Every finding on record at Pikeville Nursing and Rehab Center, LLC

Based on observation, interview, and facility policy review, the facility failed to ensure that staff maintained the oven in a clean and sanitary condition and failed to allow serviceware to air dry before stacking for storage and/or use. This failure had the potential to affect all residents who received meals from the dietary department.Findings included: An undated facility policy titled, Manual Warewashing, indicated, All serviceware and cookware will be air dried prior to storage. A facility policy titled, Equipment, revised 09/2017, revealed, All foodservice equipment will be clean, sanitary, and in proper working order. The policy also revealed, 3. All food contact equipment will be cleaned and sanitized after every use. During an observation on 01/05/2026 at 8:59 AM, the dish drying racks revealed four food service pans and 20 serving trays stored in a wet-nested manner, and food debris was observed inside the door seal of the oven door. During a follow-up observation on 01/06/2026 at 8:46 AM, the observation revealed debris remained in the oven door seal. During an interview on 01/07/2026 at 1:55 PM, Dietary Aide (DA) #9 stated pans and utensils must air dry before storage, and wet-nested items should not be stored. During an interview on 01/07/2026 at 1:40 PM, the Account Manager stated that accessing and cleaning the oven door seal required assistance from maintenance staff because the area had to be disassembled. During an interview on 01/08/2026 at 09:19 AM, the Maintenance Director stated he was not aware of the situation (debris in the oven door seal) reported by the Account Manager. During an interview on 01/07/2026 at 2:05 PM, the Director of Nursing (DON) stated that she expected that the kitchen remained clean. During an interview on 01/08/2026 at 11:15 AM, the Administrator stated that the oven should be kept clean.

Based on observation, interview, and facility policy and document review, the facility failed to fit test all staff annually for N95 respirators which had the potential to affect all residents residing in the facility. Additionally, the facility failed to ensure 2 (Certified Medication Aide [CMA] #5 and Registered Nurse [RN] #6) of 2 staff observed during medication administration followed infection control procedures when preparing medications.Findings included: 1. During an observation on 01/07/2026 at 8:41 AM, CMA #5 was observed preparing 45 milliliters (ml) of lactulose in two separate cups, one with 30 ml and the other with 15 ml then combining them into a six-ounce plastic cup. She was observed putting her right index finger inside the cup with the 30 ml and putting her index and middle fingers inside the six-ounce plastic cup into which she poured the two cups of lactulose along with the water prior to administering the medication to the resident. During an interview on 01/07/2026 at 8:48 AM, CMA #5 said she should not have put her fingers inside the cups because it could cause contamination. During an observation on 01/07/2026 at 9:00 AM, RN #6 was observed using her finger to retrieve a medication out of the blister pack prior to dropping it into a medication cup. After the medication was dropped into the cup, she took her finger and placed it inside the cup to retrieve something foreign from it before administering the medication to the resident. During an interview on 01/07/2026 at 9:16 AM, RN #6 said she should not have put her finger into the medication cup or pulled the medication out of the blister pack with her finger to prevent possible cross contamination. During an interview on 01/08/2026 at 9:54 AM, the Assistant Director of Nurses (ADON), who was also the Infection Preventionist, stated that nurses should not touch pills or put fingers inside medication cups to prevent the possibility of cross contamination. During an interview on 01/08/2026 at 10:45 AM, the Director of Nursing (DON) said she expected staff to follow infection control policies and procedures when passing medications, and they were not to touch the medications or the inside of the cups when dispensing the medications. She stated that if they touched the medications, she expected them to discard that medication and get another one that had not been contaminated. During an interview on 01/08/2026 at 10:58 AM, the Administrator said that she expected staff to follow infection control practices when passing medications, and they were not to touch medications with their fingers or hands or touch the inside of cups that they were dispensing the medications into. 2. A Center for Disease and Control Center (CDC) National Institute for Occupational Safety and Health (NIOSH) Personal Protective Equipment document dated 02/03/2025 indicated, Fit tests confirm that a respirator forms a tight seal to your face before you use it in the workplace. Further review revealed, OSHA [Occupational Safety and Health Administration] requires an annual fit test to confirm the fit of any respirator that forms a tight seal to your face before you use it in the workplace. Because each brand, model, and size of respirators will fit slightly different, you should also be fit tested every time you wear a new model, manufacturer type/brand, or size. Additionally, if your weight changes or facial/dental alterations occur, a fit test should be done again to ensure your respirator remains effective. An undated facility policy titled, N95 Respirator Fit Testing, revealed, Purpose: To ensure that all employees required to wear N95 respirators receive proper fit testing to maintain effective respiratory protection and compliance with regulatory requirements. Scope: This policy applies to all employees, contractors, and new hires who are required to wear N95 respirators as part of their job duties. The policy also revealed, All personnel required to use an N95 respirator must successfully complete fit testing prior to use and maintain a valid fit test in accordance with this policy. Fit testing ensures that the respirator forms an adequate seal to the wearer's face to provide effective protection. During an interview on 01/08/2026 at 9:08 AM, the Assistant Director of Nurses (ADON), who was also the Infection Preventionist, stated that the last time they fit-tested their staff was more than a year ago. She said they did not fit test annually since they only had one N95 mask they used. She stated that the last COVID-19 outbreak was in 10/2025. She stated that she did not know if the staff that took care of the COVID-19 positive residents had N95 masks that fit since they had not been fit-tested. During an interview on 01/08/2026 at 10:35 AM, the ADON brought in the facility policy regarding fit testing and said they should have been fit testing their staff upon hire, annually, and if there were any significant changes to the staff's face size. She provided a fit test on a staff member dated 11/14/2024 and said she was unable to find any other fit testing for anyone else on her current staff. She stated that she was the one responsible for fit testing and had all the supplies in her office to do the fit testing. During an interview on 01/08/2026 at 10:42 AM, the Director of Nursing (DON) said she expected staff to be fit tested upon hire, if there were any changes to their face circumference, and annually according to the latest CDC and OSHA guidelines. During an interview on 01/08/2026 at 10:56 AM, the Administrator said she expected staff to be fit-tested upon hire, annually, and if there were any significant changes to their face.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident was not pulled backwards in a geriatric chair to protect their dignity for 1 (Resident #65) of 1 resident reviewed for dignity.Findings included:A facility policy titled, Resident Rights 483.10, revised 01/2024, indicated, The resident has the right to be treated with respect and dignity.An admission Record revealed the facility admitted Resident #65 on 08/23/2000. According to the admission Record, the resident had a medical history that included diagnoses of cerebral palsy, unspecified intellectual disabilities, and cognitive communication deficit. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/29/2025, revealed Resident #65 had severe impairment in cognitive skills for daily decision-making and had a short-term and long-term memory problem per a Staff Assessment of Mental Status (SAMS). The MDS indicated the resident did not sit to stand due to a medical condition or safety concerns. Resident #65's Care Plan Report, included a focus area revised on 11/10/2025, that indicated the resident had an activities of daily living (ADL) self-care performance deficit related to a diagnosis of cerebral palsy, contractures, history of seizure disorder, and aphasia. The Care Plan Report revealed the resident had aphasia and could not make wants and needs known either verbally or non-verbally. Interventions directed staff to utilize a geriatric chair for the resident when the resident was out of bed. Resident #65's Order Summary Report, with active orders as of 01/08/2026, contained an order dated 09/30/2022 for utilization of a geriatric chair when out of bed. During an observation on 01/05/2026 at 11:50 AM, Unit Manager (UM) #7 pulled Resident #65 backwards in a geriatric chair into the dining room. During an interview on 01/07/2026 at 3:25 PM, UM #7 stated she had not known she could not pull a resident backwards in a geriatric chair. She stated pulling a resident backwards could be a dignity issue; it could instill fear, and it would not allow the resident knowledge of where they were headed. During an observation on 01/07/2026 at 10:59 AM, Certified Nursing Assistant (CNA) #8 pulled Resident #65 backwards in a geriatric chair down a hallway. During an observation on 01/07/2026 at 11:04 AM, CNA #8 pulled Resident #8 backwards in a geriatric chair from the dining room and into the hallway. During an interview on 01/07/2026 at 11:06 AM, CNA #8 stated she had been pulling Resident #65 backwards in the geriatric chair. She stated her training taught her to push a resident forward for their dignity. During an interview on 01/08/2026 at 9:44 AM, the Assistant Director of Nursing (ADON) stated she had observed CNA #8 pull Resident #65 backwards in the geriatric chair the previous day. She stated being pulled backwards was a dignity issue and could disorient the resident in the chair. During an interview on 01/08/2026 at 8:56 AM, the Director of Nursing (DON) stated the expectation was for a resident in a geriatric chair to be pushed forward. She stated that pulling a resident backwards could be undignified. She stated feeling undignified could have occurred if a resident could not see where they were going or if they felt they did not have a choice in the way they were going. During an interview on 01/08/2026 at 9:05 AM, the Administrator stated her expectation was that staff pushed a resident forward in a geriatric chair. She stated it was important to be pushed forward so the resident could see where they were going.

Based on interview, record review, and facility document and policy review, the facility failed to protect the resident's right to be free from physical abuse by another resident for 1 (Resident #100) of 2 residents reviewed for abuse. Specifically, on 07/01/2025, staff heard Resident #99 yell at Resident #100 and saw Resident #100 holding their right shoulder/arm. Resident #99 reported that they hit Resident #100 on the arm.Findings included: An undated facility policy titled, Abuse Protection, indicated, 1. Each resident has the right to be free from abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The policy also revealed, 3. Physical abuse includes hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. An admission Record revealed the facility admitted Resident #100 on 04/23/2025. According to the admission Record, the resident had a medical history that included diagnoses of a wedge compression fracture of thoracic vertebrae number 11 and 12 (upper mid-back area of the spine), subsequent encounter for fracture with routine healing (onset date 04/23/2025); unspecified dementia; anxiety; and repeated falls. A five day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/07/2025, revealed Resident #100 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. Resident #100's Care Plan Report included a focus area initiated on 05/05/2025, that indicated the resident had impaired cognitive function or impaired decision making related to a diagnosis of dementia. Interventions directed staff to observe for any changes in cognitive function (initiated 04/23/2025). An admission Record revealed the facility originally admitted Resident #99 on 10/02/2023. According to the admission Record, the resident had a medical history that included diagnoses of major depressive disorder, adjustment disorder with other symptoms, low back pain, peripheral vascular disease, and acquired absence of the right leg below the knee. A quarterly MDS, with an ARD of 04/30/2025, revealed Resident #99 had a BIMS score of 13, which indicated Resident #99 was cognitively intact. Per the MDS, Resident #99 utilized a wheelchair during the last seven days of the assessment look-back period. Resident #99's Care Plan Report included a focus area initiated on 02/08/2024, that indicated the resident had/had a history of behavior problems that included aggressive behavior. Interventions directed staff to minimize potential for the resident's disruptive behavior by offering tasks which diverted attention and provide non-pharmacological interventions to prevent and/or reduce behaviors (initiated 05/22/2025). Resident #99's Psychiatry Progress Note dated 07/01/2025 revealed Psychiatric Mental Health Nurse Practitioner (NP) #2 documented that Resident #99 stated I got mad yesterday, someone took my wheelchair, and I hit [the resident]. I told [the resident] the last time that if [the resident] took it again I would hit. An undated Final Report/5 Day Follow-Up revealed on 07/01/2025, Resident #99 punched Resident #100 on the arm as they passed in the hallway. According to the report, the facility investigated the incident and determined that staff heard Resident #99 curse and heard the resident say that they hit Resident #100. The facility's report also revealed that Resident #99 stated during an interview that they hit Resident #100 on the arm. The report revealed that Resident #100 sustained no injuries. Per the facility report, After concluding our investigation abuse cannot be substantiated due to no physical and/or emotional harm sustained. Licensed Practical Nurse (LPN) #3's, (who was a Certified Nursing Assistant [CNA] at the time of the incident) undated written statement revealed at approximately 2:00 AM, he heard Resident #99 call Resident #100 a name and Resident #99 stated, You won't do anything about it. Per the statement, LPN #3 observed Resident #100 holding their right shoulder. LPN #4's written statement revealed at approximately 2:00 AM on 07/01/2025, she was notified that Resident #99 and Resident #100 had a physical altercation. LPN #4's statement revealed that the LPN immediately assessed Resident #100 and found the resident holding their right arm. Per the statement, Resident #100 did not recall what happened. According to LPN #4's statement, prior to talking to Resident #99 about the incident, she heard the resident state, I don't understand why you have to be a [expletive] [expletive] all the time. During an interview on 01/07/2026 at 1:35 PM, LPN #3 stated that the statement he gave to the facility was on 07/01/2025 and was true and accurate. He stated that he did not observe either resident hitting. He stated staff separated the residents and nurses assessed Resident #100 and found no injury. During an interview on 01/07/2026 at 12:05 PM, LPN #4 stated Resident #99 got mad at Resident #100, because they thought Resident #100 had stolen their wheelchair. Per LPN #4, Resident #99 told her that they had hit Resident #100, and a CNA had reported they heard yelling between the two residents. She stated that she assessed both residents and did not find any physical injuries and stated that Resident #100 could not recall what happened. During an interview on 01/07/2026 at 11:25 AM, NP #2 stated that Resident #99 told her that they had hit another resident when the other resident had taken Resident #99's wheelchair. She stated that Resident #99 did not specify which resident they had hit. Per NP #2, that was the first time that Resident #99 had been involved in an incident with another resident. During an interview on 01/07/2026 at 2:38 PM, the Administrator stated a nurse notified of her of the incident in middle of the night on 07/01/2025. She stated that this was an isolated incident and Resident #100 was discharged approximately one week after the incident. Even though Resident #99 told staff that they hit Resident #100 on the arm and staff observed Resident #100 holding their arm/shoulder, the Administrator stated that there was no physical or emotional harm to either resident and the facility did not substantiate physical or verbal abuse.

Based on record review, interview, and facility document and policy review, the facility failed to ensure that an allegation of resident-to-resident physical abuse was reported to the state survey agency (SA) no later than two hours after the allegation was made for 1 (Resident #100) of 2 residents reviewed for abuse.Findings included: An undated facility policy titled, Abuse Protection, revealed 6. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of our residents. Our abuse prevention program provides policies and procedures that govern, as a minimum: Reporting/response - The reporting and filing of accurate documents relative to incidents of abuse; reporting to State agencies as required, analyze and implement necessary changes to prevent future occurrences of abuse. The policy did not address timeframes for reporting abuse allegations to state agencies. An admission Record revealed the facility admitted Resident #100 on 04/23/2025. According to the admission Record, the resident had a medical history that included diagnoses of a wedge compression fracture of thoracic vertebrae number 11 and 12 (upper mid-back area of the spine), unspecified dementia, anxiety, and repeated falls. A 5 Day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/07/2025, revealed Resident #100 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. An admission Record revealed the facility originally admitted Resident #99 on 10/02/2023. According to the admission Record, the resident had a medical history that included diagnoses of major depressive disorder, adjustment disorder with other symptoms, low back pain, peripheral vascular disease, and acquired absence of the right leg below the knee. A quarterly MDS, with an ARD of 04/30/2025, revealed Resident #99 had a BIMS score of 13, which indicated Resident #99 was cognitively intact. Per the MDS, Resident #99 utilized a wheelchair during the last seven days of the assessment look-back period. A Long Term Care Facility - Self-Reported Incident Form dated 07/01/2025, revealed an allegation of physical abuse had occurred on 07/01/2025 (time of incident not documented) when Resident #99 punched Resident #100 on the arm as they passed in the hallway. A Final Report/5 Day Follow-Up revealed the facility documented that state agencies were notified of the allegation via electronic mail on 07/01/2025 (time not documented). An Automatic reply email from the SA to the facility dated 07/01/2025 at 11:30 AM revealed the SA received the facility complaint related to abuse and/or deficient practice. During an interview on 01/07/2026 at 12:05 PM, Licensed Practical Nurse (LPN) #4 stated she notified the Administrator and the Director of Nursing (DON) of the allegation at approximately 2:30 AM, not long after the incident occurred at 2:00 AM on 07/01/2025. She stated staff were required to report allegations immediately to the Abuse Coordinator, who was the Administrator at that time. Per LPN #4, abuse allegations were required to be reported to the SA within two hours. During an interview on 01/07/2026 at 2:38 PM, the Administrator stated a nurse called her about the allegation in the middle of the night (exact time unknown) because the incident occurred at approximately 2:00 AM or 3:00 AM on 07/01/2025. According to the Administrator, she was aware that allegations or incidents of abuse were supposed to be reported to the SA within two hours and expected abuse allegations to be reported timely. However, the Administrator stated she did not report the allegation of abuse until 11:30 AM on 07/01/2025, which was approximately nine hours after the allegation occurred.

Based on observation, record review, interview, and facility document and policy review, the facility failed to ensure medications were not left on top of the medication cart out of sight for 1 (Certified Medication Aide [CMA] #5) of 2 staff observed during medication administration.Findings included: A facility policy titled, Medication administration - General Guidelines, dated 11/2021, revealed the section titled, Policy, included, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). The policy also revealed the section titled, Procedures, included, 16. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications. During an observation on 01/07/2026 between 8:12 AM and 8:30 AM, CMA #5 left nine medication blister packs consisting of amlodipine (blood pressure), clopidogrel (antiplatelet), cranberry capsule (urinary tract infection supplement), fexofenadine (allergy med), losartan (blood pressure), metoprolol (blood pressure), memantine (dementia), vitamin B12, (vitamin supplement), and vitamin C (vitamin supplement), along with a lidocaine patch (pain patch) on top of the front left-hand side of the cart. CMA #5 left the blister packs unattended while in a resident's room administering some of the medications, walking down the hallway into the therapy room (approximately 100 feet), and walking to the dining room (approximately 50 feet) to administer the rest of the resident's medications. During an interview on 01/07/2026 at 8:49 AM, CMA #5 said she should not have left the medication on top of the medication cart when not in sight because residents could take them and could cause problems when they were not prescribed that medication. During an interview on 01/07/2026 at 11:06 AM, the Environmental Services Supervisor said she walked by the medication cart and saw the medications that were on top of the cart and confirmed they should not be left there because anybody could have gotten them. During an interview on 01/07/2026 at 11:07 AM, the Director of Nursing (DON) said medications should not have been left on top of the medication cart when not in sight (of staff) because anyone could get them. During an interview on 01/07/2026 at 11:09 AM, the Administrator said the medications should not be left unattended because someone could get them and take something that may harm them. During an interview on 01/07/2026 at 11:24 AM, the Assistant Director of Nursing (ADON) said that medications should never be left unattended because anyone could get them.

Based on observation, interview, review of the facility's job descriptions, review of the facility's policies, and food establishment inspection reports, it was determined the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Observations from 10/27/2024 through 10/30/2024, revealed blunt, metal plumbing protruding from the wall above the toilet in two bathrooms shared by four resident rooms, flooring was uneven in hallways, and resident bathrooms; lighting issues in resident bathrooms and the kitchen, odors permeating from the floor in resident bathrooms, leaking pipes from equipment in the kitchen, chipped and peeling paint/drywall in resident rooms as well as the kitchen, peeling paint on the floor in the kitchen, rust on the door frames in resident rooms, large scuff marks on doors and walls in resident rooms and bathrooms, and a crack in the glass of the main entrance door. These identified issues provided potential impalement concerns, fall risks, and did not provide a comfortable homelike environment for residents, staff, and visitors. The findings include: Review of the facility's Homelike Environment, policy undated, revealed residents would be provided with a safe, clean, comfortable, and homelike environment. Facility staff and management would maximize the characteristics of the facility that included a clean, sanitary, and orderly environment, comfortable yet adequate lighting, and pleasant, neutral scents. Additionally, the facility staff and management were to minimize, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting which included institutional odors and institutional signage. Review of the facility's job description for the Environmental Supervisor dated 03/18/2016, revealed the Environmental Supervisor was responsible for ensuring the facility and grounds were maintained and safe for all residents, staff, and visitors. The Environmental Supervisor would recognize, remove, and/or report potential hazards. Review of the Maintenance Assistant Job Description dated 11/09/2016, revealed the Maintenance Assistant would collect and review maintenance requisitions from all units and departments of the facility. The Maintenance Assistant would maintain adequate and comfortable lighting level, appropriate for tasks. Review of the facility's document, titled Job Description: Environmental Supervisor, revised 03/08/2016, revealed the Environmental Supervisor had the following administrative responsibilities to supervise housekeeping staff with all aspects of maintaining the facility interior and grounds to ensure resident rooms were clean, safe, and comfortable. Continued review of the facility's document revealed the Environmental Supervisor would supervise maintenance staff and ensure the facility and grounds were maintained and safe for all residents, staff, and visitors by ensuring all maintenance staff comply with all life safety regulations. Review of the facility's health department inspections, dated 01/09/2024 and 07/26/2024, revealed observations from the Health Department to include paint coming off the floor, the wall at the garbage disposal is not clean to sight or touch, and poor lighting. Continued review of the inspection report revealed these are repeat violations dating back to 12/18/2019. 1. Observation on, 10/27/2024 at 1:30 PM, revealed the facility's entry door had a crack in the glass in the lower right corner. Observation on 10/27/2024 at 1:50 PM, revealed the kitchen area had paint chipping on the floor under and in-front of the three-compartment sink, the piping for the ice machine was leaking, the sink drain for the garbage disposal had cracked and was leaking into a bin below the garbage disposal, and the dishwasher was leaking and had a bin below it catching water. Continued observation revealed, the wall behind the garbage disposal had residue buildup that had leaked from a chemical dispenser and was coating the wall. The wall behind the garbage disposal had several areas where paint was chipping off. A door from the dining area to the kitchen had rust at the bottom. Additionally, the hood above the cooking area was missing 2 light bulbs. Observation on, 10/27/2024 at 2:35 PM, revealed a bathroom shared between Resident rooms [ROOM NUMBERS] had plumbing protruding from the wall behind the toilet, a broken toilet paper dispenser, cracked and chipping drywall at the base of a grab bar, scuffed and chipped paint on the door, and rust around the door frames leading into the bathroom. Observation on, 10/27/2024 at 3:32 PM, in resident room [ROOM NUMBER] revealed lighting in the bathroom to be extremely low, making it difficult to see. The flooring was uneven and was raised beginning at the base of the toilet and continued around the wall on the opposite side of the bathroom, measuring 1-foot-wide X 3 feet long. Baseboards were separating from the wall behind the toilet measuring 4 feet. A urine splash guard located behind the toilet was separated from the wall. Observation on, 10/28/2024 at 4:05 PM, in the bathroom of resident room [ROOM NUMBER] revealed a gap in vinyl plank flooring that measured 7.5 inches. Drywall was peeling and scuffed on the wall opposite of the toilet measuring 2.5 feet in length. Continued observation revealed both doors into the bathroom have rust and scuff marks. Additionally, a light switch in R5's room revealed a missing status indicator light. In an interview on, 10/27/2024 at 2:37 PM, with Resident (R)59 he stated because of the broken toilet paper dispenser the toilet paper will sometimes be placed on the floor by someone else using the bathroom and when that happens, he will have to use the call bell and wait for nursing staff to come and assist him because he is unable to reach the toilet paper in the floor. R59 stated that this was frustrating, and he knew staff were aware because of how often they had to assist him. In an interview on, 10/27/2024 at 3:45 PM, R74 stated that the bathroom light was too dim, and he had notified the nurses. R74 stated that he would sometimes have to leave the door open so he can see what he was doing while in the bathroom. R74 stated that he felt like the lighting should be brighter so he could close the door while in the bathroom and still be able to see. 44974 2. Observation on 10/27/2024 at 2:15 PM of the bathroom between rooms [ROOM NUMBERS], revealed two metal plumbing pipes, by and just to the right of the commode, protruding 2 1/2 inches from the wall and 2 inches in diameter that could cause an impalement hazard to residents. Resident (R) 6 and R 29 both utilized this bathroom. Review of R6's Admission Record revealed R6 was admitted on [DATE] with diagnoses of congestive heart failure, scoliosis, osteoarthritis, and osteoporosis. Review of R6's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 09/01/2024 revealed a Brief Interview for Mental Status (BIMS) score of 12 of 15 which indicated R6 was cognitively intact. Further review of the MDS revealed R6 was independent with transfers from the wheelchair to the commode. Review of R6's Care Plan revealed a focus for at risk for Falls related to weakness, debility, difficulty walking and lack of coordination, initiated on 05/30/2019, and revised on 05/30/2019, and on 09/18/2024. Review of R29's Admission Record revealed R29 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, Tremors, and vascular dementia. Review of R29's MDS with an ARD date of 09/13/2024 revealed a BIMS score of nine of 15, which indicated R29 was moderately cognitively impaired. Further review of the MDS revealed R29 was independent with transfers from the wheelchair to the commode. Review of R29's Care Plan revealed a focus for at risk for falls related to dementia, tremors, and a history of falls initiated on 09/20/2024. During an interveiw on 10/29/2024 at 1:57 PM with the Maintenance Director he stated he rarely looked at the (Technology Solutions and Services) TELS system (an electronic system used by facilities for communication for repairs). The Maintenance Director stated the only thing he did on TELS system was the routine tasks. The Maintenance Director stated he mainly looked at the maintenance book that was kept at each nursing station and they did work orders on paper. The Maintenance Director stated the staff would fill out what needed repaired, and then the Maintenance staff would write on the paper work order on what they fixed and how they fixed it. The Maintenance Director stated he does a walk through daily and would look at the books at the nursing station every morning and sometimes more, and would do those tasks first unless something bigger needed to be fixed. The Maintenance Director stated he was not aware of the flooring being raised up down the North Main hallway or outside room [ROOM NUMBER]. The Maintenance Director stated there was a 30 feet part of the flooring that a contracted company had repaired but the area continues to need repair. The Maintenance Director stated the uneven flooring, the clean out covers being cracked, and the uneven flooring was a hazard risk to both residents and staff that could cause injury. The Maintenance Director further stated the odor in the bathroom was where water had hooved up the flooring around the base of the commode, even though the odor was a strong urine odor. Observation on 10/29/2024 at 2:15 PM of the maintenance repair log at the North Nurses station revealed needed repairs. There was no documented evidence of missing drywall, chipped paint, and/or impalement areas listed. Surveyor: [NAME], [NAME] 49360 3. Observation of the North Main Hallway on 10/27/2024 at 1:40 PM revealed the brown flooring had loosened adhesive and uneven flooring around the clean out covers, which caused cracked areas and gaps in the brown flooring. Observation of Resident (R) 79 on 10/27/2024 at 1:44 PM revealed R79's call light was lying on the floor and out of reach of R79. Observation of the bathroom in room [ROOM NUMBER] on 10/27/2024 at 1:47 PM revealed the bathroom had a strong urine odor. Observation of R58 on 10/27/2024 at 1:56 PM revealed R58's call light was lying on the floor under his bed and out of reach of R58. Continued observation revealed the brown flooring outside R58's room had loosened adhesive which caused the flooring to rise up from its base causing a trip hazard. Observation of room [ROOM NUMBER] on 10/27/2024 at 2:04 PM revealed scuffed, chipped paint on the door facing and door leading into resident room [ROOM NUMBER]. Observation of the bathroom in room [ROOM NUMBER] on 10/27/2024 at 2:08 PM revealed a strong urine odor with an unflushed commode. Observation of R73 on 10/27/2024 at 2:53 PM revealed R73 was lying in the bed with call light lying on the floor. Observation of R73's bathroom revealed the bathroom door had scuffed, chipped paint on both the door and the door facing. Further observations on 10/28/2024 at 8:44 AM and on 10/29/2024 at 3:16 PM revealed the issues remained with no signs of staff addressing the issues. In an interview on, 10/27/2024 at 2:00 PM, the Dietary Account Manager stated that she used a computerized reporting program to notify the Administrator and Maintenance Director of work orders for the kitchen. The Dietary Account Manager stated that she had reported the leaking pipes, chipped floors, and walls needing painting on this system. The Dietary Manager provided open and in progress work order requests submitted through the computerized reporting system dating back to 2023. The Dietary Manager stated that she followed the reporting process that was in place for her and would report issues multiple times to try to get them addressed. In an interview on, 10/27/2024 at 6:15 PM, the District Manager of Dining Services stated that when work orders were submitted through the computer reporting system the Dietary Account Manager also made him aware of the work order and he compiles a report that is given to the Administrator. In an interview on, 10/28/2024 at 4:50 PM, the Maintenance Director stated that he and his assistant were responsible for the upkeep of the facility and grounds. The Maintenance Director stated he was unaware of the scuffs on resident doors, the broken toilet paper dispenser, the lighting issues, the plumbing protruding from walls, and the flooring issues in resident rooms and halls. The Maintenance Director stated that the crack in the entry door has been there for over a year and happened when a resident kicked it. He stated he was unsure if anyone had communicated with the appropriate parties to have it repaired or replaced. Continued interview with Maintenance Director revealed the uneven flooring could cause injury to residents, staff, or the public who walked on it. Additionally, the Maintenance Director stated that the plumbing sticking out from the walls could be hazardous to anyone in the bathroom if they fell into it. The Maintenance Director stated he believed the lighting in the bathroom of room [ROOM NUMBER] was too low of a wattage to provide adequate lighting. The Maintenance Director stated that he did not access work orders in the computerized reporting system. In an interview on, 10/27/2024 at 6:15 PM, the District Manager of Dining Services stated that when work orders were submitted through the computer reporting system the Dietary Account Manager also made him aware of the work order and he compiles a report that is given to the Administrator. In an interview on, 10/28/2024 at 4:50, the Maintenance Director stated that he and his assistant were responsible for the upkeep of the facility and grounds. The Maintenance Director stated he was unaware of the scuffs on resident doors, the broken toilet paper dispenser, the lighting issues, the plumbing protruding from walls, and the flooring issues in resident rooms and halls. The Maintenance Director stated that the crack in the entry door has been there for over a year and happened when a resident kicked it. He stated he was unsure if anyone had communicated with the appropriate parties to have it repaired or replaced. Continued interview with Maintenance Director revealed the uneven flooring could cause injury to residents, staff, or the public who walked on it. Additionally, the Maintenance Director stated that the plumbing sticking out from the walls could be hazardous to anyone in the bathroom if they fell into it. The Maintenance Director stated he believed the lighting in the bathroom of room [ROOM NUMBER] was too low of a wattage to provide adequate lighting. The Maintenance Director stated that he did not access work orders in the computerized reporting system. During an interview on 10/29/2024 at 2:16 PM with Licensed Practical Nurse (LPN)1 revealed the staff working the floor utilized the maintenace repair log, located at the nurse's station, to alert the Maintenance Director of needed repairs. LPN1 further stated she had not thought about the pipe protruding from the wall in the bathroom being an accident hazard. In an interview with the Environmental Services Director (ESD) on 10/30/2024 at 9:12 AM, the ESD stated her contracted staff were not allowed to touch bed pans and her staff knew to let the aides or nurses know so they could remove the bed pans and then the housekeeping staff would clean the bathrooms. The ESD stated the contracted company would not let her staff remove trash if it had soiled briefs in them. The ESD stated she was aware of the odors in some of the bathrooms and her staff cleaned those bathrooms at least twice a day but she believed the odors were in the flooring and she had told the facility Administrator but the flooring had not been replaced. The ESD stated she was aware of the uneven flooring but stated the area had flooded in the past and felt like water had gotten under the adhesive, which caused it to loosen. The ESD stated it was a safety hazard and could cause a resident or staff member to trip and fall, which could lead to injuries. In an interview on, 10/30/2024 at 3:30 PM, the Director of Nursing (DON) stated it was her expectation for the residents to live in a safe, clean, friendly, homelike environment. The DON stated that she was aware of uneven flooring in the hallways and that drain grates were sinking in the flooring. Continued interview with the DON revealed, that someone could get a puncture wound or a head injury if they fell into the visible plumbing sticking out from the wall. The DON stated occasionally she could smell odors but expected all odors not to linger in a homelike environment. In an interview on, 10/30/2024 at 3:50, the Administrator stated that she did room rounding every day but did not go into resident bathrooms during the rounds. The Administrator described a homelike environment as being free from odor, and flooring should be free of debris and cracks. Continued interview revealed the Administrator was unaware of issues with the flooring in resident rooms and hallways until 10/29/2024. Additionally, the Administrator stated that the uneven flooring could cause a tripping hazard to residents. The Administrator stated that she had access to the computerized reporting system but did not access it. Continued interview with the Administrator she stated she was not aware of the impalement issues in the bathrooms until it was brought to her attention yesterday and continued to state if a person fell into the areas it could cause injury. She further stated the nurses round twice daily and the Maintenance is to be rounding, but the Administrator was not sure there was a rounding log maintained. The Administrator further stated the Maintenance Director was required to be in the morning meeting every morning and reported to her on what repair or project he was working on for the day. The Administrator stated she followed up on larger repair projects, and the Maintenance Director makes her aware of the project he was working on. The Administrator stated with smaller jobs she normally does not follow up on their completion.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure all medications were securely stored to restrict access to only authorized personnel as evidenced by one (1) of two (2) treatment carts observed unlocked, and unattended by staff on the North Main Hallway. The findings include: Review of the facility's policy, Storage of Medications revised date December 15, 2018, and the facility's Medication Administration policy revised on April 2019, revealed compartments containing medications were required to be locked when not in use: and trays or carts used to transport such items are not left unattended if unlocked. Observation, on 10/28/2024 at 10:22AM, revealed a treatment cart on the North Main Hallway unlocked and unattended by Registered Nurse (RN)1. RN1 was standing at the medication cart, which was approximately 12-15 feet away from the treatment cart. RN1 stated on 10/28/2024 at 10:25AM, he had been using the treatment cart but had entered a resident's room to administer medications thus leaving the treatment cart unattended and unlocked. During an interview, on 10/28/2024 at 10:25AM, RN1 stated it was not acceptable for a medication cart to be unlocked when not in use. RN1 stated medications should be securely stored because the facility would not want residents to have access to the contents of the cart. RN1 stated if the cart was not in use by one of the nurses, it should be locked. RN1 acknowledged there were cognitively impaired residents nearby who were independently mobile and could pass by the carts. RN1 stated it was important to lock the cart to prevent harm or injury to residents and visitors. During an interview, on 10/28/2024 at 10:40AM, with Licensed Practical Nurse/Unit Manager1(LPN/UM1) stated her expectations were for staff to provide a safe environment for residents. She stated treatment carts were to remain locked when not attended by staff because the facility had residents who might wander. LPN/UM1 further stated she would report any concerns to the administrator. During an interview, on 10/28/2024 at 1:30PM, the Director of Nursing (DON) stated securing medications via locked storage was the facility's policy and was in place to prevent residents from having access to the contents of the carts. The DON stated the carts should always be locked when not in use. The DON stated it was important to prevent residents from coming by and getting a hold of and possibly ingesting some of the medications which could cause harm. The DON stated it was her desire to keep all residents safe. During an interview, on 10/30/2024 at 9:30AM, the Administrator stated the treatment cart should be locked when not in use. The Administrator stated this was important because of the potential harm for any resident. The Administrator stated she and her staff strive to provide a safe and happy home life for the residents and to attain as much quality of life as possible. She further stated all staff were her responsibility and the issues would be addressed immediately.

Based on observation, interview, and review of facility policy, the facility failed to maintain an infection control program to help prevent the development and transmission of communicable diseases and infections related to enhanced barrier precautions for 2 of 3 residents investigated for tube feeding care, Resident (R2 and R7). Additionally, observations revealed four unlabeled bed pans and one unlabeled wash basin lying in the bathroom floors were uncovered. The findings include:. Review of the facility policy, MDRO [multi-drug resistant organism] PPE [personal protective equipment]- Enhanced Barrier Precautions, dated 01/2024, revealed facility staff were to wear gowns and gloves when performing high-contact care for a resident with an indwelling device, such as a feeding tube. Review of the facility's policy, titled Infection Control, revised 03/2020, revealed the facility was committed to providing a safe and healthy environment for residents and to minimize or prevent the spread of infections. 46710 1a) Review of Resident (R) 7's Admission Record revealed the facility admitted the resident on 02/23/2023. Further review revealed R7's diagnoses on 10/27/2024 included Alzheimer's dementia, gastrostomy status, and adult failure to thrive. Review of the Orders tab in R7's electronic health record revealed the physician ordered enhanced barrier precautions. Observation 10/29/24 10:13 AM revealed Registered Nurse (RN)2 failed to don a gown while performing tube site care for R7. Further observation revealed a sign on R7's door for enhanced barrier precautions, as well as a container of PPE, including gowns and gloves. In an interview on 10/29/2024 at 10:57 AM, RN2 stated she thought the sign on R7's door indicated the resident had a history of a multi-drug resistant organism. She further stated she needed to ask her manager if she was supposed to wear PPE while providing care to R7. b) Review of R2's Admission Record revealed the facility admitted the resident on 08/23/2000. Further review revealed R2's diagnoses as of 10/28/2024 included cerebral palsy, gastrostomy status, and dysphagia. Observation on 10/29/24 10:50 AM revealed RN2 failed to don a gown while performing G-tube site care for R2. Further observation revealed there was no sign for enhanced barrier precautions (EBP) on R2's door, though appropriate PPE, including gowns, were available in the container hung on the door. In interview on 10/29/24 at 10:57 AM, RN2 stated she did not know why R2 had gowns hanging in a container on her door. She further stated there was no sign, so she did not know why the PPE was there or when staff were expected to wear PPE for R2. In an interview on 10/29/24 at 2:15 PM the South Unit Manager (SUM) stated the facility implemented enhanced barrier precautions (EBP) for residents colonized with multi-drug resistant organisms (MDROs), as well as for residents with indwelling devices, such as G-tubes and urinary catheters. In further interview, the SUM stated she expected staff to wear a gown and gloves for a resident in EBP any time they came into contact with the resident's bodily fluids or provided care to the G-tube or catheter. Per interview, RN2 asked the SUM if she needed to wear PPE for R2 because the sign had fallen off the door, so she did not know why the PPE was hanging on the door. In an interview on 10/29/24 at 2:23 PM, the Assistant Director of Nursing/Infection Preventionist (ADON/IP) stated the facility implemented EBP for every resident with a feeding tube, chronic wound, or foley catheter because those residents were at higher risk for developing infections. She further stated her expectations were for staff to wear a gown and gloves when providing care to a G-tube. In an interview on 10/29/24 at 2:31 PM, the Director of Nursing (DON) stated the facility policy was for staff to wear PPE, including gown and gloves when providing high-contact care, especially caring for a wound, G-tube, or other indwelling device. In an interview on 10/29/24 at 2:39 PM, the Administrator stated she expected staff to wear PPE, including gowns whenever providing care for an indwelling device, changing linens, or other high contact care. She further stated the facility maintained signage on the residents in EBP to alert staff to the PPE they needed to wear for care activities. In continued interview, the Administrator stated the importance of EBP was to protect vulnerable residents from potential bacteria on staff member clothing. 49360 2. Observation of the bathroom in room [ROOM NUMBER] on 10/27/2024 at 1:47 PM revealed one unlabeled, uncovered bed pan sitting on the floor. Observation of the bathroom in room [ROOM NUMBER] on 10/27/2024 at 2:36 PM revealed two unlabeled, uncovered bed pans and one unlabeled, uncovered wash basin sitting on the floor beside the commode. Observation of the bathroom in room [ROOM NUMBER] on 10/27/2024 at 2:53 PM revealed one unlabeled, uncovered bed pan sitting on the floor. Observation of the bathroom in room [ROOM NUMBER] on 10/27/2024 at 4:15 PM revealed one unlabeled, uncovered bed pan sitting on the floor beside the commode. In an interview with Certified Nursing Assistant (CNA) 1 on 10/27/2024 at 2:00 PM, she stated bedpans and wash basins were to be labeled with resident room number and bed number and had to be covered and placed in the bottom drawer in resident rooms. CNA1 stated if not labeled and stored properly it became an infection control issue and bacteria could be spread from resident to resident. CNA1 stated the bedpans and wash basin would be thrown away to prevent the spread of bacteria. In an interview with Licensed Practical Nurse (LPN) 1 on 10/29/2024 at 9:52 AM, he stated bedpans and wash basins were to be labeled and covered in a bag and stored in bottom drawer in a resident room to prevent the spread of infection. In an interview with the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) on 10/30/2024 at 10:18 AM, the ADON/IP stated she did infection tracking every Monday and did a walk through daily to make sure there were no infection control issues such as items on medication carts or nursing counters. The ADON/IP stated all bedpans were to be stored labeled and in a bag in the bottom drawers of resident rooms. Also, the ADON/IP stated the wash basins were treated the same way and should be labeled and in a bag. The ADON/IP stated labeling should include the resident room number and the bed number. The ADON/IP stated it was her expectation that any staff member who found a bedpan or wash basin unlabeled or uncovered, then that item would be thrown away as it was an infection control issue, which would cause germs to be passed from resident to resident or germs could be spread to a staff member. The ADON/IP stated infection control trainings occurred at least quarterly but usually something regarding infection control was reviewed monthly with staff as during her daily walk through of the facility she found little things that needed to be re-educated on. In an interview with the DON on 10/30/2024 at 3:29 PM, the DON stated she did rounds on the hallway during room rounds to look for any infection control concerns such as foley catheters without dignity bag, bedpans not stored properly, and issues with enhanced barrier precautions. The DON stated it was her expectation that bedpans and wash basins be stored in a plastic bag in bottow drawers in resident rooms with appropriate labeling on it. The DON stated it was her expectation that if it was found unlabeled or uncovered, then it would be thrown away to prevent the spread of infection. The DON stated her IP would re-educate on the spot if any issues with infection control was found in the facility. In an interview with the Administrator on 10/30/2024 at 3:49 PM, the Administrator stated she completed room rounds daily but did not go into resident bathrooms on room rounds. The Administrator stated it was her expectation that bedpans and wash basins be labeled and covered and stored in bottow drawers. The Administrator stated she would not expect bedpans, urinals, or wash basins to be left lying on the bathroom floors as it could potentially spread infection to other residents or other staff members. The Administrator stated infection control issues were discussed in quality assurance performance improvement (QAPI) meetings and any issues with infection control was discussed and plans were implemented during that time. The Administrator stated the DON and the IP did audits and education over infection control at least quarterly but as needed if any issues arose that needed attention.

Based on interview, record review, and review of facility policy, it was determined the facility failed to notify the responsible party of a change in condition for one (1) of three (3) sampled residents (Resident #1). Resident #1 had a deep tissue injury (DTI) on his/her left buttock, and on 11/12/19 the DTI area opened; however, the facility failed to notify the resident's family when the change of condition occurred, and when the wound treatment needed to be altered. The findings include: Review of the facility's policy, Notification of Change of Condition: Responsible Party/Guardian, revised on 01/03/19, revealed staff would notify the resident's responsible party or guardian of changes and/or occurrences that occurred with the resident. Further review of the policy revealed when there has been any break in the resident's skin integrity, the responsible party or guardian should be notified, and official notification exists only when there is actual contact, not an answering service, machine, or busy signal. Review of the closed medical record revealed Resident #1 was admitted by the facility on 11/07/19 with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed the resident's Brief Interview for Mental Status (BI[CONDITION]) score was three (3), indicating the resident was severely cognitively impaired. Further review of the admission MDS revealed Resident #1 had a deep tissue injury (DTI). Review of a physician's orders [REDACTED].#1's physician ordered staff to apply TheraHoney Wound Gel to the resident's left buttock every other day and cover with a border gauze. Review of Nurse's Notes dated 11/12/19 revealed Registered Nurse (RN) #1 documented she received new changed treatment orders to Resident #1's DTI on his/her left buttock to TheraHoney Wound Gel every other day and cover with border gauze. Further review of the nurse's note revealed there was no documentation that Resident #1's responsible party was notified. Interview with RN #1 on 12/04/19 at 5:29 PM revealed she received the new wound treatment order from the NP on 11/12/19, when Resident #1's DTI on his/her left buttock had opened up. RN #1 further revealed she attempted to call Resident #1's responsible party several times on 11/12/19 to inform him of the NP's new order and the opened area; however, she could not reach the responsible party and forgot to document that she attempted to contact the responsible party. RN #1 revealed she had been trained to notify the responsible party when a change of condition occurs and to document it on the nurse's notes. Interview with the Director of Nursing (DON) on 12/04/19 at 5:50 PM revealed the nurses are trained to notify the responsible party when a change of condition occurs and to document that the responsible party/guardian was notified. She revealed she tries to train staff quarterly on the change of condition policy.

Based on interview, record review, and review of facility policy, it was determined the facility failed to notify the responsible party (RP) for one (1) of three (3) sampled residents (Resident #1) when the resident experienced a change in condition and when there was a need to alter treatment. Review of Resident #1's medical record revealed the resident developed skin breakdown and had several changes in wound treatment. However the facility failed to notify the resident's RP of the skin breakdown and treatment changes. The findings include: Review of the facility's policy, Notification of Condition Change: Responsible Party/Guardian Policy, reviewed 01/03/19, revealed the RP or guardian was required to be notified of changes in a resident's condition or occurrences. The policy stated the resident's responsible party or guardian would be notified if there was a break in skin integrity, a significant change in the resident's physical, mental, or psychosocial status, or there was a need to alter therapy, medications, treatments, or the resident's plan of care. The policy also stated nursing staff was to document the name of the person notified regarding the resident's change in condition as well as the date and time the notification was made in the nursing notes. Review of Resident #1's medical record revealed the facility admitted the resident on 06/28/18 with [DIAGNOSES REDACTED]. Review of Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to be severely cognitively impaired and require extensive assistance of two staff members for bed mobility, transfers, toileting, hygiene, and bathing. The facility also assessed the resident to have no skin breakdown. Review of a Skin Observation Tool for Resident #1 dated 08/26/18 revealed the resident had no skin breakdown. Review of a Situation/Background/Appearance/Review/Notify (SBAR) Communication form dated 09/07/18, revealed Resident #1 was assessed to have a skin tear and Moisture Associated Skin Damage (MASD) to his/her sacral area. The resident's physician was notified of the skin tear and skin breakdown and a new order was received for a calcium alginate dressing (an absorbent wound dressing) to be applied to the resident's sacral area. However, there was no documented evidence in the resident's medical record that the resident's RP was notified that the resident had developed skin breakdown and was receiving treatment to the area. Review of a SBAR for Resident #1 dated 09/15/18, revealed the facility documented the resident had worsening pressure and moisture associated skin damage to the bilateral buttocks. The resident's physician was notified and a new order was received to cleanse the area with normal saline, apply calcium alginate, and cover with border gauze (an absorbent wound dressing that allows moisture vapor exchange) daily and as needed until resolved. However, there was no documented evidence that the resident's RP was notified of the change in the resident's condition or the need to alter treatment. Review of a SBAR and a skin observation tool for Resident #1, both dated 10/18/18, revealed the resident continued to have an open area to the coccyx related to MASD and excoriation to bilateral buttocks. The resident's physician was notified and an order was received to cleanse the open area to the coccyx with normal saline, apply Nu-Derm alginate (used to create a moist wound environment), and cover with a dry dressing daily and as needed until resolved. Further review revealed an order was also obtained to apply [MEDICATION NAME]/Baza/Zinc 1:1:1 cream to the excoriation on Resident #1's bilateral buttocks every shift and as needed until the excoriation had resolved. However, review of the resident's medical record revealed [REDACTED].#1's RP was notified of the resident's change in condition and the need to alter the resident's treatment. Review of a SBAR for Resident #1 dated 10/23/18 revealed the facility had assessed that the MASD to the resident's coccyx had worsened and three (3) open areas were present. The physician was notified and new orders were received to change the treatment to the coccyx area to DermaCol/Ag (an advanced wound care dressing) and cover the area with a dry protective dressing daily and as needed. However, there was no evidence that the resident's RP was notified of the change in the resident's condition or the need to alter the resident's treatment. Review of a SBAR for Resident #1 dated 11/06/18 revealed the facility assessed the resident's skin breakdown to be worse and documented that slough (dead tissue) was present. The resident's physician was notified and orders were received for Santyl ([MEDICATION NAME] ointment) to the area with slough and Puracol (collagen dressing for chronic wounds) to the MASD. However, there was no documented evidence that the resident's RP was notified of the change in the resident's condition or the need to alter the resident's treatment. Interview with Resident #1's RP on 01/14/19 at 9:33 AM revealed he had never been notified by the facility that Resident #1 had developed skin breakdown until the resident was admitted to the hospital on [DATE] for an unrelated problem. The RP stated Resident #1 required surgery on the coccyx to remove the dead tissue to the area. Interview with Registered Nurse (RN) #1 on 01/16/19 at 5:10 PM revealed she had routinely cared for Resident #1, but had never notified the resident's RP that the resident had developed skin breakdown. Interview with the Administrator and Director of Nursing (DON) on 01/16/19 at 6:31 PM revealed they had identified that nursing staff were not documenting notification of changes in resident conditions to RPs. The Administrator and DON stated an in-service had been conducted with staff related to RP notification. Continued interview with the Administrator and DON revealed Resident #1's RP should have been notified when the resident developed skin breakdown and when the area declined and/or treatment was changed.

Based on interview, record review, and review of facility policies, it was determined the facility failed to ensure one (1) of three (3) sampled residents (Resident #1) received adequate assistance to prevent accidents. Resident #1 was assessed by the facility to require extensive assistance of two staff persons for transfers. However, on 09/20/18, State Registered Nurse Aide (SRNA) #1 transferred the resident without assistance and hit the resident's right lower extremity on the bed. Subsequently, Resident #1 was transferred to the hospital on [DATE], and was diagnosed with [REDACTED]. Resident #1 underwent an open reduction and internal fixation of the right tibial shaft periprosthetic fracture on 09/22/18. The findings include: Review of the facility's Care planning/MDS/RAI Process policy, with a revision date of 11/28/18, revealed the purpose of the Resident Assessment Instrument (RAI) is to incorporate the identified medical and nursing needs of each resident into interventions and goals to meet those needs. The RAI is a process that defines an approach to resident assessment and development of the plan of care to help the resident attain the highest practicable functional level. Review of the facility policy, Nursing Services, reviewed 08/17/18, revealed the facility would have staff with the appropriate competencies and skill sets to provide nursing and related services to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Review of Resident #1's closed medical record revealed the facility admitted the resident on 09/24/09 with [DIAGNOSES REDACTED]. Review of Residents #1's Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of ten (10) indicating the resident was moderately cognitively impaired. Further review of the MDS revealed the facility assessed the resident to require the extensive assistance of two staff persons for bed mobility, transferring, dressing, toileting, and hygiene. Review of Resident #1's Comprehensive Care Plan with a projected goal date of 10/09/18, and the Certified Nursing Assistant Care Plan for (MONTH) (YEAR), revealed Resident #1 required the assistance of two staff persons for mobility and transfers. Review of a facility investigation initiated on 09/21/18 and completed on 09/26/18 revealed on 09/20/18, Resident #1 began to complain of pain to the right knee, shortly after being transferred from the bed to a wheelchair at approximately 10:00 AM. Review of the Advanced Practice Registered Nurse's (APRN's) documented assessment of Resident #1 on 09/20/18 and interview with the APRN on 09/26/18 at 1:45 PM, revealed she was asked to assess Resident #1 on 09/20/18, at approximately 11:45 AM due to the resident complaining of pain to the lower right extremity. The APRN examined Resident #1 and found the resident's right knee was swollen, unable to be extended, had decreased range of motion, and was tender. The APRN ordered an in-house x-ray of the resident's right knee. Continued interview with the APRN and review of a mobile radiology x-ray report for Resident #1 dated 09/20/18, revealed the conclusion of the mobile x-ray obtained on 09/20/18 was that the resident had an old healing right knee fracture. However, APRN #1 stated Resident #1 continued to complain of pain and she re-examined the resident and determined that considerable bruising had developed to the area with continued increased swelling even after ice was applied. The APRN stated she subsequently decided to send Resident #1 to the hospital for evaluation and treatment at approximately 5:00 PM. Further review of the APRN's documentation revealed that the facility had continued to investigate the injury to Resident #1 and had determined the injury was likely the result of an improper transfer. Continued review of the facility's investigation initiated on 09/21/18 and completed on 09/26/18, revealed that during the investigation the facility determined that SRNA #1 had failed to appropriately transfer Resident #1 on the morning of 09/20/18. The investigation discovered that when transferring Resident #1 on the morning of 09/20/18, SRNA #1 failed to utilize two staff members for transferring the resident from the bed to a wheelchair, and transferred the resident by herself. The investigation further determined that SRNA #1 had hit the resident's leg on the bed during the transfer, and the resident immediately complained of pain to the area. Interview with SRNA #1 on 09/26/18 at 12:40 PM revealed she provided care to Resident #1 on the morning of 09/20/18. SRNA #1 acknowledged that she was aware Resident #1 required the assistance of two staff members for transfers, and stated that there was another staff member present in the room at the time she transferred Resident #1 independently. However, SRNA #1 stated, I just wanted to get (the resident) up as quick as possible and did not ask SRNA #4 to help her transfer the resident. Further interview with SRNA #1 revealed that she could have bumped Resident #1's leg on the bed during the transfer. SRNA #1 stated Resident #1 yelled out in pain during the transfer, but stated the resident often yells out and that it was normal for the resident. Interview with SRNA #4 on 09/25/18 at 4:25 PM revealed she was present on 09/20/18 at approximately 10:00 AM, when SRNA #1 transferred Resident #1 from the bed to the wheelchair. SRNA #4 stated she was also aware that Resident #1 required the assistance of two staff members for transfers, but stated that SRNA #1 did not ask her for assistance with transferring Resident #1. SRNA #4 stated that after Resident #1 was transferred into the wheelchair, the resident began to yell my leg, my leg. SRNA #4 stated that SRNA #1 then proceeded to push Resident #1 out into the hallway, and eventually took the resident to the nurses' station due to the resident's complaints of pain. Interview with the Unit Manager on 09/26/18 at 1:30 PM revealed she assessed Resident #1 on 09/20/18, at approximately 11:00 AM. The Unit Manager stated SRNA #1 brought the resident to the nurses' station, and stated the resident was complaining of pain to the right lower extremity. However, the Unit Manager stated that SRNA #1 did not report that Resident #1's leg had been hit on the bed during transfer. The Unit Manager assessed Resident #1 to have swelling and a nickel-sized knot just below the right kneecap, and the resident was complaining of pain to the area. The Unit Manager stated she notified the APRN who was in the building, and the APRN assessed Resident #1. Review of Resident #1's hospital summary revealed the resident arrived at the Emergency Department on 09/20/18, at 5:55 PM. Review of a hospital Diagnostic Radiology Report dated 09/20/18 revealed Resident #1 was diagnosed with [REDACTED]. Further review of the hospital summary for Resident #1 revealed the resident subsequently underwent an open reduction and internal fixation of the right tibial shaft periprosthetic fracture on 09/22/18. Interview with the Administrator and Director of Nursing (DON) on 09/27/18 at 10:30 AM revealed resident care plans were located inside the closet door of each resident's room. They stated that staff caring for residents were expected to review the care plan before providing care to the resident, and follow the plan of care as written. Further interview revealed the DON acknowledged that SRNA #1 did not follow the plan of care for Resident #1 on 09/20/18, transferred the resident independently, and hit the resident's lower extremity on the bed during the transfer. The DON also stated that SRNA #1 failed to report hitting the resident's leg on the bed until shortly before the resident was transferred to the hospital at approximately 5:00 PM on 09/20/18, about seven hours after injuring the resident's leg and the resident's initial complaints of pain.

Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure the Comprehensive Care Plan was implemented for one (1) of three (3) sampled residents to meet the resident's medical and nursing needs that had been identified by the resident's comprehensive assessment. Resident #1 was assessed by the facility to require extensive assistance of two staff persons for transferring. However, on 09/20/18, State Registered Nurse Aide (SRNA) #1 transferred Resident #1 without assistance, resulting in the resident sustaining fractures of the proximal tibia metaphysis and fibular shaft. Subsequently, Resident #1 had an open reduction and internal fixation of the right tibial shaft periprosthetic fracture on 09/22/18. The findings include: Review of the facility's Care planning/MDS/RAI Process policy, with a revision date of 11/28/17, revealed the purpose of the Resident Assessment Instrument (RAI) was to incorporate the identified medical and nursing needs of each resident into interventions and goals to meet those needs. The policy stated the RAI would be utilized to define approaches and develop a plan of care to help the resident attain their highest practicable functional level. Review of Resident #1's closed medical record revealed the facility admitted the resident on 09/24/09 with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of ten (10) indicating the resident was moderately cognitively impaired. Further review of the MDS revealed the facility assessed the resident to require the extensive assistance of two staff persons for bed mobility, transferring, dressing, toileting, and hygiene. Review of Resident #1's Comprehensive Care Plan with a projected goal date of 10/09/18, and the Certified Nursing Assistant Care Plan for (MONTH) (YEAR), revealed Resident #1 required the assistance of two staff persons for mobility and transfers. Review of a facility investigation initiated on 09/21/18 and completed on 09/26/18 revealed the facility initiated an investigation on 09/20/18, related to Resident #1 being transferred to the hospital and diagnosed with [REDACTED]. Subsequently, Resident #1 had an open reduction and internal fixation of the right tibial shaft periprosthetic fracture on 09/22/18. Further review of the investigation revealed the facility determined that SRNA #1 failed to implement the resident's plan of care on 09/20/18, when transferring the resident from the bed to a wheelchair. SRNA #1 transferred the resident without assistance from another staff member and hit the resident's right lower leg on the bed resulting in the injury. Interview with SRNA #1 on 09/26/18 at 12:40 PM revealed she transferred Resident #1 independently, despite there being another staff member in the room at the time. SRNA #1 stated she was in a hurry to get the resident up, and did not ask SRNA #4 to assist her. Interview with SRNA #4 on 09/25/18 at 4:25 PM revealed she was in Resident #1's room with SRNA #1 on 09/20/18, and witnessed SRNA #1 transfer Resident #1 by herself. SRNA #4 stated the resident immediately began to yell my leg, my leg when placed in the wheelchair. SRNA #4 stated that she was also aware that Resident #1 required the assistance of two staff members for transfers, but stated SRNA #1 did not ask for assistance with transferring Resident #1. Interview with the Unit Manager on 09/26/18 at 1:30 PM revealed resident care plans were posted on the inside of each resident's closet door, and that all staff are expected to follow the care plan when providing care to residents. Interview with the Administrator and Director of Nursing (DON) on 09/27/18 at 10:30 AM revealed SRNAs were expected to review each resident's plan of care at the beginning of each shift to ensure they were familiar with and were providing services as outlined on the plan of care. The DON stated the facility's investigation determined that SRNA #1 failed to implement Resident #1's care plan when transferring the resident on 09/20/18, which resulted in the resident's fractures of the proximal tibia metaphysis and fibular shaft.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure food was distributed and served in accordance with professional standards for food service safety. Observation of the three-compartment sink revealed the facility failed to ensure sanitizing solution was added to the water to ensure cooking utensils were sanitized. In addition, the facility failed to ensure two ice scoops stored in a container beside the ice machine were covered. The findings include: 1. Review of the Pots and Pans Sanitizing Solution policy (dated 07/12/16) revealed to ensure pots and pans were sanitized they must be immersed in water with a sanitizing agent for at least two (2) minutes or per manufacturer guidelines. Observation in the kitchen at 10:45 AM on 07/17/18, revealed the third (sanitizing) compartment of the pot/pan sink was filled with water and contained several pots, pans, and other cooking utensils. Facility staff tested the water in the third compartment of the sink for sanitizer solution accuracy. According to the sanitizing test strip, there was no sanitizing solution in the third compartment of the sink. The Dietary Manager (DM) checked the sanitizer solution dispenser, and stated there was no sanitizing solution being dispensed into the sink. Observation revealed the sanitizing solution container was empty. Interview with the Cook at 10:50 AM on 07/17/18, revealed the sanitizing solution container for the third compartment had been empty since she came to work that morning. According to another staff member, the sanitizing solution ran out last night, on 07/16/18. 2. Review of the Ice Machines and Ice Storage Chests policy (dated (MONTH) 2012) revealed staff were required to keep the ice scoop/bin in a covered container when not in use. Observation at 10:40 AM on 07/17/18, revealed two (2) ice scoops were stored inside a container with no cover on the container. Interview with the Dietary Manager revealed the facility did not have a cover for the ice scoop container. She also stated she was not aware the scoops were supposed to be covered.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to maintain an effective pest control program. Review of a pest control report dated 06/21/18, revealed action was required to prevent entry of pests; however, the facility failed to make the repairs and flies were observed in the facility. The findings include: Review of the facility's Pest Policy, dated (MONTH) 2005, revealed the facility maintained an ongoing pest control program to ensure the building was free of insects and rodents. Further review revealed the facility had contracted a company to provide pest control. Observation on 07/17/18 at 12:24 PM, revealed Resident #72 sitting up in bed with a fly swatter lying on the bed. Further observation revealed two flies on the resident's bed. Resident #72 was observed to be hard of hearing and unable to be interviewed. However, Resident #72 stated, I don't like these flies. Observation of Resident #72 on 07/18/18 at 11:38 AM, revealed the resident was lying in bed with his/her eyes closed with a fly swatter on the resident's bed. Review of the facility's Pest Control Customer Service Report dated 06/21/18 revealed concerns were identified that included holes/gaps under the exit doors and the facility needed new door sweeps. Further review of the report revealed action was needed to seal the doors to prevent pest entry or harborage. Observation on 07/19/18 at 10:55 AM, revealed sunlight was visible inside the hallway at the bottom of the double metal exit doors at the end of the North Hallway. Observation of the exterior of the double doors revealed the door sweeps at the base of the doors had areas of the rubber sweep missing and gaps in the sweep. Interview with Maintenance Staff Member #2 on 07/19/18 at 10:55 AM, revealed the facility had the supplies to replace the door sweeps; however, the sweeps had not been replaced.

Based on observation and interview, the facility failed to maintain a safe, clean, comfortable home-like environment. Observation revealed damage to the floors/walls in the facility hallways and shower rooms, a toilet in the shower room that was loose from the floor, a missing/unrepaired shower curtain in the North Hall shower room, and Resident #41's overbed table padding was in disrepair. In addition, the facility failed to maintain a comfortable temperature in the bathroom in resident room [ROOM NUMBER]. The findings include: 1. Observation during the initial tour on 07/17/18, revealed a damaged area to the wallboard located at the corner of North A and North B Hallways across from the nurses' station. The damage included a section of the wallboard missing, approximately 3 inches in length by 2 inches in width, close to the baseboard, and two smaller sections of missing wallboard above the larger section. Observation of the North A Hallway revealed a damaged area to the corner of the wall at the end of the North A Hallway next to room [ROOM NUMBER]. The damage included a section of beadboard paneling that had pulled away from the wall and had multiple torn areas and sections of the beadboard paneling missing. Interview with Maintenance Staff Member #2 on 07/19/18 at 10:55 AM, revealed staff were aware of the areas of damage to the hallway walls; however, they were waiting to get approval from their corporate office to finish the repairs. 2. Interview with Resident #11's family on 07/17/18 at 12:05 PM revealed the shower room on the North Hallway of the facility was dirty and had a dirty shower curtain. Further interview revealed the family assisted Resident #11 with his/her shower and had observed the shower room during Resident #11's personal care. Observation on 07/18/18 at 8:03 AM, of the shower room located on the North Hallway revealed the shower floor had multiple large areas of chipped paint missing and areas where the top layer of concrete was chipped with jagged edges. In addition, observation revealed a shower curtain was not in place in the shower room for privacy. Further observation on 07/19/18 at 11:05 AM, with the maintenance staff revealed a shower curtain was hanging in the shower room, but was only secured with three curtain hooks and sections of the curtain were hanging down from the shower rod. In addition, a brown stained section was present on the curtain. Observation of the South Hallway shower room on 07/19/18 at 10:55 AM, revealed the commode in the shower room was not stable and could be moved from side to side. A rust-colored bolt was exposed on the right side of the commode base. In addition, the floor at the base of the commode had multiple chipped areas and the base of the commode was not flush with the floor. The floor in the shower room on the South Hallway had multiple areas of chipped paint. Interview on 07/19/18 at 10:55 AM, with Maintenance Staff Member #2 revealed that he had tightened the commode in the South shower room approximately one month ago, but had not done any maintenance on the floors. 3. Observation of Resident #41 on 07/17/18 at 12:42 PM, revealed the resident was sitting in a wheelchair at the resident's overbed table. Resident #41's meal tray was on the table and Resident #41 was feeding himself/herself. Observation revealed the overbed table had padding around the edge and the padding was loose and hanging down on each end of the table. Further observation on 07/17/18 at 3:01 PM revealed Resident #41 was in bed with his/her eyes closed. The overbed table was sitting next to the bed and a two-inch gap was observed in the padding. Interview with Maintenance Staff Member #2 on 07/19/18 at 10:55 AM, revealed padding was placed on the overbed table at the request of the nursing staff because residents were at risk for falls, and was replaced when nursing staff requested replacement. 4. Observation of room [ROOM NUMBER] on 07/17/18 at 11:45 AM during the initial tour revealed multiple chipped paint areas on the wall above Bed A and Bed B. Observation revealed the wall behind the beds was painted a blue-green color and the areas where the paint was missing was white. Interview with Maintenance Staff Member #2 on 07/19/18 at 11:20 AM, revealed paint was available to repair the chipped/missing paint in the room, but Maintenance staff had not made the repairs. 5. Observation of the bathroom in resident room [ROOM NUMBER] on 07/18/18 at 4:30 PM, revealed the bathroom was hot. Observation and interview with State Registered Nurse Aide (SRNA) #2 revealed the light and heater were connected on the same switch; therefore, when the light was turned on, the heater also came on. Interview with Maintenance Staff Member #9 on 07/18/18 at 4:40 PM, revealed the light switch was connected to the heater. He stated they were wired that way in the bathrooms on the end of each hallway so they would be warm. He stated he usually disconnected them during the summer, but had not disconnected them yet.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to notify the responsible party for one (1) of twenty-one (21) sampled residents (Residents #48 and #83) when there was a need to transfer the resident. The facility failed to notify Resident #48's responsible party of a physician appointment for treatment of [REDACTED]. The facility transferred the resident to the appointment unaccompanied by family or staff. The findings include: Review of the medical record for Resident #48 revealed the facility admitted the resident on 09/03/13 with [DIAGNOSES REDACTED]. Review of an Order of Appointment of Guardian, dated 11/05/15, revealed two family members, one of which was Family Member #2, were appointed guardianship of Resident #48. Review of the Minimum Data Set (MDS) quarterly assessment for Resident #48 dated 06/18/18, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eight (8), which indicated the resident had moderate cognitive impairment. The MDS also revealed the resident exhibited behavioral symptoms, not directed at others, such as hitting, scratching self, pacing, disrobing in public, tantrums, throwing food, etc. Further review of the MDS revealed the resident required extensive assistance of two (2) or more persons for bed mobility, transferring, dressing, toilet use, and personal hygiene, and was totally dependent for bathing. The MDS also revealed Resident #48 was nonambulatory. Review of the comprehensive plan of care dated 06/11/18, revealed Resident #48 had self-care deficits and required assistance with all activities of daily living (ADLs). The care plan also revealed the resident had impaired cognitive skills related to Dementia and [MEDICAL CONDITION] and required interventions such as brief, simple, and consistent words; and cues and statements. Observation of Resident #48 on 07/17/18 at 12:00 PM, revealed the resident was in the dining room, having lunch, and feeding himself/herself. Observation of Resident #48 on 07/18/18 at 11:24 AM, revealed the resident was self-propelling in a wheelchair in the hall, and was observed to ask staff where his/her room was located. Interview with Resident #48 on 07/18/18 at 11:27 AM, revealed the resident was not able to answer questions appropriately and the interview attempt was unsuccessful. Review of a Progress Notes Report dated 07/16/18 at 8:00 AM, revealed Resident #48 left the facility per a transport company for an appointment at a physician's office. Record review revealed the facility sent a copy of the resident's face sheet and Medication Administration Record [REDACTED]. Phone interview with Registered Nurse (RN) #3 on 07/19/18 at 3:08 PM, revealed she was assigned to Resident #48 on 07/16/18, the day of the physician appointment. She stated the decision as to whether or not a resident was accompanied to an appointment was dependent upon how much assistance the resident may require and the resident's mental status. According to RN #3, she believed Resident #48 was cognitively alert enough to go to the physician by himself/herself sometimes. She stated whoever took off the order for an appointment usually called the resident's family to let them know the date and time of the appointment. RN #3 further stated she believed Resident 48's family was going to meet the resident at the physician's office, although there was no confirmation. According to RN #3, she did not know whether Resident #48's family was aware of the appointment and stated she did not contact the family regarding the appointment. Review of the physician's office note, dated 07/16/18, revealed the resident was seen for [MEDICAL CONDITION] and memory loss. Review of the note revealed the physician's office documented, (The resident) must have family that knows (the resident's) history or a nurse must be with (the resident) that knows and takes care of (the resident). Interview with Family Member #2 on 07/17/18 at 11:45 AM, revealed the facility had transferred Resident #48 to a neurologist appointment on three (3) separate occasions and the facility had not notified Family Member #2 or any other family member about the appointments. The Family Member stated she was upset that Resident #48 was alone at the physician's office from approximately 8:00 AM until 10:30 AM, and had spoken to the Administrator. However, the Administrator or the Director of Nursing (DON) could not guarantee the Family Member it would not happen again. Interview with the Director of Nursing (DON) on 07/19/18 at 05:56 PM, revealed the facility's process was to encourage the family of the residents to accompany the resident to physician appointments. She also stated Resident #48's family had never said anything to her regarding their wishes to go with the resident to physician appointments. She further stated it was thought to be a safe bet that someone from the family would have met the resident at the physician's office. However, the DON agreed there was no documentation that revealed the family had been contacted regarding the appointment.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure Minimum Data Set (MDS) assessments were accurately completed for two (2) of twenty-one (21) sampled residents. The facility documented that Resident #48 had received insulin on a quarterly assessment; however, the resident was not prescribed and did not receive insulin. In addition, the facility documented Resident #73 developed a pressure ulcer on 06/19/18; however, the resident had the pressure ulcer upon admission to the facility and the date the pressure ulcer developed was not known. The findings include: Review of the facility policy, Resident Assessment Instrument, Version 3.0, revealed assessments were required to accurately reflect the resident's status. 1. Observation of Resident #48 on 07/17/18 at 12:00 PM, revealed the resident was observed in the dining room, feeding himself/herself. Review of the medical record for Resident #48 revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #48's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eight (8), which indicated the resident had moderate cognitive impairment. The MDS also revealed the resident had received insulin injections for the past seven (7) days. Review of Resident #48's Medication Administration Record [REDACTED]. Interview with MDS Nurse #3 on 07/19/18 at 10:57 AM, revealed she completed the assessment for Resident #48 and documented that the resident received insulin. However, after reviewing the resident's electronic medical record (EMR) and MAR, she stated it was a documentation error because the resident did not receive any insulin during the timeframe. 2. Record review for Resident #73 revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Further review of the medical record revealed the resident had two (2) Stage I pressure ulcers, one (1) Stage II pressure ulcer, a Stage IV pressure ulcer, and one (1) unstageable pressure ulcer. Review of the Admission Minimum Data Set (MDS) Assessment for Resident #73 completed on 07/13/18, Section M, revealed the resident had a Stage II pressure ulcer that was present upon admission. The MDS further revealed the date of the oldest Stage II pressure ulcer was 06/27/18. However, an interview with the MDS Nurse on 07/21/18 at 5:30 PM, revealed Resident #73's Stage II pressure ulcer was present upon admission to the facility and the date the pressure ulcer was acquired was unknown. The MDS Nurse stated she documented the date the pressure ulcer was acquired in error and should have documented dashes indicating the date was unknown. Interview with the Director of Nursing (DON) on 07/21/18 at 5:45 PM revealed she did not monitor MDS assessments for accuracy. The DON stated the MDS Nurse was responsible for monitoring MDS assessments.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to implement the plan of care for one (1) of twenty-one (21) sampled residents (Resident #6). Resident #6's comprehensive care plan required staff to administer pain medication as needed for pain. However, interview with Resident #6 revealed on 07/17/18, the resident had right ear pain and the facility failed to administer pain medication. The findings include: Review of the facility's Care Plans-Comprehensive policy with a revision date of 10/31/17, revealed a person-centered comprehensive care plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs was developed for each resident. The policy stated the care plan would assist the resident to meet their needs, goals, and preferences; and care plan interventions would be implemented after consideration of the resident's problem areas and their causes. According to the policy, the care plan interventions would reflect actions, treatments, or procedures to meet the objectives toward achieving the resident's goals. A review of the medical record for Resident #6 revealed the facility admitted the resident on 06/12/09, with [DIAGNOSES REDACTED]. A review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #6 to have a Brief Interview for Mental Status (BIMS) score of twelve (12), which indicated the resident was interviewable. The MDS also revealed the facility had assessed the resident to have occasional pain and required pain medication as needed. A review of Resident #6's care plan with a revision date of 05/13/18, revealed the facility developed an intervention to administer pain medication to the resident as ordered by the physician. A review of Resident #6's physician's orders [REDACTED]. Observation of and interview with Resident #6 on 07/17/18 at 10:48 AM and 1:00 PM, revealed the resident's right ear was hurting. The resident stated he/she had informed the nurse. An interview conducted with Resident #6 on 07/18/18 at 9:30 AM, revealed the resident's right ear did not stop hurting until 7:00 PM the night before. The resident stated he/she notified LPN #5 on three (3) occasions on 07/17/18, that his/her right ear was hurting on 07/17/18; however, LPN #5 did not offer the resident anything for pain. A review of Resident #6's Medication Administration Record [REDACTED]. An interview conducted with LPN #5 on 07/19/18 at 1:15 PM, revealed she was required to check resident care plans daily and as needed. The LPN stated she was aware Resident #6 had a care plan to address his/her pain and stated she should have asked the resident if he/she had wanted pain medication. LPN #5 stated she just assumed the resident would ask if he/she needed anything for pain. An interview conducted with the Director of Nursing (DON) on 07/19/18 at 5:55 PM, revealed she had not identified any concerns with staff not providing care as directed by their care plans.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure the care plan for one (1) of twenty-one (21) sampled residents (Resident #11) was developed by an interdisciplinary team that included the resident's family. Interviews revealed the facility failed to include Resident #11's family in care plan meetings. The findings include: Review of the facility's policy entitled Care Plans - Comprehensive, revealed that the comprehensive care plan was prepared by an interdisciplinary team including at least: the attending physician/nurse practitioner/physician assistant; Registered Nurse; Nurse Aide; member of the food/nutrition services team; the resident; and the resident representative to the extent practicable. Interview with Resident #11's Responsible Party (RP #3) on 07/18/18 at 10:12 AM, revealed he/she had not received notification that a care plan meeting was being held for Resident #11 in approximately one year. The Responsible Party stated he/she would have attended the meetings had he/she been aware of when they were held. Review of the medical record for Resident #11 revealed the facility admitted the resident on 10/14/16, with [DIAGNOSES REDACTED]. Further review of Resident #11's medical record revealed a letter addressed to Whom it may concern inviting the family to meet on 12/05/17 at 2:00 PM to discuss Resident #11's care. There was no evidence that the letter was delivered or that the representative responded to the letter. Further record review revealed there was no evidence of any correspondence to the resident's representative since (MONTH) (YEAR). Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had been assessed to have a Brief Interview for Mental Status (BIMS) score of zero (0), which indicated the resident had severely impaired cognition. Further review revealed the facility conducted an MDS assessment on 02/11/18. Review of Resident #11's care plan revealed the facility met after each MDS assessment and revised the resident's care plan. However, there was no documented evidence that the facility invited Resident #11's family and no evidence that the resident's family attended the care plan meetings. Interview conducted on 07/18/18 at 1:00 PM with the Administrator revealed the facility Social Worker sent invitations to care plan meetings to residents' families. Interview with the Corporate Consultant on 07/18/18 at 1:05 PM, revealed the last care plan meeting that Resident #11's family attended was in (MONTH) (YEAR); however, she was not able to produce documentation regarding the care plan meeting. The Corporate Consultant further stated the facility was unable to produce documentation for any care plan meeting in (YEAR). According to the Corporate Consultant, the facility's facility Social Worker was new and inadvertently did not send out a care plan meeting invitation for the resident's March/April meeting.

