Every finding on record at MS Care Center of Morton

Based on interviews, observations, record review, review of the facility's investigation, and facility policies review, the facility failed to develop and implement adequate supervision and individualized interventions to prevent an avoidable accident after identifying Resident #1's pattern of sitting at the facility's exit door with his hand on the door handle and documenting that he should not go outside unassisted. As a result, Resident #1 exited the facility without staff knowledge or supervision for approximately three (3) minutes on July 11, 2026. This deficient practice affected one (1) of three (3) residents reviewed for elopement risk. Resident #1.Findings include: Record review of the facility's policy titled, Wandering and Elopements, revised March 2019, revealed, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents . Record review of the facility's policy titled, Accidents, dated December 2009, revealed, .This facility will commit to safety and address resident risk and environmental hazards in order to minimize the likelihood of avoidable accidents by using an interdisciplinary systems approach. Evaluation and Analysis-Staff will evaluate hazard and accident risk data, analyze potential causes and identify or develop interventions. Ex (example).Elopement.Implementation of Interventions-Supervision will be provided to prevent avoidable accidents. Record review of the facility-reported follow-up investigation revealed that on 7/11/26, Resident #1 was sitting near the facility's exit door with his hand on the door handle. A staff member entered the access code and entered the facility through the opposite door. The staff member heard the door click shut but was unaware that Resident #1 was holding and pushing on the door handle. At 11:09:59 AM, Resident #1 exited the facility and went onto the back porch. At 11:10:12 AM, a housekeeping staff member came around the corner and observed Resident #1 outside the facility. The housekeeping staff member assisted Resident #1 back inside and immediately reported the incident to the charge nurse. The incident was verified through review of the facility's surveillance camera footage.Resident #1Record review of Resident #1's admission Record revealed the facility admitted the resident on 1/5/22 with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction affecting the right dominant side. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/5/26 revealed a Brief Interview for Mental Status (BIMS) score of two (2), indicating severe cognitive impairment.A record review of the Elopement Risk Evaluation, dated May 5, 2026, revealed Resident #1 was assessed as NA (Not Applicable), indicating the interdisciplinary team determined the resident was not at risk for elopement.Record review of the View Progress Note dated 7/11/26 at 2:23 PM revealed that Housekeeper #1 reported to the charge nurse that Resident #1 had been found outside in the porch area near the laundry exit without staff supervision and was brought back inside the facility. Staff moved Resident #1 to a more populated area and assessed him, with no apparent injuries identified. Staff initiated safety checks every 15 minutes for 24 hours, followed by hourly checks for seven days. The medical provider, Resident Representative, and Director of Nursing (DON) were notified.On 7/20/26 at 1:22 PM, during an interview with Housekeeper #1, revealed that on 7/11/26, she observed Resident #1 seated in his wheelchair outside the facility, approximately 15 steps from the rear exit doors near the ambulance entrance/exit. She immediately approached Resident #1, assisted him back into the facility, and notified the charge nurse. She reported that Housekeeper #2 was also present during the incident. She further revealed that Resident #1 did not appear to be injured and was initially hesitant to return inside when she approached him. On 7/20/26 at 1:33 PM, during an interview, Housekeeper #2 reported that Resident #1 frequently sat near the rear exit door with his hand on the door handle. He stated that before Resident #1 exited the facility on 7/11/26, he observed the resident seated in his wheelchair near the exit door with his hand on the door handle. Housekeeper #2 reported that when he entered the facility, he heard the exit door click shut and was unaware Resident #1 was holding the door handle, preventing the door from latching securely. He stated he was unaware Resident #1 intended to exit the facility. Housekeeper #2 further reported observing Housekeeper #1 assisting Resident #1 back into the facility. He stated Resident #1 was initially hesitant to re-enter the facility; however, Housekeeper #1 guided him inside and immediately notified the nurse. Housekeeper #2 confirmed the rear porch area was not intended for unsupervised resident use.On 7/20/26 at 2:00 PM, the State Agency (SA) reviewed the facility's video surveillance with the DON. The video revealed that on 7/11/26 at 11:06:30 AM, Housekeeper #2 entered the facility while Resident #1 was seated in his wheelchair inside the facility with his hand on the exit door handle. After Housekeeper #2 entered and released the door, Resident #1 pushed the door open and began independently propelling his wheelchair with his feet through the exit door. At 11:07:33 AM, Resident #1 was observed outside the facility, approximately 30 feet from the exit, propelling his wheelchair with his feet. At 11:10:30 AM, Housekeeper #1 observed Resident #1 outside without staff supervision. Housekeepers #1 and #2 then assisted Resident #1 back inside the facility, and Housekeeper #1 immediately notified Resident #1's nurse. The surveillance video confirmed Resident #1 exited the facility independently and remained outside without staff knowledge or supervision for approximately three (3) minutes until discovered by Housekeeper #1. The SA observed that the area where Resident #1 was located was a covered outdoor porch adjacent to the facility's rear exit. The porch measured approximately 10 feet by 10 feet, had a concrete surface, and was large enough to accommodate several outdoor lawn chairs.On 7/20/26 at 3:15 PM, during an interview, the DON acknowledged the interdisciplinary team had assessed Resident #1 as not at risk for elopement prior to the incident. The DON further acknowledged that after the incident the resident was reassessed, additional supervision interventions were implemented, and staff were re-educated regarding monitoring residents near the exit doors.

Based on observation, interview, record review, and facility policy review, the facility failed to honor a resident's right to refuse fingerstick blood glucose checks and use a Continuous Glucose Monitor (CGM) device for blood glucose monitoring for one (1) of (19) sampled residents (Resident #16).Findings include:A review of the facility's Resident Rights Policy, revised 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. The facility will protect and promote the rights of each resident . The facility will provide equal access to quality care regardless of diagnosis, severity of condition, or payment source .A review of the facility's policy, Continuous Glucose Monitor (CGM) Use, undated, revealed, . 1. Purpose to ensure safe, accurate, and effective use of CGM systems for residents with diabetes, improving glucose control and reducing hypoglycemia events.A record review of the admission Record revealed the facility admitted Resident #16 on 1/12/26 with diagnoses including Type 2 Diabetes Mellitus.A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/19/26 revealed Resident #16 had a Brief Interview for Mental Status (MDS) score of 8, which indicated his cognition was moderately impaired.A record review of the Order Summary Report revealed Resident #16 had a Physician's order, dated 1/14/26 for sliding scale insulin two times daily and check blood glucose prior to lunch and supper. On 3/16/26 at 1:55 PM, during an observation and interview with Resident #16, the resident was observed sitting in a bedside chair with signage posted on the bulletin board that read, Nurses/CNA (Certified Nursing Assistant) Use freestyle Librera 3 (CGM) reading to check BS (blood sugar) Reader in the top drawer. When asked about the sign, the resident reported he was not aware of the sign but stated he does not like having his fingers poked.On 3/17/26 at 11:25 AM, during an observation, a CGM sensor reader was observed on the resident's overbed table.On 3/18/26 at 11:30 AM, during an interview and observation with Licensed Practical Nurse (LPN) #2, she confirmed the signage referenced use of a CGM device but reported she was not aware the resident had a CGM and had been checking blood glucose using the facility's glucometer. The resident's daughter was present and reported the sign had been placed because the resident did not like fingersticks and staff continued to perform them. The daughter showed the CGM device located on the resident's left upper arm and the reader on the overbed table. LPN #2 reported she had not previously observed the device. During the blood glucose check, the resident stated he did not like his fingers being poked and reported it hurt. LPN #2 continued to perform the fingerstick.On 3/18/26 at 12:00 PM, during an interview with LPN #1, she reported she was aware the resident had a CGM device and had used it after the daughter provided the equipment. She reported awareness of the signage placed in the room approximately three (3) weeks prior. She stated she was unsure if there was a physician's order for the device and believed staff were using the CGM. She confirmed the resident expressed discomfort with each fingerstick.On 3/18/26 at 4:30 PM, during a phone interview with the Resident Representative (RR), she reported she placed the sign in the room approximately (3) weeks prior because staff continued to perform fingersticks after she provided the CGM device and supplies. She reported the resident had the CGM prior to admission and she provided the necessary equipment after admission. She stated she had communicated with multiple staff regarding use of the device.On 3/19/26 at 1:00 PM, during an interview with the Director of Nursing (DON), she reported she assisted with the resident's admission and discussed the CGM device with the resident's daughter. She confirmed the facility agreed to use the device if supplies were provided. She reported she was not aware of the signage in the room and had not followed up with staff or the daughter regarding use of the device. She confirmed there was no physician order for the CGM but stated staff had been trained on CGM use for another resident.On 3/19/26 at 4:46 PM, during an interview with the Director of Nursing (DON) and Administrator, they reported staff are expected to honor and respect resident rights and preferences.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's right to a safe, clean, comfortable, and homelike environment for one (1) of (19) sampled residents (Resident #70) when the facility failed to repair a leaky faucet in the resident's room.Findings include:A review of the facility's policy, Maintenance Service (undated), revealed, .Maintenance service shall be provided to all areas of the building, grounds, and equipment.Policy Interpretation and Implementation.2. Functions of maintenance personnel include.d. Maintaining the.plumbing fixtures.in good working order.f. Establishing priorities in providing repair service.A review of the facility's policy, Resident Rights Policy (revised 9/2022), revealed, Policy Statement - It is the policy of this facility to provide services based on the following requirements.The 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 his or her quality of life.A record review of the admission Record revealed the facility admitted Resident #70 on 10/16/24 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD).A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/9/26 revealed Resident #70 had a Brief Interview for Mental Status (BIMS) score of (15), which indicated the resident was cognitively intact.On 3/17/26 at 9:28 AM, during an observation and interview with Resident #70, the sink in the resident's room was observed leaking water. The resident reported she had previously reported the issue, and it had not been repaired. The resident stated she had been told the sink would be fixed but could not recall when the request was made.On 3/19/26 at 11:02 AM, during an interview with the Maintenance Director, he explained he was aware of the issue and confirmed through the computerized reporting system that the work order was submitted on 1/26/26. He stated he spoke with a plumber the morning at that time and acknowledged the repair was overdue. He explained the repair required addressing the valves prior to replacing the faucet.On 3/19/26 at 12:44 PM, during a follow-up interview with Resident #70, she reported the leaky faucet interrupts her sleep due to the sound of water dripping into the sink. The resident stated the Administrator had previously attempted a temporary repair by adjusting a screw under the faucet knobs; however, the repair was not sustained and the faucet continued to leak. The resident reported no additional repairs had been completed. On 3/19/26 at 3:08 PM, during an interview with the Administrator, she acknowledged the repair request submitted on 1/26/26 had not been completed. She confirmed attempting a temporary repair in the past but could not recall the date. She explained her expectation is for maintenance to complete repairs in a timely manner.

Based on interview, record review, and facility policy review, the facility failed to ensure a resident was free from unnecessary chemical restraints related to psychotropic medications when the facility failed to attempt or document a Gradual Dose Reduction (GDR) for a resident receiving antipsychotic and antidepressant medications initiated on 5/20/25 for one (1) of five (5) residents reviewed for unnecessary medications. (Resident #79).Findings include:A review of the facility's policy, Tapering Medications and Gradual Drug Dose Reduction, revised April 2025, revealed, . Policy Statement . 2. Residents who use psychotropic medications receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these medications. Policy Interpretation and Implementation 1. Gradual Dose Reduction (GDR) refers to the stepwise tapering of a dose to determine if symptoms, conditions, or risk can be managed at a lower dose or if a medication can be discontinued. Psychotropic Medications 1. Within the first year after a resident is admitted on a psychotropic medication or after the resident has been started on a psychotropic medication, the staff and practitioner will attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated. Documentation-Gradual Dose Reduction 1. Gradual dose reduction attempts are documented in the medical record. 2. Medical Provider documentation contains the rationale for why GDR attempts are clinically contraindicated for the resident.A record review of the admission Record revealed the facility admitted Resident #79 on 5/20/25 with diagnoses including Dementia.A record review of the Order Summary Report revealed Resident #79 had physician's orders for . Quetiapine Fumarate Tablet 25 milligrams (mg) give one (1) tablet by mouth at bedtime for hallucinations (dated 5/20/25) and Sertraline HCl Tablet 100 milligrams (mg) give two (2) tablets by mouth one time a day for depression (dated 5/20/25).A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/2/26 revealed Resident #79 had a Brief Interview for Mental Status (BIMS) score of (12), which indicated the resident's cognition was moderately impaired. A review of Section N revealed the resident received antipsychotic and antidepressant medications, and documented, No Gradual Dose Reduction has been documented by a physician as clinically contraindicated.A record review of the Medication Administration Record for 3/1/26 through 3/31/26 revealed medications were administered as ordered for Quetiapine Fumarate and Sertraline HCl.A record review of the medical record revealed no documentation of a Gradual Dose Reduction (GDR).On 3/18/26 at 2:20 PM, during an interview with the Director of Nursing (DON), she reported there were no records of a GDR attempt since Resident #79 was admitted on [DATE]. She stated the attending physician and nurse practitioner reviewed medications but did not document a GDR attempt or contraindication. She confirmed the pharmacist reviewed medications on admission but no additional GDR recommendations were documented.On 3/18/26 at 3:10 PM, during a phone interview with the Pharmacy Consultant, he reported he conducts monthly medication reviews and provides reports to the DON. He stated GDR recommendations are typically made every six (6) months for psychotropic medications. He reported he had not made a GDR recommendation for Resident #79 based on information that medications were reviewed and revised by the practitioner in October 2025 and January 2026.On 3/19/26 at 1:30 PM, during a phone interview with Nurse Practitioner #1, she reported she reviews medications at each visit and is aware of GDR requirements. She stated GDRs are typically initiated based on recommendations from the pharmacist or psychiatric services. She confirmed no GDR had been initiated for Resident #79.On 3/19/26 at 1:48 PM, during a phone interview with the attending physician, he reported he completes GDR documentation when recommendations are made by pharmacy or psychiatric services. He stated no GDR had been completed for Resident #79 and acknowledged the GDR was missed.On 3/19/26 at 4:46 PM, during an interview with the DON, she reported she expects GDRs to be completed per regulation and acknowledged the GDR for Resident #79 was missed. She stated she assumed medication reviews without changes were considered a GDR.On 3/19/26 at 4:55 PM, during an interview with the Administrator, she reported she expects the pharmacy consultant and medical providers to ensure GDRs are completed in accordance with regulations.

Based on record review, interview, and facility policy review, the facility failed to ensure the comprehensive care plan was revised when residents experienced multiple falls and failed to ensure care plan interventions were dated to reflect new or revised individualized interventions for two (2) of (19) residents reviewed for care plans. (Resident #1 and Resident #3).Findings include:A review of the facility's policy Develop/Implement Comprehensive Care Plan, revised 9/2022, revealed the facility will develop and implement a comprehensive person-centered care plan for each resident.Resident #1A record review of the Care Plan Report revealed Resident #1 had a focus of SAFETY: I am a high risk for falls. which listed multiple fall dates from 1/17/25 through 1/21/26. A review of the interventions revealed multiple interventions were listed; however, the dates initiated did not align with the dates of the falls, and there was no evidence the care plan was revised following each fall to include new or individualized interventions to address the continued fall risk.A record review of the admission Record revealed the facility admitted Resident #1 on 1/29/25 with current diagnoses including Chronic Kidney Disease.A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/18/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of (11), which indicated the resident's cognition was moderately impaired.A record review of the facility's fall investigations revealed Resident #1 experienced falls on 12/5/25 at 11:00 PM, 12/7/25 at 4:55 PM, and 1/21/26 at 7:50 AM.Resident #3A record review of the Care Plan Report revealed Resident #3 had a focus of SAFETY: I am a high risk for falls. which listed multiple fall dates from 3/23/24 through 2/7/26. A review of the interventions revealed multiple interventions were listed; however, not all dates initiated aligned with the dates of the falls, and there was no evidence the care plan was revised following each fall to include new or individualized interventions to address continued fall risk.A record review of the admission Record revealed the facility initially admitted Resident #3 on 2/1/22 and readmitted the resident on 12/2/25 with current diagnoses including History of Falling.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/6/26 revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact.A record review of the facility's fall investigations revealed Resident #3 experienced falls on 10/24/25 at 8:35 PM, 10/29/25 at 9:40 PM, 11/22/25 at 5:15 PM, 1/22/26 at 4:30 AM, and 2/7/26 at 3:20 PM.On 3/19/26 at 12:31 PM, during an interview with Registered Nurse (RN) #1, she explained care plans are developed based on resident-specific needs and are expected to be updated when there is a change in condition, including after a fall. She stated the interdisciplinary team should review fall events and determine whether additional or modified interventions are needed. She confirmed interventions added to the care plan should be documented with dates to reflect when they were initiated. After reviewing the care plans for Resident #1 and Resident #3, she confirmed the interventions did not reflect additional or revised measures following subsequent falls.On 3/19/26 at 12:50 PM, during a record review and interview with the Director of Nursing (DON), she explained the expectation is for care plans to reflect current resident needs and risk factors. She stated falls should trigger a review of contributing factors and prompt updates to the care plan. She confirmed staff should be able to identify current interventions through dated entries on the care plan. After reviewing the care plans for Resident #1 and Resident #3, she confirmed the care plans did not include updated or newly implemented interventions following repeated falls.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure services were provided in accordance with professional standards of practice when the facility failed to obtain a physician order for the use of a Continuous Glucose Monitor (CGM), failed to ensure a consistent and clinically directed method was used to obtain blood glucose readings, and failed to ensure accurate and complete documentation of blood glucose results for one (1) of (19) sampled residents. (Resident #16)Findings include:A review of the facility's policy Administering Medications with revised date of April 2019 revealed . Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation . 2. The Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions. 4. Medications are administered in accordance with prescriber orders, including any required time frame . 6. Medications errors are documented, reported, and reviewed by the QAPI (Quality Assessment and Performance Improvement) committee to inform process changes and or the need for additional staff training . 10. The individual administering the medication checks to verify the right resident, right medication, right dosage, right time, and right method (route) of administering before giving the medication. 18. The individual administering the medication initials the resident's MAR (Medication Administration Record) on the appropriate line after giving each medication and before administering the next ones. 19. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. the date and time the medication was administered. b. the dosage c. the route of administration d. the injection site (if applicable) e. any complaints or symptoms for which the drug was administered.A review of the facility's policy Continuous Glucose Monitor (CGM) Use (undated) revealed . 1. Purpose to ensure safe, accurate, and effective use of CGM systems for residents with diabetes, improving glucose control and reducing hypoglycemia events. 5. Physician orders required. Type of CGM device . 6. Staff responsibilities . Document readings and interventions . 13. Resident's rights and Education. Respect refusal .A record review of the admission Record revealed the facility admitted Resident #16 on 1/12/26 with diagnoses including Type 2 Diabetes Mellitus.A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/19/26 revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of eight (8), which indicated the resident's cognition was moderately impaired. A review of Section N revealed the resident received insulin injections.A record review of the Order Summary Report revealed Resident #16 had a physician's order, dated 1/14/26, for NovoLog (Insulin Aspart) 100 units per milliliter (mL) to inject an alternating dose subcutaneously two (2) times daily for hyperglycemia, with instructions to check blood glucose prior to lunch and supper at 11:00 AM and 4:00 PM, and administer five (5) units if blood glucose was greater than 200, ten (10) units if greater than 300, and hold if less than 200. There was no physician order identified for the use of a Continuous Glucose Monitor (CGM).A record review of the Medication Administration Records (MARs) for January, February, and March 2026 for Resident #16 revealed the following: MAR for 01/01/26-01/31/26 at 11:00 AM revealed on 01/24/26 no blood glucose (BG) reading was documented and a code of nine (9) was entered indicating other/see progress note with no corresponding note. On 01/25/26 a BG reading of 145 was documented with five (5) units of insulin administered; however, a code of nine (9) was also entered and a progress note indicating no insulin was given. On 01/30/26 a BG reading of 162 was documented with five (5) units administered, with no corresponding progress note documented. MAR for 01/01/26-01/31/26 at 4:00 PM revealed on 01/20/26 no BG reading was documented with a code of five (5) entered indicating hold/see progress note, however there was no corresponding progress note. On 1/30/26 no BG reading was documented with a code of four (4) entered indicating Vitals outside of Parameters for Administration. MAR for 02/01/26-02/28/26 at 11:00 AM revealed on 02/12/26, 02/13/26, and 02/18/26, no BG readings were documented with a code of nine (9) entered indicating other/see progress note, with no progress notes recorded. On 2/26/26 and 2/27/26, no BG reading and Code 13 was entered indicating No Insulin Required. On 02/24/26 a BG reading of 144 was documented with five (5) units administered, with no corresponding progress note documented. MAR for 02/01/26-02/28/26 at 4:00 PM revealed on 02/05/26 no BG reading was documented with a code of four (4) entered indicating vitals outside of parameters for administration. On 02/11/26, 02/14/26, 02/23/26, 02/26/26 and 02/27/26 no BG readings were documented with a code of thirteen (13) entered indicating no insulin required. On 02/12/26, 02/13/26, and 02/18/26 no BG readings were documented with a code of nine (9) entered indicating other/see progress note with no corresponding progress note. MAR for 3/1/26-3/31/26 at 11:00 AM revealed on 3/1/26, 3/4/26, 3/7/26, 3/9/26, and 3/13/26 no BG reading was documented with a code of 13 recorded. 3/12/26 and 3/13/26 no BG recorded and code of 9 recorded. 3/14 26 BG of 186 recorded with 5 units of insulin administered and on 3/15/26, BG recorded as 161 with 5 units of insulin administered. MAR for 03/01/26-03/31/26 at 4:00 PM revealed on 3/3/26, 3/4/26, 3/7/26, 3/8/26, 3/12/26, and 3/13/26 no BG reading was recorded, and Code 13 was entered. On 3/9/26, 3/13/26, and 3/16/26 no BG reading was recorded, and Code 9 was entered. On 3/1/26, BG recorded as 247 and 10 units of insulin administered.On 3/16/26 at 1:55 PM, during an observation and interview with Resident #16, the resident was observed sitting in a bedside chair. A sign was observed posted on the bulletin board stating, Nurses/CNA Use freestyle Librera 3 reading to check BS (blood sugar) reader in the top drawer. The resident reported he did not like to have his fingers stuck.On 3/17/26 at 11:25 AM, during an observation and interview with Resident #16, the resident remained in his bedside chair. A blood glucose sensor was observed on the overbed table.On 3/18/26 at 11:30 AM, during an observation and interview with Licensed Practical Nurse (LPN) #2, she confirmed signage was posted on Resident #16's bulletin board instructing staff to use the CGM device when checking blood sugars and reported she was not aware the resident had a CGM device. She stated she had always obtained blood glucose readings using the facility's glucometer. The CGM device was identified on Resident #16's left upper arm and the reader was observed on the overbed table. LPN #2 reported she had not previously observed the device on the resident. She performed an Accu-Chek using the facility's glucometer and stated she attempts to document blood glucose readings at the time obtained and writes a progress note if needed. She said she had not paid attention to the Xs documented on Resident #16's MAR or the absence of blood glucose results and reported the codes used on the MAR are explained on the last page of the MAR.On 3/18/26 at 12:00 PM, during an interview with Licensed Practical Nurse (LPN) #1, she reported she was aware the resident had a CGM device and had used the device since it was brought to the facility. She stated she was not aware whether there was a physician order for the device and believed staff were using the CGM rather than the facility glucometer.On 3/18/26 at 4:30 PM, during a phone interview with the Resident Representative (RR), she reported she provided the CGM device and supplies after admission and placed the sign in the room due to staff continuing to obtain fingerstick blood glucose readings. She reported she had spoken with multiple staff but was unsure if leadership had been notified.On 3/19/26 at 1:00 PM, during an interview with the Director of Nursing (DON), she reported she was not aware of missing blood glucose documentation or concerns related to blood glucose monitoring for Resident #16 and had not been informed of any irregularities. The DON confirmed that, to her knowledge, no irregularities had been identified or reported. She stated nursing staff had been trained on the use of CGM devices for other residents and reported staff were expected to document blood glucose readings on the MAR.On 3/19/26 at 1:15 PM, during an interview with the Administrator, she reported she was not aware the resident had a CGM device.On 3/20/26 at 12:00 PM, during a post-exit telephone interview with the Nurse Practitioner, she reported she expects staff to follow physician orders and notify her of any concerns or discrepancies related to resident care. She confirmed she had not been notified of any concerns related to blood glucose monitoring or documentation for Resident #16. She explained she relies on accurate and complete documentation to make clinical decisions.

