Every finding on record at Ocoee Transitional Care Center LLC

Based on facility policy review, medical record review, and interviews, the facility failed to revise a care plan for 2 residents (Resident #7 for fall interventions and Resident #5 for diet interventions) of 16 care plans reviewed. The findings include: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, revised 12/2016, revealed .person centered care plan .includes .objectives .to meet the resident's physical .functional needs .implemented for each resident .Assessments of residents are ongoing .care plans are revised as .information about the residents .conditions change . Review of the undated facility policy titled, Falls Incident Management Clinical Protocol, revealed .with falls .put an immediate intervention in place .place the intervention on the Falls Care Plan .date the intervention . Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Depression, Hypertension, and Adult Failure to Thrive. Review of a Facility Fall Incident report for Resident #7 dated 5/28/2026, revealed .Patient [Resident #7] was attempting to look for husband .pt [patient] lying on floor in room near recliner .New Intervention .Dycem [non-slip material to prevent sliding] to recliner . Review of a comprehensive care plan revised 5/29/2026, revealed Resident #7 .at risk for further falls related to .cognitive impairment .poor coordination . Continued review revealed no new intervention had been added after the fall on 5/28/2026 and did not include the Dycem to the recliner. Review of a significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 scored a 4 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment and had no falls since prior MDS assessment. During an interview on 7/15/2026 at 10:34 AM, the Quality Assurance Nurse confirmed the care plan for Resident #7 had not been revised to include the new intervention after the fall on 5/28/2026. During an interview on 7/15/2026 at 10:36 AM, the Director of Nursing (DON) confirmed the care plan for Resident #7 had not been revised to include the new intervention after the fall on 5/28/2026. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE], with diagnoses including Left Humerus Fracture, Adult Failure to Thrive, Weakness, and Dysphagia. Review of an admission/5-day MDS dated [DATE], revealed Resident #5 scored a 12 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Further review revealed the resident had difficulty with swallowing and had a mechanically altered diet. Review of a comprehensive care plan dated 5/6/2026, revealed Resident #5 .AT RISK FOR ALTERED NUTRITION .therapeutic diet, altered texture, thicken liquids .Provide prescribed diet as ordered . Review of the Physician's Orders for Resident #5 dated 5/26/2026, revealed .Patient is OK for thin water ONLY between meals and after oral care has been provided by caregivers/staff in order to decrease risk of dehydration and provide oral moisture/comfort . During an observation on 7/13/2026 at 10:10 AM, Resident #5 was sitting up in chair in her room, water pitcher with thin water noted on the bed side table and within resident's reach. Review of the comprehensive care plan for Resident #5, revealed the care plan had not been revised to include thin water between meals and after oral care for Resident #5 after the physician's order was received for thin liquids dated 5/26/2026.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure accurate accountability of controlled substances for 2 residents (Resident #28 and #72) on 1 of 3 medication carts observed. The findings include: Review of the facility policy titled, Controlled Substances, dated January 2019, revealed .Accurate accountability of the inventory of all controlled drugs is maintained at all times .the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record [MAR] .Date and time of administration .Amount administered .Remaining quantity .Initials of the nurse administering the dose, completed after the medication is actually administered . Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis Following Cerebral Infarction, Dementia Without Behavioral Disturbance, and Chronic Pain. Review of the Physician's Orders for Resident #28 dated 6/8/2026, revealed .Oxycodone [medication to treat pain] 10 mg [milligrams] .one tablet by mouth every 12 hours .chronic pain . Review of the MAR for Resident #28 dated 7/1/2026-7/31/2026, revealed the resident received Oxycodone 10 mg as ordered on 7/15/2026 on the morning medication pass. Review of the medical record revealed Resident #72 was admitted to the facility on [DATE] with diagnoses including Type II Diabetes Mellitus, Anxiety, and Polyneuropathy. Review of the Physician's Orders for Resident #72 dated, 6/25/2026, revealed .Gabapentin [medication used for nerve pain] 200 mg .two times a day .neuropathy . Review of the MAR for Resident #72 dated 7/1/2026-7/31/2026, revealed the resident received Gabapentin 200 mg as ordered on 7/15/2026 on the morning medication pass. During a medication storage observation and controlled substance count with Licensed Practice Nurse (LPN) A on 7/14/2026 at 8:05 AM, revealed the Oxycodone 10 mg for Resident #28 had not been documented as administered on the controlled substance record resulting in a discrepancy of 1 tablet. Further observation revealed the Gabapentin 200 mg for Resident #72 had not been documented as administered on the controlled substance record resulting in a discrepancy of 1 tablet. During an observation and interview on 7/14/2026 at 8:08 AM, LPN A confirmed she had administered Oxycodone 10 mg to Resident #28 and Gabapentin 200 mg to Resident #72 but failed to document the medication administration on the controlled substance record which led to the discrepancy in the controlled substance record. During an interview on 7/15/2026 at 2:40 PM, the Director of Nursing confirmed it was her expectation that all licensed nurses document on the controlled substance record when the medication is administered to the resident.

Based on facility policy review, medical record review, facility documentation review, and interviews, the facility failed to ensure 1 resident (Resident #1) was free from significant medication errors (59 omitted doses of Intravenous (IV) antibiotics) of 3 residents reviewed for IV medications. The findings include: Review of the facility's policy titled, Adverse Consequences and Medication Errors, revised 4/2014, revealed .The interdisciplinary team evaluates medication usage in order to prevent and detect .medication-related problems .A 'medication error' is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders .Examples of medications errors include .Omission- a drug is ordered but not administered .When a resident receives a new medication, the medication order is evaluated for the following .The dose, route of administration, duration .In the event of a significant medication-related error .immediate action is taken .to protect the resident's safety and welfare . Review of the facility's policy titled, Administering Medications, revised on 4/2019, revealed .Medications are administered in a safe and timely manner, and as prescribed .Medications are administered in accordance with prescriber orders, including any required time frame . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Urinary Tract Infection (UTI), Retention of Urine, Enterococcus Faecalis Bacteremia (a common bacterium that can cause serious opportunistic infections). Review of the hospital Discharge Summary for Resident #1 dated 12/5/2025, revealed .admit date : [DATE] .discharge date : [DATE] [12/5/2025] .Active Problems .Urinary tract infection with hematuria due to urinary retention .Enterococcal sepsis [the body's extreme response to infection] .secondary to UTI .Anemia .Left atrial thrombus per TEE [Transesophageal Echocardiogram- a heart imaging test for clear views of the heart's structure and function], presumably [likely based on reasonable assumptions, though not certain .] infected .Blood cultures confirmed persistent Enterococcus faecalis bacteremia, and urine cultures were positive for the same organism. Infectious disease [ID] consultation recommended management as infectious endocarditis [inflammation of the inner layer of the heart] .At the time of discharge planning, he was clinically stable .awaiting transfer to a skilled nursing facility for completion of intravenous antibiotic therapy and further rehabilitation .In summary .Per discussion with ID plan for ampicillin [antibiotic medication] 2 g [grams] IV every 4 hours and Rocephin [Ceftriaxone- antibiotic medication] 2 g IV every 12 hours until January 13, 2026. This represents 6 weeks of coverage after first set of negative blood cultures .It is medical necessary to admit from the hospital to SNF [skilled nursing facility] .Discharge Medication List .ampicillin .Infuse 2 g into a venous catheter every 4 (four) hours .Last Dose .December 5, 2025 at 10:07 AM .see infectious disease orders .cefTRIAXone [Rocephin] .Infuse 2 g into a venous catheter every 12 (twelve) hours .Last Dose .December 5, 2025 11:08 AM .see infectious disease orders . Review of the hospital Infectious Disease Physician Progress Note dated 12/5/2025, revealed .Orders for .long-term care facility .Ampicillin 2 g IV every 4 hours, and Rocephin [Ceftriaxone] 2 g IV every 12 hours, to continue through 2 PM [2:00 PM] on Tuesday, January, 13, 2026. This will be 6 weeks after the first set of negative blood cultures . Continued review revealed .CMP [Comprehensive Metabolic Panel], CBC [Complete Blood Count] with differential, on Mondays and Thursdays through January 13 [1/13/2026] . Review of the physician's order entered into the facility's electronic computer system (Point Click Care) (PCC) dated 12/5/2025, revealed .Order Date .12.5.2025 [12/5/2025] .Ampicillin Sodium Solution .2 GM .intravenously every 4 hours for bacterial infection until 12/13/2025 14:07 [2:07 PM] .Start Date .12/5/2025 .1600 [4:00 PM] .End Date .12/13/2025 [1 month prior the physician's ordered medication end date] . The physician's order was entered into the facility's computer system by the Admission's Nurse on 12/5/2025 at 2:08 PM and confirmed by the Registered Nurse (RN) Charge Nurse on 12/5/2025 at 9:31 PM. Continued review revealed the order for Ceftriaxone [Rocephin] had been entered into the facility's computer system correctly with the correct stop date of 1/13/2025 and the physician's order for the stop date for the Ampicillin had been entered incorrectly. Review of Resident #1's physical chart revealed the hospital Discharge Summary and the hospital Infectious Disease Physician Progress Note dated 12/5/2025 with the order for .Ampicillin 2 g IV every 4 hours, and Rocephin 2 g IV every 12 hours, to continue through 2 PM [2:00 PM] on Tuesday January 13, 2026 . was signed by the Admission's Nurse on 12/5/2025 at 2:06 PM and the RN Charge Nurse on 12/5/2025 at 9:58 PM. Review of the 24 Hour Chart Check dated 12/6/2025 at 1:00 AM, revealed Licensed Practical Nurse (LPN) A had performed the 24 Hour Chart Check including for Resident #1's admitting physician's orders. Review of the comprehensive care plan initiated on 12/6/2025, revealed . ANTIBIOTIC THERAPY r/t [related to] urinary tract infections (UTI) ceftriaxone [Rocephin] 2 GM IV 12/05/2025-01/13/2026 . Ampicillin Sodium 12/05/2025-12/13/2025 [the order was thru 1/13/2026] . Review of the Physician/Nurse Practitioner (NP) Progress Note dated 12/8/2025 at 12:32 PM, revealed .Patient [Resident #1] seen evaluated today XXX[AGE] year-old male status post acute anemia found by PCP [Primary Care Physician], required hemicolectomy [surgical procedure to remove one side of the colon] for cancerous polyp .approximately 5 weeks ago .was discharged .home, felt he was developing UTI and presented to ER [Emergency Room] for recent falls weakness. He was found to have sepsis secondary to UTI, Enterococcus faecalis bacteremia, left atrial appendage thrombus on TEE .was seen by ID for Enterococcus faecalis bacteremia, is on IV ampicillin and Rocephin [Ceftriaxone] plan for 6 weeks total .no acute distress, frail .Impression and plan .Enterococcus faecalis bacteremia secondary to UTI-continue antibiotics as scheduled per ID .Anemia-patient has routine blood work ordered for IV antibiotics .Left atrial thrombus-patient on loading dose Eliquis [anticoagulant medication] . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Resident #1 received antibiotic medication during the look back period. Resident #1 received IV medications at the facility. Review of the Physician/NP Progress Note dated 12/16/2025 at 9:09 PM, revealed .CHIEF COMPLAINT: Lab [laboratory test] review .HISTORY OF PRESENT ILLNESS: Patient [Resident #1] seen resting in bed. Evaluating today and review of labs .Overall his labs appear stable and without acute concern. He denies any fever, chills, chest pain, shortness of breath, nausea, vomiting, abdominal pain or dysuria .PHYSICAL EXAMINATION .no apparent distress .IMPRESSION/PLAN .Enterococcus faecalis bacteremia .Continue Rocephin [Ceftriaxone] 2 g [grams] every 12 hours through 1/13/2026 . Review of the Physician/NP Progress Noted dated 12/17/2025, revealed .Labs yest [yesterday] WNL [within normal limits] .denies any fever, chills, chest pain, shortness of breath, nausea, vomiting, abdominal pain, or dysuria .PHYSICAL EXAMINATION .in no apparent distress .IMPRESSION/PLAN .Enterococcus faecalis bacteremia .UTI - Continue Rocephin [Ceftriaxone] 2 g every 12 hours through 1/13/2026 . Review of a physician's order dated 12/24/2025, revealed .Ampicillin Sodium .Use 2 gram intravenously every 4 hours for antibiotic therapy until 01/13/2026 [1/13/2026] 23:59 [11:59 PM] . The order was discontinued on 12/26/2025. Review of a physician's order dated 12/26/2025, revealed .Ampicillin Sodium .Use 2 gram intravenously every 4 hours for antibiotic therapy until 01/28/2026 [1/28/2026] 06:00 [6:00 AM] . Continued review revealed .cefTRIAXone Sodium [Rocephin] .Use 2 gram intravenously every 12 hours for infection until 01/28/2026 [1/28/2026] 11:00 [11:00 AM] [the Ampicillin IV was continued through 1/28/2026 due to the lapse in treatment from 12/13/2025 thru 12/24/2025] . Review of the MEDICATION ADMINISTRATION RECORD (MAR) dated 12/1/2025 - 12/31/2025, revealed Resident #1 received Ampicillin Sodium Solution 2 g IV every four hours starting on 12/5/2025 at 8:00 PM through 12/13/2025 with the last dose being administered on 12/13/2025 at 4:45 PM. Continued review revealed Resident #1 resumed Ampicillin Sodium 2 grams IV every four hours starting on 12/24/2025 at 4:00 PM. (Resident #1 missed 59 doses of Ampicillin from 12/13/2025 - 12/24/2025). Further review revealed Ceftriaxone [Rocephin] was administered as ordered by the physician with no missed doses. Review of the MEDICATION OCCURRENCE REPORT for Resident #1 revealed .Drug Name: Ampicillin .Occurrence Date .12-13 [12/13/2025] thru 12/24 [12/24/2025] .Medication Order: Ampicillin IV 2 GM Q 4 [every 4 hours] until 1/13/26 [1/13/2026] .Name of Provider Notified .[NP A] .Patient Notified by: [RN A] .12/24/2025 .1600 [4:00 PM] .Pharmacy notified by: [RN A] .12/24/25 [12/24/2025] .11 am .TYPE OF ERROR .Omitted Dosage .CAUSE OF ERROR .admission Order Error .Chart Check Error .admission DIAGNOSES .Sepsis due to Uti [Urinary Tract Infection -UTI] SP [status post] fall, weakness .Additional Information & Patient Condition .Patient condition is stable .What caused this occurrence .Wrong stop date put in on admission .Date Error identified: 12/24/25 [12/24/2025] .11 am [11:00 AM] .Investigation .Order stop date was incorrectly entered on admission. Infectious disease orders present and had correct stop date. Stop date entered as 12/13/25 [12/13/2025] but needed to be 1/13/26 [1/13/2026] per infectious disease orders .Initials & Title of staff involved with this error: [Admission's Nurse], [RN Charge Nurse], [LPN A] .Were processes followed .NO .If No, who did not .[Admission's Nurse], [RN Charge Nurse] .Was counseling form completed .YES .What corrective action was taken .1:1 [One on One] [with] nurses involved .DON [Director of Nursing] 1:1 verbal conversation with admit nurse . Review of a COMMUNICATION note dated 12/26/2025 at 9:30 AM, revealed . RN informed the son that several doses of Ampicillin were missed inadvertently . Review of the Physician/NP Progress Note dated 12/26/2025 at 1:35 PM, revealed .Patient [Resident #1] seen evaluated today .Patient was discharged from hospital on IV ampicillin and Rocephin [Ceftriaxone] with plans to continue for 6 weeks with last doses on 1/13/2026. Order for ampicillin was noted to be discontinued on 12/13/2025, patient missed doses until restarted on 12/24/2025 .Patient has been advised .nursing spoke with son today [12/26/2025] no acute distress .Impression and plan .Enterococcus faecalis bacteremia secondary to UTI-spoke with ID today, due to missed doses of ampicillin, both ampicillin and Rocephin [Ceftriaxone] need to be extended out until January 28, 2026 stop date after a.m. doses of these medications, continue same lab work request while on IV antibiotics . Review of Resident #1's medical record from 12/5/2025 - 1/21/2026 revealed no evidence Resident #1 suffered a negative outcome related to the 59 omitted doses of Ampicillin 2 gram IV from 12/13/2025 - 12/24/2025. During an interview on 1/20/2026 at 12:26 PM, the DON stated on admission Resident #1 had orders for Ampicillin 2 gram IV q 4 hours and Rocephin (Ceftriaxone) 2 gram IV q 12 hours to be continued through 1/13/2026. The nurse [Admission's Nurse] entered the incorrect stop date for the Ampicillin as 12/13/2026 and it should have been 1/13/2026. The Admissions Nurse entered the correct stop date for the Rocephin (Ceftriaxone). The Admission's Nurse enters the admission orders into the facility's computer system, and the orders are faxed to pharmacy by someone in the admissions office. The Admissions Nurse enters the order and the RN Charge Nurse working the floor at the time the resident arrives at the facility confirms the order entered into the computer matches the physical orders sent with the resident. The DON confirmed the RN Charge Nurse didn't catch the end date discrepancy entered into the facility's computer system by the Admission's Nurse and neither did the pharmacy. The DON confirmed Resident #1's Ampicillin was discontinued on 12/13/2025 instead of 1/13/2026. The medication error was identified on 12/24/2025 by RN A while doing a chart check. Resident #1, Resident #1's representative, and the provider were made aware of the error. The DON confirmed Resident #1 did not receive Ampicillin as ordered by the physician from 12/14/2025 - 12/24/2025. A new order was obtained to resume the medication after the error was identified on 12/24/2025 and it resumed on 12/24/2025 at 4:00 PM. NP B notified the ID provider (ordering physician) of the error and the ID provider instructed that both the Rocephin and Ampicillin needed to be continued until 1/28/2026. The Admission's Nurse and the RN Charge Nurse were counseled after the error was identified. Resident #1 has had no negative outcomes related to the error. During an interview on 1/20/2026 at 3:14 PM, Resident #1 stated he was made aware by the facility that a mistake had been made with his antibiotics. During an interview on 1/20/2025 at 3:16 PM, NP B stated Resident #1 was admitted to the facility with orders for IV Ampicillin and Rocephin for bacteremia. The stop date for both antibiotics was ordered to be 1/13/2026 and stated .for some reason the Ampicillin was discontinued on 12/13/2025 . NP B stated she was unaware why the Ampicillin had been discontinued and stated .it was not intended to be discontinued on 12/13/2025 .I can't speak to why it was discontinued .I just know that was not the original stop date . NP B stated the Ampicillin was restarted on 12/24/2025. NP B notified the hospital ID physician that originally ordered the antibiotics regarding the error, and the hospital ID physician wanted both antibiotics (Rocephin and Ampicillin) to be extended until 1/28/2026 even though the Rocephin had been given as ordered. The hospital ID physician stated both antibiotics needed to be continued because they needed to .run congruently . NP B stated she was seeing Resident #1 frequently to monitor his labs and was unaware of any negative outcome related to Resident #1 not receiving the ordered antibiotics according to the physician's order. During an interview on 1/21/2026 at 1:30 PM, the DON stated Resident #1 was admitted to the facility on [DATE] with an order for Ampicillin 2 grams IV every 4 hours and Rocephin (Ceftriaxone) 2 grams IV every 12 hours with a stop date of 1/13/2026. The Admissions Nurse entered the order for Ampicillin and entered the stop date incorrectly as 12/13/2025. The stop date for the Ampicillin should have been 1/13/2026 according to the physician's order. The RN Charge Nurse confirmed the order entered by the Admissions Nurse and failed to recognize the stop date had been ordered incorrectly. A 24 hour Chart Check is performed by the night shift LPN to verify the orders entered into the computer were accurate and matched the physician's orders in the chart. LPN A did a 24 hour chart check on 12/6/2025 at 1:00 AM and failed to recognize the discrepancy in the stop date for the Ampicillin. The DON confirmed Resident #1's Ampicillin had been stopped in error on 12/13/2025 due to the incorrect stop date being entered by the Admissions Nurse. RN A identified the error on 12/24/2025 while doing a chart check and notified NP A. An order was obtained to resume the Ampicillin every 4 hours on 12/24/2025 from NP A. When NP B returned to the facility on [DATE], she called to discuss the error with the hospital ID physician that ordered the medication. The hospital ID physician ordered for both the Rocephin and Ampicillin to be continued until 1/28/2026 because the medications needed to run concurrently. The DON confirmed Resident #1's Ampicillin was ordered every 4 hours and the resident had missed doses from 12/13/2025 until it was resumed on 12/24/2025 due to the error. The DON stated Resident #1 had lab work drawn twice weekly that was reviewed by NP B. The DON stated she was unaware of any negative outcome to Resident #1 from not receiving the antibiotics. The DON confirmed the facility's medication verification processes had not been followed to ensure the medication ordered by the physician had been entered correctly into the computer system. During an interview on 1/21/2026 at 3:11 PM, RN A stated she was checking the medication (med) room to ensure any meds not used were ready for the pharmacy provider to collect the next day. RN A noticed .quite a few Ampicillin bags on the counter in the medication room . for Resident #1 which prompted her to look at the order due to the number of bags there were to see if the order had been discontinued. RN A stated the stop date for the Ampicillin on the physician's order was 1/13/2026 and the stop date in the computer system was listed as 12/13/2025. RN A notified NP A on 12/24/2025 at 11:00 AM. NP A stated she would notify the hospital ID physician. NP A called back and told RN A to resume the Ampicillin with the stop date of 1/13/2026. RN A reported the error to the ADON via the MEDICATION OCCURRENCE REPORT in the ADON's mailbox on 12/24/2025. RN A stated she provided care for Resident #1 and was unaware of any negative outcomes related to not receiving the antibiotic as scheduled. During an interview on 1/21/2026 at 3:36 PM, NP A stated she was made aware the Resident #1 had missed multiple doses of the IV Ampicillin due to the stop date being entered incorrectly in the computer system. NP A notified the ID provider through the secure messaging system and received an order to restart the Ampicillin and to continue the Rocephin (Ceftriaxone) until the Ampicillin was completed because the 2 antibiotics needed to be given in conjunction to give .adequate coverage . NP A stated Resident #1 received regular lab work and was unaware of any negative outcomes related to the omitted doses of Ampicillin. During an interview on 1/22/2026 at 11:14 AM, the Medical Director (MD) stated she had been made aware of Resident #1's medication error. Resident #1's primary source of sepsis was UTI. The MD stated . my understanding . is Resident #1's blood cultures and urine sample were both positive for Enterococcus, so UTI was determined to be source of Resident #1's infection. During the complete workup for Resident #1 the thrombus was found. The diagnosis of infective endocarditis is a presumptive diagnosis and Resident #1 is being empirically (treatment based on practical experience and educated guesswork rather than definitive scientific proof) treated to cover it. Resident #1 continued to receive Rocephin (Ceftriaxone) while the Ampicillin was stopped and had not exhibited any negative outcomes or evidence of worsening infection because of the missed doses of Ampicillin. Resident #1's labs have remained stable, and he has exhibited no concerns with fevers. The MD confirmed it was her expectation that physician's orders were followed. The MD stated the likelihood was low that Resident #1 would have any adverse outcomes due to not receiving the Ampicillin as ordered .especially since he was still receiving the Rocephin [Ceftriaxone] . During an interview on 1/22/2026 at 3:07 PM, the DON confirmed Resident #1's medication error resulted in Resident #1 missing antibiotic doses from 12/13/2025 until the error was identified and the medication resumed on 12/24/2025. Resident #1 had no negative outcomes as a result of the error according to lab results, vital signs, and observation. The DON stated Resident #1 missed .a lot of doses .In my opinion any med error is significant. See 684, 755, and 867.

