Every finding on record at Klondike Nursing and Rehabilitation Center

Based on observation, interview, record review, and facility policy review, the facility failed to ensure that one (Resident (R) 54) of two sampled residents who were reviewed for respiratory care were assessed for the ability to self-administer medications. Nursing staff left medication out for R54 to self- administer without an inter-disciplinary team first determining that the practice was clinically appropriate. The findings included: Review of the facility policy titled, Self-Administration of Medication Policy, effective 08/04/2024, revealed, Residents have the right to self-administer medication if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. 2. The IDT considers the following factors when determining whether self-administration of medication is safe and appropriate for the resident: a. The medication is appropriate for self-administration, b. The resident is able to read and understand medication labels, c. The resident can follow directions and tell time to know when to take the medication, d. The resident comprehends the medication's purpose, proper dosage, timing, signs of side effects and when to report these to the staff, e. The resident has the physical capacity to open medication bottles, remove medications from a container and to ingest and swallow (or otherwise administer) the medication, and f. The resident is able to safely and securely store the medication. 3. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. Review of an Admission Record revealed R54 was admitted on [DATE]. According to the Admission Record, the resident had a medical history that included diagnoses of acute and chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease (COPD). Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/26/2024, revealed R54 had a Brief Interview for Mental Status (BIMS) score of 11/15, which indicated the resident had moderate cognitive impairment. Review of R54's hard copy and electronic medical record (EMR) revealed no evidence that the resident had been assessed for self-administration of medication. Review of R54's care plan revealed a focus area, initiated 08/26/2024, that indicated the resident was at risk for respiratory complications. The resident's care plan did not indicate the resident was able to self-administer their medication or keep medications at their bedside. Review of R54's Order Recap Report for the time frame 08/01/2024 to 12/31/2024, revealed an order, dated 11/25/2024, for albuterol sulfate inhalation nebulization solution 0.083%, one vial inhale orally every four hours as needed for wheezing. The Order Recap Report did not reveal evidence to indicate the IDT had assessed and approved R54 for self-administration of their medication. Observations on 12/16/2024 at 10:08 AM and 11:28 AM revealed two vials of albuterol on R54's over-the-bed table. Additional observation on 12/17/2024 at 1:26 PM, and on 12/18/2024 at 11:01 AM, revealed one vial of albuterol on R54's over-the-bed table. During observation and interview on 12/18/2024 at 11:25 AM, the Assistant Director of Nursing (ADON) stated R54 should not have any medications left at the bedside. The ADON entered R54's room and removed a vial of albuterol, which was observed on the resident's over-the-bed table. R54, who was present in the room during this observation, stated the staff brought the medication in, sat it down, and took off. R54 added they would like to be able to self-administer their medication. The ADON confirmed that the resident had not been assessed for self-administration of medication and told R54 that, until they were assessed, they were not able to self-administer their own nebulizer treatment. The ADON said she was going to have to educate the nurses to not leave the medication with the resident, adding that she had previously removed two vials of albuterol on Monday, 12/16/2024 and had done education then, but would have to do it again. During an interview on 12/20/2024 at 9:52 AM, the Director of Nursing (DON) stated if a resident wanted to self-administer medications, then the facility would have to do an assessment to make sure the resident was competent and able to do it. The DON stated R54 did not have an assessment, and she was not aware that medications were being left at the resident's bedside. During an interview on 12/20/2024 at 9:55 AM, the Administrator stated he expected the staff to follow their policy, assess the resident, and get a physician's order for the resident to be able to self-administer their medication.

Based on interview, record review, and document review, the facility failed to transmit quarterly Minimum Data Set (MDS) assessments in a timely manner for two (Resident (R) 22 and R14) of two sampled residents reviewed for resident assessment. The MDS assessments were not transmitted to the Centers for Medicare and Medicaid Services (CMS) within 14 days of the MDS completion date. The findings included: Review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2024, indicated, Transmitting Data: Providers must transmit all sections of the MDS 3.0 required for their State-specific instrument, including the Care Area Assessment Summary and all tracking or correction information. Transmission requirements apply to all MDS 3.0 records used to meet both federal and state requirements .Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date. All other MDS assessments must be submitted within 14 days of the MDS Completion Date. 1. Review of R22's quarterly MDS, with an Assessment Reference Date (ARD) of 11/09/2024, revealed the MDS Coordinator signed the assessment as complete on 11/23/2024. The facility validation report, dated 12/18/2024, revealed R22's quarterly MDS, with an ARD of 11/09/2024, was accepted (transmitted) on 12/09/2024. 2. Review of R14's quarterly MDS, with an ARD of 11/09/2024, revealed the MDS Coordinator signed the assessment as complete on 11/23/2024. The facility validation report, dated 12/18/2024, revealed R4's quarterly MDS, with an ARD of 11/09/2024, was accepted (transmitted) on 12/09/2024. During an interview on 12/18/2024 at 12:44 PM, the MDS Coordinator stated she began her employment with the facility on 11/10/2024. The MDS Coordinator stated she was not aware she had to manually transmit MDS assessments, as the facility she previously worked at had a system that automatically transmitted the MDS assessments. The MDS Coordinator acknowledged the MDS assessments for R14 and R22 were transmitted late, and they should have been transmitted within 14 days of the completion date. During an interview on 12/20/2024 at 9:52 AM, the Director of Nursing (DON) stated the new MDS Coordinator just started, and she was trying to get her access and figure out what needed to be done. The DON stated that as soon as it was caught that these assessments were not transmitted, she did it. During an interview on 12/20/2024 at 9:55 AM, the Administrator stated they had a remote MDS Coordinator until the current MDS Coordinator started, and she was still trying to get acclimated to the position and the policies of the company. The Administrator stated he expected for the MDS assessments to be completed and transmitted timely.

Based on interview, record review, review of the facility's investigation, and the facility's policies, it was determined the facility's interdisciplinary team (IDT) failed to review and revise the comprehensive care plan with each assessment, including both the comprehensive and quarterly review assessments, to prevent falls for one (1) of twenty-two (22) sampled residents (Resident 9 (R9). R9 sustained twenty-two (22) falls in 2023, one (1) of which resulted in the resident experiencing a subdural hematoma, and a rib fracture during another one (1) of the falls. Review of Resident 9's Comprehensive Care Plan (CCP) revealed the facility care planned R9 for his/her risk for falls related to a history of falls prior to admission. The current interventions included staff to encourage R9 to keep his/her walker at a safe distance when ambulating throughout facility; anti-tippers to his/her wheelchair; and an intervention to encourage him/her to use a reacher to grab items out of reach. However, in interview the Director of Rehabilitation (DOR) stated R9 did not have the ability to lock the brakes on his/her wheelchair therefore, those were no longer on the resident's wheelchair. The DOR also stated R9 did not have the cognitive ability to use a reacher. The findings include: Review of the facility's policy titled, Care Plans - Baseline, revised March 2022, revealed A baseline plan of care to meet the resident's immediate health and safety needs was developed for each resident within forty-eight (48) hours of his/her admission. Per review, the baseline care plan included instructions needed to provide effective, person-centered care of the resident that met professional standards of quality care. Review revealed the baseline must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: initial goals based on admission orders and discussion with the resident/representative; Physician orders; dietary orders; therapy services; social services; and Preadmission Screening and Resident Review (PASRR). Further review revealed the baseline care plan was used until the staff could conduct the comprehensive assessment and develop an interdisciplinary person-centered comprehensive care plan, no later than twenty-one (21) days after admission. Additional review revealed the baseline care plan was to be updated as needed to meet the resident's needs until the comprehensive care plan was developed. Review of the facility's policy, Falls and Fall Risk, Managing, revised March 2018, revealed resident conditions that might contribute to the risk of falls included delirium and other cognitive impairment, lower extremity weakness, and incontinence. Per review, staff, with the input of the attending Physician, were to implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk of or with a history of falls. Continued review revealed if falls recurred despite initial interventions, staff were to implement additional or different interventions, or indicate why the current approach remained relevant. Record review revealed if the underlying causes could not be readily identified or corrected, staff were to try various interventions, based on assessment of the nature or category of the falls, until falling was reduced or stopped, or until the reason for the continued falling was identified as unavoidable. Further review revealed staff were to monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. In addition, if the resident continued to fall, staff were to re-evaluate the situation and determine whether it was appropriate to continue or change current interventions. Review further revealed as needed, the attending Physician would help staff reconsider possible causes that might not previously have been identified. Review of R9's Admission Record revealed the facility admitted him/her on 12/05/2018, with diagnoses which included: agitation, paranoid schizophrenia, dementia, difficulty in walking, weakness, and restlessness. Review of R9's Quarterly Minimum Data Set (MDS) Assessment, dated 05/12/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of seven (7) out of fifteen (15), which indicated he/she was severely cognitively impaired. Further review of R9's MDS Assessment revealed the facility assessed R9 to require supervision or touching assistance to walk ten (10) feet, and to be frequently incontinent of bladder and occasionally incontinent of bowel. Review of R9's Comprehensive Care Plan (CCP), initiated on 11/10/2021, revealed the facility care planned the resident for a focus related to at risk for falls due to his/her history of falls prior to admission, medications, prolonged hospitalization and changes in his/her environment and routine. Continued review revealed the care plan goal was for R9 to have no falls with injury through the target review date. Per review, interventions included staff to encourage R9 to keep his/her walker at safe distance when ambulating throughout the facility; encourage the resident to ask for assistance with the use of the walker and for transfers. Continued review revealed the interventions also included staff were to encourage R9 to toilet when awake during the night. Further review of R9's CCP initiated on 11/10/2021, revealed additional interventions initiated on 09/20/2023, for R9's fall risk: to keep his/her walker within arm's reach while lying on his/her bed; anti-tippers to the resident's wheelchair. In addition, a basket attached to R9's wheelchair was to assist with carrying his/her purse and items purchased which was initiated on 05/01/2023; and an intervention to encourage R9 to use a reacher to grab items out of reach instead of reaching and grabbing with his/her arms. Observation on 01/18/2024 at 2:25 PM, revealed R9 seated in his/her wheelchair in the hallway across from the dining room, with his/her brief pulled down around his/her ankles. Continued observation revealed Registered Nurse (RN) 8 saw R9 with his/her brief off and assisted the resident to the restroom. Review of the facility's Fall reports for R9 revealed he/she sustained twenty-two (22) documented falls in 2023, seventeen (17) which were either unwitnessed or the witness was not identified. Continued review revealed three (3) of the falls occurred between the hours of 12:00 AM and 4:00 AM and were documented as related to R9's toileting needs. Review of the Progress Notes *NEW*, effective date 06/05/2023 at 12:41 PM, revealed it was reported to the Director of Nursing (DON) that R9 had been lowered to the floor by staff secondary to his/her losing his/her footing. Per review, it was also reported to the DON that R9 never hit the floor with his/her head, never lost consciousness, and denied pain. Continued review revealed the resident's walker had been in use, and he/she had non-skid footwear in use. Further review revealed R9 had been walking in the hallway when change of plain occurred. Additionally, review revealed the nurse reported R9's appearance was different, his/her demeanor was off, his/her vital signs were normal; however, the nurse was sending R9 to the hospital for evaluation. Review further revealed the DON notified the Advanced Practice Registered Nurse (APRN) who was in house at the time. Review of the facility's Long Term Care Facility - Self-Reported Incident Form Initial Report, dated 06/07/2023, read as follows: R9 was lowered to the floor by staff due to lost footing. Per review, R9 had experienced a change in color and demeanor, and was sent to hospital emergency room (ER) for evaluation. Further review revealed on 06/07/2023, the hospital diagnosis was subdural hematoma (SDH), meaning a bruise inside R9's skull, of unknown origin. Review of the facility's Long Term Care Facility - Self-Reported Incident Form Final Report, dated 06/13/2023, revealed (the facility) was unable to determine cause/origin of (R9's) subdural hematoma (SDH). Per review, the hospital had not determined the cause of the resident's SDH. Continued review revealed (R9) was still in the hospital but his/her return to (the facility) was anticipated. The Report stated the facility had developed and followed the resident's care plan and interventions for (R9) on an ongoing basis. Further review revealed Psych Services followed (R9) for multiple psychiatric co-morbidities. In addition, review further revealed (R9's) care plan was to be updated as necessary, and staff would continue to monitor. In interview on 01/18/2024 at 8:05 AM, the Assistant Director of Nursing (ADON) stated when R9 sustained the fall on 06/05/2023, the resident did not lose consciousness. According to the ADON, when R9 fell , the nurse said R9 appeared off, so he/she was sent to the ER where scans were completed for R9, and revealed the resident had a SDH. The ADON stated the facility was not aware R9 had a SDH until the report came back from the ER, and she could not say R9's SDH was definitely from the 06/05/2023 fall. Review of the hospital document titled, Discharge Summary, dated 06/16/2023, revealed R9 had been admitted to acute care after sustaining the fall on 06/05/2023. Continued review revealed R9 was discharged from acute care on 06/16/2023, with a discharge diagnosis of Subdural hematoma (on 06/05/2023). Per review, the Active Problems was noted as Dementia (05/05/2023), and it was recommended R9's blood pressure (BP) systolic be below 140; holding oral anti-coagulants; Urinary retention: urology consulted, a Foley was placed, follow up to be arranged in one (1) week for a voiding trial. Review of the Progress Notes *NEW*, with an effective date 06/22/2023 at 2:08 PM, revealed the Interdisciplinary Team (IDT) met and reviewed R9's fall from 06/22/2023, and determined the root cause was slipped, shoe untied. Continued review revealed the intervention to implement was to encourage R9 to allow staff to double tie his/her shoes until Social Services (SS) could obtain some Velcro shoes for him/her. Review of the Progress Notes *NEW*, effective date 06/22/2023 at 3:35 PM, revealed R9 returned from the hospital via ambulance, and was alert and oriented to self, and able to make some needs known. Continued review revealed R9 had been diagnosed with fractured ribs. Review further revealed a Foley catheter had been placed at the hospital related to urinary retention. Additionally, the recommendation from the hospital was to have R9 follow up with urology. Review of the Progress Notes *NEW*, with an effective date of 06/22/2023 at 3:41 AM, revealed R9 had been found lying on the floor in the bathroom on his/her back, with his/her walker in the bathroom, and the contents of a basket on the floor. Continued review revealed R9's tennis shoes were on; however, his/her left shoe observed as untied. Per review, the nurse assessed R9 and his/her vital signs (vs) were stable. Further review revealed R9 reported he/she slipped and hit his/her head going to the restroom and had complaints of (c/o) pain, but was unable to state where the pain was located. In addition, review revealed the Primary Care Provider (PCP) made recommendations to send R9 to the emergency room (ER) for evaluation related to an unwitnessed fall and c/o of hitting his/her head. In interview on 01/18/2024 at 2:30 PM, Registered Nurse (RN) 8 stated he liked to ensure R9 was as busy as possible because if the resident got distracted he/she got into trouble. The RN stated R9's behaviors often came from when the resident needed to go to the bathroom. RN 8 stated if staff were not present with R9, when he/she needed to go to the bathroom, the resident would take himself/herself to the bathroom; however, we preferred he/she not do that. RN 8 stated he could not think of any (care plan) interventions to keep R9 from falling. He stated he would take R8 to the bathroom and listen to his/her needs. In interview on 01/18/2024 at 3:05 PM, the Director of Rehab (DOR) stated the therapy department set goals for residents and gave input to nursing staff, and reviewed care plan interventions together with nursing. The DOR stated once the IDT agreed on an intervention for a resident, the DOR expected nursing leadership to take the DOR's advice or recommendations for residents and communicate those interventions to the nursing department. In continued review, the DOR stated R9 did not have the ability to lock the brakes on his/her wheelchair, so there were no longer anti-tippers on his/her wheelchair. However, the State Survey Agency (SSA) Surveyor shared with the DOR there was still a care plan intervention, initiated on 09/20/2023, for R9 to have anti-tippers to resident's wheelchair. During continued interview on 01/18/2024 at 3:05 PM, the SSA Surveyor shared with the DOR there was a care plan intervention, initiated on 05/01/2023, for R9 to have a basket attached to his/her wheelchair to assist with carrying items. The DOR stated R9 had a basket on his/her rollator (type of walker with a seat) before; however, the resident no longer had it due to not going to the facility's vending machine anymore to buy snacks. During the interview the SSA Surveyor shared with the DOR, R9's care plan intervention initiated on 05/31/2023, for staff to encourage him/her to use a reacher to grab items out of his/her reach instead of trying to reach and grab the items with his/her arms. The DOR stated however, R9 did not have the cognitive ability to use a reacher. In addition, when the SSA Surveyor showed the DOR a copy of R9's care plan, she stated she had never seen the document before. In further interview 01/18/2024 at 3:05 PM, the DOR stated Physical Therapy (PT) had just discharged R9. The DOR stated R9 was not safe to ambulate with a walker anymore. The DOR stated when R9 got fidgety, staff were able to get the resident up to walk; however, R9 got up on his/her own at times, which he/she was never safe doing that. Observation, on 01/18/2024 at 2:55 PM, revealed there was not a basket attached to R9's wheelchair. In an interview on 01/18/2024 at 2:55 PM, the Activities Director stated she just looked at a resident's care plan when it comes up, usually quarterly, and did not know if R9 should have a basket attached to his/her wheelchair. During an interview, on 01/22/2024 at 4:30 PM, the MDS Coordinator stated residents' care plans were communication tools used by all members of the team who were providing care to residents. The MDS Coordinator stated care plans were important, so the team knew what was going on with the residents. She stated any licensed nurse could revise residents' care plans, and Social Services and Activities could revise their sections of the care plan. The MDS Coordinator stated residents' care plans should be updated every ninety-two (92) days, and whenever there was a change in the resident's condition. She stated if care plans were not revised, potentially a resident fall could happen. During an interview, on 01/23/2024 at 8:50 AM, the Director of Nursing (DON) stated the facility had tried everything to try to prevent R9 from falling, and acknowledged the resident's care plan needed to be revised. The DON stated residents' care plans were important because the care plan was what we go by (when providing resident care) and every licensed nurse in the facility was able to revise residents' care plans. According to the DON, Activities and Social Services were able to revise their part of residents' care plans, and stated care plan revisions should be made immediately after a resident had a change of status. The DON stated the nurses became aware of care plan revisions because the revisions showed up on the resident's care profile and nurses got it in report. Additionally, the DON stated if a resident's care plan changed, Certified Nursing Assistants (CNAs) knew of the change from the electronic health record (EHR) and in report. Further interview revealed the DON stated if the facility did not follow or revise residents' care plans people could be misinformed and that could lead to potential incidents. During an interview, on 01/23/2024 at 9:55 AM, the Administrator stated she expected staff to ensure resident's care plans were followed and updated. In the event of someone who was known to fall, the Administrator stated she expected nursing to make sure falls interventions were in place and ensure the interventions were working. Additionally, if an intervention was not working, the Administrator stated it should be switched. She stated some effective falls intervention were to bring residents to the common area, keep residents up and about so staff could keep eyes on the residents, and get family involved. She stated staff could make more frequent rounds. The Administrator stated the facility's rounding standard was every two (2) hours, but for a frequent faller staff should check on the resident more than every two (2) hours. She stated when staff passed by the room of the resident who was a frequent faller, they should make a habit of checking on the resident. The Administrator stated if staff did not update residents' plan of care, residents' needs would not be met.

Based on interview, record review, review of the facility's investigation and policies, it was determined the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for two (2) of twenty-two (22) sampled residents (Residents 9 (R9) and Resident 10 (R10)). 1. R9 sustained twenty-two (22) falls in 2023, seventeen (17) of which were either unwitnessed, or the witness was not identified. The facility had incomplete information/documentation to help determine the root cause of R9's numerous falls. Three (3) of R9's falls in 2023 occurred between the hours of 12:00 AM and 4:00 AM, and were documented as related to R9's toileting needs. However, the facility initiated only one Comprehensive Care Plan (CCP) intervention related to his/her falls and toileting issues, on 09/26/2023, nearly nine (9) months after the resident had sustained seventeen (17) falls prior to the intervention. Additionally, R9 sustained a subdural hematoma during one (1) of the falls and a rib fracture during another fall. 2. The facility care planned R10 to require a mechanical stand-alone transfer lift when transferred from the bed to the wheelchair. However, on 06/20/2023, staff failed to transfer R10 with the lift as care planned; the resident sustained a laceration to his/her lower right leg which required transfer to the hospital Emergency Department (ED) for emergent treatment of the wound. The findings include: Review of the facility's policy, Safety and Supervision of Residents, revised July 2017, read as follows: The facility strives to make the environment as free from accident hazards as possible. Continued review revealed employees were to be trained on potential accident hazards and demonstrate competency regarding how to identify and report accident hazards and try to prevent avoidable accidents. Further policy review revealed resident safety and supervision and assistance to prevent accidents were facility-wide priorities. Review of the facility's policy, Falls and Fall Risk, Managing, revised March 2018, read as follows: A fall is defined as unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force (e.g., a resident pushes another resident). Continued review revealed an episode where a resident lost his/her balance and would have fallen, if another person or the resident had not caught himself/herself, was considered a fall. Per policy review, a fall without injury is still a fall. Further review revealed unless there was evidence suggesting otherwise, if a resident was found on the floor, a fall was considered to have occurred. Additional policy review revealed residents' conditions that might contribute to the risk of falls included delirium and other cognitive impairment, lower extremity weakness, and incontinence. Further review of the facility's Falls and Fall Risk, Managing policy read as follows: The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. 1(a). Review of Resident 9 (R9)'s Admission Record revealed the facility admitted the resident on 12/05/2018. Continued review revealed R9 had the following diagnoses: dementia, paranoid schizophrenia, difficulty in walking, weakness, restlessness, and agitation. Review of R9's Quarterly Minimum Data Set (MDS) Assessment, dated 05/12/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of seven (7) of fifteen (15), which indicated the resident had severe cognitive impairment. Further review of R9's MDS Assessment revealed R9 required supervision or touching assistance to walk ten (10) feet. Review of R9's Comprehensive Care Plan (CCP), initiated on 11/10/2021, revealed the facility care planned a focus for the resident as at risk for falls related to: his/her history of falls prior to admission; prolonged hospitalization ; medications; and change in environment and routine. Continued review of the CCP revealed the goal was that R9 would have no falls with injury through the target date review. Per review, interventions included staff to intervene and encourage R9 to keep his/her walker at a safe distance in relation to when he/she was ambulating throughout the facility; staff to encourage the resident to ask for assistance when using the walker and transfers; and staff to encourage R9 to toilet when awake during the night. However, the facility initiated only one Comprehensive Care Plan (CCP) intervention related to R9's falls and toileting issues, on 09/26/2023, nearly nine (9) months after the resident had sustained seventeen (17) falls prior to the intervention. The facility's 09/26/2023 intervention for R9 was a large sign placed on restroom door to assist (R9) to identify restroom. Review of the facility's Fall reports for R9 revealed the resident had twenty-two (22) documented falls in 2023. Per review, seventeen (17) of the twenty-two (22) falls that occurred in 2023 were noted as unwitnessed or to have an unidentified witness. Additional review revealed three (3) of R9's falls occurred between the hours of 12:00 AM and 4:00 AM, and were documented as related to R9's toileting needs. Review of the Progress Notes *NEW*, effective date 06/05/2023 at 12:41 PM, read as follows: reported to the Director of Nursing (DON) R9 had been lowered to the floor by staff secondary to the resident losing his/her footing. Continued review revealed it had been reported R9 never hit his/her head on the floor, never lost consciousness, and denied pain. Per review, R9's walker had been in use, and he/she had non-skid footwear on. Continued review revealed R9 had been walking in the hallway when a change occurred. Further review revealed the nurse reported R9's appearance was different, his/her vital signs were normal; however, the resident's demeanor was off and the nurse was sending him/her to the hospital for evaluation. In addition, the DON notified the Advanced Practice Registered Nurse (APRN) who had been in house at the time. Review of the facility's Long Term Care Facility - Self-Reported Incident Form Initial Report, dated 06/07/2023, read as follows: (R9) was lowered to the floor by staff due to losing his/her footing. Per review, R9 had experienced a change in color and demeanor. Continued review revealed R9 was sent to the hospital emergency room (ER) for evaluation. In addition, on 06/07/2023 a hospital diagnosis indicated a subdural hematoma (a pool of blood between the brain and its outermost covering) of unknown origin. Review of the facility's Fall report titled, #377 Injury of, dated 06/07/2023 at 11:07 AM, revealed Nursing Description: R9 had an incident on 06/05/2023, and was sent to acute care. Continued review revealed per acute care on 06/06/2023, the facility was notified R9 had a subdural hematoma (SDH) and contusions to his/her head. During an interview on 01/18/2024 at 8:05 AM, the Assistant Director of Nursing (ADON) stated when R9 fell on [DATE], he/she did not lose consciousness. The ADON reviewed the report titled #375 Fall, dated 06/05/2023, and stated there was no loss of consciousness (LOC) of R9 documented. The ADON further stated when R9 fell , the nurse said R9 appeared off. so he/she was sent to the ER where scans were done on the resident, and revealed he/she had a SDH. Review of the document titled, Discharge Summary, dated 06/16/2023, revealed R9 was admitted to acute care after sustaining his/her 06/05/2023 fall, and was discharged from acute care on 06/16/2023. Per review, R9's Discharge Diagnoses: Principal Problem was noted as Subdural hematoma (06/05/2023), and Active Problems: Dementia (05/05/2023). Further review revealed the recommendations were: blood pressure (BP) systolic below 140; holding the resident's oral anti-coagulants (OAC); urinary retention: urology consulted, placed foley (brand of indwelling catheter); and arrange for follow up in one (1) week for a voiding trial. (b). Review of the Progress Notes *NEW*, effective date 06/22/2023 at 3:41 AM, read as follows: R9 was found in his/her bathroom lying on his/her back. Per review, R9's walker was in the bathroom with the contents of a basket lying on the floor; his/her tennis shoes were on; however, the left shoe was observed as untied. Continued review revealed R9 was assessed by the nurse with (w) stable vital signs (vs) a respiratory rate (rr) of sixteen (16), and oxygen saturation (O2 sats) at 100% on room air (RA). Further review revealed R9's blood pressure (BP) was 170/84; his/her pulse regular (reg) at seventy (70), and the resident had complaints of (c/o) pain but was unable to state where the pain was located. Additional review revealed R9 stated he/she slipped and hit his/her head going to the restroom. Review further revealed the Primary Care Provider (PCP) responded with recommendations to send R9 to the ER for evaluation (eval) related to (r/t) an unwitnessed fall and c/o of hitting head. Review of the Progress Notes *NEW*, effective date 06/22/2023 at 2:08 PM, read as follows: the Interdisciplinary Team (IDT) met and reviewed R9's fall from 06/22/2023, with the root cause noted as slipped, shoe untied. Further review revealed the intervention was noted as encourage R9 to allow staff to double tie his/her shoes until Social Services (SS) could obtain some Velcro shoes for him/her. Review of the Progress Notes *NEW*, effective date 06/22/2023 at 3:35 PM, read as follows: R9 returned from the hospital via ambulance, alert and oriented to self, and was able to make some needs known. Continued review revealed R9 had been diagnosed with fractured ribs. Further review revealed a Foley catheter had been placed at the hospital related to urinary retention. Review additionally revealed a recommendation from the hospital to have R9 follow up with urology, and no new orders were sent from the hospital. In interview on 01/18/2024 at 2:30 PM, Registered Nurse (RN) 8 stated he liked to ensure R9 was as busy as possible because if the resident got distracted he/she got into trouble. The RN stated R9's behaviors often came when the resident needed to go to the bathroom. RN 8 stated if staff were not present with R9, when he/she needed to go to the bathroom, the resident would take himself/herself to the bathroom; however, we preferred he/she not do that. Additionally, RN8 stated off the top of his head he could not think of (care plan) interventions to keep R9 from falling. He stated he would take R8 to the bathroom and listen to his/her needs. RN8 stated if patient, you can figure it out. The RN stated R9 wanted attention occasionally and every time he went by the resident he would speak to the resident. Regarding R9's falls, RN8 stated they were because he/she was trying to get somewhere, either into bed, out of bed, into the bathroom or out the door. RN8 stated one time R9 had told him he/she was going home and was easily redirected. During an interview, on 01/18/2024 at 3:05 PM, the Director of Rehab (DOR) stated the therapy department set goals for residents and gave input related to therapy to nursing staff. The DOR stated R9 had just been discharged from physical therapy (PT) and was not safe to ambulate with a walker anymore. Per the DOR, when R9 got fidgety, staff could get him/her up and walk; however, the resident was able to get up on his/her own, but was never safe doing that. 2. Review of R10's Admission Record revealed the facility admitted the resident on 03/07/2023, with the following diagnoses: difficulty in walking, weakness, and orthostatic hypotension. Review of R10's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS' score of seven (07) out of fifteen (15), which indicated he/she had severe cognitive impairment. Further review of R10's MDS Assessment revealed the facility also assessed the resident to require extensive two (2) plus (+) persons physical assist to transfer between surfaces, including to or from the bed, chair, wheelchair, and a standing position. Review of R9's Comprehensive Care Plan (CCP), revealed the facility care planned a focus, initiated on 03/07/2023, for the resident to require assistance or was dependent on staff for his/her Activities of Daily Living (ADL) care with bathing, grooming, personal hygiene, dressing, bed mobility, transfer, locomotion, and toileting related to a nondisplaced pubic ramus fracture. Further review revealed the interventions included staff to assist R10 to sit in his/her wheelchair using a mechanical stand-alone transfer lift. Review of the Progress Notes *NEW*, effective date 06/20/2023 at 9:35 AM, revealed the Aide was transferring R10 from the bed to the wheelchair. Further review revealed R10 stated his/her leg was hurt. Continued review revealed once R10 was transferred to the wheelchair, he/she was assessed regarding the location of stated pain, and bleeding was observed on the laceration to his/her lower right leg. Observation, on 01/11/2024 at 9:55 AM revealed the DOR and the Physical Therapy Assistant (PTA) transferred R10 from his/her bed to his/her wheelchair using a sling under the resident and a mechanical lift. During an interview, on 01/22/2024 at 3:33 PM, Licensed Practical Nurse (LPN) 17 stated she recalled last June when Certified Nursing Assistant (CNA) 4 transferred R10 from his/her bed to the wheelchair. LPN 17 stated she was waiting for CNA 4 to finish the transfer when R10 said ouch and the CNA showed her where the resident was bleeding. LPN 17 stated she assessed R10's injury and called Emergency Medical Services (EMS). LPN 17 stated she had not helped CNA 4 transfer R10, as the resident was a stand-pivot-sit (SPS) transfer. Further interview revealed the LPN stated R10 had not required use of a mechanical lift for transfer and she (LPN 17) had never known staff to use a mechanical lift to transfer R10. Review of the Progress Notes *NEW*, effective date 06/20/2023 at 6:00 PM, read as follows: R10 transferred back to facility; laceration to right lower leg with wound closure strips in place; woven gauze and a non-adhesive dressing. Further review revealed no new orders (NNO) received. During an interview, on 01/17/2024 at 10:05 AM, the DOR stated R10 had some reflexive tone, which meant the resident extended his/her legs when he/she was moved. The DOR recalled last June when CNA 4 was getting R10 out of bed and the resident kicked out his/her legs. Per the DOR's recollection, R10 had been sitting on his/her bed with his/her wheelchair to the right. The DOR further stated when CNA 4 picked up R10, the resident's right leg hit the wheelchair. During further interview, the DOR stated CNA 4 was doing a SPS transfer. The DOR stated after R10's incident, staff were educated to keep their own legs in between R10's legs, so the resident could not flail, or two (2) aides could transfer R10 from the bed to the wheelchair. In an additional interview on 01/18/2024 at 3:05 PM, the Director of Rehab (DOR) stated the therapy department set goals for residents and gave input to nursing staff, and care plan interventions were reviewed together with nursing. Once the IDT agreed on an intervention for a resident, the DOR expected nursing leadership to take the DOR's advice or recommendations for residents and communicate those interventions to the nursing department. Additionally, when the State Survey Agency Surveyor showed the DOR a copy of R9's care plan, she stated she had never seen the document. During an interview, on 01/22/2024 at 4:30 PM, the MDS Coordinator stated residents' care plans were communication tools used by all members of the team providing care to residents. The MDS Coordinator stated care plans were important, so the team knew what was going on with the residents and knew how to meet their care needs. During an interview, on 01/23/2024 at 8:50 AM, the Director of Nursing (DON) stated the facility had tried everything to try to prevent R9 from falling, and R9's care plan needed to be revised. The DON stated residents' care plans were important because the care plan was what we go by (when providing resident care) and every licensed nurse in the facility could revise residents' care plans. She stated Social Services and Activities could revise their portions of care plans, and that care plan revisions should be made immediately after a resident had a change of status. During an interview, on 01/23/2024 at 9:55 AM, the Administrator stated she expected staff to ensure resident's care plans were followed and updated. In the event of someone who was known to fall, the Administrator stated she expected nursing to make sure falls interventions were in place and ensure the interventions were working. Additionally, if an intervention was not working, the Administrator stated it should be switched. The Administrator stated for a frequent faller staff should check on the resident more than every two (2) hours. When staff passed by the room of the resident who was a frequent faller, they should make a habit of checking on the resident.

Based on interview, record review, review of the facility's investigations and policies, it was determined the facility failed to implement the comprehensive person-centered care plan for one (1) of twenty-two (22) sampled residents (Resident #10 (R10). The facility care planned R10 with an intervention for using a mechanical stand-alone lift when being transferred from the bed to the wheelchair. However, on 06/20/2023, facility staff transferred R10 from the bed to the wheelchair without using a mechanical stand-alone transfer lift. As a result R10 sustained a laceration to his/her lower right leg which required transfer to a higher level of care for emergent treatment. The findings include: Review of the facility's policy titled, Care Plans - Baseline, revised March 2022, read as follows: A baseline plan of care to meet the resident's immediate health and safety needs was to be developed for each resident within forty-eight (48) hours of admission. Continued review revealed the baseline care plan was to include instructions needed to provide effective, person-centered care of the resident which met professional standards of quality care. Further review revealed the baseline care plan must include minimum healthcare information necessary to properly care for the resident including, but not limited to the following: initial goals based on admission orders and discussion with the resident/representative; Physician's orders; dietary orders; therapy services; social services; and Preadmission Screening and Resident Review (PASARR). Review of the facility's policy titled, Safety and Supervision of Residents, revised July 2017, revealed the facility strived to make the environment as free from accident hazards as possible. Continued review revealed employees should be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents. Further review revealed resident safety and supervision and assistance to prevent accidents were facility-wide priorities. Review of the Admission Record for R10 revealed the facility admitted the resident on 03/07/2023, with diagnoses which included difficulty in walking, weakness, and orthostatic hypotension. Review of the Quarterly Minimum Data Set (MDS) Assessment for R10 dated 06/01/2023, revealed the facility assessed him/her to have a Brief Interview for Mental Status (BIMS) score of seven (7) of fifteen (15), indicating the resident had severe cognitive impairment. Further review of R10's MDS Assessment revealed the facility assessed R10 as requiring extensive physical assistance of two (2) plus persons to transfer between surfaces including to or from the bed, chair, wheelchair, or standing position. Review of R10's Comprehensive Care Plan (CCP) revealed the facility care planned the resident with a focus of requiring assistance or was dependent (on staff) for his/her Activities of Daily Living (ADL) care: in bathing, grooming, personal hygiene, dressing, bed mobility, transfer, locomotion, and toileting related to a nondisplaced pubic ramus fracture (a type of crack or break in a person's pelvis), initiated on 03/07/2023. Further review of R10's CCP revealed interventions for staff to provide R10 with extensive to total assist of one (1) to two (2) for bed mobility, and assist R10 into his/her wheelchair using a mechanical stand-alone transfer lift. Review of the Progress Notes *NEW*, effective date 06/20/2023 at 9:35 AM, read as follows: Aide was transferring R10 from the bed to the wheelchair. Continued review revealed R10 stated his/her leg was hurt, and once he/she was transferred to the wheelchair, the resident was assessed as to the location of his/her stated pain. Further review revealed a bleeding laceration to R10's lower right leg was observed. In interview on 01/22/2024 at 3:33 PM, Licensed Practical Nurse (LPN) 17 stated she remembered last June when Certified Nursing Assistant (CNA) 4 transferred R10 from his/her bed to the wheelchair (without using a mechanical lift as care planned). The LPN stated she had been waiting for CNA 4 to finish transferring R10 and heard the resident say ouch. She stated CNA 4 told her R10 was bleeding and showed her where. LPN 17 stated she assessed R10's injury and called Emergency Medical Services (EMS). She stated she had not been helping CNA 4 transfer R10, because R10 was a stand-pivot-sit (SPS) transfer, and did not require use of a mechanical lift for transfer. LPN 17 further stated she had never known staff to use a mechanical lift when transferring R10. Review of the Progress Notes *NEW*, effective date 06/20/2023 at 6:00 PM, revealed R10 was transferred back to the facility with the laceration to his/her right lower leg having wound closure strips, and a non-adhesive dressing in place. Further review revealed no new orders had been received. During an interview on 01/17/2024 at 10:05 AM, the Director of Rehab (DOR) stated R10 had some reflexive tone, which meant the resident extended his/her legs out when being moved. The DOR stated last June when CNA 4 was getting R10 up from the bed, the resident kicked out his/her legs. According to the DOR, R10 had been sitting on his/her bed with his/her wheelchair to the right. In continued interview the DOR stated when CNA 4 picked up R10 from off the bed the resident's right leg hit the wheelchair. The DOR stated CNA 4 had been doing a SPS transfer of R10, and at the time of the incident the SPS transfer was what therapy was working on, for the resident's transfers. The DOR further stated after R10's incident, staff was educated to keep their own legs in between R10's, so he/she could not flail, or two (2) aides could transfer the resident from the bed to the wheelchair. During an additional interview on 01/18/2024 at 3:05 PM, the DOR stated she was part of the facility's interdisciplinary team (IDT) and helped set the therapy goals for residents. The DOR stated the facility's interventions to meet residents' goals were discussed in the facility's morning meeting where we run through the gamut of things. She stated she expected the therapy recommendations which the IDT had agreed upon in the morning meetings to be communicated and implemented by staff. Additionally, when the State Survey Agency (SSA) Surveyor showed the DOR a copy of a resident's care plan, she stated she had never seen the document. In interview on 01/22/2024 at 4:30 PM, the MDS Coordinator stated residents' care plans were communication tools used by all members of the team who provided care for the residents. The MDS Coordinator further stated care plans were important in order for the team to know what was going on with the residents. During an interview on 01/23/2024 at 8:50 AM the DON stated residents' care plans were important because the care plan was what we go by (when providing resident care) and every licensed nurse in the facility could revise residents' care plans. She stated Social Services and Activities could revise their portions of care plans, and that care plan revisions should be made immediately after a resident had a change of status. The DON stated the nurses became aware of care plan revisions because the revisions showed up on the resident's care profile and nurses got it in report. She also stated the Utilization Data System (UDA) alerted people. Additionally, the DON stated if the way a resident transferred from the bed to the wheelchair changed, Certified Nursing Assistants (CNAs) knew of the change from the electronic health record (EHR) and in report. During further interview the DON stated if the facility did not follow residents' care plans, people could be misinformed and that could lead to potential incidents. In interview on 01/23/2024 at 9:55 AM, the Administrator stated she expected staff to ensure resident's care plans were followed. The Administrator stated if staff did not follow residents' plan of care, their needs would not be met.