Based on interview, record review, and facility policy review, the facility's consultant pharmacist failed to ensure monthly medication regimen reviews (MMRs) identified and reported medication-related irregularities regarding insulin administration and documentation (Resident #16), failed to identify and report the absence of a Gradual Dose Reduction (GDR) for a resident receiving psychotropic medications (Resident #79), and failed to provide resident-specific documentation of MMRs to demonstrate which residents were reviewed for two (2) of (19) sampled residents.Findings include:A review of the facility's policy Pharmacy Services-Role of the Consultant Pharmacist, revised April 2019 revealed . The facility shall have the services of a consultant pharmacist. Policy Interpretation and Implementation . 3. The consultant pharmacist shall provide consultation on all aspects of pharmacy services in the facility, and collaborate with the facility and medical director to: . e. Strive to assure that medications are requested, received, and administered in a timely manner as ordered by the authorized prescriber; . 5. The Consultant Pharmacist will provide specific activities related to medication regimen review including: a. A documented review of the medication regimen of each resident at least monthly, or more frequently under certain conditions, based on applicable federal and state guidelines; b. Appropriate communication of information to prescribers and facility leadership about potential or actual problems related to any aspect of medications and pharmacy services, including medication irregularities, and pertinent resident-specific documentation in the medical record as indicated; c. Providing the facility with written or electronic reports and recommendations related to all aspects of medication and pharmaceutical services review.Resident #16A record review of the admission Record revealed the facility admitted Resident #16 on 1/12/26 with diagnoses including Type 2 Diabetes Mellitus.A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/19/26 revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of eight (8), which indicated the resident's cognition was moderately impaired. A review of Section N revealed he received insulin injections.A record review of the Order Summary Report revealed Resident #16 had a Physician's Order, dated 1/14/26, for NovoLog (Insulin Aspart) 100 units per milliliter (mL) to inject an alternating dose subcutaneously two (2) times daily for hyperglycemia, with instructions to check blood glucose prior to lunch and supper at 11:00 AM and 4:00 PM, and administer five (5) units if blood glucose was greater than 200, ten (10) units if greater than 300, and hold if less than 200.A record review of the Medication Administration Records (MARs) for January, February, and March 2026 for Resident #16 revealed the following: MAR for 01/01/26-01/31/26 at 11:00 AM revealed on 01/24/26 no blood glucose (BG) reading was documented and a code of nine (9) was entered indicating other/see progress note with no corresponding note. On 01/25/26 a BG reading of 145 was documented with five (5) units of insulin administered; however, a code of nine (9) was also entered and a progress note indicating no insulin was given. On 01/30/26 a BG reading of 162 was documented with five (5) units administered, with no corresponding progress note documented. MAR for 01/01/26-01/31/26 at 4:00 PM revealed on 01/20/26 no BG reading was documented with a code of five (5) entered indicating hold/see progress note, however there was no corresponding progress note. On 1/30/26 no BG reading was documented with a code of four (4) entered indicating Vitals outside of Parameters for Administration. MAR for 02/01/26-02/28/26 at 11:00 AM revealed on 02/12/26, 02/13/26, and 02/18/26, no BG readings were documented with a code of nine (9) entered indicating other/see progress note, with no progress notes recorded. On 2/26/26 and 2/27/26, no BG reading and Code 13 was entered indicating No Insulin Required. On 02/24/26 a BG reading of 144 was documented with five (5) units administered, with no corresponding progress note documented. MAR for 02/01/26-02/28/26 at 4:00 PM revealed on 02/05/26 no BG reading was documented with a code of four (4) entered indicating vitals outside of parameters for administration. On 02/11/26, 02/14/26, 02/23/26, 02/26/26 and 02/27/26 no BG readings were documented with a code of thirteen (13) entered indicating no insulin required. On 02/12/26, 02/13/26, and 02/18/26 no BG readings were documented with a code of nine (9) entered indicating other/see progress note with no corresponding progress note. These irregularities were not identified or reported in the consultant pharmacist's monthly medication regimen reviews conducted in January or February 2026.Resident #79A record review of the admission Record revealed the facility admitted Resident #79 on 5/20/25 with diagnoses including Dementia.A record review of the Order Summary Report revealed Resident #79 received psychotropic medications including Quetiapine and Sertraline initiated on 5/20/25.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/2/26 revealed Resident #79 had a Brief Interview for Mental Status (BIMS) score of twelve (12), which indicated the resident's cognition was moderately impaired. Section N documented the resident received antipsychotic and antidepressant medications and indicated no Gradual Dose Reduction (GDR) had been documented as clinically contraindicated.A record review of the medical record revealed no documentation of a Gradual Dose Reduction (GDR).A record review of the facility's report Psychopharmacological Medications & Antipsychotics Drug Utilizations report for January and February 2026 revealed Resident #79 was listed as being prescribed Quetiapine Fumar with an Order Date of 2/12/2026 and next evaluation listed as 8/30/26 and Sertraline with an Order Date of 1/29/26 and next evaluation listed as 7/28/26. These order dates were inconsistent with the order dates reflected in the Physician's Orders and MARs.A record review of the facility's Psychoactive and Sedative/Hypnotic Utilizations, dated January 2026, and signed by the pharmacist consultant revealed . The pharmacist reviewed the use of all psychoactive drugs in the facility . The facility continues to monitor use of antipsychotics and document proper diagnosis of these medications. The pharmacist will continue to monitor the use of psychoactive medications and recommend any changes deemed necessary . There were no details indicating which individual residents were reviewed or if Resident #79 was reviewed.A record review of the facility's Monthly Pharmacy Report for January 2026 revealed . The Consultant pharmacist reviewed 97 charts over 3 days. 1. The Nurse Practitioner reviewed all dose reductions prior to time for review. The consultant had many discussions with nursing staff about medications and doses . Having an in-house Nurse Practitioner has helped with gradual dose reduction and reducing the number of patients on antipsychotics . There were no details indicating which individual residents were reviewed for the MMR, including Residents #16 and 79.A record review of the facility's Monthly Pharmacy Report for February 2026 revealed . The Consultant pharmacist reviewed 98 charts over 3 days. 1. The Nurse Practitioner reviewed all dose reductions prior to time for review. The consultant had many discussions with nursing staff about medications and doses . Having an in-house Nurse Practitioner has helped with gradual dose reduction and reducing the number of patients on antipsychotics . There were no details indicating which individual residents were reviewed for the MMR, including Residents #16 and 79.On 3/18/26 at 2:20 PM, during an interview with the Director of Nursing (DON), she confirmed there was no documentation of a GDR for Resident #79 and reported she had not received any recommendation from the consultant pharmacist regarding a GDR.On 3/18/26 at 3:10 PM, during a phone interview with the consultant pharmacist, he reported he conducts monthly reviews and provides reports of findings and concerns but stated he does not always review residents' MARs and was not aware of any medication errors or irregularities for Resident #16. He also reported he relies on information from nursing staff and providers regarding medication changes and had not made a GDR recommendation for Resident #79.On 3/19/26 at 1:00 PM, during an interview and record review with the DON, she confirmed the MARs for Resident #16 contained missing blood glucose readings, inconsistent documentation, and insulin dosages that did not align with physician orders. She reported she had not been notified of these irregularities and expected the consultant pharmacist to identify and report medication-related concerns during monthly reviews.On 3/19/26 at 3:30 PM, during an interview with the DON, she confirmed the pharmacy reports provided were the only documentation available and did not include resident-specific findings or recommendations. She stated she expects the consultant pharmacist to identify and report medication irregularities and provide recommendations, including GDRs when indicated.On 3/19/26 at 4:55 PM, during an interview with the Administrator, she reported she expects the consultant pharmacist to fulfill all responsibilities related to medication regimen reviews and to communicate any identified concerns or recommendations.

Based on observation, interview, record review, and facility policy review, the facility failed to prevent significant medication errors when nursing staff administered insulin outside of physician-ordered parameters for one (1) of (19) sampled residents (Resident #16).Findings include:A review of the facility's policy Administering Medications, revised April 2019 revealed . Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation . 2. The Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions. 4. Medications are administered in accordance with prescriber orders, including any required time frame . 6. Medications errors are documented, reported, and reviewed by the QAPI (Quality Assessment and Performance Improvement) committee to inform process changes and or the need for additional staff training . 10. The individual administering the medication checks to verify the right resident, right medication, right dosage, right time, and right method (route) of administering before giving the medication.A review of the facility's policy Medication Errors (undated) revealed . Medication error is defined as administration of medication other than as ordered by the physician, i.e., omission of medication, incorrect medication, incorrect dosage . Note: a significant medication error is one that cause resident discomfort and/or jeopardizes his/her health and/or safety, and one that requires the immediate notification of the physician and the Director of Nursing (DON) . Medication errors shall be reported immediately to the Head Nurse and the attending physician, who will determine and write order for the necessary follow-up treatment.A record review of the admission Record revealed the facility admitted Resident #16 on 1/12/26 with diagnoses including Type 2 Diabetes Mellitus.A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/19/26 revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of eight (8), which indicated his cognition was moderately impaired. A review of Section N revealed he received insulin injections.A record review of the Order Summary Report revealed Resident #16 had a Physician's Order, dated 1/14/26, for NovoLog (Insulin Aspart) 100 units per milliliter (mL) to inject an alternating dose subcutaneously two (2) times daily for hyperglycemia, with instructions to check blood glucose prior to lunch and supper at 11:00 AM and 4:00 PM, and administer five (5) units if blood glucose was greater than 200, ten (10) units if greater than 300, and hold if less than 200.A record review of the Medication Administration Records (MARs) for Resident #16 for January, February, and March 2026 revealed insulin was administered outside of ordered parameters. On 1/25/26 at 11:00 AM, a blood glucose reading of 145 was documented with five (5) units administered. On 1/30/26 at 11:00 AM, a blood glucose reading of 162 was documented with five (5) units administered. On 2/24/26 at 11:00 AM, a blood glucose reading of 144 was documented with five (5) units administered. On 3/14/26 at 11:00 AM, a blood glucose reading of 186 was documented with five (5) units administered. On 3/15/26 at 11:00 AM, a blood glucose reading of 161 was documented with five (5) units administered. On 3/1/26 at 4:00 PM, a blood glucose reading of 247 was documented with ten (10) units administered. On 3/14/26 at 4:00 PM, a blood glucose reading of 180 was documented with five (5) units administered. There was no corresponding documentation or clarification identified in the medical record regarding administering insulin outside of the parameters on these dates.On 03/18/2026 at 11:30 AM, during an observation and interview with Licensed Practical Nurse (LPN) #2, she performed an Accu-Chek on Resident #16 using the facility's glucometer and stated that she tries to record the blood glucose results right away. She said that she will write a progress note if one is needed. She reported that she has not paid attention to the Xs recorded Resident #16's MAR or that there was no BG results recorded. She said that the Codes used are explained on the last page of the MAR. On 3/19/26 at 1:00 PM, during an interview and record review with the Director of Nursing (DON), she confirmed the blood glucose readings and insulin dosages documented on the MAR did not align with physician orders and would be considered medication errors. She reported she had not been notified of these medication errors. She stated the facility has a Quality Assurance Nurse responsible for monitoring medication practices, and nursing staff are trained and checked off on medication administration and documentation.On 3/19/26 at 4:46 PM, during an interview with the DON, she stated she expects to be notified immediately of any medication errors or irregularities.During a post exit phone interview on 3/20/26 at 12:00 PM, with Nurse Practitioner #2, she stated she expects staff to follow medication orders as prescribed and to notify her of any concerns or discrepancies. She confirmed she had not been notified of any medication errors related to Resident #16's insulin administration and explained incorrect insulin dosing could result in low blood glucose levels and associated adverse symptoms.

Based on observation, interview, record review, and facility policy review, the facility failed to store, prepare, and serve food in accordance with professional standards for food safety, when the facility failed to repackage, label, and date opened food items, failed to discard expired and deteriorated food items, and failed to store food according to manufacturer's instructions for one (1) of two (2) kitchen observationsFindings include:A review of the facility's policy, Food Procurement, Store/Prepare/Serve - Sanitary (revised 9/2022), revealed, .The facility will.d. Store, prepare, distribute and serve food in accordance with professional standards for food service safety.A record review of the facility's Inservice Report, dated 8/5/25, revealed dietary staff received training regarding food preparation practices for food safety.On 3/16/26 at 11:17 AM, during an observation and interview with the Dietary Manager (Dietary Department #1) and Group Consultant (Dietary Department #3), in the freezer there were frozen sliced pizza that was not repackaged, labeled, or dated. There were (2) opened bags of Mexican beef taco meat that were opened, used, and resealed with rubber bands without labeling or dating. During the refrigerator inspection, a bag of shredded lettuce labeled Best if Used by March 2, 2026 was observed opened and dated March 16, 2026. The Dietary Manager stated the lettuce had been received approximately two weeks prior. (1) bag of celery was observed deteriorated and breaking down inside the packaging. Four (4) half gallons of buttermilk with expiration dates of March 4 and March 12 were also observed. (2) partially used bags of chopped boiled eggs were resealed with rubber bands. DD #1 confirmed eggs are not shipped in that manner and acknowledged improper storage. There was (1) open container of imitation bacon bits stored in the refrigerator without labeling or dating. There was (1) bottle of Kikkoman Reduced Sodium Soy Sauce that was opened, used, and stored on a shelf in the dry goods room despite manufacturer instructions requiring refrigeration after opening. DD #3 acknowledged the product was not stored according to manufacturer's instructions. DD #1 explained that all staff that are putting away deliveries are responsible for checking expiration dates.On 3/19/26 at 10:52 AM, during an interview with DD #2, she explained the plan to address the identified concerns included re-educating staff through in-service training on proper storage and labeling procedures and increasing monitoring of staff compliance.On 3/19/26 at 3:08 PM, during an interview with the Administrator, she stated she was aware of the issues identified in the dietary department and stated her expectation is for dietary staff to properly package, store, and date all food items in accordance with facility policy.

