Every finding on record at MS Care Center of Alcorn County, Inc-Snf

Based on observation, interview, record review, and facility policy review, the facility failed to ensure residents were treated with dignity by providing timely responses to requests for assistance for two (2) of two (2) residents interviewed regarding call light response (Residents #2 and #3) and for one (1) of 55 occupied rooms observed (room [ROOM NUMBER]). This failure resulted in prolonged delays in responding to call lights and residents reporting repeated waits for assistance with toileting and incontinence care. Findings Include: Record review of facility policy titled Call System dated October 2022 revealed, .2. All employees shall respond to a nurse call system in a prompt, efficient, and courteous manner within 5-7 minutes .Record review of facility policy titled Resident Rights Policy with revision date of 9/2022 revealed, .Facility will ensure the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility .During an interview on 7/22/2026 at 10:30 AM, Resident #3 stated that she often has to wait 30 minutes or longer for staff to respond to her call light. She stated staff sometimes come in and turn the call light off but do not provide the assistance she needs, requiring her to activate the call light again. She stated she is a heavy wetter and relies on staff to respond to her call light for assistance with changing her brief.During an interview on 7/22/2026 at 11:58 AM, Resident #2 stated that she had recently waited an hour and a half for staff to respond to her call light to change her soiled brief. She stated she frequently soils herself because staff take too long to answer her call light. Resident #2's daughter and niece were present during the interview and stated that approximately one month earlier, Resident #2 activated her call light at approximately 10:00 AM, but staff did not respond until after lunch. Resident #2's niece further stated she had visited the facility on numerous occasions and had not observed staff enter the resident's room during her visits. She stated her visits typically last three hours or longer.During an observation on 7/22/2026 beginning at 2:21 PM, the call light outside room [ROOM NUMBER] was visible and turned on and the call light system at the nurses' station was making an audible sound. During the observation, at least five (5) staff members, including licensed nurses and Certified Nursing Assistants (CNAs), walked past room [ROOM NUMBER] without responding to the call light. One CNA exited another resident room, placed soiled linen in a nearby linen barrel, and continued down the hallway without responding to the sounding call light. Two (2) licensed nurses exited another resident room, walked past room [ROOM NUMBER], and did not respond. Additionally, three (3) licensed nurses and one (1) CNA were observed at the nurses' station while the call light system continued to sound. No staff member responded to the call light for approximately 15- 20 minutes. During an interview on 7/23/2026 at 12:17 PM, the Director of Nursing (DON) stated it is her expectation that staff respond to call lights promptly in accordance with facility policy. She stated that all staff are responsible for answering call lights, regardless of their department or job title. She further stated that if a staff member is unable to provide the assistance requested, they are expected to determine the resident's needs and immediately notify or obtain the appropriate staff member to provide the necessary assistance. The DON confirmed that staff should not walk past an unanswered call light and that the call light should have been answered in a timely manner.Record review of admission Record revealed Resident #2 was admitted to facility on 5/31/2022 and had diagnoses of Other Fracture of Shaft of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing, Unspecified Abnormalities of Gait and Mobility, and Muscle Weakness (Generalized). Record review of the Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 5/5/2026 revealed a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #2 was cognitively intact. Record review of admission Record revealed Resident #3 was admitted to facility on 2/23/2026 and had diagnoses of Urinary Tract Infection, Site Not Specified and Type 2 Diabetes Mellitus Without Complications. Record review of the MDS with ARD of 5/31/2026 revealed a BIMS summary score of 15, indicating Resident #3 as cognitively intact.

Based on resident and staff interviews, observation, record review and facility policy review, the facility failed to ensure interventions were maintained to prevent the recurrence of a pressure injury for one (1) of 18 sampled residents. Resident #3Findings Include:Review of the facility policy titled Pressure Injury Prevention Guidelines undated, revealed, Inspect skin while providing care .Pressure Relieving Devices: 6. Provide alternative support surfaces as needed. Considerations for utilizing specialized support surfaces: a. Medical condition and weight .e. Stage 3, 4, unstageable, or deep tissue injury on trunk .Record review of the Wound Care Note dated 2/4/26, by the Wound Care Family Nurse Practitioner (FNP), revealed Resident #3 had a Stage 4 pressure injury to the sacrum that was documented as a status of healed.Record review of the Wound Care Note dated 3/25/26, by the Wound Care FNP, revealed .being seen for evaluation of a re-opened Stage 4 sacral wound Record review of the Order Summary Report revealed a Physician Order dated 3/23/26 for Sacrum, Cleanse with wound cleanser, apply Medi honey to wound bed, cover with calcium alginate, secure with bordered foam dressing, every day shift for Stage 4 pressure injury,During an interview on 3/31/26 at 8:55 AM, Resident #3 expressed frustration and sadness that his previously healed wound had reopened, stating the button on that pump wasn't set right, referring to his air mattress on his bed. He reported that the Treatment Nurse informed him his wound had reopened and that his skin was blistered on his bottom. Resident #3 further revealed the Treatment Nurse instructed him to ensure that when anyone entered his room, they did not bump the pump at the end of the bed and that it remained on.During an interview on 3/31/26 at 10:35 AM, Licensed Practical Nurse (LPN) #3 revealed the resident's air mattress had been mistakenly set to the static setting, which made the mattress firm and eliminated the alternating pressure function. She stated she believed that during care, when staff repositioned or pulled the resident up in bed, the increased firmness contributed to friction and resulted in the wound reopening.During an interview on 3/31/26 at 11:10 AM, the Director of Nursing (DON) confirmed the resident's wound had previously healed but reported receiving a text message from the Treatment Nurse on March 23, 2026, indicating that the wound had reopened and that the mattress had been set to static, preventing proper pressure redistribution.During a subsequent interview on 3/31/26 at 12:29 PM, the DON revealed that, according to facility body audits, there were no documented skin concerns after the wound had resolved on 2/2/26. The DON acknowledged that failure to ensure proper use and monitoring of pressure-relieving equipment could place the resident at risk for further skin breakdown.During an interview on 3/31/26 at 2:30 PM, the Treatment Nurse confirmed Resident #3 had a prior sacral pressure injury that was healed and resolved on 02/2/26. She reported that on 03/23/26, she was called to assess the resident after he complained of discomfort to his buttocks. Upon entering the room, she immediately assessed the control box of the resident's air mattress and observed it was set to static mode at a weight setting of 260. She explained this setting results in a fully firm surface and eliminates the alternating pressure function necessary for pressure redistribution. She stated, I don't like this control box because it is so easy to be manipulated-someone can easily bump into it and change the settings.During an interview on 3/31/26 at 3:00 PM, Certified Nurse Aide (CNA) #2 confirmed the resident previously had a significant pressure ulcer to the sacral area that had healed and stated, He was doing good. She further revealed the wound had since reopened and reported she had heard it was related to the air mattress controls not being set correctly.During an interview on 4/1/26 at 10:05 AM, CNA #1 revealed she was providing care to the resident on the day the incorrect mattress setting was identified, and the wound was noted to have reopened. She confirmed the Wound Nurse assessed the pump and instructed staff to ensure the yellow light was not activated, as it caused the mattress to become firm. CNA #1 stated the Wound Nurse explained that having the mattress set incorrectly defeated the purpose of having an air mattress if it was not working the way it should.Record review of the admission Record revealed the facility re-admitted Resident #3 on 1/31/26 with medical diagnoses that included Pressure ulcer of sacral Region, Stage 4, Heart failure, Chronic Obstructive Pulmonary Disease, and chronic kidney disease. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/9/26 revealed under Section C, a Brief Interview for Mental Status (BIMS) summary score of 10, indicating Resident #3 was moderately cognitively impaired.

Based on record review, staff interview and facility policy review, the facility failed to obtain informed consent from the resident or resident representative prior to initiating psychotropic medications for five (5) of 5 residents reviewed for unnecessary medications. Resident #4, Resident #6, Resident #10, Resident #12 and Resident #92 Findings Include: Record review revealed that the facility did not have a policy and provided a statement on letterhead signed by the Administrator dated 03/31/26 (Proper name of the facility) does not currently have a Psychotropic Consent Policy. Resident #4 Record review of the Order Summary Report revealed a physician's order dated 2/13/2026 for Zyprexa oral tablet 5 milligrams (mg) give 5 mg by mouth at bedtime for schizoaffective disorder. Record review revealed a lack of consent forms for psychotropic medications were signed prior to initiation. Record review of the admission Record revealed that Resident #4 was admitted to the facility on [DATE] with a medical diagnosis that included schizoaffective disorder. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/12/2026 revealed a Brief Interview for Mental Status score (BIMS) indicating that the resident was rarely/never understood. Resident #6 Record review of the Order Summary Report revealed a physician's order dated 9/18/25 for Olanzapine tablet 5 mg give 1 tablet by mouth two times a day for affective mood disorder, and a physician's order dated 1/15/26 for Zoloft oral tablet 50 mg give 1 tablet by mouth one time a day for depression. Record review revealed a lack of consent forms for psychotropic medications were signed prior to initiation. Record review of the admission Record revealed that Resident #6 was admitted to the facility on [DATE] with medical diagnoses that included Major Depressive Disorder, Unspecified Mood Disorder, and Generalized Anxiety Disorder. Record review of the MDS with an ARD of 2/12/26 revealed a BIMS score of 10, indicating that the resident was moderately impaired with cognition. Resident #10 Record review of the Order Summary Report revealed physician's orders dated 12/11/25 for Trazadone 50 mg give one tablet by mouth one time a day for depression and Risperidone 0.25 mg give one tablet by mouth at bedtime for depression. Record review revealed a lack of consent forms for psychotropic medications were signed prior to initiation. Interview with the Director of Nursing (DON) on 03/31/26 at 12:25 PM stated, I'm going to be honest we haven't been doing the consent forms. I just discovered this a few weeks ago at a meeting that we weren't doing them and we should have been. Record review of the admission Record revealed that Resident #10 was admitted to the facility on [DATE] with diagnosis that included Unspecified Dementia, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. Record review of the MDS with an ARD of 03/05/26 revealed a BIMS score of 03 indicating that the resident was severely impaired with cognition. Resident #12 Record review under the Order Summary Report revealed a physician's order dated 12/15/2025 for Quetiapine Fumarate oral tablet 100 MG, give 1 tablet by mouth at bedtime for affective disorder, bipolar, give with 200 mg to equal total of 300 mg at bedtime, a physician's order dated 12/15/2025 for Seroquel XR oral tablet extended release 24 hour 200 MG (Quetiapine Fumarate), give 1 tablet by mouth at bedtime for affective disorder, Bipolar Disorder take with the 100 mg for a total of 300 mg, and a physician's order dated 2/02/2026 for Risperdal oral tablet 1 mg, give 1 tablet by mouth two times a day for anxiety. Record review revealed that a lack of consent forms for psychotropic medications was signed prior to medication initiation. Record review of the admission Record revealed that Resident #12 was admitted to the facility on [DATE] with medical diagnoses that included schizoaffective disorder and dementia. Record review of the MDS with an ARD of 1/09/2026 revealed a BIMS score of 11, indicating that Resident #12 had moderate impaired cognition. Resident #92 Record review under the Order Summary Report revealed a physician's order dated 8/28/25 for Alprazolam oral tablet 0.5 mg give 1 tablet by mouth at bedtime for anxiety, Seroquel oral tablet 100 mg give 1 tablet by mouth at bedtime for Dementia illness with associated behavioral symptoms, Sertraline HCI oral tablet 100 mg, give 1 tablet by mouth one time a day for Depression, and an order dated 2/27/26 for Trazodone HCI tablet 100 mg, give 1 tablet by mouth at bedtime for Depression. Record review revealed that a lack of consent forms for psychotropic medications was signed prior to medication initiation. Record review of the admission Record revealed that Resident #92 was admitted to the facility on [DATE] with medical diagnoses that included Major Depressive Disorder, Unspecified Dementia Anxiety Disorder, and Insomnia. Record review of the MDS with an ARD of 3/3/26 revealed a BIMS score of 7, indicating that Resident #92 was moderately impaired with cognition.

Based on observations, interviews, and facility policy review, the facility failed to label and store food properly for one (1) of two (2) kitchen tours. Findings include:Review of facility policy titled Storage of Refrigerated Food revised 11/23, revealed, .All opened foods are labeled with common name of food and date stored and/or use-by date.During the initial kitchen tour with the Dietary Manager (DM) on 3/30/26 at 9:12 AM several observations were made regarding food storage practices. In reach-in cooler number one (1), several items, including sliced tomatoes, sliced cheese in a clear container, a five (5) gallon container of pasta salad, a one gallon container of sweet and sour sauce, a four (4) pound (lb.) uncovered container of sweet cornbread, 12 boiled eggs, one gallon of liquid seasoning sauce, one gallon of sweet pickle relish, one gallon of BBQ sauce, one gallon of jalapeno peppers, and one gallon of apple cider vinegar were present without dates indicating when they were opened or when they expired. In reach-in cooler number two (2), several items, including 46-ounce (oz.) containers of prune juice, grape juice, and tomato juice; one half gallon of buttermilk, two one-gallon jugs of whole milk, and a one-gallon jug of sweet tea were also present without dates indicating when they were opened or when they expired. During an interview on 3/30/26 at 9:46 AM with the Dietary Manager, she confirmed that no open food items should be stored without an open date and confirmed that the facility policy mandates that all open food items be labeled with an open date for safety and organization.

Based on observations, interviews, and facility policy review, the facility failed to maintain effective pest control management by preventing pests from entering the food and nutrition service department for one (1) of two (2) kitchen tours. Findings included:Review of facility policy titled Pest Control revised 8/17, revealed, Policy: In order to maintain a safe and sanitary environment, a pest management program is used to prevent pests from entering the food and nutrition service department and to implement measures to eliminate any pest infestations.During the initial kitchen tour with the Dietary Manager (DM) on 3/30/26 at 9:12 AM, multiple flies were observed randomly flying around in the kitchen prep and cook area and a cockroach was noted crawling on the floor in the dietary manager's office. During an interview on 3/30/26 at 9:12 AM, the Dietary Manager confirmed that the presence of pests (flies and roaches) was unsanitary and they should not be present in food prep or food storage areas.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure the resident's right to dignity was maintained by not providing privacy for a urinary catheter drainage bag for one (1) of six (6) residents with an indwelling catheter. Resident #3.Findings Include:Review of the facility policy titled Dignity and Respect, undated, revealed, Each resident at the facility has the right to a dignified existence . During an observation on 3/30/26 at 9:50 AM, Resident #3 was noted to have a urinary catheter drainage bag containing approximately 100 cubic centimeters (cc) of yellow urine hanging on the lower left side of the bed. The drainage bag was not placed in a privacy bag and was clearly visible to anyone entering the room. During an observation and interview on 3/30/26 at 9:56 AM, the Quality Assurance (QA) Nurse responded to the resident's call light and confirmed the urinary catheter drainage bag was not placed in a privacy bag. The QA Nurse acknowledged that the exposure of the drainage bag constituted a dignity concern for Resident #3. Record review of the admission Record revealed the facility re-admitted Resident #3 on 1/31/26 with medical diagnoses that included Pressure ulcer of sacral Region, Stage 4, Heart failure, Chronic Obstructive Pulmonary Disease, and chronic kidney disease. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/9/26 revealed under Section C, a Brief Interview for Mental Status (BIMS) summary score of 10, indicating Resident #3 was moderately cognitively impaired.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure resident privacy during wound care when privacy measures were not implemented for one (1) of four (4) care opportunities observed. Resident #90 Findings Include:Record review of the facility policy titled Dignity and Respect undated revealed under, .5. Residents will be examined and treated in a manner that maintains bodily privacy. A closed door and/or drawn cubicle curtain should be utilized to maximize the privacy of each resident while rendering care .Record review of Resident #90's Treatment Administration Record revealed an order dated 3/17/26, Left heel, cleanse with wound cleanser, apply collagen to wound bed, cover with bordered foam dressing every day shift for stage 3 pressure injury. During an observation of Resident #90's wound care on 3/31/26 at 2:58 PM with the Wound Nurse, she performed wound care to the resident's left heel and pulled the resident's brief down to assess the skin on the resident's buttocks without shutting the window blind for privacy. The window was visible from the courtyard, where another resident and one staff member were outdoors during this time. An interview with the Wound Nurse on 3/31/26 at 3:12 PM confirmed she did not close Resident #90's blind prior to rendering care. She stated the blind should be closed for the resident's privacy. Record review of the admission Record revealed the facility admitted Resident #90 on 3/16/26 with medical diagnoses including Nondisplaced Zone I Fracture of Sacrum, Pressure Ulcer of Left Heel, Stage 3, and Pressure Ulcer of Left Buttock, Stage 1. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/23/26 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated Resident #90 was cognitively intact.

