Every finding on record at Mountain View Rehabilitation and Healthcare Center

Based on observation, interview, record review, and facility policy the facility failed to implement changes to the Care Plan for 1 of 14 Sampled residents, (R46).The findings include:Review of the facility policy titled Comprehensive Care Plan not dated, revealed it was the policy to the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the resident's comprehensive assessment. Further review of the policy revealed the interdisciplinary team (IDT) would develop resident specific interventions, and the comprehensive care plan would be reviewed and revised by the IDT after each comprehensive and quarterly Minimum Data Set (MDS) assessment. Furthermore, the qualified staff responsible for carrying out interventions specified in the care plan would be notified of their roles and responsibilities for carrying out the interventions, initially and when changes were made,Review of Resident (R)46's admission Face Sheet revealed R46 was admitted on [DATE] with diagnoses of major depressive disorder, bipolar disorder, and difficulty walking.Review of R46's MDS dated [DATE] revealed resident was dependent with chair/bed to chair transfers.Review of R46's care plan revealed a focus for assistance with activities of daily living and personal care related to impaired cognition and impaired mobility initiated on 08/09/2024. The goal was that activities of daily living and personal care would be completed with staff support as appropriate to maintain or achieve the highest practical level of functioning through the next review, initiated 08/09/2024. Interventions listed on the care plan for this goal were, resident was dependent with maximal non-weight bearing assistance of two staff using a mechanical lift. This intervention was initiated 05/01/2025.Review of R46's Kardex revealed handling and/or movement for transfers, resident was dependent/maximal/non-weight bearing assistance for two staff using mechanical lift.During an observation on 09/24/3035 at 11:32 AM, Certified Nurse Assistant (CNA) 4 and CNA 5 was in the room with R46 preparing to get her out of bed. The CNA's closed the door. When the door reopened R46 was in the rock and go chair. There was no mechanical lift observed in R46's room at any time.During an observation on 09/25/2025 at 11:25 AM, CNA 4 and CNA 5 were coming out of R46's room with R46 in the Rock and go chair. There was no mechanical lift observed at any time in R46's room.During an interview on 09/25/2025 at 11:26 with CNA6, who was in R46's room just after the transfer, she stated R46's transfers required the use of a mechanical lift. She further stated she did not assist with transferring R46 today.During an interview on 09/25/2025 at 11:30 AM with CNA5 revealed she and CNA4 had completed a 2 person assist with R46 without the use of a lift. CNA5 stated R46 was a two-person transfer. She further stated she looked at the Kardex to know what type of assistance a resident needed, and usually the nurses would tell her if changes were made to the resident's care needs.During an interview on 09/25/2025 at 11:35 AM with CNA 4 revealed she and CNA 5 had completed a two person assist transfer from the bed to the rock and go chair with R46 without the use of a lift. CNA4 stated she was not aware that R46 was care planned for a mechanical lift. She further stated she could look at the Kardex in the kiosk to view resident specific care needs. She stated usually therapy assesses residents when there is an increase in care needs and then makes the CNAs aware of the change. She further stated not following the care plan could result in injury to the resident and/or staff.During an interview on 09/25/2025 at 12:25 PM with CNA6 she stated she was mistaken and thought that R46 could be transferred by two persons with a lift or without the lift depending on how the Resident was functioning at that time.During an interview on 09/25/2025 at 12:30 PM with the MDS coordinator she stated she made the change to R 46's care plan on 05/01/2025 for transfers to be completed using the mechanical lift. She stated this was completed during the IDT meeting after discussion with staff. She further stated the information for the change in care should have been relayed to staff via a text messaging app the facility uses, and/or the communication board at the nursing station. The MDS coordinator stated she reviews and updates the care plan at the required MDS timepoints.During an interview on 09/25/2025 at 4:17 PM with Registered Nurse (RN) 1, she stated R46 required a lift for transfers due to decline. RN1 further stated that R46 assistance needs change often. She further stated the process was to either have physical therapy to assess the resident, if a lift was needed, the order would then be put in the system. The care plan would then be updated to reflect the change and would be added to the Kardex. RN1 stated the nurses could update the care plan when needed when changes in care occurred. RN1 further stated not following the care plan could result in injury to staff and/or the resident.During an interview on 09/25/2025 at 4:30 PM with the Director of Nursing (DON) she stated the Quality Assurance Nurse was responsible for doing oversight audits. She stated staff should be made aware by in-service or verbally of any change in resident care. She further stated her expectation was for staff to follow the plan of care. She stated not following the plan of care could result in injury to staff and/or the resident.During an interview on 09/25/2025 at 5:35 PM with the Administrator she stated her expectation was for the staff to follow the care plan specific for each resident to provide the safest care for that resident and not following could result in a fall and/or injury to staff or resident. She stated the CNAs are aware to report any change with a resident to the nurse and the nurse could update the care plan and make the IDT aware. Furthermore, the MDS coordinator updates with each required MDS. The Administrator further stated there were currently no set audits in place for monitoring the care plan, but spot checks were done randomly to ensure accuracy of the care plans.

Based on interview, record review, review of the facility's local health department inspection, and review of the local health department's website, the facility failed to provide education to food handlers related to safe food handling practice to enable the food handlers to effectively carry out the functions of the food and nutrition service department. This deficient practice affected 53 residents receiving meals from the kitchen. The findings include: Review of the local health department's, Food Service Establishment Inspection Report, dated 08/17/2023, revealed the facility had been cited for areas of the kitchen floors needing cleaning; equipment needing cleaning; and three (3) overhead lights needing repair. Review of the local county health department's website, Environmental - Bell County Health Department (bellcohealthky.org), revealed an annual Food Handler Training Course for all employees who worked in the food service industry was required. Continued review revealed newly hired food service workers were to complete the food handlers online training course before beginning to work at their place of employment. Further review revealed the website noted the online Food Handler Training Course covered food safety laws and regulations and proper hygiene practices and food handling techniques. Review of the facility's dietary staffs' personnel records revealed three (3) of nine (9) dietary employees (Cook 2, Dietary Aide 1, and Dietary Aide 2) did not have a Food Handlers Card, nor documentation of having received ServSafe training, or the Clinical Dietary Manager (CDM) training. Observation on 07/15/2024 at 2:25 PM and 5:03 PM, revealed [NAME] 2 and Dietary Aide 1 were the only dietary staff members working in the kitchen area preparing and serving dinner. In an interview with [NAME] 2 on 07/15/2024 at 5:10 PM, she stated she did not have a Food Handlers Card. [NAME] 2 went on to say she and Dietary Aide 1 had both not been here (at the facility) but a couple of months. She further stated neither she or Dietary Aide 2 had done the training yet, but needed to do it. In a telephonic (phone) interview with the Dietary Manager on 07/17/2024 at 4:52 PM, she stated her cooks all had Food Handlers cards and/or ServSafe certifications. In an interview with Dietary Aide 2 on 07/18/2024 at 8:27 AM, she stated she had only worked at the facility two months and had not yet obtained her Food Handlers Card or ServSafe certification. In an additional phone interview with the Dietary Manager on 07/18/2024 at 10:27 AM, she stated a dietary worker had 30 days after starting work to obtain their Food Handlers Card. She stated the facility did not have a policy stating that requirement however, and she had never been told what action were to be taken for employees who did not comply within 30 days. The Dietary Manager expressed verbal agreement regarding a process failure and despite her asking [NAME] 2 to get her Food Handlers Card the [NAME] had not done so. She further stated [NAME] 2 continued to work at the facility. During interview with the Registered Dietician (RD) on 07/18/2024 at 10:53 AM, she stated her expectations for all dietary workers was for them to have a ServSafe or a Food Handlers certification. When the SSA Surveyor asked what should be done if a dietary staff member was working in the kitchen without one of those certifications, she stated the staff needed to be certified as soon as possible, within the week. The RD further stated her expectation was that there should always be someone with ServSafe, Food Handlers Card, or RDM certification working in the kitchen to provide supervision. When informed of the observation on 07/15/2024 at 2:25 PM and 5:03 PM, when [NAME] 2 and Dietary Aide 1 were the only dietary staff members working in the kitchen are preparing and serving dinner, the RD stated [NAME] 2 and Dietary Aide 1 needed to get their certification within the week. During interview with the Administrator on 07/19/2024 at 9:10 AM, she stated all dietary staff had 30 days to obtain their Food Handlers Card. The Administrator stated it was the duty of the Dietary Manager to follow up with new dietary staff to make sure their training was done in a timely manner. She stated she would not take the individual off the schedule if they did not do the training within the first 30 days of being hired, because there was always someone in the facility with a Food Handlers Card, ServSafe certification, or CDM. When the SSA Surveyor informed the Administrator of the observation on 07/15/2024 at 2:25 PM and 5:03 PM, when [NAME] 2 and Dietary Aide 1 were the only dietary staff working in the kitchen, the Administrator stated she would need to have better oversight of the kitchen staff in the future and ensure they received their certification before hire. The Administrator further stated dietary staff were trained on safe food handling and hand hygiene while on the job.

Based on observation, interview, and review of the facility's policies, it was determined the facility failed to provide a safe sanitary environment for food production and appropriate trash storage and disposal, which affected 54 residents receiving their meals from the kitchen. The findings include: Review of the facility's policy titled, Cleaning Procedures-Garbage Cans, Buckets, and Disposals, dated 08/2013, revealed kitchen garbage cans were to have plastic liners and those liners were to be changed as needed and disposed of frequently in the outside dumpster. Review of the facility's policy titled, Preparation of Food, dated 08/2013 and revised on 02/09/2026, revealed the preparation of foods served to residents and personnel were the responsibility of the Food Service Manager. Further review revealed food was to be produced using sanitary guidelines and served according to established rules and regulations. Review of the facility's Cleaning Assignment Sheet for July of 2024, revealed it noted all garbage can were to be emptied twice daily and the bathroom garbage can was to be emptied nightly. Observation on 07/16/2024 at 11:35 AM, during lunch tray line setup, revealed a garbage can without a lid, overflowing with trash located in the kitchen area. The State Survey Agency (SSA) Surveyor observed Dietary Aide (DA) 2 roll the trash can without a lid, overfull with trash, past the area where [NAME] 1 was setting up the steam table for the lunch service. Observation on 07/18/2024 at 8:27 AM, revealed a trash can located in the dining room that had no lid on it. In interview with DA 2 at 8:27 AM on 07/18/2024, she stated the trash can in the dining room did not have a lid. When the SSA Surveyor asked DA 2 about the process for trash removal from the dining room and the kitchen, DA 2 stated all the trash cans in the kitchen were always to be covered by a lid. When asked by the SSA Surveyor, if trash cans in the kitchen were ever overflowing with so much trash no lid could be placed on them, she stated no. DA 2 stated the process was to take out the garbage before the trash can overflowed. She stated the large trash can from the dining room and from the kitchen were rolled out to the dumpster to empty. DA 2 said the three (3) small trash cans in the dining room were emptied into the large rolling trash can that had no lid also located in the dining room, prior to it being taken from the kitchen to the dumpster. In an interview with [NAME] 1 on 07/18/2024 at 8:35 AM, she said trash cans in the kitchen should be covered with a lid. She further stated when trash cans were full they were to be taken out to the dumpster to empty. In an interview with DA 3 on 07/18/2024 at 8:55 AM, the DA stated all trash cans in the kitchen and in the dining room had lids and those lids should be placed on them when trash was not being put in them. When the SSA Surveyor asked if the trash cans in the kitchen were ever overfilled and ran over or were so full the lid could not be placed back on them, DA 3 stated yes, that did occur. In an interview with the facility's Registered Dietician (RD) on 07/18/2024 at 10:53 AM, she said garbage cans in the kitchen needed to be covered with a lid. In an interview with the Facility Administrator on 07/19/2024 at 9:10 AM, she stated her expectation were that lids should be on garbage cans when they were not being directly used.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure drugs and biologicals were labeled with residents' names. Observation of the four (4) medication carts and two (2) medication refrigerators on 07/16/2024 at 2:08 PM and 2:13 PM and on 07/18/2024 at 4:36 PM, revealed three (3) of the four (4) carts contained unlabeled medications. The findings include: Review of the facility's policy titled, Medication Storage, Version 09/2020, revealed medications were to be stored in the containers in which they were dispensed. Further policy review revealed under no circumstances should any person, other than the Pharmacist, be allowed to transfer medications from one container to another, except for immediate use. Observation on 07/16/2024 at 2:08 PM, revealed Medication Cart #2 contained a medication cup with one white pill in it. Per observation, the white pill was out of its package and the cup was labeled only with a resident's name, Resident (R) 32. Additional observation on 07/16/2024 at 2:13 PM, revealed Medication Cart #4 also had an unpackaged white pill located in a medication cup. Observation revealed the pill cup was not labeled with a resident's name and there was also a bottle of copper for R39 that was not labeled with his name; however, stored in the compartment with the resident's other medications. In an interview with Registered Nurse (RN) 1 on 07/16/2024 at 2:10 PM, she stated R32's medication (on Medication Cart #2) was opened and sitting in the medication cup because she had been unable to locate the resident to administer the medication. She stated when she did not find R32, she wrote his name on the medication cup containing the opened pill and placed it back into the section of Medication Cart #2 that contained the remainder of R32's unopened medications. RN 1 stated she should not have placed the opened pill in the cup back into the medication cart. She further stated she should have thrown the pill and cup away. In an interview with Licensed Practical Nurse (LPN) 4 on 07/16/2024 at 2:13 PM, she stated the reason the bottle of copper (on Medication Cart #4) did not have R39's name on it was because the copper had not came from the pharmacy service the facility used, the Nurse Practitioner (NP) had purchased it from an outside source. LPN 4 stated she knew the supplement belonged to R39 because no one else in the facility took that medication. She further stated the unlabeled white pill in the medicine cup was for R5. The LPN said R5 was outside smoking when she went to give his belly pill. In addition, she stated she was not supposed to place unlabeled medications in the medication cart and was observed to immediately dispose of the pill in the red biohazard container on the medication cart. Observation on 7/18/2024 at 4:36 PM, revealed Medication Cart #3 had an insulin pen labeled only with the opened date. Further observation revealed the insulin pen was not labeled with a resident's name. In an interview with LPN 1 on 07/18/2024 at 4:36 PM, she stated because the insulin pen was not labeled with a resident's name it should be discarded as she did not know to which resident it belonged. The State Survey Agency (SSA) Surveyor attempted a telephonic (phone) interview with the Pharmacist covering the facility on 07/18/2024 at 3:10 PM, with no answer received and a message was left requesting a return phone call. However, no return phone call was ever received. In an interview with the Director of Nursing (DON) on 07/19/2024 at 8:30 AM, she stated she expected anyone giving a medication, that could not be given at the time it was opened, to label the medication and place it in a secure area, such as the medication cart until they were able to give the medication. She stated the reason for labeling the medication was to prevent it being given to the incorrect resident and to make certain the medication was given at the appropriate time. The DON stated insulin pens were stored in the medication refrigerator until they were opened. She said upon opening an insulin pen, the person administering the medication, should label the pen with the resident's name and the date it was opened. The DON stated after being opened the insulin pen could be stored in the medication cart. When the SSA Surveyor asked the DON what should happen to insulin pens without a resident's name and opened date on them, she stated the pen should be thrown away. In an interview with the Facility Administrator on 07/19/2024 at 9:10 AM, she stated any medication not administered to a resident should be discarded immediately. The Administrator stated her expectation was for medications not to be set up in advance, but for the medications to be given immediately after they were opened. She further stated she was unsure of how the insulin pens were to be labeled and stored, but the pens should have a resident's name on them once they were opened.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure accurate assessments for one of 29 sampled residents. The facility failed to document Resident (R) 25's skin lesion identified on 10/07/2022 until the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/24/2024. Review of the facility's policy titled, Resident Assessment Instrument (RAI) Process, dated 10/2019, revealed the facility will use the most current version of the RAI Manual and follow guidelines therein as set forth by the Centers for Medicare and Medicaid services (CMS) for all RAI processes and completion of the MDS unless otherwise outlined in the manual. Further review revealed the facility will complete the RAI process according to state guidelines as applicable. Review of the MDS 3.0 RAI User's Manual Section M with an effective date of 10/2023 revealed the following steps for assessment: review the medical record, including skin care flow sheets or other skin tracking forms, nurses' notes, and pressure ulcer/injury risk assessments; speak with the treatment nurse and direct care staff on all shifts to confirm conclusions from the medical record review and observations of the resident; examine the resident and determine whether any ulcers, wounds, or skin problems are present. Review of R25's, Face Sheet, revealed the facility admitted the resident on 08/05/2020 with diagnoses of Alzheimer's Disease, peripheral vascular disease (PVD), and heart failure. Review of R25's MDS with an ARD of 05/24/2024 revealed a Brief Interview for Mental Status (BIMS) score of seven out of 15 indicating severe cognitive impairment. Review of R25's skin check dated 10/07/2022 revealed a documented raised lesion to the chest. Review of R25' s care plan dated 10/10/2022 revealed a focus of potential or actual skin integrity impairment related to skin lesions to chest. Further review revealed interventions that included treatment as ordered or per facility skin care protocol; observation daily/weekly; notification to nurse of changes or development of new skin impairment. Review of R25's Treatment Administration Record (TAR) for 10/2022 revealed treatment in place to chest lesion ordered 10/08/2022. Review of R25's Quarterly MDS assessment with an ARD of 10/10/2022 revealed Section M/Skin Conditions: Other Ulcers, Wounds, and Skin Problems marked as not present. Review of R25's TAR for 06/2023 revealed Hibiclens topical treatment in place for cutaneous chest abscess 06/26/2023 - 07/06/2023. Review of R25's, Lab Results Report, dated 07/09/2023 revealed a result of negative for a wound culture submitted on 07/07/2024. Review of R25's progress notes dated 12/22/2023 revealed documentation of several small, clustered lesions to the chest area. Lesions were described as raised, red, and circular with no drainage. Further review revealed a history of abscesses to this area. The Nurse Practitioner (NP) ordered treatment with antibiotics and Hibiclens topical solution. Review of R25's TAR for 12/2023 revealed Hibiclens topical treatment in place for chest abscess 12/23/2023 - 12/31/2023. Review of R25's Quarterly MDS assessment with an ARD of 12/26/2023 revealed Section M/Skin Conditions: Other Ulcers, Wounds, and Skin Problems marked as not present. Review of R25's progress note dated 03/21/2024 revealed resident received antibiotic for chest abscess. Review of R25's Quarterly MDS assessment with an ARD of 03/26/2024 revealed Section M/Skin Conditions: Other Ulcers, Wounds, and Skin Problems marked as not present. Observation on 07/15/2024 at 2:27 PM revealed R25 resting on her bed. State Survey Agency (SSA) surveyor observed a lesion approximately one and a half inches in diameter to R25's upper chest. Additional observation revealed the lesion was surrounded by four smaller scabbed areas In an interview on 07/15/2024 at 2:27 PM, R25 stated she did not know what the place was on her chest. She further stated the sore had been there forever but was getting better. In an interview with the MDS nurse on 07/18/2024 at 3:03PM, she stated, she obtained information for MDS assessments through interviews with residents, data collected from hospital documentation and facility charts. She stated she reviewed pressure ulcer flowsheets, Treatment Assessment Records (TARs), skin notes, and any other documentation that provided information related to skin. She further stated she visited most every area of a resident's medical record when collecting data for an MDS assessment. The MDS nurse stated in the past she had not participated in skin assessments, but a couple of months ago started rounds with the treatment nurse on skin assessment days. In a continued interview with the MDS nurse on 07/18/2024 at 3:44 PM, she stated from her recollection, R25's skin problem was intermittent rather than an ongoing issue. She further stated problems were not required on the MDS assessment unless they were ongoing, and resident received treatment. She stated everybody made mistakes and could not provide an answer without looking through the resident's records. Additionally, she stated she remembered she spoke with the Regional MDS Consultant, and they decided the wound failed to meet criteria under the section for other skin problems. She also stated it was not considered a problem unless the resident received treatment. In an interview with the Regional MDS Consultant on 07/18/2024 at 5:58PM, she stated the MDS was coded based on documentation at the time related to R25's skin problem. She further stated it would have had to be open at the time to include on section M for skin. The Regional MDS Consultant stated as far as she knew, they did not have a policy related to MDS and they utilized the RAI manual. In an interview on 07/19/2024 at 8:47 AM, the Director of Nursing (DON) stated Interdisciplinary Team (IDT) meetings were held every weekday morning and changes were discussed. The DON stated she did not really have a part in the MDS assessments. She further stated she thought the RAI manual was used and was not aware of a facility policy related to MDS assessments. In an interview with the facility Administrator on 07/19/2024 at 9:12 AM, she stated the facility had no specific MDS assessment policy. She further stated, the facility followed guidelines from the RAI manual for MDS assessments.

Based on interview, record review, and facility policy review, the facility failed to develop and implement a baseline care plan within 48 hours for each resident that included instructions needed to provide effective and person-centered care of the resident (R) to meet professional standards of quality care for one of 29 residents sampled for care plans, R49. The findings include: Review of the facility policy titled, Resident Care Plan, dated 11/13/2017, revealed the facility was to initiate a baseline care plan immediately upon admission by the admitting Registered Nurse (RN). Continued review revealed the baseline care plan was to include instructions needed to provide effective and resident-centered care for residents that met professional standards of care. Further review revealed the baseline care plan was to include the initial goals for the resident, physician orders, and other services to be administered for the resident in the first 48 hours. Review of the Admission Record, located in the facility's clinical record for R49, revealed the facility admitted the resident on 06/27/2024, with diagnoses including end-stage renal failure, chronic obstructive pulmonary disease (COPD), and dysphagia (trouble swallowing). Review of R49's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/04/2024, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating the resident was cognitively intact. Further review revealed the facility also assessed the resident as requiring dialysis. Continued review of the clinical record revealed no documented evidence of a baseline care plan for R49. Review of the facility's care plan for R49 revealed the first dates for documentation were on 07/01/2024 by social work areas and 07/02/2024 for nursing related areas. Observation and resident interview not conducted due to the resident being out of the facility on an approved leave of absence. In an interview on 07/19/2024 at 10:34 AM, Registered Nurse (RN) 7 stated she was the nurse responsible for R49's admission. She further stated she had not been aware she was responsible for initiating a baseline care plan for R49's and no one had ever shown her how to do that. In an interview on 07/18/2024 at 4:52 PM, the Staff Development Coordinator (SDC) stated the facility did not document the skills check-off for nurses on orientation that included initiating a baseline care plan. The SDC further stated however, she always did the newly hired nurse's first admission with them so they could see everything they needed to do. In an interview on 07/18/2024 at 4:39 PM, the Quality Improvement (QI) Nurse stated her process, for residents admitted on night shift, was to review their baseline care plans the next morning. She stated she did not know how the facility's process failed for initiating R49's baseline care plan within 48 hours as required. In an interview on 07/18/2024 at 4:01 PM, the MDS Nurse stated baseline care plans should be initiated within 48 hours of a resident's admission. She stated if she was in the building when a newly admitted resident arrived at the facility, she assisted the admitting nurse with assessments and documenting a baseline care plan. The MDS Nurse stated however, sometimes residents, including R49, were admitted late on the evening and in those cases, the process was for facility management to review the baseline care plans the next day. In an interview on 07/19/2024 at 8:31 AM, the Director of Nursing (DON) stated the facility process for initiating a new residents' baseline care plan was for the admitting nurse to initiate a baseline care plan with interventions that addressed the resident's immediate needs. The DON stated those interventions (for a resident like R49) should include resident safety concerns, location of dialysis fistula or port and precautions related to the fistula, and monitoring for dialysis complications. She further stated she believed some management staff had been on vacation when R49 was admitted , leading to a process breakdown in checking for and ensuring R49's baseline care plan. In an interview on 07/19/2024 at 9:09 AM, the Administrator stated it was her expectation for the admitting nurse, or member of management team present for an admission, to enter a baseline care plan within 48 hours of a new resident's admission. She further stated she did not know how (the facility's) process had failed in the case of R49.

Based on observation, interview, record review, and facility policy review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, to include measurable objectives and timeframes as identified in the comprehensive assessment for two of 29 residents sampled for care planning, R10 and R39. 1. The facility failed to implement R10's care plan related to respiratory care, to include ensuring the resident's supplemental oxygen was running at the prescribed liters per minute. Observation on 07/17/2024, revealed R10's oxygen running at 2.5 liters per minute (LPM); however, the Physician's order was for the resident to receive her oxygen at 4 LPM. 2. In addition, the facility failed to add resident-centered interventions regarding R39's repeated refusals of his dressing changes for his wound. The findings include: Review of the facility policy titled, Resident Care Plan dated 11/13/2017, revealed the facility was to develop and implement a multidisciplinary care plan based on the resident's comprehensive assessment. 1. Review of R10's Admission Record, located in the facility's clinical record, revealed the facility admitted the resident on 09/10/2020, with diagnoses including cerebral palsy, chronic obstructive pulmonary disease (COPD), and obesity. Review of R10's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/08/2024, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) of 13 out of 15, indicating the resident was cognitively intact. Further MDS review revealed the facility also assessed R10 to have received oxygen therapy while a resident. Review of R10's Care Plan dated 01/25/2021, revealed the facility care planned the resident as at risk for ineffective breathing and included interventions such as keeping the resident's head of bed elevated; checking the resident's oxygen saturations per facility protocol; and administering supplemental oxygen as ordered. Review of the Physician's order for R10 dated 11/16/2023, revealed an order for the resident to receive supplemental oxygen at 4 liters per minute (LPM) via nasal cannula. Observation on 07/15/2024 at 3:48 PM revealed R10's oxygen concentrator set to 2.5 LPM, not at the Physician ordered rate of 4 LPM. Additional observation on 07/17/2024 at 11:44 AM revealed R10's supplemental oxygen running at 2.5 liters per minute, which was again not at the ordered rate of 4 LPM. In an interview on 07/18/2024 at 1:49 PM, State Registered Nurse Aide (SRNA) 8 stated following the care plan was important so staff knew what each resident needed for their care. She further stated the SRNA's role with oxygen was only to assist and remind residents to keep their (nasal) cannula in their nose, not to monitor or adjust the flow of the oxygen. In an interview on 07/18/2024 at 4:52 PM, Registered Nurse (RN) 6 stated following the care plan was important so the resident received the care they needed. She stated it was not part of any facility protocol for nurses to check the supplemental oxygen flow rate every shift. In continued interview, she stated the only time a nurse would need to look at the flow meter on the oxygen concentrator was when they changed oxygen tubing, which occurred on Sunday nights. The RN stated she did not believe it was necessary to check the rate every day because no one would adjust the oxygen flow except when changing oxygen tubing. Per interview, RN 6 was not able to verify that staff followed R10's care plan as related to receiving oxygen as ordered, because she did not know how long the supplemental oxygen concentrator had been running at the incorrect rate. In an interview on 07/19/2024 at 8:31 AM, the Director of Nursing (DON) stated following the care plan was important to promote resident safety and well-being. She stated the care plan intervention (for R10) to ensure supplemental oxygen was administered as ordered meant staff needed to check the resident was wearing the cannula. The DON stated the facility did not have a process in place to check the flow meters on the oxygen concentrators to ensure the resident was receiving the correct rate of supplemental oxygen. She additionally stated that was not a daily nursing task per the resident's TAR. In an interview on 07/19/2024 at 9:09 AM, the Administrator stated she expected nursing staff to follow residents' care plans. She stated she expected care plans to reflect residents' needs, such as making sure the resident was wearing their nasal cannula. In continued interview, the Administrator stated R10's care plan did not specify checking the flow meter on the oxygen tank, so staff might not have noticed it running at the wrong rate, unless the resident began complaining of shortness of breath. 49267 2. Review of R39's Admission Record, revealed the facility admitted the resident on 03/15/2024, with diagnoses which included type 2 diabetes; and third degree burns to both lower extremities (BLE), genitals, and buttocks. Review of R39's Quarterly MDS with an ARD of 05/20/2024, revealed the facility assessed the resident to have a BIMS score of 15 out of 15, indicating the resident was cognitively intact. Further MDS review revealed the facility also assessed R39 to have burns (second or third degree) and to be receiving application of nonsurgical dressings. Review of R39's Care Plan, dated 03/29/2024, revealed the resident was not care planned for behaviors related to refusing care. Review of R39's Treatment Administration Record (TAR), dated 07/16/2024 revealed documentation noting the resident's wound care was not provided due to refusals from resident. Review of R39's, Nursing Note, dated 07/16/2024 revealed resident refused wound care to third degree burns. Further review revealed Treatment Registered Nurse (RN) 2 educated resident on potential risks of refusal and he verbalized understanding. On 07/18/2024 at 7:11 AM, the State Survey Agency (SSA) Surveyor attempted to observe R39's dressing change; however, the resident refused the dressing change. Treatment RN 2, who was to perform the dressing change, explained the risks versus benefits of dressing changes and informed R39 his burn wounds would heal faster if the dressings were changed daily; however, the resident still refused. In an interview with SRNA 8 on 07/18/2024 at 1:51 PM, she stated when residents refused care, she notified the nurse. She further stated she used resident care plans to determine the type of care a resident needed. SRNA 8 stated nurses updated the care plans when changes occurred. SRNA 8 stated the behavior tab of the care plan displayed recent or updated behaviors for residents, including refusals. In an interview with Treatment RN 2 on 07/17/2024 at 11:41 AM, she stated she typically performed R39's dressing changes early in the morning. She further stated R39 preferred the morning, and she tried to accommodate because that helped with compliance. Treatment RN 2 stated R39 refused care yesterday but allowed her to change his dressings today. In interview on 07/18/2024 at 7:11 AM, Treatment RN 2 stated she had only been working at the facility a few days, but she had noticed improvement in R39's burns since she started. In an interview with the MDS nurse on 07/18/2024 at 3:03 PM, she stated changes to care plans were addressed immediately. She further stated, when issues or concerns were discovered, they were addressed the following day in the morning meeting and changes were made as needed. Additionally, she stated morning meetings were Monday through Friday, so occurrences on a weekend were addressed first thing Monday morning. The MDS nurse stated the Quality Improvement (QI) RN and MDS RN were primarily responsible for care plan updates; however, floor nurses also made changes to care plans as needed. The MDS nurse state refusals of care were placed on care plans, and it was important for the care plan to be up to date and correct so the aides knew how to care for the residents. Attempt was made on 07/18/2024 at 3:14 PM to reach the former treatment nurse, Treatment RN 1. State Survey Agency (SSA) surveyor left a message for Treatment RN 1, but return call was not received. In an interview with the QI RN on 07/18/2024 at 4:02 PM, she stated meetings were held daily to look at changes that had occurred, and then care plans were updated to include those changes. She further stated refusals of care were behaviors that were added to care plans. The QI RN stated resident changes were ascertained by her and staff in numerous ways: examined resident charts, read progress notes, communicated with Nurse Practitioner (NP) and other staff, and looked at care guides. In a continued interview on 07/18/2024 at 4:13 PM, the MDS nurse stated it was her expectation for nurses to update care plans as needed. In an interview on 7/19/2024 at 8:47 AM with the DON, she stated floor nurses sometimes updated care plans, but the MDS nurse primarily made revisions. The DON stated care plans were updated with any change in condition or new orders. She further stated, if a resident exhibited a new behavior today, it was placed on the care plan as soon as possible. She clarified as soon as possible meant today or tomorrow. The DON stated care refusals should be on a care plan. She further stated it was important updates to care plans were made as soon as possible to protect the safety and well-being of residents. In an interview with the facility Administrator on 07/19/2024 at 9:12 AM, she stated it was her expectation all staff followed residents' care plans. She further stated it was her expectation updates to care plans were made at the time a change occurred. The Administrator stated if a new behavior with a resident occurred today, it would be added to the care plan within one day. She further stated if a resident chronically refused care, the behavior should be added to the care plan. The Administrator stated in order to provide proper care to residents, it was necessary to update care plans in a timely manner.

Based on observation, interview, record review, and facility policy review, the facility failed to provide respiratory care consistent with professional standards for 1 of 3 residents (R) sampled for respiratory care (R10), out of the total sample of 29 residents. The findings include: Review of the facility policy titled, Oxygen Therapy, dated 04/2013, revealed the facility's procedure for administering oxygen included adjusting the oxygen flow meter to the prescribed rate. Review of R10's Admission Record, revealed the facility admitted the resident on 09/10/2020, with diagnoses including chronic obstructive pulmonary disease (COPD), obesity with hypovolemia (low fluid/blood volume), and cerebral palsy. Review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/08/2024 for R10, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) of 13 out of 15. indicating the resident was cognitively intact. In addition, review revealed the facility assessed R10 to have received oxygen therapy while a resident. Review of R10's Care Plan, dated 01/25/2021, revealed the facility identified a problem of the resident being at risk for ineffective breathing. Further review revealed the interventions included keeping the head of the resident's bed elevated and administering supplemental oxygen as ordered. Review of the Physician's order for R10 dated 11/16/2023, revealed an order for the resident to receive supplemental oxygen at 4 liters per minute (LPM). Review of R10's Treatment Administration Record (TAR) for 07/2024 revealed orders for facility staff to check the resident's pulse and oxygen saturations (O2 sats) once per week. Further review revealed facility staff charted daily from 07/01/2024 through 07/18/2024, the hours the resident was on oxygen under the order, Oxygen flow is 4 L/min . nasal cannula. Observation on 07/15/2024 at 3:48 PM and on 07/17/2024 at 11:44 AM, revealed R10's oxygen concentrator set at 2.5 LPM (not the 4 LPM as ordered by the Physician). In interview on 07/17/2024 at 11:48 AM, with Registered Nurse (RN) 6, who was at R10's bedside, she stated the resident's oxygen concentrator was set to 2.5 liters per minute. Observation at the time of interview revealed RN 6 left R10's room without adjusting the oxygen flow meter to the 4 LPM as ordered by the Physician. In further interview on 07/17/2024 at 12:11 PM, RN 6 stated she did not know what R10's oxygen orders were. During the interview, RN 6 accessed R10's Physician's orders and stated the Physician ordered the resident's supplemental oxygen to run at 4 LPM. Observation, at the time of interview, revealed RN 6 went to R10's room, attempted to adjust the dial on the resident's oxygen flow meter. She stated however, the machine was malfunctioning because it would not turn above 2.5 LPM. Continued observation revealed RN 6 went to storage and brought in a different oxygen concentrator machine and adjusted the flow meter to 4 LPM (as ordered) and connected R10's oxygen tubing to the new oxygen concentrator. In an additional interview on 07/18/2024 at 4:52 PM, RN 6 stated the facility did not train nurses to check the residents' oxygen every day. She stated nurses charted R10's O2 sats and number of hours the resident used supplemental oxygen every shift; however, not the LPM the resident received. RN 6 stated the only time a nurse would routinely check a resident's oxygen flow meter was when they changed the oxygen tubing, which typically occurred on Sunday nights. The RN said other times a nurse would check the oxygen flow rate included if the resident was complaining of shortness of breath, or if the oxygen concentrator alarmed to indicate a malfunction. RN 6 further stated R10's oxygen concentrator had not alarmed to indicate it was not maintaining a flow above 2.5 LPM In an interview on 07/18/2024 at 10:08 AM, the Advanced Practice Registered Nurse (APRN) stated R10 required supplemental oxygen for treatment of the diagnosis of COPD and the hypovolemia related to obesity. The APRN further stated she expected nursing staff to check residents' oxygen equipment to ensure the equipment was delivering the oxygen flow rate as ordered. She said residents could have low oxygen saturations (if not on the correct flow rate). In an interview on 07/19/2024 at 8:31 AM, the Director of Nursing (DON) stated her expectations for nursing staff caring for residents receiving supplemental oxygen was for staff to ensure the resident's nasal cannula stayed in their nose, assess for shortness of breath, and check the resident's O2 sats once per shift. She stated the facility did not have a process in place to ensure nurses checked residents' oxygen concentrators to see if they were running at the correct rate. In continued interview, the DON further stated she expected residents to receive their supplemental oxygen as ordered. She additionally stated residents could experience shortness of breath (if not on the ordered flow rate for oxygen). In an interview on 07/19/2024 at 9:09 AM, the Administrator stated she expected residents to receive oxygen as ordered. The Administrator further stated however, there was not an auditing process in place to ensure residents had oxygen running at the prescribed rate.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure one (1) of eight (8) sampled resident's (Resident #5) care plan was implemented. The facility assessed Resident #5 to require the extensive assistance of two (2) staff persons for bed mobility, transfers, dressing, eating, toileting, and personal hygiene. The facility developed a care plan for the resident directing staff to use two person total assistance with care (personal hygiene). On [DATE], two (2) State Registered Nurse Aides (SRNA's) raised the height of Resident #5's bed prior to performing care. During care, one of the SRNA's left the room to retrieve linens and the other walked to the sink in the resident's room leaving the resident's bed in the elevated position. Resident #5 fell from the bed and was sent to the hospital for evaluation. The findings include: Review of the facility's policy, Resident Care Plan Interdisciplinary dated [DATE], revealed it was the facility policy to provide a written resident centered care plan based upon the resident needs. Review of Resident #5's medical record revealed the facility admitted the resident on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was assessed to be severely cognitively impaired. Further review of the MDS assessment revealed the resident was assessed to require assistance of two (2) staff persons for bed mobility, transfers, dressing, eating, toileting, and personal hygiene. Review of Resident #5's Care Plan [DATE] revealed intervention to provide the resident with total assist of two (2) staff persons for personal hygiene and with incontinent care. Review of nursing facility investigation dated [DATE] revealed two (2) SRNA's had raised Resident #5's bed to between knee and hip height and repositioned the resident. One SRNA stepped out of room to get linens and the other SRNA went to sink in the resident's room. Further review revealed staff heard a thump and discovered Resident #5 had fallen from the bed and was laying on his/her back between the bed and nightstand. Per the investigation, Resident #5 was transferred to a local hospital emergency room for evaluation. Review of witness statement from SRNA # 2 dated [DATE] revealed she had walked into Resident #5 room to perform patient care and Resident #5 was laying on his/her right side facing the window. Continued review revealed Resident #5's bed was soiled with tube feeding. Per the statement, SRNA #2 with assistance of SRNA #4 rolled resident #5 over to be partially on his/her back and partially on his/her left side facing the door. Further reviewed revealed SRNA #2 walked away from the bed and went to the sink in the room with her back to Resident #5 and SRNA #4 went to linen cart outside of resident #5 room door. Per the statement, SRNA # 2 heard a loud noise and when she (SRNA #2) turned around Resident #5 was on the floor. Review of witness statement from SRNA #4 dated [DATE] revealed she was assisting SRNA #2 with repositioning Resident #5 and rolled the resident to be mostly on his/her back. Per the statement, SRNA #4 went to the linen cart outside of Resident #5's room door when she heard a sudden thump sound and turned around to see Resident #5 was on the floor, on his/her back. Observation of Resident #5 revealed that resident was no longer in facility. Record review revealed that Resident #5 expired on [DATE]. Interview with SRNA #2, on [DATE] at 12:20 PM, revealed that Resident #5 required total assistance of two (2) staff to be turned and repositioned. The SRNA stated Resident #5 never moved. SRNA #2 further stated on [DATE], she and SRNA #4 provided care for Resident #5 and raised the his/her bed to knee height. Per the SRNA, they noticed tube feeding had leaked/spilled in the resident's bed requiring a linen change and personal hygiene for Resident #5 to clean off the tube feeding. SRNA #2 stated Resident #5's knees where bend and the resident would typically lean to one side but the SRNA stated she did not remember Resident #5 position prior to the fall. SRNA #2 stated SRNA #4 left to get linens and she (SRNA #2) went to sink to wet washcloths, when she heard a noise and turned back toward resident #5 to see him/her on the floor. Interview with SRNA # 4, on [DATE] at 6:05 PM, revealed that she went into Resident #5 room to assist with care and the resident's bed was elevated to knee height. SRNA #4 stated she could not remember Resident #5's exact position or if the SRNA's had repositioned the resident before realizing they needed additional supplies. SRNA #4 stated she walked to the outside of Resident #5's door to obtain linens and SRNA #2 went to the sink to wet washcloths, only turning their backs for seconds when they heard noise. SRNA #4 stated Resident #5 had fallen to the left side of the bed. Interview with RN #3, on [DATE] at 9:30 PM and LPN #3, on [DATE] at 2:35 PM, revealed Resident #5 required two (2) staff persons assistance for personal hygiene. Interview with the MDS Nurse on [DATE] at 4:30 PM revealed that if a resident is care planned for two (2) person assistance it is the expectation for two (2) staff members to assist with resident care. Interview with Staff Development Nurse, on [DATE] at 3:10 PM, revealed staff were educated and instructed to leave resident beds in the lowest position when not providing resident care. The Staff Development Nurse further started when the resident's bed is raised to provide care for a two (2) staff person assist resident, staff should stay with the resident or lower the bed prior to leaving the resident unattended. The Staff Development Nurse also stated nurses and SRNA's can find type of assistance residents require in their care guide located in their charting system. Interview with Assistant Director of Nursing, on [DATE] at 3:55 PM, revealed management teams perform daily rounds to ensure care plans are being followed. The ADON also stated SRNA's can locate the level of care assistance for residents per the care plan in the care guide of charting system. The ADON further stated if a resident was care planned for two (2) staff person assist then it is the expectation for staff to follow the care plan. Interview with the Director of Nursing (DON), on [DATE] at 4:35 PM ,revealed if a resident is care planned for two (2) staff person assist then it was his expectation for staff to follow the care plan. Interview with Administrator on [DATE] at 4:50 PM, revealed if resident was care planned for a two (2) staff person assist then it is her expectation for two (2) staff persons to provide resident care. The administrator also stated the SRNA's have access to the residents' care guide on their charting system that will entail the level of assistance the resident requires.

Based on interviews, record review and facility's policy, it was determined that the facility failed to ensure each resident received supervision to prevent accidents for one (1) of eight (8) sampled residents (Resident #5) and failed to investigate each resident's fall to determine the root cause of the fall per facility policy. The facility assessed Resident #5 to require the extensive assistance of two (2) staff persons for bed mobility, transfers, dressing, eating, toileting, and personal hygiene. On [DATE], two (2) State Registered Nurse Aides (SRNA's) raised the height of Resident #5's bed prior to performing care. During care, one of the SRNA's left the room to retrieve linens and the other walked across the room, leaving the resident's bed in the elevated position. Resident #5 fell from the bed and was sent to the hospital for evaluation. The facility failed to determine the root cause of the fall. The findings include: Review of the facility policy titled, Falls Protocol dated [DATE] revealed falls should be investigated to determine the root cause of the fall and validate investigations were complete. The policy further stated that review of trends with fall should be reviewed through the Interdisciplinary Team (IDT). Findings will be brought to Quality Assessment Performance Improvement (QAPI) meeting. Review of Resident #5's medical record revealed the facility admitted the resident on [DATE], with diagnoses of [CONDITION(S)], Alzheimer's Disease, Cardiomegaly, Diabetes Mellitus, Dementia, Depression, Coronary Artery Disease and [CONDITION(S)]. Review of Resident #5's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 99, indicating severe cognitive impairment. Review of Resident #5 facility incident report revealed that on [DATE], Resident #5 sustained a fall from bed resulting being transported to the emergency room for evaluation. Review of fall investigation dated [DATE] revealed two (2) SRNA's had raised Resident #5's bed to between knee and hip height and repositioned the resident. One SRNA stepped out of room to get linens and the other SRNA went to sink in room. Further review revealed staff heard a thump and discovered Resident #5 had fallen from the bed and was laying on his/her back between the bed and nightstand. Per the investigation, Resident #5 was transferred to a local hospital emergency room for evaluation. Observation of Resident #5 revealed that she was no longer in facility. Resident #5 expired on [DATE]. Interview with SRNA #2, on [DATE] at 12:20 PM, revealed that Resident #5 required total assistance of two (2) staff to be turned and repositioned. The SRNA stated Resident #5 never moved. SRNA #2 further stated on [DATE], she and SRNA #4 went to provide care for Resident #5 and raised the bed to knee height. Per the SRNA, they noticed tube feeding had leaked/spilled in the resident's bed requiring a linen change and personal hygiene for Resident #5 to clean off the tube feeding. SRNA #2 stated Resident #5's knees where bend and the resident would typically lean to one side but the SRNA stated she did not remember Resident #5 position prior to fall. SRNA #2 stated SRNA #4 left to get linens and she (SRNA #2) went to sink to wet washcloths, when she heard a noise and turned back toward resident #5 to see her in the floor. Interview with SRNA # 4, on [DATE] at 6:05 PM, revealed that she went into Resident #5 room to assist with care and the resident's bed was elevated to knee height. SRNA #4 stated she could not remember Resident #5's exact position or if the SRNA's had repositioned the resident before realizing they needed additional supplies. SRNA #4 stated she walked to the outside of Resident #5's door to obtain linens and SRNA #2 went to the sink to wet washcloths, only turning their backs for seconds when they heard noise. SRNA #4 stated Resident #5 had fallen to the left side of the bed. Interview with RN #3, on [DATE] at 9:30 PM and LPN #3, on [DATE] at 2:35 PM, revealed Resident #5 required two (2) staff persons assistance for personal hygiene. Interview with Staff Development Nurse, on [DATE] at 3:10 PM, revealed staff were educated and instructed to leave resident beds in the lowest position when providing resident care. The Staff Development Nurse further started when the resident's bed is raised to provide care for a two (2) staff person assist resident, staff should stay with the resident or lower the bed prior to leaving the resident unattended. The Staff Development Nurse also stated nurses and SRNA's can find type of assistance residents require in their care guide located in their charting system. Further review of the fall investigation revealed the facility listed the resident had an unwitnessed fall from bed but the investigation failed to identify the root cause of Resident #5's fall on [DATE]. Interview with Quality Improvement Nurse on [DATE] at 3:40 PM, [DATE] at 2:21 PM and [DATE] at 3:50 PM, revealed after a resident experiences a fall, she reviews the nurses notes, monitors to see if individualized interventions specific to the resident are placed/updated on the resident's care plan to prevent future falls, looks at root cause of the fall and insures an investigation report is completed. The QI nurse stated falls are discussed in daily meetings with management/administration staff. The QI nurse also reported she had been educated to track and trend falls. The QI nurse stated she was not working when Resident #5 fell . Per the QI Nurse, she had reviewed the fall investigation completed by the administrator and Nurse Consultant (NC) and no root cause for the fall had been identified for Resident #5's fall. Interview with Director of Nursing (DON), on [DATE] at 2:45 PM and [DATE] at 3:21 PM, revealed falls are discussed in the IDT (interdisciplinary team) meetings, the QI nurse reviews falls and completes investigation. The DON stated if a resident is care planned for two (2) staff person assist then it was his expectation for staff to follow the care plan. Interview with Administrator, on [DATE] at 10:00 AM, and [DATE] at 4:50 PM, revealed all falls are investigated by management staff and the Nurse Consultant sometimes assist in the first interviews and second interviews. The Administrator stated nurses and management staff look at investigations and also discussed in IDT meetings. The Administrator stated she thought Resident #5's fall on [DATE] was due to a cardiac event.

