Every finding on record at Signature Healthcare at Jefferson Manor Rehab & We

Facility failed to follow policy prior to self-administering neb treatments.The findings include: Review of facility policy, Medication Administration Self-Administration by Resident, dated 01/2023, indicated, Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe and the medications are appropriate and safe for self-administration. PROCEDURES 1. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility, during the care planning process. The policy continued, The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment, which is placed in the resident's medical record. Review of facility document, Resident Face Sheet indicated the facility admitted Resident #17 on 02/10/2025 with diagnoses including acute respiratory failure with hypoxia, wheezing, and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/26/2025, revealed the facility assess Resident #17 with a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident experienced shortness of breath or trouble breathing with exertion and when lying flat. The MDS also indicated Resident #17 received oxygen therapy while a resident and within the last 14 days of the assessment period. During an interview on 07/21/2025 at 11:30 AM, Resident #17 stated they did their own breathing treatments every 4 hours. During an observation on 07/21/2025 at 11:48 AM, Resident #17 was observed using the nebulizer machine, completing their treatment, and placing the nebulizer mask on top of the nebulizer machine. During a concurrent observation and interview on 07/22/2025 at 10:05 AM, Resident #17 was observed lying in their bed receiving a nebulizer treatment, and no nurse was present. Resident #17 was observed to turn the nebulizer machine off and set the mask on top of the nebulizer machine. Resident #17 stated they had been doing their own nebulizer treatments for a long time. Review of Resident #17's medical record revealed a Prescription Order, dated 02/10/2025, for ipratropium-albuterol solution for nebulization: 0.5 milligrams (mg) -3 mg (2.5 mg base)/3 milliliters (mL). Instructions were to take 3 mL by nebulization 4 times a day. There was no evidence of an order for self-administration. Review of Resident #17's Physician Order Report, dated 07/21/2025 through 07/22/2025, revealed no evidence of an order for the resident to self-administer their nebulizer treatments. Review of Resident #17's Progress Notes, for the timeframe from 01/01/2025 through 07/22/2025, lacked any evidence of the resident self-administering their nebulizer treatments. During an interview on 07/22/2025 at 12:28 PM, Licensed Practical Nurse (LPN) #6 stated she had no knowledge of any residents in the building who were assessed to self-administer their medications, including nebulizer treatments. LPN #6 stated she thought the resident needed a physician's order, an assessment, education on the process, and be able to demonstrate how to safely administer their own medications. LPN #6 stated Resident #17's nebulizer treatments were always on the medication cart, but she allowed the resident to pour the albuterol solution into the machine, turn the machine on and off, and walked away during the treatment. LPN #6 stated she was not able to find a self-administration assessment or an order for Resident #17 to self-administer their nebulizer treatments. During an interview on 07/22/2025 at 12:50 PM, Registered Nurse (RN) #7 stated there were no residents residing on Resident #17's hall with orders to self-administer medications, including nebulizer treatments. RN #7 stated if a resident was allowed to self-administer medications, an order and an assessment were necessary to make sure the resident was safe to administer their own medications. RN #7 stated it could be dangerous for a resident to self-administer nebulizer treatments because it could cause breathing issues if not administered correctly. RN #7 stated regarding Resident #17, she had given the resident their nebulizer solution and watched the resident place the solution into the machine and turn on the machine, but she did not normally stand and watch the resident during their treatment. RN #7 said she trusted that the resident completed their full treatment. During an interview on 07/24/2025 at 11:28 AM, the Nurse Practitioner (NP) stated she knew Resident #17 self-administered their nebulizer treatments prior to the survey but the facility had not contacted her about this until 07/23/2025. The NP stated the facility should have completed a self-administration assessment prior to allowing the resident to self-administer the nebulizer treatments. During an interview on 07/24/2025 at 3:41 PM, the Director of Nursing (DON) stated she expected the staff to do a self-administration assessment and obtain a physician's order before a resident self-administered their medications. During an interview on 07/24/2025 at 4:28 PM, the Administrator stated he expected the staff to give the medication as it was written, follow the regulations, get the documents needed, and follow facility policy.

Based on observation, interview, and review of facility policy, it was determined the facility failed to ensure drugs and biologicals were stored appropriately, without being expired, for one (1) of two (2) medication storage rooms, and two (2) of five (5) medication carts. A tour of the blue medication room, on 06/04/2024 at 11:45 AM, revealed a tube of Iodosorb with an expiration date of 02/2022, a tube of Medihoney with expiration date of 12/11/2022, and a tube of HydrofaraBlue with expiration date of 02/01/2021. Additionally, observation on 06/04/2024 at 12:50 PM, of the [NAME] Unit, Medication Cart #1, revealed the following expired medications: a bottle of nitroglycerine 0.4 milligram (mg) with an expiration date of 11/16/2023; Atrovent 17 micrograms (mcg ) hydrofluoroalkane (HFA) inhaler with an opened date of 04/24/2024; and a Miralax bottle opened on 01/29/2023. Furthermore, observation on 06/04/2024 at 1:35 PM, of the [NAME] Unit, Medication Cart #3, revealed the following expired medications: Breyna expired on 04/25/2024; and Glycopyrolate 1 milligram (mg)/5 milliliters (ml) opened on 04/08/2024. The findings include: Review of the facility's policy titled Medication Storage, undated, revealed Medications and biologicals are stored properly .to maintain their integrity and to support safe effective drug administration .Outdated, contaminated, discontinued, or deteriorated medications, and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal. Review of the facility's policy titled Medication Administration dated 01/2023, revealed The nurse shall place a date opened sticker on the medication if one is not provided at the dispensing pharmacy and enter the date opened Certain products or package types such as multi-dose vials and ophthalmic drops have specified shortened end-of-use dating, once opened, to ensure medication purity and potency. When the date open expiration dating is not available from the manufacturer, the following may be considered in determining facility policy: Position statements from the American Society of Ophthalmic Registered Nurses and American Society of Cataract & Refractive Surgery (ASCRS) state that the multi-use eye drops and ointments should be disposed of 28 days after initial use. Manufacturer recommendations for beyond use dating should take precedence, taking into consideration not to exceed limitations. All other ophthalmic drops are to be considered expired after 60 days from the date opened. During a tour of the blue medication room, on 06/04/2024 at 11:45 AM, with the Director of Nursing (DON) and Signature Clinical Consultant (SCC), observation revealed the following: a tube of Iodosorb with an expiration date of 02/2022, a tube of Medihoney with expiration date of 12/11/2022, and a tube of HydrofaraBlue with expiration date of 02/01/2021. These items were confirmed as expired by the DON, and SCC during the tour of the medication room. During an observation conducted on 06/04/2024 at 12:50 PM, of the [NAME] Unit, Medication Cart #1, accompanied by Unit Manager (UM)1, the following medications were noted to be expired: a bottle of nitroglycerine 0.4 milligram (mg) with an expiration date of 11/16/2023; Atrovent 17 micrograms (mcg ) hydrofluoroalkane (HFA) inhaler with an opened date of 04/24/2024; and Miralax bottle opened on 01/29/2023. These items were confirmed as expired by UM1 during observation of the medication cart. During an observation conducted on 06/04/2024 at 1:35 PM, of the [NAME] Unit, Medication Cart #3, accompanied by Licensed Practical Nurse (LPN)5, the following medications were noted to be expired: Breyna expired on 04/25/2024; and Glycopyrolate 1 milligram (mg)/5 milliliters (ml) opened on 04/08/2024. These items were confirmed as expired by LPN5 during observation of the medication cart. During an interview conducted on 06/04/2024 at 1:00 PM, with LPN5, the nurse was questioned concerning how long a medication was good after the opened date. LPN5 stated she thought it was 30 days, but she was not positive and would have to look it up. During an interview conducted on 06/04/2024 at 2:24 PM, with LPN4, she stated she thought medications were good for 28 -30 days after opened , but she wasn't sure.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure two (2) of 49 sampled residents (Resident (R)16 and R47) were assessed for self-administration of medications to ensure the practice was clinically appropriate. Observation on 06/03/2024 at 2:27 PM, revealed a bottle of Flonase Allergy Relief nasal spray on R16's overbed table. However, there was no documented evidence of Physician's Orders for self administration of medications. Additionally, observation, on 06/04/2024 at 12:37 PM, revealed a small yellow pill on R47's lunch tray. However, there was no documented evidence of Physician's Orders for self administration of medications. The findings include: Review of the facility's policy titled, Medication Administration Self-Administration by Resident, last reviewed on 01/2023, revealed Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe, and the medications are appropriate and safe for self-administration . 1. Review of R16's Face sheet located in the electronic medical record (EMR) under the Face Sheet tab, revealed the facility admitted the resident on 04/01/2019 with diagnoses including stroke affecting the right side, congestive heart failure, and chronic obstructive pulmonary disease (COPD). Review of R16's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/24/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. Review of R16's Physician's Orders included no orders for self-administration of medication. Observation on 06/03/2024 at 2:27 PM, revealed R16 was in bed reading. A bottle of Flonase Allergy Relief nasal spray was observed on the overbed table. When the resident was questioned about the nasal spray during this observation, she stated, I am allowed to keep the medication in my room and use it when I need to. Observation on 06/03/2024 at 2:30 PM, revealed Licensed Practical Nurse (LPN)1, came into R16's room and stated he was going to take the resident's Flonase nasal spray and keep it on the medication cart. When LPN1 was questioned, he stated, I was told by the Director of Nursing (DON) to get the Flonase. I am not sure why. When LPN1 was asked if the resident was allowed to keep the medication at bedside, he stated, I do not know. I did not give it to her. Interview on 06/04/2024 at 5:11 PM, with the DON, revealed I asked LPN1 to retrieve the medication from the bedside table. He did not know why the resident had the medication. I saw it when I passed her room. She does not have an order for self-administration. 2. Review of R47's Face Sheet located in the EMR under the Face Sheet tab, revealed the facility admitted the resident on 11/16/2023, with diagnoses including interstitial pulmonary disease, dependence on renal dialysis, and acute respiratory failure with hypoxia. Review of R47's quarterly MDS with an ARD of 02/22/2024, revealed the facility assessed the resident as having a BIMS score of 12 out of 15, indicating moderate cognitive impairment. Review of R47's Physician's Orders included no orders for self-administration of medication. Review of R47's Progress Notes located in the EMR, dated 06/04/2024 at 1:44 PM, revealed LPN6 documented, resident states she dropped medication, this nurse verified medication as aspirin. Advanced Practice Registered Nurse (APRN) notified okay to hold dose for today, new order for nursing to ensure resident takes medication. Review of R47's Care Plan dated 06/04/2024, located in the EMR under the RAI (Resident Assessment Instrument) tab, revealed, Resident prefers to take medications from med cup independently after setup. Approaches included .Observe resident swallow medications from med cup independently, offer assistance as needed. During an observation, on 06/04/2024 at 12:37 PM, there was a small yellow pill noted on R47's lunch tray. During an interview conducted with R47 during the observation, she stated the nurse left the pills at the bedside. When questioned if the nurse stayed in the room to watch her take her medications, R47 stated, No, the nurse did not. The Registered Nurse Signature Clinical Coordinator (facility consultant), confirmed the pill left on the resident's lunch tray was aspirin. During an interview, conducted on 06/04/2024 at 12:44 PM, with LPN6, (R47's nurse), the nurse was asked if she watched the resident take her medications. LPN6 stated, Yes, I stood outside the resident's room with the door cracked. LPN6 was asked what her process was for medication administration and the nurse stated she obtained the resident's vital signs, checked medications, and watched the resident take their medications. 43050

Based on interview, record review, review of the Centers for Medicare and Medicaid Services (CMS), Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, review of the CMS site, Form Instructions Advance Beneficiary Notice of Non-coverage (ABN) OMB Approval Number: 0938-0566 and review of facility policy, it was determined the facility failed to issue the appropriate notice for termination of Medicare part A benefits for two (2) of three (3) residents reviewed for beneficiary notification out of a total sample of 49 residents (Resident (R) 67 and R73). These failures had the potential to result in a lack of understanding of appeal rights and/or the termination of the current level of care against the resident's/representative's wishes. The findings include: Review of the Centers for Medicare and Medicaid Services (CMS), Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 accessed at https://www.cms.gov/medicare/medicare-general-information/bni/downloads/instructions-for-notice-of-medicare-non-coverage-nomnc.pdf on 06/04/2024, revealed, The provider must ensure that the beneficiary or representative signs and dates the NOMNC to demonstrate that the beneficiary or representative received the notice and understands that the termination decision can be disputed . CMS requires that notification of changes in coverage for an institutionalized beneficiary/enrollee who is not competent be made to a representative . If the provider is personally unable to deliver a NOMNC to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise him or her when the enrollee's services are no longer covered. The date of the conversation is the date of the receipt of the notice. Confirm the telephone contact by written notice mailed on that same date. Review of the CMS site, Form Instructions Advance Beneficiary Notice of Non-coverage (ABN) OMB Approval Number: 0938-0566 accessed at https://www.cms.gov/medicare/medicare-general-information/bni/downloads/abn-form-instructions.pdf on 06/04/2024, revealed, The beneficiary or his or her representative must choose only one of the three options listed in Blank (G). Unless otherwise instructed to do so according to the specific guidance provided in these instructions, the notifier must not decide for the beneficiary which of the 3 checkboxes to select . If the beneficiary cannot or will not make a choice, the notice should be annotated, for example: beneficiary refused to choose an option. Review of the facility's Notice of Medicare Non-Coverage (NOMNC) policy, dated 09/01/2023 and provided on paper, revealed, All NOMNCs must be completed based on Medicate guidelines and facility policy . If the resident is unable to sign, and the SNF [Skilled Nursing Facility] is working with a legally authorized representative who is unable to be present at the facility that day, the SNF may issue the NOMNC by telephone . The facility must confirm the telephone contact by sending written notice to the authorized representative the same day the call was made by: Certified Mail, returned receipt requested. The facility did not provide a policy addressing the ABN. 1. Review of R67's Face Sheet, under the Face Sheet tab of the electronic medical record (EMR), revealed the facility admitted the resident on 03/28/2024. Family Member (F)1 was listed as her financial representative. Review of R67's Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/03/2024, located under the MDS 3.0 tab of the EMR, revealed the resident scored zero (0) out of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Review of R67's Notice of Medicare Non-Coverage (NOMNC), dated 04/30/2024 and provided on paper, revealed her last covered day (LCD) of Medicare Part A services was 05/02/2024. The Social Services Director (SSD) documented F1 was provided verbal notice via telephone on 04/30/2024; however, there was no signature from F1 on the form. Review of R67's Advance Beneficiary Notice of Noncoverage (ABN), dated 04/30/2024 and provided on paper, revealed the notice was provided verbally to F1 via telephone on 04/30/2024; however, no option was checked to indicate whether F1 wanted skilled services to be continued with responsibility for payment, skilled services to be discontinued, or skilled services to continue with an appeal to Medicare for further coverage. There was no signature from F1 on the form. Review of a Progress Note, dated 04/30/2024 and located in the Progress Notes tab of the EMR, written by the Social Services Director (SSD), revealed, NOMNC/ABN issued with LCD-05/02[/2024] from therapy services, call placed to [F1]. Discussed with [F1]. [F1] is aware of ending therapy services and reviewed room [ROOM NUMBER] for LTC placement at facility. Son was agreeable. All questions answered. Social Services will continue to assist as needed. In an interview on 06/04/2024 at 10:54 AM, the SSD stated for the NOMNC and ABN, she only provided verbal notice; the written forms were not sent to F1 for signature or to keep on file. The SSD further stated she did discuss with F1 which option he wanted; however, it must have been a clerical error that the option was not documented on the form. The SSD stated she was unsure what option F1 chose and would investigate and provide further information. No additional information was provided by the SSD prior to survey exit on 06/06/2024. In an interview, on 06/06/2024 at 12:26 PM, the Administrator provided the above Progress Note written by the SSD and stated that was the only information he could locate regarding the NOMNC and ABN and no documentation could be located to indicate which option F1 chose regarding continuation of services. In a telephone interview, on 06/06/2024 at 1:39 PM with F1, he stated he did not recall receiving notice of Medicare non-coverage via telephone and stated he had not been presented with options to appeal, continue services, or end services. F1 stated he would have chosen to discontinue services had he been asked. 2. Review of R73's Face Sheet under the Face Sheet tab of the EMR, revealed the facility readmitted the resident on 12/13/2023. F2 was listed as her financial representative. Review of R73's Significant Change of Status MDS, with an ARD of 12/17/2023 and located under the MDS 3.0 tab of the EMR, revealed she scored 12 out of 15 on the BIMS, indicating moderate cognitive impairment. Review of R73's NOMNC, dated 12/27/2023 and provided on paper, revealed her LCD of Medicare Part A services was 12/29/2023. The SSD documented F2 was provided verbal notice via telephone on 12/27/2023; however, there was no signature from F2 on the form. Review of R73's ABN, dated 12/27/2023 and provided on paper, revealed the notice was provided verbally to F2 via telephone on 12/27/2023; however, no option was checked to indicate whether F2 wanted skilled services to be continued with responsibility for payment, skilled services to be discontinued, or skilled services to continue with an appeal to Medicare for further coverage. There was no signature from F2 on the form. Review of a Progress Note, dated 12/27/2023 and located in the Progress Notes tab of the EMR, written by the SSD, revealed, NOMNC/ABN issued with LCD-12/29[/2024] from therapy services. Resident notified and preferred to review with [F2] instead. SSD notified [F2]- Spoke with [F2], voiced understanding. No issues or concerns voiced. In an interview, on 06/04/2024 at 10:54 AM, the SSD stated for the NOMNC and ABN, she only provided verbal notice; the written forms were not sent to F2. The SSD also stated she did discuss with F2 which option she wanted; however, it must have been a clerical error that the option was not documented on the form. The SSD stated she was unsure what option F2 chose and would investigate and provide further information. No additional information was provided by the SSD prior to survey exit on 06/06/2024. In an interview, on 06/06/2024 at 12:26 PM, the Administrator provided the above Progress Note written by the SSD and stated that was the only information he could locate regarding the NOMNC and ABN and he was unable to find documentation to indicate which option F2 chose regarding continuation of services. In a telephone interview, on 06/06/2024 at 5:52 PM with F2, she stated she did not remember receiving a phone call to explain the NOMNC and ABN and was never asked whether she wanted skilled services to continue, to end, or to appeal the decision. F2 stated she would not want skilled services to continue.