Based on facility policy review, medical record review, and interview, the facility failed to follow physician's orders related to Intravenous (IV) medications for 1 resident (Residents #1) of 3 residents reviewed for IV medications. The findings include: Review of the facility's policy titled, Medication Orders, revised 11/2014, revealed .Each resident must be under the care of a Licensed Physician . Review of the facility's policy titled, Administering Medications, revised on 4/2019, revealed .Medications are administered in a safe and timely manner, and as prescribed .Medications are administered in accordance with prescriber orders, including any required time frame . Review of the medical record revealed Resident #1 was admitted to facility on 12/5/2025 with diagnoses including Urinary Tract Infection (UTI), Retention of Urine, Enterococcus Faecalis Bacteremia (a common bacterium that can cause serious opportunistic infections). Review of the hospital Discharge Summary for Resident #1 dated 12/5/2025, revealed .admit date : [DATE] .discharge date : [DATE] [12/5/2025] .Active Problems .Urinary tract infection with hematuria due to urinary retention .Enterococcal sepsis [the body's extreme response to infection] .secondary to UTI .Anemia .Left atrial thrombus per TEE [Transesophageal Echocardiogram- a heart imaging test for clear views of the heart's structure and function], presumably [likely based on reasonable assumptions, though not certain .] infected .Blood cultures confirmed persistent Enterococcus faecalis bacteremia, and urine cultures were positive for the same organism. Infectious disease [ID] consultation recommended management as infectious endocarditis [inflammation of the inner layer of the heart] .At the time of discharge planning, he was clinically stable .awaiting transfer to a skilled nursing facility for completion of intravenous antibiotic therapy and further rehabilitation .In summary .Per discussion with ID plan for ampicillin [antibiotic medication] 2 g [grams] IV every 4 hours .until January 13, 2026. This represents 6 weeks of coverage after first set of negative blood cultures .It is medically necessary to admit from the hospital to SNF [skilled nursing facility] .Discharge Medication List .ampicillin .Infuse 2 g into a venous catheter every 4 (four) hours .Last Dose .December 5, 2025 at 10:07 AM .see infectious disease orders . Review of the hospital Infectious Disease Physician Progress Note dated 12/5/2025, revealed .Orders for .long-term care facility .Ampicillin 2 g IV every 4 hours .to continue through 2 PM [2:00 PM] on Tuesday, January, 13, 2026 . Review of the physician's order entered into the facility's computer system dated 12/5/2025, revealed .Order Date .12.5.2025 [12/5/2025] .Ampicillin Sodium Solution .2 GM .intravenously every 4 hours for bacterial infection until 12/13/2025 14:07 [2:07 PM] .Start Date .12/5/2025 .1600 [4:00 PM] .End Date .12/13/2025 . The order was entered into the facility's computer system by the Admission's Nurse on 12/5/2025 at 2:08 PM and confirmed by the Registered Nurse (RN) Charge Nurse on 12/5/2025 at 9:31 PM (the order was to be continued through 1/13/2025). Review of Resident #1's physical chart revealed the hospital Discharge Summary and the hospital Infectious Disease Physician Progress Note dated 12/5/2025 with the order for .Ampicillin 2 g [grams] IV every 4 hours .to continue through 2 PM on Tuesday January 13, 2026 . was signed by the Admission's Nurse on 12/5/2025 at 2:06 PM and the RN Charge Nurse on 12/5/2025 at 9:58 PM. Review of the comprehensive care plan initiated on 12/6/2025, revealed . ANTIBIOTIC THERAPY r/t [related to] urinary tract infections (UTI) . Ampicillin Sodium 12/05/2025-12/13/2025 . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Resident #1 received antibiotic medication during the look back period. Resident #1 received IV medications at the facility. Review of the Physician/Nurse Practitioner (NP) Progress Note dated 12/17/2025, revealed .Labs [laboratory test] yest [yesterday] WNL [within normal limits] .denies any fever, chills, chest pain, shortness of breath, nausea, vomiting, abdominal pain, or dysuria .PHYSICAL EXAMINATION .in no apparent distress .IMPRESSION/PLAN .Enterococcus faecalis bacteremia .UTI - Continue Rocephin [Ceftriaxone] 2 g every 12 hours through 1/13/2026 . Review of a physician's order dated 12/24/2025, revealed .Ampicillin Sodium .Use 2 gram intravenously every 4 hours for antibiotic therapy . Review of the MEDICATION ADMINISTRATION RECORD (MAR) dated 12/1/2025 - 12/31/2025, revealed Resident #1 received Ampicillin Sodium Solution 2 grams IV every four hours starting on 12/5/2025 at 8:00 PM through 12/13/2025 with the last dose being administered on 12/13/2025 at 4:45 PM. Continued review revealed Resident #1 resumed Ampicillin Sodium 2 grams IV every four hours starting on 12/24/2025 at 4:00 PM. [Resident #1 missed 59 doses of Ampicillin from 12/13/2025 - 12/24/2025]. Review of the MEDICATION OCCURRENCE REPORT for Resident #1 revealed .Drug Name: Ampicillin .Occurrence Date .12-13 [12/13/2025] thru 12/24 [12/24/2025] .Medication Order: Ampicillin IV 2 GM Q 4 [every 4 hours] until 1/13/26 [1/13/2026] .Name of Provider Notified .[NP A] .Patient [Resident #1] Notified by: [RN A] .12/24/2025 .1600 [4:00 PM] .Pharmacy notified by: [RN A] .12/24/25 [12/24/2025] .11 am [11:00 AM] .TYPE OF ERROR .Omitted Dosage .CAUSE OF ERROR .admission Order Error .Chart Check Error .admission DIAGNOSES .Sepsis due to Uti [Urinary Tract Infection -UTI] SP [status post] fall, weakness .Additional Information & Patient Condition .Patient condition is stable .What caused this occurrence .Wrong stop date put in on admission .Date Error identified: 12/24/25 [12/24/2025] .11 am [11:00 AM] .Investigation .Order stop date was incorrectly entered on admission. Infectious disease orders present and had correct stop date. Stop date entered as 12/13/25 [12/13/2025] but needed to be 1/13/26 [1/13/2026] per infectious disease orders . Review of the Physician/NP Progress Note dated 12/26/2025 at 1:35 PM, revealed .Patient [Resident #1] seen evaluated today .Patient was discharged from hospital on IV ampicillin .with plans to continue for 6 weeks with last doses on 1/13/2026. Order for ampicillin was noted to be discontinued on 12/13/2025, patient missed doses until restarted on 12/24/2025 [a lapse of 11 days] .no acute distress .Impression and plan .Enterococcus faecalis bacteremia secondary to UTI-spoke with ID today, due to missed doses of ampicillin .need to be extended out until January 28, 2026 stop date after a.m. doses .continue same lab work request while on IV antibiotics . During an interview on 1/20/2026 at 12:26 PM, the Director of Nursing (DON) stated on admission Resident #1 had orders for Ampicillin 2 gram IV q 4 hours through 1/13/2026. The Admission's Nurse entered the incorrect stop date for the Ampicillin as 12/13/2026 and it should have been 1/13/2026. The Admission's Nurse entered the admission orders into the facility's computer system, and the orders were faxed to the pharmacy by a staff member in the admissions office. The Admissions Nurse is to enter the physician's order into the system and the RN Charge Nurse working the floor at the time the resident arrives to the facility confirms the order entered into the computer matches the physical orders sent with the resident. The DON confirmed the RN Charge Nurse did not catch the end date discrepancy entered into the facility's computer system by the Admission's Nurse and neither did the pharmacy consultant. The DON confirmed Resident #1's Ampicillin was discontinued on 12/13/2025 instead of 1/13/2026. The medication error was identified on 12/24/2025 by RN A while doing a chart check. The DON confirmed Resident #1 did not receive Ampicillin as ordered by the physician from 12/14/2025 - 12/24/2025. A new order was obtained to resume the medication after the error was identified on 12/24/2025 and was resumed on 12/24/2025 at 4:00 PM. Resident #1 has had no negative outcomes related to the error. During an interview on 1/22/2026 at 11:14 AM, the Medical Director (MD) stated she had been made aware of Resident #1's medication error. Resident #1's primary source of sepsis was UTI. The MD stated . my understanding . is Resident #1's blood cultures and urine sample were both positive for Enterococcus, so UTI was determined to be source of Resident #1's infection. During the complete workup for Resident #1 the thrombus was found. The diagnosis of infective endocarditis is a presumptive diagnosis and Resident #1 was being empirically (treatment based on practical experience and educated guesswork rather than definitive scientific proof) treated to cover it. Resident #1 continued to receive Rocephin (Ceftriaxone) while the Ampicillin was stopped and had not exhibited any negative outcomes or evidence of worsening infection because of the missed doses of Ampicillin. Resident #1's labs have remained stable, and he has exhibited no concerns with fevers. The MD confirmed it was her expectation that physician's orders were followed. See 755, 760, and 867.

Based on facility policy review, pharmaceutical service contract review, medical record review, and interview, the facility's consultant pharmacist and pharmacy service provider failed to identify a transcription discrepancy to prevent a medication error for 1 resident (Resident #1) of 3 residents reviewed for intravenous (IV) medications.The findings include: Review of the facility's policy titled, Pharmacy Services - Role of the Consultant Pharmacist, revised 4/2019, revealed .The facility will give the consultant pharmacist a current roster and will inform the consultant pharmacist of all new admissions .to the facility .consultant pharmacist shall provide consultation on all aspects of pharmacy services in the facility and collaborate with the facility .to .The consultant pharmacist may also collaborate on other aspects of pharmacy services, including .Helping the facility develop a process for receiving, transcribing, and recapitulating medication orders .The Consultant Pharmacist will provide specific activities related to medication regimen review including .a documented review of the medication regimen of each resident at least monthly, or more frequently under certain conditions .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 . Review of the facility's policy titled, Medication Regimen Review [MRR], dated 5/2019, revealed .The Consultant Pharmacist performs a MRR for every resident in the facility receiving medication .upon admission (or as close to admission as possible) .and at least monthly .The MRR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities, for example .omissions of ordered medications .other medication errors, including those related to documentation .An 'irregularity' refers to the use of medication that is inconsistent with accepted pharmaceutical services standards of practice . Review of the PHARMACEUTICAL PRODUCTS AND SERVICES AGREEMENT between the facility and the pharmacy provider dated 10/1/2024, revealed .Pharmacy will provide .pharmacy consulting services .Pharmacy will use a computerized medical record system for managing resident information, physician orders, and medication administration records (MAR) .Operator will timely provide Pharmacy with copies of the prescription and/or medication orders for each new order .PHARMACY CONSULTING SERVICES .consulting services .may include .the provision of a written report regarding .the results of the drug regimen review, noting any irregularities or other areas of concern .Drug Regimen Review .Pharmacy (through a licensed pharmacist) will review the drug regimen of each resident .review must include a review of the resident's medical chart. The Pharmacy must report any irregularities to the attending physician and the Facility's medical director and director of nursing .The Parties intend to use an electronic operating system to provide medication administration record services ('eMAR [electronic medication administration record] Services') .eMAR Services are intended to .provide the Parties with access to updated resident information .and enhance communication between Operator and Pharmacy .The Parties have identified PointClickCare (PCC) as such a third-party eMAR vendor . Review of the medical record revealed Resident #1 was admitted to facility on 12/5/2025 with diagnoses including Urinary Tract Infection (UTI), Retention of Urine, Enterococcus Faecalis Bacteremia (a common bacterium that can cause serious opportunistic infections). Review of the hospital Discharge Summary for Resident #1 dated 12/5/2025, revealed .Discharge Medication List .ampicillin [antibiotic medication] .Infuse 2 g [grams] into a venous catheter every 4 (four) hours .Last Dose .December 5, 2025 at 10:07 AM .see infectious disease orders . Review of the hospital Infectious Disease Physician Progress Note dated 12/5/2025, revealed .Orders for .long-term care facility .Ampicillin 2 g [grams] IV every 4 hours .to continue through 2 PM [2:00 PM] on Tuesday, January, 13, 2026 . Continued review revealed the pharmacy provider received faxed copies of Resident #1's orders on 12/5/2025 at 1:07 PM. Review of the physician's order entered into the facility's computer system (Point Click Care) (PCC) dated 12/5/2025, revealed .Ampicillin Sodium Solution .2 GM .intravenously every 4 hours for bacterial infection until 12/13/2025 14:07 [2:07 PM] .Start Date .12/5/2025 .1600 [4:00 PM] .End Date .12/13/2025 . The order was entered into the facility's computer system (PCC) on 12/5/2025 at 2:08 PM and confirmed on 12/5/2025 at 9:31 PM. Review of the facility's pharmacy provider Note to the Director of Nursing dated 12/5/2025, revealed .CMS [Centers for Medicare and Medicaid] guidelines .require a licensed pharmacist's review of a resident's medications at least monthly or a more frequent review of the regimen depending on the resident's condition and the risks or adverse consequences related to current medications .This resident [Resident #1] was reported to have recently been admitted [to the facility] .the resident's [Resident #1] medications have been reviewed .Reviewed with no recommendations . Review of the admission Pharmacy Drug Regimen Review dated 12/8/2025, revealed .medications reviewed with no recommendations or irregularities at this time . The admission Pharmacy Drug Regimen Review was completed by the facility's Pharmacy Consultant (a contracted Pharmacist not employed by the facility's pharmacy provider). Review of the MAR dated 12/1/2025 - 12/31/2025, revealed Resident #1 received Ampicillin Sodium Solution 2 GM IV every four hours starting on 12/5/2025 at 8:00 PM through 12/13/2025 with the last dose being administered on 12/13/2025 at 4:45 PM (a lapse in 11 days of treatment). Continued review revealed Resident #1 resumed Ampicillin Sodium 2 GM IV every four hours starting on 12/24/2025 at 4:00 PM. [Resident #1 missed 59 doses of Ampicillin from 12/13/2025 - 12/24/2025]. Review of the MEDICATION OCCURRENCE REPORT for Resident #1 revealed .Drug Name: Ampicillin .Occurrence Date .12-13 [12/13/2025] thru 12/24 [12/24/2025] .Medication Order: Ampicillin IV 2 GM Q 4 [every 4 hours] until 1/13/26 [1/13/2026] .Pharmacy notified by: [RN A] .12/24/25 [12/24/2025] .11 am .TYPE OF ERROR .Omitted Dosage .CAUSE OF ERROR .admission Order Error .Chart Check Error .What caused this occurrence .Wrong stop date put in on admission .Date Error identified: 12/24/25 [12/24/2025] .11 am [11:00 AM] .Investigation .Order stop date was incorrectly entered on admission. Infectious disease orders present and had correct stop date. Stop date entered as 12/13/25 [12/13/2025] but needed to be 1/13/26 [1/13/2026] per infectious disease orders . During an interview on 1/21/2026 at 1:30 PM, the Director of Nursing (DON) stated Resident #1 was admitted to the facility on [DATE] with an order for Ampicillin 2 grams IV every 4 hours with a stop date of 1/13/2026. The Admissions Nurse entered the order for Ampicillin and entered the stop date incorrectly as 12/13/2025. The stop date for the Ampicillin should have been 1/13/2026 according to the physician's order. The DON confirmed Resident #1's Ampicillin had been stopped in error on 12/13/2025 due to the incorrect stop date being entered by the Admissions Nurse. The error was identified on 12/24/2025 (11 days after the medication was stopped in error) and an order was obtained to resume the medication. The DON confirmed Resident #1's Ampicillin was ordered every 4 hours and the resident had missed doses from 12/13/2025 until it was resumed on 12/24/2025 due to the error. The facility's pharmacy provider received a copy of Resident #1's admission orders via fax on 12/5/2025 and did a Drug Regimen Review on 12/5/2025 with no recommendations noted. The Consultant Pharmacist (independent contractor that is not employed by the facility's pharmacy provider) reviewed Resident #1's medication regimen on 12/8/2025 and identified no recommendations or irregularities. The DON confirmed the facility's pharmacy provider, nor the Consultant Pharmacist identified the stop date for Ampicillin had been entered incorrectly into the PCC system. During a telephone interview on 1/21/2026 at 2:39 PM, the Consultant Pharmacist stated she was contracted and did not work for the facility's pharmacy provider. The Consultant Pharmacist stated she reviewed new admission medications and compared the physician's orders matched what was entered into PCC. If the Consultant Pharmacist noticed any discrepancies in what was ordered versus what was entered, she would notify the DON or Assistant Director of Nursing (ADON) through written communication or via text if it needed to be corrected immediately. The Consultant Pharmacist stated she did not recall Resident #1 directly and did not have access to the record at the time of the interview and stated .I should have . when this surveyor asked if she would have identified that a stop date was entered incorrectly into the computer. The Consultant Pharmacist stated stop dates were reviewed as part of the medication regimen review for accuracy. During a telephone interview on 1/22/2026 at 11:40 AM, the Director of Operations for the facility's pharmacy provider stated the facility faxed each resident's admission orders to the pharmacy provider. Medication orders were entered into PCC by the facility. The pharmacy provider's .medical records department . were responsible to ensure the orders that were faxed to the pharmacy provider matched what was entered by the facility into PCC. The review by the .medical records department . was not done right away and was completed for Resident #1 on 12/8/2025 (they don't work weekends). The Director of Operations confirmed the order faxed to the pharmacy provider for Resident #1 on 12/5/2025 showed Ampicillin 2g IV every 4 hours with a stop date of 1/13/2026. The Director of Operations confirmed the facility entered the stop date as 12/13/2025 into PCC. The Director of Operations confirmed the verification by the .medical records department . should have identified the stop date in PCC was not correct and the pharmacy provider should have notified the facility. The Drug Regimen Review (DRR) that was done by the pharmacy provider on 12/5/2025 is a different function where the pharmacist does .basically a clinical view looking at therapeutic things . but would not do a medication reconciliation to verify orders entered in PCC by the facility matched what was faxed to the pharmacy provider. See 684, 760, and 867

Based on facility policy review, medical record review, facility document review, and interview, the facility failed to timely identify a quality deficiency (significant medication error of 59 omitted doses of intravenous (IV) antibiotics) for Resident #1 and failed to implement a Process Improvement Project (PIP) to prevent recurrence. The findings include: Review of the facility's policy titled, Adverse Consequences and Medication Errors, revised 4/2014, revealed .A 'medication error' is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders .Examples of medications errors include .Omission- a drug is ordered but not administered .When a resident receives a new medication, the medication order is evaluated for the following .The dose, route of administration, duration .In the event of a significant medication-related error .immediate action is taken .to protect the resident's safety and welfare .The Attending Physician is notified promptly of any significant error .The QAPI [Quality Assurance Performance Improvement] Committee will conduct a root cause analysis of medication administration errors to determine the source of errors, implements process improvement steps, and compare results over time to determine that system improvements are effective in reducing errors . Review of the facility's policy titled, Administering Medications, revised on 4/2019, revealed .Medications are administered in a safe and timely manner, and as prescribed .Medications are administered in accordance with prescriber orders, including any required time frame .Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training . Review of the facility's policy titled, Medication Regimen Review (MRR), dated 5/2019, revealed .The Consultant Pharmacist performs a MRR for every resident in the facility receiving medication .upon admission (or as close to admission as possible) .and at least monthly .The MRR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities, for example .omissions of ordered medications .other medication errors, including those related to documentation .An 'irregularity' refers to the use of medication that is inconsistent with accepted pharmaceutical services standards of practice .The facility includes a review of key issues related to medication and medication irregularities as part of the QAPI program . Review of the facility's undated policy titled, Quality Assurance Performance Improvement Process, revealed .will enable the identification of problems at every level and will ensure appropriate measures are taken .The ultimate goals of committees at all levels are to identify trends, perform root cause analyses, prioritize issues in order of importance, initiate Process Improvement Projects to enable an effective and sustainable solution, monitor and revise as needed .Facility responsibilities .Obtain feedback from direct care staff .to identify problems and opportunities for improvement .Collect, analyze, trend and monitor facility data including outcomes of subpopulations to address any health equity issues .Determine the root cause of each identified opportunities for improvement .Prioritize the order to develop PIPs .Develop Performance Improvement Projects (PIP) .Monitor and update the PIPS as necessary . Review of the medical record revealed Resident #1 was admitted to facility on 12/5/2025 with diagnoses including Urinary Tract Infection (UTI), Retention of Urine, Enterococcus Faecalis Bacteremia (a common bacterium that can cause serious opportunistic infections). Review of the MEDICATION OCCURRENCE REPORT for Resident #1 revealed .Drug Name: Ampicillin .Occurrence Date .12-13 [12/13/2025] thru 12/24 [12/24/2025] .Medication Order: Ampicillin IV 2 GM [grams] Q 4 [every 4 hours] until 1/13/26 [1/13/2026] .TYPE OF ERROR .Omitted Dosage .CAUSE OF ERROR .admission Order Error .Chart Check Error .admission DIAGNOSES .Sepsis due to Uti [Urinary Tract Infection -UTI] SP [status post] fall, weakness .Additional Information & Patient Condition .Patient condition is stable .What caused this occurrence .Wrong stop date put in on admission .Date Error identified: 12/24/25 [12/24/2025] .11 am [11:00 AM] .Investigation .Order stop date was incorrectly entered on admission. Infectious disease orders present and had correct stop date. Stop date entered as 12/13/25 [12/13/2025]but needed to be 1/13/26 [1/13/2026] per infectious disease orders .Initials & Title of staff involved with this error: [Admissions Nurse], Registered Nurse (RN) Charge Nurse], [Licensed Practical Nurse (LPN) A] .Were processes followed .NO .Was counseling form completed .YES .What corrective action was taken .1:1 [One on One] [with] nurses involved .DON [Director of Nursing] 1:1 verbal conversation with admit nurse . Review of the facility's QAPI sign in sheets revealed the last QAPI meeting was held on 12/9/2025 (15 days prior to the identification of the medication error for Resident #1). During an interview on 1/21/2026 at 4:18 PM, the Assistant Director of Nursing (ADON) stated she was responsible for investigating medication errors to present to the QAPI committee. Resident #1's Ampicillin was ordered on admission [DATE]) every 4 hours with a stop date of 1/13/2026. The Admissions Nurse entered the order with a stop date of 12/13/2025 instead of 1/13/2026. The confirming nurse (RN Charge Nurse) confirmed the order with the incorrect stop date and failed to identify the stop date entered by the Admissions Nurse was incorrect. LPN A did the 24 Hour Chart Check on 12/6/2026 at 1:00 AM and failed to identify the stop date was entered incorrectly. The procedure of confirming orders and for the 24 Hour Chart Check included checking the written physician's order matched what was entered into the computer system. The pharmacy provider entered the stop date in their system correctly as 1/13/2026 and continued sending the Ampicillin to the facility. RN A noticed an abundance of Ampicillin in the medication room on 12/24/2025, which prompted her to do a chart check and the error was identified (11 days after the medication was stopped). The ADON confirmed the Admissions Nurse failed to enter the correct stop date, the RN Charge Nurse failed to identify the stop date was entered incorrectly when she confirmed the order, and LPN A failed to identify the error during the 24 Hour Chart Check. The ADON confirmed the facility's medication verification processes were not followed. The ADON stated her investigation revealed the error was .an admission order error .we will discuss in QAPI .the last week in January . The Admissions Nurse and the RN Charge Nurse were educated to confirm all aspects of the order were entered correctly. The ADON confirmed no new processes had been put into place to prevent recurrence and would be discussed in QAPI .the last week in January . During an interview on 1/22/2206 at 2:10 PM, the Interim Administrator stated she started at the facility on 1/6/2026. The Interim Administrator stated she was aware of Resident #1's medication error (medication error identified on 12/24/2025 prior to the Interim Administrator arriving at the facility). The Interim Administrator was unaware of any current PIP related to Resident #1's medication error. The Interim Administrator stated the facility's QAPI committee met monthly and would discuss the medication error at the January QAPI meeting. During an interview on 1/22/2026 at 3:07 PM, the DON confirmed Resident #1's medication error resulted in Resident #1 missing antibiotic doses from 12/13/2025 until the error was identified and the medication resumed on 12/24/2025 (59 missed doses). Resident #1 had no negative outcomes because of the error according to lab results, vital signs, and observation. The DON stated Resident #1 missed .a lot of doses .In my opinion any med error is significant . The DON confirmed the facility had not had an ad Hoc QAPI meeting to discuss the medication error and the failure of the Admissions Nurse, the facility's pharmacy provider, the Pharmacy Consultant, the RN Charge Nurse, and LPN A to identify the error. The DON stated the error would be discussed in the next QAPI meeting on 1/29/2026 (36 days after the error was identified by the facility) and a PIP would be put into place after the QAPI meeting. The DON confirmed there was no current PIP in place to prevent recurrence. Corrective actions taken after the incident included education to the RN Charge Nurse and the Admissions Nurse, and the ADON was confirming all orders entered by the Admissions Nurse. The DON stated there was no documentation of the ADON checking the orders entered by the Admissions Nurse were correct and stated .that will be part of the PIP . See 684, 755, and 760.

45837 Based on facility policy review, observations, and interview, the facility failed to maintain a sanitary kitchen environment by failing to ensure 2 of 3 kitchen staff wore protective beard coverings while preparing food and by storing expired food items that were observed in 1 of 1 dry storage room and 1 of 1 walk in refrigerator with the potential to affect 68 of 72 residents. The findings include: Review of the facility's policy titled, Food Preparation Area, dated [DATE], showed .Our facility maintains a clean, sanitary and safe food preparation area .food service tray line .assure that a sanitary environment is maintained . Review of the facility's policy titled, Food Storage, dated [DATE], showed .Food storage areas .maintained in a clean, safe and sanitary manner . During an observation and interview on [DATE] at 10:04 AM, with the Certified Dietary Manager (CDM) in the kitchen, the Food Service Manager and a dietary aide had beards and were preparing food with no beard coverings worn. The CDM stated staff with beards should wear beard covers to maintain a sanitary food preparation environment and confirmed the Food Service Manager and the aide were not wearing beard covers. During an observation and interview on [DATE] at 10:20 AM, with the CDM in the walk-in refrigerator, the following expired food items were observed: 5- 4 ounce (oz.) nectar thick cranberry cocktails expired ,d+[DATE] 5- 4 oz. nectar thick orange juices expired ,d+[DATE] 2- 5 pound bags grated parmesan cheese (approximately ,d+[DATE] full) expired [DATE] The CDM confirmed the food items were expired and available for resident use. During an observation and interview on [DATE] at 10:35 AM, with the CDM in the dry storage room, the following expired food items were observed: 4- 12 count packages of flour tortillas (burrito size) expired [DATE] The CDM confirmed the food items were expired and available for resident use.

