Every finding on record at PruittHealth - Shepherd Hills

Based on record review, resident and staff interviews, and review of the facility's policy titled Care Plans, the facility failed to provide assistance with showers/baths for one of three Residents (R) (R1) reviewed for Activity of Daily Living (ADL) care. The deficient practice increased the potential for poor hygiene, odor and compromised psychosocial well-being. Findings include:Review of the policy titled, Care Plans, revised 10/21/2025, documented Definitions: .Person-Centered Care-Focus is on the patient/resident as the center of control. Supports each resident in making his or her own choices . Documented under admission Comprehensive Plan of Care, .3. The comprehensive person-centered care plan is developed to include measurable goals and timeframes to meet a patient/resident's medical, nursing and psychosocial needs.4.The care plan approach serves as instructions for the patient/resident's care and provides continuity of care by all partners.Review of the electronic medical record (EMR) revealed that R1 was admitted to the facility on [DATE], with diagnoses that included, but were not limited to, spastic hemiplegia affecting the left dominant side; unspecified malignant neoplasm of skin of unspecified part of face; major depressive disorder, recurrent, moderate; cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery; cerebral infarction due to thrombosis of right carotid artery; unsteadiness on feet; muscle weakness (generalized); difficulty in walking, not elsewhere classified; epilepsy, unspecified, intractable, with status epilepticus; and dysphagia, oral phase. Review of the most recent Quarterly Minimum Data Set (MDS), dated [DATE], documented that R1 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated little to no cognitive impairment. Review of Section GG revealed that R1 was dependent on staff for toileting hygiene, showering, bathing self, and upper body care.Review of the care plan for R1 dated 06/23/2026, documented a problem for risk of compromised psycho-social well being with a documented goal that R1 will not have compromised psycho-social well being through next review. Documented approaches included, but not limited to, Provide opportunities for autonomy/choices. In addition, a problem for Activities of Daily Living (ADLs) documented, R1 requires assistance from staff with ADLs r/t {related to} hemiplegia with the goal of his needs will be anticipated and met through next review. Documented approaches included, but not limited to, Assist with showers/bathing as to patent's preference and PRN.Review of the facility provided bath sheets for R1 from February 2026 through July 2026 documented that R1 was scheduled to receive showers or bed baths on Tuesdays and Thursdays. Further review of the bath sheets revealed that in February 2026, R1 missed five out of eight scheduled showers, which included, February 6th, 13th, 20th, 24th, and 27th. R1 missed five out of eight scheduled showers in March 2026, which included March 6th, 13th, 17th, 20th, and 27th. R1 missed three out of eight scheduled showers in April 2026, which included April 3rd, 10th, and 24th. R1 missed one out of eight scheduled showers in July on July 14th, 2026.During an observation and interview of R1 on 07/29/2026 at 10:25 AM, R1 was resting in bed and watching TV. R1 stated he had gone for weeks without a shower or bed bath. R1 could not recall the exact days he missed, but that he wanted a shower, and he was not told why he did not receive one on the missed days.During an interview with the family of R1 on 07/27/2026 at 11:21 AM, it was stated that R1 had gone for weeks without a shower.During an interview on 07/28/2026 at 9:02 AM, Certified Nursing Assistant (CNA) AA stated that she provided showers to R1 on the days she worked and that R1 was scheduled to get showers on Tuesdays and Fridays. CNA AA stated that he missed some showers, but not for a whole week. She stated there were some days when the resident did not feel well and chose not to take a shower. She stated that R1 did not get a shower on 07/14/2026 and 07/17/2026, though she was not entirely sure. She stated that she did not find out about the missed showers until the following week (the week of 07/19/2026) when she came to work and was informed by R1. She stated that she asked R1 if he wanted a shower and noted that it had not been given. She stated that normally, if a resident missed a shower on the scheduled date, they could get a shower the next day.During an interview on 07/28/2026 at 9:09 AM, CNA BB revealed that she provided Activities of Daily Living (ADL) care to R1 on the days she worked. She stated that on 07/20/2026, when she arrived at work, R1 informed her that he did not get a shower on 07/14/2026 or 07/17/2026, and he was not sure why. She stated that the resident received a shower on 07/21/2026 and 07/24/2026. She stated that it was not typical for R1 to miss a whole week of showers.During an interview and review of the bath sheets on 07/29/2026 at 10:39 AM with Licensed Practical Nurse (LPN) CC, she stated that when an activity was not reflected on the Point of Care history, it meant the resident did not receive a shower or bath on those scheduled days. She confirmed that R1 missed the scheduled dates in February 2026. LPN CC stated the floor nurses monitored the CNAs, who should report a resident's refusal and document the refusal in the electronic system.During an interview on 07/29/2026 at 10:45 AM, LPN DD acknowledged that she was the floor nurse on R1's hall in February 2026. She stated that they monitored the CNAs in the system to see if a resident received a shower or bed bath. She confirmed that if an activity did not occur on the Point of Care history, it meant the resident did not receive a shower or bed bath. She stated that she expected the CNAs to notify the nurses if a resident refused a shower or bed bath.During an interview on 07/29/2026 at 10:45 AM with the Director of Nursing (DON), regarding resident showers/bed baths and her expectations of staff, she stated that showers were based on preference. She noted that a resident was allowed to refuse showers, and she expected CNAs to notify the nurses and document the refusal in the electronic system.During an interview on 07/29/2026 at 11:43 AM, CNA EE revealed that she provided ADL care for R1 occasionally. She confirmed that R1 did not receive a shower on 06/23/2026 and that she did not document the refusal. She stated that she was supposed to document in the chart whenever a resident received or refused a shower.

Based on observations, staff interviews, record review, and review of the facility policies titled, Infection Prevention-Hand Hygiene and Infection Control-Linen and Laundry, the facility failed to ensure that staff consistently followed appropriate hand hygiene and sanitation practices. Specifically, staff failed to perform hand hygiene and sanitize surfaces during wound care for 1 of 14 residents (R)(R51) and failed to perform hand hygiene between resident contacts. These deficient practices placed residents at increased risk for infection transmission and cross-contamination.Findings include:Review of the facility's policy titled Infection Prevention-Hand Hygiene revised 10/15/2024 revealed under section D. Indications Requiring Hand Wash or Hand Rub, number 5. After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, and wound dressings.Review of the facility's skills competency checklist for Wound Care Treatment, undated, under title, Dressing Change, Step 1. Loosen tape or adhesive borders pulling toward the dressing while supporting the peri (around) wound skin.Remove gloves, perform hand hygiene, and apply clean gloves.Review of the facility's policy titled Infection Control-Linen and Laundry revised 11/30/2023 under section E. Storage number 1. Clean laundry should be handled as little as possible and should be covered before being stored.Review of the electronic medical record (EMR) revealed R51 was admitted to the facility with pertinent diagnoses including, but not limited to, type 2 diabetes mellitus with hyperglycemia, peripheral vascular disease, atherosclerotic heart disease, congestive heart failure, and the presence of a suprapubic catheter.Review of R51 significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicates R51 has moderate cognitive impairment.Review of R51's care plan dated 5/28/2024 indicated a problem of risk for skin breakdown related to impaired mobility, incontinence, the presence of a suprapubic catheter, and a wound to the right ankle first documented on 6/19/2025. Goals included, but were not limited to, the resident not acquiring any staged pressure injuries through the next review period. Interventions included providing incontinence care every shift, applying barrier cream as indicated, keeping the skin clean and dry, reporting any signs of skin breakdown, and completing wound and catheter care per physician orders. Additional approaches included zinc oxide application to the buttocks, wound treatment to the right ankle, and consultation with the Quality Skin Management (QSM) team as indicated.Review of the Physician's Orders for R51 included but was not limited to:Order dated 8/20/2025 for treatment to the right ankle wound. Instructions were to cleanse the wound with wound cleanser, pat dry, apply skin prep to the peri-wound borders, apply honey to the wound bed, and cover with an adhesive foam bandage. Frequency: Once daily on Monday, Wednesday, and Friday between 7:00 am and 7:00 pm.Order dated 8/20/2025 for PRN (as needed) wound care to the right ankle with the same treatment procedure as noted above, to be used for dressing changes outside the scheduled days as needed.Observation on 10/1/2025 at 1:51 pm of the facility's laundry area revealed that clean linens were stored on multiple open shelves; however, they were not adequately protected from potential contamination. Items such as towels, washcloths, and blankets were organized on three separate shelves. These same shelves also contained various staff personal items in direct contact with the clean linens, including: a disposable Styrofoam cup, a reusable water bottle, a plastic water bottle in a cozy, a plastic bag containing soda bottles and miscellaneous items, loose papers, a clock, office supplies (e.g., scissors), and a box of additional office-related items.Interview on 10/1/2025 at 2:11 pm with Housekeeping Supervisor II revealed uncertainty regarding what items were permitted to be stored on the same shelves as clean linens. She acknowledged that personal items likely should not be stored there, as they were not considered clean. She stated she would ensure all non-linen items were removed from the shelves to prevent contact and potential contamination.Observation on 10/1/2025 at 2:21 pm revealed Licensed Practical Nurse (LPN) EE performing wound care for Resident (R) (R51). During the procedure, LPN EE failed to remove her gloves and perform hand hygiene after removing and discarding the soiled dressing and prior to cleansing the wound.Interview on 10/1/2025 at 2:32 pm with LPN EE confirmed and acknowledged she did not remove her gloves after disposing of the soiled dressing. She stated that she believed it was not necessary to change gloves at that point because she was still working with the dirty area. This rationale was confirmed twice during the interview.Interview on 10/1/2025 at 5:36 pm with the Director of Nursing (DON) revealed that she was unable to answer questions related to infection control practices and referred the surveyor to the facility's Infection Preventionist.Interview on 10/1/2025 at 5:50 pm with the Infection Preventionist (IP) revealed that clean linen must not be stored on shelves with any other items, particularly personal belongings, as this results in contamination. She emphasized that such practices require the linens to be rewashed, creating unnecessary workload and increasing the risk of infection for immunocompromised residents. The IP stated she would begin including the laundry area in her routine rounds and would provide additional infection control education to laundry staff, including the supervisor.Interview on 10/2/2025 at 11:09 am with LPN FF, Skin Integrity Nurse Manager, revealed that after removing a soiled dressing, standard practice requires the nurse to remove gloves, perform hand hygiene, and don (put on) clean gloves before proceeding with wound cleansing. She stated that failure to follow this protocol increases the risk of cross-contamination. In a follow-up interview at 1:32 pm, LPN FF added that even touching the outer surface of a soiled dressing can introduce bacteria, which may lead to infection, the need for antibiotics, and further deterioration of the wound. She confirmed that she personally assessed the resident and initiated orders to monitor for signs and symptoms of infection for the next 10 days.

Based on staff interview, record review, and review of the facility policy titled, Freedom from Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property Mission Statement, the facility failed to report physical abuse by staff to the State Survey Agency (SSA) within the required timeframe for one of six sampled residents (R) (R21) reviewed for abuse and neglect. The failure of the facility to report this incident has the likelihood of leading to future unreported injuries of unknown origin, with the potential to affect resident's quality of life.Findings include: Review of the policy titled Freedom from Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property Mission Statement revised 112/1/2016, revealed the policy of the facility to notified the state survey agency in accordance with state law through established procedures of any allegations of abuse, neglect, exploitation or mistreatment, including injuries of any unknown source an misappropriation of patient property, within 2 hours after the allegation is made of the events upon which the allegation is based involve abuse or result in serious bodily injury, and not later than 24 hours if the events upon which the allegation is base4d do not involve abuse and do not result in serious bodily injury. Review of R21's electronic medical record (EMR) admission Record under the MDS tab revealed R32 was admitted to the facility on [DATE] with diagnoses that included but not limited to, dementia with other behavioral disturbances and depression. The resident's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed his Brief Interview for Mental Status (BIMS) was not coded, indicating cognition could not be determined, due to resident is rarely/never understood. R21 is totally dependent on staff for toileting hygiene, personal hygiene. Review of Facility Incident Report Form (FRI) dated 4/11/2025 documented the type of abuse as staff to a resident. Review of the Five-Day follow-up summarized the details of the incident: on 4/11/2025 it was reported to the Unit Manager that R21 became combative and argumentative during peri-care and CNA DD put the wipe with bowel movement to R21's face. CNA DD was immediately suspended pending investigation. Medical Director (MD), Police department, and Responsible Party notified. Facility investigation initiated.The investigation reflects reported incident that occurred on 4/7/2025 and was witnessed by CNA NN. The Director of Health Services (DHS) CNA NN regarding the incident. CNA NN verbalized she did witness the incident. CNA NN reported she was surprised by what she had witnessed and immediately told CNA DD she could not do that and told her to leave the room, and she would finish providing care to R21. CNA NN reported that she cleaned R21's face and finished providing care. CAN NN reported due to CNA's DD reaction to the situation and prior experiences with CNA DD interactions with herself and other CNAs she was afraid of what CNA DD would do if she mentioned the incident. One on one education was provided to CNA NN regarding Recognizing and Reporting Abuse and the process that follows a report of abuse, online education was assigned to CNA NN for Recognizing and Reporting Abuse, a final written warning was given to CNA NN with the expectation of reporting abuse immediately, any further violation of not reporting abuse immediately will result in immediate termination.CNA DD was terminated as a result of the investigation. Review of R21's progress note from 4/11/2025 revealed: This nurse was made aware of allegations of abuse to resident by a staff member. Resident has no signs of distress noted at this time. Abuse coordinator made aware. [NAME] PD made aware. R21's made aware. NP made aware. Report number 2025-00002328. Interview with DHS on 10/02/25 at 11:40 pm revealed that CNA DD was employed at this facility from October of 2021 to April 2024, and did not have any disciplinary auctions, and no complaints from residents.

Based on records review and staff interviews, the facility failed to ensure accurate Minimum Data Set (MDS) assessment for one of 40 sampled residents (R) (R21). Specifically, the facility failed to accurately code Section P (Restraints and Alarms) for R21. The deficient practice resulted in not accurately representing R21's health status. Findings include:Review of R21's electronic medical record (EMR) admission Record under the MDS tab revealed R21 was admitted to the facility with diagnoses that included but not limited to, dementia with other behavioral disturbances and depression.Review of the quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 3/27/2025 indicated R21 does not use wander/elopement alarm.Review of the quarterly MDS with an Assessment Reference Date (ARD) of 6/21/2025 indicated R21 does not use Wander/elopement alarm.Review of current physician orders for R21 included but not limited to:Wander guard placed on left wrist-check functioning daily, start date 11/13/2024.Wander guard placed on left wrist-check placement q (every) shift, start date 11/13/2024.Review of a care plan with last reviewed/revised date of 7/8/2025 for R21 revealed Problem: risk for elopement as evidenced by exit seeking behavior. Approaches included but not limited to: Check wander guard devise for proper functioning and placement per facility protocol or manufacture's recommendations.Interview with the MDS Director on 10/2/2025 at 11:35 am confirmed that R21 wore a wander guard bracelet on her left wrist and it should be reflected on the MDS assessment. The MDS Director confirmed that quarterly assessment from 6/21/2025, section P was coded incorrectly, and she would reopen it and would make corrections.Interview with Director of Health Services (DHS) on 10/2/2025 at 11:50 am revealed that the previous MDS Director resigned a few months ago, and the facility had a new MDS Director. She stated that the MDS assessment should reflect resident's wander guard use.Interview with the Administrator on 10/2/2025 at 1:25 pm revealed that the facility did not have an MDS assessment policy, and they followed the Resident Assessment Instrument (RAI) Manual.

Based on observations, staff interviews, record review, and review of the facility policies titled, Glucometer Cleaning and Disinfecting, Infection Control, Linen and Laundry, and review of the manual for the blood glucose monitoring system, the facility failed to use proper infection control practices for one of 24 diabetic residents (R) (R61) during blood glucose monitoring, not properly covering clean linen during transport through the facility, and not properly securing an indwelling catheter. The deficient practice had the potential to spread microorganisms. Findings include: Review of the facility policy titled Glucometer Cleaning and Disinfecting with a revision date of 6/27/2023 revealed under Policy, A blood glucose monitor that is shared must be cleaned and disinfected after every use following the manufacturer's instructions to prevent carryover of blood and infectious agents. Under Procedure, 4. Clean and disinfect the meter by using the EPA (Environmental Protection Agency) approved germicidal/virucidal disinfectant wipes. Wipe all external areas of the meter including both the front and back surfaces until visibly clean. Avoid wetting the meter test strip port. Review of the Healthcare Professional Operator's Manual, page 11, for the 'company name' Blood Glucose Monitoring System revealed, to disinfect your meter, clean the meter surface with one of the approved disinfecting wipes. Review of facility policy titled Infection Control-Linen and Laundry reviewed 11/30/2023 revealed under Transporting of Soiled and Clean Laundry, 2. a. Clean laundry will be transported in covered carts used exclusively for clean laundry, or in laundry carts that have been decontaminated after being used for soiled laundry. b. Clean laundry should be covered and should remain covered until ready for use. Covers should be replaced after retrieving clean linen. 1. An observation of Licensed Practical Nurse (LPN) GG on 7/10/2024 at 12:01 pm, she was observed performing a blood glucose check for R61. She applied gloves and cleaned the area of the resident's right thumb. She allowed it to dry and then pricked the thumb, wiped the blood off, and then collected the sample. She then discarded the trash, removed her gloves, and then returned to the cart. LPN GG applied a glove and then cleaned the glucometer with a hand sanitizing wipe. During an interview with LPN GG on 7/10/2024 at 12:05 pm revealed that she was not able to give the amount of time needed for the hand sanitizing wipe to kill and disinfect any microorganisms on the used glucose monitor. LPN HH was asked if she knew what the kill time was for the hand sanitizing wipes. She stated that it should be on the container. LPN GG was asked if those were the correct wipes to be used for cleaning and disinfecting of the glucose monitor. She stated that they were the wipes that housekeeping gave her when she needed some. Observation of LPN HH on 7/10/2024 at 12:08 pm, she removed the hand sanitizing wipes container from the medication cart that LPN GG was using and replaced them with a container of disinfecting/sanitizing wipes. She stated that we would use these until she could find out if they were the correct wipes to use on the glucometers. An interview on 7/11/2024 at 4:25 pm with LPN II, she was asked if the glucometers could be cleaned and disinfected with hand sanitizing wipes. She stated that glucometers needed to be cleaned and disinfected with the purple top sanitizing wipes. An interview on 7/11/2024 at 4:45 pm with the Director of Nursing (DON), she stated that the glucometers were to be cleaned and disinfected with the purple top sanitizing wipes. 49673 2. Observation on 7/10/2024 at 9:41 am revealed in the outdoor laundry department, two clean clothing carts, uncovered, near the dryer section. Observation on 7/10/2024 at 11:18 am, Laundry Tech AA entered the south 100 hall to distribute clothes with the cart uncovered. Interview on 7/10/2024 at 11:37 am with Laundry Tech AA confirmed he entered the facility with the laundry carts covered, but when inside the facility, going room to room, he removed the covering. 49396 3. Observation and interview on 7/10/2024 at 9:28 am, R1 was in his room, washing his face and hands. His urostomy bag didn't have a privacy bag cover and was dragging on the floor. CNA CC was asked if she would come into R1's room to see the catheter bag dragging on the floor and without a privacy covering. She acknowledged that it was not appropriate, and stated the usual protocol was for it to be off the floor and in a blue privacy bag. R1 stated that he preferred it to be in a blue bag, and he was aware of the process.

Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Residents Rights, the facility failed to promote, maintain, and protect the dignity of one of four residents (R) (R1) with a catheter with the use of a catheter privacy bag. The deficient practice had the potential to diminish the resident's quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life. Findings include: Review of the facility policy, Residents Rights, dated 12/1/2023 revealed under Procedure, 2. The center will make every effort to assist the patient/resident in understanding and exercising his/her rights to assure the patient/resident is always treated with respect, kindness, and dignity. Review of R1's diagnoses in the electronic medical record (EMR) included but was not limited to attention to other artificial openings of urinary tract. Review of the annual Minimum Data Set (MDS) for R1 dated 7/3/2024 revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Review of Section G-Functional Status revealed extensive assistance with bed mobility, eating, totally dependent on transfers, locomotion, dressing, toileting, personal hygiene, and bathing; Section H-Bowel and Bladder revealed resident has a patient has a urostomy and a colostomy-risk for complications related to ostomy and stomas. Review of R1's care plan revised on 7/3/2023 revealed R1 had a urostomy catheter. Interventions included cleansing sites daily and PRN (as needed), notifying MD as indicated, and observing for any signs of redness, pain, or swelling. Observations and interview on 7/9/2024 at 9:39 am, R1 was resting in bed. He said he was being treated well and appeared well kept. A urostomy bag was noted on the left side of his bed, near his roommate in bed B, dragging on the floor without a privacy bag covering it. R1 went on to tell me he had a colostomy bag as well and raised his shirt to show me. Observation on 7/9/2024 at 4:30 pm another surveyor and I both observed R1's urostomy bag still dragging on the floor, which had no privacy bag. Observation and interview on 7/10/2024 at 9:28 am, R1 was in his room getting a warm towel from Certified Nursing Assistant (CNA) BB to wash his face and hands. R1's urostomy bag still didn't have a privacy bag and was dragging on the floor. CNA CC was asked if she could come to see the urostomy bag dragging on the floor and without a privacy covering. CNA CC acknowledged that it was not appropriate for the urostomy bag to be on the floor without a privacy bag. When asked what the usual protocol was, she said first it should be off the floor and then placed in a blue privacy bag. She said she would be right back to get this taken care of. R1 was asked if he was aware of the urostomy bag being dragged on the floor without a privacy cover. He said no, the bag had been changed the day before, and he thought she had put it in a bag and off the floor. He told me he preferred it to be in a blue bag, and he was aware of the process. CNA CC returned with a new blue privacy bag. She picked up the catheter off the floor, sanitized it, and placed it in a private bag. When asked if she understood not covering catheter bag was a deficient practice, she said, absolutely.

Based on observations, staff interviews, record review, and review of the facility policies titled, Procedure: Perineal Care and Glove Use, the facility failed to follow standard and transmission-based precautions to prevent the spread of infection for one of two residents (R) (R12) who was dependent on nursing staff to provide incontinence care. Specifically, facility staff failed to perform hand hygiene, apply clean gloves during incontinence care, after contamination of bowel movement, before cleaning the indwelling foley urinary catheter, before touching the bed control, and before touching the Continuous Positive Airway Pressure (CPAP) humidifier and mask. The deficient practice had the potential to spread infection. Findings include: Review of the facility's policy titled, Procedure: Perineal Care dated 2019 revealed .11. If heavy soiling is present, wear gloves and use tissues or wipes to remove soiling prior to perineal care .Remove and discard gloves and wash hands .13. Wash hands and put on clean gloves for perineal care. 14. Gently wash, rinse, and dry the perineal area .15. If indwelling urinary catheter is present: Hold catheter tubing .19. Perform hand hygiene Review of the facility's policy titled Glove Use dated 11/20/2020 revealed .6. Anytime a contaminated surface is touch [sic], the glove mush [sic] be changed .7. Wash hands when removing and or changing gloves. Review of R12's electronic medical record (EMR) Profile tab, indicated R12 was admitted to the facility with diagnoses of sepsis, urinary tract infection, paraplegia, morbid obesity, bed confinement status, and diarrhea. Review of R12's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/30/2024 in the EMR under the RAI (Resident Assessment Instrument) tab indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated resident was cognitively intact. The MDS indicated resident was dependent on staff for hygiene, resident was incontinent of bowel, and resident had an indwelling urinary catheter. Observation of Training Nurse Aide (TNA) 2, TNA3 and Certified Nurse Aide (CNA) 3 on 4/18/2024 at 11:10 am revealed TNA2, TNA3, and CNA3 entered R12's room and applied gloves. When the top sheet was lowered a large amount of bowel movement was observed between R12's legs on the pad. R12 was turned to her right side. TNA2 removed the bowel movement from R12's right buttocks. TNA3, TNA2, and CNA3 turned R12 to her left side and TNA3 wiped R12's left buttock of bowel movement, and with a wipe picked up the bowel movement that was on the pad. R12 was turned back onto her back. While wearing the same gloves, TNA3 was observed cleaning the catheter tubing while holding the catheter tubing close to the perineal area. While wearing the same gloves, TNA2 used the resident's bed control to raise the head of the bed. R12 requested to have her CPAP mask placed on her chest. Still wearing the same gloves, TNA2 opened the bottle of water, filled the CPAP humidifier, and then placed the CPAP mask on R12's chest. During an interview on 4/18/2024 at 12:52 pm, TNA2 was asked about R12's incontinence observation and informed that TNA2 touched the bed control and the CPAP mask without changing her gloves after they were contaminated with bowel movement. TNA2 confirmed that she did not change her gloves and did not perform hand hygiene prior to touching the bed control, the CPAP humidifier, and placing the CPAP mask on R12's chest. TNA2 stated that she was trained to change her gloves, perform hand hygiene, and apply clean gloves before touching these items. During an interview on 4/18/2024 at 1:08 pm, TNA3 confirmed that she did not change her gloves, perform hand hygiene, and apply clean gloves prior to cleaning R12's catheter tubing.

Based on staff interviews, record review, and review of the facility policies titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property and Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to protect the resident's right to be free from sexual abuse by another resident by not reporting an abuse allegation in a timely manner for two of five residents (R) (R2 and R3) reviewed for abuse. Specifically, the facility failed to ensure a final investigation report was submitted to the state survey agency within five business days. Findings include: Review of the facility's policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property dated [DATE], revealed .to comply with all applicable federal and state requirements regarding the reporting of patient abuse, neglect, exploitation, mistreatment, and misappropriation of property .Follow specific state reporting form/web portals for documenting reportable event. Unless state requirements specify otherwise, a written investigation report should be submitted to the state agency within 5 days of the incident. Review of the facility's policy titled Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property dated [DATE] revealed .to investigate allegations and occurrences of patient abuse, neglect, exploitation, mistreatment, and misappropriation of patient property .A written report of the investigation and follow-up should be submitted to the appropriate agency within five working days of the occurrence, unless otherwise indicated. Review of R2's electronic medical record (EMR) under the Profile tab revealed admission to the facility with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, cervical disc degeneration, and depression. Review of R2's quarterly Minimum Data Set (MDS) under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of six out of 15, which indicated severe cognitive impairment. Further review revealed R2 used a wheelchair and was independent with mobility. R2 had no documented behaviors. Review of R3's EMR Profile tab revealed admission to the facility with diagnoses of Alzheimer's disease, dementia with mood disturbance, and depression. The resident expired on [DATE]. Review of R3's quarterly MDS under the MDS tab of the EMR, with an ARD of [DATE], revealed a BIMS score of 00 out of 15, which indicated severe cognitive impairment. Further review revealed R3 required partial/moderate assistance with mobility. R3's medical record was documented with physical behaviors directed toward others for one to three days of the assessment period. Review of Progress Notes, located under the Progress Note tab in the EMR and written by Registered Nurse (RN) 3, dated [DATE] at 7:03 pm, indicated R2 was .rubbing another resident on the leg all the way up. RN went to see and found [R2] holding the dementia females [sic] hand on his private area and rubbing. Got them apart and took the dementia female to her room. Review of the facility's Incident Report, provided by the facility, revealed an initial report was submitted [DATE] at 7:59 pm. The incident reported a suspected sexual behavior between cognitively impaired residents. Details of the incident revealed a, Nurse witnessed male resident with dementia holding female resident's with dementia hand with hand resting over the male resident's groin area. Both residents were on [sic] male resident's room. The incident reported, Residents separated. Female resident placed on 1 to 1 monitoring until room change arrangement can be made. Will 5 day follow up. [sic] An undated Follow Up Report was provided by the facility which documented, in part, that R3 . is/was simply seeking companionship not sexual behavior. She does roam the building at times and will enter other resident rooms. She will try to sit next to male residents but not with sexual activity. It appears she simply wants to have male companionship at times. There have been no other episodes of concern. During an interview on [DATE] at 10:28 am, the Administrator stated that when he submitted the follow-up report of the abuse investigation, he had done so within the required five business days. The Administrator was unable to provide documentation that the report was submitted in a timely manner and stated that the reporting system did not show the time that the follow-up report was submitted. During an interview on [DATE] at 11:58 am, the Director of Nursing (DON) stated that she was aware that the facility had five days to get the follow-up investigation report submitted to the state survey agency. The state survey agency provided the date and time of the submitted five business day follow-up investigation which revealed the facility provided the report on [DATE] at 10:14 am. The report was received by the state survey agency on the eighth business day. During an interview on [DATE] at 2:06 pm, the Administrator stated that the facility reported back to the state survey agency in five days with the follow-up investigation report. He stated that he was not aware of why the state survey agency documented a delay in the follow-up report.