Based on interview, record review and review of the facility abuse policy, it was determined the facility failed to ensure an allegation of abuse for one (1) of four (4) sampled residents (Resident #4) was reported to the required state agencies. The findings include: A review of the facility abuse policy titled Abuse, Neglect, or Misappropriation of Resident Property Policy, revised 03/10/2017, revealed any employee who witnesses or suspects that abuse, neglect, exploitation, or misappropriation of property has occurred will report immediately to the Administrator. Further review of the policy also revealed the facility must ensure that all complaints of abuse, neglect, including injuries of unknown origin, or misappropriation of resident property were reported immediately to the Division of Licensure and Regulation, Department of Social Services and Adult Protective Services. The policy further states that the Cabinet will be notified in accordance with KRS 209.030. A review of the medical record for Resident #1 revealed the facility admitted the resident on 06/26/2018 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 4. A review of the medical record for Resident #4 revealed the facility admitted the resident on 12/21/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14. An interview with Resident #4, on 03/16/2021 at 4:36 AM, revealed on 03/13/2021 at approximately 4:30 PM, Resident #1 stated scoot over, let me get in bed with you, we will have a good time. Resident #4 revealed that Resident #1 did not get into bed with him/her, however; he/she felt like Resident #1 wanted to and it made him/her uncomfortable. Resident #4 further revealed that he/she had observed Resident #1 rubbing his/her own breast prior to this statement. Continued interview revealed that Resident #4 reported the incident to Licensed Practical Nurse (LPN) # 3. Interview with General Care Aide #1, on 03/16/2021 at 5:33 PM, revealed on 03/13/2021 at approximately 3:00 PM - 5:00 PM, Resident #4 had activated his/her call light. She stated when she checked on Resident #4, he/she appeared distraught. The General Care Aide stated Resident #4 had tears and stated he/she was afraid Resident #1 would make a move on him/her. She stated Resident #1 was not currently in the room at this time and she immediately went and notified LPN #3 of the statement. She revealed that LPN #3 immediately went to Resident #4 and Resident #1 had returned to the room at this time. The General Care Aide stated she remained with Resident #1 for one to one supervision. An interview with Licensed Practical Nurse (LPN) #3, on 03/16/2021 at 4:54 PM, revealed on 03/13/2021 at approximately 3:30 PM - 4:30 PM, General Care Aide #1 notified her that Resident #4 had reported Resident #1 had tried to get in bed with him/her. She revealed that she immediately went to Resident #4's room to interview him/her regarding the statement. Per LPN #3, Resident #4 stated Resident #1 had tried to get him/her to scoot over and he/she wanted to be moved to another room. However, the resident did not reveal anything further. LPN #3 stated that she notified her Director of Nursing (DON) regarding the statement made by Resident #4. She further revealed that Resident #1 was placed on one to one supervision with General Care Aide #1 immediately. LPN #3 revealed she received guidance to keep Resident #1 on one to one supervision and to accommodate Resident #4 request to move rooms (Resident #1 and #4 were roommates at the time of the incident.) per the DON. Continued interview revealed Resident #4's room was changed as requested on 03/13/2021. On 03/16/2021 at approximately 4:30 PM, Resident #4 told LPN #3 that Resident #1 had stated he/she could show him a good time and had rubbed his/her own breasts. LPN #3 stated following this report she notified her DON of the above statement and per guidance of the DON had utilized a standing order to obtain a urinalysis test on Resident #1. She further stated she did not notify the physician at that time. Interview with the DON, on 03/16/2021 at 5:16 PM, revealed he was notified on 03/13/2021 at approximately 3:20 PM by LPN #3 that Resident #1 had talked to Resident #4 inappropriately (scoot over he could show him a good time, something about sex). He directed LPN #3 to place Resident #1 on one to one observation and he would follow up with the Administrator on further action to take. He revealed that he notified the Administrator of the incident between Resident #1 and Resident #4 and received guidance to move Resident #4 per his/her request. Per the DON, he was also told by the Administrator to place Resident #1 back on every 15 minute checks. He stated that he notified LPN #3 of the guidance and no further issues were noted to his knowledge. Interview with Administrator, on 03/16/2021 at 6:05 PM, revealed she was notified on 03/13/2021 (Saturday) at approximately 3:00 PM - 4:00 PM of Resident #4 report that Resident #1 had stated hey can you scoot over, can I get in there with you- we'll have a good time. She stated she was also told Resident #4 had requested a room change. The Administrator stated to her knowledge Resident #1 did not touch Resident #4 and he/she did not state anything about abuse. The Administrator denied any knowledge of the resident being fearful, distraught or crying. However, she stated that she was aware that Resident #4 had stated I'm not that way, it makes me uncomfortable. Continued interview revealed that following the room change, Resident #4 stated that he/she felt safe in the facility. She stated that based on the presentation of the statement she felt it was a request for a room change and did not consider the incident an abuse allegation. The Administrator stated that she filed the issue as a grievance and it was reviewed in the Quality Assurance/Performance Improvement meeting on the following Monday (03/15/2021). However, the incident was not reported to the required agencies as an abuse allegation.

Based on interview, record review, and review of the facility's policy, it was determined that the facility failed to provide one (1) of three (3) sampled residents (Resident #95) with a written discharge notice. On 01/16/2020, Resident #95 was transferred to the hospital for a psychiatric evaluation. On 02/05/2020, the resident was to be discharged from the hospital back to the nursing facility; however, the facility discharged the resident on 02/05/2020 without issuing the resident a discharge notice. The findings include: Review of the facility's policy titled Transfer and Discharge, dated January 2009, revealed before discharging a resident the facility would notify the resident, and if known, a family member of the discharge and the reasons for the move in writing, and in a language and manner they understand. The policy stated that the notice would be provided thirty (30) days in advance. Further review of the policy revealed the facility would provide sufficient preparation and orientation to the resident to ensure a safe and orderly discharge from the facility. Review of Resident #95's medical record revealed the facility readmitted Resident #95 to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #95's Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eleven (11), indicating the resident had moderate cognitive impairment. Further review of the record revealed the resident was his/her own responsible party and listed a family member as an emergency contact. Review of Social Services documentation made on 01/15/2020, and a Health Status Note dated 01/16/2020, revealed the facility transferred Resident #95 to an inpatient hospital's psychiatric unit on 01/16/2020, related to the resident making inappropriate sexual comments toward staff. Further review of the documentation revealed the facility included a Notice of Transfer or Discharge with transfer circled, and a Bed Hold Notification, both dated 01/16/2020, with paperwork sent with the resident to the receiving facility. Interview with Resident #95's family member on 02/10/2020 at 8:48 AM revealed facility staff informed her on 02/05/2020 that Resident #95 had been discharged from the facility on 02/05/2020, when the hospital was ready to discharge Resident #95 back to the facility. However, the family member stated that neither Resident #95 nor she had received a discharge notice from the facility. Interview with the Social Services Director (SSD) on 02/10/2020 at 3:16 PM and 6:43 PM revealed she did not send a discharge notice to Resident #95 or the resident's family member when the facility discharged the resident from the facility on 02/05/2020, after the resident had exhausted his/her bed hold days. Further interview with the SSD revealed the only notice issued was the Transfer/Discharge notice sent to the hospital with the resident on 01/16/2020. Interview with the Administrator on 02/10/2020 at 5:39 PM and 7:02 PM revealed Resident #95's bed hold days were exhausted and the facility discharged the resident from the facility on 02/05/2020. He stated the SSD was responsible to ensure appropriate notices were sent to residents and responsible parties, and he was not aware that Resident #95 had not received a discharge notice.

Based on interview, record review, and review of the facility's policy, it was determined that the facility failed to allow one (1) of three (3) sampled residents (Resident #95), whose hospitalization extended beyond the allocated bed hold days, to return to the facility after the hospitalization . On 01/16/2020, the facility transferred Resident #95 to the hospital for an inpatient psychiatric stay, and the resident was ready to return to the facility on [DATE]. However, the facility refused to readmit the resident to the facility despite having available beds. The findings include: Review of the facility's policy titled Resident Rights Related to Bed Hold, dated January 2009, revealed when a resident's bed hold days were exhausted, it was the responsibility of the resident/responsible party to pay a private rate for each day over the allotted bed hold days. The policy stated if paying for the extra days was not feasible, the facility would discharge the resident from the facility. Continued review of the policy revealed the facility would readmit the resident to the first available semi-private bed, provided the facility could meet their needs. The policy further stated that the facility would notify the responsible party when the resident's bed hold days were exhausted. Review of the facility's Daily Census Form for 02/05/2020 revealed the facility had forty (40) empty beds on 02/05/2020. Review of Resident #95's medical record revealed the facility admitted the resident on 11/26/2019, with [DIAGNOSES REDACTED]. Review of Resident #95's Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eleven (11), indicating the resident was cognitively impaired. Review of a Health Status Note for Resident #95 dated 01/16/2020 revealed the facility transferred the resident to the hospital on [DATE] for an in-patient psychiatric stay. Review of the Bed Hold Notification sent with Resident #95 when transferred to the hospital on [DATE] revealed the resident had fourteen (14) available bed hold days. Interview with Resident #95's family member on 02/10/2020 at 8:48 AM, revealed she spoke to facility staff on 02/05/2020, when the hospital was ready to discharge Resident #95 back to the facility. The family member stated the facility informed her at that time that they had discharged Resident #95 from the facility due to the resident's hospitalization exceeding the allowable bed hold days, and the facility would not readmit Resident #95. However, the family member stated she had received no prior notification from the facility related to Resident #95 exhausting his/her bed hold days. Interview with the Social Services Director on 02/10/2020 at 3:16 PM and 6:43 PM revealed Resident #95's fourteen (14) bed hold days were exhausted on 01/30/2020, and the facility discharged the resident from the facility. The SSD stated the facility refused to readmit Resident #95 to the facility on [DATE] because the facility was in denial of payment for new admissions. Interview with the Administrator on 02/10/2020 at 5:39 PM and 7:02 PM revealed Resident #95's bed hold days were exhausted and the facility discharged the resident from the facility. Further interview with the Administrator revealed the facility could not readmit Resident #95 to the facility on [DATE], despite the facility having available beds, because the facility was in denial of payment and could not accept new admissions or readmissions due to not receiving payment for care and services.

Based on observation and interview it was determined the facility failed to provide a comfortable homelike environment for five (5) unsampled residents (Residents #10, #42, #77, #101, and #104). Observations conducted on 01/27/2020, 01/28/2020, and 01/29/2020 revealed a strong odor of urine was present upon entering the area of the facility where residents resided. Interviews with staff, residents, and the facility Ombudsman revealed concerns had been voiced related to odors in the facility. In addition, observations and interviews revealed water in resident rooms on the East Wing would not maintain a comfortable temperature for baths/showers. Interviews with staff and residents revealed concerns had been voiced related to water temperatures in resident rooms for approximately one (1) year. The findings include: Review of post-survey email correspondence with the Administrator on 02/04/2020 revealed the facility had no policy related to providing residents with a comfortable homelike environment. The Administrator stated the facility followed the regulatory requirements related to a homelike environment. 1. Observations conducted on 01/27/2020, 01/28/2020, and 01/29/2020 revealed the facility had a strong odor of urine and body odor when entering the resident care area. Continued observations revealed the odors were stronger on the East Wing of the facility. Review of residents' Brief Interview for Mental Status (BIMS) scores provided by the facility on 01/27/2020 and 01/29/2020 revealed Residents #10, #42, #77, and #104 were interviewable, with a BIMS score of fifteen (15). Interview with Resident #42 on 01/28/2020 at 10:20 AM revealed the facility had a strong odor of urine, and family members including his/her brother mentioned how the facility smelled every time he came to visit. The resident also stated the odors in the facility had gotten worse over the past month or longer and stated it was embarrassing. Interview with Resident #10 on 01/28/2020 at 12:50 PM and Resident #104 on 01/28/2020 at 12:55 PM revealed the facility had a strong urine odor. According to the resident, the odor in the facility was not homelike at all. Interview with Resident #77 on 01/27/2020 at 12:35 PM revealed he/she had also been bothered by the strong odors of urine in the facility. The resident stated the odor was worse in the hallways on the East Wing of the facility. Interview with Housekeeper #1 on 01/29/2020 at 12:10 PM revealed she was aware that the facility had an issue with urine odor and staff had discussed it a lot. She also stated the facility odors had been a problem for a while and she had been instructed to clean under fall mats in the residents' rooms and to clean resident mattresses more often; however, the housekeeper stated nothing had helped the odor problem in the facility. Interview with State Registered Nurse Aide (SRNA) #11 on 01/29/2020 at 12:30 PM and SRNA #13 on 01/29/2020 at 12:00 PM revealed there were identifiable odors of urine and body odor upon entering the facility. The SRNAs stated observable odor was not a homelike environment for the residents. A post-survey interview with the Facility Ombudsman on 02/03/2020 at 3:00 PM revealed she visited the facility a couple of weeks ago and stated, It smelled worse than I have ever smelled it in there. The Ombudsman stated she informed the Administrator that the facility odors were worse than she had ever smelled, and the Administrator stated he was working on it. Interview with the Administrator on 01/29/2020 at 2:20 PM revealed he did not feel like the facility had an odor, and stated no one had ever complained to him about the odors present in the facility. 2. Review of TELS Masters, the facility system utilized for water temperature monitoring, not dated, revealed the facility was required to ensure water temperatures in resident rooms were between 100-110 degrees Fahrenheit (F). Review of the facility's Logbook Documentation for water temperatures for January 2020 revealed the water temperatures were between 103 and 110 degrees F in the same two (2) resident rooms and in the shower rooms. Further review revealed water temperatures had not been documented since 01/24/2020. However, interview with Resident #42 (interviewable resident with a Brief Interview for Mental Status score of 15) on 01/28/2020 at 10:20 AM revealed staff have had to go to other rooms too many times to remember to get hot water, while providing assistance with bathing and/or shaving. Resident #42 stated while staff were shaving the resident that morning, one of the nurse aides had to go to the kitchen to get hot water to finish shaving the resident. The resident stated there had been concerns with the water temperature being too cold in his/her room for a year or longer. Observations of Resident #42's water temperature readings in his/her room conducted with the Maintenance Supervisor on 01/28/2020 at 10:40 AM revealed the initial hot water temperature reading was 97.8. Continued observations revealed it took six (6) minutes for the water to reach a temperature of 100 degrees in the resident's room. Interview with State Registered Nurse Aide (SRNA) #16 on 01/28/2020 at 11:00 AM revealed she and another SRNA were shaving Resident #42 that morning, and the resident's water lost temperature again. She stated the other SRNA went to the kitchen to get hot water because the resident requested hot water when he/she shaved. The SRNA stated water temperatures in resident rooms on the East Wing had been an issue for a while. According to the SRNA, staff had to leave resident rooms during care to get hot water at times because the water would not maintain a warm enough temperature most of the time. SRNA #16 stated resident care should be able to be provided with warm water. Interview with Resident #101 (an interviewable resident with a BIMS score of 10) on 01/28/2020 at 10:50 AM revealed nurse aides had to pack warm water from room to room because the resident's water would not get hot and/or stay hot. The resident also stated staff had left his/her room to get hot water during a bath and stated, They shouldn't have to do that. Observations conducted of the East Wing shower room on 01/29/2020 at 12:00 PM revealed hot water was running at full stream in the whirlpool tub and the sink in the shower room; however, the shower room was not being utilized by a resident. Interview with SRNA #10 on 01/29/2020 at 12:00 PM revealed Maintenance staff came early that morning and turned the water on in the shower room. The SRNA stated the Maintenance staff member instructed the SRNAs to leave the water running all day in case the state lady checked water temperatures again. The SRNA stated that prior to that day she had never seen the water running when the shower room was not in use. According to the SRNA, water temperatures had been a problem in resident rooms on the East Wing for a year or longer. She stated she had to frequently leave resident rooms to go to the facility breakroom to get hot water to provide care to the residents. SRNA #10 also stated residents get cold easy and the problem had been reported to nurses and Maintenance; however, nothing had been done to correct the problem. Interview with Registered Nurse (RN) #2, the East Wing Unit Manager, on 01/28/2020 at 11:10 AM revealed staff and residents had voiced complaints about water temperatures on the East Wing for a while. She stated Maintenance staff had been notified and were aware of the issue. Interview with the Maintenance Supervisor on 01/20/2020 at 10:40 AM revealed water temperatures had been a problem in the facility for a long time. He stated he was aware that it took several minutes for the water to get hot in some resident rooms on the East Wing of the facility and residents and staff had complained. He also stated staff had voiced concerns to him that water temperatures dropped to uncomfortable levels while resident care was being provided. He stated the hot water issue had been discussed before; however, the cost for the supplies needed to correct the water issue was $14,000 and he did not have the authority to purchase things that cost that much. The Maintenance Supervisor also stated residents should not have to wait six (6) minutes for the water temperature to rise to a comfortable level. Interview with the Administrator on 01/29/2020 at 2:20 PM revealed he was aware there were problems with water temperatures being maintained in the facility; however, he stated he was not aware that staff were going to other areas of the facility to obtain hot water when resident care was being provided. He stated staff should not have to leave a resident's room, while care was being provided, to obtain hot water to complete care and residents should not have to wait for hot water. According to the Administrator, he had obtained estimates to fix the hot water issue at the facility.

Based on observation, interview, record review, and review of the facility policy it was determined the facility failed to investigate and ensure prompt resolution of grievances for thirteen (13) unsampled residents (Residents #10, #42, #43, #73, #77, #78, #96, #97, #98, #99, #102, #103, and #104). Review of Resident Council Minutes, review of written grievances, and interviews with staff and residents revealed voiced and/or written grievances had not been resolved related to call light wait times and lack of timely assistance with toileting and/or incontinence care. The findings include: Review of the facility policy titled Resident Grievance Policy, dated 07/01/2018, revealed when a resident, family member, or resident representative reports a concern to a staff member, the staff member would forward the concern to their supervisor, department head, or the Administrator. The policy also stated the Administrator was responsible for overseeing, directing, and investigating grievances in a prompt manner. The policy also indicated the Administrator would ensure that the resident or the resident representative was notified timely of the results of the investigation and of any corrective measures taken, and that notification would be documented. Interview with the Administrator on 01/29/2020 at 2:20 PM revealed the facility had no policy related to answering call lights in the facility. Review of the BIMS scores provided by the facility on 01/27/2020 and 01/29/2020 revealed Residents #10, #42, #43, #103, #77, #96, #97, #98, #99, and #104 were interviewable with a BIMS score of fifteen (15) and Residents #73 and #78 were interviewable with a BIMS score of thirteen (13). Review of Resident Council Meeting Minutes dated 01/16/2020 revealed residents had voiced concerns that call lights are not always answered in a timely manner. 1. Review of a Facility Concern/Grievance Form, dated 12/27/2019 at 3:00 PM, revealed the Director of Therapy had filed a written grievance related to the care of Resident #97. Continued review of the grievance revealed staff was informed several times beginning at 12:00 PM that Resident #97 needed to be changed (as the resident had been incontinent of urine and was wet). The grievance indicated the resident had also informed staff that he/she needed changed. Further review of the grievance revealed at 2:20 PM the Director had informed staff again that the resident needed changed and staff was then observed to walk in and turned call bell off without changing the patient. Review of the grievance revealed at 2:50 PM (approximately three hours after the resident's initial request for incontinence care) Resident #97 was observed to still be wet/unchanged with urine under his/her wheelchair. Continued review of resident #97's grievance revealed the Administrator signed that he had received the grievance on 12/27/2019. Further review of the grievance provided no evidence that the grievance was investigated or that any follow-up had been conducted to ensure the grievance had been resolved with the resident or the person who voiced the grievance, as required. Review of the grievance revealed the Administrator had signed off on the concern/grievance resolution page of the grievance as completed on 01/02/2020. Interview with the Director of Therapy on 01/28/2020 at 9:15 AM revealed she completed the written grievance related to care that was not provided to Resident #97 and took it straight to the Administrator on 12/27/2019. The Director also stated Resident #97 required extensive assistance of two (2) staff members when assistance with incontinence care was provided. She stated the Administrator had not followed up with her to ensure resolution of the grievance related to Resident #97's care in the facility since 12/27/2019 (more than four weeks ago). Interview with Resident #97 on 01/27/2020 at 9:55 AM revealed the resident had voiced concerns related to call light wait times and incontinence care not provided in a timely manner in the facility. Resident #97 also stated, I have sat wet for hours and there's been times it's been bad, but I'd rather not discuss it. The resident stated no one had followed up with him/her to ensure his/her grievances were resolved after grievances had been voiced in the facility. 2. Review of a Facility Concern/Grievance Form, dated 12/23/2019, no time indicated, revealed Resident #42 had voiced a grievance that on 12/23/2019 around 2 AM he/she had asked to be changed because the resident had a bowel movement; however, the resident was not provided incontinence care until day shift came on at 6 AM. Continued review of Resident #42's grievance revealed Registered Nurse (RN) #2 received the grievance on 12/23/2019. Further review of the grievance revealed the Administrator had signed off on the concern/grievance resolution page of the grievance as completed on 01/05/2020. Review of Resident #42's annual Minimum Data Set Assessment ((MDS) dated [DATE] revealed he/she required extensive assistance of two (2) staff members with bed mobility and transfers, and was totally dependent on two (2) staff members for toileting. Interview with Registered Nurse (RN) #2 on 01/27/2020 at 2:20 PM revealed she received Resident #42's grievance on 12/23/2019. She stated after she received the resident's grievance she spoke to night shift aides about providing incontinence care to residents when care was requested. The RN was unable to recall which staff members she spoke with regarding the grievance and acknowledged that she had not interviewed any other residents related to care provided in the facility, or investigated the grievance any further. She also stated she had not followed up with Resident #42 to ensure his/her incontinence care was being provided in a timely manner to ensure resolution of his/her grievance. Interview with Resident #42 on 01/28/2020 at 10:20 AM confirmed he/she had filed a written grievance related to staff's failure to provide incontinence care in a timely manner during the night shift. Resident #42 stated grievances had also been voiced related to call light wait times in the facility and stated, It doesn't do any good to complain about anything here; nothing gets fixed when we complain. Resident #42 stated he/she still had concerns with receiving incontinence care in a timely manner in the facility. 3. Review of a Facility Concern/Grievance Form, dated 01/05/2020, revealed Resident #102's son had filed a grievance because nurses told him/her they are short staffed so (he/she) can't get up. Further review of the grievance revealed no evidence that the family member's complaint had been investigated or that a follow-up had been conducted to ensure the grievance was resolved. 4. Observations conducted on 01/27/2020, on the East Wing of the facility at 10:30 AM revealed Resident #96's call light was on. Interview with Resident #96 at 10:30 AM on 01/27/2020 revealed he/she stated, It's been on for ten minutes already. Continued observations revealed staff responded to the resident's call light at 10:50 AM (twenty minutes later per observation, thirty minutes per the resident's interview). Interview with Resident #96 at 10:30 AM on 01/27/2020 revealed call light wait times were a problem in the facility and he/she also stated, It's been hard to get help here for a month or longer. The resident also stated he/she had voiced complaints about call light wait times in the facility and staff informed the resident that they're working short. Resident #96 stated nothing had been done to correct the problem. Interview on 01/27/2020 with Resident #73 at 9:45 AM, Resident #98 at 10:15 AM, and Resident #99 at 12:45 PM revealed they waited up to an hour at times for their call lights to be answered and concerns had been voiced in the facility. Even though complaints had been voiced, nothing had been done to correct the problem. Interview on 01/28/2020 with Resident #10 at 12:50 PM and Resident #104 at 12:55 PM revealed call light wait times were thirty minutes or longer in the facility. Resident #10 stated he/she was President of the Resident Council and we've complained about the call lights in the meeting a few weeks ago. The resident also stated no actions had been taken to correct the voiced grievances related to call light wait times, and no one had followed up with them to ensure their grievances were resolved. Interview with Resident #99 on 01/27/2020 at 12:45 PM and Resident #43 on 01/28/2020 at 12:15 PM revealed call light wait times were thirty (30) minutes or longer at times in the facility and complaints had been voiced. The residents stated no one had followed up to ensure their grievances had been resolved, and they stated call lights were still a concern in the facility. Interview on 01/27/2020 with Resident #78 at 12:20 PM, Resident #103 at 12:25 PM, and Resident #77 at 12:35 PM revealed concerns had been voiced related to call light wait times in the facility. Continued interviews revealed no one had followed up with the residents to ensure resolution of their voiced grievance, and call light wait times remained a concern in the facility. Residents #10, #43, #73, #77, #78 #96, #98, #99, #77, #78, #103, and #104 had all voiced complaints to facility staff regarding call light wait times; however, based on a review of the facility's written grievances, the facility failed to document the residents' grievance, investigate the complaint, and/or attempt to resolve the complaint. Interview on 01/27/2020 with State Registered Nurse Aide (SRNA) #8 on at 12:40 PM, SRNA #16 at 2:00 PM, and SRNA #9 at 2:30 PM revealed they worked short-staffed at times in the facility and as a result, residents complained about call light wait times. The SRNAs stated they reported to licensed nurses when residents complained about call light wait times. Interview on 01/27/2020 with SRNA #14 at 7:40 PM and SRNA #15 at 7:50 PM, and on 01/29/2020 with SRNA #13 at 12:00 PM revealed residents complained about call light wait times in the facility and complaints were reported to licensed nurses. Interview with Licensed Practical Nurse (LPN) #8 on 01/28/2020 at 10:10 AM and LPN #5 on 01/29/2020 at 1:45 PM revealed the facility worked short of SRNAs at times and as a result, residents complained about call light wait times in the facility. LPN #8 stated resident complaints regarding call light wait times had been voiced to the Interim DON and she stated, We're working on it. Interview with the Interim Director of Nursing (DON) on 01/29/2020 at 1:00 PM revealed she was not responsible for grievances in the facility. She also stated she was not aware residents had voiced grievances related to call light wait times in the facility. Interview with the Administrator on 01/29/2020 at 2:20 PM revealed he was responsible to ensure grievances were resolved in the facility. The Administrator stated he was aware that residents had voiced grievances related to call light wait times because he heard it in resident council. The Administrator acknowledged he was aware grievances were voiced in the Resident Council meeting conducted on 01/16/2020 (thirteen days ago) and stated he was working on it. He also stated his signature on the Facility Concern/Grievance Form indicated the grievance had been investigated and resolved as outlined in the facility policy. The Administrator stated that even though he had signed the written grievances, which indicated they were resolved for Residents #42, #102, and #97, he acknowledged that he had not ensured they were investigated or that the individual that submitted the written grievances was contacted to ensure resolution of the voiced concerns. He also stated residents' call lights should be answered in a timely manner.

Based on observation, interview, and record review it was determined the facility failed to ensure five (5) unsampled residents who were unable to carry out activities of daily living received necessary care and services to maintain good personal hygiene (Residents #42, #96, #97, #99, and #103). Resident observations and interviews conducted on 01/27/2020, interviews with staff, and review of written grievances revealed residents were not provided incontinence care or assisted with activities of daily living (ADLs) in a timely manner due to short-staffing in the facility. The findings include: Interview with the Administrator on 01/29/2020 at 2:20 PM revealed the facility did not have a policy related to assisting residents with ADLs in the facility. 1. Review of Resident #96's medical record revealed the facility admitted the resident on 09/24/2015, with [DIAGNOSES REDACTED]. Review of Resident #96's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed by the facility to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) indicating the resident was cognitively intact. Further review of the MDS revealed Resident #96 required extensive assistance of two (2) staff members for bed mobility, transferring, dressing, and toilet use. The facility also assessed the resident to be incontinent of both bowel and bladder. Observation and interview on 01/27/2020 at 10:30 AM with Resident #96, who resided on the East Wing, revealed the resident's call light was on. Interview with the resident related to the call light revealed, It's (referring to the call light) been on for ten minutes already. The resident stated call light wait times were a problem in the facility, stating, It's been hard to get help here for a month or longer. The resident also stated he/she had not received assistance with ADLs since day shift staff had come on duty at 6:00 AM (approximately four and one-half hours). Resident #96 stated that staff tell him/her that they are working short when complaints were voiced about call light wait times in the facility. Continued observation revealed the resident had on a white t-shirt with food particles and a dried brown substance on the front of the shirt and dried dark yellow stains and dried food particles on the resident's bed linens. Further observation revealed staff responded to the resident's call light at 10:50 AM. Interview with Registered Nurse (RN) #2 on 01/27/2020 at approximately 10:50 AM revealed the RN acknowledged that the resident's clothing and bed linen appeared to be dirty and stated residents should be receiving assistance with ADLs at a minimum of every two (2) hours. The RN acknowledged that the East Wing should be staffed with four (4) State Registered Nurse Aides (SRNAs); however, there were only three (3) working the day shift at the time of the interview. The RN also stated one (1) of the three (3) SRNAs was at lunch; therefore, only two (2) SRNAs were available to provide assistance to residents on the East Wing of the facility when the interview was conducted. Interview on 01/27/2020 with SRNA #8 at 12:40 PM, SRNA #16 at 2:00 PM, and SRNA #9 at 2:30 PM revealed they were responsible for Resident #96's care, but they were working short-staffed. The SRNAs acknowledged they had not provided Resident #96 with assistance since they had come on duty (approximately five hours earlier), stating they had not got to the resident yet, because they were short-staffed. The SRNAs also stated residents frequently complained because timely assistance could not always be provided. 2. Review of Resident #97's medical record revealed the facility admitted the resident on 07/25/2018, with [DIAGNOSES REDACTED]. Review of Resident #97's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed by the facility to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) indicating the resident was cognitively intact. Further review of the MDS revealed Resident #97 required extensive assistance of two (2) staff members for bed mobility, transferring, dressing, and toilet use. The facility also assessed the resident to be frequently incontinent of bladder and occasionally incontinent of bowel. Review of a Facility Concern/Grievance Form for Resident #97, dated 12/27/2019 at 3:00 PM, revealed the Director of Therapy had submitted a written grievance to the Administrator on behalf of Resident #97. Review of the grievance revealed Therapy staff had informed staff several times on 12/27/2019 beginning at 12:00 PM that Resident #97 needed to be changed. The grievance also indicated the resident had also informed staff that he/she needed to be changed. Further review of the grievance revealed at 2:20 PM (two hours and twenty minutes later) Resident #97 had still not received assistance with incontinence care, and again the Director of Therapy informed staff that Resident #97 needed to be changed. Further review of the grievance revealed after Therapy staff made the report at 2:20 PM, staff was observed to walk into the resident's room, turn the call light off, and walk out without changing the resident. Continued review of the grievance form revealed at 2:50 PM (approximately three hours after the initial request for incontinence care) Therapy staff observed Resident #97 to be sitting up in a wheelchair with urine dripping from it and pooling underneath the chair on the floor. Interview with Resident # 97 on 01/27/2020 at 9:55 AM revealed he/she had voiced concerns related to call light wait times and incontinence care not being provided in a timely manner. Resident #97 stated, I've sat wet for hours and there's been times it's been bad, but I'd rather not discuss it. The resident stated no one had followed up with him/her regarding the grievance from 12/27/2019. Resident #97 stated receiving timely assistance with incontinence care remained a problem in the facility. 3. Review of Resident #42's medical record revealed the facility admitted the resident on 01/11/2017, with [DIAGNOSES REDACTED]. Review of Resident #42's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident refused to answer the questions on the assessment, but was independent with making decisions. A BIMS assessment conducted on 01/29/2020 by the facility revealed the resident scored a fifteen (15) indicating no cognitive impairment. Further review of the MDS revealed Resident #42 required extensive assistance of two (2) staff members for bed mobility, transferring, and dressing, and was totally dependent on staff for toilet use. The facility also assessed the resident to be incontinent of both bowel and bladder. Review of a Facility Concern/Grievance Form, dated 12/23/2019, revealed Resident #42 had voiced a grievance asking for assistance to be changed at around 2:00 AM on 12/23/2019, due to having a bowel movement. However, according to the grievance Resident #42 was not provided with incontinence care until day shift arrived at approximately 6:00 AM on 12/23/2019. Interview with Resident #42 on 01/28/2020 at 10:20 AM confirmed the resident had filed a written grievance on 12/23/2019, related to not receiving timely incontinence care. The resident stated he/she had also voiced complaints related to call light wait times and short-staffing in the facility, but stated, It doesn't do any good to complain about anything here; nothing gets fixed when we complain. Resident #42 stated there were still problems with receiving incontinence care in a timely manner. Interview with Registered Nurse (RN) #2 on 01/27/2020 at 2:20 PM confirmed that on 12/23/2019 she received Resident #42's grievance. The RN stated she spoke to night shift aides (unable to recall whom) about providing incontinence care to residents when care was requested. The RN acknowledged she had not interviewed any other residents related to care provided in the facility, but stated residents continue to complain about call light wait times, and assistance with ADLs not being provided timely. 4. Review of Resident #99's medical record revealed the facility admitted the resident on 02/26/2013, with [DIAGNOSES REDACTED]. Review of Resident #99's Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was assessed by the facility to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) indicating the resident was cognitively intact. Further review of the MDS revealed Resident #99 required extensive assistance of two (2) staff members for bed mobility, transferring, dressing, and toilet use. The facility also assessed the resident to be frequently incontinent of both bowel and bladder. Interview with Resident #99 on 01/27/2020 at 12:45 PM revealed the resident stated he/she has had to wait for an hour or longer for assistance with transfers in/out of bed and for incontinence care, due to requiring a mechanical lift and two staff members for the care. 5. Review of Resident #103's medical record revealed the facility admitted the resident on 11/11/2019, with [DIAGNOSES REDACTED]. Review of Resident #103's Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was assessed by the facility to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) indicating the resident was cognitively intact. Further review of the MDS revealed Resident #103 required limited assistance with toilet use, and was occasionally incontinent of both bowel and bladder. Interview with Resident #103 on 01/27/2020 at 12:25 PM revealed he/she had incontinence episodes at times and utilizes pull-ups. The resident stated when he/she had an episode of incontinence it often took an hour or longer to receive assistance with getting cleaned up, and stated he/she had sat in urine and urinated on his/herself because they won't come. Interview on 01/27/2020 with SRNA #14 at 7:40 PM and SRNA #15 at 7:50 PM, and on 01/29/2020 with SRNA #13 at 12:00 PM, revealed residents frequently complain about call light wait times and not getting timely assistance with ADL care. Interview with Licensed Practical Nurse (LPN) #8 on 01/28/2020 at 10:10 AM and LPN #5 on 01/29/2020 at 1:45 PM revealed the facility was often short of SRNAs, and as a result, residents complained about call light wait times, and not getting the assistance when needed. Interview with the Interim Director of Nursing (DON) on 01/29/2020 at 1:00 PM, revealed residents should receive assistance with ADLs in a timely manner in the facility. Interview with the Administrator on 01/29/2020 at 2:20 PM revealed he was aware that residents and staff had voiced complaints and submitted written grievances related to not receiving care in a timely manner. However, the Administrator acknowledged he had not conducted investigations into the complaints.

Based on observation, interview, and record review, it was determined the facility failed to ensure sufficient staff was available to provide nursing and related services to maintain the highest practicable physical, mental, and psychosocial well-being for twelve (12) unsampled residents (Residents #10, #42, #43, #73, #77, #78, #96, #97, #98, #99, #103, and #104). In addition, interviews with staff and residents, and review of Resident Council Meeting Minutes, revealed call lights were not answered in a timely manner. The findings include: Review of post-exit e-mail correspondence with the Administrator on 02/04/2020 revealed the facility had no policy related to staffing in the facility. Further review revealed the facility followed the regulatory requirements related to staffing. Review of the Brief Interview for Mental Status (BIMS) scores provided by the facility on 01/27/2020 and 01/29/2020 revealed Residents #10, #42, #43, #77, #96, #97, #98, #99, #103, and #104 were interviewable, with a BIMS score of fifteen (15) and Residents #73 and #78 were interviewable with a BIMS score of thirteen (13). Review of Resident Council Meeting Minutes dated 01/16/2020 revealed residents voiced concerns that call lights are not always answered in a timely manner. Observations conducted on the East Wing of the facility on 01/27/2020 at 10:30 AM revealed Resident #96's call light was on. Interview with Resident #96 at 10:30 AM on 01/27/2020 revealed he/she stated, It's been on for ten minutes already. Continued observations revealed staff responded to the resident's call light at 10:50 AM (twenty minutes later). Interview with Resident #96 on 01/27/2020 at 10:30 AM revealed call light wait times were a problem in the facility and he/she also stated, It's been hard to get help here for a month or longer. The resident stated he/she requires assistance with toileting and waits thirty minutes, and up to an hour at times, for staff to respond to his/her call light. The resident also stated staff informed the resident that they're working short. Continued observations on 01/27/2020 at 10:50 PM of the East Wing of the facility revealed three (3) State Registered Nurse Aides (SRNAs) were working on that side of the facility for the day shift. Review of the Resident Matrix dated 01/27/2020 revealed approximately forty-three (43) residents were on the East Wing of the facility. Interview on 01/27/2020 with SRNA #8 at 12:40 PM, SRNA #16 at 2:00 PM, and SRNA #9 at 2:30 PM revealed they were working short-staffed on the day shift on 01/27/2020. The SRNAs stated four (4) SRNAs were supposed to work on the East Wing of the facility on day shift; however, only three (3) were working on 01/27/2020. SRNA #16 also stated they worked with only three (3) SRNAs two to four days a week at least. The SRNAs stated residents complained about call light wait times, and acknowledged that staff informs the residents they are working short when they complain about call light wait times because we are. Interview on 01/27/2020 with Resident #73 at 9:45 AM, Resident #97 at 9:55 AM, Resident #98 at 10:15 AM, and Resident #99 at 12:45 PM revealed they waited up to an hour at times for their call lights to be answered, due to short-staffing in the facility. The residents stated staff had informed them they are working short when concerns were voiced related to call light wait times. Interview on 01/28/2020 with Resident #10 at 12:50 PM and Resident #104 at 12:55 PM revealed they had waited thirty minutes or longer for staff to respond to the call light. Resident #10 stated he/she was President of the Resident Council in the facility and required assistance with transfers, as well as other activities of daily living (ADLs). Resident #10 stated, We've complained about the call lights in the meetings a few weeks ago. The residents also stated staff informed them that they are short-staffed when concerns were voiced related to call light wait times in the facility. Interview on 01/28/2020 with Resident #42 at 10:20 AM, Resident #43 at 12:15 PM, and Resident #99 at 12:25 PM revealed the facility is short-staffed and they wait for thirty minutes or longer for their call lights to be answered in the facility. Resident #43 also stated call light wait times had been worse for the past month or more in the facility. Interview on 01/27/2020 with Resident #78 at 12:20 PM, Resident #103 at 12:25 PM, and Resident #77 at 12:35 PM revealed call light wait times were a concern in the facility and staff had informed Resident #77 and Resident #103 that the facility was short-staffed. Interview on 01/27/2020 with State Registered Nurse Aide (SRNA) #14 at 7:40 PM and SRNA #15 at 7:50 PM, and on 01/29/2020 with SRNA #13 at 12:00 PM revealed staff were not always replaced when call-ins occurred and therefore, they work short-staffed. The SRNAs stated residents complained about call light wait times in the facility. SRNA #14 and SRNA #12 stated the facility works short-staffed three to four times a week. SRNA #15 also stated staff were ending their employment at the facility because they were working short-staffed in the facility. Interview on 01/29/2020 with Licensed Practical Nurse (LPN) #8 at 10:10 AM and LPN #5 at 1:45 PM revealed the facility worked short of SRNAs at times, and residents complained about call light wait times in the facility. LPN #8 stated attempts were made to replace staff when call-ins occurred; however, if no one came in to work the shift, staff were working short. Interview with Registered Nurse (RN) #2 on 01/27/2020 at 2:20 PM revealed staffing was a concern at times in the facility related to SRNAs. She stated the required staffing on the East Wing of the facility was four (4) SRNAs on the day shift. She acknowledged the facility was short-staffed on 01/27/2020 and stated attempts were made to replace staff that failed to report to work as scheduled; however, if no one came in, they were working short. The RN also stated SRNA staffing has been a concern in the facility for a while. Interview with the Interim Director of Nursing (DON) on 01/29/2020 at 1:00 PM revealed there should be four (4) SRNAs to provide care to residents during the day shift on the East Wing of the facility. She acknowledged only three (3) SRNAs worked the day shift on 01/27/2020 and stated staff do call in at times, and if coverage is unable to be obtained for that shift staff are working short. The Interim DON also stated she was not aware that staffing was a concern in the facility or that residents had voiced complaints in the facility related to call light wait times. Interview with the Administrator on 01/29/2020 at 2:20 PM revealed he was not aware staffing was a concern in the facility. He also stated if the resident population calls for four (4) SRNAs to provide care to the residents, then there should be four (4) SRNAs. He also stated resident call lights should be answered in a timely manner.

Based on observation, interview, and record review it was determined the facility failed to ensure that residents who were diagnosed with [REDACTED].#95). Review of Resident #95's care plan revealed the facility identified that the resident made sexually inappropriate comments and developed interventions that required staff to protect residents, monitor the resident for inappropriate behavior when the resident was near peers, and do not leave unsupervised around other residents during dining. Interviews with staff revealed they were not aware the care plan interventions had been developed. Subsequently, the facility failed to supervise/monitor Resident #95 on 11/06/2019 and 01/12/2020, and the resident made inappropriate sexual comments to other residents and/or followed a resident around. The findings include: Review of post-survey e-mail correspondence with the Administrator on 02/04/2020 revealed the facility had no policy related to care of residents with Dementia. Further interview revealed the facility followed the regulatory requirements related to caring for residents with a [DIAGNOSES REDACTED]. Review of Resident #95's record revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Resident #95's quarterly Minimum Data Set Assessment ((MDS) dated [DATE] revealed Resident #95 had exhibited verbal behavioral symptoms directed toward others, one (1) to three (3) days during the assessment period. Staff assessed the resident to be interviewable, with a Brief Interview for Mental Status (BIMS) score of nine (9). Review of Resident #1's care plan dated 07/30/2018 revealed the facility identified that the resident liked to socialize with peers and staff, but had behaviors of sexual aggression and was hard to redirect. Review of the facility's interventions revealed staff were required to document the resident's behavior and monitor the resident for inappropriate behavior when he/she was near peers. Further review revealed Resident #95's care plan also indicated that on 08/15/2019 when the resident attended group B dining, staff were directed, do not leave unsupervised around other residents. Review of a facility investigation revealed on 11/06/2019, Resident #100 reported to staff that he/she was in the lounge area of the facility when Resident #95 entered the lounge and stated, Come over here. When Resident #100 told Resident #95 that he/she could not do that, Resident #95 then asked Resident #100, Would you like a different d**k? According to Resident #95's nurse's notes, staff increased supervision of Resident #95 and his/her room was changed to a room that was closer to the nurses' station. There was no documented evidence that staff were monitoring Resident #95's behavior as required by the resident's care plan. Continued review of Resident #95's care plan revealed the facility revised the care plan on 11/07/2019, after the incident with Resident #100. According to the care plan, Resident #95 had made very inappropriate sexual comments to a female resident and following her around. The facility developed a new intervention for staff to protect other residents from Resident #95, if the residents were unable to protect themselves. Review of the Resident #95's most recent MDS dated [DATE] revealed Resident #95 had exhibited verbal behavioral symptoms directed toward others, one (1) to three (3) days during the assessment period. The assessment also indicated the resident's behavioral symptoms had worsened since his/her previous assessment. Further review revealed the resident was interviewable, with a Brief Interview for Mental Status (BIMS) score of eleven (11). Further review of facility investigations and review of Resident #95's nurse's notes revealed on 01/12/2020 Resident #95 and Resident #57 were sitting outside the dining room awaiting the noon meal. Continued review revealed Resident #95 was observed holding onto Resident #57's chair and was overheard by housekeeping to state to Resident #57, I have sh*t on my d**k. Further review revealed the housekeeping staff asked Resident #95 to leave the other resident alone and Resident #95 stated, F**k you, and then touched the housekeeper's butt. According to the nurse's notes, staff assisted Resident #57 into the dining room and provided supervision. There was no evidence the facility provided supervision for Resident #95 as required by the resident's care plan or identified that the resident's care plan was not being implemented when the incident occurred. Review of Resident #57's most recent MDS assessment dated [DATE] revealed staff assessed the resident to be interviewable with a BIMS score of ten (10). However, an interview with Resident #57 on 01/27/2020 at 10:20 AM revealed he/she did not recall the incident that occurred on 01/12/2020. Further review of Resident #95's medical record revealed the resident was transferred to a hospital on [DATE] for an inpatient psychiatric stay. Resident #95 remained at the hospital on [DATE] and was unable to be observed and/or interviewed. Interview with State Registered Nurse Aide (SRNA) #13 on 01/29/2020 at 12:00 PM revealed she provided care to Resident #95 frequently and the resident was always permitted to go to the dining room unsupervised. The SRNA stated she had never been directed to supervise the resident during meal times, and had never been told to protect other residents from Resident #95. Interview with SRNA #11 on 01/29/2020 at 12:30 PM revealed Resident #95 frequently made inappropriate sexual comments to staff. The SRNA stated he provided care to the resident frequently and was working when the incident occurred on 01/12/2020, while residents were outside the dining room awaiting the noon meal. SRNA #11 stated he was not aware he was required to supervise the resident during meal times. The SRNA also stated he had never been directed to monitor the resident when he/she was around other residents in the facility. Interview with Licensed Practical Nurse (LPN) #8 on 01/29/2020 at 10:10 AM revealed she was working when the incident occurred on 01/12/2020, when Resident #95 made an inappropriate sexual comment to Resident #57. The LPN stated she was not aware staff were required to supervise Resident #95 during meal times, and was not aware the resident should be monitored while he/she was around other residents, as outlined in the resident's plan of care. Interview with the MDS Coordinator on 01/29/2020 at 10:50 AM revealed resident behaviors were discussed daily during a morning meeting Monday through Friday, and care plans were reviewed/revised at that time. The MDS Coordinator stated Resident #95's ongoing behaviors had been discussed in the morning meetings and new interventions had been implemented in attempts to protect other residents from Resident #95. The MDS Coordinator stated she was not aware that Resident #95's care plan directed staff to supervise the resident during meal times, because the previous Director of Nursing had revised the resident's care plan with that intervention in August 2019. However, the MDS Coordinator acknowledged she had implemented interventions in November 2019 that required staff to protect other residents from Resident #95 and to monitor Resident #95 when he/she was around other residents. According to the MDS Coordinator, she did not provide any education for direct care staff related to the care plan revisions because she thought it was the responsibility of the Unit Manager to educate staff. She further acknowledged that if Resident #95's care plan had been implemented as required, the incident would not have occurred on 01/12/2020. Interview with Registered Nurse (RN) #2 on 01/27/2020 at 2:20 PM revealed she was also the Unit Manager (UM) where Resident #95 resided when the incident occurred on 01/12/2020. RN #2 stated resident behaviors were monitored daily Monday through Friday during morning meetings, and resident care plans were reviewed/revised to include new interventions when behaviors were identified. The RN also stated she recalled discussing Resident #95's ongoing sexual behaviors during morning meetings; however, she was not aware that the resident had a care plan intervention that stated the resident was required to be supervised during meal times, that staff were to protect residents if they were unable to protect themselves from Resident #95, or that staff were required to monitor the resident when he/she was near peers. RN #2 also stated she had never been directed to educate direct care staff on the interventions and was not sure who was responsible to notify staff of changes to resident care plans to ensure resident care plans were implemented in the facility. Interview with the Interim Director of Nursing (DON) on 01/20/2020 at 1:00 PM revealed Resident #95's ongoing behaviors had been discussed in clinical meetings and new interventions had been added to the resident's care plan. However, the Interim DON had not identified that direct care staff had not been trained on newly implemented interventions and was not aware Resident #95's care plan had not been implemented in attempts to manage the resident's ongoing sexually inappropriate behaviors. Interview with the Administrator on 01/29/2020 at 2:20 PM revealed he was not aware that direct care staff had not been trained regarding Resident #95's care plan. The Administrator also stated he expected staff to follow residents' plans of care at the facility.