Based on interview, record review and review of the Kentucky Board of Nursing AOS #09 - Wound Assessment, Staging, and Treatment published in December 2023, it was determined the facility failed to ensure services provided or arranged by the facility meet professional standards of quality for two (2) of 49 sampled residents (Resident (R)71 and R1). The facility failed to have qualified wound care staff and physician oversight related to wound care. The findings include: Review of the Kentucky Board of Nursing Advisory Opinion Statement (AOS) #09 - Wound Assessment, Staging, and Treatment published in December 2023, provided by the facility revealed, .It is within the scope of licensed practical nursing practice for a licensed practical nurse who is educationally prepared and clinically competent to assist the qualified healthcare provider in wound assessment, staging, and treatment including debridement. This includes the application of wound dressings and wound vacs, the removal of wound drains, and the application of Unna boots . Review of the job description provided by the facility, for a Charge Nurse (LPN or RN) [Licensed Practical Nurse or Registered Nurse] under Essential Duties and Responsibilities revealed, .Administer professional services such as: catheterization, tube feedings, suction, applying and changing, dressings/bandages, packs, colostomy, and drainage bags, taking blood, giving massages and of motion exercises, care for the dead/dying, etc., as required . Review of the Director of Nursing's (DON) job description provided by the facility, revealed, .Review and verify that documentation procedures for nursing are met . Review of the Medical Director Services - Rules and Responsibilities provided by the facility revealed, The Medical Director will coordinate medical care .and provide clinical guidance and oversight . 1. Review of R71's undated Face Sheet located in the electronic medical record (EMR), under the Face Sheet tab, revealed the facility admitted R71 on 04/13/2024, with diagnoses including stroke, type 2 diabetes mellitus, malnutrition, and unstageable pressure ulcer to sacral area. Review of R71's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/19/2024, located in R71's EMR under the MDS tab, revealed the resident had a Brief Interview for Mental Status (BIMS) score of zero (0) out of 15, indicating severe cognitive impairment. R71 was also coded for an unstageable pressure ulcer that was known, but not stageable due to coverage of the wound bed by slough and/or eschar. Review of R71's Physician's Orders located in the EMR under the Orders tab, revealed clean sacrum wound with normal saline, pack with normal saline wet to dry dressing, and apply boarded dressing daily and as needed for dislodgement. 2. Review of R1's undated Face Sheet located in the EMR, under the Face Sheet tab, revealed the facility admitted the resident on 10/31/2014, with diagnoses including cerebral palsy. Further review of the EMR revealed R1 developed a Stage IV pressure ulcer in August 2023. Review of R1's Annual MDS with an ARD of 03/16/2024, located in R1's EMR under the MDS tab, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. Review of R1's Physician Orders, dated 05/15/2024, located in the EMR, under the Orders tab, revealed clean right ischium wound with normal saline, place betadine-soaked gauze loosely in the wound, and cover with an ABD (abdominal) pad using no tape twice a day and as needed for dislodgement . An interview was conducted with Wound Care Nurse (WCN)1/Licensed Practical Nurse, on 06/05/2024 at 1:26 PM. WCN1 was questioned if she was a certified wound care nurse and she stated, I have only had on the job training. I'm not certified. I am supposed to get the training at some point. Review of WCN1's employee file revealed she was hired on 02/06/2024 and the job application and resume revealed she was not a certified wound care nurse. Review of WCN1's competencies included online classes of Skin Integrity for 0.50 hour with a completion date of 04/01/2024, Infection Control and Prevention for 1.00 hour with a completion date of 02/07/2024, and Pressure Injuries: Assessment, Interventions, Prevention for 1.25 hours with a completion date of 02/08/2024. During a phone interview, on 06/06/2024 at 4:30 PM, Wound Care Certified Nurse (WCCN)1 stated, I worked with WCN1 on 03/13/2024 showing WCN1 the different types of wounds, staging of wounds, measuring of wounds, and some of the best treatments used for the different types of wounds. WCCN1 stated she worked at a sister facility of the corporation where this was education was completed with WCN1. During an interview with the Signature Clinical Coordinator (SCC) Registered Nurse (RN) who was Wound Care Certified, on 06/05/2024 at 2:29 PM, she stated she only provided support to the wound care nurse and did not review her documentation regularly nor did she make observations of the residents that had wounds that were being treated by WCN1. During an interview with the Nurse Practitioner (NP), on 06/06/2024 at 9:10 AM, the NP stated, I will visualize the wounds on admission and then if the wound care nurse sees a wound worsening, but I don't measure the wounds. The wound care nurse does this. During an interview with the Medical Director, on 06/06/2024 at 10:09 AM, he stated he did not visualize the wounds and he was not a board-certified wound care doctor. The Medical Director confirmed the Nurse Practitioner would call if there were any problems she was made aware of, but it was a consult type of occurrence. During an interview with the Director of Nursing (DON), on 06/06/2024 at 10:45 AM, she confirmed she was not a certified wound care nurse, and she did not regularly review the documentation nor observe the wound care nurse during dressing changes. On 06/06/2024 at 3:00 PM, the Administrator stated the facility did not have a job description for a Wound Care Nurse.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure that adequate assistive devices were implemented to prevent accidents for one (1) of four (4) sampled residents reviewed for falls out of a total sample of 49 residents, Resident (R)76). R76 was found on the floor on 04/20/2024, and the Interdisciplinary Team (IDT) conducted a root cause analysis and determined the resident attempted to get out of his bed and fell . A new fall intervention dated 05/04/2024, revealed the resident's bed was to be in a low position, when he was in bed. However, observations on 06/04/2024 revealed staff failed to ensure the bed was in the lowest position while the resident was in bed. The findings include: Review of the facility policy titled, Falls, dated 09/15/2023, indicated, .The intent of this policy is to ensure the facility provides an environment that is as free from accident hazards, as possible, over which the facility has control to prevent avoidable falls.All residents will have a fall risk assessment on admission/readmission, quarterly, annually, and with a significant change of condition to identify risks for falls.A Comprehensive Care Plan will be implemented based on the resident's risk for falls with an individual goal and interventions specific to each resident to attempt to reduce the risk of avoidable falls, to the extent possible. The care plan will be reviewed following each fall, quarterly, annually, and with a significant change in condition.The Interdisciplinary Team (IDT)/which includes the Director of Nursing (DON) or their designee reviews during the At-Risk Meeting as applicable. Review of R76's Resident Face Sheet, in the electronic medical records (EMR), located under the Resident tab, revealed the facility admitted the resident on 04/18/2024 with post-surgical diagnosis of traumatic subdural hematoma. Review of R76's Progress Notes, dated 04/20/2024, located in the EMR under the Progress Notes tab, revealed the resident was found when the nurse was coming out of another resident room. The nurse found the resident on the floor and the resident stated he was trying to get up. The progress notes further revealed the resident was transported to the local hospital, per resident representative (RR)1's request, for evaluation and treatment. Review of R76's Progress Notes, dated 04/22/2024, located in the EMR under the Progress Notes tab, revealed the Interdisciplinary Team (IDT) conducted a root cause analysis and determined the resident attempted to get out of his bed and fell , and determined the cause of the fall as self-transfer of the resident. Review of R76's Care Plan, dated 05/04/2024, located under the RAI (Resident Assessment Instrument) tab, revealed an intervention for the resident's bed to be in a low position, when he was in bed. Review of R76's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/10/2024, located under the RAI tab, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of nine (9) out of 15 indicating moderate cognitive impairment. The MDS assessment further revealed the resident had a history of falls prior to admission and during his admission to the facility. Under the Care Area Assessment (CAA), falls triggered and directed the staff to develop a care plan. During an observation, on 06/04/2024 at 1:10 PM, R76 was in bed, and the bed was not in a low position. During this observation, RR1 was present and stated the bed was not in the low position and she lowered it. RR1 stated when she would find the resident in bed, the bed was typically not in the low position. During an observation, on 06/04/2024 at 4:41 PM, R76 was observed to be in bed, and the bed was not in a low position. During an interview on 06/06/2024 at 8:58 AM, Certified Nursing Assistant (CNA) 3 stated she had provided care for R76 and stated the resident's bed was to be in a low position when he was in the bed. During an interview, on 06/06/2024 at 10:45 AM, the Director of Nursing (DON) stated it was her expectation for staff to implement fall precautions to prevent major injury of a resident. The DON stated the facility had placed a soft touch call light for R76 and the bed was to be lowered to the low position. The DON further stated the positioning of the resident's bed would be in a Certified Nurse Aide (CNA) guide.

Based on observation, interview, and record review, 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 and infections for two (2) of two (2) sampled residents observed for wound care out of a total sample of 49 residents, Resident (R)1 and R71. During observation of wound care for R71, on 06/04/2024, Wound Care Nurse (WCN)1 failed to implement infection control procedures as evidenced by failure to clean/disinfect the table top prior to placing a barrier in which to place wound supplies; failure to clean/disinfect scissors before using them to cut the Kerlix which she packed in the resident's wound; failure to wash hands and don new gloves after wound care and prior to cleaning/disinfecting the dirty scissors; and failure to wait three (3) minutes after disinfecting the scissors prior to placing them back into the treatment cart. Additionally, during observation of wound care for R1 on 06/06/2024 at 9:30 AM, WCN1 failed to provide incontinence care to remove stool before she started the wound care. Also, during wound care, the nurse cleaned the wound with a gauze saturated with normal saline, wiping down the center of the wound, and then wiped the same area again with the same gauze. The findings include: Review of the facility policy titled Skin Integrity, dated 09/15/2023, revealed it is recommended that a nursing leader does a follow-up visualization of skin integrity concerns that were present upon admission. Recommend ongoing observation of skin integrity by licensed nursing staff. The licensed nurse shall initiate applicable Skin Integrity documentation if a new area of impairment is identified. The Nurse Leader/Wound Nurse shall document all impaired skin integrity areas such as: pressure, stasis, surgical incision, or diabetic ulcers in the Electronic Medical Record (EMR) on an ongoing basis or until closed or the resident has been discharged . In addition to ongoing observations of skin integrity impairments mentioned above, nursing stakeholders shall observe the skin for areas of impairment during bathing, dressing, and peri care. Nursing stakeholders will notify the nurse if a new area is identified. The facility utilizes either a pressure reducing, pressure relieving, or pressure redistributing mattress on each resident bed. However, the policy did not identify infection control measures to be utilized related to wound care. 1. Review of R71's undated Face Sheet located in the electronic medical record (EMR), under the Resident tab, revealed the facility admitted the resident on 04/13/2024, with diagnoses including stroke, type 2 diabetes mellitus, malnutrition, and unstageable pressure ulcer to sacral area. Review of R71's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/19/2024, located in R71's EMR under the MDS tab, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of zero (0) out of 15, indicating severe cognitive impairment. R71 was also coded as having an unstageable pressure ulcer that was present on admission. Review of R71's Physician's Orders, dated 05/09/2024, located in the EMR under the Orders tab, revealed orders to clean sacrum wound with normal saline, pack with normal saline wet to dry dressing, and apply boarded dressing daily and as needed for dislodgement. During an observation of Wound Care Nurse (WCN)1 providing wound care to R71 on 06/04/2024 at 1:48 PM, the following was noted: 1) WCN1 did not clean and disinfect the overbed table before placing the barrier down which would hold the wound care supplies. 2) WCN1 brought scissors from the treatment cart into R71's room and did not clean/disinfect the scissors before using them to cut the Kerlix which she packed in the resident's wound. 3) After providing wound care, WCN1 then took off her gloves and failed to wash hands and don new gloves before cleaning the the dirty scissors with soap and water, and then with alcohol preps. She then with bare hands cleaned/disinfected the scissors with a Clorox wipe and placed the scissors on top of the laptop. 4) The WCN1 only waited two (2) minutes before placing the scissors into the treatment cart. During an interview with the Director of Nursing (DON), on 06/05/2024 at 1:57 PM, the DON stated, The nurse should have cleaned the overbed table with a Clorox wipe and then placed her barrier down. And then she should have worn gloves to clean her scissors When asked what the dry time for the Clorox wipes was, the DON stated, I don't know. I will have to get back in touch with you about this. During an interview with Registered Nurse/Signature Clinical Consultant/ Wound Care Nurse Certified Nurse (RN/SCC/WCCN), on 06/05/2024 at 2:29 PM, she confirmed the overbed table should have been cleaned/disinfected with a Clorox wipe before the barrier was placed on it. Further, she stated the scissors should have been cleaned/disinfected before using them to cut the Kerliz and the dry tine for the Clorox wipes was three (3) minutes before the scissors were to be placed back into the treatment cart. During an interview with WCN1, on 06/06/2024 at 1:30 PM, the nurse confirmed she should have cleaned/disinfected the over the bed table prior to placing the barrier to hold the wound care supplies. In further interview, she stated she should have cleaned/disinfected the scissors before using them to cut the kerlix to pack in the resident's wound. In continued interview, WCN1 stated she should have ensured she cleaned and disinfected the scissors after providing wound care while wearing clean gloves and should have waited the dry time of three (3) minutes before placing the clean scissors back into the treatment cart. 2. Review of R1's undated Face Sheet located in the EMR, under the Resident tab, revealed the facility admitted the resident on 10/31/2014, with a diagnosis of cerebral palsy. R1 developed a stage IV pressure ulcer in August 2023. Review of 1's annual MDS with an ARD of 03/16/2024, located in R1's EMR under the MDS tab, revealed the resident had a BIMS score of 14 out of 15, which indicted the resident was cognitively intact. R1 was also coded for having a Stage IV pressure ulcer. Review of R1's Physician's Orders, dated 05/15/2024, located in the EMR under the Orders tab, revealed orders to clean the right ischium wound with normal saline, place betadine-soaked gauze loosely in the wound, and cover with an ABD (abdominal) pad using no tape twice a day and as needed for dislodgement. During an observation of WCN1 providing wound care to R1, on 06/06/2024 at 9:30 AM, the following was noted: 1) When R1 was moved to the side lying position for wound care, the resident had a small bowel movement. The nurse did not provide incontinence care to remove the stool before she started the wound care. 2) While cleaning the wound with a gauze saturated with normal saline, WCN1 wiped down the center of the wound, then wiped the same area again with the same gauze. During continued interview with WCN1, on 06/06/2024 at 1:30 PM, the nurse confirmed she should have provided incontinence care by cleaning the stool from R1 prior to providing wound care. Further, she stated she should not have cleaned R1's wound using the same gauze as she had previously used.

Based on interview, record review, and policy review it was determined the facility failed to develop a plan of care for one (1) of nine (9) sampled residents, Resident #1. The facility failed to develop a care plan for Resident #1's [MEDICATION NAME] drain (a catheter inserted to drain excess fluid from around the lungs). The findings include: Review of the policy titled, Comprehensive Care Plans, dated 07/19/2018, revealed a person-centered plan was to be developed and was to include measurable objectives and timetables to meet a resident's medical and nursing needs. The Comprehensive Care Plan was to assist the resident to meet their needs, goals and preferences. Further review revealed the care plans were to be ongoing and were to be revised as necessary. In addition, the policy revealed the Nurse/Interdisciplinary Team (IDT) was responsible for reviewing and updating care plans. Review of the Quarterly Minimum Data Set (MDS), dated and signed 08/05/2020, revealed Resident #1 had been originally admitted to the facility on [DATE]. Continued review revealed Resident #1 had the following Diagnoses: [REDACTED]. Review of a physician's orders [REDACTED].#1'a [MEDICATION NAME] drain twice a week on Mondays and Thursdays. Continued review revealed, under the Special Instructions, upon draining the [MEDICATION NAME] drain please note if the resident allowed all fluid to be drained or if he/she complained of pain and insisted on the draining to stop, once a day on Monday and Thursday. Review of a physician's orders [REDACTED]. Review of the Special Instructions revealed upon draining the [MEDICATION NAME], please note if the resident allowed all fluid to be drained or if he/she complained of pain and insisted on the draining to be stopped. Review of a physician's orders [REDACTED]. Review of the Special Instructions revealed upon draining the [MEDICATION NAME] please note if the resident allowed all fluid to be drained or if he/she complained of pain and insisted on the draining to be stopped. Review of a physician's orders [REDACTED]. Review of the Special Instructions revealed upon draining the [MEDICATION NAME] please note if the resident allowed all fluid to be drained or if he/she complained of pain and insisted on the draining to be stopped. Review of the facility's Comprehensive Care Plan for Resident #1, with a date range of 06/13/ through 01/13/2021, revealed no documented evidence the resident's [MEDICATION NAME] drain had been incorporated into his/her plan of care as per facility policy. Interview with the MDS Nurse, on 01/19/2021 at 10:15 AM, revealed the purpose of a resident's care plan was to drive the care each resident was provided. She stated any drains a resident might have should have been care planned. Further interview revealed it was important for the nurses to develop and update residents' care plans as needed. Interview with the Director of Nursing (DON) on 01/19/2021 at 10:45 AM, revealed Resident #1's care plan should have been reviewed and revised to incorporate the care of the resident's [MEDICATION NAME] drain. Continued interview revealed the DON stated the former MDS staff must have overlooked the resident's [MEDICATION NAME] drain.

Based on interview, record review, and policy review, it was determined the faciltiy failed to ensure one (1) of nine (9) sampled resident received treatment and care in accordance with the professional standards of practice. Resident #9's medication were not signed off on the Medication Administration Record [REDACTED]. The findings include: Review of the policy titled, Physician order [REDACTED]. all medication omissions identified in EMAR require a Root Cause Analysis to be completed by the Director of Nursing (DON) or designate, and 3. following identification of root cause, individuals responsible for the error or omission would receive training to clarify proper procedure and must demonstrate (through verbal or written testing) competency. Review of Resident #9's closed medical record revealed the facility admitted the resident on 11/27/2020 with [DIAGNOSES REDACTED]. Review of Resident #9's Medication Administration Record [REDACTED]. The medications included: [MEDICATION NAME] one-hundred milligrams (100 MG) by mouth (PO) every eight (8) hours routine for [MEDICAL CONDITION] pain, [MEDICATION NAME] one (1) milligram (MG) PO every eight (8) hours routine for nausea, and [MEDICATION NAME] one-thousand (1000) milligrams (MG) PO every eight (8) hours routine for pain. Telephonic interview with Licensed Practical Nurse #1 on 01/15/2021 at 8:47 AM revealed she had been Resident # 9's nurse the morning of 12/05/2020. She revealed when she administered medications to the residents, she should sign the medication as given on the MAR. She revealed if she had not signed off the medications for Resident #9 on 12/05/2020 at 6:00 AM it could mean she missed giving the medications. LPN #1 stated she may have forgotten to confirm the medications as given. She went onto state it was very important for residents to receive their medications as ordered to treat their diseases and medical conditions. Interview with the Director of Nursing (DON) on 01/14/2021 and 01/19/2021 at 10:45 AM revealed an unknowing the medications had not been signed out as given. She revealed it was her expectation that residents received their medications as ordered by the physician, and the medications were signed off by the administering staff properly. Interview with the Administrator on 01/19/2021 at 11:07 AM revealed it was her expectation staff sign off their medications they have passed, and follow the rules of medication pass. She revealed missed medications could have an adverse effect on a resident. She stated the facility was not aware Resident #9's medications had not been signed off as administered. She revealed Quality Assurance Performance Improvement Committee (QAPI) met monthly and the department heads as well as the medical director participated. She stated the facility had not completed any education or re-education on medication administration recently. Interview with the Administrator, on 01/19/2021 at 11:07 AM, revealed it was her expectation that nursing staff sign off the medications they had administered to residents. She stated she expected staff to follow the facility's rules regarding medication pass. Per the Administrtor, missed medications could have an adverse effect on a resident. Continued interview revealed she was unaware Resident #9's medications had not been signed off as administered on 12/05/2020 at 6:00 AM. She revealed the facility did not complete any education or re-education regarding medication recently.

Based on interview, record review and review of policy, it was determined the facility failed to have an effective system to ensure clinical records were accurately documented to reflect the resident's assessment for three (3) of three (3) sampled residents (Resident #1, #2 and #3). Review of documentation of the residents' respiratory assessment for COVID-19 did not include the residents' oxygen saturation parameters. Interviews with staff revealed assessments for COVID-19 included to monitor residents' oxygen saturation levels for respiratory status. However, the staff stated they did not document it on the resident's medical record under vital signs nor did the facility include specific respiratory indicators on the resident's medical order for COVID-19 monitoring twice a day. The findings include: Review of the facility's policy, Novel Coronavirus (COVID-19), revised 08/31/2020, revealed the facility made routine observations for respiratory symptoms of COVID-19. The facility reviewed respiratory symptoms of all residents in the morning and afternoon clinical meetings. In addition, the facility would review the symptoms to ensure to monitor for respiratory illness. 1. Review of Resident #1 clinical record revealed the facility admitted the resident on 07/24/2020, with the [DIAGNOSES REDACTED]. Review of the resident's physician's orders [REDACTED]. Review of the resident's Treatment Administration Record (TAR) for August and September 2020 revealed the order included documentation of cough. However, review of the SOB record and the vital sign record revealed staff did not document the resident's oxygen saturation twice a day. Interview with Resident #1, on 09/08/2020 at 6:00 PM, revealed staff obtained oxygen saturation levels twice a day. The resident stated staff monitored the levels for COVID-19. 2. Review of Resident #2 clinical record revealed the facility admitted the resident on 06/04/2020, with the [DIAGNOSES REDACTED]. Review of the resident's physician's orders [REDACTED]. Review of the resident's Treatment Administration Record (TAR) for August and September 2020 revealed the order included documentation of cough. However, record review revealed the TAR, vital sign records and the SOB record did not include documentation of oxygen saturation, twice a day, related to COVID-19 monitoring. Interview with Resident #2, on 09/08/2020 at 5:00 PM, revealed the staff obtained oxygen saturations levels twice a day. 3. Review of Resident #3's clinical record revealed the facility admitted the resident on 05/07/18, with the [DIAGNOSES REDACTED]. Review of the resident's physician's orders [REDACTED]. Review of the resident's Treatment Administration Record (TAR) for August and September 2020 revealed the order included documentation of cough. However, the SOB record, revealed staff did not document oxygen saturation twice a day. Review of the resident's vital sign record revealed the facility staff did not document oxygen saturations twice a day daily. Interview with Licensed Practical Nurse (LPN) #1, on 09/08/2020 at 4:15 PM, revealed staff assessed a resident's status twice a day for respiratory symptoms related to COVID-19. She stated this included oxygen saturation levels. She stated the TAR did not have an area to document respiratory vital signs, including oxygen and respiratory rate. LPN #1 stated she did not put vital signs for the assessment in the resident's clinical record. She stated the facility would not be able to monitor for respiratory changes, and this piece of clinical information needed to be included for the clinical staff to review. Interview with Licensed Practical Nurse #2, on 09/08/2020 at 5:22 PM, revealed staff assessed a resident's status twice a day for respiratory symptoms related to COVID-19 as ordered by the physician. She stated an assessment included oxygen saturation levels. She stated resident the TAR's did not have an area to document respiratory vital signs, which included oxygen and respiratory rate. LPN #2 stated the facility staff monitored for respiratory changes twice a day and staff should document all respiratory related assessments. Interview with the Director of Nursing (DON), on 09/08/2020 at 6:30 PM, revealed her responsibilities included Infection Preventionist. She stated resident respiratory assessments included to monitor oxygen levels. She stated staff assessed residents twice a day for COVID-19 which included a full respiratory assessment. The DON stated staff were to document vital signs, which included oxygen saturation levels. She stated if the resident's oxygen saturations levels were not documented, as they were part of the respiratory assessment, then the facility could not review for abnormal levels. Further interview revealed if the resident's oxygen level trended lower without other symptoms the resident's and staff could be exposed to [MEDICAL CONDITION]. The Administrator was not available for interview. However, the DON stated she assumed the administrator's duties when he/she was not in the building.