Based on record review, staff interviews, document review, and review of the facility policy titled, Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to protect the residents' right to be free from sexual abuse by another resident by failing to conduct a thorough investigation for an incident of potential sexual abuse behavior for two of five residents (R) (R2 and R3) reviewed for abuse. Findings include: Review of the facility's policy titled, Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, dated [DATE], revealed .to investigate allegations and occurrences of patient abuse, neglect, exploitation, mistreatment, and misappropriation of patient property .Documentation of the investigation should include, but not be limited to, the following: names of accused and any witnesses .details of the alleged incident and injury .signed statements from pertinent parties .information gathered from the investigation .any other police or ombudsman reports or other documentation related to the investigation .Interviews should be conducted of all individuals who have relevant information, utilizing open-ended questions. Review of R2's electronic medical record (EMR) Profile tab, revealed admission to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, cervical disc degeneration, and depression. Review of R2's quarterly Minimum Data Set (MDS) under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of six out of 15 which indicated severe cognitive impairment. Further review revealed R2 used a wheelchair and was independent with mobility. R2 had no documented behaviors. Review of R3's electronic medical record (EMR) Profile tab, revealed admission to the facility with diagnoses of Alzheimer's disease, dementia with mood disturbance, and depression. The resident expired on [DATE]. Review of R3's quarterly MDS under the MDS tab of the EMR, with an ARD of [DATE], revealed a BIMS score of 00 out of 15 which indicated severe cognitive impairment. Further review revealed R3 required partial/moderate assistance with mobility. R3 was documented with physical behaviors directed toward others for one to three days of the assessment period. Review of Progress Notes, located under the Progress Note tab in the EMR for R2, and written by Registered Nurse (RN) 3, dated [DATE] at 7:03 pm, indicated Another resident came to the nurse's station and reported R2 was .rubbing another resident on the leg all the way up. RN3 went to see and found [R2] holding the dementia females (sic) hand on his private area and rubbing. Got them apart and took the dementia female to her room. The resident who came to RN3 was not interviewed for the investigation. RN3 was also not documented with an interview in the investigation report. Review of Progress Notes, located under the Progress Note tab in the EMR for R3 and written by Licensed Practical Nurse (LPN) 5, dated [DATE] at 1:11 am, documented Resident at this time on one-on-one for incident earlier in this shift where a male resident place (sic) her hand on his crotch. LPN5 was not documented with an interview in the investigation report. Review of the facility's Incident Report, provided by the facility, revealed an initial report was submitted [DATE] at 7:59 pm. The incident reported a suspected sexual behavior between cognitively impaired residents. Details of the incident revealed a, Nurse witnessed male resident with dementia holding female resident's, with dementia, hand with hand resting over male resident's groin area. Both residents were on [sic] male resident's room. The incident reported stated, Residents separated. Female resident placed on 1 to 1 monitoring until room change arrangement can be made. Will 5 day follow up. (sic) There were no statements by any residents or staff in the investigation report. An undated Follow Up Report was provided by the facility, which documented, in part, that R3 . is/was simply seeking companionship not sexual behavior. She does roam the building at times and will enter other resident rooms. She will try to sit next to male residents but not with sexual activity. It appears she simply wants to have male companionship at times. There have been no other episodes of concern. No additional documentation was provided with the investigation follow-up report to indicate a thorough investigation was completed, to include any record reviews, staff and resident interviews, or other pertinent information used in the conclusion of the report. During an interview on [DATE] at 3:50 pm, the Administrator stated that the nurse documented the observation of the two residents holding hands with the hands resting along the upper thigh of R2. He stated the incident was documented on the facility 24-hour report, but it might not have been a reportable event. He stated that both residents had dementia, and there was no intent for anything inappropriate. The Administrator stated he was not aware of whether they interviewed any staff members who saw the incident, and did not think they interviewed the residents, because they were confused. During an interview on [DATE] at 11:08 am, the Director of Nursing (DON) stated that the incident happened at nurse shift change. She stated the nurse that saw the incident was RN3, who charted the incident in the progress notes for R2. She stated that LPN5 charted the situation in R3's chart. The DON confirmed that there were no documented interviews from staff or residents about the incident, just what was in the progress notes. During an interview on [DATE] at 11:37 am, LPN2 stated that R2 and R3 both had dementia. LPN2 stated that after any potential abuse, the staff had two hours to alert the Director of Nursing and the Administrator, and then do the reportable [sic]. She stated it was important to gather statements, witness statements, and to paint a picture of what happened. LPN2 stated the staff would let the physician and the family know. During an interview on [DATE] at 2:30 pm, RN3 stated that another resident was going down the hallway and came up to her and told her that R2 had his hand on the leg of R3. RN3 stated she went down to the room and R3 was sitting on R2's bed. She stated her hand was on his groin, and his hand was resting on top of her hand. RN3 stated R2 was rubbing his hand on top of hers, not forcefully or against him. RN3 stated there was no nudity or other activity going on, but R2 should not have had his hand on R3's leg. She stated R2 was sitting in his wheelchair. She stated she had not seen this behavior before from either of them. RN3 stated she had interviewed both R2 and R3, but neither really said anything. Record review revealed no documentation of resident interview attempts in the investigation. During an interview on [DATE] at 11:58 am, the DON stated that during an investigation she would ask for statements from those who witnessed the incident. She stated she would look at the assessments to see if the resident's BIMS scores indicated they were interviewable, then she would interview them. She stated that usually after an incident, she would talk to residents and families and get observers' statements. If unclear, she stated she would ask more in-depth questions to better understand the incident. During an interview on [DATE] at 1:02 pm, LPN5 stated that she had documented the incident in the resident record only. She stated that the full investigation would be completed by the DON and Administrator. During an interview on [DATE] at 2:06 pm, the Administrator stated that he was the Abuse Coordinator. He stated that he would receive the reporting documentation and would put in the initial basic information into the State Survey Agency portal. He stated that the staff would discuss the incident in the morning meeting if there had been a reportable, and ask the team if they had any additional information that they could provide. The Administrator stated that they would process the information gathered about the situation. He stated that for a thorough investigation he would determine if there were direct witnesses or if anyone heard anything. He stated he would not want to rely on secondary information. He stated that would include talking to residents, or others as needed. He stated that they usually tried to have statements from residents if they were reliable or interviewable, and have the interview dictated and have them sign it if they could.

Based on observation, interview, record review, and review of the facility policies titled, Procedure: Perineal Care and Procedure: Catheter Care, the facility failed to clean the perineal area of bowel movement during incontinence care for one of two residents (R) (R12) reviewed for ADL (activities of daily living) care for dependent residents. The deficient practice had the potential to cause infection for R12. Findings include: Review of the facility policy titled Procedure: Perineal Care dated 2019 revealed .11. If heavy soiling is present, wear gloves and use tissues or wipes to remove soiling prior to perineal care .Remove and discard gloves and wash hands .13. Wash hands and put on clean gloves for perineal care. 14. Gently wash, rinse, and dry the perineal area, wiping from the clean urethral area toward the dirty rectal area to avoid contaminating urethral area .15. If indwelling urinary catheter is present: Hold catheter tubing .while washing perineum. 16. turn resident on their side .17. Gently wash, rinse, and dry the rectal area and buttocks wiping from the labia downward over rectal area until area is clean .19. Perform hand hygiene Review of the facility policy titled Procedure: Catheter Care dated 2019 revealed 2. Separate inner labia with nondominant hand. Wash down the center, wiping downward from front to back and stopping at the base of the labia .3. Rinse and dry the urethral and perineal area, .until entire area is clean, soap free and dry. 4. Hold catheter tubing .while washing perineum .5. When washing, rinsing, and drying the urethral area: a. Gently wash, rinse and dry around the juncture of the catheter and meatus. b. Wash the catheter from the meatus down the tube about 3 inches .12. Perform hand hygiene . Review of R12's electronic medical record (EMR) Profile tab, indicated R12 was admitted to the facility with diagnoses of sepsis, urinary tract infection, paraplegia, morbid obesity, bed confinement status, and diarrhea. Review of R12's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/30/2024 in the EMR under the RAI tab indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated resident was cognitively intact. The MDS indicated resident was dependent on staff for hygiene, resident was incontinent of bowel, and resident had an indwelling urinary catheter. Observation of Training Nurse Aide (TNA) 2, TNA3 and Certified Nurse Aide (CNA) 3 on 4/18/2024 at 11:10 am, revealed TNA2, TNA3, and CNA3 entered R12's room and applied gloves. When the top sheet was lowered, a large amount of bowel movement was observed on the pad between R12's legs and R12's indwelling foley catheter tube was underneath R12's left leg. R12 was turned to her right side. TNA2 removed the bowel movement from R12's right buttocks and folded the pad covering the bowel movement underneath R12. TNA3, TNA2, and CNA3 turned R12 to her left side and TNA3 wiped R12's left buttocks of bowel movement and with a wipe, picked up the bowel movement that was on the pad. R12's indwelling foley catheter tubing was underneath R12's leg. R12 was turned back onto her back and the indwelling urinary catheter tubing was underneath R12's left leg. While wearing the same gloves, TNA3 was observed cleaning the catheter tubing while holding the catheter tubing close to the perineum (groin) and cleaned the actual indwelling foley catheter. TNA3 did not clean R12's perineal area. TNA2, wearing the same gloves, used the resident's bed control and raised the head of the bed. R12 requested to have her the Continuous Positive Airway Pressure (CPAP) device placed on her chest. TNA2, wearing the same gloves, opened the bottle of water and filled the CPAP humidifier and then picked up the CPAP mask and placed it on R12's chest. TNA3 removed her gloves, performed hand hygiene, exited the room, and returned with clean bed linen. TNA2, TNA3, and CNA3 removed all soiled bed linen, applied clean linen, and covered R12 with the top sheet. R12's indwelling urinary foley catheter tubing remained underneath R12's left leg. During an observation and interview on 4/18/2024 at 12:10 pm, Licensed Practical Nurse (LPN) 1 was asked about the positioning of R12's indwelling urinary catheter tubing. LPN3 stated that R12's indwelling urinary catheter tubing was positioned underneath R12's left leg and it should not be under her leg. LPN3 moved the catheter tubing so that it was not under the leg. During an interview on 4/18/2024 at 12:52 pm, TNA2 was asked about R12's incontinence observation and that TNA2 touched the bed control and the CPAP device without changing her gloves after they were contaminated with bowel movement. TNA2 confirmed that she did not change her gloves and did not perform hand hygiene prior to touching the bed control, the CPAP humidifier, and placing the CPAP mask on R12's chest. TNA2 stated that she was trained to change her gloves, perform hand hygiene, and apply clean gloves before touching these items. TNA2 confirmed that R12's catheter tubing was under R12's leg and that the tubing should be over the leg, which TNA2 confirmed during the incontinence care, and also they did not clean the perineal area and they should have cleaned this area. During an interview on 4/18/2024 at 1:08 pm, TNA3 confirmed the indwelling urinary catheter tubing was under R12's leg and that it was supposed to be over her leg. TNA3 confirmed that she did not clean R12's perineal area after she cleaned the catheter tubing.

Based on facility document review and staff interview, the facility failed to provide eight hours of consecutive Registered Nurse (RN) coverage for three of 14 days on the nursing schedule. Findings include: Review of the Staffing Sheets provided by the Director of Nursing (DON), dated 4/7/2024 through 4/20/2024, indicated that there was no RN coverage for 4/10/2024, 4/17/2024, and 4/18/2024. During an interview on 4/19/2024 at 9:30 am, the DON confirmed that there was no RN coverage for 4/10/2024, 4/17/2024, and 4/18/2024. The DON stated she thought her hours working as the DON would count as the RN eight hours of consecutive coverage when there was not an RN providing direct resident care on the unit.

Based on observations, staff interview, record review, and review of the facility policy titled, State Minimum Staffing for Healthcare Centers, the facility failed to ensure that posted staffing information was accurate and current on the daily nurse staffing document and accurately reflected Registered Nurses (RN) on the unit directly responsible for resident care per shift. The deficient practice presented staffing levels higher than the actual staffing levels to residents and visitors reviewing posted staffing documents. Findings include: Review of the facility policy titled State Minimum Staffing for Healthcare Centers dated 7/15/2016 revealed .1. Each facility will complete the Daily Nursing Hours for Healthcare Centers Form Information on the form .d. The total number of each category directly responsible for resident care per shift Registered Nurse .The total number of hours worked for each category per shift . Observations on 4/17/2024 at 10:00 am, on 4/18/2024 at 9:00 am, and on 4/19/2024 at 8:30 am revealed the daily nurse staff posting document was taped to the glass information board on the North hallway. The document identified the date, the facility's name, the facility's census, the total number and the actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift. The document indicated on the day shift for 4/17/2024, three RNs working eight hours each, with the census of 105; on the day shift for 4/18/2024, three RNs were working eight hours each, with the census of 104; and on the day shift for 4/19/2024, two RNs were working eight hours each, with the census of 104. Review of the Nursing Schedule provided by the Director of Nursing (DON), dated 4/17/2024 through 4/19/2024, revealed that an RN was not scheduled on the day shift for these days. During an interview on 4/18/2024 at 1:28 pm, the DON stated that the three RNs on the day shift for 4/17/2024 and 4/18/2024 were the Infection Preventionist (IP), the Clinical Care Competency (CCC) person, and herself. During an interview on 4/19/2024 at 9:30 am, the DON stated that the Administrator called the Corporate Office and was told that the DON could not count her hours on the daily nurse staff posting document. The DON stated that was why 4/19/2024 indicated two RNs on the day shift working eight hours. The DON confirmed after reviewing the nursing schedule for 4/17/2024 to 4/19/2024, that there were no RNs scheduled on the day shift to provide direct resident care for these days.

46691 Based on resident and staff interviews and record review, the facility failed to provide activities of daily living (ADL) care for two of four residents (R)(R#85 and R#61) related to showers. Findings include: The facility did not have a policy, procedures, or formal guidance for ADL cares, including showers. 1. A review of the clinical record for R#85 revealed the resident was admitted to the facility on [DATE] with diagnoses including schizophrenia, major depressive disorder with psychotic symptoms, unspecified psychosis, anxiety disorder, diabetes mellitus with diabetic nephropathy, low back pain. The Quarterly Minimum Date Set (MDS) assessment dated [DATE] revealed R#85 presents with a Brief Interview for Mental Status (BIMS) score of 14, indicating that the resident is cognitively intact. The MDS revealed R#85 requires supervision for ADLs and required set-up assistance for bathing. Review of the care plan with ADL section dated 6/7/2021, revealed R#85 required set up assistance with ADLs due to risk for falls and weakness. Approaches included assist with baths/showers as scheduled and as needed (PRN) and to assist the resident with dressing, oral, and personal hygiene prn. During an interview with R#85 on 11/29/2022 at 9:37 a.m. and on 11/30/2022 at 10:10 a.m. she confirmed that she requires set up assistance with ADLs including showers and stated that she needs assistance with showers. She stated that she did have a shower on 11/28/2022 but had not had one for two weeks prior to that. She confirmed that she is scheduled for a shower one time a week and that she often does not get a shower weekly because staff told her there is no staff available to assist her on her shower days. Record review of documentation in the electronic medical record (EMR) in dated 9/1/2022-9/30/2022 revealed R#85 only had a shower on one of the four weeks in September (9/17/2022). A review of the document dated 10/1/2022-10/31/2022 revealed R#85 had a shower on four of the five weeks in October (10/2/2022, 10/8/2022, 10/15/2022, and 10/22/2022). A review of the document dated 11/1/2022-11/30/2022 revealed R#85 had a shower on three of the four weeks in November (11/12/2022, 11/19/2022, 11/26/2022). There was no documented refusal of a shower for the months of September 2022, October 2022, or November 2022. Review of the shower schedule (not dated) revealed R#85 scheduled shower day was to be Sunday. Record review of the nursing notes revealed no documented refusal of ADL care. During an interview on 11/30/2022 at 11:20 a.m. with Certified Nursing Aide (CNA) AA confirmed that residents are scheduled for showers once weekly and as needed (prn). She also confirmed that R#85 required set up assist with showers and her scheduled shower day is Sunday. CNA AA revealed R#85 often declines shower on Sunday and is provided shower set up when she requests assistance. CNA AA revealed she reports refusal of care to the nurse and documents in the EMR. During an interview on 11/30/2022 at 11:40 a.m. with Licensed Practical Nurse (LPN) BB revealed R#85 requires supervision with most ADLs and requires set up assist with showers. LPN BB revealed R#85 may take a shower any time she desires. She stated that ADLs, including showers and refusal of care are documented in the EMR. She stated that all residents are scheduled for showers one time a week and may have shower on other days. During an interview on 12/1/2022 at 9:00 a.m. with the Director of Health Services (DHS) she confirmed that all residents are scheduled to receive a bath/shower one time per week and prn or when requested and that it is her expectation for residents to receive cares as instructed in their care plan. DHS stated that it is her expectation that ADL care including showers and refusal of showers be documented in the EMR and that it is her expectation for all residents to receive a shower/bath weekly and prn or as requested. The shower history documentation was reviewed for R#85 with the DHS. She verified that documentation revealed that R#85 did not receive a shower weekly and that there were no documented refusals of showers. 2. A review of the clinical record revealed that R#61 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, chronic obstructive pulmonary disease, acquired absence of left leg above knee, and morbid obesity. A review of the Annual MDS dated [DATE] revealed R#61 presented with a BIMs score of 13, indicating the resident was cognitively intact. Section G (functional status) indicated that R#61 requires extensive assistance for bed mobility, toileting, personal hygiene, and dressing and total dependance for transfers. A review of care plan for R#61, with last review date of 11/29/2022, revealed the resident required assistance with ADL's due to impaired mobility with goal of maintaining current level of functioning. Interventions include but are not limited to assist with personal and oral hygiene daily and as needed as tolerated, assist with showers/baths as scheduled and as needed as tolerated, and incontinence care on rounds and as needed. These interventions were assigned to the CNA and nursing. During an interview on 11/29/2022 at 10:30 a.m. with R#61 she stated that she does not go to the shower and that she believes she only gets a bed bath due to facility not having a lift that will accommodate her weight. During an interview on 11/30/2022 at 9:15 a.m. with CNA EE, she confirmed that the facility does not have a lift to accommodate residents up to 650 lbs. During a follow-up interview on 11/30/2022 at 9:30 a.m. with R #61, she stated she has not had a bath in a month. She feels she should have a bath at least once a week and believes she is scheduled for bathing on Monday's. She further states she has asked staff multiple times for a bath but was told either there was not enough staff, or the bathtubs were not draining properly. She reports staff occasionally give her a bed bath. R#61 denies refusing baths. A review of document titled South End Shower Schedule revealed R# 61 was scheduled for showers on Tuesdays. Further review of document's titled South End Showers and South End Monthly Showers from July 2022 to current revealed R#61 did not receive a bath/shower on constantly and there was no documentation of refusals. Interview on 12/1/2022 at 10:45 a.m. with the DHS revealed that all residents are scheduled for a shower/Bath at least once a week. Residents are scheduled per their preference. Frequency of bathing is also per residents' preferences. States residents can request bath at any time, but all residents are scheduled for bathing on their preferred day(s) of week. 47146

Based on observations, staff interviews, and policy review, the facility failed to update the care plan after a fall that resulted in a closed fracture of distal end of right fibula to reflect post orthopedic care; specifically non-weight bearing with walking boot and partial weight bearing for transfers with walker and assistance, for one Resident (R) R#2 of three sampled residents. Findings include: Review of the facility policy titled Care Plans with an effective date of 12/31/1996, revealed care plan updates/reviews will be performed within seven days of each quarterly assessment, each acute change in condition, and as needed following each hospital stay. Updates to the care plans should be made with any changes in condition at the time the change in condition occurred. All updates to care plans are to be dated and signed. Care plans will be updated by nurses, Case Mix Directors (CMD), or any other interdisciplinary team member so that the care plan will reflect the patient/resident's needs at any given moment. Review of the clinical record for R#2 revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 6, which indicated severe cognitive impairment. Based on review of R#2's provided care plan, no documentation was found for the use of the orthopedic boot or the non-weight bearing status as ordered by the orthopedic Physician. Review of the facility Event Report, dated 7/8/2021 revealed R#2 had two falls on 7/8/2021: one at 11:09 a.m. and the other at 12:12 p.m. Review of the Emergency Department (ED) notes dated 7/13/2021, revealed resident presents from nursing home after apparent fall. Discovered a tibia fracture on x-ray. Review of the Encounters and Procedures report from orthopedic visit, dated 7/19/2021, revealed displaced distal fibula fracture with nursing home instructions to include pneumatic tall walking boot and non-weight bearing with tall boot and partial weight bearing with transfers only with a walker and assistance. There was no evidence that R#2 care plan reflected these instructions from the orthopedic Physician. Interview on 9/8/2021 at 2:25 p.m. with Licensed Practical Nurse (LPN) AA stated she has seen R#2 walking around in the hallway with an orthopedic boot on her right leg, but stated she was not sure why she has it. She verified that R#2 did not have documentation in the care plan to reflect the use of the orthopedic boot. She further stated that it is the receiving nurse's responsibility to update resident care plans with new instructions from the Physician. Interview on 9/8/2021 at 2:50 p.m. with the Director of Nursing (DON) confirmed that R#2's care plan was not updated to reflect a fractured right ankle or the use of orthopedic boot with non-weight bearing status and partial weight bearing status for transfers with the use of walker. Interview on 9/8/2021 at 5:00 p.m. with the Minimum Data Set (MDS) Coordinator, revealed that any clinical staff member can update a resident's care plan for changes in condition. She confirmed that the care plan for R#2 had not been updated to reflect her fractured ankle and the use of orthopedic boot with non-weight bearing status and partial weight bearing status for transfers with the use of walker. Interview on 9/8/2021 at 5:30 p.m. with the DON, stated it is her expectation for all resident care plans to be updated immediately with all changes of condition.

Based on record review, staff, family and Physician interviews, review of the facility policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to notify the Physician and the Responsible Party of a sexual abuse allegation for one resident (R) (R C). The census on 10/22/2020 was 94. On October 27, 2020, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Corporate Consultant Nurse were informed of the Immediate Jeopardy on October 27, 2020 at 12:30 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on October 16, 2020. The Immediate Jeopardy continued through October 28, 2020 and was removed on October 29, 2020. Immediate Jeopardy is outlined as follows: On October 16, 2020 at approximately 8:00 p.m. Temporary Nursing Assistant (TNA) AA, reported to Registered Nurse (RN) CC that R C reported to her that TNA DD, had sexually assaulted her. RN CC, along with TNA AA immediately went to the Social Services Director (SSD) and reported the allegation to her. RN CC instructed TNA AA, to switch her assignment with TNA DD to prevent him from caring for R C. Review of the Police Department Incident Report revealed on October 20, 2020 at 7:00 p.m. an incident was filed, by a family member, that R C reported to her that she had been sexually assaulted by TNA DD. During an interview on October 22, 2020 at 12:30 p.m. with the investigating Detective at the Police Department revealed that he arrived at the facility on October 20, 2020 sometime between 7:00 p.m. and 8:00 p.m., prior to his arrival, he made a telephone call to the facility and discovered that TNA DD was still in the facility at this time. The Detective stated he instructed that the facility remove TNA DD immediately from the building. Review of a written statement by the Director of Health Services (DHS) dated October 20, 2020 (no time indicated) revealed she was notified after the police arrived and that TNA DD had been accused of sexually assaulting one of the residents. The DHS then suspended TNA DD at this time until an investigation was completed, and that TNA DD left the property at that time. In addition, another resident, R A, came forward on October 26, 2020 at 2:35 p.m. during an interview indicating she had a sexual encounter with TNA DD approximately one month ago when he placed her hand on his penis although she stated that it was consensual. The Immediate Jeopardy was identified on October 27, 2020 and determined to exist on October 16, 2020 in the areas of 42 CFR 483.10(g)(14)(i)-(iv)(15) Notification of Changes, F580; 42 CFR 483.12 (a)(1) Abuse and Neglect, F600; 42 CFR §483.12(b)(5), F608 - Reporting of Reasonable Suspicion of a Crime; and 42 CFR §483.12(c)(1), (4), F609 - Reporting of Alleged Violations. F580, F600, F608, and F609 were cited at a Scope and Severity (S/S) of a K. Additionally, Substandard Quality of Care was identified at 42 CFR 483.12 (a)(1) Abuse and Neglect, F600; 42 CFR §483.12(b)(5), F608 - Reporting of Reasonable Suspicion of a Crime, and 42 CFR §483.12(c)(1), (4), F609 - Reporting of Alleged Violations. An Immediate Jeopardy Removal Plan was received on October 28, 2020 and approved on October 29, 2020. Based on observations, interviews, record reviews and review of facility policy, it was validated that the corrective plans and that the immediacy of the deficient practice was removed on October 28, 2020. The facility remained out of compliance at a lower scope and severity of E while the facility continued management level staff oversight of preventing and reporting of sexual abuse and continued education. Findings include: Review of the policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property revised 7/29/19, revealed but not limited to any allegation, suspicion, or identified occurrence is identified involving patient abuse, neglect, exploitation, mistreatment, and misappropriation of property should be immediately reported to the Administrator of the provider entity. In accordance with applicable laws and regulations, the Administrator or his or her designee should notify the appropriate state agency (or agencies), the patient's attending physician, and the patient's designated representative of any allegation or incident described above and of the pending investigation. The state survey agency and the state agency for adult protective services should be notified in accordance with state law through established procedures of any allegations of abuse, exploitation or mistreatment within two (2) hours after the allegation is made if the events upon which the allegation is based involve abuse or serious bodily injury. A review of the medical record for R C revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) Assessment, dated 7/22/2020, revealed in Section (C) Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impact. Section (E) Behaviors revealed no behaviors. An interview with R C on 10/22/2020 at 11:30 p.m. revealed that one day last week, and added she was not good with remembering days and times, she pressed her call light because she had wet her brief and needed changing. She stated she was in the bed with the head of the bed up when TNA DD came in her room. The resident stated she had always like TNA DD and stated he was nice and polite, and respectable. She stated sometimes she is hard to please when it comes to men but stated she had come to trust TNA DD. She stated he came over, pulled the curtain, and pulled her gown up and saw that her brief was wet. He then placed his knee between her legs, leaned forward and put his penis in her mouth. She stated he grabbed her mouth and held her lips around his penis until he ejaculated into her mouth and stated it made her sick. The resident stated that TNA DD told her they were going to have to work on that. She stated he kept asking her if she was going to tell anyone and she told him no. She stated she told TNA AA about it a few days later and TNA AA reported it, but that nobody did anything about it. A telephone interview on 10/22/2020 at 3:25 p.m. with CNA AA revealed that R C told her that TNA DD had put his penis in her mouth. CNA AA stated she immediately told Registered Nurse (RN) CC and stated RN CC told her to change assignments with TNA DD and do her job and not to worry about it. Review of written statement made by RN CC dated 10/21/2020 revealed on 10/16/2020 approximately between 8:00 p.m. and 8:30 p.m. a CNA reported to her that R C stated a male CNA made inappropriate verbal actions toward her as follows: The resident stated that the male CNA requested to insert his private part into her mouth and at that point she ordered the female CNA to switch rooms with the male CNA and for him to avoid the patient's room. RN CC revealed that she and the CNA reported the incident to the Social Services Director (SSD), immediately, but did not notify anyone else of the incident. An interview with the SSD on 10/22/2020 at 2:29 p.m. revealed that RN CC came to her at approximately 8:00 or 9:00 p.m. on 10/16/2020 and relayed the incident information to her. She further revealed not notifying anyone of the incident. During a telephone interview on 10/22/2020 at 4:15 p.m. with family member of R C, revealed that the resident had contacted her and notified her about the incident with TNA DD. She notified the police but had not been notified by the facility. An interview with the Physician for R C on 10/27/2020 at 10:25 a.m. revealed he was never notified about R C sexual abuse allegation. Cross refer to F600 The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 10/20/2020, 3 pm-11p.m RN Unit Manager made resident C family member aware of the allegation of sexual abuse by a staff member. 2. On 10/27/2020, the Administrator notified resident C Physician about the allegation of sexual abuse by a staff member. 3. On 10/27/2020, a follow up call was made to resident, R C's family member by the Administrator to provide an update on the facilities progress with the investigation of alleged sexual abuse. 4. On 10/27/2020, the Administrator and Director of Health Services were provided education by the Senior Nurse Consultant regarding the requirement to notify the physician and responsible party with each allegation of abuse. 5. From 10/23/2020 through 10/26/2020 the Director of Health Services and Unit Manager provided education to 100 percent of the licensed nurses on policy Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property which includes the need to report the alleged abuse to the resident's family and the physician. Education has been provided to the following staff: a. 8 out of 8 RN's b. 12 out of 12 LPN's c. 6 out of 6 Agency Nurses Any staff currently on leave will be provided in person education prior to returning to work. Education will be added to new partner orientation and to any new agency staff conducted by the CCC or DHS. 6. An audit will be conducted by the Administrator for 5 abuse allegations per week or 10 percent of abuse allegations if 5 are not available, to ensure that family member and Physician are notified immediately when an abuse allegation occurs. Any findings where family or the physician are not notified will be corrected immediately and reported to the QAPI committee weekly until substantial compliance is met. The State Survey Agency (SSA) validated the facility's Immediate Jeopardy (IJ) Removal Plan as follows: 1. Review of the facility incident report, dated 10/20/2020, revealed that the RN NN notified the family member of R C of the sexual abuse allegation on 10/20/2020 at 8:07 p.m., after the police left the building. A telephone interview with RN NN on 10/22/2020 at 5:45 p.m. revealed that she had notified the family member and the Physician of R C on 10/20/2020 at approximately 8:00 p.m. after the police had left the building, of the sexual abuse allegation. 2. Review of the facility incident report, dated 10/20/2020, revealed that the RN NN notified the Physician of R C of the sexual abuse allegation on 10/20/2020 at 8:07 p.m., after the police left the building. 3. Review of a written statement, by the Administrator, dated 10/27/2020, revealed that he contacted the family member of R C to give an update on the investigation to the allegation of sexual abuse. An interview with the Administrator on 10/29/2020 at 4:29 p.m. confirmed he had reached out, via telephone, to the family member of R C, to give an update on the allegation of sexual abuse. 4. Review of Education and sign in sheets, dated 10/27/2020, by the Senior Nurse Consultant, to the Administrator and the DHS revealed that the facility is required to notify the local law enforcement with any allegation where a crime has potentially been committed against a resident, within two hours and report to the State Survey Agency. The facility is required to notify the family member and the resident's Physician of an allegation of abuse. An interview with the Administrator on 10/29/2020 at 4:29 p.m. revealed that he had received the in-service education on the facility's responsibility for reporting allegations of abuse to law enforcement and the State Survey Agency. The Administrator confirmed that the facility had no new hires as of this date. An interview with the DHS on 10/29/2020 at 4:34 p.m. revealed that she had received the in-service education on the facility's responsibility for reporting allegations of abuse to law enforcement and the State Survey Agency. 5. Review of the in-service Education and sign-in sheets beginning on 10/23/2020 through 10/27/2020, regarding the Policies titled, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property and Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property revealed that eight RNs, 14 LPN's and six Agency Nurses were educated on what, who and when to report allegations of abuse, including the Administrator's off hour phone number. The in-service included that every employee is a mandatory reporter of abuse. Interviews on 10/29/2020 with the following LPNs: LPN OO at 1:30 p.m., LPN PP at 1:40 p.m., LPN BB at 2:55 p.m., LPN CC at 3:08 p.m. revealed being educated that every employee is a mandatory reporter related to abuse, and what, who and when to report allegations of abuse and the time frame for reporting. This includes notifying the police. An interview with RN EE on 10/29/2020 at 3:23 p.m. revealed that she had received education related to the facility policies and procedures for prevention and reporting of abuse. 6. The surveyor was notified on 10/29/2020 that three additional female residents had come forward reporting that TNA DD had sexually abused them. Review of the facility Incident Reports dated 10/29/2020 confirmed that the police, family members and the Physician had been notified immediately. An interview with the Administrator on 10/29/2020 at 4:29 p.m. revealed that he had come into the facility at 1:00 a.m., after being notified by the staff, and the police were already onsite. The Administrator confirmed sending the report to the State Survey Agency and notifying the family of the allegation. The Administrator revealed that two of the three residents were their own responsible party and did not want anyone else notified. The Administrator further revealed that a QAPI meeting was held on 10/26/2020 related to the abuse allegation and to formulate an action plan. The next scheduled QAPI meeting will be on 11/6/ 2020 and the additional allegations will be reviewed at that time. The Administrator revealed that not only are the audit sheets being reviewed and presented to the QAPI members but that he is reviewing every reportable.