Based on observation, interview, record review, and review of the facility's policy it was determined the facility failed to immediately notify the physician of omitted medications and/or medication errors for twelve (12) of twenty-two (22) sampled residents (Resident #3, #9, #13, #19, #28, #41, #42, #47, #63, #66, #72, and #86). Seven residents (Residents #3, #13, #19, #41, #42, #72, and #86), who were alert and oriented, all alleged they did not receive medications as ordered on the evening of 08/19/19. RN #1 was responsible for administering medications for these residents on 08/19/19. Although the residents' complaints were reported to administrative staff (DON and Administrator), the facility failed to report the medication errors to the residents' physicians. Resident #66 also reported that he/she did not receive his/her medications on the evening of 08/26/19. In addtion, RN #1 failed to administer three (3) residents (Residents #63, #47, and #9) their 10:00 PM medications on 08/26/19. Again, the facility failed to ensure the residents' physicians were notified of the medication errors. Resident #28 reported to at least three (3) facility staff members that staff had failed to administer his/her medications. RN #1 failed to administer the resident's pain medication on 08/25/19 and the medication error was reported to administrative staff (Assistant Director of Nursing and Director of Nursing); however, the facility failed to notify Resident #28's physician of the medication error. The facility's failure to immediately report the alleged omission of ordered medications for residents (Resident #3, #9, #13, #19, #28, #41, #42, #47, #63, #66, #72, and #86) has caused or is likely to cause serious harm, injury, impairment, or death to a resident. Immediate Jeopardy was identified on 09/13/19 and was determined to exist on 08/19/19 at 42 CFR 483.10 Resident Rights (F580-K), 42 CFR 483.35 Nursing Services (F726-K) and 42 CFR 483.45 Pharmacy Services (F760-J). The facility was notified of the Immediate Jeopardy on 09/13/19. An acceptable Allegation of Compliance was received on 09/18/19, which alleged removal of the Immediate Jeopardy on 09/19/19. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on 09/19/19, prior to exit on 09/25/19, which lowered the scope and severity to [NAME] level at 42 CFR 483.10 Resident Rights (F580) and 42 CFR 483.35 Nursing Services (F726) and to D level at 42 CFR 483.45 Pharmacy Services (F760) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy, Notification of Physician for Change in Resident's Condition, dated (MONTH) 2012, revealed the facility was to notify the physician when a significant change in a resident's condition occurred with documentation contained in the medical record. Review of the Medication Administration policy, not dated, revealed, All medication errors shall be described in detail on a Medication Error Report which shall be filed with the Director of Nursing (DON). Continued review revealed the facility's medication error report shall be completed in detail, making every possible effort to describe the discrepancy thoroughly; suggestion should be made as to how such discrepancy could be avoided in the future. The attending physician shall be notified immediately of significant medication errors. 1. Seven residents (Residents #3, #13, #19, #41, #42, #72, and # 86), who were alert and oriented, all alleged they did not receive medications as ordered on the evening of 08/19/19. An interview on 09/10/19 at 12:14 PM with LPN #1 revealed RN #1 had helped with medication administration on the East Unit (short hall) on the evening of 08/19/19. Per LPN #1, the RN left sometime around 10:00 PM. The LPN stated that at around 9:30 PM, Resident #41 stated he/she was ready to take his/her medication for the night. When RN #1 was informed of this, she stated she had already administered the resident's medication. LPN #1 stated Resident #41 was told what the nurse had stated and the resident replied that he/she had not received the medication. Resident #42 then asked the LPN when he/she would receive the rest of his/her medication. Per LPN #1, Resident #42 stated he/she had only received one pill and the RN had informed him/her she did not have the right cart to give the rest of the resident's medication. The LPN further stated Resident #72 asked when someone was going to perform his/her finger stick blood sugar and that he/she felt funny. LPN #1 stated the MAR for Resident #72 revealed the finger stick blood sugar had been performed with a reading of 130. LPN #1 stated she checked the MARs of Residents #13 and #19 and discovered Resident #13's fingerstick blood sugar was also documented as 130 and Resident #19 had no finger stick blood sugar documented and the ordered [MEDICATION NAME] (long-acting insulin) had not been administered. The LPN stated she did another finger stick blood sugar on Resident #13 and it was 297. LPN #1 stated she continued to review the MARs of the residents on the East short hall and discovered Residents #3 and #86 had no initials in the space on the MAR that would have indicated their evening medications were administered as ordered. Per the LPN, she notified the Assistant Director of Nursing (ADON), who was in the facility working on the West Unit, of all the allegations and MAR inaccuracies. Per the LPN, the DON was also made aware of the incidents by the ADON on 08/20/19 and she was told the DON had handled the situation. Interview with RN #1 on 09/13/19 at 3:39 PM, revealed she remembered it took a long time to complete the medication pass on 08/19/19 because she was not familiar with the hall. She further stated the two (2) book MAR system means you have to go back and forth. The RN also stated she did not remember ever being spoken to regarding allegations on 08/19/19. Interview with the DON on 09/10/19 at 3:07 PM, revealed she spoke to RN #1 the next day following the incidents on 08/19/19. She also stated she spoke to the residents on the hall and that no medication error forms were completed nor were the residents' physicians contacted. The DON stated she just did not think about doing that. Review of the Progress Notes for Residents #3, #13, #19, #41, #42, #72, and #86 for 08/19/19 and 08/20/19 did not reveal any documentation of physician notification regarding the residents' alleged medication omissions. Interview on 09/13/19 with MD (Medical Doctor) #1 at 3:00 PM and MD #2 at 3:05 PM revealed neither had been contacted related to medication errors involving their residents. The doctors stated they would expect to be notified of any resident medication errors. 2. Review of the medical record for Resident #66 revealed the facility admitted the resident on 08/09/19 with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the facility assessed the resident to have a BIMS score of 15, which indicated the resident was interviewable. Review of a Grievance filed by Resident #66 on 08/29/19 revealed the resident had reported to the Social Services Director that on 08/26/19, the nurse on duty did not give his/her medicine and failed to do a finger stick blood sugar and administer his/her insulin. Record review revealed Resident #66 was discharged from the facility on 09/04/19. Unsuccessful attempts were made to contact the resident by phone. Interview with the Social Services Director (SSD) on 09/13/19 at 2:37 PM revealed on 08/29/19, Resident #66 reported that he/she did not receive his/her medications on 08/26/19. The SSD stated she reported the medication error to the Administrator. Interview with the Administrator on 09/13/19 at 5:03 PM revealed he spoke with the Director of Nursing (DON) regarding the resident not receiving medication as ordered, and the DON assured him that she had taken care of the concern. However, an interview with the DON on 09/10/19 at 2:56 PM revealed Resident #66's physician should have been contacted related to the medication error with the resident's insulin, but she did not ensure the physician was notified. 3. Review of the medical record for Resident #63 revealed the facility admitted the resident on 06/25/19 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of eight (8), which indicates the resident was cognitively impaired, but interviewable. Further review of the medical record for Resident #63 revealed a physician's orders [REDACTED]. Further review revealed an order for [REDACTED]. Review of the Medication Administration Record (MAR) dated 08/26/19 revealed the resident's 10:00 PM dose of [MEDICATION NAME] and [MEDICATION NAME] had not been initialed as being administered. Interview with Resident #63 on 09/12/19 at 10:57 AM revealed the nurse on duty had failed to administer his/her scheduled medication at bedtime. However, the resident could not remember the exact date. Resident #63 stated the medication was to help him/her sleep and he/she had not slept at all that night. Continued interview with Resident #63 revealed the resident reported the omitted medications the following day, but he/she could not remember the nurse's name that he/she reported it to. On 09/10/19 at 6:05 PM, interview with LPN #2 revealed she worked 6:00 PM to 6:00 AM on 08/26/19. Per LPN #2, RN #1 was working when she arrived and worked until 10:00 PM, at which time LPN #2 counted narcotics with RN #1. LPN #2 stated that RN #1 did not report any problems with residents refusing medication, or that any scheduled medications had not been administered. LPN #2 stated Resident #63's 10:00 PM dose of [MEDICATION NAME] and [MEDICATION NAME] had not been signed out as administered for 08/26/19 on the MAR, nor on the Controlled Drug Sheet. LPN #2 stated she notified the DON of this and the DON stated, I will look into this. Per the LPN, she did not call the resident's physician related to the medication error for Resident #63. 4. Review of the medical record for Resident #47 revealed the facility admitted the resident on 08/17/18 with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the facility assessed the resident to have a BIMS score of 99, which indicated the resident was not interviewable. Review of the medical record for Resident #47 revealed a physician's orders [REDACTED]. The medication was scheduled at 10:00 AM and 10:00 PM. However, review of the MAR dated 08/26/19 revealed the 10:00 PM dose was not signed out. In addition, review of the Controlled Substance Receipt/Count Sheet dated 08/26/19 revealed the 10:00 PM dosage of medication had not been administered to the resident on 08/26/19. On 09/10/19 at 6:05 PM, interview with LPN #2 revealed she worked 6:00 PM to 6:00 AM on 08/26/19. LPN #2 stated she received report from the offgoing nurse, RN #1, around 10:00 PM on 08/26/19. LPN #2 stated that RN #1 did not report any problems with residents refusing medication, or that any scheduled medications had not been administered. LPN #2 stated that during her morning medication pass she discovered that Resident #47's scheduled dose of [MEDICATION NAME]/APAP on 08/26/19 at 10:00 PM had not been signed as administered on the MAR or signed out on the Controlled Drug Sheet. LPN #2 stated she informed the DON of this when she arrived at the facility but failed to contact the physician of the medication error. 5. Review of the medical record for Resident #9 revealed the facility admitted the resident on 05/30/19 with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE], revealed the facility assessed the resident to have a BIMS score of 15, which indicated the resident was interviewable. Interview with Resident #9 on 09/11/19 at 1:55 PM revealed his/her scheduled nighttime medication was missed/omitted a few weeks ago. The resident stated he/she did not recall the date, or the nurse working. Resident #9 stated he/she did not sleep at all that night, and further stated that the medication was for my nerves. Review of the medical record for Resident #9 revealed an order for [REDACTED]. Review of the MAR and the Controlled Substance Receipt/Count Sheet for 08/26/19 revealed the medications were not signed out for the 10:00 PM dose. On 09/10/19 at 6:05 PM, interview with LPN #2 revealed she worked 6:00 PM to 6:00 AM on 08/26/19. The LPN stated she received report from the offgoing nurse, RN #1, around 10:00 PM on 08/26/19. LPN #2 stated that RN #1 did not report any problems with residents refusing medication, or that any scheduled medications had not been administered. LPN #2 stated that during her morning medication pass she discovered that Resident #9's scheduled dose of [MEDICATION NAME]/APAP, [MEDICATION NAME], and [MEDICATION NAME] had not been signed out on the MAR or on the controlled drug sheet. LPN #2 stated she informed the DON of this when she arrived at the facility. Per the LPN, she had not contacted the resident's physician related to the medication error. Interview with the DON on 09/10/19 at 2:56 PM revealed she did not recall any reports that Resident #47 or Resident #9 had not received their scheduled medication. The DON stated when a medication error occurs, the resident's physician should be notified. 6. Medical record review for Resident #28 revealed the facility admitted the resident on 01/22/18 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score was eight (8) indicating the resident was cognitively impaired, but was interviewable. Interview with Resident #28 on 09/10/19 at 12:23 PM revealed he/she missed his/her medication for several days; was unable to state the exact dates. Resident #28 stated he/she felt funny and didn't rest well and had pain because of not receiving his/her medication. Review of the medical record for Resident #28 revealed a physician's orders [REDACTED]. Review of the resident's Medication Administration Record (MAR) revealed the medication was scheduled for 10:00 AM and 10:00 PM. Review of the MAR dated 08/25/19 revealed RN #1's initials were circled with no documented evidence indicating why the medication was not administered. Interview with Kentucky Medication Aide (KMA) #1 on 09/10/19 at 11:20 AM revealed Resident #28 reported that he/she did not receive his/her nighttime medication for three (3) days (unable to recall the date). KMA #1 stated she immediately reported the medication errors to LPN #2. Interview on 09/10/19 at 6:05 PM with LPN #2 revealed on 08/26/19, KMA #1 reported that Resident #28 had complained of not getting his/her medications for the past three (3) days. LPN #2 stated she reviewed Resident #28's MAR and discovered several areas that had not been initialed. The LPN stated she did notify the DON of the resident's complaint of missed medications when she discovered the error, but she was not directed by the DON to take any action. The resident's physician was not notified regarding the medication error. Interview with the SSD, who also is a KMA, on 09/13/19 at 2:37 PM revealed the SSD had worked on 08/25/19, on the 2 PM-10 PM shift as a KM[NAME] The SSD was assigned to pass medication. The SSD stated that Resident #28 reported that he/she had not received his/her scheduled morning medication. The SSD stated she reviewed the Controlled Drug Sign Sheet and discovered the morning dose of [MEDICATION NAME]/APAP was not signed out. However, the scheduled 10:00 AM dose was signed out on the MAR indicating the medication had been administered. The SSD stated that RN #1 was assigned to pass the morning medicine on 08/25/19. She further stated that she questioned RN #1 about why the narcotic was not signed out on the controlled drug log. However, RN #1 did not respond to the question. The SSD stated that later in the shift she checked Resident #28's MAR again and the 08/25/19 10:00 AM dose of [MEDICATION NAME]/APAP had been circled, indicating not given. The SSD stated she reported the medication error to the DON. Further review revealed no documented evidence that Resident #28's physician was contacted related to the medication error. Interview with the DON on 09/10/19 at 2:56 PM revealed she did not recall anyone reporting that Resident #28's medications were omitted. The DON further reported the facility had no system in place to monitor residents' MARs for completion or to ensure the physician was notified when medications were not administered as ordered. ***The facility alleged the following was implemented to remove the Immediate Jeopardy as of 09/19/19: 1. On 09/13/19, a Quality Improvement meeting was conducted after the Immediate Jeopardy (IJ) was communicated to the facility. The purpose was to develop an improvement plan to address the IJ deficiencies, and monitor guidelines to ensure compliance was maintained. This meeting was attended by the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC), and an RN Nurse Consultant. 2. On 09/14/19, the facility's Medical Director was made aware of the Immediate Jeopardy and advised of the improvement plan, by the DON. He had no concerns or additions to the plan. 3. On 09/16/19, a follow-up QI meeting was conducted to review the progress on the 09/13/19 plan. A review of all items completed and the monitoring plan was completed. There were no additional recommendations at this time. Those in attendance were the Administrator, DON, ADON, RN Consultant, and Medical Director via phone. 4. Nurse #1 has not worked in the facility since 09/08/19, and is no longer employed by the facility effective 09/16/19. 5. On 09/16/19, Nurse #2 received education regarding physician notification, which included that the physician must be notified if there was a question of whether a resident had received their medication or had their blood sugar evaluated. 6. On 09/14/19, the ADON completed an audit of 100% of the in-house residents' (MONTH) and (MONTH) 2019 Medication Administration Records (MARs). This audit was to identify medications that were not documented as administered on the MAR and medications with multiple days of refusals. The findings included that over 50% of the MARs were missing documentation to support that medications had been administered. 7. On 09/14/19, the DON completed interviews with all residents with a BIMS score above eight (8), except one resident who was not feeling well. Residents were asked about concerns with how and when medications were administered. One resident stated he/she did not know why he/she received each medication and why medications were not consistently given at the same time each day. This resident was provided education, by the staff nurse, on his/her medications and the two (2) hour window for administering medications. On 09/15/19, the ADON completed an interview with the resident who was not feeling well on 09/14/19. The resident had no concerns with how and when medications were administered. 8. On 09/15/19, the ADON and SDC completed nursing assessments on all residents with a BIMS score of eight (8) or below. This assessment included Vital Signs and Lung and Bowel assessments. Two (2) residents were noted with a concern. One resident had an oxygen (O2) saturation of 82%, the MD was notified, and orders for oxygen at 2 Liters and chest x-ray were received. Oxygen was applied and his/her O2 saturation was 94%. One resident had an erratic pulse. The MD was notified and ordered a STAT EK[NAME] The resident has a [DIAGNOSES REDACTED]. 9. On 09/13/19, the Staff Development Coordinator began education with all licensed nurses and Kentucky Medication Aides (KMAs) regarding the six (6) rights of medication administration. These included Right Resident, Right Medication, Right Dose, Right Time, Right Route, and Right Documentation. This education also included what to do if an order was not legible, or if a medication was unavailable. On 09/14/19, this education was continued by the Director of Nursing (DON), and will continue until all licensed nurses and KMAs have completed the education. No licensed nurse or KMA will work after 09/16/19, without completing this education. As of 09/18/19, 85% of the licensed nurses and KMAs have completed this education. Beginning 09/17/19 a posttest will be completed by all licensed nurses and KMAs. The quiz will cover both medication administration and physician notification and competency validation for licensed nurses and KMA will be determined by a written test. Any licensed nurse or KMA not completing the posttest by 09/18/19, will complete it prior to returning to the floor to work. Any licensed nurse or KMA not scoring 100% will receive additional education. On 09/14/19, the education was expanded to include additional medication administration information, including documentation of medications. Licensed nurses and KMAs completing the education on 09/13/19 were provided this additional education. This education was initiated by the Director of Nursing (DON), and will be continued by the DON, ADON, or SDC until all licensed nurses and KMAs have completed the education. No licensed nurse of KMA will work after 09/16/19, without completing this education. As of 09/18/19, 85% of the licensed nurses and KMAs have completed this education. Beginning 09/17/19, a posttest will be completed by all licensed nurses and KMAs. The quiz will cover both medication administration and physician notification and licensed nurses and KMAs will validate competency by a posttest. Any licensed nurse or KMA not completing the posttest by 09/18/19 will complete it prior to returning to the floor to work. Any licensed nurse or KMA not scoring 100% will receive additional education. 10. On 09/16/19, the attending physician was notified, in writing, by the Administrator of the medication omissions for Residents #3, #13, #19, #41, #42, #53, #72, and #86. No new orders were received. On 09/16/19, the attending physicians were notified that there were additional residents without documentation to support that medications had been administered as ordered. The notification was hand delivered, in writing, by the Administrator, and the attending physicians were made aware that the MARs were available for their review. 11. On 09/14/19, the DON initiated education regarding physician notification. This education included the attending physician must be notified anytime a medication was not given as ordered, unless a resident was refusing. If the resident was refusing medications routinely, the physician should be notified. a) This education will be continued by the DON, ADON, or SDC until all licensed nurses and KMAs have completed the education. No licensed nurse or KMA will work after 09/16/19, without completing this education. As of 09/18/19, 85% of the licensed nurses and KMAs have completed this education. b) Beginning on 09/17/19, a posttest will be completed by all licensed nurses and KMAs. The quiz will cover both medication administration and physician notification and competency validation for licensed nurses and KMA will be a posttest. Any licensed nurse or KMA not completing the posttest by 09/18/19 will complete it prior to returning to the floor to work. Any licensed nurse or KMA not scoring 100% will receive additional education. 12. After 09/16/19, no licensed nurse or Kentucky Medication Aide (KMA) will be allowed to leave at the end of their shift until their MAR has been audited by the DON, ADON, SDC, or MDS Nurse. The audit is to ensure all medications have the appropriate documentation completed with physician notification, as indicated. Any concerns regarding documentation of physician notification will be addressed at the time of the audit, and reported to the DON or Administrator for review in the morning Interdisciplinary Team (IDT) meeting. a) In addition, each off-going licensed Nurse or KMA will be asked to sign a statement at the end of their shift to ensure no resident has expressed concerns regarding their medication administration. This statement will include if any concerns were expressed and to whom the concern was reported to if one was expressed. Any resident concerns regarding medication administration will be reported to the DON or Administrator for review at the morning IDT meeting. b) This audit, and statement, will continue at every shift change until Jeopardy is abated and an acceptable Plan of Correction is in place. The results of these audits will be reviewed in the weekly QAPI/IDT meeting on Fridays, beginning 09/20/19. 13. On 09/14/19, an RN Nurse Consultant observed a medication pass with the DON and one with the Assistant Director of Nursing (ADON). The purpose of this observation was to ensure the competency of the DON and ADON to administer medications. The CMS (The Centers for Medicare and Medicaid) Medication Administration Observation Care Path was used for these observations. These passes included insulin administration, the DON's medication pass included [DEVICE] (gastrointestinal) administration. Both the DON and ADON completed the medication pass without concerns. On 09/14/19, an RN Nurse Consultant and the DON began medication administration observations with all licensed nurses and KMAs. The purpose of this observation was to ensure the competency of the licensed nurse or KMA to administer medications. Concerns were addressed with each licensed nurse or KMA at the time of the observation. As of 09/18/19, 85% of the licensed nurses and KMAs have a medication administration observation completed. 14. After 09/16/19, night shift, the DON, ADON or SDC will begin observing (auditing) all licensed nurses and KMAs administering medications daily. The purpose of the audit is to ensure the licensed nurse's or KMA's competency to administer medications. The CMS Medication Administration Observation Care Path will be used for these audits. These audits will take place on various shift and days of the week, including weekends. Any concerns will be addressed with the nurse at the time of the observation. Concerns regarding medication administration will be reported to the DON or Administrator for review at the morning IDT meeting. These observations will continue until Jeopardy is abated, then decrease to observation of half of the licensed nurses and KMAs administering medications daily until an acceptable Plan of Correction is in place. The results of these audits will be reviewed in the weekly QAPI/IDT meeting on Fridays, beginning 09/20/19. A record will be kept to track and offer opportunities to observe each licensed nurse and KMA with various types of medications, as permitted by their training, including oral, injections, [DEVICE]s, eye drops, inhalers, crushed etc. 15. After 09/16/19, night shift, the DON, ADON, SDC, MDS Nurses, Social Services Director or Activities Director will begin interviewing six (6) random residents with a BIMS of nine (9) or above weekly to ensure they have no concerns related to when or how their medications are to be administered. Any concerns regarding medication administration will be reported to the DON or Administrator for review at the morning IDT meeting. These interviews will continue until Jeopardy is abated and an acceptable Plan of Correction is in place. The results of these audits will be reviewed in the weekly QAPI/IDT meeting on Fridays, beginning 09/20/19. 16. Beginning the week of 09/16/19, an RN Consultant will be at the facility to provide oversight of the implementation of the QI improvement plan addressing the Immediate Jeopardy. The RN Consultant visits will continue, at least three (3) days per week until Jeopardy is abated, and then at least weekly, until an acceptable Plan of Correction is in place. An RN Consultant may complete any audit in place of the assigned auditor. 17. A DON, ADON, SDC, or MDS Nurse from a sister facility may assist with monitoring, to include MAR audits, staff interviews, resident interviews, and medication administration observations, to ensure evidence is provided that they have successfully completed a medication administration audit in the past six (6) months. ****The State Survey Agency verified the facility implemented the following actions and that Immediate Jeopardy was removed on 09/19/19, as alleged by the facility: 1. Review of Minutes revealed a Quality Improvement (QI) meeting was conducted on 09/13/19 and the minutes were signed by the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC) and a Registered Nurse (RN) Consultant. Interviews on 09/25/19 with the Administrator, at 10:30 AM, the DON at 10:05 AM, the ADON at 10:00 AM, and the SDC at 10:16 AM, revealed they had attended the QA meetings dated 09/13/19, 09/16/19, and 09/20/19. 2. A statement written by the Director of Nursing was presented detailing she had informed the Medical Director, on 09/14/19 of the Immediate Jeopardy and the current plan of correction. Interview with the DON, on 09/25/19 at 10:05 AM, revealed she had phoned the Medical Director on 09/14/19 and informed him what the Immediate Jeopardy was related to and the plan per the QA committee. 3. Review of QI meeting minutes revealed a meeting was held on 09/16/19 with documentation that the plan of correction would continue. The attendees included the Administrator, DON, SDC, RN Consultant, and ADON. Interview with the ADON on 09/25 19 at 10:00 AM, the DON at 10:05 AM, the SDC at 10:16 AM, the Administrator at 10:30 AM, and the RN Nurse Consultant at 9:16 AM revealed they all had attended the QI meetings and had signed the QI form. 4. Review of the Disciplinary Warning Notice for RN #1, dated 09/16/19 revealed the notice stated RN #1 was terminated effective immediately, and signed by the DON. The documentation revealed the RN refused to sign the notice. 5. Review of the Complete In-service Training Report, dated 09/16/19, for Licensed Practical Nurse (LPN) #1 revealed the education provided included training on notification of the physician when there was a question related to the administration of medication or whether or not a resident received a medication as ordered. The training also included specific verbage related to insulin administration and physician notification. Interview with LPN #1 on 09/25/19 at 4:50 PM, revealed she did receive training regarding physician notification on 09/16/19. She stated she was educated to notify the physician whenever a medication was not administered and that insulin could not be held without an order, if the resident's blood sugar was low. 6. Review of a statement signed by the ADON, dated 09/14/19, revealed that (TRUNCATED)

Based on interview, record review, and policy review, it was determined the facility failed to ensure nursing staff (Registered Nurse #1) had appropriate competencies and skills to safely administer medications to residents. The facility failed to evaluate the competency and skill level of Registered Nurse (RN) #1 when she was hired (05/28/19), during the orientation process, or after being notified of medication errors made by RN #1. On 07/07/19, RN #1 argued with Resident #10 that the resident did not have medication due when the resident requested scheduled medications. The RN was not aware that Medication Administration Records (MAR) for oral medications was kept in a different book, on a different medication cart, until another nurse explained the facility's process for administering medications. The incident was reported to the Director of Nursing (DON) and Administrator; however, no actions related to assessing RN #1's competency to give medication was completed. On the evening of 08/19/19, RN #1 was responsible for administering medications for seven (7) residents (Residents #3, #13, #19, #41, #42, #72, and #86). Even though RN #1 documented that Residents #13, #19, #41, #42, and #72's medications were administered, Residents #41, #42, and #72 reported that they did not receive medications. In addition, there was no documented evidence that Residents #3 and #86 received their evening medications on 08/19/19. The residents' complaints were reported to administrative staff (the DON and Administrator); however, no actions were taken to ensure the RN's competency. RN #1 failed to administer three (3) residents' (Residents #63, #47, and #9) 10:00 PM narcotic pain medication, antianxiety, and/or [MEDICAL CONDITION] medications on 08/26/19. In addition, RN #1 documented that Resident #66's blood sugar was obtained and insulin was administered. However, Resident #66 reported that he/she did not receive insulin and the RN did not check his/her blood sugar on the evening of 08/26/19. Again, the facility failed to ensure Nurse #1 was competent to administer medications. Further, Resident #28 reported that facility staff had failed to administer his/her medications. Staff determined that RN #1 failed to document that the resident's narcotic pain medication was administered on 08/25/19. Staff stated they reported the medication error to administrative staff (Assistant DON and DON); however, again, the facility did not evaluate RN #1's competency to administer medications. On an unknown date, Resident #77 reported to the Assistant Director of Nursing (ADON) that RN #1 attempted to administer an insulin injection. However, the resident did not have an order for [REDACTED].#77 stopped the nurse from administering the medication and stated the DON was aware. However, the facility took no action to ensure RN #1 was competent to administer medications. In addition, on 09/10/19, RN #1 failed to administer medication to the right resident. RN #1 administered Klonopin (treats [MEDICAL CONDITION]) medication to Resident #64; this medication was not ordered for this resident, but was ordered for Resident #63. The facility's failure to ensure nursing staff had the appropriate competencies and skills to safely administer medications to residents has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/13/19 and was determined to exist on 08/19/19 at 42 CFR 483.10 Resident Rights (F580-K), 42 CFR 483.35 Nursing Services (F726-K), and 42 CFR 483.45 Pharmacy Services (F760-J). The facility was notified of the Immediate Jeopardy on 09/13/19. An acceptable Allegation of Compliance was received on 09/18/19, which alleged removal of the Immediate Jeopardy on 09/19/19. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on 09/19/19, prior to exit on 09/25/19, which lowered the scope and severity to [NAME] level at 42 CFR 483.10 Resident Rights (F580) and 42 CFR 483.35 Nursing Services (F726) and to D level at 42 CFR 483.45 Pharmacy Services (F760) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's Medication Administration policy, not dated, revealed, All medication errors shall be described in detail on a Medication Error Report which shall be filed with the Director of Nursing (DON). The facility's medication error report shall be completed in detail, making every possible effort to describe the discrepancy thoroughly; suggestion should be made as to how such discrepancy could be avoided in the future. Interview with the facility's former Administrator on 09/12/19 at 2:16 PM, revealed the facility did not have a written policy on orientation/competency for nursing staff. However, the facility's process was for new employees to be given a skills check-off list to complete during the orientation process. When the check-off list was completed, the employee was to give the check-off list back to the Staff Development Coordinator and the Staff Development Coordinator was responsible for taking it to the Personnel Department to file in the employee's personnel file. According to the interview, the Staff Development Coordinator that was at the facility when RN #1 had orientation was no longer employed at the facility. Review of the facility's new hire orientation packet revealed an RN orientation skills checklist that included medication preparations and medication administration documentation. The assessment included a staff competency checklist for licensed nurse orientation. Per the checklist, the preceptor would evaluate the skills of the licensed nurse and indicate the completion date and the observer's initials. Review of RN #1's personnel record revealed a hire date of 05/28/19. The file did not contain RN #1's competency checklist that should be completed for each new employee. The personnel file contained no work performance concerns or counseling. 1. Review of the medical record revealed the facility admitted Resident #10 on 03/27/15, with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact. The MDS also revealed the resident was independent for the tasks of bed mobility, transfer, and dressing and used a walker or wheelchair for mobility. Review of the Medication Administration Record (MAR) for Resident #10, dated 07/01/19 through 07/31/19, revealed the resident had the medication [MEDICATION NAME] with [MEDICATION NAME] (controlled narcotic pain medication) ordered to be administered four (4) times a day. The MAR also revealed the scheduled times of 6:00 AM, 12:00 PM, 6:00 PM, and 12:00 AM. Further review of the MAR revealed the resident had an order for [REDACTED]. Interview with Resident #10 on 09/09/19 at 12:59 PM, revealed he/she had an issue on 07/07/19 regarding receiving his/her ordered medication at midnight. The resident stated, I asked for my pain pill and my sleeping pill and was told (by RN #1) that they were not ordered for me. Interview with Licensed Practical Nurse (LPN) #2 on 09/10/19 at 6:26 PM, revealed she was alerted by a State Registered Nurse Aide (SRNA) on 07/07/19, regarding an incident between RN #1 and Resident #10. She stated the resident was upset because RN #10 stated he/she did not have the medications ordered that the resident had requested. The LPN stated she reviewed the MAR and discovered the resident did have the medications ordered and showed this to RN #1. She stated the RN had been reviewing the wrong MAR for the resident's medications. RN #1 was looking at the nurses MAR which did not have the oral medications Resident #10 had requested. LPN #2 stated after explaining that Medication Aides had a MAR with oral medications, RN #1 then realized that the resident did have medication to be administered, and was preparing to administer the medications to the resident when she returned to her unit. Interview with RN #1 on 09/10/19 at 2:15 PM, revealed Resident #10's medications were in two (2) separate medication books. RN #1 further stated the ADON did come to the facility that night, but she did not remember receiving any particular instructions or any training regarding residents' MARs after the incident. 2. According to an Interview with LPN #1, on 09/10/19 at 12:14 and 12:23 PM, seven (7) residents (Residents #3, #13, #19, #41, #42, #72, and #86) did not receive medications as ordered on the evening of 08/19/19. LPN #1 stated RN #1 was supposed to help administer medications to residents on the East Unit short hall that evening. However, at approximately 9:30 PM, Resident #41 reported that he/she was ready to take his/her medication for the night. According to the LPN, when RN #1 was asked about Resident #41's medications, she stated she had already administered the resident's medication. However, when staff told Resident #41 that RN #1 had already given the resident's medication, the resident replied that he/she had not received the medication. Further interview with LPN #1 revealed Resident #42 then asked when he/she would receive the rest of his/her medication. The resident stated he/she had only received one pill and RN #1 had told the resident that she did not have the right medication cart to administer the rest of the resident's medications. LPN #1 stated she reviewed Residents #41 and #42's MAR and RN #1 had documented that the resident's medications were administered. According to LPN #1, Resident #72 also asked about his/her medications on the evening of 08/19/19. The resident asked when someone was going to check his/her finger stick blood sugar, and stated he/she felt funny. LPN #1 stated she reviewed Resident #72's MAR and found that RN #1 had documented that the resident's finger stick blood sugar was 130. The LPN further stated she checked the MARs of Residents #13 and #19, who also required finger stick blood sugars and discovered that RN #1 also documented that Resident #13's fingerstick blood sugar was 130. The LPN stated that Resident #19's finger stick blood sugar was not documented and the resident's physician-ordered [MEDICATION NAME] (insulin) had not been documented as being administered. LPN #1 stated she rechecked Resident #13's finger stick blood sugar and it was 297. Continued interview with LPN #1 revealed she continued to review the MARs of residents who resided on the East Unit short hall and discovered that RN #1 had not documented that Residents #3 and #86's medications were administered on the evening of 08/19/19. Resident #3's physician-ordered medications included [MEDICATION NAME] (treats nerve pain and [MEDICAL CONDITION]), Donepezil (treats [MEDICAL CONDITION]), and [MEDICATION NAME] (helps with sleeping), which were scheduled to be administered at 8:00 PM. Resident #86 had physician orders [REDACTED]. According to LPN #1, she notified the ADON, who was in the facility working on the West Unit, of the residents' allegations that they had not received their medications and about the MAR inaccuracies. Per the LPN, the ADON also notified the DON of the incidents on 08/20/19. She stated she was told the DON had handled the situation. Interview with RN #1 on 09/13/19 at 3:39 PM, revealed she remembered it took a long time to administer residents' medications on 08/19/19 because she was not familiar with the residents. She further stated the two (2) book MAR system meant you had to go back and forth. She also stated she did not remember ever being spoken to regarding the allegations related to 08/19/19, nor was there evidence the facility provided training regarding the two (2) book MAR system or medication administration. Interview with the DON on 09/10/19 at 3:07 PM, revealed LPN #1 had reported concerns that RN #1 had not administered medications to residents on 08/19/19. The DON stated she had spoken to RN #1 the next day following the incidents. However, the DON stated she also had spoken to the residents on the unit where the allegations occurred and according to the DON, the residents had no concerns. Subsequently, no further action was taken to ensure RN #1 was knowledgeable of the facility's system for administering medications (two resident MARs) or that RN #1 was competent to administer medications. 3. Review of the timesheet for RN #1 revealed she was scheduled to work on 08/25/19 from 6:15 AM until 6:00 PM and on 08/26/19 from 6:00 PM until 10:00 PM. (a) Review of the medical record for Resident #63 revealed the facility admitted the resident on 06/25/19 with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE], revealed the resident had a BIMS score of eight (8), which indicated the resident was cognitively impaired, but interviewable. Further review of the medical record for Resident #63 revealed a physician's orders [REDACTED]. 10:00 PM. However, review of Resident #63's MAR and Controlled Substance Receipt/Count Sheet dated 08/25/19 revealed RN #1 failed to administer the resident's [MEDICATION NAME]/APAP at 10:00 PM. Further review of the resident's MAR for 08/26/19, revealed no documented evidence that the RN administered the resident's 10:00 PM dose of [MEDICATION NAME] or [MEDICATION NAME]. Interview with Resident #63 on 09/12/19 at 10:57 AM revealed the nurse on duty failed to administer the scheduled medication at bedtime; however, the resident could not remember the exact date. Resident #63 stated the medication was to help the resident sleep and he/she did not sleep at all the night he/she did not receive his/her medications. Resident #63 stated he/she reported not receiving his/her medications to a nurse the next day, but could not remember the nurse's name. On 09/10/19 at 6:05 PM, an interview with LPN #2 revealed she worked 6:00 PM to 6:00 AM on 08/26/19. Per LPN #2, RN #1 was working when she arrived and worked until 10:00 PM, at which time LPN #2 counted narcotics with RN #1. LPN #2 stated that RN #1 did not report any problems with residents refusing medication, or that any scheduled medications had not been administered. LPN #2 stated that when she counted narcotics with RN #1, the count was correct. According to LPN #2, she later identified that RN #1 had not documented on the MAR or the Controlled Drug Sheet that Resident #63's 10:00 PM dose of [MEDICATION NAME] and [MEDICATION NAME] were administered. LPN #2 stated she notified the DON and the DON stated, I will look into this. LPN #2 stated the DON did not give her any directive regarding this matter and she was not advised of the outcome. During further interview, LPN #2 stated when a medication was held or omitted the nurse should circle his/her initials and document a reason for the omission on the back of the MAR. LPN #2 stated that Resident #63 did not have any concerns or complaints. Per the LPN, she did not complete a medication error report for Resident #63. (b) Review of the medical record for Resident #47 revealed the facility admitted the resident on 08/17/18 with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE], revealed the facility assessed the resident to have a BIMS score of 99, which indicated the resident was not interviewable. Review of the medical record for Resident #47 revealed a physician's orders [REDACTED]. However, review of the resident's MAR dated 08/26/19, revealed the 10:00 PM dose was not documented that the medication was administered. Review of the Controlled Substance Receipt/Count Sheet dated 08/26/19 revealed that only the 10:00 AM dose had been signed out on 08/26/19. On 09/10/19 at 6:05 PM, interview with LPN #2 revealed she worked 6:00 PM to 6:00 AM on 08/26/19. LPN #2 stated she received report from the off-going nurse, RN #1, at approximately 10:00 PM on 08/26/19. LPN #2 stated that RN #1 did not report any problems with residents refusing medication, or that any scheduled medications had not been administered. LPN #2 stated that during her morning medication pass she discovered that Resident #47's scheduled dose of [MEDICATION NAME]/APAP for 08/26/19 at 10:00 PM had not been signed as administered on the resident's MAR or signed out on the Controlled Drug Sheet. LPN #2 stated she informed the DON of this when she arrived at the facility. The DON stated, I will look into this. (c) Review of the medical record for Resident #9 revealed the facility admitted the resident on 05/30/19 with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE], revealed the facility assessed the resident to have a BIMS score of 15, which indicated the resident was interviewable. Interview with Resident #9 on 09/11/19 at 1:55 PM revealed his/her scheduled nighttime medications were missed/omitted a few weeks ago. The resident stated he/she did not recall the date, or the nurse who was working. Resident #9 stated the medication was for my nerves and reported he/she did not sleep at all that night. Review of the medical record for Resident #9 revealed the resident had an order for [REDACTED]. Review of the MAR and the Controlled Substance Receipt/Count Sheet for 08/26/19 revealed no documentation that RN #1 administered the resident's [MEDICATION NAME] or [MEDICATION NAME] medications at 10:00 PM. Interview with LPN #2 on 09/10/19 at 6:05 PM revealed on 08/27/19 she received report from the off-going nurse, RN #1. LPN #2 stated that RN #1 did not report that any resident refused medication or that any scheduled medication had not been administered. However, LPN #2 stated that during her morning medication pass, she identified that Resident #9's scheduled 10:00 PM dose of [MEDICATION NAME]/APAP and [MEDICATION NAME] for 08/26/19 had not been signed out on the MAR or the controlled drug sheet. LPN #2 stated she notified the DON of the medication omissions when she arrived at the facility and the DON told the LPN, I will look into this. LPN #2 stated the DON did not give her any further directive regarding this issue. Interview with the DON on 09/10/19 at 2:56 PM revealed that even though LPNs #1 and #2 stated they reported concerns regarding RN #1's competency to administer medications, the DON stated she did not recall any reports that Residents #47, #63, or #9 had not received their scheduled medications. The DON stated that the nurse responsible was required to sign each resident's MAR and Controlled Drug Sheet when administering narcotic medication; however, the DON stated to her knowledge there had been no concerns with narcotics not being signed out correctly. 4. Review of the medical record for Resident #66 revealed the facility admitted the resident on 08/09/19 with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE], revealed the facility assessed the resident to have a BIMS score of 15, which indicated the resident was interviewable. Review of Resident #66's (MONTH) 2019 Physician order [REDACTED]. Review of Resident #66's (MONTH) 2019 Medication Administration Record (MAR) revealed Registered Nurse (RN) #1 documented on 08/26/19 at 9:00 PM that the resident's blood sugar was obtained and the resident's insulin was administered as ordered. However, review of a grievance filed by Resident #66 revealed the resident reported to the Social Services Director (SSD) that on 08/26/19 the nurse on duty did not give his/her medicine (insulin) and failed to do a finger stick blood sugar that night. Record review revealed Resident #66 was discharged from the facility on 09/04/19. Attempts to contact the resident by phone for interview were unsuccessful. Interview with the SSD on 09/13/19 at 2:37 PM revealed Resident #66 reported to her that the resident did not receive his/her medication on 08/26/19. The SSD stated she documented what the resident told her and gave the documentation to the Administrator for follow-up. Interview with the Administrator on 09/13/19 at 5:03 PM revealed he was aware that Resident #66 had reported that he/she did not receive his/her medication. The Administrator stated that when he spoke with the DON regarding Resident #66's complaint, the DON assured him that she had counseled RN #1 and that the issue was resolved. However, review of RN #1's personnel file revealed no documented evidence of counseling or any evaluation of RN #1's ability to safely administer medication. 5. Review of the medical record for Resident #28 revealed the facility admitted the resident on 01/22/18 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was eight (8), which indicated the resident was cognitively impaired, but was interviewable. Review of the medical record for Resident #28 revealed a physician's orders [REDACTED]. Review of the MAR dated 08/25/19, revealed RN #1's initials were circled with no documented evidence indicating why the medication was not administered. Interview with Resident #28 on 09/10/19 at 12:23 PM revealed he/she missed his/her medication for several days. Further review revealed the resident was unable to state the exact dates/medication names and was unable to recall the nurse's name that was working that day/evening. Resident #28 stated he/she felt funny, didn't rest well, and had pain because he/she did not receive his/her physician-ordered medications. Interview with Kentucky Medication Aide (KMA) #1 on 09/10/19 at 11:20 AM revealed Resident #28 complained that he/she had not received his/her nighttime medication for three (3) days. KMA #1 was unable to recall the date, but stated he/she remembered that it was a few weeks ago. However, the KMA recalled that RN #1 was scheduled to administer medication during the time that Resident #28 reported not getting his/her medication. KMA #1 stated she reported the resident's complaint to LPN #2 immediately. Interview on 09/10/19 at 6:05 PM with LPN #2 revealed on 08/26/19, KMA #1 reported that Resident #28 did not receive his/her medications for the past three (3) days. LPN #2 stated she reviewed Resident #28's MAR and discovered that the resident's [MEDICATION NAME] had not been documented as administered. LPN #2 stated she notified the DON of the resident's complaint of missed medications when she discovered the error and was not directed by the DON to take any further action. In addition, interview with the SSD, who also is a KMA, on 09/13/19 at 2:37 PM revealed the SSD worked as a KMA on 08/25/19, from 2:00 PM until 10:00 PM, administering medications to residents. The SSD stated that while administering medications, Resident #28 reported that he/she had not received his/her scheduled morning medication. The SSD stated that she reviewed the resident's controlled drug sign sheet and discovered the morning (10:00 AM) dose of [MEDICATION NAME]/APAP was not signed out as administered on the controlled drug sheet. However, the resident's MAR indicated that the resident's 10:00 AM dose had been administered. Further interview revealed the SSD identified that RN #1 was assigned to administer the morning medicine on 08/25/19 and questioned RN #1 about why the resident's pain medication was not signed out on the controlled drug log. However, RN #1 did not respond to the question. The SSD stated that later in the shift she checked Resident #28's MAR again and the 08/25/19 10:00 AM dose of [MEDICATION NAME]/APAP had been circled, indicating it was not given. The SSD stated there was no documented reason why the medication was not given. During further interview, the SSD stated she documented what happened with the resident's medication and gave it to the DON during the Interdisciplinary Team (IDT) meeting on 08/26/19. Interview with the ADON on 09/10/19 at 4:04 PM revealed she was also aware of the complaint made by Resident #28 regarding missed medication and it was discussed during the IDT meeting on 08/26/19. The ADON stated the DON was present and the incident should have been documented. However, interview with the DON on 09/10/19 at 2:56 PM revealed she did not recall a report/conversation that RN #1 did not administer Resident #28's narcotic pain medication and there was no documented evidence that the facility ensured RN #1 was competent to administer medications. 6. Review of the medical record for Resident #77 revealed the facility admitted the resident on 10/25/18 with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the facility assessed the resident to have a BIMS score of 15, which indicated the resident was invterviewable. Interview with Resident #77 on 09/09/19 at 11:16 AM revealed RN #1 attempted to administer insulin to the resident a few weeks ago (exact date unknown); however, the resident stated he/she did not have a physician's orders [REDACTED].#77, he/she stopped RN #1 from administering the insulin and reported the incident to the Assistant Director of Nursing (ADON) and to the Director of Nursing (DON). Further interview with Resident #77 revealed the DON had asked him/her on 09/08/19 (after the State Survey Agency entered the facility for a survey) whether he/she was going to report the incident to the State Survey Agency, and the resident stated he/she told the DON that he/she planned to report the incident. Review of Resident #77's physician's orders [REDACTED]. Interview with the ADON on 09/10/19 at 4:04 PM revealed she was aware of the complaint made by Resident #77 that RN #1 had attempted to administer insulin to him/her. The ADON stated the DON was aware of the complaint and she thought the issue had been resolved. Further interview with the ADON revealed she did not participate in any investigation regarding this matter and she was not aware of any additional training or competency evaluation provided to RN #1. Interview with the DON on 09/12/19 at 11:35 AM revealed that even though the ADON and Resident #77 stated they notified her that RN #1 attempted to administer the wrong medication to the resident, the DON stated she was not aware the incident occurred. The DON stated that she provided RN #1 no additional training regarding medication administration or medication errors. She further stated that she had not evaluated RN #1's ability to safely administer and document medication. According to the DON, she did not realize that all the problems with RN #1's ability to administer medications were occurring. 7. Interview with LPN #5 on 09/10/19 at 9:49 AM revealed RN #1 was the Weekend Supervisor and assisted with medication administration if needed. On 09/02/19, during the evening medication pass, RN #1 was administering medications and LPN #5 stated she observed RN #1 administer medication to Resident #64. Further interview with LPN #5 revealed she had already given Resident #64 his/her physician-ordered medication. According to the LPN, the medication cart that RN #1 was utilizing did not have Resident #64's medication or Medication Administration Record (MAR) and she questioned what the RN had given Resident #64. She stated that upon further investigation she discovered that RN #1 had given Resident #66's Klonopin (medication used to control [MEDICAL CONDITION]) to Resident #64. The physician was notified and the resident was monitored closely for the remainder of the shift. LPN #5 stated the ADON and DON were both notified of the error and a medication error report was completed. According to LPN #5, RN #1 was not safe to administer medications. Review of a medication error report dated 09/02/19 revealed RN #1 administered the wrong medication (Klonopin) to Resident #63. According to the report, the DON counseled RN #1 about the five (5) rights when administering medications. A phone interview with RN #1 on 09/10/19 at 2:10 PM revealed she started working at the facility on 05/28/19. RN #1 stated she was hired as a weekend supervisor. The RN stated she spent four (4) days doing paperwork and watching videos. Per RN #1, she was scheduled to work with another nurse during the second week she was employed. However, when she arrived at work the nurse she was scheduled to work with for orientation had resigned and she was asked to work the floor independently. RN #1 stated she was not familiar with the residents and did not know the routine for passing medications at the facility. Continued interview revealed RN #1 was not aware that the facility had two (2) medication administration records (MARs) on each unit, one for the medication aide to use and the other MAR for the nurse to use. According to RN #1, she had only made one medication error when she administered Resident #64's medication that belonged to Resident #66. She stated this was reported, and the Director of Nursing was aware of the error and an incident report was completed. However, no additional training or evaluation of competency was conducted by the facility. RN #1 stated, Just human error when I make this mistake, referencing the medication error. RN #1 denied that she failed to administer scheduled medications including narcotics. She stated, I've been a nurse for forty years; I know how to give medicine. Interview with the ADON on 09/10/19 at 4:04 PM revealed she did not have a role with new hires but would participate in the orientation process if the DON was not available. Per the ADON, she was unsure of the amount of orientation RN #1 had prior to working independently. The ADON stated that even though she was aware that there had been numerous reports that RN #1 was not competent to administer medications, she was not aware of any additional training for RN #1, or if any further competency evaluation had been completed. Interview with the DON on 09/10/19 at 2:56 PM revealed when a nurse was hired, they were scheduled with the Staff Development Coordinator to complete a week of facility policy/procedure review and to view several videos. She stated that the facility's scheduler would then schedule the new employee to work with a nu (TRUNCATED)