Based on interviews, record review, facility policy review, and facility investigation review, the facility failed to protect the residents' right to be free from sexual abuse by another resident for two (2) of four (4) sampled residents. Resident #2 and Resident #3On 12/17/25 at 11:26 AM, Resident #1 (male) inappropriately touched the breast of Resident #2 (female) in the day room. After staff were notified, Resident #1 was taken to his room and left unsupervised. At approximately 11:32 AM, Resident #1 was assisted back to the day room by a staff member who was unaware of the incident. On 12/17/25 at 11:49 AM, Resident #1 inappropriately touched the breast of Resident #3 (female). The facility was aware prior to these incidents that Resident #1 had a history of sexually inappropriate behaviors, including sexual comments toward staff on 12/12/25, yet failed to implement immediate supervision or restrictions to protect other residents.The facility's failure to implement protective supervision resulted in Resident #2 and Resident #3 experiencing non-consensual sexual contact and placed other vulnerable female residents at risk for serious injury, serious harm, serious impairment, or death.This situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 12/12/25, when Resident #1 made sexual comments toward facility staff. The State Agency (SA) notified the Administrator of the IJ and SQC on 12/23/25 at 9:30 AM and provided an IJ Template.Based on the facility's implementation of corrective actions on 12/19/25, the SA determined the IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed on 12/20/25, prior to the SA's entrance on 12/22/25.Findings include:A review of the facility's policy, Freedom from Abuse, Neglect and Exploitation, dated September 2022, revealed, .F600 Free from Abuse and Neglect All residents of this facility will be free from abuse.The facility will take steps to ensure that the resident is protected from abuse.When a facility has identified abuse, the facility will take all appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately.A review of the facility's policy, Identifying Sexual Abuse and Capacity to Consent, dated September 2022, revealed, .Policy Interpretation and Implementation 1. 'Sexual abuse' is non-consensual sexual contact of any type with a resident.a. unwanted intimate touching of any kind especially of breasts or perineal area.Investigating an Allegation or Suspicion of Sexual Abuse 1. For any alleged violation or suspicion or sexual abuse, protective measures and an investigation.will begin immediately. These include: a. immediately implementing safeguards to prevent further potential abuse.A record review of the Facility Reported incident Initial Report dated 12/17/25, revealed an Allegation Type of Sexual Abuse. The initial report indicated that on 12/17/25 at 11:26 AM, Resident #1 inappropriately touched Resident #2 on her breast while in the Day Room. The event was witnessed by the facility's Janitor. The janitor separated the residents and notified Licensed Practical Nurse (LPN) #1, who took Resident #1 to his room and immediately went to the Director of Nursing (DON) office to notify her of the incident. While LPN #1 was walking to the DON's office, Resident #1 was attempting to come out of his room. Certified Nursing Assistant (CNA) #1, who had no knowledge of the incident and was not his assigned CNA, assisted him out of his room and back to the dayroom. At 11:49 AM, Resident #1 inappropriately touched Resident #3 on her breast. CNA #2 witnessed the incident and immediately separated the residents. The resident was immediately placed on one on one (1:1) observation.Resident #1A record review of the admission Record revealed the facility admitted Resident #1 on 4/26/2023 with current diagnoses including Cerebral Infarction.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/1/25 revealed Resident #1 had a Brief Interview for Mental Status score of 6, which indicated his cognition was severely impaired.A record review of the Progress Notes, dated 12/17/25, revealed, Nurse notified DON and Assistant Director of Nursing (ADON) of incident. While nurse was on the way to tell DON and ADON of incident, student CNA seen resident attempting to exit room, but notice wheelchair was stuck. Student CNA assisted resident out of the room due to no knowledge of the incident. While back in the day room resident inappropriately touch another female resident's breast. CNA immediately separated and took resident with her to notify nurse. ADON educated CNA and nurse that resident is to be on one on one observation. One on One observation was initiated immediately.A record review of the Behavior Reporting Form revealed that on 12/12/25 at approximately 12:00 PM in the facility's hallway, Resident #1 asked employee to see her breasts and documented that Resident stopped employee in the hallway and asked to see her breasts. Employee educated Resident on inappropriateness of request and instructed to not ask that. Resident showed understanding by nodding.A record review of the Psych Progress Note, dated 12/15/25 revealed Resident #1 had Presenting Symptoms including Inappropriate Behavior. The Mental Status Exam included .Comprehension: Difficulty with recall, unable to remember current events.Executive Function: Moderate impairment.impaired decision making.Judgement: Poor Ability to Plan, Poor Social Cognitions, Poor Memory.Thought Process: Confused/Slowed, slowed processing/intermittent confusion. The Case Conceptualization documentation included .He has some increased inappropriate behaviors (sexually impulsive). Discuss this with resident and he states, 'I only do that with people I'm comfortable with.' Discuss inappropriateness of behavior and resident v/u (verbalized understanding).Resident #2A record review of the admission Record revealed the facility admitted Resident #2 on 1/31/24 with diagnoses including Classical Phenylketonuria.A record review of the Comprehensive MDS with an ARD of 12/3/25 revealed Resident #2 required a Staff Assessment for Mental Status and that her cognitive skills for daily decision making was severely impaired.A record review of the Progress Notes, dated 12/17/2, revealed, DON notified nurse that male resident was observed making physical contact with resident's breast.Staff intervened and separated residents.Resident #3A record review of the admission Record revealed the facility admitted Resident #3 on 9/15/23 and she had diagnoses including Cerebral Infarction.A record review of the Quarterly MDS with an ARD of 10/3/25 revealed Resident #3 required a Staff Assessment for Mental Status that revealed her cognitive skills for daily decision making was severely impaired.A record review of the Progress Notes, dated 12/17/25, revealed, Resident was sitting in her wheelchair in the day room when a male resident rolled his wheelchair beside her. The male resident inappropriately touched her right breast. A CNA witnessed the incident and immediately separated the male resident from her.On 12/22/25 at 12:01 PM, during an interview with Licensed Practical Nurse (LPN) #1, she explained that on Wednesday, 12/17/25, a janitor observed Resident #1 inappropriately touching Resident #2's breast while in the day room and reported the observation to staff at the nurses' station. LPN #1 reported that she removed Resident #1 from the day room and escorted him to his room, provided him with ice cream as a distraction, and remained with him until he appeared calm. She stated that she then left the resident alone in his room and went to notify the Director of Nursing (DON), as Resident #1 was not assigned to her. LPN #1 reported that during this time, another staff member, Certified Nursing Assistant (CNA) #1, returned Resident #1 to the day room, where he was subsequently observed inappropriately touching a second resident, Resident #3. She explained that had Resident #1 not been left alone, the second incident would not have occurred. She stated she immediately returned to the nurses' station but was unsure how long it took before staff initiated one-to-one supervision. LPN #1 explained that residents have the right to be free from inappropriate touching and confirmed that Resident #1 was placed on one-to-one observation following the second incident and was later evaluated by a psychiatric nurse practitioner. On 12/22/25 at 12:25 PM, during an interview with the janitor, he explained that at approximately lunchtime on 12/17/25, he was walking through the day room to clean a room when he observed Resident #1 with his hand inside the shirt of Resident #2, touching her breast. He reported that he immediately intervened by separating the residents and transporting Resident #1 to the nurses' station. He stated that he promptly informed LPN #1 of what he had observed in an effort to protect Resident #2. He further explained that at the time of the incident, no staff were present directly in the day room supervising the residents.On 12/22/25 at 12:37 PM, during an interview with Certified Nurse Aide (CNA) #1, she explained that on 12/17/25, following the initial incident involving Resident #1, she was passing through the hallway near the resident's room and was unaware that any incident had occurred. She stated that at that time, Resident #1 was alone and was not on one-to-one (1:1) observation. She reported that she escorted Resident #1 to the day room because he was in the hallway and she was attempting to clear the hallway to maintain resident safety while lifts and resident care activities were in progress. She stated that had she been informed of the earlier incident, she would not have taken Resident #1 into the day room. She further stated that she believed the facility failed to communicate Resident #1's behaviors to her, and that appropriate communication may have prevented the second incident from occurring.On 12/22/25 at 12:41 PM, during an interview with CNA #2, she explained that on 12/17/25 she walked up the hall and observed Resident #1 seated in the day room with his hands on Resident #3's right breast, actively grabbing it. She stated that the residents were unsupervised at the time. She reported that she verbally redirected Resident #1 and then escorted him to his room until arrangements could be made for one-to-one (1:1) supervision. CNA #2 stated that at the time of the second incident, she was unaware that an earlier incident involving Resident #2 had occurred earlier. She explained that staff had not communicated the prior incident to her and stated that had communication occurred or had Resident #1 been placed on 1:1 supervision following the initial incident, the second incident could have been prevented.On 12/22/25 at 1:32 PM, during an interview with the Administrator, she explained that she had completed a behavior report for Resident #1 on 12/12/25, five (5) days prior to the incident, and submitted it to psychiatric services. She stated that on that date, Resident #1 stopped her in the hallway and asked her to show him her breasts and then asked if he could see the breasts of another CNA who was nearby. She confirmed that psychiatric services evaluated Resident #1 on 12/15/25 related to these inappropriate verbal behaviors. She reported that the incidents on 12/17/25 were the first occasions in which Resident #1 had physically touched another resident inappropriately. She further explained that Resident #1 had a known history of sexually inappropriate verbal behaviors toward staff, including making sexual comments and attempting to grab staff members' buttocks, as well as a prior incident approximately one (1) year earlier in which the resident pulled down his pants and exposed himself in the day room. She stated that there had been no prior incidents involving physical sexual contact with other residents before the events on 12/17/25.On 12/22/25 at 1:37 PM, during an interview with Registered Nurse (RN) #1, she explained that she was notified by LPN #1 around lunchtime on 12/17/25 that Resident #1 had inappropriately touched Resident #2's breast. She reported that she and the Director of Nursing (DON) immediately attempted to retrieve and review camera footage from the day room and verified that the incident had occurred. She stated that approximately twenty (20) minutes later, Certified Nurse Aide (CNA) #2 came to the office and reported that Resident #1 had inappropriately touched another resident. She explained that following the second incident, Resident #1 was returned to his room and placed on one-to-one observation. RN #1 stated that if Resident #1 had been placed on one-to-one observation after the first incident, the second incident could have been prevented. She further reported that Resident #1's family was understanding of the situation, while Resident #2's son was upset but acknowledged that incidents can occur.On 12/22/25 at 2:19 PM, during an interview with the Director of Nursing (DON), she explained that on the day the incident occurred she was seated in her office with RN #1 when LPN #1 reported that Resident #1 had inappropriately touched Resident #2's breast. She reported that at that time, she and RN #1 began reviewing video camera footage of the day room. She stated that before RN #1 was able to leave the office to ensure Resident #1 was being monitored, CNA #2 entered the office and reported that Resident #1 had inappropriately touched another resident, Resident #3. The DON acknowledged that Resident #1 should have been placed on one-to-one observation immediately following the first incident and that doing so would have prevented further harm to another resident. She stated that the dignity of both affected residents was not maintained and that their resident rights were violated, describing the incidents as traumatic occurrences. She reported that as corrective action, Resident #1 had been placed on direct one-to-one observation and would remain on one-to-one observation indefinitely. She further stated that the affected residents were being rounded on hourly until thirty (30) days following the incident.On 12/22/25 at 3:20 PM, during an interview with Resident #3's son, he stated that she likely felt embarrassed and bothered by what occurred but stated that she would have forgiven Resident #1 and understood that some residents in nursing homes are not in their right state of mind due to Alzheimer's disease or other conditions.On 12/22/25 at 3:28 PM, during an interview with Resident #2's mother and Resident Representative, she stated that she was initially upset that her daughter had been left unattended in a situation where the incident could occur. She reported that she understood that some residents have cognitive impairments or disabilities that may lead to inappropriate behaviors.On 12/23/25 at 10:50 AM, during an interview with the psychiatric Nurse Practitioner, she stated she evaluated Resident #1 on 12/15/25. She explained that she functions as a consultant and makes recommendations for psychiatric medications to the facility's in-house Nurse Practitioner, who is responsible for writing orders. She explained that, at the time of her evaluation, the behavior did not represent an escalation, the resident was easily redirected, denied ongoing impulsive thoughts, and the behaviors were consistent with dementia-related symptoms.The facility submitted a corrective action plan as follows:1. Overview of the Issuea. The facility failed to protect residents from abuse and develop and implement effective care plan interventions for Resident #1 related to known sexually inappropriate behaviors (comments). On 12/12/2025, the facility identified escalating sexually inappropriate behaviors (comments) by Resident #1. However, the facility failed to develop a care plan related to supervision and behavioral interventions prior to 12/17/2025, when Resident #1 inappropriately touched Resident #2 and Resident #3.Resident #1 was viewed inappropriately touching Resident #2 in the breast area by, Housekeeper #1. He pulled Resident #1 away from Resident #2 alerting LPN (Licensed Practical Nurse) #1. LPN #1, took Resident #1 to his room to separate them and went to report the incident to DON (Director of Nursing) and ADON (Assistant Director). While the reporting to the DON and ADON was occurring, SNA (Student Nursing Assistant) #1, unaware of the incident, brought Resident #1 back to the day room, where he inappropriately touched Resident #3 in the breast area. LPN #1 failed to implement and communicate 1-1 supervision immediately thus not protecting Resident #3 from abuse.b. The SA handed the facility the IJ template on 12/23/2025 at 9:30 AM.2. Corrective Actiona. On 12/17/2025, a QA (Quality Assurance) meeting was held. Abuse Policy and Care plan policies were reviewed. All disciplines attended. No changes were needed.b. On 12/17/2025, 1-1 observation was started by the DON and ADON when the incident was reported to them. This will be assigned to the scheduled Certified Nursing Assistant (CNA).c. On 12/17/2025, 12/18/2025, and 12/19/2025 In-services were conducted on Abuse and Identifying Sexual Abuse and Capacity to Consent by Staff Development Nurse and the Administrator. All staff received training regarding that if staff witnesses abuse, the one who perpetrates or initiates abusive behavior cannot remain in contact with other residents. Take them with you to a supervisor or another employee must remain with them until a decision is made as to what needs to be done. No staff were allowed to work until in-serviced.d. LPN #1 was disciplined and educated on 1-1 supervision when there is an abuse allegation on 12/17/2025.e. CNA #1, was educated on proper undergarment placement for Resident #2 on 12/18/2025.f. Care Plans were updated on 12/17/2025 for all Residents involved and reviewed all residents with behaviors and their care plans.g. On 12/17/2025, body audits were conducted on Resident #2 and Resident#3.h. On 12/17/2025, hourly checks were initiated on Resident #2 and Resident #3.i. On 12/17/2025, Referrals were sent out to multiple Geri-psych units and other facilities for Resident #1.3. Monitoringa. On 12/17/2025, 1-1 observation of Resident #1 will be assigned to the scheduled Certified Nursing Assistant (CNA). Post Event Hourly Monitoring Form will be used.b. Review Care Plans on Residents with behaviors weekly for 4 weeks, monthly for 3 months, and then quarterly. Social Services Director and Care Plan Nurse will be responsible for reviewing and addressing in QA.The Facility alleges all actions were completed to remove the IJ on 12/19/2025. The Immediate Jeopardy was removed on 12/20/2025, prior to the State Agency's entrance on 12/22/2025.Validation: The SA validated on 12/23/25, through interview and record review, that all corrective actions had been implemented as of 12/19/25, and the IJ was removed on 12/20/25, prior to the SA's entrance on 12/22/25.

Based on interviews, record review, facility policy review, and facility investigation review, the facility failed to develop and implement a comprehensive care plan related to sexually inappropriate behaviors for one (1) of four (4) sampled residents. Resident #1On 12/17/25 at 11:26 AM, Resident #1 (male) inappropriately touched the breast of Resident #2 (female) in the day room. After staff were notified, Resident #1 was taken to his room and left unsupervised. At approximately 11:32 AM, Resident #1 was assisted back to the day room by a staff member who was unaware of the incident. On 12/17/25 at 11:49 AM, Resident #1 inappropriately touched the breast of Resident #3 (female). The facility was aware prior to these incidents that Resident #1 had a history of sexually inappropriate behaviors, including sexual comments toward staff on 12/12/25, yet failed to implement immediate supervision or restrictions to protect other residents.The facility's failure to develop and implement a comprehensive care plan resulted in Resident #2 and Resident #3 experiencing non-consensual sexual contact and placed other vulnerable female residents at risk for serious injury, serious harm, serious impairment, or death.This situation was determined to be an Immediate Jeopardy (IJ) which began on 12/12/25, when Resident #1 made sexual comments toward facility staff. The State Agency (SA) notified the Administrator of the IJ on 12/23/25 at 9:30 AM and provided an IJ Template.Based on the facility's implementation of corrective actions on 12/19/25, the SA determined the IJ to be Past Non-Compliance (PNC) and the IJ was removed on 12/20/25, prior to the SA's entrance on 12/22/25.Findings include:A review of the facility's Develop/Implement Comprehensive Care Plan policy, dated September 2022, revealed, .The facility will develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights and that includes measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs.1. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required.A record review of the Facility Reported incident Initial Report dated 12/17/25, revealed an Allegation Type of Sexual Abuse. The initial report indicated that on 12/17/25 at 11:26 AM, Resident #1 inappropriately touched Resident #2 on her breast while in the Day Room. The event was witnessed by the facility's Janitor. The janitor separated the residents and notified Licensed Practical Nurse (LPN) #1, who took Resident #1 to his room and immediately went to the Director of Nursing (DON) office to notify her of the incident. While LPN #1 was walking to the DON's office, Resident #1 was attempting to come out of his room. Certified Nursing Assistant (CNA) #1, who had no knowledge of the incident and was not his assigned CNA, assisted him out of his room and back to the dayroom. At 11:49 AM, Resident #1 inappropriately touched Resident #3 on her breast. CNA #2 witnessed the incident and immediately separated the residents. The resident was immediately placed on one on one (1:1) observation.Resident #1A record review of the admission Record revealed the facility admitted Resident #1 on 4/26/2023 with current diagnoses including Cerebral Infarction.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/1/25 revealed Resident #1 had a Brief Interview for Mental Status score of 6, which indicated his cognition was severely impaired.A record review of the Care Plan Report for Resident #1 revealed a focus area titled Quality of Life, which included the statement, I see a mental health specialist. Further review revealed there were no individualized or specific care plan interventions, monitoring instructions, or staff guidance addressing Resident #1's documented sexually inappropriate behaviors.A record review of the Behavior Reporting Form revealed that on 12/12/25 at approximately 12:00 PM in the facility's hallway, Resident #1 asked employee to see her breasts and documented that Resident stopped employee in the hallway and asked to see her breasts. Employee educated Resident on inappropriateness of request and instructed to not ask that. Resident showed understanding by nodding.A record review of the Psych Progress Note, dated 12/15/25 revealed Resident #1 had Presenting Symptoms including Inappropriate Behavior. The Mental Stus Exam included .Comprehension: Difficulty with recall, unable to remember current events.Executive Function: Moderate impairment.impaired decision making.Judgement: Poor Ability to Plan, Poor Social Cognitions, Poor Memory.Thought Process: Confused/Slowed, slowed processing/intermittent confusion. The Case Conceptualization documentation included .He has some increased inappropriate behaviors (sexually impulsive). Discuss this with resident and he states, 'I only do that with people I'm comfortable with.' Discuss inappropriateness of behavior and resident v/u (verbalized understanding).Resident #2A record review of the admission Record revealed the facility admitted Resident #2 on 1/31/24 with diagnoses including Classical Phenylketonuria.A record review of the Comprehensive MDS with an ARD of 12/3/25 revealed Resident #2 required a Staff Assessment for Mental Status and that her cognitive skills for daily decision making was severely impaired.A record review of the Progress Notes, dated 12/17/2, revealed, DON notified nurse that male resident was observed making physical contact with resident's breast.Staff intervened and separated residents.Resident #3A record review of the admission Record revealed the facility admitted Resident #3 on 9/15/23 and she had diagnoses including Cerebral Infarction.A record review of the Quarterly MDS with an ARD of 10/3/25 revealed Resident #3 required a Staff Assessment for Mental Status that revealed her cognitive skills for daily decision making was severely impaired.A record review of the Progress Notes, dated 12/17/25, revealed, Resident was sitting in her wheelchair in the day room when a male resident rolled his wheelchair beside her. The male resident inappropriately touched her right breast. A CNA witnessed the incident and immediately separated the male resident from her.On 12/22/25 at 1:32 PM, during an interview with the Administrator, she explained Resident #1 had a known history of sexually inappropriate verbal behaviors toward staff, including making sexual comments and attempting to grab staff members' buttocks, as well as a prior incident approximately one (1) year earlier in which the resident pulled down his pants and exposed himself in the day room. She stated that she had completed a behavior report regarding sexually inappropriate comments by Resident #1 on 12/12/25, five (5) days prior to the incidents and submitted it to psychiatric services. She stated that on that date, Resident #1 stopped her in the hallway and asked her to show him her breasts and then asked if he could see the breasts of another CNA who was nearby. She confirmed that psychiatric services evaluated Resident #1 on 12/15/25 related to these inappropriate verbal behaviors. On 12/22/25 at 3:30 PM, during an interview with Registered Nurse (RN) #2, the care plan nurse, she explained that resident care plans are updated either by floor nursing staff or by the two designated care plan nurses when new orders are received. She stated that new orders are written in red ink to identify changes and are incorporated into the care plan, which is formally reviewed and updated every three (3) months. She explained that the care plan guides staff in providing appropriate care to residents.On 12/23/25 at 1:32 PM, during a follow-up interview with the Administrator, she confirmed that Resident #1's care plan was not updated until 12/17/25 although inappropriate behaviors were identified on 12/12/25. The facility submitted a corrective action plan as follows:1. Overview of the Issuea. The facility failed to protect residents from abuse and develop and implement effective care plan interventions for Resident #1 related to known sexually inappropriate behaviors (comments). On 12/12/2025, the facility identified escalating sexually inappropriate behaviors (comments) by Resident #1. However, the facility failed to develop a care plan related to supervision and behavioral interventions prior to 12/17/2025, when Resident #1 inappropriately touched Resident #2 and Resident #3.Resident #1 was viewed inappropriately touching Resident #2 in the breast area by, Housekeeper #1. He pulled Resident #1 away from Resident #2 alerting LPN (Licensed Practical Nurse) #1. LPN #1, took Resident #1 to his room to separate them and went to report the incident to DON (Director of Nursing) and ADON (Assistant Director). While the reporting to the DON and ADON was occurring, SNA (Student Nursing Assistant) #1, unaware of the incident, brought Resident #1 back to the day room, where he inappropriately touched Resident #3 in the breast area. LPN #1 failed to implement and communicate 1-1 supervision immediately thus not protecting Resident #3 from abuse.b. The SA handed the facility the IJ template on 12/23/2025 at 9:30 AM.2. Corrective Actiona. On 12/17/2025, a QA (Quality Assurance) meeting was held. Abuse Policy and Care plan policies were reviewed. All disciplines attended. No changes were needed.b. On 12/17/2025, 1-1 observation was started by the DON and ADON when the incident was reported to them. This will be assigned to the scheduled Certified Nursing Assistant (CNA).c. On 12/17/2025, 12/18/2025, and 12/19/2025 In-services were conducted on Abuse and Identifying Sexual Abuse and Capacity to Consent by Staff Development Nurse and the Administrator. All staff received training regarding that if staff witnesses abuse, the one who perpetrates or initiates abusive behavior cannot remain in contact with other residents. Take them with you to a supervisor or another employee must remain with them until a decision is made as to what needs to be done. No staff were allowed to work until in-serviced.d. LPN #1 was disciplined and educated on 1-1 supervision when there is an abuse allegation on 12/17/2025.e. CNA #1, was educated on proper undergarment placement for Resident #2 on 12/18/2025.f. Care Plans were updated on 12/17/2025 for all Residents involved and reviewed all residents with behaviors and their care plans.g. On 12/17/2025, body audits were conducted on Resident #2 and Resident#3.h. On 12/17/2025, hourly checks were initiated on Resident #2 and Resident #3.i. On 12/17/2025, Referrals were sent out to multiple Geri-psych units and other facilities for Resident #1.3. Monitoringa. On 12/17/2025, 1-1 observation of Resident #1 will be assigned to the scheduled Certified Nursing Assistant (CNA). Post Event Hourly Monitoring Form will be used.b. Review Care Plans on Residents with behaviors weekly for 4 weeks, monthly for 3 months, and then quarterly. Social Services Director and Care Plan Nurse will be responsible for reviewing and addressing in QA.The Facility alleges all actions were completed to remove the IJ on 12/19/2025. The Immediate Jeopardy was removed on 12/20/2025, prior to the State Agency's entrance on 12/22/2025.Validation: The SA validated on 12/23/25, through interview and record review, that all corrective actions had been implemented as of 12/19/25, and the facility was in compliance on 12/20/25, prior to the SA's entrance on 12/22/25.