Based on record review, staff, family and Physician interviews, review of the facility policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to report an allegation of sexual abuse to the proper authorities within the prescribed time frame in accordance with state law for one resident (R) (R C). The census on 10/22/2020 was 94. On October 27, 2020, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Corporate Consultant Nurse were informed of the Immediate Jeopardy on October 27, 2020 at 12:30 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on October 16, 2020. The Immediate Jeopardy continued through October 28, 2020 and was removed on October 29, 2020. Immediate Jeopardy is outlined as follows: On 10/16/2020 at approximately 8:00 p.m. Temporary Nursing Assistant (TNA) AA, reported to Registered Nurse (RN) CC that R C reported to her that TNA DD, had sexually assaulted her. RN CC, along with TNA AA immediately went to the Social Services Director (SSD) and reported the allegation to her. RN CC instructed TNA AA, to switch her assignment with TNA DD to prevent him from caring for R C. Review of the Police Department Incident Report revealed on 10/20/2020 at 7:00 p.m. an incident was filed, by a family member, that R C reported to her that she had been sexually assaulted by TNA DD. During an interview on 10/22/2020 at 12:30 p.m. with the investigating Detective at the Police Department revealed that he arrived at the facility on 10/20/2020 sometime between 7:00 p.m. and 8:00 p.m., prior to his arrival, he made a telephone call to the facility and discovered that TNA DD was still in the facility at this time. The Detective stated he instructed that the facility remove TNA DD immediately from the building. Review of a written statement by the Director of Health Services (DHS) dated 10/20/2020 (no time indicated) revealed she was notified after the police arrived and that TNA DD had been accused of sexual assaulting one of the residents. The DHS then suspended TNA DD at this time until an investigation was completed, and that TNA DD left the property at that time. In addition, another resident, R A, came forward on 10/26/2020 at 2:35 p.m. during an interview indicating she had a sexual encounter with TNA DD approximately one month ago when he placed her hand on his penis although she stated that it was consensual. The Immediate Jeopardy was identified on 10/27/2020 and determined to exist on 10/16/2020 in the areas of 42 CFR 483.10(g)(14)(i)-(iv)(15) Notification of Changes, F580; 42 CFR 483.12 (a)(1) Abuse and Neglect, F600; 42 CFR §483.12(b)(5), F608 - Reporting of Reasonable Suspicion of a Crime; and 42 CFR §483.12(c)(1), (4), F609 - Reporting of Alleged Violations. F580, F600, F608, and F609 were cited at a Scope and Severity (S/S) of a K. Additionally, Substandard Quality of Care was identified at 42 CFR 483.12 (a)(1) Abuse and Neglect, F600; 42 CFR §483.12(b)(5), F608 - Reporting of Reasonable Suspicion of a Crime, and 42 CFR §483.12(c)(1), (4), F609 - Reporting of Alleged Violations. An Immediate Jeopardy Removal Plan was received on October 28, 2020 and approved on October 29, 2020. Based on observations, interviews, record reviews and review of facility policy, it was validated that the corrective plans and that the immediacy of the deficient practice was removed on October 28, 2020. The facility remained out of compliance at a lower scope and severity of E while the facility continued management level staff oversight of preventing and reporting of sexual abuse and continued education. Findings include: Review of the policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property revised, revealed but not limited to any allegation, suspicion, or identified occurrence is identified involving patient abuse, neglect, exploitation, mistreatment, and misappropriation of property should be immediately reported to the Administrator of the provider entity. In accordance with applicable laws and regulations, the Administrator or his or her designee should notify the appropriate state agency (or agencies), the patient's attending physician, and the patient's designated representative of any allegation or incident described above and of the pending investigation. The state survey agency and the state agency for adult protective services should be notified in accordance with state law through established procedures of any allegations of abuse, exploitation or mistreatment within two (2) hours after the allegation is made if the events upon which the allegation is based involve abuse or serious bodily injury. A review of the medical record for R C revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 7/22/2020 Significant Change Minimum Data Set (MDS) Section (C) Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impact. Section (E) Behaviors revealed no behaviors. An interview with R C on 10/22/2020 at 11:30 p.m. revealed that one day last week, and added she was not good with remembering days and times, she pressed her call light because she had wet her brief and needed changing. She stated she was in the bed with the head of the bed up when TNA DD came in her room. The resident stated she had always like TNA DD and stated he was nice and polite, and respectable. She stated sometimes she is hard to please when it comes to men but stated she had come to trust TNA DD. She stated he came over, pulled the curtain, and pulled her gown up and saw that her brief was wet. He then placed his knee between her legs, leaned forward and put his penis in her mouth. She stated he grabbed her mouth and held her lips around his penis until he ejaculated into her mouth and stated it made her sick. The resident stated that TNA DD told her they were going to have to work on that. She stated he kept asking her if she was going to tell anyone and she told him no. She stated she told TNA AA about it a few days later and TNA AA reported it, but that nobody did anything about it. A telephone interview on 10/22/2020 at 3:25 p.m. with TNA AA revealed that R C had told her about the sexual incident with TNA DD last Thursday 10/15/2020 sometime between 3:00 p.m. and 4:00 p.m., not long after she came in to work, a family member of R C brought the resident's cell phone by the facility for her and she was asked if she would please take it to R C. TNA AA revealed that the resident asked her if she would be taking care of her and when asked her if she needed something would she come and that was when R C told her that TNA DD had put his penis in her mouth. TNA AA stated she immediately told Registered Nurse (RN) CC who told her to change assignments with TNA DD and do her job and not to worry about it. TNA AA was asked if she was certain about the date and time that R C reported the allegation of sexual abuse to her and she stated yes although all written documents confirm as Friday, 10/16/2020. Review of written statement made by RN CC dated 10/21/2020 revealed on 10/16/2020 approximately between 8:00 p.m. and 8:30 p.m. a CNA reported to her that R C stated a male CNA made inappropriate verbal actions toward her as follows: Patient said that the male CNA requested to insert his private part into her mouth and at that point she ordered the female CNA to switch rooms with the male CNA and for him to avoid the patient's room RN CC confirmed that the SSD was notified of the incident at that time. RN CC confirmed that the incident was not reported to the State Agency by either herself or the SSD. An interview on 10/22/2020 at 2:29 p.m. with Social Services Director (SSD) revealed that RN CC came to her at approximately 8:00 or 9:00 p.m., 10/16/2020, and said R C was saying TNA DD put his penis in her mouth and ask if they could go together an interview her and confirmed they did not interview the resident that night. The SSD confirmed that TNA DD was allowed to continue working although they changed his assignment, away from the resident. SSD confirmed not reporting the incident to the Administrator or DHS and did not report to the State Survey Agency. A telephone interview on 10/22/2020 at 4:15 p.m. with family member of R C, she stated on Tuesday 10/20/2020 later in the evening, she received a phone call from the resident and during the conversation R C told her that a CNA put his penis in her mouth. She stated R C remembers things very well and has never been one to make stuff up. She stated she is not an attention seeker and is mentally cognitive. She confirmed that the facility did not notify her when the incident was reported to the staff. An interview with the Administrator on 10/27/2020 at 9:57 a.m. revealed that every staff in the facility is a mandated reporter and that, as the Abuse Coordinator, he was not notified of the incident until the police arrived on 10/20/2020. The Administrator confirmed that the incident was not reported to the State Survey Agency on 10/16/2020 and it should have been reported within two hours. Cross refer to F600 The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 10/16/2020, the charge nurse and social services director failed to report the alleged sexual abuse to the Abuse Coordinator immediately per facility policy therefore, the state survey agency and local law enforcement was not notified timely. Both the Charge Nurse and Social Services Director have since been terminated for failure to report. 2. From 10/23/2020 through 10/26/2020, the Director of Health Services and Unit Manager, provided educational in-services on the facility policies titled Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property and Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property outlining what constitutes as abuse, who is the Abuse Coordinator, and how to report, to report all allegations of abuse within 2 hours if the allegation of abuse or could result is serious bodily injury and no later than 24 hours if the events do not involve serious bodily injury to the state agency. Education has been provided to the following staff: a. 8 out of 8 RN's b. 12 out of 12 LPN's c. 29 out of 29 CNA's d. 6 out of 6 CNA's in Training e. 5 out of 5 Hospitality Aide's f. 1 out of 1 Social Services Director g. 1 out of 1 Admissions Director h. 1 out of 1 Activities Director i. 11 out of 11 Dietary Staff j. 11 out of 11 Housekeeping/Laundry Staff k. 2 out of 2 Maintenance staff I. 1 out of 1 Financial Counselor m. 1 out of 1Medical Records Director n. 4 out of 4 Therapy Staff o. 1 out of 1 Administrator 3. All education was completed on 10/27/2020. This represents 100% of nursing staff and other departments. There are 8 staff members currently on leave. 6 of 8 the staff on leave received education via telephone by the Director of Health Services and Unit Manager. Any staff currently on leave will be provided in person education prior to returning to work. Education will be added to new partner orientation and to any new agency staff conducted by the Clinical Competency Coordinator (CCC) or Director of Health Services (OHS). 4. On 10/27/2020, an Ad Hoc Resident Counsel meeting was conducted by the Activities Director. The Activities Director reviewed how to report abuse, who is the Abuse Coordinator and the following policies: a. Policy: Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property. b. Policy: Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property. 5. The Director of Health Services (DHS) will conduct a weekly audit titled Occurrence of Abuse Audit of 10 residents with a BIMs greater than 10 using the survey interview questions regarding abuse. The Director of Health Services will also interview 5 staff members weekly to identify if any abuse has been reported to them. Any findings where abuse is reported will be reported to the Administrator and the appropriate state agency immediately. Findings will be reported to the QAPI committee weekly until substantial compliance is met. The State Survey Agency (SSA) validated the facility's Immediate Jeopardy (IJ) Removal Plan as follows: 1. Review of the Disciplinary Notices for RN CC and the SSD, dated 10/21/2020 for failure to follow the facility policy on reporting abuse. Review of the one on one education for RN CC and the SSD dated 10/21/2020 on abuse reporting procedure by the DHS. Review of the Separation Notices dated 10/28/2020, for both the SSD and RN CC for serious violation of rules. 2. Review of the in-service Education and sign-in sheets beginning on 10/23/2020 through 10/27/2020, regarding the Policies titled, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property and Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property revealed that eight RNs, 14 LPN, six Agency Nurses, 31 CNAs, five TNAs, four hospitality aides, seven dietary aides, three cooks, three laundry aides, seven housekeeping staff, one Admission Director, one Activity Director, one Dietary Manager, one Housekeeping Supervisor, one Maintenance Assistant, one Maintenance Director, one Financial Director, one Medical Records Director and the Administrator were educated on what, who and when to report allegations of abuse, including the Administrator's off hour phone number. The in-service included that every employee is a mandatory reporter of abuse. Interviews on 10/29/2020 with the following LPNs: LPN OO at 1:30 p.m., LPN PP at 1:40 p.m., LPN BB at 2:55 p.m., LPN QQ at 3:08 p.m. revealed being educated that every employee is a mandatory reporter related to abuse, and what, who and when to report allegations of abuse and the time frame for reporting. This includes notifying the police. Interviews on 10/29/2020 with the following RNs: RN NN at 5:45 p.m. and RN EE at 3:23 p.m. revealed that she had received education related to the facility policies and procedures for prevention and reporting of abuse. Interviews on 10/29/2020 with the following CNAs: CNA TT at 1:10 p.m., CNA UU at 1:20 p.m., and CNA RR at 2:44 p.m. revealed they had attended in-services on what is abuse, such as sexual, verbal, physical, and misappropriation of property. They were aware that the Administrator was the Abuse Coordinator although if he was not available then the DHS should be notified immediately. Additionally, they were aware that they are considered mandatory reporters of abuse and that abuse should also be reported to the police. Interviews with Dietary Aides (DA) on 10/29/2020 were as follows: DA SS at 3:15 p.m. and DA GG at 3:38 p.m. revealed they had attended in-services on what is abuse, such as sexual, verbal, physical, and misappropriation of property. They were aware that the Administrator was the Abuse Coordinator although if he was not available then the DHS should be notified immediately. They were also aware of being mandatory reporters of abuse. Interviews with Housekeeping Staff (HK) on 10/29/2020 as follows: HK HH at 3:44 p.m., HK II at 3:51 p.m., HK JJ at 3:59 p.m., HK KK at 4:05 p.m. revealed that they have received recent (within the week) training on Abuse/Neglect/Exploitation and Reporting. They were aware that the Administrator is the Abuse Coordinator, and they should report any abuse to him and in his absence then report to the DHS. They understood that abuse allegation should be reported within two hours to the police. They understood that the perpetrator would need to be removed from the building immediately. An interview with Cook FF on 10/29/2020 at 3:31 p.m. revealed that she had been educated on Abuse/Neglect and reporting of abuse this week. She knew that the Administrator was the Abuse Coordinator and any allegations of abuse or if abuse was witnessed then it should be reported immediately. She understood that abuse must be reported to the police within two hours. An interview with the Financial Counselor on 10/29/2020 at 4:14 p.m. revealed that she had been in-serviced this week on the facility Policies titled, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property and Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property. She was aware that the Administrator was the Abuse Coordinator although in his absence the DHS should be notified. She was also aware that all employees are considered mandatory reporters of abuse. She was aware of the timeframe for reporting to the police and to the SSA. She understood how important it was to remove the person accused of abuse to keep the resident's safe until an investigation can be completed. An interview with the Therapy Outcomes Coordinator on 10/29/2020 at 4:20 p.m. revealed that she had received recent education on the facility's Abuse Policies and procedures. She was aware that the Administrator was the Abuse Coordinator and the timeframes for reporting. She was aware of being considered a mandatory reporter and that the police should also be notified of allegations of abuse and to remove the accused from the building. 3. Review of a list of 11 staff members who must received education on the abuse and reporting policies prior to starting their shift. 4. Review of the QAPI sign-in sheet, dated 10/26/2020 at 4:55 p.m. revealed that Department Heads, the Administrator and the Medical Director via telephone reviewed the facility Policies titled Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, dated as revised 9/20/19, and Reporting Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property revised 9/20/19. A revision was suggested and forwarded to Corporate for review. Any Department Head on leave will be educated prior to returning to work. 5. An interview with the DHS on 10/29/2020 at 4:34 p.m. revealed that she is responsible for the audits for all deficiencies. The DHS revealed that she will interview random residents who are interviewable if they have experienced abuse or have seen anyone abused. The audits will continue for at least three months or until the facility is in compliance. She will be completing body audits to check for signs of abuse and will also conduct behavior audits due to residents who were victims of the sexual abuse are beginning to have behaviors. She further revealed that the Psychiatrist is making an emergency trip to the facility today to those residents who were effected.

Based on record review, review of facility policies titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, Reporting Suspected Crimes Under Federal Elder Justice Act and staff interview the facility failed to ensure an allegation of sexual abuse was reported to Law Enforcement for one Residents (R) (R C). This deficient practice had the potential to affect all female residents in the facility based on evidence that the perpetrator was not removed from the facility immediately. The census on 10/22/2020 was 94 residents. On October 27, 2020, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Corporate Consultant Nurse were informed of the Immediate Jeopardy on October 27, 2020 at 12:30 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on October 16, 2020. The Immediate Jeopardy continued through October 28, 2020 and was removed on October 29, 2020. Immediate Jeopardy is outlined as follows: On 10/16/2020 at approximately 8:00 p.m. Temporary Nursing Assistant (TNA) AA, reported to Registered Nurse (RN) CC that R C reported to her that TNA DD, had sexually assaulted her. RN CC, along with TNA AA immediately went to the Social Services Director (SSD) and reported the allegation to her. RN CC instructed TNA AA, to switch her assignment with TNA DD to prevent him from caring for R C. Review of the Police Department Incident Report revealed on 10/20/2020 at 7:00 p.m. an incident was filed, by a family member, that R C reported to her that she had been sexually assaulted by TNA DD. During an interview on 10/22/2020 at 12:30 p.m. with the investigating Detective at the Police Department revealed that he arrived at the facility on 10/20/2020 sometime between 7:00 p.m. and 8:00 p.m., prior to his arrival, he made a telephone call to the facility and discovered that TNA DD was still in the facility at this time. The Detective stated he instructed that the facility remove TNA DD immediately from the building. Review of a written statement by the Director of Health Services (DHS) dated 10/20/2020 (no time indicated) revealed she was notified after the police arrived and that TNA DD had been accused of sexual assaulting one of the residents. The DHS then suspended TNA DD at this time until an investigation was completed, and that TNA DD left the property at that time. In addition, another resident, R A, came forward on 10/26/2020 at 2:35 p.m. during an interview indicating she had a sexual encounter with TNA DD approximately one month ago when he placed her hand on his penis although she stated that it was consensual. The Immediate Jeopardy was identified on 10/27/2020 and determined to exist on 10/16/2020 in the areas of 42 CFR 483.10(g)(14)(i)-(iv)(15) Notification of Changes, F580; 42 CFR 483.12 (a)(1) Abuse and Neglect, F600; 42 CFR §483.12(b)(5), F608 - Reporting of Reasonable Suspicion of a Crime; and 42 CFR §483.12(c)(1), (4), F609 - Reporting of Alleged Violations. F580, F600, F608, and F609 were cited at a Scope and Severity (S/S) of a K. Additionally, Substandard Quality of Care was identified at 42 CFR 483.12 (a)(1) Abuse and Neglect, F600; 42 CFR §483.12(b)(5), F608 - Reporting of Reasonable Suspicion of a Crime, and 42 CFR §483.12(c)(1), (4), F609 - Reporting of Alleged Violations. An Immediate Jeopardy Removal Plan was received on October 28, 2020 and approved on October 29, 2020. Based on observations, interviews, record reviews and review of facility policy, it was validated that the corrective plans and that the immediacy of the deficient practice was removed on October 28, 2020. The facility remained out of compliance at a lower scope and severity of E while the facility continued management level staff oversight of preventing and reporting of sexual abuse and continued education. Findings include: Review of facility policy Reporting Suspected Crimes Under Federal Elder Justice Act revised March 2012 revealed a signed acknowledgment by RN CC on 5/18/2017 indicating she understands the requirement if requested the healthcare/assisted living/ICF/MR facility on behalf of partner will file a report to the State Agency and local law enforcement using the Facility Suspected Report Form when the partner becomes aware of a suspicion of a crime. Review of facility policy 'Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property' revised 7/29/2019 revealed 3. Notwithstanding anything contained in this policy to the contrary, in any case which there is a reasonable suspicion that a crime has been committed against a patient of a Health Care Center, in addition to reporting to the appropriate state agency (or agencies) as described above, the incident should be reported to local law enforcement within 24 hours after forming the suspicion. Record review revealed that R C was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the Significant Change, Minimum Data Set (MDS), dated [DATE], Section (C) Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) assessment of 7 indicating severe cognitive impact, Section (E) Behaviors revealed no behaviors, Section (G) Functional Status revealed the resident is a limited two plus person assist with Activities of Daily Living (ADL), Section (H) Bowel and bladder revealed she is always incontinent, and Section (N) Medication revealed she receives Insulin injections, antianxiety, antidepressant, diuretic, and an opioid 7/7 days a week. An interview with R C on 10/22/2020 at 11:30 p.m. revealed that one day last week, and added she was not good with remembering days and times, she pressed her call light because she had wet her brief and needed changing. She stated she was in the bed with the head of the bed up when TNA DD came in her room. The resident stated she had always like TNA DD and stated he was nice and polite, and respectable. She stated sometimes she is hard to please when it comes to men but stated she had come to trust TNA DD. She stated he came over, pulled the curtain, and pulled her gown up and saw that her brief was wet. He then placed his knee between her legs, leaned forward and put his penis in her mouth. She stated he grabbed her mouth and held her lips around his penis until he ejaculated into her mouth and stated it made her sick. The resident stated that TNA DD told her they were going to have to work on that. She stated he kept asking her if she was going to tell anyone and she told him no. She stated she told TNA AA about it a few days later and TNA AA reported it, but that nobody did anything about it. An interview with Registered Nurse (RN) CC on 10/22/2020 at 12:30 p.m. revealed that although it was very chaotic when the incident was reported to her, on 10/16/2020, with residents testing positive for Covid-19, trying to move residents around and administer medications and ensure medications were moved with the resident, she should have stopped everything at that point and reported the allegation to the Administrator, who is the Abuse Coordinator. She further revealed that she should have asked TNA DD to leave the premises immediately but stated she just, for whatever reason, moved him away from R C and allowed him to continue working. RN CC stated that she went and reported the allegation of abuse to the Social Services Director (SSD) but did not do anything else with the allegation. RN CC assumed that the SSD would handle reporting the incident to all necessary parties. An interview on 10/22/2020 at 12:45 p.m. with the investigating Detective for the Police Department, the Detective stated he was notified by the family member of R C on Tuesday October 20, 2020 of the alleged sexual abuse, and he arrived at the facility between 7:00 p.m. and 8:00 p.m. that night and took a statement from R C, the victim. He stated prior to arriving at the facility he asked if the perpetrator was still on the premises. The Detective stated that RN CC is a mandated reporter and according to her statement she was informed of the allegation of sexual abuse toward R C by a staff member on Friday, 10/16/2020 but did not call the police and did not remove the perpetrator. The Detective revealed that it wasn't until Tuesday, 10/20/2020 that the police were notified, by a family member of the resident, and stated his investigation is open at this time. The Detective stated he did speak with TNA DD on Tuesday (October 16, 2020) night when he came into the Police Station and stated he denied the allegation R C made against him but added that he did catch TNA DD in some inconsistencies. The Detective stated the victim, (R C) reported to him that several days after the alleged incident, she was sitting in the doorway of her room when TNA DD walked by, winked at her and blew her a kiss. The Detective stated TNA DD initially denied this allegation made by R C but then stated that TNA DD admitted to winking at the victim and blowing her a kiss. The Detective revealed that the Director of Health Services (DHS) had tried to contact TNA DD yesterday, 10/21/2020 and today, 10/22/2020 and had left messages for him to return her call but he has not returned the call. The Detective stated if TNA DD chooses not to return his call he will go ahead and file charges against him. The Detective confirmed that the interview today with R C was consistent with his interview with the resident on the 10/20/2020. Review of an email dated 10/26/2020 at 9:44 a.m. from the SSD to the Administrator reads: On Friday night, October 16, 2020 it was a mad house, and we were in the middle of moving 50+ residents. Between moving beds, furniture, clothes, etc., and cleaning, RN CC came to me and told me R C had said TNA DD had asked her to put his penis in her mouth. RN CC was in my office around this time between 8:00 p.m. and 8:30 p.m. and asked me to go with her to get a statement. I had stepped in my office to get a drink and was still in the process of moving people. RN CC had to take some meds to another hall, and she said when she came back, we would go to interview that patient. RN CC in the midst had nurses calling out, staff coming to her worried about the moves and giving out the right meds. I was involved with another resident with immediate needs so needless to say with all that was going on we forgot to go back and talk to the patient. It was an honest to God human mistake. The email is noted to be signed by the SSD. An interview with the Administrator on 10/22/2020 at 2:10 p.m. revealed that he did not leave the facility on Friday, 10/16/2020 until sometime between 9:36 p.m. and 9:53 p.m. and no one reported any allegations of abuse to him. He revealed that the process, when an allegation of abuse is reported by a resident, either he or the Director of Health Services (DHS) are to be notified immediately and, in this case, he stated the police should have also been notified immediately. He stated RN CC and the SSD have both been reprimanded for failing to report the allegation to law enforcement, and to him, and removing TNA DD from the building immediately for the safety of the residents. A telephone interview with the family member of R C on 10/22/2020 at 4:15 p.m. revealed that R C called her later in the evening of 10/20/2020 when the resident told her that a CNA put his penis in her mouth. She stated R C remembers things very well and has never been one to make stuff up. She stated she is not an attention seeker and is mentally cognitive. She stated what upset her so much was that whoever R C reported this to did not report it to anyone, not even the police. The family member revealed that she called the police to report it days after the resident had told someone in the facility what had happened to her. Review of the Police Department Incident Report dated 10/20/2020 at 1900 (7:00 p.m.) revealed an incident type of Sodomy at the facility with an incident date of 10/14/2020 at 18:30 (6:30 p.m.). Complainant is named as a family member of R C. An interview with the Detective on 10/27/2020 at 4:00 p.m. revealed that TNA DD could not be located and therefore an Arrest Warrant had been issued on 10/27/2020 for Felony, Aggravated Sodomy. Arrest Warrants for Misdemeanor-Failure to Report Abuse of Elder Person were issued on 10/27/2020 for RN CC and the SSD. Cross Reference F600 The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 10/20/2020, the local law enforcement arrived at the facility to investigate the report of alleged sexual abuse that was reported to them by resident C family member. Administrator was made aware and immediately reported to the state agency. 2. On 10/21/2020, the Administrator contacted the local law enforcement agency regarding the alleged sexual abuse. The facility continues to cooperate with the investigation with the local law enforcement agency. 3. An interview by state surveyor conducted on 10/26/2020 revealed that resident A alleged that she had a consensual encounter with TNA DD. Resident A stated that this encounter was not reported to facility staff. Resident A was interviewed on 10/26/2020 by the Senior Nurse Consultant. The incident was reported to state and local law enforcement immediately by the Administrator on 10/26/2020. 4. On 10/27/2020, the Administrator and Director of Health Services were provided education by the Senior Nurse Consultant regarding the requirement to notify the local law enforcement with any allegation of abuse where a crime has potentially been committed against a resident within 24 hours and to report within 2 hours if serious bodily injury is involved. 5. On 10/26/2020, the Administrator held an Ad Hoc QAPI meeting and in-service for 14 out of 16 department managers and the Medical Director on the following: a. Policy: Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property. Which details the notification of the suspicion of a crime to local law enforcement and time frames to report. The policy was reviewed with no revisions needed at that time. The department heads who are on leave will be provided education prior to returning to work. 6. The Director of Security for (Corporate Name) is currently conducting an internal investigation and assisting the center regarding the alleged sexual abuse. The facility and Director of Security is working in full cooperation with the local law enforcement in their investigation. 7. An audit will be conducted by the Administrator for 5 abuse allegations per week or 10 percent of abuse allegations if 5 are not available, to ensure that local law enforcement is notified when an abuse allegation that involves a potential crime against a resident. Any findings where the local law enforcement is not notified appropriately will be corrected immediately and reported to the QAPI committee weekly until substantial compliance is met. The State Survey Agency (SSA) validated the facility's Immediate Jeopardy (IJ) Removal Plan as follows: 1. Review of the facility incident report, dated 10/20/2020, revealed that the RN NN notified the family member of R C of the sexual abuse allegation on 10/20/2020 at 8:07 p.m., after the police left the building. 2. Review of a written statement, by the Administrator, dated 10/21/2020, revealed that the Administrator had contacted the local law enforcement detective to discuss R C allegation of sexual abuse and that the facility would fully cooperate with the investigation. 3. On 10/26/2020 the SSA made the facility aware of another incident of sexual abuse by TNA DD for R A. The facility immediately notified the police and reported to the SSA. Review of the Facility Incident Report, dated 10/26/2020, confirmed notification to the SSA. The RN/Senior Nurse Consultant interviewed the resident and confirmed the incident had occurred although the resident stated it was consensual. 4. Review of Education and sign in sheets, dated 10/27/2020, by the Senior Nurse Consultant, to the Administrator and the DHS revealed that the facility is required to notify the local law enforcement with any allegation where a crime has potentially been committed against a resident, within two hours and report to the State Survey Agency. The facility is required to notify the family member and the resident's Physician of an allegation of abuse. 5. Review of the QAPI sign-in sheet, dated 10/26/2020 at 4:55 p.m. revealed that Department Heads, the Administrator and the Medical Director via telephone reviewed the facility Policies titled Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, dated as revised 9/20/19, and Reporting Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property revised 9/20/19. A revision was suggested and forwarded to Corporate for review. Any Department Head on leave will be educated prior to returning to work. 6. Review of an email memo to the Administrator, dated 10/28/2020, from the Corporate Director of Security, to notify the Administrator that an internal investigation regarding the report of an assault against a resident would be conducted. The Corporate Security office would be working with the local Police Department and the United States Citizenship and Immigration Services (USCIS). 7. An interview with the Administrator on 10/29/2020 at 4:29 p.m. revealed that starting next week he would be utilizing the Occurrence of Abuse Audit form which included the resident's name, date of interview, and concerns identified. The Audit sheet will be reviewed in the weekly QAPI meetings.