Based on observation, interview, and record review, it was determined the facility failed to implement the care plan for two (2) residents, Residents #3 and #4. Observations revealed facility-provided meal trays did not contain the care planned adaptive utensils or equipment. The findings include: Review of facility policy Comprehensive Care Plans (CCP), revised 07/19/18, revealed the person-centered Comprehensive Care Plan included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs and was developed for each resident. Additionally, the CCP included how the facility assisted the resident to meet their needs, goals and preferences and included specialized services. Review of facility policy Adaptive Equipment - Feeding Devices, revised 08/30/19, revealed adaptive feeding equipment was used by residents who needed to improve their ability to feed themselves. Review of facility record revealed the facility readmitted Resident #3 on 01/23/2020 with [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. Divided plate and a ninety (90) degree spoon. Review of the CCP revealed the problem resident has a potential for nutritional risks, secondary to the following conditions: Diabetes Mellitus Type 2, Dementia, and High BMI (body mass index). An approach for this problem listed to provide diet as ordered. Observation during lunch service, on 07/02/2020 at 12:20 PM, revealed Resident #3's tray contained no ninety (90) degree spoon and the resident was utilizing a regular teaspoon to eat. Review of the tray card specified the tray required a ninety (90) degree spoon. Review of facility record revealed the facility readmitted Resident #4 on 02/13/19 with [DIAGNOSES REDACTED]. Muscle Weakness, and Dysphagia, Oropharyngeal Phase. Review of the Physician order [REDACTED]. Review of the CCP revealed a problem nutritionally at risk related to therapeutic diet and noncompliance with diet. Risk for alterations in fluid maintenance related to heart failure with diuretic use. Approaches for the Problem included diet as ordered. Observation during lunch service, on 07/02/2020 at 12:37 PM, revealed Resident #4's tray contained a cup of water and a cup containing a light yellow liquid. Interview with Certified Nursing Assistant (CNA) #1, on 07/02/2020 at 1:00 PM, revealed CNA's were responsible to insure resident meal trays included the correct adaptive equipment. CNA #1 stated adaptive equipment was necessary to enable a resident to eat better and prevent potential choking. Interview with Licensed Practical Nurse (LPN) #2, on 07/08/2020 at 1:19 PM, revealed all staff were responsible to insure the resident's meal trays contained the ordered and care planned adaptive utensils. LPN #2 stated adaptive utensils were necessary to insure a resident did not potentially lose nutrition. LPN #2 stated the care plan was not implemented if staff did not provide the ordered and care planned adaptive equipment. Interview with LPN #4, on 07/09/2020 at 3:25 PM, revealed staff developed resident care plans with goals and guidelines to meet the goals and if staff did not provide care planned adaptive equipment then staff did not implement the care plan. Interview with Green Unit Manager (Green UM), on 07/08/2020 at 4:04 PM, revealed resident care plans directed staff on the care necessary for the resident and staff implemented the care plan to provide good and necessary care. The Green UM stated staff individualized resident care plans to meet the care needs of the resident and all staff were responsible to insure meal trays contained the ordered adaptive equipment. Interview with the Blue Unit Manager (Blue UM), on 07/09/2020 at 2:55 PM, revealed staff individualized care plans to each resident to address the resident's medical needs. The Blue UM stated CNA's were responsible to insure adaptive equipment was included on resident meal trays. Interview with the Dietary Manager (DM), on 07/09/2020 at 2:01 PM, revealed dietary staff initially prepare resident trays, including providing adaptive equipment as ordered. The DM stated adaptive equipment was necessary to help the resident eat and failure to provide adaptive equipment may hinder a resident from eating or drinking properly. Interview with the Director of Nursing (DON), on 07/10/2020 at 8:45 AM, revealed all staff were responsible to insure resident meal trays contained adaptive equipment as ordered. Interview with the Administrator, on 07/10/2020 at 9:42 AM, revealed she was unaware of any issue with residents receiving adaptive equipment with meal trays. The Administrator stated the facility audited orders to meal tray cards but did not specify if the facility audited meal tray cards to the meal tray provided to residents.

Based on observation, interview, and record review, it was determined the facility failed to ensure drugs and biologicals were stored in a professional standard to prevent the presence of expired items. Observations revealed expired normal saline solution and sterile saline solution present in the emergency carts. In addition, continued observation revealed expired medical supplies including oxygen tubing and intravenous (IV) start kits. The findings include: Review of facility policy Emergency Carts, reviewed [DATE], revealed the facility insured emergency equipment was readily available and the emergency cart and staff audited the carts daily and restocked as indicated. Observation of the emergency cart on Blue Unit, on [DATE] at 1:49 PM, revealed a one (1) liter bag of normal saline with an expired date, a one hundred (100) milliliter container of sterile saline with an expiration date of [DATE]. Additional observations revealed an IV start kit with an expiration date of [DATE], and an IV tubing administration set with an expiration date of ,[DATE]. Observation of the emergency cart on the Green Unit, on [DATE] at 2:40 PM, revealed a one hundred (100) milliliter container of sterile saline solution with an expiration date of [DATE] and an IV start kit with an expiration date of [DATE]. Interview with Blue Unit Manager (Blue UM), [DATE] at 1:49 PM, revealed staff should check for product expiration dates when auditing emergency carts and indicated all items listed on the inventory should be present and unexpired. The Blue UM stated an expired item may not have the effect as intended and sterility was not guaranteed. Interview with the Green Unit Manager (Green UM), on [DATE] at 2:40 PM, revealed staff should check product expiration dates when auditing the emergency carts. The Green UM stated expired items might not have the same efficacy as intended; and use of expired items may delay care and a resident status may decline. Interview with Licensed Practical Nurse (LPN) #2, on [DATE] at 1:19 PM, revealed staff audited emergency carts to insure items were stocked appropriately and not expired. LPN #2 stated using expired items might lead to an allergic reaction, and a delay in care. Interview with the Director of Nursing (DON), on [DATE] at 8:45 AM, revealed she was unaware the facility emergency cart audit checklist did not prompt staff to audit product for an expiration date. The DON stated she was unaware of any issues concerning the facility emergency carts. Interview with the Administrator, on [DATE] at 9:42 AM, revealed she was unaware of any issues surrounding the facility emergency crash carts.

Based on observation, interview, and record review, it was determined the facility failed to provide special eating equipment and utensils for two (2) residents, Residents #3 and #4. Observations revealed facility-provided meal trays did not contain the ordered adaptive equipment. The findings include: Review of facility policy Adaptive Equipment - Feeding Devices, revised 08/30/19, revealed adaptive feeding equipment was used by residents who needed to improve their ability to feed themselves. Review of facility record revealed the facility readmitted Resident #3 on 01/23/2020 with [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. Divided plate and a ninety (90) degree spoon. Review of the CCP revealed the problem resident has a potential for nutritional risks, secondary to the following conditions: Diabetes Mellitus Type 2, Dementia, and High BMI (body mass index). An approach for this problem listed to provide diet as ordered. Observation during lunch service, on 07/02/2020 at 12:20 revealed Resident #3's tray contained no ninety (90) degree spoon and the resident was utilizing a regular teaspoon to eat. Review of the tray card specified the tray required a ninety (90) degree spoon. Review of facility record revealed the facility readmitted Resident #4 on 02/13/19 with [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. Review of the CCP revealed a problem nutritionally at risk related to therapeutic diet and noncompliance with diet. Risk for alterations in fluid maintenance related to heart failure with diuretic use. Approaches for the Problem included diet as ordered. Observation during lunch service, on 07/02/2020 at 12:37 PM, revealed Resident #4's tray contained a cup of water and a cup of a light-yellow colored liquid. Interview with Certified Nursing Assistant (CNA) #1, on 07/02/2020 at 1:00 PM, revealed CNA's were responsible to insure resident meal trays included the correct adaptive equipment. CNA #1 stated adaptive equipment was necessary to enable a resident to eat better and prevent potential choking. Interview with Licensed Practical Nurse (LPN) #2, on 07/08/2020 at 1:19 PM, revealed all staff were responsible to insure the resident's meal trays contained the ordered adaptive utensils and devices. LPN #2 stated adaptive utensils were necessary to insure a resident did not potentially lose nutrition. Interview with Green Unit Manager (Green UM), on 07/08/2020 at 4:04 PM, revealed all staff were responsible to insure meal trays contained the ordered adaptive equipment. Interview with the Blue Unit Manager (Blue UM), on 07/09/2020 at 2:55 PM, revealed CNA's were responsible to insure adaptive equipment was included on resident meal trays. Interview with the Dietary Manager (DM), on 07/09/2020 at 2:01 PM, revealed dietary staff initially prepare resident trays, including providing adaptive equipment as ordered. The DM stated adaptive equipment was necessary to help the resident eat and failure to provide adaptive equipment may hinder a resident from eating or drinking properly. Interview with the Director of Nursing (DON), on 07/10/2020 at 8:45 AM, revealed all staff were responsible to insure resident meal trays contained adaptive equipment as ordered. Interview with the Administrator, on 07/10/2020 at 9:42 AM, revealed she was unaware of any issue with residents receiving adaptive equipment with meal trays. The Administrator stated the facility audited orders to meal tray cards but did not specify if the facility audited meal tray cards to the meal tray provided to residents.

Based on observation, interview, and facility policy review, it was determined the facility failed to store and serve food in accordance with professional standards for food service safety. Observation revealed expired milk in the refrigerator and record review revealed food temperatures and sanitation temperatures not documented. The findings include: Review of the facility's policy, Food Temperatures, revised [DATE], revealed food should be served at proper temperatures to ensure food safety and palatability. Staff was to record temperature readings on the Food Temperature Chart (Form 401) or Food Temperatures/Sanitation Combined Record (Form 401B) or other designated form at the beginning of tray line and the end of tray line. If temperatures did not meet acceptable serving temperatures, reheat the product or chill the product to the proper temperature. Take the temperature of each pan of product before serving. Review of the facility's policy, Food Storage, revised [DATE], revealed food items should be stored, thawed, and prepared in accordance with good sanitary practice. Any expired or outdated food products should be discarded. 1. Observation of the kitchen, on [DATE] at 10:15 AM, revealed the reach-in refrigerator contained six (6) cartons of thickened dairy milk with expiration dates of [DATE], and available for staff use. Interview with the Assistant Dietary Director, on [DATE] at 11:32 AM, revealed he and the Food Service Director were responsible for monitoring the refrigerator and freezer for expired products to prevent residents from getting expired food that could make them sick. He stated there was not a schedule for checking for expired food and he last checked a few weeks ago. 2. Review of the facility's Food Temperature/Sanitation Record (Form 401B), dated (MONTH) 2019, revealed Records for [DATE] through [DATE] were missing. On [DATE], the sanitation temperatures were not recorded. On [DATE], [DATE], and [DATE], there were no food temperatures recorded for mechanical and pureed food for the lunch and evening meals. On [DATE], there were no temperatures recorded for mechanical and pureed food for the evening meal. On [DATE], there were no temperatures recorded for mechanical and pureed food for the breakfast, lunch, and evening meals. There was no documentation of sanitation temperatures for lunch and evening meals on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of the Food Temperature/Sanitation Records, dated [DATE] and [DATE], revealed no documentation of food temperatures for the lunch and evening meals, nor sanitation temperatures. On [DATE], the evening meal food temperatures and sanitation temperatures were not recorded. There were no Records for [DATE] through [DATE] available for review. None of the Records had initials identifying staff who took the temperatures. Interview with the Food Service Director, on [DATE] at 9:54 AM, revealed staff missed some days completing the temperatures of the meals. He stated he reminded staff to complete the form but did not audit the process. He stated the sanitation temperatures were to be documented on the same form. Interview with the Administrator, on [DATE] at 4:18 PM, revealed she was not aware of concerns related to temperatures or expired items in the kitchen.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to follow the care plan for one (1) of four (4) sampled residents, Resident #70. The facility assessed the resident was at risk for falls with an intervention to have the call light within reach. However, observation revealed the resident's call light was not functional. The findings include: Review of the facility's policy, Comprehensive Care Plans, revised 07/19/18, revealed a person-centered care plan was developed to include measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs. The care plan was designed to incorporate identified problem areas; incorporate risk factors associated with identified problems; and aid in preventing or reducing declines in the resident's functional status and/or functional levels. The policy revealed care plan interventions would reflect action, treatment, or procedures to meet the objectives toward achieving resident goals. Review of the facility's policy, Answering the Call Light, revised (MONTH) 2010, revealed staff should ensure the call light was plugged in at all times to respond to the resident's requests and needs. Review of the clinical record revealed the facility admitted Resident #70 on 04/04/16, with [DIAGNOSES REDACTED]. Review of Resident #70's Significant Change Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of eleven (11) of fifteen (15) and determined the resident interviewable. Per the MDS, the resident had a fall with a major injury since the last assessment. Review of Resident #70's Care Plan, dated 04/18/16, revealed the resident required assistance with his/her Activities of Daily Living, and was at risk for falls and required assistance with transfers and/or ambulation. Interventions included the call light was to be within reach in the resident's room, when in bed, and when in the bathroom. Observation, on 02/12/19 at 10:02 AM, revealed Resident #70 in bed and his/her left arm was in a sling. The resident stated he/she fell and broke his/her arm. Further observation, on 02/12/19 at 11:54 AM, revealed Resident #70's call light was not operational. The call light cord was wrapped around the side rail of the bed and the box/jack was out of the wall and laid on the floor behind the recliner. Interview with Certified Nursing Assistant (CNA) #1, on 02/12/19 at 12:07 PM, revealed CNAs were responsible for ensuring the call light was within reach of the resident and functioning, in case the resident needed assistance. She stated sometimes the call light cord got caught when adjusting the bed and the box would come off the wall. Interview with Registered Nurse (RN) #1, on 02/12/19 at 12:17 PM, revealed he had not noticed Resident #70's call light was off the wall and it could have happened when the bed was adjusted. He stated the resident could not ask for help from staff if he/she did not have a functional call light available. Interview with RN #2, on 02/15/19 at 1:51 PM, revealed she monitored to ensure call lights were in reach of the resident when she went into a resident's room. She stated all staff was responsible for ensuring call lights were accessible. The RN revealed it was important for residents to have access to a functioning call light so he/she could call for assistance and prevent potential skin breakdown, fall, or injury. She stated if an operational call was not within reach of the resident, then the care plan was not followed. Interview with Unit Manager (UM) #1, on 02/15/19 at 2:36 PM, revealed all staff was responsible for ensuring call lights were within reach. She stated it was important to ensure the call light was within reach and plugged into the wall so the resident could make staff aware when they needed assistance. UM #1 revealed there was a risk for the resident to fall if he/she tried to transfer or ambulate unassisted. She revealed Resident #70's care plan was not followed because an operational call light was not accessible to the resident. Interview with the Director of Nursing (DON), on 02/15/19 at 3:29 PM, revealed all staff was responsible to ensure call lights were in place and she was not aware of any issues related to call lights or call light boxes disconnected from the wall. She stated there was a risk the resident's needs would not be met if the call light were not functional. She stated Resident #70's care plan was not implemented related to the call light. Interview with the Administrator, on 02/15/19 at 4:18 PM, revealed staff did rounds to ensure functioning equipment was within reach of the residents. She was not aware of any issues related to nonfunctioning call lights.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of four (4) sampled residents, Resident #70, had a functioning call light to ensure safety. Observation revealed the call light box/jack was pulled away from the wall and not functional. The findings include: Review of the facility's policy, Safety and Supervision of Resident, reviewed 05/31/18, revealed staff should make routine resident and environmental checks to ensure the safety and well-being of the resident. Routine resident checks by nursing staff involved entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs were being met, identify a change in the resident's condition, identify whether the resident had any concerns, see if the resident was sleeping, and needed toileting assistance, etc. Review of the facility's policy, Answering the Call Light, revised (MONTH) 2010, revealed staff should ensure the call light was plugged in at all times to respond to the resident's requests and needs. Review of the clinical record revealed the facility admitted Resident #70 on 04/04/16, with [DIAGNOSES REDACTED]. Review of a Significant Change Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #70 with a Brief Interview for Mental Status (BIMS) score of eleven (11) of fifteen (15) and determined the resident interviewable. Per the MDS, the resident had sustained a fall with major injury since the last assessment. Review of the resident's Fall Risk Evaluation, dated 12/22/18, revealed the facility assessed the resident was at risk for falls with a score of sixteen (16), as a resident who scored a ten (10) or higher was at risk. Review of the Fall Risk Care Plan, dated 04/18/16, revealed Resident #70 had a history of [REDACTED]. Interventions included ensuring the call light was within reach in the resident's room and bathroom. Observation of Resident #70, on 02/12/19 at 10:02 AM, revealed the resident in bed and his/her left arm was in a sling. The resident stated he/she fell and broke his/her arm. Observation, on 02/12/19 at 11:54 AM, revealed Resident #70's call light was not functioning. The call light cord was wrapped around the side rail of the bed and the box/jack laid on the floor behind the recliner. Interview with Certified Nursing Assistant (CNA) #1, on 02/12/19 at 12:07 PM, revealed sometimes the call light cord got caught when adjusting the bed and the box would come off the wall. She stated CNAs were responsible for ensuring the call light was functional in case the resident needed assistance. She stated there was a risk the resident could try to get up unassisted and fall. Interview with CNA #2, on 02/12/19 at 12:13 PM, revealed she had not noticed the broken call light. She stated the call light should not have come off the wall easily and it might have been pulled out when the recliner chair went up and down. Interview with Registered Nurse (RN) #1, on 02/12/19 at 12:17 PM, revealed he had not noticed Resident #70's call light was disconnected from the wall and stated when the bed was adjusted, it might have pulled off the wall. He stated the resident could fall or be injured if he/she could not contact staff because the call light was not functioning. Interview with RN #2, on 02/15/19 at 1:51 PM, revealed she had never seen a call not plugged into the wall and it was important for residents to have access to a functioning call light so he/she could call for assistance to prevent potential skin breakdown, fall, or injury. Interview with Unit Manager (UM) #1, on 02/13/19 at 1:44 PM, revealed the Interdisciplinary team (IDT) was assigned to observe and monitor resident rooms daily as part of Ambassador Rounds. She stated call lights were monitored during the rounds to ensure they were operational. Further interview with UM #1, on 02/15/19 at 2:36 PM, revealed it was important to ensure the call light was operational so the resident could make staff aware they needed assistance. UM #1 stated there was a risk for the resident to fall if he/she tried to transfer or ambulate unassisted. Interview with the Director of Nursing (DON), on 02/15/19 at 3:29 PM, revealed she was not aware of any issues related to call lights or call light boxes disconnected from the walls. She stated lack of a functional call light posed a potential accident hazard for a resident; however, she did not think Resident #70 was at risk for falls. Interview with the Administrator, on 01/15/19 at 4:18 PM, revealed she was not aware of issues of call lights not functioning. She stated staff rounded to ensure equipment functioned and she reviewed the rounds with the team during the morning meetings.