Based on observation, record review, staff interviews, and facility policy review, the facility failed to ensure a resident received an ordered supplement to prevent weight loss for one (1) of four (4) residents reviewed for nutrition. Resident #8. Findings Include: Record review of facility policy titled Weight Policy with no date, revealed, The facility shall evaluate a resident with significant weight changes to identify clinical conditions and risk factors that place the resident at risk for unintended weight change and initiate interventions if needed . A dining observation of Resident #8 on 3/30/2026 at 11:30 AM revealed no nutritional supplement that was ordered was present on the lunch meal tray. The meal included barbecue chicken, sweet peas, potato salad, garlic bread, peach cobbler, and four (4) ounces (oz) of apple juice. Record review revealed a diet order of Controlled Carb Diet (CCD), No Added Salt (NAS), and Super Pudding to lunch and supper meals. An interview with Quality Assurance (QA) nurse on 3/30/2026 at 11:32 AM revealed that the super pudding was on back order, and she confirmed that is the reason that the resident did not have it on his meal tray. Record review revealed the physician order for the super pudding was received and entered on 2/27/2026. An interview with the Dietary Manager on 3/31/2026 at 3:15 PM confirmed that the super pudding was on back order. She revealed that the super pudding had been on back order for three (3) weeks. She revealed that she notified the QA nurse that the super pudding was on back order. She confirmed that Resident #8 had not received an alternative for the super pudding. Interview with QA nurse on 3/31/2026 at 3:25 pm revealed she did not communicate with Registered Dietician (RD) that the super pudding was on back order. QA nurse stated she called and confirmed with the RD that she had not been notified of the super pudding being on back order so she could offer another supplement. Record review of Resident #8's weights revealed on 01/01/2026 the resident weighed 160 pounds (lbs.). On 02/01/2026 the resident weighed 155 lbs. On 02/10/2026 the resident weighed 145 lbs. On 03/01/2026 the resident weighed 148 lbs. Record review of recipe report titled Pudding, Super - Fortified Foods revealed the super pudding contains 220 calories, 30 grams of carbohydrates, 6 grams of protein, and 9 grams of fat. Record review of the RD progress notes revealed on 03/24/2026, Resident #8 triggered for significant weight loss of 4.5% in 30 days. She stated the resident is newly started on dialysis which may result in weight loss due to removing excess fluid. Resident's weight was 148 lbs. Resident on CCD/NAS, Regular diet with excellent intake. Consuming 80% (percent) of meals to meet nutritional needs. Record review of the admission Record revealed the facility admitted Resident #8 on 11/06/2025 with medical diagnoses that included Muscle Weakness (Generalized) and Chronic Kidney Disease, unspecified. Record Review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/17/2026 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 04, indicating Resident #8 was severely cognitively impaired.

Based on observation, staff interviews, record review, and facility policy review, the facility failed to ensure physician-ordered settings and proper oxygen integration for a Trilogy ventilator for one (1) of two (2) resident reviewed for respiratory care. Resident #100Findings Include:The facility provided a statement on letterhead that read, (Proper name of the facility) does not currently have a policy in place to obtain Physician Orders regarding Trilogy settings.On 3/30/2026 at 9:59 AM, during an observation of Resident #100, he was observed lying in bed with the head of the bed elevated and extremely short of breath (SOB) with rapid respirations. Oxygen was in place at three (3) liters by nasal cannula. A Trilogy ventilator was observed sitting on the table beside the bed without an oxygen enrichment line connected to the device.On 3/31/26 at 8:02 AM, an observation revealed Resident #100's Trilogy machine did not have an oxygen enrichment line attached to the device.Record review of Resident #100's Order Summary report revealed an order dated 3/20/26, Apply Trilogy Q (every) HS (hour sleep) at bedtime without physician-ordered settings or a physician order instructing staff to ensure oxygen was connected (bled) to the machine at the physician-ordered rate per minute. Further review revealed an order dated 3/19/26, Oxygen at 3 LPM (liters per minute) per NC (nasal cannula) every shift.During an interview with Licensed Practical Nurse (LPN) #2 on 3/31/26 at 10:36 AM, she revealed Resident #100 wears the Trilogy at night and stated the settings for the Trilogy should be in the orders; however, upon review, she confirmed the resident did not have physician orders for the settings. LPN #2 stated she could ask the resident what his settings were and, if the resident could not remember, she would call the physician.On 3/31/26 at 10:45 AM, an interview with LPN #4 revealed Resident #100 brought the Trilogy machine from home with pre-set settings. She confirmed there was not a physician order for the settings and that staff had not verified the programmed settings for accuracy.During an interview with the Director of Nursing (DON) on 3/31/26 at 11:01 AM,, she revealed there were no physician orders for the settings because they don't do that and confirmed there was no process in place to ensure Resident #100 was receiving the correct settings because the machine came to the facility pre-set by the medical equipment provider. She confirmed the resident could experience respiratory distress if he was not receiving the correct settings along with the correct method of oxygen delivery.During a telephone interview with Proper name of medical equipment supplier Respiratory Therapist (RT) on 3/31/26 at 1:46 PM, she revealed she was contacted by the facility to evaluate the Trilogy machine today and she had not previously assessed the machine. The RT confirmed the facility should have ventilator settings in place to verify the parameters prescribed by the physician. She revealed the machine required oxygen to be bled into the device, between 2-4 liters per the resident's physician order and observed the machine did not have an oxygen enrichment line connected at the time of assessment today. She explained that failure to connect oxygen to the device had the potential to cause respiratory distress and low oxygen levels. She explained that she added the oxygen adapter line to the device today. Record review of the admission Record revealed the facility admitted Resident #100 on 3/19/26 with medical diagnoses that included Acute Respiratory Failure with Hypercapnia and Chronic Obstructive Pulmonary Disease (COPD) with Acute Exacerbation.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/26/26 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 5, which indicated Resident #100 was severely cognitively impaired.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure insulins were properly stored in accordance with manufacturer's guidelines to maintain safety and effectiveness for one (1) of two (2) medication carts observed. 300 hall Findings Include:Review of the facility policy titled Insulin Pen, with no date, revealed, .Insulin pens should be disposed of after 28 days.An observation of the 300 hall medication cart on 3/31/26 at 10:50 AM, with Licensed Practical Nurse (LPN) #1, revealed the following insulins were in use and were not dated when opened:Resident #2 - Lantus SoloStar that was undated. Resident #4 - Basagalar KwikPen and Tresiva FlexTouch that was undated.Record review of the Insulin 28 Day Expiration Date Calculator with no date revealed, .Discard multi-dose vials 28 days after initially opening.Record review of In-Service: Medication Pass - Tips for Success with no date revealed, .Insulin.Ensure that insulin vials are dated when opened.An interview with LPN #1 on 3/31/26 at 10:52 AM revealed that all insulins, vials or pens should be dated when opened. She stated there would be no way to determine if the insulin was still safe to administer. An interview with the Director of Nursing (DON) on 3/31/26 at 11:15 AM revealed that all insulin stored on medication carts should be checked by nursing staff to ensure they are labeled with an open date.

Based on observation, resident and staff interviews, and facility policy review the facility failed to implement and maintain an effective infection prevention and control program to prevent the spread of infection. This was evidenced by failure to utilize Enhanced Barrier Precautions (EBP) during high-risk care and failure to maintain urinary catheter equipment in a manner to prevent contamination for three (3) of 18 sampled residents. (Resident #2, #13, and #77).Findings Include: Review of facility policy titled Enhanced Barrier Precautions dated 4/1/2024, revealed, Policy: It is the policy of this facility to implement enhanced barrier precautions for preventing transmission of novel or targeted multidrug-resistant organisms .Enhanced barrier precautions refer to the use of gown and gloves for certain residents during specific high-contact resident care activities .An order for enhanced barrier precautions will be obtained for residents with any of the following: .feeding tube .High-contact resident care activities .device care or use .feeding tube . Record review of facility policy titled, Appropriate Use of Indwelling Catheters undated revealed, .It is the policy of this facility to ensure residents with urinary incontinence: . receives appropriate treatment and services to prevent urinary tract infections . All catheters must have leg strap or securement devices in place, privacy bag in use, tubing placement to prevent backflow into bladder, and while in chair or wheelchair tubing must not touch floor with privacy bag in use. Resident #2 During an observation of catheter care on 4/01/2026 at 8:40 AM for Resident #2 with Certified Nursing Assistant (CNA) #3 and CNA #4, it was observed that they failed to use EBP while performing suprapubic catheter care. Record review of the Order Summary Report revealed an order dated 11/13/2025 for Enhanced Barrier Precautions due to suprapubic catheter. During an interview on 4/01/2026 at 9:00 AM with CNA #3, she confirmed that EBP should have been used during catheter care for residents with catheters. She further stated that EBP was ordered to help prevent the spread of infection. During an interview on 4/01/2026 at 10:00 AM with the Director of Nursing (DON), she stated EBP should be used with any tubes or wounds to prevent possible cross contamination. She further stated that her expectations were for staff to follow EBP with all care provided for residents with a tube or wound. Record review of the admission Record revealed that Resident #2 was admitted to the facility on [DATE], with medical diagnoses that included urinary tract infection and retention of urine. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/15/2026 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating that Resident #2 was cognitively intact. Resident #13 During observation of Percutaneous Endoscopic Gastrostomy (PEG) medication administration for Resident #13 on 3/31/2026 at 12:17 PM, Licensed Practical Nurse (LPN) #3 failed to use EBP during care. Upon interview immediately following care, LPN #3 realized she failed to wear her gown. She stated, I just forgot. We are supposed to wear the gowns because of germs. We are supposed to wear them with feeding tubes, catheters, etc. During an interview on 3/31/2026 at 12:27 PM with the DON she confirmed that EBP should be worn during PEG medication administration to help prevent the spread of infection. Record review of the admission Record indicated that the facility admitted Resident #13 on 10/27/2022 with medical diagnoses that included Cerecral Infarction, unspecified. A record review of the MDS with an ARD of 1/17/26 revealed under section C, a BIMS was not attempted because Resident #13 was rarely or never understood. Resident #77 During an observation on 3/30/26 at 10:40 AM, Resident #77 was observed sitting in a wheelchair with an indwelling Foley catheter in place. The urinary catheter tubing was observed exposed, visibly unsecured, and in direct contact with the floor beneath the wheelchair. During a subsequent observation on 3/30/26 at 11:55 AM, Resident #77 was observed propelling himself in a wheelchair through the dining room. The Foley catheter tubing was observed, dragging on the floor underneath the wheelchair. On 3/31/26 at 10:35 AM, Resident #77 was observed sitting in his wheelchair in the doorway of his room. The Foley catheter tubing was observed hanging down and resting on the floor. During an observation and interview on 3/31/26 at 11:35 AM, Resident #77 was observed sitting at a dining room table with the urinary catheter tubing touching the floor. At that time, the DON confirmed the catheter tubing was lying on the floor, acknowledged this as an infection control concern, and stated, the tubing should be properly secured under the wheelchair to prevent contact with the floor. During an interview on 03/31/26 at 3:15 PM, the Infection Preventionist confirmed that urinary catheter tubing should be maintained off the floor and properly secured to prevent contamination and reduce the risk of infection. Record review of the admission Record revealed the facility admitted Resident #77 on 7/23/25 with medical diagnoses that included Retention of Urine and Acute Kidney Failure. Record review of the MDS with an ARD of 1/26/26 revealed under Section C, a BIMS summary score of 9, indicating Resident #77 was moderately cognitively impaired.

Based on staff and resident representative (RR) interviews, record review, and facility policy review, the facility failed to notify the resident representative of a significant change in physical condition and that the resident was being sent to the hospital for one of three residents reviewed. Resident #1. Findings Include: Review of the undated facility policy Required Notices revealed under Notification of changes: Facility will immediately inform the resident; consult with resident's physician; notify, consistent with their authority, the resident representative when: .b. The resident has a significant change in their physical, mental, or psychosocial status in either life threatening conditions or clinical complications d. A decision to transfer or discharge the resident from the facility . A phone interview on 03/17/25 at 9:06 AM with Resident #1's RR revealed that she was upset about a recent situation that occurred at the facility. RR revealed that she gone into the facility on [DATE], walked into Resident #1's room and found that her bed was stripped, and she was not there. She revealed that she went to the nurses' station and the staff told her that Resident #1 was in the hospital and had been there since 03/08/25. RR revealed that she had not been notified of a change in condition or of the transfer to the hospital and this was not acceptable. An interview on 03/17/25 at 9:42 AM with the Director of Nursing (DON), revealed that Resident #1's RR came into the facility on [DATE], found that Resident #1 was in the hospital and complained about not being notified about her change in condition or the transfer to the hospital that happened over the weekend. DON revealed that she came in on Monday morning, 03/10/25, ran a report and found out that Resident #1 had been sent out to the hospital on 03/08/25 for low oxygen levels. DON revealed that she looked into the situation and found that Licensed Practical Nurse (LPN) #2 was taking care of Resident #1 on the night shift of 03/07/25. DON revealed that LPN #2 asked LPN #1 for help to get the paperwork ready for ambulance transfer when she found that Resident #1 was having trouble breathing. DON revealed that after interviewing the two nurses, she found that LPN #1 thought LPN #2 had called the RR and that LPN #2 thought LPN #1 called her and due to miscommunication, they failed to notify the RR that the resident had been sent to the hospital and was admitted . DON confirmed that the nurse was supposed to notify the RR with any resident change in condition or transfer to the hospital and this was not done. A phone interview on 03/17/25 at 9:45 AM with LPN #1 revealed that he worked on the 11 PM - 7 AM night shift on 03/07/25 and that Resident #1's oxygen dropped too low on the morning of 03/08/25 and LPN #2 asked him to come and help with the situation. He revealed that they checked Resident #1's vital signs and found that her oxygen level was very low, reported it to the doctor and he ordered her to be sent to the hospital. LPN #1 revealed that LPN #2 asked him to print the necessary paperwork off the computer to be sent to the hospital with Resident #1. He revealed that he did not contact Resident #1's RR, that he assumed that the other nurse had since Resident #1 was her assigned patient. LPN #1 revealed that when they send a resident out to the hospital, they were supposed to always call the resident's RR and let them know. He also revealed that had he known that LPN #2 did not call the RR, he would have done it. A phone interview on 03/17/25 at 12:55 PM with LPN #2, revealed that she was working on the medication cart on the night shift, 11 PM - 7 AM, of 03/07/25. She revealed that she was preparing Resident #1's medications around 5:30 AM on the morning of 03/08/25, when an aide came to her and reported that Resident #1 was having trouble breathing. LPN #2 revealed that she went in and checked on her and found that her heart rate was elevated, and her oxygen saturation was extremely low, down in the 30's. She revealed that she called the doctor and received an order to send Resident #1 out to the emergency room . LPN #2 revealed that LPN #1 came to help, and she asked him to print out all the necessary paperwork for the transfer. She revealed that while he did that, she called 911 and then called the ER (emergency room ) and gave them a report. LPN #2 revealed that LPN #1 printed the paperwork, and she stated, I just assumed he did everything else. She revealed that she was in the middle of the medication pass, there was a lot going on, and she thought LPN #1 had called the RR and he assumed she had. LPN #2 revealed that she should not have assumed that LPN #1 called the Resident #1's RR, she should have checked with LPN #1 and made sure it was handled. LPN #2 revealed that she realized that because she failed to notify the RR, Resident #1 went out to the hospital without any family knowing her condition, and this should not have happened. LPN #2 confirmed that they were supposed to inform the RR of any changes in a resident's condition and supposed to notify the RR if a resident had to transfer to the hospital. Record review of Resident #1's Late Entry Progress Note with effective date of 03/08/25 at 05:50 revealed CNA (Certified Nursing Assistant) reported resident was not breathing correctly. went to check on resident and residents bipap trilogy was in use. resident was having difficulty breathing .MD (Medical Doctor) notified New orders to send resident to ER (emergency room ) for treatment. Dispatch notified. Report called to ER. Resident transported to ER via ambulance. Was able to get 02 (oxygen) up to 62%. Record review of the facility Change of Condition Report dated 03/08/25 revealed that Resident #1 was sent to the hospital at 5:50 AM for dyspnea. Record review of Grievance/Complaint Report dated 03/11/25, revealed that (proper name) Resident #1's RR wasn't notified about resident being sent to the hospital. Documentation on the form revealed Under Details: (proper name) states she wasn't notified when resident was sent to hospital. She found out when she came to visit resident on Monday, 3-10-25. Record review of Resident #1's Admission Record revealed an admitted [DATE] and that she had diagnoses that included Hemiplegia and Hemiparesis following Cerebrovascular Disease, Cerebral Infarction, and Acute Respiratory Failure with Hypoxia and Hypercapnia. Record review of Resident #1's Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 01/22/25 revealed that a Brief Interview for Mental Status (BIMS) should not be conducted because the resident was rarely/never understood.