40639 45837 Based on facility policy review, record review and interview, the facility failed to document evidence the residents or their representatives had received information to formulate an advance directive for 24 residents (Residents #2, #8, #12, #16, #20, #21, #27, #30, #38, #40, #47, #48, #51, #58, #59, #163, #164, #165, #167, #213, #214, #313, #314 and #316) of 25 residents reviewed for advance directives. The findings include: Review of the facility's policy titled, Advance Directives, dated 6/22/2023, showed .Upon admission .the business office will provide .information .resident's right to prepare an advance directive . Resident #2 was admitted to the facility on [DATE] with diagnoses including Chronic Kidney Disease and Congestive Heart Failure. Resident #8 was admitted to the facility on [DATE] with diagnoses including Cellulitis of Left Lower Limb and Essential (Primary) Hypertension. Resident #12 was admitted to the facility on [DATE] with diagnoses including Post-Traumatic Stress Disorder, Parkinson's Disease, and Chronic Obstructive Pulmonary Disease. Resident #16 was admitted to the facility on [DATE] with diagnoses including Vascular Dementia, Atrial Fibrillation, and Transient Ischemic Attack. Resident #20 was admitted to the facility on [DATE] with diagnoses including Back Pain and Pain in Right Knee. Resident #21 was admitted to the facility on [DATE] with diagnoses including Infection and Inflammatory Reaction due to Internal Right Hip Prosthesis, and Hypertension. Resident #27 was admitted to the facility on [DATE] with diagnoses including Fracture of Unspecified Part of Neck of Left Femur. Resident #30 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure with Hypoxia, and Depression. Resident #38 was admitted to the facility on [DATE] with diagnoses including Chronic Congestive Heart Failure and Parkinson's Disease. Resident #40 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure with Hypoxia, and Type 2 Diabetes Mellitus. Resident #47 was admitted to the facility on [DATE] with diagnoses including Acute Respiratory Failure and History of Falling. Resident #48 was admitted to the facility on [DATE] with diagnoses including Metabolic Encephalopathy, Adult Failure to Thrive, and Chronic Kidney Disease. Resident #51 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, and Chronic Kidney Disease. Resident #58 was admitted to the facility on [DATE] with diagnoses including Encounter for Orthopedic Aftercare Following Surgical Amputation and Type 2 Diabetes Mellitus. Resident #59 was admitted to the facility on [DATE] with diagnoses including Displaced Fracture of Right Femur and Dementia. Resident #163 was admitted to the facility on [DATE] with diagnoses including Fracture to Left Femur and Type 2 Diabetes Mellitus. Resident #164 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease and Congestive Heart Failure. Resident #165 was admitted to the facility on [DATE] with diagnoses including Malignant Neoplasm of Colon and Chronic Obstructive Pulmonary Disease. Resident #167 was admitted to the facility on [DATE] with diagnoses including Benign Prostatic Hyperplasia and Chronic Kidney Disease. Resident #213 was admitted to the facility on [DATE] with diagnoses including Encephalopathy and Urinary Tract Infection. Resident #214 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Chronic Kidney Disease and Dysphagia. Resident #313 was admitted to the facility on [DATE] with diagnoses including Pneumonia and Type 2 Diabetes Mellitus. Resident #314 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease and Muscle Weakness. Resident #316 was admitted to the facility on [DATE] with diagnoses including Malignant Neoplasm of Lung, Acute Respiratory Failure and Dysphagia. Record review, during the initial screening process, showed no documented evidence Residents #2, #8, #12, #16, #20, #21, #27, #30, #38, #40, #47, #48, #51, #58, #59, #163, #164, #165, #167, #213, #214, #313, #314 and #316 or their representatives had received information to formulate an advance directive. During an interview on 8/15/2023 at 9:31 AM, the Director of Nursing (DON) stated the facility offered education related to advance directives on admission for every resident. The DON confirmed the facility did not have signed confirmation maintained in the residents' medical record for Residents #2, #8, #12, #16, #20, #21, #27, #30, #38, #40, #47, #48, #51, #58, #59, #163, #164, #165, #167, #213, #214, #313, #314 and #316 or their representatives had received information to formulate advance directives. 48581

Based on facility policy review, record review, and interview, the facility failed to develop a comprehensive care plan for trauma informed care for 1 resident ( Resident #12 ), anti-coagulant therapy for 1 resident ( Resident #27 ), and pressure ulcers for 2 residents ( Resident #38, and #51 ) of 25 residents reviewed for comprehensive care plans. The findings include: Review of the facility's policy titled, Resident Assessment/Care Plan Process, dated 7/3/2019, showed .A comprehensive care plan should be completed no later than seven (7) calendar days after the CAA [Care Area Assessment] completion date per RAI [Resident Assessment Instrument] guidelines . Resident #12 was admitted to the facility on [DATE] with diagnoses including Post-Traumatic Stress Disorder (PTSD), Parkinson's Disease, and Chronic Obstructive Pulmonary Disease. Review of Resident #12 's admission Minimum Data Set (MDS) assessment dated [DATE], showed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Further review showed the resident had no mood indicators, no behaviors, and a diagnosis for Post Traumatic Stress Disorder. Review of Resident #12's comprehensive care plan dated 7/13/2023, showed no documentation for trauma informed care. Resident #27 was admitted to the facility on [DATE] with diagnoses including, Fractured Femur with Repair, Anxiety Disorder, and Pulmonary Fibrosis. Review of Resident #27's admission MDS assessment dated [DATE], showed the resident had a BIMS score of 15, which indicated the resident was cognitively intact. Further review showed the resident required extensive assistance of 2 staff members for transfers, mobility, bathing, and toileting, and received 7 anticoagulants for the review period. Review of Resident #27's comprehensive care plan dated 7/21/2023, showed no documentation for anti-coagulant therapy. Resident #38 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Pressure Ulcer of Sacral Region, Juvenile Idiopathic Scoliosis and Parkinson's Disease. Review of Resident #38's 5-day admisssion MDS assessment dated [DATE], showed the resident had a BIMS score of 15, which indicated the resident was cognitively intact. Further review showed the resident required extensive assistance of 2 staff members for bed mobility, transfers, dressing, toilet use, and personal hygiene. Continued review showed the resident had an unhealed, unstageable pressure ulcer. Review of Resident #38's comprehensive care plan dated 7/25/2023, showed no documentation of the unstageable pressure ulcer. Resident #51 admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, and Chronic Kidney Disease. Review of Resident # 51's admission MDS assessment dated [DATE], showed the resident had a BIMS score of 15, which indicated the resident was cognitively intact. Further review showed the resident required limited assistance with bed mobility, supervision with eating, and extensive assistance of 1 staff member with toileting, transfers, bathing, and ambulation. Continued review showed the following pressure ulcers were present on admission: 1 stage 2 wound and 2 stage 3 wounds. Review of Resident #51's comprehensive care plan dated 7/21/2023, showed no documentation of the 3 pressure ulcers. During an interview on 8/16/2023 at 10:56 AM, the MDS Coordinator stated Resident #38's pressure ulcer was present on the 5-day MDS assessment dated [DATE]. The MDS Coordinator confirmed there was no care plan developed for the pressure ulcer. During an interview on 8/16/2023 at 11:00 AM, the MDS Coordinator, confirmed the pressure ulcers assessed on the MDS dated [DATE] for Resident #51 was not documented or addressed on the comprehensive care plan for wound care. Further interview confirmed Resident #27's anticoagulation therapy was not addressed on the comprehensive care plan. During an interview on 8/16/2023 at 11:02 AM, the MDS Coordinator confirmed the facility did not develop a comprehensive care plan for trauma informed care related to PTSD for Resident #12. During an interview on 8/16/2023 at 11:30 AM, the Director of Nursing (DON) confirmed Resident #12's trauma informed care related to PTSD was not addressed on the comprehensive care plan. Further interview confirmed Resident #38 and Resident #51's pressure ulcers/skin risk identified on admission assessments was not addressed on the comprehensive care plan. 40639 45837 48581

Based on facility policy review, record review, and interview the facility failed to revise the comprehensive care plan for 1 resident (Resident #16) to include fall interventions of 7 residents reviewed for falls and failed to revise the comprehensive care plan for 1 resident (Resident #30) to include a pressure ulcer of 3 residents reviewed for pressure ulcers The findings include: Review of the facility policy titled, Resident Assessment/Care Plan Process, last reviewed 12/21/2022, showed .Care plans should be revised as changes in the patient's condition dictates . Resident # 16 was admitted to the facility on [DATE] with diagnoses including Fracture of Left Femur, Difficulty in Walking, Muscle Weakness, and Vascular Dementia. Review of a 5-Day admission Minimum Data Set (MDS) assessment dated [DATE], showed the resident had a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderate cognitive impairment. The resident required limited assistance of 1 staff member for transfers, extensive assistance of 2 staff members for toilet use and personal hygiene. Review of Resident #16's comprehensive care plan dated 7/21/2023 showed .AT RISK FOR FALLS .call light .within reach and encourage the resident to use it for assistance .Bed in low position .Encourage and assist to wear proper, non-slip footwear .Encourage to use handrails or assistive devices . Review of a facility Fall Investigation Form dated 8/8/2023, showed .found by staff on the floor at the foot of her bed .stated .getting up to go to bed .was in bed prior to getting up .Bruise noted to forehead with small abrasion between eyes .Bed alarm placed . Review of Resident #16's active Physician Orders dated 8/16/2023 showed .bed alarm .Order Date .8/8/2023 . Review of Resident #16's comprehensive care plan showed the care plan had not been revised to include a bed alarm. During an interview on 8/16/2023 at 10:00 AM, the MDS Coordinator confirmed Resident #16's comprehensive care plan had not been revised to include a bed alarm ordered on 8/8/2023. Resident #30 was admitted to the facility on [DATE] with diagnoses including Cellulitis of Left Lower Limb, Chronic Obstructive Pulmonary Disease, Need for Assistance with Personal Care, and Depression. Review of a 5-day admission MDS assessment dated [DATE], showed the resident had a BIMS score of 12 which indicated the resident had moderate cognitive impairment. The resident required extensive assistance of 2 staff members for bed mobility, dressing, toilet use, and personal hygiene. Further review showed the resident was at risk of developing pressure ulcers. Review of Resident #30's comprehensive care plan dated 7/18/2023, showed .at risk for .ALTERATION IN SKIN INTEGRITY . Review of a wound note dated 8/1/2023, showed .Rt [right] buttock stage 2 .4x5cm [centimeter] . Review of Resident #30's active Physician Orders dated 8/16/2023 showed .Bilat [Bilateral] buttock .cleanse NS [Normal Saline], pat dry, apply [paste] qid [four times a day] . During an interview on 8/16/2023 at 2:25 PM, the MDS Coordinator confirmed Resident #30's comprehensive care plan had not been revised to reflect the stage 2 pressure ulcer.

Based on record review, and interview the facility failed to notify a resident/family in writing of a transfer and discharge for 1 resident (Resident #61) of 3 residents reviewed for discharge. The findings include: Resident #61was admitted to the facility on [DATE] with diagnoses including Adult Failure to Thrive, and Unspecified Protein-Calorie Malnutrition. Review of Resident #61's nurse progress note dated 6/2/2023, showed the resident was transferred to a local hospital for evaluation and treatment due to rectal bleeding. Resident #61 was admitted to the hospital. Review of Resident #61's discharge Minimum Data Set (MDS) dated [DATE], showed the resident had an unplanned discharge to an acute care hospital. During an interview on 8/16/2023 at 1:30 PM, the Director of Nursing (DON) confirmed there was no written notification sent to Resident #61's family regarding transfer to hospital.

Based on facility policy review, observation, and interview the facility failed to maintain infection control practices while delivering meal trays to residents on 1 of 2 units observed. The findings include: Review of the facility policy titled, Hand Hygiene and Handwashing, last reviewed 6/1/2023, showed .Handwashing and Hand Hygiene is regarded by this organization as the single most important means of preventing the spread of infections .Handwashing facilities or alcohol-based hand rubs are readily available in patient [resident] rooms .After removal of .gloves .wash hands .immediately .Alcohol hand gel may be used if hands are not visibly soiled .Hand hygiene shall be used in place of handwashing .After removing gloves .After passing out .meal trays .After .direct resident contact . During an observation of meal delivery on 8/15/2023 at 7:46 AM, on the 200 unit, revealed the following: Certified Nursing Assistant (CNA) #1 retrieved a breakfast tray from the meal cart with gloved hands. The CNA entered room [ROOM NUMBER], the meal tray was served/set up, the CNA removed the gloves, and exited the room without washing or sanitizing the hands. Further observation showed CNA #1 applied a new pair of gloves, retrieved another meal tray from the meal cart, and entered room [ROOM NUMBER]. The CNA touched the side rail of the bed, repositioned the resident, positioned the bedside table, the meal tray was served/set up, and placed in the residents reach. The CNA removed the gloves and exited the room without washing or sanitizing the hands. Continued observation showed CNA #1 applied a new pair of gloves, retrieved another meal tray from the meal cart and entered room [ROOM NUMBER], the meal tray was served/set up, the CNA removed the gloves, and exited the room without washing or sanitizing the hands. During an interview on 8/15/2023 at 8:12 AM, CNA #1 confirmed she failed to wash or sanitize the hands while delivering meal trays to residents on the 200 unit. During an interview on 8/15/2023 at 8:16 AM, Registered Nurse #1 stated it was the expectation of the facility for staff to wash or sanitize the hands when delivering meal trays between residents and after glove removal. During an interview on 8/15/2023 at 9:24 AM, the Director of Nursing (DON) stated it was the expectation for staff to wash or use hand sanitizer after meal delivery to each resident and after glove removal. The DON confirmed the facility failed to follow the handwashing/hand hygiene policy while delivering meal trays to residents on the 200 unit.

Based on record review, and interviews, the facility failed to ensure 1 resident (Resident #12) of 25 sampled residents received trauma-informed care in accordance with professional standards of practice and accounting for a resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. The findings include: Resident #12 was admitted to the facility on [DATE] with diagnoses including Depression, Post-Traumatic Stress Disorder (PTSD), Parkinson's Disease, and Fracture of Lower Right Tibia. Review of the facility's trauma informed care process showed .Upon admission trauma informed care screening is completed for each resident .Triggers may include .war .historical trauma . Review of a 5-Day admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #12 had a Brief Interview for Mental Status of 15 which indicated the resident was cognitively intact, had no mood indicators, and no behaviors. Further review showed .Psychiatric/Mood Disorder .Depression .Post Traumatic Stress Disorder . Review of Resident #12's comprehensive care plan initiated 7/13/2023, showed there was no identified problems or needs listed for PTSD/Trauma Informed Care. Review of a Trauma-Informed Screening dated 7/17/2023, showed .During the last 30 days how often have you experienced .Repeated, disturbing memories, thoughts, or images of a stressful experience from the past .Sometimes .Feeling very upset when reminded of a stressful experience from the past .Sometimes .Avoid situations or activities that remind you of a stressful experience from the past .Sometimes .Trauma Screening .Notes .[no documented information] . Review of a Psychiatric Evaluation dated 7/19/2023, showed .Seen today for evaluation of PTSD .Psychiatric Medications .Abilify [medication used for psychotic disorders] .requires current dose for stability related to PTSD . Review of a Psychological Diagnostic Interview dated 7/27/2023, showed .Army-retired after 24 yrs [years] .Not sleeping good .Regarding PTSD he said that TV programs, movies, and conversations about Vietnam. Pt [patient] said that so far he has not identified any triggers .Recommendations Please make sure the Staff does not engage him in conversation about his time in Vietnam or current political events related to military conflicts to avoid triggering . During an interview on 8/15/2023 at 2:58 PM, Resident #12 stated he had PTSD since 1971 after the Vietnam war. The resident's last triggered episode was on July 4th when he heard fireworks. Other triggers were movies, books, and when he was asked a lot of questions about Vietnam. He also stated Dr. T with the Veterans Administration (VA) was his physician, and he was evaluated every 4 months. He takes multiple medications for the PTSD, his medications had been adjusted multiple times, and the current regimen had him stable. The facility did not assess the resident upon admission to the facility for PTSD or interview him on what triggered the PTSD. Resident #12 had no triggered episodes at the facility since admission. During an interview on 8/16/2023 at 7:24 AM, Licensed Practical Nurse #2 stated she was unaware Resident #12 had a diagnosis of PTSD and what would trigger a behavioral episode. During an interview on 8/16/2023 at 7:28 AM, Certified Nursing Assistant #2 stated he was unaware Resident #12 had a diagnosis of PTSD and what would trigger a behavioral episode. During an interview on 8/16/2023 at 8:15 AM, Registered Nurse #3 stated she was unaware Resident #12 had a diagnosis of PTSD and what would trigger a behavioral episode. During an interview on 8/16/2023 at 8:57 AM, the Social Worker (SW) stated she had completed a Trauma-Informed Screening for Resident #12 after his admission to the facility. The SW confirmed she did not screen the resident for PTSD and what triggers could cause him to have an episode. During an interview on 8/16/2023 at 11:02 AM, the MDS Coordinator confirmed the facility had not implemented trauma informed care related to PTSD for Resident #12.

Based on facility policy review, medical record review, and interview the facility failed to ensure ongoing communication between the facility and an outside dialysis center for 1 resident (Resident #164) of 2 residents reviewed for dialysis. The findings include: Review of the facility policy titled Interim Plan of Care for a Dialysis Patient, revised 8/2014 showed .Communication with the dialysis clinic will be documented on the dialysis communication form . Resident #164 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease, and Congestive Heart Failure. Review of Resident # 164 's care plan dated 8/8/2023, showed Hemodialysis (HD) Monday-Wednesday-Friday at noon. Review of a physician's order dated 8/7/2023, showed complete daily maintence of line assessment for (Perm-Cath HD port) (a vascular access used to administer dialysis). Review of Resident #164's medical record showed no documentation the Dialysis Clinic Communication Form had been completed on 8/7/2023, 8/9/2023, 8/11/2023, and 8/14/2023 (the days resident was transferred to the dialysis clinic for dialysis treatments). During an interview on 8/15/2023 at 5:22 PM, Registered Nurse (RN) #2 charge nurse confirmed the Dialysis Clinic Communication Form had not been completed for Resident #164 for the days she had received dialysis treatments at the clinic. He stated dialysis staff usually call with any new orders or changes for the resident's care, the physician would be notified, and the new orders would be placed into the electronic medical record. During an interview on 8/15/2023 at 5:40 PM, the Director of Nursing confirmed the Dialysis Communication form should have been completed each time the resident was sent out for dialysis treatments and the form should be returned with the resident upon completion of dialysis.

Based on the facility policy review, record review, and interview, the facility failed to develop a baseline care plan for 4 residents (Residents #12, #30, #38, and #51) of 25 residents reviewed for baseline care plans. The findings include: Review of the facility policy titled, Resident Assessment/Care Plan Process, revised on 7/3/2019, showed .A baseline care plan should be completed within 48 hours of admission in accordance with the State Operational Manual guidelines . Resident #12 was admitted to the facility on [DATE] with diagnoses including Post-Traumatic Stress Disorder (PTSD), Parkinson's Disease, and Chronic Obstructive Pulmonary Disease. Review of Resident #12 's admission Minimum Data Set (MDS) assessment dated [DATE], showed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Further review showed the resident had no mood indicators, no behaviors, and a diagnosis for Post Traumatic Stress Disorder. Review of Resident #12's medical record showed no baseline care plan was developed for trauma informed care. Resident #30 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure with Hypoxia, and Depression. Review of Resident #30 's admission MDS assessment dated [DATE], showed the resident had a BIMS score of 12, which indicated the resident had moderate cognitive impairment. The resident was at risk for developing a pressure ulcer and had no pressure ulcer on admission. Review of Resident #30's medical record showed no baseline care plan for at risk for impaired skin integrity. Resident #38 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Pressure Ulcer of Sacral Region, Juvenile Idiopathic Scoliosis and Parkinson's Disease. Review of Resident #38's 5-day admission MDS assessment dated [DATE], showed the resident had a BIMS score of 15, which indicated the resident was cognitively intact. Further review showed the resident required extensive assistance of 2 staff members for bed mobility, transfers, dressing, toilet use, and personal hygiene. Further review showed the resident had an unhealed, unstageable pressure ulcer. Review of Resident #38's medical record showed no baseline care plan was developed to address the resident's unstageable pressure ulcer. Resident #51 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, and Chronic Kidney Disease. Review of Resident #51's admission MDS assessment dated [DATE], showed the resident had a BIMS score of 15, which indicated the resident was cognitively intact. Further review showed the resident required limited assistance with bed mobility, supervision with eating, and extensive assistance of 1 staff member with toileting, transfers, bathing, and ambulation. Continued review showed the following pressure ulcers were present on admission: 1 stage 2 wound, and 2 stage 3 wounds. Review of Resident #51's medical record showed no baseline care plan was developed for the stage 2 and stage 3 pressure ulcers. During an interview on 8/16/2023 at 11:00 AM, the MDS Coordinator confirmed a baseline care plan was not developed for Resident #12's trauma informed care, Resident #30's risk for impaired skin integrity, Resident #38's pressure ulcer, and Resident #51's pressure ulcers. During an interview on 8/16/2023 at 11:30 AM, the Director of Nursing (DON) confirmed Resident #12's PTSD was not addressed on the baseline care plan. Further interview confirmed Resident #30, Resident #38 and Resident #51's pressure ulcers/skin risk identified on admission assessments was not addressed on the baseline care plans. 40639 45837

Based on facility policy review, medical record review, and interview the facility failed to immediately place 1 resident (#1) in [MEDICATION(S)]/contact precautions with suspected [CONDITION(S)] (C-diff which is a disruption of normal healthy bacteria in the colon, often from antibiotics causing diarrhea) of 3 residents reviewed for [MEDICATION(S)]/contact precautions. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility policy titled, Standard and Transmission Based Precautions revised 12/7/2016 showed .[MEDICATION(S)]/Contact Precautions .[CONDITION(S)] . [MEDICATION(S)] Precautions will be implemented on any resident that is suspected or confirmed as having [CONDITION(S)] . Review of a Medical Visit note dated 7/3/2021 and timed 16:35 (4:35 PM) showed the Nurse Practitioner (NP) evaluated Resident #1 on this date and documented the following: .seen and evaluated today .Nursing states patient has had 8 liquid stools yesterday, several during the night and several thus far today .send stool for C. difficile .start [MEDICATION(S)] [[MEDICATION(S)]-medication used to treat C- diff] .most likely C. difficile . Review of a physician's order dated 7/3/2021 showed an order .stool for c-diff .diarrhea . Review of a physician's order dated 7/3/2021 showed .[MEDICATION(S)] Capsule 125 MG [milligram] .by mouth . every 6 hours for diarrhea for 10 days . During an interview on 8/10/2021 at 12:59 PM, the NP stated she had evaluated Resident #1 on 7/3/2021 for an elevated white count and the resident had several loose stools observed by staff since 7/2/2021. The NP ordered for the facility to obtain a stool sample and send to the laboratory to check Resident #1's stool for C-diff and start [MEDICATION(S)]. During an interview on 8/10/2021 at 2:04 PM, the Infection Preventionist stated Resident #1 was admitted to the facility and started to have diarrhea approximately 72 hours after her admission. She also stated the NP was notified of the diarrhea, the NP evaluated the resident, and an order was given to have stool checked for C-diff. Resident #1 was transferred to a private room for precautionary measures until the laboratory results for C-diff was obtained. After the facility obtained the positive C-diff laboratory results on 7/5/2021 the resident was placed on [MEDICATION(S)] contact isolation. During a telephone interview on 8/10/2021 at 2:47 PM, Resident #1's daughter stated she visited the resident on 7/4/2021 and was informed by a nurse at the facility the resident had been moved to a private room because the reident had multiple episodes of diarrhea and a stool sample had been sent to the laboratory to check for C-diff. Resident #1's daughter also stated the resident was not placed in any type of isolation, there was no personal protective equipment outside the room, and no signage on the door to indicate precautions to take. During an interview on 8/10/2021 at 3:15 PM, the Director of Nursing (DON) stated she spoke with Resident #1's daughter on 7/5/2021 regarding the daughter's concern about Resident #1 not being in isolation for C-diff when she visited the resident on 7/4/2021. The DON informed Resident #1's daughter the resident was moved to a private room for precautionary measures. The DON explained the facility was awaiting the laboratory results to confirm C-diff then the resident would be placed in isolation. The DON confirmed the facility obtained laboratory results on 7/5/2021 and Resident #1 was confirmed to be positive for C-diff and was placed in [MEDICATION(S)] contact isolation on 7/5/2021.