Based on interview, record review, and review of the facility's policy for medication administration it was determined the facility failed to ensure three (3) of twenty-two (22) sampled residents (Residents #9, #63, and #80) were free of significant medication errors. On 08/26/19, the facility failed to administer [MEDICATION NAME] (used to treat high blood pressure) to Resident #9 as ordered, and failed to administer [MEDICATION NAME] (used to treat [MEDICAL CONDITION]) and [MEDICATION NAME] (used to treat [MEDICAL CONDITION]) to Resident #63 as ordered. The facility failed to obtain and administer the medication Diulo (a medication to help the kidneys remove fluid) to Resident #80 daily on 09/02/19-09/04/19. The resident was congested and voiced complaints of being short of breath due to [MEDICAL CONDITION] and was treated at the facility. Refer to F726. The facility's failure to ensure residents were free from significant medications errors has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/13/19 and was determined to exist on 08/19/19 at 42 CFR 483.10 Resident Rights (F580-K), 42 CFR 483.35 Nursing Services (F726-K), and 42 CFR 483.45 Pharmacy Services (F760-J). The facility was notified of the Immediate Jeopardy on 09/13/19. An acceptable Allegation of Compliance was received on 09/18/19, which alleged removal of the Immediate Jeopardy on 09/19/19. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on 09/19/19, prior to exit on 09/25/19, which lowered the scope and severity to [NAME] level at 42 CFR 483.10 Resident Rights (F580) and 42 CFR 483.35 Nursing Services (F726) and to D level at 42 CFR 483.45 Pharmacy Services (F760) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Interview with the Director of Nursing (DON) on 09/12/19 at 11:25 AM revealed the facility did not have a written policy for obtaining medications from the pharmacy, but the facility's procedure was for a copy of the physician's orders [REDACTED]. Review of the Medication Administration policy, not dated, revealed, All medication errors shall be described in detail on a Medication Error Report which shall be filed with the Director of Nursing (DON). The facility's medication error report shall be completed in detail, making every possible effort to describe the discrepancy thoroughly; suggestion should be made as to how such discrepancy could be avoided in the future. A review of the medical record for Resident #80 revealed the facility admitted the resident on 08/17/19 with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was assessed to have a Brief Interview for Mental Status (BIMS) score of 15 and was cognitively intact. Review of Nurse's Notes dated 09/01/19 at 12:45 PM, revealed the resident had increasing [MEDICAL CONDITION] and a weight gain of 15 pounds in two (2) days. The physician was contacted and orders received for [MEDICATION NAME] (a medication to treat fluid retention), 40 milligrams, to be administered daily for four (4) days. Further review of the record revealed on 09/02/19 at 4:07 PM, the resident was noted to have increased [MEDICAL CONDITION] and redness to the lower extremities and a fluid-filled blister under the abdomen. Review of the Notes revealed the physician was present and evaluated the resident on 09/02/19. The physician ordered the resident to continue the [MEDICATION NAME] 40 milligrams daily and ordered Diulo (a medication to treat fluid retention) 5 milligrams to be administered thirty minutes before the [MEDICATION NAME] for seven (7) days to assist with the removal of increased fluids. Further review of the Notes revealed Resident #80 continued to complain of shortness of breath at times on 09/02/19 at 9:59 PM and on 09/03/19 at 11:32 AM. Continued review of the Nurse's Notes revealed on 09/05/19 at 2:38 PM, Resident #80 was noted to be complaining of shortness of breath with an oxygen saturation of 94 percent with oxygen at two liters per minute. The resident was also noted to have a nonproductive cough. According to the Nurse's Notes and the Medication Administration Record (MAR), the Diulo was not administered as ordered on [DATE], 09/03/19, or 09/04/19. On 09/05/19, the physician was contacted because the Diulo had not been administered and Resident #80 was congested and short of breath. The resident's [MEDICATION NAME] medication was increased to 80 milligrams daily and Diulo 5 milligrams thirty minutes prior to the [MEDICATION NAME] was again ordered to be given for seven (7) days. A review of a medication incident report dated 09/06/19 at 2:23 PM revealed a new order for Diulo medication received from the physician for Resident #80 on 09/02/19. The incident report revealed that the medication order for Diulo was faxed to the pharmacy with confirmation received and the medication was placed on the Medication Administration Record (MAR). According to an investigation summary, the medication was ordered on [DATE]. Continued review of the incident report revealed when the MAR was reviewed on 09/05/19, the Diulo medication was circled as not available for 09/02/19, 09/03/19, and 09/04/19. According to the summary, the order was again faxed to the pharmacy on 09/05/19; the medication Diulo was obtained and administered to the resident on 09/05/19. Interview with Resident #80 conducted on 09/08/19 at 3:12 PM revealed the resident was recently admitted to the facility after not being able to care for himself/herself at home. The resident voiced no concerns with care and treatment at the facility and could not recall having any concerns with medications. However, the resident stated he/she is often short of breath and requires the use of oxygen. An interview with the facility's Pharmacy Technician on 09/13/19 at 9:04 AM revealed the Pharmacy had received the physician's orders [REDACTED].#80. However, according to the Pharmacy Technician, the order was illegible and the technician was not able to read the physician's handwriting. The technician stated she attempted to call the facility with no answer and faxed a note to the facility asking for clarification of the order. An interview with Licensed Practical Nurse (LPN) #3 on 09/13/19 at 8:45 AM, revealed on 09/05/19 Resident #80 was short of breath and it was discovered the Diulo was not available or had not been delivered by the pharmacy. LPN #3 stated the physician was contacted and the resident was ordered to have an increased dosage of [MEDICATION NAME] and to administer the Diulo when obtained. Interview with the Assistant Director of Nursing (ADON) on 09/12/19 at 4:30 PM revealed the medication error for Resident #80 was discovered on 09/05/19. The ADON stated the medication was not being administered and had been circled on the MAR as not administered because the medication was not available or had not been delivered from the pharmacy. According to the ADON, the physician was contacted and an incident report was initiated. An interview with the Director of Nursing (DON) on 09/13/19 at 9:22 AM revealed she had discussed the error with staff but did not have any evidence of staff training regarding the omission error. In addition, the DON stated she was still working on completing the medication error report and had not had time to finish the report or the investigation. 2. a. Review of the medical record for Resident #63 revealed the facility admitted the resident on 06/25/19 with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident had a BIMS score of eight (8), which indicated the resident was cognitively impaired but interviewable. Further review of the medical record for Resident #63 revealed physician's orders [REDACTED]. The medication was scheduled to be administered at 10:00 AM and 10:00 PM; and [MEDICATION NAME] 500 mg, one tablet by mouth three (3) times per day, used to treat [MEDICAL CONDITION], was scheduled for 10:00 AM, 2:00 PM, and 10:00 PM. Review of the Medication Administration Record (MAR) dated 08/26/19, revealed the medications had not been initialed as being administered for the 10:00 PM dose. Review of the schedule and time card documentation revealed Registered Nurse (RN) #1 was responsible for administering the resident's 10:00 PM medications on 08/26/19. Interview with Resident #63 on 09/12/19 at 10:57 AM revealed he/she had missed a nighttime dose of medication a few weeks ago. Resident #63 stated he/she did not know the name of the medicine, but it helps him/her sleep. The resident stated he/she was unsure of the nurse's name that worked that night. Continued interview revealed the resident did not tell anyone about it, but this (omitted medications) had occurred several times. b. Review of the medical record for Resident #9 revealed the facility admitted the resident on 05/30/19 with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE], revealed the facility assessed the resident to have a BIMS score of 15, which indicated the resident was interviewable. Further review of the medical record for Resident #9 revealed a physician's orders [REDACTED]. Interview with Resident #9 on 09/11/19 at 1:55 PM revealed he/she had missed the scheduled nighttime medication a few weeks ago. The resident stated he/she did not recall the date, or who the nurse was working that evening. Review of the MAR revealed no documentation that the resident's [MEDICATION NAME] had been administered for the evening shift on 08/26/19. Review of the schedule and timecard revealed RN #1 was responsible for administering Resident #9's medications on 08/26/19. Phone interview with RN #1 on 09/10/19 at 2:10 PM revealed she had started working at the facility on 05/28/19. RN #1 stated she was hired as a weekend supervisor. The RN stated she spent four (4) days doing paperwork and watching videos. RN #1 indicated she was scheduled to work with another nurse during the second week she was employed. However, when she arrived at work the nurse she was scheduled with for orientation has resigned and she was asked to work the floor independently. RN #1 stated she was not familiar with the residents and did not know the routine for passing the medications. RN #1 further stated she was not aware that the facility has two (2) Medication Administration Records (MARs) on each unit, one for the medication aide to use and the other MAR for the nurse to use. RN #1 stated she had only made one medication error. Per the RN, she administered Resident #64 medication that belonged to Resident #66. The RN stated she had no additional training after the error and was just advised by the DON to follow the five (5) rights of medication administration. RN#1 stated she had not been observed by the DON or other administrative staff during a medication pass. RN #1 stated just human error when I made this mistake referencing the medication error. RN #1 denied that she failed to administer scheduled medications to Resident #9 and Resident #63. On 09/10/19 at 6:05 PM, interview with LPN #2 revealed she worked 6:00 PM to 6:00 AM on 08/26/19. Per LPN #2, RN #1 was working when she arrived and worked until 10:00 PM, at which time LPN #2 counted narcotics with RN #1. LPN #2 stated that RN #1 did not report any problems with residents refusing medication, or that any scheduled medications had not been administered. LPN #2 stated when she counted narcotics with RN #1, the count was correct. LPN #2 stated that during her morning medication pass she discovered that Resident #9's scheduled dose of [MEDICATION NAME] was not signed out as administered on 08/26/19 for the 10:00 PM dose. LPN #2 also stated Resident #63's 10:00 PM dose of [MEDICATION NAME] and [MEDICATION NAME] had not been signed out as administered for 08/26/19 on the MAR, nor on the Controlled Drug Sheet. LPN #2 stated she notified the DON of this and the DON stated, I will look into this. The LPN stated the DON did not give her any directive regarding this matter and she was not advised of the outcome. LPN #2 stated when a medication was held or omitted the nurse should circle her initials and document a reason for the omission on the back of the MAR. LPN #2 stated that Resident #63 did not have any concerns or complaints. Per the LPN, she did not complete a medication error report for Resident #63 or Resident #9. Interview with the DON on 09/12/19 at 11:35 AM revealed the DON was not aware of any issues regarding missed or omitted medication. The DON was advised that on 08/26/19 Resident #9's and Resident #63's MARs indicated the 10:00 PM medications were not signed as being administered. The DON stated she was not aware of these errors. Continued interview revealed the DON acknowledged the doctor and family should have been notified and a medication error report completed. Per the DON, the expectation was that when a medication was omitted the nurse would circle her initials on the MAR and document a reason indicating why the medication was not given. The DON acknowledged that missing scheduled medications could have an adverse impact on the resident. She further stated she did not monitor the MAR or the Controlled Drug Count sheet to ensure medications were administered as ordered. The DON stated that RN #1 had no additional training on medication administration and medication errors. The DON stated she has not evaluated RN #1's ability to safely administer and document medication. Continued interview revealed she did not realize that all these problems were occurring. ***The facility alleged the following was implemented to remove the Immediate Jeopardy as of 09/19/19: 1. On 09/13/19, a Quality Improvement meeting was conducted after the Immediate Jeopardy (IJ) was communicated to the facility. The purpose was to develop an improvement plan to address the IJ deficiencies, and monitor guidelines to ensure compliance was maintained. This meeting was attended by the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC), and an RN Nurse Consultant. 2. On 09/14/19, the facility's Medical Director was made aware of the Immediate Jeopardy and advised of the improvement plan, by the DON. He had no concerns or additions to the plan. 3. On 09/16/19, a follow-up QI meeting was conducted to review the progress on the 09/13/19 plan. A review of all items completed and the monitoring plan was completed. There were no additional recommendations at this time. Those in attendance were the Administrator, DON, ADON, RN Consultant, and Medical Director via phone. 4. Nurse #1 has not worked in the facility since 09/08/19, and is no longer employed by the facility effective 09/16/19. 5. On 09/16/19, Nurse #2 received education regarding physician notification, which included that the physician must be notified if there was a question of whether a resident had received their medication or had their blood sugar evaluated. 6. On 09/14/19, the ADON completed an audit of 100% of the in-house residents' (MONTH) and (MONTH) 2019 Medication Administration Records (MARs). This audit was to identify medications that were not documented as administered on the MAR and medications with multiple days of refusals. The findings included that over 50% of the MARs were missing documentation to support that medications had been administered. 7. On 09/14/19, the DON completed interviews with all residents with a BIMS score above eight (8), except one resident who was not feeling well. Residents were asked about concerns with how and when medications were administered. One resident stated he/she did not know why he/she received each medication and why medications were not consistently given at the same time each day. This resident was provided education, by the staff nurse, on his/her medications and the two (2) hour window for administering medications. On 09/15/19, the ADON completed an interview with the resident who was not feeling well on 09/14/19. The resident had no concerns with how and when medications were administered. 8. On 09/15/19, the ADON and SDC completed nursing assessments on all residents with a BIMS score of eight (8) or below. This assessment included Vital Signs and Lung and Bowel assessments. Two (2) residents were noted with a concern. One resident had an oxygen (O2) saturation of 82%, the MD was notified, and orders for oxygen at 2 Liters and chest x-ray were received. Oxygen was applied and his/her O2 saturation was 94%. One resident had an erratic pulse. The MD was notified and ordered a STAT EK[NAME] The resident has a [DIAGNOSES REDACTED]. 9. On 09/13/19, the Staff Development Coordinator began education with all licensed nurses and Kentucky Medication Aides (KMAs) regarding the six (6) rights of medication administration. These included Right Resident, Right Medication, Right Dose, Right Time, Right Route, and Right Documentation. This education also included what to do if an order was not legible, or if a medication was unavailable. On 09/14/19, this education was continued by the Director of Nursing (DON), and will continue until all licensed nurses and KMAs have completed the education. No licensed nurse or KMA will work after 09/16/19, without completing this education. As of 09/18/19, 85% of the licensed nurses and KMAs have completed this education. Beginning 09/17/19 a posttest will be completed by all licensed nurses and KMAs. The quiz will cover both medication administration and physician notification and competency validation for licensed nurses and KMA will be determined by a written test. Any licensed nurse or KMA not completing the posttest by 09/18/19, will complete it prior to returning to the floor to work. Any licensed nurse or KMA not scoring 100% will receive additional education. On 09/14/19, the education was expanded to include additional medication administration information, including documentation of medications. Licensed nurses and KMAs completing the education on 09/13/19 were provided this additional education. This education was initiated by the Director of Nursing (DON), and will be continued by the DON, ADON, or SDC until all licensed nurses and KMAs have completed the education. No licensed nurse of KMA will work after 09/16/19, without completing this education. As of 09/18/19, 85% of the licensed nurses and KMAs have completed this education. Beginning 09/17/19, a posttest will be completed by all licensed nurses and KMAs. The quiz will cover both medication administration and physician notification and licensed nurses and KMAs will validate competency by a posttest. Any licensed nurse or KMA not completing the posttest by 09/18/19 will complete it prior to returning to the floor to work. Any licensed nurse or KMA not scoring 100% will receive additional education. 10. On 09/16/19, the attending physician was notified, in writing, by the Administrator of the medication omissions for Residents #3, #13, #19, #41, #42, #53, #72, and #86. No new orders were received. On 09/16/19, the attending physicians were notified that there were additional residents without documentation to support that medications had been administered as ordered. The notification was hand delivered, in writing, by the Administrator, and the attending physicians were made aware that the MARs were available for their review. 11. On 09/14/19, the DON initiated education regarding physician notification. This education included the attending physician must be notified anytime a medication was not given as ordered, unless a resident was refusing. If the resident was refusing medications routinely, the physician should be notified. a) This education will be continued by the DON, ADON, or SDC until all licensed nurses and KMAs have completed the education. No licensed nurse or KMA will work after 09/16/19, without completing this education. As of 09/18/19, 85% of the licensed nurses and KMAs have completed this education. b) Beginning on 09/17/19, a posttest will be completed by all licensed nurses and KMAs. The quiz will cover both medication administration and physician notification and competency validation for licensed nurses and KMA will be a posttest. Any licensed nurse or KMA not completing the posttest by 09/18/19 will complete it prior to returning to the floor to work. Any licensed nurse or KMA not scoring 100% will receive additional education. 12. After 09/16/19, no licensed nurse or Kentucky Medication Aide (KMA) will be allowed to leave at the end of their shift until their MAR has been audited by the DON, ADON, SDC, or MDS Nurse. The audit is to ensure all medications have the appropriate documentation completed with physician notification, as indicated. Any concerns regarding documentation of physician notification will be addressed at the time of the audit, and reported to the DON or Administrator for review in the morning Interdisciplinary Team (IDT) meeting. a) In addition, each off-going licensed Nurse or KMA will be asked to sign a statement at the end of their shift to ensure no resident has expressed concerns regarding their medication administration. This statement will include if any concerns were expressed and to whom the concern was reported to if one was expressed. Any resident concerns regarding medication administration will be reported to the DON or Administrator for review at the morning IDT meeting. b) This audit, and statement, will continue at every shift change until Jeopardy is abated and an acceptable Plan of Correction is in place. The results of these audits will be reviewed in the weekly QAPI/IDT meeting on Fridays, beginning 09/20/19. 13. On 09/14/19, an RN Nurse Consultant observed a medication pass with the DON and one with the Assistant Director of Nursing (ADON). The purpose of this observation was to ensure the competency of the DON and ADON to administer medications. The CMS (The Centers for Medicare and Medicaid) Medication Administration Observation Care Path was used for these observations. These passes included insulin administration, the DON's medication pass included [DEVICE] (gastrointestinal) administration. Both the DON and ADON completed the medication pass without concerns. On 09/14/19, an RN Nurse Consultant and the DON began medication administration observations with all licensed nurses and KMAs. The purpose of this observation was to ensure the competency of the licensed nurse or KMA to administer medications. Concerns were addressed with each licensed nurse or KMA at the time of the observation. As of 09/18/19, 85% of the licensed nurses and KMAs have a medication administration observation completed. 14. After 09/16/19, night shift, the DON, ADON or SDC will begin observing (auditing) all licensed nurses and KMAs administering medications daily. The purpose of the audit is to ensure the licensed nurse's or KMA's competency to administer medications. The CMS Medication Administration Observation Care Path will be used for these audits. These audits will take place on various shift and days of the week, including weekends. Any concerns will be addressed with the nurse at the time of the observation. Concerns regarding medication administration will be reported to the DON or Administrator for review at the morning IDT meeting. These observations will continue until Jeopardy is abated, then decrease to observation of half of the licensed nurses and KMAs administering medications daily until an acceptable Plan of Correction is in place. The results of these audits will be reviewed in the weekly QAPI/IDT meeting on Fridays, beginning 09/20/19. A record will be kept to track and offer opportunities to observe each licensed nurse and KMA with various types of medications, as permitted by their training, including oral, injections, [DEVICE]s, eye drops, inhalers, crushed etc. 15. After 09/16/19, night shift, the DON, ADON, SDC, MDS Nurses, Social Services Director or Activities Director will begin interviewing six (6) random residents with a BIMS of nine (9) or above weekly to ensure they have no concerns related to when or how their medications are to be administered. Any concerns regarding medication administration will be reported to the DON or Administrator for review at the morning IDT meeting. These interviews will continue until Jeopardy is abated and an acceptable Plan of Correction is in place. The results of these audits will be reviewed in the weekly QAPI/IDT meeting on Fridays, beginning 09/20/19. 16. Beginning the week of 09/16/19, an RN Consultant will be at the facility to provide oversight of the implementation of the QI improvement plan addressing the Immediate Jeopardy. The RN Consultant visits will continue, at least three (3) days per week until Jeopardy is abated, and then at least weekly, until an acceptable Plan of Correction is in place. An RN Consultant may complete any audit in place of the assigned auditor. 17. A DON, ADON, SDC, or MDS Nurse from a sister facility may assist with monitoring, to include MAR audits, staff interviews, resident interviews, and medication administration observations, to ensure evidence is provided that they have successfully completed a medication administration audit in the past six (6) months. ****The State Survey Agency verified the facility implemented the following actions and that Immediate Jeopardy was removed on 09/19/19, as alleged by the facility: 1. Review of Minutes revealed a Quality Improvement (QI) meeting was conducted on 09/13/19 and the minutes were signed by the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC) and a Registered Nurse (RN) Consultant. Interviews on 09/25/19 with the Administrator, at 10:30 AM, the DON at 10:05 AM, the ADON at 10:00 AM, and the SDC at 10:16 AM, revealed they had attended the QA meetings dated 09/13/19, 09/16/19, and 09/20/19. 2. A statement written by the Director of Nursing was presented detailing she had informed the Medical Director, on 09/14/19 of the Immediate Jeopardy and the current plan of correction. Interview with the DON, on 09/25/19 at 10:05 AM, revealed she had phoned the Medical Director on 09/14/19 and informed him what the Immediate Jeopardy was related to and the plan per the QA committee. 3. Review of QI meeting minutes revealed a meeting was held on 09/16/19 with documentation that the plan of correction would continue. The attendees included the Administrator, DON, SDC, RN Consultant, and ADON. Interview with the ADON on 09/25 19 at 10:00 AM, the DON at 10:05 AM, the SDC at 10:16 AM, the Administrator at 10:30 AM, and the RN Nurse Consultant at 9:16 AM revealed they all had attended the QI meetings and had signed the QI form. 4. Review of the Disciplinary Warning Notice for RN #1, dated 09/16/19 revealed the notice stated RN #1 was terminated effective immediately, and signed by the DON. The documentation revealed the RN refused to sign the notice. 5. Review of the Complete In-service Training Report, dated 09/16/19, for Licensed Practical Nurse (LPN) #1 revealed the education provided included training on notification of the physician when there was a question related to the administration of medication or whether or not a resident received a medication as ordered. The training also included specific verbage related to insulin administration and physician notification. Interview with LPN #1 on 09/25/19 at 4:50 PM, revealed she did receive training regarding physician notification on 09/16/19. She stated she was educated to notify the physician whenever a medication was not administered and that insulin could not be held without an order, if the resident's blood sugar was low. 6. Review of a statement signed by the ADON, dated 09/14/19, revealed that an audit of all residents' (MONTH) and (MONTH) 2019 Medication Administration Records (MAR) had been conducted. The review also included a copy of all MARs reviewed and highlighted areas that revealed discrepancy or incomplete documentation. Interview with the ADON, on 09/25/19 at 10:00 AM, revealed she conducted the MAR audits as stated and any concerns were addressed. 7. Review of documentation revealed a medication questionnaire was used for interviews of all residents with a Brief Interview Mental Status (BIMS) score above eight (8). All questionnaires were dated 09/14/19 and were signed by the DON. One (1) resident had declined the interview on 09/14/19; however, the ADON conducted the interview with the resident on 09/15/19. Interview with the DON on 09/25/19 at 10:05 AM, revealed she conducted the interviews on 09/14/19 and 09/15/19 for all residents with a BIMS score above eight (8). She also stated she had the opportunity to educate some of the residents who had concerns, which included Resident #43, Resident #25, and Resident #24. Interview with Resident #25, on 09/25/19 at 8:15 AM, revealed he/she had concerns with some medications, staff educated him/her, and he/she was satisfied with the explanation. Interview with Resident #24, on 09/25/19 at 8:20 AM, revealed the resident could not remember the discussion related to medications. Interview with Resident #43, on 09/25/19 at 8:25 AM, revealed he/she was educated, but stated he/she still got confused when some medicines had different names. 8. Review of assessment documentation revealed assessments for all resident with a BIMS of eight (8) or less were completed on 09/15/19 by the ADON or the SDC. Interview with the ADON on 09/25/19 at 10:00 AM, revealed an assessment was performed on all residents with a BIMS of eight (8) or lower. Physicians were contacted with all concerns and they were addressed. 9. Review of education documentation revealed staff were trained regarding the six (6) rights of medication administration. A sign in sheet was available with nurses and KMAs who attended on 09/13/19. There was documented evidence of continued education by the DON and the SDC. Each nurse and KMA employed by the facility was on a roster and was checked off as education was provided in each of the areas. Interview with the SDC, on 09/25/19 at 10:16 AM, revealed on 09/13/19 she immediately educated the nurses and KMAs on the six (6) rights of medication administration as well as documentation on the MAR. She stated that education would continue daily until all nurses and KMAs had received the education. She also stated no nurse or KMA would be permitted to work the floor to administer medications until all education was provided and had scored 100% on the posttest. Interview with the DON, on 09/25/19 at 10:05 AM, revealed she initiated education on 09/14/19 that included additional medication information and accurate documentation on the MAR. She stated the education had continued daily and no nurse or KMA was allowed to work and administer medications until they had received all the education provided and passed the posttest with a score of 100%. Interviews on 09/25/19 with KMA #3 at 8:10 AM, RN #2 at 8:30 AM, RN #4 at 8:45 AM, LPN #8 at 8:54 AM, LPN #5 at 9:00 AM, LPN #4 at 9:10 AM, LPN #13 at 10:40 AM and LPN #1 at 4:50 PM revealed they all had received training on the six (6) rights of medication administration and documentation on the MAR. A posttest was completed after the training. 10. Reviewed letters addressed to the physicians for Residents #3, #13, # (TRUNCATED)

Based on interview, record review and review of the facility's policy it was determined the facility failed to consult with the resident's physician when a change in condition or a need to alter treatment occurred for twenty-six (26) of thirty-one (31) sampled residents (Resident #2, Resident #5, Resident #6, Resident 7, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, Resident #16, Resident #17, Resident #18, Resident #19, Resident #20, Resident #21, Resident #22, Resident #23, Resident #24, Resident 25, Resident #26, Resident #27, Resident #28, Resident #29, Resident #30, and Resident #31). Resident #11 had finger stick blood sugars ordered to be obtained two (2) times per day. Review of the facility's policy regarding medication administration revealed deviations, such as blanks on the Medication Administration Records (MAR) would be reported to the physician. Review of MARs from 05/13/15 to 07/22/15, and 10/13/15 to 12/29/15 revealed two hundred thirty-four (234) resident medications were not documented as being administered (blanks on the MAR) for Resident #5, Resident #6, Resident #10, Resident #12, Resident #13, Resident #14, Resident #15, Resident #17, Resident #18, Resident #19, Resident #20, Resident #22, Resident #23, Resident #24, Resident 25, Resident #26, Resident #27, Resident #28, Resident #29, Resident #30, and Resident #31 and the physician was not notified. In addition, review of MARs for Resident #2, Resident #7, Resident #16, and Resident #21, revealed nineteen (19) resident medications which were documented as not being administered to the residents and the physician was not notified. Refer to F333. Furthermore, review of the Medication Administration Records (MAR) for November 2015 and December 2015 for Resident #11 revealed the resident's finger stick blood sugar (FSBS) levels ran consistently below 200 milligrams per deciliter (mg/dL). Review of the MARs, dated January and February 2016, revealed the resident experienced a change and the resident's FSBS results began to consistently run over 200 mg/dL. There was no documented evidence the physician was notified of the change in condition. The facility's failure to notify the physician of a change in condition and medication errors has caused, or is likely to cause, serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy was determined to exist on 05/13/15. An acceptable Allegation of Compliance was received on 01/16/16, which alleged removal of the Immediate Jeopardy on 01/16/16. The State Survey Agency determined the Immediate Jeopardy was removed on 01/16/16 as alleged, which lowered the Scope and Severity to E while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled, Notification of Physician For Change in Resident's Condition, updated 12/15/15, revealed the facility staff should notify the physician with a significant change in the resident's condition and document the notification in the medical record. Review of the facility's Medication Administration policy, undated, revealed any deviations such as blanks on the MAR would be reported to the physician. 1. Review of the Medication Administration Records (MARS) for Resident #5, Resident #6, Resident #10, Resident #15, Resident #17, Resident #18, Resident #19, Resident #20, Resident #21, Resident #22, Resident #23, Resident #24, Resident #25, Resident #26, Resident #27, Resident #28, Resident #29, Resident #30, and Resident #31 from 05/13/15 to 07/22/15, and 10/13/15 to 12/29/15 revealed two hundred thirty-four (234) of the residents' medications that were not documented as being administered as ordered (blanks on the MAR). There was no evidence that the physician was notified of the deviations. In addition, review of MARs for Resident #2, Resident #7, Resident #16, and Resident #21, revealed nineteen (19) resident medications which were documented as not being administered to the residents and the physician was not notified of the deviations. Refer to F333. Interview on 01/07/16 at 2:32 PM with the Quality Assurance Nurse revealed the unsigned blocks on the MARs for Resident #2, Resident #5, Resident #6, Resident #7, Resident #10, Resident #15, Resident #16, Resident #17, Resident #18, Resident #19, Resident #20, Resident #21, Resident #22, Resident #23, Resident #24, Resident #25, Resident #26, Resident #27, Resident #28, Resident #29, Resident #30, and Resident #31 should have been reported to the residents' physicians as omissions. Interview with the Medical Director on 02/24/16, at 10:30 AM, revealed staff was required to report all medication errors to physicians. The Medical Director revealed any medications such as blood pressure, [MEDICAL CONDITION], diabetes, or cardiac medications would be considered significant errors and could cause a serious harm to the resident. The Medical Director stated the physician should be notified with any medication error or deviation. 2. Review of the medical record for Resident #11 revealed the facility readmitted the resident on 12/14/15 with [DIAGNOSES REDACTED]. Review of Resident #11's physician's orders [REDACTED]. Further review of the physician's orders [REDACTED]. Review of Resident #11's MAR, dated November 2015 and December 2015, revealed the resident's FSBS consistently ran under 200 mg/dL. Review of Resident #11's MAR, dated January 2016, revealed the resident had FSBS results over 200 mg/dL at 8:00 AM on the following dates: 01/04/16, 01/18/16, 01/19/16, 01/21/16 through 01/28/16 and 01/30/16. Further review of the MAR revealed Resident #11 had FSBS results over 200 mg/dL at 8:00 PM on the following days: 01/01/16 through 01/11/16, 01/14/16, 01/16/16, 01/18/16 through 01/22/16, 01/24/16 through 01/26/16, 01/28/16, and 01/29/16. Continued review of the MAR revealed Resident #1 had FSBS results over 300 mg/dL on the following days: 01/12/16, 01/15/16, and 01/17/16. Review of Resident #11's MAR, dated February 2016, revealed the resident had FSBS results over 200 mg/dL at 8:00 AM on the following days: 02/02/16, 02/04/16, 02/05/16, 02/10/16, and 02/11/16. Further review of the MAR revealed Resident #11 had FSBS results of over 300 mg/dL at 8:00 AM on the following days: 02/01/16 and 02/05/16 through 02/08/16 and the FSBS was over 400 mg/dL on 02/09/16. Review of the MAR revealed Resident #11 had FSBS results over 200 mg/dL at 8:00 PM on the following days: 02/01/16, 02/02/16, 02/14/16, 02/06/16, and 02/10/16. Further review of the MAR revealed Resident #11 had FSBS results over 300 mg/dL at 8:00 PM on the following days: 02/03/16, 02/05/16 and 02/09/16 and FSBS results over 400 mg/dL on the following day 02/08/16. Review of Resident #1's Nurse's Notes and physician's orders [REDACTED]. Interview on 02/25/16 at 4:00 PM with Resident #11's Physician revealed the facility staff should have notified him/her of Resident #11's FSBS results being consistently over 200 mg/dL as this was a change in the resident's condition. Interview on 02/25/16 at 9:52 AM with Licensed Practical Nurse (LPN) #11 revealed the LPN had notified Resident #11's Physician about his/her elevated FSBS a couple of months ago and the physician decreased the frequency for obtaining the FSBS from four (4) times per day to (2) times per day. The interview further revealed Resident #11's physician should have been notified when the resident's FSBS was running consistently over 200 mg/dL if there was no treatment ordered to treat the elevated blood sugar. Interviews on 02/25/16 with LPN #7 at 11:29 AM, LPN #8 at 12:45 PM, and LPN #3 at 4:37 PM revealed the nurses had provided care for Resident #11 and obtained the resident's FSBS while caring for him/her. The interviews with the nurses revealed Resident #11's Physician should have been notified if the resident's FSBS results were consistently running over 200 mg/dL. The LPNs stated they had not notified Resident #11's Physician of the resident's elevated blood sugar results. Interviews on 02/25/16 with LPN #9 at 4:12 PM and LPN #10 at 5:01 PM revealed Resident #11's Physician should have been notified if the resident's FSBS results were consistently running over 300 mg/dL. The LPNs stated they did not notify Resident #11's Physician of the resident's elevated blood sugar results. Interview on 02/25/16 at 1:30 PM with the Administrator revealed she was not aware Resident #11's FSBS were consistently running over 200 mg/dL and was also not aware the resident did not have an order for [REDACTED].#11's Physician about the resident's elevated blood sugar results. **The facility provided an acceptable Allegation of Compliance (AOC) on 01/16/16. The facility implemented the following actions to remove the Immediate Jeopardy: 1) Employee #1 no longer works at the facility. The facility did not report Employee #1's action to the governing agency. Employee #1 resigned her position with no notice on 12/29/15. The facility did not report Employee #1 to her licensing/credentialing agency, as they stated they did not know to whom to report the incident. 2) On 01/06/16 through 01/07/16, 100 percent of current licensed staff and KMA records were audited by the Administrator, Staff Development Coordinator, and Human Resources. One hundred percent of licensed staff and KMAs were found to have appropriate credentials to continue being a qualified staff member of this facility. 3) Licensed Nurses, KMAs, and State Registered Nurse Aides (SRNAs) assessed all in-house residents' vital signs to include blood pressure, temperature, pulse, respirations, and oxygen saturations (02 sats) on 01/08/16. Necessary vital signs were reassessed as indicated by initial findings. 4) Resident #2's October, November, and December 2015 Medication Administration Records were reviewed by the Director of Nurses (DON) on 01/08/16 for any medications that had not been documented as given. On the same date at approximately 3:30 PM, a licensed Nurse conducted a head to toe assessment of Resident #2 and the SRNA obtained vital signs. On 01/08/16, the DON reviewed the head to toe assessment and vital signs. Resident #2's blood pressure (B/P) was 180/80, temperature (T) was 96.4 axillary, pulse (P) was 80, respirations (R) were 18, and 02 sat was 96%. Resident #2's Physician was notified by the DON, after review, of medications not being documented, head to toe assessment findings, and current vital signs. No new orders were given by the Physician. After Physician notification, Resident #2's family member was informed by the DON of investigative findings. Resident #2's blood pressure was reassessed by a licensed Nurse at 4:25 PM and was 142/68. Vital signs were obtained on the next shift by a SRNA and reviewed by a licensed Nurse on the next shift. 5) All in-house residents' vital signs were promptly taken on 01/08/16 by SRNAs, KMAs, and licensed Nurses. After vital signs were obtained, the Administrator, who is a Registered Nurse, reviewed all the residents' vital signs. The licensed Nurses reviewed and reassessed twelve (12) B/Ps, nine (9) Ts, and twelve (12) Ps. Repeat vital signs obtained by the SRNAs and reviewed by licensed Nurses on 01/08/16 revealed that four (4) B/Ps and (4) Ts continued to be outside normal baseline for those particular residents. On 01/08/16 licensed Nurses, KMAs, and SRNAs, were given instructions by the Administrator to continue to reassess vital signs as indicated by results of individual residents. On 01/08/16, the Administrator informed licensed Nurses that all in-house residents must have their vital signs, B/P, T, P, and R, assessed each shift, and reassessed as indicated upon findings, until the immediate jeopardy was removed, based on acceptance of the facility's Allegation of Compliance. Once this occurs, the Administrator informed the staff that the Administrator would place an OFFICIAL SIGN at each nurses' station, with the date and Administrator's signature, indicating the updated process requirements. 6) All in-house residents' Medication Administration Records were reviewed on 01/08/16 for October, November, and December 2015. All facility staff has signed a Health Insurance Portability and Accountability Act (HIPAA) agreement. Based on that signed HIPAA agreement the Data Entry Clerk, Medical Records Personnel, KMA, Accounts Receivable, and Admissions Coordinator reviewed MARs and highlighted medications with omission of initials and began a log for each specific resident and medication. After that process the DON, Assistant Director of Nurses (ADON), Staff Development Coordinator (SDC), and a Licensed Practical Nurse (LPN) reviewed those same MARs for October, November, and December 2015 a second time to ensure that all omissions were identified on each resident's MAR and documented on the log. Based on the second review of each resident's MARs, interventions such as review/reassessment of vital signs, blood sugars, review of medical record for absence/presence of [MEDICAL CONDITION], etc., were taken by the DON, ADON, SDC, and Social Services Director/LPN to further assess each individual resident's condition. During this process there were 89 residents identified as having one or more medications not initialed as given. Throughout the process there were 0 residents identified as being in immediate danger. The process revealed that all licensed Nurses and KMAs required reminders/education on medication administration. 7) On 01/08/16 and 01/09/16 all in-house resident Physicians were notified by the DON, ADON, SDC, Quality Assurance(QA) Nurse, LPN, and/or the SSD/LPN of resident assessment findings and the potential omission of medication or documentation of the medication. 8) The facility was unable to reach five (5) resident family members, despite numerous calls and voice messages. On 01/11/16, a certified letter was forwarded to those five (5) family members with a request to call the facility to discuss medications. There were no individual resident medication error reports completed during this process. On 01/11/16, the Administrator wrote an overall statement of the omission of medications/initials and forwarded the document to the QA Committee and the Medical Director. 9) On 01/08/16 at 9:45 PM, the Administrator notified the facility's Medical Director (MD) via telephone. The MD was informed of the immediate jeopardy, all residents having the potential to be affected, measures that had and were being taken to ensure that all in-house residents were safe and having no complications that were not being addressed, i.e., vital signs and reassessment of vital signs as indicated, audit of all medication records for October, November, and December 2015, and Physician/resident/family member notification. The Administrator informed the MD of the CMA being a Certified Medical Assistant, not a KMA. The Administrator further informed the MD that all current licensed staff and KMAs had been validated to be active and in good standing. The Medical Director's input was to continue to assess for any resident having medical concerns since the facility could not say with certainty that the medication had been omitted or just not documented. The MD further stated to continue checking for appropriate credentials of licensed staff, KMAs, and unlicensed staff as required. 10) During this process the DON learned that there was a difference between Kentucky Medication Aide (KMA) and Certified Medical Assistant (CMA), and the required education and testing that are to be completed to be a Certified Medical Assistant verses a Kentucky Medication Aide were different. The Administrator learned that while there was a QA system in place for verifying credentials/status of licensed nurses and nursing assistants, the facility lacked a QA system to ensure that newly hired KMAs had the required credentials. To decrease this confusion the facility will utilize terminology from the actual Kentucky Medication Administration certification and call them KMAs. 11) On 01/06/16, the Human Resources/Payroll clerk and the Director of Nurses were educated by the facility's Administrator. The education included the difference in CMA vs. CMA and that it was used in two different ways, Certified Medical Assistant and a Certified Medication Aide. Other terminology for medication aides through the years has included Certified Medication Technician (CMT) and Kentucky Medication Aide (KMA). The education also included that the appropriate credentials must be verified before anyone can be granted access to orientation and this facility will now utilize KMA in job titles instead of CMA. 12) On 01/06/16, the Administrator reviewed the policy and procedure on medication administration. The medication administration policy included: the right resident, the right medication, the right dose, the right route, the right method, and the right time. The policy further clarified that the licensed Nurse or KMA administering the medication was responsible for documentation of the medication. On 01/06/16, the DON reviewed the medication administration policy. Once this education was completed by the Administrator, the DON completed a competency quiz on medication administration. 13) On 01/06/16, 01/07/16, and 01/08/16 licensed Nurses and KMAs were provided education related to the five (5) rights of medication administration and what KMAs were allowed to do based on the KMA certification. Following the education/discussion of medication administration, a competency medication administration quiz was given by the Administrator and/or the DON. The purpose of the education and the quiz was to ensure that the licensed Nurses knew the five (5) rights of medication administration and had adequate knowledge in delegation of medication administration to the KMAs. The education/discussion and quiz also validated that the KMAs had knowledge of the five rights of medication administration and what they were permitted to do based on their preparedness through previous education/classes and passing of the required State exam to practice as a KMA. 14) Any licensed Nurse or KMA who was off duty, on vacation, and/or off for illness or other legitimate reason will be re-educated prior to going to nursing units and being allowed to work. Three (3) persons were not scheduled to work on those dates. One returned on 01/09/16 and was provided with education/discussion and was administered the medication quiz prior to working. A second person remains on vacation and will return on 01/18/16 and will be provided with the required education/discussion and will be administered the medication quiz by the Administrator or DON prior to working. The third person is on suspension with an undetermined date of return. If allowed to return to work, this staff member will be administered the education/discussion and medication quiz prior to working. All new hires will be provided with the medication administration education and will be required to complete a medication pass audit prior to being permitted to administer resident medications without supervision. 15) Based upon the education/discussion provided and the passing of the medication administration quiz, the Administrator made the decision that the current licensed Nurses and KMAs were competent to continue to administer medications safely to facility residents. On 01/14-15/16, the DON, ADON, and SDC were validated competent to administer resident medications via Corporate Nurse education and medication pass audit (minimum 10 meds each) by the facility's Corporate Nurse. The Corporate Nurse, DON, ADON, and/or SDC will continue to educate licensed nurses and/or KMAs related to medication administration. 16) Each licensed Nurse and KMA will demonstrate competency through observation of a medication pass audit (minimum 10 meds each) by the Corporate Nurse, DON, ADON, or SDC. All licensed Nurses and KMAs that were off will not be allowed to work until educated on medication administration and observed completing a medication pass audit (minimum 10 meds each) by the corporate nurse, DON, ADON, or SDC. 17) The Administrator, DON, ADON, or SDC will conduct monthly QA medication pass audits on each licensed Nurse and KMA for the next three months. Any problems identified during the medication pass audit will be forwarded to the DON/ADON promptly for resolution. The DON, ADON, and SDC will report any identified concerns/problems to the QA Committee five days per week, a cumulative total to the QA Committee monthly, and a cumulative total to the executive QA Committee quarterly. 18) The Staff Development Coordinator (SDC) and Human Resources (HR) were educated by the Administrator on 01/09/16 that newly hired license staff and KMAs must be validated through the appropriate registries prior to allowing them to attend orientation. Telephone numbers and web sites were discussed as a means to validate those credentials. The SDC and HR was further educated that KMAs would have to be verified by calling the school in which they attended if appropriate documentation (letter validating passing score and/or actual KMA card signed by representative of school) was not presented upon hire and request a hard copy of validation. SDC will place a hard copy of the monthly licensed nurse validation in a binder as they are completed and will report findings to the QA Committee the following business day. The SDC and HR will conduct a monthly audit of the binder. Any problems identified during the audit will be reported immediately to the Administrator. The results of the QA audit by the SDC and HR will be forwarded to the QA Committee monthly. The SDC will forward the cumulative reports to the Executive Committee quarterly. This process will be utilized to ensure that all licensed staff has remained active and in good standing with the respective Boards of Nursing. 19) On 01/08/16 and 01/09/16, the licensed staff and the KMAs were educated by the Administrator, Director of Nurses (DON), Assistant Director of Nurses (ADON), and/or the Quality Assurance (QA) Nurse. The education of licensed staff included attendance of an accredited school, requirement of a work permit or licensed issued by the Board of Nursing, not being allowed to practice as a licensed nurse if license was revoked, suspended, or lapsed, continuing education requirements and completion day, and notification of the Board of Nursing and facility with any changes, questions, or concerns. 20) The KMAs were educated on the difference between a CMA (certified medical assistant) and a CMA (certified medication aide), attendance of an approved medication aide class, passing of exam and receiving certification as a medication aide, and number of local school related to any questions regarding KMA certifications. Both KMAs and licensed staff were educated on the facility's responsibility to ensure that they have obtained and maintain appropriate licensure and certification. Further education of both disciplines included documentation of medication when administered and failure to document implies was not done. 21) On 01/09/16 the facility immediately altered the QA system to address new hires from the point of application to hire, to ensure all needed credentials has been validated. The credentials of all new hires will be validated by HR, respective department head, and/or the SDC. A hard copy of the KMA certifications and licensed staff will be placed in the personnel file by HR. Prior to entry into orientation another audit will be completed by the HR, SDC, DON, ADON, QA, or Administrator to ensure credentials have been assessed. Once this step is completed and signed off by the Administrator or DON the employee will be allowed to enter the orientation process. The SDC will keep a monthly QA log of any problems identified during the hiring process and will report to the QA Committee up to five (5) days per week as issues are identified during the hiring process. The QA Committee will provide further instructions for the SDC based upon the problems identified throughout the hiring process. The SDC will forward a cumulative QA log and report any problems identified to the Executive QA Committee on a quarterly basis. The SDC was educated by the Administrator on the new QA tool on 01/09/16. Human Resources was on vacation but will be educated by the Administrator upon return to work on 01/18/16 and before taking applications. 22) A QA Buddy system tool for Medication Administration Records was developed. On 01/08/16, 01/09/16, and 01/10/16, the facility Administrator, SDC, DON, ADON, or QA Nurse educated the staff Nurses and KMAs on the buddy assessment tool. There were five (5) persons not included in the education. Three (3) have returned to work and were educated on the process. One remains on vacation and will return to work on 01/18/16. The second one remains on suspension. Both will be educated by the Administrator, DON, ADON, or QA nurse when they return to work. The buddy tool monitors omission of documentation blanks on the MAR. The facility will illicit the assistance of staff Nurses and KMAs in auditing each other each shift for the next 60 days. The original audit is to be turned in each shift to the DON and a copy to the Administrator. 23) The DON/ADON is responsible for comparing the completed buddy audit five (5) days per week to the individual resident MARs for the next 30 days to ensure that all medications not documented were noted on the buddy system audit form. The DON and the ADON will be accountable for ensuring prompt resolution and notification of the Physician, resident, and the resident's Responsible Party or an interested family member, dependent upon audit results. The DON/ADON will be responsible for reporting audit findings to the QA committee five (5) days per week. Dependent upon the results of the QA audits, the frequency will be adjusted by the QA Committee. The DON will report findings to the Executive QA Committee quarterly for further guidance. **The State Survey Agency validated on 01/16/15 the Immediate Jeopardy was removed as follows: 1) Review of a statement by the Administrator, undated, revealed Employee #1 was no longer employed by the facility. Employee #1 did not return to work, she resigned on 12/29/15 with no notice. Review of Employee #1's personnel file revealed an Absence/Vacation Report dated 01/01/16 stating Employee #1 had resigned from the facility on that date. Review of Employee #1's timesheet revealed the last date of work for Employee #1 was 12/29/15. Interview with Employee #1 on 01/19/16 at 3:32 PM, the DON on 1/21/16 at 4:20 PM, and the Administrator on 01/21/16 at 4:25 PM, revealed Employee #1 had resigned on 01/01/16. The interviews also revealed Employee #1 had not worked at the facility since 12/29/15. 2) Review of an audit completed by the facility on 01/06/16 through 01/07/16 of all Kentucky Medication Aides (KMAs) and licensed Nurses employed by the facility revealed all KMAs and Nurses currently working in the facility had appropriate credentials, valid licenses, and had been deemed by the facility to be a qualified staff member. Review of a Quality Assurance form in use by the facility revealed the SDC was responsible for ensuring all staff licenses had been validated prior to employment. Interview conducted with the SDC on 01/21/16 at 2:35 PM revealed she was responsible for monitoring to ensure all licenses for all licensed personnel had been validated prior to employment. According to the SDC, Human Resources (HR), the Department Manager, and the Administrator and DON (a total of four persons) are required to check the validity of each employee's license/certification. Interviews conducted with the SDC on 01/21/16 at 2:35 PM, HR on 01/21/16 at 3:06 PM, and the Administrator on 01/21/16 at 4:25 PM, revealed they had completed an audit of all currently working KMAs and Nurses on 01/06/16 through 01/07/16 and had found all had valid licenses, appropriate training and were qualified to work at the facility. 3) Review was conducted of the vital signs and oxygen saturations form completed on all residents in the facility on 01/08/16. Vital signs were then repeated on residents with an abnormal vital sign, and it was documented on the form. Interviews conducted with KMA #1 on 01/21/16 at 1:50 PM, KMA #6 on 01/21/16 at 2:15 PM, KMA #3 on 01/21/16 at 2:20 PM, SRNA #1 on 01/21/16 at 3:20 PM, SRNA #2 on 01/21/16 at 3:25 PM, and LPN #3 on 01/21/16 at 3:27 PM, revealed they assisted in obtaining vital signs and oxygen saturations on residents on 01/08/16. LPN #3 stated she reviewed residents' vital signs and if any were abnormal they would be repeated. The staff also revealed all residents' vital signs were being obtained every shift and reviewed by the Nurse. 4) Review of Resident #2's MARs dated October 2015, November 2015, and December 2015 revealed an attached document by the DON which stated she had reviewed and notified Resident #2's Physician and next of kin of the missed doses of medication. Interviews conducted with the DON on 01/21/16 at 4:20 PM, Resident #2's Physician on 01/21/16 at 1:22 PM, and Resident #2's family member on 01/21/16 at 4:30 PM, revealed the DON had reviewed Resident #2's MARs for October 2015, November 2015, and December 2015, vital signs, and skin assessment. The DON notified the physician and responsible party of Resident #2's missed medications and abnormal vital signs. According to the interviews, no new orders were received from the Physician. Review of a skin assessment completed on 01/08/16 on Resident #2 revealed no open areas had been observed by LPN #3. Interview with LPN #3 on 01/21/16 at 3:41 PM revealed she had completed the skin assessment on Resident #2 and reviewed the resident's vital signs. Interviews with SRNA #2 on 01/21/16 at 3:25 PM, and LPN #3 on 01/21/16 at 3:27 PM, revealed Resident #2's vital signs were obtained on 01/09/16 and were reviewed by LPN #3. 5) Review of the vital sign flow sheets revealed that all in-house resident vital signs were promptly taken on 01/08/16 by SRNAs, KMAs, and licensed Nurses. Interviews conducted with KMA #1 on 01/21/16 at 1:50 PM, KMA #6 on 01/21/16 at 2:15 PM, KMA #3 on 01/21/16 at 2:20 PM, SRNA #1 on 01/21/16 at 3:20 PM, SRNA #2 on 01/21/16 at 3:25 PM, LPN #3 on 01/21/16 at 3:27 PM, and LPN #6 on 01/21/16 at 3:37 PM revealed all in-house residents' vital signs were taken on 01/08/16 by SRNAs, KMAs and licensed Nurses. Interview with the Administrator on 01/21/16 at 4:25 PM revealed that she reviewed all the resident vital signs. Record review and interview with KMA #1 on 01/21/16 at 1:50 PM, KMA #6 on 01/21/16 at 2:15 PM, KMA #3 on 01/21/16 at 2:20 PM, SRNA #1 on 01/21/16 at 3:20 PM, SRNA #2 on 01/21/16 at 3:25 PM, and LPN #3 on 01/21/16 at 3:37 PM, revealed licensed Nurses reviewed and reassessed twelve (12) residents' B/Ps, nine (9) residents' temperatures, and 12 residents' pulses. Repeat vital signs obtained by the SRNAs and reviewed by licensed Nurses on 01/08/16 revealed that four (4) B/Ps and four (4) Ts continued to be outside normal baseline for those particular residents. Record review and interview with the Administrator on 01/21/16 at 4:25 PM, KMA #1 on 01/21/16 at 1:50 PM, KMA #6 on 01/21/16 at 2:15 PM, KMA #3 on 01/21/16 at 2:20 PM, SRNA #1 on 01/21/16 at 3:20 PM, SRNA #2 on 01/21/16 at 3:25 PM, LPN #3 o