Based on observation, interviews, record reviews, facility policy reviews, and the facility's investigation, the facility failed to provide adequate supervision to prevent Resident #1, who was identified as a wandering risk, from exiting the facility unnoticed and unsupervised for one (1) of three (3) residents reviewed. Resident #1. The facility failed to provide supervision to prevent an elopement for Resident #1, who was a wandering risk. The resident left the facility unnoticed and unsupervised on 3/4/25 at 5:09 AM and was discovered asleep in the back seat of someone's car at their place of residency which was approximately eight (8) miles from the facility on 3/4/25 at approximately 9:30 AM after the resident rode home with them from their place of employment. During the investigation, the State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 3/4/25 and existed at 42 CFR: 483.25 (d)(1)(2)- Free of Accidents Hazards/Supervision/Devices (F689) - Scope and Severity J. This situation placed Resident #1 and other residents at risk for wandering and elopement, at risk for serious injury, serious harm, serious impairment, or death. The SA notified the facility's Administrator of the IJ and SQC on 3/5/25 at 2:00 PM and provided the Administrator with the IJ template. Based on the facility's implementation of corrective actions on 3/4/25, the SA determined the IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed on 3/5/25, prior to the SA's entrance on 3/5/25. Findings Include: A review of the facility's policy Elopements and Wandering Residents revealed This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk . Policy Explanation and Compliance Guidelines: 1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. Record review of the facility's Incident Description and Reportable Summary revealed that on 3/4/25 at 7:35 AM while delivering breakfast trays Resident #1 was found not to be in his room. A Code W (missing resident) was initiated, and staff began searching for the resident. The local Police Department, Attorney General, Nurse Practitioner, and Resident #1's Responsible Party were notified. Resident #1 exited the facility at 5:09 AM through the front door. Resident #1's shoes were found across the street in a local crisis center parking lot. Review of security footage from the local crisis center revealed Resident #1 in the crisis center parking lot from 5:12 AM until 6:55 AM when he entered an employee's car. The crisis center employee was unaware that the resident was in their car and drove home. The crisis center notified their employee who looked in the car, saw Resident #1 sleeping and notified the local Police Department. The resident was transported to the local hospital by emergency services and returned to the facility on [DATE] at 11:16 AM, with no injuries. Review of the facility camera footage for 3/4/25, with the Administrator present on 3/5/25 at 12:00 PM revealed Resident #1 exited the front door of the facility at 5:09:10 AM on 3/4/25. Further observation of the video footage revealed a staff member, identified as Licensed Practical Nurse #1 (LPN), by the Administrator, walking toward the front door of the building at 5:09:49 looking at her phone. She is seen entering the door code, looking back down at her phone, turning and walking away. This is approximately 39 seconds after Resident #1 exited the building. Telephone interview on 3/5/25 at 12:38 PM with Certified Nursing Assistant #1 (CNA), who was assigned to Resident #1 on the 11 PM to 7 AM shift stated that she had gotten the resident up just before 5:00 AM and assisted him to get dressed and took him to the 200-hall sitting area. She stated that the resident sat down in the recliner. She stated that this is his routine every morning and he usually sits in the recliner until breakfast and will sometimes nap. She stated that was the last time she saw the resident before the end of her shift. She stated that he was not displaying agitation or anxiety, he was not having increased wandering nor was he exit seeking. She stated that the resident does wander around the inside of the facility, but he has never gone into anyone else's room or attempted to exit the building. She stated that the resident was wearing a long sleeve gray shirt, heavy plaid pants and gray shoes. She stated that she starts her rounds in the hall furthest away from the front door so if the alarm was sounding, she would not have been able to hear it. A telephone interview with LPN #1 on 3/5/25 at 1:34 PM, she stated that she last saw Resident #1 around 5:00 AM on 3/4/25, when he walked past the nurse's station while she was preparing medication for another resident. She stated that he usually sits in the recliner in the 200 Hall lounge area until breakfast. She stated that sometimes when the resident is near the front door the alarm would go off, but she initially stated that she did not hear any alarms sounding. Upon further interview with LPN #1 she was notified, by the SA, of the video showing her walk to the front door a few seconds after Resident #1 exited the building and entering a code on the door alarm. When asked about this she stated she guessed the alarm was going off and thought a phlebotomist set it off when she came in. She stated she looked out the door but did not see anyone. An interview with the Administrator (ADM) on 3/5/25 at 1:45 PM, he verified that the Resident #1 was noted missing 3/4/25 at 7:35 AM, and Code W, which is the code for a missing resident, was initiated. All other residents were accounted for; staff began looking for Resident #1. He stated upon review of the camera footage Resident #1 was seen exiting the front door of the building 3/4/25 at 5:09 AM, and LPN #1 was seen entering the alarm code on the front door at 5:09 AM. He stated that he believes when the phlebotomist came into the facility, prior to the resident's exit, the door did not latch when it closed, and the resident was able to push it open and exit the building. He verified upon review of camera footage from the crisis center across the street from the facility, Resident #1 was seen sitting on the bumper of a vehicle from 5:16 AM until 6:55 AM when he found the door unlocked and got into the vehicle. A crisis center employee who owned the vehicle went home after work not realizing the resident was in the car. The employee was contacted and asked to check her vehicle, and the resident was noted to be asleep in the back of the car. The local police department was notified, and Emergency Medical Services (EMS) transported the resident to the local emergency room (ER) for evaluation then the resident returned to the facility around 11:16 AM. He stated that the resident was placed on increased monitoring and the locksmith was called to evaluate the door closure. He stated the door closure was not malfunctioning, but that it was replaced with a more heavy-duty closure. The facility notified Resident #1's responsible party (RP) and nurse practitioner as well as the State Agency (SA) and Attorney General's Office (AGO). The Administrator stated the facility began to have additional elopement drills and all employees were in-serviced on elopement, supervision of residents and care plans. The Administrator provided the SA with copies of the statements received regarding the investigation and the sign-in page of the Quality Assurance Performance Improvement (QAPI) meeting that was held on the afternoon of the incident to discuss the incident and steps needed to prevent this from happening again. The facility conducted an investigation and submitted it to the SA and AGO. Following their investigation, they determined there were no signs of abuse or neglect. Through a root cause analysis by the Director of Nursing (DON) and Administrator, it was determined that the resident exited the building through the front door when the door did not latch properly after the phlebotomist entered and the nurse did not respond appropriately to the alarm when the resident exited the building. During an interview with the DON on 3/4/25 at 1:50 PM, she confirmed that Resident #1 did wander but did not have exit seeking behavior or verbalizations of wanted to leave. She verified that it was his usual routine to get up early and sit in the recliner in the 200 Hall area until breakfast. She stated upon return to the facility a body audit was conducted, and Resident #1 was noted to have no injuries. Resident #1 was placed on increased visual monitoring for 24 hours and then continued every hour visual monitoring. She stated that his elopement assessment and care plan were updated on 3/4/25. She stated that his wander guard was present and functional upon return to the facility and that placement and function are checked every shift. The DON also stated that all residents in the facility were assessed for elopement and their care plans were updated as needed. She stated that all residents at risk for elopement will be visually monitored every hour. She revealed LPN #1 was suspended pending termination on 3/4/25 when the facility camera footage revealed that she entered the alarm code without investigating the cause of the alarm. An interview with the Locksmith on 3/5/25 at 2:30 PM, he stated that the closure on the door was worn but not in disrepair. He verified that he replaced the closure with a stronger closure system. Record review of the door check form for March 2025, with the Administrator, on 3/5/25 at 2:35 PM, revealed all doors were checked for functionality in the morning and at 3:00 PM daily. On 3/5/25 at 3:00 PM, during an observation walk-through of the route from the facility to crisis center across the street where Resident #1 was seen to get into an employee's vehicle and the distance was determined to be 400 feet across a commercial road. During the observation, there was 1 car on the road and 1 streetlight in place. A record review of the weather report from the website https://www.localconditions.com/weather-corinth-mississippi/38834/past.php revealed that it was 52 degrees on 3/4/35 at 5:00 AM. Wind speed 13.2 miles per hour with gusts of 22.1 miles per hour. Record review of the Elopement Risk Evaluation for Resident #1, dated 2/13/25 revealed Resident wanders, no other risks for elopement. Elopement Risk Score 0. Record review of the Admission Record revealed that the facility admitted Resident #1 on 2/12/24 with diagnoses including Diabetes Mellitus, Cognitive Communication Deficit, and Difficulty Walking. Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/13/25 revealed a Brief Interview for Mental Status (BIMS) score of 99 indicating that the resident is rarely/never understood. The facility implemented the following Corrective Action Plan prior to the State Agency's entrance on 3/5/25. Immediate action started on 3/4/25 at 7:35 AM. On 3/4/25 at 7:35 AM, resident #1 was noticed to be missing when his dining room tray was delivered to the hall by Certified Nursing Assistant (CNA). On 3/4/25 at 7:37 AM, a Code W was initiated by Unit Manager, Registered Nurse (RN). All staff searching for resident and one hundred percent audit was completed to ensure all other residents were present. On 3/4/25 at 7:41 AM, Assistant Director of Nursing (ADON) notified Director of Nursing (DON). On 3/4/25 at 7:59 AM, Director of Nursing (DON) notified Administrator. On 3/4/25 at 7:54 AM, Local Police Department, Local Fire and Rescue, and Attorney General Investigation Team were notified resident missing by Quality Assurance Licensed Practical Nurse (LPN). On 3/4/25 7:56 AM, Resident #1 House shoe was located by Housekeeper #1 in parking lot of local crisis center. On 3/4/25 at approximately 8:05 AM, Resident Responsible Party and Resident Physician Family Nurse Practitioner (FNP) notified by Assistant Director of Nursing (ADON). On 3/4/25 at 8:15 AM, Review of security cameras by Minimum Data Set (MDS) Registered Nurse (RN) saw Resident #1 exiting facility via front door at 5:09 AM. On 3/4/25 at 8:20 AM, Janitor #1 was assigned to monitor the front door and the Maintenance Supervisor contacted Locksmith to evaluate door closure mechanism. On 3/4/25 at 09:22 AM, Facility was notified by the Dietary Manager while watching security footage at the Crisis Center that the resident was seen getting into the back of an employee vehicle. Crisis Center then notified the employee to have someone check in the car and notify police. Resident was asleep in the back seat. On 3/4/25 at 9:30 AM, Local police department went to the crisis center ' s staff member ' s residence and called Emergency Medical Services (EMS) for transport to Local Hospital for evaluation. Resident #1 was evaluated and noted to have no injury or signs of distress. On 3/4/25 at 10:03 AM, Resident #1 arrived at local emergency room and Infection Control, Registered Nurse (RN) was sent to supervise Resident #1 until return to facility. On 3/4/25 at 11:00 AM, Locksmith present and working on front door to replace door closures. On 3/4/25 at 11:16 AM, Resident #1 returned to facility, Body Audit completed revealing no injuries. Visual checks initiated every 15 minutes for total of four (4) hours, every 30 minutes for total of 4 hours, and every 1 hour for eight (8) hours to total 24 hours. Resident #1 will be monitored every hour indefinitely. On 3/4/26 at 11:17 AM, Resident #1 Wander Guard Bracelet was checked and was determined to be functioning. All residents with Wander Guards were checked and found to be functional. They will be checked each shift by nurse for functional status. On 3/4/25 at 11:19 AM, Resident Elopement Assessment and Care Plan were updated to include actual elopement on Resident #1 On 3/4/25 at 11:20 AM, DON, Assistant DON, Minimum Data Set Registered Nurse (RN), and Admissions Registered Nurse (RN) did one hundred percent Elopement Assessment on all residents. Care Plans for residents with Elopement Risk were updated to include visual checks every hour. Visual Monitoring will be monitored by the nurse each shift, any discrepancies will be reported to the Quality Assurance Nurse who will report findings to the Quality Assurance Committee monthly for three (3) months, then quarterly. On 3/4/25 at 1:00 PM, an Ad Hoc Emergency Quality Assurance and Improvement Committee meeting was held related to resident elopement to conduct a root cause analysis and Policy and Procedure for changes. Attendees were the Nursing Home Administrator, Director of Nursing, Infection Preventionist, Social Services, Quality Assurance Coordinator, Maintenance Supervisor, Housekeeping Supervisor, Dietary Supervisor, Nurse Practitioner attended by phone for the Medical Director who is off on medical leave. No policy and procedure changes were made at this time. On 3/4/25 at 2:00 PM, Director of Nursing, Quality Assurance Nurse, and Staff Development Nurse initiated in-services for all staff related to Elopement and Wandering Prevention, Response to Alarms, and following Care Plans. No employee will be allowed to return to work without training. On 3/4/25 at 4:00 PM, an Elopement Drill was completed and will continue to be conducted daily for 3 days on each shift, then weekly for three (3) weeks, then monthly. Social Services will report findings to the Quality Assurance Committee monthly. On 3/4/25 at 4:11 PM License Practical Nurse (LPN) #1 was suspended pending termination. All corrective actions were completed on 3/4/25 and facility alleges the IJ was removed on 3/5/25. The State Agency validated the facility's Corrective Action Plan on-site during the Complaint Investigation by record review and interviews on 3/5/25 and 3/6/25. The SA determined all corrective actions were completed on 3/4/25 and the IJ was removed on 3/5/25.

Based on record reviews, staff interviews and facility policy review, the facility failed to ensure a resident's right to be free from abuse and neglect as required for one (1) of 20 residents reviewed. Resident A. Cross Reference F609, F656, F697 Findings Include: Review of facility policy Freedom from Abuse, Neglect and Exploitation revised October 2022 revealed Policy Statement: All residents of this facility have the right to be free from neglect .Residents must not be subject to abuse by anyone .Practices of omitting part of resident care or neglecting resident and misappropriation of property is to be considered as leading to abuse and should be investigated and treated as abuse. A record review of the Grievance/Complaint Report documented by Social Services on 10/22/24 revealed that Resident A reported that staff was rude to him and refused to give him his medications, stating it was bad for him and that he did not need it. He further reported that staff threw his call light on the floor, refused to assist him onto the bedside commode, and that he was scared. A record review of the Record of Complaint documented by the Director of Nursing (DON) on 10/21/24 indicated that Resident A's responsible party stated that the night shift nurse was rude and hateful. The resident expressed a desire to discharge home, stating he felt unsafe and was not receiving proper care at night. The investigation found that the resident's pain was left untreated, and staff interviews revealed examples of misconduct toward resident by the nurse. The immediate corrective actions at the time of the incident included the termination of the night shift nurse, relocating the resident to a different hall per his request, and in-servicing staff on professional conduct, abuse, and neglect. A record review of the Witness Statement documented by the Physical Therapy Assistant (PTA) on 10/21/24 revealed that Resident A stated he wanted to leave the facility. The resident became emotional and expressed fear, stating he had no defense and could not protect himself. He also reported that no one answered his call light, that staff threw it on the floor, and when he asked for it back, they refused, telling him he did not need it. During an interview with the PTA on 1/29/25 at 9:25 AM, she confirmed that her statement accurately reflected what Resident A had reported to her on 10/21/24. A record review of a Witness Statement documented by Licensed Practical Nurse (LPN) #2 on 10/22/24 revealed that she heard LPN #3 yelling, Shut up! down the hall on 10/19/24 while Resident A was calling for help. She also stated that LPN #3 said she was not going to give Resident A anything for pain because he could not have a bowel movement. During an interview and record review of the Grievance/Complaint Report, Record of Complaint, and Witness Statements on 1/29/25 at 9:28 AM, the Social Services/Grievance Official agreed that Resident A's complaint constituted an allegation of abuse and neglect. In an interview with the DON on 1/29/25 at 10:05 AM, she stated that when she arrived at work on 10/21/24, she was reviewing nursing notes and found documentation by LPN #3 that Resident A had yelled that he had requested pain medication over an hour ago. The DON further stated that, while in the Assistant Director of Nursing's (ADON) office, the resident's son reported that the previous evening, the resident had requested pain medication, but the nurse told him he did not need it due to stomach issues. The DON later spoke with the resident in the therapy department, where he confirmed he had not received his pain medication the previous night and expressed fear of LPN #3 due to her loud and rude behavior. The DON stated that during her investigation, she received reports from LPN #2 that LPN #3 had been loud and cursing in the hallway. When she interviewed LPN #3, the nurse admitted to withholding the pain medication because the resident was constipated. The DON informed her that this was not a valid reason to deny medication. The nurse was subsequently terminated. However, the DON stated she could not substantiate the allegations that staff had taken or ignored the resident's call light and that after review of the camera footage at that time you could see a CNA going in and answering his call light that night. The DON agreed that this incident was an allegation of abuse and neglect. In an interview at 10:12 AM on 1/29/25 with the Administrator he confirmed that the Grievance Investigation was an allegation of abuse. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/22/24 revealed that Resident A had a Brief Interview for Mental Status (BIMS) score of 15, indicating that he was cognitively intact. A record review of the Admission Record revealed that Resident A was admitted to the facility on [DATE] with diagnoses including Left-sided Maxillary Fracture, Left-sided Fracture of the Medial Orbital Wall, Multiple Left-sided Rib fractures, other Physical Fracture of the Lower End of the Radius, and Unspecified Pain. Resident A was discharged home on 10/26/24.

