Every finding on record at Perry County Nursing Center

Based on interviews, record review, and facility policy review, the facility failed to ensure an indwelling catheter was managed in a manner to prevent possible complications when nursing staff failed to assess and respond timely to a resident's complaint of catheter-related discomfort for one (1) of (1) residents reviewed for urinary catheters. Resident #1.Findings include:A review of the facility's policy, Quality of Care, revised 08/24, revealed, .1. Commitment to Quality of Care. The Facility is committed to providing care and services necessary to work toward, attain and/or maintain each resident's physical, mental and psychosocial well-being.3. Assessment and Treatment. The assessment and treatment of residents should be undertaken by competent and qualified individuals who have the authority and responsibility to conduct that assessment and treatment.A review of the facility's Standing Orders, dated 2/27/26, revealed, .Urinary System: If resident has Foley catheter, check for patency.If over 6 hours of no or decreased output, notify Provider.A record review of the Order Summary Report revealed Resident #1 had a Physician's Order, dated 10/2/25, to Change catheter and catheter bag monthly and prn (as needed) . A record review of the Bladder Voiding and Toilet Use record revealed Resident #1 had documented urine output on 3/17/26 at 6:23 AM of 400 milliliters (ml) and at 1:12 PM of 1000 milliliters (ml). A record review of the Client Coordination Note Report revealed a note for Resident #1, dated 3/17/26, entered by the hospice nurse, which documented, Patient requesting catheter to be changed today while hospice nurse in building.Patient states he felt his catheter was clogged up and burning noted to penis. Patient's catheter changed.blood noted to tubing and large amount of sediment noted. On 4/20/26 at 12:45 PM, during an interview with the Hospice Registered Nurse (RN), she explained that on 3/17/26 at 9:42 AM, she received a text message from Licensed Practical Nurse (LPN) #1 asking when she would return to the facility, as Resident #1 was complaining of urinary spasms and requesting his Foley (indwelling catheter) be changed. She reported she did not return to the facility until 3/17/26 at 3:07 PM and, upon changing the catheter, obtained a return of 600 milliliters (ml) of urine with sediment, which occurred over five (5) hours after notification from the facility.On 4/20/26 at 1:11 PM, during an interview with LPN #1, she explained that on 3/17/26 at approximately 8:50 AM, she was informed that Resident #1 requested his catheter be changed due to urinary spasms. She confirmed she did not assess the resident or evaluate catheter output during her shift and that the catheter was not changed until the hospice nurse returned later that afternoon.On 4/20/26 at 1:30 PM, during an interview with Resident #1, he reported that on 3/17/26, he informed staff early in the day that he was experiencing bladder spasms and discomfort and requested his catheter be changed. He reported the catheter was not changed until the hospice nurse returned later that afternoon. He confirmed he did not repeatedly request assistance throughout the day after his initial report.On 4/20/26 at 2:00 PM, during an interview with the Director of Nursing (DON), she explained that nursing staff are expected to assess residents promptly when complaints such as bladder spasms or catheter discomfort are reported. She confirmed that nursing staff should have assessed the resident and, if indicated, changed the catheter or obtained appropriate orders without waiting for hospice to return.On 4/20/26 at 2:20 PM, during an interview with the Administrator, he explained that staff are expected to provide timely assessment and intervention when residents report symptoms and confirmed nursing staff should not delay care when it can be addressed by facility staff.On 4/21/26 at 10:00 AM, during an interview with the Nurse Practitioner (NP), she confirmed that when a resident reports bladder spasms, with or without a catheter, the resident should be assessed promptly by facility nursing staff.A record review of the Face Sheet revealed the facility admitted Resident #1 on 5/5/25 with diagnoses including Multiple Sclerosis. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/18/26 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of (15), which indicated the resident was cognitively intact.

Based on interview, record review, and facility policy and assessment review, the facility failed to designate a licensed nurse to serve as the charge nurse for each tour of duty for two (2) of three (3) shifts reviewed (3:00 PM-11:00 PM and 11:00 PM-7:00 AM), which had the potential to affect all 57 residents residing in the facility.Findings include:A review of the facility's policy, Nursing Services-Staffing, revised 11/17, revealed, .3. Each facility will designate a nurse.as a Charge Nurse on each tour of duty. The Charge Nurse.will supervise the care rendered to the residents to promote quality of life, resident rights, and to assure that the care rendered is consistent with areas identified in the comprehensive care plan.A record review of the facility's Facility Assessment, dated 11/17/25, revealed, .Facility Resources needed to Provide Competent Support and Care for Our Resident Population.Staffing Plan.7AM-3PM shift 7 aides (Certified Nurse Aides)/2 LPNs (Licensed Practical Nurse)/1 Charge/TX (Treatment) RN (Registered Nurse); 3PM-11PM shift 4 aides/2 LPNs; 11PM-7AM shift 4 aides/1 LPN.A record review of the facility's Monthly Staff Schedule for February 2026 revealed that on 2/23/26 there were three (3) nurses scheduled for the 7:00 AM to 3:00 PM shift, two (2) nurses scheduled for the 3:00 PM to 11:00 PM shift, and one (1) nurse scheduled for the 11:00 PM to 7:00 AM shift. No designated charge nurse was identified on the schedule for any shift.On 2/23/26 at 10:45 AM, during an interview, the Staff Development Nurse explained the facility has three halls (B, C, and D) and that nursing staff work eight-hour shifts. She reported that during the 7:00 AM to 3:00 PM shift there are three nurses consisting of two medication nurses and one treatment nurse. She stated that during the 3:00 PM to 11:00 PM shift there are two LPNs, and during the 11:00 PM to 7:00 AM shift there is one LPN. She confirmed she does not schedule a designated charge nurse after 3:00 PM each day.On 2/23/26 at 1:00 PM, during an interview with the Director of Nursing (DON), Staff Development Nurse, and the Administrator, the DON reported the facility does not have a designated charge nurse for each tour of duty except for the 7:00 AM to 3:00 PM shift. The DON explained the facility recently lost the RN supervisor and is actively recruiting for the position. She stated the 7:00 AM to 3:00 PM charge nurse also provides treatments to residents. She confirmed there is no designated charge nurse for the 3:00 PM to 11:00 PM or 11:00 PM to 7:00 AM shifts.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident's right to the provision of care in a respectful and dignified manner when staff provided incontinent care for one (1) of nine (9) sampled residents without ensuring privacy. (Resident #1).Findings include:A review of the facility's document, A Matter of RIGHTS: A Guide to Your Rights and Responsibilities as a Resident, Copyright 2020, revealed, .Dignity and Respect: You have the right to dignity and respect in the care you receive.A review of the facility's Aide Check List, with the latest revision dated December 2020, revealed, .Ensure privacy for Residents.A record review of the admission Record revealed the facility admitted Resident #1 on 8/13/24 and he had diagnoses including Vascular Dementia.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/17/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated he was severely cognitively impaired.On 10/2/25 at 8:27 AM, during an observation, Certified Nurse Aide (CNA) #1 and CNA #3 were observed providing incontinence care and changing the incontinence brief for Resident #1. The CNAs lifted the resident using a sit-to-stand lift and removed his brief without pulling either his privacy curtain or that of his roommate. The resident's roommate was lying in bed, facing Resident #1, with a full view of the resident's perineal area. On 10/2/25 at 1:40 PM, during an interview, the Staff Development Coordinator stated the facility provided monthly in-service training on Resident Rights, including each resident's right to respect and dignity. She explained that all new staff received Resident Rights training during orientation, which included both video and one-on-one instruction on providing respectful and dignified care. She stated that CNAs were instructed to ensure privacy prior to beginning any care procedure and that competency checkoffs for Activities of Daily Living (ADL) care, including incontinence care, required demonstration of privacy measures.On 10/2/25 at 2:13 PM, during an interview, CNA #1 stated she had not considered the privacy issue while changing the resident in front of his roommate. She acknowledged that it was undignified to change the resident in full view of another resident.On 10/2/25 at 2:28 PM, during an interview, CNA #3 stated she was aware that residents had the right to privacy during care to maintain dignity. She acknowledged that she should have ensured the resident's privacy prior to beginning incontinence care and stated that the privacy curtain did not fully close around the resident's bed.On 10/2/25 at 2:55 PM, during an interview, the Director of Nursing (DON) stated her expectation was for staff to provide privacy for residents by using the room's privacy curtains during all personal care procedures. She confirmed that CNA #1 and CNA #3 failed to ensure Resident #1's privacy prior to providing incontinence care and stated that this failure violated the resident's right to respectful and dignified care.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure medications were administered in accordance with professional standards of quality and accepted standards of practice by not referencing the Medication Administration Record (MAR) during medication preparation and administration for one (1) of three (3) residents observed for medication administration (Residents #8).Findings include:Review of the facility's Oral Medication Administration Procedures, dated 03/25, revealed, .3. Verify the physicians order, comparing the medication label to the MAR to verify the following: a. Right medication b. Right dosage c. Right route d. Right time e. Right resident .On 10/1/25 at 4:26 PM, during an observation, Licensed Practical Nurse (LPN) #1 prepared and administered medications to Resident #8 without reference to the MAR. The laptop on top of the medication cart displayed only the resident roster and not an individual MAR as LPN #1 prepared and administered medications.On 10/1/25 at 5:00 PM, during an interview, LPN #1 confirmed she prepared and administered medications for Resident #8 without use of the MAR. She stated she felt confident because she knew the residents' medications and reviewed the Twenty-Four (24)-Hour Report for new or changed physician orders.On 10/2/25 at 1:40 PM, during an interview, the Staff Development Coordinator stated that all licensed nurses received in-service training upon hire and at least annually regarding medication administration, including competency checkoffs. She stated the training required nurses to begin each medication pass by viewing the MAR to confirm physician orders and verify the five (5) rights of medication administration.On 10/2/25 at 2:55 PM, during an interview, the Director of Nursing (DON) stated it was not acceptable practice for nurses to go by memory or rely on the Twenty-Four (24)-Hour Report as a substitute for the MAR. The DON stated proper procedure required referencing each resident's MAR to confirm physician orders and ensure the five (5) rights of medication administration were followed for every resident. A record review of the admission Record revealed the facility admitted Resident #8 on 9/21/22 with current diagnoses including Type 2 Diabetes Mellitus.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/17/25 revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact.A record review of the Order Summary Report revealed Resident #8 had Physician's Orders for Warfarin Sodium 5 milligrams (mg), one (1) tablet by mouth every evening on Monday through Friday, dated 8/5/25 and Oxycodone/Acetaminophen 10-325 mg, one (1) tablet by mouth every six (6) hours for pain, dated 11/26/24.A record review of the electronic Medication Administration Record (eMAR) for October 2025 revealed LPN #1 documented the 1700 (5:00 PM) administration of Warfarin Sodium and the 1800 (6:00 PM) administration of Oxycodone/Acetaminophen on 10/1/25.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure that a resident who was unable to perform activities of daily living (ADLs) received personal hygiene and incontinence care in a safe and dignified manner, consistent with accepted standards of practice, for one (1) of nine (9) sampled residents (Resident #1).Findings include:A review of the facility's policy, Activities for Daily Living, reviewed 09/25, revealed, .Procedure.2. ADLs shall include, but are not limited to personal hygiene, bathing, voiding, toileting, repositioning, and meals offered.A review of the facility's Aide Check List, dated 12/20, revealed, .DOES YOUR RESIDENT HAVE.3. Resident shaved-males and females .A review of the facility's policy, Disposable Brief, dated of 01/24, revealed, .Procedure.REMOVING SOILED BRIEF 4. For a bedbound resident: a. loosen the tapes (tabs) securing the soiled brief. b. Assist the resident to roll onto their side facing away from you.APPLYING A CLEAN BRIEF 6. For the bedbound resident.b. Assist the resident to roll to their side, facing away from you.e. assist the resident to turn onto their back, ensuring that the brief stays in place while they turn.A record review of the admission Record revealed the facility admitted Resident #1 on 8/13/24 with diagnoses including Vascular Dementia.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/17/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident was severely cognitively impaired. The MDS revealed the resident required substantial/maximal assistance for toileting hygiene, showering/bathing, dressing the lower body, and toilet transfer, and required partial/moderate assistance for personal hygiene, including shaving.On 10/1/2025 at 1:45 PM, during an observation, Resident #1 was observed with a short gray beard and mustache. On 10/2/2025 at 8:20 AM, during an observation, Resident #1 continued to have a short gray beard.On 10/2/2025 at 8:27 AM, during an observation and interview, Certified Nurse Aide (CNA) #1 and CNA #3 were observed providing incontinent care for Resident #1 in his room. The CNAs lifted the resident with a sit-to-stand lift and removed his soiled brief while the resident was suspended in the lift. The CNAs attempted to cleanse the resident's perineal area and apply a clean brief while he remained suspended. Resident #1 continued to have a short beard and mustache and had not been shaved. The Director of Nursing (DON) entered the room and instructed both CNAs that incontinence care should be provided with the resident in bed rather than while suspended in the lift. Both CNAs verbalized they were unaware of this procedure.On 10/2/2025 at 8:37 AM, during an interview, CNA #4 stated she was the designated shower aide and was responsible for shaving male residents during showers unless the resident declined or there were safety concerns. She reported Resident #1 received a shower on 10/1/25 but was not shaved due to jerking movements. CNA #4 stated she did not report this to the assigned CNA or the nurse. She acknowledged she knew she was required to report unusual signs, symptoms, or uncompleted ADL tasks to the nurse for follow-up.On 10/2/2025 at 1:40 PM, during an interview, the Staff Development Coordinator stated sit-to-stand lifts were designed for transfers and were not safe for incontinence care. She confirmed all CNAs received training, including competency checkoffs for ADL care, which covered appropriate incontinent care techniques.On 10/2/2025 at 2:13 PM, during an interview, CNA #1 stated she should have known better than to use a sit-to-stand lift to provide incontinence care. She stated she thought the shower aide was responsible for shaving residents on their shower days. CNA #1 acknowledged that Resident #1 required assistance with transfers using the sit-to-stand lift and stated she was unaware that incontinence care should be performed after transferring the resident into bed.On 10/2/2025 at 2:28 PM, during an interview, CNA #3 stated she believed the shower aide was responsible for shaving residents during showers. CNA #3 confirmed Resident #1 required assistance with transfers using the sit-to-stand lift and stated she was not aware that residents who could not stand independently should be transferred into bed before incontinence care.On 10/2/2025 at 2:55 PM, during an interview, the DON stated her expectation was for staff to provide complete ADL care, including shaving, while honoring resident preferences. She confirmed male residents should be shaved during showers unless refused, and that shaving was part of personal hygiene. The DON stated nurses and management were responsible for supervising resident care. She confirmed that providing incontinence care while a resident was suspended in a sit-to-stand lift presented a risk and was inconsistent with standards of practice. She stated the purpose of the lift was for transfers only and that residents unable to stand unassisted should receive incontinence care in bed.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure respiratory medications were administered in accordance with manufacturer's instructions by not instructing a resident to rinse the mouth following administration of an inhaled corticosteroid for one (1) of three (3) medication administrations reviewed, Resident #4. Findings included:A review of the facility's policy, Administration of Medications, revised 03/25, revealed, PURPOSE: To administer medications in accordance with best practice.A record review of the admission Record revealed the facility admitted Resident #4 on 6/10/25 with current diagnoses including Chronic Obstructive Pulmonary Disease (COPD).A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/16/25 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated he was cognitively intact.A record review of the Order Summary Report revealed Resident #4 had a Physician's Order, dated 9/12/25 for Symbicort Inhalation Aerosol 80-4.5 micrograms (mcg)/ACT, two (2) puffs to be inhaled orally two (2) times daily, related to COPD.A record review of the Medication Administration Record (MAR) for October 2025 revealed Licensed Practical Nurse (LPN) #2 documented Symbicort Inhalation Aerosol for Resident #4 as administered on 10/2/25.A record review of the SYMBICORT 80/4.5 (budesonide 80 mcg and formoterol fumarate dihydrate 4.5 mcg) Inhalation Aerosol manufacturer's package insert, dated 07/2019 revealed, .WARNINGS AND PRECAUTIONS: Localized infections: Candida albicans infection of the mouth and throat may occur. Advise the patient to rinse his/her mouth with water without swallowing after inhalation to help reduce the risk.On 10/2/25 at 7:50 AM, during an observation, Licensed Practical Nurse (LPN) #2 administered Symbicort, an oral inhalation medication, to Resident #4 and failed to instruct the resident to rinse his mouth following inhalation.On 10/2/25 at 7:56 AM, during an interview, LPN #2 confirmed she did not provide water or instruct Resident #4 to rinse his mouth after using the inhaler.On 10/2/25 at 2:55 PM, during an interview, the Director of Nursing (DON) stated that residents should be instructed and assisted as needed to rinse their mouths and spit out the water after administration of an oral inhaler to prevent the risk of thrush. She stated that the facility did not have a specific medication administration policy for oral inhalers and that nurses were expected to follow the manufacturer's instructions provided with the medication.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure the residents' right to a safe, clean, comfortable, and homelike environment by not maintaining appropriate and comfortable water temperatures in resident rooms on three (3) of three (3) resident halls, affecting all 57 residents residing in the facility. Findings included: A review of the facility's policy, Resident Environment, dated 9/15, revealed, It is the policy of this facility to provide a safe, clean, comfortable, and homelike environment . Resident #21 On 5/5/25 at 11:53 AM, during an observation, the hot water in Resident #21's bathroom (room [ROOM NUMBER]) reached a lukewarm temperature after a few minutes but never became hot. On 5/6/25 at 1:00 PM, during an interview with Resident #21, he explained the hot water in his bathroom never gets hot and he must wash his face with cold water every day. He stated he had told everyone about the issue, but nothing had been done. He added that even after running the water for a long time, it would only get warm. A record review of Resident #21's Admission Record revealed the facility admitted the resident on 4/10/2024 with current diagnoses including Vascular Dementia. A record review of the 5-Day Assessment Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/2/25 revealed Resident #21 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. Resident #56 On 5/5/25 at 12:00 PM, during an observation, the hot water in the bathroom of Resident #56's room (room [ROOM NUMBER]) only became warm after three (3) minutes and never reached a hot, comfortable temperature. A record review of Resident #56's Admission Record revealed the facility admitted the resident on 1/30/25 with the diagnoses including Hemiplegia and Hemiparesis. A record review of Resident #56's Admission MDS with an ARD of 2/6/25 revealed a BIMS score of 15, which indicated the resident was cognitively intact. Resident #12 On 5/5/25 at 12:05 PM, during an observation and interview with Resident #12 she reported the bathroom water has never been hot and only gets lukewarm. The State Agency (SA) observed the hot water running in the bathroom (room [ROOM NUMBER]) for over two (2) minutes, and the water never got hot. A record review of Resident #12's Admission Record revealed the facility admitted the resident on 12/6/21 with current diagnoses including Type 2 Diabetes Mellitus. A record review of Resident #12's Comprehensive MDS with an ARD of 3/10/25 revealed a BIMS score of 15, which indicated the resident was cognitively intact. On 5/5/25 at 12:13 PM, during an observation of the hall (Rooms 213-224), the hot water in both sinks and showers throughout the hall was lukewarm. Residents #29 and #42 On 5/5/25 at 12:20 PM, during an interview with Residents #29 and #42, both residents reported the water in their rooms had been lukewarm for a long time. They stated they had reported the issue to nursing and maintenance staff, but no action had been taken. A record review of Resident #29's Admission Record revealed the facility admitted the resident on 9/5/24 with current diagnoses including Atrial Fibrillation. A record review of Resident #29's Quarterly MDS with an ARD of 4/1/25 revealed a BIMS score of 11, indicating the resident's cognition was moderately impaired. A record review of Resident #42's Admission Record revealed the resident was admitted on [DATE] with current diagnoses including Parkinson's Disease. A record review of Resident #42's Quarterly MDS with an ARD of 3/17/25 revealed a BIMS score of 11, which indicated the resident's cognition was moderately impaired. On 5/5/25 at 1:00 PM, during an observation of the visitor bathroom in the center of the building, the hot water did not become hot after running for over two (2) minutes. On 5/5/25 at 3:00 PM, during a Resident Council meeting, council members stated they had complained multiple times about the lack of hot water in their bathrooms and showers to Administration, Activities, and Maintenance, but no corrective actions had been taken. Resident #22 On 5/6/25 at 12:20 PM, during an observation of Rooms 201-209, the SA allowed the hot water to run for one (1) minute in each bathroom sink, and the water remained lukewarm. During an interview with Resident #22 in room [ROOM NUMBER], he confirmed the hot water in the sink only gets warm after one (1) to two (2) minutes but never gets hot. A record review of Resident #22's Admission Record revealed the facility admitted the resident on 8/8/17 with current diagnoses including Pulmonary Hypertension. A record review of Resident #22's Quarterly MDS with an ARD of 4/23/25 revealed a BIMS score of 15, which indicated the resident was cognitively intact. On 5/6/25 at 12:27 PM, during an observation, room [ROOM NUMBER]'s hot water remained lukewarm after running for one (1) minute. On 5/6/25 at 1:15 PM, during an interview with Certified Nurse Aide (CNA) #4, he confirmed that the hot water in resident rooms had not been hot in several months and that upper management had been notified multiple times without resolution. On 5/6/25 at 1:30 PM, during an interview with Licensed Practical Nurse (LPN) #2, she stated residents across all halls had complained about the hot water in their rooms not getting hot. She confirmed the water in the shower rooms does get hot, but not in the residents' rooms. On 5/6/25 at 2:35 PM, during an interview with CNA #5, she stated she had been at the facility since February 2025 and the water in resident rooms had never gotten hot. She explained that the issue had been reported to the Administrator and other members of management without resolution. She stated that residents had consistently complained and that staff are supposed to wash their hands with warm, soapy water-but the water never gets hot. On 5/7/25 at 3:05 PM, during an interview and observation of water temperature checks with Housekeeping/Maintenance #2, he stated that hot water temperatures are checked once a week, usually on Tuesdays. He confirmed residents had complained for months. He reported that during his last recorded check in December 2024, no improvements had been made. He stated the highest temperature he had observed was around 110 degrees Fahrenheit (F) after letting water run for ten (10) minutes. He provided the following temperature readings: room [ROOM NUMBER] was 70 F and reached 90 F after two (2) minutes; room [ROOM NUMBER] was 90 F and remained there after two (2) and three (3) minutes; room [ROOM NUMBER] was 70 F and reached only 72 F after three (3) minutes; and room [ROOM NUMBER] was 76 F with low pressure and reached 90 F after three (3) minutes. This temperature check encompassed one room on each hall. On 5/8/25 at 3:30 PM, during an interview with the Administrator, she confirmed she was aware of the hot water problems in resident rooms. She explained the facility had consulted several water companies and was told the facility needed a new boiler system or additional tankless hot water heaters. She confirmed that recommendation had been made in December 2024, but no decisions or corrective actions had been implemented.

Based on observations, interviews, record reviews, and facility policy review, the facility failed to honor a resident's rights to make choices regarding daily routines by not assisting a cognitively impaired resident outdoors for scheduled smoking breaks (Resident #25) and regarding bathing times (Resident Council Attendees: Res #33, #2, #51, #5, #10, #41, #31, #16, #11, and #20) for 11 of 57 residents residing in the facility. Findings included: A review of the facility's policy, Resident's Rights Policy, dated of 3/24 revealed, Every resident in this facility has the right to .22. Use tobacco in accordance with applicable policies, rules, and laws . A review of the facility's policy, Dignity and Respect, dated 7/22 revealed, A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident's individuality. This facility shall protect and promote the rights of the resident. 1. Facility staff shall display respect when .caring for .residents, as constant affirmation of their individuality and dignity as human beings. 2. Each resident of the facility has the right to a dignified existence. 3. All residents should have autonomy of choice .4. Schedules of daily activities allow flexibility for residents to exercise choice about what they will do and when they will do it. Resident's individual preferences regarding such things as . activities, friendships . will be elicited and respected by the facility, and efforts will be made to accommodate these wishes .5. Residents will be .treated in a manner that maintains bodily privacy. A closed door and/or drawn cubicle curtain should be utilized to maximize the privacy of each resident while rendering care . A review of the facility's policy, Bathing dated 01/24 revealed, Purpose To ensure resident comfort and dignity .Processes Inquire with the resident concerning bathing preferences, (e.g., time of day, type of bathing, shower, bed bath, etc.). Offer the resident choice in their bathing routine . Choices (Smoking) A record review of the Care Plan Item/Task Listing Report dated 5/2/25 revealed a total of eighteen (18) residents that smoke, including Resident #25. On 5/5/25 at 12:13 PM, during an observation and interview, Resident #25 was observed up in her wheelchair in her room. She explained that she had been at the facility for a couple of years and typically went out to smoke a couple of times a day. She stated she had smoked for most of her life. Other residents were observed heading out to the designated smoking area, but Resident #25 remained in her room. On 5/5/25 at 12:30 PM, during an observation, Resident #25 remained in her room watching television, while other residents were observed returning from the smoking area. On 5/5/25 at 12:45 PM, during an observation and interview, no residents or staff were observed outdoors at the smoking area. Certified Nurse Aide (CNA) #2 explained that the smoke break had been changed to 12:00 or 12:30 PM and had already occurred. She stated that housekeeping was responsible for taking residents out for the morning and noon breaks. She confirmed that Resident #25 still smoked but would sometimes forget to go, and if the staff remembered, they would take her; otherwise, it was overlooked. She confirmed she did not take Resident #25 out to smoke that day. On 5/6/25 at 12:40 PM, during an observation and interview, Resident #25 was sitting in her room watching television and stated she had not been out to smoke that day and that no one had come to get her or inform her of the smoking times. On 5/6/25 at 1:00 PM, during an interview with CNA #3, she explained that she tries to get Resident #25 for smoke breaks if she is in her room. She reported that the resident had still been in the dining room during the smoke break and confirmed she did not take her out that day. On 5/6/25 at 1:25 PM, during an interview with Licensed Practical Nurse (LPN) #1, she explained that Resident #25 is very forgetful and does not always remember to go out to smoke. She did not know if the resident had gone out that day. She reported that staff sometimes reminded her and assisted her outdoors but acknowledged this did not happen every day. She explained the facility typically has four smoke breaks per day and that the mid-day break had been changed from 1:00 PM to either 12:00 or 12:30 PM. She stated that housekeeping staff took the residents out, but they did not retrieve them individually; rather, the residents would line up in the hallway after lunch. On 05/08/25 at 09:00 AM, during an interview, Resident #25 reported she has not been outside to smoke today. On 05/08/25 at 10:50 AM, during an interview with Housekeeping/Maintenance #1, he reported he did smoke break this morning for the residents and confirmed that Resident #25 was not at the smoke break this morning. On 5/8/25 at 2:00 PM, during an interview with the Director of Nursing (DON), she confirmed that Resident #25 was a smoker and was not being reminded daily or consistently assisted out for smoke breaks. She stated she expected staff to honor the residents' right and ensure that cognitively impaired residents are informed of and assisted with smoking times. On 5/8/25 at 2:20 PM, during an interview with the Administrator, she confirmed that Resident #25 was a smoker and often forgot about smoke breaks. She stated that the resident's family occasionally came to take her out to smoke but was unaware that staff were not informing or assisting the resident. She confirmed there were no posted smoke break times in the facility and stated she expected staff to assist cognitively impaired residents with smoking if they wished to do so. A record review of the Admission Record revealed the facility admitted Resident #25 on 3/10/23 with current diagnoses including Alzheimer's Disease. A record review of Resident #25's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/10/25 revealed she had a Brief Interview for Mental Status (BIMS) score of 6, which indicated her cognition was severely impaired. Choices and Privacy (Bathing) A record review of the Resident Council Minutes dated April 2025 revealed the residents complained about the bath schedules, not knowing when they are scheduled. On 05/05/25 at 3:00 PM, during a meeting with the Resident Council, ten (10) residents were present, each with a Brief Interview for Mental Status (BIMS) score averaging 14, indicating cognitively intact status. The residents expressed multiple concerns regarding shower practices. Several residents reported they were not informed in advance of their scheduled shower days and were frequently awakened as early as 5:00 AM for bathing. While some residents preferred early showers, others stated they would rather bathe in the afternoon but were told that if they did not shower between 5:00 AM and 1:00 PM, they would not receive a shower that day. Residents also raised concerns regarding a lack of privacy in the shower room. They reported being bathed simultaneously with another resident-one in the whirlpool and one in the shower stall-without the privacy curtain being drawn. After their showers, residents stated they were pulled into the middle of the shower room floor to be dried off and dressed, exposing their bodies to the other resident. Additionally, staff were entering and exiting the shower room and conversing with the bathing staff, often leaving the door open and privacy curtain not pulled, resulting in potential exposure to the hallway. On 05/06/25 at 11:43 AM, during an interview with Certified Nursing Assistant (CNA) #1, she stated she serves as the designated shower aide and is scheduled to work Monday through Friday from 5:00 AM to 1:00 PM. She added that she occasionally works on the floor during weekends when the facility is short-staffed. CNA #1 explained that resident showers are routinely provided between 5:00 AM and 1:00 PM, Monday through Saturday, and are not scheduled during the afternoon or evening. She acknowledged that some residents have voiced complaints about receiving showers so early in the morning but stated that all showers are scheduled during that time frame because that is when staff are available. CNA #1 also stated that because the residents were the same sex she didn't think it was a problem for them to take showers at the same time. On 05/06/25 at 12:05 PM, during an interview with Certified Nursing Assistant (CNA) #2, she stated she serves as a shower aide and is scheduled to work Monday through Friday from 5:00 AM to 1:00 PM. CNA #2 explained the resident shower schedule: residents on B Hall and the right side of D Hall receive showers on Monday, Wednesday, and Friday, while residents on C Hall and the left side of D Hall are scheduled for Tuesday, Thursday, and Saturday. She further explained that residents with scheduled physician appointments or dialysis are prioritized to receive showers first, typically between 5:00 AM and 6:00 AM. CNA #2 stated that shower services pause during breakfast and lunch hours so that shower aides can assist with meal service. She confirmed that showers are not provided after 1:00 PM daily and that showering residents of the same sex in the shower room at the same time was not a problem and that the shower room does not have a lot of space. During an interview on 05/08/25 at 3:00 PM, the Administrator stated she had recently returned from leave and had been back at the facility for approximately one (1) month. She explained she was not aware of any resident complaints regarding the shower schedule or process. The Administrator stated she would collaborate with the Director of Nursing (DON) to assess each resident's shower preferences and ensure they are being accommodated.

Based on observation, interview, record review, and facility policy review, the facility failed to honor a resident's food preferences and provide a menu alternative for one (1) of sixteen (16) sampled residents. Resident #30. Findings Included: A review of the facility's policy, Dignity and Respect, dated 7/2022 revealed, A facility must treat each resident with dignity and respect and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident's individuality . 4 . Residents' individual preferences regarding such things as menus . will be elicited and respected by the facility, and efforts will be made to accommodate these wishes . A review of the facility's policy, Alternate Food for Food Preferences, dated 5/2018 revealed, Substitutes of similar nutritive value are offered to residents who refuse food served . 7. The nursing assistant, on observing that a resident is refusing a food, offers the alternate food to the resident . On 5/5/25 at 11:04 AM, during an interview and observation, Resident #30 explained that he did not eat chicken, but the facility continued to serve it to him. He reported he had informed Certified Nurse Aides (CNAs), but his food tray continued to include chicken. In an interview and observation on 5/5/25 at 11:54 AM, Resident #30 was observed from the hallway sitting upright in a chair in his room as CNA #1 brought in his tray. The meal consisted of chicken and dumplings, fried okra, and a roll. The resident told CNA #1 that he did not eat chicken however, CNA #1 did not offer an alternate meal and placed the tray on the bedside table before entering the hallway. The State Agency (SA) asked CNA #1 what the resident had for lunch and CNA #1 and SA returned to the resident's room. The resident again stated he did not eat chicken. CNA #1 stated she was unsure what was on the menu as the alternate meal for the day. On 5/6/25 at 1:47 PM, during an interview with the Dietary Manager, she revealed she had been made aware of Resident #30's food preference on 5/2/25 but had forgotten to input the information into the meal ticket system. She explained that residents are typically asked about food preferences upon admission. She reported that the resident's dislike for chicken was now added to his meal ticket and that CNA #1 had notified her of the issue. A record review of the Admission Record revealed the facility admitted Resident #30 on 4/10/25 with diagnoses including Fracture of Shaft of Humerus, Left Arm. A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/17/25 revealed Resident #30 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact.

Based on interview and facility policy review the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to ensure the program was sustained during transitions in leadership and failed to maintain implemented procedures and monitor the interventions the committee put into place in March 2021. This was for one (1) recited deficiency originally cited in March 2021 on an annual recertification survey. The deficiency was in the area of activities. The facility's continued failure during two federal surveys shows a pattern of the facility's inability to sustain an effective QAPI Committee. Findings Include: Review of the facility's, Quality Assurance Performance Improvement Program, revised 11/22, revealed .This facility shall develop, implement, and maintain an effective, comprehensive, data-driven Quality Assurance Performance Improvement (QAPI) program that focuses on indicators of the outcomes of care and quality of life. The facility shall have in place a system that continuously strive to improve the quality of care and services received by residents in this facility .Objectives .each department shall institute outcome measurements designed to monitor effectiveness of established systems .Procedure .Many sources of information will be used in QAPI activities to include but not be limited to .State, Federal .surveys to prioritize and assign PIP's (Performance Improvement Projects) or corrective action plans as needed .Each department must identify the problem areas, investigate, and determine the probable cause, establish a plan of correction, and evaluate the outcome . F679 Based on observations, staff and resident interviews, record review, and the facility policy review, the facility failed to provide consistent activities for three (3) of 13 sampled residents. This has the potential to affect all residents that reside in the facility. Resident #23, Resident #27, Resident #32 F679 was also previously cited in March 2021 for failing to ensure activities were provided for the residents residing in the facility. An interview on 11/2/23 at 12:35 PM, with the Activity Director (AD), revealed that he did not attend QAPI meetings because he had been working in the Maintenance Department and did not have time. The AD stated that he was unaware the facility had received deficiencies for failing to provide activities during the previous annual survey in March of 2021 and that he had not read the previous survey information. The AD confirmed that he had not submitted activity reports to be reviewed by the Administrator. During an interview on 11/2/23 at 1:00 PM, with the Director of Nursing (DON), she said she became employed by the facility in July of 2023 and was not working at the facility during the previous annual survey in March of 2021. The DON stated that she had not read any information regarding the previous survey and was not aware of the previous citation regarding resident activities or the submitted plan of correction. The DON reported that the QAPI team had not discussed the Activities Program in their QAPI meetings. During an interview on 11/2/23 at 1:30 PM, the Administrator revealed she was not working at the facility during the last annual survey in March of 2021, but she was aware of the previous citation regarding resident activities. The Administrator confirmed that the QAPI team had not discussed the Activity Program or the previous survey deficiencies in the QAPI meetings. She explained that she felt as if the previous deficiency had been corrected and did not realize that the AD was performing maintenance duties. The Administrator stated that resident activities should have been completed before the AD assisted in the Maintenance Department.