Based on observation, interview, record review and review of the facility's policy it was determined the facility failed to provide care and services in accordance with the written plan of care for four (4) of thirty (30) sampled residents (Residents #11, #15, #16, and #17) and one (1) unsampled resident (Resident A). Review of the plan of care for Resident #11 revealed the resident had interventions in place that included giving medications as ordered for the treatment of [REDACTED]. Review of the plans of care for [MEDICAL CONDITION] activity or at risk for [MEDICAL CONDITION] for Residents #15, #16, and #17 revealed the residents had interventions in place that included administering medications as ordered. The facility documented on the residents' Medication Administration Records (MAR) that the residents' medications were administered according to physician's orders [REDACTED].#15's medication and review of Residents #11, #16, and #17's pharmacy medication dispensing records revealed the facility failed to administer the residents' medications as ordered by the residents' physicians. Resident #11's fourteen (14) day supply of [MEDICATION NAME] (medication to treat an abnormal heart beat) was not reordered for up to thirty-seven (37) days; Resident #17's thirty (30) day supply of [MEDICATION NAME] [MEDICATION]) went up to sixty-five (65) days between refills and up to forty-three (43) days between refills for a thirty (30) day supply of [MEDICATION NAME] (medication to prevent [MEDICAL CONDITION] and treat some psychiatric disorders); and Resident #16's fifteen (15) day supply of [MEDICATION NAME] went up to twenty-five (25) days between refills (refer to F333, F425, F490, and F514). Review of the plan of care for Resident A revealed interventions to provide wound care according to the physician's orders [REDACTED]. However, nursing staff failed to provide the wound care and dressing according to the plan of care. The facility's failure to have an effective system in place to ensure care and services were provided as per the resident's plan of care was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was determined to exist on 04/02/15 at 42 CFR 483.20 Resident Assessment (F282), 42 CFR 483.25 Quality of Care (F333), 42 CFR 483.60 Pharmacy Services (F425), and 42 CFR 483.75 Administration (F490 and F514). The facility was notified of the Immediate Jeopardy on 04/20/15. An acceptable Allegation of Compliance was received on 04/23/15, which alleged removal of the Immediate Jeopardy on 04/23/15. An extended survey was conducted on 04/24/15. The State Survey Agency determined the Immediate Jeopardy was removed on 04/23/15, which lowered the Scope and Severity to an "E" at 42 CFR 483.20 Resident Assessment (F282), 42 CFR 483.25 Quality of Care (F333), 42 CFR 483.60 Pharmacy Services (F425), and, 42 CFR 483.75 Administration (F490 and F514) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy, titled "Using the Care Plan," not dated, revealed the care plan shall be used in developing the resident's daily care routines and will be available for staff personnel who have responsibility for providing care or services to the resident. The policy further revealed the documentation must be consistent with the resident's care plan. 1. Review of Resident #11's medical record revealed the facility admitted the resident on 10/04/13, with [DIAGNOSES REDACTED]. Review of Resident #11's actual/potential cardiovascular problems care plan, revised date 12/19/14, revealed the resident had an intervention in place to give medications as ordered. Review of Resident #11's April 2015 physician's orders [REDACTED]. Review of the Pharmacy Medication Dispensing Records, dated 12/01/14 through 04/17/15, revealed Resident #11's [MEDICATION NAME] was dispensed with fourteen (14) tablets per medication card and had been dispensed seven (7) times from 12/10/14 to 04/15/15 (dispensed on 12/10/14, 12/21/14, 01/28/15, 02/11/15, 02/25/15, 03/25/15, and 04/15/15). During the timeframe reviewed (12/10/14 through 04/15/15) the pharmacy dispensed ninety-eight (98) [MEDICATION NAME] tablets; however, a total of one hundred twenty-eight (128) tablets were needed for staff to be able to administer the resident's [MEDICATION NAME] as it was ordered, per the physician's orders [REDACTED]. Review of Resident #11's [MEDICATION NAME] laboratory level obtained on 01/05/15 and 04/03/15 revealed the resident's [MEDICATION NAME] level was subtherapeutic. 2. Review of Resident #17's medical record revealed the facility admitted the resident on 10/23/98. The resident had [DIAGNOSES REDACTED]. Review of Resident #17's [MEDICAL CONDITION] Activity/At Risk for [MEDICAL CONDITION] care plan, revised 12/17/14, revealed the resident had an intervention to administer medications as ordered. Review of Resident #17's April 2015 physician's orders [REDACTED]. Review of the Pharmacy Medication Dispensing Records for Resident #17, dated 12/01/14 through 04/17/15, revealed the pharmacy dispensed thirty (30) capsules of [MEDICATION NAME] 250 mg (a 30-day supply) twice from 12/18/14 through 04/04/15 (on 12/18/14 and 01/28/15), for a total of sixty (60) capsules. However, for staff to be able to administer the resident's medications as physician ordered in order to follow the plan of care, one hundred seven (107) capsules were required. There was no explanation or documented evidence to account for the forty-seven (47) tablets that were needed in order for staff to administer the medication as physician ordered to follow the plan of care. Further review of the Pharmacy Medication Dispensing Records revealed the pharmacy dispensed one hundred twenty (120) capsules of [MEDICATION NAME] 125 mg, which was a thirty (30) day supply, on 02/20/15. However, the medication was not dispensed to the facility again until 04/05/15, forty-four (44) days later. There was no explanation or documented evidence to account for the medication that was needed for administration for approximately fourteen (14) days to ensure the medication was given per the plan of care. The SSA's Pharmacist Consultant conducted a post survey review of the facility's pharmacy dispensing records. Review of Resident #17's medication orders dated 04/01/15, revealed the resident was ordered to receive [MEDICATION NAME] 250 mg, one tablet each morning and evening, which had been in effect since 12/16/15; the dosage was verified via post survey phone interview with the Advanced Registered Nurse Practitioner on 05/01/15, as the physician was unavailable. In the initial citation narrative, the State Survey Agency's Surveyor stated the resident's [MEDICATION NAME] was to be given only once daily (in the morning) when, in fact, the dosage was two (2) tablets per day. It was noted, based on the pharmacy's dispensing records, that Resident #17 had been provided two refills each of 30 tablets (on 12/18/14 again on 01/28/15) during the review period. It was noted that each 30 tablet quantity was a 30-day supply when, in fact, the refills were only fifteen (15)-day supplies. The surveyor further noted that, from 12/18/14 through 04/04/15, the resident would have required a total of one-hundred and seven (107) tablets to achieve the required dosage requirement for that time period. However, because the daily dosage called for two (2) tablets per day, the required number of tablets for that time period would have called for twice that amount, or up to two-hundred and fourteen (214) tablets. Since only sixty (60) tablets had been dispensed to Resident #17 during that time period, there would have been a shortage of approximately one-hundred and fifty-six (156) tablets during that time period. 3. Review of Resident #16's medical record revealed the facility admitted the resident on 09/05/14. The resident had [DIAGNOSES REDACTED]. Review of Resident #16's [MEDICAL CONDITION] activity/at risk for [MEDICAL CONDITION] activity care plan, revised 02/03/15, revealed the resident had an intervention in place to administer medications as ordered. Review of Resident #16's physician's orders [REDACTED]. Review of Pharmacy Medication Dispensing Records for Resident #16, dated 12/01/14 through 04/17/15, revealed the pharmacy dispensed a 150-ml bottle (a 15-day supply) of [MEDICATION NAME] on 01/24/15. However, the medication was not refilled again until 02/18/15, approximately twenty-six (26) days later. There was no documented evidence or explanation for the medication that was needed for the eleven (11) days to ensure the medication was given per the physician's orders [REDACTED]. Review of the [MEDICATION NAME] Acid laboratory values for Resident #16 revealed the [MEDICATION NAME] Acid level was sub-therapeutic on 04/03/15. 4. Review of Resident #15's medical record revealed the facility admitted the resident on 10/18/13 and readmitted the resident on 03/20/15, after a hospital stay. The resident had a [DIAGNOSES REDACTED]. Review of Resident #15's [MEDICAL CONDITION] Activity/at risk for [MEDICAL CONDITION] Care Plan, revision date of 02/22/15, revealed the resident had an intervention in place to administer medications as ordered. Review of Resident #15's April 2015 physician's orders [REDACTED]. Staff was to administer 5 ml of [MEDICATION NAME] every morning and 7.5 ml of [MEDICATION NAME] at bedtime. Review of the Pharmacy Medication Dispensing Records for Resident #15 revealed 473 ml of [MEDICATION NAME] was dispensed to the facility on [DATE]. Observation on 04/17/15 at 2:20 PM, of Resident #15's [MEDICATION NAME] bottle from the facility's medication cart revealed the medication was dated as opened on 03/21/15, one day after the resident was readmitted to the facility. Observation revealed the [MEDICATION NAME] bottle contained 150 ml of medication. According to the resident's physician's orders [REDACTED]. However, review of Resident #15's MAR for 03/20/15 through 04/17/15 revealed staff documented they administered [MEDICATION NAME] to Resident #15 as ordered by the resident's physician. Interview on 04/15/15 at 4:00 PM with the Pharmacy Director revealed no additional medication had been dispensed to the facility as they would not be able to reorder the medication until they were out of the medication, or on the last dose of medication. Interview with RN #1 on 04/14/15 at 5:03 PM, with Licensed Practical Nurse (LPN) #5 on 04/16/15 at 11:55 PM, with RN #6 on 04/16/15 at 12:14 PM, with Kentucky Medication Aide (KMA) #1 on 04/17/15 at 1:27 PM, and with LPN #6 on 04/17/15 at 3:29 PM, revealed that the resident's medications were administered per the physician's orders [REDACTED]. Interview on 04/14/15 at 6:07 PM with the Director of Nursing (DON) revealed facility staff should follow the plan of care for a resident. The interview further revealed residents' medications should be administered per physician's orders [REDACTED]. 5. Review of the medical record for Resident A revealed the facility admitted the resident on 04/07/15, with [DIAGNOSES REDACTED]. Review of the "Weekly Skin Integrity Review" dated 04/08/15, revealed the resident had a diabetic ulcer to the right foot located near the last digit. Review of the "Interim Plan of Care" dated 04/15/15, revealed the resident had a disruption of skin surface not related to pressure with the wound type being an open lesion located on the right outer dorsal foot. Further review revealed the Plan of Care stated, "Wound care as ordered; see current treatment record and physician's orders [REDACTED]." Review of Resident A's physician's orders [REDACTED]. Review of the five-day final report of the facility's investigation, dated 04/16/15, revealed Resident A had requested on 04/16/15 at 5:00 AM for LPN #3 to replace the dressing that had fallen off during the night. Further review of the investigation revealed LPN #3 did not replace the dressing and had instructed the resident the dressing change would not be completed until the wound care nurses arrived at 8:00 AM. Interview with LPN #3 on 04/20/15 at 4:30 PM revealed the resident had requested the dressing be replaced; however, it was not done. The LPN stated she did not follow the resident's care plan. She stated she should have checked and followed the care plan. Interview with the DON on 04/20/15 at 2:37 PM revealed staff should follow the residents' care plans. She stated wound care should be done according to the care plan. Interview with the Administrator on 04/20/15 at 1:30 PM, revealed LPN #3 should have followed the resident's plan of care and replaced the resident's dressing. **The facility provided an acceptable Allegation of Compliance (AOC) on 04/23/15. The facility implemented the following actions to remove the Immediate Jeopardy: 1) The Physician and Power of Attorney (POA) for Residents #11, #13, #14, #15, #16, and #17 were notified immediately upon identification of potential medication errors by the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADONs), Staff Development Coordinator (SDC), Quality Assurances (QA)Nurse, Nursing Supervisor, Medical Records Nurse or Regional Nurse Consultant on 04/20/15. Residents #11, #13, #14, #15, #16, and #17 were assessed by the ADONs or QA Nurse on 04/20/15 for any signs and symptoms of adverse reactions, with no issues identified. Laboratory levels were drawn on all six (6) residents, the physician was notified of the results, and the residents' care plans were updated, as needed. All six (6) residents' medications were counted and a medication reconciliation was completed for accuracy and a current count was placed on each individual pill packet and/or bottle of liquid medicine on 04/20/15 by the DON, ADONs, SDC, QA Nurse, Medical Records Nurse or Regional Nurse Consultant. 2) The physician and POAs for Residents #11, #15, #16, and #17 were notified immediately upon identification of inappropriate documentation by the Administrator, DON, ADONs, SDC, QA Nurse, Nursing Supervisor, Medical Record's Nurse, or Regional Nurse Consultant on 04/20/15. Residents #11, #15, #16, and #17 were re-assessed by the ADONs or QA Nurse, on 04/20/15, for any signs and symptoms of adverse reactions, with no issues identified. 3) All residents' medications were audited by the DON, ADON, SDC, Nursing Supervisor, Medical Record's Nurse or Regional Nurse Consultant, on 04/20/15, to ensure that the current medications, compared to the current Physician order [REDACTED]. A new bottle of medications were requested and placed into service on 04/22/15 for the liquid medications that could not be counted, due to opacity of container. 4) All residents' charts were audited by the Administrator, Assistant Administrator, DON, ADONs, SDC, QA Nurse, MDS Coordinators, Nursing Supervisor, Admissions, Social Services Director, Quality of Life, Dietary Manager, Chaplain, Medical Record's Nurse or Regional Nurse Consultant by 04/22/15 for accuracy of the clinical records and that the records were complete and accurately documented. The following issues were identified and corrected: a. Social Services Quarterly Notes were not within compliance- for three (3) residents b. Activity Quarterly Notes not within compliance-three (3) residents c. Care plan updates-two (2) residents d. Behavior Management care plan updates-two (2) residents 5) All residents' care plans were audited by the Administrator, Assistant Administrator, DON, ADONs, SDC, QA Nurse, MDS Coordinators, Nursing Supervisor, Admissions, Social Services Director, Quality of life, Dietary Manager, Chaplain, Medical Records or Regional Nurse Consultant by 04/22/15 to ensure all resident care plans reflected the current resident care needs. 6) Education was provided to the Administrator, HR, Med Record's Nurse, BOM, Quality of Life, Admissions, Assistant Administrator, Plant Ops, Food Service Director, SSD, Central Supply, Housekeeping Supervisor, DON, ADONs, SDC, MDS Coordinators, and Nursing Supervisors on 04/20/15 by the Regional Nurse Consultant regarding the facility's medication administration policy and procedure which included medication reconciliation. The care plan policy and the procedure included following the care plan, administering care to ensure highest practical physical, mental, and psychosocial well-being of each resident, and maintain clinical records in acceptable professional standards and practices that were complete, accurately documented, readily accessible and systematically organized. 7) Education was initiated for licensed staff, Kentucky Medication Aides (KMAs) and State Registered Nurse Aides (SRNAs) on 04/20/15 by the Administrator, Assistant Administrator, Regional Nurse Consultant, DON, ADONs or the SDC regarding the Medication Administration Policy and Procedure which included medication reconciliation, care plan policy and the procedure to include following the care plan, administering care to ensure highest practical physical, mental, and psychosocial well-being of each resident, and maintain clinical records in acceptable professional standards and practices that were complete, accurately documented, readily accessible and systematically organized. All clinical staff completed or will complete a post-test and score 100% to ensure understanding of education/training provided. If 100% is not obtained then the staff member will be re-educated and a post-test re-administered until the staff member obtains 100% score to ensure understanding of the material covered. Clinical staff was not allowed to work prior to receiving the above stated education. Those clinical staff members that were on Family Medical Leave Act (FMLA), leave or work "as needed" (PRN) were sent a certified letter and were not allowed to work until the education had been received and a post-test completed with 100% score obtained. As of 04/23/15, 60% of all licensed staff and clinical staff had been educated with post-test completed and 100% score obtained; 15% have been contacted by phone, provided education and notified that they cannot work until 1:1 education with post-test was completed, and, 100% score obtained. The remaining 25% were in the process of being contacted and will not be allowed to work until education with post-test has been completed and 100% score obtained. Once education has been provided, each licensed nurse will complete a medication administration observation pass with the DON, ADONs, SDC, Nursing Supervisor, or Regional Nurse Consultant. 8) Education regarding medication administration policy and procedure, care plan policy and procedure, administrative oversight, and complete and accurate clinical records were included in the new hire orientation. 9) A new process was initiated on 04/22/15 for medication reconciliation of residents' medications. The process is as follows: a. One random nurse per day, per shift, will complete a medication pass observation with the DON, ADONs, SDC, Medical Records Nurse, MDS Coordinators, Nursing Supervisor or Regional Nurse Consultant to ensure compliance with medication administration, the resident's care plan was being followed and accurate along with completed documentation was noted. b. DON, ADONs, SDC, Medical Records Nurse, MDS Coordinators, Nursing Supervisor, or Regional Nurse Consultant reconciled the medications of four (4) randomly selected residents daily to ensure compliance with medication administration. This process was continued until immediacy was lifted. c. Nurses/KMAs received education on 04/21/15 by the Regional Nurse Consultant, DON, ADONs, SDC, or Nursing Supervisor on placing the discarded pill packets/bottles in the bottom drawer of the medication cart when packet/bottle was finished. The DON, ADONs, SDC, Medical Records Nurse, MDS Coordinators, Nursing Supervisor or Regional Nurse Consultant audited, daily, ten (10) discarded packets/bottles per side compared to packets/bottles that were put into service to reconcile medications, confirm reorder process and that the medications were being given per the physician's orders [REDACTED]. The process continued until immediacy was lifted. d. Nurses/KMAs placed the date/time and their initials on the side of any new medication packet/bottle placed into service to ensure an accurate date which will allow for accurate reconciliation. Those liquid medications, a total of twenty-one (21), that could not be counted, due to opacity of container, a new bottle was obtained and placed in service by 04/22/15. e. Reorder process below will continue until immediacy was lifted: i) A nurse re-ordered medications via the ezMAR alert system when three (3) to four (4) days of medication were left to administer. ii) A nurse then placed, on the current medication bubble pack, the date of reorder, and their initials. iii) The DON and/or ADONs ran the "Refill Reminder Report" from the ezMAR system, Monday - Friday, and validated that all medications due to be reordered, had actually been reordered. iv) Facility Formulary Nurse, ADONs, SDC, QA Nurse, or Nursing Supervisors reconciled the Refill Reminder Report with the nightly medication manifest report with the actual medication packet on the cart or stored in overflow to ensure medications that were reordered have actually arrived at facility. f. Nurses and KMAs were educated/trained on the medication administration policy and procedure to include documentation along with the scope of practice of the KMA. KMAs will not administer or document administering any medications other than by mouth (PO) or topical. 10) All residents medications were reconciled two (2) times weekly, starting 04/20/15 by the DON, ADONs, SDC, Medical Records Nurse, QA Nurse, Nursing Supervisor, Regional Nurse Consultant or Chief Nursing Executive, to ensure reorder process system was intact and within compliance along with ensuring residents medications were administered as ordered. This process will continue for two (2) weeks and results will be reviewed in a weekly QAPI meeting. The QAPI committee will determine ongoing frequency of resident medication reconciliation at that time. 11) Education was provided for Licensed Nursing Staff by the Administrator, Assistant Administrator, DON, ADON, the SDC, or the Regional Nurse Consultant regarding the above stated plan by 04/21/15. 12) Medication pass audits were completed by the DON, ADON, SDC, Medical Records Nurse, or Regional Nurse Consultant for all nurses and KMAs by 04/22/15 to ensure that medications were administered without significant medication error. Nurses or KMAs who had not completed a medication pass observation were not allowed to work until the medication pass observations had been completed for shifts scheduled after 04/22/15. As of 04/24/15, 75% of all nurses and KMAs had completed a medication pass observation. 13) Administrative oversight of the facility was completed by the Special Projects Administrator, the Regional Vice President of Operations, or the Chief Operating Officer daily until removal of immediacy, weekly for four (4) weeks after removal of immediacy, then monthly. 14) The Administrator, Assistant Administrator, Special Projects, DON, Chief Operating Officer, Chief Nurse Executive or Regional Nurse Consultant audited compliance of the above stated audits/observations daily until removal of immediacy, then twice weekly for four (4) weeks and reported findings during weekly QA for four (4)weeks, for recommendations and further follow-up as indicated. 15) A Quality Assurance meeting was held on 04/17/15, and again on 04/20/15 for further recommendations regarding the plan for removal of Immediate Jeopardy. A Quality Assurance meeting will be held weekly for four (4) weeks, then monthly for recommendations and further follow up regarding the above stated plan. **The State Survey Agency validated the Immediate Jeopardy was removed as follows: 1) Review of the medical records of Residents #11, #13, #14, #15, #16, and #17 revealed the residents' physicians and POAs were notified of the potential medication errors by the administrative staff. Further review of the medical records revealed Residents #11, #13, #14, #15, #16, and #17 were assessed by the ADONs or the QA Nurse, on 04/20/15, for any signs and symptoms of adverse reactions from potential medication errors, with no issues identified. The facility obtained laboratory levels on all six (6) residents, the physician was notified of the results, and the residents' care plans were updated as needed. The residents' laboratory results were obtained on the following days by the facility: Resident #11 on 04/03/15, 04/06/15, and 04/20/15, Resident #13 on 04/03/15 and 04/19/15, Resident #14 on 04/17/15, 04/17/15 and 04/19/15, Resident #15 on 04/03/15 and 04/20/15, Resident #16 on 04/03/15 and 04/17/15 and Resident #17 on 04/20/15. The Administrative Staff counted all six (6) residents' medications and a medication reconciliation was completed for accuracy and a current count was placed on each individual pill packet and/or bottle of liquid medicine on 04/20/15 by the DON, ADONs, SDC, QA Nurse, Medical Records Nurse or Regional Nurse Consultant. 2) Review of the medical record revealed the physicians and POAs for Residents #11, #15, #16, and #17 were notified immediately upon identification of inappropriate documentation by the Administrator, DON, ADONs, SDC, QA Nurse, Nursing Supervisor, Medical Record's Nurse, or Regional Nurse Consultant on 04/20/15. Further review of the medical records revealed Residents #11, #15, #16, and #17 were re-assessed by the ADONs or QA Nurse, on 04/20/15, for any signs and symptoms of adverse reactions, with no issues identified. 3) Review of the medication audits revealed the audits were completed by the DON, ADON, SDC, Nursing Supervisor, Medical Record's Nurse or Regional Nurse Consultant, on 04/20/15, and ensured that the current medications, compared to the current Physician order [REDACTED]. Observations, on 04/24/15 revealed new bottles of medication were placed into service on 04/22/15. 4) Review of the facility's audits revealed all residents' charts were audited by the Administrator, Assistant Administrator, DON, ADONs, SDC, QA Nurse, MDS Coordinators, Nursing Supervisor, Admissions, Social Services Director (SSD), Quality of Life, Dietary Manager, Chaplain, Medical Record's Nurse or Regional Nurse Consultant by 04/22/15 for accuracy of the clinical records and that the records were complete and accurately documented. The audits revealed issues identified were corrected by the facility staff. 5) Review of the facility's audits on 04/24/15, revealed all residents care plans were audited by the Administrator, Assistant Administrator, DON, ADONs, SDC, QA Nurse, MDS Coordinators, Nursing Supervisor, Admissions, Social Services Director, Quality of life, Dietary Manager, Chaplain, Medical Records or Regional Nurse Consultant by 04/22/15 to ensure all residents' care plans reflected the current resident care needs. 6) Review of the facility's in-services revealed education was provided to the Administrator, HR, Medical Record's Nurse, BOM, Quality of Life, Admissions, Assistant Administrator, Plant Ops, Food Service Director, SSD, Central Supply, Housekeeping Supervisor, DON, ADONs, SDC, MDS Coordinators, and Nursing Supervisors on 04/20/15 by the Regional Nurse Consultant. The education provided included the medication administration policy and procedure to include medication reconciliation, care plan policy, and the procedure to include following the care plan, administering care to ensure highest practical physical, mental, and psychosocial well-being of each resident, and maintain clinical records in acceptable professional standards and practices that were complete, accurately documented, readily accessible and systematically organized. Interviews conducted on 04/24/15, with the Administrator, HR, Med Record's Nurse, BOM, Quality of Life, Admissions, Assistant Administrator, Plant Ops, Food Service Director, SSD, Central Supply, Housekeeping Supervisor, DON, ADONs, SDC, MDS Coordinators, and Nursing Supervisors revealed the staff was educated on 04/20/15 on care plans, the medication administration policy and procedure and accurate medical records. 7) Review of the facility's in-services revealed education was initiated for licensed staff, KMAs and SRNAs on 04/20/15 by the Administrator, Assistant Administrator, Regional Nurse Consultant, DON, ADONs or the SDC regarding the medication administration policy and procedure to include medication reconciliation, care plan policy and the procedure to include following the care plan, administering care to ensure highest practical physical, mental, and psychosocial well-being of each resident, and maintain clinical records in acceptable professional standards and practices that were complete, accurately documented, readily accessible and systematically organized. Interviews on 04/24/15 with licensed staff, KMAs, and SRNAs revealed the facility provided staff education that included information on the medication administration policy, medical record documentation, care planning and following the care plan and medication reconciliation. Review of the POS [REDACTED]"as needed") had completed the post-test with a 100% score. 8) Review of new employee orientation revealed newly hired staff would receive education regarding medication administration policy and procedure, care plan policy and procedure, administrative oversight, and complete and accurate clinical records and that the information was added to the new hire orientation. Interviews on 04/24/15, with newly hired staff revealed the staff had been provided information on medication administration policy and procedure, care plan policy and procedure, administrative oversight, and complete and accurate clinical records. 9) Review of the new process for medication reconciliation of residents' medications revealed the process was initiated on 04/22/15. The process was as follows: a. Review of the facility audits revealed one random nurse per day, per shift completed a medication pass observation with the DON, ADONs, SDC, Medical Record's Nurse, MDS Coordinators, Nursing Supervisor or Regional Nurse Consultant to ensure compliance with medication administration, the resident's

Based on observation, interview, and review of medical records, pharmacy medication dispensing records, and the facility's policies, it was determined the facility failed to ensure five (5) of thirty (30) sampled residents (Residents #11, #13, #15, #16, and #17) were free of significant medication errors. Review of the residents' Medication Administration Records (MAR) revealed documentation that the residents' medications were administered according to physician's orders [REDACTED].#15's medication and review of Residents #11, #13, #16, and #17's pharmacy medication dispensing records revealed the facility failed to administer the residents' medications as ordered by the residents' physicians. Review of pharmacy dispensing records dated 12/01/14 thru 04/17/15 and review of physician's orders [REDACTED].#11; failed to administer [MEDICATION NAME] and [MEDICATION NAME] [MEDICATION]s) as ordered to Resident #17; failed to administer [MEDICATION NAME] [MEDICATION]) as ordered to Resident #13; and failed to administer [MEDICATION NAME] Acid (a medication used to prevent [MEDICAL CONDITION]) twice daily to Resident #16. In addition, observation on 04/17/15, revealed Resident #15's [MEDICATION NAME] medication bottle contained 150 milliliters (ml) of liquid; however, since the resident was readmitted to the facility on [DATE], only 130.5 ml should have been present if the medication had been administered per physician's orders [REDACTED]. The facility's failure to have an effective system in place to ensure care and services were provided as per the resident's plan of care was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was determined to exist on 04/02/15 at 42 CFR 483.20 Resident Assessment (F282), 42 CFR 483.25 Quality of Care (F333), 42 CFR 483.60 Pharmacy Services (F425), and 42 CFR 483.75 Administration (F490 and F514). The facility was notified of the Immediate Jeopardy on 04/20/15. An acceptable Allegation of Compliance was received on 04/23/15, which alleged removal of the Immediate Jeopardy on 04/23/15. An extended survey was conducted on 04/24/15. The State Survey Agency determined the Immediate Jeopardy was removed on 04/23/15, which lowered the Scope and Severity to an "E" at 42 CFR 483.20 Resident Assessment (F282), 42 CFR 483.25 Quality of Care (F333), 42 CFR 483.60 Pharmacy Services (F425), and, 42 CFR 483.75 Administration (F490 and F514) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled "Medication Administration General Guidelines," dated December 2012, revealed medications were administered as prescribed in accordance with the manufacturer's specifications, good nursing principles and practices, and only by persons legally authorized to do so. Review of the facility's policy titled "Medication Administration - Medication Discrepancies," dated December 2009, revealed medication discrepancies were documented and reported to the resident's attending physician, Director of Nursing, responsible party, and the Performance Improvement Committee. The policy defined a medication discrepancy as an omission of medication due to a prescribing, dispensing, or administering error. The policy further revealed when a medication discrepancy occurred immediate action should be taken to protect the patient's safety and welfare. Continued review of the policy revealed the attending physician was notified of the error or significant medication discrepancy and the patient was to be monitored closely for 24 to 72 hours or as directed by the physician. The policy stated a medication discrepancy/error/incident report was to be completed. Review of the facility's procedure for reordering medication, not dated, revealed staff should reorder medications when there was a three (3) day supply of medication remaining. 1. Review of Resident #11's medical record revealed the facility admitted the resident on 10/04/13, with [DIAGNOSES REDACTED]. Review of Resident #11's April 2015 physician's orders [REDACTED]. The medication was initially ordered 08/17/14. Record review and review of the facility's investigation related to Resident #11, dated 04/07/15, revealed on 04/01/15, Resident #11's [MEDICATION NAME] medication card dated 03/24/15 (the date the medication card was received by the facility for use) revealed only four (4) tablets had been dispensed from the card leaving ten (10) tablets remaining on the medication card. The facility audited the medication card again on 04/03/15, prior to the morning medication pass (the medication was ordered to be administered every morning). At that time, Resident #11's [MEDICATION NAME] medication card still had ten (10) tablets remaining on the card. Review of the Medication Administration Record (MAR) revealed staff documented the medication had been administered on 04/02/15. There was no documented evidence the medication had not been held or refused the previous day. Review of the Pharmacy's Medication Dispensing Records, dated 12/01/14 through 04/17/15, revealed Resident #11's [MEDICATION NAME] was dispensed with fourteen (14) tablets per medication card. This medication was dispensed seven (7) times since 12/10/14 (dispensed on 12/10/14, 12/21/14, 01/28/15, 02/11/15, 02/25/15, 03/25/15, and 04/15/15). During the timeframe reviewed (12/10/14 through 04/16/15), the pharmacy dispensed ninety-eight (98) [MEDICATION NAME] tablets; however, one hundred twenty-eight (128) tablets were required for the staff to be able to administer the resident's [MEDICATION NAME] per the physician's orders [REDACTED]. Review of Resident #11's [MEDICATION NAME] laboratory level obtained on 01/05/15 revealed the level was not therapeutic at 0.80 ng/ml (nanograms/milliliter) (therapeutic range is 0.9 to 2.0 ng/ml). Further review of Resident #11's [MEDICATION NAME] level dated 04/03/15 revealed the resident's medication was also not therapeutic at 0.5 ng/ml. 2. Review of Resident #17's medical record revealed the facility admitted the resident on 10/23/98. The resident had [DIAGNOSES REDACTED]. Review of Resident #17's April 2015 physician's orders [REDACTED]. Review of the Pharmacy Medication Dispensing Records dated 12/01/14 through 04/17/15, revealed the pharmacy dispensed thirty (30) capsules of [MEDICATION NAME] 250 mg (a 30-day supply) twice from 12/18/14 through 04/04/15 (on 12/18/14 and 01/28/15), for a total of sixty (60) capsules. However, one hundred seven (107) capsules were required for the staff to be able to administer the resident's [MEDICATION NAME], per the physician's orders [REDACTED]. Further review of the Pharmacy Medication Dispensing Records revealed the pharmacy dispensed one hundred twenty (120) capsules of [MEDICATION NAME] 125 mg (a 30-day supply) on 02/20/15. However, the medication was not dispensed to the facility again until 04/05/15, approximately forty-four (44) days later. Review of Resident #17's MAR for 12/01/14 through 04/04/15 revealed staff omitted one (1) dose of [MEDICATION NAME] for the resident on 01/05/15. Staff documented all other doses were administered per physician's orders [REDACTED]. Registered Nurse (RN) #1 documented that three (3) evening doses of [MEDICATION NAME] were not administered to Resident #17 on 03/08/15, 03/18/15, and 03/23/15 because the resident's blood pressure or pulse was too low. On 03/17/15, RN #1 documented the resident refused the evening dose; and on 03/22/15 RN #1 documented [MEDICATION NAME] was not administered because the resident had no insulin coverage. On 04/19/15 at 1:20 PM, after reviewing Resident #17's MAR, interview with RN #1 revealed she administered the resident's medications as ordered. She stated the resident did not refuse medications and the documentation on the resident's MAR was inaccurate because it was easy to enter the wrong code on the electronic MAR. Review of Resident #17's laboratory levels revealed on 04/03/15, the resident's [MEDICATION NAME] Acid ([MEDICATION NAME]) level was sub-therapeutic at less than 10 mcg/ml (therapeutic range is 50 - 100 mcg/ml). Further review of Resident #17's lab levels revealed on 03/16/15, the resident's [MEDICATION NAME] level was sub-therapeutic at less than 2.5 mcg/ml (therapeutic range is 5-12 mcg/ml). On 03/19/15, the resident's [MEDICATION NAME] level had increased to 9.1 mcg/ml. The SSA's Pharmacy Consultant conducted a post survey review. This review revealed Resident #17's Physician order [REDACTED]. During a post survey phone interview with the Advanced Registered Nurse Practitioner on 06/01/15, she acknowledged the resident was to receive 250 mg each morning and each evening. From 12/08/14 through 04/04/15, the resident would have needed a total of one-hundred and seven (107) tablets of [MEDICATION NAME] 250 mg to meet the dosage required for the time period, if the order was for once a day. However, only sixty (60) tablets had been dispensed and delivered for the resident during that time period, as validated by the pharmacy's Delivery Manifest Record (aka, the pharmacy dispensing record). Record review revealed the resident was actually ordered to receive two (2) tablets per day of the [MEDICATION NAME] during that time. The resident would have needed approximately twice that amount, between 210-214 tablets, to achieve the dosage that was ordered. 3. Review of Resident #13's medical record revealed the facility admitted the resident on 06/10/13, and the resident had [DIAGNOSES REDACTED]. Review of Resident #13's physician's orders [REDACTED]. Review of the Pharmacy Medication Dispensing Records dated 12/01/14 through 04/17/15, revealed the pharmacy dispensed 300 ml (a 30-day supply) of [MEDICATION NAME] liquid medication three (3) times from 12/03/14 through 03/18/15, for a total of 900 ml. However, 1,050 ml of [MEDICATION NAME] was required to administer the medication per physician's orders [REDACTED]. Review of Resident #13's MARs for January through March 2015 revealed staff documented the resident's [MEDICATION NAME] medication was administered as ordered. Review of the [MEDICATION NAME] medication laboratory results revealed on 12/01/15, the resident's [MEDICATION NAME] level was 23 mcg/ml which was therapeutic (normal range is 5 - 63 mcg/ml). On 03/02/15, the resident's [MEDICATION NAME] level was sub-therapeutic at 2.0 mcg/ml. Further review of Resident #13's laboratory results revealed on 04/03/15 the resident's [MEDICATION NAME] level was also sub-therapeutic at 2.9 mcg/ml. The SSA's Pharmacy Consultant conducted a post survey review of the facility's pharmacy dispensing records. Review of Resident #13's MARs for January through April 2015 revealed no documented evidence (staff did not sign off as having been administered) staff administered the [MEDICATION NAME] liquid medication as ordered; two (2) doses were omitted in January 2015, one (1) dose in February 2015, and two (2) doses in April 2015 for a total of five (5) doses (50 ml) missed. 4. Review of Resident #16's medical record revealed the facility admitted the resident on 09/05/14. The resident had [DIAGNOSES REDACTED]. Review of Resident #16's physician's orders [REDACTED]. Review of the Pharmacy Medication Dispensing Records dated 12/01/14 through 04/17/15, for Resident #16 revealed the pharmacy dispensed a 150-ml bottle (a 15-day supply) of [MEDICATION NAME] on 01/24/15. However, the medication was not refilled again until 02/18/15, twenty-six (26) days later. Review of Resident #16's MAR for 12/01/14 through 01/31/15 revealed staff omitted the resident's morning dose of [MEDICATION NAME] Acid on 01/05/15. Staff documented the medication was administered as ordered for all other doses during these months. However, review of Resident #16's [MEDICATION NAME] Acid laboratory level dated 04/03/15, revealed the resident's [MEDICATION NAME] Acid level was sub-therapeutic at 20.6 mcg/ml (therapeutic range is 50 - 100 mcg/ml). 5. Review of Resident #15's medical record revealed the facility admitted the resident on 10/18/13 and readmitted the resident on 03/20/15, after a hospital stay. The resident had a [DIAGNOSES REDACTED]. Review of Resident #15's April 2015 physician's orders [REDACTED]. Review of the Pharmacy Medication Dispensing Records for Resident #15 revealed 473 ml of [MEDICATION NAME] was dispensed to the facility on [DATE]. Observation on 04/17/15 at 2:20 PM of Resident #15's [MEDICATION NAME] bottle from the facility's medication cart revealed the medication was dated as opened on 03/21/15, one (1) day after the resident was readmitted to the facility. Observation revealed the [MEDICATION NAME] bottle contained 150 ml of liquid medication. However, according to the resident's physician's orders [REDACTED]. Review of Resident #15's MAR from 03/20/15 through 04/17/15 revealed staff documented they administered [MEDICATION NAME] to Resident #15 as ordered by the resident's physician. Interview with the Pharmacy Director on 04/15/15 at 4:00 PM, revealed residents' medications were sent back to the pharmacy when the resident was out of the facility. The medications were re-dispensed when the resident returned to the facility. Review of Resident #15's laboratory results for [MEDICATION NAME] revealed on 01/20/15, the resident's level was 8.0 mcg/ml (therapeutic range is 5 - 63 mcg/ml). However, on 04/03/15, the resident's level had decreased to 5.0 mcg/ml. Review of the facility's "Status Change" document that listed residents who had been admitted , transferred, or discharged from December 2014 through April 2015 revealed Residents #11, #13, #15, #16, and #17 had not been discharged or transferred from the facility during the times when there were discrepancies identified with their medications. Interview with RN #1 on 04/14/15 at 5:03 PM, with Licensed Practical Nurse (LPN) #5 on 04/16/15 at 11:55 PM, with RN #6 on 04/16/15 at 12:14 PM, with Kentucky Medication Aide (KMA) #1 on 04/17/15 at 1:27 PM, and with LPN #6 on 04/17/15 at 3:29 PM, revealed that if staff documented on the resident's MAR that their medication was administered, then the medication was administered per the physician's orders [REDACTED]. card had two (2) to seven (7) days remaining in the card. The nurses stated the facility did not have a system in place to determine when a medication card was placed in use after it was dispensed from the pharmacy. Interview on 04/15/15 at 4:00 PM with the Pharmacy Director revealed the pharmacy sends a dispensing report to the facility that lists the quantity of the medication and the date the medication was sent to the facility. Continued interview revealed the facility notified the pharmacy when a resident was sent out to the hospital and the resident's medications were sent back to the pharmacy. The Pharmacy Director stated the facility notified the pharmacy of new admissions or readmissions. When the resident's orders were received by the pharmacy, the medications were sent to the facility. The interview revealed the facility's nurses reorder residents' medications when the supply gets low. Per interview, the pharmacy did not have a way to know if the facility was reordering medication when needed and administering the medication according to physician's orders [REDACTED]. Interview on 04/14/15 at 6:07 PM, with the Director of Nursing (DON) revealed she did a random medication cart audit on 04/01/15 after the morning medication pass. She stated Resident #11's [MEDICATION NAME] raised a "red flag" because the medication card label was dated 03/24/15 and only four (4) tablets had been administered from the medication card leaving ten (10) tablets on the card. The DON stated she reviewed Resident #11's MAR and no doses (no documented evidence) had been held or refused. The DON revealed she immediately initiated an investigation, which included assessments of all residents on the hall where Resident #11 resided. The investigation included obtaining laboratory levels for all residents that lived on that hall, that were on medications that required therapeutic monitoring, and interviewing staff and alert and oriented residents. Continued interview revealed the assessments had not revealed any abnormal findings and the laboratory results had not revealed a pattern or a trend because some residents' laboratory levels were sub-therapeutic, some were normal, and some were elevated. The DON stated reviews of the pharmacy dispensing records were not evaluated as part of the investigation. Further interview with the DON revealed the administrative staff reviewed the investigation and did not feel there was enough concrete evidence to say Resident #11 did not receive his/her medications as ordered by the facility. She stated the only concrete information she had was a quantity of medication that was possibly more than she felt should have been in the resident's drawer; however, all the nurses interviewed revealed Resident #11's medications were administered as ordered. The DON further revealed the facility did not have a system to know how much of a particular medication the resident had in the medication cart at a given time. **The facility provided an acceptable Allegation of Compliance (AOC) on 04/23/15. The facility implemented the following actions to remove the Immediate Jeopardy: 1) The Physician and Power of Attorney (POA) for Residents #11, #13, #14, #15, #16, and #17 were notified immediately upon identification of potential medication errors by the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADONs), Staff Development Coordinator (SDC), Quality Assurances (QA)Nurse, Nursing Supervisor, Medical Records Nurse or Regional Nurse Consultant on 04/20/15. Residents #11, #13, #14, #15, #16, and #17 were assessed by the ADONs or QA Nurse on 04/20/15 for any signs and symptoms of adverse reactions, with no issues identified. Laboratory levels were drawn on all six (6) residents, the physician was notified of the results, and the residents' care plans were updated, as needed. All six (6) residents' medications were counted and a medication reconciliation was completed for accuracy and a current count was placed on each individual pill packet and/or bottle of liquid medicine on 04/20/15 by the DON, ADONs, SDC, QA Nurse, Medical Records Nurse or Regional Nurse Consultant. 2) The physician and POAs for Residents #11, #15, #16, and #17 were notified immediately upon identification of inappropriate documentation by the Administrator, DON, ADONs, SDC, QA Nurse, Nursing Supervisor, Medical Record's Nurse, or Regional Nurse Consultant on 04/20/15. Residents #11, #15, #16, and #17 were re-assessed by the ADONs or QA Nurse, on 04/20/15, for any signs and symptoms of adverse reactions, with no issues identified. 3) All residents' medications were audited by the DON, ADON, SDC, Nursing Supervisor, Medical Record's Nurse or Regional Nurse Consultant, on 04/20/15, to ensure that the current medications, compared to the current Physician order [REDACTED]. A new bottle of medications were requested and placed into service on 04/22/15 for the liquid medications that could not be counted, due to opacity of container. 4) All residents' charts were audited by the Administrator, Assistant Administrator, DON, ADONs, SDC, QA Nurse, MDS Coordinators, Nursing Supervisor, Admissions, Social Services Director, Quality of Life, Dietary Manager, Chaplain, Medical Record's Nurse or Regional Nurse Consultant by 04/22/15 for accuracy of the clinical records and that the records were complete and accurately documented. The following issues were identified and corrected: a. Social Services Quarterly Notes were not within compliance- for three (3) residents b. Activity Quarterly Notes not within compliance-three (3) residents c. Care plan updates-two (2) residents d. Behavior Management care plan updates-two (2) residents 5) All residents' care plans were audited by the Administrator, Assistant Administrator, DON, ADONs, SDC, QA Nurse, MDS Coordinators, Nursing Supervisor, Admissions, Social Services Director, Quality of life, Dietary Manager, Chaplain, Medical Records or Regional Nurse Consultant by 04/22/15 to ensure all resident care plans reflected the current resident care needs. 6) Education was provided to the Administrator, HR, Med Record's Nurse, BOM, Quality of Life, Admissions, Assistant Administrator, Plant Ops, Food Service Director, SSD, Central Supply, Housekeeping Supervisor, DON, ADONs, SDC, MDS Coordinators, and Nursing Supervisors on 04/20/15 by the Regional Nurse Consultant regarding the facility's medication administration policy and procedure which included medication reconciliation. The care plan policy and the procedure included following the care plan, administering care to ensure highest practical physical, mental, and psychosocial well-being of each resident, and maintain clinical records in acceptable professional standards and practices that were complete, accurately documented, readily accessible and systematically organized. 7) Education was initiated for licensed staff, Kentucky Medication Aides (KMAs) and State Registered Nurse Aides (SRNAs) on 04/20/15 by the Administrator, Assistant Administrator, Regional Nurse Consultant, DON, ADONs or the SDC regarding the Medication Administration Policy and Procedure which included medication reconciliation, care plan policy and the procedure to include following the care plan, administering care to ensure highest practical physical, mental, and psychosocial well-being of each resident, and maintain clinical records in acceptable professional standards and practices that were complete, accurately documented, readily accessible and systematically organized. All clinical staff completed or will complete a post-test and score 100% to ensure understanding of education/training provided. If 100% is not obtained then the staff member will be re-educated and a post-test re-administered until the staff member obtains 100% score to ensure understanding of the material covered. Clinical staff was not allowed to work prior to receiving the above stated education. Those clinical staff members that were on Family Medical Leave Act (FMLA), leave or work "as needed" (PRN) were sent a certified letter and were not allowed to work until the education had been received and a post-test completed with 100% score obtained. As of 04/23/15, 60% of all licensed staff and clinical staff had been educated with post-test completed and 100% score obtained; 15% have been contacted by phone, provided education and notified that they cannot work until 1:1 education with post-test was completed, and, 100% score obtained. The remaining 25% were in the process of being contacted and will not be allowed to work until education with post-test has been completed and 100% score obtained. Once education has been provided, each licensed nurse will complete a medication administration observation pass with the DON, ADONs, SDC, Nursing Supervisor, or Regional Nurse Consultant. 8) Education regarding medication administration policy and procedure, care plan policy and procedure, administrative oversight, and complete and accurate clinical records were included in the new hire orientation. 9) A new process was initiated on 04/22/15 for medication reconciliation of residents' medications. The process is as follows: a. One random nurse per day, per shift, will complete a medication pass observation with the DON, ADONs, SDC, Medical Records Nurse, MDS Coordinators, Nursing Supervisor or Regional Nurse Consultant to ensure compliance with medication administration, the resident's care plan was being followed and accurate along with completed documentation was noted. b. DON, ADONs, SDC, Medical Records Nurse, MDS Coordinators, Nursing Supervisor, or Regional Nurse Consultant reconciled the medications of four (4) randomly selected residents daily to ensure compliance with medication administration. This process was continued until immediacy was lifted. c. Nurses/KMAs received education on 04/21/15 by the Regional Nurse Consultant, DON, ADONs, SDC, or Nursing Supervisor on placing the discarded pill packets/bottles in the bottom drawer of the medication cart when packet/bottle was finished. The DON, ADONs, SDC, Medical Records Nurse, MDS Coordinators, Nursing Supervisor or Regional Nurse Consultant audited, daily, ten (10) discarded packets/bottles per side compared to packets/bottles that were put into service to reconcile medications, confirm reorder process and that the medications were being given per the physician's orders [REDACTED]. The process continued until immediacy was lifted. d. Nurses/KMAs placed the date/time and their initials on the side of any new medication packet/bottle placed into service to ensure an accurate date which will allow for accurate reconciliation. Those liquid medications, a total of twenty-one (21), that could not be counted, due to opacity of container, a new bottle was obtained and placed in service by 04/22/15. e. Reorder process below will continue until immediacy was lifted: i) A nurse re-ordered medications via the ezMAR alert system when three (3) to four (4) days of medication were left to administer. ii) A nurse then placed, on the current medication bubble pack, the date of reorder, and their initials. iii) The DON and/or ADONs ran the "Refill Reminder Report" from the ezMAR system, Monday - Friday, and validated that all medications due to be reordered, had actually been reordered. iv) Facility Formulary Nurse, ADONs, SDC, QA Nurse, or Nursing Supervisors reconciled the Refill Reminder Report with the nightly medication manifest report with the actual medication packet on the cart or stored in overflow to ensure medications that were reordered have actually arrived at facility. f. Nurses and KMAs were educated/trained on the medication administration policy and procedure to include documentation along with the scope of practice of the KMA. KMAs will not administer or document administering any medications other than by mouth (PO) or topical. 10) All residents medications were reconciled two (2) times weekly, starting 04/20/15 by the DON, ADONs, SDC, Medical Records Nurse, QA Nurse, Nursing Supervisor, Regional Nurse Consultant or Chief Nursing Executive, to ensure reorder process system was intact and within compliance along with ensuring residents medications were administered as ordered. This process will continue for two (2) weeks and results will be reviewed in a weekly QAPI meeting. The QAPI committee will determine ongoing frequency of resident medication reconciliation at that time. 11) Education was provided for Licensed Nursing Staff by the Administrator, Assistant Administrator, DON, ADON, the SDC, or the Regional Nurse Consultant regarding the above stated plan by 04/21/15. 12) Medication pass audits were completed by the DON, ADON, SDC, Medical Records Nurse, or Regional Nurse Consultant for all nurses and KMAs by 04/22/15 to ensure that medications were administered without significant medication error. Nurses or KMAs who had not completed a medication pass observation were not allowed to work until the medication pass observations had been completed for shifts scheduled after 04/22/15. As of 04/24/15, 75% of all nurses and KMAs had completed a medication pass observation. 13) Administrative oversight of the facility was completed by the Special Projects Administrator, the Regional Vice President of Operations, or the Chief Operating Officer daily until removal of immediacy, weekly for four (4) weeks after removal of immediacy, then monthly. 14) The Administrator, Assistant Administrator, Special Projects, DON, Chief Operating Officer, Chief Nurse Executive or Regional Nurse Consultant audited compliance of the above stated audits/observations daily until removal of immediacy, then twice weekly for four (4) weeks and reported findings during weekly QA for four (4)weeks, for recommendations and further follow-up as indicated. 15) A Quality Assurance meeting was held on 04/17/15, and again on 04/20/15 for further recommendations regarding the plan for removal of Immediate Jeopardy. A Quality Assurance meeting will be held weekly for four (4) weeks, then monthly for recommendations and further follow up regarding the above stated plan. **The State Survey Agency validated the Immediate Jeopardy was removed as follows: 1) Review of the medical records of Residents #11, #13, #14, #15, #16, and #17 revealed the residents' physicians and POAs were notified of the potential medication errors by the administrative staff. Further review of the medical records revealed Residents #11, #13, #14, #15, #16, and #17 were assessed by the ADONs or the QA Nurse, on 04/20/15, for any signs and symptoms of adverse reactions from potential medication errors, with no issues identified. The facility obtained laboratory levels on all six (6) residents, the physician was notified of the results, and the residents' care plans were updated as needed. The residents' laboratory results were obtained on the following days by the facility: Resident #11 on 04/03/15, 04/06/15, and 04/20/15, Resident #13 on 04/03/15 and 04/19/15, Resident #14 on 04/17/15, 04/17/15 and 04/19/15, Resident #15 on 04/03/15 and 04/20/15, Resident #16 on 04/03/15 and 04/17/15 and Resident #17 on 04/20/15. The Administrative Staff counted all six (6) residents' medications and a medication reconciliation was completed for accuracy and a current count was placed on each individual pill packet and/or bottle of liquid medicine on 04/20/15 by the DON, ADONs, SDC, QA Nurse, Medical Records Nurse or Regional Nurse Consultant. 2) Review of the medical record revealed the physicians and POAs for Residents #11, #15, #16, and #17 were notified immediately upon identification of inappropriate documentation by the Administrator, DON, ADONs, SDC, QA Nurse, Nursing Supervisor, Medical Record's Nurse, or Regional Nurse Consultant on 04/20/15. Further review of the medical records revealed Residents #11, #15, #16, and #17 were re-assessed by the ADONs or QA Nurse, on 04/20/15, for any signs and symptoms of adverse reactions, with no issues identified. 3) Review of the medication audits revealed the audits were completed by the DON, ADON, SDC, Nursing Supervisor, Medical Record's Nurse or Regional Nurse Consultant, on 04/20/15, and ensured that the current medications, compared to the current Physician order [REDACTED].

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to provide pharmaceutical services to meet the needs of four (4) of thirty (30) sampled residents (Residents #11, #13, #16, and #17). The facility failed to have an effective system to reorder residents' medications timely to ensure the residents received their medications as physician ordered. Review of Pharmacy Medication Dispensing Records revealed Resident #11's Digoxin (medication to treat an abnormal heartbeat) was dispensed to the facility in a fourteen (14) day supply. However, this medication went up to thirty-seven (37) days between refills. Resident #17's Primidone (anti-seizure medication) went up to sixty-five (65) days between refills of a thirty (30) day supply and up to forty-three (43) days between refills for a thirty (30) day supply of Depakote (medication to prevent seizures and treat some psychiatric disorders). There was a forty-seven (47) day span between refills for a thirty (30) day supply of Resident #13's Keppra (medication to prevent seizures); and up to twenty-five (25) days between refills of a fifteen (15) day supply for Resident #16's Depakote. Laboratory tests revealed the residents' labs values for these medications that required monitoring were sub-therapeutic (refer to F282, F333, F490, and F514). The facility's failure to have an effective system in place to ensure care and services were provided as per the resident's plan of care was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was determined to exist on 04/02/15 at 42 CFR 483.20 Resident Assessment (F282), 42 CFR 483.25 Quality of Care (F333), 42 CFR 483.60 Pharmacy Services (F425), and 42 CFR 483.75 Administration (F490 and F514). The facility was notified of the Immediate Jeopardy on 04/20/15. An acceptable Allegation of Compliance was received on 04/23/15, which alleged removal of the Immediate Jeopardy on 04/23/15. An extended survey was conducted on 04/24/15. The State Survey Agency determined the Immediate Jeopardy was removed on 04/23/15, which lowered the Scope and Severity to an "E" at 42 CFR 483.20 Resident Assessment (F282), 42 CFR 483.25 Quality of Care (F333), 42 CFR 483.60 Pharmacy Services (F425), and, 42 CFR 483.75 Administration (F490 and F514) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled "Medication Ordering and Receiving From the Pharmacy Provider (Ordering and Receiving Non-Controlled Medications)," dated September 2010, revealed medications and related products were received from the provider pharmacy on a timely basis. The policy stated that the facility maintained accurate records of medication order and receipt. A licensed nurse or appropriate personnel received medications delivered to the facility from the pharmacy and documented on the medication delivery receipt/manifest. The policy stated that facility staff re-ordered medications by writing the medication name and prescription number or applying the peel-off bar coded label from the prescription label on the reorder sheet and faxing or otherwise transmitting the order to the pharmacy. Interview with Registered Nurse (RN) #1 on 04/14/15 at 5:03 PM, Licensed Practical Nurse (LPN) #5 on 04/16/15 at 11:55 AM, RN #6 on 04/16/15 at 12:14 PM, Kentucky Medication Aide (KMA) #1 on 04/17/15 at 1:27 PM, and LPN #6 on 04/17/15 at 3:29 PM revealed medications could also be ordered on the computer from the resident's Electronic Medication Administration Record [REDACTED]. 1. Review of Resident #11's medical record revealed the facility admitted the resident on 10/04/13. The resident had [DIAGNOSES REDACTED]. Review of Resident #11's April 2015 physician's orders [REDACTED]. Review of the pharmacy's Medication Dispensing Records, dated 12/01/14 through 04/17/15, revealed Resident #11's Digoxin was dispensed with fourteen (14) tablets per medication card and was dispensed seven (7) times since 12/10/14. The medication was dispensed on 12/10/14, 12/21/14, 01/28/15, 02/11/15, 02/25/15, 03/25/15, and on 04/15/15. During this timeframe (12/10/14 through 04/15/15), the pharmacy dispensed ninety-eight (98) Digoxin tablets. However, to ensure the resident received the medications as prescribed by the physician, one hundred twenty-eight (128) tablets were required for the staff to be able to administer the resident's Digoxin. 2. Review of Resident #17's medical record revealed the facility admitted the resident on 10/23/98. The resident had [DIAGNOSES REDACTED]. Review of Resident #17's April 2015 physician's orders [REDACTED]. Review of the Pharmacy's Medication Dispensing Records revealed the pharmacy dispensed thirty (30) capsules of Primidone 250 mg (a 30-day supply) twice from 12/18/14 through 04/04/15 (on 12/18/14 and 01/28/15), for a total of sixty (60) capsules. However, one hundred seven (107) capsules were required for the staff to be able to administer the resident's Primidone per the physician's orders [REDACTED]. Further review of the pharmacy Medication Dispensing Records revealed the pharmacy dispensed one hundred twenty (120) capsules of Depakote 125 mg (a 30-day supply) on 02/20/15. However, the medication was not dispensed to the facility again until 04/05/15, forty-four (44) days later. The SSA's Pharmacy Consultant conducted post survey review of the facility's pharmacy's dispensing records. Review of the Physician order [REDACTED]. Thus, the resident had been ordered two (2) tablets per day of the Primidone 150 mg since 12/16/14. The dosage of 250 mg twice daily was validated on 06/01/15 during a post survey phone interview with the Advanced Registered Nurse Practitioner. Resident #17 would have required a total of one-hundred and seven (107) tablets of Primidone to meet the dosage requirement from 12/08/14 through 04/04/15, if the order was for once a day. However, only sixty (60) tablets had been dispensed for the resident during that period. Based on the fact the resident was actually ordered to be receiving two (2) tablets daily of the Primidone during that period, the resident would have needed approximately twice that amount (between 204-214) tablets to achieve the dosage requirement as the physician had ordered. 3. Review of Resident #13's medical record revealed the facility admitted the resident on 06/10/13 with [DIAGNOSES REDACTED]. Review of Resident #13's physician's orders [REDACTED]. Review of the Pharmacy's Medication Dispensing Records for Resident #13 revealed the pharmacy dispensed 300 ml (a 30-day supply) of Keppra liquid medication three (3) times from 12/03/14 through 03/18/15 (there were 47 days between two of the refills), for a total of 900 ml. However, 1,050 ml of Keppra was required to administer the medication, per physician's orders [REDACTED]. During the SSA's post survey review, the SSA's Consultant Pharmacist reviewed the pharmacy's Delivery Manifest Reports (aka, dispensing records) for 12/01/14 through 04/04/15. This review revealed Resident #13 received four (4) refills for a 30-day supply (300 ml) of Keppra Liquid (12/03/14, 01/08/15, 02/24/15, and 03/19/15). Further review revealed there was a twenty-three (23) day time span between two (2)of Resident #13's Keppra refills. Specifically, the resident received 300 ml (30 day supply) on 12/03/14, then received a subsequent refill of 300 ml on 01/08/15. The subsequent refill should have been received approximately thirty (30) days later, (from 12/03/14) or on/about 01/02/15. Thus, the refill was approximately six (6) days late. Further review revealed after receiving the refill on 01/08/15, the resident received the next subsequent refill of 300 ml forty-seven (47) days later on 02/25/15, or approximately seventeen (17) days late. That refill should have been received approximately thirty (30) days later, on/about 02/07/15. 4. Review of Resident #16's medical record revealed the resident had [DIAGNOSES REDACTED]. Review of the medical record revealed a physician's orders [REDACTED]. Review of Resident #16's 01/2015 MAR indicated [REDACTED]. Review of the Pharmacy's Medication Dispensing Records revealed the pharmacy dispensed a 150 ml (a 15-day supply) bottle of Depakote for Resident #16 on 01/24/15. However, the medication was not refilled again until 02/18/15, twenty-six (26) days later. Further review of the MARs revealed the facility documented that the resident's medication had been administered as ordered per the physician. Review of Resident #16's Valproic Acid laboratory level dated 04/03/15, revealed the resident's Valproic Acid level was sub-therapeutic at 20.6 mcg/ml (micrograms/milliliter)(normal range is 50 - 100 mcg/ml). Review of the facility's "Status Change" document that listed residents who had been admitted , transferred, or discharged from December 2014 through April 2015 revealed Residents #11, #13, #15, #16, and #17 had not been discharged or transferred from the facility during the times when there were discrepancies identified with their medications. Interview with RN #1 on 04/14/15 at 5:03 PM, with Licensed Practical Nurse (LPN) #5 on 04/16/15 at 11:55 PM, with RN #6 on 04/16/15 at 12:14 PM, with Kentucky Medication Aide (KMA) #1 on 04/17/15 at 1:27 PM, and with LPN #6 on 04/17/15 at 3:29 PM, revealed that if staff documented on the resident's MAR indicated [REDACTED]. The interviews further revealed the residents' medications had to be re-ordered by the nursing staff when the resident's medication card had two (2) to seven (7) days remaining in the card. The nurses stated the facility did not have a system in place to determine when a medication card was placed in use after it was dispensed from the pharmacy. Interview on 04/15/15 at 3:40 PM with the Facility's Pharmacist revealed all prescription medication labels contained a re-order date. The interview further revealed the pharmacy notified the facility if a medication was being re-ordered too early; however, the pharmacy did not notify the facility if a medication was not re-ordered when a refill was due. Interview on 04/15/15 at 4:00 PM with the Pharmacy Director revealed facility nursing staff reordered residents' medications when the supply was low. However, the pharmacy did not have a way to track if medications were not being reordered timely. He stated Pharmacy sent a dispensing report to the facility that listed the quantity of the medication and the date the medication was sent to the facility. Interview with the Facility's Corporate Nurse Consultant on 04/17/15 at 2:45 PM revealed a report was available on the facility's computer system that listed all residents' medications that were pending reorder by the facility. The Nurse Consultant stated the Director of Nursing (DON) was required to compare the medications (that were pending re-order) to a report that was delivered with residents' medications to ensure the residents' medications were available. The Nurse Consultant stated the DON had identified no issues. Interview on 04/14/15 at 6:07 PM with the Director of Nursing revealed the facility did not have a system to know how much medication a resident had in stock at the facility at any given time. Further interview with the DON on 04/17/15 at 3:45 PM, revealed she had not identified any issues with medications not being re-ordered and administered per physician's orders [REDACTED]. **The facility provided an acceptable Allegation of Compliance (AOC) on 04/23/15. The facility implemented the following actions to remove the Immediate Jeopardy: 1) The Physician and Power of Attorney (POA) for Residents #11, #13, #14, #15, #16, and #17 were notified immediately upon identification of potential medication errors by the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADONs), Staff Development Coordinator (SDC), Quality Assurances (QA)Nurse, Nursing Supervisor, Medical Records Nurse or Regional Nurse Consultant on 04/20/15. Residents #11, #13, #14, #15, #16, and #17 were assessed by the ADONs or QA Nurse on 04/20/15 for any signs and symptoms of adverse reactions, with no issues identified. Laboratory levels were drawn on all six (6) residents, the physician was notified of the results, and the residents' care plans were updated, as needed. All six (6) residents' medications were counted and a medication reconciliation was completed for accuracy and a current count was placed on each individual pill packet and/or bottle of liquid medicine on 04/20/15 by the DON, ADONs, SDC, QA Nurse, Medical Records Nurse or Regional Nurse Consultant. 2) The physician and POAs for Residents #11, #15, #16, and #17 were notified immediately upon identification of inappropriate documentation by the Administrator, DON, ADONs, SDC, QA Nurse, Nursing Supervisor, Medical Record's Nurse, or Regional Nurse Consultant on 04/20/15. Residents #11, #15, #16, and #17 were re-assessed by the ADONs or QA Nurse, on 04/20/15, for any signs and symptoms of adverse reactions, with no issues identified. 3) All residents' medications were audited by the DON, ADON, SDC, Nursing Supervisor, Medical Record's Nurse or Regional Nurse Consultant, on 04/20/15, to ensure that the current medications, compared to the current Physician order [REDACTED]. A new bottle of medications were requested and placed into service on 04/22/15 for the liquid medications that could not be counted, due to opacity of container. 4) All residents' charts were audited by the Administrator, Assistant Administrator, DON, ADONs, SDC, QA Nurse, MDS Coordinators, Nursing Supervisor, Admissions, Social Services Director, Quality of Life, Dietary Manager, Chaplain, Medical Record's Nurse or Regional Nurse Consultant by 04/22/15 for accuracy of the clinical records and that the records were complete and accurately documented. The following issues were identified and corrected: a. Social Services Quarterly Notes were not within compliance- for three (3) residents b. Activity Quarterly Notes not within compliance-three (3) residents c. Care plan updates-two (2) residents d. Behavior Management care plan updates-two (2) residents 5) All residents' care plans were audited by the Administrator, Assistant Administrator, DON, ADONs, SDC, QA Nurse, MDS Coordinators, Nursing Supervisor, Admissions, Social Services Director, Quality of life, Dietary Manager, Chaplain, Medical Records or Regional Nurse Consultant by 04/22/15 to ensure all resident care plans reflected the current resident care needs. 6) Education was provided to the Administrator, HR, Med Record's Nurse, BOM, Quality of Life, Admissions, Assistant Administrator, Plant Ops, Food Service Director, SSD, Central Supply, Housekeeping Supervisor, DON, ADONs, SDC, MDS Coordinators, and Nursing Supervisors on 04/20/15 by the Regional Nurse Consultant regarding the facility's medication administration policy and procedure which included medication reconciliation. The care plan policy and the procedure included following the care plan, administering care to ensure highest practical physical, mental, and psychosocial well-being of each resident, and maintain clinical records in acceptable professional standards and practices that were complete, accurately documented, readily accessible and systematically organized. 7) Education was initiated for licensed staff, Kentucky Medication Aides (KMAs) and State Registered Nurse Aides (SRNAs) on 04/20/15 by the Administrator, Assistant Administrator, Regional Nurse Consultant, DON, ADONs or the SDC regarding the Medication Administration Policy and Procedure which included medication reconciliation, care plan policy and the procedure to include following the care plan, administering care to ensure highest practical physical, mental, and psychosocial well-being of each resident, and maintain clinical records in acceptable professional standards and practices that were complete, accurately documented, readily accessible and systematically organized. All clinical staff completed or will complete a post-test and score 100% to ensure understanding of education/training provided. If 100% is not obtained then the staff member will be re-educated and a post-test re-administered until the staff member obtains 100% score to ensure understanding of the material covered. Clinical staff was not allowed to work prior to receiving the above stated education. Those clinical staff members that were on Family Medical Leave Act (FMLA), leave or work "as needed" (PRN) were sent a certified letter and were not allowed to work until the education had been received and a post-test completed with 100% score obtained. As of 04/23/15, 60% of all licensed staff and clinical staff had been educated with post-test completed and 100% score obtained; 15% have been contacted by phone, provided education and notified that they cannot work until 1:1 education with post-test was completed, and, 100% score obtained. The remaining 25% were in the process of being contacted and will not be allowed to work until education with post-test has been completed and 100% score obtained. Once education has been provided, each licensed nurse will complete a medication administration observation pass with the DON, ADONs, SDC, Nursing Supervisor, or Regional Nurse Consultant. 8) Education regarding medication administration policy and procedure, care plan policy and procedure, administrative oversight, and complete and accurate clinical records were included in the new hire orientation. 9) A new process was initiated on 04/22/15 for medication reconciliation of residents' medications. The process is as follows: a. One random nurse per day, per shift, will complete a medication pass observation with the DON, ADONs, SDC, Medical Records Nurse, MDS Coordinators, Nursing Supervisor or Regional Nurse Consultant to ensure compliance with medication administration, the resident's care plan was being followed and accurate along with completed documentation was noted. b. DON, ADONs, SDC, Medical Records Nurse, MDS Coordinators, Nursing Supervisor, or Regional Nurse Consultant reconciled the medications of four (4) randomly selected residents daily to ensure compliance with medication administration. This process was continued until immediacy was lifted. c. Nurses/KMAs received education on 04/21/15 by the Regional Nurse Consultant, DON, ADONs, SDC, or Nursing Supervisor on placing the discarded pill packets/bottles in the bottom drawer of the medication cart when packet/bottle was finished. The DON, ADONs, SDC, Medical Records Nurse, MDS Coordinators, Nursing Supervisor or Regional Nurse Consultant audited, daily, ten (10) discarded packets/bottles per side compared to packets/bottles that were put into service to reconcile medications, confirm reorder process and that the medications were being given per the physician's orders [REDACTED]. The process continued until immediacy was lifted. d. Nurses/KMAs placed the date/time and their initials on the side of any new medication packet/bottle placed into service to ensure an accurate date which will allow for accurate reconciliation. Those liquid medications, a total of twenty-one (21), that could not be counted, due to opacity of container, a new bottle was obtained and placed in service by 04/22/15. e. Reorder process below will continue until immediacy was lifted: i) A nurse re-ordered medications via the ezMAR alert system when three (3) to four (4) days of medication were left to administer. ii) A nurse then placed, on the current medication bubble pack, the date of reorder, and their initials. iii) The DON and/or ADONs ran the "Refill Reminder Report" from the ezMAR system, Monday - Friday, and validated that all medications due to be reordered, had actually been reordered. iv) Facility Formulary Nurse, ADONs, SDC, QA Nurse, or Nursing Supervisors reconciled the Refill Reminder Report with the nightly medication manifest report with the actual medication packet on the cart or stored in overflow to ensure medications that were reordered have actually arrived at facility. f. Nurses and KMAs were educated/trained on the medication administration policy and procedure to include documentation along with the scope of practice of the KMA. KMAs will not administer or document administering any medications other than by mouth (PO) or topical. 10) All residents medications were reconciled two (2) times weekly, starting 04/20/15 by the DON, ADONs, SDC, Medical Records Nurse, QA Nurse, Nursing Supervisor, Regional Nurse Consultant or Chief Nursing Executive, to ensure reorder process system was intact and within compliance along with ensuring residents medications were administered as ordered. This process will continue for two (2) weeks and results will be reviewed in a weekly QAPI meeting. The QAPI committee will determine ongoing frequency of resident medication reconciliation at that time. 11) Education was provided for Licensed Nursing Staff by the Administrator, Assistant Administrator, DON, ADON, the SDC, or the Regional Nurse Consultant regarding the above stated plan by 04/21/15. 12) Medication pass audits were completed by the DON, ADON, SDC, Medical Records Nurse, or Regional Nurse Consultant for all nurses and KMAs by 04/22/15 to ensure that medications were administered without significant medication error. Nurses or KMAs who had not completed a medication pass observation were not allowed to work until the medication pass observations had been completed for shifts scheduled after 04/22/15. As of 04/24/15, 75% of all nurses and KMAs had completed a medication pass observation. 13) Administrative oversight of the facility was completed by the Special Projects Administrator, the Regional Vice President of Operations, or the Chief Operating Officer daily until removal of immediacy, weekly for four (4) weeks after removal of immediacy, then monthly. 14) The Administrator, Assistant Administrator, Special Projects, DON, Chief Operating Officer, Chief Nurse Executive or Regional Nurse Consultant audited compliance of the above stated audits/observations daily until removal of immediacy, then twice weekly for four (4) weeks and reported findings during weekly QA for four (4)weeks, for recommendations and further follow-up as indicated. 15) A Quality Assurance meeting was held on 04/17/15, and again on 04/20/15 for further recommendations regarding the plan for removal of Immediate Jeopardy. A Quality Assurance meeting will be held weekly for four (4) weeks, then monthly for recommendations and further follow up regarding the above stated plan. **The State Survey Agency validated the Immediate Jeopardy was removed as follows: 1) Review of the medical records of Residents #11, #13, #14, #15, #16, and #17 revealed the residents' physicians and POAs were notified of the potential medication errors by the administrative staff. Further review of the medical records revealed Residents #11, #13, #14, #15, #16, and #17 were assessed by the ADONs or the QA Nurse, on 04/20/15, for any signs and symptoms of adverse reactions from potential medication errors, with no issues identified. The facility obtained laboratory levels on all six (6) residents, the physician was notified of the results, and the residents' care plans were updated as needed. The residents' laboratory results were obtained on the following days by the facility: Resident #11 on 04/03/15, 04/06/15, and 04/20/15, Resident #13 on 04/03/15 and 04/19/15, Resident #14 on 04/17/15, 04/17/15 and 04/19/15, Resident #15 on 04/03/15 and 04/20/15, Resident #16 on 04/03/15 and 04/17/15 and Resident #17 on 04/20/15. The Administrative Staff counted all six (6) residents' medications and a medication reconciliation was completed for accuracy and a current count was placed on each individual pill packet and/or bottle of liquid medicine on 04/20/15 by the DON, ADONs, SDC, QA Nurse, Medical Records Nurse or Regional Nurse Consultant. 2) Review of the medical record revealed the physicians and POAs for Residents #11, #15, #16, and #17 were notified immediately upon identification of inappropriate documentation by the Administrator, DON, ADONs, SDC, QA Nurse, Nursing Supervisor, Medical Record's Nurse, or Regional Nurse Consultant on 04/20/15. Further review of the medical records revealed Residents #11, #15, #16, and #17 were re-assessed by the ADONs or QA Nurse, on 04/20/15, for any signs and symptoms of adverse reactions, with no issues identified. 3) Review of the medication audits revealed the audits were completed by the DON, ADON, SDC, Nursing Supervisor, Medical Record's Nurse or Regional Nurse Consultant, on 04/20/15, and ensured that the current medications, compared to the current Physician order [REDACTED]. Observations, on 04/24/15 revealed new bottles of medication were placed into service on 04/22/15. 4) Review of the facility's audits revealed all residents' charts were audited by the Administrator, Assistant Administrator, DON, ADONs, SDC, QA Nurse, MDS Coordinators, Nursing Supervisor, Admissions, Social Services Director (SSD), Quality of Life, Dietary Manager, Chaplain, Medical Record's Nurse or Regional Nurse Consultant by 04/22/15 for accuracy of the clinical records and that the records were complete and accurately documented. The audits revealed issues identified were corrected by the facility staff. 5) Review of the facility's audits on 04/24/15, revealed all residents care plans were audited by the Administrator, Assistant Administrator, DON, ADONs, SDC, QA Nurse, MDS Coordinators, Nursing Supervisor, Admissions, Social Services Director, Quality of life, Dietary Manager, Chaplain, Medical Records or Regional Nurse Consultant by 04/22/15 to ensure all residents' care plans reflected the current resident care needs. 6) Review of the facility's in-services revealed education was provided to the Administrator, HR, Medical Record's Nurse, BOM, Quality of Life, Admissions, Assistant Administrator, Plant Ops, Food Service Director, SSD, Central Supply, Housekeeping Supervisor, DON, ADONs, SDC, MDS Coordinators, and Nursing Supervisors on 04/20/15 by the Regional Nurse Consultant. The education provided included the medication administration policy and procedure to include medication reconciliation, care plan policy, and the procedure to include following the care plan, administering care to ensure highest practical physical, mental, and psychosocial well-being of each resident, and maintain clinical records in acceptable professional standards and practices that were complete, accurately documented, readily accessible and systematically organized. Interviews conducted on 04/24/15, with the Administrator, HR, Med Record's Nurse, BOM, Quality of Life, Admissions, Assistant Administrator, Plant Ops, Food Service Director, SSD, Central Supply, Housekeeping Supervisor, DON, ADONs, SDC, MDS Coordinators, and Nursing Supervisors revealed the staff was educated on 04/20/15 on care plans, the medication administration policy and procedure and accurate medical records. 7) Review of the facility's in-services revealed education was initiated for licensed staff, KMAs and SRNAs on 04/20/15 by the Administrator, Assistant Administrator, Regional Nurse Consultant, DON, ADONs or the SDC regarding the medication administration policy and procedure to include medication reconciliation, care plan policy and the procedure to include following the care plan, administering care to ensure highest practical physical, mental, and psychosocial well-being of each resident, and maintain clinical records in acceptable professional standards and practices that were complete, accurately documented, readily accessible and systematically organized. Interviews on 04/24/15 with licensed staff, KMAs, and SRNAs revealed the facility provided staff education that included information on the medication administration policy, medical record documentation, care planning and following the care plan and medication reconciliation. Review of the POS [REDACTED]"as needed") had completed the post-test with a 100% score. 8) Review of new employee orientation revealed newly hired staff would receive education regarding medication administration policy and procedure, care plan policy and procedure, administrative oversight, and complete and accurate clinical records and that the information was added to the new hire orientation. Interviews on 04/24/15, with newly hired staff revealed the staff had been provided information on medication administration policy and procedure, care plan policy and procedure, administrative oversight, and complete and accurate clinical records. 9) Review of the new process for medication reconciliation of residents' medications revealed the process was initiated on 04/22/15. The process was as follows: a. Review of the facility audits revealed one random nurse per day, per shift completed a medication pass observation with the DON, ADONs, SDC, Medical Record's Nurse, MDS Coordinators, Nursing Supervisor or Regional Nurse Consultant to ensure compliance with medication administration, the resident's care plan was being followed and accurate, and to ensure documentation was completed. b. Review of the facility's audits revealed the DON, ADONs, SDC, Medical Records Nurse, MDS Coordinators, Nursing Supervisor or Regional Nurse Consultant reconciled the medications of four (4) randomly selected residents daily to ensure compliance with medication administration. The audits revealed the process was ongoing on 04/24/15. c. Review of the facility's in-services revealed the nurses/KMAs received education on 04/21/15 by the Regional Nurse Consultant, DON, ADONs, SDC, or Nursing Supervisor on placing the discarded pill packets/bottles in the bottom drawer of the medication cart when the packet/bottle was finished. Review of the facility's audits revealed the DON, ADONs, SDC, Medical Records Nurse, MDS Coordinators, Nursing Supervisor or Regional Nurse Consultant audited ten (10) discarded packets/bottles per unit daily and compared them to packets/bottles that were put into service to reconcile medications, confirm the reorder process and that the medications were being given per the physician's orders [REDACTED]. Review of the facility's audits and an observation of the medication cart on 04/24/15, revealed the process was ongoing on 04/24/15. d. Observations of the medication carts on 04/24/15 revealed the nurses/KMAs had placed the date/time and their initials on the side of new medication packet/bottle. Further observations of the medication carts revealed liquid medications were dated 04/22/15. e. Review of the medication re-order process revealed the following process was in place i) Interviews, on 04/24/15, with nursing staff revealed a nurse reordered medications via the ezMAR alert sys

