Every finding on record at Macon Valley Nursing and Rehabilitation Center

Based on record review, staff, Nurse Practitioner (NP), and Medical Director interviews the facility failed to ensure a resident ' s scheduled pain medication was administered as ordered for 1 of 1 resident reviewed for pain. Resident #523 stated the missed pain medication caused her pain level to be greater than a 10 on 5/31/2025 and caused her to cry and almost scream. The findings included: Resident #523 was admitted to the facility on [DATE] with diagnoses that included enterocolitis (inflammation in the small intestine and colon's inner lining) due to clostridium difficile (inflammation of the colon caused by bacteria), essential hypertension, osteoporosis, history of deep vein thrombosis (a blood clot in a deep vein), and pulmonary embolism (a serious medical condition involving a blockage in a lung artery), congestive heart failure, avascular necrosis of bilateral lower extremities (a condition where bone tissue dies due to insufficient blood supply) on chronic opiate therapy, lower quadrant pain. Resident #523 was admitted with physician's orders that included: A physician order dated 05/30/25 read, Oxycodone HCL (pain medication) 5 milligrams (mg) by mouth four times a day and every 6 hours as needed for pain. A physician order dated 05/30/25 read, Tramadol HCL (pain medication) 50mg give one tablet by mouth every 6 hours as needed for pain. A review of #523's Medication Administration Record (MAR) dated May 2025 revealed the following: Scheduled oxycodone HCL 5mg on 5/30/2025 at 9:00 PM was documented as administered by Nurse #2 with a pain level of 0. Pain scale every shift monitoring documented by Nurse #2 at a level of 0. During a telephone interview on 06/04/25 5:16 PM Nurse #2 stated she was assigned to Resident #523 when she was admitted to the facility and Resident #523 arrived at the facility at approximately 9:30 to 10:00 PM on 5/30/2025. Nurse #2 stated Resident #523 was alert and oriented. Nurse #2 stated the oxycodone HCL 5mg, for Resident #523 was obtained from the emergency medication kit. Nurse #2 stated when Resident #523 was admitted on [DATE] she did not appear to be in a lot of pain and reported a pain level of 0 when scheduled pain medication was administered. Review of Resident #523's MAR dated May 2025 revealed the following: Scheduled oxycodone HCL 5mg on 5/31/2025 at 9:00 am, 1:00 PM and 5:00 PM was documented by Nurse #1 as other see nurses notes. Review of Resident #523's medical record revealed: An electronic Medication Administration Record (eMAR) note dated 5/31/2025 at 11:34 AM written by Nurse #1 that read: oxycodone HCL oral tablet 5mg give 1 tablet by mouth four times a day for pain- waiting on pharmacy. An eMAR note dated 5/31/2025 at 3:02 PM written by Nurse #1 that read: oxycodone HCL oral tablet 5mg give 1 tablet by mouth four times a day for pain- waiting on pharmacy. An eMAR note dated 5/31/2025 at 5:41 PM written by Nurse #1 that read: oxycodone HCL oral tablet 5mg give 1 tablet by mouth four times a day for pain- pharmacy. Pain scale every shift monitoring documented by Nurse #1 at a level of 4. No as needed doses of Oxycodone were initialed as being administered. No as needed doses of Tramadol were initialed as being administered. During an interview on 6/4/2025 at 11:02 AM Nurse #1 was accompanied by the Assistant Director of Nursing (ADON). Nurse #1 stated she was an agency nurse and started at the facility the week prior. Nurse #1 verified she was assigned to Resident #523 on 5/31/2025 and 6/1/2025. Nurse #1 stated Resident #523 was alert and oriented. Nurse #1 stated Resident #523's medication had not been delivered from the pharmacy on 5/31/2025. Nurse #1 stated she had pulled some medications from the emergency medication kit for Resident #523 and that she initially did not know where the emergency controlled medications were located, because she had received her tour from maintenance and was only shown in passing where the emergency medication kit was located. Nurse #1 stated she later asked another nurse working about a backup for controlled medications and was told which nurse had the keys to the emergency-controlled medication kit. Nurse #1 stated she went with the nurse who had the key to pull the tramadol HCL for Resident #523, which is when Nurse #1 realized the emergency controlled medication kit was located next to the emergency medication kit. Nurse #1 stated she was not aware oxycodone HCL 5mg was in the emergency-controlled medication kit. Nurse #1 verified she had told Resident #523 the oxycodone HCL 5mg was not available from the pharmacy on 5/31/2025. Nurse #1 stated she did not call the pharmacy or the on-call provider regarding not having Resident #523's scheduled oxycodone. Nurse #1 stated she observed Resident #523 crying with no tears and holding her hands bending them towards her face shaking her hands, then talking with no problem when other staff entered the room, then crying again when staff left. During a follow up interview on 6/5/2025 at 1:00 PM Nurse #1 stated on 5/31/2025 she administered as needed Tramadol HCL to Resident #523 after obtaining it from the emergency medication kit, but forgot to document it on the MAR. Nurse #1 stated Resident #523 had a pain level of 8 when the as needed tramadol was administered on 5/31/2025 and quieted down after the medication was given so I figured her pain was at a zero. Nurse #1 stated she was very busy on 5/312025 and that is probably why she forgot to document that she administered tramadol HCL 50mg to Resident #523. Nurse #1 stated she did not call the provider because she was told they were to call the on-call provider. Nurse #1 stated she called and left a message for the on-call provider and did not hear back. Nurse #1 verified there was no documentation she had called the on-call provider. Nurse #1 stated she did not attempt to call the pharmacy, and did not ask any other nurses, and did not call the facilities on-call nurse regarding not having Resident #523's scheduled oxycodone HCL 5mg. During an interview on 6/5/2025 at 12:49 PM Nursing Assistant (NA) #1 stated she worked with Resident #523 on 5/30/2025 and 5/31/2025. NA #1 recalled Resident #523 stated she was hurting on 5/31/2025 but her pain medication had not come in. NA #1 stated Resident #523 said her legs were hurting her. NA #1 stated on 5/30/2025 she did not observe Resident #523 cry but did observe Resident #523 cry on 5/31/2025 and attempted to comfort Resident #523 and reported Resident #523's reports of pain to the nurse passing medications. NA #1 did not recall the name of the nurse passing meds, but stated she was new. Review of Resident #523's (MAR) dated May 2025 revealed the following: Scheduled oxycodone 5mg 5/31/2025 at 9:00 PM documented by Nurse #2 as administered with a pain level 5. Pain scale every shift monitoring documented by Nurse #2 at a level 0. During a telephone interview on 06/04/25 5:16 PM Nurse #2 stated on 5/31/2025 she noticed a big difference in Resident #523, Nurse #2 stated Resident #523 was crying and acting differently, and Resident #523 stated her pain level was a 5 when scheduled pain medication was administered on 5/31/2025. Nurse #2 stated on 6/1/2025 Resident #523 started to ask for tramadol HCL, instead of the scheduled oxycodone. Nurse #2 stated Resident #523 reported her primary care provider had tried to change the oxycodone prior to admission to the hospital. Nurse #2 stated she discussed with Resident #523 what medications were ordered for her at the facility. Nurse #2 told Resident #523 she would administer the tramadol, and if Resident #523 did not have relief, there was scheduled and as needed oxycodone ordered that could be administered. Review of Resident #523's MAR dated June 2025 revealed the following: Pain scale every shift monitoring documented by Nurse #2 at a level 0. PRN tramadol 50mg 6/1/2025 at 3:15 AM documented by Nurse #2 with a pain level of 4. Review of Resident #523's MAR dated June 2025 revealed the following: Scheduled oxycodone 5mg 6/1/2025 at 9:00 AM documented by Nurse #1 as other/see nurses notes. Scheduled oxycodone 5mg 6/1/2025 at 1:00 PM documented by Nurse #1 as other/see nurses notes. PRN tramadol 50mg 6/1/2025 at 12:25 PM documented by Nurse #1 with a pain level of 8. Scheduled oxycodone 5mg 6/1/2025 at 5:00 PM documented by Nurse #1 as refused. Review of Resident #523's medical record revealed: An eMAR note dated 6/1/2025 at 12:21 PM written by Nurse #1 that read: oxycodone HCL oral tablet 5mg give 1 tablet by mouth four times a day for pain- pharmacy. An eMAR note dated 6/1/2025 at 12:25 PM written by Nurse #1 that read: tramadol HCL 50mg give 1 tablet by mouth every 6 hours as needed for pain- Resident in pain and crying 8 out of 10. An eMAR note dated 6/1/2025 at 12:26 PM written by Nurse #1 that read: oxycodone HCL oral tablet 5mg give 1 tablet by mouth four times a day for pain- pharmacy. An eMAR note dated 6/1/2025 at 2:47 PM written by Nurse #1 that read in part PRN administration was: Effective- Follow up Pain Scale was : 1. An eMAR note dated 6/1/2025 at 3:55 PM written by Nurse #1 that read oxycodone HCL oral tablet 5mg give 1 tablet by mouth four times a day for pain- (Resident) States I want to talk to my doctor about staying on it, the hospital said it would hurt my liver but it helps with the pain. Pain scale every shift monitoring documented by Nurse #1 at a level of 2. A nursing progress note dated 6/1/2025 at 5:31 PM written by Nurse #1 that read: This resident has been crying due to pain. She has been given PRN medications throughout this day. At this time, she is resting in her bed with eyes closed, respirations even and non-labored. Staff will continue to monitor this resident throughout this shift and follow the current plan of care. During an interview on 6/4/2025 at 11:02 AM Nurse #1 was accompanied by the Assistant Director of Nursing (ADON). Nurse #1 stated on 6/1/2025 Resident #523 had stated the oxycodone worked better, but did not want to take the oxycodone until she talked to the doctor, because Resident #523 said her primary care provider had previously said she shouldn ' t take it. Nurse #1 stated that was why the 6/1/2025 5:00 PM oxycodone was documented as refused. Nurse #1 stated Resident #523 was quieter on 6/1/2025 and did not act out as much. Review of Resident #523's MAR dated June 2025 revealed the following PRN tramadol 50mg 6/1/2025 at 8:48 PM documented by Nurse #2 with a pain scale of 5. Scheduled oxycodone 5mg 6/1/2025 at 9:00 PM documented by Nurse #2 as refused with a pain level of 5. During an interview on 6/3/2025 at 8:30am Resident #523 stated she had not received some of her scheduled pain medication on 5/31/2025 or 6/1/2025, and the nurses told her it was because the medication had not been received from the pharmacy. Resident #523 stated the missed pain medication caused her pain level to be greater than a 10 on 5/31/2025 and caused her to cry and almost scream. Resident #523 stated she always experienced pain. Resident #523 stated she had sharp pain in both ankles and it increased when she moved. Resident #523 described her abdominal pain as strong and stated the pain would come and go. Resident #523 stated prior to her admission her primary care provider had tried to change her medications, but it didn't work, and the hospital had put her back on the medicine that helped. Resident #523 stated after she was admitted to the facility her pain was much worse during the weekend, and it was getting better since her medication had arrived on Sunday (6/1/2025) night. During a telephone interview on 06/04/25 at 4:30 PM Nurse #5 stated on 6/2/2025 Resident #523 appeared to have a pain level of 1 or 2. Nurse #5 stated Resident #523 had asked for pain medication but had to wait for the next time it was due. Nurse #5 stated Resident #523 did not mention missed pain meds over the weekend. Nurse #5 stated she pulled Resident #523's oxycodone from the emergency medication kit on 6/2/2025 and reported to the NP that a script was needed. Nurse #5 was not aware Resident #523 did not receive oxycodone as ordered on 5/31/2025 and 6/1/2025. Nurse #5 thought all scheduled doses had been pulled from the emergency controlled medication kit. Nurse #5 stated any nurse was able to call the on-call pharmacy, provider or the DON if there were any issues with a resident not having an ordered medication. A Nurse Practitioner (NP) note dated 6/2/2025 that read in part: needs hard script for her pain medication per Nurse and Pain is currently controlled . NP note lists a past medical history that included in part: chronic opiate therapy, multiple non-obstructing renal calculi, Left Lower Quadrant abdominal pain, acute on chronic pain. Patient is oriented to person place time and situation. During a telephone interview on 6/04/25 at 3:37 PM the Nurse Practitioner (NP) stated when she saw Resident #523 on 6/2/2025, Resident #523 was concerned about how she would get her meds at home, related to her primary care provider and being able to have blood work completed when she was at home. The NP stated Resident #523 did not mention she had not received pain medication over the weekend. The NP stated Nurse #5 reported Resident #523 had been given oxycodone from the backup emergency kit over the weekend and needed a script sent to the pharmacy. The NP was not aware Resident #523 had not received her oxycodone as scheduled on 5/31/2025 and 6/1/2025. The NP stated during her visit with Resident #523 she had not observed Resident #523 crying and Resident #523 appeared comfortable. The NP stated Resident #523's cognition was intact. The NP stated after 5:00 PM during the week and on the weekend, there are on-call providers that are part of their group. If a resident was admitted and the hospital did not send a script, the on-call provider could have been called to send in an electronic script if the resident needed the medication and it was not in the back up box. The NP stated she would expect residents to receive their ordered medication from the emergency controlled medication kit if it was available. A progress note from the Medical Director dated 6/3/2025 that read in part: pain in ankles under general review. Under physical exam the note read in part: No acute distress or pain, Patient is oriented to person place time and situation. During an interview on 6/3/2025 at 11:20 AM the Medical Director stated he had seen Resident #523 that morning, and she did not report missing pain medication over the weekend. The Medical Director stated Resident #523 was alert and oriented and did not appear to be in significant pain. The Medical Director stated he would expect medications to be administered as ordered and pulled from the emergency controlled medication kit when available. The Medical Director stated they have on-call providers available after 5:00 PM during the week and on weekends. An observation on 6/4/2025 at 3:30 PM of the facility's emergency-controlled medication kit revealed a list of medication that was contained in the kit, and the list included oxycodone 5mg and tramadol 50mg. During a joint interview with the Director of Nursing (DON), and Administrator on 6/5/2025 at 2:01 PM the DON stated she was in the facility on 5/31/2025 and no one had reported Resident #523 did not have her scheduled pain medication that was ordered. The DON stated she had reordered medications for the controlled emergency medication kit from the pharmacy on 5/30/2025 that would have the emergency-controlled medication kit completely full after the medication were delivered by the pharmacy the night of 5/30/2025. The DON verified the emergency medication kit would hold 14 doses of oxycodone 5mg when it was fully stocked. The DON stated she expected nurses to ask other nurses, call the on-call nurse, the on-call provider or the pharmacy if a resident was missing ordered medications. The DON stated she expected nurses to obtain and administer ordered medications from the emergency controlled medication kit if the medication was available. The Administrator stated she expected ordered medications to be administered as ordered, and for the emergency medication kit to be utilized when it contained the ordered medication.

Based on observations, record review, and staff and Pharmacy Consultant interviews, the facility failed to protect the resident's right to be free from misappropriation of controlled medications for 1 of 3 residents reviewed (Resident #473). The findings included: Resident #473 was admitted to the facility on [DATE]. The resident was discharged from the facility on 08/15/2024. A physician order dated 07/18/2024 read Oxycodone HCL (controlled pain medication) oral tablet 5 milligrams (mg). Give 2 tablets by mouth every 6 hours as needed for pain. A packing slip from the pharmacy dated 08/03/24 revealed that 120 Oxycodone 5 mg tablets were delivered to the facility on [DATE] no time noted. Nurse #2 and Nurse #3 initialed the packing slip along with the courier from the pharmacy. The facility reported incident dated 08/07/2024 read in part, the Director of Nursing (DON) and Administrator were notified that a count of a resident's narcotic medication revealed a discrepancy. Facility verified that the resident still had an adequate supply of medication. All residents were safe and protected in the facility. This report was signed by the facility Administrator. The shift change controlled substance count check for the gray cart (cart where Resident #473's-controlled substances were stored) was counted by the following two nurses at the following dates and times: - Nurse #3 and Nurse #10 at 11:00 PM on 08/03/2024 and was correct. - Nurse #9 and Nurse #3 at 7:30 AM on 08/04/2024 and was correct. - Nurse #10 and Nurse #9 at 3:20 PM on 08/04/2024 and was correct. - Nurse #3 and Nurse #10 at 11:00 PM on 08/04/2024 and was correct. - Nurse #6 and Nurse #3 at 7:00 AM on 08/05/2024 and was correct. - Nurse #7 and Nurse #6 at 11:00 PM on 08/05/2024 and was correct. Nurse #6 was on duty when the discrepancy was noted. A written statement by the former Assistant Director of Nursing (ADON) was typed on 08/08/2024 and reported that on 08/05/2024 at approximately 3:30 PM, she completed a narcotic audit on all three facility medication carts. The ADON reported a medication error to the DON, because the electronic Medication Administration Record (eMAR) showed that a full dose of two (2) tablets was given to the resident, but only one (1) tablet was documented on the declination narcotic sheet. The ADON reported that the DON notified the ADON at 4:40 PM that the discrepancy was not a medication error and told the ADON to conduct a further investigation. It was the ADON's discovery at approximately 6:00 PM on 08/05/2024 that 1 of 4 declining count sheets and 1 card of medications (oxycodone 5 mg) were unable to be located after a thorough review of all medication carts and narcotic books. The ADON's statement did not reveal when the DON was notified about the missing medication. The ADON further wrote that a thorough search of all medication carts and narcotic books was conducted. The shift-to-shift count sheet was correct, showing 33 cards on the cart that matched the amount of declination sheets in the narcotic book. At 5:46 PM on 06/04/2025 an attempt was made to speak to the former ADON and was unsuccessful. The former DON's witness statement was dated 08/06/2024 and read, in part, that on 08/06/2024 she noticed that Resident #473's oxycodone was signed off card 2 of 4 on a new prescription set. She stated that she was informed that card 1 of 4 for the resident's oxycodone was not on the cart, and she instituted a full audit and investigation of all narcotics, the eMARs, medication carts, shift to shift count sheets, packing slips, and returned drugs. The DON stated that the investigation revealed that card 1 card of Oxycodone 5 mg 30 tablets that had been delivered to the facility on [DATE] and placed on the medication cart was missing. Her statement read that no other resident's medications were missing, and all counts were correct on all other carts in the facility. She wrote that she notified the Administrator and removed Nurse #6 from staffing. The statement read that on 08/07/2024 the Staff Development Coordinator (SDC) and ADON escorted Nurse #6 to the DON's office to inform her of the discrepancies. The DON stated that she informed Nurse #6 that all parties suspected would be suspended and be required to complete drug tests. The statement revealed that Nurse #6 refused and was escorted out of the building. An attempt to speak to the former DON was made on 06/04/25 at 4:08 PM and was unsuccessful. A written statement by Nurse #9 dated 08/06/2024 was reviewed and revealed that she was assigned to the gray hall cart on 08/03/2024 and 08/04/2024 beginning at 7:00 AM on both days. She wrote that on both days the narcotic cards and number of declining count sheets were correct. Nurse #9 was interviewed at 9:34 AM on 06/05/2025, and she stated that if the controlled substance count sheet was full, then it would be placed in the DON's box with the empty pill card matching it stapled together. When asked about the process, Nurse #9 stated that it was usual to place the pill blister pack cards in order (e.g. 1 of 2 and 2 of 2). A written statement given by Nurse #3 on 08/06/2024 read that she worked a shift on 08/02/2024 and was aware that Resident #473 only had about five to six (5-6) oxycodone pills remaining. The nurse reported being concerned that the pills would run out, so she arranged for the daytime nurse [Nurse #9] to call the pharmacy and verify that the refill was ordered. The oxycodone arrived at the facility by courier on 08/03/2024 and she counted the narcotics with a second nurse [Nurse #2], and she was at the nurses' station with the other nurse when they were adding the medications to their carts. She reported not physically going to the other nurses' [Nurse #2] cart to see her add them on her cart at that time. An interview with Nurse #3 was conducted at 9:10 AM on 06/05/2025 and revealed that she did not remember Resident #473. Nurse #3 stated that the process to receive medications from the pharmacy courier is that the carrier of the main keys will count and sign receipt of the medications. If narcotics were delivered from the pharmacy, then the pharmacy courier and two nurses will count the narcotics and sign the pharmacy packing slip. Nurse #3 stated that if she counted medications and sheets on a cart and signed it, then that meant it was correct. A witness statement written on 08/06/2024 by Nurse #2 revealed that medication came from the pharmacy on 08/03/2024 and that she counted the medications with another nurse (Nurse #3) and the pharmacy courier. She stated that she worked the orange hall, and the other nurse (Nurse #3 worked gray hall) and Nurse #2 did not physically watch Nurse #3 put the narcotics on her medication carts. On 06/04/2025 at 5:45 PM, Nurse #2 was interviewed by phone. She worked nightshift on the orange hall cart 08/03/2024 and 08/04/2024. Nurse #2 stated that she and Nurse #3 signed in the medications with the pharmacy courier on 08/03/2024. Nurse #2 did not watch Nurse #3 on Gray Hall put the narcotics in the cart. A witness statement given by Nurse #10 on 08/05/2024 revealed that when she administered a dose of oxycodone 10 mg to the resident on 08/04/2024, she had taken the last pill off of one card and then took one off the next card. She did not remember what the card number was or what order the cards were in. She stated she believed at the time there was at least 3 cards of Resident #473's oxycodone left on the medication cart. Nurse #10 was interviewed by phone at 12:06 PM on 06/05/2025, and she stated that the pill packs of oxycodone were signed out and given out of order. For instance, instead of using card 1 of 4, card 2 was started. She explained that when she counted the narcotic cards at the beginning of the shift, she would count like 13 of 13 in chronological order. Then she would count the pills card for card. Nurse #10 stated that if the count was off on either the sheets or the cards, then she would report it to the DON. She said that if a prescription number was added or subtracted, then she would look in the cart to see what was newly added and look for the prescription card and sheet of what was taken out. Nurse #10 stated that she would always check the prescription number on the card with the prescription number written on the count sheet and performed the count of cards and pills with another nurse. She stated that she never noticed a pill card or count sheet out of order for Resident #473. The witness statement given by the former Staff Development Coordinator (SDC) was dated 08/07/2025 and revealed that she walked Nurse #6 from the front door of building on 08/05/2024 to the DON office. The statement revealed that Nurse #6 was asked to write a statement and refused to write anything. Nurse #6 also refused to do a drug screen and stated that she no longer worked at the facility. The statement read that Nurse #6 was escorted out of the building. At 8:55 AM on 06/05/2025 an attempt to speak to the former SDC was unsuccessful. An attempt to speak to Nurse #6 was made at 10:46 AM on 06/04/2025 and was unsuccessful. A Pharmacy Consultant was interviewed via phone at 3:05 PM on 06/04/2025 and revealed that 120 Oxycodone 5 mg tablets (4 cards of 30) were delivered by the courier in the early hours of 08/03/2024. The packing slip was initialed by the pharmacy courier and was signed by two nurses at the facility. The receipt of medications is not time stamped by the nurses at the facility. The pharmacist stated that check marks beside each listed medication were verified before it left the facility and that 30 pills of oxycodone 5 mg per card were delivered for a total of 120 pills of oxycodone 5 mg. A phone interview was completed on 06/05/2025 at 2:18 PM with the former Administrator on duty on the date of the incident. He stated that he vaguely remembered the name of Resident #473. The former Administrator did not recall details of the misappropriation or the specific date. The facility provided the following corrective action plan: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice? - The DON and the ADON completed a 100% controlled substance audit of all carts and medication rooms on 08/06/2024. No additional discrepancies observed. - On 08/06/2024, the DON/ADON/Unit Manager inspected the narcotic blister pill packages for any tampering of medications. On 08/07/2024, the DON reported Nurse #6 to the Board of Nursing (BON). Address how the facility will identify other resident having the potential to be affected by the same deficient practice: - On 08/06/2024 the DON/ADON initiated assessment of all residents for pain. The DON/ADON will ensure that staff will initiate non-pharmacological interventions, pain medications and/or physician notification for any identified areas of concern during the audit. The audit will be completed by 08/08/2024. - On 08/06/2024, the ADON/DON/SDC initiated interviews with all alert and oriented residents regarding (1) Do you have any concerns with medication administration to include pain medication? A concern form will be completed for any identified area of concern. Completed on 08/07/2024. - On 08/08/2024, the DON/ADON completed an audit of the last 30 days of ordered narcotic medications to ensure the medications were in the medication cart, administered, or returned to pharmacy per protocol. They also will ensure that the numbers for any returns match the count sheet vs. the return sheet. The DON will initiate an investigation into any identified areas of concern. - On 08/08/2024, the DON/ADON completed a 100% audit of all residents' Controlled Substance Count sheets in comparison to the narcotic medication blister packs in the medication art to ensure there were no discrepancies in the count of the medications. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: On 08/06/2025 the Administrator, DON, ADON, and SDC held a ad hoc Quality Assurance (QA) meeting and discussed the issue and implemented a plan to correct. - On 08/06/2024, the DON/ADON/SDC initiated an in-service with all nurse and medication aides regarding Controlled Substance Diversion to include: the definition, implications, and the process for returning narcotic medications, new shift-to-shift report, appropriately counting medications during shift change, signage of new shift change sheets to include number of sheets, two nurse signature when adding medications to the cart, procedure for what to do if discrepancy is discovered and to contact administration staff for guidance. All nursing staff will be assigned to education for medication administration process. - All in-services will be completed on 08/11/2024. After 08/11/2024, all nurses or medication aides that have not worked and received the in-service will complete upon their next scheduled shift. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: - 100% of all ordered narcotic medications will be reviewed by the DON/ADON/Unit Manager 5 times a week, for 8 weeks. They will compare the medication name, dose, number, card number and number of tablets during this audit. This will be compared to the Controlled Substance Count Sheets, medication administration record, and/or return of drug slips to ensure the narcotic medications are being administered or have been returned to the pharmacy as required per policy and there are no signs of drug diversion utilizing a Controlled Substance Audit tool. All areas of concern will be addressed during the audit including re-educating nurses. The DON will review all audits. - The Administrator or DON will present the findings of the Audit Tool to the Quality Assurance Performance Improvement (QAPI) Committee monthly for 3 months. The QAPI Committee will meet monthly for 2 months and review the Audit Tools to determine trends and/or issues that may need further interventions and the need for additional monitoring. Date of compliance: 08/12/2024 During the onsite validation on 06/05/2025 it was observed that staff were entering new narcotic entries correctly and documenting appropriately on the declining count sheets. Upon narcotic book reviews, it was noted that shift-to-shift counts were performed and documented with two signatures. A count of the number of narcotic sheets was documented at each count. A review of the narcotic count sheet audit by the DON was reviewed and found to be performed. An observation of the narcotic count sheets and actual narcotic cards in the art were found matching and in order. Staff interviews revealed that they had received education in the process of having two nurses sign in controlled substances on the packing slip with the courier and two nurses signing in on the medication count sheets. Upon observation, the DON was maintaining file folders with narcotic tracking information. The Administrator was interviewed and stated that the results of the narcotic count audits were discussed in each QAPI meeting. Meeting minutes supported that this was being done. The correction action's completion date of 8/12/2024 was validated.

Based on record review and staff interviews, the facility failed to develop a baseline care plan that addressed the resident's anticoagulant (blood thinner) therapy and pain medication for 1 of 5 residents reviewed for baseline care plan (Resident #523). The findings included: Resident #523 was admitted to the facility on [DATE] with diagnoses that included a history of deep vein thrombosis (a blood clot in a deep vein), and pulmonary embolism (a serious medical condition involving a blockage in a lung artery), avascular necrosis of bilateral lower extremities (a condition where bone tissue dies due to insufficient blood supply) on chronic opiate therapy, lower quadrant pain. Resident #523's baseline care plan dated 5/31/2025 did not include goals and interventions for the use of anticoagulant therapy or the use of narcotic/pain medication. Record review revealed Resident #523 had admission orders for: Xarelto 20 milligram (mg) give one tablet by mouth one time a day for blood thinner. Oxycodone HCL 5mg tablet give one by mouth four times daily for pain. Oxycodone HCL 5mg tablet give one by mouth every six hour as needed (PRN) for pain Tramadol HCL 50mg tablet give one by mouth every six hours as needed for pain A review of Resident #523's Medication Administration Record (MAR) for May and June of 2025 revealed: Resident #523 received Xarelto 20mg daily from 6/1/2025 through 6/4/2025. Resident #523 received doses of Oxycodone HCL on 5/30/2025 through 6/3/2025. Resident #523 received doses of Tramadol HCL on 6/1/2025 through 6/3/2025 During an interview on 06/04/25 5:16 PM Nurse #2 stated she was working when Resident #523 was admitted and Nurse #2 and Nurse #3 worked together on completing Resident #523's admission. Nurse #2 stated Nurse #3 worked on completing the assessments for Resident #523. During an interview on 6/5/2025 9:04 AM Nurse #3 stated she did complete some of the admission paperwork for Resident #523 to help Nurse #2. Nurse #3 stated she did not complete the baseline care plan, that it was normally completed by one of the Administration Nurses. During an interview on 6/5/2025 at 9:14 AM the Unit Manager #1 stated she normally completed the baseline care plan for new admissions. The Unit Manager #1 stated if a resident was admitted on Friday evening, the Baseline Care Plan would be completed on Monday unless she happened to be in the facility on the weekend. The Unit Manager #1 stated there was not anyone who completed baseline care plans on the weekend. The Unit Manager #1 verified Resident #523 was admitted on an anticoagulant therapy and scheduled and as needed pain medication on 5/30/2025 and the baseline care plan did not include goals or interventions for anticoagulant therapy, or pain/narcotic medication. The Unit Manager #1 stated she normally would have completed the baseline care plan on Monday morning, but their Annual Survey had started and it had not been completed. During a joint interview with the Director of Nursing (DON), Regional Assistant [NAME] President, and Administrator on 6/5/2025 at 2:01 PM the DON stated the Unit Manager #1 completed the baseline care plan for new admissions and if the resident was admitted on Friday evening the Unit Manager #1 would complete the baseline care plan Monday morning. The DON stated she expected if a resident had anticoagulant therapy and pain medication ordered, that it would be included on the baseline care plan. The Regional Assistant [NAME] President stated the baseline care plan should be completed within 48 hours of admission. The Regional Assistant [NAME] President also stated the facility had a new weekend supervisor that was not aware that baseline care plans needed to be completed on the weekend due to being new and still learning the position. The Administrator stated she expected the baseline care plan to be completed within 48 hours of admission and for anticoagulant therapy and pain medication to be included in the baseline care plan for residents that received anticoagulant therapy and pain medication.