Based on facility policy review, record review, and interview the facility failed to immediately inform the family of a change in room and health status for 1 resident (#1) of 3 residents reviewed for a change in room and health status. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility policy titled, Change in a Resident's Condition or Status last reviewed 4/28/2020 showed .Our facility shall promptly notify .next-of-kin/representative .of changes in the resident's condition and/or status including all new orders .The provider .will notify .next-of-kin or representative .when .There is a need to alter the resident's room assignment .A need to alter treatment significantly .Notifications will be made immediately following a change in resident's condition . Review of a Medical Visit note dated 7/3/2021 and timed 16:35 (4:35 PM) showed the Nurse Practitioner (NP) evaluated Resident #1 on this date and documented the following: .seen and evaluated today .White blood cell count .up .Nursing states patient has had 8 liquid stools yesterday, several during the night and several thus far today .Mouth appears dry .send stool for C. difficile [disruption of normal healthy bacteria in the colon, often from antibiotics causing diarrhea] . start [MEDICATION(S)] [[MEDICATION(S)]-medication used to treat C-diff], NS [normal saline used for fluid [MEDICATION(S)]] x [times] 1 liter at 60 ml [milliliters] hr [hour] . Review of a physician's order dated 7/3/2021 showed .stool for c-diff .For .diarrhea . Review of a physician's order dated 7/3/2021 showed .[MEDICATION(S)] Capsule 125 MG [milligram] .by mouth . very 6 hours for diarrhea for 10 days . Review of a physician's order dated 7/3/2021 showed .NS x 1 liter at 60 ml hr . During an interview on 8/10/2021 at 12:59 PM, the NP stated she had evaluated Resident #1 on 7/3/2021 for an elevated white count and the resident had several loose stools observed by staff since 7/2/2021. The NP ordered for the facility to obtain a stool sample and send to the laboratory to check Resident #1's stool for C-diff, start [MEDICATION(S)], and normal saline IV (within a vein). The NP also stated she did not notify Resident #1's daughter of the change in health status the nursing staff would do that. During a telephone interview on 8/10/2021 at 2:47 PM, Resident #1's daughter stated she went to the facility to visit Resident #1 on 7/4/2021. She also stated she went to the resident's room and the resident was not in the room. The daughter went to the nurse's station to ask where the resident was, and a nurse informed her the resident had moved to a private room on 7/3/2021. The nurse also informed Resident #1's daughter the reason for the room change was because the resident had multiple episodes of diarrhea (possible C-diff), received IV fluids for dehydration and was placed on an antibiotic. The daughter had not been notified on 7/3/2021 of Resident #1's change in condition or the room change. During a telephone interview on 8/11/2021 at 11:12 AM, the Registered Nurse/ Charge Nurse stated Resident #1's daughter arrived at the facility at approximately 10:00 AM on 7/4/2021. Resident #1's daughter checked in at the nurse's station and the RN Charge Nurse informed Resident #1's daughter of the resident's change in health condition and room change. During a telephone interview on 8/11/2021 at 11:18 AM, the Director of Nursing confirmed the facility did not notify Resident #1's daughter of the resident's room change or change in health condition until 7/4/2021 at approximately 10:00 AM when the daughter arrived at the facility.

Based on review of facility policy, medical record review, and interview, the facility failed to document wound care in the Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Review of the facility policy Medication Administration dated 2/2019, showed .Documentation on Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review showed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of a Physician's Order dated 7/7/2021 showed .cleanse left lateral knee with NS [normal saline]. Pat dry. Apply .dressing .change daily until staples removed . Medical record review of Resident #2's EMAR dated July 2021 showed no documentation the treatment was administered on 7/15/2021, 7/20/2021, 7/21/2021, 7/23/2021, and 7/24/2021. During an interview on 7/26/2021 at 12:00 PM, Resident #2 stated staff had performed all dressing changes. Medical record review showed Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of a Physician's Order dated 6/25/2021 showed .apply skin prep [liquid film-forming dressing] to bilateral heels day and night. Encourage to float with pillow all times . every day and night . Continued review showed .cleanse buttocks with NS .pat dry. Apply Triad [wound dressing] to wound bed .every day and night shift . Medical record review of Resident #3's EMAR dated July 2021 showed no documentation the treatments were performed on following dates: 7/6/2021 on the day shift 7/12/2021 on the night shift 7/15/2021 on the day shift 7/20/2021 on the day shift 7/21/2021 on the day shift 7/23/2021 on the day shift 7/24/2021 on the day shift Medical record review of a Physician's Order dated 7/20/2021 showed .Skin Care left calf xeroform [Wound Dressing with petroleum] with allevyn [wound dressing] .one time a day every other day . Medical record review of Resident #3's EMAR dated July 2021 showed the treatment was not administered on 7/20/2021, 7/22/2021, and 7/24/2021. During an interview on 7/26/2021 at 12:10 PM, Resident #3 stated staff had performed all dressing changes. During an interview on 7/27/2021 at 1:12 PM, the Director of Nursing stated staff were expected to document treatments on the EMAR. Continued interview confirmed staff failed to document the treatments on the EMAR for Resident #2 and Resident #3. During an interview on 7/26/21 at 12:43 PM, the Administrator stated .in-services were started .we are auditing all [EMARs] .always some have holes .but not to this level .

Based on facility policy review, medical record review, and interview, the facility failed obtain weights as ordered for 1 resident (Resident #1) of 4 residents reviewed for weights. The findings include: Review of the facility's policy titled Identifying and Maintaining an Adequate Weight for Patients Considered to be High Risk for Weight Loss dated 5/2021 showed .Weekly weights should be completed as ordered . Medical record review showed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Weekly weights one time a day every Monday .start date 4/26/2021 . Medical record review of Resident #1's Weights and Vitals Summary showed the resident's weekly weights began on 5/3/2021 and not on 4/26/2021 as ordered by the physician. During an interview on 7/27/2021 at 11:00 AM, the Certified Dietary Manager (CDM) revealed a weekly weight sheet was located at the nurses' station for staff to know which residents need to be weighed. Continued interview revealed the CDM recommended nursing staff obtain 3 consecutive reweights on Resident #1 beginning on 6/1/2021. Continued interview confirmed the consecutive weights were not obtained until 6/6/2021, 6/7/2021, and 6/8/2021, 5 days after the recommendation was made. During an interview on 7/27/2021 at 2:44 PM, the Assistant Director of Nursing (ADON) confirmed staff are expected to obtain weekly weights as ordered by the Physician and reweights as recommended by the CDM.

Based on medical record review and interview, the facility failed to ensure the medical record contained pictures taken by a provider of a wound for 1 resident (Resident #1) of 3 residents reviewed for complete medical records. The findings include: Medical record review showed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Nurse Practitioner (NP) Progress note dated 9/25/2020 at 2:20 PM showed .(wound) graft appears to be peeling off of (Resident #1's) heel. Several staples appear to be only secured (at) one end into the skin .pictures of this sent per perfect serve (communication software) to (surgeon) for review . During a telephone interview on 11/12/2020 at 5:02 PM, the Administrator stated the NP took 2 pictures of Resident #1's wound on a work issued cell phone and sent the pictures to a surgeon for review. Continued interview confirmed the medical record did not contain the pictures taken by the NP of Resident #1's wounds because the facility felt the pictures were .a conversation between providers and not part of the medical record .

Based on review of facility policy, medical record review, interview, and review of facility investigation, the facility failed to notify the resident, resident's family, and/or physician of medication errors for fifteen residents (#262, #457, #188, #453, #452, #454, #455, #279, #111, #398, #105, #197, #23, #411, and #238) of twenty-four residents reviewed for medication errors, and failed to notify the physician of a significant weight loss for one resident (#388) of four residents reviewed for weight loss. The facility's failure to notify the resident, resident's family, and/or physician of medication errors placed the residents in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death). The facility's failure to develop and implement a plan of action to address the systemic failures was likely to place any resident who received medications at risk for Immediate Jeopardy. The facility's failure to ensure the physician was notified of a significant weight loss resulted in harm for resident #388. The Administrator, Medical Director, Chief Medical Officer/In House Legal Counsel, Chief Nursing Officer, and Director of Nursing were informed of the Immediate Jeopardy on September 30, 2014, at 4:00 p.m., in the conference room. The Immediate Jeopardy was effective February 12, 2014 through October 1, 2014. An extended survey was conducted September 30 through October 2, 2014. Acceptable Allegation of Compliance was received on October 2, 2014, and actions which removed the immediacy of the Jeopardy were verified on-site on October 2, 2014. Noncompliance continues at the severity of "F." The findings included: Review of facility policy, Change in a Patient's Condition or Status, last revised June 2012 revealed, "...1. Policy Statement: Our facility shall promptly notify the patient, his or her attending physician, and next-of-kin or representative (sponsor) of changes in the patient's condition and/or status...D. Regardless of the patient's mental or physical condition, nursing services will inform patients of any changes in their medical care or nursing treatments..." Resident #262 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Medication Administration Record [REDACTED]. Medical record review of physician's orders [REDACTED]. from the facility) revealed no orders for administration of [MEDICATION NAME] 200 mg, [MEDICATION NAME] 25 mg, [MEDICATION NAME] 40 mg, or [MEDICATION NAME] 0.5 mg. Medical record review of a nurse's note dated July 25, 2014, revealed "...05:30 unit secretary found med (medication) error as...was putting in other orders on another pt (patient). Pt. had 3 meds that were not (patient's) orders. VS (vital signs) B/P (blood pressure, normal blood pressure is 120/90 )...Pt very sleepy hard to arouse...Physician notified, orders noted..." Review of a nurse's note dated July 25, 2014, revealed "...06:30 B/P 100/62...P 77...R 24...O2 sat 92%...slightly more arouseable respirations deeper regular will continue to observe..." Medical record review of a nurse's note date July 25, 2014, at 9:45 a.m., revealed the nurse started an intravenous access to administer fluids of normal saline at 60 ml/hr (milliliters per hour), as ordered by the physician, to treat [MEDICAL CONDITION] (low blood pressure). Medical record review of the nurses note dated July 25, 2014, at 2:45 p.m. revealed, "...reported to (family members) medications given to pt last night. Pt family spoke with (NP - Nurse Practitioner) and (Clinical Educator/Quality Assurance Nurse - CE/QA), voiced concerns regarding medications. Requested pt be sent to ER (emergency room ) for evaluation..." Medical record review of a facility Discharge Summary dated July 25, 2014, revealed "...Pt discharged to hospital, dx (diagnosis): accidental overdose..." Interview with the Director of Nursing (DON) on September 23, 2014, at 3:40 p.m., in the DON's office, confirmed the resident's family had not been immediately notified of the medication error. The error had been discovered at 4:00 a.m., and the family was notified by the Quality Assurance Nurse at 2:45 p.m., over ten hours after the discovery of the medication error. Resident #457 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Hospital Discharge Medication List dated March 14, 2014, revealed "[MEDICATION NAME] (a medication to prolong blood clotting time, to prevent blood clots)...0.4 ml (millilters), subcutaneous, every 24 hours..." Medical record review of the Physician's Recapitulation Orders dated March 14, 2014, revealed "[MEDICATION NAME]...40 mg /0.4 ml sol (solution) give 0.4 ml...subcutaneous once a day for blood clotting control..." Medical record review of the Medication Record (MAR) dated March 14, 2014, through March 20, 2014, revealed the days for administration of the medication was indicated as every other day and and the resident did not receive [MEDICATION NAME] 40 mg subcutaneous on March 15 and March 17, 2014. Medical record review of a physician's orders [REDACTED]. Medical record review of a Diagnostic Report dated March 19, 2014, revealed "...Exam...Lower Venous Right...Clinical: RLE [MEDICAL CONDITION] and Warmth...Findings...Significant nonocclusive thrombus (blood clot) is seen within the right posterior tibial and peroneal veins...Impression: significant nonocclusive thrombus below the knee within the right peroneal and posterior tibial veins..." Medical record review of a Physician's Progress Note dated March 19, 2014, revealed "...results RLE doppler show nonocclusive thrombus (blood clot) below knee (within) right peroneal (and) post tibial veins. Pt has had [DIAGNOSES REDACTED] (redness)/[MEDICAL CONDITION] x (times) 2 days..." Medical record review of a physician's orders [REDACTED]. Stop [MEDICATION NAME] when INR (international normalized ratio) between 2-3...stop [MEDICATION NAME] with pharmacy to give [MEDICATION NAME] 100 mg sq q (every) 12 hours...give additional 60 mg [MEDICATION NAME] to equal to 100 mg [MEDICATION NAME] today..." Review of the facility investigation dated March 20, 2014, revealed "...Error when entering order. clicked frequency options and entered every 2 days..." Review of the facility investigation dated March 21, 2014, revealed "...Event Date: 3/14/2014...Order entry error off admission orders [REDACTED]. Nurse did not notice the change in time frequencies...Medication involved: [MEDICATION NAME] ([MEDICATION NAME])..." Medical record review of the Anticoagulation [MEDICATION NAME] Orders dated March 21, 2014, revealed "...Continue [MEDICATION NAME] 100 mg SQ Q 12h, begin [MEDICATION NAME] 5 mg daily for new onset [MEDICAL CONDITIONS]..." Medical record review of the Admission Minimum Data Set (MDS) dated [DATE], revealed the resident was cognitively intact. Interview with the CE/QA Nurse on September 29, 2014, at 8:30 a.m., in the conference room, confirmed the [MEDICATION NAME] order was transcribed incorrectly, entered as every other day, and the resident missed the dose on March 15 and 17, 2014. Continued interview confirmed the ward clerk entered the order incorrectly with the frequency of every other day. Interview with Registered Nurse (RN) #6 on September 29, 2014, at 9:10 a.m., in the conference room, confirmed the RN was responsible for verifying the order of [MEDICATION NAME] and failed to verify the order for accuracy. Continued interview confirmed the RN signed the twenty-four hour chart check on March 15, 2014, and did not identify the error. Interview with NP #1 on September 29, 2014, at 11:00 a.m., in the conference room, confirmed it would be possible the missed doses contributed to the development of the [MEDICAL CONDITION]. Interview with the Medical Director on September 29, 2014, at 2:40 p.m., in the conference room, confirmed "...always conceivable the resident developed the [MEDICAL CONDITION] due to two missed doses of [MEDICATION NAME]" Interview with the CE/QA Nurse on September 29, 2014, at 10:15 a.m., in the conference room, confirmed the error was identified on March 20, 2014. Further interview confirmed neither the patient nor family had been notified of the medication error. Resident #188 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the admission orders [REDACTED] Medical record review of the Medication Record dated March 25, 2014, revealed "[MEDICATION NAME] 2 mg TAB (tablet) ([MEDICATION NAME] Sodium) Oral Every night @ (at) 6pm for Blood Clotting Control, stop date of March 26, 2014..." Medical record review of the physician's orders [REDACTED]. Medical record review of the MAR indicated [REDACTED]. Medical record review of the physician's orders [REDACTED]." Review of the facility investigation dated March 27, 2014, revealed "...no [MEDICATION NAME] order in chart. Pt only had [MEDICATION NAME] order for 3/25 - 3/26 but has been here since 3/22. RX (Pharmacy) status says it was ordered and canceled on 3/25 but still active 3/26..." Continued review revealed ''...patient not aware of the medication error..." Review of the facility investigation addendum (to the facility investigation dated March 27, 2014) revealed "...placed order in computer under wrong pt, so pharmacy called...canceled order..." Interview with RN #7 Charge Nurse, on September 29, 2014, at 5:50 p.m., in the conference room, confirmed "...we are not required to notify the family with a med (medication) error..." Interview with RN #3 Patient Care Coordinator (PCC) on September 30, 2014, at 8:25 a.m., in the conference room, confirmed the RN was responsible for the investigation of the administration of [MEDICATION NAME] for Resident #188. Continued interview confirmed "...residents and families are not notified of medication errors..." Interview with the CE/QA Nurse on September 30, 2014, at 8:56 a.m., in the conference room, confirmed the facility had failed to notify the family of Resident #188 of the medication error. Resident #453 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical Record review of the Admission MDS dated [DATE], revealed the resident scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. Medical record review of a physician's orders [REDACTED]. Medical record review of the Medication Record dated February 10, 2014, through March 10, 2014, revealed the physician's orders [REDACTED]. Review of a facility investigation signed and dated March 6, 2014, revealed, "...Was patient aware of medication error?..." Continued review of the investigation revealed the box marked "...No..." was checked. Interview with the DON on September 25, 2014, at 11:36 a.m., in the conference room, confirmed the resident received 22 doses of potassium which were not ordered for the resident. Continued interview with the DON confirmed the resident was not notified of the medication error. Further interview confirmed the facility had failed to follow facility policy for notification. Interview with the CE/QA Nurse on September 30, 2014, at 8:37 a.m., in the Classroom, confirmed the facility does not immediately notify residents or resident's family of medication errors. Continued interview confirmed the facility had failed to notify the resident of the medication error. Interview with the Administrator on September 30, 2014, at 10:13 a.m., in the conference room, confirmed the facility policy does not specifically address medication errors, however the policy addressed resident notification related to any incident which might affect the resident. Continued interview confirmed the facility had failed to notify the resident of the medication error. Resident #452 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Admission MDS dated [DATE], revealed the resident was cognitively intact. Medical record review of the Physician's Recapitulation Orders dated January 24, 2014, revealed "[MEDICATION NAME] (brand name of [MEDICATION NAME], a narcotic pain reliever) 325 mg-5 mg tab...every 6 hours prn (as needed) for pain..." Medical record review of a physician's orders [REDACTED]. may repeat in 1 (hour) if ineffective..." Medical record review of a physician's orders [REDACTED]. Medical record review of a prescription dated January 27, 2014, revealed "[MEDICATION NAME]/APAP (a narcotic pain reliever) 5/325...1 tab po Q 6 (hours) PRN pain...1 tab po Q 8 (hours) schedule..." Medical record review of a physician's orders [REDACTED]. Medical record review of the Medication Record dated January 24, 2014, through January 31, 2014, revealed "...1/27/14 [MEDICATION NAME]...325 mg-5 mg 1 tab...oral every 8 hours for pain..." Continued review revealed the resident received the [MEDICATION NAME] scheduled every eight hours from January 27, 2014 through January 30, 2014. Medical record review of the Medication Record dated January 24, 2014, through January 31, 2014, revealed "[MEDICATION NAME]...325 mg-5 mg 1 tab...oral every 6 hours prn for pain..." Continued review revealed the resident received a total of five doses of the medication on January 27 and 28, 2014. Medical record review of the Medication Record dated January 24, 2014, through January 31, 2014, revealed "[MEDICATION NAME] 325 mg-5 mg...oral every 6 hours prn for pain..." Continued review revealed the resident received a total of seven doses on January 24 - 28, 2014, and three doses on January 30, 2014. Review of the facility investigation dated February 4, 2014, revealed "...Event Date: 1/27/2014...Wrong Medication...MD (Medical Doctor #2) wrote order in chart for [MEDICATION NAME] 5/325 mg Q 8 hr and Q 6 hr-prn. (Medical Doctor #2) wrote a prescription for [MEDICATION NAME] 5/325 mg Q 8 hr and Q 6 hr-prn for the same patient on the date. Prescription was not signed off and not noted if it had been faxed to pharmacy. Pt. received both medications. Script omission not caught on 24 hour chart check and not by the Registered Nurse (RN) in charge..." Interview with the CE/QA Nurse on September 25, 2014, at 10:30 a.m., in the conference room, confirmed the resident received the [MEDICATION NAME] and [MEDICATION NAME] on January 27, 28, and 30th. Continued interview confirmed the nurse should have clarified the order and it was discovered on January 31, 2014, by chart check because the NP wrote an order to discontinue the [MEDICATION NAME]. Telephone interview with the resident's physician on September 29, 2014, at 3:50 p.m., confirmed the physician did not intend for the resident to have both [MEDICATION NAME] ([MEDICATION NAME]) and [MEDICATION NAME]. Telephone interview with RN #2 on September 30, 2014, at 8:20 a.m., confirmed when new orders were written, the RN verified the orders with the computer. Further interview confirmed the RN was not aware of the medication order for [MEDICATION NAME] and [MEDICATION NAME], two pain medications. Interview with the CE/QA Nurse on September 30, 2014, at 8:37 a.m., in the Classroom, confirmed the facility does not immediately notify residents or residents' families of medication errors. Resident #454 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of Admission MDS dated [DATE], revealed the resident scored a 15 out of 15 on the BIMS indicating the resident was cognitively intact. Medical record review of a physician's orders [REDACTED]. Medical record review of the Medication Record dated February 6, 2014, through March 6, 2014, revealed the order for the medication was entered to start on February 27, 2014, and entered with a stop date for March 6, 2014 (7 days later) instead of for March 4, 2014 (5 days later). Continued review revealed the resident received 5 extra doses of the antibiotic. Review of a facility investigation signed and dated March 6, 2014, revealed, "...Was patient aware of medication error?..." Continued review of the facility investigation revealed the box marked "...No..." was checked. Interview with the DON on September 30, 2014, at 12:40 p.m., in the conference room, confirmed the resident was not notified of the medication error, and confirmed the facility had failed to follow their policy regarding notification. Resident #455 was admitted to the facility on [DATE], with admitting [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Medical record review of the physician's orders [REDACTED]. Medical record review of the resident's MAR for March 2014 revealed [MEDICATION NAME] was not administered from March 3 through March 8, 2014. Review of a facility investigation dated March 13, 2014, revealed the order for [MEDICATION NAME] was not discovered by Licensed Practical Nurse (LPN) #9 or by RN #1 on the twenty-four hour chart check. Continued review revealed the resident's physician was notified at 1:00 p.m., on March 28 2014, twenty five days after the error. Interview with the DON on September 30, 2014, at 3:00 p.m., in the DON's office, confirmed the Physician had not been immediately notified and the family had not been notified of the medication error. Resident #279 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Medical record review of the resident's Medication Record for April, 2014, revealed the order had not been transcribed to the MAR. Continued review of the resident's MAR indicated [REDACTED]. Review of a facility investigation dated April 17, 2014, revealed the order for the [MEDICATION NAME] 1 gram IV had not been transcribed. Continued review revealed the cause of the error listed was the order was not processed. Interview with the DON on September 30, 2014, at 3:00 p.m., in the DON's office, confirmed the family had not been notified of the medication error. Resident #111 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the facility admission records dated July 21, 2014, revealed "[MEDICATION NAME] 5 mg, 1 tab ORALLY, every 4 hours as needed, for 3 days, as needed, pain management..." Further review revealed a duplicate [MEDICATION NAME] order from a prescription detail (prescription paper order for narcotics). Medical record review of the Medication Record for July 2014, revealed "[MEDICATION NAME] HCL oral every 4 hours prn for moderate pain." Continued review revealed the [MEDICATION NAME] was given from July 25 through July 29, 2014, by four LPNs for five additional days and eleven additional doses after the date the medication was to be discontinued. Medical record review of the 5 day MDS assessment dated [DATE], revealed a BIMS of 14 (10 and above, cognitively intact). Further review of the MDS revealed "...Preferences...very important to have your family involved in discussions about your care." Review of the facility investigation dated July 29, 2014, revealed the event occurred on July 21, 2014, at 10:32 p.m., and "...medication was not discontinued after 3 days as ordered..." Continued review revealed Resident #111 continued to receive [MEDICATION NAME] 5 mg for five additional days and eleven additional doses. Continued review revealed the patient was not notified of the medication error. Interview with NP #1 on September 29, 2014, at 11:30 a.m., in the conference room, confirmed resident #111 was not notified of the medication error. Interview with RN #3 PCC on September 30, 2014, at 8:25 a.m., in the conference room, confirmed "...residents and families are not notified of med errors..." Interview with the DON on October 1, 2014, at 2:20 p.m., in the conference room, confirmed the facility failed to notify Resident #111 of receiving [MEDICATION NAME] for five additional days and eleven additional doses after the discontinued date. Resident #398 was admitted to the facility on [DATE], with admitting [DIAGNOSES REDACTED]. Medical record review of a physician's admission order dated July 21, 2014, revealed an order for [REDACTED]. Medical record review of the MAR for July 21, 2014, through July 29, 2014, revealed [MEDICATION NAME] 5 mg was transcribed to be administered as a scheduled dose, twice per day, instead of as needed. Further review of the MAR indicated [REDACTED]. The resident had received fifteen doses of the medicine. Review of a facility investigation dated July 29, 2014, revealed "...a copy of the report had been placed on clipboard by (LPN #11). The medication order was for [MEDICATION NAME] 5 mg BID (twice daily) PRN (as needed). The order was transcribed into the computer as a routine scheduled order twice daily instead of as needed..." Interview with the DON on September 30, 2014, at 3:00 p.m., in the DON's office, confirmed the resident and the family had not been notified of the medication error. Resident #105 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the 5 day MDS assessment dated [DATE], revealed a BIMS of 14 (10 and above cognitively intact). Medical record review of the physician's orders [REDACTED]. (electrolyte replacement for low blood levels of potassium) Extended Release Tablet, 10 milliequivalent (meq) every day.'' Medical record review of the physician's orders [REDACTED]. meq po q am (every morning) (start in am) x 3 days ([MEDICAL CONDITION]).'' Medical record review of the MAR for July 2014 revealed the order for ''Potassium Chloride 20 meq oral once a day'' was dated for three days, July 24, 25, and 26, 2014. Further review revealed the Potassium Chloride 10 meq daily was not placed on hold and remained on the MAR. Medical record review of the MAR indicated [REDACTED]. Medical record review of the physician's orders [REDACTED]. Review of the facility investigation dated August 14, 2014, revealed "...Pt already on KCL 10 meq daily, but new order for 20 meq x 3 days received. 10 meq not placed on hold so the pt received 30 meq on the first day of the three day order. Potassium level to be checked the next am (morning). No harm noted. WC did not notice the 10 meq order needed to be placed on hold..." Further review revealed the patient was not notified of the medication error. Interview with the RN #7 Charge Nurse on September 29, 2014, at 5:50 p.m., in the conference room, confirmed "...we are not required to notify the family with a med (medication) error..." Interview with RN #3 PCC on September 30, 2014, at 8:25 a.m., in the conference room, confirmed "...residents and families are not notified of med errors..." Telephone interview with RN #5 on September 30, 2014, at 9:00 a.m., confirmed "...I don't notify families for med errors...you don't know if the med caused problems..." Resident #197 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Physician's admission orders [REDACTED]. Review of a facility investigation dated July 25, 2014, revealed the resident was not given [MEDICATION NAME] 200 mg, [MEDICATION NAME] 25 mg, [MEDICATION NAME] 40 mg, and [MEDICATION NAME] 0.5 mg, on the evening of July 24, 2014, due to a transcription error. Continued review revealed the medications had been given to another resident in error. Interview with PCC #8 on September 23, 2014, at 3:50 p.m., in the hall, outside the Director of Nursing (DON)'s office, confirmed the resident and family had not been notified of the omission of medications. Resident #23 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the resident's admission orders [REDACTED]. Medical record review of the resident's MAR indicated [REDACTED]. Continued review revealed the medication had been administered to the resident as a routine medication eight times from July 29, through August 5, 2014. Review of a facility investigation dated August 7, 2014, revealed the order for [MEDICATION NAME] was put into the computer as routine and an additional order was put in for [MEDICATION NAME] 15 mg QHS PRN. Continued review revealed the reason for the occurrence was the order was not entered correctly upon admission. Interview with the DON on September 30, 2014, at 3:00 p.m., in the DON's office, confirmed the family had not been notified of the medication error. Resident #411 was admitted to the facility on [DATE], with admitting [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Medical record review of the MAR for August, 2014, revealed "...08/05/14 [MEDICATION NAME] 10 mg SUP (suppository) ([MEDICATION NAME]) rectal once a day for constipation...start date: 08/06/14...stop date: 08/28/14..." and "...08/05/14 Magnesium [MEDICATION NAME] 1.75 GM (grams)/30 ml sol (Magnesium [MEDICATION NAME]) oral once a day for constipation...start date: 08/06/14...stop date: 08/28/14..." The [MEDICATION NAME] and Magnesium [MEDICATION NAME] had been initialed as held, due to resident refusal, on the morning of August 6, and had been initialed as given on August 9, 10, and 25, 2014, for a total of three doses of each medication. Review of a facility investigation dated September 4, 2014, revealed "...med order was [MEDICATION NAME] Supp. X I in am, order was processed as [MEDICATION NAME] Supp. PR (rectally) daily @ (at) 9:00 this was on emar (electronic medication administration record) x (times) twenty three days but pt. refused all but three doses. (RN #11) notified me of error on 8/28/14 (date of discharge)...(there was total of 2 extra doses given), cause of occurrence: order not processed correctly..." Interview with the DON on September 30, 2014, at 3:00 p.m., in the DON's office, confirmed the family had not been notified of the medication error. Resident #238 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE], revealed the resident had a BIMS of 13 (resident cognitively intact). Medical record review of the Physician order [REDACTED].@ 6 am for [MEDICAL CONDITION]" Medical record review of the physician's orders [REDACTED]. Medical record review of the Physician Telephone Orders dated August 20, 2014 revealed "...D/C (discontinue) [MEDICATION NAME]" Medical record review of the Medication Record dated August 2014 revealed the resident received [MEDICATION NAME] 40 mg daily on August 21 and August 22, 2014, two days after the medication had been discontinued. Medical record review of the Medication Record dated August 2014 revealed the resident did not receive the now dose of medication as ordered on August 19, 2014. Review of the facility investigation prepared August 22, 2014, revealed "...Drug name [MEDICATION NAME] Order D/C [MEDICATION NAME] Dosage...Cause of Error Order Not Signed Off [MEDICATION NAME] was discontinued...Was patient aware of medication error? No... Drug had been entered in under generic name as well so not noticed when signing order... admission orders [REDACTED]. WC and