Based on record reviews and staff interviews the facility failed to identify and report an allegation of abuse and neglect to the proper authorities within prescribed timeframes as required for one (1) of 20 residents reviewed. Resident A. Cross reference F600, F656, F697 Findings Included: Review of facility policy Freedom from Abuse, Neglect and Exploitation revised October 2022 revealed Policy Statement: Practices of omitting part of resident care or neglecting resident and misappropriation of property is to be considered as leading to abuse and should be investigated and treated as abuse .5. The facility will ensure that all alleged violations involving mistreatment, neglect, or abuse .are reported immediately to the supervisor, and the administrator of the facility, or other officials, such as the State Board of Health and the Office of the Attorney General . A review of the Record of Complaint documented by the Director of Nursing (DON) on 10/21/24 indicated that Resident A's responsible party (RP) stated that the night shift nurse was rude and hateful. The resident expressed a desire to discharge home, stating he felt unsafe and was not receiving proper care at night. The investigation found that the resident's pain was left untreated, and staff interviews revealed examples of misconduct toward resident. The immediate actions included the termination of the night shift nurse, relocating the resident to a different hall per his request, and in-servicing staff on professional conduct, abuse, and neglect. A record review of the Grievance/Complaint Report documented by Social Services on 10/22/24 revealed that Resident A reported staff was rude to him and refused to give him his medications, stating it was bad for him and that he did not need it. He further reported that staff threw his call light on the floor, refused to assist him onto the bedside commode, and that he was scared. Record review of the Witness Statement documented by the Physical Therapy Assistant (PTA) on 10/21/24 revealed that Resident A stated he wanted to leave the facility. The resident became emotional and expressed fear, stating he had no defense and could not protect himself. He also reported that no one answered his call light, that staff threw it on the floor, and when he asked for it back, they refused, telling him he did not need it. Record review of a Witness Statement documented by Licensed Practical Nurse (LPN) #2 on 10/22/24 revealed that she heard LPN #3 yelling, Shut up! down the hall on 10/19/24 while Resident A was calling for help. She also stated that LPN #3 said she was not going to give Resident A anything for pain because he could not have a bowel movement. On 1/29/25 at 9:28 AM, during an interview with the Social Services/Grievance Official, she agreed that Resident A's complaint constituted an allegation of abuse and neglect and confirmed that it had not been reported to the State Agency. At 10:10 AM on 1/29/25, the DON confirmed that this incident was an allegation of abuse and acknowledged that it had not been reported to the State Agency because she had not identified it as such at the time. At 10:12 AM on 1/29/25, the Administrator confirmed that it constituted an allegation of abuse and neglect and should have been reported to the State Agency and stated that he typically reports all such allegations but did not recall being aware of this specific incident. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/22/24 revealed that Resident A had a Brief Interview for Mental Status (BIMS) score of 15, indicating that he was cognitively intact. A record review of the Admission Record revealed that Resident A was admitted to the facility on [DATE] with diagnoses including Left-sided Maxillary Fracture, Left-sided Fracture of the Medial Orbital Wall, Multiple Left-sided Rib fractures, other Physical Fracture of the Lower End of the Radius, and Unspecified Pain. Resident A was discharged home on 10/26/24.

Based on record review, staff interview and facility policy review, the facility failed to implement pain management care plan interventions and failed to develop a care plan with individualized interventions to include triggers for Post Traumatic Stress Disorder (PTSD) for two (2) of 20 sampled resident care plans reviewed. Resident A and Resident #64. Findings include: Record review of the facility policy Pain Management revealed, Policy: The facility will ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. A record review of Resident A's Care Plan revealed, Focus: Risk for altered comfort related to benign hypertrophy of the prostate (BHP) and pain related to fractures, with interventions including: .Administer pain medication as needed . A record review of the Grievance/Complaint Report documented by Social Services/Grievance Official on 10/22/24 revealed that Resident A reported staff refused to administer his pain medication. The investigation findings noted: Resident pain left unattended. A record review of Progress Notes for Resident A, dated 10/21/24 at 1:39 AM, revealed that the resident yelled out, stating, I asked for my medicine an hour ago. Do you just not have any help? A record review of the Medication Administration Record (MAR) revealed that Resident A had an active order for Hydrocodone-Acetaminophen Oral Tablet 5-325 mg (milligrams), with instructions to administer one (1) tablet orally every six (6) hours as needed for pain. Further review of the MAR revealed that on 10/20/24, Resident A received a dose of pain medication at 1:34 PM. However, there was no documentation that the resident received any additional pain medication until 9:58 AM on 10/21/24. In an interview with the Director of Nursing (DON) on 1/29/25 at 10:05 AM, she stated that when she arrived at work on 10/21/24, Resident A's son voiced concerns that the nurse did not give his father any pain medication last night. The DON stated that she interviewed Licensed Practical Nurse (LPN) #3 regarding not administering pain medications to the resident and the nurse stated that she withheld the pain medication because the resident was constipated. On 1/30/25 at 9:41 AM, during an interview with the Minimum Data Set (MDS) Coordinator and the MDS LPN, they stated that the purpose of the care plan is to guide staff in providing appropriate care for the resident. The MDS Nurses confirmed that the nurse failed to follow the care plan when she did not administer pain medication as needed and that were requested by the resident. They further explained that the potential negative outcomes of untreated pain include unrelieved pain, increased anxiety, and difficulty participating in therapy and Activities of Daily Living (ADLs). A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/22/24 revealed that Resident A had a Brief Interview for Mental Status (BIMS) score of 15, indicating that he was cognitively intact. The Pain Assessment Interview in section J documented that Resident A had experienced occasional pain over the past five (5) days, which limited his daily activities. He rated his pain as a five (5) on a numeric scale from zero (0) to ten (10), with zero (0) representing no pain and ten (10) representing the worst pain imaginable. A record review of the Admission Record revealed that Resident A was admitted to the facility on [DATE] with diagnoses including Left-sided Maxillary Fracture, Left-sided Fracture of the Medial Orbital Wall, Multiple Left-sided Rib fractures, other Physical Fracture of the Lower End of the Radius, and Unspecified Pain. Resident A was discharged home on 10/26/24. Resident #64 Record review of facility policy titled, Trauma-Informed Care undated, revealed, The general idea of trauma-informed care is to provide increased sensitivity to residents who have experienced trauma. Educating staff on how to interact with residents in an effort to limit triggering events and provide sensitive psychosocial interventions. A Care Plan for a resident who has experienced requires the same structure as all resident care plans - there is an identified problem, a goal and interventions. The problems must be measurable and time-based. Broad generalizations are insufficient. Goal: . Resident will describe any triggers or stresses related to traumatic events and how they cope with it. The policy also revealed, Person centered care plan is the key to Trauma Informed Care, Resident Centered Care mandates include: address training needs of staff to improve knowledge and sensitivity; identify an individual's hope, capacities, interests, preferences, needs, and abilities; the individual is the expert of his/her life; practice is a collaborative process; individual choice is evident; resident's voice is used in treatment plans - goals are in his/her own words; strength based, recovery-oriented principles; assess for traumatic histories and symptoms; recognition of culture and practices that are re-traumatizing. Record review of Resident #64's Care Plan, date initiated 10/10/24, revealed, Focus: Psychiatric diagnosis related to post traumatic stress disorder, but the care plan did not include specific triggers that the resident experienced due to his diagnosis. During an interview on 1/28/25 at 11:55 AM, Resident #64 revealed he was in the Vietnam War, and he suffered from Post Traumatic Stress Disorder (PTSD) from his military service. He stated he was left for dead and the two soldiers with him were killed and it was a miracle he survived. He said that during that event, he was praying for God to keep him still so they would think he was dead and then he talked about how his mother prayed constantly for him to safely return home. He believed that God gave him the strength not to move even though he was getting kicked and beaten. He acknowledged he had triggers such as loud thunder or a loud noise from something being dropped, and when he heard these things, I almost hit the floor. While he was talking about his experience, he became teary eyed and cried softly. During an interview on 1/29/25 at 4:15 PM, the Director of Nursing (DON) revealed the resident had a diagnosis of PTSD and a care plan was developed for this. She stated a care plan should guide staff in the individualized care of each resident. She confirmed a PTSD assessment was not done, and triggers were not identified, therefore, the care plan did not give staff information needed for the triggers that affected this resident's mental health status. An interview with Registered Nurse (RN) MDS Coordinator on 1/30/25 at 9:30 AM, revealed she was responsible for developing and updating care plans to provide the staff with a guide for the resident's care. She stated that since the resident was not assessed for his PTSD needs and triggers, the care plan did not contain these items. She stated for a resident with PTSD, the staff should be aware of triggers that could cause the resident to have increased anxiety and they needed to be included in the care plan. She confirmed the facility failed to individualize a care plan by including triggers for a resident with PTSD. Record review of Resident #64's Admission Record revealed the facility admitted the resident on 7/15/22. Diagnoses included PTSD. Record review of the MDS Section C dated 1/7/25, revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #64 was cognitively intact. Record review of Resident #64's admission MDS Section I dated 7/21/22 and the most recent quarterly assessment dated [DATE] revealed a diagnosis of PTSD.

Based on record reviews, staff interviews, and facility policy reviews, the facility failed to ensure that a resident received pain medication as ordered by the physician for one (1) of one (1) resident reviewed for pain management. Resident A. Cross reference F600, F656, F609 Findings include: Record review of the facility policy Pain Management dated September 2022 revealed, Policy: The facility will ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. A record review of the Admission Record revealed that Resident A was admitted to the facility on [DATE] with diagnoses including Left-sided Maxillary Fracture, Left-sided Fracture of the Medial Orbital Wall, Multiple Left-sided Rib fractures, other Physical Fracture of the Lower End of the Radius, and Unspecified Pain. Resident A was discharged home on 10/26/24. A record review of the Grievance/Complaint Report documented by Social Services/Grievance Official on 10/22/24 revealed that Resident A reported staff refused to administer his pain medication. The investigation findings noted, resident pain left unattended. A record review of Progress Notes for Resident A, dated 10/21/24 at 1:39 AM, revealed that the resident yelled out, stating, I asked for my medicine an hour ago. Do you just not have any help? A record review of the Medication Administration Record (MAR) revealed that Resident A had an active order for Hydrocodone-Acetaminophen Oral Tablet 5-325 mg (milligrams), with instructions to administer one (1) tablet orally every six (6) hours as needed for pain. Further review of the MAR revealed that on 10/20/24, Resident A received a dose of pain medication at 1:34 PM. However, there was no documentation that the resident received any additional pain medication until 9:58 AM on 10/21/24. Record review of the Pain Assessment Interview dated 10/01/24 in Section J documented that Resident A had experienced occasional pain over the past five (5) days, which limited his daily activities. He rated his pain as a five (5) on a numeric scale from zero (0) to 10, with zero (0) representing no pain and 10 representing the worst pain imaginable. A record review of a Witness Statement dated 10/22/24 revealed that Licensed Practical Nurse (LPN) #2 reported hearing LPN #3 state that she was not giving Resident A pain medication because he could not have a bowel movement. On 1/29/25 at 10:05 AM, an interview with the Director of Nursing (DON) she stated that when she arrived at work on 10/21/24, she was reviewing nursing notes and saw the documentation by LPN #3 regarding Resident A's request for medication. While reviewing this information, Resident A's son approached her and reported that his father had requested pain medication the previous evening, but the nurse told him he did not need it due to stomach issues. Later, in the therapy department, Resident A confirmed to the DON that he had not received his pain medication the previous night. Upon interviewing LPN #3 regarding not administering requested pain medication, the nurse stated that she withheld the pain medication because the resident was constipated. The DON stated that she informed the nurse that this was not a valid reason to withhold pain medication, and that the medication should have been administered as ordered by the physician. The DON agreed that the resident's pain was left untreated throughout that night. During an interview with the Minimum Data Set (MDS) Coordinator on 1/30/25 at 9:41 AM, she stated that failure to administer pain medication as prescribed could lead to unrelieved pain, anxiety, and difficulty participating in therapy and Activities of Daily Living (ADLs). A record review of the MDS with an Assessment Reference Date (ARD) of 10/22/24 revealed that Resident A had a Brief Interview for Mental Status (BIMS) score of 15, indicating that he was cognitively intact.

Based on observation, staff and resident interviews, record review, and facility policy review, the facility failed to ensure food temperatures were completed and documented adequately for one (1) of three (3) kitchen observations. Findings include: A review of the facility policy titled Kitchen Thermometers undated revealed, A food thermometer should also be used to ensure that cooked food is held at safe temperatures until served. Cold foods should be held at 40 degrees F (Fahrenheit) or below. Hot food should be kept hot at 140 degrees F or above . Temperature Recording Preserves the Food's Quality. If facilities don't keep food at the proper temperature, its quality can quickly deteriorate . During the initial tour of the facility with resident interviews on 1/28/25 at 10:10 AM, Resident #28 revealed, I have received cold chicken soup on more than one occasion. Last week, I requested two bowls of soup; they brought it, but it was cold. During dining room observation on 1/28/25 at 11:50 AM, Resident #28 was overheard telling a staff member that his soup was cold. The soup was returned to the kitchen, and Dietary Worker #1 confirmed the food item was chicken noodle soup. She checked the temperature of the chicken soup and revealed the temperature was a little under 80 degrees, and she wasn't sure what the temperature for the soup was supposed to be. The Dietary Manager checked the soup temperature and revealed it was 80 degrees when it was supposed to be at least 135 degrees. Dietary workers #2 and #3 confirmed the soup temperature was not checked today. In an interview on 1/28/25 at 12:40 PM, Dietary worker #3 revealed she cooked breakfast and lunch meals today and did not check food temperatures for either meal. She revealed that her initials with the temperatures were on the Prepared Food Record; however, she had not checked the temperatures or initialed the sheet. She stated, I think (Dietary worker #1) filled that sheet out. She confirmed she was supposed to check the temperature of the food items on the steam table but just didn't. A record review and observation on 01/28/25 at 12:30 PM revealed a document titled Prepared Food Temperature Record dated January 2025 revealed that all food temperatures were documented for all three meals for the 28th of January with staff member initials under the date of the 28th. In an interview on 1/28/25 at 12:45 PM, the Dietary Manager confirmed the temperatures on the Prepared Food Temperature Record were already documented for today despite the temperatures not being taken. She revealed that the temperature record was already filled out for the upcoming dinner meal, which hadn't even happened yet. She stated, I don't watch my dietary workers take the food temperatures; I trust them to do their jobs correctly, and the way it looks, they are not doing what they should have been. She revealed that it is very important that temperature checks are done for each food item that is put on that steam table and served to the residents. She revealed that a resident could get a foodborne illness by not ensuring all food temperatures are within the normal range. She revealed this is just not acceptable and the dietary workers should ensure the food temps are being done. She confirmed the soup was cold and that, according to her staff admission, they had not checked the temperature of the soup before sending it out to the resident. In an interview on 1/28/25 at 1:00 PM, Dietary worker #1 confirmed that she had recorded the temperatures but did not check any food items for breakfast or lunch and had already documented the temperatures for the dinner meal for that evening on the log. She confirmed that what she did was false documenting. She stated, I filled out the sheet because if I didn't do it, it wouldn't get done. During an interview on 1/29/25 at 2:07 PM, the Administrator revealed he felt the food quality was improving and had not heard any complaints about the food being cold. He revealed it is of the utmost importance that the temperature of the food is checked before serving it to our residents, which ensures good quality of the food being served and ensures no potential food-borne illness. He revealed he was unaware that the dietary staff did not check the food temperatures yesterday, which is unacceptable. A record review of Resident #28's Admission Record revealed the resident was admitted to the facility on [DATE]. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/14/2024 revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact.