Based on observation, interview, facility policy review, and controlled mediation count review, it was determined the facility failed to account for controlled medication for one (1) of eighteen (18) sampled residents, Resident #26. Observation and record review revealed an inaccurate account of the resident's medication. The findings include: Review of the facility's policy, Medication Administration Controlled Substances, revised (MONTH) (YEAR), revealed controlled medications were substances that fell under U.S. Drug Enforcement Agency (DEA) Schedule II-V, and had a potential for abuse, ranging from low to high, and might also lead to physical or psychological dependence. These medications were subject to special handling, storage, disposal, and record keeping at the facility in accordance with federal and state laws and regulations. The policy stated when a controlled medication was administered, the licensed nurse administering the medication immediately entered the date and time of administration, amount administered, and signature of the nurse administering the dose on the accountability record when removing a dose from controlled storage. Observation, on 02/14/19 at 8:50 AM, during reconciliation of controlled medication with Licensed Practical Nurse (LPN) #1, revealed there was one (1) pill missing from Resident #26's [MEDICATION NAME] (Schedule IV) 0.5 milligram (mg) supply. Review of the narcotic count sheet revealed there should have been thirty (30) pills left in the supply and the count was twenty-nine (29). LPN #1 stated she gave the [MEDICATION NAME] 0.5 mg earlier that morning but forgot to sign it out. Continued interview with LPN #1, on 02/14/19 at 9:00 AM, revealed she should have signed out the controlled medication on the narcotic count sheet when she took it out of the supply but she forgot. LPN #1 stated Resident #26 was agitated in the mornings so each morning before he/she got breakfast, she gave the medication to the resident. LPN#1 also stated when administering controlled medication, the nurse was to first pull the narcotic sheet and sign out the right medication, make sure it was the right dose, then sign the narcotic sheet right away, as trained to do at this facility. According to the LPN, it was important to sign out controlled medication when given to prevent medication errors and to prevent the risk of controlled medication diversion. LPN #1 stated she did not follow the facility's policy for administering controlled medications. Interview with Registered Nurse (RN) #2, on 02/15/19 at 1:53 PM, revealed it was important to sign out controlled medication when removed from the drawer for accountability, and it was good nursing practice, in addition to facility protocol. Interview with RN #3, on 02/15/19 at 3:10 PM, revealed all nurses should sign out controlled medication when given per policy. When controlled medications were removed from the narcotic drawer, signage would prevent a medication error and provide accurate administration time. Interview with Unit Manager (UM) #1, on 02/14/19 at 2:39 PM, revealed nursing staff was to sign out controlled medication immediately so there was accountability of the medication and to ensure staff knew when then next dose could be administered. The UM stated signing out controlled medication at the time given was facility policy. Interview with the Director of Nursing (DON), on 02/15/19 at 3:35 PM, revealed nursing staff was to sign out controlled medication when given for best nursing practice and accountability of the medication. Interview with the Administrator, on 02/15/19 at 4:20 PM, revealed proper documentation needed to be done at the time of medication administration by the nursing staff.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure proper storage of medications in two (2) of six (6) medication carts, Green Hall Medication Carts 1 and 2. Observation revealed sixty-one (61) loose, unpackaged pills in the carts. In addition, Medication Cart #1 was left unlocked and unattended and medications were left unattended at Resident #37's bedside. The findings include: 1. Review of the facility's policy, Preparation for Medication Administration, dated (MONTH) 2007, revealed the facility maintained equipment and supplies necessary for the storage, preparation, and administration of medications to residents. The nurse or authorized staff member on duty ensured equipment and supplies related to medication storage and use were clean and orderly. Review of the facility's policy, Medication Administration General Guidelines, dated (MONTH) 2012, revealed medications were administered as prescribed in accordance with manufacturer's specifications, good nursing principles and practices, and only by persons legally authorized to do so. During the administration of medications, the medication cart was kept closed and locked when out of sight of the medication nurse. The cart must be clearly visible to the personnel administering medications when unlocked. Observation of Green Hall Medication Cart 2, with Registered Nurse (RN) #4, on 02/12/19 at 11:38 AM, revealed twenty-two (22) unidentified pills and three (3) unidentified capsules loose and unpackaged in the second drawer of the cart. There was loose paper and particles in the base of the drawers. Interview with RN #4, on 02/12/19 at 11:38 AM, during the observation, revealed she cleaned the medication cart on the outside, but did not routinely pull all the medications out and look for medications on the bottom of the cart. She stated she was concerned the medication was not dropped in the medication cup and residents might not have gotten their dose of medication. Observation of Green Hall Medication Cart 1, on 02/12/19 at 11:48 AM, with RN #1, revealed thirty-six (36) unidentified pills were loose and unpackaged in the second drawer, along with loose paper and particles in the base of the drawers. Observation of Green Hall Medication Cart 1, on 02/12/19 at 2:00 PM, revealed RN #1 walked into a resident's room and left the cart unlocked and unattended. Interview with RN #1, on 02/12/19 at 2:10 PM, revealed medication carts were to be locked when unattended to prevent a resident from obtaining medications and having a negative outcome. He stated he stepped away for just a few seconds and did not relock the medication cart. The RN stated he cleaned the medication cart every shift he worked and cleaned the drawers yesterday at the beginning of his shift and at the end of his shift, and cleaned the cart this morning. He stated he did not know how or why there were loose pills in the cart, as he held the medication cup to the back of the card so the medication popped into the cup and not into the medication cart. Interview with Unit Manager (UM) #1, on 02/12/19 at 2:25 PM, revealed staff was not to leave medication carts unlocked when they stepped away because it was not safe for the residents, as a confused resident might be able to access the cart and ingest medication. Interview with RN #2, on 02/145/19 at 1:31 PM, revealed the night shift nurse was responsible for cleaning the medication cart, which would include disposing of medications that had dropped in the drawers; however, she was not aware of a cleaning schedule. She stated sometimes pills would drop in the cart when punched out and she discarded them in the sharps container. RN #2 stated if sixty-one (61) pills were found loose in the carts, then the carts had not been cleaned recently. According to the nurse, it was important to maintain a clean cart for infection control and for accountability of the medications. Continued interview with UM #1, on 02/15/19 at 2:36 PM, revealed every nurse was supposed to clean their medication cart before the end of the shift, which included wiping down the cart, changing the water, and emptying the trash. She stated deep cleaning was done monthly. The UM stated she did monthly random audits and turned them in to the Director of Nursing (DON) and had found loose pills in the cart during the last audit, which was concerning because of the cost to the residents. She stated it was also dangerous to have loose pills in the cart because some pills needed to be handled wearing gloves. According to the UM, it was possible the pills were punched out and fell in the drawer instead of the medication cup and residents did not get their medication. Interview with the DON, on 02/15/19 at 3:29 PM, revealed the nurse in charge of the medication cart should ensure the cart was clean, and if pills laid loose in the cart, it revealed the cart was not cleaned as it should have been. Once the nurse punched the pills out of the card, the nurse should ensure the pill was in the medication cup. She stated a dirty medication cart was an infection control concern. She did not do audits of the carts but stated cleanliness was part of the pharmacy's audit when they did random checks and she had not been notified of any concerns. According to the DON, there was no scheduled cleaning of the medication carts. Interview with the Administrator, on 02/15/19 at 4:18 PM, revealed she was not aware of issues with the medication carts prior to the survey. 2. Continued review of the facility's policy, Medication Administration General Guidelines, revealed residents were allowed to self-administer medications when specifically authorized by the prescriber, the Interdisciplinary team, and in accordance with procedures for self-administration of medications and state regulations. The resident was always observed after administration to ensure the dose was completely ingested. Observation, on 02/12/19 at 11:49 AM, revealed Resident #37 in bed with eyes closed. There was a medication cup on the over bed table with three (3) pills inside. Interview with RN #1, on 02/12/19 at 12:17 PM, revealed he was Resident #37's nurse and identified the pills in the resident's room were Vitamin C, [MEDICATION NAME] (antidepressant), and Vitamin D. He stated the resident had the pills in his/her hand when he left the room. He stated it was not okay to leave medication in a resident's room and staff was to ensure residents took their medication for therapeutic benefits. According to the nurse, another resident could take the medication, or the resident could drop the pills on the floor. The RN stated staff could not confirm residents took their medication if they did not witness them taking the medication. Interview with RN #2, on 02/15/19 at 1:15 PM, revealed staff should not leave medication at the bedside because staff would not know if the resident took the medication and there was a risk of other residents accessing them. She stated staff was to stay with the resident to ensure he/she ingested their medication. Interview with UM #1, on 02/15/19 at 2:36 PM, revealed staff was not allowed to leave medication at the bedside unless the resident was assessed as capable to self-medicate, and she did not think Resident #70 was assessed as such. She stated staff was to witness residents taking their medication to ensure they took them and ensure they did not choke. According to the UM, a confused resident could go in the room and take the pills and have a negative reaction. She revealed she was not aware of staff leaving medication at the bedside. Interview with the DON, on 02/15/19 at 3:29 PM, revealed she had not identified concerns with medication left at the bedside prior to the survey. She stated the medication nurse was responsible to ensure the resident safely took the medication prior to leaving the room. There was a potential risk the resident would forget to take the pills, or another resident could take them, according to the DON.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to maintain an effective infection control program to help prevent the development and transmission of disease and infection for one (1) of six (6) sampled residents, Resident #13. Observation of Resident #13's Oxygen tubing revealed it was dated 07/11/18, several months prior to the survey. The findings include: Review of the facility's policy, Infection Control, revised (MONTH) (YEAR), revealed the objectives of the infection control practices served to prevent, investigate, and control infections in the facility. The facility was to maintain a safe, sanitary environment for personnel, residents, visitors, and the general public. The policy further stated all personnel were trained on infection control policies and practices, upon hire and periodically, which included how and where to find and use pertinent procedures and equipment related to infection control. Review of Resident #13's clinical record revealed the facility readmitted the resident on 10/13/18, with [DIAGNOSES REDACTED]. Review of the Medication Administration Records (MAR) for Resident #13, dated (MONTH) 2019 through (MONTH) 2019, revealed the resident had an Oxygen treatment scheduled during the night for 2 liters per minute via nasal cannula. Observation of Resident #13's Oxygen concentrator, on 02/13/19 at 8:41 AM, revealed a plastic bag hanging from the dusty concentrator, which contained the Oxygen tubing, and was dated 07/11/18. Interview with Unit Manager (UM) #1, on 02/13/19 at 2:20 PM, revealed Oxygen tubing was changed every Tuesday on third shift and documented on the Medication/Treatment Administration Record (MAR/TAR). She stated she periodically checked tubing because tubing could collect bacteria and could enter the lung, and make a resident sick with a respiratory infection. The UM further stated Resident #13 had comorbidities and was therefore more vulnerable than a healthy person was, and she was not sure if the resident received Oxygen in compromised tubing. She stated the facility had not conducted audits to ensure Oxygen tubing was changed. The UM did not know why Resident #13's tubing was not changed and stated all nurses should check to ensure tubing had been changed. Further review of Resident #13's MAR indicated [REDACTED] Interview with Registered Nurse (RN) #2, on 02/15/19 at 2:25 PM, revealed she knew Resident #13 and was aware he/she had Oxygen tubing and a mask for ordered breathing treatments. She stated if she saw a date of 07/11/18 on a bag containing the Oxygen tubing, she would replace it and inform the UM. RN #2 stated bacteria could grow in the tubing and could cause respiratory infections because the elderly had a compromised immune system. She did not know if anyone monitored or checked for outdated Oxygen tubing. Interview with RN #3, on 02/15/19 at 2:44 PM, revealed night shift nurses changed the Oxygen tubing weekly to make sure the tubing was clean. She stated nurses changed the tubing to decrease infections because when residents got sick it was harder for them to fight infections. If she had seen a date of 07/11/18, she would have immediately changed the Oxygen tubing. RN #3 stated all nurses were responsible to ensure the tubing was changed and she was trained by the facility during her orientation. The RN was unsure who monitored the change of Oxygen tubing and thought it was the UM's responsibility. Interview with the Director of Nursing (DON), on 02/14/19 at 3:46 PM, revealed there should have been a treatment order to change Resident #13's Oxygen tubing weekly on night shift on a specifically designated day. However, since it was not done, she stated it was an infection control issue because the resident was vulnerable, as he/she lacked the ability to fight off an infection, specifically a respiratory infection. The DON further stated she rounded and was responsible to make sure Oxygen tubing was changed and dated. Additional interview on 02/15/19 at 3:29 PM, revealed the Oxygen tubing should have been changed and dated weekly and the UMs were to ensure orders were on the MAR; however, this had not occurred. Interview with the Administrator, on 02/15/19 at 4:39 PM, revealed the DON decided who followed up on Oxygen tubing changes and dating. She stated Resident #13 was vulnerable and his/her Oxygen tubing should have been changed.