Based on observation, interview, record review, review of pharmacy medication dispensing records, review of the facility's investigation, and review of facility policy, it was determined the facility's Administration failed to ensure its resources were used effectively and efficiently to maintain the highest practicable physical, mental, and psychosocial well-being of each resident. On 04/03/15, the facility initiated an investigation of an allegation of neglect related to Resident #11's [MEDICATION NAME] (a medication used to slow the heart rate of patients with [MEDICAL CONDITION]). Review of the facility's investigation revealed the facility determined on 04/01/15 that Resident #11 had ten (10) [MEDICATION NAME] tablets in the medication cart, and on 04/03/15 ten (10) [MEDICATION NAME] tablets remained in the cart. The facility obtained a laboratory level for the resident's medication [MEDICATION NAME] on 04/03/15, which revealed the resident's medication level was sub-therapeutic. In addition, six (6) of nine (9) other residents had sub-therapeutic medication levels when tests were obtained on 04/03/15. The Administrator took no further action to conduct additional investigations or to address the medication concerns (refer to F282, F333, F425, and F514). The facility's failure to have an effective system in place to ensure care and services were provided as per the resident's plan of care was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was determined to exist on 04/02/15 at 42 CFR 483.20 Resident Assessment (F282), 42 CFR 483.25 Quality of Care (F333), 42 CFR 483.60 Pharmacy Services (F425), and 42 CFR 483.75 Administration (F490 and F514). The facility was notified of the Immediate Jeopardy on 04/20/15. An acceptable Allegation of Compliance was received on 04/23/15, which alleged removal of the Immediate Jeopardy on 04/23/15. An extended survey was conducted on 04/24/15. The State Survey Agency determined the Immediate Jeopardy was removed on 04/23/15, which lowered the Scope and Severity to an "E" at 42 CFR 483.20 Resident Assessment (F282), 42 CFR 483.25 Quality of Care (F333), 42 CFR 483.60 Pharmacy Services (F425), and, 42 CFR 483.75 Administration (F490 and F514) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled "Medication Administration - Medication Discrepancies," dated December 2009, revealed medication discrepancies were documented and reported to the resident's attending physician, Director of Nursing, responsible party, and the Performance Improvement Committee. The policy defined a medication discrepancy as an omission of medication due to a prescribing, dispensing, or administration error. The policy further revealed when a medication discrepancy occurred immediate action should be taken to protect the patient's safety and welfare. The policy revealed a medication discrepancy/error/incident report was to be completed. Review of the facility's Administrator Job Description, dated December 2011, revealed the Administrator would "lead and direct the overall operations of the facility in accordance with customer needs, government regulations and Company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives." Review of Resident #11's April 2015 physician's orders [REDACTED]. The medication was initially ordered 08/17/14. Review of the facility's investigation related to Resident #11, dated 04/07/15, revealed on 04/01/15, Resident #11's [MEDICATION NAME] medication card dated 03/24/15 (the date the medication card was received from the pharmacy), revealed only four (4) tablets had been dispensed from the card leaving ten (10) tablets remaining on the medication card. The facility audited the medication card again on 04/03/15, prior to the morning dose of [MEDICATION NAME] being administered, and Resident #11's [MEDICATION NAME] medication card still had ten (10) tablets remaining on the card. Even though the pill count remained the same, review of the Medication Administration Record (MAR) revealed staff documented the medication was administered on 04/02/15; and that the medication had not been held or refused the previous day. The facility initiated an investigation on 04/03/15, which included obtaining laboratory results for nine (9) residents who received medications that must maintain a therapeutic level. Review of the laboratory tests revealed six (6) of the nine (9) residents tested had sub-therapeutic laboratory levels. Further review of the facility's investigation revealed the facility unsubstantiated the allegation. Review of the Pharmacy's Medication Dispensing records, dated 12/01/14 through 04/17/15, revealed medications that required monitoring were not being dispensed by the pharmacy in the amount required to ensure they were available to be administered per physician's orders [REDACTED]. Further review of the Dispending Records revealed Resident #11's [MEDICATION NAME] went up to thirty-seven (37) days between refills; Resident #17 went up to sixty-five (65) days for his/her [MEDICATION NAME] [MEDICATION]) and up to forty-three (43) days to get the [MEDICATION NAME] (anti- [MEDICAL CONDITION] medication) refilled. Further review revealed there were up to forty-seven (47) days between refills of Resident #13's [MEDICATION NAME] (anti-[MEDICAL CONDITION]); and up to twenty-five (25) days between refills of Resident #16's [MEDICATION NAME]. Further review revealed 473 ml of [MEDICATION NAME] (a 30-day supply) was dispensed to the facility on [DATE] for Resident #15 and dated as opened on 03/21/15; the [MEDICATION NAME] bottle contained 150 ml of liquid medication and by the documentation on the MAR there should have only been 130.5 ml remaining in the bottle. The SSA's Consultant Pharmacist's post survey review revealed there was a delay of approximately twenty-three (23) days between receipt of two of Resident #13's refills of [MEDICATION NAME] Liquid (30-day supply). Interview on 04/14/15 at 6:07 PM with the Director of Nursing (DON) revealed she conducted a random medication cart audit on 04/01/15 after the morning medication pass. She stated Resident #11's [MEDICATION NAME] raised a "red flag" because the medication card label was dated 03/24/15 and only four (4) tablets had been administered from the medication card leaving ten (10) tablets on the card. The DON stated she reviewed Resident #11's MAR and no doses had been held or refused. Further interview revealed she immediately initiated an investigation which included assessments of all residents on the hall where Resident #11 resided. Laboratory levels for all residents on that hall that were ordered medications that require therapeutic monitoring were obtained. However, the DON stated review of the Pharmacy Dispensing Records was not conducted as part of the investigation. She stated the administrative staff reviewed the investigation and did not feel there was enough concrete evidence to say Resident #11 did not receive his/her medications as ordered by the physician. Although six (6) residents were identified to have sub-therapeutic laboratory levels, interview with the Director of Nursing revealed no pattern or trend was identified and no further action was taken. Interview on 04/20/15 at 1:30 PM with the Administrator revealed the allegation was discussed by the Interdisciplinary Treatment Team and it was determined there had been a thorough investigation of the discrepancy. Even though the Administrator was aware that Resident #11's medication had the same number of pills for two (2) days (04/01/15-04/03/15), and other residents had sub-therapeutic levels of medications, he stated he did not feel the allegation could be substantiated without proof that the medication was not administered to Resident #11 per the physician's orders [REDACTED]. According to the facility's policy, when a medication discrepancy occurred immediate action should be taken to protect the patient's safety and welfare. **The facility provided an acceptable Allegation of Compliance (AOC) on 04/23/15. The facility implemented the following actions to remove the Immediate Jeopardy: 1) The Physician and Power of Attorney (POA) for Residents #11, #13, #14, #15, #16, and #17 were notified immediately upon identification of potential medication errors by the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADONs), Staff Development Coordinator (SDC), Quality Assurances (QA)Nurse, Nursing Supervisor, Medical Records Nurse or Regional Nurse Consultant on 04/20/15. Residents #11, #13, #14, #15, #16, and #17 were assessed by the ADONs or QA Nurse on 04/20/15 for any signs and symptoms of adverse reactions, with no issues identified. Laboratory levels were drawn on all six (6) residents, the physician was notified of the results, and the residents' care plans were updated, as needed. All six (6) residents' medications were counted and a medication reconciliation was completed for accuracy and a current count was placed on each individual pill packet and/or bottle of liquid medicine on 04/20/15 by the DON, ADONs, SDC, QA Nurse, Medical Records Nurse or Regional Nurse Consultant. 2) The physician and POAs for Residents #11, #15, #16, and #17 were notified immediately upon identification of inappropriate documentation by the Administrator, DON, ADONs, SDC, QA Nurse, Nursing Supervisor, Medical Record's Nurse, or Regional Nurse Consultant on 04/20/15. Residents #11, #15, #16, and #17 were re-assessed by the ADONs or QA Nurse, on 04/20/15, for any signs and symptoms of adverse reactions, with no issues identified. 3) All residents' medications were audited by the DON, ADON, SDC, Nursing Supervisor, Medical Record's Nurse or Regional Nurse Consultant, on 04/20/15, to ensure that the current medications, compared to the current Physician order [REDACTED]. A new bottle of medications were requested and placed into service on 04/22/15 for the liquid medications that could not be counted, due to opacity of container. 4) All residents' charts were audited by the Administrator, Assistant Administrator, DON, ADONs, SDC, QA Nurse, MDS Coordinators, Nursing Supervisor, Admissions, Social Services Director, Quality of Life, Dietary Manager, Chaplain, Medical Record's Nurse or Regional Nurse Consultant by 04/22/15 for accuracy of the clinical records and that the records were complete and accurately documented. The following issues were identified and corrected: a. Social Services Quarterly Notes were not within compliance- for three (3) residents b. Activity Quarterly Notes not within compliance-three (3) residents c. Care plan updates-two (2) residents d. Behavior Management care plan updates-two (2) residents 5) All residents' care plans were audited by the Administrator, Assistant Administrator, DON, ADONs, SDC, QA Nurse, MDS Coordinators, Nursing Supervisor, Admissions, Social Services Director, Quality of life, Dietary Manager, Chaplain, Medical Records or Regional Nurse Consultant by 04/22/15 to ensure all resident care plans reflected the current resident care needs. 6) Education was provided to the Administrator, HR, Med Record's Nurse, BOM, Quality of Life, Admissions, Assistant Administrator, Plant Ops, Food Service Director, SSD, Central Supply, Housekeeping Supervisor, DON, ADONs, SDC, MDS Coordinators, and Nursing Supervisors on 04/20/15 by the Regional Nurse Consultant regarding the facility's medication administration policy and procedure which included medication reconciliation. The care plan policy and the procedure included following the care plan, administering care to ensure highest practical physical, mental, and psychosocial well-being of each resident, and maintain clinical records in acceptable professional standards and practices that were complete, accurately documented, readily accessible and systematically organized. 7) Education was initiated for licensed staff, Kentucky Medication Aides (KMAs) and State Registered Nurse Aides (SRNAs) on 04/20/15 by the Administrator, Assistant Administrator, Regional Nurse Consultant, DON, ADONs or the SDC regarding the Medication Administration Policy and Procedure which included medication reconciliation, care plan policy and the procedure to include following the care plan, administering care to ensure highest practical physical, mental, and psychosocial well-being of each resident, and maintain clinical records in acceptable professional standards and practices that were complete, accurately documented, readily accessible and systematically organized. All clinical staff completed or will complete a post-test and score 100% to ensure understanding of education/training provided. If 100% is not obtained then the staff member will be re-educated and a post-test re-administered until the staff member obtains 100% score to ensure understanding of the material covered. Clinical staff was not allowed to work prior to receiving the above stated education. Those clinical staff members that were on Family Medical Leave Act (FMLA), leave or work "as needed" (PRN) were sent a certified letter and were not allowed to work until the education had been received and a post-test completed with 100% score obtained. As of 04/23/15, 60% of all licensed staff and clinical staff had been educated with post-test completed and 100% score obtained; 15% have been contacted by phone, provided education and notified that they cannot work until 1:1 education with post-test was completed, and, 100% score obtained. The remaining 25% were in the process of being contacted and will not be allowed to work until education with post-test has been completed and 100% score obtained. Once education has been provided, each licensed nurse will complete a medication administration observation pass with the DON, ADONs, SDC, Nursing Supervisor, or Regional Nurse Consultant. 8) Education regarding medication administration policy and procedure, care plan policy and procedure, administrative oversight, and complete and accurate clinical records were included in the new hire orientation. 9) A new process was initiated on 04/22/15 for medication reconciliation of residents' medications. The process is as follows: a. One random nurse per day, per shift, will complete a medication pass observation with the DON, ADONs, SDC, Medical Records Nurse, MDS Coordinators, Nursing Supervisor or Regional Nurse Consultant to ensure compliance with medication administration, the resident's care plan was being followed and accurate along with completed documentation was noted. b. DON, ADONs, SDC, Medical Records Nurse, MDS Coordinators, Nursing Supervisor, or Regional Nurse Consultant reconciled the medications of four (4) randomly selected residents daily to ensure compliance with medication administration. This process was continued until immediacy was lifted. c. Nurses/KMAs received education on 04/21/15 by the Regional Nurse Consultant, DON, ADONs, SDC, or Nursing Supervisor on placing the discarded pill packets/bottles in the bottom drawer of the medication cart when packet/bottle was finished. The DON, ADONs, SDC, Medical Records Nurse, MDS Coordinators, Nursing Supervisor or Regional Nurse Consultant audited, daily, ten (10) discarded packets/bottles per side compared to packets/bottles that were put into service to reconcile medications, confirm reorder process and that the medications were being given per the physician's orders [REDACTED]. The process continued until immediacy was lifted. d. Nurses/KMAs placed the date/time and their initials on the side of any new medication packet/bottle placed into service to ensure an accurate date which will allow for accurate reconciliation. Those liquid medications, a total of twenty-one (21), that could not be counted, due to opacity of container, a new bottle was obtained and placed in service by 04/22/15. e. Reorder process below will continue until immediacy was lifted: i) A nurse re-ordered medications via the ezMAR alert system when three (3) to four (4) days of medication were left to administer. ii) A nurse then placed, on the current medication bubble pack, the date of reorder, and their initials. iii) The DON and/or ADONs ran the "Refill Reminder Report" from the ezMAR system, Monday - Friday, and validated that all medications due to be reordered, had actually been reordered. iv) Facility Formulary Nurse, ADONs, SDC, QA Nurse, or Nursing Supervisors reconciled the Refill Reminder Report with the nightly medication manifest report with the actual medication packet on the cart or stored in overflow to ensure medications that were reordered have actually arrived at facility. f. Nurses and KMAs were educated/trained on the medication administration policy and procedure to include documentation along with the scope of practice of the KMA. KMAs will not administer or document administering any medications other than by mouth (PO) or topical. 10) All residents medications were reconciled two (2) times weekly, starting 04/20/15 by the DON, ADONs, SDC, Medical Records Nurse, QA Nurse, Nursing Supervisor, Regional Nurse Consultant or Chief Nursing Executive, to ensure reorder process system was intact and within compliance along with ensuring residents medications were administered as ordered. This process will continue for two (2) weeks and results will be reviewed in a weekly QAPI meeting. The QAPI committee will determine ongoing frequency of resident medication reconciliation at that time. 11) Education was provided for Licensed Nursing Staff by the Administrator, Assistant Administrator, DON, ADON, the SDC, or the Regional Nurse Consultant regarding the above stated plan by 04/21/15. 12) Medication pass audits were completed by the DON, ADON, SDC, Medical Records Nurse, or Regional Nurse Consultant for all nurses and KMAs by 04/22/15 to ensure that medications were administered without significant medication error. Nurses or KMAs who had not completed a medication pass observation were not allowed to work until the medication pass observations had been completed for shifts scheduled after 04/22/15. As of 04/24/15, 75% of all nurses and KMAs had completed a medication pass observation. 13) Administrative oversight of the facility was completed by the Special Projects Administrator, the Regional Vice President of Operations, or the Chief Operating Officer daily until removal of immediacy, weekly for four (4) weeks after removal of immediacy, then monthly. 14) The Administrator, Assistant Administrator, Special Projects, DON, Chief Operating Officer, Chief Nurse Executive or Regional Nurse Consultant audited compliance of the above stated audits/observations daily until removal of immediacy, then twice weekly for four (4) weeks and reported findings during weekly QA for four (4)weeks, for recommendations and further follow-up as indicated. 15) A Quality Assurance meeting was held on 04/17/15, and again on 04/20/15 for further recommendations regarding the plan for removal of Immediate Jeopardy. A Quality Assurance meeting will be held weekly for four (4) weeks, then monthly for recommendations and further follow up regarding the above stated plan. **The State Survey Agency validated the Immediate Jeopardy was removed as follows: 1) Review of the medical records of Residents #11, #13, #14, #15, #16, and #17 revealed the residents' physicians and POAs were notified of the potential medication errors by the administrative staff. Further review of the medical records revealed Residents #11, #13, #14, #15, #16, and #17 were assessed by the ADONs or the QA Nurse, on 04/20/15, for any signs and symptoms of adverse reactions from potential medication errors, with no issues identified. The facility obtained laboratory levels on all six (6) residents, the physician was notified of the results, and the residents' care plans were updated as needed. The residents' laboratory results were obtained on the following days by the facility: Resident #11 on 04/03/15, 04/06/15, and 04/20/15, Resident #13 on 04/03/15 and 04/19/15, Resident #14 on 04/17/15, 04/17/15 and 04/19/15, Resident #15 on 04/03/15 and 04/20/15, Resident #16 on 04/03/15 and 04/17/15 and Resident #17 on 04/20/15. The Administrative Staff counted all six (6) residents' medications and a medication reconciliation was completed for accuracy and a current count was placed on each individual pill packet and/or bottle of liquid medicine on 04/20/15 by the DON, ADONs, SDC, QA Nurse, Medical Records Nurse or Regional Nurse Consultant. 2) Review of the medical record revealed the physicians and POAs for Residents #11, #15, #16, and #17 were notified immediately upon identification of inappropriate documentation by the Administrator, DON, ADONs, SDC, QA Nurse, Nursing Supervisor, Medical Record's Nurse, or Regional Nurse Consultant on 04/20/15. Further review of the medical records revealed Residents #11, #15, #16, and #17 were re-assessed by the ADONs or QA Nurse, on 04/20/15, for any signs and symptoms of adverse reactions, with no issues identified. 3) Review of the medication audits revealed the audits were completed by the DON, ADON, SDC, Nursing Supervisor, Medical Record's Nurse or Regional Nurse Consultant, on 04/20/15, and ensured that the current medications, compared to the current Physician order [REDACTED]. Observations, on 04/24/15 revealed new bottles of medication were placed into service on 04/22/15. 4) Review of the facility's audits revealed all residents' charts were audited by the Administrator, Assistant Administrator, DON, ADONs, SDC, QA Nurse, MDS Coordinators, Nursing Supervisor, Admissions, Social Services Director (SSD), Quality of Life, Dietary Manager, Chaplain, Medical Record's Nurse or Regional Nurse Consultant by 04/22/15 for accuracy of the clinical records and that the records were complete and accurately documented. The audits revealed issues identified were corrected by the facility staff. 5) Review of the facility's audits on 04/24/15, revealed all residents care plans were audited by the Administrator, Assistant Administrator, DON, ADONs, SDC, QA Nurse, MDS Coordinators, Nursing Supervisor, Admissions, Social Services Director, Quality of life, Dietary Manager, Chaplain, Medical Records or Regional Nurse Consultant by 04/22/15 to ensure all residents' care plans reflected the current resident care needs. 6) Review of the facility's in-services revealed education was provided to the Administrator, HR, Medical Record's Nurse, BOM, Quality of Life, Admissions, Assistant Administrator, Plant Ops, Food Service Director, SSD, Central Supply, Housekeeping Supervisor, DON, ADONs, SDC, MDS Coordinators, and Nursing Supervisors on 04/20/15 by the Regional Nurse Consultant. The education provided included the medication administration policy and procedure to include medication reconciliation, care plan policy, and the procedure to include following the care plan, administering care to ensure highest practical physical, mental, and psychosocial well-being of each resident, and maintain clinical records in acceptable professional standards and practices that were complete, accurately documented, readily accessible and systematically organized. Interviews conducted on 04/24/15, with the Administrator, HR, Med Record's Nurse, BOM, Quality of Life, Admissions, Assistant Administrator, Plant Ops, Food Service Director, SSD, Central Supply, Housekeeping Supervisor, DON, ADONs, SDC, MDS Coordinators, and Nursing Supervisors revealed the staff was educated on 04/20/15 on care plans, the medication administration policy and procedure and accurate medical records. 7) Review of the facility's in-services revealed education was initiated for licensed staff, KMAs and SRNAs on 04/20/15 by the Administrator, Assistant Administrator, Regional Nurse Consultant, DON, ADONs or the SDC regarding the medication administration policy and procedure to include medication reconciliation, care plan policy and the procedure to include following the care plan, administering care to ensure highest practical physical, mental, and psychosocial well-being of each resident, and maintain clinical records in acceptable professional standards and practices that were complete, accurately documented, readily accessible and systematically organized. Interviews on 04/24/15 with licensed staff, KMAs, and SRNAs revealed the facility provided staff education that included information on the medication administration policy, medical record documentation, care planning and following the care plan and medication reconciliation. Review of the post-tests revealed staff (with the exception of staff who was on medical leave or who worked "as needed") had completed the post-test with a 100% score. 8) Review of new employee orientation revealed newly hired staff would receive education regarding medication administration policy and procedure, care plan policy and procedure, administrative oversight, and complete and accurate clinical records and that the information was added to the new hire orientation. Interviews on 04/24/15, with newly hired staff revealed the staff had been provided information on medication administration policy and procedure, care plan policy and procedure, administrative oversight, and complete and accurate clinical records. 9) Review of the new process for medication reconciliation of residents' medications revealed the process was initiated on 04/22/15. The process was as follows: a. Review of the facility audits revealed one random nurse per day, per shift completed a medication pass observation with the DON, ADONs, SDC, Medical Record's Nurse, MDS Coordinators, Nursing Supervisor or Regional Nurse Consultant to ensure compliance with medication administration, the resident's care plan was being followed and accurate, and to ensure documentation was completed. b. Review of the facility's audits revealed the DON, ADONs, SDC, Medical Records Nurse, MDS Coordinators, Nursing Supervisor or Regional Nurse Consultant reconciled the medications of four (4) randomly selected residents daily to ensure compliance with medication administration. The audits revealed the process was ongoing on 04/24/15. c. Review of the facility's in-services revealed the nurses/KMAs received education on 04/21/15 by the Regional Nurse Consultant, DON, ADONs, SDC, or Nursing Supervisor on placing the discarded pill packets/bottles in the bottom drawer of the medication cart when the packet/bottle was finished. Review of the facility's audits revealed the DON, ADONs, SDC, Medical Records Nurse, MDS Coordinators, Nursing Supervisor or Regional Nurse Consultant audited ten (10) discarded packets/bottles per unit daily and compared them to packets/bottles that were put into service to reconcile medications, confirm the reorder process and that the medications were being given per the physician's orders [REDACTED]. Review of the facility's audits and an observation of the medication cart on 04/24/15, revealed the process was ongoing on 04/24/15. d. Observations of the medication carts on 04/24/15 revealed the nurses/KMAs had placed the date/time and their initials on the side of new medication packet/bottle. Further observations of the medication carts revealed liquid medications were dated 04/22/15. e. Review of the medication re-order process revealed the following process was in place i) Interviews, on 04/24/15, with nursing staff revealed a nurse reordered medications via the ezMAR alert system when three (3) to four (4) days of a medication was left to administer. ii) Observations on 04/24/15, and interviews with nursing staff, on 04/24/15, revealed a nurse placed the date of reorder and their initials on the current medication bubble package. iii) Interviews, on 04/24/15, with the DON and ADONs revealed the administrative staff ran the "Refill Reminder Report" from the ezMAR system, Monday -Friday, and validated that all medications due to be reordered, had actually been reordered. iv) Interviews on 04/24/15, with the Facility Formulary Nurse, ADONs, SDC, QA Nurse, and Nursing Supervisors revealed the staff reconciled the Refill Reminder Report with the nightly medication manifest report and the actual medication packet on the cart or stored in overflow to ensure medications that were reordered had actually arrived at the facility. f. Review of the facility in-services revealed nurses and KMAs were educated/trained on the medication administration policy and procedure to include documentation along with the scope of practice of the KMA. Interviews, on 04/24/15, with nurses and KMAs revealed the staff had been trained on documentation practices and scope of practice for the KMA. 10) Review of the facility's audits revealed all residents' medications were reconciled two (2) times weekly, starting on 04/20/15 by the DON, ADONs, SDC, Medical Records Nurse, QA Nurse, Nursing Supervisor, Regional Nurse Consultant or Chief Nursing Executive. Interviews on 04/24/15 with the DON, ADONs, SDC, Medical Records Nurse, QA Nurse, Nursing Supervisor, Regional Nurse Consultant and Chief Nursing Executive revealed all residents' medications were reconciled two (2) times weekly with no issues identified. 11) Review of the facility's in-services revealed education was provided for Licensed Nursing Staff by the Administrator, Assistant Administrator, DON ADONs SDC, or the Regional Nurse Consultant regarding the above stated plan by 04/21/15. Interviews on 04/24/15 with the Administrator, DON, ADON, SDC, and the Regional Nurse Consultant revealed licensed nursing staff was provided education regarding all areas of the corrective plan. 12) Review of medication pass audits revealed the audits were completed by the DON, ADON, SDC, Medical Records Nurse, or Regional Nurse Consultant for all nurses and KMA by 04/22/15. Interviews on 04/24/15 with the DON, ADON, SDC, Medical Records Nurse and Regional Nurse Consultant revealed a medication pass had been completed with all nurses and KMAs by 04/22/15. 13) Interviews on 04/24/15 with the Special Projects Administrator, the Regional Vice President of Operations, and the Chief Operating Officer revealed administrative oversight of the facility was completed by the Special Projects Administrator, the Regional Vice President of Operations, or the Chief Operating Officer daily. 14) Review of the audits and interviews on 04/24/15 with the Administrator, Assistant Administrator, Special Projects, DON, Chief Operating Officer, Chief Nurse Executive or Regional Nurse Consultant revealed the administrative staff audited the compliance of the above stated audits/observations daily. 15) Review of the Quality Assurance meeting minutes revealed a meeting was held on 04/17/15 and again on 04/20/15.

Based on observation, interview, and review of the facility's policies, pharmacy medication dispensing records, and review of Kentucky Board of Nursing Advisory Opinion Statement #15 it was determined the facility failed to maintain accurately documented Medication Administration Records (MARs) for five (5) of thirty (30) sampled residents (Residents #11, #13, #15, #16 and #17). Review of the residents' MARs and interviews with staff revealed from December 2014 through 04/17/15, staff documented they administered residents' medications per physician's orders [REDACTED].#11, #13, #16, and #17, and observation of Resident #15's medication, revealed the following medications were not administered as ordered by the residents' physicians: Resident #11's [MEDICATION NAME] (medication to treat an abnormal heartbeat); Resident #17's [MEDICATION NAME] [MEDICATION]) and [MEDICATION NAME] (anti-[MEDICAL CONDITION] and treat some psychiatric disorders); Resident #13's [MEDICATION NAME] (anti-[MEDICAL CONDITION]); Resident #16's [MEDICATION NAME]; and Resident #15's [MEDICATION NAME]. On 04/03/15, the facility obtained physician's orders [REDACTED].#17's [MEDICATION NAME]. The lab results revealed Residents #11, #17, #13, and #16's medication levels were subtherapeutic (less than the amount required to treat or cure the disease process) (refer to F282, F333, F425, and F490). Additional review of Medication Administration Records (MARs) revealed a medication aide, who is not authorized in the state of Kentucky to administer medications via a resident's gastrostomy tube (a gastrostomy tube, or [DEVICE], is a tube inserted through the abdomen that delivers nutrition directly to the stomach), documented she administered medications via Residents #11, #15, #16, and #17's gastrostomy tubes, when the medications were administered by licensed staff. The facility's failure to have an effective system in place to ensure care and services were provided as per the resident's plan of care was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was determined to exist on 04/02/15 at 42 CFR 483.20 Resident Assessment (F282), 42 CFR 483.25 Quality of Care (F333), 42 CFR 483.60 Pharmacy Services (F425), and 42 CFR 483.75 Administration (F490 and F514). The facility was notified of the Immediate Jeopardy on 04/20/15. An acceptable Allegation of Compliance was received on 04/23/15, which alleged removal of the Immediate Jeopardy on 04/23/15. An extended survey was conducted on 04/24/15. The State Survey Agency determined the Immediate Jeopardy was removed on 04/23/15, which lowered the Scope and Severity to an "E" at 42 CFR 483.20 Resident Assessment (F282), 42 CFR 483.25 Quality of Care (F333), 42 CFR 483.60 Pharmacy Services (F425), and, 42 CFR 483.75 Administration (F490 and F514) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled "Medication Administration General Guidelines," dated December 2012, revealed medications were administered as prescribed in accordance with the manufacturer's specifications, good nursing principles and practices, and only by persons legally authorized to do so. The policy further stated medications were administered in accordance with written orders of the prescriber. The individual who administered the medication dose was required to record the administration on the resident's MAR immediately following the medication being given. If a dose of regularly scheduled medication was withheld, refused, or given at a time other than the scheduled time, the space provided on the front of the MAR for that dosage administration was initialed and circled. Review of the facility's policy titled "Medication Administration - Medication Discrepancies," dated December 2009, revealed medication discrepancies were documented and reported to the resident's attending physician, Director of Nursing, responsible party, and the Performance Improvement Committee. The policy defined a medication discrepancy as an omission of medication due to a prescribing, dispensing, or administering error. The policy further revealed when a medication discrepancy occurred immediate action should be taken to protect the patient's safety and welfare. Continued review of the policy revealed the attending physician was notified of the error or significant medication discrepancy and the patient was to be monitored closely for 24 to 72 hours or as directed by the physician. The policy revealed a medication discrepancy/error/incident report was to be completed. 1. Review of Resident #11's medical record revealed the resident had [DIAGNOSES REDACTED]. Further review revealed physician's orders [REDACTED]. Review of Resident #11's MARs for December 2014 through 04/17/15 staff documented one (1) dose of [MEDICATION NAME] was omitted on 01/05/15. Staff documented all other doses of [MEDICATION NAME] were administered per the physician's orders [REDACTED]. However, review of the facility's investigation related to Resident #11, dated 04/07/15, revealed on 04/01/15, Resident #11's [MEDICATION NAME] medication card dated 03/24/15 (the date the medication card was received by the facility for use) revealed ten (10) of fourteen (14) tablets were remaining on the medication card. The facility audited the medication card again on 04/03/15 (two days later), prior to the morning dose of [MEDICATION NAME], and Resident #11's [MEDICATION NAME] medication card still had ten (10) tablets remaining on the card. Review of the Medication Administration Record (MAR) revealed staff documented the medication was administered on 04/02/15 and the medication had not been held or refused the previous day. Review of the pharmacy's medication dispensing records, dated 12/01/14 through 04/17/15, revealed fourteen (14) [MEDICATION NAME] tablets were dispensed for Resident #11 seven (7) times since 12/10/14 (dispensed on 12/10/14, 12/21/14, 01/28/15, 02/11/15, 02/25/15, 03/25/15, and 04/15/15). During the timeframe reviewed (12/10/14 through 04/16/15) the pharmacy dispensed ninety-eight (98) [MEDICATION NAME] tablets; however, the resident required one hundred twenty-eight (128) tablets for the staff to be able to administer the resident's [MEDICATION NAME] per the physician's orders [REDACTED]. Review of Resident #11's [MEDICATION NAME] laboratory levels dated 01/05/15 and 04/03/15 revealed the resident's medication was at a sub-therapeutic level. 2. Review of Resident #17's medical record revealed the resident had a [DIAGNOSES REDACTED].#17's physician's orders [REDACTED]. Review of Resident #17's MARs for 12/01/14 through 04/04/15 revealed staff omitted one dose of [MEDICATION NAME] for the resident on 01/05/15. Staff documented all other doses had been administered. Further review revealed staff omitted one dose of [MEDICATION NAME] on 04/04/15 and documented that the medication was not administered on five (5) other occasions (03/08/15, 03/17/15, 03/18/15, 03/22/15, and 03/23/15). All other doses were administered, according to the MARs. Review of the pharmacy medication dispensing records dated 12/01/14 through 04/17/15, revealed the pharmacy dispensed thirty (30) capsules of [MEDICATION NAME] 250 mg (a 30-day supply) twice from 12/18/14 through 04/04/15 (12/18/14 and 1/28/15), for a total of sixty (60) capsules. However, one hundred seven (107) capsules were required for the staff to be able to administer the resident's [MEDICATION NAME] per the physician's orders [REDACTED]. Further review of the pharmacy medication dispensing records revealed the pharmacy dispensed one hundred twenty (120) capsules of [MEDICATION NAME] 125 mg (a 30-day supply) on 02/20/15; however, the medication was not refilled again until 04/05/15, forty-four (44) days later. Review of Resident #17's laboratory results revealed on 04/03/15, the resident's [MEDICATION NAME] Acid ([MEDICATION NAME]) level was not therapeutic. Further review of Resident #17's lab levels revealed on 03/16/15, the resident's [MEDICATION NAME] level was sub-therapeutic at less than 2.5 mcg/ml (micrograms/milliliter) (therapeutic range is 5 - 12 mcg/ml), but had increased to 9.1 mcg/ml on 03/19/15. As a result of post-survey review by the SSA 's pharmacist consultant, it was determined Resident #17's had Physician order [REDACTED]. 3. Review of Resident #13's medical record revealed the resident had [DIAGNOSES REDACTED]. Review of April 2015 physician's orders [REDACTED]. Review of Resident #13's MARs for January through March 2015, revealed staff documented the resident's [MEDICATION NAME] medication was administered as ordered. Review of the pharmacy medication dispensing records for Resident #13 revealed the pharmacy dispensed 300 ml (a 30-day supply) of [MEDICATION NAME] liquid medication four (4) times from 12/03/14 through 03/18/15, for a total of 900 ml. There were forty-seven (47) days between refills from 01/08/15 through 02/24/15. However, 1,050 ml of [MEDICATION NAME] was required to administer the medication per physician's orders [REDACTED]. Review of Resident #13's laboratory results revealed on 12/01/15, the resident's [MEDICATION NAME] level was therapeutic at 23 mcg/ml (normal range is 5 - 63 mcg/ml). However, on 03/02/15 and 04/03/15, the resident's [MEDICATION NAME] level was sub-therapeutic (2.0 mcg/ml and 2.9 mcg/ml, respectively). During the SSA's post-survey review by the State Agency Pharmacist Consultant, it was determined through review of the pharmacy's Delivery Manifest Report from 12/01/14 through 04/04/15 revealed Resident # 13's [MEDICATION NAME] Liquid refills were supplied as 30-day increments of 300 ml each. The review also revealed the resident received four (4) refills (12/03/14, 01/08/15, 02/24/15, and 03/19/15) of [MEDICATION NAME] Liquid during that time. Thus, the subsequent refill was approximately six (6) days late. Likewise, after receiving the 300 ml refill on 01/08/15, the resident received a subsequent refill of 300 ml forty-seven (47) days later on 02/25/15, or approximately seventeen (17) days late, as the subsequent refill should have been received approximately 30 days later, on/about 02/07/15. Post Survey review of the January through April 2015 revealed staff did not administer the [MEDICATION NAME] liquid medication as ordered; two (2) doses were omitted in January 2015, one (1) dose in February 2015, and two (2) doses in April 2015 for a total of five (5) doses (50 ml). 4. Review of Resident #16's medical record revealed the resident had [DIAGNOSES REDACTED]. Further review revealed a physician's orders [REDACTED]. Review of Resident #16's MARs for 12/01/14 through 04/17/15 revealed staff omitted the resident's morning dose of [MEDICATION NAME] Acid on 01/05/15; however, staff documented the resident's [MEDICATION NAME] Acid was administered as ordered for all other doses during these months. However, review of the pharmacy medication dispensing records revealed the pharmacy dispensed a 150-ml bottle (a 15-day supply) of [MEDICATION NAME] for Resident #16 on 01/24/15. However, the medication was not refilled again until 02/18/15, twenty-six (26) days later. Review of Resident #16's [MEDICATION NAME] Acid laboratory level dated 04/03/15 revealed the resident's [MEDICATION NAME] Acid level was sub-therapeutic at 20.6 mcg/ml (therapeutic range is 50 - 100 mcg/ml). 5. Review of Resident #15's medical record revealed the facility readmitted the resident on 03/20/15, after a hospital stay. Further review revealed the resident had a [DIAGNOSES REDACTED]. However, review of Resident #15's MARs for 03/20/15 through 04/17/15 revealed staff documented they administered [MEDICATION NAME] to Resident #15 as ordered by the resident's physician. Review of the pharmacy's medication dispensing records for Resident #15 revealed 473 ml of [MEDICATION NAME] was dispensed to the facility on [DATE]. Observation on 04/17/15 at 2:20 PM of Resident #15's [MEDICATION NAME] medication bottle, that was available for use in the medication cart, revealed the medication was dated as opened on 03/21/15, one day after the resident was readmitted to the facility. The bottle contained 150 ml. However, according to the resident's physician's orders [REDACTED]. Review of Resident #15's laboratory results revealed on 01/20/15, the resident's level was 8.0 mcg/ml (normal range is 5 - 63 mcg/ml). However, on 04/03/15, the resident's level had decreased to a sub-therapeutic level of 5.0 mcg/ml. Review of the facility's "Status Change" document that listed residents who had been admitted , transferred, or discharged from December 2014 through April 2015 revealed Residents #11, #13, #15, #16, and #17 had not been absent from the facility, during the times the discrepancies were identified with their medication. Interview with RN #1 on 04/14/15 at 5:03 PM, with Licensed Practical Nurse (LPN) #5 on 04/16/15 at 11:55 PM, with RN #6 on 04/16/15 at 12:14 PM, with Kentucky Medication Aide (KMA) #1 on 04/17/15 at 1:27 PM, and with LPN #6 on 04/17/15 at 3:29 PM, revealed staff denied any resident's medication was not administered per physician's orders [REDACTED]. [REDACTED]. Interview on 04/14/15 at 6:07 PM with the Director of Nursing (DON) revealed the DON only reviewed MARs for omissions and discrepancies daily and had not identified any concerns. The DON further stated administrative staff observed random medication passes with the nursing staff and had not identified any concerns. 6. Review of Kentucky Board of Nursing Advisory Opinion Statement #15 revealed unlicensed personnel known as medication aides may function by administering oral and topical medications in long-term care facilities only through delegation by and under the supervision of a registered nurse or licensed practical nurse. Review of the Kentucky Medication Aide (KMA) course curriculum revealed medication aides "DO NOT:... administer medications via tubes inserted into any body cavity." Review of Residents #11, #15, #16, and #17's physician's orders [REDACTED]. Review of Resident #11 and #17's MARs for January 2015 through April 2015 revealed KMA #1 documented that she administered [DEVICE] medications to the residents on four (4) days in January 2015, three (3) days in February 2015, one day in March 2015, and four (4) days in April 2015. Review of Resident #15's MARs for January 2015 through April 2015 revealed KMA #1 documented she administered Resident #15's [DEVICE] medications on four (4) days in January 2015, three (3) days in February 2015, and three (3) days in April 2015. Review of Resident #16's MARs for January 2015 through April 2015 revealed KMA #1 documented she administered the resident's [DEVICE] medications on four (4) days in January 2015, three (3) days in February 2015, one (1) day in March 2015, and three (3) days in April 2015. Interview with KMA #1 on 04/17/15 at 1:27 PM revealed she did not administer medications via residents' [DEVICE]s. She stated the residents' MARs had her name on them because she was signed into the electronic Medication Administration Record (eMAR) when the licensed nurses administered the medications. KMA #1 stated nursing staff failed to sign into the electronic MAR under their own names when they administered [DEVICE] medications. The KMA further stated she only administered oral medications. Interview with RN #1 on 04/14/15 at 5:03 PM, with Licensed Practical Nurse (LPN) #5 on 04/16/15 at 11:55 PM, with RN #6 on 04/16/15 at 12:14 PM, and with LPN #6 on 04/17/15 at 3:29 PM, revealed they always administered medications for residents with [DEVICE]s. They stated they were required to have the KMA sign out of the resident's electronic MAR and they should sign in before administering [DEVICE] medications or they should document a note in the electronic MAR; however, the staff could provide no evidence this practice occurred. Interview with the facility's Corporate Nurse Consultant on 04/17/15 at 2:45 PM and the DON on 04/17/15 at 3:45 PM revealed they were not aware nursing staff was not signing in or documenting when they administered [DEVICE] medications when the KMA was signed/logged into the electronic MAR system. Interview on 04/14/15 at 6:07 PM with the DON revealed she reviewed MARs for omissions and discrepancies daily and administrative staff randomly observed medication administration. She further stated no concerns had been identified related to KMAs documenting administration of [DEVICE] medications. **The facility provided an acceptable Allegation of Compliance (AOC) on 04/23/15. The facility implemented the following actions to remove the Immediate Jeopardy: 1) The Physician and Power of Attorney (POA) for Residents #11, #13, #14, #15, #16, and #17 were notified immediately upon identification of potential medication errors by the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADONs), Staff Development Coordinator (SDC), Quality Assurances (QA)Nurse, Nursing Supervisor, Medical Records Nurse or Regional Nurse Consultant on 04/20/15. Residents #11, #13, #14, #15, #16, and #17 were assessed by the ADONs or QA Nurse on 04/20/15 for any signs and symptoms of adverse reactions, with no issues identified. Laboratory levels were drawn on all six (6) residents, the physician was notified of the results, and the residents' care plans were updated, as needed. All six (6) residents' medications were counted and a medication reconciliation was completed for accuracy and a current count was placed on each individual pill packet and/or bottle of liquid medicine on 04/20/15 by the DON, ADONs, SDC, QA Nurse, Medical Records Nurse or Regional Nurse Consultant. 2) The physician and POAs for Residents #11, #15, #16, and #17 were notified immediately upon identification of inappropriate documentation by the Administrator, DON, ADONs, SDC, QA Nurse, Nursing Supervisor, Medical Record's Nurse, or Regional Nurse Consultant on 04/20/15. Residents #11, #15, #16, and #17 were re-assessed by the ADONs or QA Nurse, on 04/20/15, for any signs and symptoms of adverse reactions, with no issues identified. 3) All residents' medications were audited by the DON, ADON, SDC, Nursing Supervisor, Medical Record's Nurse or Regional Nurse Consultant, on 04/20/15, to ensure that the current medications, compared to the current Physician order [REDACTED]. A new bottle of medications were requested and placed into service on 04/22/15 for the liquid medications that could not be counted, due to opacity of container. 4) All residents' charts were audited by the Administrator, Assistant Administrator, DON, ADONs, SDC, QA Nurse, MDS Coordinators, Nursing Supervisor, Admissions, Social Services Director, Quality of Life, Dietary Manager, Chaplain, Medical Record's Nurse or Regional Nurse Consultant by 04/22/15 for accuracy of the clinical records and that the records were complete and accurately documented. The following issues were identified and corrected: a. Social Services Quarterly Notes were not within compliance- for three (3) residents b. Activity Quarterly Notes not within compliance-three (3) residents c. Care plan updates-two (2) residents d. Behavior Management care plan updates-two (2) residents 5) All residents' care plans were audited by the Administrator, Assistant Administrator, DON, ADONs, SDC, QA Nurse, MDS Coordinators, Nursing Supervisor, Admissions, Social Services Director, Quality of life, Dietary Manager, Chaplain, Medical Records or Regional Nurse Consultant by 04/22/15 to ensure all resident care plans reflected the current resident care needs. 6) Education was provided to the Administrator, HR, Med Record's Nurse, BOM, Quality of Life, Admissions, Assistant Administrator, Plant Ops, Food Service Director, SSD, Central Supply, Housekeeping Supervisor, DON, ADONs, SDC, MDS Coordinators, and Nursing Supervisors on 04/20/15 by the Regional Nurse Consultant regarding the facility's medication administration policy and procedure which included medication reconciliation. The care plan policy and the procedure included following the care plan, administering care to ensure highest practical physical, mental, and psychosocial well-being of each resident, and maintain clinical records in acceptable professional standards and practices that were complete, accurately documented, readily accessible and systematically organized. 7) Education was initiated for licensed staff, Kentucky Medication Aides (KMAs) and State Registered Nurse Aides (SRNAs) on 04/20/15 by the Administrator, Assistant Administrator, Regional Nurse Consultant, DON, ADONs or the SDC regarding the Medication Administration Policy and Procedure which included medication reconciliation, care plan policy and the procedure to include following the care plan, administering care to ensure highest practical physical, mental, and psychosocial well-being of each resident, and maintain clinical records in acceptable professional standards and practices that were complete, accurately documented, readily accessible and systematically organized. All clinical staff completed or will complete a post-test and score 100% to ensure understanding of education/training provided. If 100% is not obtained then the staff member will be re-educated and a post-test re-administered until the staff member obtains 100% score to ensure understanding of the material covered. Clinical staff was not allowed to work prior to receiving the above stated education. Those clinical staff members that were on Family Medical Leave Act (FMLA), leave or work "as needed" (PRN) were sent a certified letter and were not allowed to work until the education had been received and a post-test completed with 100% score obtained. As of 04/23/15, 60% of all licensed staff and clinical staff had been educated with post-test completed and 100% score obtained; 15% have been contacted by phone, provided education and notified that they cannot work until 1:1 education with post-test was completed, and, 100% score obtained. The remaining 25% were in the process of being contacted and will not be allowed to work until education with post-test has been completed and 100% score obtained. Once education has been provided, each licensed nurse will complete a medication administration observation pass with the DON, ADONs, SDC, Nursing Supervisor, or Regional Nurse Consultant. 8) Education regarding medication administration policy and procedure, care plan policy and procedure, administrative oversight, and complete and accurate clinical records were included in the new hire orientation. 9) A new process was initiated on 04/22/15 for medication reconciliation of residents' medications. The process is as follows: a. One random nurse per day, per shift, will complete a medication pass observation with the DON, ADONs, SDC, Medical Records Nurse, MDS Coordinators, Nursing Supervisor or Regional Nurse Consultant to ensure compliance with medication administration, the resident's care plan was being followed and accurate along with completed documentation was noted. b. DON, ADONs, SDC, Medical Records Nurse, MDS Coordinators, Nursing Supervisor, or Regional Nurse Consultant reconciled the medications of four (4) randomly selected residents daily to ensure compliance with medication administration. This process was continued until immediacy was lifted. c. Nurses/KMAs received education on 04/21/15 by the Regional Nurse Consultant, DON, ADONs, SDC, or Nursing Supervisor on placing the discarded pill packets/bottles in the bottom drawer of the medication cart when packet/bottle was finished. The DON, ADONs, SDC, Medical Records Nurse, MDS Coordinators, Nursing Supervisor or Regional Nurse Consultant audited, daily, ten (10) discarded packets/bottles per side compared to packets/bottles that were put into service to reconcile medications, confirm reorder process and that the medications were being given per the physician's orders [REDACTED]. The process continued until immediacy was lifted. d. Nurses/KMAs placed the date/time and their initials on the side of any new medication packet/bottle placed into service to ensure an accurate date which will allow for accurate reconciliation. Those liquid medications, a total of twenty-one (21), that could not be counted, due to opacity of container, a new bottle was obtained and placed in service by 04/22/15. e. Reorder process below will continue until immediacy was lifted: i) A nurse re-ordered medications via the ezMAR alert system when three (3) to four (4) days of medication were left to administer. ii) A nurse then placed, on the current medication bubble pack, the date of reorder, and their initials. iii) The DON and/or ADONs ran the "Refill Reminder Report" from the ezMAR system, Monday - Friday, and validated that all medications due to be reordered, had actually been reordered. iv) Facility Formulary Nurse, ADONs, SDC, QA Nurse, or Nursing Supervisors reconciled the Refill Reminder Report with the nightly medication manifest report with the actual medication packet on the cart or stored in overflow to ensure medications that were reordered have actually arrived at facility. f. Nurses and KMAs were educated/trained on the medication administration policy and procedure to include documentation along with the scope of practice of the KMA. KMAs will not administer or document administering any medications other than by mouth (PO) or topical. 10) All residents medications were reconciled two (2) times weekly, starting 04/20/15 by the DON, ADONs, SDC, Medical Records Nurse, QA Nurse, Nursing Supervisor, Regional Nurse Consultant or Chief Nursing Executive, to ensure reorder process system was intact and within compliance along with ensuring residents medications were administered as ordered. This process will continue for two (2) weeks and results will be reviewed in a weekly QAPI meeting. The QAPI committee will determine ongoing frequency of resident medication reconciliation at that time. 11) Education was provided for Licensed Nursing Staff by the Administrator, Assistant Administrator, DON, ADON, the SDC, or the Regional Nurse Consultant regarding the above stated plan by 04/21/15. 12) Medication pass audits were completed by the DON, ADON, SDC, Medical Records Nurse, or Regional Nurse Consultant for all nurses and KMAs by 04/22/15 to ensure that medications were administered without significant medication error. Nurses or KMAs who had not completed a medication pass observation were not allowed to work until the medication pass observations had been completed for shifts scheduled after 04/22/15. As of 04/24/15, 75% of all nurses and KMAs had completed a medication pass observation. 13) Administrative oversight of the facility was completed by the Special Projects Administrator, the Regional Vice President of Operations, or the Chief Operating Officer daily until removal of immediacy, weekly for four (4) weeks after removal of immediacy, then monthly. 14) The Administrator, Assistant Administrator, Special Projects, DON, Chief Operating Officer, Chief Nurse Executive or Regional Nurse Consultant audited compliance of the above stated audits/observations daily until removal of immediacy, then twice weekly for four (4) weeks and reported findings during weekly QA for four (4)weeks, for recommendations and further follow-up as indicated. 15) A Quality Assurance meeting was held on 04/17/15, and again on 04/20/15 for further recommendations regarding the plan for removal of Immediate Jeopardy. A Quality Assurance meeting will be held weekly for four (4) weeks, then monthly for recommendations and further follow up regarding the above stated plan. **The State Survey Agency validated the Immediate Jeopardy was removed as follows: 1) Review of the medical records of Residents #11, #13, #14, #15, #16, and #17 revealed the residents' physicians and POAs were notified of the potential medication errors by the administrative staff. Further review of the medical records revealed Residents #11, #13, #14, #15, #16, and #17 were assessed by the ADONs or the QA Nurse, on 04/20/15, for any signs and symptoms of adverse reactions from potential medication errors, with no issues identified. The facility obtained laboratory levels on all six (6) residents, the physician was notified of the results, and the residents' care plans were updated as needed. The residents' laboratory results were obtained on the following days by the facility: Resident #11 on 04/03/15, 04/06/15, and 04/20/15, Resident #13 on 04/03/15 and 04/19/15, Resident #14 on 04/17/15, 04/17/15 and 04/19/15, Resident #15 on 04/03/15 and 04/20/15, Resident #16 on 04/03/15 and 04/17/15 and Resident #17 on 04/20/15. The Administrative Staff counted all six (6) residents' medications and a medication reconciliation was completed for accuracy and a current count was placed on each individual pill packet and/or bottle of liquid medicine on 04/20/15 by the DON, ADONs, SDC, QA Nurse, Medical Records Nurse or Regional Nurse Consultant. 2) Review of the medical record revealed the physicians and POAs for Residents #11, #15, #16, and #17 were notified immediately upon identification of inappropriate documentation by the Administrator, DON, ADONs, SDC, QA Nurse, Nursing Supervisor, Medical Record's Nurse, or Regional Nurse Consultant on 04/20/15. Further review of the medical records revealed Residents #11, #15, #16, and #17 were re-assessed by the ADONs or QA Nurse, on 04/20/15, for any signs and symptoms of adverse reactions, with no issues identified. 3) Review of the medication audits revealed the audits were completed by the DON, ADON, SDC, Nursing Supervisor, Medical Record's Nurse or Regional Nurse Consultant, on 04/20/15, and ensured that the current medications, compared to the current Physician order [REDACTED]. Observations, on 04/24/15 revealed new bottles of medication were placed into service on 04/22/15. 4) Review of the facility's audits revealed all residents' charts were audited by the Administrator, Assistant Administrator, DON, ADONs, SDC, QA Nurse, MDS Coordinators, Nursing Supervisor, Admissions, Social Services Director (SSD), Quality of Life, Dietary Manager, Chaplain, Medical Record's Nurse or Regional Nurse Consultant by 04/22/15 for accuracy of the clinical records and that the records were complete and accurately documented. The audits revealed issues identified were corrected by the facility staff. 5) Review of the facility's audits on 04/24/15, revealed all residents care plans were audited by the Administrator, Assistant Administrator, DON, ADONs, SDC, QA Nurse, MDS Coordinat

Based on interview, record review, review of the facility's investigation, and review of the facility's policies, "Medication Administration" and "Medication Ordering and Receiving from Pharmacy Provider," it was determined the facility failed to ensure services provided by the facility met professional standards of quality of care related to medication administration for one (1) of four (4) sampled residents (Resident #1). Interviews and review of documentation on the facility's investigation revealed on 06/12/14, Advanced Registered Nurse Practitioner (ARNP) #1 prescribed 800 milligrams (mg) of Bactrim to be administered to Resident #1 two (2) times a day. Continued interviews and review of documentation revealed Assistant Director of Nursing (ADON) #1 transcribed the Bactrim order for Resident #1 onto the resident's Medication Administration Record (MAR). Registered Nurse (RN) #1 obtained the Bactrim from the facility's Emergency Drug Kit (EDK) and instructed KMA #1 to administer the medication; Kentucky Medication Aide (KMA) #1 administered Bactrim (antibiotic) to Resident #1. However, review of documentation on Resident #1's medical record binder, the MAR, and care plan revealed facility staff had previously identified that Resident #1 had a drug allergy to Bactrim. Interviews with ARNP #1, ADON #1, RN #1, and KMA #1 revealed they had failed to determine the resident's drug allergies before ordering, obtaining, and administering the medication. The facility's failure to ensure services provided by the facility met professional standards of quality related to medication administration caused, or was likely to cause, serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy with Substandard Quality of Care was determined to exist on 06/12/14 at 42 CFR 483.20 Resident Assessment (F281 and F282), 42 CFR 483.25 Quality of Care (F333), and, 42 CFR 483.75 Administration (F490 and F520) at a scope and severity of "J." Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care (F333). The facility was notified of the Immediate Jeopardy on 06/18/14. An acceptable Allegation of Compliance was received on 06/24/14, which alleged removal of the Immediate Jeopardy on 06/25/14. The State Survey Agency determined the Immediate Jeopardy was removed on 06/25/14, prior to exit, which lowered the scope and severity to "D" at 42 CFR 483.20 Resident Assessment (F281 and F282), 42 CFR 483.25 Quality of Care (F333), and 42 CFR 483.75 Administration (F490 and F520) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: According to the facility's policy titled, "Medication Ordering and Receiving from Pharmacy Provider," dated September 2010, revealed staff was to verify and review the prescriber's orders for appropriateness and to check the resident's allergies prior to obtaining the medication (i.e., the facility's Emergency Drug Kit). Review of the facility's policy titled, "Medication Administration," dated December 2010, revealed staff was required to verify the resident was not allergic to the medication before administering any antibiotic for the first time. Review of Lippincott's Nursing Center recommendations, dated 05/27/11, revealed there were eight rights of medication administration. Continued review of the recommendations revealed before administering medications, licensed staff should ensure it is the right medication and the right dose being administered to the right patient, via the right route and at the right time. Continued review of the recommendations revealed licensed staff should confirm rationale for the ordered medications, and document administration of medications, after the medication has been administered. According to the recommendations, licensed staff should ensure medications had the desired effect for the patient receiving the medication. Record review revealed the facility admitted Resident #1 on 01/22/13. Review of the Quarterly Minimum Data Set Assessment ((MDS) dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident's cognition was intact. Review of the resident's medical record, the Medication Administration Record (MAR), and care plan (updated May 2014) revealed facility staff had identified and documented the resident's allergy to Bactrim (an antibiotic). Review of Physician order [REDACTED].#1 prescribed 800 mg of Bactrim two times a day. Continued review of the medical record revealed facility staff documented on the MAR that the Bactrim was administered on 06/12/14 at 12:00 PM. Review of the investigative report dated 06/12/14, revealed the pharmacy received the medication order on 06/12/14 at approximately 3:30 PM, and contacted the facility approximately three hours after they received the order. The pharmacy informed the facility the resident was allergic to the Bactrim and not to administer the medication. However, during the facility's investigation, it was determined RN #1 had obtained the Bactrim from the facility's Emergency Drug Kit (EDK) prior to the pharmacy contacting the facility. ARNP #1 confirmed in interview conducted on 06/17/14 at 1:56 PM she had prescribed Bactrim (an antibiotic medication) for Resident #1 and failed to review the resident's list of allergies on 06/12/14. In addition, ADON #1 acknowledged in interview conducted on 06/17/14 at 1:30 PM that he had transcribed the order for Bactrim onto Resident #1's MAR and failed to verify the resident's medication allergies on 06/12/14. RN #1 acknowledged in interview conducted on 06/17/14 at 1:50 PM that she "assumed" ADON #1 had verified the resident's allergies, and therefore she obtained the Bactrim from the EDK on 06/12/14 and instructed KMA #1 to administer the medication to Resident #1. RN #1 stated she failed to verify the resident's medication allergies prior to obtaining the medication and instructing KMA #1 to administer the medication. KMA #1 stated in interview on 06/17/14 at 1:00 PM that RN #1 had instructed her to administer the Bactrim to Resident #1 on 06/12/14 and, because she "assumed" that RN #1 had verified the resident's allergies, she administered the medication and did not review the resident's allergies herself. Interviews with ADON #1, RN #1, and KMA #1 on 06/17/14 revealed they had been trained to verify allergies before obtaining and/or administering medications to residents but failed to do so. Interview with the Director of Nursing (DON) on 06/18/14 at 11:30 AM revealed staff was required to review/verify a resident's medication allergy when new medication orders were obtained/received and before they administered the medication to a resident. The DON acknowledged staff had administered Bactrim to Resident #1 on 06/12/14. According to the DON, staff failed to review Resident's #1's list of identified allergies on 06/12/14 before they prescribed, obtained, and administered the Bactrim. The DON acknowledged it was a standard of practice to verify the list of the resident's allergies before administering medications. The Administrator also acknowledged in interview on 06/18/14 at 4:00 PM that it was a standard of practice to verify the list of the resident's allergies before administering medications. He continued to state staff was required to verify medication allergies before administering medications and failed to do so when they administered the Bactrim to Resident #1 on 06/12/14. **The facility provided an acceptable Allegation of Compliance (AOC) on 06/24/14. The facility implemented the following actions to remove the Immediate Jeopardy: --The Administrator and Director of Nursing (DON) were notified of the medication error on 06/12/14 by Registered Nurse (RN) #1. Advanced Registered Nurse Practitioner (ARNP) #1, Assistant Director of Nursing (ADON) #1, RN #1, and Kentucky Medication Aide (KMA) #1, were all suspended on 06/12/14, pending results of an investigation. The DON initiated an investigation on 06/12/14. The DON reported the medication administration error that occurred on 06/12/14 to the regulatory agency on 06/12/14 to meet state/federal guidelines to ensure reporting requirements were met. The Physician for Resident #1 was notified upon identification of the medication error related to administration of Bactrim on 06/12/14. The Physician instructed facility staff to assess Resident #1 and monitor him/her for any signs and symptoms of allergic reaction. Resident #1 was assessed by facility staff on 06/12/14 for any signs and symptoms of reaction, no concerns were identified. Resident #1, who has a Brief Interview for Mental Status (BIMS) score of 14 was notified of the medication error along with the resident's Power of Attorney (POA) on 06/12/14 by facility staff. --Based on the conclusion the investigation, staff members/the contract consultant involved was disciplined as below: -ARNP #1, ADON #1, and RN #1's employment was terminated from the facility. -KMA #1 received coaching/counseling, completed with restrictions that the KMA received 1:1 training by the Staff Development Coordinator (SDC) to address medication administration, specifically not giving medications that she does not pull herself, checking for allergies, and providing care as outlined in the care plan in relation to medication administration. Furthermore, KMA #1 had to complete a medication pass with a pharmacy field consultant prior to passing any medications upon return to work. She will also complete a weekly medication pass with the Staff Development Coordinator for ongoing continued education/compliance for four weeks. (The facility determined, after reviewing the KMA's 33-year history with the facility as a KMA and having exceptional evaluations and no coaching/counseling during her years of service, that with appropriate education and training she should be allowed to return to work.) --Facility staff was interviewed by the DON, ADONs, Facility Formulary Nurse (FFN), SDC, Minimum Data Set (MDS) Coordinator, and Regional Nurse Consultant on 06/12/14 for any knowledge of these four individuals transcribing or administering any medication in which a resident had an allergy. --Interviews were completed on 06/12/14, with residents which were assessed to have a BIMS score of 8 or greater, by the Social Services Director and Chaplain regarding their knowledge of any medications they were allergic to and may have received. No concerns were identified. --Skin assessments were completed on 06/12/14 by the DON, ADON, MDS Coordinator, or SDC on all residents with a BIMS score less than 8, for any signs or symptoms of allergic reaction. No concerns were identified. --All facility residents' charts were audited, which validated allergy stickers were on the outside of the resident's chart, face sheet, and care plans. The residents' Medication Administration Records (MARs) and Treatment Administration Records (TARs) and the allergy sheet in front of the MARs, along with the Physician and Nurse Practitioner's (NP's) orders since 05/01/14 were audited, for any new medication orders versus resident allergies. These audits were conducted by 06/13/14, by the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, the MDS Coordinators, Social Services Director, Admissions/Marketing or Regional Nurse Consultant to ensure allergies had been appropriately identified and no medications were ordered and/or administered that were listed as an allergy for a resident. No concerns were identified. --Education for facility staff was initiated on 06/12/14 by the SDC, DON, ADONs, or the Nurse Consultant regarding the abuse/neglect policy and appropriate reporting of neglect. The education also included information related to significant medication errors, care plans in regards to following care plans and delivering care as outlined in the care plan, emergency medication kit to include pharmacist approval and allergy verification prior to med removal. Education provided also included medication administration related to the responsibilities and expectations of the nurse related to how the medications were obtained and delivered to meet professional standards requirements. Staff will be monitored during medication pass and will complete questionnaires from training received. Staff was also trained related to the Quality Assurance Performance Improvement process which included reporting of concerns to the Administrator and line staff participation in development of Quality Assurance Performance Improvement (QAPI) plans. Staff will not be permitted to work prior to receiving the education and passing a post-test with a score of 100 percent. All new licensed nurses hired after 06/12/14 will receive the above training. --Follow-up questionnaires will be completed by the Administrator, DON, ADON, MDS Coordinator, Social Services Director, Quality of Life Director, Dietary Manager, Plant Operations Director, or the Environmental Services Manager for five different staff members daily until removal of the immediacy of the Jeopardy. After the immediacy has been removed the questionnaires will be conducted weekly for two weeks, to ensure continued understanding regarding the abuse/neglect policy and procedure, and then the Quality Assurance (QA) Committee will evaluate and determine need of ongoing frequency. --Pharmerica is providing field consultants on-site, starting on 06/16/14 for two days per week for two weeks to provide further education/training on medication administration. The education will include delivery of medications and validation of allergies to meet professional standards. All nurses will complete a med pass with a Pharmerica field consultant. The QA Committee will evaluate and determine the need for services required from the pharmacy field consultant at the end of two weeks. --The facility obtained a contract on 06/16/14 with an external independent clinical consultant to provide services two days per week on-site. This external independent clinical consultant will provide clinical oversight of process and procedures to validate that professional standards are being met until the immediacy is removed. After the immediacy is removed, the QA Committee will evaluate and determine the need for ongoing services required from the external independent clinical consultant. --Upon receiving a new medication order, all new medication orders will be reconciled with the resident's listed allergies by two nurses. The pharmacy will then be contacted to reconcile the new medication with the resident's listed allergies and new medication orders will be signed off by the same two nurses on the Physician order [REDACTED]. The nurse receiving the new medication order will transcribe the order to the MAR and a second nurse will co-sign validating compliance. Prior to administration of newly ordered medications for any resident, the DON, ADONs, SDC or Regional Nurse Consultant will review the above process with the Charge Nurse or certified medication technician to determine compliance to ensure the resident doesn't have an allergy to the medication. This validation process will continue until the immediacy is removed, then daily review for compliance with the above process will continue for four weeks. The findings will be reviewed weekly in the QA meeting to determine the need of the ongoing frequency with new medication monitoring. --Education was provided on 06/12/14, for Licensed Nursing Staff by the SDC or the Regional Nurse Consultant regarding the above stated plan. Licensed Nursing Staff which was not trained on 06/12/14 will not be permitted to work until the above stated education has been received. --All new medication orders were audited and logged onto the administrative nursing monitoring form by the DON, ADONs, SDC, FFN, MDS Coordinator, or Regional Nurse Consultant (three regional nurse consultants have been on-site for 24-hour coverage to ensure all new medication orders have gone through the process outlined below, since the incident which occurred on 06/12/14) every shift (during night shift the Charge Nurse is to call the designated Administrative Nurse or the Regional Nurse Consultant with all new medications) to ensure all new medications orders have been signed off by two nurses. Audits have also included ensuring the pharmacist had been contacted to verify allergies and two nurses have signed off on the transcription of the new medication to the MAR prior to the new medication being administered to the resident. In Addition, the Regional Nurse Consultant, the Special Projects Administrator, Vice President of Operations (VPO), Chief Nursing Executive (CNE), or Chief Operating Officer (COO) will audit all new orders daily to ensure compliance with the process starting on 06/13/14; this process will be continued until the immediacy has been removed. When the immediacy has been removed audits will be conducted twice weekly for four weeks, and at that time the QA Committee will evaluate the need for the continued frequency of monitoring. --The Director of Nursing will conduct daily reviews of the above log sheet for compliance. The Regional Nurse Consultants will validate compliance with the above process daily and the COO, CNE, VPO, or Special Projects Administrator will validate compliance with the above process twice weekly until the removal of the immediacy of the Jeopardy. When the immediacy has been removed, then the DON or ADONs will review daily for four weeks; the Regional Nurse Consultant will review three times a week for four weeks; and the COO, CNE, VPO, or Special Projects Administrator will review weekly for four weeks to ensure that compliance is maintained. The findings will be reported weekly to QA for recommendations and further follow-up as indicated and to determine ongoing frequency of monitoring. --Medication pass audits were completed by the Director of Nursing, Assistant Directors of Nursing, Staff Development Coordinator, MDS Coordinator, FFN, or Regional Nurse Consultant for all nurses and KMAs who had worked on 06/12/14 to ensure proper medication administration technique, proper identification of allergies, that professional standards were being met, and that care plans were being followed. Further medication pass audits were completed for all nurses and KMAs during their initial medication pass by 06/17/14 except four PRN nurses. Certified letters have been mailed to the four PRN licensed nurses to inform them they would not be permitted to work until a medication pass audit was completed with the ADONs or SDC. During the medication pass audit, a questionnaire will be completed by the DON, ADON, FFN, MDS Coordinator, SDC, or Regional Nurse Consultant to ensure their knowledge of where to review for allergies prior to the administration of the medication. --When all nurses have completed a medication pass audit, the DON, ADONs, SDC, FFN, MDS Coordinator, or Regional Nurse Consultant will conduct a medication pass audit with two nurses per day (one nurse per nursing unit) to ensure ongoing proper medication administration technique, proper identification of allergies, that professional standards are being met, and that care plans are being followed until the immediacy has been removed. When the immediacy has been removed, one nurse per day will complete a medication pass audit for two weeks, and then the QA Committee will evaluate and determine the frequency of ongoing medication pass audits. --Administrative oversight of the facility was completed by the Special Projects Administrator, Regional Nurse Consultant, the Regional Vice President of Operations, Chief Nursing Executive, or the Chief Operating Officer daily until removal of the immediacy. After the removal of the immediacy, the oversight will continue weekly for four weeks, then monthly. --Education was provided by the Regional Nurse Consultant on 06/12/14 for the Administrator, DON, ADON, SDC, Quality of Life Director, Social Services Director, Plant Operations Director, Chaplain, Medical Records Coordinator, Dietary Manager, and Admissions Director regarding the Quality Assurance Process and appropriate methods of identification of concerns including significant medication errors, failure to report neglect, auditing pharmacy services, care plans, and professional services. --A Quality Assurance meeting was held on 06/12/14 with the Medical Director for further recommendations regarding the plan for removal of Jeopardy. The Medical Director was involved with creation and approval of the current plan to address the identified areas of concern in regards to appropriate identification of resident allergies. All primary physicians, along with covering physicians, were provided with education/training along with a letter which detailed the facility's QAPI plan, along with appropriate identification of resident allergies prior to new medication prescribing on 06/24/14 by the Regional Nurse Consultant or DON. A Quality Assurance meeting will be held weekly for four weeks, then monthly for recommendations and further follow-up regarding the above stated plan. **The surveyors validated the Immediate Jeopardy was removed as follows: --Interviews conducted with the Administrator and the Director of Nursing (DON) on 06/25/14 revealed Registered Nurse (RN) #1 notified them of the medication error that occurred on 06/12/14 when facility staff had prescribed, obtained, and administered a medication to Resident #1 that had previously been identified as a medication allergy for the resident. Further interviews and review of the facility's investigation confirmed staff members involved with the incident (ARNP #1, ADON #1, RN #1, and KMA #1) were all suspended on 06/12/14, pending results of the investigation. Resident #1's physician was notified, and new orders were received and implemented on 06/12/14, when the medication error was identified by facility staff. Continued review of the investigation revealed Resident #1 was assessed by facility staff on 06/12/14 for any signs and symptoms of reaction and no concerns were identified. Continued review of the investigation revealed Resident #1, who has a BIMS score of 14 was notified, along with the resident's Power of Attorney (POA), of the medication error that occurred on 06/12/14. --Interviews with facility staff and review of the facility's investigation on 06/25/14 revealed the following actions were taken, as a result of the facility's investigation findings: ARNP #1, ADON #1, and RN #1's employment was terminated from the facility. KMA #1 received coaching/counseling and 1:1 training by the Staff Development Coordinator (SDC) which addressed medication administration, specifically not giving medications that she did not pull herself, checking for resident allergies, and providing care as outlined in the care plan in relation to medication administration. Continued interview and a review of the investigation confirmed KMA #1 had completed a medication pass with the facility's Pharmacy Consultant prior to administering any further medications to facility residents. Further interviews revealed KMA #1 would also complete a weekly medication pass with the SDC for ongoing continued education/compliance for four weeks. The facility's investigation findings revealed they had determined, after reviewing the KMA's 33-year work history with the facility, and having exceptional evaluations and no previous disciplinary actions, with appropriate education and training she should be allowed to return to work. --Interviews with staff and further review of the facility's investigation on 06/25/14 revealed the facility staff was interviewed by the DON, ADONs, FFN, SDC, MDS Coordinator, or Regional Nurse Consultant on 06/12/14 for any knowledge of the four individuals identified in the incident transcribing or administering any medication which had been listed as an allergy for any other resident. --Interviews and review of the facility's investigation conducted on 06/25/14 revealed residents who were assessed to have a BIMS score of 8 or greater were interviewed on 06/12/14, by the Social Services Director and Chaplain to determine if medications they had an allergy to had been administered to them while in the facility. The investigation further revealed no concerns were identified. --Interview with the DON and review of the facility's investigation on 06/25/14 confirmed skin assessments were conducted to ensure no allergic reactions had occurred on all facility residents with a BIMS score of 8 or below on 06/12/14. --Review of facility audits and interviews with staff on 06/25/14 revealed all facility residents' charts were audited and staff validated allergy stickers were on the outside of the residents' charts, face sheets, and care plans. Further reviews and interviews with staff conducted on 06/25/14 revealed the residents' Medication Administration Records (MARs) and Treatment Administration Records (TARs), allergy sheets located in front of the residents' MARs, along with physician orders [REDACTED]. Continued review confirmed audits were conducted by 06/13/14, by the DON, ADON, SDC, MDS Coordinators, Social Services Director, Admissions/Marketing, or Regional Nurse Consultant. Interviews conducted on 06/25/14 revealed audits were conducted to ensure allergies had been appropriately identified and no medications were ordered and/or administered that were listed as an allergy for a resident, with no concerns identified. --A review of staff education provided by the facility, initiated on 06/12/14, confirmed the SDC, DON, ADONs, or the Nurse Consultant instructed staff about the facility's abuse/neglect policy and appropriate reporting of neglect. The education review conducted on 06/25/14 also revealed information was included related to significant medication errors, implementation of care plans, emergency medication kit to include pharmacist approval, and allergy verification prior to medication removal. Continued review of the education provided to facility staff also included medication administration and the responsibilities and expectations of the nurse on how the medications were obtained and delivered to meet professional standards requirements. Interviews conducted with facility staff on 06/25/14 confirmed staff was monitored during medication pass and had been required to complete questionnaires related to the training they received. KMA #1 stated in interview on 06/25/14 that she received training related to the Quality Assurance Performance Improvement (QAPI) process which included reporting of concerns to the Administrator and line staff participation in development of QAPI plans. Interview with the Regional Nurse Consultant and the DON on 06/25/14 revealed staff was not permitted to work until they were educated and completed a post-test with a score of 100 percent. Interview with the DON on 06/25/14 revealed all new licensed nurses hired after 06/12/14 will receive the above training during their orientation. --Interviews with the Regional Nurse Consultant on 06/25/14 confirmed follow-up questionnaires were completed by the Administrator, DON, ADON, MDS Coordinator, Social Services Director, Quality of Life Director, Dietary Manager, Plant Operations Director, or the Environmental Services Manager for five different staff members daily. The Nurse Consultant further stated after the immediacy had been removed the questionnaires would be conducted weekly for two weeks to ensure continued understanding regarding the abuse/neglect policy and procedure, and the QA Committee would evaluate further the need for the questionnaires. --Review of Medication Pass audits conducted, and an interview with the Regional Nurse Consultant on 06/25/14, revealed the facility's Pharmacy had provided Field Consultants on-site, which started on 06/16/14, for two days per week for a total of two weeks. He stated the pharmacy service was to provide further education/training on medication administration. The education would include delivery of medications and validation of the residents' allergies to meet professional standards. The Consultant stated all nurses would complete a medication pass with a Pharmacy Field Consultant and the QA Committee would evaluate and determine the continued need for services required from the Pharmacy Field Consultant at the end of two weeks. --Interview with the DON and the Administrator on 06/25/14 confirmed the facility had obtained a contract on 06/16/14 with an external Independent Clinical Consultant to provide services two days per week on-site. The Administrator stated the external Independent Clinical Consultant would provide clinical oversight of processes and procedures to validate those professional standards were met until the immediacy was removed. After the immediacy was removed, the Administrator stated the QA Committee would evaluate and determine the need for services required from an external Independent Clinical Consultant. --Interviews with KMA #1 on 06/17/14 at 1:00 PM and Administrative staff on 06/25/14 confirmed training was initiated on 06/12/14 and included guidance on what staff was required to do when a new medication order was received. Allergies were to be validated and all new medication orders were to be reconciled and transcribed onto the resident's MAR by two nurses. Continued interview confirmed the pharmacy would be contacted to reconcile new medications, with the resident's listed allergies. Continued review of trainings and interviews with KMA #1 on 06/17/14 at 1:00 PM, the DON on 06/18/14 at 11:30 AM, and the Administrator on 06/18/14 at 4:00 PM confirmed new medication orders would be signed off by the two nurses that validated reconciliation of new medications to the resident's listed allergies. The nurse receiving the new medication order would transcribe the order to the MAR and a second nurse would co-sign which would validate compliance. Continued interview revealed staff was required to contact the DON, ADONs, SDC, or Regional Nurse Consultant, before any new medication was administered for any resident, to validate all required checks had been completed. Continued interviews on 06/25/14 revealed this validation process would continue until the immediacy was removed. The Regional Nurse Consultant stated on 06/25/14 at 1:00 PM the validation process would be reviewed daily for compliance and would be continued for four weeks. The Nurse Consultant further stated the findings would be reviewed weekly in the QA meeting to determine the need of ongoing frequency with new medication monitoring. --Interview with the DON and the Nurse Consultant on 06/25/14 revealed Licensed Nursing Staff that had not received the training on 06/12/14 would not be permitted to work until the above stated education has been received. --A review of facility audits and interviews with Administrative staff on 06/25/14 revealed all new medication orders were audited and logged onto the administrative nursing monitoring form by the DON, ADONs, SDC, FFN, MDS Coordinator, or Regional Nurse Consultant. Continued interview revealed three Regional Nurse Consultants had been on-site 24 hours a day since the incident occurred on 06/12/14 to ensure staff had validated all new medication orders. The Regional Nurse Consultant stated during night shift the Charge Nurse was required to call the designated Administrative Nurse or Regional Nurse Consultant with all new medication orders, to ensure all new orders had been signed off by two nurses as required. Continued interview on 06/25/14 confirmed facility audits included ensuring the pharmacist had been contacted to verify allergies, and that two nurses had signed off on the transcription of the new medication to the MAR prior to the administration of any new medications to the residents. Continued interview revealed the Regional Nurse Consultant, Special Projects Administrator, VPO, CNE, or COO would audit all new orders daily to ensure compliance with the process starting on 06/13/14 and would continue to audit the orders until the immediacy had been remov