Based on interviews, record review, and facility policy review, the facility failed to ensure a medication was secured in a locked storage area and available to only authorized personnel when a medication was left at a resident's bedside for one (1) of three (3) sampled residents. Resident #1 Findings include: A review of the facility policy titled Administration and Documentation, revised July 24, 2015, revealed, . Under no circumstances is medication to be left at the bedside or given to the resident without him/her swallowing it in your presence, unless a physician has written an order to this effect and unless the facility has determined that the resident is mentally and physically capable of self-administration . On 12/4/24 at 12:00 PM, during an interview with Resident #1, he confirmed that in September 2024 of this year, his nurse left his new face cream at his bedside, and he used it all the time, hoping his face would heal faster. He confirmed that his daughter was upset because instead of healing faster, it irritated his face, and it had to be stopped. A record review of the dermatological consultation revealed the Visit Note, dated 9/4/24, revealed a local dermatologist, prescribed Fluorouracil 5% topical cream, to be applied two times a day on his scalp and down temples for two (2) weeks related to Actinic Keratosis. A record review of the Order Recap Report, with active orders for September, revealed an order for Fluorouracil External Cream 5% to be applied topically every shift related to Actinic Keratosis until 9/19/24, then discontinued. However, further review of the order revealed the Fluorouracil Cream was discontinued on 9/13/24 and a new order for Triamcinolone Lotion was ordered. The Triamcinolone Lotion was ordered to be applied BID (twice a day) for four (4) days on irritated places on the face, with a start date of 9/14/24 and an end date of 9/17/24. During an interview with License Practical Nurse (LPN) #1 on 12/4/24 at 1:15 PM, she stated she had left the Fluorouracil External Cream 5 % at Resident #1's bedside. The resident was fussing about the cream, so she just left the cream in his room for a few days. LPN #1 stated that when she spoke to the resident's dermatologist, the dermatologist became upset when she learned the medication was at the resident's bedside. Following the incident, the nurse said the resident's physician discontinued the medication and prescribed a different cream because of his face being irritated. LPN #1 stated she reported the situation to the prior Director of Nurses (DON) before she resigned. On 12/4/24 at 1:30 PM, during an interview with DON, she revealed she began working at the facility on 8/31/24; during that time, the previous DON was present. The current DON confirmed that the facility must follow physician orders on medications, and they are not to be left at the bedside. On 12/4/24 at 2:30 PM, during an additional interview with the DON, she stated that after the incident related to Resident #1, the facility had a QAPI (Quality Assurance and Performance Improvement) meeting to discuss the incident. Following the meeting, there was Nurses' Meeting to plan additional in-services to reinforce the policy that medications and creams are not to be left at the bedside unless it is ordered. The in-services were mandatory for all nursing staff prior to returning to work. On 12/4/24 at 3:00 PM, during an interview with the Medical Provider, he confirmed that when he was made aware that Resident #1 had the prescribed Fluorouracil External Cream 5% topically at his bedside for approximately 9 days, and he observed the resident's face to be irritated. He stated that he discontinued the Fluorouracil External Cream and Triamcinolone lotion was ordered to be applied to the resident's face twice a day for 4 days. He stated that the facility should not leave any medication at the residents' bedside unless they are prescribed to be there. A record review of the Admission Record, revealed the facility admitted Resident #1 to the facility on [DATE]. The resident had diagnoses that included Type 2 Diabetes Mellitus with Hyperglycemia, Neoplasm of Uncertain Behavior of Skin, Actinic Keratosis, and Rosacea, Unspecified. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 11/20/24, revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident was moderately impaired. Validation: On 12/4/24, the State Agency (SA) validated through staff interviews, record review, and facility policy review the facility began an immediate investigation when they were aware of the incident involving Resident #1. A review of the emergency QAPI meeting minutes revealed the facility held a QAPI meeting on 9/24/24 at 1:30 PM, in which the Infection Preventionist (IP) was present, and the Medical Director attended via phone. The SA verified through an interview with the DON and Administrator they attended the QAPI meeting to discuss the situation, and the facility policies related to not leaving medication at the bedside unless the facility has physician orders. The QAPI meeting concluded that Correction planned to in-service all nurses and interview all residents with Brief Interview of Mental Status (BIMS) over 12 to determine if any other residents experienced medications being left at the bedside. The SA reviewed in-service sign-in sheets that began on 9/24/24 related to the administration of medications and reinforced the policy that stated, medication (pills or creams) are not to be left in a resident's room, unless the physician has written an order to this effect and the facility has determined that the resident in mentally and physically capable of self-administration. The DON conducted in-services in which they had every nurse sign the policies on medication administration.

Based on observation, interviews, record review, and facility policy review, the facility failed to implement a care plan intervention regarding changing oxygen (O2) tubing for one (1) of twenty-two (22) sampled residents. Resident #76. Findings Include: A review of the facility's policy titled Comprehensive Resident-Centered Care Plans (undated) revealed, . It is the policy of this facility to provide services based on the following requirements .Development/Implement Comprehensive Care Plan. The facility will develop and implement a comprehensive person-centered care plan for each resident consistent with the resident's rights and that includes measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment. A review of the facility ' s policy titled Oxygen Policy (undated) revealed, . It is the policy of this facility that oxygen will be utilized as follows: . with the specific physician orders . Date the tubing . A record review of the Comprehensive Care Plan with a start date of 3/22/23, revealed Resident #76 had a care plan intervention to Change my O2 tubing and wash filter every week on Friday. On 10/15/24 at 12:08 PM, during an observation, Resident #76 was observed receiving oxygen via nasal cannula at 2 liters per minute. The tubing was not dated to indicate the tubing had been changed. The resident reported that she must wear oxygen at all times. On 10/16/24 at 1:30 PM, during an observation and interview, Registered Nurse (RN) #4 observed and confirmed that Resident #76's oxygen tubing was not dated and stated the oxygen tubing should be changed weekly and dated. During an interview on 10/17/24 at 2:10 PM, the Minimum Data Set (MDS)/Care Plan Coordinator explained that the purpose of each resident's care plan is to inform staff about how to care for each resident. She emphasized that she expects all staff to follow a resident's care plan to ensure proper care. During an interview on 10/17/24 at 2:25 PM, the Director of Nursing (DON) stated that she expects all staff to follow the resident's care plan when providing care to any resident. A record review of the Admission Record revealed that the facility admitted Resident #76 on 01/18/23 with diagnoses including Chronic Diastolic (Congestive) Heart Failure and Chronic Obstructive Pulmonary Disease (COPD) with (Acute) Exacerbation. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/20/24 revealed in Section O of the MDS that Resident #76 received oxygen therapy. A record review of the Medication Review Report dated 10/16/24 revealed Resident #76 a physician's order, dated 08/27/24, to change the oxygen tubing and wash the filter every week on Fridays. 50751

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure residents received meals that were palatable and served at an appetizing temperature for three (3) of ten (10) residents observed for dining. Resident #63, Resident #85, and Resident #90. Findings Include: A review of the facility's policy titled Meal Service, dated 12/23, revealed: .Food will be delivered promptly to ensure safe, palatable, and high-quality food served at the appropriate temperature .Procedure .6. Food will be served at palatable temperatures (hot food hot and cold food cold) as discerned by the patients/residents and customary practice . Resident #63: During an interview on 10/15/24 at 11:42 AM, Resident #63 stated that he was not pleased with the meals, describing them as hit or miss and noting that only one (1) out of (10) meals were good. He explained that by the time food arrived at his room, it was cold, sometimes warm, but often was not warm. During an interview on 10/16/24 at 9:03 AM, Resident #63 stated that his breakfast that morning, which included a biscuit, sausage, eggs, and grits, was lukewarm. He mentioned that the two (2) slices of pizza he had received were also lukewarm, although they tasted acceptable. During an interview on 10/16/24 at 3:10 PM, Resident #63 recalled his lunch, which consisted of chicken patties, greens, black-eyed peas, and cornbread. He stated that the food was lukewarm, noting that the black-eyed peas were bland and could benefit from added seasoning like ham. He shared that he mixed mayonnaise with his peas to improve the taste. A record review of the Admission Record revealed the facility admitted Resident #63 on 02/27/23 with diagnoses including Diabetes Mellitus. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/23/24 revealed Resident #63 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated he was cognitively intact. Resident #85 During an interview on 10/15/24 at 11:10 AM, Resident #85 stated that the food was either too salty or had no taste. She emphasized that she preferred her food to have more flavor. During an interview on 10/15/24 at 12:20 PM, Resident #85 reported that she had not eaten her lunch because it lacked taste and seasoning. A record review of the Admission Record revealed the facility admitted Resident #85 on 11/03/23 with diagnoses including Hypertensive Heart Disease. A record review of the Comprehensive MDS with an ARD of 10/07/24 revealed Resident #85 had a BIMS score of nine (9), which indicated her cognition was moderately impaired. Resident #90 During an interview on 10/16/24 at 12:14 PM, Resident #90 stated that the food was bland, had no taste, and was cold. She reported that she did not eat her lunch and instead had her family bring her a meal. She mentioned that she had spoken with the previous Dietary Manager about the food quality, but no improvements were made. A record review of the Admission Record revealed the facility admitted Resident #90 on 08/19/22 with diagnoses including Hypertensive Heart Disease. A record review of the Annual MDS with an ARD of 09/11/24 revealed Resident #90 had a BIMS score of fifteen (15), which indicated she was cognitively intact. On 10/16/24 at 10:54 AM, during an observation of food temperature checks, Dietary #1 was observed taking food temperatures at the steam table: Chicken patties: 139 Fahrenheit (F), Black-eyed peas: 140 F, and Greens: 160 F. During an observation on 10/16/24, meal tray preparation began at 11:05 AM, with Cart #1 and the dining hall service began at 11:05 AM. The dietary staff began plating Cart #6, which was the last meal cart, at 12:08 PM and it was completed at 12:18 PM. All meal carts used to deliver meal trays to residents on the hall were delivered on an open style cart. The cart was transported to the hall and the last tray was delivered as a test tray at 12:33 PM. Dietary #2 took the food temperatures of the test tray which revealed: Chicken patties: 99 F, Turnip greens: 100 F, and Black-eyed peas: 85 F. The test tray was sampled and the food was bland and at a lukewarm, non-appetizing temperature. During an interview on 10/16/24 at 12:45 PM, Dietary #2 confirmed that some of the food was bland and lukewarm. She explained that only salt and pepper were used for seasoning due to the loss of recipes from a previous roof leak. She noted that the open cart system and the time taken for food to reach residents' rooms contributed to the lukewarm temperatures. During an interview on 10/16/24 at 1:44 PM, Dietary #1 stated that she was still being trained to cook and had not been provided with recipes. She explained that she used only salt and pepper for seasoning, avoiding excess salt due to residents' complaints. She believed that the open carts contributed to the food cooling before reaching residents. During an interview on 10/16/24 at 2:23 PM, Dietary #3 stated that the kitchen staff were being retrained on meal preparation. She confirmed that Dietary #2 was not certified and that Dietary #1 was still learning cooking techniques. During an interview on 10/17/24 at 10:45 AM, the Director of Nursing (DON) confirmed that residents had complained about the food being too salty or lacking taste (bland) and that it was often cold. The DON reported this to the Administrator, who was working with the kitchen to address the issues. During an interview on 10/17/24 at 1:26 PM, the Administrator acknowledged residents' complaints about the salty food but was unaware of complaints about the food's bland taste or temperature. She stated that the facility had contracted with an outside company to train the kitchen staff on proper cooking techniques and recipe use.

Based on observations, interviews, record reviews, and facility policy review, the facility failed to follow standards of practice for respiratory care regarding dating and changing oxygen tubing weekly and storing it in a plastic bag when not in use for one (1) of two (2) residents observed for respiratory care. Resident #76. Findings Include: A review of the facility's policy titled Oxygen Policy, (undated) revealed, . It is the policy of this facility that oxygen will be utilized as follows: . With the specific physician orders . Date the tubing . A record review of Resident #76's Admission Record revealed that the facility admitted the resident on 01/18/23. The resident had diagnoses that included Chronic Diastolic (Congestive) Heart Failure and Chronic Obstructive Pulmonary Disease (COPD) with (Acute) Exacerbation. A record review of Resident #76's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/20/24 revealed a Brief Interview for Mental Status (BIMS) Summary Score of 11, which indicated that the resident's cognition was moderately impaired. Section O of the MDS indicated that Resident #76 received oxygen therapy. A record review of Resident #76's 10/16/24 Medication Review Report, revealed physician orders, dated 8/27/24, to change the oxygen (O2) tubing and wash the filter every week on Fridays. During an observation on 10/15/24 at 12:08 PM, Resident #76 was observed receiving oxygen via nasal cannula at 2 liters per minute. The oxygen tubing was not dated. The resident reported that she must wear oxygen at all times. During an observation on 10/15/24 at 3:00 PM, Resident #76 was observed lying in bed wearing oxygen via nasal cannula. The oxygen tubing was still not dated. During an observation on 10/16/24 at 9:35 AM, Resident #76 was not in her room, and the nasal cannula was observed lying on top of the oxygen concentrator, without any type of storage to prevent contamination of the tubing and nasal cannula. The oxygen tubing continued to be undated. During an observation and interview on 10/16/24 at 1:30 PM, Registered Nurse (RN) #4 observed that Resident #76's oxygen tubing was not dated, nor was there a plastic storage bag present. RN #4 confirmed that oxygen tubing is to be changed weekly, dated, and stored in a plastic bag when not in use. During an interview on 10/16/24 at 1:45 PM, Licensed Practical Nurse (LPN) #5 explained that Resident #76 is to wear her oxygen at all times, especially while in bed, but the resident removes it when attending activities. LPN #5 added that when oxygen is not in use, the tubing should be stored in a plastic storage bag and that all tubing should be changed and dated weekly, with the filter cleaned. She mentioned that either the cart nurse or the treatment nurse is responsible for changing the tubing and cleaning the filter. During an interview on 10/16/24 at 3:15 PM, RN #1 stated that all oxygen tubing should be stored in a plastic bag when not in use, and that the tubing and bag should be changed weekly to minimize infection risks for the resident. During an interview on 10/17/24 at 2:25 PM, the Director of Nursing (DON) stated that she expects all staff to adhere to the facility's policies and procedures and follow standards of practice for all residents receiving respiratory care. She confirmed that oxygen tubing should be changed and dated each Friday and stored in a plastic bag when not in use.

Based on record reviews, interviews, and facility policy review, the facility failed to complete a Minimum Data Set (MDS) discharge assessments accurately for one (1) of twenty-two (22) residents reviewed for assessments. Resident #109. Findings Include: A review of the facility's policy titled Resident Assessment Instrument (RAI) Policy (undated) revealed, It is the policy of the facility that the RAI will be done as follows: According to the guideline specified by: .Division of Medicaid . A record review of Resident #109's Face Sheet revealed an admitted [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Hypertensive Chronic Kidney Disease, and Hypertensive Heart Disease with Heart Failure. A record review of Resident #109's Discharge MDS with an Assessment Reference Date (ARD) of 08/08/24 revealed that the discharge was coded as a short-term general hospital stay (acute hospital). A record review of Resident #109's Physician Order Sheet revealed a physician's order, written on 08/08/24 at 8:53 AM for Resident #109 to . (Name of home health) to follow up at home. A record review of the Departmental Notes dated 8/8/24 at 9:29 AM and signed by Social Services revealed MDS discharge assessment completed .on Thursday, August 8, 2024 .Resident left facility under the care of family . During an interview on 10/17/24 at 1:55 PM, the Registered Nurse/MDS Coordinator stated that the discharge should have been coded as the resident going home. During an interview on 10/17/24 at 2:08 PM, Licensed Practical Nurse (LPN) #3, an MDS nurse, stated that she had incorrectly coded the resident as being discharged to the hospital. She acknowledged that it should have been coded as a discharge to home and explained that she entered the information in error.

Based on interviews, record reviews, and facility policy review, the facility failed to ensure that a resident who did not have an advance directive received information or assistance in formulating an advance directive for one (1) of twenty-two (22) residents reviewed for advance directives. Resident #7. Findings Include: A record review of the Admission Record for Resident #7, revealed an admitted [DATE] with diagnoses including Dysphagia, Dementia, and Alzheimer's Disease. A record review of Resident #7's Admission Agreement Checklist dated 10/9/21, revealed that the resident does not have a Power of Attorney (POA) and that the checklist does not indicate acknowledgment of an Advance Directive. During an interview on 10/15/24 at 11:54 AM, Resident #7's Resident Representative (RR) stated that he has not established a Power of Attorney. During a record review of Resident #7's chart, there was no documentation acknowledging the existence of an Advance Directive or a Power of Attorney. During an interview on 10/16/24 at 1:50 PM, the Administrator stated that Resident #7 does not have an Advance Directive Acknowledgment Form or Power of Attorney. She mentioned that while they provided Resident #7's RR with a booklet on Advance Directives upon admission, there was no documentation indicating that the resident acknowledged receiving this information. During an interview on 10/16/24 at 2:10 PM, the Director of Nursing (DON) confirmed that Resident #7 does not have a Power of Attorney or a copy of the facility's Advance Directive Acknowledgment Form in her records.

Based on observation, interviews, record review and facility policy review, the facility failed to honor residents' rights for self-determination by not allowing residents to go outside together for two (2) of 22 sampled residents. Residents #13 and #14. Findings Include: A review of the facility's policy titled Resident Rights Policy, revised 09/2022, revealed: .Facility will ensure that 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. The 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, recognizing each resident's individuality . Resident #13: A record review of Resident #13's Admission Record revealed the facility admitted the resident on 10/18/21. The resident had diagnoses that included Paranoid Schizophrenia and Neuroleptic Induced Parkinsonism. A record review of Resident #13's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/24/24 revealed a Brief Interview for Mental Status (BIMS) Summary Score of 14, which indicated the resident was cognitively intact. Section F indicated that it is very important to Resident #13 to engage in his favorite activities and to go outside for fresh air when the weather is favorable. Section GG revealed no impairment in range of motion for upper or lower extremities and that Resident #13 is independent or requires supervision for Activities of Daily Living (ADLs). Resident #14: A record review of Resident #14's Admission Record revealed the facility admitted the resident on 09/20/21. The resident had diagnoses that included End Stage Renal Disease and Dependence on Renal Dialysis. A record review of Resident #14's Annual MDS with an ARD of 02/27/24 revealed a BIMS summary score of 15, which indicated the resident was cognitively intact. Section F indicated that it is very important to Resident #14 to engage in favorite activities and to go outside for fresh air when the weather is good. A record review of Resident #14's Quarterly MDS with an ARD of 08/13/24, Section GG, revealed that Resident #14 had no impairment in range of motion for upper or lower extremities, used a wheelchair, and was dependent on staff for transfers. During an observation and interview on 10/15/24 at 11:07 AM, Resident #13 and Resident #14 reported that they wished to go outside together, but were not allowed to do so because Resident #13 had previously tried to assist his wife, Resident #14. As a result, they were no longer permitted to be outside together alone. Resident #13 explained that he was trying to prevent his wife from falling. Resident #14 stated that while they could go outside for activities, they wished to be allowed outside at other times as well. She added that she attends dialysis three (3) times a week, and her husband, Resident #13, attends outpatient therapy three (3) times a week, meaning they are not together daily. Both residents reported that they have asked staff, both during the week and on weekends, to be allowed to go outside together but were consistently told that they could not. Both residents expressed that it is very important to them to spend time together outside and enjoy fresh air. During an observation on 10/16/24 at 9:20 AM, Resident #13 was not in his room, while Resident #14 was observed still in bed. Resident #13 explained that her husband was away for outpatient services and would return later that day. During an interview on 10/16/24 at 10:00 AM, Certified Nursing Aide (CNA) #2 in training explained that she had never seen Residents #13 and #14 go outside together. She had been working at the facility since August and had seen Resident #13 go outside by himself but had never seen the two together. During an interview on 10/16/24 at 11:04 AM, Licensed Practical Nurse (LPN) #4 stated that she was aware that Resident #13 and Resident #14 were not allowed to go outside together. She mentioned that she had been informed by staff that Resident #13 had previously attempted to assist Resident #14 when she almost fell , leading to the restriction. During an interview on 10/17/24 at 11:26 AM, Social Services #1 explained that she was unaware of the residents' complaints or that staff were not allowing Resident #13 and Resident #14 to go outside together. She recalled a past incident where Resident #13 tried to help his wife into a van but was not aware of staff preventing the couple from going outside by themselves. She mentioned that the facility employs agency staff and has different personnel on weekends, which might impact consistency. She emphasized that it is the residents' right to go outside when they choose, and she expects all staff to respect residents' rights at all times. During an interview on 10/17/24 at 12:05 PM, the Administrator stated that she was not aware that Resident #13 and Resident #14 were being prevented from going outside together. She emphasized her expectation that staff respect residents' rights at all times. During an interview on 10/17/24 at 2:00 PM, the Director of Nursing (DON) confirmed that she expects all staff to respect and honor residents' rights at all times.