Based on interview, record review, and facility policy review, it was determined the facility failed to provide pneumococcal vaccinations to three (3) of eighteen (18) sampled residents, Resident #9, #22, and #70. The findings include: Review of the facility's policy, Pneumococcal Vaccine, revised (MONTH) (YEAR), revealed all residents would be offered Pneumococcal vaccine to aid in preventing pneumonia/pneumococcal infection. Prior to or upon admission, residents should be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, would be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident had already been vaccinated. Assessments of pneumococcal vaccination status would be conducted within five (5) working days of the resident's admission if not conducted prior to admission. Record review revealed the facility admitted Resident #9 on 02/10/18. There was no evidence the resident received or declined a pneumococcal vaccination. Record review revealed the facility admitted Resident #22 on 07/30/18. There was no evidence the resident received or declined a pneumococcal vaccination. The consent for the vaccination was blank. Record review revealed the facility admitted Resident #70 on 12/21/18. There was no evidence the resident received or declined a pneumococcal vaccination. Interview with Registered Nurse (RN) #2, on 02/15/19 at 1:51 PM, revealed the Unit Manager (UM) was responsible for obtaining the pneumococcal vaccination consent/declination. She stated the Admissions Coordinator prepared the packets with the consent form. The RN revealed it was important to ensure the vaccination information/administration was done so the facility knew who was vaccinated because it was a potential infection control concern. Interview with UM #1, on 02/14/19 at 2:39 PM, revealed she was responsible for obtaining the pneumonia vaccination consent/declination during the admission process on her unit. She stated vaccinations were important to prevent potential infection control concerns. The UM revealed the facility was to track and trend infections and vaccination statuses. According to the UM, the Center for Disease Control (CDC) recommended the pneumonia vaccine be offered because the data supported those who received the vaccine lowered the risk of catching the infection and the elderly population had an increased risk and were immunocompromised. Interview with the Admissions Coordinator, on 02/15/19 at 3:20 PM, revealed medical records made up the chart with the consents for new admissions and the nursing staff was responsible for getting them signed. Interview with Medical Records Director, on 02/15/19 at 3:25 PM, revealed she was responsible for putting the packets together for new admissions, to include the pneumonia and flu consents, and the admitting nurse was to ensure the consent was signed upon admission. Interview with the Director of Nursing (DON), on 02/15/19 at 3:35 PM, revealed the admitting nurses were responsible for ensuring consents were signed. She stated she thought the UMs were reviewing the consents during the chart audit of a new admission. The DON stated there was no process in place to ensure residents received the pneumococcal vaccination.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system in place in order to notify the physician regarding the decision to cancel the delivery of [MEDICAL CONDITION] treatment medication for one (1) of three (3) sampled residents, Resident #2. Interviews revealed the facility did not administer Resident #2 his/her physician ordered medication because of the expense and did not notify the physician or resident that the medication was withheld. The facility's failure to have an effective system in place to ensure residents received physician ordered medication has caused or is likely to cause serious injury, harm, impairment, or death. The Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE]. The facility was notified on [DATE]. The facility submitted an acceptable Allegation of Compliance (AoC) on [DATE] alleging the removal of Immediate Jeopardy on [DATE]. The State Survey Agency validated the Immediate Jeopardy was removed on [DATE] as alleged, prior to exit on [DATE], with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy, Ordering and Receiving Medications, dated (MONTH) 2010, revealed medications and related products were received from the provider pharmacy on a timely basis. If the resident's first dose of medication was scheduled to be given before the next regularly scheduled pharmacy delivery, staff should telephone or transmit the medication orders to the pharmacy immediately upon receipt. Staff was to inform the pharmacy of the need for prompt delivery. Timely delivery of new medication orders was required so that medication administration was not delayed. Staff would promptly report discrepancies and omissions to the issuing pharmacy and the charge nurse or supervisor. Review of the facility's policy, Resident Rights, not dated, revealed the resident had the right to participate in healthcare decisions and care planning. Review of Resident #2's closed clinical record revealed the facility originally admitted the resident [DATE] and readmitted the resident on [DATE], with [DIAGNOSES REDACTED]. In addition, a history of [MEDICAL CONDITION] with a new [DIAGNOSES REDACTED]. Review of Resident #2's admission Minimum Data Set, dated dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status score of fifteen (15) out of fifteen (15) and determined the resident interviewable. Review of Resident #2's Physician Order, dated [DATE], revealed an order for [REDACTED]. However, review of Resident #2's Medication Administration Record [REDACTED]. Review of Resident #2's Progress Notes, dated [DATE], revealed nursing staff documented Afinitor was not available for administration. However, nursing staff did not document a reason the Afinitor was not administered on [DATE] or [DATE]. In addition, there was no documented evidence nursing staff or the facility notified the physician or the resident regarding the Afinitor not being available or administered. Interview with the Oncology Physician, on [DATE] at 4:00 PM, revealed he expected the facility to notify him if a medication he ordered was not available or administered to Resident #2, as he could have ordered a different medication. He stated it was not in the best interest of Resident #2 for the facility not to administer [MEDICAL CONDITION] treatment medication, Afinitor. He stated Resident #2 experienced a decline while at the nursing facility, which required a transfer to an acute care hospital. He stated after hospitalization , the resident rapidly expired from [MEDICAL CONDITION]. Interview, on [DATE] at 12:13 PM, with Licensed Practical Nurse (LPN) #2, revealed Resident #2 returned to the facility from an acute hospitalization on [DATE], with medication orders that included [MEDICAL CONDITION] treatment drug Afinitor. She stated she called the facility physician to obtain medication orders, to include the Afinitor, and sent the orders to the pharmacy. LPN #2 stated the pharmacy contacted her back and informed her the Director of Nursing (DON) must approve the medication Afinitor, prior to delivery. She stated the pre-approval was required due to the cost of the medication. She stated she heard from the Unit Manager the facility was not going to approve the medication due to the cost; however, the facility did not notify Resident #2 or the physician of the facility's decision not to approve the delivery/administration of the medication to treat the resident'[MEDICAL CONDITION]. Interview, on [DATE] at 10:30 AM, with the Pharmacist, revealed on [DATE], the facility sent an order for [REDACTED]. Interview, on [DATE] and [DATE], via telephone with the Interim DON while Resident #2 was at the facility, was unsuccessful. Interview, on [DATE] at 2:55 PM, with the Unit Manager of the Blue Unit, revealed she identified on [DATE], Resident #2's medication Afinitor was not available for staff to administer. She stated she spoke with the Administrator on [DATE], regarding the unavailable medication and he informed her the medication was too expensive for the facility to order. The Unit Manager stated the Administrator informed her the facility would try to contact the Oncology Physician regarding the medication on [DATE]. She stated during their conversation, he asked her to call the physician to see if there was another less expensive medication to treat Resident #2'[MEDICAL CONDITION]; however, when she went back to the unit, Resident #2 requested a transfer to the hospital because he/she was not feeling well and the facility transferred the resident to the hospital. The Unit Manager stated prior to [DATE], the facility had not notified the physician or the resident regarding the reason the facility denied the delivery and administration of [MEDICAL CONDITION] treatment medication, Afinitor. Interview, on [DATE] at 10:30 AM and 4:00 PM, with the Administrator, revealed he was ultimately responsible for the care and services the residents received in the facility. He stated the facility put a hold order on Resident #2'[MEDICAL CONDITION] treatment medication Afinitor, after he/she returned from the acute hospital stay. He stated he called the pharmacist to determine if the medication was on the facility's formulary for covered medications, and it was not. The Administrator stated he did not approve [MEDICAL CONDITION] treatment medication for delivery due to the cost. He revealed he wanted to wait until [DATE], due to the holiday, to determine if the insurance company would cover any more of the cost. He stated it was a Thanksgiving holiday week and the facility chose to wait until [DATE], to contact the Oncologist to seek further direction. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], the Unit Managers (UM), Staff Development Coordinator (SDC), Medical Records Director, and Regional Support Staff (RSS) completed a one-time review of resident admissions from [DATE] to [DATE], in order to determine compliance with physician orders [REDACTED]. The facility shared the one-time review of admission information with members of the Interdisciplinary Team. 2. The facility assessed all new admits for [MEDICAL CONDITION] treatment medications to determine if the Immediate Jeopardy identified on [DATE], could affect them. No additional newly admitted residents were noted [MEDICAL CONDITION] treating medications prescribed. 3. On [DATE], the Administrator, Assistant Director of Nursing (ADON), Medical Director, and RSS made the determination policy and procedures, related to the immediate jeopardy, did not require revisions. 4. The UMs, SDC, Administrator, and RSS initiated re-education of the Licensed Nursing Staff, Certified Medication Technicians, and Non-Facility Personnel on [DATE], regarding medication administration and notification of the physician, resident, and family of a decision to withhold resident medication. In addition, staff was re-educated on the development and implementation of the baseline care plan, to include goals and interventions. The facility currently employed twelve (12) Licensed Nurses and one (1) Certified Medication Technician. Any Licensed Nurse who had not completed the re-education by 11:59 PM on [DATE], would receive the re-education at the time of their next scheduled shift. 5. The SDC would educate newly hired nurses and certified medication technicians during the orientation process. 6. The Director of Nursing (DON), Administrator, ADON, UM, Minimum Data Set (MDS) Coordinator, SDC, or RSS would conduct audits beginning [DATE], of new admissions to monitor for the ordering and obtaining of medications, per the physician order, three (3) times a week for eight (8) weeks, then once a week for four (4) weeks, then monthly. Any issues noted by the facility during the auditing process would be immediately corrected with one-on-one re-education and/up to disciplinary action as deemed necessary. 7. The DON, Administrator, ADON, UM, MDS Coordinator, SDC, or RSS would be responsible for conducting audits beginning [DATE], regarding compliance with the initiation of the baseline care plan at the time of admission, three (3) times a week for eight (8) weeks, then once a week for four (4) weeks, then monthly. Any issues noted by the facility during the auditing process would be immediately corrected with one-on-one re-education and/up to disciplinary action as deemed necessary. 8. The DON, Administrator, ADON, UM, MDS Coordinator, SDC, or RSS would be responsible for conducting audits beginning [DATE], for the provision [MEDICAL CONDITION] treatments as the time of admission three (3) times a week for eight (8) weeks, then once a week for four (4) weeks, then monthly. Any issues noted by the facility during the auditing process would be immediately corrected with one-on-one re-education and/up to disciplinary action as deemed necessary. 9. The Administrator, DON, or RSS would be responsible for reviewing the results of the audits. 10. The Regional Director of Special Projects re-educated the Interdisciplinary Team (IDT) on [DATE], regarding administrative roles and responsibilities. The IDT consisted of the Administrator, DON, Admissions, ADON, SDC, UM, Social Services (SS), Business Office Manager (BOM), MDS Coordinator, and Rehabilitation Services Manager (RSM). 11. The facility held an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting on [DATE], with the Medical Director, Administrator, DON, ADON, Medical Records, BOM, Maintenance, Admissions, Housekeeping Manager, Rehabilitation Services Manager, and the Regional Director of Clinical Operations to review the statement of deficiencies, corrective actions taken, and results of the audits performed. 12. On [DATE], the Regional Vice President of Operations (VPO) reviewed with the Administrator the Administrator Job description and responsibilities. The VPO discussed with the Administrator the role of ensuring resources were available to provide for the needs of the resident, which included medications and other services. 13. On [DATE], the Regional Vice President of Operations (VPO) met with the Administrator and the DON to validate the facility's Allegation of Compliance. These meetings would continue weekly until the immediacy of the jeopardy was lifted and substantial compliance was achieved. 14. The facility Administrator would present all findings of the audits to the QAPI committee monthly for three months (3), then quarterly thereafter for further recommendations and follow up. 15. The Administrator would oversee the QAPI committee meeting in conjunction with the DON and Medical Director. The State Survey Agency validated the removal of Immediate Jeopardy on [DATE] prior to exit as follows: 1. Interview with the Staff Development Coordinator (SDC), on [DATE] at 1:41 PM, and the Unit Manager (UM), on [DATE] at 10:20 AM, revealed the facility reviewed resident admission orders [REDACTED]. Interview with the Minimum Data Set (MDS) Coordinator, on [DATE] at 9:24 AM, revealed she was on the IDT. She stated the team reviewed the information from the one-time review of resident admissions to determine if the facility had administered medications as ordered and there were no identified issues found from the review. Interview with the Social Services Director (SSD), on [DATE] at 10:15 AM, and the Medical Records Director (MRD), on [DATE] at 10:00 AM, revealed they were on the Interdisciplinary Team (IDT). The SSD and MRD stated they reviewed the information obtained from the one-time review of resident admissions, from [DATE] to [DATE], and determined the facility had administered medications as ordered. Record review revealed the facility reviewed resident admission orders [REDACTED]. Review of Unsampled Resident I's medical record revealed the facility admitted the resident on [DATE] and readmitted the resident on [DATE]. The medication orders from the hospital's discharge summary, dated [DATE], corresponded with both the medication orders listed on the Physician order [REDACTED]. Review of Unsampled Resident N's medical record revealed the facility admitted the resident on [DATE]. Medication orders listed on the POS, dated [DATE], and the medication orders on the Medication Administration Record [REDACTED]. 2. Interview with the Administrator, on [DATE] at 3:00 PM, revealed the facility did not have residents in the facility [MEDICAL CONDITION] treatment medications. Interview with the Director of Nursing (DON), on [DATE] at 9:35 AM, revealed the facility did not have a resident in the facility [MEDICAL CONDITION] treatment medications. Review of an untitled typed statement, dated [DATE], revealed as of the alleged compliance date of [DATE], the facility had not admitted or readmitted residents with orders [MEDICAL CONDITION] related medications. 3. Interview with the Administrator, on [DATE] at 8:30 AM, and the Regional Support Staff (RSS), on [DATE] at 2:45 PM, revealed the facility reviewed policies and procedures related to Physician Notification, Care Plan Development, and Medication Administration, and determined revisions to the polices were not necessary. 4. Interview with Registered Nurse (RN) #4, on [DATE] at 3:00 PM, revealed she was trained on medication, change of condition, and care plans. She stated care plans should be individualized with new information passed on to the CNAs. RN #4 stated she would call the pharmacy if a medication was not available and STAT (immediate) medications would be delivered within one (1) hour. She revealed if she was unable to obtain the medication, the resident's physician and family would be notified. Interview with RN #1, on [DATE] at 8:45 AM, revealed she was trained on documentation, updating care plans, and physician notification. She stated the procedure for pre-authorization of medications included contacting the pharmacy and receiving an approval number. She had never experienced an instance where a medication was not approved. Interview with Licensed Practical Nurse (LPN) #7, on [DATE] 8:30 AM, revealed the facility recently educated her on medication administration, change of condition, and medication changes. She stated she was trained to notify the physician, resident (when applicable), family, and manager any time a resident reacted to, refused, or missed a medication dose and if they had a change in condition. LPN #7 stated she was educated to review the resident care plans each shift, make changes when applicable, and inform her manager if revisions were necessary. Interview with the MDS Coordinator, on [DATE] at 9:24 AM, revealed the facility trained her to provide training to the staff on physician, family, and resident notification, medication administration, and care plan development and implementation. Interview with CNA #5, on [DATE] at 2:50 PM, revealed she kept a copy of the care plan with her on the floor. She stated the care plans were developed by nursing staff in the care planning meetings when residents were first admitted . If the resident had a change of condition, she stated she would fill out a Stop and Watch form and tell the nurse. The form was then signed by the nurse to prove the CNA informed them of the change. CNA #5 stated the Unit Manager and the nurses kept care plans updated. Review of facility's In-Service Attendance Sheets revealed staff re-education began on [DATE], and education continued on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The facility trained Licensed Nursing Staff and Certified Medication Technicians on physician, family, and resident notification, care plan development, and medication administration. Record review revealed the facility used the policy, Medication Administration, dated (MONTH) (YEAR), to re-educate Licensed Nursing Staff and Medication Technicians. Continued review revealed the facility used an undated document, Baseline Care Plan Process, to re-educate the Licensed Nursing Staff. The goal stated the facility would meet newly admitted and/or readmitted resident care needs. During the admission process, staff would complete all required assessments and based on those assessments, would create a care plan for the identified high-risk areas. Review of the Employee Listing Payroll Services document, dated (MONTH) (YEAR), revealed the facility employed twelve (12) licensed nursing staff and one (1) Certified Medication Technician. Review of the facility's In-Service Attendance Sheets, dated [DATE], [DATE], and [DATE], revealed staff assigned to work after [DATE], received training prior to their shift. 5. Interview with LPN #6, on [DATE] at 3:45 PM, revealed she was an agency nurse and the facility recently educated her regarding physician notification, care plan development, and medication administration prior to her beginning her shift. She stated all new orders required notification of resident and family, and nursing staff must document their notifications. She stated the facility kept a copy of the resident care plans on each medication cart and she signed the plans each shift to show she had reviewed them for potential revisions. Interview with the SDC, on [DATE] at 1:41 PM, revealed she scheduled agency staff to come in one (1) hour prior to the beginning of their shift in order for the staff member to receive training on physician, family, and resident notification, care plan development, and medication administration. She stated new hires would receive the training in orientation; however, the facility had not conducted new hire orientation as of yet. 6. Interview with LPN #7, on [DATE] at 8:30 AM, revealed she would notify the physician, resident, and family if she could not administer a resident's medication. She stated she readmitted Unsampled Resident I to the facility on [DATE], and after she had processed the admission, her Unit Manager and Corporate Nurses reviewed all the medications and orders for accuracy. She stated the Unit Manager and Corporate Nurses performed the audit of her documentation and did not find any issues. Interview with the DON, on [DATE] at 9:35 AM, revealed she assisted with auditing the medical records and found no concerns requiring corrective action. Review of Plan of Correction Auditing Form for Physician Notification, not dated, revealed no new resident admissions had occurred. The facility conducted random medical record audits three (3) times a week to determine compliance with physician notification related to a medication order or compliance with obtaining medication per the physician order. The facility began audits on [DATE], and audits continued on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The facility audited residents' medical records for compliance after re-admission from a hospitalization on [DATE] and [DATE]. No identified concerns were noted. 7. Interview with the SDC, on [DATE] at 1:41 PM, revealed she assisted with conducting audits three (3) times a week and had not identified concerns with care plan audits. Review of Unsampled Resident G's Care Plan, undated, revealed the facility developed and implemented interventions to meet the resident's care needs. Interview with Unsampled Resident G, on [DATE] at 2:30 PM, revealed the resident had no concerns with medication administration and staff kept him/her informed of changes in his/her plan of care. Review of a Plan of Correction Auditing Form, not dated, for the initiation of the Baseline Care Plan upon admission, revealed no new resident admissions had occurred. Continued review revealed the facility conducted random medical record audits three (3) times a week, to include residents readmitted after a hospitalization . The facility began the audits on [DATE] and continued the audits on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], to determine compliance with initiation of the Baseline Care Plan development. No identified concerns were noted requiring corrective action. 8. Interview with RN #1, on [DATE] at 3:25 PM, revealed management was conducting audits of resident medical records to determine if residents had orders [MEDICAL CONDITION] treatment and to determine if nursing staff administered medications as ordered. She stated she did not know of any resident that had orders [MEDICAL CONDITION] treatment drugs. Interview with the Unit Manager, on [DATE] at 10:20 AM, revealed she assisted with conducting audits three (3) times a week and found no concerns that required corrective action. Review of a Plan of Correction Auditing Form, not dated, regarding the provision [MEDICAL CONDITION] treatments per the physician order [REDACTED]. Continued review revealed the facility conducted random audits three (3) times a week of resident medical records to include residents readmitted after a hospitalization . The facility conducted audits on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. No identified concerns were noted which required corrective action. Review of the clinical record for Unsampled Resident G revealed all of the medications listed on the Medication Administration Record [REDACTED]. Continued Review of the MAR indicated [REDACTED]. 9. Interview with the RSS, on [DATE] at 2:45 PM, revealed she reviewed the audit forms for completion and for issues needing corrective action. She stated she discussed the findings with the Interdisciplinary Team, which included the Administrator and DON. She stated audits were conducted three (3) times a week as planned, and no issues were identified that required corrective action. Review of a Plan of Correction Auditing Form, not dated, regarding physician notification, baseline care plans, [MEDICAL CONDITION] treatment services revealed the RSS reviewed the audit forms. 10. Interview with the Rehabilitation Services Manager, on [DATE] at 11:00 AM, and Social Services, on [DATE] at 10:15 AM, revealed the Regional Director of Special Projects re-educated them on their roles and responsibilities in regards to meeting resident care needs. Interview with the Admissions Director, on [DATE] at 2:00 PM, and SDC, on [DATE] at 1:41 PM, revealed the Regional Director of Special Projects met with the IDT on [DATE], to provide re-education regarding the team's roles and responsibility to ensure residents received the care and services ordered by the physician. Interview with the Regional Director of Special Projects, on [DATE] at 3:00 PM, revealed he had re-educated the IDT on their administrative roles and responsibilities regarding care plan development, physician, family and resident notification, and medication administration. 11. Interview, on [DATE] at 8:03 AM, with the Medical Director revealed he had attended the Ad Hoc Quality Assurance meeting held on [DATE]. He stated the facility audits were discussed and other actions taken to ensure compliance with medication administration, notification, and care plan implementation. He stated no concerns were identified requiring corrective action. Interview with the Director of Housekeeping, on [DATE] at 9:04 AM, and the Medical Records Director, on [DATE] at 10:00 AM, revealed they attended the [DATE] QAPI committee meeting. They stated the committee discussed the facility's compliance with medication administration, physician notification, and care plan implementation, along with facility audits. They stated no identified concerns were noted. Review of the Ad Hoc Quality Assurance sign in sheet, dated [DATE], revealed the Medical Director, Administrator, DON, ADON, Medical Records, BOM, Maintenance, Admissions, Housekeeping Manager, Rehabilitation Services Manager, and the Regional Director of Clinical Operations attended the meeting. 12. Interview with the Administrator, on [DATE] at 9:05 AM, revealed the Vice President of Operations (VPO) re-educated him on [DATE], regarding his job description and role as an administrator. He stated the VPO instructed him to approve medication, regardless of cost, when pharmacy requested payment approval. He stated the facility must ensure resident's needs were met. Interview with the VPO, on [DATE] at 9:26 AM, revealed he re-educated the Administrator on [DATE], regarding his job description and responsibilities to ensure resident care needs were met. The VPO stated he instructed the Administrator to approve medication, regardless of cost, when pharmacy requested a payment approval. 13. Interview with the Administrator, on [DATE] at 9:05 AM, and the DON, on [DATE] at 9:35 AM, revealed the VPO met with them on [DATE], to validate the Allegation of Compliance (A[NAME]). They stated the plan was to meet weekly on Thursday until the abatement of the Immediate Jeopardy and substantial compliance was achieved. Interview with the VPO, on [DATE] at 9:26 AM, revealed he met with the Administrator and DON on [DATE], to validate the facility's compliance with the A[NAME]. He stated he would meet with weekly until the abatement of the immediate jeopardy and substantial compliance was achieved. Review of the Meeting with Administrator and DON form, dated [DATE], revealed the VPO met with the Administrator and DON to validate compliance with the A[NAME]. The form stated the VPO would continue to meet with them weekly on Thursday until the abatement of immediate jeopardy and substantial compliance was achieved. 14. Interview with the Administrator, on [DATE] at 9:05 AM, and the DON, on [DATE] at 9:35 AM, revealed all audits would be presented to the QAPI committee monthly for three (3) months, then quarterly thereafter for further recommendations and follow up. 15. Interview with the Administrator, on [DATE] at 9:05 AM, the DON, on [DATE] at 9:35 AM, and with the Medical Director, on [DATE] at 8:03 AM, revealed they would oversee the QAPI committee process.

