no longer at the facility. He stated he was made aware of the error upon his arrival to the facility on [DATE]. He indicated he would have expected Nurse #3 to have called the physician as soon as she was aware that she had made a medication error. He stated he would have sent the resident to the hospital to be monitored due to the insulin being that of a long acting type and the large dosage amount the was administered to Resident #139. During an interview on 12/29/14 at 6:14 PM the DON stated he was not aware of the medication error until 12/12/14 at 8:15 AM. He indicated the UM told him of the medication error. He stated he expected the nursing staff to use at least two resident identifiers before administering any medications. He further stated he would have expected Nurse #3 to have notified the physician when the insulin medication error was detected and to have not left the facility without informing her supervisor and/or another nurse. He indicated he would have expected Nurse #2 to have also contacted the physician of Resident #139's low and fluctuating FSBS. He stated he would have always expected all of his nursing staff to have contacted him, their supervisor or the nurse on call, and/or the physician with any medication errors and/or concerns that would involve the well-being of a resident. The Administrator was informed of Immediate Jeopardy on 12/29/14 at 6:32 PM for Resident #139. A Credible Allegation of Compliance was accepted on 12/31/14 at 11:54 AM as follows: Credible Allegation of Compliance: Quality of Care 1. Residents identified to be affected by the deficient practice. On 12/11/14, Resident #139 was administered long-acting insulin without a physician's order. The licensed nurses caring for the resident on second and third shifts on the evening of 12/11/14 failed to notify the supervisor and the physician per the facility's Diabetic Protocol of the medication error and low blood sugar level so that interventions could be put in place to provide for the resident's wellbeing. The facility identified the medication error on 12/12/14 and began an investigation into the causes of the deficient practice. The physician was notified on the morning of 12/12/14 and interventions were continued based on his direction. A Medication Variance Report was completed by the Unit Manager on 12/12/14. One to one counseling with the nurses regarding the requirement for notification of the physician and supervisor in the event of a medication error, as well as implementing interventions to maintain the resident's wellbeing was conducted by the Director of Nursing on 12/12/14. 2. Residents with the potential to be affected by the deficient practice. Residents who exhibit acute changes in condition related to finger sticks indicating low blood sugar levels requiring intervention have the potential to be affected by the alleged deficient practice. The Director of Nursing has identified current residents who have had an acute change in condition related to low blood sugar levels in the last 30 days and reviewed their corresponding documentation to a determine that a nursing assessment has been documented and interventions were implemented in a timely fashion. Plans of care will continue to be reviewed by the Interdisciplinary Team quarterly, annually and with significant change of condition. 3. Systemic Measures The Interdisciplinary Team (including the Director of Nursing, Administrator, Social Services Director, Activities Director, Therapy Program Manager, Dietary Manager, Unit Coordinator or Unit Manager, and Resident Care Management Director) will review on a daily basis, Monday through Friday, those residents who have exhibited acute changes in condition to assure that assessments or observations of symptoms have been documented, interventions were initiated timely, and the attending physician was contacted as appropriate. On weekends, the RN on Duty will perform the review of the 24-hour Report to identify residents who have experienced acute changes in condition and ensure assessment or observations have been documented, interventions initiated timely, and the attending physician has been contacted as appropriate. Adjustments to the plan of care and Care Grids will be made based on these reviews and the input of medical professionals. The Division Director of Clinical Services and the Director of Nursing have conducted training with licensed nurses beginning December 29, 2014 regarding the identification of changes in condition, use of Change of Condition tools as guidelines for assessment/evaluation components, and the expectation of timely intervention and physician involvement for identified acute changes in resident condition. Licensed nursing staff will not be allowed to work until the training is completed. Licensed nursing staff will be provided this education at least annually via the Director of Nursing or Resident Care Management Director. This education will be included in the facility's new hire orientation and newly hired licensed nursing staff will not be permitted to assume their floor responsibilities until they have completed this education. Immediate Jeopardy was removed on 12/31/14 at 11:54 AM when interviews with nurses revealed awareness of the prevention of medication errors by using the Rights of Administration which include Right Resident, Right Dose, Right Time, Right Drug, and Right Route. They verified they had received in-service training and were made aware of the importance of the notification of the physician, family, nursing supervisor, and DON, which included actively listening to the residents when they inform them of a potential error in medication administration, and the reporting process for medication variances to include a mediation variance report. The nurses further indicated the in-service training included the definition of neglect and to ensure the residents' needs and well-being have been met and not neglected before leaving the facility, as well as observations of administering medications to residents in the facility, and included examples and potential factors for medication errors, such as, distraction, knowledge deficits, and what should be done if a resident questions the medications for which they are to be given.