Based on review of Lippincott Manual of Nursing Practice, review of the Rules and Regulations of Licensed Practical Nurses, review of facility policy and procedures, medical record review, review of facility investigation, and interview, the facility failed to follow facility policy for transcribing medication orders, reconciling physician's orders with medication administration records, and for completing 24 hour chart checks to ensure no medication errors occurred. The failure resulted in medication errors and placed sixteen residents (#262, #457, #188, #453, #452, #454, #455, #456, #279, #111, #398, #105, #197, #23, #411, #238) of twenty-four residents reviewed for medication errors in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death). The facility's failure was likely to place any resident who received medications at risk for immediate jeopardy. The Administrator, Medical Director, Chief Medical Officer/In House Legal Counsel, Chief Nursing Officer, and Director of Nursing were informed of the Immediate Jeopardy on September 30, 2014, at 4:00 p.m., in the conference room. The Immediate Jeopardy was effective February 12, 2014 through October 1, 2014. An extended survey was conducted September 30 - October 2, 2014. The facility submitted an Acceptable Allegation of Compliance to the survey team on October 2, 2014. The survey team verified the actions taken by the facility removed the immediacy of the jeopardy on October 2, 2014. Noncompliance continues at the "F" level. The findings included: Review of Lippincott Manual of Nursing Practice, Ninth Edition, revealed, "...Chapter 2 Standards of Care, Ethical and Legal Issues...Accountability...Maintaining familiarity of relevant, current facility policies, procedures, and regulations as they apply to the nurse's practice and specialty area...Examining the quality (accuracy and completeness) of documentation...Common Departures from the Standards of Nursing Care...failure to...follow physician orders, follow appropriate nursing measures...adhere to facility policy or procedure...administer medications as ordered, and follow physician's orders that should have been questioned or not followed, such as orders containing medication dosage errors..." Review of the facility Medication Administration General Guidelines revealed "...Medications are administered as prescribed, in accordance with good nursing principles and practices and only persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication...Medications are administered in accordance with written orders of the attending physician. If a dose seems excessive considering the resident's age and condition, or a medication order seems unrelated to the resident's current [DIAGNOSES REDACTED]. Review of the facility policy Charge Nurse with revision date October 2012 revealed "...the charge nurse, at a minimum, is responsible for... reviewing medication cards for completeness of information, accuracy in the transcription of physician orders, and adherence to stop order policies..." Review of the facility procedure Night Shift RN (Registered Nurse) Checklist undated revealed "...check charts after midnight (24 hr (hour) chart checks). If any new medicines ordered, verify they were on the MAR (Medication Administration Record [REDACTED] Resident #262 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Medication Administration Record [REDACTED]. Medical record review of Physician's orders from July 23 through July 25, 2014, revealed no orders for [MEDICATION NAME] 200 mg, [MEDICATION NAME] 25 mg, [MEDICATION NAME] 40 mg, or Resperidone 0.5 mg. Review of the facility investigation initiated July 24, 2014 revealed resident #262 was given [MEDICATION NAME] 200 mg [MEDICATION NAME] 25 mg, [MEDICATION NAME] 40 mg, and [MEDICATION NAME] 0.5 mg one time. Further review of the facility investigation revealed "...orders from one new admission were put on a pt. (patient) that had already been there x (times) 2 days...WC (Ward Clerk) was still in a new admission profile & (and) went into (resident #262) profile did not switch back to the new admission profile, new admission meds put in (resident #262's) profile..." Medical record review of a facility Discharge Summary dated July 25, 2014, revealed "...Pt discharged to hospital, dx (diagnosis): accidental overdose..." Telephone interview with Registered Nurse (RN) #5 on September 23, 2014, at 8:45 a.m., revealed RN #5 had taken resident #262's chart to the ward clerk to correct an order in the computer; the ward clerk had made the correction and then transcribed resident #197's new admission orders [REDACTED]#5 had failed to follow policy for ensuring accuracy in the transcription of physician orders. Telephone interview with Licensed Practical Nurse (LPN) #8 on September 23, 2014, at 9:31 a.m., confirmed the [MEDICATION NAME], and [MEDICATION NAME] were given in error to the resident on July 24, 2014, at 9:00 p.m., and LPN #8 failed to follow policy for ensuring accuracy in the transcription of physician orders and the 24 hour chart checks. Interview with ward clerk #1 on September 29, 2014, at 2:50 p.m., in the DON's (Director of Nursing) office, confirmed the ward clerk was not aware of the medication error and confirmed the ward clerk had not followed transcription policy. Resident #457 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Hospital Discharge Medication List dated March 14, 2014, revealed "[MEDICATION NAME] (a medication to prevent blood clots)...0.4 ml (milliliters), subcutaneous (injection given into the tissue just under the skin), every 24 hours..." Medical record review of the Physician's Recapitulation Orders dated March 14, 2014, revealed "[MEDICATION NAME]...40 mg/0.4 ml sol (solution) give 0.4 ml...subcutaneous once a day for blood clotting control..." Medical record review of the MAR indicated [REDACTED]. Medical record review of the Medication Record dated March 14, 2014, through March 20, 2014, revealed resident #457 did not receive the [MEDICATION NAME] 40 mg subcutaneous on March 15 and March 17, 2014. Medical record review of a Physician's Order dated March 18, 2014, revealed "...Vascular US (ultrasound) RLE (right lower extremity) Dx: (diagnosis) warmth, [MEDICAL CONDITION] (swelling)...Dx: chills, warm, swollen RLE..." Medical record review of a Diagnostic Report dated March 19, 2014, revealed "...Exam...Lower Venous Right...Clinical: RLE [MEDICAL CONDITION] and Warmth...Findings...Significant nonocclusive thrombus (blood clot) is seen within the right posterior tibial and peroneal veins...Impression: significant nonocclusive thrombus below the knee within the right peroneal and posterior tibial veins..." Medical record review of a Physician's Progress Note dated March 19, 2014, revealed "...results RLE doppler show nonocclusive thrombus below knee (within) right peroneal (and) post tibial veins. Pt has had [DIAGNOSES REDACTED] (redness)/[MEDICAL CONDITION] x 2 days..." Medical record review of a Physician's Order dated March 19, 2014, revealed "[MEDICATION NAME] ([MEDICATION NAME]) 1 mg/kg (kilogram) SQ (subcutaneous) every 12 hours...clarified with pharmacy to give [MEDICATION NAME] 100 mg sq q (every) 12 hours...give additional 60 mg [MEDICATION NAME] to equal to 100 mg [MEDICATION NAME] today..." Review of the facility investigation dated March 20, 2014, revealed "...Error when entering order. clicked frequency options and entered every 2 days...suggest to prevent similar occurrences? Read order thoroughly recheck after entered for accuracy..." Review of the facility investigation dated March 21, 2014, revealed "...Event Date: 3/14/2014...Order entry error off admission orders [REDACTED]. Nurse did not notice the change in time frequencies...Medication involved: [MEDICATION NAME] ([MEDICATION NAME])..." Medical record review of the physician's order dated March 21, 2014, revealed "...Continue [MEDICATION NAME] 100 mg SQ Q 12h (hour)...for new onset [MEDICAL CONDITIONS]..." Interview with the Clinical Educator/Quality Assurance (CE/QA) Nurse, on September 29, 2014, at 8:30 a.m., in the conference room, confirmed the [MEDICATION NAME] order was transcribed incorrectly, entered as every other day, and the resident missed the dose on March 15 and 17, 2014. Continued interview confirmed the ward clerk entered the order incorrectly with the frequency of every other day. Interview with Registered Nurse (RN) #6 on September 29, 2014, at 9:10 a.m., in the conference room, confirmed RN #6 was responsible for verifying the order of [MEDICATION NAME] and failed to verify the order for accuracy. Continued interview confirmed the RN signed the twenty-four hour chart check on March 15, 2014, and did not identify the error. Interview with Nurse Practitioner (NP) #1 on September 29, 2014, at 11:00 a.m., in the conference room, confirmed it would be possible the missed doses contributed to the development of the [MEDICAL CONDITION]. Interview with the Medical Director on September 29, 2014, at 2:40 p.m., in the conference room, confirmed "...always conceivable...the resident developed the [MEDICAL CONDITION] due to two missed doses of [MEDICATION NAME]" Resident #188 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Hemorrhage, Subdural Hematoma, and [MEDICAL CONDITION] Fibrillation. Medical record review of the admission orders [REDACTED] Medical record review of the Medication Record (MAR) dated March 25, 2014, revealed "[MEDICATION NAME] ([MEDICATION NAME] Sodium) 2 mg TAB (tablet) Oral Every night @ (at) PM (night) for Blood Clotting Control, stop date of March 26, 2014..." Medical record review of the Physician's Orders for March 25, 2014, revealed no order for [MEDICATION NAME]. Medical record review of the MAR indicated [REDACTED]. Medical record review of the Physician's Orders dated March 26, 2014, revealed "dc (discontinue) [MEDICATION NAME] order". Review of the facility investigation dated March 27, 2014, revealed "...no [MEDICATION NAME] order in chart. Pt (patient) only had [MEDICATION NAME] order for 3/25 - 3/26 but has been here since 3/22. RX (Pharmacy) status says it was ordered and canceled on 3/25 but still active 3/26..." Review of the facility investigation dated April 1, 2014, revealed "...order entered in on wrong patient. Order was discontinued but did not disappear. Not sure why it did not go away. LPN gave one dose to wrong patient..." Review of the facility investigation addendum (for the investigation intitiated March 27, 2014), revealed "...placed order in computer under wrong pt (patient), so pharmacy called...canceled order..." Interview with the Medical Director on September 29, 2014, at 2:30 p.m., in the conference room, confirmed "...aware of process issues...systemic problems..." Interview with the DON on October 1, 2014, at 2:20 p.m., in the conference room, confirmed staff failed to follow accepted standards of practice for medication administration which resulted in resident #188 receiving [MEDICATION NAME]. Resident #453 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's order dated February 12, 2014, revealed, "...Kcl (potassium chloride) 20 meq (milliequivalant) po (by mouth) x 1..." Medical record review of the Medication Record dated February 10, 2014, through March 10, 2014, revealed the physician's order was transcribed to the Medication Record for medication administration as "...Potassium Chloride 20 meq oral once a day at 0900 (9:00 a.m.) for abnormal labs..." Continued review of the Medication Record revealed the resident was administered Potassium 20 meq every day at 9:00 a.m., for a total of 22 days. Medical record review of a 24 Hour Chart Check form revealed no documentation a 24 hour chart check was completed on February 13, 2014. Review of a facility investigation dated March 6, 2014, revealed, "...Cause of Error...Order not signed off correctly...Daily chart check error...Order entry-Transcription Error..." Continued review revealed, "...Additional information and patient condition: was not put in as a 1x order therefore pt (patient) received daily..." Further review of the facility investigation dated and signed on March 14, 2014, by (RN) #8 revealed, "...Nursing Supervisor Comments/Actions and Suggestions to Prevent Occurrence in Future: The taking off and signing off were done in error and I can't find a 24 hour chart check...Breakdown in process..." Review of a facility investigation with date received March 19, 2014, revealed, "...Was ordered as a one time medication but was not entered into computer as ordered. Pt received 22 daily doses before caught...Daily chart check was not done on evening-night shift that night. Order not signed off correctly. Discontinue date and time was not entered into computer to stop order...Incorrect order confirmation...transcription error..." Review of a facility investigation dated and signed by the CE/QA Nurse on March 19, 2014, revealed, "...What causes this occurrence?...Carelessness..." Continued review revealed, "...What do you suggest to prevent similar occurrences...I would think that if the med nurse has to override a med consistently they would check the order- hopefully before the 22nd dose..." Interview with LPN #13 on September 29, 2014, at 3:44 p.m., in the conference room, confirmed LPN #13 was responsible for verifying the order for potassium after it was entered into the computer by the ward clerk. Continued interview confirmed LPN #13 did not ensure the order was transcribed correctly in the computer; and confirmed the order for potassium was written as a one time order, and the order was put into the computer as a daily dosing order. Further interview confirmed the resident received 22 total doses of potassium which were not ordered for the resident. Continued interview confirmed LPN #13 failed to follow the facility's policy for verification of physician's orders. Resident #452 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Physician's Recapitulation Orders dated January 24, 2014, revealed "[MEDICATION NAME] ([MEDICATION NAME]) 325 mg-5 mg tab...every 6 hours prn (as needed) for pain..." Medical record review of a Physician's Order dated January 24, 2014, revealed "...Order clarification [MEDICATION NAME] 5/325 1 q 6 (hours) prn for pain. may repeat in 1 (hour) if ineffective..." Medical record review of a Physician's Order dated January 27, 2014, revealed "[MEDICATION NAME] 5/325 po (by mouth) Q 8 (hours) scheduled (and) Q 6 (hours) PRN pain..." Medical record review of a prescription dated January 27, 2014, revealed "[MEDICATION NAME]/APAP (narcotic pain reliever) 5/325...1 tab po Q 6 (hours) PRN pain...1 tab po Q 8 (hours) schedule..." Medical record review of a Physician's Order dated January 31, 2014, revealed "...Discontinue [MEDICATION NAME] order (and) continue [MEDICATION NAME] order per script..." Medical record review of the Medication Record dated January 24, 2014, through January 31, 2014, revealed "...1/27/14 [MEDICATION NAME]...325 mg-5 mg 1 tab...oral every 8 hours for pain..." Continued review revealed the resident received the [MEDICATION NAME] scheduled every eight hours from January 27, 2014 through January 30, 2014. Medical record review of the Medication Record dated January 24, 2014, through January 31, 2014, revealed "[MEDICATION NAME]...325 mg-5 mg 1 tab...oral every 6 hours prn for pain..." Continued review revealed the resident received a total of five doses of the medication on January 27, and 28, 2014. Medical record review of the Medication Record dated January 24, 2014, through January 31, 2014, revealed "[MEDICATION NAME] 325 mg-5 mg...oral every 6 hours prn for pain..." Continued review revealed the resident received seven doses of [MEDICATION NAME] January 24, 2014, through January 28, 2014, and three doses on January 30, 2014. Review of the facility investigation dated February 4, 2014, revealed "...Event Date: 1/27/2014...Wrong Medication...MD (Medical Doctor #2) wrote order in chart for [MEDICATION NAME] 5/325 mg Q 8 hr and Q 6 hr-prn. (Medical Doctor #2) wrote a prescription for [MEDICATION NAME] 5/325 mg Q 8 hr and Q 6 hr-prn for the same patient on the (same) date. Prescription was not signed off and not noted if it had been faxed to pharmacy. Pt. received both medications. Script omission not caught on 24 hour chart check and not by the RN in charge..." Interview with the CE/QA Nurse on September 25, 2014, at 10:30 a.m., in the conference room, confirmed the resident received the [MEDICATION NAME] and [MEDICATION NAME] on January 27, 28, and 30th. Continued interview confirmed the nurse should have clarified the order, and it was discovered on January 31, 2014, by chart check because the NP wrote an order to discontinue the [MEDICATION NAME] on this date. Interview with the resident's physician on September 29, 2014, by telephone, at 3:50 p.m., confirmed the physician did not intend for the resident to have both [MEDICATION NAME] and [MEDICATION NAME]. Interview with RN #2 on September 30, 2014, at 8:20 a.m., by telephone, confirmed when new orders were written, the RN verifies the orders with the computer. Further interview confirmed RN #2 was not aware of the MEDICATION ORDERS FOR [REDACTED]. Resident #454 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's order dated February 27, 2014, revealed "[MEDICATION NAME] (an antibiotic) 300 mg PO q12 (every 12) hours x 5 days..." Medical record review of the Medication Record dated February 6, 2014, through March 6, 2014, revealed the order for the medication was entered to start on February 27, 2014, and entered with a stop date for March 6, 2014 (7 days later) instead of for March 4, 2014 (5 days later). Continued review revealed the resident received 5 extra doses of the antibiotic. Review of a facility investigation signed and dated March 6, 2014, revealed, "...Cause of error...Order not signed off correctly...Daily chart check error...Order entry-transcription error..." Continued review revealed, "...Additional information and patient condition: No stop date entered into computer when order put in..." Review of a facility investigation with date received March 17, 2014, revealed, "...No stop date entered into computer and patient got 5 extra days of medication= (equals) 5 doses...Chart check error...incorrect order confirmation...transcription error..." Review of a facility investigation signed and dated by the CE/QA Nurse on March 17, 2014, revealed, "...What causes this occurrence? Carelessness...What do you suggest to prevent similar occurrences? Be careful..." Interview with Ward Clerk #6 on September 29, 2014, at 2:24 p.m., in the conference room, confirmed the medication order for the antibiotic was transcribed incorrectly for administration for seven days instead of five days. Telephone interview with RN #1 on September 29, 2014, at 3:50 p.m., confirmed the RN had completed the 24 hour chart check of the resident's medications. Continued interview confirmed the RN had not identified the transcription error during the 24 hour chart check, and had not followed the facility's policy for verification of physician's orders. Resident #455 was admitted to the facility on [DATE], with admitting [DIAGNOSES REDACTED]. Medical record review of a physician's order dated March 3, 2014, revealed an order for [REDACTED]. Medical record review of the physician's orders dated March 8, 2014, revealed the physician reordered the [MEDICATION NAME] 20 mg daily. Medical record review of the resident's MAR for March 2014 revealed the resident did not receive [MEDICATION NAME] from March 3 through March 8, 2014. Review of a facility investigation dated March 13, 2014, revealed the order for [MEDICATION NAME] 20 mg daily was not discovered by LPN #9 or by RN #1 on the twenty-four hour chart check. Continued review revealed the cause for the error was listed as failure to read complete order sheet for orders. Telephone interview with RN #1 on September 25, 2014, at 3:45 p.m., confirmed the order had been missed on the twenty-four hour check and the RN had not followed the facility Night Shift RN Checklist. Interview with LPN #9 on September 25, 2014, at 4:30 p.m., in the conference room, confirmed the order for [MEDICATION NAME] had been missed and LPN #9 had not followed facility policy for accuracy in the transcription of physician orders. Resident #456 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's order dated March 20, 2014, revealed "...Change [MEDICATION NAME] (an antidepressant medication) 10 mg po qhs (at bedtime) x 5 days then d/c..." Medical record review of the Medication Record dated February 25, 2014, through March 25, 2014, revealed "...3/20/14 [MEDICATION NAME] 10 mg tab...oral every night at bedtime...stop date 3/21/14..." Continued review of the Medication Record revealed the resident received the medication on March 20, 2014, and did not receive another dose of the medication until March 22, 2014, when the medication error was discovered, resulting in the resident missing one dose of the scheduled medication. Review of a facility investigation signed and dated March 22, 2014, revealed, "...Receive orders error: Order put in wrong..." Continued review of the facility investigation revealed, "...Nursing Supervisor Comments/Actions to prevent Occurrence in Future: Will re-educate on order take off with stop dates included..." Review of a facility investigation with date received April 1, 2014, revealed, "...chart check error...delay in processing order(s)...error in documentation...incorrect order confirmation...transcription error..." Review of a facility investigation signed and dated by the CE/QA Nurse on April 7, 2014, revealed, "...What causes this occurrence? Put in computer wrong 5 day order put in for 1 day only start date 3/20 end 3/21..." Interview with RN #6 on September 29, 2014, at 3:26 p.m., in the conference room, confirmed RN #6 completed the 24 hour chart check for the resident. Continued interview confirmed RN #6 did not identify the stop date for the order was transcribed incorrectly during the 24 hour chart check and failed to follow facility policy for 24 hour chart checks. Resident #279 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's order dated April 10, 2014, revealed an order for [REDACTED]. Medical record review of the resident's medication record for April, 2014, revealed the order had not been transcribed to the MAR. Continued review of the resident's MAR indicated [REDACTED]. Review of a facility investigation dated April 17, 2014, revealed "...the order for the [MEDICATION NAME] 1 gram IV had not been transcribed...the cause listed...order was not processed...suggestion to prevent similar occurrences...RN must review orders thoroughly for accuracy, 24 hour chart check in place for a double check..." Interview with RN #10 on September 25, 2014, at 11:17 a.m., in the conference room, confirmed the facility policy to ensure accuracy of transcription of orders had not been followed. Telephone interview with RN #4 on September 25, 2014, at 1:35 p.m., confirmed could not recall the error, but if the medication was missed the transcription policy was not followed. Telephone interview with ward clerk #3 on September 29, 2014, at 3:40 p.m., confirmed the order for the [MEDICATION NAME] IV on April 10, 2014, had not been transcribed and the transcription policy had not been followed. Resident #111 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the facility admission records dated July 21, 2014, revealed "[MEDICATION NAME] (synthetic opioid pain medication) 5 mg, 1 tab ORALLY, every 4 hours as needed, (for) 3 days, as needed, pain management." Further review revealed a duplicate [MEDICATION NAME] order from a prescription detail (a paper subscription used for narcotics). Medical record review of the MAR for July 2014, revealed "[MEDICATION NAME] HCL oral every 4 hours prn for moderate pain." Continued review revealed the [MEDICATION NAME] was given from July 25 through July 29, 2014, by four LPNs for five additional days and eleven additional doses. Review of the facility investigation dated July 29, 2014, revealed "...medication was not discontinued after 3 days as ordered..." and resident #111 continued to receive [MEDICATION NAME] 5 mg for five additional days and eleven additional doses. Review of the facility investigation dated August 8, 2014, revealed "...order entry error- missed by RN sign off w (with) 24 hour chart check...". Further review revealed the report was signed by RN #8, PCC (Patient Care Coordinator). Review of the facility investigation dated August 12, 2014, revealed "...medication not stopped after 3 days as ordered...Transcription error, chart check error, incorrect order confirmation..." Review of the facility investigation dated August 13, 2014, revealed "...Rushing- there were 9 admissions that day for 1 WC & (and) 1 RN after 11:00..." Continued review revealed the review was conducted by the Clinical Educator/Quality Assurance Nurse. Interview with RN #6 on September 29, 2014, at 10:15 a.m., in the conference room, confirmed RN #6 signed off the admission orders [REDACTED]" Further interview confirmed it is the RN's responsibility to verify the written orders with the computer. Interview with the RN #8 PCC on September 29, 2014, at 4:45 p.m., in the conference room, confirmed "...it was an input error..." Interview with the Director of Nursing and the Nurse Educator/Quality Assurance on September 29, 2014, at 2:18 p.m., in the conference room, confirmed the facility failed to follow physician's orders and medication administration policies for Resident #111. Resident #398 was admitted to the facility on [DATE], with admitting [DIAGNOSES REDACTED]. Medical record review of the Physician's admission order dated July 22, 2014, revealed an order for [REDACTED]. Medical record review of the MAR for July 21, 2014, through July 29, 2014, revealed [MEDICATION NAME] 5 mg (milligrams) had been transcribed to be given routinely twice daily. Further review of the MAR indicated [REDACTED]. Review of a facility investigation dated July 29, 2014, revealed the medication order was for [MEDICATION NAME] 5 mg BID (twice daily) PRN (as needed) and the order was transcribed into the computer as a routine scheduled order twice daily instead of as needed. Interview with ward clerk #1 on September 29, 2014, at 2:50 p.m., in the Director of Nursing's office, confirmed the ward clerk had not followed facility policy for accuracy in the transcription of physician's orders. Interview with RN #4 on September 29, 2014, in the conference room, at 3:40 p.m., confirmed the [MEDICATION NAME] 5 mg had been transcribed incorrectly as a scheduled medication, and RN #4 missed the transcription error on the admission order and on the twenty four hour chart check. Resident #105 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician's orders dated July 10, 2014, revealed ''...Potassium Chloride (electrolyte replacement for low blood levels of potassium) Extended Release Tablet, 10 milliequivalent (meq) every day..." Medical record review of the Physician's Orders dated July 23, 2014, at 6:30 p.m., revealed ''...KCL 20 meq po (every morning) (start in am) x (times) 3 days ([MEDICAL CONDITION])..." Medical record review of the MAR indicated [REDACTED]. Medical record review of the MAR indicated [REDACTED]. Medical record review of the Physician's Orders dated July 25, 2014, at 8:23 a.m., revealed "...kcl (potassium chloride) on hold until 7/27 due to increase in meds..." Review of the facility investigation dated August 14, 2014, revealed "...Pt already on KCL 10 meq daily, but new order for 20 meq x 3 days received. 10 meq not placed on hold so the pt received 30 meq on the first day of the three day order...WC did not notice the 10 meq order needed to be placed on hold..." Interview with the DON on September 29, 2014, at 2:25 p.m., in the conference room, confirmed when a new order for the same medication was received, "...the old order has to be discontinued by the ward clerk..." Interview with RN #7 Charge Nur

