Every finding on record at Riverside Care & Rehabilitation Center

Based on observation, interview, and review of facility policy, the facility failed to treat each resident with respect, dignity and care in a manner and an environment that enhances his or her quality of life by not announcing themselves before entering the room of (5) residents. (Resident (R) R9, R16, R17, R27, and R28). The findings include: Review of the facility's policy titled, Resident Rights, reviewed 09/13/2024, revealed all residents had the right to be treated with respect and dignity. These rights would be promoted and protected by the facility. All residents would be treated in a manner and in an environment that promoted maintenance or enhancement of quality of life. When providing care and services, the stakeholders would respect the resident's individuality and value their input by providing them a dignified existence, through self-determination and communication with and access to persons and services inside and outside the facility. Further review of the policy revealed the facility would make every effort to support each resident in exercising his/her right to assure that the resident is always treated with respect, kindness, and dignity. 1. Review of R9's medical record revealed the facility admitted the resident on 03/20/2023 with diagnoses which included: chronic obstructive pulmonary disease, type 2 diabetes mellitus, and gastro-esophageal reflux disease. Review of R9's Annual Minimum Data Set (MDS) Assessmennt with an Assessment Reference Date (ARD) date of 02/11/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. [NAME] an interview with R9 on 03/12/2025 at 1:28 PM, she stated, sometimes staff knock but not always. R9 stated she would like for staff to knock on the door before entering. 2. Review of R16's medical record revealed the facility admitted the resident on 01/24/2024 with diagnoses which included: type 2 diabetes mellitus, cognitive communication deficit and gastro-esophageal reflux disease. Revoew of R16's Quarterly MDS Assessment with an ARD date of 02/19/202, revealed the facility assessed the resident to have a BIMS score of 8 out of 15, indicating intact cognition. During an interview with R16 on 03/12/2025 at 1:05 PM, she stated staff were always coming in and out of her room without knocking. She further stated it would be nice if someone knocked on the door. 3. Review of R17's medical record revealed the facility admitted the resident on 02/07/2025 with diagnoses which included: chronic obstructive pulmonary disease and gastro-esophageal reflux disease. Review of R17's Quarterly MDS Assessment with an ARD date of 02/07/2025, revealed the facility assessed the resident to have a BIMS score of 15 out of 15, indicating intact cognition. 4. Review of R28's medical record revealed the facility admitted the resident on 04/05/2019 with diagnoeses which included: unspecified dementia and a history of abnormal weight loss. Review of R28's Quarterly MDS Assessment with an ARD date of 02/06/2025, revealed the facility assessed the resident to have a BIMS score of three (3) out of 15, which indicated severe cognition. 5. Review of R27's medical record noted she was admitted to the facility on [DATE] with diagnoses which include generalized anxiety disorder and moderate intellectual disabilities. Review of R27's Quarterly MDS Assessment with an ARD date of 01/31/2025, revealed the facility assessed the resident to have a BIMS score of 3 out of 15 which indicated severe cognition During a lunch observation meal pass on 03/12/2025 at 11:45 AM, Registered Nurse (RN) 1 was passing trays to rooms [ROOM NUMBERS] and failed to announce herself or knock on the resident's door prior to enterting the room. Further observation of the meal pass 03/12/2025 at 11:45 AM, revealed Certified Nurse Aide, (CNA) 4 failed to announce herself or knock on the resident's door prior to enterting the rooms [ROOM NUMBER]. During an interview with RN1 on 03/12/2025 at 2:18 PM, she stated she should have knocked on the resident's door before entering the resident rooms. She stated she knew it was a dignity issue since this is the residents' home. During an interview with CNA4 on 03/12/2025 at 2:10 PM, she stated she was aware she was supposed to knock on resident's doors before entering the room; however, she stated she had her hands full with a tray and didn't want to drop the tray. She further stated she could have voiced her arrival at doorway and alerted residents she was entering their room. CNA 4 stated she was trained to knock on resident rooms prior to entering because it was the residents home and staff should respect that. During an interview with the Administrator on 03/13/25 at 3:48 PM, he stated he expected staff to knock on residents' doors or verbally announce themselves prior to entering the rooms per the facility policy and practices. During an interview with the Director of Nursing (DON) on 03/13/25 at 3:50 PM, she stated she expected staff to introduce themselves before entering residents rooms.

Based on observation, interview, record review, review of facility policy, and review of the Centers for Disease Control and Prevention (CDC) guidelines the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of three (3) residents. Observation of wound care for Resident (R)54 revealed a failure to remove contaminated gloves prior to touching Resident's clothing, bedding, walker, table, and chair. The findings include: Review of policy Infection Control, reviewed 01/17/2025, revealed Facility infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections . All personnel will be trained on infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities. Review of policy Hand Hygiene, reviewed 09/13/2024, revealed All personnel shall be trained on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . hand hygiene is the final step after removing and disposing of personal protective equipment. The use of gloves does not replace hand washing/hand hygiene. Review of the (CDC) guidelines, dated 02/27/2024. revealed Gloves should be used whenever healthcare workers anticipate contact with blood, bodily fluids, mucous membranes, nonintact skin, or potentially contaminated surfaces and equipment. The CDC stresses that gloves must be changed between, patient contacts and when moving from contaminated to clean tasks for the same patient. This practice helps ensure that microorganisms are not inadvertently spread . Review of R54's Face Sheet, located in the resident's Electronic Health Record (EHR), revealed the facility admitted the resident on 10/20/2023 with diagnoses to include chronic obstructive pulmonary disease, unspecified dementia, and type two diabetes mellitus with hyperglycemia. Review of R54's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 01/30/2025, completed related to a significant change, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] of 3 out of 15, which indicated severe cognitive impairment. Review of R54's Comprehensive Care Plan, revealed R54 was care planned for Enhanced Barrier Precautions related to chronic wounds, with a start date of 02/13/2025. The short-term goal, with a target date of 05/13/2025, was that Resident would not experience any adverse outcomes related to enhanced barrier precautions. The goal would be achieved by the following approaches: disinfect high touch surfaces as able/as needed (PRN), attempt to maintain environmental cleanliness, personal protective equipment as indicated, and report to physician signs and symptoms of infection as needed. Observation of the dressing change of R54's coccyx wound on 03/12/25 at 10:25 AM revealed the Assistant Director of Nursing (ADON) did not remove her gloves and sanitize her hands after changing the dressing and before assisting the resident to a chair at the bedside. Failure to remove her gloves and sanitize her hands resulted in contaminating resident's clothing, walker, table and any other item that were touched. In an interview with ADON on 03/12/2025 at 10:35 AM, she stated she should have removed her gloves after completing R54's dressing change and donned clean gloves before placing the resident's clothing back on and assisting her to the bedside chair. In an interview on 03/13/25 9:43 AM with Licensed Practical Nurse/Infection Preventionist/Staff Development Coordinator (LPN IP/SDC), she stated skills checks were done with a skills checkoff for hand hygiene and other skills. She further stated surveillance was done daily to ensure staff were using proper infection control techniques regarding hand hygiene and wound care as well as enhanced barrier precautions. She further stated she expected all staff to follow the facility policies and procedures as written related to infection control practices.

Based on observation, interview, record review, and review of the facility policy it was determined the facility failed to ensure revision of a comprehensive care plan for one (1) of nineteen (19) sampled residents and failed to ensure the notification/invitation of a care plan meeting for one (1) of nineteen (19) sampled residents. The facility failed to notify/invite Resident #38 to the care plan meeting for (MONTH) 2019 following the quarterly comprehensive assessment dated [DATE]. The comprehensive care plan for Resident #314 did not reveal a revision to the code status change from full code to the status of do not resuscitate (DNR), which occurred on [DATE]. The findings include: Review of the facility policy, Comprehensive Care Plans, dated [DATE], revealed each resident had the right to participate in the choosing of treatment options and will be given the opportunity to participate in the development, review, and revision of their care plan. Further review of the facility policy revealed that care plans are ongoing and revised as information about the resident and the resident's condition changes. 1. Observation of Resident #38 during initial tour on [DATE] at 2:00 PM, revealed the resident in bed, lying on his/her back with the head of bed up about forty-five (45) degrees watching TV. The resident stated he/she had not been informed of care plan meetings and did not remember attending one. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) quarterly assessment, dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of fourteen (14) which indicated the resident was cognitively intact. Further review of the medical record revealed a quarterly MDS assessment was completed on [DATE]. Review of the Care Plan Conference Summary forms for Resident #39 revealed a summary form not done for the (MONTH) quarterly assessment. Further review revealed the most recent form completed prior to the (MONTH) assessment was dated for (MONTH) 2019. This Care Plan Conference Summary was noted to have the attendees as the Director of Nursing, the Social Services Director, and a family member. Review of the progress notes dated [DATE] revealed a note that stated an Interdisciplinary Team meeting was held discussing the quarterly assessment dated [DATE]. The documentation did not reveal attendance by the resident and did not reveal why the resident was not in attendance. Interview with Resident #38 on [DATE] at 4:16 PM, revealed he/she had not received any notifications regarding care plan meetings. Interview with the Social Services Director (SSD) on [DATE] at 1:15 PM, revealed she was responsible for notifying and inviting residents and family to the care plan meetings. She stated the resident was always invited verbally, but this was not documented. Interview with the Administrator on [DATE] at 3:05 PM, revealed residents were invited verbally to the care plan meetings; however, this had not been documented. He stated he could not provide any evidence that the resident had been invited or notified regarding the care plan meeting in (MONTH) 2019. The Administrator also stated the facility policy stated the resident was to be included in the care plan meeting. 2. Review of the medical record revealed that Resident #314 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED].#314 had a Kentucky Emergency Medical Services Do Not Resuscitate (DNR) form located in the medical record, which was signed by the resident's representative and dated [DATE]. Review of current physician orders revealed the resident had an order for [REDACTED]. Review of Resident #314's care plan dated [DATE] revealed a Full Code status care plan with interventions that cardio-pulmonary resuscitation (CPR) would be initiated in the event of a code (cardiopulmonary arrest). Interview with the Social Services Director (SSD) on [DATE] at 1:52 PM, revealed she was responsible for updating the code status care plans. She stated that sometimes she did not update the care plan if Nursing told her they updated it with the new order. She stated she was unaware that the care plan for Resident #314 had not been updated with the new code status of DNR and stated she must not have been aware of the new order. Interview with the Director of Nursing (DON) on [DATE] at 2:08 PM, revealed that in the event that the SSD was unavailable to update the care plan with new orders then Nursing was responsible to update the care plan.