Based on record reviews and staff interviews the facility failed to prevent a significant medication error by administering a long acting insulin with no physician's order for 1 of 2 residents reviewed for medication errors (Resident #139). Immediate Jeopardy began on 12/11/14 when Resident #139 received a long acting insulin with no physician's order. Immediate Jeopardy was removed on 12/31/14 at 11:54 AM when the facility provided an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems are in place and the completion of employee education. The findings included: Resident #139 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 5 day admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #139 was cognitively intact and was capable of daily decision making. A review of the physician's orders dated 12/11/14 indicated [MEDICATION NAME] 500 milligrams (mg) one tablet by mouth three times a day for [MEDICATION NAME] related to complications of type 2 diabetes. Further review of the physician's orders indicated finger stick blood sugars (FSBS) twice daily (6:30 AM and 9:00 PM) related to diabetes. Further review revealed there was no physician's order for [MEDICATION NAME] indicated for Resident #139. ([MEDICATION NAME] is a long acting insulin which starts to work in 1 to 3 hours, with a peak in 8 to 10 hours, and lasts for 18 to 26 hours). A review of the Medication Administration Record [REDACTED]. Additional review of the MAR indicated [REDACTED]. The [MEDICATION NAME] was held on 12/12/14 due to Resident #139's low FSBS and was re-started on 12/13/14 at 9:00 AM. Further review of the MAR indicated [REDACTED]. A review of the nurse's notes dated 12/11/14 through 12/12/14 revealed the following entries: ? 12/11/14 at 11:38 PM---Nurse #3, working the 3PM until 11PM shift, documented that Resident #139 was resting comfortably and medications were tolerated with no adverse effect noted. There was no documentation in Nurse #3's notes or on the Medication Administration Record [REDACTED]. Further review of the MAR indicated [REDACTED]. ? 12/12/14 at 12:31 AM-Nurse #2, working the 11PM to 7AM shift, documented that Resident #139's FSBS was 48 and that the resident was given 8 ounces (oz.) of orange juice and peanut butter crackers. Nurse #2 documented a re-check FSBS 15 minutes later of 76 at which time she gave Resident #139 an 8 oz. cup of med pass (a fortified nutritional shake) with another re-check FSBS 30 minutes later of 88. ? 12/12/14 at 1:45 AM---Nurse #2 documented a re-check FSBS of 51 and Resident #139 was sleepy but alert and oriented to person, place, and time. Nurse #2 documented that she had administered 15 grams of glucose gel by mouth to Resident #139 and gave her milk and a tangerine, at which time Resident #139 consumed the entire carton of milk and ate half of the tangerine. Nurse #2 documented a re-check FSBS 20 minutes later of 88 and again provided Resident #139 with milk, another pack of crackers, and a container of yogurt. ? 12/12/14 at 7:30 AM---The Unit Manager (UM) documented that she notified the physician of Resident #139's low blood sugars and that the low blood sugar protocol was being followed. The UM documented that the physician had advised her to continue the protocol and monitor Resident #139's urine output for next 24 hours. ? 12/12/14 at 8:00 AM---Nurse #4, working the 7AM to 3PM shift, documented a FSBS of 47 and that Resident #139 was alert with confusion. Nurse #4 documented an IV (intravenous) was started and [MEDICATION NAME] 50 (D50) was pushed via the IV and a bag of fluid which contained [MEDICATION NAME] 5% (D5) & ? normal saline (NS) was hung for infusion and was set to run at 100 milliliters (ml) per hour. Nurse #4 documented a re-check FSBS 15 minutes after giving the D50 of 427. A review of a Medication Variance Report written by the UM dated 12/12/14 at 7:30 AM indicated Nurse #3 had administered the wrong medication to the wrong resident. The report noted the medication administered was [MEDICATION NAME]of 45 Units one time by SQ (subcutaneous) to Resident #139. The report indicated "error/harm: an error occurred that may have contributed to or resulted in temporary resident harm and required intervention." The variance report revealed the Physician was contacted on 12/12/14 at 7:30 AM and orders were received and the Director of Nursing (DON), the Pharmacy, the Family, and the Administrator were contacted on 12/12/14 at 8:15 AM. The report further indicated the findings/actions taken: Nurse #3 was suspended, was re-educated, and required medication administration observations. The report was signed by the DON and the Administrator on 12/12/14. During an interview on 12/29/14 at 10:45 AM the UM