Based on record review, review of facility policies titled 'Abuse Prevention and Reporting; Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property; Freedom from Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property Mission Statement, staff and family interview, the facility failed to prevent an occurrence of sexual abuse by a staff member for 2 Residents, (R) (R C and R A). This deficient practice had the potential to affect every female resident in the facility based on evidence that the incident was reported on [DATE] and the staff member in question was not removed from the facility until [DATE]. The census on [DATE] was 94 residents. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Corporate Consultant Nurse were informed of the Immediate Jeopardy on [DATE] at 12:30 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. The Immediate Jeopardy continued through [DATE] and was removed on [DATE]. Immediate Jeopardy is outlined as follows: On [DATE] at approximately 8:00 p.m. Temporary Nursing Assistant (TNA) AA, reported to Registered Nurse (RN) CC that R C reported to her that TNA DD, had sexually assaulted her. RN CC, along with TNA AA immediately went to the Social Services Director (SSD) and reported the allegation to her. RN CC instructed TNA AA, to switch her assignment with TNA DD to prevent him from caring for R C. Review of the Police Department Incident Report revealed on [DATE] at 7:00 p.m. an incident was filed, by a family member, that R C reported to her that she had been sexually assaulted by TNA DD. During an interview on [DATE] at 12:30 p.m. with the investigating Detective at the Police Department revealed that he arrived at the facility on [DATE] sometime between 7:00 p.m. and 8:00 p.m., prior to his arrival, he made a telephone call to the facility and discovered that TNA DD was still in the facility at this time. The Detective stated he instructed that the facility remove TNA DD immediately from the building. Review of a written statement by the Director of Health Services (DHS) dated [DATE] (no time indicated) revealed she was notified after the police arrived and that TNA DD had been accused of sexual assaulting one of the residents. The DHS then suspended TNA DD at this time until an investigation was completed, and that TNA DD left the property at that time. In addition, another resident, R A, came forward on [DATE] at 2:35 p.m. during an interview indicating she had a sexual encounter with TNA DD approximately one month ago when he placed her hand on his penis although she stated that it was consensual. The Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] in the areas of 42 CFR 483.10(g)(14)(i)-(iv)(15) Notification of Changes, F580; 42 CFR 483.12 (a)(1) Abuse and Neglect, F600; 42 CFR §483.12(b)(5), F608 - Reporting of Reasonable Suspicion of a Crime; and 42 CFR §483.12(c)(1), (4), F609 - Reporting of Alleged Violations. F580, F600, F608, and F609 were cited at a Scope and Severity (S/S) of a K. Additionally, Substandard Quality of Care was identified at 42 CFR 483.12 (a)(1) Abuse and Neglect, F600; 42 CFR §483.12(b)(5), F608 - Reporting of Reasonable Suspicion of a Crime, and 42 CFR §483.12(c)(1), (4), F609 - Reporting of Alleged Violations. An Immediate Jeopardy Removal Plan was received on [DATE] and approved on [DATE]. Based on observations, interviews, record reviews and review of facility policy, it was validated that the corrective plans and that the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance at a lower scope and severity of E while the facility continued management level staff oversight of preventing and reporting of sexual abuse and continued education. Findings include: Review of the Abuse Prevention and Reporting policy dated [DATE] revealed the definition of sexual abuse to indicate but is not limited to sexual harassment, sexual coercion, and sexual assault. Procedure: 1. Anyone witnessing, suspecting, or hearing an allegation of mental, physical, verbal or sexual abuse; neglect or exploitation of any resident will immediately report this to the Administrator whether the Administrator is on the premises or not. 2. The Administrator will immediately begin an investigation and implement measures necessary to assure the safety and protection of the resident from the actual or alleged perpetrator. 2. In the event the Administrator has knowledge that the resident has been abused, neglected or exploited while residing in the home, he/she will immediately make a report by phone or in person to the Department of Community Health. In the event that an immediate report to the Department is not possible, the Administrator shall make the report to the appropriate law enforcement agency. 4. The initial report of actual or suspected abuse shall contain al least the following: Name and address of person making the report, Name and address of the resident or former resident, Name and address of the facility, Nature and extent of any injuries or condition resulting from the suspected abuse, neglect or exploitation, The suspected cause of the incident, Any other information that the reporter believes might be helpful in determining the cause of the resident injuries or condition and determining the identity of person or persons responsible for the incident. 5. Within 24 hours of the initial report, the Administrator shall also make a written report, using the Incident Report, documenting all known and relevant information, the investigation results, and any corrective or protective actions taken. 6. The written Incident Report shall be faxed to the Department of Community Health, Health Care Facility Regulation Department, Complaint Division. 7. The fax confirmation sheet shall be attached to the Incident Report and maintained in the central Incident Report file. 8. If the alleged perpetrator(s) is a staff member of the home, the Administrator will place them on administrative leave until a determination of the allegation is made. Confirmed allegations shall result in termination with notification to the appropriate boards, registries and agencies and the police as appropriate. Review of facility policy 'Freedom from Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property Mission Statement' revised [DATE] revealed: Our policies and procedures apply to all who come in contact with, or have the potential to come in contact with, patients, including without limitation provider staff, other patients, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends, and other individuals. Review of facility policy 'Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property' revised [DATE] revealed Sexual Abuse is non-consensual sexual contact of any type with a resident. Partners are expected to recognize that engaging in a sexual relationship with a resident, even with an apparently willing engaged and consensual relationship, is not consistent with the partner's role as a care giver and is considered an abuse of power. Also, for some healthcare professionals, it is prohibited by licensure and certification requirements for partners to have relationships with a resident. 1. Record review revealed that R C was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the Significant Change, Minimum Data Set (MDS), dated [DATE], Section (C) Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) assessment of 7 indicating severe cognitive impact, Section (E) Behaviors revealed no behaviors, Section (G) Functional Status revealed the resident is a limited two plus person assist with Activities of Daily Living (ADL), Section (H) Bowel and bladder revealed she is always incontinent, and Section (N) Medication revealed she receives Insulin injections, antianxiety, antidepressant, diuretic, and an opioid ,[DATE] days a week. An interview with R C on [DATE] at 11:30 p.m. revealed that one day last week, and added she was not good with remembering days and times, she pressed her call light because she had wet her brief and needed changing. She stated she was in the bed with the head of the bed up when TNA DD came in her room. The resident stated she had always like TNA DD and stated he was nice and polite, and respectable. She stated sometimes she is hard to please when it comes to men but stated she had come to trust TNA DD. She stated he came over, pulled the curtain, and pulled her gown up and saw that her brief was wet. He then placed his knee between her legs, leaned forward and put his penis in her mouth. She stated he grabbed her mouth and held her lips around his penis until he ejaculated into her mouth and stated it made her sick. The resident stated that TNA DD told her they were going to have to work on that. She stated he kept asking her if she was going to tell anyone and she told him no. She stated she told TNA AA about it a few days later and TNA AA reported it, but that nobody did anything about it. An interview with Registered Nurse (RN) CC on [DATE] at 12:30 p.m. revealed that although it was very chaotic when the incident was reported to her, on [DATE], with residents testing positive for Covid-19, trying to move residents around and administer medications and ensure medications were moved with the resident, she should have stopped everything at that point and reported the allegation to the Administrator, who is the Abuse Coordinator. She further revealed that she should have asked TNA DD to leave the premises immediately but stated she just, for whatever reason, moved him away from R C and allowed him to continue working. RN CC stated that she went and reported the allegation of abuse to the Social Services Director (SSD) but did not doing anything else with the allegation. An interview on [DATE] at 12:45 p.m. with the investigating Detective for the Police Department, the Detective stated he was notified by the family member of R C on Tuesday [DATE] of the alleged sexual abuse, and he arrived at the facility between 7:00 p.m. and 8:00 p.m. that night and took a statement from R C, the victim. He stated prior to arriving at the facility he asked if the perpetrator was still on the premises. The Detective stated he was informed that he (the perpetrator) was on the premises and that he instructed that the perpetrator be removed from the facility immediately. The Detective stated that RN CC is a mandated reporter and according to her statement she was informed of the allegation of sexual abuse toward R C by a staff member on Friday, [DATE] but did not call the police and did not remove the perpetrator. The Detective revealed that it wasn't until Tuesday, [DATE] that the police were notified, by a family member of the resident, and stated his investigation is open at this time. The Detective stated he did speak with TNA DD on Tuesday ([DATE]) night when he came into the Police Station and stated he denied the allegation R C made against him but added that he did catch TNA DD in some inconsistencies. The Detective stated the victim, (R C) reported to him that several days after the alleged incident, she was sitting in the doorway of her room when TNA DD walked by, winked at her and blew her a kiss. The Detective stated TNA DD initially denied this allegation made by R C but then stated that TNA DD admitted to winking at the victim and blowing her a kiss. The Detective revealed that the Director of Health Services (DHS) had tried yesterday, [DATE] and today, [DATE] to contact TNA DD and had left messages for him to return her call but he has not returned the call. The Detective stated if TNA DD chooses not to return his call he will go ahead and file charges against him. The Detective confirmed that the interview today with R C was consistent with his interview with the resident on the [DATE]. An interview with the SSD on [DATE] at 2:29 p.m. revealed that RN CC came to her at approximately 8:00 p.m. or 9:00 p.m. on [DATE] and said R C was saying TNA DD put his penis in her mouth and asked if they could go together and interview her, but they never interviewed the resident. She stated RN CC told TNA DD to change assignments with TNA AA so that he would not be around or taking care of R C. The SSD stated she did not report the allegation to anyone on Friday and stated she spoke with R C on Monday while in her office. A telephone interview on [DATE] at 3:25 p.m. with TNA AA, she stated last Thursday [DATE] sometime between 3:00 p.m. and 4:00 p.m., not long after she came in to work, R C's family member brought her cell phone by the facility and asked if she would please take the phone to R C. She stated R C asked her if she would be taking care of her and asked her if she needed something would she be the one to come and that was when R C told her that TNA DD had put his penis in her mouth. TNA AA stated she immediately told RN CC and that RN CC told her to change assignments with TNA DD and do her job and not to worry about it. TNA AA was asked if she was certain about the date and time that R C reported the allegation of sexual abuse to her and she stated yes. An interview on [DATE] at 4:00 p.m. with R C revealed that 2 or 3 days after the incident with the TNA DD she was sitting in her wheelchair in the doorway of her room and TNA DD walked by her room. The resident revealed that TNA DD smiled and winked at her and it scared her so bad that she pulled her curtain and went back to her bed. The resident stated she is scared a lot of the time and was afraid TNA DD will come in her room. She revealed that today, for example, there was a male dressed in a black uniform outside her door today and that TNA DD sometimes wore a black uniform and she kept peaking around her curtain to see if it was him. She stated if she had somewhere else to go, she would go right now and added that it has been as if no one here cared what happened to her while TNA DD was allowed to go and come as he pleased and she is scared, peaking around her curtain to make sure he isn't coming into her room. During a telephone interview on [DATE] at 4:15 p.m. with the family member of R C, revealed that on Tuesday, [DATE], later in the evening, the resident called her saying that TNA DD put his penis in her mouth. The family member revealed that R C remembers things very well and has never been one to make stuff up. The resident is not an attention seeker and is mentally cognitive. The family member stated being very upset because the person this incident was reported, did nothing to protect the resident, did not report the incident to the policy which also upset the resident. Review of a written statement made by RN CC dated [DATE] revealed the following: on [DATE] approximately between 8:00 p.m. and 8:30 p.m. a Certified Nursing Assistant (CNA) reported to her that R C stated a male CNA made inappropriate verbal actions toward her as follows: Patient said that the male CNA requested to insert his private part into her mouth and at that point she (RN CC) ordered the female CNA to switch rooms with the male CNA and for him to avoid the patient's room. The male CNA stated he would and did not reenter the resident's room. RN CC stated she then escorted the female staff member to the SSD and asked that she repeat what the resident had told her. The SSD and RN CC agreed they would go to the patient and question her further about her statement along with filing a report and inform the patients family member. RN CC stated at the time all staff members were moving approximately twenty six Covid-19 positive resident's, along with their meds and completing medication administration, SSD was moving patient's clothing and other belongings so during the ensuing activities she (RN CC) and the SSD, without malice, failed to do so. RN CC stated she was not the nurse for the Resident that night ([DATE]) but was her nurse on the following Sunday [DATE] and on that day she entered R C's room to administer medications and she did not bring the subject up to her at any time during their face to face contact and added that R C's demeanor was calm, she was laughing and joking with her and physically and mentally showed no distress nor trauma. RN CC stated R C did speak with her nurse on [DATE] and stated to her that he (TNA DD) stuck his finger in my mouth, contraindicating her previous statement of female CNA on [DATE]. RN CC stated R C had called her family member and repeated the story to her, police were called, and report filed, State notified, and the male and female CNA were questioned by law enforcement. RN CC added at the bottom of her signed, written statement, that on [DATE] R C stated she was tired of being on the Covid-19 Unit and wanted to go home closer to her family member. There was no time documented on the written statement. Review of facility statement by the Director of Health Services (DHS) dated [DATE] revealed that she had been contacted the evening of [DATE] by the Nurse Supervisor (RN NN) advising that the police were in the building and wanted to interview R C. She immediately notified the Administrator that the police were in the building to interview R C. The DHS also contacted the SSD via telephone to see if she might be aware of the reason the police were in the building and she stated no. Although, the SSD did state that the resident had come to her office today but did not document the interview. The Nurse Supervisor called the DHS after the police completed their interview and revealed it was about a sexual assault by TNA DD, who was working tonight. The DHS instructed the Nurse Supervisor to move TNA DD to the other hall to work. The Nurse Supervisor stated that the police said he could not be in the building due to an allegation of sexual assault. The DHS revealed she would call TNA DD and explain the situation to him and why he would be suspended during the investigation, which she revealed occurred. The next morning, [DATE], RN CC, spoke with the DHS saying she had done something stupid. She revealed that on [DATE], while moving residents around due to COVID-19, TNA AA came to her regarding R C's accusation. She and TNA AA went to the SSD and relayed the incident. RN CC assumed that the SSD would handle the situation, report to the State, but that did not happen. It was a very busy night and that RN CC had forgotten the incident. The DHS then interviewed both RN CC and the SSD and both confirmed they were made aware on [DATE] but did not make the DHS or the Administrator aware. The DHS then interviewed R C regarding the events of last week. The resident revealed that she had turned her light on to get changed and the TNA DD came into her room, checked to see if she was wet. The resident revealed that TNA DD forced his penis into her mouth and said, Oh that feels good, but we are going to need to practice. The resident revealed that TNA DD also said, you are not going to tell anyone, are you?. The resident expressed being so scared and that she had kept her eyes closed. The resident expressed that the incident had happened a day or two before she told TNA AA. The DHS interviewed R C again on Saturday, [DATE], to ask how she was feeling about what happened to her. The resident stated, I do feel better now, I feel safe. The DHS informed the resident that TNA DD would not be returning and no longer works at the facility. The resident stated that she would not be here much longer and wanted to go home with her family member. Review of the medical record for R C revealed no documentation to indicate she has attention seeking behaviors. Review of the care plan for R C revised [DATE] revealed nothing to indicate negative behaviors or attention seeking behaviors. Review of the Psychotherapy Progress Note dated [DATE], for R C revealed this was a tele-mental health treatment session. The resident reported that she endured a horrible experience last week and indicated that her anxiety and depression have gotten worse since the incident. The resident indicated that the horrible experience has left her feeling uncomfortable and unsafe. The resident disclosed that she may be moving in with her family member very soon because she feels unsafe and uncomfortable as a result of the incident. The resident shared that the incident was reported two times: the incident was first reported immediately after the incident. The second time was to her family member who contacted the proper authorities (e.g., police) on yesterday ([DATE]). Additionally, the resident disclosed that she continues to experience difficulty sleeping at night and is following the medication regimen consistently. An interview with the Detective on [DATE] at 4:00 p.m. revealed that TNA DD could not be located and therefore an Arrest Warrant had been issued on [DATE] for Felony, Aggravated Sodomy. 2. R A was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed in Section (C), Cognition Patterns, a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Section (D) Mood revealed the resident had a mood severity score of 12 with thoughts of hurting herself or being better off dead nearly every day, feeling bad about herself nearly every day and trouble falling asleep or staying asleep nearly every day. Section (E) Behaviors revealed no behaviors were identified. Section (G) Functional Status revealed the resident was independent to supervision for all Activities of Daily Living (ADL) care. Section (N) Medication revealed the resident was administered routine antipsychotic medication and antidepressant medication seven (7) of seven (7) days. Review of the Care Plan for R A, dated [DATE] and revised on [DATE], revealed [DIAGNOSES REDACTED]. She is at risk for alterations with cognition due to diagnoses. Goal will be to maintain current level of cognitive level for 90 days. Interventions include but are not limited to Psych services as indicated, reminders and cues to help stimulate memory as needed. [DIAGNOSES REDACTED]. She has a potential for behaviors such as being verbally abusive toward others, physically abusive, refusing care, and risk for sexual behaviors. She has a potential for inattention and disorganized thinking that fluctuates. Goal will be to have one fewer behavioral episode's per week for 90 days. Interventions include but are not limited to medications as needed as ordered, notify Medical Doctor (MD) as indicated, Psych consult as indicated, Observe for behaviors that might be harmful to patient or others and notify MD as needed. During an interview with R A on [DATE] at 2:35 p.m. revealed that she has never been abused physically, emotionally, or sexually but stated she has had a sexual encounter one time, about a month ago, with TNA DD. R A revealed TNA DD placed her hand on his penis, but she could not remember if it was over his clothes or bare skin and stated he did not ejaculate. The resident stated she did not mind the encounter and that it was consensual. She stated TNA DD asked her not to tell anybody and she had not told anyone until today because she is not like that. Review of the Psychotherapy Progress Note dated [DATE] revealed that staff reported that the resident may have been taken advantage of by a former staff member. The resident disclosed that a staff member (Certified Nursing Assistant) got familiar with her and had his way with her. The resident disclosed that she consented to some personal stuff but would not disclose the specific details of it. Resident disclosed that the incident happened only one time. Resident reported that she was not traumatized by the incident. Resident also reported that she has been recently hallucinating. Resident indicated that she has been seeing bugs on the wall. The resident also disclosed that it appeared as if the clouds in a picture hanging over her bed were moving. An interview with the Physician for R A on [DATE] at 10:25 a.m. revealed that the resident may have a BIMS score of 15, however she is very demented with frequent psychotic episodes. The Physician revealed that he and the Nurse Practitioner (NP) have attempted multiple Gradual Dose Reduction (GDR) for her psychotic medications with disastrous results. R B was admitted to the facility on [DATE], the roommate of R A, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated [DATE], for R B revealed in Section (C) Cognitive Patterns revealed a BIMS score of 15 indicating intact cognition. Section (E) Behaviors revealed no behaviors present. An interview with R B on [DATE] at 2:47 p.m. revealed that her roommate, R A, tries to get with all the men and she will push her call button just to have male staff answer her light. R B stated a while ago TNA DD, was laying in the bed with R A and they were giggling and carrying on and she (R B) got so angry she went and got the nurse to get TNA DD out of her roommates bed. R B stated she has not seen TNA DD in about a week and stated she has talked with the SSD about changing rooms multiple times. An attempt was made to contact the nurse R B reported to, messages were left asking for a return call, but she did not return the calls. The SSD had been suspended and was unavailable for interview. An interview with Area Vice President on [DATE] at 1:30 p.m. revealed there was another female resident (R D who came forward alleging TNA DD had sexually assaulted her by placing his finger in her vagina when changing her brief. She stated the CNA, the resident reported it to, immediately reported it to her supervisor, the police was called, the Administrator came into the facility and began the State Report process, the MD, and the family were notified. She stated all residents who have intact cognition are being interviewed. Review of the Employment Eligibility Verification dated [DATE] revealed TNA DD has a United States of America Employment Authorization that expired on [DATE]. Review of the Background Check for TNA DD, dated [DATE], revealed there were no offenses identified. Arrest History for TNA DD, provided by the investigating Detective on [DATE], includes two misdemeanors on [DATE] of public drunkenness and criminal trespass. Review of the Certificate of Completion Temporary Nurse Aide dated [DATE] revealed TNA DD had completed his online course prior to working with residents in the facility. Review of the time sheets for TNA DD revealed he worked on Friday, (Incident reported to TNA AA, RN CC, and SSD) [DATE] from 3:57 p.m. to 8:53 p.m., an unscheduled shift on Sunday, [DATE] from 7:00 p.m. to 7:12 a.m., Monday, [DATE] from 2:59 p.m. to 11:02 p.m., and Tuesday, [DATE] from 4:02 p.m. to 7:55 p.m. During this 4-day period TNA DD cared for 27 female residents and 25 male residents on 2 of 2 halls, North and South. Review of the training for TNA AA revealed he had received Abuse and Neglect training upon hire through the facility's online training site, dated [DATE]. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE] resident C reported sexual abuse to Temporary Nurse Aide (TNA) #1. TNA #1 reported the incident to the Charge Nurse and Social Services Director on [DATE]. The charge nurse and social services director failed to report the alleged sexual abuse to the Abuse Coordinator immediately per facility policy. On [DATE], when the local law enforcement agency arrived at the facility to investigate the alleged incident, the Abuse Coordinator was made aware of the alleged sexual abuse by the Director of Health Services. TNA #2 was suspended on [DATE] immediately upon identification of the alleged incident to the Abuse Coordinator and it was reported to the appropriate state agency per regulatory guidelines. 2. On [DATE] the Charge Nurse and Social Services Director were provided a written disciplinary warning and one on one education regarding abuse reporting procedure by the Director of Health Services ( DHS). 3. On [DATE] the Charge Nurse and Social Services Director were suspended by the Administrator for violation of policy related to abuse reporting. Both the Charge Nurse and Social Services Director have since been terminated. 4. On [DATE] and [DATE], all female and male residents with a BIMs above a 10 were interviewed by the DHS, Unit Manager, and Social Services Director to identify any concerns related to abuse. 33 out of 34 residents stated that they have not been abused or have knowledge of abuse. 1 out of 34 residents stated that they had been verbally abused, this incident was reported by the DHS on [DATE]. A follow up interview was conducted with all female and male residents with a BIMs above a 10 on [DATE] and [DATE] by the DHS and Unit Manager. 34 out of 34 residents stated that they have not been abused or have knowledge of abuse. 5. From [DATE] through [DATE], all female and male residents with a BIMs less than 10 were observed with a full body audit to identify if there are any signs of abuse present. 56 out of 56 residents had no signs of abuse present upon assessment. 6. From [DATE] through [DATE], the Director of Health Services and Unit Manager, provided educational in-services on the facility policies titled Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property and Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property outlining what constitutes as abuse, who is the Abuse Coordinator and to report any and all reports of abuse. Education has been provided to the following staff: a. 8 out of 8 R N's b. 12 out of 12 LPN's c. 29 out of 29 CNA's d. 6 out of 6 CNA's in Training e. 5 out of 5 Hospitality Aide's f. 1 out of 1 Social Services Director g. 1 out of 1 Admissions Director h. 1 out of 1 Activities Director i. 11 out of 11 Dietary Staff j. 11 out of 11 Housekeeping/Laundry Staff k. 2 out of 2 Maintenance staff l. 1 out of 1 Financial Counselor m. 1 out of 1 Medical Records Director n. 4 out of 4 Therapy Staff o. 1 out of 1 Administrator 7. All education was completed on [DATE]. This represents 100% of nursing staff and other departments. There are 8 staff members currently on leave. 6 of 8 the staff on leave received education via telephone by the Director of Health Services and Unit Manager. Any staff currently on leave will be provided in person education prior to returning to work. Education will be added to new partner orientati (TRUNCATED)

Based on observation, interview, review of facility policy titled Medication Administration: Oral Medication, and review of the Georgia Nurse Practice Act, the facility failed to provide supervision during the administration of medication for one of five sampled residents, (R) (R#13). Findings include: A review of the Georgia Nurse Practice Act, (chapter 410-10) revealed the following: The Practice of Nursing includes, but is not limited to, provision of nursing care; administration, supervision, evaluation, or any combination thereof, of nursing practice; teaching; counseling; the administration of medications and treatments as prescribed by a physician [MEDICATION NAME] medicine in accordance with Article 2 of Chapter 34 of this title. A review of the facility policy titled Medication Administration: Oral Medication reviewed and revised on 1/28/2020, Guideline #13, revealed the following: Administer medication and remain with the patient/resident while medication is swallowed. On 2/12/2020 at 9:59 a.m. Licensed Practical Nurse (LPN) AA was observed placing a medication cup containing eleven pills down on the over bed table with a cup of juice containing a powdered medication, and a cup of water, in front of R#13, then leaving the room and returning to hallway where R#13 was out of sight. Review of the clinical record for R#13 revealed on admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Speech Therapy Evaluation dated 6/28/18 revealed R#13 had no signs of dysphagia, with no swallowing deficit and was recommended to continue with a regular texture diet and thin liquids, and no additional Speech Therapy required. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed R#13's Brief Interview for Mental Status (BIMS) score of 13, indicating his cognition was intact. Review of the February 2020 Medication Administration Record [REDACTED] [MEDICATION NAME] 100 milligram (mg) one po (by mouth) [MEDICATION NAME] 10 mg one po [MEDICATION NAME] 5 mg one po [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg one po [MEDICATION NAME] 25 mg one po Sodium [MEDICATION NAME] 650 mg one po Vitamin D3 1000 units (u) five tablets po [MEDICATION NAME] 4 grams, one packet mixed with 60 milliliters (mls) fluid po An interview with LPN AA on 2/12/2020 at 10:01 a.m. revealed she usually does not watch R#13 take his medication because he does not have a problem swallowing the medications and always takes them. An interview was conducted with R#13 on 2/20/2020 at 11:35 a.m. R#13 revealed he gets his medications on time and as far as he knows, as the Physician has ordered. R#13 revealed some nurses watch him swallow the medications and some just leave them on the table. R#13 revealed he has never choked on his medications or not taken the medications when the nurse just left them on his table. An interview was conducted with the Director of Nurses (DON) on 2/20/2020 at 2:25 p.m. The DON revealed the medication nurses are to observe all the residents swallow their medications according to facility policy. The DON revealed all nurses are aware of this and the facility provides education related to the nurses watching residents take their medications. The DON revealed the Consultant Pharmacist monitors medication administration each month in an effort to ensure residents are being administered medications in accordance with facility policy and standards of the profession. The DON did not know why a medication nurse would walk away from a resident leaving them with medication to take without supervision.