Based on observation, staff interview, record review, and facility policy review, the facility failed to handle linens in a manner to prevent the possible spread of infection (Resident #12) and failed to wear appropriate Personal Protective Equipment (PPE) during administration of a bolus feeding for a resident that required Enhanced Barrier Precautions (EBP) (Resident #56) for two (2) of 22 sampled residents. Findings include: A review of the facility policy titled Infection Control, dated 09/2022, revealed: .The facility has established and will maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The infection prevention and control program (IPCP) will include, at a minimum the following elements .Linens. Personnel will handle, store, process, and transport linens so as to prevent the spread of infection . A review of the facility's policy Enhanced Barrier Precautions dated 03/13/24 revealed . Use of Enhanced Barrier Precautions can effectively reduce the spread of Multi-drug resistant Organism (MDRO), specifically those CDC (Center for Disease Control and Prevention) targeted organisms . Definition: Enhanced Barrier Precautions: include use of gowns and gloves for those residents that would not already be in Contact Precautions. It also could include eye covering if there is an anticipation of a splash . Indwelling medical device: Devices such as central lines, PICC (Peripherally inserted central catheter) lines, urinary catheters, feeding tubes, tracheostomy/ventilator require EBP . Resident #12 During an observation and interview on 10/16/24 at 10:07 AM, Certified Nurse Aide (CNA) #1 had completed incontinence care on Resident #12. There were dirty linens and a soiled brief directly on the floor of the resident's room. She confirmed she had placed the dirty items on the floor and agreed they should not have been placed directly onto the floor. During an interview on 10/16/24 at 2:10 PM, Licensed Practical Nurse (LPN) #2, confirmed CNA #1 should not have placed the dirty linens and brief directly onto the floor. During an interview on 10/16/24 at 2:27 PM, Registered Nurse (RN) #1, the Infection Preventionist (IP), explained that dirty linens should not be on the floor because it could cause infection to be spread to the residents. During an interview on 10/16/24 at 2:48 PM, the Director of Nursing (DON) stated that dirty linens should not come in contact of the floor due to infection control concerns. A record review of Resident #12's Admission Record revealed that the facility admitted Resident #12 on 03/10/21 with diagnoses including Type 2 Diabetes Mellitus. Resident #56 During an observation on 10/16/24 at 09:25 AM, Resident #56 was lying in bed and there was signage on the resident's room door that indicated he required EBP. On 10/16/24 at 11:00 AM, during an observation and interview, LPN #4 administered Resident #56's bolus feeding per a Percutaneous Endoscopic Gastrostomy (PEG) tube. LPN #4 wore gloves while administering the feeding and did not have a gown on. She stated that because there was no chance of being splashed, she was required to only wear gloves. She confirmed the signage on the resident's door indicated that gloves and gowns should be worn, but reiterated that she had been instructed that she only needed to wear gloves. On 10/16/24 at 03:30 PM, during an interview with RN #1, she confirmed a gown, and gloves were required to be worn when administering feedings or medication via a PEG tube. She also confirmed the facility's policy and the signage on the door indicated the correct PPE worn for EBP (gown and gloves). At 02:15 PM on 10/17/24, during an interview with the DON, she confirmed the staff should wear a gown and gloves for residents with peg tubes. She stated she expected all staff to follow the facility's policies and procedures regarding EBP. A record review of the Admission Record revealed the facility admitted Resident #56 on 04/15/24 with diagnoses including Encounter For Attention To Gastrostomy and Gastrostomy Status. A record review of the Medication Review Report revealed Resident #56 on had a Physician's Order, dated 9/3/24, for .Enhanced Barrier Precautions D/T (due to) Feeding Tube . A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/12/24 revealed in Section K that Resident #56 had a feeding tube. 50751

Based on record review, staff interview, and policy review the facility failed to implement care plan interventions related to Activities of Daily Living (ADL) care for one (1) of three (3) residents reviewed for care plans. Resident #1. Based on the facility's implementation of corrective actions completed by 2/8/24, the SA determined this to be Past non-compliance (PNC) as of 2/8/24, prior to the SA's entrance into the facility on [DATE]. Findings Include: Record review of the facility's policy, Develop/Implement Comprehensive Care Plan, revised September 2022, revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights and that includes measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment . Record review of the comprehensive care plan for Resident #1 revealed a care plan with a start date of 1/19/24 revealed Care Plan Goal I want to be kept clean, dry and needs met .Intervention .I require sub/max (submaximal) assist w/ (with) roll left and right in bed ext (extensive) x 2 w/bed mobility) . During an interview on 03/19/24 at 11:30 AM, with the facility Administrator (ADM) revealed that the facility had investigated on 02/03/24 and determined that an agency Certified Nursing Assistant (CNA #1) had not followed the resident's care plan and had not requested assistance with the care of the Resident #1. CNA #1 rolled Resident #1 over in his bed and he fell out of bed onto the floor and hit his head and elbow. The facility began in-service training on 02/03/24 and no employee was allowed to work until they were in-serviced on following care plans. The facility had two (2) Quality Assurance Committee meetings from 02/05/24 through 02/08/24. The ADM stated that the facility had put a corrective action plan in place immediately following the incident on 02/03/24 and that the facility had made all corrections for non-compliance by 02/08/24. During an interview on 03/19/24 at 11:30 AM, with the facility's Director of Nursing (DON) revealed that Resident #1 had always been care planned since his admission several years ago, as a total care resident with two (2) persons to assist with all ADL's. The DON stated that the care plans for all residents are placed in the CNA's hands for review and can be referred to, at any point during a shift, in the CNA 's computer stations. The DON stated that CNA #1 admitted that she had attempted to deliver care to Resident #1 alone and had not attempted to ask for help from the other staff that were present on first shift on 02/03/24. Interview on 03/19/24 at 1:30 PM, with Resident #1 revealed there was one (1) CNA in the room when he fell from the bed on 2/3/24. During an interview on 03/20/24 at 12:45 PM, with Licensed Practical Nurse (LPN) #1, Safety Nurse, revealed that CNA #1 had not followed procedures and had solely attempted to care for Resident #1 without following the care plan for a two (2) person assist for all care. During an interview on 03/20/24 at 12:55 PM, with CNA #2, revealed CNA #1 was alone in the resident's room when she went in to assist Resident #1 from the floor. She stated that CNA #2 had voiced that she thought that she could care for Resident #1 by herself. CNA #2 stated that all the CNA's had access to all resident care plans and Resident #1 had always been a two (2) person assist with all his needs since he was admitted to the facility. CNA #2 confirmed that CNA #1 had not followed the care plan of Resident #1 which caused his fall. Interview on 03/20/24 at 1:10 PM, with Registered Nurse (RN) #1, Treatment Nurse, revealed the entire staff had been in-serviced on following the care plans of all residents and to especially be mindful of residents that need two (2) people to assist with their care. Interview on 03/20/24 at 2:00 PM, with Registered Nurse (RN) #2, Care Plan Nurse, revealed Resident #1 had been care planned as a two (2) person assist with all his ADL's since he was admitted to the facility. RN #2 stated that CNA #1 had not followed the care plan that was in place for Resident #1 and had caused Resident #1 to fall off the bed onto the floor. RN #2 stated that CNA #1 had access to the care plan of Resident #1 and that she did not follow the ADL interventions to prevent accidents, injuries, and/or falls. RN #2 confirmed that all staff had been in-serviced on following the care plans to prevent accidents since Resident #1 fell on [DATE]. Record review of the Face Sheet revealed the facility admitted Resident #1 on 11/5/2015 and he had current diagnoses including Paraplegia. Record review for Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/18/2024 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated his cognition was moderately impaired. The facility began their investigation and corrective actions on 02/03/24 as follows: 1-Evaluated/assessed all residents that were assigned to CNA #1's care. 2-Evaluated/assessed Resident #1 and sent him out to the local hospital for further evaluation. 3-Investigated and obtained statements from all staff that worked on 02/03/24. 4-Suspended CNA #1 from the facility at 3:00 PM on 02/03/24. 5-Contacted the contract Nursing agency and terminated CNA #1 from working at the facility. 6-In-serviced all staff concerning fall preventions and following care plans. 7-Completed all plans of action on 02/08/24. 8-Continued ongoing assessments and evaluations of Resident #1 and had reviewed and updated his care plan. 9-Conducted two (2) Quality Assurance (QA) committee meetings from 02/05/24 through 02/08/24. On 3/20/24 the State Agency (SA) validated through observation, interview, and record reviews that the correction actions were implemented by the facility as follows: 1-The SA validated all residents were evaluated/assessed that were assigned to CNA #1's care. 2-The SA validated Resident #1 was evaluated/assessed and sent out to the local hospital for further evaluation. 3-The SA validated the facility investigated and statements were obtained from all staff that worked on 02/03/24. 4-The SA validated CNA #1 was suspended from the facility on 2/3/24 at 3:00 PM. 5-The SA validated the facility contacted the contract Nursing agency and terminated CNA #1 from working at the facility. 6-The SA validated all staff were inserviced concerning fall preventions and following care plans. 7-The SA validated all plans of action were completed by 02/08/24. 8-The SA validated continued ongoing assessments and evaluations of Resident #1 and validated the facility had reviewed and updated his care plan. 9- The SA validated the facility conducted two (2) Quality Assurance (QA) committee meetings from 02/05/24 through 02/08/24.

Based on interviews, record reviews, facility investigation review, and facility policy review, the facility failed to follow the plan of care as evidenced by failure to give Resident #2 ordered insulin and gave Resident #1 insulin that was not ordered for two (2) of five (5) records reviewed. (Resident #1 and Resident #2) The SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 11/12/15 when Licensed Practical Nurse (LPN) #2 entered Resident #2's order for insulin into Resident #1's electronic Medication Administration Record [REDACTED]. On 11/13/15 at approximately 5:00 AM, the night nurse for Resident #1 went into Resident #1's room and found her unresponsive and cold. The night nurse then checked Resident #1's finger-stick blood glucose and the reading was LO. The night nurse called the ambulance and when the ambulance arrived, Resident #1 was without a pulse and without a blood pressure. Resident #1 was a Do Not Resuscitate (DNR); the coroner was called. Review of the death certificate for Resident #1 listed death at 5:52 AM on 11/13/15. Resident #2 did not receive insulin on 11/12/15, the day of admission, which resulted in an elevation of blood glucose levels to 313 milligrams per deciliter (mg/dl) on 11/13/15 at 7:15 AM. The facility's failure to follow/implement the residents' care plans resulted in the death of Resident #1 and placed other residents of the facility in a situation that would likely cause serious injury, harm, impairment or death. Based on the facility's corrective action completed as of 11/16/15 prior to the State Agency facility entrance on 11/17/15, the State Agency determined Immediate Jeopardy (IJ) to be Past Non-Compliance for F282. The SA determined the IJ was removed and the facility was in substantial compliance as of 11/16/15. Findings Include: Review of the facility's policy entitled, Care Plans-Comprehensive, undated, revealed the facility would develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet the needs of the resident and maximize the resident's highest level of functioning. Resident #1 Record review of the Comprehensive Care Plan for Resident #1 revealed intervention for Medications as ordered. Review of Resident #1's Medication Administration Record [REDACTED]. Review of the Physician order [REDACTED]. Review of the written orders revealed no order for [MEDICATION NAME]54 units for Resident #1. Review of Resident #1's Cumulative Physician orders [REDACTED].#1; however, this insulin was never ordered for Resident #1. Resident #1 did not have a hand written order (hard copy order) for insulin on review of the medical record. Interview on 11/18/15 at 12:02 PM with LPN #1 confirmed she does not normally check the care plan for each resident prior to administering medications but reviews them at intervals. Interview on 11/18/15 at 2:42 PM with LPN #2 revealed Care Plans are done on admission and updated as needed and quarterly. Resident #2 had been a resident here before so we reviewed and used the old care plan until the full admission one was completed. Record review revealed the facility admitted Resident #1 on 10/1/15 with the [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set with an Assessment Reference Date (ARD) of 7/20/15 indicated Resident #1's Brief Interview for Mental Status (BIMS) score was 14 which indicated Resident #1 was cognitively intact. Resident #2 In a review of the Admission Care Plan for Resident #2 revealed the potential for hyper/[DIAGNOSES REDACTED] related to Diabetes Mellitus and to administer medications as ordered. On 11/18/15 at 2:42 PM, LPN #2 stated Resident #2 had an old care plan from a previous admission that was used since the identified concerns were the same with the addition of the new fracture to her arm. Review of the Admission Electronic physician's orders [REDACTED]. Due to the order entry error for the insulin, the insulin did not appear on the MAR indicated [REDACTED] The Medication Administration Record [REDACTED]. Record review revealed the facility admitted Resident #2 on 11/12/15 with the [DIAGNOSES REDACTED]. The Minimum Data Set was not due on Resident #2. Review of the facility's investigation revealed the facility failed to follow the care plan for Resident #1 and Resident #2 on 11/12/15 by Resident #1 receiving insulin not ordered and Resident #2 not receiving insulin that was ordered. LPN #2 ordered insulin that was intended for Resident #2 into the electronic record for Resident #1 and that resulted in Resident #1 receiving 54 units of insulin. This order entry error and significant medication error resulted in the death of Resident #1, who was not a diabetic and should not have received insulin. The facility implemented the following Corrective Action Plan prior to the State Agency's entrance on 11/17/15. On 11/13/15 at 5:00 AM, rounds per LPN #3 found Resident #1 unresponsive. Coroner pronounced death. The facility began investigation. The Medical Director was notified and came to facility. 1. On 11/13/15 at 6:45 AM- Medical Director was updated on the possible incident and offered suggestions with investigation and asked to be kept informed of findings. Investigation began with ADON requesting written statements for LPN #3, LPN #2 and LPN #1. 2. On 11/13/15 at 8:00 AM- Consultant Pharmacist notified of incident by RN #2. 3. On 11/13/15 at 10:00 AM- Administrator went to Medical Director's clinic to inform him of findings at this point. DON conducted interviews with all staff who may have knowledge. 4. On 11/13/15 at 1:00 PM- Quality Assurance (QA) Committee met with the following members: Administrator, DON, ADON, Administrative Assistant #1, Medical Records, Staff Development and Chaplin. Reviewed the following policies and procedures: checking order, order entry, borrowing medication, medication errors, medication availability and notification of pharmacist and physician. Begin to gather information regarding incident. Talking to staff, written statements, interviews, etc. DON to interview nurse giving insulin and nurse inputting order. Pull personal files for training for nurse given med and nurse inputting orders. Review incident reports, medication reports, etc. Notified the consultant pharmacist to replace all [MEDICATION NAME]on B-1 Cart. Review Resident #1 and Resident #2's chart. Provide staff and family counseling. Speak to coroner and Medical Director. Finalize all documentation needed and file final reports with all necessary agencies. 5. On 11/13/15 at 2:00 PM- Called Manager of Client Services at the Computer Software Company to request review of software to assure safeguards are in place. 6. On 11/13/15 at 2:30 PM- Disciplinary Action (Warning) done on LPN #2 for entering medication on wrong resident. 7. On 11/13/15 at 3:00 PM- LPN #1 placed on suspension until investigation complete by the DON for borrowing a high risk med and giving to Resident #1. 8. On 11/13/15 at approximately 5:00 PM- ADON called pharmacist and notified of need for replacement bottles sent to every resident who gets [MEDICATION NAME] on B-1 cart since LPN #1 could not identify which resident she took it from. Delivered per pharmacist and placed on cart. 9. On 11/14/15 at 10:00 AM- Met with Responsible Party (RP) and his wife for Resident #1 to inform of incident. 10. On 11/14/15 at 9:00 PM- DON completed in-servicing of 100 % of licensed staff on: a. Verification of Orders, b. Entering new orders, and c. Facility policy on not borrowing medications from another resident. 11. On 11/16/15 at 8:00 AM- DON met with Consultant Pharmacist to update. 10:00 AM QA Committee met with the following attending: Administrator, Office Manager, Medical Director, DON, ADON, Dietary Manager, Admission Coordinator, Administrative Assistant, Maintenance Supervisor, Chaplin, Staff Development, Housekeeping Supervisor, Social Services and Medical Record Director. *Reported final report of incident to the Attorney General's Office, State Board of Nursing, State Agency and Area Ombudsman. *Change in Verification of orders procedure. *Consultant pharmacist replaced all [MEDICATION NAME]on B-1 Cart on 11/13/15. *Our system of checking orders prior to and after the incident is effective and we will continue this practice as 100% of resident's orders were checked on 11/14/15 with no errors found. * Policy review/revision: physician's orders [REDACTED].#1 and Resident #2, Medication Ordering and Reordering, The Five Rights and Drug Administration and Documentation. * DON will audit 20% of physician's orders [REDACTED]. * Audit the availability of medications by checking the medication sign in sheet against the orders and routing a copy of the medication sign in sheet against the orders and routing a copy of medication sign in sheet to the DON. DON will report to QA weekly times six (6) weeks then monthly to follow findings of audits to check for compliance. * Disciplinary Action and Termination of LPN #1, LPN for failing to follow facility policies and nurse practice standards after extensive training by facility as documented in personal file AEB: Failure to verify the hard copy order. Borrowing a high risk medication (insulin) and gave to resident. *Disciplinary Action done for LPN #2 for order input error. 12. On 11/16/15 at Approx. 12:30 PM Area Ombudsman informed of incident. 13. On 11/16/15 at 2:00 PM Disciplinary Action (Terminated) LPN #1 by the DON for failure to verify hard copy order and borrowing a high risk medication and gave to Resident #1. 14. On 11/16/15 at 4:00 PM Disciplinary Action for LPN #2 for failure to check orders for Resident #2 on 11/13/15. 15. On 11/16/15 at 4:00 PM completed a chart audit of 100% of the resident's orders and care plans by the DON, ADON, Medical Records LPN, Medical Records RN with no errors found. The facility alleged the Corrective Action plan was completed on 11/16/15. The State Agency (SA) validated the facility's corrective action on 11/17/15 to 11/20/15. 1. The SA validated the facility's investigation of Resident #1 incident on 11/12/15 of receiving insulin caused by incorrect order entry and a high risk medication being borrowed and given that resulted on the death of Resident #1. The SA verified by record review, interviews, written statements of staff and written reports to the SA. 2. The SA validated the Medical Director was notified of the possible occurrence. 3. The SA validated the Consultant Pharmacist was notified of incident. 4. The SA validated the Medical Director was notified by the facility. Validated by an interview with the DON and review of documents: Physicians Orders, MARs, and Death Certificate for Resident #1. The SA validated interviews with staff that may have had knowledge of the event. 5. The SA validated by interview with the Facility Administrator and the Medical Director and review of a sign in sheet dated 11/13/15 that the facility initiated a Quality Assurance (QA) Committee meeting with the following members: Medical Director, Administrator, DON, ADON, Administrative Assistant #1, Medical Records, Staff Development and Chaplin. The QA Committee reviewed the following policies and procedures: checking order, order entry, borrowing medication, medication errors, medication availability and notification of pharmacist and physician. The QA Committee discussed gathering information regarding the incident that involved Resident #1 and Resident #2. The QA Committee reviewed written statements, interviews, by the DON, reviewed personal files for training for nurse given med and nurse in-putting orders, reviewed incident reports, medication reports, etc. The facility notified the consultant pharmacist to replace [MEDICATION NAME] insulin, by the facility, on B-1 Cart for all the residents that received [MEDICATION NAME] insulin. Review Resident #1 and Resident #2's chart. Provide staff and family counseling. Speak to coroner and Medical Director. Finalize all documentation needed and file final reports with all necessary agencies. 6. The SA validated the Manager of Client Services at the Computer Software Company was contacted by interview with the facility Administrator to assure safeguards are in place. The SA validated by phone interview with the Computer Software Company. 7. The SA validated by interview from the DON and written statement of Disciplinary Action done on LPN #2 for entering medication on wrong resident. 8. The SA validated a written statement and interview of the DON that LPN #1 was placed on suspension until investigation complete by the DON for borrowing a med and giving to Resident #1. 9. The SA validated by interview with the ADON and the Pharmacist that the ADON called the pharmacist and notified of need for replacement bottles sent to every resident who gets [MEDICATION NAME]on B-1 cart since LPN #1 could not identify which resident she took it from. The insulin was paid for by the facility. Delivered per pharmacist and placed on cart per interview of the pharmacist. 10. The SA validated per written statement the RP for Resident #1 was notified and informed of the incident. Interview with the DON confirmed the completed in-servicing of 100 % of licensed staff on: a. Verification of Orders, b. Entering new orders, and c. Facility policy on not borrowing medications from another resident. 11. The SA validated by interview with the DON on 11/16/15 8:00 AM that the DON met with Consultant Pharmacist to update him of the progress of the investigation. The SA validated by interview with the Facility Administrator and a sign in sheet at 10:00 AM the QA Committee met with the following attending: Administrator, Office Manager, Medical Director, DON, ADON, Dietary Manager, Admission Coordinator, Administrative Assistant, Maintenance Supervisor, Chaplin, Staff Development, Housekeeping Supervisor, Social Services and Medical Record Director. Written evidence the QA committee discussed reporting final report of incident to the Attorney General's Office, State Board of Nursing, State Agency and Area Ombudsman; changed the verification of orders procedure; consultant pharmacist replaced all [MEDICATION NAME]on B-1 Cart on 11/13/15; discussed the system of checking orders prior to and after the incident effectiveness; 100% of resident's orders were checked on 11/14/15 with no errors found; the Policy review/revision: physician's orders [REDACTED].#1 and Resident #2, Medication Ordering and Reordering, The Five Rights and Drug Administration and Documentation; the DON audit of 20% of physician's orders [REDACTED]. The DON will report to QA weekly times six (6) weeks then monthly to follow findings of audits to check for compliance. The SA verified Disciplinary Action and Termination of LPN #1 for failing to follow facility policies and nurse practice standards by failure to verify the hard copy order and borrowing a high risk medication (insulin) to administer to a resident. SA verified disciplinary action done for LPN #2 for order input error. 12. The SA validated Area Ombudsman was notified by documentation from the Facility Administration and interview of the Facility Administrator of the incident involving Resident #1 and Resident #2. The SA attempted to reach the Area Ombudsman and was unable to reach. 13. The SA validated by interview of the DON of the Disciplinary Action (Terminated) for LPN #1 by the DON for failure to verify hard copy order and borrowing a high risk medication and gave to Resident #1. 14. The SA validated by documentation review and interview of the DON of the Disciplinary Action for LPN #2 for failure to check orders for Resident #2 on 11/13/15. 15. The SA validated by documentation review and interview of the DON of the Completed chart audit of 100% of the resident's orders and care plans by the DON, ADON, Medical Records LPN, Medical Records RN with no errors found.