Based on record review and interviews with resident, staff, and the Medical Director (MD), the facility failed to protect residents' rights to be free from misappropriation of controlled substances for 1 of 1 resident (Resident #1) reviewed for misappropriation of residents' property. The findings included: The facility's Abuse, Neglect, or Misappropriation of Resident property policy, last revised on September 11, 2017, revealed in part the facility would ensure all residents to remain free from abuse or misappropriation of their property. Resident #1 was admitted to the facility on [DATE] with diagnoses including osteoporosis and hip fractures. A review of the physician's order dated 02/10/24 revealed Resident #1 had an order to receive 1 tablet of oxycodone (a semi-synthetic narcotic analgesic for pain) 5 milligrams (mg) by mouth once every 3 hours as needed for pain. The admission Minimum Data Set (MDS) dated [DATE] coded Resident #1 with an intact cognition. A review of the medication administration records (MARs) revealed Resident #1 had received 1 tablet of oxycodone 5 mg as needed on 02/19/24 and 03/07/24. A review of the controlled substance count sheet for orange halls on 03/07/24 at 7:00 PM revealed when Nurse #1 took over the medication cart from Nurse #4, the total number of controlled substance cards in the cart was 50 cards according to the count, but it was documented as 48 cards on the count sheet. As Nurse #2 depleted one card during the shift, the balance became 49 cards before the shift transition on 03/08/24 at 7:00 AM. However, Nurse #2 did not update the balance and it remained unchanged at 48 cards. The initial allegation report dated 03/08/24 revealed the facility became aware of the misappropriation of residents' property on 03/08/24 at 7:30 AM when the Director of Nursing (DON) and Administrator were notified that a count of Resident #1's narcotic medication revealed discrepancy. The facility confirmed Resident #1 still had adequate supply of the prescribed narcotic medication and the missing narcotic medications were replaced by the facility. Investigation was initiated by DON immediately. The 5-day investigation report dated 03/13/24 revealed on 03/08/24, a blister card of 30 tablets of oxycodone 5 mg was noted missing from the medication cart for orange halls during shift transition. According to the investigation summary, Nurse #1 had a family emergency on 03/07/24 around 9 PM and needed to leave the facility immediately. She asked Nurse Aide (NA) #1 who happened to be in the parking lot at approximately 9:15 PM to hold the medication cart keys until Nurse #2 arrived to relieve her. Nurse #2 arrived at the facility around 9:45 PM and received the medication cart keys from NA#1 in the parking lot. She went ahead to start her shift without counting the medication cart with any nursing staff in the facility. On 03/08/24 at approximately 7:00 AM, Nurse #3 came on shift to relieve Nurse #2. She noted a blister card of 30 tablets of oxycodone 5 mg went missing when counting the medication cart with Nurse 2. Nurse #1 and Nurse #2 were drug screened with negative results and the allegation of misappropriation of residents' property was unsubstantiated. A phone interview was conducted with Nurse #4 on 04/01/24 at 3:40 PM. She recalled working the first shift on 03/07/24 and was relieved by Nurse #1 in the evening. She counted the controlled substances with Nurse #1 during the shift transition without noticing any discrepancy. She passed the medication cart keys to Nurse #1 after Nurse #1 had signed the controlled substance count sheet. During a phone interview conducted on 04/01/24 at 4:06 PM, Nurse #1 stated when she counted the controlled substances with Nurse #4 on 03/07/24 at around 7:00 PM, she checked the medication cards while Nurse #4 verified the controlled substance count sheets. She stated she should verify the actual numbers shown in the controlled substance count sheets, but it did not happen. The initial count indicated there were 48 cards of controlled substance in the medication cart. A recount confirmed the actual balance was 50 cards. She signed the controlled substance count sheet but had forgotten to update the total number of cards to 50. She stated she had a family emergency at approximately 9:00 PM that night and had to leave the facility immediately. She did not count the controlled substance in the medication cart with any nursing staff before leaving as she was having a nerve breaking family emergency. While she was talking to her family in the parking lot, she saw NA #1 in the car and decided to pass the medication cart keys to her so that she could leave as soon as possible. She told NA #1 that the controlled substance count was good before passing the keys to her. The DON tried to contact her in the morning on 03/08/24 regarding the incident. However, due to the nature of the family emergency, she was unable to talk to the DON. She contacted DON several days later and was drug screened with a negative result. She denied using any narcotic medication except taking Adderall with a prescription for many years. A phone interview was conducted with NA #1 on 04/01/24 at 2:15 PM. She stated she was a medication aide (MA) and had a habit of coming to the facility's parking lot early to take a nap before her shift. On 03/07/24 at around 9:20 PM, Nurse #1 told her that she had a family emergency and wanted her to hold the medication cart keys for orange halls until Nurse #2 arrived at the facility to relieve her. Nurse #1 told her that she had counted the controlled substances, and the count was good. At approximately 9:45 PM, Nurse #2 picked up the keys from her in the parking lot. However, Nurse #2 did not ask her to count the controlled substances in the medication cart together before started her shift. NA #1 stated she did not enter the facility until approximately 10:42 PM that night. The timecard dated 03/07/24 revealed NA#1 started her shift at 10:42 PM and clocked out on 03/08/24 at 7:05 AM. A phone interview was conducted with Nurse #2 on 04/01/24 at 2:47 PM. She stated when she arrived at the facility's parking lot on 03/07/24 at around 9:45 PM, she found that NA #1 was parked next to her car and told her that she had the medication cart keys for her. She asked NA #1 if she had counted the medication cart with Nurse #1 and was told it had not been done. NA #1 stated Nurse #1 told her that the medication cart was counted, and it was fine. As she assumed the medication cart was counted by Nurse #1 without any discrepancies, she stated she made a big mistake to start the shift without counting the controlled substances in the medication cart with any nursing staff. She denied seeing anything unusual with her medication cart during the shift and stated she had the medication cart keys throughout the shift. She completed a drug screening on 03/08/24, and the result was negative. She was later disciplined for not following the facility protocol to count the controlled substances during shift transition. During a phone interview conducted on 04/01/24 at 3:06 PM, Nurse #3 stated she noticed there were 49 controlled substance count sheets but only 48 controlled substance cards in the medication cart for orange halls during the shift transition on 03/08/24 at around 7:00 AM. After she had recounted the medication cart together with Nurse #2, she found that the missing controlled substance card belonged to Resident #1, and it consisted of 30 tablets of oxycodone 5 mg. Nurse #2 reported the incident to the DON immediately. An interview was conducted with DON on 04/01/24 at 12:15 PM. She stated she received a call from Nurse #1 on 03/07/24 night around 9:00 PM stating she had to leave the facility immediately due to family emergency. On 03/08/24 around 7:20 AM, Nurse #2 called to notify her about the narcotic medication loss. She called Nurse #1 immediately and realized that she was unable to talk at that point. On 03/08/24 at 10:30 AM, she received a text message from Nurse #1 stating that she had counted the medication cart with Nurse #4 before taking over the medication cart on 03/07/24 around 7:00 PM. The total number of controlled medications in the medication cart was 50 cards. However, Nurse #1 admitted she did not update the count and continued to document 48 cards on the controlled substance count Sheet. In addition, Nurse #1 did not count the medication cart with any nursing staff in the facility before leaving for family emergency on 03/07/24 night. Nurse #2 was drug screened immediately on 03/08/24 while Nurse #1 was tested on [DATE] due to the nature of her family emergency. Both Nurse #1 and Nurse #2 were tested negative. Nurse #2 told her that after she took the medication cart keys from NA #1, she started her shift without counting the controlled substances in the medication cart with any nursing staff. She stated Nurse #5 was working during the shift on 03/07/24 but none of the nurses had requested him to count the controlled substances together for orange halls that night. After she was made aware of the incident, she ordered Assistant Director of Nursing (ADON) to assist in the investigation immediately by assessing pain for all residents who used narcotic medications, notifying Resident #1's family and the Medical Director of the incident, and communicating with the pharmacy to determine if the missing narcotics were returned to the pharmacy accidentally. She reported the incident to the North Carolina Department of Health & Human Services (NC DHHS) and the local Sheriff's office. All the missing oxycodone was replaced and paid for by the facility after the incident. She concluded that the incident could be avoided if both Nurse #1 and Nurse #2 had updated the controlled substance count sheets in a timely manner and counted the controlled substances in the medication cart with another nurse during shift transition. During an interview conducted on 04/01/24 at 12:49 PM, Resident #1 stated she was notified of the incident and being assessed for pain on 03/08/24. She added all the missing pain medication were replaced by the facility and denied having any issues to receive her pain medication as needed in a timely manner so far. During a phone interview conducted on 04/01/24 at 2:32 PM, Nurse #5 could not recall any nurses had asked him to count the medication cart for orange halls together during his shift from 3 PM to 11 PM on 03/07/24. He denied seeing NA #1 entering the facility before 10:45 PM on 03/07/24. During a phone interview conducted on 04/02/24 at 10:35 AM, the MD stated he was notified of the incident on 03/08/24 and provided with the name of the resident affected. He stated Resident #1 was assessed immediately without any adverse consequences noted as the missing drugs were used as needed basis and the facility had adequate supply of the missing narcotic medication. He added all the missing medications were replaced and paid for by the facility later. It was his expectation for all the nursing staff to follow the facility's protocol to count the controlled substance in the medication cart during shift transition. A subsequent interview was conducted with DON on 04/02/24 at 11:33 AM. It was her expectation for all the nursing staff to follow the facility's protocol to complete controlled substance count and update the balance of cards in the controlled substance count sheets before taking over a medication cart during shift transition. During an interview conducted with the Administrator on 04/02/24 at 11:45 AM, he expected all the nursing staff to follow facility's policies and procedures to count all the controlled substances in the medication cart during shift transition to prevent misappropriation of residents' property.

Based on record review and interviews with resident, staff, and the Medical Director (MD), the facility failed to keep an accurate accounting of controlled medications on the controlled substance count sheets and failed to conduct controlled substance counts in the medication cart with at least 2 nurses for verification of accuracy during shift transitions. As a result, a blister card of 30 tablets of a controlled substance was missing from a medication cart during shift transition for 1 of 1 resident reviewed for misappropriation of residents' property (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses including osteoporosis and hip fractures. A review of the physician's order dated 02/10/24 revealed Resident #1 had an order to receive 1 tablet of oxycodone (a semi-synthetic narcotic analgesic for pain) 5 milligrams (mg) by mouth once every 3 hours as needed for pain. A review of the medication administration records (MARs) revealed Resident #1 had received 1 tablet of oxycodone 5 mg as needed on 02/19/24 and 03/07/24. A review of the controlled substance count sheet for orange halls on 03/07/24 at 7:00 PM revealed when Nurse #1 took over the medication cart from Nurse #4, the total number of controlled substance cards in the cart was 50 cards according to the count, but it was documented as 48 cards on the count sheet. As Nurse #2 depleted one card during the shift, the balance became 49 cards before the shift transition on 03/08/24 at 7:00 AM. However, Nurse #2 did not update the balance and it remained unchanged at 48 cards. A phone interview was conducted with Nurse #4 on 04/01/24 at 3:40 PM. She recalled working the first shift on 03/07/24 and was relieved by Nurse #1 in the evening. She counted the controlled substances with Nurse #1 during the shift transition without noticing any discrepancy. She passed the medication cart keys to Nurse #1 after Nurse #1 had signed the controlled substance count sheet. During a phone interview conducted on 04/01/24 at 4:06 PM, Nurse #1 stated when she counted the controlled substances with Nurse #4 on 03/07/24 at around 7:00 PM, she checked the medication cards while Nurse #4 verified the controlled substance count sheets. She stated she should verify the actual numbers shown in the controlled substance count sheets, but it did not happen. The initial count indicated there were 48 cards of controlled substance in the medication cart. A recounted confirmed the actual balance was 50 cards. She signed the controlled substance count sheet but had forgotten to update the total number of cards to 50. She stated she had a family emergency at approximately 9:00 PM that night and had to leave the facility immediately. She did not count the controlled substance in the medication cart with any nursing staff before leaving as she was having a nerve breaking family emergency. While she was talking to her family in the parking lot, she saw NA #1 in the car and decided to pass the medication cart keys to her so that she could leave as soon as possible. She told NA #1 that the controlled substance count was good before passing the keys to her. A phone interview was conducted with NA #1 on 04/01/24 at 2:15 PM. She stated she had a habit of coming to the facility's parking lot early to take a nap before her shift. On 03/07/24 at around 9:20 PM, Nurse #1 told her that she had a family emergency and wanted her to hold the medication cart keys for orange halls until Nurse #2 arrived at the facility to relieve her. Nurse #1 told her that she had counted the controlled substances, and the count was good. At approximately 9:45 PM, Nurse #2 picked up the keys from her in the parking lot. However, Nurse #2 did not ask her to count the controlled substances in the medication cart together before started her shift. NA #1 stated she did not enter the facility until approximately 10:42 PM that night. The timecard dated 03/07/24 revealed NA#1 started her shift at 10:42 PM and clocked out on 03/08/24 at 7:05 AM. A phone interview was conducted with Nurse #2 on 04/01/24 at 2:47 PM. She stated when she arrived at the facility's parking lot on 03/07/24 at around 9:45 PM, she found that NA #1 was parked next to her car and told her that she had the medication cart keys for her. She asked NA #1 if she had counted the medication cart with Nurse #1 and was told it had not been done. NA #1 stated Nurse #1 told her that the medication cart was counted, and it was fine. As she assumed the medication cart was counted by Nurse #1 without any discrepancies, she stated she made a big mistake and started the shift without counting the controlled substances in the medication cart with any nursing staff. She denied seeing anything unusual with her medication cart during the shift and stated she had the medication cart keys throughout the shift. Nurse #2 stated she was later disciplined for not following the facility protocol to count the controlled substances during shift transition. During a phone interview conducted on 04/01/24 at 2:32 PM, Nurse #5 could not recall any nurses had asked him to count the medication cart for orange halls together during his shift from 3 PM to 11 PM on 03/07/24. He denied seeing NA #1 entering the facility before 10:45 PM on 03/07/24. During a phone interview conducted on 04/01/24 at 3:06 PM, Nurse #3 stated she noticed there were 49 controlled substance count sheets but only 48 controlled substance cards in the medication cart for orange halls during the shift transition on 03/08/24 at around 7:00 AM. After she had recounted the medication cart together with Nurse #2, she found that the missing controlled substance card belonged to Resident #1, and it consisted of 30 tablets of oxycodone 5 mg. Nurse #2 reported the incident to the DON immediately. During a phone interview conducted on 04/02/24 at 10:35 AM, the MD stated it was his expectation for all the nursing staff to follow the facility's protocol to count the controlled substance in the medication cart during shift transition. An interview was conducted with DON on 04/01/24 at 12:15 PM. She stated she received a call from Nurse #1 on 03/07/24 night around 9:00 PM stating she had to leave the facility immediately due to family emergency. Nurse #1 asked Nurse Aide (NA) #1 who happened to be in the parking lot at approximately 9:15 PM to hold the medication cart keys until Nurse #2 arrived to relieve her. Nurse #2 arrived at the facility around 9:45 PM and received the medication cart keys from NA#1 in the parking lot. Nurse #2 went ahead to start her shift without counting the medication cart with any nursing staff in the facility. On 03/08/24 at approximately 7:00 AM, Nurse #3 came on shift to relieve Nurse #2. She noted a blister card of 30 tablets of oxycodone 5 mg went missing when counting the medication cart with Nurse 2. On 03/08/24 around 7:20 AM, Nurse #2 called to notify her about the narcotic medication loss. She called Nurse #1 immediately and realized that she was unable to talk at that point. On 03/08/24 at 10:30 AM, she received a text message from Nurse #1 stating that she had counted the medication cart with Nurse #4 before taking over the medication cart on 03/07/24 around 7:00 PM. The total number of controlled medications in the medication cart was 50 cards. However, Nurse #1 admitted she did not update the count and continued to document 48 cards on the controlled substance count Sheet. In addition, Nurse #1 stated she did not count the medication cart with any nursing staff in the facility before leaving for family emergency on 03/07/24 night. Nurse #2 told her that after she took the medication cart keys from NA #1, she started her shift without counting the controlled substances in the medication cart with any nursing staff. She stated Nurse #5 was working during the shift on 03/07/24 but none of the nurses had requested him to count the controlled substances together for orange halls that night. She concluded that the incident could be avoided if both Nurse #1 and Nurse #2 had updated the controlled substance count sheets in a timely manner and counted the controlled substances in the medication cart with another nurse during shift transition. A subsequent interview was conducted with DON on 04/02/24 at 11:33 AM. It was her expectation for all the nursing staff to follow the facility's protocol to complete controlled substance count and update the balance of cards in the controlled substance count sheets before taking over a medication cart during shift transition. During an interview conducted with the Administrator on 04/02/24 at 11:45 AM, he expected all the nursing staff to follow facility's policies and procedures to count all the controlled substances in the medication cart during shift transition to prevent misappropriation of residents' property.

Based on observations, record review and staff interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint survey conducted on 02/16/24 and the complaint investigation survey conducted on 04/02/24. This was for a repeat deficiency in the area of misappropriation/exploitation of resident's property that was originally cited on 02/16/24 during the recertification and complaint survey, and subsequently recited during the complaint investigation survey completed on 04/02/24. The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is cross referenced to: F 602 - Based on record review and interviews with resident, staff, and the Medical Director (MD), the facility failed to protect residents' rights to be free from misappropriation of controlled substances for 1 of 1 resident (Resident #1) reviewed for misappropriation of residents' property. During the recertification and complaint survey on 02/16/24, the facility failed to protect residents' rights to be free from misappropriation of controlled medications for 4 of 4 residents reviewed for misappropriation of residents' property. During an interview conducted with the Administrator on 04/02/24 at 11:45 AM, he stated the facility conducted QAA meeting at least once monthly to discuss areas of previously and/or newly identified concerns in the facility. It also included deficiencies from the surveys. The areas of concern were tracked from month to month for progression toward the goals. The Administrator attributed the failure of facility during the recent federal surveys to failure of nursing staff to follow the policies and procedures to count, verify, and confirm the quantity of controlled substances in the medication cart during shift transition. He stated the recited deficiency was different in nature from the previous citation and added all the plan of corrections were properly implemented and monitored as planned since the last survey.

Based on record review and interviews with residents, staff, and physician, the facility failed to protect residents' rights to be free from misappropriation of controlled medications for 4 of 4 residents (Resident #16, #17, #35, and #116) reviewed for misappropriation of residents' property. The findings included: The facility's Abuse, Neglect, or Misappropriation of Resident property policy, last revised on [DATE], revealed in part the facility would ensure all residents to remain free from abuse or misappropriation of their property. A review of the initial allegation report dated [DATE] revealed the facility became aware of the misappropriation of residents' property on [DATE] at 6:35 AM when a total of 4 tablets of oxycodone (a semi-synthetic narcotic analgesic for pain) had potentially been diverted (1 tablet each for Resident #16, #17, #35, and #116) by Nurse #1. The 5-day investigation report dated [DATE] revealed on [DATE], 4 tablets of oxycodone 5 milligrams (mg) were signed out as given by Nurse #1. Interviews with all the 4 residents by the Assistant Director of Nursing (ADON) revealed that they did not ask for or receive any oxycodone that morning. Nurse #1 was asked to do a drug screening, but she refused to comply and became belligerent. The allegation of diversion of Residents' drugs was substantiated and Nurse #1 was terminated on [DATE]. An interview was conducted with the Director of Nursing (DON) on [DATE] at 2:27 PM. She stated the incident occurred on [DATE] morning. NA #1 noticed that she had difficulty finding Nurse #1 several times during the 7 PM through 7 AM shift on [DATE] night. NA#1 noted Nurse #1 had spent a lot of time in the restroom repeatedly that night. At one point, NA#1 went into the same bathroom immediately after Nurse #1 came out and saw some unknown white powders scattered on top of the sink in the bathroom. NA#1 took a picture and texted it to her around 4:30 AM that morning. She notified the on-call Administrator and corporate nurse consultant for further instructions. She called Nurse #2 who was the second nurse on duty that night around 5:30 AM and was told that Nurse #1 stayed in the bathroom repeatedly for long periods of time that night. She instructed Nurse #2 to begin the investigation immediately by reviewing the MARs and the controlled medication count sheets. Nurse #2 noted Nurse #1 had signed out oxycodone for 4 Residents within a short time frame of 30 minutes during that shift. DON stated these residents normally would not request pain medication during that time. She instructed the ADON at that time to go to the facility to start the on-site investigation immediately. Interviews with all 4 residents whose oxycodone was signed out by Nurse #1 by ADON revealed that they had not requested nor received any oxycodone from Nurse #1 that night. Nurse #1 was told later that she was suspected of drug diversion and instructed to submit urine specimen for a drug screening. However, Nurse #1 refused to comply. She was asked to surrender the medication cart key and being escorted out of the building by the ADON. Later, Nurse #2 claimed that Nurse #1 had attempted to get a urine specimen from her to be used for drug screening and was being rejected. She ordered ADON to assess all the affected residents immediately. Then, the ADON informed all the residents and families affected by the incident, notified the Medical Director (MD), reported to North Carolina Department of Health & Human Services (NC DHHS), the Board of Nursing (BON), and the local Sheriff's office. The ADON further investigated all other residents for potential drug diversion and determined that it affected 4 residents, and 4 tablets of oxycodone 5 mg were potentially diverted. All the missing drugs were replaced and paid for by the facility after the incident. She ordered ADON to start an in-service related to drug diversion, safeguarding of controlled medications and it was completed [DATE]. An attempt to conduct a phone interview with Nurse Aide (NA) #1 on [DATE] at 6:05 PM was unsuccessful. She did not return the call. An attempt to conduct a phone interview with Nurse #1 on [DATE] at 6:43 PM was unsuccessful. She did not return the call. An attempt to conduct a phone interview with the former Assistant Director of Nursing (ADON) on [DATE] at 6:06 PM was unsuccessful. He did not return the call. An attempt to conduct a phone interview with Nurse #2 on [DATE] at 6:11 PM was unsuccessful. She did not return the call. All the 4 Residents affected by the incident were in the facility when it occurred on [DATE]. Resident #35 and Resident #116 were not present in the facility at the time of the recertification and complaint investigation survey conducted from [DATE] through [DATE]. Resident #17 was admitted to the facility on [DATE] with diagnoses including polyneuropathy. The quarterly Minimum Data Set (MDS) dated [DATE] coded him with an intact cognition. Resident #35 was admitted to the facility on [DATE] with diagnoses including age-related osteoporosis. The quarterly MDS dated [DATE] coded her with a severely impaired cognition. She expired in the facility on [DATE]. Resident #16 was admitted to the facility on [DATE] with diagnoses including chronic pain. The quarterly MDS dated [DATE] coded her with a moderately impaired cognition. Resident #116 was admitted to the facility on [DATE] with diagnoses including osteoarthritis. The admission MDS dated [DATE] coded her with an intact cognition. She was discharged home on [DATE]. A review of the physician's order revealed 4 Residents affected by the incident had the following orders: - Resident #16 - oxycodone 5 mg, take 1 tablet by mouth once every 6 hours as needed for pain. Initiated [DATE]. - Resident #17 - oxycodone 5 mg, take 1 tablet by mouth once every 8 hours as needed for pain. Initiated [DATE]. - Resident #35 - oxycodone 5 mg, take 1 tablet by mouth once every 6 hours as needed for pain. Initiated [DATE]. - Resident #116 - oxycodone 5 mg, take 1 tablet by mouth once every 6 hours as needed for pain. Initiated [DATE]. A review of the controlled medication count sheets revealed 1 tablet of oxycodone 5 mg was signed out by Nurse #1 on [DATE] for Resident #116 at 4:30 AM, Resident #17 at 4:45 AM, Resident #16 at 4:50 AM, and Resident #35 at 5:00 AM. A review of medication administration records (MAR) revealed 1 tablet of oxycodone 5 mg was signed out by Nurse #1 on [DATE] for Resident #116 at 4:39 AM, Resident #17 at 4:43 AM, Resident #16 at 4:50 AM, and Resident #35 at 4:49 AM. An interview was conducted with Resident #17 on [DATE] at 9:35 AM. He recalled the incident related to drug diversion a few months ago. When a management staff interviewed him during the incident, he told him that he did not request the pain medication on [DATE] around 4:00 AM to 5:00 AM and it was not given by the nurse that morning. During an interview conducted on [DATE] at 3:22 PM, Resident #16 could not recall the incident related to diversion of her pain medication by Nurse #1 that occurred a few months ago. During a phone interview conducted on [DATE] at 4:21 PM, the MD stated he was notified of potential controlled medication diversion on [DATE] morning and provided with the list of residents affected. He stated all the affected residents were assessed immediately without any adverse consequences noted as the missing drugs were used as needed basis. He added all the missing medications were replaced and paid for by the facility later. The facility provided the following corrective action plan with a completion date of [DATE]: Problem Statement: On [DATE] at approximately 4:23 am, Nurse Aide #1, notified the Director of Nursing to report a suspicion of drug diversion. She reported that immediately after Nurse #1 came out of the restroom, she noted a white powdery substance on multiple areas of the bathroom sink. A phone interview was conducted with Nurse #2 who was present in the facility at approximately 5:30 am. Nurse #2 confirmed her suspicions of drug diversion as well. Nurse #2 stated that she observed Nurse #1 pull medications from the controlled drawer of her cart however did not see Nurse #1 give these medications. Nurse #2 looked at the Medication Administration Record and the Controlled substance log for the cart of Nurse #1 and observed Oxycodone 5mg signed out as given for the following residents: Resident #116, #16, #17, and #35. All oxycodone 5mg medication were ordered as needed and were signed out both in Point Click Care and in the Controlled Substance Count log as given. The timeframe ranged between 4:30 am and 5:00 am on [DATE]. The Assistant Director of Nursing entered the facility at approximately 6:00am on [DATE] and continued investigation. He interviewed Nurse #2 and Nurse Aide #1. He also interviewed resident # 116, #16, #17, and #35. During these interviews, the 4 residents identified in the investigation stated they had not asked nor received any pain medications after the identified time of approximately 4:00am. The nurse assessed these four residents for pain at this time and none of the 4 were noted to have pain at the time of their interview and had not requested pain medication at the time of the incident. At 6:35am, the Assistant Director of Nursing attempted to conduct an interview with Nurse #1 to discuss the incident and obtain a statement and a drug screen, however Nurse #1 refused. Nurse #1 was suspended at this time pending investigation and escorted from the facility with Nurse #2 as a witness. The Medical Director was informed of this concern at approximately 8:16 am with no further orders given. Resident representatives were also informed at this time as well. A report was made to the Department of Health and Human Services at approximately 8:40 am followed by a call to the [NAME] County Sheriff's Office at approximately 8:58am. Nurse #1 was terminated on [DATE]. The Director of Nursing filed a report alleging controlled substance diversion with the North Carolina Board of Nursing on [DATE] with additional documentation requested and sent on [DATE]. Address how the corrective action will be accomplished for those residents found to have been affected by the deficient practice: Interviews were conducted by the Assistant Director of Nursing on [DATE] with the 4 residents having been identified as having controlled medications signed out during the hours identified in the investigation to determine if the medications had been given. It was determined that these 4 residents were identified as having not received medications that were signed out by Nurse #1. Pain scales were performed for all residents identified by a licensed nurse on duty on [DATE] verbally at approximately 6:00am prior to the interview with Nurse #1. No complaints of pain were identified. Pain scales were also conducted again throughout day shift on this same day for these same residents. The Medical Director was made aware with no new orders given. The pharmacy was notified, and 1 oxycodone 5mg tablet was replaced for each resident identified in the investigation. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: A medication count of all controlled drugs was conducted by the Assistant Director of Nursing and the Director of Nursing on [DATE] to ensure all controlled medications were accurate and available as ordered by the physician. Any medications that were diverted were replaced by the pharmacy as appropriate. No concerns were identified during this audit. All residents who received controlled pain medications were assessed for pain to include signs and symptoms of pain both verbal and non-verbal to ensure pain levels were being addressed appropriately. Any concerns were reported to the charge nurse, Director of Nursing or Assistant Director of Nursing and addressed immediately. The Medical Director was notified, and orders were given as appropriate. An in-service was initiated on [DATE] by the Staff Development Coordinator on Abuse Neglect, Misappropriation, Reporting, Reporting, Code of Ethics, and Diversion. An in-service was also initiated on [DATE] by the Director of Nursing/Assistant Director of Nursing/Staff Development Coordinator with all nurses and medication aides to include agency staff regarding Controlled Substance Diversion to include: the definition, implications, and the process for returning controlled medications. All education was completed by [DATE]. Any nurse or medication aide, to include agency staff that have not completed the education as stated above by the completion date will do so by their next scheduled shift. Any newly hired licensed nurse, medication aide or agency staff will receive the above stated in-service education during orientation prior to their first shift. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: The pharmacy will conduct monthly cart and med-pass audits to ensure nurses and medication aides, including agency nurses, are following policy and procedures related to medication administration. All residents will be monitored daily and every shift for signs and symptoms of pain both verbal and non-verbal to ensure pain levels are being addressed appropriately. Any concerns are reported to the charge nurse, Director of Nursing or Assistant Director of Nursing and addressed immediately. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: 100% of all residents receiving controlled medications will be reviewed by the Assistant Director of Nursing/Director of Nursing once weekly x4 weeks and compared to the Controlled Substance Count Sheets, medication administration record, and/or return of drug slips to ensure the controlled medications are being administered or have been returned to pharmacy as required per policy as well as no signs of drug diversion utilizing a Controlled Substance Audit tool. All concerns will be addressed during the audit including re-education of all licensed nurses and medication aides to include agency nurses. Any newly hired/agency employees who are licensed nurses or medication aides will receive education during orientation prior to their first shift. Nursing Administrative staff to include Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, or Quality Improvement Nurse, will conduct pain assessments and interviews of 5 residents daily who have pain for 4 weeks. Any concerns will be addressed and investigated immediately. The Medical Director and Responsible Party will be notified of any concerns and care-plans/care-guides will be updated as appropriate. The Administrator or Director of Nursing will present the findings of the audit tools to the Quality Assurance Performance Improvement Committee monthly for 1 month. The Quality Assurance Performance Improvement Committee will meet monthly for 1 month and review the audit tools to determine trends and/or issues that may need further interventions and the need for additional monitoring. QAPI meetings were held on [DATE] and [DATE]. Date of Compliance: [DATE] The facility's corrective action plan with a correction date of [DATE] was validated onsite on [DATE] by record review, observations, and interviews with nursing staff and the DON. Medication Administration observations were conducted on [DATE] and it consisted of 25 medications, 3 different residents, and 3 Nurses. Controlled medication was pulled from the double-locked compartment in the medication cart during the medication pass observation. The nurse documented the retrieval of controlled medication in the controlled medication count sheet properly. Random samples of 3 controlled medications were pulled from each medication cart to verify accuracy and the controlled substance counts were consistent with the records in the count sheets. An observation was conducted during a shift transition. The arriving and the departing nurses started the process by counting the total number of blister cards containing controlled medication in the double-locked compartment in the medication cart to verify the recorded balance in the count sheet. Then, they counted each blister card of controlled medication to ensure the quantity listed in the count sheet was consistent with the actual counts. The departing nurse read out the number of pills for each blister card from the controlled medication count sheets and the arriving nurse pulled the blister card to verify the quantity. After all the counts were completed without any discrepancies, the arriving nurse signed the controlled medication count sheet before the departing nurse passed the medication cart key to her. Nursing staff confirmed during the interview that they had received in-service training on Abuse, neglect, misappropriation, reporting, code of ethics, and diversion and Definition, implications, and the process for returning narcotic medications. They were assigned to review the handouts related to the in-service prior to the training. The training was conducted in-person by DON, ADON, and the Staff Development Coordinator (SDC), and it included multiple examples and scenarios. A total of 79 staff completed the training and signed in the in-service records. The training was completed on [DATE]. Review of audit records revealed all residents receiving controlled medications were audited by the DON or ADON once per week for 4 weeks by comparing controlled substance count sheets, MAR, and the controlled medication return sheets. On the other hand, DON and ADON had conducted pain assessments and interviews with 5 residents who had pain once daily for 4 weeks to ensure all the pains were addressed and the facility was free of drug diversion. The Administrator or Director of Nursing presented the findings of the audit tools to the Quality Assurance Performance Improvement Committee (QAPI) on [DATE]. Interview with DON revealed she started the in-service immediately after the incident to re-educate all the licensed nurses and medication aides. She audited the medication cart at least once per week randomly for 4 weeks to ensure all controlled medication counts were conducted properly and the count sheets were documented properly. She stated the interventions were successful as the facility did not have any similar drug diversion issues since then. The compliance date of [DATE] was validated.