Based on facility policy review, medical record review, review of facility investigations, and interview, the facility failed to prevent systemic failures of inaccurate medication transcription; failed to verify physician orders [REDACTED]. The facility's failure placed sixteen residents (#262, #457, #188, #453, #452, #454, #455, #456, #279, #111, #398, #105, #197, #23, #411, #238) of twenty-four residents reviewed for medication errors in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death). The facility's failure was likely to place any resident who received medications at risk for immediate jeopardy. The Administrator, Medical Director, Chief Medical Officer/In House Legal Counsel, Chief Nursing Officer, and Director of Nursing were informed of the Immediate Jeopardy on September 30, 2014, at 4:00 p.m., in the conference room. The Immediate Jeopardy was effective February 12, 2014 through October 1, 2014. An extended survey was conducted on September 30, to October 2, 2014. Substandard Quality of Care was cited at F309-L. The facility submitted an Acceptable Allegation of Compliance to the survey team on October 2, 2014. The survey team verified the actions taken by the facility removed the jeopardy on October 2, 2014. Noncompliance continues at the "F" level. The findings included: Review of facility policy Medication Administration: General Guidelines, no date, revealed "...Procedures: 2) Medications are administered in accordance with written orders of the attending physician. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current [DIAGNOSES REDACTED]. This interaction with the physician is documented in the nursing notes and elsewhere in the medical record as appropriate." Review of facility policy Charge Nurse Review, dated June, 2012, revealed "...C) 2: Reviewing medication cards for completeness of information, accuracy in the transcription of physician orders, and adherence to stop order policies..." Review of Night Shift RN (Registered Nurse) Checklist, undated, revealed "...3: Check charts after midnight (24 hour chart checks). If any new medications ordered, verify they were on the MAR (Medication Administration Record)..." Resident #262 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Medication Record (MAR - record for documenting medication administration) for July 2014, revealed on July 24, 2014, at 2100, the resident was given [MEDICATION NAME] (an antipsychotic medication) 200 mg, [MEDICATION NAME] (an antidepressant medication) 25 mg, [MEDICATION NAME] 40 mg (an anti-cholesterol medication), and [MEDICATION NAME] 0.5 mg (an antipsychotic medication). Review of the physician's orders [REDACTED]. Medical record review of a nurse's note dated July 25, 2014, revealed "...05:30 unit secretary found med (medication) error as...was putting in other orders on another pt (patient). Pt. had 3 meds that were not her orders. VS (vital signs) B/P (blood pressure, normal blood pressure is 120/80 )...88/53...Pt very sleepy hard to arouse...(Physician) notified, orders noted..." Medical record review of a nurse's note date July 25, 2014, at 9:45 a.m., revealed the nurse started and intravenous access to administer fluids of normal saline at 60 ml/hr (milliliters per hour), as ordered by the physician, to treat [MEDICAL CONDITION] (low blood pressure). Medical record review of the nurses note dated July 25, 2014, at 2:45 p.m. revealed, "...reported to (family members) medications given to pt last night. Pt family spoke with (NP) and CE/QA nurse (Clinical Educator/Quality Assurance Nurse), voiced concerns regarding medications. Requested pt (patient) be sent to ER (emergency room ) for evaluation..." Medical record review of a Physician's progress note dated July 25, 2014, at 1:50 p.m., by NP #1, revealed "...Called to room by (RN) to discuss with (family member) some follow up concerns. (Family member) requests discussion out of room...voices concern Re: (regarding) jerking movements and effects of [MEDICATION NAME] & (and) [MEDICATION NAME] on these movements...In room patient awake - (family) stating not like (normal). Counseled them on expected side effects [MEDICATION NAME] & [MEDICATION NAME], todays lab results to include tx (treatment) for elevated potassium and use of IVF (intravenous fluids) for management/correction of [MEDICAL CONDITION]. Discussed option of hospitalization for more aggressive evaluation of [DIAGNOSES REDACTED] ([MEDICAL CONDITION] activity) to include possibility of further imaging & neurology eval (evaluation)...somnolence (excessive sleepiness) significantly improved [DIAGNOSES REDACTED] now exacerbated (made worse)..." Medical record review of a facility Discharge Summary dated July 25, 2014, revealed "... Pt discharged to hospital, dx (diagnosis): accidental overdose..." Review of the facility investigation initiated July 24, 2014, revealed resident #262 was given [MEDICATION NAME] 200 mg, [MEDICATION NAME] 25 mg, [MEDICATION NAME] 40 mg, and [MEDICATION NAME] 0.5 mg one time. Further review of the facility investigation revealed "...Pharmacist contacted for additional...orders from one new admission were put on a pt. that had already been there x 2 days...WC (ward clerk) was still in a new admission profile & went into (resident #262) profile did not switch back to the new admission profile, new admission meds put in (resident #262's) profile..." Interview with RN #5 on September 23, 2014, at 8:45 a.m., by telephone, revealed the ward clerk transcribed a new admission's [MEDICATION NAME], and [MEDICATION NAME] ([MEDICATION NAME]), from the computer screen of resident #197 into resident 262's MAR indicated [REDACTED]. The order was discovered during the 24 hour check by RN #5 at 4:00 a.m., and the Physician was notified of the medication error. Orders were received to watch the resident and take vital signs every 2 hours. RN #5 stated the resident became more somnolent and not arousable later in the morning, the blood pressure was slightly low at 100/62. RN #5 gave report in the morning shift change to Licensed Practical Nurse (LPN) #7 and also to PCC (Patient Care Coordinator) #8. RN #5 completed a facility investigation report. Interview with charge RN #7 on September 23, 2014, at 8:55 a.m., in the conference room, revealed RN #7 assessed the resident with LPN #7 and PCC #8 on the morning of July 25, 2014, received report from LPN #7 about the medication error the previous night, performed a sternal rub with response from the resident, but the resident did not open eyes. RN #7 went in later to start an IV (intravenous access for fluid and medication administration) with LPN #7, started the IV in the right forearm, and administered normal saline at 60 cc (cubic centimeters)/hr. (per hour) per the order from NP #1 to treat the resident's [MEDICAL CONDITION]. Interview with LPN #8 on September 23, 2014, at 9:31 a.m., by telephone, confirmed the [MEDICATION NAME] 200 mg, [MEDICATION NAME] 25 mg, [MEDICATION NAME] 40 mg, and [MEDICATION NAME] 0.5 mg were administered by LPN #8 in error to the resident on July 24, 2014, at 9:00 p.m. Interview with PCC (patient care coordinator) #8 on September 23, 2014, at 9:50 a.m., in the conference room, revealed RN #7 had spoken about the resident's medication error and overall condition around 7:00 a.m., on July 25, 2014, and had notified NP #1 when the NP arrived at around 7:45 a.m. The PCC assessed the resident with LPN #7 and charge RN #2 and found the resident to be unarousable. Interview with charge RN #7 on September 23, 2014, at 10:56 a.m., in the conference room, revealed the RN #7 had assessed the resident at shift change on the morning of July 25, 2014, found the resident's mental status to be more confused, called NP #1, received orders for a chest x-ray, an ECG (electrocardiogram) and to start IV fluids of Normal Saline 1 liter at 60cc/ hour to treat [MEDICAL CONDITION]. Resident #457 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Hospital Discharge Medication List dated March 14, 2014, revealed "[MEDICATION NAME] (a medication to prevent blood clots)...0.4 ml (millilters), subcutaneous, every 24 hours..." Medical record review of the Physician's Recapitulation Orders dated March 14, 2014, revealed "[MEDICATION NAME]...40 mg/0.4 ml sol (solution) give 0.4 ml...subcutaneous once a day for blood clotting control..." Medical record review of the Medication Record dated March 14, 2014, through March 20, 2014, revealed the days for administration of the medication was indicated as every other day and and the resident did not receive [MEDICATION NAME] 40 mg subcutaneous on March 15 and March 17, 2014. Medical record review of a physician's orders [REDACTED]. Medical record review of a Diagnostic Report dated March 19, 2014, revealed "...Exam...Lower Venous Right...Clinical: RLE [MEDICAL CONDITION] and Warmth...Findings...Significant nonocclusive thrombus (blood clot) is seen within the right posterior tibial and peroneal veins...Impression: significant nonocclusive thrombus below the knee within the right peroneal and posterior tibial veins..." Medical record review of a Physician's Progress Note dated March 19, 2014, revealed "...results RLE doppler show nonocclusive thrombus below knee (within) right peroneal (and) post tibial veins. Pt has had [DIAGNOSES REDACTED] (redness)/[MEDICAL CONDITION] x (times) 2 days..." Medical record review of a physician's orders [REDACTED]. Review of the facility investigation dated March 20, 2014, revealed "...Error when entering order. clicked frequency options and entered every 2 days...suggest to prevent similar occurrences? Read order thoroughly recheck after entered for accuracy..." Review of the facility investigation dated March 21, 2014, revealed "...Event Date: 3/14/2014...Order entry error off admission orders [REDACTED]. Nurse did not notice the change in time frequencies...Medication involved: [MEDICATION NAME] ([MEDICATION NAME])..." Medical record review of the physician's orders [REDACTED]. Interview on September 29, 2014, at 8:30 a.m., with the CE/QA Nurse in the conference room, confirmed the [MEDICATION NAME] order was transcribed incorrectly, entered as every other day, and the facility failed to administer the medication as ordered to Resident #457 on March 15 and 17, 2014. Continued interview confirmed the ward clerk entered the order incorrectly with the frequency of every other day. Interview with RN #6 on September 29, 2014, at 9:10 a.m., in the conference room, confirmed was responsible for verifying the order of [MEDICATION NAME] and failed to verify the order for accuracy. Continued interview confirmed "...probably had a lot of admissions and may have been interrupted...resident was admitted sometime around 4:00 p.m...most admissions come in between 5:00 p.m. and 7:00 p.m..." Continued interview confirmed signed the twenty-four hour chart check on March 15, 2014, and did not identify the error. Interview with NP #1 on September 29, 2014, at 11:00 a.m., in the conference room, confirmed it would be possible the missed doses contributed to the development of the [MEDICAL CONDITION]. Resident #188 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the admission orders [REDACTED]" Further review revealed Ward Clerk #4 completed transcription of the orders on March 22, 2014, at 5:50 p.m., and RN #4 signed off as reviewing the orders on March 23, 2014, at 12:27 a.m. Medical record review of the 24-Hour Chart Check revealed the signature of RN #4 on March 23, 2014 at 12:29 a.m. Medical record review of the MAR indicated [REDACTED]@ (at) 6pm for Blood Clotting Control, stop date of March 26, 2014..." Medical record review of the physician's orders [REDACTED]. Medical record review of the MAR indicated [REDACTED]. Medical record review of the physician's orders [REDACTED]." Review of the facility investigation dated March 27, 2014, revealed "...no [MEDICATION NAME] order in chart. Pt only had [MEDICATION NAME] order for 3/25-3/26 but has been here since 3/22. RX (Pharmacy) status says it was ordered and canceled on 3/25 but still active 3/26..." Continued review revealed event date of March 25, 2014. Review of the facility investigation dated April 1, 2014, revealed "...order entered in on wrong patient. Order was discontinued but did not disappear. Not sure why it did not go away. LPN gave one dose to wrong patient..." Record review of the facility investigation addendum, dated March 26, 2014, revealed "...placed order in computer under wrong pt, so pharmacy called...canceled order..." Interview with the Clinical Educator/Quality Assurance Nurse on September 25, 2014, at 10:55 a.m., in the conference room, confirmed responsibilities include completion and investigation of the facility investigation. Further interview confirmed "...the whole thing was done incorrectly, the drug, the dose, and the frequency..." Interview with the LPN #2 on September 29, 2014, at 8:50 a.m., by telephone in the conference room, confirmed administering the [MEDICATION NAME] 2 mg tablet on March 25, 2014. Further interview confirmed overriding the Pyxis (computerized medication dispensary) to obtain the [MEDICATION NAME]. Continued interview confirmed "...I was never told I made a med error..." Interview with NP #1 on September 29, 2014, at 11:20 a.m., in the conference room, confirmed notice of medication error on March 26, 2014. Further interview confirmed "...I don't review all of the EMARS (Electronic Medication Administration Record) or I would never get done...that is a significant med error..." Interview with RN PCC #3 on September 29, 2014, at 5:30 p.m., by telephone, confirmed the [MEDICATION NAME] investigation was conducted with interviews with Ward Clerk #4 and RN #4 "...re-educated on comparing the computer and paper orders..." Further interview confirmed the interviews and re-education were not documented "...we only document if they are in the disciplinary process..." Interview with Pharmacy Consultant #1 on September 30, 2014, at 9:30 a.m., in the conference room, confirmed the pharmacy notified the facility of the [MEDICATION NAME] dose due to "...the INR (International Normalized Ratio) results (lab test for patients taking [MEDICATION NAME])...if we had not received the INR, we would not have caught it...would have continued to receive it...yes...and I consider it a significant med error..." Interview with RN #4 on September 30, 2014, at 5:25 p.m., by telephone, confirmed signing off the admission orders [REDACTED]. Further interview confirmed RN #4 signed the 24 Hour Chart Check at 12:29 a.m., on March 23, 2014, and at 12:20 a.m., on March 26, 2014. Further interview confirmed "...kind of remember it..." and RN #4 confirmed had no re-education on medication errors. Resident #453 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Medical record review of the Medication Administration Record [REDACTED]" Continued review of the MAR indicated [REDACTED]. Review of facility investigation dated March 6, 2014, revealed, "...Cause of Error...Order not signed off correctly...Daily chart check error...Order entry-Transcription Error..." Continued review revealed, "...Additional information and patient condition: was not put in as a 1x order therefore pt received daily..." Further review of the facility investigation dated and signed on March 14, 2014, by RN #8 revealed, "...Nursing Supervisor Comments/Actions and Suggestions to Prevent Occurrence in Future: The taking off and signing off were done in error and I can't find a 24 hour chart check...Breakdown in process..." Review of facility investigation with date received March 19, 2014, revealed, "...Was ordered as a one time medication but was not entered into computer as ordered. Pt received 22 daily doses before caught. Daily chart check was not done on evening-night shift that night. Order not signed off correctly. Discontinue date and time was not entered into computer to stop order...Incorrect order confirmation...transcription error..." Review of facility investigation dated and signed by the CE/QA Nurse on March 19, 2014, revealed, "...What causes this occurrence?...Carelessness..." Continued review revealed, "...What do you suggest to prevent similar occurrences?...I would think that if the med nurse has to override a med consistently they would check the order- hopefully before the 22nd dose..." Resident #452 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Medical record review of a prescription dated January 27, 2014, revealed "[MEDICATION NAME]/APAP (narcotic pain reliever) 5/325...1 tab (tablet) po Q 6 (hours) PRN pain...1 tab po Q 8 (hours) schedule..." Medical record review of a physician's orders [REDACTED]. Medical record review of the MAR indicated [REDACTED]...1/27/14 [MEDICATION NAME]...325 mg-5 mg 1 tab...oral every 8 hours for pain..." Continued review revealed the resident received the [MEDICATION NAME] scheduled every eight hours from January 27, 2014, through January 30, 2014. Medical record review of the MAR indicated [REDACTED]...325 mg-5 mg 1 tab...oral every 6 hours prn for pain..." Continued review revealed the resident received the medication prn on January 27 and 28, 2014. Medical record review of the MAR indicated [REDACTED]" Continued review revealed the resident received the [MEDICATION NAME] on January 24, 2014, through January 28, 2014, and on January 30, 2014. Review of the facility investigation dated February 4, 2014, revealed "...Event Date: 1/27/2014...Wrong Medication...MD (Medical Doctor #2) wrote order in chart for [MEDICATION NAME] 5/325 mg Q 8 hr and Q 6 hr-prn. (Medical Doctor #2) wrote a prescription for [MEDICATION NAME] 5/325 mg Q 8 hr and Q 6 hr-prn for the same patient on the same date. Prescription was not signed off and not noted if it had been faxed to pharmacy. Pt. received both medications. Script omission not caught on 24 hour chart check and not by the RN in charge. However, while researching this error, I discovered this MD likes to fax the script to pharmacy and then put the script in the WC basket at the desk. This is not how the process is meant to flow. All scripts are to be placed in the chart for the order to be faxed and secured to the physician order [REDACTED]. Interview with the CE/QA Nurse on September 25, 2014, at 10:30 a.m., in the conference room, confirmed the resident received both the [MEDICATION NAME] and [MEDICATION NAME] on January 27, 28, and 30th. Continued interview confirmed the nurse should have clarified the order, it was discovered on January 31, 2014, by chart check because the NP wrote an order to discontinue the [MEDICATION NAME] on this date. Interview with the resident's physician on September 29, 2014, by telephone, at 3:50 p.m., confirmed did not intend for the resident to have both [MEDICATION NAME] and [MEDICATION NAME]. Resident #454 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Medical record review of the Medication Administration Record [REDACTED]. Continued review revealed the resident received 5 extra doses of the antibiotic. Review of facility investigation signed and dated March 6, 2014, revealed, "...Cause of error...Order not signed off correctly...Daily chart check error...Order entry-transcription error..." Continued review revealed, "...Additional information and patient condition: No stop date entered into computer when order put in..." Review of facility investigation with date received March 17, 2014, revealed, "...No stop date entered into computer and patient got 5 extra days of medication= (equals) 5 doses...Chart check error...incorrect order confirmation...transcription error..." Review of facility investigation signed and dated by the CE/QA Nurse on March 17, 2014, revealed, "...What causes this occurrence? Carelessness...What do you suggest to prevent similar occurrences? Be careful..." Interview with Ward Clerk #6 on September 29, 2014, at 2:24 p.m., in the conference room, confirmed the medication order for the antibiotic was transcribed incorrectly for 7 days instead of 5 days. Continued interview revealed the Ward Clerk had not been made aware of the transcription error prior to the interview. Interview with RN #1 on September 29, 2014, at 3:50 p.m., by phone, confirmed had completed the 24 hour chart check of the resident's medications. Continued interview confirmed the RN did not identify the transcription error during the 24 hour chart check. Further interview revealed the RN was not made aware by nursing administration of the nurse's failure to identify the error prior to the interview. Resident #455 was admitted to the facility on [DATE], with admitting [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Review of the resident's MAR for March, 2014, revealed [MEDICATION NAME] 20 mg was not administered from March 3 through March 8, 2014. Medical record review of a facility investigation dated March 13, 2014, revealed the order for [MEDICATION NAME] 20 mg qd was overlooked by LPN #9 and by RN #1 on the twenty-four hour chart check. The cause for the error was listed as failure to read complete order sheet for orders with an intervention to prevent future occurences of "...make sure to check for all dates..." and "...check dates on orders..." Interview with RN #1 on September 25, 2014 at 3:45 p.m., by telephone, confirmed the order had been missed on the twenty-four hour check. Interview with LPN #9 on September 25, 2014, at 4:30 p.m., in the conference room, confirmed the order for [MEDICATION NAME] 20 mg every day had been missed. Interview with the CE/QA Nurse on September 29, 2014, at 3:45 p.m., in the conference room, revealed "... initiated the medication error report..." and confirmed the medication error. Resident #456 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Medical record review of the Medication Administration Record [REDACTED]...3/20/14 [MEDICATION NAME] 10 mg tab...oral every night at bedtime...stop date 3/21/14..." Continued review of the Medication Administration Record [REDACTED]. Review of facility investigation signed and dated March 22, 2014, revealed, "...Receive orders error: Order put in wrong..." Continued review of facility investigation revealed, "...Nursing Supervisor Comments/Actions to prevent Occurrence in Future: Will re-educate on order take off with stop dates included..." Review of facility investigation with date received April 1, 2014, revealed, "...chart check error...delay in processing order(s)...error in documentation...incorrect order confirmation...transcription error..." Review of facility investigation signed and dated by CE/QA Nurse on April 7, 2014, revealed, "...What causes this occurrence? Put in computer wrong 5 day order put in for 1 day only start date 3/20 end 3/21..." Further review of facility investigation revealed the section "...What do you suggest to prevent similar occurrences?..." was blank. Interview with RN #6 on September 29, 2014, at 3:26 p.m., in the conference room, confirmed RN #6 completed the 24 hour chart check for the resident. Continued interview confirmed the RN did not identify the transcription error during the 24 hour chart check. Resident #279 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]. Review of the resident's MAR for April, 2014, revealed the order had not been transcribed to the MAR. Continued review of the resident's MAR indicated [REDACTED]. Four doses of [MEDICATION NAME] had not been administered per the physician's orders [REDACTED]. Review of a facility investigation dated April 17, 2014, revealed the order for the [MEDICATION NAME] 1 gram IV had not been transcribed and the cause was documented as order not processed. A suggestion to prevent similar occurrences was RN must review orders thoroughly for accuracy and 24 hour chart check in place for a double check. Interview with RN #10 on September 25, 2014, at 11:17 a.m., in the conference room, after observing the physician's orders [REDACTED]. RN #10 had not been made aware of the medication error by the CE/QA Nurse. Interview with charge RN #4 on September 25, 2014, at 1:35 p.m., by telephone, when asked about the missed medication verification for the dosages of [MEDICATION NAME] "...had no specific memory...when a medication error record was initiated...was usually notified...not aware of this medication error...if...initialed the order and the medication was missed, it was...responsibility and medication transcription policy was not followed..." Resident #111 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]." Continued review revealed WC #1 signed off the order at 10:32 p.m., on July 21, 2014, and RN #6 signed off the order at 1:31 a.m., on July 22, 2014. Further review of the physician orders [REDACTED].#1 at 10:24 p.m., on July 21, 2014, and RN #6 on 1:14 a.m. on July 22, 2014. Review of the 24 Hour Chart Check dated July 22 and 23, 2014, revealed the signature of RN #6. Review of the MAR for July 2014, revealed "[MEDICATION NAME] HCL oral every 4 hours prn for moderate pain." Continued review revealed the [MEDICATION NAME] was given from July 25 through July 29, 2014, after it had been discontinued. Further review revealed the [MEDICATION NAME] had been given by four LPN's (#2, #14, #4, and #6) for five additional days and eleven additional doses after the stop date of July 24, 2014. Review of the facility investigation dated July 29, 2014, revealed "...medication was not discontinued after 3 days as ordered..." and resident #111 continued to receive [MEDICATION NAME] 5 mg for five additional days and eleven additional doses. Continued review revealed the report was generated by LPN #15. Review of the facility investigation dated August 8, 2014, revealed "...order entry error- missed by RN sign off w (with) 24 hour chart check..." Further review revealed the report was signed by RN #8 PCC. Review of the facility investigation dated August 12, 2014, revealed "...medication not stopped after 3 days as ordered...Parameters...Transcription error, chart check error, incorrect order confirmation..." Review of the facility investigation of the August medication errors for resident #111, dated August 13, 2014, revealed "...Rushing-there were 9 admissions that day for 1 WC & 1 RN after 11:00..." Continued review revealed the review was conducted by the Clinical Educator/Quality Assurance Nurse. Interview with the RN #6 on September 29, 2014, at 10:15 a.m., in the conference room, confirmed sign