Based on resident and staff interviews, record review, and facility policy review, the facility failed to act upon and resolve resident grievances regarding cold food and lack of hot water for six (6) of eight (8) residents in the Resident Council meeting. Resident #5, Resident #13, Resident #28, Resident #43, Resident #64, and Resident #73 Findings Include: Review of the facility policy titled Grievances undated, revealed under, . 2. The resident has the right and the facility will make prompt efforts to resolve grievances the resident has . Record review of the Resident Council Meeting Agenda dated 10/29/24 revealed Resident #73, Resident #43, and Resident #5 voiced concerns: Food is getting cold by the time it gets to us (Breakfast, Lunch, Supper). Record review of the Resident Council Meeting Agenda dated 11/26/24 revealed, Resident #43 voiced a complaint of bacon being cold. Resident #64 voiced, The food is cold because staff doesn't start passing trays until about 10-15 minutes after trays are on the hall. Also revealed under, Dietary . talked with staff about serving hot food. Record review of the Resident Council Meeting Agenda dated 12/31/24 revealed, under, Dietary: . talked with cook about cold food. Record review of the Record of Complaint for Resident #73 dated 1/15/25 revealed under, Nature of Complaint: Says gravy is always cold, eggs are cold . Record review of the Grievance/Complaint Report for Resident #43 dated 1/20/25 revealed under, Grievance/Complaint . food cold on 1/17/25 at lunch. Also revealed under, Details: Friday in dining room at lunch - trays came out and it was about 10 minutes before staff came to pass trays and my fries were cold. During a Resident Council meeting held on 1/28/25 at 4:00 PM, Resident's #13, #28, #43, #64, and #73 revealed, cold food had been a problem for a while, and it had been discussed in the Resident Council meetings. Resident #13 voiced at lunch that her chicken pot pie was cold. She revealed that she got the dietary department to come down to her room and asked for it to be heated. Resident #28 revealed, he ate in the dining room at lunch and his soup was cold. Residents #5, #13, #43, #64, and #73 revealed they had been getting cold food at times for breakfast, lunch, and supper. All residents agreed they get cold food commonly when they eat in their room but agreed it does happen in the dining room. Resident #5 (the Resident Council President) revealed he was not aware of anything the facility had done to address the cold food. Resident #43, #64, and #73 voiced once the kitchen brings the meal carts out, it normally takes 10-15 minutes before anyone touches the trays to begin passing them out to the residents. An interview with Social Services #1 on 1/29/25 at 10:00 AM revealed she attends the Resident Council meetings every month. She confirmed the residents had been complaining about cold food, but she thought the issue had gotten better. SS #1 revealed she writes up the things discussed in the meetings and afterward she distributes the concerns to whoever was over the department, and they were to handle it. She revealed if there was a dietary concern, such as cold food, it would have been given to the Dietary Manager to handle. She revealed the Dietary Manager had started overhead paging to notify the staff when the meal trays were out and ready to be served. SS #1 acknowledged cold food was a topic trend in the past couple of Resident Council meetings and confirmed the issue with cold food was an unresolved grievance. An interview with the Dietary Manger (DM) on 1/29/25 at 10:18 AM confirmed she was aware of the concerns coming from the Resident Council meetings related to cold food. She revealed she had talked to the dietary staff and explained to them, they needed to cut the hot box on sooner, so the plates would get warm. The DM revealed she had also started announcing when the meal trays were ready, so there would not be a delay in pass time. An interview with the Administrator (ADM) on 1/29/25 at 2:00 PM revealed he was not aware of any resident concerns related to cold food. He revealed they did have trouble at one point in the past with cold food, but that had gotten better. The ADM confirmed resident grievances should be acted upon promptly and resolved. He stated, Nobody wants cold food. Record review of the Admission Record revealed the facility admitted Resident #5 on 5/21/12. Record review of the Brief Interview for Mental Status (BIMS) Evaluation dated 12/20/24 revealed a BIMS summary score of 12, indicating Resident #5 was moderately cognitively impaired. Record review of the Admission Record revealed the facility admitted Resident #13 on 7/26/24. Record review of the BIMS dated 1/10/25 revealed a BIMS summary score of 14, indicating Resident #13 was cognitively intact. Record review of the Admission Record revealed the facility admitted Resident #28 on 3/29/24. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/14/24 revealed a BIMS summary score of 15, indicating Resident #28 was cognitively intact. Record review of the Admission Record revealed the facility admitted Resident #43 on 9/09/19. Record review of the BIMS dated 1/17/25 revealed a score of 15, indicating Resident #43 was cognitively intact. Record review of the Admission Record revealed the facility admitted Resident #64 on 7/15/22. Record review of the BIMS dated 1/07/25 revealed a score of 15, indicating Resident #64 was cognitively intact. Record review of the Admission Record revealed the facility admitted Resident #73 on 4/04/23. Record review of the BIMS dated 1/01/25 revealed a score of 15, indicating Resident #73 was cognitively intact.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure a home-like environment, as evidenced by cold water temperatures in the 300-hall shower room for one (1) of two (2) shower rooms observed. Findings include: Review of the facility policy titled, Resident Rights undated revealed, Facility will treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of their quality of life . During an interview on 1/28/25 at 10:15 AM, Resident #28 revealed that the shower room on the 300 hall where we take our showers is often without hot water. He revealed that it was a big problem last week, and when my aide brought me back to my room after the cold shower, I saw the Administrator in the hallway and told him about the issue. An interview on 1/29/25 at 9:50 AM, Certified Nurse Aide (CNA) #1 revealed she has had several residents complain of the water being cold in the 300-hall shower room. She revealed last week that she took Resident #28 to the 300-hall shower room for his shower, turned the water on, and waited for about a minute; it got a little warm but not warm enough for a shower. She stated, I kept apologizing to (Resident #28), I felt so bad for him. When I was taking (Resident #28) back to his room, we saw the Administrator in the hallway, and (Resident #28) told him about the water being cold. She revealed that she had reported the issue to the unit manager before, and maintenance would test the water in the shower room, and they would say that it was ok. She revealed that the water still does not get warm enough. During an interview on 1/29/25 at 9:55 AM, CNA #2 revealed that multiple residents complained of the cold water in the 300-hall shower room. She revealed that she had not reported it to anyone because maintenance was already aware of the issue. In an interview on 1/29/25 at 11:10 AM, Resident #28 revealed he got a bed bath today. He also revealed that CNA #1 was assigned to him today and she told him that the water was cold in the shower and that it would be better for me to have a bed bath, so I did that. During an interview on 1/29/25 at 11:20 AM, CNA #3 revealed that residents have been complaining of the 300-hall shower room water being cold, and she revealed that she had reported it to maintenance in the past. In an interview on 1/29/25 at 11:30 AM, Maintenance worker #1 revealed that he is aware of complaints about the cold water in the shower room on 300 Hall. He revealed that he checked the water this morning, which was 105 degrees. During an interview and observation on 1/29/25 at 11:45 AM, Maintenance worker #2 revealed he checks the water temperatures two times daily and does it at random rooms. The water temperature is always running between 105-110. He revealed that he didn't understand how the water temperature in the 300-hall shower room was running colder. Maintenance worker #2 offered to check the water temperature in the shower room and stated, We can check it in the shower room sink since they are on the same water line. The State Agent (SA) encouraged the Maintenance worker to check the water from the middle shower stall, where the staff gave the residents their showers instead. Maintenance worker #1 tested the water temperature with a digital thermometer and after two minutes of running the water, an observation of the digital thermometer temperature gauge revealed that the water temperature was 88 degrees. Maintenance workers #1 and #2 confirmed the water was too cold for a shower and revealed they needed to fix this. An observation of the water temperature in the shower room sink revealed the hot water temperature at 106 degrees. Maintenance workers #1 and #2 revealed they always checked the sink in the 300-shower room and didn't check the water from the shower faucet because they felt like the water in the sink gave a more accurate reading, which was always around 105 degrees. During an interview on 1/29/25 at 2:00 PM, the Administrator revealed he wasn't aware of an issue with the cold water until his maintenance department notified him today. He revealed he did recall talking with Resident #28 last week in the hallway but did not recall the context of his conversation. He confirmed that there was obviously a problem with the valves in that shower stall. He confirmed this is the resident's home, and we were not promoting a homelike environment by not ensuring the residents get a warm shower. A record review of Resident #28's Admission Record revealed the resident was admitted to the facility on [DATE]. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/14/24 revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact.