Based on record review and interviews with the staff, Consultant Pharmacist, and Medical Director (MD), the Consultant Pharmacist failed to identify drug irregularities and provide recommendations and cholesterol levels for 1 of 5 residents reviewed for unnecessary medications (Resident #25). Review of the lipid guidelines published in 2019 by the American College of Cardiology and American Heart Association indicated a lipid panel should be conducted at baseline for patient receiving statin (medications used to lower cholesterol) therapy, then 4 to 12 weeks after statin therapy was started or when dosage was adjusted. Afterwards, lipid panel test should be repeated once every 3 to 12 months as needed. Resident #25 was admitted to the facility on [DATE] with diagnoses including hyperlipidemia (high level of lipids/fats in the blood). Review of Resident #25's medical records revealed the most recent lipid panel was done on 12/22/22 when Resident #25 was in the hospital prior to being admitted to the facility. The hospital list of active medications included ezetimibe give 10 milligrams (mg) daily and atorvastatin give 40 mg at bedtime. There were no other lipid panels included in the medical records after 12/22/22. A review of the active physician orders included to administer atorvastatin 40 mg at bedtime for cholesterol started on 12/28/22 and ezetimibe 10 mg at bedtime for cholesterol started on 12/29/22. A review of the Medication Administration Records (MAR) from January 2023 through February 2024 revealed Resident #25 received atorvastatin 40 mg and ezetimibe 10 mg at bedtime as ordered. Review of the Monthly Medication Regimen (MRR) for Resident #20 revealed the Consultant Pharmacist reviews were completed on the following days: 1/12/23, 2/8/23, 3/9/23, 4/6/23, 5/5/23, 6/5/23, 7/10/23, 8/17/23, 9/20/23, 10/21/23, 1/26/24. There were no recommendations made by the Consultant Pharmacist related to monitoring the lipid panel for the use of the medication atorvastatin and ezetimibe. During an interview on 02/15/24 at 10:54 AM Nurse #6 checked the active physician orders for ezetimibe 10 mg and atorvastatin 40 mg and stated both were current orders administered nightly by the nurses. An interview was conducted with the Medical Records Coordinator on 02/15/24 at 1:33 PM. She confirmed she was responsible for scanning lab test results in the electronic medical record and was unable to find a lipid panel for Resident #25 after being admitted to the facility on [DATE]. An attempt to conduct a phone interview with the current Consultant Pharmacist on 02/15/24 at 3:54 PM was unsuccessful. He did not return the phone call. During a phone interview on 02/15/24 at 4:12 PM the MD stated a lipid panel was obtained every six months or annually for use of atorvastatin and ezetimibe. He revealed Resident #25 was taking both atorvastatin and ezetimibe to reduce cholesterol levels and would need a lipid panel for efficacy and to check liver function due to statin use can affect the liver. He revealed it was his expectation the Consultant Pharmacist alert him when labs needed to be done for the use of atorvastatin and ezetimibe. During a phone interview on 02/15/24 at 4:35 PM the Supervisor for the Consultant Pharmacist stated a lipid panel was a standard lab obtained when using statin medications. After he reviewed Resident #25's medical records, he stated the most recent lipid panel was obtained on 12/2022 by the hospital. After review of the Pharmacist Consultant MMR, he stated no recommendations were made to obtain a lipid panel. An interview was conducted on 02/16/24 01:30 PM with the Director of Nursing (DON). The DON stated the process was for the Consultant Pharmacist to make recommendations and the MD to follow up. She revealed labs were ordered by the MD as needed and there was no schedule in place for routine labs including a lipid panel but was something she would check on implementing. She was unsure why the lipid panel for Resident #25 was not ordered and stated it had been addressed. During an interview conducted on 02/16/24 at 1:38 PM the Administrator revealed he expected the Consultant Pharmacist provide the appropriate recommendations for labs for the use of medications that require monitoring.

Based on record review and interviews with the resident, staff, Consultant Pharmacist, and Medical Director (MD), the facility failed to monitor thyroid stimulating hormone (TSH) (Resident #20) and cholesterol levels (Resident #25) for 2 of 5 residents reviewed for unnecessary medications. The findings included: 1.A review of the guidelines published in 2017 by American Thyroid Association indicated TSH level should be checked about 6-8 weeks after starting levothyroxine or having a change in the dosage. Then, it should be monitored at least once a year to ensure TSH level remained wiin the normal ranges of 0.4 to 4.0 milli-international units per milliliter ([NAME]/mL). Resident #20 was admitted to the facility on [DATE] with diagnoses including hypothyroidism (A condition occurred when the thyroid gland could not make enough thyroid hormone to keep the body functioning normally). A review of Resident #20's lab records revealed her most recent TSH lab was completed on 02/03/23 when she was in the hospital. No subsequent TSH labs had been documented in her medical records since then. A review of the physician's order dated 02/05/23 indicated Resident #20 had an order to receive 1 tablet of levothyroxine 50 micrograms (mcg) by mouth once daily in the morning for thyroid disease. This order was discontinued on 02/09/24. However, it was restarted with the same dosage and directions on 02/13/24. The quarterly Minimum Data Set (MDS) dated [DATE] coded Resident #20 with severe impairment in cognition. A review of the medication administration records (MAR) from February 2023 through February 2024 revealed Resident #20 had received 1 tablet of levothyroxine 50 mcg once daily as ordered since it was started on 02/05/23 until it was discontinued on 02/09/24. Resident #20 resumed receiving the same dosage of levothyroxine again when it was re-started on 02/13/24. An attempt to interview Resident #20 on 02/14/24 at 8:48 AM was unsuccessful. She was unable to engage in the interview. During an interview conducted on 02/14/24 at 4:08 PM, Nurse #3 stated she had administered levothyroxine to Resident #20 as ordered at times. She did not recall receiving any lab order to check Resident #20's TSH level in the past few months. An interview was conducted with the Medical Record Coordinator on 02/15/24 at 10:14 AM. She confirmed the most recent TSH lab for Resident #20 was conducted on 02/03/23. She could not find any TSH labs documented in the medical records for Resident #20 after 02/03/23. A phone interview was conducted with the MD on 02/15/24 at 4:21 PM. He stated residents receiving levothyroxine on regular basis without checking TSH levels could have an increased risk of under-treatment. It was his expectation for the facility to monitor TSH level as indicated for residents receiving levothyroxine. An attempt to conduct a phone interview with the current Consultant Pharmacist on 02/15/24 at 3:54 PM was unsuccessful. He did not return the phone call. During a phone interview conducted on 02/15/24 at 4:31 PM, the Supervisor for the Consultant Pharmacist stated TSH level should be monitored as indicated according to the published guidelines for residents receiving levothyroxine on regular basis. An interview was conducted with the Director of Nursing (DON) on 02/15/24 at 4:41 PM. She expected the facility to monitor TSH level as indicated for residents receiving levothyroxine on regular basis according to the published thyroid guidelines. During an interview conducted on 02/16/24 at 10:35 AM, the Administrator expected the facility to check TSH level for residents receiving levothyroxine as indicated to ensure all the labs were completed in a timely manner. 37538 2. Review of the lipid guidelines published in 2019 by the American College of Cardiology and American Heart Association indicated a lipid panel should be conducted at baseline for patient receiving statin (medications used to lower cholesterol) therapy, then 4 to 12 weeks after statin therapy was started or when dosage was adjusted. Afterwards, lipid panel test should be repeated once every 3 to 12 months as needed. Resident #25 was admitted to the facility on [DATE] with diagnoses including hyperlipidemia (high level of lipids/fats in the blood). Review of Resident #25's medical records revealed the most recent lipid panel was done on 12/22/22 when Resident #25 was in the hospital prior to being admitted to the facility. The hospital list of active medications included ezetimibe give 10 milligrams (mg) daily and atorvastatin give 40 mg at bedtime. A review of the active physician orders included to administer atorvastatin 40 mg at bedtime for cholesterol started on 12/28/22 and ezetimibe 10 mg at bedtime for cholesterol started on 12/29/22. A review of the Medication Administration Records (MAR) from January 2023 through February 2024 revealed Resident #25 received atorvastatin 40 mg and ezetimibe 10 mg at bedtime as ordered. During an interview on 02/15/24 at 10:54 AM Nurse #6 checked the active physician orders for ezetimibe 10 mg and atorvastatin 40 mg and stated both were current orders administered nightly by the nurses. An interview conducted with the Medical Records Coordinator on 02/15/24 at 1:33 PM revealed she was responsible for scanning lab test results in the electronic medical record of residents. She revealed she was unable to find a lipid panel for Resident #25 after he was admitted to the facility on [DATE]. During a phone interview on 02/15/24 at 4:12 PM the MD stated a lipid panel was obtained every six months or annually for use of atorvastatin and ezetimibe. He revealed Resident #25 was taking both atorvastatin and ezetimibe to reduce cholesterol levels and would need a lipid panel for efficacy and to check liver function due to statin use can affect the liver and he was unsure how it was missed. During a phone interview on 02/15/24 at 4:35 PM the Supervisor for the Consultant Pharmacist stated a lipid panel was a standard lab obtained when using statin medications. He revealed the most recent lipid panel obtained for Resident #25 was on 12/2022 by the hospital. An interview was conducted on 02/16/24 01:30 PM with the Director of Nursing (DON). The DON revealed a lipid panel was a routine lab and she was unsure why it was not done for Resident #25. During an interview conducted on 02/16/24 at 1:38 PM the Administrator revealed he expected the appropriate labs were obtained for the use of medications that require monitoring.

Based on observations and staff interviews the facility failed to indicate the expiration date of thawed milkshakes in 2 of 2 nourishment rooms (Spark Unit and 100 Hall). This practice had the potential to affect beverage items served to residents. Findings included: 1. An observation of the Spark Unit nourishment room refrigerator on [DATE] at 3:43 PM revealed 8 thawed milkshakes sitting on a shelf. The manufacturer's instructions stamped on each carton of milkshake indicated the product was good for 14 days after being thawed. The milkshakes did not have a date indicating when they were placed in the refrigerator or when they expired. An interview with the Dietary Manager on [DATE] at 9:02 AM revealed dietary staff dated the milkshakes when they removed them from the walk-in freezer in the kitchen, and they were good for 14 days after being removed from the freezer. She explained the milkshakes were then placed in the nourishment room refrigerators by dietary staff. The Dietary Manager confirmed the milkshakes in the nourishment rooms had no date indicating when they were placed in the refrigerator to thaw or when they expired. An interview with the Administrator on [DATE] at 1:45 PM revealed he expected the milkshakes to have a pull date when they were placed in the walk-in cooler and be provided to residents as needed before the 14-day expiration date. 2. An observation of the 100 Hall nourishment room refrigerator on [DATE] at 3:09 PM revealed 8 thawed milkshakes sitting on a shelf. The manufacturer's instructions stamped on each carton of milkshake indicated the product was good for 14 days after being thawed. The milkshakes did not have a date indicating when they were placed in the refrigerator or when they expired. An interview with the Dietary Manager on [DATE] at 9:02 AM revealed dietary staff dated the milkshakes when they removed them from the walk-in freezer in the kitchen, and they were good for 14 days after being removed from the freezer. She explained the milkshakes were then placed in the nourishment room refrigerators by dietary staff. The Dietary Manager confirmed the milkshakes in the nourishment rooms had no date indicating when they were placed in the refrigerator to thaw or when they expired. An interview with the Administrator on [DATE] at 1:45 PM revealed he expected the milkshakes to have a pull date when they were placed in the walk-in cooler and be provided to residents as needed before the 14-day expiration date.

Based on record review and staff interview the facility failed to submit a request for an evaluation for an updated Preadmission Screening and Resident Review (PASRR) determination for a resident who was admitted to the facility with mental health disorders and received a change in treatment (Resident #37) for 1 of 2 residents reviewed for PASRR. The findings included: Record review of the North Carolina Medicaid Uniform Screening Tool (NC MUST) inquiry document dated 05/08/21 revealed Resident #37 had a Level I PASRR effective 05/08/21. There were no requests for a Level II PASRR evaluation submitted or completed since 05/08/21. Resident #37 was admitted to the facility on [DATE] with diagnosis that included vascular dementia severe with mood disturbance, bipolar disorder, delusional disorders, psychological and behavioral factors associated with disorders or diseases classified elsewhere. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #37 had not been evaluated by Level II PASRR and determined to have a serious mental illness, intellectual disability or other related condition. Resident #37 received antipsychotic medication on a routine and as needed basis. Record review of the physicians' orders for Resident #37 revealed in part an order dated 12/30/23 for RisperDAL Consta Intramuscular Suspension Reconstituted Extended Release (antipsychotic medication) 37.5 milligrams (MG) Injection intramuscularly one time a day every 14 day(s) for behavioral and psychological symptoms of dementia (BSPD). Record review of the medication administration records (MAR) from December 2023 to February 2024 revealed it was documented that Resident #37 was administered RisperDAL Consta Intramuscular Suspension Reconstituted Extended Release 37.5 milligrams (MG) Injection intramuscularly per the physician's order. An interview on 02/16/24 at 9:27 AM with the Admission/ Marketing Director/ Interim Social Services revealed that she received PASRR training from the Admissions Director at the time and corporate support person who is no longer with the company. She stated the former social worker would do monthly audits. MDS will notify her of significant changes which triggers her to request a level II PASRR as well as communication from nursing staff about significant changes. She stated that she attends the morning meeting but does not always stay for the clinical interdisciplinary team (IDT). She stated that if she did stay for the clinical IDT portion of the daily morning meeting it would help with her needing to know if residents should be considered for a level II evaluation. She feels that Resident #37 not receiving a level II evaluation after her change in treatment was just overlooked and that she would get it fixed. An interview on 02/16/24 at 1:38 PM with the Administrator revealed he expected the person responsible for monitoring Level II PASRRs to submit requests for evaluation when appropriate.

Based on observations, record review, interviews with the Responsible Party and staff the facility failed to assess the risk of entrapment after the placement of an alternating pressure air mattress for a cognitively impaired resident dependent on staff for bed mobility (Resident #27) and failed to complete the bed rail assessment and obtain informed consent from the Responsible Party (Resident #28) for 2 of 3 residents reviewed for bed rails. Findings included: 1. Resident #27 was admitted to the facility on [DATE] with diagnoses including dementia and chronic obstructive pulmonary disease. A physician's order with a start date of 03/28/22 with directions to validate the settings of the alternating pressure air mattress. Review of the alternating pressure air mattress operation manual for the type used on the bed of Resident #27 revealed no warnings or contraindications for use with bed rails. The care plan focus area for bed rails revised on 09/05/23 indicated Resident #27 required the use of bilateral bed rails to increase or maintain her current level of bed mobility for turning and repositioning. Interventions included reviewing the risks and benefits for the use of bed rails with the resident and/or resident's representative. The care plan focus area for skin breakdown revised on 09/07/23 was for the placement of a winged tipped air mattress on the bed of Resident #27 with interventions including to validate the pressure setting on the winged tipped air mattress. Review of the bed rail assessment dated [DATE] indicated alternatives tried prior to placing included rehab, positional devices, review of medications, and pain management. The benefits listed for the use were to promote dignity and prevent transfer without assistance. The assessment indicated there were no risks for the use of bed rails and an attempt to notify the Responsible Party (RP) of Resident #27 was made by leaving a voicemail to return the call. The quarterly Minimum Data Set assessment dated [DATE] indicated Resident #27's cognition was severely impaired and extensive assistance was needed for bed mobility. No falls had occurred since the previous MDS assessment and bed rails were not used as a restraint. Review of the bed rail assessment dated [DATE] revealed the questions including what alternatives were tried, what were the risk and benefits, and was the risk, benefits, and alternatives explained to the Responible Party (RP) of Resident #27 and the RP was notified were left blank. None of the questions were completed on the assessment for the use of bed rails. During an observation on 02/12/24 at 12:22 PM Resident #27 was in bed with bilateral quarter bed rails in the up position. A winged tipped alternating pressure air mattress was in place with the setting lights on to indicate it was functioning. There was a gap between the air mattress and bed rail of approximately 3 to 4 inches wide on one side of bed. An observation and interview were conducted on 02/15/24 at 9:46 AM with Resident #27. Resident #27 was in bed with bilateral bed rails in the up position with the alternating pressure air mattress functioning. Attempts to ask Resident #27 about her ability to use the bed rail were unsuccessful. Resident #27 stated she could hear the questions but did not understand what was being asked. During an interview on 02/15/24 at 9:56 AM Nurse Aide (NA) #2 stated Resident #27 required extensive 1-person assist with bed mobility and was able to grab hold of the bed rail and hold on during care. NA #2 was unsure if Resident #27 was able to use the bed rail to reposition when in bed without assistance from staff. An interview was conducted on 02/15/24 at 10:09 AM with the Maintenance Assistant. The Maintenance Assistant revealed the facility used a computer system that generated tasks to inspect bed rails, but he was not sure how frequently the safety inspections were done. He revealed Housekeeping was responsible for placing the air mattress on the bed and maintenance was responsible for bed rail safety inspections. He revealed bed rail safety inspections were done to ensure they properly attach to the bed frame and lock in place when moving up and down. He stated he did not officially check for gaps between the mattress and bed rails and was not made aware a safety check needed to be done when a mattress was replaced including an alternating pressure air mattress. During an interview on 02/15/24 at 11:42 AM the Maintenance Director stated nursing made the initial request to install bed rails and maintenance was responsible for installation and monthly safety checks. He revealed the facility used a computer maintenance system that generated a list of tasks to complete for bed rail safety checks that included proper function but did not specify to check for gaps between the mattress and bed rail or complete if the mattress was replaced including an alternating pressure air mattress. The Maintenance Director revealed the computer-generated bed rail safety check printed in way that made it difficult to read when the last bed rail safety check was done for Resident #27. An interview was conducted on 02/16/24 at 11:17 AM with Director of Nursing (DON). The DON stated bed rail assessments were done upon admission, quarterly, and when the resident had a change of condition. The DON stated Resident #27 used the bed rails to grab hold of when nursing staff were doing care, but she was unsure if caught against the bed rail Resident #27 was physically able to move away from it. The DON revealed the assessment dated [DATE] was not completed and Resident #27 was not assessed for the risk of entrapment. The DON stated she would expect the assessment on 01/17/24 to be completed and include information about alternatives tried, the risk and benefits, and that the risk, benefits, and alternatives were explained to the RP and consent was obtained. The DON revealed a bed rail assessment was not done when the alternating pressure air mattress was put on the bed of Resident #27, and she was not aware an assessment was needed to assess the risk of entrapment when the air mattress was placed. During an interview on 02/16/24 at 1:42 PM the Administrator stated bed rail assessments were done upon admission, quarterly, and if there was a change in the resident's condition. He stated it was the responsibility of the nurses to complete the bed rail assessments and was his expectation they were done. The Administrator revealed he was not aware an assessment should be completed for the risk of entrapment after the placement of an alternating pressure air mattress for a cognitively impaired resident. He revealed a tool could be utilized to check for gaps between the mattress and bed rail and he was checking on obtaining one to include on the safety inspections and the possibility of paper documentation for easier access of the inspections. 2. Resident #28 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease. The bed rail assessment completed on 10/05/22 indicated quarter rails were in place to enhance independence with bed mobility and assist with turning and repositioning and that the risk, benefits, and alternatives were explained to the RP. The most current bed rail assessment was completed on 03/17/23. The assessment indicated quarter rails were in place to enhance independence with bed mobility and assist with turning and repositioning. The assessment included information that the risk, benefits, and alternatives were explained to the RP. No other bed rail assessments were completed after 03/17/23. The care plan focus area for bed rails revised on 06/28/23 indicated Resident #28 required the use to increase or maintain the current level of bed mobility or ability to safely transfer. Interventions included evaluate the continued use for effectiveness and appropriateness, the use of bedrails to assist resident to turn and reposition when in bed and to increase the ability to enter and exit the bed independently or at the highest mobility level. The quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident #28 cognition was severely impaired and extensive assistance was needed for bed mobility. No falls had occurred since the previous MDS assessment and bed rails were not used as a restraint. Observations on 02/13/24 at 9:45 AM and 02/15/24 at 9:43 AM revealed Resident #28 was not in her room. Bilateral bed rails were secured in place on the bed and locked in the up position. An interview was conducted with the RP of Resident #28 on 02/13/24 at 11:25 AM. The RP stated she did not recall being told about the risk or benefits for the use of bed rails. The RP stated Resident #28 was able to use the rails for bed mobility to reposition without the assistance of nursing staff. An interview was conducted on 02/16/24 at 10:53 AM with Nurse #4 who was assigned to provide care for Resident #28. Nurse #4 revealed Resident #28 used the bed rails for mobility and repositioning. She revealed Resident #28 was able to sit at the edge of the bed and stand up using the bed rail to assist and could safely use the rails. Nurse #4 stated the nurses were responsible for completing bed rail assessments and were done on admission, quarterly, and as needed if the resident had a significant change in condition or decline in their mobility. An interview was conducted on 02/16/24 at 11:17 AM with the DON. The DON stated bed rail assessments were done upon admission, quarterly, and when the resident had a change of condition. She confirmed the most recent two bed rail assessments for Resident #28 were completed on 10/05/22 and 03/17/23. The DON did not know why the bed rail assessments were not completed after 03/17/23. During an interview on 02/16/24 at 1:42 PM the Administrator stated bed rail assessments were done upon admission, quarterly, and if there was a change in the resident's condition. He stated it was the responsibility of the nurses to complete the bed rail assessments and was his expectation they were done.

Based on record review, observations, and staff interviews, the facility failed to maintain a medication error rate of less than 5% as evidenced by 1 medication given without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #28). The findings included: 1. Resident #7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] An observation was made on 6/15/2022 at 8:50 AM of Nurse #1 while she prepared and administered Resident #7's medications. Nurse #1 did look at the Medication Administration Record (MAR) while she prepared the medications which included [MEDICATION(S)] powder 17 grams (medication used to relieve symptoms of constipation) that she pulled from the house stock and mixed in water. Nurse #1 administered the medications which included the [MEDICATION(S)] powder to Resident #7. Resident #7's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview along with an observation of Resident #7's MAR and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #7's MAR or in the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #7 without an order. Nurse #1 further stated Resident #7 used to have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #7, but that was not an excuse for giving the medication without an order. An interview was conducted with the Director of Nursing (DON) on 6/15/2022 at 1:17 PM and revealed Nurse #1 should not have given Resident #7 [MEDICATION(S)] powder without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with the Medical Director (MD) on 6/15/2022 at 2:43 PM which revealed the [MEDICATION(S)] powder should not have been administered to Resident #7 without an order. The MD stated he did not feel there would be any harm to Resident #7 from receiving the [MEDICATION(S)] powder. 2. Resident #28 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #28's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation was made on 6/15/2022 at 11:55 AM of Nurse #2 while she prepared and administered Resident #28's medications. Nurse #2 did look at the Medication Administration Record (MAR) while she prepared the medications which included [MEDICATION(S)] alcohol solution. Nurse #2 was observed to instill 1 drop into both eyes of Resident #28. An interview was conducted with Nurse #2 on 6/15/2022 at 12:27 PM in which Nurse #2 stated she had only instilled 1 drop of the eye drop into Resident #28's eyes because she did not realize Resident #28 was supposed to get 2 drops in both eyes. Nurse #2 further stated she had not read the order very well and had assumed Resident #28 was only supposed to receive 1 drop in both eyes. An interview was conducted with the Director of Nursing (DON) on 6/15/2022 at 1:17 PM which revealed Nurse #2 should have read the orders on the MAR and given the eye drop according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] An interview was conducted with the Medical Director (MD) on 6/15/2022 at 2:43 PM which revealed the MD did want the medications to be given as they have been ordered and Resident #28 probably should have received 2 drops of the eye drop in both eyes. The MD revealed staff should be checking the orders and looking at the details of the order when administering medications.

Based on record review and staff interviews, the facility failed to provide a CMS- SNF ABN (Centers for Medicare and Medicaid Services Skilled Nursing Facility Advanced Beneficiary Notice) prior to discharge from Medicare Part A skilled services to 2 of 3 residents reviewed for beneficiary protection notification review (Residents #16 and #52). Findings included: 1. Resident #16 was admitted to the facility on [DATE]. A review of the medical record revealed a CMS- Notice of Medicare Non-Coverage letter (NOMNC) was discussed with Resident #16's Responsible Party (RP) on 6/1/22 which indicated Medicare Part A coverage for skilled services would end on 6/7/22. Resident #16 remained in the facility. A review of the medical record revealed a CMS- SNF ABN was not provided to Resident #16 or her RP. An interview was conducted with the Business Office Manager on 6/14/22 at 2:38 PM. The Business Office Manager revealed he was not aware that the resident and/or their RP should be given a SNF ABN in conjunction with the NOMNC. The Business Office Manager confirmed Resident #16 nor her RP was issued a SNF ABN. An interview was conducted with the Administrator on 6/14/22 at 4:33 PM. The Administrator stated she expected whatever form that was required should be completed and she had just become aware the SNF ABN form should have been issued to the resident and/or their RP as of that day. 2. Resident #52 was admitted to the facility on [DATE]. A review of the medical record revealed a CMS- Notice of Medicare Non-Coverage letter (NOMNC) was discussed with Resident #52 on 3/31/22 which indicated Medicare Part A coverage for skilled services would end on 4/4/22. Resident #52 remained in the facility. A review of the medical record revealed a CMS- SNF ABN was not provided to Resident #52. An interview was conducted with the Business Office Manager on 6/14/22 at 2:38 PM. The Business Office Manager revealed he was not aware that the resident and/or their RP should be given a SNF ABN in conjunction with the NOMNC. The Business Office Manager confirmed Resident #52 was not issued a SNF ABN. An interview was conducted with the Administrator on 6/14/22 at 4:33 PM. The Administrator stated she expected whatever form that was required should be completed and she had just become aware the SNF ABN form should have been issued to the resident and/or their RP as of that day.

Based on record review and staff interviews, the facility failed to clarify the code status for 1 of 1 resident reviewed for advanced directives (Resident #37). Findings included: Resident #37 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #37's Electronic Medical Record (EMR) revealed a physician's orders [REDACTED]. Resident #37's advanced directive care plan, last revised on [DATE], revealed a focus of end of life/planning directives: Full Code/Hospice with the goal his wishes would be honored. Interventions included Full Code and for staff to review code status quarterly and at care plan meetings. The significant Minimum Data Set ((MDS) dated [DATE] assessed Resident #37 with severe impairment in cognition. The MDS noted Resident #37 had a prognosis of a life expectancy of less than 6 months and received hospice services. Resident #37's paper medical record revealed a Resident Request Do Not Resuscitate (DNR) Form signed by Resident #37's guardian on [DATE] authorizing facility staff to withhold CPR in the event of an emergency situation. Further review revealed a DNR form signed by the Nurse Practitioner (NP) with an effective date of [DATE] and no expiration date. During an interview on [DATE] at 9:16 AM, Nurse #1 stated she referred to the advanced directive information documented in the resident's EMR when determining code status. Nurse #1 reviewed Resident #37's EMR and confirmed his code status was listed as Full Code. During an interview on [DATE] at 2:30 PM, the Social Worker (SW) explained he reviewed a resident's code status quarterly and/or during care plan meetings and initiated code status changes when hospice services were elected if the resident was a Full Code or requested by the resident or their family. He added once the DNR form was signed, he gave the form to the Nurse to write the order and update code status in the resident's EMR. He confirmed Resident #37 was listed as a Full Code in his EMR and reported he was working on getting a DNR form signed by the facility's physician. The SW was unaware a DNR form, signed by the NP with an effective date of [DATE], was in Resident #37's paper medical record. During an interview on [DATE] at 3:12 PM, the Director of Nursing (DON) stated the SW typically reviewed a resident's code status during quarterly care plan meetings or as needed and nurses were responsible for getting a signed physician's orders [REDACTED]. The DON was unsure who had placed the DNR form dated [DATE], which was signed by the NP, in Resident #37's paper medical record without updating the physician's orders [REDACTED]. The DON added she reviewed physician orders [REDACTED].#37's code status from a full code to a DNR was missed.

Based on record review and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) in the areas of Hospice (Resident #79) and Falls (Resident #60) for 2 of 5 residents whose MDS assessments were reviewed. The findings included: Resident #79 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. She was re-admitted on [DATE] with a [DIAGNOSES REDACTED]. A physician's orders [REDACTED].>Resident #79's Care Plan updated on 01/28/20 revealed that Resident #79 family had chosen Hospice Care Services for End of Life Care related to decline of [MEDICAL CONDITION]. Resident #79's significant change MDS dated [DATE] revealed the resident was not coded as having received Hospice care. An interview with the MDS nurse on 03/11/2020 at 8:52 AM revealed that a significant change MDS would occur for major injury, Hospice, decline in health, or at least 2 declines with activities of daily living and must be done within 14 days after acknowledgement of change. She reported that Hospice should have been coded on any MDS and that it was a mistake that Hospice was not coded on the resident's 02/12/20 significant change MDS. An interview with the Director of Nursing (DON) on 03/11/20 at 11:22 AM revealed that there was a process for significant change MDS that included change in status, doctor decision, change in family dynamics, Hospice, other health related changes that would impact the resident. She reported that Hospice should have been coded in Section O of the significant change MDS and thereafter and in the case of Resident #79, it was an error that it was not coded. An interview with the Administrator on 03/12/2020 at 3:24 PM revealed that clearly the 02/12/20 significant change MDS for Resident #79 was because of the order for Hospice and believed it was a clerical error. Her expectation was for the MDS staff to follow the Clinical Guidelines for MDS. 2. Resident #60 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of the nurse progress notes for Resident #60 revealed the following entries: · 12/22/19 read in part, Resident #60 was found in her room, sitting on the floor between the wall and bed. Resident #60 was assessed with [REDACTED]. · 01/17/20 read in part, Resident #60 was found on the floor of her room in a seated position with no visible injuries noted upon nurse assessment. The quarterly MDS assessment dated [DATE] assessed Resident #60 with no memory impairment and independent with making decisions regarding tasks of daily life. The MDS noted Resident #60 displayed no behaviors and required extensive staff assistance with bed mobility and transfers. It was further noted she had no falls during the MDS assessment period. During an interview on 03/11/20 at 4:47 PM, the MDS Coordinator confirmed Resident #60 had 2 documented falls that occurred after the MDS assessment dated [DATE] that should have been coded on the MDS assessment dated [DATE]. The MDS Coordinator stated when reviewing Resident #60's medical record to code the MDS assessment, they had overlooked the falls documented in the nurse progress notes. She added a modification of the MDS assessment dated [DATE] would be submitted to accurately reflect Resident #60 had 2 falls with no injuries since the previous MDS assessment. During an interview on 03/12/20 at 3:39 PM, the Director of Nursing (DON) confirmed she was aware of the issues identified with MDS accuracy and felt it was an honest mistake on the part of the MDS Coordinator who simply overlooked the documented falls for Resident #60 when completing the MDS assessment. The DON stated she would expect for MDS assessments to be accuracy coded. During an interview on 03/12/20 at 4:24 PM, the Administrator stated resident falls were reviewed during daily meetings and felt the missed opportunity for coding Resident #60's falls on the MDS assessment dated [DATE] were due to human error. The Administrator stated she would expect for MDS assessments to be accurately coded.

Based on observations and staff interview, the facility failed to keep the trash compactor free of holes to prevent leaks, the compactor's door closed and area around the compactor free of accumulated medical waste and debris for 1 of 2 dumpsters observed. The findings include: Observations were conducted on 3/9/20 at 10:30 AM, on 3/10/20 at 10:30 AM, and on 3/11/20 at 10:30 AM, of the facility's automatic trash compactor. During each of these observations of the trash compactor an opaque fluid was leaking from the following three rusted areas; the front lower outer edge where the compactor's winch hook was located, the right back lower corner and an inaccessible area underneath the compactor. The fluid leaking from the trash compactor dripped onto the concrete pad the compactor was positioned on, drained down the pad's edges and onto the asphalt parking lot, where it collected and drained into the ground and into a depression in the parking lot. Here, the fluid had pooled to an area measuring approximately 2 feet wide and 4 feet in length. These observations also revealed the compactor's door was open and not securely fastened. The area around the trash compactor contained accumulated debris including; medical blue and white examination gloves, tinfoil, cleaning wipes, white and brown colored paper, hospital masks, assorted metal cans and plastic containers, alcohol pads, foam cups and containers, plastic wear, cardboard containers, smoking paraphernalia, medicine ointment tube, and a plastic syringe. An Interview conducted on 3/10/20 at 11:45 AM with the Director of Maintenance revealed that two months ago he had contacted the refuse contractor and complained the compactor was leaking and that the contractor told the Maintenance Director they would try to fix the leak as soon as possible, as the contractor only had one compactor and could not replace it with another compactor. An Interview and observations were conducted on 3/11/20 at 11:30 AM of facility's trash compactor and surrounding area with the facility's Administrator and Director of Maintenance. The Administrator stated the Director of Maintenance was responsible for managing the refuse for the facility and monitoring the disposable units, which included leaks, trash found around the compactor and on the grounds. During the observation the facility's Administrator expressed concerned regarding the amount of trash that was on the ground and the fluid leaking from the trash compactor. The Administrator requested the Director of Maintenance to immediately have his staff pick up and dispose of all the trash that was on the ground. The Administrator then contacted the refuse contractor to have the compactor immediately removed from the premises and have four additional refuse bins placed with daily refuse removal by the contractor until the compactor could be repaired and/or replaced.