Based on observation, interviews, record review, and the facility policy review, the facility failed to implement activity care plan approaches for three (3) of 13 sampled residents. Resident #23, Resident #27, Resident #32. Findings include: Review of the facility's policy, Care Plan Process, revised 8/17, revealed, .The results of the assessment, which must accurately reflect the resident's status and needs, are to be used to develop, review, and revise each resident's comprehensive person-centered plan of care .Interventions are actions that should promote meeting the established goal . Resident #23 Record review of the Care Plan for Resident #23 with a problem onset date of 09/21/2022 revealed Problem/Need: Resident needs encouragement and assistance to activities . Approaches . One on one activities, music TV .Invite resident to church, bingo, and group discussion . During an observation on 10/30/23 at 4:00 PM, Resident #23 was in her wheelchair being pushed by a therapy staff down the hallway. The staff member asked the resident if she wanted to go to the dayroom for activities. The resident asked what the activities were, and the staff member responded that the residents were watching TV. Resident #23 stated that she could watch television in her room. On 11/01/23 at 3:15 PM, during an observation, Resident #23 was in the dayroom, sitting at a table with a book. The television was on, and other residents were watching the program. There were no structured activities taking place. On 11/01/23 at 03:22 PM, an interview with Resident #23 revealed she was not enjoying the television program that was playing in the dayroom. Resident #23 explained that she enjoyed participating in activities and getting out of her room and it made her feel bad when there was nothing to do at the facility. She stated that once she realized Bingo was canceled, she got her puzzle book to work on. Resident #27 Record review of the Care Plan for Resident #27 with a problem onset date of 09/26/2022 revealed Problem/Need: Resident needs encouragement and assistance to activities .Approaches . One on one activities, music TV .Invite resident to church, bingo, and group discussion . During observations on 10/30/23 at 11:00 AM, Resident #27 was sitting in the dayroom and at 11:10 AM. The activity of Noodle Balloon Ball as noted on the Activity Calendar was not in progress. During an observation on 11/1/23 at 10:00 AM, Resident #27 was sitting in the dayroom. The activity of Team Building Exercise as noted on the Activity Calendar was not in progress. During an observation on 11/1/23 at 12:15 PM, Resident #27 was sitting in the dayroom. The activity of Bean Bag N A Bucket as noted on the Activity Calendar was not in progress. During an observation on 11/1/2023 at 3:10 PM, Resident #27 was sitting in the dayroom and at 3:15 PM, Resident #23 was in the dayroom. The activity of Fun Bingo as noted on the Activity Calendar was not in progress. Resident #32 Record review of the Care Plan for Resident #32 with a problem on set date of 07/07/2022 revealed Problem/Need: Resident needs encouragement and assistance to activities .Approaches One on one activities, music TV .Invite resident to church, bingo, and group discussion . During observations on 10/30/23 at 11:00 AM, Resident #32 was sitting in the dayroom. The activity of Noodle Balloon Ball as noted on the Activity Calendar was not in progress. Record review of the Activity Calendar for October 2023 revealed on 10/30/23, Noodle Balloon Ball was scheduled for 11:00 AM and Team Building Exercise Games were scheduled for 2:00 PM. During an observation on 10/30/23 at 2:10 PM, Resident #32 was wandering the hallways and Resident #27 was sitting in the dayroom. The activity of Team Building Exercise Games as noted on the Activity Calendar was not in progress. Record review of the Activity Calendar for November 2023 revealed on 11/1/23, Team Building Exercise was scheduled for 10:00 AM, Prize Bean Bag N A Bucket was scheduled for 12:00 PM, and Fun Bingo was scheduled for 03:00 PM. On 11/02/23 at 12:15 PM, an interview with Registered Nurse #2/MDS Nurse revealed it is the responsibility of the Activities Director (AD) to assure the Resident's care plan goals and interventions are met. On 11/02/23 at 12:50 PM, in an interview with the AD, he confirmed that resident care plans were not followed consistently regarding the care plan interventions. On 11/02/23 at 12:56 PM, in an interview with the Director of Nursing (DON), she acknowledged the facility did not follow the care plan regarding activities. She stated that she expected the staff to follow the care plan for the residents. On 11/02/23 at 01:02 PM, an interview with the Administrator confirmed the care plan was not followed consistently regarding activities. 43283 48181

Based on observations, staff and resident interviews, record review, and the facility policy review, the facility failed to provide structured activities for three (3) of 13 sampled residents. Resident #23, Resident #27, and Resident #32 Findings Include: Review of the facility's, Activity Programs & Activity Program Scheduling, revised 11/17, revealed, The facility will provide for an ongoing program of age-appropriate activities designed to meet, in accordance with the comprehensive assessment, the interest and the physical, mental, and psychosocial needs of each resident .Activity Programs & Activity Programs Scheduling .Activity Programs - Scheduling .Activity programs will be conducted as scheduled. An alternate will be provided upon cancellation of a scheduled program. Procedures .1. Programs are to be held as reflected on the activity calendar, as well as in the daily morning announcements. 2. If, for some reason, the scheduled program cannot be held .activity staff should either conduct that program or conduct an alternative program. 3. Only under rare circumstances should an activity be canceled and not replaced with another activity .4. If, for some reason, a program or alternate program cannot be held, announce the change .notify each Charge Nurse so that they man notify all floor staff, and note the change on the large activity calendar . Resident #23 During an observation on 10/30/23 at 4:00 PM, Resident #23 was in her wheelchair being pushed by therapy staff down the hallway. The staff member asked the resident if she wanted to go to the dayroom for activities. The resident asked what the activities were, and the staff member responded that the residents were watching television (TV). Resident #23 stated that she could watch TV in her room. Record review of the November Activity Calendar for November 2023 revealed Fun Bingo was scheduled for 3:00 PM on 11/1/23. On 11/01/23 at 3:15 PM, during an observation, Resident #23 was in the dayroom, sitting at a table with a book. The television was on, and other residents were watching the program. There were no structured activities taking place. On 11/01/23 at 03:22 PM, an interview with Resident #23 revealed she was not enjoying the television program that was playing in the dayroom. Resident #23 explained that she enjoyed participating in activities and getting out of her room and it made her feel bad when there was nothing to do at the facility. She stated that once she realized Bingo was canceled, she got her puzzle book to work on. A record review of the Face Sheet revealed the facility admitted Resident #23 on 09/21/22 with diagnoses that included Wedge Compression Fracture of the Lumbar. A review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/11/23, revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated she was cognitively intact. Further review revealed her activity preferences, listed as very important, were reading, listening to music, being around animals, keeping up with the news, favorite activities, going outside for fresh air, and participating in religious services or practices. Resident #27 Record review of the Activity Calendar for October 2023 revealed Noodle Balloon Ball was scheduled for 11:00 AM on 10/30/23. During an observation and interview on 10/30/23 at 11:00 AM, Resident #27 was sitting in the dayroom talking to other residents. There were no structured activities, such as Noodle Balloon Ball, observed in the dayroom. Resident #27 stated that she was bored. Record review of the Activity Calendar for October 2023 revealed Team Building Exercise Games were scheduled for 2:00 PM on 10/30/23. During an observation on 10/30/23 at 2:10 PM, Resident #27 was sitting in the dayroom. There were no structured activities, such as Team Building Exercise Games, observed in the dayroom. There were residents in the day room sleeping in wheelchairs and Geri chairs, others were watching a television program, while others sat with a blank stare. Record review of the Activity Calendar for November 2023 revealed Team Building Exercise was scheduled for 10:00 AM on 11/1/23. During an observation on 11/1/23 at 10:00 AM, Resident #27 was sitting in the dayroom but there were no structured activities, including no Team Building Exercise observed. There were residents in the dayroom sleeping in wheelchairs and Geri chairs, others were watching a television program, while others sat with a blank stare. Record review of the Activity Calendar for November 2023 revealed Prize Bean Bag N A Bucket was scheduled for 12:00 PM on 11/1/23. During an observation on 11/1/23 at 12:15 PM, Resident #27 was sitting in the dayroom. There were no structured activities, including Bean Bag N A Bucket observed. There were residents in the dayroom sleeping in wheelchairs and Geri chairs, others were watching a television program, while others sat with a blank stare. Record review of the Activity Calendar for November 2023 revealed Fun Bingo was scheduled for 3:00 PM on 11/1/23. During an observation on 11/1/2023 at 3:10 PM, Resident #27 was sitting in the dayroom. There were no structured activities observed, including Bingo. There were residents in the dayroom sleeping in wheelchairs and Geri chairs, others were watching a television program, while others sat with a blank stare. A record Review of the Face Sheet revealed the facility admitted Resident #27 on 09/26/22 with diagnoses including Hypothyroidism, Depression, and Hypertension. A record review of the Annual MDS with an ARD of 9/7/23 revealed Resident #27 had a BIMS score of 7, which indicated her cognition was severely impaired. Further review revealed that it was very important for the resident to do her favorite activities. Resident #32 During an observation on 10/30/23 at 11:10 AM, Resident #32 was sitting in a chair in the dayroom and was not interacting with other residents. The television was on, but there were no structured activities, including Noodle Balloon Ball in progress. During an observation on 10/30/23 at 12:25 PM, Resident #32 was sitting in the dayroom. There were no structured activities taking place and other residents were in the day room watching television. During an observation on 10/30/23 at 01:23 PM, Resident #32 was walking in the hallway while other residents continued to watch television in the dayroom. The next scheduled activities on the activity calendar were scheduled for 2:00 PM Team Building Exercise Game. On 10/30/23 at 2:10 PM, Resident #32 continued to wander the halls. On the activity calendar team building exercise game noted in the day activity day room. During an observation on 10/31/23 at 1:40 PM, Resident #32 was walking in the hallway during the resident's Halloween Party in the dayroom. There was no one-on-one (1:1) activities conducted for Resident #32. No activities were provided for Resident #32 during the survey. Record review of the Face Sheet revealed the facility admitted Resident #32 on 07/07/2022 with diagnoses including Adult Failure to Thrive, Unspecified Dementia without Behavior Disturbances, and Restless and Agitation. Record review of the Annual MDS with an ARD of 6/23/23 revealed it was very important for Resident #32 to go outside when the weather was good and to participate in religious practices. Record review of the Quarterly MDS with an ARD of 09/18/23 revealed Resident #32 required Staff Assessment for Mental Status, which indicated that her cognition was severely impaired. At 1:45 PM on 10/31/23, during an interview with Certified Nursing Assistant (CNA) #5, she explained Resident #32 usually did not participate in activities with the other residents, however she would occasionally go outside, and she enjoyed dancing. CNA #5 confirmed that Resident #32 had not been involved in any activities during the week. During an interview on 10/31/23 at 10:00 AM, with the resident council members, they complained the facility did not provide enough activities and that the scheduled activities were not conducted daily. They stated that there were no activities on weekends, which caused them to be bored with nothing to do. Previously, the facility provided movies, popcorn, and snacks on Sundays and the members expressed they would like to do that again, but there was no one at the facility on weekends to set it up. During an interview on 11/1/23 at 09:30 AM, with Registered Nurse (RN) #1, she confirmed there is no one scheduled to conduct activities on weekends. The nurse said the residents had several coloring books and arts and crafts they can do, or they can watch television. RN #1 also confirmed that the churches that are scheduled to come on Sundays do not always show up, so the staff will ensure the television is turned on to a church service for the residents. During an interview on 11/2/23 at 09:00 AM, with CNA #1, she confirmed the facility did not have staff scheduled to conduct activities with the residents on weekends. CNA #1 confirmed that the churches that are scheduled on Sundays do not always show up to the facility, and she tried to turn the television on to keep the residents occupied when that happened. CNA #1 also confirmed that the residents did not have activities during the week because the Activities Director (AD) was busy performing maintenance work. During an interview on 11/2/23 at 09:10 AM, with CNA #2, she confirmed the facility did not have activities on weekends. She also confirmed that the resident activities are not consistent because the AD wears two (2) hats (maintenance and activities), which is why he is unable to perform activities that are scheduled on the calendar. During an interview on 11/2/23 at 9:25 AM, with CNA #3, she confirmed the activities are not consistent and that the residents become upset sometimes because they are looking forward to certain activities, especially Bingo, and are disappointed when the activity does not occur. CNA #3 also confirmed there was no one scheduled to provide activities on weekends. On 11/02/23 at 9:30 AM, during an interview with the Director of Nursing (DON), she confirmed that Resident #32 should have 1:1 scheduled activities. She explained Resident #32 should be more involved in activities. During an interview on 11/02/23 at 9:54 AM, the DON confirmed that activities were not consistent because the AD was also used as the Maintenance Director and was pulled to do maintenance work while also performing activity duties. The DON also confirmed the facility did not have staff scheduled to conduct weekend activities with the residents. The DON stated the residents were bored and had nothing to do during the week because the activities were not consistent. On 11/02/23 at 10:00 AM, during an interview with the AD, he explained that Resident #32 liked activities that were 1:1 and that she enjoyed dancing. The AD confirmed that Resident #32 had not had any 1:1 activity during the week of survey because he was conducting maintenance for the facility and was not able to complete the activities that were scheduled. During an interview on 11/02/23 at 10:12 AM, with the AD confirmed that he failed to provide consistent activities for the residents. The AD said he also worked doing the maintenance for the facility, and if something broke down, he had to repair it. The AD confirmed he did not follow the activity calendar during the week of the survey because he was called to do maintenance duties several times. He said that he improvised by doing a quick devotion or talk with the residents in the dayroom. The AD confirmed that he did not notify the residents or the Charge Nurse of the changes in the Activity schedule, but going forward they would be notified. He stated that he had made the activities calendar three (3) weeks ago and had not updated the calendar. He acknowledged the activities were not consistent. During an interview on 11/02/23 at 11:29 AM, the Administrator confirmed that the resident activities were not consistent, and that the AD also does maintenance work for the facility. The Administrator said that she was unaware that the resident activities were not being completed because the AD was doing maintenance duties and that she had hired a maintenance person who will begin employment with the facility next week. 43283 48181

Based on observation, interviews, record review, and facility policy review, the facility failed to provide respiratory care consistent with professional standards of practice as evidenced by nebulizer mask and oxygen tubing for a resident (Resident #40) did not have a designated storage bag for two (2) of four (4) observations. Findings include: A review of the facility's policy, Infection Control Oxygen Equipment Cleaning revised 08/21 revealed Use disposable tubing, mask, and cannula's for patients receiving oxygen therapy .10. When not in use, store the mask/cannula in a plastic bag clearly labeled with the resident's name and date . A review of the facility's policy Nebulizer, revised 10/17 revealed . Cleaning Nebulizers . 4 . Store in clean plastic bag . On 10/30/23 at 12:03 PM, during an observation and interview with Resident #40, she explained that she wore oxygen as needed and received breathing (nebulizer) treatments three times a day and once at night. There was an oxygen concentrator in her room in which oxygen tubing with a nasal cannula was stored on top of the oxygen concentrator. There was also a nebulizer machine and mask sitting on the resident's bed, and not in a plastic storage bag. An observation on 10/31/23 at 12:33 PM revealed a nebulizer machine and mask lying on the bed in Resident #40's room. There was also oxygen tubing draped on top of the oxygen concentrator. At 1:50 PM on 10/31/23, during an interview with Certified Nurse Aide (CNA) #5, she explained Resident #40 asked for assistance from the nurses when she needed a nebulizer treatment. CNA #5 said that the resident does not normally use her oxygen. CNA #5 confirmed the nebulizer machine and mask were lying on the resident's bed and the oxygen tubing with the nasal cannula was stored on top of the oxygen concentrator and not in a plastic bag. At 2:00 PM on 10/31/23, during an interview and observation with Licensed Practical Nurse (LPN) #1, she administered a nebulizer treatment for Resident #40. She confirmed the nebulizer mask was on the resident's bed and she used the same mask to administer the treatment. After completing the nebulizer treatment, LPN #1 placed the nebulizer mask and tubing in the top drawer of the nightstand. She did not place it in a storage bag. LPN #1 reported that Resident #40 did not wear oxygen continuously but only as she needed it for shortness of breath. She confirmed the oxygen tubing was stored on top of the concentrator but stated that it is usually in a clear bag. On 10/31/23 at 2:30 PM, during an interview with the Director of Nursing (DON), she explained all respiratory equipment, including oxygen tubing and nebulizer masks, were to be stored in clear bags. The purpose of storing the equipment in the bags was to prevent the equipment from falling on the floor and to prevent contamination. A record review of the Physician Orders for the month of November 2023, revealed Resident #40 had a Physician's Order, dated 9/13/23, for inhaled nebulization four times daily and a Physician's Order, dated 5/30/23, for Oxygen per nasal cannula as needed. A record review of the Face Sheet revealed the facility admitted Resident #40 on 09/30/21 with diagnoses that included Chronic Obstructive Pulmonary Disease. A record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/25/23, revealed Resident #40 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated she was cognitively intact.

Based on interviews, record review, and facility policy review, the facility failed to change a resident's suprapubic catheter as needed for leakage for one (1) of two (2) residents reviewed with indwelling catheters. Resident #1. Findings Include: Record review of the facility policy, Indwelling Catheterization, revised 11/17, revealed, .Catheters should only be inserted by licensed, adequately trained personnel. Supra-pubic catheters may be changed by a physician or a qualified professional nurse . Record review of the Face Sheet revealed the facility admitted Resident #1 on 5/19/22 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) on 8/22/22 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. A review of Section H revealed Resident #1 had an indwelling catheter. Record review of Physician Orders for the month of November 2022 revealed, Resident #1 had a Physician's Order with an order date of 10/3/22 to Insert new 18 FR (French) 30 cc (centimeter) indwelling suprapubic catheter every month or as needed for leakage or dislodgment. Record review of Departmental Notes for Resident #1 revealed documentation by the Director of Nursing (DON) on 11/4/2022 at 4:21 PM, for Late entry: 11/3/2022 Resident suprapubic catheter changed by myself . On 11/8/22 at 10:45 AM, during an interview with Resident #1, he stated that his supra pubic catheter had been leaking for a few days and he reported it to Registered Nurse (RN) #1 who is the wound care nurse. RN #1 told him that she was not comfortable changing the suprapubic catheter and would notify the DON that the catheter was leaking and needed to be changed. However, the DON did not change the catheter until the next day when the Ombudsman came into the facility to visit him. He said it made him uncomfortable to have to lay on sheets that were wet with urine and it caused his room to smell bad. On 11/8/22 at 11:04 AM, during an interview with RN #1, she confirmed that Resident #1's supra pubic catheter was leaking on 11/2/22. She informed the DON on 11/2/22, but she (RN #1) did not follow up the same day to ensure that the leaking catheter had been changed. The DON did not change the catheter until 11/03/22. On 11/8/22 at 1:30 PM, during an interview with the Ombudsman, she confirmed that on 11/3/22, she visited Resident #1 and observed that his linens were wet up to his mid back area and there was a strong urine odor in his room. She immediately reported it to the DON and she changed his leaking suprapubic catheter that day (11/3/22). On 11/8/22 at 2:15 PM, during an interview with the DON, she confirmed that on 11/2/22, RN #1 reported that Resident #1's supra-pubic catheter was leaking and needed to be changed. She said the catheter wasn't changed on 11/2/22 due to miscommunication. The DON did not change the leaking catheter until 11/3/22. The DON commented that it is her expectation that the staff immediately change any catheters noted to be leaking.

Based on record reviews, staff interviews and facility policy reviews, the facility failed to revise the Comprehensive Care Plan related to weight loss from potential to actual weight for one (1) of four (4) care plans reviewed. Resident #1. On 8/25/21, a [MEDICATION(S)] Swallow Study was obtained which revealed that Resident #1 was a Level 3 on the Penetration/Aspiration Scale, which indicated high risk for aspiration. The facility failed to ensure recommendations were implemented and a care plan developed following the [MEDICATION(S)] Swallow Study as evidenced by Resident #1 was observed by the State Agency (SA) feeding himself a pureed diet without assistance of staff. Resident #1 required placement of an enteral feeding tube on 9/29/21. The facility failed to obtain orders for enteral feedings until 10/6/21, six (6) days after the placement of Resident #1's feeding tube. Resident #1 lost an additional four (4) pounds from 9/28/21 until 10/6/21. Resident #1 had severe weight loss of 10.8% over six months. The facility failed to revise the comprehensive person-centered care Comprehensive care plan to reflect Resident #1's change in status from potential to actual weight loss and ensure Resident #1 received adequate care according to the Comprehensive Care Plan, placed the resident in a situation that caused or is likely to cause serious harm, injury, impairment, or death. The State Agency (SA) identified an Immediate Jeopardy (IJ) that began on 8/25/21 when the facility failed to implement recommendations following a [MEDICATION(S)] Swallow Study for a resident who was high risk for aspiration. The SA notified the Administrator on 10/13/21 at 2:15 PM of the IJ and provided the facility with IJ templates. The facility submitted an acceptable Removal Plan on 10/14/21, in which the facility alleged all corrective actions were completed by 10/14/21 and the IJ was removed on 10/15/21. The SA validated the removal plan on 10/16/21 and determined the IJ was removed on 10/14/21, prior to exit, therefore the scope and severity for 42 CFR 483.21(b)(2)(iii) were lowered from a J to a level D, while the facility developed a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Review of the facility's policy, Care Plan Process, with a revision date of 8/2017 revealed, Regulations require facilities to complete, at a minimum and at regular intervals, a comprehensive, standardized assessment of each resident's functional capacity and needs . The results of the assessments which must accurately reflect the resident's status and needs, are to be used to develop, review, and revise each resident's comprehensive person-centered plan of care . Record review of the Registered Dietition (RD) Nutrition assessment dated [DATE] at 2:49 PM revealed, RD consulted to make recommendations for enteral feedings as resident is s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] .weight 124 # (pounds) .87% IBW . wt (weight) loss in 30 days and 10.8% wt loss in 180 days-significant .Nutrition Interventions: Recommend: Initiate Glucerna 1.2 at final goal rate of 65 ml/hour from 8 p.m. to 6 a.m. (10 hours total). Flush with 150 ml free water every 6 hours. Record review of the Comprehensive Care Plan with a problem onset date of 2/3/20 with a goal/target date of 10/20/21 revealed Problem/Need: Potential for weight loss. Record review of all care plans in the medical record revealed there was no care plan for actual weight loss in the medical record. On 10/11/21 at 1:55 PM, in an interview with Registered Nurse #3 (RN) the care plan nurse, stated care plans are used for the type of care the resident will receive. She stated if problems are left off the care plan the staff will not know the type of care to give to the resident. She stated she updates the care plan daily with new physician orders, changes in resident status and every quarter. She stated the paper chart and computer chart has the same care plan information. She stated the nurses can use either one for care. She stated it would be very important to have a care plan for dysphagia She stated the care plan tells the staff what to look out for. She stated if it is not on the care plan Resident #1 could choke if his liquids are not at the right thickness. She confirmed the resident has had weight loss and she should have taken potential out of the weight loss care plan. She stated she should have revised the care plan. She stated by taking out potential weight loss the staff would have weighted Resident #1 more often and kept up with how much he ate. On 10/11/21 at 4:05 PM, in an interview with the Director of Nursing (DON), she stated Care Plans should have been updated. She stated he should have had a care plan for Dysphagia. She stated care plans are used by the nursing staff to know how to take care of the residents. She stated if it is not on the care plan the nursing staff would not know if they needed to do something special. She stated care plans should be reviewed and revised as needed. On 10/11/21 at 4:33 PM, in an interview with the Administrator stated the care plans should be updated for staff to use. She stated it could have life and death for Resident #1 by staff not checking orders or following the care plan. Record review of Resident #1's Face Sheet revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Comprehensive Care Plan revealed, Resident #1 has a potential for weight loss and does not have a Risk for Aspiration or Dysphagia care plan. Interventions for [potential weight loss was provided, assistance as needed (cueing, feeding resident). Removal Plan On October 13, 2021, at 2:31pm State Agency notified the Administrator that the facility was in Immediate Jeopardy (IJ) and templates were provided to the Administrator. The facility failed to implement the comprehensive person centered care plan for Resident #1 who required assistance with feeding, failed to provide supplement as ordered, and failed to provide assistance with eating during meals. The facility failed to revise the person centered care plan from potential to actual weight loss. On August 25, 2021 a [MEDICATION(S)] swallow study was obtained related to swallowing difficulties. The facility failed to obtain results of the [MEDICATION(S)] swallow study. On September 29, 2021 Resident #1 underwent a procedure to place a percutaneous endoscopic gastrostomy tube. Resident #1 returned to the facility with recommendations to consult nutritionist but with no enteral feeding orders. The facility failed to obtain orders for enteral feedings for six days after feeding tube placement. Resident #1 had a weight loss of 7.58% in the last 30 days and a weight loss of 17.51% in the last 180 days. Corrective Action: 1. Facility Registered Dietitian #1 made recommendations for enteral feedings for Resident #1 on October 6, 2021. Recommendations discussed with Attending Physician #1 on October 6, 2021. New orders obtained and implemented on October 6, 2021. On October 13, 2021 results of [MEDICATION(S)] swallow study was discussed with Registered Dietitian #1 and Attending Physician #1 with new order received and implemented on October 13, 2021 for Fibersource HN at 65ml/hr continuously. 2. Director of Nurses (DON) and Licensed Practical Nurse (LPN) #1 immediately initiated in-services with Registered Nurses, Licensed Nurses, Certified Nursing Assistants and Temporary Nurse Aides on October 13, 2021, at 3:10pm on Tube Feedings, obtaining orders timely for enteral feedings, Comprehensive care plans, Revision of Comprehensive Care Plans, Weight Loss interventions to include obtaining the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In-services will be on-going and no Registered Nurses, Licensed Nurses, Certified Nursing Assistants, Temporary Aides or contract nursing and aide staff will be allowed to work until participation of the in-services are completed. 3. The facility Quality Assurance Committee Meeting was held on Wednesday October 13, 2021 at 3:45pm with the committee consisting of facility Director of Nurses, Nursing Home Administrator, Medical Director, Infection Preventionist, Registered Nurses (RN) #1, Registered Nurse (RN) #2, Registered Nurse (RN) #3, and Licensed Practical Nurse (LPN) #1. Topics discussed included on Tube Feedings, Comprehensive Careplans, Revision of Comprehensive Careplans, Weight Loss interventions to include obtaining the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No policy changes were made however, facility made procedural changes on October 13, 2021 to include obtaining and addressing recommendations for [MEDICATION(S)] swallow studies as well as obtaining orders for new peg tube placement enteral feedings. The Director of Nurses (DON), Registered Nurse (RN) #1 and Registered Nurse (RN) #2 will review recommendations of [MEDICATION(S)] swallow studies to ensure recommendations are addressed with the Resident, Resident Representative and Physician and are implemented. All supplement orders have been placed on the electronic Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Forty one active residents were assessed by Registered Nurse #3 and the Director of Nurses (DON) for the level of assistance needed with meals on October 13, 2021. Three of forty one active residents were identified as needing assistance with meals. Staff will assist these residents with in-room dining or at assistive dining tables per resident's preference. 5. On October 13, 2021 Registered Nurse (RN) #1 reviewed records to identify residents requiring enteral feedings. Forty one active residents' records were reviewed and one of forty one active resident was identified as requiring enteral feedings. Registered Nurse (RN) #1 physically assessed one of forty one active residents' requiring enteral feeding. On October 13, 2021 Registered Nurse (RN) #1 reviewed records to identify residents requiring assistance with eating. Forty one active residents' records were reviewed and three of forty one active residents' were identified as requiring assistance with eating. Registered Nurse (RN) #1 physically assessed the three of forty one active residents identified as needing assistance with eating. On October 13, 2021 Registered Nurse (RN) #1 reviewed records to identify residents with significant weight loss. Forty one active residents' records were reviewed and six of forty one active residents were identified as having significant weight loss. Registered Nurse (RN) #1 physically assessed the six of forty one active residents identified as having significant weight loss. On October 13, 2021 Registered Nurse (RN) #1 reviewed records to identify residents requiring supplements. Forty one active residents' records were reviewed and nine of forty one active residents were identified as requiring supplements. Registered Nurse (RN) #1 physically assessed the nine of forty one active residents identified as requiring supplements with no significant findings identified. In the last six months three of forty one active residents had [MEDICATION(S)] swallow studies performed. Registered Nurse (RN) #1 assessed and observed those three of forty one active residents on October 13, 2021 and also reviewed their [MEDICATION(S)] swallow study results for recommendations. It was determined that the recommendations were being followed at this time. Care plans were reviewed by Registered Nurse (RN) #1, Registered Nurse (RN) #2, Registered Nurse (RN) #3, and Director of Nursing for eighteen of forty one active residents on October 13, 2021. Care plans were revised and implemented on seven of the eighteen residents on October 13, 2021 for significant weight loss, assistance with eating, and supplements. The facility alleges removal of the immediacy as of October 14, 2021 8:00am Validation: On 10/16/21, the SA validated the facility's corrective actions through observation, interview, record review and in-service sign in sheets. 1.SA validated by interviews, observation and record reviews Resident #1 feeding started on 10/6/21. Facility Registered Dietitian #1 made recommendations for enteral feedings for Resident #1 on October 6, 2021. Recommendations discussed with Attending Physician #1 on October 6, 2021. New orders obtained and implemented on October 6, 2021. On October 13, 2021 results of [MEDICATION(S)] swallow study was discussed with Registered Dietitian #1 and Attending Physician #1 with new order received and implemented on October 13, 2021 for Fibersource HN at 65ml/hr continuously. 2. SA validated by interviews and record reviews that the Director of Nurses (DON) and Licensed Practical Nurse (LPN) #1 immediately initiated in-services with Registered Nurses, Licensed Nurses, Certified Nursing Assistants and Temporary Nurse Aides on October 13, 2021, at 3:10pm on Tube Feedings, obtaining orders timely for enteral feedings, Comprehensive care plans, Revision of Comprehensive Care Plans, Weight Loss interventions to include obtaining the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In-services will be on-going and no Registered Nurses, Licensed Nurses, Certified Nursing Assistants, Temporary Aides or contract nursing and aide staff will be allowed to work until participation of the in-services are completed. 3. SA validated through Quality Assurance sign in sheet dated 10/13/21 all disciplines attended. SA also interviewed staff who attended the Quality Assurance Committee Meeting held on Wednesday October 13, 2021 at 3:45pm with the committee consisting of facility Director of Nurses, Nursing Home Administrator, Medical Director, Infection Preventionist, Registered Nurses (RN) #1, Registered Nurse (RN) #2, Registered Nurse (RN) #3, and Licensed Practical Nurse (LPN) #1. Topics discussed included on Tube Feedings, Comprehensive Careplans, Revision of Comprehensive Careplans, Weight Loss interventions to include obtaining the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No policy changes were made however, facility made procedural changes on October 13, 2021 to include obtaining and addressing recommendations for [MEDICATION(S)] swallow studies as well as obtaining orders for new peg tube placement enteral feedings. The Director of Nurses (DON), Registered Nurse (RN) #1 and Registered Nurse (RN) #2 will review recommendations of [MEDICATION(S)] swallow studies to ensure recommendations are addressed with the Resident, Resident Representative and Physician and are implemented. All supplement orders have been placed on the electronic Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. SA validated through observation, interviews, and record reviews that forty-one active residents were assessed by Registered Nurse #3 and the Director of Nurses (DON) for the level of assistance needed with meals on October 13, 2021. Three of forty-one active residents were identified as needing assistance with meals. Staff will assist these residents with in-room dining or at assistive dining tables per resident's preference. 5. SA validated through record review, staff interview, observation, interview and record review of residents with significant weight loss that on October 13, 2021, Registered Nurse (RN) #1 reviewed records to identify residents requiring enteral feedings. Forty-one active residents' records were reviewed, and one of forty-one active resident was identified as requiring enteral feedings. Registered Nurse (RN) #1 physically assessed one of forty-one active residents' requiring enteral feeding. On October 13, 2021, Registered Nurse (RN) #1 reviewed records to identify residents requiring assistance with eating. Forty-one active residents' records were reviewed, and three of forty-one active residents were identified as requiring assistance with eating. Registered Nurse (RN) #1 physically assessed the three of forty-one active residents identified as needing assistance with eating. On October 13, 2021, Registered Nurse (RN) #1 reviewed records to identify residents with significant weight loss. Forty-one active residents' records were reviewed, and six of forty-one active residents were identified as having significant weight loss. Registered Nurse (RN) #1 physically assessed the six of forty-one active residents identified as having significant weight loss. On October 13, 2021, Registered Nurse (RN) #1 reviewed records to identify residents requiring supplements. Forty-one active residents' records were reviewed, and nine of forty-one active residents were identified as requiring supplements. Registered Nurse (RN) #1 physically assessed the nine of forty-one active residents identified as requiring supplements with no significant findings identified. In the last six months three of forty-one active residents had [MEDICATION(S)] swallow studies performed. Registered Nurse (RN) #1 assessed and observed those three of forty-one active residents on October 13, 2021 and also reviewed their [MEDICATION(S)] swallow study results for recommendations. It was determined that the recommendations were being followed at this time. Care plans were reviewed by Registered Nurse (RN) #1, Registered Nurse (RN) #2, Registered Nurse (RN) #3, and Director of Nursing for eighteen of forty-one active residents on October 13, 2021. Care plans were revised and implemented on seven of the eighteen residents on October 13, 2021, for significant weight loss, assistance with eating, and supplements. The SA validated that all corrective actions to remover the IJ had been completed as of 10/14/21 and the IJ was removed on 10/15/21, prior to exit.