verified she had completed the medication variance report. She stated on the morning of 12/12/14 at 7:15 AM she overheard the 3rd shift nurse, Nurse #2, and the 1st shift nurse, Nurse #4, discussing the fluctuation of Resident #139's FSBS. She indicated at that time she went to check on the resident and Resident #139 informed her of the injection of insulin the 2nd shift nurse had administered. The UM further indicated that during the course of her investigation she "figured out" that Resident #139 was given Resident #134's insulin; Resident #134 was across the hall from Resident #139. She stated she immediately advised the DON of the error and called the physician. During a telephone interview on 12/29/14 at 11:36 AM Nurse #2 indicated she was responsible for the care of Resident #139 on 12/11/14 at 11PM until 12/12/14 at 7AM. She stated during the change of shift report at 11PM, she was not made aware of any concerns and/or problems with Resident #139. She further stated she always checked on her residents at the beginning of her shift and during her initial check that night of Resident #139, when she opened the resident's door, Resident #139 called out to her for assistance to the bathroom. At which time, Nurse #2 stated Resident #139 indicated to her that she was "feeling funny and weird" and advised her that she had been given a shot of insulin. Nurse #2 stated she checked Resident #139's blood sugar and noted it was in the 40's. She further stated she gave Resident #139 carbohydrates to eat and when she re-checked Resident #139's blood sugar it had come up into the 80's. She indicated she did not call the physician during the night but continued to check Resident #139's blood sugar and gave her carbohydrates to eat throughout her shift. During a telephone interview on 12/29/14 at 11:51 AM Nurse #4 indicated she was responsible for the care of Resident #139 on 12/12/14 from 7AM until 3PM. She stated during the change of shift report at 7AM she was informed by Nurse #2 of Resident #139's fluctuating blood sugars throughout the night. Nurse #4 indicated after she received report, she and the UM went to assess Resident #139. Nurse #4 stated she checked Resident #139's blood sugar and noted it to be 46. She further indicated the UM called the physician and the physician gave them the orders to start an IV, administer D50, and infuse fluids of D5 ? NS at 100 ml/hour. During a telephone interview on 12/29/14 at 1:47 PM Nurse #3 indicated she was responsible for the care of Resident #139 on 12/11/14 from 3PM until 11PM. She admitted she gave Resident #139 the wrong medication on 12/11/14 around 9PM. She indicated she gave the resident [MEDICATION NAME]45 Units. She further indicated she did not use any of the resident identifiers nor did she ask the resident to state her name and/or her date of birth. She stated she told Resident #139 she was going to give her an insulin shot and the resident stated "I don ' t take insulin." Nurse #3 further stated she replied to Resident #139 that the insulin was ordered for her and she was supposed to have it. Nurse #3 stated she realized she had given the wrong medication when she went to back to the Medication Administration Record [REDACTED]. Nurse #3 indicated that she did not document that she had given Resident #139 the insulin and she only checked Resident #139's blood sugar 2 more times before her shift ended at 11PM. She further indicated she clocked out and left the facility without telling anyone that she had administered the long acting insulin, [MEDICATION NAME], to Resident #139. She stated she was unaware of what to do at the time she made the error. She further stated she did not talk with anyone about the medication error until the next morning when the DON called her at home and asked her about the insulin medication error. She indicated on 12/15/14 she had to take a class titled "Medication Management" and was observed on 12/15/14 by the Area Staff Development Coordinator administer medications to the residents during her shift. She further indicated she was observed 2 other times to administer medications; on 12/16/14 and on 12/18/14. During an interview on 12/29/14 at 6:14 PM the DON stated he was not aware of the medication error until 12/12/14 at 8:15 AM. He indicated the UM told him of the medication error. He stated he expected the nursing staff to use at least two resident identifiers before administering any medications. He further stated he would have expected Nurse #3 and/or any of his nursing staff to have contacted him, their supervisor or the nurse on call with any questions, concerns, doubt, or any medication errors. The Administrator was informed of Immediate Jeopardy on 12/29/14 at 