Based on interview, record review, and facility policy review, it was determined the facility failed to have an effective system to develop a plan of care with goals and interventions related [MEDICAL CONDITION] medication treatment needs for one (1) of three (3) sampled residents, Resident #2. Interview and record review revealed the facility failed to develop a care plan to address Resident #2'[MEDICAL CONDITION] treatment and the resident did not receive the [MEDICAL CONDITION] treatment medication. The facility's failure to have an effective system in place to ensure residents had care plans developed related [MEDICAL CONDITION] treatment medications has caused or is likely to cause serious injury, harm, impairment, or death. The Immediate Jeopardy (IJ) was identified on 03/01/18 and was determined to exist on 11/22/17. The facility was notified on 03/01/18. The facility submitted an acceptable Allegation of Compliance (AoC) on 03/02/18 alleging the removal of Immediate Jeopardy on 03/02/18. The State Survey Agency validated the Immediate Jeopardy was removed on 03/02/18 as alleged, prior to exit on 03/07/18, with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy, Care Plans-Comprehensive, not dated, revealed a person-centered comprehensive care plan that included measurable objectives and timetable to meet the resident's medical, nursing, mental, and psychological needs, would be developed for each resident. The care plan would include how the facility would assist the resident to meet their needs, goals, and preferences. The nurse/Interdisciplinary Team was responsible for the review and updating of the care plan. The care plan should reflect the current status of the resident and be updated with changes in the residents status i.e., when there had been a significant change in the resident's condition, or goals changed, when the desired outcome was not met, or when the resident had been readmitted to the facility from a hospital stay. Each resident had the right to participate in choosing treatment options and would be given the opportunity to participate in the development, review, and revision of their plan of care. Review of Resident #2's closed clinical record revealed the facility originally admitted the resident 10/20/17 and readmitted the resident on 11/21/17, with [DIAGNOSES REDACTED]. In addition, a history of [MEDICAL CONDITION] with a new [DIAGNOSES REDACTED]. Continued review of Resident #2's clinical record revealed a Physician Order, dated 11/21/17, that directed staff to administer Afinitor (medication used to [MEDICAL CONDITION]) ten (10) milligrams, one (1) tablet by mouth daily at 9:00 AM. Review of Resident #2's Interim Admission Care Plan, dated 11/10/17, revealed the resident had two (2) identified problems, one for Pain and the other for Nutrition and Hydration Risk, both related to the resident'[MEDICAL CONDITION] metastasis. However, nursing staff did not develop goals or staff interventions related to the problems. Continued review of Resident #2's plan of care revealed no evidence nursing staff developed an intervention directing staff to administer the physician [MEDICAL CONDITION] treatment medication, Afinitor. Review of Resident #2's Medication Administration Record [REDACTED]. Review of Progress Notes for Resident #2, dated 11/22/17, revealed nursing staff noted the Afinitor was not available for administration. Continued review of nursing documentation revealed nursing did not document a reason on 11/23/17 or 11/24/17, for not administering the Afinitor. Interview with Licensed Practical Nurse (LPN) #5, on 02/06/18 at 2:35 PM, revealed she did not remember developing goals or interventions for Resident #2's [MEDICAL CONDITION] related problems of Pain, and Nutrition and Hydration Risk. She stated nursing staff had twenty-four (24) hours to develop an interim plan of care for newly admitted residents. LPN #5 revealed her role was to initiate the plan upon admission, which included developing care plan interventions for staff to implement. She stated the plan of care directed staff in the care of the resident in order to meet their needs. Interview with LPN #2, on 02/06/18 at 12:13 PM, revealed the purpose of the plan of care was to provide staff with information regarding the resident's care needs. She stated if the Interim Admission Plan of Care did not have goals or interventions, the plan was not fully developed. In addition, LPN #2 stated if the plan did not have interventions for staff to follow, the facility would not meet the resident needs. LPN #2 stated nursing staff should have developed and implemented a plan of care that directed staff to [MEDICAL CONDITION] treatment medication as ordered by the physician. Interview with the Unit Manager of the Blue Unit, on 02/06/18 at 2:55 PM, revealed she had not reviewed Resident #2's Interim Admission Care Plan for completion after his/her admission. She stated the nurse that assessed Resident #2 upon admission was responsible for developing the Interim Admission Plan of Care, which included the development of goals and interventions. The Unit Manager stated if a plan of care did not have interventions, staff would not have the necessary direction to meet the resident's needs. She stated the plan of care should have had an intervention that directed staff to administer [MEDICAL CONDITION] treatment drug Afinitor, per the physician order. She stated the facility did not administer Resident #2's medication on 11/22/17, 11/23/17, or 11/24/17, due to cost. She stated on 11/24/17, the resident's health declined and the facility transferred the resident to the hospital. Interview with the Oncology Physician, on 02/06/18 at 4:00 PM, revealed the facility not administering Afinitor was not in the best interest of Resident #2. He stated the facility transferred Resident #2 to an acute care hospital because the resident experienced a decline while at the facility. Interview with the Interim Director of Nursing (DON), on 02/06/18 at 4:55 PM, revealed the purpose of the plan of care was to direct staff in the care needs of the resident. The DON stated nursing staff should have developed Resident #2's Interim Admission Plan of Care with goals and interventions. She stated leaving blanks on the care plan meant it was incomplete. She stated staff should have included an intervention directing staff to administer the resident'[MEDICAL CONDITION] treatment medication. The DON stated she was not acting as the DON at the time Resident #2 was at the facility and when she began her interim role, she was not informed of any medication issues with Resident #2. Interview with the Administrator, on 02/06/18 at 10:30 AM and 4:00 PM, revealed Resident #2 had a physician's orders [REDACTED]. He stated nursing staff should have developed an Interim Admission Care Plan with goals and interventions related to the administration of [MEDICAL CONDITION] treatment medication because if not, staff would not have the required direction to meet the needs of the resident. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 02/07/18, the Unit Managers (UM), Staff Development Coordinator (SDC), Medical Records Director, and Regional Support Staff (RSS) completed a one-time review of resident admissions from 11/10/17 to 02/07/18, in order to determine compliance with physician orders [REDACTED]. The facility shared the one-time review of admission information with members of the Interdisciplinary Team. 2. The facility assessed all new admits for [MEDICAL CONDITION] treatment medications to determine if the Immediate Jeopardy identified on 02/07/18, could affect them. No additional newly admitted residents were noted [MEDICAL CONDITION] treating medications prescribed. 3. On 02/07/18, the Administrator, Assistant Director of Nursing (ADON), Medical Director, and RSS made the determination policy and procedures, related to the immediate jeopardy, did not require revisions. 4. The UMs, SDC, Administrator, and RSS initiated re-education of the Licensed Nursing Staff, Certified Medication Technicians, and Non-Facility Personnel on 02/07/18, regarding medication administration and notification of the physician, resident, and family of a decision to withhold resident medication. In addition, staff was re-educated on the development and implementation of the baseline care plan, to include goals and interventions. The facility currently employed twelve (12) Licensed Nurses and one (1) Certified Medication Technician. Any Licensed Nurse who had not completed the re-education by 11:59 PM on 03/01/18, would receive the re-education at the time of their next scheduled shift. 5. The SDC would educate newly hired nurses and certified medication technicians during the orientation process. 6. The Director of Nursing (DON), Administrator, ADON, UM, Minimum Data Set (MDS) Coordinator, SDC, or RSS would conduct audits beginning 02/08/18, of new admissions to monitor for the ordering and obtaining of medications, per the physician order, three (3) times a week for eight (8) weeks, then once a week for four (4) weeks, then monthly. Any issues noted by the facility during the auditing process would be immediately corrected with one-on-one re-education and/up to disciplinary action as deemed necessary. 7. The DON, Administrator, ADON, UM, MDS Coordinator, SDC, or RSS would be responsible for conducting audits beginning 02/08/18, regarding compliance with the initiation of the baseline care plan at the time of admission, three (3) times a week for eight (8) weeks, then once a week for four (4) weeks, then monthly. Any issues noted by the facility during the auditing process would be immediately corrected with one-on-one re-education and/up to disciplinary action as deemed necessary. 8. The DON, Administrator, ADON, UM, MDS Coordinator, SDC, or RSS would be responsible for conducting audits beginning 02/08/18, for the provision [MEDICAL CONDITION] treatments as the time of admission three (3) times a week for eight (8) weeks, then once a week for four (4) weeks, then monthly. Any issues noted by the facility during the auditing process would be immediately corrected with one-on-one re-education and/up to disciplinary action as deemed necessary. 9. The Administrator, DON, or RSS would be responsible for reviewing the results of the audits. 10. The Regional Director of Special Projects re-educated the Interdisciplinary Team (IDT) on 02/08/18, regarding administrative roles and responsibilities. The IDT consisted of the Administrator, DON, Admissions, ADON, SDC, UM, Social Services (SS), Business Office Manager (BOM), MDS Coordinator, and Rehabilitation Services Manager (RSM). 11. The facility held an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting on 02/22/18, with the Medical Director, Administrator, DON, ADON, Medical Records, BOM, Maintenance, Admissions, Housekeeping Manager, Rehabilitation Services Manager, and the Regional Director of Clinical Operations to review the statement of deficiencies, corrective actions taken, and results of the audits performed. 12. On 03/01/18, the Regional Vice President of Operations (VPO) reviewed with the Administrator the Administrator Job description and responsibilities. The VPO discussed with the Administrator the role of ensuring resources were available to provide for the needs of the resident, which included medications and other services. 13. On 03/01/18, the Regional Vice President of Operations (VPO) met with the Administrator and the DON to validate the facility's Allegation of Compliance. These meetings would continue weekly until the immediacy of the jeopardy was lifted and substantial compliance was achieved. 14. The facility Administrator would present all findings of the audits to the QAPI committee monthly for three months (3), then quarterly thereafter for further recommendations and follow up. 15. The Administrator would oversee the QAPI committee meeting in conjunction with the DON and Medical Director. The State Survey Agency validated the removal of Immediate Jeopardy on 03/07/18 prior to exit as follows: 1. Interview with the Staff Development Coordinator (SDC), on 03/06/18 at 1:41 PM, and the Unit Manager (UM), on 03/06/18 at 10:20 AM, revealed the facility reviewed resident admission orders [REDACTED]. Interview with the Minimum Data Set (MDS) Coordinator, on 03/06/18 at 9:24 AM, revealed she was on the IDT. She stated the team reviewed the information from the one-time review of resident admissions to determine if the facility had administered medications as ordered and there were no identified issues found from the review. Interview with the Social Services Director (SSD), on 03/06/18 at 10:15 AM, and the Medical Records Director (MRD), on 03/06/18 at 10:00 AM, revealed they were on the Interdisciplinary Team (IDT). The SSD and MRD stated they reviewed the information obtained from the one-time review of resident admissions, from 11/10/17 to 02/07/18, and determined the facility had administered medications as ordered. Record review revealed the facility reviewed resident admission orders [REDACTED]. Review of Unsampled Resident I's medical record revealed the facility admitted the resident on 11/04/17 and readmitted the resident on 01/08/18. The medication orders from the hospital's discharge summary, dated 01/08/18, corresponded with both the medication orders listed on the Physician order [REDACTED]. Review of Unsampled Resident N's medical record revealed the facility admitted the resident on 03/10/17. Medication orders listed on the POS, dated 03/01/18, and the medication orders on the Medication Administration Record [REDACTED]. 2. Interview with the Administrator, on 03/05/18 at 3:00 PM, revealed the facility did not have residents in the facility [MEDICAL CONDITION] treatment medications. Interview with the Director of Nursing (DON), on 03/07/18 at 9:35 AM, revealed the facility did not have a resident in the facility [MEDICAL CONDITION] treatment medications. Review of an untitled typed statement, dated 03/06/18, revealed as of the alleged compliance date of 03/02/18, the facility had not admitted or readmitted residents with orders [MEDICAL CONDITION] related medications. 3. Interview with the Administrator, on 03/06/18 at 8:30 AM, and the Regional Support Staff (RSS), on 03/07/18 at 2:45 PM, revealed the facility reviewed policies and procedures related to Physician Notification, Care Plan Development, and Medication Administration, and determined revisions to the polices were not necessary. 4. Interview with Registered Nurse (RN) #4, on 03/05/18 at 3:00 PM, revealed she was trained on medication, change of condition, and care plans. She stated care plans should be individualized with new information passed on to the CNAs. RN #4 stated she would call the pharmacy if a medication was not available and STAT (immediate) medications would be delivered within one (1) hour. She revealed if she was unable to obtain the medication, the resident's physician and family would be notified. Interview with RN #1, on 03/06/18 at 8:45 AM, revealed she was trained on documentation, updating care plans, and physician notification. She stated the procedure for pre-authorization of medications included contacting the pharmacy and receiving an approval number. She had never experienced an instance where a medication was not approved. Interview with Licensed Practical Nurse (LPN) #7, on 03/06/18 8:30 AM, revealed the facility recently educated her on medication administration, change of condition, and medication changes. She stated she was trained to notify the physician, resident (when applicable), family, and manager any time a resident reacted to, refused, or missed a medication dose and if they had a change in condition. LPN #7 stated she was educated to review the resident care plans each shift, make changes when applicable, and inform her manager if revisions were necessary. Interview with the MDS Coordinator, on 03/06/18 at 9:24 AM, revealed the facility trained her to provide training to the staff on physician, family, and resident notification, medication administration, and care plan development and implementation. Interview with CNA #5, on 03/06/18 at 2:50 PM, revealed she kept a copy of the care plan with her on the floor. She stated the care plans were developed by nursing staff in the care planning meetings when residents were first admitted . If the resident had a change of condition, she stated she would fill out a Stop and Watch form and tell the nurse. The form was then signed by the nurse to prove the CNA informed them of the change. CNA #5 stated the Unit Manager and the nurses kept care plans updated. Review of facility's In-Service Attendance Sheets revealed staff re-education began on 02/07/18, and education continued on 02/08/18, 02/09/18, 02/14/18, 02/16/18, 02/19/18, and 03/01/18. The facility trained Licensed Nursing Staff and Certified Medication Technicians on physician, family, and resident notification, care plan development, and medication administration. Record review revealed the facility used the policy, Medication Administration, dated (MONTH) (YEAR), to re-educate Licensed Nursing Staff and Medication Technicians. Continued review revealed the facility used an undated document, Baseline Care Plan Process, to re-educate the Licensed Nursing Staff. The goal stated the facility would meet newly admitted and/or readmitted resident care needs. During the admission process, staff would complete all required assessments and based on those assessments, would create a care plan for the identified high-risk areas. Review of the Employee Listing Payroll Services document, dated (MONTH) (YEAR), revealed the facility employed twelve (12) licensed nursing staff and one (1) Certified Medication Technician. Review of the facility's In-Service Attendance Sheets, dated 03/04/18, 03/05/18, and 03/06/18, revealed staff assigned to work after 03/02/18, received training prior to their shift. 5. Interview with LPN #6, on 03/05/18 at 3:45 PM, revealed she was an agency nurse and the facility recently educated her regarding physician notification, care plan development, and medication administration prior to her beginning her shift. She stated all new orders required notification of resident and family, and nursing staff must document their notifications. She stated the facility kept a copy of the resident care plans on each medication cart and she signed the plans each shift to show she had reviewed them for potential revisions. Interview with the SDC, on 03/06/18 at 1:41 PM, revealed she scheduled agency staff to come in one (1) hour prior to the beginning of their shift in order for the staff member to receive training on physician, family, and resident notification, care plan development, and medication administration. She stated new hires would receive the training in orientation; however, the facility had not conducted new hire orientation as of yet. 6. Interview with LPN #7, on 03/06/18 at 8:30 AM, revealed she would notify the physician, resident, and family if she could not administer a resident's medication. She stated she readmitted Unsampled Resident I to the facility on [DATE], and after she had processed the admission, her Unit Manager and Corporate Nurses reviewed all the medications and orders for accuracy. She stated the Unit Manager and Corporate Nurses performed the audit of her documentation and did not find any issues. Interview with the DON, on 03/07/18 at 9:35 AM, revealed she assisted with auditing the medical records and found no concerns requiring corrective action. Review of Plan of Correction Auditing Form for Physician Notification, not dated, revealed no new resident admissions had occurred. The facility conducted random medical record audits three (3) times a week to determine compliance with physician notification related to a medication order or compliance with obtaining medication per the physician order. The facility began audits on 02/08/18, and audits continued on 02/09/18, 02/12/18, 02/19/18, 02/21/18, 02/27/18, 03/01/18, and 03/02/18. The facility audited residents' medical records for compliance after re-admission from a hospitalization on [DATE] and 02/14/18. No identified concerns were noted. 7. Interview with the SDC, on 03/06/18 at 1:41 PM, revealed she assisted with conducting audits three (3) times a week and had not identified concerns with care plan audits. Review of Unsampled Resident G's Care Plan, undated, revealed the facility developed and implemented interventions to meet the resident's care needs. Interview with Unsampled Resident G, on 03/06/18 at 2:30 PM, revealed the resident had no concerns with medication administration and staff kept him/her informed of changes in his/her plan of care. Review of a Plan of Correction Auditing Form, not dated, for the initiation of the Baseline Care Plan upon admission, revealed no new resident admissions had occurred. Continued review revealed the facility conducted random medical record audits three (3) times a week, to include residents readmitted after a hospitalization . The facility began the audits on 02/08/18 and continued the audits on 02/10/18, 02/12/18, 02/15/18, 02/19/18, 02/21/18, 02/27/18, 02/27/18, and 03/01/18, to determine compliance with initiation of the Baseline Care Plan development. No identified concerns were noted requiring corrective action. 8. Interview with RN #1, on 03/05/18 at 3:25 PM, revealed management was conducting audits of resident medical records to determine if residents had orders [MEDICAL CONDITION] treatment and to determine if nursing staff administered medications as ordered. She stated she did not know of any resident that had orders [MEDICAL CONDITION] treatment drugs. Interview with the Unit Manager, on 03/06/18 at 10:20 AM, revealed she assisted with conducting audits three (3) times a week and found no concerns that required corrective action. Review of a Plan of Correction Auditing Form, not dated, regarding the provision [MEDICAL CONDITION] treatments per the physician order [REDACTED]. Continued review revealed the facility conducted random audits three (3) times a week of resident medical records to include residents readmitted after a hospitalization . The facility conducted audits on 02/08/18, 02/09/18, 02/10/18, 02/12/18, 02/15/18, 02/19/18, 02/21/18, 02/26/18, 02/27/18, and 03/01/18. No identified concerns were noted which required corrective action. Review of the clinical record for Unsampled Resident G revealed all of the medications listed on the Medication Administration Record [REDACTED]. Continued Review of the MAR indicated [REDACTED]. 9. Interview with the RSS, on 03/07/18 at 2:45 PM, revealed she reviewed the audit forms for completion and for issues needing corrective action. She stated she discussed the findings with the Interdisciplinary Team, which included the Administrator and DON. She stated audits were conducted three (3) times a week as planned, and no issues were identified that required corrective action. Review of a Plan of Correction Auditing Form, not dated, regarding physician notification, baseline care plans, [MEDICAL CONDITION] treatment services revealed the RSS reviewed the audit forms. 10. Interview with the Rehabilitation Services Manager, on 03/06/18 at 11:00 AM, and Social Services, on 03/06/18 at 10:15 AM, revealed the Regional Director of Special Projects re-educated them on their roles and responsibilities in regards to meeting resident care needs. Interview with the Admissions Director, on 03/06/18 at 2:00 PM, and SDC, on 03/06/18 at 1:41 PM, revealed the Regional Director of Special Projects met with the IDT on 02/08/18, to provide re-education regarding the team's roles and responsibility to ensure residents received the care and services ordered by the physician. Interview with the Regional Director of Special Projects, on 03/06/18 at 3:00 PM, revealed he had re-educated the IDT on their administrative roles and responsibilities regarding care plan development, physician, family and resident notification, and medication administration. 11. Interview, on 03/07/18 at 8:03 AM, with the Medical Director revealed he had attended the Ad Hoc Quality Assurance meeting held on 02/22/18. He stated the facility audits were discussed and other actions taken to ensure compliance with medication administration, notification, and care plan implementation. He stated no concerns were identified requiring corrective action. Interview with the Director of Housekeeping, on 03/07/18 at 9:04 AM, and the Medical Records Director, on 03/06/18 at 10:00 AM, revealed they attended the 02/22/18 QAPI committee meeting. They stated the committee discussed the facility's compliance with medication administration, physician notification, and care plan implementation, along with facility audits. They stated no identified concerns were noted. Review of the Ad Hoc Quality Assurance sign in sheet, dated 02/22/18, revealed the Medical Director, Administrator, DON, ADON, Medical Records, BOM, Maintenance, Admissions, Housekeeping Manager, Rehabilitation Services Manager, and the Regional Director of Clinical Operations attended the meeting. 12. Interview with the Administrator, on 03/07/18 at 9:05 AM, revealed the Vice President of Operations (VPO) re-educated him on 03/01/18, regarding his job description and role as an administrator. He stated the VPO instructed him to approve medication, regardless of cost, when pharmacy requested payment approval. He stated the facility must ensure resident's needs were met. Interview with the VPO, on 03/07/18 at 9:26 AM, revealed he re-educated the Administrator on 03/01/18, regarding his job description and responsibilities to ensure resident care needs were met. The VPO stated he instructed the Administrator to approve medication, regardless of cost, when pharmacy requested a payment approval. 13. Interview with the Administrator, on 03/07/18 at 9:05 AM, and the DON, on 03/07/18 at 9:35 AM, revealed the VPO met with them on 03/01/18, to validate the Allegation of Compliance (A[NAME]). They stated the plan was to meet weekly on Thursday until the abatement of the Immediate Jeopardy and substantial compliance was achieved. Interview with the VPO, on 03/07/18 at 9:26 AM, revealed he met with the Administrator and DON on 03/01/18, to validate the facility's compliance with the A[NAME]. He stated he would meet with weekly until the abatement of the immediate jeopardy and substantial compliance was achieved. Review of the Meeting with Administrator and DON form, dated 03/01/18, revealed the VPO met with the Administrator and DON to validate compliance with the A[NAME]. The form stated the VPO would continue to meet with them weekly on Thursday until the abatement of immediate jeopardy and substantial compliance was achieved. 14. Interview with the Administrator, on 03/07/18 at 9:05 AM, and the DON, on 03/07/18 at 9:35 AM, revealed all audits would be presented to the QAPI committee monthly for three (3) months, then quarterly thereafter for further recommendations and follow up. 15. Interview with the Administrator, on 03/07/18 at 9:05 AM, the DON, on 03/07/18 at 9:35 AM, and with the Medical Director, on 03/07/18 at 8:03 AM, revealed they would oversee the QAPI committee process.