Based on observations, interview, record review, and facility policy review, the facility failed to ensure the environment for one (1) of nineteen (19) sampled residents (Resident #314) remained free of accident hazards. Resident #314 was assessed upon admission to be at risk for elopement. The facility failed to reassess the resident's risk for elopement quarterly according to facility policy. The findings include: Review of the facility policy titled Elopement/Wandering, dated 05/30/2018, revealed an elopement/wandering assessment would be completed upon admission and quarterly thereafter. Observation of Resident #314 on 01/21/2020 at 2:26 PM, 3:45 PM, and 4:01 PM and on 01/23/2020 at 10:09 AM revealed the resident was wandering throughout the facility. The resident was observed to have a wander guard bracelet (device that alarms if a resident is attempting to exit the facility) on his/her left ankle. Review of the record for Resident #314 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the record revealed the most recent Minimum Data Set (MDS) on 01/14/2020 revealed the resident had impaired cognition with the resident being rarely/never understood. The MDS further revealed that the resident displayed wandering behavior 1 to 3 days during the assessment period. The record revealed a physician order for [REDACTED].#314's information was in the book and the resident was identified as an elopement risk. Further review of the record revealed no evidence that an assessment had been completed since admission to reassess the resident's risk for elopement. Interview with the MDS Coordinator on 01/22/2020 at 2:37 PM revealed that the Social Services Director (SSD) was responsible for completing the elopement assessments. Interview with the SSD on 01/22/2020 at 2:40 PM revealed that the charge nurses on each hallway were responsible for completing the elopement assessments and that she was responsible to update the binder that included information about wandering residents. Interview with Licensed Practical Nurse (LPN) #1 on 01/22/2020 at 3:00 PM revealed she was responsible for the care of Resident #314. LPN #1 further stated that the nurses were not responsible for the elopement assessments and stated that the SSD was responsible for completing the elopement assessments. Interviews with the Director of Nursing (DON) on 01/22/2020 at 2:50 PM and on 01/23/2020 at 1:34 PM revealed elopement assessment should be completed for residents on a quarterly basis and should be completed by nursing staff. The DON further stated he was unaware that Resident #314's assessment had not been completed quarterly according to policy.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure residents received retorative services to maintain, or increase range of motion amd/or mobility for five (5) of twenty-one (21) sampled residents (Residents #3, #11, #40, #50, and #51), and five (5) unsampled residents (Residents #2, #6, #31, #45, and #55). Review of the Restorative Service Delivery Records for ten (10) of ten (10) residents in the Restorative Program related to range of motion and mobility (Residents #2, #3, #4, #6, #11, #31, #40, #45, #46, #51, and #55) revealed the residents received restorative nursing services for only three (3) to four (4) days during (MONTH) (YEAR). In addition, Resident #50 was discharged from Rehabilitation Services on 10/18/18 to Restorative Services for transfers; however, the restorative services for mobility were not started until 11/01/18, (fourteen days later). The findings include: Review of the facility policy titled, Restorative Nursing Policy and Procedure Manual, dated (MONTH) 2010, revealed restorative nursing is a collection of interventions designed to promote resident independence and safety. It is part of a three-level process. Level III is Rehabilitation Therapy, Level II is Restorative Nursing, and Level I is Basic Nursing Care. The goal, at all levels, is to restore the resident's functionality whenever possible, improve the ability for self-care, and maintain independence as long as possible. Further review of the policy revealed the Restorative Nursing Staff will provide the care in accordance with the Restorative Plan of Care to help enhance resident's normal range of motion, and activities of daily living. 1. Record review revealed the facility readmitted Resident #11 on 09/02/18, with [DIAGNOSES REDACTED]. Review of Resident #11's Comprehensive Care Plan, dated 01/15/15, revealed the resident required assist of staff with Activities of Daily Living (ADLs) due to decreased mobility. Further review of the care plan revealed, on 08/02/18, the resident was care planned for restorative nursing therapy program for Active Range of Motion (AROM) to bilateral upper extremities. Review of the Physician's Order, dated (MONTH) (YEAR), revealed an order for [REDACTED]. Review of the Restorative Service Delivery Record, dated (MONTH) (YEAR), revealed Resident #11 had received only three (3) days of restorative therapy. Observation of Resident #11, on 11/02/18 at 8:37 AM, with Restorative Nursing staff and Occupational Therapist (OT) #1, revealed the resident demonstrated no decline in his/her AROM. 2. Record review revealed the facility readmitted Resident #3 on 06/15/18, with [DIAGNOSES REDACTED]. Review of Resident #3's Comprehensive Care Plan, dated 08/14/18, revealed the resident to be at risk for decline in his/her ability to transfer with limited level of assistance. Further review of the care plan revealed approaches to include a restorative transfer program to assist the resident in transfers from bed to chair, transfers from chair to bed with the use of a gait belt. Review of the Restorative Service Delivery Record, dated October, (YEAR), revealed Resident #3 had received only three (3) days of restorative therapy. Observation of Resident #3, on 11/02/18 at 11:10 AM, with restorative nursing staff and Physical Therapist (PT) #1, revealed the resident demonstrated no decline in his/her ability to transfer. 3. Record review revealed the facility admitted Resident #6 on 03/26/18, with [DIAGNOSES REDACTED]. Review of Resident #6's Comprehensive Care Plan, dated 08/14/18, revealed the resident to have impaired functional mobility related to weakness and neurological deficit. Further review of the care plan revealed approaches to include Passive Range of Motion (PROM), assist in moving through tolerated range, supporting joints above and below lower extremities (hip/thigh). Review of the Restorative Service Delivery Record, dated October, (YEAR), revealed Resident #6 had received only three (3) days of restorative therapy. Observation of Resident #6, on 11/02/18 at 8:44 AM, with restorative nursing staff and PT #1, revealed the resident demonstrated no decline in his/her PROM. 4. Record review revealed the facility admitted Resident #45 on 06/26/18, with [DIAGNOSES REDACTED]. Review of Resident #45's Comprehensive Care Plan, dated 06/13/18, revealed the resident to have actual declines in ability to self-transfer secondary to weakness. Further review of the care plan revealed approaches to include transfer from bed to chair, transfer from chair to bed, transfer from wheelchair to commode and transfer from commode to wheelchair. Review of the Restorative Service Delivery Record, dated October, (YEAR), revealed Resident #45 had received only three (3) days of restorative therapy. Interview with Resident #45 revealed he/she refused to allow the surveyor to observe care on 11/02/18 at 10:40 AM. 5. Record review revealed the facility readmitted Resident #55 on 11/10/17, with [DIAGNOSES REDACTED]. Review of Resident #55's Comprehensive Care Plan, dated 07/12/18, revealed the resident required a restorative therapy program for AROM to the upper extremities. Review of the Restorative Service Delivery Record, dated October, (YEAR), revealed Resident #55 had received only three (3) days of restorative therapy. Observation of Resident #55, on 11/02/18 at 8:30 AM, with restorative nursing staff and OT #1, revealed the resident demonstrated no decline in his/her AROM. 6. Record review revealed the facility admitted Resident #31 on 10/04/17, with [DIAGNOSES REDACTED]. Review of Resident #31's Comprehensive Care Plan, dated 07/11/18, revealed the resident was at risk for developing an impairment in functional joint mobility related to weakness and was care planned to receive restorative therapy for AROM to bilateral upper extremities. Review of Physician's orders revealed an order, dated 07/11/18, for Restorative Therapy, AROM for upper extremities. Review of the Restorative Delivery Record, dated (MONTH) (YEAR), revealed Resident #31 had received only four (4) days of restorative therapy for the entire month of October. An attempt was made to observe Restorative Therapy with Resident #31, on 11/02/18 at 9:32 AM; however, the resident refused, stating he/she did not feel well, was cold and had a headache. 7. Record review revealed the facility admitted Resident #40 on 01/14/14, with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan, dated 06/13/18, revealed Resident #40 had impaired functional mobility related to weakness and was care planned for restorative therapy for AROM to the bilateral upper extremities. Review of Physician's orders revealed an order, dated 06/13/18, for Restorative Therapy, AROM for upper bilateral extremities. Review of the Restorative Delivery Record, dated (MONTH) (YEAR), revealed Resident #40 had received only four (4) days of restorative therapy for the entire month of October. Observation of Resident #40, on 11/02/18 at 9:14 AM, with restorative nursing staff and Occupational Therapist revealed the resident demonstrated no decline in ADLs. 8. Record review revealed the facility admitted Resident #51 on 02/26/16 with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan, dated 08/10/18, revealed Resident #51 had impaired functional mobility related to weakness and was care planned for restorative therapy for AROM to the bilateral upper extremities and grooming and hygiene. Review of Physician's orders revealed an order, dated 08/10/18, for AROM for bilateral upper extremities and grooming and hygiene. Review of the Restorative Delivery Record, dated October, (YEAR), revealed Resident #51 had received only four (4) days of restorative therapy for the entire month of October. Observation of Resident #51, on 11/02/18 at 9:36 AM, with restorative nursing staff and OT revealed the resident demonstrated no decline in ADLs. 9. Record review revealed the facility admitted Resident #2 to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's Quarterly MDS assessment, dated 10/31/18, revealed the facility assessed the resident's Brief Interview for Mental Status (BIMS) score to be a three (3), which indicated he/she had severely impaired cognition and was not interviewable. Review of Resident #2's restorative nursing walking program, dated 07/11/18, revealed Resident #2 was to be assisted to ambulate three-hundred (300) feet one (1) time per day six (6) to seven (7) days per week. Review of the Restorative Delivery Record, dated October, (YEAR), revealed Resident #2 had received only four (4) days of restorative therapy for the entire month of October. Observation of Resident #2, on 11/02/18 at 8:43 AM, with restorative nursing staff and PT revealed the resident demonstrated no decline in ambulation. 10. Record review revealed the facility admitted Resident #50 to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #50's Quarterly MDS assessment, dated 10/18/18, revealed the facility assessed his/her BIMS score to be a fifteen (15), which indicated his/her cognition was intact and interviewable. Review of a Physician's order, dated 10/18/18, revealed an order to discontinue Physical Therapy to Restorative Nursing Program. Review of therapy's communication to nursing, dated 10/18/18, revealed Resident #50 was to be on a restorative nursing program for transfers to be done six (6) to seven (7) days a week and a restorative nursing program for range of motion (ROM) to be done six (6) days a week. Review of Resident #50's clinical record revealed restorative nursing was not started until 11/01/18 for Resident #50, which was fourteen (14) days after the initial order to start restorative nursing programs. Interview with Resident #50, on 10/31/18 at 8:59 AM, revealed he/she stated the facility had not implemented his/her restorative nursing program for him/her due to the census had been low and the restorative nursing CNAs had to work the floor. Interview with the Restorative Nurse Coordinator, on 11/01/18 at 10:16 AM, revealed therapy communication to nursing was on 10/18/18, for Resident #50, to be on restorative nursing for strengthening and ROM. She stated they did not start Resident #50's restorative programs until 11/01/18. She stated the program was not started immediately due to trying to get the new restorative pilot program up and running. Interview with Restorative Aide (RA) #1, on 11/01/18 at 11:10 AM, revealed she was pulled to the floor several times a week and while she worked the floor she did not have enough time to complete restorative duties. She further stated she had voiced her concerns to the restorative nurse coordinator and nothing had changed. She further stated if she had provided restorative care she would have documented it. Interview with RA #2, on 11/02/18 at 11:15 AM, revealed she was pulled to the floor frequently to work as an aide. She stated it was impossible to do the fifteen (15) minute restorative programs for all residents while on the floor because some residents have more than one (1) care area. She stated she had not made anyone aware of restorative tasks not being done because they must know since she was being pulled to the floor so much. Interview with RA #3, on 11/02/18 at 11:24 AM, revealed she was pulled to the floor about fifty (50) percent of the time to work as an aide because the resident census was low. She stated she had been told by the restorative nurse to get restorative programs done if we could. She stated she had not made anyone aware that restorative was not being done because they know it was impossible to do all of it while working the floor. Further interview with the Restorative Nurse Coordinator, on 11/01/18 at 12:02 PM, revealed she was not aware the Restorative Service Delivery Records for residents were incomplete for the month of (MONTH) (YEAR). She stated she had noticed some holes for (MONTH) in the restorative records, but failed to follow-up as to why. She stated she knew the restorative aides were being pulled to the floor, but assumed they were doing their restorative duties with the help of other aides. She further stated she had told the restorative aides to make her or the Director of Nursing (DON) aware if restorative care was not being provided so they could help and ensure restorative programs were being done. She stated none of the restorative aides had made her aware the restorative programs were not being provided to the residents, and she thought it was being done while residents were receiving daily care needs. She stated if she knew the tasks were not being done, she would have made the DON aware. She stated the restorative aides were being pulled to the floor because resident census was down and the restorative case load could be completed while they worked the floor. Interview with the DON, on 11/01/18 at 12:54 PM, revealed if the restorative aides were on the floor, they should still be doing the restorative. She further stated she would expect the restorative programs to be done and if not, they should be reporting it to her, or another manager. She stated she had been off sick recently and was not made aware the restorative was not being done. Telephone interview with the DON, on 11/16/18 at 2:28 PM, revealed restorative was available seven (7) days a week and must be provided at least six (6) days a week to be counted on the MDS assessment. She further stated restorative was a nursing measure and the orders do not specify as to how many days the resident will receive restorative therapy. Interview with the Administrator, on 11/02/18 at 11:59 AM, revealed the restorative aides were directed to complete both the floor duties and restorative duties when pulled to the floor. He stated based on resident census, acuity, and restorative case load, they should have completed the restorative and documented it.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Observation of the kitchen, on 10/30/18, revealed open and unsealed foods being stored in the freezer, sanitation bucket not measuring any sanitation present and staff failed to wash hands prior to starting trayline. Review of the facility Census and Condition, dated 10/30/18, revealed fifty-eight (58) of fifty-eight (58) residents received their meals from the kitchen. The findings include: Review of facility policy Food Storage, revised 09/14/18, revealed frozen foods should be stored in their original containers if designed for freezing and foods to be frozen should be stored in airtight containers or wrapped in heavy-duty aluminum foil or special laminated papers. Review of facility policy Proper Handwashing, dated 01/14, revealed hands must be washed prior to beginning work in the kitchen and after contact with unsanitary surfaces. Review of facility policy Sanitizer Use Concentrations For Food Service and Food Production Communities, dated 09/01/2014, revealed sanitation buckets must be established with appropriate sanitizing solution. Observation of the kitchen's walk-in freezer #1, on 10/30/18 10:34 AM, revealed walk-in freezer #1 had an open to air/unsealed bag of country beef breaded patties being stored on the shelf. Observation of the kitchen's walk-in freezer #2, on 10/30/18 10:35 AM, revealed walk-in freezer #2 had an open to air/unsealed bag of cookie dough being stored on the shelf. Observation of the lunch trayline in the kitchen, on 10/30/18 at 11:50 AM, revealed Dietary Aide #1 had been throughout the kitchen touching various items, then started to assist in setting up resident trays and never washed her hands prior to handling clean dishes and setting up trays for the residents' lunch meals. Observation of the kitchen, on 10/30/18 at 11:59 AM, revealed one (1) sanitation bucket inside the kitchen which measured no sanitation present when the Dietary Manager was asked to measure the sanitation level. Interview with the Dietary Manager, on 10/30/18 at 10:37 AM, revealed all food items in the freezers were to be covered and sealed completely. Further interview at 11:55 AM, revealed she expected all staff that work on the trayline to wash their hands prior to starting trayline. Additional interview at 12:01 PM, revealed the sanitation bucket should measure an appropriate sanitizing solution level and the sanitation bucket should have had new sanitizing solution put in it. Interview with the Registered Dietician, on 10/31/18 at 03:48 PM, revealed she expected all foods to be sealed in the freezer completely, the sanitation water in the sanitation bucket to be changed routinely, and staff to start trayline with clean hands.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to implement or develop a comprehensive person-centered care plan for six (6) of twenty-one (21) sampled residents (Residents #3, #11, #20, #40, #50, and #51), and seven (7) unsampled residents (Residents #2, #4, #6, #31, #45, #46, and #55). Resident #20 was care planned for staff to ensure his/her shoes were on properly; however, on 10/24/18, the resident stumbled and sustained a bruise to his/her right leg due to his/her shoes not being on properly. Review of Restorative Services Delivery Records for Residents #3, #11, #40, and #51; and Unsampled Residents #2, #4, #6, #31, #45, #46, and #55 revealed the residents were not provided restorative nursing services per care plan. In addition, Resident #50 was referred to the Restorative Program on 10/18/18; however, the facility failed to develop a care plan for restorative services for Resident #50. The findings include: Review of the facility policy titled, Comprehensive Care Plans, not dated, revealed a person-centered comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Further review of the policy revealed the care plan will include how the facility will assist the resident to meet their needs, goals, and preferences. Continued review of the policy revealed each resident's comprehensive care plan is designed to incorporate identified problem areas; Incorporate risk factors associated with identified problems; Build on residents' strengths; Identify the professional services that are responsible for each element of care; Aid in preventing or reducing declines in the resident's functional status and/or functional levels; Enhance the optimal functioning of the resident by focusing on a rehabilitative program. 1. Record review revealed the facility readmitted Resident #20 on 07/05/17, with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/14/18, revealed the facility assessed Resident #20's cognition as intact with a Brief Interview for Mental Status (BIMS) score of eight (8). Review of the Comprehensive Care Plan, dated 10/04/12, revealed an intervention for staff to ensure shoes were completely on and tied (secured). However, review of the facility provided fall investigation revealed, on 10/24/18 at 12:00 PM, revealed the resident did not have his/her shoes on properly and the heels were flopping which resulted in the resident stumbling into the door facing and sustaining a hematoma to the right leg. Several attempted interviews with the resident revealed he/she was unable to provide information about his/her fall on 10/24/18. Interview with Certified Nurse Aide (CNA) #1, on 11/01/18 at 12:45 PM, revealed she was assisting Resident #20 when he/she fell and stated the resident's shoes appeared to be on correctly. She stated the resident was walking really fast during this time. Interview with Licensed Practical Nurse (LPN) #3 who completed the fall investigation, on 11/01/18 at 12:26 PM, revealed an aide was present when Resident #20 fell but she couldn't catch the resident. She stated she would have expected the aide to ensure the resident's shoes were on properly per care plan. Interview with the Director of Nursing (DON), on 11/01/18 at 12:49 PM, revealed the resident had a tendency to put his/her shoes on the wrong feet and staff were constantly attempting to redirect the resident. She stated she would have expected the staff to ensure the resident's shoes were on properly prior to ambulation per care plan. 2. Record review revealed the facility readmitted Resident #11 on 09/02/18, with [DIAGNOSES REDACTED]. Review of Resident #11's Comprehensive Care Plan, revealed on 08/02/18, the resident was care planned for restorative nursing therapy for Active Range of Motion (AROM) to the bilateral upper extremities. However, review of the Restorative Service Delivery Record, dated (MONTH) (YEAR), revealed Resident #11 had received only three (3) days of restorative therapy. 3. Record review revealed the facility readmitted Resident #3 on 06/15/18, with [DIAGNOSES REDACTED]. Review of Resident #3's Comprehensive Care Plan, dated 08/14/18, revealed the resident to be at risk for decline in the ability to transfer with limited level of assistance. Further review of the care plan revealed approaches to include a restorative transfer program to assist the resident in transfers from bed to chair, and transfers from chair to bed with the use of a gait belt. However, review of the Restorative Service Delivery Record, dated (MONTH) (YEAR), revealed Resident #3 had received only three (3) days of restorative therapy. 4. Record review revealed the facility admitted Resident #6 on 03/26/18, with [DIAGNOSES REDACTED]. Review of Resident #6's Comprehensive Care Plan, dated 08/14/18, revealed the resident to have impaired functional mobility related to weakness and neurological deficit. Further review of the care plan revealed approaches to include Passive Range of Motion (PROM), assist in movement through tolerated range, supporting joints above and below the lower extremities (hip/thigh). However, review of the Restorative Service Delivery Record, dated (MONTH) (YEAR), revealed Resident #6 had received only three (3) days of restorative therapy. 5. Record review revealed the facility admitted Resident #45 on 06/26/18, with [DIAGNOSES REDACTED]. Review of Resident #45's Comprehensive Care Plan, dated 06/13/18, revealed the resident to have actual declines in the ability to self-transfer secondary to weakness. Further review of the care plan revealed approaches to include a restorative transfer program to assist the resident in transfers from bed to chair, transfer from chair to bed, transfer from wheelchair to commode and transfer from commode to wheelchair. However, review of the Restorative Service Delivery Record, dated (MONTH) (YEAR), revealed Resident #45 had received only three (3) days of restorative therapy. 6. Record review revealed the facility readmitted Resident #55 on 11/10/17, with [DIAGNOSES REDACTED]. Review of Resident #55's Comprehensive Care Plan, dated 07/12/18, revealed the resident required a restorative therapy program for AROM to the upper extremities; however, review of the Restorative Service Delivery Record, dated (MONTH) (YEAR), revealed Resident #55 had received only three (3) days of restorative therapy. 7. Record review revealed the facility admitted Resident #2 to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's Quarterly MDS assessment, dated 10/31/18, revealed the facility assessed the resident's BIMS score to be three (3), which indicated he/she had severely impaired cognition and was not interviewable. Review of the Restorative Nursing Care Plan, dated 07/11/18, revealed Resident #2 was to be assisted to ambulate three-hundred (300) feet, one (1) time per day, six (6) to seven (7) days per week; however, review of the Restorative Delivery Record, dated (MONTH) (YEAR), revealed Resident #2 had received only four (4) days of restorative therapy for the entire month of (MONTH) (YEAR). 8. Record review revealed the facility admitted Resident #4 on 10/31/15, with [DIAGNOSES REDACTED]. Review of Resident #4's Comprehensive Care Plan, dated 08/15/18, revealed the resident was at risk for decline in ability to perform ADLs and was care planned for restorative therapy for grooming and hygiene. However, review of the Restorative Service Delivery Record, dated (MONTH) (YEAR), revealed Resident #4 had received only five (5) days of restorative therapy for the entire month of (MONTH) (YEAR). 9. Record review revealed the facility admitted Resident #31 on 10/04/17, with [DIAGNOSES REDACTED]. Review of Resident #31's Comprehensive Care Plan, dated 07/11/18, revealed the resident was at risk for developing an impairment in functional joint mobility related to weakness and was care planned to receive restorative therapy for AROM to the bilateral upper extremities. However, review of the Restorative Delivery Record, dated (MONTH) (YEAR), revealed Resident #31 had received only four (4) days of restorative therapy for the entire month of (MONTH) (YEAR). 10. Record review revealed the facility admitted Resident #40 on 01/14/14, with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan, dated 06/13/18, revealed Resident #40 had impaired functional mobility related to weakness and was care planned for restorative therapy for AROM to the bilateral upper extremities. However, review of the Restorative Delivery Record, dated (MONTH) (YEAR), revealed Resident #40 had received only four (4) days of restorative therapy for the entire month of (MONTH) (YEAR). 11. Record review revealed the facility admitted Resident #46 on 03/01/13, with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan, dated 08/10/18, revealed Resident #46 had an actual decline in the ability to feed self secondary to positioning and was care planned for restorative therapy for dining. However, review of the Restorative Delivery Record, dated (MONTH) (YEAR), revealed Resident #46 had received only five (5) days of restorative therapy for the entire month of (MONTH) (YEAR). 12. Record review revealed the facility admitted Resident #51 on 02/26/16 with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan, dated 08/10/18, revealed Resident #51 had impaired functional mobility related to weakness and was care planned for restorative therapy for AROM to the bilateral upper extremities and grooming and hygiene. However, review of the Restorative Delivery Record, dated (MONTH) (YEAR), revealed Resident #51 had received only four (4) days of restorative therapy for the entire month of (MONTH) (YEAR). 13. Record review revealed the facility admitted Resident #50 on 03/08/18 with [DIAGNOSES REDACTED]. Review of Resident #50's Quarterly MDS assessment, dated 10/18/18, revealed the facility assessed the resident's BIMS score to be a fifteen (15), which indicated his/her cognition was intact and interviewable. Review of a Physician's order, dated 10/18/18, revealed an order to discontinue Physical Therapy to Restorative Nursing Program. Review of Therapy's Communication to Nursing form, dated 10/18/18, revealed Resident #50 should be on a restorative nursing program for transfers, to be done six (6) to seven (7) days per week, and a restorative nursing program for range of motion to be done six (6) days per week. However, review of the Comprehensive Care Plan, last revised 10/19/18, revealed there was no evidence a restorative nursing program care plan was developed for him/her regarding the restorative nursing programs which was to be implemented. Review of Resident #50's clinical record, revealed there was no Restorative Delivery Record for Resident #50's restorative for transfers and range of motion and no documentation the restorative was provded. Interview with the Restorative Nurse Coordinator, on 11/01/18 at 10:16 AM, revealed therapy communication to nursing was on 10/18/18, for Resident #50, to be on restorative nursing for strengthening and ROM. She stated they did not start Resident #50's restorative programs or develop a restorative care plan until 11/01/18. She stated the program was not started immediately due to trying to get the new restorative pilot program up and running. Interview with Restorative Aide (RA) #1, on 11/01/18 at 11:10 AM, revealed she was pulled to the floor several times a week, and while she worked the floor she did not have enough time to complete restorative duties. She further stated she had voiced her concerns to the Restorative Nurse Coordinator and nothing had changed. She further stated if she had provided restorative care, she would have documented it. Interview with RA #2, on 11/02/18 at 11:15 AM, revealed she was pulled to the floor frequently to work as an aide. She stated it was impossible to do the fifteen (15) minute restorative programs for all residents while on the floor, because some residents have more than one (1) care area. She stated she had not made anyone aware of restorative tasks not being done, and stated they must know since she was being pulled to the floor so much. Interview with RA #3, on 11/02/18 at 11:24 AM, revealed she was pulled to the floor about fifty (50) percent of the time to work as an aide because the resident census was low. She stated she had been told by the restorative nurse to get restorative programs done if possible. She stated she had not made anyone aware that restorative was not being done because they knew it was impossible to do all of it while working the floor. Interview with the Restorative Nurse Coordinator, on 11/01/18 at 12:02 PM, revealed she was not aware the Restorative Service Delivery Records for residents were incomplete for the month of (MONTH) (YEAR). She stated she had noticed some holes for (MONTH) in the restorative records, but failed to follow-up as to why. She stated she knew the restorative aides were being pulled to the floor, but assumed they were doing their restorative duties with the help of other aides. She further stated she had told the restorative aides to make her or the DON aware if restorative care was not being provided so they could help and ensure restorative programs were being done. She stated none of the restorative aides had made her aware the restorative programs were not being provided to the residents, and she thought it was being done while residents were receiving daily care needs. She stated if she knew the tasks were not being done, she would have made the DON aware. She stated the restorative aides were being pulled to the floor because resident census was down and the restorative case load could be completed while they worked the floor. Interview with the DON, on 11/01/18 at 12:54 PM, revealed if the restorative aides were on the floor, they should still be doing the restorative. She further stated she would expect the restorative programs to be done and if not, they should be reporting it to her, or another manager. She stated she had been off sick recently and was not made aware the restorative was not being done. Interview with the Administrator, on 11/02/18 at 11:59 AM, revealed the restorative aides were directed to complete both the floor duties and restorative duties when pulled to the floor. He stated based on resident census, acuity, and restorative case load, they should have completed the restorative and documented it.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure there was sufficient nursing staff to provide restorative nursing services for five (5) of twenty-one (21) sampled residents (Residents #3, #11, #40, #50, and #51), and seven (7) unsampled residents (Residents #2, #4, #6, #31, #45, #46, and #55). Review of the Restorative Service Delivery Records for all twelve (12) residents in the facility's Restorative Program had received restorative nursing services for only three (3) to five (5) days during the month of (MONTH) (YEAR). In addition, Resident #50 was discharged from Rehabiltaion Services to Restorative Nursing on 10/18/18; however, restorative nursing was not started until 11/01/18, fourteen (14) days after therapy's communication to nursing. The findings include: Review of the facility policy titled, Scheduling and Staffing, last revised 05/24/18, revealed the facility is to establish consistent work shift scheduling practices to allow for efficient business operations and continuity of resident care. Further review of the policy revealed the facility will establish an electronic master schedule and the facility will staff the building using the following considerations, when applicable as it pertains to each individual facility resident needs and population: acuity based staffing (ABS) modeling as a guideline, not a minimum, which considers the resident population's Minimum Data Set (MDS) input; each facility's volume of assessments and admissions. Further review of the policy revealed, based on the resident census and acuity, a facility may need to add or cancel Stakeholders work shifts in order to maintain appropriate levels of resident care. 1. Record review revealed the facility readmitted Resident #11 on 09/02/18, with [DIAGNOSES REDACTED]. Review of the care plan, dated 08/02/18, revealed restorative nursing therapy program for Active Range of Motion (AROM) to bilateral upper extremities. Review of the Restorative Service Delivery Record, dated (MONTH) (YEAR), revealed Resident #11 had received only three (3) days of restorative therapy. 2. Record review revealed the facility readmitted Resident #3 on 06/15/18, with [DIAGNOSES REDACTED]. Review of the care plan, dated 08/14/18, revealed a restorative transfer program to assist the resident in transfers from bed to chair, transfers from chair to bed with the use of a gait belt. Review of the Restorative Service Delivery Record, dated October, (YEAR), revealed Resident #3 had received only three (3) days of restorative therapy. 3. Record review revealed the facility admitted Resident #6 on 03/26/18, with [DIAGNOSES REDACTED]. Review of the care plan, dated 08/14/18, revealed Passive Range of Motion (PROM), assist in moving through tolerated range, supporting joints above and below lower extremities (hip/thigh). Review of the Restorative Service Delivery Record, dated October, (YEAR), revealed Resident #6 had received only three (3) days of restorative therapy. 4. Record review revealed the facility admitted Resident #45 on 06/26/18, with [DIAGNOSES REDACTED]. Review of the care plan, dated 06/13/18, revealed transfer from bed to chair, transfer from chair to bed, transfer from wheelchair to commode and transfer from commode to wheelchair. Review of the Restorative Service Delivery Record, dated October, (YEAR), revealed Resident #45 had received only three (3) days of restorative therapy. 5. Record review revealed the facility readmitted Resident #55 on 11/10/17, with [DIAGNOSES REDACTED]. Review of the care plan, dated 07/12/18, revealed the resident required a restorative therapy program for AROM to the upper extremities. Review of the Restorative Service Delivery Record, dated October, (YEAR), revealed Resident #55 had received only three (3) days of restorative therapy. 6. Record review revealed the facility admitted Resident #4 on 10/31/15, with [DIAGNOSES REDACTED]. Review of the care plan, dated 08/15/18, revealed the resident was at risk for decline in ability to perform ADLs and was care planned for restorative therapy for grooming and hygiene. Review of the Restorative Service Delivery Record, dated October, (YEAR), revealed Resident #4 had received only five (5) days of restorative therapy for the entire month of October. 7. Record review revealed the facility admitted Resident #31 on 10/04/17, with [DIAGNOSES REDACTED]. Review of the care plan, dated 07/11/18, revealed the resident was at risk for developing an impairment in functional joint mobility related to weakness and was care planned to receive restorative therapy for AROM to bilateral upper extremities. Review of the Restorative Delivery Record, dated (MONTH) (YEAR), revealed Resident #31 had received only four (4) days of restorative therapy for the entire month of October. 8. Record review revealed the facility admitted Resident #40 on 01/14/14, with [DIAGNOSES REDACTED]. Review of the care plan, dated 06/13/18, revealed the resident had impaired functional mobility related to weakness and was care planned for restorative therapy for AROM to the bilateral upper extremities. Review of the Restorative Delivery Record, dated (MONTH) (YEAR), revealed Resident #40 had received only four (4) days of restorative therapy for the entire month of October. 9. Record review revealed the facility admitted Resident #46 on 03/01/13, with [DIAGNOSES REDACTED]. Review of the care plan, dated 08/10/18, revealed the resident had an actual decline in ability to feed self secondary to positioning and was care planned for restorative therapy for dining. Review of the Restorative Delivery Record, dated (MONTH) (YEAR), revealed Resident #46 had received only five (5) days of restorative therapy for the entire month of October. 10. Record review revealed the facility admitted Resident #51 on 02/26/16 with [DIAGNOSES REDACTED]. Review of the care plan, dated 08/10/18, revealed the resident had impaired functional mobility related to weakness and was care planned for restorative therapy for AROM to the bilateral upper extremities and grooming and hygiene. Review of the Restorative Delivery Record, dated October, (YEAR), revealed the resident had received only four (4) days of restorative therapy for the entire month of October. 11. Record review revealed the facility admitted Resident #2 to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the restorative nursing walking program, dated 07/11/18, revealed the resident was to be assisted to ambulate three-hundred (300) feet one (1) time per day six (6) to seven (7) days per week. Review of the Restorative Delivery Record, dated October, (YEAR), revealed Resident #2 had received only four (4) days of restorative therapy for the entire month of October. 12. Record review revealed the facility admitted Resident #50 to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of therapy's communication to nursing, dated 10/18/18, revealed the resident was to be on a restorative nursing program for transfers to be done six (6) to seven (7) days a week and a restorative nursing program for range of motion (ROM) to be done six (6) days a week. Review of Resident #50's clinical record revealed restorative nursing was not started until 11/01/18 for Resident #50, which was fourteen (14) days later. Interview with the Restorative Nurse Coordinator, on 11/01/18 at 10:16 AM, revealed therapy communication to nursing was on 10/18/18, for Resident #50, to be on restorative nursing for strengthening and ROM. She stated they did not start Resident #50's restorative programs until 11/01/18. She stated the program was not started immediately due to trying to get the new restorative pilot program up and running. Interview with Restorative Aide (RA) #1, on 11/01/18 at 11:10 AM, revealed she was pulled to the floor several times a week and while she worked the floor she does not have enough time to complete restorative duties. She further stated she had voiced her concerns to the restorative nurse coordinator and nothing had changed. She further stated if she had provided restorative care she would have documented it. Interview with RA #2, on 11/02/18 at 11:15 AM, revealed she was pulled to the floor frequently to work as an aide. She stated it was impossible to do the fifteen (15) minute restorative programs for all residents while on the floor because some residents have more than one (1) care area. She stated she had not made anyone aware of restorative tasks not being done because they must know since she was being pulled to the floor so much. Interview with RA #3, on 11/02/18 at 11:24 AM, revealed she was pulled to the floor about fifty (50) percent of the time to work as an aide because the resident census was low. She stated she had been told by the restorative nurse to get restorative programs done if we could. She stated she had not made anyone aware that restorative was not being done because they know it was impossible to do all of it while working the floor. Further interview with the Restorative Nurse Coordinator, on 11/01/18 at 12:02 PM, revealed she was not aware the Restorative Service Delivery Records for residents were incomplete for the month of (MONTH) (YEAR). She stated she had noticed some holes for (MONTH) in the restorative records, but failed to follow-up as to why. She stated she knew the restorative aides were being pulled to the floor, but assumed they were doing their restorative duties with the help of other aides. She further stated she had told the restorative aides to make her or the Director of Nursing (DON) aware if restorative care was not being provided so they could help and ensure restorative programs were being done. She stated none of the restorative aides had made her aware the restorative programs were not being provided to the residents, and she thought it was being done while residents were receiving daily care needs. She stated if she knew the tasks were not being done, she would have made the DON aware. She stated the restorative aides were being pulled to the floor because resident census was down and the restorative case load could be completed while they worked the floor. Interview with the DON, on 11/01/18 at 12:54 PM, revealed If the restorative aides were on the floor, they should still be doing the restorative. She further stated she would expect the restorative programs to be done and if not they should be reporting it to her, or another manager. She stated she had been off sick recently and was not made aware the restorative was not being done. She stated the facility was staffed based on resident census and needs. She further stated if the restorative aides had communicated to management that restorative had not been done, appropriate steps would have been taken my herself or the unit manager to ensure residents received restorative. Interview with the Administrator, on 11/02/18 at 11:59 AM, revealed the restorative aides were directed to complete both the floor duties and restorative duties when pulled to the floor. He stated based on resident census, acuity, and restorative case load they should have completed the restorative and documented it. He further stated he did not feel there was an issue with staffing.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure two (2) residents not in the selected sample of twenty-one (21) residents received restorative services to maintain or improve his/her ability to carry out eating or grooming/hygiene (Residents #4 and #46). Review of the Restorative Service Delivery Records for Resident #4 and #46, two (2) of two (2) residents who were assessed and care planned for restorative services for eating or hygiene/grooming, revealed the residents had received restorative nursing services for only five (5) days during (MONTH) (YEAR). The findings include: Review of the facility policy titled, Restorative Nursing Policy and Procedure Manual, dated (MONTH) 2010, revealed restorative nursing is a collection of interventions designed to promote resident independence and safety. It is part of a three-level process. Level III is Rehabilitation Therapy, Level II is Restorative Nursing, and Level I is Basic Nursing Care. The goal, at all levels, is to restore the resident's functionality whenever possible, improve the ability for self-care, and maintain independence as long as possible. Further review of the policy revealed the Restorative Nursing Staff will provide the care in accordance with the Restorative Plan of Care to help enhance resident's normal range of motion, and activities of daily living. 1. Record review revealed the facility admitted Resident #4 on 10/31/15, with [DIAGNOSES REDACTED]. Review of Resident #4's Comprehensive Care Plan, dated 08/15/18, revealed the resident was at risk for decline in ability to perform ADLs and was care planned for restorative therapy for grooming and hygiene. Review of Physician's orders, dated (MONTH) (YEAR), revealed an order for [REDACTED]. Review of the Restorative Service Delivery Record, dated October, (YEAR), revealed Resident #4 had received only five (5) days of restorative therapy for the entire month of October. Observation of Resident #4, on 11/02/18 at 9:03 AM, with restorative nursing staff and the OT revealed the resident demonstrated no decline in ADLs. 2. Record review revealed the facility admitted Resident #46 on 03/01/13, with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan, dated 08/10/18, revealed Resident #46 had an actual decline in ability to feed self secondary to positioning and was care planned for restorative therapy for dining. Review of Physician's orders revealed an order, dated 08/15/18, for Restorative Therapy, restorative dining for swallowing. Review of the Restorative Delivery Record, dated (MONTH) (YEAR), revealed Resident #46 had received only five (5) days of restorative therapy for the entire month of October. Surveyor was unable to observe Resident #46 for decline as he/she was sent to the emergency roiagnom on [DATE] for an acute episode. Interview with Restorative Aide (RA) #1, on 11/01/18 at 11:10 AM, revealed she was pulled to the floor several times a week and while she worked the floor she did not have enough time to complete restorative duties. She further stated she had voiced her concerns to the restorative nurse coordinator and nothing had changed. She revealed if she had provided restorative care she would have documented it. Interview with RA #2, on 11/02/18 at 11:15 AM, revealed she was pulled to the floor frequently to work as an aide. She stated it was impossible to do the fifteen (15) minute restorative programs for all residents while on the floor because some residents have more than one (1) care area. She stated she had not made anyone aware of restorative tasks not being done because they must know since she was being pulled to the floor so much. Interview with RA #3, on 11/02/18 at 11:24 AM, revealed she was pulled to the floor about fifty (50) percent of the time to work as an aide because the resident census was low. She stated she had been told by the restorative nurse to get restorative programs done if we could. She stated she had not made anyone aware that restorative was not being done because they know it was impossible to do all of it while working the floor. Interview with the Restorative Nurse Coordinator, on 11/01/18 at 12:02 PM, revealed she was not aware the Restorative Service Delivery Records for residents were incomplete for the month of (MONTH) (YEAR). She stated she had noticed some holes for (MONTH) in the restorative records, but failed to follow-up as to why. She stated she knew the restorative aides were being pulled to the floor, but assumed they were doing their restorative duties with the help of other aides. She further stated she had told the restorative aides to make her or the Director of Nursing (DON) aware if restorative care was not being provided so they could help and ensure restorative programs were being done. She stated none of the restorative aides had made her aware the restorative programs were not being provided to the residents, and she thought it was being done while residents were receiving daily care needs. She stated if she knew the tasks were not being done, she would have made the DON aware. She stated the restorative aides were being pulled to the floor because resident census was down and the restorative case load could be completed while they worked the floor. Interview with the Directive of Nursing (DON), on 11/01/18 at 12:54 PM, revealed if the restorative aides were on the floor, they should still be doing the restorative. She further stated she would expect the restorative programs to be done and if not, they should be reporting it to her, or another manager. She stated she had been off sick recently and was not made aware the restorative was not being done. Telephone interview with the DON, on 11/16/18 at 2:28 PM, revealed restorative was available seven (7) days a week and must be provided at least six (6) days a week to be counted on the MDS assessment. She further stated restorative was a nursing measure and the orders do not specify as to how many days the resident will receive restorative therapy. Interview with the Administrator, on 11/02/18 at 11:59 AM, revealed the restorative aides were directed to complete both the floor duties and restorative duties when pulled to the floor. He stated based on resident census, acuity, and restorative case load, they should have completed the restorative and documented it.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure the one (1) of twenty-one (21) residents environment was free of accident hazards (Resident #20). The facility identified Resident #20's shoes could be an accident hazard for the resident due to the resident not having shoes on properly and care planned for staff to ensure the resident's shoes were on properly and shoe laces were tied. However, on 10/24/18, Resident #20 was being assisted by staff and the resident stumbled and fell sustaining a hematoma to the right leg. It was determined the resident's shoes were not on properly and the heels were flopping. The findings include: Review of the facility policy titled, Falls, not dated, revealed falls resulting from environmental factors will be reviewed at monthly Safety Committee. Further review of the policy revealed a Comprehensive Care Plan will be implemented and interventions are to be revised as indicated. Record review revealed the facility readmitted Resident #20 on 07/05/17, with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/14/18, revealed the facility assessed Resident #20's cognition as intact with a Brief Interview for Mental Status (BIMS) score of eight (8). Review of the Comprehensive Care Plan, dated 10/04/12, revealed an intervention for staff to ensure shoes were completely on and tied (secured). Review of a facility fall investigation revealed, on 10/24/18 at 12:00 PM, Resident #20 stumbled into the door facing and sustained a hematoma to the right leg. Further review revealed the resident did not have his/her shoes on properly and the heels were flopping. Attempted interviews with Resident #20 on 10/30/18 at 4:20 PM and 10/31/18 at 8:29 AM revealed the resident was unable to provide information about the fall on 10/24/18. Interview with Certified Nurse Aide (CNA) #1, on 11/01/18 at 12:45 PM, revealed she was assisting Resident #20 when he/she fell and stated the resident's shoes appeared to be on correctly. She stated the resident was walking really fast during this time. Interview with Licensed Practical Nurse (LPN) #3 who completed the fall investigation, on 11/01/18 at 12:26 PM, revealed an aide was present when Resident #20 fell but she could not catch the resident. She stated she would have expected the aide to ensure the resident's shoes were on properly. Interview with the Director of Nursing (DON), on 11/01/18 at 12:49 PM, revealed the resident had a tendency to put his/her shoes on the wrong foot and staff were constantly attempting to redirect the resident. She stated she would have expected the staff to ensure the residents shoes were on properly prior to ambulation.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of twenty-one (21) sampled residents received the appropriate catheter care to prevent urinary tract infections (Resident #40). Observation of Resident #40, on 10/20/18, 10/31/18, and 11/02/18, revealed the catheter tubing was placed at a level higher than the bladder, not allowing the bladder to drain properly. The findings include: Review of the facility policy titled, Catheterization Care, not dated, revealed to routinely check to ensure catheter tubing is not looped or positioned above the level of the bladder. Record review revealed the facility admitted Resident #40 on 01/14/14 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 09/07/18, revealed the facility assessed Resident #40's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of nine (9), which indicated the resident was interviewable. However, the resident had impaired communication due to mumbled and slurred speech making it difficult to interview him/her. Further review of the MDS revealed the resident had limited functional range of motion (ROM) to bilateral upper and lower extremities, required extensive to total assist with all activities of daily living (ADLs), and had an indwelling urinary catheter. Review of Resident #40's Comprehensive Care Plan for I have a (diagnosis) of [MEDICAL CONDITION] bladder retention and atony of bladder with supra-pubic catheter for urinary elimination; at risk for complications/Urinary Tract Infection, last reviewed 09/11/18, with an approach to Keep drainage bag positioned to promote urinary drainage. However, further review revealed there was no specific approach to address proper placement of the tubing to allow for urine drainage. Further review of the medical record revealed Resident #40 had been hospitalized [DATE] through 07/04/18 and again on 09/26/18 through 09/29/18 for urinary tract infections. Observation, on 10/30/18 at 11:17 AM, and on 10/31/18 at 8:25 AM and 11:15 AM, revealed the supra-pubic catheter tubing was positioned so that it was draped up and over the bed bolster causing the tubing to be at a higher level than Resident #40's bladder; therefore, not allowing the bladder to drain properly. Interview with Certified Nurse Aide (CNA) #3, on 10/31/18 at 11:15 AM, revealed the tubing should not be draped in this fashion (over the bed bolster), because it doesn't allow the urine to drain properly. Observation, on 11/02/18 at 9:18 AM, revealed the catheter tubing had been extended to the foot of the bed with the drainage bag hanging from the bed frame. However, the foot of the bed was elevated which allowed urine to back flow into the bladder and did not allow the bladder to empty properly. Interview with CNA #4, on 11/02/18 at 12:16 PM, revealed she just received an in-service regarding the placement of urinary catheter tubing on the morning of 11/02/18. She stated the drainage tubing should be placed under the bed bolster, not over it so the catheter can drain correctly and not back flow into the bladder. CNA #4 further stated she was not aware of proper placement of drainage tubing until this morning's in-service and often placed the catheter over the bed bolster when providing care, I just didn't think about it. Interview with CNA #5, on 11/02/18 at 12:24 PM, revealed the tubing and the bag were suppose to be placed lower than the bladder. She stated she received an in-service on this information on the morning of 11/02/18, but was aware that the tubing and drainage bag needed to be placed lower than the bladder prior to the in-service. CNA #5 revealed she was aware if the tubing and the drainage bag were not placed appropriately, the urine could drain back into the bladder and cause infections. CNA #5 further stated the resident's bladder leaked often, but was not aware about the urine black flow, and extension of the bladder could cause the leakage. Interview with Licensed Practical Nurse (LPN) #4, on 10/31/18 at 11:25 AM, revealed the catheter tubing over the bed bolster was too high and it allowed urine to back flow into the bladder. She stated she would position the catheter so it was below the bladder level, at least. Interview with the Assistant Director of Nursing (ADON), on 11/01/18 at 10:15 AM, revealed she would expect the catheter tubing to be placed under the bolster, at the resident's side or at least lower than bladder level. Interview with the Director of Nursing (DON), on 11/01/18 at 10:37 AM, revealed the catheter tubing should be placed under the bed bolster and expected staff to follow the policy regarding tubing and drainage bag placement.