6:32 PM for Resident #139. A Credible Allegation of Compliance was accepted on 12/31/14 at 11:54 AM as follows: Credible Allegation of Compliance: Significant Medication Error 1. Residents identified to be affected by the deficient practice. On 12/11/14, Resident #139 was administered long-acting insulin without a physician's order. The licensed nurse failed to follow the resident identification procedures of validating the resident's identity via name or confirming the resident's identity with another nurse prior to the administration of medication. The licensed nurse also failed to acknowledge the resident's advising that she (the resident) was not on insulin. The facility identified the medication error on 12/12/14 and began an investigation into the causes of the deficient practice. The licensed nurse was suspended on 12/12/14 pending the outcome of the investigation. One to one education regarding medication administration practices and prevention of medication errors was completed on 12/15/14 for the licensed nurse by the Area Staff Development Manager. A total of three medication pass observations were completed for this nurse; one by the Area Staff Development Manager on 12/15/14 and two by the second shift Supervisor on 12/16/14 and 12/18/14. 2. Residents with the potential to be affected by the deficient practice. Residents who require the administration of medications have the potential to be affected by the deficient practice. The Director of Nursing will complete an audit of all current residents' Medication Administration Records for the last 30 days to review for significant medication errors to be completed by 12/30/14. A Medication Variance Report and investigation will be completed for any identified errors and any affected resident will be evaluated by the physician for side effects. 3. Systemic Measures The Director of Nursing, Administrator, and Unit Managers will review on a daily basis, Monday through Friday, Medication Variance Reports and conduct investigations to identify corrective actions necessary. The Director of Nursing and Unit Managers will review the 24-hour Report to identify that nurses have monitored the resident. If Medication Variances occur on weekends, the nurse will report the variance to the Supervisor or Director of Nursing. The Division Director of Clinical Services and the Director of Nursing have conducted training with all scheduled licensed nurses beginning December 29, 2014 regarding prevention of medication errors by using the Rights of Administration which include Right Resident, Right Dose, Right Time, Right Drug, and Right Route. This education also included examples of errors and factors affecting the potential for medication errors, such as, systemic issues, distraction, poor habits, lack of medication knowledge, knowledge deficits, and performance deficits, and what to do if a resident questions the medications being given. This education included the reporting process for medication variances that includes completion of a Medication Variance Report, notification of the physician, Nursing Supervisor, if applicable, responsible party, and the Director of Nursing. Licensed nursing staff will not be allowed to work until the training is completed. Licensed nursing staff will be provided this education at least annually via the Director of Nursing or Area Staff Development Manager. This education will be included in the facility's new hire orientation and newly hired licensed nursing staff will not be permitted to assume their floor responsibilities until they have completed this education. Medication Pass Observations by the Director of Nursing, Unit Manager, Unit Coordinator, or Area Staff Development Manager will begin on 12/30/14 for at least three (3) licensed nurses per week until all nurses have been observed and then will be conducted randomly at least twice per month ongoing. Immediate Jeopardy was removed on 12/31/14 at 11:54 AM when interviews with nurses revealed awareness of the prevention of medication errors by using the Rights of Administration which include Right Resident, Right Dose, Right Time, Right Drug, and Right Route. They verified they had received in-service training and were made aware of the reporting process for medication variances to include a mediation variance report, notification of the physician, family, nursing supervisor, and DON. The nurses further indicated the in-service training included observations of administering medications to residents in the facility, and included examples and potential factors for medication errors, such as, distraction, knowledge deficits, and what should be done if a resident questions the medications for which they are to be given.