Based on observation and interviews, the facility failed to ensure that it was maintained in a safe, clean and comfortable home-like environment in three rooms on one of three halls (215 B, 221 A, 222 B); also failed to clean wheelchair for one (1) resident (#209) . The facility census was 106. Findings include: Observation on 4/15/19 at 12:02 p.m. revealed in room [ROOM NUMBER]-B, three small patches of ripped sheetrock, approximately two by two inches in diameter. Observation on 4/15/19 at 12:02 p.m. revealed resident (R) R#209 wheelchair to have heavy layer of dirt/dust buildup around the wheels and spokes. Observation on 4/16/19 at 8:34 a.m. revealed in room [ROOM NUMBER]-B, two broken slats on wooden window blinds; also bathroom door knobs were loose and wobbly. Observation on 4/16/19 at 9:57 a.m. revealed in room [ROOM NUMBER]-A, top drawer of the nightstand is broken off track and there are no knobs to pull the drawer open. Interview on 4/19/19 at 11:00 a.m. with Maintenance Director, stated his daily duties include checking the wander guards, exit doors and water temperatures. He further stated that staff complete electronic work orders for items that need to be serviced. He also stated that staff will tell him things in passing if repairs are needed. He verified during walking rounds the concerns identified during the survey. He stated that he is not certain who is responsible for washing the resident wheelchairs. Interview on 4/19/19 at 11:43 a.m. with Housekeeping Supervisor, stated that the 3:00 p.m. to 11:00 p.m. floor tech washes wheelchairs on Mondays, Wednesdays and Fridays. He further stated the floor tech is washing six-eight wheelchairs each day. He stated there is no documentation being done as far as the washing of the wheelchairs. He stated that he does get a list of all new admits, and stated that he was not aware of R#209 having a wheelchair. He verified the dust buildup on R#209 wheelchair and stated he would have the floor tech wash it.

Based on record review and staff interview the facility failed to have an effective Quality Assessment and Assurance (QAA) Committee that developed and implemented a process to ensure medication administration in accordance with Physicians' orders, and failed to continue quality assurance monitoring of plans of action implemented to correct an identified problem with resident identification by staff nurses during orientation. Additionally the facility failed to provide oversight to a newly hired nurse administering medications without supervision. This failure resulted in a significant medication error involving the administration of two (2) antihypertensive medications to the wrong resident (R#2) on 10/14/15, when a photograph was not available on the Medication Administration Record (MAR) for an unsupervised orienting nurse to use for identification. Photographs were not available for six (6) residents (#16, #17, #18, #19, #20, and #21) residing in the facility when the MAR books were reviewed on 2/19/16 at 2:10 p.m. and on 2/25/16 at 10:40 a.m. The facility failed to provide accurate identification and adequate investigation of medication errors and comply with established policies and procedures related to medication management. Resident #1 was administered [MEDICATION NAME] 20 mg SL twice within thirty (30) minutes. Due to an omission of documentation on December 20, 2016, on the MAR and Controlled Drug Record of a dose of [MEDICATION NAME] 20 mg SL scheduled for 5:30 a.m. and not given until 7:00 a.m., Resident #1 recieved a second dose of [MEDICATION NAME] 20 mg SL at 7:30 a.m. This was not identified as an error despite the Medication Administration Guidelines Policy specifying medications must be given within one hour before or after they are scheduled. The Policy further specifies that administered medications must be recorded on the MAR before the nurse goes home and should be initialed on the MAR after the administration. The medication errors and adverse reactions involving Resident #1 and Resident #2 were not reported as required by the Medication Discrepancy and Adverse Reaction Report Policy. The total survey sample was twenty-four (24) residents. The facility ' s Administrator, Corporate Clinical Consultant, Director of Health Services (DHS) and Nursing Supervisor EE Registered Nurse (RN) were informed of the Immediate Jeopardy on February 25, 2016 at 5:00 p.m. The non-compliance related to the Immediate Jeopardy was identified to have existed as of October 14, 2015, the date Resident #2 was administered another residents antihypertensive medications. An allegation of jeopardy removal was recieved on February 26, 2016. Based on corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on March 1, 2016, and the facility remained out of compliance at the lower scope and severity of D while the process of evaluation of the nursing staff's compliance with physician's orders [REDACTED]. In-service materials and records were reviewed. Interviews were conducted with nursing staff to ensure they were knowledgeable about the administration of resident medication. Findings include: Cross refer to F333, F329, F490, and F514 An interview with the Corporate Clinical Consultant on 2/18/16 at 5:00 p.m. revealed the investigation of Resident #1 being administered [MEDICATION NAME] 20 mg Sublingual (SL) on 12/20/15 at 7:00 a.m. and again at 7:30 a.m. had not resulted in identifying a problem with narcotic administration and monitoring or medication administration and documentation. The Corporate Clinical Consultant acknowledged the Corporate Medication Administration General Guidelines clearly state that medications are to be signed for on the MAR as soon as they are administered and that in no case should a nurse go off duty without signing for administered medications and this policy had not been followed. Licensed Practical Nurse (LPN) BB had been educated to sign for the medications she administered on 12/20/15 and since no [MEDICATION NAME] was unaccounted for the facility did not identify this as an error. LPN BB was interviewed on 2/19/16 at 11:55 a.m.and revealed she had administered a dose of [MEDICATION NAME] 20 mg SL to Resident #1 ninety minutes late, at 7:00 a.m. just prior to going home. BB then revealed she had not signed for the [MEDICATION NAME] on the Controlled Drug Record and had not initialed on the MAR that she had administered the medication. She acknowledged she had not indicated why the administration was 90 minutes late, flagged the MAR with this information or communicated this to the oncoming nurse. LPN BB confirmed her failure to follow the Medication Administration: General Guidelines Policy had resulted in LPN AA administering a second dose of [MEDICATION NAME] on schedule at 7:30 a.m., which should not have been administered because Resident #1 was diagnosed with [REDACTED]. Review of the clinical record for Resident #2 revealed he was administered [MEDICATION NAME] 30 mg and [MEDICATION NAME] 100 mg by mouth on 10/14/15 at 6:00 a.m., and did not have orders for these medications. He was discovered to be severely hypotensive at 7:10 a.m., and transferred emergently to the closest hospital and admitted to the Intensive Care Unit (ICU) with a [DIAGNOSES REDACTED]. Observation of the MAR books conducted on 2/19/16 at 2:10 p.m. and on 2/25/16 at 10:40 a.m. revealed six (6) resident pictures missing. In an interview conducted with Nurse HH Licensed Practical Nurse (LPN) on 2/24/16 at 3:00 p.m. she revealed she had oriented LPN BB to pass medications on the North Hall from 11:00 p.m. on 10/13/15 to 7:00 a.m. on 10/14/15. She remembered observing LPN BB preparing two (2) antihypertensive medications at the cart for Resident #4 to be given at 6:00 a.m., she did not enter the room with LPN BB . She further revealed there were no pictures of R#2 or R#4 (the roommate) on the Medication Admnistration Record's (MARs) because the pictures had not been changed on October 1, 2015 from the previous months MAR book, in the medication room. LPN HH acknowledged that she thought LPN BB had been on orientation long enough to remember who the two (2) residents in that room were and which one received medications at 6:00 a.m., but should not have left her to give any medication unattended. LPN HH revealed she had been notified by a Certified Nursing Assistant (CNA) that R#4 said he did not get his usual 6:00 a.m. medication and his roommate, R#2 might have received it. Interview with the Administrator on 2/24/16 at 2:30 p.m. revealed the medication errors and adverse reactions involving Resident #1 and Resident #2 were not reported on Medication Discrepancy and Adverse Reaction reports as required by this Policy. These reports had not been completed for an unknown length of time. Interview conducted on 2/25/16 at 10:40 a.m. with Nursing Supervisor EE Registered Nurse (RN) revealed that the six (6) missing resident pictures had either fallen out of the sleeves they are kept in or left in the last months MAR books kept in the medication rooms on both the North and South Halls. Supervisor EE acknowledged that each book should have a picture of each resident. In an interview on 2/25/16 at 3:30 p.m. the Administrator revealed the QAA Committee had identified the issue involving identification of residents by photographs on 10/14/15, and this was considered to be resolved on 10/14/15, after R#2 had been transferred to the hospital and all MAR's had been equipped with pictures. The Administrator then acknowledged there were six (6) residents whose pictures were missing on 2/19/16 at 2:10 p.m. and 2/25/16 at 10:40 a.m. and additional monitoring and auditing of the MAR's was necessary. MARs were monitored for pictures of residents and staff interview were conducted. Continued interview with the Administrator on 2/25/16 at 3:30 p.m. related to the facility' s QAA Committee, the Administrator was asked about the QAA Committee' s oversight of the facility' s compliance with the corporate policy entitled Medication Administration: General Guidelines, revised on 1/23/16. The policy indicated Patients/Residents are to be identified before medication is administered. When in doubt: Check photograph attached to the medical record. The Administrator acknowledged the pictures were to be on all MAR' s according to her decision following the administration of antihypertensive medication to the wrong resident on 10/14/15. The pictures had been moved from the previous months MAR books on 10/14/15 to the current MAR books and the QAA committee and Medical Director had recommended two (2) sets of pictures be available for each resident, one on each MAR book. The Administrator revealed the committee had not continued the process of monitoring this identified problem and acknowledged there were six (6) residents who did not have pictures available in the current MAR book. The Administrator revealed there had not been any errors resulting from lack of identification for these six (6) residents, and acknowledged if there had been any new nurses orienting and they were left unsupervised, this may have been a problem. The Administrator revealed the QAA committee with the Medical Director also recommended hiring a Clinical Competency Coordinator (CCC) as soon as possible and the position was filled on December 16, 2015. Based on the above, the facility' s QAA Committee failed to ensure the necessary monitoring of a plan of action, developed by the facility in response to an identified problem with the identification of residents by staff who are unfamiliar with them, when passing medication, to ensure the implementation of the newly developed intervention. The facility's failure to follow established policy and procedure for Medication Administration resulted in a significant medication error. The facility's failure to identify and report errors and adverse reactions as required by the Medication Discrepancy and Adverse Reaction Report Policy resulted in failure to provide continuing surveillance and identify potential educational needs related to medication issues by the Consultant Pharmacist and the Quality Assurance Committee. Interview conducted on 3/21/16 at 1:30 p.m. with the Administrator revealed there had been only one (1) identified medication error on 2/29/16. Resident #22 received [MEDICATION NAME] 0.5 mg by mouth (po) twice daily (BID) until 2/9/16 when the order was changed to [MEDICATION NAME] 0.5 mg po every day (QD). On 2/29/16 Nurse AA administered a second dose of [MEDICATION NAME] 0.5 mg to R#22 at 9:00 p.m. The Administrator revealed this had been identified as an error as the Director of Health service (DHS) had monitored the Controlled Drug Records the next day and an incident report was made, family and physician were notified and a Medication Discrepancy and Adverse Reaction form was completed according to corporate policy. These records were reviewed and found to be complete. R#22 was observed according to physician order [REDACTED]. The Quality Assurance Committee had not held a meeting but would be informed at the next meeting. Nurse AA had terminated her employment with the facility during a disciplinary discussion of the incident with the DHS. The facility implemented the following actions to remove the Immediate Jeopardy: 1.Education was provided to 34 nurses by the clinical competency coordinator and Registered Nurse supervisor on 2/19/16 regarding the general guidelines for medication administration including following physician orders, medication pass times, consistent and accurate documentation of medication and acceptance/refusal of medications, medication discrepancies, adverse medication reactions, accurate transcription of medication orders and identification of residents. Education content and sign in sheets were reviewed 2. Pictures of residents were audited on 2/25/16 and will be reviewed monthly and updated as needed 3. The clinical competency coordinator provided education to nurses regarding utilization of other staff members to assist with the identification process of residents as needed. 4. Nurses were in serviced by the clinical competency coordinator and registered nurse supervisor on 2/26/16 related to pain including observation and documentation of pain with routine pain medication administration, and observation of respiratory and sedation status with controlled substance pain medication administration. Education content and sign in sheets were reviewed . 5. nursing education was provided on 2/29/16 by the clinical competency coordinator and are in supervisor regarding errors, omissions and late entries. Education content and sign in sheets were reviewed. 6. DHS or RN supervisor will complete daily review of medication administration records for omissions. 7. RN supervisor will complete review of medication administration records monthly during change over to ensure pictures of residents are in place. 8. DHS or RN supervisor will monitor/observe med pass for 10% of nurses weekly for one month then monthly for three months was initiated on 2/25/16. 9. The pharmacy consultant will observe at least one random med pass monthly during her visit 10. All findings will be taken to the quality assurance performance improvement committee for action as needed 11. 34 nurses reviewed medication administration video from American Society of consultant pharmacists, which included oral medications, I met medications/inhalers/patches, and medications by [DEVICE] administration of medication was successful completion of posttests beginning 2/26/16 Education content and sign in sheets were reviewed 12. The director of health services or registered nurse supervisor will review medication administration records weekly to ensure that level of pain is being monitored. 13 Newly hired nurses will be in serviced by the clinical competency coordinator and mentor nurse on medication administration general guidelines including following physician orders, med pass times, consistent and accurate documentation of medication and acceptance/refusal of medications, medication discrepancies, adverse medication reactions, accurate transcription of medication orders, and identification of patients and will be required to complete the orientation skills checklists, medication administration video with posttest, and medication card orientation. Medication pass observation will also be completed with each newly hired nurse was successful completion. 14. Education was provided to 34 nurses completed on 2/29/16 by clinical competency coordinator, senior nurse consultant, and RN supervisor regarding medication discrepancy form and documentation regarding any discrepancy and reporting of discrepancy to physician and pharmacist. Education content and sign in sheets were reviewed 15. Charge nurses will review medication administration records and controlled substance reports at shift change for completion. On 03/21/16 an extended survey was conducted the sample was expanded by three residents (R#22, R#23, R#24) who were all receiving narcotic and antihypertensive medications. Clinical record reviews of physician orders, medication administration records, controlled drug records and observations revealed no further indication of deficient practice.

Based on clinical record review, staff interview, and review of established corporate policy and procedures, 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. The facility failed to ensure resident drug therapy was administered safely, accurately, and in accordance with physician's orders [REDACTED].#1 and #2) from a total survey sample of twenty-four (24) residents. Resident #1, with a physician order [REDACTED]., when he was transferred to an acute longterm care facility. Resident #2, who did not have an order for [REDACTED]. On February 25, 2016, a determination was made that a situation in which the facility's non-compliance with one or more of the requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Corporate Clinical Consultant, Director of Health Services (DHS) and Nursing Supervisor EE Registered Nurse (RN) were informed of the Immediate Jeopardy on February 25, 2016 at 5:00 p.m. The Immediate Jeopardy was identified to have existed on October 14, 2015, when the facility failed to ensure the accurate administration of medication to Resident #2. An allegation of jeopardy removal was received on February 26, 2016. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on March 1, 2016, and the facility remained out of compliance at the lower scope and severity of D while the process of evaluation of the nursing staffs' compliance with physicians orders, education, and facility policies and procedures, continued. In-service materials and records were reviewed, all medication administration records were reviewed for resident pictures. Interviews were conducted with nursing staff to ensure they were knowledgeable about the administration of resident medication. Findings include: Review of the Corporate policy entitled Medication Discrepancies and Adverse Reactions revealed medication discrepancies and adverse reactions are to be reported to the patient/residents attending physician, the consultant and provider pharmacists, and the Pharmaceutical Services Subcommittee and/or the Quality Assurance Committee. Review of Procedure, Section 5 indicated a Medication Discrepancy/Adverse Drug Reaction Report is to be completed. Section 8 revealed the report is to be reviewed by the consultant pharmacist and on a quarterly basis by the Pharmaceutical Services Subcommittee and/or the Quality Assurance Committee and acted upon as appropriate. In addition to reporting discrepancies that result in the patient receiving an incorrect medication, medication discrepancies that have the potential for but do not actually result in the patient receiving an incorrect medication are documented and reported. Review of the Corporate Policy entitled Medication Administration; General Guidelines, Procedure #7 revealed patients/residents are identified before medication is administered. Procedure #9 indicated that in no case should the individual who administered the medications report off duty without first recording the administration of any medications. Procedure #10 revealed medications are to be administered within 60 minutes before or after scheduled time. Procedure #11 revealed after medication administration the patient/residents MAR indicated [REDACTED]. Review of Lippincott Procedures- Pain management, provided by the administrator when a pain management policy was requested, revealed under subheading of Giving medications: [REDACTED]. Reassess pain in a timely manner according to the onset of the prescribed medication. Reassessment should include not only pain relief but also adverse reactions or events produced by treatment. Cross refer to F329 regarding the facility's failure to administer [MEDICATION NAME] according to the Corporate Policy entitled Medication Administration: General Guidelines Cross refer to F333 regarding the facility's failure to administer medication correctly to Resident #1 and Resident #2, according to physicians orders, and according to the Corporate Policy entitled Medication Administration General Guidelines. Cross refer to F 520 regarding the failure of the Facility's Quality Assurance Committee to adequately monitor a plan of action to ensure an accurate and easily accessible method for staff unfamiliar with the resident's names to identify them for safe medication administration. In an interview conducted on 2/18/16 at 5:15 p.m. with the facility Corporate Clinical Nurse Consultant revealed she had investigated the administration of [MEDICATION NAME] 20 mg SL twice within thirty (30) minutes to Resident #1 on 12/20/15, but did not think this was an error because he did not receive an extra dose. The Corporate Clinical Nurse Consultant acknowledged the Medication Administration: General Guidelines policy indicates medications are to be given within one hour before or after the scheduled dose and this medication was administered ninety minutes late, but she did not think this was an error. The Consultant acknowledged BB LPN had not signed for 2 doses of [MEDICATION NAME] on the MAR indicated [REDACTED]. The Corporate Clinical Consultant confirmed [MEDICATION NAME] administration to a debilitated resident with a [DIAGNOSES REDACTED]. She acknowledged the [MEDICATION NAME] 20 mg SL had been administered every 2 hours on 12/20/15 beginning at 9:30 p.m. until the resident was discovered in respiratory distress with an oxygen saturation of 55%, and the only assessment for the 7:00 p.m. to 7:00 a.m. shift appeared on the reverse side of the MAR indicated [REDACTED]. Interview with the Clinical Competency Coordinator (CCC) on 2/23/16 at 9:45 a.m. revealed when LPN BB LPN and LPN AA were oriented in October there was no CCC. The Minimum Data Set (MDS) Coordinator had to oversee staff education and orientation in addition to other assigned duties. She resigned in December, 2015. The CCC acknowledged the orientation of nurses has always consisted of a general orientation checklist, a skills checklist, computer learning modules, a medication test, and learning med pass with a preceptor. In an interview conducted on 2/24/16 at 3:00 p.m. with the Consultant Pharmacist, she revealed the Medication Discrepancy and Adverse Reaction reports were to review, track and trend medication errors and determine the need for interventions such as staff education. She acknowledged she had received a verbal report when Resident #2 received 2 antihypertensive medications and she had offered to observe a medication pass by LPN BB, but since BB was only in the building at night and on weekends she was not able to do this. The Consultant Pharmacist indicated she had also been made aware of Resident #1 receiving 2 doses of [MEDICATION NAME] within 30 minutes and his subsequent [MEDICAL CONDITION] the next morning and since he was admitted to the hospital she did not review any documentation for Resident #1. The Consultant Pharmacist acknowledged she had consulted for the facility since 2007 and had never received a completed Medication Discrepancy and Adverse Reaction Report. She confirmed these reports should be completed for any deviation from the Five Rights of Medication Administration, including right resident, right medication, right route, right time and right dose. Interview conducted on 2/25/16 at 3:30 p.m. with the Administrator revealed the administration of 2 antihypertensive medications ordered for Resident #4 and administered to Resident #2 on 10/14/15, was considered an error. The Medical Director had been notified and the error had been reported in the October QA meeting. The intervention of assuring pictures of all the residents were on the MAR's had already been initiated and this was supposed to be monitored monthly by the unit managers. The Administrator acknowledged that on observations on 2/19/16 at 2:10 p.m. and on 2/25/16 at 10:40 a.m., of the one hundred eight (108) MAR's in the facility, there were six (6) missing pictures. The administrator indicated the unit managers must not be checking the MAR's for pictures. Continued interview revealed that Medication Discrepancy and Adverse Reaction forms were not completed for Resident #1 after receiving 2 doses of [MEDICATION NAME] within 30 minutes, or receiving scheduled doses of [MEDICATION NAME] every 2 hours without assessment of respiratory status or level of consciousness, or for Resident #2 who was administered his room mates medications. The Administrator revealed she had verbally informed the Consultant Pharmacist and the QA Committee of these situations, but there was no record of this. The facility had not completed these reports for any medication error for an unknown length of time. On 03/21/16 an extended survey was conducted the sample was expanded by three residents (R#22, R#23, R#24) who were all receiving narcotic and antihypertensive medications. Clinical record reviews of physician orders, medication administration records, controlled drug records and observations revealed no further indication of deficient practice. Interview conducted on 3/21/16 at 1:30 p.m. with the Administrator revealed there had been only one (1) medication error on 2/29/16. Resident #22 received [MEDICATION NAME] 0.5 mg by mouth (po) twice daily (BID) until 2/9/16 when the order was changed to [MEDICATION NAME] 0.5 mg po every day (QD). On 2/29/16 Nurse AA administered a second dose of [MEDICATION NAME] 0.5 mg to R#22 at 9:00 p.m. The Administrator revealed this had been identified as an error as the Director of Health service (DHS) had monitored the Controlled Drug Records the next day and an incident report was made, family and physician were notified and a Medication Discrepancy and Adverse Reaction form was completed according to corporate policy. These records were reviewed and found to be complete. R#22 was observed according to physician order [REDACTED]. The Quality Assurance Committee had not held a meeting but would be informed at the next meeting. Nurse AA had terminated her employment with the facility during a disciplinary discussion of the incident with the DHS. The facility implemented the following actions to remove the Immediate Jeopardy: 1.Education was provided to 34 nurses by the clinical competency coordinator and Registered Nurse supervisor on 2/19/16 regarding the general guidelines for medication administration including following physician orders, medication pass times, consistent and accurate documentation of medication and acceptance/refusal of medications, medication discrepancies, adverse medication reactions, accurate transcription of medication orders and identification of residents. Education content and sign in sheets were reviewed 2. Pictures of residents were audited on 2/25/16 and will be reviewed monthly and updated as needed 3. The clinical competency coordinator provided education to nurses regarding utilization of other staff members to assist with the identification process of residents as needed. 4. Nurses were in serviced by the clinical competency coordinator and registered nurse supervisor on 2/26/16 related to pain including observation and documentation of pain with routine pain medication administration, and observation of respiratory and sedation status with controlled substance pain medication administration. Education content and sign in sheets were reviewed . 5. nursing education was provided on 2/29/16 by the clinical competency coordinator and are in supervisor regarding errors, omissions and late entries. Education content and sign in sheets were reviewed. 6. DHS or RN supervisor will complete daily review of medication administration records for omissions. 7. RN supervisor will complete review of medication administration records monthly during change over to ensure pictures of residents are in place. 8. DHS or RN supervisor will monitor/observe med pass for 10% of nurses weekly for one month then monthly for three months was initiated on 2/25/16. 9. The pharmacy consultant will observe at least one random med pass monthly during her visit 10. All findings will be taken to the quality assurance performance improvement committee for action as needed 11. 34 nurses reviewed medication administration video from American Society of consultant pharmacists, which included oral medications, I met medications/inhalers/patches, and medications by [DEVICE] administration of medication was successful completion of posttests beginning 2/26/16 Education content and sign in sheets were reviewed 12. The director of health services or registered nurse supervisor will review medication administration records weekly to ensure that level of pain is being monitored. 13 Newly hired nurses will be in serviced by the clinical competency coordinator and mentor nurse on medication administration general guidelines including following physician orders, med pass times, consistent and accurate documentation of medication and acceptance/refusal of medications, medication discrepancies, adverse medication reactions, accurate transcription of medication orders, and identification of patients and will be required to complete the orientation skills checklists, medication administration video with posttest, and medication card orientation. Medication pass observation will also be completed with each newly hired nurse was successful completion. 14. Education was provided to 34 nurses completed on 2/29/16 by clinical competency coordinator, senior nurse consultant, and RN supervisor regarding medication discrepancy form and documentation regarding any discrepancy and reporting of discrepancy to physician and pharmacist. Education content and sign in sheets were reviewed 15. Charge nurses will review medication administration records and controlled substance reports at shift change for completion.