CI MS # Based on staff interview, record review and policy review, the facility failed to ensure that the Responsible Party (RP) was notified timely of the need to alter medication for one (1) of six (6) residents reviewed (Resident #1) on 7/20/13 at 10:00 a.m. when the incident occurred. The RP was not notified following the incident until 6:00 p.m. on 7/20/13 when the RP arrived at the facility for a visit. Findings include: Review of the facility's policy/procedure entitled "Medication Errors", not dated, provided by the Director of Nursing on 8/7/13, revealed: "Resident's representative must be notified of error, notification of the MD and any treatment that was ordered. Include the name, time and representative response in your report." Review of the facility's policy entitled "Change in a Resident's Condition or Status", not dated, provided by the Director of Nursing (DON) on 8/9/13 revealed: "Policy Statement Our facility shall promptly notify the resident, his or her attending physician, and responsible party of changes in the resident's condition and/or status at time of change." Interview with Licensed Practical Nurse (LPN) #2 on 8/7/13 at 6:20 p.m. revealed that he should have notified the Responsible Party (RP) for Resident #1, of the medication error that occurred on 7/20/13 during the 10:00 a.m. medication pass and of the physician's orders [REDACTED]. LPN #2 stated that the physician was notified and orders were received to hold Resident #1's [MEDICATION NAME] for the next dose. LPN #2 stated that he had gotten busy and had forgotten to call Resident #1's RP after the medication error and order change and did not notify the RP until around 6:00 p.m. on 7/20/13 when the RP came to the facility. Review of a Medication Error Report dated 7/20/13 revealed that Resident #1 received the wrong medication. The resident was not properly identified. The time of the error was noted at 10:00 a.m. Review of a physician's orders [REDACTED].#1's [MEDICATION NAME] 800 mg for one (1) dose. Resident #1 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/1/13 revealed that she had a severe cognitive deficit with a Brief Interview for Mental Status score of three (3). (0-7 indicated a severe deficit). An Allegation of Compliance related to the Immediate Jeopardy was submitted by the facility on 8/8/13 at 4:50 p.m. A review of the Allegation of Compliance revealed the following: ? Resident #1's was assessed by LPN #2 at 10:00am on 7/20/13. LPN #2 stated upon notification by LPN #1 of Medication Error, Resident was immediately evaluated and found to be alert and oriented to self only, Resident confirmed swallowing medications, up in wheelchair and able to maintain posture Blood Pressure was 144/89. Resident #1 was monitored throughout the day of 7/20/13 by LPN #2 with no signs or symptoms of adverse reactions. LPN #2 failed to document Medication Error, evaluation of physical status, and evaluation of mental status in Resident #1's chart. ? LPN #2 notified Resident #1's physician at 10:05 a.m. on 7/20/2013. Resident #1's Physician was informed of medications [MEDICATION NAME] 5/500, [MEDICATION NAME] 0.1mg, [MEDICATION NAME] Sodium 100mg, and B Complex vitamin were given to Resident #1. Order received to hold [MEDICATION NAME] 800mg x 1 dose. ? Med Error Report completed on 7/20/13 by LPN #2 due to Resident #1 receiving Resident #2's prescribed medications. ? Responsible Party #1 was notified of Medication Administration error at 6 p.m. on 7/20/13 by LPN #2 ? Resident #1's Care Plan revised and updated on 8/8/13 to include goal of maintaining administration of medications as evidenced by following five rights(listed individually on care plan) and medications to be given according to physician's orders [REDACTED]. ? LPN #1 was counseled verbally at 10:20am on 7/20/13 by LPN #2 following Medication Error on Identifying Residents before Medication Administration with emphasis on Photo identification on MAR, Names on Door, and A and B bed assignment. A written disciplinary action was written on LPN #1 on 8/7/13 by LPN #2 for failure to properly identify Resident #1 prior to medication administration. ? LPN #1 was observed by LPN #2 for remainder of shift on 7/20/13 with no medication errors noted. ? 24 Report sheet was documented by Quality Assurance Nurse #1 on 7/20/13 and 7/21/13 with LPN Unit Manager #1 documenting on 24hr report sheet on 7/22/13 for monitoring Resident #1 for signs and symptoms of adverse reactions due to medications given in error. ? Shift Report at 7 a.m. on 7/21/13, given by LPN #3 to LPN #2 revealed an uneventful night with no adverse reaction reported for Resident #1. ? In-service performed by Staff Development Nurse on 5 Rights of Medication Administration, Medication Errors, Notifying Family and Physician at time of Medication Error to LPN #1 and LPN #2 on 7/22/13. ? Disciplinary Action given by ADON on 7/22/13 to LPN #2 for failure to notify Resident #1's Responsible Party in a timely manner. ? In-service on 7/22/13 at 08:15 a.m. performed by Staff Development Nurse on Physician order [REDACTED]. Facility policy states that responsible party will be notified if resident is involved in any accident or incident: if there is a significant change in the resident's physical, mental, or psychosocial status; if there is a reason to alter the resident's treatment; a decision has been made to discharge the resident from the facility; and/or when the resident is transferred to the hospital. The nurse will record in the resident's medical record any changes in the resident's medical condition or status; including, but not limited to, date and time the responsible party and physician was notified; name of person; change of condition report and response. ? In-service on 7/29/13-7/31/13 performed by Staff Development Nurse regarding Medication Error, Drug Administration, and Documentation to include 5 rights. Facility policy states that 5 rights include resident identification (check picture, check name on door, ask resident to state his/her name, if unable to state name consult staff to help identify resident, if unable to identify resident, hold medications until positive identification and notify physician); right medication, right dose, & right route. In-service was performed due to Medication Error on 7/20/13 to ensure licensed nursing staff is educated to current policy and procedures. Facility policy of Medication Errors and Adverse Reactions states that documentation include date and time of incident, kind of medication error, or adverse reaction, name of physician, date and time physician was contacted, any physicians orders, residents condition in detail at time of incident, the date, time, & responsible party's name along with response, and other information as necessary or appropriate. Documentation should include assessment of resident and monitoring of activities. ? On 8/7/13 at 7 p.m., Interviews were conducted on 100 hall with 9 cognitive residents and 7 cognitive residents on remaining halls conducted by RN Unit Manager #1, Registered Nurse #1, Quality Assurance Nurse #2, LPN #3, LPN #4, LPN #5, LPN #6, LPN #7 and Staff Development Nurse. Interviews related to administration of medications. All residents interviewed reported that they received their own prescribed medication as ordered by physician. ? On 8/7/13 at 9 p.m., In-service on current Policy and Procedure Related to Identification of Residents prior to Medication Administration conducted by DON to ensure licensed nursing staff is knowledgeable to current policy and procedure related to Identification of Residents prior to Medication Administration. Facility policy states that 5 rights include resident identification (check picture, check name on door, ask resident to state his/her name, if unable to state name consult staff to help identify resident, if unable to identify resident, hold medications until positive identification and notify physician); right medication, right dose, & right route. ? On 8/7/13 at 9 p.m., In-service on Policy and Procedure Related to Assessment and Documentation after Medication Error conducted by DON to ensure licensed nursing staff is knowledgeable to current policy and procedure related to Assessment and Documentation after Medication Error. Facility policy of Medication Errors and Adverse Reactions states that documentation include date and time of incident, kind of medication error, or adverse reaction, name of physician, date and time physician was contacted, any physicians orders, residents condition in detail at time of incident, the date, time, & responsible party's name along with response, and other information as necessary or appropriate. Documentation should include assessment of resident and monitoring of activities. ? On 8/7/13 at 9 p.m., In-service on Policy and Procedure Related to Care Plan for Medication Error conducted by DON to ensure licensed nursing staff is knowledgeable to current policy and procedure related to Care Plan for Medication Error. Facility policy states that Medication Error Care Plan will be implemented on every medication error to include nursing diagnosis, goals, and specific interventions related to medication error. ? On 8/7/13 at 9 p.m., In-service via Video and Written materials related to Medication Administration to include 5 Rights. In-Service conducted by DON to ensure licensed nursing staff is knowledgeable to principles of medication administration ? On 8/7/13 at 9 p.m., In-service on Initiation of Medication Error Evaluation Flow Sheet conducted by DON for monitoring resident's status [REDACTED]. ? On 8/7/13 at 9 p.m., New Hire - Licensed Nurse Orientation Process - Administrator reviewed and revised policy and procedure related to New Hire - Licensed Nurse Orientation to ensure designated Preceptor of new hire license nurses has defined and measurable responsibilities in the orientation process of newly hired licensed nurses, i.e., sequence of orientation, subjects covered, suitability, and competency evaluation of newly hired licensed nurses. Preceptor is to ensure newly hired nurses are competent in basic nursing skills needed to successfully perform their assigned job description, such as properly identifying residents prior to the administration of medications and or treatments, following physician's orders [REDACTED]. ? On 8/7/13 at 9 p.m. In-Service on New Hire Licensed Nurse Orientation Process conducted by Administrator to include responsibilities of the preceptor and the new hire. Preceptor must ensure that new hire licensed nurse has demonstrated competency on all check-off skills including; right resident (check picture, check door names, ask resident to state his/her name, and if unable to identify resident withhold medications until a positive identification and notify physician), right time, right medication, right dose, right route of administration. If preceptor observes any concerns related to performance of assigned tasks he/she is to cease New Hire participation and notify the DON or designee, preceptor is not to leave New Hire alone after concern has been observed. New Hire Licensed Nurse is responsible for demonstrating to the preceptor competency in all skills check-off areas which include properly identifying a resident prior to administering prescribed medications which are: right resident (check picture, check door names, ask resident to state his/her name, and if unable to identify resident withhold medications until a positive identification and notify physician), right time, right medication, right dose, right route of administration. ? All In-services were given to Licensed Nurses. ? No Licensed Nurses will be allowed to work until In-services have been completed. ? On 8/8/13 at 8 a.m., Quality Assurance meeting conducted by Administrator, attended by Medical Director, Administrator, DON, ADON, Staff Development Nurse, and Quality Assurance Nurse #1 to discuss circumstances regarding medication error on 7/20/13 for Resident #1. Discussion topics included Medication Error, Documentation, Interventions, New Training Guidelines, Notification of Responsible Party and Physician, and Quality Assurance Monitoring Post Error Events. Committee concurred with current actions, no new recommendations offered. ? On 8/8/13 at 9 a.m., Audit of room and bed assignments and face sheet information was conducted by Social Services Director and Social Services Assistant to ensure the information is accurate and photos on all EMARS. Audit revealed no discrepancies. ? Additional Disciplinary Action on 8/8/13 by ADON given to LPN #2 on failure to document Resident #1's evaluation on 7/20/13 after receiving medications not ordered. ? On 8/7/13, Review of Medication Error Reports by DON revealed no other issues with residents' receiving of another resident's medication." The surveyor validated the corrective actions taken by the facility as follows: Interview with LPN #1 on 8/7/13 at 4:05 p.m., LPN #2 on 8/7/13 at 6:20 p.m. and CNA #1 on 8/8/13 at 4:20 p.m. confirmed that Resident #1 was alert and had no adverse effects from receiving Resident #2's medication on 7/20/13. LPN #2 confirmed that he did evaluate Resident #1 immediately after the error and throughout the day but failed to document. LPN #2 also confirmed that he monitored LPN #1 for the remainder of the shift with no other medication errors on 7/20/13. Review of Resident #1's care plan dated 8/8/13 confirmed that it had been updated for the potential for injury or adverse drug reaction related to high number of medications or medication error with interventions of medication as ordered and a goal to maintain proper administration of medication as evidenced by following the five rights of right resident, dose, route, medication and time. Review of a Disciplinary Action Record dated and signed by LPN #1 on 8/7/13 and interview with LPN #1 on 8/9/13 at 2:40 p.m. confirmed that she had received a written disciplinary action on 8/7/13 for not properly identifying Resident #1 prior to administering her medication. Interview also revealed that she had been in-serviced on 8/7/13 on the 5 rights of medication administration. In-service also included documentation of resident status, notification of MD/RP, med error report with flow sheet, updating the care plan and following physician's orders [REDACTED]. Review of a Disciplinary Action Record dated 8/8/13 confirmed that LPN #2 was disciplined for failure to correctly document a medication error, notify the physician/RP and update the care plan after a medication error. Interview with LPN #2 on 8/9/13 at 10:45 a.m. confirmed the disciplinary action. Review of policies Medication Administration and Documentation, and Medication Errors which included notification to the physician and not giving a resident medication that had not been ordered was confirmed with signatures of LPN #1 and LPN #2 of in-service provided by the Staff Development Nurse dated 7/22/13. Review of in-service records and sign-in sheets validated in-services held on 7/22/13 and interviews with licensed nurses further validated their attendance and content which included completing and carrying out physician's orders [REDACTED]. Review of in-service records and sign-in sheets validated in-services held on 8/7/13, beginning at 9:00 p.m., and interviews with licensed nurses validated their attendance and content which included the following information for updated policy/practice: 1)Identification of Residents Prior to Medication Administration-policy expanded to include more information regarding the 5 rights related to Resident Identification which included check picture, check door, ask resident to state name, if unable to state name-consult staff regarding identity of resident, and if unable to identify resident withhold medications until a positive ID and notify the MD. 2) Assessment and Documentation after Medication Error-policy expanded to include documentation in the nurse's notes for assessment, monitoring, medication error, notification of MD/RP, following physician orders, documentation on the 24 Hour report sheet, medication error flow sheet and Care Plan updated. 3) Care Plan Related to Medication Error-policy expanded to include medication error care plans will be implemented on every medication error to include nursing diagnosis, goals, and specific interventions related to medication error. 4) Video/Documentation of Principles of Medication Administration of which included "Before you administer the med pass ID your resident per facility policy and procedure". 5) Initiation of Medication Error Evaluation Flow Sheet- initiated at time of medication error with documentation of vital signs, level of consciousness, pupil response, motor functions, and pain response. Review of documentation and interview with the Staff Development Nurse on 8/9/13 at 11:25 a.m., and Unit Manager RN #1 on 8/9/13 at 9:48 a.m. revealed that 16 residents, all with Brief Interview for Mental Status (BIMS) scores of 13-15, were interviewed with no issues of receiving medication that wasn't ordered for them. Review of a statement dated 8/9/13 and interview with the DON on 8/9/13 at 10:15 a.m. confirmed that no other resident had medication errors of receiving another resident's medications. Review of six (6) sampled resident charts, review of medication error reports, and interviews with four (4) cognitive residents, Resident #3, #5, #A and #B, by the surveyor on 8/9/13 beginning at 2:30 p.m. validated that residents had not received medications that were ordered for other residents. Interview with LPN #8 on 8/9/13 at 9:20 a.m. revealed that she identified Resident #C prior to administering medications by pointing out the photo on the EMAR, pointing out the name on the door and asking the resident to state her name. physician's orders [REDACTED]. LPN #8 stated that she had attended in-service on 8/7/13, came in at 9:00 p.m., on subjects which included medication administration and observance of the 5 rights-especially identification (ID) of resident. LPN #8 stated that in-service included updating the care plan with interventions and documentation in the nurse's note and evaluation of the resident's condition and to initiate the medication error flow sheet. LPN #8 stated there was a video that outlined areas of medication administration and also included not to give any resident another resident's medication or giving a resident medication that was prepared by someone else and following the physician's orders [REDACTED]. Observation of medication pass and interview with LPN #9 on 8/9/13 at 9:40 a.m. revealed that she identified Resident #D by asking the resident to state her name, and looking at the photo on the EMAR and the name on the door, stating that resident was in the A bed. Medications were administered as ordered. LPN #9 stated that she had came in on 8/7/13 for in-services from 9:00 p.m. until around 10:45 p.m. LPN #9 stated that the in-services included watching a video on medication administration, policy/procedures for the 5 rights of med administration. LPN #9 stated that updating the care plan and documentation in the medical record for any incident or med error was to be done as well as notification of the RP/MD with date and time documented. LPN #9 stated that physician's orders [REDACTED]. LPN #9 verified that she had attended in-services the last part of July which included notification, 5 rights of medication administration and following physician's orders [REDACTED]. Observation of medication pass and interview with LPN #10 on 8/9/13 at 9:50 a.m. revealed that she identified Resident #E prior to med administration by looking at photo, name on door and asking resident to state his name. Medications were administered as ordered. LPN #10 stated that she had attended in-service on 8/7/13 at 9:00 p.m. along with about 40 other nurses which included 5 rights of med administration. In-service also included medication errors and making sure to initiate a med error report, flow sheet, notification of MD/RP, assess/evaluate and document resident status, update the care plan and make sure to follow the physician's orders [REDACTED]. Interview with LPN #2 on 8/9/13 at 10:05 a.m. and observation of medication pass at 11:00 a.m. revealed that LPN #2 identified Resident #6 prior to medication administration by asking resident to state her name, observation of the photo on the EMAR and pointing to the name on the door as the "B" bed. Medications were administered as ordered. LPN #2 stated that he had been in-serviced on different subjects 8/7/13 which included ID of resident prior to giving medications, orders were to be followed and the care plan updated with interventions and the med error. LPN #2 stated that he received disciplinary action on 8/8/13 for not documenting an assessment of Resident #1 after the med error and not updating the care plan. Interview with the DON on 8/9/13 at 1:00 p.m. validated that all physician's orders [REDACTED]. An acceptable Allegation of Compliance was received on 8/8/13 which alleged removal of Immediate Jeopardy. On 8/9/13, the State Agency validated the facility's corrective actions and determined the Immediate Jeopardy was removed on 8/9/13, prior to exit, which lowered the scope and severity to a "D" at 42 CFR 482.10 - Notify of Changes (F-157), while the facility monitors the effectiveness of systemic changes and quality assurance activities.