Based on review of facility policy and procedure, medical record review, facility investigation review, and interview, the facility failed to prevent significant medication errors for four residents (#262, #457, #188, #453) of twenty-four residents reviewed for medication errors. The facility's failure to ensure physician's orders were transcribed accurately, failure to ensure the Registered Nurse verified orders for accurate transcription and failure to identify inaccurate medication transcription on 24 hour chart checks resulted in a system failure that placed all residents receiving medication in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death). The Administrator, Medical Director, Chief Medical Officer In House Legal Counsel, Chief Nursing Officer, and Director of Nursing were informed of the Immediate Jeopardy on September 30, 2014, at 4:00 p.m., in the conference room. The Immediate Jeopardy was effective February 12, 2014 through October 1, 2014. An extended survey was conducted on September 30, 2014, through October 2, 2014. F333-L is substandard Quality of Care. An acceptable Allegation of Compliance was received on October 2, 2014, and actions which removed the Immediate Jeopardy were verified on-site on October 2, 2014. Noncompliance continues at the severity of "F". The findings included: Review of the facility policy Medication Administration: General Guidelines, undated, revealed "...Procedures: 2) Medications are administered in accordance with written orders of the attending physician. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current [DIAGNOSES REDACTED]. This interaction with the physician is documented in the nursing notes and elsewhere in the medical record as appropriate..." Review of the facility policy Charge Nurse, dated June, 2012, revealed "...C) 2: Reviewing medication cards for completeness of information, accuracy in the transcription of physician orders, and adherence to stop order policies..." Review of the facility procedure Night Shift RN (Registered Nurse) Checklist, undated, revealed "...3). Check charts after midnight (24 hr (hour) chart checks). If any new medications ordered, verify they were on the MAR (Medication Administration Record)..." Resident #262 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Medication Record (MAR - record for documenting medication administration) for July 2014, revealed on July 24, 2014, at 9:00 p.m., the resident was given [MEDICATION NAME] 200 mg (milligrams) (an antipsychotic medication), [MEDICATION NAME] 25 mg (an antidepressant medication), [MEDICATION NAME] 40 mg (an anti-cholesterol medication), and [MEDICATION NAME] 0.5 mg (an antipsychotic medication). Medical record review of Physician's orders from July 23, through July 25, 2014, revealed there were no orders for [MEDICATION NAME], or [MEDICATION NAME]. Medical record review of a nurse's note dated July 25, 2014, revealed "...05:30 unit secretary found med (medication) error as...was putting in other orders on another pt (patient). Pt. had 3 meds that were not her orders. VS (vital signs) B/P (blood pressure, normal blood pressure is 120/80)...88/53...Pt very sleepy hard to arouse...(Physician) notified, orders noted..." Medical record review of a nurse's note date July 25, 2014, at 9:45 a.m., revealed the nurse started and intravenous access to administer fluids of normal saline at 60 ml/hr (milliliters per hour), as ordered by the physician, to treat [MEDICAL CONDITION] (low blood pressure). Medical record review of a Physician's progress note dated July 25, 2014, at 1:50 p.m., by NP #1, revealed "...Called to room by (RN) to discuss with (family member) some follow up concerns. (Family member) requests discussion out of room...voices concern Re: (regarding) jerking movements and effects of [MEDICATION NAME] & (and) [MEDICATION NAME] on these movements...In room patient awake - (family) stating not like (normal). Counseled them on expected side effects [MEDICATION NAME] & [MEDICATION NAME], todays lab results to include tx (treatment) for elevated potassium and use of IVF (intravenous fluids) for management/correction of [MEDICAL CONDITION]. Discussed option of hospitalization for more aggressive evaluation of [DIAGNOSES REDACTED] ([MEDICAL CONDITION] activity) to include possibility of further imaging & neurology eval (evaluation)...somnolence (excessive sleepiness) significantly improved [DIAGNOSES REDACTED] now exacerbated (made worse)..." Medical record review of a facility discharge summary dated July 25, 2014, revealed "... Pt discharged to hospital, dx (diagnosis): accidental overdose..." Resident #457 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Hospital Discharge Medication List dated March 14, 2014, revealed "[MEDICATION NAME] (a medication to prevent blood clots)...0.4 ml (milliliters), subcutaneous, every 24 hours..." Medical record review of the Physician's Recapitulation Orders dated March 14, 2014, revealed "[MEDICATION NAME]...40 mg/0.4 ml sol (solution) give 0.4 ml...subcutaneous once a day for blood clotting control..." Medical record review of the Medication Record dated March 14, 2014, through March 20, 2014, revealed resident #457 did not receive [MEDICATION NAME] 40 mg subcutaneous on March 15 and March 17, 2014. Medical record review of a Physician's Order dated March 18, 2014, revealed "...Vascular US (ultrasound) RLE (right lower extremity) Dx: warmth, [MEDICAL CONDITION] (swelling)... Dx: chills, warm, swollen RLE..." Medical record review of a Diagnostic Report dated March 19, 2014, revealed "...Exam...Lower Venous Right...Clinical: RLE [MEDICAL CONDITION] and Warmth...Findings...Significant nonocclusive thrombus (blood clot) is seen within the right posterior tibial and peroneal veins...Impression: significant nonocclusive thrombus below the knee within the right peroneal and posterior tibial veins..." Medical record review of a Physician's Progress Note dated March 19, 2014, revealed "...results RLE doppler show nonocclusive thrombus below knee (within) right peroneal (and) post tibial veins. Pt has had [DIAGNOSES REDACTED] (redness)/[MEDICAL CONDITION] x (times) 2 days..." Review of the facility investigation dated March 20, 2014, revealed "...Error when entering order. clicked frequency options and entered every 2 days...suggest to prevent similar occurrences? Read order thoroughly recheck after entered for accuracy..." Review of the facility investigation dated March 21, 2014, revealed "...Event Date: 3/14/2014...Order entry error off admission orders [REDACTED]. Nurse did not notice the change in time frequencies...Medication involved: [MEDICATION NAME] ([MEDICATION NAME])..." Interview with the CE/QA (Clinical Educator/Quality Assurance) Nurse on September 29, 2014, at 8:30 a.m., in the conference room, confirmed the [MEDICATION NAME] order was transcribed incorrectly, entered as every other day, and the resident missed the dose on March 15 and 17, 2014. Continued interview confirmed the ward clerk entered the order incorrectly with the frequency of every other day, Interview with NP (Nurse Practitioner) #1 on September 29, 2014, at 11:00 a.m., in the conference room, confirmed it would be possible the missed doses contributed to the development of the blood clot in the leg. Resident #188 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of resident #188's admission orders [REDACTED]" Medical record review of the Medication Record dated March 25, 2014, revealed "[MEDICATION NAME] 2 mg TAB (tablet) ([MEDICATION NAME] Sodium) Oral Every night @ (at) 6 pm for Blood Clotting Control, stop date of March 26, 2014..." Medical record review of the Physician's Orders for Resident #188 revealed no order for [MEDICATION NAME] on March 25, 2014. Medical record review of the MAR indicated [REDACTED]. Interview with the CE/QA Nurse on September 25, 2014, at 10:55 a.m., in the conference room, confirmed "...the whole thing was done incorrectly, the drug, the dose, and the frequency...we thought the order was entered wrong...we have trouble with the (hospital) orders..." Interview with LPN #2 on September 29, 2014, at 8:50 a.m., via telephone, confirmed the LPN administered [MEDICATION NAME] 2 mg on March 25, 2014. Interview with NP #1 on September 29, 2014, at 11:20 a.m., in the conference room, confirmed notice of medication error on March 26, 2014. Further interview confirmed "...I don't review all of the EMARS (Electronic Medication Administration Record) or I would never get done...that is a significant med error..." Interview with Pharmacy Consultant #1 on September 30, 2014, at 9:30 a.m., in the conference room, confirmed the [MEDICATION NAME] dose was a significant medication error. Resident #453 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's order dated February 12, 2014, revealed, "...Kcl (potassium) 20 meq (milliequivalent) po (by mouth) x (times) 1..." Medical record review of the Medication Record dated February 10, 2014, through March 10, 2014, revealed the physician's order was transcribed to the Medication Record for medication administration as "...Potassium Chloride 20 meq oral once a day at 0900 (9:00 a.m.) for abnormal labs..." Continued review of the Medication Record revealed the resident was administered Potassium 20 meq every day at 9:00 a.m. for a total of 22 days, (21 doses in error from February 13, 2014, through March 5, 2014). Interview with the Medical Director on September 29, 2014, at 2:34 p.m., in the conference room, confirmed the resident receiving daily dose of potassium for 22 days, when the original order for potassium was a one time order, was a significant medication error. The Immediate Jeopardy was effective from February 12 through October 1, 2014, and was removed onsite on October 2, 2014. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated by the surveyors through review of documents, staff interviews, and observations conducted onsite on October 2, 2014. The surveyors verified the allegation of compliance by: 1. Review of the facility's in-service records to ensure nursing staff were educated regarding changes for medication administration which included the implementation of paper Medication Administration Records (MARs). Review included the facility's plan of action to ensure all nurses were educated on the new system before being allowed to work a shift (coordinated by the Director of Nursing), and the facility's plan for education for nurses who were not scheduled to work or who were on vacation or Family Medical Leave. 2. Verification of the new medication administration system by the facility which included discontinuation of the Electronic Medication Administration Record [REDACTED]. Verification included review reconciling new physician's orders and the correct reconciliation to the new paper MARs. 3. Verification through interview with the Director of Nursing and Medical Director, and review of facility documentation all current resident's medication orders were accurately transcribed to paper MARs. 4. Verification through interview with the Administrator, and review of facility documentation the facility's identification of eight transcription errors during the facility's audit of all current resident's medication orders. Review of facility documentation verified residents or resident's family, and physician were notified of the errors. Verification through interview with the Medical Director of immediate intervention to assess resident's status after identification of the error, and provide clarification orders where needed. 5. Review of a random sample of active resident charts to verify the accurate transcription of new physician's orders to the paper MARs. Review of random sample of active resident charts for the completeness and accuracy of 24 hour chart checks. 6. Verification through observation in both nursing stations new orders were being transcribed by Registered Nurses only. 7. Verification through observation of 3 Licensed Practical Nurses (two on the ground floor and one on main floor) of medication administration by Licensed Practical Nurses with the addition of Registered Nurses assisting to ensure the accuracy of administered medications. 8. Verification through interviews with nine Registered Nurses, seven Licensed Practical Nurses, and three Ward Clerks/Certified Nursing Assistants to determine the comprehension gained through in-services conducted by the Director of Nursing regarding the changes and implementation of the facility's new transcription and verification procedures. 9. Verification through interview with the Administrator, Medical Director, Chief Nursing Officer, Risk Management Team, Director of Nursing, and Director of the Pharmacy Vendor of their participation in risk management meeting to address the system changes with medication administration, and involvement of all parties in ongoing quality assurance. 10. Verification through observation and interview with ward clerks and registered nurses the facility discontinued the process of entering physician orders electronically by the ward clerks. 11. Verification through observation faxed medication orders were reconciled in real time. 12. Verification by interview with the Director of Pharmacy Vendor the pharmacy consultant will reconcile new medication orders weekly. Non-compliance continues at an "F" level for monitoring the effectiveness of corrective actions and evaluation of monitoring by the Quality Assurance Committee. The facility is required to submit a plan of correction. Complaint #

Based on review of pharmacy contract, medical record review, review of facility policy and procedures, review of facility investigation, and interview, the facility failed to ensure a system of pharmacy oversight was in place to ensure medication orders were accurately transcribed to the Medication Record, physicians orders were reconciled and verified, and medications were accurately administered according to physician's orders [REDACTED].#262, #457, #188, #453, #452, #454, #455, #456, #279, #111, #398, #105, #197, #23, #411, #238) of twenty-four residents reviewed for medication errors in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death). The facility's failure was likely to place any resident who received medications at risk for immediate jeopardy. The Administrator, Medical Director, Chief Medical Officer/In House Legal Counsel, Chief Nursing Officer, and Director of Nursing were informed of the Immediate Jeopardy on September 30, 2014, at 4:00 p.m., in the conference room. The Immediate Jeopardy was effective February 12, 2014 through October 1, 2014. An extended survey was conducted on September 30, 2014, through October 2, 2014. The facility submitted an Acceptable Allegation of Compliance to the survey team on October 2, 2014. The survey team verified the actions taken by the facility removed the jeopardy on October 2, 2014. Noncompliance continues at the "F" level. The findings included: Review of the facility's contract with the pharmacy, effective June 1, 2010, revealed, "...Duties and Obligation of the Pharmacy...Establish and maintain accurate drug profiles on each resident of Facility...Provide and maintain an appropriate medication administration system...and accessories for such system...Work with Facility to insure that Medical Administration Records, treatment sheets, physician order [REDACTED]. Telephone interview with Pharmacy Consultant #1 on September 30, 2014, at 9:30 a.m., confirmed the pharmacy consultant tried to see residents within seven days of admission; performed weekly reviews; and was responsible for reviewing the medications the resident was on for drug interactions. Further interview confirmed the pharmacy consultant did not reconcile the medications with the electronic Medication Administration Record [REDACTED]. Continued interview confirmed Pharmacy Consultant #1 was notified of a medication error on residents #262, #197, and #188, but was not aware of the extent of those medication errors. Telephone interview with the Pharmacy Director (the Pharmacy also employed the pharmacy consultants) on October 1, 2014, at 9:55 a.m., confirmed the pharmacy consultants had not been reconciling the individual resident medication administration records against the physician's orders [REDACTED]. Continued interview confirmed if the medications were not put into the computer system accurately, the pharmacy would not have any knowledge of the inaccuracy. Refer to F157-L, F281-L, F309-L, F333-L. The Immediate Jeopardy was effective from February 12 through October 1, 2014, and was removed onsite on October 2, 2014. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated by the surveyors through review of documents, staff interviews, and observations conducted onsite on October 2, 2014. The surveyors verified the allegation of compliance by: 1. Review of the facility's in-service records to ensure nursing staff were educated regarding changes for medication administration which included the implementation of paper Medication Administration Records (MARs). Review included the facility's plan of action to ensure all nurses were educated on the new system before being allowed to work a shift (coordinated by the Director of Nursing), and the facility's plan for education for nurses who were not scheduled to work or who were on vacation or Family Medical Leave. 2. Verification of the new medication administration system by the facility which included discontinuation of the Electronic Medication Administration Record [REDACTED]. Verification included review reconciling new physician's orders [REDACTED]. 3. Verification through interview with the Director of Nursing and Medical Director, and review of facility documentation all current resident's medication orders were accurately transcribed to paper MARs. 4. Verification through interview with the Administrator, and review of facility documentation the facility's identification of eight transcription errors during the facility's audit of all current resident's medication orders. 5. Review of a random sample of active resident charts to verify the accurate transcription of new physician's orders [REDACTED]. Review of random sample of active resident charts for the completeness and accuracy of 24 hour chart checks. 6. Verification through observation in both nursing stations new orders were being transcribed by Registered Nurses only. 7. Verification through observation of 3 Licensed Practical Nurses (two on the ground floor and one on main floor) of medication administration by Licensed Practical Nurses with the addition of Registered Nurses assisting to ensure the accuracy of administered medications. 8. Verification through interviews with nine Registered Nurses, seven Licensed Practical Nurses, and three Ward Clerks/Certified Nursing Assistants to determine the comprehension gained through in-services conducted by the Director of Nursing regarding the changes and implementation of the facility's new transcription and verification procedures. 9. Verification through interview with the Administrator, Medical Director, Chief Nursing Officer, Risk Management Team, Director of Nursing, and Director of the Pharmacy Vendor of their participation in risk management meeting to address the system changes with medication administration. 10. Verification through observation and interview with ward clerks and registered nurses the facility discontinued the process of entering physician orders [REDACTED]. 11. Verification through observation faxed medication orders were reconciled in real time. 12. Verification by interview with the Director of Pharmacy Vendor the pharmacy consultant will reconcile new medication orders weekly. Non-compliance continues at an "F" level for monitoring the effectiveness of corrective actions and evaluation of monitoring by the Quality Assurance Committee. The facility is required to submit a plan of correction. c/o #

Based on review of pharmacy contract, review of facility investigations, medical record review, interview, and review of facility policy, the pharmacy failed to provide accurate drug regimen reviews to prevent the systemic failure of inaccurate medication transcription and verification of physician orders [REDACTED].#262, #457, #188, #453, #452, #454, #455, #456, #279, #111, #398, #105, #197, #23, #411, #238) of twenty-four residents reviewed for medication errors in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death). The facility's failure was likely to place any resident who received medications at risk for Immediate Jeopardy. The Administrator, Medical Director, Chief Medical Officer/In House Legal Counsel, Chief Nursing Officer, and Director of Nursing were informed of the Immediate Jeopardy on September 30, 2014, at 4:00 p.m., in the conference room. The Immediate Jeopardy was effective February 12, 2014 through October 1, 2014. An extended survey was conducted September 30 through October 1, 2014. The facility submitted an Acceptable Allegation of Compliance to the survey team on October 2, 2014. The survey team verified the actions taken by the facility removed the jeopardy on October 2, 2014. Noncompliance continues at the "F" level. The findings included: Review of the facility's contract with the pharmacy, effective June 1, 2010, revealed, "...Duties and Obligation of the Pharmacy...Establish and maintain accurate drug profiles on each resident of Facility...Provide and maintain an appropriate medication administration system...and accessories for such system...Work with Facility to insure that Medical Administration Records, treatment sheets, physician order [REDACTED]. Review of facility investigations for sixteen residents (#262, #457, #188, #453, #452, #454, #455, #456, #279, #111, #398, #105, #197, #23, #411, and #238) revealed a pattern of medication errors as a result of inaccurate transcription and failure to verify medication records with written physician's orders [REDACTED]. Telephone interview with pharmacy consultant #1 on September 25, 2014, at 2:45 p.m., revealed the consultant was aware of the medication error involving resident #262 and resident #197 on July 25, 2014, and was asked by the facility for drug interaction guidance. The consultant provided drug interaction information to the Clinical Educator/Quality Assurance Nurse and the Director of Nursing. The pharmacy consultant was also aware of a Warfarin medication error with resident #188, but was not aware of the medication errors detailed in the other thirteen facility investigations. The Pharmacy Consultant confirmed the thirteen investigations were not reviewed during the the quarterly advisory board meetings. Telephone interview with Pharmacy Consultant #1 on September 30, 2014, at 9:30 a.m., confirmed the pharmacy consultant did not reconcile the medications with the electronic Medication Administration Record [REDACTED]. Interview with Pharmacy Consultant #1 on September 29, 2014, at 2:35 p.m., in the Clinical Educator/Quality Assurance Nurse's office, confirmed no communication from the facility had been forwarded on the medication errors for residents #457, #453, #452, #454, #455, #456, #279, #111, #398, #105, #23, #411, or #238. The pharmacy consultant stated "...attend quarterly advisory board meetings, last meeting was August 27, 2014, where antidepressants, hypnotics, Coumadin, dosages were discussed, and outliers and percentages of medications within range were discussed..." Refer to F157-L, F281-L, F309-L, F333-K, F425-L The Immediate Jeopardy was effective from February 12 through October 1, 2014, and was removed onsite on October 2, 2014. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated by the surveyors through review of documents, staff interviews, and observations conducted onsite on October 2, 2014. The surveyors verified the allegation of compliance by: 1. Review of the facility's in-service records to ensure nursing staff were educated regarding changes for medication administration which included the implementation of paper Medication Administration Records (MARs). Review included the facility's plan of action to ensure all nurses were educated on the new system before being allowed to work a shift (coordinated by the Director of Nursing), and the facility's plan for education for nurses who were not scheduled to work or who were on vacation or Family Medical Leave. 2. Verification of the new medication administration system by the facility which included discontinuation of the Electronic Medication Administration Record [REDACTED]. Verification included review reconciling new physician's orders [REDACTED]. 3. Verification through interview with the Director of Nursing and Medical Director, and review of facility documentation all current resident's medication orders were accurately transcribed to paper MARs. 4. Verification through interview with the Administrator, and review of facility documentation the facility's identification of eight transcription errors during the facility's audit of all current resident's medication orders. 5. Review of a random sample of active resident charts to verify the accurate transcription of new physician's orders [REDACTED]. Review of random sample of active resident charts for the completeness and accuracy of 24 hour chart checks. 6. Verification through observation in both nursing stations new orders were being transcribed by Registered Nurses only. 7. Verification through observation of 3 Licensed Practical Nurses (two on the ground floor and one on main floor) of medication administration by Licensed Practical Nurses with the addition of Registered Nurses assisting to ensure the accuracy of administered medications. 8. Verification through interviews with nine Registered Nurses, seven Licensed Practical Nurses, and three Ward Clerks/Certified Nursing Assistants to determine the comprehension gained through in-services conducted by the Director of Nursing regarding the changes and implementation of the facility's new transcription and verification procedures. 9. Verification through interview with the Administrator, Medical Director, Chief Nursing Officer, Risk Management Team, Director of Nursing, and Director of the Pharmacy Vendor of their participation in risk management meeting to address the system changes with medication administration. 10. Verification through observation and interview with ward clerks and registered nurses the facility discontinued the process of entering physician orders [REDACTED]. 11. Verification through observation faxed medication orders were reconciled in real time. 12. Verification by interview with the Director of Pharmacy Vendor the pharmacy consultant will reconcile new medication orders weekly. Non-compliance continues at an "F" level for monitoring the effectiveness of corrective actions and evaluation of monitoring by the Quality Assurance Committee. The facility is required to submit a plan of correction. c/o #

Based on medical record review, facility policy and procedures review, review of facility investigations, and interview, the facility failed to be administered in a manner to ensure residents were free of medication errors. The facility's failure to address systemic failures for medication administration placed sixteen residents (#262, #457, #188, #453, #452, #454, #455, #456, #279, #111, #398, #105, #197, #23, #411, #238) of twenty-four residents reviewed for medication errors in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death). The facility's failure was likely to place any resident who received medications at risk for immediate jeopardy. The Administrator, Medical Director, Chief Medical Officer/In House Legal Counsel, Chief Nursing Officer, and Director of Nursing were informed of the Immediate Jeopardy on September 30, 2014, at 4:00 p.m., in the conference room. The Immediate Jeopardy was effective February 12, 2014 through October 1, 2014. An extended survey was conducted on September 30, to October 2, 2014. The facility submitted an Acceptable Allegation of Compliance to the survey team on October 2, 2014. The survey team verified the actions taken by the facility removed the jeopardy on October 2, 2014. Noncompliance continues at the "F" level. The findings included: Interview with the Administrator on September 30, 2014, at 10:12 a.m., in the conference room, revealed the Administrator was aware of medication errors. Continued interview revealed the Administrator stated the medication errors were more of an individual problem, and "...have been handled on an individual basis..." Further interview revealed the Administrator stated there was a problem in the three step process of transcription and verification of physician's orders [REDACTED]. The ward clerk transcribing physician's orders [REDACTED].#2. The RN checking to verify the orders were correct, and #3. The Night Shift RN Checklist double-checking for any transcription errors). Further interview revealed, "...I don't think we have come down to a clear answer...I don't know the root cause of the problem..." The Administrator stated individual nurses who made the medication errors not being informed/re-educated was "...a problem..." Further interview confirmed the Administrator had not identified a trend with the repeated occurrence of medication errors. Refer to F157-L, F281-L, F309-L, F333-L, F425-L, F428-L Assurance Committee. The facility is required to submit a plan of correction. The Immediate Jeopardy was effective from February 12 through October 1, 2014, and was removed onsite on October 2, 2014. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated by the surveyors through review of documents, staff interviews, and observations conducted onsite on October 2, 2014. The surveyors verified the allegation of compliance by: 1. Review of the facility's in-service records to ensure nursing staff were educated regarding changes for medication administration which included the implementation of paper Medication Administration Records (MARs). Review included the facility's plan of action to ensure all nurses were educated on the new system before being allowed to work a shift (coordinated by the Director of Nursing), and the facility's plan for education for nurses who were not scheduled to work or who were on vacation or Family Medical Leave. 2. Verification of the new medication administration system by the facility which included discontinuation of the Electronic Medication Administration Record [REDACTED]. Verification included review reconciling new physician's orders [REDACTED]. 3. Verification through interview with the Director of Nursing and Medical Director, and review of facility documentation all current resident's medication orders were accurately transcribed to paper MARs. 4. Verification through interview with Director of Nursing and review of the Medication Occurrence Report modified to require the date and time of notification of resident and/or family of medication errors. 5. Verification through interview with the Administrator, and review of facility documentation the facility's identification of eight transcription errors during the facility's audit of all current resident's medication orders. Review of facility documentation verified residents or resident's family, and physician were notified of the errors. Verification through interview with the Medical Director of immediate intervention to assess resident's status after identification of the error, and provide clarification orders where needed. 6. Review of a random sample of active resident charts to verify the accurate transcription of new physician's orders [REDACTED]. Review of random sample of active resident charts for the completeness and accuracy of 24 hour chart checks. 7. Verification through observation in both nursing stations new orders were being transcribed by Registered Nurses only. 8. Verification through observation of 3 Licensed Practical Nurses (two on the ground floor and one on main floor) of medication administration by Licensed Practical Nurses with the addition of Registered Nurses assisting to ensure the accuracy of administered medications. 9. Verification through interviews with nine Registered Nurses, seven Licensed Practical Nurses, and three Ward Clerks/Certified Nursing Assistants to determine the comprehension gained through in-services conducted by the Director of Nursing regarding the changes and implementation of the facility's new transcription and verification procedures. 10. Verification through interview with the Administrator, Medical Director, Chief Nursing Officer, Risk Management Team, Director of Nursing, and Director of the Pharmacy Vendor of their participation in risk management meeting to address the system changes with medication administration, and involvement of all parties in ongoing quality assurance. 11. Verification through observation and interview with ward clerks and registered nurses the facility discontinued the process of entering physician orders [REDACTED]. 12. Verification through observation faxed medication orders were reconciled in real time. 13. Verification by interview with the Director of Pharmacy Vendor the pharmacy consultant will reconcile new medication orders weekly. Non-compliance continues at an "F" level for monitoring the effectiveness of corrective actions and evaluation of monitoring by the Quality