Based on interview, record review, and review of the Skilled Nursing Facility Beneficiary Protections Notifications, it was determined the facility failed to issue the required Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to residents/beneficiaries when Medicare covered services ended, for three (3) unsampled residents (Residents #4, #21 and #38). The facility Area Business Office Manager stated no SNF ABN forms had been issued for any residents. Review of Residents #4, #21 and #38's Medicare Discharges revealed the facility did not issue a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN), Form CMS- . The findings include: Review of the facility's Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) Form CMS- , dated (YEAR), revealed Medicare requires SNF's to issue the SNF ABN to beneficiaries prior to providing care that Medicare usually covered, but may not pay for in this instance because the care is not medically reasonable and necessary or considered custodial. 1. Review of the Skilled Nursing Facility Beneficiary Protection Notification Review completed by the facility revealed the facility discharged Resident #4 from Medicare Part 'A' services with the last covered day being 08/09/18; however, the resident still had benefit days which were not exhausted. Further review of the Skilled Nursing Facility Beneficiary Protection Notification Review, revealed the facility did not provide an SNF ABN form CMS- to the resident. 2. Review of the Skilled Nursing Facility Beneficiary Protection Notification Review completed by the facility revealed the facility discharged Resident #21 from Medicare Part 'A' services with the last covered day being 06/08/18; however, the resident still had benefit days which were not exhausted. Further review of the Skilled Nursing Facility Beneficiary Protection Notification Review, revealed the facility did not provide an SNF ABN form CMS- to the resident. 3. Review of the Skilled Nursing Facility Beneficiary Protection Notification Review completed by the facility revealed the facility discharged Resident #38 from Medicare Part 'A' services with the last covered day being 10/03/18; however, the resident still had benefit days which were not exhausted. Further review of the Skilled Nursing Facility Beneficiary Protection Notification Review, revealed the facility did not provide an SNF ABN form CMS- to the resident. Interview with the Area Business Office Manager, on 11/01/18 at 2:21 PM, revealed they had not issued any SNF ABN forms due to having a different understanding of the requirements; however, they now understood the requirements.

Based on interview, record review, and review of the facility policy, it was determined the facility failed to ensure a written notice of transfer/discharge, which included the reason for the resident's transfer, was sent to a representative of the Office of the State Long-Term Care Ombudsman, for four (4) of twenty-one (21) sampled residents (Residents #1, #11, #40 and #52). The Social Services Director stated she had not been notifying the Ombudsman of any resident transfers/discharges per facility policy. Review of Residents #1, #11, #40, and #52's record revealed no documented evidence a representative of the Office of the State Long-Term Care Ombudsman was notified regarding resident transfers. The findings include: Review of the facility policy titled, Discharge and Transfer Summary, not dated, revealed when a resident is discharged or transferred (voluntary or involuntary), a discharge summary and post-discharge plan will be developed. Prior to a resident transfer or discharge, the facility will do the following: Notify the resident and/or the resident's representative of the transfer or discharge and the reason for the move in writing and in a language and manner they understand. The facility will send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. 1. Record review revealed the facility readmitted Resident #11 on 09/02/18, with [DIAGNOSES REDACTED]. Review of the Physician Discharge Summary, dated 09/02/18, revealed Resident #11 was admitted to an acute care facility on 08/31/18 and returned to the facility on [DATE]. However, further review of the medical record revealed there was no documented evidence a representative of the Office of the State Long-Term Care Ombudsman was notified about the resident's transfer to the hospital. 2. Record review revealed the facility admitted Resident #1 on 06/12/17 with [DIAGNOSES REDACTED]. Review of the Physician Discharge Summary revealed Resident #1 was hospitalized from [DATE] to 10/19/18. However, further review of the medical record revealed there was no documented evidence a representative of the Office of the State Long-Term Care Ombudsman was notified regarding the resident's transfer. 3. Record review revealed the facility admitted Resident #40 on 01/14/14 with [DIAGNOSES REDACTED]. Review of the Physician Discharge Summary revealed Resident #40 was hospitalized from [DATE] to 09/29/18. However, further review of the medical record revealed there was no documented evidence a representative of the Office of the State Long-Term Care Ombudsman was notified regarding the resident's transfer. 4. Record review revealed the facility admitted Resident #52 on 05/22/13 with [DIAGNOSES REDACTED]. Review of the Physician Discharge Summary revealed Resident #52 was hospitalized from [DATE] to 10/02/18. However, further review of the medical record revealed there was no documented evidence a representative of the Office of the State Long-Term Care Ombudsman was notified regarding the resident's transfer. Interview with the Social Services Director (SSD), on 11/01/18 at 10:54 AM, revealed she was responsible for notifying the Ombudsman's Office of transfers/discharges. The SSD stated she had not been notifying the Ombudsman for transfers/discharges per facility policy.

Based on interview, record review, and facility policy review, it was determined the facility failed to provide written notice to the resident and resident's representative at the time of transfer for hospitalization s that specified the duration of the bed-hold policy for five (5) of twenty-one (21) sampled residents (Residents #1, #11, #40, #52, and #60). The Administrator stated the facility had not issued the bed hold form, nor sent the bed hold letter when any resident was transferred/discharged from the facilty. The findings include: Review of the facility policy titled, Facility Bed Hold, not dated, revealed the facility will notify the resident/responsible party of the facility's bed hold and readmission policies at admission and anytime a resident is transferred to the hospital or goes out on therapeutic leave. The facility will also notify the resident/responsible party in writing of the reason for transfer/discharge to another legally responsible institutional or non-institutional setting and about the resident's right to appeal the transfer/discharge. The facility's bed hold and re-admission policies will be discusses with the resident/responsible party and the facility will provide written notice of the bed hold and re-admission policies before a resident's transfer to the hospital or for overnight therapeutic leave and included in the resident's transfer packet. 1. Record review the facility readmitted Resident #11 on 09/02/18, with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. 2. Record review the facility readmitted Resident #60 on 08/03/18, with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. 3. Record review revealed the facility admitted Resident #1 on 06/12/17, with [DIAGNOSES REDACTED]. Further record review revealed Resident #1 was hospitalized from [DATE] through 10/19/18; however, there was no documented evidence a written bed hold information was given to the resident or resident's representative for the transfer. 4. Record review revealed the facility admitted Resident #40 on 01/14/14, with [DIAGNOSES REDACTED]. Further record review revealed Resident #40 was hospitalized from [DATE] through 09/29/18; however, there was no documented evidence a written bed hold information was given to the resident or resident's representative for the transfer. 5. Record review revealed the facility admitted Resident #52 on 05/22/13, with [DIAGNOSES REDACTED]. Further record review revealed Resident #52 was hospitalized from [DATE] through 10/02/18; however, there was no documented evidence a written bed hold information was given to the resident or resident's representative for the transfer. Interview with the Administrator, on 11/01/18 at 11:58 AM, revealed the bed hold form was not being used, nor the bed hold letters being issued on residents' transfers/discharges.