Based on observation, interviews, record reviews, and facility policy review, the facility failed to ensure a supplement was included on a meal tray, failed to follow recommendations from a Video Swallow Evaluation ([MEDICATION(S)] Swallow Study) for a resident identified as high risk for aspiration and failed to obtain orders for Percutaneous Endoscopic Gastrostomy (PEG) tube feedings after the placement of a PEG tube for a resident with severe weight loss for one (1) of four (4) residents reviewed for weight loss. Resident #1. On 8/25/21, a [MEDICATION(S)] Swallow Study was obtained which revealed that Resident #1 was a Level 3 on the Penetration/Aspiration Scale, which indicated high risk for aspiration. The facility failed to ensure recommendations were implemented following the [MEDICATION(S)] Swallow Study as evidenced by Resident #1 was observed by the State Agency (SA) feeding himself a pureed diet without assistance of staff. Resident #1 required placement of an enteral feeding tube on 9/29/21. The facility failed to obtain orders for enteral feedings until 10/6/21, six (6) days after the placement of Resident #1's feeding tube. Resident #1 lost an additional four (4) pounds from 9/28/21 until 10/6/21. The facility's failure to ensure recommendations were implemented following a [MEDICATION(S)] Swallow and failure to obtain orders for enteral feedings for 6 days after the placement of Resident #1's feeding tube, placed this resident and other residents at risk, in a situation that was likely to cause serious harm, injury, impairment, or death. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 8/25/21 when the facility failed to implement recommendations following a [MEDICATION(S)] Swallow Study for a resident who was high risk for aspiration. The State Agency (SA) notified the Administrator on 10/13/21 at 2:15 PM, of the IJ and SQC and provided the facility with IJ templates. The facility submitted an acceptable Removal Plan on 10/14/21, in which the facility alleged all corrective actions were completed by 10/14/21 and the IJ was removed on 10/15/21. The SA validated the Removal Plan on 10/16/21 and determined the IJ was removed on 10/14/21, prior to exit, therefore the scope and severity for 42 CFR(s) 483.25(g)(1) Assisted nutrition and hydration (F692), was lowered from a J to a D, while the facility developed a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility's policy titled, Physician Orders, revision date 9/2018, it is the policy of the facility that all physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the facility's policy titled, Nutritional Supplements, dated 12/2020, document intake of supplement. Nurses shall pass and document intake of nutritional supplements. The order for the supplement is obtained and added to the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing staff document the amount of nutritional supplement consumed on the MAR. Record review of the Video Swallow Evaluation ([MEDICATION(S)] Swallow Study) performed 8/25/21, revealed, .ASSESSMENT SUMMARY: (Formal Name) evidenced severe oropharyngeal dysphagia characterized by decreased sensation, loss of bolus, impairment with tongue base retraction, residue in the vallecular cavity and on the post pharyngeal wall, and delayed cricopharyngeal opening. Secondary to these impairments, pt (patient) is a high risk for aspiration. Patient is a poor candidate for speech therapy services secondary to his decreased ability to follow commands and cognitive/communication impairments. Patient did evidence s/s (sign/symptoms) of aspiration/penetration with no signs of sensation or awareness by patient. SLP (Speech Language Pathologist) rx (prescribed) alternate means of nutrition for primary nutrition with allowance of pleasure feedings of nectar viscosity only, to maintain quality of life at this time. At this time, (Formal Name) is a Level 3, with the above consistencies provided, on the Penetration/Aspiration Scale as explained below: .Level 3 Contrast enters the airway, remains above the vocal folds, and is not ejected from the airway (is seen in the airway after the swallow) .Other Recommendations: Compensatory techniques: Due to patient's cognitive status, pt will need to be fed for any PO (by mouth) intake and observed closely for any s/s of aspiration; he should be upright for all p.o. intake and for 30 minutes after, small bites/sips, alternate bites/sips; cue to swallow x2 . and Diet Recommendations: Alternate means of nutrition; okay for PO of nectar viscosity for pleasure purpose only . Record review of the RD Nutrition assessment dated [DATE] revealed weight was 128 pounds, . Weight was stable at 30 days, 7.9% weight loss at 90-days and 13.5 % weight loss at 180 days -- significant. RD interventions continue current interventions. If PEG placed and enteral nutrition-initiated consult RD. (Subjective information: Noted of consult for PEG per family request. Weight loss follow up. Appetite stimulant ordered 5/11/21 .Supplement ordered. Weights stable x30 days .Current Nutritional Prescription: Pureed; avoid dry foods (bread, crackers, nuts, dried fruits) nectar thickened liquids; Ensure with meals (6/29/21) .90% Ideal Body Weight (IBW OF 142 POUNDS) . On 10/4/21 at 12:30 PM, an observation of Resident #1 eating lunch revealed the resident trying to feed himself but was spilling more food than he could get in his mouth. Licensed Practical Nurse #3 (LPN) and several CNAs were in the dining room assisting with passing out lunch trays to residents. Resident #1's left arm was paralyzed. Resident #1 was trying to eat with his right hand. Resident #1's right hand was trembling, and he had limited use of his fingers. SA observed the resident trying to put food in his mouth and spilling a larger portion on his clothing protector. Staff did not offer assistance to Resident #1 during the observation. Resident did not have Ensure on meal tray. On 10/5/21 at 11:52 AM in an interview with Responsible Party (RP) #2 for Resident #1, stated resident is on a pureed diet. RP #2 stated he did not understand resident was losing weight when he is on a pureed diet. RP #2 stated that when he visited Resident #1, he was skinny. RP #2 stated he talked to the nurse, and she told him that Resident #1's meal intake was 100%. RP #2 stated if he was eating 100 % of meals then he should not be losing weight. He stated Resident #1 has had problems swallowing before. RP #2 stated he made an appointment with a Gastroenterologist (GI) for Resident #1. RP #2 stated Resident #1 got a feeding tube five (5) days ago and still has not started getting feedings through the tube. He stated the Medical Doctor #1 told him they could start feedings in 24 hours after insertion. RP #2 stated the facility told him they were waiting on the Speech Therapist or Registered Dietician for a feeding order. RP #2 stated he has not been in the building during mealtime to observe Resident #1 eat but stated Resident #1 has had trouble feeding himself before. RP #2 stated he has talked to the Director of Nursing (DON) and Administrator about Resident #1, and they told him that he eats 100% of meals. RP #2 stated they falsified the records or did look at his shirt and see the food on his shirt. On 10/5/21 at 12:35 PM, an observation of Resident #1 trying to feed himself without assistance revealed he continued to struggle with feeding himself and spilled about 25% of his lunch on his clothing protector. On 10/5/21 at 12:52 PM, an observation of LPN #2 walked over to Resident #1 table and removed his clothes protector. SA asked LPN #1 open clothing protector to see how much was left on the clothes protector. The resident had pureed meatloaf, green peas and mash potatoes. SA observed the resident tray had 35 percent(%) of food left on the tray. SA estimated that Resident consumed 40 percent of his food. SA observed 25% of Resident #1 food was on his clothing protector. Record review of Resident #1 meal tickets reveals Ensure with all meals dated 10/4/21 and 10/5/21. Record review of Resident #1's documented meal intake for 10/4/21 revealed the resident consumed 75% of his lunch and on 10/5/21 he consumed 50% of his lunch. On 10/5/21 at 1:15 PM, in an interview with Certified Nursing Assistant #1 (CNA) stated she was told Resident #1 could feed himself. She stated they tell staff in report who needs assistance with eating. She stated she has tried to encourage him to feed himself. She stated Resident #1 will let staff feed him. She stated he spills a lot of his food somedays. Record review of Resident #1 Discharge Summary from the local hospital, dated 9/29/21, revealed please follow the post-PEG recommendations including nutritional consult for formula and volume external bolster 1 cm from abdominal wall, dry dressing only. Nothing by mouth for four (4) hours then water today, may use PEG today for medication and water. May use PEG tomorrow for feedings, antibiotic ointment to site for 24 hours and clean with soap and water daily and dry thoroughly. Remove dressing after 24 hours, then clean and dry daily. On 10/5/21 at 4:45 PM, in an interview with DON, she stated Resident #1 had a PEG tube placed on 9/29/21. She stated it was placed per family request. They wanted him to get another route of nutrition. She stated he had been having a fluctuating of his weight up and down. She stated they had talked to the family about his weight. She stated their provider had talked to the family. She stated Resident #1 did not like diet ordered and he wanted regular diet and she stated they started resident on appetite stimulants. She stated the appetite stimulants helped the resident. We have tried everything. She stated staff was assisting resident with eating during this time. On 10/6/21 at 3:48 PM, in an interview with CNA #2/Transportation Driver stated she was given paperwork in relation to Resident #1's PEG tube, and she gave it to medical records. She stated she gives the order summary to the nurse at the nurse station. On 10/6/21 at 3:57 PM, in an interview with the DON stated when nurses receive orders, they should carry them out. She stated Resident #1 came back from PEG tube placement on 9/29/21 at 4:26 PM. She stated LPN #4 was his nurse. The DON stated the GI doctor did not want feedings started until resident had a Registered Dietician (RD) evaluation, she stated she trusted what Registered Nurse #1 (RN)/Charge Nurse told her. She stated the charge nurse told her she would contact the RD to get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated when a resident does not eat or get feedings it can lead to death or a compromised immune system. She stated the resident would not have the strength to fight off diseases. She stated it could lead to failure to thrive. She stated she had not received the results of the [MEDICATION(S)] Swallow performed 8/24/21. She informed SA that she would call local hospital to get results. On 10/6/21 at 4:15 PM, in an interview with LPN #4, stated that she could not recall getting any orders for Resident #1 on 9/29/21. She stated the local hospital called the report in. She stated they told her about a nutrition consult. She stated RN #1 usually makes the appointments. She stated she did not have an RD in the building when Resident #1 came back from the hospital. She stated it was her responsibility to let the oncoming nurse (11-7) know what was going on. She stated she told the nurse in report to make sure it is done. She stated it would be possible for the resident to have more weight loss if feedings were not started. She stated RN #1 puts the orders in the computer. She stated she did not know how to put orders in for a RD consult. On 10/6/21 at 4:39 PM, in an interview with RN #1/Charge Nurse stated she was not at the facility when Resident #1 returned from PEG tube placement or if she was here, it was just a few minutes. She stated she does not remember getting discharge papers form the local hospital. She stated she usually gets discharge papers and make sure orders are carried out. She stated if she does not get paperwork it goes to the Medical Records and they put the orders in. She stated she was not informed about Resident #1's PEG tube care. She stated if she had seen the discharge papers, she would have given it to CNA #2/Transportation Driver to make the appointment. She stated she did know who the RD was. She stated normally resident get feedings immediately. She stated Resident #1 should have feedings by now. She stated she called local hospital, and they told her resident needed a nutrition consult. She stated she called CNA #2/Transportation about Resident #1 not having an appointment for Nutrition Consult. She stated that CNA #2 /Transportation told her that she had to call back an make the appointment. She stated it was her understanding that Resident #1 had to be taken to see a Nutritionist for a consultation to start feedings. On 10/6/21 at 4:59 PM, in an interview with the DON stated a nutritionist consult means the resident needs to be seen by the RD. The DON stated she contacted the RD today for an order. She stated somebody dropped the ball and Resident #1 should have started feedings by day 2 following PEG tube placement. She stated Resident #1 will start feedings today. On 10/7/21 at 10:59 AM, DON gave [MEDICATION(S)] Swallow results to SA. She stated this is not the final results. She stated this is the pre results. On 10/7/21 at 11:23 AM, in an interview with the RD stated she was contacted by the facility yesterday or the day before about an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated facility contacts her by phone for orders. She stated the facility did not contact her before yesterday or day before for an order. She stated if they had she would have written the order at that time. On 10/7/21 at 3:42 PM in an interview with MD #1 stated that Resident #1 had difficulty eating, family requested a PEG tube. He stated flushing should start right way after placement. He stated he usually waits four (4) hours before starting flushing. He stated Resident #1's feeding should have started within 24 hours of placement. On 10/8/21 at 4:15 PM, in an interview with DON stated MD #1 ordered the [MEDICATION(S)] Swallow. She stated part of the pre-op for PEG tube placement is a [MEDICATION(S)] Swallow study. She stated the resident's nurse or RN #1 is responsible for getting test results. She stated if they don't get the results then it is the DON's responsibility to get the results. She stated resident was at risk for aspiration and could die. On 10/11/21 at 12:09 PM in an interview with MD #2 stated he was aware that resident had some weight loss. He stated Dementia can cause loss of appetite. He stated the appetite enhancers seem not to work. He stated the resident was being weighed weekly. He stated he has not observed Resident #1 eating. He stated they discuss weight loss in the Quality Assurance (QA) meetings. He stated Resident #1was not capable of feeding himself 100 % of meals. He stated with Resident #1's history, he cannot feed self. He stated the resident has limited motion due to Cerebral Infarction. He stated the nutritional consult should have been done within a week. On 10/11/21 at 4:05 PM, in an interview with the DON, stated we had a system failure. Our system needs to be changed. She stated things were not done in a timely manner. She stated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the nurses are supposed to report to each other what was not done to the oncoming nurse. She stated staff needs to document what they do better. On 10/11/21 at 4:33 PM in an interview with Administrator stated it is their policy when a nurse receive orders, they are carried out. She stated she has stand up meetings. She stated the nurses should have followed up with the [MEDICATION(S)] Swallow results. She stated people should be doing their job. She stated it could have been a big giant thing. She stated it could have been life and death for Resident #1 by staff not checking orders. She stated if staff did not document it, it did not happen. She stated she has observed Resident #1 eating. She stated he would be a little messy eating. She stated she has never watched the whole meal. On 10/12/21 at 1:30 PM, the SA attempted to interview Resident #1 in his room. He is able to understand handwritten messages and he used his cell phone to FaceTime with his son. The SA would ask Resident #1's son questions and he would then use sign language to communicate with the resident. The resident confirmed that staff will help him eat and he does not refuse their assistance. The SA asked if staff has always helped him eat and the son responded that he (the son) could answer that question for the SA. The son stated that Resident #1 used to eat without assistance but when the diet was changed to pureed consistency, he had trouble keeping food on the spoon and he would spill most of the food into his lap or on his clothes. The resident confirmed by nodding his head no that he has not received Ensure on his meal trays. On 10/13/21 at 9:21 AM, during a phone interview with RP #2, spouse answered the phone. RP #2 was not available. RP #2 spouse stated that she had been to the facility mostly in the evening she did not see Ensure on his tray during meals. She stated Resident #1 would be in his room or in the Dining room feeding himself. She stated the staff did not feed resident when she visited him. On 10/13/21 at 9:37AM, in an interview with the Speech Therapist (ST), stated she started with the facility in 1/2021. She stated Resident #1 received ST services from 4/16/21 thru 6/17/21. She stated he was taken off the program due to non-compliance. She stated he was on a puree diet, and he was okay with it for meals. She stated when the snack cart came around, he wanted chips, cookies and crackers. She stated Resident #1 requested the puree diet because he coughed a lot. She stated she was aware he was on supplements. She watched him eat 2-3 times a week, and he coughed a lot while eating. She stated he would waste some on himself. She stated she could not estimate how much he wasted. She stated that she observed him eat lunch only in the dining room and his room. She stated she did not remember seeing Ensure on his tray in his room or dining room. She stated she was not aware of MD orders to feed the resident. She stated if the resident got Ensure and MD orders to feed resident were carried out then she believes his eating could have been restored. On 10/13/21 at 10:53 AM, in an interview with the RD stated she has not been in the facility since the Pandemic started in March 2020. She stated she has never seen the resident eat. On 10/15/21 at 1:19 PM in an interview with DM, stated she puts supplement orders on the printed meal ticket. She stated she gets a diet order from the medical records nurse gives me a printout of resident diet and supplements. She stated when she gets copy she puts it in the computer and it prints out on their tray card. She stated she relies on staff to put what is on ticket on the tray. She stated she cannot recall ever not seeing Ensure on Resident #1's tray. On 10/15/21 at 1:50 PM in an interview with CNA #5 stated she has observed Resident #1 eat. She stated he feeds himself most of the time. She stated he wasted more with the puree diet. She stated she charted a 100 percent because the plate was clean. Record review of the RD Nutrition assessment dated [DATE] at 2:49 PM revealed, RD consulted to make recommendations for enteral feedings as resident is s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] .weight 124 # (pounds) .87% IBW . wt (weight) loss in 30 days and 10.8% wt loss in 180 days-significant .Nutrition Interventions: Recommend: Initiate Glucerna 1.2 at final goal rate of 65 ml/hour from 8 p.m. to 6 a.m. (10 hours total). Flush with 150 ml free water every 6 hours. Record review of the RD Nutrition assessment dated [DATE] at 4:55 PM revealed, Edited assessment from 10/6/21 .weight 124 # .Nutritioanl Interventions: Recommend: 1) Initiate Fibersource HN at final goal rate of 65 ml (milliliters)/hr (hour) from 8 p.m. to 6 a.m. (10 hours total). Flush with 150 ml free water every six (6) hours. This will provide 780 kcal, 35grams protein, 1129ml fluid and 1250 total ml. 2) Discontinue Ensure as resident has not been consuming these . Record review of Resident #1's Face Sheet revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the quarterly Minimum Data Set with an Assessment Record date of 7/6/21 revealed a Brief Interview of Mental Status (BIMS) of seven (7). Review of section G revealed a 2 which means physical help with eating. Removal Plan On October 13, 2021, at 2:31pm State Agency notified the Administrator that the facility was in Immediate Jeopardy (IJ) and templates were provided to the Administrator. The facility failed to implement the comprehensive person-centered care plan for Resident #1 who required assistance with feeding, failed to provide supplement as ordered, and failed to provide assistance with eating during meals. The facility failed to revise the person-centered care plan from potential to actual weight loss. On August 25, 2021, a [MEDICATION(S)] swallow study was obtained related to swallowing difficulties. The facility failed to obtain results of the [MEDICATION(S)] swallow study. On September 29, 2021, Resident #1 underwent a procedure to place a percutaneous endoscopic gastrostomy tube. Resident #1 returned to the facility with recommendations to consult nutritionist but with no enteral feeding orders. The facility failed to obtain orders for enteral feedings for six days after feeding tube placement. Resident #1 had a weight loss of 7.58% in the last 30 days and a weight loss of 17.51% in the last 180 days. Corrective Action: 1. Facility Registered Dietitian #1 made recommendations for enteral feedings for Resident #1 on October 6, 2021. Recommendations discussed with Attending Physician #1 on October 6, 2021. New orders obtained and implemented on October 6, 2021. On October 13, 2021, results of [MEDICATION(S)] swallow study was discussed with Registered Dietitian #1 and Attending Physician #1 with new order received and implemented on October 13, 2021 for Fibersource HN at 65ml/hr continuously. 2. Director of Nurses (DON) and Licensed Practical Nurse (LPN) #1 immediately initiated in-services with Registered Nurses, Licensed Nurses, Certified Nursing Assistants and Temporary Nurse Aides on October 13, 2021, at 3:10pm on Tube Feedings, obtaining orders timely for enteral feedings, Comprehensive care plans, Revision of Comprehensive Care Plans, Weight Loss interventions to include obtaining the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In-services will be on-going, and no Registered Nurses, Licensed Nurses, Certified Nursing Assistants, Temporary Aides or contract nursing and aide staff will be allowed to work until participation of the in-services are completed. 3. The facility Quality Assurance Committee Meeting was held on Wednesday October 13, 2021, at 3:45pm with the committee consisting of facility Director of Nurses, Nursing Home Administrator, Medical Director, Infection Preventionist, Registered Nurses (RN) #1, Registered Nurse (RN) #2, Registered Nurse (RN) #3, and Licensed Practical Nurse (LPN) #1. Topics discussed included on Tube Feedings, Comprehensive Careplans, Revision of Comprehensive Careplans, Weight Loss interventions to include obtaining the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No policy changes were made however, facility made procedural changes on October 13, 2021, to include obtaining and addressing recommendations for [MEDICATION(S)] swallow studies as well as obtaining orders for new peg tube placement enteral feedings. The Director of Nurses (DON), Registered Nurse (RN) #1 and Registered Nurse (RN) #2 will review recommendations of [MEDICATION(S)] swallow studies to ensure recommendations are addressed with the Resident, Resident Representative and Physician and are implemented. All supplement orders have been placed on the electronic Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Forty-one active residents were assessed by Registered Nurse #3 and the Director of Nurses (DON) for the level of assistance needed with meals on October 13, 2021. Three of forty-one active residents were identified as needing assistance with meals. Staff will assist these residents with in-room dining or at assistive dining tables per resident's preference. 5. On October 13, 2021, Registered Nurse (RN) #1 reviewed records to identify residents requiring enteral feedings. Forty-one active residents' records were reviewed and one of forty-one active resident was identified as requiring enteral feedings. Registered Nurse (RN) #1 physically assessed one of forty-one active residents' requiring enteral feeding. On October 13, 2021, Registered Nurse (RN) #1 reviewed records to identify residents requiring assistance with eating. Forty-one active residents' records were reviewed, and three of forty-one active residents were identified as requiring assistance with eating. Registered Nurse (RN) #1 physically assessed the three of forty-one active residents identified as needing assistance with eating. On October 13, 2021, Registered Nurse (RN) #1 reviewed records to identify residents with significant weight loss. Forty-one active residents' records were reviewed, and six of forty-one active residents were identified as having significant weight loss. Registered Nurse (RN) #1 physically assessed the six of forty-one active residents identified as having significant weight loss. On October 13, 2021, Registered Nurse (RN) #1 reviewed records to identify residents requiring supplements. Forty-one active residents' records were reviewed, and nine of forty-one active residents were identified as requiring supplements. Registered Nurse (RN) #1 physically assessed the nine of forty-one active residents identified as requiring supplements with no significant findings identified. In the last six months three of forty-one active residents had [MEDICATION(S)] swallow studies performed. Registered Nurse (RN) #1 assessed and observed those three of forty-one active residents on October 13, 2021, and also reviewed their [MEDICATION(S)] swallow study results for recommendations. It was determined that the recommendations were being followed at this time. Care plans were reviewed by Registered Nurse (RN) #1, Registered Nurse (RN) #2, Registered Nurse (RN) #3, and Director of Nursing for eighteen of forty-one active residents on October 13, 2021. Care plans were revised and implemented on seven of the eighteen residents on October 13, 2021, for significant weight loss, assistance with eating, and supplements. The facility alleges removal of the immediacy as of October 14, 2021, 8:00am. Validation: On 10/16/21, the SA validated the facility's corrective actions through observation, interview, record review and in-service sign in sheets. 1.SA validated by interviews, observation and record reviews Resident #1 feeding started on 10/6/21. Facility Registered Dietitian #1 made recommendations for enteral feedings for Resident #1 on October 6, 2021. Recommendations discussed with Attending Physician #1 on October 6, 2021. New orders obtained and implemented on October 6, 2021. On October 13, 2021 results of [MEDICATION(S)] swallow study was discussed with Registered Dietitian #1 and Attending Physician #1 with new order received and implemented on October 13, 2021 for Fibersource HN at 65ml/hr continuously. 2. SA validated by interviews and record reviews that the Director of Nurses (DON) and Licensed Practical Nurse (LPN) #1 immediately initiated in-services with Registered Nurses, Licensed Nurses, Certified Nursing Assistants and Temporary Nurse Aides on October 13, 2021, at 3:10pm on Tube Feedings, obtaining orders timely for enteral feedings, Comprehensive care plans, Revision of Comprehensive Care Plans, Weight Loss interventions to include obtaining the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In-services will be on-going and no Registered Nurses, Licensed Nurses, Certified Nursing Assistants, Temporary Aides or contract nursing and aide staff will be allowed to work until participation of the in-services are completed. 3. SA validated through Quality Assurance sign in sheet dated 10/13/21 all disciplines attended. SA also interviewed staff who attended the Quality Assurance Committee Meeting held on Wednesday October 13, 2021 at 3:45pm with the committee consisting of facility Director of Nurses, Nursing Home Administrator, Medical Director, Infection Preventionist, Registered Nurses (RN) #1, Registered Nurse (RN) #2, Registered Nurse (RN) #3, and Licensed Practical Nurse (LPN) #1. Topics discussed included on Tube Feedings, Comprehensive Careplans, Revision of Comprehensive Careplans, Weight Loss interventions to include obtaining the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No policy changes were made however, facility made procedural changes on October 13, 2021 to include obtaining and addressing recommendations for [MEDICATION(S)] swallow studies as well as obtaining orders for new peg tube placement enteral feedings. The Director of Nurses (DON), Registered Nurse (RN) #1 and Registered Nurse (RN) #2 will review recommendations of [MEDICATION(S)] swallow studies to ensure recommendations are addressed with the Resident, Resident Representative and Physician and are implemented. All supplement orders have been placed on the electronic Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. SA validated through observation, interviews, and record reviews that forty-one active residents were assessed by Registered Nurse #3 and the Director of Nurses (DON) for the level of assistance needed with meals on October 13, 2021. Three of forty-one active residents were identified as needing assistance with meals. Staff will assist these residents with in-room dining or at assistive dining tables per resident's preference. 5. SA validated through record review, staff interview, observation, interview and record review of residents with significant weight loss that on October 13, 2021, Registered Nurse (RN) #1 reviewed records to identify residen

Based on record reviews, staff interviews and facility policy reviews, the facility failed to develop a care plan for a resident with a high risk of aspiration for one (1) of four (4) care plans reviewed. Resident #1. On 8/25/21, a [MEDICATION(S)] Swallow Study was obtained which revealed that Resident #1 was a Level 3 on the Penetration/Aspiration Scale, which indicated high risk for aspiration. The facility failed to ensure recommendations were implemented and a care plan developed following the [MEDICATION(S)] Swallow Study as evidenced by Resident #1 was observed by the State Agency (SA) feeding himself a pureed diet without assistance of staff. Resident #1 required placement of an enteral feeding tube on 9/29/21. The facility failed to obtain orders for enteral feedings until 10/6/21, six (6) days after the placement of Resident #1's feeding tube. Resident #1 lost an additional four (4) pounds from 9/28/21 until 10/6/21. The failure to revise Comprehensive Care Plan to ensure residents receive adequate care according to the Comprehensive Care Plan, placed the resident in a situation that caused or is likely to cause serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) on 10/13/21 that began on 8/25/21 when the facility failed to ensure recommendations were implemented following a [MEDICATION(S)] Swallow for Resident #1. The facility failed to implement a comprehensive person-centered care plan for Resident #1 who required assistance with feeding. Resident #1 was observed attempting to feed himself without assistance from staff as identified on the comprehensive care plan. The SA notified the Administrator on 10/13/21 at 2:15 PM of the IJ and provided the facility with IJ templates. The IJ existed at: 42 CFR 483.21 (b)(1) Comprehensive Care Plans The facility submitted an acceptable removal plan on 10/14/21, in which the facility alleged all corrective actions were completed by 10/14/21 and the IJ was removed on 10/15/21. The SA validated the removal plan on 10/16/21 and determined the IJ was removed on 10/14/21, prior to exit, therefore the scope and severity for 42 CFR 483.21(b)(1) was lowered from a J to a level D, while the facility developed a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Record review of the facility's policy Care Plan Process, revision date 8/2017, when implemented properly, the CAA (care area assessment) process should help staff: . identify areas of concern that may warrant interventions; Develop, to the extent possible interventions to help improve, stabilize or prevent decline in physical, functional and psychosocial well-being, in the context of the resident's condition, choices, and preferences for interventions; . Record review of a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/4/21 at 12:30 PM, an observation of Resident #1 eating lunch revealed the resident attempting to feed himself but was spilling more food than he could get in his mouth. Licensed Practical Nurse #3 (LPN) and several CNAs were in the dining room assisting with passing out lunch trays to residents. Resident #1's left arm was paralyzed. Resident #1 was trying to eat with his right hand. Resident #1's right hand was trembling, and he had limited use of his fingers. SA observed the resident trying to put food in his mouth and spilling a larger portion on his clothing protector. Staff did not offer assistance to Resident #1 during the observation. Resident did not have Ensure on the meal tray. On 10/4/21 at 12:40 PM, in an interview with LPN #2 she stated that usually the residents in the dining room feed themselves. She stated they had one feeding table. She pointed at a table with 4 residents. Resident #1 was at another table trying to feed himself. Observation on 10/4/21 at 12:43, revealed Resident #1's left arm was paralyzed due to a Cerebral Infarction. Resident #1 was attempting to feed himself with his right hand.The SA observed the resident trying to put food in his mouth and wasting a larger portion on his clothes. SA observed staff in dining room but staff did not offer assistance to Resident #1 during the observation. On 10/5/21 at 12:52 PM, an observation of LPN #2 walked over to Resident #1 table and removed his clothes protector. SA asked LPN #1 open clothing protector to see how much was left on the clothes protector. The resident had pureed meatloaf, green peas and mash potatoes. SA observed the resident tray had 35 percent(%) of food left on the tray. SA estimated that Resident consumed 40 percent of his food. SA observed 25% of Resident #1 food was on his clothing protector. On 10/5/21 at 1:15 PM, in an interview with Certified Nursing Assistant #1 (CNA) stated she was told Resident #1 could feed himself. She stated they tell staff in report who needs assistance with eating. She stated she has tried to encourage him to feed himself. She stated Resident #1 will let staff feed him. She stated he spills a lot of his food somedays. On 10/5/21 at 4:45 PM, in an interview with Director of Nursing (DON) stated staff are assisting Resident #1 with feeding. On 10/11/21 at 1:55 PM, in an interview with Registered Nurse #3, the care plan nurse stated care plans are used for the type of care resident will receive. She stated the staff should follow the care plan. She confirmed that she has observed Resident #1 trying to feed himself. She stated he drops a lot of his food, but he does get some in mouth. On 10/11/21 at 4:05 PM, in an interview with the DON, she stated we had a system failure. She stated care plans are used by the nursing staff to know how to take care of the residents and care plans should be followed. On 10/11/21 at 4:33 PM, in an interview with Administrator stated whenever she had observed Resident #1 he was not getting assistance with eating. She stated he would be a little messy eating. She stated she has never watched the whole meal. Record review of the Face Sheet revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Comprehensive Care Plan with a problem onset date of 2/3/20 revealed, Resident #1 receives a mechanically altered diet. Approaches included .Serve diet as ordered .Allow ample time to ingest meal. Feed resident slowly. Record review of the Comprehensive Care Plan did not include care for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Removal Plan On October 13, 2021, at 2:31pm State Agency notified the Administrator that the facility was in Immediate Jeopardy (IJ) and templates were provided to the Administrator. The facility failed to implement the comprehensive person centered care plan for Resident #1 who required assistance with feeding, failed to provide supplement as ordered, and failed to provide assistance with eating during meals. The facility failed to revise the person centered care plan from potential to actual weight loss. On August 25, 2021 a [MEDICATION(S)] swallow study was obtained related to swallowing difficulties. The facility failed to obtain results of the [MEDICATION(S)] swallow study. On September 29, 2021 Resident #1 underwent a procedure to place a percutaneous endoscopic gastrostomy tube. Resident #1 returned to the facility with recommendations to consult nutritionist but with no enteral feeding orders. The facility failed to obtain orders for enteral feedings for six days after feeding tube placement. Resident #1 had a weight loss of 7.58% in the last 30 days and a weight loss of 17.51% in the last 180 days. Corrective Action: 1. Facility Registered Dietitian #1 made recommendations for enteral feedings for Resident #1 on October 6, 2021. Recommendations discussed with Attending Physician #1 on October 6, 2021. New orders obtained and implemented on October 6, 2021. On October 13, 2021 results of [MEDICATION(S)] swallow study was discussed with Registered Dietitian #1 and Attending Physician #1 with new order received and implemented on October 13, 2021 for Fibersource HN at 65ml/hr continuously. 2. Director of Nurses (DON) and Licensed Practical Nurse (LPN) #1 immediately initiated in-services with Registered Nurses, Licensed Nurses, Certified Nursing Assistants and Temporary Nurse Aides on October 13, 2021, at 3:10pm on Tube Feedings, obtaining orders timely for enteral feedings, Comprehensive care plans, Revision of Comprehensive Care Plans, Weight Loss interventions to include obtaining the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In-services will be on-going and no Registered Nurses, Licensed Nurses, Certified Nursing Assistants, Temporary Aides or contract nursing and aide staff will be allowed to work until participation of the in-services are completed. 3. The facility Quality Assurance Committee Meeting was held on Wednesday October 13, 2021 at 3:45pm with the committee consisting of facility Director of Nurses, Nursing Home Administrator, Medical Director, Infection Preventionist, Registered Nurses (RN) #1, Registered Nurse (RN) #2, Registered Nurse (RN) #3, and Licensed Practical Nurse (LPN) #1. Topics discussed included on Tube Feedings, Comprehensive Careplans, Revision of Comprehensive Careplans, Weight Loss interventions to include obtaining the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No policy changes were made however, facility made procedural changes on October 13, 2021 to include obtaining and addressing recommendations for [MEDICATION(S)] swallow studies as well as obtaining orders for new peg tube placement enteral feedings. The Director of Nurses (DON), Registered Nurse (RN) #1 and Registered Nurse (RN) #2 will review recommendations of [MEDICATION(S)] swallow studies to ensure recommendations are addressed with the Resident, Resident Representative and Physician and are implemented. All supplement orders have been placed on the electronic Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Forty one active residents were assessed by Registered Nurse #3 and the Director of Nurses (DON) for the level of assistance needed with meals on October 13, 2021. Three of forty one active residents were identified as needing assistance with meals. Staff will assist these residents with in-room dining or at assistive dining tables per resident's preference. 5.On October 13, 2021 Registered Nurse (RN) #1 reviewed records to identify residents requiring enteral feedings. Forty one active residents' records were reviewed and one of forty one active resident was identified as requiring enteral feedings. Registered Nurse (RN) #1 physically assessed one of forty one active residents' requiring enteral feeding. On October 13, 2021 Registered Nurse (RN) #1 reviewed records to identify residents requiring assistance with eating. Forty one active residents' records were reviewed and three of forty one active residents' were identified as requiring assistance with eating. Registered Nurse (RN) #1 physically assessed the three of forty one active residents identified as needing assistance with eating. On October 13, 2021 Registered Nurse (RN) #1 reviewed records to identify residents with significant weight loss. Forty one active residents' records were reviewed and six of forty one active residents were identified as having significant weight loss. Registered Nurse (RN) #1 physically assessed the six of forty one active residents identified as having significant weight loss. On October 13, 2021 Registered Nurse (RN) #1 reviewed records to identify residents requiring supplements. Forty one active residents' records were reviewed and nine of forty one active residents were identified as requiring supplements. Registered Nurse (RN) #1 physically assessed the nine of forty one active residents identified as requiring supplements with no significant findings identified. In the last six months three of forty one active residents had [MEDICATION(S)] swallow studies performed. Registered Nurse (RN) #1 assessed and observed those three of forty one active residents on October 13, 2021 and also reviewed their [MEDICATION(S)] swallow study results for recommendations. It was determined that the recommendations were being followed at this time. Care plans were reviewed by Registered Nurse (RN) #1, Registered Nurse (RN) #2, Registered Nurse (RN) #3, and Director of Nursing for eighteen of forty one active residents on October 13, 2021. Care plans were revised and implemented on seven of the eighteen residents on October 13, 2021 for significant weight loss, assistance with eating, and supplements. The facility alleges removal of the immediacy as of October 14, 2021 8:00am On 10/16/21, the SA validated the facility's corrective actions through observation, interview, record review and in-service sign in sheets. 1.SA validated by interviews, observation and record reviews Resident #1 feeding started on 10/6/21. Facility Registered Dietitian #1 made recommendations for enteral feedings for Resident #1 on October 6, 2021. Recommendations discussed with Attending Physician #1 on October 6, 2021. New orders obtained and implemented on October 6, 2021. On October 13, 2021 results of [MEDICATION(S)] swallow study was discussed with Registered Dietitian #1 and Attending Physician #1 with new order received and implemented on October 13, 2021 for Fibersource HN at 65ml/hr continuously. 2. SA validated by interviews and record reviews that the Director of Nurses (DON) and Licensed Practical Nurse (LPN) #1 immediately initiated in-services with Registered Nurses, Licensed Nurses, Certified Nursing Assistants and Temporary Nurse Aides on October 13, 2021, at 3:10pm on Tube Feedings, obtaining orders timely for enteral feedings, Comprehensive care plans, Revision of Comprehensive Care Plans, Weight Loss interventions to include obtaining the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In-services will be on-going and no Registered Nurses, Licensed Nurses, Certified Nursing Assistants, Temporary Aides or contract nursing and aide staff will be allowed to work until participation of the in-services are completed. 3. SA validated through Quality Assurance sign in sheet dated 10/13/21 all disciplines attended. SA also interviewed staff who attended the Quality Assurance Committee Meeting held on Wednesday October 13, 2021 at 3:45pm with the committee consisting of facility Director of Nurses, Nursing Home Administrator, Medical Director, Infection Preventionist, Registered Nurses (RN) #1, Registered Nurse (RN) #2, Registered Nurse (RN) #3, and Licensed Practical Nurse (LPN) #1. Topics discussed included on Tube Feedings, Comprehensive Careplans, Revision of Comprehensive Careplans, Weight Loss interventions to include obtaining the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No policy changes were made however, facility made procedural changes on October 13, 2021 to include obtaining and addressing recommendations for [MEDICATION(S)] swallow studies as well as obtaining orders for new peg tube placement enteral feedings. The Director of Nurses (DON), Registered Nurse (RN) #1 and Registered Nurse (RN) #2 will review recommendations of [MEDICATION(S)] swallow studies to ensure recommendations are addressed with the Resident, Resident Representative and Physician and are implemented. All supplement orders have been placed on the electronic Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. SA validated through observation, interviews, and record reviews that forty-one active residents were assessed by Registered Nurse #3 and the Director of Nurses (DON) for the level of assistance needed with meals on October 13, 2021. Three of forty-one active residents were identified as needing assistance with meals. Staff will assist these residents with in-room dining or at assistive dining tables per resident's preference. 5. SA validated through record review, staff interview, observation, interview and record review of residents with significant weight loss that on October 13, 2021, Registered Nurse (RN) #1 reviewed records to identify residents requiring enteral feedings. Forty-one active residents' records were reviewed, and one of forty-one active resident was identified as requiring enteral feedings. Registered Nurse (RN) #1 physically assessed one of forty-one active residents' requiring enteral feeding. On October 13, 2021, Registered Nurse (RN) #1 reviewed records to identify residents requiring assistance with eating. Forty-one active residents' records were reviewed, and three of forty-one active residents were identified as requiring assistance with eating. Registered Nurse (RN) #1 physically assessed the three of forty-one active residents identified as needing assistance with eating. On October 13, 2021, Registered Nurse (RN) #1 reviewed records to identify residents with significant weight loss. Forty-one active residents' records were reviewed, and six of forty-one active residents were identified as having significant weight loss. Registered Nurse (RN) #1 physically assessed the six of forty-one active residents identified as having significant weight loss. On October 13, 2021, Registered Nurse (RN) #1 reviewed records to identify residents requiring supplements. Forty-one active residents' records were reviewed, and nine of forty-one active residents were identified as requiring supplements. Registered Nurse (RN) #1 physically assessed the nine of forty-one active residents identified as requiring supplements with no significant findings identified. In the last six months three of forty-one active residents had [MEDICATION(S)] swallow studies performed. Registered Nurse (RN) #1 assessed and observed those three of forty-one active residents on October 13, 2021 and also reviewed their [MEDICATION(S)] swallow study results for recommendations. It was determined that the recommendations were being followed at this time. Care plans were reviewed by Registered Nurse (RN) #1, Registered Nurse (RN) #2, Registered Nurse (RN) #3, and Director of Nursing for eighteen of forty-one active residents on October 13, 2021. Care plans were revised and implemented on seven of the eighteen residents on October 13, 2021, for significant weight loss, assistance with eating, and supplements. The SA validated that all corrective actions to remover the IJ had been completed as of 10/14/21 and the IJ was removed on 10/15/21, prior to exit.