Based on staff interviews, resident record reviews, and facility investigation review, the facility failed to provide nursing care to ensure a resident maintained their highest wellbeing for two (2) of five (5) residents reviewed. (Resident #1 and Resident #2) This Immediate Jeopardy was determined to exist when The SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on [DATE] when Licensed Practical Nurse (LPN) #2 entered Resident #2's order for insulin into Resident #1's electronic Medication Administration Record [REDACTED]. The night nurse then checked Resident #1's finger-stick blood glucose and the reading was LO. The night nurse called the ambulance and when the ambulance arrived, Resident #1 was without a pulse and without a blood pressure. Resident #1 was a Do Not Resuscitate (DNR); the coroner was called. Review of the death certificate for Resident #1 listed death at 5:52 AM on [DATE]. Resident #2 did not receive insulin on [DATE], the day of admission, which resulted in an elevation of blood glucose levels to 313 milligrams per deciliter (mg/dl) on [DATE] at 7:15 AM. The facility staff's administration of insulin to a non-diabetic resident lead to the decline and death of Resident #1 and caused a situation that would likely result in serious injury, harm, impairment or death to other residents in the facility. Based on the facility's corrective action completed as of [DATE] prior to the State Agency facility entrance on [DATE], the State Agency determined Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) to be Past Non-Compliance for F309. The SA determined the IJ and SQC were removed and the facility was in substantial compliance as of [DATE]. Findings Include: Review of the facility's investigation dated [DATE] revealed on [DATE] while entering orders for a newly readmitted resident (Resident #2), Licensed Practical Nurse (LPN) #2 mistakenly entered an order into the electronic record for insulin for Resident #1. The investigation revealed that while administering 9:00 PM medications, LPN #1 pulled insulin from another resident's insulin bottle on the B Station Medication Cart and administered 54 units of [MEDICATION NAME]to Resident #1. Review of the [DATE] Medication Administration Record [REDACTED]. Review of the [DATE] electronic Cumulative physician's orders [REDACTED].#2 entered the insulin order into the computer. Record review of handwritten physician's orders [REDACTED]. In an interview on [DATE] at 2:42 PM, LPN #2 stated she entered the admission orders [REDACTED]. LPN #2 revealed she had to confirm the insulin dose for Resident #2 before entering it into the computer, and RN #1 was leaving for the day. LPN #2 stated after verifying the dose she entered the insulin and accuchecks order into the computer for who she thought was Resident #2 but the order was accidentally entered in the computer for Resident #1 instead. LPN #2 confirmed the insulin order was not verified by any other staff since Resident #2 was then sent to the hospital before the orders were completely entered into the computer. LPN #2 stated had she printed the orders out, it would have shown the missing insulin and accuchecks. LPN #2 also stated this would have triggered her because she would have known the orders had been entered into the computer and she would have immediately started researching the error. On [DATE] at 12:02 PM an interview with LPN #1 revealed she worked from 7:00 PM to 11:00 PM on [DATE] when Resident #1 received the insulin. LPN #1 stated during the medication pass, she saw a new order for insulin and accuchecks for Resident #1. LPN #1 stated she knew Resident #1 had not previously been on insulin, so she compared the MAR indicated [REDACTED]. LPN #1 confirmed she did not look for the initial written order. LPN #1 stated she checked Resident #1's finger-stick Blood Glucose with a result of either 113 or 123 (milligrams per deciliter), she was not sure which. LPN #1 stated when she was unable to located a bottle of [MEDICATION NAME]labeled for Resident #1, she borrowed the insulin from another resident on the B Station Medication Cart. She then administered 54 units of [MEDICATION NAME] Insulin to Resident #1. LPN #1 stated that because the Pharmacy did not deliver medications until 12:00 AM to 1:00 AM for Resident #1, she made the decision, in order to avoid a missed dose, to borrow and administer insulin Resident #1. LPN #1 stated at the time, she had no reason to think anything was wrong with the order. LPN #1 stated she knew Resident #1 had not been on insulin prior to [DATE] but remembered Resident #1 had a history of [REDACTED].#1 must have been recently diagnosed with [REDACTED]. Review of Resident #1's departmental notes, physician's orders [REDACTED].#1. In an interview on [DATE] at 10:26 AM, the Facility Administrator confirmed during the investigation of the incident involving Resident #1 that the facility discovered LPN #1 administered insulin to Resident #1. The Administrator stated on [DATE] around 5:00 AM, Resident #1's nurse during the night shift went into Resident #1's room and found the resident unresponsive and cold to touch. The Administrator stated the night nurse (LPN #3) then checked Resident #1's finger-stick blood glucose and the reading was LO. The Administrator stated the night nurse then administered glucogon per standing orders and called the ambulance and physician. When the ambulance arrived, Resident #1 was without a pulse, without a blood pressure, and her blood sugar read 39 milligrams per deciliter (mg/dl). The Administrator stated since Resident #1 had a Do Not Resuscitate (DNR) order, the coroner was called because she had expired. Review of the death certificate for Resident #1 listed the date and time of death as [DATE] at 5:52 AM at the facility. Record review revealed the facility admitted Resident #1 on [DATE] with the [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set with an Assessment Reference Date (ARD) of [DATE] indicated Resident #1's Brief Interview for Mental Status (BIMS) score was 14 which indicated Resident #1 was cognitively intact. Resident #2 Review of Resident #2's Admission Electronic physician's orders [REDACTED]. Review of Physician orders [REDACTED].#1's insulin order on Resident #2's computer generated orders and MAR. Record review of Resident #2's [DATE] Medication Administration Record [REDACTED]. Record review of the [DATE] MAR indicated [REDACTED]. Record review revealed the facility readmitted Resident #2 on [DATE] with the [DIAGNOSES REDACTED]. Resident #2's Minimum Data Set was not due. The facility implemented the following Corrective Action Plan prior to the State Agency's entrance on [DATE]. On [DATE] at 5:00 AM, rounds per LPN #3 found Resident #1 unresponsive. Coroner pronounced death. The facility began investigation. The Medical Director was notified and came to facility. 1. On [DATE] at 6:45 AM- Medical Director was updated on the possible incident and offered suggestions with investigation and asked to be kept informed of findings. Investigation began with ADON requesting written statements for LPN #3, LPN #2 and LPN #1. 2. On [DATE] at 8:00 AM- Consultant Pharmacist notified of incident by RN #2. 3. On [DATE] at 10:00 AM- Administrator went to Medical Director's clinic to inform him of findings at this point. DON conducted interviews with all staff who may have knowledge. 4. On [DATE] at 1:00 PM- Quality Assurance (QA) Committee met with the following members: Administrator, DON, ADON, Administrative Assistant #1, Medical Records, Staff Development and Chaplin. Reviewed the following policies and procedures: checking order, order entry, borrowing medication, medication errors, medication availability and notification of pharmacist and physician. Begin to gather information regarding incident. Talking to staff, written statements, interviews, etc. DON to interview nurse giving insulin and nurse inputting order. Pull personal files for training for nurse given med and nurse inputting orders. Review incident reports, medication reports, etc. Notified the consultant pharmacist to replace all [MEDICATION NAME]on B-1 Cart. Review Resident #1 and Resident #2's chart. Provide staff and family counseling. Speak to coroner and Medical Director. Finalize all documentation needed and file final reports with all necessary agencies. 5. On [DATE] at 2:00 PM- Called Manager of Client Services at the Computer Software Company to request review of software to assure safeguards are in place. 6. On [DATE] at 2:30 PM- Disciplinary Action (Warning) done on LPN #2 for entering medication on wrong resident. 7. On [DATE] at 3:00 PM- LPN #1 placed on suspension until investigation complete by the DON for borrowing a high risk med and giving to Resident #1. 8. On [DATE] at approximately 5:00 PM- ADON called pharmacist and notified of need for replacement bottles sent to every resident who gets [MEDICATION NAME] on B-1 cart since LPN #1 could not identify which resident she took it from. Delivered per pharmacist and placed on cart. 9. On [DATE] at 10:00 AM- Met with Responsible Party (RP) and his wife for Resident #1 to inform of incident. 10. On [DATE] at 9:00 PM- DON completed in-servicing of 100 % of licensed staff on: a. Verification of Orders, b. Entering new orders, and c. Facility policy on not borrowing medications from another resident. 11. On [DATE] at 8:00 AM- DON met with Consultant Pharmacist to update. 10:00 AM QA Committee met with the following attending: Administrator, Office Manager, Medical Director, DON, ADON, Dietary Manager, Admission Coordinator, Administrative Assistant, Maintenance Supervisor, Chaplin, Staff Development, Housekeeping Supervisor, Social Services and Medical Record Director. *Reported final report of incident to the Attorney General's Office, State Board of Nursing, State Agency and Area Ombudsman. *Change in Verification of orders procedure. *Consultant pharmacist replaced all [MEDICATION NAME]on B-1 Cart on [DATE]. *Our system of checking orders prior to and after the incident is effective and we will continue this practice as 100% of resident's orders were checked on [DATE] with no errors found. * Policy review/revision: physician's orders [REDACTED].#1 and Resident #2, Medication Ordering and Reordering, The Five Rights and Drug Administration and Documentation. * DON will audit 20% of physician's orders [REDACTED]. * Audit the availability of medications by checking the medication sign in sheet against the orders and routing a copy of the medication sign in sheet against the orders and routing a copy of medication sign in sheet to the DON. DON will report to QA weekly times six (6) weeks then monthly to follow findings of audits to check for compliance. * Disciplinary Action and Termination of LPN #1, LPN for failing to follow facility policies and nurse practice standards after extensive training by facility as documented in personal file AEB: Failure to verify the hard copy order. Borrowing a high risk medication (insulin) and gave to resident. *Disciplinary Action done for LPN #2 for order input error. 12. On [DATE] at Approx. 12:30 PM Area Ombudsman informed of incident. 13. On [DATE] at 2:00 PM Disciplinary Action (Terminated) LPN #1 by the DON for failure to verify hard copy order and borrowing a high risk medication and gave to Resident #1. 14. On [DATE] at 4:00 PM Disciplinary Action for LPN #2 for failure to check orders for Resident #2 on [DATE]. 15. On [DATE] at 4:00 PM completed a chart audit of 100% of the resident's orders and care plans by the DON, ADON, Medical Records LPN, Medical Records RN with no errors found. The facility alleged the Corrective Action plan was completed on [DATE]. The State Agency (SA) validated the facility's corrective action from [DATE] to [DATE]. 1. The SA validated the facility's investigation of Resident #1 incident on [DATE] of receiving insulin caused by incorrect order entry and a high risk medication being borrowed and given that resulted on the death of Resident #1. The SA verified by record review, interviews, written statements of staff and written reports to the SA. 2. The SA validated the Medical Director was notified of the possible occurrence. 3. The SA validated the Consultant Pharmacist was notified of incident. 4. The SA validated the Medical Director was notified by the facility. Validated by an interview with the DON and review of documents: Physicians Orders, MARs, and Death Certificate for Resident #1. The SA validated interviews with staff that may have had knowledge of the event. 5. The SA validated by interview with the Facility Administrator and the Medical Director and review of a sign in sheet dated [DATE] that the facility initiated a Quality Assurance (QA) Committee meeting with the following members: Medical Director, Administrator, DON, ADON, Administrative Assistant #1, Medical Records, Staff Development and Chaplin. The QA Committee reviewed the following policies and procedures: checking order, order entry, borrowing medication, medication errors, medication availability and notification of pharmacist and physician. The QA Committee discussed gathering information regarding the incident that involved Resident #1 and Resident #2. The QA Committee reviewed written statements, interviews, by the DON, reviewed personal files for training for nurse given med and nurse in-putting orders, reviewed incident reports, medication reports, etc. The facility notified the consultant pharmacist to replace [MEDICATION NAME] insulin, by the facility, on B-1 Cart for all the residents that received [MEDICATION NAME] insulin. Review Resident #1 and Resident #2's chart. Provide staff and family counseling. Speak to coroner and Medical Director. Finalize all documentation needed and file final reports with all necessary agencies. 6. The SA validated the Manager of Client Services at the Computer Software Company was contacted by interview with the facility Administrator to assure safeguards are in place. The SA validated by phone interview with the Computer Software Company. 7. The SA validated by interview from the DON and written statement of Disciplinary Action done on LPN #2 for entering medication on wrong resident. 8. The SA validated a written statement and interview of the DON that LPN #1 was placed on suspension until investigation complete by the DON for borrowing a med and giving to Resident #1. 9. The SA validated by interview with the ADON and the Pharmacist that the ADON called the pharmacist and notified of need for replacement bottles sent to every resident who gets [MEDICATION NAME]on B-1 cart since LPN #1 could not identify which resident she took it from. The insulin was paid for by the facility. Delivered per pharmacist and placed on cart per interview of the pharmacist. 10. The SA validated per written statement the RP for Resident #1 was notified and informed of the incident. Interview with the DON confirmed the completed in-servicing of 100 % of licensed staff on: a. Verification of Orders, b. Entering new orders, and c. Facility policy on not borrowing medications from another resident. 11. The SA validated by interview with the DON on [DATE] 8:00 AM that the DON met with Consultant Pharmacist to update him of the progress of the investigation. The SA validated by interview with the Facility Administrator and a sign in sheet at 10:00 AM the QA Committee met with the following attending: Administrator, Office Manager, Medical Director, DON, ADON, Dietary Manager, Admission Coordinator, Administrative Assistant, Maintenance Supervisor, Chaplin, Staff Development, Housekeeping Supervisor, Social Services and Medical Record Director. Written evidence the QA committee discussed reporting final report of incident to the Attorney General's Office, State Board of Nursing, State Agency and Area Ombudsman; changed the verification of orders procedure; consultant pharmacist replaced all [MEDICATION NAME]on B-1 Cart on [DATE]; discussed the system of checking orders prior to and after the incident effectiveness; 100% of resident's orders were checked on [DATE] with no errors found; the Policy review/revision: physician's orders [REDACTED].#1 and Resident #2, Medication Ordering and Reordering, The Five Rights and Drug Administration and Documentation; the DON audit of 20% of physician's orders [REDACTED]. The DON will report to QA weekly times six (6) weeks then monthly to follow findings of audits to check for compliance. The SA verified Disciplinary Action and Termination of LPN #1 for failing to follow facility policies and nurse practice standards by failure to verify the hard copy order and borrowing a high risk medication (insulin) to administer to a resident. SA verified disciplinary action done for LPN #2 for order input error. 12. The SA validated Area Ombudsman was notified by documentation from the Facility Administration and interview of the Facility Administrator of the incident involving Resident #1 and Resident #2. The SA attempted to reach the Area Ombudsman and was unable to reach. 13. The SA validated by interview of the DON of the Disciplinary Action (Terminated) for LPN #1 by the DON for failure to verify hard copy order and borrowing a high risk medication and gave to Resident #1. 14. The SA validated by documentation review and interview of the DON of the Disciplinary Action for LPN #2 for failure to check orders for Resident #2 on [DATE]. 15. The SA validated by documentation review and interview of the DON of the Completed chart audit of 100% of the resident's orders and care plans by the DON, ADON, Medical Records LPN, Medical Records RN with no errors found.