Based on interview, record review, a review of the facility's investigation, and a review of the facility's policy, Care Plans-Comprehensive, it was determined the facility failed to ensure care was provided by qualified persons in accordance with each resident's plan of care for one (1) of four (4) sampled residents (Resident #1). Review of Resident #1's Comprehensive Care Plan, last revised May 2014, revealed Resident #1 was allergic to Bactrim (antibiotic). In addition, review of Resident #1's medical record, including the actual binder, and the Medication Administration Record (MAR), revealed the outside cover of the medical record was labeled with a red and white sticker which identified the resident's allergy to Bactrim. The MAR also contained documented evidence of the resident's allergy to Bactrim. Even though the resident's medical record, MAR, and Comprehensive Care Plan were labeled with the resident's allergy to Bactrim, facility staff administered 800 milligrams (mg) of Bactrim (antibiotic) to the resident on 06/12/14. The facility's failure to ensure resident care was provided in accordance with the resident's plan of care was likely to cause serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy with Substandard Quality of Care was determined to exist on 06/12/14. 42 CFR 483.20 Resident Assessment (F281 and F282), 42 CFR 483.25 Quality of Care (F333), and 42 CFR 483.75 Administration (F490 and F520) at a scope and severity of "J." Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care (F333). The facility was notified of the Immediate Jeopardy on 06/18/14. An acceptable Allegation of Compliance was received on 06/24/14, which alleged removal of the Immediate Jeopardy on 06/25/14. The State Survey Agency determined the Immediate Jeopardy was removed on 06/25/14, prior to exit, which lowered the scope and severity to "D" at 42 CFR 483.20 Resident Assessment (F281 and F282), 42 CFR 483.25 Quality of Care (F333), and 42 CFR 483.75 Administration (F490 and F520) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled Care Plans-Comprehensive, dated October 2010, revealed the resident's comprehensive care plan was developed based on a thorough assessment of the resident. Continued review of the policy revealed the residents' care plans were designed to incorporate risk factors related to the problems identified by facility staff. Review of Resident #1's medical record on 06/17/14, revealed the facility admitted the resident on 01/22/13. Further review revealed the facility assessed Resident #1 and documented on a Quarterly Minimum Data Set Assessment ((MDS) dated [DATE] that the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident's cognition was intact. Review of Resident #1's Comprehensive Care Plan, last updated May 2014, revealed facility staff had identified that the resident had an allergy to Bactrim and developed interventions related to the resident's allergy. Further review revealed interventions on the Comprehensive Care Plan which stated staff was to ensure the resident's allergies were "well documented" throughout the resident's "chart, medication records, and all other pertinent documents." Review of the physician's orders [REDACTED].#1 wrote an order for [REDACTED].#1. Review of Resident #1's Medication Administration Record (MAR) revealed the MAR contained documentation that Resident #1 was allergic to Bactrim. However, documentation revealed staff administered 800 mg of Bactrim to Resident #1 on 06/12/14 at approximately 12:00 PM. Review of the facility's investigation revealed the facility had identified that Resident #1's Comprehensive Care Plan, dated May 2014, listed Bactrim as an allergy for the resident. However, facility staff administered the medication to the resident. An interview on 06/18/14 at 10:35 AM, with Assistant Director of Nursing (ADON) #2, who was also the Minimum Data Set (MDS) Nurse, revealed staff developed a care plan, with interventions, any time a resident was identified to have a drug allergy. ADON #2 also acknowledged staff had identified that Resident #1 had an allergy to Bactrim and had developed a care plan to address the problem. Continued interview with ADON #2 revealed staff should not have administered the Bactrim to Resident #1 since it was listed as an allergy on the Comprehensive Care Plan. Further interview with ADON #2 revealed staff did not review the resident's plan of care during the administration of medications. An interview with the Director of Nursing (DON) on 06/18/14 at 11:30 AM revealed staff had been trained to identify any medication allergies on the resident's Comprehensive Plan of Care. She further stated staff should have verified Resident #1's medication allergies before the Bactrim was administered to the resident on 06/12/14. According to the DON, staff was required to provide resident care, including administering medications, as outlined in the resident's plan of care. An interview with the Administrator on 06/18/14 at 4:00 PM revealed staff was required to include any medication allergies on the resident's plan of care. The Administrator further stated staff had been trained to verify if a resident had a medication allergy prior to the administration of the medication. The Administrator acknowledged staff failed to verify Resident #1's allergies before they prescribed, obtained, and administered the medication to the resident on 06/12/14. **The facility provided an acceptable Allegation of Compliance (AOC) on 06/24/14. The facility implemented the following actions to remove the Immediate Jeopardy: --The Administrator and Director of Nursing (DON) were notified of the medication error on 06/12/14 by Registered Nurse (RN) #1. Advanced Registered Nurse Practitioner (ARNP) #1, Assistant Director of Nursing (ADON) #1, RN #1, and Kentucky Medication Aide (KMA) #1, were all suspended on 06/12/14, pending results of an investigation. The DON initiated an investigation on 06/12/14. The DON reported the medication administration error that occurred on 06/12/14 to the regulatory agency on 06/12/14 to meet state/federal guidelines to ensure reporting requirements were met. The Physician for Resident #1 was notified upon identification of the medication error related to administration of Bactrim on 06/12/14. The Physician instructed facility staff to assess Resident #1 and monitor him/her for any signs and symptoms of allergic reaction. Resident #1 was assessed by facility staff on 06/12/14 for any signs and symptoms of reaction, no concerns were identified. Resident #1, who has a Brief Interview for Mental Status (BIMS) score of 14 was notified of the medication error along with the resident's Power of Attorney (POA) on 06/12/14 by facility staff. --Based on the conclusion the investigation, staff members/the contract consultant involved was disciplined as below: -ARNP #1, ADON #1, and RN #1's employment was terminated from the facility. -KMA #1 received coaching/counseling, completed with restrictions that the KMA received 1:1 training by the Staff Development Coordinator (SDC) to address medication administration, specifically not giving medications that she does not pull herself, checking for allergies, and providing care as outlined in the care plan in relation to medication administration. Furthermore, KMA #1 had to complete a medication pass with a pharmacy field consultant prior to passing any medications upon return to work. She will also complete a weekly medication pass with the Staff Development Coordinator for ongoing continued education/compliance for four weeks. (The facility determined, after reviewing the KMA's 33-year history with the facility as a KMA and having exceptional evaluations and no coaching/counseling during her years of service, that with appropriate education and training she should be allowed to return to work.) --Facility staff was interviewed by the DON, ADONs, Facility Formulary Nurse (FFN), SDC, Minimum Data Set (MDS) Coordinator, and Regional Nurse Consultant on 06/12/14 for any knowledge of these four individuals transcribing or administering any medication in which a resident had an allergy. --Interviews were completed on 06/12/14, with residents which were assessed to have a BIMS score of 8 or greater, by the Social Services Director and Chaplain regarding their knowledge of any medications they were allergic to and may have received. No concerns were identified. --Skin assessments were completed on 06/12/14 by the DON, ADON, MDS Coordinator, or SDC on all residents with a BIMS score less than 8, for any signs or symptoms of allergic reaction. No concerns were identified. --All facility residents' charts were audited, which validated allergy stickers were on the outside of the resident's chart, face sheet, and care plans. The residents' Medication Administration Records (MARs) and Treatment Administration Records (TARs) and the allergy sheet in front of the MARs, along with the Physician and Nurse Practitioner's (NP's) orders since 05/01/14 were audited, for any new medication orders versus resident allergies. These audits were conducted by 06/13/14, by the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, the MDS Coordinators, Social Services Director, Admissions/Marketing or Regional Nurse Consultant to ensure allergies had been appropriately identified and no medications were ordered and/or administered that were listed as an allergy for a resident. No concerns were identified. --Education for facility staff was initiated on 06/12/14 by the SDC, DON, ADONs, or the Nurse Consultant regarding the abuse/neglect policy and appropriate reporting of neglect. The education also included information related to significant medication errors, care plans in regards to following care plans and delivering care as outlined in the care plan, emergency medication kit to include pharmacist approval and allergy verification prior to med removal. Education provided also included medication administration related to the responsibilities and expectations of the nurse related to how the medications were obtained and delivered to meet professional standards requirements. Staff will be monitored during medication pass and will complete questionnaires from training received. Staff was also trained related to the Quality Assurance Performance Improvement process which included reporting of concerns to the Administrator and line staff participation in development of Quality Assurance Performance Improvement (QAPI) plans. Staff will not be permitted to work prior to receiving the education and passing a post-test with a score of 100 percent. All new licensed nurses hired after 06/12/14 will receive the above training. --Follow-up questionnaires will be completed by the Administrator, DON, ADON, MDS Coordinator, Social Services Director, Quality of Life Director, Dietary Manager, Plant Operations Director, or the Environmental Services Manager for five different staff members daily until removal of the immediacy of the Jeopardy. After the immediacy has been removed the questionnaires will be conducted weekly for two weeks, to ensure continued understanding regarding the abuse/neglect policy and procedure, and then the Quality Assurance (QA) Committee will evaluate and determine need of ongoing frequency. --Pharmerica is providing field consultants on-site, starting on 06/16/14 for two days per week for two weeks to provide further education/training on medication administration. The education will include delivery of medications and validation of allergies to meet professional standards. All nurses will complete a med pass with a Pharmerica field consultant. The QA Committee will evaluate and determine the need for services required from the pharmacy field consultant at the end of two weeks. --The facility obtained a contract on 06/16/14 with an external independent clinical consultant to provide services two days per week on-site. This external independent clinical consultant will provide clinical oversight of process and procedures to validate that professional standards are being met until the immediacy is removed. After the immediacy is removed, the QA Committee will evaluate and determine the need for ongoing services required from the external independent clinical consultant. --Upon receiving a new medication order, all new medication orders will be reconciled with the resident's listed allergies by two nurses. The pharmacy will then be contacted to reconcile the new medication with the resident's listed allergies and new medication orders will be signed off by the same two nurses on the Physician order [REDACTED]. The nurse receiving the new medication order will transcribe the order to the MAR and a second nurse will co-sign validating compliance. Prior to administration of newly ordered medications for any resident, the DON, ADONs, SDC or Regional Nurse Consultant will review the above process with the Charge Nurse or certified medication technician to determine compliance to ensure the resident doesn't have an allergy to the medication. This validation process will continue until the immediacy is removed, then daily review for compliance with the above process will continue for four weeks. The findings will be reviewed weekly in the QA meeting to determine the need of the ongoing frequency with new medication monitoring. --Education was provided on 06/12/14, for Licensed Nursing Staff by the SDC or the Regional Nurse Consultant regarding the above stated plan. Licensed Nursing Staff which was not trained on 06/12/14 will not be permitted to work until the above stated education has been received. --All new medication orders were audited and logged onto the administrative nursing monitoring form by the DON, ADONs, SDC, FFN, MDS Coordinator, or Regional Nurse Consultant (three regional nurse consultants have been on-site for 24-hour coverage to ensure all new medication orders have gone through the process outlined below, since the incident which occurred on 06/12/14) every shift (during night shift the Charge Nurse is to call the designated Administrative Nurse or the Regional Nurse Consultant with all new medications) to ensure all new medications orders have been signed off by two nurses. Audits have also included ensuring the pharmacist had been contacted to verify allergies and two nurses have signed off on the transcription of the new medication to the MAR prior to the new medication being administered to the resident. In Addition, the Regional Nurse Consultant, the Special Projects Administrator, Vice President of Operations (VPO), Chief Nursing Executive (CNE), or Chief Operating Officer (COO) will audit all new orders daily to ensure compliance with the process starting on 06/13/14; this process will be continued until the immediacy has been removed. When the immediacy has been removed audits will be conducted twice weekly for four weeks, and at that time the QA Committee will evaluate the need for the continued frequency of monitoring. --The Director of Nursing will conduct daily reviews of the above log sheet for compliance. The Regional Nurse Consultants will validate compliance with the above process daily and the COO, CNE, VPO, or Special Projects Administrator will validate compliance with the above process twice weekly until the removal of the immediacy of the Jeopardy. When the immediacy has been removed, then the DON or ADONs will review daily for four weeks; the Regional Nurse Consultant will review three times a week for four weeks; and the COO, CNE, VPO, or Special Projects Administrator will review weekly for four weeks to ensure that compliance is maintained. The findings will be reported weekly to QA for recommendations and further follow-up as indicated and to determine ongoing frequency of monitoring. --Medication pass audits were completed by the Director of Nursing, Assistant Directors of Nursing, Staff Development Coordinator, MDS Coordinator, FFN, or Regional Nurse Consultant for all nurses and KMAs who had worked on 06/12/14 to ensure proper medication administration technique, proper identification of allergies, that professional standards were being met, and that care plans were being followed. Further medication pass audits were completed for all nurses and KMAs during their initial medication pass by 06/17/14 except four PRN nurses. Certified letters have been mailed to the four PRN licensed nurses to inform them they would not be permitted to work until a medication pass audit was completed with the ADONs or SDC. During the medication pass audit, a questionnaire will be completed by the DON, ADON, FFN, MDS Coordinator, SDC, or Regional Nurse Consultant to ensure their knowledge of where to review for allergies prior to the administration of the medication. --When all nurses have completed a medication pass audit, the DON, ADONs, SDC, FFN, MDS Coordinator, or Regional Nurse Consultant will conduct a medication pass audit with two nurses per day (one nurse per nursing unit) to ensure ongoing proper medication administration technique, proper identification of allergies, that professional standards are being met, and that care plans are being followed until the immediacy has been removed. When the immediacy has been removed, one nurse per day will complete a medication pass audit for two weeks, and then the QA Committee will evaluate and determine the frequency of ongoing medication pass audits. --Administrative oversight of the facility was completed by the Special Projects Administrator, Regional Nurse Consultant, the Regional Vice President of Operations, Chief Nursing Executive, or the Chief Operating Officer daily until removal of the immediacy. After the removal of the immediacy, the oversight will continue weekly for four weeks, then monthly. --Education was provided by the Regional Nurse Consultant on 06/12/14 for the Administrator, DON, ADON, SDC, Quality of Life Director, Social Services Director, Plant Operations Director, Chaplain, Medical Records Coordinator, Dietary Manager, and Admissions Director regarding the Quality Assurance Process and appropriate methods of identification of concerns including significant medication errors, failure to report neglect, auditing pharmacy services, care plans, and professional services. --A Quality Assurance meeting was held on 06/12/14 with the Medical Director for further recommendations regarding the plan for removal of Jeopardy. The Medical Director was involved with creation and approval of the current plan to address the identified areas of concern in regards to appropriate identification of resident allergies. All primary physicians, along with covering physicians, were provided with education/training along with a letter which detailed the facility's QAPI plan, along with appropriate identification of resident allergies prior to new medication prescribing on 06/24/14 by the Regional Nurse Consultant or DON. A Quality Assurance meeting will be held weekly for four weeks, then monthly for recommendations and further follow-up regarding the above stated plan. **The surveyors validated the Immediate Jeopardy was removed as follows: --Interviews conducted with the Administrator and the Director of Nursing (DON) on 06/25/14 revealed Registered Nurse (RN) #1 notified them of the medication error that occurred on 06/12/14 when facility staff had prescribed, obtained, and administered a medication to Resident #1 that had previously been identified as a medication allergy for the resident. Further interviews and review of the facility's investigation confirmed staff members involved with the incident (ARNP #1, ADON #1, RN #1, and KMA #1) were all suspended on 06/12/14, pending results of the investigation. Resident #1's physician was notified, and new orders were received and implemented on 06/12/14, when the medication error was identified by facility staff. Continued review of the investigation revealed Resident #1 was assessed by facility staff on 06/12/14 for any signs and symptoms of reaction and no concerns were identified. Continued review of the investigation revealed Resident #1, who has a BIMS score of 14 was notified, along with the resident's Power of Attorney (POA), of the medication error that occurred on 06/12/14. --Interviews with facility staff and review of the facility's investigation on 06/25/14 revealed the following actions were taken, as a result of the facility's investigation findings: ARNP #1, ADON #1, and RN #1's employment was terminated from the facility. KMA #1 received coaching/counseling and 1:1 training by the Staff Development Coordinator (SDC) which addressed medication administration, specifically not giving medications that she did not pull herself, checking for resident allergies, and providing care as outlined in the care plan in relation to medication administration. Continued interview and a review of the investigation confirmed KMA #1 had completed a medication pass with the facility's Pharmacy Consultant prior to administering any further medications to facility residents. Further interviews revealed KMA #1 would also complete a weekly medication pass with the SDC for ongoing continued education/compliance for four weeks. The facility's investigation findings revealed they had determined, after reviewing the KMA's 33-year work history with the facility, and having exceptional evaluations and no previous disciplinary actions, with appropriate education and training she should be allowed to return to work. --Interviews with staff and further review of the facility's investigation on 06/25/14 revealed the facility staff was interviewed by the DON, ADONs, FFN, SDC, MDS Coordinator, or Regional Nurse Consultant on 06/12/14 for any knowledge of the four individuals identified in the incident transcribing or administering any medication which had been listed as an allergy for any other resident. --Interviews and review of the facility's investigation conducted on 06/25/14 revealed residents who were assessed to have a BIMS score of 8 or greater were interviewed on 06/12/14, by the Social Services Director and Chaplain to determine if medications they had an allergy to had been administered to them while in the facility. The investigation further revealed no concerns were identified. --Interview with the DON and review of the facility's investigation on 06/25/14 confirmed skin assessments were conducted to ensure no allergic reactions had occurred on all facility residents with a BIMS score of 8 or below on 06/12/14. --Review of facility audits and interviews with staff on 06/25/14 revealed all facility residents' charts were audited and staff validated allergy stickers were on the outside of the residents' charts, face sheets, and care plans. Further reviews and interviews with staff conducted on 06/25/14 revealed the residents' Medication Administration Records (MARs) and Treatment Administration Records (TARs), allergy sheets located in front of the residents' MARs, along with physician orders [REDACTED]. Continued review confirmed audits were conducted by 06/13/14, by the DON, ADON, SDC, MDS Coordinators, Social Services Director, Admissions/Marketing, or Regional Nurse Consultant. Interviews conducted on 06/25/14 revealed audits were conducted to ensure allergies had been appropriately identified and no medications were ordered and/or administered that were listed as an allergy for a resident, with no concerns identified. --A review of staff education provided by the facility, initiated on 06/12/14, confirmed the SDC, DON, ADONs, or the Nurse Consultant instructed staff about the facility's abuse/neglect policy and appropriate reporting of neglect. The education review conducted on 06/25/14 also revealed information was included related to significant medication errors, implementation of care plans, emergency medication kit to include pharmacist approval, and allergy verification prior to medication removal. Continued review of the education provided to facility staff also included medication administration and the responsibilities and expectations of the nurse on how the medications were obtained and delivered to meet professional standards requirements. Interviews conducted with facility staff on 06/25/14 confirmed staff was monitored during medication pass and had been required to complete questionnaires related to the training they received. KMA #1 stated in interview on 06/25/14 that she received training related to the Quality Assurance Performance Improvement (QAPI) process which included reporting of concerns to the Administrator and line staff participation in development of QAPI plans. Interview with the Regional Nurse Consultant and the DON on 06/25/14 revealed staff was not permitted to work until they were educated and completed a post-test with a score of 100 percent. Interview with the DON on 06/25/14 revealed all new licensed nurses hired after 06/12/14 will receive the above training during their orientation. --Interviews with the Regional Nurse Consultant on 06/25/14 confirmed follow-up questionnaires were completed by the Administrator, DON, ADON, MDS Coordinator, Social Services Director, Quality of Life Director, Dietary Manager, Plant Operations Director, or the Environmental Services Manager for five different staff members daily. The Nurse Consultant further stated after the immediacy had been removed the questionnaires would be conducted weekly for two weeks to ensure continued understanding regarding the abuse/neglect policy and procedure, and the QA Committee would evaluate further the need for the questionnaires. --Review of Medication Pass audits conducted, and an interview with the Regional Nurse Consultant on 06/25/14, revealed the facility's Pharmacy had provided Field Consultants on-site, which started on 06/16/14, for two days per week for a total of two weeks. He stated the pharmacy service was to provide further education/training on medication administration. The education would include delivery of medications and validation of the residents' allergies to meet professional standards. The Consultant stated all nurses would complete a medication pass with a Pharmacy Field Consultant and the QA Committee would evaluate and determine the continued need for services required from the Pharmacy Field Consultant at the end of two weeks. --Interview with the DON and the Administrator on 06/25/14 confirmed the facility had obtained a contract on 06/16/14 with an external Independent Clinical Consultant to provide services two days per week on-site. The Administrator stated the external Independent Clinical Consultant would provide clinical oversight of processes and procedures to validate those professional standards were met until the immediacy was removed. After the immediacy was removed, the Administrator stated the QA Committee would evaluate and determine the need for services required from an external Independent Clinical Consultant. --Interviews with KMA #1 on 06/17/14 at 1:00 PM and Administrative staff on 06/25/14 confirmed training was initiated on 06/12/14 and included guidance on what staff was required to do when a new medication order was received. Allergies were to be validated and all new medication orders were to be reconciled and transcribed onto the resident's MAR by two nurses. Continued interview confirmed the pharmacy would be contacted to reconcile new medications, with the resident's listed allergies. Continued review of trainings and interviews with KMA #1 on 06/17/14 at 1:00 PM, the DON on 06/18/14 at 11:30 AM, and the Administrator on 06/18/14 at 4:00 PM confirmed new medication orders would be signed off by the two nurses that validated reconciliation of new medications to the resident's listed allergies. The nurse receiving the new medication order would transcribe the order to the MAR and a second nurse would co-sign which would validate compliance. Continued interview revealed staff was required to contact the DON, ADONs, SDC, or Regional Nurse Consultant, before any new medication was administered for any resident, to validate all required checks had been completed. Continued interviews on 06/25/14 revealed this validation process would continue until the immediacy was removed. The Regional Nurse Consultant stated on 06/25/14 at 1:00 PM the validation process would be reviewed daily for compliance and would be continued for four weeks. The Nurse Consultant further stated the findings would be reviewed weekly in the QA meeting to determine the need of ongoing frequency with new medication monitoring. --Interview with the DON and the Nurse Consultant on 06/25/14 revealed Licensed Nursing Staff that had not received the training on 06/12/14 would not be permitted to work until the above stated education has been received. --A review of facility audits and interviews with Administrative staff on 06/25/14 revealed all new medication orders were audited and logged onto the administrative nursing monitoring form by the DON, ADONs, SDC, FFN, MDS Coordinator, or Regional Nurse Consultant. Continued interview revealed three Regional Nurse Consultants had been on-site 24 hours a day since the incident occurred on 06/12/14 to ensure staff had validated all new medication orders. The Regional Nurse Consultant stated during night shift the Charge Nurse was required to call the designated Administrative Nurse or Regional Nurse Consultant with all new medication orders, to ensure all new orders had been signed off by two nurses as required. Continued interview on 06/25/14 confirmed facility audits included ensuring the pharmacist had been contacted to verify allergies, and that two nurses had signed off on the transcription of the new medication to the MAR prior to the administration of any new medications to the residents. Continued interview revealed the Regional Nurse Consultant, Special Projects Administrator, VPO, CNE, or COO would audit all new orders daily to ensure compliance with the process starting on 06/13/14 and would continue to audit the orders until the immediacy had been removed. The Nurse Consultant stated when immediacy had been removed audits would be conducted twice weekly for four weeks, and then the QA Committee would evaluate the need for continued frequency of monitoring. --The Director of Nursing stated on 06/25/14 at 3:25 PM she had conducted daily reviews of the medication audit log sheets for compliance. The Regional Nurse Consultant stated on 06/25/14 that he had validated compliance with the above process daily and the COO, CNE, VPO, or the Special Projects Administrator had validated compliance with the above process, twice weekly, until removal of the immediacy. The DON stated when the immediacy had been removed, then she or the ADONs would review the log sheets daily for four weeks, the Regional Nurse Consultant would review the log sheets three times a week for four weeks, and the COO, CNE, VPO, or the Special Projects Administrator would review the log sheets weekly for four weeks to ensure that compliance has been maintained. The DON further stated the findings would be reported weekly to the QA Committee for recommendations and further follow-up as indicated and to determine ongoing frequency of monitoring. Interviews with the Administrator on 06/25/14 at 3:00 PM and review of the facility's audits on 06/25/14 revealed medication pass audits were completed by the DON, ADON, SDC, MDS Coordinator, FFN, or Regional Nurse Consultant for all nurses and KMAs that had worked on 06/12/14. Continued review of the audits revealed the audits ensured proper medication administration technique, proper identification of allergies, that professional standards were met, and that care plans were followed. Further review and interview revealed by 06/17/14 medication pass audits had been completed for the KMAs and all but fo

Based on interviews, record reviews, review of the facility's investigation, and review of the facility's policies entitled "Medication Administration" and "Medication Ordering and Receiving from Pharmacy Provider," it was determined the facility failed to ensure one (1) of four (4) sampled residents (Resident #1) was free from significant medication errors. Review of Resident #1's medical record revealed the resident was allergic to Bactrim (antibiotic). Interview and record reviews conducted on 06/17/14 at 1:56 PM revealed on 06/12/14 Advanced Registered Nurse Practitioner (ARNP) #1 prescribed Bactrim (antibiotic) to Resident #1 for an abnormal urinalysis. Interview with ARNP #1 also revealed she failed to review the resident's medication allergies before she prescribed the Bactrim. An interview with Assistant Director of Nursing (ADON) #1 on 06/17/14, revealed he had transcribed the Bactrim that had been prescribed for Resident #1 to the resident's Medication Administration Record (MAR) on 06/12/14, and failed to review the resident's allergies before he transcribed the medication to the MAR. An interview conducted on 06/17/14 at 1:50 PM with Registered Nurse (RN) #1 revealed she had retrieved the Bactrim from the facility's Emergency Drug Kit (EDK) on 06/12/14. RN #1 further stated she had failed to review the resident's allergies before the medication was obtained and before she instructed Kentucky Medication Aide (KMA) #1 to administer the medication to Resident #1. KMA #1 acknowledged she administered the medication to Resident #1 on 06/12/14 and failed to review or verify the resident's medication allergies with the resident before she administered the medication on 06/12/14. Record review revealed the facility learned of the medication error when the pharmacy telephoned the facility, approximately three hours after the pharmacy had received the prescription on 06/12/14, to ask staff to clarify the order because the resident was allergic to Bactrim. When facility staff was notified of the medication error, Resident #1 was assessed and monitored, with no injury or reactions identified to occur for the resident. The facility's failure to ensure residents were free from significant medication errors caused, or was likely to cause, serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy with Substandard Quality of Care was determined to exist on 06/12/14 at 42 CFR 483.20 Resident Assessment (F281 and F282), 42 CFR 483.25 Quality of Care (F333), and 42 CFR 483.75 Administration (F490 and F520) at a scope and severity of "J." Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care (F333). The facility was notified of the Immediate Jeopardy on 06/18/14. An acceptable Allegation of Compliance was received on 06/24/14, which alleged removal of the Immediate Jeopardy on 06/25/14. The State Survey Agency determined the Immediate Jeopardy was removed on 06/25/14, prior to exit, which lowered the scope and severity to "D" at 42 CFR 483.20 Resident Assessment (F281 and F282), 42 CFR 483.25 Quality of Care (F333), and 42 CFR 483.75 Administration (F490 and F520) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled "Medication Administration," dated December 2010, revealed staff was required to verify the resident was not allergic to the medication before administering any antibiotic for the first time. Review of the facility's policy titled "Medication Ordering and Receiving from Pharmacy Provider," dated September 2010, revealed when a medication was needed from the facility's Emergency Drug Kit (EDK), staff should first verify and review the prescriber's orders for appropriateness and check the resident's allergies. Review of Resident #1's medical record revealed the facility admitted the resident on 01/22/13, with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set Assessment ((MDS) dated [DATE], revealed Resident #1 was alert and oriented. In addition, based on the facility's assessment on 05/21/14 Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident's cognition was intact. Review of Resident #1's Comprehensive Care Plan, last updated May 2014, revealed staff had documented the resident was allergic to Bactrim. A review of Resident #1's medical record revealed the record was labeled indicating the resident had an allergy to Bactrim. review of the resident's medical record revealed [REDACTED]. Continued review revealed each page of the resident's MAR had documentation of the resident's allergy to Bactrim. In addition, there was a separate page with the MAR that was used only for allergy information that identified the resident had an allergy to Bactrim. Review of Resident #1's Physician orders [REDACTED].#1 prescribed 800 milligrams (mg) of Bactrim to be administered to the resident two times a day to treat an abnormal urinalysis. Review of the resident's MAR revealed facility staff had administered one dose of the Bactrim to Resident #1 on 06/12/14 at approximately 12:00 PM. Record review revealed the facility conducted an investigation related to the staff's failure to review and/or verify Resident #1's allergies prior to the administration of the Bactrim. According to the investigation, the facility learned of the medication error when the pharmacy contacted facility staff approximately three hours after the pharmacy had filled the prescription for the Bactrim on 06/12/14 and asked staff to clarify the order because the resident was allergic to Bactrim. ARNP #1 confirmed in an interview conducted on 06/17/14 at 1:56 PM that she had prescribed Bactrim (an antibiotic medication) for Resident #1 on 06/12/14. ARNP #1 acknowledged she failed to review Resident #1's medication allergy list prior to prescribing the Bactrim to the resident on 06/12/14. The ARNP stated she should have reviewed the resident's allergy lists before the order for Bactrim was prescribed to Resident #1 on 06/12/14. An interview conducted with ADON #1 on 06/17/14 at 1:30 PM, revealed after the ARNP wrote the order for the Bactrim, ADON #1 transcribed the order onto Resident #1's MAR on 06/12/14. The interview further revealed even though he had been trained to verify allergies before he transcribed them onto the MAR, he failed to review the resident's list of allergies and had transcribed the newly prescribed antibiotic onto Resident #1's MAR on 06/12/14. The ADON further stated he was in a hurry on 06/12/14 due to a scheduled meeting he had to attend, and "was under the impression the ARNP had checked the resident's allergies before prescribing the medication." Interview with RN #1 at 1:50 PM on 06/17/14 revealed the ADON had instructed the RN to obtain the Bactrim from the EDK to administer to Resident #1. RN #1 acknowledged she failed to review the resident's medication allergies when she obtained the medication from the EDK for Resident #1 and stated she had "assumed" the ADON had verified the resident's allergies before he had asked her to obtain the medication. Continued interview with RN #1 revealed she had instructed KMA #1 to administer the Bactrim to Resident #1. An interview with KMA #1 on 06/17/14 at 1:00 PM revealed she had administered Bactrim to Resident #1 on 06/12/14, and failed to review Resident #1's allergies or ask the resident if he/she had any drug allergies before administering the newly ordered medication. The KMA stated she "assumed" since RN #1 had given her the resident's medication, still packaged, and instructed her to administer the medication, that the RN had verified the resident's medication allergies. An interview with the Director of Nursing (DON) on 06/18/14 at 11:30 PM, revealed staff had previously been trained and instructed to review a resident's allergies before they administered newly prescribed medications. The DON acknowledged staff had failed to verify Resident #1's allergies prior to administering the Bactrim on 06/12/14. An interview with the Administrator on 06/18/14 at 4:00 PM revealed staff had been trained to verify the facility's residents' medication allergies before administering medications. The Administrator further stated Resident #1's medication allergies should have been verified before the medication was prescribed, transcribed, or administered on 06/12/14. **The facility provided an acceptable Allegation of Compliance (AOC) on 06/24/14. The facility implemented the following actions to remove the Immediate Jeopardy: --The Administrator and Director of Nursing (DON) were notified of the medication error on 06/12/14 by Registered Nurse (RN) #1. Advanced Registered Nurse Practitioner (ARNP) #1, Assistant Director of Nursing (ADON) #1, RN #1, and Kentucky Medication Aide (KMA) #1, were all suspended on 06/12/14, pending results of an investigation. The DON initiated an investigation on 06/12/14. The DON reported the medication administration error that occurred on 06/12/14 to the regulatory agency on 06/12/14 to meet state/federal guidelines to ensure reporting requirements were met. The Physician for Resident #1 was notified upon identification of the medication error related to administration of Bactrim on 06/12/14. The Physician instructed facility staff to assess Resident #1 and monitor him/her for any signs and symptoms of allergic reaction. Resident #1 was assessed by facility staff on 06/12/14 for any signs and symptoms of reaction, no concerns were identified. Resident #1, who has a Brief Interview for Mental Status (BIMS) score of 14 was notified of the medication error along with the resident's Power of Attorney (POA) on 06/12/14 by facility staff. --Based on the conclusion the investigation, staff members/the contract consultant involved was disciplined as below: -ARNP #1, ADON #1, and RN #1's employment was terminated from the facility. -KMA #1 received coaching/counseling, completed with restrictions that the KMA received 1:1 training by the Staff Development Coordinator (SDC) to address medication administration, specifically not giving medications that she does not pull herself, checking for allergies, and providing care as outlined in the care plan in relation to medication administration. Furthermore, KMA #1 had to complete a medication pass with a pharmacy field consultant prior to passing any medications upon return to work. She will also complete a weekly medication pass with the Staff Development Coordinator for ongoing continued education/compliance for four weeks. (The facility determined, after reviewing the KMA's 33-year history with the facility as a KMA and having exceptional evaluations and no coaching/counseling during her years of service, that with appropriate education and training she should be allowed to return to work.) --Facility staff was interviewed by the DON, ADONs, Facility Formulary Nurse (FFN), SDC, Minimum Data Set (MDS) Coordinator, and Regional Nurse Consultant on 06/12/14 for any knowledge of these four individuals transcribing or administering any medication in which a resident had an allergy. --Interviews were completed on 06/12/14, with residents which were assessed to have a BIMS score of 8 or greater, by the Social Services Director and Chaplain regarding their knowledge of any medications they were allergic to and may have received. No concerns were identified. --Skin assessments were completed on 06/12/14 by the DON, ADON, MDS Coordinator, or SDC on all residents with a BIMS score less than 8, for any signs or symptoms of allergic reaction. No concerns were identified. --All facility residents' charts were audited, which validated allergy stickers were on the outside of the resident's chart, face sheet, and care plans. The residents' Medication Administration Records (MARs) and Treatment Administration Records (TARs) and the allergy sheet in front of the MARs, along with the Physician and Nurse Practitioner's (NP's) orders since 05/01/14 were audited, for any new medication orders versus resident allergies. These audits were conducted by 06/13/14, by the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, the MDS Coordinators, Social Services Director, Admissions/Marketing or Regional Nurse Consultant to ensure allergies had been appropriately identified and no medications were ordered and/or administered that were listed as an allergy for a resident. No concerns were identified. --Education for facility staff was initiated on 06/12/14 by the SDC, DON, ADONs, or the Nurse Consultant regarding the abuse/neglect policy and appropriate reporting of neglect. The education also included information related to significant medication errors, care plans in regards to following care plans and delivering care as outlined in the care plan, emergency medication kit to include pharmacist approval and allergy verification prior to med removal. Education provided also included medication administration related to the responsibilities and expectations of the nurse related to how the medications were obtained and delivered to meet professional standards requirements. Staff will be monitored during medication pass and will complete questionnaires from training received. Staff was also trained related to the Quality Assurance Performance Improvement process which included reporting of concerns to the Administrator and line staff participation in development of Quality Assurance Performance Improvement (QAPI) plans. Staff will not be permitted to work prior to receiving the education and passing a post-test with a score of 100 percent. All new licensed nurses hired after 06/12/14 will receive the above training. --Follow-up questionnaires will be completed by the Administrator, DON, ADON, MDS Coordinator, Social Services Director, Quality of Life Director, Dietary Manager, Plant Operations Director, or the Environmental Services Manager for five different staff members daily until removal of the immediacy of the Jeopardy. After the immediacy has been removed the questionnaires will be conducted weekly for two weeks, to ensure continued understanding regarding the abuse/neglect policy and procedure, and then the Quality Assurance (QA) Committee will evaluate and determine need of ongoing frequency. --Pharmerica is providing field consultants on-site, starting on 06/16/14 for two days per week for two weeks to provide further education/training on medication administration. The education will include delivery of medications and validation of allergies to meet professional standards. All nurses will complete a med pass with a Pharmerica field consultant. The QA Committee will evaluate and determine the need for services required from the pharmacy field consultant at the end of two weeks. --The facility obtained a contract on 06/16/14 with an external independent clinical consultant to provide services two days per week on-site. This external independent clinical consultant will provide clinical oversight of process and procedures to validate that professional standards are being met until the immediacy is removed. After the immediacy is removed, the QA Committee will evaluate and determine the need for ongoing services required from the external independent clinical consultant. --Upon receiving a new medication order, all new medication orders will be reconciled with the resident's listed allergies by two nurses. The pharmacy will then be contacted to reconcile the new medication with the resident's listed allergies and new medication orders will be signed off by the same two nurses on the Physician order [REDACTED]. The nurse receiving the new medication order will transcribe the order to the MAR and a second nurse will co-sign validating compliance. Prior to administration of newly ordered medications for any resident, the DON, ADONs, SDC or Regional Nurse Consultant will review the above process with the Charge Nurse or certified medication technician to determine compliance to ensure the resident doesn't have an allergy to the medication. This validation process will continue until the immediacy is removed, then daily review for compliance with the above process will continue for four weeks. The findings will be reviewed weekly in the QA meeting to determine the need of the ongoing frequency with new medication monitoring. --Education was provided on 06/12/14, for Licensed Nursing Staff by the SDC or the Regional Nurse Consultant regarding the above stated plan. Licensed Nursing Staff which was not trained on 06/12/14 will not be permitted to work until the above stated education has been received. --All new medication orders were audited and logged onto the administrative nursing monitoring form by the DON, ADONs, SDC, FFN, MDS Coordinator, or Regional Nurse Consultant (three regional nurse consultants have been on-site for 24-hour coverage to ensure all new medication orders have gone through the process outlined below, since the incident which occurred on 06/12/14) every shift (during night shift the Charge Nurse is to call the designated Administrative Nurse or the Regional Nurse Consultant with all new medications) to ensure all new medications orders have been signed off by two nurses. Audits have also included ensuring the pharmacist had been contacted to verify allergies and two nurses have signed off on the transcription of the new medication to the MAR prior to the new medication being administered to the resident. In Addition, the Regional Nurse Consultant, the Special Projects Administrator, Vice President of Operations (VPO), Chief Nursing Executive (CNE), or Chief Operating Officer (COO) will audit all new orders daily to ensure compliance with the process starting on 06/13/14; this process will be continued until the immediacy has been removed. When the immediacy has been removed audits will be conducted twice weekly for four weeks, and at that time the QA Committee will evaluate the need for the continued frequency of monitoring. --The Director of Nursing will conduct daily reviews of the above log sheet for compliance. The Regional Nurse Consultants will validate compliance with the above process daily and the COO, CNE, VPO, or Special Projects Administrator will validate compliance with the above process twice weekly until the removal of the immediacy of the Jeopardy. When the immediacy has been removed, then the DON or ADONs will review daily for four weeks; the Regional Nurse Consultant will review three times a week for four weeks; and the COO, CNE, VPO, or Special Projects Administrator will review weekly for four weeks to ensure that compliance is maintained. The findings will be reported weekly to QA for recommendations and further follow-up as indicated and to determine ongoing frequency of monitoring. --Medication pass audits were completed by the Director of Nursing, Assistant Directors of Nursing, Staff Development Coordinator, MDS Coordinator, FFN, or Regional Nurse Consultant for all nurses and KMAs who had worked on 06/12/14 to ensure proper medication administration technique, proper identification of allergies, that professional standards were being met, and that care plans were being followed. Further medication pass audits were completed for all nurses and KMAs during their initial medication pass by 06/17/14 except four PRN nurses. Certified letters have been mailed to the four PRN licensed nurses to inform them they would not be permitted to work until a medication pass audit was completed with the ADONs or SDC. During the medication pass audit, a questionnaire will be completed by the DON, ADON, FFN, MDS Coordinator, SDC, or Regional Nurse Consultant to ensure their knowledge of where to review for allergies prior to the administration of the medication. --When all nurses have completed a medication pass audit, the DON, ADONs, SDC, FFN, MDS Coordinator, or Regional Nurse Consultant will conduct a medication pass audit with two nurses per day (one nurse per nursing unit) to ensure ongoing proper medication administration technique, proper identification of allergies, that professional standards are being met, and that care plans are being followed until the immediacy has been removed. When the immediacy has been removed, one nurse per day will complete a medication pass audit for two weeks, and then the QA Committee will evaluate and determine the frequency of ongoing medication pass audits. --Administrative oversight of the facility was completed by the Special Projects Administrator, Regional Nurse Consultant, the Regional Vice President of Operations, Chief Nursing Executive, or the Chief Operating Officer daily until removal of the immediacy. After the removal of the immediacy, the oversight will continue weekly for four weeks, then monthly. --Education was provided by the Regional Nurse Consultant on 06/12/14 for the Administrator, DON, ADON, SDC, Quality of Life Director, Social Services Director, Plant Operations Director, Chaplain, Medical Records Coordinator, Dietary Manager, and Admissions Director regarding the Quality Assurance Process and appropriate methods of identification of concerns including significant medication errors, failure to report neglect, auditing pharmacy services, care plans, and professional services. --A Quality Assurance meeting was held on 06/12/14 with the Medical Director for further recommendations regarding the plan for removal of Jeopardy. The Medical Director was involved with creation and approval of the current plan to address the identified areas of concern in regards to appropriate identification of resident allergies. All primary physicians, along with covering physicians, were provided with education/training along with a letter which detailed the facility's QAPI plan, along with appropriate identification of resident allergies prior to new medication prescribing on 06/24/14 by the Regional Nurse Consultant or DON. A Quality Assurance meeting will be held weekly for four weeks, then monthly for recommendations and further follow-up regarding the above stated plan. **The surveyors validated the Immediate Jeopardy was removed as follows: --Interviews conducted with the Administrator and the Director of Nursing (DON) on 06/25/14 revealed Registered Nurse (RN) #1 notified them of the medication error that occurred on 06/12/14 when facility staff had prescribed, obtained, and administered a medication to Resident #1 that had previously been identified as a medication allergy for the resident. Further interviews and review of the facility's investigation confirmed staff members involved with the incident (ARNP #1, ADON #1, RN #1, and KMA #1) were all suspended on 06/12/14, pending results of the investigation. Resident #1's physician was notified, and new orders were received and implemented on 06/12/14, when the medication error was identified by facility staff. Continued review of the investigation revealed Resident #1 was assessed by facility staff on 06/12/14 for any signs and symptoms of reaction and no concerns were identified. Continued review of the investigation revealed Resident #1, who has a BIMS score of 14 was notified, along with the resident's Power of Attorney (POA), of the medication error that occurred on 06/12/14. --Interviews with facility staff and review of the facility's investigation on 06/25/14 revealed the following actions were taken, as a result of the facility's investigation findings: ARNP #1, ADON #1, and RN #1's employment was terminated from the facility. KMA #1 received coaching/counseling and 1:1 training by the Staff Development Coordinator (SDC) which addressed medication administration, specifically not giving medications that she did not pull herself, checking for resident allergies, and providing care as outlined in the care plan in relation to medication administration. Continued interview and a review of the investigation confirmed KMA #1 had completed a medication pass with the facility's Pharmacy Consultant prior to administering any further medications to facility residents. Further interviews revealed KMA #1 would also complete a weekly medication pass with the SDC for ongoing continued education/compliance for four weeks. The facility's investigation findings revealed they had determined, after reviewing the KMA's 33-year work history with the facility, and having exceptional evaluations and no previous disciplinary actions, with appropriate education and training she should be allowed to return to work. --Interviews with staff and further review of the facility's investigation on 06/25/14 revealed the facility staff was interviewed by the DON, ADONs, FFN, SDC, MDS Coordinator, or Regional Nurse Consultant on 06/12/14 for any knowledge of the four individuals identified in the incident transcribing or administering any medication which had been listed as an allergy for any other resident. --Interviews and review of the facility's investigation conducted on 06/25/14 revealed residents who were assessed to have a BIMS score of 8 or greater were interviewed on 06/12/14, by the Social Services Director and Chaplain to determine if medications they had an allergy to had been administered to them while in the facility. The investigation further revealed no concerns were identified. --Interview with the DON and review of the facility's investigation on 06/25/14 confirmed skin assessments were conducted to ensure no allergic reactions had occurred on all facility residents with a BIMS score of 8 or below on 06/12/14. --Review of facility audits and interviews with staff on 06/25/14 revealed all facility residents' charts were audited and staff validated allergy stickers were on the outside of the residents' charts, face sheets, and care plans. Further reviews and interviews with staff conducted on 06/25/14 revealed the residents' Medication Administration Records (MARs) and Treatment Administration Records (TARs), allergy sheets located in front of the residents' MARs, along with physician orders [REDACTED]. Continued review confirmed audits were conducted by 06/13/14, by the DON, ADON, SDC, MDS Coordinators, Social Services Director, Admissions/Marketing, or Regional Nurse Consultant. Interviews conducted on 06/25/14 revealed audits were conducted to ensure allergies had been appropriately identified and no medications were ordered and/or administered that were listed as an allergy for a resident, with no concerns identified. --A review of staff education provided by the facility, initiated on 06/12/14, confirmed the SDC, DON, ADONs, or the Nurse Consultant instructed staff about the facility's abuse/neglect policy and appropriate reporting of neglect. The education review conducted on 06/25/14 also revealed information was included related to significant medication errors, implementation of care plans, emergency medication kit to include pharmacist approval, and allergy verification prior to medication removal. Continued review of the education provided to facility staff also included medication administration and the responsibilities and expectations of the nurse on how the medications were obtained and delivered to meet professional standards requirements. Interviews conducted with facility staff on 06/25/14 confirmed staff was monitored during medication pass and had been required to complete questionnaires related to the training they received. KMA #1 stated in interview on 06/25/14 that she received training related to the Quality Assurance Performance Improvement (QAPI) process which included reporting of concerns to the Administrator and line staff participation in development of QAPI plans. Interview with the Regional Nurse Consultant and the DON on 06/25/14 revealed staff was not permitted to work until they were educated and completed a post-test with a score of 100 percent. Interview with the DON on 06/25/14 revealed all new licensed nurses hired after 06/12/14 will receive the above training during their orientation. --Interviews with the Regional Nurse Consultant on 06/25/14 confirmed follow-up questionnaires were completed by the Administrator, DON, ADON, MDS Coordinator, Social Services Director, Quality of Life Director, Dietary Manager, Plant Operations Director, or the Environmental Services Manager for five different staff members daily. The Nurse Consultant further stated after the immediacy had been removed the questionnaires would be conducted weekly for two weeks to ensure continued understanding regarding the abuse/neglect policy and procedure, and the QA Committee would evaluate further the need for the questionnaires. --Review of Medication Pass audits conducted, and an interview with the Regional Nurse Consultant on 06/25/14, revealed the facility's Pharmacy had provided Field Consultants on-site, which started on 06/16/14, for two days per week for a total of two weeks. He stated the pharmacy service was to provide further education/training on medication administration. The education would include delivery of medications and validation of the residents' allergies to meet professional standards. The Consultant stated all nurses would complete a medication pass with a Pharmacy Field Consultant and the QA Committee would evaluate and determine the continued need for services required from the Pharmacy Field Consultant at the end of two weeks. --Interview with the DON and the Administrator on 06/25/14 confirmed the facility had obtained a contract on 06/16/14 with an external Independent Clinical Consultant to provide services two days per week on-site. The Administrator stated the external Independent Clinical Consultant would provide clinical oversight of processes and procedures to validate those professional standards were met until the immediacy was removed. After the immediacy was removed, the Administrator stated the QA Committee would evaluate and determine the need for services required from an external Independent Clinical Consultant. --Interviews with KMA #1 on 06/17/14 at 1:00 PM and Administrative staff on 06/25/14 confirmed training was initiated on 06/12/14 and included guidance on what staff was required to do when a new medication order was received. Allergies were to be validated and all new medication orders were to be reconciled and transcribed onto the resident's MAR by two nurses. Continued interview confirmed the pharmacy would be contacted to reconcile new medications, with the resident's listed allergies. Continued review of trainings and interviews with KMA #1 on 06/17/14 at 1:00 PM, the DON on 06/18/14 at 11:30 AM, and the Administrator on 06/18/14 at 4:00 PM confirmed new medication orders would be signed off by the two nurses that validated reconciliation of new medications to the resident's listed allergies. The nurse receiving the new medication order would transcribe the order to the MAR and a second nurse would co-sign which would validate compliance. Continued interview revealed staff was required to contact the DON, ADONs, SDC, or Regional Nurse Consultant, before any new medication was administered for any resident, to validate all required checks had been completed. Continued interviews on 06/25/14 revealed this validation process would continue until the immediacy was removed. The Regional Nurse Consultant stated on 06/25/14 at 1:00 PM the validation process would be reviewed daily for compliance and would be continued for four weeks. The Nurse Consultant further stated the findings would be reviewed weekly in the QA meeting to determine the need of ongoing frequency with new medication monitoring. --Interview with the DON and the Nurse Consultant on 06/25/14 revealed Licensed Nursing Staff that had not received the training on 06/12/14 would not be permitted to work until the above stated education has been received. --A review of facility audits and interviews with Administrative staff on 06/25/14 revealed all new medication orders were audited and logged onto the administrative nursing monitoring form by the DON, ADONs, SDC, F

Based on interview, record review, review of the facility's investigation, and a review of the facility's policies, titled "Medication Administration" and "Medication Ordering and Receiving from Pharmacy Provider," it was determined the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for one (1) of four (4) sampled residents (Resident #1). The facility's Administration failed to ensure residents were free from significant medication errors. Staff interviews, record reviews, and review of the facility's investigation revealed staff had identified Resident #1 was allergic to Bactrim (antibiotic). Interviews revealed Advanced Registered Nurse Practitioner (ARNP) #1, Assistant Director of Nursing (ADON) #1, Registered Nurse (RN) #1, and Kentucky Medication Aide (KMA) #1 failed to review Resident #1's list of allergies prior to prescribing the medication, transcribing the medication onto the MAR, obtaining the medication from the facility's Emergency Drug Kit (EDK), and before administering the Bactrim to Resident #1 on 06/12/14. As a result of the facility's failure to ensure staff reviewed and/or verified Resident #1's drug allergy to Bactrim, the resident received one (1) dose of 800 milligrams (mg) of Bactrim on 06/12/14 at approximately 12:00 PM. (Refer to F281, F282, F333, and F520.) The facility's failure to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of facility residents related to medication administration caused, or was likely to cause, serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy with Substandard Quality of Care was determined to exist on 06/12/14 at 42 CFR 483.20 Resident Assessment (F281 and F282), 42 CFR 483.25 Quality of Care (F333), and 42 CFR 483.75 Administration (F490 and F520) at a scope and severity of "J." Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care (F333). The facility was notified of the Immediate Jeopardy on 06/18/14. An acceptable Allegation of Compliance was received on 06/24/14, which alleged removal of the Immediate Jeopardy on 06/25/14. The State Survey Agency determined the Immediate Jeopardy was removed on 06/25/14, prior to exit, which lowered the scope and severity to "D" at 42 CFR 483.20 Resident Assessment (F281 and F282), 42 CFR 483.25 Quality of Care (F333), and 42 CFR 483.75 Administration (F490 and F520) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: According to the facility's policy titled, "Medication Administration," dated December 2010, "Before administering any antibiotic for the first time, check to be certain that the resident is not allergic to the drug." In addition, review of the facility's policy titled "Medication Ordering and Receiving from Pharmacy Provider," dated September 2010, revealed when a medication was needed from the facility's Emergency Drug Kit (EDK), staff should first verify and review the prescriber's orders for appropriateness and check the resident's allergies. Review of the facility's Administrator Job Description, dated December 2011, revealed the Administrator would "lead and direct the overall operations of the facility in accordance with customer needs, government regulations and Company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives." Documentation in the medical record revealed the facility admitted Resident #1 on 01/22/13. Review of Resident #1's Medication Administration Record (MAR) for June 2014 revealed facility staff had documented on the MAR the resident had an allergy to Bactrim. Review of Resident #1's medical record and the MAR revealed staff had documented on a red and white sticker, located on the outside of Resident #1's medical record, and on the resident's MAR, that Resident #1 was allergic to Bactrim. In addition, review of an updated Comprehensive Care Plan dated May 2014, revealed staff had documented Resident #1 was allergic to Bactrim and developed interventions to address the resident's allergy. However, review of Physician order [REDACTED].#1 wrote an order for [REDACTED].#1 two times a day and, based on documentation on the MAR, staff administered one dose of Bactrim to Resident #1 on 06/12/14 at approximately 12:00 PM. Review of the facility's investigative report dated 06/12/14 revealed the pharmacy received the order for the Bactrim and contacted the facility approximately three hours after they had received the order for the medication to inform the facility Resident #1 was allergic to Bactrim. However, based on the facility's investigation, RN #1 obtained the Bactrim from the facility's Emergency Drug Kit (EDK) (prior to the pharmacy's contact with the facility) and instructed KMA #1 to administer the medication. The KMA administered the medication on 06/12/14. An interview with the Administrator on 06/18/14 at 4:00 PM revealed the facility had policies and procedures in place on medication administration that required staff to review resident allergies before they administered medications. The Administrator also stated staff was expected to administer medications in accordance with nursing standards. According to the Administrator, prior to the incident that occurred on 06/12/14 with Resident #1, the Quality Assurance Committee had implemented a plan to monitor staff to ensure medications, including medications residents were allergic to, were accurately transcribed from the physician's orders [REDACTED]., to ensure residents received the medications as ordered. However, interview with the Administrator revealed he failed to implement a plan for staff to audit to ensure they were following facility policy. According to facility policy, staff was to check "before administering any antibiotic for the first time" and "check to be certain that the resident is not allergic to the drug." The Administrator acknowledged staff should have verified Resident #1's allergies prior to ordering the medication, obtaining the medication, and administering the medication. **The facility provided an acceptable Allegation of Compliance (AOC) on 06/24/14. The facility implemented the following actions to remove the Immediate Jeopardy: --The Administrator and Director of Nursing (DON) were notified of the medication error on 06/12/14 by Registered Nurse (RN) #1. Advanced Registered Nurse Practitioner (ARNP) #1, Assistant Director of Nursing (ADON) #1, RN #1, and Kentucky Medication Aide (KMA) #1, were all suspended on 06/12/14, pending results of an investigation. The DON initiated an investigation on 06/12/14. The DON reported the medication administration error that occurred on 06/12/14 to the regulatory agency on 06/12/14 to meet state/federal guidelines to ensure reporting requirements were met. The Physician for Resident #1 was notified upon identification of the medication error related to administration of Bactrim on 06/12/14. The Physician instructed facility staff to assess Resident #1 and monitor him/her for any signs and symptoms of allergic reaction. Resident #1 was assessed by facility staff on 06/12/14 for any signs and symptoms of reaction, no concerns were identified. Resident #1, who has a Brief Interview for Mental Status (BIMS) score of 14 was notified of the medication error along with the resident's Power of Attorney (POA) on 06/12/14 by facility staff. --Based on the conclusion the investigation, staff members/the contract consultant involved was disciplined as below: -ARNP #1, ADON #1, and RN #1's employment was terminated from the facility. -KMA #1 received coaching/counseling, completed with restrictions that the KMA received 1:1 training by the Staff Development Coordinator (SDC) to address medication administration, specifically not giving medications that she does not pull herself, checking for allergies, and providing care as outlined in the care plan in relation to medication administration. Furthermore, KMA #1 had to complete a medication pass with a pharmacy field consultant prior to passing any medications upon return to work. She will also complete a weekly medication pass with the Staff Development Coordinator for ongoing continued education/compliance for four weeks. (The facility determined, after reviewing the KMA's 33-year history with the facility as a KMA and having exceptional evaluations and no coaching/counseling during her years of service, that with appropriate education and training she should be allowed to return to work.) --Facility staff was interviewed by the DON, ADONs, Facility Formulary Nurse (FFN), SDC, Minimum Data Set (MDS) Coordinator, and Regional Nurse Consultant on 06/12/14 for any knowledge of these four individuals transcribing or administering any medication in which a resident had an allergy. --Interviews were completed on 06/12/14, with residents which were assessed to have a BIMS score of 8 or greater, by the Social Services Director and Chaplain regarding their knowledge of any medications they were allergic to and may have received. No concerns were identified. --Skin assessments were completed on 06/12/14 by the DON, ADON, MDS Coordinator, or SDC on all residents with a BIMS score less than 8, for any signs or symptoms of allergic reaction. No concerns were identified. --All facility residents' charts were audited, which validated allergy stickers were on the outside of the resident's chart, face sheet, and care plans. The residents' Medication Administration Records (MARs) and Treatment Administration Records (TARs) and the allergy sheet in front of the MARs, along with the Physician and Nurse Practitioner's (NP's) orders since 05/01/14 were audited, for any new medication orders versus resident allergies. These audits were conducted by 06/13/14, by the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, the MDS Coordinators, Social Services Director, Admissions/Marketing or Regional Nurse Consultant to ensure allergies had been appropriately identified and no medications were ordered and/or administered that were listed as an allergy for a resident. No concerns were identified. --Education for facility staff was initiated on 06/12/14 by the SDC, DON, ADONs, or the Nurse Consultant regarding the abuse/neglect policy and appropriate reporting of neglect. The education also included information related to significant medication errors, care plans in regards to following care plans and delivering care as outlined in the care plan, emergency medication kit to include pharmacist approval and allergy verification prior to med removal. Education provided also included medication administration related to the responsibilities and expectations of the nurse related to how the medications were obtained and delivered to meet professional standards requirements. Staff will be monitored during medication pass and will complete questionnaires from training received. Staff was also trained related to the Quality Assurance Performance Improvement process which included reporting of concerns to the Administrator and line staff participation in development of Quality Assurance Performance Improvement (QAPI) plans. Staff will not be permitted to work prior to receiving the education and passing a post-test with a score of 100 percent. All new licensed nurses hired after 06/12/14 will receive the above training. --Follow-up questionnaires will be completed by the Administrator, DON, ADON, MDS Coordinator, Social Services Director, Quality of Life Director, Dietary Manager, Plant Operations Director, or the Environmental Services Manager for five different staff members daily until removal of the immediacy of the Jeopardy. After the immediacy has been removed the questionnaires will be conducted weekly for two weeks, to ensure continued understanding regarding the abuse/neglect policy and procedure, and then the Quality Assurance (QA) Committee will evaluate and determine need of ongoing frequency. --Pharmerica is providing field consultants on-site, starting on 06/16/14 for two days per week for two weeks to provide further education/training on medication administration. The education will include delivery of medications and validation of allergies to meet professional standards. All nurses will complete a med pass with a Pharmerica field consultant. The QA Committee will evaluate and determine the need for services required from the pharmacy field consultant at the end of two weeks. --The facility obtained a contract on 06/16/14 with an external independent clinical consultant to provide services two days per week on-site. This external independent clinical consultant will provide clinical oversight of process and procedures to validate that professional standards are being met until the immediacy is removed. After the immediacy is removed, the QA Committee will evaluate and determine the need for ongoing services required from the external independent clinical consultant. --Upon receiving a new medication order, all new medication orders will be reconciled with the resident's listed allergies by two nurses. The pharmacy will then be contacted to reconcile the new medication with the resident's listed allergies and new medication orders will be signed off by the same two nurses on the Physician order [REDACTED]. The nurse receiving the new medication order will transcribe the order to the MAR and a second nurse will co-sign validating compliance. Prior to administration of newly ordered medications for any resident, the DON, ADONs, SDC or Regional Nurse Consultant will review the above process with the Charge Nurse or certified medication technician to determine compliance to ensure the resident doesn't have an allergy to the medication. This validation process will continue until the immediacy is removed, then daily review for compliance with the above process will continue for four weeks. The findings will be reviewed weekly in the QA meeting to determine the need of the ongoing frequency with new medication monitoring. --Education was provided on 06/12/14, for Licensed Nursing Staff by the SDC or the Regional Nurse Consultant regarding the above stated plan. Licensed Nursing Staff which was not trained on 06/12/14 will not be permitted to work until the above stated education has been received. --All new medication orders were audited and logged onto the administrative nursing monitoring form by the DON, ADONs, SDC, FFN, MDS Coordinator, or Regional Nurse Consultant (three regional nurse consultants have been on-site for 24-hour coverage to ensure all new medication orders have gone through the process outlined below, since the incident which occurred on 06/12/14) every shift (during night shift the Charge Nurse is to call the designated Administrative Nurse or the Regional Nurse Consultant with all new medications) to ensure all new medications orders have been signed off by two nurses. Audits have also included ensuring the pharmacist had been contacted to verify allergies and two nurses have signed off on the transcription of the new medication to the MAR prior to the new medication being administered to the resident. In Addition, the Regional Nurse Consultant, the Special Projects Administrator, Vice President of Operations (VPO), Chief Nursing Executive (CNE), or Chief Operating Officer (COO) will audit all new orders daily to ensure compliance with the process starting on 06/13/14; this process will be continued until the immediacy has been removed. When the immediacy has been removed audits will be conducted twice weekly for four weeks, and at that time the QA Committee will evaluate the need for the continued frequency of monitoring. --The Director of Nursing will conduct daily reviews of the above log sheet for compliance. The Regional Nurse Consultants will validate compliance with the above process daily and the COO, CNE, VPO, or Special Projects Administrator will validate compliance with the above process twice weekly until the removal of the immediacy of the Jeopardy. When the immediacy has been removed, then the DON or ADONs will review daily for four weeks; the Regional Nurse Consultant will review three times a week for four weeks; and the COO, CNE, VPO, or Special Projects Administrator will review weekly for four weeks to ensure that compliance is maintained. The findings will be reported weekly to QA for recommendations and further follow-up as indicated and to determine ongoing frequency of monitoring. --Medication pass audits were completed by the Director of Nursing, Assistant Directors of Nursing, Staff Development Coordinator, MDS Coordinator, FFN, or Regional Nurse Consultant for all nurses and KMAs who had worked on 06/12/14 to ensure proper medication administration technique, proper identification of allergies, that professional standards were being met, and that care plans were being followed. Further medication pass audits were completed for all nurses and KMAs during their initial medication pass by 06/17/14 except four PRN nurses. Certified letters have been mailed to the four PRN licensed nurses to inform them they would not be permitted to work until a medication pass audit was completed with the ADONs or SDC. During the medication pass audit, a questionnaire will be completed by the DON, ADON, FFN, MDS Coordinator, SDC, or Regional Nurse Consultant to ensure their knowledge of where to review for allergies prior to the administration of the medication. --When all nurses have completed a medication pass audit, the DON, ADONs, SDC, FFN, MDS Coordinator, or Regional Nurse Consultant will conduct a medication pass audit with two nurses per day (one nurse per nursing unit) to ensure ongoing proper medication administration technique, proper identification of allergies, that professional standards are being met, and that care plans are being followed until the immediacy has been removed. When the immediacy has been removed, one nurse per day will complete a medication pass audit for two weeks, and then the QA Committee will evaluate and determine the frequency of ongoing medication pass audits. --Administrative oversight of the facility was completed by the Special Projects Administrator, Regional Nurse Consultant, the Regional Vice President of Operations, Chief Nursing Executive, or the Chief Operating Officer daily until removal of the immediacy. After the removal of the immediacy, the oversight will continue weekly for four weeks, then monthly. --Education was provided by the Regional Nurse Consultant on 06/12/14 for the Administrator, DON, ADON, SDC, Quality of Life Director, Social Services Director, Plant Operations Director, Chaplain, Medical Records Coordinator, Dietary Manager, and Admissions Director regarding the Quality Assurance Process and appropriate methods of identification of concerns including significant medication errors, failure to report neglect, auditing pharmacy services, care plans, and professional services. --A Quality Assurance meeting was held on 06/12/14 with the Medical Director for further recommendations regarding the plan for removal of Jeopardy. The Medical Director was involved with creation and approval of the current plan to address the identified areas of concern in regards to appropriate identification of resident allergies. All primary physicians, along with covering physicians, were provided with education/training along with a letter which detailed the facility's QAPI plan, along with appropriate identification of resident allergies prior to new medication prescribing on 06/24/14 by the Regional Nurse Consultant or DON. A Quality Assurance meeting will be held weekly for four weeks, then monthly for recommendations and further follow-up regarding the above stated plan. **The surveyors validated the Immediate Jeopardy was removed as follows: --Interviews conducted with the Administrator and the Director of Nursing (DON) on 06/25/14 revealed Registered Nurse (RN) #1 notified them of the medication error that occurred on 06/12/14 when facility staff had prescribed, obtained, and administered a medication to Resident #1 that had previously been identified as a medication allergy for the resident. Further interviews and review of the facility's investigation confirmed staff members involved with the incident (ARNP #1, ADON #1, RN #1, and KMA #1) were all suspended on 06/12/14, pending results of the investigation. Resident #1's physician was notified, and new orders were received and implemented on 06/12/14, when the medication error was identified by facility staff. Continued review of the investigation revealed Resident #1 was assessed by facility staff on 06/12/14 for any signs and symptoms of reaction and no concerns were identified. Continued review of the investigation revealed Resident #1, who has a BIMS score of 14 was notified, along with the resident's Power of Attorney (POA), of the medication error that occurred on 06/12/14. --Interviews with facility staff and review of the facility's investigation on 06/25/14 revealed the following actions were taken, as a result of the facility's investigation findings: ARNP #1, ADON #1, and RN #1's employment was terminated from the facility. KMA #1 received coaching/counseling and 1:1 training by the Staff Development Coordinator (SDC) which addressed medication administration, specifically not giving medications that she did not pull herself, checking for resident allergies, and providing care as outlined in the care plan in relation to medication administration. Continued interview and a review of the investigation confirmed KMA #1 had completed a medication pass with the facility's Pharmacy Consultant prior to administering any further medications to facility residents. Further interviews revealed KMA #1 would also complete a weekly medication pass with the SDC for ongoing continued education/compliance for four weeks. The facility's investigation findings revealed they had determined, after reviewing the KMA's 33-year work history with the facility, and having exceptional evaluations and no previous disciplinary actions, with appropriate education and training she should be allowed to return to work. --Interviews with staff and further review of the facility's investigation on 06/25/14 revealed the facility staff was interviewed by the DON, ADONs, FFN, SDC, MDS Coordinator, or Regional Nurse Consultant on 06/12/14 for any knowledge of the four individuals identified in the incident transcribing or administering any medication which had been listed as an allergy for any other resident. --Interviews and review of the facility's investigation conducted on 06/25/14 revealed residents who were assessed to have a BIMS score of 8 or greater were interviewed on 06/12/14, by the Social Services Director and Chaplain to determine if medications they had an allergy to had been administered to them while in the facility. The investigation further revealed no concerns were identified. --Interview with the DON and review of the facility's investigation on 06/25/14 confirmed skin assessments were conducted to ensure no allergic reactions had occurred on all facility residents with a BIMS score of 8 or below on 06/12/14. --Review of facility audits and interviews with staff on 06/25/14 revealed all facility residents' charts were audited and staff validated allergy stickers were on the outside of the residents' charts, face sheets, and care plans. Further reviews and interviews with staff conducted on 06/25/14 revealed the residents' Medication Administration Records (MARs) and Treatment Administration Records (TARs), allergy sheets located in front of the residents' MARs, along with physician orders [REDACTED]. Continued review confirmed audits were conducted by 06/13/14, by the DON, ADON, SDC, MDS Coordinators, Social Services Director, Admissions/Marketing, or Regional Nurse Consultant. Interviews conducted on 06/25/14 revealed audits were conducted to ensure allergies had been appropriately identified and no medications were ordered and/or administered that were listed as an allergy for a resident, with no concerns identified. --A review of staff education provided by the facility, initiated on 06/12/14, confirmed the SDC, DON, ADONs, or the Nurse Consultant instructed staff about the facility's abuse/neglect policy and appropriate reporting of neglect. The education review conducted on 06/25/14 also revealed information was included related to significant medication errors, implementation of care plans, emergency medication kit to include pharmacist approval, and allergy verification prior to medication removal. Continued review of the education provided to facility staff also included medication administration and the responsibilities and expectations of the nurse on how the medications were obtained and delivered to meet professional standards requirements. Interviews conducted with facility staff on 06/25/14 confirmed staff was monitored during medication pass and had been required to complete questionnaires related to the training they received. KMA #1 stated in interview on 06/25/14 that she received training related to the Quality Assurance Performance Improvement (QAPI) process which included reporting of concerns to the Administrator and line staff participation in development of QAPI plans. Interview with the Regional Nurse Consultant and the DON on 06/25/14 revealed staff was not permitted to work until they were educated and completed a post-test with a score of 100 percent. Interview with the DON on 06/25/14 revealed all new licensed nurses hired after 06/12/14 will receive the above training during their orientation. --Interviews with the Regional Nurse Consultant on 06/25/14 confirmed follow-up questionnaires were completed by the Administrator, DON, ADON, MDS Coordinator, Social Services Director, Quality of Life Director, Dietary Manager, Plant Operations Director, or the Environmental Services Manager for five different staff members daily. The Nurse Consultant further stated after the immediacy had been removed the questionnaires would be conducted weekly for two weeks to ensure continued understanding regarding the abuse/neglect policy and procedure, and the QA Committee would evaluate further the need for the questionnaires. --Review of Medication Pass audits conducted, and an interview with the Regional Nurse Consultant on 06/25/14, revealed the facility's Pharmacy had provided Field Consultants on-site, which started on 06/16/14, for two days per week for a total of two weeks. He stated the pharmacy service was to provide further education/training on medication administration. The education would include delivery of medications and validation of the residents' allergies to meet professional standards. The Consultant stated all nurses would complete a medication pass with a Pharmacy Field Consultant and the QA Committee would evaluate and determine the continued need for services required from the Pharmacy Field Consultant at the end of two weeks. --Interview with the DON and the Administrator on 06/25/14 confirmed the facility had obtained a contract on 06/16/14 with an external Independent Clinical Consultant to provide services two days per week on-site. The Administrator stated the external Independent Clinical Consultant would provide clinical oversight of processes and procedures to validate those professional standards were met until the immediacy was removed. After the immediacy was removed, the Administrator stated the QA Committee would evaluate and determine the need for services required from an external Independent Clinical Consultant. --Interviews with KMA #1 on 06/17/14 at 1:00 PM and Administrative staff on 06/25/14 confirmed training was initiated on 06/12/14 and included guidance on what staff was required to do when a new medication order was received. Allergies were to be validated and all new medication orders were to be reconciled and transcribed onto the resident's MAR by two nurses. Continued interview confirmed the pharmacy would be contacted to reconcile new medications, with the resident's listed allergies. Continued review of trainings and interviews with KMA #1 on 06/17/14 at 1:00 PM, the DON on 06/18/14 at 11:30 AM, and the Administrator on 06/18/14 at 4:00 PM confirmed new medication orders would be signed off by the two nurses that validated reconciliation of new medications to the resident's listed allergies. The nurse receiving the new medication order would transcribe the order to the MAR and a second nurse would co-sign which would validate compliance. Continued interview revealed staff was required to contact the DON, ADONs, SDC, or Regional Nurse Consultant, before any new medication was administered for any resident, to validate all required checks had been completed. Continued interviews on 06/25/14 revealed this validation process would continue until the immediacy was removed. The Regional Nurse Consultant stated on 06/25/14 at 1:00 PM the validation process would be reviewed daily for compliance and would be continued for four weeks. The Nurse Consultant further stated the findings would be reviewed weekly in the QA meeting to determine the need of ongoing frequency with new medication monitoring. --Interview with the DON and the Nurse Consultant on 06/25/14 revealed Licensed Nursing Staff that had not received the training on 06/12/14 would not be permitted to work until the above stated education has been received. --A review of facility audits and interviews with Administrative staff on 06/25/14 revealed all new medication orders were audited and logged onto the administrative nursing monitoring form by the DON, ADONs, SDC, FFN, MDS Coordinator, or Regional Nurse Consultant. Continued interview revealed three Regional Nurse Consultants had been on-site 24 hours a day since the incident occurred on 06/12/14 to ensure staff had validated all new medication orders. The Regional Nurse Consultant stated during night shift the Charge Nurse was required to call the designated Administrative Nurse or Regional Nurse Consultant with all new medication orders, to ensure all new orders had been signed off by two nurses as required. Continued interview on 06/25/14 confirmed facility audits included ensuring the pharmacist had been contacted to verify allergies, and that two nurses had signed off on the transcription of the new medication to the MAR prior to the administration of any new medications to the residents. Continued interview revealed the Regional Nurse Consultant, Special Projects Administrator, VPO, CNE, or COO would audit all new orders daily to ensure compliance with the process starting on 06/13/14 and would continue to audit the orders until the immediacy had been removed. The Nurse Consultant stated when immediacy had been removed audits would be conducted twice weekly for four weeks, and then the QA Committee would evaluate the need for continued frequency of monitoring. --The Director of Nursing stated on 06/25/14 at 3:25 PM she had conducted daily reviews of the medication audit log sheets for compliance. The Regional Nurse Consultant stated on 06/25/14 that he had validated compliance with the above process daily and the COO, CNE, VPO, or the Special Projects Administrator had validated compliance with the above process, twice weekly, until removal of the immediacy. The DON stated when the immediacy had been removed, then she or the ADONs would review the log sheets daily for four weeks, the Regional Nurse Consultant would review the log sheets three times a week for four weeks, and the COO, CNE, VPO, or the Special Projects Administrator would review the log sheets weekly for four weeks to ensure th