Based on interview, record review, and review of the facility's policy and nursing standards of practice, it was determined the facility failed to ensure care and services were provided in accordance with accepted standards of clinical practice for one (1) of twenty-six (26) sampled residents, Resident #6. On the morning of 10/04/2023, Certified Nursing Assistant/Certified Medication Technician (CNA/CMT) #1 and Registered Nurse (RN) #2 were administering residents' medications at the same time and might have administered Resident #19's medication to Resident #6. Resident #6 was transferred to the hospital Emergency Department (ED) for evaluation and observation of possible adverse effects. The findings include: Review of the facility's policy, Administering Medications, revised 04/2019, revealed medications were administered in a safe and timely manner, and as prescribed. Further review revealed the individual administering medications verified the resident's identity before giving the resident's medications. Review of the article, Understanding the Basics of Medication Administration, dated 12/16/2015, revealed in the principles of medication administration nurses must personally prepare the properly ordered medications and personally administer those medications. Additional review revealed it was not an accepted practice to prepare any type of medication for another person to administer, nor was it acceptable practice to administer a medication that another staff member had prepared. Further review revealed the reasons included that medication preparation and administration were fraught with potential for error. Review of the article, Medication Safety: Go Beyond the Basics, dated 05/10/2016, from Lippincott Nursing Center revealed that safely administering medications required that the nurse must prepare medications for one (1) patient at a time. (a). Review of Resident #6's Electronic Medical Record (EMR) revealed the facility admitted Resident #6 on 11/29/2021, from a psychiatric facility where he/she had been admitted after altered mental status. Resident #6's diagnoses upon admission to the facility included unspecified Dementia, Altered Mental Status, and unspecified Psychosis not due to a substance or known physiological condition. Review of Resident #6's Progress Note dated 10/04/2023 at 9:59 AM, revealed a Change in Condition was noted after the nurse notified the Assistant Director of Nursing (ADON) that the resident was administered the wrong medications. Further review revealed the on call provider was notified with a new order received from the Physician to send Resident #6 to the ED for closer monitoring. (b). Review of Resident #19's EMR revealed the facility admitted the resident on 12/06/2022, with diagnoses including Cerebral infarction due to unspecified occlusion, Type 2 Diabetes Mellitus and Unspecified Convulsions. Review of Resident #19's Physician's Orders and Medication Administration Record (MAR) revealed the resident's scheduled medications for the morning of 10/04/2023, included Vitamin B12 1000 micrograms (mcg), Folic Acid 1 mg, Metformin 1000 mg, Pepcid 20 mg, Pioglitazone (a diabetic medication) 30 mg, Vitamin D tablet, 125 mcg, Zoloft (an antidepressant) 50 mg, Keppra (a medication used to control epilepsy) 500 mg, Metoprolol (high blood pressure medication) 25 mg, Baclofen (a muscle relaxant) 20 mg, Buspirone HCL (medication used to treat anxiety) 10 mg and Oxycodone (narcotic pain medication) 5 mg. Review of the hospital ED Summary Notes, dated 10/04/2023, revealed Resident #6's vital signs upon arrival to the ED were: blood pressure (B/P) 125/71 millimeters mercury (mm); respiration rate of 16 breaths per minute; heart rate 48 beats per minute; and oxygenation saturation of 95% on room air. Continued review revealed Resident #6's blood glucose level was 102 mg/deciliter (dL) and a repeat glucose level at 11:53 AM was 107 mg/dL. Review of the Summary further revealed a 12 lead electrocardiogram (EKG) identified Resident #6 to have bradycardia (slower than expected heart rate). Per review of the Summary Notes revealed the evaluation concern was due to Resident #6 having received a betablocker medication as well as Oxycodone and Metformin medications. Further review revealed Resident #6's B/P was benign and he/she appeared non-drowsy and was in no distress. Additional review revealed Resident #6 was considered safe to return to the nursing home after exhibiting no symptoms from receiving the wrong medications. Observation of medication administration by Licensed Practical Nurse (LPN) #7, LPN #17 and CNA/CMT #1 across all three (3) medication carts on 01/11/2024, beginning at 8:02 AM, revealed no observation of the LPN's or CNA/CMT preparing more than one (1) resident's medications at a time. Observation of all the drawers in the carts during medication pass revealed no advance prepared medications. During interview with Resident #6 on 01/11/2024 at 11:51 AM, he/she stated I don't know in response to question of whether any of the nurses had ever made a mistake with his/her medications. During interview with Resident #19 on 01/22/2024 at 11:33 AM, he/she stated on the day Resident #6 went to the hospital, Registered Nurse (RN) #2 brought both Resident #6 and himself/herself medicine in the cups as usual. Resident #19 stated RN #2 gave one (1) cup to Resident #6 then the other to him/her. The resident stated after receiving the cup of medicine, he/she did not recognize the pills in the cup, and handed the cup back to RN #2, who took the cup and discarded the pills. In further interview, Resident #19 stated another nurse brought the right medicine back to him/her. The resident stated since then, the nurses brought only one (1) resident's medicines at a time and he/she had no further incidents with his/her medicines. During interview with CNA/CMT #1 on 01/10/2024 at 3:48 PM, she stated she knew the residents fairly well because since she could not give all medications, such as insulin injections or gastrostomy tube (g-tube) medications. She stated when she was done with her medication pass, she made residents' appointments and performed other supportive tasks, such as putting away supplies, and worked the dining room during meals. During an additional interview with CNA/CMT #1 on 01/11/2024 at 1:25 PM, she stated on 10/04/2023, she did not recall the reason she pulled the residents' medications, it might have been that the day shift nurse was running late, and the night shift nurse stayed over to help. In continued interview, CNA/CMT #1 stated she pulled Residents #6's and #19's medications, as they were roommates when the nurse went to give the medications. She stated she was not sure there had really been a mistake because Resident #6 suffered no ill effects from receiving the wrong medications, as the resident was sent out to the hospital for monitoring and had no bad outcome. CNA/CMT #1 stated she was not sure why the nurse thought she might have given the wrong medications in error. She stated she should not have prepared two (2) residents' medications at the same. The CNA stated she knew the reason was that it was not an accepted standard of practice to prepare more than one (1) person's medications at a time due to the potential for error. She further stated she did receive re-education afterwards as did the nurse. During interview with RN #1 on 01/16/2024 at 3:59 PM, she stated she thought the night nurse was going to stay a couple of hours after shift to help pass medications because we were short staffed. She stated the CMT pulled the medications and gave them to the nurse or it might have been the other way around, she was not sure. During interview, she stated the medication pass was on the split cart and she was working on the South Unit. RN #1 stated she might have taken over the cart while the other nurse and CMT sorted the situation out with the Director of Nursing (DON) and ADON. She further stated her understanding was that the only person who got wrong medications was Resident #6, and she thought Resident #19 got the right medications. During telephone interview with RN #2 on 01/16/2024 at 4:08 PM, she stated she had stayed over from night shift on 10/04/2023, because they were short staffed. In interview, she stated the CMT had set up medicines for Resident #6 and Resident #19 with their room numbers noted on the cups. She stated she gave Resident #6 the medications that were marked for him/her. RN #2 stated she typically would never, ever pre-pull medications or give medications she had not prepared herself; however, she had done so that day. She stated the CMT put the wrong medications in Resident #6's cup, and the medications in that cup were meant for Resident #19. RN #2 stated the CMT had placed Resident #6's medications in the cup marked for Resident #19. In continued interview, she stated Resident #19 recognized a pain pill and told her the rest of the medication were not his/hers. RN #2 stated Resident #6 had already taken the medications in the cup she had given him/her, so she had no way to make sure if there had been a mistake or not. In continued telephone interview with RN #2 on 01/16/2024 at 4:08 PM, she stated she was shook up because Resident #19 took Metformin and some other medications that could have been detrimental to Resident #6's health. She stated she immediately reported the possible medication error to the ADON immediately. RN #2 stated they notified the attending medical provider, got paperwork together and sent Resident #6 out immediately to the ED. The RN stated Resident #6 seemed fine; however, they were being cautious and sent him/her out to the ED. RN #2 stated she recalled thinking it was odd that the pain pill was in the cup, and was not with the other medications. In additional interview, RN #2 stated pre-pulling meds was not in the facility's policy, nor was giving medications to more than one (1) resident at a time. She stated she always prepared one (1) medication cup for one (1) resident at a time, and passed them as she went, taking her cart from patient to patient. In final interview, RN #2 stated she admitted that protocol was not followed. During interview with the DON on 01/23/2024 at 8:46 AM, she stated on 10/04/2023 the day nurse was running late, so the night nurse agreed to stay over for a couple of hours and was helping the CMT pass medications. She stated it was not an accepted practice to pre-pull multiple medications for residents. In continued interview, she stated the CMT had told her she was trying to help the RN since she knew the residents, but the CMT was aware that we do not do that here. The DON stated they sent Resident #6 out to the hospital for evaluation and he/she returned that same afternoon. In additional interview, the DON stated RN #2 and CNA/CMT #1 were re-educated on medication administration, particularly on not pre pulling and preparing more than one (1) resident's medication at a time, and received disciplinary actions. During interview with the Administrator on 01/23/2024 at 9:55 AM, she stated she expected nurses and CMT's to follow the facility's policy, which was important because failing to follow the policy could precipitate a major error with adverse outcomes for the residents. The Administrator stated pre-pulling medications, pulling medications for multiple residents, or one (1) staff pulling medications and another staff member administering it were examples of what could cause a major error with adverse resident outcomes.

Based on interview, record review, review of the facility's investigation, and the facility's policies, it was determined the facility failed to protect residents from sexual abuse, for two (2) of twenty-two (22) sampled residents (Resident 3 (R3) and Resident 5 (R5)). On 08/07/2023 Resident 4 (R4) told R3 (his/her) stuff does not work, and R4 touched R3's knee. On 09/12/2023 R4 was observed with his/her hand on R5's buttock. On 11/15/2023 Resident 6 (R6) was observed with his/her hand on R5's breast. The findings include: Review of the facility's policy titled, Abuse Prohibition, dated 10/24/2022, revealed the facility prohibited abuse, mistreatment, neglect, misappropriation of resident/patient (hereinafter patient) property, and exploitation for all patients. Per policy review, abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Continued review revealed abuse also included the deprivation by an individual, including a caretaker, of goods or services that were necessary to attain or maintain physical, mental, and psychosocial well-being. Review revealed instances of abuse of all residents, irrespective of any mental or physical condition, caused physical harm, pain, or mental anguish. Further review revealed it included verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. In addition, further review revealed willful, as used in the definition of abuse, meant the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Review of the policy further revealed sexual abuse was defined as non-consensual sexual contact of any type with a resident. Review of the facility's policy, Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revised April 2021, revealed residents had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Continued review revealed that included but was not limited to, freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Continued review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revealed the resident abuse, neglect and exploitation prevention program consisted of a facility-wide commitment and resource allocation. Per policy review, the program was to support the following objectives: protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including other residents; establish and maintain a culture of compassion and caring for all residents, particularly those with behavioral, cognitive or emotional problems. Additional review revealed the program was also to implement measures to address factors that might lead to abusive situations, for example, help staff understand how cultural, religious and ethnic differences could lead to misunderstanding and conflicts. 1. (a). Review of the Admission Record revealed the facility admitted Resident 3 (R3) on 04/21/2021, with diagnoses which included: unspecified dementia; general anxiety disorder; cerebral infarction due to unspecified occlusion or stenosis of the right middle cerebral artery; and abnormal posture. Review of R3's Quarterly Minimum Data Set (MDS) Assessment, dated 06/16/2023, revealed the facility assessed him/her to have a Brief Interview for Mental Status (BIMS) score of eleven (11) out of fifteen (15), which indicated he/she had moderate cognitive impairment. (b). Review of Resident #4's (R4) Admission Record revealed the facility admitted the resident on 06/21/2023, with the following diagnoses: unspecified dementia; cognitive communication deficit; major depressive disorder, recurrent, mild. Review of R4's Re-admission MDS Assessment, dated 06/27/2023, revealed the facility assessed the resident to have a BIMS' score of nine (9) of fifteen (15), indicative of moderate cognitive impairment. Review of R4's Comprehensive Care Plan (CCP) revealed the facility care planned the resident for impaired/decline in cognitive function or impaired thought processes related to a condition other than delirium: dementia, which was initiated 06/23/2023. However, further review revealed no documented evidence the facility care planned R4 for sexually inappropriate behaviors, even though R4's psychiatry services provider (PA) stated during interview the resident had a history of those behaviors. Review of the facility's Long Term Care Facility - Self-Reported Incident Form Initial Report, dated 08/07/2023, revealed R3 reported when he/she was visiting with other residents in the courtyard, R4 told him/her that his/her stuff does not work, and then touched R3's knee. Continued review revealed R3 indicated he/she thought when R4 said his/her stuff it meant his/her private parts. Per review, the residents were separated and had no injury/harm. Further review revealed R4 indicated he/she was swatting away a fly from his/her knee, and the resident was educated on not touching others. Review of R4's Progress Notes *NEW*, effective date 08/07/2023, read as follows: Both the Social Service Director (SSD) and Director of Nursing (DON) spoke to R4 due to (d/t) him/her making sexually inappropriate comments to another resident of the opposite sex. Continued review revealed they explained to the resident that his/her behavior was inappropriate. Per the Note, R4 stated he/she wanted to share with his/her friend how he/she felt. Further review revealed the SSD and DON explained to R4 that he/she needed to defer from making sexually inappropriate comments. In addition, R4 shared that he/she wanted to be referred elsewhere; however, then said he/she liked living at the facility. Review further revealed both psychiatric (psych) and the counselor were to see R4 regarding his/her behavior. Review of R3's Progress Notes *NEW*, effective date 08/07/2023, revealed the SSD met with R3 regarding the inappropriate statement that was directed to him/her from another resident (R4). Further review revealed R3 stated he/she was upset in the moment; however, now was okay. Review additionally revealed the SSD was to have psych supportive counseling see resident. During an interview, on 01/17/2024 at 2:35 PM, R3 stated he/she recalled the time last summer when another facility resident touched him/her. R3 stated R4 took his/her hand and was patting his/her leg while they were talking. R3 stated that made him/her feel a little upset that R4 was touching him/her. R3 stated it was a bad thing having R4 touching my leg and R3 stated he/she told R4 not to do it. 2. (a). Review of the Admission Record revealed the facility admitted Resident 5 (R5) on 05/18/2023, with diagnoses that included Alzheimer's Disease, Dementia, and Type 2 Diabetes Mellitus without complications. Review of R5's Quarterly MDS Assessment, dated 09/22/2023, revealed the facility assessed the resident to have a BIMS' score of zero (0) out of fifteen (15), which indicated the resident had severe cognitive impairment. Review of R5's Comprehensive Care Plan (CCP), initiated on 09/27/2023, revealed the facility care planned the resident for a focus of R5 has a tendency to hug and rub and shows non-sexual affection to others. This is a way that (he/she) communicates with others. Further review revealed R5's goal was he/she would not rub, touch, or hug any staff or resident inappropriately by next review. The one (1) intervention was staff will encourage R5 to keep his/her hands to himself/herself and not touch staff or other residents. However, record review revealed Resident #5 was a severely cognitively impaired resident. (b). Review of Resident 4 (R4)'s, Admission Record revealed the facility admitted the resident on 06/21/2023, with the following diagnoses: unspecified dementia; cognitive communication deficit; and major depressive disorder, recurrent, mild. Review of R4's Re-admission MDS Assessment, dated 06/27/2023, revealed the facility assessed the resident to have a BIMS' score of nine (9) of fifteen (15), which indicated he/she had moderate cognitive impairment. Review of the facility's Long Term Care Facility - Self-Reported Incident Form Initial Report, dated 09/12/2023, revealed during breakfast R4 was seen rubbing on R5's left buttock at which time R4 was redirected. Staff remained with R5. Review of R4's Progress Notes *NEW*, effective date 09/13/2023, read as follows: (R4) was seen by psych as an acute visit on 09/12/2023 due [to] inappropriate sexual behavior (see psych note for details). Per review, R4 was started on Climara (Estradiol) Patch, (a medication used in the treatment of aggressive behavior in patients with advanced dementia). Continued review revealed currently R4 was on one on one (1:1) supervision, meaning one (1) staff member was assigned to supervise only R4, until he/she was seen by psych the next week. Further review revealed the SSD spoke to R4, and the resident stated that he/she was doing fine and slept well last night. In addition, Resident had been encouraged [sic] to sit with male peers in the dining room, with no behaviors noted. Review of the Psychiatry Progress Note, dated 09/12/2023, revealed the chief complaint/reason for the visit was Acute PsychMed visit for inappropriate sexual behavior. Continued review revealed when the provider asked R4 about touching another female resident, the resident reported he/she was touching me on my hand and my shoulders. I thought that meant for me to touch him/her. Further review revealed the resident was referring to had advanced dementia and was unable to communicate with staff or others. Additional review of the Psychiatry Progress Note revealed it was reported that (R4) touched (R5's) left buttock. Review of the Psychiatry Progress Note, dated 09/12/2023, revealed Orders for this Visit were to start the resident on a Climara patch 0.05 mg weekly due to diagnosis of Vascular dementia with other behavioral disturbances. Review of R4's Order Listing, revealed an order for Climara Transdermal Patch Weekly 0.05 MG/24 HR (Estradiol). Continued review revealed apply one (1) patch transdermally every Wednesday for vascular dementia with behavioral disturbances and remove per schedule. Observation on 01/12/2024 at 12:10 PM revealed R4 sat in his/her wheelchair at a table in the facility's dining room, with no other facility residents seated near R4. During an interview, on 01/22/2023 at 1:20 PM, the Physician's Assistant (PA) stated she was the facility's psychiatry services provider and had been since July 2022. The PA stated lots of the facility's residents did not have the capacity to make decisions about sexual relations based on their BIMS' scores, past medical histories, and conversations with the residents. Per interview, the PA stated R5 had advanced stage dementia and his/her daughter did not understand what R5 said, and that R5 was not able to verbally communicate. The PA stated R5's advanced state of dementia did not give R5 the capacity to make decisions about sexual relations. She stated R4 had vascular dementia and a history of sexually inappropriate behavior. The PA stated that due to R4's vascular dementia diagnosis, his/her cognition could change day by day. She stated R4's mental status waxed and waned, and R4 was confused at baseline. The PA stated she had talked with R4 multiple times about how sometimes, when R4 said things people took it the wrong way and that could make staff and other residents feel uncomfortable. Further interview revealed the PA stated R4 had been started on a Climara patch, which had been effective for R4. The PA additionally stated the Climara patch was a pretty low dose, however, could be increased if needed. 3. (a). Review of Resident 6 (R6)'s Admission Record, revealed the facility admitted R6 on 11/29/2021, with diagnoses that included unspecified dementia, altered mental status and anxiety disorder. Review of R6's Quarterly MDS Assessment, dated 09/07/2023, revealed the facility assessed the resident to have a BIMS' score of ninety-nine (99), which indicated the resident was unable to complete the interview. Review of R6's Comprehensive Care Plan (CCP), initiated on 12/03/2021, revealed the facility care planned a focus for R6 who had a history of exhibiting physical behaviors related to history of touching all the tables and other residents. The CCP goal was R6 would demonstrate less [sic] episodes of physical behaviors touching tables and other residents. Staff would intervene to divert R6 by giving alternative objects or activities. (b). Review of R5's Comprehensive Care Plan (CCP), initiated on 09/27/2023, revealed the facility care planned the resident for a focus of having a tendency to show non-sexual affection towards others, such as hugging and rubbing, which was the way he/she communicated with others. Continued review revealed R5's goal was for him/her to not rub, touch, or hug any staff or resident inappropriately by next review. Further review revealed there was only one (1) intervention noted that staff were to encourage R5 to keep his/her hands to himself/herself and not touch staff or other residents. (This was an intervention to be implemented for a severely cognitively impaired resident.) Review of the facility's Long Term Care Facility - Self-Reported Incident Form Initial Report, dated 11/15/2023, revealed R6 was observed having his/her left hand under R5's shirt on his/her left breast, they were both in the common area on couch. Continued review revealed an LPN statement which noted CNA 1 came to me and told me we need to keep them separated and I did not know why until she told me what had happened. Review of R6's Progress Notes *NEW*, effective date 11/15/2023, read as follows: Social Services Director (SSD) visited R6 and used a translator app to speak to resident. SSD explained to resident that (he/she) needs to keep (his/her) hands to (himself/herself) and not touch others inappropriately (especially females). R6 shook (his/her) head indicating (he/she) understood. Review of R6's Psychiatry Progress Note, date of service 11/21/2023, revealed R6 was seen by the facility's psychiatric care provider for a chronic psych medication follow up visit in the long-term care setting for medication management. Interval events: noted were since last visit, staff report that R6 was seen with his/her hand under the shirt of a female resident holding her breast. Further review of Psychiatry Progress Note read as follows: When R6 is asked how he/she is doing he/she reports I'm fine. R6 unable to recall recent event of inappropriate sexual behavior. During an interview, on 01/22/2023 at 1:20 PM, the Physician's Assistant (PA), who was the facility's psychiatric care provider, stated when the facility admitted R6 he/she came from the hospital and was very confused. The PA stated R6 had a history of bipolar & dementia and had no capacity to make decisions about sexual relations. During an interview, on 01/17/2024 at 4:08 PM, R5's family member (F1) stated in the country her relative was from people touched each other to show they were friendly. F1 stated if R5 saw a person he/she would touch that person and thought that made the person happy, and R5 was that way even before he/she had dementia. F1 stated the facility notified her about R6 touching R5 on the breast, and after that the residents no longer sat together. During an interview, on 01/17/2024 at 10:20 AM, RN1 stated she was aware that R5 touched people. RN1 stated R5's dementia was very bad, and she was not sure if R5 understood what people said to him/her. The RN stated most of the time R5 expressed himself/herself by touching others. RN1 stated R5 would pat RN1's arm and smile at staff when they were trying to do anything for him/her, like check his/her blood glucose level. RN1 stated staff noticed R5's way of communicating was by touching other people, and staff always tried to keep an eye on him/her. RN1 further stated it was not okay for R6 to put his/her hands on R5's breast. During an interview, on 01/11/2024 at 1:30 PM, CNA 1 stated after lunch R5 and R6 sat in the television area and watched television. She stated on 11/15/2023 she came into the television area and saw R5's shirt was pulled up, and saw R6 rubbing R5's breast. CNA1 stated when she saw R6 touching R5, she told him/her to stop; however, R6 did not stop. She stated she separated the two (2) residents, and notified the nurse. During an interview, on 01/23/2024 at 8:50 AM, the Director of Nursing (DON) stated R6 just touched R5 one (1) time and she had not seen that type of behavior from R6 before the 11/15/2023 incident or afterwards. The DON stated she knew R5 and R6 were friends and did not want to limit their friendship; however, the facility staff tried to keep R5 and R6 separated. During an interview, on 01/23/2024 at 9:55 AM, the facility's Administrator stated she expected staff to do frequent rounding to ensure inappropriate touching was not going on. She stated if a resident was touchy-feely, staff needed to make sure the resident was involved in activities and stayed busy. The Administrator stated she always liked to involve family who could give her some history on a resident, and that staff kept an eye on R5 and R6, due to the 11/15/2023 incident.

Based on interview, record review, review of the facility's investigation,and the facility's policy review, it was determined the facility failed to ensure medications were not misappropriated for one (1) of ten (10) sampled residents ( Resident #6). On 01/13/2020, staff noticed five (5) of Resident #6's antidepressant pills were missing from the resident's medication card. Additionally, the next day, the Center Nurse Executive (CNE) observed six (6) more of the resident's pills to be unaccounted for. The suspected staff (LPN#2) was suspended and later terminated following the facility's investigation. The findings include: Review of facility's policy,titled, Abuse Prohibition, revised 07/01/19, revealed the facility prohibits abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents. Continued review of the facility's policy revealed misappropriation of the resident's property was defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings without the resident's consent. Review of Resident #6's closed clinical record revealed the resident was admitted on [DATE] and readmitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident was assessed to have a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicating the resident was cognitively intact. Review of Resident #6's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed this order was discontinued, date unknown. On 10/25/19, the resident was ordered to have the [MEDICATION(S)] HCI Tablet 10 MG to be given one (1) time a day by mouth. This order was discontinued, date unknown. On 11/04/19, the resident's [MEDICATION(S)] physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was discontinued on 11/24/19. On 12/13/19, the resident was prescribed the [MEDICATION(S)] HCI Tablet 10 MG to be given one (1) tablet by mouth at bedtime. Review of the facility's Investigation Summary, dated 01/21/2020, revealed on 01/13/2020, Licensed Practical Nurse (LPN) #2 received a card of [MEDICATION(S)] on night shift, Monday, January 13th, 2020. The next morning, 01/14/2020, Resident #6 asked Registered Nurse (RN) #3 for his/her [MEDICATION(S)] for the day. Per the facility's investigation, RN #3 informed the resident she would have to check to see if the medication came in overnight. RN #3 noticed the resident was missing six (6) pills and informed the Center Nurse Executive (CNE) who started to look into the incident to make sure this was not an issue with the medication being lost in the cart. On 01/16/2020, the CNE checked LPN #2's cart and the card of Resident #6's [MEDICATION(S)] showed six (6) more pills punched out of the resident's card. Continued review of the investigation summary revealed LPN #2 did not know what happened to the five (5) missing pills, one (1) was administered to Resident #6. LPN #2 stated she popped one (1) and brought it to the resident and admitted to dropping one (1), but did not know what happened to the others. LPN #2 was asked about the second night she worked were there were several pills missing. LPN #2 stated she did not know anything about those missing pills. Per the investigation, there were no witnesses to the incident. LPN #2 was suspended pending the outcome of the investigation. The facility completed a full cart audit to determine if any other medications were unaccounted for and there were not. Continued review revealed the police were contacted on 01/21/2020. All residents with a BIMS greater than seven (7) were interviewed to determine if anyone had any concerns about not receiving any of their medications. Per the facility's investigation, no residents were identified to have had concerns with misappropriation. The facility substantiated the allegation. LPN#2 was terminated and reported to the Kentucky Board of Nursing. Review of the facility's Action Plan, dated 01/21/2020, revealed the problem identified was the Medication was received from pharmacy, with thirty (30) [MEDICATION(S)] for Resident #6 on 01/13/2020; on 01/14/2020, six (6) pills noted to be punched out of card; with one (1) administered to the resident. This was verified by the Medication Administration Record (MAR), the resident was interviewed and five (5) were unaccounted for. Further review revealed on 01/16/2020, six (6) more pills were missing; one (1) was administered to the resident, and it was verified by the MAR. The resident was interviewed and five (5) of the resident's [MEDICATION(S)] was unaccounted for. Interviews were conducted by the Center Nurse Executive (CNE) and Center Executive Director (CED) with involved nurse (LPN #2). Further review of the action plan revealed Resident #6 medications were available and administered by licensed nurse as ordered by the Physician on 01/13/2020 and 01/15/2020, and validated by reviewing the MAR and interview with the resident on 01/17/2020. The allegation of misappropriation of the resident's medications was reported to all state entities on 01/16/2020. Additionally, law enforcement was notified of a potential drug diversion on 01/21/2020 by the Center Executive Director (CED). Review of the facility's cart audit, dated 12/2020, no specific date, revealed the facility performed a split cart audit and all medications were available. There were;however, no specific medications listed related to the medications that were audited. Additionally, the facility reported Resident #6's [MEDICATION(S)] was missing on 02/20/2020, after LPN #2 was terminated; however, there was no documented evidence this concern was brought before Quality Assurance Performance Improvement (QAPI). Review of Resident #6's statement, dated 01/17/2020, provided by the facility, revealed the resident stated he/she did not have difficulty receiving his/her [MEDICATION(S)]. Resident #6 stated the only issue he/she had was when the Medical Director discontinued his/her medications. Per review, Resident #6 stated he/she had no concerns with receiving his/her medications. Resident #6 was discharged prior to the State Agency Surveyor's (SAS) investigation. Post telephonic interview with Certified Nursing Assistant (CNA) #5, on 02/09/2021 at approximately 2:48 PM, revealed she cared for Resident #6. She stated the resident was demanding of staff when it came to her care. Per interview, CNA #5 stated the resident; however, never made any concerns about missing his/her medications. Further interview revealed she worked night shift with Licensed Practical Nurse (LPN) #2. CNA #5 stated she observed LPN #2 administer medications to other residents and did not suspect diversion. Additionally, she stated she had not observed LPN #2 misappropriate the residents' medications. Review of Licensed Practical Nurse (LPN) #2's statement, provided by the facility, dated 01/16/2020, revealed LPN #2 was informed she received a card of medications last night and several extra doses were missing. The next night LPN #2 worked, the same thing happened. LPN #2 was asked if she had an explanation and LPN #2 responded by saying, No, not really. I did not realize that many were missing. Post telephonic interview with LPN #2, on 02/09/2021 at 1:25 PM, revealed she worked night shift with LPN #3. LPN #2 stated the CNE questioned her about Resident #6's [MEDICATION(S)]. Per interview, LPN #2 stated that particular medication was one the Medical Director would start and discontinue often because it made the resident sleepy. LPN #2 stated the CNE informed her Resident #6 was missing six (6) to nine (9) of his/her pills from his/her card. LPN #2 stated she was not aware of the resident's missing pills, adding, There were other nurses who had access to my cart. Additionally, per interview, the facility terminated LPN #2 following the investigation. Post telephonic interview with LPN #3, on 02/10/2021 at 10:30 AM, revealed she worked at the facility for over a year. She stated she was often the only nurse that worked with LPN #2 on night shift. Per interview, the facility-trained staff often on abuse and misappropriation. LPN #3 stated she was interviewed related to Resident #6's missing pills, but could not offer any information related to how the resident's medication became missing. LPN #3 added the other nurses have access to their medication carts. LPN #3 stated the medication was not a controlled drug, thus, would not require staff to have two (2) nurses to sign and/or count the medication. LPN #3 stated to have caught a non-controlled drug, the facility would have utilized the Point Click Care (PCC) system and/or the Electronic Medication Administration Records (EMAR), along with identifying when the resident's medications were ordered. LPN #3 stated Resident #6 kept track of his/her [MEDICATION(S)] because that was a medication he/she wanted most. Further interview revealed the resident did not complain to staff about missing a dose. LPN #3 stated she has known LPN #2 in and outside of work and have never known LPN #2 to misappropriate the residents' medications. Review of Registered Nurse (RN)#3's statement, provided by the facility, undated, revealed Resident #6 asked RN #3 on Monday, 01/13/2020 for his/her [MEDICATION(S)]. RN #3 stated she looked in the drawer and the card was missing six (6) pills. RN #3 notified the Center Nursing Executive (CNE) who took the delivery ticket and the card of [MEDICATION(S)]. Post telephonic interview with Registered Nurse (RN) #3, on 02/10/2021 at approximately 1:30 PM, revealed she no longer worked at the facility, but was employed by the facility for over two (2) years. RN #3 stated the facility provided education on abuse often, adding misappropriation of the resident's property was included. RN #3 stated she was familiar with the incident related to Resident #6's missing medications. Per interview, RN #3 stated she worked the day of 01/13/2020 and received the Pharmacy's delivery of Resident #6's [MEDICATION(S)]. RN #3 stated she took the medications and placed them in the resident's cart for the night shift nurse to have access to the medications. She further stated she never administered the [MEDICATION(S)] to the resident as this was a medication given to the resident nightly, adding, the resident would not have asked me for this particular medication. Continued interview revealed the next day, while retrieving a different medication for the resident, she noticed the resident's medication card to have had several punches in it. RN #3 stated she could not recall how many pills were missing, but thought it would have been between seven (7) to thirteen (13) pills removed from the packet. RN #3 revealed she notified the Center Nursing Executive (CNE) who conducted an investigation. Further interview revealed the resident's [MEDICATION(S)] was not a controlled drug, thus would not have been caught unless staff were aware of the medication that was brought in by pharmacy. Post telephonic interview with the Assistant Director of Nursing (ADON), on 02/11/2021 at 3:47 PM, revealed she assisted the CNE with investigating Resident #6's missing [MEDICATION(S)]. Per interview, the ADON stated the nurse (RN #3) notified her and the CNE that the resident's medications were missing. The ADON stated RN #3 stated she accepted the medications the day prior and noticed the next day that multiple of the resident's pills were missing. Further interview revealed it was unclear if RN #3 determined at that time how many of the resident's pills were missing. The ADON revealed the [MEDICATION(S)] was a medication that was not a controlled drug, thus a nurse would have had to noticed the medication as missing. Continued interview revealed as part of the facility's Plan of Correction,controlled-drugs were audited and staff were educated on wasting narcotic medications. Continued interview revealed she was not certain of what the facility did in terms of auditing and re-educating staff on non-controlled drugs, but stated it should have been part of the facility's Plan of Correction. Post telephonic interview, on 02/09/2021 at 11:00 AM, with the Center Nursing Executive (CNE), revealed she has been the CNE with the facility since 2018. Per interview, the CNE stated she first became aware of the misappropriation of the residents' medications when Pharmacy sent a notice to the facility advising the facility filled the resident's medications too soon. She stated medications included [MEDICATION(S)], Trazadone, and [MEDICATION(S)]. The CNE stated she thought Pharmacy had made a mistake, thus the facility paid for the extra medications and began auditing the nurses medication carts and the blue book. The CNE stated she noted Licensed Practical Nurse (LPN) #2 was the nurse assigned to the cart with the missing medications. Further interview revealed the facility placed LPN #2 on suspension pending the facility's investigation. Post telephonic interview with the Operations Pharmacist, on 02/11/2021 at approximately 11:30 AM, revealed the resident's medication, [MEDICATION(S)] HCI 10 MG, was prescribed at a low dose. Per interview, the pharmacist revealed the medication was a non-controlled medication and when taken for other than what it was prescribed for would only make a person drowsy. The Pharmacist stated that per review of the delivery, the [MEDICATION(S)] was delivered to the facility on [DATE] at around 7:41 PM and LPN #2 signed off having received it. Continued interview with the pharmacist reveled the resident's medication was ordered as schedule and there were no red flags to suggest the medication was ordered in access. Further interview revealed the [MEDICATION(S)] would not have been caught as missing because it was not a medication that required two (2) staff members, as one would with controlled medications, to count to verify the medication was not diverted. The Operations Pharmacist stated it probably would not have been caught until it was time to re-order the medication. Post telephonic interview with the Medical Director, on 02/12/2021 at 1:10 PM, revealed Resident #6 was followed by psych and thus could not speak towards the resident's [MEDICATION(S)]. She further stated the resident was no longer a resident within the facility. Per interview, the Medical Director stated the incident occurred about a year ago and could not speak towards actions taken by the facility. In terms of the resident's medication, [MEDICATION(S)], the Medical Director stated the facility could check the Electronic Medical Administration Record (EMAR) to determine if there were discrepancy with the residents medications. An Additional telephonic interview with the CNE, on 02/12/2021 at 3:00 PM, revealed she could not recall the details of the investigation at this time. Per interview, the CNE stated she believed Registered Nurse (RN)#3 told her about the missing pills, but could not recall how many were missing. The CNE stated she could not locate the Pharmacy Delivery sheet, which was part of the facility's investigation, to show the concern with Resident #6's [MEDICATION(S)]. In terms of the Plan of Correction, provided by the facility, the CNE stated the previous Administrator wrote the Plan of Correction and revealed the nurses carts were audited. Per interview, she stated she has kept track of the non-controlled drugs by checking in with the nurses to determine if they had concerns with any medications that were unaccounted for. She further stated she has not had a concern since LPN #2 left the facility; however, review of the audit sheet provided by the facility, dated 02/20/2020, revealed Resident #6's [MEDICATION(S)] was missing, the facility did not provide a count of how many were missing. Interview with the Administrator, on 01/27/2021 at 9:21 AM, revealed he was not the Administrator at the time of this incident. The Administrator stated it would be his expectation that staff suspected of abuse would be immediately suspended and an investigation would be initiated. Continued interview revealed he oversees the facility's abuse investigations and coordinate leadership efforts for interviews, audits,quality assurance, monitoring, and reporting.

Based on observation, record review, and interview it was determined the facility failed to notify the physician of a worsening blister and the development of a new pressure area for one (1) out of the thirty-seven (37) sampled residents. Resident #10 had a blister on the right heel that had worsened and an unidentified pressure area on the bottom of the left foot under the little toe. The findings include: Record review of the facility policy titled, Skin Integrity Management revised 07/01/19, revealed staff should continually observe and monitor patients for changes and implement revisions to the plan of care as needed. The policy further revealed there should be documentation of any decline and the physician should be notified of the decline. Record review of the facility policy titled, Change In Condition: Notification dated 11/28/16, revealed the facility must immediately consult with the patients physician when there was a need to alter treatment significantly and, that would be when, there was a need to discontinue, or change an existing form of treatment, or to commence a new form of treatment. Record review revealed the facility admitted Resident #10 on 06/07/17 with [DIAGNOSES REDACTED]. Record review of the annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/24/19, revealed Resident #10 had a Basic Interview for Mental Status (BIMS) of fifteen (15), which indicated the resident was interviewable. The MDS further revealed Resident #10 was totally dependent and needed the assist of one person for bed mobility, transfer, dressing, eating, toilet use, and bathing. The MDS further revealed Resident #10 had a limited range of motion (ROM) on both upper and lower extremities and had one (1) stage four (4) pressure ulcer to the coccyx. Record review of the comprehensive care plan, revealed a problem was listed for actual skin breakdown, related to a Stage IV pressure ulcer to the coccyx and left heel, not right heel. Interventions included evaluating the wound daily, including surrounding tissue and any presence of drainage. It further revealed if a new wound was discovered it was to be reported to the physician. Review of the care plan revealed the resident was to be monitored for signs and symptoms of skin breakdown, blistering, redness, and drainage. Weekly skin assessments were to be done and should have included measurements and descriptions of the wound. Positioning devices were to be utilized to prevent pressure. Interview with Resident #10, on 09/03/19 at 3:29 PM, revealed he/she was a quadriplegic and was unable to move his/her arms or legs. Observation, on 09/06/19 at 10:30 AM, during the wound assessment with Registered Nurse (RN) #1 and License Practical Nurse (LPN) #2 revealed Resident #10 was lying on a Dermaflow mattress and had black booties on both feet. LPN #1 removed the black boot from the left foot and the wound on the bottom of the left foot under the little toe stuck to the black boot and the boot had to be peeled away from Resident #10's foot. Observation of the left foot on the bottom under the little toe revealed a nickel size red area with pink tissue surrounding. RN #1 wrapped the left foot with kerlix and put the dirty black boot back on the foot. Interview with RN #1 revealed the area under the toe was noted yesterday but they did not have an order for [REDACTED]. Observation, on 09/06/19 at 10:30 AM, of the right foot revealed the black boot was removed and there was no bandage on the right heel. Observation of the right heel revealed a dark area that was approximately silver dollar size . Interview with RN #1 revealed the dark area to the right heel was unstageable and looked like a deep tissue wound to her. She further revealed it had skin prep on it. Interview during the observation with the Wound Nurse, on 09/06/19 at 4:30 PM, revealed the pressure area on the left foot under the little toe should have been reported to the physician and treatment should have been obtained when it was first noted. She revealed Resident #10 was diabetic and at risk for pressure sore formation and infection. She further revealed the area under to left foot looked like something had pressed against it causing pressure. She stated the area was blanchable and probably a Stage one (1) or Stage two (2) pressure area. She revealed it was not a blister area and it looked like it may open. Interview with the Wound Nurse, on 09/06/19 at 4:45 PM, revealed the right heel was necrotic and unstageable. The wound nurse revealed a skin assessment monitoring sheet should have been started for the right heel and the left foot in order to monitor if the areas were worsening and the healing process. She revealed after reviewing the clinical record for Resident #10 that no skin assessment monitoring sheet had been started, the physician had not been notified, and there was no treatment obtained for the areas. She further revealed she did not see any documentation that the family had been notified of the areas and they should have been. The wound nurse further revealed the documentation should include what the pressure area looked like, the size and a skin monitoring sheet should have been started with that information documented on it. She revealed Resident #10 was at risk for infection and could loose his foot. Record review of the physician orders revealed prep was to be applied to the left and right heels. Record review revealed there was no documentation the physician had been notified of the new blister to the right heel, nor the pressure area to the left foot under the little toe. Record review revealed there was no new treatments obtained for the right heel and no treatment obtained for the new pressure area on the left foot. Record review of the progress notes for 09/03/19 through 09/05/19 revealed there was no documentation that the physician had been notified of the blister area to the right heel. Record review of the progress notes for 09/06/19 revealed there was no documentation that the physician had been notified of the darkened area to the right heel or the newly identified area to the left foot under the little toe as observed earlier that morning. Record review of the skin checks done from 5/30/19 to 8/30/19 revealed pressure areas were noted for the right buttock, the coccyx, and left buttock. Review further revealed there was no documentation of any skin issues to the right or left heels. Interview with the Nurse Practitioner (NP), on 09/06/19 at 6:27 PM by telephone, revealed Resident #10 had recurring problems with blister areas but she was not aware they were recurring again. The NP revealed she thought someone might have called her today about the skin prep order; however, she was not aware of any wound to the bottom of the left foot under the little toe and no one had described the area to the right heel to her. She revealed she would expect staff to inform her of the new wound. The NP revealed typically blisters do not turn black. Interview with RN #3, on 09/06/19 at 7:50 PM, revealed she noticed the area to the right heel Monday. She revealed she did not call the physician or start a skin assessment because she thought someone else had done it since there was a dressing on the right heel when she noticed it. The dressing was undated and did not have a signature on it of who had done the treatment. RN #3 revealed it was a standard of care that if you find a new wound you should start the skin assessment monitoring, call the physician, get an order, start the treatment, start the skin assessments with measurements and description of the wound. RN #3 revealed she did not do a skin assessment that night and was not aware of any skin issues on the left foot under the little toe. Interview with the Director of Nursing (DON), on 09/06/19 at 7:31 PM revealed Resident #10 had recurring blisters and sitting rubbed the blister. The DON revealed since the areas were not significant changes then the physician did not have to be called. Interview with Administrator, on 09/06/19 at 2:36 PM, revealed he expected staff to follow facility policy and he monitored the staff by following policy. He revealed his main tool was quality assurance process improvement and observations.