Based on interview, record review, review of the facility's policy, review of The Chronicle of Nursing, journal, and review of the Kentucky Board of Nursing Advisory Opinion Statement it was determined the facility failed to provide care which meets professional standards of quality for twenty-one (21) of thirty-one (31) sampled residents (Resident #5, Resident #6, Resident #10, Resident #12, Resident #13, Resident #14, Resident #15, Resident #17, Resident #18, Resident #19, Resident #20, Resident #22, Resident #23, Resident #24, Resident 25, Resident #26, Resident #27, Resident #28, Resident #29, Resident #30, and Resident #31). Employee #1 was employed by the facility on 05/13/15 to 07/22/15, and from 10/13/15 to 12/29/15. The facility assigned Employee #1 to administer medications to residents on the West Wing, on the evening shift; even though Employee #1 was unlicensed/uncertified and presented no documented evidence to the facility that she was qualified to administer medications. Review of a list of residents revealed Employee #1 had been assigned to provide medication administration to twenty-seven (27) residents in the facility. Review of the Medication Administration Records (MARS) for Resident #5, Resident #6, Resident #10, Resident #15, Resident #17, Resident #18, Resident #19, Resident #20, Resident #21, Resident #22, Resident #23, Resident #24, Resident #25, Resident #26, Resident #27, Resident #28, Resident #29, Resident #30, and Resident #31 and review of schedules/timecards revealed Employee #1 was assigned to administer medications from 05/13/15 to 07/22/15, and 10/13/15 to 12/29/15. During this time, there were two hundred thirty-four (234) of the residents' medications that were not documented as being administered as ordered. The residents' medications that were not documented as being administered included medications to treat [MEDICAL CONDITION], high blood sugar, high blood pressure, high cholesterol, [MEDICAL CONDITION] reflux Disease (GERD), [MEDICAL CONDITION], allergies [REDACTED]. On 05/13/15, the facility hired Employee #1, who was not licensed, not certified, or trained to administer medications. Upon hire, the facility failed to check Employee #1's credentials to ensure she was qualified to administer medications. The facility rehired Employee #1 on 10/13/15 the facility once again did not check Employee #1's credentials to ensure she was qualified to administer medications. After the facility became aware Employee #1 was not qualified to administer medications, she was still allowed to administer medications. The facility failed to ensure Employee #1 could meet the professional standards related to the administration of medications, as Employee #1 was not licensed, trained, or certified to administer medications. The facility's failure to provide care which meets professional standards of quality has caused, or is likely to cause, serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy was determined to exist on 05/13/15. An acceptable Allegation of Compliance was received on 01/16/16, which alleged removal of the Immediate Jeopardy on 01/16/16. The State Survey Agency determined the Immediate Jeopardy was removed on 01/16/16 as alleged, which lowered the Scope and Severity to E while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of an article titled, Charting and Documentation, in The Chronicle of Nursing, by the American Society of Registered Nurses, dated 05/01/08, revealed the medical record is a legal document and documentation of any treatment or medication should be completed as close to the event as possible to prevent an error. The article stated proper nursing documentation prevented errors and facilitated continuity of care. Review of a Kentucky Board of Nursing Advisory Opinion Statement, with a revision date of October 2014, revealed the administration of medication is the practice of nursing. The administration of medication to patients in health care facilities is both the responsibility of nurses and an integral part of the nursing care rendered to patients. Medication may be administered to patients in health care facilities by physicians, or other health care professionals. In Kentucky, unlicensed personnel known as medication aides or other similar titles may function by administering oral and topical medications in long term care facilities only through delegation by and under the supervision of a Registered Nurse (RN) or Licensed Practical Nurse (LPN). Unlicensed personnel must have successfully completed the state approved course for administration of medications. Review of the facility's Medication Administration policy, undated, revealed only licensed Nurses (Registered Nurses or Licensed Practical Nurses), Medication Aides, Respiratory Therapists, Physicians, or Physician Extenders (Nurse Practitioners or Physician Assistants) would be allowed to administer medications to residents. All medication errors would be described in detail on a Medication Error Report which would then be reviewed and filed with the Director of Nursing (DON). The attending Physician shall be notified immediately of all medication errors. Any deviation from the following principles shall be considered a medication error: 1) To the right resident; 2) administration of the right medication; 3) In the right dose; 4) by the right route; 5) by the right method; 6) and at the right time. Any recognized deviations such as blanks on the Medication Administration Records (MARs), would be reported to the Physician, Responsible Party, and the Supervisor immediately. The Supervisor would then initiate a Medication Error Report which would then be submitted to the DON. The Supervisor would also evaluate the incident and the resident for adverse effects. Both the physician and the responsible party would be notified immediately. The Medication Error Reports would be reviewed quarterly by the Quality Improvement Committee. The Quality Improvement Committee should evaluate these reports and determine whether or not proper steps have been taken to prevent the recurrence of such errors. The types of errors would be summarized. 1. Review of Resident #23's medical record revealed the facility admitted the resident on 06/03/08. The resident had current [DIAGNOSES REDACTED]. Review of Resident #23's physician's orders [REDACTED]. [REDACTED]. Review of Resident #23's MAR indicated [REDACTED]. 2. Review of Resident #20's medical record revealed the facility admitted the resident on 03/03/09 with [DIAGNOSES REDACTED]. Review of Resident #20's physician's orders [REDACTED]. [REDACTED]. Review of Resident #20's MAR indicated [REDACTED]. 3. Review of the medical record for Resident #5, revealed the facility admitted the resident on 05/19/09, with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the MARs for Resident #5 revealed on 05/22/15, at 10:00 PM, 06/09/15, at 10:00 PM, 06/15/15, at 10:00 PM, 06/16/15, at 10:00 PM, and on 06/30/15, at 10:00 PM, there was no documented evidence [MEDICATION NAME] was documented as having been administered to Resident #5. 4. Review of the medical record for Resident #30, revealed the facility admitted the resident on 10/26/10, with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Memantine (for Dementia) 5 mg twice daily; and, an order dated 08/14/15, for [MEDICATION NAME] (stool softener) 250 mg twice daily. Review of Resident #30's MARs revealed on 10/29/15, at 8:00 PM, and on 10/30/15 at 8:00 PM, [MEDICATION NAME], Memantine, [MEDICATION NAME] Aerosol, and [MEDICATION NAME] had not been documented as having been administered to Resident #30. 5. Review of the medical record for Resident #24, revealed the facility admitted the resident on 06/03/11, with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. mg three (3) times daily, [MEDICATION NAME] Montelukast (for Sinusitis) 10 mg every night, [MEDICATION NAME] 10 mg every night, [MEDICATION NAME](for [MEDICAL CONDITION]) 5 mg every night. Review of the MARS for Resident #24 revealed on 10/28/15, 10/29/15, and 10/30/15, there was no documented evidence Resident #24 was administered [MEDICATION NAME] Aerosol, [MEDICATION NAME] Extended Release, [MEDICATION NAME] Montelukast, [MEDICATION NAME], and Ambien, nor had the Nitrodur Patch been removed. 6. Review of Resident #14's medical record revealed the facility admitted the resident on 12/09/11, with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]., Gas-X (for excess gas) 80 mg every four hours, [MEDICATION NAME] (for Hypertension) 1 mg every night [MEDICATION NAME](for [MEDICAL CONDITION]) 5 mg every night. Review of Resident #14's MARS, revealed on 11/09/15, the following medications were not documented as having been administered to Resident #14: Removal of the [MEDICATION NAME] Patch (for Hypertension, [MEDICATION NAME] (stool softener), [MEDICATION NAME], Micro K , [MEDICATION NAME], Gas X, [MEDICATION NAME], and Ambien. In addition, on 11/11/15, there was no documentation the [MEDICATION NAME] Patch had been removed. 7. Review of Resident #22's medical record revealed the facility admitted the resident on 02/12/12 with [DIAGNOSES REDACTED]. Review of Resident #22's Physician order [REDACTED]. [REDACTED]. Review of Resident #22's MAR indicated [REDACTED]. 8. Review of the medical record for Resident #31, revealed the facility admitted the resident on 05/04/12, with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the MARS for Resident #31, revealed on 10/30/15, at 10:00 PM; and on 12/11/15, at 10:00 PM, [MEDICATION NAME] (diabetic medication) had not been documented as having been administered to Resident #31. 9. Review of the medical record for Resident #13, revealed the facility admitted the resident on 07/14/14, with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the MARS dated June 2015, for Resident #13, revealed no documentation on 06/05/15, at 10:00 PM, that [MEDICATION NAME], [MEDICATION NAME], and [MEDICATION NAME] had been administered to the resident. Review of Resident #13's MARS dated October 2015, revealed no documentation on 10/30/15, at 10:00 PM, that [MEDICATION NAME] (for Hypertension), [MEDICATION NAME] (for allergies [REDACTED]. Review of Resident #13's MARS dated December 2015, revealed on 12/11/15, at 10:00 PM no documentation that [MEDICATION NAME] (treat [MEDICAL CONDITION]), [MEDICATION NAME] (treat [MEDICAL CONDITION]), [MEDICATION NAME] (treat [MEDICAL CONDITION]), [MEDICATION NAME] (treat Diabetes Mellitus), [MEDICATION NAME] (treat Hypertension), [MEDICATION NAME] (treat Hypertension), and [MEDICATION NAME] (treat Depression) had been administered to the resident. 10. Review of the medical record for Resident #12, revealed the facility admitted the resident on 08/07/14, with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. (for [MEDICAL CONDITION]) 1 mg twice daily, [MEDICATION NAME] (for [MEDICAL CONDITION] and Agitation) 1 mg twice daily, [MEDICATION NAME] (for Agitation) 5 mg twice daily, and Atorvastatin (for [MEDICAL CONDITION]) 40 mg every night. Review of Resident #12's MARS dated June 2015, revealed on 06/05/15, 06/09/15, 06/15/15, and 06/16/15, at 10:00 PM, there was no documented evidence [MEDICATION NAME] Sodium, [MEDICATION NAME], [MEDICATION NAME], and Atorvastatin had been administered to the resident. Review of the MARS for Resident #12 dated 10/30/15, at 10:00 PM, revealed no documented evidence [MEDICATION NAME], [MEDICATION NAME] Sodium, [MEDICATION NAME], and Atorvastatin had been administered to the resident. 11. Review of the medical record for Resident #19, revealed the facility admitted the resident on 08/28/14, with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the MARS for Resident #19, revealed on 10/30/15, at 4:00 PM, there was no documented evidence [MEDICATION NAME] or [MEDICATION NAME] were administered to Resident #19; and, on 10/30/15, at 10:00 PM, there was no documented evidence [MEDICATION NAME], or [MEDICATION NAME] had been administered. 12. Review of Resident #10's medical record revealed the facility admitted the resident on 06/26/13 with [DIAGNOSES REDACTED]. Review of Resident #10's physician's orders [REDACTED]. Review of Resident #10's MAR indicated [REDACTED]. 13. Review of Resident #26's medical record revealed the facility admitted the resident on 04/22/14 with [DIAGNOSES REDACTED]. Review of Resident #26's physician's orders [REDACTED]. Review of Resident #26's MAR indicated [REDACTED]. 14. Review of Resident #15's medical record revealed the facility readmitted the resident on 06/03/14 with [DIAGNOSES REDACTED]. Review of Resident #15's physician's orders [REDACTED]. Review of Resident #15's MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. 15. Review of Resident #17's medical record revealed the facility admitted the resident on 08/14/15 with [DIAGNOSES REDACTED]. Review of Resident #17's physician's orders [REDACTED]. [REDACTED]. Review of Resident #17's MAR indicated [REDACTED]. 16. Review of Resident #18's medical record revealed the facility admitted the resident on 02/27/15 with [DIAGNOSES REDACTED]. Review of Resident #18's physician's orders [REDACTED]. [REDACTED]. Review of Resident #18's MAR indicated [REDACTED]. Further review of Resident #18's MAR indicated [REDACTED]. On 10/28/15, the 4:00 PM dose of [MEDICATION NAME] 10 mg was not documented as administered to Resident #18. Review of Resident #18's MAR indicated [REDACTED]. 17. Review of Resident #29's medical record revealed the facility admitted the resident on 09/10/15 with [DIAGNOSES REDACTED]. Review of Resident #29's physician's orders [REDACTED]. [REDACTED]. Review of Resident #29's MAR indicated [REDACTED]. Review of the resident's November 2015 MAR indicated [REDACTED]. Staff also failed to document the following 8:00 PM doses on 11/09/15 as being administered as required: [MEDICATION NAME] 5 mg, [MEDICATION NAME] 75 mg, [MEDICATION NAME] 5 mg, [MEDICATION NAME] 250 mg, [MEDICATION NAME] 0.2 mg, and [MEDICATION NAME] 5 mg. The November 2015 MAR further revealed staff failed to document the following medications as being administered on 11/21/15 at 8:00 PM: [MEDICATION NAME] 75 mg and [MEDICATION NAME] 5 mg. Review of Resident #29's December 2015 MAR indicated [REDACTED]. 18. Review of Resident #6's medical record revealed the facility admitted the resident on 09/22/15 with [DIAGNOSES REDACTED]. Review of Resident #6's physician's orders [REDACTED]. [REDACTED]. Review of Resident #6's MAR indicated [REDACTED]. Review of the resident's December 2015 MAR indicated [REDACTED]. 19. Review of Resident #28's medical record revealed the facility admitted the resident on 10/09/15 with [DIAGNOSES REDACTED]. Review of Resident #28's physician's orders [REDACTED]. Review of Resident #28's MAR indicated [REDACTED]. 20. Review of the medical record for Resident #27 revealed the facility admitted the resident on 10/20/15 with [DIAGNOSES REDACTED]. Review of Resident #27's physician's orders [REDACTED]. Review of the MARs for Resident #27, revealed on 10/30/15, at 10:00 PM, [MEDICATION NAME] and Actigall were not documented as administered as ordered by the physician. 21. Review of the medical record for Resident #25, revealed the resident was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the MARs for Resident #25, revealed on 11/14/15, at 8:00 PM, there was no documentation of [MEDICATION NAME] (medication for GERD) having been administered to Resident #25. The MARs also revealed on 11/29/15, at 8:00 PM, there was no documentation of Atorvastatin having been administered to Resident #25. Interview on 02/22/16, at 4:15 PM, with Employee #1, who was unlicensed and uncertified to administer medications in a facility, revealed she was employed by the facility from 05/13/15 to 07/22/15 and 10/13/15 to 12/29/15, and was assigned to administer medications to residents on the West Wing during that time. According to Employee #1, she was responsible for administering medication on the evening shift to the following residents: Resident #5, Resident #6, Resident #10, resident #12, Resident #13, Resident #14, Resident #15, Resident #17, Resident #18, Resident #19, Resident #20, Resident #22, Resident #23, Resident #24, Resident 25, Resident #26, Resident #27, Resident #28, Resident #29, Resident #30, and Resident #31. When Employee #1 was interviewed about the numerous medications that were not documented as being administered, during the timeframe she was responsible for administering residents' medications, she stated she could not remember if she administered the medications to the residents or not. However, Employee #1 stated she always documented her medications after she had administered them to the resident. Interview with Kentucky Medication Aide (KMA) #3 on 02/24/16 at 10:30 AM revealed if a blank space was found on a Medication Administration Record [REDACTED]. A Medication Error form should be completed and the attending Physician, the Responsible Party, and the Nurse should be notified. Interview with the Quality Assurance Nurse (QA Nurse) on 01/07/16 at 2:32 PM revealed the unsigned blocks on the MARs for Resident #5, Resident #6, Resident #10, Resident #12, Resident #13, Resident #14, Resident #15, Resident #17, Resident #18, Resident #19, Resident #20, Resident #22, Resident #23, Resident #24, Resident 25, Resident #26, Resident #27, Resident #28, Resident #29, Resident #30, and Resident #31 should have been reported as medication omissions and the residents' Physicians and Responsible Parties should have been notified. The omissions should also have been documented in the resident's medical records, Incident Reports completed, and investigations conducted. Interview with the Director of Nursing (DON) on 01/06/16 at 3:06 PM and 4:40 PM, revealed Employee #1, who was not licensed and not certified or trained to administer medications, was assigned to administer medications for Resident #5, Resident #6, Resident #10, Resident #12, Resident #13, resident #14, Resident #15, Resident #17, Resident #18, Resident #19, Resident #20, Resident #22, Resident #23, Resident #24, Resident #25, Resident #26, Resident #27, Resident #28, Resident #29, Resident #30, and Resident #31, on 06/09/15, 06/15/15, 06/16/15, 06/30/15, 10/15/15, 10/23/15, 10/28/15, 10/29/15, 10/30/15, 11/09/15, 11/14/15, 11/21/15, 11/29/15, 12/11/15, and 12/23/15, when the medication errors occurred. The DON stated the medications that had not been documented as being given by Employee #1 should have been identified as medication errors and Medication Error Reports completed. The DON stated all medications were required to be signed off immediately, on the resident's MAR, after they had been administered. She further stated the Physician and Responsible Parties should have been notified and Incident Reports completed for the medication errors. The DON said investigations should also have been conducted. Further interview revealed the facility did not have a system to audit MARs to check for omissions. The DON stated she was not aware Employee #1 had been unqualified/unlicensed to administer medications until around the end of November 2015 or early December 2015. She stated when the employee returned to work on 10/13/15 she presented a Clinical Medical Assistant Certification. The DON stated she believed the employee had attended a State approved training program and was certified to independently administer residents medications, but she had not contacted the Kentucky Board of Nursing to ensure the school was a state approved program for Kentucky Medication Aides. Further interview with the DON revealed sometime in November 2015 a staff member told her that the Clinical Medical Assistant Certification did not qualify Employee #1 to administer medications. She stated she contacted staff at the school who told her that Employee #1 could pass medications with a physician present, and she believed that the certification

Based on observations, interviews, record reviews, and review of the facility's policy, it was determined the facility failed to have an effective system to ensure four (4) of thirty-one (31) sampled residents (Resident #2, Resident #7, Resident #16, and Resident #21) were free from significant medication errors. Employee #1, who was not licensed and not certified to administer medications, was hired by the facility to administer resident medication. Employee #1 was responsible for administering medications to Resident #2, Resident #7, Resident #16, and Resident #21 on the evening shift (2:00 PM till 10:00 PM). The facility failed to ensure Employee #1 was licensed/certified to administer resident medications when she was hired. The facility permitted the employee to administer resident medications from 05/13/15 to 07/22/15 and from 10/13/15 to 12/29/15. The employee had no training, certification, or license that qualified her to administer resident medications. During the time Employee #1 was responsible to administer medications, there were significant medication errors identified for Resident #2, Resident #7, Resident #16, and Resident #21. Resident #2 was ordered to receive two (2) doses of a [MEDICAL CONDITION] medication ([MEDICATION NAME]), one dose of two different blood pressure medications ([MEDICATION NAME] and [MEDICATION NAME]), and two doses of pain medication ([MEDICATION NAME]) on the evening shift on 11/02/15. Review of the Medication Administration Record (MAR) revealed no documented evidence that Resident #2 received his/her 4:00 PM and 8:00 PM scheduled medications on 11/02/15. The facility failed to identify the omission of Resident #2's medications on 11/02/15. Resident #16 was ordered to receive [MEDICATION NAME] (antipsychotic) and [MEDICATION NAME] ([MEDICAL CONDITION] medication) on the evening shift of 10/29/15 and 10/30/15. However, review of Resident #16's MAR for October 2015 revealed no documented evidence that Resident #16 received the 8:00 PM doses of [MEDICATION NAME] and [MEDICATION NAME] on 10/29/15 and 10/30/15. Resident #7 had physician's orders [REDACTED]. Review of the MARs for Resident #7 revealed on 06/30/15, there was no documented evidence [MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME]) had been administered to Resident #7. Resident #21 was ordered to receive [MEDICATION NAME] (medication to decrease blood sugar). Review of Resident #21's MAR revealed the following 5:00 PM doses of [MEDICATION NAME] were not documented as administered to the resident: 12/16/15, 12/17/15, 12/20/15, 12/22/15, 12/23/15, 12/26/15, 12/27/15, and 12/28/15 (a total of eight doses). The facility's failure to ensure residents were free from significant medication errors has caused, or is likely to cause, serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy was determined to exist on 05/13/15. An acceptable Allegation of Compliance was received on 01/16/16, which alleged removal of the Immediate Jeopardy on 01/16/16. The State Survey Agency determined the Immediate Jeopardy was removed on 01/16/16 as alleged, which lowered the Scope and Severity to E while the facility monitors the effectiveness of systemic changes and quality assurance activities. Refer to F499. The findings include: Review of the facility's Medication Administration policy, not dated, revealed only licensed Nurses (Registered Nurses or Licensed Practical Nurses), Medication Aides, Respiratory Therapists, Physicians, or Physician extenders (Nurse Practitioners or Physician Assistants) shall be allowed to administer medications to residents. All medication errors shall be described in detail on a Medication Error Report which shall be filed with the Director of Nursing (DON). The attending Physician shall be notified immediately of all significant medication errors. Any deviation from the following principles shall be considered a medication error: 1) To the right resident; 2) Administration of the right medication; 3) In the right dose; 4) By the right route; 5) By the right method; 6) At the right time. All recognized deviations from the above principles shall be reported to the Supervisor immediately. The Supervisor shall initiate a Medication Error Report which shall be submitted to the DON. The Supervisor shall evaluate the incident and the resident for adverse effects. If the Supervisor determines that the incident may have a potentially significant adverse effect on the resident, the attending Physician shall be notified immediately. The facility's Medication Error Report shall be completed in detail, making every possible effort to describe the discrepancy thoroughly. Suggestion should be made as to how such discrepancies could be avoided in the future. The Medication Error Reports shall be reviewed at least quarterly by the Quality Improvement Committee. The Quality Improvement Committee should evaluate these reports and determine whether or not proper steps have been taken to prevent the recurrence of such errors. The types of errors shall be summarized. However, interview with the Administrator on 02/24/16, at 10:45 AM, revealed staff was required to notify the physicians and responsible party with any medication errors. The Supervisor was to notify the physician if he/she observed any concerns which had not been identified by the nurse. 1. Review of Resident #2's medical record revealed the facility admitted the resident on 05/10/04 with [DIAGNOSES REDACTED]. Review of the resident's printed physician's orders [REDACTED]. four (4) times daily (originally ordered 05/25/15). Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of twelve (12), which indicated the resident was interviewable. Review of Resident #2's Medication Administration Record (MAR) revealed on 11/02/15 the following medications were not documented as administered to the Resident: [MEDICATION NAME] 12.5 mg - 8:00 PM dose; [MEDICATION NAME] 0.2 mg - 8:00 PM dose; [MEDICATION NAME] 300 mg - 4:00 PM and 8:00 PM dose; and [MEDICATION NAME] ([MEDICATION NAME] ) 100 mg - 4:00 PM and 8:00 PM dose. Interview with Resident #2 on 01/07/16 at 1:55 PM revealed Employee #1 failed to administer the resident's medications on 11/02/15. Interview with Resident #2's attending Physician on 01/21/16 at 1:22 PM revealed the facility contacted him approximately two weeks ago informing him of the medications that may have been missed. The Physician said the resident's blood pressure (B/P) could have gone up with the potentially missed B/P medications, and if the therapeutic level of the [MEDICATION NAME] fell too low the resident could have a [MEDICAL CONDITION]. According to the Physician, the missed medications could have caused harm. Interview with Employee #1 on 01/06/16 at 11:54 AM, and on 01/08/16 at 2:00 PM, revealed she did not remember failing to give Resident #2 his/her medications on 11/02/15. According to Employee #1 if an error was made a Medication Error form should be completed and the physician contacted. 2. Review of Resident #16's medical record revealed the facility admitted the resident on 09/05/07 with [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. The facility assessed the resident was interviewable with a BIMS score of fifteen (15). Review of Resident #16's physician's orders [REDACTED]. Review of Resident #16's MAR dated October 2015 revealed staff failed to document that the resident's 8:00 PM doses of [MEDICATION NAME] and [MEDICATION NAME] were administered to the resident as ordered by the physician, on 10/29/15 and 10/30/15. Interview with Employee #1 on 02/22/16, at 4:15 PM, revealed she could not recall whether she had administered Resident #16's [MEDICATION NAME] (antipsychotic medication) and [MEDICATION NAME] ([MEDICAL CONDITION] medication) on 10/29/15 and 10/30/15. Employee #1 stated if she had administered the medications, she would have documented them on the MAR. 3. Review of the medical record for Resident #7, revealed the facility admitted the resident on 03/25/14, with [DIAGNOSES REDACTED]. Review of a Quarterly MDS assessment dated [DATE], revealed the facility had assessed Resident #7 to have a BIMS score of eight (8) which indicated the resident had moderately impaired cognition and was interviewable. Review of the physician's orders [REDACTED]. Review of the MARS for Resident #7, revealed on 06/30/15, there was no documented evidence [MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME]) had been administered to Resident #7. Interview with Employee #1 on 02/22/16, at 4:15 PM, revealed she could not recall whether she had administered Resident #7's [MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME])on 06/30/15. Employee #1 stated if she had administered the medications, she would have documented them on the MAR. 4. Review of Resident #21's medical record revealed the facility admitted the resident on 12/11/15 with [DIAGNOSES REDACTED]. Review of the resident's Admission MDS dated [DATE], revealed the resident had a BIMS score of 99 and was not interviewable. Review of the blood glucose testing done by the facility revealed in December 2015 and January 2016, the facility was performing blood glucose testing for Resident #21 twice daily. Resident #21's blood glucose levels ranged from 143 to 255 mg/dL. Review of Resident #21's physician's orders [REDACTED]. Review of Resident #21's MAR dated December 2015 revealed the following 5:00 PM doses of [MEDICATION NAME] were not documented as administered to the resident: 12/16/15, 12/17/15, 12/20/15, 12/22/15, 12/23/15, 12/26/15, 12/27/15, and 12/28/15 (a total of eight (8) doses). Interview with Employee #1 on 02/22/16, at 4:15 PM, revealed she could not recall whether she had administered Resident #21's [MEDICATION NAME] (medication to treat high blood sugar) on 12/16/15, 12/17/15, 12/20/15, 12/22/15, 12/23/15, 12/26/15, 12/27/15, and 12/28/15. However, Employee #1 stated she always documented her medications after she had administered them to the resident. Record reviews revealed no documented evidence the residents' physicians or families were notified at the time of the medications errors with Resident #7, Resident #16 and Resident #21. Interview with Kentucky Medication Aide (KMA) #3 on 02/24/16 at 10:30 AM revealed if a blank space was found on a Medication Administration Record (MAR) that would be considered an error. A Medication Error form should be completed and the attending Physician, the Responsible Party, and the Nurse should be notified. KMA #3 revealed she had been the preceptor for Employee #1 when she was in orientation. The KMA stated she had been with Employee #1 for two (2) days and had observed her to prepare medications for administration and to administer medications. KMA #3 stated she had not identified any concerns with Employee #1 administering medications. Review of the facility's policy titled, General Orientation, dated January 2009, revealed on days three, four, and five, employees would be assigned to a preceptor who would complete a skills checklist by the fifth day. The Staff Development Coordinator (SDC) would then evaluate the new employee after the fifth day of employment to assess his/her ability to function independently on an assignment. If the new employee was assessed to require additional preceptor time, the SDC would assign additional time as needed. Interview with Licensed Practical Nurse (LPN) #4 on 02/24/16, at 10:40 AM, revealed he had been the preceptor for Employee #1 on her third day of orientation. The LPN stated he had observed her administer medications to residents and had not identified any concerns with Employee #1 administering medications. Interview with the Quality Assurance Nurse (QA Nurse) on 01/07/16 at 2:32 PM revealed the unsigned blocks on Resident #2, Resident #7, Resident #16, and Resident #21's MARs should have been reported as omissions and the Physicians should have been notified. The omissions should also have been charted in the records, the Responsible Parties notified, Incident Reports completed, and investigations conducted. Interview with the Director of Nursing (DON) on 01/06/16, at 3:06 PM and 4:40 PM, and on 02/22/16, at 2:30 PM, revealed the missed medications for Resident #2 on 11/02/15, Resident #7 on 06/30/15, Resident #16 on 10/29/15 and 10/30/15, and Resident #21 on 12/16/15, 12/17/15, 12/20/15, 12/22/15, 12/23/15, 12/26/15, 12/27/15, and 12/28/15, should have been identified as medication errors and Medication Error Reports completed, the Physician and Responsible Parties should have been notified, and Incident Reports completed. The DON said investigations should have been conducted. According to the DON, the missed blood pressure medication for Resident #2 could have caused the resident's blood pressure to become elevated. The DON also stated that Resident #7 could have had breathing difficulty, Resident #16 could have experienced [MEDICAL CONDITION], and Resident #21's blood glucose levels could have risen due to the missed doses of medication. She stated that the facility did not have a system to audit the MARs to check for omissions. The DON stated she had not reported Employee #1 to the Kentucky Board of Nursing because she was not sure to whom to make the report. She stated she was not aware Employee #1 was not qualified and was not licensed to administer medications until around the end of November 2015 or early December 2015. The DON stated when the employee returned to work on 10/13/15 Employee #1 presented a Clinical Medical Assistant Certification. The DON said she believed the employee had attended a State approved training program and was certified to independently administer resident medications, but she had not contacted the Kentucky Board of Nursing to ensure the school was a state approved program for Kentucky Medication Aides. Further interview with the DON revealed sometime in November 2015 a staff member told her that the Clinical Medical Assistant Certification did not qualify Employee #1 to administer medications. The DON stated she contacted staff at the school and was told that Employee #1 could pass medications with a physician present. She stated she believed that the certification permitted the employee to administer medications, but she (the DON) still did not contact the Kentucky Board of Nursing to ensure the program was a state approved program for Kentucky Medication Aides. However, the DON stated when she called the training center a second time (approximately two weeks later) she determined that the Clinical Medical Assistant Certification that Employee #1 obtained was not a State approved training program that qualified the employee to administer medications at the facility. Although the DON determined Employee #1 was unqualified/unlicensed to administer medications, the DON allowed the employee to continue to administer medications to residents of the facility. Employee #1 was terminated for not showing up to work on 01/02/16. The DON stated, I know I should have suspended her (Employee #1) until I verified her credentials, but I didn't. Interview with the Administrator on 01/08/16 at 2:26 PM, and on 02/24/16, at 10:45 AM, revealed Resident #2, Resident #7, Resident #16, and Resident #21's missed medications should have been identified and Medication Error forms completed. The Administrator said the Physicians and Responsible Parties should have been notified. According to the Administrator, Resident #2 should have been monitored for any increase in B/P and for any other adverse reactions, Resident #7 should have been monitored for difficulty breathing, Resident #16 should have been monitored for [MEDICAL CONDITION], and Resident #21 should have been monitored for high blood glucose levels. The Administrator stated Employee #1's qualifications should have been verified as a Kentucky Medication Aide before the employee was permitted to administer resident medications. She stated that she was not aware Employee #1 was uncertified/unlicensed until the surveyor brought it to her attention. The Administrator stated the residents' Responsible Parties and Physicians had been notified of the medication errors on 01/08/16; however, they were not notified Employee #1 who was responsible for the errors was unlicensed/uncertified to administer medications. The Administrator stated she had not been aware there had been no system to monitor for medication errors in place prior to the Immediate Jeopardy, and stated there should have been. Interview with the Administrator on 02/24/16, at 10:45 AM, revealed staff was required to notify the physicians and responsible party with any medication errors. The Supervisor was to notify the physician if he/she observed any concerns which had not been identified by the nurse. The Administrator also stated Employee #1 was no longer employed by the facility and had not worked since 12/29/15. The Administrator stated she had not reported Employee #1 to the Kentucky Board of Nursing because they did not regulate Clinical Medical Assistants. The Administrator stated she was not aware of whom to report this issue. Interview with the Medical Director on 02/24/16, at 10:30 AM, revealed staff was required to report all medication errors to physicians. The Medical Director stated he felt the errors were significant medication errors. **The facility provided an acceptable Allegation of Compliance (AOC) on 01/16/16. The facility implemented the following actions to remove the Immediate Jeopardy: 1) Employee #1 no longer works at the facility. The facility did not report Employee #1's action to the governing agency. Employee #1 resigned her position with no notice on 12/29/15. The facility did not report Employee #1 to her licensing/credentialing agency, as they stated they did not know to whom to report the incident. 2) On 01/06/16 through 01/07/16, 100 percent of current licensed staff and KMA records were audited by the Administrator, Staff Development Coordinator, and Human Resources. One hundred percent of licensed staff and KMAs were found to have appropriate credentials to continue being a qualified staff member of this facility. 3) Licensed Nurses, KMAs, and State Registered Nurse Aides (SRNAs) assessed all in-house residents' vital signs to include blood pressure, temperature, pulse, respirations, and oxygen saturations (02 sats) on 01/08/16. Necessary vital signs were reassessed as indicated by initial findings. 4) Resident #2's October, November, and December 2015 Medication Administration Records were reviewed by the Director of Nurses (DON) on 01/08/16 for any medications that had not been documented as given. On the same date at approximately 3:30 PM, a licensed Nurse conducted a head to toe assessment of Resident #2 and the SRNA obtained vital signs. On 01/08/16, the DON reviewed the head to toe assessment and vital signs. Resident #2's blood pressure (B/P) was 180/80, temperature (T) was 96.4 axillary, pulse (P) was 80, respirations (R) were 18, and 02 sat was 96%. Resident #2's Physician was notified by the DON, after review, of medications not being documented, head to toe assessment findings, and current vital signs. No new orders were given by the Physician. After Physician notification, Resident #2's family member was informed by the DON of investigative findings. Resident #2's blood pressure was reassessed by a licensed Nurse at 4:25 PM and was 142/68. Vital signs were obtained on the next shift by a SRNA and reviewed by a licensed Nurse on the next shift. 5) All in-house residents' vital signs were promptly taken on 01/08/16 by SRNAs, KMAs, and licensed Nurses. After vital signs were obtained, the Administrator, who is a Registered Nurse, reviewed all the residents' vital signs. The licensed Nurses reviewed and reassessed twelve (12) B/Ps, nine (9) Ts, and twelve (12) Ps. Repeat vital signs obtained by the SRNAs and reviewed by licensed Nurses on 01/08/16 revealed that four (4) B/Ps and (4) Ts continued to be outside normal baseline for those particular residents. On 01/08/16 licensed Nurses, KMAs, and SRNAs, were given instructions by the Administrator to continue to reassess vital signs as indicated by results of individual residents. On 01/08/16, the Administrator informed licensed Nurses that all in-house residents must have their vital signs, B/P, T, P, and R, assessed each shift, and reassessed as indicated upon findings, until the immediate jeopardy was removed, based on acceptance of the facility's Allegation of Compliance. Once this occurs, the Administrator informed the staff that the Administrator would place an OFFICIAL SIGN at each nurses' station, with the date and Administrator's signature, indicating the updated process requirements. 6) All in-house residents' Medication Administration Records were reviewed on 01/08/16 for October, November, and December 2015. All facility staff has signed a Health Insurance Portability and Accountability Act (HIPAA) agreement. Based on that signed HIPAA agreement the Data Entry Clerk, Medical Records Personnel, KMA, Accounts Receivable, and Admissions Coordinator reviewed MARs and highlighted medications with omission of initials and began a log for each specific resident and medication. After that process the DON, Assistant Director of Nurses (ADON), Staff Development Coordinator (SDC), and a Licensed Practical Nurse (LPN) reviewed those same MARs for October, November, and December 2015 a second time to ensure that all omissions were identified on each resident's MAR and documented on the log. Based on the second review of each resident's MARs, interventions such as review/reassessment of vital signs, blood sugars, review of medical record for absence/presence of [MEDICAL CONDITION], etc., were taken by the DON, ADON, SDC, and Social Services Director/LPN to further assess each individual resident's condition. During this process there were 89 residents identified as having one or more medications not initialed as given. Throughout the process there were 0 residents identified as being in immediate danger. The process revealed that all licensed Nurses and KMAs required reminders/education on medication administration. 7) On 01/08/16 and 01/09/16 all in-house resident Physicians were notified by the DON, ADON, SDC, Quality Assurance(QA) Nurse, LPN, and/or the SSD/LPN of resident assessment findings and the potential omission of medication or documentation of the medication. 8) The facility was unable to reach five (5) resident family members, despite numerous calls and voice messages. On 01/11/16, a certified letter was forwarded to those five (5) family members with a request to call the facility to discuss medications. There were no individual resident medication error reports completed during this process. On 01/11/16, the Administrator wrote an overall statement of the omission of medications/initials and forwarded the document to the QA Committee and the Medical Director. 9) On 01/08/16 at 9:45 PM, the Administrator notified the facility's Medical Director (MD) via telephone. The MD was informed of the immediate jeopardy, all residents having the potential to be affected, measures that had and were being taken to ensure that all in-house residents were safe and having no complications that were not being addressed, i.e., vital signs and reassessment of vital signs as indicated, audit of all medication records for October, November, and December 2015, and Physician/resident/family member notification. The Administrator informed the MD of the CMA being a Certified Medical Assistant, not a KMA. The Administrator further informed the MD that all current licensed staff and KMAs had been validated to be active and in good standing. The Medical Director's input was to continue to assess for any resident having medical concerns since the facility could not say with certainty that the medication had been omitted or just not documented. The MD further stated to continue checking for appropriate credentials of licensed staff, KMAs, and unlicensed staff as required. 10) During this process the DON learned that there was a difference between Kentucky Medication Aide (KMA) and Certified Medical Assistant (CMA), and the required education and testing that are to be completed to be a Certified Medical Assistant verses a Kentucky Medication Aide were different. The Administrator learned that while there was a QA system in place for verifying credentials/status of licensed nurses and nursing assistants, the facility lacked a QA system to ensure that newly hired KMAs had the required credentials. To decrease this confusion the facility will utilize terminology from the actual Kentucky Medication Administration certification and call them KMAs. 11) On 01/06/16, the Human Resources/Payroll clerk and the Director of Nurses were educated by the facility's Administrator. The education included the difference in CMA vs. CMA and that it was used in two different ways, Certified Medical Assistant and a Certified Medication Aide. Other terminology for medication aides through the years has included Certified Medication Technician (CMT) and Kentucky Medication Aide (KMA). The education also included that the appropriate credentials must be verified before anyone can be granted access to orientation and this facility will now utilize KMA in job titles instead of CMA. 12) On 01/06/16, the Administrator reviewed the policy and procedure on medication administration. The medication administration policy included: the right resident, the right medication, the right dose, the right route, the right method, and the right time. The policy further clarified that the licensed Nurse or KMA administering the medication was responsible for documentation of the medication. On 01/06/16, the DON reviewed the medication administration policy. Once this education was completed by the Administrator, the DON completed a competency quiz on medication administration. 13) On 01/06/16, 01/07/16, and 01/08/16 licensed Nurses and KMAs were provided education related to the five (5) rights of medication administration and what KMAs were allowed to do based on the KMA certification. Following the education/discussion of medication administration, a competency medication administration quiz was given by the Administrator and/or the DON. The purpose of the education and the quiz was to ensure that the licensed Nurses knew the five (5) rights of medication administration and had adequate knowledge in delegation of medication administration to the KMAs. The education/discussion and quiz also validated that the KMAs had knowledge of the five rights of medication administration and what they were permitted to do based on their preparedness through previous education/classes and passing of the required State exam to practice as a KMA. 14) Any licensed Nurse or KMA who was off duty, on vacation, and/or off for illness or other legitimate reason will be re-educated prior to going to nursing units and being allowed to work. Three (3) persons were not scheduled to work on those dates. One returned on 01/09/16 and was provided with education/discussion and was administered the medication quiz prior to working. A second person remains on vacation and will return on 01/18/16 and will be provided with the required education/discussion and will be administered the medication quiz by the Administrator or DON prior to working. The third person is on suspension with an undetermined date of return. If allowed to return to work, this staff member will be administered the education/discussion and medication quiz prior to working. All new hires will be provided with the medication administration education and will be required to complete a medication pass audit prior to being permitted to administer resident medications without supervision. 15) Based upon the education/discussion provided and the passing of the medication administration quiz, the Administrator made the decision that the current licensed Nurses and KMAs were competent to continue to administer medications safely to facility residents. On 01/14-15/16, the DON, ADON, and SDC were validated competent to administer resident medications via Corporate Nurse education and medication pass audit (minimum 10 meds each) by the facility's Corporate Nurse. The Corporate Nurse, DON, ADON, and/or SDC will continue to educate licensed nurses and/or KMAs related to medication administration. 16) Each licensed Nurse and KMA will demonstrate competency through observation of a medication pass audit (minimum 10 meds each) by the Corporate Nurse, DON, ADON, or SDC. All licensed Nurses and KMAs that were off will not be allowed to work until educated on medication administration and observed completing a medication pass audit (minimum 10 meds each) by the corporate nurse, DON, ADON, or SDC. 17) The Administrator, DON, ADON, or SDC will conduct monthly QA medication pass audits on each licensed Nurse and KMA for the next three months. Any problems identified during the medication pass audit will be forwarded to the DON/ADON promptly for resolution. The DON, ADON, and SDC will report any identified concerns/problems to the QA Committee five days per week, a cumulative total to the QA Committee monthly, and a cumulative total to the executive QA Committee quarterly. 18) The Staff Development Coordinator (SDC) and Human Resources (HR) were educated by the Administrator on 01/09/16 that newly hired license staff and KMAs must be validated through the appropriate registries prior to allowing them to attend orientation. Telephone numbers and web sites were discussed as a means to validate those credentials. The SDC and HR was further educated that KMAs would have to be verified by calling the school in which they attended if appropriate documentation (letter validating passing score and/or actual KMA card signed by representative of school) was not presented upon hire and request a hard copy of validation. SDC will place a hard copy of the monthly licensed nurse validation in a binder as they are completed and will report findings to the QA Committee the following business day. The SDC and HR will conduct a monthly audit of the binder. Any problems identified during the audit will be reported immediately to the Administrator. The results of the QA audit by the SDC and HR will be forwarded to the QA Committee monthly. The SDC will forward the cumulative reports to the Executive Committee quarterly. This process will be utilized to ensure that all licensed staff has remained active and in good standing with the respective Boards of Nursing. 19) On 01/08/16 and 01/09/16, the licensed staff and the KMAs were educated by the Administrator, Director of Nurses (DON), Assistant Director of Nurses (ADON), and/or the Quality Assurance (QA) Nurse. The education of licensed staff included attendance of an accredited school, requirement of a work permit or licensed issued by the Board of Nursing, not being allowed to practice as a licensed nurse if license was revoked, s