Based on interview, record review, and facility policy review, the facility failed to provide scheduled showers per resident preference at least three times a week for one (1) of three (3) residents observed. Resident #2. Findings: Review of facility policy titled, Quality of Care, revised 4/19, revealed, Each resident shall receive optimal care to attain and/or maintain the highest possible mental and physical functional status as determined by the comprehensive assessment and person-centered plan of care. Each resident's care is tailored to the functional status and needs they may have.A. Bathing, b. each resident receives a full bath at least three times weekly (unless otherwise indicated in facility policy or resident need). On 10/4/21 at 1:50 PM, in an interview with Resident #2 she stated that she is supposed to get a bath three (3) times a week. She stated she is lucky if she gets one once a week. She stated the staff wants to give me bed bath and she does not like bed baths she likes lay (shower gurney in the shower room) baths. She stated she talked to the Certified Nursing Assistant (CNA) about not liking bed baths and nothing has changed. On 10/6/21 at 10:00 AM, in an interview with Resident #2 she stated she still has not had a bath. She stated she wants a bath and no one has offered to give her a bath today. On 10/6/21 at 2:30 PM, in an interview with the Director of Nurses (DON) she stated the residents have assigned bath days. She stated B hall bath days are Monday, Wednesday and Friday and C hall days are Tuesday, Thursday, and Saturday. She stated staff are supposed to talk to the resident and see what kind of bath they want. She stated if a resident refuses, they are supposed to tell the nurse. She stated if staff did not document, it was not done. On 10/7/21 at 11:45 AM, in an interview with Resident #2 revealed, I have not had a shower or bath in about 3 weeks. I have had bed baths but not in the shower, bed baths. Resident #2 revealed, I have told the DON of the shower situation. The facility offers me shower chair showers, but my preference is the shower gurney, it has to be two (2) CNA to perform, and I am not sure why they haven't done it. Resident #2 revealed, gurney showers really make me feel relaxed. I am in a lot of pain, frequently. On 10/7/21 at 2:25 PM, in an interview with CNA #8 revealed when a CNA gives a bath/shower they mark it on the bath roster but if Non-Applicable (N/A) is marked, it is probably because the CNA did not mark Activities Daily Living (ADL) and nurse completed, marked N/A, so charting would be complete. CNA #8 revealed Resident #2 requested a bed bath because she is in pain frequently and its more convenient for her to receive bed bath, plus she only liked one particular CNA to give her a shower, but she is no longer working at the facility. On 10/7/21 at 3:00 PM, in an interview with the DON revealed not having an actual shower bath or whirlpool may cause mental or physical problems, shower/whirlpool baths are very much required for mental wellbeing. The DON confirmed the bath roster is the only place baths are recorded and she did confirm the resident was not given showers according to the bath roster but she did get bed baths daily because of her requests. Review of Resident #2's Face Sheet revealed the facility admitted Resident #2 on 10/01/18 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2 annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/2/21 indicated a Brief Interview for Mental Status (BIMS) summary score of 10, which indicated the resident is moderately cognitively impaired, and Section G revealed, requires physical help in part of bathing activity. Record review of Resident #2's Bath Roster which indicates the type of bath received, revealed from 8/28/21 to 9/30/21, Resident #2 had five (5) entries recorded as N/A, five (5) entries recorded as a bed bath, five (5) entries recorded as a shower, and one (1) entry recorded as Rejects shower-nurse notified. On 8/28/21 Non-applicable (N/A) is recorded, on 8/31/21 bed bath is recorded, on 9/2/21 N/A is recorded, on 9/4/21 bed bath is recorded, on 9/7/21 a shower is recorded, on 9/9/21 it is recorded as rejects shower-nurse notified, on 9/11/21 a shower is recorded, on 9/14/21 N/A is recorded, on 9/16/21 N/A is recorded, on 9/18/21 a bed bath is recorded, on 9/21/21 a bed bath is recorded, on 9/23/21 N/A is recorded, on 9/25/21 a shower is recorded, on 9/28/21 a shower is recorded, and on 9/30/21 a shower is recorded. Record review of Resident #2's Care Plan with a Problem Onset date of 10/1/2018 lists the Problem/Need as Resident needs assist with shower/bathe self and lists the Goal as Resident will need substantial/maximal assist to shower/bathe self . Record review of Resident #2 Care Plan with a Problem Onset date of 10/1/2018 lists the Problem/Need as Resident is dependent with ADLS R/T left sided spastic [CONDITION(S)] and lists the Goal as Resident will have no complications . Care Plan Approaches include .Staff assistance with lift x 2 manual staff assistance .

Based on observation, interviews, record review and facility policy review the facility failed to provide an ongoing activities program for five (5) of (14) sampled residents, Resident #28, Resident #32, Resident #15, Resident #24, and Resident #25. The facility's, Activity Programs and Activity Program Scheduling policy, revised 11/17, revealed the facility has a policy in place to provide an ongoing program of activities. Purpose: To assure that the activities program occurs within the context of each resident's comprehensive assessment and care plan, and is reflective of each resident's individual needs and interests. Resident #28 Record Review of the Face Sheet revealed Resident #28 was admitted on [DATE]. She has [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 12/18/20, revealed Resident #28 had a Brief Interview for Mental Status (BIMS) of 15, which indicated she was cognitively intact. Review of Care Plan implemented 3/27/2014, revealed Resident #28 enjoys Bingo and other activities. Review of the activity documentation revealed, since 12/28/20 through 2/9/21, the facility documented one (1) activity on 1/27/21 and the next activity on 2/9/21. There were no other activities documented from 12/28/20 through 2/9/21. On 02/09/21, at 9:31 AM, during an interview, Resident #28 stated she was really tired of the COVID-19 quarantine. Resident #28 stated, We don't do anything but stay in our room. They don't come to our rooms and do any activities. On 2/9/21, at 1:45 PM, Resident #28 stated, We have not done any kind of activities for a while. I am tired of staying in my room. Resident #28 stated, proper name-Activities #1, is the activity director and she brought me a coloring book this past weekend. I enjoy Bingo. Sometimes I get in my bed and cry myself to sleep. I have [MEDICAL CONDITION] and it makes me feel depressed. On 2/10/21, at 1:12 PM, in an interview with Licensed Practical Nurse (LPN) #1, revealed Resident #28 usually would sleep until time for the 10:00 AM activity, which she attended. Then LPN #1 confirmed Resident #28 would sleep until time for the 2:00 PM activity and she would also attend that activity. LPN #1 stated Resident #28 is very social and loves Bingo. On 02/11/21, at 8:28 AM, Resident #28 was observed up in her wheelchair rolling herself in the hall. State Agency (SA) said, Good morning, you are out of your room. and Resident #28 replied, Yes, we have been freed. Resident #32 Record review of the Face Sheet revealed Resident #32 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #32's Annual MDS, with the ARD of 1/12/21, revealed a BIMS score of eight (8) which indicates moderate cognitive impairment. Review of Resident #32's Care Plan, dated 5/11/20, revealed Resident #32 has an identified concern of being at risk for social isolation. The interventions noted Resident #32 are to have an activity calendar in room, have one on one activities to include music, television (TV), conversation, touch therapy, and exercise. Further review of Resident #32's Care Plan identified a problem on 3/17/20 that Resident #32 was at risk for Psychosocial well-being concerns related to medically imposed restrictions related to COVID-19 restrictions. One of the interventions was to provide in room activities of choice. Review of the documentation of activities from 3/1/20 to 2/9/21 revealed there was no documentation of in room activities since 5/12/20. On 2/8/21 at 10:15 AM, Resident #32 was observed in bed under covers. On 2/8/21 12:23 PM, Resident #32 was observed standing in her room. On 2/8/21 at 12:40 PM, Residents #32 was in bed under the covers. On 2/9/21 at 8:00 AM, Resident #32 was observed in her bed with the covers over her head. On 2/9/21 at 12:30 PM, Resident #32 was observed in bed asleep. Review of Activity notes date 12/24/20 through 2/9/21, revealed there was no documentation of any activities for Resident #32. On 2/9/21 at 12:41 PM in an interview with Activities #2, revealed since May, she has been working part time, 3 to 4 days a week, only as a CNA. When she was asked when was the last time she conducted activities she replied, around May and then today. On 02/11/21 at 09:01 AM in an interview with CNA #1 revealed Resident #32 likes to color, visit, talk, and play Bingo. She really has been the same since we have been on lock down. On 02/11/21 at 09:05 AM in an interview with CNA #2 revealed residents likes to color. She stated her behaviors have been the same since we locked down for COVID-19. On 02/11/21 at 09:06 AM an unsampled resident was sitting by the Nurses' Station and stated, I am so glad to be out of my room, aren't you? This resident then sang, God Bless America, in a really loud voice. Resident #15 During an interview on 02/09/21, at 09:59 AM, with Resident #15, she stated the facility has not allowed them to leave their rooms because they have two (2) positive residents on the COVID-19 Unit. Resident #15 said the facility does not allow them to do any type of activities. Resident #15 said he is bored and going stir crazy. Resident #15 said he is tired of TV. Record review of the Comprehensive Care Plan revealed, Resident #15 should have social involvement with independent activities. Interventions are to post activity calendar where the resident can easily view, encourage to attend activities of choice, respect resident's choice in regard to limited/no activity, resident enjoys smoking and interaction with other residents during smoke times. Resident #15 is also care planned to be at risk for psychosocial well-being concern related to medically imposed restrictions related to COVID-19 restrictions. Record review of Resident #15's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/17/20, revealed Resident #15 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact. Resident #24 During an interview on 02/09/21, at 09:53 AM, with Resident #24, she confirmed the facility has quarantined the residents to their rooms. Resident #24 said she does not like being in the room all day with nothing to do. Resident #24 also said there is only so much on the television. Record review of the Comprehensive Care Plan, dated 1/4/21, revealed Resident #24 is at risk for social isolation and has the potential for mood state related to the [DIAGNOSES REDACTED]. Resident #24 needs encouragement and assistance to attend activities. Resident #24's interventions are to place activity calendar in room, encourage self-initiated activities, one on one activities, music, TV, conversation, touch therapy, exercise,. provide residents with reading, invite resident to church, bingo, and group discussion. A review of Resident #24's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/11/21, revealed Resident #24 had a Brief Interview of Mental Status (BIMS) score of 12, which indicated the resident is cognitively intact. Resident #25 During an interview on 02/09/21, at 09:45 AM, with Resident #25 revealed she is tired of staying in her room. Resident #25 said she makes every effort not to complain. Resident #25 also said if you stick your head out the door you are told to go back in your room. Resident #25 said both residents that are COVID-19 positive are on the COVID-19 Unit so she does not understand why they could not socially distance and smoke. Resident #25 said she is tired of watching TV. Resident #25 stated the facility has not provided activities since December. Review of the Comprehensive Care Plan revealed the Resident #25 needs encouragement and assistance to attend activities. The interventions are to place an activity calendar in Resident #25's room, encourage her to attend self-initiated activities, one on one activities, music, TV, touch therapy, exercise, provide resident with reading, invite the resident to church, bingo and group discussion and transport resident to activities. This Care Plan noted Resident #25 is at risk for social isolation. Resident #25 has a potential for altered mood state related to the [DIAGNOSES REDACTED]. A review of Resident #25's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/28/20, revealed Resident #25 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact. On 2/9/21 at 2:00, PM, an interview with the Administrator and LPN #2/Staff Development Nurse revealed when asked to speak to the Activity Director, they stated Activity #1 currently works nights from 7 PM to 7 AM because she is the CNA for the COVID-19 unit and is currently at home asleep. On 2/10/21 at 8:15 AM, in an interview with Activity #1, revealed she has been the Activity Director since the end of September/first of October. She stated I am not a certified Activity Director and because of COVID-19 they have not been able to send me for training. I have been working on the COVID-19 Unit as a Certified Nursing Assistant (CNA) on the COVID-19 Unit and I usually work 7:00 PM to 7:00 AM. When asked who does the activities while you are working on the COVID-19 as the CNA she stated, whoever has time, sometimes the dietary staff. Asked where the activity documentation is kept when they do the activities, she replied they document it on paper or in a notebook and I keep the notebook with me in my car. Asked about Resident #32, she stated she likes to socialize and likes to come and sit in Bingo and watch. She stated Resident #32 also enjoys talking with her roommate and I. Asked a second time where the documentation for Resident #32 activities is because there is no documentation since December 2020 in her chart and she replied it should be in Resident #32's chart.

Based on observation, interviews, record review and facility policy review, the facility failed to honor the resident's rights by not allowing them to smoke for three (3) of five (5) residents reviewed for smoking for Resident #15, Resident #24, and Resident #25. Findings include: Review of the facility's policy, Resident Rights, revised 11/2017, revealed all residents in long term care facility have rights guaranteed to them under Federal and state law. Residents residing in this facility will be guaranteed a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. These rights Include: To participate in other activities, including social, religious, and community activities that do not interfere with rights of other residents. To reside and receive services in the facility with reasonable accommodation of resident needs and preferences. Review of the facility's policy, Smoking Policies and Regulations, revised 04/2015, revealed residents are permitted to smoke in designated areas. This policy noted the staff will monitor residents for safety purposes during smoking. Review of the facility's list of smokers in the facility, dated 2/10/21, revealed five (5) residents were on the smoking list. Resident #15 Observation 02/09/21 at 09:59 AM of Resident #15 lying in bed watching television. Resident is alert an oriented, speech is clear, able to make needs known. During an interview on 02/09/21 at 09:59 AM, with Resident #15, revealed the facility has not allowed the residents to leave their rooms because they have two (2) COVID-19 positive residents on the COVID-19 unit. Resident #15 said he was told he could not smoke because all residents are quarantined. Resident #15 also said the nurse told him chew the nicotine gum to help with the sensation. Resident #15 said he refused the gum because he did not like it. Record review of the Comprehensive Care Plan, revised 12/10/20, revealed Resident #15 has a potential for injury related to smoking. Interventions included supervision with smoking and was prescribed nicotine gum. Record review of the physician's orders [REDACTED].#15 was ordered Nicotine four (4) milligrams (mg) chewing gum by mouth (PO) every (q) four (4) hours as needed (PRN) for nicotine cravings. Record review of Resident #15's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/17/20, revealed Resident #15 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact. Resident #24 During an interview on 02/09/21 at 09:53 AM with Resident #24, stated the facility refused to let the residents come out of the rooms to smoke. Resident #24 said the facility has two (2) COVID-19 positive residents on the COVID-19 unit. Resident #24 said the facility offered nicotine gum. Resident #24 also said she does not like being in the room all day with nothing to do. Resident #24 stated there is only so much on the television. Resident #24 stated she did not think it was fair. Record review of the Comprehensive Care Plan, revealed Resident #24 has potential for injury related to smoking. Record review of the physician's orders [REDACTED]. Record review of Resident #24's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/11/21, revealed Resident #24 had a Brief Interview of Mental Status (BIMS) score of 12, which indicated the resident is cognitively intact. Resident #25 During an interview on 02/09/21 at 09:45 AM with Resident #25, revealed she is tired of staying in her room. Resident #25 stated she tries to stay out of trouble. Resident #25 said she does not like to complain, but she doesn't like that nicotine gum. Resident #25 stated, if you stick your head out the door you are told to go back in your room. Resident #25 also stated the residents are not allowed to smoke because they are quarantined. The facility has two (2) residents that are positive for COVID-19 in the building. Resident #25 said both residents are on the COVID-19 Unit, which is closed. Resident #25 stated she doesn't understand why they could not socially distance and smoke. Record review of Resident #25's physician's orders [REDACTED]. Record review of the Comprehensive Care Plan, revised 1/12/21, revealed Resident #25 has a potential for injury related to smoking. Record review of Resident #25's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/28/20, revealed Resident #25 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact. During an interview on 02/11/21 at 11:14 AM, the Administrator confirmed the facility has not allowed the residents out of their rooms because two (2) residents tested positive and were placed on the COVID-19 unit. The Administrator also confirmed the residents were not allowed to smoke because of the positive residents on the COVID-19 unit.

Based on observation, staff interview, record review, and facility policy review, the facility failed to address pain on the Comprehensive Care Plan, related to wound care, for two (2) of (6) wound care plans reviewed. Resident #3 and Resident #11. Findings Include: A review of the facility's policy titled, Care Plan Process dated 08/2017, revealed: The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs. The care plan should be reviewed and revised as needed and staff should follow the care plan. Resident #3: Review of Resident #3's care plan, initiated 5/22/17, revealed Resident #3 had Pressure injury to the sacral area. The care plan did not address any monitoring of pain prior, during, or after treatment. Review of a care plan initiated 2/17/17, revealed Resident #3 was at risk for pain due to muscle spasm. Interventions included to administer pain medication as ordered and notify the physician of unrelieved pain. There was no risk of pain identified for the wound/treatment or intervention to monitor pain during wound treatment. An observation of wound care on 10/11/17 at 10:45 AM, revealed Resident #3 had a Stage 4 wound to the Sacrum and an Unstageable wound to the left Ischium. Registered Nurse (RN) #1 failed to assess the resident's pain prior to the treatment. RN #1 cleansed the left Ischium and Resident #3 started grimacing and said, It hurts. When asked if the resident received something for pain, RN #1 said yes. RN #1 continued pack the wound with Promagrand and cover with a [MEDICATION NAME] dressing. RN #1 then cleansed Resident #3's Sacrum with Dakin's solution. Resident #3 continued to complain of pain and RN #1 told Resident #3 that she was almost finished. RN #1 packed the Sacrum with Silver Alginate and covered with [MEDICATION NAME] dressing. Resident #3 continued to complain of pain to the wounds. During an interview on 10/12/2017 at 1:00 PM, RN #1 confirmed she failed to assess Resident #3 for pain prior to the treatment and during the treatment. RN #1 confirmed that Resident #3 complained of pain during the treatment on her wounds. During an interview on 10/12/17 at 2:45, RN #2, Minimum Data Set Nurse, confirmed pain was not addressed on Resident #3's care plan for wound care. RN #2 said she didn't know what happened. A review of the facility's face sheet revealed the facility admitted Resident #3 on 2/17/17, with [DIAGNOSES REDACTED]. A review of Resident 3's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/4/17, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. Resident #11: Review of the,Comprehensive Care Plan, dated 10/4/17, revealed Resident #11 had an Unstageable injury to the right hip. The Care Plan, dated 10/4/17, revealed Resident #11 was at risk for pain related to [MEDICAL CONDITION]/spasm, with interventions to administer pain medications as ordered and notify the physician of unrelieved pain. The care plans failed to address pain related to the wound or wound care. During observation on 10/12/17 at 11:30 AM, RN#1 provided wound care to Resident #11's right hip wound. Resident #11 complained of right hip pain throughout the whole process of the wound care. RN #1 asked the resident if she was hurting and the resident answered, yes. RN #1 continued to provide wound care. During an interview on 10/12/17 at 11:30 AM, RN #1 confirmed that Resident #11 complained of right hip wound pain prior and during wound care. During an interview on 10/12/17 at 2:45 PM, RN #2, MDS Nurse, confirmed pain for Resident #11's Unstageable right hip wound was not addressed on the care plan. RN #2 said she don't know what happened. A review of the facility's face sheet revealed the facility admitted Resident #11 on 10/04/17, with diagnoses, which included [MEDICAL CONDITION], Right Hip Pressure Ulcer, [MEDICAL CONDITION], Dementia and [MEDICAL CONDITION] Fibrillation. Resident #11's admission MDS had not been completed. During an interview on 10/12/17 at 2:30 PM, the Director of Nursing (DON) confirmed both Resident #3 and Resident #11's care plans did not address pain due to wound and/or wound care.

Based on observation, staff interview, record review, resident interview and facility policy review the facility failed to assess pain prior to performing wound care and failed to ensure pain was relieved prior to completing wound care for two (2) of six (6) wound care observations. Resident #3, Resident #11 Findings Include: A review of the facility's Pain Policy titled, Potentially Painful Treatments or Procedures dated 01/2016, revealed a pain Scale Rating is completed on the Medication Administration Record [REDACTED]. The resident will be observed for non-verbal indicators of pain as well as using pain scale rating. At any time the rating exceeds 3 on the pain scale, the resident will be offered medication for pain or the medical doctor notified of need for pain management as applicable. If the treatment/procedure is in progress, it will be delayed until intervention is effective. Resident #3: During an observation of wound care, on 10/11/17 at 10:45 AM, Registered Nurse (RN) #1 failed to assess Resident # 3 for pain during the treatment of [REDACTED]. RN #1 cleansed the left Ischium with normal saline and Resident #3 started grimacing and said, It hurts. When asked if the resident had received anything for pain, prior to the treatment, RN #1 said yes. RN #1 continued to pack the wound with Promagrand and covered with a [MEDICATION NAME] dressing. Resident #3 continued to complain of pain. RN #1 cleansed Resident # 3's Sacrum with Dakin's solution. Resident #3 continued to complain of pain. RN #1 told Resident #3 that she was almost finished. RN #1 packed the Sacrum with Silver Alginate and covered with a [MEDICATION NAME] dressing. RN #1 did not ask the resident to rate her pain, offer pain medication, nor did she contact the physician or delay the treatment once the resident started to complain of pain. Review of Resident #3's physician's orders [REDACTED].#3 had [MEDICATION NAME] 5-325 milligram (mg) every six (6) hours ordered for pain. Further orders revealed she had [MEDICATION NAME] 500 mg, two (2) every four (4) hours as needed for pain. During an interview, on 10/12/17 at 1:00 PM, RN #1 confirmed she failed to assess Resident #3 for her pain level prior to the treatment and during the treatment of [REDACTED].#1 stated Resident #3 did complain of pain during the treatment of [REDACTED]. RN #1 said she did not check to see when the resident received her last pain medication, and did not realize she had last received the pain medication at 6:00 AM that morning, which was almost 5 hours prior to wound treatment. An interview with License Practical Nurse (LPN) #1, on 10/11/17 at 11:15 AM, revealed Resident #3 did not receive pain medication just prior to wound care. LPN #1 said the last time Resident #1 receive pain medication was at 6:00 AM. LPN #1 said the next dose was due at 12:00 PM. An interview with Certified Nursing Center (CNA) #2, on 10/11/17 at 11:00 AM, revealed that Resident #3 complained of pain to her buttocks all the time. CNA #2 said she notifies the Medication Nurse, who says the resident received pain medication on a routine basis. Further interview with CNA #2, on 10/12/17 at 9:00 AM, revealed Resident #3 complained of wound pain all the time during incontinent care. CNA #2 said she reported it to the Medication nurse. During an interview with CNA #4 on 10/11/17 at 3:00 PM, revealed Resident #3 complained of wound pain all the time and she notifies the medication Nurse. During an interview, on 10/12/2017 at 1:00 PM, the Director of Nursing (DON) confirmed RN #1 should have assessed Resident #3's pain prior to starting the wound care and during the wound treatment. The DON said RN #1 should have stopped the treatment the first time the resident complained of pain and notified the Doctor or Nurse Practitioner that the pain medication was not working for Resident #3. There was no documented evidence of a pain scale for Resident #3 prior or after wound treatment on the Medication Administration Record [REDACTED] A review of the facility's face sheet revealed the facility admitted Resident #3 with [DIAGNOSES REDACTED]. A review of Resident 3's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/4/17, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. Resident #11: During observation on 10/12/17 at 11:30 AM, RN #1 failed to address/assess Resident #11's pain prior to providing wound care. RN #1 cleansed the left leg ulcer, applied Santyl and a dry dressing. Resident #11 stated that her right hip wound was hurting. RN #1 provided wound care to the unstageable right hip wound with normal saline, applied Santyl and a dry dressing. Resident #11 continued to complain of pain throughout the procedure. RN #1 did ask the resident if she was hurting and the resident answered yes. RN #1 continued with the wound treatment. RN #1 did not ask the resident to rate her pain, offer the resident pain medication, nor stop the treatment and notify the physician of unrelieved pain. Review of Physician Orders, dated October 2017, revealed [MEDICATION NAME] 300 milligram (mg) to be given three (3) times a day for [MEDICAL CONDITION] and [MEDICATION NAME] 600 mg to be given every six (6) hours as needed for fever. There was nothing additionally ordered for wound pain. During an interview, on 10/12/17 at 11:45 AM, Resident #11 revealed that she had complained of pain to her right hip to the nurse all of the time, indicating the pain was not always relieved. During an interview, on 10/12/17 at 11:30 AM, RN #1 confirmed she failed to address/assess Resident #11's pain prior to and during treatment to her unstageable wound to the right hip. RN #1 confirmed that Resident #11 complained of pain during the treatment and treatment should have been stopped when the resident first complained. She stated that she should have stopped and checked for pain medication or notified the MD or NP instead of continuing with the treatment. During an interview on 10/12/2017 at 2:30 PM, the DON confirmed RN #1 failed to assess and treat Resident #1's pain and should have checked for pain medication or notified the Doctor or Nurse Practitioner. The DON said RN #1 should have stopped the treatment when the Resident first complained of pain. There was no documented pain assessment scale on the MAR prior and after treatment of [REDACTED]. A review of the facility's face sheet revealed the facility admitted Resident #11 on 10/04/17, with [DIAGNOSES REDACTED]. Resident #11's admission MDS had not been completed.