Based on interview, record review, a review of the facility's investigation, and a review of the facility's policy, "Performance Improvement with Abaqis," it was determined the facility failed to maintain a Quality Assessment and Assurance Committee to develop and implement appropriate plans of action to correct identified quality deficiencies related to ensuring facility residents were free from significant medication errors for one (1) of four (4) sampled residents (Resident #1). Interviews with facility staff revealed Quality Assurance (QA) audits were conducted every morning during the daily clinical meeting to ensure facility residents were not allergic to any newly prescribed medications. Continued interviews revealed Assistant Director of Nursing (ADON) #1 was responsible to conduct QA audits daily and to ensure residents remained free from significant medication errors. Interviews and record reviews revealed on 06/12/14 at approximately 12:00 PM, Advanced Registered Nurse Practitioner (ARNP) #1 prescribed 800 milligrams (mg) of Bactrim for Resident #1 due to a laboratory report of an abnormal urinalysis. The ARNP failed to review the resident's allergies. Assistant Director of Nursing (ADON) #1 transcribed the order for Bactrim onto Resident #1's Medication Administration Record on 06/12/14. The ADON failed to verify the resident's medication allergies. Registered Nurse (RN) #1 obtained the Bactrim from the facility's Emergency Drug Kit (EDK) for Resident #1. RN #1 failed to review the resident's allergies. RN #1 instructed Kentucky Medication Aide (KMA) #1 to administer the medication to Resident #1. KMA #1 administered the Bactrim to Resident #1. KMA #1 failed to review Resident #1's drug allergies before the medication was administered on 06/12/14 at approximately 12:00 PM. (Refer to F281, F282, F333, and F490.) The facility's failure to maintain a quality assessment and assurance committee to develop and implement appropriate plans of action to correct identified quality deficiencies related to ensuring facility residents were free from significant medication errors caused or was likely to cause, serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy with Substandard Quality of Care was determined to exist on 06/12/14 at 42 CFR 483.20 Resident Assessment (F281 and F282), 42 CFR 483.25 Quality of Care (F333), and 42 CFR 483.75 Administration (F490 and F520) at a scope and severity of "J." Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care (F333). The facility was notified of the Immediate Jeopardy on 06/18/14. An acceptable Allegation of Compliance was received on 06/24/14, which alleged removal of the Immediate Jeopardy on 06/25/14. The State Agency determined the Immediate Jeopardy was removed on 06/25/14, prior to exit, which lowered the scope and severity to "D" at 42 CFR 483.20 Resident Assessment (F281 and F282), 42 CFR 483.25 Quality of Care (F333), and 42 CFR 483.75 Administration (F490 and F520) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: A review of the facility's policy titled "Performance Improvement with Abaqis" (PI) dated 2012, revealed the facility would conduct an ongoing performance improvement program designed to systematically monitor, evaluate, and improve the quality of resident care. An interview conducted with Assistant Director of Nursing (ADON) #1 on 06/17/14 at 1:30 PM revealed he conducted daily audits of all new medication orders during the facility's Daily Standup Meetings. The ADON stated the meetings were conducted Monday through Friday to ensure residents remained free from significant medication errors. The ADON acknowledged he transcribed the medication order for Bactrim for Resident #1 on 06/12/14, which was later identified to be listed as an allergy for the resident. The ADON stated he had been trained to verify allergies; however, he failed to verify the resident's allergies when he transcribed the order for Bactrim for Resident #1 on 06/12/14. An interview with the Director of Nursing (DON) on 06/18/14 at 11:30 AM revealed audits were conducted daily on all new medication orders for facility residents to ensure residents were free from significant medication errors. She further stated ARNP #1, ADON #1, RN #1, and KMA #1 had been trained and should have verified Resident #1's medication allergies before the Bactrim was prescribed, transcribed, and administered to the resident on 06/12/14. The DON stated the QA audits would have identified the medication error the next day, during the daily meeting. An interview with the Administrator on 06/18/14 at 4:00 PM confirmed staff was conducting daily audits to ensure residents were free from significant medication errors. The Administrator further stated Resident #1's allergy to Bactrim should have been verified before the medication was prescribed, transcribed, or administered on 06/12/14. The facility failed to maintain a Quality Assessment and Assurance Committee that developed and implemented appropriate plans of action to correct identified quality deficiencies related to ensuring facility residents were free from significant medication. **The facility provided an acceptable Allegation of Compliance (AOC) on 06/24/14. The facility implemented the following actions to remove the Immediate Jeopardy: --The Administrator and Director of Nursing (DON) were notified of the medication error on 06/12/14 by Registered Nurse (RN) #1. Advanced Registered Nurse Practitioner (ARNP) #1, Assistant Director of Nursing (ADON) #1, RN #1, and Kentucky Medication Aide (KMA) #1, were all suspended on 06/12/14, pending results of an investigation. The DON initiated an investigation on 06/12/14. The DON reported the medication administration error that occurred on 06/12/14 to the regulatory agency on 06/12/14 to meet state/federal guidelines to ensure reporting requirements were met. The Physician for Resident #1 was notified upon identification of the medication error related to administration of Bactrim on 06/12/14. The Physician instructed facility staff to assess Resident #1 and monitor him/her for any signs and symptoms of allergic reaction. Resident #1 was assessed by facility staff on 06/12/14 for any signs and symptoms of reaction, no concerns were identified. Resident #1, who has a Brief Interview for Mental Status (BIMS) score of 14 was notified of the medication error along with the resident's Power of Attorney (POA) on 06/12/14 by facility staff. --Based on the conclusion the investigation, staff members/the contract consultant involved was disciplined as below: -ARNP #1, ADON #1, and RN #1's employment was terminated from the facility. -KMA #1 received coaching/counseling, completed with restrictions that the KMA received 1:1 training by the Staff Development Coordinator (SDC) to address medication administration, specifically not giving medications that she does not pull herself, checking for allergies, and providing care as outlined in the care plan in relation to medication administration. Furthermore, KMA #1 had to complete a medication pass with a pharmacy field consultant prior to passing any medications upon return to work. She will also complete a weekly medication pass with the Staff Development Coordinator for ongoing continued education/compliance for four weeks. (The facility determined, after reviewing the KMA's 33-year history with the facility as a KMA and having exceptional evaluations and no coaching/counseling during her years of service, that with appropriate education and training she should be allowed to return to work.) --Facility staff was interviewed by the DON, ADONs, Facility Formulary Nurse (FFN), SDC, Minimum Data Set (MDS) Coordinator, and Regional Nurse Consultant on 06/12/14 for any knowledge of these four individuals transcribing or administering any medication in which a resident had an allergy. --Interviews were completed on 06/12/14, with residents which were assessed to have a BIMS score of 8 or greater, by the Social Services Director and Chaplain regarding their knowledge of any medications they were allergic to and may have received. No concerns were identified. --Skin assessments were completed on 06/12/14 by the DON, ADON, MDS Coordinator, or SDC on all residents with a BIMS score less than 8, for any signs or symptoms of allergic reaction. No concerns were identified. --All facility residents' charts were audited, which validated allergy stickers were on the outside of the resident's chart, face sheet, and care plans. The residents' Medication Administration Records (MARs) and Treatment Administration Records (TARs) and the allergy sheet in front of the MARs, along with the Physician and Nurse Practitioner's (NP's) orders since 05/01/14 were audited, for any new medication orders versus resident allergies. These audits were conducted by 06/13/14, by the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, the MDS Coordinators, Social Services Director, Admissions/Marketing or Regional Nurse Consultant to ensure allergies had been appropriately identified and no medications were ordered and/or administered that were listed as an allergy for a resident. No concerns were identified. --Education for facility staff was initiated on 06/12/14 by the SDC, DON, ADONs, or the Nurse Consultant regarding the abuse/neglect policy and appropriate reporting of neglect. The education also included information related to significant medication errors, care plans in regards to following care plans and delivering care as outlined in the care plan, emergency medication kit to include pharmacist approval and allergy verification prior to med removal. Education provided also included medication administration related to the responsibilities and expectations of the nurse related to how the medications were obtained and delivered to meet professional standards requirements. Staff will be monitored during medication pass and will complete questionnaires from training received. Staff was also trained related to the Quality Assurance Performance Improvement process which included reporting of concerns to the Administrator and line staff participation in development of Quality Assurance Performance Improvement (QAPI) plans. Staff will not be permitted to work prior to receiving the education and passing a post-test with a score of 100 percent. All new licensed nurses hired after 06/12/14 will receive the above training. --Follow-up questionnaires will be completed by the Administrator, DON, ADON, MDS Coordinator, Social Services Director, Quality of Life Director, Dietary Manager, Plant Operations Director, or the Environmental Services Manager for five different staff members daily until removal of the immediacy of the Jeopardy. After the immediacy has been removed the questionnaires will be conducted weekly for two weeks, to ensure continued understanding regarding the abuse/neglect policy and procedure, and then the Quality Assurance (QA) Committee will evaluate and determine need of ongoing frequency. --Pharmerica is providing field consultants on-site, starting on 06/16/14 for two days per week for two weeks to provide further education/training on medication administration. The education will include delivery of medications and validation of allergies to meet professional standards. All nurses will complete a med pass with a Pharmerica field consultant. The QA Committee will evaluate and determine the need for services required from the pharmacy field consultant at the end of two weeks. --The facility obtained a contract on 06/16/14 with an external independent clinical consultant to provide services two days per week on-site. This external independent clinical consultant will provide clinical oversight of process and procedures to validate that professional standards are being met until the immediacy is removed. After the immediacy is removed, the QA Committee will evaluate and determine the need for ongoing services required from the external independent clinical consultant. --Upon receiving a new medication order, all new medication orders will be reconciled with the resident's listed allergies by two nurses. The pharmacy will then be contacted to reconcile the new medication with the resident's listed allergies and new medication orders will be signed off by the same two nurses on the Physician order [REDACTED]. The nurse receiving the new medication order will transcribe the order to the MAR and a second nurse will co-sign validating compliance. Prior to administration of newly ordered medications for any resident, the DON, ADONs, SDC or Regional Nurse Consultant will review the above process with the Charge Nurse or certified medication technician to determine compliance to ensure the resident doesn't have an allergy to the medication. This validation process will continue until the immediacy is removed, then daily review for compliance with the above process will continue for four weeks. The findings will be reviewed weekly in the QA meeting to determine the need of the ongoing frequency with new medication monitoring. --Education was provided on 06/12/14, for Licensed Nursing Staff by the SDC or the Regional Nurse Consultant regarding the above stated plan. Licensed Nursing Staff which was not trained on 06/12/14 will not be permitted to work until the above stated education has been received. --All new medication orders were audited and logged onto the administrative nursing monitoring form by the DON, ADONs, SDC, FFN, MDS Coordinator, or Regional Nurse Consultant (three regional nurse consultants have been on-site for 24-hour coverage to ensure all new medication orders have gone through the process outlined below, since the incident which occurred on 06/12/14) every shift (during night shift the Charge Nurse is to call the designated Administrative Nurse or the Regional Nurse Consultant with all new medications) to ensure all new medications orders have been signed off by two nurses. Audits have also included ensuring the pharmacist had been contacted to verify allergies and two nurses have signed off on the transcription of the new medication to the MAR prior to the new medication being administered to the resident. In Addition, the Regional Nurse Consultant, the Special Projects Administrator, Vice President of Operations (VPO), Chief Nursing Executive (CNE), or Chief Operating Officer (COO) will audit all new orders daily to ensure compliance with the process starting on 06/13/14; this process will be continued until the immediacy has been removed. When the immediacy has been removed audits will be conducted twice weekly for four weeks, and at that time the QA Committee will evaluate the need for the continued frequency of monitoring. --The Director of Nursing will conduct daily reviews of the above log sheet for compliance. The Regional Nurse Consultants will validate compliance with the above process daily and the COO, CNE, VPO, or Special Projects Administrator will validate compliance with the above process twice weekly until the removal of the immediacy of the Jeopardy. When the immediacy has been removed, then the DON or ADONs will review daily for four weeks; the Regional Nurse Consultant will review three times a week for four weeks; and the COO, CNE, VPO, or Special Projects Administrator will review weekly for four weeks to ensure that compliance is maintained. The findings will be reported weekly to QA for recommendations and further follow-up as indicated and to determine ongoing frequency of monitoring. --Medication pass audits were completed by the Director of Nursing, Assistant Directors of Nursing, Staff Development Coordinator, MDS Coordinator, FFN, or Regional Nurse Consultant for all nurses and KMAs who had worked on 06/12/14 to ensure proper medication administration technique, proper identification of allergies, that professional standards were being met, and that care plans were being followed. Further medication pass audits were completed for all nurses and KMAs during their initial medication pass by 06/17/14 except four PRN nurses. Certified letters have been mailed to the four PRN licensed nurses to inform them they would not be permitted to work until a medication pass audit was completed with the ADONs or SDC. During the medication pass audit, a questionnaire will be completed by the DON, ADON, FFN, MDS Coordinator, SDC, or Regional Nurse Consultant to ensure their knowledge of where to review for allergies prior to the administration of the medication. --When all nurses have completed a medication pass audit, the DON, ADONs, SDC, FFN, MDS Coordinator, or Regional Nurse Consultant will conduct a medication pass audit with two nurses per day (one nurse per nursing unit) to ensure ongoing proper medication administration technique, proper identification of allergies, that professional standards are being met, and that care plans are being followed until the immediacy has been removed. When the immediacy has been removed, one nurse per day will complete a medication pass audit for two weeks, and then the QA Committee will evaluate and determine the frequency of ongoing medication pass audits. --Administrative oversight of the facility was completed by the Special Projects Administrator, Regional Nurse Consultant, the Regional Vice President of Operations, Chief Nursing Executive, or the Chief Operating Officer daily until removal of the immediacy. After the removal of the immediacy, the oversight will continue weekly for four weeks, then monthly. --Education was provided by the Regional Nurse Consultant on 06/12/14 for the Administrator, DON, ADON, SDC, Quality of Life Director, Social Services Director, Plant Operations Director, Chaplain, Medical Records Coordinator, Dietary Manager, and Admissions Director regarding the Quality Assurance Process and appropriate methods of identification of concerns including significant medication errors, failure to report neglect, auditing pharmacy services, care plans, and professional services. --A Quality Assurance meeting was held on 06/12/14 with the Medical Director for further recommendations regarding the plan for removal of Jeopardy. The Medical Director was involved with creation and approval of the current plan to address the identified areas of concern in regards to appropriate identification of resident allergies. All primary physicians, along with covering physicians, were provided with education/training along with a letter which detailed the facility's QAPI plan, along with appropriate identification of resident allergies prior to new medication prescribing on 06/24/14 by the Regional Nurse Consultant or DON. A Quality Assurance meeting will be held weekly for four weeks, then monthly for recommendations and further follow-up regarding the above stated plan. **The surveyors validated the Immediate Jeopardy was removed as follows: --Interviews conducted with the Administrator and the Director of Nursing (DON) on 06/25/14 revealed Registered Nurse (RN) #1 notified them of the medication error that occurred on 06/12/14 when facility staff had prescribed, obtained, and administered a medication to Resident #1 that had previously been identified as a medication allergy for the resident. Further interviews and review of the facility's investigation confirmed staff members involved with the incident (ARNP #1, ADON #1, RN #1, and KMA #1) were all suspended on 06/12/14, pending results of the investigation. Resident #1's physician was notified, and new orders were received and implemented on 06/12/14, when the medication error was identified by facility staff. Continued review of the investigation revealed Resident #1 was assessed by facility staff on 06/12/14 for any signs and symptoms of reaction and no concerns were identified. Continued review of the investigation revealed Resident #1, who has a BIMS score of 14 was notified, along with the resident's Power of Attorney (POA), of the medication error that occurred on 06/12/14. --Interviews with facility staff and review of the facility's investigation on 06/25/14 revealed the following actions were taken, as a result of the facility's investigation findings: ARNP #1, ADON #1, and RN #1's employment was terminated from the facility. KMA #1 received coaching/counseling and 1:1 training by the Staff Development Coordinator (SDC) which addressed medication administration, specifically not giving medications that she did not pull herself, checking for resident allergies, and providing care as outlined in the care plan in relation to medication administration. Continued interview and a review of the investigation confirmed KMA #1 had completed a medication pass with the facility's Pharmacy Consultant prior to administering any further medications to facility residents. Further interviews revealed KMA #1 would also complete a weekly medication pass with the SDC for ongoing continued education/compliance for four weeks. The facility's investigation findings revealed they had determined, after reviewing the KMA's 33-year work history with the facility, and having exceptional evaluations and no previous disciplinary actions, with appropriate education and training she should be allowed to return to work. --Interviews with staff and further review of the facility's investigation on 06/25/14 revealed the facility staff was interviewed by the DON, ADONs, FFN, SDC, MDS Coordinator, or Regional Nurse Consultant on 06/12/14 for any knowledge of the four individuals identified in the incident transcribing or administering any medication which had been listed as an allergy for any other resident. --Interviews and review of the facility's investigation conducted on 06/25/14 revealed residents who were assessed to have a BIMS score of 8 or greater were interviewed on 06/12/14, by the Social Services Director and Chaplain to determine if medications they had an allergy to had been administered to them while in the facility. The investigation further revealed no concerns were identified. --Interview with the DON and review of the facility's investigation on 06/25/14 confirmed skin assessments were conducted to ensure no allergic reactions had occurred on all facility residents with a BIMS score of 8 or below on 06/12/14. --Review of facility audits and interviews with staff on 06/25/14 revealed all facility residents' charts were audited and staff validated allergy stickers were on the outside of the residents' charts, face sheets, and care plans. Further reviews and interviews with staff conducted on 06/25/14 revealed the residents' Medication Administration Records (MARs) and Treatment Administration Records (TARs), allergy sheets located in front of the residents' MARs, along with physician orders [REDACTED]. Continued review confirmed audits were conducted by 06/13/14, by the DON, ADON, SDC, MDS Coordinators, Social Services Director, Admissions/Marketing, or Regional Nurse Consultant. Interviews conducted on 06/25/14 revealed audits were conducted to ensure allergies had been appropriately identified and no medications were ordered and/or administered that were listed as an allergy for a resident, with no concerns identified. --A review of staff education provided by the facility, initiated on 06/12/14, confirmed the SDC, DON, ADONs, or the Nurse Consultant instructed staff about the facility's abuse/neglect policy and appropriate reporting of neglect. The education review conducted on 06/25/14 also revealed information was included related to significant medication errors, implementation of care plans, emergency medication kit to include pharmacist approval, and allergy verification prior to medication removal. Continued review of the education provided to facility staff also included medication administration and the responsibilities and expectations of the nurse on how the medications were obtained and delivered to meet professional standards requirements. Interviews conducted with facility staff on 06/25/14 confirmed staff was monitored during medication pass and had been required to complete questionnaires related to the training they received. KMA #1 stated in interview on 06/25/14 that she received training related to the Quality Assurance Performance Improvement (QAPI) process which included reporting of concerns to the Administrator and line staff participation in development of QAPI plans. Interview with the Regional Nurse Consultant and the DON on 06/25/14 revealed staff was not permitted to work until they were educated and completed a post-test with a score of 100 percent. Interview with the DON on 06/25/14 revealed all new licensed nurses hired after 06/12/14 will receive the above training during their orientation. --Interviews with the Regional Nurse Consultant on 06/25/14 confirmed follow-up questionnaires were completed by the Administrator, DON, ADON, MDS Coordinator, Social Services Director, Quality of Life Director, Dietary Manager, Plant Operations Director, or the Environmental Services Manager for five different staff members daily. The Nurse Consultant further stated after the immediacy had been removed the questionnaires would be conducted weekly for two weeks to ensure continued understanding regarding the abuse/neglect policy and procedure, and the QA Committee would evaluate further the need for the questionnaires. --Review of Medication Pass audits conducted, and an interview with the Regional Nurse Consultant on 06/25/14, revealed the facility's Pharmacy had provided Field Consultants on-site, which started on 06/16/14, for two days per week for a total of two weeks. He stated the pharmacy service was to provide further education/training on medication administration. The education would include delivery of medications and validation of the residents' allergies to meet professional standards. The Consultant stated all nurses would complete a medication pass with a Pharmacy Field Consultant and the QA Committee would evaluate and determine the continued need for services required from the Pharmacy Field Consultant at the end of two weeks. --Interview with the DON and the Administrator on 06/25/14 confirmed the facility had obtained a contract on 06/16/14 with an external Independent Clinical Consultant to provide services two days per week on-site. The Administrator stated the external Independent Clinical Consultant would provide clinical oversight of processes and procedures to validate those professional standards were met until the immediacy was removed. After the immediacy was removed, the Administrator stated the QA Committee would evaluate and determine the need for services required from an external Independent Clinical Consultant. --Interviews with KMA #1 on 06/17/14 at 1:00 PM and Administrative staff on 06/25/14 confirmed training was initiated on 06/12/14 and included guidance on what staff was required to do when a new medication order was received. Allergies were to be validated and all new medication orders were to be reconciled and transcribed onto the resident's MAR by two nurses. Continued interview confirmed the pharmacy would be contacted to reconcile new medications, with the resident's listed allergies. Continued review of trainings and interviews with KMA #1 on 06/17/14 at 1:00 PM, the DON on 06/18/14 at 11:30 AM, and the Administrator on 06/18/14 at 4:00 PM confirmed new medication orders would be signed off by the two nurses that validated reconciliation of new medications to the resident's listed allergies. The nurse receiving the new medication order would transcribe the order to the MAR and a second nurse would co-sign which would validate compliance. Continued interview revealed staff was required to contact the DON, ADONs, SDC, or Regional Nurse Consultant, before any new medication was administered for any resident, to validate all required checks had been completed. Continued interviews on 06/25/14 revealed this validation process would continue until the immediacy was removed. The Regional Nurse Consultant stated on 06/25/14 at 1:00 PM the validation process would be reviewed daily for compliance and would be continued for four weeks. The Nurse Consultant further stated the findings would be reviewed weekly in the QA meeting to determine the need of ongoing frequency with new medication monitoring. --Interview with the DON and the Nurse Consultant on 06/25/14 revealed Licensed Nursing Staff that had not received the training on 06/12/14 would not be permitted to work until the above stated education has been received. --A review of facility audits and interviews with Administrative staff on 06/25/14 revealed all new medication orders were audited and logged onto the administrative nursing monitoring form by the DON, ADONs, SDC, FFN, MDS Coordinator, or Regional Nurse Consultant. Continued interview revealed three Regional Nurse Consultants had been on-site 24 hours a day since the incident occurred on 06/12/14 to ensure staff had validated all new medication orders. The Regional Nurse Consultant stated during night shift the Charge Nurse was required to call the designated Administrative Nurse or Regional Nurse Consultant with all new medication orders, to ensure all new orders had been signed off by two nurses as required. Continued interview on 06/25/14 confirmed facility audits included ensuring the pharmacist had been contacted to verify allergies, and that two nurses had signed off on the transcription of the new medication to the MAR prior to the administration of any new medications to the residents. Continued interview revealed the Regional Nurse Consultant, Special Projects Administrator, VPO, CNE, or COO would audit all new orders daily to ensure compliance with the process starting on 06/13/14 and would continue to audit the orders until the immediacy had been removed. The Nurse Consultant stated when immediacy had been removed audits would be conducted twice weekly for four weeks, and then the QA Committee would evaluate the need for continued frequency of monitoring. --The Director of Nursing stated on 06/25/14 at 3:25 PM she had conducted daily reviews of the medication audit log sheets for compliance. The Regional Nurse Consultant stated on 06/25/14 that he had validated compliance with the above process daily and the COO, CNE, VPO, or the Special Projects Administrator had validated compliance with the above process, twice weekly, until removal of the immediacy. The DON stated when the immediacy had been removed, then she or the ADONs would review the log sheets daily for four weeks, the Regional Nurse Consultant would review the log sheets three times a week for four weeks, and the COO, CNE, VPO, or the Special Projects Administrator would review the log sheets weekly for four weeks to ensure that compliance has been maintained. The DON further stated the findings would be reported weekly to the QA Committee for recommendations and further follow-up as indicated and to determine ongoing frequency of monitoring. Interviews with the Administrator on 06/25/14 at 3:00 PM and review of the facility's audits on 06/25/14 revealed medication pass audits were completed by the DON, ADON, SDC, MDS Coordinator, FFN, or Regional Nurse Consultant for all nurses and KMAs that had worked on 06/12/14. Continued review of the audits revealed the audits ensured proper medication administration technique, proper identification of allergies, that professional standards were met, and that care plans were followed. Further review and interview revealed by 06/17/14 medication pass audits had been completed for the KMAs and all but four nurses (who worked on a PRN basis) during their initial medication pass. The Regional Nurse Consultant stated certified letters had been mailed to the four PRN licensed nurses to inform them they would not be permitted to work until a medication pass audit had been completed by the ADONs or SDC. During the medication pass audit, a questionnaire was completed by the DON, ADON, FFN, MDS Coordinator, SDC, or Regional Nurse Consultant to ensure their knowledge of where to review for allergies prior to the administration of medication. --Interview with t

Based on interview, record review, and review of the facility's performance improvement plan, "Performance Improvement with Abaqis," dated 2012, and the "Abuse, Neglect and Misappropriation" policy dated April 2013, it was determined the facility failed to maintain a Quality Assessment and Assurance Committee to develop and implement appropriate plans of action to correct identified quality deficiencies for one (1) of three (3) sampled residents (Resident #32). On 05/25/14, staff observed bruising to Resident #32's arm and the resident made an allegation that "fat Pat" (identified by the facility as SRNA #2) "grabbed" his/her arm. Interview and record review revealed Administrative staff and the Quality Assurance Committee failed to ensure the allegations of abuse were reported immediately to State Agencies, failed to ensure residents were protected from further potential abuse while an investigation was conducted, and failed to ensure investigations of allegations included resident and staff interviews and assessment of other residents for signs of abuse and neglect. The facility failed to recognize that their established abuse policy for reporting abuse was not effective and therefore failed to implement any corrective actions to correct these problems. (Refer to F225, F226, and F490.) The facility's failure to ensure their Quality Assessment and Assurance Committee developed and implemented appropriate plans of action related to abuse prevention caused, or was likely to cause, serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy was determined to exist on 05/24/14 at 42 CFR 483.13 Resident Behavior and Facility Practices (F225 and F226) and 42 CFR 483.75 Administration (F490 and F520) with Substandard Quality of Care at 42 CFR 483.13 Resident Behavior and Facility Practices (F225 and F226). The facility was notified of the Immediate Jeopardy on 05/29/14. An acceptable Allegation of Compliance was received on 06/02/14 which alleged removal of the Immediate Jeopardy on 05/31/14. A partial extended survey was conducted on 06/03/14 through 06/04/14. The State Survey Agency determined the Immediate Jeopardy was removed on 05/31/14 as alleged, which lowered the scope and severity to "D" at 42 CFR 483.13 Resident Behavior and Facility Practices (F225 and F226) and "D" at 42 CFR 483.75 Administration (F490 and F520) while the facility monitors the effectiveness of systemic changes and quality assurance activities. (Refer to F225, F226, and F490). The findings include: Review of the facility's policy titled "Abuse, Neglect and Misappropriation," dated April 2013 revealed facility staff would report and investigate all allegations of verbal, sexual, physical, and mental abuse, corporal punishment, neglect, and involuntary seclusion of the resident and resident exploitation as well as misappropriation of resident property. According to the policy, all allegations would be reported immediately to the Administrator and other officials as required and the alleged staff would be immediately removed from the care of all residents. In addition, the policy revealed the Administrator/designee would make reasonable efforts to investigate and address alleged reports, concerns, and grievances. Review of the facility's performance improvement plan titled, "Performance Improvement with Abaqis," dated 2012, revealed the facility would conduct an ongoing performance improvement program designed to systematically monitor, evaluate, and improve the quality of resident care. The plan further stated the facility's Performance Improvement (PI) process was to be incorporated into the ongoing weekly clinical processes and was to ensure immediate concerns identified were promptly investigated, which included allegations of abuse. Review of incident reports and interviews revealed staff observed bruising to Resident #32's arm on 05/25/14 and the resident reported "fat Pat" (identified by the facility as SRNA #2) "grabbed" his/her arm. Review of the Daily Standup Meeting documentation dated 05/26/14, revealed the observation of Resident #32's bruised arm and the allegation made by the resident were discussed in the meeting. Interview conducted with the Staff Development Coordinator (SDC) on 05/29/14 at 4:37 PM, revealed Quality Assurance (QA)/Standup meetings were conducted Monday through Friday. The SDC further stated she had attended the meeting on 05/26/14, and stated Resident #32's bruises and the statement made by Resident #32 had been discussed. However, the SDC stated the incident and the resident's statement had not been "discussed as an allegation of abuse" and the QA Committee had not recommended any actions to address the resident's report. An interview conducted with Assistant Director of Nursing (ADON) #1 on 05/29/14 at 5:31 PM revealed the facility's "quality concerns" were discussed during the Daily Standup Meetings, which were conducted Monday through Friday. ADON #1 confirmed Resident #32's statement that the SRNA had "grabbed" his/her arm and the bruises to the resident's arm had been discussed in the meeting with members of the QA Committee on 05/26/14. The ADON further stated the incident had been reported to the DON and the Administrator, who were responsible for conducting abuse investigations. Therefore, he "felt like it had been addressed." ADON #1 further stated no other actions were recommended by members of the QA Committee when the incident was discussed on 05/26/14. An interview with the Director of Nursing (DON) on 05/29/14 at 6:06 PM revealed the facility's Daily Standup Meetings were conducted Monday through Friday and were part of the facility's Quality Assurance Program. The DON further stated the incident and actions which had been taken related to the bruises to Resident #32's arm, along with the resident's statement that the SRNA had grabbed his/her arm, were discussed with members of the QA Committee during the Daily Standup Meeting on 05/26/14. However, the DON stated the incident was not identified to be an allegation of abuse, and the QA Committee had not recommended any actions to be taken. An interview conducted with the Administrator on 05/29/14 at 6:17 PM confirmed that the facility had Daily Standup Meetings that were utilized as part of the facility's QA process and that facility concerns were discussed as a committee. The Administrator stated he had not attended the QA/Daily Standup Meeting on 05/26/14, when the incident related to the bruises observed on Resident #32's arm and the resident's allegation related to SRNA #2 had been discussed with members of the QA Committee. The Administrator stated he would have expected the facility's QA Committee to have determined the resident's report was an allegation of abuse. He stated facility staff should have reported and investigated the report in accordance with the facility's policy. **The facility provided an acceptable Allegation of Compliance (AOC) on 06/02/14. The facility implemented the following actions to remove the Immediate Jeopardy: --The allegation of abuse reported by Resident #32 was reported to the Office of Inspector General (OIG) on 05/27/14 by the DON. Resident #32 has a BIMS score greater than 8 and a statement was obtained on 05/25/14. The alleged perpetrator was suspended on 05/25/14. The facility's investigation was initiated and ongoing with a five-day report to be submitted to OIG on 05/30/14. All residents were assessed for any signs and symptoms of abuse/neglect. Those residents with BIMS scores greater than 8 were interviewed by the Social Services Director or Chaplain for any abuse/neglect concerns on 05/29/14. On 05/29/14, the Assistant Directors of Nursing (ADONs) assessed the physical status of residents with BIMS scores less than 8 for any signs and symptoms of abuse/neglect. The facility attempted to contact the 41 Power of Attorneys (POAs) for the residents with a BIMS score less than 8 to ask if they had any concerns related to abuse/neglect and successfully contacted 26; the Social Services Director, the Chaplain, the DON, and/or the Administrator will continue to attempt to contact the remaining 15 POAs until all have successfully been contacted. --The allegation of abuse related to Resident #33 that occurred on 05/24/14 was reported to OIG on 05/29/14 by the DON and reported to Adult Protective Services (APS), the Ombudsman, the resident's physician, and the POA on 05/30/14 by the DON. A facility nurse assessed Resident #33 on 05/29/14 and the resident had a psychosocial assessment completed by the Social Services Director on 05/30/14. Resident #33 was interviewed and a statement was obtained by the facility's Social Services Director on 05/30/14. The alleged perpetrator was no longer employed by the facility. The facility's investigation was initiated and ongoing with a five-day report to be submitted to OIG on 05/30/14. All residents were assessed for any signs and symptoms of abuse/neglect. Those residents with BIMS scores greater than 8 were interviewed by the Social Services Director or Chaplain for any abuse/neglect concerns on 05/29/14. On 05/29/14, the ADONs assessed the physical status of residents with a BIMS score less than 8 for any signs and symptoms of abuse/neglect. The facility attempted to contact the 41 POAs for the residents with a BIMS score less than 8 to ask if they had any concerns related to abuse/neglect and successfully contacted 26; the Social Services Director, the Chaplain, the DON, and/or the Administrator will continue to attempt to contact the remaining 15 POAs until all have successfully have been contacted. --The allegation of abuse reported by Resident #35 was reported to the Office of Inspector General on 05/29/14 by the DON and reported to APS, the Ombudsman, the resident's physician, and the POA on 05/30/14 by the DON. Resident #35 was physically assessed by a nurse and psychosocially assessed by the Social Services Director on 05/30/14. Resident #35 was interviewed and a statement was obtained by the Social Services Director on 05/30/14. The alleged perpetrator is no longer employed by the facility. The facility's investigation was initiated and ongoing with a five-day report to be submitted to OIG on 05/30/14. All residents were assessed for any signs and symptoms of abuse/neglect. Those residents with BIMS scores greater than 8 were interviewed by the Social Services Director or Chaplain for any abuse/neglect concerns on 05/29/14. On 05/29/14, the ADONs assessed the physical status of residents with BIMS scores less than 8 for any signs and symptoms of abuse/neglect. The facility attempted to contact the 41 POAs for the residents with a BIMS score less than 8 to ask if they had any concerns related to abuse/neglect and successfully contacted 26; the Social Services Director, the Chaplain, the DON, and/or the Administrator will continue to attempt to contact the remaining 15 POAs until all have successfully have been contacted. --All residents were assessed for any signs and symptoms of abuse/neglect. Those residents with BIMS scores greater than 8 were interviewed by the Social Services Director or Chaplain for any abuse/neglect concerns on 05/29/14. On 05/29/14, the ADONs assessed the physical status of residents with BIMS scores less than 8 for any signs and symptoms of abuse/neglect. The facility attempted to contact the 41 POAs for the residents with a BIMS score less than 8 to ask if they had any concerns related to abuse/neglect and successfully contacted 26; the Social Services Director, the Chaplain, the DON, and/or the Administrator will continue to attempt to contact the remaining 15 POAs until all have successfully been contacted. The Administrator, the Regional Nurse Consultant, and the Chief Nurse Executive reviewed abuse/neglect audits, assessments, interviews, and questionnaires on 05/30/14 for any indications of abuse/neglect concerns. --The facility's Regional Nurse Consultant from the corporate office re-educated the facility Administrator, the DON, the ADONs, the Minimum Data Set (MDS) Coordinator, the Staff Development Coordinator (SDC), the Director of Dining Services, the Business Office Manager, the Social Services Director, the Activities Director, the Chaplain, Marketing/Admissions, Medical Records, Human Resources, and Wound Care staff on 05/29/14 on the facility's abuse policy and procedure. The education included but was not limited to thorough investigations, reporting immediately, and the Quality Assurance Performance Improvement (QAPI) process, including reporting of concerns to the Administrator and floor staff participation in development of QAPI plans. This training was performed face to face in order to facilitate discussion and questions and included examples of items that would be considered as reportable: reports of staff being mean, injuries of unknown origin, withholding belongings, resident-to-resident altercations to include verbal or physical, and taking belongings or exploitation. Department administrative managers were not allowed to return to work until abuse education was provided, post-tests administered, and a score of 100% obtained. If the manager did not score 100% on post-test, then the manager was immediately re-educated and re-tested . This process continued until all managers obtained a 100% score on the post-test. All post-tests were reviewed for compliance by the Chief Nursing Executive (CNE). --After the facility Administrator, DON, ADONs, Minimum Data Set (MDS) Coordinator, Staff Development Coordinator (SDC), Director of Dining Services, Business Office Manager, Social Services Director, Activities Director, Chaplain, Marketing/Admissions staff, Medical Records staff or Director, Human Relations (HR) staff, or Wound Care staff were re-educated on the abuse policy, the Administrative staff was assigned to re-educate the staff on the abuse policy and procedure which included but was not limited to reporting, protection, and investigation requirements, which started on 05/29/14. The facility did not allow any employee to work until abuse education was provided, post-test administered, and 100% score obtained. If the employee did not score 100% on the post-test, the employee was immediately re-educated and the post-test re-administered. This process continued until all employees obtained a 100% score on the post-test. Education regarding the abuse policy and procedure, including identification/reporting and the Quality Assurance Performance Improvement process was added in the orientation process for all newly hired staff members. No newly hired employee would be allowed to work until abuse education was provided, post-test administered, and 100% score obtained. If the employee did not score 100% on the post-test, the employee was immediately re-educated and re-tested . This process continued until employees obtained a 100% score on the post-test. --Staff questionnaires regarding abuse, including the question, "What would you do if a resident told you that you were mean to them?" were administered by the Administrator, DON, ADONs, MDS Coordinator, SDC, Director of Dining Services, Business Office Manager, Social Services Director, Activities Director, Chaplain, Marketing/Admissions, Medical Records, HR, or Wound Care staff to five staff members on each shift and different staff members until immediacy was removed. After removal of immediacy, ten staff questionnaires were administered to staff daily to ensure continued understanding of the abuse/neglect policy and procedure, appropriate investigating, and reporting of abuse/neglect. The questionnaire also included questions related to the QAPI process to include reporting of concerns to the Administrator and floor staff participation in development of the QAPI plan. Results of the staff questionnaire were reported to the Quality Assurance (QA) Committee weekly to determine the further need of continued education or revision of the plan. At that time, based on evaluation, the QA Committee would determine at what frequency the staff questionnaire would need to continue. Concerns identified were corrected immediately and reported to the Administrator to ensure investigation of suspected abuse/neglect was investigated/completed and reporting guidelines were met. --HR performed an audit of all personnel files for any abuse concerns on 05/29/14. Items that were reviewed: Coaching and Counseling forms, suspension forms, and termination forms. Results of the audit were given to the Chief Nursing Executive on 05/30/14, to review for any abuse/neglect concerns that needed reporting. There were no concerns identified. --A nurse from the facility's regional team or corporate office had been on-site since 05/29/14 and remained in the facility daily until the jeopardy was removed. The nurses from the regional team or home office assisted with investigations, observed staff treatment of [REDACTED]. The Chief Nurse Executive, Clinical Compliance Nurse, or Director of Clinical Programs were in daily contact with the regional nurse consultant and reviewed allegations. --All facility grievances filed since 04/01/14 were reviewed by the Administrator, DON, or Regional Nurse Consultant on 05/30/14 to determine if any items documented were a reportable event. The Administrator was notified of one allegation of possible abuse. The Administrator reported the allegations to the Office of Inspector General on 05/30/14. The Administrator, Social Services Director, or the Director of Nursing reviewed the grievances and incident/accident reports daily, until immediacy was lifted, which was initiated on 05/29/14, to determine if there were reportable allegations that had not been identified. The Social Services Director or the Director of Nursing reported to the Administrator any identified allegations of abuse, neglect, or misappropriation immediately after their review. The Administrator will report any allegations of abuse, neglect, or misappropriation to the Office of Inspector General, Adult Protective Services, and the Ombudsman. --An emergency resident council meeting was held on 05/30/14; the Administrator and SDC attended the meeting to discuss any abuse/neglect concerns and to provide education on whom to report any abuse/neglect concerns without fear of retribution. The Social Services Director attempted to contact the POAs of all residents with BIMS scores less than 8 to discuss any abuse/neglect concerns and to provide education on whom to report any abuse/neglect concerns without fear of retribution on 05/30/14. --The Administrator, DON, ADONs, MDS Coordinator, SDC, Director of Dining Services, Business Office Manager, Social Services Director, Activities Director, Chaplain, Marketing/Admissions, Medical Records, HR, and Wound Care Nurse (one per shift) were to be on-site each shift to perform walking rounds in which ten residents (five with BIMS scores greater than 8 and five with BIMS scores less than 8) were visited by the Department Head and those residents that could be interviewed were interviewed regarding the staff treatment. The Department Head visited and a nurse conducted a skin check on the residents that were not able to be interviewed. The Department Head also spoke to nursing staff and State Registered Nursing Assistants (SRNAs) regarding any noted changes in the residents' behaviors. The facility Department Head also interviewed five staff members each shift regarding the types of abuse, who the facility's Abuse Coordinator was, when to report suspected abuse, what to do if the resident reported you were mean to them, etc., which began on 05/29/14 and continued until the immediate jeopardy was lifted. Results of resident and staff questionnaires were reported to the Administrator, DON, Regional Nurse Consultant, or Vice President (VP) of Operations daily and if the Administrator was not in the facility, the Department Director conducted the questionnaires and telephoned the Administrator or VP of Operations with the results of the resident and staff questionnaires. This continued until the immediate jeopardy was lifted. --The DON, ADONs, MDS Coordinator, SDC, Director of Dining Services, Business Office Manager, Social Services Director, Activities Director, Chaplain, Marketing/Admissions, Medical Records, HR, or Wound Care staff immediately notified the Administrator of any concerns regarding the above resident and staff questionnaires related to abuse, mistreatment, neglect, or misappropriation and ensured the resident was safe. A binder (which contains a resident roster in which the interview date and shift is noted next to the resident name), which is passed on to each Department Head assigned to perform the resident and staff questionnaires each shift, to ensure that residents with BIMS scores greater than 8 were interviewed and residents with BIMS scores less than 8 were visited and skin checks completed, began on 05/29/14 and continued until the jeopardy was lifted. The MDS Coordinators had the responsibility for updating the binder weekly to identify residents with BIMS scores greater than 8 and residents with BIMS scores less than 8. If abuse, mistreatment, neglect, or misappropriation was alleged during the interviews or visits or reported by a staff member, the Department Head ensured the resident was safe, reported to a Charge Nurse, the Charge Nurse removed the alleged perpetrator to a non-patient care area, and notified the Administrator, Director of Nursing, and/or Social Services Director/Abuse Coordinator. The alleged perpetrator was suspended and an investigation began immediately. --The Administrator, Director of Nursing, Social Services Director, or a member of the facility's regional staff reviewed all resident and staff questionnaires daily for any grievances/concerns. Investigations of grievances/concerns were initiated upon receipt, starting on 05/30/14. --Nursing Administration (DON, ADONs, Unit Managers, SDC, MDS staff, facility formulary nurse), or the Medical Records or Social Services Director, reviewed documentation in the Nursing Notes in order to assess for any signs of documented evidence regarding abuse, neglect, or misappropriation daily on ten different residents each day. If any of the above concerns were identified, the member of Nursing Administration first ensured the resident was safe by performing an assessment and then notified a Charge Nurse. The abuse policy was followed in which the alleged perpetrator was removed from a resident care area (if on duty) and the Administrator, DON, or Social Services Director was notified. --All resident charts were reviewed from 04/01/14 by Nursing Administration (DON, ADONs, Unit Manager, Staff Development Coordinator, MDS staff, Facility Formulary Nurse, Medical Records, Marketing/Admissions, or Social Services Director) or regional/corporate nurses by 05/30/14 for any documentation regarding abuse with no new incident being identified. Ten charts were reviewed by a member of Nursing Administration or the facility's regional or home office nurse daily to ensure that no other abuse allegations had been documented but not reported. This continued until the immediate jeopardy was removed. --The Administrator, Director of Nursing, and Social Services Director reviewed and discussed all abuse investigations daily to ensure that the residents were protected, the alleged perpetrator was removed from the resident care area, reports to the Office of Inspector General were filed timely, and a thorough investigation was completed. The Administrator maintained an abuse investigation log that included documentation of the following: ensured protection of residents, removed perpetrator from resident care area, reports to the Office of Inspector General filed timely, and thorough investigations completed. The Administrator and one of the following, Chief Operating Officer, Chief Nurse Executive, or Regional Nurse Consultant, reviewed the abuse investigation to ensure protection of the resident; that the perpetrator was removed from the resident care area; that reports to the Office of Inspector General were filed timely; and that a thorough investigation had been completed. This will occur daily until removal of immediate jeopardy. --For new reports of alleged abuse, neglect, or misappropriation of property, after the immediate jeopardy was removed, one of the following was contacted prior to making the final five-day investigation report to OIG: Signature Care Consultant, VP of Operations, Chief Operating Officer, Special Projects Administrator, or Chief Nursing Executive. The reviewer (Signature Care Consultant, VP of Operations, Chief Operating Office, Special Projects Administrator, or Chief Nursing Executive) ensured the resident was protected, report was filed timely, the perpetrator was removed from the patient care area, and a thorough investigation was completed. --With any new report of alleged abuse, neglect, or misappropriation of property, one of the following was contacted within 24 hours to review the abuse investigation to ensure that a thorough investigation was completed and reporting timelines were met: Signature Care Consultant, VP of Operations, Chief Operating Office, Special Projects Administrator, or CNE. --All incident reports from January 2014 to 03/29/14 were reviewed by the Director of Nursing, the Assistant Director of Nursing, Staff Development Coordinator, or Regional Nurse Consultant to identify any concerns of suspected neglect by 05/30/14. None was identified. --During care plan conference for each resident, any abuse/neglect concerns were discussed and abuse/neglect education, to include reporting, was provided to the resident and/or POA with supporting documentation noted. --Administrative oversight of the facility was completed by the Special Projects Administrator, the Regional Vice President of Operations, a member of regional staff, or the CEO daily until removal of immediacy beginning 05/29/14, then weekly for four weeks, and then monthly. --The DON, ADONs, or SDC observed the care delivery for any suspected abuse/neglect concerns on five residents daily until the removal of immediacy and then weekly (Monday through Friday). The results of the care delivery audits were reported to the QA Committee weekly to determine the further need of continued education or revision of plan. At that time, based on evaluation, the QA Committee would determine at what frequency the audits needed to continue. Concerns identified were corrected immediately and reported to the Administrator to ensure investigations of suspected abuse/neglect were investigated/completed and reporting guidelines were met. --A Quality Assurance meeting was held weekly for four weeks beginning 05/29/14, then monthly for recommendations and further follow-up regarding the above stated plan. At that time, based upon evaluation, the QA Committee would determine at what frequency any ongoing audits would need to continue. The Administrator had the oversight to ensure an effective plan was in place to meet resident well-being as well as an effective plan to identify facility concerns and implement a plan of correction to involve all staff of the facility. Corporate Administrative oversight of the Quality Assurance meeting was to be completed by the Special Projects Administrator, the Regional Vice President of Operations, a member of regional staff, or the Chief Executive Officer (CEO) daily until removal of immediacy beginning 05/29/14, then weekly for four weeks, and then monthly. **The surveyors validated the Immediate Jeopardy was removed as follows: Review of the facility's investigation and interviews with Administrative Staff revealed the allegation involving Resident #32 was investigated and reported to the appropriate State agency. The investigation included interviews with staff and residents and physical assessments of residents that were not interviewable. The investigation also included interviews with POAs, questioning for any concerns related to abuse or neglect. Review of the facility's investigation and interviews with Administrative staff revealed the allegation involving Resident #33 was investigated and reported to the appropriate state agency. The investigation included interviews with staff and residents and physical assessments of residents that were not interviewable. The investigation also included interviews with POAs, questioning for any concerns related to abuse or neglect. Review of the facility's investigation and interviews with Administrative staff revealed the allegation that involved Resident #35 was investigated and reported to the appropriate state agency. The investigation included interviews with Resident #35, staff, and residents and physical assessments of residents that were not interviewable. The investigation also included interviews with POAs, questioning for any concerns related to abuse or neglect. Review of the facility's assessments for signs and symptoms of abuse and resident interviews revealed the facility completed them on 05/29/14. Interview with the Regional Nurse Consultant on 06/04/14 at 9:15 AM revealed as of 06/03/14, only six POAs had not been contacted so the facility sent the abuse/neglect questionnaire by certified mail to the POAs. A review of the abuse/neglect assessments, abuse/neglect audits, and abuse/neglect interviews revealed the Administrative staff provided validation and oversight. Review of Administrative staff education and testing, provided on 05/29/14, related to abuse/neglect policy, investigations, reporting, and the Quality Assessment process was reviewed and validated by the Chief Nursing Executive (CNE). Review of staff education and post-testing related to the abuse policy and procedure which included reporting, protection, and investigation requirements revealed the education was provided on 05/29/14, as per the AOC. Interview with the Regional Nurse Consultant on 06/04/14 at 9:15 AM, revealed during the staff in-service examples were given of different situations of abuse/neglect and the staff had to explain the appropriate actions. Further interview with the Regional Nurse Consultant revealed the facility had not hired any new employees. A review of the staff questionnaire regarding abuse was being done as reported in the AOC. Interview on 06/04/14 at 9:15 AM with the Regional Nurse Consultant revealed no issues had been identified through the staff questionnaires. Review of the HR Audits of personnel files revealed the CNE validated review by signature on the back of the audit forms. Interview with the Regional Nurse Consultant on 06/04/14 at 9:15 AM revealed there were no issues identified with the review of the employee files. Interview on 06/04/14 at 9:15 AM with the Regional Nurse Consultant revealed a corporate staff member had been at the facility since the jeopardy was identified and had been reviewing all allegations to ensure a thorough investigation was conducted. Further interview revealed the corporate staff was also conducting chart audits, observed staff treatment of [REDACTED]. Interview on 06/04/14 at 9:15 AM with the Regional Nurse Consultant revealed all facility grievances filed since 04/01/14 were reviewed for possible allegations of abuse/neglect. The interview revealed one grievance was related to cigarettes that were missing. The incident was investigated with no concerns identified. Continued interview revealed the facility's smoking policy had recently been updated to account for all residents' cigarettes. Interviews on 06/04/14 with the Regional Nurse Consultant and SDC revealed a Resident Council meeting was held on 05/30/14 to discuss abuse/neglect concerns and education was provided on reporting abuse/neglect concerns without fear of retribution. The interview further revealed residents that did not attend the meeting were also provided education related to reporting abuse. Interview on 06/04/14 with the Regional Nurse Consultant and the Administrator revealed as of 05/29/14 a daily census was completed and residents were chosen by the Administrator to be interviewed and to observe staff as they provided care to the resident which was done by Administrative Staff. The interview further revealed staff providing care to residents with a B

Based on interview, record review, review of the facility's incident report, review of staff witness statements, and review of the facility's policy, "Abuse, Neglect and Misappropriation," revised March 2013, it was determined the facility failed to ensure policies that prohibited abuse were implemented for two (2) of thirty-five (35) sampled residents (Residents #32 and #35). The facility failed to ensure staff implemented its policy and immediately reported allegations of abuse to the facility's Administrator, the State Survey Agency, and other officials in accordance with State law, failed to ensure all allegations were investigated, and failed to ensure residents were protected from further potential abuse during the facility's investigation. Review of incident reports and interviews revealed on 05/25/14, staff observed bruising to Resident #32's arm. The resident reported to staff on 05/25/14 that "fat Pat grabbed" his/her arm (Resident #32 reported the incident the same day it occurred). The facility identified the alleged perpetrator as State Registered Nurse Aide (SRNA) #2. Interviews revealed the Director of Nursing (DON) initiated an investigation and SRNA #2 was suspended on 05/25/14 during the investigation. The DON stated she didn't feel "like it was an allegation of abuse" because the resident reported different stories about the incident; SRNA #2 was allowed to return to work to provide direct resident care on 05/26/14. However, the facility failed to follow its policies which stated, "...The charge nurse will immediately remove the suspected perpetrator from resident care areas, obtain the staff members witness statement and immediately suspend the employee pending the outcome of the investigation ...All allegations of abuse involving abuse along with injuries of unknown origin are reported immediately to the charge nurse and/or administrator of the facility along with other officials in accordance with State law through established guidelines..." In addition, interviews and review of witness statements revealed on 05/24/14, Resident #35 reported State Registered Nurse Aide (SRNA) #3 talked mean to him/her when the resident requested a cold, wet washcloth. The facility received reports that identified the alleged perpetrator in the incident related to Resident #35 as State Registered Nurse Aide #3; however, the facility did not implement its policy. The facility's policy stated, "...The charge nurse will immediately remove the suspected perpetrator from resident care areas, obtain the staff members witness statement and immediately suspend the employee pending the outcome of the investigation..." The facility allowed SRNA #3 to continue to provide care to other residents in the facility after the allegations were made. The facility's failure to implement its policies and procedures that prohibited neglect, mistreatment, and abuse that included reporting allegations of abuse, protecting residents during the course of the investigation, and conducting an investigation of an allegation of abuse caused, or was likely to cause, serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy was determined to exist on 05/24/14 at 42 CFR 483 Resident Behavior and Facility Practices (F225 and F226) and 42 CFR 483.75 Administration (F490 and F520). An acceptable Allegation of Compliance was received on 06/02/14, which alleged removal of the Immediate Jeopardy on 05/31/14. A partial extended survey was conducted on 06/03/14 through 06/04/14. The State Survey Agency determined the Immediate Jeopardy was removed on 05/31/14, as alleged, which lowered the scope and severity to "D" at 42 CFR 483.13 Resident Behavior and Facility Practices (F225 and F226) and "D" at 42 CFR 483.75 Administration (F490 and F520) while the facility monitors the effectiveness of systemic changes and quality assurance activities. (Refer to F225.) The findings include: Review of the facility's policy entitled "Abuse, Neglect and Misappropriation," revised March 2013 revealed "All allegations of abuse involving abuse along with injuries of unknown origin are reported immediately to the charge nurse and/or administrator of the facility along with other officials in accordance with State law through established guidelines." In addition, the policy revealed, "...The charge nurse will immediately remove the suspected perpetrator from resident care areas, obtain the staff members witness statement and immediately suspend the employee pending the outcome of the investigation..." The policy revealed, "...The charge nurse will immediately notify the Administrator, DON and/or Abuse Coordinator as appropriate...The Administrator and/or DON will notify state agencies according to their reporting guidelines..." In addition, according to the policy, "...All allegations of abuse will be investigated and reported to the appropriate agencies...The Administrator/designee will make all reasonable efforts to investigate and address alleged reports, concerns, and grievances..." Continued review of the policy revealed under section II, "Training/Identification/Prevention," staff is trained to identify "...Signs & Symptoms of abuse (bruises, injuries of unknown origin, crying, fearful, increased agitation, and withdrawal)..." as part of their orientation. 1. The facility admitted Resident #32 on 12/06/13 with [DIAGNOSES REDACTED]. Review of Resident #32's Minimum Data Set (MDS) Quarterly Assessment, dated 02/04/14, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident's cognition was moderately impaired. Review of an incident report, dated 05/25/14 revealed staff observed two bruises to Resident #32's arm. The resident told staff, "Fat Pat grabbed my arm and wouldn't let it go; I had to pull myself loose." The facility identified the alleged perpetrator as SRNA #2. Facility staff immediately notified the Director of Nursing (DON) of the bruises to Resident #32's arm and was instructed to conduct a skin assessment for Resident #32, obtain witness statements from all staff present, and SRNA #2 was to be suspended. The DON acknowledged in interview conducted on 05/28/14 at 4:30 PM that staff had not interviewed other residents for which SRNA #2 had provided direct care for signs of abuse and the only staff interviews conducted were from staff working when the alleged incident occurred, and the interviews were related only to the alleged incident. According to the DON, the incident was investigated on 05/25/14, and she "didn't think it was abuse, because the resident had different stories about what had happened." Interview and review of the investigation revealed the facility failed to ensure staff acted in accordance with the facility's policy to ensure that "...The Administrator and/or DON will notify state agencies according to their reporting guidelines...The charge nurse will immediately remove the suspected perpetrator from resident care areas, obtain the staff members witness statement and immediately suspend the employee pending the outcome of the investigation..." The Administrator stated in interview conducted on 05/29/14 at 6:17 PM that staff had notified him of the bruises to Resident #32's arm and he had instructed staff to follow the directions given by the DON. The Administrator stated he had not considered the resident's statement as an allegation of abuse but as an injury of unknown origin because the resident had "told a lot of stories" as to how the bruises occurred. Further interview revealed he had not reported the incident to the State Agencies. The Administrator acknowledged staff had not conducted assessments/interviews with other residents during the course of the facility's investigation in an effort to identify other residents that might exhibit signs/symptoms of abuse. However, review of the facility's policy, revealed staff was trained to identify "...Signs & Symptoms of abuse (bruises, injuries of unknown origin, crying, fearful, increased agitation, and withdrawal)..." as part of their orientation. 2. Review of Resident #35's medical record revealed the facility admitted the resident on 04/29/14, with [DIAGNOSES REDACTED]. The facility assessed the resident to have a BIMS score of 11, which indicated the resident's cognition was moderately impaired. Review of SRNA #3's personnel files revealed a witness statement that indicated on 05/24/14, Licensed Practical Nurse (LPN) #2 had observed the SRNA between 3:00 AM and 4:00 AM on 05/24/14 walking down the hall making the statement, "I hate these people; I don't know what a washcloth's going to do for (him/her)." Continued review of the witness statement revealed at that time on 05/24/14, Resident #35 requested LPN #2 to check his/her blood sugar and the LPN observed the resident crying. The statement revealed on 05/24/14, Resident #35 informed the nurse, "That boy that was just in here talked mean to me." According to documentation on the witness statement, Resident #35 had asked SRNA #3 for a cold, wet washcloth for knee pain and SRNA #3 informed the resident he had knee pain but did not have insurance to see a doctor like the residents. The resident reported the SRNA stated, "I don't know what a wet washcloth's going to do for your leg pain." Continued review of the witness statement revealed the resident was very upset and did not want SRNA #3 in his/her room again. Further review of the witness statement revealed LPN #2 contacted the on-call nurse to report the incident and was instructed to switch SRNA #3 with a resident from the other hall and to contact the DON. The LPN contacted the DON on 05/24/14, and was instructed by the DON to place the information about the incident on the 24-hour report sheet and to keep SRNA #3 out of Resident #35's room. However, there was no documented evidence that staff was instructed to follow and/or followed the facility's policy and "...immediately remove(d) the suspected perpetrator from resident care areas, obtain(ed) the staff members witness statement and immediately suspend(ed) the employee pending the outcome of the investigation...," or that the allegation of abuse had been "...investigated and reported to the appropriate agencies..." in accordance with facility policy. Interview with LPN #2 on 05/29/14 at 5:09 PM revealed the LPN called the DON on 05/24/14 to inform her of the incident and was told by the DON to put SRNA #3 on another hall to work and put the incident on the 24-hour report sheet to be investigated. However, the DON failed to direct the LPN to follow the facility's policy which stated, "...The charge nurse will immediately remove the suspected perpetrator from resident care areas, obtain the staff members witness statement and immediately suspend the employee pending the outcome of the investigation...All allegations of abuse will be investigated and reported to the appropriate agencies..." Continued interview with LPN #2 revealed when the DON came to the facility on [DATE], nursing staff from the night shift informed the DON of SRNA #3's negative behaviors and provided the DON witness statements about the incident that had been reported on 05/24/14. The DON acknowledged in interview conducted on 05/28/14 at 5:20 PM that staff had notified her on 05/24/14 of the incident related to SRNA #3 and Resident #35. The DON stated she had informed staff to keep SRNA #3 out of Resident #35's room. Further interview revealed the DON talked with the night shift nurses the next morning, was informed of reports that SRNA #3 had argued with staff and cursed in the hallway, and was given the staff's witness statements about the incident. The DON stated the reports were nothing she considered abusive so the incident was not investigated or reported. Interview with the Administrator on 05/29/14 at 6:17 PM revealed the Administrator was not made aware of the incident or of the witness statements involving SRNA #3 and Resident #35 until 05/28/14. Continued interview revealed the Administrator revealed the allegations should have been investigated and reported per the facility's policy. **The facility provided an acceptable Allegation of Compliance (AOC) on 06/02/14. The facility implemented the following actions to remove the Immediate Jeopardy: --The allegation of abuse reported by Resident #32 was reported to the Office of Inspector General (OIG) on 05/27/14 by the DON. Resident #32 has a BIMS score greater than 8 and a statement was obtained on 05/25/14. The alleged perpetrator was suspended on 05/25/14. The facility's investigation was initiated and ongoing with a five-day report to be submitted to OIG on 05/30/14. All residents were assessed for any signs and symptoms of abuse/neglect. Those residents with BIMS scores greater than 8 were interviewed by the Social Services Director or Chaplain for any abuse/neglect concerns on 05/29/14. On 05/29/14, the Assistant Directors of Nursing (ADONs) assessed the physical status of residents with BIMS scores less than 8 for any signs and symptoms of abuse/neglect. The facility attempted to contact the 41 Power of Attorneys (POAs) for the residents with a BIMS score less than 8 to ask if they had any concerns related to abuse/neglect and successfully contacted 26; the Social Services Director, the Chaplain, the DON, and/or the Administrator will continue to attempt to contact the remaining 15 POAs until all have successfully been contacted. --The allegation of abuse related to Resident #33 that occurred on 05/24/14 was reported to OIG on 05/29/14 by the DON and reported to Adult Protective Services (APS), the Ombudsman, the resident's physician, and the POA on 05/30/14 by the DON. A facility nurse assessed Resident #33 on 05/29/14 and the resident had a psychosocial assessment completed by the Social Services Director on 05/30/14. Resident #33 was interviewed and a statement was obtained by the facility's Social Services Director on 05/30/14. The alleged perpetrator was no longer employed by the facility. The facility's investigation was initiated and ongoing with a five-day report to be submitted to OIG on 05/30/14. All residents were assessed for any signs and symptoms of abuse/neglect. Those residents with BIMS scores greater than 8 were interviewed by the Social Services Director or Chaplain for any abuse/neglect concerns on 05/29/14. On 05/29/14, the ADONs assessed the physical status of residents with a BIMS score less than 8 for any signs and symptoms of abuse/neglect. The facility attempted to contact the 41 POAs for the residents with a BIMS score less than 8 to ask if they had any concerns related to abuse/neglect and successfully contacted 26; the Social Services Director, the Chaplain, the DON, and/or the Administrator will continue to attempt to contact the remaining 15 POAs until all have successfully have been contacted. --The allegation of abuse reported by Resident #35 was reported to the Office of Inspector General on 05/29/14 by the DON and reported to APS, the Ombudsman, the resident's physician, and the POA on 05/30/14 by the DON. Resident #35 was physically assessed by a nurse and psychosocially assessed by the Social Services Director on 05/30/14. Resident #35 was interviewed and a statement was obtained by the Social Services Director on 05/30/14. The alleged perpetrator is no longer employed by the facility. The facility's investigation was initiated and ongoing with a five-day report to be submitted to OIG on 05/30/14. All residents were assessed for any signs and symptoms of abuse/neglect. Those residents with BIMS scores greater than 8 were interviewed by the Social Services Director or Chaplain for any abuse/neglect concerns on 05/29/14. On 05/29/14, the ADONs assessed the physical status of residents with BIMS scores less than 8 for any signs and symptoms of abuse/neglect. The facility attempted to contact the 41 POAs for the residents with a BIMS score less than 8 to ask if they had any concerns related to abuse/neglect and successfully contacted 26; the Social Services Director, the Chaplain, the DON, and/or the Administrator will continue to attempt to contact the remaining 15 POAs until all have successfully have been contacted. --All residents were assessed for any signs and symptoms of abuse/neglect. Those residents with BIMS scores greater than 8 were interviewed by the Social Services Director or Chaplain for any abuse/neglect concerns on 05/29/14. On 05/29/14, the ADONs assessed the physical status of residents with BIMS scores less than 8 for any signs and symptoms of abuse/neglect. The facility attempted to contact the 41 POAs for the residents with a BIMS score less than 8 to ask if they had any concerns related to abuse/neglect and successfully contacted 26; the Social Services Director, the Chaplain, the DON, and/or the Administrator will continue to attempt to contact the remaining 15 POAs until all have successfully been contacted. The Administrator, the Regional Nurse Consultant, and the Chief Nurse Executive reviewed abuse/neglect audits, assessments, interviews, and questionnaires on 05/30/14 for any indications of abuse/neglect concerns. --The facility's Regional Nurse Consultant from the corporate office re-educated the facility Administrator, the DON, the ADONs, the Minimum Data Set (MDS) Coordinator, the Staff Development Coordinator (SDC), the Director of Dining Services, the Business Office Manager, the Social Services Director, the Activities Director, the Chaplain, Marketing/Admissions, Medical Records, Human Resources, and Wound Care staff on 05/29/14 on the facility's abuse policy and procedure. The education included but was not limited to thorough investigations, reporting immediately, and the Quality Assurance Performance Improvement (QAPI) process, including reporting of concerns to the Administrator and floor staff participation in development of QAPI plans. This training was performed face to face in order to facilitate discussion and questions and included examples of items that would be considered as reportable: reports of staff being mean, injuries of unknown origin, withholding belongings, resident-to-resident altercations to include verbal or physical, and taking belongings or exploitation. Department administrative managers were not allowed to return to work until abuse education was provided, post-tests administered, and a score of 100% obtained. If the manager did not score 100% on post-test, then the manager was immediately re-educated and re-tested . This process continued until all managers obtained a 100% score on the post-test. All post-tests were reviewed for compliance by the Chief Nursing Executive (CNE). --After the facility Administrator, DON, ADONs, Minimum Data Set (MDS) Coordinator, Staff Development Coordinator (SDC), Director of Dining Services, Business Office Manager, Social Services Director, Activities Director, Chaplain, Marketing/Admissions staff, Medical Records staff or Director, Human Relations (HR) staff, or Wound Care staff were re-educated on the abuse policy, the Administrative staff was assigned to re-educate the staff on the abuse policy and procedure which included but was not limited to reporting, protection, and investigation requirements, which started on 05/29/14. The facility did not allow any employee to work until abuse education was provided, post-test administered, and 100% score obtained. If the employee did not score 100% on the post-test, the employee was immediately re-educated and the post-test re-administered. This process continued until all employees obtained a 100% score on the post-test. Education regarding the abuse policy and procedure, including identification/reporting and the Quality Assurance Performance Improvement process was added in the orientation process for all newly hired staff members. No newly hired employee would be allowed to work until abuse education was provided, post-test administered, and 100% score obtained. If the employee did not score 100% on the post-test, the employee was immediately re-educated and re-tested . This process continued until employees obtained a 100% score on the post-test. --Staff questionnaires regarding abuse, including the question, "What would you do if a resident told you that you were mean to them?" were administered by the Administrator, DON, ADONs, MDS Coordinator, SDC, Director of Dining Services, Business Office Manager, Social Services Director, Activities Director, Chaplain, Marketing/Admissions, Medical Records, HR, or Wound Care staff to five staff members on each shift and different staff members until immediacy was removed. After removal of immediacy, ten staff questionnaires were administered to staff daily to ensure continued understanding of the abuse/neglect policy and procedure, appropriate investigating, and reporting of abuse/neglect. The questionnaire also included questions related to the QAPI process to include reporting of concerns to the Administrator and floor staff participation in development of the QAPI plan. Results of the staff questionnaire were reported to the Quality Assurance (QA) Committee weekly to determine the further need of continued education or revision of the plan. At that time, based on evaluation, the QA Committee would determine at what frequency the staff questionnaire would need to continue. Concerns identified were corrected immediately and reported to the Administrator to ensure investigation of suspected abuse/neglect was investigated/completed and reporting guidelines were met. --HR performed an audit of all personnel files for any abuse concerns on 05/29/14. Items that were reviewed: Coaching and Counseling forms, suspension forms, and termination forms. Results of the audit were given to the Chief Nursing Executive on 05/30/14, to review for any abuse/neglect concerns that needed reporting. There were no concerns identified. --A nurse from the facility's regional team or corporate office had been on-site since 05/29/14 and remained in the facility daily until the jeopardy was removed. The nurses from the regional team or home office assisted with investigations, observed staff treatment of [REDACTED]. The Chief Nurse Executive, Clinical Compliance Nurse, or Director of Clinical Programs were in daily contact with the regional nurse consultant and reviewed allegations. --All facility grievances filed since 04/01/14 were reviewed by the Administrator, DON, or Regional Nurse Consultant on 05/30/14 to determine if any items documented were a reportable event. The Administrator was notified of one allegation of possible abuse. The Administrator reported the allegations to the Office of Inspector General on 05/30/14. The Administrator, Social Services Director, or the Director of Nursing reviewed the grievances and incident/accident reports daily, until immediacy was lifted, which was initiated on 05/29/14, to determine if there were reportable allegations that had not been identified. The Social Services Director or the Director of Nursing reported to the Administrator any identified allegations of abuse, neglect, or misappropriation immediately after their review. The Administrator will report any allegations of abuse, neglect, or misappropriation to the Office of Inspector General, Adult Protective Services, and the Ombudsman. --An emergency resident council meeting was held on 05/30/14; the Administrator and SDC attended the meeting to discuss any abuse/neglect concerns and to provide education on whom to report any abuse/neglect concerns without fear of retribution. The Social Services Director attempted to contact the POAs of all residents with BIMS scores less than 8 to discuss any abuse/neglect concerns and to provide education on whom to report any abuse/neglect concerns without fear of retribution on 05/30/14. --The Administrator, DON, ADONs, MDS Coordinator, SDC, Director of Dining Services, Business Office Manager, Social Services Director, Activities Director, Chaplain, Marketing/Admissions, Medical Records, HR, and Wound Care Nurse (one per shift) were to be on-site each shift to perform walking rounds in which ten residents (five with BIMS scores greater than 8 and five with BIMS scores less than 8) were visited by the Department Head and those residents that could be interviewed were interviewed regarding the staff treatment. The Department Head visited and a nurse conducted a skin check on the residents that were not able to be interviewed. The Department Head also spoke to nursing staff and State Registered Nursing Assistants (SRNAs) regarding any noted changes in the residents' behaviors. The facility Department Head also interviewed five staff members each shift regarding the types of abuse, who the facility's Abuse Coordinator was, when to report suspected abuse, what to do if the resident reported you were mean to them, etc., which began on 05/29/14 and continued until the immediate jeopardy was lifted. Results of resident and staff questionnaires were reported to the Administrator, DON, Regional Nurse Consultant, or Vice President (VP) of Operations daily and if the Administrator was not in the facility, the Department Director conducted the questionnaires and telephoned the Administrator or VP of Operations with the results of the resident and staff questionnaires. This continued until the immediate jeopardy was lifted. --The DON, ADONs, MDS Coordinator, SDC, Director of Dining Services, Business Office Manager, Social Services Director, Activities Director, Chaplain, Marketing/Admissions, Medical Records, HR, or Wound Care staff immediately notified the Administrator of any concerns regarding the above resident and staff questionnaires related to abuse, mistreatment, neglect, or misappropriation and ensured the resident was safe. A binder (which contains a resident roster in which the interview date and shift is noted next to the resident name), which is passed on to each Department Head assigned to perform the resident and staff questionnaires each shift, to ensure that residents with BIMS scores greater than 8 were interviewed and residents with BIMS scores less than 8 were visited and skin checks completed, began on 05/29/14 and continued until the jeopardy was lifted. The MDS Coordinators had the responsibility for updating the binder weekly to identify residents with BIMS scores greater than 8 and residents with BIMS scores less than 8. If abuse, mistreatment, neglect, or misappropriation was alleged during the interviews or visits or reported by a staff member, the Department Head ensured the resident was safe, reported to a Charge Nurse, the Charge Nurse removed the alleged perpetrator to a non-patient care area, and notified the Administrator, Director of Nursing, and/or Social Services Director/Abuse Coordinator. The alleged perpetrator was suspended and an investigation began immediately. --The Administrator, Director of Nursing, Social Services Director, or a member of the facility's regional staff reviewed all resident and staff questionnaires daily for any grievances/concerns. Investigations of grievances/concerns were initiated upon receipt, starting on 05/30/14. --Nursing Administration (DON, ADONs, Unit Managers, SDC, MDS staff, facility formulary nurse), or the Medical Records or Social Services Director, reviewed documentation in the Nursing Notes in order to assess for any signs of documented evidence regarding abuse, neglect, or misappropriation daily on ten different residents each day. If any of the above concerns were identified, the member of Nursing Administration first ensured the resident was safe by performing an assessment and then notified a Charge Nurse. The abuse policy was followed in which the alleged perpetrator was removed from a resident care area (if on duty) and the Administrator, DON, or Social Services Director was notified. --All resident charts were reviewed from 04/01/14 by Nursing Administration (DON, ADONs, Unit Manager, Staff Development Coordinator, MDS staff, Facility Formulary Nurse, Medical Records, Marketing/Admissions, or Social Services Director) or regional/corporate nurses by 05/30/14 for any documentation regarding abuse with no new incident being identified. Ten charts were reviewed by a member of Nursing Administration or the facility's regional or home office nurse daily to ensure that no other abuse allegations had been documented but not reported. This continued until the immediate jeopardy was removed. --The Administrator, Director of Nursing, and Social Services Director reviewed and discussed all abuse investigations daily to ensure that the residents were protected, the alleged perpetrator was removed from the resident care area, reports to the Office of Inspector General were filed timely, and a thorough investigation was completed. The Administrator maintained an abuse investigation log that included documentation of the following: ensured protection of residents, removed perpetrator from resident care area, reports to the Office of Inspector General filed timely, and thorough investigations completed. The Administrator and one of the following, Chief Operating Officer, Chief Nurse Executive, or Regional Nurse Consultant, reviewed the abuse investigation to ensure protection of the resident; that the perpetrator was removed from the resident care area; that reports to the Office of Inspector General were filed timely; and that a thorough investigation had been completed. This will occur daily until removal of immediate jeopardy. --For new reports of alleged abuse, neglect, or misappropriation of property, after the immediate jeopardy was removed, one of the following was contacted prior to making the final five-day investigation report to OIG: Signature Care Consultant, VP of Operations, Chief Operating Officer, Special Projects Administrator, or Chief Nursing Executive. The reviewer (Signature Care Consultant, VP of Operations, Chief Operating Office, Special Projects Administrator, or Chief Nursing Executive) ensured the resident was protected, report was filed timely, the perpetrator was removed from the patient care area, and a thorough investigation was completed. --With any new report of alleged abuse, neglect, or misappropriation of property, one of the following was contacted within 24 hours to review the abuse investigation to ensure that a thorough investigation was completed and reporting timelines were met: Signature Care Consultant, VP of Operations, Chief Operating Office, Special Projects Administrator, or CNE. --All incident reports from January 2014 to 03/29/14 were reviewed by the Director of Nursing, the Assistant Director of Nursing, Staff Development Coordinator, or Regional Nurse Consultant to identify any concerns of suspected neglect by 05/30/14. None was identified. --During care plan conference for each resident, any abuse/neglect concerns were discussed and abuse/neglect education, to include reporting, was provided to the resident and/or POA with supporting documentation noted. --Administrative oversight of the facility was completed by the Special Projects Administrator, the Regional Vice President of Operations, a member of regional staff, or the CEO daily until removal of immediacy beginning 05/29/14, then weekly for four weeks, and then monthly. --The DON, ADONs, or SDC observed the care delivery for any suspected abuse/neglect concerns on five residents daily until the removal of immediacy and then weekly (Monday through Friday). The results of the care delivery audits were reported to the QA Committee weekly to determine the further need of continued education or revision of plan. At that time, based on evaluation, the QA Committee would determine at what frequency the audits needed to continue. Concerns identified were corrected immediately and reported to the Administrator to ensure investigations of suspected abuse/neglect were investigated/completed and reporting guidelines were met. --A Quality Assurance meeting was held weekly for four weeks beginning 05/29/14, then monthly for recommendations and further follow