Based on observation, interview and review of the facility's policy and procedure, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases for one (1) of five (5)sampled residents (Resident #3) and two (2) unsampled residents (Resident B and D). Observation during medication passes revealed Certified Medication Aide (CMA) #1 and Licensed Practical Nurse (LPN) #1 failed to wash their hands in between passing medications to different residents. The findings include: Review of the facility's policy and procedure titled, Handwashing/Hand Hygiene, last revised (MONTH) (YEAR), revealed all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. Further review of this policy, revealed staff are to use alcohol-based hand rub; or alternatively, soap and water before and and after all contact with residents and before handling medications. Review of the facility nursing procedures, titled Lippincott's Nursing Procedures sixth edition, revealed under the procedure for administering oral drug administration on pages 529-530, it states staff are to perform hand hygiene prior to administration of medication and again after administration of medication. 1. Record review revealed the facility admitted Unsampled Resident B on 02/07/17 with [DIAGNOSES REDACTED]. Observation of medication administration pass, on 04/03/18 at 1:00 PM, revealed CMA #1 passed physician ordered medications to Unsampled Resident A in this resident's room then left the room and returned to the medication cart without performing any hand hygiene. CMA #1 set up Unsampled Resident B's medication and went directly to Unsampled Resident B's room and administered the medication to this resident. After CMA #1 administered the ordered medication to Unsampled Resident B, she left the room and went directly to the medication cart to chart the administered medications without performing hand hygiene once again. Interview with CMA #1 on 04/03/18 at 1:08 PM, revealed she is expected to wash her hands directly after administering medications to each individual resident prior to doing anything else. 2. Record review revealed the facility admitted Unsampled Resident D on 12/20/13 with [DIAGNOSES REDACTED]. Record review revealed the facility admitted Resident #3 on 09/27/13 with [DIAGNOSES REDACTED]. Observation of medication administration pass, on 04/03/18 at 1:20 PM, revealed LPN #1 administered physician ordered medication to Unsampled Resident C and after administering the medication left Unsampled Resident C's room and went directly to the medication cart and did not perform hand hygiene. LPN #1 then prepared Unsampled Resident D's physician ordered medication and took this medication to Unsampled Resident D's room and administered the medication to this resident. LPN #1 then went directly to the medication cart without performing hand hygiene and started to prepare Resident #3's physician ordered medication and took the prepared medication and administered it to Resident #3 who was in the therapy gym. LPN #3 administered the medication to Resident #3 and then went directly back to the medication cart again without performing hand hygiene once again. Interview with LPN #1 on 04/03/18 at 1:30 PM, revealed she is supposed to wash her hands after administering medications to each resident and before handling anything else. She stated she realized that she had failed to wash her hands in between passing medications to the different residents and stated she was nervous and just forgot to do it. Interview with facility Staff Development Coordinator on 04/04/18 at 9:09 AM, revealed licensed staff and medication aides are all trained on appropriate procedures of medication administration. She stated staff passing medications must perform hand hygiene in between each resident and all staff that are licensed and who are medication aides know this and are trained on this. Interview with the Director of Nursing (DON), on 04/04/18 at 11:24 AM, revealed she expected all staff who pass medications to the residents to perform hand hygiene between each resident they administer medications to and she expected all staff to follow facility policies. She stated staff failing to perform appropriate hand hygiene during medication administration would be an infection control issue.

Based on interview, record review, and review of facility policy, it was determined the facility failed to provide medications in accordance with professional standards of practice for one (1) of three (3) sampled residents (Resident #3). Resident #3 had Physician order [REDACTED]. The findings include: Review of the facility's policy titled, Medication Administration, dated (MONTH) (YEAR)), revealed the need for crushing medications is indicated on the resident's orders and Medication Administration Record [REDACTED]. Further review of this policy, revealed Long-acting, Extended Release and [MEDICATION NAME]-coated dosage forms should generally not be crushed and an alternative should be sought. Record review revealed the facility admitted Resident #3 on 09/27/13 with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. However, observation of Licensed Practical Nurse (LPN) #1 on 04/03/18 at 1:25 PM, revealed she crushed Resident #3's [MEDICATION NAME] Arthritis Extended Release 650 milligram caplet even though it was extended release, mixed it with applesauce, and administered it to Resident #3. Interview with Licensed Practical Nurse (LPN) #1 on 04/03/18 at 1:26 PM, revealed she crushes Resident #3's [MEDICATION NAME] Arthritis Extended Release medication and mixes it with jelly due to that is how this resident likes to take that medication. Interview with LPN #1 on 04/03/18 at 1:32 PM revealed typically it is not appropriate to crush Extended Release medication and administer it crushed. She stated the physician should have been notified to see if a different medication could have been ordered that could be crushed. Interview with Pharmacist #1 on 04/03/18 at 2:17 PM, revealed she was a staff pharmacist for the pharmacy the facility uses. She stated it was not appropriate for staff to crush Resident #3's [MEDICATION NAME] Arthritis Extended Release medication and administer it crushed. She revealed Extended Release medications are not supposed to be crushed and it would hinder the medication's efficacy. She also stated she did not feel like the crushing and administering this medication to Resident #3 would cause any harm to the resident it just may hinder the efficacy of this medication. Interview with Pharmacist #2 on 04/03/18 at 3:49 PM, revealed he was the facility's consultant pharmacist. He stated Extended Release medications should not be crushed because the medication would not be as effective and would be shorter acting. He revealed he did not think there would be any harm to the resident from the crushing of the medication but by crushing the medication it would cause the medication to not be effective for the amount of time it was ordered for. He stated if staff were crushing Extended Release medications it would not be appropriate. Interview with the Director of Nursing (DON), on 04/03/18 at 4:04 PM, revealed she expected licensed staff and the Certified Medication Aides to know to not crush Extended Released medications as it would not be appropriate and staff crushing Extended Release medication was a professional standards issue. Interview with Physician #1 on 04/04/18 at 1:37 PM, revealed he expected his physician's orders [REDACTED]. He stated he would expect the staff to inform him if a resident needed their medications crushed so he could change the medications to something other than extended release.

Based on interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to follow interventions of the care plan related to a fall for one (1) of three (3) sampled residents, (Resident #2). Resident #2 was care planned for falls with an intervention for Nurse to report falls to physician and responsible party. On 08/12/17, Resident #2 was transferred, with assistance of two (2) staff, from the bed to the wheelchair and during the transfer, Resident #2 legs became shaky so staff assisted the resident to the floor. However, the daughter and physician were not made aware of the fall until 08/14/17 when the resident was identified to have a fractured left tibia/fibula (lower leg) at the hospital. The findings include: Review of the Care Plans-Comprehensive policy, not dated, revealed an individualized comprehensive care plan that includes measurable objectives and time tables to meet the resident's medical, nursing, mental, and psychosocial needs is developed for each resident. Care plans are revised as information about the resident and the resident's condition change. Record review revealed the facility admitted Resident #2 on 10/23/15, with [DIAGNOSES REDACTED]. Review of Resident #2's Comprehensive Care Plan for at risk for fall related injury related to decreased mobility, last revised 06/14/17, revealed the Nurse is to report falls to physician and responsible party. However, review of the facility's Nursing Assessment Event Report, dated 08/14/17, revealed on 08/12/17 at 5:30 AM (two {2} days earlier), Resident #2 had an assisted fall to the floor while transferring from the bed to the wheelchair by two (2) staff members and Resident #2's daughter (listed as emergency contact), was not notified until 08/14/17 at 7:50 PM; and, Resident #2's Primary Care Physician was not notified until on 08/14/17 at 8:00 PM. Interviews with Resident #2's daughter, on 09/22/17 at 11:03 AM, and with Physician #2, on 09/25/17 at 2:00 PM, revealed they were not notified of Resident #2's fall on 08/12/17 until the resident was sent to the hospital on [DATE] and was identified to have a Left Tibia/Fibula Fracture and Urinary Tract Infection [MEDICAL CONDITION]. Interview with Licensed Practical Nurse (LPN) #3, on 09/22/17 at 12:35 PM, revealed she was the nurse assigned to Hall 2 on 08/12/17 at the time of Resident #2's fall. LPN #3 stated she did not report the fall to the Physician and Resident #2's daughter because she did not consider it a fall because staff had assisted the resident to the floor. Interview with the Director of Nursing (DON), on 09/25/17 at 4:40 PM, revealed she expected the nurse to follow the care plan and to have reported the assisted transfer to floor to the Physician and family member.

Based on interview, record review, and facility policy review, it was determined the facility failed to identify an assisted transfer to the floor as a fall for one (1) of three (3) sampled residents (Resident #2) which resulted in the facility failing to assess the resident each shift for seventy-two (72) hours, failing to notify physician and family, failing to document assessment and pertinent facts and incident in Event Manager; and failing to make oncoming staff aware per facility policy. Resident #2 sustained a fall on 08/12/17 during a transfer from bed to wheelchair when he/she stumbled and staff had to lower him/her to the floor. Licensed staff failed to complete an Event Report of the incident which would have included documentation of an assessment of the resident, to make the oncoming shift aware to ensure assessed for seventy-two hours after the fall, and failed to notify the physician and family; per facility policy. On 08/14/17, the resident was sent to the hospital and was identified to have a fracture to the Tibia/Fibula (lower leg). The findings include: Review of the Federal regulatory tag F-323: Quality of Care 483.25(h), definition of a fall refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force. An episode where a resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall. A fall without injury is still a fall. Review of the facility policy and procedures for Falls, dated 06/01/15, revealed it is the intent of the facility to provide residents with assistance and supervision in an effort to minimize the risk of falls and fall related injuries. If a fall occurs the following actions will be taken: a. Assess resident including neurochecks, pain, range of motion, skin, joints, vital signs b. assess resident each shift for seventy-two (72) hours e. notify physician and family f. document assessment, pertinent facts and incident in Event Manager k. enter residents name on the twenty-four (24) report Record review revealed the facility admitted Resident #2 on 10/23/15, with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/07/17, revealed the facility assessed Resident #2's cognition as intact with a Brief Inventory of Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Review of Resident #2's Fall Risk Evaluation, dated 06/08/17, revealed a total score of sixteen (16). Further review of the evaluation revealed a resident who scores a ten (10) or higher is at risk for falls. Review of Resident #2's Comprehensive Care Plan for at risk for fall related injury related to decreased mobility, last revised 06/14/17, revealed the Nurse is to report falls to physician and responsible party. Interview with Resident #2, on 09/22/17 at 10:15 AM, revealed he/she complained of instant pain to left lower leg after the fall. Resident #2 stated he/she rated his/her pain at eight (8) on a scale of one (1) to ten (10) with (10) being the worst. Resident #2 revealed he/she does not remember whether he/she was medicated for the pain following the fall. Interview with State Registered Nurse Aide (SRNA) #4, on 09/22/17 at 7:05 AM, revealed on 08/12/17 at approximately 6:00 to 6:30 AM, she and SRNA #5 was transferring Resident #2 from the bed to the wheelchair. She stated the Resident stood up, and as SRNA #4 was pulling up Resident #2's pants the Resident's knees buckled, and SRNA #4 stated, the resident complained that his/her knees gave way, so we slid the resident to the floor. Interview with SRNA #5, on 9/22/17 at 7:18 AM, revealed she and SRNA #4 were in the process of transferring Resident #2 from bed to wheelchair. She stated Resident #2 was using the walker, took one (1) step forward when the resident knees got wobbly. She revealed SRNA #4 attempted to get the wheelchair; however' the resident continued to go down. SRNA #5 stated, We assisted Resident #2 to the floor, she ended up on my right foot. Interview with Licensed Practical Nurse (LPN) #2, on 09/22/17 at 7:37 AM, revealed she assisted SRNA #4 and #5 in getting Resident #2 off the floor. She stated she assessed Resident #2 and the resident did not complain of any pain. She revealed Resident #2's vital signs were not taken and she did not document the fall in the resident's Nurses Notes or on an Event Manager Report. LPN #2 revealed she was not the Nurse assigned to Resident #2's care at the time of the incident. Interview with LPN #3, on 09/22/17 at 12:35 PM, revealed she was the nurse assigned to Hall 2 on 08/12/17 at the time of Resident #2's fall. LPN #3 stated she was informed of the incident by SRNA #4. LPN #3 revealed she entered Resident #2's room and noted the resident lying on the floor with a pillow underneath his/her head. LPN #3 stated she performed neurochecks on the resident, assessed range of motion, and assessed for pain, swelling, and bruising; however, she failed to obtain Resident #2's vital signs, document the assessment and/or other pertinent facts of the incident, nor did she report the fall to the oncoming shift because she did not consider the incident a fall, but an assisted transfer. Review of the facility's Nursing Assessment Event Report, dated 08/14/17 (two days after fall), revealed on 08/12/17 at 5:30 AM, Resident #2 was transferred, with assistance of two (2) staff, from the bed to the wheelchair. During the transfer, Resident #2 legs became shaky so staff assisted the resident to the floor. Interview with Resident #2's daughter, on 09/22/17 at 11:03 AM, revealed the facility sent Resident #2 to the hospital on [DATE] and the resident was hospitalized with a Fracture of the Left Tibia/Fibula (bones of the lower leg) and a Urinary Tract Infection (UTI). She stated Resident #2 reported he/she fell at the facility but the daughter stated she was not aware of the fall even though she was the Emergency Contact. She further stated Resident #2 had bruising to left foot and ankle when she arrived at the hospital. Interview with Physician #1, on 09/22/17 at 10:18 AM, revealed Resident #2's Left Tibia/Fibula fracture was consistent with a fall (trauma). Physician #1 stated Resident #2's fracture was not the result of Arthritis or any other medical condition. Interview with the Administrator and Director of Nursing (DON), on 09/25/17 at 4:40 PM, revealed they expected an Event Manager Report related to Resident #2's incident whether identified as an assisted transfer to floor or a fall. Further interview revealed they expected the nurse to notify the family and physician of the fall, to document the incident, and to report to the oncoming nurse.