Based on record review and staff and Physician interviews the facility failed to prevent a cognitively impaired resident from exiting the facility unsupervised into an enclosed courtyard resulting in a fall with a [MEDICAL CONDITION] for 1 of 3 residents reviewed for supervision to prevent accidents. Findings included: Resident #1 was admitted to the facility 09/03/18 with [DIAGNOSES REDACTED]. Resident #1's care plan for wandering and/or being at risk for unsupervised exit from the facility related to attempts to leave the unit if not prevented, cognitive impairment, and dementia last updated 03/08/19 revealed her goals were to have no episodes of unsupervised exits from the facility and to wander only within specified boundaries. Interventions included allowing resident to wander on the unit and approaching Resident #1 in a non-threatening manner. Resident #1's significant change Minimum Data Set ((MDS) dated [DATE] revealed she was severely impaired for cognition and did not have any episodes of wandering. A Wandering Risk Evaluation dated 03/08/19 revealed Resident #1 scored 16 on the evaluation and the follow up comment stated a wanderguard (a departure alert system) was placed on Resident #1's left ankle. The Wandering Risk Evaluation stated a resident who scored greater than 5 was at risk for wandering. A review of the medication list for Resident #1 revealed she received [MEDICATION NAME] (a medication that prevents platelets from forming blood clots) 75 milligrams (mg) daily at 8:00 AM. The incident report dated 06/05/19 at 8:50 AM completed by Nurse #1 revealed Resident #1 fell on the courtyard patio concrete. Resident #1 fell on to her right side and had a hematoma (bruise) to her right forehead and a laceration beside her right eye temporal (near the temple) area. Resident #1 was bleeding a large amount and was on a blood thinner. Resident #1 did not lose consciousness. A dressing and ice were applied to her forehead and Emergency Medical Service (EMS) was called for transport to the hospital. A Witness Statement from NA #1 regarding Resident #1's fall revealed a therapist (a physical therapy assistant and abbreviated as PTA) came to the dementia unit and asked where Resident #1 was located. NA #1 stated Resident#1 was at the far end of the unit. PTA #1 walked to the far end of the unit and stated Resident #1's chair was there but she was not. NA #1 walked over to PTA #1 and they began looking for Resident #1. NA #1 glanced over and saw Resident #1 on the ground outside the dementia unit. PTA #1 went outside to check on Resident #1 and NA #1 paged overhead the code for a fall. Review of Resident #1's medical record revealed a nurse's note dated 06/05/19 at 11:22 AM by Nurse #1 stated Resident #1 fell on the courtyard patio concrete on her right side. Resident #1 had a hematoma to her right forehead and a laceration beside her right eye and was bleeding a large amount. EMS came and transferred Resident #1 to the hospital. Review of Resident #1's EMS report dated 06/05/19 at 9:06 AM stated Resident #1 was found outside the Spark unit (dementia unit) lying on a concrete pad. Staff stated it was unknown why the resident was outside or why she fell . It was also unknown if the resident had lost consciousness. Review of Resident #1's hospital record dated 06/05/19 revealed she came to the Emergency Department after a fall with details unknown and had a laceration and bruising to the right side of her head. Resident #1 received sutures (stitches) to her [MEDICAL CONDITION] and was admitted to the Intensive Care Unit (ICU) with a [DIAGNOSES REDACTED]. An interview with Nurse #1 on 06/11/19 at 11:20 AM revealed she was working in the dementia unit 06/05/19 on the 7:00 AM to 3:00 PM shift and was caring for Resident #1. Nurse #1 stated she had to leave the unit to obtain a medication for another resident when Resident #1 fell . Nurse #1 stated when she left the unit Nurse #2 stayed on the unit until she could return. Nurse #1 stated she heard the overhead code paged for a fall in the dementia unit and returned to the dementia unit. Nurse #1 stated when she returned to the dementia unit Resident #1 was outside on the patio ground lying on her right side and her head was bleeding. Nurse #1 stated a dressing and ice were applied to Resident #1's head wound and 911 was called. PTA #1, NA #1, and Nurse #2 were with Resident #1. Nurse #1 stated the double doors at the end of the dementia unit were to remain locked at all times and she was not sure how Resident #1 was able to exit the dementia unit unsupervised. Nurse #1 stated she had not seen anyone enter or exit through the double doors at the end of the dementia unit on 06/05/19 prior to Resident #1's unsupervised exit and fall. Nurse #1 stated she could not recall for certain the last time she saw Resident #1 prior to her unsupervised exit from the unit the morning of 06/05/19 but she had already taken her morning medications. An interview with NA #1 on 06/11/19 at 12:13 PM revealed she was working in the dementia unit on 06/05/19 and was caring for Resident #1. NA #1 stated she was looking at the shower list on the dementia unit with Nurse #2 when PTA #1 entered the unit and asked where Resident #1 was. NA #1 stated Resident #1 was at the far end of the room. PTA #1 went to the end of the unit and said Resident #1's chair was there but she was not. NA #1 stated she went to the far end of the dementia unit to help PTA #1 look for Resident #1. NA #1 stated she glanced at the double doors at the end of the dementia unit and saw Resident #1 outside lying on the patio concrete. PTA #1 went out to check on Resident #1 and NA #1 paged the code for a fall overhead. NA #1 stated Nurse #2 also went out to check on Resident #1. NA #1 stated she did not know how Resident #1 got outside the dementia unit because the double doors at the end of the unit were to be locked at all times and required a key code to be opened. NA #1 stated only staff had the key code to the double doors. NA #2 stated she could not recall for sure the last time she saw Resident #1 before she was found outside the morning of 06/05/19 but she had eaten breakfast in the common area around 7:30 AM that morning. NA #1 stated no one had entered or exited the dementia unit through the double doors prior to Resident #1's unsupervised exit and fall on 06/05/19 that she was aware of. An interview with PTA #1 on 06/11/19 at 12:24 PM revealed he entered the dementia unit the morning of 06/05/19 and asked NA #1 where Resident #1 was. NA #1 stated Resident #1 was close to the end of the unit near the double doors in her wheelchair. PTA #1 stated Resident #1's wheelchair was empty and he told NA #1 he did not see Resident #1. PTA #1 and NA #1 started looking for Resident #1 and saw her outside the dementia unit on the ground in the patio area. PTA #1 stated he went outside to check on Resident #1. PTA #1 stated when opened the door to the patio area he did not have to put in a key code to open the door and the door opened easily. An interview with the Maintenance Director on 06/11/19 at 12:36 PM revealed there were 3 doors alarmed for the wanderguard system and they were the front door to the facility, a service door near the laundry room, and double doors on a unit that did not house residents. He stated the dementia unit was not connected to the wanderguard system. The Maintenance Director stated the double doors on the dementia unit were locked by a key pad magnetic lock. The Maintenance Director stated he was asked to check the double doors at the end of the dementia unit on 06/05/19 after Resident #1 was found outside. He stated he could not find any problems with the double doors on 06/05/19. The Maintenance Director stated he was asked to check the double doors again on 06/07/19 and when the left double door was allowed to close slowly it did not lock properly. He stated he determined the magnetic lock on the left double door was not contacting all the way when the door was allowed to close slowly. The Maintenance Director stated he tightened up a loose screw on part of the locking mechanism of the left double door and then the door closed correctly on 06/07/19. The Maintenance Director stated prior to Resident #1 being found outside he was not aware of any concerns with the double doors on the dementia unit not closing correctly. An interview with the former Maintenance Director on 06/11/19 at 12:57 PM revealed the double doors on the dementia unit were secured with a magnetic key code lock and were not supposed to be able to be unlocked or opened without a key code. The former maintenance director stated he was not aware of any problems with double doors on the dementia unit prior to Resident #1's unsupervised exit and fall on 06/05/19. An interview with Nurse #2 on 06/11/19 at 2:23 PM revealed she came to the dementia unit the morning of 06/05/19 to check the shower list. Nurse #2 stated she was talking with NA #2 when PTA #1 came to the dementia unit and asked where Resident #1 was. She stated NA #1 told PTA #1 Resident #1 was at the other end of the common room. Nurse #2 stated she left the dementia unit and then heard the code for a fall paged overhead. Nurse #2 stated she immediately returned to the dementia unit and saw Resident #1 outside on the ground in the patio area. Nurse #2 stated she stayed with Resident #1 and applied a pressure dressing and ice to her head. Nurse #2 stated the double doors were already open when she exited the dementia unit to assist Resident #1 due to staff going back and forth outside while assisting Resident #1. An interview with NA #2 on 06/11/19 at 3:40 PM revealed he was assigned to the dementia unit on 06/05/19 for the 7:00 AM to 3:00 PM shift. NA #2 stated he had just returned to the unit from either being on break or taking laundry to housekeeping when he saw several staff members gathered around Resident #1 outside in the courtyard. NA #2 stated he stayed on the dementia unit caring for the other residents while other staff attended Resident #1. NA #2 stated he did not recall the last time he saw Resident #1 the morning of 06/05/19 prior to her unsupervised exit and fall and he was not aware of anyone entering or exiting the dementia unit through the double doors prior to Resident #1's fall 06/05/19. An interview with the Director of Nursing (DON) on 06/11/19 at 4:11 PM revealed the double doors on the dementia unit were to be locked at all times. After Resident #1 was sent to the hospital 06/05/19 maintenance was asked to check the double doors at the end of the dementia unit. The Maintenance Department did not find any concerns with the double doors on 06/05/19. The DON stated Maintenance was asked to check the double doors of the dementia unit again on 06/07/19 and found there was a loose bolt on 1 of the doors and he corrected that. The DON stated an investigation was conducted by the Administrator regarding Resident #1's unsupervised exit and fall but no one knew how she got out of the dementia unit. The Administrator was unavailable for interview during the survey. An interview with the Physician on 06/12/19 at 11:49 AM revealed Resident #1 was at risk for wandering due to her [DIAGNOSES REDACTED].

Based on record review and staff and Physician interviews the facility failed to use a mechanical lift to safely transfer a resident for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). Two staff were in the process of manually transferring Resident #1 and had to lower her to the floor. Resident #1 complained of knee pain and the following day was diagnosed at the hospital with a fractured right leg. Findings included: Resident #1 was admitted to the facility 03/03/17 with [DIAGNOSES REDACTED]. Resident #1's Resident Care Guide last updated 02/07/19 revealed she was to be transferred via a mechanical lift. Resident #1's care plan for transfer last updated 02/22/19 revealed Resident #1 required assistance with transfers related to a fracture of her right hip, lack of strength, physical limitations, and unsteady gait. The goal was for Resident #1 to receive the necessary physical assistance to transfer daily. Interventions included transferring Resident #1 with a mechanical lift, showing her how to position her body parts when transferring, and monitoring her for safety awareness. Resident #1's quarterly Minimum Data Set ((MDS) dated [DATE] revealed she was severely cognitively impaired and was completely dependent for transfers. Resident #1's medical record revealed a nurse's note dated 04/16/19 at 10:53 PM written by Nurse #1 which stated she received a report from another nurse that Resident #1 was in the floor in the shower room. When Nurse #1 entered the shower room Resident #1 was sitting on her buttocks with a nurse aide (NA) supporting her from behind. Staff reported they were transferring Resident #1 from her chair to the shower chair and could not hold her up so they lowered her to the floor. Resident #1 was assessed and no apparent injury was noted but Resident #1 did complain of right knee pain. No [MEDICAL CONDITION] (swelling) or discoloration was noted to Resident #1's knee. Resident #1 was assisted with using the mechanical lift. The Physician was notified and gave a new order to obtain a mobile x-ray and have the clinician follow-up with a knee assessment when in the building the following day. Nurse #1 was unavailable for interview during the survey. The incident report dated 04/16/19 revealed staff lowered Resident #1 to the floor during transfer. Interventions put into place post incident included reviewing care guide access, in-servicing staff to use the mechanical lift, and obtaining a mobile x-ray of Resident #1's right knee. A review of the Resident Incident Witness Statement dated 04/16/19 and written by NA #1 revealed Resident #1 was lowered to the floor during transfer. The statement revealed Resident #1 reported her knee was hurting but asked to go ahead with her shower. An interview with NA #1 on 06/04/19 at 5:56 PM revealed she and NA #2 were caring for Resident #1 the evening of 04/16/19. NA #1 stated she and NA #2 wheeled Resident #1 to the shower room in her wheelchair. NA #1 stated she and NA #2 were supporting Resident #1 under each arm to move Resident #1 from the wheelchair to the shower chair. The NA stated Resident #1 began to slip during the transfer and was lowered to the floor. During the process of Resident #1 being lowered to the floor her right leg ended up underneath her. NA #1 stated she was not sure who straightened out Resident #1's leg from underneath her. The NA stated she sent NA #2 to notify the nurse of the fall while she stayed with Resident #1 and supported her back. NA #1 stated she and NA #2 did not look at the Resident Care Guide before transferring Resident #1. NA #1 stated she should have looked at the Resident Care Guide before transferring Resident #1 and she was not sure why she did not. The NA stated she had cared for Resident #1 previously and was not aware she needed to be transferred with a mechanical lift. A Resident Incident Witness Statement was not completed by NA #2 for Resident #1's 04/16/19 incident. NA #2 was not available for interview during the survey. An interview with Nurse #2 on 06/03/19 at 12:50 PM revealed she was called to the shower room when Resident #1 fell because Nurse #1 (the nurse assigned to Resident #1) was busy. She stated when she entered the shower room on 04/16/19 Resident #1 was sitting on the floor. Nurse #2 stated Resident #1 complained of pain in her right knee but asked to complete her shower. Nurse #2 stated after Resident #1 was assessed she was transferred to the shower chair with a mechanical lift. She stated there was no mechanical lift in the shower room when she responded to the shower room and the NAs caring for Resident #1 stated they attempted to transfer Resident #1 from her chair to the shower chair without using the mechanical lift. An interview with Nurse #3 (charge nurse for the gray unit) on 06/03/19 at 2:47 PM revealed she was working the evening of 04/16/19 and was getting ready to leave when she was notified Resident #1 had a fall in the shower room. Nurse #3 stated she asked the 2 NAs caring for Resident #1 the evening of 04/16/19 what happened when Resident #1 fell and they both stated they transferred Resident #1 without using the mechanical lift. A nurse's note dated 04/17/19 at 8:22 AM written by Nurse #3 stated Resident #1 reported right knee pain after a fall during transfer on 04/16/19. Resident #1's right knee was bruised and swollen. New physician's orders [REDACTED].#1 to the hospital. Resident #1's medical record revealed she was seen in the Emergency Department on 04/17/19 because she fell at the facility and was assisted to the ground. Resident #1 was diagnosed with [REDACTED]. Orthopedics was consulted and recommended a knee immobilizer and follow up as an outpatient. Resident #1 was discharged back to the facility. An interview with the Director of Nursing (DON) on 06/03/19 at 3:49 PM revealed she expected staff to review the Resident Care Guide prior to transferring residents and to follow the Resident Care Guide for transfers. An interview with the interim Administrator on 06/03/19 at 5:10 PM revealed she completed the fall investigation after Resident #1's fall on 04/16/19. The interim Administrator stated NA #1 confirmed she and NA #2 transferred Resident #1 without using the mechanical lift. NA #1 stated she and NA #2 did not look at the Resident Care Guide to determine how Resident #1 transferred before transferring Resident #1. The Interim Administrator stated she did not talk to Nurse #1 after Resident #1's fall. She also stated NA #2 was not available for interview during the fall investigation because she never returned to the facility after 04/16/19. The interim Administrator specified she expected staff to review the Resident Care Guide prior to transfers and to follow the Resident Care Guide when transferring residents. An interview with the Physician on 06/03/19 at 6:04 PM revealed he expected staff to follow the Resident Care Guide for transfers.

Based on record review and staff interviews the facility failed to notify resident's responsible party of a fracture for 1 of 3 residents reviewed for notification (Resident #1) and failed to notify the resident's responsible party of a follow up appointment for 1 of 3 residents (Resident #1). Findings included: Resident #1 was admitted to the facility 03/03/17 with [DIAGNOSES REDACTED]., and lack of coordination. Review of Resident #1's care plan for transfer last updated 02/22/19 revealed Resident #1 required assistance with transfers. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was severely cognitively impaired and was completely dependent for transfers. Review of Resident #1's medical record revealed she was sent the hospital 04/17/19 after a fall at the facility where she was assisted to the floor on 04/16/19. Resident #1 was diagnosed with [REDACTED]. Resident #1 was to follow up with an Orthopedist as an outpatient. 1a. A telephone interview with Resident #1's responsible party on 06/03/19 at 10:47 AM revealed she was aware Resident #1 had been to the hospital on [DATE] after an assisted fall at the facility and had been wearing a knee immobilizer after the hospital visit. When Resident #1's responsible party visited Resident #1 on 05/13/19 she noticed Resident #1 was wearing a different knee immobilizer than she had seen before. She asked Resident #1 why she had a different knee immobilizer and Resident #1 told the responsible party she had a broken leg. The responsible party said she asked the charge nurse if Resident #1 had a broken leg and the charge nurse directed her to the Director of Nursing (DON). The DON told the responsible party Resident #1 was diagnosed with [REDACTED]. The responsible party stated she was not aware Resident #1 had a fractured leg until 05/13/19. An interview with the DON on 06/03/19 at 3:49 PM revealed Resident #1's responsible party came to her 05/13/19 and asked her why Resident #1 had a different knee immobilizer on than she had previously worn. The DON informed the responsible party that Resident #1 had a fracture with delayed healing of her right leg diagnosed on [DATE] and saw the Orthopedist 05/10/19. The Orthopedist changed the type of immobilizer Resident #1 wore. The DON stated she skimmed Resident #1's hospital record and did not see the part of Resident #1's hospital record which stated Resident #1 had an acute [MEDICAL CONDITION] leg tibial tubercle from the 04/17/19 hospital visit. The DON stated she told Resident #1's responsible party Resident #1 had a fracture of her right leg with delayed healing from the 04/17/19 hospital visit. The DON stated Resident #1's responsible party should have been notified she was diagnosed with [REDACTED]. An interview with the Administrator 06/04/19 at 10:21 AM revealed she expected residents' responsible party to be notified of fractures. 1b. A telephone interview with Resident #1's responsible party on 06/03/19 at 10:47 AM revealed she was aware Resident #1 had been to the hospital on [DATE] after an assisted fall at the facility and had been wearing a knee immobilizer after the hospital visit. When Resident #1's responsible party visited Resident #1 on 05/13/19 she noticed Resident #1 was wearing a different knee immobilizer than she had seen before. She asked Resident #1 why she had a different knee immobilizer and Resident #1 told the responsible party she had a broken leg. The responsible party said she asked the charge nurse if Resident #1 had a broken leg and the charge nurse directed her to the Director of Nursing (DON). The DON told the responsible party Resident #1 was diagnosed with [REDACTED]. The responsible party stated she was not aware Resident #1 had a fractured leg or had a follow up appointment with an Orthopedist until 05/13/19. Review of a nurse's note dated 05/10/19 written by Nurse #4 stated Resident #1 was to follow up with orthopedics on 05/10/19. An interview with Nurse #4 on 06/03/19 at 2:37 PM revealed she cared for Resident #1 on 05/10/19 and sent Resident #1 to her orthopedic appointment. Nurse #4 stated she thought the responsible party for Resident #1 was aware of the follow up appointment. An interview with Nurse #3 (a charge nurse) on 06/03/19 at 2:47 PM revealed there was previously no consent required from the responsible party for follow up appointments. Nurse #3 stated when the facility became aware of Resident #1's responsible party not being notified of the follow up appointment the facility developed a system for notifying responsible parties of follow up appointments. An interview with the DON on 06/03/19 at 3:49 PM revealed Resident #1's responsible party came to her 05/13/19 and asked her why Resident #1 had a different knee immobilizer on than she had previously worn. The DON informed the responsible party that Resident #1 had seen the Orthopedist for a follow up appointment 05/10/19. The Orthopedist changed the type of immobilizer Resident #1 wore. The DON stated Resident #1's responsible party should have been notified of the follow up appointment with the Orthopedist before going to the follow up appointment. An interview with the Administrator on 06/04/19 at 10:21 AM revealed she expected residents' responsible parties to be notified of follow up appointments.

Based on observations, record review, resident interviews, family interviews, staff interviews and physician interview, the facility failed to provide social services which followed up with families and/or residents in obtaining consent and payment for prescription glasses for 3 of 5 sampled residents. Resident #6 received prescription glasses 8 months following the original order and after expressing concern for the glasses and Residents #13 and #14 had no follow up to assist them in obtaining their prescription eyeglasses. The findings included: 1. Resident #14 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Her most recent annual Minimum (MDS) data set [DATE] coded her as having some cognitive impairment, scoring an 11 out of 15 on the Brief Interview for Mental Status. On 11/20/18 at 2:48 PM Resident #14 stated during interview that she recalled getting her eyes examined in the facility and she picked out the style of frames at the same time. She stated she has never heard anymore about her prescription glasses and has not received them. Resident #14 stated she was not told about any cost of the glasses or if she needed to do anything else to receive the prescription glasses. She further stated she would like to have the prescription glasses. At this time she was in the lounge not wearing any glasses. Review of Resident #14's medical record revealed her eyes were examined on 03/08/18. The evaluation included a Payment Worksheet which included a written prescription for eyeglasses and a cost associated with them of $126.00. The form included a statement that the glasses would be ordered and delivered to the resident upon full payment. The Minimum Data Sets dated 1/20/18, 4/22/18, 7/20/18 and 10/19/18 coded her as having adequate vision with glasses. Interview with the medical records staff on 11/20/18 at 9:40 AM revealed the social worker was responsible for contacting the family regarding necessary payment for the prescription glasses and then let the eye physician know if they could order the glasses. Interview with the Social Worker on 11/20/18 at 10:31 AM revealed that he was not the designated social worker at the time of the eye exam. He explained that the family should have been told there was a prescription for glasses and explained the payment process. He stated that he did not know why there was no follow up regarding the prescription glasses. An attempt to reach the former social worker by phone was unsuccessful. Review of the medical record revealed no documentation of any further communication with the resident or the family regarding the status of the prescription glasses. A phone interview was conducted on 11/20/18 at 1:55 PM with the physician who examined Resident #14 on 03/08/18. The physician stated that following the exam, the paperwork and payment needed was left with the facility so follow up could be made by the facility. Once payment was received, the physician would order the glasses and then deliver them to the facility. An attempt to call Resident #14's responsible party was unsuccessful. A follow up interview with the social worker on 11/20/18 at 2:34 PM revealed he found the list of who was seen on 03/08/18 in the previous social worker's office. He provided the list which indicated 9 residents were found to need prescription eye glasses, including Resident #14. He further stated he could not say if there had been any follow up with the residents/responsible parties regarding the prescription and monies needed to fill the prescriptions. Interview with the Administrator on 11/20/18 at 3:28 PM revealed that the eye physician comes to the facility and left the documentation which included any prescription and cost with medical records staff and the social worker after the evaluation. The social worker was responsible for following up with the resident/family including informing them of the cost of the glasses. Once the payment was received then the glasses would be ordered. The Administrator stated she believed the breakdown occurred because of a changes in social workers. She further stated she would have expected a social work note in the record to reflect steps taken in attempts to obtain the prescription glasses. A phone interview with Resident #14 on 11/28/18 at 11:45 AM revealed she used to wear glasses a long time ago but hasn't had any glasses in a very long time. She stated that because she does not have any glasses everything is blurry. The television is blurry and people she talks to are blurry. She further stated that it made her feel really bad that it has taken so long to get glasses. She still wants to get the glasses. 2. Resident #13 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The most recent Minimum Data Set, a quarterly dated 10/26/18 coded him with some cognitive impairment scoring a 12 out of 15 on the Brief Interview for Mental Status. During an interview on 11/20/18 at 3:20 PM, Resident #13 stated he had an eye exam a while ago. He stated he had picked out frames for the prescription but never got any glasses and never heard another word about it. Resident #13 stated no one ever discussed the need for money or what was further needed for him to do in order to obtain his prescription glasses. When asked if he was interested in still obtaining the glasses, he stated he was not sure how much money he had currently and stated he got money at the beginning of the month. At this time, Resident #13 was not wearing glasses. Review of the medical record revealed Resident #13 received an eye examination on 03/08/18. The evaluation included a Payment Worksheet which included a written prescription for eyeglasses and a cost associated with them of $86.00. The form included a statement that the glasses would be ordered and delivered to the resident upon full payment. Review of the Minimum Data Sets dated 1/24/18, 4/26/18, 7/27/18 and 10/26/18 he was coded as having adequate vision without glasses. Interview with the medical records staff on 11/20/18 at 9:40 AM revealed the social worker was responsible for contacting the family regarding necessary payment for the prescription glasses and then let the eye clinic know if they could order the glasses. Interview with the Social Worker on 11/20/18 at 10:31 AM revealed that he was not the designated social worker at the time of the eye exam. He explained that the family should have been told there was a prescription for glasses and explained the payment process. He stated that he did not know why there was no follow up regarding the prescription glasses. An attempt to reach the former social worker by phone was unsuccessful. Review of the medical record revealed no documentation of any further communication with the resident regarding the status of the prescription glasses. A phone interview was conducted on 11/20/18 at 1:55 PM with the physician who examined Resident #13 on 03/08/18. The physician stated that following the exam, the paperwork and payment needed was left with the facility so follow up could be made. Once payment was received, the physician would order the glasses and then deliver them to the facility. A follow up interview with the social worker on 11/20/18 at 2:34 PM revealed he found the list of who was seen on 03/08/18 in the previous social workers office. He provided the list which indicated 9 residents were found to need prescription eye glasses, including Resident #13. He further stated he could not say if there had been any follow up with the resident/responsible parties regarding the prescription and monies needed to fill the prescriptions. Interview with the Administrator on 11/20/18 at 3:28 PM revealed that the eye physician comes to the facility and left the documentation which included any prescription and cost with medical records staff and the social worker after the evaluation. The social worker was responsible for following up with the resident/family including informing them of the cost of the glasses. Once the payment was received then the glasses would be ordered. The Administrator stated she believed the breakdown occurred because of a changes in social workers. She further stated she would have expected a social work note in the record to reflect steps taken in attempts to obtain the prescription glasses. A phone interview was conducted on 11/28/18 at 11:48 AM with Resident #13. Resident #13 stated that he has not had any glasses for years. He stated that he can't see to read very long as his eyes get tired and sentences get blurry and run together. He further stated he was unable to see the television unless he was sitting up close to it. He still wants to get glasses and stated it bothers him that it has taken so long to get his glasses. 3. Resident #6 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The most recent Minimum (MDS) data set [DATE] coded her with cognitive impairment, scoring a 9 out of 15 on the Brief Interview for Mental Status. During interviews conducted with Resident #6 on 11/19/18 at 3:50 PM, on 11/20/18 at 9:26 AM and again on 11/20/18 at 1:09 PM, Resident #6 was observed to be alert and oriented and able to follow and engage thoroughly in the conversations. On 11/19/18 at 3:50 PM, Resident #6 was observed in bed watching television. She was observed to be wearing glasses at this time. Resident #6 stated that her glasses were brand new and she just received them last week. She further stated that it had taken 6 to 7 months to obtain the glasses following her eye examination and she could see well with them now. Review of the medical record revealed Resident #6 had her eyes examined on 03/08/18. The evaluation included a Payment Worksheet which included a written prescription for eyeglasses and a cost associated with them of $126.00. The form included a statement that the glasses would be ordered and delivered to the resident upon full payment. Review of the Minimum Data Sets dated 3/21/18, 6/20/18 and 9/03/18, she was coded as having adequate vision with glasses. Interview with the medical records staff on 11/20/18 at 9:40 AM revealed the social worker was responsible for contacting the family regarding necessary payment for the prescription glasses and then let the eye clinic know if they could order the glasses. Interview with the Social Worker on 11/20/18 at 9:07 AM revealed the ward clerk scheduled the eye exams and the physician came to the facility. He stated that for some reason, after the eye exam, the glasses were never ordered. He stated he was not in the role as the social worker at the time of her exam. He stated he came back to work at the facility in (MONTH) (YEAR). He was unaware of any problems with the eye exam or need for glasses until Resident #6's family started questioning when the resident was going to get her glasses. The Social Worker stated this was around mid (MONTH) (YEAR). He then contacted the eye physician, obtained the prescription for the eyeglasses presented 03/08/18 and subsequently obtained payment for them and ordered the glasses on 10/19/18. He stated Resident #6 received the glasses on 11/15/18. Upon follow up interview on 11/20/18 at 10:31 AM the social worker explained that the family should have been told there was a prescription for glasses and explained the payment process. He stated that he did not know why there was no follow up regarding the prescription glasses. An attempt to reach the former social worker by phone was unsuccessful. Family, who visited daily, was interviewed on 11/20/18 at 1:09 PM and revealed she was never informed there was a payment needed in order to obtain the glasses. Family stated there was a breakdown in the communication as she never was contacted by the former social worker about needing to pay. She stated she found out about the necessary payment when she spoke to the current social worker and asked him about the prescription and status of the glasses. A phone interview was conducted on 11/20/18 at 1:55 PM with the physician who examined Resident #13 on 03/08/18. The physician stated that following the exam, the paperwork and payment needed was left with the facility so follow up could be made. Once payment was received, the physician would order the glasses and then deliver them to the facility. Interview with the responsible party via phone on 11/20/18 at 2:13 PM revealed no one ever called him to inform him of the needed monies to purchase Resident #6's glasses. Interview with the Administrator on 11/20/18 at 3:28 PM revealed that the eye physician comes to the facility and left the documentation which included any prescription and cost with medical records staff and the social worker after the evaluation. The social worker was responsible for following up with the resident/family including informing them of the cost of the glasses. Once the payment was received then the glasses would be ordered. The Administrator stated she believed the breakdown occurred because of a changes in social workers. She further stated she would have expected a social work note in the record to reflect steps taken in attempts to obtain the prescription glasses.