Based on interview, record review, review of the facility's incident report, review of staff witness statements, and review of the facility's policy, it was determined the facility failed to ensure allegations of abuse and neglect were reported immediately to the facility's Administrator, the State Survey Agency, and other officials in accordance with State law for two (2) of three (3) sampled residents (Residents #32 and #35). The facility failed to ensure all allegations were investigated and failed to ensure residents were protected from further potential abuse during the facility's investigation. The facility documented on an incident report dated 05/25/14, that facility staff observed bruises to Resident #32's left wrist/forearm on 05/25/14. The resident informed staff on 05/25/14 that a nurse aide (identified by the facility as State Registered Nurse Aide #2) had "grabbed" his/her arm and "wouldn't let go." Review of the investigation revealed staff working at the time the resident's bruises were discovered was interviewed; however, other residents were not interviewed and the staff did not conduct skin assessments of other residents to determine if there were other bruises, and/or if there were other allegations of abuse until 05/28/14, three (3) days after the bruises on Resident #32's arm were observed. Further review of the investigation revealed the facility identified State Registered Nurse Aide (SRNA) #2 as the alleged perpetrator; the SRNA was suspended from resident care on 05/25/14 (the day staff observed the bruises on the resident's arm) but was allowed to return to work and provide direct resident care on 05/26/14 (two days prior to the assessments of other residents). Continued review of the investigation revealed the facility failed to notify the State Survey Agency of the allegation of abuse until 05/28/14 (three days after the bruises had been observed). The facility failed to ensure staff acted in accordance with the facility's policy that indicated, "...All allegations of abuse will be investigated and reported to the appropriate agencies...The Administrator and/or DON will notify state agencies according to their reporting guidelines...All allegations of abuse involving abuse along with injuries of unknown origin are reported immediately to the charge nurse and/or administrator of the facility along with other official in accordance with State law through established guidelines." In addition, review of employee files revealed staff witness statements in SRNA #3's personnel file that alleged SRNA #3 had been verbally abusive to Resident #35. Review of a witness statement written on 05/24/14, by Licensed Practical Nurse (LPN) #2 revealed on 05/23/14, Resident #35 reported that SRNA #3 had talked mean to him/her when he/she requested a cold, wet washcloth. The facility failed to provide written documentation that staff conducted a thorough investigation. The facility's investigation did not include interviews with other residents or evidence that the allegations had been reported to the facility's Administrator and the State Survey Agency. The facility allowed SRNA #3 to provide direct resident care on 05/23/14 and 05/25/14 which was not in accordance with facility policy which stated, "...The charge nurse will immediately remove the suspected perpetrator from resident care areas, obtain the staff members witness statement and immediately suspend the employee pending the outcome of the investigation...," and that "...All allegations of abuse involving abuse along with injuries of unknown origin are reported immediately to the charge nurse and/or administrator of the facility along with other officials in accordance with State law through established guidelines..." The facility's failure to immediately report all allegations of abuse/neglect, failure to protect residents during the course of an investigation of abuse/neglect, and failure to investigate allegations of abuse/neglect caused, or was likely to cause, serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy was determined to exist on 05/24/14 at 42 CFR 483.13 Resident Behavior and Facility Practices (F225 and F226) and 42 CFR 483.75 Administration (F490 and F520). An acceptable Allegation of Compliance was received on 06/02/14 which alleged removal of the Immediate Jeopardy on 05/31/14. A partial extended survey was conducted on 06/03/14 and 06/04/14. The State Survey Agency determined the Immediate Jeopardy was removed on 05/31/14 as alleged, which lowered the scope and severity to "D" at 42 CFR 483.13 Resident Behavior and Facility Practices (F225 and F226) and "D" at 42 CFR 483.75 Administration (F490 and F520) while the facility monitors the effectiveness of systemic changes and quality assurance activities. (Refer to F226.) The findings include: Review of the facility's policy, "Abuse, Neglect and Misappropriation," revised March 2013, revealed " ...All allegations of abuse involving abuse along with injuries of unknown origin are reported immediately to the charge nurse and/or administrator of the facility along with other officials in accordance with State law through established guidelines..." In addition, the policy revealed, "...The charge nurse will immediately remove the suspected perpetrator from resident care areas, obtain the staff members witness statement and immediately suspend the employee pending the outcome of the investigation..." The facility's policy also revealed, "...The charge nurse will immediately notify the Administrator, DON and/or Abuse Coordinator as appropriate...The Administrator and/or DON will notify state agencies according to their reporting guidelines...All allegations of abuse will be investigated and reported to the appropriate agencies...The Administrator/designee will make all reasonable efforts to investigate and address alleged reports, concerns, and grievances..." 1. Review of Resident #32's medical record revealed the facility admitted the resident on 12/06/13 with [DIAGNOSES REDACTED]. Review of Resident #32's Minimum Data Set (MDS) Quarterly Assessment, dated 02/04/14, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 8 which indicated the resident's cognition was moderately impaired. Review of an incident report, dated 05/25/14, revealed on 05/25/14, an SRNA called a nurse to Resident #32's room because she had observed two dark blue bruises on the resident's left wrist/forearm area. Continued review of the incident report revealed the resident stated, "Fat Pat grabbed my arm and wouldn't let it go; I had to pull myself loose." Interview was attempted with Resident #32 on 05/28/14 at 11:10 AM. However, the resident stated, "I don't want to talk about this (s**t) anymore," and refused to provide any further information. Licensed Practical Nurse (LPN) #1 stated in interview conducted on 05/29/14 at 11:53 AM that she assessed Resident #32 when the bruises were identified by facility staff on 05/25/14. The LPN stated Resident #32 reported to her on 05/25/14 that "Fat Pat grabbed" his/her arm. LPN #1 identified the alleged perpetrator as SRNA #2. According to interview, LPN #1 stated she immediately notified the Director of Nursing (DON) on 05/25/14 of the resident's bruises and of Resident #32's allegation. The LPN stated the DON instructed staff to conduct a skin assessment of Resident #32, to obtain written statements from staff members that were present, and to immediately suspend the alleged perpetrator, SRNA #2. However, interview with LPN #1 revealed the DON failed to instruct her "to notify other officials in accordance with State law through established guidelines" as per the facility's policy. Interview with Registered Nurse (RN) #1 on 05/29/14 at 12:30 PM revealed she also assessed Resident #32 on 05/25/14, when the bruises were identified by facility staff. She further stated the alleged perpetrator had been identified, based on the resident's description, as SRNA #2. RN #1 stated she immediately notified the Administrator on 05/25/14 of the resident's bruises and the allegation of abuse. The RN further revealed the Administrator instructed her to follow the directions of the DON. Interview with the DON, on 05/28/14 at 4:30 PM, revealed she had been notified of the bruises to Resident #32's arm on 05/25/14 and that the resident had alleged "fat Pat" had grabbed his/her arm. The DON stated she had instructed staff to assess Resident #32, to "gather statements from staff," and to tell the alleged perpetrator not to come to work that day (05/25/14) or until the incident had been "investigated." The DON stated staff had conducted an investigation of the alleged incident on 05/25/14. However, the DON acknowledged the facility had not assessed and/or interviewed other residents, including the residents that had received direct care by SRNA #2, for signs and/or reports of abuse during the investigation. The DON stated during the facility's investigation they had only interviewed staff that worked at the facility on the day the alleged incident was reported, and had only asked the staff about the alleged incident that occurred. In addition, the DON stated that based on the facility's investigation she "didn't think it was abuse because the resident had different stories about what had happened," had investigated the incident as an injury of unknown origin, and had not notified State Agencies of the incident. However, a review of the facility's policy revealed, "All allegations of abuse involving abuse along with injuries of unknown origin are reported immediately to the charge nurse and/or administrator of the facility along with other officials in accordance with State law through established guidelines." The DON further stated the alleged perpetrator (SRNA #2) was permitted to return to work on 05/26/14, the day after the alleged incident was reported. Interview with the Administrator on 05/29/14 at 6:17 PM revealed he was notified on 05/25/14 that Resident #32 had bruises on his/her arm and the resident had stated that "fat Pat grabbed" his/her arm. The Administrator stated he had not considered the resident's statement as an allegation of abuse, but as an injury of unknown origin, because the resident had "told a lot of stories" as to how the bruises occurred when questioned by facility staff. However, based on the facility's policy, "The Administrator/designee will make all reasonable efforts to investigate and address alleged reports, concerns, and grievances." Continued interview revealed the alleged perpetrator had been instructed not to come to work on the day the incident was reported (05/25/14) but had been allowed to return to work and provide direct resident care on 05/26/14. The Administrator acknowledged the facility had not included resident assessments and interviews in their investigation, and had not reported the resident's complaint to the State Agencies. 2. Review of Resident #35's medical record revealed the facility admitted the resident on 04/29/14 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set admission assessment, dated 05/15/14, revealed the facility assessed Resident #35 to have a BIMS score of 11, which indicated the resident's cognition was moderately impaired. Interview with Resident #35 on 05/29/14 at 9:45 AM revealed the resident had asked SRNA #3 for a cold, wet washcloth for knee pain on 05/24/14 and the SRNA told the resident he didn't have insurance like the "rest of us." Continued interview revealed SRNA #3 brought the washcloth to the resident's room, threw the washcloth to the resident, and hit the resident's chest with the washcloth. Further interview revealed Resident #35 reported to nursing staff that SRNA #3 talked mean to him/her. Although the resident could not recall the exact date the incident occurred, the resident reported it all happened at the same time. Review of a witness statement written by LPN #2, on the night shift of 05/23/14 to 05/24/14, revealed on 05/24/14, between 3:00 AM and 4:00 AM, SRNA #3 was observed walking down the hall making statements that "I hate these people; I don't know what a washcloth's going to do for (him/her)." Continued review of the witness statement revealed on 05/24/14, Resident #35 called LPN #2 to his/her room to check the resident's blood sugar and she observed the resident crying. Further review of the witness statement revealed the resident reported, "That boy that was just in here talked mean to me." The witness statement further revealed Resident #35 had asked SRNA #3 for a cold, wet washcloth for knee pain and SRNA #3 made statements to the resident that the SRNA also had knee pain but did not have insurance to see a doctor like the residents and he didn't know what a washcloth was going to do to help. Continued review of the witness statement revealed the resident was very upset and did not want SRNA #3 in his/her room again. According to the witness statement, LPN #2 contacted the on-call nurse on 05/24/14 to report the incident and was instructed to switch SRNA #3 with an SRNA from the other hall and to contact the DON. The DON was contacted and she instructed LPN #2 to place the information about the incident on the 24 Hour Report Sheet and to keep SRNA #3 out of Resident #35's room. However, the facility's policy stated, "...The charge nurse will immediately remove the suspected perpetrator from resident care areas, obtain the staff members witness statement and immediately suspend the employee pending the outcome of the investigation..." In addition, according to the policy, "...All allegations of abuse will be investigated and reported to the appropriate agencies..." LPN #2 confirmed in interview conducted on 05/29/14 at 5:09 PM that she had overheard SRNA #3 in the hall making the statement, "I hate these people, every damn one of them." Continued interview revealed the LPN was called to Resident #35's room by the resident to check the resident's blood sugar and, upon entering the resident's room, she observed Resident #35 crying. LPN #2 stated SRNA #3 had talked mean to the resident when the resident requested a cold, wet washcloth for knee pain. Further interview with LPN #2 revealed she called the DON on 05/24/14 to inform her of the incident and was told by the DON to put SRNA #3 on another hall to provide direct care, document the incident on the 24 Hour Report Sheet, and it would be investigated. However, according to the facility's policy, "...The charge nurse will immediately remove the suspected perpetrator from resident care areas, obtain the staff members witness statement and immediately suspend the employee pending the outcome of the investigation..." The LPN further revealed the nursing staff from night shift "stayed over" the morning of 05/24/14 to talk with the DON about SRNA #3's negative behaviors and to turn in the witness statements about the incident. Review of the witness statement written by LPN #3 revealed between 3:00 AM and 3:30 AM, on 05/24/14, SRNA #3 was observed coming out of Resident #35's room shouting, "I hate these people, every damn one of them." The witness statement further revealed Resident #35 had reportedly asked SRNA #3 for a wet washcloth and the SRNA had asked the resident why he/she needed the washcloth. Continued review of the witness statement revealed the SRNA talked hatefully to the resident and informed the resident he had knee problems for a long time and he did not have insurance like the residents and could not go to the doctor any time he wanted. Interview with the DON on 05/28/14 at 5:20 PM revealed the DON had been informed by facility staff by telephone on 05/24/14, that SRNA #3 had made a negative comment to Resident #35 after the resident requested a washcloth. Continued interview revealed the DON informed the caller to keep SRNA #3 out of Resident #35's room. Further interview revealed the DON talked with the night shift nurses the next morning and was informed of reports that SRNA #3 had argued with staff and had cursed in the hallway. The DON obtained witness statements from staff about the incident. The DON stated the reports were nothing she considered abusive so the incident was not investigated or reported to State Agencies. In addition, the DON acknowledged the alleged perpetrator was allowed to provide resident care after receipt of the allegation and had continued to provide resident care at the facility. However, the facility's policy revealed, "...All allegations of abuse will be investigated and reported to the appropriate agencies...remove the suspected perpetrator from resident care areas, obtain the staff members witness statement and immediately suspend the employee pending the outcome of the investigation..." The Administrator stated in interview conducted on 05/29/14 that staff should have reported and investigated the allegations in accordance with facility policy. However, the Administrator stated facility staff had not made him aware of the witness statements involving SRNA #3 and Resident #35 until 05/28/14, four days after the alleged incident occurred on 05/24/14. **The facility provided an acceptable Allegation of Compliance (AOC) on 06/02/14. The facility implemented the following actions to remove the Immediate Jeopardy: --The allegation of abuse reported by Resident #32 was reported to the Office of Inspector General (OIG) on 05/27/14 by the DON. Resident #32 has a BIMS score greater than 8 and a statement was obtained on 05/25/14. The alleged perpetrator was suspended on 05/25/14. The facility's investigation was initiated and ongoing with a five-day report to be submitted to OIG on 05/30/14. All residents were assessed for any signs and symptoms of abuse/neglect. Those residents with BIMS scores greater than 8 were interviewed by the Social Services Director or Chaplain for any abuse/neglect concerns on 05/29/14. On 05/29/14, the Assistant Directors of Nursing (ADONs) assessed the physical status of residents with BIMS scores less than 8 for any signs and symptoms of abuse/neglect. The facility attempted to contact the 41 Power of Attorneys (POAs) for the residents with a BIMS score less than 8 to ask if they had any concerns related to abuse/neglect and successfully contacted 26; the Social Services Director, the Chaplain, the DON, and/or the Administrator will continue to attempt to contact the remaining 15 POAs until all have successfully been contacted. --The allegation of abuse related to Resident #33 that occurred on 05/24/14 was reported to OIG on 05/29/14 by the DON and reported to Adult Protective Services (APS), the Ombudsman, the resident's physician, and the POA on 05/30/14 by the DON. A facility nurse assessed Resident #33 on 05/29/14 and the resident had a psychosocial assessment completed by the Social Services Director on 05/30/14. Resident #33 was interviewed and a statement was obtained by the facility's Social Services Director on 05/30/14. The alleged perpetrator was no longer employed by the facility. The facility's investigation was initiated and ongoing with a five-day report to be submitted to OIG on 05/30/14. All residents were assessed for any signs and symptoms of abuse/neglect. Those residents with BIMS scores greater than 8 were interviewed by the Social Services Director or Chaplain for any abuse/neglect concerns on 05/29/14. On 05/29/14, the ADONs assessed the physical status of residents with a BIMS score less than 8 for any signs and symptoms of abuse/neglect. The facility attempted to contact the 41 POAs for the residents with a BIMS score less than 8 to ask if they had any concerns related to abuse/neglect and successfully contacted 26; the Social Services Director, the Chaplain, the DON, and/or the Administrator will continue to attempt to contact the remaining 15 POAs until all have successfully have been contacted. --The allegation of abuse reported by Resident #35 was reported to the Office of Inspector General on 05/29/14 by the DON and reported to APS, the Ombudsman, the resident's physician, and the POA on 05/30/14 by the DON. Resident #35 was physically assessed by a nurse and psychosocially assessed by the Social Services Director on 05/30/14. Resident #35 was interviewed and a statement was obtained by the Social Services Director on 05/30/14. The alleged perpetrator is no longer employed by the facility. The facility's investigation was initiated and ongoing with a five-day report to be submitted to OIG on 05/30/14. All residents were assessed for any signs and symptoms of abuse/neglect. Those residents with BIMS scores greater than 8 were interviewed by the Social Services Director or Chaplain for any abuse/neglect concerns on 05/29/14. On 05/29/14, the ADONs assessed the physical status of residents with BIMS scores less than 8 for any signs and symptoms of abuse/neglect. The facility attempted to contact the 41 POAs for the residents with a BIMS score less than 8 to ask if they had any concerns related to abuse/neglect and successfully contacted 26; the Social Services Director, the Chaplain, the DON, and/or the Administrator will continue to attempt to contact the remaining 15 POAs until all have successfully have been contacted. --All residents were assessed for any signs and symptoms of abuse/neglect. Those residents with BIMS scores greater than 8 were interviewed by the Social Services Director or Chaplain for any abuse/neglect concerns on 05/29/14. On 05/29/14, the ADONs assessed the physical status of residents with BIMS scores less than 8 for any signs and symptoms of abuse/neglect. The facility attempted to contact the 41 POAs for the residents with a BIMS score less than 8 to ask if they had any concerns related to abuse/neglect and successfully contacted 26; the Social Services Director, the Chaplain, the DON, and/or the Administrator will continue to attempt to contact the remaining 15 POAs until all have successfully been contacted. The Administrator, the Regional Nurse Consultant, and the Chief Nurse Executive reviewed abuse/neglect audits, assessments, interviews, and questionnaires on 05/30/14 for any indications of abuse/neglect concerns. --The facility's Regional Nurse Consultant from the corporate office re-educated the facility Administrator, the DON, the ADONs, the Minimum Data Set (MDS) Coordinator, the Staff Development Coordinator (SDC), the Director of Dining Services, the Business Office Manager, the Social Services Director, the Activities Director, the Chaplain, Marketing/Admissions, Medical Records, Human Resources, and Wound Care staff on 05/29/14 on the facility's abuse policy and procedure. The education included but was not limited to thorough investigations, reporting immediately, and the Quality Assurance Performance Improvement (QAPI) process, including reporting of concerns to the Administrator and floor staff participation in development of QAPI plans. This training was performed face to face in order to facilitate discussion and questions and included examples of items that would be considered as reportable: reports of staff being mean, injuries of unknown origin, withholding belongings, resident-to-resident altercations to include verbal or physical, and taking belongings or exploitation. Department administrative managers were not allowed to return to work until abuse education was provided, post-tests administered, and a score of 100% obtained. If the manager did not score 100% on post-test, then the manager was immediately re-educated and re-tested . This process continued until all managers obtained a 100% score on the post-test. All post-tests were reviewed for compliance by the Chief Nursing Executive (CNE). --After the facility Administrator, DON, ADONs, Minimum Data Set (MDS) Coordinator, Staff Development Coordinator (SDC), Director of Dining Services, Business Office Manager, Social Services Director, Activities Director, Chaplain, Marketing/Admissions staff, Medical Records staff or Director, Human Relations (HR) staff, or Wound Care staff were re-educated on the abuse policy, the Administrative staff was assigned to re-educate the staff on the abuse policy and procedure which included but was not limited to reporting, protection, and investigation requirements, which started on 05/29/14. The facility did not allow any employee to work until abuse education was provided, post-test administered, and 100% score obtained. If the employee did not score 100% on the post-test, the employee was immediately re-educated and the post-test re-administered. This process continued until all employees obtained a 100% score on the post-test. Education regarding the abuse policy and procedure, including identification/reporting and the Quality Assurance Performance Improvement process was added in the orientation process for all newly hired staff members. No newly hired employee would be allowed to work until abuse education was provided, post-test administered, and 100% score obtained. If the employee did not score 100% on the post-test, the employee was immediately re-educated and re-tested . This process continued until employees obtained a 100% score on the post-test. --Staff questionnaires regarding abuse, including the question, "What would you do if a resident told you that you were mean to them?" were administered by the Administrator, DON, ADONs, MDS Coordinator, SDC, Director of Dining Services, Business Office Manager, Social Services Director, Activities Director, Chaplain, Marketing/Admissions, Medical Records, HR, or Wound Care staff to five staff members on each shift and different staff members until immediacy was removed. After removal of immediacy, ten staff questionnaires were administered to staff daily to ensure continued understanding of the abuse/neglect policy and procedure, appropriate investigating, and reporting of abuse/neglect. The questionnaire also included questions related to the QAPI process to include reporting of concerns to the Administrator and floor staff participation in development of the QAPI plan. Results of the staff questionnaire were reported to the Quality Assurance (QA) Committee weekly to determine the further need of continued education or revision of the plan. At that time, based on evaluation, the QA Committee would determine at what frequency the staff questionnaire would need to continue. Concerns identified were corrected immediately and reported to the Administrator to ensure investigation of suspected abuse/neglect was investigated/completed and reporting guidelines were met. --HR performed an audit of all personnel files for any abuse concerns on 05/29/14. Items that were reviewed: Coaching and Counseling forms, suspension forms, and termination forms. Results of the audit were given to the Chief Nursing Executive on 05/30/14, to review for any abuse/neglect concerns that needed reporting. There were no concerns identified. --A nurse from the facility's regional team or corporate office had been on-site since 05/29/14 and remained in the facility daily until the jeopardy was removed. The nurses from the regional team or home office assisted with investigations, observed staff treatment of [REDACTED]. The Chief Nurse Executive, Clinical Compliance Nurse, or Director of Clinical Programs were in daily contact with the regional nurse consultant and reviewed allegations. --All facility grievances filed since 04/01/14 were reviewed by the Administrator, DON, or Regional Nurse Consultant on 05/30/14 to determine if any items documented were a reportable event. The Administrator was notified of one allegation of possible abuse. The Administrator reported the allegations to the Office of Inspector General on 05/30/14. The Administrator, Social Services Director, or the Director of Nursing reviewed the grievances and incident/accident reports daily, until immediacy was lifted, which was initiated on 05/29/14, to determine if there were reportable allegations that had not been identified. The Social Services Director or the Director of Nursing reported to the Administrator any identified allegations of abuse, neglect, or misappropriation immediately after their review. The Administrator will report any allegations of abuse, neglect, or misappropriation to the Office of Inspector General, Adult Protective Services, and the Ombudsman. --An emergency resident council meeting was held on 05/30/14; the Administrator and SDC attended the meeting to discuss any abuse/neglect concerns and to provide education on whom to report any abuse/neglect concerns without fear of retribution. The Social Services Director attempted to contact the POAs of all residents with BIMS scores less than 8 to discuss any abuse/neglect concerns and to provide education on whom to report any abuse/neglect concerns without fear of retribution on 05/30/14. --The Administrator, DON, ADONs, MDS Coordinator, SDC, Director of Dining Services, Business Office Manager, Social Services Director, Activities Director, Chaplain, Marketing/Admissions, Medical Records, HR, and Wound Care Nurse (one per shift) were to be on-site each shift to perform walking rounds in which ten residents (five with BIMS scores greater than 8 and five with BIMS scores less than 8) were visited by the Department Head and those residents that could be interviewed were interviewed regarding the staff treatment. The Department Head visited and a nurse conducted a skin check on the residents that were not able to be interviewed. The Department Head also spoke to nursing staff and State Registered Nursing Assistants (SRNAs) regarding any noted changes in the residents' behaviors. The facility Department Head also interviewed five staff members each shift regarding the types of abuse, who the facility's Abuse Coordinator was, when to report suspected abuse, what to do if the resident reported you were mean to them, etc., which began on 05/29/14 and continued until the immediate jeopardy was lifted. Results of resident and staff questionnaires were reported to the Administrator, DON, Regional Nurse Consultant, or Vice President (VP) of Operations daily and if the Administrator was not in the facility, the Department Director conducted the questionnaires and telephoned the Administrator or VP of Operations with the results of the resident and staff questionnaires. This continued until the immediate jeopardy was lifted. --The DON, ADONs, MDS Coordinator, SDC, Director of Dining Services, Business Office Manager, Social Services Director, Activities Director, Chaplain, Marketing/Admissions, Medical Records, HR, or Wound Care staff immediately notified the Administrator of any concerns regarding the above resident and staff questionnaires related to abuse, mistreatment, neglect, or misappropriation and ensured the resident was safe. A binder (which contains a resident roster in which the interview date and shift is noted next to the resident name), which is passed on to each Department Head assigned to perform the resident and staff questionnaires each shift, to ensure that residents with BIMS scores greater than 8 were interviewed and residents with BIMS scores less than 8 were visited and skin checks completed, began on 05/29/14 and continued until the jeopardy was lifted. The MDS Coordinators had the responsibility for updating the binder weekly to identify residents with BIMS scores greater than 8 and residents with BIMS scores less than 8. If abuse, mistreatment, neglect, or misappropriation was alleged during the interviews or visits or reported by a staff member, the Department Head ensured the resident was safe, reported to a Charge Nurse, the Charge Nurse removed the alleged perpetrator to a non-patient care area, and notified the Administrator, Director of Nursing, and/or Social Services Director/Abuse Coordinator. The alleged perpetrator was suspended and an investigation began immediately. --The Administrator, Director of Nursing, Social Services Director, or a member of the facility's regional staff reviewed all resident and staff questionnaires daily for any grievances/concerns. Investigations

Based on interview, record review, review of the facility's investigation, review of the facility's Abuse, Neglect and Misappropriation policy, dated April 2013, and review of the job description for the Administrator, it was determined the Administrator failed to administer the facility in a manner to ensure its resources, including policies related to abuse and neglect, were implemented to maintain the highest practicable physical, mental, and psychosocial well-being for two (2) of three (3) sampled residents (Residents #32 and #35). Interviews and review of witness statements revealed on 05/24/14 Resident #35 reported that State Registered Nurse Aide (SRNA) #3 talked mean to him/her when the resident had requested a cold, wet washcloth. Even though the facility identified the alleged perpetrator in the incident related to Resident #35 as State Registered Nurse Aide (SRNA) #3, the facility failed to protect the residents as per facility policy which indicated, "...The charge nurse will immediately remove the suspected perpetrator from resident care areas, obtain the staff members witness statement and immediately suspend the employee pending the outcome of the investigation..." In addition, review of incident reports and interviews revealed on 05/25/14 staff observed bruising to Resident #32's arm and the resident alleged "fat Pat grabbed" his/her arm. The facility identified the alleged perpetrator as SRNA #2. Interviews revealed SRNA #2 was suspended on 05/25/14 while the Director of Nursing (DON) investigated the incident. Although the facility had not assessed or interviewed other residents for signs of abuse, and had not interviewed staff related to care delivered by the alleged perpetrator to facility residents, the SRNA was allowed to return to work to provide direct resident care on 05/26/14. The DON stated she hadn't felt "like it was an allegation of abuse" because the resident reported different stories about the incident. Interview and record review revealed the facility's Administration failed to ensure allegations of abuse and neglect were reported immediately to appropriate State Agencies; and failed to ensure residents were protected from potential abuse while an investigation of the alleged abuse was conducted. In addition, the facility's Administration failed to ensure the facility's investigation included resident and staff interviews and assessment of other residents for signs of abuse and neglect. (Refer to F225 and 226.) The facility's policy revealed, "...remove the suspected perpetrator from resident care areas, obtain the staff members witness statement and immediately suspend the employee pending the outcome of the investigation...The Administrator and/or DON will notify state agencies according to their reporting guidelines..." Section II, "Training/Identification/Prevention," of the facility policy revealed staff is trained to identify "...Signs & Symptoms of abuse (bruises, injuries of unknown origin, crying, fearful, increased agitation, and withdrawal)..." as part of their orientation. In addition, review of the job description for the facility's Administrator revealed the Administrator would "lead and direct the overall operations of the facility in accordance with customer needs, government regulations and Company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives." The Administration's failure to ensure the facility's policies/procedures related to abuse prevention were implemented caused, or was likely to cause, serious injury, harm, impairment, or death to residents at the facility. Immediate Jeopardy was determined to exist on 05/24/14 at 42 CFR 483.13 Resident Behavior and Facility Practices (F225 and F226) and 483.75 Administration (F490 and F520) with Substandard Quality of Care at 42 CFR 483.13 Resident Behavior and Facility Practices (F225 and F226). The facility was notified of the Immediate Jeopardy on 05/29/14. An acceptable Allegation of Compliance was received on 06/02/14 which alleged removal of the Immediate Jeopardy on 05/31/14. A partial extended survey was conducted on 06/03/14 and 06/04/14. The State Survey Agency determined the Immediate Jeopardy was removed on 05/31/14 as alleged, which lowered the Scope and Severity to "D" at 42 CFR 483.13 Resident Behavior and Facility Practices (F225 and F226) and "D" at 42 CFR 483.75 Administration (F490 and F520) while the facility monitors the effectiveness of systemic changes and quality assurance activities. (Refer to F225, F226, and F520.) The findings include: The facility's policy entitled "Abuse, Neglect and Misappropriation," revised March 2013, revealed "...All allegations of abuse involving abuse along with injuries of unknown origin are reported immediately to the charge nurse and/or administrator of the facility along with other officials in accordance with State law through established guidelines..." In addition, the policy revealed, "...The charge nurse will immediately remove the suspected perpetrator from resident care areas, obtain the staff members witness statement and immediately suspend the employee pending the outcome of the investigation..." The policy revealed, "...The charge nurse will immediately notify the Administrator, DON and/or Abuse Coordinator as appropriate...The Administrator and/or DON will notify state agencies according to their reporting guidelines..." In addition, according to the policy, "...All allegations of abuse will be investigated and reported to the appropriate agencies...The Administrator/designee will make all reasonable efforts to investigate and address alleged reports, concerns, and grievances..." According to section II, "Training/Identification/Prevention," of the facility policy, staff is trained to identify "...Signs & Symptoms of abuse (bruises, injuries of unknown origin, crying, fearful, increased agitation, and withdrawal)..." as part of their orientation. Review of the facility's "Job Description" for "Administrator," dated December 2011, revealed the Administrator would "lead and direct the overall operations of the facility in accordance with customer needs, government regulations and Company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives." Review of an incident report dated 05/25/14, revealed facility staff observed bruising to Resident #32's wrist/forearm area on 05/25/14 at 4:00 AM. Further review of the incident report revealed the resident stated, "Fat Pat grabbed my arm and wouldn't let go; I had to pull myself loose." Interview conducted with Licensed Practical Nurse (LPN) #1 on 05/29/14 at 11:53 AM revealed she had assessed Resident #32 when the bruises were identified on 05/25/14, and had immediately notified the DON. Interview with the Administrator on 05/29/14 at 6:17 PM revealed staff had notified him on 05/25/14 of the bruises to Resident #32's arm and forearm. The facility determined the alleged perpetrator was identified as SRNA #2. Further interviews revealed the SRNA was suspended on 05/25/14 while the DON investigated the incident. The Administrator further stated the facility had not assessed or interviewed other residents for signs of abuse, and staff had not been interviewed related to care delivered by the alleged perpetrator to facility residents. However, the facility's policy stated, "...All allegations of abuse involving abuse along with injuries of unknown origin are reported immediately to the charge nurse and/or administrator of the facility along with other officials in accordance with State law through established guidelines...The charge nurse will immediately remove the suspected perpetrator from resident care areas, obtain the staff members witness statement and immediately suspend the employee pending the outcome of the investigation..." **The facility provided an acceptable Allegation of Compliance (AOC) on 06/02/14. The facility implemented the following actions to remove the Immediate Jeopardy: --The allegation of abuse reported by Resident #32 was reported to the Office of Inspector General (OIG) on 05/27/14 by the DON. Resident #32 has a BIMS score greater than 8 and a statement was obtained on 05/25/14. The alleged perpetrator was suspended on 05/25/14. The facility's investigation was initiated and ongoing with a five-day report to be submitted to OIG on 05/30/14. All residents were assessed for any signs and symptoms of abuse/neglect. Those residents with BIMS scores greater than 8 were interviewed by the Social Services Director or Chaplain for any abuse/neglect concerns on 05/29/14. On 05/29/14, the Assistant Directors of Nursing (ADONs) assessed the physical status of residents with BIMS scores less than 8 for any signs and symptoms of abuse/neglect. The facility attempted to contact the 41 Power of Attorneys (POAs) for the residents with a BIMS score less than 8 to ask if they had any concerns related to abuse/neglect and successfully contacted 26; the Social Services Director, the Chaplain, the DON, and/or the Administrator will continue to attempt to contact the remaining 15 POAs until all have successfully been contacted. --The allegation of abuse related to Resident #33 that occurred on 05/24/14 was reported to OIG on 05/29/14 by the DON and reported to Adult Protective Services (APS), the Ombudsman, the resident's physician, and the POA on 05/30/14 by the DON. A facility nurse assessed Resident #33 on 05/29/14 and the resident had a psychosocial assessment completed by the Social Services Director on 05/30/14. Resident #33 was interviewed and a statement was obtained by the facility's Social Services Director on 05/30/14. The alleged perpetrator was no longer employed by the facility. The facility's investigation was initiated and ongoing with a five-day report to be submitted to OIG on 05/30/14. All residents were assessed for any signs and symptoms of abuse/neglect. Those residents with BIMS scores greater than 8 were interviewed by the Social Services Director or Chaplain for any abuse/neglect concerns on 05/29/14. On 05/29/14, the ADONs assessed the physical status of residents with a BIMS score less than 8 for any signs and symptoms of abuse/neglect. The facility attempted to contact the 41 POAs for the residents with a BIMS score less than 8 to ask if they had any concerns related to abuse/neglect and successfully contacted 26; the Social Services Director, the Chaplain, the DON, and/or the Administrator will continue to attempt to contact the remaining 15 POAs until all have successfully have been contacted. --The allegation of abuse reported by Resident #35 was reported to the Office of Inspector General on 05/29/14 by the DON and reported to APS, the Ombudsman, the resident's physician, and the POA on 05/30/14 by the DON. Resident #35 was physically assessed by a nurse and psychosocially assessed by the Social Services Director on 05/30/14. Resident #35 was interviewed and a statement was obtained by the Social Services Director on 05/30/14. The alleged perpetrator is no longer employed by the facility. The facility's investigation was initiated and ongoing with a five-day report to be submitted to OIG on 05/30/14. All residents were assessed for any signs and symptoms of abuse/neglect. Those residents with BIMS scores greater than 8 were interviewed by the Social Services Director or Chaplain for any abuse/neglect concerns on 05/29/14. On 05/29/14, the ADONs assessed the physical status of residents with BIMS scores less than 8 for any signs and symptoms of abuse/neglect. The facility attempted to contact the 41 POAs for the residents with a BIMS score less than 8 to ask if they had any concerns related to abuse/neglect and successfully contacted 26; the Social Services Director, the Chaplain, the DON, and/or the Administrator will continue to attempt to contact the remaining 15 POAs until all have successfully have been contacted. --All residents were assessed for any signs and symptoms of abuse/neglect. Those residents with BIMS scores greater than 8 were interviewed by the Social Services Director or Chaplain for any abuse/neglect concerns on 05/29/14. On 05/29/14, the ADONs assessed the physical status of residents with BIMS scores less than 8 for any signs and symptoms of abuse/neglect. The facility attempted to contact the 41 POAs for the residents with a BIMS score less than 8 to ask if they had any concerns related to abuse/neglect and successfully contacted 26; the Social Services Director, the Chaplain, the DON, and/or the Administrator will continue to attempt to contact the remaining 15 POAs until all have successfully been contacted. The Administrator, the Regional Nurse Consultant, and the Chief Nurse Executive reviewed abuse/neglect audits, assessments, interviews, and questionnaires on 05/30/14 for any indications of abuse/neglect concerns. --The facility's Regional Nurse Consultant from the corporate office re-educated the facility Administrator, the DON, the ADONs, the Minimum Data Set (MDS) Coordinator, the Staff Development Coordinator (SDC), the Director of Dining Services, the Business Office Manager, the Social Services Director, the Activities Director, the Chaplain, Marketing/Admissions, Medical Records, Human Resources, and Wound Care staff on 05/29/14 on the facility's abuse policy and procedure. The education included but was not limited to thorough investigations, reporting immediately, and the Quality Assurance Performance Improvement (QAPI) process, including reporting of concerns to the Administrator and floor staff participation in development of QAPI plans. This training was performed face to face in order to facilitate discussion and questions and included examples of items that would be considered as reportable: reports of staff being mean, injuries of unknown origin, withholding belongings, resident-to-resident altercations to include verbal or physical, and taking belongings or exploitation. Department administrative managers were not allowed to return to work until abuse education was provided, post-tests administered, and a score of 100% obtained. If the manager did not score 100% on post-test, then the manager was immediately re-educated and re-tested . This process continued until all managers obtained a 100% score on the post-test. All post-tests were reviewed for compliance by the Chief Nursing Executive (CNE). --After the facility Administrator, DON, ADONs, Minimum Data Set (MDS) Coordinator, Staff Development Coordinator (SDC), Director of Dining Services, Business Office Manager, Social Services Director, Activities Director, Chaplain, Marketing/Admissions staff, Medical Records staff or Director, Human Relations (HR) staff, or Wound Care staff were re-educated on the abuse policy, the Administrative staff was assigned to re-educate the staff on the abuse policy and procedure which included but was not limited to reporting, protection, and investigation requirements, which started on 05/29/14. The facility did not allow any employee to work until abuse education was provided, post-test administered, and 100% score obtained. If the employee did not score 100% on the post-test, the employee was immediately re-educated and the post-test re-administered. This process continued until all employees obtained a 100% score on the post-test. Education regarding the abuse policy and procedure, including identification/reporting and the Quality Assurance Performance Improvement process was added in the orientation process for all newly hired staff members. No newly hired employee would be allowed to work until abuse education was provided, post-test administered, and 100% score obtained. If the employee did not score 100% on the post-test, the employee was immediately re-educated and re-tested . This process continued until employees obtained a 100% score on the post-test. --Staff questionnaires regarding abuse, including the question, "What would you do if a resident told you that you were mean to them?" were administered by the Administrator, DON, ADONs, MDS Coordinator, SDC, Director of Dining Services, Business Office Manager, Social Services Director, Activities Director, Chaplain, Marketing/Admissions, Medical Records, HR, or Wound Care staff to five staff members on each shift and different staff members until immediacy was removed. After removal of immediacy, ten staff questionnaires were administered to staff daily to ensure continued understanding of the abuse/neglect policy and procedure, appropriate investigating, and reporting of abuse/neglect. The questionnaire also included questions related to the QAPI process to include reporting of concerns to the Administrator and floor staff participation in development of the QAPI plan. Results of the staff questionnaire were reported to the Quality Assurance (QA) Committee weekly to determine the further need of continued education or revision of the plan. At that time, based on evaluation, the QA Committee would determine at what frequency the staff questionnaire would need to continue. Concerns identified were corrected immediately and reported to the Administrator to ensure investigation of suspected abuse/neglect was investigated/completed and reporting guidelines were met. --HR performed an audit of all personnel files for any abuse concerns on 05/29/14. Items that were reviewed: Coaching and Counseling forms, suspension forms, and termination forms. Results of the audit were given to the Chief Nursing Executive on 05/30/14, to review for any abuse/neglect concerns that needed reporting. There were no concerns identified. --A nurse from the facility's regional team or corporate office had been on-site since 05/29/14 and remained in the facility daily until the jeopardy was removed. The nurses from the regional team or home office assisted with investigations, observed staff treatment of [REDACTED]. The Chief Nurse Executive, Clinical Compliance Nurse, or Director of Clinical Programs were in daily contact with the regional nurse consultant and reviewed allegations. --All facility grievances filed since 04/01/14 were reviewed by the Administrator, DON, or Regional Nurse Consultant on 05/30/14 to determine if any items documented were a reportable event. The Administrator was notified of one allegation of possible abuse. The Administrator reported the allegations to the Office of Inspector General on 05/30/14. The Administrator, Social Services Director, or the Director of Nursing reviewed the grievances and incident/accident reports daily, until immediacy was lifted, which was initiated on 05/29/14, to determine if there were reportable allegations that had not been identified. The Social Services Director or the Director of Nursing reported to the Administrator any identified allegations of abuse, neglect, or misappropriation immediately after their review. The Administrator will report any allegations of abuse, neglect, or misappropriation to the Office of Inspector General, Adult Protective Services, and the Ombudsman. --An emergency resident council meeting was held on 05/30/14; the Administrator and SDC attended the meeting to discuss any abuse/neglect concerns and to provide education on whom to report any abuse/neglect concerns without fear of retribution. The Social Services Director attempted to contact the POAs of all residents with BIMS scores less than 8 to discuss any abuse/neglect concerns and to provide education on whom to report any abuse/neglect concerns without fear of retribution on 05/30/14. --The Administrator, DON, ADONs, MDS Coordinator, SDC, Director of Dining Services, Business Office Manager, Social Services Director, Activities Director, Chaplain, Marketing/Admissions, Medical Records, HR, and Wound Care Nurse (one per shift) were to be on-site each shift to perform walking rounds in which ten residents (five with BIMS scores greater than 8 and five with BIMS scores less than 8) were visited by the Department Head and those residents that could be interviewed were interviewed regarding the staff treatment. The Department Head visited and a nurse conducted a skin check on the residents that were not able to be interviewed. The Department Head also spoke to nursing staff and State Registered Nursing Assistants (SRNAs) regarding any noted changes in the residents' behaviors. The facility Department Head also interviewed five staff members each shift regarding the types of abuse, who the facility's Abuse Coordinator was, when to report suspected abuse, what to do if the resident reported you were mean to them, etc., which began on 05/29/14 and continued until the immediate jeopardy was lifted. Results of resident and staff questionnaires were reported to the Administrator, DON, Regional Nurse Consultant, or Vice President (VP) of Operations daily and if the Administrator was not in the facility, the Department Director conducted the questionnaires and telephoned the Administrator or VP of Operations with the results of the resident and staff questionnaires. This continued until the immediate jeopardy was lifted. --The DON, ADONs, MDS Coordinator, SDC, Director of Dining Services, Business Office Manager, Social Services Director, Activities Director, Chaplain, Marketing/Admissions, Medical Records, HR, or Wound Care staff immediately notified the Administrator of any concerns regarding the above resident and staff questionnaires related to abuse, mistreatment, neglect, or misappropriation and ensured the resident was safe. A binder (which contains a resident roster in which the interview date and shift is noted next to the resident name), which is passed on to each Department Head assigned to perform the resident and staff questionnaires each shift, to ensure that residents with BIMS scores greater than 8 were interviewed and residents with BIMS scores less than 8 were visited and skin checks completed, began on 05/29/14 and continued until the jeopardy was lifted. The MDS Coordinators had the responsibility for updating the binder weekly to identify residents with BIMS scores greater than 8 and residents with BIMS scores less than 8. If abuse, mistreatment, neglect, or misappropriation was alleged during the interviews or visits or reported by a staff member, the Department Head ensured the resident was safe, reported to a Charge Nurse, the Charge Nurse removed the alleged perpetrator to a non-patient care area, and notified the Administrator, Director of Nursing, and/or Social Services Director/Abuse Coordinator. The alleged perpetrator was suspended and an investigation began immediately. --The Administrator, Director of Nursing, Social Services Director, or a member of the facility's regional staff reviewed all resident and staff questionnaires daily for any grievances/concerns. Investigations of grievances/concerns were initiated upon receipt, starting on 05/30/14. --Nursing Administration (DON, ADONs, Unit Managers, SDC, MDS staff, facility formulary nurse), or the Medical Records or Social Services Director, reviewed documentation in the Nursing Notes in order to assess for any signs of documented evidence regarding abuse, neglect, or misappropriation daily on ten different residents each day. If any of the above concerns were identified, the member of Nursing Administration first ensured the resident was safe by performing an assessment and then notified a Charge Nurse. The abuse policy was followed in which the alleged perpetrator was removed from a resident care area (if on duty) and the Administrator, DON, or Social Services Director was notified. --All resident charts were reviewed from 04/01/14 by Nursing Administration (DON, ADONs, Unit Manager, Staff Development Coordinator, MDS staff, Facility Formulary Nurse, Medical Records, Marketing/Admissions, or Social Services Director) or regional/corporate nurses by 05/30/14 for any documentation regarding abuse with no new incident being identified. Ten charts were reviewed by a member of Nursing Administration or the facility's regional or home office nurse daily to ensure that no other abuse allegations had been documented but not reported. This continued until the immediate jeopardy was removed. --The Administrator, Director of Nursing, and Social Services Director reviewed and discussed all abuse investigations daily to ensure that the residents were protected, the alleged perpetrator was removed from the resident care area, reports to the Office of Inspector General were filed timely, and a thorough investigation was completed. The Administrator maintained an abuse investigation log that included documentation of the following: ensured protection of residents, removed perpetrator from resident care area, reports to the Office of Inspector General filed timely, and thorough investigations completed. The Administrator and one of the following, Chief Operating Officer, Chief Nurse Executive, or Regional Nurse Consultant, reviewed the abuse investigation to ensure protection of the resident; that the perpetrator was removed from the resident care area; that reports to the Office of Inspector General were filed timely; and that a thorough investigation had been completed. This will occur daily until removal of immediate jeopardy. --For new reports of alleged abuse, neglect, or misappropriation of property, after the immediate jeopardy was removed, one of the following was contacted prior to making the final five-day investigation report to OIG: Signature Care Consultant, VP of Operations, Chief Operating Officer, Special Projects Administrator, or Chief Nursing Executive. The reviewer (Signature Care Consultant, VP of Operations, Chief Operating Office, Special Projects Administrator, or Chief Nursing Executive) ensured the resident was protected, report was filed timely, the perpetrator was removed from the patient care area, and a thorough investigation was completed. --With any new report of alleged abuse, neglect, or misappropriation of property, one of the following was contacted within 24 hours to review the abuse investigation to ensure that a thorough investigation was completed and reporting timelines were met: Signature Care Consultant, VP of Operations, Chief Operating Office, Special Projects Administrator, or CNE. --All incident reports from January 2014 to 03/29/14 were reviewed by the Director of Nursing, the Assistant Director of Nursing, Staff Development Coordinator, or Regional Nurse Consultant to identify any concerns of suspected neglect by 05/30/14. None was identified. --During care plan conference for each resident, any abuse/neglect concerns were discussed and abuse/neglect education, to include reporting, was provided to the resident and/or POA with supporting documentation noted. --Administrative oversight of the facility was completed by the Special Projects Administrator, the Regional Vice President of Operations, a member of regional staff, or the CEO daily until removal of immediacy beginning 05/29/14, then weekly for four weeks, and then monthly. --The DON, ADONs, or SDC observed the care delivery for any suspected abuse/neglect concerns on five residents daily until the removal of immediacy and then weekly (Monday through Friday). The results of the care delivery audits were reported to the QA Committee weekly to determine the further need of continued education or revision of plan. At that time, based on evaluation, the QA Committee would determine at what frequency the audits needed to continue. Concerns identified were corrected immediately and reported to the Administrator to ensure investigations of suspected abuse/neglect were investigated/completed and reporting guidelines were met. --A Quality Assurance meeting was held weekly for four weeks beginning 05/29/14, then monthly for recommendations and further follow-up regarding the above stated plan. At that time, based upon evaluation, the QA Committee would determine at what frequency any ongoing audits would need to continue. The Administrator had the oversight to ensure an effective plan was in place to meet resident well-being as well as an effective plan to identify facility concerns and implement a plan of correction to involve all staff of the facility. Corporate Administrative oversight of the Quality Assurance meeting was to be completed by the Special Projects Administrator, the Regional Vice President of Operations, a member of regional staff, or the Chief Executive Officer (CEO) daily until removal of immediacy beginning 05/29/14, then weekly for four weeks, and then monthly. **The surveyors validated the Immediate Jeopardy was removed as follows: Review of the facility's investigation and interviews with Administrative Staff revealed the allegation involving Resident #32 was investigated and reported to the appropriate State agency. The investigation included interviews with staff and residents and physical assessments of residents that were not interviewable. The investigation also included interviews with POAs, questioning for any concerns related to abuse or neglect. Review of the facility's investigation and interviews with Administrative staff revealed the allegation involving Resident #33 was investigated and reported to the appropriate state agency. The investigation included interviews with staff and residents and physical assessments of residents that were not interviewable. The investigation also included interviews with POAs, questioning for any concerns related to abuse or neglect. Review of the facility's investigation and interviews with Administrative staff revealed the allegation that involved Resident #35 was investigated and reported to the appropriate state agency. The investigation included interviews with Resident #35, staff, and residents and physical assessments of residents that were not interviewable. The investigation also included interviews with POAs, questioning for any concerns related to abuse or neglect. Review of the facility's assessments for signs and symptoms of abuse and resident interviews revealed the facility completed them on 05/29/14. Interview with the Regional Nurse Consultant on 06/04/14 at 9:15 AM revealed as of 06/03/14, only six POAs had not been contacted so the facility sent the abuse/neglect questionnaire by certified mail to the POAs. A review of the abuse/neglect assessments, abuse/neglect audits, and abuse/neglect interviews revealed the Administrative staff provided validation and oversight. Review of Administrative staff education and testing, provided on 05/29/14, related to abuse/neglect policy, investigations, reporting, and the Quality Assessment process was reviewed and validated by the Chief Nursing Executive (CNE). Review of staff education and post-testing related to the abuse policy and procedure which included reporting, protection, and investigation requirements revealed the education was provided on 05/29/14, as per the AOC. Interview with the Regional Nurse Consultant on 06/04/14 at 9:15 AM, revealed during the staff in-service examples were given of different situations of abuse/neglect and the staff had to explain the appropriate actions. Further interview with the Regional Nurse Consultant revealed the facility had not hired any new employees. A review of the staff questionnaire regarding abuse was being done as reported in the AOC. Interview on 06/04/14 at 9:15 AM with the Regional Nurse Consultant revealed no issues had been identified through the staff questionnaires. Review of the HR Audits of personnel files revealed the CNE validated review by signature on the back of the audit forms. Interview with the Regional Nurse Consultant on 06/04/14 at 9:15 AM revealed there were no issues identified with the review of the employee files. Interview on 06/04/14 at 9:15 AM with the Regional Nurse Consultant revealed a corporate staff member had been at the facility since the jeopardy was identified and had been reviewing all allegations to ensure a thorough investigation was conducted. Further interview revealed the corporate staff was also conducting chart audits, observed staff treatment of [REDACTED]. Interview on 06/04/14 at 9:15 AM with the Regional Nurse Consultant revealed all facility grievances f

Based on observation, interview, record review, review of the facility's investigation, and review of facility policies, it was determined the facility failed to ensure all allegations of resident neglect were investigated and reported immediately to the State Survey Agency and other officials in accordance with state law for one (1) of twenty-one (21) sampled residents (Resident #8). Review of the medical record revealed a copy of a History and Physical report from an acute care facility, dated 08/27/13, that revealed Resident #8 was allergic to [MEDICATION NAME] (antibiotic). In addition, interview conducted with Resident #8 on 03/26/14 at 2:25 PM revealed the resident had told Registered Nurse (RN) #1 on the day of his/her admission to the facility that he/she was allergic to [MEDICATION NAME]. Review of an Admission Assessment completed by Registered Nurse (RN) #1 for Resident #8, dated 09/09/13, revealed the nurse had not identified and/or documented the resident was allergic to [MEDICATION NAME]. Documentation revealed that from 03/08/14 to 03/11/14, facility staff administered seven doses of [MEDICATION NAME] to Resident #8. On 03/11/14, Resident #8 complained of chest tightness, asked the nurse what medications he/she had received, and was told by the nurse that she had received [MEDICATION NAME]. Record review revealed the [MEDICATION NAME] was discontinued and the facility conducted an investigation of the incident. The facility's investigation revealed RN #1 reviewed all medications with Resident #8 at the time of admission and had not been aware of any allergy the resident had to [MEDICATION NAME]. However, based on a review of the facility's investigation, the facility failed to conduct a review of Resident #8's medical record that included the History and Physical from the acute care facility that indicated the resident had an allergy to [MEDICATION NAME] and failed to report the incident of neglect to the appropriate state agencies. The facility's failure to immediately report all allegations of abuse, neglect, exploitation, and misappropriation of resident property, and failure to investigate an allegation of abuse or neglect caused or was likely to cause serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy with Substandard Quality of Care was determined to exist on 03/08/14 at 42 CFR 483.13 Resident Behavior and Facility Practices (F225), 42 CFR 483.25 Quality of Care (F333), 42 CFR 483.60 Pharmacy Services (F428), and 42 CFR 483.75 Administration (F520) at a scope and severity of "J." Substandard Quality of Care was identified at 42 CFR 483.13 Resident Behavior and Facility Practices (F225) and 42 CFR 483.25 Quality of Care (F333). The facility was notified of the Immediate Jeopardy on 03/28/14. An acceptable Allegation of Compliance was received on 04/01/14 which alleged removal of the Immediate Jeopardy on 03/31/14. The State Agency determined the Immediate Jeopardy was removed on 03/31/14, prior to exit, which lowered the scope/severity to "D" at 42 CFR 483.13 Resident Behavior and Facility Practices (F225), 42 CFR 483.25 Quality of Care (F333), 42 CFR 483.60 Pharmacy Services (F428), and 42 CFR 483.75 Administration (F520) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled "Abuse, Neglect, and Misappropriation," with a revision date of March 2013, revealed the Administrator would make all reasonable efforts to investigate and address alleged reports of abuse or neglect, concerns, and grievances. In addition, the policy revealed all allegations were to be reported within the timeframe allotted by the state agency. However, the policy did not define what constituted neglect. Review of Resident #8's medical record revealed the facility admitted the resident on 09/09/13 with [DIAGNOSES REDACTED]. Continued review of the medical record revealed a copy of a History and Physical report from a recent hospitalization , dated 08/27/13, that revealed Resident #8 was allergic to [MEDICATION NAME]. Resident #8's attending physician at the facility documented his initials and the date 09/09/13 on the copy of the History and Physical report as acknowledgement of receipt/review of the report. Review of the Minimum Data Set (MDS) Significant Change assessment completed by the facility for Resident #8 on 12/25/13, revealed the facility assessed the resident to have a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident's cognition was intact. Review of the physician's orders [REDACTED].#8, by mouth, twice a day for ten days for a [DIAGNOSES REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of a Communication and Progress Note for Resident #8 dated 03/11/14, at 9:30 PM, revealed Resident #8 complained of "chest tightness," asked the nurse what medications he/she had received, and was told by the nurse that he/she had received [MEDICATION NAME]. Based on documentation review, facility staff notified the resident's physician of the resident's complaints, discontinued the [MEDICATION NAME], and conducted an investigation of the incident. The Communication and Progress Note also revealed the physician requested staff to administer 50 mg of [MEDICATION NAME] (allergy medicine) orally, and 120 mg of Solu-[MEDICATION NAME] (anti-[MEDICAL CONDITION]) intramuscularly, "now" due to a possible allergic reaction. Review of an Incident/Occurrence Investigation completed by Assistant Director of Nursing (ADON) #1 dated 03/11/14, revealed Resident #8 received eight doses of [MEDICATION NAME] from 03/08/14 through 03/11/14. The investigation revealed the ADON had interviewed RN #1 who completed the admission nursing assessment for Resident #8 on 09/09/13, and noted RN #1 had reviewed all medications with Resident #8 at the time of admission and had not been aware of any allergy the resident had to [MEDICATION NAME]. However, based on documentation, the facility failed to conduct a review of the resident's medical record, to include a review of the History and Physical provided to the facility by the acute care facility that included the resident's allergy to [MEDICATION NAME], as part of the investigation. In addition, review of documentation revealed the facility failed to interview Resident #8 during the investigation of the incident and failed to report the incident to the appropriate state agencies. Resident #8 was observed on 03/25/14 at 10:55 AM to be alert and lying in bed. An interview was conducted with Resident #8 on 03/26/14 at 2:25 PM. Resident #8 stated he/she had informed RN #1 of his/her allergy to [MEDICATION NAME] on the day he/she was admitted to the facility. The resident stated the facility had not informed him/her that they had administered [MEDICATION NAME] to the resident until he/she began to have complaints of "chest tightness," asked the nurse what he/she was taking, and was told by the nurse she had given the resident [MEDICATION NAME]. RN #1 acknowledged in interview conducted on 03/27/14 at 4:00 PM that she had completed the admission assessment for Resident #8 on 09/09/13. The RN stated she reviewed all hospital paperwork sent to the facility when the resident was admitted to the facility, including the History and Physical report dated 08/27/13 from the acute care facility, and did not recall information in the medical record that indicated Resident #8 had an allergy to [MEDICATION NAME]. The RN stated she was unaware of how she had missed the documentation of the resident's allergy to [MEDICATION NAME]. Interview conducted with RN #2 on 03/27/14, at 4:55 PM, revealed Resident #8 had reported chest tightness to her on 03/11/14, at 9:50 PM. The RN stated she immediately notified the resident's attending physician and an investigation was begun immediately. The RN stated she had not identified Resident #8 had a documented allergy to [MEDICATION NAME] and had not viewed the incident as neglect. The RN stated she was aware any allegation of abuse or neglect must be reported immediately to state agencies by the Administrator and the Administrator was responsible for notifying state agencies of incidents of abuse/neglect. Interview conducted with Resident #8's physician on 03/27/14, at 3:37 PM, revealed the resident "could have been harmed" from the administration of the [MEDICATION NAME] since the resident had experienced a "similar allergic reaction with tightness in the chest" after the resident received [MEDICATION NAME] during a previous hospitalization . Interview conducted with the Director of Nursing (DON) on 03/28/14, at 8:45 AM, revealed ADON #1 had investigated the incident related to the administration of [MEDICATION NAME] to Resident #8, and acknowledged the facility had not reported the incident to the state agencies as indicated in the facility's policy because they had not identified the incident as abuse or neglect. The DON stated they had not identified the documentation located in the resident's medical record on a History and Physical report dated 08/27/13 from the acute care facility indicating the resident was allergic to [MEDICATION NAME]. The DON stated when nurses completed an admission assessment on any new or readmitted resident they were required to review all hospital paperwork sent to the facility. Interview conducted with Assistant Director of Nursing (ADON) #1 on 04/03/14, at 1:40 PM revealed she had completed the Incident/Occurrence Investigation on 03/11/14 and had not identified Resident #8 had an allergy documented on the History and Physical report dated 08/27/13 from the acute care facility. The ADON stated she had determined the resident had experienced a new allergy to the medication and had not identified the incident as abuse or neglect or as a medication error. Interview conducted with the Administrator on 03/28/14, at 9:00 AM, revealed he was responsible to report allegations of abuse and neglect to the state agencies. The Administrator stated the incident related to the administration of [MEDICATION NAME] to Resident #8 had not been reported to the state agencies because the facility had not identified the incident as an allegation of abuse or neglect. **The facility provided an acceptable Allegation of Compliance (AOC) on 04/01/14. The facility implemented the following actions to remove the Immediate Jeopardy: The physician for Resident #8 was notified by the staff nurse immediately upon identification of symptoms that may have been related to the administration of [MEDICATION NAME]. physician's orders [REDACTED]. The treatment was effective as evidenced by every shift assessment along with supporting documentation. The resident was monitored by staff nurses to ensure continued effectiveness. The physician was notified by the Assistant Director of Nursing (ADON) for Resident #6 on 03/28/14 to clarify the resident's allergy to [MEDICATION NAME]. A sheet was added in front of the resident's Medication Administration Record [REDACTED]. A care plan was initiated with interventions to decrease the risk of an allergic reaction. Chart audits to include review of hospital discharge summaries and/or discharge documentation and outside consultation visits were completed by the Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC), MDS Coordinators, and Regional Nurse Consultant on 03/27/14 for all residents to ensure allergies were appropriately identified. During the audit, allergy stickers on the outside of residents' charts were reviewed to ensure accuracy. A medication allergy sheet was completed for each resident on 03/27/14 by the DON, ADON, SDC, MDS Coordinator, and the Regional Nurse Consultant and placed in front of each resident's MARs. All allergies were clarified with the physician. The Regional Nurse Consultant, DON, and SDC initiated education for licensed staff and Kentucky Medication Aides (KMAs) on 03/27/14 and advised staff to review hospital documentation upon each resident admission or readmission to ensure allergies were appropriately identified. Licensed nursing staff/KMAs were not allowed to work prior to receiving the above stated education. A posttest was given upon completion of education. A score of 100 percent must be obtained before being allowed to work. Those staff members not obtaining a passing score of 100 percent would be educated on the spot and retested . Resident #8's attending physician, who is also the facility's Medical Director, received education from the Administrator, SDC, and the Regional Nurse Consultant on 03/28/14 regarding appropriately identifying resident allergies. The Administrator, DON, and Regional Nurse Consultant provided education to the Pharmacy Consultant on 03/28/14 regarding reviewing hospital discharge records for all residents to ensure allergies were appropriately identified. The Pharmacy Consultants were on-site on 03/29/14 and reviewed all resident records to ensure allergies were appropriately identified. The Regional Nurse Consultant provided education to the Administrator, DON, SDC, and ADONs on 03/28/14 regarding reporting of neglect for any significant medication error. The SDC, DON, ADONs, and the Regional Nurse Consultant initiated staff education on 03/28/14 regarding the abuse/neglect policy and appropriate reporting of neglect to include significant medication errors, the Quality Assurance Performance Improvement (QAPI) process to include reporting of concerns to the Administrator, and front line staff participation in development of QAPI plans. Staff was not permitted to work prior to receiving the education. A posttest was given upon completion of education. A score of 100 percent must be obtained before being allowed to work. Those staff members not obtaining a passing score of 100 percent would be educated on the spot and retested . Education regarding reporting abuse, reporting of significant medication errors, obtaining allergies from the discharge summary, resident history or POA history, verification of allergy orders from the physician, as well as places on the MAR indicated [REDACTED]. A follow-up questionnaire would be completed by the Administrator, DON, ADONs, MDS Coordinator, Social Services Director, Quality of Life Director, Dietary Manager, Plant Operations Director, Chaplain, Medical Records, Human Resources Director, SDC, Business Office Manager, Facility Formulary Nurse, or the Environmental Services Manager for ten staff members daily to include all shifts and different staff members until removal of immediacy, then weekly for four weeks, to ensure continued understanding of regarding the abuse/neglect policy and appropriate reporting of neglect to include significant medication errors, implementing care plans for allergies, the QAPI process to include reporting concerns to the Administrator, and front line staff participation in the development of QAPI plans. The Social Services Director, DON, ADONs, SDC, and MDS Coordinator conducted interviews on 03/27/14 with residents who had a BIMS score above 8 regarding their knowledge of allergies. This was compared to what was listed in the medical record and allergies were updated with assessment and/or physician's orders [REDACTED]. The Social Services Director, DON, ADONs, MDS Coordinator, Administrator, or Regional Nurse Consultant conducted interview with the responsible party for residents with a BIMS score of less than 8 by 03/27/14 to identify any allergies or concerns with medications. This was compared to what was listed in the medical record and allergies were updated with assessment and/or physician's orders [REDACTED]. Allergies will be identified on the day of admission and/or readmission by the admitting nurse on the nursing admission information document. The admission nurse will document allergies on the resident's medication allergy record that will be placed in the front of the MAR for that resident. The admitting nurse will review the resident's allergies with the resident and/or POA for confirmation. A care plan will be initiated that identifies allergies and interventions to decrease the risk of allergic reactions. The procedure which includes identification of allergies on the day of admission/readmission by the admitting nurse along with documenting the allergies on the medication allergy record, the nursing admission assessment, and the physician's orders [REDACTED]. The physician will be notified of any allergies by the charge nurse following review of all documents sent by the hospital, resident, and POA interview. Charts for newly admitted residents and readmitted residents will be reviewed and discussed in the Daily Clinical meeting on weekdays by the DON, MDS Coordinator, Social Services Director, Medical Records, SDC, ADONs, Activities Director, Dietary Manager, and Chaplain with a comparison review completed at that time of the resident's admission packet and their medication allergy form, against the hospital discharge summary and/or discharge documentation of resident allergies, to ensure that allergies are appropriately identified. On weekends, this review will be completed by the DON, ADONs, SDC, or MDS Coordinator until removal of immediacy. Following removal of immediacy, on weekends, two charge nurses will review the discharge documentation and history and physical for newly admitted or readmitted residents to ensure allergies are appropriately identified as well as all paperwork complete and accurate, care plan updated, physician notification complete, and all allergy lists updated or initialed. Allergy stickers and allergy lists were updated for all residents to include all medication allergies identified. This was completed by the Director of Nursing, Assistant Director of Nursing, MDS Coordinators, Staff Development Coordinator, and Regional Nurse Consultant on 03/28/14. Education was provided for licensed nursing staff/Kentucky Medication Aides by the Director of Nursing, Assistant Director of Nursing, the Staff Development Coordinator, and the Regional Nurse Consultant regarding all paperwork forwarded from the hospital, interview with resident/POA, verifying allergies with physician, noting allergies on the allergy sticker, allergy listings, physician orders, and MARs. Licensed nursing staff will not be allowed to work prior to receiving the above stated education. Nursing Administration to include the Director of Nursing, Assistant Directors of Nursing, Staff Development Coordinator, MDS Coordinators, Facility Formulary Nurse, or Regional Nurse Consultant are reviewing every physician's orders [REDACTED]. This will continue daily until immediacy lifted. Once immediacy is lifted a daily review will continue (Monday-Friday) by the above team. During care plan conference for each elder the allergy list will also be reviewed for any updates. Medication pass audits were completed by the Director of Nursing, Assistant Directors of Nursing, Staff Development Coordinator, and Regional Nurse Consultant for all nurses and Certified Medication Technicians working on 03/28/14 to ensure that allergies are appropriately identified and medications are administered without significant medication error. Medication pass audits will be completed for all nurses and certified medication technicians during their initial medication pass for shifts scheduled after 03/28/14 until all nurses and certified medication technicians have had a medication pass audit completed. During the medication pass audit, a questionnaire will be completed by the Director of Nursing, Assistant Directors of Nursing, Staff Development Coordinator, and Regional Nurse Consultant to ensure their knowledge of where to review for allergies prior to the administration of medication. The Assistant Director of Nursing, MDS Coordinator, or the Staff Development Coordinator will audit the Medication Administration Record [REDACTED]. All allergy clarifications for all residents have been sent to Pharmacy as of 03/29/14 in which Pharmacy has updated their listing in their computer system. Pharmacy will review all new orders and compare to any allergies listed and notify facility if an allergy exists regarding the new medication at which time the nurse will notify the physician for any new orders. All incident reports were reviewed by the Director of Nursing, the Assistant Director of Nursing, Staff Development Coordinator, or Regional Nurse Consultant to identify any further significant medication errors by 03/29/14. None was identified. All incidents or concerns are reviewed daily during the daily standup meeting to include Administrator, Director of Nursing, Assistant Director of Nursing, Dietary Manger, Chaplain, MDS Coordinators, Plant Operations Director, Medical Records, Admissions Director, Housekeeping/Central Supply Director, Quality of Life Director, Business Office Manager, Rehabilitation Manager, or Regional Staff to identify any allegation of abuse or neglect. The Administrator has been on-site daily to review all concerns or incidents to ensure abuse or neglect has been appropriately identified and reported. Administrative oversight of the facility will be completed by the Special Projects Administrator, the Regional Vice President of Operations, or the Chief Operating Officer daily until removal of immediacy, then weekly for four weeks after removal of immediacy, and then monthly. Education was provided by the Regional Nurse Consultant on 03/28/14 for the Administrator, the Director of Nursing, Assistant Directors of Nursing, Staff Development Coordinator, Quality of Life Director, Social Services Director, Plant Operations Director, Chaplain, Medical Records Coordinator, Dietary Manger, and Admission Director regarding the Quality Assurance Process and appropriate methods of identification of concerns including significant mediation errors, failure to report neglect, and auditing pharmacy services. The Administrator, Director of Nursing, Chief Operating Officer, Chief Nurse Executive, or Regional Nurse Consultant will audit compliance of the above stated audits daily until removal of immediacy, and then twice weekly for four weeks and report findings during weekly QA for four weeks, for recommendations and further follow-up as indicated. A Quality Assurance meeting was held on 03/28/14 with the Medical Director for further recommendations regarding the plan for removal of jeopardy. A Quality Assurance meeting will be held weekly for four weeks, and then monthly for recommendations and further follow-up regarding the above stated plan. **The surveyors validated the Immediate Jeopardy was removed as follows: Review of a physician's orders [REDACTED]." Review of the MAR for Resident #8 revealed staff administered 120 milligrams of Solu-[MEDICATION NAME] intramuscularly and 50 milligrams of [MEDICATION NAME] orally on 03/11/14. Interview conducted with RN #2 on 03/27/14, at 4:55 PM, revealed she administered 120 milligrams of Solu-[MEDICATION NAME] intramuscularly and 50 milligrams of [MEDICATION NAME] orally to Resident #8 after Resident #8 complained of "tightness" of the chest, after learning the resident had an allergy to [MEDICATION NAME] (antibiotic), and obtained a physician's orders [REDACTED]. Interview conducted with Resident #6's physician on 04/02/14, at 4:30 PM, revealed he had been contacted by ADON #2 regarding the resident's allergy to [MEDICATION NAME]. Review of an allergy sheet for Resident #6 on 04/02/14, at 5:00 PM, revealed [MEDICATION NAME] was listed on the allergy sheet which was located in the front of the resident's MAR. Review of a care plan dated 03/30/14, revealed interventions to address Resident #6's allergy to [MEDICATION NAME]. Review of a chart audit sheet the facility used to audit all residents' medical records for hospital discharge summaries and discharge documentation was reviewed to ensure allergies were identified. The audits were signed by the DON, ADON, SDC, MDS Coordinator, and the Regional Nurse Consultant as being completed on 03/27/14. The reviews of the medication allergy sheets for all residents were dated 03/27/14. Reviewed physician telephone orders to verify facility staff had contacted physicians to clarify the resident's drug allergies. Interview with ADON #1 on 04/03/14 at 1:40 PM, ADON #2 on 04/03/14 at 2:30 PM, the SDC on 04/03/14 at 2:40 PM, the MDS Coordinator on 04/03/14 at 2:35 PM, and the Regional Nurse Consultant on 04/03/14 at 2:45 PM revealed they had assisted with the chart audits on 03/27/14 to identify medication allergies by reviewing hospital discharge summaries, outside consultation notes, and discharge documentation. The interviews revealed allergy stickers were reviewed for accuracy, and medication allergy sheets were completed for all residents and placed in the front of each resident's MAR. The interview revealed all allergies were then clarified with the resident's physician. The interview also revealed the DON had assisted with the audits; however, she was no longer employed by the facility. Review of an in-service roster dated 03/27/14, revealed nurses and KMAs were in-serviced by the Regional Nurse Consultant, DON, and SDC regarding reviewing all hospital documentation upon admission or readmission to the facility to ensure allergies were appropriately identified. Posttests taken by licensed nurses and KMAs regarding in-service roster dated 03/27/14 were reviewed. Interview with the SDC on 04/03/14 at 2:40 PM, and the Regional Nurse Consultant on 04/03/14 at 2:45 PM revealed they had provided an in-service to the licensed nurses and KMAs regarding reviewing all hospital documentation upon each resident admission or readmission to the facility to ensure allergies were appropriately identified. Interviews conducted with RN #6 on 04/03/14 at 9:40 AM, RN #5 on 04/03/14 at 9:50 AM, LPN #4 on 04/03/14 at 10:00 AM, and LPN #1 on 04/03/14 at 10:05 AM all revealed they had attended an in-service regarding reviewing all hospital documentation to ensure allergies were appropriately identified with every admission or readmission. Review of an in-service roster dated 03/28/14 revealed the Medical Director attended an in-service provided by the Regional Nurse Consultant, SDC, and the Administrator regarding appropriately identifying allergies for residents. Interview conducted with the Medical Director on 04/02/14, at 4:30 PM, revealed he had attended an in-service provided by the facility on 03/28/14, regarding identifying allergies for the residents. Interview with the SDC on 04/03/14 at 2:40 PM, Regional Nurse Consultant on 04/03/14 at 2:45 PM, and the Administrator on 04/03/14 at 2:55 PM revealed they had provided an in-service to the Medical Director on 03/28/14 regarding ensuring resident allergies were appropriately identified. Review of an in-service syllabus and an email confirmation revealed the Consultant Pharmacist had been in-serviced by the Administrator, DON, and Regional Nurse Consultant on 03/28/14, regarding reviewing of all hospital discharge records for residents to ensure allergies were appropriately identified. Interview conducted with the Consultant Pharmacist on 04/02/14, at 4:35 PM, revealed he had attended an in-service by phone on 03/28/14 provided by the facility regarding reviewing all hospital discharge documentation to ensure residents' allergies were appropriately identified. Interview with the Regional Nurse Consultant on 04/03/14 at 2:45 PM, and the Administrator on 04/03/14 at 2:55 PM revealed they, along with the former DON, had provided an in-service to the Consultant Pharmacist on 03/28/14 regarding reviewing all hospital discharge documentation to ensure resident allergies were appropriately identified. Review of documentation from the facility's pharmacy revealed the Pharmacy Consultants had completed a review of all residents' medical records to ensure all allergies had been identified. Interview conducted with the Consultant Pharmacist on 04/02/14, at 4:35 PM, revealed the consulting pharmacy had completed an audit on all resident medical records in the facility on 03/29/14, to ensure residents' allergies were appropriately identified. Review of an in-service roster dated 03/28/14, revealed the Administrator, DON, SDC, and ADONs attended an in-service provided by the Regional Nurse Consultant regarding the reporting of significant medication errors as neglect. Interview with the Regional Nurse Consultant on 04/03/14, at 2:45 PM, revealed he had provided an in-service to the Administrator, DON, ADONs, and SDC on 03/28/14 regarding reporting of significant medication errors as neglect to the appropriate state agencies and investigating them as an allegation of neglect. Interview with ADON #1 on 04/03/14 at 1:40 PM, ADON #2 on 04/03/14 at 2:30 PM, the SDC on 04/03/14 at 2:40 PM, and the Administrator on 04/03/14 at 2:55 PM revealed they had attended an in-service provided by the Regional Nurse Consultant regarding reporting of significant medication errors to the state agencies and they were to investigate them as an allegation of neglect. Review of an in-service roster dated 03/28/14, revealed the SDC, DON, ADONs, and the Regional Nurse Consultant provided an in-service for all staff regarding the facility's Abuse/Neglect policy and the appropriate reporting of neglect to include significant medication errors, the QAPI process which included reporting of any concerns to the Administrator. Review of posttests regarding the in-service had been completed by staff. Interview with ADON #1 on 04/03/14 at 1:40 PM, ADON #2 on 04/03/14 at 2:30 PM, the SDC on 04/03/14 at 2:40 PM, and the Regional Nurse Consultant on 04/03/14 at 2:45 PM revealed they had provided an in-service to all staff regarding the facility's Abuse/Neglect policy and the appropriate reporting of neglect to include significant medication errors, the QAPI process which included reporting of any concerns to the Administrator. Interviews conducted with RN #6 on 04/03/14 at 9:40 AM, RN #5 on 04/03/14 at 9:50 AM, LPN #4 on 04/03/14 at 10:00 AM, LPN #1 on 04/03/14 at 10:05 AM, SRNA #1 on 04/03/14 at 1:55 PM, SRNA #2 on 04/03/14 at 2:00 PM, SRNA #3 on 04/03/14 at 2:05 PM, and SRNA #4 on 04/03/14 at 2:10 PM, all revealed they had attended an in-service regarding the facility's Abuse/Neglect policy and the appropriate reporting of neglect to include significant medication errors, the QAPI process which included reporting of any concerns to the Administrator. The staff also revealed they had been required to take a posttest on the in-service prior to working. Review of a syllabus for all new licensed nurses and KMAs revealed staff would be provided education regarding reporting of abuse, reporting of significant medication errors, where to review and document allergies, and verification of allergy orders. Interview with the SDC on 04/03/14, at 2:40 PM, revealed she was responsible for providing all new employee orientation. The SDC stated all new licensed nurses and KMAs would be provided education regarding reporting of abuse, reporting of significant medication errors, where to review and document allergies, and verification of allergy orders. The SDC stated no new licen