Based on observation, record review, and interview it was determined the facility failed to ensure that a resident who acquired a pressure sore on the foot received proper treatment to facilitate wound healing and not worsening of the wound for one (1) resident out of the thirty-seven (37) sampled residents. Resident #10 had a blistered on the right heel that had worsened and an unidentified pressure area on the bottom of the left foot under the little toe. The findings include: Record review of the facility policy titled, Skin Integrity Management revised 07/01/19, revealed staff should continually observe and monitor patients for changes and implement revisions to the plan of care as needed. The policy revealed the purpose of the policy was to provide safe and effective care to prevent the occurrence of pressure ulcers, manage the treatment, and promote healing of the wounds. Review further revealed one practice standard was to include all patients who had a newly identified skin impairment on the centers twenty-four (24) hour summary report. Wound observations and measurements should be completed an documented on the skin integrity report upon initial identification of an altered skin integrity. The wounds should be monitored daily for the presence of any decline and it should be documented. The policy revealed a care plan should be developed and included prevention and treatment. The physician or nurse practitioner and the family should be notified. Daily monitoring of the ulcer should be documented with what the site looked like, the status of the dressing and the status of the surrounding tissue. It should also be documented of any decline in the area and the physician should be notified of the decline. Record review revealed the facility admitted Resident #10 on 06/07/17 with [DIAGNOSES REDACTED]. Record review of the annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/24/19, revealed Resident #10 had a Basic Interview for Mental Status (BIMS) of fifteen (15), which indicated the resident was interviewable. The MDS further revealed Resident #10 was totally dependent and needed the assist of one person for bed mobility, transfer, dressing, eating, toilet use, and bathing. The MDS further revealed Resident #10 had a limited range of motion (ROM) on both upper and lower extremities and had one (1) stage four (4) pressure ulcer to the coccyx. Record review of the comprehensive care plan revealed a problem was listed for actual skin breakdown related to a Stage IV pressure ulcer to the coccyx and left heel, not right heel. Interventions included evaluating the wound daily, including surrounding tissue and any presence of drainage. It further revealed if a new wound was discovered it was to be reported to the physician. Review of the care plan revealed the resident was to be monitored for signs and symptoms of skin breakdown, blistering, redness, and drainage. Weekly skin assessments were to be done and should have included measurements and descriptions of the wound. Positioning devices were to be utilized to prevent pressure. Observation on 09/03/19 at 3:29 PM, revealed Resident #10 was sitting up in his/her motorized scooter. Observation further revealed blue booties were lying on the floor. Interview with Resident #10, on 09/03/19 at 3:29 PM, revealed he/she wore the blue booties at night when in bed. Resident #10 stated he/she was a quadriplegic and was unable to move his/her arms . Resident #10 stated the black button on the wheelchair, that he/she can touch with the his/her head was broken. Resident #10 stated he/she could not move the wheelchair up and back which helped to relieve pressure on the coccyx where there was a pressure sore. Resident #10 stated it would be okay for this surveyor to observe the wound and the treatment. Observation of Resident #10, on 09/06/19 09:12 AM, revealed the resident was lying in bed and watching TV. Observation on 09/06/19 at 10:30 AM, during the wound assessment with Registered Nurse (RN) #1 and License Practical Nurse (LPN) #2, revealed Resident #10 was lying on a Dermaflow mattress and had black booties on both feet. The over-bed table had resident items on it and the wound supplies, which included packages of gauze, kerlix, Integrity Wound Cleaner, and skin prep, were placed onto the over-bed table without it being cleaned off and a barrier was not applied. Observation revealed the resident had black booties on both feet. Observation further revealed RN #1 removed the old dressing with serosanguious drainage on it, from the left gluteal fold (coccyx) and placed it directly on Resident #10's bed with the soiled side up. RN #1 continued the assessment and placed an [MEDICATION NAME] dressing back on the wound. RN #1 removed her gloves and washed her hands. LPN #2 removed the black boot from the left foot and the wound on the bottom of the left foot under the little toe stuck to the black boot and the boot had to be peeled away from Resident #10's foot. Observation revealed no bleeding was noted. Observation revealed the left black boot had dried white substance in it that had touched the area on the foot. Observation of the left foot on the bottom under the little toe revealed a nickel size red area with pink tissue surrounding . RN #1 wrapped the left foot with kerlix and put the dirty black boot back on the foot. Interview with RN #1 revealed the area under the toe was noted yesterday but they did not have an order for [REDACTED]. Observation, on 09/06/19 at 10:30 AM, of Resident #10's right foot, revealed the black boot was removed by RN #1 and there was no bandage on the right heel. The black boot on the right foot had white dried material in it that was directly on the heel wound. The area to the right heel was approximately silver dollar size . Interview with RN #1, during the observation of the right foot, revealed the dark area to the right heel was unstageable and looked like a deep tissue wound to her. She further revealed it had skin prep on it and the boot was dirty and filthy as well. RN#1 revealed the black boots needed to be taken to the laundry. Interview revealed Resident #10 had some new boot that therapy had ordered but they were not in yet. Observation with the Wound Nurse, on 09/06/19 at 4:30 PM, revealed Resident #10's feet had black booties on them and they were wrapped in kerlix. Observation further revealed she removed the kerlix from the left foot and the right heel and the dressing to the heel stuck to the wound. Interview during the observation with the Wound Nurse, on 09/06/19 at 4:30 PM, revealed the pressure area on the left foot under the little toe should have been reported to the physician and treatment should have been obtained when it was first noted. She revealed Resident #10 was diabetic and at risk for pressure sore formation and infection. She further revealed the area under the left foot looked like something had pressed against it causing pressure. She stated the area was blanchable and probably a Stage one (1) or Stage two (2) pressure area. She revealed it was not a blister area and it looked like it may open. Interview with the Wound Nurse, on 09/06/19 at 4:45 PM, revealed the right heel was necrotic and unstageable. She further revealed the boots were dirty and needed to be changed. The wound nurse revealed a skin assessment monitoring sheet should have been started for the right heel and the left foot in order to monitor if the areas were worsening and the healing process. She revealed after reviewing the clinical record for Resident #10 that no skin assessment monitoring sheet had been started, the physician had not been notified, and there was no treatment obtained for the areas. She further revealed she did not see any documentation that the family had been notified of the areas and they should have been. The wound nurse further revealed the documentation should include what the pressure area looked like, the size and a skin monitoring sheet should have been started with that information documented on it. She revealed Resident #10 was at risk for infection and could loose his foot. She revealed a care plan should have been initiated for the right heel and the left foot and he/she should have clean boots. Interview, on 09/06/19 at 4:45 PM, with Resident #10 revealed he had not gotten any clean boots put on since this surveyor had been in the room earlier with RN #1. Record review of the physician orders revealed a treatment to the coccyx directed staff to cleanse the wound with Microcyn, pack with [MEDICATION NAME] rope, apply [MEDICATION NAME] to the wound edges and cover with a dry dressing and it was to be done daily. The orders further revealed skin prep was to be applied to the left and right heels. Record review revealed there was no documentation that the physician had been notified of the new blister to the right heel and to the pressure area to the left foot under the little toe. Record review revealed there was no new treatments obtained for the right heel and no treatment obtained for the new pressure area on the left foot. Record review of the progress notes for 09/03/19 at 1:39 AM, revealed treatment was completed as ordered. A dressing was noted on Resident #10's right heel. The dressing was removed and an opened blister was noted and had bled. It further revealed skin prep and lotion was applied. Review revealed there was no documentation the physician had been notified of the ruptured blister. Record review of the progress notes for 09/04/19 and 09/05/19 revealed there was no documentation that the physician had been notified of the blister area to the right heel. Record review of the progress notes for 09/06/19 revealed there was no documentation that the physician had been notified of the darkened area to the right heel or the newly identified area to the left foot under the little toe. Record review of the skin checks done from 5/30/19 to 8/30/19 revealed pressure areas were noted for the right buttock, the coccyx, and left buttock. Review further revealed there was no documentation of any skin issues to the right or left heels. Interview with the Minimum Data Set (MDS) Coordinator LPN, on 09/06/19 at 5:00 PM, revealed she was not aware of any wound areas to the right heel or to the left foot under the little toe. She revealed if Resident #10 had a new area it would have been discussed at the morning meetings and she was not aware of any discussion about the new wound areas. Interview with the Nurse Practitioner (NP), on 09/06/19 at 6:27 PM, by telephone, revealed Resident #10 had recurring problems with blister areas but she was not aware they were recurring again. The NP revealed she thought someone might have called her today about the skin prep order but she was not aware of any wound to the bottom of the left foot under the little toe and no one had described the area to the right heel to her. She revealed she would expect staff to inform her of the new wound. The NP revealed typically blisters do not turn black. Interview with RN #3, on 09/06/19 at 7:50 PM, revealed she noticed the area to the right heel Monday because there was a dressing on the right foot so she removed it and there was a small blister to the heel, which was about the size of the end of your thumb. RN #3 reveal the blister was partially ruptured and the skin look wrinkly and had a bloody look to it. She stated the boots were dirty from the drainage of the blister. RN #3 stated she cleaned the area, dried it, and left it open to air. She stated she obtained clean boots and put them on Resident #10. She further revealed she did not call the physician or start a skin assessment because she thought someone else had done it since there was a dressing on the right heel when she noticed it. The dressing was undated and did not have a signature on it of who had done the treatment. RN #3 stated it was a standard of care that if you find a new wound you should start the skin assessment monitoring, call the physician, obtain a physicians order, start the treatment, start the skin assessments with measurements and description of the wound. RN #3 stated she did not do a skin assessment that night and was not aware of any skin issues on the left foot under the little toe. Interview with the Director of Nursing (DON), on 09/06/19 at 7:31 PM, revealed Resident #10 had recurring blisters and sitting rubbed the blister. She revealed new boots had been ordered for the resident but they had not come in yet. She stated if the boots were dirty they should have been removed and clean boots applied. She stated the area to the right heel was very small, dimelike in area, a couple of days ago when RN #1 had informed them of the area to the heel. She stated they use skin prep to toughen the heel and it would help absorb the blister. She further stated the reason the boot stuck to the wound under the left foot little toe was because staff did not let the skin prep dry and it became like a liquid bandage. She stated skin assessments should be done weekly to monitor the areas and they should be looked at every day. The DON did not want to review the chart as requested in order to verify if the skin assessments, progress notes, and care plan had been done or not on the right heel and left foot. The DON revealed since the areas were not significant changes then the physician did not have to be called. The DON revealed the area to the right heel had been brought up at the clinical meeting on Tuesday morning and her and the MDS coordinator updated the care plan at that time to reflect the area. Interview with the Administrator, on 09/06/19 at 2:36 PM, revealed he expected the staff to follow the facility policies and he monitored the staff by following policy. He revealed his main tool was quality assessment and conducting observations.

Based on observation, record review, and interview it was determined the facility failed to ensure a comprehensive care plan was implemented for three (3) of the thirty-seven (37) sampled residents, Residents #10, #37, and #45. Resident #45 did not have a nutrition care plan related to a therapeutic diet. In addition the facility failed to initiate a comprehensive care plan for an identified area to the right heel and the left foot under the little toe for Resident #10 and the call light for Resident #37 was not working. The findings include: 1. Record review of the facility policy titled, Skin Integrity Management revised 07/01/19, revealed staff should continually observe and monitor patients for changes and implement revisions to the plan of care as needed. The policy revealed the purpose of the policy was to provide safe and effective care to prevent the occurrence of pressure ulcers, manage the treatment, and promote healing of the wounds. The policy revealed a care plan should be developed and included prevention and treatment. Record review revealed the facility admitted Resident #10 on 06/07/17 with [DIAGNOSES REDACTED]. Record review of the annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/24/19, revealed Resident #10 had a Basic Interview for Mental Status (BIMS) of fifteen (15), which indicated the resident was interviewable. The MDS further revealed Resident #10 was totally dependent and needed the assist of one person for bed mobility, transfer, dressing, eating, toilet use, and bathing. The MDS further revealed Resident #10 had a limited range of motion (ROM) on both upper and lower extremities and had one (1) stage four (4) pressure ulcer to the coccyx. Record review of the comprehensive care plan revealed a problem was listed for actual skin breakdown related to a Stage IV pressure ulcer to the coccyx and left heel, not right heel. Interventions included evaluating the wound daily, including surrounding tissue and any presence of drainage. It further revealed if a new wound was discovered it was to be reported to the physician. Review of the care plan revealed the resident was to be monitored for signs and symptoms of skin breakdown, blistering, redness, and drainage. Weekly skin assessments were to be done and should have included measurements and descriptions of the wound. Positioning devices were to be utilized to prevent pressure. Observation on 09/06/19 at 10:30 AM, during the wound assessment with Registered Nurse (RN) #1 and License Practical Nurse (LPN) #2 revealed Resident #10 was lying on a Dermaflow mattress and had black booties on both feet. LPN #1 moved the black boot from the left foot and the wound on the bottom of the left foot under the little toe stuck to the black boot and the boot had to be peeled away from Resident #10's foot. Observation revealed no bleeding was noted. Observation revealed the left black boot had dried white substance in it that had touched the area on the foot. Observation of the left foot on the bottom under the little toe revealed a nickel size red area with pink tissue surrounding. RN #1 wrapped the left foot with kerlix and put the dirty black boot back on the foot. Interview with RN #1 revealed the area under the toe was noted yesterday but they did not have an order for [REDACTED]. Observation, on 09/06/19 at 10:30 AM, of the right foot, revealed the black boot was removed and there was no bandage on the right heel. The black boot on the right foot had white dried material in it that was directly on the heel wound. The area to the right heel was approximately silver dollar size. Interview with RN #1 revealed the dark area to the right heel was unstageable and looked like a deep tissue wound to her. Observation with the Wound Nurse, on 09/06/19 at 4:30 PM, revealed Resident #10's feet had black booties on them and they were wrapped in kerlix. Observation further revealed she removed the kerlix from the left foot and removed the kerlix and dressing from the right heel and the dressing to the heel stuck to the wound. Interview during the observation with the Wound Nurse, on 09/06/19 at 4:30 PM, revealed the pressure area on the left foot under the little toe should have been reported to the physician and treatment should have been obtained when it was first noted. She revealed Resident #10 was diabetic and at risk for pressure sore formation and infection. She further revealed the area under to left foot looked like something had pressed against it causing pressure. She stated the area was blanchable and probably a Stage one (1) or Stage two (2) pressure area. She revealed it was not a blister area and it looked like it may open. Interview with the Wound Nurse, on 09/06/19 at 4:45 PM, revealed a care plan should have been initiated for the right heel and the left foot. Interview with the Minimum Data Set (MDS) Coordinator LPN on 09/06/19 at 5:00 PM revealed she was not aware of any wound areas to the right heel or to the left foot under the little toe. She revealed if Resident #10 had a new area it would have been discussed at the morning meetings and she was not aware of any discussion about the new wound areas. She stated if they had discussed the heel and new area to Resident #10's feet she would have double checked the comprehensive care plan and if it had not been updated she would have updated it. The MDS Coordinator further revealed a care plan should have been initiated for the right heel and the left foot under the toe because the care plan directs the care for the resident. The MDS Coordinator reviewed the current comprehensive care plan and revealed a problem for the new skin issues had not been addressed. She further stated that any of the nursing staff could update or intiate a care plan. Interview with the Director of Nursing (DON), on 09/06/19 at 7:31 PM, revealed the area on Resident #10's right heel had been brought up at the clinical meeting on Tuesday morning and her and the MDS coordinator updated the care plan at that time to reflect the area. Interview on 09/06/19 at 2:36 PM, with the Administrator, revealed he expected the staff to follow the policy and he monitored the staff by following policy. He revealed his main tool was quality assessment and observations. 2. Review of the policy Person-Centered Care Plan, revised 07/01/19, revealed a comprehensive person-centered care plan must be developed for each patient and must describe services that were to be furnished; any services that would otherwise be required but were not provided due to the patient's exercise of rights, including the right to refuse treatment; any specialized services or specialized rehabilitative services the Center would provide as a result of PASRR recommendations; and in consultation with the patient and the resident representative(s), goals for admission and desired outcomes, preference and potential for future discharge, and discharge plan, as appropriate. Observation, on 09/04/19 at 11:41 AM, revealed a water pitcher and straw on Resident #45's over bed table. Observation, on 09/05/19 at 8:49 AM, revealed Resident #45 seated in bed eating breakfast served with regular, thin consistency orange juice and coffee. Review of the clinical record revealed the facility admitted Resident #45 on 07/17/19 with [DIAGNOSES REDACTED]. Review of the Care Plan for nutritional risk revealed goals of the plan included adequate swallowing as evidenced by no choking. Interventions included providing a regular liberalized diet with ground meat and nectar thick liquids as ordered; and no water pitcher at bedside. Interview with Certified Nursing Assistant (CNA) #2, on 09/05/19 at 8:58 AM, revealed she served Resident #45 thin liquids for breakfast. Interview, on 09/05/19 at 3:00 PM, with the Unit Manager (UM) for South Hall revealed Resident #45 was prescribed a therapeutic diet with nectar thick liquids and should not have a water pitcher in the room. Interview with the Assistant Director of Nursing (ADON), on 09/06/19 at 4:08 PM, revealed the purpose of the care plan was to ensure proper care to meet resident needs. The ADON revealed Resident #45's care plan for nutritional risk was not implemented related to the therapeutic diet and fluid consistency. Interview with the Director of Nursing (DON), on 09/06/19 at 6:35 PM, revealed CNA's and nurses were responsible for ensuring residents were served the correct therapeutic diet and liquids. She further revealed nurses were responsible for ensuring CNA's provided water pitchers to the appropriate residents according to the therapeutic diet. Interview with the Administrator, on 09/06/19 at 7:41 PM, revealed the facility had not identified any issues related to implementation of care plans. 3. Observation, on 09/03/19 at 2:55 PM, revealed Resident #37 lying on his/her right side at the edge of the bed and the call light attached to the left 1/4 rail located behind the resident. Interview during observation revealed the resident had a bowel movement in his/her brief and could not reach the call light. Further observation of Resident #37, on 09/03/19 at 3:41 PM, revealed the resident's call light was missing the red push button and not functional. Interview with the resident during observation revealed the call light had been broken for a long time. Interview with CNA #1, on 09/03/19 at 3:42 PM, during observation of Resident #37 revealed she gave the resident the call light after incontinent care but had not noticed it was broken. Review of the clinical record revealed the facility admitted Resident #37 on 10/15/18 with [DIAGNOSES REDACTED]. Review of the Brief Interview for Mental Status (BIMS) exam, dated 08/05/19, revealed the facility assessed the resident with a total score of 10 out of 15 and determined he/she was interviewable. Review of the annual Minimum Data Set (MDS), dated [DATE], revealed Resident #37 was totally dependent upon staff for bed mobility and toileting. Review of the Resident #37's Care Plan for Fall Risk, revised 05/01/19, revealed the resident had a history of [REDACTED]. Interventions included placing the call light within reach while in bed or close proximity to the bed. Interview with the South Hall Unit Manager (UM), on 09/05/19 at 3:00 PM, The UM further revealed Resident #37's fall risk care plan was not implemented related to the call light access. Interview with the ADON, on 09/06/19 at 4:08 PM, revealed the purpose of the care plan was to ensure proper care to meet resident needs and stated Resident #37's care plan was not implemented because the call light was broken. Interview with the Maintenance Director, on 09/03/19 at 3:50 PM, revealed he was not aware of the broken call light. He stated he rounded routinely in resident rooms for maintenance items but could not verbalize how this call light was missed, or how long the call light was broken. Interview with the DON, on 09/06/19 at 6:35 PM, revealed she tried to round and scan resident rooms daily but she was not always successful. She stated the South Hall UM mainly did rounds of the rooms, which included observing call lights to ensure they were within reach; however, the lights were not checked for function. The DON revealed she was not aware of any issues related to broken call lights and stated it was the responsibility of the Maintenance Director to monitor call lights. Interview with the Administrator, on 09/06/19 at 7:41 PM, revealed he was not aware of any concerns related to implementation of care plans.

Based on interview, record review, and facility policy review it was determined the facility failed to ensure the activity department provided community outings to meet the interests of residents. The findings include: Review of Resident Rights revealed residents had the right to participate in social, religious, and community activities if the activities did not interfere with the rights of other residents in the nursing facility. Review of the policy Program Components, revised 04/01/18, revealed the Recreation Department would create a program environment that supported an individual's well being and wellness. The purpose of the policy was to provide an ongoing person-centered recreation program that incorporated the individual's interests, hobbies, and cultural preferences which were integral to maintaining and improving a resident's/patient's physical, mental, and psychosocial well being and independence. Review of the Job Description for Center Executive Director (CED), effective 01/01/16, revealed an essential function of the CED role was to create a culture of Service Excellence which focused on the patient experience, and was responsive to patients/families concerns and grievances. Interview with Resident #10, on 09/04/19 at 2:05 PM, revealed residents were not able to go on community outings because the facility's two (2) buses had been broken down for over a year. Review of Resident Council Meeting Minutes, dated 04/09/19, revealed residents would like more movie outings and picnics. Review of Resident Council Meeting Minutes, dated 05/14/19, revealed residents would like more picnics and movie outings. Review of Resident Council Meeting Minutes, dated 08/13/19, revealed residents would enjoy a movie outing when the facility bus was fixed. Interview with the Activities Director, on 09/04/19 at 3:41 PM, revealed residents often talked about community outings, especially during resident council meetings, but there was always something wrong with the bus. She revealed it would be important for residents to go on outings to get a change of scenery; however, it had probably been about a year since there was a leisure outing because of maintenance issues with the bus. According to the Activities Director, the Center Executive Director (CED) was aware of the issue and was in the process of having the bus repaired. Interview with the Administrator, on 09/06/19 at 7:41 PM, revealed he was aware of maintenance issues with the facility bus. He stated one bus caught fire and was not usable; and the lift and air conditioner was not working on the other bus. The CED revealed the facility obtained quotes and approval for the repair of the bus. According to the CED, the bus needed to be taken to the mechanic for repair.

Based on interview, record review, and facility policy review it was determined the facility failed to ensure advance directives were in the clinical record for two (2) of thirty-seven (37) sampled residents, Resident #10 and #45. The findings include: 1. Review of facility policy, Health Care Decision Making, revised [DATE], revealed it was the right of all patients to participate in their own health care decision-making, which included the right to decide whether they wish to request, accept, refuse, or discontinue treatment, and to formulate or not formulate an advance directive. The purpose of the policy was to assure the patients' wishes concerning health care decisions were communicated to all staff so patients' rights were honored and their wishes executed at the appropriate time. The policy revealed a copy of the advance directive and/or portable medical orders were placed in the medical record upon admission and the inter-professional team would be notified of the directive. If the patient/resident representative had not brought the document(s) to the Center, the Center Admissions Designee would advise the patient/resident representative that wishes would not be honored without a copy in the medical record and would request the patient/resident representative bring the document(s) to the Center as soon as possible. Review of the clinical record revealed the facility admitted Resident #45 on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. Further review of the clinical record revealed no advance directive. The facility did not provide a copy of Resident #45's advance directive. Interview with the Unit Manager (UM) for South Hall, on [DATE] at 3:00 PM, revealed the admission nurse and UM were responsible for ensuring a copy of the advance directive was in the clinical record and an order entered in the electronic record. The UM revealed she did not audit Resident #45's admission records to verify the clinical record was complete. According to the UM, the Director of Nursing (DON) and Minimum Data Set (MDS) Coordinator audited charts during the morning meeting and notified UM's if records were missing, including the advance directive. She stated the clinical record should include a copy of Resident #45's advance directive to ensure the resident's wishes were respected; however, he/she would be considered a Full Code until there was a directive on the chart. Interview with the Social Services Director (SSD), on [DATE] at 3:40 PM, revealed the Admissions Director was responsible for ensuring a copy of Resident #45's advance directive was in the clinical record. She stated the interdisciplinary team (IDT) also reviewed advance directives during care plan meetings with the resident/responsible party. According to the SSD, the advance directive was a legal document that communicated the resident's wishes for code status. Interview with the Admissions Director (AD), on [DATE] at 9:29 AM, revealed she obtained the consent for code status/advance directive upon admission. She stated after the resident signed a DNR consent, she scanned the document to the electronic record and gave the consent to the DON for the physician's signature. The AD further revealed Medical Records was responsible for ensuring the signed consent was placed in the clinical record. The AD revealed she did not obtain an advance directive for Resident #45. Interview with the Assistant Director of Nursing (ADON), on [DATE] at 4:08 PM, revealed the Admissions Director was responsible for obtaining advance directive/consent during the admission process and ensuring the directive was filed in the chart. She further revealed UM's were responsible for audits of the clinical record to ensure accuracy of the physician orders [REDACTED]. Interview with the DON, on [DATE] at 6:35 PM, revealed the Admissions Director was responsible for initiating the advance directive and the SSD was supposed to follow-up on it. The DON further revealed she audited admission orders [REDACTED]. The DON revealed Resident #45's DNR order was from a previous admission in (YEAR). Interview with the Administrator, on [DATE] at 7:41 PM, revealed he had not identified any issues related to advance directives. 2. Review of the clinical record for Resident #10 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed the facility assessed Resident #10 with a Brief Interview for Mental Status (BIMS) exam score of fifteen (15) and determined the resident was interviewable. Interview with Resident #10, on [DATE] at 2:44 PM, revealed the resident completed an advance directive and supplied the facility with a copy. Review of the advance directive section of the clinical record revealed no advance directive in the chart. Review of the physician orders [REDACTED]. Review of the Nurse Practitioner progress notes dated [DATE] revealed facility staff were to attempt resuscitation or cardiopulmonary resuscitation (CPR) on Resident #10. Interview with the Assistant Director of Nursing (ADON), on [DATE] at 8:50 AM, revealed Resident #10 did not have an advance directive on file.

Based on observation, interview, and facility policy review it was determined the facility failed to ensure a homelike environment for one (1) of thirty-seven (37) sampled residents, Resident #25. The plastic covering on Resident #25's over bed table was partially peeled off and exposed bare particle board surface underneath. In addition, observations of the Resident's smoking area revealed an unkept area containing cigarette butts and trash. The findings include: 1. Review of the facility's Resident Rights revealed the resident had the right to receive treatment, care, and services in an environment that promoted maintenance or enhancement of each resident's quality of life. Observation of Resident #25's room, on 09/03/19 at 2:50 PM, revealed the brown plastic covering of the over bed table was torn and peeled away exposing a bare particle board surface. Interview with Resident #25, on 09/05/19 at 1:25 PM, revealed the over bed table needed to be replaced because he/she liked the house to look cute. Interview with Certified Nursing Assistant (CNA) #2, on 09/05/19 at 1:58 PM, revealed she had not noticed the torn up over bed table and stated the torn lamination was kind of sharp and could cut a residents skin. CNA #2 further revealed she liked everything in order at her house and did not consider the table homelike. Interview with the South Hall Unit Manager (UM), on 09/05/19 at 3:00 PM, revealed she performed walking rounds of the unit and had not noticed any issues with peeling plastic on the over bed tables. She stated it was important to ensure the tables were in good repair because it did not look nice and a resident could get skin tears. Interview with the Assistant Director of Nursing (ADON), on 09/06/19 at 4:08 PM, revealed she performed daily rounds of resident rooms to ensure they were clean. She stated she was not aware of any issues with peeling plastic on over bed tables and stated the missing plastic was an infection control issue. Interview with the Director of Nursing (DON), on 09/06/19 at 6:35 PM, revealed she attempted daily rounds of resident rooms but stated she was not aware of any issues with over bed tables. 2. Review of Resident Rights revealed a resident had the right to receive treatment, care, and services that were in an environment that promoted, maintained or enhanced each resident's quality of life. Observation, on 09/03/19 at 1:30 PM, revealed a red metal container by the back gate at the back of the courtyard with flying insects that appeared to be wasps, entering and exiting the container. Observation, on 09/03/19 at 1:56 PM, revealed multiple residents attempted to enter/exit the smoking area/courtyard. Observations revealed residents unable to open the door or they became impinged with the door as they attempted to go through the door with a wheelchair. Further observation revealed a manually operated door. Observation, on 09/05/19 at 1:44 PM, revealed Resident #11 in the courtyard with a smoking bib present to his/her front chest and lap area. The apron contained multiple, large cracks to the front of the bib. Observation, on 09/03/19 at 2:09 PM, revealed Resident #16 attempted to open the door to the courtyard and failed. Continued observation revealed Resident #16 made multiple attempts while in a wheelchair to open the door and staff eventually assisted the resident through the door. Continued observations, on 09/05/19 at 1:45 PM, revealed the courtyard contained leaves and dry brush-like matter encircling the sides of the courtyard edge up to two (2) feet in width. The leaves and matter held old discarded cigarette butts, which contained too many to count throughout the three (3) sides of the courtyard. A red metal container was noted present and appeared approximately one-quarter (1/4) full. The courtyard contained six (6) large plastic rings, white paper, both thin and thick to all three (3) sides of the courtyard. Further observations revealed a green heavy plastic cover/awning, identified by residents who were in the courtyard as the cover they used when it rained. The cover/awning contained large tears and open areas on the top through which the sky was observed. In addition, a ceiling fan, under the cover, contained blades all broken in various degrees. Interview with Resident #25, on 09/03/19 at 1:56, revealed he/she sat out in the smoking area as much as possible. Resident #25 stated when it rained the cover did not protect him/her or other residents from the rain. Interview with the Maintenance Director, on 09/05/19 at 1:48 PM, revealed the Activity Director notified him when the facility required new smoking aprons and stated he was not required to inspect the aprons. He stated the facility last used a landscape company to clean the courtyard about three (3) months ago. He stated he observed the cigarette butts in the courtyard, mixed in among the dry leaves and debris, which could cause a fire. He further stated the area was not clean nor pleasant to look at. Interview with the Activity Director, on 09/05/19 at 2:23 PM, revealed staff changed the smoking aprons every so often. She stated the residents had complained about the condition of the cover/awning and they were not able to keep from being wet. She stated the cover/awning condition was discussed in resident council last month and a grievance form was completed. She stated the previous administrator stated he would have the cover/awning repaired but it never occurred. She stated she supervised residents in the courtyard when smoking and provided education to residents when she observed residents throwing cigarette butts to the ground. She further stated the courtyard contained a large amount of dry leaves and brush. Interview with the Assistant Director of Nursing (ADON), on 09/06/19 at 4:08 PM, revealed the courtyard was unattractive and a fire hazard with the cigarette butts in the leaves. Interview with the Director of Nursing (DON), on 09/06/19 at 6:35 PM, revealed she was unaware of the holes with the cover/awning in the smoking area and stated her attention was not focused on the cover. She stated the facility cleaned the cigarette butts and stated she thought the cigarette butts blew out of the ash tray. The DON stated the courtyard currently looked better than before and she was unaware the fan blades were broken off under the cover in the courtyard. She stated maintenance staff were responsible to monitor the courtyard, and the equipment in the courtyard. She stated she knew Residents #6 and #25 regularly utilized the courtyard and sought protection under the cover/awning during rain. She stated it was important for residents to be outside. She further stated the facility previously discussed the condition in the courtyard and it was horrible to look at. Interview with the Center Executive Director, on 09/06/19 at 7:41 PM, revealed residents had approached him previously with complaints about the cover/awning. He stated the facility utilized a landscaping company for the courtyard which lacked obvious preventive maintenance.

Based on interview, record review, and review of the Centers for Medicare and Medicaid REsident Assiessment Instrument 3.0 Manual, it was determined the facility failed to ensure the discharge Minimum Data Set (MDS) was transmitted within fourteen (14) days of completion for one (1) of thirty-seven (37) sampled residents, Resident #1. The findings include: Review of the Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) 3.0 Manual, Chapter 5.2, dated (MONTH) (YEAR), revealed the long-term care facility must transmit the MDS Discharge Assessment within fourtenn (14) days of the completion date. Review of the clinical record revealed the facility discharged Resident #1 on 03/28/19. Interview with the MDS Coordinator, on 09/06/19 at 3:47 PM, revealed Resident #1's discharge MDS assessment was not transmitted timely. According to the Coordinator, the discharge assessment did not appear on the transmit list because of an error. She revealed she audited MDS assessments of current residents to ensure they were transmitted; however, she did not audit the assessments of discharged residents. Interview with the Administrator, on 09/06/19 at 7:41 PM, revealed he was not aware of any issues related to timely submission of MDS assessments.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to develop and implement a baseline care plan for one (1) of thirty-seven (37) sampled residents, Resident #3. Record review discovered no baseline care plan for Resident #3 initiated within forty-eight (48) hours of admission. The findings include: Review of facility policy, Person-Centered Care Plan, revised 07/01/19, revealed the center developed and implemented baseline, person-centered care plans within forty-eight (48) hours for each resident that included the instructions needed to provide effective and person-centered care that met professional standards of quality care. Review of the clinical record revealed the facility admitted Resident #3 on 03/30/19 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Admission Assessment, dated 04/06/19, revealed Resident #3 needed extensive assistance with mobility, toileting, personal hygiene, and dressing. Resident received antipsychotic, antidepressant, and anticoagulant medications on seven (7) of the last seven (7) days, and Activities of Daily Living, Falls, Pressure Ulcers, [MEDICAL CONDITION] Drug Use, and Urinary Incontinence were triggered care areas on the assessment. Review of care plans revealed the facility initiated a baseline care plan on 04/04/19, five (5) days after admission. Interview with the MDS Coordinator, on 09/06/19 at 4:11 PM, revealed the facility did not initiate the baseline care plan within forty-eight (48) hours. She referenced the care plan and was unable to explain why it was not completed timely nor did she know who was responsible for her duties in her absence. She stated she checked for admission orders [REDACTED]. Interview with the Director of Nursing (DON), on 09/06/19 at 7:11 PM, revealed the admitting nurse initiated the baseline care plan upon the resident's admission, and the MDS Coordinator reviewed the care plan for needed corrections. She stated nursing staff audited charts nightly but did not document these audits.

Based on record review and interview it was determined the facility failed to provide two (2) of three (3) Certified Nursing Aides (CNA) with a performance evaluations annually for Employee #2 and #3. The findings include: The facility failed to provide a policy for employee performance evaluations. Review of the file for Employee #2, on 09/06/19 at 2:00 PM, revealed the employee's file did not contain a performance evaluation. Continued review revealed the facility listed a hire date of 12/01/12. Review of the file for Employee #3, on 09/06/19 at 2:05 PM, revealed the employee's file did not contain a performance evaluation. Continued review revealed the facility listed a hire date of 08/10/17. Interview with the Director of Nursing (DON), on 09/06/19 at 5:39 PM, revealed she was not provided an annual performance evaluation. She stated staff were not given staff evaluations in the year she has been the DON and added performance evaluations review the strengths and weakness of staff. She stated the tool allowed staff and the facility to set goals for performance and to work toward the goals. She stated the performance evaluations also identified poor work habits and performance which may affect the care provided to residents. The DON stated staff were evaluated annually and she was aware regulations included performance evaluations yearly with which the facility was to comply. Interview with Genesis Nurse, on 09/06/19 at 5:45 PM, revealed the corporation was without a policy for staff performance review. Interview with the Center Executive Director, on 09/06/19 at 7:04 PM, revealed he was surprised to learn evaluations were not required and there was no facility policy.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to ensure one (1) of six (6) sampled residents was served thickened liquids according to the physician's orders [REDACTED]. The findings include: Review of the policy Therapeutic Diets, revised 09/2017, revealed a therapeutic diet was defined as a diet ordered by a physician, or delegated registered or licensed dietitian, as part of the treatment for [REDACTED]. The purpose of a therapeutic diet was to eliminate or decrease specific nutrients in the diet (e.g. sodium), or to increase specific nutrients in the diet (e.g. potassium), or to provide food that a resident was able to eat (e.g. mechanically altered diet). The policy revealed diets were prepared in accordance with the guidelines in the approved Diet Manual and the individualized plan of care. Review of the policy Dining and Food Preferences, revised 09/2017, revealed the individual tray assembly ticket would identify all food items appropriate for the resident/patient based on diet order, allergies [REDACTED]. Observation, on 09/04/19 at 11:41 AM, revealed a water pitcher and straw on Resident #45's over bed table. Observation, on 09/05/19 at 8:49 AM, revealed Resident #45 seated in bed eating breakfast served with regular, thin consistency orange juice and coffee. Observation of Resident #45, on 09/06/19 at 8:56 AM, revealed the resident was eating breakfast in his/her room and there was a water pitcher on the over bed table. Review of the clinical record revealed the facility admitted Resident #45 on 07/17/19 with [DIAGNOSES REDACTED]. Review of Resident #45's Modified [MEDICATION NAME] Swallow Study, dated 8/30/19, revealed recommendations for mechanical soft diet and nectar thick liquids; no straws; small bites and sips; and strict upright positioning with all intake related to moderate oropharyngeal dysphagia. Further review of the clinical record revealed a physician's orders [REDACTED]. Interview with CNA #2, on 09/05/19 at 8:58 AM, revealed she referred to the nameplate at the entrance to the room to determine if a resident was prescribed thickened liquids. She stated an n indicated the resident received nectar thick liquids and an h honey thick liquids. Observation of Resident #45 nameplate during interview revealed there was no label indicating the resident was prescribed thickened liquids. Interview with CNA #3, on 09/05/19 at 9:03 AM, revealed the nameplate at the entrance to the resident room was labeled with the consistency of thickened liquids and stated the tray ticket also listed the type of diet and consistency. She stated a resident could potentially choke, aspirate, or get pneumonia if the wrong consistency was served. According to the CNA, the nurse or CNA was responsible for verifying the tray to ensure the prescribed diet was served. Interview, on 09/05/19 at 3:00 PM, with the Unit Manager (UM) for South Hall revealed Resident #45 was prescribed a therapeutic diet with nectar thick liquids and should not have a water pitcher in the room. She further revealed UM's were responsible for ensuring the name plate was labeled correctly when the diet was changed; however, she forgot to label Resident #45's. Further interview with the UM revealed nurses placed a copy of new diet orders in the Dietary Manager's mailbox located in the business office and after hours gave the copy to the night cook. The UM stated the dietary department was responsible for ensuring the correct therapeutic diet and liquid consistency was listed on the tray ticket. Observation of Resident #45, on 09/06/19 at 8:56 AM revealed the resident seated in bed eating breakfast and a water pitcher with a straw on the over bed table. Further observation revealed the order for nectar thick liquids was not listed on the tray ticket or on nameplate at the door. Interview with the Dietary Aide, on 09/06/19 at 9:36 AM, revealed she was responsible for verifying tray tickets in the kitchen to ensure residents were served the correct diet and liquids; however, she did not really have to look at the tickets because she knew who was on thickened liquids. She stated it was important to serve the prescribed consistency because a resident could choke on thin liquids and aspirate. Further interview with the Dietary Aide revealed nurses brought diet change orders to the kitchen and the Dietary Manager was responsible for entering the change in the computer. She stated diet orders received after hours was placed on the Dietary Manager's desk to enter the next morning. Interview with the Dietary Manager (DM), on 09/06/19 at 9:44 AM, revealed she was responsible for revising the tray tickets with new diet orders. The Manager revealed Resident #45 was prescribed thickened liquids; however, the order was not listed on the tray ticket. Interview with the Speech Therapist (ST), on 09/06/19 at 2:00 PM, revealed he assessed Resident #45, noticed the resident had trouble swallowing, and recommended a swallow study. The ST further revealed he was not aware of any concerns related to the resident's prescribed therapeutic diet or liquids. Interview with the Assistant Director of Nursing (ADON), on 09/06/19 at 4:08 PM, revealed staff were responsible for verifying the tray ticket when passing out meal trays to ensure the prescribed diet was served. She stated the labels on the name plates were inconsistent and should not be used as a reference for fluid consistency. According to the ADON, there was no audit process in place to ensure the label on the name plates were accurate and stated there was a risk a resident could choke or aspirate if the label was incorrect. Further interview with the ADON revealed nurses were responsible for ensuring CNA's were aware of those residents prescribed thickened liquids, fluid restrictions, or were nothing by mouth (NPO) when they passed water pitchers. According to the ADON, she monitored CNA's and resident care daily during walking rounds. Interview with the DON, on 09/06/19 at 6:35 PM, revealed she was not aware of any issues related to communication of new diet orders. The DON stated nurses and CNA's were responsible for verifying tray tickets to ensure the correct therapeutic diet and liquids were served. She revealed nurses kept up with the water pitchers and stated a list of residents who received a pitcher was posted in the kitchen and on the resident's name plate. The DON further revealed name plates were labeled for those residents on thickened liquids; however, she did not have a hand in the process and thought speech therapy labeled them. The DON revealed water pitchers were changed every night and nurses were responsible for checking behind CNA's to verify the appropriate residents received a pitcher. The DON stated she assumed the system worked because the facility did not have any residents with aspiration pneumonia. Interview with the Administrator, on 09/06/19 at 7:41 PM, revealed he was not aware of any concerns related to therapeutic diets.