Based on observation, interview, record review, and review of the facility's policy and State Regulations 902 KAR 20:300, it was determined the facility failed to have an effective system to ensure professional staff was licensed or certified in accordance with applicable state laws for two (2) of nineteen (19) employee files reviewed. The facility failed to ensure Employee #1 was qualified/licensed to administer resident medications upon on and allowed Employee #1 to administer medications to residents from [DATE] to [DATE]. Even though Employee #1 was not licensed and not certified to administer medications, the facility rehired her on [DATE] to [DATE] to administer medications. Employee #1, who was unlicensed/uncertified to administer medications, was responsible for administering Resident #2's medication on the afternoon and evening (2:00 PM - 10:00 PM) on [DATE]. Resident #2 was ordered to receive two (2) doses of a [MEDICAL CONDITION] medication ([MEDICATION NAME]), one dose of two (2) different blood pressure medications ([MEDICATION NAME] and [MEDICATION NAME]), and two doses of pain medication ([MEDICATION NAME]) on the evening shift on [DATE]. Review of the Medication Administration Record (MAR) revealed no documented evidence that Resident #2 received his/her 4:00 PM and 8:00 PM scheduled medications on [DATE]. In addition, during Employee #1's employment from [DATE] to [DATE], review of a list of residents that Employee #1 had been assigned to administer medications, revealed twenty-five (25) of twenty-seven (27) residents had medication errors observed. The facility also failed to ensure licensed nurses employed at the facility had a valid nursing license. Licensed Practical Nurse (LPN) #1 was hired by the facility on [DATE] to provide nursing care for residents in a long-term care environment under the supervision of a registered nurse. LPN #1 worked at the facility from [DATE] until [DATE] performing nursing duties on a lapsed LPN license. The facility's failure to ensure staff, professional and unprofessional, was licensed or certified in accordance with applicable state laws has caused, or is likely to cause, serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy was determined to exist on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE] as alleged, which lowered the scope and severity to E while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of State Regulations 902 KAR 20:300 Operation and Services, Nursing Facilities, Section 14.(1)(b) Administration of medications, revealed, All medications shall be administered by licensed medical or nursing personnel in accordance with the Medical Practice Act (KRS 311.530 to 311.620) and Nurse Practice Act (KRS Chapter 314) or by personnel who have completed a state approved training program from a state approved provider. The administration of oral and topical medicines by certified medicine technicians shall be under the supervision of licensed medical or nursing personnel. Intramuscular injections shall be administered by a licensed or registered nurse, or a physician. If intravenous injections are necessary they shall be administered by a licensed physician, registered nurse, or properly trained licensed practical nurse. Each dose administered shall be recorded in the medical record. Review of a Kentucky Board of Nursing Advisory Opinion Statement, with a revision date of [DATE], revealed The administration of medication is the practice of nursing. The administration of medication to patients in health care facilities is both the responsibility of nurses and an integral part of the nursing care rendered to patients. Medication may be administered to patients in health care facilities by physicians, or other health care professionals. In Kentucky, unlicensed personnel known as medication aides or other similar titles may function by administering oral and topical medications in long term care facilities only through delegation by and under the supervision of a Registered Nurse (RN) or Licensed Practical Nurse (LPN). Unlicensed personnel must have successfully completed the state approved course for administration of medications. Review of the facility's policy titled, General Orientation, dated [DATE], revealed on days three, four, and five, employees would be assigned to a preceptor who would complete a skills checklist by the fifth day. The Staff Development Coordinator (SDC) would then evaluate the new employee after the fifth day of employment to assess his/her ability to function independently on an assignment. If the new employee was assessed to require additional preceptor time, the SDC would assign additional time as needed. Review of the facility's Medication Administration policy, not dated, revealed only licensed Nurses (Registered Nurses or Licensed Practical Nurses), Medication Aides, Respiratory Therapists, Physicians, or Physician extenders (Nurse Practitioners or Physician Assistants) shall be allowed to administer medications to residents. However, the policy did not address how the facility would monitor medication administration to ensure residents' medications were administered as ordered by the physician. 1. Review of Employee #1's personnel file revealed the facility hired the employee on [DATE] to [DATE], and rehired the employee on [DATE] as a Kentucky Medication Aide (KMA); she worked until [DATE]. The responsible of a KMA includes administering medications to residents. Further review of the personnel file revealed Employee #1, was not licensed and was not certified or trained to be a KMA. Employee #1 obtained a Clinical Medical Assistant (CMA) certification on [DATE]; however, there was no evidence Employee #1 attended a State approved training program for medication administration. A CMA is trained to perform duties in a physician's office. Interview with Employee #1 on [DATE] at 11:54 AM, on [DATE] at 2:00 PM, and on [DATE], at 4:15 PM, revealed she started working at the facility in [DATE]. She stated she had told the Director of Nursing (DON) she was enrolled in the CMA class and would not graduate until [DATE]. The Employee stated she had left employment with the facility in [DATE]. Employee #1 stated she returned to work at the facility in [DATE] as a CMA and gave a copy of her CMA certificate to the Director of Nursing (DON). According to Employee #1, she was responsible for administering medication to residents. Employee #1 said she had taken the Clinical Medical Assistant class and graduated from this class in [DATE]. According to Employee #1, she had not taken the Kentucky Medication Technician class (State approved course to prepare/teach to administer medications). Employee #1 said she continued to administer medications to residents until the last day she worked, on [DATE]. She stated the DON had checked with the school she had attended and had told her it was okay for her to pass (administer) medication. The Employee stated she had believed the DON. An interview was conducted with the DON on [DATE], at 3:06 PM, related to Employee #1's qualifications. The DON stated when the facility hired Employee #1 on [DATE] she was enrolled in Certified Medical Assistant training. The DON stated when the employee was rehired in [DATE] Employee #1 provided the facility with a Medical Assistant Certificate. The DON stated she believed the Clinical Medical Assistant training was a state approved medication administration course. She stated she had not known the difference between a Kentucky Medication Aide KMA and Clinical Medical Assistant CMA, which was not a state approved training for medication administration. The DON stated she was unsure of the date she had called the school attended by Employee #1. During further interview with the DON, she stated she had thought a Kentucky Medication Aide and a Clinical Medical Assistant were the same certification/qualifications. The DON stated she had not called the Kentucky Board of Nursing and realized she should have to verify Employee #1's qualifications. An interview on [DATE], at 2:00 PM, with the Supervisor at the Clinical Medical Assistant school that Employee #1 attended revealed Clinical Medical Assistant (CMA) students were not trained to administer medications in a facility. The Supervisor stated students were taught and prepared to work in a physician's office under the supervision of a physician and were not trained to administer medications in a nursing facility. She stated she had provided the same information to the facility's Director of Nursing (DON) on at least two occasions several months prior, when the DON contacted the school. Interview with Kentucky Medication Aide (KMA) #1 on [DATE] at 2:12 PM revealed Employee #1 returned to the facility in [DATE] with a Certificate, which she gave to the Director of Nursing (DON). KMA #1 stated she had taken the same class as Employee #1 and knew the class was not the State approved Kentucky Medication Aide Course. KMA #1 said she had talked to the DON multiple times about the course Employee #1 had taken and explained to her this course was not a Medication Course. According to KMA #1, the DON said she called the school and was told the course covered passing medications. KMA #1 said Employee #1 told the DON she was a CMA and was not required to produce proof of her training. According to KMA #1, Employee #1 continued to administer medications to the residents even after she (KMA#1) had voiced concerns about her qualifications and training. An interview with the DON on [DATE] at 3:06 PM and 4:40 PM, [DATE], at 2:15 PM, revealed the facility was not aware Employee #1 was not qualified to administer medications until the end of [DATE] or early [DATE]. The DON stated when the employee returned to work at the facility on [DATE], Employee #1 presented a Clinical Medical Assistant Certification. The DON stated she believed the employee had attended a State approved training program and was certified to independently administer resident medications. Further interview with the DON revealed sometime in [DATE] a staff member told her that the Medical Assistant Certification did not qualify Employee #1 to administer medications. The DON stated she contacted staff at the school, who told her that Employee #1 could pass medications with a physician present, and she believed that the certification permitted the employee to administer medications. However, the DON stated when she called the training center a second time (approximately two weeks later), after being informed by KMA #1 that Employee #1 was not qualified to administer medications because she was attending the same class as Employee #1, the school told the DON that the Medical Assistant Certification that Employee #1 obtained, was not a State approved training program that qualified the employee to administer medications at the facility. Although the DON determined Employee #1 was not qualified/certified to administer medications, the DON allowed the employee to continue to administer medications to residents of the facility. Employee #1 was terminated for not showing up to work on [DATE]. The DON stated, I know I should have suspended her (Employee #1) until I verified her credentials, but I didn't. I do not know why I did not. She stated she had not reported Employee #1 because she did not know to whom to report the incident. The DON stated the facility did not have a procedure for verifying and auditing KMA's personnel files. Interview with Kentucky Medication Aide (KMA) #3 on [DATE] at 10:30 AM revealed she had been with Employee #1 as a preceptor for two (2) days and had observed her prepare medications for administration and administer medications. KMA #3 stated she had not identified any concerns with Employee #1 administering medications. Interview with Licensed Practical Nurse (LPN) #4 on [DATE], at 10:40 AM, revealed he had been the preceptor for Employee #1 on her third day of orientation. The LPN stated he had observed her administer medications to residents and had not identified any concerns with Employee #1 administering medications. Review of Resident #2's MAR revealed that on [DATE] the following medications had not been documented as administered to the resident: [MEDICATION NAME] 12.5 milligrams (mg) - 8:00 PM dose; [MEDICATION NAME] 0.2 mg - 8:00 PM dose; [MEDICATION NAME] 300 mg - 4:00 PM and 8:00 PM dose; and [MEDICATION NAME] ([MEDICATION NAME]) 100 mg - 4:00 PM and 8:00 PM dose. Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of twelve (12), which indicated the resident was interviewable. Interview with Resident #2 on [DATE] at 1:55 PM revealed Employee #1 failed to administer the resident's medications on [DATE]. The resident stated that he/she could remember that he/she had not received his/her evening medications on [DATE] and that Employee #1 was slow and medications were often late. According to Resident #2, it appeared that Employee #1 . did not know what she was doing. Review of residents' MARS that Employee #1 had been assigned to administer medications from [DATE] to [DATE], revealed two hundred and thirty four (234) medications with no documented evidence that these scheduled medications were administered to residents. Interview with the Human Resources Manager (HRM) on [DATE] at 4:09 PM, [DATE], at 2:00 PM, revealed that she had been employed at the facility for [AGE] years. The HRM said she performed all the background checks and licensure validation when employees were first hired but she did not validate Kentucky Medication Aides (KMAs). According to the HRM, she did not know they had to be certified. The HRM stated the Staff Development Coordinator (SDC) did all the yearly validations on the Nurses and the State Registered Nurse Aides (SRNAs). Interview with the SDC on [DATE] at 12:49 PM, [DATE], at 2:30 PM, revealed she was responsible for overseeing the orientation process for all new employees and completed yearly certification validation for nurses and state registered nurse aides, but not for Kentucky Medication Aides. The Staff Development Coordinator stated there was no documented evidence that Employee #1 received orientation at the facility. In addition, she stated that even though the facility's policy required her to evaluate Employee #1 after orientation, she stated she was unable to find the skills check list which had been completed by KMA #3. The Staff Development Coordinator stated she had signed that Employee #1 was qualified to perform her job duties which had included administration of medications to residents. She stated she was required to review the employee's skills checklist to assist in the determination of a staff person being qualified to perform their job duties. The Staff Development Coordinator stated she should have located Employee #1's skills checklist prior to signing that the employee was qualified to perform her job duties. She stated she had signed that Employee #1 had completed her orientation, but she did not determine if the employee was qualified to do the job. Interview with the Administrator on [DATE] at 2:26 PM and on [DATE], at 3:06 PM, revealed Employee #1's qualifications should have been verified as a Kentucky Medication Aide before the employee was permitted to administer resident medications. The Administrator said that she was not aware that the DON allowed Employee #1 to continue to pass medications until the surveyor brought it to her attention. She stated Employee #1 should not have been allowed to continue to pass medication after the DON suspected that she was not licensed/certified. The Administrator stated it had been the HR's responsibility to check the credentials of all new employees. During further interview, the Administrator stated she had not reported Employee #1 to the Kentucky Board of Nursing because they did not regulate CMAs and she was not aware of whom to report this issue. The Administrator stated the residents', with medication errors, family members and physicians had been notified of the medication errors, but they had not been notified that Employee #1, who had been responsible for administering the medications and made the medication errors, was unlicensed/uncertified to administer medications. 2. Review of LPN #1's personnel file revealed she was hired by the facility on [DATE] to administer nursing care in a long-term care environment under the supervision of a Registered Nurse. Further review revalued that LPN #1's license had expired on [DATE]. LPN #1 worked at the facility from [DATE] until [DATE] performing nursing duties on a lapsed LPN license. Interview with LPN #1 on [DATE] at 12:54 PM revealed she went online to renew her license around 12:10 AM on [DATE]. The LPN stated she was charged double the usual renewal fee and thought her license had been renewed. According to LPN #1, the DON told her on [DATE] or [DATE] that her license had lapsed. LPN #1 stated she did not work again after learning that her license had lapsed. Interview with Nurse Consultant #2 on [DATE] at 2:07 PM revealed on [DATE], she had reviewed LPN #1's license to verify that the LPN's license was valid. According to the Nurse Consultant, she overlooked it somehow and did not identify that the LPN's license had lapsed. An interview with the DON on [DATE] at 3:06 PM and 4:40 PM revealed she was not aware of LPN #1's license being lapsed until [DATE] when the LPN had told her that she had checked the Kentucky Board of Nursing website and her LPN license had lapsed. The DON said staff validating the nurse's license should have caught that the LPN's license had lapsed. Interview with the Administrator on [DATE] at 2:26 PM revealed staff should have seen that LPN #1's license had lapsed when they did the Validation Audit on [DATE]. The Administrator said she would expect staff that had trouble renewing their license to notify her of the problem. Interview conducted with the Kentucky Board of Nursing (KBN) Reinstatement Coordinator on [DATE], at 10:15 AM, revealed for a nurse to reinstate a lapsed LPN license you must complete an application and submit a fee, complete a Criminal Background Check, Federal Background Check, Submit Verification of Continuing Education Requirements, and Fingerprint cards from the Kentucky State Police. The Reinstatement Coordinator stated the process of reinstatement could take up to three (3) months. **The facility provided an acceptable Allegation of Compliance (AOC) on [DATE]. The facility implemented the following actions to remove the Immediate Jeopardy: 1) Employee #1 no longer works at the facility. The facility did not report Employee #1's action to the governing agency. Employee #1 resigned her position with no notice on [DATE]. The facility did not report Employee #1 to her licensing/credentialing agency, as they stated they did not know to whom to report the incident. 2) On [DATE] through [DATE], 100 percent of current licensed staff and KMA records were audited by the Administrator, Staff Development Coordinator, and Human Resources. One hundred percent of licensed staff and KMAs were found to have appropriate credentials to continue being a qualified staff member of this facility. 3) Licensed Nurses, KMAs, and State Registered Nurse Aides (SRNAs) assessed all in-house residents' vital signs to include blood pressure, temperature, pulse, respirations, and oxygen saturations (02 sats) on [DATE]. Necessary vital signs were reassessed as indicated by initial findings. 4) Resident #2's October, November, and [DATE] Medication Administration Records were reviewed by the Director of Nurses (DON) on [DATE] for any medications that had not been documented as given. On the same date at approximately 3:30 PM, a licensed Nurse conducted a head to toe assessment of Resident #2 and the SRNA obtained vital signs. On [DATE], the DON reviewed the head to toe assessment and vital signs. Resident #2's blood pressure (B/P) was ,[DATE], temperature (T) was 96.4 axillary, pulse (P) was 80, respirations (R) were 18, and 02 sat was 96%. Resident #2's Physician was notified by the DON, after review, of medications not being documented, head to toe assessment findings, and current vital signs. No new orders were given by the Physician. After Physician notification, Resident #2's family member was informed by the DON of investigative findings. Resident #2's blood pressure was reassessed by a licensed Nurse at 4:25 PM and was ,[DATE]. Vital signs were obtained on the next shift by a SRNA and reviewed by a licensed Nurse on the next shift. 5) All in-house residents' vital signs were promptly taken on [DATE] by SRNAs, KMAs, and licensed Nurses. After vital signs were obtained, the Administrator, who is a Registered Nurse, reviewed all the residents' vital signs. The licensed Nurses reviewed and reassessed twelve (12) B/Ps, nine (9) Ts, and twelve (12) Ps. Repeat vital signs obtained by the SRNAs and reviewed by licensed Nurses on [DATE] revealed that four (4) B/Ps and (4) Ts continued to be outside normal baseline for those particular residents. On [DATE] licensed Nurses, KMAs, and SRNAs, were given instructions by the Administrator to continue to reassess vital signs as indicated by results of individual residents. On [DATE], the Administrator informed licensed Nurses that all in-house residents must have their vital signs, B/P, T, P, and R, assessed each shift, and reassessed as indicated upon findings, until the immediate jeopardy was removed, based on acceptance of the facility's Allegation of Compliance. Once this occurs, the Administrator informed the staff that the Administrator would place an OFFICIAL SIGN at each nurses' station, with the date and Administrator's signature, indicating the updated process requirements. 6) All in-house residents' Medication Administration Records were reviewed on [DATE] for October, November, and [DATE]. All facility staff has signed a Health Insurance Portability and Accountability Act (HIPAA) agreement. Based on that signed HIPAA agreement the Data Entry Clerk, Medical Records Personnel, KMA, Accounts Receivable, and Admissions Coordinator reviewed MARs and highlighted medications with omission of initials and began a log for each specific resident and medication. After that process the DON, Assistant Director of Nurses (ADON), Staff Development Coordinator (SDC), and a Licensed Practical Nurse (LPN) reviewed those same MARs for October, November, and [DATE] a second time to ensure that all omissions were identified on each resident's MAR and documented on the log. Based on the second review of each resident's MARs, interventions such as review/reassessment of vital signs, blood sugars, review of medical record for absence/presence of [MEDICAL CONDITION], etc., were taken by the DON, ADON, SDC, and Social Services Director/LPN to further assess each individual resident's condition. During this process there were 89 residents identified as having one or more medications not initialed as given. Throughout the process there were 0 residents identified as being in immediate danger. The process revealed that all licensed Nurses and KMAs required reminders/education on medication administration. 7) On [DATE] and [DATE] all in-house resident Physicians were notified by the DON, ADON, SDC, Quality Assurance(QA) Nurse, LPN, and/or the SSD/LPN of resident assessment findings and the potential omission of medication or documentation of the medication. 8) The facility was unable to reach five (5) resident family members, despite numerous calls and voice messages. On [DATE], a certified letter was forwarded to those five (5) family members with a request to call the facility to discuss medications. There were no individual resident medication error reports completed during this process. On [DATE], the Administrator wrote an overall statement of the omission of medications/initials and forwarded the document to the QA Committee and the Medical Director. 9) On [DATE] at 9:45 PM, the Administrator notified the facility's Medical Director (MD) via telephone. The MD was informed of the immediate jeopardy, all residents having the potential to be affected, measures that had and were being taken to ensure that all in-house residents were safe and having no complications that were not being addressed, i.e., vital signs and reassessment of vital signs as indicated, audit of all medication records for October, November, and [DATE], and Physician/resident/family member notification. The Administrator informed the MD of the CMA being a Certified Medical Assistant, not a KMA. The Administrator further informed the MD that all current licensed staff and KMAs had been validated to be active and in good standing. The Medical Director's input was to continue to assess for any resident having medical concerns since the facility could not say with certainty that the medication had been omitted or just not documented. The MD further stated to continue checking for appropriate credentials of licensed staff, KMAs, and unlicensed staff as required. 10) During this process the DON learned that there was a difference between Kentucky Medication Aide (KMA) and Certified Medical Assistant (CMA), and the required education and testing that are to be completed to be a Certified Medical Assistant verses a Kentucky Medication Aide were different. The Administrator learned that while there was a QA system in place for verifying credentials/status of licensed nurses and nursing assistants, the facility lacked a QA system to ensure that newly hired KMAs had the required credentials. To decrease this confusion the facility will utilize terminology from the actual Kentucky Medication Administration certification and call them KMAs. 11) On [DATE], the Human Resources/Payroll clerk and the Director of Nurses were educated by the facility's Administrator. The education included the difference in CMA vs. CMA and that it was used in two different ways, Certified Medical Assistant and a Certified Medication Aide. Other terminology for medication aides through the years has included Certified Medication Technician (CMT) and Kentucky Medication Aide (KMA). The education also included that the appropriate credentials must be verified before anyone can be granted access to orientation and this facility will now utilize KMA in job titles instead of CMA. 12) On [DATE], the Administrator reviewed the policy and procedure on medication administration. The medication administration policy included: the right resident, the right medication, the right dose, the right route, the right method, and the right time. The policy further clarified that the licensed Nurse or KMA administering the medication was responsible for documentation of the medication. On [DATE], the DON reviewed the medication administration policy. Once this education was completed by the Administrator, the DON completed a competency quiz on medication administration. 13) On [DATE], [DATE], and [DATE] licensed Nurses and KMAs were provided education related to the five (5) rights of medication administration and what KMAs were allowed to do based on the KMA certification. Following the education/discussion of medication administration, a competency medication administration quiz was given by the Administrator and/or the DON. The purpose of the education and the quiz was to ensure that the licensed Nurses knew the five (5) rights of medication administration and had adequate knowledge in delegation of medication administration to the KMAs. The education/discussion and quiz also validated that the KMAs had knowledge of the five rights of medication administration and what they were permitted to do based on their preparedness through previous education/classes and passing of the required State exam to practice as a KMA. 14) Any licensed Nurse or KMA who was off duty, on vacation, and/or off for illness or other legitimate reason will be re-educated prior to going to nursing units and being allowed to work. Three (3) persons were not scheduled to work on those dates. One returned on [DATE] and was provided with education/discussion and was administered the medication quiz prior to working. A second person remains on vacation and will return on [DATE] and will be provided with the required education/discussion and will be administered the medication quiz by the Administrator or DON prior to working. The third person is on suspension with an undetermined date of return. If allowed to return to work, this staff member will be administered the education/discussion and medication quiz prior to working. All new hires will be provided with the medication administration education and will be required to complete a medication pass audit prior to being permitted to administer resident medications without supervision. 15) Based upon the education/discussion provided and the passing of the medication administration quiz, the Administrator made the decision that the current licensed Nurses and KMAs were competent to continue to administer medications safely to facility residents. On ,[DATE]-,[DATE], the DON, ADON, and SDC were validated competent to administer resident medications via Corporate Nurse education and medication pass audit (minimum 10 meds each) by the facility's Corporate Nurse. The Corporate Nurse, DON, ADON, and/or SDC will continue to educate licensed nurses and/or KMAs related to medication administration. 16) Each licensed Nurse and KMA will demonstrate competency through observation of a medication pass audit (minimum 10 meds each) by the Corporate Nurse, DON, ADON, or SDC. All licensed Nurses and KMAs that were off will not be allowed to work until educated on medication administration and observed completing a medication pass audit (minimum 10 meds each) by the corporate nurse, DON, ADON, or SDC. 17) The Administrator, DON, ADON, or SDC will conduct monthly QA medication pass audits on each licensed Nurse and KMA for the next three months. Any problems identified during the medication pass audit will be forwarded to the DON/ADON promptly for resolution. The DON, ADON, and SDC will report any identified concerns/problems to the QA Committee five days per week, a cumulative total to the QA Committee monthly, and a cumulative total to the executive QA Committee quarterly. 18) The Staff Development Coordinator (SDC) and Human Resources (HR) were educated by the Administrator on [DATE] that newly hired license staff and KMAs must be validated through the appropriate registries prior to allowing them to attend orientation. Telephone numbers and web sites were discussed as a means to validate those credentials. The SDC and HR was further educated that KMAs would have to be verified by calling the school in which they attended if appropriate documentation (letter validating passing score and/or actual KMA card signed by representative of school) was not presented upon hire and request a hard copy of validation. SDC will place a hard copy of the monthly licensed nurse validation in a binder as they are completed and will report findings to the QA Committee the following business day. The SDC and HR will conduct a monthly audit of the binder. Any problems identified during the audit will be reported immediately to the Administrator. The results of the QA audit by the SDC and HR will be forwarded to the QA Committee monthly. The SDC will forward the cumulative reports to the Executive Committee quarterly. This process will be utilized to ensure that all licensed staff has remained active and in good

Based on record review, interview, and state regulation it was determined the facility failed to ensure that clinical records were maintained for twenty-six (26) of thirty-one (31) residents in accordance with accepted professional standards. Review of Medication Administration Records (MARS) from 05/13/15 to 07/22/15 and 10/13/15 to 12/29/15, for Resident #2, Resident #5, Resident #6, Resident #7, Resident #10, Resident #12, Resident #13, Resident #14, Resident #15, Resident #16, Resident #17, Resident #18, Resident #19, Resident #20, Resident #21, Resident #22, Resident #23, Resident #24, Resident 25, Resident #26, Resident #27, Resident #28, Resident #29, Resident #30, and Resident #31, revealed that two hundred fifty-three (253) doses of resident medications that were ordered by the physician and to be administered by the facility to the resident were left blank on the medication records. The review also revealed there was no explanation contained on the MAR or in the resident's medical record as to why the medication was not administered as ordered, rendering the resident's medical record incomplete and inaccurately documented. Furthermore, the facility failed to document that treatments were completed as ordered to a Stage Two (2) pressure sore on Resident #11's left heel two (2) times between 01/05/16 and 01/14/16. The facility failed to document that the dressing to the same pressure sore was checked/assessed as ordered five (5) times in the same time frame (01/05/16 and 01/14/16). The facility's failure to ensure clinical records were accurately maintained has caused, or is likely to cause, serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy was determined to exist on 05/13/15. An acceptable Allegation of Compliance was received on 01/16/16, which alleged removal of the Immediate Jeopardy on 01/16/16. The State Survey Agency determined the Immediate Jeopardy was removed on 01/16/16 as alleged, which lowered the Scope and Severity to E while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Interview on 03/02/16 at 10:30 AM with the Director of Nursing (DON) revealed the facility did not have a policy related to ensuring medical records were accurate. Review of the facility's Medication administration policy, undated revealed one licensed nurse or medication aide at a time will be responsible for preparing, administering, and recording medication doses for a given resident. However, the policy did not specify how staff were to record the doses that were given. Review of State Regulations 902 KAR 20:300 Operation and Services, Nursing Facilities, Section 14.(1)(b) Administration of medications, revealed, All medications shall be administered by licensed medical or nursing personnel in accordance with the Medical Practice Act (KRS 311.530 to 311.620) and Nurse Practice Act (KRS Chapter 314) or by personnel who have completed a state approved training program from a state approved provider. The administration of oral and topical medicines by certified medicine technicians shall be under the supervision of licensed medical or nursing personnel. Intramuscular injections shall be administered by a licensed or registered nurse, or a physician. If intravenous injections are necessary they shall be administered by a licensed physician, registered nurse, or properly trained licensed practical nurse. Each dose administered shall be recorded in the medical record. 1. Review of the Resident's MARs from 05/13/15 to 07/22/15, and 10/13/15 to 12/29/15 revealed the following number of omissions were present on each of the resident's MARs: Resident #5 had five (5) omissions, Resident #6 had eight (8) omissions, Resident #10 had four (4) omissions, Resident #12 had fifty-two (52) omissions, Resident #13 had twenty-two (22) omissions, Resident #14 had nine (9) omissions, Resident #15 had six (6) omissions, Resident #17 had six (6) omissions, Resident #18 had eleven (11) omissions, Resident #19 had five (5) omissions, Resident #20 had four (4) omissions, Resident #22 had twelve (12) omissions, Resident #23 fifteen (15) omissions, Resident #24 had twenty-seven (27) omissions, Resident #25 had two (2) omissions, Resident #26 had six (6) omissions, Resident #27 had two (2) omissions, Resident #28 had twelve (12) omissions, Resident #29 had twelve (12) omissions, Resident #30 twelve (12) omissions, and Resident #31 had two (2) omissions. These omissions totaled two hundred thirty-four omissions. In addition, review of MARs for Resident #2, Resident #7, Resident #16, and Resident #21, revealed nineteen (19) resident medications which were documented as not being administered to the residents. Refer to F333. Interviews on 01/06/16, at 2:12 PM, with KMA #1, on 02/24/16 at 10:30 AM with KMA #3, on 2/24/16, at 10:40 AM, with LPN #4, revealed that they were to administer residents' medications and to place their initial in the corresponding area on the MAR to signify that the medication had been administered as ordered by the physician. Additionally, staff stated that if the medication could not be administered as ordered they were required to notify the physicians, initial and circle their initials, and document why they were unable to administer the medication to the resident. Interview with the DON on 01/08/16 at 2:26 PM; and, on 02/24/16, at 10:45 AM, revealed the facility did not have a system for monitoring and reviewing MARs. Interview with the Administrator on 01/08/16 at 2:26 PM, and on 02/24/16, at 10:45 AM, revealed that they were not aware of blank spaces (undocumented) on the MARS. The Administrator stated medications should be documented immediately on the MAR, after administering them. 2. Review of the medical record for Resident #11 revealed the facility readmitted the resident on 12/14/15 with [DIAGNOSES REDACTED]. Review of Resident #11's Wound Ulcer Flow sheet, dated 01/06/16, revealed the resident had a suspected deep tissue injury to the left heel. Review of Resident #11's Skin Check sheet, dated 01/12/16, revealed the resident had a pressure area noted to the left heel with a dressing in place. Review of Resident #11's physician's orders [REDACTED]. Review of Resident #11's Treatment Record, dated January 2016, revealed no documented evidence the treatment had been completed to the resident's left heel on 01/05/16 and 01/08/16. Further review of the Treatment Administration Record revealed no documentation that the area on the left heel had been checked on 01/06/16, 01/09/16, 01/10/16, 01/13/16, and 01/14/16. Interviews on 02/25/16 with State Registered Nurse Aide (SRNA) #5 at 10:21 AM, and SRNA #4 at 2:45 PM revealed the SRNAs remembered Resident #11 having a dressing in place to his/her heel. Interviews on 02/25/16 with Licensed Practical Nurse (LPN) #7 revealed the LPN was the facility's part-time treatment nurse and she did the residents' treatments on the days that she was scheduled to work and the floor nurses do the treatments on the other days. The LPN revealed she had provided care and done wound care and dressing checks for Resident #11 at times between 01/05/16 and 01/14/16. The interview further revealed the LPN stated that she always ensured the treatments were done per the physician's orders [REDACTED].#11's treatment or dressing check. Continued interview revealed all treatments should be documented in the resident's medical record. Interviews on 02/25/16 with LPN #8 at 12:45 PM, LPN #9 at 4:12 PM, LPN #3 at 4:37 PM, LPN #10 at 5:01 PM and Registered Nurse (RN) #1 at 4:45 PM revealed the nurses were assigned to provide care to Resident #11 at times between 01/05/16 and 01/14/16 and were all sure they had completed the resident's wound care treatment and/or dressing check and had just forgot to sign that the treatment had been completed. The interviews further revealed the nursing staff should ensure treatments were completed per physician's orders [REDACTED]. Interview on 02/25/16 at 1:30 PM with the Administrator revealed the nursing staff should always ensure treatments were completed per the physician's orders [REDACTED]. **The facility provided an acceptable Allegation of Compliance (AOC) on 01/16/16. The facility implemented the following actions to remove the Immediate Jeopardy: 1) Employee #1 no longer works at the facility. The facility did not report Employee #1's action to the governing agency. Employee #1 resigned her position with no notice on 12/29/15. The facility did not report Employee #1 to her licensing/credentialing agency, as they stated they did not know to whom to report the incident. 2) On 01/06/16 through 01/07/16, 100 percent of current licensed staff and KMA records were audited by the Administrator, Staff Development Coordinator, and Human Resources. One hundred percent of licensed staff and KMAs were found to have appropriate credentials to continue being a qualified staff member of this facility. 3) Licensed Nurses, KMAs, and State Registered Nurse Aides (SRNAs) assessed all in-house residents' vital signs to include blood pressure, temperature, pulse, respirations, and oxygen saturations (02 sats) on 01/08/16. Necessary vital signs were reassessed as indicated by initial findings. 4) Resident #2's October, November, and December 2015 Medication Administration Records were reviewed by the Director of Nurses (DON) on 01/08/16 for any medications that had not been documented as given. On the same date at approximately 3:30 PM, a licensed Nurse conducted a head to toe assessment of Resident #2 and the SRNA obtained vital signs. On 01/08/16, the DON reviewed the head to toe assessment and vital signs. Resident #2's blood pressure (B/P) was 180/80, temperature (T) was 96.4 axillary, pulse (P) was 80, respirations (R) were 18, and 02 sat was 96%. Resident #2's Physician was notified by the DON, after review, of medications not being documented, head to toe assessment findings, and current vital signs. No new orders were given by the Physician. After Physician notification, Resident #2's family member was informed by the DON of investigative findings. Resident #2's blood pressure was reassessed by a licensed Nurse at 4:25 PM and was 142/68. Vital signs were obtained on the next shift by a SRNA and reviewed by a licensed Nurse on the next shift. 5) All in-house residents' vital signs were promptly taken on 01/08/16 by SRNAs, KMAs, and licensed Nurses. After vital signs were obtained, the Administrator, who is a Registered Nurse, reviewed all the residents' vital signs. The licensed Nurses reviewed and reassessed twelve (12) B/Ps, nine (9) Ts, and twelve (12) Ps. Repeat vital signs obtained by the SRNAs and reviewed by licensed Nurses on 01/08/16 revealed that four (4) B/Ps and (4) Ts continued to be outside normal baseline for those particular residents. On 01/08/16 licensed Nurses, KMAs, and SRNAs, were given instructions by the Administrator to continue to reassess vital signs as indicated by results of individual residents. On 01/08/16, the Administrator informed licensed Nurses that all in-house residents must have their vital signs, B/P, T, P, and R, assessed each shift, and reassessed as indicated upon findings, until the immediate jeopardy was removed, based on acceptance of the facility's Allegation of Compliance. Once this occurs, the Administrator informed the staff that the Administrator would place an OFFICIAL SIGN at each nurses' station, with the date and Administrator's signature, indicating the updated process requirements. 6) All in-house residents' Medication Administration Records were reviewed on 01/08/16 for October, November, and December 2015. All facility staff has signed a Health Insurance Portability and Accountability Act (HIPAA) agreement. Based on that signed HIPAA agreement the Data Entry Clerk, Medical Records Personnel, KMA, Accounts Receivable, and Admissions Coordinator reviewed MARs and highlighted medications with omission of initials and began a log for each specific resident and medication. After that process the DON, Assistant Director of Nurses (ADON), Staff Development Coordinator (SDC), and a Licensed Practical Nurse (LPN) reviewed those same MARs for October, November, and December 2015 a second time to ensure that all omissions were identified on each resident's MAR and documented on the log. Based on the second review of each resident's MARs, interventions such as review/reassessment of vital signs, blood sugars, review of medical record for absence/presence of [MEDICAL CONDITION], etc., were taken by the DON, ADON, SDC, and Social Services Director/LPN to further assess each individual resident's condition. During this process there were 89 residents identified as having one or more medications not initialed as given. Throughout the process there were 0 residents identified as being in immediate danger. The process revealed that all licensed Nurses and KMAs required reminders/education on medication administration. 7) On 01/08/16 and 01/09/16 all in-house resident Physicians were notified by the DON, ADON, SDC, Quality Assurance(QA) Nurse, LPN, and/or the SSD/LPN of resident assessment findings and the potential omission of medication or documentation of the medication. 8) The facility was unable to reach five (5) resident family members, despite numerous calls and voice messages. On 01/11/16, a certified letter was forwarded to those five (5) family members with a request to call the facility to discuss medications. There were no individual resident medication error reports completed during this process. On 01/11/16, the Administrator wrote an overall statement of the omission of medications/initials and forwarded the document to the QA Committee and the Medical Director. 9) On 01/08/16 at 9:45 PM, the Administrator notified the facility's Medical Director (MD) via telephone. The MD was informed of the immediate jeopardy, all residents having the potential to be affected, measures that had and were being taken to ensure that all in-house residents were safe and having no complications that were not being addressed, i.e., vital signs and reassessment of vital signs as indicated, audit of all medication records for October, November, and December 2015, and Physician/resident/family member notification. The Administrator informed the MD of the CMA being a Certified Medical Assistant, not a KMA. The Administrator further informed the MD that all current licensed staff and KMAs had been validated to be active and in good standing. The Medical Director's input was to continue to assess for any resident having medical concerns since the facility could not say with certainty that the medication had been omitted or just not documented. The MD further stated to continue checking for appropriate credentials of licensed staff, KMAs, and unlicensed staff as required. 10) During this process the DON learned that there was a difference between Kentucky Medication Aide (KMA) and Certified Medical Assistant (CMA), and the required education and testing that are to be completed to be a Certified Medical Assistant verses a Kentucky Medication Aide were different. The Administrator learned that while there was a QA system in place for verifying credentials/status of licensed nurses and nursing assistants, the facility lacked a QA system to ensure that newly hired KMAs had the required credentials. To decrease this confusion the facility will utilize terminology from the actual Kentucky Medication Administration certification and call them KMAs. 11) On 01/06/16, the Human Resources/Payroll clerk and the Director of Nurses were educated by the facility's Administrator. The education included the difference in CMA vs. CMA and that it was used in two different ways, Certified Medical Assistant and a Certified Medication Aide. Other terminology for medication aides through the years has included Certified Medication Technician (CMT) and Kentucky Medication Aide (KMA). The education also included that the appropriate credentials must be verified before anyone can be granted access to orientation and this facility will now utilize KMA in job titles instead of CMA. 12) On 01/06/16, the Administrator reviewed the policy and procedure on medication administration. The medication administration policy included: the right resident, the right medication, the right dose, the right route, the right method, and the right time. The policy further clarified that the licensed Nurse or KMA administering the medication was responsible for documentation of the medication. On 01/06/16, the DON reviewed the medication administration policy. Once this education was completed by the Administrator, the DON completed a competency quiz on medication administration. 13) On 01/06/16, 01/07/16, and 01/08/16 licensed Nurses and KMAs were provided education related to the five (5) rights of medication administration and what KMAs were allowed to do based on the KMA certification. Following the education/discussion of medication administration, a competency medication administration quiz was given by the Administrator and/or the DON. The purpose of the education and the quiz was to ensure that the licensed Nurses knew the five (5) rights of medication administration and had adequate knowledge in delegation of medication administration to the KMAs. The education/discussion and quiz also validated that the KMAs had knowledge of the five rights of medication administration and what they were permitted to do based on their preparedness through previous education/classes and passing of the required State exam to practice as a KMA. 14) Any licensed Nurse or KMA who was off duty, on vacation, and/or off for illness or other legitimate reason will be re-educated prior to going to nursing units and being allowed to work. Three (3) persons were not scheduled to work on those dates. One returned on 01/09/16 and was provided with education/discussion and was administered the medication quiz prior to working. A second person remains on vacation and will return on 01/18/16 and will be provided with the required education/discussion and will be administered the medication quiz by the Administrator or DON prior to working. The third person is on suspension with an undetermined date of return. If allowed to return to work, this staff member will be administered the education/discussion and medication quiz prior to working. All new hires will be provided with the medication administration education and will be required to complete a medication pass audit prior to being permitted to administer resident medications without supervision. 15) Based upon the education/discussion provided and the passing of the medication administration quiz, the Administrator made the decision that the current licensed Nurses and KMAs were competent to continue to administer medications safely to facility residents. On 01/14-15/16, the DON, ADON, and SDC were validated competent to administer resident medications via Corporate Nurse education and medication pass audit (minimum 10 meds each) by the facility's Corporate Nurse. The Corporate Nurse, DON, ADON, and/or SDC will continue to educate licensed nurses and/or KMAs related to medication administration. 16) Each licensed Nurse and KMA will demonstrate competency through observation of a medication pass audit (minimum 10 meds each) by the Corporate Nurse, DON, ADON, or SDC. All licensed Nurses and KMAs that were off will not be allowed to work until educated on medication administration and observed completing a medication pass audit (minimum 10 meds each) by the corporate nurse, DON, ADON, or SDC. 17) The Administrator, DON, ADON, or SDC will conduct monthly QA medication pass audits on each licensed Nurse and KMA for the next three months. Any problems identified during the medication pass audit will be forwarded to the DON/ADON promptly for resolution. The DON, ADON, and SDC will report any identified concerns/problems to the QA Committee five days per week, a cumulative total to the QA Committee monthly, and a cumulative total to the executive QA Committee quarterly. 18) The Staff Development Coordinator (SDC) and Human Resources (HR) were educated by the Administrator on 01/09/16 that newly hired license staff and KMAs must be validated through the appropriate registries prior to allowing them to attend orientation. Telephone numbers and web sites were discussed as a means to validate those credentials. The SDC and HR was further educated that KMAs would have to be verified by calling the school in which they attended if appropriate documentation (letter validating passing score and/or actual KMA card signed by representative of school) was not presented upon hire and request a hard copy of validation. SDC will place a hard copy of the monthly licensed nurse validation in a binder as they are completed and will report findings to the QA Committee the following business day. The SDC and HR will conduct a monthly audit of the binder. Any problems identified during the audit will be reported immediately to the Administrator. The results of the QA audit by the SDC and HR will be forwarded to the QA Committee monthly. The SDC will forward the cumulative reports to the Executive Committee quarterly. This process will be utilized to ensure that all licensed staff has remained active and in good standing with the respective Boards of Nursing. 19) On 01/08/16 and 01/09/16, the licensed staff and the KMAs were educated by the Administrator, Director of Nurses (DON), Assistant Director of Nurses (ADON), and/or the Quality Assurance (QA) Nurse. The education of licensed staff included attendance of an accredited school, requirement of a work permit or licensed issued by the Board of Nursing, not being allowed to practice as a licensed nurse if license was revoked, suspended, or lapsed, continuing education requirements and completion day, and notification of the Board of Nursing and facility with any changes, questions, or concerns. 20) The KMAs were educated on the difference between a CMA (certified medical assistant) and a CMA (certified medication aide), attendance of an approved medication aide class, passing of exam and receiving certification as a medication aide, and number of local school related to any questions regarding KMA certifications. Both KMAs and licensed staff were educated on the facility's responsibility to ensure that they have obtained and maintain appropriate licensure and certification. Further education of both disciplines included documentation of medication when administered and failure to document implies was not done. 21) On 01/09/16 the facility immediately altered the QA system to address new hires from the point of application to hire, to ensure all needed credentials has been validated. The credentials of all new hires will be validated by HR, respective department head, and/or the SDC. A hard copy of the KMA certifications and licensed staff will be placed in the personnel file by HR. Prior to entry into orientation another audit will be completed by the HR, SDC, DON, ADON, QA, or Administrator to ensure credentials have been assessed. Once this step is completed and signed off by the Administrator or DON the employee will be allowed to enter the orientation process. The SDC will keep a monthly QA log of any problems identified during the hiring process and will report to the QA Committee up to five (5) days per week as issues are identified during the hiring process. The QA Committee will provide further instructions for the SDC based upon the problems identified throughout the hiring process. The SDC will forward a cumulative QA log and report any problems identified to the Executive QA Committee on a quarterly basis. The SDC was educated by the Administrator on the new QA tool on 01/09/16. Human Resources was on vacation but will be educated by the Administrator upon return to work on 01/18/16 and before taking applications. 22) A QA Buddy system tool for Medication Administration Records was developed. On 01/08/16, 01/09/16, and 01/10/16, the facility Administrator, SDC, DON, ADON, or QA Nurse educated the staff Nurses and KMAs on the buddy assessment tool. There were five (5) persons not included in the education. Three (3) have returned to work and were educated on the process. One remains on vacation and will return to work on 01/18/16. The second one remains on suspension. Both will be educated by the Administrator, DON, ADON, or QA nurse when they return to work. The buddy tool monitors omission of documentation blanks on the MAR. The facility will illicit the assistance of staff Nurses and KMAs in auditing each other each shift for the next 60 days. The original audit is to be turned in each shift to the DON and a copy to the Administrator. 23) The DON/ADON is responsible for comparing the completed buddy audit five (5) days per week to the individual resident MARs for the next 30 days to ensure that all medications not documented were noted on the buddy system audit form. The DON and the ADON will be accountable for ensuring prompt resolution and notification of the Physician, resident, and the resident's Responsible Party or an interested family member, dependent upon audit results. The DON/ADON will be responsible for reporting audit findings to the QA committee five (5) days per week. Dependent upon the results of the QA audits, the frequency will be adjusted by the QA Committee. The DON will report findings to the Executive QA Committee quarterly for further guidance. **The State Survey Agency validated on 01/16/15 the Immediate Jeopardy was removed as follows: 1) Review of a statement by the Administrator, undated, revealed Employee #1 was no longer employed by the facility. Employee #1 did not return to work, she resigned on 12/29/15 with no notice. Review of Employee #1's personnel file revealed an Absence/Vacation Report dated 01/01/16 stating Employee #1 had resigned from the facility on that date. Review of Employee #1's timesheet revealed the last date of work for Employee #1 was 12/29/15. Interview with Employee #1 on 01/19/16 at 3:32 PM, the DON on 1/21/16 at 4:20 PM, and the Administrator on 01/21/16 at 4:25 PM, revealed Employee #1 had resigned on 01/01/16. The interviews also revealed Employee #1 had not worked at the facility since 12/29/15. 2) Review of an audit completed by the facility on 01/06/16 through 01/07/16 of all Kentucky Medication Aides (KMAs) and licensed Nurses employed by the facility revealed all KMAs and Nurses currently working in the facility had appropriate credentials, valid licenses, and had been deemed by the facility to be a qualified staff member. Review of a Quality Assurance form in use by the facility revealed the SDC was responsible for ensuring all staff licenses had been validated prior to employment. Interview conducted with the SDC on 01/21/16 at 2:35 PM revealed she was responsible for monitoring to ensure all licenses for all licensed personnel had been validated prior to employment. According to the SDC, Human Resources (HR), the Department Manager, and the Administrator and DON (a total of four persons) are required to check the validity of each employee's license/certification. Interviews conducted with the SDC on 01/21/16 at 2:35 PM, HR on 01/21/16 at 3:06 PM, and the Administrator on 01/21/16 at 4:25 PM, revealed they had completed an audit of all currently working KMAs and Nurses on 01/06/16 through 01/07/16 and had found all had valid licenses, appropriate training and were qualified to work at the facility. 3) Review was conducted of the vital signs and oxygen saturations form completed on all residents in the facility on 01/08/16. Vital signs were then repeated on residents with an abnormal vital sign, and it was documented on the form. Interviews conducted with KMA #1 on 01/21/16 at 1:50 PM, KMA #6 on 01/21/16 at 2:15 PM, KMA #3 on 01/21/16 at 2:20 PM, SRNA #1 on 01/21/16 at 3:20 PM, SRNA #2 on 01/21/16 at 3:25 PM, and LPN #3 on 01/21/16 at 3:27 PM, revealed they assisted in obtaining vital signs and oxygen saturations on residents on 01/08/16. LPN #3 stated she reviewed residents' vital signs and if any were abnormal they would be repeated. The staff also revealed all residents' vital signs were being obtained every shift and reviewed by the Nurse. 4) Review of Resident #2's MARs dated October 2015, November 2015, and December 2015 revealed an attached document by the DON which stated she had reviewed and notified Resident #2's Physician and next of kin of the missed doses of medication. Interviews conducted with the DON on 01/21/16 at 4:20 PM, Resident #2's Physician on 01/21/16 at 1:22 PM, and Resident #2's family member on 01/21/16 at 4:30 PM, revealed the DON had reviewed Resident #2's MARs for October 2015, November 2015, and December 2015, vital signs, and skin assessment. The DON notified the physician and responsible party of Resident #2's missed medications and abnormal vital signs. According to the interviews, no new orders were received from the Physician. Review of a skin assessment completed on 01/08/16 on Resident #2 revealed no open areas had been observed by LPN #3. Interview with LPN #3 on 01/21/16 at 3:41 PM revealed she had completed the skin assessment on Resident #2 and reviewed the resident's vital signs. Interviews with SRNA #2 on 01/21/16 at 3:25 PM, and LPN #3 on 01/21/16 at 3:27 PM, revealed Resident #2's vital signs were obtained on 01/09/16 and were reviewed by LPN #3. 5) Review of the vital sign flow sheets revealed that all in-house resident vital signs were promptly taken on 01/08/16 by SRNAs, KMAs, and licensed Nurses. Interviews conducted with KMA #1 on 01/21/16 at 1:50 PM, KMA #6 on 01/21/16 at 2:15 PM, KMA #3 on 01/21/16 at 2:20 PM, SRNA #1 on 01/21/16 at 3:20 PM, SRNA #2 on 01/21/16 at 3:25 PM, LPN #3 on 01/21/16 at 3:27 PM, and LPN #6 on 01/21/16 at 3:37 PM revealed all in-house residents' vital signs were taken on 01/08/16 by SRNAs, KMAs and licensed Nurses. Interview with the Administrator on 01/21/16 at 4:25 PM revealed that she reviewed all the resident vital signs. Record review and interview with KMA #1 on 01/21/16 at 1:50 PM, KMA #6 on 01/21/16 at 2:15 PM, KMA #3 on 01/21/16 at 2:20 PM, SRNA #1 on 01/21/16 at 3:20 PM, SRNA #2 on 01/21/16 at 3:25 PM, and LPN #3 on 01/21/16 at 3:37 PM, revealed licensed Nurses reviewed and reassessed twelve (12) residents' B/Ps, nine (9) residents' temperatures, and 12 residents' pulses. Repeat vital signs obtained by the SRNAs and reviewed by licensed Nurses on 01/08/16 revealed that four (4) B/Ps and four (4) Ts continued to be outside normal baseline for those particular residents. Record review and interview with the Administrator on 01/21/16 at 4:25 PM, KMA #1 on 01/21/16 at 1:50 PM, KMA #6 on 01/21/16 at 2:15 PM, KMA #3 on 01/21/16 at 2:20 PM, SRNA #1 on 01/21/16 at 3:20 PM, SRNA #2 on 01/21/16 at 3:25 PM, LPN #3 on 01/21/16 at 3:27 PM, and LPN #6 on 01/21/16 at 3:37 PM revealed that on 01/08/16 licensed Nurses, KMAs and SRNAs were given instructions by the Administrator to continue to reassess vital signs as indicated by results of individual residents. Review of the weights and vitals summary and interviews with the Administrator on 01/21/16 at 4:25 PM, KMA #1 on 01/21/16 at 1:50 PM, KMA #6 on 01/21/16 at 2:15 PM, KMA #3 on 01/21/16 at 2:20 PM, SRNA #1 on 01/21/16 at 3:20 PM, SRNA #2 on 01/21/16 at 3:25 PM, LPN #3 on 01/21/16 at 3:27 PM, and LPN #6 on 01/21/16 at 3:2