Based on interview, record review, review of the facility's incident report, review of staff witness statements, and review of the facility's policy, it was determined the facility failed to ensure allegations of abuse and neglect were reported immediately to the facility's Administrator, the State Survey Agency, and other officials in accordance with state law for two (2) of three (3) sampled residents (Residents #32 and #35). The facility failed to ensure all allegations were investigated and failed to ensure residents were protected from further potential abuse during the facility's investigation. The facility documented on an incident report dated 05/25/14, that facility staff observed bruises to Resident #32's left wrist/forearm. The resident reported a nurse aide (identified by the facility as State Registered Nurse Aide #2) had "grabbed" his/her arm and "wouldn't let go." Review of the investigation revealed staff working at the time the resident's bruises were discovered were interviewed; however, other residents were not interviewed and the staff did not conduct skin assessments of other residents to determine if there were other bruises, and/or if there were other allegations of abuse until 05/28/14, three (3) days after the bruises on Resident #32's arm were observed. Further review of the investigation revealed the facility identified State Registered Nurse Aide (SRNA) #2 as the alleged perpetrator; the SRNA was suspended from resident care on 05/25/14 (the day staff observed the bruises on the resident's arm) but was allowed to return to work on 05/26/14 (two days prior to the assessments of other residents). Continued review of the investigation revealed the facility failed to notify the State Survey Agency of the allegation of abuse until 05/28/14 (three days after the bruises had been observed). In addition, review of employee files revealed staff witness statements in SRNA #3's personnel file that alleged SRNA #3 had been verbally abusive to Resident #35. Review of a witness statement written on 05/24/14, by Licensed Practical Nurse (LPN) #2 revealed on 05/23/14, Resident #35 reported that SRNA #3 had talked mean to him/her when he/she requested a cold, wet washcloth. The facility failed to provide written documentation that staff and/or residents had been interviewed during the investigation, or that the allegations had been reported to the facility's Administrator and the State Survey Agency. The facility permitted SRNA #3 to provide direct resident care on 05/23/14 and 05/25/14. The facility's failure to immediately report all allegations of abuse/neglect, failure to protect residents during the course of an investigation of abuse/neglect, and failure to investigate allegations of abuse/neglect caused, or was likely to cause, serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy was determined to exist on 05/23/14 at 42 CFR 483.13 Resident Behavior and Facility Practices (F225 and F226) and 42 CFR 483.75 Administration (F490 and F520). A partial extended survey was conducted on 06/03/14 and 06/04/14. An acceptable Allegation of Compliance was received on 06/02/14 which alleged removal of the Immediate Jeopardy on 05/31/14. The State Survey Agency determined the Immediate Jeopardy was removed on 05/31/14 as alleged, which lowered the scope and severity to "D" at 42 CFR 483.13 Resident Behavior and Facility Practices (F225 and F226) and "D" at 42 CFR 483.75 Administration (F490 and F520) while the facility monitors the effectiveness of systemic changes and quality assurance activities. (Refer to F226.) The findings include: Review of the facility's policy, "Abuse, Neglect and Misappropriation, revised March 2013, revealed the facility would report and investigate all allegations of verbal, physical, and mental abuse, and neglect. Additionally, all allegations would be reported immediately to the Administrator and other officials as required. Further review of the policy revealed that alleged staff would be immediately removed from the care of all residents. 1. Review of Resident #32's medical record revealed the facility admitted the resident on 12/06/13 with [DIAGNOSES REDACTED]. Review of Resident #32's Minimum Data Set (MDS) quarterly assessment, dated 02/04/14, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident's cognition was moderately impaired. Review of an incident report, dated 05/25/14, revealed a SRNA called a nurse to Resident #32's room because she had observed two dark blue bruises on the resident's left wrist/forearm area. Continued review of the incident report revealed the resident stated, "Fat Pat grabbed my arm and wouldn't let it go; I had to pull myself loose." Interview was attempted with Resident #32 on 05/28/14 at 11:10 AM. However, the resident stated, "I don't want to talk about this (s**t) anymore," and refused to provide any further information. Licensed Practical Nurse (LPN) #1 stated in interview conducted on 05/29/14 at 11:53 AM that she assessed Resident #32 when the bruises were identified by facility staff on 05/25/14. The LPN stated Resident #32 reported "fat Pat grabbed" his/her arm. LPN #1 identified the alleged perpetrator as SRNA #2. According to interview, LPN #1 stated she immediately notified the Director of Nursing (DON) of the resident's bruises and of Resident #32's allegation. The LPN stated the DON instructed staff to conduct a skin assessment of Resident #32, to obtain written statements from staff members that were present, and to immediately suspend the alleged perpetrator, SRNA #2. Interview with Registered Nurse (RN) #1 on 05/29/14 at 12:30 PM revealed she also assessed Resident #32 on 05/25/14 when the bruises were identified by facility staff. She further stated the alleged perpetrator had been identified, based on the resident's description, as SRNA #2. RN #1 stated she notified the Administrator of the resident's bruises and the allegation of abuse immediately. The RN further revealed the Administrator instructed her to follow the directions of the DON. Interview with the DON on 05/28/14 at 4:30 PM revealed she had been notified of the bruises to Resident #32's arm on 05/25/14 and that the resident had alleged "fat Pat" had grabbed his/her arm. The DON stated she had instructed staff to assess Resident #32, to "gather statements from staff," and to tell the alleged perpetrator not to come to work that day (05/25/14) or until the incident had been "investigated." The DON stated staff had conducted an investigation of the alleged incident on 05/25/14. However, the DON acknowledged the facility had not assessed and/or interviewed other residents, including the residents that had received direct care by SRNA #2, for signs and/or reports of abuse during the investigation. The DON stated during the facility's investigation they had only interviewed staff that worked at the facility on the day the alleged incident was reported, and had only asked the staff about the alleged incident that occurred. In addition, the DON stated based on the facility's investigation she "didn't think it was abuse because the resident had different stories about what had happened," had investigated the incident as an injury of unknown origin, and had not notified State Agencies of the incident. She further stated the alleged perpetrator (SRNA #2) was permitted to return to work on 05/26/14, the day after the alleged incident was reported. Interview with the Administrator on 05/29/14 at 6:17 PM revealed he was notified on 05/25/14 that Resident #32 had bruises on his/her arm and the resident had stated that "fat Pat grabbed" his/her arm. The Administrator stated he had not considered the resident's statement as an allegation of abuse, but as an injury of unknown origin, because the resident had "told a lot of stories" as to how the bruises occurred when questioned by facility staff. Continued interview revealed the alleged perpetrator had been instructed not to come to work on the day the incident was reported, 05/25/14, but had been allowed to return to work and provide direct resident care on 05/26/14. The Administrator acknowledged the facility had not included resident assessments and interviews in their investigation, and had not reported the resident's complaint to the State Agencies. 2. Review of Resident #35's medical record revealed the facility admitted the resident on 04/29/14 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set admission assessment, dated 05/15/14, revealed the facility assessed Resident #35 to have a BIMS score of 11, which indicated the resident's cognition was moderately impaired. Interview with Resident #35 on 05/29/14 at 9:45 AM revealed the resident had asked SRNA #3 for a cold, wet washcloth for knee pain and the SRNA told the resident he didn't have insurance like the "rest of us." Continued interview revealed SRNA #3 brought the washcloth to the resident's room, threw the washcloth to the resident, and hit the resident's chest with the washcloth. Further interview revealed Resident #35 reported to nursing staff that SRNA #3 talked mean to the resident. Review of a witness statement written by LPN #2, dated 05/23/14, revealed between 3:00 AM and 4:00 AM, SRNA #3 was observed walking down the hall making statements that "I hate these people; I don't know what a washcloth's going to do for (him/her)." Continued review of the witness statement revealed Resident #35 called LPN #2 to his/her room to check the resident's blood sugar and she observed the resident crying. Further review of the witness statement revealed the resident reported, "That boy that was just in here talked mean to me." The witness statement further revealed Resident #35 had asked SRNA #3 for a cold, wet washcloth for knee pain and SRNA #3 made statements to the resident that the SRNA also had knee pain but did not have insurance to see a doctor like the residents and he didn't know what a washcloth was going to do to help. Continued review of the witness statement revealed the resident was very upset and did not want SRNA #3 in his/her room again. Further review of the witness statement revealed LPN #2 contacted the on-call nurse to report the incident and was instructed to switch SRNA #3 with an SRNA from the other hall and to contact the DON. The DON was contacted and LPN #2 was instructed to place the information about the incident on the 24 Hour Report Sheet and to keep SRNA #3 out of Resident #35's room. LPN #2 confirmed in interview conducted on 05/29/14 at 5:09 PM that she had overheard SRNA #3 in the hall making the statement, "I hate these people, every damn one of them." Continued interview revealed the LPN was called to Resident #35's room by the resident to check the resident's blood sugar and, upon entering the resident's room, she observed Resident #35 crying. LPN #2 stated SRNA #3 had talked mean to the resident when the resident requested a cold, wet washcloth for knee pain. Further interview with LPN #2 revealed the LPN called the DON to inform her of the incident and was told by the DON to put SRNA #3 on another hall to work and put the incident on the 24 Hour Report Sheet and it would be investigated. The LPN further revealed the nursing staff from night shift stayed over the next morning to talk with the DON about SRNA #3's negative behaviors and to turn in the witness statements about the incident. Review of the witness statement written by LPN #3, dated 05/23/14, revealed between 3:00 AM and 3:30 AM, SRNA #3 was observed coming out of Resident #35's room shouting, "I hate these people, every damn one of them." The witness statement further revealed Resident #35 had reportedly asked SRNA #3 for a wet washcloth and the SRNA had asked the resident why he/she needed the washcloth. Continued review of the witness statement revealed the SRNA talked hateful to the resident and informed the resident he had knee problems for a long time and he did not have insurance like the residents and could not go to the doctor any time he wanted. Interview with the DON on 05/28/14 at 5:20 PM revealed the DON had been informed by facility staff by telephone on the night of the alleged incident that SRNA #3 had made a negative comment to Resident #35 after the resident requested a washcloth. Continued interview revealed the DON informed the caller to keep SRNA #3 out of Resident #35's room. Further interview revealed the DON talked with the night shift nurses the next morning and was informed of reports that SRNA #3 had argued with staff and had cursed in the hallway. The DON obtained witness statements from staff about the incident. The DON stated the reports were nothing she considered abusive so the incident was not investigated or reported to State Agencies. In addition, the DON acknowledged the alleged perpetrator was allowed to provide resident care after receipt of the allegation and had continued to provide resident care at the facility. Interview with the Administrator on 05/29/14 at 6:17 PM, revealed the Administrator was not made aware of the witness statements involving SRNA #3 and Resident #35 until 05/28/14. Continued interview revealed the Administrator revealed the allegations should have been investigated and reported per the facility's policy. **The facility provided an acceptable Allegation of Compliance (AOC) on 06/02/14. The facility implemented the following actions to remove the Immediate Jeopardy: --The allegation of abuse reported by Resident #32 was reported to the Office of Inspector General (OIG) on 05/27/14 by the DON. Resident #32 has a BIMS score greater than 8 and a statement was obtained on 05/25/14. The alleged perpetrator was suspended on 05/25/14. The facility's investigation was initiated and ongoing with a five-day report to be submitted to OIG on 05/30/14. All residents were assessed for any signs and symptoms of abuse/neglect. Those residents with BIMS scores greater than 8 were interviewed by the Social Services Director or Chaplain for any abuse/neglect concerns on 05/29/14. On 05/29/14, the Assistant Directors of Nursing (ADONs) assessed the physical status of residents with BIMS scores less than 8 for any signs and symptoms of abuse/neglect. The facility attempted to contact the 41 Power of Attorneys (POAs) for the residents with a BIMS score less than 8 to ask if they had any concerns related to abuse/neglect and successfully contacted 26; the Social Services Director, the Chaplain, the DON, and/or the Administrator will continue to attempt to contact the remaining 15 POAs until all have successfully been contacted. --The allegation of abuse related to Resident #33 that occurred on 05/24/14 was reported to OIG on 05/29/14 by the DON and reported to Adult Protection Services (APS), the Ombudsman, the resident's physician, and the POA on 05/30/14 by the DON. A facility nurse assessed Resident #33 on 05/29/14 and the resident had a psychosocial assessment completed by the Social Services Director on 05/30/14. Resident #33 was interviewed and a statement was obtained by the facility's Social Services Director on 05/30/14. The alleged perpetrator was no longer employed by the facility. The facility's investigation was initiated and ongoing with a five-day report to be submitted to OIG on 05/30/14. All residents were assessed for any signs and symptoms of abuse/neglect. Those residents with BIMS scores greater than 8 were interviewed by the Social Services Director or Chaplain for any abuse/neglect concerns on 05/29/14. On 05/29/14, the ADONs assessed the physical status of residents with a BIMS score less than 8 for any signs and symptoms of abuse/neglect. The facility attempted to contact the 41 POAs for the residents with a BIMS score less than 8 to ask if they had any concerns related to abuse/neglect and successfully contacted 26; the Social Services Director, the Chaplain, the DON, and/or the Administrator will continue to attempt to contact the remaining 15 POAs until all have successfully have been contacted. --The allegation of abuse reported by Resident #35 was reported to the Office of Inspector General on 05/29/14 by the DON and reported to APS, the Ombudsman, the resident's physician, and the POA on 05/30/14 by the DON. Resident #35 was physically assessed by a nurse and psychosocially assessed by the Social Services Director on 05/30/14. Resident #35 was interviewed and a statement was obtained by the Social Services Director on 05/30/14. The alleged perpetrator is no longer employed by the facility. The facility's investigation was initiated and ongoing with a five-day report to be submitted to OIG on 05/30/14. All residents were assessed for any signs and symptoms of abuse/neglect. Those residents with BIMS scores greater than 8 were interviewed by the Social Services Director or Chaplain for any abuse/neglect concerns on 05/29/14. On 05/29/14, the ADONs assessed the physical status of residents with BIMS scores less than 8 for any signs and symptoms of abuse/neglect. The facility attempted to contact the 41 POAs for the residents with a BIMS score less than 8 to ask if they had any concerns related to abuse/neglect and successfully contacted 26; the Social Services Director, the Chaplain, the DON, and/or the Administrator will continue to attempt to contact the remaining 15 POAs until all have successfully have been contacted. --All residents were assessed for any signs and symptoms of abuse/neglect. Those residents with BIMS scores greater than 8 were interviewed by the Social Services Director or Chaplain for any abuse/neglect concerns on 05/29/14. On 05/29/14, the ADONs assessed the physical status of residents with BIMS scores less than 8 for any signs and symptoms of abuse/neglect. The facility attempted to contact the 41 POAs for the residents with a BIMS score less than 8 to ask if they had any concerns related to abuse/neglect and successfully contacted 26; the Social Services Director, the Chaplain, the DON, and/or the Administrator will continue to attempt to contact the remaining 15 POAs until all have successfully been contacted. The Administrator, the Regional Nurse Consultant, and the Chief Nurse Executive reviewed abuse/neglect audits, assessments, interviews, and questionnaires on 05/30/14 for any indications of abuse/neglect concerns. --The facility's Regional Nurse Consultant from the corporate office re-educated the facility Administrator, the DON, the ADONs, the Minimum Data Set (MDS) Coordinator, the Staff Development Coordinator (SDC), the Director of Dining Services, the Business Office Manager, the Social Services Director, the Activities Director, the Chaplain, Marketing/Admissions, Medical Records, Human Resources, and Wound Care on 05/29/14 on the facility's abuse policy and procedure. The education included, but was not limited to, thorough investigations, reporting immediately, and the Quality Assurance Performance Improvement (QAPI) process, including reporting of concerns to the Administrator and floor staff participation in development of QAPI plans. This training was performed face to face in order to facilitate discussion and questions and included examples of items that would be considered as reportable: reports of staff being mean, injuries of unknown origin, withholding belongings, resident-to-resident altercations to include verbal or physical, and taking belongings or exploitation. Department administrative managers were not allowed to return to work until abuse education was provided, post-tests administered, and a score of 100% obtained. If the manager did not score 100% on post-test, then the manager was immediately re-educated and re-tested . This process continued until all managers obtained a 100% score on the post-test. All post-tests were reviewed for compliance by the Chief Nursing Executive (CNE). --After the facility Administrator, DON, ADONs, Minimum Data Set (MDS) Coordinator, Staff Development Coordinator (SDC), Director of Dining Services, Business Office Manager, Social Services Director, Activities Director, Chaplain, Marketing/Admissions staff , Medical Records staff or Director, Human Relations (HR) staff, or Wound Care staff were re-educated on the abuse policy, the Administrative staff was assigned to re-educate the staff on the abuse policy and procedure which included, but was not limited to, reporting, protection, and investigation requirements, which started on 05/29/14. The facility did not allow any employee to work until abuse education was provided, post-test administered, and 100% score obtained. If the employee did not score 100% on the post-test, the employee was immediately re-educated and the post-test re-administered. This process continued until all employees obtained a 100% score on the post-test. Education regarding the abuse policy and procedure, including identification/reporting and the Quality Assurance Performance Improvement process was added in the orientation process for all newly hired staff members. No newly hired employee would be allowed to work until abuse education was provided, post-test administered, and 100% score obtained. If the employee did not score 100% on the post-test, the employee was immediately re-educated and re-tested . This process continued until employees obtained a 100% score on the post-test. --Staff questionnaires regarding abuse, including the question, "What would you do if a resident told you that you were mean to them," were administered by the Administrator, DON, ADONs, MDS Coordinator, SDC, Director of Dining Services, Business Office Manager, Social Services Director, Activities Director, Chaplain, Marketing/Admissions, Medical Records, HR, or Wound Care to five staff members on each shift and different staff members until immediacy was removed. After removal of immediacy, ten staff questionnaires were administered to staff daily to ensure continued understanding of the abuse/neglect policy and procedure, appropriate investigating, and reporting of abuse/neglect. The questionnaire also included questions related to the QAPI process to include reporting of concerns to the Administrator and floor staff participation in development of the QAPI plan. Results of the staff questionnaire were reported to the Quality Assurance (QA) Committee weekly to determine the further need of continued education or revision of the plan. At that time, based on evaluation, the QA Committee would determine at what frequency the staff questionnaire would need to continue. Concerns identified were corrected immediately and reported to the Administrator to ensure investigation of suspected abuse/neglect was investigated/completed and reporting guidelines were met. --HR performed an audit of all personnel files for any abuse concerns on 05/29/14. Items that were reviewed: Coaching and Counseling forms, suspension forms, and termination forms. Results of the audit were given to the Chief Nursing Executive on 05/30/14, to review for any abuse/neglect concerns that needed reporting. There were no concerns identified. --A nurse from the facility's regional team or corporate office had been on-site since 05/29/14 and remained in the facility daily until the jeopardy was removed. The nurses from the regional team or home office assisted with investigations, observed staff treatment of [REDACTED]. The Chief Nurse Executive, Clinical Compliance Nurse, or Director of Clinical Programs were in daily contact with the regional nurse consultant and reviewed allegations. --All facility grievances filed since 04/01/14 were reviewed by the Administrator, DON, or Regional Nurse Consultant on 05/30/14 to determine if any items documented were a reportable event. The Administrator was notified of one allegation of possible abuse. The Administrator reported the allegations to the Office of Inspector General on 05/30/14. The Administrator, Social Services Director, or the Director of Nursing reviewed the grievances and incident/accident reports daily, until immediacy was lifted, which was initiated on 05/29/14, to determine if there were reportable allegations that had not been identified. The Social Services Director or the Director of Nursing reported to the Administrator any identified allegations of abuse, neglect, or misappropriation immediately after their review. The Administrator will report any allegations of abuse, neglect, or misappropriation to the Office of Inspector General, Adult Protective Services, and the Ombudsman. --An emergency resident council meeting was held on 05/30/14; the Administrator and SDC attended the meeting to discuss any abuse/neglect concerns and to provide education on whom to report any abuse/neglect concerns without fear of retribution. The Social Services Director attempted to contact the POAs of all residents with BIMS scores less than 8 to discuss any abuse/neglect concerns and to provide education on whom to report any abuse/neglect concerns without fear of retribution on 05/30/14. --The Administrator, DON, ADONs, MDS Coordinator, SDC, Director of Dining Services, Business Office Manager, Social Services Director, Activities Director, Chaplain, Marketing/Admissions, Medical Records, HR, and Wound Care Nurse (one per shift) were to be on-site each shift to perform walking rounds in which ten residents (five with BIMS scores greater than 8 and five with BIMS scores less than 8) were visited by the Department Head and those residents that could be interviewed were interviewed regarding the staff treatment. The Department Head visited and a nurse conducted a skin check on the residents that were not able to be interviewed. The Department Head also spoke to nursing staff and State Registered Nursing Assistants (SRNAs) regarding any noted changes in the residents' behaviors. The facility Department Head also interviewed five staff members each shift regarding the types of abuse, who the facility's Abuse Coordinator was, when to report suspected abuse, what to do if the resident reported you were mean to them, etc., which began on 05/29/14 and continued until the immediate jeopardy was lifted. (See attached Resident and Staff Questionnaires.) Results of resident and staff questionnaires were reported to the Administrator, DON, Regional Nurse Consultant, or Vice President (VP) of Operations daily and if the Administrator was not in the facility, the Department Director conducted the questionnaires and telephoned the Administrator or VP of Operations with the results of the resident and staff questionnaires. This continued until the immediate jeopardy was lifted. --The DON, ADONs, MDS Coordinator, SDC, Director of Dining Services, Business Office Manager, Social Services Director, Activities Director, Chaplain, Marketing/Admissions, Medical Records, HR, or Wound Care staff immediately notified the Administrator of any concerns regarding the above resident and staff questionnaires related to abuse, mistreatment, neglect, or misappropriation and ensured the resident was safe. A binder (which contains a resident roster in which the interview date and shift is noted next to the resident name), which is passed on to each Department Head assigned to perform the resident and staff questionnaires each shift, to ensure that residents with BIMS scores greater than 8 were interviewed and residents with BIMS scores less than 8 were visited and skin checks completed, began on 05/29/14 and continued until the jeopardy was lifted. The MDS Coordinators had the responsibility for updating the binder weekly to identify residents with BIMS scores greater than 8 and residents with BIMS scores less than 8. If abuse, mistreatment, neglect, or misappropriation was alleged during the interviews or visits or reported by a staff member, the Department Head ensured the resident was safe, reported to a charge nurse, and the charge nurse removed the alleged perpetrator to a non-patient care area and notified the Administrator, Director of Nursing, and/or Social Services Director/Abuse Coordinator. The alleged perpetrator was suspended and an investigation began immediately. --The Administrator, Director of Nursing, Social Services Director, or a member of the facility's regional staff reviewed all resident and staff questionnaires daily for any grievances/concerns. Investigations of grievances/concerns were initiated upon receipt, starting on 05/30/14. --Nursing Administration (DON, ADONs, Unit Managers, SDC, MDS staff, facility formulary nurse), or the Medical Records or Social Services Director, reviewed documentation in the nursing notes in order to assess for any signs of documented evidence regarding abuse, neglect, or misappropriation daily on ten different residents each day. If any of the above concerns were identified, the member of Nursing Administration first ensured the resident was safe by performing an assessment and then notified a charge nurse. The abuse policy was followed in which the alleged perpetrator was removed from a resident care area (if on duty) and the Administrator, DON, or Social Services Director was notified. --All resident charts were reviewed from 04/01/14 by Nursing Administration (DON, ADONs, Unit Manager, Staff Development Coordinator, MDS staff, facility formulary nurse, Medical Records, Marketing/Admissions, or Social Services Director) or regional/corporate nurses by 05/30/14 for any documentation regarding abuse with no new incident being identified. Ten charts were reviewed by a member of Nursing Administration or the facility's regional or home office nurse daily to ensure that no other abuse allegations had been documented but not reported. This continued until the immediate jeopardy was removed. --The Administrator, Director of Nursing, and Social Services Director reviewed and discussed all abuse investigations daily to ensure that the residents were protected, the perpetrator was removed from the resident care area, reports to the Office of Inspector General were filed timely, and a thorough investigation was completed. The Administrator maintained an abuse investigation log that included documentation of the following: ensured protection of residents, removed perpetrator from resident care area, reports to the Office of Inspector General filed timely, and thorough investigations completed. The Administrator and one of the following: Chief Operating Officer, Chief Nurse Executive, or Regional Nurse Consultant reviewed the abuse investigation to ensure protection of the resident, that the perpetrator was removed from the resident care area, that reports to the Office of Inspector General were filed timely, and a thorough investigation had been completed. This will occur daily until removal of immediate jeopardy. --New reports of alleged abuse, neglect, or misappropriation of property, after the immediate jeopardy was removed, one of the following were contacted prior to making the final five-day investigation report to OIG: Signature Care Consultant, VP of Operations, Chief Operating Officer, Special Projects Administrator, or Chief Nursing Executive. The reviewer (Signature Care Consultant, VP of Operations, Chief Operating Office, Special Projects Administrator, or Chief Nursing Executive) ensured the resident was protected, report was filed timely, the perpetrator was removed from the patient care area, and a thorough investigation was completed. --With any new report of alleged abuse, neglect, or misappropriation of property, one of the following was contacted within 24 hours to review the abuse investigation to ensure that a thorough investigation was completed and reporting timelines were met: Signature Care Consultant, VP of Operations, Chief Operating Office, Special Projects Administrator, or CNE. --All incident reports from January 2014 to 03/29/14 were reviewed by the Director of Nursing, the Assistant Director of Nursing, Staff Development Coordinator, or Regional Nurse Consultant to identify any concerns of suspected neglect by 05/30/14. None was identified. --During care plan conference for each resident, any abuse/neglect concerns were discussed along with abuse/neglect education, to include reporting, was prov

Based on observations, interviews, record reviews, and review of the facility's policy, it was determined the facility failed to ensure two (2) of twenty-one (21) sampled residents (Resident #8 and Resident #6) were free from significant medication errors. Review of Resident #8's History and Physical report from an acute care facility, dated 08/27/13 revealed Resident #8 was allergic to [MEDICATION NAME] (antibiotic). Interview on 03/26/14, at 2:25 PM with Resident #8 revealed the resident had informed Registered Nurse (RN) #1 on the day of admission to the facility that he/she was allergic to [MEDICATION NAME]. However, review of the resident's admission assessment completed by RN #1 dated 09/09/13, revealed facility staff failed to document the resident's allergy to [MEDICATION NAME] in the resident's medical record and/or on the resident's Medication Administration Record [REDACTED]. Interview with the facility's Medical Director revealed Resident #8 could have been harmed as a result of receiving [MEDICATION NAME]. In addition, review of the medical record revealed the facility admitted Resident #6 on 11/08/13 with a documented allergy to [MEDICATION NAME] (narcotic [MEDICATION NAME]). Record review revealed documentation on the front of Resident #6's medical record that the resident had an allergy to [MEDICATION NAME]. However, review of Resident #6's MAR for December 2013 and January, February, and March 2014 revealed staff failed to document the resident's allergy to [MEDICATION NAME] and had noted Resident #6 had no known allergies. Review of Physicians Orders for March 2014 revealed the physician and/or facility staff had failed to document the resident's allergy to [MEDICATION NAME] and noted Resident #6 had no known allergies. The facility's failure to ensure residents were free from significant medication errors caused, or was likely to cause, serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy with Substandard Quality of Care was determined to exist on 03/08/14 at 42 CFR 483.13 Resident Behavior and Facility Practices (F225), 42 CFR 483.25 Quality of Care (F333), 42 CFR 483.60 Pharmacy Services (F428), and 42 CFR 483.75 Administration (F520) at a Scope and Severity of "J." Substandard Quality of Care was identified at 42 CFR 483.13 Resident Behavior and Facility Practices (F225) and 42 CFR 483.25 Quality of Care (F333). The facility was notified of the Immediate Jeopardy on 03/28/14. An acceptable Allegation of Compliance (AOC) was received on 04/01/14, which alleged removal of the Immediate Jeopardy on 03/31/14. The State Survey Agency determined the Immediate Jeopardy was removed on 03/31/14, prior to exit, which lowered the scope and severity to "D" at 42 CFR 483.13 Resident Behavior and Facility Practices (F225), 42 CFR 483.25 Quality of Care (F333), 42 CFR 483.60 Pharmacy Services (F428), and 42 CFR 483.75 Administration (F520) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's Admission Standard of Practice policy, effective date of December 2010, revealed that nurses would obtain clinical resident information to assist in the completion of Admission Assessments on all new admissions and readmissions. Review of the facility's "Medication Administration-New Orders, Reorders, Receiving" policy, effective date of December 2010, revealed the Medication Order Form was to be completed for all new MEDICATION ORDERS FOR [REDACTED]. Further review of the policy revealed the medications were to be called into the pharmacy with the following information: nurse's name, resident's full name, physician's name, location of resident, Medicaid number if necessary, and medication strengths and full directions. 1. Review of Resident #8's medical record revealed the facility admitted the resident on 09/09/13, with [DIAGNOSES REDACTED]. Review of a History and Physical (H&P) report from an acute care facility dated 08/27/13, revealed Resident #8 had a drug allergy to [MEDICATION NAME]. Review of the Nursing Admission Information Report dated 09/09/13, revealed staff had listed and identified the resident's allergies to [MEDICATION NAME] ([MEDICATION NAME]), Influenza Vaccine, [MEDICATION NAME] (anti-depressant), [MEDICATION NAME] ([MEDICATION NAME]), and [MEDICATION NAME] (cough syrup) but had failed to include the resident's allergy to [MEDICATION NAME] (antibiotic). Further review of the H&P revealed the resident's attending physician, who was also the facility's Medical Director, had initialed and dated the report on 09/12/13 with no time documented. However, review of the resident's Record of Admission to the facility revealed facility staff failed to include information related to the resident's allergy to [MEDICATION NAME] or other allergies. Review of a Significant Change Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident's cognition was intact. Review of Resident #8's Comprehensive Care Plan dated 12/31/13 revealed the resident had allergies and the potential for injury and discomfort. Further review revealed the resident was allergic to [MEDICATION NAME] ([MEDICATION NAME]), [MEDICATION NAME] (cough syrup), [MEDICATION NAME] ([MEDICATION NAME]), [MEDICATION NAME] (antibiotic), Influenza Vaccine, History of positive PPD (Purified Protein Derivative), and Pneumonia Vaccine. However, facility staff failed to include the resident's allergy to [MEDICATION NAME] (antibiotic) on the care plan. Review of Resident #8's Physician order [REDACTED]. Tract Infection [MEDICAL CONDITION]. Continued review of the physician's orders [REDACTED]. Review of Resident #8's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. Observation of Resident #8 on 03/26/14 at 2:45 PM revealed the resident was lying in bed watching television. Interview with Resident #8 on 03/26/14 at 2:45 PM revealed facility staff had administered [MEDICATION NAME] to him/her "about two weeks ago." Resident #8 stated that he/she had informed the facility upon admission that he/she was allergic to [MEDICATION NAME]. Resident #8 stated he/she started having "tightness in my chest" and thought that staff might have given him/her something he/she was allergic to. The resident stated he/she notified staff of his/her symptoms and learned he/she had received [MEDICATION NAME]. According to the resident, he/she had experienced tightness in the chest when he/she had taken [MEDICATION NAME] in the past, prior to admission to the facility, and had learned he/she was allergic to [MEDICATION NAME]. Interview with Resident #8's attending physician on 03/27/14 at 3:37 PM revealed he was not aware Resident #8 had a drug allergy to [MEDICATION NAME] when he prescribed the medication. The physician stated the resident could have suffered harm from the [MEDICATION NAME] as a result of the resident's allergy. Interview with RN #1 on 03/27/14 at 4:00 PM revealed she failed to review the allergies from the acute care facility's H&P when Resident #8 was admitted to facility. Interview with RN #2 on 03/27/14 at 4:55 PM revealed Resident #8 had complained of tightness in his/her chest after she administered the evening dose of [MEDICATION NAME] on 03/11/14. RN# 2 stated that she learned at that time Resident #8 had experienced an allergic reaction to [MEDICATION NAME] in the past. She notified the Assistant Director of Nursing (ADON), the resident's physician, and the resident's family member. Interview with the facility's Consultant Pharmacist on 03/27/14 at 4:40 PM, revealed at the time the facility admitted Resident #8, the pharmacist reviewed the resident's medical record, including the History and Physical, dated 08/27/13, to determine if the resident had any drug allergies. Although the Pharmacist stated he had identified the resident's allergies to Antibiotics, [MEDICATION NAME], Opioids, and [MEDICATION NAME], he failed to identify the resident's allergy to [MEDICATION NAME]. Interview with the Administrator on 03/28/14 at 8:45 AM revealed the facility had addressed Resident #8 being administered a medication that he/she had an allergy to in the daily Quality Assurance meeting on 03/28/14 and had a plan in place on 03/27/14 to prevent significant medication errors for other residents. However, the facility failed to provide any proof that a plan to protect residents was in place. 2. Review of Resident #6's medical record revealed the facility admitted the resident on 11/08/13 and documented the resident had an allergy to [MEDICATION NAME] (narcotic [MEDICATION NAME]). Record review also revealed facility staff had noted on the front of the resident's medical record that the resident had an allergy to [MEDICATION NAME]. Review of the most recent Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) of 15, which indicated the resident's cognition was intact. Review of the resident's MAR for December 2013 and January, February, and March 2014 revealed staff had failed to document the resident's allergy to [MEDICATION NAME] on the MAR. The facility indicated the resident had no known allergies. Further record review revealed the Physicians Orders for March 2014 identified Resident #6 as having no known allergies. Interview with Resident #6 on 03/27/14 at 2:40 PM, revealed the resident was allergic to [MEDICATION NAME]. Resident #6 stated he/she had informed the facility on the day of admission that he/she was allergic to [MEDICATION NAME]. Interview with Licensed Practical Nurse (LPN) #1 on 03/27/14 at 3:20 PM revealed staff obtained the information related to allergies at the time a resident was admitted to the facility. The LPN stated the list of allergies could be located in the resident's admission packet. LPN #1 stated if a resident was admitted to a hospital and returned to the facility with a documented change in allergies, staff would investigate the cause of the change, notify the resident's physician, and obtain an order for [REDACTED]. Interview with the Corporate Nurse Consultant on 03/28/14 at 8:30 AM, revealed staff was to ask the resident, or his/her representative, of his/her allergies at the time of admission and document the information in the admission packet. The Nurse Consultant also stated a record of the resident's medication allergy was completed upon admission and taken to the daily meeting with administrative staff for review. Further interview revealed the Corporate Nurse Consultant stated if the resident was discharged to the hospital and returned to the facility with a change in allergies, staff was to research the reported allergy and take the report to the daily meeting with administrative staff for review. The Corporate Nurse Consultant stated the nurse "should follow the orders on the discharge paperwork" if staff was unable to clarify the discrepancy. **The facility provided an acceptable Allegation of Compliance (AOC) on 04/01/14. The facility implemented the following actions to remove the Immediate Jeopardy: The physician for Resident #8 was notified by the staff nurse immediately upon identification of symptoms that may have been related to the administration of [MEDICATION NAME]. physician's orders [REDACTED]. The treatment was effective as evidenced by every shift assessment along with supporting documentation. The resident was monitored by staff nurses to ensure continued effectiveness. The physician was notified by the Assistant Director of Nursing (ADON) for Resident #6 on 03/28/14 to clarify the resident's allergy to [MEDICATION NAME]. A sheet was added in front of the resident's Medication Administration Record [REDACTED]. A care plan was initiated with interventions to decrease the risk of an allergic reaction. Chart audits to include review of hospital discharge summaries and/or discharge documentation and outside consultation visits were completed by the Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC), MDS Coordinators, and Regional Nurse Consultant on 03/27/14 for all residents to ensure allergies were appropriately identified. During the audit, allergy stickers on the outside of residents' charts were reviewed to ensure accuracy. A medication allergy sheet was completed for each resident on 03/27/14 by the DON, ADON, SDC, MDS Coordinator, and the Regional Nurse Consultant and placed in front of each resident's MARs. All allergies were clarified with the physician. The Regional Nurse Consultant, DON, and SDC initiated education for licensed staff and Kentucky Medication Aides (KMAs) on 03/27/14 and advised staff to review hospital documentation upon each resident admission or readmission to ensure allergies were appropriately identified. Licensed nursing staff/KMAs were not allowed to work prior to receiving the above stated education. A posttest was given upon completion of education. A score of 100 percent must be obtained before being allowed to work. Those staff members not obtaining a passing score of 100 percent would be educated on the spot and retested . Resident #8's attending physician, who is also the facility's Medical Director, received education from the Administrator, SDC, and the Regional Nurse Consultant on 03/28/14 regarding appropriately identifying resident allergies. The Administrator, DON, and Regional Nurse Consultant provided education to the Pharmacy Consultant on 03/28/14 regarding reviewing hospital discharge records for all residents to ensure allergies were appropriately identified. The Pharmacy Consultants were on-site on 03/29/14 and reviewed all resident records to ensure allergies were appropriately identified. The Regional Nurse Consultant provided education to the Administrator, DON, SDC, and ADONs on 03/28/14 regarding reporting of neglect for any significant medication error. The SDC, DON, ADONs, and the Regional Nurse Consultant initiated staff education on 03/28/14 regarding the abuse/neglect policy and appropriate reporting of neglect to include significant medication errors, the Quality Assurance Performance Improvement (QAPI) process to include reporting of concerns to the Administrator, and front line staff participation in development of QAPI plans. Staff was not permitted to work prior to receiving the education. A posttest was given upon completion of education. A score of 100 percent must be obtained before being allowed to work. Those staff members not obtaining a passing score of 100 percent would be educated on the spot and retested . Education regarding reporting abuse, reporting of significant medication errors, obtaining allergies from the discharge summary, resident history or POA history, verification of allergy orders from the physician, as well as places on the MAR indicated [REDACTED]. A follow-up questionnaire would be completed by the Administrator, DON, ADONs, MDS Coordinator, Social Services Director, Quality of Life Director, Dietary Manager, Plant Operations Director, Chaplain, Medical Records, Human Resources Director, SDC, Business Office Manager, Facility Formulary Nurse, or the Environmental Services Manager for ten staff members daily to include all shifts and different staff members until removal of immediacy, then weekly for four weeks, to ensure continued understanding of regarding the abuse/neglect policy and appropriate reporting of neglect to include significant medication errors, implementing care plans for allergies, the QAPI process to include reporting concerns to the Administrator, and front line staff participation in the development of QAPI plans. The Social Services Director, DON, ADONs, SDC, and MDS Coordinator conducted interviews on 03/27/14 with residents who had a BIMS score above 8 regarding their knowledge of allergies. This was compared to what was listed in the medical record and allergies were updated with assessment and/or physician's orders [REDACTED]. The Social Services Director, DON, ADONs, MDS Coordinator, Administrator, or Regional Nurse Consultant conducted interview with the responsible party for residents with a BIMS score of less than 8 by 03/27/14 to identify any allergies or concerns with medications. This was compared to what was listed in the medical record and allergies were updated with assessment and/or physician's orders [REDACTED]. Allergies will be identified on the day of admission and/or readmission by the admitting nurse on the nursing admission information document. The admission nurse will document allergies on the resident's medication allergy record that will be placed in the front of the MAR for that resident. The admitting nurse will review the resident's allergies with the resident and/or POA for confirmation. A care plan will be initiated that identifies allergies and interventions to decrease the risk of allergic reactions. The procedure which includes identification of allergies on the day of admission/readmission by the admitting nurse along with documenting the allergies on the medication allergy record, the nursing admission assessment, and the physician's orders [REDACTED]. The physician will be notified of any allergies by the charge nurse following review of all documents sent by the hospital, resident, and POA interview. Charts for newly admitted residents and readmitted residents will be reviewed and discussed in the Daily Clinical meeting on weekdays by the DON, MDS Coordinator, Social Services Director, Medical Records, SDC, ADONs, Activities Director, Dietary Manager, and Chaplain with a comparison review completed at that time of the resident's admission packet and their medication allergy form, against the hospital discharge summary and/or discharge documentation of resident allergies, to ensure that allergies are appropriately identified. On weekends, this review will be completed by the DON, ADONs, SDC, or MDS Coordinator until removal of immediacy. Following removal of immediacy, on weekends, two charge nurses will review the discharge documentation and history and physical for newly admitted or readmitted residents to ensure allergies are appropriately identified as well as all paperwork complete and accurate, care plan updated, physician notification complete, and all allergy lists updated or initialed. Allergy stickers and allergy lists were updated for all residents to include all medication allergies identified. This was completed by the Director of Nursing, Assistant Director of Nursing, MDS Coordinators, Staff Development Coordinator, and Regional Nurse Consultant on 03/28/14. Education was provided for licensed nursing staff/Kentucky Medication Aides by the Director of Nursing, Assistant Director of Nursing, the Staff Development Coordinator, and the Regional Nurse Consultant regarding all paperwork forwarded from the hospital, interview with resident/POA, verifying allergies with physician, noting allergies on the allergy sticker, allergy listings, physician orders, and MARs. Licensed nursing staff will not be allowed to work prior to receiving the above stated education. Nursing Administration to include the Director of Nursing, Assistant Directors of Nursing, Staff Development Coordinator, MDS Coordinators, Facility Formulary Nurse, or Regional Nurse Consultant are reviewing every physician's orders [REDACTED]. This will continue daily until immediacy lifted. Once immediacy is lifted a daily review will continue (Monday-Friday) by the above team. During care plan conference for each elder the allergy list will also be reviewed for any updates. Medication pass audits were completed by the Director of Nursing, Assistant Directors of Nursing, Staff Development Coordinator, and Regional Nurse Consultant for all nurses and Certified Medication Technicians working on 03/28/14 to ensure that allergies are appropriately identified and medications are administered without significant medication error. Medication pass audits will be completed for all nurses and certified medication technicians during their initial medication pass for shifts scheduled after 03/28/14 until all nurses and certified medication technicians have had a medication pass audit completed. During the medication pass audit, a questionnaire will be completed by the Director of Nursing, Assistant Directors of Nursing, Staff Development Coordinator, and Regional Nurse Consultant to ensure their knowledge of where to review for allergies prior to the administration of medication. The Assistant Director of Nursing, MDS Coordinator, or the Staff Development Coordinator will audit the Medication Administration Record [REDACTED]. All allergy clarifications for all residents have been sent to Pharmacy as of 03/29/14 in which Pharmacy has updated their listing in their computer system. Pharmacy will review all new orders and compare to any allergies listed and notify facility if an allergy exists regarding the new medication at which time the nurse will notify the physician for any new orders. All incident reports were reviewed by the Director of Nursing, the Assistant Director of Nursing, Staff Development Coordinator, or Regional Nurse Consultant to identify any further significant medication errors by 03/29/14. None was identified. All incidents or concerns are reviewed daily during the daily standup meeting to include Administrator, Director of Nursing, Assistant Director of Nursing, Dietary Manger, Chaplain, MDS Coordinators, Plant Operations Director, Medical Records, Admissions Director, Housekeeping/Central Supply Director, Quality of Life Director, Business Office Manager, Rehabilitation Manager, or Regional Staff to identify any allegation of abuse or neglect. The Administrator has been on-site daily to review all concerns or incidents to ensure abuse or neglect has been appropriately identified and reported. Administrative oversight of the facility will be completed by the Special Projects Administrator, the Regional Vice President of Operations, or the Chief Operating Officer daily until removal of immediacy, then weekly for four weeks after removal of immediacy, and then monthly. Education was provided by the Regional Nurse Consultant on 03/28/14 for the Administrator, the Director of Nursing, Assistant Directors of Nursing, Staff Development Coordinator, Quality of Life Director, Social Services Director, Plant Operations Director, Chaplain, Medical Records Coordinator, Dietary Manger, and Admission Director regarding the Quality Assurance Process and appropriate methods of identification of concerns including significant mediation errors, failure to report neglect, and auditing pharmacy services. The Administrator, Director of Nursing, Chief Operating Officer, Chief Nurse Executive, or Regional Nurse Consultant will audit compliance of the above stated audits daily until removal of immediacy, and then twice weekly for four weeks and report findings during weekly QA for four weeks, for recommendations and further follow-up as indicated. A Quality Assurance meeting was held on 03/28/14 with the Medical Director for further recommendations regarding the plan for removal of jeopardy. A Quality Assurance meeting will be held weekly for four weeks, and then monthly for recommendations and further follow-up regarding the above stated plan. **The surveyors validated the Immediate Jeopardy was removed as follows: Review of a physician's orders [REDACTED]." Review of the MAR for Resident #8 revealed staff administered 120 milligrams of Solu-[MEDICATION NAME] intramuscularly and 50 milligrams of [MEDICATION NAME] orally on 03/11/14. Interview conducted with RN #2 on 03/27/14, at 4:55 PM, revealed she administered 120 milligrams of Solu-[MEDICATION NAME] intramuscularly and 50 milligrams of [MEDICATION NAME] orally to Resident #8 after Resident #8 complained of "tightness" of the chest, after learning the resident had an allergy to [MEDICATION NAME] (antibiotic), and obtained a physician's orders [REDACTED]. Interview conducted with Resident #6's physician on 04/02/14, at 4:30 PM, revealed he had been contacted by ADON #2 regarding the resident's allergy to [MEDICATION NAME]. Review of an allergy sheet for Resident #6 on 04/02/14, at 5:00 PM, revealed [MEDICATION NAME] was listed on the allergy sheet which was located in the front of the resident's MAR. Review of a care plan dated 03/30/14, revealed interventions to address Resident #6's allergy to [MEDICATION NAME]. Review of a chart audit sheet the facility used to audit all residents' medical records for hospital discharge summaries and discharge documentation was reviewed to ensure allergies were identified. The audits were signed by the DON, ADON, SDC, MDS Coordinator, and the Regional Nurse Consultant as being completed on 03/27/14. The reviews of the medication allergy sheets for all residents were dated 03/27/14. Reviewed physician telephone orders to verify facility staff had contacted physicians to clarify the resident's drug allergies. Interview with ADON #1 on 04/03/14 at 1:40 PM, ADON #2 on 04/03/14 at 2:30 PM, the SDC on 04/03/14 at 2:40 PM, the MDS Coordinator on 04/03/14 at 2:35 PM, and the Regional Nurse Consultant on 04/03/14 at 2:45 PM revealed they had assisted with the chart audits on 03/27/14 to identify medication allergies by reviewing hospital discharge summaries, outside consultation notes, and discharge documentation. The interviews revealed allergy stickers were reviewed for accuracy, and medication allergy sheets were completed for all residents and placed in the front of each resident's MAR. The interview revealed all allergies were then clarified with the resident's physician. The interview also revealed the DON had assisted with the audits; however, she was no longer employed by the facility. Review of an in-service roster dated 03/27/14, revealed nurses and KMAs were in-serviced by the Regional Nurse Consultant, DON, and SDC regarding reviewing all hospital documentation upon admission or readmission to the facility to ensure allergies were appropriately identified. Posttests taken by licensed nurses and KMAs regarding in-service roster dated 03/27/14 were reviewed. Interview with the SDC on 04/03/14 at 2:40 PM, and the Regional Nurse Consultant on 04/03/14 at 2:45 PM revealed they had provided an in-service to the licensed nurses and KMAs regarding reviewing all hospital documentation upon each resident admission or readmission to the facility to ensure allergies were appropriately identified. Interviews conducted with RN #6 on 04/03/14 at 9:40 AM, RN #5 on 04/03/14 at 9:50 AM, LPN #4 on 04/03/14 at 10:00 AM, and LPN #1 on 04/03/14 at 10:05 AM all revealed they had attended an in-service regarding reviewing all hospital documentation to ensure allergies were appropriately identified with every admission or readmission. Review of an in-service roster dated 03/28/14 revealed the Medical Director attended an in-service provided by the Regional Nurse Consultant, SDC, and the Administrator regarding appropriately identifying allergies for residents. Interview conducted with the Medical Director on 04/02/14, at 4:30 PM, revealed he had attended an in-service provided by the facility on 03/28/14, regarding identifying allergies for the residents. Interview with the SDC on 04/03/14 at 2:40 PM, Regional Nurse Consultant on 04/03/14 at 2:45 PM, and the Administrator on 04/03/14 at 2:55 PM revealed they had provided an in-service to the Medical Director on 03/28/14 regarding ensuring resident allergies were appropriately identified. Review of an in-service syllabus and an email confirmation revealed the Consultant Pharmacist had been in-serviced by the Administrator, DON, and Regional Nurse Consultant on 03/28/14, regarding reviewing of all hospital discharge records for residents to ensure allergies were appropriately identified. Interview conducted with the Consultant Pharmacist on 04/02/14, at 4:35 PM, revealed he had attended an in-service by phone on 03/28/14 provided by the facility regarding reviewing all hospital discharge documentation to ensure residents' allergies were appropriately identified. Interview with the Regional Nurse Consultant on 04/03/14 at 2:45 PM, and the Administrator on 04/03/14 at 2:55 PM revealed they, along with the former DON, had provided an in-service to the Consultant Pharmacist on 03/28/14 regarding reviewing all hospital discharge documentation to ensure resident allergies were appropriately identified. Review of documentation from the facility's pharmacy revealed the Pharmacy Consultants had completed a review of all residents' medical records to ensure all allergies had been identified. Interview conducted with the Consultant Pharmacist on 04/02/14, at 4:35 PM, revealed the consulting pharmacy had completed an audit on all resident medical records in the facility on 03/29/14, to ensure residents' allergies were appropriately identified. Review of an in-service roster dated 03/28/14, revealed the Administrator, DON, SDC, and ADONs attended an in-service provided by the Regional Nurse Consultant regarding the reporting of significant medication errors as neglect. Interview with the Regional Nurse Consultant on 04/03/14, at 2:45 PM, revealed he had provided an in-service to the Administrator, DON, ADONs, and SDC on 03/28/14 regarding reporting of significant medication errors as neglect to the appropriate state agencies and investigating them as an allegation of neglect. Interview with ADON #1 on 04/03/14 at 1:40 PM, ADON #2 on 04/03/14 at 2:30 PM, the SDC on 04/03/14 at 2:40 PM, and the Administrator on 04/03/14 at 2:55 PM revealed they had attended an in-service provided by the Regional Nurse Consultant regarding reporting of significant medication errors to the state agencies and they were to investigate them as an allegation of neglect. Review of an in-service roster dated 03/28/14, revealed the SDC, DON, ADONs, and the Regional Nurse Consultant provided an in-service for all staff regarding the facility's Abuse/Neglect policy and the appropriate reporting of neglect to include significant medication errors, the QAPI process which included reporting of any concerns to the Administrator. Review of posttests regarding the in-service had been completed by staff. Interview with ADON #1 on 04/03/14 at 1:40 PM, ADON #

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure the pharmacist reported irregularities to the attending physician and the Director of Nursing (DON) to act upon for one (1) of twenty-one (21) sampled residents (Resident #8). Review of Resident #8's medical record revealed an acute care facility had provided the facility with a copy of a History and Physical dated 08/27/13 that revealed Resident #8 was allergic to Macrodantin (antibiotic). Review of Resident #8's Medication Administration Record [REDACTED]. Resident #1 complained of "tightness" in his/her chest on 03/11/14 at 9:50 PM, asked what medications he/she had received, and staff informed the resident he/she had received Macrodantin. At that time, the resident informed staff he/she was allergic to the medication and the Macrodantin was discontinued. Record review and interview revealed the Consultant Pharmacist failed to identify Resident #8 had an allergy to Macrodantin and, as a result, failed to inform the resident's attending physician and the Director of Nursing (DON) of the resident's allergy. The facility's failure to ensure the pharmacist reported any irregularities to the attending physician and the DON caused or was likely to cause serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy with Substandard Quality of Care was determined to exist on 03/08/14 at 42 CFR 483.13 Resident Behavior and Facility Practices (F225), 42 CFR 483.25 Quality of Care (F333), 42 CFR 483.60 Pharmacy Services (F428), and 42 CFR 483.75 Administration (F520) at a scope and severity of "J." Substandard Quality of Care was identified at 42 CFR 483.13 Resident Behavior and Facility Practices (F225) and 42 CFR 483.25 Quality of Care (F333). The facility was notified of the Immediate Jeopardy on 03/28/14. An acceptable Allegation of Compliance was received on 04/01/14, and alleged removal of the Immediate Jeopardy on 03/31/14. The State Survey Agency determined the Immediate Jeopardy was removed on 03/31/14, prior to exit, which lowered the scope and severity to "D" at 42 CFR 483.13 Resident Behavior and Facility Practices (F225), 42 CFR 483.25 Quality of Care (F333), 42 CFR 483.60 Pharmacy Services (F428), and 42 CFR 483.75 Administration (F520) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled, "Summary Pharmerica Consulting Standards and Expectations," undated, revealed the policy stated the pharmacist was responsible to complete a medication regimen review on all residents. The policy stated the pharmacist would visit and exit with the Administrator and the DON. Review of Resident #8's medical record revealed the facility admitted the resident on 09/09/13 with [DIAGNOSES REDACTED]. Although documentation in the Record of admitted d 09/09/13 failed to indicate Resident #8 had any allergies, review of a History and Physical report dated 08/27/13 from an acute care facility, which was included in the resident's medical record, revealed the resident had allergies to Darvocet, Elavil, Flu Vaccine, Penicillin, Macrodantin, Ultram, and Codeine. In addition, the Nursing Admission Information dated 09/09/13, revealed the resident had allergies to Codeine, Influenza, Elavil, Darvocet, and Tussionex. Resident #8's attending physician acknowledged the History and Physical by documentation of the date and his initials on the History and Physical on 09/12/13. Review of Resident #8's Medication Administration Record [REDACTED]. Further record review revealed the resident received one dose of Macrobid on 03/08/14, two doses on 03/09/14, two doses on 03/10/14, and two doses on 03/11/14. Continued review revealed on 03/11/14 at 9:50 PM, Resident #1 complained of "tightness" in his/her chest and asked what medications he/she had received. The resident was informed he/she had received Macrodantin, and the resident informed staff he/she was allergic to the medication. Based on documentation, facility staff informed the resident's physician of the resident's complaint and the Macrodantin was discontinued. Review of the Pharmacy Drug Regimen Review dated 09/16/13, for Resident #8 revealed the pharmacist failed to document the resident had an allergy to Macrodantin on the review. An interview with the facility's Consultant Pharmacist on 03/27/14 at 4:40 PM revealed that he was not aware Resident #8 was allergic to Macrodantin. The Consultant Pharmacist stated when the facility admitted a resident, the pharmacist reviewed the medical record and discharge information located in the hospital's paperwork to determine if the resident had any drug allergies. The Consultant Pharmacist stated he had reviewed Resident #8's medical record and the information from the acute care facility's discharge information and had identified Resident #8 had allergies to Antibiotics, Penicillin, Opioids, and Darvocet. However, the Pharmacist stated he failed to identify Resident #8's allergy to Macrodantin and, as a result, had not informed the resident's physician or the DON of the resident's allergy. Resident #8's attending physician stated in interview conducted on 03/27/14, at 3:37 PM, the resident "could have been harmed" from the administration of the Macrodantin since the resident had experienced a "similar allergic reaction with tightness in the chest" after the resident had received Macrodantin during a previous hospitalization . The physician stated the facility's Consultant Pharmacist had not informed him of Resident #8's allergy to Macrodantin. An interview with the Administrator and the DON on 03/28/14 at 8:45 AM revealed the pharmacist was required to conduct a monthly medication regimen review and that the pharmacist always met with both him and the DON prior to leaving the facility. The Administrator stated the pharmacist was required to review all acute care paperwork sent to the facility. **The facility provided an acceptable Allegation of Compliance (AOC) on 04/01/14. The facility implemented the following actions to remove the Immediate Jeopardy: The physician for Resident #8 was notified by the staff nurse immediately upon identification of symptoms that may have been related to the administration of Macrodantin. physician's orders [REDACTED]. The treatment was effective as evidenced by every shift assessment along with supporting documentation. The resident was monitored by staff nurses to ensure continued effectiveness. The physician was notified by the Assistant Director of Nursing (ADON) for Resident #6 on 03/28/14 to clarify the resident's allergy to Morphine. A sheet was added in front of the resident's Medication Administration Record [REDACTED]. A care plan was initiated with interventions to decrease the risk of an allergic reaction. Chart audits to include review of hospital discharge summaries and/or discharge documentation and outside consultation visits were completed by the Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC), MDS Coordinators, and Regional Nurse Consultant on 03/27/14 for all residents to ensure allergies were appropriately identified. During the audit, allergy stickers on the outside of residents' charts were reviewed to ensure accuracy. A medication allergy sheet was completed for each resident on 03/27/14 by the DON, ADON, SDC, MDS Coordinator, and the Regional Nurse Consultant and placed in front of each resident's MARs. All allergies were clarified with the physician. The Regional Nurse Consultant, DON, and SDC initiated education for licensed staff and Kentucky Medication Aides (KMAs) on 03/27/14 and advised staff to review hospital documentation upon each resident admission or readmission to ensure allergies were appropriately identified. Licensed nursing staff/KMAs were not allowed to work prior to receiving the above stated education. A posttest was given upon completion of education. A score of 100 percent must be obtained before being allowed to work. Those staff members not obtaining a passing score of 100 percent would be educated on the spot and retested . Resident #8's attending physician, who is also the facility's Medical Director, received education from the Administrator, SDC, and the Regional Nurse Consultant on 03/28/14 regarding appropriately identifying resident allergies. The Administrator, DON, and Regional Nurse Consultant provided education to the Pharmacy Consultant on 03/28/14 regarding reviewing hospital discharge records for all residents to ensure allergies were appropriately identified. The Pharmacy Consultants were on-site on 03/29/14 and reviewed all resident records to ensure allergies were appropriately identified. The Regional Nurse Consultant provided education to the Administrator, DON, SDC, and ADONs on 03/28/14 regarding reporting of neglect for any significant medication error. The SDC, DON, ADONs, and the Regional Nurse Consultant initiated staff education on 03/28/14 regarding the abuse/neglect policy and appropriate reporting of neglect to include significant medication errors, the Quality Assurance Performance Improvement (QAPI) process to include reporting of concerns to the Administrator, and front line staff participation in development of QAPI plans. Staff was not permitted to work prior to receiving the education. A posttest was given upon completion of education. A score of 100 percent must be obtained before being allowed to work. Those staff members not obtaining a passing score of 100 percent would be educated on the spot and retested . Education regarding reporting abuse, reporting of significant medication errors, obtaining allergies from the discharge summary, resident history or POA history, verification of allergy orders from the physician, as well as places on the MAR indicated [REDACTED]. A follow-up questionnaire would be completed by the Administrator, DON, ADONs, MDS Coordinator, Social Services Director, Quality of Life Director, Dietary Manager, Plant Operations Director, Chaplain, Medical Records, Human Resources Director, SDC, Business Office Manager, Facility Formulary Nurse, or the Environmental Services Manager for ten staff members daily to include all shifts and different staff members until removal of immediacy, then weekly for four weeks, to ensure continued understanding of regarding the abuse/neglect policy and appropriate reporting of neglect to include significant medication errors, implementing care plans for allergies, the QAPI process to include reporting concerns to the Administrator, and front line staff participation in the development of QAPI plans. The Social Services Director, DON, ADONs, SDC, and MDS Coordinator conducted interviews on 03/27/14 with residents who had a BIMS score above 8 regarding their knowledge of allergies. This was compared to what was listed in the medical record and allergies were updated with assessment and/or physician's orders [REDACTED]. The Social Services Director, DON, ADONs, MDS Coordinator, Administrator, or Regional Nurse Consultant conducted interview with the responsible party for residents with a BIMS score of less than 8 by 03/27/14 to identify any allergies or concerns with medications. This was compared to what was listed in the medical record and allergies were updated with assessment and/or physician's orders [REDACTED]. Allergies will be identified on the day of admission and/or readmission by the admitting nurse on the nursing admission information document. The admission nurse will document allergies on the resident's medication allergy record that will be placed in the front of the MAR for that resident. The admitting nurse will review the resident's allergies with the resident and/or POA for confirmation. A care plan will be initiated that identifies allergies and interventions to decrease the risk of allergic reactions. The procedure which includes identification of allergies on the day of admission/readmission by the admitting nurse along with documenting the allergies on the medication allergy record, the nursing admission assessment, and the physician's orders [REDACTED]. The physician will be notified of any allergies by the charge nurse following review of all documents sent by the hospital, resident, and POA interview. Charts for newly admitted residents and readmitted residents will be reviewed and discussed in the Daily Clinical meeting on weekdays by the DON, MDS Coordinator, Social Services Director, Medical Records, SDC, ADONs, Activities Director, Dietary Manager, and Chaplain with a comparison review completed at that time of the resident's admission packet and their medication allergy form, against the hospital discharge summary and/or discharge documentation of resident allergies, to ensure that allergies are appropriately identified. On weekends, this review will be completed by the DON, ADONs, SDC, or MDS Coordinator until removal of immediacy. Following removal of immediacy, on weekends, two charge nurses will review the discharge documentation and history and physical for newly admitted or readmitted residents to ensure allergies are appropriately identified as well as all paperwork complete and accurate, care plan updated, physician notification complete, and all allergy lists updated or initialed. Allergy stickers and allergy lists were updated for all residents to include all medication allergies identified. This was completed by the Director of Nursing, Assistant Director of Nursing, MDS Coordinators, Staff Development Coordinator, and Regional Nurse Consultant on 03/28/14. Education was provided for licensed nursing staff/Kentucky Medication Aides by the Director of Nursing, Assistant Director of Nursing, the Staff Development Coordinator, and the Regional Nurse Consultant regarding all paperwork forwarded from the hospital, interview with resident/POA, verifying allergies with physician, noting allergies on the allergy sticker, allergy listings, physician orders, and MARs. Licensed nursing staff will not be allowed to work prior to receiving the above stated education. Nursing Administration to include the Director of Nursing, Assistant Directors of Nursing, Staff Development Coordinator, MDS Coordinators, Facility Formulary Nurse, or Regional Nurse Consultant are reviewing every physician's orders [REDACTED]. This will continue daily until immediacy lifted. Once immediacy is lifted a daily review will continue (Monday-Friday) by the above team. During care plan conference for each elder the allergy list will also be reviewed for any updates. Medication pass audits were completed by the Director of Nursing, Assistant Directors of Nursing, Staff Development Coordinator, and Regional Nurse Consultant for all nurses and Certified Medication Technicians working on 03/28/14 to ensure that allergies are appropriately identified and medications are administered without significant medication error. Medication pass audits will be completed for all nurses and certified medication technicians during their initial medication pass for shifts scheduled after 03/28/14 until all nurses and certified medication technicians have had a medication pass audit completed. During the medication pass audit, a questionnaire will be completed by the Director of Nursing, Assistant Directors of Nursing, Staff Development Coordinator, and Regional Nurse Consultant to ensure their knowledge of where to review for allergies prior to the administration of medication. The Assistant Director of Nursing, MDS Coordinator, or the Staff Development Coordinator will audit the Medication Administration Record [REDACTED]. All allergy clarifications for all residents have been sent to Pharmacy as of 03/29/14 in which Pharmacy has updated their listing in their computer system. Pharmacy will review all new orders and compare to any allergies listed and notify facility if an allergy exists regarding the new medication at which time the nurse will notify the physician for any new orders. All incident reports were reviewed by the Director of Nursing, the Assistant Director of Nursing, Staff Development Coordinator, or Regional Nurse Consultant to identify any further significant medication errors by 03/29/14. None was identified. All incidents or concerns are reviewed daily during the daily standup meeting to include Administrator, Director of Nursing, Assistant Director of Nursing, Dietary Manger, Chaplain, MDS Coordinators, Plant Operations Director, Medical Records, Admissions Director, Housekeeping/Central Supply Director, Quality of Life Director, Business Office Manager, Rehabilitation Manager, or Regional Staff to identify any allegation of abuse or neglect. The Administrator has been on-site daily to review all concerns or incidents to ensure abuse or neglect has been appropriately identified and reported. Administrative oversight of the facility will be completed by the Special Projects Administrator, the Regional Vice President of Operations, or the Chief Operating Officer daily until removal of immediacy, then weekly for four weeks after removal of immediacy, and then monthly. Education was provided by the Regional Nurse Consultant on 03/28/14 for the Administrator, the Director of Nursing, Assistant Directors of Nursing, Staff Development Coordinator, Quality of Life Director, Social Services Director, Plant Operations Director, Chaplain, Medical Records Coordinator, Dietary Manger, and Admission Director regarding the Quality Assurance Process and appropriate methods of identification of concerns including significant mediation errors, failure to report neglect, and auditing pharmacy services. The Administrator, Director of Nursing, Chief Operating Officer, Chief Nurse Executive, or Regional Nurse Consultant will audit compliance of the above stated audits daily until removal of immediacy, and then twice weekly for four weeks and report findings during weekly QA for four weeks, for recommendations and further follow-up as indicated. A Quality Assurance meeting was held on 03/28/14 with the Medical Director for further recommendations regarding the plan for removal of jeopardy. A Quality Assurance meeting will be held weekly for four weeks, and then monthly for recommendations and further follow-up regarding the above stated plan. **The surveyors validated the Immediate Jeopardy was removed as follows: Review of a physician's orders [REDACTED]." Review of the MAR for Resident #8 revealed staff administered 120 milligrams of Solu-Medrol intramuscularly and 50 milligrams of Benadryl orally on 03/11/14. Interview conducted with RN #2 on 03/27/14, at 4:55 PM, revealed she administered 120 milligrams of Solu-Medrol intramuscularly and 50 milligrams of Benadryl orally to Resident #8 after Resident #8 complained of "tightness" of the chest, after learning the resident had an allergy to Macrodantin (antibiotic), and obtained a physician's orders [REDACTED]. Interview conducted with Resident #6's physician on 04/02/14, at 4:30 PM, revealed he had been contacted by ADON #2 regarding the resident's allergy to Morphine. Review of an allergy sheet for Resident #6 on 04/02/14, at 5:00 PM, revealed Morphine was listed on the allergy sheet which was located in the front of the resident's MAR. Review of a care plan dated 03/30/14, revealed interventions to address Resident #6's allergy to Morphine. Review of a chart audit sheet the facility used to audit all residents' medical records for hospital discharge summaries and discharge documentation was reviewed to ensure allergies were identified. The audits were signed by the DON, ADON, SDC, MDS Coordinator, and the Regional Nurse Consultant as being completed on 03/27/14. The reviews of the medication allergy sheets for all residents were dated 03/27/14. Reviewed physician telephone orders to verify facility staff had contacted physicians to clarify the resident's drug allergies. Interview with ADON #1 on 04/03/14 at 1:40 PM, ADON #2 on 04/03/14 at 2:30 PM, the SDC on 04/03/14 at 2:40 PM, the MDS Coordinator on 04/03/14 at 2:35 PM, and the Regional Nurse Consultant on 04/03/14 at 2:45 PM revealed they had assisted with the chart audits on 03/27/14 to identify medication allergies by reviewing hospital discharge summaries, outside consultation notes, and discharge documentation. The interviews revealed allergy stickers were reviewed for accuracy, and medication allergy sheets were completed for all residents and placed in the front of each resident's MAR. The interview revealed all allergies were then clarified with the resident's physician. The interview also revealed the DON had assisted with the audits; however, she was no longer employed by the facility. Review of an in-service roster dated 03/27/14, revealed nurses and KMAs were in-serviced by the Regional Nurse Consultant, DON, and SDC regarding reviewing all hospital documentation upon admission or readmission to the facility to ensure allergies were appropriately identified. Posttests taken by licensed nurses and KMAs regarding in-service roster dated 03/27/14 were reviewed. Interview with the SDC on 04/03/14 at 2:40 PM, and the Regional Nurse Consultant on 04/03/14 at 2:45 PM revealed they had provided an in-service to the licensed nurses and KMAs regarding reviewing all hospital documentation upon each resident admission or readmission to the facility to ensure allergies were appropriately identified. Interviews conducted with RN #6 on 04/03/14 at 9:40 AM, RN #5 on 04/03/14 at 9:50 AM, LPN #4 on 04/03/14 at 10:00 AM, and LPN #1 on 04/03/14 at 10:05 AM all revealed they had attended an in-service regarding reviewing all hospital documentation to ensure allergies were appropriately identified with every admission or readmission. Review of an in-service roster dated 03/28/14 revealed the Medical Director attended an in-service provided by the Regional Nurse Consultant, SDC, and the Administrator regarding appropriately identifying allergies for residents. Interview conducted with the Medical Director on 04/02/14, at 4:30 PM, revealed he had attended an in-service provided by the facility on 03/28/14, regarding identifying allergies for the residents. Interview with the SDC on 04/03/14 at 2:40 PM, Regional Nurse Consultant on 04/03/14 at 2:45 PM, and the Administrator on 04/03/14 at 2:55 PM revealed they had provided an in-service to the Medical Director on 03/28/14 regarding ensuring resident allergies were appropriately identified. Review of an in-service syllabus and an email confirmation revealed the Consultant Pharmacist had been in-serviced by the Administrator, DON, and Regional Nurse Consultant on 03/28/14, regarding reviewing of all hospital discharge records for residents to ensure allergies were appropriately identified. Interview conducted with the Consultant Pharmacist on 04/02/14, at 4:35 PM, revealed he had attended an in-service by phone on 03/28/14 provided by the facility regarding reviewing all hospital discharge documentation to ensure residents' allergies were appropriately identified. Interview with the Regional Nurse Consultant on 04/03/14 at 2:45 PM, and the Administrator on 04/03/14 at 2:55 PM revealed they, along with the former DON, had provided an in-service to the Consultant Pharmacist on 03/28/14 regarding reviewing all hospital discharge documentation to ensure resident allergies were appropriately identified. Review of documentation from the facility's pharmacy revealed the Pharmacy Consultants had completed a review of all residents' medical records to ensure all allergies had been identified. Interview conducted with the Consultant Pharmacist on 04/02/14, at 4:35 PM, revealed the consulting pharmacy had completed an audit on all resident medical records in the facility on 03/29/14, to ensure residents' allergies were appropriately identified. Review of an in-service roster dated 03/28/14, revealed the Administrator, DON, SDC, and ADONs attended an in-service provided by the Regional Nurse Consultant regarding the reporting of significant medication errors as neglect. Interview with the Regional Nurse Consultant on 04/03/14, at 2:45 PM, revealed he had provided an in-service to the Administrator, DON, ADONs, and SDC on 03/28/14 regarding reporting of significant medication errors as neglect to the appropriate state agencies and investigating them as an allegation of neglect. Interview with ADON #1 on 04/03/14 at 1:40 PM, ADON #2 on 04/03/14 at 2:30 PM, the SDC on 04/03/14 at 2:40 PM, and the Administrator on 04/03/14 at 2:55 PM revealed they had attended an in-service provided by the Regional Nurse Consultant regarding reporting of significant medication errors to the state agencies and they were to investigate them as an allegation of neglect. Review of an in-service roster dated 03/28/14, revealed the SDC, DON, ADONs, and the Regional Nurse Consultant provided an in-service for all staff regarding the facility's Abuse/Neglect policy and the appropriate reporting of neglect to include significant medication errors, the QAPI process which included reporting of any concerns to the Administrator. Review of posttests regarding the in-service had been completed by staff. Interview with ADON #1 on 04/03/14 at 1:40 PM, ADON #2 on 04/03/14 at 2:30 PM, the SDC on 04/03/14 at 2:40 PM, and the Regional Nurse Consultant on 04/03/14 at 2:45 PM revealed they had provided an in-service to all staff regarding the facility's Abuse/Neglect policy and the appropriate reporting of neglect to include significant medication errors, the QAPI process which included reporting of any concerns to the Administrator. Interviews conducted with RN #6 on 04/03/14 at 9:40 AM, RN #5 on 04/03/14 at 9:50 AM, LPN #4 on 04/03/14 at 10:00 AM, LPN #1 on 04/03/14 at 10:05 AM, SRNA #1 on 04/03/14 at 1:55 PM, SRNA #2 on 04/03/14 at 2:00 PM, SRNA #3 on 04/03/14 at 2:05 PM, and SRNA #4 on 04/03/14 at 2:10 PM, all revealed they had attended an in-service regarding the facility's Abuse/Neglect policy and the appropriate reporting of neglect to include significant medication errors, the QAPI process which included reporting of any concerns to the Administrator. The staff also revealed they had been required to take a posttest on the in-service prior to working. Review of a syllabus for all new licensed nurses and KMAs revealed staff would be provided education regarding reporting of abuse, reporting of significant medication errors, where to review and document allergies, and verification of allergy orders. Interview with the SDC on 04/03/14, at 2:40 PM, revealed she was responsible for providing all new employee orientation. The SDC stated all new licensed nurses and KMAs would be provided education regarding reporting of abuse, reporting of significant medication errors, where to review and document allergies, and verification of allergy orders. The SDC stated no new licensed nurses or KMAs had been hired since the facility had added the new education to the syllabus. Review of the follow-up questionnaire revealed the facility had completed ten questionnaires daily from all shifts and different staff regarding understanding of the Abuse/Neglect policy, appropriate reporting of neglect to include significant medication errors, implementing care plans for allergies, the QAPI process, and their participation in the QAPI process, and reporting to the Administrator. Interviews conducted with RN #6 on 04/03/14 at 9:40 AM, RN #5 on 04/03/14 at 9:50 AM, LPN #4 on 04/03/14 at 10:00 AM, LPN #1 on 04/03/14 at 10:05 AM, SRNA #1 on 04/03/14 at 1:55 PM, SRNA #2 on 04/03/14 at 2:00 PM, SRNA #3 on 04/03/14 at 2:05 PM, and SRNA #4 on 04/03/14 at 2:10 PM, all revealed they had randomly completed a follow-up questionnaire regarding the facility's Abuse/Neglect policy and the appropriate reporting of neglect to include significant medication errors, the QAPI process which included reporting of any concerns to the Administrator. Review of an interview sheet revealed on 03/27/14, all residents with a BIMS score of greater than 8 had been interviewed by the Social Services Director, DON, ADONs, SDC, and the MDS Coordinator. Review of physician's orders [REDACTED]. Interviews conducted on 04/02/14, at 4:40 PM with Resident #6, at 4:50 PM with Resident #9, and at 4:55 PM with Resident #8 revealed they had been interviewed by the facility staff and had been asked about their allergies. Interview with ADON #1 on 04/03/14 at 1:40 PM, ADON #2 on 04/03/14 at 2:30 PM, SDC on 04/03/14 at 2:40 PM, and the MDS Coordinator on 04/03/14 at 2:35 PM, revealed they had interviewed all residents who had a BIMS score above 8 regarding their knowledge of their medication allergies. The allergies were then compared to what had been listed and the physician was notified for orders with any new allergy. Record review revealed on 03/27/14, responsible parties of residents with a BIMS score of less than 8 were interviewed about the residents' allergies. The interviews were conducted by the Social Services Director, DON, ADONs, SDC, Administrator, MDS Coordinator, or the Regional Nurse Consultant. Any new allergies that were identified as a result of the interviews were confirmed with the resident's physician. Interview with ADON #1 on 04/03/14 at 1:40 PM, ADON #2 on 04/03/14 at 2:30 PM, the SDC on 04/03/14 at 2:40 PM, the MDS Coordinator on 04/03/14 at 2:35 PM, the Regional Nurse Consultant on 04/03/14 at 2:45 PM, and the Administrator on 04/03/14 at 2:55 PM, revealed they had interviewed all responsible parties of residents who had a BIMS score of less than 8 regarding their knowledge of the resident's medication allergies. The allergies were then compared to what had been listed and the physician was notified for orders with any new allergy. Interviews conducted with Resident #7's responsible party on 04/02/14, at 5:45 PM, and Resident #14's responsible party on 04/02/14, at 6:00 PM, revealed the facility had contacted them regarding the resident's allergies. Review of Resident B's medical record revealed the resident was readmitted to the facility on [DATE], the resident did not have any known allergies, and the information was documented on the resident's medication allergy record, on the allergy sticker on the front of the resident's medical record, on the nursing admission assessment, physician's orders [REDACTED]. Review of Resident C's medical record revealed the resident was readmitted to the facility on [DATE], and the resident was allergic to Aspirin (analgesic) and Tubersol (medication to test for [DIAGNOSES REDACTED]) and the allergies were documented on the resident's medication allergy record, on the allergy sticker on the front of the resident's medical record, on the nursing admission assessment, physician's orders [REDACTED]. Review of Resident A's medical record revealed the resident was readmitted to the facility on [DATE], and the resident was allergic to Morphin