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure care and treatment services [MEDICAL CONDITION] was provided for one (1) of three (3) sampled residents, Resident #2. Resident #2 had a physician order, dated [DATE], to receive Afinitor (cancer treatment medication); however, the facility made the decision to put a hold on the medication due to the cost. The facility failed to inform the physician of the cost in order to determine if another medication could be substituted, resulting in [MEDICAL CONDITION] treatment medication not being administered to the resident. On [DATE], Resident #2 experienced a decline while at the nursing facility, which required a transfer to an acute care hospital. The resident expired on [DATE] due to [MEDICAL CONDITION], Hepatic Failure, Acute [MEDICAL CONDITION], and Metastatic [MEDICAL CONDITION]. The facility's failure to have an effective system in place to ensure the resident's choice to [MEDICAL CONDITION] treatment medications has caused or is likely to cause serious injury, harm, impairment, or death. The Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE]. The facility was notified on [DATE]. The facility submitted an acceptable Allegation of Compliance (AoC) on [DATE] alleging the removal of Immediate Jeopardy on [DATE]. The State Survey Agency validated the Immediate Jeopardy was removed on [DATE] as alleged, prior to exit on [DATE], with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy, Ordering and Receiving Medications, dated (MONTH) 2010, revealed medications and related products were received from the provider pharmacy on a timely basis. If the resident's first dose of medication was scheduled to be given before the next regularly scheduled pharmacy delivery, staff should telephone or transmit the medication orders to the pharmacy immediately upon receipt. Staff was to inform the pharmacy of the need for prompt delivery. Timely delivery of new medication orders was required so that medication administration was not delayed. Staff would promptly report discrepancies and omissions to the issuing pharmacy and the charge nurse or supervisor. Review of the facility's policy, Resident Rights, not dated, revealed the resident had the right to participate in healthcare decisions and care planning. Review of the facility's policy, Care Plans-Comprehensive, not dated, revealed each resident had the right to participate in choosing treatment options and would be given the opportunity to participate in the development, review, and revision of their plan of care. Review of Resident #2's closed clinical record revealed the facility originally admitted the resident [DATE] and readmitted the resident on [DATE], with [DIAGNOSES REDACTED]. In addition, a history of [MEDICAL CONDITION] with a new [DIAGNOSES REDACTED]. Review of Resident #1's admission Minimum Data Set, dated dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status score of fifteen (15) out of fifteen (15) and determined the resident interviewable. Review of Resident #2's Physician Order, dated [DATE], revealed the physician ordered Afinitor 10 milligrams, one (1) tablet administered by mouth daily at 9:00 AM. However, review of Resident #2's Medication Administration Record [REDACTED]. Review of Resident #2's Interim Admission Care Plan, dated [DATE], revealed nursing staff did not develop goals or staff interventions related to the resident'[MEDICAL CONDITION] metastasis. Continued review of Resident #2's Interim Admission plan of care revealed no evidence nursing staff developed interventions directing staff to administer the physician ordered medication, Afinitor, to ensure the resident'[MEDICAL CONDITION] treatment needs were met. Interview, on [DATE] at 4:00 PM, with the Oncology Physician, revealed Resident #2 experienced a decline while at the nursing facility, which required a transfer to an acute care hospital. He stated it was not in the best interest of Resident #2 for the facility not to administer [MEDICAL CONDITION] treatment medication, Afinitor. He stated after hospitalization , the resident rapidly expired from [MEDICAL CONDITION]. Interview with Licensed Practical Nurse (LPN) #2, on [DATE] at 12:13 PM, revealed on [DATE], Resident #2 returned to the facility after hospitalization with medication orders including Afinitor, [MEDICAL CONDITION] treatment drug. She stated she obtained orders, from the facility's physician, that included the Afinitor, and sent the orders to the pharmacy. LPN #2 stated the pharmacy informed her the Director of Nursing must approve the Afinitor prior to delivery due to the cost of the medication. She stated the Unit Manager told her the facility was not going to approve the medication due to the cost, as the cost was eight thousand dollars ($8,000) for a fourteen (14) day supply. The facility did not notify Resident #2 or the physician of the decision not to approve the delivery/administration of the medication. Interview with the Pharmacist, on [DATE] at 10:30 AM, revealed on [DATE], the facility sent an order to the pharmacy for Resident #2's Afinitor. She stated due to the resident's insurance coverage, a seven (7) day supply of the Afinitor would cost the facility four thousand one hundred and forty-five dollars ($4145). The Pharmacist stated due to the cost, there was required approval needed from the Director of Nursing prior to delivery. She stated the pharmacy did not deliver Afinitor to the facility because the Interim Director of Nursing canceled the prescription. Attempted interview with the Interim Director of Nursing at the time Resident #2 was in the facility, on [DATE] at 3:38 PM and [DATE] at 12:59 PM, via telephone, was unsuccessful. Interview with the Unit Manager of the Blue Unit where the resident resided, on [DATE] at 2:55 PM, revealed she identified on [DATE], three (3) days after the medication had been ordered, Resident #2's Afinitor was not available and she informed the resident on [DATE], the facility had not administered the Afinitor to him/her as ordered by the Oncologist. The Unit Manager stated the resident told her he/she wanted to fight [MEDICAL CONDITION] and thought the facility was administering [MEDICAL CONDITION] treatment drug. The Unit Manager stated she spoke with the Administrator on [DATE], and was told the medication was too expensive to order and the facility would try to contact the Oncology Physician regarding the medication on [DATE], six (6) days after the medication had been ordered. She stated she tried to get an approval for a three (3) or four (4) day supply of the Afinitor; however, the Administrator denied the request because five hundred dollars ($500) to eight hundred dollars ($800) per pill would be charged to the facility. She stated the Administrator told her to contact the physician to see if there was another less expensive medication to treat Resident #2'[MEDICAL CONDITION]. However, when she went back to the unit, Resident #2 was not feeling well and requested a transfer to the hospital. The Unit Manager stated the facility did not administer the Afinitor on [DATE], [DATE], or [DATE], and in order to meet resident care needs, the facility should had administered the medication as ordered. Interview, on [DATE] at 4:55 PM, with the Interim Director of Nursing (DON), revealed she was not the DON during Resident #2's stay at the facility. The DON stated she was not aware of the incident regarding Resident #2's Afinitor medication denial. The DON stated if a physician ordered a medication that was not part of the facility's formulary and required her approval, she would call the physician to determine if another medication could be substituted, and if not, she would approve the medication. The DON stated it was important for the facility to take care of residents' cancer treatment needs, regardless of medication cost. Interview with the Administrator, on [DATE] at 10:30 AM and 4:00 PM, revealed he called the pharmacist to determine if Resident #2'[MEDICAL CONDITION] treatment medication, Afinitor, was on the facility's formulary for covered medications, and found out it was not and he decided to put a hold order on the medication due to cost. He stated it was Thanksgiving holiday week and he chose to wait until [DATE], to contact the Oncologist to seek further direction. The Administrator stated he went to Resident #2's unit on [DATE], after staff raised questions regarding the availability of the Afinitor; however, he did not inform staff at that time the facility did not approve the medication for delivery due to cost, nor did he instruct staff to call the physician to inform him the medication was not available and seek further direction. He stated he was not opposed to the request for a three (3) to four (4) day supply; however, he made the decision to wait until [DATE], due to the holiday week, to determine if the insurance company would cover more of the cost. According to the Administrator, he was ultimately responsible for the care and services the residents received in the facility. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], the Unit Managers (UM), Staff Development Coordinator (SDC), Medical Records Director, and Regional Support Staff (RSS) completed a one-time review of resident admissions from [DATE] to [DATE], in order to determine compliance with physician orders [REDACTED]. The facility shared the one-time review of admission information with members of the Interdisciplinary Team. 2. The facility assessed all new admits for [MEDICAL CONDITION] treatment medications to determine if the Immediate Jeopardy identified on [DATE], could affect them. No additional newly admitted residents were noted [MEDICAL CONDITION] treating medications prescribed. 3. On [DATE], the Administrator, Assistant Director of Nursing (ADON), Medical Director, and RSS made the determination policy and procedures, related to the immediate jeopardy, did not require revisions. 4. The UMs, SDC, Administrator, and RSS initiated re-education of the Licensed Nursing Staff, Certified Medication Technicians, and Non-Facility Personnel on [DATE], regarding medication administration and notification of the physician, resident, and family of a decision to withhold resident medication. In addition, staff was re-educated on the development and implementation of the baseline care plan, to include goals and interventions. The facility currently employed twelve (12) Licensed Nurses and one (1) Certified Medication Technician. Any Licensed Nurse who had not completed the re-education by 11:59 PM on [DATE], would receive the re-education at the time of their next scheduled shift. 5. The SDC would educate newly hired nurses and certified medication technicians during the orientation process. 6. The Director of Nursing (DON), Administrator, ADON, UM, Minimum Data Set (MDS) Coordinator, SDC, or RSS would conduct audits beginning [DATE], of new admissions to monitor for the ordering and obtaining of medications, per the physician order, three (3) times a week for eight (8) weeks, then once a week for four (4) weeks, then monthly. Any issues noted by the facility during the auditing process would be immediately corrected with one-on-one re-education and/up to disciplinary action as deemed necessary. 7. The DON, Administrator, ADON, UM, MDS Coordinator, SDC, or RSS would be responsible for conducting audits beginning [DATE], regarding compliance with the initiation of the baseline care plan at the time of admission, three (3) times a week for eight (8) weeks, then once a week for four (4) weeks, then monthly. Any issues noted by the facility during the auditing process would be immediately corrected with one-on-one re-education and/up to disciplinary action as deemed necessary. 8. The DON, Administrator, ADON, UM, MDS Coordinator, SDC, or RSS would be responsible for conducting audits beginning [DATE], for the provision [MEDICAL CONDITION] treatments as the time of admission three (3) times a week for eight (8) weeks, then once a week for four (4) weeks, then monthly. Any issues noted by the facility during the auditing process would be immediately corrected with one-on-one re-education and/up to disciplinary action as deemed necessary. 9. The Administrator, DON, or RSS would be responsible for reviewing the results of the audits. 10. The Regional Director of Special Projects re-educated the Interdisciplinary Team (IDT) on [DATE], regarding administrative roles and responsibilities. The IDT consisted of the Administrator, DON, Admissions, ADON, SDC, UM, Social Services (SS), Business Office Manager (BOM), MDS Coordinator, and Rehabilitation Services Manager (RSM). 11. The facility held an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting on [DATE], with the Medical Director, Administrator, DON, ADON, Medical Records, BOM, Maintenance, Admissions, Housekeeping Manager, Rehabilitation Services Manager, and the Regional Director of Clinical Operations to review the statement of deficiencies, corrective actions taken, and results of the audits performed. 12. On [DATE], the Regional Vice President of Operations (VPO) reviewed with the Administrator the Administrator Job description and responsibilities. The VPO discussed with the Administrator the role of ensuring resources were available to provide for the needs of the resident, which included medications and other services. 13. On [DATE], the Regional Vice President of Operations (VPO) met with the Administrator and the DON to validate the facility's Allegation of Compliance. These meetings would continue weekly until the immediacy of the jeopardy was lifted and substantial compliance was achieved. 14. The facility Administrator would present all findings of the audits to the QAPI committee monthly for three months (3), then quarterly thereafter for further recommendations and follow up. 15. The Administrator would oversee the QAPI committee meeting in conjunction with the DON and Medical Director. The State Survey Agency validated the removal of Immediate Jeopardy on [DATE] prior to exit as follows: 1. Interview with the Staff Development Coordinator (SDC), on [DATE] at 1:41 PM, and the Unit Manager (UM), on [DATE] at 10:20 AM, revealed the facility reviewed resident admission orders [REDACTED]. Interview with the Minimum Data Set (MDS) Coordinator, on [DATE] at 9:24 AM, revealed she was on the IDT. She stated the team reviewed the information from the one-time review of resident admissions to determine if the facility had administered medications as ordered and there were no identified issues found from the review. Interview with the Social Services Director (SSD), on [DATE] at 10:15 AM, and the Medical Records Director (MRD), on [DATE] at 10:00 AM, revealed they were on the Interdisciplinary Team (IDT). The SSD and MRD stated they reviewed the information obtained from the one-time review of resident admissions, from [DATE] to [DATE], and determined the facility had administered medications as ordered. Record review revealed the facility reviewed resident admission orders [REDACTED]. Review of Unsampled Resident I's medical record revealed the facility admitted the resident on [DATE] and readmitted the resident on [DATE]. The medication orders from the hospital's discharge summary, dated [DATE], corresponded with both the medication orders listed on the Physician order [REDACTED]. Review of Unsampled Resident N's medical record revealed the facility admitted the resident on [DATE]. Medication orders listed on the POS, dated [DATE], and the medication orders on the Medication Administration Record [REDACTED]. 2. Interview with the Administrator, on [DATE] at 3:00 PM, revealed the facility did not have residents in the facility [MEDICAL CONDITION] treatment medications. Interview with the Director of Nursing (DON), on [DATE] at 9:35 AM, revealed the facility did not have a resident in the facility [MEDICAL CONDITION] treatment medications. Review of an untitled typed statement, dated [DATE], revealed as of the alleged compliance date of [DATE], the facility had not admitted or readmitted residents with orders [MEDICAL CONDITION] related medications. 3. Interview with the Administrator, on [DATE] at 8:30 AM, and the Regional Support Staff (RSS), on [DATE] at 2:45 PM, revealed the facility reviewed policies and procedures related to Physician Notification, Care Plan Development, and Medication Administration, and determined revisions to the polices were not necessary. 4. Interview with Registered Nurse (RN) #4, on [DATE] at 3:00 PM, revealed she was trained on medication, change of condition, and care plans. She stated care plans should be individualized with new information passed on to the CNAs. RN #4 stated she would call the pharmacy if a medication was not available and STAT (immediate) medications would be delivered within one (1) hour. She revealed if she was unable to obtain the medication, the resident's physician and family would be notified. Interview with RN #1, on [DATE] at 8:45 AM, revealed she was trained on documentation, updating care plans, and physician notification. She stated the procedure for pre-authorization of medications included contacting the pharmacy and receiving an approval number. She had never experienced an instance where a medication was not approved. Interview with Licensed Practical Nurse (LPN) #7, on [DATE] 8:30 AM, revealed the facility recently educated her on medication administration, change of condition, and medication changes. She stated she was trained to notify the physician, resident (when applicable), family, and manager any time a resident reacted to, refused, or missed a medication dose and if they had a change in condition. LPN #7 stated she was educated to review the resident care plans each shift, make changes when applicable, and inform her manager if revisions were necessary. Interview with the MDS Coordinator, on [DATE] at 9:24 AM, revealed the facility trained her to provide training to the staff on physician, family, and resident notification, medication administration, and care plan development and implementation. Interview with CNA #5, on [DATE] at 2:50 PM, revealed she kept a copy of the care plan with her on the floor. She stated the care plans were developed by nursing staff in the care planning meetings when residents were first admitted . If the resident had a change of condition, she stated she would fill out a Stop and Watch form and tell the nurse. The form was then signed by the nurse to prove the CNA informed them of the change. CNA #5 stated the Unit Manager and the nurses kept care plans updated. Review of facility's In-Service Attendance Sheets revealed staff re-education began on [DATE], and education continued on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The facility trained Licensed Nursing Staff and Certified Medication Technicians on physician, family, and resident notification, care plan development, and medication administration. Record review revealed the facility used the policy, Medication Administration, dated (MONTH) (YEAR), to re-educate Licensed Nursing Staff and Medication Technicians. Continued review revealed the facility used an undated document, Baseline Care Plan Process, to re-educate the Licensed Nursing Staff. The goal stated the facility would meet newly admitted and/or readmitted resident care needs. During the admission process, staff would complete all required assessments and based on those assessments, would create a care plan for the identified high-risk areas. Review of the Employee Listing Payroll Services document, dated (MONTH) (YEAR), revealed the facility employed twelve (12) licensed nursing staff and one (1) Certified Medication Technician. Review of the facility's In-Service Attendance Sheets, dated [DATE], [DATE], and [DATE], revealed staff assigned to work after [DATE], received training prior to their shift. 5. Interview with LPN #6, on [DATE] at 3:45 PM, revealed she was an agency nurse and the facility recently educated her regarding physician notification, care plan development, and medication administration prior to her beginning her shift. She stated all new orders required notification of resident and family, and nursing staff must document their notifications. She stated the facility kept a copy of the resident care plans on each medication cart and she signed the plans each shift to show she had reviewed them for potential revisions. Interview with the SDC, on [DATE] at 1:41 PM, revealed she scheduled agency staff to come in one (1) hour prior to the beginning of their shift in order for the staff member to receive training on physician, family, and resident notification, care plan development, and medication administration. She stated new hires would receive the training in orientation; however, the facility had not conducted new hire orientation as of yet. 6. Interview with LPN #7, on [DATE] at 8:30 AM, revealed she would notify the physician, resident, and family if she could not administer a resident's medication. She stated she readmitted Unsampled Resident I to the facility on [DATE], and after she had processed the admission, her Unit Manager and Corporate Nurses reviewed all the medications and orders for accuracy. She stated the Unit Manager and Corporate Nurses performed the audit of her documentation and did not find any issues. Interview with the DON, on [DATE] at 9:35 AM, revealed she assisted with auditing the medical records and found no concerns requiring corrective action. Review of Plan of Correction Auditing Form for Physician Notification, not dated, revealed no new resident admissions had occurred. The facility conducted random medical record audits three (3) times a week to determine compliance with physician notification related to a medication order or compliance with obtaining medication per the physician order. The facility began audits on [DATE], and audits continued on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The facility audited residents' medical records for compliance after re-admission from a hospitalization on [DATE] and [DATE]. No identified concerns were noted. 7. Interview with the SDC, on [DATE] at 1:41 PM, revealed she assisted with conducting audits three (3) times a week and had not identified concerns with care plan audits. Review of Unsampled Resident G's Care Plan, undated, revealed the facility developed and implemented interventions to meet the resident's care needs. Interview with Unsampled Resident G, on [DATE] at 2:30 PM, revealed the resident had no concerns with medication administration and staff kept him/her informed of changes in his/her plan of care. Review of a Plan of Correction Auditing Form, not dated, for the initiation of the Baseline Care Plan upon admission, revealed no new resident admissions had occurred. Continued review revealed the facility conducted random medical record audits three (3) times a week, to include residents readmitted after a hospitalization . The facility began the audits on [DATE] and continued the audits on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], to determine compliance with initiation of the Baseline Care Plan development. No identified concerns were noted requiring corrective action. 8. Interview with RN #1, on [DATE] at 3:25 PM, revealed management was conducting audits of resident medical records to determine if residents had orders [MEDICAL CONDITION] treatment and to determine if nursing staff administered medications as ordered. She stated she did not know of any resident that had orders [MEDICAL CONDITION] treatment drugs. Interview with the Unit Manager, on [DATE] at 10:20 AM, revealed she assisted with conducting audits three (3) times a week and found no concerns that required corrective action. Review of a Plan of Correction Auditing Form, not dated, regarding the provision [MEDICAL CONDITION] treatments per the physician order [REDACTED]. Continued review revealed the facility conducted random audits three (3) times a week of resident medical records to include residents readmitted after a hospitalization . The facility conducted audits on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. No identified concerns were noted which required corrective action. Review of the clinical record for Unsampled Resident G revealed all of the medications listed on the Medication Administration Record [REDACTED]. Continued Review of the MAR indicated [REDACTED]. 9. Interview with the RSS, on [DATE] at 2:45 PM, revealed she reviewed the audit forms for completion and for issues needing corrective action. She stated she discussed the findings with the Interdisciplinary Team, which included the Administrator and DON. She stated audits were conducted three (3) times a week as planned, and no issues were identified that required corrective action. Review of a Plan of Correction Auditing Form, not dated, regarding physician notification, baseline care plans, [MEDICAL CONDITION] treatment services revealed the RSS reviewed the audit forms. 10. Interview with the Rehabilitation Services Manager, on [DATE] at 11:00 AM, and Social Services, on [DATE] at 10:15 AM, revealed the Regional Director of Special Projects re-educated them on their roles and responsibilities in regards to meeting resident care needs. Interview with the Admissions Director, on [DATE] at 2:00 PM, and SDC, on [DATE] at 1:41 PM, revealed the Regional Director of Special Projects met with the IDT on [DATE], to provide re-education regarding the team's roles and responsibility to ensure residents received the care and services ordered by the physician. Interview with the Regional Director of Special Projects, on [DATE] at 3:00 PM, revealed he had re-educated the IDT on their administrative roles and responsibilities regarding care plan development, physician, family and resident notification, and medication administration. 11. Interview, on [DATE] at 8:03 AM, with the Medical Director revealed he had attended the Ad Hoc Quality Assurance meeting held on [DATE]. He stated the facility audits were discussed and other actions taken to ensure compliance with medication administration, notification, and care plan implementation. He stated no concerns were identified requiring corrective action. Interview with the Director of Housekeeping, on [DATE] at 9:04 AM, and the Medical Records Director, on [DATE] at 10:00 AM, revealed they attended the [DATE] QAPI committee meeting. They stated the committee discussed the facility's compliance with medication administration, physician notification, and care plan implementation, along with facility audits. They stated no identified concerns were noted. Review of the Ad Hoc Quality Assurance sign in sheet, dated [DATE], revealed the Medical Director, Administrator, DON, ADON, Medical Records, BOM, Maintenance, Admissions, Housekeeping Manager, Rehabilitation Services Manager, and the Regional Director of Clinical Operations attended the meeting. 12. Interview with the Administrator, on [DATE] at 9:05 AM, revealed the Vice President of Operations (VPO) re-educated him on [DATE], regarding his job description and role as an administrator. He stated the VPO instructed him to approve medication, regardless of cost, when pharmacy requested payment approval. He stated the facility must ensure resident's needs were met. Interview with the VPO, on [DATE] at 9:26 AM, revealed he re-educated the Administrator on [DATE], regarding his job description and responsibilities to ensure resident care needs were met. The VPO stated he instructed the Administrator to approve medication, regardless of cost, when pharmacy requested a payment approval. 13. Interview with the Administrator, on [DATE] at 9:05 AM, and the DON, on [DATE] at 9:35 AM, revealed the VPO met with them on [DATE], to validate the Allegation of Compliance (A[NAME]). They stated the plan was to meet weekly on Thursday until the abatement of the Immediate Jeopardy and substantial compliance was achieved. Interview with the VPO, on [DATE] at 9:26 AM, revealed he met with the Administrator and DON on [DATE], to validate the facility's compliance with the A[NAME]. He stated he would meet with weekly until the abatement of the immediate jeopardy and substantial compliance was achieved. Review of the Meeting with Administrator and DON form, dated [DATE], revealed the VPO met with the Administrator and DON to validate compliance with the A[NAME]. The form stated the VPO would continue to meet with them weekly on Thursday until the abatement of immediate jeopardy and substantial compliance was achieved. 14. Interview with the Administrator, on [DATE] at 9:05 AM, and the DON, on [DATE] at 9:35 AM, revealed all audits would be presented to the QAPI committee monthly for three (3) months, then quarterly thereafter for further recommendations and follow up. 15. Interview with the Administrator, on [DATE] at 9:05 AM, the DON, on [DATE] at 9:35 AM, and with the Medical Director, on [DATE] at 8:03 AM, revealed they would oversee the QAPI committee process.