Based on interviews, record reviews, facility investigation review and facility policy review, the facility failed to remain free of significant medication errors for two (2) of five (5) records reviewed as evidenced by Resident #1 received insulin without a written order which resulted in death and Resident #2 did not receive insulin as ordered that resulted in an elevation in blood glucose levels. (Resident #1 and Resident #2) The SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on [DATE] when Licensed Practical Nurse (LPN) #2 entered Resident #2's order for insulin into Resident #1's electronic Medication Administration Record (MAR) and the Electronic Physician Orders. During the following medication pass, LPN #1 noted the insulin on Resident #1's MAR then borrowed insulin from another resident. LPN #1 administered Resident #1 the insulin that was inaccurately entered into the orders and MAR. On [DATE] at approximately 5:00 AM, the night nurse for Resident #1 went into Resident #1's room and found her unresponsive and cold. The night nurse then checked Resident #1's finger-stick blood glucose and the reading was LO. The night nurse called the ambulance and when the ambulance arrived, Resident #1 was without a pulse and without a blood pressure. Resident #1 was a Do Not Resuscitate (DNR); the coroner was called. Review of the death certificate for Resident #1 listed death at 5:52 AM on [DATE]. Resident #2 did not receive insulin on [DATE], the day of admission, which resulted in an elevation of blood glucose levels to 313 milligrams per deciliter (mg/dl) on [DATE] at 7:15 AM. The facility's failure to ensure residents were free of significant medication errors resulted in the death of Resident #1, an elevated blood glucose level for Resident #2, and placed all residents in the facility in a situation that was likely to cause serious injury, harm, impairment or death. Based on the facility's corrective action completed as of [DATE] prior to the State Agency facility entrance on [DATE], the State Agency determined Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) to be Past Non-Compliance for F333. The SA determined the IJ and SQC were removed and the facility was in substantial compliance as of [DATE]. Findings Include: Review of the facility's policy entitled, Drug Administration and Documentation, dated revised [DATE], revealed to obtain an order for [REDACTED]. Right Resident, 2. Right Time, 3. Right Medication, 4. Right Dose, 5. Right Route of Administration. Medications prescribed for one resident will not be administered to another resident. The Nursing 2013 Drug Handbook revealed [MEDICATION NAME]when given SQ has a unknown onset, half-life of 5 to 7 hours, a peak of ,[DATE] hours and a duration of ,[DATE] hours. This drug has a safety alert meaning this drug has life-threatening effects associated with its use. This drug handbook lists the overdose signs and symptoms as [DIAGNOSES REDACTED] (low blood sugar). Review of the facility's investigation revealed, on [DATE] Resident #1 received 54 units of insulin by Licensed Practical Nurse (LPN) #1 that was ordered incorrectly into the computer by LPN #2. LPN #2 borrowed the insulin from another resident from B Station Cart. Resident #2's order for insulin 54 units was not entered into the electronic record by LPN #2, resulting in a missed dose. Resident #1 In an interview on [DATE] at 12:02 PM with LPN #1 revealed she worked as the medication nurse for Resident #1 from 7:00 PM to 11:00 PM on [DATE]. After verifying the MAR against the computer generated orders, LPN #1 stated there was no [MEDICATION NAME]on the B Side Station medication cart or the medication room for Resident #1. LPN #1 stated just to check she reviewed the Electronic Physicians Orders and verified the order for the insulin. LPN #1 then stated she borrowed the insulin from another resident from the B Station Medication Cart. LPN #1 stated Resident #1's Pharmacy did not deliver until 12:00 AM to 1:00 AM and she did not want Resident #1 to miss the dose of insulin or give it that late. LPN #1 stated, I had no reason to thinks anything was wrong with the order. Interview on [DATE] at 2:42 PM with LPN #2 revealed admission orders [REDACTED]. LPN #2 revealed the insulin dose had to be confirmed before entering it into the computer and RN #1 was leaving for the day. LPN #2 confirmed after verifying the dose she entered the insulin and accuchecks order into the computer. LPN #2 confirmed the insulin order was not verified by any other staff and it was accidentally entered in the computer for Resident #1 instead of Resident #2. LPN #2 stated Resident #2 was sent to the hospital before the orders were completely entered into the computer because she had bleeding from her arm and if she had printed the orders out it would have shown the missing insulin and accuchecks. LPN #2 also stated this would have triggered her because she would have known the orders had been entered into the computer and she would have immediately started looking for them. Interview on [DATE] at 10:26 AM with the Facility Administrator and the Director of Nursing (DON) present revealed during the facility's investigation revealed LPN #1 gave insulin to Resident #1 that was written for Resident #2 but incorrectly entered into the computer for Resident #1. The Administrator stated the facility was aware the computer system was sensitive with order entry. The Administrator stated the keyboard or mouse could be moved or bumped causing the computer to drop to the next name on the computer. The Administrator stated when an order is entered into the computer, every order has to be saved and the resident name turns blue and can be changed to another resident. The Administrator stated the nurse has to click back on the resident name before another order can be entered. The Administrator stated she was not sure how but when the resident's name turned blue it dropped to the next resident, Resident #1 and LPN #2 entered the insulin on Resident #1, not Resident #2. LPN #1 verified the order by the electronic order which was the same as the MAR. The Administrator stated on [DATE] around 5:00 AM the night nurse for Resident #1 went into Resident #1's room and found her unresponsive and cold. The Administrator stated the night nurse then checked Resident #1's finger-stick blood glucose and the reading was LO. The Administrator stated the night nurse called the ambulance and when the ambulance arrived, Resident #1 was without a pulse and without a blood pressure. The Administrator stated since Resident #1 was a Do Not Resuscitate (DNR) the coroner was called because she had expired. In a review of the MAR for [DATE] for Resident #1 revealed she received 54 units of insulin Subcutaneous (SQ) at 9:00 PM and was electronically signed by LPN #1. Review of Resident #1's [DATE] electronic Cumulative physician's orders [REDACTED].#2. Record review of handwritten physician's orders [REDACTED]. Interview with Resident #1's Responsible Party (RP) was attempted during the survey. Interview post exit with Resident #'1 RP on [DATE] at 10:00 AM revealed the RP stated the facility Administrator met with him and his wife and notified them of the events and medication error that occurred when insulin was borrowed and given to his mother. Resident #1's RP stated he had always been pleased with his mother's care at the facility. Record review revealed the facility admitted Resident #1 on [DATE] with the [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set with an Assessment Reference Date (ARD) of [DATE] indicated Resident #1's Brief Interview for Mental Status (BIMS) score was 14 which indicated Resident #1 was cognitively intact. Resident #2 In an interview on [DATE] at 2:42 PM with LPN #2 revealed when Resident #2 was admitted she failed to enter the order for 54 units of insulin into the computer. LPN #2 stated she had to leave the computer while entering the admission orders [REDACTED]#2. In a review of Resident #2's Electronic physician's orders [REDACTED]. Record review of the [DATE] Medication Administration Record (MAR) revealed Resident #2 did not receive the ordered 54 units of Insulin Subcutaneous (SQ) at 9:00 PM on [DATE]. On [DATE] at 7:15 AM Resident #2's blood glucose levels were elevated to 313 mg/dl. Record review revealed the facility admitted Resident #2 on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set was not due on Resident #2. The facility implemented the following Corrective Action Plan prior to the State Agency's entrance on [DATE]. On [DATE] at 5:00 AM, rounds per LPN #3 found Resident #1 unresponsive. Coroner pronounced death. The facility began investigation. The Medical Director was notified and came to facility. 1. On [DATE] at 6:45 AM- Medical Director was updated on the possible incident and offered suggestions with investigation and asked to be kept informed of findings. Investigation began with ADON requesting written statements for LPN #3, LPN #2 and LPN #1. 2. On [DATE] at 8:00 AM- Consultant Pharmacist notified of incident by RN #2. 3. On [DATE] at 10:00 AM- Administrator went to Medical Director's clinic to inform him of findings at this point. DON conducted interviews with all staff who may have knowledge. 4. On [DATE] at 1:00 PM- Quality Assurance (QA) Committee met with the following members: Administrator, DON, ADON, Administrative Assistant #1, Medical Records, Staff Development and Chaplin. Reviewed the following policies and procedures: checking order, order entry, borrowing medication, medication errors, medication availability and notification of pharmacist and physician. Begin to gather information regarding incident. Talking to staff, written statements, interviews, etc. DON to interview nurse giving insulin and nurse inputting order. Pull personal files for training for nurse given med and nurse inputting orders. Review incident reports, medication reports, etc. Notified the consultant pharmacist to replace all [MEDICATION NAME]on B-1 Cart. Review Resident #1 and Resident #2's chart. Provide staff and family counseling. Speak to coroner and Medical Director. Finalize all documentation needed and file final reports with all necessary agencies. 5. On [DATE] at 2:00 PM- Called Manager of Client Services at the Computer Software Company to request review of software to assure safeguards are in place. 6. On [DATE] at 2:30 PM- Disciplinary Action (Warning) done on LPN #2 for entering medication on wrong resident. 7. On [DATE] at 3:00 PM- LPN #1 placed on suspension until investigation complete by the DON for borrowing a high risk med and giving to Resident #1. 8. On [DATE] at approximately 5:00 PM- ADON called pharmacist and notified of need for replacement bottles sent to every resident who gets [MEDICATION NAME] on B-1 cart since LPN #1 could not identify which resident she took it from. Delivered per pharmacist and placed on cart. 9. On [DATE] at 10:00 AM- Met with Responsible Party and his wife for Resident #1 to inform of incident. 10. On [DATE] at 9:00 PM- DON completed in-servicing of 100 % of licensed staff on: a. Verification of Orders, B. Entering new orders, and c. Facility policy on not borrowing medications from another resident. 11. On [DATE] at 8:00 AM- DON met with Consultant Pharmacist to update. 10:00 AM QA Committee met with the following attending: Administrator, Office Manager, Medical Director, DON, ADON, Dietary Manager, Admission Coordinator, Administrative Assistant, Maintenance Supervisor, Chaplin, Staff Development, Housekeeping Supervisor, Social Services and Medical Record Director. *Reported final report of incident to the Attorney General's Office, State Board of Nursing, State Agency and Area Ombudsman. *Change in Verification of orders procedure. *Consultant pharmacist replaced all [MEDICATION NAME]on B-1 Cart on [DATE]. *Our system of checking orders prior to and after the incident is effective and we will continue this practice as 100% of resident's orders were checked on [DATE] with no errors found. * Policy review/revision: physician's orders [REDACTED].#1 and Resident #2, Medication Ordering and Reordering, The Five Rights and Drug Administration and Documentation. * DON will audit 20% of physician's orders [REDACTED]. * Audit the availability of medications by checking the medication sign in sheet against the orders and routing a copy of the medication sign in sheet against the orders and routing a copy of medication sign in sheet to the DON. DON will report to QA weekly times six (6) weeks then monthly to follow findings of audits to check for compliance. * Disciplinary Action and Termination of LPN #1, LPN for failing to follow facility policies and nurse practice standards after extensive training by facility as documented in personal file AEB: Failure to verify the hard copy order. Borrowing a high risk medication (insulin) and gave to resident. *Disciplinary Action done for LPN #2 for order input error. 12. On [DATE] at Approx. 12:30 PM Area Ombudsman informed of incident. 13. On [DATE] at 2:00 PM Disciplinary Action (Terminated) LPN #1 by the DON for failure to verify hard copy order and borrowing a high risk medication and gave to Resident #1. 14. On [DATE] at 4:00 PM Disciplinary Action for LPN #2 for failure to check orders for Resident #2 on [DATE]. 15. On [DATE] at 4:00 PM completed a chart audit of 100% of the resident's orders and care plans by the DON, ADON, Medical Records LPN, Medical Records RN with no errors found. The facility alleged Corrective Action plan was completed on [DATE]. The State Agency (SA) validated the facility's corrective action on [DATE] to [DATE]. 1. The SA validated the facility's investigation of Resident #1 incident on [DATE] of receiving insulin caused by incorrect order entry and a high risk medication being borrowed and given that resulted on the death of Resident #1. The SA verified by record review, interviews, written statements of staff and written reports to the SA. 2. The SA validated the Medical Director was notified of the possible occurrence. 3. The SA validated the Consultant Pharmacist was notified of incident. 4. The SA validated the Medical Director was notified by the facility. Validated by an interview with the DON and review of documents: Physicians Orders, MARs, and Death Certificate for Resident #1. The SA validated interviews with staff that may have had knowledge of the event. 5. The SA validated by interview with the Facility Administrator and the Medical Director and review of a sign in sheet dated [DATE] that the facility initiated a Quality Assurance (QA) Committee meeting with the following members: Medical Director, Administrator, DON, ADON, Administrative Assistant #1, Medical Records, Staff Development and Chaplin. The QA Committee reviewed the following policies and procedures: checking order, order entry, borrowing medication, medication errors, medication availability and notification of pharmacist and physician. The QA Committee discussed gathering information regarding the incident that involved Resident #1 and Resident #2. The QA Committee reviewed written statements, interviews, by the DON, reviewed personal files for training for nurse given med and nurse in-putting orders, reviewed incident reports, medication reports, etc. The facility notified the consultant pharmacist to replace [MEDICATION NAME] insulin, by the facility, on B-1 Cart for all the residents that received [MEDICATION NAME] insulin. Review Resident #1 and Resident #2's chart. Provide staff and family counseling. Speak to coroner and Medical Director. Finalize all documentation needed and file final reports with all necessary agencies. 6. The SA validated the Manager of Client Services at the Computer Software Company was contacted by interview with the facility Administrator to assure safeguards are in place. The SA validated by phone interview with the Computer Software Company. 7. The SA validated by interview from the DON and written statement of Disciplinary Action done on LPN #2 for entering medication on wrong resident. 8. The SA validated a written statement and interview of the DON that LPN #1 was placed on suspension until investigation complete by the DON for borrowing a med and giving to Resident #1. 9. The SA validated by interview with the ADON and the Pharmacist that the ADON called the pharmacist and notified of need for replacement bottles sent to every resident who gets [MEDICATION NAME]on B-1 cart since LPN #1 could not identify which resident she took it from. The insulin was paid for by the facility. Delivered per pharmacist and placed on cart per interview of the pharmacist. 10. The SA validated per written statement the RP for Resident #1 was notified and informed of the incident. Interview with the DON confirmed the completed in-servicing of 100 % of licensed staff on: a. Verification of Orders, b. Entering new orders, and c. Facility policy on not borrowing medications from another resident. 11. The SA validated by interview with the DON on [DATE] 8:00 AM that the DON met with Consultant Pharmacist to update him of the progress of the investigation. The SA validated by interview with the Facility Administrator and a sign in sheet at 10:00 AM the QA Committee met with the following attending: Administrator, Office Manager, Medical Director, DON, ADON, Dietary Manager, Admission Coordinator, Administrative Assistant, Maintenance Supervisor, Chaplin, Staff Development, Housekeeping Supervisor, Social Services and Medical Record Director. Written evidence the QA committee discussed reporting final report of incident to the Attorney General's Office, State Board of Nursing, State Agency and Area Ombudsman; changed the verification of orders procedure; consultant pharmacist replaced all [MEDICATION NAME]on B-1 Cart on [DATE]; discussed the system of checking orders prior to and after the incident effectiveness; 100% of resident's orders were checked on [DATE] with no errors found; the Policy review/revision: physician's orders [REDACTED].#1 and Resident #2, Medication Ordering and Reordering, The Five Rights and Drug Administration and Documentation; the DON audit of 20% of physician's orders [REDACTED]. The DON will report to QA weekly times six (6) weeks then monthly to follow findings of audits to check for compliance. The SA verified Disciplinary Action and Termination of LPN #1 for failing to follow facility policies and nurse practice standards by failure to verify the hard copy order and borrowing a high risk medication (insulin) to administer to a resident. SA verified disciplinary action done for LPN #2 for order input error. 12. The SA validated Area Ombudsman was notified by documentation from the Facility Administration and interview of the Facility Administrator of the incident involving Resident #1 and Resident #2. The SA attempted to reach the Area Ombudsman and was unable to reach. 13. The SA validated by interview of the DON of the Disciplinary Action (Terminated) for LPN #1 by the DON for failure to verify hard copy order and borrowing a high risk medication and gave to Resident #1. 14. The SA validated by documentation review and interview of the DON of the Disciplinary Action for LPN #2 for failure to check orders for Resident #2 on [DATE]. 15. The SA validated by documentation review and interview of the DON of the Completed chart audit of 100% of the resident's orders and care plans by the DON, ADON, Medical Records LPN, Medical Records RN with no errors found.

Based on interviews, record reviews, facility investigation review, and facility policy review, the facility failed to maintain accurate electronic medical records as evidenced by insulin and accuchecks being entered into the computer on the wrong resident, Resident #1, resulting in the death of Resident #1, and failed to be entered into the computer on the correct resident, Resident #2 for two (2) of five (5) records reviewed. (Resident #1 and Resident #2) The SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 11/12/15 when Licensed Practical Nurse (LPN) #2 entered Resident #2's order for insulin into Resident #1's electronic Medication Administration Record [REDACTED]. On 11/13/15 at approximately 5:00 AM, the night nurse for Resident #1 went into Resident #1's room and found her unresponsive and cold. The night nurse then checked Resident #1's finger-stick blood glucose and the reading was LO. The night nurse called the ambulance and when the ambulance arrived, Resident #1 was without a pulse and without a blood pressure. Resident #1 was a Do Not Resuscitate (DNR); the coroner was called. Review of the death certificate for Resident #1 listed death at 5:52 AM on 11/13/15. Resident #2 did not receive insulin on 11/12/15, the day of admission, which resulted in an elevation of blood glucose levels to 313 milligrams per deciliter (mg/dl) on 11/13/15 at 7:15 AM. The facility's failure to ensure accurate medical records and physician orders [REDACTED].#1, an elevated blood glucose level for Resident #2, and placed all residents in the facility in a situation that was likely to cause serious injury, harm, impairment or death. Based on the facility's corrective action completed as of 11/16/15 prior to the State Agency facility entrance on 11/17/15, the State Agency determined Immediate Jeopardy (IJ) to be Past Non-Compliance for F514. The SA determined the IJ was removed and the facility was in substantial compliance as of 11/16/15. Findings Include: Review of the facility's policy entitled, Orders Entry Procedure, dated April 15, 2013, revealed to select the resident for whom you wish to enter physician orders [REDACTED]. All orders have to be entered after information is put into the computer on the resident chosen. Resident #1 Review of the facility's investigation revealed on 11/12/15, LPN #1 administered insulin to Resident #1 that was ordered incorrectly into the computer by LPN #2 and resulted in death. LPN #2 failed to enter into the computer the ordered insulin for Resident #2 which resulted in a missed dose of insulin for Resident #2. Interview on 11/18/15 at 12:02 PM with LPN #1 revealed on 11/12/15 worked from 7:00 PM to 11:00 PM stated she reviewed the Electronic Physicians Orders and compared it to the Medication Administration Record [REDACTED]. LPN #1 stated, I had no reason to thinks anything was wrong with the order. In an interview on 11/18/15 at 2:42 PM with LPN #2, she stated the admission orders [REDACTED]. LPN #2 revealed the insulin dose had to be confirmed before entering it into the computer, and RN #1 was leaving for the day. LPN #2 confirmed after verifying the dose she entered the insulin and accuchecks order into the computer. LPN #2 confirmed the insulin order was not verified by any other staff and it was accidentally entered in the computer for Resident #1 instead of Resident #2. LPN #2 stated Resident #2 was sent to the hospital before the orders were completely entered into the computer and if she had printed the orders out it would have shown the missing insulin and accuchecks. LPN #2 also stated this would have triggered her because she would have known the orders had been entered into the computer and she would have immediately started looking for them. Interview on 11/18/15 at 2:02 PM with LPN #5 revealed LPN #5 stated the facility used written orders to enter resident orders into the computer and the compare the Physician order [REDACTED]. Interview on 11/17/15 at 10:26 AM with the Facility Administrator and the Director of Nursing (DON) present revealed the facility's investigation showed LPN #2 incorrectly entered an insulin order into the computer for Resident #1. The Administrator stated the facility was aware the computer system was sensitive with order entry and stated if the keyboard or mouse from the computer was accidentally bumped it would move down to the next resident. The Administrator stated when an order is entered into the computer, every order has to be saved and the resident name turns blue and at this point it can be changed to another resident. The Administrator stated the nurse has to click back on the resident name on the computer before another order can be entered. The Administrator stated she was not sure how, but when the resident's name turned blue it dropped to the next resident, which was Resident #1, and LPN #2 entered the insulin on Resident #1, not Resident #2. In an interview with the computer software company on 11/19/15 at 3:30 PM, the software company spokesperson stated for order entry you have to select the resident and the system will only respond to the keyboard action; You can't just bump it to make it skip to the next resident. The software company spokesperson explained, You actually have to click and select another resident to change the resident. The spokesperson went on to explain a person could use the drop down box to select a resident or enter the first letter of a resident's last name to pull a list of all resident's whose name begins with that letter. Record review of the Medication Administration Record [REDACTED]. Review of the November 2015 Cumulative Electronic physician's orders [REDACTED].#2. Review of Resident #1's hand written orders (hard copy) revealed no order for insulin. Record review revealed the facility admitted Resident #1 on 10/1/15 with the [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set with an Assessment Reference Date (ARD) of 7/20/15 indicated Resident #1's Brief Interview for Mental Status (BIMS) score was 14 which indicated Resident #1 was cognitively intact. Resident #2 Record review revealed the facility admitted Resident #2 on 11/12/15 with the [DIAGNOSES REDACTED]. The Minimum Data Set was not due on Resident #2. The Admission Electronic physician's orders [REDACTED]. an order for [REDACTED].>The November 2015 Medication Administration Record [REDACTED]. Resident #2 did not receive insulin on 11/12/15, the day of admission, which resulted in an elevated blood glucose level of 313 mg/dl on 11/13/15 at 7:15 AM. The facility implemented the following Corrective Action Plan prior to the State Agency's entrance on 11/17/15. On 11/13/15 at 5:00 AM, rounds per LPN #3 found Resident #1 unresponsive. Coroner pronounced death. The facility began investigation. The Medical Director was notified and came to facility. 1. On 11/13/15 at 6:45 AM- Medical Director was updated on the possible incident and offered suggestions with investigation and asked to be kept informed of findings. Investigation began with ADON requesting written statements for LPN #3, LPN #2 and LPN #1. 2. On 11/13/15 at 8:00 AM- Consultant Pharmacist notified of incident by RN #2. 3. On 11/13/15 at 10:00 AM- Administrator went to Medical Director's clinic to inform him of findings at this point. DON conducted interviews with all staff who may have knowledge. 4. On 11/13/15 at 1:00 PM- Quality Assurance (QA) Committee met with the following members: Administrator, DON, ADON, Administrative Assistant #1, Medical Records, Staff Development and Chaplin. Reviewed the following policies and procedures: checking order, order entry, borrowing medication, medication errors, medication availability and notification of pharmacist and physician. Begin to gather information regarding incident. Talking to staff, written statements, interviews, etc. DON to interview nurse giving insulin and nurse inputing order. Pull personal files for training for nurse given med and nurse inputting orders. Review incident reports, medication reports, etc. Notified the consultant pharmacist to replace all [MEDICATION NAME]on B-1 Cart. Review Resident #1 and Resident #2's chart. Provide staff and family counseling. Speak to coroner and Medical Director. Finalize all documentation needed and file final reports with all necessary agencies. 5. On 11/13/15 at 2:00 PM- Called Manager of Client Services at the Computer Software Company to request review of software to assure safeguards are in place. 6. On 11/13/15 at 2:30 PM- Disciplinary Action (Warning) done on LPN #2 for entering medication on wrong resident. 7. On 11/13/15 at 3:00 PM- LPN #1 placed on suspension until investigation complete by the DON for borrowing a high risk med and giving to Resident #1. 8. On 11/13/15 at approximately 5:00 PM- ADON called pharmacist and notified of need for replacement bottles sent to every resident who gets [MEDICATION NAME] on B-1 cart since LPN #1 could not identify which resident she took it from. Delivered per pharmacist and placed on cart. 9. On 11/14/15 at 10:00 AM- Met with Responsible Party and his wife for Resident #1 to inform of incident. 10. On 11/14/15 at 9:00 PM- DON completed in-servicing of 100 % of licensed staff on: a. Verification of Orders, b. Entering new orders, and c. Facility policy on not borrowing medications from another resident. 11. On 11/16/15 at 8:00 AM- DON met with Consultant Pharmacist to update. 10:00 AM QA Committee met with the following attending: Administrator, Office Manager, Medical Director, DON, ADON, Dietary Manager, Admission Coordinator, Administrative Assistant, Maintenance Supervisor, Chaplin, Staff Development, Housekeeping Supervisor, Social Services and Medical Record Director. *Reported final report of incident to the Attorney General's Office, State Board of Nursing, State Agency and Area Ombudsman. *Change in Verification of orders procedure. *Consultant pharmacist replaced all [MEDICATION NAME]on B-1 Cart on 11/13/15. *Our system of checking orders prior to and after the incident is effective and we will continue this practice as 100% of resident's orders were checked on 11/14/15 with no errors found. * Policy review/revision: physician's orders [REDACTED].#1 and Resident #2, Medication Ordering and Reordering, The Five Rights and Drug Administration and Documentation. * DON will audit 20% of physician's orders [REDACTED]. * Audit the availability of medications by checking the medication sign in sheet against the orders and routing a copy of the medication sign in sheet against the orders and routing a copy of medication sign in sheet to the DON. DON will report to QA weekly times six (6) weeks then monthly to follow findings of audits to check for compliance. * Disciplinary Action and Termination of LPN #1, LPN for failing to follow facility policies and nurse practice standards after extensive training by facility as documented in personal file AEB: Failure to verify the hard copy order. Borrowing a high risk medication (insulin) and gave to resident. *Disciplinary Action done for LPN #2 for order input error. 12. On 11/16/15 at Approx. 12:30 PM Area Ombudsman informed of incident. 13. On 11/16/15 at 2:00 PM Disciplinary Action (Terminated) LPN #1 by the DON for failure to verify hard copy order and borrowing a high risk medication and gave to Resident #1. 14. On 11/16/15 at 4:00 PM Disciplinary Action for LPN #2 for failure to check orders for Resident #2 on 11/13/15. 15. On 11/16/15 at 4:00 PM completed a chart audit of 100% of the resident's orders and care plans by the DON, ADON, Medical Records LPN, Medical Records RN with no errors found. The facility alleged the Corrective Action plan was completed on 11/16/15. The State Agency (SA) validated the facility's corrective action on 11/17/15 to 11/20/15. 1. The SA validated the facility's investigation of Resident #1 incident on 11/12/15 of receiving insulin caused by incorrect order entry and a high risk medication being borrowed and given that resulted on the death of Resident #1. The SA verified by record review, interviews, written statements of staff and written reports to the SA. 2. The SA validated the Medical Director was notified of the possible occurrence. 3. The SA validated the Consultant Pharmacist was notified of incident. 4. The SA validated the Medical Director was notified by the facility. Validated by an interview with the DON and review of documents: Physicians Orders, MARs, and Death Certificate for Resident #1. The SA validated interviews with staff that may have had knowledge of the event. 5. The SA validated by interview with the Facility Administrator and the Medical Director and review of a sign in sheet dated 11/13/15 that the facility initiated a Quality Assurance (QA) Committee meeting with the following members: Medical Director, Administrator, DON, ADON, Administrative Assistant #1, Medical Records, Staff Development and Chaplin. The QA Committee reviewed the following policies and procedures: checking order, order entry, borrowing medication, medication errors, medication availability and notification of pharmacist and physician. The QA Committee discussed gathering information regarding the incident that involved Resident #1 and Resident #2. The QA Committee reviewed written statements, interviews, by the DON, reviewed personal files for training for nurse given med and nurse in-putting orders, reviewed incident reports, medication reports, etc. The facility notified the consultant pharmacist to replace [MEDICATION NAME] insulin, by the facility, on B-1 Cart for all the residents that received [MEDICATION NAME] insulin. Review Resident #1 and Resident #2's chart. Provide staff and family counseling. Speak to coroner and Medical Director. Finalize all documentation needed and file final reports with all necessary agencies. 6. The SA validated the Manager of Client Services at the Computer Software Company was contacted by interview with the facility Administrator to assure safeguards are in place. The SA validated by phone interview with the Computer Software Company. 7. The SA validated by interview from the DON and written statement of Disciplinary Action done on LPN #2 for entering medication on wrong resident. 8. The SA validated a written statement and interview of the DON that LPN #1 was placed on suspension until investigation complete by the DON for borrowing a med and giving to Resident #1. 9. The SA validated by interview with the ADON and the Pharmacist that the ADON called the pharmacist and notified of need for replacement bottles sent to every resident who gets [MEDICATION NAME]on B-1 cart since LPN #1 could not identify which resident she took it from. The insulin was paid for by the facility. Delivered per pharmacist and placed on cart per interview of the pharmacist. 10. The SA validated per written statement the RP for Resident #1 was notified and informed of the incident. Interview with the DON confirmed the completed in-servicing of 100 % of licensed staff on: a. Verification of Orders, b. Entering new orders, and c. Facility policy on not borrowing medications from another resident. 11. The SA validated by interview with the DON on 11/16/15 8:00 AM that the DON met with Consultant Pharmacist to update him of the progress of the investigation. The SA validated by interview with the Facility Administrator and a sign in sheet at 10:00 AM the QA Committee met with the following attending: Administrator, Office Manager, Medical Director, DON, ADON, Dietary Manager, Admission Coordinator, Administrative Assistant, Maintenance Supervisor, Chaplin, Staff Development, Housekeeping Supervisor, Social Services and Medical Record Director. Written evidence the QA committee discussed reporting final report of incident to the Attorney General's Office, State Board of Nursing, State Agency and Area Ombudsman; changed the verification of orders procedure; consultant pharmacist replaced all [MEDICATION NAME]on B-1 Cart on 11/13/15; discussed the system of checking orders prior to and after the incident effectiveness; 100% of resident's orders were checked on 11/14/15 with no errors found; the Policy review/revision: physician's orders [REDACTED].#1 and Resident #2, Medication Ordering and Reordering, The Five Rights and Drug Administration and Documentation; the DON audit of 20% of physician's orders [REDACTED]. The DON will report to QA weekly times six (6) weeks then monthly to follow findings of audits to check for compliance. The SA verified Disciplinary Action and Termination of LPN #1 for failing to follow facility policies and nurse practice standards by failure to verify the hard copy order and borrowing a high risk medication (insulin) to administer to a resident. SA verified disciplinary action done for LPN #2 for order input error. 12. The SA validated Area Ombudsman was notified by documentation from the Facility Administration and interview of the Facility Administrator of the incident involving Resident #1 and Resident #2. The SA attempted to reach the Area Ombudsman and was unable to reach. 13. The SA validated by interview of the DON of the Disciplinary Action (Terminated) for LPN #1 by the DON for failure to verify hard copy order and borrowing a high risk medication and gave to Resident #1. 14. The SA validated by documentation review and interview of the DON of the Disciplinary Action for LPN #2 for failure to check orders for Resident #2 on 11/13/15. 15. The SA validated by documentation review and interview of the DON of the Completed chart audit of 100% of the resident's orders and care plans by the DON, ADON, Medical Records LPN, Medical Records RN with no errors found.