Based on observation and interview it was determined the facility failed to ensure the daily staffing information was posted for public view. Observations revealed the facility failed to post the staffing post on 09/06/19. Interviews with the Unit Manager and the Director of Nursing (DON) revealed the posted staff information was not completed for the week on 09/02/19 through 09/06/19. The findings include: The facility was unable to provide a policy regarding posting of staffing information. The facility was unable to provide documentation of posted staffing information for 09/02/19 through 09/06/19. Observation, on 09/06/19 at 2:50 PM, revealed the no posted staffing information at the main entrance or at the entrance of the two (2) units, north and south, in the facility. Interview with the Unit Manager, on 09/06/19 at 2:50 PM, revealed she was responsible to post the nursing information daily. However, the Unit Manager stated she was not here at the facility for the week until 09/06/19. She stated the posted staffing information included the number of staff for each licensure level for each shift, the hours for each shift with the total hours for the day in addition to the resident census. She stated she placed the posted information to each unit but not at the entrance of the facility. She stated the DON assigned her to post the information each day of the week except weekends. Interview with the DON, on 09/06/19 at 2:52 PM, revealed staffing information was posted daily. She stated she assigned the Unit Manager to complete the documentation and post it daily. However, she stated the unit manager was out of the building all week, nor did she (the DON) post the information in the Unit Manager's absence. Additionally, the DON stated it was her responsibility to ensure the information was posted. She stated the posted staffing information was to be visible to all which informed all about the staffing level in the facility. Interview with the Executive Center Director, on 09/06/19 at 7:41 PM, revealed he was unaware posted staff information was not visible or posted in the facility. However, he stated it was supposed to be posted daily.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to ensure infection control policies were followed during a dressing change for one (1) of thirty-seven (37) sampled residents, Resident #10. Observations revealed staff failed to sanitize or provide a barrier to a table surface prior to placing dressing change supplies on the surface. Additionally, staff's hair fell into a soiled dressing just removed from Resident #10's buttock area. The findings include: Review of the facility policy, Wound Dressing Policy, revised 01/02/14, revealed staff performed wound dressings using aseptic technique, which decreased the risk of wound contamination and cross contamination during dressing changes. Review of the facility policy, Wound Dressing Aseptic, revised 11/28/17, revealed staff gather supplies and a clean barrier. Staff were to clean the over-bed table and a barrier applied before supplies were placed on the table. The policy further revealed a plastic bag should be in reach for the soiled dressing and the dressing and gloves were discarded according to policy. Review of the clinical record for Resident #10 revealed the facility admitted the resident on 06/07/17 with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/24/19 revealed the facility assessed Resident #10 with a Brief Interview for Mental Status (BIMS) exam score of fifteen (15) and determined the resident was interviewable. The MDS further revealed Resident #10 was totally dependent on staff with one (1) person assist for bed mobility, transfers, dressing, eating, toilet use, and bathing. The MDS further revealed Resident #10 had limited range of motion (ROM) on both the upper and lower extremities and had one (1) stage four (4) pressure ulcer to the coccyx. Observation, on 09/06/19 at 10:30 AM, during the wound assessment with Registered Nurse (RN) #1, revealed Resident #10 lying on a Dermaflow mattress. Continued observations revealed RN #1 placed wound care items, including packages of gauze, kerlix, Integrity Wound Cleaner, and skin prep onto the over-bed table, which also contained some personal items. RN #1 failed to sanitize the table and nor was a barrier applied. Observation further revealed RN #1 removed the old dressing from the left gluteal fold and placed it directly onto Resident #10's bed with the soiled side up. The soiled dressing contained serosanguious drainage as stated by RN #1. RN #1 held her head down by the soiled dressing and some of her hair fell on to the dressing with the serosanguious drainage on it. RN #1 moved her head and stated she did not want her face to get into the dressing. RN #1 removed her gloves and washed her hands when finished. Interview, on 09/06/19 at 11:00 AM, with RN #1 revealed she did not clean the over-bed table off when she laid the supplies on it because it was not a sterile procedure and all she had to do was to open packages. RN #1 revealed she usually put the old dressing in her glove as she removed the glove however she stated she only had two (2) gloves on and not three (3) like normal so she just laid the dirty dressing on the bed until she pulled the gloves off and then wrapped them. RN #1 revealed normally she pulled her hair up out of the way and she did not realize her hair had fallen into the old dressing that was lying on the bed. RN #1 revealed it was a risk for everyone because germs could transfer from one (1) person to another. RN #1 revealed she was going to wash her hair immediately. Interview with the Director of Nursing (DON), on 09/06/19 at 2:36 PM, revealed staff can move items around on the over-bed table and they did not have to clean the table if they were just putting supplies on it. The DON further revealed it was not appropriate to put the old dressing on the residents' bed because it could pose a risk of the dressing having something on it that would be transferred to the bed. The DON further revealed the nurse's hair falling into the old dressing was an infection control issue. She revealed if the old dressing had germs on it then that could be passed from room to another room. Interview, on 09/06/19 at 2:36 PM, with the Administrator, revealed staff should follow the Infection Control Policy.

Based on interview, record review, and facility policy review, it was determined the facility failed to have an effective system in place to ensure an allegation of sexual abuse was reported to the State Survey Agency timely for one (1) of three (3) sampled residents, Resident #1. Resident #1 alleged a male staff sexually assaulted him/her on 08/15/18; however, record review revealed the facility did not report the allegation to the State Agency until 08/20/18, five (5) days after the alleged incident occurred. The facility's failure to report allegations of abuse has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 11/05/18 and was determined to exist on 08/15/18. The facility was notified of the IJ on 11/05/18. The facility provided an Acceptable Allegation of Compliance (A[NAME]) on 11/07/18, which alleged removal of the Immediate Jeopardy on 11/07/18. The State Survey Agency verified the Immediate Jeopardy was removed on 11/07/18, prior to exit on 11/09/18. The Scope and Severity was lowered to a D while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systematic changes. The findings include: Review of the facility's policy, Abuse Prohibition, revised 07/01/18, revealed upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the Center Executive Director or designee would enter the allegation into the Risk Management System. The Center Executive Director would report allegations involving physical, verbal, mental, and sexual abuse no later than two (2) hours after the allegation was made. Review of the closed clinical record for Resident #1 revealed the facility admitted the resident on 08/09/18 with [DIAGNOSES REDACTED]. The resident was not in the facility long enough to have an Admission MDS assessment. Review of a facility Self-Reported Incident Form, received by the State Survey Agency on 08/20/18, revealed a Social Worker at a [MEDICAL TREATMENT] center reported to the facility's Center Executive Director (CED) that Resident #1 stated someone had been coming into his/her room and having sex with him/her. Review of the facility's investigation for Resident #1's allegation revealed the [MEDICAL TREATMENT] center reported the allegation to the CED of the facility on 08/15/18. However, there was no documented evidence the CED reported the allegation of sexual abuse to the State Survey Agency until 08/20/18. Interviews with Registered Nurse (RN) #1 and RN #2, on 10/31/18 at 2:45 PM, revealed they had no recollection of any reports being sent to the State Survey Agency. Interview with the current CED, on 11/09/18 at 11:52 AM, revealed any incident or unusual occurrence was entered into the Risk Management System; however, he could not locate a report regarding Resident #1's abuse allegation. Interview with the former CED, on 11/02/18 at 3:40 PM, revealed she thought she had notified the State Survey Agency. She stated Resident #1 did not give consistent answers and refused to allow a skin check. She stated the resident was sent to the hospital for an evaluation and refused to cooperate with staff there and was sent back to the facility. The resident left the faciity on [DATE]. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #1 is no longer in the facility. 2. The CED reviewed all grievances/concerns since 08/15/18 to present on 11/05/18 to ensure that all allegations of sexual assault had been reported to the Division of Health Care, Office of Inspector General (OIG). 3. The Social Worker (SW), Center Nurse Executive (CNE), RN Unit Managers (UM) and CED conducted interviews with current residents with a Brief Interview for Mental Status (BIMS) at eight (8) or above on 11/02/18. There were no allegations of sexual assault during these interviews and residents felt safe in the facility. 4. Licensed Nurses conducted body audits of residents with BIMS less than eight (8), on 11/06/18, to ensure no evidence of physical trauma. No concerns were identified. 5. Center staff received reeducation beginning on 11/02/18 by the CED, NPE and the CNE. Forty-two (42) of eighty-nine (89) employees have received education since 11/06/18. The reeducation included nursing staff, therapy staff, housekeeping, laundry aides, maintenance staff, dietary staff, and department entities to ensure all allegations (sexual) were reported to OIG and those allegations were thoroughly investigated in a timely manner to protect residents from harm during an investigation. A Post-Test requiring a score of 100% was required to pass. Staff not available during this time will be provided this education plus the post- test prior to returning to work by the CNE, CED or by the NPE. 6. New hires would be educated and pass a post-test prior to working at the facility. 7. The Regional Vice President of Operations (RVP) conducted education with the Center CED, SSW, and DNE on 11/05/18 regarding the Abuse Policy and implementation of the policy. Including allegations of abuse, reporting of abuse to OIG, investigating thoroughly, and protecting the resident during an investigation. A post-test was administered by the RVP at the time of the education with a 100% score required to validate understanding. 8. The CED and/or the CNE will review grievances, [MEDICATION NAME], and concerns and sign off on them. All investigations will be thoroughly completed in a timely manner and residents will be protected from harm during the investigation. The CNE, RN, UM, and SSW will conduct interviews with five (5) random residents per hall and five (5) random staff members per unit daily for two (2) weeks across all shifts, including weekends. Then, the audits will be completed three (3) times a week for two (2) weeks, then weekly for eight (8) weeks, then every other week for eight (8) weeks, then monthly times two (2) months to ensure allegations of sexual abuse are reported to OIG. The CNE or the CED would QA report findings monthly times six (6) months to the Quality Assurance Performance Improvement Committee (QAPI), which includes the CED, CNE, Assistant Director of Nursing, Medical Director, SSW, FSM, Dietician, Health Information Manager, Business Office Manager, Therapy Program Director, Maintenance Director, Activity Director and Certified Aides, for additional follow-up in servicing until the issue is resolved and ongoing thereafter as determined by the QAPI Committee. The SSA validated the facility implemented the following actions: 1. Review of the Roster Matrix on 10/29/18, revealed Resident #1 no longer resided at the facility. 2. Review of the grievances/concerns, dated 08/15/18 to 11/09/18, revealed there were no other allegations of sexual assault. 3. Record review revealed interviews were conducted. Interview with the Social Services Worker, on 11/09/18 at 12:25 PM, revealed all residents with a Brief Interview for Mental Status (BIMS) score of eight (8) and higher were interviewed on 11/02/18. Review of the interviews, completed by the facility, from residents on 11/02/18, revealed there were no allegations of sexual assault and the residents felt safe in the facility. Interview with Unsampled Resident F, on 11/09/18 at 10:21 AM, revealed the resident had no concerns regarding care and was treated well by staff. He/She revealed feeling safe in the facility. Interview with Unsampled Resident E, on 11/09/18 at 10:35 AM, revealed he/she had no concerns regarding safety in the facility as there were no problems with staff. Interview with Unsampled Resident D, on 11/09/18 at 10:51 AM, revealed the resident was not concerned regarding safety, and if there were a problem, he/she would report it to the SSW. 4. Review of the Body Audits completed on 11/06/18 of residents with BIMS scores less than eight (8), revealed no physical trauma. Interview with RN #1, on 11/07/18 at 3:41 PM, revealed she completed body audits on all residents in the facility with a BIMS score of less than eight (8). She stated she found no injuries or concerns with any resident. 5. Review of the Staff reeducation beginning on 11/02/18, revealed forty-nine (49) of eighty-nine (89) staff members reeducated as of 11/09/18. Interview with the CED on 11/09/18, revealed he and the CNE provided the education on the abuse regulations. Interview with the CED, on 11/08/18, revealed staff was not allowed to return to work until they received reeducation and passed the Post-Test. This education would be provided for by the CED or CNE. Those requiring reeducation were taken to the CED's office and provided the abuse education and took the test afterwards. Interview with Licensed Practical Nurse (LPN) #4, on 11/08/18 at 9:10 AM, revealed she attended the abuse in-service last week and was able to recognize and name the types of abuse and to report any abuse to the CED and the CNE immediately. Interview with Certified Nurse Aide (CNA) #10, on 11/08/18 at 9:20 AM, revealed she did attend the abuse reeducation and could name the types of abuse and their definition. She revealed she would notify the CED and the CNE immediately if she saw abuse. Interview with CNA #11 at 9:32 AM on 11/08/18, revealed he attended the in-service training last week and could name and define the types of abuse. He stated he would report any abuse to the CED and the CNE immediately. Interview with CNA #10, at 10:05 AM on 11/08/18, revealed she attended the in-service training on abuse last week and was able to name the types of abuse and give their definition. She added she would report any abuse to the CED and CNE immediately. Interview with Dietary Aide #1, on 11/08/18 at 12:40 PM, revealed she attended the in-service last week and was able to name and define the types of abuse. She stated she would notify the CED and the CNE immediately. Interview with Dietary Aide #2, on 11/08/18 at 12:30 PM, revealed she did attend the abuse training last week and was able to name and define the types of abuse. She reported she would notify the CED and the CNE immediately. Interview with Housekeeper #1, on 11/08/18 at 12:30 PM, revealed she attended the abuse in-service and could name the types of abuse and describe them. She revealed she would report abuse immediately to the supervisor and the CED. Interview with Medical Records, on 11/08/18 at 1:10 PM, revealed she did attend the in-service on abuse last week and stated she was able to name the types of abuse and their definition. She stated she would notify the CED and CNE of any abuse immediately. Interview with the Director of Therapy, on 11/08/18 at 1:20 PM, revealed he was reeducated on the abuse policy last week and was able to name and describe the types of abuse. He stated he would notify the CNE and the CED immediately if abuse seen. Interview with Physical Therapist #1, on 11/08/18 at 1:29 PM, revealed he was in-serviced on abuse and the facility policy and could name the types of abuse. He stated he would report abuse to his supervisor and the CED immediately. Interview with the Occupational Therapist, on 11/08/18 at 1:38 PM, revealed she was educated on abuse last week and could name the types of abuse. She stated she would report abuse immediately to the CED. Interview with Laundry Staff #1, on 11/08/18 at 1:45 PM, revealed she was educated on abuse and could name the types of abuse. She stated she would notify the CED immediately of any abuse. Interview with Laundry Staff #2, on 11/08/18 at 1:56 PM, revealed she was trained on abuse last week and could name the types of abuse and would report it immediately to the CDE. Interview with the Laundry Supervisor, on 11/08/18 at 2:05 PM, revealed she was trained on abuse last week and could name the types of abuse. She stated she would report abuse to the CED immediately. Interview with RN #4, on 11/08/18 at 2:12 PM revealed she was trained on abuse last week and could name all the types of abuse. She stated that abuse should be reported immediately to the CED. Interview with LPN #3, on 11/08/18 at 2:25 PM, revealed she attended the abuse training last week and could name the types of abuse and what each type was. She added, she would notify the CED and the CNE immediately for abuse. Interview with CNA #8, on 11/08/18 at 2:38 PM, revealed she was trained on abuse last week and was able to name and describe each type of abuse. She stated she would report abuse to the CED and the CNE immediately. Interview with RN #1, on 11/08/18 at 2:50 PM, revealed she was reeducated on the abuse policy and could name the types of abuse. She stated abuse was reported immediately to the CED and the CNE. Interview with CNA #9, on 11/08/18 at 3:10 PM, revealed she was reeducated last week on abuse and could name the types of abuse. She stated the abuse was reported immediately to the CED and the CNE. Interview with LPN # 1, on 11/08/18 at 3:20 PM, revealed she was reeducated on the abuse policy last week and was able to name the types of abuse. She stated abuse was reported immediately to the CED and the CNE. Review of the POS [REDACTED]. Interview with the CNE, on 11/07/18, revealed all staff scored 100%. Interview with the Regional Vice President of Operations (RVP), on 11/08/18 revealed the company was adamant regarding preventing abuse, reporting timely, and investigating thoroughly. He stated he educated the CED, CNE, and the SSW on 11/02/18 regarding the Abuse Policy and implementation of the policies. These policies included allegations of abuse to OIG, investigation thoroughly, and protecting the resident during investigations. Review of the sign-in sheet for the reeducation, dated 11/02/18, revealed the CED and CNE attended the reeducation. The education included the Abuse Policy, the Risk Management System, and incident reports. Review of the POS [REDACTED]. Staff not available during the time of the reeducation would be required to be reeducated plus take the Post-Test and score 100% prior to returning to work. Observation of the CED, on 11/08/18 at 2:35 PM, revealed the CED at the time clock waiting for staff to come in so they could be reeducated. 6. Interview with the CED and the CNE on 11/09/18, revealed all new staff would receive this education during orientation as per the orientation checklist reviewed. 7. Interview with the Regional Vice President of Operations, on 11/07/18 at 2:00 PM, revealed he educated the CED and the CNE on abuse and the policy of the company. 8. Interview with the CED, on 11/08/18, revealed he or the CNE would review all grievances and concerns, and signed off on them weekly. The CNE, RN, UM, and SSW would conduct interviews with five (5) random residents per hall and five (5) random staff members per unit per day for two (2) weeks about any abuse/neglect issues across all shifts including weekends. He stated audits would continue three (3) times per week for two (2) weeks, then weekly for eight (8) weeks, then every other week for eight (8) weeks then monthly times two (2) months to ensure compliance with the Abuse Policy. Review of the random audits for 11/07/18 and 11/08/18, verified the audits were enforce.

Based on interview, record review, facility policy review, and review of the facility's investigation, it was determined the facility failed to have an effective system in place to protect residents from potential abuse for one (1) of three (3) sampled residents, Resident #1. On 08/15/18, Resident #1 alleged a male staff sexually assaulted him/her. Per interview and record review, the facility did not remove the alleged perpetrator from resident care to prevent the potential for further abuse. In addition, the facility did not train staff on abuse prevention after the alleged incident. The facility's failure to protect residents from abuse has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 11/05/18 and was determined to exist on 08/15/18. The facility was notified of the IJ on 11/05/18. The facility provided an Acceptable Allegation of Compliance (A[NAME]) on 11/07/18, which alleged removal of the Immediate Jeopardy on 11/07/18. The State Survey Agency verified the Immediate Jeopardy was removed on 11/07/18, prior to exit on 11/09/18. The Scope and Severity was lowered to a D while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systematic changes. The findings include: Review of the facility's policy, Abuse Prohibition, revised 07/01/18, revealed the facility prohibited abuse for all residents. The facility implemented an abuse prohibition program by investigating incidents and allegations, protecting residents during the abuse investigation, and training employees (both new employees and ongoing training for all employees). Training would be provided to all employees, through orientation and a minimum of annually. The policy further stated the employee alleged to have committed the act of abuse would be immediately removed from duty, pending investigation. Review of the closed clinical record for Resident #1 revealed the facility admitted the resident on 08/09/18 with [DIAGNOSES REDACTED]. The resident was not in the facility long enough to have an Admission MDS assessment. Review of the facility's investigation revealed Resident #1 was transported to the [MEDICAL TREATMENT] center on the morning of 08/15/18. The resident reported to the Social Worker at the [MEDICAL TREATMENT] center that a youngish white male with a mask had sex with the resident that morning between 4:00 AM and 5:00 AM. The [MEDICAL TREATMENT] center reported the allegation to the Center Executive Director (CED) of the facility. The resident was sent to the hospital emergency room to be evaluated but refused all services. The resident did not want to return to the facility as staff treated him/her roughly but the resident was sent back to the facility. Review of the facility's investigation revealed no documented evidence the male staff working that evening, Licensed Practical Nurse (LPN) #5, was suspended. Review of the Time Card for LPN #5 revealed he worked on 08/15/18, was off 08/16/18, and worked again on 08/17/18. Further review revealed the LPN worked twenty-two (22) more shifts before leaving employment at the end of (MONTH) (YEAR). On 11/02/18 at 8:30 AM, a telephone interview with LPN #5 was attempted; however, the phone was disconnected. Interview with Registered Nurse (RN) #1, on 11/08/18 at 2:50 PM, revealed the former CED resigned on 08/20/18. She stated there was no Director of Nursing (DON) at that time and she was helping until a new DON arrived. She stated she had concerns regarding LPN #5 not being suspended during the investigation; however, she did not know much about the allegation, only that it involved a white male and LPN #5 was working that night. In addition, there was no evidence the facility took corrective action, as there was no evidence of staff training regarding prevention of abuse after the incident. Interview with the Dietary Manager, on 11/08/18 at 12:49 PM, Certified Nurse Assistant (CNA) #10, on 11/09/18 at 9:20 AM, and Housekeeper #1, on 11/09/18 at 1:01 PM revealed they did not remember an in-service in (MONTH) of (YEAR) regarding preventing abuse. Interview with the former CED, on 11/02/18 at 3:40 PM, revealed she received a call from the [MEDICAL TREATMENT] center's Social Worker informing her a resident alleged sexual assault by a youngish white male at the facility. She stated the only white young male working told her he did not go into Resident #1's room on 08/15/18. The CED determined Resident #1 was not clear, as he/she sometimes made no sense, and she did not substantiate the allegation of sexual assault and therefore did not suspend LPN #5. Interview with the current CED, on 10/29/18 at 2:10 PM, revealed he was not employed by the facility until (MONTH) (YEAR) and was unaware of the incident with Resident #1. He stated the LPN should have been suspended to protect residents until the investigation was completed and a determination was made. Per interview, there were no files to verify education occurred, although he stated he tried to locate them. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #1 is no longer in the facility. 2. The CED reviewed all grievances/concerns since 08/15/18 to present on 11/05/18 to ensure that all allegations of sexual assault had been reported to the Division of Health Care, Office of Inspector General (OIG). 3. The Social Worker (SW), Center Nurse Executive (CNE), RN Unit Managers (UM) and CED conducted interviews with current residents with a Brief Interview for Mental Status (BIMS) at eight (8) or above on 11/02/18. There were no allegations of sexual assault during these interviews and residents felt safe in the facility. 4. Licensed Nurses conducted body audits of residents with BIMS less than eight (8), on 11/06/18, to ensure no evidence of physical trauma. No concerns were identified. 5. Center staff received reeducation beginning on 11/02/18 by the CED, NPE and the CNE. Forty-two (42) of eighty-nine (89) employees have received education since 11/06/18. The reeducation included nursing staff, therapy staff, housekeeping, laundry aides, maintenance staff, dietary staff, and department entities to ensure all allegations (sexual) were reported to OIG and those allegations were thoroughly investigated in a timely manner to protect residents from harm during an investigation. A Post-Test requiring a score of 100% was required to pass. Staff not available during this time will be provided this education plus the post- test prior to returning to work by the CNE, CED or by the NPE. 6. New hires would be educated and pass a post-test prior to working at the facility. 7. The Regional Vice President of Operations (RVP) conducted education with the Center CED, SSW, and DNE on 11/05/18 regarding the Abuse Policy and implementation of the policy. Including allegations of abuse, reporting of abuse to OIG, investigating thoroughly, and protecting the resident during an investigation. A post-test was administered by the RVP at the time of the education with a 100% score required to validate understanding. 8. The CED and/or the CNE will review grievances, [MEDICATION NAME], and concerns and sign off on them. All investigations will be thoroughly completed in a timely manner and residents will be protected from harm during the investigation. The CNE, RN, UM, and SSW will conduct interviews with five (5) random residents per hall and five (5) random staff members per unit daily for two (2) weeks across all shifts, including weekends. Then, the audits will be completed three (3) times a week for two (2) weeks, then weekly for eight (8) weeks, then every other week for eight (8) weeks, then monthly times two (2) months to ensure allegations of sexual abuse are reported to OIG. The CNE or the CED would QA report findings monthly times six (6) months to the Quality Assurance Performance Improvement Committee (QAPI), which includes the CED, CNE, Assistant Director of Nursing, Medical Director, SSW, FSM, Dietician, Health Information Manager, Business Office Manager, Therapy Program Director, Maintenance Director, Activity Director and Certified Aides, for additional follow-up in servicing until the issue is resolved and ongoing thereafter as determined by the QAPI Committee. The SSA validated the facility implemented the following actions: 1. Review of the Roster Matrix on 10/29/18, revealed Resident #1 no longer resided at the facility. 2. Review of the grievances/concerns, dated 08/15/18 to 11/09/18, revealed there were no other allegations of sexual assault. 3. Record review revealed interviews were conducted. Interview with the Social Services Worker, on 11/09/18 at 12:25 PM, revealed all residents with a Brief Interview for Mental Status (BIMS) score of eight (8) and higher were interviewed on 11/02/18. Review of the interviews, completed by the facility, from residents on 11/02/18, revealed there were no allegations of sexual assault and the residents felt safe in the facility. Interview with Unsampled Resident F, on 11/09/18 at 10:21 AM, revealed the resident had no concerns regarding care and was treated well by staff. He/She revealed feeling safe in the facility. Interview with Unsampled Resident E, on 11/09/18 at 10:35 AM, revealed he/she had no concerns regarding safety in the facility as there were no problems with staff. Interview with Unsampled Resident D, on 11/09/18 at 10:51 AM, revealed the resident was not concerned regarding safety, and if there were a problem, he/she would report it to the SSW. 4. Review of the Body Audits completed on 11/06/18 of residents with BIMS scores less than eight (8), revealed no physical trauma. Interview with RN #1, on 11/07/18 at 3:41 PM, revealed she completed body audits on all residents in the facility with a BIMS score of less than eight (8). She stated she found no injuries or concerns with any resident. 5. Review of the Staff reeducation beginning on 11/02/18, revealed forty-nine (49) of eighty-nine (89) staff members reeducated as of 11/09/18. Interview with the CED on 11/09/18, revealed he and the CNE provided the education on the abuse regulations. Interview with the CED, on 11/08/18, revealed staff was not allowed to return to work until they received reeducation and passed the Post-Test. This education would be provided for by the CED or CNE. Those requiring reeducation were taken to the CED's office and provided the abuse education and took the test afterwards. Interview with Licensed Practical Nurse (LPN) #4, on 11/08/18 at 9:10 AM, revealed she attended the abuse in-service last week and was able to recognize and name the types of abuse and to report any abuse to the CED and the CNE immediately. Interview with Certified Nurse Aide (CNA) #10, on 11/08/18 at 9:20 AM, revealed she did attend the abuse reeducation and could name the types of abuse and their definition. She revealed she would notify the CED and the CNE immediately if she saw abuse. Interview with CNA #11 at 9:32 AM on 11/08/18, revealed he attended the in-service training last week and could name and define the types of abuse. He stated he would report any abuse to the CED and the CNE immediately. Interview with CNA #10, at 10:05 AM on 11/08/18, revealed she attended the in-service training on abuse last week and was able to name the types of abuse and give their definition. She added she would report any abuse to the CED and CNE immediately. Interview with Dietary Aide #1, on 11/08/18 at 12:40 PM, revealed she attended the in-service last week and was able to name and define the types of abuse. She stated she would notify the CED and the CNE immediately. Interview with Dietary Aide #2, on 11/08/18 at 12:30 PM, revealed she did attend the abuse training last week and was able to name and define the types of abuse. She reported she would notify the CED and the CNE immediately. Interview with Housekeeper #1, on 11/08/18 at 12:30 PM, revealed she attended the abuse in-service and could name the types of abuse and describe them. She revealed she would report abuse immediately to the supervisor and the CED. Interview with Medical Records, on 11/08/18 at 1:10 PM, revealed she did attend the in-service on abuse last week and stated she was able to name the types of abuse and their definition. She stated she would notify the CED and CNE of any abuse immediately. Interview with the Director of Therapy, on 11/08/18 at 1:20 PM, revealed he was reeducated on the abuse policy last week and was able to name and describe the types of abuse. He stated he would notify the CNE and the CED immediately if abuse seen. Interview with Physical Therapist #1, on 11/08/18 at 1:29 PM, revealed he was in-serviced on abuse and the facility policy and could name the types of abuse. He stated he would report abuse to his supervisor and the CED immediately. Interview with the Occupational Therapist, on 11/08/18 at 1:38 PM, revealed she was educated on abuse last week and could name the types of abuse. She stated she would report abuse immediately to the CED. Interview with Laundry Staff #1, on 11/08/18 at 1:45 PM, revealed she was educated on abuse and could name the types of abuse. She stated she would notify the CED immediately of any abuse. Interview with Laundry Staff #2, on 11/08/18 at 1:56 PM, revealed she was trained on abuse last week and could name the types of abuse and would report it immediately to the CDE. Interview with the Laundry Supervisor, on 11/08/18 at 2:05 PM, revealed she was trained on abuse last week and could name the types of abuse. She stated she would report abuse to the CED immediately. Interview with RN #4, on 11/08/18 at 2:12 PM revealed she was trained on abuse last week and could name all the types of abuse. She stated that abuse should be reported immediately to the CED. Interview with LPN #3, on 11/08/18 at 2:25 PM, revealed she attended the abuse training last week and could name the types of abuse and what each type was. She added, she would notify the CED and the CNE immediately for abuse. Interview with CNA #8, on 11/08/18 at 2:38 PM, revealed she was trained on abuse last week and was able to name and describe each type of abuse. She stated she would report abuse to the CED and the CNE immediately. Interview with RN #1, on 11/08/18 at 2:50 PM, revealed she was reeducated on the abuse policy and could name the types of abuse. She stated abuse was reported immediately to the CED and the CNE. Interview with CNA #9, on 11/08/18 at 3:10 PM, revealed she was reeducated last week on abuse and could name the types of abuse. She stated the abuse was reported immediately to the CED and the CNE. Interview with LPN # 1, on 11/08/18 at 3:20 PM, revealed she was reeducated on the abuse policy last week and was able to name the types of abuse. She stated abuse was reported immediately to the CED and the CNE. Review of the POS [REDACTED]. Interview with the CNE, on 11/07/18, revealed all staff scored 100%. Interview with the Regional Vice President of Operations (RVP), on 11/08/18 revealed the company was adamant regarding preventing abuse, reporting timely, and investigating thoroughly. He stated he educated the CED, CNE, and the SSW on 11/02/18 regarding the Abuse Policy and implementation of the policies. These policies included allegations of abuse to OIG, investigation thoroughly, and protecting the resident during investigations. Review of the sign-in sheet for the reeducation, dated 11/02/18, revealed the CED and CNE attended the reeducation. The education included the Abuse Policy, the Risk Management System, and incident reports. Review of the POS [REDACTED]. Staff not available during the time of the reeducation would be required to be reeducated plus take the Post-Test and score 100% prior to returning to work. Observation of the CED, on 11/08/18 at 2:35 PM, revealed the CED at the time clock waiting for staff to come in so they could be reeducated. 6. Interview with the CED and the CNE on 11/09/18, revealed all new staff would receive this education during orientation as per the orientation checklist reviewed. 7. Interview with the Regional Vice President of Operations, on 11/07/18 at 2:00 PM, revealed he educated the CED and the CNE on abuse and the policy of the company. 8. Interview with the CED, on 11/08/18, revealed he or the CNE would review all grievances and concerns, and signed off on them weekly. The CNE, RN, UM, and SSW would conduct interviews with five (5) random residents per hall and five (5) random staff members per unit per day for two (2) weeks about any abuse/neglect issues across all shifts including weekends. He stated audits would continue three (3) times per week for two (2) weeks, then weekly for eight (8) weeks, then every other week for eight (8) weeks then monthly times two (2) months to ensure compliance with the Abuse Policy. Review of the random audits for 11/07/18 and 11/08/18, verified the audits were enforce.

Based on interview, record review, the facility's investigation review, and review of the facility's policy, it was determined the facility failed to have an effective system in place to thoroughly investigate an allegation of sexual abuse for one (1) of three (3) sampled residents, Resident #1. On 08/15/18, Resident #1 alleged sexual assault by a male staff. Record review and interview revealed the facility failed to interview staff that was present when the alleged incident occurred and failed to assess cognitively impaired residents for injury. The facility's failure to thoroughly investigate allegations of abuse has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 11/05/18 and was determined to exist on 08/15/18. The facility was notified of the IJ on 11/05/18. The facility provided an Acceptable Allegation of Compliance (A[NAME]) on 11/07/18, which alleged removal of the Immediate Jeopardy on 11/07/18. The State Survey Agency verified the Immediate Jeopardy was removed on 11/07/18, prior to exit on 11/09/18. The Scope and Severity was lowered to a D while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systematic changes. The findings include: Review of the facility's policy, Abuse Prohibition, revised 07/01/18, revealed the facility prohibited abuse, mistreatment, neglect, misappropriation, and exploitation of all residents. Upon receiving information concerning a report of suspected or alleged abuse, the Center Executive Director (CED) or designee would initiate an investigation with twenty-four (24) hours that focused on whether abuse or neglect occurred, clinical examination for signs of injuries, causative factors, and interventions to prevent further injury. The investigation would be thoroughly documented in the Risk management System. Interviews would be conducted using the alleged Perpetrator/Victim Interview record and Witness Interview Record and a summary of the interviews would be entered into the Risk Management System. Review of an Intake Summary from Adult Protective Services, dated 08/15/18, revealed Resident #1 reported being abused sexually at the facility this morning by a youngish, he/she guessed mid-twenty, white male whose face was covered, between 4:00 AM and 5:00 AM. Review of the Hospital Report, dated 08/15/18, revealed Resident #1 refused examination and any care and returned to the facility. Review of the facility's Self-Reported Incident Form, received by the State Survey Agency on 08/20/18, revealed Resident #1 reported to the Social Worker at a [MEDICAL TREATMENT] center that someone had been coming into his/her room and having sex with him/her. The Social Worker informed the facility's Center Executive Director (CED). However, the report did not include the date the facility was notified of the allegation of sexual abuse. Review of the facility's staffing schedule for 08/15/18, revealed Licensed Practical Nurse (LPN) #5 was a male that worked during the alleged incident. Review of the closed clinical record for Resident #1 revealed the facility admitted the resident on 08/09/18, with [DIAGNOSES REDACTED]. The Admission Minimum Data Set assessment was not yet completed. Interview with Certified Nurse Assistant (CNA) #5, on 11/01/18 at 1:33 PM, revealed she worked 08/15/18 and she did not hear any cries for help or noises from Resident #1's room between 4:00 AM and 5:00 AM, she stated the unit it was quiet that morning. She added LPN #5 visited the unit several times that shift; however, she did not see him enter any residents' room. Interview with CNA #6, on 11/01/18 at 2:00 PM, revealed she worked on Resident #1's hall on 08/15/18 and did not hear any yells or cries for help. She stated rounds were made at 4:00 AM and 5:00 AM on 8/15/18 and no concerns were noted. Interview with the Director of Nursing (DON), on 11/01/18 at 1:10 PM, revealed there were two (2) men working on 08/15/18. One (1) was an older black man and the other was a young white agency nurse, LPN #5. She stated staff informed her there were no suspensions. Review of the facility's investigation file, not located until 11/09/18, revealed Resident #1 alleged he/she was sexually assaulted at the facility between 4:00 AM and 5:00 AM on 08/15/18. The resident described the perpetrator as young, twentyish, white male wearing a mask. The Former CED interviewed LPN #5 on 08/17/18 at 3:00 PM, and he stated he was on the North Hall on Wednesday morning and did not care for Resident #1; however, he provided care for the resident after he/she returned from the hospital. Twenty (20) residents were interviewed by staff and had no concerns. These residents had Brief Interviews for Mental Status (BIMS) scores above eight (8) or were able to give an interview. This was the entire contents of the investigation file. There was no documented evidence staff was interviewed or cognitive impaired residents were assessed for potential injury. Interview with the current CED, on 11/09/18 at 11:52 AM, revealed any incident or unusual occurrence was entered into the Risk Management System. He stated no report regarding Resident #1 could be located. In addition, he stated abuse investigations should be thorough and include interviews from staff; however, these could not located. Interviews with Registered Nurse (RN) #1 and RN #2, on 10/31/18 at 2:45 PM, revealed there was no Director of Nursing during the time of the incident but they interviewed residents with BIMS scores of eight (8) and above. Interviews revealed no resident had any complaints of being touched inappropriately and they felt safe in the facility. Per interview, they did not physically assess any residents for signs of possible abuse and did not interview other staff. Interview with the facility's Social Worker, on 10/31/18 at 2:50 PM, revealed she spoke with Resident #1 and the resident did not make sense. She stated all staff that worked the morning of 08/15/18 was female; however, later in the interview, she stated that information was incorrect. She revealed she interviewed several residents on 08/17/18 and there seemed to be no concerns. She stated she was not aware that a white male nurse worked the night the resident alleged sexual abuse and no staff was suspended. She stated staff that worked on 08/15/18 during the alleged incident was not interviewed, but they should have been per policy. Interview with the former CED, on 11/02/18 at 3:40 PM, revealed she received a call from the [MEDICAL TREATMENT] center's Social Worker informing her a resident reported sexual assault by a youngish white male with his face covered who had sex with the resident that morning at the facility. She stated she requested the [MEDICAL TREATMENT] center to send the resident to the emergency room for an evaluation and the resident did go to the hospital; however, refused the evaluation and skin assessment and returned to the facility. The CED stated the only white young male working stated he did go to the resident's unit that night but did not go into anyone's room. She determined the resident was not clear and sometimes made no sense and that the allegation of sexual assault was unsubstantiated. Interview with the current CED, on 10/29/18 at 2:10 PM, revealed he was not employed by the facility until (MONTH) (YEAR) and was unaware of the incident with Resident #1. He stated a thorough abuse investigation should have been completed as required by the regulations. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #1 is no longer in the facility. 2. The CED reviewed all grievances/concerns since 08/15/18 to present on 11/05/18 to ensure that all allegations of sexual assault had been reported to the Division of Health Care, Office of Inspector General (OIG). 3. The Social Worker (SW), Center Nurse Executive (CNE), RN Unit Managers (UM) and CED conducted interviews with current residents with a Brief Interview for Mental Status (BIMS) at eight (8) or above on 11/02/18. There were no allegations of sexual assault during these interviews and residents felt safe in the facility. 4. Licensed Nurses conducted body audits of residents with BIMS less than eight (8), on 11/06/18, to ensure no evidence of physical trauma. No concerns were identified. 5. Center staff received reeducation beginning on 11/02/18 by the CED, NPE and the CNE. Forty-two (42) of eighty-nine (89) employees have received education since 11/06/18. The reeducation included nursing staff, therapy staff, housekeeping, laundry aides, maintenance staff, dietary staff, and department entities to ensure all allegations (sexual) were reported to OIG and those allegations were thoroughly investigated in a timely manner to protect residents from harm during an investigation. A Post-Test requiring a score of 100% was required to pass. Staff not available during this time will be provided this education plus the post- test prior to returning to work by the CNE, CED or by the NPE. 6. New hires would be educated and pass a post-test prior to working at the facility. 7. The Regional Vice President of Operations (RVP) conducted education with the Center CED, SSW, and DNE on 11/05/18 regarding the Abuse Policy and implementation of the policy. Including allegations of abuse, reporting of abuse to OIG, investigating thoroughly, and protecting the resident during an investigation. A post-test was administered by the RVP at the time of the education with a 100% score required to validate understanding. 8. The CED and/or the CNE will review grievances, [MEDICATION NAME], and concerns and sign off on them. All investigations will be thoroughly completed in a timely manner and residents will be protected from harm during the investigation. The CNE, RN, UM, and SSW will conduct interviews with five (5) random residents per hall and five (5) random staff members per unit daily for two (2) weeks across all shifts, including weekends. Then, the audits will be completed three (3) times a week for two (2) weeks, then weekly for eight (8) weeks, then every other week for eight (8) weeks, then monthly times two (2) months to ensure allegations of sexual abuse are reported to OIG. The CNE or the CED would QA report findings monthly times six (6) months to the Quality Assurance Performance Improvement Committee (QAPI), which includes the CED, CNE, Assistant Director of Nursing, Medical Director, SSW, FSM, Dietician, Health Information Manager, Business Office Manager, Therapy Program Director, Maintenance Director, Activity Director and Certified Aides, for additional follow-up in servicing until the issue is resolved and ongoing thereafter as determined by the QAPI Committee. The SSA validated the facility implemented the following actions: 1. Review of the Roster Matrix on 10/29/18, revealed Resident #1 no longer resided at the facility. 2. Review of the grievances/concerns, dated 08/15/18 to 11/09/18, revealed there were no other allegations of sexual assault. 3. Record review revealed interviews were conducted. Interview with the Social Services Worker, on 11/09/18 at 12:25 PM, revealed all residents with a Brief Interview for Mental Status (BIMS) score of eight (8) and higher were interviewed on 11/02/18. Review of the interviews, completed by the facility, from residents on 11/02/18, revealed there were no allegations of sexual assault and the residents felt safe in the facility. Interview with Unsampled Resident F, on 11/09/18 at 10:21 AM, revealed the resident had no concerns regarding care and was treated well by staff. He/She revealed feeling safe in the facility. Interview with Unsampled Resident E, on 11/09/18 at 10:35 AM, revealed he/she had no concerns regarding safety in the facility as there were no problems with staff. Interview with Unsampled Resident D, on 11/09/18 at 10:51 AM, revealed the resident was not concerned regarding safety, and if there were a problem, he/she would report it to the SSW. 4. Review of the Body Audits completed on 11/06/18 of residents with BIMS scores less than eight (8), revealed no physical trauma. Interview with RN #1, on 11/07/18 at 3:41 PM, revealed she completed body audits on all residents in the facility with a BIMS score of less than eight (8). She stated she found no injuries or concerns with any resident. 5. Review of the Staff reeducation beginning on 11/02/18, revealed forty-nine (49) of eighty-nine (89) staff members reeducated as of 11/09/18. Interview with the CED on 11/09/18, revealed he and the CNE provided the education on the abuse regulations. Interview with the CED, on 11/08/18, revealed staff was not allowed to return to work until they received reeducation and passed the Post-Test. This education would be provided for by the CED or CNE. Those requiring reeducation were taken to the CED's office and provided the abuse education and took the test afterwards. Interview with Licensed Practical Nurse (LPN) #4, on 11/08/18 at 9:10 AM, revealed she attended the abuse in-service last week and was able to recognize and name the types of abuse and to report any abuse to the CED and the CNE immediately. Interview with Certified Nurse Aide (CNA) #10, on 11/08/18 at 9:20 AM, revealed she did attend the abuse reeducation and could name the types of abuse and their definition. She revealed she would notify the CED and the CNE immediately if she saw abuse. Interview with CNA #11 at 9:32 AM on 11/08/18, revealed he attended the in-service training last week and could name and define the types of abuse. He stated he would report any abuse to the CED and the CNE immediately. Interview with CNA #10, at 10:05 AM on 11/08/18, revealed she attended the in-service training on abuse last week and was able to name the types of abuse and give their definition. She added she would report any abuse to the CED and CNE immediately. Interview with Dietary Aide #1, on 11/08/18 at 12:40 PM, revealed she attended the in-service last week and was able to name and define the types of abuse. She stated she would notify the CED and the CNE immediately. Interview with Dietary Aide #2, on 11/08/18 at 12:30 PM, revealed she did attend the abuse training last week and was able to name and define the types of abuse. She reported she would notify the CED and the CNE immediately. Interview with Housekeeper #1, on 11/08/18 at 12:30 PM, revealed she attended the abuse in-service and could name the types of abuse and describe them. She revealed she would report abuse immediately to the supervisor and the CED. Interview with Medical Records, on 11/08/18 at 1:10 PM, revealed she did attend the in-service on abuse last week and stated she was able to name the types of abuse and their definition. She stated she would notify the CED and CNE of any abuse immediately. Interview with the Director of Therapy, on 11/08/18 at 1:20 PM, revealed he was reeducated on the abuse policy last week and was able to name and describe the types of abuse. He stated he would notify the CNE and the CED immediately if abuse seen. Interview with Physical Therapist #1, on 11/08/18 at 1:29 PM, revealed he was in-serviced on abuse and the facility policy and could name the types of abuse. He stated he would report abuse to his supervisor and the CED immediately. Interview with the Occupational Therapist, on 11/08/18 at 1:38 PM, revealed she was educated on abuse last week and could name the types of abuse. She stated she would report abuse immediately to the CED. Interview with Laundry Staff #1, on 11/08/18 at 1:45 PM, revealed she was educated on abuse and could name the types of abuse. She stated she would notify the CED immediately of any abuse. Interview with Laundry Staff #2, on 11/08/18 at 1:56 PM, revealed she was trained on abuse last week and could name the types of abuse and would report it immediately to the CDE. Interview with the Laundry Supervisor, on 11/08/18 at 2:05 PM, revealed she was trained on abuse last week and could name the types of abuse. She stated she would report abuse to the CED immediately. Interview with RN #4, on 11/08/18 at 2:12 PM revealed she was trained on abuse last week and could name all the types of abuse. She stated that abuse should be reported immediately to the CED. Interview with LPN #3, on 11/08/18 at 2:25 PM, revealed she attended the abuse training last week and could name the types of abuse and what each type was. She added, she would notify the CED and the CNE immediately for abuse. Interview with CNA #8, on 11/08/18 at 2:38 PM, revealed she was trained on abuse last week and was able to name and describe each type of abuse. She stated she would report abuse to the CED and the CNE immediately. Interview with RN #1, on 11/08/18 at 2:50 PM, revealed she was reeducated on the abuse policy and could name the types of abuse. She stated abuse was reported immediately to the CED and the CNE. Interview with CNA #9, on 11/08/18 at 3:10 PM, revealed she was reeducated last week on abuse and could name the types of abuse. She stated the abuse was reported immediately to the CED and the CNE. Interview with LPN # 1, on 11/08/18 at 3:20 PM, revealed she was reeducated on the abuse policy last week and was able to name the types of abuse. She stated abuse was reported immediately to the CED and the CNE. Review of the POS [REDACTED]. Interview with the CNE, on 11/07/18, revealed all staff scored 100%. Interview with the Regional Vice President of Operations (RVP), on 11/08/18 revealed the company was adamant regarding preventing abuse, reporting timely, and investigating thoroughly. He stated he educated the CED, CNE, and the SSW on 11/02/18 regarding the Abuse Policy and implementation of the policies. These policies included allegations of abuse to OIG, investigation thoroughly, and protecting the resident during investigations. Review of the sign-in sheet for the reeducation, dated 11/02/18, revealed the CED and CNE attended the reeducation. The education included the Abuse Policy, the Risk Management System, and incident reports. Review of the POS [REDACTED]. Staff not available during the time of the reeducation would be required to be reeducated plus take the Post-Test and score 100% prior to returning to work. Observation of the CED, on 11/08/18 at 2:35 PM, revealed the CED at the time clock waiting for staff to come in so they could be reeducated. 6. Interview with the CED and the CNE on 11/09/18, revealed all new staff would receive this education during orientation as per the orientation checklist reviewed. 7. Interview with the Regional Vice President of Operations, on 11/07/18 at 2:00 PM, revealed he educated the CED and the CNE on abuse and the policy of the company. 8. Interview with the CED, on 11/08/18, revealed he or the CNE would review all grievances and concerns, and signed off on them weekly. The CNE, RN, UM, and SSW would conduct interviews with five (5) random residents per hall and five (5) random staff members per unit per day for two (2) weeks about any abuse/neglect issues across all shifts including weekends. He stated audits would continue three (3) times per week for two (2) weeks, then weekly for eight (8) weeks, then every other week for eight (8) weeks then monthly times two (2) months to ensure compliance with the Abuse Policy. Review of the random audits for 11/07/18 and 11/08/18, verified the audits were enforce.