Based on resident interview, staff interview, record review, and policy review, the facility failed to adequately update the resident's care plan to address potential high risk pain management related to the surgical repair of Resident #3's left shoulder on 5/6/16, for one (1) of two (2) residents reviewed for pain. Findings include: The facility policy entitled Pain Screen and Management, (Latest Revision: 1/16), revealed: The resident's statements are the most valid measurement of pain. A plan for pain and symptom management is developed based upon the collected data in collaboration with the appropriate interdisciplinary care team members, which includes the resident and family as needed. Care plans are reviewed and changes are documented as appropriate. Documentation, using the pain scale, of a new type of pain, a pain medication and/or treatment change, is done every shift until the pain is managed effectively. Potentially Painful Treatment or Procedures: At any time the rating exceeds three (3) on the pain scale, the resident will be offered medication for pain and the Medical Doctor (MD) notified of need for pain management as applicable. On 6/21/16 at 12:55 PM, interview with Resident #3 revealed she had to go to the local hospital emergency room (ER) on 5/15/16 due to having severe left shoulder pain. Resident #3 stated the facility did not have a refill order for [MEDICATION NAME] after she took the last tablet on 5/14/16 during the PM. Resident #3 stated, I have a history of bone disease with a lot of pain and left shoulder surgery done due to bone deterioration on 5/6/16. Resident #3 stated she was told by the nurse on duty that they would have to wait until Monday (5/16/16) for a refill order from the physician for the prn [MEDICATION NAME]. Resident #3's Departmental Notes, dated 5/15/2016 at 3:54 PM, revealed the Resident complained of severe pain to the left shoulder with no relief with medication; states she can not get comfortable; and pain was unbearable. The Resident's sister came to check in with the resident and came to the nurse stating the resident wanted to go to the ER to see if she could get some relief from pain. The On call physician was called concerning the situation and orders were received to transfer the resident to the local ER for treatment and evaluation of severe pain. The Departmental Note, dated 5/15/2016 at 6:22 PM, revealed Resident #3 returned to the facility at 5:00 PM with no new orders. A report from the ER nurse noted the resident received Intramuscular (IM) [MEDICATION NAME] and [MEDICATION NAME] during the ER visit for pain. Resident #3's Individual Resident Narcotics Record for [MEDICATION NAME] 10-325 milligram (mg) tablet every six (6) hours PRN dated 4/23/16 revealed the resident received the last [MEDICATION NAME] tablet from the card on 5/14/16 at 7:13 PM. Review of a Departmental Note, dated 5/16/16 at 1:35 PM, noted that the Orthopedic Clinic was notified to inquire about Resident #3's pain medication. No order was received at that time due to the Clinic's response that Resident #3 was given a prescription on 5/6/16 for pain medication. The note reflected the resident had no prescription on return to the facility on [DATE]. The orders included post op care and Physical Therapy orders. Resident #3's Physician's Telephone Order, dated 5/12/2016, revealed orders, Non-weight bearing to left upper extremity (Left Total Shoulder Arthoplasty) and Shoulder Immobilizer to Left Shoulder at all times. On 6/22/16 at 11: 20 PM, review of Resident #3's care plan, with Licensed Practical Nurse (LPN) #2, confirmed there was no documented evidence that the facility updated the resident's care plan to address pain management and after her shoulder surgery on 5/6/16, or that they contacted the resident's physician to refill Resident #3's [MEDICATION NAME] PRN pain medication for continued complaint of shoulder pain after return to the facility on [DATE]. Record review revealed the facility admitted Resident #3 on 12/16/13, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 5/23/2016, revealed Resident #3's Brief Interview for Mental Status (BIMS) scored 15, which indicated the resident had no cognitive impairment.

Based on observation, resident/family interview, staff interview, record review, and facility policy review, the facility failed to ensure Resident #3 was free from pain after a surgical procedure, due to the facility's failure to notify the physician and obtain a refill order for pain medication ([MEDICATION NAME]) in a timely manner after the resident took the last pain pill on 5/14/16 at 7:13 PM. This affected one (1) of five (5) residents reviewed, Resident #3. The failure to have [MEDICATION NAME] available, as ordered, resulted in Resident #3 going to the local emergency room (ER) for unrelieved postoperative (post op) left shoulder pain on 5/15/16. Findings include: Review of the facility's policy entitled Pain Screen and Management, (Latest Revision: 1/16), noted: All residents who experience routine pain receive a comprehensive pain screening and a treatment plan until acceptable level of relief is achieved. All residents have the right to treatment for [REDACTED]. Family members are involved when appropriate. Pain medications are ordered by a physician or physician extender per state guidelines. Acute onset of pain: A Pain Screen is completed when a resident has a new onset of pain, a new type of pain, new pain medication or treatment, or when a resident has not experienced an acceptable level of pain relief. New or changed medication orders are transcribed per facility standard of practice and clinical notes are documented. Documentation, using the pain scale, of a new type of pain, a pain medication and/or treatment change, is done every shift until the pain is managed effectively. Potentially Painful Treatment or Procedures: The resident will be observed for non-verbal indicators of pains as well as using the pain scale rating. At any time the rating exceeds three (3) on the pain scale, the resident will be offered medication for pain and the physician notified of need for pain management as applicable. Review of the facility policy entitled Change in Resident Medical Status, (Latest Revision: 5/11), revealed: A facility must immediately inform the resident: consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is: A significant change in the resident's physical, mental, or psychosocial status or a need to alter treatment significantly. Review of the facility policy entitled ALF - Emergency Pharmacy Services, (Latest Revision: 12/98), revealed, Telephone numbers for emergency pharmacy services are posted in the ALF and, where appropriate, maintained in the resident's file. The pharmacy provider is called if an emergency arises that requires immediate pharmacist consultation. Review of the facility policy Physicians Standing Orders, (no date), revealed an order for [REDACTED]. [MEDICATION NAME] Coated (EC) 500 mg one (1) by mouth every 12 hours PRN and [MEDICATION NAME] 200 mg, two (2) PO every six (6) hours PRN. Observation and Interview with Resident #3 on 6/21/16 at 12:55 PM, revealed she had a sling to the left arm. She was alert and oriented and stated she had to go to the local hospitalER on [DATE] due to having severe left shoulder pain and no refill order for [MEDICATION NAME] after taking the last tablet on the evening of 5/14/16. Resident #3 stated she had a history of [REDACTED]. Resident #3 stated she was told by the nurse on duty (5/14/16) that she would have to wait until Monday (5/16/16) for a refill order from the physician for the PRN [MEDICATION NAME]. Resident #3 stated she was in severe pain prior to going to the hospital on [DATE] due to not getting pain relief for her shoulder. Review of Resident #3's Departmental Notes, dated 5/6/16 at 4:08 AM, revealed: Resident out to local surgery clinic. Resident #3 returned to the facility on [DATE] at 5:50 PM per Departmental Notes on 5/9/16 at 9:56 PM. The resident had a (Name Brand) neutral wedge sling noted to the left arm and Certified Nurse Aides (CNAs) reported Resident #3 was in a lot of pain. Crying and increased anxiety was noted. [MEDICATION NAME] was given per orders and monitoring continued. Review of Resident #3's May 2016 Physician Orders revealed an order for [REDACTED]. Resident #3's Physician's Orders, dated 5/9/16, revealed an order to resume all previous Nursing Home orders other than the listed clarification to discontinue (D/C) Tylenol 325 mg PO, Q 6 hours PRN for pain; and D/C Tylenol 500 mg PO, Q 8 hours PRN for pain. Resident #3's Physician's Telephone Order, dated 5/12/2016, revealed orders, Non-weight bearing to left upper extremity (Left Total Shoulder Arthoplasty) and Shoulder Immobilizer to Left Shoulder at all times. Resident #3's Physician's Telephone Order on 5/15/2016 at 3:08 PM, noted an order to transfer the resident to the local emergency room (ER) for treatment and evaluation of severe pain to the left shoulder. Review of Resident #3's Departmental Notes, dated 5/15/2016 at 3:54 PM, noted the resident complained of severe pain to the left shoulder; no relief of pain with medication, and he/she couldn't get comfortable due to pain was unbearable. The resident's sister came to check on the with resident and reported to the nurse that Resident #3 wanted to go to the ER to see if she could get some relief from pain. The On call physician was notified concerning the situation and an order received to transfer the resident to the ER for the resident's choice of treatment and evaluation of severe pain. A Departmental Note, dated 5/15/2016 at 6:22 PM, noted Resident #3 returned to the facility at 5 PM, with no new orders. Report from the ER Nurse revealed the resident received Intramuscular (IM) [MEDICATION NAME] and [MEDICATION NAME] for pain, during the ER visit. Observation on 6/21/16 at 4:21 PM, of Resident #3's incision site with the Treatment Nurse/LPN and the Director of Nursing (DON), revealed the resident's left arm in a sling; gauze dressing and steri-strips covered the left anterior shoulder surgical incision site. Interview with the Treatment Nurse revealed she daily painted the incision site with (name of Medication). Resident #3 reported the steri-strips will be removed during the follow-up physician visit on 6/30/16, and the physician was holding off with therapy at this time due to previous complications. Telephone interview on 6/22/16 at 11:30 AM, with Resident #3's sister, revealed that Resident #3 was in bed on Sunday 5/15/16 about 3:30 PM with a wash cloth over her eyes crying and complaining of severe left shoulder pain. The sister recalled being told, by the nurse on duty at the facility, that the resident had no order for pain medication ([MEDICATION NAME]) and she asked the nurse to send the resident out to the local hospital ER for evaluation of her pain because it was so bad. The resident's sister also reported she was told by the facility nurse on 5/16/16, that Resident #3 returned to the facility on [DATE] without a prescription for pain medication after surgery on 5/6/16. The sister reported she had to pick up a prescription for Resident #3's [MEDICATION NAME] 10-325 mg tablets from the Orthopedic clinic after work on 5/16/16 at 4:00 PM. The sister stated there was no reason Resident #3 should be out of her pain medication ([MEDICATION NAME]). Review of Resident #3's Individual Resident Narcotics Record for [MEDICATION NAME] 10-325 mg every six (6) hours PRN, dated 4/23/16. revealed the resident received the last [MEDICATION NAME] tablet from the card on 5/14/16 at 7:13 PM. There was no documented evidence that the [MEDICATION NAME] was re-ordered or that the physician was contacted for another prescription for [MEDICATION NAME] until 5/16/16. Record review revealed there was no documented evidence that the facility contacted Resident #3's physician or the Orthopedic clinic to refill Resident #3's PRN [MEDICATION NAME] pain medication after surgery on the resident's left shoulder on 5/6/16, or when she was noted to be crying in severe pain at approximately 3:54 PM on 5/15/16, and was transferred to the ER for unrelieved pain. The facility failed to immediately contact the physician, after realizing the resident was out of [MEDICATION NAME] on 5/14/16, to ensure that medication was available at a strength necessary to alleviate and/or maintain control of the resident's pain. The physician wasn't notified until 5/16/2016 at 1:35 PM. Interview on 6/22/16 at 11:00 AM, with the Administrator, revealed Resident #3 failed to return to the facility with a prescription for pain medication post-op on 5/9/16, after admission to an out of town hospital for three (3) days. The Administrator confirmed that LPN #1 had knowledge about Resident #3 not having an order to refill his/her pain medication. Interview on 6/22/16 at 11:46 AM, and record review with LPN #1, confirmed Resident #3 received the last [MEDICATION NAME] 10-325 mg tablet for pain from the medication card on 5/14/16 at 7:13 PM. LPN #1 confirmed that the facility failed to contact a physician to refill Resident #3's PRN [MEDICATION NAME] pain medication after the resident's surgery of the left shoulder on 5/6/16, or contact the Orthopedic clinic for a pain medication order after the resident returned to the facility on [DATE], until 5/16/2016 at 1:35 PM. LPN #1 reported the following findings: Contacting the Orthopedic clinic staff on 5/16/2016 during the AM, and being told that Resident #3 received a hard script (prescription) for pain medication after surgery on 5/6/16. Resident #3 was admitted to the hospital out town after surgery for [REDACTED]. The facility received a phone call from Resident #3's sister on 5/16/16, who informed the staff with a rude tone of voice, of picking up a hard script for pain medication from the Orthopedic clinic that PM. The hard script copy arrived to the facility on [DATE] after 5:00 PM, for [MEDICATION NAME] 10-325 MG tablets. The local Back-Up Pharmacy was out of [MEDICATION NAME] 10-325 tablet and the facility obtained an order from Resident #3's physician for Tylenol with [MEDICATION NAME] #3 tablets, one (1) PO every 6 hours as needed for pain. Resident #3 received a Tylenol with [MEDICATION NAME] #3 tablet for pain from the facility emergency kit on 5/16/16 at 5:45 PM. Resident #3's [MEDICATION NAME] 10-325 mg tablets arrived to the facility from the Back-Up Pharmacy on 5/17/16 at 11:00 AM, and was administered to the resident at 11:05 AM. Interview on 6/22/16 at 1:02 PM, with the Director of Nursing (DON), revealed she was a new DON at the facility on 5/9/16, and had not been made aware that Resident #3 was out of refills for pain medication ([MEDICATION NAME]) on 5/14/16. The DON stated that the facility staff should have made Resident #3's physician or the on-call physician aware of the resident's need for a refill order for pain medication post-op and prior to giving the last dose of [MEDICATION NAME] to Resident #3. The DON reported that the facility Medical Director was the resident's primary physician and also the after hours physician. Resident #3 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #3 was also re-admitted to the facility on [DATE] after left shoulder surgery. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 5/23/2016, revealed Resident #3's Brief Interview for Mental Status (BIMS) scored 15, which indicated the resident had no cognitive impairment. Section J of the MDS noted that Resident #3 had frequent and severe pain.

Based on resident interview, record review, staff interview, and policy review, the facility failed to notify the physician in a timely manner to refill an order related to Resident #3's pain medication ([MEDICATION NAME]) upon return to the facility on [DATE], after left shoulder repair on 5/6/16, for one (1) of five (5) residents reviewed. Resident #3 had unrelieved pain and was sent to the emergency roiagnom on [DATE] due to not having the [MEDICATION NAME] available for pain. Findings include: The facility policy entitled Change in Resident Medical Status, (Latest Revision: 5/11), revealed, A facility must immediately inform the resident: consult with the resident's physician; and if know, notify the resident's legal representative or an interested family member when there is: A significant change in the resident's physical, mental, or psychosocial status; A need to alter treatment significantly. Review of the facility policy entitled Pain Screen and Management, (Latest Revision: 1/16), revealed, Pain medications are ordered by a physician or physician extender per state guidelines. Acute onset of pain: A Pain Screen is complaint when a resident has a new onset of pain, a new type of pain, new pain medication or treatment, or when a resident has not experienced an acceptable level of pain relief. New or changed medication orders are transcribed per facility standard of practice and clinical note is documented. Documentation, using the pain scale, of a new type of pain, a pain medication and/or treatment change, is done every shift until the pain is managed effectively. Potentially Painful Treatment or Procedures: At any time the rating exceeds three (3) on the pain scale, the resident will be offered medication for pain and the Medical Doctor (MD) notified of need for pain management as applicable. During an observation and interview on 6/21/16 at 12:55 PM, Resident #3 had a sling on the left arm. She reported she had shoulder surgery (5/6/16). Resident #3 stated on 5/14/16 the nurse told her she only had one (1) [MEDICATION NAME] left and would need to wait as long as possible to take it. Resident #3 stated she had to go to the local hospitalER on [DATE], due to having severe Left Shoulder Pain, because there was no refill order for the [MEDICATION NAME] after she had taken the last tablet on 5/14/16. Resident #3 stated she had a history of [REDACTED]. Resident #3 reported she was told by the nurse on duty on Friday (5/14/16) that she would have to wait until Monday (5/16/16) for a refill order from the physician for the [MEDICATION NAME]. Interview with Resident #3's family member, on 6/22/16 at 11:30 AM, revealed she had visited and found Resident #3 in bed crying with a wash cloth over her eyes. The resident complained of severe shoulder pain. According to the interview, the nurse on duty was informed of the resident's pain. The nurse reported that the resident's pain medication could not be refilled until Monday 5/16/16. The family member stated the nurse had not notified the physician for an order to refill the pain medication. The family member stated that Resident #3 was in so much pain that she asked for an order to send her to the ER. Review of a Physician's order, dated 4/23/16, revealed Resident #3 had orders for [MEDICATION NAME] 10/325 milligram (mg), one (1) tablet every six (6) hours as needed (PRN) for pain. Record review of Resident #3's Individual Resident Narcotics Record and documentation on the Medication Administration Record [REDACTED]. Record review lacked documented evidence that the facility notified/contacted a physician to refill Resident #3's [MEDICATION NAME] PRN pain medication after the 5/6/16 surgery on Resident #3's shoulder and prior to the resident taking the last [MEDICATION NAME] available on 5/14/16. The facility also did not contact the Orthopedic Clinic for a pain medication prescription or refill of the [MEDICATION NAME] after the resident returned to the facility on [DATE]. The physician was not notified of a [MEDICATION NAME] refill order for Resident #3 until 5/16/2016 at 1:35 PM. Record review and interview with LPN #1, on 6/22/16 at 11:46 AM, confirmed Resident #3 received the last [MEDICATION NAME] 10-325 MG tablet for pain from the card on 5/14/16 at 7:13 PM and that the facility failed to contact a physician to refill Resident #3's [MEDICATION NAME] PRN pain medication until 5/16/2016 at 1:35 PM. Interview with the Director of Nursing on 6/22/16 at 1:02 PM revealed the facility staff should have contacted Resident #3's physician for a refill of pain medication prior to the resident taking the last [MEDICATION NAME] 10-325 mg on 5/14/16, and before Monday, 5/16/16. The facility readmitted Resident #3 on 12/16/13, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 5/23/2016, revealed Resident #3's Brief Interview for Mental Status (BIMS) scored 15, which indicated the resident had no cognitive impairment.

Based on observations, interviews, record reviews, and the facility's Resident Incident Report, the facility failed to provide coffee at a safe temperature resulting in first and second degree burns when Resident #3 spilled the coffee into her lap for one (1) of four (4) residents reviewed. Findings include: Review of the Resident Incident Report, dated 1/10/16 at 4:51 PM, revealed Certified Nursing Assistant (CNA) #1, reported to Licensed Practical Nurse (LPN) #1 that Resident #3 spilled coffee in her lap. The type of injury listed on the report was a second degree burn. This report indicated Resident #3 had red areas and a small blister noted the left inner thigh and the facility transferred the resident to the emergency room after contacting the physician. In a review of the history and physical examination [REDACTED]has burns on legs. The assessment revealed burns to legs, 4-5% total body surface area, 1% second degree burn, 3-4% first degree burns. In an interview with Certified Nurses Assistant (CNA) #1 on 1/19/16 at 2:52 PM revealed Resident #3 was in the dining room for an activity on 1/10/16 when CNA #2 told her, we have a spill indicating Resident #3 had spilled coffee into her lap. CNA #1 stated she observed steam coming up from Resident #3's lap and attempted to pull Resident #3's pants legs up away from her skin. She stated she took the resident to her room to remove her pants. CNA #1 explained she was attempting to get the hot liquid away from her skin by pulling upward on her pants legs. Interview with CNA #2 on 1/19/16 at 2:55 PM revealed Resident #3 was in the dining room on 1/10/16 for an activity and CNA #3 gave Resident #3 coffee to drink. CNA #2 stated she then observed Resident #3 drop her coffee into her lap and observed steam rising it was so hot. CNA #2 also stated, We have a coffee dispenser in the dining room and the coffee that comes out of there is really really hot. Interview with CNA #3 on 1/20/16 at 10:30 AM revealed Resident #3 was in the dining room for an activity when CNA #3 gave Resident #3 coffee from the dispenser in the dining room. CNA #3 stated she left the area to answer a call light and when she returned Resident #3 had spilled the coffee into her lap. CNA #3 stated there was two other CNAs in the dining room at the time of the incident, CNA #1 and CNA #2. Interview on 1/19/16 at 1:50 PM with the Director of Nursing (DON) stated Resident #3 had a second degree burn to the top of her thighs and perineal area secondary to spilling hot coffee between her legs. The DON stated Resident #3 was transferred to the emergency room for treatment and evaluation. An interview on 1/20/16 at 3:40 PM with Occupational Therapist (OT) #1 revealed during her assessment of Resident #3 on 12/10/15 in the dining room, she observed Resident #3 spilling food, not liquid spillage. OT #1 stated she observed Resident #3 at least twice and the resident did not exhibit a lot of tremors when she observed her. OT #1 stated the goal was for Resident #3 to increase her ability to eat independently. OT #1 revealed Resident #3 did not need increased supervision or special equipment for liquids at the time of the assessment. OT #1 stated following assessments, she made sure the facility staff were aware of any OT recommendations. OT #1 stated, We tell the nurses and the CNAs. OT #1 also stated Resident #3 had been improving and was more alert. In an observation on 1/19/16 at 3:30 PM with the Facility Administrator present, the State Agency (SA) calibrated a thermometer to 32 degrees Fahrenheit using ice with water. The Facility Administrator then dispensed coffee into a cup. The SA immediately checked the temperature of the coffee. The temperature read 160 degrees Fahrenheit and the Administrator confirmed by the reading. On 1/20/16 at 10:00 AM, the facility's Administrator provided a statement on letterhead that read, This facility does not have a policy on hot beverage temperatures. Observation on 1/19/16 at 3:52 PM revealed the Dietary Supervisor calibrated a thermometer to 32 degrees Fahrenheit and checked the coffee temperature with the SA present. The facility obtained a temperature reading of 152 degrees Fahrenheit at that time. Both the facility's and the SA's thermometers were used to verify the results. In an observation on 1/20/16 at 9:10 AM revealed a sign reading Out of Order on the Automatic Coffee Maker in the dining room. Interview on 1/19/16 at 3:40 PM revealed the Dietary Supervisor stated the temperature of the coffee from the dispenser was checked weekly but was unable to provide documentation of the coffee temperature being checked. The Dietary Supervisor stated the coffee temperature was checked this morning with a reading of 145 degrees Fahrenheit, but the Dietary Supervisor again was unable to provide documentation. The facility readmitted Resident #3 to the facility on [DATE] per the Face Sheet with the [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 10/16/15 revealed Resident #3's Brief Interview for Mental Status (BIMS) score was eight (8) which indicated Resident #3 was moderately cognitively impaired.

Based on observation, interviews, record reviews and facility policy review, the facility failed to maintain a resident safety per the care plan and failed to provide wound care for a resident's burn as directed by Resident #3's care plan for one (1) of four (4) care plans reviewed. Findings Include: The facility's policy entitled, Care Plan Process, dated 6/15 revealed the facility would develop, review, and revise each resident's comprehensive plan of care that accurately reflected the resident's status and needs. Review of Resident #3's care plan revealed a care plan for poor safety awareness dated 12/15/15 with an intervention to maintain the resident's environment free of safety hazards. Review of a Resident Incident Report dated 1/10/16 at 4:51 PM, revealed Certified Nursing Assistant (CNA) #1, reported to Licensed Practical Nurse (LPN) #1 that Resident #3 spilled coffee in her lap that resulted in a second degree burn. On 1/19/16 at 2:52 PM, an interview with Certified Nursing Assistant (CNA) #1 revealed Resident #3 was in the dining room for an activity on 1/10/16 when CNA #2 told her, we have a spill indicating Resident #3 had spilled hot coffee into her lap. CNA #1 stated she observed steam coming up from the coffee on Resident #3's lap and attempted to pull Resident #3's pants legs up away from her skin. She stated she took the resident to her room to remove her pants. Interview on 1/19/16 at 1:50 PM with the Director of Nursing (DON) stated Resident #3 had a second degree burn to the top of her thighs and perineal area secondary to spilling hot coffee between her legs. Review of Resident #3's Plan of Care revealed on 1/10/16 the Care Plan was updated to include the care [MEDICAL CONDITION] both inner thighs with the approach to, keep burn area clean and dry. Apply [MEDICATION NAME] Cream daily and keep covered. In a review of the physician's orders [REDACTED]. Review of the Emergency Department Home Instructions for Resident #3 on 1/10/16 noted to keep burn area clean and dry, apply ointment daily and use bandages to keep area covered. On 1/19/16 at 3:12 PM, observation during a skin audit with Licensed Practical Nurse (LPN) #2 revealed no bandages covering the Second Degree burn to Resident #3's left inner thigh. In an observation of incontinent care on 1/20/16 at 2:28 PM, Certified Nurses Assistant (CNA) #3 removed Resident #3's clothing and there was no dressing as ordered covering the burn to the left inner thigh wound. Observation of wound care on 1/20/16 at 3:00 PM, revealed LPN #2 failed to clean [MEDICAL CONDITION] the left inner thigh with wound cleanser and failed to cover [MEDICAL CONDITION] bandages as ordered. On 1/20/16 at 3:26 PM, an interview with LPN #2 revealed she confirmed treatment of [REDACTED]. Review of the resident's Face Sheet revealed the facility readmitted Resident #3 on 12/10/15 with the [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 10/16/15 revealed Resident #3's Brief Interview for Mental Status (BIMS) score was eight (8) which indicated Resident #3 was moderately cognitively impaired.

CI MS # 9680 Based on Administrative review by Centers for Medicare and Medicaid Services (CMS) a new complaint investigation was conducted to investigate the status of missing medications and narcotics. Additional information was gathered on 08/17/11. The partially extended survey was concluded on 08/17/11. During the investigation, the facility was found not to be in compliance with the requirements of Medicare and Medicaid Requirements. A partially extended survey was conducted on 08/03-07/11. An Immediate Jeopardy was identified on 08/05/11 at 12:50 p.m. The Administrator and the Director of Nursing (DON)were notified at that time. The Immediate Jeopardy was determined to begin on 04/30/11. The facility submitted an Allegation of Compliance on 08/07/11 and it was determined not acceptable. The Immediate Jeopardy (IJ) was not removed upon exit from the facility on 08/17/11 and is considered on going. Based on record review, staff interview, consultant pharmacist interview, Medical Director interview and policy review, the facility failed to ensure that the process of acquiring, receiving, storing, controlling and reconciling of medications was followed. This was evidenced by inconsistencies in documentation of narcotic count reconciliation, disposal of narcotic, and failure to ensure that the Medication Reorder Form and the Delivery List was reconciled for accuracy. The facility also failed to ensure that a process of identifying, evaluating and addressing medication related issues related to the prevention and reporting of medication inconsistencies. This was confirmed by review of forms titled Cart B, Cart C, Cabinet and the Emergency Box Requisition. This was evidenced by inconsistent documentation by two (2) nurses (LPN #2 and LPN #10) for the reconciliation of narcotic medications at the shift change, incorrect narcotic counts, reorder forms for medication ordered and delivered, count of syringes ABHR ([MEDICATION NAME] and [MEDICATION NAME]) containing medications not correct, [MEDICATION NAME] Patches wasted by Hospice not matching that which was wasted, inconsistency of two (2) licensed nurses (LPN #2 and LPN #10) witnessing the disposal of narcotics. Review of the Plan of Correction submitted to the State Licensing Agency with a date and signature by the Administrator on 05/05/10, and a correction date of 02/19/10, revealed the PoC to state: Any discrepancies will be reported to the Quality Assurance (QA) Committee. Findings Include: Cross refer to F-425 for additional information related to the facilities failure to monitor the process of acquiring, receiving, storing, controlling and reconciling the medications. Interview on 8/17/11 at 10:55 a.m. with the Director of Nursing (DON) and the Nurse Consultant revealed that the issues would be identified and brought to the CQI (Continuous Quality Improvement). The DON and the Administrator coordinate the meetings and the medical director attends the meetings. Review of the facility policy " Quality Assessment and Improvement Committee "with a latest revision date of 01/11 revealed: "Organizational Structure of Committee: *1. The Quality Assessment and Improvement Committee (QA&IC) is set up to provide structure and direction for the Quality Assessment and Improvement program (QA&I). The QA& IC is responsible for establishing priorities, and to assign project teams when deemed appropriate. *2. Composition of the QA & IC shall include: Administrator Medical Director Director of Nursing Services (DON) And at least two other facility staff persons. (Other potential committee members include Housekeeping, Maintenance, Social Services, Activities, Dietary and CNAs) *3. The quality improvement committee shall meet on a quarterly basis. *4. Minutes shall be taken at all meetings. Documentation shall include date, names of those in attendance, length of meeting, issues discussed, findings and recommendations. *5. All individual Resident specific data will be kept in a confidential manner with access limited to Administrator and DON." Interview with the DON, Administrator, and a member of the Corporate Staff on 8/17/11 at 2:45 p.m. revealed that "QA looks at the last three months and the QA meeting was held in 2010 prior to the arrival of the Statement of Deficiencies. We told them that it was sent, returned and the facility was put back in compliance." The Corporate staff member stated that the facility "Had two nurses counting" and he was informed that as of the entrance date of the current survey that was not the practice. A document, in the form of a MEMO, dated August 17, 2011 and signed by the Administrator with the subject to be "RE: to the QA & I committee" revealed: "You asked for information concerning what steps our committee took based on the complaint investigation of January 6, 2010. As you can see, the committee met on January 28, 2010, to review the months of October, November and December of 2009. At this time we did not have the 2567 (Statement of Deficiencies) (it came in the afternoon of 01/28/2010) related to the complaint investigation so it was not presented. Individual members of the team were responsible for ensuring that the PoC was adequate and upon revisit we were found to be in compliance. The next meeting of the QA & I committee was held on April 29, 2010. At this time since the facility was back in substantial compliance letter dated April 12, 2010) with all state and federal guideline the committee had no additional input as to how to correct the issue (.)" There was not documented evidence that the committee met and discussed the issue of the 2445 [MEDICATION NAME] that were missing from the facility or how to monitor the issue. Interview was conducted on 8/17/11 at 10:05 a.m. with Consultant Pharmacist #1 who stated that she had been visiting at the facility for the previous three months. She stated that the first month she came she reviewed, glanced at, the narcotic records. " Unless I know they had Ian issue I just do an audit. Knew issue in the past but thought resolved. No one told me to look for problems. " She stated she would look for things that required signatures such as the back of the Medication Record. Interview was conducted with the Consultant Pharmacist #3 on 8/17/11 at 2:05 p.m. (who was responsible for the facility at the time of the 01/10 survey). She stated she "kinda remembered the incident. Changed how nurses signed off at shift change. Not like just missing -just realized she was only one signing out for patients that never got it." "Talked with (Previous DON at time of incident) and did not set up any additional procedures. Talked about prns, not doing the pain scale." She stated that she was not sure if she was notified when QA meetings were held. The Consultant Pharmacist #2 made a visit to the facility on [DATE] and prepared a Monthly Report. Portions of that report included the following information. "I have reviewed a lot of your prn documentation today and found it to be in order. A review of your full MAR indicated [REDACTED]. There should never be any gaps or holes in documentation but I regarded what I found to be very good performance." The Consultant Pharmacist documented "AREAS OF ATTENTION" in the 8/15/11 Monthly Report: "Please consider your order of prn documentation to show chronology of doses. Right now there is a habit to record the flip side documentation for prns on whatever sheet is flipped to. This makes it extremely difficult to establish that all prn doses are supported with reason and result documentation and may be a reason that this has been questioned by surveyors. Please consider directing/teaching/instructing your nurses to begin prn documentation on the back of the 1st (first) PRN flip side sheet until full and then proceed to use other sheets until full in order." Interview with Consultant Pharmacist #2 on 8/17/11 at 1:38 p.m. revealed that he had been requested to come to the facility and performed a complete regime review. Interview was conducted with the Medical Director (who was the same Medical Director during the 01/10 survey) on 8/17/11 at 4:20 p.m. He stated that he was not made aware of the [MEDICATION NAME] theft until the nurse was arrested. He was unaware of the issue. He did not recall the facility seeking input from him regarding the issue of missing narcotics.