Based on interview, record review, and facility policy review, it was determined the facility failed to have an effective quality assessment and assurance program to identify quality deficiencies, and to develop and implement appropriate plans of action to correct identified quality deficiencies. The facility failed to have a Quality Assurance system in place to monitor and ensure that professional staff was licensed or certified in accordance with applicable state laws. The facility failed to ensure that Employee #1 was certified as a Kentucky Medication Technician, and allowed her to pass medication to residents from 05/13/15 to 07/22/15 and rehired her on 10/13/15 to 12/29/15 to pass medications, without validating her credentials. The facility also failed to ensure that Licensed Practical Nurse (LPN) #1 had a valid nursing license. LPN #1 allowed her nursing license to lapse on 11/01/15 and continued to work until 12/24/15. Refer to F499. In addition, the facility failed to have an effective Quality Assurance system to monitor Medication Administration Records (MARs) to ensure residents' medications were administered as ordered by the physicians. On 11/02/15, Employee #1 failed to administer medications to Resident #2, which included [MEDICAL CONDITION] medication, two (2) blood pressure medications, and pain medication. Review of MARs of residents that Employee #1 had been assigned to administer medications during her employment at the facility from 05/13/15 to 07/22/15 and 10/13/15 to 12/29/15, revealed two hundred thirty-four (234) examples of scheduled medications with no documented evidence the medications were administered to residents as physician ordered. The facility failed to ensure it had an effective system to monitor medication administration in order to identify medication errors. The facility was not aware of the errors until it was brought to the facility's attention by the State Survey Agency on 01/07/16. Refer to F333. The facility's failure to ensure an effective Quality Assurance Program was in place, which identified quality concerns and implemented action plans to correct the concerns has caused or is likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was determined to exist on 05/13/15. An acceptable Allegation of Compliance was received on 01/16/16, which alleged removal of the Immediate Jeopardy on 01/16/16. The State Survey Agency determined the Immediate Jeopardy was removed on 01/16/16 as alleged, which lowered the scope and severity to E while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the Quality Improvement policy (dated January 2011) revealed the Quality Improvement Committee was responsible to determine if changes in plans of action were required to improve outcomes, if action plans needed to be formed or modified, and if increased monitoring of resident care was required. Review of the facility's Medication Administration policy, undated, revealed only licensed Nurses (Registered Nurses or Licensed Practical Nurses), Medication Aides, Respiratory Therapists, Physicians, or Physician Extenders (Nurse Practitioners or Physician Assistants) would be allowed to administer medications to residents. All medication errors would be described in detail on a Medication Error Report which would then be reviewed and filed with the Director of Nursing (DON). The attending Physician shall be notified immediately of all medication errors. Any deviation from the following principles shall be considered a medication error: 1) To the right resident; 2) administration of the right medication; 3) In the right dose; 4) by the right route; 5) by the right method; 6) and at the right time. Any recognized deviations such as blanks on the Medication Administration Records (MARS), would be reported to the Physician, Responsible Party, and the Supervisor immediately. The Supervisor would then initiate a Medication Error Report which would then be submitted to the DON. Both the physician and the responsible party would be notified immediately. The Medication Error Reports would be reviewed quarterly by the Quality Improvement Committee. The Quality Improvement Committee should evaluate these reports and determine whether or not proper steps have been taken to prevent the recurrence of such errors. The types of errors would be summarized. Interview with the Director of Nursing (DON) on 01/06/16 at 3:06 PM and 4:40 PM revealed the facility did not have a policy in place to ensure all professional staff was currently licensed or certified in accordance with applicable state laws. 1. Review of Employee #1's personnel file revealed the facility employed the employee from 05/13/15 to 07/22/15 and rehired her 10/13/15 to 12/29/15. Further review of the personnel file revealed Employee #1 obtained a Clinical Medical Assistant certification on 08/11/15; however, there was no evidence Employee #1 attended a State approved training program for medication administration. Employee #1's personnel file revealed that she had been administering medication to residents as a Kentucky Medication Aide (KMA) beginning 05/13/15 to 07/22/15. Upon Employee #1's initial hire, the facility failed to ensure she was actually qualified and had credentials to pass medications. The facility rehired Employee #1 on 10/13/15 and again failed to ensure the employee was qualified to administer medications. Employee #1 was allowed to work, until her employment was terminated on 12/29/15. Review of LPN #1's personnel file revealed the LPN was hired on 04/14/15 to provide nursing care to residents. Review of LPN #1's nursing license revealed the license had lapsed on 11/01/15, and the LPN continued to work until 12/24/15. Interview with the Quality Assurance Nurse (QA Nurse) on 01/07/16 at 2:32 PM revealed that she was not aware that Employee #1 was not certified to pass medications until approximately one week ago, and she was not sure exactly when she became aware. The QA Nurse stated the facility did not have a system in place to monitor to ensure staff was certified in accordance with applicable state laws. Interview with the Director of Nursing (DON) on 01/06/16 at 3:06 PM and 4:40 PM revealed the facility did not have a QA monitor in place to ensure all professional staff was licensed or certified in accordance with applicable state laws. The DON stated she became aware Employee #1 was not qualified to administer medications at approximately the end of November 2015 or early December 2015. However, she allowed the employee to continue to administer medications to residents even though Employee #1 was unlicensed/uncertified to administer medications. According to the DON, on 01/02/16 the employee was terminated for not showing up to work. Interview with the Administrator on 01/08/16 at 2:26 PM revealed the facility did not have a system in place to monitor to ensure professional staff was certified in accordance with applicable state laws, and she had not been aware of it. The Administrator stated Employee #1 should not have been allowed to administer medications to residents and LPN #1 should not have been allowed to work after her license had lapsed and this should have been identified by the facility. 2. According to the facility's medication error policy, blank spaces, no documented evidence of medications being administered were considered medication errors. Review of residents' MARs revealed Employee #1 made medication errors during the period she was first hired and continued to make errors after she was rehired. Review of Resident #2's MARs revealed on 11/02/15 Resident #2 was to receive [MEDICATION NAME] ([MEDICAL CONDITION] medication) at 4:00 PM and 8:00 PM, [MEDICATION NAME] (blood pressure medication) at 8:00 PM, and [MEDICATION NAME] (blood pressure medication) at 8:00 PM, and [MEDICATION NAME] (pain medication) at 4:00 PM and 8:00 PM. Resident #2's MAR revealed no documented evidence the resident received his/her 4:00 PM and 8:00 PM scheduled medications on 11/02/15. Employee #1, who was hired by the facility to administer resident medication, was responsible for administering Resident #2's medication on the afternoon and evening (2:00 - 10:00 PM) on 11/02/15. The facility failed to identify the omission of Resident #2's medications on 11/02/15. Review of the MARs for Resident #7, revealed on 06/30/15, there was no evidence [MEDICATION NAME] ([MEDICATION NAME][MEDICATION NAME]) had been administered to Resident #7. Review of Resident #16's MARs revealed staff failed to document that the resident's 8:00 PM doses of [MEDICATION NAME] and [MEDICATION NAME] had been administered to the resident as ordered by the physician, on 10/29/15 and 10/30/15. Review of Resident #21's MARs revealed the following 5:00 PM doses of [MEDICATION NAME] were not documented as administered to the resident: 12/16/15, 12/17/15, 12/20/15, 12/22/15, 12/23/15, 12/26/15, 12/27/15, and 12/28/15 (a total of eight doses). In addition, during Employee #1's employment from 05/13/15 to 12/29/15, review of a list of residents Employee #1 had been assigned to administer medications for revealed two hundred twenty-three (223) medication errors were observed. Continued interview with the QA Nurse on 01/07/16 at 2:32 PM revealed the facility did not have a system in place to monitor residents' MARs to ensure medications had been administered and documented as given to the residents as they were ordered by the physicians. Continued interview with the DON on 01/06/16 at 3:06 PM and 4:40 PM and 02/22/16, at 2:15 PM, revealed the facility did not have a QA monitor in place to review residents' MARs to ensure medications had been administered and documented as given to the residents as they were ordered by the physicians. The DON stated they had not been aware of any medications not administered to Resident #2, Resident #7, Resident #16, and Resident #21 until it was brought to the facility's attention by the State Survey Agency on 01/07/16. Continued interview with the Administrator on 01/08/16 at 2:26 PM, 02/24/16, at 10:45 AM, revealed she had not been aware the facility did not have a system in place to monitor residents' MARs to ensure medications had been administered and documented as given to the residents as they were ordered by the physicians. Any staff person or member of the QA committee was responsible for bringing any concerns to the QA committee. **The facility provided an acceptable Allegation of Compliance (AOC) on 01/16/16. The facility implemented the following actions to remove the Immediate Jeopardy: 1) Employee #1 no longer works at the facility. The facility did not report Employee #1's action to the governing agency. Employee #1 resigned her position with no notice on 12/29/15. The facility did not report Employee #1 to her licensing/credentialing agency, as they stated they did not know to whom to report the incident. 2) On 01/06/16 through 01/07/16, 100 percent of current licensed staff and KMA records were audited by the Administrator, Staff Development Coordinator, and Human Resources. One hundred percent of licensed staff and KMAs were found to have appropriate credentials to continue being a qualified staff member of this facility. 3) Licensed Nurses, KMAs, and State Registered Nurse Aides (SRNAs) assessed all in-house residents' vital signs to include blood pressure, temperature, pulse, respirations, and oxygen saturations (02 sats) on 01/08/16. Necessary vital signs were reassessed as indicated by initial findings. 4) Resident #2's October, November, and December 2015 Medication Administration Records were reviewed by the Director of Nurses (DON) on 01/08/16 for any medications that had not been documented as given. On the same date at approximately 3:30 PM, a licensed Nurse conducted a head to toe assessment of Resident #2 and the SRNA obtained vital signs. On 01/08/16, the DON reviewed the head to toe assessment and vital signs. Resident #2's blood pressure (B/P) was 180/80, temperature (T) was 96.4 axillary, pulse (P) was 80, respirations (R) were 18, and 02 sat was 96%. Resident #2's Physician was notified by the DON, after review, of medications not being documented, head to toe assessment findings, and current vital signs. No new orders were given by the Physician. After Physician notification, Resident #2's family member was informed by the DON of investigative findings. Resident #2's blood pressure was reassessed by a licensed Nurse at 4:25 PM and was 142/68. Vital signs were obtained on the next shift by a SRNA and reviewed by a licensed Nurse on the next shift. 5) All in-house residents' vital signs were promptly taken on 01/08/16 by SRNAs, KMAs, and licensed Nurses. After vital signs were obtained, the Administrator, who is a Registered Nurse, reviewed all the residents' vital signs. The licensed Nurses reviewed and reassessed twelve (12) B/Ps, nine (9) Ts, and twelve (12) Ps. Repeat vital signs obtained by the SRNAs and reviewed by licensed Nurses on 01/08/16 revealed that four (4) B/Ps and (4) Ts continued to be outside normal baseline for those particular residents. On 01/08/16 licensed Nurses, KMAs, and SRNAs, were given instructions by the Administrator to continue to reassess vital signs as indicated by results of individual residents. On 01/08/16, the Administrator informed licensed Nurses that all in-house residents must have their vital signs, B/P, T, P, and R, assessed each shift, and reassessed as indicated upon findings, until the immediate jeopardy was removed, based on acceptance of the facility's Allegation of Compliance. Once this occurs, the Administrator informed the staff that the Administrator would place an OFFICIAL SIGN at each nurses' station, with the date and Administrator's signature, indicating the updated process requirements. 6) All in-house residents' Medication Administration Records were reviewed on 01/08/16 for October, November, and December 2015. All facility staff has signed a Health Insurance Portability and Accountability Act (HIPAA) agreement. Based on that signed HIPAA agreement the Data Entry Clerk, Medical Records Personnel, KMA, Accounts Receivable, and Admissions Coordinator reviewed MARs and highlighted medications with omission of initials and began a log for each specific resident and medication. After that process the DON, Assistant Director of Nurses (ADON), Staff Development Coordinator (SDC), and a Licensed Practical Nurse (LPN) reviewed those same MARs for October, November, and December 2015 a second time to ensure that all omissions were identified on each resident's MAR and documented on the log. Based on the second review of each resident's MARs, interventions such as review/reassessment of vital signs, blood sugars, review of medical record for absence/presence of [MEDICAL CONDITION], etc., were taken by the DON, ADON, SDC, and Social Services Director/LPN to further assess each individual resident's condition. During this process there were 89 residents identified as having one or more medications not initialed as given. Throughout the process there were 0 residents identified as being in immediate danger. The process revealed that all licensed Nurses and KMAs required reminders/education on medication administration. 7) On 01/08/16 and 01/09/16 all in-house resident Physicians were notified by the DON, ADON, SDC, Quality Assurance(QA) Nurse, LPN, and/or the SSD/LPN of resident assessment findings and the potential omission of medication or documentation of the medication. 8) The facility was unable to reach five (5) resident family members, despite numerous calls and voice messages. On 01/11/16, a certified letter was forwarded to those five (5) family members with a request to call the facility to discuss medications. There were no individual resident medication error reports completed during this process. On 01/11/16, the Administrator wrote an overall statement of the omission of medications/initials and forwarded the document to the QA Committee and the Medical Director. 9) On 01/08/16 at 9:45 PM, the Administrator notified the facility's Medical Director (MD) via telephone. The MD was informed of the immediate jeopardy, all residents having the potential to be affected, measures that had and were being taken to ensure that all in-house residents were safe and having no complications that were not being addressed, i.e., vital signs and reassessment of vital signs as indicated, audit of all medication records for October, November, and December 2015, and Physician/resident/family member notification. The Administrator informed the MD of the CMA being a Certified Medical Assistant, not a KMA. The Administrator further informed the MD that all current licensed staff and KMAs had been validated to be active and in good standing. The Medical Director's input was to continue to assess for any resident having medical concerns since the facility could not say with certainty that the medication had been omitted or just not documented. The MD further stated to continue checking for appropriate credentials of licensed staff, KMAs, and unlicensed staff as required. 10) During this process the DON learned that there was a difference between Kentucky Medication Aide (KMA) and Certified Medical Assistant (CMA), and the required education and testing that are to be completed to be a Certified Medical Assistant verses a Kentucky Medication Aide were different. The Administrator learned that while there was a QA system in place for verifying credentials/status of licensed nurses and nursing assistants, the facility lacked a QA system to ensure that newly hired KMAs had the required credentials. To decrease this confusion the facility will utilize terminology from the actual Kentucky Medication Administration certification and call them KMAs. 11) On 01/06/16, the Human Resources/Payroll clerk and the Director of Nurses were educated by the facility's Administrator. The education included the difference in CMA vs. CMA and that it was used in two different ways, Certified Medical Assistant and a Certified Medication Aide. Other terminology for medication aides through the years has included Certified Medication Technician (CMT) and Kentucky Medication Aide (KMA). The education also included that the appropriate credentials must be verified before anyone can be granted access to orientation and this facility will now utilize KMA in job titles instead of CMA. 12) On 01/06/16, the Administrator reviewed the policy and procedure on medication administration. The medication administration policy included: the right resident, the right medication, the right dose, the right route, the right method, and the right time. The policy further clarified that the licensed Nurse or KMA administering the medication was responsible for documentation of the medication. On 01/06/16, the DON reviewed the medication administration policy. Once this education was completed by the Administrator, the DON completed a competency quiz on medication administration. 13) On 01/06/16, 01/07/16, and 01/08/16 licensed Nurses and KMAs were provided education related to the five (5) rights of medication administration and what KMAs were allowed to do based on the KMA certification. Following the education/discussion of medication administration, a competency medication administration quiz was given by the Administrator and/or the DON. The purpose of the education and the quiz was to ensure that the licensed Nurses knew the five (5) rights of medication administration and had adequate knowledge in delegation of medication administration to the KMAs. The education/discussion and quiz also validated that the KMAs had knowledge of the five rights of medication administration and what they were permitted to do based on their preparedness through previous education/classes and passing of the required State exam to practice as a KMA. 14) Any licensed Nurse or KMA who was off duty, on vacation, and/or off for illness or other legitimate reason will be re-educated prior to going to nursing units and being allowed to work. Three (3) persons were not scheduled to work on those dates. One returned on 01/09/16 and was provided with education/discussion and was administered the medication quiz prior to working. A second person remains on vacation and will return on 01/18/16 and will be provided with the required education/discussion and will be administered the medication quiz by the Administrator or DON prior to working. The third person is on suspension with an undetermined date of return. If allowed to return to work, this staff member will be administered the education/discussion and medication quiz prior to working. All new hires will be provided with the medication administration education and will be required to complete a medication pass audit prior to being permitted to administer resident medications without supervision. 15) Based upon the education/discussion provided and the passing of the medication administration quiz, the Administrator made the decision that the current licensed Nurses and KMAs were competent to continue to administer medications safely to facility residents. On 01/14-15/16, the DON, ADON, and SDC were validated competent to administer resident medications via Corporate Nurse education and medication pass audit (minimum 10 meds each) by the facility's Corporate Nurse. The Corporate Nurse, DON, ADON, and/or SDC will continue to educate licensed nurses and/or KMAs related to medication administration. 16) Each licensed Nurse and KMA will demonstrate competency through observation of a medication pass audit (minimum 10 meds each) by the Corporate Nurse, DON, ADON, or SDC. All licensed Nurses and KMAs that were off will not be allowed to work until educated on medication administration and observed completing a medication pass audit (minimum 10 meds each) by the corporate nurse, DON, ADON, or SDC. 17) The Administrator, DON, ADON, or SDC will conduct monthly QA medication pass audits on each licensed Nurse and KMA for the next three months. Any problems identified during the medication pass audit will be forwarded to the DON/ADON promptly for resolution. The DON, ADON, and SDC will report any identified concerns/problems to the QA Committee five days per week, a cumulative total to the QA Committee monthly, and a cumulative total to the executive QA Committee quarterly. 18) The Staff Development Coordinator (SDC) and Human Resources (HR) were educated by the Administrator on 01/09/16 that newly hired license staff and KMAs must be validated through the appropriate registries prior to allowing them to attend orientation. Telephone numbers and web sites were discussed as a means to validate those credentials. The SDC and HR was further educated that KMAs would have to be verified by calling the school in which they attended if appropriate documentation (letter validating passing score and/or actual KMA card signed by representative of school) was not presented upon hire and request a hard copy of validation. SDC will place a hard copy of the monthly licensed nurse validation in a binder as they are completed and will report findings to the QA Committee the following business day. The SDC and HR will conduct a monthly audit of the binder. Any problems identified during the audit will be reported immediately to the Administrator. The results of the QA audit by the SDC and HR will be forwarded to the QA Committee monthly. The SDC will forward the cumulative reports to the Executive Committee quarterly. This process will be utilized to ensure that all licensed staff has remained active and in good standing with the respective Boards of Nursing. 19) On 01/08/16 and 01/09/16, the licensed staff and the KMAs were educated by the Administrator, Director of Nurses (DON), Assistant Director of Nurses (ADON), and/or the Quality Assurance (QA) Nurse. The education of licensed staff included attendance of an accredited school, requirement of a work permit or licensed issued by the Board of Nursing, not being allowed to practice as a licensed nurse if license was revoked, suspended, or lapsed, continuing education requirements and completion day, and notification of the Board of Nursing and facility with any changes, questions, or concerns. 20) The KMAs were educated on the difference between a CMA (certified medical assistant) and a CMA (certified medication aide), attendance of an approved medication aide class, passing of exam and receiving certification as a medication aide, and number of local school related to any questions regarding KMA certifications. Both KMAs and licensed staff were educated on the facility's responsibility to ensure that they have obtained and maintain appropriate licensure and certification. Further education of both disciplines included documentation of medication when administered and failure to document implies was not done. 21) On 01/09/16 the facility immediately altered the QA system to address new hires from the point of application to hire, to ensure all needed credentials has been validated. The credentials of all new hires will be validated by HR, respective department head, and/or the SDC. A hard copy of the KMA certifications and licensed staff will be placed in the personnel file by HR. Prior to entry into orientation another audit will be completed by the HR, SDC, DON, ADON, QA, or Administrator to ensure credentials have been assessed. Once this step is completed and signed off by the Administrator or DON the employee will be allowed to enter the orientation process. The SDC will keep a monthly QA log of any problems identified during the hiring process and will report to the QA Committee up to five (5) days per week as issues are identified during the hiring process. The QA Committee will provide further instructions for the SDC based upon the problems identified throughout the hiring process. The SDC will forward a cumulative QA log and report any problems identified to the Executive QA Committee on a quarterly basis. The SDC was educated by the Administrator on the new QA tool on 01/09/16. Human Resources was on vacation but will be educated by the Administrator upon return to work on 01/18/16 and before taking applications. 22) A QA Buddy system tool for Medication Administration Records was developed. On 01/08/16, 01/09/16, and 01/10/16, the facility Administrator, SDC, DON, ADON, or QA Nurse educated the staff Nurses and KMAs on the buddy assessment tool. There were five (5) persons not included in the education. Three (3) have returned to work and were educated on the process. One remains on vacation and will return to work on 01/18/16. The second one remains on suspension. Both will be educated by the Administrator, DON, ADON, or QA nurse when they return to work. The buddy tool monitors omission of documentation blanks on the MAR. The facility will illicit the assistance of staff Nurses and KMAs in auditing each other each shift for the next 60 days. The original audit is to be turned in each shift to the DON and a copy to the Administrator. 23) The DON/ADON is responsible for comparing the completed buddy audit five (5) days per week to the individual resident MARs for the next 30 days to ensure that all medications not documented were noted on the buddy system audit form. The DON and the ADON will be accountable for ensuring prompt resolution and notification of the Physician, resident, and the resident's Responsible Party or an interested family member, dependent upon audit results. The DON/ADON will be responsible for reporting audit findings to the QA committee five (5) days per week. Dependent upon the results of the QA audits, the frequency will be adjusted by the QA Committee. The DON will report findings to the Executive QA Committee quarterly for further guidance. **The State Survey Agency validated on 01/16/15 the Immediate Jeopardy was removed as follows: 1) Review of a statement by the Administrator, undated, revealed Employee #1 was no longer employed by the facility. Employee #1 did not return to work, she resigned on 12/29/15 with no notice. Review of Employee #1's personnel file revealed an Absence/Vacation Report dated 01/01/16 stating Employee #1 had resigned from the facility on that date. Review of Employee #1's timesheet revealed the last date of work for Employee #1 was 12/29/15. Interview with Employee #1 on 01/19/16 at 3:32 PM, the DON on 1/21/16 at 4:20 PM, and the Administrator on 01/21/16 at 4:25 PM, revealed Employee #1 had resigned on 01/01/16. The interviews also revealed Employee #1 had not worked at the facility since 12/29/15. 2) Review of an audit completed by the facility on 01/06/16 through 01/07/16 of all Kentucky Medication Aides (KMAs) and licensed Nurses employed by the facility revealed all KMAs and Nurses currently working in the facility had appropriate credentials, valid licenses, and had been deemed by the facility to be a qualified staff member. Review of a Quality Assurance form in use by the facility revealed the SDC was responsible for ensuring all staff licenses had been validated prior to employment. Interview conducted with the SDC on 01/21/16 at 2:35 PM revealed she was responsible for monitoring to ensure all licenses for all licensed personnel had been validated prior to employment. According to the SDC, Human Resources (HR), the Department Manager, and the Administrator and DON (a total of four persons) are required to check the validity of each employee's license/certification. Interviews conducted with the SDC on 01/21/16 at 2:35 PM, HR on 01/21/16 at 3:06 PM, and the Administrator on 01/21/16 at 4:25 PM, revealed they had completed an audit of all currently working KMAs and Nurses on 01/06/16 through 01/07/16 and had found all had valid licenses, appropriate training and were qualified to work at the facility. 3) Review was conducted of the vital signs and oxygen saturations form completed on all residents in the facility on 01/08/16. Vital signs were then repeated on residents with an abnormal vital sign, and it was documented on the form. Interviews conducted with KMA #1 on 01/21/16 at 1:50 PM, KMA #6 on 01/21/16 at 2:15 PM, KMA #3 on 01/21/16 at 2:20 PM, SRNA #1 on 01/21/16 at 3:20 PM, SRNA #2 on 01/21/16 at 3:25 PM, and LPN #3 on 01/21/16 at 3:27 PM, revealed they assisted in obtaining vital signs and oxygen saturations on residents on 01/08/16. LPN #3 stated she reviewed residents' vital signs and if any were abnormal they would be repeated. The staff also revealed all residents' vital signs were being obtained every shift and reviewed by the Nurse. 4) Review of Resident #2's MARs dated October 2015, November 2015, and December 2015 revealed an attached document by the DON which stated she had reviewed and notified Resident #2's Physician and next of kin of the missed doses of medication. Interviews conducted with the DON on 01/21/16 at 4:20 PM, Resident #2's Physician on 01/21/16 at 1:22 PM, and Resident #2's family member on 01/21/16 at 4:30 PM, revealed the DON had reviewed Resident #2's MARs for October 2015, November 2015, and December 2015, vital signs, and skin assessment. The DON notified the physician and responsible party of Resident #2's missed medications and abnormal vital signs. According to the interviews, no new orders were received from the Physician. Review of a skin assessment completed on 01/08/16 on Resident #2 revealed no open areas had been observed by LPN #3. Interview with LPN #3 on 01/21/16 at 3:41 PM revealed she had completed the skin assessment on Resident #2 and reviewed the resident's vital signs. Interviews with SRNA #2 on 01/21/16 at 3:25 PM, and LPN #3 on 01/21/16 at 3:27 PM, revealed Resident #2's vital signs were obtained on 01/09/16 and were reviewed by LPN #3. 5) Review of the vital sign flow sheets revealed that all in-house resident vital signs were promptly taken on 01/08/16 by SRNAs, KMAs, and licensed Nurses. Interviews conducted with KMA #1 on 01/21/16 at 1:50 PM, KMA #6 on 01/21/16 at 2:15 PM, KM

Based on interview, record review, and review of the facility Social Service Worker (SSW) job description, it was determined the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing for two (2) of five (5) sampled residents (Residents #3 and #5). Resident #3 was involved in a resident-to-resident incident resulting in Resident #3 being slapped in the face by Resident #5 on 12/13/15. Although the SSW initially investigated, there was no documented evidence of further Social Services follow-up assessments and documentation with interventions related to this resident's mood, fear, or depression after the 12/13/15 incident. Interview with Resident #3 revealed the resident was afraid of Resident #5 and would not come out of his/her room anymore due to the fear of being hit by Resident #5. In addition, although the SSW was aware of Resident #5 being combative and striking other residents in the past, there was no documented evidence of the incidents in the social services notes with interventions related to the incidents. The findings include: Review of the job description for the SSW revealed the SSW was responsible for planning, developing, organizing, implementing, evaluating, and directing the Social Services Department in accordance with federal, state, and local standards as well as established policies and procedures to ensure that the medically related emotional and social needs of the patients/residents were met and maintained on an individual basis. Further review revealed the SSW would work with emotional problems including assisting residents/family with anxiety and stress caused by illness and admission to the facility, difficulties in coping with residual physical disabilities, fears related to helplessness and death and the need for institutional and specialized care, maintain written documentation in the medical record per facility policy and state and federal guidelines, and develop the social service component of the resident's plan of care identifying specific problems, goals, and approaches. Review of incident reports revealed on 09/01/15 Resident #5 was combative and trying to get into the bed of an unsampled resident (Resident A). Further review of the incident report revealed a witness statement entered by Licensed Practical Nurse (LPN) #3 that stated Resident #5 was smacking the arm of Resident A in Resident A's room on 09/01/15 at 7:45 PM. The documentation further revealed that Resident #5 was put on 15-minute checks on 09/02/15 from 7:00 AM to 6:45 AM on 09/03/15. Review of another incident report dated 11/24/15 revealed Resident #5 slapped Resident #1 on 11/24/15. The incident report stated that Resident #5 was re-educated on how physical violence is not appropriate and to ask staff for assistance with getting through hallway. Review of another incident report dated 12/13/15 revealed Resident #5 slapped Resident #3 on 12/13/15. The incident report stated that Resident #5 was removed from the hallway and taken to his/her room and 15-minute checks were initiated and continued until 12/16/15 at 9:45 PM. The incident report further revealed the physician ordered an additional dose of Xanax (medication used to treat anxiety) on 12/13/15. 1. Review of Resident #5's medical record revealed that the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician Discharge Summary Outline dated 08/27/15 from the resident's previous hospitalization revealed the resident was hospitalized due to agitation, aggressive behaviors, striking at staff, and verbally threatening staff and peers. Review of Resident #5's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident's Cognitive Skills for Daily Decision Making were assessed at a score of 2 that indicated the resident was moderately impaired (decisions poor, cues/supervision required). Review of the comprehensive care plan dated 08/27/15 revealed the resident wandered and was at risk for unsupervised exits from the facility related to cognitive impairment and the inability to locate the resident's own room. The interventions to address the problems were assigned to the social worker and were to allow the resident to ventilate feelings regarding nursing home placement. Further review of the care plan revealed non-pharmacological interventions were as follows: allow/encourage the resident to make choices, approach the wandering resident in a non-threatening manner, be careful to not invade the resident's personal space, break activities into manageable subtasks, give one instruction at a time, encourage loved ones to visit, encourage small group activities, and give the resident an item or task in an attempt to distract (the resident has a baby doll and believes it to be real). Review of the Social Progress Notes signed by the SSW dated 09/16/15 revealed the resident will swing/hit at staff/others and was easily annoyed/agitated at times. Review of the Cognitive Pattern for the last seven days dated 12/03/15 revealed the resident was confused and propelled self via a wheelchair throughout the facility with cues and redirection required; required assistance from staff to the dining room for meals because the resident did not know the location or time meals were served; and the resident was unable to recall three words out of three after five minutes. Interview with the Social Service Worker on 12/18/15 at 10:30 AM revealed that the Director of Nursing (DON) informed the SSW to interview residents after a resident-to-resident incident occurred. The SSW stated she was unaware of the incidents involving Resident #5 and other residents that occurred on 09/01/15 and 11/24/15 and therefore did not provide other social services. 2. Review of Resident #3's medical record revealed the facility admitted the resident on 04/25/09 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 12 indicating the resident was moderately cognitively impaired and was interviewable. Review of Resident #3's comprehensive care plan revealed a problem dated 10/12/15 of alteration in mood, Depressive Disorder and Anxiety, with trouble falling asleep. The goal for the problems was to have improved mood state with no signs or symptoms of anxiety/depression through the next review, and to have improved sleep pattern as evidenced by reporting adequate rest with no insomnia through next review. The interventions included: administer medications per physician's orders [REDACTED]. There was no documented evidence the care plan was revised to indicate increased anxiety, fear, or depression related to the incident that occurred with Resident #5 on 12/13/15. Review of the nurse's notes from Resident #3's record dated 12/13/15 at 4:44 PM revealed Resident #5 was yelling in the hallway and then a slap noise was heard. The note further revealed when staff arrived, Resident #5 was holding Resident #3's wheelchair with one hand, and slapping Resident #3 with the other hand. Resident #5 slapped Resident #3 on the left cheek. The note stated that Resident #3 was assessed and had no redness to the cheek at that time. The note stated that Resident #3 was upset about the incident and Resident #5 was removed from the room. Review of the nurse's notes revealed follow-up charting on 12/14/15 and 12/15/15 with no further concerns noted. Review of the nurse's note on 12/15/15 at 3:15 PM revealed that Resident #3 has been kept separated from the resident with whom the altercation occurred. There was no documented evidence of Social Services interventions related to the incident on 12/13/15. Interview with Resident #3 on 12/15/15 at 9:30 AM revealed that he/she was sitting in the hall waiting on staff to put him/her in bed on 12/13/15 when out of nowhere Resident #5 got behind Resident #3's wheelchair and pushed it into the wall almost causing him/her to fall out of the wheelchair. Resident #3 stated that Resident #5 then came around to the side of Resident #3's wheelchair and smacked him/her across the face on the left side. Resident #3 stated he/she would not let Resident #5 do that again because he/she was going to stay in the room and not come out anymore; Resident #3 stated I am afraid of him/her and nurse aides have bruises from Resident #5 and I am afraid to sit in the hallway; I enjoyed sitting in the hallway but I am not going out there because of Resident #5. Interview with the Social Service Worker on 12/18/15 at 10:30 AM revealed she interviewed Resident #3 on 12/14/15 and asked what happened. The SSW reported that Resident #3 said he/she was sitting in the wheelchair outside his/her room and Resident #5 pushed Resident #3's wheelchair and slapped Resident #3. The SSW stated she investigated the incident between Resident #3 and Resident #5, but did not ask Resident #3 if the resident was afraid, or how the incident made the resident feel. Interview with the DON on 12/16/15 at 5:39 PM and 12/18/15 at 12:55 PM revealed she was not aware that Resident #5 had been involved in three altercations with other residents since 09/01/15. She stated when an incident occurred the nurse on the floor started the investigation, and then the SSW, DON, and Administrator completed the investigation if it was really bad.

Based on interview, record review, and review of the facility policies and procedures, it was determined the facility failed to review and revise the care plan for two (2) of five (5) sampled residents (Residents #3 and #5) after Resident #5 displayed behaviors and Resident #3 was involved in an altercation with Resident #5. Resident #5 was involved in three (3) resident-to-resident altercations from 09/01/15 through 12/13/15 in which Resident #5 was physically aggressive and hit other residents. There was no documented evidence the facility revised the care plans and the behavior interventions to prevent further resident-to-resident incidents. Interview and record review revealed that even though the facility identified the resident-to-resident incidents were occurring, there was no documented evidence the facility implemented interventions to prevent further incidents. Furthermore, Resident #3 was involved in a resident-to-resident Incident resulting in Resident #3 being slapped in the face by Resident #5 on 12/13/15. Although the incident was investigated, there was no documented evidence of further follow-up assessments or revision in the care plan related to Resident #3's mood, fear, or depression after the 12/13/15 incident. Interview with Resident #3 revealed the resident was afraid of Resident #5 and would not come out of his/her room anymore due to the fear of being hit by Resident #5. The findings include: Review of the facility's Care Plan policy, dated October 2007, revealed the Interdisciplinary Care Plan Team developed care plans within seven days after completion of the Comprehensive Minimum Data Set assessment. The policy further stated that the care plans were updated quarterly, annually, upon significant change in a resident's condition, or as indicated. 1. Review of Resident #5's medical record revealed the facility admitted the resident on 08/27/15 with [DIAGNOSES REDACTED]. Review of the Physician Discharge Summary Outline from the resident's previous hospitalization dated 08/27/15 revealed the resident was hospitalized due to agitation, aggressive behaviors, striking at staff, and verbally threatening staff and peers. Review of Resident #5's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident's cognitive skills for daily decision making were assessed at a score of 2 which indicated that the resident was moderately impaired (decisions poor, cues/supervision required). Review of the comprehensive care plan dated 08/27/15 revealed the resident wandered and was at risk for unsupervised exits from the facility related to cognitive impairment and the inability to locate the resident's own room. The interventions to address the problems were assigned to the social worker and were to allow the resident to ventilate feelings regarding nursing home placement. Further review of the care plan revealed non-pharmacological interventions were as follows: allow/encourage the resident to make choices, approach the wandering resident in a non-threatening manner, be careful to not invade the resident's personal space, break activities into manageable subtasks, give one instruction at a time, encourage loved ones to visit, encourage small group activities, and give the resident an item or task in an attempt to distract (the resident has a baby doll and believes it to be real). Review of incident reports revealed on 09/01/15 Resident #5 was being combative and trying to get into the bed of an unsampled resident (Resident A). Further review of the incident report revealed a witness statement entered by Licensed Practical Nurse (LPN) #3 that stated Resident #5 was smacking the arm of Resident A on 09/01/15 at 7:45 PM. The documentation further revealed that Resident #5 was put on 15-minute checks on 09/02/15 from 7:00 AM to 6:45 AM on 09/03/15. Review of another incident report dated 11/24/15 revealed Resident #5 slapped Resident #1 on 11/24/15. The incident report stated that Resident #5 was re-educated on how physical violence is not appropriate and to ask staff for assistance with getting through hallway. Review of another incident report dated 12/13/15 revealed Resident #5 slapped Resident #3 on 12/13/15. The incident report stated that Resident #5 was removed from the hallway and taken to his/her room and 15-minute checks were initiated and continued until 12/16/15 at 9:45 PM. The incident report further revealed the physician ordered an additional dose of [MEDICATION NAME] (medication used to treat anxiety) on 12/13/15. Review of the resident's care plan revealed there was no documented evidence the facility reviewed or revised the care plan after the 09/01/15 and 11/24/15 altercations to prevent further incidents. 2. Review of Resident #3's medical record revealed the facility admitted the resident on 04/25/09 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 12 indicating the resident was moderately cognitively impaired and was interviewable. Review of Resident #3's comprehensive care plan revealed a problem dated 10/12/15 of alteration in mood, [MEDICAL CONDITION] and Anxiety, with trouble falling asleep. The goal for the problems was to have improved mood state with no signs or symptoms of anxiety/depression through the next review, and to have improved sleep pattern as evidenced by reporting adequate rest with no [MEDICAL CONDITION] through next review. The interventions included: administer medications per physician's orders [REDACTED]. Review of the nurse's notes from Resident #3's record dated 12/13/15 at 4:44 PM revealed Resident #5 was yelling in the hallway and then a slap noise was heard. The note further revealed when staff arrived, Resident #5 was holding Resident #3's wheelchair with one hand, and slapping Resident #3 with the other hand. Resident #5 slapped Resident #3 on the left cheek. The note stated that Resident #3 was assessed and had no redness to the cheek at that time. The note stated that Resident #3 was upset about the incident and Resident #5 was removed from the room. Review of the nurse's notes revealed follow-up charting on 12/14/15 and 12/15/15 with no further concerns noted. Review of the nurse's note on 12/15/15 at 3:15 PM revealed that Resident #3 has been kept separated from the resident with whom the altercation occurred. Review of the resident's care plan revealed there was no documented evidence the facility reviewed or revised the care plan after the 12/13/15 incident. Interview with Resident #3 on 12/15/15 at 9:30 AM revealed that he/she was sitting in the hall waiting on staff to put him/her in bed on 12/13/15 when out of nowhere Resident #5 got behind Resident #3's wheelchair and pushed it into the wall almost causing him/her to fall out of the wheelchair. Resident #3 stated that Resident #5 then came around to the side of Resident #3's wheelchair and smacked him/her across the face on the left side. Resident #3 stated he/she would not let Resident #5 do that again because he/she was going to stay in the room and not come out anymore. Resident #3 stated I am afraid of him/her and nurse aides have bruises from Resident #5 and I am afraid to sit in the hallway; I enjoyed sitting in the hallway but I am not going out there because of Resident #5. Interview with the Social Service Worker on 12/18/15 at 10:30 AM revealed she interviewed Resident #3 on 12/14/15 and asked what happened. The SSW reported that Resident #3 said he/she was sitting in the wheelchair outside his/her room and Resident #5 pushed Resident #3's wheelchair and slapped Resident #3. The SSW stated she investigated the incident between Resident #3 and Resident #5, but did not ask Resident #3 if the resident was afraid, or how the incident made the resident feel and therefore did not revise the care plan to address Resident #3's fear of Resident #5. Further interview with the SSW revealed that she was unaware of the incidents involving Resident #5 and other residents that occurred on 09/01/15 and 11/24/15 and therefore did not provide other social services or revise the care plan to address the behaviors. Interview with the DON on 12/16/15 at 5:39 PM and 12/18/15 at 12:55 PM revealed she was not aware that Resident #5 had been involved in three altercations with other residents since 09/01/15. She stated when an incident occurred the nurse on the floor started the investigation and then the SSW, DON, and Administrator completed the investigation if it was really bad. The DON went on to say she would expect the care plan to be updated within two days and it should have been revised after the 09/01/15 incident and the 11/24/15 incident. Interview with the Facility Administrator on 12/18/15 at 1:40 PM revealed she had been employed at the facility for seven days. According to the Administrator, the QA person was responsible for monitoring incident reports and then the administrator was notified and reviewed them also. The Administrator said the only incident involving Resident #5 that she had reviewed was the one dated 12/13/15. The Administrator stated resident care plans should have been updated and appropriate interventions developed after the incidents occurred involving Resident #5.

Based on interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to ensure one (1) of five (5) sampled residents (Resident #5) received adequate supervision to prevent resident-to-resident altercations. Record review revealed Resident #5 was involved in three (3) resident-to-resident altercations (09/01/15, 11/24/15, and 12/13/15) in which Resident #5 was physically aggressive toward other residents of the facility. On 12/13/15 Resident #5 slapped Resident #3, causing Resident #3 to be fearful and remain in his/her room due to fear of the resident. The findings include: Review of the facility's Abuse, Neglect, or Misappropriation of Resident Property Policy revised 07/01/13, revealed the facility will deploy staff to meet the resident's needs, as appropriate. The facility's staff will investigate allegations in a timely manner and develop corrective measures as indicated. The facility staff will monitor the provision of resident care and services every shift. Further review of the policy revealed a section titled Resident-to-Resident Aggression. The policy stated that residents who exhibit aggressive physical and verbal behavior may present a risk to the facility's other residents. These behaviors may not be abuse since these residents are often not able to willfully intend to harm others, yet they might have the potential to cause injury. The policy stated residents were assessed upon admission for evidence of a pattern of aggressive behavior through the comprehensive assessment process and when a significant risk was identified, the care plan team should develop goals and intervention strategies that address the prevention of injury to other residents and include these items on the resident's care plan. The policy further stated that residents who developed behaviors that present a risk to others after admission were reviewed to determine if a significant change occurred, reassessed if necessary, and referred to the care plan team for revision of the care plan to address the potential for injury to other residents. Residents who present a risk factor to others, whether physical or mental, should be monitored by staff. If the planned interventions were not effective, the care plan should be revised to offer alternative interventions. The policy stated that the Social Worker ensured that the facility works to protect residents from other residents through monitoring, assessment, care planning, and referral services. Review of Resident #5's medical record revealed that the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician Discharge Summary Outline from the resident's previous hospitalization dated 08/27/15 revealed the resident was hospitalized due to agitation, aggressive behaviors, striking at staff, and verbally threatening staff and peers. Review of Resident #5's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident's Cognitive Skills for Daily Decision Making were assessed as a score of 2 which indicated that the resident was severely impaired. Review of section Eo200 (Behavioral Symptoms) from the 12/03/15 MDS revealed the resident was coded as not having any behaviors exhibited in the previous seven days. Review of the care plan dated 08/27/15 revealed the resident displayed wandering behaviors and was at risk for unsupervised exits from the facility. The plan included interventions related to behaviors for staff to ensure alarmed exits were functional; ensure the resident's picture and name were on the wandering board; approach the wandering resident in a non-threatening manner; and allow the resident to ventilate feelings regarding nursing home placement. Review of the care plan dated 12/14/15 revealed that Resident #5 had a history of [REDACTED]. The plan included interventions for staff to not invade personal space, elicit family input for best approaches to the resident, give medication as prescribed, document episodes of any changes in mood and/or mental status and notify the physician, give resident item or task in an attempt to distract, and document behavior as it occurs (combative/threatening) per facility protocol. Review of incident reports and nurse's notes revealed on 09/01/15 Resident #5 was combative and trying to get into the bed of unsampled Resident A. Further review of the incident report revealed a witness statement entered by Licensed Practical Nurse (LPN) #3 that stated Resident #5 was smacking the arm of Resident A in Resident A's room on 09/01/15 at 7:45 PM. The documentation further revealed that Resident #5 was put on 15-minute checks on 09/02/15 from 7:00 AM to 6:45 AM on 09/03/15. Review of another incident report dated 11/24/15 revealed Resident #5 slapped Resident #1 on 11/24/15. The incident report stated that Resident #5 was re-educated on how physical violence is not appropriate and to ask staff for assistance with getting through hallway. Review of another incident report dated 12/13/15 revealed Resident #5 slapped Resident #3 on 12/13/15. The incident report stated that Resident #5 was removed from the hallway and taken to his/her room and 15-minute checks were initiated and continued until 12/16/15 at 9:45 PM. The incident report further revealed the physician ordered one additional dose of Xanax (medication used to treat anxiety) on 12/13/15. Observation on 12/17/15 at 6:25 PM revealed Resident #5 was observed to enter Resident #1's room and pass within arm's reach of Resident #1 while four staff members were standing approximately 20 feet away at the nurses' station and could see Resident #1's room. Staff did not intervene when Resident #5 entered Resident #1's room after raising a Velcro door barrier so he/she could roll the wheelchair under it. Resident #5 then rolled his/her wheelchair to the foot of the bed. Resident #5 shouted at Resident A, who was lying in bed closest to the window of the room. Resident A then shouted at Resident #5 to get out. Facility staff walked by the door at this time and had a clear line of sight of Resident #5 but did not intervene. Resident #5 then rolled the wheelchair back and was by Resident #1's bedside table. Resident #5 was going through Resident #1's drawers, pulling sheets and a pillow off of the bed. Four facility staff members were observed to walk past Resident #1's room. Resident #5 was observed to be inside Resident #1's room for ten minutes before LPN #2 removed Resident #5 from the room. Interview with State Registered Nurse Aide (SRNA) #6 on 12/17/15 at 5:00 PM revealed on 09/01/15 at 7:45 PM she observed Resident #5 in Resident A's room beside Resident A's bed between the two beds, but could not remember if Resident #5 hit Resident A. SRNA #6 stated she took Resident #5 out of the room and reported to the nurse that Resident #5 was in another resident's room again. Interview with Licensed Practical Nurse (LPN) #9 on 12/18/15 at 12:28 PM revealed that he was at the nurses' station on 11/24/15 and Resident #1 and a bunch of other residents were sitting around the nurses' station when Resident #5 came up the hall and tried to get through and asked several times for Resident #1 to move and then smacked Resident #1 on the shoulder. He said he did not think Resident #5 hit Resident #1 very hard and that Resident #5 was capable of hitting a lot harder. LPN #9 stated he told Resident #5 how physical violence was not appropriate and to ask staff for assistance with getting through the hallway. Interview with SRNA #7 on 12/15/15 at 2:08 PM revealed that she was working on 12/13/15 and said she heard Resident #5 smack Resident #3 but did not see the incident. She stated when she went around the corner, she saw Resident #3 holding Resident #5's hands on the wheelchair so Resident #5 could not hit him/her again. SRNA #7 said she got between the residents and got Resident #3 to let go of Resident #5. Interview with LPN #2 on 12/17/15 at 6:40 PM revealed Resident #5 needed one-on-one supervision at all times due to Resident #5's behaviors of hitting other residents. LPN #2 said the facility was not able to provide the supervision needed for Resident #5. According to LPN #2, there was no excuse for staff to walk by Resident #1's room and not intervene when they saw Resident #5 inside the room. LPN #2 said the facility had not received training on how to care for Resident #5's behaviors. Interview with Resident #3 on 12/15/15 at 9:30 AM revealed that he/she was sitting in the hall waiting on staff to put him/her in bed on 12/13/15 when out of nowhere Resident #5 got behind Resident #3's wheelchair and pushed it into the wall almost causing him/her to fall out of the wheelchair. Resident #3 stated that Resident #5 then came around to the side of Resident #3's wheelchair and smacked him/her across the face on the left side. Resident #3 stated he/she would not let Resident #5 do that again because he/she was going to stay in the room and not come out anymore. Resident #3 stated I am afraid of him/her and nurse aides have bruises from Resident #5 and I am afraid to sit in the hallway; I enjoyed sitting in the hallway but I am not going out there because of Resident #5. Interview with LPN #3 on 12/18/15 at 8:30 AM revealed that she had been working at the facility for seven years and was the Quality Assurance (QA) Nurse. LPN #3 stated that she reviewed all incident reports and that Resident #5 wandered all over the building in a wheelchair. LPN #3 reported that on 09/01/15, Resident #5 was trying to get into another resident's bed. The LPN stated she was unaware that Resident #5 had slapped a resident at that time. LPN #3 described another incident on 11/24/15 where there were several residents sitting in the hallway by the nurses' station. Resident #5 was attempting to get through the hallway and smacked Resident #1 on the shoulder. LPN #3 stated the only interventions after this incident were that Resident #5 was educated by staff that physical violence was not appropriate, but stated that due to Resident #5's cognitive status the resident could not be educated. LPN #3 stated she was aware that Resident #5 was involved in another incident with a resident on 12/13/15, but had not completed the review. She stated she implemented 15-minute checks after each incident and reported the incidents to the Director of Nursing (DON) and Administrator. She stated the DON and Administrator then determine when to stop the 15-minute checks. Interview with the DON on 12/18/15 at 12:55 PM revealed that incident reports were initiated by the floor nurses and then sent to Social Services, the DON, and finally to the Administrator. The DON stated the incident reports were to be reviewed within two days of the incident. The DON stated that the QA Nurse and Social Service Worker were responsible for investigating the incidents and initiating interventions. The DON said the incident reports were reviewed in morning meetings and the interventions were reviewed. The DON then went on to say she was not aware that Resident #5 had slapped Resident A on 09/01/15 because that information was not on the incident report, but was in a witness statement. The DON stated the care plan should have been updated on 09/01/15 and 11/24/15 when Resident #5 slapped other residents. She stated that residents were usually put on a 15-minute watch after an incident and one-on-one supervision if required. The DON stated if a resident had three incidents of hitting other residents, then the facility would send them out for a psychological evaluation, but the DON stated that she was not aware the resident had three incidents of striking other residents. Interview with the Facility Administrator on 12/18/15 at 1:40 PM revealed she had been employed at the facility for seven days. According to the Administrator, the QA person was responsible for monitoring incident reports and then the Administrator was notified and reviewed them also. The Administrator said the only incident involving Resident #5 that she had reviewed was the one dated 12/13/15. The Administrator said resident care plans should have been updated and appropriate interventions developed after the incidents involving Resident #5. According to the Administrator, if there was a pattern of behaviors (resident-to-resident altercations) she would expect the resident to be put on a 15-minute watch, one-on-one supervision, and/or be sent out for a psychological evaluation, medication review, physical assessment, etc.