Based on interview, record review, review of the facility's policy, and the Center's Executive Director (CED) job description it was determined the facility failed have an effective system to address a broader systems failure related to pharmacy services through regularly scheduled Quality Assurance Performance Improvement (QAPI) meetings. The QAPI Committee, aware of delays in medication delivery for newly admitted residents, did not implement a formal plan. In addition, the QAPI Committee failed to identify discrepancies in resident Medication Administration Records (MARs), for medications not administered due to the pharmacy's delayed delivery of the medications. Record review revealed Resident #40 had a Physician order [REDACTED]. The resident was transferred to the hospital on [DATE] for difficulty breathing, an elevated heart rate, and a decrease in blood oxygenation. Resident #51 had a Physician order [REDACTED]. However, the resident did not receive fifteen (15) doses of the medication between 05/22/18 - 05/29/18. The resident had periods of confusion and an elevated ammonia level during the time when the medication was not administered, which according to interview was a result of not receiving the antibiotic. The facility admitted Resident #38 on 05/11/18 with orders to administer [MEDICATION NAME]. However, interview and record review revealed the resident did not receive seven (7) doses of the medication in (MONTH) (YEAR). The facility's failure to address systems failures and implement correction plans for these issues has caused, or is likely to cause, serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 06/25/18, and determined to exist on 05/22/18. The facility was notified of the Immediate Jeopardy on 06/25/18. The facility provided an acceptable Credible Allegation of Compliance on 06/27/18, alleging the removal of Immediate Jeopardy on 06/28/18. The State Survey Agency verified Immediate Jeopardy was removed on 06/28/18 as alleged, prior to exit on 07/01/18. The Scope and Severity was lowered to a E while the facility develops and implements the Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the Job Description for the Center's Executive Director (CED), effective 01/01/16, revealed the CED would assure the QAPI Process was understood and utilized by all members of the Center Leadership Team to continually improve all aspects of Center performance. Review of the facility's policy, Center Quality Assurance Performance Improvement (QAPI) Process, revised 02/13/17, revealed the Center was committed to incorporating the principles of Quality Assurance and Performance Improvement (QAPI) into all aspects of the Center work processes, service lines, and departments. All staff and stakeholders were involved in QAPI to improve the quality of life and quality of care for the patients' experience. Further review of the policy, revealed the QAPI program was ongoing, integrated, data driven, and comprehensive, addressing all aspects of care, quality of life, and patient centered rights and choice. The Center Executive Director (CED) led the center's QAPI processes and involved departments, staff and stakeholders-balancing a culture of safety, quality, and patient centeredness. The QAPI processes and improvements were based on evidence drawing from multiple sources, prioritizing improvement opportunities, and bench marking results against developed targets. Improvement Activities and Performance Improvement Projects were the structure and means through which identified problem areas were addressed. The learning, through applied QAPI plans, was continuous, systematic and organized. Continued review of the policy revealed the QAPI Committee met at least ten (10) times annually to monitor quality within the Center, identify issues, and develop and implement appropriate plans of action to correct identified quality issues. Attendees included the CED, the Chief Nurse Executive (CNE), the Medical Director, the Infection Preventionist, a representative from each department, including one (1) Certified Nursing Assistant (CNA), and divisional support leaders, as appropriate, to provide further insight and resource management. Review of the clinical record for Resident #40 revealed orders for [MEDICATION NAME] three (3) times a day for four (4) days and [MEDICATION NAME] three (3) times daily for continued management of his/her compromised lung status. The facility ordered the [MEDICATION NAME] on 06/10/18, but the pharmacy did not deliver the medication until 06/14/18. The resident received only two (2) doses of the [MEDICATION NAME] from 06/10/18 to 06/13/18, and according to interviews with licensed nurses, staff obtained those two (2) doses from the facility's Emergency Drug Kit (EDK). Further review of the clinical record for Resident #40 revealed the resident did not receive all scheduled breathing treatments from 06/10/18 - 06/13/18. The facility transferred Resident #40 back to the hospital on the morning of 06/13/18 with an elevated heart rate of 147 beats per minute, shortness of air, congestion, and a blood oxygen saturation of 88% while receiving oxygen at 2 liters per minute. Review of clinical record for Resident #51 revealed the facility admitted the resident on 05/22/18 with an order for [REDACTED]. During this time period the resident exhibited periods of confusion, as documented in the clinical record. The facility contacted the APRN, who ordered a urinalysis and labs which revealed Resident #51 experienced elevated serum ammonia levels during the time when the Rifaximin was not administered. Record review revealed the facility conducted an audit, dated 06/13/18, for twelve (12) residents to determine if the facility had the physician ordered medications available for administration. However, medication administration was audited only for the month of (MONTH) (YEAR). Those medications determined not administered to residents were listed and forwarded to the Medical Director for their review of the records of the applicable residents. Interview with the CNE, on 06/28/18 at 11:16 AM, revealed her audit consisted of only a random sample of residents on the North and South units, but not for all residents on census. The CNE did not note missed breathing treatments for Resident #40, as she did not recall auditing the entire MAR for Resident #40. Additionally, the CNE stated she only audited regularly scheduled medications to ensure the medications were available for the selected residents. The CNE forwarded the results of the audit to the CED who reviewed it prior to forwarding to the Medical Director for their review. Interview with the Medical Director, on 06/21/18 at 11:30 AM, revealed attention was given regarding medication management about one (1) week ago when the APRN expressed concerns about residents not getting their medications, and learned from the CED about issues with not receiving medications, and/or not receiving them timely from the pharmacy. She stated the CNE conducted a medication cart audit on 06/13/18 and at least ten (10) residents were identified with medication administration concerns. Continued interview with the CNE, on 06/26/18 at 1:45 PM, revealed while not positive, she believed the issues with medications was discussed at the (MONTH) (YEAR) QAPI meeting. She stated she was concerned with the holes in the medication administration records (MAR), and failure of staff to not notify the Physicians when medications were not available for use. She further stated the nurses could not explain why they did not document as expected, other than too busy during their shifts. Interview with the CED, on 06/22/18 at 6:50 PM, revealed Nursing leadership had not routinely audited the residents' MARS, but stated night shift nurses performed a 24-hour chart checks. The CED stated the facility should conduct routine audits of resident clinical records, specifically the MARs and Treatment Administration Records (TARS), but these audits had not been done routinely. Continued interview, on 06/22/18 at 6:50 PM, with the CED revealed facility leadership was aware, since the week of 05/07/18, the contracted pharmacy had not delivered medications, as ordered, for residents newly admitted to the facility. As a result, she stated nurses requested hospitals administer a dose of pain medication before transferring the resident to the facility, as pharmacy delivery was known to be slow and pain medications might not be delivered timely, and nurses questioned why they requested medications be sent by STAT delivery when they were not being delivered in the delineated four (4) hour time frame. She stated a meeting with the Contracted Pharmacy Management needed to occur. Further interview with the CED revealed she initiated conversation via a conference call with the Pharmacy's Manager on 05/18/18 and discussed staff and leadership's concerns with delayed delivery of medications for newly admitted residents and for other residents with new Physician orders. The CED stated two (2) additional conference calls with the Pharmacy Manager scheduled for 05/25/18 and 06/01/18 were not attended by Pharmacy Manager. The CED stated the first in-person meeting with the Pharmacy Manager occurred on 06/08/18 when they discussed issues surrounding delayed delivery of medications and delayed refills of the Emergency Drug Kit (EDK). She stated the Pharmacy Manager expressed concerns regarding his staff's ability to reach facility nurses by telephone for order clarification, and not receiving face sheet/demographic information from the facility for newly admitted residents, as that information was necessary for billing purposes. Continued interview with the CED, on 06/22/18 at 8:50 PM, revealed the QAPI Committee had not finalized training and monitoring related to the identified delayed pharmacy deliveries and for additional training and monitoring of the nursing staff to ensure they communicated effectively with the pharmacy, prescribers, and with facility administration when medications were not delivered within an appropriate time frame. Further interview with the CED, on 06/25/18 at 4:50 PM, revealed the QAPI Committee reviewed medication errors, when reported correctly, and included errors such as wrong medication, wrong dose, and wrong route. However, the facility did not record medication omissions as errors, therefore, the QAPI committee had not reviewed documents that recorded medication omissions. The CED stated data collected from routine audits of MARs and Chart Checks should have been available for review and discussion during monthly QAPI meetings, and review of that data should have already been in place prior to the identification of the issues with the contracted pharmacy. The facility had not fully implemented a Plan of Action to the address the Quality Assurance Issue related to omitted medications/medication errors. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #51 had received the Rifaximin since 05/30/18. 2. Resident #40 was no longer in the facility. 3. From 06/11/18 - 06/21/18 re-education of staff nurses and Certified Medication Technicians (CMT) occurred. Education included the facility policy on ordering and obtaining medications from the pharmacy for all admissions, re-admissions, and new physician orders. Education also included policies and processes for obtaining medications that are unavailable from the Emergency Drug Kit (EDK), as well as notification of the Physician when medications were not available from the pharmacy and were not available in the EDK. 4. The Center Nurse Executive (CNE) conducted an audit of all resident Medication Administration Records (MAR) from 06/01/18 - 06/13/18. Twelve (12) residents were identified to have missed medication dosages. On 06/14/18, a pharmacy consultant conducted an audit of available medications in comparison to the Physician orders. 5. The Medical Director was notified of the twelve (12) residents that had missed medication dosages on 06/14/18. The Medical Director assessed the identified residents and findings were documented in the resident charts. No new medication or laboratory orders were received. 6. On 06/14/18, an adHoc QAPI meeting was conducted with the Medical Director, the CNE, and the Center Executive Director (CED). During the meeting, audits, education, and compliance monitors were developed and to be implemented on 06/23/18. 7. Two (2) additional discrepancies of missed medications were self-identified by the CNE and the CED during audits performed on 06/23/18. 8. Additional education of licensed staff and two (2) CMTs was completed on 06/25/18. Education included procedure for sending medication orders to pharmacy; procedure for unavailable medications including refusals and notification of the pharmacy and physicians; when to notify the CNE and CED of unavailable medications; and the care plan process of revising and implementing the care plan with new orders. Posttests provided to validate understanding. 9. On 06/25/18, an adHoc QAPI meeting was conducted with the CED, the CNE, and the Medical Director to review additional education conducted. 10. Beginning 06/26/18, the Pharmacy Program Manager would contact the facility daily, including weekends, and speak with the CED, the CNE, or Registered Nurse (RN) Charge Nurse to confirm any medications needed would be sent to the facility stat (immediately). 11. On 06/26/18, the facility's EDK was re-stocked. 12. The CNE, CED, and/or Unit Manager will monitor MARs, conduct observations, and ensure daily communications occur with the Pharmacy Program Manager daily times two (2) weeks across all shifts; then three (3) times weekly for two (2) weeks; then weekly for two (2) months; then bi-weekly for two (2) months; and, then monthly for one (1) month to ensure medications were available as prescribed and the care plans were being followed. 13. The Regional Vice President of Operations and/or the Clinical Quality Specialist will review the QAPI minutes monthly for six (6) months and ongoing thereafter to ensure audits, education, and in-services are completed as needed. The SSA validated the facility implemented the following actions: 1. Record review of the MARs for Resident #51 revealed he/she had received all medications since 05/30/18 as ordered. 2. Record review revealed Resident #40 was no longer in the facility. 3. Interviews with RN #5 on 06/30/18 at 10:50 AM; the MDS Coordinator on 06/30/18 at 10:15 AM; the Unit Manager on 06/30/18 at 11:10 AM; RN #1 on 06/30/18 at 11:00 AM; CMT #1 on 06/30/18 at 11:22 AM; LPN #3 on 07/01/18 at 10:45 AM; and, RN #4 on 07/01/18 at 10:45 AM, revealed they had received and had an understanding of the education. Review of the sign-in sheet for the in-service education provided between 06/11/18 - 06/21/18 revealed all licensed staff and two (2) CMTs signed acknowledgement of the education. 4. Interview with the CNE, on 07/01/18 at 2:17 PM, revealed she completed medication audits for all resident MARs and documented twelve (12) residents had missed medications for (MONTH) (YEAR). The Audit tool was reviewed against the MARs for the residents identified with missed medications. 5. Record review revealed assessments were completed for eleven (11) of the twelve (12) identified residents. The twelfth resident had been discharged home at the time of the discovery. 6. Interviews with the CED on 07/01/18 at 10:33 AM and the CNE on 07/01/18 at 2:17 PM, revealed they began auditing for availability of medications and documentation of medications on 06/23/18. Record review revealed audits began on 06/23/18 and were signed by the CED or CNE daily. Random audits of the medication carts, conducted by the SSA on 06/30/18, revealed medications were available for randomly selected residents when compared to medications ordered by the Physician. 7. Review of the audit tools revealed missing medications were identified on 06/23/18 and medications were ordered from the pharmacy prior to medication dosages being missed. 8. Review of the sign-in sheet for the additional education related to care plans and following Physician orders [REDACTED]. Posttests reviewed for each of the licensed staff revealed a 100% pass rate. Review of the sign-in sheet for the additional education related to ordering medications for new admissions and re-admissions; re-ordering the EDK; and, the procedure for unavailable medications revealed all licensed staff and two (2) CMTs were educated. Posttests reviewed revealed a 100% pass rate. Interviews with RN #5 on 06/30/18 at 10:50 AM; the MDS Coordinator on 06/30/18 at 10:15 AM; the Unit Manager on 06/30/18 at 11:10 AM; RN #1 on 06/30/18 at 11:00 AM; CMT #1 on 06/30/18 at 11:22 AM; LPN #3 on 07/01/18 at 10:45 AM; and, RN #4 on 07/01/18 at 10:45 AM, revealed they had an understanding of the education provided. 9. Interview with the MDS Coordinator, on 06/30/18 at 9:26 AM, revealed she was present at a QAPI meeting and medication issues were discussed. Interviews with the CED on 07/01/18 at 10:33 AM and the CNE on 07/01/18 at 2:17 PM revealed they discussed medication issues in the QAPI meeting held on 06/25/18. Review of the sign-in sheet for the QAPI meeting on 06/25/18 revealed the MDS Coordinator, the CED, the CNE, and the Medical Director attended the meeting. 10. Interview with the CED, on 07/01/18 at 10:33 AM, revealed conversations with pharmacy were occurring daily. Review of the log documenting daily pharmacy phone calls revealed calls occurred daily as alleged. 11. Observation of the EDK revealed the box had been refilled. Interview with the Unit Manager, on 06/30/18 at 11:10 AM, revealed if staff took medication out of the EDK, staff filled out a form and faxed it to the pharmacy. If the entire stock of the medication was used, pharmacy refilled the EDK the same day. 12. Interviews with the CED on 07/01/18 at 10:33 AM and the CNE on 07/01/18 at 2:17 PM, revealed audits of the MARs and Physician orders [REDACTED]. Review of the audits revealed the CNE or CED audited the MARs and Physician orders [REDACTED]. 13. Observations during the A[NAME] validation revealed the Clinical Quality Specialist (CQS) was in the facility daily assisting with MAR/TAR audits and medication cart audits. Interviews with the CED on 07/01/18 at 10:33 AM and the CNE on 07/01/18 at 2:17 PM revealed the CQS or Regional Vice President would review QAPI minutes monthly. Review of the most recent QAPI sign-in sheet revealed the CQS attended the meeting.

Based on interview, record review, and review of the facility's policy, it was determined the governing body for the facility failed to effectively ensure full and timely implementation of policies and procedures for addressing a systems failure related to administration of residents' medications. The facility recognized the week of 05/07/18, the pharmacy was not delivering residents' medications per the agreed upon time frames and nursing staff was not administering medications, as ordered by the prescriber(s). Record review revealed Resident #40 had a Physician order [REDACTED]. The resident was transferred to the hospital on [DATE] for difficulty breathing, an elevated heart rate, and a decrease in blood oxygenation. Resident #51 had a Physician order [REDACTED]. However, the resident did not receive fifteen (15) doses of the medication between 05/22/18 - 05/29/18. The resident had periods of confusion and an elevated ammonia level during the time when the medication was not administered, which according to interview was a result of not receiving the antibiotic. The facility admitted Resident #38 on 05/11/18 with orders to administer [MEDICATION NAME]. However, interview and record review revealed the resident did not receive seven (7) doses of the medication in (MONTH) (YEAR). The facility's governing body's failure to ensure full and timely implementation of policies and procedures for addressing system failures related to medication administration has caused, or is likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 06/25/18, and determined to exist on 05/22/18. The facility was notified of the Immediate Jeopardy on 06/25/18. The facility provided an acceptable Allegation of Compliance on 06/27/18, alleging the removal of Immediate Jeopardy on 06/28/18. The State Survey Agency verified Immediate Jeopardy was removed on 06/28/18 as alleged, prior to exit on 07/01/18. The Scope and Severity was lowered to a E while the facility develops and implements the Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy, Governing Body: Centers, revised 06/01/17, revealed the governing body consisted of the Center Executive Director, Center Nurse Executive, and the Regional Vice President of Operations of the Center's administrative services provider. Additionally, the governing body was legally responsible for: establishing and implanting policies regarding the management and operation of the Center; appointing a licensed administrator for the management of the Center, and Maintenance of the Quality Assurance Performance Improvement (QAPI) Program. Review of the clinical record for Resident #40 revealed the facility readmitted the resident on 06/09/18, after a hospitalization for treatment of [REDACTED]. The facility ordered the [MEDICATION NAME] on 06/10/18, but the pharmacy did not deliver the medication until 06/14/18, four (4) days later. The resident received only two (2) doses of the [MEDICATION NAME] from 06/10/18 to 06/13/18, and according to interviews with licensed nurses, staff obtained those two (2) doses from the facility's Emergency Drug Kit (EDK). Further review of the clinical record for Resident #40 revealed the resident did not receive all scheduled breathing treatments from 06/10/18 - 06/13/18. The facility transferred Resident #40 back to the hospital on the morning of 06/13/18 with an elevated heart rate of 147 beats per minute, shortness of air, congestion, and a blood oxygen saturation of 88% while receiving oxygen at 2 liters per minute. Review of clinical record for Resident #51 revealed the facility admitted the resident on 05/22/18 multiple [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. However, continued review of the clinical record revealed from 05/22/18 - 05/29/18 no scheduled doses of Rifaximin, for management of diagnosed fatty liver disease, were administered. During this time period the resident exhibited periods of confusion, as documented in the clinical record. The facility contacted the APRN, who ordered a urinalysis and labs which revealed Resident #51 experienced elevated Serum Ammonia levels during the time when the Rifaximin was not administered. Interview with the Center Executive Director (CED), on 06/22/18 at 6:50 PM, revealed facility leadership had awareness, since the week of 05/07/18, the contracted pharmacy had not delivered medications, as ordered, for newly admitted residents. In addition, the contracted pharmacy failed to deliver STAT medications in the specified four (4) hour time frame, and staff nurses requested hospitals administer a dose of pain medication to residents before transferring the resident to the facility, as pharmacy delivery was known to be slow and pain medications may not be delivered timely. The CED stated she notified the Regional Vice President and the Director of Clinical Operations on 05/14/18, regarding the issues with the contracted pharmacy, and received guidance for facility leadership to continue to monitor the situation and coordinate the process. The facility established a monitoring team, including the Center Nurse Executive (CNE), nurses who were admitting residents to the facility, and the CED. She stated, as a result of monitoring, the facility learned the pharmacy issue was more widespread than just delayed deliveries for newly admitted residents. Additionally, the CED learned, around 06/09/18 to 06/10/18, that facility nurses were initialing and circling their initials in the Medication Administration Record [REDACTED]. The CED stated Corporate leadership did not give any other directions in the matter, other than to monitor the situation, with no specifics given by corporate leaders on how to monitor the situation. Interview with the CNE, on 06/28/18 at 11:16 AM, revealed she conducted an audit of a random sample of residents, and only audited for regularly scheduled medications to ensure those medications were available for those residents. Review of the Audit Tool, dated 06/13/18, revealed the CNE reviewed twelve (12) resident records. Resident #40's MAR indicated [REDACTED]. She did not list Resident #40's missed [MEDICATION NAME] treatments, the 12 noon doses on 06/10/18, 06/11/18 and 06/12/18. Interview with the CED, on 06/25/18 at 4:50 PM, revealed the facility did not record medication omissions as errors, therefore, the QAPI committee had not reviewed documents that recorded medication omissions. Per interview, the facility had not fully implemented a Plan of Action to the address the Quality Assurance Issue related to omitted medications/medication errors. Interview with the Corporate Regional Vice President, on 06/27/18 at 12:01 PM, revealed he became aware that issues with the contracted pharmacy and residents not receiving scheduled medications during the recent recertification survey, and could not recall when he first became aware of the issues with the contracted pharmacy. He further stated he was on vacation, and any notes he might have were not available at the time of the interview, and could not recall if he provided guidance. He told the surveyor to contact the Director of Clinical Operations. Interview with the Director of Clinical Operations (DCO), on 06/27/18 at 12:34 PM, revealed she first became aware of the facility's issues with the contracted Pharmacy Service on 05/15/18, as she was copied on an e-mail from the facility's CNE to the Pharmacy Manager. The DCO stated she did not remember providing the facility leaders with any specific guidance after reading the e-mail(s). The DCO stated if the facility's leadership cannot resolve a matter, then the CED should contact the RVP for additional guidance. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #51 had received the Rifaximin since 05/30/18. 2. Resident #40 was no longer in the facility. 3. From 06/11/18 - 06/21/18 re-education of staff nurses and Certified Medication Technicians (CMT) occurred. Education included the facility policy on ordering and obtaining medications from the pharmacy for all admissions, re-admissions, and new physician orders. Education also included policies and processes for obtaining medications that are unavailable from the Emergency Drug Kit (EDK), as well as notification of the Physician when medications were not available from the pharmacy and were not available in the EDK. 4. The Center Nurse Executive (CNE) conducted an audit of all resident Medication Administration Records (MAR) from 06/01/18 - 06/13/18. Twelve (12) residents were identified to have missed medication dosages. On 06/14/18, a pharmacy consultant conducted an audit of available medications in comparison to the Physician orders. 5. The Medical Director was notified of the twelve (12) residents that had missed medication dosages on 06/14/18. The Medical Director assessed the identified residents and findings were documented in the resident charts. No new medication or laboratory orders were received. 6. On 06/14/18, an adHoc QAPI meeting was conducted with the Medical Director, the CNE, and the Center Executive Director (CED). During the meeting, audits, education, and compliance monitors were developed and to be implemented on 06/23/18. 7. Two (2) additional discrepancies of missed medications were self-identified by the CNE and the CED during audits performed on 06/23/18. 8. Additional education of licensed staff and two (2) CMTs was completed on 06/25/18. Education included procedure for sending medication orders to pharmacy; procedure for unavailable medications including refusals and notification of the pharmacy and physicians; when to notify the CNE and CED of unavailable medications; and the care plan process of revising and implementing the care plan with new orders. Posttests provided to validate understanding. 9. On 06/25/18, an adHoc QAPI meeting was conducted with the CED, the CNE, and the Medical Director to review additional education conducted. 10. Beginning 06/26/18, the Pharmacy Program Manager would contact the facility daily, including weekends, and speak with the CED, the CNE, or Registered Nurse (RN) Charge Nurse to confirm any medications needed would be sent to the facility stat (immediately). 11. On 06/26/18, the facility's EDK was re-stocked. 12. The CNE, CED, and/or Unit Manager will monitor MARs, conduct observations, and ensure daily communications occur with the Pharmacy Program Manager daily times two (2) weeks across all shifts; then three (3) times weekly for two (2) weeks; then weekly for two (2) months; then bi-weekly for two (2) months; and, then monthly for one (1) month to ensure medications were available as prescribed and the care plans were being followed. 13. The Regional Vice President of Operations and/or the Clinical Quality Specialist will review the QAPI minutes monthly for six (6) months and ongoing thereafter to ensure audits, education, and in-services are completed as needed. The SSA validated the facility implemented the following actions: 1. Record review of the MARs for Resident #51 revealed he/she had received all medications since 05/30/18 as ordered. 2. Record review revealed Resident #40 was no longer in the facility. 3. Interviews with RN #5 on 06/30/18 at 10:50 AM; the MDS Coordinator on 06/30/18 at 10:15 AM; the Unit Manager on 06/30/18 at 11:10 AM; RN #1 on 06/30/18 at 11:00 AM; CMT #1 on 06/30/18 at 11:22 AM; LPN #3 on 07/01/18 at 10:45 AM; and, RN #4 on 07/01/18 at 10:45 AM, revealed they had received and had an understanding of the education. Review of the sign-in sheet for the in-service education provided between 06/11/18 - 06/21/18 revealed all licensed staff and two (2) CMTs signed acknowledgement of the education. 4. Interview with the CNE, on 07/01/18 at 2:17 PM, revealed she completed medication audits for all resident MARs and documented twelve (12) residents had missed medications for (MONTH) (YEAR). The Audit tool was reviewed against the MARs for the residents identified with missed medications. 5. Record review revealed assessments were completed for eleven (11) of the twelve (12) identified residents. The twelfth resident had been discharged home at the time of the discovery. 6. Interviews with the CED on 07/01/18 at 10:33 AM and the CNE on 07/01/18 at 2:17 PM, revealed they began auditing for availability of medications and documentation of medications on 06/23/18. Record review revealed audits began on 06/23/18 and were signed by the CED or CNE daily. Random audits of the medication carts, conducted by the SSA on 06/30/18, revealed medications were available for randomly selected residents when compared to medications ordered by the Physician. 7. Review of the audit tools revealed missing medications were identified on 06/23/18 and medications were ordered from the pharmacy prior to medication dosages being missed. 8. Review of the sign-in sheet for the additional education related to care plans and following Physician orders [REDACTED]. Posttests reviewed for each of the licensed staff revealed a 100% pass rate. Review of the sign-in sheet for the additional education related to ordering medications for new admissions and re-admissions; re-ordering the EDK; and, the procedure for unavailable medications revealed all licensed staff and two (2) CMTs were educated. Posttests reviewed revealed a 100% pass rate. Interviews with RN #5 on 06/30/18 at 10:50 AM; the MDS Coordinator on 06/30/18 at 10:15 AM; the Unit Manager on 06/30/18 at 11:10 AM; RN #1 on 06/30/18 at 11:00 AM; CMT #1 on 06/30/18 at 11:22 AM; LPN #3 on 07/01/18 at 10:45 AM; and, RN #4 on 07/01/18 at 10:45 AM, revealed they had an understanding of the education provided. 9. Interview with the MDS Coordinator, on 06/30/18 at 9:26 AM, revealed she was present at a QAPI meeting and medication issues were discussed. Interviews with the CED on 07/01/18 at 10:33 AM and the CNE on 07/01/18 at 2:17 PM revealed they discussed medication issues in the QAPI meeting held on 06/25/18. Review of the sign-in sheet for the QAPI meeting on 06/25/18 revealed the MDS Coordinator, the CED, the CNE, and the Medical Director attended the meeting. 10. Interview with the CED, on 07/01/18 at 10:33 AM, revealed conversations with pharmacy were occurring daily. Review of the log documenting daily pharmacy phone calls revealed calls occurred daily as alleged. 11. Observation of the EDK revealed the box had been refilled. Interview with the Unit Manager, on 06/30/18 at 11:10 AM, revealed if staff took medication out of the EDK, staff filled out a form and faxed it to the pharmacy. If the entire stock of the medication was used, pharmacy refilled the EDK the same day. 12. Interviews with the CED on 07/01/18 at 10:33 AM and the CNE on 07/01/18 at 2:17 PM, revealed audits of the MARs and Physician orders [REDACTED]. Review of the audits revealed the CNE or CED audited the MARs and Physician orders [REDACTED]. 13. Observations during the A[NAME] validation revealed the Clinical Quality Specialist (CQS) was in the facility daily assisting with MAR/TAR audits and medication cart audits. Interviews with the CED on 07/01/18 at 10:33 AM and the CNE on 07/01/18 at 2:17 PM revealed the CQS or Regional Vice President would review QAPI minutes monthly. Review of the most recent QAPI sign-in sheet revealed the CQS attended the meeting.