Based on interviews, record reviews, facility investigation review and facility policy review, the facility failed to meet professional standards as evidenced by failure to enter electronic physician orders [REDACTED].#1 receiving insulin that was not ordered and Resident #2 not receiving ordered insulin for two (2) of five (5) residents reviewed receiving insulin. (Resident #1 and Resident #2) This Immediate Jeopardy was determined to exist on [DATE] at 9:00 PM when The SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on [DATE] when Licensed Practical Nurse (LPN) #2 entered Resident #2's order for insulin into Resident #1's electronic Medication Administration Record (MAR) and the Electronic Physician Orders. During the following medication pass, LPN #1 noted the insulin on Resident #1's MAR then borrowed insulin from another resident. LPN #1 administered Resident #1 the insulin that was inaccurately entered into the orders and MAR. On [DATE] at approximately 5:00 AM, the night nurse for Resident #1 went into Resident #1's room and found her unresponsive and cold. The night nurse then checked Resident #1's finger-stick blood glucose and the reading was LO. The night nurse called the ambulance and when the ambulance arrived, Resident #1 was without a pulse and without a blood pressure. Resident #1 was a Do Not Resuscitate (DNR); the coroner was called. Review of the death certificate for Resident #1 listed death at 5:52 AM on [DATE]. Resident #2 did not receive insulin on [DATE], the day of admission, which resulted in an elevation of blood glucose levels to 313 milligrams per deciliter (mg/dl) on [DATE] at 7:15 AM. The facility's failure to follow professional standards related to order entry, medication verification, and medication ordering lead to the death of Resident #1 and an elevated blood glucose level for Resident #2 and placed other residents of the facility in a situation that was likely to cause serious injury, harm, impairment or death. Based on the facility's corrective action completed as of [DATE] prior to the State Agency facility entrance on [DATE], the State Agency determined Immediate Jeopardy (IJ) to be Past Non-Compliance for F281. The SA determined the IJ was removed and the facility was in substantial compliance as of [DATE]. Findings Include: Review of the Mississippi Board of Nursing webite for Frequently Asked Questions (http://www.msbn.ms.gov/Pages/FAQs.aspx) revealed, When administering any medication, the nurse should be knowledgeable of and comply with all applicable state and federal laws, rules, regulations and guidelines pertaining to the specific medication including, but not limited to, those of the Food and Drug Administration (FDA), Drug Enforcement Administration (DEA), the Mississippi Board of Pharmacy and the Board of Nursing. In a review of the facility's policy entitled, Drug Administration and Documentation, dated revised [DATE], revealed it is the responsibility of the nurse to obtain an order for [REDACTED]. Right Resident, 2. Right Time, 3. Right Medication, 4. Right Dose, 5. Right Route of Administration. Medications prescribed for one resident will not be administered to another resident. Resident #1 Record review of the [DATE] Medication Administration Record (MAR) revealed Resident #1 received Insulin 54 units Subcutaneous (SQ) at 9:00 PM on [DATE] which was electronically signed given by Licensed Practical Nurse (LPN) #1. Review of the Electronic Cumulative physician's orders [REDACTED].#1 with on order date of [DATE] that was entered into the computer by LPN #2. However, Resident #1 did not have a hand written order for insulin during record review. Review of the facility's investigation revealed, on [DATE] LPN #2 entered into the computer an order for [REDACTED]. This was ordered for Resident #1 and should have been ordered on Resident #2. Resident #2 was readmitted on [DATE]. LPN #2 confirmed all the orders with RN #1 except the insulin and blood glucose checks due to the insulin dose amount was not listed on the orders and had to be verified. When LPN #2 verified the dose amount, she entered it into the computer for Resident #1 and not Resident #2 causing the insulin to come up on to the Medication Administration Record (MAR) to be given to Resident #1. LPN #1 borrowed the insulin instead of ordering it from the pharmacy, from the B-1 Medication Cart from an unknown resident when it was not available to be administered. Resident #1 received 54 units of insulin by Licensed Practical Nurse (LPN) #1 that was borrowed from B Station Medication Cart and was entered incorrectly into the computer by LPN #2. Resident #2 did not receive the ordered insulin because LPN #2 failed to enter the insulin in the computer for Resident #2. Interview on [DATE] at 12:04 PM with LPN #1 revealed she worked on [DATE] from 7:00 PM to 11:00 PM. LPN #1 stated there was no insulin on the B Side Station medication cart for Resident #1, so she borrowed the insulin from another unknown resident. LPN #1 also stated the pharmacy delivered medications around 12:00 midnight and she borrowed the medication so it would not be late. Interview on [DATE] at 2:42 PM with LPN #2 revealed she entered the order for insulin and accuchecks into the electronic record on the wrong resident, Resident #1. LPN #2 confirmed she omitted entering into the computer the insulin and blood glucose checks for Resident #2 which resulted in a missed dose on [DATE]. LPN #1 confirmed all medications given by mouth (po) were checked by the day shift Registered Nurse (RN) but because she had to verify the dose of the insulin she had to wait to enter it into the computer. LPN #1 confirmed she entered the insulin into the computer on the wrong resident, Resident #1. Interview at 1:45 PM on [DATE] with LPN #2 revealed it was her responsibility to print the orders and check them, but she did not get anyone to check the last two orders she entered which was the [MEDICATION NAME]and accucheck orders due to end of shift. She stated that she gave report to the night nurses who were responsible for checking the orders during the night shift. Interview on [DATE] at 12:04 PM with LPN #1 revealed the order for insulin for Resident #1 should have been caught by the RN who was supposed to check behind the LPN who entered the order on the wrong resident. Interview on [DATE] at 10:26 AM with the Facility Administrator and Director of Nursing (DON) present revealed during the facility's investigation revealed LPN #2 entered into the computer insulin orders for Resident #1 intended for Resident #2. Resident #1 received the insulin from LPN #1 when she borrowed the insulin from another unknown resident on the B-1 Medication cart and Resident #1 died . Resident #2 did not receive insulin as ordered and resulted in an elevation of blood glues levels to 313 mg/dl. The Administrator stated it was against professional standards of care for a nurse to borrow medication from another resident. In an interview with the Medical Director on [DATE] at 11:55 PM, the Medical Director confirmed he was notified immediately after Resident #1 expired. The Medical Director confirmed a QA (Quality Assurance) meeting was called immediately by phone and discussed changed that needed to occur to include revision of policies and procedures, order entry, care plan revision and not borrowing medications. On [DATE] at 12:09 PM during a phone interview with the Consultant Pharmacist, he stated the facility would fax the hand written order to the pharmacy for medications to be dispensed. The Consultant Pharmacist also stated, There have been times orders have been called in and filled. The nurses are never to borrow medication. That is totally against policy. Record review revealed the facility admitted Resident #1 on [DATE] with the [DIAGNOSES REDACTED]. In a review of the Quarterly Minimum Data Set with an Assessment Reference Date (ARD) of [DATE] indicated Resident #1's Brief Interview for Mental Status (BIMS) score was 14 which indicated Resident #1 was cognitively intact. Resident #2 Record review of the [DATE] Medication Administration Record (MAR) revealed Resident #2's Blood Glucose level was 313 milligrams per deciliter (mg/dl) at 7:15 AM on [DATE] that indicated Resident #2's blood glucose was elevated. Review of Resident #2's Admission Electronic physician's orders [REDACTED]. The facility had entered the resident's insulin order on Resident #2's orders and MAR. Record review of the [DATE] MAR revealed Resident #2 did not receive [MEDICATION NAME] Insulin 54 units Subcutaneous (SQ) at 9:00 PM on [DATE]. Record review revealed the facility readmitted Resident #2 on [DATE] with the [DIAGNOSES REDACTED]. Resident #2's Minimum Data Set was not due. The facility implemented the following Corrective Action Plan prior to the State Agency's entrance on [DATE]. On [DATE] at 5:00 AM, rounds per LPN #3 found Resident #1 unresponsive. Coroner pronounced death. The facility began investigation. The Medical Director was notified and came to facility. 1. On [DATE] at 6:45 AM- Medical Director was updated on the possible incident and offered suggestions with investigation and asked to be kept informed of findings. Investigation began with ADON requesting written statements for LPN #3, LPN #2 and LPN #1. 2. On [DATE] at 8:00 AM- Consultant Pharmacist notified of incident by RN #2. 3. On [DATE] at 10:00 AM- Administrator went to Medical Director's clinic to inform him of findings at this point. DON conducted interviews with all staff who may have knowledge. 4. On [DATE] at 1:00 PM- Quality Assurance (QA) Committee met with the following members: Administrator, DON, ADON, Administrative Assistant #1, Medical Records, Staff Development and Chaplin. Reviewed the following policies and procedures: checking order, order entry, borrowing medication, medication errors, medication availability and notification of pharmacist and physician. Begin to gather information regarding incident. Talking to staff, written statements, interviews, etc. DON to interview nurse giving insulin and nurse inputting order. Pull personal files for training for nurse given med and nurse inputting orders. Review incident reports, medication reports, etc. Notified the consultant pharmacist to replace all [MEDICATION NAME]on B-1 Cart. Review Resident #1 and Resident #2's chart. Provide staff and family counseling. Speak to coroner and Medical Director. Finalize all documentation needed and file final reports with all necessary agencies. 5. On [DATE] at 2:00 PM- Called Manager of Client Services at the Computer Software Company to request review of software to assure safeguards are in place. 6. On [DATE] at 2:30 PM- Disciplinary Action (Warning) done on LPN #2 for entering medication on wrong resident. 7. On [DATE] at 3:00 PM- LPN #1 placed on suspension until investigation complete by the DON for borrowing a high risk med and giving to Resident #1. 8. On [DATE] at approximately 5:00 PM- ADON called pharmacist and notified of need for replacement bottles sent to every resident who gets [MEDICATION NAME] on B-1 cart since LPN #1 could not identify which resident she took it from. Delivered per pharmacist and placed on cart. 9. On [DATE] at 10:00 AM- Met with Responsible Party (RP) and his wife for Resident #1 to inform of incident. 10. On [DATE] at 9:00 PM- DON completed in-servicing of 100 % of licensed staff on: a. Verification of Orders, b. Entering new orders, and c. Facility policy on not borrowing medications from another resident. 11. On [DATE] at 8:00 AM- DON met with Consultant Pharmacist to update. 10:00 AM QA Committee met with the following attending: Administrator, Office Manager, Medical Director, DON, ADON, Dietary Manager, Admission Coordinator, Administrative Assistant, Maintenance Supervisor, Chaplin, Staff Development, Housekeeping Supervisor, Social Services and Medical Record Director. *Reported final report of incident to the Attorney General's Office, State Board of Nursing, State Agency and Area Ombudsman. *Change in Verification of orders procedure. *Consultant pharmacist replaced all [MEDICATION NAME]on B-1 Cart on [DATE]. *Our system of checking orders prior to and after the incident is effective and we will continue this practice as 100% of resident's orders were checked on [DATE] with no errors found. * Policy review/revision: physician's orders [REDACTED].#1 and Resident #2, Medication Ordering and Reordering, The Five Rights and Drug Administration and Documentation. * DON will audit 20% of physician's orders [REDACTED]. * Audit the availability of medications by checking the medication sign in sheet against the orders and routing a copy of the medication sign in sheet against the orders and routing a copy of medication sign in sheet to the DON. DON will report to QA weekly times six (6) weeks then monthly to follow findings of audits to check for compliance. * Disciplinary Action and Termination of LPN #1, LPN for failing to follow facility policies and nurse practice standards after extensive training by facility as documented in personal file AEB: Failure to verify the hard copy order. Borrowing a high risk medication (insulin) and gave to resident. *Disciplinary Action done for LPN #2 for order input error. 12. On [DATE] at Approx. 12:30 PM Area Ombudsman informed of incident. 13. On [DATE] at 2:00 PM Disciplinary Action (Terminated) LPN #1 by the DON for failure to verify hard copy order and borrowing a high risk medication and gave to Resident #1. 14. On [DATE] at 4:00 PM Disciplinary Action for LPN #2 for failure to check orders for Resident #2 on [DATE]. 15. On [DATE] at 4:00 PM completed a chart audit of 100% of the resident's orders and care plans by the DON, ADON, Medical Records LPN, Medical Records RN with no errors found. The facility alleged the Corrective Action plan was completed on [DATE]. The State Agency (SA) validated the facility's corrective action on [DATE] to [DATE]. 1. The SA validated the facility's investigation of Resident #1 incident on [DATE] of receiving insulin caused by incorrect order entry and a high risk medication being borrowed and given that resulted on the death of Resident #1. The SA verified by record review, interviews, written statements of staff and written reports to the SA. 2. The SA validated the Medical Director was notified of the possible occurrence. 3. The SA validated the Consultant Pharmacist was notified of incident. 4. The SA validated the Medical Director was notified by the facility. Validated by an interview with the DON and review of documents: Physicians Orders, MARs, and Death Certificate for Resident #1. The SA validated interviews with staff that may have had knowledge of the event. 5. The SA validated by interview with the Facility Administrator and the Medical Director and review of a sign in sheet dated [DATE] that the facility initiated a Quality Assurance (QA) Committee meeting with the following members: Medical Director, Administrator, DON, ADON, Administrative Assistant #1, Medical Records, Staff Development and Chaplin. The QA Committee reviewed the following policies and procedures: checking order, order entry, borrowing medication, medication errors, medication availability and notification of pharmacist and physician. The QA Committee discussed gathering information regarding the incident that involved Resident #1 and Resident #2. The QA Committee reviewed written statements, interviews, by the DON, reviewed personal files for training for nurse given med and nurse in-putting orders, reviewed incident reports, medication reports, etc. The facility notified the consultant pharmacist to replace [MEDICATION NAME] insulin, by the facility, on B-1 Cart for all the residents that received [MEDICATION NAME] insulin. Review Resident #1 and Resident #2's chart. Provide staff and family counseling. Speak to coroner and Medical Director. Finalize all documentation needed and file final reports with all necessary agencies. 6. The SA validated the Manager of Client Services at the Computer Software Company was contacted by interview with the facility Administrator to assure safeguards are in place. The SA validated by phone interview with the Computer Software Company. 7. The SA validated by interview from the DON and written statement of Disciplinary Action done on LPN #2 for entering medication on wrong resident. 8. The SA validated a written statement and interview of the DON that LPN #1 was placed on suspension until investigation complete by the DON for borrowing a med and giving to Resident #1. 9. The SA validated by interview with the ADON and the Pharmacist that the ADON called the pharmacist and notified of need for replacement bottles sent to every resident who gets [MEDICATION NAME]on B-1 cart since LPN #1 could not identify which resident she took it from. The insulin was paid for by the facility. Delivered per pharmacist and placed on cart per interview of the pharmacist. 10. The SA validated per written statement the RP for Resident #1 was notified and informed of the incident. Interview with the DON confirmed the completed in-servicing of 100 % of licensed staff on: a. Verification of Orders, b. Entering new orders, and c. Facility policy on not borrowing medications from another resident. 11. The SA validated by interview with the DON on [DATE] 8:00 AM that the DON met with Consultant Pharmacist to update him of the progress of the investigation. The SA validated by interview with the Facility Administrator and a sign in sheet at 10:00 AM the QA Committee met with the following attending: Administrator, Office Manager, Medical Director, DON, ADON, Dietary Manager, Admission Coordinator, Administrative Assistant, Maintenance Supervisor, Chaplin, Staff Development, Housekeeping Supervisor, Social Services and Medical Record Director. Written evidence the QA committee discussed reporting final report of incident to the Attorney General's Office, State Board of Nursing, State Agency and Area Ombudsman; changed the verification of orders procedure; consultant pharmacist replaced all [MEDICATION NAME]on B-1 Cart on [DATE]; discussed the system of checking orders prior to and after the incident effectiveness; 100% of resident's orders were checked on [DATE] with no errors found; the Policy review/revision: physician's orders [REDACTED].#1 and Resident #2, Medication Ordering and Reordering, The Five Rights and Drug Administration and Documentation; the DON audit of 20% of physician's orders [REDACTED]. The DON will report to QA weekly times six (6) weeks then monthly to follow findings of audits to check for compliance. The SA verified Disciplinary Action and Termination of LPN #1 for failing to follow facility policies and nurse practice standards by failure to verify the hard copy order and borrowing a high risk medication (insulin) to administer to a resident. SA verified disciplinary action done for LPN #2 for order input error. 12. The SA validated Area Ombudsman was notified by documentation from the Facility Administration and interview of the Facility Administrator of the incident involving Resident #1 and Resident #2. The SA attempted to reach the Area Ombudsman and was unable to reach. 13. The SA validated by interview of the DON of the Disciplinary Action (Terminated) for LPN #1 by the DON for failure to verify hard copy order and borrowing a high risk medication and gave to Resident #1. 14. The SA validated by documentation review and interview of the DON of the Disciplinary Action for LPN #2 for failure to check orders for Resident #2 on [DATE]. 15. The SA validated by documentation review and interview of the DON of the Completed chart audit of 100% of the resident's orders and care plans by the DON, ADON, Medical Records LPN, Medical Records RN with no errors found.