CI MS # 9680 Based on Administrative review by Centers for Medicare and Medicaid Services (CMS) a new complaint investigation was conducted to investigate the status of missing medications and narcotics. Additional information was gathered on 08/17/11. The partially extended survey was concluded on 08/17/11. Based on record review, staff interview and resident interview, the facility failed to ensure that physician orders [REDACTED].#1, Resident #3, Resident #5, Resident #7 and Resident #17. Resident #1 did not receive [MEDICATION NAME] 7.5 milligrams (mg) due to being asleep. The [MEDICATION NAME] 7.5 mg was a routine scheduled medication and the order did not state to withhold the [MEDICATION NAME] 7.5 mg if Resident #1 was asleep. Resident #3 did not [MEDICATION NAME] mg every night as ordered. Resident #5 did not have [MEDICATION NAME] 30 mg administered on 07/25/11. Resident #7 did not received [MEDICATION NAME] 10/500 four times a day (QID). Medication received from the pharmacy for Resident #17 did not match the physician's orders [REDACTED]. There was no documented evidence why the medications were not administered per physician's orders [REDACTED]. During the investigation, the facility was found not to be in compliance with the requirements of Medicare and Medicaid Requirements. A partially extended survey was conducted on 08/03-07/11. An Immediate Jeopardy was identified on 08/05/11 at 12:50 p.m. The Administrator and the Director of Nursing (DON)were notified at that time. The Immediate Jeopardy was determined to begin on 04/30/11. The facility submitted an Allegation of Compliance on 08/07/11 and it was determined not acceptable. The Immediate Jeopardy (IJ) was not removed upon exit from the facility on 08/17/11 and is considered on going. Findings Include: Resident #1 Review of Resident #1's medical record revealed an admission date of [DATE] and a readmission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #1's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/07/2011 revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated that Resident #1 was cognitively intact. Long term and short term memory was coded "OK". Section J Health Conditions revealed that the resident was on a scheduled pain medication regimen and received prn (as needed) pain medications. Review of Resident #1's medical record revealed a confirmed that the resident was on scheduled and PRN (as needed) medication and had recently complained of pain. Resident #1 had described the pain at a score of six (6) (on a scale of 1-10). Resident #1's "Care Plan" with an date of 05/31/2011 identified a problem of pain. Review of Resident #1's Physician order [REDACTED]. "5/31/11 [MEDICATION NAME] 50 MG (milligram) 1 PO (by mouth) TID (three times a day) ARTHRITIS Generic: [MEDICATION NAME] HCL" "6/15/11 [MEDICATION NAME] 7.5 MG Q 4 HOURS---PAIN" "7/15/11 ok TO GIVE [MEDICATION NAME] 5/500 1 ? (one and one half) tab (tablet) @ (at) 1A (a.m.) et (and) 5: (a.m.) today only" "7/15/11 [MEDICATION NAME] 5 mg one tab q 4 hrs (hours) until [MEDICATION NAME] 7.5 mg tablets are available". Review of a form titled "MEDICATIONS" (medication administration record) for July 2011 revealed: [MEDICATION NAME] 7.5 mg was ordered every four hours for pain with a start date of 6/23/11. Documentation on the MEDICATION form revealed that on July 7,8, 13, 14 and 23, 2011 at the scheduled time of 1:00 a.m. [MEDICATION NAME] 7.5 mg was not administered. There was no documented evidence of why the [MEDICATION NAME] 7.5 mg was not administered to Resident #1 as ordered by the physician. In the space for the date of 07/15/11 at 9:00 a.m. there was an X written in. There was no documented evidence why the [MEDICATION NAME] 7.5 mg was not administered to Resident #1 at 9:00 a.m. on 7/15/11. Interview conducted with LPN#2 on 08/03/11 at 6:40 p.m. revealed that she had wasted the 2.5 mg [MEDICATION NAME] in the sharps container and LPN #7 was supposed to have documented that she witnessed the wasting of the [MEDICATION NAME]. LPN #7 did not sign the document to indicate that she had witnessed the wasting of the [MEDICATION NAME] 2.5 mg. Review of Resident #1's Physician order [REDACTED]. "7/15/11 ok TO GIVE [MEDICATION NAME] 5/500 1 ? (one and one half) tab (tablet) @ (at) 1 A (a.m.) et (and) 5 A (a.m.) today only". "7/15/11 [MEDICATION NAME] 5 mg one tab q 4 hrs (hours) until [MEDICATION NAME] 7.5 mg tablets are available". Interview and record review conducted with the DON on 8/17/11 at 4:30 p.m. revealed that Resident #1 had not been provided her pain medications, [MEDICATION NAME]. He stated that the original order was for the [MEDICATION NAME] to be administered prn and the order had changed to a routine scheduled dose on 6/23/11. After the change from prn to routine schedule the facility continued to administer the medication that had been previously delivered for the prn schedule. The reason that [MEDICATION NAME] was removed from the Ekit and administered to Resident #1 was because the facility was waiting on a hard copy prescription to provide to the Pharmacy for the obtaining of [MEDICATION NAME] to be administered on a q 4 hour routine basis as ordered. Review of the "Emergency Box Requisition" form revealed that [MEDICATION NAME] 5 mg was signed out for Resident #1 on the following dates: 3 [MEDICATION NAME] 5 mg on 07/16/11, 2 [MEDICATION NAME] 5 mg on 07/26/11, 3 [MEDICATION NAME] 5 mg on 07/27/11. Review of an "EMPLOYEE STATEMENT" dated 08/03/11 revealed that LPN #2 wrote, "I, (LPN #2), on Wednesday 7/27/11 gave a Res. (Resident), (name of Resident #1), 1 ? [MEDICATION NAME] which = (equaled) to 7.5 mg. I broke the [MEDICATION NAME] in half et discarded the other half in the sharps container. This was witnessed by (LPN #7)." Review of an "EMPLOYEE STATEMENT" dated 08/03/11 revealed that LPN #7 wrote, "I, (LPN #7) witnessed (LPN #2) wasting ? of 5 mg [MEDICATION NAME] in Sharp Container on 7/27/11." Resident #3 Review of Resident #3's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's MDS with an ARD of 06/27/11 revealed that Resident #3 was coded with a BIMS score of 15 which was defined as cognitively intact. Review of Resident #3's care plan revealed an onset date of 06/05/2009 for the problem of: "SLEEP DISTURBANCE R/T (RELATED TO) DX (DIAGNOSIS) OF [MEDICAL CONDITION] E/B (EVIDENCED BY) TALES (TAKES)[MEDICATION NAME] AT HS). The approaches included "[MEDICATION NAME] MG 1 PO Q HS (HOUR OF SLEEP) ---[MEDICAL CONDITION]". Review of the July 2011 computerized Physician order [REDACTED]. day except Sunday)". Review of the document titled "MEDICATIONS" dated June 2011 revealed that "AMBIEN 10 MG 1 PO Q HS-[MEDICAL CONDITION] Start Date 4/24/11" revealed that [MEDICATION NAME] mg was not administered every night at 09:00 p.m. as ordered. There was no documented evidence that [MEDICATION NAME] mg was administered on at 09:00 p.m. June 5, 12 19, 26 or 30. All of those dates were Sundays except 06/30/11 which was a Thursday. Review of the document titled "MEDICATIONS", for Resident #3, dated July 2011 revealed that : "AMBIEN 10 MG 1 PO Q HS Start Date 4/24/11" was not administered every night at 09:00 p.m. as ordered. There was no documented evidence that [MEDICATION NAME] mg was administered at 09:00 p.m. on July 3, 4, 10,17,24,30 or 31, 2011. All of those dates were Sundays except for 07/04/11 which was a Monday and 07/30/11 which was a Saturday. Resident #5 Review of Resident #5's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5's Admission MDS with an ARD of 06/27/11 revealed a BIMS score of 15 which was defined as cognitively intact. Review of the computerized Physician order [REDACTED]. Review of the document titled "MEDICATIONS" dated July 2011 revealed no documented evidence that the [MEDICATION NAME] 30 mg nor the Trazadone HCL/50MG was administered on July 25, 2011 at 09:00 p.m. as ordered by the physician. Resident #7 Review of Resident #7's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #7's Annual MDS with an ARD of 03/14/11 revealed a BIMS score of 15 which was defined as cognitively intact. Review of Resident #7's Care Plan revealed a problem with an onset date of 08/25/06 for "COMFORT ALTERED-PAIN R/T CHRONIC ARTHRITIC PAIN/PERIPHERAL [MEDICAL CONDITION]" with an approach of "[MEDICATION NAME] 10/500 1 PO QID ---PAIN". Review of the computerized Physician order [REDACTED]. Interview with Resident #7 on 08/05/11 at 09:45 a.m. revealed that she experienced pain "awfully bad last night". She stated that she did not receive her pain medication. Review of the document titled "MEDICATIONS" dated August 2011 revealed no documented evidence that the "[MEDICATION NAME]/500 1 PO QID PAIN" was administered on 08/05/11 at 12:00 A.M. as ordered by the physician. The block for the "[MEDICATION NAME] 10/500 12:00 A.M." 08/05/11 revealed the nurses initials were circled indicating that the medication was not administered. There was no documented evidence why the [MEDICATION NAME] 10/500 was not administered at 12:00 a.m. as ordered by the physician. Interview conducted with Resident #7 on 8/17/11 at 1:10 p.m. confirmed that she did want to be awakened at night for the administration of her medications because it helped her to rest. Resident #17 Review of Resident #17's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #17's computerized Physician order [REDACTED]. "4/25/11 [MEDICATION NAME] 10/325 MG GIVE 2 PO Q 4 HOURS PRN ---SEVERE PAIN". Review of Resident #17's "INDIVIDUAL RESIDENT NARCOTICS RECORD" with a beginning date of 4/26 (11) revealed that on 4/30/11 at 08:00 p.m. there was a count of 44 [MEDICATION NAME] 7.5/325 mg tablets "with two given which left 42 remaining tablets. On " 5/1/11 " there was a beginning count of 43 with 1 administered which had a documented amount of 41 remaining tablets. The count remained out of sequence for the remaining documentation with no reason documented why the count went from 44 to 42 to 43 [MEDICATION NAME] 7.5/325 mg tablets being counted. (Note: not only was the count out of sequence the physicians order did not match the pharmacy label for the [MEDICATION NAME].)

CI MS # 9680 Based on the complaint survey results dated 08/17/11, the facility failed to ensure that physician orders [REDACTED].#1, Resident #3, Resident #5, Resident #7 and Resident #17. Resident #1 did not receive [MEDICATION NAME] 7.5 milligrams (mg) due to being asleep. The [MEDICATION NAME] 7.5 mg was a routine scheduled medication and the order did not state to withhold the [MEDICATION NAME] 7.5 mg if Resident #1 was asleep. Resident #3 did not [MEDICATION NAME] mg every night as ordered. Resident #5 did not have [MEDICATION NAME] 30 mg or Trazadone 50 mg administered on 07/25/11 as ordered by the physician. Resident #7 did not receive [MEDICATION NAME] 10/500 four times a day (QID) as ordered by the physician. Medication received from the pharmacy for Resident #17 did not match the physician's orders [REDACTED]. There was no documented evidence why the medications were not administered per physician's orders [REDACTED]. This was deemed as an Immediate Jeopardy on 08/05/11 at 12:50 p.m. A revisit survey was conducted on 09/08/11 to validate the Allegation of Compliance (AoC). The Immediate Jeopardy began on 04/30/11 and was determined to be removed on 09/07/11. The validation of the Credible Allegation of Compliance was accomplished through observation, interview and record review. The facility provided evidence that the facility had implemented the corrective actions listed in the AoC, however, additional information has been added to the Statement of Deficiencies (SoD) to reflect concerns identified during the survey of 09/08/11 related to the facility's 100% daily audits and the signing of Nurses Narcotic Checklist by two (2) nurses (LPN #2 and LPN #11), the oncoming and off going, at shift change verifying that the narcotic count was correct. The facility remained out of compliance at a Scope and Severity level "E", a pattern deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility will remain out of compliance to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Improvement and Assessment Committee. Findings Include: The facility provided an Allegation of Compliance (AoC) that was accepted on 09/07/11. CMS authorized the State Agency (SA) to conduct a revisit in order to determine if corrective actions implemented by the facility have been able to demonstrate removal of the immediate jeopardy. Allegation of Compliance: "On August 5, 2011, a 100% audit was conducted on all MARs and physician(s) orders by LPN #2 and LPN #15 to ensure that all medications were given as ordered by the physicians. On August 5, 2011, a 100% audit was conducted on med cart B and med cart C by LPN #2 and LPN #15 to verify all narcotics were accounted for. The outcome of the audits identified no missing medications, all narcotics were accounted for in the audit, and there were no discrepancies identified. The results of these audits revealed there was no harm to the residents. On August 5, 2011, a 100% audit was conducted reconciling the MARs to the physician (s) orders for resident #1 to ensure that all medications were given as ordered by the physician(s). The audit was conducted by the Director of Nursing. On 7/15/11, [MEDICATION NAME] 7.5 milligram at 9 am was not documented as being administered on MAR for resident #1. There was an "x" in the block on the MAR, "x" on back of MAR indicated [REDACTED]. According to nurses notes on 7/15/11, at 8 am, resident was transported out of facility to dental clinic and returned at 12:05 pm on 7/15/11. Resident was not in facility on 7/15/11 at 9 am to receive [MEDICATION NAME] medication. On 7/7/11, 7/8/11, 7/13/11, 7/14/11, and 7/23/11 according to MAR, resident #1 did not receive [MEDICATION NAME] 7.5 mg at 1 am. LPN #4 initialed and circled block on MAR for 7/7/11, 7/8/11, 7/13/11, 7/14/11, and 7/23/11 indicating resident refused medication. LPN #4 did not document on back of MAR indicated [REDACTED]. Medication error report completed by DON on 8/11/11 addressing lack of documentation for refusal of medications. The outcome of the audit identified no additional discrepancies. The results of the audit revealed there was no harm to the resident. On August 9, 2011, the resident's physician changed the [MEDICATION NAME] order from a routine medication to a PRN medication. On August 5, 2011, a 100% audit was conducted reconciling MARs to the physician(s) orders for resident #3 to ensure time codes were accurate that all medications were administered as ordered. The audit was conducted by the DON. On 6/5/11, 6/11/11, 6/26/11, 6/30/11, 7/3/11, 7/34/11, 7/10/11, 7/17/11, 7/24/11, 7/30/11, and 7/31/11, according to MAR, resident #3 did not [MEDICATION NAME] mg at 9 pm. On 8/5/11, at 9 am, DON interviewed resident #3 regarding his sleeping patterns in June 2011 and July 2011. Resident #3 stated he did not see a difference in sleep pattern when he did not receive [MEDICATION NAME] nights a week. He also stated he slept good during this time frame. Medication error report completed by DON on 8/9/11 addressing medication error. The outcome of the audit identified no additional discrepancies. The results of the audit revealed there was no harm to the resident. On August 5, 2011, a 100% audit was conducted reconciling MARs to the physician(s) orders for resident #5 to verify MARs matched the physician orders [REDACTED]. The audit was conducted by the DON. On 7/25/11, according to MAR indicated [REDACTED]. There was no documentation on MAR indicated [REDACTED]. On 7/25/11, according to MAR indicated [REDACTED]. There was no documentation on MAR indicated [REDACTED]. [MEDICATION NAME] 30 mg was documented on the Individual Narcotic Record. Medication error report was completed on 8/11/11 by DON regarding documentation of medication administration. Medication error report was completed on 8/11/11 by DON regarding medication error. The outcome of the audit identified no additional discrepancies. The results of the audit revealed there was no harm to the resident. On August 5, 2011, a 100% audit was conducted reconciling MARs to the physician(s) orders for resident #7 to verify all medication were administered as ordered and all meds were accounted for. On 8/5/11, according to MAR indicated [REDACTED]. MAR block was initialed and circled by LPN #5 indicating refusal of medication. LPN #5 did not document on back of MAR indicated [REDACTED]. New physician ordered noted to d/c scheduled [MEDICATION NAME] and continue PRN [MEDICATION NAME]. Medication error report was completed on 8/6/11 by DON addressing lack of documentation for refusal of medications. The outcome of the audit verified that all other medications were administered per orders and all medications were accounted for. The results of the audit revealed there was no harm to the resident. On August 5, 2011, a 100% audit was conducted on all narcotics by the DON on resident #17. On 4/25/11, according to physician(s) orders for resident #1, there were orders noted for [MEDICATION NAME] 10/325 mg 1 by mouth every four hours for pain and [MEDICATION NAME] 10/325 mg 2 by mouth every four hours prn sever pain. Individual Narcotic Record for resident #17 stated [MEDICATION NAME] 7.5/325 mg give 1-2 tablets by mouth every 4 to 6 hours as needed for pain. MAR for April 2011 for resident #17 stated [MEDICATION NAME] 10/325 mg give 1 by mouth every 4 hours prn pain and [MEDICATION NAME] 10/325 give 2 by mouth every 4 hours prn severe pain. MAR for May 2011 for resident #17 stated [MEDICATION NAME] 10/325 mg give 1 by mouth every 4 hours prn pain and [MEDICATION NAME] 10/325 mg give 2 by mouth every 4 hours prn for severe pain. MAR for June 2011 for resident #17 stated [MEDICATION NAME] 10/325 mg give 1 by mouth every 4 hours prn pain and [MEDICATION NAME] 10/325 give 2 by mouth every 4 hours prn for severe pain. MAR for July 1-22, 2011 for resident #17 stated [MEDICATION NAME] 10/325 mg give 1 by mouth every 4 hours prn for pain and [MEDICATION NAME] 10/325 mg give 2 by mouth every 4 hours prn for severe pain. The outcome of the audit revealed all narcotics were accounted for and [MEDICATION NAME] was discontinued on 7/22/11. The results of the audit revealed there was no harm to the resident. According to Individual Narcotic Record for resident #17, on 4/26/11 (facility confirmed that this date should have been 04/30/11) [MEDICATION NAME] count was 44. On 4/30/11 at 8 pm LPN #10 signed out 2 [MEDICATION NAME] leaving count at 42. On 5/1/11 at 8:30 am, LPN #2 signed out one [MEDICATION NAME] leaving count at 41. LPN #2 entered incorrect count for amount on hand column but correct count of 42 was entered for amount remaining. Count in amount remaining column of individual narcotic record remained consistent throughout the remaining documentation on individual narcotic record. Inservices were conducted by the DON with LPNs, RNs, and agency nurses prior to staff being able to provide resident care on August 5, 6, and 7, 2011, on ordering, receiving of medications, storage of medications, accounting of medications, accuracy of narcotic cards each shift, wasting of narcotics, refusal of medications, pain management, notifying DON and Administrator immediately of discrepancies in meds. No LPN, RN, or agency nurse will be allowed to work until they have been inserviced. All residents have the potential to be affected by this practice. A 100% audit of all MARs, individual resident narcotics records, controlled drug package inventory drug sheets, narcotic shift count sheet, and reconciling drug delivery sheets to mediation oder (order)/reorder forms are being audited daily beginning August 5, 2011, for four (4) weeks and a 10% audit weekly thereafter by the DON or his designee. Any discrepancies will be taken to the Administrator and DON for resolution, who in turn, will refer them to the QA & I Committee. A directed in-service was conducted for all staff on August 23, 2011 by Attorney General Investigator #1 relating to inconsistent documentation, abuse, neglect, and exploitation of vulnerable adults. On 8/15/11, the QA & I Committee met and discussed all aspects of medication administration. Member present in the 8/15/11 QA & I Committee meeting were Medial Director #1, DON #1, Administrator #1, MDS RN #1, the Medicare Nurse Case Manger #1, the Social Services Director #1, the Medical Records Nurse #1, Outside Consultant #2, Dietary Manager #1, and Activities Director #1. Residents #1, #3, #5, #7 and #17 suffered no adverse affects. LPN #1 (facility staff confirmed that this should have been LPN #4, not LPN #1) was counseled and an employee warning report was completed in regard to not following proper policies and procedures on 8/7/11. LPN #8 was not employed at time of survey. LPN #2 and LPN #10 were counseled and employee warning reports were completed regarding not following proper policies and procedures. All residents received the appropriate medications." The aforementioned information is as quoted in AoC. Review of the AoC with the Administrator, Director of Nursing and Outside Consultant #2 was conducted on 09/08/11 beginning at 09:00 a.m. and revealed the following information was validated: Validation of the review of statements from LPN #2 and LPN #15 dated 08/05/11 revealed that they had conducted a 100% audit of MAR's and Physician order [REDACTED].#2 and LPN #15 confirmed that all MAR ' s and Physician order [REDACTED]. Validated was a Directed Inservice training conducted for nursing staff, to include agency staff, by Outside Consultant #1 on 08/08/11 regarding proper implementation of physician orders. Validated was audit statements dated August 5, 2011 for the MARs conducted by LPN #2 and LPN #15 were reviewed. Copies of statements regarding Med Cart B and Med Cart C were witnessed by Administrator. Administrator stated no additional issues were found. Validated was an audit for Resident #1 which revealed a statement from the DON dated 8/5/11 with no additional issues identified. 07/15/11 [MEDICATION NAME] was not documented as administered to Resident #1. An X on the MAR indicated [REDACTED] Validated was a statement from LPN #4 which revealed that Resident #1's medication were not administered on 07/05/11, 07/07/11, 7/8/11, 7/13/11, 7/14/11 and 7/23/11. That statement revealed "7/5 5a (05:00 a.m.), 7/7 1a (1:00 a.m.), 7/8 1 a (01:00 a.m.), 7/13 1a (1:00 a.m.), 7/14 1a (1:00 a.m.), 7/23 1a (1:00 a.m.). On these dates, at the times listed, (Resident #1) refused to take her scheduled med (medication) as prescribed." The DON stated he had talked with the resident (date unknown of when he talked to Resident #1) who said she had always gotten her medication ([MEDICATION NAME] 7.5 mg one every four hours) and a medication error report dated 08/11/11 for omission (of scheduled [MEDICATION NAME]) on MAR/refusal of [MEDICATION NAME] was reviewed. (Note: dates noted in LPN #4's statement differ from dates noted in LPN #4's disciplinary action). Validated was disciplinary action for LPN #4 which was a warning with suspension for failure to improve. The DON stated that LPN #4 was suspended and eventually had employment terminated on 8/12/11 due to failure to follow policy and procedure. A Medication Error Report dated 08/11/11 revealed that LPN #4 had "Resident refused [MEDICATION NAME] on 7/8/11, 7/13/11, 7/14/11, 7/23/11, & on 7/15/11 omission on MAR indicated [REDACTED]. (Note: dates noted in LPN #4's statement differ from dates noted in LPN #4's disciplinary action). The DON stated no harm/adverse effects were contributed to Resident #1 due to the lack of Receiving [MEDICATION NAME] and on 08/09/11 the [MEDICATION NAME] 7.5 mg order was changed to be administered every four hours as needed. Validated was a 100% audit that was conducted by the DON on 08/05/11 and revealed no additional problems for Resident #3. Resident #3 now has an order for [REDACTED]. Validated was that medication error reports were completed for LPN #4 on 08/11/11(regarding Resident #1), LPN #5 on 08/06/11 (regarding Resident #7) and LPN # 10 on 08/11/11 (regarding Resident #5). Validated was that the Medication Error Report revealed the error to be "Ambien ordered every HS (at hour of sleep). This was coded on MAR for a drug holiday on Sundays. Dosage missed on Sundays for June & July was for total of (12) missed doses." Validated was an Employee Warning Report for LPN #10 dated 08/05/11 was reviewed and revealed: "LPN did not admin (administer)[MEDICATION NAME] ordered on [DATE], 6/12 (11), 6/26 (11)/7/10 (11), 7/24 (11), 7/31 11. 3/11/11 signed for [MEDICATION NAME] ii (2) tabs then placed line through entry. 0 (no) documentation as to why did so. On 3/30/11 did not add card to card count." Validated was an Employee Warning Report for LPN #4 dated 08/05/11 revealed "Nurse did not [MEDICATION NAME] ordered on 6/19 (11)& 7/17 (11). Inserviced verbally regarding P & P (policy and procedure) for admin of meds." Validated of a review of an Employee Warning Report dated 08/05/11 for LPN #5 revealed "Employee circled [MEDICATION NAME] on resident MAR indicated [REDACTED]. On 8/4/11 Nurse circled resident 12 MN (midnight) [MEDICATION NAME] et did not document reason why. Did not [MEDICATION NAME] ordered on [DATE]." Validation of a review of a Medication Error Report dated 8/10/11 for Resident #5 revealed "Nurse did not sign for administration of the Trazadone & [MEDICATION NAME] 30 mg". That document was signed by LPN #10. Validation of a review of the Nurses Notes for Resident #7 revealed a notation "8-5-11 1055 pm withheld 12 am [MEDICATION NAME] because resident sleeping unable to arouse." That entry was signed by LPN #5. Validation of a review of an Employee Warning Report dated 8/5/11 revealed "Employee circled [MEDICATION NAME] on resident's MAR indicated [REDACTED]. On 8/4/11 Nurse circled resident's 12 MN [MEDICATION NAME] et did not document reason why. Did not [MEDICATION NAME] ordered on [DATE]." That document was signed by LPN #5. Validation of a review of a Medication Error Report dated 8/10/11 revealed "Resident refused her 12 midnight [MEDICATION NAME]. Nurse documented by circling entry on the MAR but did not document additional information needed." That document was signed by LPN #5 on 08/10/11. LPN #10 designated that she was an agency nurse. Validation of an audit was conducted by the DON on 08/05/11. This was in reference to the [MEDICATION NAME] order for Resident #17. He stated he could not verify whether there was a label discrepancy or an actual mediation error because he did not have the medication card for review. He stated he only had the narcotic sheet and MAR but did not complete a medication error report because he could not 100% verify the [MEDICATION NAME] administration was wrong. He stated that LPN #2 had conducted inservices. Validation of a review of an Employee Warning Report for LPN #1 dated 8/5/11 revealed "Date of violation 3/21/11 1230 am Nurse indicated on narcotic record on 3/21/11 [MEDICATION NAME] wasted s (without) additional documentation. Not following medication disposal P & P." That document was signed by LPN #1 on 08/07/11. Validation of a review of an Employee Warning Report for LPN #10 dated 08/05/11 revealed "Date of Violation 7/29/11 LPN signed on a line of an individual narc (narcotic) record for admin (administration) of a med where another nurse had already signed on line et not voided signature out." LPN #10 signed that document on 08/05/11. Validation of an audit was conducted on 8/5/11 by LPN #2 and LPN #15 for Resident #8, #12, #15, #17, and #19 with no evidence of misappropriation of drugs. Validation of a review of an Employee Warning Report for LPN #2 dated 08/05/11 revealed "Date of Violation 7/29/11 Nurse signed her name on wrong line of individual narc record. Did not void it out as should have." LPN #2 signed that document on 08/05/11. Validation of a directed Inservice was conducted on 08/23/11 by a staff member of the Attorney General's Office. The Administrator stated that she had requested for the Nurse Investigator from the Attorney General's Office to present an inservice, however, the Nurse Investigator was not available at this time. The inservice that was conducted covered the subjects of documentation, abuse, neglect and exploitation. Validation of The Quality Assurance and Improvement Committee met on 08/15/11. Signature sheet was provided. The Administrator stated that they went over in detail the results of the current survey, the plan of action and monitoring. There will be a new Pharmacy Consultant visiting the facility. The State Board of Pharmacy visited the facility after 08/19/11 and a Pharmacy Consultant will be attending the upcoming QA &I Committee meeting to be held on 09/12/11. The Administrator stated that there were no adverse effects because of the medication errors by LPN #2, LPN #4, LPN #8 and LPN #10 for Resident #1, Resident #3, Resident #5, Resident #7, and Resident #17 but all of those LPN's were disciplined (Disciplines were conducted for LPN #2 on 8/5/11, LPN #4 on 8/4/11, LPN #8 was not employed at time of survey on 9/8/11, and LPN #10 on 8/5/11). Further validation revealed: LPN #1 disposed of a [MEDICATION NAME] for Resident #8 and did not obtain a witness. DON stated that LPN #11 was no longer employed at the time of the survey (9/8/11). LPN #1 disposed of a [MEDICATION NAME] 7.5 mg, for Resident #12, on 03/21/11 at 12:30 p.m. with no witness and was counseled by the DON with a warning on 08/05/11. LPN #2 disposed of a [MEDICATION NAME] 7.5 mg for Resident #12 with no witness on 08/03/11. LPN #2 initialed on the incorrect line on Resident #14 medical record dated 7/29/11 and did not void it out. She was given a Disciplinary warning on 8/5/11 and inserviced on 8/8/11 on documentation and the proper way to sign out medication. Based on verification of the facility's corrective actions that was validated by staff interviews, observation, record review and inservice reviews, the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on 09/07/11 to an "E" level, which constituted no actual harm with potential for more than minimal harm to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance and Improvement Committee.