Based interview, record review, facility policy review, and review of the job description for the Center Executive Director, it was determined the facility failed to be effectively administered in a manner that enabled effective use of resources to attain and maintain the highest practicable physical, mental, and psycho-social wellbeing for three (3) of twenty-three (23) sampled residents, Residents #38, #40 and #51. The facility failed to procure medications for administration as ordered by the residents' physician. Record review revealed Resident #40 had a Physician order [REDACTED]. However, the resident did not receive all doses of the antibiotic nor breathing treatments between 06/10/18 - 06/13/18. The resident was transferred to the hospital on [DATE] for difficulty breathing, an elevated heart rate, and a decrease in blood oxygenation. Resident #51 had a Physician order [REDACTED]. However, the resident did not receive fifteen (15) doses of the medication between 05/22/18 - 05/29/18. The resident had documented periods of confusion and an elevated ammonia level during the time when the medication was not administered, which according to interview was a result of not receiving the antibiotic. The facility admitted Resident #38 on 05/11/18 with orders to administer [MEDICATION NAME]. However, interview and record review revealed the resident did not receive seven (7) doses of the medication in (MONTH) (YEAR). The facility's failure to be administered in an effective manner to ensure procurement of medications for administration to residents has caused, or is likely to cause, serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 06/25/18, and determined to exist on 05/22/18. The facility was notified of the Immediate Jeopardy on 06/25/18. The facility provided an acceptable Credible Allegation of Compliance on 06/27/18, alleging the removal of Immediate Jeopardy on 06/28/18. The State Survey Agency verified Immediate Jeopardy was removed on 06/28/18 as alleged, prior to exit on 07/01/18. The Scope and Severity was lowered to a E while the facility develops and implements the Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the Job Description for the Center Executive Director (CED), effective 01/01/16, revealed the CED would create an environment where staff members were highly engaged and focused on providing the highest level of clinical care and [MEDICATION NAME] to patients, residents, and families. The CED would administer and coordinate all activities of the facility to assure the highest degree of quality of care was consistently provided to residents, subject to the rules and regulations promulgated by government agencies to ensure residents received the proper services. Review of the facility's policy, Medication Shortages/Unavailable Medications, revised 01/01/13, revealed upon discovery of an inadequate supply of a medication to administer to a resident, staff should call the pharmacy to determine the status of the order. If the next available delivery caused delay or a missed dose in a resident's medications schedule, the nurse should obtain the medication from the Emergency Medication Supply. If the medication was not available in the Emergency Medication Supply, staff should notify the pharmacy and arrange for an emergency delivery. If a medication shortage was discovered after normal pharmacy hours, the nurse should obtain the ordered medication from the Emergency Medication Supply. If the ordered medication was not available in the Emergency Medication Supply, the nurse should call the pharmacy's emergency answering service and request to speak with the Pharmacist on duty to manage the plan of action, which might include emergency delivery or use of an emergency (back up) third party pharmacy. If an emergency delivery was unavailable, the nurse should contact the attending Physician to obtain orders or directions. If the medication was unavailable from the pharmacy or third party pharmacy, and could not be supplied from the manufacturer, the facility should obtain alternate Physician/Prescriber orders, as necessary. Review of the facility's Pharmacy Services Agreement, effective date 04/01/15, revealed the pharmacy agreed to provide services as requested by the facility pursuant to the order of the resident's attending physician or for the facility's account. The pharmacy would furnish and replenish, on a regular basis, an emergency and interim medication supply. The facility would assist the pharmacy in its efforts to allocate inventory removed from the interim supply to individual residents, and the facility agreed to pay the pharmacy directly for contents, which could not be so allocated. The pharmacy agreed to provide medication delivery during regular business hours, and on an emergency basis, twenty-four (24) hours per day/seven (7) days per week, except in circumstances and conditions beyond its control, which included, but not limited to, situations where the pharmacy's manufacturer/supplier was unable to provide the required item and the pharmacy was unable to provide an acceptable alternative. Continued review revealed the facility agreed to use its best efforts to support the provision of services by the pharmacy at all times. The facility agreed it was solely responsible for direct care rendered to the residents for provision of skilled nursing services including all direct and indirect intravenous nursing care, and for all activities necessary for the operation of the facility under applicable federal and state laws. Review of the clinical record for Resident #40 revealed the facility readmitted the resident on 06/09/18, after a hospitalization for treatment of [REDACTED]. The facility ordered the [MEDICATION NAME] on 06/10/18, but the pharmacy did not deliver the medication until 06/14/18, four (4) days later. The resident received only two (2) doses of the [MEDICATION NAME] from 06/10/18 to 06/13/18, and according to interviews with licensed nurses, staff obtained those two (2) doses from the facility's Emergency Drug Kit (EDK). Further review of the clinical record for Resident #40 revealed the resident did not receive all scheduled breathing treatments from 06/10/18 - 06/13/18. The facility transferred Resident #40 back to the hospital on the morning of 06/13/18 with an elevated heart rate of 147 beats per minute, shortness of air, congestion, and a blood oxygen saturation of 88% while receiving oxygen at 2 liters per minute. Review of clinical record for Resident #51 revealed the facility admitted the resident on 05/22/18 multiple [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. However, continued review of the clinical record revealed from 05/22/18 - 05/29/18 no scheduled doses of Rifaximin, for management of diagnosed fatty liver disease, were administered. During this time period the resident exhibited periods of confusion, as documented in the clinical record. The facility contacted the APRN, who ordered a urinalysis and labs which revealed Resident #51 experienced elevated Serum Ammonia levels during the time when the Rifaximin was not administered. Interview with the CED, on 06/22/18 at 6:50 PM, revealed the facility leadership became aware the week of 05/07/18, the contracted pharmacy was not delivering ordered medications for newly admitted residents. Additionally, medications ordered and requested for STAT delivery from contracted pharmacy, were not delivered in the specified four (4) hour time frame. The CED stated she had not instructed nursing leadership to conduct audits of the residents' Medication Administration Records (MARs) during the month of May, when she learned there were delays in the delivery of medications. The CED stated a conference call with the pharmacy was held on 05/18/18, and an in-person meeting occurred on 06/08/18, to discuss medications not delivered as delineated in the facility contract with the pharmacy, as well as the issues of non-timely refilling of the EDK. The CED stated she learned, during these meetings, the facility contract with the pharmacy allowed for a back-up, third party pharmacy option for obtaining medications. The CED further stated the Center Nurse Executive (CNE) managed the nursing staff and the CNE should ensure the nurses notified the pharmacy, the prescribers, and the nursing and administrative leadership when there were issues with non-timely delivery of scheduled medications. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #51 had received the Rifaximin since 05/30/18. 2. Resident #40 was no longer in the facility. 3. From 06/11/18 - 06/21/18 re-education of staff nurses and Certified Medication Technicians (CMT) occurred. Education included the facility policy on ordering and obtaining medications from the pharmacy for all admissions, re-admissions, and new physician orders. Education also included policies and processes for obtaining medications that are unavailable from the Emergency Drug Kit (EDK), as well as notification of the Physician when medications were not available from the pharmacy and were not available in the EDK. 4. The Center Nurse Executive (CNE) conducted an audit of all resident Medication Administration Records (MAR) from 06/01/18 - 06/13/18. Twelve (12) residents were identified to have missed medication dosages. On 06/14/18, a pharmacy consultant conducted an audit of available medications in comparison to the Physician orders. 5. The Medical Director was notified of the twelve (12) residents that had missed medication dosages on 06/14/18. The Medical Director assessed the identified residents and findings were documented in the resident charts. No new medication or laboratory orders were received. 6. On 06/14/18, an adHoc QAPI meeting was conducted with the Medical Director, the CNE, and the Center Executive Director (CED). During the meeting, audits, education, and compliance monitors were developed and to be implemented on 06/23/18. 7. Two (2) additional discrepancies of missed medications were self-identified by the CNE and the CED during audits performed on 06/23/18. 8. Additional education of licensed staff and two (2) CMTs was completed on 06/25/18. Education included procedure for sending medication orders to pharmacy; procedure for unavailable medications including refusals and notification of the pharmacy and physicians; when to notify the CNE and CED of unavailable medications; and the care plan process of revising and implementing the care plan with new orders. Posttests provided to validate understanding. 9. On 06/25/18, an adHoc QAPI meeting was conducted with the CED, the CNE, and the Medical Director to review additional education conducted. 10. Beginning 06/26/18, the Pharmacy Program Manager would contact the facility daily, including weekends, and speak with the CED, the CNE, or Registered Nurse (RN) Charge Nurse to confirm any medications needed would be sent to the facility stat (immediately). 11. On 06/26/18, the facility's EDK was re-stocked. 12. The CNE, CED, and/or Unit Manager will monitor MARs, conduct observations, and ensure daily communications occur with the Pharmacy Program Manager daily times two (2) weeks across all shifts; then three (3) times weekly for two (2) weeks; then weekly for two (2) months; then bi-weekly for two (2) months; and, then monthly for one (1) month to ensure medications were available as prescribed and the care plans were being followed. 13. The Regional Vice President of Operations and/or the Clinical Quality Specialist will review the QAPI minutes monthly for six (6) months and ongoing thereafter to ensure audits, education, and in-services are completed as needed. The SSA validated the facility implemented the following actions: 1. Record review of the MARs for Resident #51 revealed he/she had received all medications since 05/30/18 as ordered. 2. Record review revealed Resident #40 was no longer in the facility. 3. Interviews with RN #5 on 06/30/18 at 10:50 AM; the MDS Coordinator on 06/30/18 at 10:15 AM; the Unit Manager on 06/30/18 at 11:10 AM; RN #1 on 06/30/18 at 11:00 AM; CMT #1 on 06/30/18 at 11:22 AM; LPN #3 on 07/01/18 at 10:45 AM; and, RN #4 on 07/01/18 at 10:45 AM, revealed they had received and had an understanding of the education. Review of the sign-in sheet for the in-service education provided between 06/11/18 - 06/21/18 revealed all licensed staff and two (2) CMTs signed acknowledgement of the education. 4. Interview with the CNE, on 07/01/18 at 2:17 PM, revealed she completed medication audits for all resident MARs and documented twelve (12) residents had missed medications for (MONTH) (YEAR). The Audit tool was reviewed against the MARs for the residents identified with missed medications. 5. Record review revealed assessments were completed for eleven (11) of the twelve (12) identified residents. The twelfth resident had been discharged home at the time of the discovery. 6. Interviews with the CED on 07/01/18 at 10:33 AM and the CNE on 07/01/18 at 2:17 PM, revealed they began auditing for availability of medications and documentation of medications on 06/23/18. Record review revealed audits began on 06/23/18 and were signed by the CED or CNE daily. Random audits of the medication carts, conducted by the SSA on 06/30/18, revealed medications were available for randomly selected residents when compared to medications ordered by the Physician. 7. Review of the audit tools revealed missing medications were identified on 06/23/18 and medications were ordered from the pharmacy prior to medication dosages being missed. 8. Review of the sign-in sheet for the additional education related to care plans and following Physician orders [REDACTED]. Posttests reviewed for each of the licensed staff revealed a 100% pass rate. Review of the sign-in sheet for the additional education related to ordering medications for new admissions and re-admissions; re-ordering the EDK; and, the procedure for unavailable medications revealed all licensed staff and two (2) CMTs were educated. Posttests reviewed revealed a 100% pass rate. Interviews with RN #5 on 06/30/18 at 10:50 AM; the MDS Coordinator on 06/30/18 at 10:15 AM; the Unit Manager on 06/30/18 at 11:10 AM; RN #1 on 06/30/18 at 11:00 AM; CMT #1 on 06/30/18 at 11:22 AM; LPN #3 on 07/01/18 at 10:45 AM; and, RN #4 on 07/01/18 at 10:45 AM, revealed they had an understanding of the education provided. 9. Interview with the MDS Coordinator, on 06/30/18 at 9:26 AM, revealed she was present at a QAPI meeting and medication issues were discussed. Interviews with the CED on 07/01/18 at 10:33 AM and the CNE on 07/01/18 at 2:17 PM revealed they discussed medication issues in the QAPI meeting held on 06/25/18. Review of the sign-in sheet for the QAPI meeting on 06/25/18 revealed the MDS Coordinator, the CED, the CNE, and the Medical Director attended the meeting. 10. Interview with the CED, on 07/01/18 at 10:33 AM, revealed conversations with pharmacy were occurring daily. Review of the log documenting daily pharmacy phone calls revealed calls occurred daily as alleged. 11. Observation of the EDK revealed the box had been refilled. Interview with the Unit Manager, on 06/30/18 at 11:10 AM, revealed if staff took medication out of the EDK, staff filled out a form and faxed it to the pharmacy. If the entire stock of the medication was used, pharmacy refilled the EDK the same day. 12. Interviews with the CED on 07/01/18 at 10:33 AM and the CNE on 07/01/18 at 2:17 PM, revealed audits of the MARs and Physician orders [REDACTED]. Review of the audits revealed the CNE or CED audited the MARs and Physician orders [REDACTED]. 13. Observations during the A[NAME] validation revealed the Clinical Quality Specialist (CQS) was in the facility daily assisting with MAR/TAR audits and medication cart audits. Interviews with the CED on 07/01/18 at 10:33 AM and the CNE on 07/01/18 at 2:17 PM revealed the CQS or Regional Vice President would review QAPI minutes monthly. Review of the most recent QAPI sign-in sheet revealed the CQS attended the meeting.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to have an effective system to ensure staff implemented care plans related to following physician orders [REDACTED].#5, #9, #16, #23, #26, #38, #40, #42 and #51. Per record review and staff interview, Resident #40 was readmitted to the facility after an acute hospital stay on 06/09/18, with care plan interventions to administer respiratory treatments as ordered. Resident #40 did not receive all doses of breathing treatments, nor antibiotics, between 06/10/18 - 06/13/18. The resident was transferred to the hospital on the morning of 06/13/18 for difficulty breathing, an elevated heart rate, and a decrease in blood oxygenation. Resident #51 was admitted on [DATE] with care plan interventions to monitor conditions that could contribute to his/her mood/state, such as liver disease, and to monitor newly ordered medications for side effects, drug toxicity, or errors. The resident was ordered Rifaximin (antibiotic) for treatment of [REDACTED]. The resident had documented periods of confusion and elevated serum ammonia levels during the time when the medication was not administered. In addition, staff did not follow the care plan for wound treatments for Resident #5, #16, and #26, and did not follow the care plan for medication administration for Resident #9, #23, #38, and #42. The facility's failure to have a system in place to ensure care plan interventions were implemented, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 06/25/18 and was determined to exist on 05/22/18. The facility was notified of the Immediate Jeopardy on 06/25/18. The facility provided an acceptable Allegation of Compliance (A[NAME]) on 06/27/18, which alleged removal of the IJ on 06/28/18. The State Survey Agency (SSA) verified the IJ was removed on 06/28/18, prior to exit on 07/01/18. The Scope and Severity was lowered to a E while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy, Person-Centered Care Plan, revised 03/01/18, revealed the facility must develop and implement a baseline care plan within 48 hours for each resident that included the instructions needed to provide effective and person-centered care that met professional standards and quality of care. A comprehensive, individualized care plan must be developed within seven (7) days after completion of the comprehensive assessment for each resident that included measurable objectives and timetables to meet the resident's medical, nursing, nutrition, and psychosocial needs that were identified in the comprehensive assessments. The care plan would be developed by the interdisciplinary team that include the Physician, the Registered Nurse with responsibility for the resident, a nurse aid responsible for the resident, food and nutrition services staff, and to the extent practicable the resident or the resident representative(s). Further review of the policy revealed the purpose of the care plan was to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Care plans would be communicated to appropriate staff, the resident and family, and would be reviewed and revised by the interdisciplinary team after each assessment, and as needed to reflect the response to care and changing needs and goals. Interview, on 06/26/18 at 1:45 PM, with the CNE revealed the care plan was a guide to assist staff in the delivery of the best resident care and was a communication tool for staff across all disciplines. She stated if Physician ordered interventions included in the care plan were not done, then the care plan was not followed. She stated if a resident did not receive medications as ordered, and if the Medication Administration Record (MAR) and/or the Treatment Administration Record (TAR) showed no documented evidence medications or treatments were provided, then the care plan was not followed. 1. Review of Resident #40's clinical record revealed the facility readmitted the resident on 10/27/17, with [DIAGNOSES REDACTED]. The resident was transferred to the hospital on [DATE] for low oxygenation, an increase pulse, coughing up white thick sputum, and an altered level of consciousness. The resident was transferred back to the facility on [DATE] at 9:10 PM. Review of the Hospital Discharge Summary, dated 06/09/18, revealed the resident was treated for [REDACTED]. In addition, an order for [REDACTED]. Review of Resident #40's Progress Notes, dated 06/10/18 at 2:30 AM, revealed the nurse faxed the medication list to the pharmacy and notified the pharmacy the resident was a new admission and to please STAT (immediately) deliver the medications. According to the documentation, the nurse called the pharmacy as well, there was no answer, and left a message to call the nurse for confirmation. The nurse called the pharmacy again at 8:40 AM on 06/10/18 and informed pharmacy staff the medications for Resident #40 had not been received. The nurse reiterated the order faxed stated the resident was a new admission and to please STAT the medications and the nurse was informed by pharmacy the medications would be sent as soon as possible. Review of Resident #40's Care Plan, dated 12/30/16, revealed the resident was at risk for complications of infection with an intervention for the administration of antibiotics, as ordered, but the intervention was dated 06/21/18, after the resident was readmitted to the facility from his/her hospitalization of 06/13/18 through 06/19/18. The facility did not provide any other care plan documents. Review of Resident #40's MAR, dated (MONTH) (YEAR), revealed the [MEDICATION NAME] was scheduled for administration at 8:00 AM, 12:00 PM, and 8:00 PM. Documentation revealed the resident did not receive the [MEDICATION NAME] on 06/10/18 at 8:00 AM, 12:00 PM, and 8:00 PM, 06/11/18 at 8:00 AM and 12:00 PM, 06/12/18 at 8:00 AM and 12:00 PM, and 06/13/18 at 8:00 AM. In addition, the [MEDICATION NAME]-[MEDICATION NAME] was scheduled for 8:00 AM, 12:00 PM, and 8:00 PM. Documentation revealed the resident did not receive the medication on 06/10/18 at 12:00 PM, 12/11/18 at 12:00 PM, and 06/12/18 at 12:00 PM. Interview, on 06/22/18 at 11:05 AM, with Licensed Practical Nurse (LPN) #3 revealed she cared for Resident #40 on 06/10/18 and 06/12/18. LPN #3 stated she was under the impression Resident #40's antibiotic had been ordered upon his/her readmission on 06/09/18; however, the medication was not delivered on 06/10/18. She stated she did not call the pharmacy to follow up when she realized she did not have the medication for the resident. LPN #3 stated she worked again on 06/12/18 and the resident's antibiotic was still not available for the scheduled doses. Interview, on 06/22/18 at 5:10 PM, with LPN #4 revealed care plans assisted staff in the delivery of resident care. She stated if a resident did not receive breathing treatments or medications, as ordered and as listed on the care plan, then the care plan was not followed. She stated if the care plan was not followed, the resident's condition could worsen. LPN #4 stated care plans should stay up to date to ensure nurses and other caregivers delivered correct care as driven by the Physician orders [REDACTED]. Interview, on 06/28/18 at 12:47 PM, with the Minimum Data Set (MDS) Assistant revealed the care plan was a guide to ensure all staff caring for a resident knew the care the resident needed. She stated it was a communication tool for use across all disciplines. She stated she made sure the care area needs identified through routine MDS assessments were taken into consideration as the care plans were developed. She stated the care plan should address any care areas associated with infections, such as administration of antibiotics, and insulin administration for diagnosed Diabetes. She stated if a resident had an order for [REDACTED]. She stated if breathing treatments were not administered as care planned, then the care plan was not being followed and there would be the potential for the resident's condition to worsen, and could result in hospitalization or even death. 2. Review of Resident #51's clinical record revealed the facility admitted the resident on 05/22/18, with multiple diagnoses, which included Nonalcoholic [MEDICAL CONDITION] (NASH). Review of Resident #51's Physician Orders, dated 05/22/18, revealed Rifaximin 550 mg every twelve (12) hours for NASH diagnosis. Review of the Care Plan for Resident #51, created 05/28/18, revealed the resident exhibited or was at risk for distressed/fluctuating mood/anxiety symptoms with interventions to monitor for conditions that could contribute to his/her mood/state, such as liver disease and electrolyte imbalances. Staff was to monitor medications, especially those newly ordered, changed, or discontinued for any observed side effects, drug interactions, adverse drug reactions, drug toxicity, or errors, and monitor lab values and report abnormal results to the physician or mid-level practitioner. In addition, the resident was at risk for complications related to use of [MEDICAL CONDITION] medications, antidepressants, and antipsychotic medicines with interventions to monitor for side effects of the medications, and consult the physician and/or pharmacist, as needed. Review of Resident #51's MAR, dated (MONTH) (YEAR), revealed fifteen (15) doses of Rifaximin were documented as not administered. The MAR revealed the 9:00 PM dose on 05/22/18 was blank. The doses scheduled on 05/23/18, 05/24/18, 05/25/18, and 05/26/18 at 9:00 AM and 9:00 PM had circled staff initials. The 9:00 AM dose on 05/27/18 had circled initials and the 9:00 PM dose was blank. The 05/28/18 and 05/29/18 scheduled doses at 9:00 AM and 9:00 PM had circled initials. Interview with LPN #3, on 06/22/18 at 3:45 PM revealed when medication was not available for administration; staff initialed the MAR and circled the initials, which indicated the medication was not given. Interview with the Pharmacist, on 06/28/18 at 11:51 AM, revealed the pharmacy received Resident #51's Rifaximin order on 05/22/18; however, the order was not filled because of a billing issue. He stated the order was delivered to the facility on [DATE]. Review of laboratory results for Resident #51, dated 05/24/18 at 12:50 AM, revealed the resident's ammonia level was elevated at 98, (normal range of 18-75). Review of the Progress Notes for Resident #51, dated 05/26/18, revealed the resident was alert to person (self) and place, but verbalized confusion from time to time while packing his/her clothes and wanting to go home. Review of the Progress Notes, dated 05/28/18, revealed he/she was alert and oriented to person (self), place, and approximate time of day. The resident showed signs of confusion and required redirection several times during the day. The resident took his/her dressing off of his/her foot and rolled away in his/her wheelchair from his/her intravenous (IV) pump/pole while the IV was infusing. Results of an ammonia level, dated 05/29/18 at 1:00 AM, revealed the resident's ammonia level was elevated at 118. Continued interview with LPN #3, on 06/22/18 at 3:45 PM, revealed she cared for Resident #51 during the time he/she did not receive the Rifaximin. She stated she did not do anything about Resident #51's missing Rifaximin such as call the pharmacy, Physician, or the CNE; however, she stated she should have notified all of them. She stated by not receiving the medication, the resident was not treated for [REDACTED]. Interview with LPN #1/UM, on 06/22/18 at 11:07 AM and 1:49 PM, revealed missing medications should be reported to the Physician, and pharmacy and have it delivered STAT. She stated as she reviewed the MAR for Resident #51 and there were fifteen (15) doses of Rifaximin not administered. The fifteen doses were circled not available and not administered. She stated the Rifaximin was given for Resident #51's liver disease and the lack of the medication could lead to high ammonia levels and increase the resident's confusion. Interview with the CNE, on 06/26/18 at 1:46 PM, revealed nurses should administer antibiotics as ordered, and if not done, the care plan was not followed. Interview, on 06/26/18 at 9:44 AM, with the Center Executive Director (CED) revealed from a systems perspective, there had been no identified issues with care not being provided as care planned. 3. Review of the clinical record for Resident #42 revealed the facility admitted the resident on 04/04/18, with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Review of Resident #42's Care Plan revealed the resident was insulin dependent related to a [DIAGNOSES REDACTED]. However, review of the MAR, dated (MONTH) (YEAR), revealed on 05/09/18, 05/14/18, and 05/30/18, the date and time spaces for the [MEDICATION NAME] 60 unit doses were blank, with no explanation why the insulin was not administered. In addition, on 05/12/18 and 05/13/18, the date and time spaces for [MEDICATION NAME] 50 unit doses were blank, with no explanation why the insulin was not administered. Review of the MAR, dated (MONTH) (YEAR), revealed [MEDICATION NAME] 60 unit dose was not documented as given on 06/23/18, nor the [MEDICATION NAME] 50 unit dose on 06/21/18. The date and time spaces for both of the scheduled doses were blank, with no explanation why the insulin was not administered. Interview, on 06/26/18 at 11:25 AM, with LPN#1/UM revealed the nurses should have documented the reasons why Resident #42 did not receive his/her insulin, and should have informed the provider of those missed doses. She stated it was very important to follow the resident's care plan for management of Diabetes and one interventions was to provide Diabetes medications as ordered. She stated the care plan was in place to guide staff with maintaining acceptable blood sugar levels. 4. Review of Resident #23's clinical record revealed the facility admitted the resident on 04/27/18, with multiple diagnoses, which included Diabetes Mellitus Type 1. Review of Resident #23's Comprehensive Care Plan, initiated 04/28/18, revealed interventions for the resident's [DIAGNOSES REDACTED]. Review of Resident #23's MAR, for (MONTH) (YEAR), revealed an order for [REDACTED]. Documentation revealed the insulin was not administered on 05/07/18 and 05/14/18. Continue review revealed the insulin order was discontinued on 05/26/18 and a new order started for Basaglar KwikPen Solution Pen-Injector (insulin), 8 units in the morning at 8:00 AM. However, documentation on the MAR revealed the resident did not receive the Basaglar insulin on 05/26/18 and 05/27/18. Review of the (MONTH) (YEAR) MAR revealed the resident did not receive insulin on 06/07/18. Interview, on 06/22/18 at 4:33 PM, with LPN #4 revealed if Resident #23's insulin dosages were not documented as done, then there would not be evidence the care plan was followed. LPN #4 stated the resident blood sugar could elevate if not administered the insulin, which could result in the resident to be unconscious. Interview with the CNE, on 06/26/18 at 2:29 PM, revealed nurses should administer medications per Physician order [REDACTED]. The CNE stated nurses were responsible for the MAR/TAR and if the document showed missed medications and no documented evidence why the medications were missed, it meant the care plan was not followed. 5. Review of the clinical record for Resident #38 revealed the facility admitted the resident on 05/11/18, with [DIAGNOSES REDACTED]. Review of the Care Plan for Resident #38, dated 05/23/18, revealed the resident had a [DIAGNOSES REDACTED]. Review of Resident #38's MAR, for (MONTH) (YEAR), revealed an order for [REDACTED]. Documentation revealed the medication were not administered on 05/12/18, 05/13/18 at 9:00 AM, 05/14/18 at 9:00 AM, 05/23/18 at 9:00 PM, and 05/30/18. In addition, there was an order for [REDACTED]. The medication was not administered on 05/12/18, 05/13/18, 05/14/18, 05/19/18, 05/20/18, 05/29/18, and 05/30/18. Further review of the MAR revealed [MEDICATION NAME] Concentrate Nebulization Solution 0.5 ML via nebulizer every six (6) hours at 2:00 AM, 8:00 AM, 2:00 PM, and 8:00 PM. Documentation revealed the medication was not administered on 05/12/18, 05/13/18 at 2:00 AM, 8:00 AM, and 2:00 PM, 05/14/18 at 8:00 AM, 05/16/18 at 2:00 AM, 05/21/18 at 2:00 PM, 05/25/18 at 2:00 AM, 05/26/18 at 2:00 AM, 05/28/18 at 2:00 AM, and 05/30/18 at 8:00 PM. Additional review revealed an order for [REDACTED]. The medication was not administered on 05/12/18 for either dose or at 9:00 AM on 05/13/18. Interview with the MDS Assistant, on 06/26/18 at 12:47 PM, revealed failure to administer medications as ordered, including breathing treatments, could result in adverse consequences for the resident. She further stated that all breathing treatments and inhalers should be listed on the care plan as an intervention and not administering the treatments/inhalers meant the care plan was not followed. Interview with the CNE, on 06/26/18 at 1:46 PM, revealed she expected all breathing treatments to be administered as ordered by the Physician and if not documented, it was not given. She stated if medications were not administered as ordered by the Physician, the care plan was not followed. 6. Review of the clinical record for Resident #9 revealed the facility admitted this resident on 03/13/18, with a [DIAGNOSES REDACTED]. Review of the Care Plan for Resident #9, dated 04/06/18, revealed the resident had a [DIAGNOSES REDACTED]. Review of the MAR, dated (MONTH) (YEAR), for Resident #9 revealed an order for [REDACTED]. Documentation revealed the resident did not receive seven (7) doses of insulin, on 05/04/18 at 8:00 AM, 05/16/18 at 8:00 PM, 05/21/18 at 8:00 AM, 05/23/18 at 8:00 AM, 05/30/18 at 8:00 AM and 8:00 PM, and 05/31/18 at 8:00 PM. Review of the (MONTH) (YEAR) MAR revealed the resident did not receive the insulin on 06/04/18 at 8:00 PM and 06/08/18 at 8:00 PM. Interview with LPN #1/UM, on 06/26/18 at 10:44 AM, revealed if insulin was not administered as ordered, the resident could experience [MEDICAL CONDITION], decreased urine output, a sugar coma, and the overall health of the resident would be negatively impacted. She stated not administering insulin as ordered meant staff did not follow the care plan. Interview with the MDS Assistant, on 06/26/18 at 12:47 PM, revealed insulin should be administered as ordered and listed on the care plan as an intervention for Diabetes. She stated if staff did not document insulin administration, it indicated the medication was not given and the care plan was not followed. She stated if insulin was not given as ordered, the resident could return to the hospital. In addition to staff not following care plans for medication administration, care plans related to wound treatment were also not followed. 7. Review of Resident #5's clinical record revealed the facility admitted the resident on 06/07/17, with a [DIAGNOSES REDACTED]. Review of Physician order [REDACTED]. Review of Resident #5's Care Plan, revised 03/23/18, revealed the resident had actual skin breakdown for a pressure ulcer to the coccyx and to the left outer aspect of the left heel with an intervention to provide wound treatment as ordered. Review of Resident #5's MAR, for (MONTH) (YEAR), revealed no documentation the left heel wound care was performed on 05/08/18 and 05/20/18. Review of the TAR, dated (MONTH) (YEAR), revealed the buttocks wound care was scheduled for 6:00 AM - 2:00 PM and 10:00 PM - 6:00 AM. There was no documentation wound care was performed on 05/08/18 and 05/21/18 for 10:00 PM - 6:00 AM, and on 05/11/18, 05/14/18, 05/17/18, and 05/24/18 for 6:00 AM - 2:00 PM. Review of Resident #5's TAR, dated (MONTH) (YEAR), revealed no documentation wound care for the left heel was performed on 06/08/18, 06/15/18, 06/19/18, 06/20/18, and 06/21/18. There was no documentation the buttocks wound care was performed on 06/01/18, 06/08/18, 06/11/18, and 06/22/18 for 6:00 AM - 2:00 PM, and on 06/15/18 and 06/21/18 for 10:00 PM - 6:00 AM. 8. Review of the clinical record for Resident #16 revealed the facility readmitted this resident on 04/18/18, with multiple diagnoses, which included Pressure Ulcer. Review of the Admission MDS for Resident #16, dated 04/25/18, revealed the facility assessed the resident as interviewable with a Brief Interview for Mental Status score of thirteen (13) out of fifteen (15). Review of the Care Plan for Resident #16, dated 05/01/18, revealed the resident had actual skin breakdown with an intervention to provide wound treatment as ordered to the left heel. Review of the TAR for Resident #16, for (MONTH) (YEAR), revealed an order for [REDACTED]. The dressing was to be changed every third day on day shift. Interview with Resident #16, on 06/20/18 at 8:41 AM, revealed the resident had a pressure ulcer on his/her left foot and negative pressure wound therapy (a [DEVICE]) was being used for treatment of [REDACTED].#16 stated the dressing on the foot connected to the [DEVICE] was supposed to be changed every three (3) days and it had not been changed in at least four (4) days. Observation of the [DEVICE] dressing for Resident #16, on 06/20/18 at 10:35 AM, revealed there was no date or time on the dressing. Continued review of the TAR revealed the last dressing change was performed on 06/15/18 and the next dressing change due on 06/18/18. Documentation revealed the dressing change was not completed on 06/18/18. Interview with LPN #2, on 06/20/18 at 10:35 AM, revealed the bandage on Resident #16's [DEVICE] should be dated and wound care should be documented on the TAR. She stated if wound care was not documented, it was not done. Interview with LPN #7, on 06/21/18 at 10:00 AM, revealed she was the nurse assigned to care for Resident #16 on 06/18/18 and she did not complete the wound care because she did not check the TAR and did not know she had orders for a [DEVICE] dressing. She stated she should have checked the TAR for any treatments that might be due. 9. Review of Resident #26's clinical record revealed the facility admitted the resident on 10/15/17, with multiple diagnoses, which included Gastroparesis (stomach cannot empty food). Review of Resident #26's Care Plan, revised 04/25/18, revealed the resident had an enteral feeding tube ([DEVICE]) with a goal that the resident would not develop any [DEVICE] related complications. Review of Resident #26's TAR, for (MONTH) (YEAR), revealed an order for [REDACTED]. Documentation revealed the treatment was not completed on 06/07/18, 06/09/18, 06/16/18, and 06/17/18. Documentation revealed the treatment was completed on 06/18/18 and 06/19/18. Observation of Resident #26, on 06/20/18 at 9:15 AM, revealed LPN #1/UM administered medication via the resident's [DEVICE]. The dressing around the [DEVICE] site was dated 06/18/18; however, the TAR revealed the dressing was changed on 06/19/18. The dressing had brown and yellow stains and appeared old. The LPN changed the dressing and dated it 06/20/18. Interview with LPN #1/UM, on 06/20/18 at 9:15 AM, during the observation revealed Resident #26's dressing would have been dated 06/19/18 if the dressing were changed as documented. She stated the Mupirocin Ointment to the [DEVICE] site and the dressing change prevented infection and allowed the wound to heal. Telephone interview with LPN #8, on 06/20/18 at 2:57 PM, revealed she changed Resident #26's dressing to the [DEVICE] site on 06/18/18 and 06/19/18 she was not sure why the dressing was labeled 06/18/18 instead of 06/19/18. LPN #8 stated all treatments were completed as ordered and initialed on the TAR. She knew it was important to change the dressing as ordered to prevent infection to the resident. Continued interview with LPN #7, on 06/21/18 at 10:00 AM, revealed not completing wound care as ordered could result in wounds worsening, or in the development of an infection. She stated not completing wound care meant the care plan was not followed. Continued interview with LPN #1/UM, on 06/21/18 at 12:07 PM, revealed it was important to complete wound care as ordered to ensure the wound was healing and to monitor the wound for changes. She further stated if the wound care was not performed as ordered, the wound could worsen or become infected which could lead [MEDICAL CONDITION] or re-hospitalization of the resident. She also stated not completing wound treatments as ordered meant staff did not follow the care plan. Interview with the MDS Assistant, on 06/26/18 at 12:46 PM, revealed the care plan communicated about resident needs and providing care for each resident and interventions on the care plan should be followed since they were ordered by the Physician. She stated if treatments were not provided, then the care plan was not followed and the residents did not receive the care that was ordered. Interview with the CNE, on 06/21/18 at 2:13 PM and 06/26/18 at 1:46 PM, revealed a [DEVICE] was generally used on more severe wounds and she would be concerned about failure to change the dressing. She stated if the dressing was not changed as ordered, the wound could not be monitored for worsening or signs of infection. She further stated she would be concerned residents might develop an infection if dressings were not changed as ordered and might develop skin breakdown. She stated not providing wound care as ordered meant the facility had not provided the care and services needed and care plans were not followed. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #51 had received the Rifaximin since 05/30/18. 2. Resident #40 was no longer in the facility. 3. From 06/11/18 - 06/21/18 re-education of staff nurses and Certified Medication Technicians (CMT) occurred. Education included the facility policy on ordering and obtaining medications from the pharmacy for all admissions, re-admissions, and new physician orders. Education also included policies and processes for obtaining medications that are unavailable from the Emergency Drug Kit (EDK), as well as notification of the Physician when medications were not available from the pharmacy and were not available in the EDK. 4. The Center Nurse Executive (CNE) conducted an audit of all resident Medication Administration Records (MAR) from 06/01/18 - 06/13/18. Twelve (12) residents were identified to have missed medication dosages. On 06/14/18, a pharmacy consultant conducted an audit of available medications in comparison to the Physician orders. 5. The Medical Director was notified of the twelve (12) residents that had missed medication dosages on 06/14/18. The Medical Director assessed the identified residents and findings were documented in the resident charts. No new medication or laboratory orders were received. 6. On 06/14/18, an adHoc QAPI meeting was conducted with the Medical Director, the CNE, and the Center Executive Director (CED). During the meeting, audits, education, and compliance monitors were developed and to be implemented on 06/23/18. 7. Two (2) additional discrepancies of missed medications were self-identified by the CNE and the CED during audits performed on 06/23/18. 8. Additional education of licensed staff and two (2) CMTs was completed on 06/25/18. Education included procedure for sending medication orders to pharmacy; procedure for unavailable medications including refusals and notification of the pharmacy and physicians; when to notify the CNE and CED of unavailable medications; and the care plan process of revising and implementing the care plan with new orders. Posttests provided to validate understanding. 9. On 06/25/18, an adHoc QAPI meeting was conducted with the CED, the CNE, and the Medical Director to review additional education conducted. 10. Beginning 06/26/18, the Pharmacy Program Manager would contact the facility daily, including weekends, and speak with the CED, the CNE, or Registered Nurse (RN) Charge Nurse to confirm any medications needed would be sent to the facility stat (immediately). 11. On 06/26/18, the facility's EDK was re-stocked. 12. The CNE, CED, and/or Unit Manager will monitor MARs, conduct observations, and ensure daily communications occur with the Pharmacy Program Manager daily times two (2) weeks across all shifts; then three (3) times weekly for two (2) weeks; then weekly for two (2) months; then bi-weekly for two (2) months; and, then monthly for one (1) month to ensure medications were available as prescribed and the care plans were being followed. 13. The Regional Vice President of Operations and/or the Clinical Quality Specialist will review the QAPI minutes monthly for six (6) months and ongoing thereafter to ensure audits, education, and in-services are completed as needed. The SSA validated the facility implemented the following actions: 1. Record review of the MARs for Resident #51 revealed he/she had received all medications since 05/30/18 as ordered. 2. Record review revealed Resident #40 was no longer in the facility. 3. Interviews with RN #5 on 06/30/18 at 10:50 AM; the MDS Coordinator on 06/30/18 at 10:15 AM; the Unit Manager on 06/30/18 at 11:10 AM; RN #1 on 06/30/18 at 11:00 AM; CMT #1 on 06/30/18 at 11:22 AM; LPN #3 on 07/01/18 at 10:45 AM; and, RN #4 on 07/01/18 at 10:45 AM, revealed they had received and had an understanding of the education. Review of the sign-in sheet for the in-service education provided between 06/11/18 - 06/21/18 revealed all licensed staff