Based on interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to provide nursing services to meet professional standards when the (former) Director of Nursing (FDON) directed the Medical Records Licensed Practical Nurse (LPN) to write orders to discontinue or change medications for ten (10) residents, in the selected sample of ten (10) residents (Residents #2, #3, #4, #5, #6, #7, #8, #9, #10 and #11). The finding include: Review of the facility's policy, Physician Orders, not dated, revealed the physician's orders [REDACTED]. 1. Record review revealed the facility admitted Resident #2 on 05/29/15 with [DIAGNOSES REDACTED]. Review of Resident #2's Physician order [REDACTED]. The resident missed two (2) doses of each medication. The resident's blood pressure was monitored daily for three (3) days without significant change. 2. Record review revealed the facility admitted Resident #3 on 07/24/13 with [DIAGNOSES REDACTED]. Review of Resident #3's Physician order [REDACTED]. The resident missed two (2) doses, and there was no change made to the [MEDICATION NAME] by the MD. 3. Record review revealed the facility admitted Resident #4 on 10/26/15 with [DIAGNOSES REDACTED]. Review of Resident #4's Physician order [REDACTED]. The MD did not change these medication reductions of discontinuation, and the resident was monitored. 4. Record review revealed the facility admitted Resident #5 on 10/13/15 with [DIAGNOSES REDACTED]. Review of Resident #5's Physician order [REDACTED]. The MD allowed the [MEDICATION NAME] dose to remain at every other day and restarted the [MEDICATION NAME]/HCTZ after three (3) doses were omitted. 5. Record review revealed the facility admitted Resident #6 on 05/26/14 with [DIAGNOSES REDACTED]. Review of Resident #6's Physician order [REDACTED]. 6. Record review revealed the facility admitted Resident #7 on 04/01/11 with [DIAGNOSES REDACTED]. Review of Resident #7's Physician order [REDACTED]. The resident missed two (2) doses of [MEDICATION NAME] and four (4) doses of [MEDICATION NAME]; however, there was no adverse effect and the medications were restarted by the MD on 06/23/17. 7. Record review revealed the facility admitted Resident #8 on 05/01/14 with [DIAGNOSES REDACTED]. Review of Resident #8's Physician order [REDACTED]. The MD did not restart the [MEDICATION NAME] and the O2 saturations were to be monitored and utilized as needed. 8. Record review revealed the facility admitted Resident #9 on 02/20/15 with [DIAGNOSES REDACTED]. Review of Resident #9's Physician order [REDACTED]. 9. Record review revealed the facility admitted Resident #10 on 11/24/14 [DIAGNOSES REDACTED]. Review of Resident #10's Physician order [REDACTED]. The MD restarted [MEDICATION NAME] at 10 mg daily and the GDR of [MEDICATION NAME] remained in effect. 10. Record review revealed the facility admitted Resident #11 on 02/29/16 with [DIAGNOSES REDACTED]. Review of Resident #11's Physician order [REDACTED]. The MD did not restart either the [MEDICATION NAME] or the APAP and discontinued the [MEDICATION NAME] altogether. Interview with the Medical Records LPN, on 07/20/17 at 11:25 AM, revealed she, the current Interim DON, the Social Services Director (SSD), and the former DON attended a Care Partners Team quarterly meeting on 06/21/17. In this meeting, the administrative nursing staff and SSD discussed the residents' behaviors, pharmacy GDR's and psychotherapeutic medications of which residents were prescribed by the MD. She stated they compared the pharmacy's recommendations for GDR, the residents' behaviors and noted any failures of the GDR to discuss with the MD. During this meeting, the former DON brought out a list of other medications where the former DON stated she reviewed and compared several resident's medications to the BEERS list. Further stating that she had spoken to the MD and wanted to get rid of some of the medications residents were administered. Additionally, the Medical Records LPN's delegated duty for this change would be to write the orders and change the electronic Medication Administration Records (eMAR) to reflect the order changes and write patient monitoring instructions for the staff nurses. The Medical Records LPN and Interim DON questioned changing or discontinuing blood pressure medications and/or antihyperlipidemics when the former DON put her hand up in front of her like a stop sign and said I've talked to the Doctor and he's ok with the changes. Further interview with the Medical Records LPN revealed she followed the former DON's delegation of the task to write the orders to change medications on the front cart of hall one (1) for approximately ten (10) residents' orders, eMAR's, and monitoring plan for 72 hours. Additional interview revealed even though she questioned the former DON she did not feel right about writing orders, the former DON directed her to write, and discussed it with the Interim DON, and took the orders to the MD's office the following morning. She revealed when the MD saw and read those order changes he commented, I did not authorize anyone to change those medications and stated he would come to the facility and take care of the problem. Interview with the SSD, on 07/20/17 at 12:50 PM, revealed she, the Medical Records LPN, the Assistant Director of Nursing (ADON) and the former DON attended a Care Partners Team quarterly meeting on 06/21/17. In this meeting, the administrative nursing staff and SSD discussed the residents' behaviors, pharmacy GDR's and psychotherapeutic medications of which residents were prescribed by the MD. She stated they compared the pharmacy's recommendations for GDR, the residents' behaviors and noted any failures of the GDR to discuss with the MD. During this meeting, the former DON brought out a list of other medications where the former DON stated she reviewed and compared several resident's medications to the BEERS list. Further stating that she had spoken to the MD and wanted to get rid of some of the medications residents were administered. Additionally, the Interim DON's duty for this change would be to review the residents' behaviors and the consents for psychotherapeutic medications and get the consents updated with the families. The Interim DON questioned changing or discontinuing blood pressure medications and/or antihyperlipidemics when the former DON put her hand up in front of her like a stop sign and said I've talked to the Doctor and he's ok with the changes. Interview with the Interim DON, on 07/20/17 at 10:10 AM, revealed she, the Medical Records LPN, the SSD and the former DON attended a Care Partners Team quarterly meeting on 06/21/17. In this meeting, the administrative nursing staff and SSD discussed the residents' behaviors, pharmacy Gradual Dose Reductions (GDR) and psychotherapeutic medications of which residents were prescribed by the Medical Director (MD). She stated they compared the pharmacy's recommendations for GDR, the residents' behaviors and noted any failures of the GDR to discuss with the MD. During this meeting, the former DON brought out a list of other medications where she stated she reviewed and compared several resident's medications to the BEERS list. She further stated she spoke to the MD and wanted to get rid of some of the medications residents were administered. Additionally, the Interim DON's duty for this change would be to review the residents' behaviors and the consents for psychotherapeutic medications and get the consents updated with the families. The Interim DON questioned changing or discontinuing blood pressure medications and/or antihyperlipidemics when the former DON put her hand up in front of her like a stop sign and said I've talked to the Doctor and he's ok with the changes. Interview with the Medical Director, on 07/18/17 at 4:00 PM, revealed he had spoken with the former DON in general about inappropriate medications in the elderly population; however, he never gave her specific orders of any medication changes. Interview with the former DON, on 07/19/17 at 5:15 PM, revealed she was leading a Care Partners Team meeting on 06/20/17 or 06/21/17 with the ADON, Medical Records LPN, and SSD where they were discussing behaviors of the residents, psychotherapeutics and GDR'ing some medications. She stated I had been doing some reading and research on inappropriate medications in the elderly population and had discussed it with the MD. We (the team) were making some changes to the residents' medications. I asked the Medical Records LPN to write the orders for those medication changes. Interview with the Administrator, on 07/18/17 at 4:20 PM, revealed the nurses thought the former DON had spoken with the MD about specific medication changes when probably the conversation had been a general agreement that some of the medications should be changed. The former DON delegated those changes be made; however, the Physician was unaware of the specific changes. **The facility implemented the following actions to correct the deficient practice: 1. The former DON was suspended from duty on 07/01/17. The Assistant DON was directed to function as Interim DON at that time. The DON's employment was terminated on 07/03/17. 2. Education was initiated and provided by the Corporate Nurse Consultant (CNC) to the Interim DON and the Medical Records LPN, 07/06/17, on Physician Orders, RN/LPN Scope of Practice, Physician order [REDACTED]. 3. The Interim DON provided education for the Licensed Nurses regarding Physician Orders, RN/LPN Scope of Practice, Physician order [REDACTED].'s (PA) are to give orders. The education was completed for the facility's Licensed staff on 07/07/17. 4. On 07/03/17 an interdisciplinary team made up of the Administrator, Director of Nursing, MDS Coordinator, Medical Records LPN, Social Services, Quality of Life Director, Dietary Manager, Admissions Coordinator, and Central Supply/Staffing Coordinator initiated clinical morning meetings; to be conducted Monday through Friday, and the Weekend Manager was to review Saturday and Sunday's agenda to include review of telephone orders, SBAR's, 24 hour report, green cards (nursing monitoring indicators) and Electronic Medical Record (EMR) to ensure proper documentation and notifications were made. 5. The DON will audit ten percent (10%) of Resident's Electronic Medical Record (EMR) weekly for four (4) weeks, then monthly for three (3) months to ensure a Licensed Independent Prescriber gave any orders and notification of responsible parties was conducted. 6. The DON will report findings of the above three (3) audits to the Administrator and Quality Assurance Performance Improvement (QAPI) committee monthly for three (3) months for further recommendations and follow-up where indicated. **The State Survey Agency validated the facility's plan of action was carried out by: 1. Review of the former DON's personnel file revealed the former DON was suspended on 07/01/17 and terminated from employment on 07/03/17. 2. Interview with the Interim Director of Nursing (IDON) on 07/20/17 at 10:10 AM revealed she was educated by the CNC related to Physician Orders, RN/LPN Scope of Practice and, Physician order [REDACTED]. Interview with the Medical Records LPN on 07/20/17 at 11:25 AM revealed she was provided education by the CNC regarding Physician Orders, RN/LPN Scope of Practice an, Physician order [REDACTED]. 3. Interview with the IDON on 07/20/17 at 10:10 AM revealed she had provided education for all the licensed nurses in regards to RN/LPN Scope of Practice and Physician Orders; who may give and from whom orders may be taken (Licensed Independent Providers, Medical Doctors, Advanced Practice Registered Nurses, Psychiatrists and/or Doctors of Dental Medicine) and notification of Responsible Parties of Prescriber Orders or changes. Interview with RN #1 on 07/20/17 at 12:45 PM revealed she was provided education by the CNC regarding Physician Orders, RN/LPN Scope of Practice, Physician order [REDACTED]. Interview on 07/20/17 at 1:45 PM with LPN #1 revealed she was provided education by the CNC and the IDON on Physician Orders, RN/LPN Scope of Practice, Physician order [REDACTED]. 4. Interview with the IDON on 07/20/17 at 10:10 AM and the MRLPN and the Weekend Manager 07/20/17 at 11:20 AM revealed review of any orders (verbal or telephone) was completed on a daily basis Monday through Friday, and by the Weekend Manager on Saturday and Sunday. Revealed of documentation of the daily reviews and green cards (order and monitoring indicator) were reviewed to confirm the daily review was accomplished by the Interim DON and the Medical Records LPN; as well as the Week-end Manager's reviews. 5. Interview with the IDON 07/20/17 at 12:55 PM revealed she had performed a random audit of 10% of the EMRs for new or changed Physician order [REDACTED]. 6. The first report to the Administrator and QAPI Committee was not due until 08/06/17.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure medications dated when opened to ensure the safe administration of medications on one (1) of three (3) medication carts and two (2) of two (2) medication refrigerators. The findings include: Review of facility policy titled Storage of Medication, dated [DATE] revealed medications and biologicals should be stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The procedures of the policy revealed Insulin products should be stored in the refrigerator until opened. Note the date on the label for insulin vials and pens when first used. Further review of the procedures revealed outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures should be immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy, if a current order exists. 1. Observation with Registered Nurse (RN) #1 of the medication refrigerator for Hall one (1) and Hall two (2), on [DATE] at 9:53 AM, revealed there were seven (7) of nine (9) multi-dose insulin vials opened and not dated. There was (one (1) vial of Humulin R 100 units (u)/milliliter (ml), one (1) vial of Novolin R 100 u/ml, two (2) vials of Levemir 100 u/ml, two (2) vials of Lantus 100 u/ml, and one (1) vial of Humalog 100 u/ml. Further observation of each insulin vial revealed a pharmacy label stating, expires twenty-eight (28) days after opening. In addition, there were four (4) of twelve (12) eye drop bottles (Travatan Z 0.004% 2.5 ml bottle, Timolol Maleate 0.5% 5 ml bottle, Latanoprost .005% 2.5 ml bottle, and Sodium Chloride 5% 15 ml bottle that were opened and not dated. Interview with RN #1, on [DATE] at 10:20 AM revealed You do not want to give a medication that is expired because it is compromised and you would not know if it is beyond the use date if there is not a date when the medication was opened. 2. Observation of the Hall 3 medication refrigerator wit Licensed Practical Nurse (LPN) #2, on [DATE] at 10:28 AM, revealed a multi-dose vial of Tubersol, dated [DATE]. 3. Observation of the Hall 3 medication cart with LPN #2, on [DATE] at 10:35 AM, revealed one (1) Breo Inhaler Ellipta ,[DATE] micrograms (mcg) was not dated when opened. Review of the package instructions revealed to discard after six (6) weeks. In addition, there was one (1) bottle of ear drops (Ciprodex Otic 7.5 ml) and one (1) bottle of eye drops (Artificial Tears 1.4% 15 ml) not dated when opened. Interview with LPN #2 on [DATE] at 10:43 PM revealed when there was no opened date on the medication they would have to take it for granted it was opened twenty-eight (28) days ago, discard the medication, and reorder. She stated if the medication was not dated, there was no way of knowing when the medication was opened. Interview with facility contracting Pharmacist, on [DATE] at 9:33 AM revealed Tubersol was only good for thirty (30) days from when the vial has been punctured, the Breo inhaler should be discarded six (6) weeks after opening. He stated the Humulin R should be discarded in thirty-one (31) days, Levemir and Novolin R should be discarded in forty-two (42) days, Lantus and Humalog should be discarded in twenty-eight (28) days, the eye and eardrops should be discarded in sixty (60) days with a few exceptions, and Latanoprost should be discarded in forty-two (42) days. Further interview revealed inhalers once taken out of the foil pouch start to decline in effectiveness and the discarded dates varies depending on the type of inhaler some are thirty (30) days, forty-five (45) days, while some are good for twelve (12) months. She further stated liquids are good for sixty (60) days and that varies on the type of liquid. She further revealed if the medications are not discarded after, the date recommended after opening, the medications lose their sterility and effectiveness. She stated that items that are to be discarded after a certain date after opening should be dated when opened. Interview on [DATE] at 10:08 AM with LPN #1 revealed eye and eardrops, inhalers, and insulin should be dated when used for the first time as these drugs are only stable for a certain amount of time and the nurses would need to know when to reorder and discard. She stated that Tubersol should be discarded thirty (30) days after first dose. Interview on [DATE] at 10:15 AM with RN #2 revealed all inhalers, Tubersol, insulin, and ear and eye drops should be dated when opened. She stated the nurse/CMA should not give an expired medication past the beyond use date to the residents as the stability of the medications is decreased. She further revealed Tubersol and insulin are good for twenty-eight (28) days and the ear and eye drops and inhalers are okay for longer. Interview on [DATE] at 10:30 AM with the Director of Nursing (DON) revealed she expected the nurses to date and initial eye and eardrops, inhalers, insulin, and Tubersol with the first dose administered and opening and would prefer the nurses to date when the medication should be discarded. She stated there was a potential adverse effect for the resident to continue to use past the beyond use date (BUD). She stated that there was a potential the medication could increase or decrease in their therapeutic response.