Based on staff, Physician, Nurse Practitioner, and Medical Examiner interviews and medical record reviews the facility Administration failed to provide effective leadership and oversight of processes and policies and procedures to ensure that residents were provided basic nursing care and free from abuse for 3 of 3 residents reviewed for abuse, neglect, well being, notification of change, and medication administration (Resident's #2, #3, #20). Immediate Jeopardy began on 09/11/18 for Resident #2 when Nurse #4 did not notify the physician of the unavailability of the physician ordered insulin's which resulted in Resident #2 developing DKA. Immediate Jeopardy began on 09/22/18 for Resident # 20 when the facility failed to perform neurological checks per the facility's neurological guide after a fall from the bed to the floor and failed to communicate to the physician that the resident had an unwitnessed fall and was on a blood thinner. Immediate jeopardy began for Resident #3 on 10/1/18 when Nurse Aide (NA) #1 observed NA #8 forcibly trying to make Resident #3 sit down on the toilet and yelling at her for being soiled. Immediate Jeopardy was removed for Resident # 20 on 10/11/18 and 10/22/18 for Resident # 2 and Resident # 3 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee education and ensure monitoring systems in place are effective. The findings included: 1. This tag is cross referred to F 580: Based on staff interviews, Nurse Practitioner interview, and record reviews, the facility failed to notify the physician of the missing insulin medication which caused the resident to be sent to the hospital with diabetic ketoacidosis (DKA), a serious complication of diabetes, for 1 of 3 residents reviewed for notification of change (Resident #2). The failure of the facility to notify the physician resulted in Resident #2 not receiving the medications he needed to prevent admission to the hospital for DKA. Based on record review, staff, and Physician, the facility failed to communicate to the physician that the resident had an unwitnessed fall and was on a blood thinner for one of three sampled residents reviewed for notification of change. The failure of the facility to communicate an unwitnessed fall from bed to the floor and blood thinner use to the physician resulted in the high likelihood of serious injury or death (Resident #20). 2. This tag is cross referred to F 600: Based on record review and staff interviews the facility failed to protect a cognitively impaired resident from being handled roughly by a staff member for 1 of 3 residents reviewed for abuse (Resident #3). Based on record review, resident, staff, and Nurse Practitioner interviews the facility failed to administer insulin per physician order's or contact physician which caused the resident to be sent out to the hospital with diabetic ketoacidosis (DKA), a serious complication of diabetes, for 1 of 3 residents reviewed with insulin dependent diabetes (Resident #2). 3. This tag is cross referred to F607: Based on record review and staff interviews the facility failed to implement their abuse policy and procedures to protect the resident, report, and investigate an allegation of staff to resident abuse for 1 of 3 residents reviewed for abuse (Resident #3). 4. This tag is cross referred to F 684: Based on record review, staff, Physician and Medical Examiner interviews, the facility failed to perform neurological checks per the facility's neurological guide after a fall from the bed to the floor and failed to communicate to the physician that the resident had an unwitnessed fall and was on a blood thinner. This affected one of three sampled residents reviewed for assessment following an acute episode. The failure of the facility to assess Resident #20's neurological status per the facility's protocol and communicate an unwitnessed fall from the bed to the floor and blood thinner use to the physician resulted in the high likelihood of serious injury or death (Resident #20). Based on observations, record review, resident, staff, and Nurse Practitioner interviews the facility failed to administer insulin per physician order's which caused the resident to be sent out to the hospital with diabetic ketoacidosis (DKA), a serious complication of diabetes, for 1 of 3 residents reviewed with insulin dependent diabetes (Resident #2). 5. This tag is cross referred to F 760: Based on observations, record review, resident, staff, and Nurse Practitioner interviews, the facility failed to administer physician ordered insulin medication to keep residents free of significant medication errors in accordance with accepted professional standards and principles for 1 of 3 residents reviewed for pharmacy services (Resident #2). An interview conducted on 10/23/18 at 11:45 AM with the Director of Nursing (DON) revealed she was new to the facility and had been the DON for approximately two months. She stated she felt like there was facility wide breakdown in communication and education and that was the cause for the system failures that caused the deficient practice. An interview conducted on 10/23/18 at 11:55 AM with the Administrator revealed there had been a lack of communication between staff, administration, and the physician. She stated education needed to be provided to make sure facility policies and procedures were being followed so residents could be kept safe and appropriate care provided. On 10/11/18 at 3:49 PM the Director of Nursing and the Corporate Consultant were notified of Immediate Jeopardy for Resident # 20. On 10/18/18 administration was notified of additional immediate jeopardy for Resident # 2 and # 3. On 10/22/18 the facility provided an acceptable credible allegation of Immediate Jeopardy removal that included: Macon Valley Nursing and Rehabilitation Center was placed into Immediate Jeopardy on (MONTH) 19, (YEAR). 1. How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 9/11/18, Nurse #4 failed to follow the physician's orders [REDACTED].#2 as prescribed. On 9/12/18, Resident #2's blood glucose level continued to register as HI; the nurse practitioner gave an order to send Resident #1 to the hospital. The director of nursing (DON) failed to effectively implement training and monitoring processes to maintain Resident #2's highest practicable physical well-being. On 9/22/18, Nurse #1 and Nurse #2 failed to initiate neurological checks and properly inform the physician of Resident #20's change in condition after a fall. The DON failed to effectively implement training and supervision to ensure basic care was provided to attain Resident #20's highest practicable well-being. On 10/1/18, nursing assistant (NA) #1 abused Resident #3 when NA #1 held the resident to keep the resident from leaving the bathroom during incontinent care. NA #8 failed to follow the abuse policy when NA #8 did not intervene and immediately report NA #1's abuse of a resident. On 10/11/18 upon notification of abuse, the DON ensured Resident #3 was safe and initiated an abuse investigation. Upon completion of the investigation, the DON determined quality of life, quality of care, and resident abuse issues occurred due to staff not being properly trained, lack of supervision, and staff burnout. On 10/11/18 - 10/19/18, the DON and quality improvement (QI) nurse audited Resident #20's and Resident #2's Medication Administration Record [REDACTED]. The DON identified effective systems were not in place to maintain Resident #20's and Resident #2's highest practicable physical, mental, and psychosocial well-being. The reviews and audits revealed communication breakdowns within the nursing department created deficiencies in facility practices related to training on policies, following physician orders, notifying physician of changes, medication errors, and providing basic nursing care which neglected Resident #20's, and Resident #2's well-being. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice: On 10/19/18, the DON and staff facilitator (SF) initiated multiple in-services for 100% of appropriate staff to include RNs, LPNs, nursing assistants, geriatric care assistants, agency staff, housekeeping, laundry, dietary, therapy, and department heads regarding resident safety, neurological checks, abuse, neglect, and staff burnout. After 10/19/18, no staff, agency, or contracted staff will be allowed to work until the in-service is completed. The in-service with be added to new staff orientation, including agency and contracted staff. On 10/19/18, the DON, QI nurse or SF nurse began five day per week reviews of the nursing 24-hour report sheets for any new orders, notification of changes to the physician/NP in the progress notes, hypo/hyperglycemic episodes, neurological checks, and abuse/neglect. On 10/19/18, the administrator initiated multiple audit tools which will be completed by the administrative department heads (DON, QI nurse, SF, social worker, dietary, activities): the assistant dietary manager, activity director, and weekend manager-on-duty will complete supervision observations utilizing the Administrative Rounds tool, the social worker will complete weekly interviews with interviewable residents to ensure no abuse occurred. QI nurse/unit manager will complete five times per week the Insulin Audit Tool to ensure diabetic residents are receiving insulin as ordered by the physician and medication is available. On 10/22/18, the administrator, other department heads and corporate facility consultants began meeting during the interdisciplinary team (IDT) meeting to perform a root cause analysis using the 5-Whys process. Communication as evidenced by lack of information and lack of access to needed resources has been determined to be the root cause of why the facility failed to have resources and processes in place to administer basic nursing care and resident treatment to promote resident well-being. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not occur: On 10/11/18 - 10/15/18, the corporate nurse consultants mentored the administrator, DON, QI nurse and SF on where to find and access corporate policies, procedures, and action checklists. The corporate nurse consultants also assisted with drafting in-services to include: falls, neurological checks, blood glucose monitoring, insulin administration, and abuse/neglect. The purpose was to instruct facility staff to provide basic nursing care and treatment to residents in a manner which promotes well-being and respect. On 10/19/18, the DON, the QI nurse, and SF nurse initiated an education to set the DON's expectation for all registered nurses (RNs), and licensed practical nurses (LPNs). The expectation is blood glucose monitoring and insulin administration as ordered by the physician, checking the emergency drug kit (EDK) for a backup, and notification of the physician/NP. On 10/19/18, the administrator, DON, QI nurse, SF, Vice President of Operations and/or corporate consultant will review and analyze the audit tool results weekly, for six months to validate the facility has provided each resident with the means to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The administrator, DON, vice president, and/or corporate consultant will initial the bottom right corner of the audit tools with the date as validation of review. On-going mentoring with the administrator and administrative team will continue to be provided by the Vice President of Operations and/or consultant team at a minimum of at least monthly. On 10/20/18 and 10/22/18, the Vice President of Operations contacted the Quality Improvement Organization (QIO) and requested mentoring assistance monitoring recommendations. On-going mentoring will also be provided to the administrator and administrative team by the QIO beginning 10/26/18 during a facility visit. On 10/21/18, the corporate nurse consultant provided information on how a utilization of the cause and effect (fishbone) diagram, Pareto chart, and/or 5 Whys Root Cause Analysis (RCA) will be used to help the facility uncover the real causes for showers not being offered, incontinent care not provided, falls, neurological checks, blood glucose monitoring, insulin administration, and abuse/neglect to promote resident well-being and respect. The provided information and root-cause analysis tools will be used by the IDT and the QI committee to drill down to identify areas needing improvement. On 10/22/18, the administrator will begin working with the QIO to improve effective leadership and management and seek guidance on how changes leadership can make to implement a safe, healthy, and respectful environment for the residents. 4. How the facility plans to monitor its performance to make sure solutions are sustained (include dates when correction action will be competed). Beginning 10/11/18, the facility increased communication in the form of: verbal communication during in-services and daily interdisciplinary team (IDT) meetings, written education, posted reminders, and audit forms to ensure the facility provides residents with: medications as ordered, basic nursing care, dignity and respect and the means to resident well-being. The IDT, QI and QAPI committees will continue to monitor the facility to identify other factors causing the failure to communicate issues related stemming from training, staffing, basic nursing care, abuse/neglect, or supervision issues. Beginning 10/19/18, the DON, and QI nurse will present the in-service/mentoring comments, supervision observations, and audit trends to the IDT and monthly QI committee for six months. The IDT and QI committee will focus on improving residents' well-being, including the provision of medication as ordered and neurological checks through developing communication. The administrator and/or DON will present the daily IDT and monthly QI committee recommendations to the quarterly QAPI committee for additional recommendations for monitoring and continued compliance. The QAPI committee will continue consulting with the QIO until substantial compliance is achieved. The administrator will be responsible for implementing this plan of correction to ensure any issues of failure to provide a resident with dignity and respect or promote well-being will be addressed through additional root cause analysis, process correction, training, and monitoring. Macon Valley alleges compliance of removal of IJ as of 10/22/18. On 10/23/18 facility staff were interviewed and demonstrated they had been trained on QI. Immediate jeopardy was removed effective 10/22/18.

Based on staff interviews, Nurse Practitioner interview, and record reviews, the facility failed to notify the physician of the missing insulin medication which caused the resident to be sent to the hospital with diabetic ketoacidosis (DKA), a serious complication of diabetes, for 1 of 3 residents reviewed for notification of change (Resident #2). The failure of the facility to notify the physician resulted in Resident #2 not receiving the medications he needed to prevent admission to the hospital for DKA. Immediate Jeopardy began on [DATE] when Nurse #4 did not notify the physician of the unavailability of the physician ordered insulin's which resulted in Resident #2 developing DKA. Immediate Jeopardy was removed on [DATE] when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee education and ensure monitoring systems in place are effective. Based on record review, staff, and Physician, the facility failed to communicate to the physician that the resident had an unwitnessed fall and was on a blood thinner for one of three sampled residents reviewed for notification of change. The failure of the facility to comunicate an unwitnessed fall from bed to the floor and blood thinner use to the physician resulted in the high likelihood of serious injury or death (Resident #20). Immediate Jeopardy began on [DATE] for Resident # 20 when the facility failed to communicate to the physician that the resident had an unwitnessed fall and was on a blood thinner. Immediate Jeopardy was removed on [DATE] when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee education and ensure monitoring systems in place are effective. The findings included: 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the nurse practitioner (NP) progress note dated [DATE] indicated Resident #2 was seen on [DATE] after a capillary blood glucose (CBG) reading was 'HI'. The progress note indicated Resident #2 had also developed nausea and vomiting and he was clammy and anxious. An order was given by the NP to transfer the resident to the emergency department for possible diabetic ketoacidosis (DKA). Review of the nurse notes for [DATE] at 2:05 PM revealed the CBG taken at 7:30 AM read HI. The nurse gave Resident #2 12 units of regular insulin per physician admission orders [REDACTED]. The note further revealed Resident #2 was vomiting and not feeling well and was seen by the NP who wrote an order for [REDACTED]. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. A record review of the (MONTH) (YEAR) MAR further revealed Resident #2 received the physician ordered 6 units of regular insulin on [DATE] at 8:00 AM. Resident #2 also received 6 units of SSI regular insulin on [DATE] at 7:30 AM to cover a CBG of HI. Review of the Blood Glucose Monitoring Sheet for [DATE] for Resident #2 revealed the following readings: [DATE] 1:00 PM CBG 236 [DATE] 4:12 PM CBG 206 [DATE] 8:50 PM CBG 240 Per physician order [REDACTED].#2 should have received 2 units regular insulin on [DATE] at 4:30 PM. Per physician order [REDACTED].#2 should have received 2 units regular insulin on [DATE] at 8:30 PM. An interview with Nurse #4 on [DATE] at 9:06 AM revealed she did not give Resident #2 his physician ordered insulin's on [DATE] at 4:30 PM and [DATE] at 5:00 PM or [DATE] at 8:30 PM. She further stated she did not give Resident #2 his Detemir insulin scheduled for [DATE] at 9:00 PM. She stated she did not look for the insulin and just did not give it. An interview with the NP on [DATE] at 10:00 AM revealed she was unaware Resident #2 had not received his insulin's the evening before he was sent to the hospital. Further interview with the NP revealed her expectation was for the facility nurse to contact the on-call physician if the insulin was not available. An interview with Nurse #4 on [DATE] at 10:45 AM revealed she did not contact the on-call physician to notify them of the unavailability of insulin or for further orders. During an interview with DON on [DATE] at 4:05 PM she revealed she expected facility staff to contact the physician for all missing medications. On [DATE] at 8:30 AM the Director of Nursing and the Administrator were notified of Immediate Jeopardy via telephone. 1. How corrective action will be accomplished for those residents found to have been affected by the deficient practice: Resident #2 was admitted to the facility on [DATE], with a primary [DIAGNOSES REDACTED]. Resident #2 had insulin orders for 6 units of Regular insulin with meals, 10 units of Detemir ([MEDICATION NAME]) at bedtime and a sliding scale of Regular insulin before meals and at bedtime. On [DATE] at approximately 4:12 pm, Resident #2's finger-stick blood sugar (FSBS) was 206. Nurse #4 did not administer 2 units of Regular insulin, sliding scale (SS), as ordered by the physician. Nurse #4 did not follow the system place for when medication is not available. Nurse #4 should have obtained insulin from the emergency drug kit (EDK) or contacted the physician to give the physician opportunity to alter treatment. Nurse #4 failed to follow the system in place due to lack of communication during Nurse #4's new employee orientation; upon accessing the EDK, Nurse #4 failed to identify the medication. On [DATE] at approximately 5 pm, Resident #2's supper meal coverage dose of Regular insulin 6 units were not given. On [DATE] at approximately 8:50 pm, Resident #2's FSBS was 240. 2 Units of SS Regular insulin were not given. On [DATE] 9 pm, Resident #2's bedtime dose of [MEDICATION NAME] 10 units were not given. On the morning of [DATE], Resident #2 experienced at FSBS reading of HI. The resident received two doses of 6 units of Regular insulin; however the resident's FSBS reading would not drop below HI. Resident #2 was sent to the emergency room , where the resident was admitted with Diabetic Ketoacidosis, and placed on an insulin drip to lower his blood sugar. On [DATE], the director of nursing (DON) interviewed Nurse #4 assigned to Resident #2, for date of service [DATE], which revealed Nurse #4 did not give the insulin because it was unavailable. The immediate jeopardy (IJ) situation was created when Nurse #4 failed to notify the physician that the insulin for Resident #2 was not available, which did not allow the physician the opportunity to alter treatment orders for Resident #2. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice: On [DATE], the DON and unit manager reviewed all current residents on insulin to ensure no other doses were omitted in the last 30 days. The review identified 28 occurrences where the administration of insulin was not documented according to physician's orders [REDACTED]. On [DATE] the unit manager contacted the physician regarding undocumented doses of insulin. The physician gave no new orders. On [DATE], the DON and Unit Manager audited to ensure all residents on insulin have the insulin available in the facility. All Residents had Insulin available to match order. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur: On [DATE], the DON, QI nurse and staff facilitator (SF) began education with all licensed nurses on the importance of following insulin orders. This education included: 1) the physician must be notified anytime the prescribed insulin is not available to administer as ordered, 2) the contents of the EDK are available for use if the medication ordered for the resident is not available, 3) insulin cannot be missed, the nurse must address immediately. On [DATE], the education was 50% completed with all registered nurses (RNs) and licensed practical nurses (LPNs). No nurse is allowed to work until the education is completed. 4. How the facility plans to monitor its performance to make sure solutions are sustained (include dates when corrective action will be completed) Beginning [DATE], the DON, QI nurse, SF, or unit manager will audit each resident receiving insulin to ensure their insulin was available and given as ordered, and if the MD was notified if insulin was not administered as ordered. This audit will be completed five times weekly and recorded on the Insulin Audit Sheet. Any concerns identified by the auditor will have corrective action taken by the auditor immediately. The completed audits will be reviewed at the daily interdisciplinary team (IDT) meeting for additional corrective measures. The daily IDT's role in this plan of correction includes implementation, monitoring, and ensuring the interventions are effective. The IDT also makes recommendations for revisions as needed. The daily IDT review findings will be brought to the next quarterly quality assurance and performance improvement (QAPI) meeting for additional review and recommendations. On [DATE], the administrator notified the QAPI committee of the audit results and the facility's plan of correction, including the QAPI committee's role in the plan of correction. Beginning [DATE], the administrator will be responsible for implementing and monitoring corrective measures to ensure solutions are sustained. Macon Valley Nursing and Rehabilitation Center alleges compliance of removal of IJ as of [DATE]. Facility staff were interviewed [DATE] and demonstrated they had been trained on the topics of medication administration, and how to call the pharmacy for medications, and to notify the physician if medications weren't available. Immediate jeopardy was removed effective [DATE]. 2. Review of the Neuro Checks Guide located at each nurse's station revealed neuro checks should be done as follows: every thirty minutes for 4 hours, every hour for 4 hours and every shift for 3 days once initiated. Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission nursing assessment dated [DATE] revealed Resident #20 was alert to person, place and time. Review of the On-Call Provider sheet with a Revision Date of [DATE] located at each nurse's station revealed the following when calling an on-call provider: Please have the following information ready before calling which included current medications, if reporting a change in condition, have a description of the signs and symptoms associated with the change, a brief synopsis, relevant past history, and incident report. Review of the physician orders [REDACTED]. An interview conducted on [DATE] at 11:07 AM with Nurse Aide (NA) #1 revealed he had just started his shift and was doing his first set of rounds when he heard Resident #20 screaming around 3:45 PM. He stated he went to her room and she was lying on her right side with her right arm underneath her and her head lying on the floor facing the bed. NA #1 stated Resident #20 was bleeding from skin tears to both sides of her body. He stated the bed was in the high position and there were no fall mats on the floor. NA #1 stated he called a code green for help and Resident #20 was yelling out in pain. He stated NA #2, NA #3, and Nurse #1 came into the room. NA #1 stated Nurse #1 assessed the resident and then the 4 of them moved Resident #20 back to bed using a sheet underneath her. NA #1 stated he did not ask and did not hear Nurse #1 ask Resident #20 if she hit her head on the floor but her head was laying on the floor when he found her. An interview conducted on [DATE] at 12:05 PM with NA #3 revealed she helped NA #2 transfer Resident #20 from the chair to the bed on [DATE] close to shift change around 2:45 PM and then went back to her hall. She stated she heard the code green around 4:00 PM and went to Resident #20's room. She stated Resident #20 was lying on the floor with her head on the floor facing her bed that was in the high position. NA #3 stated she helped transfer Resident #20 back to bed and then went back to her hall. She further stated Resident #20 was yelling out in pain before, during and after the transfer. An interview conducted on [DATE] at 10:30 AM with NA #2 revealed he had transferred Resident #20 from the chair to the bed just before shift change on [DATE] and he was at the nurse's desk and heard the code green called. He stated he went to Resident #20's room and she was lying on the floor on her right side with her right arm twisted underneath her and her head was lying on the floor with the bed in the high position. He stated she was yelling out in pain and was bleeding from some skin tears. NA #2 stated he helped Nurse #1, NA #1 and NA #3 transfer Resident #20 back to bed and then left the room. An interview conducted on [DATE] at 1:39 PM with Nurse #1 revealed she was called to Resident #20's room by a code green and when she went in the room Resident #20 was lying on her left side with her head on the ground. She stated she didn't remember what position the bed was in. Nurse #1 stated Resident #20 was yelling out in pain while she assessed her but she had good range of motion of all extremities and multiple skin tears. Nurse #1 stated Resident #20's Responsible Party (RP) came in during the assessment and felt like the resident had broken her right shoulder/arm and wanted her sent out to the hospital. She stated she told the RP they could have an x-ray done at the facility and it would be quicker than going to the hospital and he was good with doing it that way. Nurse #1 stated she didn't remember calling the on-call provider and thought the on-coming nurse had called them but after reviewing her nurse's notes she stated, I guess I probably called the physician and got the order for the x-ray of her shoulder. She stated she would not have told the physician Resident #20 was on [MEDICATION NAME] after the unwitnessed fall because she wouldn't have sent Resident #20 out, she would have started neuro checks and monitored her condition. Nurse #1 stated she did not start neuro checks but reported off to the on-coming nurse about the fall. She stated she did have NA #1 obtain vital signs. Review of the Incident note dated [DATE] 6:44 PM revealed Resident #20 had multiple skin tears and they were cleaned and treated. The right shoulder was swollen and Responsible Party (RP) felt it was broken and wanted the resident to go to the emergency room . The note revealed Nurse #1 didn't feel her arm/shoulder was broken because she had range of motion and was using it, not in pain while moving. The Physician was contacted. an order for [REDACTED]. Review of the physician order's dated [DATE] at 4:00 PM an order was written for Resident #20 by Nurse #1 and signed by the Physician for an x-ray of right shoulder to rule out injury from a fall. Review of the x-ray right shoulder results dated [DATE] revealed there was no evidence of an acute fracture or dislocation. Further interview with Nurse #1 on [DATE] at 1:39 PM revealed she was Resident #20's nurse on [DATE] on the 7:00 AM to 7:00 PM shift and the resident was alert, and talking during the morning of [DATE]. Nurse #1 stated the NA yelled for her and when she got to the room and assessed Resident #20 she had stopped breathing. She stated she checked her code status and she was a DNR so she didn't initiate CPR. Two attempts were unsuccessful to interview Nurse #2 via phone on [DATE] at 2:00 PM and [DATE] at 8:40 AM. An interview conducted on [DATE] at 3:57 PM with the facility Physician revealed he did not recall being called about Resident #20's fall on [DATE]. He stated if he had been called about a resident having an unwitnessed fall was on [MEDICATION NAME] he would have expected her to be sent out to the hospital for evaluation and a Computed tomography, a scan to see inside the body, to rule out a bleed. An interview conducted on [DATE] at 3:04 PM with the Director of Nursing revealed it was her expectation for nurse's to report to the physician that a resident's fall was unwitnessed or witnessed and what medications they were on. She further stated she expected neuro checks to be completed per facility protocol. On [DATE] at 3:49 PM the Director of Nursing and the Corporate Consultant were notified of Immediate Jeopardy. On [DATE] the facility provided an acceptable credible allegation of Immediate Jeopardy removal that included: 1. How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On [DATE] at approximately 3:50 pm, Resident #20 was on the floor next to the resident's bed. Resident #20 was on her side, head was on the floor, and demonstrated signs of pain. The nursing assistant called a code to announce the resident's fall in the resident's room. On [DATE] at approximately 3:55 pm, Nurse #1 directed the nursing assistant to take vital signs. Resident #20's vital signs post fall were blood pressure ,[DATE], pulse 88, respirations 20, tympanic temperature 97.8 F, and oxygen saturation 95%. On [DATE], Nurse #1 and three nursing assistants assisted Resident #20 to the bed. On [DATE] at approximately 4:00 pm, the treatment nurse noted, cleaned, and dressed five (5) skin tears on Resident #20: right upper arm, right forearm, right knee/leg, right lower leg, left foot second toe. After completing the skin tear treatments, the treatment nurse completed five (5) individual flow sheets of non-ulcer skin conditions in the electronic health record under the assessment tab. On [DATE] at approximately 4:00 pm, Nurse #1 noted Resident #20's right shoulder was swollen. The nurse notified the physician and the physician gave an order for [REDACTED].#1 did not notify the physician that the resident had a fall and Nurse #1 did not notify the physician that Resident #20 was taking [MEDICATION NAME]. On [DATE] at approximately 4:30 pm the Nurse #1 initiated neurological checks on Resident #20. On [DATE], the Nurse #1 completed five (5) neurological checks on Resident #20: 4:30 pm, 5:00 pm, 5:30 pm, 6:00 pm, and 6:30pm. Nurse #1 documented the neurological checks in Resident #20's electronic health record under nurse progress notes type: neurological observations. Nurse #1 reported off at approximately 7:00 pm to the oncoming shift nurse that x-ray was pending. The oncoming 7:00 pm - 7:00 am Nurse #2 did not document any neurological checks. On [DATE] at approximately 1:48 am, Nurse #2 documented a skilled post-acute note stating neurological: alert and oriented, cardiac: regular rate and rhythm, [MEDICAL CONDITION] at times, peripheral pulse present, respiratory rate clear, several wounds with dressings intact, clean, and dry. On [DATE] at approximately 12:45 pm, Nurse #1 completed a discharge summary in Resident #20's electronic health record. The summary included: the assigned nursing assistant was unable to attain vital signs, the Nurse #1 was unable to attain vital signs. The Nurse #1 contacted 911. Resident #20's husband was at bedside. Resident #20 was a Do Not Resuscitate (DNR). Resident #20 was pronounced dead at approximately 12:45 pm. On [DATE], the DON re-educated Nurse #1 regarding resident incident/accidents, post-fall assessments, neurological checks for all unobserved falls, documentation, shift change report, and reporting all relevant information to the physician, nurse practitioner, and DON. On [DATE], the DON re-educated Nurse #2 regarding resident incident/accidents, post-fall assessments, neurological checks for all unobserved falls, documentation, shift change report, and reporting all relevant information to the physician, nurse practitioner, and DON. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice: On [DATE], the quality improvement (QI) nurse audited 100% of resident current medication administration records (MARs) to identify all residents with current orders to receive [MEDICATION NAME]. The audit identified one (1) resident with [MEDICATION NAME] listed on the MAR. On [DATE], the director of nursing (DON) performed an audit on 100% of residents receiving [MEDICATION NAME]. The audit was to identify any [MEDICATION NAME] resident having a fall within the past 60 days. The audit identified zero/no resident currently taking [MEDICATION NAME] who had a fall within the past 60 days. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur: On [DATE], the QI nurse and staff facilitator initiated a re-education for all RNs, LPNs, MAs, NAs, and contracted therapy personnel. The re-education covered: In the event of any/all falls, especially for those residents receiving medication that has blood thinning properties, the physician must be called right away. Nurses, including Nurse #1 and Nurse #2, are being instructed to use the PCC E-Interact form to ensure the nurse provides the physician with all relevant information for all falls. Nurses will document relevant information on the 24 hour report sheets and report relevant information to the on-coming shift nurse regarding all falls. Nurses must follow the facility's policy on PT/INRs when resident is on [MEDICATION NAME]. Nurses are being instructed to start neuro-checks and follow the posted neuro-check guidelines which details the frequency of performing the neuro-check; only licensed registered nurses and licensed practical nurses will perform the neuro-checks, NAs may take the vital signs. Repeat PT/INR after three days or as ordered by the physician/nurse practitioner. If the resident has to be sent out for evaluation and treatment due to an injury post-fall and the resident returns to the facility the neurological checks must be re-started at the appropriate time. The DON must be notified within two hours of all falls with injuries to ensure proper interventions are in place. The re-education was completed on [DATE] with all staff working; no RN, LPN, MA, NA, or contracted therapy personnel will be allowed to work, including Nurse #1 and Nurse #2, until the re-education is completed. The re-education is added to the new staff orientation for all RNs, LPNs, MAs, NAs, and contracted therapy personnel. On [DATE], the QI nurse initiated a re-education for all RNs and LPNs. This re-education instructs the RNs and LPNs, including Nurse #1 and Nurse #2, to enter all neurological checks into the electronic medical record (PCC) under neurological observation. By having neurological observations documented in the PCC system, the documents are available for review by the physician, nurse practitioner, and clinical teams. The in-service was completed on [DATE] with all staff working; no RN or LPN will be allowed to work until the re-education is completed, including Nurse #1 and Nurse #2. The re-education is added to the new staff orientation for all RNs and LPNs. On [DATE], the DON initiated in the morning inter-disciplinary team (IDT) meeting a review of all falls, to include residents on medication with blood-thinning properties. The review included verifying that an assessment was completed immediately post-fall, that the physician/nurse practitioner was notified of all falls with all relevant information provided. The resident representative was notified, if the resident is on medication with blood-thinning properties, if the resident required outside treatment, and if the DON was notified of the fall. 4. How the facility plans to monitor its performance to make sure solutions are sustained (include dates when corrective action will be completed) Beginning [DATE], the DON and/or QI nurse will review the 24 hour report sheets for all falls. Beginning [DATE], the DON, QI nurse, and/or staff facilitator will review the 24 hour PCC progress notes. Beginning [DATE], the 24 hour report sheet review findings will be reconciled with the 24 hour PCC progress note review findings to ensure all falls have documented assessments and reports to physician/nurse practitioner which include current medications with blood-thinning properties including [MEDICATION NAME]. These reviews and reconciliations will be completed five times each week for a period of six months. On [DATE], the DON and corporate clinical director notified the daily quality assurance and performance improvement (QAPI) team. The daily QAPI team's role in this plan of correction includes implementation and monitoring, ensuring the interventions are effective. The QAPI team also making recommendations for revisions as needed. The daily QAPI review findings will be brought to the next quarterly QAPI meeting for additional review and recommendations. Beginning [DATE], the administrator will be responsible for implementing and monitoring corrective measures to ensure solutions are sustained. Macon Valley alleges credible allegation of IJ removal as of [DATE]. On [DATE] facility staff were interviewed and demonstrated they had been trained on the topics of using the PCC E-Interact forms to ensure nurses provided the physician with all relevant information after falls, when and how to perform neuro checks, DON notification, reporting of falls to on-coming nurse, and documenting on the 24 hour report sheets. Immediate jeopardy was removed effective [DATE].