Based on interview, record review, facility policy review, and review of the Pharmacy Contract, it was determined the facility failed to have an effective system in place to ensure medications were available and administered to meet the needs for four (4) of twenty-three (23) sampled residents, Residents #23, #38, #40, and #51. Per record review, the facility readmitted Resident #40 on 06/09/18 from the hospital after treatment for [REDACTED]. In addition, the resident did not receive all doses of the breathing treatment and the resident was transferred back to the hospital for additional treatment on 06/13/18. According to the Advanced Practice Registered Nurse (APRN), the omission of the antibiotic and breathing treatments negatively affected the resident's condition, which brought about his/her transfer back to the hospital for further treatment. Additional record review revealed Resident #51 had a Physician order, dated 05/22/18, to administer an antibiotic to treat the resident's fatty liver disease. However, per interview, the antibiotic was not available for administration 05/22/18 - 05/29/18. Progress notes revealed the resident experienced periods of confusion and an ammonia level, dated 05/29/18, resulted in an elevated reading of 118 (normal range of 18-75). Per interview, the increased ammonia level, which resulted from failure to receive the antibiotic, caused the increase in confusion and behaviors. In addition, Residents #23 and #38 did not receive medications as ordered. The facility's failure to have an effective system in place to ensure residents received ordered medication, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 06/25/18 and was determined to exist on 05/22/18. The facility was notified of the IJ on 06/25/18. The facility provided an acceptable Allegation of Compliance (A[NAME]) on 06/27/18, which alleged removal of the IJ on 06/28/18. The State Survey Agency (SSA) verified the IJ was removed on 06/28/18, prior to exit on 07/01/18. The Scope and Severity was lowered to a E while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy, Medication Administration, revised 11/28/17, revealed if medication discrepancies, including medication not available, were identified, staff was to notify the Physician/advanced practice provider and/or the pharmacy. Review of the facility's policy, Medication Shortages/Unavailable Medications, revised 01/01/13, revealed upon discovery of an inadequate supply of a medication to administer to a resident, staff should call the pharmacy to determine the status of the order. If the next available delivery caused delay or a missed dose in a resident's medications schedule, the nurse should obtain the medication from the Emergency Medication Supply. If the medication was not available in the Emergency Medication Supply, staff should notify the pharmacy and arrange for an emergency delivery. If a medication shortage was discovered after normal pharmacy hours, the nurse should obtain the ordered medication from the Emergency Medication Supply. If the ordered medication was not available in the Emergency Medication Supply, the nurse should call the pharmacy's emergency answering service and request to speak with the Pharmacist on duty to manage the plan of action, which might include emergency delivery or use of an emergency (back up) third party pharmacy. If an emergency delivery was unavailable, the nurse should contact the attending Physician to obtain orders or directions. If the medication was unavailable from the pharmacy or third party pharmacy, and could not be supplied from the manufacturer, the facility should obtain alternate Physician/Prescriber orders, as necessary. Review of the facility's Pharmacy Services Agreement, effective date 04/01/15, revealed the pharmacy agreed to provide services as requested by the facility pursuant to the order of the resident's attending physician or for the facility's account. The pharmacy would furnish and replenish, on a regular basis, an emergency and interim medication supply. The facility would assist the pharmacy in its efforts to allocate inventory removed from the interim supply to individual residents, and the facility agreed to pay the pharmacy directly for contents, which could not be so allocated. The pharmacy agreed to provide medication delivery during regular business hours, and on an emergency basis, twenty-four (24) hours per day/seven (7) days per week, except in circumstances and conditions beyond its control, which included, but not limited to, situations where the pharmacy's manufacturer/supplier was unable to provide the required item and the pharmacy was unable to provide an acceptable alternative. Continued review revealed the facility agreed to use its best efforts to support the provision of services by the pharmacy at all times. The facility agreed it was solely responsible for direct care rendered to the residents for provision of skilled nursing services including all direct and indirect intravenous nursing care, and for all activities necessary for the operation of the facility under applicable federal and state laws. 1. Review of Resident #40's clinical record revealed the facility readmitted the resident on 06/09/18 at 9:10 PM after treatment for [REDACTED]. Review of the Hospital Discharge Summary, dated 06/09/18, revealed Resident #40 had an order for [REDACTED]. Review of Resident #40's Progress Notes, dated 06/09/18 to 06/10/18, revealed the Physician was notified of the resident's admission and verified the orders. The nurse faxed the medication list to the pharmacy on 06/10/18 at 2:30 AM, and informed them to send the medication STAT (immediate) and was followed-up with a phone call to ensure the pharmacy received the fax. At 8:40 AM, the nurse called to inform the pharmacy Resident #40's medication had not arrived and reiterated the medication needed to be delivered STAT. Review of Resident #40's Medication Administration Record [REDACTED]. Documentation revealed the resident did not receive eight (8) doses of [MEDICATION NAME], on 06/10/18 at 8:00 AM, 12:00 PM, and 8:00 PM, 06/11/18 at 8:00 AM and 12:00 PM, 06/12/18 at 8:00 AM and 12:00 PM, and 06/13/18 at 8:00 AM. In addition, [MEDICATION NAME]-[MEDICATION NAME] was scheduled for 8:00 AM, 12:00 PM, and 8:00 PM. Documentation revealed the resident did not receive three (3) breathing treatments, on 06/10/18 at 12:00 PM, 12/11/18 at 12:00 PM, and 06/12/18 at 12:00 PM. Further review of the clinical record revealed the resident was transferred back to the hospital on [DATE], at approximately 9:00 AM per interview, with an elevated heart rate of 147 (normal 60-100), had difficulty breathing, had a cough, and an oxygenation level of 88% (normal 95%-100% on room air) while on two (2) liters of oxygen. Review of the Hospital Discharge Summary revealed the resident was diagnosed with [REDACTED]. Interview with the APRN, on 06/22/18 at 12:01 PM, revealed in her professional opinion, Resident #40 missing doses of the antibiotic and breathing treatments from 06/10/18 - 06/13/18, would have negatively impacted Resident #40's condition and necessitated his/her transfer back to the hospital for further treatment. Interview with the Medical Assistant for the Medical Director, on 06/21/18 at 10:15 AM, revealed she thought medications were not always available for administration because nurses would tell her medications were not in the medication cart, and had not been delivered. The Medical Assistant stated she did not think Resident #40 received his/her antibiotic and had to be transferred back to the hospital. Interview with Licensed Practical Nurse (LPN) #3, on 06/22/18 at 11:05 AM, revealed she was under the impression Resident #40's antibiotic had been ordered on [DATE]; however, the medication was not available on 06/10/18 when she cared for the resident. She stated she did not call the pharmacy to follow up or notify the Center Nurse Executive (CNE), Physician, or APRN. She stated the APRN was in the facility that day, but she did not tell her about the antibiotic not being available and was not sure why because usually she informed the APRN of resident issues. She stated the pharmacy delivery staff delivered to the facility on [DATE] and told her the medication might be on the way, but she did not call the pharmacy to learn the status of the delivery. LPN #3 stated the next time she worked was 06/12/18, and the antibiotic was still not available and she thought she contacted the pharmacy that day, but did not inform the CNE that the antibiotic was still not available. Interview with Registered Nurse (RN) #3, on 06/29/18 at 7:05 AM, revealed she worked the night of 06/11/18 and administered Resident #40's evening dose of [MEDICATION NAME] from the Emergency Drug Kit (EDK). RN #3 stated after using the EDK supply, there was not enough of the medication left in the EDK for the resident's next dose, so she notified pharmacy to refill the EDK, and also told the pharmacy the resident still needed his/her own supply of the medicine. RN #3 stated she thought she reported to the next shift nurses that she used the EDK supply of [MEDICATION NAME], because the doses previously ordered from the pharmacy on 06/10/18 at 2:30 AM, had not been delivered. RN #3 said she left a note for the CNE to inform her that the antibiotic had to be taken from the EDK to administer, as Resident #40's own supply of the antibiotic had not been delivered. Interview with LPN #8, on 06/30/18 at 11:38 AM, revealed she obtained Resident #40's evening does of antibiotic out of the EDK on 06/12/18 because it was not in the medication cart. Interview with LPN #4, on 06/22/18 at 3:25 PM, revealed on 06/13/18 around 7:30 AM - 7:45 AM, Resident #40 had difficulty breathing, was coughing, and sounded like he/she had mucous in his/her throat. LPN #4 stated the APRN arrived, assessed the resident, and gave orders for the resident to be transferred to the hospital for further evaluation. Interview with the Pharmacist, on 06/21/18 at 2:40 PM, revealed the pharmacy received the order for Resident #40's antibiotic ([MEDICATION NAME]) on 06/10/18 at 2:00 AM by fax, but the medication was not delivered to the facility until 06/14/18. Continued interview at 3:15 PM revealed the [MEDICATION NAME] order was cancelled because of a billing issue and with the product's National Drug Code (NDC) number. He stated the drug might have needed to be entered under another NDC number to get approval for payment and obtaining another NDC for the medication did not happen, which the pharmacy was responsible to obtain. He further stated the pharmacy did not call the facility to let them know and did nothing further about the issue until late on 06/13/18, when the facility contacted the pharmacy about non-delivery of the antibiotic. Continued interview with the APRN, on 06/22/18 at 12:01 PM, revealed she thought Resident #40 had received the [MEDICATION NAME] as scheduled since 06/09/18, and was not informed he/she had not until the morning of 06/13/18, even though she saw the resident on 06/12/18 related to the resident vomiting. The APRN stated on 06/13/18, staff reported the resident was short of air with congestion and an oxygen saturation level of 88%, and she gave the order to transfer the resident to the hospital. Interview with LPN #1/Unit Manager (UM), on 06/22/18 at 1:45 PM, revealed for about two (2) months, she noticed medications would be unavailable for administration, and would call the pharmacy and was informed of billing issues that prevented delivery of the medications. She stated it was the nurse's responsibility to obtain the resident's medicine, and had noticed, during her two (2) months on duty as an LPN, that other nurses did not always notify the provider when medications were not available. The UM stated the EDK did not always have medication needed such as on 06/11/18, there was not enough antibiotic to administer to Resident #40 so the resident went without. Interview with the CNE, on 06/22/18 at 8:10 AM, revealed she was not aware Resident #40 had not received the antibiotic until 06/13/18. She stated she contacted the pharmacy on 06/13/18 to inquire about the resident's antibiotic and was informed the medicine had an incorrect NDC. 2. Review of Resident #51's clinical record revealed the facility admitted the resident on 05/22/18 with a [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. Review of Resident #51's MAR, dated (MONTH) (YEAR), revealed fifteen (15) doses of Rifaximin were documented as not administered. The MAR indicated [REDACTED]. The doses scheduled on 05/23/18, 05/24/18, 05/25/18, and 05/26/18 at 9:00 AM and 9:00 PM had circled staff initials. The 9:00 AM dose on 05/27/18 had circled initials and the 9:00 PM dose was blank. The 05/28/18 and 05/29/18 scheduled doses at 9:00 AM and 9:00 PM had circled initials. Interview with the Pharmacist, on 06/28/18 at 11:51 AM, revealed the pharmacy received Resident #51's Rifaximin order on 05/22/18; however, the order was not filled because of a billing issue. He stated the order was delivered to the facility on [DATE]. Review of the Progress Notes for Resident #51 revealed on 05/26/18, the resident was verbalizing confusion from time to time while packing clothes and wanting to go home. On 05/28/18, the resident showed signs of confusion, requiring redirection several times during the day. Review of laboratory results for Resident #51, dated 05/29/18 at 1:00 AM, revealed the resident's ammonia level was elevated at 118 (normal range of 18-75). Interview, on 06/22/18 at 3:45 PM, with LPN #3 revealed she did not administer Resident #51's Rifaximin because it was not available and stated she did not take any action such as call the pharmacy, Physician, and the CNE; however, stated she should have notified all of them. She stated she looked in the EDK but the medication was not there. Interview, on 06/22/18 at 4:35 PM, with LPN #4 revealed the nurse should call the pharmacy when medication was not available and have the medication delivered STAT. She stated intravenous medications, insulin, or any medication that caused a resident to have a negative outcome if not administered should be requested for STAT delivery. Interview, on 06/22/18 at 11:07 AM and 1:49 PM, with the LPN #1/UM revealed she reviewed the (MONTH) (YEAR) MAR for Resident #51 and stated there were fifteen (15) doses of Rifaximin not administered, as the doses were circled not available and not administered. She stated the Rifaximin was for the resident's liver disease and the lack of the medication could lead to high ammonia levels and increase the resident's confusion. Interview, on 06/22/18 at 12:01 PM, with the APRN revealed the facility contacted her because Resident #51 was exhibiting increase in behaviors the week after admission and she learned the resident had not been receiving his/her doses of Rifaximin. Continued interview at 4:15 PM revealed she thought the facility had consistent issues with medications not being available for administration. 3. Review of Resident #23's clinical record revealed the facility admitted the resident on 04/27/18, with multiple diagnoses, which included Diabetes Mellitus Type 1. Review of Resident #23's MAR, dated (MONTH) (YEAR), revealed an order for [REDACTED]. Review of Resident #23's Progress Notes, dated 05/26/18 to 05/28/18, revealed no documentation regarding the missed doses of insulin on 05/26/18 and 05/27/18, nor documentation the Physician was notified of the missed doses. Continued review of Physician order [REDACTED]. The order was signed by the APRN on 05/30/18. Interview with LPN #2, on 06/22/18 at 12:05 PM, revealed the pharmacy had a hard time delivering all medications at once and would send two (2) to three (3) medications instead of the entire order. LPN #2 stated if a resident did not receive his/her medication, their condition could get worse. Interview with the APRN, on 06/22/18 at 12:26 PM, revealed she received a request from the pharmacy to change the [MEDICATION NAME]to Basaglar KwikPen insulin for Resident #23. However, she thought Resident #23 had not received the Basaglar KwikPen insulin for a few days because there was a mix-up with the insurance billing. The APRN stated she was concerned the nurses had not initiated a clarification order after the billing issue became known. Interview with the Center Nurse Executive (CNE) on, 06/22/18 at 8:22 AM, revealed she was aware about an issue with the insurance for Resident #23. However, she was unsure about the exact nature of the issue. She stated she was aware pharmacy would deliver partial medication orders instead of the entire order and the issue was even worse for STAT orders. 4. Review of the clinical record for Resident #38 revealed the facility admitted the resident on 05/11/18, with [DIAGNOSES REDACTED]. Review of Resident #38's MAR, dated (MONTH) (YEAR), revealed an order for [REDACTED]. In addition, there was an order for [REDACTED]. Further review of the MAR indicated [REDACTED]. Documentation revealed fourteen (14) doses of the medication were not administered, on 05/12/18 at 2:00 AM, 8:00 AM, 2:00 PM, and 8:00 PM , 05/13/18 at 2:00 AM, 8:00 AM, and 2:00 PM, 05/14/18 at 8:00 AM, 05/16/18 at 2:00 AM, 05/21/18 at 2:00 PM, 05/25/18 at 2:00 AM, 05/26/18 at 2:00 AM, 05/28/18 at 2:00 AM, and 05/30/18 at 8:00 PM. Additional review revealed an order for [REDACTED]. Interview, on 06/26/18 at 10:44 AM, with LPN #1/UM revealed if staff did not initial a medication was given on the MAR, then it was not administered to the resident. The UM stated circled initials meant the medication was not administered. According to the UM, if staff did not give Resident #38 the [MEDICATION NAME] as scheduled, it could result in the formation of a blood clot and failure to administer breathing treatments and inhalers could result in the resident experiencing respiratory distress. Interview, on 06/28/18 at 11:51 AM, with the Pharmacist via telephone revealed the pharmacy received Resident #38's medication orders on 05/11/18 at 10:22 PM. He stated the [MEDICATION NAME], breathing treatment, and inhalers were not filled and sent to the facility immediately because there were issues with insurance coverage and the availability of the medications. He stated the [MEDICATION NAME] was dispensed on 05/13/18. He revealed he did not have documentation the facility had called to follow-up on the medication orders. Interview with the Medical Director, on 06/21/18 at 11:30 AM, revealed she and the APRN saw residents on a weekly basis and addressed resident care issues brought to their attention. She stated attention was given regarding medication management about one (1) week ago when the APRN expressed concerns about residents not getting their medications, and learned from the CED about issues with not receiving medications timely from the pharmacy. Interview, on 06/21/18 at 4:00 PM, with the APRN revealed she, the Medical Director, and the facility had concerns with residents not receiving medications from the pharmacy. Per interview, they also became aware the nursing staff had not been administering medications to residents because of medications not being delivered to the facility. She stated she and the Medical Director discussed their concerns with the CED, and the facility started providing education to the nursing staff on notifying the prescriber when medications were not available for resident administration. Further interview with CNE, on 06/22/18 at 8:22 AM, revealed she started training nurses on the process of ordering medications. Part of the training was to either call her or the CED if medications were not delivered as expected. She stated the breakdown with deliveries was related to the fact the pharmacy had a lack of delivery drivers and the pharmacy was not meeting residents' medication needs timely. She further stated she escalated the issue up to the corporate nurse. However, the direction she received was to speak about the issue to the pharmacy manager who she already had spoken to and the direction from the corporate nurse was not helpful in resolving the ongoing issue. The CNE stated ultimately, the facility was responsible to assure medications were delivered and received as requested. Interview with the CED, on 06/21/18 at 5:14 PM, revealed there had been consistent issues identified with delayed delivery of medications for newly admitted residents, originally centered around delayed delivery of pain medications. She stated the nursing staff would ask the discharging hospital to provide the resident with a dose of pain medication, if possible, before discharge as they had experienced delays in delivery of medications. The CED stated issues with delayed or non-delivered medications were occurring more often after normal business hours, so the nurses were instructed to call the pharmacy and then notify the CNE or herself. She stated some medications would arrive but not in the four (4) hour window for delivery, as promised. In addition, not all medications ordered for a resident would arrive and the nurses had to frequently follow-up with the pharmacy on the status of medicines that had not been delivered. She stated issues had been discussed with the Pharmacy Manager and he told the CED if nurses did not transmit a newly admitted resident's face sheet/demographics to the pharmacy, it could impede/impact the billing process. She stated the Pharmacy Manager also stated pharmacy staff sometimes had difficulty reaching nurses by phone when clarification of an order or other resident information was needed. The CED stated an audit of residents' medication records was conducted by the CNE on 06/12/18 and about ten (10) residents were identified to have had issues with not receiving medications as ordered. Although meetings were held and some re-education of staff had occurred, the facility had not developed a written plan of action to implement, monitor, and evaluate the process to ensure residents were received their medications. Continued interview with the CED, on 06/22/18 at 6:53 PM, revealed she had first learned about the pharmacy issue on 05/18/18 and was told medications were not in the EDK. She stated the situation revolved around new admissions and she heard nurses say why should we request medications stat, what is the point of it when the pharmacy did not deliver the medications as expected. She wanted to resolve the issue rather than finger point and recognized additional training for the nurses was needed. The CED revealed the CNE audited some clinical records and found a pattern that went beyond the pharmacy's lack of timely delivery of stat medication orders. The CNE realized nurses would document on the MAR medications were not administered, but would not notify the CNE or herself. The CED stated she knew at this point that pharmacy could not fix this and the facility began retraining on 06/08/18. Continued interview, on 06/26/18 at 3:28 PM with the CED, revealed the facility was ultimately responsible for ensuring care and services were provided in accordance with Physician orders [REDACTED]. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #51 had received the Rifaximin since 05/30/18. 2. Resident #40 was no longer in the facility. 3. From 06/11/18 - 06/21/18 re-education of staff nurses and Certified Medication Technicians (CMT) occurred. Education included the facility policy on ordering and obtaining medications from the pharmacy for all admissions, re-admissions, and new physician orders. Education also included policies and processes for obtaining medications that are unavailable from the Emergency Drug Kit (EDK), as well as notification of the Physician when medications were not available from the pharmacy and were not available in the EDK. 4. The Center Nurse Executive (CNE) conducted an audit of all resident Medication Administration Records (MAR) from 06/01/18 - 06/13/18. Twelve (12) residents were identified to have missed medication dosages. On 06/14/18, a pharmacy consultant conducted an audit of available medications in comparison to the Physician orders. 5. The Medical Director was notified of the twelve (12) residents that had missed medication dosages on 06/14/18. The Medical Director assessed the identified residents and findings were documented in the resident charts. No new medication or laboratory orders were received. 6. On 06/14/18, an adHoc QAPI meeting was conducted with the Medical Director, the CNE, and the Center Executive Director (CED). During the meeting, audits, education, and compliance monitors were developed and to be implemented on 06/23/18. 7. Two (2) additional discrepancies of missed medications were self-identified by the CNE and the CED during audits performed on 06/23/18. 8. Additional education of licensed staff and two (2) CMTs was completed on 06/25/18. Education included procedure for sending medication orders to pharmacy; procedure for unavailable medications including refusals and notification of the pharmacy and physicians; when to notify the CNE and CED of unavailable medications; and the care plan process of revising and implementing the care plan with new orders. Posttests provided to validate understanding. 9. On 06/25/18, an adHoc QAPI meeting was conducted with the CED, the CNE, and the Medical Director to review additional education conducted. 10. Beginning 06/26/18, the Pharmacy Program Manager would contact the facility daily, including weekends, and speak with the CED, the CNE, or Registered Nurse (RN) Charge Nurse to confirm any medications needed would be sent to the facility stat (immediately). 11. On 06/26/18, the facility's EDK was re-stocked. 12. The CNE, CED, and/or Unit Manager will monitor MARs, conduct observations, and ensure daily communications occur with the Pharmacy Program Manager daily times two (2) weeks across all shifts; then three (3) times weekly for two (2) weeks; then weekly for two (2) months; then bi-weekly for two (2) months; and, then monthly for one (1) month to ensure medications were available as prescribed and the care plans were being followed. 13. The Regional Vice President of Operations and/or the Clinical Quality Specialist will review the QAPI minutes monthly for six (6) months and ongoing thereafter to ensure audits, education, and in-services are completed as needed. The SSA validated the facility implemented the following actions: 1. Record review of the MARs for Resident #51 revealed he/she had received all medications since 05/30/18 as ordered. 2. Record review revealed Resident #40 was no longer in the facility. 3. Interviews with RN #5 on 06/30/18 at 10:50 AM; the MDS Coordinator on 06/30/18 at 10:15 AM; the Unit Manager on 06/30/18 at 11:10 AM; RN #1 on 06/30/18 at 11:00 AM; CMT #1 on 06/30/18 at 11:22 AM; LPN #3 on 07/01/18 at 10:45 AM; and, RN #4 on 07/01/18 at 10:45 AM, revealed they had received and had an understanding of the education. Review of the sign-in sheet for the in-service education provided between 06/11/18 - 06/21/18 revealed all licensed staff and two (2) CMTs signed acknowledgement of the education. 4. Interview with the CNE, on 07/01/18 at 2:17 PM, revealed she completed medication audits for all resident MARs and documented twelve (12) residents had missed medications for (MONTH) (YEAR). The Audit tool was reviewed against the MARs for the residents identified with missed medications. 5. Record review revealed assessments were completed for eleven (11) of the twelve (12) identified residents. The twelfth resident had been discharged home at the time of the discovery. 6. Interviews with the CED on 07/01/18 at 10:33 AM and the CNE on 07/01/18 at 2:17 PM, revealed they began auditing for availability of medications and documentation of medications on 06/23/18. Record review revealed audits began on 06/23/18 and were signed by the CED or CNE daily. Random audits of the medication carts, conducted by the SSA on 06/30/18, revealed medications were available for randomly selected residents when compared to medications ordered by the Physician. 7. Review of the audit tools revealed missing medications were identified on 06/23/18 and medications were ordered from the pharmacy prior to medication dosages being missed. 8. Review of the sign-in sheet for the additional education related to care plans and following Physician orders [REDACTED]. Posttests reviewed for each of the licensed staff revealed a 100% pass rate. Review of the sign-in sheet for the additional education related to ordering medications for new admissions and re-admissions; re-ordering the EDK; and, the procedure for unavailable medications revealed all licensed staff and two (2) CMTs were educated. Posttests reviewed revealed a 100% pass rate. Interviews with RN #5 on 06/30/18 at 10:50 AM; the MDS Coordinator on 06/30/18 at 10:15 AM; the Unit Manager on 06/30/18 at 11:10 AM; RN #1 on 06/30/18 at 11:00 AM; CMT #1 on 06/30/18 at 11:22 AM; LPN #3 on 07/01/18 at 10:45 AM; and, RN #4 on 07/01/18 at 10:45 AM, revealed they had an understanding of the education provided. 9. Interview with the MDS Coordinator, on 06/30/18 at 9:26 AM, revealed she was present at a QAPI meeting and medication issues were discussed. Interviews with the CED on 07/01/18 at 10:33 AM an (TRUNCATED)

Based on interview, record review, and facility policy review, it was determined the facility failed to have an effective system in place to ensure residents were free from significant medication errors for three (3) of twenty-three (23) sampled residents, Residents #38, #40, and #51. The facility readmitted Resident #40 on 06/09/18 from the hospital after treatment for [REDACTED]. From 06/10/18 - 06/13/18, the facility failed to administer the antibiotic as ordered, and did not administer all scheduled breathing treatments, and the resident was transferred back to the hospital for additional treatment on 06/13/18. Per interview with the Advanced Practice Registered Nurse (APRN), the omission of the antibiotics and breathing treatments negatively impacted the resident's condition, which necessitated his/her transfer back to the hospital for further treatment. The facility admitted Resident #51 on 05/22/18 with an order to administer an antibiotic to treat the resident's fatty liver disease. The facility did not administer the antibiotic as ordered 05/22/18 - 05/29/18. Record review revealed the resident experienced periods of confusion and behaviors, and an ammonia level was ordered on [DATE] that resulted in an elevated reading of 118 (normal range of 18-75). Per interview, the increased ammonia level, caused by failure to receive the antibiotic, had caused the confusion and behaviors. The facility admitted Resident #38 on 05/11/18 with orders to administer [MEDICATION NAME]. However, interview and record review revealed the resident did not receive seven (7) doses of the medication in (MONTH) (YEAR). The facility's failure to ensure residents were free of significant medication errors, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 06/25/18 and was determined to exist on 05/22/18. The facility was notified of the Immediate Jeopardy on 06/25/18. The facility provided an acceptable Allegation of Compliance (A[NAME]) on 06/27/18, which alleged removal of the IJ on 06/28/18. The State Survey Agency (SSA) verified the IJ was removed on 06/28/18, prior to exit on 07/01/18. The Scope and Severity was lowered to a D while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the facility/s policy, Medication Administration: General, revised 11/28/17, revealed if medication discrepancies, including medication not available, were identified, notify the Physician/advanced practice provider, and/or pharmacy. Review of the facility's policy, Medication Errors, last reviewed 03/01/16, revealed a medication error was identified as a discrepancy between what the Physician/mid-level provider ordered and what the resident received. Types of errors included medication omission; wrong patient, dose, route, rate, or time, incorrect preparation; and/or incorrect administration technique. Review of the facility's policy, Medication Shortages/Unavailable Medications, revised 01/01/13, revealed upon discovery that the facility had an inadequate supply of a medication to administer to a resident, staff should call the pharmacy to determine the status of the order. If the medication had not been ordered, the nurse should place the order, or reorder, for the next scheduled delivery. If the next available delivery caused delay or a missed dose in a resident's medication schedule, the nurse should obtain the medication from the Emergency Medication Supply to administer the dose. If the medication was not available in the Emergency Medication Supply, staff should notify the pharmacy and arrange for an emergency delivery. If a medication shortage was discovered after normal pharmacy hours, the nurse should obtain the ordered medication from the Emergency Medication Supply. If the ordered medication was not available in the Emergency Medication Supply, the nurse should call the pharmacy's emergency answering service and request to speak with the Pharmacist on duty to manage the plan of action, which might include emergency delivery or use of an emergency (back up) third party pharmacy. If an emergency delivery was unavailable, the nurse should contact the attending Physician to obtain orders or directions. If the medication was unavailable from the pharmacy or third party pharmacy, and could not be supplied from the manufacturer, the facility should obtain alternate Physician/Prescriber orders, as necessary. 1. Review of Resident #40's clinical record revealed the facility readmitted the resident on 10/27/17, with multiple diagnoses, which included a history of [MEDICAL CONDITION] and Pneumonitis (lung inflammation) due to Inhalation of Food and Vomit. The resident transferred to the hospital on [DATE] for low oxygenation, a pulse of 174, coughing up white thick sputum, and altered level of consciousness, and transferred back to the facility on [DATE] at 9:10 PM. Review of the nurses' notes revealed staff contacted the Physician and verified orders. Review of the Hospital Discharge Summary, dated 06/09/18, revealed Resident #40 was treated for [REDACTED]. In addition, there was an order for [REDACTED]. Review of the Progress Notes, dated 06/10/18 at 2:30 AM, revealed the nurse faxed the medication list to the pharmacy and notified pharmacy to STAT (immediately) deliver the medications. According to the documentation, the nurse called the pharmacy and she left message to call and confirm receipt of the faxed orders. Continued review of the notes revealed on 06/10/18 at 8:40 AM, the nurse called the pharmacy and informed them the medications for Resident #40 had not been received. The pharmacy indicated the order was not sent as a STAT request for delivery, but the nurse reiterated the order faxed stated to please STAT the medications. The note also revealed pharmacy staff informed the nurse the medications would be sent as soon as possible. Review of Resident #40's Medication Administration Record (MAR), dated (MONTH) (YEAR), revealed [MEDICATION NAME] 450 mg scheduled for 8:00 AM, 12:00 PM, and 8:00 PM. Documentation revealed the resident did not receive the [MEDICATION NAME] on 06/10/18 at 8:00 AM, 12:00 PM, and 8:00 PM, 06/11/18 at 8:00 AM and 12:00 PM, 06/12/18 at 8:00 AM and 12:00 PM, and 06/13/18 at 8:00 AM. In addition, [MEDICATION NAME]-[MEDICATION NAME] 3 ml was scheduled for 8:00 AM, 12:00 PM, and 8:00 PM. Documentation revealed the resident did not receive the breathing treatment on 06/10/18 at 12:00 PM, 12/11/18 at 12:00 PM, and 06/12/18 at 12:00 PM. Further review of the clinical record and interview with Licensed Practical Nurse (LPN) #4, on on 06/22/18 at 3:25 PM, revealed the resident was transferred back to the hospital, on 06/13/18 between 8:30 AM - 9:00 AM, with an elevated heart rate of 147, difficulty breathing with a cough, and an oxygenation level of 88% while on two (2) liters of Oxygen. Review of the Hospital Discharge Summary revealed the resident was diagnosed with [REDACTED]. Interview with LPN #3, on 06/22/18 at 11:05 AM, revealed she cared for Resident #40 on 06/10/18 and 06/12/18. LPN #3 stated she thought Resident #40's antibiotic was ordered on [DATE]; however, the medication was not delivered on 06/10/18. She stated she did not call the pharmacy to follow-up when she realized she did not have the medication for the resident, nor did she notify the Center Nurse Executive (CNE), Physician, or APRN. LPN #3 stated when she came back to work on 06/12/18, Resident #40's antibiotic was still not available and she thought she contacted the pharmacy that day, but did not inform the CNE the antibiotic had not been delivered. Interview with Registered Nurse (RN) #3, on 06/29/18 at 7:05 AM, revealed she worked the night of 06/11/18 and administered Resident #40's evening dose of [MEDICATION NAME] from the Emergency Drug Kit (EDK). RN #3 stated after using the EDK supply there was not enough of the medication left for another dose and she notified the pharmacy to refill the EDK and that the resident still needed his/her own supply of the medication. RN #3 stated she thought she left a note for the CNE informing her she had to use the EDK supply for Resident #40's night dose of antibiotic. Interview with LPN #8, on 06/30/18 at 11:38 AM, revealed she obtained Resident #40's evening does of antibiotic out of the EDK on 06/12/18 because it was not in the medication cart. Interview with LPN #4, on 06/22/18 at 3:25 PM, revealed she observed Resident #40 on 06/13/18 around 7:30 AM - 7:45 AM and he/she seemed to have difficulty breathing, was coughing, and sounded like he/she had mucous in his/her throat. LPN #4 stated the APRN arrived shortly, assessed Resident #40, and ordered the resident transferred to the hospital for further evaluation approximately 8:30 AM - 9:00 AM. Interview with the APRN, on 06/22/18 at 12:01 PM, revealed she did not learn Resident #40 had not received the [MEDICATION NAME] until the morning of 06/13/18, even though she had been in to see the resident on 06/12/18 related to vomiting the resident had the day before. The APRN stated on 06/13/18, staff reported the resident was short of air, had congestion and an oxygen saturation of 88%, and she gave the order to transfer the resident to the hospital. Continued interview at 4:15 PM revealed she thought the facility had been having consistent issues with medications not being administered due to lack of availability of the medications. She further stated in her professional opinion, the omission of the antibiotics and breathing treatments, as ordered for the time period from 06/10/18 - 06/13/18, would have negatively impacted the resident's condition on 06/13/18, which necessitated his/her transfer back to the hospital for further treatment in the acute care setting. Interview with the Medical Director, on 06/21/18 at 11:30 AM, revealed Resident #40 missed scheduled doses of an antibiotic and had to be transferred back to the hospital. She stated the antibiotic was ordered but the pharmacy did not deliver the medication. Interview with LPN #1/Unit Manager (UM), on 06/22/18 at 1:45 PM, revealed on 06/11/18, during the day shift, Resident #40's medication was not available and she checked the EDK, but there was not enough of the antibiotic to provide a full dose. She notified the APRN the medicine was not available, but she did not document the notification. The UM stated when a medicine was not available for administration at the scheduled time, the nurse should try to obtain the medicine. She stated the nurse should notify the pharmacy to send the medicine, and the prescriber in case he or she would want to give additional orders. The UM further stated the nurse should notify the CNE and the Center Executive Director (CED), so they would be aware of the delayed deliveries and further address the matter with the pharmacy staff. Interview with the CNE, on 06/26/18 at 1:45 PM, revealed it was very concerning to her that Resident #40's medications were not administered. She stated nurses should administer medication as ordered by the Physician and if not, the nurse should make it clear in the clinical record why the medication was not administered. She stated if the resident refused medications or the medication was not effective, then that information should be documented and communicated so the providers and other members of the Interdisciplinary Team could attempt other care interventions. 2. Review of Resident #51's clinical record revealed the facility admitted the resident on 05/22/18, with a [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. Review of Resident #51's MAR, dated (MONTH) (YEAR), revealed fifteen (15) doses of Rifaximin were documented as not administered. The MAR revealed the 9:00 PM dose on 05/22/18 was blank. The doses scheduled on 05/23/18, 05/24/18, 05/25/18, and 05/26/18 at 9:00 AM and 9:00 PM had circled staff initials. The 9:00 AM dose on 05/27/18 had circled initials and the 9:00 PM dose was blank. The 05/28/18 and 05/29/18 scheduled doses at 9:00 AM and 9:00 PM had circled initials. Interview with the Pharmacist, on 06/28/18 at 11:51 AM, revealed the pharmacy received Resident #51's Rifaximin order on 05/22/18; however, the order was not filled because of a billing issue. He stated the order was delivered to the facility on [DATE]. Interview with LPN #3, on 06/22/18 at 3:45 PM, revealed when medication was not available for administration; staff initialed the MAR and circled the initials, which indicated the medication was not given. LPN #3 stated she did not do anything about Resident #51's missing Rifaximin such as call the pharmacy, Physician, or the CNE; however, she stated she should have notified all of them. She stated she looked in the EDK but Rifaximin was not there. She stated by not receiving the medication, the resident was not treated for [REDACTED]. Review of laboratory results for Resident #51, dated 05/24/18 at 12:50 AM, revealed the resident's ammonia level was elevated at 98 (normal range of 18-75). The Practitioner noted on the results to check the ammonia level again on 05/29/18. Review of the Progress Notes for Resident #51, dated 05/26/18 at 3:55 PM, revealed the resident was verbalizing confusion from time to time, while packing clothes and wanting to go home. The Practitioner was notified and a new order obtained for a STAT ammonia level. Review of laboratory results, dated 05/26/18, revealed an ammonia level of 52. Review of the Progress Notes, dated 05/28/18 at 5:41 PM, revealed Resident #51 showed signs of confusion, requiring redirection several times during the day. The resident was taking his/her dressing off his/her foot and rolling away in his/her wheelchair from the intravenous (IV) pump/pole while the IV was infusing. Review of the follow-up ammonia laboratory results for Resident #51, dated 05/29/18 at 1:00 AM, revealed the resident's ammonia level was elevated at 118. Interview with LPN #4, on 06/22/18 at 4:35 PM, revealed the Rifaximin was for Resident #51's ammonia level and he/she did not benefit by the omission of his/her medication. Interview with LPN #1/UM, on 06/22/18 at 11:07 AM and 1:49 PM, revealed missing medications should be reported to the Physician, the pharmacy so it was placed on a STAT delivery, the responsible party, the CNE, and the CED. She stated as she reviewed the (MONTH) (YEAR) MAR for Resident #51, there were fifteen (15) doses of Rifaximin not administered as the doses were circled not available and not administered. This was a significant medication error as a result of the omission of the Rifaximin, which contributed to elevated ammonia levels. She stated the Rifaximin treated Resident #51's liver disease and the lack of the medication could increase the resident's confusion. Continued interview, on 06/26/18 at 10:55 AM, revealed she was supposed to follow-up on all resident orders and monitor the MARs for holes/omissions. However, she stated she had been working on the floor and had not had an opportunity to monitor. Interview with the CNE, on 06/26/18 at 1:46 PM, revealed she was very concerned about missed medications for Resident #51 because the increased serum ammonia levels, caused by failure to receive the Rifaximin, had caused confusion and behavioral changes in the resident. She further stated the increased confusion could lead to refusal of other necessary care and treatment. She stated the facility failed to prevent a significant medication error and provide the resident with the care and services to meet his/her healthcare needs. Interview with the APRN, on 06/22/18 at 12:01 PM, revealed the facility contacted her about Resident #51 exhibiting an increase in behaviors the week after his/her admission. She stated it was around that time she learned the resident had not been receiving the Rifaximin for management of his/her fatty liver disease. She stated she ordered a urinalysis to rule out a Urinary Tract Infection and a serum ammonia level, which resulted as elevated at 118. She stated the high normal for serum ammonia was 75, and the elevated ammonia level could have been the result of the failure to administer the Rifaximin. 3. Review of the clinical record for Resident #38 revealed the facility admitted the resident on 05/11/18, with [DIAGNOSES REDACTED]. Review of Resident #38's MAR, dated (MONTH) (YEAR), revealed an order for [REDACTED]. Documentation revealed seven (7) doses of the medication were not administered, on 05/12/18 at 9:00 AM and 9:00 PM, 05/13/18 at 9:00 AM, 05/14/18 at 9:00 AM, 05/23/18 at 9:00 PM, and 05/30/18 at 9:00 AM and 9:00 PM. Interview, on 06/28/18 at 11:51 AM, with the Pharmacist via telephone revealed the pharmacy received Resident #38's medication orders on 05/11/18 at 10:22 PM. He stated the [MEDICATION NAME] was not filled and sent to the facility immediately because there were issues with insurance coverage. He stated the [MEDICATION NAME] was dispensed on 05/13/18. He revealed he did not have documentation the facility had called to follow-up on the medication orders. Interview, on 06/26/18 at 10:44 AM, with LPN #1/UM revealed if staff did not give Resident #38 the [MEDICATION NAME] as scheduled, it could result in the formation of a blood clot. Interview with the CED, on 06/22/18 at 8:50 AM, revealed the facility tracked medication errors, such as wrong doses, wrong medication given, or a medication given by the wrong route, but the facility had not been completing medication error forms when medications were not administered. Therefore, the facility had not been tracking the medication omissions. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #51 had received the Rifaximin since 05/30/18. 2. Resident #40 was no longer in the facility. 3. From 06/11/18 - 06/21/18 re-education of staff nurses and Certified Medication Technicians (CMT) occurred. Education included the facility policy on ordering and obtaining medications from the pharmacy for all admissions, re-admissions, and new physician orders. Education also included policies and processes for obtaining medications that are unavailable from the Emergency Drug Kit (EDK), as well as notification of the Physician when medications were not available from the pharmacy and were not available in the EDK. 4. The Center Nurse Executive (CNE) conducted an audit of all resident Medication Administration Records (MAR) from 06/01/18 - 06/13/18. Twelve (12) residents were identified to have missed medication dosages. On 06/14/18, a pharmacy consultant conducted an audit of available medications in comparison to the Physician orders. 5. The Medical Director was notified of the twelve (12) residents that had missed medication dosages on 06/14/18. The Medical Director assessed the identified residents and findings were documented in the resident charts. No new medication or laboratory orders were received. 6. On 06/14/18, an adHoc QAPI meeting was conducted with the Medical Director, the CNE, and the Center Executive Director (CED). During the meeting, audits, education, and compliance monitors were developed and to be implemented on 06/23/18. 7. Two (2) additional discrepancies of missed medications were self-identified by the CNE and the CED during audits performed on 06/23/18. 8. Additional education of licensed staff and two (2) CMTs was completed on 06/25/18. Education included procedure for sending medication orders to pharmacy; procedure for unavailable medications including refusals and notification of the pharmacy and physicians; when to notify the CNE and CED of unavailable medications; and the care plan process of revising and implementing the care plan with new orders. Posttests provided to validate understanding. 9. On 06/25/18, an adHoc QAPI meeting was conducted with the CED, the CNE, and the Medical Director to review additional education conducted. 10. Beginning 06/26/18, the Pharmacy Program Manager would contact the facility daily, including weekends, and speak with the CED, the CNE, or Registered Nurse (RN) Charge Nurse to confirm any medications needed would be sent to the facility stat (immediately). 11. On 06/26/18, the facility's EDK was re-stocked. 12. The CNE, CED, and/or Unit Manager will monitor MARs, conduct observations, and ensure daily communications occur with the Pharmacy Program Manager daily times two (2) weeks across all shifts; then three (3) times weekly for two (2) weeks; then weekly for two (2) months; then bi-weekly for two (2) months; and, then monthly for one (1) month to ensure medications were available as prescribed and the care plans were being followed. 13. The Regional Vice President of Operations and/or the Clinical Quality Specialist will review the QAPI minutes monthly for six (6) months and ongoing thereafter to ensure audits, education, and in-services are completed as needed. The SSA validated the facility implemented the following actions: 1. Record review of the MARs for Resident #51 revealed he/she had received all medications since 05/30/18 as ordered. 2. Record review revealed Resident #40 was no longer in the facility. 3. Interviews with RN #5 on 06/30/18 at 10:50 AM; the MDS Coordinator on 06/30/18 at 10:15 AM; the Unit Manager on 06/30/18 at 11:10 AM; RN #1 on 06/30/18 at 11:00 AM; CMT #1 on 06/30/18 at 11:22 AM; LPN #3 on 07/01/18 at 10:45 AM; and, RN #4 on 07/01/18 at 10:45 AM, revealed they had received and had an understanding of the education. Review of the sign-in sheet for the in-service education provided between 06/11/18 - 06/21/18 revealed all licensed staff and two (2) CMTs signed acknowledgement of the education. 4. Interview with the CNE, on 07/01/18 at 2:17 PM, revealed she completed medication audits for all resident MARs and documented twelve (12) residents had missed medications for (MONTH) (YEAR). The Audit tool was reviewed against the MARs for the residents identified with missed medications. 5. Record review revealed assessments were completed for eleven (11) of the twelve (12) identified residents. The twelfth resident had been discharged home at the time of the discovery. 6. Interviews with the CED on 07/01/18 at 10:33 AM and the CNE on 07/01/18 at 2:17 PM, revealed they began auditing for availability of medications and documentation of medications on 06/23/18. Record review revealed audits began on 06/23/18 and were signed by the CED or CNE daily. Random audits of the medication carts, conducted by the SSA on 06/30/18, revealed medications were available for randomly selected residents when compared to medications ordered by the Physician. 7. Review of the audit tools revealed missing medications were identified on 06/23/18 and medications were ordered from the pharmacy prior to medication dosages being missed. 8. Review of the sign-in sheet for the additional education related to care plans and following Physician orders [REDACTED]. Posttests reviewed for each of the licensed staff revealed a 100% pass rate. Review of the sign-in sheet for the additional education related to ordering medications for new admissions and re-admissions; re-ordering the EDK; and, the procedure for unavailable medications revealed all licensed staff and two (2) CMTs were educated. Posttests reviewed revealed a 100% pass rate. Interviews with RN #5 on 06/30/18 at 10:50 AM; the MDS Coordinator on 06/30/18 at 10:15 AM; the Unit Manager on 06/30/18 at 11:10 AM; RN #1 on 06/30/18 at 11:00 AM; CMT #1 on 06/30/18 at 11:22 AM; LPN #3 on 07/01/18 at 10:45 AM; and, RN #4 on 07/01/18 at 10:45 AM, revealed they had an understanding of the education provided. 9. Interview with the MDS Coordinator, on 06/30/18 at 9:26 AM, revealed she was present at a QAPI meeting and medication issues were discussed. Interviews with the CED on 07/01/18 at 10:33 AM and the CNE on 07/01/18 at 2:17 PM revealed they discussed medication issues in the QAPI meeting held on 06/25/18. Review of the sign-in sheet for the QAPI meeting on 06/25/18 revealed the MDS Coordinator, the CED, the CNE, and the Medical Director attended the meeting. 10. Interview with the CED, on 07/01/18 at 10:33 AM, revealed conversations with pharmacy were occurring daily. Review of the log documenting daily pharmacy phone calls revealed calls occurred daily as alleged. 11. Observation of the EDK revealed the box had been refilled. Interview with the Unit Manager, on 06/30/18 at 11:10 AM, revealed if staff took medication out of the EDK, staff filled out a form and faxed it to the pharmacy. If the entire stock of the medication was used, pharmacy refilled the EDK the same day. 12. Interviews with the CED on 07/01/18 at 10:33 AM and the CNE on 07/01/18 at 2:17 PM, revealed audits of the MARs and Physician orders [REDACTED]. Review of the audits revealed the CNE or CED audited the MARs and Physician orders [REDACTED]. 13. Observations during the A[NAME] validation revealed the Clinical Quality Specialist (CQS) was in the facility daily assisting with MAR/TAR audits and medication cart audits. Interviews with the CED on 07/01/18 at 10:33 AM and the CNE on 07/01/18 at 2:17 PM revealed the CQS or Regional Vice President would review QAPI minutes monthly. Review of the most recent QAPI sign-in sheet revealed the CQS attended the meeting.