Based on interview, record review, review of hospital records, review of the facility's policy and procedure, and review of the Kentucky Board of Nursing (KBN) Advisory Opinion Statement (AOS) #14, it was determined the facility failed to ensure professional standards of quality were provided for one (1) of three (3) sampled residents (Resident #1) related to administering medications as ordered. Review of Resident #1's physician's orders [REDACTED]. However, review of Resident #1's May 2016 EZMAR (Electronic Medication Administration Record) revealed the resident's order for [MEDICATION NAME] 6 mg, give one (1) tablet daily, was discontinued after the 05/26/16 dose was administered. The facility's system to ensure physicians' orders were transcribed to the EZMAR correctly was ineffective. The facility checked the Administrative side (physician order [REDACTED]. However, the facility failed to identify there was no hour of administration (HOA) which would have caused the order for [MEDICATION NAME] to not be renewed on the on the Administration side of the EZMAR. In addition, the facility failed to check the Administration side (medication pass side) that the nurses use to administer the medication, which resulted in the facility failing to identify that the order had been discontinued on the EZMAR. This resulted in Resident #1 missing seventeen (17) doses of [MEDICATION NAME] (05/27/16-06/12/16). On 06/12/16, Resident #1 was sent to the emergency room (ER) and was admitted to the hospital with [REDACTED]. The resident was placed on [MEDICATION NAME] Drip due to low (International Normalized Ratio) INR to increase the resident's INR due to missing the doses of [MEDICATION NAME]. Immediate Jeopardy (IJ) was identified on 06/17/16 and was determined to exist on 05/26/16. The facility was notified of the Immediate Jeopardy (IJ) on 06/17/16. An acceptable Allegation of Compliance (AoC) was received on 06/27/16, alleging the removal of the Immediate Jeopardy (IJ) on 06/21/16. The State Survey Agency validated, on 06/28/16 through 06/30/16, that the Immediate Jeopardy (IJ) was removed on 06/21/16, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the KBN, AOS #14 Patient Care, last revised October 2010, revealed licensed nurses were responsible for the administration of medication and treatment as prescribed by the physician and/or advanced practice registered nurse. Review of the facility's policy and procedure, Physician order [REDACTED]. Copies of the order were to be provided to the Director of Nursing (DON) or Assistant Director of Nursing (ADON), Medical Records, and the original copy stayed in the chart. Copies of the order were to be taken to the daily clinical meeting; the orders were to be compared for accuracy; and, following the clinical meeting, the DON, or designee reviewed the EZMAR and chart for new order accuracy. Record review revealed the facility admitted Resident #1 on 02/11/10 with diagnoses, which included [MEDICAL CONDITION] Fibrillation, [MEDICAL CONDITION] [MEDICAL CONDITIONS], and Cerebral [MEDICAL CONDITION]. Review of the Progress Notes, dated 06/12/16 at 9:37 AM, and interview with LPN #1 on 06/15/16 at 11:45 AM and on 06/25/16 at 11:45 AM revealed LPN #1 was called to Resident #1's room due to Resident #1 acting different. LPN #1 identified Resident #1 had left sided weakness, the resident's left pupil was pinpoint and nonreactive, and the resident was nonverbal. The resident's physician and Emergency Medical Services (EMS) were notified at this time. LPN #1 stated the hospital Physician called and asked about the resident's [MEDICATION NAME] and that was when she identified the order had been discontinued on 05/26/16 and the resident had not received [MEDICATION NAME] for seventeen (17) days. Review of Resident #1's Hospital Records, dated 06/12/16, revealed the resident was admitted to the hospital with [REDACTED]. The resident was placed on [MEDICATION NAME] Drip due to low (International Normalized Ratio) INR. Review of the physician's orders [REDACTED]. However, review of the May 2016 EZMAR, revealed the order for [MEDICATION NAME] 6 mg, give one (1) tablet daily, was discontinued after the 05/25/16 dose was administered. Review of the June 2016 EZMAR, revealed there was no documented evidence the order was continued. Interview with Licensed Practical Nurse (LPN) #2, on 06/15/16 at 11:24 AM, revealed she entered the new order into the Administrative side of the EZMAR and hit save but she did not check the EZMAR to ensure the order was on the EZMAR, as this was not the facility's process. In addition, she stated she did not recall if she had included the HOA and or stop date, which was needed to ensure the medication, would renew on the Administration side of the EZMAR. Interviews on 06/16/16 with LPN #6 at 8:22 AM and LPN #7 at 4:10 PM; and on 06/15/16 with LPN #3 at 3:10 PM, and LPN #4 at 3:18 PM, revealed the nurses enter the physician's orders [REDACTED]. They stated they do not go into the Administration side (medication pass side) of the EZMAR to verify the order was there, as it was not part of their process. The LPNs stated the facility did not have a system to verify that all the physicians' orders had been transferred over to the EZMAR from month to month. Interview with LPN #8, on 06/20/16 at 2:15 PM, revealed part of her responsibility as part of the Interdisciplinary Team (IDT) was to review all the new written physicians' orders to make sure they were in the EZMAR correctly. She stated she compared the written order in the Administrative portion (physician order [REDACTED]. She further revealed it was not part of the facility's process to go into the Administration portion side (medication pass side) of the EZMAR screen where the nurses sign off the medications. She stated she just verified the slips with the orders on the Administrative side of the EZMAR. Interview with the Director of Nursing (DON), on 06/12/16 at 2:15 PM, and 5:53 PM; on 06/16/16 at 10:09 AM and 3:06 PM; on 06/17/16 at 10:45 AM; and, on 06/20/16 at 1:25 PM and 2:01 PM, revealed the Interdisciplinary Team (IDT) reviewed all new Physicians' Orders daily Monday through Friday. She stated the facility did not require the nursing staff to double check the physician's orders [REDACTED]. Interview with Resident #1's Physician, on 06/15/16 at 3:47 PM, revealed Resident #1 has been on [MEDICATION NAME] for many years for [MEDICAL CONDITION] Fibrillation and missing seventeen (17) doses of [MEDICATION NAME] would be considered a significant medication error and could lead to a potential stroke, clot, or [MEDICAL CONDITION] Fibrillation. Interview with the Administrator, on 06/17/16 at 9:31 AM, revealed he would expect Resident #1 to have received his/her medication as ordered by his/her physician. Further interview revealed he was not aware of anything in place to check the MARs for accuracy at the end of the month, or to determine if medications were still in the system for administration after the nurses entered a new physician's orders [REDACTED].>**The facility implemented the following actions to remove the Immediate Jeopardy: 1. LPN #1 completed a review of the Electronic Medication Administration Records (EZMARs) for the other three (3) residents who received [MEDICATION NAME] to ensure their orders were in place in the system and that [MEDICATION NAME] was being administered to all others as ordered. This was completed on 06/12/16 with no concerns identified. 2. A physical assessment was completed on all other residents with orders for [MEDICATION NAME] (3) by LPN #1 on 06/12/16 with no concerns. No changes of condition were identified. 3. Three (3) medication carts were audited by LPN #1 on 06/12/16 to ensure the ordered doses of [MEDICATION NAME] were available for all residents who have orders for [MEDICATION NAME]. No concerns were identified. A follow-up audit of the three (3) medication carts was completed by the DON on 06/12/16 with no concerns identified. In addition, a 100% internal audit of all residents' medications to include medications that require monitoring was conducted. 4. The DON and the Staff Development Coordinator (SDC) completed an audit on the electronic physician's orders [REDACTED]. No other orders were identified as not having an hour of administration (HOA). 5. Education was initiated on 06/12/16 and completed on 06/20/16 by the Staff Development Coordinator (SDC) and DON for full-time and part-time Licensed Nurses and Certified Medication Aides (CMAs) regarding general medication orders; the EZMAR (Electronic Medication Administration) policy regarding the inclusion of hours of administration (HOA); daily review of physicians' orders; medication discrepancies; the seven (7) rights of accurate medication administration; non-controlled medication orders; transcription of Medication Orders; the Anticoagulation Management Policy; and, the Electronic Medical Records process. 6. Certified letters were drafted by the Administrator and mailed out on 06/15/16 to inform all staff on medical leave, on FMLA (Family Medical Leave Act), vacation, and all PRN (as needed) staff that they would require education prior to returning to work. 7. Physicians' Orders were reviewed on 06/13/16 for all residents by the DON, ADON, SDC, Medical Records Nurse (MRN), Restorative Nurse Manager, and Nursing Consultant and compared to the Electronic Medication Administration Record to ensure that all other medications were being administered as ordered. No further discrepancies were identified. 8. The DON or the ADON will review medication administration records (EZMAR), hour of administration (HOA), and review of [MEDICATION NAME] count sheets daily (5 days per week) for four (4) weeks then three (3) times per week for four (4) weeks to ensure anticoagulant medications have been administered as ordered which began on 06/13/16. Audits will be continued based on recommendation from the Quality Assurance/Process Improvement committee. On weekends, an Administrative Nurse, (Director of Nursing, Assistant Director of Nursing, Restorative Nurse Manager, Medical Records Nurse, MDS Nurse, or Staff Development Coordinator) will be assigned to review medication administration records to ensure anticoagulant medications have been administered as ordered and meet intent. If concerns are identified, the DON will be notified after an assessment of the resident has been conducted in order to make sure the resident is safe. If any change is identified, the Physician and the Resident's Responsible Party will immediately be notified. If no change of condition is identified, the Physician will be notified. 9. On 06/13/16, the DON moved [MEDICATION NAME]/[MEDICATION NAME] to the narcotic drawer, and now requires that [MEDICATION NAME]/[MEDICATION NAME] be counted and signed out by licensed nurses and/or Certified Medication Aides to ensure appropriate administration. The DON, ADON and SDC will compare the [MEDICATION NAME] count sheets to the Medication Administration Record (EZMAR) process daily (Monday through Friday). On the weekends, this will be assigned to an Administrative Nurse (DON, ADON, Restorative Nurse Manager, Medical Records Nurse, MDS Nurse, or SDC). 10. Residents requiring the use of anticoagulants will be discussed in the clinical meeting daily as an on-going process, attended by the interdisciplinary team to include, but not limited to the Director of Nursing, Assistant Director of Nursing, Social Services Director, Staff Development Coordinator, Dietary Manager, and Quality of Life Director, Monday through Friday. This includes review of their Medication Administration Records, Nurse's Notes, Care Plans, and [MEDICATION NAME] count sheets to ensure anticoagulants medications have been administered as ordered. On weekends, an Administrative Nurse will be assigned to review Medication Administration Records, Nurse's Notes, Care Plans, and [MEDICATION NAME] count sheets to ensure anticoagulant medications have been administered as ordered. This process began on 06/13/16 and will continue as an ongoing process. 11. Education was initiated and completed on 06/13/16 by the Nurse Consultant for the interdisciplinary team including the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Social Services, Dietary Manager, and Quality of Life Director regarding the Anticoagulation Management Policy and daily follow-up for residents who require the use of Anticoagulant medications. 12. On 06/15/16, directed education was completed by the Nurse Consultant for Nurses and Certified Medication Aides who were responsible for passing medications to Resident #1 at the 4:00 PM medication pass from May 27, 2016 through June 11, 2016. 13. On 06/15/16, the PharMerica Product Training and Implementation Consultant came to the facility to assist with identification of the electronic medication administration system concerns. She provided education on 06/15/16 to the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Medical Records Coordinator, and licensed nursing staff regarding approving or rejecting orders, discharging residents, leave of absence, and readmit function. She will be available to provide further assistance and training as indicated. 14. On 06/15/16, the Business Development Analyst from the corporation's Information Technology Department came to the facility to correct the identified concern with the electronic medication administration system. He identified a concern with the compatibility of one (1) of the facility's computers with the PharMerica (owner of the electronic medication administration program utilized by the facility) system. He determined if the compatibility setting was found to be on Internet Explorer 10, there was no compatibility concern, which was the case with all but one (1) of the laptop computers used by the licensed nursing staff. On one (1) laptop computer, the compatibility settings were found to be on Internet Explorer 11, which was not compatible with the PharMerica suite. He changed the compatibility setting to correct the identified issue. A sign was placed on desktop computers instructing users not to enter physicians' orders on the desktop computers until further notice. The concern with the compatibility of desktop computers was addressed and resolved by PharMerica with a server side update that was completed on 06/16/16. These corrections ensured orders must contain the hour of administration (HOA) or they would not be accepted by the system. The Business Development Analyst would be available to provide further technical assistance, as needed. 15. Care plans were reviewed by the Nurse Consultant on 06/12/16 to ensure interventions were in place regarding the use of anticoagulation therapy. No Concerns were identified. Care plans were again reviewed on 06/13/16 by the Interdisciplinary Team: Director of Nursing, Assistant Director of Nursing, Social Services, Dietary Director, and Quality of Life Director, for residents requiring the use of anticoagulant therapy, to ensure further updates were not needed. There were no concerns identified. 16. The Nurse Consultant will audit the physician's orders [REDACTED]. 17. A nurse from the regional team or home office has been available since 06/12/16. The nurses from the regional team or home office are performing chart audits to compare anticoagulant orders with MARs, observing care delivery as per care plans and providing oversight and consultation to licensed staff and Certified Medication Aides. Onsite visits from the regional team or corporate office will occur daily until immediacy is removed and then weekly for four (4) weeks. Concerns identified will be corrected immediately and reported to the Administrator and the Director of Nursing. 18. A Quality Assurance Performance Improvement (QAPI) meeting was held on 06/13/16 with the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, Social Services Director, Dietary Director, Quality of Life Director, Admissions Coordinator, and the Maintenance Director to discuss Resident #1; the findings of the investigation into the occurrence; and, the above stated plan of corrective actions. The Medical Director was consulted regarding the plan to correct the identified concerns. 19. Quality Assurance Performance Improvement (QAPI) meetings will be held weekly, to include but not limited to, the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, Social Services, Dietary Director, Quality of Life Director, Admissions Coordinator, the Maintenance Director. The meetings are held to ensure continued compliance with the corrective action plan and for further recommendations, as indicated. QAPI meetings will be held weekly until immediacy is removed, then monthly for recommendation and further follow up regarding the above stated plan. The Administrator has the oversight to ensure an effective plan is in place to ensure facility concerns are identified in a timely manner and to assist in the development of corrective action plans. Corporate Administrative oversight of the Quality Assurance meeting will be completed by the Nurse Consultant or member of the regional/home office team daily until removal of the immediacy of the jeopardy, beginning 06/13/16, then weekly for four (4) weeks, then monthly. **The State Survey Agency validated the corrective action by the facility as follows: 1. Interview with LPN #1, on 06/28/16 at 3:03 PM, revealed she completed a review of the Electronic Medication Administration Records for the other three (3) residents on [MEDICATION NAME]. The review was to ensure their orders were in place in the EZMAR system; and, to ensure all medications had been administered as ordered. LPN #1 identified no concerns and revealed this had been completed on 06/12/16. 2. Interview with LPN #1, on 06/28/16 at 3:03 PM, revealed she completed physical assessments for the other three (3) residents with orders for [MEDICATION NAME]. No change of condition was identified on 06/12/16. 3. Interview with LPN #1, on 06/28/16 at 3:03 PM, revealed she conducted three (3) medication cart audits to ensure doses of [MEDICATION NAME] were available for all residents who had orders. No concerns were identified on 06/12/16. Further interview revealed the DON went behind LPN #1 to double check the cart and identified no concerns on 06/12/16. 4. Interview with the DON, on 06/29/16 at 9:05 AM, and the SDC, on 06/28/16 at 3:40 PM, revealed an audit of the electronic physicians' orders (POS), was conducted on 06/12/16. This audit was to ensure all medication orders contained an hour of administration (HOA) with a focus on anticoagulation medications. No other issues were identified on 06/12/16. 5. Interviews on 06/28/16 with LPN #1 at 3:03 PM, the ADON at 4:30 PM, and on 06/29/16 with RN #3 at 8:17 AM, LPN #3 at 10:40 AM, RN #4 at 11:55 AM, LPN #4 at 12:10 PM, RN #5 at 12:20 PM, CMA #14 at 12:50 PM, CMA #6 at 1:05 PM, CMA #15 at 1:20 PM, RN #6 at 1:25 PM, LPN #8 at 1:50 PM, RN #1 at 2:29 PM, LPN #10 at 3:47 PM, and RN #7 at 4:44 PM, revealed they had received education regarding general medication orders; the EZMAR (Electronic Medication Administration) policy regarding inclusion of hour administration (HOA); daily review of physician's orders [REDACTED]. The [MEDICATION NAME] was now locked up and counted as if it was a narcotic and had to be signed out on the [MEDICATION NAME] count sheet. Also, someone from the Administrative nursing staff compares the [MEDICATION NAME] sheets to the EZMAR to ensure the [MEDICATION NAME] has been given as ordered. 6. Interview with the Administrator, on 06/29/16 at 4:00 PM, revealed he drafted and mailed out certified letters to all the staff that was on vacation, medical leave, FMLA (Family Medical Leave Act), and all PRN staff requiring education prior to returning to work. 7. Interviews, on 06/28/16, with LPN #1 (Restorative Nurse Manager) at 3:03 PM, the SDC at 3:40 PM, the ADON at 4:30 PM, and on 06/29/16 with the DON at 9:05 AM, the Nurse Consultant at 10:20 AM, and LPN #8 (Medical Records) revealed all Physicians' Orders were reviewed on 06/13/16 and compared to the electronic Medication Administration Record to ensure that all medications were being administered as ordered, with no discrepancies identified. 8. Interviews, on 06/28/16, with LPN #1 (Restorative Nurse Manager) at 3:03 PM, the SDC at 3:40 PM, the ADON at 4:30 PM; and, on 06/29/16 with the DON at 9:05 AM, LPN #8 (Medical Records) at 1:50 PM and MDS at 4:50 PM, revealed the DON or the ADON will review medication administration records (EZMAR), hour of administration (HOA), and review [MEDICATION NAME] count sheets daily (5 days per week) for four (4) weeks, then three (3) times per week for four (4) weeks to ensure anticoagulant medications have been administered as ordered, which began on 06/13/16. Audits will be continued based on recommendation from the Quality Assurance/Process Improvement committee. On weekends, an Administrative Nurse, (Director of Nursing, Assistant Director of Nursing, Restorative Nurse Manager, Medical Records Nurse, MDS Nurse, or Staff Development Coordinator) will be assigned to review medication administration records to ensure anticoagulant medications have been administered as ordered and meet intent. If any concerns are identified, the DON will be notified after an assessment of the resident has been conducted in order to ensure the resident is safe. If any change is identified, the Physician and the Resident's Responsible Party will immediately be notified. If no change of condition is identified, the physician will be notified. No concerns were identified. 9. Interview with the DON, on 06/29/16 at 9:09 AM, revealed she moved the [MEDICATION NAME]/[MEDICATION NAME] to the narcotic drawer. The facility now requires [MEDICATION NAME]/[MEDICATION NAME] be counted and signed out by licensed nurses and/or Certified Medication Aides to ensure appropriate administration. Further interview with the ADON on 06/28/16 at 4:30 PM, SDC at 3:40 PM, on 06/29/16 at 1:50 PM, and MDS at 4:50 PM, revealed someone from the nurse administrative team will be assigned to review the [MEDICATION NAME] sheets, physician orders, and medications of all residents on [MEDICATION NAME] on weekends to ensure appropriate administration. 10. Interview with the DON on 06/29/16 at 9:09 AM, the ADON on 06/28/16 at 4:30 PM, the SDC at 3:40 PM, the Quality of Life Director on 06/30/16 at 8:45 AM, and the Dietary Manager at 9:05 AM, revealed residents requiring the use of Anticoagulants were being discussed in the clinical meeting daily as an ongoing process. They stated the meeting was attended by the Director of Nursing, Assistant Director of Nursing, Social Services Director, Staff Development Coordinator, Dietary Manager, and Quality of Life Director, Monday through Friday. They stated they reviewed the Medication Administration Records, Nurse's Notes, Care Plans, and [MEDICATION NAME] count sheets to ensure anticoagulants medications had been administered as ordered. In addition, they stated the Administrative Nurse will review the Medication Administration Records, Nurse's Notes, Care Plans, and [MEDICATION NAME] count sheets to ensure anticoagulant medications have been administered as ordered. They stated this process began on 06/13/16 and will continue as an ongoing process. 11. Interviews with the DON on 06/29/16 at 9:09 AM, Nurse Consultant at 10:20 AM, the ADON on 06/28/16 at 4:30 PM, the SDC at 3:40 PM, the Quality of Life Director on 06/30/16 at 8:45 AM, and the Dietary Manager at 9:05 AM, revealed education was initiated and completed on 06/13/16 by the Nurse Consultant. Those inserviced included the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Social Services, Dietary Manager, and Quality of Life Director regarding the Anticoagulation Management Policy and daily follow-up for residents who require the use of Anticoagulant medications. 12. Interviews with the SDC on 06/28/16 at 4:05 PM, the ADON at 4:30 PM, RN #3 on 06/29/16 at 8:17 AM, the DON at 9:40 AM, the Nurse Consultant at 10:20 AM, LPN #3 at 10:40 AM, and LPN #4 at 12:15 PM, revealed, on 06/15/16, directed education was completed by the Nurse Consultant. Those inserviced included the nurses and Certified Medication Aides who were responsible for passing medications to Resident #1 at the 4:00 PM medication pass from May 27, 2016 through June 11, 2016. The in-service addressed further investigation into medications that were present for a resident in the medication cart, but were not identified on the electronic medication record as being required to administer. 13. Interview with the PharMerica Product Training and Implementation Consultant, on 06/29/16 at 11:31 AM, revealed she came to the facility to assist with identification of the electronic medication administration system concerns. She provided education on 06/15/16 to the DON, ADON, SDC, MDR and licensed nursing staff regarding approving or rejecting orders, discharging residents, leave of absence, and the readmit function. She will be available to provide further assistance and training, as indicated. 14. Interview with the Business Development Analyst from the Information Technology Department, on 06/29/16 at 8:49 AM, revealed he came to the facility on [DATE] to correct the identified concern with the electronic medication administration system. He identified a concern with the compatibility of one (1) of the facility's computers with the PharMerica system. He determined if the compatibility setting was found to be on Internet Explorer 10, there were no compatibility concerns, which was the case with all but one (1) of the laptop computers used by the licensed nursing staff. On one (1) laptop computer, the compatibility settings were found to be on Internet Explorer 11, which was not compatible with the PharMerica suite. He changed the compatibility setting to correct the identified issue by setting the compatibility view setting to include the PharMerica suite. A sign was placed on desktop computers instructing users not to enter physician's orders [REDACTED]. The concern with the compatibility of desktop computers was addressed and resolved by PharMerica with a server side update that was completed on 06/16/16. These corrections ensured orders must contain the hour of administration (HOA) or they would not be accepted by the system. The Business Development Analyst will be available to provide further technical assistance as needed. 15. Interview with the ADON on 06/28/16 at 4:30 PM, and the DON on 06/29/16 at 9:05 AM, the Nurse Consultant at 10:20 AM, the Quality of Life Director on 06/30/16 at 8:45 AM, and the Dietary Manager at 9:05 AM, revealed Care Plans were reviewed by the Nurse Consultant on 06/12/16 to ensure interventions were in place regarding the use of Anticoagulation therapy. No Concerns were identified. Care plans were again reviewed on 06/13/16 by the Interdisciplinary Team which included the Director of Nursing, Assistant Director of Nursing, Social Services, Dietary Director, and Quality of Life Director, for residents requiring the use of anticoagulant therapy, to ensure further updates were not needed. There were no concerns identified. 16. Interview with the Nurse Consultant, on 06/29/16 at 10:20 AM, revealed she audited physician's orders [REDACTED]. 17. Interview with the Nurse Consultant, on 06/29/16 at 10:20 AM, revealed a nurse from the regional team or home office has been available since June 12, 2016. The nurse(s) from the regional team or home office are performing chart audits to compare anticoagulant orders with Medication Administration Records, observing care delivery as per care plans and providing oversight and consultation to licensed staff and Certified Medication Aides. Onsite visits from the regional team or Corporate office will occur daily until immediacy is removed and then weekly for four (4) weeks. Concerns identified will be corrected immediately and reported to the Administrator and the Director of Nursing. 18. Interview with the Medical Director, on 06/29/16 at 3:34 PM, Administrator at 4:00 PM, Admissions Coordinator on 06/30/16 at 8:30 AM, Quality of Life Director at 8:45 AM, Maintenance Director at 8:55 AM, Dietary Manager at 9:05 AM, Director of Nursing at 9:15 AM and the Assistant Director of Nursing at 9:30 AM, revealed a Quality Assurance Performance Improvement (QAPI) meeting was held on 06/13/16. Those in attendance included the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, Social Services Director, Dietary Director, Quality of Life Director, Admissions Coordinator, and the Maintenance Director. The discussion included Resident #1; the findings of the investigation into the occurrence; and, the above stated plan of corrective actions. The Medical Director was consulted regarding the plan to correct the identified concerns. 19. Interview with the Administrator, on 06/29/16 at 3:34 PM, revealed QAPI had met on a weekly basis since 06/13/16. He stated meetings will be held on a weekly basis until the immediacy is removed, then they will be held monthly for any recommendations, as indicated. Corporate Administrative oversight of the QA meeting will be completed by the Nurse Consultant of the regional/home office team daily until removal of the immediacy beginning on 06/13/16, then weekly for four (4) weeks, then monthly.