CI MS # 9680 Based on Administrative review by Centers for Medicare and Medicaid Services (CMS) a new complaint investigation was conducted to investigate the status of missing medications and narcotics. Additional information was gathered on 08/17/11. The partially extended survey was concluded on 08/17/11. Based on observation, record review, staff interview and policy review, the facility failed to ensure that the process of acquiring, receiving, storing, controlling and reconciling of medications was followed. This was evidenced by inconsistencies in documentation of narcotic count reconciliation, disposal of narcotics, and failure to ensure that the Medication Reorder form and the Delivery List was reconciled for accuracy. This is for two (2) of 2 medication carts and five (5) of 21 residents reviewed (Residents #12, #8, #15, #17, and #19). The facility's failure to ensure that a process of identifying, evaluating and addressing medication related issues related to the prevention and reporting of medication inconsistencies. This was confirmed by review of forms for Cart B, Cart C, Cabinet and the Emergency Box Requisition. This was evidenced by inconsistent documentation by two (2) nurses (LPN #2 and LPN #10) for the reconciliation of narcotic medications at the shift change, incorrect narcotic counts, reorder forms for medications not reconciled for medications ordered and delivered, count of syringes ABHR (Ativan, Benadryl, Haldol, Reglan) containing medications not correct, Fentanyl Patches wasted by Hospice not matching that which was wasted, inconsistency of two (2) licensed nurses(LPN #2 and LPN #10) witnessing the disposal of narcotics. During the complaint survey that was concluded on 01/06/2010 it was determined that 2445 Lortab (a controlled medication used for the treatment of [REDACTED]. The facility did not ensure that medications that were ordered and delivered from the pharmacy was signed in at the time of the delivery. Review of the Plan of Correction submitted to the State Licensing Agency with a date of signature by the Administrator of 02/05/10, and a correction date of 02/19/10, revealed the PoC to state: "Alleged misappropriation of medications were reported to the MSDH (Mississippi State Department of Health), Attorney General's Office Baord (Board) of Pharmacy and Board of Nursing." "All residents have the potential of being affected." "The following measures will be implemented: a)Reordering of medications: 11/7 shift nurse will check medications for reorders two times per week, Thursday and Sunday to ensure there is sufficient medication available. Medications identified to be reordered will be logged on " Mediation Order Form, NS 637" and faxed to the appropriate pharmacy. Medication reorder Form will then be placed in the Medication Reorder binder along with fax confirmation. b)Receiving of Medications: Medication label will be checked by 11/7 shift nurse for accuracy to include: Resident Full name, physician name, prescription number, Drug name and strength, Number of Tablets or Amount of liquid, directions for administration, Expiration day, caution label on controlled Substances or accessory labels, NDC (National Drug Code) Code, & Pharmacists initials. After checking for accuracy medication quantity received along with nurses initials will be documented on "Medication Reorder Form ". At any time between medication reorder checks there is an order change, it will be documented on "Medication Reorder Form" and faxed to the necessary pharmacy. If medications are received on "Cycle Fill Order" the delivery sheet from the pharmacy will be received and reconciled with physician order to ensure accuracy per medication floor nurses. Medications that have been discontinued will be sent Back to the pharmacy immediately. Delivery sheet From pharmacy will be placed in the mediation (medication) reorder Binder after reconciliation. When medications that are narcotics are delivered they will be added to the narcotic count. All appropriate medications will be placed in lock up and counted at end/beginning of each shift. Nurses have been inserviced that Any discrapancy (discrepancy) in Count will be immediately reported to the DON (Director of Nursing) and/or Administrator. Medication delivery sheets will forwarded to the DON Then the DON will reconcile medication delivery sheets with medication reorder form to ensure that all medications Ordered have been delivered and appropriate medications Delivered have been added to lock up." During the investigation, the facility was found not to be in compliance with the requirements of Medicare and Medicaid Requirements. A partially extended survey was conducted on 08/03-07/11. An Immediate Jeopardy was identified on 08/05/11 at 12:50 p.m. The Administrator and the Director of Nursing (DON)were notified at that time. The Immediate Jeopardy was determined to begin on 04/30/11. The facility submitted an Allegation of Compliance on 08/07/11 and it was determined not acceptable. The Immediate Jeopardy (IJ) was not removed upon exit from the facility on 08/17/11 and is considered on going. Findings Include: There was no documented evidence provided during the survey that: 1. Medication labels were checked by the 11:00 p.m. to 07:00 a.m. shift nurse for accuracy. 2. After checking for accuracy medication quantity the nurses did not document on the "Medication Reorder Form". 3. The delivery sheets from the pharmacy were reconciled with the physicians order to ensure accuracy. 4. All medications that were narcotics were added to the narcotic count. 5. All appropriate medications were placed in the lock up and counted at end/beginning of each shift. 6. Medication delivery sheets were forwarded to the DON for reconciliation of the medication delivery sheets with medication form. Resident #12 Review of Resident #12's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #12's "INDIVIDUAL RESIDENT NARCOTICS RECORD" with a beginning date of 03/12 and an ending date of 08/03/11 revealed that on 3/21 (11) at 12:30 a.m. there was a Lortab 7.5 milligram (mg) tablet wasted without a second nurse witnessing the waste. On 08/03(11) a Lortab 7.5 mg tablet was "popped by mistake-wasted" without a documented time or second nurse witnessing the disposal of the tablet. Resident #8 Review of Resident #8's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Resident #8's July 2011 computerized Physician's Orders revealed an order dated 03/23/09 for LORTAB 10/500 MG 1 PO (by mouth) Q (every) 6 HRS (hours) PRN (as needed) PAIN. Review of "INDIVIDUAL RESIDENT NARCOTICS RECORD" for Resident #8's Lortab, with a beginning date of 01/30(11) revealed that a Lortab was wasted on 05/03/11 due to being punched out. There was no milligram amount noted on the record and no second nurse witnessing the waste of the Lortab. Review of the facility policy "Drug-Controlled Substances" with a "Latest Revision: 11/10" revealed: Page 1 of 2: "Controlled medications are to be signed out in the narcotic book at the time they are to be administered." Page 2 of 2: "When disposing of controlled medications, whether by necessity, (i.e. refused or withheld dose) or error, indicate the disposal date, time, resident's name, drug amount wasted, nurse's signature, and the witness and signature of another nurse." "A controlled drug count is to be done at the beginning of each shift by the outgoing and the on-coming medication nurses. This will include counting and documenting number of Med Cards (containers). All controlled drugs and containers are to be accounted for and the narcotic count sheet signed by both nurses." Resident #15 Review of Resident #15's medical record revealed an admission date of [DATE]. A handwritten physician order on 07/14/11 revealed an order for [REDACTED]. Review of Resident #15's "Individual Resident Narcotics Record" for Ultram 50 mg 1 PO q 4(hours) PRN with a beginning date of 07/20/11 revealed that on 07/29/11 at 04:00 p.m. two (2) nurses signatures were in the section of "NAME OF PERSON GIVING". There was a line drawn through one (1) of the nurses name and the date. Another nurses signature was noted to the left of the first signature. Interview with LPN #2 and LPN #10 on 08/05/11 at 03:15 p.m. related to Resident #15's documentation on the Ultram "Individual Resident Narcotics Record" revealed that LPN #2 stated "I started to sign the med (medication) out on the wrong line -should have been on one above (line)". LPN #10 stated that, "I just used the same line the same day". Resident #17 Review of Resident #17's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #17's computerized Physician Orders with a date of April 2011 revealed orders for "4/25/11 PERCOCET 10/325 MG 1 PO Q 4 HOURS PRN-PAIN" and "4/25/11 PERCOCET 10/325 MG GIVE 2 PO Q 4 HOURS PRN ---SEVERE PAIN". Review of Resident #17's "INDIVIDUAL RESIDENT NARCOTICS RECORD" with a beginning date of 4/26 (11) revealed that on 4/30/11 at 08:00 p.m. there was a count of 44 Percocet 7.5/325 mg tablets "with two given which left 42 remaining tablets. On " 5/1/11 " there was a beginning count of 43 with 1 administered which had a documented amount of 41 remaining tablets. The count remained out of sequence for the remaining documentation with no reason documented why the count went from 44 to 42 to 43 Percocet 7.5/325 mg tablets being counted. (Note: not only was the count out of sequence the physicians order did not match the pharmacy label for the Percocet.) Review of a facility policy "Medication Reordering and Receiving Procedures (F-425)" with a latest revision date of 08/08 revealed on Page 1 of 2: "A. Reordering Medications: Medications will be checked and reordered the same day(s) each week. Facility is responsible for setting the day(s) for medications to be checked for reorder. *The nurse on the 11-7 shift will be responsible for checking medications for reorder. *As medications are checked, any reorders will be recorded on the "Medication Order Form" or if double labeled, on the label sheet provided by the pharmacy, or the company form if pharmacy does not provide their own reorder form. Be sure to number each page. *On the established medication check day (i.e., Sunday night) the 11-7 (10-6) nurse will check all medications, not just punch cards, and reorder any medications that need to be recorded on appropriate form. *At the end of the shift, after all medications have been checked, the reorder will be faxed to the appropriate pharmacy. *A copy of the form will be retained in the medication reorder binder with the fax confirmation. B. Receiving Mediation (Medication): At time medication is delivered or received by facility the following procedure will be followed: 1. Check label for accuracy: *Resident's full name * Physician's name *Prescription number *Drug name and strength-(both name brand and generic name, if a generic is used.) *Number of tablets or amount of liquid *Directions for administration *Expiration day-no greater than 1 year from date of issuance, if dispensed in container other than original one. *Caution label on controlled substances or accessory labels. *NDC Code (National Drug Code) *Pharmacist's initials (MS) *Pharmacists name (LA)" Page 2 revealed the following documentation: "2. Make certain count is accurate 3. If ordered on Cycle Fill Order List, write in quantity received and initial. 4. If ordered on Medication Order Form, write in quantity received and sign on original which was returned from the pharmacy with the medication. Destroy copy. 5. If ordered on Medication Reorder Form, (NS-637) or Pharmacy's form, initial each label on original form. Destroy Xerox copy. 6. If prescription number has changed, draw a line through old number and insert new number on form. Nurses never write on a medication label." Interview with the Nurse Consultant on 08/07/11 at 2:45 p.m. revealed that there was no original Medication Order Form that was returned to the facility from the pharmacy that would be written on and returned to the pharmacy. There was no documented evidence provided by the facility that nurses checked the Medication Reorder Forms to ensure that the medications that were reordered by the facility were the medications that were received. There was no documented evidence that the nurse checked to ensure that the number of medications reordered was the number of the medications received. Review of documents titled "NURSES NARCOTIC CHECK LIST" with beginning dates of 05/16/11, 06/15/11 and 07/15/11 and ending dates of 06/14/11, 07/15/11 and 08/04/11 revealed that columns for documentation which included : "DATE NURSE ON 7 AM NURSE OFF 7 AM NURSE ON 3 PM NURSE OFF 3 PM NURSE ON 11 PM NURSE OFF 11 PM" The "Nurse's Narcotic Check" list lacked the signatures of nurses for the "NURSE ON 7 AM" on the dates of 05/23/11, 05/27/11, 05/30/11, 06/06/11 and 06/13/11, 06/18/11, 06/20/11, 06/21/11, 06/24/11, 07/04/11, 07/08/11, 07/16/11, 07/17/11, 07/18/11, 07/30/11, 08/01/11, 08/02/11 and 08/03/11. The document also lacked the signatures of nurses for the "NURSE OFF 7 AM" on the dates of 05/17/11, 05/18/11, 05/24/11, 05/25/11, 05/29/11, 05/30/11, 06/15/11, 06/16/11, 06/18/11, and 08/03/11. The document lacked the signatures of nurses for the "NURSE ON 3 PM" on the dates of 05/16/11, 06/06/11, 06/29/11, 07/22/11 and 08/01/11. The document lacked the signatures of nurses for the "NURSE OFF 3 PM" on the dates of 05/23/11, 05/27/11, 06/06/11, 06/13/11, 06/19/11, 06/24/11, 06/27/11, 07/02/11, 07/03/11, 07/04/11, 07/08/11, 07/11/11, 07/16/11, 07/18/11, 07/21/11, 07/30/11, 08/01/11, 08/02/11, and 08/03/11. That document lacked the signatures of nurses for the "NURSE ON 11 PM" on the dates of 05/16/11, 05/17/11, 05/24/11, 05/29/11, 06/14/11, 06/15/11 and 06/17/11. That document lacked the signatures of nurses for the "NURSE OFF 11 PM" on the dates of 05/29/11, 05/30/11, 06/06/11, 06/07/11, 06/08/11, 06/09/11, 06/14/11, 06/18/11, 06/19/11, 06/23/11, 06/29/11, 07/01/11, 07/03/11, 07/22/11, 07/29/11, and 08/01/11. Review of another document titled "NURSES NARCOTIC CHECK LIST" revealed that the first two lines were blank and the third line contained the date of 08/03/11. There was no signature in the column for "NURSE ON 7 AM", "NURSE OFF 7 AM", "NURSE OFF 3 PM". The next entry was dated 08/04/11 and revealed no signature in the column for "NURSE ON 7 AM". Those were the only dates documented on that form. Review of a document "DELIVERY SHEETS" with a date of 07/29/11 revealed that Hydrocodone 120 tablets were delivered to the facility and a nurse signed the "DELIVERY SHEET" on 07/30/11 at 03:15 a.m. There was no documented evidence that the Hydrocodone 120 tablets were added to the cart count or that an "INDIVIDUAL RESIDENT NARCOTIC RECORD" provided during survey for the Hydrocodone that was delivered on 07/30/11 for Resident #12. Review of a document "MED CART B" revealed columns for "DATE", "MED'S REMOVED/REPLACED", "# OF CARDS", "# OF VIALS","# OF PATCHES", "# OF SYRINGES", "# OF BOTTLES". The beginning date was 07/02/11 and last date on the document was 07/09/11. The dates did not flow numerically -the documentation revealed the dates to be: 07/02/11 07/03/11 07/04/11 07/05/11 07/06 07/06 07/06/11 07/06/11 02/06/11 02/07/11 02/07/11 07/07/11 07/07/11 Review of a document tilted "MED CART B" with a beginning date of "07/28" and an ending date of "08/02/11" revealed the following count: "Cart" was in the column for "MEDS REMOVED/REPLACED" Column for "# OF CARDS" was documented as 50" "08/01(11)- # OF CARDS" was documented as "50" "08/01(11) -# OF CARDS" was documented as "49" There was no documented evidence of why the count went from 50 to 49. Review of a document titled "MED CART B" with a beginning date of 06/27/11 and an ending date of 06/29/11 revealed: "06/28/11 Fentanyl patch 100 mcg (microgram)-18 rem (removed)". Documentation on a "PRESCRIPTION DRUG INVENTORY FOR DESTRUCTION" form with a date of destruction of 07/26/11 revealed that Fentanyl 100 mcg x 17 was destroyed with the DON and the Pharmacist. Resident #19 Documentation on Resident #19's "INDIVIDUAL RESIDENT NARCOTICS RECORD" revealed that a total of 16 patches were destroyed with the DON and the Pharmacist on 07/26/11. That left a discrepancy of 18 patches removed on 06/28/11 and 17 destroyed, or 16 destroyed (according to the documentation on the "INDIVIDUAL RESIDENT NARCOTIC RECORD") on 07/26/11. Review of a document titled MED CART B with a beginning date of 06/16/11 and ending date of 06/21/11 revealed: "06/20/11 - # OF SYRINGES 17 06/20/11 - # OF SYRINGES 16" There was no documented evidence of the disposition of the missing syringe. Review of document titled MED CART B with a beginning date of 6/21/11 revealed: "06/21/11 - # of SYRINGES 15 06/21/11 - # OF SYRINGES 14" There was no documented evidence of the disposition of the missing syringe. Review of a document titled MED CART B with a beginning date of 06/24/11 and an ending date of 06/27/11 revealed: "06/26/11 - # OF SYRINGES 14 06/26/11 - # OF SYRINGES 13" A notation was written on the next line "completed i (one) sm (small) ABHR syringes leaves syringes at 13". Review of a document titled MED CART B with a beginning date of 06/29/11 and an ending date of 07/03/11 revealed: "06/29/11 - # OF PATCHES 19 06/30/11 - # OF PATCHES 17" There was no documented evidence detailing the disposition of the two missing patches. Review of a document titled MED CART B with a beginning date of 06/24/11 and ending date 06/27/11 revealed the number of "bottles" to be five (5) on 06/27/11. The next entry was on a page dated beginning 06/29/11 and ending 07/03/11 where the total number of bottles was documented as two (2) with no explanation of what happened to the other three (3) bottles that had been included in the count on 06/24/11. The count of bottles remained as two (2) until 07/05/11 when one (1) bottle was added making a total of three (3). Review of a document titled MED CART C with a beginning date of "04/21" and an ending date "04/26" revealed the dates to not be in sequence. The dates went from April to February back to April. The documentation revealed that on 02/24 the number of cards was documented at 47 and on that same date the number of cards went from 47 to 48 with no documentation that a narcotic card was added to the count. Review of a document titled "MED CART C" with a start date of "07/12" and an ending date of "07/16" revealed that there were 54 cards of narcotics on 07/16. Another entry dated 07/16 documented that there was 56 cards of narcotics and there was no documented evidence that narcotic cards had been added or deleted from the narcotic card count. Interview with the DON on 08/04/11 at 1:40 p.m. revealed that the " Nurses Narcotic Checklist " went away when the policy " Drug Controlled Substance " was revised in November 2010. " The Med Cart sheet is not a company form. " When the DON was asked where the on-coming/off- going nurses would document the narcotic count at shift change he called the nurse consultant. He asked her where the narcotic count sheet was that the nurses should document where the on-coming/off-going nurses would sign that they had completed the narcotic count. There was no document provided during the survey that would ensure that on coming/off going nurses would document that they had counted the narcotics for accuracy. Interview conducted on 08/05/11 at 5:45 p.m. with LPN #2 confirmed that she had worked the night shift on occasion. She stated that when the medications arrived at the facility on the night shift a sheet was signed and sent back to the pharmacy. There was one (1) nurse working on the night shift (11:00 p.m. to 07:00 a.m). The driver, in conjunction with the on duty nurse would count the medications that were delivered on the night shift. Narcotics were to be placed in the medication cart immediately after being logged into the appropriate narcotic book. Interview conducted on 08/05/11 at 6:25 p.m. with LPN #4 confirmed that she had worked the 11:00 p.m. to 7:00 a.m. shift at the facility and had received medication deliveries from the pharmacy on that shift. She stated that when she first started working the night shift she and the courier would count the medications together. After the first two (2) to three (3) nights the courier informed her that it was not his responsibility to stay and inventory the medication cards that he delivered from the pharmacy. He told her that she needed to sign the document he provided so he could go on about his deliveries. When asked if she checked the medications by a list of medications that were reordered the response was "No, just check the list to be sure that what they sent is what they say they sent." She stated that she had been oriented to night shift but never received any training on the Policy and Procedure for receiving medications. She stated that she put the locked medications away first then put the other medications away. Interview was conducted on 8/17/11 at 10:05 a.m. with Consultant Pharmacist #1 who stated that she had been visiting at the facility for the previous three months. She stated that the first month she came she reviewed, glanced at, the narcotic records. " Unless I know they had Ian issue I just do an audit. Knew issue in the past but thought resolved. No one told me to look for problems. " She stated she would look for things that required signatures such as the back of the Medication Record. Interview with Consultant Pharmacist #2 on 8/17/11 at 1:38 p.m. revealed that he had been requested to come to the facility and performed a complete regime review. Interview was conducted with the Consultant Pharmacist #3 on 8/17/11 at 2:05 p.m. (who was responsible for the facility at the time of the 01/10 survey). She stated she "kinda remembered the incident. Changed how nurses signed off at shift change. Not like just missing -just realized she was only one signing out for patients that never got it." "Talked with (Previous DON at time of incident) and did not set up any additional procedures. Talked about prns, not doing the pain scale." She stated that she was not sure if she was notified when QA meetings were held. Interview and review of the orientation checklist for licensed nurses with the DON on 08/17/11 at 2:45 p.m., confirmed training in pharmacy policies and procedures to include ordering, discontinued, emergency drug kit, controlled drugs and appropriate storage of drugs. Interview was conducted with the Medical Director (who was the same Medical Director during the 01/10 survey) on 8/17/11 at 4:20 p.m. He stated that he was not made aware of the Lortab theft until the nurse was arrested. He was unaware of the issue. He did not recall the facility seeking input from him regarding the issue of missing narcotics. Interview with the DON on 08/17/11 at 5:00 p.m. revealed that the last inservice conducted by the pharmacist was on 04/27/10, and the DON had conducted an inservice on 06/24/11. The content of both inservices included ordering medication, drug storage, receiving medications, Emergency Drug Kit and the Administration and documentation related to medications.

CI MS #8573 Based on record review, interview and policy review, the facility failed to ensure that a significant medication error did not occur for one (1) of five (5) residents reviewed (Resident #1). Resident #1 had an order for [REDACTED]. The times of administration documented on the Medication Administration Record (MAR) were listed as every six (6) hours. Resident #1 was given the incorrect dosage of [MEDICATION NAME] (an antiarrythmic medication) from [DATE] to [DATE] every six (6) hours, and not as ordered every 12 hours. Licensed Practical Nurse (LPN) #1 found the error on [DATE] and the time codes were changed to every 12 hours on [DATE]. The prescribing physician (MD #1) was not notified of the medication error until [DATE] at 4:00 p.m. At that time the medication order was changed and an order given to check Resident #1's pulse and blood pressure every two (2) hours until her appointment on [DATE] with MD (#1). There was also an order [REDACTED]. Resident #1 was monitored every two (2) hours beginning on [DATE] without incident until [DATE]. Resident #1 was found on [DATE] at 6:30 a.m. with no pulse, no respirations and non-responsive. A Full Code was initiated and the Resident was transported to the hospital emergency room (ER) and was pronounced dead at 7:19 a.m. The "Certificate of Death" listed the cause of death as "Cardio-Respiratory Arrest" and [MEDICAL CONDITIONS]". There were eight (8) licensed nurses that had documented administering the incorrect dosage of [MEDICATION NAME] to Resident #1 from [DATE]-[DATE]. The eight (8) licensed nurses did not follow policy and procedure for checking the medication dosage prior to administration. Review of the "2010 Nursing Handbook" revealed that [MEDICATION NAME] is an antiarrhythmic medication that is used for treatment and prevention of supraventricular arrhythmias that haven't responded to conventional treatment. Initial dosage is [PHONE NUMBER] mg/day in ,[DATE] divided doses for ,[DATE] weeks and after the arrhythmia is controlled the dosage is reduced to ,[DATE] mg/day for about four (4) weeks. Maintenance dosage is ,[DATE] mg daily. Adverse reactions could include serious, potentially fatal [MEDICAL CONDITION] toxicity, [MEDICAL CONDITION], and worsening or new arrythmia. The facility's failure to ensure that a significant medication error did not occur for Resident #1 from [DATE]-[DATE] was deemed as Substandard Quality of Care and an Immediate Jeopardy (IJ) on [DATE] at 4:55 p.m. to begin on [DATE]. The Administrator was notified at that time. The facility provided a Credible Allegation of Compliance (AoC) on [DATE] at 10:30 a.m. Based on the verification of the facility's implementation of corrective actions the Immediate Jeopardy (IJ) was removed on [DATE] and the scope and severity was lowered to a "D" level which constitutes no actual harm with a potential for more than minimal harm to allow the facility to monitor the effectiveness of the corrective actions through their Quality Assurance Program. Findings Include: The State Agency received a written complaint on [DATE] regarding an allegation that Resident #1 had received the wrong dosage of medication while at the facility and had "coded and died on [DATE]". Record review revealed that Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 had Aortic Valve Replacement and Coronary Artery Bypass Graft on [DATE]. Resident #1 was readmitted to the facility on [DATE] (after the heart surgery). Review of a "Chart Review" from (hospital) dated [DATE], on page 10 of 16, revealed that Resident #1 was alert and oriented x 3. It also revealed that Resident #1 was severely deconditioned and malnourished and approaching end-stage heart failure and was a marginal surgical candidate under the best of circumstances. Impression included: "Decompensated [MEDICAL CONDITION], Severe [DIAGNOSES REDACTED], Moderate to severe [DIAGNOSES REDACTED], Coronary Occlusive Disease, Severe Left Ventricular Systolic Dysfunction with an estimated ejection fraction of 25%, Moderate [MEDICAL CONDITION] HTN, Extensive Dental Caries, HTN, Deconditioned and Malnourished State, and Severe [MEDICAL CONDITION]". Review of an "Operative Report" dated [DATE] revealed that Resident #1 had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an assessment reference date (ARD) of [DATE] revealed that Resident #1 had modified independence in cognitive skills for daily decision making with some difficulty in new situations only. The MDS documented that Resident #1 had a Durable Power of Attorney/Health care but was responsible for himself/herself. Review of Resident #1's physician's orders [REDACTED]. [MEDICATION NAME] is an antiarrhythmia medication. Review of the [DATE] Medication Administration Record (MAR) for Resident #1 documented directions to administer [MEDICATION NAME] 400 mg every 12 hours but the time code section was documented for 12:00 a.m., 6:00 a.m., 12:00 p.m. and 6:00 p.m. The MAR documented that [MEDICATION NAME] 400 mg was administered three (3) times on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]; four (4) times on [DATE] - [DATE] and [DATE]. The MAR time codes were changed on [DATE] for [MEDICATION NAME] 400 mg every 12 hours to 9:00 a.m. and 9:00 p.m. This was documented as given twice on [DATE] and once on [DATE] at 9:00 a.m. and " hold " was documented for the 9:00 p.m. time. The [DATE] MAR revealed that eight (8) different nurses had administered [MEDICATION NAME] to Resident #1 from [DATE]-[DATE]. A new order was noted on [DATE] to hold the [MEDICATION NAME] 400 mg orally every 12 hours for that night and restart in the morning. The strength was changed to 200 mg orally every 12 hours. There was an order to check the heart rate and blood pressure every two (2) hours until appointment on [DATE] at 10:30 with the physician. The order stated "If heart rate goes below 40 notify (MD#1) regardless of the hour." Review of the MAR revealed documentation [MEDICATION NAME] 200 mg given twice on [DATE]. Review of a physician's orders [REDACTED]. Review of the [DATE] MAR for Resident #1 revealed documented blood pressures and apical pulse every two (2) hours beginning at 7:00 p.m. on [DATE] and ending on [DATE] at 5:00 a.m. The pulse rate ranged from ,[DATE] beats per minute and the blood pressure ranged from ,[DATE] millimeters of mercury (mm/hg) to ,[DATE] mm/hg. Review of a "Documentation Record" for Resident #1 dated [DATE] and [DATE] revealed no documentation of changing the medication times for the [MEDICATION NAME] and no documentation that the Resident/Responsible Party or Physician was notified that the resident was getting [MEDICATION NAME] 400 mg every six (6) hours instead of the ordered every 12 hours. There was no documented assessment of Resident #1's condition related to the discovery of a medication error. Review of a "Documentation Record" dated [DATE] at 4:00 p.m. revealed that Resident #1 had a bradycardic heart rate of 42 beats/minute and blood pressure of ,[DATE] mm/hg. Review of the MAR revealed a clarification order for the [MEDICATION NAME] was implemented on [DATE]. There was no documentation that the Cardiologist was notified until [DATE] (2 days after the medication error was found.) The Cardiologist (MD #1) was notified with new orders to hold the [MEDICATION NAME] that night and restart the next day at 200 mg. every 12 hours and to check Resident #1's heart rate and blood pressure every two (2) hours and if the heart rate fell below 40 mm/hg to immediately notify the physician. Resident #1 was notified on [DATE] at 7:30 p.m. about the medication discrepancy and of the interventions and verbalized understanding. There was no documented evidence that Resident #1's primary physician (MD #2) or the Director of Nurses (DON) was notified when the medication error was discovered as per facility policy. Review of the Nurse's Note dated [DATE] revealed from 1:00 a.m. to 6:00 a.m. that Resident #1 was responsive and pulse/blood pressure were taken every two (2) hours. At 6:30 a.m. the documentation revealed that Resident #1 was not responsive, no breath sounds and no pulse. Cardio-pulmonary Resuscitation (CPR) was initiated. Resident #1 was transferred to the hospital per ambulance with CPR in progress at 7:00 a.m. Review of the Death Certificate revealed that Resident #1 was pronounced being expired on [DATE] at 7:19 a.m. with [DIAGNOSES REDACTED]. Review of an "Initial and Quarterly Nursing Data" sheet dated [DATE] revealed that Resident #1 was alert and oriented x 3 (person, place and time) and able to make needs known with clear speech. Review of a "Power of Attorney for Health Care" dated and signed by Resident #1 on [DATE] revealed that the agent's authority became effective when the resident's primary physician determined that the resident was unable to make his/her own health care decisions. Review of a "Social Assessment" dated [DATE] revealed that Resident #1 was responsible for himself/herself with a Durable Power of Attorney/health care. Review of an incident report dated [DATE] revealed that [MEDICATION NAME] 400 mg was ordered twice daily for Resident #1 and was reportedly transcribed one (1) every six (6) hours from [DATE] -[DATE]. The MAR was corrected on [DATE]. The report stated "Received report from (RN #1) of finding error on [DATE] and (MD #1) was notified and new orders received and implemented. The Resident was notified as the Responsible Party on [DATE]. Attending physician was notified per phone, written report and med error report. The State Agency was marked "no " for notification." Review of a "Medication Error Report" dated [DATE] revealed that Resident #1 had orders for [MEDICATION NAME] 400 mg every 12 hours and was given [MEDICATION NAME] 400 mg every six (6) hours from [DATE]-[DATE]. Order adjusted on the MAR on [DATE] and new order [DATE] to decrease to 200 mg every 12 hours. Review of the facility investigation revealed that eight (8) LPN's had given the wrong medication dosages of [MEDICATION NAME] to Resident #1 from [DATE] to [DATE]. LPN #1, LPN #2, LPN #3, LPN #4, LPN #5, LPN #6, LPN #7 and LPN #8 and the Medical Records Director (MRD) had a documented "Employee Warning Report" dated [DATE] for failure to follow the policy and procedure relating to medication administration and medication error policy. An interview with Family Member #1 on [DATE] at 1:30 p.m. revealed that he/she had received information from Friend #1 that Resident #1 had been upset one night because a nurse had come in and told her that the wrong dose of medication had been administered to her and they would have to wake her every two (2) hours. Family Member #1 stated that Friend #1 had confronted one (1) of the nurses and was told "everyone makes mistakes". Family Member #1 stated that two (2) days later Resident #1 was dead. Family Member #1 did not know the name of the nurse that told Resident #1 about the medication error or the specific medication that was administered. Family Member #1 stated that Family Member #2 was the Responsible Party (RP) and that no one had told her of a medication error. Family Member #1 stated that Resident #1 was alert and oriented to person, place and time. Interview with Family Member #2 on [DATE] per phone at 1:55 p.m. revealed that she had Power of Attorney for Resident #1 and had carried a copy of it to the hospital when Resident #1 was there and had assumed that they would give it to the facility. She had also told Resident #1 to make sure the facility had a copy. Family Member #2 stated that Resident #1 was very alert, knew things and was "with it". She stated that Resident #1 had checked herself into the facility and that Friend #1 also had helped the resident with her things. Family Member #2 stated that she had talked to Resident #1 on that Tuesday ([DATE]). Family Member #2 stated that Resident #1 was upset because she was getting some laxatives or something . Family Member #2 stated that she contacted Friend #1 to see if she knew anything about the situation and was told by Friend #1 that on Tuesday, before Resident #1 died on Thursday, Resident #1 had called her and was upset because the staff was waking her every two (2) hours. Resident #1 told her that the reason was that they (facility) had over-medicated her. Family Member #2 stated that she had never talked to anyone at the nursing home, and only talked with Resident #1 by phone. Family Member #2 stated that Resident #1 had several friends in the area. Family Member #1 stated that the only family lived 100 miles away so the friends took care of the resident's needs. Family Member #2 stated that she talked with the resident per phone a couple times per week. Family Member #2 stated that Resident #1 wrote her own checks and took care of everything for herself. Family Member #2 stated that it was Friend #1 who had reported that Resident #1 had expired. Family Member #2 stated that she had not talked to anyone at the facility. Interview with Friend #1 per telephone on [DATE] at 3:15 p.m. revealed that Resident #1 had lived at home alone prior to coming to the Nursing Home and had gotten sick with extreme [MEDICAL CONDITION] in the lower extremities. Friend #1 stated that Resident #1 had [MEDICAL CONDITION], two (2) heart blockages and two (2) leaking heart valves. Friend #1 stated that there was nothing wrong with Resident #1's mind and that she had elected to do surgery. Then she went to the Nursing Home to get built up prior to surgery. Friend #1 stated that she had visited with Resident #1 on [DATE]. Friend #1 stated that after she returned to her home, Resident #1 phoned and stated that she was in a mess because they were going to have to take her blood pressure and pulse every two (2) hours because they had given her too much heart medication. Friend #1 stated that she confronted one (1) of the nurses the next day and that she had verified what Resident #1 had reported and said that the medication had been put into the computer wrong and that they had taken Resident #1's blood pressure (BP) and pulse every two (2) hours and notified the physician. Friend #1 stated that Resident #1 had commented on feeling weak and that her arm had been hurting due to them taking BP so often. Friend #1 stated that Resident #1 was still alert and oriented. Friend #1 stated that she was getting ready to take Resident #1 to her Physician's appointment on [DATE] when Friend #2 called and reported that Resident #1 had expired. Interview on [DATE] at 2:05 p.m. with Registered Nurse (RN) #1, Medicare Nurse, revealed that there had been a medication error for Resident #1 a few weeks ago. RN #1 stated that upon assessment of Resident #1 that she had noted that the resident's pulse rate had dropped from the day before. Upon review of Resident #1's medication, RN #1 stated that she discovered that there was a difference in how the medication was ordered and the way that Resident #1 had received it. RN #1 stated that [MEDICATION NAME] had been ordered twice daily but had been administered four (4) times daily for about 10 days. RN #1 stated that it was the time codes that were wrong on the MAR. RN #1 stated that she saw where the codes had been changed a couple of days prior but that the physician had not been notified. RN #1 stated that that she notified the physician (MD #1) and had received an order to hold the medication, check BP and pulse every two (2) hours until the Resident's return visit, and to also reduce the dosage of the medication. The order included to call the physician if the resident's heart rate decreased below 40. RN #1 stated that it had not dropped that low. RN #1 stated that Resident #1 did expire and that Resident #1 had a lot of cardiac issues. RN #1 did not feel that the medication error had caused the death. RN #1 stated that there had been several in-services after the event that included medication administration, errors and reporting and abuse and neglect. RN #1 stated that other resident's medications were checked and no concerns were noted. RN #1 stated that Resident #1 was alert and oriented and was her own RP. RN #1 stated that she had told Resident #1 about the medication error and how they would monitor her. RN #1 stated that Resident #1 had not seemed upset and had voiced understanding. RN #1 stated that Resident #1 had no family nearby but had several friends and neighbors who visited regularly. RN #1 stated that Resident #1 had a cell phone for use and called people daily. RN #1 stated that she had not notified Resident #1's primary physician (MD #2) of the medication error because it was after hours. RN #1 stated that the DON and MD #2 were notified the next day. RN #1 stated that she did not give medications but if an error was made that the Physician, Resident/RP and DON should be notified and an incident report and medication error report initiated. RN #1 stated that the physician's orders [REDACTED]. An interview with the Director of Nursing (DON) on [DATE] at 2:20 p.m. revealed that a medication error had occurred for Resident #1. When LPN #1 first found the error and she did not report it to the Physician or to the DON. LPN #1 made the changes to reflect the correct time that the medication was supposed to be given. The DON stated that was on a Sunday and on that Tuesday RN #1 caught the error and reported it to the Cardiologist (MD #1) because the resident's heart rate was decreased. The medication was [MEDICATION NAME] and the order was correct on the MAR and the medication card for every 12 hours but the time codes on the MAR was for every six (6) hours. That was how it had been documented as being given. The DON stated that he/she had been notified by RN #1 the next day of the error and started an immediate investigation. The DON stated that the Pharmacy Consultant had came at the end of [DATE] and was not scheduled to return until the end of [DATE], so they had not caught the error. The DON stated that he/she went through the medication cart and orders and checked all the MARs to ensure that they matched. The DON stated that when an order was written it was supposed to be put on the MAR by the nurse. Then whoever took the order off placed the pink slip (carbon copy of the order) in the box for the Medical Records Director who input the order into the computer. The DON stated that it was the incorrect input into the computer that caused the time codes to be inaccurate, and that the nurses had gone by the time codes to administer the medications instead of by the order/medication card directions. The DON stated that she immediately began inservices on the policy and procedure for medication administration, medication errors and reporting/notification. The DON stated that all of the nurses had been trained before and knew better. Further interview with the DON on [DATE] at 11:10 a.m. reiterated that Resident #1 was given [MEDICATION NAME] at twice the dosage that was ordered daily from [DATE]-[DATE] before the error was caught. She also stated that it had been two (2) more days before the physician and resident were notified of the error. The DON stated that he/she had a meeting with the nurses on [DATE] to include all shifts and went over the policies. There was also a meeting held by the Pharmacy Consultant on [DATE] that included the importance of checking medication orders. The Corporate QA Nurse had a meeting with the Nurses on [DATE] about comparing the Orders/MARs/Medication and to immediately report incidents to the DON. Another inservice was held on [DATE] on abuse and neglect for all staff. The DON stated that he/she immediately started looking at other resident's medication and comparing the MARs to physician's orders [REDACTED]. The DON stated that she pulled every single medication in the building checking labels, time codes, directions and completed all of this on [DATE]. The DON stated that she felt comfortable at that point that everything had been checked and was without problems. The DON stated that she had also done random medication passes with some of the nurses. The DON stated that she had talked with all of the nurses who were involved in the medication error and wrote them up and the only answer that was given for the medication error was that they just didn't pay enough attention and was going by the time codes. The DON stated that the Administrator also completed a personnel action for the MRD. The DON stated that the process to help ensure that this doesn't occur again is for the MRD to print a dummy MAR for her and inputs the orders into the computer from the pink slips and leaves the pink slip attached. The DON stated these were discussed and checked in the daily stand up meeting to ensure they match. The DON stated that MD #2, who is also the Medicare Medical Director, was notified of the medication error for Resident #1 on [DATE]. An interview with LPN #4 on [DATE] at 3:30 p.m. revealed that she did not check the label against the MAR like she should have with Resident #1's [MEDICATION NAME]. LPN #4 stated that she went by the time codes when giving the noon doses of the medication. LPN #4 stated that she came in on Tuesday and was told that the time codes had been wrong for the [MEDICATION NAME]. She recalled taking Resident #1's BP/Pulse every two (2) hours. LPN #4 stated that Resident #1 was alert and talkative and really didn't complain about anything. LPN #4 stated that she had not talked to any of Resident #1's family or friends about the medication error. LPN #4 reviewed the MAR and confirmed that she had administered Resident #1's [MEDICATION NAME] several times from [DATE] to [DATE] and did not know why she had not caught the error. LPN #4 stated that she attended inservices on policy/procedure for medication administration and errors, and now checked and double/triple checked the medications before administering them. An interview with LPN #9 on [DATE] at 2:58 p.m. revealed that she had attended inservices on abuse/neglect, medication errors, filling out reports and notifying everyone. He/she verified that each order/MAR/and medication card were to be checked prior to administration of medication to ensure the correct dosage. Interview with LPN #5 on [DATE] at 3:00 p.m. revealed that he/she had come to work the morning that Resident #1 had already coded and had assisted with CPR but the resident never responded. LPN #5 stated that he/she had worked the ,[DATE] shift until about one (1) month ago but now works days and had given Resident #1's noon dosages of medication and went strictly by the MAR. LPN #5 stated that he/she had been notified later that there had been an error in giving the medication [MEDICATION NAME]. LPN #5 stated that the DON called everyone to a meeting-for policy and procedure of medication administration, medication errors/reports and notification procedures. LPN #5 stated that he/she now checks everything three (3) times before administering medications, especially checks MAR/physician's orders [REDACTED]. LPN #5 stated that he/she was not sure why he/she did not catch the medication error/time codes for Resident #1's medication. LPN #5 stated that Resident #1 was alert and oriented and didn't have any complaints other than being tired. An interview with LPN #2 on [DATE] at 3:10 p.m. revealed that she had given Resident #1's 6:00 p.m. dose of [MEDICATION NAME] and doesn't know why he/she didn't catch that the time codes were not the same as the orders other than he/she didn't check the orders the way he/she should have and only went by the time codes on the MAR. LPN #2 stated that Resident #1 had acted like he/she was doing well except for being tired after surgery. LPN #2 stated that he/she worked the evening that RN #1 discovered the medication error and the [MEDICATION NAME] was held that night and Resident #1's BP and Pulse were taken every two (2) hours and the heart rate never fell below 40 or they would have notified the MD. LPN #2 stated that Resident #1 did not seem upset. LPN #2 stated that he/she had attended inservices on medication policy/procedures, errors, reporting etc and stated that he/she now makes sure that everything is checked to ensure that the correct dosage of medication is given. LPN #2 explained the procedure for checking the pink slip order against the MAR and again once the MAR is printed against the orders. An interview with LPN #7 on [DATE] at 3:15 p.m. revealed that she had been one of the nurse's to give Resident #1's [MEDICATION NAME]. LPN #7 stated that she just didn't pay close enough attention and went by the time codes on the MAR. LPN #7 stated that now she checks the order/MAR/time codes/Med Card to make sure they all match before giving any medication. LPN #7 stated that she was recently inserviced on medication policy/procedure that included medication errors and reporting. LPN #7 stated that Resident #1 was alert and oriented and didn't complain of anything except generalized back pain and weakness. LPN #7 stated that she had attended inservice training on medication errors, checking the MAR against the orders and the label on the medications. An interview with the Administrator on [DATE] at 3:30 p.m. revealed that the significant medication error for Resident #1 receiving extra doses of [MEDICATION NAME] was not reported to the State Agencies because they did not think it was a reportable event because they that did not think that Resident #1's death was due to the medication error but due to the extensive heart problems. The Administrator stated that the nurses and Medical Records person involved in the medication error were all reprimanded and steps were taken to help prevent this from happening again. The Administrator stated that staff was inserviced on proper policy and procedures. Further interview with the Administrator on [DATE] at 10:15 a.m. revealed that the POA for Resident #1 was only if the resident became incapacitated. The Administrator stated that she had not seen or heard from the person listed as the first contact on the POA (Family Member #2). The Administrator stated that Resident #1 was her own RP and made her own decisions. Interview with LPN #1 on [DATE] at 4:05 p.m. revealed that she had worked ,[DATE] and had failed to notice Resident #1's time codes were different from the physician's orders [REDACTED]. LPN #1 stated that she realized that the time codes were listed as 6:00 a.m., 12:00 noon, 6:00 p.m., and 12:00 midnight instead of for every 12 hours. LPN #1 stated that she changed the time codes to 9:00 a.m. and 9:00 p.m. and yellowed out the previous orders. LPN #1 stated that she had not notified the MD due to the lateness of the hour and had thought she had reported it to the oncoming nurse. She could not remember who the nurse was. LPN #1 stated that Resident #1 was very alert and was monitored with no problems. LPN #1 stated that several days later when the MD was notified of the error that Resident #1's BP and Pulse were checked every two (2) hours and documented on the MAR. There was no pulse rate below 40 beats per minute. LPN #1 stated when she saw Resident #1 at 6:00 a.m. on the morning of [DATE] that she was scheduled to see the Cardiologist. Resident #1 was talkative and alert. LPN #1 stated that when she returned to Resident #1's room about 6:30 a.m. Resident #1 was found without pulse and respirations. LPN #1 stated that she initiated CPR and Resident #1 was sent to the hospital per ambulance. LPN #1 stated that Resident #1 was never revived. LPN #1 stated that she should have filled out a medication error report that Sunday ([DATE]) and notified the MD but that she just had not thought about it. LPN #1 stated that she corrected the times on the MAR. LPN #1 stated that she had extensive training since the event related to medication errors, filling out reports, notifying appropriately and following policy and procedure for checking/ensuring that the right doses of medication were given. LPN #1 stated that she checks the orders/cards/MARs and codes. LPN #1 stated that she did not mean any harm to Resident #1. LPN #1 stated that she had been reprimanded due to the medication error. An interview with the Medical Records Clerk/Director (MRD) on [DATE] at 5:40 p.m. revealed that when a resident was admitted /readmitted to the facility that all orders were handwritten. The MRD stated that he/she put the orders in the computer and then prints the orders. Then she gives them to the nurse who is supposed to check them. The MRD stated that she had put Resident #1's orders into the computer when the resident returned from the hospital. The MRD stated that the orders were put in correctly for the [MEDICATION NAME] but that she had failed to put in the correct time codes on the MAR. She stated that the codes were put in for every six (6) hours instead of every 12 hours. The MRD stated that after the incident occurred there are now two (2) people who check the orders daily. Further interview with the MRD on [DATE] at 12:00 noon revealed that orders from the previous day were checked against the MAR that had been printed out after the medication and codes were entered for all new medications. An attempt was made to contact MD #1 on [DATE] at 9:40 p.m. and the receptionist stated that he was out of the country at present time. An interview with the Attending Physician, MD #2, on [DATE] at 8:00 p.m. revealed that he had been notified of the medication error for Resident #1 "after the fact". MD #2 stated that the Cardiologist, MD #1, had been notified and orders given. MD #2 stated that he could not say that the medication error had caused the death of Resident #1 because the resident had previously had a very sick heart. MD #2 stated that [MEDICATION NAME] could possibly cause a slow heart beat or cardiogenic shock. MD #2 stated that he had been notified of the medication error and had thought that the facility had notified the state agency of the error. An interview with the Administrator on [DATE] at 5:00 p.m. revealed that she agreed that the failure to follow policy/procedures for filling out a medication error report, notifying the physician, and for failure to follow the medication administration policy resulted in a significant medication error that could have caused injury or even death to Resident #1. An interview with the Social Services Director (SSD) on [DATE] at 9:15 a.m. revealed that after Resident #1 expired, Friend #1 came to the facility to pick up the resident's things. The SSD stated that Friend #1 did tell her that Resident #1 had phoned her about getting the wrong medication. The SSD stated that he/she was not aware of the wrong medication being administered and would have to check with someone about it. SSD stated that since Friend #1 was not listed as the RP or a contact person she did not want to discuss this with her. The SSD stated that she did go to the DON and the issues with the medication was confirmed. The SSD stated that Friend #2 was a friend and neighbor of Resident #1. Resident #1 had asked for Friend #2 to assist with signing her in to the facility because the resident was weak. The SSD stated that Resident #1 had a cell phone and called whomever he/she wanted to and was very alert and oriented. The SSD stated that Resident #1 was listed as her own RP and did not give names of anyone to come for careplan meetings. Resident #1 had stated that she could do it herself. The SSD stated that Resident #1 might repeat herself occasionally and might forget some things was sharp and stated