Based on record review and staff interviews the facility failed to protect a resident's right to be free from physical and verbal abuse 1 of 3 residents reviewed for abuse (Resident #3). Immediate jeopardy began on 10/01/18 when Nurse Aide (NA) #1 observed NA #8 forcibly trying to make Resident #3 sit down on the toilet and yelling at her for being soiled. Immediate Jeopardy was removed on 10/22/18 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee education and ensure monitoring systems in place are effective. Based on record review, resident, staff, and Nurse Practitioner interviews the facility failed to administer insulin per physician order's or contact physician which caused the resident to be sent out to the hospital with diabetic ketoacidosis (DKA), a serious complication of diabetes, for 1 of 3 residents reviewed with insulin dependent diabetes (Resident #2). Immediate Jeopardy began on 09/11/18 when Nurse #4 did not administer insulin per physician's orders [REDACTED].#2 developing DKA. Immediate Jeopardy was removed on 10/22/18 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee education and ensure monitoring systems in place are effective. The findings included: 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 was severely cognitively impaired. The MDS further revealed Resident #3 had delusions, physical and verbal behaviors toward others, rejection of care and wandering 1 to 3 days during the assessment period. Review of the nurse's notes from 09/30/18 through 10/12/18 revealed no documentation of Nurse Aide (NA) #1 having concerns that NA #8 had been physically or verbally abusive to Resident #3 on the morning of 10/01/18. Review of the facility incident reports from 09/30/18 through 10/12/18 revealed there was no incident report for alleged physical/verbal abuse of Resident #3 by NA #8 on 10/01/18. An interview conducted on 10/11/18 at 10:36 AM with NA #1 revealed he worked the 7:00 AM to 3:00 PM shift on the(NAME)Unit on 10/01/18. NA #1 stated when he went onto the unit that morning the 11:00 PM to 7:00 AM NA #8 was not out on the floor and he assumed she was with a resident. He stated he was at the nurse's station and he heard Resident #3 start screaming and immediately went to her room because it wasn't Resident #3's normal behavior to scream or yell out. NA #1 stated when he went into Resident #3's room she was in the bathroom with NA #8, who was yelling at her and was forcibly trying to make her sit down on the commode. He stated NA #8 was yelling at Resident #3 because she had been incontinent and had feces running down her legs and wouldn't sit down on the commode. NA #1 stated he told NA #8 it was time for her to leave the room because he thought she was being too rough with the resident and he would finish taking care of Resident #3 but she refused and told him she wasn't finished with her yet. He stated he left the room to get some gloves to go back in to help NA #8 and Medication Aide (Med Aide) #9 and Med Aide #10 were at the medication cart counting meds and he told them what was happening. NA #1 stated when he went back in Resident #3's bathroom NA #8 told him to leave. NA #1 stated he went back out to the nurse's station and wrote a statement of what had happened and had Med Aide #9 write a statement of what she heard and took them to the sub-acute hall to Nurse #1 and reported the incident because she was the Nurse that covered the(NAME)Unit. An interview conducted on 10/11/18 at 11:01 AM with Med Aide #9 revealed she worked as a Medication Aide on the(NAME)Unit on 10/01/18 7:00 AM to 7:00 PM shift and was counting medications with the off-going Med Aide on the(NAME)Unit around 7:00 AM. Med Aide #9 stated she heard Resident #3 screaming like she was in pain, which wasn't normal behavior for her and then NA #1 came out of her room and told her NA #8 had Resident #3 in the bathroom and was being rough with her, trying to make her sit on the commode and yelling at her for having feces running down her legs because she had to clean her up. Med Aide #10 stated NA #1 told her he tried to get NA #8 to leave the room but she refused and he came out to get some gloves to go back in to help her. She stated she observed NA #1 go back into Resident #3's room and then come back out and he told her NA #8 told him to get out. Med Aide #9 stated she wrote a statement of what she heard, observed, and was told by NA #1 and he took the statements to Nurse #1 on the sub-acute hall to report the incident because she also was the nurse covering the(NAME)Unit. An interview conducted on 10/11/18 at 1:39 PM with Nurse #1 revealed she was on the sub-acute hall receiving report from the off-going 7:00 PM to 7:00 AM shift Nurse #5, when NA #1 came to her and told her there had been an incident of abuse with NA #8 and Resident #3 on the(NAME)Unit and gave her 2 written statements. Two attempts were unsuccessful to interview NA #8 via phone on 10/11/18 at 2:00 PM and 10/11/18 at 4:00 PM. An interview conducted on 10/11/18 at 2:18 PM with Nurse #5 revealed she was giving report to Nurse #1 on 10/01/18 when NA #1 came up and pulled Nurse #1 to the side and told her NA #8 and Resident #3 had an incident and he thought NA #8 had been verbally and physically abusive with Resident #3. On 10/18/18 at 8:30 AM the Director of Nursing and the Administrator were notified of Immediate Jeopardy via telephone. On 10/22/18 the facility provided an acceptable credible allegation of Immediate Jeopardy removal that included: 1. How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 10/1/18 at approximately 7:15am, Resident #3 was yelling and Nursing Assistant (NA) #1 went to check on Resident #3 and Nursing Assistant #8 abused the Resident by taking Resident #3's hand and pushed her onto the toilet. Nursing Assistant # 8 yelled at Resident # 3. NA #1 asked NA #8 to leave the bathroom and NA #8 refused. On 10/1/18 at approximately 7:30am, Nursing Assistant #1 returned Resident #3 to the resident's room. On 10/11/18 at approximately 4:10 pm the director of nursing (DON) determined there was an allegation of abuse and abuse potentially occurred when Nursing Assistant #8 was providing incontinent care to Resident #3 in the dementia unit bathroom on 10/01/18. The abuse occurred when Nursing Assistant #8 took Resident #3's hand and pushed Resident #3 onto the toilet. On 10/11/18 at approximately 4:20pm, the treatment nurse completed a head-to-toe physical and emotional assessment of Resident #3. The assessment revealed no new changes in Resident #3's skin condition or behavior. On 10/11/18 at approximately 4:30pm, the DON ensured Resident #3 was safe from abuse; the DON ensured Nursing Assistant #8 was not working at the facility and Nursing Assistant #1 was re-educated on abuse and immediate in-person reporting. On 10/11/18 at approximately 5pm the DON initiated resident abuse re-education for all facility staff, including contracted staff. On 10/15/18 at 3:00pm Nursing Assistant # 8 was re-educated on abuse, both verbal and physical abuse. On 10/19/18, the administrator held an emergency interdisciplinary team (IDT) meeting to discuss a root cause analysis to know why the Nursing Assistant #8 abused Resident #3 and how the facility can fix the problem. The IDT reviewed Nursing Assistant #8's work hours for the previous two weeks and noted the nursing assistant had worked overtime. The IDT also reviewed Resident #3's progress notes and care plan and noted the resident has on-going difficult behaviors. The IDT determined the root cause was Nursing Assistant #8 was tired, frustrated, and didn't receive assistance needed to meet the resident's needs. In response to the root cause, the IDT determined the staff required re-training on resident abuse and new training on recognizing burnout and working as a team. An addition, the administrator added additional staff to the staff assignments. The DON, the Administrator, the Facility Consultant, and the Vice President of Operations interviewed Nursing Assistant #1. The Nursing Assistant was re-educated on never leaving a resident who they feel is being abused and to yell for assistance from other staff. Nursing Assistant # 1 was also re-educated on calling the Administrator or Director of Nursing to never leave notes for any abuse/neglect allegation. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice: On 10/11/18, the treatment nurse performed a head-to-toe skin audit on 100% of dementia unit residents to identify any residents with signs/symptoms of abuse. The audit identified no findings. On 10/11/18, the DON instructed the Social Services Director (SSD) to perform Resident Abuse/Neglect Questionnaires on the residents. The questionnaires revealed no further allegations of abuse. Starting on 10/19/18, the Social Worker (SW) will do weekly rounds asking all interview able residents if staff are being good to the residents. The weekly rounds will be completed for 6 months. On 10/19/18, the administrative nursing staff will monitor direct care of 10 % of residents daily from varied shifts for 4 weeks, then weekly for 4 weeks, then monthly for 6 months to ensure no abuse is occurring. Starting 10/19/18, the results will be taken to the quality assurance and performance improvement (QAPI) meeting monthly for discussion and further recommendations. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur: On 10/11/18, the QI nurse and staff facilitator initiated a re-education for all staff including contracted staff. The re-education covered: Abuse/Neglect and reporting any abuse allegation immediately to the Administrator or Director of Nursing 24 hours a day. All staff, all departments, all contracted employees, including Nursing Assistant #1 and Nurse #1, are being instructed to keep resident safe at all times. If you suspect a resident is in harm's way do not leave the resident and call for help. All staff are responsible for keeping our residents safe at all times. On 10/19/18, the administrator, DON, QI nurse, and staff facilitator initiated small group meetings with 100% of staff, including contracted and agency staff, to discuss the facility's zero tolerance for abuse and not abusing residents. The no abuse discussions were presented with the burnout in-service to help staff recognize preventative measures that will ensure residents are not abused but treated with dignity and respect. No staff, including contracted and agency staff will be allowed to work until participating in the small group discussions and completing the burnout education. The small group meetings and burnout in-service will be completed by 10/31/18. The discussion and in-service will be added to new employee orientation, including contracted and agency staff. Starting 10/19/18, the Social Worker (SW) will do weekly rounds asking interview able residents if staff are not abusing resident but treating residents with dignity and respect. The weekly SW rounds will be completed for 6 months and the results taken to the monthly QAPI meetings for review and further recommendations. Starting on 10/19/18, the administrative nursing staff will monitor direct care of 10 % of residents daily from varied shifts x 4 weeks, then weekly x 4 weeks, then monthly for 6 months to ensure no abuse is occurring. Starting on 10/19/18, the audit results will be taken to the QAPI meeting monthly for discussion and further recommendations. 4. How the facility plans to monitor its performance to make sure solutions are sustained (include dates when corrective action will be completed) On 10/11/18, the DON and corporate clinical director notified the daily quality assurance and performance improvement (QAPI) team. The daily QAPI team's role in this plan of correction includes implementation and monitoring, ensuring the interventions are effective. The QAPI team also making recommendations for revisions as needed. The daily QAPI review findings will be brought to the next quarterly QAPI meeting for additional review and recommendations. On 10/19/18, The Social Worker will do weekly rounds asking interview able residents if staff are being good to the residents for 6 months. On 10/19/18, The Administrative nursing staff will monitor direct care of 10% of resident's daily from varied shifts for 4 weeks, then weekly for 4 weeks, then monthly for 6 months starting 10/19/2018 to ensure no abuse is occurring. On 10/19/18, the results will be taken to the QAPI meeting monthly for discussion. Beginning 10/19/18, the administrator will be responsible for implementing and monitoring corrective measures to ensure solutions are sustained. Macon Valley alleges compliance of removal of IJ as of 10/22/18. On 10/23/18 facility staff were interviewed and demonstrated they had been trained on the topics residents having the right to be free from abuse and abuse would not be tolerated at the facility. Immediate jeopardy was removed effective 10/22/18. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the (MONTH) (YEAR) MAR further revealed Resident #2 did not receive his physician ordered insulin's of 6 units on 09/11/18 at 5:00 PM and 10 units at 9:00 PM and his sliding scale insulin coverage at 4:30 PM for a CBG of 206 that required 2 units of coverage and 8:30 PM for a CBG of 240 that required 2 units of coverage. A record review of the (MONTH) (YEAR) MAR further revealed Resident #2 received the physician ordered 6 units of regular insulin on 09/12/18 at 8:00 AM. Resident #2 also received 6 units of SSI regular insulin on 09/12/18 at 7:30 AM to cover a CBG of HI. Review of the Blood Glucose Monitoring Sheet for 09/11/18 for Resident #2 revealed the following readings: 09/11/18 1:00 PM CBG 236 09/11/18 4:12 PM CBG 206 09/11/18 8:50 PM CBG 240 Per physician order [REDACTED].#2 should have received 2 units regular insulin on 09/11/18 at 4:30 PM. Per physician order [REDACTED].#2 should have received 2 units regular insulin on 09/11/18 at 8:30 PM. An interview with Nurse #3 on 10/09/18 at 1:00 PM revealed she gave Resident #2 12 units of regular insulin on 09/12/18 at 7:30 AM. This included the 6 units of regular scheduled insulin and 6 units of regular insulin for SSI coverage of CBG reading HI. Nurse #3 further revealed the recheck of Resident #2's CBG at 9:30 AM still read HI. Nurse #3 notified the NP, who was at the facility and she examined the resident and ordered him transferred to the hospital for possible DKA. An interview with Nurse #4 on 10/10/18 at 9:06 AM revealed she did not give Resident #2 his physician ordered insulin's on 09/11/18 at 4:30 PM and 09/11/18 at 5:00 PM or 09/11/18 at 8:30 PM. She further stated she did not give Resident #2 his Detemir insulin scheduled for 09/11/18 at 9:00 PM. She stated she did not look for the insulin and just did not give it. An interview with Nurse #3 on 10/10/18 at 9:30 AM revealed she obtained the regular insulin administered to Resident #2 on 09/11/18 and 09/12/18 from house stock in the emergency box. Review of the nurse notes dated 09/12/18 at 2:05 PM revealed the CBG taken at 7:30 AM read HI. The nurse gave Resident #2 12 units of regular insulin per physician admission orders [REDACTED]. The note further revealed Resident #2 was vomiting and not feeling well and was seen by the Nurse Practitioner (NP) who wrote an order for [REDACTED]. Review of the Nurse Practitioner (NP) progress note dated 9/12/18 indicated Resident #2 was seen on 09/12/18 after a CBG reading was 'HI'. The progress note indicated Resident #2 had also developed nausea and vomiting and he was clammy and anxious. An order was given by the NP to transfer the resident to the emergency department for possible DKA. An interview with the NP on 10/10/18 at 10:00 AM revealed she was unaware Resident #2 had not received his insulin's the evening before he was sent to the hospital. Further interview with the NP revealed her expectation was for the facility nurse to contact the on-call physician if the insulin was not available. An interview with Nurse #4 on 10/10/18 at 10:45 AM revealed she did not remember if she had reported to the 3rd shift nurse that Resident #2 had not received his insulin. She stated she did not contact the on-call physician to notify them of the unavailability of insulin. Nurse #4 further stated she did not call the pharmacy to obtain the insulin or look for the insulin in the emergency box which contains emergency medications. During an interview with Director of Nursing on 10/09/18 at 4:05 PM she stated she expected the facility staff to contact the physician for all missing medications. She further stated she expected staff to check for the ordered medications in the emergency box and to contact pharmacy for missing medications. Review of the hospital records revealed Resident #2 was admitted to the hospital intensive care unit for DKA on 09/12/18. Blood sugar on admission to the hospital was 485. Resident #2 required an insulin drip which he was weaned from the morning of 09/13/18. He was discharged on [DATE]. On 10/18/18 at 8:30 AM the Director of Nursing and the Administrator were notified of Immediate Jeopardy via telephone. 1. How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On (MONTH) 11, (YEAR) at approximately 11:30am, Resident #2 was admitted to Macon Valley Nursing and Rehabilitation center following a hospitalization for [DIAGNOSES REDACTED]. On (MONTH) 11, (YEAR) at 11:30 am, Resident #2 had a blood glucose reading of 236; blood glucose procedure was performed by Nurse #3. On (MONTH) 11, (YEAR) at 11:30 am, Resident #2 was given 2 units of regular insulin subcutaneously by Nurse #3, according to physician order, for blood glucose of 236. On (MONTH) 11, (YEAR) at 12 noon, Resident #2 was given regular insulin 6 units subcutaneously, according to physician order, for scheduled insulin by Nurse #3. On (MONTH) 11, (YEAR) at 4:12 pm, Resident #2 had a blood glucose reading of 206; blood glucose procedure was performed by Nurse #4. On (MONTH) 11, (YEAR) no documentation that Resident #2 received 2 units of regular insulin for blood glucose of 206, as ordered by physician. On (MONTH) 11, (YEAR) 5:00 pm, Resident #2 has no documentation of administration of scheduled dose of 6 units of regular insulin, as ordered by physician. On (MONTH) 11, (YEAR) at 8:50 pm, Resident #2 had a blood glucose reading of 240; procedure was performed by Nurse #4. On (MONTH) 11, (YEAR) at 8:50 pm, Resident #2 has no documentation of administration of 2 units regular insulin for a blood glucose reading of 240, as ordered by physician. On (MONTH) 11, (YEAR) at 9:00 pm, Resident #2 has no documentation of administration of [MEDICATION NAME] 10 units, as ordered by physician. On (MONTH) 12, (YEAR) at 7:30 am, Resident #2 had a blood glucose result of HI; procedure was performed by Nurse #3. On (MONTH) 12, (YEAR) at 7:30 am, 6 units Regular Insulin subcutaneous was administered by Nurse #3, as ordered by the physician, to Resident #2. On (MONTH) 12, (YEAR) at 8:00, am Resident #2 was administered Regular Insulin 6 units subcutaneous by Nurse #3, for schedule insulin dose as ordered by physician. On (MONTH) 12, (YEAR) at 9:30 am, Nurse #3 rechecked Resident #2's blood glucose with a result of HI. On (MONTH) 12, (YEAR) approximately 9:30, am the nurse practitioner was notified of blood glucose reading remaining HI, the action taken by Nurse #3 of administrating 6 units of regular insulin for the initial HI reading, and Nurse #3 administering the 6 units of regular insulin as scheduled by Nurse #3 for Resident #2. On (MONTH) 12, (YEAR), the nurse practitioner gave a verbal order to Nurse #3 for Resident # #2 to be sent to emergency room . On (MONTH) 12, (YEAR), Resident #2 was sent to the emergency room , where the resident was admitted with diabetic ketoacidosis, and placed on an insulin drip to lower the blood sugar level. On (MONTH) 19, (YEAR) the DON initiated abuse/neglect re-education to correct the staff involved in the deficient practice. The neglect re-education covered that neglect includes not providing medications as ordered. The neglect re-education will be covered with 100% staff, including Nurse #4 and agency staff. No nurse is allowed to work until the education is completed. On (MONTH) 19, (YEAR) all licensed nurses, including agency staff, were in-serviced on administering medication per physician orders, including obtaining medications when not available on the medication cart/in the facility. On (MONTH) 22, (YEAR), the facility determined the root cause of the deficient practice that led to neglect of Resident #2 was the nurse's failure to follow established policy in obtaining medications when the medication is not available on the medication cart. On 10/19/18 at 8:30 AM the Director of Nursing and the Administrator were notified of Immediate Jeopardy. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice: On (MONTH) 19, (YEAR), the director of nursing (DON) and Unit Manager reviewed all current residents on insulin to ensure no other doses were omitted in the last 30 days. The review identified 28 occurrences where the administration of insulin was not documented according to physician's orders [REDACTED]. The physician gave no new orders. On (MONTH) 19, (YEAR), the DON and Unit Manager audited to ensure all residents on insulin have the insulin available in the facility. All Residents had Insulin available to match order. On (MONTH) 11, (YEAR), the DON instructed the social worker (SW) to perform resident abuse/neglect questionnaires with the residents. The questionnaires results revealed no further allegations of abuse. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur: On (MONTH) 20, (YEAR), the DON, QI nurse, SF, administrator, and/or licensed nurse began auditing 100% of residents on insulin once daily 5 times weekly x 12 weeks to ensure insulin is available for administration as ordered. This audit will be documented on the insulin audit tool. On (MONTH) 20, (YEAR), the DON, quality improvement (QI) nurse, staff facilitator (SF), administrator, and/or licensed nurse began auditing audit 100% of residents on insulin. The auditing will be completed once daily 5 times weekly x 12 weeks to ensure insulin was administered as ordered. This audit will be documented on the insulin audit tool. On (MONTH) 20, (YEAR), the DON, QI nurse, SF, and/or administrator began reviewing all referrals to ensure, if a new admission resident is on insulin, the insulin medication is available prior to the resident's new admission. This audit will be documented on the Insulin Referral Audit tool. This audit will be completed for 12 week for each referral before admission. 4. How the facility plans to monitor its performance to make sure solutions are sustained (include dates when corrective action will be completed) Beginning (MONTH) 19, (YEAR), the DON, QI nurse, SF, or unit manager will audit each resident receiving insulin to ensure their insulin was available and given as ordered, and if the MD was notified if insulin was not administered as ordered. This audit will be completed five times weekly and recorded on the Insulin Audit Sheet. Any concerns identified by the auditor will have corrective action taken by the auditor immediately. The completed audits will be reviewed at the daily interdisciplinary team (IDT) meeting for additional corrective measures. Beginning (MONTH) 20, (YEAR) the DON will present the Insulin Audit Sheet results to the interdisciplinary team (IDT) weekly for review. This review will include ensuring insulin was administered as ordered and insulin is available for administration. Presentation of the Insulin Audit Sheet to the IDT will serve as a second verification. Beginning (MONTH) 20, (YEAR), the DON will present the insulin referral audit tool results to the IDT weekly for review. This review will ensure potential admissions with a need for insulin have the medication available upon admission. Presentation of the insulin referral audit tool to the IDT will serve as a second verification. The daily IDT's role in this plan of correction includes implementation, monitoring, and ensuring the interventions are effective. The IDT also makes recommendations for revisions as needed. The daily IDT review findings will be brought to the next quarterly quality assurance and performance improvement (QAPI) meeting for additional review and recommendations. On 10/22/18, the administrator notified the QAPI committee of the significant medication error IJ and the facility's plan of correction, including the QAPI committee's role in the plan of correction. Beginning (MONTH) 19, (YEAR), the administrator will be responsible for implementing and monitoring corrective measures to ensure solutions are sustained. Macon Valley Nursing and Rehabilitation Center alleges compliance of removal of IJ as of (MONTH) 22, (YEAR). On 10/23/18 facility staff were interviewed and demonstrated they had been trained on the topics of medication administration, and how to call the pharmacy for medications. Immediate jeopardy was removed effective 10/22/18.

Based on record review and staff interviews the facility failed to implement their abuse policy and procedures in the areas of prevention, identification, protecting, reporting, and investigating for 1 of 3 residents reviewed for abuse (Resident #3). Immediate jeopardy began on 10/01/18 when Nurse Aide (NA) #1 observed NA #8 forcibly trying to make Resident #3 sit down on the toilet and yelling at her for being soiled. NA #1 reported the incident to Nurse #1, who did not assess Resident #3 or report the abuse to the Director of Nursing or the Administrator. Immediate Jeopardy was removed on 10/22/18 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee education and ensure monitoring systems in place are effective. The findings included: Review of the facility Abuse, Neglect, or Misappropriation of Resident Property Policy dated 01/2009 with a revision date of 03/10/17 read in part: The facility believes that residents have the right to be free from abuse, neglect, involuntary seclusion, exploitation, or misappropriation of property. The facility will do whatever is in its control to prevent mistreatment, neglect, exploitation, and abuse of our residents or misappropriation of their property. Any employee who witnesses or suspects that abuse, neglect, exploitation, or misappropriation of property has occurred will immediately report the alleged incident to their supervisor, who will immediately report the incident to the Administrator. Failure to report any concern related to neglect, exploitation, abuse, or misappropriation of property will result in disciplinary action and possible termination of employment. The Administrator is responsible to ensure that complaints of abuse, neglect, exploitation, or misappropriation of property and injuries of unknown origin are investigated. Measures will be implemented to prevent further potential abuse, while the investigation is in progress. The Administrator is responsible to review the results of the investigation and report the alleged incident to the appropriate agencies in accordance with state and federal regulations. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 was severely cognitively imapaired. The MDS further revealed Resident #3 had delusions, physical and verbal behaviors toward others, rejection of care and wandering 1 to 3 days during the assessment period. Review of the nurse's notes from 09/30/18 through 10/12/18 revealed no documentation of Nurse Aide (NA) #1 or NA #9 having concerns that NA #8 had been physically or verbally abusive to Resident #3 on the morning of 10/01/18. Review of the facility incident reports from 09/30/18 through 10/12/18 revealed there was no incident report for alleged physical/verbal abuse of Resident #3 by NA #8 on 10/01/18. An interview conducted on 10/11/18 at 10:36 AM with NA #1 revealed he worked the 7:00 AM to 3:00 PM shift on the(NAME)Unit on 10/01/18. NA #1 stated when he went onto the unit that morning the 11:00 PM to 7:00 AM NA #8 was not out on the floor and he assumed she was with a resident. He stated he was at the nurse's station and he heard Resident #3 start screaming, which was not normal for her, and immediately went to her room. NA #1 stated when he went into Resident #3's room she was in the bathroom with NA #8, who was yelling at her and was forcibly trying to make her sit down on the commode. He stated NA #8 was yelling at Resident #3 because she had been incontinent and had feces running down her legs and wouldn't sit down on the commode. NA #1 stated he told NA #8 it was time for her to leave the room because he thought she was being too rough with the resident and he would finish taking care of Resident #3 but she refused and told him she wasn't finished with her yet. He stated he left the room to get some gloves to go back in to help NA #8 and Medication Aide (Med Aide) #9 and Med Aide #10 were at the medication cart counting meds and he told them what was happening. NA #1 stated when he went back in Resident #3's bathroom NA #8 told him to leave. NA #1 stated he left Resident #3's room and went back out to the nurse's station and wrote a statement of what had happened and had Med Aide #9 write a statement of what she heard and took them to the sub-acute hall to Nurse #1 and reported the incident to her because she was the Nurse that was covering the(NAME)Unit. He stated he didn't stay with Resident #3 and NA #8 because she told him to leave and he didn't know it was his responsibility to with them and he wanted to report the incident right away to the nurse. He further stated he was never interviewed by Administration about the incident and NA #8 continued to work on the(NAME)Unit. An interview conducted on 10/11/18 at 11:01 AM with Med Aide #9 revealed she worked as a Medication Aide on the(NAME)Unit on 10/01/18 7:00 AM to 7:00 PM shift and was counting medications with the off-going Med Aide on the(NAME)Unit around 7:00 AM. Med Aide #9 stated she heard Resident #3 screaming like she was in pain and then NA #1 came out of her room and told her NA #8 had Resident #3 in the bathroom and was being rough with her, trying to make her sit on the commode and yelling at her for having feces running down her legs because she had to clean her up. Med Aide #10 stated NA #1 told her he tried to get NA #8 to leave the room but she refused and he came out to get some gloves to go back in to help her. She stated she observed NA #1 go back into Resident #3's room and then come back out and he told her NA #8 told him to get out. Med Aide #9 stated she wrote a statement of what she heard, observed, and was told by NA #1 and he took the statements to Nurse #1 on the sub-acute hall to report the incident because she also was the nurse covering the(NAME)Unit. Med Aide #9 further stated Resident #9 did not have behaviors of yelling or screaming like she was doing on the morning of 10/01/18. An interview conducted on 10/11/18 at 1:39 PM with Nurse #1 revealed she was on the sub-acute hall receiving report from the off-going 7:00 PM to 7:00 AM shift Nurse #5, when NA #1 came to her and told her there had been an incident of abuse with NA #8 and Resident #3 on the(NAME)Unit and gave her 2 written statements. Nurse #1 stated she didn't go to the(NAME)Unit and assess Resident #3 or talk to NA #8 and didn't report the incident to the Director of Nursing or the Administrator at that time because NA #8 wasn't on her shift and she thought Nurse #5 should take care of the incident. She stated she did not discuss the incident with Nurse #5 regarding who was going to report it. Nurse #1 stated after she received report she took the witness statements and put them under the Administrators door and that was how she reported the incident. She stated she met NA #8 in the hall and asked her what happened and NA #8 told her it was all a misunderstanding so she didn't ask any more questions. Nurse #1 stated when there was an allegation of abuse it should be reported to the Administrator which was what she did by putting the witness statements under her door for review. Nurse #1 further stated she did not read the witness statements. An interview conducted on 10/11/18 2:15 PM with the Director of Nursing revealed she was never informed of the incident between Resident #3 and NA #8 until now. She stated she should have been informed immediately so an investigation could have been started and the 24-hour 5-day reports could have been sent to the state agency. An interview conducted on 10/11/18 at 2:18 PM with Nurse #5 revealed she was giving report to Nurse #1 on 10/01/18 when NA #1 came up and pulled Nurse #1 to the side and told her NA #8 and Resident #3 had an incident and he thought NA #8 had been verbally and physically abusive with Resident #3. Nurse #5 stated she didn't report the incident because NA #1 reported it to Nurse #1 and she assumed she would report the incident to the Director of Nursing and the Administrator. Nurse #5 further stated Resident #5 didn't have behaviors of yelling and screaming. An interview conducted on 10/11/18 at 2:22 PM with the Administrator revealed no one had reported an abuse allegation to her regarding NA #8 and Resident #3 and there were no witness statements under her door on 10/01/18. She stated the surveyor's call was the first time she had heard about the incident. The Administrator stated NA #1 and Nurse #1 should have reported this incident to her immediately via phone if she wasn't in the building and the Director of Nursing NA #8 should have been escorted off the hall until an investigation was completed. She further stated it was her expectation for all abuse allegations to be reported to her and the Director of Nursing immediately. On 10/18/18 at 8:30 AM the Director of Nursing and the Administrator were notified of Immediate Jeopardy via telephone. On 10/22/18 the facility provided an acceptable credible allegation of Immediate Jeopardy removal that included: 1. How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 10/1/18 at approximately 7:00 am, Resident #3 was in the dementia unit bathroom. Resident #3 was sitting, clothed, in a wheelchair. Nursing Assistant #8 was assisting Resident #1 with ADL care. On 10/1/18 at approximately 7am, Nursing Assistant #1 observed Resident #3 in the dementia unit bathroom loudly screaming. Nursing Assistant #1 asked Nursing Assistant #8 what she needed. Nursing Assistant #8 replied wipes now. Nursing Assistant #1 then went to the linen room and obtained wipes. On 10/1/18 at approximately 7:15am Nursing Assistant #1 states that he saw Nursing Assistant #8 take residents hand and push her onto the toilet and yelled at her. On 10/1/18, at approximately 7:35 am Nursing Assistant #1 reported the observations of Nursing Assistant #8's interactions with Resident #3 in the bathroom to Nurse #1. Nurse #1 collected statements from Medication Aide #9 and Nursing Assistant #1. Nurse #1 placed the statements under the administrator's door at approximately 7 pm before leaving work. The administrator never received the statements from Medication Aide #9 or Nursing Assistant #1. On 10/1/18 Nurse #1 did not assess resident after allegation of abuse was made. On 10/11/18 at approximately 3:00 pm, immediately upon notification from the state surveyor, the director of nursing (DON), the DON initiated an investigation. On 10/11/18 at approximately 3:15 pm the DON, corporate clinical facility consultant and corporate clinical director interviewed Nursing Assistant #1 The DON and corporate clinical director gave Nursing Assistant #1 a verbal re-education to include immediate interventions to protect Resident #3, immediate isolation of Nursing Assistant #8, immediate reporting to a supervisor, and proper way to report to the DON and administrator. On 10/11/18 at approximately 4pm, the treatment nurse completed a head-to-toe physical and emotional assessment of Resident #3. The assessment revealed no findings. On 10/11/18 at approximately 4pm, the DON contacted the police department. At approximately 5pm, the police arrived at the facility. The police officers obtain statements. On 10/11/18 at approximately 4:15pm, the DON contacted Resident #3's physician and resident representative (RR). The physician gave no new orders. The RR did not answer. A message was left to please contact facility. On 10/11/18 at approximately 4:12 pm, the DON submitted an Initial Allegation Report to the North Carolina Complaint Intake and Health Care Personnel Investigation. On 10/12/18 at approximately 5:00pm, The RR returned the DON's call. The DON told the RR about the Allegation. On 10/15/18 at approximately 5:40pm, The RR was called by the administrator, the incident was discussed. On 10/16/18, the administrator and DON met with Nursing Assistant #8 and obtained a written statement. After obtaining the written statement the administrator and DON told Nursing Assistant #8 that the investigation would not be complete until the sheriff's department was finished and we would notify her of results of investigation. On 10/17/18, the sheriff's department arrested Nursing Assistant #8. On 10/19/18, the administrator and DON met with Nurse #1, she was given a written warning for failing to assess and protect resident # 3. Also for not reporting immediately in person or by phone to the Administrator or DON that an allegation of abuse had been made. On 10/19/18, the administrator and DON met with Med Aide #9 and the Med Aide was given a verbal consultation and re-in serviced on proper procedure to protect resident at all times and proper notification to the Administrator and/ or Director of Nursing. On 10/19/18 the abuse/neglect re-education, including immediate actions and proper reporting, was 100% completed with all staff and contracted staff by Staff facilitator. On 10/17/18 at approximately 3:29 pm, the administrator submitted a 5-day report to the North Carolina Complaint Intake and Health Care Personnel Investigation. On 10/17/18 at approximately 4:30pm, the administrator called the RR with the sheriff's department's findings. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice: On 10/11/18, the treatment nurse performed a head-to-toe skin audit on 100% of dementia unit residents to identify any residents with signs/symptoms of abuse. The audit identified no findings. On 10/11/18, the DON performed an audit on 100% of the staff schedule and staff assignment sheets. The audit was to identify any assignment where Nursing Assistant #8 had worked since the 10/1/18 incident date. The scheduling audit revealed six shifts. On 10/11/18 immediately after the audit, the DON reported the audit results to the administrator. The DON also instructed the quality improvement (QI) nurse not to schedule Nursing Assistant #8 to work. Also, the DON instructed the payroll staff, not to allow Nursing Assistant #8 past the facility front door entry, if Nursing Assistant #8 were to come to the facility. The DON attempted to contact Nursing Assistant #8 by telephone without success. The DON contacted the local authorities who came to the facility. On 10/17/18, the county sheriff's department arrested Nursing Assistant #8. On 10/11/18, the DON instructed the Social Services Director (SSD) to perform Resident Abuse/Neglect Questionnaires on the residents. The questionnaires revealed no further allegations of abuse. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur: On 10/11/18, the QI nurse and staff facilitator initiated a re-education for all RNs, LPNs, MAs, NAs, and contracted therapy personnel. The re-education covered: Abuse/Neglect and reporting. All staff, all departments, all contracted employees, including Nursing Assistant #1 and Nurse #1, are being instructed to keep resident safe at all times. If you suspect a resident is in harm's way do not leave the resident. Nurses will document relevant information on the 24 hour report sheets and report relevant information to the on-coming shift nurse regarding abuse/neglect. All staff and contracted staff must follow the facility's policy on abuse/neglect when staff become aware of actual or potential resident abuse/neglect. The administrator and DON must be notified immediately of all abuse/neglect allegation to ensure proper interventions are in place. The re-education was completed on 10/18/18 with all staff working; no RN, LPN, MA, NA, or contracted therapy personnel will be allowed to work, including Nursing Assistant #1 and Nurse #1, until the re-education is completed. The re-education is added to the new staff orientation for all staff and contracted therapy personnel On 10/11/18, the DON initiated in the morning inter-disciplinary team (IDT) meeting a review of all incidents, to include abuse/neglect. The review included verifying that abuse/neglect allegations were reported to the administrator and DON, the offender was immediately removed from resident areas, an assessment was completed immediately post-incident, that the physician/nurse practitioner was notified of all abuse/neglect allegations with all relevant information provided. The resident representative was notified. That the authorities were contacted. On 10/19/18 An in-service was completed with Nurse #1 about assessing a resident immediately if an allegation of abuse is made. In serviced by Director of Nursing. On 10/19/18, The Administrative nursing staff will monitor direct care of 10 % of resident's daily X 4 weeks, then weekly X 4 weeks, then monthly for 6 months starting 10/19/2018 to insure no abuse is occurring. On 10/19/18, The Social Worker will do weekly rounds asking interview able residents if staff are being good to the residents for 6 months. 4. How the facility plans to monitor its performance to make sure solutions are sustained (include dates when corrective action will be completed) Beginning 10/11/18, the DON, QI nurse, and/or staff facilitator will review the 24 hour PCC progress notes. Beginning 10/11/18, the 24 hour report sheet review findings will be reconciled with the 24 hour PCC progress note review findings to ensure all allegations of abuse/neglect have documented assessments and reports to the administrator, DON, physician/nurse practitioner, resident representative, and authorities. These reviews and reconciliations will be completed five times each week for a period of six months. On 10/19/2018, The Administrative nursing staff will monitor direct care of 10 % of resident's daily X 4 weeks, then weekly X 4 weeks, then monthly for 6 months starting 10/19/2018 to insure no abuse is occurring. On 10/19/18, The Social Worker will do weekly rounds asking interview able residents if staff are being good to the residents for 6 months. On 10/11/18, the DON and corporate clinical director notified the daily quality assurance and performance improvement (QAPI) team. The daily QAPI team's role in this plan of correction includes implementation and monitoring, ensuring the interventions are effective. The QAPI team also making recommendations for revisions as needed. The daily QAPI review findings will be brought to the next quarterly QAPI meeting for additional review and recommendations. Beginning 10/11/18, the administrator will be responsible for implementing and monitoring corrective measures to ensure solutions are sustained. Macon Valley alleges compliance of removal of IJ as of 10/22/18. On 10/23/18 facility staff were interviewed and demonstrated they had been trained on the topics of what to do if a resident was being abused, how to report abuse and neglect, and what to do for staff burn out. Immediate jeopardy was removed effective 10/22/18.