Based on interview, record review, review of hospital records, and review of the facility's policy and procedure, it was determined the facility failed to have an effective system to ensure one (1) of three (3) sampled residents (Resident #1) was free of significant medication errors. Review of the physician's orders [REDACTED]. However, review of Resident #1's May 2016 EZMAR (Electronic Medication Administration Record) revealed the resident's order for [MEDICATION NAME] 6 mg, give one (1) tablet daily, was discontinued after the 05/26/16 dose was administered. The facility's failure resulted in Resident #1 not receiving seventeen (17) doses of [MEDICATION NAME]. On 06/12/16, Resident #1 was sent to the emergency room (ER) and was admitted to the hospital with [REDACTED]. The resident was placed on [MEDICATION NAME] Drip due to low (International Normalized Ratio) INR. Immediate Jeopardy (IJ) was identified on 06/17/16 and was determined to exist on 05/26/16. The facility was notified of the Immediate Jeopardy (IJ) on 06/17/16. An acceptable Allegation of Compliance (AoC) was received on 06/27/16, alleging the removal of the Immediate Jeopardy (IJ) on 06/21/16. The State Survey Agency validated, on 06/28/16 through 06/30/16, that the Immediate Jeopardy (IJ) was removed on 06/21/16, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy and procedure, Physician order [REDACTED]. Copies of the order were to be provided to the Director of Nursing (DON) or Assistant Director of Nursing (ADON), Medical Records, and the original copy stayed in the chart. Copies of the order were to be taken to the daily clinical meeting; the orders were to be compared for accuracy; and, following the clinical meeting, the DON or designee reviewed the EZMAR and chart for new order accuracy. However, the facility's policy failed to include a second step to ensure the medication was transferred to the electronic MAR (EZMAR). Record review revealed the facility admitted Resident #1 on 02/11/10 with diagnoses, which included [MEDICAL CONDITION] Fibrillation, [MEDICAL CONDITION] [MEDICAL CONDITIONS], and Cerebral [MEDICAL CONDITION]. Review of the Progress Notes, dated 06/12/16 at 9:37 AM, revealed Licensed Practical Nurse (LPN) #1 was called to Resident #1's room due to Resident #1 acting different. Upon entering the room, LPN #1 observed Resident #1 with left sided weakness. The resident's left pupil was pinpoint and nonreactive, and the resident was nonverbal. Resident #1 required assistance for most movements. LPN #1 tried to evaluate Resident #1's grasp by instructing the resident to grasp both of her hands at the same time. Resident #1 would grasp one (1) hand, then release and grasp the other hand and release. Resident #1 was then instructed to grasp and hold LPN #1's hands. When Resident #1 grasped both hands, his/her left sided grasp was noted to be weaker. While LPN #1 and the Charge Nurse were evaluating Resident #1, another Charge Nurse notified the Medical Doctor (MD) and Power of Attorney (POA), the State Guardian on call, and the Emergency Medical Systems (EMS). Review of the 06/12/16 AM Progress Note, timed at 9:37 AM, revealed Resident #1's vital signs were as follows: Blood Pressure 108/48 (normal range 120/80{millimeter of Mercury}mm/Hg); Pulse 47- irregular (normal range 60-100); Oxygen (O2) 92% (normal range 95-100%); Temperature - 97.5 degrees Fahrenheit (normal range 97.8-99.1); Blood sugar -123 mg/dl (normal range 80 to 130 mg/dl). A skin assessment was completed with no skin issues noted. Report was called to the Regional Hospital (RH). The resident was transferred to the hospital. Review of Resident #1's Hospital Records, dated 06/12/16, revealed he/she was admitted to the hospital with [REDACTED]. His/Her INR was 1.02 (Reference range 0.84-1.17) and vital signs were Blood Pressure-87/97 mmHg; Pulse-64; Temperature-97.8 degrees; Respirations-15; and Oxygen (O2)-93% (Pulse oximetry interpretation: Hypoxic). Review of the Facility Progress Notes, dated 06/12/16 at 12:33 PM, recorded by LPN #1, revealed the emergency room (ER) Physician called the facility at approximately 11:00 AM to question about Resident #1 receiving [MEDICATION NAME]. Review of the MAR revealed the last dose the resident received was on 05/26/16. LPN #1 called the hospital at approximately 11:30 AM and followed up with the ER Physician and informed him that Resident #1 had not received his/her [MEDICATION NAME]. Further review revealed the Neurologist from the hospital called the facility to inquire about Resident #1's signs and symptoms prior to sending him/her to the hospital. Review of the documentation revealed the Neurologist stated Resident #1 was having confusion, but he believed that was due to being in a different setting. Review of the computer generated physician's orders [REDACTED]. However, there was no Hour of Administration (HOA) on the order. Review of Resident #1's May 2016 EZMAR, revealed the order for [MEDICATION NAME] 6 mg, give one (1) tablet daily, was discontinued after the 05/25/16 dose was administered. Review of the June 2016 EZMAR, revealed no evidence of an order for [REDACTED]. Interview with LPN #2, on 06/15/16 at 11:24 AM, revealed when she received the new physician's orders [REDACTED]. However, she did not go back into the EZMAR to ensure the order was still in the EZMAR, as this was not the facility's process. Interview with LPN #1, on 06/15/16 at 11:45 AM, revealed she observed Resident #1 with left sided weakness, the left pupil was pinpoint and nonreactive, and he/she was nonverbal and required assistance from staff for most movements. Further interview revealed the ER Physician had called to inquire if Resident #1 had been receiving his/her [MEDICATION NAME]. She stated she looked at the EZMAR and noticed the order for the [MEDICATION NAME] was not on the MAR for June. She told the ER Physician she would have to call him back, and that was when she noticed there was not an hour of administration (HOA) beside the order. Further interview with LPN #1, on 06/25/16 at 11:45 AM, revealed she did review Resident #1's Physician order [REDACTED]. After the DON looked into the system from her home, she verified Resident #1 had missed several doses of [MEDICATION NAME] and told LPN #1 to call the ER Physician back and make him aware. Further interview revealed, when entering the physician's orders [REDACTED]. LPN #1 stated when someone entered the stop date; it triggered the system as to when to stop the medication on the EZMAR. She stated, This is just something that I have always done when entering an order for [REDACTED]. Interview with LPN #3, on 06/15/16 at 3:10 PM, revealed she was familiar with Resident #1 and was aware he/she took [MEDICATION NAME] every day at 4:00 PM on a routine basis. LPN #3 stated when the resident's name did not pop up at the 4:00 PM medication pass she did not think anything about it. She stated it never crossed her mind that Resident #1 was not scheduled to receive his/her routine [MEDICATION NAME]. The LPN stated she relied on the EZMAR system to tell her who was due medications at a certain time. Further interview revealed once she entered a physician's orders [REDACTED]. She stated there would be no way for her to know that the HOA did not transfer over to the medication pass side. Interview with LPN #4, on 06/15/16 at 3:18 PM, revealed she was familiar with Resident #1 and knew he/she did take [MEDICATION NAME] on a routine basis. She stated she relied on the EZMAR system to tell her what medications were due at a certain time for certain residents. She stated that if the resident's name did not pop up on the screen, it would not register to her that they were to receive medication. When entering an order into the Administrative side, she did not go back and verify the order was on the Administration side of the EZMAR, as that was not part of what she did when entering an order. Interview with Registered Nurse (RN) #1, on 06/15/16 at 7:41 PM, revealed she was very familiar with Resident #1, but not his/her medications. Further interview revealed that if Resident #1's name did not pop up on the administration screen, she would not have known Resident #1 was to have received [MEDICATION NAME] at 4:00 PM. Further interview revealed she relied entirely on the EZMAR system to alert her to whom received medications and what time those medications were due to be administered. Interview with LPN #6, on 06/16/16 at 8:22 AM, revealed she was not aware of any process in place to verify the EZMAR for accuracy. She stated the facility did not have a system to verify that all the physicians' orders had been transferred over to the EZMAR from month to month. Further interview revealed she was not familiar with Resident #1's medications and would have to rely on the EZMAR system to tell her who received medications and what time to administer them. Interview with LPN #7, on 06/16/16 at 4:10 PM, revealed she had never been instructed to go back into the EZMAR system to verify the physician's orders [REDACTED].#7 stated she had never been part of the process for entering physician's orders [REDACTED].#1. Interview with the Business Development Analyst, on 06/15/16 at 3:41 PM and on 06/23/16 at 1:02 PM, revealed in the EZMAR system there were Stops set up in the system to keep a nurse from entering physicians' orders that did not have an hour of administration. He stated this did not take place on 05/27/16, when the nurse entered the physician's orders [REDACTED]. Further interview revealed a bug/glitch was found in the software of the EZMAR system that was not compatible with the Internet Explorer 11 of the corporation's desktop. He stated, We were unaware Internet Explorer eleven (11) was not compatible with the EZMAR software until this issue occurred. He stated in this situation, there was nothing in place that would have alerted the nurse that the order was not saved over onto the medication page for administration, because it was an Internet Explorer issue. Further interview revealed that through the facility's investigation with the pharmacy company, We have determined the pharmacy is going to make an update to their software to keep this from happening again. During interview with the Pharmacy Customer Field Services, on 06/16/16 at 1:30 PM; and, on 06/22/16 at 8:59 AM he stated, We have researched the issue and found an order was entered into the EZMAR without an Hour of Administration (HOA). When I looked into the order, there was no HOA, which should have been entered. If an HOA is not entered, the facility should follow their policy and procedure on how to correct the concern. Up until now, the order could be entered without an HOA or without a stop date, but as I stated before, we are rolling out today a process that will not allow any order to be entered without an HOA. There is nothing built into the system itself that would have alerted them the order would have been discontinued and not have carried over to the medication pass page. Once an order is entered, the nurses can go over to see if the order has been successfully entered correctly, that would be the medication administration page. Interview with the Director of Nursing (DON), on 06/12/16 at 2:15 PM, and 5:53 PM; on 06/16/16 at 10:09 AM and 3:06 PM; on 06/17/16 at 10:45 AM; and, on 06/20/16 at 1:25 PM and 2:01 PM, revealed she first became aware of the missed [MEDICATION NAME] for Resident #1 when LPN #1 notified her on 06/12/16. She stated the facility notified all appropriate authorities and immediately started their investigation. The DON stated that during the facility's investigation, they found some type of technical problem regarding an update with the Internet Explorer system that somehow allowed an order to be saved without an HOA. Further interview with the DON revealed Resident #1 had missed seventeen (17) doses of [MEDICATION NAME], which would be considered a significant medication error. She stated, However, it would be my expectation as the DON that a resident who has been receiving medication on a routine basis and suddenly that medication is not on the MAR for administration, for the nurse to go check the physician's orders [REDACTED]. She stated, We have had an influx of inconsistent nursing staff on that unit for the last several weeks, not a shortage, but not the same staff who were familiar with Resident #1's routine medications, and when working the floor, the nursing staff relied heavily on the EZMAR system to know who to administer medications to and what time the medications were due. Continued interview with the DON revealed when LPN #2 entered the physician's orders [REDACTED]. She stated if the stop date had been entered into the system this would not have occurred. The DON stated this was found when reviewing the system. Further interview revealed the Interdisciplinary Team (IDT) reviewed all new Physicians' Orders daily Monday through Friday. During that process, LPN #8 reviewed the written orders with the orders in the EZMAR System. The DON stated the HOA not being on the order was a technical problem and the clinical team reviewer should have caught that when the orders were reviewed on 05/31/16 with the previous process. Further interview revealed she spoke with LPN #8 and she too was unaware how the order was missed. She stated, The order was there all along for the nurse to view, it just did not have a stop date or an HOA. We did not require the nursing staff to double check the physician's orders [REDACTED]. Interview with LPN #8, on 06/20/16 at 2:15 PM, revealed part of her responsibility as part of the Interdisciplinary Team (IDT) was to review all the new written physicians' orders to make sure they were in the EZMAR correctly. She stated she compared the written order in the Administrative portion of the EZMAR for accuracy. Then she sent the signed physicians' orders to the physician for review. Further interview revealed it was not part of the process to go into the Administration portion side of the EZMAR screen where the nurses sign off the medications. She stated she just verified the slips with the orders on the Administrative side of the EZMAR. Further interview, revealed she had reviewed multiple orders on 05/31/16, and could not recall the exact details of Resident #1's orders. LPN #8 stated she could not say whether she viewed the actual HOA, but she was aware the order should not have populated over into the Administration side (for medication pass) without an HOA. She stated, It has not been our process in the past to verify orders by going over into the medication pass side of the EZMAR. However, we may have to add this process to verify the HOA is actually there. Interview with the facility's Pharmacist, on 06/15/16 at 12:21 PM, revealed he became aware of the missing doses of [MEDICATION NAME] when he was notified by e-mail on 06/13/16 by the DON of the facility. He stated missing doses of [MEDICATION NAME] could be severe, depending on the patient. The Pharmacist stated [MEDICATION NAME] required close monitoring of labs to ensure the resident was at a therapeutic or established level. Interview with Resident #1's Physician, on 06/15/16 at 3:47 PM, revealed Resident #1 has been on [MEDICATION NAME] for many years for [MEDICAL CONDITION] Fibrillation and missing seventeen (17) doses of [MEDICATION NAME] would be considered a significant medication error and could lead to a potential stroke, clot, or [MEDICAL CONDITION] Fibrillation. Interview with the Administrator, on 06/17/16 at 9:31 AM, revealed he became aware of the incident involving Resident #1's missed [MEDICATION NAME] when the DON notified him on 06/12/16. He immediately came to the facility to initiate an investigation. Further interview revealed he felt there was a technical problem with the EZMAR system. He stated he would consider missing seventeen (17) doses of [MEDICATION NAME] to be a significant medication error and his expectation was that Resident #1 should have received his/her medication as ordered by his/her physician. Further interview revealed he had taken this matter very seriously and had been working diligently with the EZMAR Pharmacy Company (the company who provided their EZMAR system) to ensure this did not happen again. Further interview revealed he was not aware of anything in place to check the MARs for accuracy at the end of the month, or to determine if medications were still in the system for administration after the nurses entered a new physician's orders [REDACTED].>**The facility implemented the following actions to remove the Immediate Jeopardy: 1. LPN #1 completed a review of the Electronic Medication Administration Records (EZMARs) for the other three (3) residents who received [MEDICATION NAME] to ensure their orders were in place in the system and that [MEDICATION NAME] was being administered to all others as ordered. This was completed on 06/12/16 with no concerns identified. 2. A physical assessment was completed on all other residents with orders for [MEDICATION NAME] (3) by LPN #1 on 06/12/16 with no concerns. No changes of condition were identified. 3. Three (3) medication carts were audited by LPN #1 on 06/12/16 to ensure the ordered doses of [MEDICATION NAME] were available for all residents who have orders for [MEDICATION NAME]. No concerns were identified. A follow-up audit of the three (3) medication carts was completed by the DON on 06/12/16 with no concerns identified. In addition, a 100% internal audit of all residents' medications to include medications that require monitoring was conducted. 4. The DON and the Staff Development Coordinator (SDC) completed an audit on the electronic physician's orders [REDACTED]. No other orders were identified as not having an hour of administration (HOA). 5. Education was initiated on 06/12/16 and completed on 06/20/16 by the Staff Development Coordinator (SDC) and DON for full-time and part-time Licensed Nurses and Certified Medication Aides (CMAs) regarding general medication orders; the EZMAR (Electronic Medication Administration) policy regarding the inclusion of hours of administration (HOA); daily review of physicians' orders; medication discrepancies; the seven (7) rights of accurate medication administration; non-controlled medication orders; transcription of Medication Orders; the Anticoagulation Management Policy; and, the Electronic Medical Records process. 6. Certified letters were drafted by the Administrator and mailed out on 06/15/16 to inform all staff on medical leave, on FMLA (Family Medical Leave Act), vacation, and all PRN (as needed) staff that they would require education prior to returning to work. 7. Physicians' Orders were reviewed on 06/13/16 for all residents by the DON, ADON, SDC, Medical Records Nurse (MRN), Restorative Nurse Manager, and Nursing Consultant and compared to the Electronic Medication Administration Record to ensure that all other medications were being administered as ordered. No further discrepancies were identified. 8. The DON or the ADON will review medication administration records (EZMAR), hour of administration (HOA), and review of [MEDICATION NAME] count sheets daily (5 days per week) for four (4) weeks then three (3) times per week for four (4) weeks to ensure anticoagulant medications have been administered as ordered which began on 06/13/16. Audits will be continued based on recommendation from the Quality Assurance/Process Improvement committee. On weekends, an Administrative Nurse, (Director of Nursing, Assistant Director of Nursing, Restorative Nurse Manager, Medical Records Nurse, MDS Nurse, or Staff Development Coordinator) will be assigned to review medication administration records to ensure anticoagulant medications have been administered as ordered and meet intent. If concerns are identified, the DON will be notified after an assessment of the resident has been conducted in order to make sure the resident is safe. If any change is identified, the Physician and the Resident's Responsible Party will immediately be notified. If no change of condition is identified, the Physician will be notified. 9. On 06/13/16, the DON moved [MEDICATION NAME]/[MEDICATION NAME] to the narcotic drawer, and now requires that [MEDICATION NAME]/[MEDICATION NAME] be counted and signed out by licensed nurses and/or Certified Medication Aides to ensure appropriate administration. The DON, ADON and SDC will compare the [MEDICATION NAME] count sheets to the Medication Administration Record (EZMAR) process daily (Monday through Friday). On the weekends, this will be assigned to an Administrative Nurse (DON, ADON, Restorative Nurse Manager, Medical Records Nurse, MDS Nurse, or SDC). 10. Residents requiring the use of anticoagulants will be discussed in the clinical meeting daily as an on-going process, attended by the interdisciplinary team to include, but not limited to the Director of Nursing, Assistant Director of Nursing, Social Services Director, Staff Development Coordinator, Dietary Manager, and Quality of Life Director, Monday through Friday. This includes review of their Medication Administration Records, Nurse's Notes, Care Plans, and [MEDICATION NAME] count sheets to ensure anticoagulants medications have been administered as ordered. On weekends, an Administrative Nurse will be assigned to review Medication Administration Records, Nurse's Notes, Care Plans, and [MEDICATION NAME] count sheets to ensure anticoagulant medications have been administered as ordered. This process began on 06/13/16 and will continue as an ongoing process. 11. Education was initiated and completed on 06/13/16 by the Nurse Consultant for the interdisciplinary team including the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Social Services, Dietary Manager, and Quality of Life Director regarding the Anticoagulation Management Policy and daily follow-up for residents who require the use of Anticoagulant medications. 12. On 06/15/16, directed education was completed by the Nurse Consultant for Nurses and Certified Medication Aides who were responsible for passing medications to Resident #1 at the 4:00 PM medication pass from May 27, 2016 through June 11, 2016. 13. On 06/15/16, the PharMerica Product Training and Implementation Consultant came to the facility to assist with identification of the electronic medication administration system concerns. She provided education on 06/15/16 to the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Medical Records Coordinator, and licensed nursing staff regarding approving or rejecting orders, discharging residents, leave of absence, and readmit function. She will be available to provide further assistance and training as indicated. 14. On 06/15/16, the Business Development Analyst from the corporation's Information Technology Department came to the facility to correct the identified concern with the electronic medication administration system. He identified a concern with the compatibility of one (1) of the facility's computers with the PharMerica (owner of the electronic medication administration program utilized by the facility) system. He determined if the compatibility setting was found to be on Internet Explorer 10, there was no compatibility concern, which was the case with all but one (1) of the laptop computers used by the licensed nursing staff. On one (1) laptop computer, the compatibility settings were found to be on Internet Explorer 11, which was not compatible with the PharMerica suite. He changed the compatibility setting to correct the identified issue. A sign was placed on desktop computers instructing users not to enter physicians' orders on the desktop computers until further notice. The concern with the compatibility of desktop computers was addressed and resolved by PharMerica with a server side update that was completed on 06/16/16. These corrections ensured orders must contain the hour of administration (HOA) or they would not be accepted by the system. The Business Development Analyst would be available to provide further technical assistance, as needed. 15. Care plans were reviewed by the Nurse Consultant on 06/12/16 to ensure interventions were in place regarding the use of anticoagulation therapy. No Concerns were identified. Care plans were again reviewed on 06/13/16 by the Interdisciplinary Team: Director of Nursing, Assistant Director of Nursing, Social Services, Dietary Director, and Quality of Life Director, for residents requiring the use of anticoagulant therapy, to ensure further updates were not needed. There were no concerns identified. 16. The Nurse Consultant will audit the physician's orders [REDACTED]. 17. A nurse from the regional team or home office has been available since 06/12/16. The nurses from the regional team or home office are performing chart audits to compare anticoagulant orders with MARs, observing care delivery as per care plans and providing oversight and consultation to licensed staff and Certified Medication Aides. Onsite visits from the regional team or corporate office will occur daily until immediacy is removed and then weekly for four (4) weeks. Concerns identified will be corrected immediately and reported to the Administrator and the Director of Nursing. 18. A Quality Assurance Performance Improvement (QAPI) meeting was held on 06/13/16 with the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, Social Services Director, Dietary Director, Quality of Life Director, Admissions Coordinator, and the Maintenance Director to discuss Resident #1; the findings of the investigation into the occurrence; and, the above stated plan of corrective actions. The Medical Director was consulted regarding the plan to correct the identified concerns. 19. Quality Assurance Performance Improvement (QAPI) meetings will be held weekly, to include but not limited to, the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, Social Services, Dietary Director, Quality of Life Director, Admissions Coordinator, the Maintenance Director. The meetings are held to ensure continued compliance with the corrective action plan and for further recommendations, as indicated. QAPI meetings will be held weekly until immediacy is removed, then monthly for recommendation and further follow up regarding the above stated plan. The Administrator has the oversight to ensure an effective plan is in place to ensure facility concerns are identified in a timely manner and to assist in the development of corrective action plans. Corporate Administrative oversight of the Quality Assurance meeting will be completed by the Nurse Consultant or member of the regional/home office team daily until removal of the immediacy of the jeopardy, beginning 06/13/16, then weekly for four (4) weeks, then monthly. **The State Survey Agency validated the corrective action by the facility as follows: 1. Interview with LPN #1, on 06/28/16 at 3:03 PM, revealed she completed a review of the Electronic Medication Administration Records for the other three (3) residents on [MEDICATION NAME]. The review was to ensure their orders were in place in the EZMAR system; and, to ensure all medications had been administered as ordered. LPN #1 identified no concerns and revealed this had been completed on 06/12/16. 2. Interview with LPN #1, on 06/28/16 at 3:03 PM, revealed she completed physical assessments for the other three (3) residents with orders for [MEDICATION NAME]. No change of condition was identified on 06/12/16. 3. Interview with LPN #1, on 06/28/16 at 3:03 PM, revealed she conducted three (3) medication cart audits to ensure doses of [MEDICATION NAME] were available for all residents who had orders. No concerns were identified on 06/12/16. Further interview revealed the DON went behind LPN #1 to double check the cart and identified no concerns on 06/12/16. 4. Interview with the DON, on 06/29/16 at 9:05 AM, and the SDC, on 06/28/16 at 3:40 PM, revealed an audit of the electronic physicians' orders (POS), was conducted on 06/12/16. This audit was to ensure all medication orders contained an hour of administration (HOA) with a focus on anticoagulation medications. No other issues were identified on 06/12/16. 5. Interviews on 06/28/16 with LPN #1 at 3:03 PM, the ADON at 4:30 PM, and on 06/29/16 with RN #3 at 8:17 AM, LPN #3 at 10:40 AM, RN #4 at 11:55 AM, LPN #4 at 12:10 PM, RN #5 at 12:20 PM, CMA #14 at 12:50 PM, CMA #6 at 1:05 PM, CMA #15 at 1:20 PM, RN #6 at 1:25 PM, LPN #8 at 1:50 PM, RN #1 at 2:29 PM, LPN #10 at 3:47 PM, and RN #7 at 4:44 PM, revealed they had received education regarding general medication orders; the EZMAR (Electronic Medication Administration) policy regarding inclusion of hour administration (HOA); daily review of physician's orders [REDACTED]. The [MEDICATION NAME] was now locked up and counted as if it was a narcotic and had to be signed out on the [MEDICATION NAME] count sheet. Also, someone from the Administrative nursing staff compares the [MEDICATION NAME] sheets to the EZMAR to ensure the [MEDICATION NAME] has been given as ordered. 6. Interview with the Administrator, on 06/29/16 at 4:00 PM, revealed he drafted and mailed out certified letters to all the staff that was on vacation, medical leave, FMLA (Family Medical Leave Act), and all PRN staff requiring education prior to returning to work. 7. Interviews, on 06/28/16, with LPN #1 (Restorative Nurse Manager) at 3:03 PM, the SDC at 3:40 PM, the ADON at 4:30 PM, and on 06/29/16 with the DON at 9:05 AM, the Nurse Consultant at 10:20 AM, and LPN #8 (Medical Records) revealed all Physicians' Orders were reviewed on 06/13/16 and compared to the electronic Medication Administration Record to ensure that all medications were being administered as ordered, with no discrepancies identified. 8. Interviews, on 06/28/16, with