CI MS #8573 Based on record review, interview and policy review, the facility failed to ensure that one (1) of five (5) resident's reviewed (Resident #1) had accurately documented Medication Administration Records (MAR) for the administration of [MEDICATION NAME] 400 mg every 12 hours. The [MEDICATION NAME] 400 mg was documented on the MAR to be administered every 12 hours however, the time codes were listed for every six (6) hours. The facility administered the [MEDICATION NAME] 400 mg every six (6) hours from [DATE] through [DATE]. ([MEDICATION NAME] is an antiarrythmic medication.) Resident #1 was found on [DATE] at 6:30 a.m. with no pulse, no respirations and non-responsive. A Full Code was initiated and the Resident was transported to the hospital emergency room (ER) and was pronounced dead at 7:19 a.m. The "Certificate of Death" listed the cause of death as "Cardio-Respiratory Arrest" and [MEDICAL CONDITIONS]". There were eight (8) licensed nurses that had documented administering the incorrect dosage of [MEDICATION NAME] to Resident #1 from [DATE]-[DATE]. The facility's failure to ensure that the time codes for the administration of the [MEDICATION NAME] 400 mg every 12 hours was correct on the MAR resulting in the [MEDICATION NAME] to be administered every six (6) hours for 12 days was deemed as an Immediate Jeopardy on [DATE] at 4:55 p.m. to begin on [DATE]. The facility provided a Credible Allegation of Compliance (AoC) on [DATE] at 10:30 a.m. Based on the verification of the facility's implementation of corrective actions the Immediate Jeopardy (IJ) was removed on [DATE] and the scope and severity was lowered to a "D" level which constitutes no actual harm with a potential for more than minimal harm to allow the facility to monitor the effectiveness of the corrective actions through their Quality Assurance Program. Findings Include: Cross refer to F-333 for the facility's failure to ensure that the MAR had the correct time codes in place for the administration of the [MEDICATION NAME] 400 mg every 12 hours. The [MEDICATION NAME] 400 mg was administered every six (6) hours. On [DATE] at 10:30 a.m. the Administrator provided the following Credible Allegation of Compliance (AoC): "Resident #1 was admitted to the nursing facility on [DATE] with a physician's orders [REDACTED]. Medical Records Director entered incorrect time code for the [MEDICATION NAME] 400 mg 1 PO Q 12 hours on the Medication Administration Record. The time code entered on Medication Administration Record was 12:00am; 6:00am; 12:00pm; 6:00pm. Medication was given Q 6 hours from [DATE]-[DATE]. Resident #1 did expire on [DATE] with a death certificate listing immediate cause of death being Cardio Respiratory Arrest and secondary being [MEDICAL CONDITION]. LPN #1 discovered a wrong time code on [DATE] at which time LPN #1 corrected the MAR to Q 12 hours at 9:00am and 9:00pm however did not notify the physician, resident/responsible party or the DON per the Medication Error Policy. Medication Error Policy states that "Medication errors shall be reported immediately to the DON and the Attending Physician, who will determine and write the order for the necessary follow-up treatment" as well as "Medication Error Investigation form (NS-635) shall be initiated for all medication errors, to be completed by the person who made the error, or by the person finding the error, or both." On [DATE] RN #1 at 4pm assessed Resident #1 and noted a heart rate of 42 and bradycardic. RN #1 then reviewed MAR and noted the change of time code to 9am and 9pm as the order should have been from [DATE]. RN #1 then noted that the MD was not notified therefore contacted MD #1 at 4pm on [DATE]. New orders were received from MD #1 to hold [MEDICATION NAME] this night and to check BP and heart rate Q 2 hours and notify MD #1 if heart rate fall below 40. RN #1 informed Resident #1 of the medication error who was her own Responsible Party regarding the [MEDICATION NAME]. The DON was notified on [DATE]. the DON completed an incident report, medication error report and summary notification to Attending Physician #2 who is also the Medicare Medical Director on [DATE]. DON conducted in-service on [DATE] to include Medication Administration, Medication Errors. DON began initial investigation beginning with Resident #1 on [DATE] to include all medication orders reviewed, chart audited and data gathered. From [DATE] through [DATE] at 6:00am Resident #1 heart rate and blood pressure was monitored and recorded in the medical record with no recorded Heart Rate below 40 and resident was alert without complaints. On [DATE] at 9:00am, Administrator was informed at Daily Stand Up Meeting by the DON that Resident #1 had a medication error. On [DATE] at approximately 9:30 am a call was placed to Corporate Nurse and to Regional Director by the Administrator of the facility to inform of Resident #1 having a medication error and that Resident #1 had deceased earlier that morning. Administrator instructed DON to pull all Resident #1 records for review and collaboration of data. [DATE]; [DATE]; [DATE]; [DATE] in-services were conducted Per DON on [DATE] re: Medication Administration, Medication Errors, etc. The Corporate Nurse conducted in-service on [DATE] at 2:45pm with nursing staff regarding medication pass, importance of comparing MAR with Physician order [REDACTED]. Pharmacist Consultant conducted in-service on [DATE] Medication Pass and reporting medication errors and DON regarding policy and procedures. Policy and procedures were reviewed with nurses regarding notification of all medication errors to be reported immediately to the Director of Nurses (DON). [DATE] Administrator conducted scheduled in-service regarding Abuse, Neglect, Exploitation, Resident Rights, Recognizing and Dealing with Signs of Burnout, Frustration and Stress that May Lead to Abuse. Full-time nurses have been educated to the above stated topics related to Medication Administration and Medication Errors. No nurse will be allowed to work until they are educated on the above named training sessions. [DATE] audit of all Residents orders and Medication Administration Records were conducted by the DON and Medical Records Director on all medications of facility residents and completed on [DATE] with no further errors noted. [DATE]-[DATE] all Medication Cards/bottles were compared to MAR's with no further errors noted. [DATE] Medical Records Clerk began tracking all pink slips (hand written physician orders) to the Medication Administration Record by printing MAR's for comparison to pink slips to ensure time code accuracy entry. [DATE] DON began checking all pink slips that continue to be checked by tracking to the Medication Administration Record and to be reviewed at the Daily Stand Up Meetings as an added agenda item indefinitely. [DATE] all involved nurses LPN #1, LPN #2, LPN #3, LPN #, LPN #5, LPN #6, #7, #8 were issued an Employee Warning Report covering failure to follow policy and procedure related to Medication Administration and Medication Error Policy. the Medical Records Director Employee Warning Report for failure to follow policy and procedure related to input of correct time codes in to the computer system not coinciding with the physician order." Verification of corrective actions on [DATE]-[DATE] was conducted by observation, record review, policy review and staff interviews. Interviews with random licensed nurses revealed that they had been retrained in policy and procedures of abuse/neglect, medication administration, medication errors, and documentation. Documentation of in-services were reviewed for verification. Medication Pass was was conducted with three (3) different nurses on [DATE] with no errors identified. Random review of Medication Administration Records (MAR) were reviewed with no errors noted in the time codes compared to physician orders.

CI MS #8573 Based on interview, record review and policy review, the facility failed to ensure that one (1) of five (5) residents reviewed (Resident #1) received the correct dosage of medication that was ordered by the Physician from [DATE] to [DATE]. When the facility noted that Resident #1 was receiving the incorrect dosage of medication they neglected to notify the Physician until two (2) days later. Resident #1 had an order for [REDACTED]. [MEDICATION NAME] is an antiarrythmic medication The times of administration documented on the Medication Administration Record (MAR) were listed as every six (6) hours. Resident #1 was given the incorrect dosage of [MEDICATION NAME] (an antiarrythmic medication) from [DATE] to [DATE] every six (6) hours, and not as ordered every 12 hours. Licensed Practical Nurse (LPN) #1 found the error on [DATE] and the time codes were changed to every 12 hours on [DATE]. The prescribing physician (MD #1) was not notified of the medication error until [DATE] at 4:00 p.m. At that time the medication order was changed and an order given to check Resident #1's pulse and blood pressure every two (2) hours until her appointment on [DATE] with MD (#1). There was also an order [REDACTED]. Resident #1 was monitored every two (2) hours beginning on [DATE] without incident until [DATE]. Resident #1 was found on [DATE] at 6:30 a.m. with no pulse, no respirations and non-responsive. A Full Code was initiated and the Resident was transported to the hospital emergency room (ER) and was pronounced dead at 7:19 a.m. The "Certificate of Death" listed the cause of death as "Cardio-Respiratory Arrest" and [MEDICAL CONDITIONS]". There were eight (8) licensed nurses that had documented administering the incorrect dosage of [MEDICATION NAME] to Resident #1 from [DATE]-[DATE]. The eight (8) licensed nurses did not follow policy and procedure for checking the medication dosage prior to administration. The facility did not report this incident to the appropriate State Agencies. Due to the neglect of the facility to ensure that the medication was being administered at the correct dosage Substandard Quality of Care and an Immediate Jeopardy was identified on [DATE] at 4:55 p.m. to begin on [DATE]. The facility provided a Credible Allegation of Compliance (AoC) on [DATE] at 10:30 a.m. Based on the verification of the facility's implementation of corrective actions the Immediate Jeopardy (IJ) was removed on [DATE] and the scope and severity was lowered to a "D" level which constitutes no actual harm with a potential for more than minimal harm to allow the facility to monitor the effectiveness of the corrective actions through their Quality Assurance Program. Findings include: Cross refer to F-333 for the facility's failure to ensure that Resident #1 was not neglected for a significant medication error that began on [DATE]-[DATE]. This time frame indicated that eight (8) licensed nurses administered the antiarrythmic medication at twice the dosage that was ordered. On [DATE] at 10:30 a.m. the Administrator provided the following acceptable credible Allegation of Compliance (AoC): "Resident #1 was admitted to the nursing facility on [DATE] with a physician's orders [REDACTED]. Medical Records Director entered incorrect time code for the [MEDICATION NAME] 400 mg 1 PO Q 12 hours on the Medication Administration Record. The time code entered on Medication Administration Record was 12:00 am; 6:00 am; 12:00 pm; 6:00 pm. Medication was given Q 6 hours from [DATE]-[DATE]. Resident #1 did expire on [DATE] with a death certificate listing immediate cause of death being Cardio Respiratory Arrest and secondary being [MEDICAL CONDITION]. LPN #1 discovered a wrong time code on [DATE] at which time LPN #1 corrected the MAR to Q 12 hours at 9:00 am and 9:00 pm however did not notify the physician, resident/responsible party or the DON per the Medication Error Policy. Medication Error Policy states that "Medication errors shall be reported immediately to the DON and the Attending Physician, who will determine and write the order for the necessary follow-up treatment" as well as "Medication Error Investigation form (NS-635) shall be initiated for all medication errors, to be completed by the person who made the error, or by the person finding the error, or both." On [DATE] RN #1 at 4 pm assessed Resident #1 and noted a heart rate of 42 and bradycardic. RN #1 then reviewed MAR and noted the change of time code to 9 am and 9 pm as the order should have been from [DATE]. RN #1 then noted that the MD was not notified therefore contacted MD #1 at 4 pm on [DATE]. New orders were received from MD #1 to hold [MEDICATION NAME] this night and to check BP and heart rate Q 2 hours and notify MD #1 if heart rate fall below 40. RN #1 informed Resident #1 of the medication error who was her own Responsible Party regarding the [MEDICATION NAME]. The DON was notified on [DATE]. the DON completed an incident report, medication error report and summary notification to Attending Physician #2 who is also the Medicare Medical Director on [DATE]. DON conducted in-service on [DATE] to include Medication Administration, Medication Errors. DON began initial investigation beginning with Resident #1 on [DATE] to include all medication orders reviewed, chart audited and data gathered. From [DATE] through [DATE] at 6:00 am Resident #1 heart rate and blood pressure was monitored and recorded in the medical record with no recorded Heart Rate below 40 and resident was alert without complaints. On [DATE] at 9:00 am, Administrator was informed at Daily Stand Up Meeting by the DON that Resident #1 had a medication error. On [DATE] at approximately 9:30 am a call was placed to Corporate Nurse and to Regional Director by the Administrator of the facility to inform of Resident #1 having a medication error and that Resident #1 had deceased earlier that morning. Administrator instructed DON to pull all Resident #1 records for review and collaboration of data. [DATE]; [DATE]; [DATE]; [DATE] in-services were conducted Per DON on [DATE] re: Medication Administration, Medication Errors, etc. The Corporate Nurse conducted in-service on [DATE] at 2:45pm with nursing staff regarding medication pass, importance of comparing MAR with Physician order [REDACTED]. Pharmacist Consultant conducted in-service on [DATE] Medication Pass and reporting medication errors and DON regarding policy and procedures. Policy and procedures were reviewed with nurses regarding notification of all medication errors to be reported immediately to the Director of Nurses (DON). [DATE] Administrator conducted scheduled in-service regarding Abuse, Neglect, Exploitation, Resident Rights, Recognizing and Dealing with Signs of Burnout, Frustration and Stress that May Lead to Abuse. Full-time nurses have been educated to the above stated topics related to Medication Administration and Medication Errors. No nurse will be allowed to work until they are educated on the above named training sessions. [DATE] audit of all Residents orders and Medication Administration Records were conducted by the DON and Medical Records Director on all medications of facility residents and completed on [DATE] with no further errors noted. [DATE]-[DATE] all Medication Cards/bottles were compared to MAR's with no further errors noted. [DATE] Medical Records Clerk began tracking all pink slips (hand written physician orders) to the Medication Administration Record by printing MAR's for comparison to pink slips to ensure time code accuracy entry. [DATE] DON began checking all pink slips that continue to be checked by tracking to the Medication Administration Record and to be reviewed at the Daily Stand Up Meetings as an added agenda item indefinitely. [DATE] all involved nurses LPN #1, LPN #2, LPN #3, LPN #, LPN #5, LPN #6, #7, #8 were issued an Employee Warning Report covering failure to follow policy and procedure related to Medication Administration and Medication Error Policy. the Medical Records Director Employee Warning Report for failure to follow policy and procedure related to input of correct time codes in to the computer system not coinciding with the physician order." Verification of corrective actions on [DATE]-[DATE] was conducted by observation, record review, policy review and staff interviews. Interviews with random licensed nurses revealed that they had been retrained in policy and procedures of abuse/neglect, medication administration, medication errors, and documentation. Documentation of in-services were reviewed for verification. Medication Pass was was conducted with three (3) different nurses on [DATE] with no errors identified. Random review of Medication Administration Records (MAR) were reviewed with no errors noted in the time codes compared to physician orders.

CI MS #8573 Based on interview, record review and policy review, the facility failed to ensure that the physician was immediately notified of a significant medication error for one (1) of five (5) residents reviewed. This is for Resident #1. Resident #1 had an order for [REDACTED]. The time codes on the Medication Administration Record (MAR) for administration were listed every six (6) hours. Resident #1 was given the incorrect dosage of [MEDICATION NAME] (an antiarrythmic medication) from [DATE]-[DATE]. It was administered every six (6) hours and not every 12 hours as ordered. LPN #1 identified the timing error on [DATE] and changed the times on the MAR to q 12 hours starting on [DATE]. The prescribing physician (MD #1) was not notified of the medication error until [DATE] at 4:00 p.m. A new order was received at that time to check Resident #1's pulse and blood pressure every two (2) hours until her appointment on [DATE] with MD (#1). The order also stated to notify the MD if the resident's heart rate fell below 40 beats per minute. Resident #1 was monitored every two (2) hours beginning on [DATE] without incident until [DATE]. Resident #1 was found on [DATE] at 6:30 a.m. with no pulse, no respirations and non-responsive. A Full Code was initiated and the Resident was transported to the hospital emergency room (ER) and was pronounced dead at 7:19 a.m. The "Certificate of Death" had the cause of death as "Cardio-Respiratory Arrest" and "[MEDICAL CONDITION]" ([MEDICAL CONDITION])." The facility's failure to ensure that Resident #1's Physician was immediately notified of the significant medication error when it was first discovered on [DATE] was deemed as an Immediate Jeopardy (IJ) on [DATE] at 4:55 p.m. to begin on [DATE]. The facility provided a Credible Allegation of Compliance (AoC) on [DATE] at 10:30 a.m. Based on the verification of the facility's implementation of corrective actions the Immediate Jeopardy (IJ) was removed on [DATE] and the scope and severity was lowered to a "D" level which constitutes no actual harm with a potential for more than minimal harm to allow the facility to monitor the effectiveness of the corrective actions through their Quality Assurance Program. Findings Include: Cross refer findings to F-333 for the facility's failure to ensure that the Physician was notified of Resident #1's significant medication error that occurred from [DATE]-[DATE]. Resident #1 received [MEDICATION NAME] 400 mg every six (6) hours and not every 12 hours as ordered by the Physician. Resident was found without pulse or respiration on [DATE] and CPR was initiated. Resident expired on [DATE] at the emergency room . On [DATE] at 10:30 a.m. the Administrator provided the following Credible Allegation of Compliance (AoC): "Resident #1 was admitted to the nursing facility on [DATE] with a physician's orders [REDACTED]. Medical Records Director entered incorrect time code for the [MEDICATION NAME] 400 mg 1 PO Q 12 hours on the Medication Administration Record. The time code entered on Medication Administration Record was 12:00 am; 6:00 am; 12:00 pm; 6:00 pm. Medication was given Q 6 hours from [DATE]-[DATE]. Resident #1 did expire on [DATE] with a death certificate listing immediate cause of death being Cardio Respiratory Arrest and secondary being [MEDICAL CONDITION]. LPN #1 discovered a wrong time code on [DATE] at which time LPN #1 corrected the MAR to Q 12 hours at 9:00 am and 9:00 pm however did not notify the physician, resident/responsible party or the DON per the Medication Error Policy. Medication Error Policy states that "Medication errors shall be reported immediately to the DON and the Attending Physician, who will determine and write the order for the necessary follow-up treatment" as well as "Medication Error Investigation form (NS-635) shall be initiated for all medication errors, to be completed by the person who made the error, or by the person finding the error, or both." On [DATE] RN #1 at 4pm assessed Resident #1 and noted a heart rate of 42 and bradycardic. RN #1 then reviewed MAR and noted the change of time code to 9am and 9pm as the order should have been from [DATE]. RN #1 then noted that the MD was not notified therefore contacted MD #1 at 4pm on [DATE]. New orders were received from MD #1 to hold [MEDICATION NAME] this night and to check BP and heart rate Q 2 hours and notify MD #1 if heart rate fall below 40. RN #1 informed Resident #1 of the medication error who was her own Responsible Party regarding the [MEDICATION NAME]. The DON was notified on [DATE]. the DON completed an incident report, medication error report and summary notification to Attending Physician #2 who is also the Medicare Medical Director on [DATE]. DON conducted in-service on [DATE] to include Medication Administration, Medication Errors. DON began initial investigation beginning with Resident #1 on [DATE] to include all medication orders reviewed, chart audited and data gathered. From [DATE] through [DATE] at 6:00am Resident #1 heart rate and blood pressure was monitored and recorded in the medical record with no recorded Heart Rate below 40 and resident was alert without complaints. On [DATE] at 9:00am, Administrator was informed at Daily Stand Up Meeting by the DON that Resident #1 had a medication error. On [DATE] at approximately 9:30 am a call was placed to Corporate Nurse and to Regional Director by the Administrator of the facility to inform of Resident #1 having a medication error and that Resident #1 had deceased earlier that morning. Administrator instructed DON to pull all Resident #1 records for review and collaboration of data. [DATE]; [DATE]; [DATE]; [DATE] in-services were conducted Per DON on [DATE] re: Medication Administration, Medication Errors, etc. The Corporate Nurse conducted in-service on [DATE] at 2:45pm with nursing staff regarding medication pass, importance of comparing MAR with Physician order [REDACTED]. Pharmacist Consultant conducted in-service on [DATE] Medication Pass and reporting medication errors and DON regarding policy and procedures. Policy and procedures were reviewed with nurses regarding notification of all medication errors to be reported immediately to the Director of Nurses (DON). [DATE] Administrator conducted scheduled in-service regarding Abuse, Neglect, Exploitation, Resident Rights, Recognizing and Dealing with Signs of Burnout, Frustration and Stress that May Lead to Abuse. Full-time nurses have been educated to the above stated topics related to Medication Administration and Medication Errors. No nurse will be allowed to work until they are educated on the above named training sessions. [DATE] audit of all Residents orders and Medication Administration Records were conducted by the DON and Medical Records Director on all medications of facility residents and completed on [DATE] with no further errors noted. [DATE]-[DATE] all Medication Cards/bottles were compared to MAR's with no further errors noted. [DATE] Medical Records Clerk began tracking all pink slips (hand written physician orders) to the Medication Administration Record by printing MAR's for comparison to pink slips to ensure time code accuracy entry. [DATE] DON began checking all pink slips that continue to be checked by tracking to the Medication Administration Record and to be reviewed at the Daily Stand Up Meetings as an added agenda item indefinitely. [DATE] all involved nurses LPN #1, LPN #2, LPN #3, LPN #, LPN #5, LPN #6, #7, #8 were issued an Employee Warning Report covering failure to follow policy and procedure related to Medication Administration and Medication Error Policy. the Medical Records Director Employee Warning Report for failure to follow policy and procedure related to input of correct time codes in to the computer system not coinciding with the physician order." Verification of corrective actions on [DATE]-[DATE] was conducted by observation, record review, policy review and staff interviews. Interviews with random licensed nurses revealed that they had been retrained in policy and procedures of abuse/neglect, medication administration, medication errors, and documentation. Documentation of in-services were reviewed for verification. Medication Pass was was conducted with three (3) different nurses on [DATE] with no errors identified. Random review of Medication Administration Records (MAR) were reviewed with no errors noted in the time codes compared to physician orders.

CI MS #8573 Based on record review, interview and policy review, the facility failed to ensure that one (1) of five (5) resident's reviewed received the correct dosage of medication as ordered by the Physician. This is for Resident #1. Resident #1 had an order for [REDACTED]. The times of administration documented on the Medication Administration Record (MAR) were listed as every six (6) hours. Resident #1 was given the incorrect dosage of [MEDICATION NAME] (an antiarrythmic medication) from [DATE] to [DATE] every six (6) hours, and not as ordered every 12 hours. Licensed Practical Nurse (LPN) #1 found the error on [DATE] and the time codes were changed to every 12 hours on [DATE]. The prescribing physician (MD #1) was not notified of the medication error until [DATE] at 4:00 p.m. At that time the medication order was changed and an order given to check Resident #1's pulse and blood pressure every two (2) hours until her appointment on [DATE] with MD (#1). Resident #1 was found on [DATE] at 6:30 a.m. with no pulse, no respirations and non-responsive. A Full Code was initiated and the Resident was transported to the hospital emergency room (ER) and was pronounced dead at 7:19 a.m. The "Certificate of Death" listed the cause of death as "Cardio-Respiratory Arrest" and [MEDICAL CONDITIONS]". There were eight (8) licensed nurses that had documented administering the incorrect dosage of [MEDICATION NAME] to Resident #1 from [DATE]-[DATE]. The eight (8) licensed nurses did not follow policy and procedure for checking the medication dosage prior to administration. Review of the "2010 Nursing Handbook" revealed that [MEDICATION NAME] is an antiarrhythmic medication that is used for treatment and prevention of supraventricular arrhythmias that haven't responded to conventional treatment. Initial dosage is [PHONE NUMBER] mg/day in ,[DATE] divided doses for ,[DATE] weeks and after the arrhythmia is controlled the dosage is reduced to ,[DATE] mg/day for about four (4) weeks. Maintenance dosage is ,[DATE] mg daily. Adverse reactions could include serious, potentially fatal [MEDICAL CONDITION] toxicity, [MEDICAL CONDITION], and worsening or new arrythmia. The facility's failure to ensure that the physician's orders [REDACTED]. The facility provided a Credible Allegation of Compliance (AoC) on [DATE] at 10:30 a.m. Based on the verification of the facility's implementation of corrective actions the Immediate Jeopardy (IJ) was removed on [DATE] and the scope and severity was lowered to a "D" level which constitutes no actual harm with a potential for more than minimal harm. Based on the verification of the facility's implementation of corrective actions the Immediate Jeopardy (IJ) was removed on [DATE] and the scope and severity was lowered to a "D" level which constitutes no actual harm with a potential for more than minimal harm to allow the facility to monitor the effectiveness of the corrective actions through their Quality Assurance Program. Findings Include: Cross refer to F-333 for the facility's failure to ensure that Resident #1 received [MEDICATION NAME] 400 mg every twelve hours as ordered from [DATE] through [DATE]. Resident #1 received the [MEDICATION NAME] 400 mg every six (6) hours. On [DATE] at 10:30 a.m. the Administrator provided the following Credible Allegation of Compliance (AoC): "Resident #1 was admitted to the nursing facility on [DATE] with a physician's orders [REDACTED]. Medical Records Director entered incorrect time code for the [MEDICATION NAME] 400 mg 1 PO Q 12 hours on the Medication Administration Record. The time code entered on Medication Administration Record was 12:00 am; 6:00 am; 12:00 pm; 6:00 pm. Medication was given Q 6 hours from [DATE]-[DATE]. Resident #1 did expire on [DATE] with a death certificate listing immediate cause of death being Cardio Respiratory Arrest and secondary being [MEDICAL CONDITION]. LPN #1 discovered a wrong time code on [DATE] at which time LPN #1 corrected the MAR to Q 12 hours at 9:00am and 9:00pm however did not notify the physician, resident/responsible party or the DON per the Medication Error Policy. Medication Error Policy states that "Medication errors shall be reported immediately to the DON and the Attending Physician, who will determine and write the order for the necessary follow-up treatment" as well as "Medication Error Investigation form (NS-635) shall be initiated for all medication errors, to be completed by the person who made the error, or by the person finding the error, or both." On [DATE] RN #1 at 4pm assessed Resident #1 and noted a heart rate of 42 and bradycardic. RN #1 then reviewed MAR and noted the change of time code to 9am and 9pm as the order should have been from [DATE]. RN #1 then noted that the MD was not notified therefore contacted MD #1 at 4pm on [DATE]. New orders were received from MD #1 to hold [MEDICATION NAME] this night and to check BP and heart rate Q 2 hours and notify MD #1 if heart rate fall below 40. RN #1 informed Resident #1 of the medication error who was her own Responsible Party regarding the [MEDICATION NAME]. The DON was notified on [DATE]. the DON completed an incident report, medication error report and summary notification to Attending Physician #2 who is also the Medicare Medical Director on [DATE]. DON conducted in-service on [DATE] to include Medication Administration, Medication Errors. DON began initial investigation beginning with Resident #1 on [DATE] to include all medication orders reviewed, chart audited and data gathered. From [DATE] through [DATE] at 6:00am Resident #1 heart rate and blood pressure was monitored and recorded in the medical record with no recorded Heart Rate below 40 and resident was alert without complaints. On [DATE] at 9:00am, Administrator was informed at Daily Stand Up Meeting by the DON that Resident #1 had a medication error. On [DATE] at approximately 9:30 am a call was placed to Corporate Nurse and to Regional Director by the Administrator of the facility to inform of Resident #1 having a medication error and that Resident #1 had deceased earlier that morning. Administrator instructed DON to pull all Resident #1 records for review and collaboration of data. [DATE]; [DATE]; [DATE]; [DATE] in-services were conducted Per DON on [DATE] re: Medication Administration, Medication Errors, etc. The Corporate Nurse conducted in-service on [DATE] at 2:45pm with nursing staff regarding medication pass, importance of comparing MAR with Physician order [REDACTED]. Pharmacist Consultant conducted in-service on [DATE] Medication Pass and reporting medication errors and DON regarding policy and procedures. Policy and procedures were reviewed with nurses regarding notification of all medication errors to be reported immediately to the Director of Nurses (DON). [DATE] Administrator conducted scheduled in-service regarding Abuse, Neglect, Exploitation, Resident Rights, Recognizing and Dealing with Signs of Burnout, Frustration and Stress that May Lead to Abuse. Full-time nurses have been educated to the above stated topics related to Medication Administration and Medication Errors. No nurse will be allowed to work until they are educated on the above named training sessions. [DATE] audit of all Residents orders and Medication Administration Records were conducted by the DON and Medical Records Director on all medications of facility residents and completed on [DATE] with no further errors noted. [DATE]-[DATE] all Medication Cards/bottles were compared to MAR's with no further errors noted. [DATE] Medical Records Clerk began tracking all pink slips (hand written physician orders) to the Medication Administration Record by printing MAR's for comparison to pink slips to ensure time code accuracy entry. [DATE] DON began checking all pink slips that continue to be checked by tracking to the Medication Administration Record and to be reviewed at the Daily Stand Up Meetings as an added agenda item indefinitely. [DATE] all involved nurses LPN #1, LPN #2, LPN #3, LPN #, LPN #5, LPN #6, #7, #8 were issued an Employee Warning Report covering failure to follow policy and procedure related to Medication Administration and Medication Error Policy. the Medical Records Director Employee Warning Report for failure to follow policy and procedure related to input of correct time codes in to the computer system not coinciding with the physician order." Verification of corrective actions on [DATE]-[DATE] was conducted by observation, record review, policy review and staff interviews. Interviews with random licensed nurses revealed that they had been retrained in policy and procedures of abuse/neglect, medication administration, medication errors, and documentation. Documentation of in-services were reviewed for verification. Medication Pass was was conducted with three (3) different nurses on [DATE] with no errors identified. Random review of Medication Administration Records (MAR) were reviewed with no errors noted in the time codes compared to physician orders.