Based on interview, record review, and facility policy review, it was determined the facility failed to have an effective system in place to notify the Physician and/or the Advanced Practice Registered Nurse (APRN) when medications were not available to treat diagnosed conditions for two (2) of twenty-three (23) sampled residents, Resident #40 and #51. Record review revealed Resident #40 had a Physician order [REDACTED]. The resident was transferred to the hospital on [DATE] for difficulty breathing, an elevated heart rate, and a decrease in blood oxygenation. Resident #51 had a Physician order [REDACTED]. However, the resident did not receive fifteen (15) doses of the medication between 05/22/18 - 05/29/18 due to the unavailability of the medication. Staff failed to notify the provider and the resident had periods of confusion and an elevated ammonia level during the time when the medication was not administered, which according to interview, was a result of not receiving the antibiotic. The facility's failure to have an effective system in place to ensure the Physician was notified when residents did not receive ordered medication, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 06/25/18 and was determined to exist on 05/22/18. The facility was notified of the IJ on 06/25/18. The facility provided an acceptable Allegation of Compliance (A[NAME]) on 06/27/18, which alleged removal of the IJ on 06/28/18. The State Survey Agency (SSA) verified the IJ was removed on 06/28/18, prior to exit on 07/01/18. The Scope and Severity was lowered to a D while the facility develops and implements a Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy, Medication Administration: General, revised 11/28/17, under the section Practice Standards, if there were medication discrepancies, including medication not available, notify physician/advanced practice provider and/or pharmacy as indicated. Review of the facility's policy, Medication Shortages/Unavailable Medications, revised 01/01/13, revealed upon discovery that the facility had an inadequate supply of a medication to administer to a resident, and the medication was not available in the Emergency Medication Supply and was unavailable from the pharmacy or third party pharmacy and could not be supplied from the manufacturer, the facility should obtain alternate Physician/Prescriber orders, as necessary. 1. Review of Resident #40's clinical record revealed the facility readmitted the resident on 10/27/17, with [DIAGNOSES REDACTED]. The resident was transferred to the hospital on [DATE] for low oxygenation, increase pulse, coughing up white thick sputum, and an altered level of consciousness. The resident was transferred back to the facility on [DATE] at 9:10 PM. Review of the Hospital Discharge Summary, date 06/09/18, revealed an order for [REDACTED]. In addition, there was an order for [REDACTED]. Review of Resident #40's Medication Administration Record (MAR), dated (MONTH) (YEAR), revealed [MEDICATION NAME] 450 mg scheduled for 8:00 AM, 12:00 PM, and 8:00 PM. Documentation revealed the resident did not receive the medication on 06/10/18 at 8:00 AM, 12:00 PM, and 8:00 PM, 06/11/18 at 8:00 AM and 12:00 PM, 06/12/18 at 8:00 AM and 12:00 PM, and 06/13/18 at 8:00 AM. In addition, [MEDICATION NAME]-[MEDICATION NAME] was scheduled for 8:00 AM, 12:00 PM, and 8:00 PM. Documentation revealed the resident did not receive the breathing treatments on 06/10/18 at 12:00 PM, 12/11/18 at 12:00 PM, and 06/12/18 at 12:00 PM. However, there was no documented evidence the Physician was notified of the missed doses. Interview with Licensed Practical Nurse (LPN) #3, on 06/22/18 at 11:05 AM, revealed she cared for Resident #40 on 06/10/18 and 06/12/18. LPN #3 stated she thought Resident #40's antibiotic was ordered on [DATE]; however, the medication was not delivered on 06/10/18. She stated she did not notify the Center Nurse Executive (CNE), Physician, or APRN, even though the APRN was in the facility that day (06/10/18). She stated she was not sure why she did not inform the APRN because she usually made the APRN aware of any resident issues. LPN #3 revealed she did not call the pharmacy to follow up when she realized she did not have the medication for the resident and when she came back to work on 06/12/18, Resident #40's antibiotic was still not available. She stated she thought she contacted the pharmacy that day, but did not inform the CNE the antibiotic had not been delivered. Interview with LPN #4, on 06/22/18 at 3:25 PM, revealed she observed Resident #40 on 06/13/18 around 7:30 AM - 7:45 AM and he/she seemed to have difficulty breathing, was coughing, and sounded like he/she had mucous in his/her throat. LPN #4 stated the APRN arrived shortly, assessed Resident #40, and ordered the resident transferred to the hospital for further evaluation. Interview with the APRN, on 06/22/18 at 12:01 PM, revealed in her professional opinion, Resident #40 missed doses of the antibiotic and breathing treatments from 06/10/18 - 06/13/18, would have negatively impacted the resident's condition and necessitated his/her transfer back to the hospital for further treatment. She stated she did not learn Resident #40 had not received all of the [MEDICATION NAME] doses until the morning of 06/13/18, even though she had been in to see the resident on 06/12/18 related to vomiting the resident had the day before. The APRN stated, on 06/13/18 staff reported the resident was short of air, had congestion and an Oxygen saturation of 88%, and she gave the order to transfer the resident to the hospital. She revealed as the CNE was preparing the paperwork for the resident's transfer to the hospital, the CNE told her Resident #40 had not received all doses of his/her [MEDICATION NAME] because it had not been delivered to the facility. She further stated nurses had not been notifying her or the Medical Director that medications were not available, and therefore not administered per the orders. According to the APRN, it was difficult to the treat residents' condition if the provider was not aware of medications the resident did or did not receive. 2. Review of the clinical record for Resident #51 revealed the facility admitted the resident on 05/22/18, with a [DIAGNOSES REDACTED]. Review of Physician order [REDACTED]. Review of the MAR, for Resident #51, dated (MONTH) (YEAR), revealed Rifaximin 550 mg was to be administered every twelve (12) hours. Documentation revealed fifteen (15) doses of the medication were not administered. On 05/22/18, the dose at 9:00 PM was left blank. The doses on 05/23/18, 05/24/18, 05/25/18, and 05/26/18 at 9:00 AM and 9:00 PM had staff initials circled. The 05/27/18 9:00 AM dose had staff initials circled, and the 9:00 PM dose was blank. The 05/28/18 and 05/29/18 scheduled doses at 9:00 AM and 9:00 PM had staff initials circled. Interview, on 06/22/18 at 3:45 PM, with LPN #3 revealed when medication was not available for administration; staff initialed the MAR and circled their initials, which indicated the medication was not given. Review of Resident #51's ammonia level results, dated 05/29/18 at 1:00 AM, revealed the ammonia level was elevated at 118, with a normal range of 18 - 75. Interview, on 06/22/18 at 4:35 PM, with LPN #4 revealed her process was not notify the Physician of missed medication until three (3) doses of a resident's medication had been withheld or missed, and then she notified the provider. LPN #4 stated she might have told the provider about missed medications if she saw the provider in the building. LPN #4 further stated in relation to Resident #51, if the Rifaximin was not administered per the Physician order, his/her ammonia level could go up, and it would not be beneficial for the resident to miss his/her ordered medications. Interview, on 06/22/18 at 12:01 PM, with the APRN revealed she received a call from the facility about a week after Resident #51's admission, and staff reported the resident had an increase in behaviors and confusion. She stated it was at about that time when she learned the resident had not been receiving the Rifaximin that was ordered on [DATE], when the resident was admitted . She further stated the resident's missed doses of the medication could have been a contributing factor to the resident's increased ammonia level. Interview, on 06/22/18 at 1:45 PM, LPN #1/Unit Manager (UM), revealed before assuming the position of UM, two (2) weeks ago, she worked as a floor nurse at the facility and would notice medications were unavailable for resident administration. In her two (2) months of employment at the facility, she stated she witnessed nurses notifying the pharmacy when medications were not available, but they would not notify the provider. The UM stated when a medicine was not available for administration at the scheduled time, the nurse should try to obtain the medicine by notifying the pharmacy to send the medicine, and the prescriber in case he or she would want to give additional orders. The UM further stated the nurse should notify the CNE and the Center Executive Director (CED) so they would be aware of the delayed medication deliveries and further address the matter with the pharmacy staff. Interview, on 06/28/18 at 2:00 PM, with the Medical Director revealed her Medical Assistant somehow learned that medications were not being administered to residents as ordered because they were not available. The Medical Director stated she thought she and the APRN became aware of the issue about two (2) weeks ago. She stated when she learned of the issue with missed medications and the delayed pharmacy deliveries, she talked with the CED and told her the nurses must report that information to the prescriber, as well as the CNE, and follow other parts of the protocol for notifications. In addition, she stated she informed the CNE that the nurses needed to know how to make notifications to her via the call center, and how to report pertinent resident information. The Medical Director stated she had an answering service and nurses could phone the call center seven (7) days per week around the clock. Interview with the CNE, on 06/26/18 at 1:45 PM, revealed it was very concerning to her that residents had not received medications as ordered. She stated if the resident refused medications or the medication was not effective, that information should be documented and communicated to the physician so other interventions could be attempted. Interview, on 06/22/18 at 8:50 PM, with the CED revealed she delegated management of the nursing staff to the CNE who should ensure the nurses notified the prescribers, and the nursing and administrative leadership when there were issues with non-timely delivery of scheduled medications, and when medications could not be administered as ordered. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #51 had received the Rifaximin since 05/30/18. 2. Resident #40 was no longer in the facility. 3. From 06/11/18 - 06/21/18 re-education of staff nurses and Certified Medication Technicians (CMT) occurred. Education included the facility policy on ordering and obtaining medications from the pharmacy for all admissions, re-admissions, and new physician orders. Education also included policies and processes for obtaining medications that are unavailable from the Emergency Drug Kit (EDK), as well as notification of the Physician when medications were not available from the pharmacy and were not available in the EDK. 4. The Center Nurse Executive (CNE) conducted an audit of all resident Medication Administration Records (MAR) from 06/01/18 - 06/13/18. Twelve (12) residents were identified to have missed medication dosages. On 06/14/18, a pharmacy consultant conducted an audit of available medications in comparison to the Physician orders. 5. The Medical Director was notified of the twelve (12) residents that had missed medication dosages on 06/14/18. The Medical Director assessed the identified residents and findings were documented in the resident charts. No new medication or laboratory orders were received. 6. On 06/14/18, an adHoc QAPI meeting was conducted with the Medical Director, the CNE, and the Center Executive Director (CED). During the meeting, audits, education, and compliance monitors were developed and to be implemented on 06/23/18. 7. Two (2) additional discrepancies of missed medications were self-identified by the CNE and the CED during audits performed on 06/23/18. 8. Additional education of licensed staff and two (2) CMTs was completed on 06/25/18. Education included procedure for sending medication orders to pharmacy; procedure for unavailable medications including refusals and notification of the pharmacy and physicians; when to notify the CNE and CED of unavailable medications; and the care plan process of revising and implementing the care plan with new orders. Posttests provided to validate understanding. 9. On 06/25/18, an adHoc QAPI meeting was conducted with the CED, the CNE, and the Medical Director to review additional education conducted. 10. Beginning 06/26/18, the Pharmacy Program Manager would contact the facility daily, including weekends, and speak with the CED, the CNE, or Registered Nurse (RN) Charge Nurse to confirm any medications needed would be sent to the facility stat (immediately). 11. On 06/26/18, the facility's EDK was re-stocked. 12. The CNE, CED, and/or Unit Manager will monitor MARs, conduct observations, and ensure daily communications occur with the Pharmacy Program Manager daily times two (2) weeks across all shifts; then three (3) times weekly for two (2) weeks; then weekly for two (2) months; then bi-weekly for two (2) months; and, then monthly for one (1) month to ensure medications were available as prescribed and the care plans were being followed. 13. The Regional Vice President of Operations and/or the Clinical Quality Specialist will review the QAPI minutes monthly for six (6) months and ongoing thereafter to ensure audits, education, and in-services are completed as needed. The SSA validated the facility implemented the following actions: 1. Record review of the MARs for Resident #51 revealed he/she had received all medications since 05/30/18 as ordered. 2. Record review revealed Resident #40 was no longer in the facility. 3. Interviews with RN #5 on 06/30/18 at 10:50 AM; the MDS Coordinator on 06/30/18 at 10:15 AM; the Unit Manager on 06/30/18 at 11:10 AM; RN #1 on 06/30/18 at 11:00 AM; CMT #1 on 06/30/18 at 11:22 AM; LPN #3 on 07/01/18 at 10:45 AM; and, RN #4 on 07/01/18 at 10:45 AM, revealed they had received and had an understanding of the education. Review of the sign-in sheet for the in-service education provided between 06/11/18 - 06/21/18 revealed all licensed staff and two (2) CMTs signed acknowledgement of the education. 4. Interview with the CNE, on 07/01/18 at 2:17 PM, revealed she completed medication audits for all resident MARs and documented twelve (12) residents had missed medications for (MONTH) (YEAR). The Audit tool was reviewed against the MARs for the residents identified with missed medications. 5. Record review revealed assessments were completed for eleven (11) of the twelve (12) identified residents. The twelfth resident had been discharged home at the time of the discovery. 6. Interviews with the CED on 07/01/18 at 10:33 AM and the CNE on 07/01/18 at 2:17 PM, revealed they began auditing for availability of medications and documentation of medications on 06/23/18. Record review revealed audits began on 06/23/18 and were signed by the CED or CNE daily. Random audits of the medication carts, conducted by the SSA on 06/30/18, revealed medications were available for randomly selected residents when compared to medications ordered by the Physician. 7. Review of the audit tools revealed missing medications were identified on 06/23/18 and medications were ordered from the pharmacy prior to medication dosages being missed. 8. Review of the sign-in sheet for the additional education related to care plans and following Physician orders [REDACTED]. Posttests reviewed for each of the licensed staff revealed a 100% pass rate. Review of the sign-in sheet for the additional education related to ordering medications for new admissions and re-admissions; re-ordering the EDK; and, the procedure for unavailable medications revealed all licensed staff and two (2) CMTs were educated. Posttests reviewed revealed a 100% pass rate. Interviews with RN #5 on 06/30/18 at 10:50 AM; the MDS Coordinator on 06/30/18 at 10:15 AM; the Unit Manager on 06/30/18 at 11:10 AM; RN #1 on 06/30/18 at 11:00 AM; CMT #1 on 06/30/18 at 11:22 AM; LPN #3 on 07/01/18 at 10:45 AM; and, RN #4 on 07/01/18 at 10:45 AM, revealed they had an understanding of the education provided. 9. Interview with the MDS Coordinator, on 06/30/18 at 9:26 AM, revealed she was present at a QAPI meeting and medication issues were discussed. Interviews with the CED on 07/01/18 at 10:33 AM and the CNE on 07/01/18 at 2:17 PM revealed they discussed medication issues in the QAPI meeting held on 06/25/18. Review of the sign-in sheet for the QAPI meeting on 06/25/18 revealed the MDS Coordinator, the CED, the CNE, and the Medical Director attended the meeting. 10. Interview with the CED, on 07/01/18 at 10:33 AM, revealed conversations with pharmacy were occurring daily. Review of the log documenting daily pharmacy phone calls revealed calls occurred daily as alleged. 11. Observation of the EDK revealed the box had been refilled. Interview with the Unit Manager, on 06/30/18 at 11:10 AM, revealed if staff took medication out of the EDK, staff filled out a form and faxed it to the pharmacy. If the entire stock of the medication was used, pharmacy refilled the EDK the same day. 12. Interviews with the CED on 07/01/18 at 10:33 AM and the CNE on 07/01/18 at 2:17 PM, revealed audits of the MARs and Physician orders [REDACTED]. Review of the audits revealed the CNE or CED audited the MARs and Physician orders [REDACTED]. 13. Observations during the A[NAME] validation revealed the Clinical Quality Specialist (CQS) was in the facility daily assisting with MAR/TAR audits and medication cart audits. Interviews with the CED on 07/01/18 at 10:33 AM and the CNE on 07/01/18 at 2:17 PM revealed the CQS or Regional Vice President would review QAPI minutes monthly. Review of the most recent QAPI sign-in sheet revealed the CQS attended the meeting.

Based on interview, record review, review of the facility's training tool on Nursing Rounds, and review of Standards of Practice for Nursing Assistants, it was determined the facility failed to have an effective system to ensure services provided met professional standards of care related to the failure to round (visual checks of residents' whereabouts) on residents identified with cognitive impairment and communication deficits for one (1) of seven (7) sampled residents, Resident #1. The facility had assessed Resident #1 to have cognitive impairment and communication problems and independent with most Activities of Daily Living. On [DATE], staff observed Resident #1 in the facility at approximately 3:30 PM. However, the staff did not see or try to locate the resident until 10:30 PM, approximately seven (7) hours later, when staff discovered the resident was not in bed. Interviews with staff revealed the resident was not in his room for dinner at 5:00 PM nor when the tray was discovered untouched at 6:30 PM. In addition, rounds were not conducted by staff during shift change at 6:30 PM, which was facility protocol. At 6:50 PM, staff reported, to the Center Nurse Executive (CNE), a screen was out of one of the windows with the window opened; however, no investigation was conducted. A search was conducted at 10:30 PM after the resident could not be located. The resident could not be found and was reported missing. Facility video surveillance recorded Resident #1 walking outside of the facility from approximately 4:12 PM to 4:34 PM. The facility's investigation determined the resident probably exited the building through the opened window with the missing screen. The resident was found deceased on [DATE], four (4) days later, approximately 3.5 miles from the facility at an abandoned building. Per the Deputy Coroner's interview, the preliminary findings from the autopsy included the resident's health conditions with minor abrasions/contusions on the extremities. The facility's failure to ensure services provided met professional standards of quality has caused or is likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. The facility provided an acceptable Allegation of Compliance (A(NAME)) on [DATE], alleging removal of the Immediate Jeopardy on [DATE]; however the State Survey Agency (SSA) verified Immediate Jeopardy was removed on [DATE], prior to exit on [DATE]. Interview and record review revealed rounding protocols and audits were not implemented until [DATE]. Therefore, it was determined the Immediate Jeopardy was not removed until [DATE] versus [DATE] as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the Mosby's Textbook for Long-Term Care Nursing Assistants, sixth (6th) edition, dated 2011, revealed Nursing Assistant standards included assisting the nurse with observing residents and identifying their needs. Review of the facility's Registered Nurse-Charge Nurse Job Description, revised [DATE], revealed the Charge Nurse was responsible to complete rounds on the unit to observe patients and determine if nursing needs were being met. Review of the facility's training tool on Nursing Rounds, undated, revealed nursing rounds should be performed by the licensed nurse at least twice per shift. Review of the closed clinical record for Resident #1 revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. The record revealed an additional [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) for Resident #1, dated [DATE], revealed the facility assessed the resident was severely cognitively impaired and required limited assistance of one (1) staff for dressing, extensive assistance of one (1) staff for hygiene and bathing, and setup help only with eating. Review of an Elopement Evaluation, dated [DATE], revealed the facility assessed Resident #1 had a history of [REDACTED]. Review of Resident #1's Care Plan, dated [DATE], revealed the resident exhibited symptoms of decline in cognitive function with interventions to give one direction or ask one question at a time and keep it simple, and re-orient as to day, time of day, and current events if not upsetting to the resident. The facility determined the resident had difficulty making himself/herself understood and had slurred speech with interventions to ask questions that required one or two word answers and/or yes or no answers, if resident became upset then re-approach later, and allow time for resident to process and respond. The resident was at risk for falls due to a shuffling gait, cognition, and lack of safety awareness with interventions to assess for changes in medical status, pain status, mental status, and report to the Physician as indicated. Interview with Certified Nurse Aide (CNA) #3, via telephone, on [DATE] at 3:08 PM, revealed she worked on [DATE] from 3:00 PM to 11:00 PM on the South Hall (where Resident #1 resided). She stated she delivered the resident's dinner tray to his/her room at approximately 5:00 PM, but Resident #1 was not in the room and she was busy and forgot to check on the resident. Interview with CNA #2, on [DATE] at 2:30 PM and [DATE] at 2:55 PM, revealed he was assigned to Resident #1 on [DATE] from 3:00 PM through 11:00 PM. Per interview, he was supposed to check on each resident every two (2) hours; however, he was busy caring for other residents. He later went to pick-up the resident's food tray from his/her room and noticed the resident had not eaten; however, he did not look for Resident #1 at that time. Interview with Licensed Practical Nurse (LPN) #6, on [DATE] at 10:12 AM, revealed she was the charge nurse assigned to Resident #1 on [DATE] until 7:00 PM. She stated she gave report on her assigned residents to the CNE shortly before clocking out; however, they did not complete a walking round. She revealed she was supposed to complete a walking round with the on-coming nurse to round on each resident while giving report; however, failed to do so that evening. Interview with the CNE, on [DATE] at 10:45 AM and [DATE] at 12:50 PM, revealed a nurse had called in for the night shift and she was required to cover as the Charge Nurse for Resident #1's hall from approximately 6:30 PM to 11:00 PM. She stated it was expected for the on-coming nurse to complete a walking round with the previous nurse and to observe each resident while getting report. However, per interview, she did not do a walking round when she took over care for Resident #1 from LPN #6 at approximately 6:30 PM. She stated at approximately 10:30 PM, CNA #1 reported she could not find Resident #1 in his/her room or bathroom and the CNE went to the resident's room and observed the resident's food tray untouched and initiated a search for the resident. She stated she expected CNAs to complete rounds every two (2) hours on all residents; however, supervision was based on the needs of the resident. She further revealed she expected staff to ensure a resident's whereabouts at least two (2) times per shift and when residents needed assistance. Interview with the Center Executive Director (CED), on [DATE] at 12:40 PM, [DATE] at 12:30 PM, and [DATE] at 1:07 PM, revealed she was called and informed about the missing resident at approximately 10:50 PM on [DATE]. She stated she expected licensed staff to make rounds twice per shift (according to the training tool) and more often depending on the needs of each resident. She revealed licensed staff traditionally completed a walking round; however, they were not expected to search for the resident if the resident was not in their room. The CED further revealed higher functioning residents did not necessarily need to be observed every two (2) hours and Resident #1 was high functioning regardless of his/her diagnoses; however, she expected staff to verify the resident's whereabouts on [DATE] prior to 10:30 PM. Interview with Medical Doctor (MD) #1, on [DATE] at 4:10 PM and [DATE] at 9:00 AM, revealed he was the MD for Resident #1 until [DATE]. He revealed it was difficult to measure the resident's intellect due to his/her [DIAGNOSES REDACTED]. He expected the facility standard was to monitor residents every two (2) hours. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The Center Nurse Executive (CNE) and the North Hall Charge Nurse initiated a visual validation of residents that resided in the center on [DATE] at 10:30 PM, to determine fifty-three (53) residents were accounted for, with no concerns. 2. The Clinical Quality Specialist (CQS) educated the CNE and Center Executive Director (CED) on [DATE], over the phone, on the facility's elopement policy with instruction to initiate resident rounds and window checks every two (2) hours. 3. On [DATE], the Maintenance Director arrived at the facility and began a round on the perimeter windows to determine all were secure. He added two (2) additional screws to the window in room [ROOM NUMBER] and three (3) other rooms that had double pane windows. Additionally, he ensured proper functioning of the six (6) exit doors in the facility. 4. A Registered Nurse (RN) reviewed the elopement books for accuracy on [DATE]. The Care Plan and Kardex were also reviewed for one (1) resident identified at risk for elopement in the facility. 5. The Clinical Reimbursement Coordinator (CRC) was trained on the Resident Assessment Instrument (RAI) Process to include Brief Interview for Mental Status (BIMS) assessments per on-line training on [DATE]. The CRC reviewed fifty-three (53) resident's BIMS assessments for accuracy on [DATE]. 6. On [DATE], the CNE completed Elopement Risk evaluations, with outcomes reviewed with the CRC, for fifty-two (52) of fifty-three (53) residents, with one (1) resident evaluation completed [DATE]. 7. Re-education was initiated by the CNE and CED on [DATE], with completion on [DATE] (with the exception of one (1) PRN (as needed) CNA and one (1) Physical Therapy Assistant (PTA) on medical leave, both would be required to receive the re-education before returning to work). The re-education included center policies on Elopement Prevention and Management, the purpose, and benefits of rounding, rounding during shift change and all three meals, and what to do if a resident was not accounted for during rounds. Each employee completed a post-test to validate the learning. 8. Beginning on the morning shift on [DATE], the CED, CNE, Maintenance Director, Social Service Director, Business Office Manager, RN and/or Licensed Practical Nurse (LPN) would document a head count on the Windows/Visual Account Audit Tool to complete visual observation rounds every two (2) hours (six (6) rounds per shift) and determine all windows were secured for two (2) weeks, including weekends, then four (4) rounds per shift by a Department Manager, RN, or LPN starting [DATE]. 9. On [DATE], an ad-Hoc Quality Assurance/Performance Improvement (QAPI) meeting was conducted by the CED and the Physician. The CED and CNE reviewed the timeline, investigation outlines, immediate action to ensure the issue would not recur, and the plan for ongoing monitoring. It was discussed at that time to change the licensed staff rounding protocol from two (2) times per shift to four (4) times per shift. 10. Starting [DATE], the Maintenance Director rounded weekly on the security of all windows and record on an audit tool. The results would be reported to the CED and/or CNE upon completion of the rounds with corrective action upon discovery. The QAPI Committee would determine if changes to the weekly time frame needed to be adjusted. 11. An elopement drill was conducted [DATE], on all three (3) shifts. The elopement drills would continue monthly on each shift for six (6) months with corrective action and/or re-education provided upon discovery of an issue during the drill. The SSA validated the facility implemented the following actions: 1. Documentation verified a visual validation was documented for fifty-three (53) residents in the facility on [DATE], by the CNE and LPN #3. Interview with LPN #3, on [DATE] at 1:40 PM, verified a head count was done immediately after Resident #1 was determined missing. 2. Interview with the CQS, on [DATE] at 2:28 PM, revealed she spoke with the CED and CNE over the phone on [DATE], and educated about the elopement process and their responsibility as supervisors. She stated she instructed them to initiate resident rounds and window security checks every two (2) hours. Interviews with the CNE, on [DATE] at 2:47 PM, and the CED, on [DATE] at 3:17 PM, revealed they received training by the CQS immediately after the incident on [DATE]. 3. Interview with the Maintenance Director, on [DATE] at 10:30 AM, revealed he was called in to the facility after the elopement to check all the windows in the facility. He added two (2) additional screws to secure the window in room [ROOM NUMBER], and enforced windows in four (4) different areas of the facility. He also verified all six (6) exit doors were functioning properly. 4. Review of three (3) elopement books revealed two (2) residents, one (1) of which recently returned from the hospital, at risk for elopement with their picture and information contained in the books. Interview with RN #4, on [DATE], revealed she reviewed all three (3) elopement books in the facility with no concerns. She also reviewed the Care Plan and Kardex for the one (1) resident identified at risk for elopement. 5. Verified documentation of CRC on-line training for the RAI process on [DATE]. Interview, on [DATE] at 11:20 AM, with the CRC, revealed she reviewed all resident BIMS assessments to validate accuracy on [DATE], with no concerns identified. 6. Documentation verified Elopement Risk Evaluations were completed by the CNE on [DATE], for fifty-two (52) residents and one (1) resident on [DATE]. Interview with the CNE, on [DATE] at 10:45 AM, revealed all elopement evaluations were updated as of [DATE]. Interview with the CRC, on [DATE] at 11:20 AM, revealed Elopement Risk evaluations were completed by the CNE on [DATE]. 7. Record review revealed elopement education post-tests and rounding education post-tests completed by all staff by [DATE]. A detailed two (2) page agenda on rounding was in the re-education binder with instruction for rounding at least every two (2) hours. Interviews with the CNE, on [DATE] at 2:47 PM and the CED, on [DATE] at 3:17 PM, verified staff was re-educated to complete resident rounds every two (2) hours by [DATE]. Interview with LPN #2, on [DATE], revealed she was asked by the CNE, after the elopement, to fill out two (2) tests, one (1) on elopement and the other about rounding. Interview with LPN #3, on [DATE], revealed re-education included the CNE and CED giving her a handout with information, including every two (2) hour rounds, and she was required to take a test. Interview with CNA #9, on [DATE], revealed staff must search for the resident if not in their room when meal trays were passed, make a walking-round at the beginning of the shift, and round based on the needs of the resident. 8. Documentation verified a Window/Visual Account Audit Tool was used to complete rounds every two (2) hours (six (6) times per shift ) from [DATE] through [DATE]. Documentation verified the Window/Visual Account Audit Tool was changed from every two (2) hour rounds to four (4) times per shift. Interview with the CNE, on [DATE] at 2:47 PM, and the CED, on [DATE] at 3:17 PM, revealed documentation of the two (2) hour rounds (to visualize each resident and check to ensure window security) was initiated immediately after the elopement. Interview with the Maintenance Director, on [DATE] at 10:30 AM, revealed he checked the security of windows daily. Interview with RN #3, on [DATE] at 1:15 PM, revealed licensed staff were to round four (4) times per shift looking at window and residents. 9. Interview with the CED, on [DATE] at 3:05 PM, revealed she spoke with the Physician via telephone and reviewed the immediate action taken and the Physician had no concerns. Interview with the CNE and the CED on [DATE], revealed they had discussed changing the licensed staff rounding protocol to four (4) times per shift on [DATE]. However, interview with LPN #2, on [DATE] at 8:12 AM, and LPN #6, on [DATE] at 8:45 AM revealed they were not instructed to document rounds four (4) times per shift until [DATE]. 10. Documentation verified window audits signed by the Maintenance Director on [DATE], [DATE], [DATE], and [DATE]. Interview with the Maintenance Director, on [DATE] at 10:30 AM, revealed he had been checking the security of the windows daily but he did not document the results. He revealed he was not instructed until [DATE], by the CED to complete the audit tool; however, per the A(NAME), beginning [DATE], the Maintenance Director would round weekly and record on an audit tool. Interview with the CED, on [DATE] at 3:17 PM, revealed the audit tool was not initiated on [DATE]; however, per the A(NAME), the Maintenance Director would round weekly and record on an audit tool beginning [DATE]. 11. Documentation verified Elopement Drills began on [DATE] for each shift. Interview with the CNE, on [DATE] at 2:47 PM, revealed she, or the Maintenance Director, would continue monthly drills on each shift for six (6) months with re-education provided immediately with issues. She revealed results would be discussed in monthly QAPI meetings.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system to ensure residents assessed with [REDACTED].#1. The facility had assessed Resident #1 to have cognitive impairment and communication problems and independent with most Activities of Daily Living. On [DATE], staff observed Resident #1 in the facility at approximately 3:30 PM. However, the staff did not see or try to locate the resident until 10:30 PM, approximately seven (7) hours later, when staff discovered the resident was not in bed. Interviews with staff revealed the resident was not in his room for dinner at 5:00 PM nor when the tray was discovered untouched at 6:30 PM. In addition, rounds were not conducted by staff during shift change at 6:30 PM, which was facility protocol. At 6:50 PM, staff reported, to the Center Nurse Executive (CNE), a screen was out of one of the windows with the window opened; however, no investigation was conducted. A search was conducted at 10:30 PM after the resident could not be located. The resident could not be found and was reported missing. Facility video surveillance recorded Resident #1 walking outside of the facility from approximately 4:12 PM to 4:34 PM. The facility's investigation determined the resident probably exited the building through the opened window with the missing screen. The resident was found deceased on [DATE], four (4) days later, approximately 3.5 miles from the facility at an abandoned building. Per the Deputy Coroner's interview, the preliminary findings from the autopsy included the resident's health conditions with minor abrasions/contusions on the extremities. Review of the weather history for [DATE] revealed a high of eighty (80) degrees Fahrenheit (F) and a low of fifty-four (54) degrees F. On [DATE], the high was seventy-three (73) degrees F with a low of fifty-two (52) degrees F. On [DATE], the high was seventy-seven (77) degrees F and the low was fifty-one (51) degrees F. The facility's failure to ensure residents were free from neglect has caused or is likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. The facility provided an acceptable Allegation of Compliance (A(NAME)) on [DATE], alleging removal of the Immediate Jeopardy on [DATE]; however the State Survey Agency (SSA) verified Immediate Jeopardy was removed on [DATE], prior to exit on [DATE]. Interview and record review revealed rounding protocols and audits were not implemented until [DATE]. Therefore, it was determined the Immediate Jeopardy was not removed until [DATE] versus [DATE] as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction and monitors the effectiveness of the systemic changes. The findings include: Review of the facility's Abuse Prohibition Policy, revised [DATE], revealed the facility would prohibit abuse, mistreatment, and neglect. The facility defined neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the facility's Registered Nurse-Charge Nurse Job Description, revised [DATE], revealed the Charge Nurse was responsible to complete rounds on the unit to observe patients and determine if nursing needs were being met. Review of the facility's training tool on Nursing Rounds, undated, revealed nursing rounds should be performed by the licensed nurse at least twice per shift. Observation of the facility's video surveillance cameras, on [DATE], revealed Resident #1 exited the facility on [DATE] at approximately 4:12 PM. The resident walked around the back of the building at approximately 4:13 PM, and the side of the building near the staff smoking area at approximately 4:32 PM. Resident #1 looked around the corner toward the front of the building, and then he/she walked back down the side of the building. The resident was last observed on camera at approximately 4:34 PM. Review of Resident #1's closed clinical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. The record revealed an additional [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) for Resident #1, dated [DATE], revealed the facility assessed the resident was severely cognitively impaired and required limited assistance of one (1) staff for dressing, extensive assistance of one (1) staff for hygiene and bathing, and setup help only with eating. Review of an Elopement Evaluation, dated [DATE], revealed the facility assessed Resident #1 had a history of [REDACTED]. Review of the Care Plan for Resident #1, dated [DATE], revealed the resident exhibited symptoms of decline in cognitive function with interventions to give one direction or ask one question at a time and keep it simple, and re-orient as to day, time of day, and current events if not upsetting to the resident. The facility determined the resident had difficulty making himself/herself understood and had slurred speech with interventions to ask questions that required one or two word answers and/or yes or no answers, if resident became upset then re-approach later, and allow time for resident to process and respond. The resident was at risk for falls due to a shuffling gait, cognition, and lack of safety awareness with interventions to assess for changes in medical status, pain status, mental status, and report to the Physician as indicated. Interview with Certified Nurse Aide (CNA) #3, via telephone, on [DATE] at 3:08 PM, revealed she worked on [DATE] from 3:00 PM to 11:00 PM on the South Hall (where Resident #1 resided). She stated Resident #1 was assigned to CNA #2, but she remembered seeing the resident in his/her room at approximately 3:30 PM. She verified she delivered the resident's dinner tray to his/her room at approximately 5:00 PM, but Resident #1 was not in the room. She stated it was her normal practice to check the courtyard when the resident was not in the room; however, she was busy and had forgotten to check on him/her. Interview with CNA #2, on [DATE] at 2:30 PM and [DATE] at 2:55 PM, revealed he was assigned to Resident #1 on [DATE] from 3:00 PM through 11:00 PM. He stated he last observed the resident walking to his/her room between 3:00 PM and 3:30 PM. He stated the resident was independent and did not require a lot of care. CNA #2 revealed he was supposed to check on each resident every two (2) hours; however, he was busy caring for other residents. He later attempted to pick up the resident's food tray from his/her room and noticed the resident had not eaten, but did not look for Resident #1 at that time. Interview with Licensed Practical Nurse (LPN) #6, on [DATE] at 10:12 AM, revealed she was the charge nurse assigned to Resident #1 on [DATE] until 7:00 PM. She recalled observing the resident walking between the dining room and kitchen area between 2:00 PM and 3:00 PM. She gave report on her assigned residents to the CNE shortly before clocking out; however, did not complete a walking round. She revealed she was supposed to complete a walking round with the on-coming nurse, and visualize each resident while giving report. Interview with the CNE, on [DATE] at 10:45 AM and [DATE] at 12:50 PM, revealed she arrived at the facility on [DATE] between 8:30 AM and 8:45 AM. She revealed she completed her routine walking round that morning when she arrived at work, and she saw Resident #1 at approximately 2:00 PM going toward the kitchen area. She stated a nurse had called in for the night shift and she was required to cover as the Charge Nurse for Resident #1's hall from approximately 6:30 PM to 11:00 PM. She stated it was expected for the on-coming nurse to complete a walking round with the previous nurse, to observe each resident while getting report. The CNE further stated a walking round was not completed and Resident #1 was not observed before she took over the assignment from LPN #6 at approximately 6:30 PM. Interview with CNA #1, via telephone, on [DATE] at 2:00 PM, revealed she normally worked third shift; however, was called in to work early on [DATE]. She stated she clocked in at approximately 6:50 PM and immediately went to answer a call light in room [ROOM NUMBER] (across the hall from Resident #1's room). She revealed both windows in room [ROOM NUMBER] were open and the screen was out of the one on the right side and reported her findings to the CNE. She further revealed Resident #1 was not in bed at approximately 10:00 PM and the CNE was made aware and a search was initiated for Resident #1. Continued interview with the CNE, on [DATE] at 10:45 AM and [DATE] at 12:50 PM, revealed CNA #1 did report a screen was out of the window in room [ROOM NUMBER] (across the hall from Resident #1's room), but she was unsure of the exact report time. She did not investigate the issue, as she stated the windows only opened six (6) inches, and both residents were in the room. She stated at approximately 10:30 PM, CNA #1 reported she could not find Resident #1 in his/her room or bathroom. The CNE stated she went to the resident's room and observed the resident's food tray untouched; therefore, initiated a search for the resident. She expected facility staff to report to her when a resident had not eaten dinner and expected CNAs to complete rounds every two (2) hours on all residents. In a later interview the CNE stated supervision was based on the needs of the resident and Resident #1 did not need to be supervised, as he/she was independent with Activities of Daily Living (ADL's). However, she further revealed she expected staff to ensure the resident's whereabouts at least two (2) times per shift. Interview with the Center Executive Director (CED), on [DATE] at 12:40 PM, [DATE] at 12:30 PM, and [DATE] at 1:07 PM, revealed she was called and informed about the missing resident at approximately 10:50 PM on [DATE]. She stated it was determined Resident #1 had exited one of the windows in room [ROOM NUMBER]. She stated the facility did not have a policy related to supervision and monitoring of residents, but licensed staff and CNAs supervised residents based on their care needs. She expected licensed staff to make rounds twice per shift (according to the training tool) and more often depending on the needs of each resident. She revealed licensed staff traditionally completed a walking round; however, they were not expected to search for the resident if not in their room. The CED further revealed higher functioning residents did not necessarily need to be observed every two (2) hours and Resident #1 was high functioning regardless of his/her diagnoses; however, she expected staff to verify the resident's whereabouts on [DATE] prior to 10:30 PM. Interview with Medical Doctor (MD) #1, on [DATE] at 4:10 PM and [DATE] at 9:00 AM, revealed he was the MD for Resident #1 until [DATE]. He revealed it was difficult to measure the resident's intellect due to his/her [DIAGNOSES REDACTED]. He revealed survival on the street with no food or water would be an issue for any resident. He stated Resident #1 had a history of [REDACTED]. He expected the facility standard was to monitor residents every two (2) hours. Interview with the Police Detective, via telephone, on [DATE] at 9:15 AM, revealed Resident #1 was found deceased early in the morning on [DATE]. He indicated the estimated time of death was the night of [DATE]. Interview with the Deputy Coroner, via telephone, on [DATE] at 10:10 AM, revealed the preliminary findings of the autopsy included Hypertensive and [MEDICAL CONDITION] Cardiovascular Disease, Moderate [MEDICAL CONDITIONS], Cerebral Atrophy, and minor abrasions/contusions on extremities. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The Center Nurse Executive (CNE) and the North Hall Charge Nurse initiated a visual validation of residents that resided in the center on [DATE] at 10:30 PM, to determine fifty-three (53) residents were accounted for, with no concerns. 2. The Clinical Quality Specialist (CQS) educated the CNE and Center Executive Director (CED) on [DATE], over the phone, on the facility's elopement policy with instruction to initiate resident rounds and window checks every two (2) hours. 3. On [DATE], the Maintenance Director arrived at the facility and began a round on the perimeter windows to determine all were secure. He added two (2) additional screws to the window in room [ROOM NUMBER] and three (3) other rooms that had double pane windows. Additionally, he ensured proper functioning of the six (6) exit doors in the facility. 4. A Registered Nurse (RN) reviewed the elopement books for accuracy on [DATE]. The Care Plan and Kardex were also reviewed for one (1) resident identified at risk for elopement in the facility. 5. The Clinical Reimbursement Coordinator (CRC) was trained on the Resident Assessment Instrument (RAI) Process to include Brief Interview for Mental Status (BIMS) assessments per on-line training on [DATE]. The CRC reviewed fifty-three (53) resident's BIMS assessments for accuracy on [DATE]. 6. On [DATE], the CNE completed Elopement Risk evaluations, with outcomes reviewed with the CRC, for fifty-two (52) of fifty-three (53) residents, with one (1) resident evaluation completed [DATE]. 7. Re-education was initiated by the CNE and CED on [DATE], with completion on [DATE] (with the exception of one (1) PRN (as needed) CNA and one (1) Physical Therapy Assistant (PTA) on medical leave, both would be required to receive the re-education before returning to work). The re-education included center policies on Elopement Prevention and Management, the purpose, and benefits of rounding, rounding during shift change and all three meals, and what to do if a resident was not accounted for during rounds. Each employee completed a post-test to validate the learning. 8. Beginning on the morning shift on [DATE], the CED, CNE, Maintenance Director, Social Service Director, Business Office Manager, RN and/or Licensed Practical Nurse (LPN) would document a head count on the Windows/Visual Account Audit Tool to complete visual observation rounds every two (2) hours (six (6) rounds per shift) and determine all windows were secured for two (2) weeks, including weekends, then four (4) rounds per shift by a Department Manager, RN, or LPN starting [DATE]. 9. On [DATE], an ad-Hoc Quality Assurance/Performance Improvement (QAPI) meeting was conducted by the CED and the Physician. The CED and CNE reviewed the timeline, investigation outlines, immediate action to ensure the issue would not recur, and the plan for ongoing monitoring. It was discussed at that time to change the licensed staff rounding protocol from two (2) times per shift to four (4) times per shift. 10. Starting [DATE], the Maintenance Director rounded weekly on the security of all windows and record on an audit tool. The results would be reported to the CED and/or CNE upon completion of the rounds with corrective action upon discovery. The QAPI Committee would determine if changes to the weekly time frame needed to be adjusted. 11. An elopement drill was conducted [DATE], on all three (3) shifts. The elopement drills would continue monthly on each shift for six (6) months with corrective action and/or re-education provided upon discovery of an issue during the drill. The SSA validated the facility implemented the following actions: 1. Documentation verified a visual validation was documented for fifty-three (53) residents in the facility on [DATE], by the CNE and LPN #3. Interview with LPN #3, on [DATE] at 1:40 PM, verified a head count was done immediately after Resident #1 was determined missing. 2. Interview with the CQS, on [DATE] at 2:28 PM, revealed she spoke with the CED and CNE over the phone on [DATE], and educated about the elopement process and their responsibility as supervisors. She stated she instructed them to initiate resident rounds and window security checks every two (2) hours. Interviews with the CNE, on [DATE] at 2:47 PM, and the CED, on [DATE] at 3:17 PM, revealed they received training by the CQS immediately after the incident on [DATE]. 3. Interview with the Maintenance Director, on [DATE] at 10:30 AM, revealed he was called in to the facility after the elopement to check all the windows in the facility. He added two (2) additional screws to secure the window in room [ROOM NUMBER], and enforced windows in four (4) different areas of the facility. He also verified all six (6) exit doors were functioning properly. 4. Review of three (3) elopement books revealed two (2) residents, one (1) of which recently returned from the hospital, at risk for elopement with their picture and information contained in the books. Interview with RN #4, on [DATE], revealed she reviewed all three (3) elopement books in the facility with no concerns. She also reviewed the Care Plan and Kardex for the one (1) resident identified at risk for elopement. 5. Verified documentation of CRC on-line training for the RAI process on [DATE]. Interview, on [DATE] at 11:20 AM, with the CRC, revealed she reviewed all resident BIMS assessments to validate accuracy on [DATE], with no concerns identified. 6. Documentation verified Elopement Risk Evaluations were completed by the CNE on [DATE], for fifty-two (52) residents and one (1) resident on [DATE]. Interview with the CNE, on [DATE] at 10:45 AM, revealed all elopement evaluations were updated as of [DATE]. Interview with the CRC, on [DATE] at 11:20 AM, revealed Elopement Risk evaluations were completed by the CNE on [DATE]. 7. Record review revealed elopement education post-tests and rounding education post-tests completed by all staff by [DATE]. A detailed two (2) page agenda on rounding was in the re-education binder with instruction for rounding at least every two (2) hours. Interviews with the CNE, on [DATE] at 2:47 PM and the CED, on [DATE] at 3:17 PM, verified staff was re-educated to complete resident rounds every two (2) hours by [DATE]. Interview with LPN #2, on [DATE], revealed she was asked by the CNE, after the elopement, to fill out two (2) tests, one (1) on elopement and the other about rounding. Interview with LPN #3, on [DATE], revealed re-education included the CNE and CED giving her a handout with information, including every two (2) hour rounds, and she was required to take a test. Interview with CNA #9, on [DATE], revealed staff must search for the resident if not in their room when meal trays were passed, make a walking-round at the beginning of the shift, and round based on the needs of the resident. 8. Documentation verified a Window/Visual Account Audit Tool was used to complete rounds every two (2) hours (six (6) times per shift ) from [DATE] through [DATE]. Documentation verified the Window/Visual Account Audit Tool was changed from every two (2) hour rounds to four (4) times per shift. Interview with the CNE, on [DATE] at 2:47 PM, and the CED, on [DATE] at 3:17 PM, revealed documentation of the two (2) hour rounds (to visualize each resident and check to ensure window security) was initiated immediately after the elopement. Interview with the Maintenance Director, on [DATE] at 10:30 AM, revealed he checked the security of windows daily. Interview with RN #3, on [DATE] at 1:15 PM, revealed licensed staff were to round four (4) times per shift looking at window and residents. 9. Interview with the CED, on [DATE] at 3:05 PM, revealed she spoke with the Physician via telephone and reviewed the immediate action taken and the Physician had no concerns. Interview with the CNE and the CED on [DATE], revealed they had discussed changing the licensed staff rounding protocol to four (4) times per shift on [DATE]. However, interview with LPN #2, on [DATE] at 8:12 AM, and LPN #6, on [DATE] at 8:45 AM revealed they were not instructed to document rounds four (4) times per shift until [DATE]. 10. Documentation verified window audits signed by the Maintenance Director on [DATE], [DATE], [DATE], and [DATE]. Interview with the Maintenance Director, on [DATE] at 10:30 AM, revealed he had been checking the security of the windows daily but he did not document the results. He revealed he was not instructed until [DATE], by the CED to complete the audit tool; however, per the A(NAME), beginning [DATE], the Maintenance Director would round weekly and record on an audit tool. Interview with the CED, on [DATE] at 3:17 PM, revealed the audit tool was not initiated on [DATE]; however, per the A(NAME), the Maintenance Director would round weekly and record on an audit tool beginning [DATE]. 11. Documentation verified Elopement Drills began on [DATE] for each shift. Interview with the CNE, on [DATE] at 2:47 PM, revealed she, or the Maintenance Director, would continue monthly drills on each shift for six (6) months with re-education provided immediately with issues. She revealed results would be discussed in monthly QAPI meetings.