Based on interview, record review, and review of facility policy it was determined the facility failed to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect for one (1) of twelve (12) sampled residents (Resident #11). Interview with Resident #11 conducted on 11/18/15 revealed, a while back (unable to recall dates/times) after the resident reported Licensed Practical Nurse (LPN) #5 to the Social Worker, the LPN came into the resident's room, stuck her finger in my face, and asked me why I had reported her. The resident stated the incident made him/her feel stupid and like I meant nothing here. Resident #11 was observed to be tearful at different intervals throughout the interview. Interviews with staff revealed the resident was shaking all over after the incident and stated LPN #5 talked to him/her like a dog. The findings include: Review of the facility's policy titled Dignity, dated October 2005, revealed care and treatment was to be provided to facility residents in a manner that helped preserve their dignity, self-esteem, and self-respect. Facility staff was also required to ensure each resident was valued as an individual, and that staff interactions with facility residents were conducted respectfully. Review of the medical record for Resident #11 revealed the facility admitted the resident on 12/09/11 with [DIAGNOSES REDACTED]. Review of Resident #11's Annual Minimum Data Set Assessment ((MDS) dated [DATE] revealed staff assessed the resident to be interviewable with a Brief Interview for Mental Status (BIMS) score of 15. Interview with Resident #11 on 11/18/15 at 3:00 PM revealed he/she had reported to the Social Worker that Licensed Practical Nurse (LPN) #5 had verbally abused him/her a while back (unable to recall dates/times). The resident stated a few minutes after the report was made to the social worker, LPN #5 came into his/her room, stuck her finger in my face, and asked me why I had reported her. The resident stated the incident made him/her feel stupid and like I meant nothing here. The resident further stated, I will never report anything else that happens here again. Resident #11 was observed to be tearful at different times throughout the interview. Interview with Certified Medication Aide (CMA) #2 on 11/18/15 at 11:30 AM revealed she had entered Resident #11's room to administer medications a few months ago (unable to recall exact date) and the resident was observed to be shaking all over. CMA #2 stated that the resident told her, She talked to me like a dog, she shouldn't work with people like us (referring to LPN #5). The CMA stated that the resident told her that after he/she reported the incident to the Social Worker, LPN #5 came back to Resident #11's room and jumped all over him/her. Interview with LPN #3 on 11/18/15 at 10:50 AM revealed she had reported to the DON over and over that LPN #5 was rude and hateful to residents. However, the LPN stated the DON took no action related to the reports of concern of resident treatment by LPN #5. Interview with State Registered Nurse Aide (SRNA) #12 on 11/19/15 at 12:15 PM revealed LPN #5 was short and hateful with residents. The SRNA stated she had reported it a while back to a nurse (unable to recall who); however, she was told, She's been reported and nothing's been done, so just forget it. The SRNA was unable to recall any residents involved. Interview with the Social Worker (SW) on 11/18/15 at 4:15 PM revealed Resident #11 stated he/she felt like LPN #5 was rude and had offended him/her, and that could be a dignity issue for the resident. The SW acknowledged that LPN #5 had talked to the resident about the allegations made against her. Interview with LPN #5 on 11/19/15 at 2:35 PM revealed she denied being rude or verbally abusive to Resident #11. The LPN stated she had been notified by the Social Worker or previous Administrator (unable to recall which one) that Resident #11 had accused me of talking mean and slamming the door in his/her face. LPN #5 stated, If I would have done this, it would have been a concern of dignity for a resident. The LPN stated she had gone into the resident's room after the resident had voiced the allegation against her and said the resident stated, I didn't tell the Social Worker that. The LPN stated that since she was accused of something, she wanted to know what she had done. Interview with the DON on 11/18/15 at 5:00 PM revealed she denied ever receiving and/or requesting a written statement from any staff member related to any incident that involved LPN #5. The DON denied any staff members had ever reported to her any concerns of LPN #5's treatment of [REDACTED]. The DON stated she had not interviewed or discussed the incident with Resident #11 after she had received a report that the resident had stated that LPN #5 had slammed the door in his/her face. However, the DON stated, Looking back, I probably should have interviewed the resident. The DON acknowledged if a resident felt that a staff person had been rude or had offended him/her that was a concern for a resident's dignity.

Based on observation, interview, record review, and a review of the facility's policy, it was determined the facility failed to ensure the resident's physician was notified when a need to alter treatment occurred for two of three sampled residents (Residents #2 and #1). 1) Observations conducted on 12/18/12, of stoma care for Resident #2's [MEDICAL CONDITION] (an abdominal opening surgically created to allow intestinal waste to leave the body) revealed the skin surrounding the resident's [MEDICAL CONDITION] stoma was red, irritated, and had two small blisters present to the irritated area. Further observations revealed facility staff had placed a bath towel over the resident's [MEDICAL CONDITION] stoma to collect the resident's intestinal waste. Staff stated Resident #2 had behaviors of removing [MEDICAL CONDITION] bags and, as a result, the skin tissue that surrounded the resident's [MEDICAL CONDITION] stoma had been red and irritated "off and on" for approximately three years. However, interviews with facility staff and a review of Resident #2's medical record revealed facility staff failed to contact the resident's physician of the ongoing skin irritation to the resident's [MEDICAL CONDITION] stoma and failed to ensure the physician was aware of the resident's behaviors of removing the [MEDICAL CONDITION] bag. 2) Interviews and a review of Resident #1's facility and hospital records revealed the resident developed open and black areas to the sacrum area at the facility and facility staff failed to notify the resident's physician of the change in the resident's status. Based on documentation in the hospital record, Resident #1 was observed to have a Stage 4 pressure ulcer, with necrotic (black) tissue which covered fifty percent of the resident's wound, the day following the resident's admission to the hospital from the facility. Interviews with facility staff revealed the resident developed open areas to the sacrum on 12/07/12. Further interviews revealed facility staff also observed open and black areas to Resident #1's sacrum on 12/08/12 and 12/09/12; however, based on record reviews and interviews, the facility failed to ensure the physician was notified of the changes in the resident's skin condition and, as a result, failed to ensure treatment was provided to the areas. The findings include: A review of the facility's policy entitled "Notification of Physician for Change in Resident's Condition," dated August 2012, revealed staff was to notify the residents' physician when a significant change in a resident's condition occurred. 1. A review on 12/18/12 of Resident #2's medical record revealed the facility admitted the resident on 03/03/09 with [DIAGNOSES REDACTED]. A review of the Quarterly Minimum Data Set Assessment ((MDS) dated [DATE], revealed the facility assessed the resident had the ability to make his/her self understood, the ability to understand others, and was interviewable. The MDS revealed the resident required extensive assistance of two staff members for bed mobility, dressing, toilet use, and personal hygiene. In addition, the MDS revealed Resident #2 had Moisture Associated Skin Damage (MASD) and required applications of ointments/medications other than to the feet. The MDS provided no evidence that Resident #2 had exhibited any behavioral symptoms, or rejection of care during the assessment period. A review on 12/18/12 of the Comprehensive Care plan for Resident #2, last updated 10/25/12, revealed the resident had an alteration in bowel elimination and had a permanent [MEDICAL CONDITION]. According to the care plan, facility staff was to report any changes in the resident's skin integrity or skin impairment to the physician. The care plan further directed staff to observe and report any changes which occurred in the resident's mood or behavior to the physician. A review of the Behavior Observation sheets, utilized by facility staff to document behaviors exhibited by Resident #2 in October 2012, November 2012, and December 2012 revealed no documented evidence that Resident #2 exhibited behaviors. A review on 12/18/12 of Resident #2's weekly skin assessments conducted on 12/03/12, 12/10/12, and 12/17/12 revealed treatments were provided daily to the resident's [MEDICAL CONDITION] stoma site. Further review revealed no evidence that staff had documented the appearance of the resident's skin or assessed the stoma related to worsening in appearance. Documentation revealed Resident #2's physician had prescribed [MEDICATION NAME] Cream (topical anti-infective) to be applied to Resident #2's stoma on a daily and "as needed" basis on 12/19/11 (approximately one year prior to the date of the review, interview, and observation). A review of the Treatment Administration Record (TAR) revealed staff had applied [MEDICATION NAME] Cream to the resident's [MEDICAL CONDITION] stoma as ordered. Observations conducted at 8:30 AM on 12/18/12 revealed a bath towel had been placed over Resident #2's [MEDICAL CONDITION] stoma to collect intestinal wastes. Observations of the skin around the resident's stoma revealed the skin was red, irritated, and had two small blisters. Further observations revealed Resident #2 had facial grimacing and verbalized "that hurts, that burns" when Certified Nurse Aide (CNA) #1 and CNA #2 provided the resident with [MEDICAL CONDITION] care. At the completion of the [MEDICAL CONDITION] care, CNA #1 applied a [MEDICAL CONDITION] bag over the resident's red, irritated skin and [MEDICAL CONDITION] stoma; however, the CNAs failed to ensure nursing staff applied the prescribed [MEDICATION NAME] Cream to the resident's [MEDICAL CONDITION] stoma prior to the application of the [MEDICAL CONDITION] bag. During an interview conducted on 12/18/12 at 9:00 AM, Resident #2 stated, "My [MEDICAL CONDITION] fire around my [MEDICAL CONDITION]; they put medicine on it but it's not helping." The resident continued to state he/she was unaware of how long the skin irritation had been present, and stated, "They leave the bag off of me at times, because it hurts so bad when it's on me because of my skin." Interview with CNA #1 on 12/18/12 at 8:40 AM revealed Resident #2's skin had been red and irritated around the [MEDICAL CONDITION] site for "a year," and that Resident #2 had behaviors of removing the [MEDICAL CONDITION] bag. According to the CNA, Resident #2's skin "looks a lot better now than what it did look like." The CNA stated the nursing staff had been made aware of the resident's skin condition and behaviors of removing the [MEDICAL CONDITION] bag. Interview with CNA #3 on 12/18/12 at 4:15 PM confirmed Resident #2 had behaviors of "scratching" at his/her [MEDICAL CONDITION] site. The CNA stated she had reported to the facility nursing staff "numerous" times of the irritation to the skin around the resident's [MEDICAL CONDITION] stoma. An interview with Licensed Practical Nurse (LPN) #2 on 12/18/12 at 2:45 PM revealed she had observed Resident #2's [MEDICAL CONDITION] stoma on 12/07/12 to be red and irritated, and that the stoma was covered with a towel. LPN #2 stated she had not documented or reported the resident's skin condition to the resident's physician. An interview with LPN #3 on 12/18/12 at 3:30 PM revealed she had provided care to Resident #2 for three years and facility staff had "always had a problem" with the skin around the resident's [MEDICAL CONDITION] stoma. The LPN stated the resident puts his/her fingers "in and around the stoma site all the time." The LPN stated she had discussed the resident's ongoing skin irritation with the Director of Nursing one or two days prior to the interview conducted on 12/18/12. LPN #3 acknowledged she had not contacted the resident's physician related to the resident's behaviors, or the ongoing skin irritation present to the resident's [MEDICAL CONDITION] stoma and stated "someone probably should have." Interview with LPN #4 on 12/18/12 at 4:30 PM revealed Resident #2 "picks" at his/her [MEDICAL CONDITION] constantly, and has had irritated skin surrounding his/her [MEDICAL CONDITION] for "one year." The LPN confirmed she failed to document the resident's behavior on the behavior sheet and stated she had not contacted the resident's physician related to the resident's ongoing skin irritation because "it was the treatment nurse's responsibility." An interview with the facility's full time treatment nurse, Registered Nurse (RN) #1, on 12/18/12 at 3:00 PM, revealed Resident #2 had behaviors of "unhooking" the [MEDICAL CONDITION] bag his/herself, and RN #1 stated she failed to document the resident's behaviors. The RN stated the resident's skin was red and inflamed and the RN was unsure of when the resident's skin irritation initially developed. The RN stated she notified the resident's physician related to the resident's behaviors of removing the [MEDICAL CONDITION] bag and the skin irritation, but was unable to recall when or to provide documentation of the physician contact. Continued review of the resident's medical record revealed [REDACTED]. Interview with the Director of Nursing (DON) on 12/19/12 at 8:30 AM revealed facility staff received physician's orders [REDACTED]. stoma as directed. A review of physician's orders [REDACTED]. stoma site. Interview with Resident #2's physician on 12/19/12 at 2:00 PM revealed staff had notified him of the resident's skin irritation in the past; however, the physician could not recall when the notification occurred. In addition, the physician would not acknowledge if staff had or had not notified him of the resident's behavior of removing the [MEDICAL CONDITION] bag, and stated, "I'll take care of it." 2. A review on 12/18/12, of the medical record for Resident #1 revealed the facility readmitted the resident from an acute hospital stay on 11/07/12 with [DIAGNOSES REDACTED]. A review of a 14-day Minimum Data Set (MDS) assessment dated [DATE] revealed facility staff assessed the resident to be at risk for the development of pressure sores and to have Moisture Associated Skin Damage (MASD). Facility staff assessed Resident #1 to be totally dependent and required the assistance of two staff members for bathing, toileting, bed mobility, and personal hygiene. In addition, staff documented the resident was incontinent of bowel and bladder. A review on 12/18/12, of the admission skin assessment conducted for Resident #1 on 11/07/12 revealed RN #1 identified excoriation and redness to the resident's sacrum and bilateral buttocks. Further review of RN #1's documentation revealed Resident #1 had a small denuded area, with the appearance of redness/excoriation (MASD), to the sacral area. Continued review of the skin assessment revealed the RN had not identified any open areas to Resident #1's sacral area or buttocks upon admission to the facility. A review on 11/07/12, of Resident #1's physician's orders [REDACTED]. Continued review of the physician's orders [REDACTED]. Continued review of the medical record revealed no evidence that facility staff had documented or notified the resident's physician of any open or discolored areas to the resident's sacral area. Documentation revealed the resident was transferred to the hospital on [DATE] when the resident became unresponsive. A review of the resident's hospital record on 12/18/12, revealed hospital staff admitted the resident on 12/10/12, the day the resident was transferred from the facility. Further review revealed on 12/11/12 (the day after the resident was admitted to the hospital) hospital staff assessed Resident #1 to have a Stage 4 pressure ulcer to the sacrum. Documentation also revealed hospital staff assessed 50 percent of the resident's pressure ulcer wound beds were necrotic (black) in color. Interview with CNA #3 on 12/18/12 at 4:15 PM revealed she had provided care to Resident #1 on 12/07/12 and noted the resident's sacral area was "purple" in color and an open area was present to the sacral area. The CNA stated she notified the treatment nurse, LPN #2, and the resident's nurse, LPN #4, at that time of the change observed in the resident's skin condition. The CNA continued, stating she provided personal care for the resident again on 12/09/12, noted the resident's sacral area was black in color, and notified the treatment nurse (LPN #1). Interview with LPN #1 on 12/18/12 at 11:20 AM revealed she had provided treatment to Resident #1's sacral and bilateral buttocks on 12/08/12 and 12/09/12. Continued review revealed the LPN stated the resident had two open and blackened areas to the sacrum. The LPN stated she had not provided care to the resident prior to 12/08/12, therefore, was unaware if a change had occurred in the appearance of the resident's skin integrity impairment. The LPN stated "wound care" was "new" for her, and she acknowledged she had not contacted the resident's physician to obtain further treatment related to the change in the resident's skin condition. Interview with LPN #4 on 12/18/12 at 4:30 PM confirmed she was notified of a change in the skin status of Resident #1 and observed on 12/07/12 that Resident #1 had developed an open area to the sacrum; however, according to LPN #4, she did not contact the resident's physician to obtain further treatment orders for the resident. The LPN stated she discussed the change in the resident's skin condition with the treatment nurse (LPN #2), and stated the treatment nurse was responsible to contact the resident's physician to obtain a change in treatment orders when a change in skin condition occurred. Interview with LPN #2 on 12/18/12 at 2:45 PM revealed she provided wound care to Resident #1 on 12/07/12. The LPN stated the resident's sacral area appeared to be a deep dark red color and open areas were observed to the resident's sacral area. The LPN stated she does not "do treatments enough to know if a change had occurred or not," and just followed the current orders. The LPN acknowledged she had not contacted the resident's physician related to the status of the resident's skin condition. Registered Nurse (RN) #1 stated in interview conducted on 12/18/12 at 3:00 PM that she provided wound care to Resident #1 on 12/10/12 (the same day the resident was transferred to the hospital). The RN stated she observed that the excoriation to the resident's buttock/sacrum appeared more "pronounced." However, RN #1 stated she had not identified any open areas or other appearance changes to the resident's sacral/buttock area that would have required a change in the current treatment for [REDACTED]. Interview with the Director of Nursing on 12/18/12 at 6:30 PM revealed staff should have contacted the physician when Resident #1 experienced a change in skin condition. The DON stated she ensured a resident's physician was contacted appropriately related to treatment of [REDACTED]. Interview with Resident #1's physician on 12/18/12 at 4:00 PM revealed facility staff should have contacted her when the resident developed necrotic tissue to the sacrum.

Based on observation, interview, and record review it was determined the facility failed to ensure a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity was initially and periodically conducted for one of three sampled residents (Resident #2). Observations conducted on 12/18/12, of [MEDICAL CONDITION] (an abdominal opening surgically created to allow intestinal waste to leave the body) care for Resident #2 revealed the [MEDICAL CONDITION] was not covered by a [MEDICAL CONDITION] bag and the skin surrounding the resident's [MEDICAL CONDITION] was red, irritated, and had two small blisters present to the irritated area. Further observations revealed facility staff had placed a bath towel over the resident's [MEDICAL CONDITION] to collect the resident's intestinal waste. Staff stated Resident #2 had behaviors of removing [MEDICAL CONDITION] bags and the skin tissue that surrounded the resident's [MEDICAL CONDITION] had been red and irritated "off and on" for approximately "three years." However, facility staff failed to document Resident #2's behaviors on the Minimum Data Set Assessment (MDS). The findings include: An interview with the Minimum Data Set Assessment (MDS) and Care Plan Coordinator on 12/18/12 at 6:20 PM revealed they followed the guidelines provided on the MDS document for completion of the assessment. An interview with the Director of Nursing (DON) at 6:30 PM on 12/18/12 revealed the facility did not have a specific policy related to resident behaviors. The DON stated staff was responsible to document any behaviors exhibited during their shift. A review on 12/18/12 of Resident #2's medical record revealed the facility admitted the resident on 03/03/09 with [DIAGNOSES REDACTED]. A review of the Quarterly Minimum Data Set Assessment ((MDS) dated [DATE], revealed the facility assessed the resident had the ability to make his/her self understood, the ability to understand others, and was interviewable. The MDS revealed the resident required extensive assistance of two staff members for bed mobility, dressing, toilet use, and personal hygiene. The MDS provided no evidence that Resident #2 had exhibited any behavioral symptoms or rejection of care during the assessment period. The MDS also revealed Resident #2 had Moisture Associated Skin Damage (MASD) and required applications of ointments/medications other than to the feet. A review on 12/18/12 of the Comprehensive Care plan for Resident #2, last updated on 10/25/12, revealed the resident had an alteration in bowel elimination with a permanent [MEDICAL CONDITION]. According to the care plan, facility staff was to report any redness, inflammation, or drainage at the resident's [MEDICAL CONDITION] site to a nurse. Facility staff also identified that Resident #2 "picks at bag and around and in stoma site." Interventions identified on the care plan related to the resident's behaviors included to use one-piece clothing outfits for the resident to prevent the resident from picking at the stoma site, and to provide a [MEDICAL CONDITION] bag change as needed. The care plan further directed staff to observe and report to the physician any changes that occurred in the resident's mood or behavior. A review of the Behavior Observation sheets, utilized by facility staff to document behaviors exhibited by Resident #2 in October 2012, November 2012, and December 2012 provided no documented evidence that Resident #2 had exhibited behaviors. Interview with CNA #1 on 12/18/12 at 8:40 AM revealed Resident #2 had behaviors of removing the [MEDICAL CONDITION] bag and that the resident's skin had been red and irritated for a "year." According to the CNA, the nursing staff had been made aware of the resident's behaviors of removing the [MEDICAL CONDITION] bag. Interview with CNA #3 on 12/18/12 at 4:15 PM confirmed Resident #2 had behaviors of "scratching" at his/her [MEDICAL CONDITION] site, however, interview revealed the CNA had failed to document the behaviors. The CNA stated she had reported to the facility nursing staff "numerous" times the resident's refusal to wear the one-piece outfits. An interview with Licensed Practical Nurse (LPN) #2 on 12/18/12 at 2:45 PM revealed she was unaware of why staff had not provided a [MEDICAL CONDITION] bag for the resident and stated, "I think the resident's bag overflows." LPN #2 stated she had not inquired why facility staff had not provided the resident with a [MEDICAL CONDITION] bag, and had not documented or reported the resident's behaviors to the MDS nurse. An interview with LPN #3 on 12/18/12 at 3:30 PM revealed she had provided care to Resident #2 for three years and the resident puts his/her fingers "in and around the stoma site all the time." The LPN stated she had not documented the resident's behaviors, had not notified the resident's physician of the resident's behaviors, and had not informed the MDS staff of the resident's behaviors in order for an assessment to be updated. Interview with LPN #4 on 12/18/12 at 4:30 PM revealed Resident #2 "picks at" his/her [MEDICAL CONDITION] "constantly." The LPN confirmed she failed to document the resident's behaviors on the behavior sheet, and stated she should have. An interview with the facility's full time treatment nurse, Registered Nurse (RN) #1, on 12/18/12 at 3:00 PM, revealed Resident #2 had behaviors of "unhooking" the [MEDICAL CONDITION] bag his/herself. The RN stated she should have documented the resident's behaviors, but failed to do so. Continued interview with the MDS and Care Plan Coordinator on 12/18/12 at 6:20 PM revealed she reviewed and relied on documentation by facility staff to aid in obtaining information needed to complete and update the Resident Assessment Instrument (included in the MDS assessment) and to update the resident's care plans. The Director of Nursing (DON) stated in an interview conducted on 12/18/12 at 6:30 PM that she reviewed resident behavior sheets, in addition to random chart audits, on a daily basis. The DON stated she had not identified that Resident #2 exhibited behaviors or that the MDS assessment had not been updated to include the resident's behaviors of removing the [MEDICAL CONDITION] bag. The DON confirmed that staff should have documented Resident #2's behaviors related to his/her [MEDICAL CONDITION] in order for the MDS assessment to be updated.

Based on observation, interview, record review, and a review of the facility's policy, it was determined the facility failed to ensure the comprehensive plan of care was developed, reviewed, and revised based on staff assessment for one of three sampled residents (Resident #2). Observations conducted on 12/18/12 of [MEDICAL CONDITION] (an abdominal opening surgically created to allow intestinal waste to leave the body) care for Resident #2 revealed the resident's skin surrounding the [MEDICAL CONDITION] stoma was red, irritated, and had two small blisters present to the irritated skin. Observation revealed facility staff had placed a cloth towel directly over the resident's [MEDICAL CONDITION] stoma to collect the intestinal waste. Interviews with facility staff on 12/18/12 revealed the resident had behaviors of removing the [MEDICAL CONDITION] bag his/herself. The staff further stated the resident's skin surrounding the resident's stoma had been red and irritated "off and on" for approximately three years. A review of the Comprehensive Care Plan revealed Resident #2 had skin integrity impairment around the [MEDICAL CONDITION] stoma, and staff had developed interventions that included the use of a [MEDICAL CONDITION] bag and one-piece clothing items to prevent the resident from "picking" at the stoma site. However, facility staff failed to ensure Resident #2's plan of care was reviewed/revised to reflect the continued redness/irritation of the skin around the resident's [MEDICAL CONDITION] stoma. (Refer to F309.) The findings include: A review of the facility's policy titled Resident Care Plan, dated August 2012, revealed the development of a resident's care plan would be an ongoing process, and would include current problems and problems identified between the scheduled care plan reviews. The policy revealed modifications to a resident's care plan would be completed as the Care Plan Coordinator directed. A review of Resident #2's medical record on 12/18/12 revealed the facility admitted the resident on 03/03/09 with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A review of the Quarterly Minimum Data Set Assessment ((MDS) dated [DATE], revealed facility staff had assessed the resident to be interviewable and to have the ability to make his/her self understood and to understand others. In addition, the MDS revealed facility staff had assessed the resident to require the extensive assistance of two staff members for bed mobility, dressing, toilet use, and personal hygiene. Continued review of the MDS revealed no evidence that the resident had exhibited any behavioral symptoms or rejection of care during the assessment period. A review on 12/18/12 of the Comprehensive Care Plan for Resident #2, updated on 10/25/12, revealed staff had identified the resident to have an alteration in bowel elimination with placement of a permanent [MEDICAL CONDITION]. Facility staff also noted the resident "picks at bag and around and in stoma site" and developed interventions that included dressing the resident in one-piece outfits in an effort to prevent the resident from picking at the stoma site, and to ensure the [MEDICAL CONDITION] bag was changed as needed. Observations conducted on 12/18/12 at 8:30 AM of Resident #2's [MEDICAL CONDITION] care revealed a towel, used for bathing, had been placed over the resident's [MEDICAL CONDITION] to collect intestinal wastes. Observations of the resident's skin surrounding the stoma, revealed the resident's skin was red, irritated, and had two small blisters present. Resident #2 was observed to have facial grimacing and verbalized, "That hurts, that burns," when Certified Nursing Assistant (CNA) #1 and CNA #2 provided the resident with stoma site care. After CNA #1 cleansed the resident's skin surrounding the [MEDICAL CONDITION], the resident was observed to have facial grimacing when the CNA applied a [MEDICAL CONDITION] bag over the resident's red, irritated skin. An interview conducted on 12/18/12 at 9:00 AM with Resident #2 revealed, "My [MEDICAL CONDITION] fire around my [MEDICAL CONDITION]; they put medicine on it, but it's not helping." The resident continued to state he/she was unaware of how long the skin irritation had been present, and stated, "They leave the bag off of me at times, because it hurts so bad when it's on me because of my skin." Interview on 12/18/12 at 8:40 AM with CNA #1 revealed she had been assigned to provide care to Resident #2 on 12/18/12. CNA #1 stated Resident #2's skin had been red and irritated for a "year" and that the resident's skin "looks a lot better now than what it did look like." According to the CNA, nursing staff had been made aware of the resident's skin condition. The CNA also stated staff frequently left the resident's [MEDICAL CONDITION] bag off during the night because the resident's skin was red and irritated and the resident had a history of [REDACTED]. Interview with CNA #3 on 12/18/12 at 4:15 PM revealed Resident #2's [MEDICAL CONDITION] bag had frequently been left off because it would not stick to the resident's "raw skin." The CNA stated the resident had one-piece outfits to wear to keep the resident from "picking" at the [MEDICAL CONDITION] bag but the resident had refused to wear the one-piece clothing. The CNA stated she had reported the status of the resident's skin to facility nursing staff and had also reported that the resident refused to wear one-piece outfits "numerous" times. An interview with Licensed Practical Nurse (LPN) #1 on 12/18/12 at 11:30 AM revealed she provided treatment to Resident #2's [MEDICAL CONDITION] on 12/15/12 and 12/16/12. The LPN stated she observed the resident's [MEDICAL CONDITION] stoma to be red and irritated on 12/15/12 and 12/16/12, but failed to review and revise the resident's plan of care. An interview with LPN #2 on 12/18/12 at 2:45 PM revealed she had provided treatment to Resident #2's [MEDICAL CONDITION] on 12/07/12 and had observed the resident's [MEDICAL CONDITION] stoma to be red and irritated. The LPN stated she cleansed the resident's [MEDICAL CONDITION] and applied [MEDICATION NAME] and a [MEDICAL CONDITION] bag to the resident's irritated skin surrounding the stoma. LPN #2 stated she had not revised or updated the resident's plan of care related to the resident's skin condition because she had not been educated in treatments and had "just followed the current physician orders." An interview with LPN #3 on 12/18/12 at 3:30 PM revealed she had provided care to Resident #2 for three years and facility staff had "always" had a problem with the skin surrounding the resident's stoma. The LPN further stated the skin around the resident's stoma had been irritated and red "off and on" since the LPN's employment began "three years ago." The LPN stated she had discussed the resident's skin irritation and redness, and other treatments that could be attempted for the resident, with the Director of Nursing (DON) approximately one or two days prior to the interview; however, LPN #3 stated she had not revised the resident's care plan to reflect the ongoing skin irritation and redness. Interview with LPN #4 on 12/18/12 at 4:30 PM revealed she was aware that Resident #2's [MEDICAL CONDITION] had been irritated for approximately a "year." The LPN acknowledged the treatment to the resident's [MEDICAL CONDITION] was not effective and should have been changed. LPN #4 stated the treatment nurse and/or the MDS staff was to develop changes in the care plan related to residents' wounds and treatments. An interview with the facility's full time treatment nurse, Registered Nurse (RN) #1, on 12/18/12 at 3:00 PM, revealed she was aware Resident #2's skin surrounding the [MEDICAL CONDITION] had been red and inflamed but was unsure of when the resident's skin irritation had initially developed. The RN stated she was unaware that staff had provided only a towel to the resident's [MEDICAL CONDITION] and stated the irritation around the resident's [MEDICAL CONDITION] would have increased with contact from intestinal waste. RN #1 acknowledged she had not updated the resident's plan of care related to concerns with the [MEDICAL CONDITION]. Documentation revealed Resident #2's physician had prescribed [MEDICATION NAME] Cream to be applied to the resident's stoma on a daily and "as needed" basis on 12/19/11 (approximately one year prior to the date of the review, interview, and observation). A review of the Treatment Administration Record revealed staff had applied the [MEDICATION NAME] Cream to the resident's stoma as ordered. However, a review of Resident #2's Plan of Care revealed staff failed to update the resident's plan of care to include application of the [MEDICATION NAME] Cream to the skin surrounding the [MEDICAL CONDITION]. Interview with the Director of Nursing (DON) on 12/19/12 at 8:30 AM revealed facility staff had received physician's orders [REDACTED]. A review of physician's orders [REDACTED]. However, it could not be determined by a review of the physician's orders [REDACTED]. Continued review of the resident's plan of care revealed no evidence the plan of care had been updated to include the use of the [MEDICATION NAME]. The MDS Coordinator stated in interview conducted on 12/18/12 at 6:20 PM that she was not aware of Resident #2's ongoing irritation of the skin surrounding the resident's [MEDICAL CONDITION] site prior to 12/18/12 and, as a result, had not updated the resident's care plan. The MDS Coordinator stated she relied on staff documentation in each resident's medical record to identify behaviors and treatments being provided in order to update the plan of care. The MDS Coordinator stated she was not aware that facility staff had utilized only a cloth towel to cover Resident #2's [MEDICAL CONDITION] site prior to 12/18/12, and had added the intervention of using a towel on the resident's stoma, instead of a [MEDICAL CONDITION] bag, on the morning of 12/18/12. An interview with the Director of Nursing (DON) on 12/18/12 at 6:30 PM revealed she attended wound care meetings monthly and conducted chart reviews on a random basis to ensure resident care plan interventions had been provided and/or revised. The DON stated she had not been made aware of the ongoing irritation of the skin surrounding Resident #2's [MEDICAL CONDITION]. The DON stated the MDS staff received copies of all physician's orders [REDACTED]. The DON stated Resident #2's care plan interventions should have been updated based on staff assessment of the resident's condition.

Based on observation, interview, record review, and a review of the facility's policy, it was determined the facility failed to ensure services were provided in accordance with each resident's written plan of care for one of three sampled residents (Resident #2). Observations conducted on 12/18/12 of [MEDICAL CONDITION] (an abdominal opening surgically created to allow intestinal waste to leave the body) care for Resident #2 revealed the resident's skin surrounding the [MEDICAL CONDITION] stoma was red, irritated, and had two small blisters present to the irritated skin. Observation revealed facility staff had placed a cloth towel directly over the resident's [MEDICAL CONDITION] stoma to collect the intestinal waste. Interviews with facility staff on 12/18/12 revealed the resident had behaviors of removing the [MEDICAL CONDITION] bag his/herself. The staff further stated the resident's skin, surrounding the resident's stoma, had been red and irritated "off and on" for approximately three years. A review of the Comprehensive Care Plan revealed staff noted Resident #2 had skin integrity impairment around the [MEDICAL CONDITION] stoma, and staff had developed interventions that included the use of a [MEDICAL CONDITION] bag and one-piece clothing items to prevent the resident from "picking" at the stoma site. In addition, based on a review of the care plan, staff was to monitor and report changes in the resident's skin integrity and behaviors to the resident's physician. Interviews conducted with facility staff on 12/18/12, revealed Resident #2's skin around the stoma site had been red and irritated "off and on" for approximately three years. However, based on interviews and record reviews, facility staff failed to notify the resident's physician of the resident's skin condition or behaviors. (Refer to F157.) The findings include: A review of the facility's policy titled Resident Care Plan, dated August 2012, revealed the development of a resident's care plan would be an ongoing process, and would include current problems and problems identified between the scheduled care plan reviews. The policy revealed modifications and the implementation of a resident's care plan would be completed as the Care Plan Coordinator directed. A review of Resident #2's medical record on 12/18/12 revealed the facility admitted the resident on 03/03/09 with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A review of the Quarterly Minimum Data Set Assessment ((MDS) dated [DATE] revealed facility staff had assessed the resident to be interviewable and to have the ability to make his/herself understood and to understand others. In addition, the MDS revealed facility staff had assessed the resident to require the extensive assistance of two staff members for bed mobility, dressing, toilet use, and personal hygiene. Continued review of the MDS revealed no evidence that the resident had exhibited any behavioral symptoms or rejection of care during the assessment period. A review on 12/18/12 of the Comprehensive Care plan for Resident #2, updated on 10/25/12, revealed staff had identified the resident to have an alteration in bowel elimination with placement of a permanent [MEDICAL CONDITION]. Facility staff also noted the resident "picks at bag and around and in stoma site" and developed interventions that included dressing the resident in one-piece outfits in an effort to prevent the resident from picking at the stoma site. In addition, staff was to ensure the [MEDICAL CONDITION] bag was changed as needed. Facility staff was also to report any redness, inflammation, or drainage at the resident's [MEDICAL CONDITION] site to the physician. Observations conducted on 12/18/12 at 8:30 AM of Resident #2's [MEDICAL CONDITION] care revealed a towel, used for bathing, had been placed over the resident's [MEDICAL CONDITION] to collect intestinal wastes. Observations of the resident's skin surrounding the stoma, revealed the resident's skin was red, irritated, and had two small blisters present. Resident #2 was observed to have facial grimacing and verbalized, "That hurts, that burns," when Certified Nursing Assistant (CNA) #1 and CNA #2 provided the resident with stoma site care. After CNA #1 cleansed the resident's skin surrounding the [MEDICAL CONDITION], the resident was observed to have facial grimacing when the CNA applied a [MEDICAL CONDITION] bag over the resident's red, irritated skin. An interview conducted on 12/18/12 at 9:00 AM with Resident #2 revealed, "My [MEDICAL CONDITION] fire around my [MEDICAL CONDITION]; they put medicine on it, but it's not helping." The resident continued to state he/she was unaware of how long the skin irritation had been present, and stated, "They leave the bag off of me at times, because it hurts so bad when it's on me because of my skin." Interview on 12/18/12 at 8:40 AM with CNA #1 revealed she had been assigned to provide care to Resident #2 on 12/18/12. CNA #1 stated Resident #2's skin had been red and irritated for a "year" and that the resident's skin "looks a lot better now than what it did look like." According to the CNA, nursing staff had been made aware of the resident's skin condition. The CNA also stated staff frequently left the resident's [MEDICAL CONDITION] bag off during the night because the resident's skin was red and irritated and the resident had a history of [REDACTED]. Interview with CNA #3 on 12/18/12 at 4:15 PM revealed Resident #2's [MEDICAL CONDITION] bag had frequently been left off because it would not stick to the resident's "raw skin." The CNA stated the resident had one-piece outfits to wear to keep the resident from "picking" at the [MEDICAL CONDITION] bag but the resident refused to wear the one-piece clothing. The CNA stated she had reported the status of the resident's skin to facility nursing staff "numerous" times. An interview with Licensed Practical Nurse (LPN) #1 on 12/18/12 at 11:30 AM revealed she provided treatment to Resident #2's [MEDICAL CONDITION] on 12/15/12 and 12/16/12. The LPN stated she had observed the resident's [MEDICAL CONDITION] stoma to be red and irritated on 12/15/12 and 12/16/12, but failed to notify the resident's physician of the appearance of Resident #2's [MEDICAL CONDITION] site as directed in the resident's plan of care. An interview with LPN #2 on 12/18/12 at 2:45 PM revealed she had provided treatment to Resident #2's [MEDICAL CONDITION] on 12/07/12 and had observed the resident's [MEDICAL CONDITION] stoma to be red and irritated. The LPN stated she cleansed the resident's [MEDICAL CONDITION] and applied [MEDICATION NAME] and a [MEDICAL CONDITION] bag to the resident's irritated skin surrounding the stoma. LPN #2 stated she had not contacted the resident's physician related to the resident's skin condition because she had not been educated in treatments and had "just followed the current physician orders." Interview with LPN #4 on 12/18/12 at 4:30 PM revealed she was aware that Resident #2's [MEDICAL CONDITION] had been irritated for approximately a "year." The LPN acknowledged the treatment to the resident's [MEDICAL CONDITION] was not effective and should have been changed. LPN #4 stated she had not contacted the resident's physician or notified MDS staff of the resident's skin condition in order for them to direct care plan changes. The LPN further stated the treatment nurse and/or the MDS staff was to develop changes in the care plan related to residents' wounds and treatments. An interview with the facility's full time treatment nurse, Registered Nurse (RN) #1, on 12/18/12 at 3:00 PM, revealed she was aware Resident #2's skin surrounding the [MEDICAL CONDITION] had been red and inflamed but was unsure of when the resident's skin irritation had initially developed. The RN stated she was unaware that staff had provided only a towel to the resident's [MEDICAL CONDITION] and stated the irritation around the resident's [MEDICAL CONDITION] would have increased with contact from intestinal waste. RN #1 acknowledged it was her responsibility to contact the resident's physician related to any concerns with wounds or current treatment orders and to assist with updating the resident's plan of care; however, RN #1 stated she had not contacted the resident's physician related to the ongoing irritation of the resident's [MEDICAL CONDITION]. An interview with the Director of Nursing (DON) on 12/18/12 at 6:30 PM revealed she attended wound care meetings monthly and conducted chart reviews on a random basis to ensure resident care plan interventions had been implemented. The DON stated she had not been made aware of the ongoing irritation of the skin surrounding Resident #2's [MEDICAL CONDITION] and acknowledged staff should have informed the resident's physician of the continued skin irritation surrounding the resident's [MEDICAL CONDITION].

Based on observation, interview, and record review it was determined the facility failed to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, for one of three sampled residents (Resident #2). Observations conducted on 12/18/12, of Resident #2 s [MEDICAL CONDITION] (an abdominal opening surgically created to allow intestinal waste to leave the body) care revealed facility staff had placed a cloth towel directly over the resident's stoma site to collect the intestinal waste which was being secreted from the resident's body. Further observations revealed the resident's skin surrounding the stoma site was red, irritated, and had two small blisters present to the irritated skin. Interviews with facility staff on 12/18/12 revealed the resident's skin, surrounding the resident's [MEDICAL CONDITION], had been red and irritated, off and on, for approximately three years. However, the facility failed to ensure staff informed Resident #2's physician of the ongoing irritation of the skin surrounding the resident's [MEDICAL CONDITION] as indicated in the plan of care in order for the physician to determine if the prescribed treatment needed to be altered, and failed to ensure the resident's plan of care was updated, as needed, related to the facility's assessment of the improvement/lack of improvement of the skin irritation. A review of the plan of care also revealed facility staff failed to inform the resident's physician of the resident's resistance to comply with the use of a [MEDICAL CONDITION] bag to cover the stoma based on the facility's observations/assessment of the resident. The findings include: An interview with the Minimum Data Set Assessment (MDS) and Care Plan Coordinator on 12/18/12 at 6:20 PM revealed they followed the guidelines provided on the MDS document for completion of the assessment. A review of the facility's policy titled Resident Care Plan, dated August 2012, revealed the development of a resident's care plan would be an ongoing process, and would include current problems and problems identified between the scheduled care plan reviews. The policy revealed modifications to a resident's care plan would be completed as the Care Plan Coordinator directed. In addition, a review of the facility's policy entitled Notification of Physician for Change in Resident's Condition, dated August 2012, revealed staff was to notify the resident's physician when a significant change in a resident's condition occurred. Continued review of policies revealed the facility's policy titled [MEDICAL CONDITION] and [MEDICAL CONDITION] Care, dated February 2007. Based on the policy, the facility's objective was to maintain cleanliness and provide good skin care to the facility residents. An interview with the Director of Nursing (DON) at 6:30 PM on 12/18/12 revealed the facility did not have a specific policy related to resident behaviors. The DON stated staff was responsible to document any behaviors exhibited during their shift. A review of Resident #2's medical record on 12/18/12 revealed the facility admitted the resident on 03/03/09 with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A review of the Quarterly Minimum Data Set Assessment ((MDS) dated [DATE], revealed facility staff had assessed the resident to have the ability to make his/herself understood, and to understand others, and was interviewable. Further review of the MDS revealed facility staff had assessed the resident to require the extensive assistance of two staff members for bed mobility, dressing, toilet use, and personal hygiene. The MDS provided no evidence that the resident had exhibited any behavioral symptoms or rejection of care during the assessment period. A review on 12/18/12 of the Comprehensive Care Plan for Resident #2 last updated on 10/25/12 revealed staff had identified the resident to have an alteration in bowel elimination with placement of a permanent [MEDICAL CONDITION]. Facility staff also noted the resident "picks at bag and around and in stoma site." Interventions included dressing the resident in one-piece outfits to prevent the resident's access to the [MEDICAL CONDITION] site and prevent the resident from picking at the [MEDICAL CONDITION] stoma. In addition, staff was to ensure the [MEDICAL CONDITION] bag was changed as needed. Facility staff was also to report any redness, inflammation, or drainage at the resident's [MEDICAL CONDITION] site to the nurse. A review conducted on 12/18/12 of the weekly skin assessments conducted by facility staff of Resident #2 on 12/03/12, 12/10/12, and 12/17/12 revealed staff had performed the daily treatment to the resident's [MEDICAL CONDITION]. Further review revealed no evidence staff had documented the appearance of the resident's skin surrounding the [MEDICAL CONDITION] or assessed the area related to healing or worsening in appearance. Observations conducted of Resident #2's [MEDICAL CONDITION] care on 12/18/12 at 8:30 AM revealed a towel, used for bathing, had been placed over the resident's [MEDICAL CONDITION] to collect the intestinal wastes. Observations of the resident's skin surrounding the [MEDICAL CONDITION] revealed the resident's skin was red, irritated, and had two small blisters present. Resident #2 was observed during [MEDICAL CONDITION] care to have facial grimacing and verbalized, "That hurts, that burns," when Certified Nursing Assistant (CNA) #1 and CNA #2 provided the resident with stoma site care. After CNA #1 cleansed the resident's skin surrounding the [MEDICAL CONDITION], the CNA applied a [MEDICAL CONDITION] bag over the resident's red, irritated skin and the resident was observed to have facial grimacing while the CNA applied the [MEDICAL CONDITION] bag. Observations further revealed staff failed to ensure the [MEDICATION NAME] Cream was applied to the resident's irritated skin surrounding the [MEDICAL CONDITION] as prescribed by the physician. An interview conducted on 12/18/12 at 9:00 AM with Resident #2 revealed, "My [MEDICAL CONDITION] fire, around my [MEDICAL CONDITION]; they put medicine on it, but it's not helping." The resident continued to state he/she was unaware of how long the skin irritation had been present, and stated, "They leave the bag off of me at times, because it hurts so bad when it's on me because of my skin." Interview on 12/18/12 at 8:40 AM, with CNA #1, assigned to provide care to Resident #2 on 12/18/12, revealed Resident #2's skin around the [MEDICAL CONDITION] had been red and irritated for a "year." CNA #1 stated the resident's skin "looks a lot better now than what it did look like." The CNA stated staff frequently left the resident's [MEDICAL CONDITION] bag off during the night because the resident's skin was red and irritated and the resident had a history of [REDACTED]. The CNA continued to state the facility nursing staff had been made aware of the resident's skin condition. Interview with CNA #3 on 12/18/12 at 4:15 PM revealed Resident #2's [MEDICAL CONDITION] bag had frequently been left off because it would not stick to the resident's "raw skin." The CNA stated the resident had one-piece outfits to wear to keep the resident from "picking" at the [MEDICAL CONDITION] bag, when it was applied, but the resident refused to wear them. The CNA stated she had reported the status of the resident's skin to nursing staff and that the resident refused to wear one-piece outfits "numerous" times. The CNA also stated the nursing staff was aware that a towel was used to cover the resident's [MEDICAL CONDITION] site. An interview with Licensed Practical Nurse (LPN) #1 on 12/18/12 at 11:30 AM revealed she had been assigned to provide treatment to Resident #2's [MEDICAL CONDITION] on 12/15/12 and 12/16/12. The LPN stated she had observed the skin surrounding resident's [MEDICAL CONDITION] to be red and irritated on 12/15/12 and 12/16/12, and was aware staff had not provided the resident with a [MEDICAL CONDITION] bag to collect the resident's intestinal wastes. The LPN stated she had applied [MEDICATION NAME] Cream (topical anti-infective) and a [MEDICAL CONDITION] bag to the resident's [MEDICAL CONDITION] on 12/15/12 and 12/16/12. LPN #1 stated she was "new" at providing treatments, and didn't know if the treatment ordered for Resident #2 was "appropriate or not," and stated she had not contacted the resident's physician related to the appearance of Resident #2's [MEDICAL CONDITION] as directed in the plan of care. An interview with LPN #2 on 12/18/12 at 2:45 PM revealed she had provided treatment to Resident #2's [MEDICAL CONDITION] on 12/07/12 and observed the resident's [MEDICAL CONDITION] stoma to be red and irritated. The LPN stated she had observed "just a towel" to be present to the resident's [MEDICAL CONDITION] and was unsure why a [MEDICAL CONDITION] bag had not been provided for the resident. The LPN stated she cleansed the resident's [MEDICAL CONDITION] and applied [MEDICATION NAME] and a [MEDICAL CONDITION] bag to the resident's irritated skin. The LPN also stated she had not contacted the resident's physician related to the resident's skin condition as directed in the plan of care because she had not been educated in treatments and had "just followed the current physician orders." An interview with LPN #3 on 12/18/12 at 3:30 PM revealed she had provided care to Resident #2 for three years and facility staff had "always had a problem with the resident's skin surrounding the resident's stoma." The LPN further stated the resident's skin which surrounded his/her [MEDICAL CONDITION] stoma had been irritated and red off and on, approximately "three years." The LPN stated she had discussed the resident's skin irritation, redness, and other treatments that could be attempted for the resident with the Director of Nursing (DON) approximately one or two days prior to the interview; however, the LPN stated she wasn't aware of any further assessment or treatment that had been provided to Resident #2. The LPN acknowledged, based on documentation, staff failed to contact the resident's physician related to the status of the resident's skin around the stoma as directed in the plan of care and stated "someone probably should have." Interview with LPN #4 on 12/18/12 at 4:30 PM revealed she was aware that Resident #2's skin had been irritated for approximately a year. Although the LPN stated the resident's skin treatment should have been changed because it had not been effective, the LPN acknowledged she had not contacted the resident's physician because it was the responsibility of the treatment nurse. An interview with the facility's full time treatment nurse, Registered Nurse (RN) #1 on 12/18/12 at 3:00 PM, revealed Resident #2's skin surrounding the [MEDICAL CONDITION] had been red and inflamed and she was unsure of when the resident's skin irritation had initially developed, or when staff had contacted the resident's physician related to the condition of the resident's skin surrounding the [MEDICAL CONDITION]. RN #1 stated she thought [MEDICATION NAME] had been an "appropriate treatment" in the past for the resident's skin condition and had not contacted the resident's physician related to the status of the resident's skin. The RN stated she was unaware that staff had provided only a towel to the resident's [MEDICAL CONDITION] site, and confirmed the intestinal wastes in direct contact with the resident's skin would have increased the resident's skin irritation. Based on documentation, staff had applied [MEDICATION NAME] Cream to Resident #2's [MEDICAL CONDITION] on a daily and "as needed" basis; however, observation on 12/19/12 revealed the resident's skin surrounding the [MEDICAL CONDITION] was red, irritated, and had two small blisters present. A review conducted on 12/18/12 and 12/19/12 of documentation in the medical record revealed staff had not contacted/informed the resident's physician of the ongoing redness/irritation of the skin surrounding Resident #2's [MEDICAL CONDITION] as directed in the resident's plan of care. Interview with the Director of Nursing (DON) revealed on 12/19/12 at 8:30 AM facility staff had received physician's orders [REDACTED]. as directed. A review of physician's orders [REDACTED]. stoma site. In addition, a review of the resident's comprehensive plan of care provided no evidence that staff had completed any modifications related to the resident's ongoing skin redness/irritation. An interview with the Director of Nursing (DON) on 12/18/12 at 6:30 PM revealed she attended the monthly wound care meetings and conducted chart reviews of charts selected at random. The DON stated she had not been made aware of the ongoing skin irritation and redness to Resident #2's [MEDICAL CONDITION] or that staff had failed to contact the resident's physician as directed in the plan of care. The DON stated she had not assessed the resident's skin prior to 12/18/12 and had relied on the facility's treatment nurse to intervene appropriately for the residents.