CI MS # Based on observation, interview, record review and facility policy review, the facility failed to correctly identify Resident #1 prior to medication administration. The facility failed to ensure the resident was properly identified and physician's orders were followed for one (1) of six (6) residents reviewed (Resident #1). Resident #1 received four (4) medications that were not ordered for her, due to Trainee Licensed Practical Nurse (LPN) #1's failure to properly identify the resident. Findings include: Review of the standard of practice from Lippincott's Nursing Center.com revealed, "Rights of medication administration: 1. Right Patient: Check the name on the order and the patient. Use two identifiers. Ask patient to identify himself/herself. When available, use technology (for example, bar-code system)." Review of the facility's policy entitled, "Drug Administration and Documentation: Read the medication label and compare it with the E-MAR. Remember the 5 rights: Right Resident, Right time, Right medication, Right dose and Right route of administration. Medications prescribed for one resident will not be administered to another resident. Properly identify the resident before administering medications. A current picture of the resident can be found on the top right hand corner of each E-MAR". This policy was updated after the 7/20/13 medication error to reflect emphasis on resident identification. Interview with the Director of Nursing (DON) on 8/7/13 at 5:45 p.m. revealed confirmation that physician's orders were not followed. Resident #1 received medications in error that were not ordered for her. Review of a Medication Error Report dated 7/20/13 revealed that Resident #1 received the wrong medications of [MEDICATION NAME] 5-500- a pain medication, and Fludrocortisone 0.1 milligram (mg)-a steroid medication on 7/20/13 at 10:00 a.m. An amended Medication Error Report revealed that additional medications of Ducosate Sodium 100 mg-stool softener, and B-Complex-Vitamin were administered to Resident #1 on 7/20/13 at 10:00 a.m. The Medication Error Reports documented the type of error as the wrong medication/ wrong resident and the reason as failure to identify resident. The report identified the staff member making the error as Trainee LPN #1. Review of Resident #1's July 2013 printed physician's orders revealed an order for [REDACTED]. There was no physician's order for Resident #1 to receive [MEDICATION NAME], B-Complex Vitamin, Fludrocortisone, or Ducosate Sodium. Resident #1's allergies [REDACTED]. Review of a physician's order for Resident #1 dated 7/20/13 at 10:05 a.m. revealed an order to hold [MEDICATION NAME] 800 mg for one (1) dose. Record review revealed Trainee LPN#1 was hired on 7/15/13. Trainee LPN #1 was oriented to the medication cart on 7/17/13. LPN #2 (Preceptor) observed Trainee LPN #1 prepare and administer medications starting 7/17/13 at 5:00 p.m. until 11:00 p.m. Trainee LPN #1 returned to orientation on 7/20/13 at 6:45 a.m. after being off duty for two days and expressed that she was ready to administer medications without supervision. Preceptor was in agreement. Interview with Trainee Licensed Practical Nurse (LPN) #1 on 8/7/13 at 4:05 p.m. revealed she had mistakenly administered Resident #2's 10:00 a.m. medications to Resident #1 on 7/20/13. Trainee LPN #1 identified the medications error as [MEDICATION NAME] 5-500 mg, Fludrocortisone 0.1 mg, Ducosate Sodium 100 mg, and B-Complex vitamin. Trainee LPN #1 stated that she had pulled the medications for Resident #2, had looked at the photo of Resident #2 on the computer E-Mar (electronic medication administration record) prior to going into the resident's room. Trainee LPN #1 stated that when she went into the room there was a resident sitting in a chair between the two beds and that she called out Resident #2's name and the Resident #1 answered "yes". Trainee LPN #1 stated that she administered the medications to the resident, then looked around at the photos in the room and thought that she may have made a mistake and called LPN #2 to the room. LPN #2 verified that she had administered Resident #2's medications to Resident #1. Trainee LPN #1 stated that Resident #1 took the medication without problems and had no adverse effects during the rest of the shift (7a-7p). Trainee LPN #1 confirmed that Resident #1 could have been put at great risk due to not being properly identified for medications. Review of Resident #1's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/1/13 revealed that she had a severe cognitive deficit with a Brief Interview for Mental Status of three (3). (0-7 indicates a severe deficit). Observation of Resident #1 on 8/7/13 at 2:00 p.m. revealed that she was alert and oriented to name only. Resident #1 was able to state her name when asked. Interview with the Director of Nursing (DON) on 8/7/13 at 2:15 p.m. revealed that there had been a medication error for Resident #1 on 7/20/13. The DON stated that Trainee LPN #1 had mistakenly given Resident #2's medications to Resident #1 (her roommate). The DON stated that LPN #2 was orienting Trainee LPN #1 to the 100 hall and was ultimately responsible for the residents. Interview with the LPN Unit Manager on 8/7/13 at 3:05 p.m. revealed that she was made aware of the 7/20/13 medication error for Resident #1 on 7/22/13 by reviewing the 24 Hour Report and by LPN #2. The Unit Manager stated that she talked with Trainee LPN #1 about the medication error for Resident #1, who had received Resident #2's medications, on 7/22/13 and was informed that Trainee LPN #1 had glanced at Resident #2's photo on the EMAR and had called Resident #2's name to which Resident #1 answered "yes". The UM stated that Trainee LPN #1 should have positively identified Resident #2 by the photo and then asked her to state her name. Interview with LPN #2 on 8/7/13 at 6:20 p.m. revealed that he was orienting Trainee LPN #1 to the 100 hall on 7/20/13 on the 7a-7p shift and had watched her pull up Resident #2's medication. LPN #2 stated that he had reminded Trainee LPN #1 that Resident #2 was blind and that she would have to put the pills in Resident #2's hand. LPN #2 stated that Trainee LPN #1 came out of the room and said that she thought she had "goofed" and given the wrong resident medications. LPN #2 stated that he went to the room and Resident #1 was the only resident in the room and Trainee LPN #1 said that was who she'd given Resident #2's medication. LPN #2 stated that Trainee LPN #1 said that she'd called Resident #2's name out and Resident #1 had answered "yes". LPN #2 stated that he called the physician and reported the medication error and received orders to monitor and hold the next dose of [MEDICATION NAME]. LPN #2 stated that Resident #1 was monitored the rest of the shift without adverse effects and was not drowsy or different than her normal self. Interview with Resident #1's physician on 8/8/13 at 1:55 p.m. revealed that he was notified of Resident #1 receiving another resident's medication, he thought a stool softener, vitamin, [MEDICATION NAME] and Cortisone. The physician stated that he wasn't concerned with any of the medications hurting the resident but told the facility to watch her and to hold the next [MEDICATION NAME] dose when the nurse told him all of the medications that Resident #1 was taking. The physician stated that no adverse effects had been reported due to Resident #1 receiving the medications in error. Resident #1 was admitted [DATE] with [DIAGNOSES REDACTED]. An Allegation of Compliance related to the Immediate Jeopardy was submitted by the facility on 8/8/13 at 4:50 p.m. A review of the Allegation of Compliance revealed the following: ? Resident #1's was assessed by LPN #2 at 10:00am on 7/20/13. LPN #2 stated upon notification by LPN #1 of Medication Error, Resident was immediately evaluated and found to be alert and oriented to self only, Resident confirmed swallowing medications, up in wheelchair and able to maintain posture Blood Pressure was 144/89. Resident #1 was monitored throughout the day of 7/20/13 by LPN #2 with no signs or symptoms of adverse reactions. LPN #2 failed to document Medication Error, evaluation of physical status, and evaluation of mental status in Resident #1's chart. ? LPN #2 notified Resident #1's physician at 10:05 a.m. on 7/20/2013. Resident #1's Physician was informed of medications [MEDICATION NAME] 5/500, [MEDICATION NAME] 0.1mg, [MEDICATION NAME] Sodium 100mg, and B Complex vitamin were given to Resident #1. Order received to hold [MEDICATION NAME] 800mg x 1 dose. ? Med Error Report completed on 7/20/13 by LPN #2 due to Resident #1 receiving Resident #2's prescribed medications. ? Responsible Party #1 was notified of Medication Administration error at 6 p.m. on 7/20/13 by LPN #2 ? Resident #1's Care Plan revised and updated on 8/8/13 to include goal of maintaining administration of medications as evidenced by following five rights(listed individually on care plan) and medications to be given according to physician's orders. ? LPN #1 was counseled verbally at 10:20am on 7/20/13 by LPN #2 following Medication Error on Identifying Residents before Medication Administration with emphasis on Photo identification on MAR, Names on Door, and A and B bed assignment. A written disciplinary action was written on LPN #1 on 8/7/13 by LPN #2 for failure to properly identify Resident #1 prior to medication administration. ? LPN #1 was observed by LPN #2 for remainder of shift on 7/20/13 with no medication errors noted. ? 24 Report sheet was documented by Quality Assurance Nurse #1 on 7/20/13 and 7/21/13 with LPN Unit Manager #1 documenting on 24hr report sheet on 7/22/13 for monitoring Resident #1 for signs and symptoms of adverse reactions due to medications given in error. ? Shift Report at 7 a.m. on 7/21/13, given by LPN #3 to LPN #2 revealed an uneventful night with no adverse reaction reported for Resident #1. ? In-service performed by Staff Development Nurse on 5 Rights of Medication Administration, Medication Errors, Notifying Family and Physician at time of Medication Error to LPN #1 and LPN #2 on 7/22/13. ? Disciplinary Action given by ADON on 7/22/13 to LPN #2 for failure to notify Resident #1's Responsible Party in a timely manner. ? In-service on 7/22/13 at 08:15 a.m. performed by Staff Development Nurse on Physician order to be completed and carried out; Notify resident's responsible party of status change at time of change; and Document date, time, name of responsible party talked with, and reply in nurse's notes. Facility policy states that responsible party will be notified if resident is involved in any accident or incident: if there is a significant change in the resident's physical, mental, or psychosocial status; if there is a reason to alter the resident's treatment; a decision has been made to discharge the resident from the facility; and/or when the resident is transferred to the hospital. The nurse will record in the resident's medical record any changes in the resident's medical condition or status; including, but not limited to, date and time the responsible party and physician was notified; name of person; change of condition report and response. ? In-service on 7/29/13-7/31/13 performed by Staff Development Nurse regarding Medication Error, Drug Administration, and Documentation to include 5 rights. Facility policy states that 5 rights include resident identification (check picture, check name on door, ask resident to state his/her name, if unable to state name consult staff to help identify resident, if unable to identify resident, hold medications until positive identification and notify physician); right medication, right dose, & right route. In-service was performed due to Medication Error on 7/20/13 to ensure licensed nursing staff is educated to current policy and procedures. Facility policy of Medication Errors and Adverse Reactions states that documentation include date and time of incident, kind of medication error, or adverse reaction, name of physician, date and time physician was contacted, any physicians orders, residents condition in detail at time of incident, the date, time, & responsible party's name along with response, and other information as necessary or appropriate. Documentation should include assessment of resident and monitoring of activities. ? On 8/7/13 at 7 p.m., Interviews were conducted on 100 hall with 9 cognitive residents and 7 cognitive residents on remaining halls conducted by RN Unit Manager #1, Registered Nurse #1, Quality Assurance Nurse #2, LPN #3, LPN #4, LPN #5, LPN #6, LPN #7 and Staff Development Nurse. Interviews related to administration of medications. All residents interviewed reported that they received their own prescribed medication as ordered by physician. ? On 8/7/13 at 9 p.m., In-service on current Policy and Procedure Related to Identification of Residents prior to Medication Administration conducted by DON to ensure licensed nursing staff is knowledgeable to current policy and procedure related to Identification of Residents prior to Medication Administration. Facility policy states that 5 rights include resident identification (check picture, check name on door, ask resident to state his/her name, if unable to state name consult staff to help identify resident, if unable to identify resident, hold medications until positive identification and notify physician); right medication, right dose, & right route. ? On 8/7/13 at 9 p.m., In-service on Policy and Procedure Related to Assessment and Documentation after Medication Error conducted by DON to ensure licensed nursing staff is knowledgeable to current policy and procedure related to Assessment and Documentation after Medication Error. Facility policy of Medication Errors and Adverse Reactions states that documentation include date and time of incident, kind of medication error, or adverse reaction, name of physician, date and time physician was contacted, any physicians orders, residents condition in detail at time of incident, the date, time, & responsible party's name along with response, and other information as necessary or appropriate. Documentation should include assessment of resident and monitoring of activities. ? On 8/7/13 at 9 p.m., In-service on Policy and Procedure Related to Care Plan for Medication Error conducted by DON to ensure licensed nursing staff is knowledgeable to current policy and procedure related to Care Plan for Medication Error. Facility policy states that Medication Error Care Plan will be implemented on every medication error to include nursing diagnosis, goals, and specific interventions related to medication error. ? On 8/7/13 at 9 p.m., In-service via Video and Written materials related to Medication Administration to include 5 Rights. In-Service conducted by DON to ensure licensed nursing staff is knowledgeable to principles of medication administration ? On 8/7/13 at 9 p.m., In-service on Initiation of Medication Error Evaluation Flow Sheet conducted by DON for monitoring resident's status [REDACTED]. ? On 8/7/13 at 9 p.m., New Hire - Licensed Nurse Orientation Process - Administrator reviewed and revised policy and procedure related to New Hire - Licensed Nurse Orientation to ensure designated Preceptor of new hire license nurses has defined and measurable responsibilities in the orientation process of newly hired licensed nurses, i.e., sequence of orientation, subjects covered, suitability, and competency evaluation of newly hired licensed nurses. Preceptor is to ensure newly hired nurses are competent in basic nursing skills needed to successfully perform their assigned job description, such as properly identifying residents prior to the administration of medications and or treatments, following physician's orders, physician and family notification. Preceptor is to provide verbal and written notification to DON of any concerns observed during the orientation process. ? On 8/7/13 at 9 p.m. In-Service on New Hire Licensed Nurse Orientation Process conducted by Administrator to include responsibilities of the preceptor and the new hire. Preceptor must ensure that new hire licensed nurse has demonstrated competency on all check-off skills including; right resident (check picture, check door names, ask resident to state his/her name, and if unable to identify resident withhold medications until a positive identification and notify physician), right time, right medication, right dose, right route of administration. If preceptor observes any concerns related to performance of assigned tasks he/she is to cease New Hire participation and notify the DON or designee, preceptor is not to leave New Hire alone after concern has been observed. New Hire Licensed Nurse is responsible for demonstrating to the preceptor competency in all skills check-off areas which include properly identifying a resident prior to administering prescribed medications which are: right resident (check picture, check door names, ask resident to state his/her name, and if unable to identify resident withhold medications until a positive identification and notify physician), right time, right medication, right dose, right route of administration. ? All In-services were given to Licensed Nurses. ? No Licensed Nurses will be allowed to work until In-services have been completed. ? On 8/8/13 at 8 a.m., Quality Assurance meeting conducted by Administrator, attended by Medical Director, Administrator, DON, ADON, Staff Development Nurse, and Quality Assurance Nurse #1 to discuss circumstances regarding medication error on 7/20/13 for Resident #1. Discussion topics included Medication Error, Documentation, Interventions, New Training Guidelines, Notification of Responsible Party and Physician, and Quality Assurance Monitoring Post Error Events. Committee concurred with current actions, no new recommendations offered. ? On 8/8/13 at 9 a.m., Audit of room and bed assignments and face sheet information was conducted by Social Services Director and Social Services Assistant to ensure the information is accurate and photos on all EMARS. Audit revealed no discrepancies. ? Additional Disciplinary Action on 8/8/13 by ADON given to LPN #2 on failure to document Resident #1's evaluation on 7/20/13 after receiving medications not ordered. ? On 8/7/13, Review of Medication Error Reports by DON revealed no other issues with residents' receiving of another resident's medication." The surveyor validated the corrective actions taken by the facility as follows: Interview with LPN #1 on 8/7/13 at 4:05 p.m., LPN #2 on 8/7/13 at 6:20 p.m. and CNA #1 on 8/8/13 at 4:20 p.m. confirmed that Resident #1 was alert and had no adverse effects from receiving Resident #2's medication on 7/20/13. LPN #2 confirmed that he did evaluate Resident #1 immediately after the error and throughout the day but failed to document. LPN #2 also confirmed that he monitored LPN #1 for the remainder of the shift with no other medication errors on 7/20/13. Review of Resident #1's care plan dated 8/8/13 confirmed that it had been updated for the potential for injury or adverse drug reaction related to high number of medications or medication error with interventions of medication as ordered and a goal to maintain proper administration of medication as evidenced by following the five rights of right resident, dose, route, medication and time. Review of a Disciplinary Action Record dated and signed by LPN #1 on 8/7/13 and interview with LPN #1 on 8/9/13 at 2:40 p.m. confirmed that she had received a written disciplinary action on 8/7/13 for not properly identifying Resident #1 prior to administering her medication. Interview also revealed that she had been in-serviced on 8/7/13 on the 5 rights of medication administration. In-service also included documentation of resident status, notification of MD/RP, med error report with flow sheet, updating the care plan and following physician's orders after any medication error/incident. Review of a Disciplinary Action Record dated 8/8/13 confirmed that LPN #2 was disciplined for failure to correctly document a medication error, notify the physician/RP and update the care plan after a medication error. Interview with LPN #2 on 8/9/13 at 10:45 a.m. confirmed the disciplinary action. Review of policies Medication Administration and Documentation, and Medication Errors which included notification to the physician and not giving a resident medication that had not been ordered was confirmed with signatures of LPN #1 and LPN #2 of in-service provided by the Staff Development Nurse dated 7/22/13. Review of in-service records and sign-in sheets validated in-services held on 7/22/13 and interviews with licensed nurses further validated their attendance and content which included completing and carrying out physician's orders. Review of in-service records and sign-in sheets validated in-services held on 8/7/13, beginning at 9:00 p.m., and interviews with licensed nurses validated their attendance and content which included the following information for updated policy/practice: 1)Identification of Residents Prior to Medication Administration-policy expanded to include more information regarding the 5 rights related to Resident Identification which included check picture, check door, ask resident to state name, if unable to state name-consult staff regarding identity of resident, and if unable to identify resident withhold medications until a positive ID and notify the MD. 2) Assessment and Documentation after Medication Error-policy expanded to include documentation in the nurse's notes for assessment, monitoring, medication error, notification of MD/RP, following physician orders, documentation on the 24 Hour report sheet, medication error flow sheet and Care Plan updated. 3) Care Plan Related to Medication Error-policy expanded to include medication error care plans will be implemented on every medication error to include nursing diagnosis, goals, and specific interventions related to medication error. 4) Video/Documentation of Principles of Medication Administration of which included "Before you administer the med pass ID your resident per facility policy and procedure". 5) Initiation of Medication Error Evaluation Flow Sheet- initiated at time of medication error with documentation of vital signs, level of consciousness, pupil response, motor functions, and pain response. Review of documentation and interview with the Staff Development Nurse on 8/9/13 at 11:25 a.m., and Unit Manager RN #1 on 8/9/13 at 9:48 a.m. revealed that 16 residents, all with Brief Interview for Mental Status (BIMS) scores of 13-15, were interviewed with no issues of receiving medication that wasn't ordered for them. Review of a statement dated 8/9/13 and interview with the DON on 8/9/13 at 10:15 a.m. confirmed that no other resident had medication errors of receiving another resident's medications. Review of six (6) sampled resident charts, review of medication error reports, and interviews with four (4) cognitive residents, Resident #3, #5, #A and #B, by the surveyor on 8/9/13 beginning at 2:30 p.m. validated that residents had not received medications that were ordered for other residents. Interview with LPN #8 on 8/9/13 at 9:20 a.m. revealed that she identified Resident #C prior to administering medications by pointing out the photo on the EMAR, pointing out the name on the door and asking the resident to state her name. Physician's orders were followed for medications administered. LPN #8 stated that she had attended in-service on 8/7/13, came in at 9:00 p.m., on subjects which included medication administration and observance of the 5 rights-especially identification (ID) of resident. LPN #8 stated that in-service included updating the care plan with interventions and documentation in the nurse's note and evaluation of the resident's condition and to initiate the medication error flow sheet. LPN #8 stated there was a video that outlined areas of medication administration and also included not to give any resident another resident's medication or giving a resident medication that was prepared by someone else and following the physician's orders. Observation of medication pass and interview with LPN #9 on 8/9/13 at 9:40 a.m. revealed that she identified Resident #D by asking the resident to state her name, and looking at the photo on the EMAR and the name on the door, stating that resident was in the A bed. Medications were administered as ordered. LPN #9 stated that she had came in on 8/7/13 for in-services from 9:00 p.m. until around 10:45 p.m. LPN #9 stated that the in-services included watching a video on medication administration, policy/procedures for the 5 rights of med administration. LPN #9 stated that updating the care plan and documentation in the medical record for any incident or med error was to be done as well as notification of the RP/MD with date and time documented. LPN #9 stated that physician's orders were to be followed and any interventions/orders were to be care planned. LPN #9 verified that she had attended in-services the last part of July which included notification, 5 rights of medication administration and following physician's orders. Observation of medication pass and interview with LPN #10 on 8/9/13 at 9:50 a.m. revealed that she identified Resident #E prior to med administration by looking at photo, name on door and asking resident to state his name. Medications were administered as ordered. LPN #10 stated that she had attended in-service on 8/7/13 at 9:00 p.m. along with about 40 other nurses which included 5 rights of med administration. In-service also included medication errors and making sure to initiate a med error report, flow sheet, notification of MD/RP, assess/evaluate and document resident status, update the care plan and make sure to follow the physician's orders. Interview with LPN #2 on 8/9/13 at 10:05 a.m. and observation of medication pass at 11:00 a.m. revealed that LPN #2 identified Resident #6 prior to medication administration by asking resident to state her name, observation of the photo on the EMAR and pointing to the name on the door as the "B" bed. Medications were administered as ordered. LPN #2 stated that he had been in-serviced on different subjects 8/7/13 which included ID of resident prior to giving medications, orders were to be followed and the care plan updated with interventions and the med error. LPN #2 stated that he received disciplinary action on 8/8/13 for not documenting an assessment of Resident #1 after the med error and not updating the care plan. Interview with the DON on 8/9/13 at 1:00 p.m. validated that all physician's orders should be followed and care plans initiated and/or updated with all medication errors. An acceptable Allegation of Compliance was received on 8/8/13 which alleged removal of Immediate Jeopardy. On 8/9/13, the State Agency validated the facility's corrective actions and determined the Immediate Jeopardy was removed on 8/9/13, prior to exit, which lowered the scope and severity to a "D" at 42 CFR 482.20 - Services Meet Professional Standards (F-281), while the facility monitors the effectiveness of systemic changes and quality assurance activities.