Based on medical record review, review of facility investigations, review of facility policy and procedures, and interview the facility Governing Body failed to ensure facility policies for accurate medication administration were implemented, and failed to identify a systemic problem of medication errors related to failure to follow policies. The failure placed sixteen residents (#262, #457, #188, #453, #452, #454, #455, #456, #279, #111, #398, #105, #197, #23, #411, #238) of twenty-four residents reviewed for medication errors in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death). The facility's failure was likely to place any resident who received medications at risk for Immediate Jeopardy. The Administrator, Medical Director, Chief Medical Officer/In House Legal Counsel, Chief Nursing Officer, and Director of Nursing were informed of the Immediate Jeopardy on September 30, 2014, at 4:00 p.m., in the conference room. The Immediate Jeopardy was effective February 12, 2014 through October 1, 2014. An extended survey was conducted on September 30, to October 2, 2014. The facility submitted an Acceptable Allegation of Compliance to the survey team on October 2, 2014. The survey team verified the actions taken by the facility removed the jeopardy on October 2, 2014. Noncompliance continues at the "F" level. The findings included: Interviews with the Chief Nursing Officer and the Chief Medical Officer/In House Legal Counsel of a local hospital, during the survey, revealed the local hospital owned, and was responsible for Administration and Governing of the facility. Interview with the Chief Nursing Officer (CNO) of the hospital on September 30, 2014, at 5:53 p.m., in the conference room, revealed the Chief Nursing Officer is one of several members of the Steering Committee of the hospital which reviewed medication errors reported to the hospital by the facility. Continued interview with the CNO confirmed the hospital's Steering Committee conducted a root-cause analysis of the medication error of resident #262, and the committee discussed some interventions which needed to be implemented to address the specific issue with resident #262. Continued interview confirmed the CNO was not aware of the scope and extent of the repeated medication errors. Interview with members of the hospital's Risk Management Team: Chief Nursing Officer, Director of Quality Management, and Risk Manager, on October 1, 2014, at 8:45 a.m., in the conference room, revealed the facility's process of notifying the hospital of medication errors was by the facility's staff entering medication error reports into a computerized tracking system for the hospital. Continued interview confirmed the medication error reports are reviewed by the Risk Manager, however in-depth, root-cause analysis occurs only in specific cases. Further interview with the Risk Management Team confirmed the Risk Management Team had not identified any trends related to the facility's medication administration processes. Interview with the Patient Safety Officer of the hospital on October 1, 2014, at 10:50 a.m., in the conference room, revealed the Patient Safety Officer had conducted root cause analysis of specific, individualized medication errors (resident #262) and had identified "...some opportunity at many levels..." of the facility's medication administration system. Continued interview confirmed the Patient Safety Officer had only focused on one resident (#262) to complete a root-cause analysis. Further interview with the Patient Safety Officer confirmed the Patient Safety Officer had not identified, and was not aware of any trends related to the facility's systemic problems with medication administration. Interview with the Chief Medical Officer of the hospital on October 2, 2014, at 8:20 a.m., in the conference room, confirmed the Chief Medical Officer of the hospital was the presiding chair of the Risk Management committee. Continued interview with the Chief Medical Officer confirmed was aware of "...some of the medication errors..." Further interview confirmed the Chief Medical Officer was not aware "...of the extent and number..." of medication errors and was not aware of the facility's repeated pattern of medication errors. Refer to F157-L, F281-L, F309-L, F333-L, F425-L, F428-L, F F490-L The Immediate Jeopardy was effective from February 12 through October 1, 2014, and was removed onsite on October 2, 2014. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated by the surveyors through review of documents, staff interviews, and observations conducted onsite on October 2, 2014. The surveyors verified the allegation of compliance by: 1. Review of the facility's in-service records to ensure nursing staff were educated regarding changes for medication administration which included the implementation of paper Medication Administration Records (MARs). Review included the facility's plan of action to ensure all nurses were educated on the new system before being allowed to work a shift (coordinated by the Director of Nursing), and the facility's plan for education for nurses who were not scheduled to work or who were on vacation or Family Medical Leave. 2. Verification of the new medication administration system by the facility which included discontinuation of the Electronic Medication Administration Record [REDACTED]. Verification included review reconciling new physician's orders [REDACTED]. 3. Verification through interview with the Director of Nursing and Medical Director, and review of facility documentation all current resident's medication orders were accurately transcribed to paper MARs. 4. Verification through interview with Director of Nursing and review of the Medication Occurrence Report modified to require the date and time of notification of resident and/or family of medication errors. 5. Verification through interview with the Administrator, and review of facility documentation the facility's identification of eight transcription errors during the facility's audit of all current resident's medication orders. Review of facility documentation verified residents or resident's family, and physician were notified of the errors. Verification through interview with the Medical Director of immediate intervention to assess resident's status after identification of the error, and provide clarification orders where needed. 6. Review of a random sample of active resident charts to verify the accurate transcription of new physician's orders [REDACTED]. Review of random sample of active resident charts for the completeness and accuracy of 24 hour chart checks. 7. Verification through observation in both nursing stations new orders were being transcribed by Registered Nurses only. 8. Verification through observation of 3 Licensed Practical Nurses (two on the ground floor and one on main floor) of medication administration by Licensed Practical Nurses with the addition of Registered Nurses assisting to ensure the accuracy of administered medications. 9. Verification through interviews with nine Registered Nurses, seven Licensed Practical Nurses, and three Ward Clerks/Certified Nursing Assistants to determine the comprehension gained through in-services conducted by the Director of Nursing regarding the changes and implementation of the facility's new transcription and verification procedures. 10. Verification through interview with the Administrator, Medical Director, Chief Nursing Officer, Risk Management Team, Director of Nursing, and Director of the Pharmacy Vendor of their participation in risk management meeting to address the system changes with medication administration, and involvement of all parties in ongoing quality assurance. 11. Verification through observation and interview with ward clerks and registered nurses the facility discontinued the process of entering physician orders [REDACTED]. 12. Verification through observation faxed medication orders were reconciled in real time. 13. Verification by interview with the Director of Pharmacy Vendor the pharmacy consultant will reconcile new medication orders weekly. Non-compliance continues at an "F" level for monitoring the effectiveness of corrective actions and evaluation of monitoring by the Quality Assurance Committee. The facility is required to submit a plan of correction.

Based on review of review of the Medical Director Agreement Contract, medical record review, review of facility investigations, review of facility policy and procedures, and interview, the Medical Director of the facility failed to ensure medications were reconciled, transcribed, and administered to residents in a safe manner. The Medical Director's failure to address the systemic problems related to the processes for accurate medication administration resulted in medication errors and placed sixteen residents (#262, #457, #188, #453, #452, #454, #455, #456, #279, #111, #398, #105, #197, #23, #411, #238) of twenty-four residents reviewed for medication errors in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death). The facility's failure was likely to place any resident who received medications at risk for Immediate Jeopardy. The Administrator, Medical Director, Chief Medical Officer/In House Legal Counsel, Chief Nursing Officer, and Director of Nursing were informed of the Immediate Jeopardy on September 30, 2014, at 4:00 p.m., in the conference room. The Immediate Jeopardy was effective February 12, 2014 through October 1, 2014. An extended survey was conducted on September 30, to October 2, 2014. The facility submitted an Acceptable Allegation of Compliance to the survey team on October 2, 2014. The survey team verified the actions taken by the facility removed the jeopardy on October 2, 2014. Noncompliance continues at the "F" level. The findings included: Review of the Medical Director Agreement contract signed and dated by the Medical Director on August 16, 2012, revealed, "...2. Responsibilities of Medical Director...b. Develop Policies and Procedures. Assist in developing, executing, and periodically reviewing facility's written policies and procedures, medical protocols and standing orders as requested by Hospital and/or Department Leadership...n. Participate in Quality Assessment and Performance Improvement Program. Actively participate in the facility's Performance Improvement program, including identifying best practices, evaluating patient care, evaluating indicators relating to improved outcomes and patient and family satisfaction, and creating clinical models of care both within facility..." Interview with the Medical Director on September 29, 2014, at 2:34 p.m., in the conference room, revealed the Medical Director was aware of a specific case of medication error in which a resident required physician intervention (#262). Further interview confirmed the Medical Director made specific recommendations related to the medication errors with resident #262. Continued interview confirmed the Medical Director was not aware of a pattern of medication errors which had occurred and was related to the transcription, verification, and 24 hour chart checks by the Night Shift Licensed Nurses. Further interview with the Medical Director confirmed the facility had identified a "systemic issue" related to the facility's use of a software program for order entry and medication administration which required intervention and re-education of specific employees, however had not made any specific recommendations to the facility to address the systemic failure in the facility's medication administration process. Refer to F157-L, F 281-L, F309-L, F333-L, F425-L, F428-L, F490-L, F493-L The Immediate Jeopardy was effective from February 12 through October 1, 2014, and was removed onsite on October 2, 2014. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated by the surveyors through review of documents, staff interviews, and observations conducted onsite on October 2, 2014. The surveyors verified the allegation of compliance by: 1. Review of the facility's in-service records to ensure nursing staff were educated regarding changes for medication administration which included the implementation of paper Medication Administration Records (MARs). Review included the facility's plan of action to ensure all nurses were educated on the new system before being allowed to work a shift (coordinated by the Director of Nursing), and the facility's plan for education for nurses who were not scheduled to work or who were on vacation or Family Medical Leave. 2. Verification of the new medication administration system by the facility which included discontinuation of the Electronic Medication Administration Record [REDACTED]. Verification included review reconciling new physician's orders [REDACTED]. 3. Verification through interview with the Director of Nursing and Medical Director, and review of facility documentation all current resident's medication orders were accurately transcribed to paper MARs. 4. Verification through interview with Director of Nursing and review of the Medication Occurrence Report modified to require the date and time of notification of resident and/or family of medication errors. 5. Verification through interview with the Administrator, and review of facility documentation the facility's identification of eight transcription errors during the facility's audit of all current resident's medication orders. Review of facility documentation verified residents or resident's family, and physician were notified of the errors. Verification through interview with the Medical Director of immediate intervention to assess resident's status after identification of the error, and provide clarification orders where needed. 6. Review of a random sample of active resident charts to verify the accurate transcription of new physician's orders [REDACTED]. Review of random sample of active resident charts for the completeness and accuracy of 24 hour chart checks. 7. Verification through observation in both nursing stations new orders were being transcribed by Registered Nurses only. 8. Verification through observation of 3 Licensed Practical Nurses (two on the ground floor and one on main floor) of medication administration by Licensed Practical Nurses with the addition of Registered Nurses assisting to ensure the accuracy of administered medications. 9. Verification through interviews with nine Registered Nurses, seven Licensed Practical Nurses, and three Ward Clerks/Certified Nursing Assistants to determine the comprehension gained through in-services conducted by the Director of Nursing regarding the changes and implementation of the facility's new transcription and verification procedures. 10. Verification through interview with the Administrator, Medical Director, Chief Nursing Officer, Risk Management Team, Director of Nursing, and Director of the Pharmacy Vendor of their participation in risk management meeting to address the system changes with medication administration, and involvement of all parties in ongoing quality assurance. 11. Verification through observation and interview with ward clerks and registered nurses the facility discontinued the process of entering physician orders [REDACTED]. 12. Verification through observation faxed medication orders were reconciled in real time. 13. Verification by interview with the Director of Pharmacy Vendor the pharmacy consultant will reconcile new medication orders weekly. Non-compliance continues at an "F" level for monitoring the effectiveness of corrective actions and evaluation of monitoring by the Quality Assurance Committee. The facility is required to submit a plan of correction.

Based on medical record review, review of facility investigations, review of facility policies and procedures, and interview, the facility failed to maintain an effective Quality Assurance Program which identified and addressed the systemic failures of inaccurate medication transcription, verification of physician orders [REDACTED]. The failure resulted in medication errors and placed sixteen residents (#262, #457, #188, #453, #452, #454, #455, #456, #279, #111, #398, #105, #197, #23, #411, #238) of twenty-four residents reviewed for medication errors in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death). The facility's failure was likely to place any resident who received medications at risk for Immediate Jeopardy. The Administrator, Medical Director, Chief Medical Officer/In House Legal Counsel, Chief Nursing Officer, and Director of Nursing were informed of the Immediate Jeopardy on September 30, 2014, at 4:00 p.m., in the conference room. The Immediate Jeopardy was effective February 12, 2014 through October 1, 2014. An extended survey was conducted on September 30, to October 2, 2014. The facility submitted an Acceptable Allegation of Compliance to the survey team on October 2, 2014. The survey team verified the actions taken by the facility removed the jeopardy on October 2, 2014. Noncompliance continues at the "F" level. The findings included: Interview with the Clinical Educator/Quality Assurance (CE/QA) Nurse on September 30, 2014, at 8:37 a.m., in the conference room, revealed the CE/QA Nurse was responsible for the review of medication errors and was responsible for reporting the errors to the Continuous Quality Improvement Committee (CQI). Continued interview with the CE/QA Nurse revealed the CE/QA nurse only conducted a root-cause analysis of medication errors "...if it was something really complicated..." Interview with the Administrator on September 30, 2014, at 10:13 a.m., in the conference room, confirmed the Administrator was the chair of the CQI committee, and had oversight of quality assurance of the facility. Continued interview with the Administrator confirmed the Administrator had been aware of medication errors which had occurred in the facility, and confirmed medication errors were discussed in CQI meetings. Continued interview with the Administrator confirmed the number of medication errors which occurred in the facility was reported during each CQI meeting. Further interview with the Administrator revealed the CQI team had identified an issue with the computer software program which the facility utilized for entering orders and for medication administration. Further interview confirmed the facility "...did one update..." to the software to address problems identified. Further interview confirmed the Administrator was aware of continued medication errors in the facility. The Administrator stated, "...don't look at all of them..." Continued interview confirmed the Director of Nursing was responsible for the communication to the CQI committee regarding medication errors, "...did not discuss every single one..." Further interview with the Administrator revealed the CQI committee did not identify a breakdown in the process of medication administration "...felt like more individualized (focused on specific staff members that made transcription or verification mistakes)..." Continued interview confirmed the Administrator and CQI committee "...do not have a clear answer..." to address the systemic problems with medication administration in the facility. The Administrator stated, "...I don't know...I'm just speculating where I think the problem is..." Interview with the CE/QA Nurse on September 30, 2014, at 10:45 a.m., in the conference room, revealed the CQI committee had discussed specific medication errors which had occurred and had been sent to the Risk Management Team. Continued interview revealed had identified a trend related to the new employee education process, and trends related to specific employees with transcription errors which "...required retraining (on an individual basis)..." Further interview revealed the CE/QA Nurse had identified, in the process of 24 hour chart checks, the same nurse completing order verification was the same nurse which was completing the 24 hour chart checks, and had discussed with the Director of Nursing a plan to include Licensed Practical Nurses (LPNs) in the completion of the 24 hour chart checks. Continued interview confirmed LPNs were educated in the completion of 24 hour chart checks. Continued interview confirmed neither the CE/QA Nurse nor the Director of Nursing (DON) monitored the addition of the LPNs. Further interview with the CE/QA Nurse confirmed the CE/QA Nurse regularly attended CQI meetings and was present during Quarterly Advisory meetings. Continued interview revealed the CE/QA Nurse was asked by the Medical Director of the facility "...to look at process..." Further interview confirmed "...identified that the process of med (medication) entry by ward clerks was being interrupted..." and the intervention initiated by the CE/QA Nurse was to inform the ward clerks to no longer take charts to another floor during the completion of medication entry in the computer. Continued interview with the CE/QA Nurse revealed the ward clerks were also instructed to complete order entry "...in the back..." of the nurse station, "...probably biggest thing I've seen..." (for addressing medication errors). Further interview confirmed the only significant intervention put in place by the facility was the instruction provided to the ward clerks by the CE/QA Nurse, and the facility failed to identify a continued pattern of medication and transcription errors. Refer to F157-L, F281-L, F309-L, F333-L, F425-L, F428-L, F490-L, F493-L, F501-L The Immediate Jeopardy was effective from February 12 through October 1, 2014, and was removed onsite on October 2, 2014. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated by the surveyors through review of documents, staff interviews, and observations conducted onsite on October 2, 2014. The surveyors verified the allegation of compliance by: 1. Review of the facility's in-service records to ensure nursing staff were educated regarding changes for medication administration which included the implementation of paper Medication Administration Records (MARs). Review included the facility's plan of action to ensure all nurses were educated on the new system before being allowed to work a shift (coordinated by the Director of Nursing), and the facility's plan for education for nurses who were not scheduled to work or who were on vacation or Family Medical Leave. 2. Verification of the new medication administration system by the facility which included discontinuation of the Electronic Medication Administration Record [REDACTED]. Verification included review reconciling new physician's orders [REDACTED]. 3. Verification through interview with the Director of Nursing and Medical Director, and review of facility documentation all current resident's medication orders were accurately transcribed to paper MARs. 4. Verification through interview with Director of Nursing and review of the Medication Occurrence Report modified to require the date and time of notification of resident and/or family of medication errors. 5. Verification through interview with the Administrator, and review of facility documentation the facility's identification of eight transcription errors during the facility's audit of all current resident's medication orders. Review of facility documentation verified residents or resident's family, and physician were notified of the errors. Verification through interview with the Medical Director of immediate intervention to assess resident's status after identification of the error, and provide clarification orders where needed. 6. Review of a random sample of active resident charts to verify the accurate transcription of new physician's orders [REDACTED]. Review of random sample of active resident charts for the completeness and accuracy of 24 hour chart checks. 7. Verification through observation in both nursing stations new orders were being transcribed by Registered Nurses only. 8. Verification through observation of 3 Licensed Practical Nurses (two on the ground floor and one on main floor) of medication administration by Licensed Practical Nurses with the addition of Registered Nurses assisting to ensure the accuracy of administered medications. 9. Verification through interviews with nine Registered Nurses, seven Licensed Practical Nurses, and three Ward Clerks/Certified Nursing Assistants to determine the comprehension gained through in-services conducted by the Director of Nursing regarding the changes and implementation of the facility's new transcription and verification procedures. 10. Verification through interview with the Administrator, Medical Director, Chief Nursing Officer, Risk Management Team, Director of Nursing, and Director of the Pharmacy Vendor of their participation in risk management meeting to address the system changes with medication administration, and involvement of all parties in ongoing quality assurance. 11. Verification through observation and interview with ward clerks and registered nurses the facility discontinued the process of entering physician orders [REDACTED]. 12. Verification through observation faxed medication orders were reconciled in real time. 13. Verification by interview with the Director of Pharmacy Vendor the pharmacy consultant will reconcile new medication orders weekly. Non-compliance continues at an "F" level for monitoring the effectiveness of corrective actions and evaluation of monitoring by the Quality Assurance Committee. The facility is required to submit a plan of correction.

Based on review of facility policies, medical record review, and interview, the facility failed to prevent a significant weight loss for one resident (#388) of four residents reviewed for nutritional status of forty-one residents reviewed. The facility's failure resulted in harm for resident #388. The findings included: Resident #388 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the policy, Pressure Ulcer Management, revised July 2013, revealed "...monitor nutritional status, including food and fluid intake. Assess Pre-[MEDICATION NAME], Transferrin, and [MEDICATION NAME] levels to determine protein status..." Review of the Supervision of Resident Nutrition, revised October 2009, revealed "...food and fluid intake must be observed...recorded and reported..." Medical record review of the facility's Standing admission orders [REDACTED]" Medical record review of the resident's Nutritional History, dated August 18, 2014, revealed an admission weight of 99.4 pounds, UBW (Usual Body Weight) of 96 pounds, and a BMI (Body Mass Index) of 18 (underweight less than 18.5). Continued review of the nutritional history dated August 18, 2014 revealed a diet order of ''CCHO (Consistent Carbohydrate Diet) c (with) glucerna (nutritional supplement) c meals/Regular. glucerna TID (three times a day).'' Further review of the nutritional history dated August 18, 2014, revealed, "...alert, confused...r (right) heel SDTI (suspected deep tissue injury), r buttock decubitus (pressure ulcer)...consumes 75% (percent) (of meal)... suggest daily MVI (multivitamin), vit C (Vitamin C) and Zinc to promote wound heeling..." Medical record review of the 5 day Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview Mental Status (BIMS) of 9 (indicating moderate cognitive impairment), supervision for eating, set-up only, and a weight of 99 pounds. Medical record review of the dietary notes dated August 28, 2014, revealed "...pt (patient) request/family change glucerna to 2 pm..." Medical record review of the Plan of Care, dated August 28, 2014, ''...Needs therapeutic diet related to low BMI...interventions...Regular diet with Glucerna once daily, monitor meal consumption offering substitutes if resident consumes less than 50% of meals..." Medical record review of the Weights Detail Report revealed a weight of 95 pounds (4.1% loss) dated on September 7, 2014. Continued review revealed a weight of 91 pounds (8.1% loss) on September 22, 2014. Medical record review of the Interdisciplinary Progress Notes of August 25 to September 23, 2014, revealed no documentation of weight loss. Medical record review of the facility's Meal & (and) Fluid Detail Report from August 24 to September 21, 2014 revealed the Glucerna 2:00 p.m. documented as consumed on September 5 and 6, 2014. Continued review revealed the resident received Glucerna for two out of twenty-five days. Medical record review of the 30 day MDS, dated [DATE], revealed a BIMS of 10 (10 and above is cognitively intact), supervision for eating, set- up only, and a weight of 95 pounds. Medical record review revealed a CBC (complete blood count), BMP (basic metabolic profile), a Sed (sedimentation) rate (measures [MEDICAL CONDITION] activity), drawn on September 12, 2014, for ''ble (bilateral lower extremity) inflammation, ckd (cyclin-dependant kinase), [MEDICAL CONDITION]''. Further review revealed the BUN (blood urea nitrogen), a test to measure urea nitrogen that forms when protein breaks down, with a level of 32 mg/dl (milligrams/deciliters), (normal range of BUN of 6 to 20 mg/dl) and the Creatinine (measurement of muscle wasting) level on September 12, 2014, revealed 1.28 mg/dl, (normal level of 0.6 to 1.2 mg/dl). Continued review revealed no Pre-[MEDICATION NAME] (blood test for protein deficiency), [MEDICATION NAME] (measures protein), or Transferrin (iron metabolism) levels were ordered per facility policy. Medical record review of the laboratory blood work, drawn on September 23, 2014, revealed orders for a CBC and BMP. Further review revealed the BUN of 35 mg/dl and a Creatinine of 3.12 mg/dl. Continued review revealed no [MEDICATION NAME], Pre-[MEDICATION NAME], or Transferrin levels were ordered per policy. Interview with the Certified Nursing Assistants (CNA's) #1, #5, and #6, on September 23, 2014, at 4:15 p.m., in the dining room, confirmed the CNA's were not instructed to document the 2:00 p.m. snacks. Interview with the Registered Nurse (RN) #2 Charge Nurse, on September 23, 2014, at 4:00 p.m., in the main nursing station, confirmed no knowledge of the resident #388's weight loss. Interview with the Registered Dietician on September 23, 2014, at 4:30 p.m., in the dining room, confirmed the Pre-[MEDICATION NAME], and Transferrin labs were not ordered, nutritional supplement was not documented, not aware of the weight loss, and had no further dietary consults with resident #388. Further interview confirmed "...I have been on vacation...the dietary manager doesn't take over for me..." Interview with Director of Nursing (DON) on September 24, 2014, at 7:45 a.m., in the main level nursing station, confirmed the facility failed to obtain labs, document nutritional supplements, and notify dietary or the physician of the weight loss. Continued interview confirmed "...RN's responsibility to notify the RD..." Further interview confirmed "...it doesn't look like the policy was followed..."