Based on observations, facility and clinical record review, and staff interviews, the facility failed to ensure that two (2) residents (R#1, R#2) were free of significant medication errors, when licensed nursing staff failed to sign or initial when a medication was given on the Medication Administration Record (MAR) or Controlled Drug Record (CDR) which resulted in R#1 receiving the narcotic [MEDICATION NAME] two (2) times within thirty (30) minutes, and failed to ensure that licensed staff administering [MEDICATION NAME] assessed R#1 for pain level and/or respiratory status prior to continued administration of the narcotic which resulted in R#1 found in respiratory distress with an oxygen saturation of 55% and was transferred emergently to a hospital where he required mechanical ventilation; and the administration of Antihypertensive medications administered to R#2, who did not have a Physician's order for [MEDICATION NAME] or [MEDICATION NAME], received both medications in error. The sample size was twenty-four (24) residents. On February 25, 2016, a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Corporate Clinical Consultant, Director of Heath Services (DHS) and Nursing Supervisor EE Registered Nurse (RN) were informed of the Immediate Jeopardy on February 25, 2016 at 5:00 p.m. An allegation of jeopardy removal was received on February 26, 2016. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on March 1, 2016, and the facility remained out of compliance at the lower scope and severity of D while the process of evaluation of the nursing staffs' compliance with physicians orders, education, and facility policies and procedures, continued. In-service materials and records were reviewed, all medication administration records were reviewed for resident pictures. Interviews were conducted with nursing staff to ensure they were knowledgeable about the administration of resident medication. Cross reference to F281, F329, F490, and F514 Findings include: 1. Review of the clinical record for Resident #1 revealed he was flown to a landing strip in the area of the facility on 12/18/15 by Medivac Helicopter, then transferred to the facility by ambulance. He had been hospitalized for [REDACTED].). His [DIAGNOSES REDACTED]. He arrived with a Peripherally Inserted Central Catheter (PICC Line), a Percutaneous Endoscopic Gastrostomy (PEG) tube, a Foley Catheter, multiple pressure ulcers, a [MEDICAL CONDITION], paralysis in three extremities and minimal movement in the right upper extremity and could not speak. He used a communication board with numbers and letters to communicate. Continued review of the transfer record from the hospital revealed he had been diagnosed with [REDACTED]. Review of the Physician orders for R#1 revealed he had an admission order, dated 12/18/15 at 9:00 p.m., for [MEDICATION NAME] 20 milligrams (mg) per milliliter (ml) sublingual (SL) give 0.5 ml every four (4) hours. Another Physician order was received by the facility on 12/19/15 at 8:00 a.m. indicating that due to continued pain [MEDICATION NAME] 20 mg/ ml give 1 ml every 3 hours was to be administered. On 12/19/15 at 3:30 p.m. an order to increase the [MEDICATION NAME] to 20 mg / ml give 1 ml every 2 hours was received due to pain level eight of ten (8/10). Review of the Controlled Drug Record revealed that the [MEDICATION NAME] 20 mg /ml 1 ml SL was administered on 12/19/15 at 3:30 p.m., 5:30 p.m. by LPN AA. The next administrations were given by LPN BB and took place on 12/19/15 at 8:00 p.m., 10:00 p.m., on 12/20/15 at 12:00 a.m., 2:00 a.m., 4:30 a.m. and 7:00 a.m. LPN AA returned and administered the next dose of [MEDICATION NAME] at 7:30 a.m. Further review of the Controlled Drug Record revealed that on 12/20/15 at 5:30 p.m. and 7:30 p.m. [MEDICATION NAME] 20 mg/ ml, 1 ml q 2 hours was not administered, indicated as refused on the corresponding line. [MEDICATION NAME] was administered as scheduled on 12/20/15 at 9:30 p.m., 11:30 p.m., on 12/21/15 at 1:30 a.m., 3:30 p.m., and 5:30 a.m. Review of the reverse side of the Medication Administration Record dated 12/20/15 revealed that LPN BB had recorded R#1 could not be aroused at 7:30 p.m. and the [MEDICATION NAME] was held. There is no other documentation on the reverse side of the MAR for subsequent doses. Review of the Nurses Notes for R#1 dated 12/20/15 revealed no indication of an assessed pain level, blood pressure, pulse, oxygen saturation or efforts to provide tracheal suctioning for the 12/20/15 7:00 a.m. to 7:00 p.m. shift by LPN AA. The Nurses notes for that time period did reveal that due to omission of documentation of [MEDICATION NAME] administration by LPN BB for 4:30 a.m. and 7:00 a.m., a dose of [MEDICATION NAME] had been administered at 7:30 a.m. Further review of the Nurses Notes for 12/20/15 7:00 p.m. through 12/21/15 at 7:00 a.m. indicated that R#1 had refused suctioning at 10:00 p.m. and 2:00 a.m. There was no mention of his sedation level, pain level, for the twelve (12) hour night shift or R#1 respiratory status after 2:00 a.m. A pulse oximeter reading was recorded at 2:00 a.m. revealing an oxygen saturation of 90 %. At 5:55 a.m. the resident's physician was notified that he had been found in respiratory distress with an oxygen saturation of 55 %, had been suctioned, oxygen setting increased, a nebulized breathing treatment administered, and the oxygen saturation was 63%. EMS was called, and transported R#1 to the hospital where he was emergently placed on mechanical ventilation and admitted to Intensive Care Unit. Review of the EMS Patient Care Report dated 12/21/15 revealed that R#1 had been administered [MEDICATION NAME] 0.5 mg intravenous (IV) at 6:41 a.m. with rapid response of increased level of consciousness, increased level of oxygenation, increased rate of respirations and increased pupil size. Review of the Corporate policy entitled Medication Administration: General Guidelines, Procedure, revealed the following: #10, Medications are to be administered within sixty (60) minutes before or after scheduled time. #11, After medication administration the residents MAR is initialed by the person administering the medication. #19, Signal stickers that denote important information regarding the medications are used to assist in accurate medication administration 2. Record review for Resident #2 revealed an Annual Minimum Data Set (MDS) assessment having an Assessment Reference Date of 12/11/15 which documented Section I -Active [DIAGNOSES REDACTED].#2 was extensive assist of one (1) person with Activities of Daily Living (ADLs). In comparison, review of the medical record for the roommate of R#2 revealed a Quarterly MDS assessment having an Assessment Reference Date of 12/21/15 which documented Section I -Active [DIAGNOSES REDACTED]. A Nurse's Notes (NN) entry for R#2 dated 10/14/15 with no time listed documented that the resident was in bed this a.m. and was given meds that were for another resident by trainee. Resident was given [MEDICATION NAME] 30 mg and [MEDICATION NAME] 100 mg. Vitals are 136/58, 57, 96.8 and no signs of acute distress. Doctor made aware. A NN entry dated 10/14/15 at 7:10 a.m. documented Resident now starting to fall in Blood Pressure (B/P) and becoming unresponsive. Called 911, placed in bed in Trendelenburg. B/P now 64/38. Resident fading in and out of responsiveness. Very drowsy and not answering staff. Placed on oxygen (O2) at 2 liters (L) per minute via mask. Eyes are open. 68/50 manual B/P. Awaiting ambulance. Further review of a NN entry dated 10/14/15 at 7:20 a.m. documented Resident out by ambulance to Hutcheson Medical Center. Responsible party (RP) aware. MD made aware of resident being sent out. The facility presented an Investigation Report (IR) related to the facility's investigation into R#2's significant medication error involving the antihypertensive medications given to the wrong resident. In this IR, the facility documented that, based on its investigation, it was found that on 10/14/15 R#2 had received antihypertensive medications during the 6:00 a.m. med pass that were prescribed for the roommate. The residents ' roommate reported the medication error to a Certified Nursing Assistant (CNA) who reported it to the Charge Nurse. A hospital History and Physical (H&P) report for R#2 documented the resident's 10/14/15 admission to the hospital. This H&P documented, in the History of Present Illness section, R#2 presented to the hospital with complaints of [MEDICAL CONDITION]. The patient is currently a resident of Shepherd Hill Nursing Home and was given the medications of another resident by accident, resulting in accidental overdose. The patient was given 100 mg of [MEDICATION NAME] and 30 mg of [MEDICATION NAME] by mistake and his blood pressure went down into the 50's and 60's systolic. The patient was transferred to the emergency department where Poison Control was called and they recommended IV fluid resuscitation with close monitoring of blood pressure in ICU. There is no antidote required or recommended by Poison Control and he was transferred up the ICU for further monitoring, on presentation to the ICU his blood pressure is 90/64 and he is alert and responsive without any focal neurologic deficits. The medication error occurred about 6:00 a.m. and his medicines were given by a nurse who was new to the facility and undergoing orientation. Past Medical History documented Dementia, Hypertension and History of [MEDICAL CONDITION]. Assessment documented Accidental overdose with antihypertensive medications including [MEDICATION NAME] and [MEDICATION NAME], Severe [MEDICAL CONDITION], Dementia, and History of Hypertension and [MEDICAL CONDITION]. Review of the Cardiologist Progress Note dated 10/15/15 documented Demand Ischemia with minimal Left Ventricle damage. Review of the hospital Discharge Summary for R#2 documented a hospital discharge date of [DATE]. The Discharge [DIAGNOSES REDACTED]. Review of the Incident Report for the medication error that occurred on October 14, 2015 revealed the roommate reported to the Certified Nursing Assistant (CNA) that R#2 had been given 6:00 a.m. medications that were meant for him. Interview with the former roommate of R#2 on 2/18/16 at 4:20 p.m. revealed that he remembered very clearly the day R#2 received his blood pressure medications. He said he woke up to to the sounds of his roommate receiving medication and knew he received medication at that time of day and his roommate did not. He revealed he was scared and told the CNA right away to get help for his roommate. He said the nurses checked on his roommate and then a little while later sent him to the hospital. Interview with the Administrator on 2/19/16 at 6:30 p.m. revealed that an inservice was conducted when this medication error was discovered and she had both nurses in her office and wrote up the nurse that was training the new nurse because she was sitting at the nurse's station leaving the new nurse to administer medications alone. Interview with the Administrator on 2/22/16 at 1:00 p.m., she acknowledged that the supervising nurse had left LPN BB unattended to administer medications and that BB did not know the residents. She further acknowledged that pictures of the residents were always on the MARs but had been recently updated. Review of the facility policy: Medication Administration: General Guidelines, revised 1/23/2015 and reviewed 1/26/2016, revealed: Policy Statement: 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 familiarized themselves with the medication. Procedure: (2) Medications are administered in accordance with written orders of the attending physician. If a dose seems excessive considering the patient/resident's current [DIAGNOSES REDACTED]. This interaction with the physician is documented in the nursing notes and elsewhere in the medical record as appropriate. Procedure: (7) Patients/residents are identified before medication is administered. When in doubt: (a) Check identification band (b) Check photograph attached to medical record. (c) Call patient/resident by name. (d) If necessary, verify patient/resident identification with other healthcare center personnel. Procedure: (14) Medications supplied for one patient/resident are never administered to another patient/resident. Review of the Lexi-Comp's Drug Reference Handbook 12th Edition, revealed on page. 1100 [MEDICATION NAME], a Calcium Channel Blocker, used for treatment of [REDACTED]. Contraindications; Serious adverse events ([MEDICAL CONDITION] ischemia, [MEDICAL CONDITION], heart block, stroke, sinus arrest, severe [MEDICAL CONDITION], acute [MEDICAL CONDITION] infarction, and EKG changes) have been reported in relation to each use. Blood pressure lowering should be done at a rate appropriate for the patient's condition. Rapid drops in blood pressure can lead to arterial insufficiency. Increased [MEDICAL CONDITION] and/or MI has occurred with initiation or dosage titration of calcium channel blockers. Hypersensitivities to [MEDICATION NAME] ([MEDICATION NAME]) or any component of the formulation, immediate release preparation for treatment of [REDACTED]. Warnings/Precautions: The use of sublingual short-acting [MEDICATION NAME] in hypertensive emergencies and pseudoemergencies is neither safe nor effective and should be abandoned! Severe [MEDICAL CONDITION] may occur in patients taking immediate release nifepine concurrently with beta blockers when undergoing CABG with high dose [MEDICATION NAME] anesthesia. page. 1311 [MEDICATION NAME], a Beta-Blocker, used for management of Hypertension, [MEDICAL CONDITION] Pectoris, [DIAGNOSES REDACTED]s, arrhythmias, and prevention of [MEDICAL CONDITION] Infarction. Contraindications: Hypersensitivity to [MEDICATION NAME], beta-blockers, or any component of the formulation; uncompensated [MEDICAL CONDITION]. Warnings/Precautions: Administer cautiously in compensated heart failure, and monitor for worsening of the condition (U.S. Boxed Warning): Beta-block therapy should not be withdrawn abruptly (particularly in patients with CAD), but gradually tapered (over 2 weeks) to avoid acute [MEDICAL CONDITION] hypertension, and/or ischemia, pgs 739-740 [MEDICATION NAME], Used for management of moderate to severe Hypertension, [MEDICAL CONDITION], Warning/Precautions: Use with caution in CAD(increase in [MEDICAL CONDITION] increase [MEDICAL CONDITION] Oxygen Demand), Use in caution with [MEDICAL CONDITION] Hypertension (may cause [MEDICAL CONDITION]) and , pgs 739-740 [MEDICATION NAME], Used for management of moderate to severe Hypertension, [MEDICAL CONDITION], Warning/Precautions: Use with caution in CAD(increase in [MEDICAL CONDITION] increase [MEDICAL CONDITION] Oxygen Demand), Use in caution with [MEDICAL CONDITION] Hypertension (may cause [MEDICAL CONDITION]) Observations conducted on February 19, 2016 of the MARs located on the medication carts revealed six (6) resident pictures were not available on the MARs. On February 25, 2016 the same 6 resident pictures remained missing. Interview with the Administrator on 2/22/16 at 2:30 p.m. revealed that the supervising nurse had left LPN BB unattended. The Administrator further revealed that BB did not know the residents and gave the 6:00 a.m. doses belonging to the roommate to R#2 by accident. She further revealed that pictures of the residents are to identify the residents. Interview conducted on 2/23/16 at 10:00 a.m. with LPN HH , who was the nurse supervising LPN BB on October 14, 2015 when R#2 received the wrong medications revealed that she thought BB had been working with the residents long enough to know who they were. LPN HH further revealed that she was at the medication cart when the medications were prepared and also acknowledged that there were no pictures of these two residents on the MARs. In an Interview conducted on 2/24/16 at 10:00 a.m. with the Administrator revealed that the next day when she was made aware of the medication error she had both the trainee and the nurse training her in the office and verbally reprimanded both of them, she further acknowledged that the Medical Director was made aware and recommended pictures identifying residents placed on all MARs, and a revamp of the orientation process for nurses required to administer medications. Observations conducted on February 19, 2016 at 2:10 p.m. revealed four (4) residents on the North Hall and two (2) residents on the South Hall did not have pictures identifying the residents. Subsequent observations conducted on February 25, 2016 at 10:40 a.m. of the books containing the MARs revealed six (6) residents did not have pictures to identify them. 1. Interview on 2/18/16 at 5:15 p.m. with the Corporate Clinical Consultant revealed on 12/20/15 Resident #1 received 2 doses of [MEDICATION NAME] 30 minutes apart, at 7:00 a.m. and 7:30 a.m., resulting from an omission of documentation for the 7:00 a.m. administration. The Consultant indicated this was investigated by pouring out the [MEDICATION NAME] and measuring it and determining after Nurse BB had signed out the previously undocumented doses that no [MEDICATION NAME] was missing and no extra administrations had occurred. The Consultant acknowledged that this concluded the investigation and that despite the low level of tolerance for a timing discrepancy with [MEDICATION NAME], with the resulting administration 30 minutes beyond what the corporate policy allowed, with the resident history of Chronic [MEDICAL CONDITION], and with the weight of 110 lbs. and general debility placing the resident at higher risk of adverse reaction, this was not considered a medication error. The five (5) doses of [MEDICATION NAME] that occurred on 12/20/15 beginning at 9:30 p.m. through 12/21/15 at 5:30 a.m., without assessment of pain level for 24 hours, no record of oxygen saturation after 2:00 a.m. and with 2 doses at 5:30 p.m. and 7:30 p.m. held due to sedation witnessed by 2 additional nurses, that were charted as refused, and the residents subsequent respiratory depression less than 30 minutes after the last dose, were also not identified as an error. Interview on 2/19/16 at 10:35 a.m. with LPN AA revealed she had administered scheduled [MEDICATION NAME] 20 mg 1 ml SL at 7:30 a.m. and left 2 spaces for the 7:00 p.m. to 7 a.m. LPN BB to fill in. She acknowledged the MAR was not decipherable, due to her errors in scheduling and recording doses on the wrong time and date, circling doses that had actually been administered and crossing out her initials to attempt to correct errors. She acknowledged she had not questioned LPN BB until 7:00 p.m. about the missing documentation on the MAR and Controlled Drug Record and she should have reported this to the supervisor immediately before administering the 7:30 a.m. dose. LPN AA revealed she had received no mention in report of LPN BBs administration of [MEDICATION NAME] at 7:00 a.m. when it was scheduled for 5:30 a.m., 30 minutes outside the one hour allowed by policy, and there was no flag on the MAR or any other indication this had been administered late. LPN AA revealed at 5:30 p.m. when it was time to administer a scheduled dose of [MEDICATION NAME] she had indicated on the back of the Controlled Drug record that the resident had refused [MEDICATION NAME]. She had called the Registered Nurse (RN) Supervisor EE from the North Hall and the resident had been evaluated as being too sedated to receive the [MEDICATION NAME]. The resident did not actually not respond to her when she asked if he was going to take his pain medication or the level of his pain. She acknowledged she should have recorded an oxygen saturation, blood pressure, pulse, pain level and level of sedation for this 12 hour shift. She acknowledged she should have recorded the [MEDICATION NAME] was held for sedation and not recorded that it was refused. Interview on 2/19/16 at 11:55 a.m. with LPN BB revealed that she had not signed the MAR or Controlled Drug Record for two administrations of [MEDICATION NAME] to R#1 scheduled at 3:30 a.m. and 5:30 a.m. and given late at 4:30 a.m. and 7:00 a.m. and she had not communicated this to LPN AA . LPN AA further revealed that she should have signed and initialed the medication as well as reported and flagged the MAR with the information. BB acknowledged this failure resulted in R#1 receiving 2 doses of [MEDICATION NAME] within 30 minutes and for a Resident with Chronic [MEDICAL CONDITION], this resulted in a high likelihood of an adverse reaction. LPN BB revealed she had recorded holding the [MEDICATION NAME] at 7:30 p.m. as refused on the Controlled Drug Record and on the back of the MAR as held because she and LPN AA and Supervisor EE had not been able to arouse the resident. BB revealed that she could not remember why she wrote refused, and could not remember if the resident had actually responded to refuse the suctioning at 10:00 p.m. or 2:00 a.m., or if he just did not respond at all. Continued interview revealed that she did remember R#1 had been sedated and comprehending less throughout the shift. LPN BB acknowledged that she had not assessed a pain level, or assessed respiratory status throughout the 12/20/15 7:00 p.m. to 12/21/15 7:00 a.m. shift and she did not check oxygen saturation after 2:00 a.m. when it was 90%. She revealed she should have evaluated this resident for respiratory depression and she had not performed these assessments. LPN BB acknowledged she gave the [MEDICATION NAME] every 2 hours because it was ordered to be given every 2 hours. Interview with the parent and responsible party for R#1 on 2/19/16 at 2:00 p.m. revealed that his son had communicated to him using his letter board, during his most recent hospitalization , he had awakened during his last night at the facility, with medication being administered in his mouth, with no one explaining what they were doing or what the medication was. He did not remember anything after that. Interview on 2/22/16 at 1:00 p.m. with the Administrator revealed she had discussed with the Medical Director, who was also R#1's Physician, the order changes for [MEDICATION NAME], the administration of two doses within 30 minutes, and the hospitalization of R#1 for respiratory distress and the Medical Director responded by saying the only thing he could have done differently would have been to add to the [MEDICATION NAME] order to hold for sedation, but he thought that was standard nursing practice. Interview on 2/23/16 at 1:30 p.m. with the Physician of R#1, revealed that he had changed the order for [MEDICATION NAME] twice because the resident continued to complain of pain. He had been made aware of the administration of two doses of [MEDICATION NAME] within 30 minutes on 12/20/15, but this was not discovered until 12 hours after the administrations and because [MEDICATION NAME] is metabolized so rapidly this would not have caused the residents respiratory distress 24 hours later. The Medical Director acknowledged he expected any nurse administering [MEDICATION NAME] to assess the resident's respiratory status and to check for any adverse reactions with every administration whether it was scheduled or as needed (prn). Review of corporate policy entitled Pain Management, Lippincott Procedures, indicated that safe medication practices should be followed when administering strong opioid medications such as [MEDICATION NAME]. Pain and adverse reactions produced by treatment should be assessed in a timely manner according to the onset of the prescribed medication. Review of Nursing Drug Guide, Nursing 2014, Drug Handbook, by Lippincott, Williams and Wilkins, 34th edition, Copyright 2014, page 953, [MEDICATION NAME], Adverse reactions include Apnea, Respiratory Arrest and Respiratory Depression. The onset of [MEDICATION NAME] administered by oral route is takes place in 30 minutes, peak action in 1-2 hours and duration of action is 4-12 hours. Based on the above findings the facility failed to administer [MEDICATION NAME], a drug capable of producing Respiratory Depression, with in the scheduled times, for a debilitated and underweight resident with a [DIAGNOSES REDACTED]. On 03/21/16 a partial extended survey was conducted the sample was expanded by three residents (R#22, R#23, R#24) who were all receiving narcotic and antihypertensive medications. Clinical record reviews of physician orders, medication administration records, controlled drug records and observations revealed no further indication of deficient practice. Interview on 3/21/16 at 6:00 p.m. with the Director of Health Services (DHS) revealed all nurses are to monitor the MAR's for pictures and unsigned medications on the MAR's. The unit managers are also monitoring daily and the DHS monitors at least once weekly and checks the Controlled Drug Records against the MAR's, physician orders and checks assessments when narcotic or sedating medication is administered. He further revealed he has not found any non-compliance. Medication pass is observed weekly for three (3) nurses, and the consultant pharmacist observes medpass monthly. The facility implemented the following actions to remove the Immediate Jeopardy: 1.Education was provided to 34 nurses by the clinical competency coordinator and Registered Nurse supervisor on 2/19/16 regarding the general guidelines for medication administration including following physician orders, medication pass times, consistent and accurate documentation of medication and acceptance/refusal of medications, medication discrepancies, adverse medication reactions, accurate transcription of medication orders and identification of residents. Education content and sign in sheets were reviewed 2. Pictures of residents were audited on 2/25/16 and will be reviewed monthly and updated as needed 3. The clinical competency coordinator provided education to nurses regarding utilization of other staff members to assist with the identification process of residents as needed. 4. Nurses were in serviced by the clinical competency coordinator and registered nurse supervisor on 2/26/16 related to pain including observation and documentation of pain with routine pain medication administration, and observation of respiratory and sedation status with controlled substance pain medication administration. Education content and sign in sheets were reviewed . 5. nursing education was provided on 2/29/16 by the clinical competency coordinator and are in supervisor regarding errors, omissions and late entries. Education content and sign in sheets were reviewed. 6. DHS or RN supervisor will complete daily review of medication administration records for omissions. 7. RN supervisor will complete review of medication administration records monthly during change over to ensure pictures of residents are in place. 8. DHS or RN supervisor will monitor/observe med pass for 10% of nurses weekly for one month then monthly for three months was initiated on 2/25/16. 9. The pharmacy consultant will observe at least one random med pass monthly during her visit 10. All findings will be taken to the quality assurance performance improvement committee for action as needed 11. 34 nurses reviewed medication administration video from American Society of consultant pharmacists, which included oral medications, I met medications/inhalers/patches, and medications by [DEVICE] administration of medication was successful completion of posttests beginning 2/26/16 Education content and sign in sheets were reviewed 12. The director of health services or registered nurse supervisor will review medication administration records weekly to ensure that level of pain is being monitored. 13 Newly hired nurses will be in serviced by the clinical competency coordinator and mentor nurse on medication administration general guidelines including following physician orders, med pass times, consistent and accurate documentation of medication and acceptance/refusal of medications, medication discrepancies, adverse medication reactions, accurate transcription of medication orders, and identification of patients and will be required to complete the orientation skills checklists, medication administration video with posttest, and medication card orientation. Medication pass observation will also be completed with each newly hired nurse was successful completion. 14. Education was provided to 34 nurses completed on 2/29/16 by clinical competency coordinator, senior nurse consultant, and RN supervisor regarding medication discrepancy form and documentation regarding any discrepancy and reporting of discrepancy to physician and pharmacist. Education content and sign in sheets were reviewed 15. Charge nurses will review medication administration records and controlled substance reports at shift change for completion.