Based on observation, record review, and staff and family interviews, the facility failed to remove a bedpan from under a resident on the 3:00 PM to 11:00 PM shift for 1 of 4 residents reviewed for activities of daily living. (Resident #133). The findings included: Resident #133 was admitted to the facility 11/06/14 with [DIAGNOSES REDACTED]. An admission Minimum Data Set ((MDS) dated [DATE] described Resident #133's speech was clear, made herself understood, and was able to understand others. The MDS specified cognition was intact and the resident required extensive assistance of 2 staff for bed mobility, personal hygiene, and toileting. The MDS indicated the resident had an indwelling urinary catheter and was occasionally incontinent of bowel. A Care Area Assessment (CAA) specified the resident required extensive assistance with all activities of daily living and was able to make her needs known. A care plan dated 11/18/14 described Resident #133 with a self-care performance deficit for activities of daily living related to terminal illness. The care plan goal specified the resident would maintain the current level of function through the next 90 day review. Interventions included the resident required extensive assistance of 2 staff members to turn and reposition in bed on care rounds and as necessary and the resident was totally dependent on 2 staff members for toilet use. On 12/29/14 at 1:51 PM, Resident #133 was observed during a dressing change to a pressure ulcer on her sacral area. The resident was observed lying on an air mattress. When the resident was rolled to her left side, a bruise was noted from the top of the right thigh and ascending over the right buttock. Just above the sacral area, the bruise curved and extended across the resident's lower back. The bruise curved again and descended down the left buttock to the top of the left thigh. The bruise was in the shape of a thin line in width and dark red to light red in color. The bruise had the appearance and shape of the edge of a bedpan. The bruise was observed with no skin breakdown. An interview was conducted with the resident's Responsible Party (RP) on 12/29/14 at 2:49 PM. The RP stated she left the resident on 12/26/14 around 4:30 PM and the resident's buttocks showed no signs of bruising. She stated she returned to the facility on [DATE] around 11:30 AM and the resident was complaining that it hurt her to use the bedpan. The RP stated she noted bruising on the resident's buttocks when she was informed by a nurse aide the resident had been left on the bedpan through the night. The RP stated the resident had used her call light when she needed something. The RP explained the resident was declining due to her terminal illness. At times the resident used her call light if she needed care. At other times she yelled out. An interview was conducted with the Director of Nursing (DON) on 12/30/14 at 3:30 PM. The DON stated she had received a report on the morning of 12/27/14 between 5:30 AM and 6:00 AM that the night nurse found a bedpan under Resident #133. She explained Resident #133 was assessed on the morning of 12/27/14 for other bruises or injuries and none were found. An interview was conducted via phone with Nurse #1 on 12/31/14 at 9:41 AM. Nurse #1 stated she worked the 11PM to 7AM shift on the evening of 12/26/14. She stated as she started her medication pass about 5:30 AM to 5:45 AM, she heard Resident #133 calling out for help. When asked, Resident #133 stated her backside was burning. Nurse #1 explained she solicited Nurse Aide (NA) #3 to assist with repositioning the resident. As they rolled the resident to her side, a bedpan was found under her. Nurse #1 stated Resident #133 had an indention where the bedpan had touched her skin. Nurse #1 explained she and NA #3 cleaned the resident and applied a moisture barrier cream to her backside. An interview was conducted with NA #1 via phone on 12/31/14 at 10:09 AM. NA #1 stated she and NA #2 had worked the 3PM to 11PM shift on 12/26/14. She stated they were assigned to the end of the hall where Resident #133 resided. NA #1 stated she and NA #2 were extremely busy answering call lights and attending to residents' needs. NA #1 explained about 10:15 PM to 10:20 PM, Resident #133 turned on her call light. NA #1 responded to the light and the resident asked to be put on the bedpan. NA #1 described Resident #133 used her call light several times during the evening and NA #1 was waiting for the resident to let her know when she was ready to get off the bedpan. NA #1 stated she got very busy and did not go back to see about Resident #133. She stated since she had not heard Resident #133's call light, she assumed NA #2 had taken her off the bedpan. NA #1 stated she should have gone back to check on the resident, but she did not. NA #1 further explained before she left the facility that evening, she did not give a report to the relieving nurse aide. An interview was conducted with NA #3 via phone on 12/31/14 at 10:43 AM. NA #3 stated she had worked 11PM to 7AM shift on the evening of 12/26/14. She stated she did not get a report from any of the nurse aides she was relieving. NA #3 stated about 5:00 AM to 5:15 AM she went into Resident #133's room. The resident complained of her backside hurting. NA #3 explained Nurse #1 was nearby administering medications and came to help her. When they turned Resident #133 over, they found a bedpan under the resident. NA #3 stated Resident #133 had been using the call light until a couple of weeks ago. NA #3 stated the resident started yelling out when she needed something. NA #3 acknowledged she was unaware Resident #133 was on the bedpan. NA #3 stated she was unaware the resident had been on the bedpan throughout her shift. An additional interview was conducted with the DON on 12/31/14 at 12:03 PM. The DON explained she expected residents in this facility to receive the care they need and as they need it. An interview was conducted with NA #2 via phone on 12/31/14 at 12:21 PM. NA #2 stated she worked the 3PM to 11PM shift on 12/26/14 and was assigned to Resident #133's end of the hall. She stated she assisted Resident #133 with the bedpan right after supper. She acknowledged she shared the hall with NA #1 and did not answer Resident #133's call light later in the shift.