CI MS # Based on staff interview, record review and policy review the facility failed to ensure accurate and completely documented medical records and Medication Error Report for one (1) of six (6) residents (Resident #1). There was no documentation of an assessment/evaluation or monitoring of Resident #1 after receiving four (4) medications that were administered in error due to the facility's failure to properly identify the resident. There was no documentation of notification to the Responsible Party following the incident on 7/20/13. Findings include: Review of the policy/procedure provided by the DON on 8/9/13 for Change in a Resident's Condition or Status: "The Nurse will record in the resident's medical record any changes in the resident's medical condition or status; including but not limited to, date and time the responsible party and physician was notified; name of person; change of condition report and response." Interview with the DON on 8/7/13 at 5:45 p.m. and again on 8/9/13 at 10:15 a.m. revealed confirmation that there was no documentation in Resident #1's medical record of the medications that were received without orders, monitoring or assessment of the resident. Interview with Trainee LPN #1 on 8/7/13 at 4:05 p.m. revealed that she had mistakenly administered Resident #2's 10:00 a.m. medications to Resident #1 on 7/20/13. Trainee LPN #1 confirmed that she had not documented any of the medication error, notification of the Resident's Responsible Party or monitoring of Resident #1, in the medical record after the medication error had occurred. Interview with LPN #2 on 8/7/13 at 6:20 p.m. revealed, LPN #2 stated that he failed to document the Ducosate and B Complex Vitamin on the medication error report dated 7/20/13 because he didn't think they were significant but in hindsight he should have. LPN #2 stated that Resident #1 was monitored the rest of the shift without adverse effects and was not drowsy or different than her normal self. LPN #2 stated that he failed to document a mental/physical evaluation of Resident #1 and monitoring of her activities after the medication error in the nurse's notes and should have. LPN #2 stated that he was responsible for the documentation and notification since he was LPN #1's Preceptor. Interview with Certified Nursing Assistant (CNA) #1 on 8/8/13 at 4:20 p.m. revealed that she was assigned to Resident #1 (7/20/13) and had been told by LPN #2 to watch her close and to let him know if she acted any differently. CNA #1 stated that Resident #1 was alert and didn't act any differently than normal, that she ambulated to the bathroom and dining room and was alert all shift. Resident #1 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/1/13 revealed that she had a severe cognitive deficit with a Brief Interview for Mental Status of three (3). (0-7 indicates a severe deficit). Review of the policy/procedure provided by the Director of Nursing for Medication Errors: "In addition to the appropriate notations on the medical record, Medication Error Reports shall be initiated for all medication errors, to be completed by the person who made the error, or by the person finding the error, or both." An Allegation of Compliance related to the Immediate Jeopardy was submitted by the facility on 8/8/13 at 4:50 p.m. A review of the Allegation of Compliance revealed the following: ? Resident #1's was assessed by LPN #2 at 10:00am on 7/20/13. LPN #2 stated upon notification by LPN #1 of Medication Error, Resident was immediately evaluated and found to be alert and oriented to self only, Resident confirmed swallowing medications, up in wheelchair and able to maintain posture Blood Pressure was 144/89. Resident #1 was monitored throughout the day of 7/20/13 by LPN #2 with no signs or symptoms of adverse reactions. LPN #2 failed to document Medication Error, evaluation of physical status, and evaluation of mental status in Resident #1's chart. ? LPN #2 notified Resident #1's physician at 10:05 a.m. on 7/20/2013. Resident #1's Physician was informed of medications [MEDICATION NAME] 5/500, [MEDICATION NAME] 0.1mg, [MEDICATION NAME] Sodium 100mg, and B Complex vitamin were given to Resident #1. Order received to hold [MEDICATION NAME] 800mg x 1 dose. ? Med Error Report completed on 7/20/13 by LPN #2 due to Resident #1 receiving Resident #2's prescribed medications. ? Responsible Party #1 was notified of Medication Administration error at 6 p.m. on 7/20/13 by LPN #2 ? Resident #1's Care Plan revised and updated on 8/8/13 to include goal of maintaining administration of medications as evidenced by following five rights(listed individually on care plan) and medications to be given according to physician's orders [REDACTED]. ? LPN #1 was counseled verbally at 10:20am on 7/20/13 by LPN #2 following Medication Error on Identifying Residents before Medication Administration with emphasis on Photo identification on MAR, Names on Door, and A and B bed assignment. A written disciplinary action was written on LPN #1 on 8/7/13 by LPN #2 for failure to properly identify Resident #1 prior to medication administration. ? LPN #1 was observed by LPN #2 for remainder of shift on 7/20/13 with no medication errors noted. ? 24 Report sheet was documented by Quality Assurance Nurse #1 on 7/20/13 and 7/21/13 with LPN Unit Manager #1 documenting on 24hr report sheet on 7/22/13 for monitoring Resident #1 for signs and symptoms of adverse reactions due to medications given in error. ? Shift Report at 7 a.m. on 7/21/13, given by LPN #3 to LPN #2 revealed an uneventful night with no adverse reaction reported for Resident #1. ? In-service performed by Staff Development Nurse on 5 Rights of Medication Administration, Medication Errors, Notifying Family and Physician at time of Medication Error to LPN #1 and LPN #2 on 7/22/13. ? Disciplinary Action given by ADON on 7/22/13 to LPN #2 for failure to notify Resident #1's Responsible Party in a timely manner. ? In-service on 7/22/13 at 08:15 a.m. performed by Staff Development Nurse on Physician order [REDACTED]. Facility policy states that responsible party will be notified if resident is involved in any accident or incident: if there is a significant change in the resident's physical, mental, or psychosocial status; if there is a reason to alter the resident's treatment; a decision has been made to discharge the resident from the facility; and/or when the resident is transferred to the hospital. The nurse will record in the resident's medical record any changes in the resident's medical condition or status; including, but not limited to, date and time the responsible party and physician was notified; name of person; change of condition report and response. ? In-service on 7/29/13-7/31/13 performed by Staff Development Nurse regarding Medication Error, Drug Administration, and Documentation to include 5 rights. Facility policy states that 5 rights include resident identification (check picture, check name on door, ask resident to state his/her name, if unable to state name consult staff to help identify resident, if unable to identify resident, hold medications until positive identification and notify physician); right medication, right dose, & right route. In-service was performed due to Medication Error on 7/20/13 to ensure licensed nursing staff is educated to current policy and procedures. Facility policy of Medication Errors and Adverse Reactions states that documentation include date and time of incident, kind of medication error, or adverse reaction, name of physician, date and time physician was contacted, any physicians orders, residents condition in detail at time of incident, the date, time, & responsible party's name along with response, and other information as necessary or appropriate. Documentation should include assessment of resident and monitoring of activities. ? On 8/7/13 at 7 p.m., Interviews were conducted on 100 hall with 9 cognitive residents and 7 cognitive residents on remaining halls conducted by RN Unit Manager #1, Registered Nurse #1, Quality Assurance Nurse #2, LPN #3, LPN #4, LPN #5, LPN #6, LPN #7 and Staff Development Nurse. Interviews related to administration of medications. All residents interviewed reported that they received their own prescribed medication as ordered by physician. ? On 8/7/13 at 9 p.m., In-service on current Policy and Procedure Related to Identification of Residents prior to Medication Administration conducted by DON to ensure licensed nursing staff is knowledgeable to current policy and procedure related to Identification of Residents prior to Medication Administration. Facility policy states that 5 rights include resident identification (check picture, check name on door, ask resident to state his/her name, if unable to state name consult staff to help identify resident, if unable to identify resident, hold medications until positive identification and notify physician); right medication, right dose, & right route. ? On 8/7/13 at 9 p.m., In-service on Policy and Procedure Related to Assessment and Documentation after Medication Error conducted by DON to ensure licensed nursing staff is knowledgeable to current policy and procedure related to Assessment and Documentation after Medication Error. Facility policy of Medication Errors and Adverse Reactions states that documentation include date and time of incident, kind of medication error, or adverse reaction, name of physician, date and time physician was contacted, any physicians orders, residents condition in detail at time of incident, the date, time, & responsible party's name along with response, and other information as necessary or appropriate. Documentation should include assessment of resident and monitoring of activities. ? On 8/7/13 at 9 p.m., In-service on Policy and Procedure Related to Care Plan for Medication Error conducted by DON to ensure licensed nursing staff is knowledgeable to current policy and procedure related to Care Plan for Medication Error. Facility policy states that Medication Error Care Plan will be implemented on every medication error to include nursing diagnosis, goals, and specific interventions related to medication error. ? On 8/7/13 at 9 p.m., In-service via Video and Written materials related to Medication Administration to include 5 Rights. In-Service conducted by DON to ensure licensed nursing staff is knowledgeable to principles of medication administration ? On 8/7/13 at 9 p.m., In-service on Initiation of Medication Error Evaluation Flow Sheet conducted by DON for monitoring resident's status [REDACTED]. ? On 8/7/13 at 9 p.m., New Hire - Licensed Nurse Orientation Process - Administrator reviewed and revised policy and procedure related to New Hire - Licensed Nurse Orientation to ensure designated Preceptor of new hire license nurses has defined and measurable responsibilities in the orientation process of newly hired licensed nurses, i.e., sequence of orientation, subjects covered, suitability, and competency evaluation of newly hired licensed nurses. Preceptor is to ensure newly hired nurses are competent in basic nursing skills needed to successfully perform their assigned job description, such as properly identifying residents prior to the administration of medications and or treatments, following physician's orders [REDACTED]. ? On 8/7/13 at 9 p.m. In-Service on New Hire Licensed Nurse Orientation Process conducted by Administrator to include responsibilities of the preceptor and the new hire. Preceptor must ensure that new hire licensed nurse has demonstrated competency on all check-off skills including; right resident (check picture, check door names, ask resident to state his/her name, and if unable to identify resident withhold medications until a positive identification and notify physician), right time, right medication, right dose, right route of administration. If preceptor observes any concerns related to performance of assigned tasks he/she is to cease New Hire participation and notify the DON or designee, preceptor is not to leave New Hire alone after concern has been observed. New Hire Licensed Nurse is responsible for demonstrating to the preceptor competency in all skills check-off areas which include properly identifying a resident prior to administering prescribed medications which are: right resident (check picture, check door names, ask resident to state his/her name, and if unable to identify resident withhold medications until a positive identification and notify physician), right time, right medication, right dose, right route of administration. ? All In-services were given to Licensed Nurses. ? No Licensed Nurses will be allowed to work until In-services have been completed. ? On 8/8/13 at 8 a.m., Quality Assurance meeting conducted by Administrator, attended by Medical Director, Administrator, DON, ADON, Staff Development Nurse, and Quality Assurance Nurse #1 to discuss circumstances regarding medication error on 7/20/13 for Resident #1. Discussion topics included Medication Error, Documentation, Interventions, New Training Guidelines, Notification of Responsible Party and Physician, and Quality Assurance Monitoring Post Error Events. Committee concurred with current actions, no new recommendations offered. ? On 8/8/13 at 9 a.m., Audit of room and bed assignments and face sheet information was conducted by Social Services Director and Social Services Assistant to ensure the information is accurate and photos on all EMARS. Audit revealed no discrepancies. ? Additional Disciplinary Action on 8/8/13 by ADON given to LPN #2 on failure to document Resident #1's evaluation on 7/20/13 after receiving medications not ordered. ? On 8/7/13, Review of Medication Error Reports by DON revealed no other issues with residents' receiving of another resident's medication." The surveyor validated the corrective actions taken by the facility as follows: Interview with LPN #1 on 8/7/13 at 4:05 p.m., LPN #2 on 8/7/13 at 6:20 p.m. and CNA #1 on 8/8/13 at 4:20 p.m. confirmed that Resident #1 was alert and had no adverse effects from receiving Resident #2's medication on 7/20/13. LPN #2 confirmed that he did evaluate Resident #1 immediately after the error and throughout the day but failed to document. LPN #2 also confirmed that he monitored LPN #1 for the remainder of the shift with no other medication errors on 7/20/13. Review of Resident #1's care plan dated 8/8/13 confirmed that it had been updated for the potential for injury or adverse drug reaction related to high number of medications or medication error with interventions of medication as ordered and a goal to maintain proper administration of medication as evidenced by following the five rights of right resident, dose, route, medication and time. Review of a Disciplinary Action Record dated and signed by LPN #1 on 8/7/13 and interview with LPN #1 on 8/9/13 at 2:40 p.m. confirmed that she had received a written disciplinary action on 8/7/13 for not properly identifying Resident #1 prior to administering her medication. Interview also revealed that she had been in-serviced on 8/7/13 on the 5 rights of medication administration. In-service also included documentation of resident status, notification of MD/RP, med error report with flow sheet, updating the care plan and following physician's orders [REDACTED]. Review of a Disciplinary Action Record dated 8/8/13 confirmed that LPN #2 was disciplined for failure to correctly document a medication error, notify the physician/RP and update the care plan after a medication error. Interview with LPN #2 on 8/9/13 at 10:45 a.m. confirmed the disciplinary action. Review of policies Medication Administration and Documentation, and Medication Errors which included notification to the physician and not giving a resident medication that had not been ordered was confirmed with signatures of LPN #1 and LPN #2 of in-service provided by the Staff Development Nurse dated 7/22/13. Review of in-service records and sign-in sheets validated in-services held on 7/22/13 and interviews with licensed nurses further validated their attendance and content which included completing and carrying out physician's orders [REDACTED]. Review of in-service records and sign-in sheets validated in-services held on 8/7/13, beginning at 9:00 p.m., and interviews with licensed nurses validated their attendance and content which included the following information for updated policy/practice: 1)Identification of Residents Prior to Medication Administration-policy expanded to include more information regarding the 5 rights related to Resident Identification which included check picture, check door, ask resident to state name, if unable to state name-consult staff regarding identity of resident, and if unable to identify resident withhold medications until a positive ID and notify the MD. 2) Assessment and Documentation after Medication Error-policy expanded to include documentation in the nurse's notes for assessment, monitoring, medication error, notification of MD/RP, following physician orders, documentation on the 24 Hour report sheet, medication error flow sheet and Care Plan updated. 3) Care Plan Related to Medication Error-policy expanded to include medication error care plans will be implemented on every medication error to include nursing diagnosis, goals, and specific interventions related to medication error. 4) Video/Documentation of Principles of Medication Administration of which included "Before you administer the med pass ID your resident per facility policy and procedure". 5) Initiation of Medication Error Evaluation Flow Sheet- initiated at time of medication error with documentation of vital signs, level of consciousness, pupil response, motor functions, and pain response. Review of documentation and interview with the Staff Development Nurse on 8/9/13 at 11:25 a.m., and Unit Manager RN #1 on 8/9/13 at 9:48 a.m. revealed that 16 residents, all with Brief Interview for Mental Status (BIMS) scores of 13-15, were interviewed with no issues of receiving medication that wasn't ordered for them. Review of a statement dated 8/9/13 and interview with the DON on 8/9/13 at 10:15 a.m. confirmed that no other resident had medication errors of receiving another resident's medications. Review of six (6) sampled resident charts, review of medication error reports, and interviews with four (4) cognitive residents, Resident #3, #5, #A and #B, by the surveyor on 8/9/13 beginning at 2:30 p.m. validated that residents had not received medications that were ordered for other residents. Interview with LPN #8 on 8/9/13 at 9:20 a.m. revealed that she identified Resident #C prior to administering medications by pointing out the photo on the EMAR, pointing out the name on the door and asking the resident to state her name. physician's orders [REDACTED]. LPN #8 stated that she had attended in-service on 8/7/13, came in at 9:00 p.m., on subjects which included medication administration and observance of the 5 rights-especially identification (ID) of resident. LPN #8 stated that in-service included updating the care plan with interventions and documentation in the nurse's note and evaluation of the resident's condition and to initiate the medication error flow sheet. LPN #8 stated there was a video that outlined areas of medication administration and also included not to give any resident another resident's medication or giving a resident medication that was prepared by someone else and following the physician's orders [REDACTED]. Observation of medication pass and interview with LPN #9 on 8/9/13 at 9:40 a.m. revealed that she identified Resident #D by asking the resident to state her name, and looking at the photo on the EMAR and the name on the door, stating that resident was in the A bed. Medications were administered as ordered. LPN #9 stated that she had came in on 8/7/13 for in-services from 9:00 p.m. until around 10:45 p.m. LPN #9 stated that the in-services included watching a video on medication administration, policy/procedures for the 5 rights of med administration. LPN #9 stated that updating the care plan and documentation in the medical record for any incident or med error was to be done as well as notification of the RP/MD with date and time documented. LPN #9 stated that physician's orders [REDACTED]. LPN #9 verified that she had attended in-services the last part of July which included notification, 5 rights of medication administration and following physician's orders [REDACTED]. Observation of medication pass and interview with LPN #10 on 8/9/13 at 9:50 a.m. revealed that she identified Resident #E prior to med administration by looking at photo, name on door and asking resident to state his name. Medications were administered as ordered. LPN #10 stated that she had attended in-service on 8/7/13 at 9:00 p.m. along with about 40 other nurses which included 5 rights of med administration. In-service also included medication errors and making sure to initiate a med error report, flow sheet, notification of MD/RP, assess/evaluate and document resident status, update the care plan and make sure to follow the physician's orders [REDACTED]. Interview with LPN #2 on 8/9/13 at 10:05 a.m. and observation of medication pass at 11:00 a.m. revealed that LPN #2 identified Resident #6 prior to medication administration by asking resident to state her name, observation of the photo on the EMAR and pointing to the name on the door as the "B" bed. Medications were administered as ordered. LPN #2 stated that he had been in-serviced on different subjects 8/7/13 which included ID of resident prior to giving medications, orders were to be followed and the care plan updated with interventions and the med error. LPN #2 stated that he received disciplinary action on 8/8/13 for not documenting an assessment of Resident #1 after the med error and not updating the care plan. Interview with the DON on 8/9/13 at 1:00 p.m. validated that all physician's orders [REDACTED]. An acceptable Allegation of Compliance was received on 8/8/13 which alleged removal of Immediate Jeopardy. On 8/9/13, the State Agency validated the facility's corrective actions and determined the Immediate Jeopardy was removed on 8/9/13, prior to exit, which lowered the scope and severity to a "D" at 42 CFR 483.75 - Resident Records Complete/Accurate/Accessible (F-514), while the facility monitors the effectiveness of systemic changes and quality assurance activities.