Based on record review, staff, physician, family and Emergency Medical Services (EMS) interview, the facility failed to ensure monitoring of respiratory status and pain level to ensure the safe administration of [MEDICATION NAME] twenty (20) milligrams (mg) sublingual (SL) every (q) two (2) hours in accordance with Physician orders, for one (1) resident (R#1) from a total survey sample of twenty-four (24) residents. The facility census was 107. On February 25, 2016, a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Corporate Clinical Consultant, Director of Heath Services (DHS) and Nursing Supervisor EE Registered Nurse (RN) were informed of the Immediate Jeopardy on February 25, 2016 at 5:00 p.m. An allegation of jeopardy removal was received on February 26, 2016. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on March 1, 2016, and the facility remained out of compliance at the lower scope and severity of D while the process of evaluation of the nursing staffs' compliance with physicians orders, education, and facility policies and procedures, continued. In-service materials and records were reviewed, all medication administration records were reviewed for resident pictures. Interviews were conducted with nursing staff to ensure they were knowledgeable about the administration of resident medication. Findings include: Record review for Resident #1 revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Neurological Involvement. He was chronically ill with a tracheotomy, Foley catheter, crustaceous endoscopies gastronomy (PEG) tube, peripherally inserted central catheter (PICC) line, and multiple pressure ulcers. He was completely paralyzed in three extremities and had minimal movement in the right upper extremity. He was unable to speak and used a communication board to point to letters. He weighed one hundred ten (110) pounds (lbs). He required humidified oxygen at 5 Liters [MEDICAL CONDITION], mobilized breathing treatments and tracheal suctioning. He was able to perform his own oropharyngeal suctioning by [MEDICATION NAME] suction catheter. On admission his oxygen saturation was ninety six percent (96%). Review of transferring hospital records revealed an order for [REDACTED]. Additional review of transfer records revealed R#1 had completed a course of [MEDICATION NAME] for [MEDICAL CONDITION] and Pseudomonas Pneumonia. Review of facility admission orders [REDACTED]. Review of the Admission Nurses Notes, date 12/18/15 at 10:30 p.m., revealed R#1 had been transferred from out of state by a Medivac flight and had required the administration of [MEDICATION NAME] 100 mg IV for pain and a nebulized respiratory treatment enroute. Nurse's notes on 12/19/15 at 8:20 a.m., written by the night shift nurse, indicated the resident did not experience sufficient pain relief with the admission order of [MEDICATION NAME] 10 mg SL q 4 hours, the physician was notified on 12/19/15 at 8:00 a.m., and the order was changed to [MEDICATION NAME] 20 mg/1 ml give 1 ml SL every three (3) hours. R#1 continued to experience pain after administrations of [MEDICATION NAME] 20 mg every 3 hours and the physician increased the frequency of routine scheduled [MEDICATION NAME] 20 mg SL to every two (2) hours on 12/19/15 at 3:30 p.m. There was one pulse oximeter oxygen saturation of 93%, recorded at 3:30 p.m. on 12/19/15 and one recorded pain level of eight (8). He had allowed suctioning four times. Review of the Nurses Note on 12/20/15 at 1:30 a.m. revealed the resident denied pain and allowed suctioning and [MEDICAL CONDITION] care as ordered. The next entry at 8:05 p.m. by the day shift nurse Licensed Practical Nurse (LPN) AA revealed that the resident had experienced a fever of 102, was congested, and had received [MEDICATION NAME] 20 mg SL at 7:00 a.m. and again at 7:30 a.m. due to a documentation omission by the prior shift. He had allowed suctioning and [MEDICAL CONDITION] care as ordered. The physician had been notified of the fever and gave orders for lab work. The fever had lowered to 99.9 at 6:00 p.m. No further vital signs except for temperature were recorded for the 7:00 a.m. to 7:00 p.m. shift and no pain scale or oxygen saturation were recorded. The facility had not assessed pain level, blood pressure, pulse, or oxygen saturation levels for R#1. The physician was notified of the medication error on 12/20/15 at 8:00 p.m. and gave orders for vital signs to be checked every hour until midnight. Review of the Controlled Drug Record revealed R#1 received [MEDICATION NAME] 20 mg SL on 12/20/15 at 7:00 a.m. and again at 7:30 a.m. He then received [MEDICATION NAME] 20 mg SL every 2 hours until 3:30 p.m. as scheduled. [MEDICATION NAME] was not administered on 12/20/15 at 5:30 p.m. and 7:30 p.m. The Controlled Drug Record has these doses listed as refused. The reverse side of the Medication Administration Record (MAR) indicated the 5:30 p.m. dose was refused and this was signed by LPN AA . Continued review of the reverse side of the MAR revealed an entry by LPN BB that she had not been able to administer the 7:30 p.m. dose of [MEDICATION NAME] because she could not arouse R#1. LPN BB also recorded on the MAR that R#1 had refused suctioning on 12/20/15 at 10:00 p.m. and on 12/21/15 at 2:00 a.m. Review of the Nurses Notes for 12/21/15 at 2:00 a.m. records the following vital signs in the date and time margin: 10:00 p.m. - 11:00 p.m. : 60, 18, 90/50 11:00 p.m. - 12:00 p.m. : 61, 16, 92/60, 93% Review of the Nurses Note recorded by LPN BB dated 12/21/15 at 2:00 a.m. indicated the vital signs at 2:00 a.m. was 97.1, 75, 17, 91/53 and an oxygen saturation of 90%. This Nurses Note indicated the resident had refused suctioning twice during the shift, but had been suctioned orally via [MEDICATION NAME] suction. No assessments were recorded for level of pain, congestion or general respiratory status, or level of sedation for the shift, or oxygen saturation after 2:00 a.m. The Controlled Drug Record indicated the resident was administered [MEDICATION NAME] 20 mg SL on 12/20/15 at 9:30 p.m., and 11:30 p.m. and on 12/21/15 at 1:30 a.m., 3:30 a.m. and 5:30 a.m. Review of the Nurses Progress Notes dated 12/21/15 on the Situation Background Assessment Request (SBAR), with no time recorded, LPN CC recorded being called to the residents room due to low oxygen level of 55%. The physician had been notified at 5:55 a.m., ordered transfer to hospital and the EMS system arrived for transport at 6:30 a.m. The resident had responded to suctioning, breathing treatment and an increase in the oxygen setting, with an oxygen saturation of 63%. Review of EMS Patient Care Report 12/21/15 at 6:25 a.m. revealed the following: Upon initial arrival he seemed very sleepy and had pinpoint pupils. The report revealed once in the ambulance he was deep suctioned and large amounts of mucous and emesis resulted. Respiratory rate was eight (8) and shallow, and 15 liters of oxygen was applied by mask over trach. [MEDICATION NAME] 0.5 mg was administered after intravenous (IV) access was obtained and the resident responded with an increase in respirations to an acceptable rate and volume and his pupils became less constricted. The transport was upgraded to urgent after airway findings and arrived at destination hospital at 7:32 a.m. Review of Emergency Department clinical record 12/21/15 from 7:43 a.m. through 11:15 a.m. revealed on arrival was alert, with emesis and mucous on gown, skin and dressings on arrival. His level of consciousness diminished and at 9:30 a.m. was placed on mechanical ventilation. The Emergency Department Physician charted greater than 35 minutes critical care. ICU admission [DIAGNOSES REDACTED]. The facility increased the dosage and scheduling of [MEDICATION NAME] as ordered by the Physician, but failed to assess the residents pain level and respiratory status, and administered the [MEDICATION NAME] without regard to the level of sedation for the doses administered on December 20, 2015 at 9:30 p.m., 11:30 p.m. and on December 21, 2015 at 1:30 a.m., 3:30 a.m. and 5:30 a.m. R#1 was discovered in respiratory distress on December 21, 2015 at 5:50 a.m. and was transferred to the hospital, admitted to the Intensive Care Unit, and remained hospitalized until February 4, 2016. The facility' s failure to monitor the resident's level of consciousness, respiratory status and pain level resulted in a situation which the facility ' s non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. In an interview on 2/18/16 at 5:15 p.m. with the Corporate Clinical Consultant revealed the facility did not administer [MEDICATION NAME] by IV route, so the attending physician had changed the order to a corresponding oral dosage. The facility did not consider the administration of [MEDICATION NAME] 20 mg SL on 12/20/15 at 7:00 a.m. by LPN BB and at 7:30 a.m. by LPN AA due to the omission of documentation by LPN BB, an error because after pouring the medication out and measuring what remained, there was no [MEDICATION NAME] missing. The Consultant then acknowledged there was a dose unaccounted for on 12/19/15 between 6:00 a.m. and 8:00 a.m. and said this was not an error either. She revealed that the 2 administrations within 30 minutes had been reported to the physician twelve (12)hours later, when discovered, and the physician said the resident would have had a problem within an hour, by 8:30 a.m. and so this was not considered to have caused a problem the next day when he was found in respiratory distress. The Consultant acknowledged there were no assessments of pain on the Nurses Notes, or anywhere on the chart for twenty four (24) hours prior to being discovered in respiratory distress. She also acknowledged the [MEDICATION NAME] had been held at 7:30 p.m. on 12/20/15, because he could not be aroused, but no mention of his level of consciousness except refusal of suctioning at 10:00 p.m. and 2:00 a.m. can be found in the nurses notes for that shift. LPN BB had charted on the Controlled Drug Record the resident had refused [MEDICATION NAME] at 7:30 p.m. on 12/20/15 and, on the back of the MAR, had charted for the same time that he could not be aroused. The Consultant explained R#1 had refused suctioning twice during the night of 12/20/15 through the a.m., but was unable to explain that since, with the [MEDICATION NAME] at 7:30 pm being held because he could not be aroused, but was charted as a refusal on the Controlled Drug Record by LPN BB , if this could have been the reason the suctioning was charted as refused, when the resident may have not responded to the request to suction due to sedation. The Consultant acknowledged that asking a resident for a level of pain would be an appropriate method to determine level of sedation and mentation, as well as pain. Interview on 2/19/16 at 10:35 a.m. with LPN AA revealed she works every weekend from 7:00 a.m. to 7:00 p.m. She remembered this resident. She acknowledged she had called the physician on 12/19/15 at 8:00 am, for the residents' complaints of no pain relief from [MEDICATION NAME] 20 mg/ml 0.5 ml q 4 hours, and received an order to increase the dose to [MEDICATION NAME] 20 mg/ml give 1 ml q 3 hours. Then she called the physician again at 3:30 p.m. because the resident still complained of pain and the physician increased the frequency to [MEDICATION NAME] 20 mg /ml give 1 ml q 2 hours. She acknowledged the next morning on 12/20/15 at 7:30 a.m. she administered a dose of [MEDICATION NAME] in accordance with the physicians order at the scheduled time of 7:30 a.m. and the nurse working the prior shift, LPN BB had not documented her last 2 scheduled administrations of the [MEDICATION NAME] due at 3:30 a.m. and 5:30 a.m. and she left her spaces to document. LPN AA discovered at 7:30 p.m. when LPN BB returned and filled in the missing documentation that LPN BB had administered [MEDICATION NAME] 20 mg/ml 1 ml at 7:00 p.m. LPN AA knew this was an error to give this [MEDICATION NAME] with only 30 minutes between doses and called the physician and family. LPN AA acknowledged the narcotic count was performed on 12/20/15 at 7:00 a.m. but the liquid was clear and difficult to see and she and LPN BB had both signed the count was correct, but with 2 doses not accounted for it could not have been correct. Continued interview revealed that the physician had told her since this had happened twelve hours previously the effects would have caused a problem within an hour after the administrations and she conveyed this information to the family when she notified them. LPN AA indicated she should have called the supervisor prior to administering the [MEDICATION NAME] at 7:30 a.m. and reported the missing documentation. She revealed on the controlled drug record at 5:30 p.m. she had indicated the resident had refused [MEDICATION NAME] but he was actually sedated and she had not indicated this on the back of the MAR as she should have or in the Nurses Notes. She revealed she had not recorded a pain level or mental status, level of sedation, and blood pressure, pulse or respiratory rate or oxygen saturation at all and could not remember what she had assessed except the congestion in his lungs and temperature. She acknowledged these assessments were of importance when a debilitated resident with [MEDICAL CONDITION] was receiving [MEDICATION NAME] every 2 hours. LPN AA had requested the assistance of the 7:00 am to 7:00 p.m. Registered Nurse Supervisor EE from the North Hall to assist her in determining whether it was safe to administer [MEDICATION NAME] to R#1 at 5:30 p.m. and it was determined the scheduled [MEDICATION NAME] should be held due to sedation. LPN AA revealed she should have indicated holding this [MEDICATION NAME] on the reverse side of the MAR but did not record this anywhere except as refused on the Controlled Drug Record. LPN AA then revealed at 7:30 p.m. she requested further assistance when she entered the room of R#1 with the oncoming nurse BB when the next [MEDICATION NAME] was due, and discovered Resident #1 was still sedated. Supervisor EE , LPN AA and LPN BB decided to hold this dose of [MEDICATION NAME] as well. Supervisor EE then gave education to the nursing staff regarding the importance of using nursing judgement when administering medication, and assessing oxygenation with opiates like [MEDICATION NAME]. Interview on 2/19/16 at 11:55 a.m. with LPN BB revealed that she remembered not signing the MAR or Controlled Drug Record for [MEDICATION NAME] 20 mg /ml one ml to be administered to R#1 on 12/20/15 at 3:30 a.m. and 5:30 a.m., but actually administered at 4:30 a.m. and 7:00 a.m. LPN BB was unable to remember why these doses were administered late. She acknowledged that omitting this documentation had resulted in 2 doses of [MEDICATION NAME] being administered within 30 minutes and this was an error and could have caused R#1 oversedation and respiratory depression. She acknowledged she had not assessed the resident's pain level throughout the 12/20/15 7 p.m. to 7:00 a.m. shift and had administered the [MEDICATION NAME] at 9:30 p.m., 11:30 p.m., 1:30 a.m., 3:30 a.m. and 5:30 a.m. because it was ordered to be given on that schedule. LPN BB revealed she could not remember if the resident actually responded to her request to suction him or just did not answer her at 10:00 p.m. and 2:00 a.m. LPN BB confirmed she had not obtained an oxygen saturation after 2:00 a.m. when it was 90% and she did not know why she did not check the oxygen level after a low reading. BB remembered the resident had been sedated and comprehending less throughout the entire shift. She could not explain why she had recorded on the Controlled Drug Record that R#1 had refused the 7:30 p.m. dose of [MEDICATION NAME] and then charted on the back of the MAR that he could not be aroused when she and 2 other nurses had not been able to awaken him. LPN BB acknowledged receiving education from Registered Nurse (RN) Supervisor EE regarding using nursing judgement even when a medication was scheduled and the need to use objective data such as vital signs and subjective data such as the resident's ability to use a pain scale to determine whether it was safe to administer a prescribed medication. LPN BB remembered signing an education roster for this discussion but could not remember why she did not apply this education to administering [MEDICATION NAME] to R#1. BB further revealed that she had been told to document her medications after she gave them and not to wait until the end of the shift to chart. In an interview with a family member of R #1 on 2/19/16 at 2:00 p.m. revealed the resident had been in and out of the Intensive Care Unit for about two months, needing mechanical ventilation most of the time and multiple IV medications. The resident had communicated to the family member, who was unable to give an exact date, by using his letter board that at some point during the night before he was transferred from the facility to the hospital he had awakened to medication being administered in his mouth, without any one speaking to him, and did not remember anything after that. In an interview on 2/22/16 at 2:50 p.m. with the EMS Paramedic that transferred Resident #1 to the hospital on [DATE] at 6:30 a.m. stated he remembered the resident was very sedated with pinpoint pupils that are classic in a [MEDICATION NAME] overdose. The respiratory rate was 6 to 8 breaths per minute and shallow and the resident was lethargic. The Paramedic revealed he attended to clearing the residents' airway, administering high flow O2 and suctioning. He applied the cardiac monitor, started an IV and gave [MEDICATION NAME] 0.5 mg IV as soon as he possibly could because he was sure this would improve the residents' condition. The residents' condition did improve with increased respiratory rate and depth and pupil size, but he had to suction copious amounts of secretions constantly and the resident was vomiting as well, so the transfer was upgraded to urgent and the resident reached the Emergency Department at 7:30 a.m. Interview on 2/23/16 at 1:30 p.m. with the attending Physician of R#1 revealed that he had changed the original transfer order for [MEDICATION NAME] from intravenous (IV) to sublingual (SL) administration because the facility did not administer IV [MEDICATION NAME]. He revealed this required an increased dose because [MEDICATION NAME] is metabolized very differently when administered SL. The Physician revealed he had been called twice after his original order because R#1 had complained of no pain relief. He had, on the morning of 12/19/15, first increased the 10 mg [MEDICATION NAME] dose to 20 mg and decreased the schedule from every 4 hours to every 3 hours, and on the second call the afternoon of 12/19/15 had again decreased the scheduling from every 3 hours to every 2 hours. He had been made aware of the resident receiving 2 doses of [MEDICATION NAME] 20 mg SL within 30 minutes on the morning of 12/20/15, but indicated due to the rapid metabolism of [MEDICATION NAME] this would not have caused the Resident a problem with respiratory depression the next day. The Physician indicated he would expect a nurse to hold a scheduled dose of [MEDICATION NAME] for sedation and to evaluate a resident's respiratory status prior to administration of [MEDICATION NAME], whether it is scheduled or as needed. In an interview on 2/23/16 at 9:45 a.m. with the Clinical Competency Coordinator (CCC) revealed there was no Clinical Competency Coordinator during the orientation of LPN BB who was hired on 10/1/15. The orientation program consisted of 2 checklists, a medication test, computer learning modules and learning medication pass with another nurse supervising. The Nurse in charge of completing Minimum Data Set Assessments was given the extra duty of being responsible for orienting new nurses. She resigned in December 2015. The Clinical Competency Coordinator was hired for this position on December 16, 2015. The CCC further revealed that she teaches orienting nurses that an actual pain level may not be needed for each dose of a scheduled pain medication but for a narcotic being administered every 2 hours an in-depth assessment of respiratory status and level of consciousness should be assessed with [REDACTED]. On 03/21/16 a partial extended survey was conducted the sample was expanded by three residents (R#22, R#23, R#24) who were all receiving narcotic and antihypertensive medications. Clinical record reviews of physician orders, medication administration records, controlled drug records and observations revealed no further indication of deficient practice. Interview conducted on 3/21/16 at 1:30 p.m. with the Administrator revealed there had been one (1) medication error on 2/29/16. Resident #22 received [MEDICATION NAME] 0.5 mg by mouth (po) twice daily (BID) until 2/9/16 when the order was changed to [MEDICATION NAME] 0.5 mg po every day (QD). On 2/29/16 Nurse AA administered a second dose of [MEDICATION NAME] 0.5 mg to R#22 at 9:00 p.m. The Administrator revealed this had been identified as an error as the Director of Health service (DHS) had monitored the Controlled Drug Records the next day and an incident report was made, family and physician were notified and a Medication Discrepancy and Adverse Reaction form was completed according to corporate policy. These records were reviewed and found to be complete. R#22 was observed according to physician order [REDACTED]. The Quality Assurance Committee had not held a meeting but would be informed at the next meeting. Nurse AA had terminated her employment with the facility during a disciplinary discussion of the incident with the DHS. A family interview was conducted with the son of R#22 on 3/21/16 at 3:45 p.m. revealed he was not concerned that she received an extra [MEDICATION NAME] a month ago. He indicated she was quite used to them and he had confidence in the facility to give his mother medications correctly. He confirmed her symptoms were well controlled and she did not have any adverse reactions or side effects. The facility implemented the following actions to remove the Immediate Jeopardy: 1.Education was provided to 34 nurses by the clinical competency coordinator and Registered Nurse supervisor on 2/19/16 regarding the general guidelines for medication administration including following physician orders, medication pass times, consistent and accurate documentation of medication and acceptance/refusal of medications, medication discrepancies, adverse medication reactions, accurate transcription of medication orders and identification of residents. Education content and sign in sheets were reviewed 2. Pictures of residents were audited on 2/25/16 and will be reviewed monthly and updated as needed 3. The clinical competency coordinator provided education to nurses regarding utilization of other staff members to assist with the identification process of residents as needed. 4. Nurses were in serviced by the clinical competency coordinator and registered nurse supervisor on 2/26/16 related to pain including observation and documentation of pain with routine pain medication administration, and observation of respiratory and sedation status with controlled substance pain medication administration. Education content and sign in sheets were reviewed . 5. nursing education was provided on 2/29/16 by the clinical competency coordinator and are in supervisor regarding errors, omissions and late entries. Education content and sign in sheets were reviewed. 6. DHS or RN supervisor will complete daily review of medication administration records for omissions. 7. RN supervisor will complete review of medication administration records monthly during change over to ensure pictures of residents are in place. 8. DHS or RN supervisor will monitor/observe med pass for 10% of nurses weekly for one month then monthly for three months was initiated on 2/25/16. 9. The pharmacy consultant will observe at least one random med pass monthly during her visit 10. All findings will be taken to the quality assurance performance improvement committee for action as needed 11. 34 nurses reviewed medication administration video from American Society of consultant pharmacists, which included oral medications, I met medications/inhalers/patches, and medications by [DEVICE] administration of medication was successful completion of posttests beginning 2/26/16 Education content and sign in sheets were reviewed 12. The director of health services or registered nurse supervisor will review medication administration records weekly to ensure that level of pain is being monitored. 13 Newly hired nurses will be in serviced by the clinical competency coordinator and mentor nurse on medication administration general guidelines including following physician orders, med pass times, consistent and accurate documentation of medication and acceptance/refusal of medications, medication discrepancies, adverse medication reactions, accurate transcription of medication orders, and identification of patients and will be required to complete the orientation skills checklists, medication administration video with posttest, and medication card orientation. Medication pass observation will also be completed with each newly hired nurse was successful completion. 14. Education was provided to 34 nurses completed on 2/29/16 by clinical competency coordinator, senior nurse consultant, and RN supervisor regarding medication discrepancy form and documentation regarding any discrepancy and reporting of discrepancy to physician and pharmacist. Education content and sign in sheets were reviewed 15. Charge nurses will review medication administration records and controlled substance reports at shift change for completion.

Based on record review, and staff interviews, the facility failed to provide care, related to medication administration as per physician's orders and in a manner to avoid adverse medication effects, as specified by the Care Plan of one (1) resident (R#2) on the total survey sample of twenty-four (24) residents. This failure of the facility to administer to Resident #2 only those medications which were ordered, to avoid adverse effects from medications as specified by the Care Plan, resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment, or death to residents. The census was 107 residents. On February 25, 2016, a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Corporate Clinical Consultant, Director of Heath Services (DHS) and Nursing Supervisor EE Registered Nurse (RN) were informed of the Immediate Jeopardy on February 25, 2016 at 5:00 p.m. An allegation of jeopardy removal was received on February 26, 2016. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on March 1, 2016, and the facility remained out of compliance at the lower scope and severity of D while the process of evaluation of the nursing staffs' compliance with physicians orders, education, and facility policies and procedures, continued. In-service materials and records were reviewed, all medication administration records were reviewed for resident pictures. Interviews were conducted with nursing staff to ensure they were knowledgeable about the administration of resident medication. Cross reference to F 333 Findings include: Record review for R#2 revealed an Annual Minimum Data Set assessment of 12/11/2015 which documented, in Section I-Active Diagnoses, that the resident had [DIAGNOSES REDACTED]. Further review of R#2's clinical record revealed that the October Physician Orders Form specified the administration of [MEDICATION NAME] XR 28 milligram (mg) daily at 9:00 a.m. for Alzheimer's, Vitamin D3 2000 units daily at 9:00 a.m. for bone health, [MEDICATION NAME] 20 mg every 12 hours at 9:00 a.m. and 9:00 p.m., Hold for heart rate less than 50, for Hypertension, (listed as a Beta blocker), Donepezil 10 mg every evening at 5:00 p.m. for Alzheimer's/Dementia. Additional record review for R#2, included review of the October Physician Orders Form, which revealed no evidence of a current or past Physician's order for the administration of the Antihypertensives [MEDICATION NAME] 30 mg (listed as Calcium Channel blocker) or [MEDICATION NAME] 100 mg. Review of the Care Plan for R#2 revealed multiple identified Problems involving the administration of drug therapy, and specifying as Approaches that drug therapy be administered in accordance with Physician's orders. The Care Plan identified the following: Problem: [DIAGNOSES REDACTED]. Problem: [DIAGNOSES REDACTED]. Problem: risk for constipation and impactions, as specified as an Approach to administer laxatives/stool softeners as ordered by physician. Document effectiveness. Problem: risk for pain, specified as an Approach administer medications as ordered as needed Problem: risk for Respiratory infections and Pneumonia specified as an Approach Antibiotics/medications as ordered Problem: risk for Urinary Tract Infections, specified as an Approach Administer antibiotics/medications as ordered Problem: history of inappropriate behaviors, specified as Approach Medications as needed/as ordered. The Care Plan of R# 2 specifically directed to give medications as ordered and as needed by the physician. Record review of Nurses Note (NN) for October 14, 2015 with no time listed; entry for R#2 documented that the resident was in bed this a.m. and was given medications by trainee, that were for another resident . R#2 was given [MEDICATION NAME] 30 mg and [MEDICATION NAME] 100 mg, vitals were blood pressure (B/P) 136/58, Pulse 57, Temperature 96.8 and no signs of acute distress. Medical Doctor (MD) made aware. Review of NN for October 14, 2015 at 7:10 a.m. documented R#2 now starting to fall in blood pressure (BP) and becoming unresponsive, called 911, placed in bed in Trendelenburg; BP now 64/38. Resident fading in and out of responsiveness. Very drowsy and not answering staff. Placed on oxygen (O2) at two liters per minute (2L/M) via mask. Eyes are open 68/50 manual BP. Awaiting ambulance. On October 14, 2015 at 7:20 a.m. R#2 out by ambulance to Hutcheson Medical Center (HMC). Responsible Party (RP) aware. MD made aware of resident being sent out. Review of the hospital's History and Physical (H&P) report documented a Cardiology Consult requested due to increase in Troponin level which revealed Demand Ischemia with minimal Left Ventricle damage and [DIAGNOSES REDACTED]. Medications given [MEDICATION NAME] (Calcium Channel blocker) and [MEDICATION NAME]. The resident was given the medications of another resident by accident, resulting in accidental overdose. The resident was given 100 mg of [MEDICATION NAME] and 30 mg of [MEDICATION NAME] by mistake and his blood pressure went down into the 50's and 60's systolic. On presentation to the Intensive Care Unit (ICU) the residents' B/P was 90/64 and he was alert and responsive. The H&P further documented the medication error occurred about 6:00 a.m. and his medicines were given by a nurse who was new to the facility and undergoing orientation. The hospital Discharge Summary for R#2 documented [DIAGNOSES REDACTED]. Review of the facility Investigation Report (IR) for R#2 October 14, 2015 at 6:15 a.m. documented that Blood Pressure medication had been given in error during 6:00 a.m. medpass. The room mate of R#2 reported the error to a Certified Nursing Assistant (CNA) and the CNA reported it to the Charge Nurse. Interview conducted on February 19, 2016 at 6:30 p.m. with the Administrator revealed the supervising nurse had left Licensed Practical Nurse (LPN) BB, who did not know the residents, unattended and BB administered the 6 a.m. medications for another resident to R#2. The Administrator further revealed that when she was made aware of the medication error she had both the trainee and the nurse training her in the office and verbally reprimanded both nurses. Pictures of residents were placed on the Medication Administration Records and an in service was completed on supervision of new employees during medication administration on October 14, 2015. Interview conducted on February 24, 2016 at 5:10 p.m. with LPN HH revealed that she was the nurse training LPN BB on the morning of October 14, 2015 when the wrong medication was given to R#2. She further acknowledged that she did not go into the room with BB when the medications were administered and that she should have went with her. HH also acknowledged that there were no pictures on the MARs at the time of the error but the next day pictures were placed on the MARs identifying the residents. On 03/21/16 a partial extended survey was conducted the sample was expanded by three residents (R#22, R#23, R#24) who were all receiving narcotic and antihypertensive medications. Clinical record reviews of physician orders, medication administration records, controlled drug records and observations revealed no further indication of deficient practice. The facility implemented the following actions to remove the Immediate Jeopardy: 1.Education was provided to 34 nurses by the clinical competency coordinator and Registered Nurse supervisor on 2/19/16 regarding the general guidelines for medication administration including following physician orders, medication pass times, consistent and accurate documentation of medication and acceptance/refusal of medications, medication discrepancies, adverse medication reactions, accurate transcription of medication orders and identification of residents. Education content and sign in sheets were reviewed 2. Pictures of residents were audited on 2/25/16 and will be reviewed monthly and updated as needed 3. The clinical competency coordinator provided education to nurses regarding utilization of other staff members to assist with the identification process of residents as needed. 4. Nurses were in serviced by the clinical competency coordinator and registered nurse supervisor on 2/26/16 related to pain including observation and documentation of pain with routine pain medication administration, and observation of respiratory and sedation status with controlled substance pain medication administration. Education content and sign in sheets were reviewed . 5. nursing education was provided on 2/29/16 by the clinical competency coordinator and are in supervisor regarding errors, omissions and late entries. Education content and sign in sheets were reviewed. 6. DHS or RN supervisor will complete daily review of medication administration records for omissions. 7. RN supervisor will complete review of medication administration records monthly during change over to ensure pictures of residents are in place. 8. DHS or RN supervisor will monitor/observe med pass for 10% of nurses weekly for one month then monthly for three months was initiated on 2/25/16. 9. The pharmacy consultant will observe at least one random med pass monthly during her visit 10. All findings will be taken to the quality assurance performance improvement committee for action as needed 11. 34 nurses reviewed medication administration video from American Society of consultant pharmacists, which included oral medications, I met medications/inhalers/patches, and medications by [DEVICE] administration of medication was successful completion of posttests beginning 2/26/16 Education content and sign in sheets were reviewed 12. The director of health services or registered nurse supervisor will review medication administration records weekly to ensure that level of pain is being monitored. 13 Newly hired nurses will be in serviced by the clinical competency coordinator and mentor nurse on medication administration general guidelines including following physician orders, med pass times, consistent and accurate documentation of medication and acceptance/refusal of medications, medication discrepancies, adverse medication reactions, accurate transcription of medication orders, and identification of patients and will be required to complete the orientation skills checklists, medication administration video with posttest, and medication card orientation. Medication pass observation will also be completed with each newly hired nurse was successful completion. 14. Education was provided to 34 nurses completed on 2/29/16 by clinical competency coordinator, senior nurse consultant, and RN supervisor regarding medication discrepancy form and documentation regarding any discrepancy and reporting of discrepancy to physician and pharmacist. Education content and sign in sheets were reviewed 15. Charge nurses will review medication administration records and controlled substance reports at shift change for completion.