Based on record review, staff, Physician and Medical Examiner interviews, the facility failed to perform neurological checks per the facility's neurological guide after a fall from the bed to the floor and failed to communicate to the physician that the resident had an unwitnessed fall and was on a blood thinner. This affected one of three sampled residents reviewed for assessment following an acute episode. The failure of the facility to assess Resident #20's neurological status per the facility's protocol and communicate an unwitnessed fall from the bed to the floor and blood thinner use to the physician resulted in the high likelihood of serious injury or death (Resident #20). Immediate Jeopardy began on [DATE] for Resident # 20 when the facility failed to perform neurological checks per the facility's neurological guide after a fall from the bed to the floor and failed to communicate to the physician that the resident had an unwitnessed fall and was on a blood thinner. Immediate Jeopardy was removed on [DATE] when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee education and ensure monitoring systems in place are effective. Based on observations, record review, resident, staff, and Nurse Practitioner interviews the facility failed to administer insulin per physician order's which caused the resident to be sent out to the hospital with diabetic ketoacidosis (DKA), a serious complication of diabetes, for 1 of 3 residents reviewed with insulin dependent diabetes (Resident #2). Immediate Jeopardy began on [DATE] for Resident # 2 when Nurse #4 did not administer insulin per physician's orders [REDACTED].#2 developing DKA. Immediate Jeopardy was removed on [DATE] when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee education and ensure monitoring systems in place are effective. The findings included: 1. Review of the Neuro Checks Guide located at each nurse's station revealed neuro checks should be done as follows: every thirty minutes for 4 hours, every hour for 4 hours and every shift for 3 days once initiated. Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission nursing assessment dated [DATE] revealed Resident #20 was alert to person, place and time. Review of the care plan dated [DATE] revealed Resident #20 was at risk for falls/actual falls, injury, multiple risk factors related to deconditioning, incontinence, impaired balance and impaired mobility. The goal was for Resident #20 to be free of falls, and not sustain serious injury through the next review. The interventions included having the resident's bed in the lowest position. Review of the On-Call Provider sheet with a Revision Date of [DATE] located at each nurse's station revealed the following when calling an on-call provider: Please have the following information ready before calling which included current medications, if reporting a change in condition, have a description of the signs and symptoms associated with the change, a brief synopsis, relevant past history, and incident report. Review of the physician orders [REDACTED]. An interview conducted on [DATE] at 11:07 AM with Nurse Aide (NA) #1 revealed he had just started his shift and was doing his first set of rounds when he heard Resident #20 screaming around 3:45 PM. He stated he went to her room and she was lying on her right side with her right arm underneath her and her head lying on the floor facing the bed. NA #1 stated Resident #20 was bleeding from skin tears to both sides of her body. He stated the bed was in the high position and there were no fall mats on the floor. NA #1 stated he called a code green for help and Resident #20 was yelling out in pain. He stated NA #2, NA #3, and Nurse #1 came into the room. NA #1 stated Nurse #1 assessed the resident and then the 4 of them moved Resident #20 back to bed using a sheet underneath her. NA #1 stated he did not ask and did not hear Nurse #1 ask Resident #20 if she hit her head on the floor but her head was laying on the floor when he found her. An interview conducted on [DATE] at 12:05 PM with NA #3 revealed she helped NA #2 transfer Resident #20 from the chair to the bed on [DATE] close to shift change around 2:45 PM and then went back to her hall. She stated she heard the code green around 4:00 PM and went to Resident #20's room. She stated Resident #20 was lying on the floor with her head on the floor facing her bed that was in the high position. NA #3 stated she helped transfer Resident #20 back to bed and then went back to her hall. She further stated Resident #20 was yelling out in pain before, during and after the transfer. An interview conducted on [DATE] at 10:30 AM with NA #2 revealed he had transferred Resident #20 from the chair to the bed just before shift change on [DATE] and he was at the nurse's desk and heard the code green called. He stated he went to Resident #20's room and she was lying on the floor on her right side with her right arm twisted underneath her and her head was lying on the floor with the bed in the high position. He stated she was yelling out in pain and was bleeding from some skin tears. NA #2 stated he helped Nurse #1, NA #1 and NA #3 transfer Resident #20 back to bed and then left the room. An interview conducted on [DATE] at 1:39 PM with Nurse #1 revealed she was called to Resident #20's room by a code green and when she went in the room Resident #20 was lying on her left side with her head on the ground. She stated she didn't remember what position the bed was in. Nurse #1 stated Resident #20 was yelling out in pain while she assessed her but she had good range of motion of all extremities and multiple skin tears. Nurse #1 stated Resident #20's Responsible Party (RP) came in during the assessment and felt like the resident had broken her right shoulder/arm and wanted her sent out to the hospital. She stated she told the RP they could have an x-ray done at the facility and it would be quicker than going to the hospital and he was good with doing it that way. Nurse #1 stated she didn't remember calling the on-call provider and thought the on-coming nurse had called them but after reviewing her nurse's notes she stated, I guess I probably called the physician and got the order for the x-ray of her shoulder. She stated she would not have told the physician Resident #20 was on [MEDICATION NAME] after the unwitnessed fall because she wouldn't have sent Resident #20 out, she would have started neuro checks and monitored her condition. Nurse #1 stated she did not start neuro checks but reported off to the on-coming nurse about the fall. She stated she did have NA #1 obtain vital signs. Review of the Incident note dated [DATE] 6:44 PM revealed Resident #20 had multiple skin tears and they were cleaned and treated. The right shoulder was swollen and Responsible Party (RP) felt it was broken and wanted the resident to go to the emergency room . The note revealed Nurse #1 didn't feel her arm/shoulder was broken because she had range of motion and was using it, not in pain while moving. The Physician was contacted. an order for [REDACTED]. Review of the physician order's dated [DATE] at 4:00 PM an order was written for Resident #20 by Nurse #1 and signed by the Physician for an x-ray of right shoulder to rule out injury from a fall. Review of the x-ray right shoulder results dated [DATE] revealed there was no evidence of an acute fracture or dislocation. Review of the nurse's notes revealed the following: [DATE] 6:48 PM Neurological Observations - Vital Signs - 4:30 PM ,[DATE] Blood Pressure (B/P), 139 Pulse (P), 20 Respirations (R), 97% Oxygen saturation (O2). 5:00 PM - B/P-,[DATE], P-100, R-20, Temperature (temp), 98.7 96% (O2), 5:30 PM - ,[DATE] B/P, 98 P, 18 R, 96% O2, 6:00 PM - ,[DATE] B/P, 88 P, 20 R, ,[DATE] Temp, 94% O2, 6:30 PM - ,[DATE] B/P, 88 P, 20 R, 97.8 Temp, 95% O2. Level of Consciousness - 4:30 PM alert/conscious (a/c), 5:00 PM -a/c, 5:30 PM -a/c, 6:00 PM a/c, 6:30 PM -a/c. Pupil Check - 4:30 PM Pupils Equal Responsive Light (PERL), 5:00 PM -PERL, 5:30 PM - PERL, 6:00 PM -PERL, 6:30 PM -PERL. Hand Grasp - 4:30 PM =, 5:00 PM =, 5:30 PM =, 6:00 PM =, 6:30 =. Further interview with Nurse #1 on [DATE] at 1:39 PM revealed she was Resident #20's nurse on [DATE] on the 7:00 AM to 7:00 PM shift and the resident was alert, and talking during the morning of [DATE]. Nurse #1 stated the NA yelled for her and when she got to the room and assessed Resident #20 she had stopped breathing. She stated she checked her code status and she was a DNR so she didn't initiate CPR. Two attempts were unsuccessful to interview Nurse #2 via phone on [DATE] at 2:00 PM and [DATE] at 8:40 AM. An interview conducted on [DATE] at 3:57 PM with the facility Physician revealed he did not recall being called about Resident #20's fall on [DATE]. He stated if he had been called about a resident having an unwitnessed fall was on [MEDICATION NAME] he would have expected her to be sent out to the hospital for evaluation and a Computed tomography, a scan to see inside the body, to rule out a bleed. An interview conducted on [DATE] at 3:04 PM with the Director of Nursing revealed it was her expectation for nurse's to report to the physician that a resident's fall was unwitnessed or witnessed and what medications they were on. She further stated she expected neuro checks to be completed per facility protocol. Review of the nurse's note dated [DATE] at 12:45 PM written by Nurse #1 revealed Resident #20's RP had been at her bedside since after breakfast. The NA went in to get Resident #20's vital signs and called Nurse #1 to the room. The NA stated when she put the blood pressure cuff on the resident she looked like she stopped breathing. The note revealed Nurse #1 told the RP she would send Resident #20 to the emergency room for evaluation but she stopped breathing. Resident #20 was a Do Not Resuscitate (DNR) and Cardio [MEDICAL CONDITION] Resuscitation (CPR) was not initiated. Review of the Death Certificate dated [DATE] and signed by the Medical Examiner revealed the cause of death for Resident #20 was from complications of a [MEDICAL CONDITION]. An interview conducted on [DATE] at 12:09 PM with the Medical Examiner (ME) revealed he was contacted by the funeral home due to the fact Resident #20 had a fall which was considered an accident before her death which meant the Medical Examiner had to be called. The ME stated the facility Physician had put the cause of death on the death certificate for complications of a [MEDICAL CONDITION]. The ME stated he reviewed the hospital and nursing home records for Resident #20 but was unaware she had an unwitnessed fall on [DATE]. He stated had he known about the unwitnessed fall and the fact that she was on a blood thinner he may have looked at the case differently but it was acceptable to leave the cause of death complications from a [MEDICAL CONDITION] because that was the reason she was in the facility to begin with. On [DATE] at 3:49 PM the Director of Nursing and the Corporate Consultant were notified of Immediate Jeopardy. On [DATE] the facility provided an acceptable credible allegation of Immediate Jeopardy removal that included: 1. How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On [DATE] at approximately 3:50 pm, Resident #20 was on the floor next to the resident's bed. Resident #20 was on her side, head was on the floor, and demonstrated signs of pain. The nursing assistant called a code to announce the resident's fall in the resident's room. On [DATE] at approximately 3:55 pm, Nurse #1 directed the nursing assistant to take vital signs. Resident #20's vital signs post fall were blood pressure ,[DATE], pulse 88, respirations 20, tympanic temperature 97.8 F, and oxygen saturation 95%. On [DATE], Nurse #1 and three nursing assistants assisted Resident #20 to the bed. On [DATE] at approximately 4:00 pm, the treatment nurse noted, cleaned, and dressed five (5) skin tears on Resident #20: right upper arm, right forearm, right knee/leg, right lower leg, left foot second toe. After completing the skin tear treatments, the treatment nurse completed five (5) individual flow sheets of non-ulcer skin conditions in the electronic health record under the assessment tab. On [DATE] at approximately 4:00 pm, Nurse #1 noted Resident #20's right shoulder was swollen. The nurse notified the physician and the physician gave an order for [REDACTED].#1 did not notify the physician that the resident had a fall and Nurse #1 did not notify the physician that Resident #20 was taking [MEDICATION NAME]. On [DATE] at approximately 4:30 pm the Nurse #1 initiated neurological checks on Resident #20. On [DATE], the Nurse #1 completed five (5) neurological checks on Resident #20: 4:30 pm, 5:00 pm, 5:30 pm, 6:00 pm, and 6:30pm. Nurse #1 documented the neurological checks in Resident #20's electronic health record under nurse progress notes type: neurological observations. Nurse #1 reported off at approximately 7:00 pm to the oncoming shift nurse that x-ray was pending. The oncoming 7:00 pm - 7:00 am Nurse #2 did not document any neurological checks. On [DATE] at approximately 1:48 am, Nurse #2 documented a skilled post-acute note stating neurological: alert and oriented, cardiac: regular rate and rhythm, [MEDICAL CONDITION] at times, peripheral pulse present, respiratory rate clear, several wounds with dressings intact, clean, and dry. On [DATE] at approximately 12:45 pm, Nurse #1 completed a discharge summary in Resident #20's electronic health record. The summary included: the assigned nursing assistant was unable to attain vital signs, the Nurse #1 was unable to attain vital signs. The Nurse #1 contacted 911. Resident #20's husband was at bedside. Resident #20 was a Do Not Resuscitate (DNR). Resident #20 was pronounced dead at approximately 12:45 pm. On [DATE], the DON re-educated Nurse #1 regarding resident incident/accidents, post-fall assessments, neurological checks for all unobserved falls, documentation, shift change report, and reporting all relevant information to the physician, nurse practitioner, and DON. On [DATE], the DON re-educated Nurse #2 regarding resident incident/accidents, post-fall assessments, neurological checks for all unobserved falls, documentation, shift change report, and reporting all relevant information to the physician, nurse practitioner, and DON. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice: On [DATE], the quality improvement (QI) nurse audited 100% of resident current medication administration records (MARs) to identify all residents with current orders to receive [MEDICATION NAME]. The audit identified one (1) resident with [MEDICATION NAME] listed on the MAR. On [DATE], the director of nursing (DON) performed an audit on 100% of residents receiving [MEDICATION NAME]. The audit was to identify any [MEDICATION NAME] resident having a fall within the past 60 days. The audit identified zero/no resident currently taking [MEDICATION NAME] who had a fall within the past 60 days. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur: On [DATE], the QI nurse and staff facilitator initiated a re-education for all RNs, LPNs, MAs, NAs, and contracted therapy personnel. The re-education covered: In the event of any/all falls, especially for those residents receiving medication that has blood thinning properties, the physician must be called right away. Nurses, including Nurse #1 and Nurse #2, are being instructed to use the PCC E-Interact form to ensure the nurse provides the physician with all relevant information for all falls. Nurses will document relevant information on the 24 hour report sheets and report relevant information to the on-coming shift nurse regarding all falls. Nurses must follow the facility's policy on PT/INRs when resident is on [MEDICATION NAME]. Nurses are being instructed to start neuro-checks and follow the posted neuro-check guidelines which details the frequency of performing the neuro-check; only licensed registered nurses and licensed practical nurses will perform the neuro-checks, NAs may take the vital signs. Repeat PT/INR after three days or as ordered by the physician/nurse practitioner. If the resident has to be sent out for evaluation and treatment due to an injury post-fall and the resident returns to the facility the neurological checks must be re-started at the appropriate time. The DON must be notified within two hours of all falls with injuries to ensure proper interventions are in place. The re-education was completed on [DATE] with all staff working; no RN, LPN, MA, NA, or contracted therapy personnel will be allowed to work, including Nurse #1 and Nurse #2, until the re-education is completed. The re-education is added to the new staff orientation for all RNs, LPNs, MAs, NAs, and contracted therapy personnel. On [DATE], the QI nurse initiated a re-education for all RNs and LPNs. This re-education instructs the RNs and LPNs, including Nurse #1 and Nurse #2, to enter all neurological checks into the electronic medical record (PCC) under neurological observation. By having neurological observations documented in the PCC system, the documents are available for review by the physician, nurse practitioner, and clinical teams. The in-service was completed on [DATE] with all staff working; no RN or LPN will be allowed to work until the re-education is completed, including Nurse #1 and Nurse #2. The re-education is added to the new staff orientation for all RNs and LPNs. On [DATE], the DON initiated in the morning inter-disciplinary team (IDT) meeting a review of all falls, to include residents on medication with blood-thinning properties. The review included verifying that an assessment was completed immediately post-fall, that the physician/nurse practitioner was notified of all falls with all relevant information provided. The resident representative was notified, if the resident is on medication with blood-thinning properties, if the resident required outside treatment, and if the DON was notified of the fall. 4. How the facility plans to monitor its performance to make sure solutions are sustained (include dates when corrective action will be completed) Beginning [DATE], the DON and/or QI nurse will review the 24 hour report sheets for all falls. Beginning [DATE], the DON, QI nurse, and/or staff facilitator will review the 24 hour PCC progress notes. Beginning [DATE], the 24 hour report sheet review findings will be reconciled with the 24 hour PCC progress note review findings to ensure all falls have documented assessments and reports to physician/nurse practitioner which include current medications with blood-thinning properties including [MEDICATION NAME]. These reviews and reconciliations will be completed five times each week for a period of six months. On [DATE], the DON and corporate clinical director notified the daily quality assurance and performance improvement (QAPI) team. The daily QAPI team's role in this plan of correction includes implementation and monitoring, ensuring the interventions are effective. The QAPI team also making recommendations for revisions as needed. The daily QAPI review findings will be brought to the next quarterly QAPI meeting for additional review and recommendations. Beginning [DATE], the administrator will be responsible for implementing and monitoring corrective measures to ensure solutions are sustained. Macon Valley alleges credible allegation of IJ removal as of [DATE]. On [DATE] facility staff were interviewed and demonstrated they had been trained on the topics of using the PCC E-Interact forms to ensure nurses provided the physician with all relevant information after falls, when and how to perform neuro checks, DON notification, reporting of falls to on-coming nurse, and documenting on the 24 hour report sheets. Immediate jeopardy was removed effective [DATE]. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the (MONTH) (YEAR) MAR further revealed Resident #2 did not receive his physician ordered insulin's of 6 units on [DATE] at 5:00 PM and 10 units at 9:00 PM and his sliding scale insulin coverage at 4:30 PM for a CBG of 206 that required 2 units of coverage and 8:30 PM for a CBG of 240 that required 2 units of coverage. A record review of the (MONTH) (YEAR) MAR further revealed Resident #2 received the physician ordered 6 units of regular insulin on [DATE] at 8:00 AM. Resident #2 also received 6 units of SSI regular insulin on [DATE] at 7:30 AM to cover a CBG of HI. Review of the Blood Glucose Monitoring Sheet for [DATE] for Resident #2 revealed the following readings: [DATE] 1:00 PM CBG 236 [DATE] 4:12 PM CBG 206 [DATE] 8:50 PM CBG 240 Per physician order [REDACTED].#2 should have received 2 units regular insulin on [DATE] at 4:30 PM. Per physician order [REDACTED].#2 should have received 2 units regular insulin on [DATE] at 8:30 PM. An interview with Nurse #3 on [DATE] at 1:00 PM revealed she gave Resident #2 12 units of regular insulin on [DATE] at 7:30 AM. This included the 6 units of regular scheduled insulin and 6 units of regular insulin for SSI coverage of CBG reading HI. Nurse #3 further revealed the recheck of Resident #2's CBG at 9:30 AM still read HI. Nurse #3 notified the NP, who was at the facility and she examined the resident and ordered him transferred to the hospital for possible DKA. Nurse #3 further revealed she did not recheck the glucometer when it read HI and she did not try another glucometer to verify test results. An interview with Nurse #4 on [DATE] at 9:06 AM revealed she did not give Resident #2 his physician ordered insulin's on [DATE] at 4:30 PM and [DATE] at 5:00 PM or [DATE] at 8:30 PM. She further stated she did not give Resident #2 his Detemir insulin scheduled for [DATE] at 9:00 PM. She stated she did not look for the insulin and just did not give it. An interview with Nurse #3 on [DATE] at 9:30 AM revealed she obtained the regular insulin administered to Resident #2 on [DATE] and [DATE] from house stock in the emergency box. Review of the nurse notes dated [DATE] at 2:05 PM revealed the CBG taken at 7:30 AM read HI. The nurse gave Resident #2 12 units of regular insulin per physician admission orders [REDACTED]. The note further revealed Resident #2 was vomiting and not feeling well and was seen by the Nurse Practitioner (NP) who wrote an order for [REDACTED]. Review of the Nurse Practitioner (NP) progress note dated [DATE] indicated Resident #2 was seen on [DATE] after a CBG reading was 'HI'. The progress note indicated Resident #2 had also developed nausea and vomiting and he was clammy and anxious. An order was given by the NP to transfer the resident to the emergency department for possible DKA. An interview with the NP on [DATE] at 10:00 AM revealed she was unaware Resident #2 had not received his insulin's the evening before he was sent to the hospital. Further interview with the NP revealed her expectation was for the facility nurse to contact the on-call physician if the insulin was not available. An interview with Nurse #4 on [DATE] at 10:45 AM revealed she did not remember if she had reported to the 3rd shift nurse that Resident #2 had not received his insulin. She stated she did not contact the on-call physician to notify them of the unavailability of insulin. Nurse #4 further stated she did not call the pharmacy to obtain the insulin or look for the insulin in the emergency box which contains emergency medications. During an interview with Director of Nursing on [DATE] at 4:05 PM she stated she expected the facility staff to contact the physician for all missing medications. She further stated she expected staff to check for the ordered medications in the emergency box and to contact pharmacy for missing medications. Review of the hospital records revealed Resident #2 was admitted to the hospital intensive care unit for DKA on [DATE]. Blood sugar on admission to the hospital was 485. Resident #2 required an insulin drip which he was weaned from the morning of [DATE]. He was discharged on [DATE]. On [DATE] at 8:30 AM the Director of Nursing and the Administrator were notified of Immediate Jeopardy via telephone. 1. How corrective action will be accomplished for those residents found to have been affected by the deficient practice: On [DATE] at approximately 11:30am, Resident #2 was admitted to Macon Valley Nursing and Rehabilitation center following a hospitalization for [DIAGNOSES REDACTED]. On [DATE] at 11:30 am, Nurse #3 checked Resident #2's blood glucose; Resident #2 had a blood glucose reading of 236. On [DATE] at 11:30 am, Nurse #3 administered to Resident #2 two units of Regular insulin subcutaneously, as ordered by the physician, for a blood glucose level of 236. On [DATE] at 12 noon, Nurse #3 administered to Resident #2 six units of Regular insulin subcutaneously, as ordered by the physician. On [DATE] at 4:12 pm, Nurse #4 checked Resident #2's blood glucose; Resident #2 had a blood glucose reading of 206. On [DATE], the Medication Administration Record [REDACTED]. On [DATE] 5:00 pm, the MAR indicated [REDACTED]. On [DATE] at 8:50 pm, Nurse #4 checked Resident #2's blood glucose; Resident #2 had a blood glucose reading of 240. On [DATE] at 8:50 pm, the MAR indicated [REDACTED]. On [DATE] at 9:00 pm, the MAR indicated [REDACTED]. On [DATE] at 7:30 am, Nurse #3 check Resident #2's blood glucose; Resident #2 had a blood glucose result of HI. On [DATE] at 7:30 am, Nurse #3 administered six units of Regular insulin subcutaneously to Resident #2 ordered by the physician. On [DATE] at 8:00 am, Nurse #3 administered six units of Regular insulin subcutaneously to Resident #2, as ordered by the physician. On [DATE] at 9:30 am, Nurse #3 rechecked Resident #2's blood glucose with a result of HI. On [DATE] approximately 9:30 am, Nurse #3 ensured Resident #2's well-being by: contacting the nurse practitioner of the blood glucose reading remaining HI, administration of 6 units of Regular insulin for the initial HI reading, and Nurse #3 administering the scheduled 6 units of Regular insulin as scheduled by the physician's orders [REDACTED]. On [DATE], the nurse practitioner gave a verbal order to Nurse #3 for Resident # 2 to be sent to emergency room . On [DATE], Resident # 2 was transferred to the hospital emergency room by emergency medical services for evaluation of elevated blood glucose. The facility determined the root cause of the deficient practice that threatened Resident #2's well-being was the nurse's failure to follow established policy in obtaining medications when the medication is not available on the medication cart. On [DATE], the DON, quality improvement (QI) nurse, and staff facilitator (SF) initiated the in-service titled Promoting a Resident's Well-Being. The in-service included the importance of following physicians' orders, keeping the physician informed if unable to administer physician orders, attending to resident needs, and treating residents with dignity and respect was reviewed with all staff, including agency and contracted staff. After [DATE], no staff, agency, or contracted staff will be allowed to work until the in-service is completed. Nurse # 4 was educated on [DATE]. The in-service will be added to new staff orientation, including agency and contracted staff. Beginning [DATE] to correct the deficient practice, all licensed nurses, including agency staff, will be in-serviced on administering medication. Insulin must be administered per physician orders, including obtaining medications when the medication is not available on the medication cart or in the facility. After [DATE], no staff, agency, or contracted staff will be allowed to work until the in-service is completed. Nurse # 4 was educated on [DATE]. The in-service with be added to new staff orientation, including agency and contracted staff. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice: On [DATE], the DON and unit manager reviewed all current residents on insulin to ensure no other doses were omitted in the last 30 days. The review identified 28 occurrences where the administration of insulin was not documented according to physician's orders [REDACTED]. On [DATE] the unit manager contacted the physician regarding undocumented doses of insulin. The physician gave no new orders. Multiple nurses failed to either administer insulin as ordered or failed to document administration of insulin as ordered on multiple residents, throughout the facility at multiple times during the day. The medication errors occurred due to multiple nurses' failure to follow the medication administration policy. On [DATE], the DON and Unit Manager audited to ensure all residents on insulin have the insulin available in the facility. All Residents had Insulin available to match order. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur: On [DATE], the DON, QI nurse, SF, administrator, and/or licensed nurse began auditing 100% of residents on insulin once daily 5 times weekly x 12 weeks to ensure insulin is available for administration as ordered. This audit will be documented on the insulin audit tool. On [DATE], the DON, QI nurse, SF, administrator, and/or licensed nurse began auditing audit 100% of residents on insulin. The auditing will be completed once daily 5 times weekly x 12 weeks to ensure insulin was administered as ordered. This audit will be documented on the insulin audit tool. On [DATE], the DON, QI nurse, SF, and/or administrator began reviewing all referrals to ensure if a potential resident would be on insulin and the medication is available prior to resident admission. This audit will be documented on the insulin referral audit tool. This audit wil