Based on interview, record review, review of hospital records, and review of the facility's policies and procedures, it was determined the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for one (1) of three (3) sampled residents (Resident #1). Resident #1 received an order for [REDACTED]. However, the order did not appear on the May and June 2016 Electronic Medication Administration Records (EZMAR) which resulted in Resident #1 not receiving his/her [MEDICATION NAME] for a total of seventeen (17) days (05/27/16-06/12/16). On 06/12/16, Resident #1 was sent to the emergency room (ER) and admitted to the hospital with [REDACTED]. Immediate Jeopardy (IJ) was identified on 06/17/16 and was determined to exist on 05/26/16. The facility was notified of the Immediate Jeopardy (IJ) on 06/17/16. An acceptable Allegation of Compliance (AoC) was received on 06/27/16 alleging the removal of the Immediate Jeopardy (IJ) on 06/21/16. The State Survey Agency validated, on 06/28/16 through 06/30/16, the Immediate Jeopardy (IJ) was removed on 06/21/16 as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Physician Orders At-A-Glance, no date, revealed medications are placed in the EZMAR for a specific resident by a designated nurse, including dosage, medication, route, and frequency of administration, stop time and qualifying diagnosis. Review of the facility's policy titled, Charting and Documentation, no date, revealed services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record to ensure consistency in the charting and documentation of the resident's clinical record. Review of the facility's policy and procedure, Physician Orders at a Glance, not dated, revealed copies of new physician orders were to be taken to the daily clinical meeting; the orders were to be compared for accuracy; and, following the clinical meeting, the DON or designee reviewed the EZMAR and chart for new order accuracy. Record review revealed the facility admitted Resident #1 on 02/11/10, with diagnoses, which included [MEDICAL CONDITION] Fibrillation, [MEDICAL CONDITION] [MEDICAL CONDITIONS], and Cerebral [MEDICAL CONDITION]. Review of the facility's Progress Notes, dated 06/12/16 at 9:37 AM, and interview with Licensed Practical Nurse (LPN) #1, on 06/15/16 at 11:45 AM (seventeen {17}days without receiving [MEDICATION NAME]), revealed on 06/12/16, Resident #1 was identified as having left sided weakness; non-verbal, and his/her left pupil was pinpoint and nonreactive. Resident #1 was sent to the hospital emergency room (ER). Review of Resident #1's Hospital Records, dated 06/12/16, revealed the resident was admitted to the hospital with [REDACTED]. The resident received [MEDICATION NAME] drip due to his/her INR being low. Review of the Physician's Order, dated 05/27/16, revealed to continue [MEDICATION NAME] 6 milligrams (mg) daily, and recheck his/her INR in one (1) month. However, review of Resident #1's May 2016 and June 2016 EZMAR, revealed the order to administer [MEDICATION NAME] 6 mg, was not documented on the EZMAR after 05/26/16. This resulted in the resident missing seventeen (17) doses of [MEDICATION NAME] from 05/26/16 through 06/12/16, when the resident was sent to the hospital with signs/symptoms of a [MEDICAL CONDITION] TIA. Interview with LPN #2, the nurse who entered the order into the computer, on 06/15/16 at 11:24 AM, revealed that once she received the new Physician's Order, she entered it into the computer and hit save. However, she did not go back into the EZMAR to ensure the order was still in the EZMAR, as that was not the facility's process. Interview with the Business Development Analysts, on 06/15/16 at 3:41 PM and 06/23/16 at 1:02 PM, revealed in the EZMAR system there were stops set up in the system to keep a nurse from entering orders without an hour of administration (HOA). However, this did not occur on 05/27/16, when the nurse entered the order into the system. He stated a bug was found in the software of the EZMAR system that was not compatible with the Internet Explorer used on the facility's computers. He revealed the Stop did not work, as the nurse was able to enter a physician's order without the HOA and the physician's order did not transfer over to the medication page for administration. He further stated, Through our investigation with the Pharmacy Company, we have determined the pharmacy is going to make an update to their software to keep this from happening again. Interview with LPN #8, on 06/20/16 at 2:15 PM, revealed part of her responsibility as part of the Interdisciplinary Team (IDT) is to review all the new written Physician's Orders to make sure they were in the EZMAR correctly. She stated she compares the written order in the Administrative portion of the EZMAR for accuracy, but she does not compare it to the actual EZMAR, which is used by the nurses to administer the medications. Interview with the Director of Nursing (DON), on 06/12/16 at 2:15 PM, and 5:53 PM; on 06/16/16 at 10:09 AM and 3:06 PM; on 06/17/16 at 10:45 AM; and, on 06/20/16 at 1:25 PM and 2:01 PM, revealed during their investigation, there was found to be some type of technical problem regarding an update with the Internet Explorer system that somehow allowed an order to be saved without an hour of administration. She stated Resident #1 had missed seventeen (17) doses of [MEDICATION NAME], due to this technical problem. She revealed the IDT team checked the Physicians orders with the Administrative side of the system but did not check the physician's order with the Administration side of the system and that was why they failed to identify the order had been discontinued on the EMAR. Interview with the Administrator, on 06/17/16 at 9:31 AM, revealed there was a technical problem with the EZMAR system. He stated he had been working diligently with the EZMAR pharmacy company who provided their EZMAR system, to ensure this does not happen again. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. LPN #1 completed a review of the Electronic Medication Administration Records (EZMARs) for the other three (3) residents who received [MEDICATION NAME] to ensure their orders were in place in the system and that [MEDICATION NAME] was being administered to all others as ordered. This was completed on 06/12/16 with no concerns identified. 2. A physical assessment was completed on all other residents with orders for [MEDICATION NAME] (3) by LPN #1 on 06/12/16 with no concerns. No changes of condition were identified. 3. Three (3) medication carts were audited by LPN #1 on 06/12/16 to ensure the ordered doses of [MEDICATION NAME] were available for all residents who have orders for [MEDICATION NAME]. No concerns were identified. A follow-up audit of the three (3) medication carts was completed by the DON on 06/12/16 with no concerns identified. In addition, a 100% internal audit of all residents' medications to include medications that require monitoring was conducted. 4. The DON and the Staff Development Coordinator (SDC) completed an audit on the electronic Physician's Order Sheets (POS) on 06/12/16 to ensure that all medication orders had an hour of administration (HOA) with a focus on anticoagulation medications. No other orders were identified as not having an hour of administration (HOA). 5. Education was initiated on 06/12/16 and completed on 06/20/16 by the Staff Development Coordinator (SDC) and DON for full-time and part-time Licensed Nurses and Certified Medication Aides (CMAs) regarding general medication orders; the EZMAR (Electronic Medication Administration) policy regarding the inclusion of hours of administration (HOA); daily review of physicians' orders; medication discrepancies; the seven (7) rights of accurate medication administration; non-controlled medication orders; transcription of Medication Orders; the Anticoagulation Management Policy; and, the Electronic Medical Records process. 6. Certified letters were drafted by the Administrator and mailed out on 06/15/16 to inform all staff on medical leave, on FMLA (Family Medical Leave Act), vacation, and all PRN (as needed) staff that they would require education prior to returning to work. 7. Physicians' Orders were reviewed on 06/13/16 for all residents by the DON, ADON, SDC, Medical Records Nurse (MRN), Restorative Nurse Manager, and Nursing Consultant and compared to the Electronic Medication Administration Record to ensure that all other medications were being administered as ordered. No further discrepancies were identified. 8. The DON or the ADON will review medication administration records (EZMAR), hour of administration (HOA), and review of [MEDICATION NAME] count sheets daily (5 days per week) for four (4) weeks then three (3) times per week for four (4) weeks to ensure anticoagulant medications have been administered as ordered which began on 06/13/16. Audits will be continued based on recommendation from the Quality Assurance/Process Improvement committee. On weekends, an Administrative Nurse, (Director of Nursing, Assistant Director of Nursing, Restorative Nurse Manager, Medical Records Nurse, MDS Nurse, or Staff Development Coordinator) will be assigned to review medication administration records to ensure anticoagulant medications have been administered as ordered and meet intent. If concerns are identified, the DON will be notified after an assessment of the resident has been conducted in order to make sure the resident is safe. If any change is identified, the Physician and the Resident's Responsible Party will immediately be notified. If no change of condition is identified, the Physician will be notified. 9. On 06/13/16, the DON moved [MEDICATION NAME]/[MEDICATION NAME] to the narcotic drawer, and now requires that [MEDICATION NAME]/[MEDICATION NAME] be counted and signed out by licensed nurses and/or Certified Medication Aides to ensure appropriate administration. The DON, ADON and SDC will compare the [MEDICATION NAME] count sheets to the Medication Administration Record (EZMAR) process daily (Monday through Friday). On the weekends, this will be assigned to an Administrative Nurse (DON, ADON, Restorative Nurse Manager, Medical Records Nurse, MDS Nurse, or SDC). 10. Residents requiring the use of anticoagulants will be discussed in the clinical meeting daily as an on-going process, attended by the interdisciplinary team to include, but not limited to the Director of Nursing, Assistant Director of Nursing, Social Services Director, Staff Development Coordinator, Dietary Manager, and Quality of Life Director, Monday through Friday. This includes review of their Medication Administration Records, Nurse's Notes, Care Plans, and [MEDICATION NAME] count sheets to ensure anticoagulants medications have been administered as ordered. On weekends, an Administrative Nurse will be assigned to review Medication Administration Records, Nurse's Notes, Care Plans, and [MEDICATION NAME] count sheets to ensure anticoagulant medications have been administered as ordered. This process began on 06/13/16 and will continue as an ongoing process. 11. Education was initiated and completed on 06/13/16 by the Nurse Consultant for the interdisciplinary team including the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Social Services, Dietary Manager, and Quality of Life Director regarding the Anticoagulation Management Policy and daily follow-up for residents who require the use of Anticoagulant medications. 12. On 06/15/16, directed education was completed by the Nurse Consultant for Nurses and Certified Medication Aides who were responsible for passing medications to Resident #1 at the 4:00 PM medication pass from May 27, 2016 through June 11, 2016. 13. On 06/15/16, the PharMerica Product Training and Implementation Consultant came to the facility to assist with identification of the electronic medication administration system concerns. She provided education on 06/15/16 to the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Medical Records Coordinator, and licensed nursing staff regarding approving or rejecting orders, discharging residents, leave of absence, and readmit function. She will be available to provide further assistance and training as indicated. 14. On 06/15/16, the Business Development Analyst from the corporation's Information Technology Department came to the facility to correct the identified concern with the electronic medication administration system. He identified a concern with the compatibility of one (1) of the facility's computers with the PharMerica (owner of the electronic medication administration program utilized by the facility) system. He determined if the compatibility setting was found to be on Internet Explorer 10, there was no compatibility concern, which was the case with all but one (1) of the laptop computers used by the licensed nursing staff. On one (1) laptop computer, the compatibility settings were found to be on Internet Explorer 11, which was not compatible with the PharMerica suite. He changed the compatibility setting to correct the identified issue. A sign was placed on desktop computers instructing users not to enter physicians' orders on the desktop computers until further notice. The concern with the compatibility of desktop computers was addressed and resolved by PharMerica with a server side update that was completed on 06/16/16. These corrections ensured orders must contain the hour of administration (HOA) or they would not be accepted by the system. The Business Development Analyst would be available to provide further technical assistance, as needed. 15. Care plans were reviewed by the Nurse Consultant on 06/12/16 to ensure interventions were in place regarding the use of anticoagulation therapy. No Concerns were identified. Care plans were again reviewed on 06/13/16 by the Interdisciplinary Team: Director of Nursing, Assistant Director of Nursing, Social Services, Dietary Director, and Quality of Life Director, for residents requiring the use of anticoagulant therapy, to ensure further updates were not needed. There were no concerns identified. 16. The Nurse Consultant will audit the physician's orders for residents who require anticoagulant medication and compare them to medication administration records daily for one (1) week, then weekly for four (4) weeks to ensure appropriate administration of anticoagulants, then monthly for six (6) months, at which time the QAPI (Quality Assurance Performance Improvement) Committee will determine if further action is needed. 17. A nurse from the regional team or home office has been available since 06/12/16. The nurses from the regional team or home office are performing chart audits to compare anticoagulant orders with MARs, observing care delivery as per care plans and providing oversight and consultation to licensed staff and Certified Medication Aides. Onsite visits from the regional team or corporate office will occur daily until immediacy is removed and then weekly for four (4) weeks. Concerns identified will be corrected immediately and reported to the Administrator and the Director of Nursing. 18. A Quality Assurance Performance Improvement (QAPI) meeting was held on 06/13/16 with the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, Social Services Director, Dietary Director, Quality of Life Director, Admissions Coordinator, and the Maintenance Director to discuss Resident #1; the findings of the investigation into the occurrence; and, the above stated plan of corrective actions. The Medical Director was consulted regarding the plan to correct the identified concerns. 19. Quality Assurance Performance Improvement (QAPI) meetings will be held weekly, to include but not limited to, the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, Social Services, Dietary Director, Quality of Life Director, Admissions Coordinator, the Maintenance Director. The meetings are held to ensure continued compliance with the corrective action plan and for further recommendations, as indicated. QAPI meetings will be held weekly until immediacy is removed, then monthly for recommendation and further follow up regarding the above stated plan. The Administrator has the oversight to ensure an effective plan is in place to ensure facility concerns are identified in a timely manner and to assist in the development of corrective action plans. Corporate Administrative oversight of the Quality Assurance meeting will be completed by the Nurse Consultant or member of the regional/home office team daily until removal of the immediacy of the jeopardy, beginning 06/13/16, then weekly for four (4) weeks, then monthly. **The State Survey Agency validated the corrective action by the facility as follows: 1. Interview with LPN #1, on 06/28/16 at 3:03 PM, revealed she completed a review of the Electronic Medication Administration Records for the other three (3) residents on [MEDICATION NAME]. The review was to ensure their orders were in place in the EZMAR system; and, to ensure all medications had been administered as ordered. LPN #1 identified no concerns and revealed this had been completed on 06/12/16. 2. Interview with LPN #1, on 06/28/16 at 3:03 PM, revealed she completed physical assessments for the other three (3) residents with orders for [MEDICATION NAME]. No change of condition was identified on 06/12/16. 3. Interview with LPN #1, on 06/28/16 at 3:03 PM, revealed she conducted three (3) medication cart audits to ensure doses of [MEDICATION NAME] were available for all residents who had orders. No concerns were identified on 06/12/16. Further interview revealed the DON went behind LPN #1 to double check the cart and identified no concerns on 06/12/16. 4. Interview with the DON, on 06/29/16 at 9:05 AM, and the SDC, on 06/28/16 at 3:40 PM, revealed an audit of the electronic physicians' orders (POS), was conducted on 06/12/16. This audit was to ensure all medication orders contained an hour of administration (HOA) with a focus on anticoagulation medications. No other issues were identified on 06/12/16. 5. Interviews on 06/28/16 with LPN #1 at 3:03 PM, the ADON at 4:30 PM, and on 06/29/16 with RN #3 at 8:17 AM, LPN #3 at 10:40 AM, RN #4 at 11:55 AM, LPN #4 at 12:10 PM, RN #5 at 12:20 PM, CMA #14 at 12:50 PM, CMA #6 at 1:05 PM, CMA #15 at 1:20 PM, RN #6 at 1:25 PM, LPN #8 at 1:50 PM, RN #1 at 2:29 PM, LPN #10 at 3:47 PM, and RN #7 at 4:44 PM, revealed they had received education regarding general medication orders; the EZMAR (Electronic Medication Administration) policy regarding inclusion of hour administration (HOA); daily review of physician's orders; medication discrepancies; the seven (7) rights of accurate Medication Orders; the Anticoagulation Management Policy; and, the Electronic Records Process. The [MEDICATION NAME] was now locked up and counted as if it was a narcotic and had to be signed out on the [MEDICATION NAME] count sheet. Also, someone from the Administrative nursing staff compares the [MEDICATION NAME] sheets to the EZMAR to ensure the [MEDICATION NAME] has been given as ordered. 6. Interview with the Administrator, on 06/29/16 at 4:00 PM, revealed he drafted and mailed out certified letters to all the staff that was on vacation, medical leave, FMLA (Family Medical Leave Act), and all PRN staff requiring education prior to returning to work. 7. Interviews, on 06/28/16, with LPN #1 (Restorative Nurse Manager) at 3:03 PM, the SDC at 3:40 PM, the ADON at 4:30 PM, and on 06/29/16 with the DON at 9:05 AM, the Nurse Consultant at 10:20 AM, and LPN #8 (Medical Records) revealed all Physicians' Orders were reviewed on 06/13/16 and compared to the electronic Medication Administration Record to ensure that all medications were being administered as ordered, with no discrepancies identified. 8. Interviews, on 06/28/16, with LPN #1 (Restorative Nurse Manager) at 3:03 PM, the SDC at 3:40 PM, the ADON at 4:30 PM; and, on 06/29/16 with the DON at 9:05 AM, LPN #8 (Medical Records) at 1:50 PM and MDS at 4:50 PM, revealed the DON or the ADON will review medication administration records (EZMAR), hour of administration (HOA), and review [MEDICATION NAME] count sheets daily (5 days per week) for four (4) weeks, then three (3) times per week for four (4) weeks to ensure anticoagulant medications have been administered as ordered, which began on 06/13/16. Audits will be continued based on recommendation from the Quality Assurance/Process Improvement committee. On weekends, an Administrative Nurse, (Director of Nursing, Assistant Director of Nursing, Restorative Nurse Manager, Medical Records Nurse, MDS Nurse, or Staff Development Coordinator) will be assigned to review medication administration records to ensure anticoagulant medications have been administered as ordered and meet intent. If any concerns are identified, the DON will be notified after an assessment of the resident has been conducted in order to ensure the resident is safe. If any change is identified, the Physician and the Resident's Responsible Party will immediately be notified. If no change of condition is identified, the physician will be notified. No concerns were identified. 9. Interview with the DON, on 06/29/16 at 9:09 AM, revealed she moved the [MEDICATION NAME]/[MEDICATION NAME] to the narcotic drawer. The facility now requires [MEDICATION NAME]/[MEDICATION NAME] be counted and signed out by licensed nurses and/or Certified Medication Aides to ensure appropriate administration. Further interview with the ADON on 06/28/16 at 4:30 PM, SDC at 3:40 PM, on 06/29/16 at 1:50 PM, and MDS at 4:50 PM, revealed someone from the nurse administrative team will be assigned to review the [MEDICATION NAME] sheets, physician orders, and medications of all residents on [MEDICATION NAME] on weekends to ensure appropriate administration. 10. Interview with the DON on 06/29/16 at 9:09 AM, the ADON on 06/28/16 at 4:30 PM, the SDC at 3:40 PM, the Quality of Life Director on 06/30/16 at 8:45 AM, and the Dietary Manager at 9:05 AM, revealed residents requiring the use of Anticoagulants were being discussed in the clinical meeting daily as an ongoing process. They stated the meeting was attended by the Director of Nursing, Assistant Director of Nursing, Social Services Director, Staff Development Coordinator, Dietary Manager, and Quality of Life Director, Monday through Friday. They stated they reviewed the Medication Administration Records, Nurse's Notes, Care Plans, and [MEDICATION NAME] count sheets to ensure anticoagulants medications had been administered as ordered. In addition, they stated the Administrative Nurse will review the Medication Administration Records, Nurse's Notes, Care Plans, and [MEDICATION NAME] count sheets to ensure anticoagulant medications have been administered as ordered. They stated this process began on 06/13/16 and will continue as an ongoing process. 11. Interviews with the DON on 06/29/16 at 9:09 AM, Nurse Consultant at 10:20 AM, the ADON on 06/28/16 at 4:30 PM, the SDC at 3:40 PM, the Quality of Life Director on 06/30/16 at 8:45 AM, and the Dietary Manager at 9:05 AM, revealed education was initiated and completed on 06/13/16 by the Nurse Consultant. Those inserviced included the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Social Services, Dietary Manager, and Quality of Life Director regarding the Anticoagulation Management Policy and daily follow-up for residents who require the use of Anticoagulant medications. 12. Interviews with the SDC on 06/28/16 at 4:05 PM, the ADON at 4:30 PM, RN #3 on 06/29/16 at 8:17 AM, the DON at 9:40 AM, the Nurse Consultant at 10:20 AM, LPN #3 at 10:40 AM, and LPN #4 at 12:15 PM, revealed, on 06/15/16, directed education was completed by the Nurse Consultant. Those inserviced included the nurses and Certified Medication Aides who were responsible for passing medications to Resident #1 at the 4:00 PM medication pass from May 27, 2016 through June 11, 2016. The in-service addressed further investigation into medications that were present for a resident in the medication cart, but were not identified on the electronic medication record as being required to administer. 13. Interview with the PharMerica Product Training and Implementation Consultant, on 06/29/16 at 11:31 AM, revealed she came to the facility to assist with identification of the electronic medication administration system concerns. She provided education on 06/15/16 to the DON, ADON, SDC, MDR and licensed nursing staff regarding approving or rejecting orders, discharging residents, leave of absence, and the readmit function. She will be available to provide further assistance and training, as indicated. 14. Interview with the Business Development Analyst from the Information Technology Department, on 06/29/16 at 8:49 AM, revealed he came to the facility on [DATE] to correct the identified concern with the electronic medication administration system. He identified a concern with the compatibility of one (1) of the facility's computers with the PharMerica system. He determined if the compatibility setting was found to be on Internet Explorer 10, there were no compatibility concerns, which was the case with all but one (1) of the laptop computers used by the licensed nursing staff. On one (1) laptop computer, the compatibility settings were found to be on Internet Explorer 11, which was not compatible with the PharMerica suite. He changed the compatibility setting to correct the identified issue by setting the compatibility view setting to include the PharMerica suite. A sign was placed on desktop computers instructing users not to enter physician's orders on the desktop computers until further notice. The concern with the compatibility of desktop computers was addressed and resolved by PharMerica with a server side update that was completed on 06/16/16. These corrections ensured orders must contain the hour of administration (HOA) or they would not be accepted by the system. The Business Development Analyst will be available to provide further technical assistance as needed. 15. Interview with the ADON on 06/28/16 at 4:30 PM, and the DON on 06/29/16 at 9:05 AM, the Nurse Consultant at 10:20 AM, the Quality of Life Director on 06/30/16 at 8:45 AM, and the Dietary Manager at 9:05 AM, revealed Care Plans were reviewed by the Nurse Consultant on 06/12/16 to ensure interventions were in place regarding the use of Anticoagulation therapy. No Concerns were identified. Care plans were again reviewed on 06/13/16 by the Interdisciplinary Team which included the Director of Nursing, Assistant Director of Nursing, Social Services, Dietary Director, and Quality of Life Director, for residents requiring the use of anticoagulant therapy, to ensure further updates were not needed. There were no concerns identified. 16. Interview with the Nurse Consultant, on 06/29/16 at 10:20 AM, revealed she audited physician's orders for residents who required anticoagulants and have compared them with the physician's orders. She did this for the first week, and no concerns were identified, and she will continue to audit weekly for the next four (4) weeks to ensure appropriate administration of anticoagulants, then monthly for six (6) months, at which time the QAPI (Quality Assurance Performance Improvement) Committee will determine if further action is needed. 17. Interview with the Nurse Consultant, on 06/29/16 at 10:20 AM, revealed a nurse from the regional team or home office has been available since June 12, 2016. The nurse(s) from the regional team or home office are performing chart audits to compare anticoagulant orders with Medication Administration Records, observing care delivery as per care plans and providing oversight and consultation to licensed staff and Certified Medication Aides. Onsite visits from the regional team or Corporate office will occur daily until immediacy is removed and then weekly for four (4) weeks. Concerns identified will be corrected immediately and reported to the Administrator and the Director of Nursing. 18. Interview with the Medical Director, on 06/29/16 at 3:34 PM, Administrator at 4:00 PM, Admissions Coordinator on 06/30/16 at 8:30 AM, Quality of Life Director at 8:45 AM, Maintenance Director at 8:55 AM, Dietary Manager at 9:05 AM, Director of Nursing at 9:15 AM and the Assistant Director of Nursing at 9:30 AM, revealed a Quality Assurance Performance Improvement (QAPI) meeting was held on 06/13/16. Those in attendance included the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, Social Services Director, Dietary Director, Quality of Life Director, Admissions Coordinator, and the Maintenance Director. The discussion included Resident #1; the findings of the investigation into the occurrence; and, the above stated plan of corrective actions. The Medical Director was consulted regarding the plan to correct the identified concerns. 19. Interview with the Administrator, on 06/29/16 at 3:34 PM, revealed QAPI had met on a weekly basis since 06/13/16. He stated meetings will be held on a weekly basis until the immediacy is removed, then they will be held monthly for any recommendations, as indicated. Corporate Administrative oversight of the QA meeting will be completed by the Nurse Consultant of the regional/home office team daily until removal of the immediacy beginning on 06/13/16, then weekly for four (4) weeks, then monthly.