Based on observations, record review and interview the facility failed to ensure that nursing services were provided in accordance with professional standards of practice, regarding medication administration and monitoring for one (1) resident (R#1), who incorrectly received two (2) doses of [MEDICATION NAME] within a thirty (30) minute period and continued to receive [MEDICATION NAME] routinely every two (2) hours for pain without monitoring or assessment for adverse effects; and regarding accurate resident identification prior to medication administration for one (1) resident (R#2), who received another resident's medications in error, from a total sample size of twenty-four (24) residents. On February 25, 2016, a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Administrator, Corporate Clinical Consultant, Director of Heath Services (DHS) and Nursing Supervisor EE Registered Nurse (RN) were informed of the Immediate Jeopardy on February 25, 2016 at 5:00 p.m. An allegation of jeopardy removal was received on February 26, 2016. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on March 1, 2016 as alleged, and the facility remained out of compliance at the lower scope and severity of D while the process of evaluation of the nursing staffs' compliance with physicians orders, education, and facility policies and procedures, continued. In-service materials and records were reviewed, all medication administration records were reviewed for resident pictures. Interviews were conducted with nursing staff to ensure they were knowledgeable about the administration of resident medication. Cross reference to F333. Findings include: 1. Review of the facility's Medication Administration General Guidelines policy included information on identifying residents. The procedure section documented residents are identified before medication is administered. A list of methods of identification to use, when in doubt about the resident's identity, included to check for an identification band, check for photograph attached to the medical record, call the resident by name and if necessary verify the resident's identify with other healthcare staff. Record review for R#2 revealed an Annual Minimum Data Set assessment dated [DATE] that documented R#2 as admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Section C, Cognitive Patterns, revealed Resident #1 had severe cognitive impairment with a Brief Interview for Mental Status Score of five (5). A record review for R#2 revealed nursing notes dated October 14, 2015 documenting that the resident was given 30 mg of [MEDICATION NAME] and 100 mg [MEDICATION NAME] in error by (newly hired) Licensed Practical Nurse (LPN) BB during the 6:00 a.m. medication pass. A further review of the 10/14/15 nurses notes revealed that, after the medications were administered in error, the resident's blood pressure (B/P) began to drop and the resident faded in and out of consciousness. The B/P was documented at 64/38. R#2 was placed in Trendelenburg position and Oxygen at 2 liters per minute via mask was administered. R#2 was transferred to the hospital and admitted to the Intensive Care Unit (ICU) with [DIAGNOSES REDACTED]. There was no evidence of how LPN BB verified R#2's identity prior to administering him the incorrect medications. Review of the facility Incident Report for the medication error that occurred on October 14, 2015 revealed the medication error was identified after R#2's roommate reported to the Certified Nursing Assistant (CNA) that R#2 had been incorrectly given 6:00 a.m. medications that were meant for him (the roommate). During an interview with the Administrator on February 19, 2016 at 6:30 p.m. she stated that an inservice was conducted when this medication error was discovered and she had both nurses in her office and gave a verbal reprimand to the nurse that was providing training to the new nurse because she (the nurse providing training) was sitting at the nurses station and allowing the new nurse to administer medications unsupervised. The Administrator further acknowledged that neither nurse had received a written reprimand on this error. In an interview on February 22, 2016 at 9:30 a.m. the Administrator acknowledged the supervising licensed nurse HH had left licensed nurse BB unattended and licensed nurse BB did not know the residents. She further acknowledged that pictures of the residents were always on the MARs but were updated recently. Observations conducted on February 19, 2016 at 2:10 p.m. of the Medication Administration Record's (MAR's) for one hundred eight residents residing in the facility that day, located on the medication carts revealed six (6) pictures were not on the MAR's. On February 25, 2016 at 10:40 a.m. the same 6 resident pictures remained missing on the MAR's, with these residents still residing at the facility. During an interview on February 23, 2016 at 10:00 a.m. Licensed Practical Nurse (LPN) HH, the nurse who was supervising newly hired LPN BB on October 14, 2015 when R#2 received the wrong medications, stated that she thought LPN BB had been working with the residents long enough to know who they were. LPN HH further revealed that she was at the medication cart when the medications were prepared and also acknowledged there were no pictures of these two residents on the MARs. An attempted telephone interview on February 26, 2016 at 11:25 a.m. with LPN BB who had resigned was unsuccessful. A messasge was left to call surveyor with no response from LPN BB Review of the National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules revealed that the Model Nursing Administrative Rules, Chapter 2 - Standards of Nursing Practice, Section 2.3.2(c), specified that the nurse demonstrate attentiveness and provide resident surveillance and monitoring. 2. Review of the clinical record for Resident #1 revealed he was admitted to the facility on [DATE] after a six (6) month hospitalization . He was brought to the facility to be closer to his family and was chronically ill, debilitated and underweight, paralyzed in three extremities and had minimal movement in his right upper extremity, allowing him to use a communication board of numbers and letters because he was unable to speak. He had a Percutaneous Endoscopic Gastrostomy (PEG) tube, a Peripherally Inserted Central Catheter (PICC line), a Foley Catheter, a [MEDICAL CONDITION] and multiple pressure ulcers. The resident's [DIAGNOSES REDACTED]. Review of the admission orders [REDACTED]. On 12/19/15 at 8 a.m. the order was changed to [MEDICATION NAME] 20 mg/ml 1 ml sl every three hours (q3h). However, on 12/19/15 at 3:30 pm, the order was again changed to [MEDICATION NAME] 20 mg/ml give 1 ml SL every two hours (q2h) for continued pain. A review of the Controlled Drug Record for 12/20/15 revealed the following: At 4:30 a.m. R#1 received a one (1) ml dose of [MEDICATION NAME] 20 mg /ml. At 7:00 a.m. R#1 received a one (1) ml dose of [MEDICATION NAME] 20 mg /ml. At 7:30 a.m. R#1 received a one (1) ml dose of [MEDICATION NAME] 20 mg /ml. A continued review of the Controlled Drug Record for 12/20/15 revealed R#1 did not receive the [MEDICATION NAME] scheduled for 5:30 p.m. and 7:30 p.m. These doses were recorded as refused. However R#1 did receive a dose of [MEDICATION NAME], as ordered, at 9:30 p.m., 11:30 p.m. and on 12/21/15 at 1:30 a.m., 3:30 a.m. and 5:30 a.m. A review of the back of the Medication Administration Record [REDACTED]. The 7:30 p.m. dose was documented by LPN BB as held due to being unable to arouse (the resident). Review of the Nurses Notes for 12/20/15 revealed that at 8:00 p.m. it was discovered that due to LPN BB not documenting administrations of [MEDICATION NAME] at 4:30 a.m. and 7:00 a.m., an administration of [MEDICATION NAME] scheduled for 7:30 a.m. was given by Nurse AA , thirty minutes after the previous dose that was scheduled for 5:30 a.m., but given at 7:00 a.m. There was no indication of assessment of oxygen saturation, pain level or level of sedation for 7:00 a.m. to 7:00 p.m. Review of Nurses Notes for 12/20/15 by the 7:00 p.m. to 7:00 a.m. LPN BB gave no indication of oxygen saturation after 2:00 a.m. when it was 90%, no indication of level of pain or sedation. In an interview with LPN AA on 2/19/16 at 10:35 a.m. revealed she had not known the correct way to transcribe the orders for [MEDICATION NAME] 20 mg/ml give 1 ml q 3 hours and [MEDICATION NAME] 20 mg/ml give 1 ml q 2 hours, to the MAR indicated [REDACTED]. She realized the documentation's on the front of the MAR indicated [REDACTED]. AA revealed she had asked someone, she could not remember who, for assistance, but they could not help her. She stated she arrived on 12/20/15 at 7:00 a.m. and counted narcotics with LPN BB and the count for the [MEDICATION NAME] had seemed to come out correct, but it was difficult to see because the liquid was clear and the count must not have been correct because BB had failed to document administration of [MEDICATION NAME] scheduled at 3:30 a.m. and 5:30 a.m. She left two (2) lines and gave the dose scheduled for 7:30 a.m. She learned when BBreturned at 7:00 p.m. that the 5:30 a.m. dose had been administered ninety (90) minutes late, at 7:00 a.m., and AA had administered [MEDICATION NAME] just 30 minutes later. Continued interview with LPN AA revealed that she had informed the Physician and had been told that since 12 hours had passed since the error there would not be any problem because [MEDICATION NAME] was metabolized rapidly and if the resident were going to have a problem it would have been within one hour. She acknowledged she had recorded the residents lungs were congested, but had not recorded checking an oxygen saturation for the entire 12 hours shift, and was unable to remember if she had checked this. She acknowledged recording [MEDICATION NAME] held at 5:30 p.m. as refused, but she had actually requested the assistance of the North Hall Supervisor Nurse EE Registered Nurse (RN) to advise her of whether [MEDICATION NAME] should be administered at this time because the resident was sedated. EE RN assessed the resident with her and they decided to use Nursing Judgement and hold the medication. She acknowledged she should not have recorded the dose held as refused. She revealed she had checked on R#1 when LPN BB arrived at 7:00 p.m. and Supervisor EE was requested to assist again with assessment. The [MEDICATION NAME] scheduled for 7:30 p.m. on 12/20/15 was also held for sedation and Supervisor EE gave education regarding using nursing judgement when administering scheduled or as needed (prn) medication and this was especially important in the case of opioid medication that could suppress respiration. Supervisor EE educated both LPN AA and LPN BB at this time. In an interview on 2/19/16 at 11:55 a.m. with LPN BB revealed that she had failed to document administration of [MEDICATION NAME] on 12/20/15 at 4:30 a.m. and 7:00 a.m. She could not remember why she gave the 5:30 a.m. scheduled [MEDICATION NAME] at 7:00 a.m., or why she failed to document, why she failed to mention this in report, or why she did not note this on the back of the MAR indicated [REDACTED]AA and Supervisor EE had witnessed the resident had been too sedated to receive the medication. LPN BB remembered that R#1 was sedated and comprehending less throughout the entire shift that night. LPN BB acknowledged that she had not assessed a pain scale, or charted a level of sedation during the 12/20/15 7:00 p.m. through 12/21/15 7:00 a.m. shift. She was not able to remember if the resident had actually indicated refusal of suctioning at 10:00 p.m. and 2:00 a.m., or just did not answer her, as when she charted refusal of the [MEDICATION NAME] at 7:30 p.m. LPN BB confirmed that she should have checked an oxygen saturation after 2:00 a.m. when it was 90%, and a pain level to know if the resident could answer and comprehend every 2 hours with each of the five (5) times [MEDICATION NAME] was administered. LPN BB further revealed that she discovered R#1 in respiratory distress about fifteen (15) minutes after her last administration of [MEDICATION NAME] at 5:30 a.m. and requested assistance. R#1 was transferred to the hospital. In an interview on 2/22/16 at 2:50 p.m. with Emergency Medical Service (EMS) Paramedic who transferred R#1 to the hospital on [DATE] at 6:30 a.m. revealed that he assessed the resident was over sedated due to the facility staff reporting he had been administered [MEDICATION NAME] and he noted the resident had pinpoint pupils, which is a sign of [MEDICATION NAME] overdose. He further revealed that he administered [MEDICATION NAME] to reverse the [MEDICATION NAME] as soon as possible and the residents condition improved, with increased level of consciousness, respiratory rate and effort, pulse oximetry and a decrease of pupil size. Review of the EMS Patient Care Report, dated 12/21/15 at 6:41 a.m. revealed that an administration of [MEDICATION NAME] 0.5 mg to R#1 with respirations increasing from 8 and shallow, with oxygen saturation of 85 % on high flow oxygen at 10 liters per minute on first assessment, to respiratory rate of 16, normal depth and 98 % oxygen saturation after [MEDICATION NAME] and suctioning at 7:15 a.m. In an interview on 2/23/16 at 1:30 p.m. with the attending Physician of R#1 revealed that he had been informed of the resident being administered [MEDICATION NAME] 20 mg/ml 1 ml at 7:00 a.m. and 7:30 a.m. when the situation had been discovered twelve (12) hours later but did not consider this as causing his respiratory distress the following morning at 5:55 a.m. The Physician revealed he would expect the nurses to hold a medication like [MEDICATION NAME] for sedation and check for mentation and respiratory status with every administration because this is a nursing standard. Review of Corporate policy entitled Pain Management, Lippincott Procedures, indicated that when administering strong opiod medications, pain level, and adverse reactions produced by treatment should be assessed in a timely manner, according to the onset of the prescribed medication. On 03/21/16 a partial extended survey was conducted the sample was expanded by three residents (R#22, R#23, R#24) who were all receiving narcotic and antihypertensive medications. Clinical record reviews of physician orders, medication administration records, controlled drug records and observations revealed no further indication of deficient practice. The facility implemented the following actions to remove the Immediate Jeopardy: 1.Education was provided to 34 nurses by the clinical competency coordinator and Registered Nurse supervisor on 2/19/16 regarding the general guidelines for medication administration including following physician orders, medication pass times, consistent and accurate documentation of medication and acceptance/refusal of medications, medication discrepancies, adverse medication reactions, accurate transcription of medication orders and identification of residents. Education content and sign in sheets were reviewed 2. Pictures of residents were audited on 2/25/16 and will be reviewed monthly and updated as needed 3. The clinical competency coordinator provided education to nurses regarding utilization of other staff members to assist with the identification process of residents as needed. 4. Nurses were in serviced by the clinical competency coordinator and registered nurse supervisor on 2/26/16 related to pain including observation and documentation of pain with routine pain medication administration, and observation of respiratory and sedation status with controlled substance pain medication administration. Education content and sign in sheets were reviewed . 5. nursing education was provided on 2/29/16 by the clinical competency coordinator and are in supervisor regarding errors, omissions and late entries. Education content and sign in sheets were reviewed. 6. DHS or RN supervisor will complete daily review of medication administration records for omissions. 7. RN supervisor will complete review of medication administration records monthly during change over to ensure pictures of residents are in place. 8. DHS or RN supervisor will monitor/observe med pass for 10% of nurses weekly for one month then monthly for three months was initiated on 2/25/16. 9. The pharmacy consultant will observe at least one random med pass monthly during her visit 10. All findings will be taken to the quality assurance performance improvement committee for action as needed 11. 34 nurses reviewed medication administration video from American Society of consultant pharmacists, which included oral medications, I met medications/inhalers/patches, and medications by [DEVICE] administration of medication was successful completion of posttests beginning 2/26/16 Education content and sign in sheets were reviewed 12. The director of health services or registered nurse supervisor will review medication administration records weekly to ensure that level of pain is being monitored. 13 Newly hired nurses will be in serviced by the clinical competency coordinator and mentor nurse on medication administration general guidelines including following physician orders, med pass times, consistent and accurate documentation of medication and acceptance/refusal of medications, medication discrepancies, adverse medication reactions, accurate transcription of medication orders, and identification of patients and will be required to complete the orientation skills checklists, medication administration video with posttest, and medication card orientation. Medication pass observation will also be completed with each newly hired nurse was successful completion. 14. Education was provided to 34 nurses completed on 2/29/16 by clinical competency coordinator, senior nurse consultant, and RN supervisor regarding medication discrepancy form and documentation regarding any discrepancy and reporting of discrepancy to physician and pharmacist. Education content and sign in sheets were reviewed 15. Charge nurses will review medication administration records and controlled substance reports at shift change for completion.

Based on clinical record review, staff interview, Controlled Drug Record review, and Medication Administration Record (MAR) review, the facility failed to accurately document medications administered for two (2) residents (R#1 and R#3), from a sample of twenty-four (24) residents. 1. Specifically for Resident #1, who had [DIAGNOSES REDACTED]. to failure to document the 7:00 a.m. dose on the resident's MAR or Controlled Drug Record after administration. R#1 had been admitted with an order for [REDACTED]. The Physician was contacted two (2) times with the residents' complaints of ongoing pain and the facility received 2 additional physician orders [REDACTED]. The facility failed to record the subsequent physician orders [REDACTED]. 2. Additionally, Resident #3 received [MEDICATION NAME] Insulin seventy (70) units subcutaneously (sq) four (4) times, administration of [MEDICATION NAME] Diskus one (1) inhalation 1 time and Fluvall 0.5 ml intramuscular (IM) 1 time, during the month of October, without the accompanying documentation on the MAR. This resulted in a situation in which the facility' s non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility' s Administrator, Director of Health Services (DHS), Corporate Clinical Consultant, and Nursing Supervisor EE Registered Nurse (RN) were informed of the Immediate Jeopardy on February 25, 2016 at 5:00 p.m. The non-compliance related to the Immediate Jeopardy was identified to have existed on October 14, 2015, the date another resident (#2) received two (2) antihypertensive medications with no order for these medications and was transferred emergently to the hospital, according to Nurses notes, fading in and out of consciousness with a blood pressure of 64/38. He was subsequently admitted to the ICU with a [DIAGNOSES REDACTED]. The Immediate Jeopardy continued through December 20, 2015, the date Resident #1 received, due to an omission of documentation, two (2) doses of [MEDICATION NAME] 20 mg SL within 30 minutes, at 7:00 a.m. and 7:30 a.m. The night of 12/20/15 and the morning of 12/21/15, from 9:30 p.m. through 5:30 a.m. Resident #1 received [MEDICATION NAME] 20 mg SL every 2 hours without assessment of respiratory status, pain level and without regard to sedation level and education provided by a Nursing Supervisor advising the use of nursing judgement, the residents ability to use a pain scale to assess sedation, and the possibility of respiratory depression with the use of opioid medication. An interview with the Corporate Clinical Consultant on 2/18/16 at 5:00 p.m. revealed the investigation of these events had not resulted in identifying a problem with narcotic administration and monitoring or medication administration and documentation. The Immediate Jeopardy remained on going, pending the acceptance of a final Credible Allegation of Jeopardy Removal. Observations were made of medication administration to assess staff' s conformance with accurate documentation of medication administration. Record reviews were conducted to assess staffs conformance with correct scheduling of medications when transcribing orders to the Medication Administration Records. An allegation of jeopardy removal was recieved on February 26, 2016. Based on corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on March 1, 2016, and the facility remained out of compliance at the lower scope and severity of D while the process of evaluation of the nursing staff's compliance with physician's orders [REDACTED]. In-service materials and records were reviewed. Interviews were conducted with nursing staff to ensure they were knowledgeable about the administration of resident medication. Findings include 1. Record review for Resident #1 revealed an admission date of [DATE]. Physician orders [REDACTED]. Review of Physician orders [REDACTED]. This order did not specify the concentration or mg to be given. The next telephone order on the Physician order [REDACTED]. This order does not specify concentration of the liquid, route of administration or number of mg to be given. Review of the MAR for R#1 revealed the admission order for [MEDICATION NAME] had been transcribed with the concentration of 20 mg per ml, give 0.5 ml q 4 hours routinely. No time for the order appeared on the MAR and the times administered were recorded correctly. The next order transcribed to the MAR had no time when the order was received and was transcribed as [MEDICATION NAME] 1 ml q 3 hrs, with no concentration, mg, route or date. Two doses were signed as given on 12/19/15 at 8:00 a.m. and 11:00 a.m. The next order was written on the MAR as [MEDICATION NAME] 1 ml SL q 2 hours routine 12/19/15. No time of the order, concentration or mg was included. The order was initialed as given at 1:00 p.m. This order was marked as changed and rewritten with a concentration and no date or time and was initialed as given on 12/19/15 at 1:30 a.m., 3:30 a.m., 5:30 a.m., 7:30 a.m., and 9:30 a.m. These doses were recorded as administered before the order existed. The next four doses on 12/19/15 at 11:30 a.m., 1:30 p.m., 3:30 p.m. and 5:30 p.m. were correctly recorded on the MAR then at 7:30 p.m. and 9:30 p.m. initials were crossed out. The 11:30 p.m. dose was initialed as given. Continued review of the MAR for 12/20/15 revealed [MEDICATION NAME] 20 mg/ml 1 ml was initialed as administered every 2 hours until the initials were circled at 3:30 p.m., 5:30 p.m., 7:30 p.m. and 9:30 p.m., indicating these doses were not administered. At 11:30 p.m. the [MEDICATION NAME] was initialed as administered. On 12/21/15 at 1:30 a.m., 3:30 a.m. and 5:30 a.m. the [MEDICATION NAME] was initialed as administered. Review of the Controlled Drug Record for R#1 revealed [MEDICATION NAME] was correctly signed as given on 12/19/16 at 2:00 a.m. and 6:00 a.m. Then a 0.5 ml/ 10 mg dose had been signed out without a time. The next dose on 12/19/15 at 8:00 a.m. is a 1 ml 20 mg dose in conformance with the order. According to review of the Controlled Drug Record the next doses of [MEDICATION NAME] were administered as ordered until a 20 mg [MEDICATION NAME] dose was given on 12/20/15 at 7:00 a.m. and another was administered at 7:30 a.m. Review of Corporate policy entitled Physician order [REDACTED]. Review of Corporate policy entitled Medication Administration: General Guidelines revealed if a dose of regularly scheduled medication is withheld, refused or given at other than the scheduled time the space provided on the front of the MAR is initialed and circled and an explanatory note is entered on the reverse side of the record. Continued review revealed after medication administration the MAR is initialed by the person administering the medication. Record review of Nurses Notes dated 12/20/15 at 1:30 a.m. by Licensed Practical Nurse (LPN) BB revealed no indication that medication was not given at the scheduled times. Review of the reverse side of the MAR revealed no note regarding a variation in the time [MEDICATION NAME] was administered. The following note written by the 7:00 a.m. to 7:00 p.m. LPN AA on 12/20/15 at 8:05 p.m. revealed that upon checking narcotic count at 7:00 p.m. a medication error was found. The 7:00 p.m. to 7:00 a.m. LPN BB had not signed out the doses of [MEDICATION NAME] administered at 4:30 a.m. or 7:00 a.m. and the day shift nurse AA had assumed the [MEDICATION NAME] had been administered at the correct time, which would have been 5:30 a.m. and administered a dose of 20 mg [MEDICATION NAME] thirty (30) minutes later at 7:30 a.m. AA documented notification of the physician and family, and an assessment of the residents respiratory status. LPN AA noted the physician had responded that since the two doses within 30 minutes had occurred twelve hours previously any adverse reaction would have already occurred. Interview on 2/18/16 at 5:15 p.m. with the Corporate Clinical Consultant revealed that this incident had been investigated and since there were no doses of [MEDICATION NAME] missing and it had measured out correctly this was not considered to be an error. The Corporate Clinical Consultant revealed that the policy for medication administration allows for a one hour variation before or after the medication is due, the administration of a dose of [MEDICATION NAME] due at 4:30 p.m. and given ninety (90) minutes later at 7:00 a.m., even though it was thirty (30) minutes past the allotted hour, was not considered an error. The Corporate Clinical Consultant acknowledged that the omission of documentation for the doses administered at 4:30 a.m. and 7:00 a.m. had resulted in 2 doses being administered within 30 minutes and the resident, already with a [DIAGNOSES REDACTED]. The Clinical Consultant indicated the unaccounted for dose of [MEDICATION NAME] recorded on the Controlled Drug Report on 12/19/15 without a time between 6:00 a.m. and 8:00 a.m. had been questioned with LPN AA and she had been unable to give an explanation of this entry, but this was also not considered an error. Review of Nurses Notes for R#1 dated 12/23/15 revealed an entry as follows: Investigation completed by Admin SR RN Consultant, DHS (DON). All meds, doses accounted for. No med error. This entry was signed by the Corporate Clinical Consultant. Interview on 2/19/16 at 10:35 a.m. with LPN AA revealed that when writing the orders for the increased doses of [MEDICATION NAME] she did not know she needed to include the concentration and milligrams. A indicated she also had not known the time of the order, concentration, and milligrams needed to be transcribed on the MAR, but she had received clarification of the last order on 12/19/15 at 3:30 p.m. by calling the physician and she rewrote the order with the concentration and mg at that time. LPN AA revealed that she had difficulty writing the scheduled times and this resulted in doses being initialed that were not given, before the order was written, and the MAR really could not be deciphered due to crossed out initials, circled doses, missing documentation on the back of the MAR, as well as doses initialed that were not actually given. LPN AA revealed that she had asked another nurse on duty on 12/19/15 how to correct the MAR and they did not have any suggestions. AA was asked about the extra dose signed on the Controlled Drug Report on 12/19/15 between 6:00 a.m. and 8:00 a.m. and she was unable to account for this. LPN AA revealed that when she arrived for work on 12/20/15 at 7:00 a.m. she discovered two doses of [MEDICATION NAME] for R#1, scheduled for 3:30 a.m. and 5:30 a.m. were not initialed as given on the MAR or signed on the Controlled Drug Report. She reported she assumed they had been administered as scheduled and the next dose due at 7:30 a.m. was administered as scheduled. LPN AA further revealed that she should have called LPN BB but did not. She acknowledged the narcotic count had been performed that morning before LPN BB left and it had looked correct but it was difficult to see the liquid because it was clear and it must not have been counted correctly. Continued interview revealed that she left 2 spaces on the Controlled Drug Report and asked LPN BB to fill in the spaces as well as the empty spaces on the MAR, when she returned on 12/20/15 at 7:00 p.m. When LPN BB filled in the time for her administration due at 5:30 a.m. as 7:00 a.m. AA reported to the physician, family and facility. LPN AA revealed that she should not have left empty spaces on the Controlled Drug Record. Interview with LPN BB on 2/19/16 at 11:55 a.m. revealed that she remembers not signing the MAR and Controlled Drug Record on 12/20/15 for the 3:30 a.m. and 5:30 a.m. doses she had administered late at 4:30 a.m. and 7:00 a.m. She was unable to remember why she had administered these doses late or why she had not reported this to LPN AA , or why she had not signed as having administered the [MEDICATION NAME]. She acknowledged leaving the spaces blank on the MAR and not documenting them on the Controlled Drug Report, and not reporting giving the last dose 90 minutes late to the oncoming Nurse had resulted in 2 doses of [MEDICATION NAME] being administered 30 minutes apart and this could have caused the resident to have a serious adverse reaction. LPN BB revealed there was no disciplinary action regarding the missing documentation, but someone had told her to be sure to document medication administration. 2. Record review for Resident #3 revealed a re-entry date of 6/29/15, with an admission [DIAGNOSES REDACTED]. Review of the October Physician orders [REDACTED]. Review of the MAR for Resident #3 for the month of October revealed [MEDICATION NAME] Insulin 70 units had not been initialed as given on 10/12/15 at 9:00 p.m., on 10/29/15 at 9:00 p.m., on 10/30/15 at 9:00 a.m. and 9:00 p.m. [MEDICATION NAME] Diskus 250/50 one puff q 12 hours had not been initialed on 10/13/15 at 9:00 p.m. and Fluvall 0.5 ml IM to left deltoid was to be administered on 10/25/15 and was not initialed. Continued review of the clinical record revealed Resident #3 had been in the facility on the dates the above medications were to be administered and there was no clinical indication not to administer the medications. The back of the MAR for the month of October does not indicate the [MEDICATION NAME] Insulin, [MEDICATION NAME] Diskus and Fluvall were held for any reason. The Nurses Notes for the month of October were reviewed and no indication of holding these medication on the above dates could be found. Interview with the Administrator on 2/19/16 at 2:30 p.m. revealed the documentation omissions for [MEDICATION NAME] Insulin 70 units sq a.m. and hs had been investigated by the facility as a follow up to a Quality Assurance Intervention that was considered resolved in August, 2015. The facility had determined the insulin had been administered and the nurses had received written disciplinary action for not documenting according to policy. The MAR' s are supposed to be checked by the unit manager at the end of each shift but there was no unit manager on the South Hall for the month of October and the MAR' s did not get checked. The administration of Fluvall was documented in the Nurses' notes but never was documented on the MAR and the missing initials were not addressed and the administration of the [MEDICATION NAME] Diskus on 10/13/15 at 9:00 p.m. was never investigated. The Administrator confirmed that nurses are expected to initial the MAR according to policy, as soon as a medication has been administered. Interview on 2/25/16 at 1:35 p.m. with LPN LL revealed that she received counseling regarding missing documentation of [MEDICATION NAME] Insulin on 10/12/15 at 9:00 p.m. and 10/30/15 at 9:00 a.m. and remembered she had administered the insulin but had not documented. LL acknowledged also giving the [MEDICATION NAME] Discus 250/50 one puff q 12 hours on 10/13/15 at 9:00 p.m. but failed to document. LPN LL confirmed that she was aware that not documenting the administration of medications could lead to serious harm to the residents. Interview on 2/25/16 at 1:30 p.m. with LPN FF revealed that she had administered [MEDICATION NAME] Insulin 70 units to R#3 on 10/29/15 and 10/30/15 at 9:00 p.m. and had not initialed the MAR. She indicated she received counseling and was aware that missing documentation could have serious consequences for the resident. Based on the above findings omission of documentation on the MAR immediately following medication administration had a high likelihood of causing harm to two residents, Resident #3 with undocumented insulin administration, and Resident #1, with undocumented [MEDICATION NAME] administration resulting in 2 doses being administered in thirty minutes. Interview conducted on 3/21/16 at 1:30 p.m. with the Administrator revealed there had been only one (1) medication error on 2/29/16. Resident #22 received [MEDICATION NAME] 0.5 mg by mouth (po) twice daily (BID) until 2/9/16 when the order was changed to [MEDICATION NAME] 0.5 mg po every day (QD). On 2/29/16 Nurse AA administered a second dose of [MEDICATION NAME] 0.5 mg to R#22 at 9:00 p.m. The Administrator revealed this had been identified as an error as the Director of Health service (DHS) had monitored the Controlled Drug Records the next day and an incident report was made, family and physician were notified and a Medication Discrepancy and Adverse Reaction form was completed according to corporate policy. These records were reviewed and found to be complete. R#22 was observed according to physician order [REDACTED]. The Quality Assurance Committee had not held a meeting but would be informed at the next meeting. Nurse AA had terminated her employment with the facility during a disciplinary discussion of the incident with the DHS. Interview on 3/21/16 at 6:00 p.m. with the Director of Health Services (DHS) revealed all nurses are to monitor the MAR's for pictures and unsigned medications on the MAR's. The unit managers are also monitoring daily and the DHS monitors at least once weekly and checks the Controlled Drug Records against the MAR's, physician orders [REDACTED]. He further revealed he has not found any non-compliance. Medication pass is observed weekly for three (3) nurses, and the consultant pharmacist observes medpass monthly. The facility implemented the following actions to remove the Immediate Jeopardy: 1.Education was provided to 34 nurses by the clinical competency coordinator and Registered Nurse supervisor on 2/19/16 regarding the general guidelines for medication administration including following physician orders, medication pass times, consistent and accurate documentation of medication and acceptance/refusal of medications, medication discrepancies, adverse medication reactions, accurate transcription of medication orders and identification of residents. Education content and sign in sheets were reviewed 2. Pictures of residents were audited on 2/25/16 and will be reviewed monthly and updated as needed 3. The clinical competency coordinator provided education to nurses regarding utilization of other staff members to assist with the identification process of residents as needed. 4. Nurses were in serviced by the clinical competency coordinator and registered nurse supervisor on 2/26/16 related to pain including observation and documentation of pain with routine pain medication administration, and observation of respiratory and sedation status with controlled substance pain medication administration. Education content and sign in sheets were reviewed . 5. nursing education was provided on 2/29/16 by the clinical competency coordinator and are in supervisor regarding errors, omissions and late entries. Education content and sign in sheets were reviewed. 6. DHS or RN supervisor will complete daily review of medication administration records for omissions. 7. RN supervisor will complete review of medication administration records monthly during change over to ensure pictures of residents are in place. 8. DHS or RN supervisor will monitor/observe med pass for 10% of nurses weekly for one month then monthly for three months was initiated on 2/25/16. 9. The pharmacy consultant will observe at least one random med pass monthly during her visit 10. All findings will be taken to the quality assurance performance improvement committee for action as needed 11. 34 nurses reviewed medication administration video from American Society of consultant pharmacists, which included oral medications, I met medications/inhalers/patches, and medications by [DEVICE] administration of medication was successful completion of posttests beginning 2/26/16 Education content and sign in sheets were reviewed 12. The director of health services or registered nurse supervisor will review medication administration records weekly to ensure that level of pain is being monitored. 13 Newly hired nurses will be in serviced by the clinical competency coordinator and mentor nurse on medication administration general guidelines including following physician orders, med pass times, consistent and accurate documentation of medication and acceptance/refusal of medications, medication discrepancies, adverse medication reactions, accurate transcription of medication orders, and identification of patients and will be required to complete the orientation skills checklists, medication administration video with posttest, and medication card orientation. Medication pass observation will also be completed with each newly hired nurse was successful completion. 14. Education was provided to 34 nurses completed on 2/29/16 by clinical competency coordinator, senior nurse consultant, and RN supervisor regarding medication discrepancy form and documentation regarding any discrepancy and reporting of discrepancy to physician and pharmacist. Education content and sign in sheets were reviewed 15. Charge nurses will review medication administration records and controlled substance reports at shift change for completion. On 03/21/16 an extended survey was conducted the sample was expanded by three residents (R#22, R#23, R#24) who were all receiving narcotic and antihypertensive medications. Clinical record reviews of physician orders, medication administration records, controlled drug records and observations revealed no further indication of deficient practice.

Based on record review, the facility failed to provided care related to fall prevention, per the Care Plan, for one (1) resident (#1) from a survey sample of five (5) residents. The resident subsequently experienced a fall which resulted in a hematoma to the forehead, [MEDICAL CONDITION] to the nose and the area beneath the nose, and a laceration requiring stitches. Findings include: Record review for Resident # 1 revealed an entry on the Admission Care Plan Record which identified that the resident was at risk for falls, and included as Approaches that a Sensor pad was to be provided as ordered, and that staff had been educated that alarms were to be on at all times and activated. A Nurse's Note dated 06/11/2009 at 6:00 p.m. documented that the resident was observed in the room, face down on the floor, with a small laceration above the right eye, a hematoma to the forehead, and [MEDICAL CONDITION] to the bridge of the nose and to the area under the nose. This Note further documented that at the time of the resident's fall, the Sensor pad was in place, but was not activated. A Nurse's Note of 06/11/2009 at 10:45 p.m. documented that the resident had received sutures to the forehead. Refer to F323 for more information regarding Resident # 1.

Based on record review and staff interview, the facility failed to provided adequate supervision related to fall prevention, per the Care Plan, for one (1) resident (#1) from a survey sample of five (5) residents. The resident subsequently experienced a fall which resulted in a hematoma to the forehead, edema to the nose and the area beneath the nose, and a laceration requiring stitches. Findings include: Record review for Resident # 1 revealed an entry on the Admission Care Plan Record which identified that the resident was at risk for falls, and included as Approaches to address this problem that a Sensor pad was to be provided as ordered, and that staff had been educated that alarms were to be on at all times and activated. A Nurse's Note dated 06/11/2009 at 6:00 p.m. documented that the nurse entered the resident's room and observed the resident face down on the floor with a moderate amount of blood around the head. This Note documented that upon assessment, a small laceration was noted above the right eye, a hematoma was noted to the forehead, and edema was noted to the bridge of the nose and to the area under the nose. This Note documented that Emergency Medical Services 911 was activated and transported the resident to the hospital emergency room . This Note further documented that at the time of the resident's fall, the Sensor pad was in place, but was not activated. A Nurse's Note of 06/11/2009 at 10:45 p.m. documented that the resident had returned to the facility, having received sutures to the forehead. During interview with Administrative Staff "AA" conducted at 11:30 a.m. on 08/03/2009, this staff member acknowledged the incident. This staff member also stated that after the incident, the nurse had inserviced some, but not all, certified nursing assistant staff about the incident and the importance of keeping alarms turned on.