Based on observations, record review, resident, staff, and Nurse Practitioner interviews, the facility failed to administer physician ordered insulin medication to keep residents free of significant medication errors in accordance with accepted professional standards and principles for 1 of 3 residents reviewed for pharmacy services (Resident #2). Immediate Jeopardy began on 09/11/18 when Nurse #4 did not administer insulin per physician's orders [REDACTED].#2 developing DKA. Immediate Jeopardy was removed on 10/22/18 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee education and ensure monitoring systems in place are effective. The findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the Medication Administration Record [REDACTED]. Review of the (MONTH) (YEAR) MAR further revealed Resident #2 did not receive his physician ordered insulin's of 6 units on 09/11/18 at 5:00 PM and 9:00 PM and his sliding scale insulin coverage at 4:30 PM for a CBG of 206 that required 2 units of coverage and 8:30 PM for a CBG of 240 that required 2 units of coverage. Review of the Blood Glucose Monitoring Sheet for 09/11/18 for Resident #2 revealed the following readings: 09/11/18 1:00 PM CBG 236 09/11/18 4:12 PM CBG 206 09/11/18 8:50 PM CBG 240 Per physician order [REDACTED].#2 should have received 2 units regular insulin on 09/11/18 at 4:30 PM. Per physician order [REDACTED].#2 should have received 2 units regular insulin on 09/11/18 at 8:30 PM. An interview with Nurse #3 on 10/09/18 at 1:00 PM revealed she gave Resident #2 12 units of regular insulin on 09/12/18 at 7:30 AM. This included the 6 units of regular scheduled insulin and 6 units of regular insulin for SSI coverage of CBG reading HI. Nurse #3 further revealed the recheck of Resident #2 CBG at 9:30 AM still read HI. Nurse #3 notified the NP, who was at the facility and she examined the resident and ordered him transferred to the hospital for possible diabetic ketoacidosis (DKA). An interview with Nurse #4 on 10/10/18 at 9:06 AM revealed she did not give Resident #2 his regular insulin on 09/11/18 at 4:30 PM and 09/11/18 at 5:00 PM or 09/11/18 at 8:30 PM. Nurse #4 further stated she did not give Resident #2 his 10 units of Detemir insulin scheduled for 09/11/18 at 9:00 PM. A follow up interview with Nurse #3 on 10/10/18 at 9:30 AM revealed she obtained the regular insulin administered to Resident #2 on 09/11/18 and 09/12/18 from house stock in the emergency box. A review of the Nurse Practitioner (NP) progress note dated 9/12/18 indicated Resident #2 was seen on 09/12/18 after a CBG reading was 'HI'. The progress note indicated Resident #2 had also developed nausea and vomiting and he was clammy and anxious. An order was given by the NP to transfer the resident to the emergency department for possible DKA. An interview with the NP on 10/10/18 at 10:00 AM revealed she was unaware Resident #2 had not received his insulin's the evening before he was sent to the hospital. Further interview with the NP revealed her expectation was for the facility nurse to contact the on-call physician if the insulin was not available. A follow up interview with Nurse #4 on 10/10/18 at 10:45 AM revealed she did not remember if she had reported to the 3rd shift nurse that Resident #2 had not received his insulin. She stated she did not contact the on-call physician to notify them of the unavailability of insulin. Nurse #4 indicated she did not call the pharmacy to obtain the insulin or look for the insulin in the emergency box which contains emergency medications. During an interview with Director of Nursing on 10/09/18 at 4:05 PM she stated she expected the facility staff to contact the physician for all missing medications. She further revealed she expected staff to check for the ordered medications in the emergency box and to contact pharmacy for missing medications. Review of the hospital records revealed Resident #2 was admitted to the hospital intensive care unit for DKA on 09/12/18. Blood sugar on admission to the hospital was 485. Resident #2 required an insulin drip which he was weaned from the morning of 09/13/18. He was discharged on [DATE]. On 10/18/18 at 8:30 AM the Director of Nursing and the Administrator were notified of Immediate Jeopardy via telephone. 1. How corrective action will be accomplished for those residents found to have been affected by the deficient practice: Resident #2 was admitted to the facility on [DATE], with a primary [DIAGNOSES REDACTED]. Resident #2 had insulin orders for 6 units of Regular insulin with meals, 10 units of Detemir ([MEDICATION NAME]) at bedtime and a sliding scale of Regular insulin before meals and at bedtime. On 9/11/18 at approximately 4:12 pm, Resident #2's finger-stick blood sugar (FSBS) was 206. Nurse #4 did not administer 2 units of Regular insulin, sliding scale (SS), as ordered by the physician. Nurse #4 did not follow the system place for when medication is not available. Nurse #4 should have obtained insulin from the emergency drug kit (EDK) or contacted the physician to give the physician opportunity to alter treatment. Upon accessing the EDK, Nurse #4 failed to identify the medication. On 9/11/18 at approximately 5 pm, Resident #2's supper meal coverage dose of Regular Insulin 6 units were not given. On 9/11/18 at approximately 8:50 pm, Resident #2's FSBS was 240. 2 Units of SS Regular Insulin were not given. On 9/11/18 9 pm, Resident #2's bedtime dose of [MEDICATION NAME] 10 units were not given. On the morning of 9/12/18, Resident #2 experienced at FSBS reading of HI. The resident received two doses of 6 units of Regular Insulin; however the resident's FSBS reading would not drop below HI. Resident #2 was sent to the emergency room , where the resident was admitted with Diabetic Ketoacidosis, and placed on an insulin drip to lower his blood sugar. On 10/17/18, the director of nursing (DON) interviewed Nurse #4 assigned to Resident #2, for date of service 09/11/18, which revealed Nurse #4 did not give the insulin because it was unavailable. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice: On 10/19/18, the DON and unit manager reviewed the medication availability of all facility residents receiving insulin to ensure insulin was available. This review compared each resident's current insulin orders with the Medication Administration Record [REDACTED]. No concerns were identified, all residents with an order for [REDACTED].> On 10/19/18, the DON and unit manager reviewed all current residents on insulin to ensure no other doses were omitted in the last 30 days. The review identified 28 occurrences where the administration of insulin was not documented according to physician's orders [REDACTED]. On 10/22/18 the unit manager contact the physician regarding undocumented doses of insulin. The physician gave no new orders. Multiple nurses failed to either administer insulin as ordered or failed to document administration of insulin as ordered on multiple residents, throughout the facility at multiple times during the day. The medication errors occurred due to multiple nurses' failure to follow the medication administration policy. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur: On 10/19/18, the DON, QI nurse and staff facilitator (SF) began education with all licensed nurses on the importance of following insulin orders. This education included: 1) the physician must be notified anytime the prescribed insulin is not available to administer as ordered, 2) the contents of the EDK are available for use if the medication ordered for the resident is not available, 3) insulin cannot be missed, the nurse must address immediately. On 10/21/18, the education was 50% completed with all registered nurses (RNs) and licensed practical nurses (LPNs). No nurse is allowed to work until the education is completed. 4. How the facility plans to monitor its performance to make sure solutions are sustained (include dates when corrective action will be completed) Beginning 10/19/18, the DON, QI nurse, SF, or unit manager will audit each resident receiving insulin to ensure their insulin was available and given as ordered, and if the MD was notified if insulin was not administered as ordered. This audit will be completed five times weekly and recorded on the Insulin Audit Sheet. Any concerns identified by the auditor will have corrective action taken by the auditor immediately. The completed audits will be reviewed at the daily interdisciplinary team (IDT) meeting for additional corrective measures. The daily IDT's role in this plan of correction includes implementation, monitoring, and ensuring the interventions are effective. The IDT also makes recommendations for revisions as needed. The daily IDT review findings will be brought to the next quarterly quality assurance and performance improvement (QAPI) meeting for additional review and recommendations. On 10/22/18, the administrator notified the QAPI committee of the significant medication error IJ and the facility's plan of correction, including the QAPI committee's role in the plan of correction. Beginning 10/19/18, the administrator will be responsible for implementing and monitoring corrective measures to ensure solutions are sustained. Macon Valley Nursing and Rehabilitation Center alleges compliance of removal of IJ, F 760, as of 10/22/18. On 10/23/18 facility staff were interviewed and demonstrated they had been trained on the topics of medication administration, and how to call the pharmacy for medications, and to notify the physician if medications weren't available. Immediate jeopardy was removed effective 10/22/18.

Based on observations, resident, family and staff interviews and record reviews, the facility failed to honor the choices of 7 of 7 sampled residents to be showered or receive baths as often as they preferred which caused one resident state they felt miserable and dirty and another resident to state they were upset (Residents #1, #5, #10, #13, #16, #19 and #21). The findings included: 1. Resident #19 was admitted to the facility on [DATE]. The admission Minimum (MDS) data set [DATE] coded him with having moderate cognitive impairment, scoring a 12 out of 15 on the Brief Interview for Mental Status. He was coded to need extensive assistance with most activities of daily living including bathing. During an interview with Resident #19, he stated that he had not received a shower in the entire time he was at the facility. He further stated he was offered a shower twice and waited for staff to get him but they never returned. He stated he had never refused a shower. He stated he would like a shower at least once a week and that he feels miserable and dirty. Review of the computer and paper documentation for Resident #19 revealed no evidence he was ever provided a shower. Interview with Nurse Aide #3 on 10/10/18 at 9:54 AM revealed that there is often no time to give showers on the hall so she does her best to wash residents up but not in the shower. She further stated there have been lots of complaints about showers being missed. Interview with Nurse Aide #6 on 10/10/18 at 10:29 AM revealed Resident #19 was independent with his own care. Nurse Aide #8 was interviewed on 10/10/18 at 12:52 PM. He stated he got information about resident needs and abilities via word of mouth or asking the resident. He further stated that he thought he was told Resident #19 did all care for himself. He stated that in the few weeks he has been at this facility, he was finding out that residents who reportedly could do for themselves really needed more assistance. Interview with the Director of Nursing (DON) on 10/10/18 at 6:33 PM revealed some days there was not enough staff to get the bathing completed. She stated she has received a lot of complaints from families and residents about showers not being completed. The DON also stated that she expected the showers and bathing schedules to be followed. 2. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum (MDS) data set [DATE] revealed Resident #5 was cognitively intact and required limited assistance with bathing. Review of the care plan dated 08/27/18 revealed Resident #5 required assistance to restore or maintain maximum function of self-sufficiency for bathing related to physical limitations and weakness. The goal was for Resident #5 to be neat, clean and odor free daily. The interventions included: set up help from staff for bathing, ensure hair was washed and nails manicured on bathing days. Review of the 200 hall facility shower sheets revealed Resident #5 received four showers from 09/08/18 through 10/09/18 on 09/11/18, 09/18/18, 09/28/18, and 10/06/18. There were no refusals of showers noted on the shower sheets. An interview conducted on 10/09/18 at 8:10 AM with Nurse Aide #5 (NA) revealed he was the only NA on the 200 Hall for the 7:00 AM to 3:00 PM shift. He stated there was no way to do showers, incontinence rounds, pass trays, assist with feeding residents and get residents dressed and out of bed for 28 residents when he was by himself on the hall. He stated showers didn't get done and rounds were usually only done once a day. An interview conducted on 10/09/18 at 10:47 AM with Resident #5 revealed she was upset because she wasn't receiving two showers a week. She stated the facility was short staffed and they didn't have time to help her with her showers. An interview conducted on 10/10/18 at 11:55 AM with NA #7 revealed she all halls and when she had to work the hall by herself she was not able to give showers. She stated she usually worked a hall by herself 3 to 4 days a week. An interview conducted on 10/10/18 at 6:30 PM with the Director of Nursing revealed she was aware that some days there wasn't enough staff to give resident showers and she has had many complaints from families and residents regarding showers not being given. She further stated it was her expectation that shower schedules be followed. 3. Resident #21 was admitted to the facility on [DATE] and most recently on 09/10/18. The admission Minimum (MDS) data set [DATE] coded her as having moderately impaired cognition, scoring a 12 out of 15 on the Brief Interview for Mental Status. She was coded as requiring extensive assistance with most activities of daily living skills including bathing. On 10/09/18 at 8:31 AM, a family member left Resident #21's room and was observed to ask Nurse Aide (NA) #1 to give Resident #21 a shower. NA #1 stated he would check the shower schedule and give her a bath. On 10/09/18 at 8:38 AM, Resident #21 stated during interview that she had been here approximately 2 months and only received 3 showers while in the facility. During a follow up interview on 10/10/18 at 8:20 AM, Resident #21 stated that she preferred bed baths and would like a bed bath once a week. Resident #21 stated she was not receiving one bed bath a week and last Friday a family member complained about it. She stated again she wanted a bed bath once a week. Review of the computer and handwritten documentation of showers/bathing provided revealed Resident #21 was bathed on 08/28/18, 09/03/18, refused on 09/29/18 and received a bed bath on 10/05/18. There was no other evidence provided to show Resident #21 had received more than 3 showers/baths since admission. On 10/09/18 at 9:01 AM, NA #4 stated she usually worked the hall alone and was unable to get all the care completed. She did quick bed baths, washing the underarms and peri-area when getting residents up but was unable to give full baths/showers. She stated that she has told Administration about the care not being completed. Interview with the Director of Nursing (DON) on 10/10/18 at 6:33 PM revealed some days there was not enough staff to get the bathing completed. She stated she has received a lot of complaints from families and residents about showers not being completed. The DON also stated that she expected the showers and bathing schedules to be followed. 4. Resident #13 was admitted to the facility on [DATE]. The annual Minimum (MDS) data set [DATE] coded her with severely impaired cognitive skills. She was coded as requiring extensive assistance with most activities of daily living skills including bathing. During the assessment period, the MDS coded that she had not had a bath/shower during the 7 day look back period. On 10/09/18 at 11:30 AM, family was interviewed and stated today was her shower day. Upon follow up interview on 10/10/18 at 11:25 AM, family stated she preferred for Resident #13 to receive 2 showers per week. On 10/09/18 at 9:01 AM, NA #4 stated she usually worked the hall alone and was unable to get all the care completed. She did quick bed baths, washing the underarms and peri-area when getting residents up but was unable to give full baths/showers. She stated that she has told Administration about the care not being completed. Review of the computer and hand written shower documentation revealed she was scheduled to have showers on day shift Tuesdays and Fridays. Since 08/28/18 she missed her shower on 08/31/18, 09/07/18, 09/18/18, 09/21/18, 09/25/18, 09/28/18, and 10/05/18. There was no other evidence provided to support she had received showers on other days to make up for the missed showers. Interview with the Director of Nursing (DON) on 10/10/18 at 6:33 PM revealed some days there was not enough staff to get the bathing completed. She stated she has received a lot of complaints from families and residents about showers not being completed. The DON also stated that she expected the showers and bathing schedules to be followed. 5. Resident #16 was admitted to the facility on [DATE]. Per review of the Minimum Data Set, an admitted d 07/04/18, Resident #16 had moderately impaired cognitive skills and required extensive assistance with bathing. On 10/09/18 at 9:06 AM Resident #16 was observed asking Nurse Aide #4 for a shower this morning. NA #4 told the resident she would try to squeeze her in but she was on the floor by herself. On 10/09/18 at 9:06 AM, Resident #16 stated in an interview that she only received a shower once every two weeks. She stated the staff keep putting her off when she asked for her shower. She stated she was supposed to be showered on Tuesday and Fridays. Review of the computer and hand written shower records revealed she was not given a shower on 08/31/18, 09/07/18, on 09/11/18, 09/17/18, 09/21/18, 09/28/18, and 10/05/18. There was no documentation to support that she received showers as make up for these missed showers. On 10/09/18 at 9:01 AM, NA #4 stated she usually worked the hall alone and was unable to get all the care completed. She did quick bed baths, washing the underarms and peri-area when getting residents up but was unable to give full baths/showers. She stated that she has told Administration about the care not being completed. Interview with the Director of Nursing (DON) on 10/10/18 at 6:33 PM revealed some days there was not enough staff to get the bathing completed. She stated she has received a lot of complaints from families and residents about showers not being completed. The DON also stated that she expected the showers and bathing schedules to be followed. 6. Resident #1 was admitted to the facility on [DATE]. The admission Minimum (MDS) data set [DATE] coded him with severely impaired cognition, and requiring total assistance with bathing. On 10/10/18 at 10:32 AM, a phone interview was conducted with family. Family stated at that time Resident #1 only received 1 shower per week and she wanted him to have 2 showers a week. Review of the computer and handwritten shower records revealed he was given a shower on Monday 08/27/18 but none the rest of the week, on Monday 09/03/18 and none the rest of the week, once during the week of 9/10/18, none the week of 09/17/18, only once the week of 10/01/18. On 10/09/18 at 9:01 AM, NA #4 stated she usually worked the hall alone and was unable to get all the care completed. She did quick bed baths, washing the underarms and peri-area when getting residents up but was unable to give full baths/showers. She stated that she has told Administration about the care not being completed. Interview with the Director of Nursing (DON) on 10/10/18 at 6:33 PM revealed some days there was not enough staff to get the bathing completed. She stated she has received a lot of complaints from families and residents about showers not being completed. The DON also stated that she expected the showers and bathing schedules to be followed. 7. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the significant change Minimum (MDS) data set [DATE] revealed Resident #10 was moderately cognitively impaired and required total assistance with bathing. Review of the care plan dated 08/01/18 revealed Resident #10 required assistance to restore or maintain maximum function of self-sufficiency for bathing related to cognitive impairment, impaired mobility, and physical limitations. The goal was for Resident #10 to be neat, clean, and odor free. The interventions included: bathing - one person physical assist/mechanical lift for transfer only. Encourage resident to participate in self-care as ability permits .Ensure hair is washed and nails are manicured on bathing day. Review of the 300 hall facility shower sheets from 09/08/18 through 10/09/18 revealed Resident #10 received a shower on 09/08/18, 09/17/18, and 09/27/18. There was no documentation of refusals or bed baths on the shower sheets. An interview conducted on 09/10/18 at 3:30 PM with Resident #10 revealed she was very upset because she wasn't getting her showers as scheduled. She stated she was supposed to have 2 showers a week and most weeks she received 1 or none. She stated they didn't have enough staff to give showers. An interview conducted on 10/10/18 at 2:10 PM with Nurse Aide #3 (NA) revealed she worked the 7:00 AM to 3:00 PM and the 3:00 PM to 11:00 PM shifts on the 300 hall. She stated she often worked the hall by herself and there was no way to do resident showers when she was on the hall by herself. An interview conducted on 10/10/18 at 11:55 AM with NA #7 revealed she worked all halls and when she had to work the hall by herself she was not able to give showers. She stated she usually worked a hall by herself 3 to 4 days a week. An interview conducted on 10/10/18 at 6:30 PM with the Director of Nursing revealed she was aware that some days there wasn't enough staff to give resident showers and she has had many complaints from families and residents regarding showers not being given. She further stated it was her expectation that shower schedules be followed.

Based on record review, staff interviews, Ombudsman interview, Adult Protective Service Worker interview and former resident interview, the facility failed to provide 1 of 3 sampled residents (Resident #1) with a discharge planning process which included the residents discharge goals and needs, caregiver support and referrals to local contact agencies as appropriate and involvement of the resident and interdisciplinary team in developing the discharge plan. The discharge place had not been assessed prior to Resident #1 being taken there and dropped off by the facility transport driver. Immediate jeopardy began on 04/30/18 when Resident #1 was transported to his residence by a facility transport driver without any assessment, preparation or planning. Resident #1 was assisted out of the facility vehicle in his wheelchair to a utility building with no electricity or running water that could be seen by the facility driver. The facility driver returned to the facility and reported to the Director of Nursing (DON) how the area appeared. On 05/01/18 the facility submitted an Adult Protective Services (APS) report detailing the concerns of the living environment for Resident #1. Immediate Jeopardy was removed on 06/13/18 based on the allegation of compliance that was provided. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective related to training of facility staff regarding the discharge planning process. The findings included: Resident #1 was admitted to the facility on [DATE] after a hospitalization . The admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 had moderately impaired cognitive skills and required assistance with most activities of daily living. The MDS also indicated Resident #1 required assistance with stabilization during transfers. The MDS further indicated Resident #1 had [DIAGNOSES REDACTED]. The MDS also noted Resident #1 expected to be discharged to the community although no discharge planning had started. The most recent quarterly MDS dated [DATE] revealed Resident #1 was cognitively intact with a mini-mental score 14 out of a possible 15. Record review of the hospitalization for Resident #1 indicated he had lived alone in a shack with no running water or electricity prior to his hospitalization . The record review also revealed the neighbor of Resident #1 found him injured on 11/26/17, emergency services were contacted and he was transported to the hospital. Resident #1 had a right [MEDICAL CONDITION] resulting from this hospitalization . Resident #1 was discharged from the hospital on [DATE] to the nursing home. Record review of the care plan dated 12/27/17 revealed Resident #1 wished to return home after his rehabilitation in the facility. Goals to assist Resident #1 to achieve his wishes included the following: resident will receive adequate preparation and orientation for discharge to home upon completion of rehabilitation therapy. Record review of progress notes on 01/25/18 revealed the Social Worker (SW) had sent a referral for placement to another skilled nursing facility that was a smoking facility. Resident #1 had been found throughout the day smoking in the parking lot (against facility rules). Additional progress notes dated 01/28/18 revealed referrals had been sent to 6 other facilities that allowed smoking. Record review of the transfer/discharge notice was issued to the resident on 04/03/18 which indicated he had been non-compliant with the facility's smoking policy. The transfer/discharge notice had been signed by the Administrator. At no time did the resident request an appeal of the discharge notice. A home visit was made to the residence of Resident #1 with the Adult Protective Services (APS) worker on 06/19/18 at 11:49 AM. An observation of the residence revealed it was a small utility building with burning trash within a foot of the entranceway. Resident #1 was present, sitting up in his wheelchair, smoking a cigarette. An interview with Resident #1 revealed he had no electricity, no running water, no refrigeration, no toilet or shower, no cell phone or land line, and was unable to close one of the doors of his utility building. He stated he was okay living there and stated there was nothing else he needed as this was where he lived prior to his facility stay. Resident #1 stated the SW at the facility told him he was being discharged but he couldn't remember why. When asked if it was due to his smoking Resident #1 stated he didn't think so. Resident #1 stated he told various staff in the facility that he was coming back to his little trailer when he left. Resident #1 also stated that he had 2 checks given to him from the facility, but he had lost one and it was written for over $8,000.00. During an interview on 06/19/18 at 12:12PM with the APS worker, she stated that APS had received a report on Resident #1 on 05/01/18. She also stated the APS report revealed Resident #1 had multiple hazards in the utility building including, but not limited to: being a fire hazard, having inadequate heating and cooling, falling/tripping hazards, no access to transportation, no telephone access, no way to prepare meals, do laundry or housekeeping, and no way to make repairs. The APS worker further stated she made her first visit with Resident #1 at the utility building on 05/03/18 and he told her he didn't have electricity or running water but stated he was fine living there. During repeated meetings with Resident #1 he continued to state the utility building was where he wanted to be. Resident #1 was observed by the APS worker to be wearing the same clothes at this visit and he had been wearing when she first met him on 05/03/18 and each time she has seen him since. The Department of Social Service APS Department did substantiate self-neglect on 05/31/18 and Resident #1 had agreed to protective services and signed a contract on 06/04/18 allowing them to 1) be his payee 2) set up transportation services for him and 3) find him a new play to live. It had taken the APS worker a month to convince Resident #1 to agree to the protective service contract which allowed them to assist with his social security check, assist with transportation and attempt to locate him a place to live. During an interview on 06/19/18 at 3:52 PM with the Transport Driver (TD) who assisted Resident #1 to his residence on 04/30/18, the TD stated the plan was to take Resident #1 to the bank to cash his checks and then to a hotel. The total amount of the 2 checks was quite substantial. The TD also stated the first bank would not cash the checks for Resident #1 because he had no identification so he drove back to the facility, got a copy of the face sheet for Resident #1 and then drove to the second bank, who was the issuer of the checks to Resident #1. At the second bank, the bank teller stated she knew Resident #1 and was uncomfortable giving him this amount of money. Resident #1 told the TD to forget it and just take him home. After calling the facility for guidance, the Director of Nursing (DON) told the TD that Resident #1 was of sound mind and body and could make that decision independently. Resident #1 was taken to an area off the road that had no mailbox and no driveway up to a small shack with 2 windows, no toilet, no refrigerator and phone that he could see. Realizing that Resident #1 had no way to be mobile, the TD left the facility wheelchair with him. Upon his arrival back to the facility, the TD stated he reported the place looked horrible to the DON and the Quality Improvement (QI) nurse. The next morning, the TD was concerned that Resident #1 may not have anything to eat and went to a local restaurant to buy breakfast for him. While he was driving back to the shack of Resident #1, the TD saw him on the highway and stopped to let him know he had brought him some food. Resident #1 asked the TD if he would take the food up to his trailer because he was on his way to meet someone to take him into town to cash his check. Per his request, the TD took his food up to the shack and left it and when he drove back down to the road, Resident #1 was no longer on the road. The facility Social Worker (SW) (who no longer works in the facility) was given the information about the condition of the shack by the TD and he stated she called in an APS report and told the TD that was all they could do for Resident #1. During an interview with the current Rehabilitation Director (RD) on 06/19/18 at 4:31 PM, the RD stated when Resident #1 first came to them he was very disoriented, confused, impulsive and having pain, but was able to progress quickly with therapy and was eventually able to transfer and walk several hundred feet with a wheeled walker. Resident #1 had said he was going home after his therapy and they had offered a home assessment for him but he denied wanting this. The RD also stated they became aware he would not be going home at that time but would be staying in the facility. He was discharged from speech therapy on 01/19/18 for noncompliance with following his plan of care and discharged from physical therapy and occupational therapy on 02/01/18 after his goals had been met. Resident #1 had refused to consider a prosthesis for his amputation. The amputation area of his right leg was also noted to be healed by 01/16/18. During an interview on 06/20/18 at 11:35 AM, the Ombudsman stated he had not been made aware of the discharge for Resident #1 until about 04/15/18 and there was no documentation about discharge planning, where he was discharging to, or any type of home assessment on the notice to determine if it was a safe discharge for him. The transfer/discharge notice did indicate the reason for his discharge was non-compliant with safety procedures, smoking in non-designated areas. During an interview on 06/20/18 at 12:03PM, the Administrator stated Resident #1 had indicated from his arrival in the facility that after his therapy was done he would be leaving. Resident #1 had received a 30-day discharge notice on 04/03/18 as he would not comply with the facility smoking policy. The Director of Nursing and the Administrator had tried to discuss with Resident #1 an option of moving to a disability apartment but Resident #1 stated he wanted to go home. The Administrator stated she had also discussed purchasing a small travel trailer with his Social Security back pay, but he continued to state that he had a little trailer on the property that he was returning to. Resident #1 had previously advised the Administrator that he would not use his back pay of over $8,000.00 dollars from social security to pay for a prosthetic leg because he was fine in a wheelchair. During morning stand up meetings starting on 04/04/18, they had started talking about him going home and the Physical Therapy Supervisor was present and aware that Resident #1 would be returning home. The Administrator stated she was out on leave at the time of the discharge for Resident #1 and is unsure what the SW did to help with his discharge. During an interview on 06/20/18 at 12:32 PM with the previous RD during the time of the discharge for Resident #1, the RD stated he did not recall any discussions of the upcoming discharge for Resident #1 during morning meetings. During the facility stay for Resident #1, the RD stated he only had either one or two meetings with Resident #1 and he had never mentioned wanting to go home to him. The RD also stated he had been on vacation the first week of (MONTH) and when he came back the following week was when he found out that Resident #1 was gone and assumed he had been discharged home. The RD further stated the purpose of the home visit was to see what barriers exist for the resident at the home. He indicated Resident #1 was not on the therapy caseload at the time of his discharge so a home assessment would not have been done. During an interview on 06/20/18 at 6:42 PM with the DON, she stated Resident #1 had indicated from the time he came into the facility that he was going to go home after his therapy. On the afternoon of 04/30/18, the DON was contacted by the TD and he had explained about the banks not cashing the checks for Resident #1 and he was requesting to return to his home. The DON stated she looked up his BIMS and told the TD Resident #1 was his own Responsible Party (RP) and was of sound mind and body and could make that decision for himself. The DON stated she had talked to the doctor and he agreed with the discharge for Resident #1 and did not feel any other services were needed except the discharge. She also stated there was nothing else they could do for Resident #1 as he was competent, had no medical needs and he refused other options. As the Administrator was out of the facility, the DON contacted the Vice President of Operations for validation it was okay to let Resident #1 discharge to his residence. The DON was notified of immediate jeopardy on 06/19/18 at 10:02 AM. The facility provided a credible allegation of compliance on 06/20/18 at 3:13 PM as follows: ·Plan of correcting the specific deficiency On 12/25/18, the social worker history reflects Resident #1's prior level of living, lived alone, and discharge plan was short term rehab (STR). On 12/27/18, Resident #1's care plan reflected the resident's desire to return home upon completion of rehabilitation therapy. On 1/25/18, the social worker sent a referral to Valley View Nursing (a smoking facility) to review for placement. On 1/28/18, the social worker sent referrals to the following to review for placement (smoking facilities): Hayesville House, Blue Ridge on Mountain, Clay County Care Center, Valley View skilled nursing facility, Franklin House Assisted Living, Grandview Assisted Living. On 2/1/18, Resident #1 was discharged from rehabilitation therapy, all goals met. By the end of (MONTH) (YEAR), after Resident #1 received wound therapy treatment by the facility, the resident's amputation area had healed. On 3/31/18, Resident #1 was assessed with [REDACTED]. On 4/3/18, the administrator issued a 30-day discharge to Resident #1. The facility did not contact the ombudsman or the adult protective services worker that this time. On 4/3/18, the administrator reviewed the discharge plan with Resident #1. They discussed at length where Resident #1 would go upon discharge. Resident #1 told the administrator he wanted to go to his trailer. The administrator informed Resident #1 that he had enough money for an apartment and he responded No, I have a trailer and want to go there. At this time a facility representative did not go and look at the trailer. On 4/30/18, Resident #1 was discharged to the community upon agreement with the facility social worker that the resident would go to the hotel where Resident #1 had friends. After leaving the facility, Resident #1 changed the desired discharge location to Resident #1's home. Resident #1 exercised the right not to go to his agreed community destination but rather to return directly to his homestead. After discovering the resident did not go to the community motel as agreed, the facility did not do a home visit or have staff do a home visit to evaluate Resident #1's homestead situation. Further at this time, Resident #1 demanded he be taken to his homestead situation and the transportation employee honored the residents request. Resident #1's home was a tin storage building with no electricity or running water. What lead to the deficiency of the resident being discharged to an unsafe situation was the facility did not go and look at Resident #1's trailer or contact the ombudsman, either of which may have helped to identify the potential for discharge to an unsafe location. ·The procedure for implementing the acceptable plan of correction for the specific deficiency cited On 5/17/18, the DON initiated an in-service for licensed nurses on documentation for discharge of a resident. This includes assessment, discharge summary, medication release form, and discharge instructions. This in-service was completed on 6/4/18. This in-service will be part of the orientation for all newly hired licensed nurses. The in-service will ensure residents are provided with a safe and orderly discharge. On 5/25/18, the DON reviewed all residents discharged in the last 14 days ensuring documentation is present verifying needed equipment, medication, nursing assessments, and services were arranged at time of a resident's discharge. All discharges had necessary arrangements made prior to discharge to ensure residents are being discharged to a safe location. Beginning 5/25/18 when the facility interdisciplinary team (IDT) determines resident needs cannot be met or it is necessary for the facility to issue a 30-day discharge notice, the DON and/or administrator will notify the regional vice president (RVP). The RVP will provide guidance to the facility to ensure the resident is provided with a correct 30-day discharge notice and safe and orderly discharge, including a safe location. The director of nursing will be responsible for determining the discharge location is safe. On 5/31/18, the facility consultant provided an in-service to the DON on ensuring residents are provided a safe, orderly discharge including when issued a 30-day discharge notice. The in-service included documentation of discharge preparations, barriers, and resident status. On 6/6/18, the DON was in-serviced by the regional ombudsman on correctly completing a 30- day discharge notice. This in-service included notifying the ombudsman on the same day the 30-day discharge notice is presented to the resident/resident representative. The DON now understands the ombudsman should be involved in the beginning to ensure a resident is discharged to a safe location. The DON is responsible for reviewing 30-day discharge notices. This in-service will ensure any future 30-day discharge notices are completed accurately and completely. This in-service will ensure the resident is provided with a safe and orderly discharge, including safe discharge location. ·The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements The DON, quality assurance nurse(QI), and/or staff facilitator will review discharges occurring during the last 7 days weekly x 12 weeks to ensure the discharge was safe and orderly, including medications, equipment, and services were arranged and documented prior to discharge. This audit will be documented on the Day of Discharge Item Checklist/Audit. The audit will include verifying contact of the ombudsman. The DON, and/or QI nurse will review all 30-day discharge notices weekly x 6 months. The review will include ensuring the documentation is complete and accurate, including ensuring a safe discharge location. This will be documented on the discharge audit tool. The monthly QI committee will review the results of the discharge audit tool for 6 months for identification of trends, actions taken, and to determine the need for and/or frequency of continued monitoring, and make recommendations for monitoring for continued compliance. The administrator and/or DON will present the findings and recommendations of the monthly QI committee to the quarterly executive QA committee for further recommendations and oversight. The QI Committee met on 6/13/18 and reviewed discharges to ensure documentation supports a safe and orderly discharge. ·The title of the person responsible for implementing the acceptable plan of correction. The Administrator and DON will be responsible for the implementation of correctly issuing a 30- day discharge notice and ensuring a resident has a safe and orderly discharge. Corporate oversight will be provided by the corporate RVP to ensure the administrator and DON implements and monitors the plan of correction. The credible allegation was verified on 06/20/18 and as evidenced by the following: verification of re-education for licensed nurses of documentation for discharge of a resident including assessment, discharge summary, medication release from and discharge instructions, validating the DON was reviewing resident discharges daily to verify needed equipment, medication, nursing assessment, documentation and services were arranged at the time of discharge, education to the DON by the facility consultant regarding safe and orderly discharges for residents being given a 30-day discharge notice including documentation of discharge preparations, barriers, and resident status, and education to the DON by the Ombudsman of correctly completing 30-day discharge notices.