Based on observations, record review, and staff interviews, the facility failed to provide positioning in a wheelchair that allowed a resident's feet to touch in floor at a 90 degree angle for 1 of 2 residents reviewed for well being (Resident #101). The findings included: Resident #101 was readmitted to the facility 04/29/14 with [DIAGNOSES REDACTED]. An annual Minimum Data Set ((MDS) dated [DATE] indicated the resident's cognition was severely impaired, could be understood, and understands others. The MDS specified Resident #101 did not ambulate during the assessment period and required limited staff assistance of 2 people for transfers from surface to surface. An observation on 11/18/14 at 4:11 PM revealed Resident #101 was sitting in his wheelchair self propelling down the hall. He was observed self propelling by slowly turning the wheelchair wheels with his hands and pulling on the hand rails located on the side of the hallway. His toes were observed pointed downward and touching the floor. His heels were observed suspended above his toes and not touching the floor. No footrests were observed on the wheel chair. An observation on 11/19/14 at 7:26 AM revealed Resident #101 was sitting in his wheelchair self propelling out of his room. The resident self propelled by slowly rolling the wheelchair wheels with his hands. His toes were observed pointed downward and touching the floor. His heels were observed suspended off the floor. No footrests were observed on the wheelchair. An observation on 11/19/14 at 8:31 AM revealed Resident #101 was seated in his wheelchair at the breakfast table in the dining room. His toes were observed pointing downward and touching the floor. His heels were suspended above the floor. No footrests were observed on the wheelchair. Continued observations on 11/19/14 at 10:42 AM and 1:25 PM revealed Resident #101 was in the hallway sitting in his wheelchair. His toes were pointed downward and touching the floor. His heels were suspended above his toes and did not touch the floor. An interview with the Occupational Therapist (OT) on 11/19/14 at 1:28 PM revealed when positioned properly in a wheelchair, the resident's back, hips, knees, and ankles should be at 90 degree angles. During the interview, the OT observed Resident #101 sitting in his wheelchair with his heels not touching the floor. The OT confirmed Resident #101 was not seated with his ankles at 90 degree angles. When the resident was asked if he could self propel his wheelchair with his feet, he was unable to place his heels on the floor. The resident was observed moving his wheelchair by turning the chair wheels with his hands while his heels remained off the floor. An interview was conducted with Nursing Assistant (NA) #4 on 11/19/14 at 3:01 PM. NA #4 stated she had worked in the facility since the middle of September 2014. She added she had never seen Resident #101's feet fully touch the floor. NA #4 stated his toes touched the floor but his heels don't. An interview was conducted with the Director of Nursing (DON) on 11/20/14 at 8:42 AM. The DON stated Resident #101's feet should touch the floor at a 90 degree angle. He added he expected nurses to observe residents for problems with positioning. An interview with Unit Manager on 11/20/14 at 4:08 PM revealed she was unaware Resident #101's feet did not touch the floor at a 90 degree angle.