the Immediate Jeopardy on 03/31/14. The State Survey Agency determined the Immediate Jeopardy was removed on 03/31/14, prior to exit, which lowered the scope and severity to Based on interview, the facility's investigation, and review of the facility's policies entitled "Abuse, Neglect, and Misappropriation" and "Performance Improvement Plan," it was determined the facility failed to maintain a Quality Assessment and Assurance Committee that identified quality deficiencies and failed to develop and implement appropriate plans of action to correct identified deficiencies for one (1) of twenty-one (21) sampled residents (Resident #8). Review of the medical record revealed the facility admitted Resident #8 on 09/09/13 and received a History and Physical report from an acute care facility, dated 08/27/13, that indicated Resident #8 was allergic to [MEDICATION NAME] (antibiotic), but staff failed to document the resident's allergy to [MEDICATION NAME] on documents in the resident's medical record and on the Medication Administration Record [REDACTED]#8 experienced "tightness" in the chest, asked facility staff what medications he/she had received, and was informed he/she had received [MEDICATION NAME]. At that time, the resident informed staff he/she had an allergy to [MEDICATION NAME] and facility staff contacted the resident's physician and the [MEDICATION NAME] was discontinued. Further review of the Incident/Occurrence Investigation revealed the facility determined Registered Nurse (RN) #1 had reviewed all of Resident #8's medications with the resident at the time of admission and not been made aware the resident had an allergy to [MEDICATION NAME]. Interview and review of the facility's investigation revealed the facility failed to identify the resident's allergy to [MEDICATION NAME] and, as a result, failed to develop and implement appropriate plans of action through a Quality Assurance Program to correct the identified deficiency to prevent significant medication errors, the pharmacist's failure to identify and report drug irregularities to the physician, and the facility's failure to report/investigate allegations of neglect. (Refer to F225, F333, and F428.) The facility's failure to identify quality deficiencies and failure to develop and implement appropriate plans of action to correct identified deficiencies regarding reporting/investigating all allegations of neglect, preventing significant medication errors, and pharmacist reporting irregularities to the physician, caused or was likely to cause serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy with Substandard Quality of Care was determined to exist on 03/08/14 at 42 CFR 483.13 Resident Behavior and Facility Practices (F225), 42 CFR 483.25 Quality of Care (F333), 42 CFR 483.60 Pharmacy Services (F428), and 42 CFR 483.75 Administration (F520) at a scope and severity of "J." Substandard Quality of Care was identified at 42 CFR 483.13 Resident Behavior and Facility Practices (F225) and 42 CFR 483.25 Quality of Care (F333). The facility was notified of the Immediate Jeopardy on 03/28/14. An acceptable Allegation of Compliance was received on 04/01/14, and alleged removal of "D" at 42 CFR 483.13 Resident Behavior and Facility Practices (F225), 42 CFR 483.25 Quality of Care (F333), 42 CFR 483.60 Pharmacy Services (F428), and 42 CFR 483.75 Administration (F520) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's "Abuse, Neglect, and Misappropriation" policy with an effective date of April 2013, revealed the Quality Assurance/ Performance Improvement (QAPI) Committee would review allegations of abuse/neglect for resolution related to educational opportunities. Review of the facility's "Performance Improvement Plan" policy, undated, revealed the facility would conduct an ongoing performance improvement program designed to systematically monitor, evaluate, and improve the quality and appropriateness of resident care. The policy also revealed the Performance Committee would examine both outcomes and processes in an effort to improve the organization's overall performance. In addition, the policy revealed the performance improvement committee would include the Administrator, Director of Nursing, Medical Director, Nurse Practitioner, Consulting Pharmacist, Registered Dietitian, Medical Records, and any other staff deemed necessary. Review of the medical record revealed the facility admitted Resident #8 on 09/09/13 and received a copy of a History and Physical report from an acute care facility (dated 08/27/13) that revealed Resident #8 was allergic to [MEDICATION NAME] (antibiotic). Review of the Admission assessment dated [DATE] revealed Registered Nurse (RN) #1 assessed Resident #8 but failed to identify or document that the resident had an allergy to [MEDICATION NAME] (antibiotic). In addition, interview with Resident #8 on 03/26/14, at 2:25 PM revealed he/she had informed RN #1 on 09/09/13 that he/she was allergic to [MEDICATION NAME]. Review of the Medication Administration Record [REDACTED]. Interview and review of the Incident/Occurrence Investigation completed by the facility on 03/11/14, revealed on 03/11/14 at 9:50 PM, Resident #8 informed RN #2 that she had "tightness" in the chest, asked the nurse what medications he/she had received, and was informed he/she had received [MEDICATION NAME]. At that time, the resident informed the nurse he/she was allergic to [MEDICATION NAME], the nurse contacted the resident's physician, and the physician discontinued the [MEDICATION NAME]. Interview with the facility's Consultant Pharmacist on 03/27/14 at 4:40 PM revealed he/she had reviewed Resident #8's medical record, including the History and Physical report dated 08/27/13, and had failed to identify Resident #8 had an allergy to [MEDICATION NAME]. Review of the facility's investigation revealed the ADON interviewed RN #1, and noted the nurse had reviewed all medications with Resident #8 at the time of admission. However, the facility's investigation failed to reveal the information related to the resident's allergy to [MEDICATION NAME] was documented in the History and Physical report in the medical record and that staff had failed to identify the resident's allergy to the medication when the resident was admitted . Interview conducted with the Administrator on 03/28/14, at 9:00 AM, revealed he was responsible for coordinating the Performance Improvement program for the facility. The Administrator stated the facility was unaware the documentation of the resident's allergy to [MEDICATION NAME] was listed on the History and Physical in the resident's medical record until the day of the interview on 03/28/14. The Administrator stated because staff and the facility's investigation failed to identify the resident's allergy documented on the History and Physical in the medical record, the Performance Improvement Committee had not identified or developed quality assurance interventions, actions, or plans of correction necessary to address and correct the identified deficiency. The Administrator also stated the facility's investigation and the Performance Improvement Committee had not identified the incident related to the administration of [MEDICATION NAME] to Resident #8 as neglect and, as a result, did not report the incident to the state agencies as a suspected incident of neglect. **The facility provided an acceptable Allegation of Compliance (AOC) on 04/01/14. The facility implemented the following actions to remove the Immediate Jeopardy: The physician for Resident #8 was notified by the staff nurse immediately upon identification of symptoms that may have been related to the administration of [MEDICATION NAME]. physician's orders [REDACTED]. The treatment was effective as evidenced by every shift assessment along with supporting documentation. The resident was monitored by staff nurses to ensure continued effectiveness. The physician was notified by the Assistant Director of Nursing (ADON) for Resident #6 on 03/28/14 to clarify the resident's allergy to [MEDICATION NAME]. A sheet was added in front of the resident's Medication Administration Record [REDACTED]. A care plan was initiated with interventions to decrease the risk of an allergic reaction. Chart audits to include review of hospital discharge summaries and/or discharge documentation and outside consultation visits were completed by the Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC), MDS Coordinators, and Regional Nurse Consultant on 03/27/14 for all residents to ensure allergies were appropriately identified. During the audit, allergy stickers on the outside of residents' charts were reviewed to ensure accuracy. A medication allergy sheet was completed for each resident on 03/27/14 by the DON, ADON, SDC, MDS Coordinator, and the Regional Nurse Consultant and placed in front of each resident's MARs. All allergies were clarified with the physician. The Regional Nurse Consultant, DON, and SDC initiated education for licensed staff and Kentucky Medication Aides (KMAs) on 03/27/14 and advised staff to review hospital documentation upon each resident admission or readmission to ensure allergies were appropriately identified. Licensed nursing staff/KMAs were not allowed to work prior to receiving the above stated education. A posttest was given upon completion of education. A score of 100 percent must be obtained before being allowed to work. Those staff members not obtaining a passing score of 100 percent would be educated on the spot and retested . Resident #8's attending physician, who is also the facility's Medical Director, received education from the Administrator, SDC, and the Regional Nurse Consultant on 03/28/14 regarding appropriately identifying resident allergies. The Administrator, DON, and Regional Nurse Consultant provided education to the Pharmacy Consultant on 03/28/14 regarding reviewing hospital discharge records for all residents to ensure allergies were appropriately identified. The Pharmacy Consultants were on-site on 03/29/14 and reviewed all resident records to ensure allergies were appropriately identified. The Regional Nurse Consultant provided education to the Administrator, DON, SDC, and ADONs on 03/28/14 regarding reporting of neglect for any significant medication error. The SDC, DON, ADONs, and the Regional Nurse Consultant initiated staff education on 03/28/14 regarding the abuse/neglect policy and appropriate reporting of neglect to include significant medication errors, the Quality Assurance Performance Improvement (QAPI) process to include reporting of concerns to the Administrator, and front line staff participation in development of QAPI plans. Staff was not permitted to work prior to receiving the education. A posttest was given upon completion of education. A score of 100 percent must be obtained before being allowed to work. Those staff members not obtaining a passing score of 100 percent would be educated on the spot and retested . Education regarding reporting abuse, reporting of significant medication errors, obtaining allergies from the discharge summary, resident history or POA history, verification of allergy orders from the physician, as well as places on the MAR indicated [REDACTED]. A follow-up questionnaire would be completed by the Administrator, DON, ADONs, MDS Coordinator, Social Services Director, Quality of Life Director, Dietary Manager, Plant Operations Director, Chaplain, Medical Records, Human Resources Director, SDC, Business Office Manager, Facility Formulary Nurse, or the Environmental Services Manager for ten staff members daily to include all shifts and different staff members until removal of immediacy, then weekly for four weeks, to ensure continued understanding of regarding the abuse/neglect policy and appropriate reporting of neglect to include significant medication errors, implementing care plans for allergies, the QAPI process to include reporting concerns to the Administrator, and front line staff participation in the development of QAPI plans. The Social Services Director, DON, ADONs, SDC, and MDS Coordinator conducted interviews on 03/27/14 with residents who had a BIMS score above 8 regarding their knowledge of allergies. This was compared to what was listed in the medical record and allergies were updated with assessment and/or physician's orders [REDACTED]. The Social Services Director, DON, ADONs, MDS Coordinator, Administrator, or Regional Nurse Consultant conducted interview with the responsible party for residents with a BIMS score of less than 8 by 03/27/14 to identify any allergies or concerns with medications. This was compared to what was listed in the medical record and allergies were updated with assessment and/or physician's orders [REDACTED]. Allergies will be identified on the day of admission and/or readmission by the admitting nurse on the nursing admission information document. The admission nurse will document allergies on the resident's medication allergy record that will be placed in the front of the MAR for that resident. The admitting nurse will review the resident's allergies with the resident and/or POA for confirmation. A care plan will be initiated that identifies allergies and interventions to decrease the risk of allergic reactions. The procedure which includes identification of allergies on the day of admission/readmission by the admitting nurse along with documenting the allergies on the medication allergy record, the nursing admission assessment, and the physician's orders [REDACTED]. The physician will be notified of any allergies by the charge nurse following review of all documents sent by the hospital, resident, and POA interview. Charts for newly admitted residents and readmitted residents will be reviewed and discussed in the Daily Clinical meeting on weekdays by the DON, MDS Coordinator, Social Services Director, Medical Records, SDC, ADONs, Activities Director, Dietary Manager, and Chaplain with a comparison review completed at that time of the resident's admission packet and their medication allergy form, against the hospital discharge summary and/or discharge documentation of resident allergies, to ensure that allergies are appropriately identified. On weekends, this review will be completed by the DON, ADONs, SDC, or MDS Coordinator until removal of immediacy. Following removal of immediacy, on weekends, two charge nurses will review the discharge documentation and history and physical for newly admitted or readmitted residents to ensure allergies are appropriately identified as well as all paperwork complete and accurate, care plan updated, physician notification complete, and all allergy lists updated or initialed. Allergy stickers and allergy lists were updated for all residents to include all medication allergies identified. This was completed by the Director of Nursing, Assistant Director of Nursing, MDS Coordinators, Staff Development Coordinator, and Regional Nurse Consultant on 03/28/14. Education was provided for licensed nursing staff/Kentucky Medication Aides by the Director of Nursing, Assistant Director of Nursing, the Staff Development Coordinator, and the Regional Nurse Consultant regarding all paperwork forwarded from the hospital, interview with resident/POA, verifying allergies with physician, noting allergies on the allergy sticker, allergy listings, physician orders, and MARs. Licensed nursing staff will not be allowed to work prior to receiving the above stated education. Nursing Administration to include the Director of Nursing, Assistant Directors of Nursing, Staff Development Coordinator, MDS Coordinators, Facility Formulary Nurse, or Regional Nurse Consultant are reviewing every physician's orders [REDACTED]. This will continue daily until immediacy lifted. Once immediacy is lifted a daily review will continue (Monday-Friday) by the above team. During care plan conference for each elder the allergy list will also be reviewed for any updates. Medication pass audits were completed by the Director of Nursing, Assistant Directors of Nursing, Staff Development Coordinator, and Regional Nurse Consultant for all nurses and Certified Medication Technicians working on 03/28/14 to ensure that allergies are appropriately identified and medications are administered without significant medication error. Medication pass audits will be completed for all nurses and certified medication technicians during their initial medication pass for shifts scheduled after 03/28/14 until all nurses and certified medication technicians have had a medication pass audit completed. During the medication pass audit, a questionnaire will be completed by the Director of Nursing, Assistant Directors of Nursing, Staff Development Coordinator, and Regional Nurse Consultant to ensure their knowledge of where to review for allergies prior to the administration of medication. The Assistant Director of Nursing, MDS Coordinator, or the Staff Development Coordinator will audit the Medication Administration Record [REDACTED]. All allergy clarifications for all residents have been sent to Pharmacy as of 03/29/14 in which Pharmacy has updated their listing in their computer system. Pharmacy will review all new orders and compare to any allergies listed and notify facility if an allergy exists regarding the new medication at which time the nurse will notify the physician for any new orders. All incident reports were reviewed by the Director of Nursing, the Assistant Director of Nursing, Staff Development Coordinator, or Regional Nurse Consultant to identify any further significant medication errors by 03/29/14. None was identified. All incidents or concerns are reviewed daily during the daily standup meeting to include Administrator, Director of Nursing, Assistant Director of Nursing, Dietary Manger, Chaplain, MDS Coordinators, Plant Operations Director, Medical Records, Admissions Director, Housekeeping/Central Supply Director, Quality of Life Director, Business Office Manager, Rehabilitation Manager, or Regional Staff to identify any allegation of abuse or neglect. The Administrator has been on-site daily to review all concerns or incidents to ensure abuse or neglect has been appropriately identified and reported. Administrative oversight of the facility will be completed by the Special Projects Administrator, the Regional Vice President of Operations, or the Chief Operating Officer daily until removal of immediacy, then weekly for four weeks after removal of immediacy, and then monthly. Education was provided by the Regional Nurse Consultant on 03/28/14 for the Administrator, the Director of Nursing, Assistant Directors of Nursing, Staff Development Coordinator, Quality of Life Director, Social Services Director, Plant Operations Director, Chaplain, Medical Records Coordinator, Dietary Manger, and Admission Director regarding the Quality Assurance Process and appropriate methods of identification of concerns including significant mediation errors, failure to report neglect, and auditing pharmacy services. The Administrator, Director of Nursing, Chief Operating Officer, Chief Nurse Executive, or Regional Nurse Consultant will audit compliance of the above stated audits daily until removal of immediacy, and then twice weekly for four weeks and report findings during weekly QA for four weeks, for recommendations and further follow-up as indicated. A Quality Assurance meeting was held on 03/28/14 with the Medical Director for further recommendations regarding the plan for removal of jeopardy. A Quality Assurance meeting will be held weekly for four weeks, and then monthly for recommendations and further follow-up regarding the above stated plan. **The surveyors validated the Immediate Jeopardy was removed as follows: Review of a physician's orders [REDACTED]." Review of the MAR for Resident #8 revealed staff administered 120 milligrams of Solu-[MEDICATION NAME] intramuscularly and 50 milligrams of [MEDICATION NAME] orally on 03/11/14. Interview conducted with RN #2 on 03/27/14, at 4:55 PM, revealed she administered 120 milligrams of Solu-[MEDICATION NAME] intramuscularly and 50 milligrams of [MEDICATION NAME] orally to Resident #8 after Resident #8 complained of "tightness" of the chest, after learning the resident had an allergy to [MEDICATION NAME] (antibiotic), and obtained a physician's orders [REDACTED]. Interview conducted with Resident #6's physician on 04/02/14, at 4:30 PM, revealed he had been contacted by ADON #2 regarding the resident's allergy to [MEDICATION NAME]. Review of an allergy sheet for Resident #6 on 04/02/14, at 5:00 PM, revealed [MEDICATION NAME] was listed on the allergy sheet which was located in the front of the resident's MAR. Review of a care plan dated 03/30/14, revealed interventions to address Resident #6's allergy to [MEDICATION NAME]. Review of a chart audit sheet the facility used to audit all residents' medical records for hospital discharge summaries and discharge documentation was reviewed to ensure allergies were identified. The audits were signed by the DON, ADON, SDC, MDS Coordinator, and the Regional Nurse Consultant as being completed on 03/27/14. The reviews of the medication allergy sheets for all residents were dated 03/27/14. Reviewed physician telephone orders to verify facility staff had contacted physicians to clarify the resident's drug allergies. Interview with ADON #1 on 04/03/14 at 1:40 PM, ADON #2 on 04/03/14 at 2:30 PM, the SDC on 04/03/14 at 2:40 PM, the MDS Coordinator on 04/03/14 at 2:35 PM, and the Regional Nurse Consultant on 04/03/14 at 2:45 PM revealed they had assisted with the chart audits on 03/27/14 to identify medication allergies by reviewing hospital discharge summaries, outside consultation notes, and discharge documentation. The interviews revealed allergy stickers were reviewed for accuracy, and medication allergy sheets were completed for all residents and placed in the front of each resident's MAR. The interview revealed all allergies were then clarified with the resident's physician. The interview also revealed the DON had assisted with the audits; however, she was no longer employed by the facility. Review of an in-service roster dated 03/27/14, revealed nurses and KMAs were in-serviced by the Regional Nurse Consultant, DON, and SDC regarding reviewing all hospital documentation upon admission or readmission to the facility to ensure allergies were appropriately identified. Posttests taken by licensed nurses and KMAs regarding in-service roster dated 03/27/14 were reviewed. Interview with the SDC on 04/03/14 at 2:40 PM, and the Regional Nurse Consultant on 04/03/14 at 2:45 PM revealed they had provided an in-service to the licensed nurses and KMAs regarding reviewing all hospital documentation upon each resident admission or readmission to the facility to ensure allergies were appropriately identified. Interviews conducted with RN #6 on 04/03/14 at 9:40 AM, RN #5 on 04/03/14 at 9:50 AM, LPN #4 on 04/03/14 at 10:00 AM, and LPN #1 on 04/03/14 at 10:05 AM all revealed they had attended an in-service regarding reviewing all hospital documentation to ensure allergies were appropriately identified with every admission or readmission. Review of an in-service roster dated 03/28/14 revealed the Medical Director attended an in-service provided by the Regional Nurse Consultant, SDC, and the Administrator regarding appropriately identifying allergies for residents. Interview conducted with the Medical Director on 04/02/14, at 4:30 PM, revealed he had attended an in-service provided by the facility on 03/28/14, regarding identifying allergies for the residents. Interview with the SDC on 04/03/14 at 2:40 PM, Regional Nurse Consultant on 04/03/14 at 2:45 PM, and the Administrator on 04/03/14 at 2:55 PM revealed they had provided an in-service to the Medical Director on 03/28/14 regarding ensuring resident allergies were appropriately identified. Review of an in-service syllabus and an email confirmation revealed the Consultant Pharmacist had been in-serviced by the Administrator, DON, and Regional Nurse Consultant on 03/28/14, regarding reviewing of all hospital discharge records for residents to ensure allergies were appropriately identified. Interview conducted with the Consultant Pharmacist on 04/02/14, at 4:35 PM, revealed he had attended an in-service by phone on 03/28/14 provided by the facility regarding reviewing all hospital discharge documentation to ensure residents' allergies were appropriately identified. Interview with the Regional Nurse Consultant on 04/03/14 at 2:45 PM, and the Administrator on 04/03/14 at 2:55 PM revealed they, along with the former DON, had provided an in-service to the Consultant Pharmacist on 03/28/14 regarding reviewing all hospital discharge documentation to ensure resident allergies were appropriately identified. Review of documentation from the facility's pharmacy revealed the Pharmacy Consultants had completed a review of all residents' medical records to ensure all allergies had been identified. Interview conducted with the Consultant Pharmacist on 04/02/14, at 4:35 PM, revealed the consulting pharmacy had completed an audit on all resident medical records in the facility on 03/29/14, to ensure residents' allergies were appropriately identified. Review of an in-service roster dated 03/28/14, revealed the Administrator, DON, SDC, and ADONs attended an in-service provided by the Regional Nurse Consultant regarding the reporting of significant medication errors as neglect. Interview with the Regional Nurse Consultant on 04/03/14, at 2:45 PM, revealed he had provided an in-service to the Administrator, DON, ADONs, and SDC on 03/28/14 regarding reporting of significant medication errors as neglect to the appropriate state agencies and investigating them as an allegation of neglect. Interview with ADON #1 on 04/03/14 at 1:40 PM, ADON #2 on 04/03/14 at 2:30 PM, the SDC on 04/03/14 at 2:40 PM, and the Administrator on 04/03/14 at 2:55 PM revealed they had attended an in-service provided by the Regional Nurse Consultant regarding reporting of significant medication errors to the state agencies and they were to investigate them as an allegation of neglect. Review of an in-service roster dated 03/28/14, revealed the SDC, DON, ADONs, and the Regional Nurse Consultant provided an in-service for all staff regarding the facility's Abuse/Neglect policy and the appropriate reporting of neglect to include significant medication errors, the QAPI process which included reporting of any concerns to the Administrator. Review of posttests regarding the in-service had been completed by staff. Interview with ADON #1 on 04/03/14 at 1:40 PM, ADON #2 on 04/03/14 at 2:30 PM, the SDC on 04/03/14 at 2:40 PM, and the Regional Nurse Consultant on 04/03/14 at 2:45 PM revealed they had provided an in-service to all staff regarding the facility's Abuse/Neglect policy and the appropriate reporting of neglect to include significant medication errors, the QAPI process which included reporting of any concerns to the Administrator. Interviews conducted with RN #6 on 04/03/14 at 9:40 AM, RN #5 on 04/03/14 at 9:50 AM, LPN #4 on 04/03/14 at 10:00 AM, LPN #1 on 04/03/14 at 10:05 AM, SRNA #1 on 04/03/14 at 1:55 PM, SRNA #2 on 04/03/14 at 2:00 PM, SRNA #3 on 04/03/14 at 2:05 PM, and SRNA #4 on 04/03/14 at 2:10 PM, all revealed they had attended an in-service regarding the facility's Abuse/Neglect policy and the appropriate reporting of neglect to include significant medication errors, the QAPI process which included reporting of any concerns to the Administrator. The staff also revealed they had been required to take a posttest on the in-service prior to working. Review of a syllabus for all new licensed nurses and KMAs revealed staff would be provided education regarding reporting of abuse, reporting of significant medication errors, where to review and document allergies, and verification of allergy orders. Interview with the SDC on 04/03/14, at 2:40 PM, revealed she was responsible for providing all new employee orientation. The SDC stated all new licensed nurses and KMAs would be provided education regarding reporting of abuse, reporting of significant medication errors, where to review and document allergies, and verification of allergy orders. The SDC stated no new licensed nurses or KMAs had been hired since the facility had added the new education to the syllabus. Review of the follow-up questionnaire revealed the facility had completed ten questionnaires daily from all shifts and different staff regarding understanding of the Abuse/Neglect policy, appropriate reporting of neglect to include significant medication errors, implementing care plans for allergies, the QAPI process, and their participation in the QAPI process, and reporting to the Administrator. Interviews conducted with RN #6 on 04/03/14 at 9:40 AM, RN #5 on 04/03/14 at 9:50 AM, LPN #4 on 04/03/14 at 10:00 AM, LPN #1 on 04/03/14 at 10:05 AM, SRNA #1 on 04/03/14 at 1:55 PM, SRNA #2 on 04/03/14 at 2:00 PM, SRNA #3 on 04/03/14 at 2:05 PM, and SRNA #4 on 04/03/14 at 2:10 PM, all revealed they had randomly completed a follow-up questionnaire regarding the facility's Abuse/Neglect policy and the appropriate reporting of neglect to include significant medication errors, the QAPI process which included reporting of any concerns to the Administrator. Review of an interview sheet revealed on 03/27/14, all residents with a BIMS score of greater than 8 had been interviewed by the Social Services Director, DON, ADONs, SDC, and the MDS Coordinator. Review of physician's orders [REDACTED]. Interviews conducted on 04/02/14, at 4:40 PM with Resident #6, at 4:50 PM with Resident #9, and at 4:55 PM with Resident #8 revealed they had been interviewed by the facility staff and had been asked about their allergies. Interview with ADON #1 on 04/03/14 at 1:40 PM, ADON #2 on 04/03/14 at 2:30 PM, SDC on 04/03/14 at 2:40 PM, and the MDS Coordinator on 04/03/14 at 2:35 PM, revealed they had interviewed all residents who had a BIMS score above 8 regarding their knowledge of their medication allergies. The allergies were then compared to what had been listed and the physician was notified for orders with any new allergy. Record review revealed on 03/27/14, responsible parties of residents with a BIMS score of less than 8 were interviewed about the residents' allergies. The interviews were conducted by the Social Services Director, DON, ADONs, SDC, Administrator, MDS Coordinator, or the Regional Nurse Consultant. Any new allergies that were identified as a result of the interviews were confirmed with the resident's physician. Interview with ADON #1 on 04/03/14 at 1:40 PM, ADON #2 on 04/03/14 at 2:30 PM, the SDC on 04/03/14 at 2:40 PM, the MDS Coordinator on 04/03/14 at 2:35 PM, the Regional Nurse Consultant on 04/03/14 at 2:45 PM, and the Administrator on 04/03/14 at 2:55 PM, revealed they had interviewed all responsible parties of residents who had a BIMS score of less than 8 regarding their know

Based on interview, record review, and review of the facility's performance improvement plan, "Performance Improvement with Abaqis," dated 2012, and the "Abuse, Neglect and Misappropriation" policy dated April 2013, it was determined the facility failed to maintain a Quality Assessment and Assurance Committee to develop and implement appropriate plans of action to correct identified quality deficiencies for one (1) of three (3) sampled residents (Resident #32). On 05/25/14, staff observed bruising to Resident #32's arm and the resident made an allegation that "fat Pat" (identified by the facility as SRNA #2) "grabbed" his/her arm. Interview and record review revealed Administrative staff and the Quality Assurance Committee failed to ensure the allegations of abuse were reported immediately to State Agencies, failed to ensure residents were protected from further potential abuse while an investigation was conducted, and failed to ensure investigations of allegations included resident and staff interviews and assessment of other residents for signs of abuse and neglect. The facility failed to recognize that their established abuse policy for reporting abuse was not effective and therefore failed to implement any corrective actions to correct these problems. (Refer to F225, F226, and F490.) The facility's failure to ensure their Quality Assessment and Assurance Committee developed and implemented appropriate plans of action related to abuse prevention caused, or was likely to cause, serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy was determined to exist on 05/24/14 at 42 CFR 483.13 Resident Behavior and Facility Practices (F225 and F226) and 42 CFR 483.75 Administration (F490 and F520) with Substandard Quality of Care at 42 CFR 483.13 Resident Behavior and Facility Practices (F225 and F226). The facility was notified of the Immediate Jeopardy on 05/29/14. An acceptable Allegation of Compliance was received on 06/02/14 which alleged removal of the Immediate Jeopardy on 05/31/14. A partial extended survey was conducted on 06/03/14 through 06/04/14. The State Survey Agency determined the Immediate Jeopardy was removed on 05/31/14 as alleged, which lowered the scope and severity to "D" at 42 CFR 483.13 Resident Behavior and Facility Practices (F225 and F226) and "D" at 42 CFR 483.75 Administration (F490 and F520) while the facility monitors the effectiveness of systemic changes and quality assurance activities. (Refer to F225, F226, and F490). The findings include: Review of the facility's policy titled "Abuse, Neglect and Misappropriation," dated April 2013 revealed facility staff would report and investigate all allegations of verbal, sexual, physical, and mental abuse, corporal punishment, neglect, and involuntary seclusion of the resident and resident exploitation as well as misappropriation of resident property. According to the policy, all allegations would be reported immediately to the Administrator and other officials as required and the alleged staff would be immediately removed from the care of all residents. In addition, the policy revealed the Administrator/designee would make reasonable efforts to investigate and address alleged reports, concerns, and grievances. Review of the facility's performance improvement plan titled, "Performance Improvement with Abaqis," dated 2012, revealed the facility would conduct an ongoing performance improvement program designed to systematically monitor, evaluate, and improve the quality of resident care. The plan further stated the facility's Performance Improvement (PI) process was to be incorporated into the ongoing weekly clinical processes and was to ensure immediate concerns identified were promptly investigated, which included allegations of abuse. Review of incident reports and interviews revealed staff observed bruising to Resident #32's arm on 05/25/14 and the resident reported "fat Pat" (identified by the facility as SRNA #2) "grabbed" his/her arm. Review of the Daily Standup Meeting documentation dated 05/26/14, revealed the observation of Resident #32's bruised arm and the allegation made by the resident were discussed in the meeting. Interview conducted with the Staff Development Coordinator (SDC) on 05/29/14 at 4:37 PM, revealed Quality Assurance (QA)/Standup meetings were conducted Monday through Friday. The SDC further stated she had attended the meeting on 05/26/14, and stated Resident #32's bruises and the statement made by Resident #32 had been discussed. However, the SDC stated the incident and the resident's statement had not been "discussed as an allegation of abuse" and the QA Committee had not recommended any actions to address the resident's report. An interview conducted with Assistant Director of Nursing (ADON) #1 on 05/29/14 at 5:31 PM revealed the facility's "quality concerns" were discussed during the Daily Standup Meetings, which were conducted Monday through Friday. ADON #1 confirmed Resident #32's statement that the SRNA had "grabbed" his/her arm and the bruises to the resident's arm had been discussed in the meeting with members of the QA Committee on 05/26/14. The ADON further stated the incident had been reported to the DON and the Administrator, who were responsible for conducting abuse investigations. Therefore, he "felt like it had been addressed." ADON #1 further stated no other actions were recommended by members of the QA Committee when the incident was discussed on 05/26/14. An interview with the Director of Nursing (DON) on 05/29/14 at 6:06 PM revealed the facility's Daily Standup Meetings were conducted Monday through Friday and were part of the facility's Quality Assurance Program. The DON further stated the incident and actions which had been taken related to the bruises to Resident #32's arm, along with the resident's statement that the SRNA had grabbed his/her arm, were discussed with members of the QA Committee during the Daily Standup Meeting on 05/26/14. However, the DON stated the incident was not identified to be an allegation of abuse, and the QA Committee had not recommended any actions to be taken. An interview conducted with the Administrator on 05/29/14 at 6:17 PM confirmed that the facility had Daily Standup Meetings that were utilized as part of the facility's QA process and that facility concerns were discussed as a committee. The Administrator stated he had not attended the QA/Daily Standup Meeting on 05/26/14, when the incident related to the bruises observed on Resident #32's arm and the resident's allegation related to SRNA #2 had been discussed with members of the QA Committee. The Administrator stated he would have expected the facility's QA Committee to have determined the resident's report was an allegation of abuse. He stated facility staff should have reported and investigated the report in accordance with the facility's policy. **The facility provided an acceptable Allegation of Compliance (AOC) on 06/02/14. The facility implemented the following actions to remove the Immediate Jeopardy: --The allegation of abuse reported by Resident #32 was reported to the Office of Inspector General (OIG) on 05/27/14 by the DON. Resident #32 has a BIMS score greater than 8 and a statement was obtained on 05/25/14. The alleged perpetrator was suspended on 05/25/14. The facility's investigation was initiated and ongoing with a five-day report to be submitted to OIG on 05/30/14. All residents were assessed for any signs and symptoms of abuse/neglect. Those residents with BIMS scores greater than 8 were interviewed by the Social Services Director or Chaplain for any abuse/neglect concerns on 05/29/14. On 05/29/14, the Assistant Directors of Nursing (ADONs) assessed the physical status of residents with BIMS scores less than 8 for any signs and symptoms of abuse/neglect. The facility attempted to contact the 41 Power of Attorneys (POAs) for the residents with a BIMS score less than 8 to ask if they had any concerns related to abuse/neglect and successfully contacted 26; the Social Services Director, the Chaplain, the DON, and/or the Administrator will continue to attempt to contact the remaining 15 POAs until all have successfully been contacted. --The allegation of abuse related to Resident #33 that occurred on 05/24/14 was reported to OIG on 05/29/14 by the DON and reported to Adult Protective Services (APS), the Ombudsman, the resident's physician, and the POA on 05/30/14 by the DON. A facility nurse assessed Resident #33 on 05/29/14 and the resident had a psychosocial assessment completed by the Social Services Director on 05/30/14. Resident #33 was interviewed and a statement was obtained by the facility's Social Services Director on 05/30/14. The alleged perpetrator was no longer employed by the facility. The facility's investigation was initiated and ongoing with a five-day report to be submitted to OIG on 05/30/14. All residents were assessed for any signs and symptoms of abuse/neglect. Those residents with BIMS scores greater than 8 were interviewed by the Social Services Director or Chaplain for any abuse/neglect concerns on 05/29/14. On 05/29/14, the ADONs assessed the physical status of residents with a BIMS score less than 8 for any signs and symptoms of abuse/neglect. The facility attempted to contact the 41 POAs for the residents with a BIMS score less than 8 to ask if they had any concerns related to abuse/neglect and successfully contacted 26; the Social Services Director, the Chaplain, the DON, and/or the Administrator will continue to attempt to contact the remaining 15 POAs until all have successfully have been contacted. --The allegation of abuse reported by Resident #35 was reported to the Office of Inspector General on 05/29/14 by the DON and reported to APS, the Ombudsman, the resident's physician, and the POA on 05/30/14 by the DON. Resident #35 was physically assessed by a nurse and psychosocially assessed by the Social Services Director on 05/30/14. Resident #35 was interviewed and a statement was obtained by the Social Services Director on 05/30/14. The alleged perpetrator is no longer employed by the facility. The facility's investigation was initiated and ongoing with a five-day report to be submitted to OIG on 05/30/14. All residents were assessed for any signs and symptoms of abuse/neglect. Those residents with BIMS scores greater than 8 were interviewed by the Social Services Director or Chaplain for any abuse/neglect concerns on 05/29/14. On 05/29/14, the ADONs assessed the physical status of residents with BIMS scores less than 8 for any signs and symptoms of abuse/neglect. The facility attempted to contact the 41 POAs for the residents with a BIMS score less than 8 to ask if they had any concerns related to abuse/neglect and successfully contacted 26; the Social Services Director, the Chaplain, the DON, and/or the Administrator will continue to attempt to contact the remaining 15 POAs until all have successfully have been contacted. --All residents were assessed for any signs and symptoms of abuse/neglect. Those residents with BIMS scores greater than 8 were interviewed by the Social Services Director or Chaplain for any abuse/neglect concerns on 05/29/14. On 05/29/14, the ADONs assessed the physical status of residents with BIMS scores less than 8 for any signs and symptoms of abuse/neglect. The facility attempted to contact the 41 POAs for the residents with a BIMS score less than 8 to ask if they had any concerns related to abuse/neglect and successfully contacted 26; the Social Services Director, the Chaplain, the DON, and/or the Administrator will continue to attempt to contact the remaining 15 POAs until all have successfully been contacted. The Administrator, the Regional Nurse Consultant, and the Chief Nurse Executive reviewed abuse/neglect audits, assessments, interviews, and questionnaires on 05/30/14 for any indications of abuse/neglect concerns. --The facility's Regional Nurse Consultant from the corporate office re-educated the facility Administrator, the DON, the ADONs, the Minimum Data Set (MDS) Coordinator, the Staff Development Coordinator (SDC), the Director of Dining Services, the Business Office Manager, the Social Services Director, the Activities Director, the Chaplain, Marketing/Admissions, Medical Records, Human Resources, and Wound Care staff on 05/29/14 on the facility's abuse policy and procedure. The education included but was not limited to thorough investigations, reporting immediately, and the Quality Assurance Performance Improvement (QAPI) process, including reporting of concerns to the Administrator and floor staff participation in development of QAPI plans. This training was performed face to face in order to facilitate discussion and questions and included examples of items that would be considered as reportable: reports of staff being mean, injuries of unknown origin, withholding belongings, resident-to-resident altercations to include verbal or physical, and taking belongings or exploitation. Department administrative managers were not allowed to return to work until abuse education was provided, post-tests administered, and a score of 100% obtained. If the manager did not score 100% on post-test, then the manager was immediately re-educated and re-tested . This process continued until all managers obtained a 100% score on the post-test. All post-tests were reviewed for compliance by the Chief Nursing Executive (CNE). --After the facility Administrator, DON, ADONs, Minimum Data Set (MDS) Coordinator, Staff Development Coordinator (SDC), Director of Dining Services, Business Office Manager, Social Services Director, Activities Director, Chaplain, Marketing/Admissions staff, Medical Records staff or Director, Human Relations (HR) staff, or Wound Care staff were re-educated on the abuse policy, the Administrative staff was assigned to re-educate the staff on the abuse policy and procedure which included but was not limited to reporting, protection, and investigation requirements, which started on 05/29/14. The facility did not allow any employee to work until abuse education was provided, post-test administered, and 100% score obtained. If the employee did not score 100% on the post-test, the employee was immediately re-educated and the post-test re-administered. This process continued until all employees obtained a 100% score on the post-test. Education regarding the abuse policy and procedure, including identification/reporting and the Quality Assurance Performance Improvement process was added in the orientation process for all newly hired staff members. No newly hired employee would be allowed to work until abuse education was provided, post-test administered, and 100% score obtained. If the employee did not score 100% on the post-test, the employee was immediately re-educated and re-tested . This process continued until employees obtained a 100% score on the post-test. --Staff questionnaires regarding abuse, including the question, "What would you do if a resident told you that you were mean to them?" were administered by the Administrator, DON, ADONs, MDS Coordinator, SDC, Director of Dining Services, Business Office Manager, Social Services Director, Activities Director, Chaplain, Marketing/Admissions, Medical Records, HR, or Wound Care staff to five staff members on each shift and different staff members until immediacy was removed. After removal of immediacy, ten staff questionnaires were administered to staff daily to ensure continued understanding of the abuse/neglect policy and procedure, appropriate investigating, and reporting of abuse/neglect. The questionnaire also included questions related to the QAPI process to include reporting of concerns to the Administrator and floor staff participation in development of the QAPI plan. Results of the staff questionnaire were reported to the Quality Assurance (QA) Committee weekly to determine the further need of continued education or revision of the plan. At that time, based on evaluation, the QA Committee would determine at what frequency the staff questionnaire would need to continue. Concerns identified were corrected immediately and reported to the Administrator to ensure investigation of suspected abuse/neglect was investigated/completed and reporting guidelines were met. --HR performed an audit of all personnel files for any abuse concerns on 05/29/14. Items that were reviewed: Coaching and Counseling forms, suspension forms, and termination forms. Results of the audit were given to the Chief Nursing Executive on 05/30/14, to review for any abuse/neglect concerns that needed reporting. There were no concerns identified. --A nurse from the facility's regional team or corporate office had been on-site since 05/29/14 and remained in the facility daily until the jeopardy was removed. The nurses from the regional team or home office assisted with investigations, observed staff treatment of [REDACTED]. The Chief Nurse Executive, Clinical Compliance Nurse, or Director of Clinical Programs were in daily contact with the regional nurse consultant and reviewed allegations. --All facility grievances filed since 04/01/14 were reviewed by the Administrator, DON, or Regional Nurse Consultant on 05/30/14 to determine if any items documented were a reportable event. The Administrator was notified of one allegation of possible abuse. The Administrator reported the allegations to the Office of Inspector General on 05/30/14. The Administrator, Social Services Director, or the Director of Nursing reviewed the grievances and incident/accident reports daily, until immediacy was lifted, which was initiated on 05/29/14, to determine if there were reportable allegations that had not been identified. The Social Services Director or the Director of Nursing reported to the Administrator any identified allegations of abuse, neglect, or misappropriation immediately after their review. The Administrator will report any allegations of abuse, neglect, or misappropriation to the Office of Inspector General, Adult Protective Services, and the Ombudsman. --An emergency resident council meeting was held on 05/30/14; the Administrator and SDC attended the meeting to discuss any abuse/neglect concerns and to provide education on whom to report any abuse/neglect concerns without fear of retribution. The Social Services Director attempted to contact the POAs of all residents with BIMS scores less than 8 to discuss any abuse/neglect concerns and to provide education on whom to report any abuse/neglect concerns without fear of retribution on 05/30/14. --The Administrator, DON, ADONs, MDS Coordinator, SDC, Director of Dining Services, Business Office Manager, Social Services Director, Activities Director, Chaplain, Marketing/Admissions, Medical Records, HR, and Wound Care Nurse (one per shift) were to be on-site each shift to perform walking rounds in which ten residents (five with BIMS scores greater than 8 and five with BIMS scores less than 8) were visited by the Department Head and those residents that could be interviewed were interviewed regarding the staff treatment. The Department Head visited and a nurse conducted a skin check on the residents that were not able to be interviewed. The Department Head also spoke to nursing staff and State Registered Nursing Assistants (SRNAs) regarding any noted changes in the residents' behaviors. The facility Department Head also interviewed five staff members each shift regarding the types of abuse, who the facility's Abuse Coordinator was, when to report suspected abuse, what to do if the resident reported you were mean to them, etc., which began on 05/29/14 and continued until the immediate jeopardy was lifted. Results of resident and staff questionnaires were reported to the Administrator, DON, Regional Nurse Consultant, or Vice President (VP) of Operations daily and if the Administrator was not in the facility, the Department Director conducted the questionnaires and telephoned the Administrator or VP of Operations with the results of the resident and staff questionnaires. This continued until the immediate jeopardy was lifted. --The DON, ADONs, MDS Coordinator, SDC, Director of Dining Services, Business Office Manager, Social Services Director, Activities Director, Chaplain, Marketing/Admissions, Medical Records, HR, or Wound Care staff immediately notified the Administrator of any concerns regarding the above resident and staff questionnaires related to abuse, mistreatment, neglect, or misappropriation and ensured the resident was safe. A binder (which contains a resident roster in which the interview date and shift is noted next to the resident name), which is passed on to each Department Head assigned to perform the resident and staff questionnaires each shift, to ensure that residents with BIMS scores greater than 8 were interviewed and residents with BIMS scores less than 8 were visited and skin checks completed, began on 05/29/14 and continued until the jeopardy was lifted. The MDS Coordinators had the responsibility for updating the binder weekly to identify residents with BIMS scores greater than 8 and residents with BIMS scores less than 8. If abuse, mistreatment, neglect, or misappropriation was alleged during the interviews or visits or reported by a staff member, the Department Head ensured the resident was safe, reported to a Charge Nurse, the Charge Nurse removed the alleged perpetrator to a non-patient care area, and notified the Administrator, Director of Nursing, and/or Social Services Director/Abuse Coordinator. The alleged perpetrator was suspended and an investigation began immediately. --The Administrator, Director of Nursing, Social Services Director, or a member of the facility's regional staff reviewed all resident and staff questionnaires daily for any grievances/concerns. Investigations of grievances/concerns were initiated upon receipt, starting on 05/30/14. --Nursing Administration (DON, ADONs, Unit Managers, SDC, MDS staff, facility formulary nurse), or the Medical Records or Social Services Director, reviewed documentation in the Nursing Notes in order to assess for any signs of documented evidence regarding abuse, neglect, or misappropriation daily on ten different residents each day. If any of the above concerns were identified, the member of Nursing Administration first ensured the resident was safe by performing an assessment and then notified a Charge Nurse. The abuse policy was followed in which the alleged perpetrator was removed from a resident care area (if on duty) and the Administrator, DON, or Social Services Director was notified. --All resident charts were reviewed from 04/01/14 by Nursing Administration (DON, ADONs, Unit Manager, Staff Development Coordinator, MDS staff, Facility Formulary Nurse, Medical Records, Marketing/Admissions, or Social Services Director) or regional/corporate nurses by 05/30/14 for any documentation regarding abuse with no new incident being identified. Ten charts were reviewed by a member of Nursing Administration or the facility's regional or home office nurse daily to ensure that no other abuse allegations had been documented but not reported. This continued until the immediate jeopardy was removed. --The Administrator, Director of Nursing, and Social Services Director reviewed and discussed all abuse investigations daily to ensure that the residents were protected, the alleged perpetrator was removed from the resident care area, reports to the Office of Inspector General were filed timely, and a thorough investigation was completed. The Administrator maintained an abuse investigation log that included documentation of the following: ensured protection of residents, removed perpetrator from resident care area, reports to the Office of Inspector General filed timely, and thorough investigations completed. The Administrator and one of the following, Chief Operating Officer, Chief Nurse Executive, or Regional Nurse Consultant, reviewed the abuse investigation to ensure protection of the resident; that the perpetrator was removed from the resident care area; that reports to the Office of Inspector General were filed timely; and that a thorough investigation had been completed. This will occur daily until removal of immediate jeopardy. --For new reports of alleged abuse, neglect, or misappropriation of property, after the immediate jeopardy was removed, one of the following was contacted prior to making the final five-day investigation report to OIG: Signature Care Consultant, VP of Operations, Chief Operating Officer, Special Projects Administrator, or Chief Nursing Executive. The reviewer (Signature Care Consultant, VP of Operations, Chief Operating Office, Special Projects Administrator, or Chief Nursing Executive) ensured the resident was protected, report was filed timely, the perpetrator was removed from the patient care area, and a thorough investigation was completed. --With any new report of alleged abuse, neglect, or misappropriation of property, one of the following was contacted within 24 hours to review the abuse investigation to ensure that a thorough investigation was completed and reporting timelines were met: Signature Care Consultant, VP of Operations, Chief Operating Office, Special Projects Administrator, or CNE. --All incident reports from January 2014 to 03/29/14 were reviewed by the Director of Nursing, the Assistant Director of Nursing, Staff Development Coordinator, or Regional Nurse Consultant to identify any concerns of suspected neglect by 05/30/14. None was identified. --During care plan conference for each resident, any abuse/neglect concerns were discussed and abuse/neglect education, to include reporting, was provided to the resident and/or POA with supporting documentation noted. --Administrative oversight of the facility was completed by the Special Projects Administrator, the Regional Vice President of Operations, a member of regional staff, or the CEO daily until removal of immediacy beginning 05/29/14, then weekly for four weeks, and then monthly. --The DON, ADONs, or SDC observed the care delivery for any suspected abuse/neglect concerns on five residents daily until the removal of immediacy and then weekly (Monday through Friday). The results of the care delivery audits were reported to the QA Committee weekly to determine the further need of continued education or revision of plan. At that time, based on evaluation, the QA Committee would determine at what frequency the audits needed to continue. Concerns identified were corrected immediately and reported to the Administrator to ensure investigations of suspected abuse/neglect were investigated/completed and reporting guidelines were met. --A Quality Assurance meeting was held weekly for four weeks beginning 05/29/14, then monthly for recommendations and further follow-up regarding the above stated plan. At that time, based upon evaluation, the QA Committee would determine at what frequency any ongoing audits would need to continue. The Administrator had the oversight to ensure an effective plan was in place to meet resident well-being as well as an effective plan to identify facility concerns and implement a plan of correction to involve all staff of the facility. Corporate Administrative oversight of the Quality Assurance meeting was to be completed by the Special Projects Administrator, the Regional Vice President of Operations, a member of regional staff, or the Chief Executive Officer (CEO) daily until removal of immediacy beginning 05/29/14, then weekly for four weeks, and then monthly. **The surveyors validated the Immediate Jeopardy was removed as follows: Review of the facility's investigation and interviews with Administrative Staff revealed the allegation involving Resident #32 was investigated and reported to the appropriate State agency. The investigation included interviews with staff and residents and physical assessments of residents that were not interviewable. The investigation also included interviews with POAs, questioning for any concerns related to abuse or neglect. Review of the facility's investigation and interviews with Administrative staff revealed the allegation involving Resident #33 was investigated and reported to the appropriate state agency. The investigation included interviews with staff and residents and physical assessments of residents that were not interviewable. The investigation also included interviews with POAs, questioning for any concerns related to abuse or neglect. Review of the facility's investigation and interviews with Administrative staff revealed the allegation that involved Resident #35 was investigated and reported to the appropriate state agency. The investigation included interviews with Resident #35, staff, and residents and physical assessments of residents that were not interviewable. The investigation also included interviews with POAs, questioning for any concerns related to abuse or neglect. Review of the facility's assessments for signs and symptoms of abuse and resident interviews revealed the facility completed them on 05/29/14. Interview with the Regional Nurse Consultant on 06/04/14 at 9:15 AM revealed as of 06/03/14, only six POAs had not been contacted so the facility sent the abuse/neglect questionnaire by certified mail to the POAs. A review of the abuse/neglect assessments, abuse/neglect audits, and abuse/neglect interviews revealed the Administrative staff provided validation and oversight. Review of Administrative staff education and testing, provided on 05/29/14, related to abuse/neglect policy, investigations, reporting, and the Quality Assessment process was reviewed and validated by the Chief Nursing Executive (CNE). Review of staff education and post-testing related to the abuse policy and procedure which included reporting, protection, and investigation requirements revealed the education was provided on 05/29/14, as per the AOC. Interview with the Regional Nurse Consultant on 06/04/14 at 9:15 AM, revealed during the staff in-service examples were given of different situations of abuse/neglect and the staff had to explain the appropriate actions. Further interview with the Regional Nurse Consultant revealed the facility had not hired any new employees. A review of the staff questionnaire regarding abuse was being done as reported in the AOC. Interview on 06/04/14 at 9:15 AM with the Regional Nurse Consultant revealed no issues had been identified through the staff questionnaires. Review of the HR Audits of personnel files revealed the CNE validated review by signature on the back of the audit forms. Interview with the Regional Nurse Consultant on 06/04/14 at 9:15 AM revealed there were no issues identified with the review of the employee files. Interview on 06/04/14 at 9:15 AM with the Regional Nurse Consultant revealed a corporate staff member had been at the facility since the jeopardy was identified and had been reviewing all allegations to ensure a thorough investigation was conducted. Further interview revealed the corporate staff was also conducting chart audits, observed staff treatment of [REDACTED]. Interview on 06/04/14 at 9:15 AM with the Regional Nurse Consultant revealed all facility grievances filed since 04/01/14 were reviewed for possible allegations of abuse/neglect. The interview revealed one grievance was related to cigarettes that were missing. The incident was investigated with no concerns identified. Continued interview revealed the facility's smoking policy had recently been updated to account for all residents' cigarettes. Interviews on 06/04/14 with the Regional Nurse Consultant and SDC revealed a Resident Council meeting was held on 05/30/14 to discuss abuse/neglect concerns and education was provided on reporting abuse/neglect concerns without fear of retribution. The interview further revealed residents that did not attend the meeting were also provided education related to reporting abuse. Interview on 06/04/14 with the Regional Nurse Consultant and the Administrator revealed as of 05/29/14 a daily census was completed and residents were chosen by the Administrator to be interviewed and to observe staff as they provided care to the resident which was done by Administrative Staff. The interview further revealed staff providing care to res

Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure the Comprehensive Plan of Care was revised for one (1) of four (4) sampled residents (Resident #1). Resident #1 sustained a pathological [MEDICAL CONDITION] femur on 10/06/13 and the physician requested the use of a "pillow splint" to immobilize the resident's leg. However, the facility failed to revise the Comprehensive Plan of Care after the resident sustained [REDACTED]. leg under the "pillow splint" to ensure the resident attained or maintained his/her physical well-being. On 11/13/13, Resident #1 was transported to the local emergency room (ER) after he/she had a change in condition. Based on documentation, upon admission to the ER hospital staff removed the "pillow splint" from the resident's left leg and observed a 3.5 centimeter (cm) open pressure sore to the top of the resident's left, lower leg and black eschar (dead tissue) to the resident's left heel. The findings include: Review of the facility's policy entitled "Care Plans-Comprehensive" and dated October 2010, revealed facility staff was to revise the Comprehensive Plan of Care when a resident experienced a significant change in condition. Review of the facility's policy entitled "Splinting" and dated July 2010, revealed splints should be removed and the resident observed for areas of redness, [MEDICAL CONDITION], or the development of any open [MEDICAL CONDITION] and to report the findings to the Charge Nurse and physician. Review of the medical record for Resident #1 revealed the facility admitted the resident on 04/28/12. The resident's [DIAGNOSES REDACTED]. In addition, the facility assessed the resident to be cognitively impaired. Further review of the medical record revealed Resident #1 sustained a pathological [MEDICAL CONDITION] on 10/06/13. Documentation in the progress notes by the orthopedic surgeon dated 10/07/13 revealed the resident's fracture was pathologic in nature. As a result of the fracture, the physician immobilized the resident's left femur with the use of a "pillow splint." Review of physician's orders [REDACTED]. Continued review of physician's orders [REDACTED]. to the side of the resident's left leg to aid in positioning, to continue the pillow splint to the resident's left leg at all times, and to remove only for care as necessary. Review of the comprehensive care plan for Resident #1, dated 10/02/13 and updated on 10/08/13, revealed the resident was at risk for the development of skin breakdown and needed extensive assistance with bed mobility. In addition, the goals established by staff for Resident #1 revealed the resident's skin was to remain intact and free of redness, blisters, or discoloration over bony prominences through the next review date. Interventions to achieve the established goals were based on the physician's orders [REDACTED]. However, continued review of the comprehensive care plan for Resident #1 revealed staff had not identified the conditions and/or symptoms that would require staff to remove the resident's "pillow splint" in order to assess the resident's skin status and failed to update the comprehensive care plan to reflect the requirements identified in the facility's policy entitled "Splinting." Interview with Licensed Practical Nurse (LPN) #4 on 11/19/13 at 9:35 AM, revealed she had readmitted Resident #1 to the facility after the resident returned from theER on [DATE] and had added the use of the "pillow splint" to the resident's care plan. LPN #4 stated she called the orthopedic surgeon and was told to remove the splint "if necessary," that the fracture might not heal and to utilize two (2) to three (3) people to hold the resident's leg still and in position to change the "pillow splint." However, LPN #4 did not include this information on Resident #1's care plan. According to LPN #4, the nurses did not remove the pillow splint because the physician had said the resident's fracture might not heal, that he did not want the positioning of the femur to move, and did not want the pillow splint removed unless "necessary." On 11/13/13, documentation in the medical record revealed Resident #1 was transported to the ER after he/she had a change in mental status. Based on documentation in the resident's ER medical record, upon the resident's admission to theER on [DATE] the ER physician and nurse removed the pillow splint from the resident's leg and discovered a 3.5 cm by 6.5 cm open pressure sore to the top of the resident's left, lower leg and black eschar to the resident's left heel. Observation of Resident #1 on 11/19/13 at 12:30 PM at the local hospital revealed the resident was not able to be interviewed as the resident was cognitively impaired. A skin observation with a nurse at the hospital revealed a gauze dressing to the top of the resident's left leg that was removed by the hospital nurse. The nurse removed the dressing from the resident's left leg and obtained measurements of an open area on the leg. According to the nurse, the area on the resident's left leg was a Stage II pressure area that measured 3.5 cm by 6.5 cm in diameter. Upon removal of the gauze dressing from the resident's left heel by the nurse, a black area was observed on the resident's left heel. The nurse at the hospital identified the area as an unstageable pressure area that was covered with black eschar. Interview with Certified Nurse Aide (CNA) #1 on 11/18/13 at 1:55 PM, CNA #2 on 11/18/13 at 2:10 PM, CNA #3 on 11/18/13 at 2:15 PM, CNA #4 on 11/18/13 at 3:05 PM, and Certified Medication Aide (CMA) #1 on 11/18/13 at 2:22 PM revealed the aides had provided direct care to Resident #1 after his/her return from the hospital on [DATE] with a fractured femur. The aides stated they had not been directed to remove the resident's "pillow splint" and had left the splint intact. The aides said if the pillow splint became soiled they notified the nurse in charge. According to the aides, nurses were to remove the pillow splint and apply a clean pillowcase and/or splint as needed. The aides stated they had not observed Resident #1 to have any pressure sores, and stated if there was any change in the resident's condition they would have notified the nurses. Interview with Licensed Practical Nurse (LPN) #1 on 11/18/13 at 2:44 PM, LPN #2 on 11/18/13 at 2:55 PM, LPN #3 on 11/18/13 at 4:05 PM, Registered Nurse (RN) #1 on 11/18/13 at 5:00 PM, RN #2 on 11/19/13 at 8:55 AM, LPN #4 on 11/19/13 at 9:35 AM, LPN #5 on 11/19/13 at 3:10 PM, and the South Hall Unit Manager on 11/19/13 at 3:25 PM revealed they were aware of the physician's orders [REDACTED].#1's left femur on an "as needed" basis. Further interview revealed the "pillow splint" was removed when it became heavily soiled and no pressure sores had been observed. The nurses stated the CNAs had not reported any concerns, including pressure areas, related to the resident's skin condition that had not already been identified. The interviews revealed staff had provided treatment to a scabbed area on Resident #1's great toe, and applied medicated creams to the resident's buttocks after incontinence care. LPN #3 stated in interview conducted on 11/18/13 at 4:05 PM that she had performed a head to toe assessment of Resident #1 on 11/13/13 prior to the resident's transfer to theER on that date related to a change in the resident's mental status. According to LPN #3, she had not identified pressure areas to Resident #1's lower left leg or left heel; however, LPN #3 stated she had not removed the pillow splint to examine Resident #1's skin because the physician did not want the splint removed. LPN #3 was not aware of a blackened area to Resident #1's left heel or of the open area to the resident's left lower leg. Interview with the orthopedic surgeon on 11/19/13 at 11:45 AM revealed the surgeon utilized the "pillow splint" on 10/06/13 related to Resident #1's [DIAGNOSES REDACTED]. According to the physician, the pillow splint should have been removed to check for pressure and should have been changed when it became soiled. The Administrator and the Nurse Consultant acknowledged in an interview conducted on 11/19/13 at 3:40 PM that the orthopedic surgeon had requested the "pillow splint" to Resident #1's left leg to only be removed, as needed, to provide care. The Nurse Consultant stated nursing staff should have contacted the resident's physician to clarify the orders related to removing the pillow splint and should have updated the care plan to reflect when and how to remove the splint to ensure Resident #1's leg remained stable and the skin integrity remained intact.

Based on interview, record review, and policy review, it was determined the facility failed to ensure care was provided in accordance with the resident's Plan of Care for one (1) of four (4) sampled residents (Resident #1). The facility assessed Resident #1 to be at risk for impaired skin integrity and developed a plan of care to address and/or implement in an effort to prevent the development of pressure areas. However, on 11/13/13, the facility transferred Resident #1 to the local emergency room (ER) related to a change in the resident's mental status and ER staff noted the resident had a visible area of black eschar (hardened/dead tissue) to the left heel. In addition, upon removal of a "pillow splint" that had been utilized to support the resident's left femur due to a recent fracture, ER staff observed a 3.5 centimeter (cm) by 6.5 cm pressure sore to the top of the resident's lower leg. Continued review of the resident's medical record revealed [REDACTED]. report the changes in the resident's skin integrity to the physician in accordance with the plan of care. The findings include: Review of the facility's policy entitled "Care Plans-Comprehensive" and dated October 2010, revealed the Comprehensive Care Plan incorporated risk factors associated with identified problems, identified interventions to aid in the prevention or reduction of declines in the resident's functional status and/or functional levels, and identified the professional services that were responsible for each element of care. Continued review of the facility's policies revealed a policy entitled "Splinting" and dated July 2010, that revealed splints should be removed and the resident observed for areas of redness, [MEDICAL CONDITION], or the development of any open [MEDICAL CONDITION], and the findings reported to the Charge Nurse and physician. Record review revealed the facility admitted Resident #1 on 04/28/13 with [DIAGNOSES REDACTED]. The facility also assessed the resident to be cognitively impaired. Review of the facility's plan of care for Resident #1 dated 10/02/13 revealed due to the resident's assessed risk for skin impairment due to age and not eating/drinking well, facility staff was to immediately notify the nurse of any new areas of skin breakdown, redness, blisters, bruises, or discolorations noted during bathing and/or daily care, complete weekly skin assessments, and report changes to the physician. In addition, staff was to assist the resident, as needed, to reposition/shift his/her weight to relieve pressure to utilize "off-loading" devices (e.g., heel pads) to the resident's bilateral lower extremities to prevent pressure and to ensure prolonged skin-to-skin exposure was avoided. Documentation in the medical record revealed when staff provided morning care to Resident #1 on 10/06/13, they observed a "deformity" to the resident's left leg, and the resident was transported to the ER for evaluation. Resident #1 was assessed at the ER and diagnosed to have a fractured left femur. An orthopedic surgeon diagnosed the fracture and documented the fracture was "pathogenic in nature, related to the [DIAGNOSES REDACTED]." The physician applied a "pillow splint" to the left leg and the resident was transferred back to the facility. Continued review of the plan of care revealed facility staff revised Resident #1's plan of care on 10/08/13 after he/she had been assessed in the ER and diagnosed with [REDACTED]." The staff identified goals related to the resident's skin status based on the physician's orders [REDACTED]." However, staff had not identified the conditions and/or symptoms that would require staff to remove the resident's "pillow splint" "as necessary" in order to assess the resident's skin status, and failed to update the plan of care to reflect the requirements identified in the facility's policy entitled "Splinting." Continued review of Resident #1's medical record revealed on 11/13/13, the facility transferred Resident #1 to the ER due to a change in the resident's mental status. Although the facility failed to document the time of the resident's transfer to the ER, review of the ambulance transfer form revealed Resident #1 was transported to the local Emergency Department at 12:15 PM on 11/13/13. Review of a skin assessment performed by facility staff on 11/13/13 (no time documented) prior to the resident's transfer to the ER revealed Resident #1's buttocks were pink, the left leg "pillow splint" was in use, petechia (red rash) was present to the resident's arms and legs, and the resident's skin was dry. According to the skin assessment, there was a dressing noted to the resident's left great toe and scabs were noted to the resident's left foot. However, review of documentation obtained from the ER revealed upon Resident #1's arrival to theER on [DATE] at 12:36 PM, the physician removed the "pillow splint" from the resident's left leg and observed a 6.5 cm by 3.5 cm decubitus ulcer on the top of the resident's lower leg and a pressure ulcer with black eschar on the left heel. Based on review of the resident's medical record, facility staff failed to assess the discolored area to the resident's heel and the impaired skin integrity to the top of the resident's left leg, and failed to report the change in the resident's condition to the physician as planned in the resident's plan of care. Interview conducted on 11/18/13 at 1:55 PM with Certified Nurse Aide (CNA) #1, 11/18/13 at 2:10 PM with CNA #2, 11/18/13 at 2:15 PM with CNA #3, 11/18/13 at 3:05 PM with CNA #4, and 11/18/13 at 2:22 PM with Certified Medication Aide (CMA) #1 revealed if the aides identified any problems related to the skin condition of any resident, or if a resident's dressing became soiled, they notified the nurse immediately. According to the aides, they were not permitted to remove the "pillow splint" from Resident #1's left leg and stated the nurses were responsible for dressing changes. The aides said after the "pillow splint" was in place for Resident #1 they had not noticed any pressure sores when they provided incontinence care or bathed the resident. The aides said when the pillow splint became heavily soiled the nurses would change the splint. The aides also stated that Resident #1 wore heel protectors to relieve pressure from the heels, and the protectors were removed to provide bathing/showers. According to the aides, they had not observed pressure sores to Resident #1's heels. Interview with Licensed Practical Nurse (LPN) #1 on 11/18/13 at 2:44 PM, LPN #2 on 11/18/13 at 2:55 PM, LPN #3 on 11/18/13 at 4:05 PM, Registered Nurse (RN) #1 on 11/18/13 at 5:00 PM, RN #2 on 11/19/13 at 8:55 AM, LPN #4 on 11/19/13 at 9:35 AM, LPN #5 on 11/19/13 at 3:10 PM, and the South Hall Unit Manager on 11/19/13 at 3:25 PM revealed if the CNAs observed any skin problems when they provided care to residents, they were to report the problems immediately to the nurse. The interviews revealed the nurse aides had not notified the nurses of any concerns related to Resident #1's skin condition. Continued interviews with the nurses revealed nursing staff was required to conduct resident skin assessments on a weekly basis and they had not observed any concerns with Resident #1's skin condition when they had assessed the resident during the weekly skin assessments. However, the nurses stated they only removed the resident's splint when it became heavily soiled because the resident's physician only wanted the "pillow splint" to be removed when necessary. LPN #3 stated she performed a "head to toe" assessment of Resident #1 on 11/13/13, prior to the resident's transfer to the ER, and observed the resident's buttock was pink, the left leg "pillow splint" was in use, petechia was present to the resident's arms and legs, and the resident's skin was dry. In addition, LPN #3 stated Resident #1 had a dressing to the left great toe and scabs were noted to the resident's left foot. However, LPN #3 stated she did not remove the pillow splint to examine Resident #1's skin prior to the resident's transfer to the ER because the physician had not wanted the splint removed. Interview with LPN #5 revealed splints and heel booties were routinely removed to perform skin assessments; however, the LPN stated the physician only wanted the splint to Resident #1's leg to be removed when necessary. Interview with the Administrator and the Nurse Consultant on 11/19/13 at 3:40 PM revealed staff was to follow each resident's plan of care when they provided care. According to interviews, staff that performed/assisted residents with the activities of daily living (bathing, incontinence care) was to assess each resident's skin condition and report any abnormal findings to the nurses. The interviews also revealed as directed in the plan of care, nurses were to assess residents, document their findings, and notify the physician for orders if there were any concerns identified. The Nurse Consultant said administrative staff was to monitor CNAs and nurses to see that plans of care were followed and any problems identified were addressed immediately. The Administrator and the Nurse Consultant did not know why the black eschar observed on Resident #1's left heel and the open area on the resident's left leg were not reported by the CNAs or assessed/documented by the nurses.

Based on observation, interview, record review, and review of facility policy it was determined the facility failed to ensure one (1) of four (4) sampled residents (Resident #1) who entered the facility without pressure sores did not develop pressure sores. Documentation revealed Resident #1 returned from an emergency room visit on 10/06/13 after he/she was diagnosed with [REDACTED]. was intact with no open areas, and assessed the resident to have a discoloration to the left side of the left knee, reddened areas to the buttocks, and multiple red areas to the right thigh. The resident was also noted to have a "pillow splint" in place to the left leg. Review of Resident #1's medical record revealed facility staff conducted skin assessments on 10/08/13, 10/09/13, 10/10/13, 10/17/13, 10/24/13, 10/31/13, 11/05/13, 11/07/13, and 11/13/13 and noted the resident's skin was intact. On 11/13/13, the facility transferred Resident #1 to the emergency room (ER) due to a change in the resident's mental status. Upon Resident #1's arrival to theER on [DATE], the ER physician removed the "pillow splint" from the resident's left leg and observed a 3.5 centimeter (cm) by 6.5 cm decubitus ulcer to the top of the left lower leg and purulent drainage on the "pillow splint." In addition, the ER physician documented Resident #1 had a pressure area to the left heel that had black eschar (dead tissue). The findings include: Review of the facility's policy entitled "Prevention of Pressure Ulcers" and dated October 2013, revealed staff should make every attempt to "float" heels (keep heels from direct contact with the bed) when residents were in bed to avoid pressure. According to the policy, staff was to place a pillow from the resident's knee to the ankle or to use other devices as recommended by clinical staff or the physician. Review of the facility's policy entitled "Splinting" and dated July 2010, revealed splints should be removed and the resident observed for areas of redness, [MEDICAL CONDITION], or the development of any open [MEDICAL CONDITION] and the findings reported to a Charge Nurse and physician. Based on documentation in the medical record, the facility admitted Resident #1 on 04/28/12 with [DIAGNOSES REDACTED]. According to documentation on the Minimum Data Set (MDS) assessment, Resident #1 "rarely/never understood" and as a result, a Brief Interview for Mental Status (BIMS) assessment was not conducted. However, facility staff documented on the MDS that Resident #1's cognition was "severely impaired." Continued review of Resident #1's medical record revealed on 10/06/13, facility staff transferred the resident to the ER due to a deformity of the left leg. Resident #1 was diagnosed with [REDACTED]. Documentation in the ER record revealed the ER staff applied a "pillow splint" to the resident's left femur in an effort to stabilize the resident's leg due to the fracture and transferred the resident back to the facility. Interview with the orthopedic surgeon on 11/19/13 at 11:45 AM revealed he had assessed Resident #1 when he/she had presented to theER on [DATE] and determined the resident had a fractured femur. According to the orthopedic surgeon, due to the resident's [DIAGNOSES REDACTED].#1's left thigh for stabilization. The surgeon also stated facility staff should have removed the "pillow splint" to assess Resident #1 for pressure, and changed the splint when it became soiled. Upon Resident #1's return to the facility from theER on [DATE], facility staff assessed the resident to have "discoloration" to the left side of the left knee, reddened areas to the buttocks, and multiple red areas to the right thigh. In addition, on 10/08/13, 10/09/13, 10/10/13, 10/17/13, 10/24/13, 10/31/13, 11/05/13, 11/07/13, and 11/13/13 facility staff documented that skin assessments revealed there were no open areas to Resident #1's skin. On 11/13/13 at 12:15 PM facility staff transferred Resident #1 to the ER due to a change in mental status. Documentation in Resident #1's ER record revealed the resident arrived to theER on [DATE] at 12:34 PM. Based on documentation, when the ER physician removed the pillow splint from Resident #1's left leg, he observed a 3.5 cm by 6.5 cm decubitus ulcer to the resident's left lower leg and a pressure area with black eschar on the resident's left heel. Observation of Resident #1 was conducted at the hospital on [DATE] at 12:30 PM, and an interview was attempted; however, due to the resident's impaired cognition the interview was not successful. A skin observation of Resident #1 was conducted on 11/19/13 at 12:30 PM with a nurse at the hospital and, after the nurse removed the gauze dressing from the top of Resident #1's left leg, an area was observed on the resident's left lower leg that was open and had yellow drainage. According to the nurse, the area measured 3.5 cm by 6.5 cm in diameter. In addition, continued observations revealed an area on the resident's left heel that was black and unstageable. According to interviews conducted with Certified Nurse Aide (CNA) #1 on 11/18/13 at 1:55 PM, CNA #2 on 11/18/13 at 2:10 PM, CNA #3 on 11/18/13 at 2:15 PM, CNA #4 on 11/18/13 at 3:05 PM, and Certified Medication Aide (CMA) #1 on 11/18/13 at 2:22 PM, they had provided direct care to Resident #1 after his/her return from the hospital on [DATE]. The aides stated they had not been directed to remove the resident's splint and had left the splint intact. The aides said if the splint became soiled they notified the nurse in charge, and the nurses changed the splint. According to interviews with the aides, they did not observe Resident #1 to have any pressure sores prior to the resident's transfer to theER on [DATE]. The aides stated if they observed a pressure area they would have reported the change in the resident's condition to the nurse. Interviews with nursing staff, Licensed Practical Nurse (LPN) #1 on 11/18/13 at 2:44 PM, LPN #2 on 11/18/13 at 2:55 PM, LPN #3 on 11/18/13 at 4:05 PM, Registered Nurse (RN) #1 on 11/18/13 at 5:00 PM, RN #2 on 11/19/13 at 8:55 AM, LPN #4 on 11/19/13 at 9:35 AM, LPN #5 on 11/19/13 at 3:10 PM, and the South Hall Unit Manager on 11/19/13 at 3:25 PM, revealed they were only to remove Resident #1's "pillow splint" as "necessary." Based on the interviews, the CNAs/CMAs were to report any concerns related to any resident to the nurses and stated they had not reported any concerns related to Resident #1's condition or "pillow splint" to them. According to interview, the nurses had conducted skin assessments on a weekly basis of all residents. The interviews revealed they had not observed any concerns related to Resident #1's skin integrity; however, with the exception of LPN #5, they had not removed the splints and heel protectors to perform skin assessments. LPN #3 stated in an interview conducted on 11/18/13 at 4:05 PM that she had performed a head to toe assessment of Resident #1 prior to the resident's transfer to theER on [DATE]. LPN #3 stated she was not aware of a blackened area to Resident #1's left heel. In addition, the LPN stated she had not removed Resident #3's "pillow splint" because the physician did not want the splint removed. The Administrator and the Nurse Consultant stated in interview conducted on 11/19/13 at 3:40 PM that all splints, assistive devices, and pressure prevention devices should be removed prior to skin assessments unless there were physician's orders [REDACTED]. According to the Administrator, the physician had requested for the "pillow splint" to Resident #1's left leg to only be removed "if necessary" to provide care. The Administrator and the Nurse Consultant stated they did not know if facility staff had removed the "pillow splint" from Resident #1's left leg or why staff failed to identify the pressure areas to Resident #1's left lower leg and the left heel.

Based on interview, record review, and review of the facility's investigation, it was determined the facility failed to provide services to one of nine sampled residents (Resident #9) in accordance with the resident's written plan of care. Based on the facility's assessment, Resident #9 required the assistance of two staff persons and a mechanical lift for all transfers. On 08/26/11, at 6:30 PM, two CNAs transferred Resident #9 without the use of a mechanical lift and during the process heard Resident #9's left arm "pop." Resident #9 was assessed on 08/26/11, to be pain free. However, on 08/27/11, at 8:50 AM, Resident #9 was assessed to be in pain, was sent to the local emergency room for evaluation, and was diagnosed with [REDACTED]. The findings include: The facility was asked to provide a care plan policy but no facility policy related to resident care plans was presented. A review of the medical record for Resident #9 revealed the facility admitted the resident on 10/23/98, with [DIAGNOSES REDACTED]. A review of the Nurse Aide Care Plan dated 07/11 revealed the facility staff had assessed Resident #9 to require the assistance of two staff persons and a mechanical lift for safe transfers. A review of the Annual Minimum Data Set ((MDS) dated [DATE], revealed facility staff had assessed Resident #9 to require extensive assistance of two staff persons with the use of a mechanical lift for all transfers. Resident #9 was assessed to be cognitively impaired. A review of Resident #9's individual care plan dated 08/04/11, revealed facility staff assessed Resident #9 to have physical mobility impairment with transfers from a bed to a chair. A review of care plan interventions revealed staff was required to utilize a mechanical lift for transfers due to the resident's limited range of motion and cognitive deficit. The care plan also indicated staff was to provide the appropriate level of assistance to promote safety for the resident. In addition, on 08/26/11, at 6:30 PM, two CNAs transferred Resident #9 without the use of a mechanical lift and during the process heard Resident #9's left arm "pop," and although the resident was assessed to be pain free at that time the resident exhibited pain on 08/27/11, was sent to the Emergency Department, and diagnosed with [REDACTED]. Facility staff modified the resident's care plan to reflect the resident's pain and staff obtained a physician's orders [REDACTED]. Observation of Resident #9 on 08/31/11, at 3:45 PM and 4:30 PM, revealed the resident was in bed and the resident's left arm was observed to be in a sling. Resident #9 was smiling and did not appear to be in pain. Observation of Resident #9 on 09/01/11, at 11:00 AM, revealed the resident was sitting in a geri-chair in the dining room, smiling, and the resident's left arm was observed in a sling. No signs and symptoms of pain were observed. An interview with Resident #9 was not attempted due to the resident's cognitive status. An interview with CNA #3 on 08/31/11, at 5:40 PM, and with CNA #4 on 08/31/11, at 6:35 PM, revealed the CNAs assisted Resident #9 into bed from a geri-chair on 08/26/11. The CNAs indicated they transferred the resident without the use of a mechanical lift. CNA #3 stated during the manual lift a "popping" sound was heard from Resident #9's left arm. The CNAs stated the CNA care plan contained information related to the resident's care and they were aware two staff persons and a mechanical lift was to be used to safely transfer Resident #9 and stated they made the decision to transfer without the mechanical lift. A review of the facility's investigation dated 08/31/11, revealed two Certified Nursing Assistants (CNAs) transferred Resident #9 on 08/26/11, at 6:30 PM, and heard the resident's left arm "pop." The CNAs immediately reported the incident to the RN supervisor who assessed Resident #9. The investigation further revealed the resident did not exhibit any signs of pain or distress until 08/27/11, at 8:50 AM (approximately 14 hours after the transfer), at which time staff observed the resident cry when staff touched the resident's left arm. On 08/27/11, Resident #9 was sent to the emergency room for evaluation and x-ray of the left arm. emergency room reports revealed the resident was diagnosed with [REDACTED]. A review of the witness statements from CNAs #3 and #4, dated 08/27/11 and 08/28/11, revealed the CNAs transferred Resident #9 without the use of a mechanical lift. An interview with the Director of Nursing (DON) on 09/01/11, at 3:00 PM, revealed the investigation into Resident #9's injury determined that CNAs #3 and #4 transferred Resident #9 improperly. Based on interview, both CNAs were terminated from the facility as a result of not following the plan of care for Resident #9.

Based on interview, record review, and review of the facility's investigation, it was determined the facility failed to provide the appropriate assistive devices to prevent an avoidable accident for one of nine sampled residents (Resident #9). Resident #9 was diagnosed with [REDACTED]. During a transfer from Resident #9's geri-chair on 08/26/11, at 6:30 PM, staff did not utilize the mechanical lift which resulted in Resident #9's left arm "popping." Resident #9 remained pain free until 08/27/11, at 8:50 AM, when the resident was assessed to be in pain and was transported to the emergency room for evaluation and x-rays. Resident #9 returned to the facility on [DATE], with a [DIAGNOSES REDACTED]. The findings include: The Administrator was asked for a policy related to assistive devices but no policy was received. A review of the medical record for Resident #9 revealed the facility admitted the resident on 10/23/98, with [DIAGNOSES REDACTED]. Facility staff developed a Nurse Aide Care Plan in 07/11 and had assessed Resident #9 to require the assistance of two staff persons with use of a mechanical lift for safe transfers. A review of the Annual Minimum data Set ( (MDS) dated [DATE], revealed the facility staff had assessed Resident #9 to require extensive assistance of two staff persons with a mechanical lift for all transfers. Resident #9 was assessed to be cognitively impaired and therefore an interview was not conducted. A review of Resident #9's individual care plan dated 08/04/11, revealed the facility staff assessed Resident #9 to have physical mobility impairment with transfers from bed to chair and required a mechanical lift related to limited range of motion and cognitive deficit. A review of the interventions revealed staff was required to utilize a mechanical lift for transfers with the assistance of two staff persons. The care plan was modified after the resident experienced a fall and sustained a Left Humeral Neck Fracture to include pain management. A review of the physician's orders [REDACTED]. Observations were conducted of Resident #9 on 08/31/11, at 3:45 PM and 4:30 PM, and on 09/01/11, at 11:00 AM. The observations revealed the resident's left arm was in a sling and the resident did not appear to be in pain. The resident was in bed on the right side with the left arm in a sling. Resident #9 was smiling and did not exhibit signs and symptoms of pain. Observation of Resident #9 on 09/01/11, at 9:00 AM, revealed the resident was upset and trying to pinch and hit staff when staff was attempting to assist the resident to change positions. According to the staff, that was usual behavior for Resident #9, and the staff left the room so Resident #9 could calm down. Further observation of Resident #9 at 11:00 AM, revealed the resident was up in a geri-chair in the dining room with a fly swatter, watching television and smiling; the resident's left arm was in a sling. No signs and symptoms of pain were observed. Based on a review of the facility's investigation dated 08/31/11, on 08/26/11, Resident #9 was transferred by two CNAs without the use of a mechanical lift, resulting in the resident's left arm "popping." On 08/27/11, Resident #9 was sent to the emergency room for evaluation of pain to the left arm and for x-rays. Resident #9 returned to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of the witness statements from CNAs #3 and #4, dated 08/27/11 and 08/28/11, revealed the CNAs had transferred Resident #9 without the use of a mechanical lift. Interviews with CNA #3 on 08/31/11, at 5:40 PM, and with CNA #4 on 08/31/11, at 6:35 PM, revealed the CNAs assisted Resident #9 into bed from the geri-chair manually, without the use of a mechanical lift. Both CNAs stated a lift was available, but the lift was on the other unit and they chose not to get the lift. CNA #3 stated during the manual lift a "popping" sound was heard from Resident #9's left arm. The CNAs immediately reported the incident to the Registered Nurse (RN) supervisor and Resident #9 was assessed. CNAs #3 and #4 stated the CNA care plan contained information regarding how to safely transfer Resident #9 and both CNAs verbalized they knew the resident required two staff persons with a mechanical lift for transfers. Interview revealed CNAs #3 and #4 made the decision to transfer Resident #9 without the mechanical lift. An interview with the Director of Nursing (DON) on 09/01/11, at 3:00 PM, revealed staff was instructed to utilize the CNA care plans to determine how to safely transfer residents. The DON further stated staff was to utilize any assistive device that residents were assessed to require, even if that meant staff was to go find the assistive device. The DON further stated that the Assistant Director of Nurses (ADON) monitored CNAs weekly to assure equipment and assistive devices were being utilized as ordered for each resident and had not identified any problems.