Based on interview, record review, and review of the facility's policy, it was determined the facility's administration failed to have an effective system in place to ensure resources were effectively utilized to provide care and services related to the administration [MEDICAL CONDITION] treatment medications for one (1) of three (3) sampled residents, Resident #2. Interviews revealed the facility did not administer Resident #2 his/her physician ordered medication because of the expense and did not notify the physician or resident that the medication was withheld. Resident #2 experienced a decline while at the nursing facility, which required a transfer to an acute care hospital on [DATE] where the resident expired on [DATE] due to [MEDICAL CONDITION], Hepatic Failure, Acute [MEDICAL CONDITION], and Metastatic [MEDICAL CONDITION]. The facility's failure to have an effective system in place to ensure the facility administered care and services effectively has caused or is likely to cause serious injury, harm, impairment, or death. The Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE]. The facility was notified on [DATE]. The facility submitted an acceptable Allegation of Compliance (AoC) on [DATE] alleging the removal of Immediate Jeopardy on [DATE]. The State Survey Agency validated the Immediate Jeopardy was removed on [DATE] as alleged, prior to exit on [DATE], with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the Administrator's Job Description, dated (MONTH) 2011, revealed the Administrator would lead and direct the overall operations of the facility in accordance with customer needs, government regulations, and company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives. Essential duties and responsibilities included overseeing regular rounds to monitor delivery of nursing care, operation of support department, cleanliness and appearance of the facility, morale of staff, and ensure resident needs were addressed. Review of Resident #2's closed clinical record revealed a physician's orders [REDACTED]. However, review of Resident #2's Medication Administration Record [REDACTED]. Interview, on [DATE] at 12:13 PM, with Licensed Practical Nurse (LPN) #2 revealed on [DATE], Resident #2 returned to the facility after hospitalization with medication orders including Afinitor. She stated the Unit Manager told her the facility was not going to approve the medication due to the cost. Interview, on [DATE] at 10:30 AM, with the Pharmacist revealed the Interim Director of Nursing canceled the prescription and the pharmacy did not deliver Afinitor to the facility. Interview, on [DATE] at 2:55 PM, with the Unit Manager (UM) of the Blue Unit revealed she spoke with the Administrator on [DATE], and he said the medication was too expensive to order. Per interview, she tried to get an approval for a three (3) or four (4) day supply of the Afinitor; however, the Administrator denied the request. Interview, on [DATE] at 10:30 AM and 4:00 PM, with the Administrator revealed he put a hold on the medication due to the cost. He chose to wait until [DATE], to contact the Oncologist to seek further direction because it was the Thanksgiving holiday week. The Administrator stated he did not inform staff he did not approve the medication due to cost, nor did he instruct staff to call the physician to seek further direction. According to the Administrator, he was ultimately responsible for the care and services the residents received in the facility. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], the Unit Managers (UM), Staff Development Coordinator (SDC), Medical Records Director, and Regional Support Staff (RSS) completed a one-time review of resident admissions from [DATE] to [DATE], in order to determine compliance with physician orders [REDACTED]. The facility shared the one-time review of admission information with members of the Interdisciplinary Team. 2. The facility assessed all new admits for [MEDICAL CONDITION] treatment medications to determine if the Immediate Jeopardy identified on [DATE], could affect them. No additional newly admitted residents were noted [MEDICAL CONDITION] treating medications prescribed. 3. On [DATE], the Administrator, Assistant Director of Nursing (ADON), Medical Director, and RSS made the determination policy and procedures, related to the immediate jeopardy, did not require revisions. 4. The UMs, SDC, Administrator, and RSS initiated re-education of the Licensed Nursing Staff, Certified Medication Technicians, and Non-Facility Personnel on [DATE], regarding medication administration and notification of the physician, resident, and family of a decision to withhold resident medication. In addition, staff was re-educated on the development and implementation of the baseline care plan, to include goals and interventions. The facility currently employed twelve (12) Licensed Nurses and one (1) Certified Medication Technician. Any Licensed Nurse who had not completed the re-education by 11:59 PM on [DATE], would receive the re-education at the time of their next scheduled shift. 5. The SDC would educate newly hired nurses and certified medication technicians during the orientation process. 6. The Director of Nursing (DON), Administrator, ADON, UM, Minimum Data Set (MDS) Coordinator, SDC, or RSS would conduct audits beginning [DATE], of new admissions to monitor for the ordering and obtaining of medications, per the physician order, three (3) times a week for eight (8) weeks, then once a week for four (4) weeks, then monthly. Any issues noted by the facility during the auditing process would be immediately corrected with one-on-one re-education and/up to disciplinary action as deemed necessary. 7. The DON, Administrator, ADON, UM, MDS Coordinator, SDC, or RSS would be responsible for conducting audits beginning [DATE], regarding compliance with the initiation of the baseline care plan at the time of admission, three (3) times a week for eight (8) weeks, then once a week for four (4) weeks, then monthly. Any issues noted by the facility during the auditing process would be immediately corrected with one-on-one re-education and/up to disciplinary action as deemed necessary. 8. The DON, Administrator, ADON, UM, MDS Coordinator, SDC, or RSS would be responsible for conducting audits beginning [DATE], for the provision [MEDICAL CONDITION] treatments as the time of admission three (3) times a week for eight (8) weeks, then once a week for four (4) weeks, then monthly. Any issues noted by the facility during the auditing process would be immediately corrected with one-on-one re-education and/up to disciplinary action as deemed necessary. 9. The Administrator, DON, or RSS would be responsible for reviewing the results of the audits. 10. The Regional Director of Special Projects re-educated the Interdisciplinary Team (IDT) on [DATE], regarding administrative roles and responsibilities. The IDT consisted of the Administrator, DON, Admissions, ADON, SDC, UM, Social Services (SS), Business Office Manager (BOM), MDS Coordinator, and Rehabilitation Services Manager (RSM). 11. The facility held an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting on [DATE], with the Medical Director, Administrator, DON, ADON, Medical Records, BOM, Maintenance, Admissions, Housekeeping Manager, Rehabilitation Services Manager, and the Regional Director of Clinical Operations to review the statement of deficiencies, corrective actions taken, and results of the audits performed. 12. On [DATE], the Regional Vice President of Operations (VPO) reviewed with the Administrator the Administrator Job description and responsibilities. The VPO discussed with the Administrator the role of ensuring resources were available to provide for the needs of the resident, which included medications and other services. 13. On [DATE], the Regional Vice President of Operations (VPO) met with the Administrator and the DON to validate the facility's Allegation of Compliance. These meetings would continue weekly until the immediacy of the jeopardy was lifted and substantial compliance was achieved. 14. The facility Administrator would present all findings of the audits to the QAPI committee monthly for three months (3), then quarterly thereafter for further recommendations and follow up. 15. The Administrator would oversee the QAPI committee meeting in conjunction with the DON and Medical Director. The State Survey Agency validated the removal of Immediate Jeopardy on [DATE] prior to exit as follows: 1. Interview with the Staff Development Coordinator (SDC), on [DATE] at 1:41 PM, and the Unit Manager (UM), on [DATE] at 10:20 AM, revealed the facility reviewed resident admission orders [REDACTED]. Interview with the Minimum Data Set (MDS) Coordinator, on [DATE] at 9:24 AM, revealed she was on the IDT. She stated the team reviewed the information from the one-time review of resident admissions to determine if the facility had administered medications as ordered and there were no identified issues found from the review. Interview with the Social Services Director (SSD), on [DATE] at 10:15 AM, and the Medical Records Director (MRD), on [DATE] at 10:00 AM, revealed they were on the Interdisciplinary Team (IDT). The SSD and MRD stated they reviewed the information obtained from the one-time review of resident admissions, from [DATE] to [DATE], and determined the facility had administered medications as ordered. Record review revealed the facility reviewed resident admission orders [REDACTED]. Review of Unsampled Resident I's medical record revealed the facility admitted the resident on [DATE] and readmitted the resident on [DATE]. The medication orders from the hospital's discharge summary, dated [DATE], corresponded with both the medication orders listed on the Physician order [REDACTED]. Review of Unsampled Resident N's medical record revealed the facility admitted the resident on [DATE]. Medication orders listed on the POS, dated [DATE], and the medication orders on the Medication Administration Record [REDACTED]. 2. Interview with the Administrator, on [DATE] at 3:00 PM, revealed the facility did not have residents in the facility [MEDICAL CONDITION] treatment medications. Interview with the Director of Nursing (DON), on [DATE] at 9:35 AM, revealed the facility did not have a resident in the facility [MEDICAL CONDITION] treatment medications. Review of an untitled typed statement, dated [DATE], revealed as of the alleged compliance date of [DATE], the facility had not admitted or readmitted residents with orders [MEDICAL CONDITION] related medications. 3. Interview with the Administrator, on [DATE] at 8:30 AM, and the Regional Support Staff (RSS), on [DATE] at 2:45 PM, revealed the facility reviewed policies and procedures related to Physician Notification, Care Plan Development, and Medication Administration, and determined revisions to the polices were not necessary. 4. Interview with Registered Nurse (RN) #4, on [DATE] at 3:00 PM, revealed she was trained on medication, change of condition, and care plans. She stated care plans should be individualized with new information passed on to the CNAs. RN #4 stated she would call the pharmacy if a medication was not available and STAT (immediate) medications would be delivered within one (1) hour. She revealed if she was unable to obtain the medication, the resident's physician and family would be notified. Interview with RN #1, on [DATE] at 8:45 AM, revealed she was trained on documentation, updating care plans, and physician notification. She stated the procedure for pre-authorization of medications included contacting the pharmacy and receiving an approval number. She had never experienced an instance where a medication was not approved. Interview with Licensed Practical Nurse (LPN) #7, on [DATE] 8:30 AM, revealed the facility recently educated her on medication administration, change of condition, and medication changes. She stated she was trained to notify the physician, resident (when applicable), family, and manager any time a resident reacted to, refused, or missed a medication dose and if they had a change in condition. LPN #7 stated she was educated to review the resident care plans each shift, make changes when applicable, and inform her manager if revisions were necessary. Interview with the MDS Coordinator, on [DATE] at 9:24 AM, revealed the facility trained her to provide training to the staff on physician, family, and resident notification, medication administration, and care plan development and implementation. Interview with CNA #5, on [DATE] at 2:50 PM, revealed she kept a copy of the care plan with her on the floor. She stated the care plans were developed by nursing staff in the care planning meetings when residents were first admitted . If the resident had a change of condition, she stated she would fill out a Stop and Watch form and tell the nurse. The form was then signed by the nurse to prove the CNA informed them of the change. CNA #5 stated the Unit Manager and the nurses kept care plans updated. Review of facility's In-Service Attendance Sheets revealed staff re-education began on [DATE], and education continued on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The facility trained Licensed Nursing Staff and Certified Medication Technicians on physician, family, and resident notification, care plan development, and medication administration. Record review revealed the facility used the policy, Medication Administration, dated (MONTH) (YEAR), to re-educate Licensed Nursing Staff and Medication Technicians. Continued review revealed the facility used an undated document, Baseline Care Plan Process, to re-educate the Licensed Nursing Staff. The goal stated the facility would meet newly admitted and/or readmitted resident care needs. During the admission process, staff would complete all required assessments and based on those assessments, would create a care plan for the identified high-risk areas. Review of the Employee Listing Payroll Services document, dated (MONTH) (YEAR), revealed the facility employed twelve (12) licensed nursing staff and one (1) Certified Medication Technician. Review of the facility's In-Service Attendance Sheets, dated [DATE], [DATE], and [DATE], revealed staff assigned to work after [DATE], received training prior to their shift. 5. Interview with LPN #6, on [DATE] at 3:45 PM, revealed she was an agency nurse and the facility recently educated her regarding physician notification, care plan development, and medication administration prior to her beginning her shift. She stated all new orders required notification of resident and family, and nursing staff must document their notifications. She stated the facility kept a copy of the resident care plans on each medication cart and she signed the plans each shift to show she had reviewed them for potential revisions. Interview with the SDC, on [DATE] at 1:41 PM, revealed she scheduled agency staff to come in one (1) hour prior to the beginning of their shift in order for the staff member to receive training on physician, family, and resident notification, care plan development, and medication administration. She stated new hires would receive the training in orientation; however, the facility had not conducted new hire orientation as of yet. 6. Interview with LPN #7, on [DATE] at 8:30 AM, revealed she would notify the physician, resident, and family if she could not administer a resident's medication. She stated she readmitted Unsampled Resident I to the facility on [DATE], and after she had processed the admission, her Unit Manager and Corporate Nurses reviewed all the medications and orders for accuracy. She stated the Unit Manager and Corporate Nurses performed the audit of her documentation and did not find any issues. Interview with the DON, on [DATE] at 9:35 AM, revealed she assisted with auditing the medical records and found no concerns requiring corrective action. Review of Plan of Correction Auditing Form for Physician Notification, not dated, revealed no new resident admissions had occurred. The facility conducted random medical record audits three (3) times a week to determine compliance with physician notification related to a medication order or compliance with obtaining medication per the physician order. The facility began audits on [DATE], and audits continued on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The facility audited residents' medical records for compliance after re-admission from a hospitalization on [DATE] and [DATE]. No identified concerns were noted. 7. Interview with the SDC, on [DATE] at 1:41 PM, revealed she assisted with conducting audits three (3) times a week and had not identified concerns with care plan audits. Review of Unsampled Resident G's Care Plan, undated, revealed the facility developed and implemented interventions to meet the resident's care needs. Interview with Unsampled Resident G, on [DATE] at 2:30 PM, revealed the resident had no concerns with medication administration and staff kept him/her informed of changes in his/her plan of care. Review of a Plan of Correction Auditing Form, not dated, for the initiation of the Baseline Care Plan upon admission, revealed no new resident admissions had occurred. Continued review revealed the facility conducted random medical record audits three (3) times a week, to include residents readmitted after a hospitalization . The facility began the audits on [DATE] and continued the audits on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], to determine compliance with initiation of the Baseline Care Plan development. No identified concerns were noted requiring corrective action. 8. Interview with RN #1, on [DATE] at 3:25 PM, revealed management was conducting audits of resident medical records to determine if residents had orders [MEDICAL CONDITION] treatment and to determine if nursing staff administered medications as ordered. She stated she did not know of any resident that had orders [MEDICAL CONDITION] treatment drugs. Interview with the Unit Manager, on [DATE] at 10:20 AM, revealed she assisted with conducting audits three (3) times a week and found no concerns that required corrective action. Review of a Plan of Correction Auditing Form, not dated, regarding the provision [MEDICAL CONDITION] treatments per the physician order [REDACTED]. Continued review revealed the facility conducted random audits three (3) times a week of resident medical records to include residents readmitted after a hospitalization . The facility conducted audits on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. No identified concerns were noted which required corrective action. Review of the clinical record for Unsampled Resident G revealed all of the medications listed on the Medication Administration Record [REDACTED]. Continued Review of the MAR indicated [REDACTED]. 9. Interview with the RSS, on [DATE] at 2:45 PM, revealed she reviewed the audit forms for completion and for issues needing corrective action. She stated she discussed the findings with the Interdisciplinary Team, which included the Administrator and DON. She stated audits were conducted three (3) times a week as planned, and no issues were identified that required corrective action. Review of a Plan of Correction Auditing Form, not dated, regarding physician notification, baseline care plans, [MEDICAL CONDITION] treatment services revealed the RSS reviewed the audit forms. 10. Interview with the Rehabilitation Services Manager, on [DATE] at 11:00 AM, and Social Services, on [DATE] at 10:15 AM, revealed the Regional Director of Special Projects re-educated them on their roles and responsibilities in regards to meeting resident care needs. Interview with the Admissions Director, on [DATE] at 2:00 PM, and SDC, on [DATE] at 1:41 PM, revealed the Regional Director of Special Projects met with the IDT on [DATE], to provide re-education regarding the team's roles and responsibility to ensure residents received the care and services ordered by the physician. Interview with the Regional Director of Special Projects, on [DATE] at 3:00 PM, revealed he had re-educated the IDT on their administrative roles and responsibilities regarding care plan development, physician, family and resident notification, and medication administration. 11. Interview, on [DATE] at 8:03 AM, with the Medical Director revealed he had attended the Ad Hoc Quality Assurance meeting held on [DATE]. He stated the facility audits were discussed and other actions taken to ensure compliance with medication administration, notification, and care plan implementation. He stated no concerns were identified requiring corrective action. Interview with the Director of Housekeeping, on [DATE] at 9:04 AM, and the Medical Records Director, on [DATE] at 10:00 AM, revealed they attended the [DATE] QAPI committee meeting. They stated the committee discussed the facility's compliance with medication administration, physician notification, and care plan implementation, along with facility audits. They stated no identified concerns were noted. Review of the Ad Hoc Quality Assurance sign in sheet, dated [DATE], revealed the Medical Director, Administrator, DON, ADON, Medical Records, BOM, Maintenance, Admissions, Housekeeping Manager, Rehabilitation Services Manager, and the Regional Director of Clinical Operations attended the meeting. 12. Interview with the Administrator, on [DATE] at 9:05 AM, revealed the Vice President of Operations (VPO) re-educated him on [DATE], regarding his job description and role as an administrator. He stated the VPO instructed him to approve medication, regardless of cost, when pharmacy requested payment approval. He stated the facility must ensure resident's needs were met. Interview with the VPO, on [DATE] at 9:26 AM, revealed he re-educated the Administrator on [DATE], regarding his job description and responsibilities to ensure resident care needs were met. The VPO stated he instructed the Administrator to approve medication, regardless of cost, when pharmacy requested a payment approval. 13. Interview with the Administrator, on [DATE] at 9:05 AM, and the DON, on [DATE] at 9:35 AM, revealed the VPO met with them on [DATE], to validate the Allegation of Compliance (A[NAME]). They stated the plan was to meet weekly on Thursday until the abatement of the Immediate Jeopardy and substantial compliance was achieved. Interview with the VPO, on [DATE] at 9:26 AM, revealed he met with the Administrator and DON on [DATE], to validate the facility's compliance with the A[NAME]. He stated he would meet with weekly until the abatement of the immediate jeopardy and substantial compliance was achieved. Review of the Meeting with Administrator and DON form, dated [DATE], revealed the VPO met with the Administrator and DON to validate compliance with the A[NAME]. The form stated the VPO would continue to meet with them weekly on Thursday until the abatement of immediate jeopardy and substantial compliance was achieved. 14. Interview with the Administrator, on [DATE] at 9:05 AM, and the DON, on [DATE] at 9:35 AM, revealed all audits would be presented to the QAPI committee monthly for three (3) months, then quarterly thereafter for further recommendations and follow up. 15. Interview with the Administrator, on [DATE] at 9:05 AM, the DON, on [DATE] at 9:35 AM, and with the Medical Director, on [DATE] at 8:03 AM, revealed they would oversee the QAPI committee process.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to notify the physician of an abnormal International Normalized Ratio (INR) for one (1) of eighteen (18) sampled residents, Resident #67. Resident #67 had an abnormal INR result on 11/17/17, and the facility did not notify the physician until 11/20/17, when the resident became unresponsive. The facility transferred the resident to the hospital and the Computed Tomography (CT scan) of the head revealed a small acute left subdural hemorrhage with mild subarachnoid hemorrhage (bleeding) and a ten (10) millimeter midline shift. The findings include: Review of the facility's undated PT/INR Testing Policy revealed the purpose of the testing was to evaluate resident's INR levels to determine effectiveness of [MEDICATION NAME] therapy and to reduce the risk of adverse events that may be associated with anticoagulation therapy. The date and time the PT/INR was done was to be recorded in the medical record. The name and title of the individual who performed the procedure were to be documented in the medical record. The PT/INR results and interventions done, and physician and family notification, if any, were to be documented in the medical record. The policy revealed unexpected results or results outside of the INR target range was to be reported to the charge nurse and physician; however, the policy did not indicate the INR target range. Review of the facility's undated PT/INR Results Protocol revealed licensed nurses were to notify the physician of PT/INR results and respond with any new orders or to maintain current medication dose. The attending physician or nurse practitioner would then review at the next visit. Review of the clinical record for Resident #67 revealed the facility admitted the resident on 12/28/16 and readmitted the resident on 07/01/17, with [DIAGNOSES REDACTED]. Review of Resident #67's annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15) and determined the resident interviewable. Observation of Resident #67, on 12/12/17 at 8:56 AM, revealed the resident lying in bed. Interview, on 12/12/17 at 8:56 AM, with Resident #67, revealed he/she had a decline in function because of health reasons. Resident #67 stated he/she had been in the hospital for a few days and had only been back to the facility a couple of weeks and received physical and occupational therapy since the return to the facility. Further review of the clinical record for Resident #67 revealed the resident had a hospital stay from 11/20/17 to 11/29/17. Review of Resident #67's Medication Administration Record [REDACTED]. Review of Resident #67's Comprehensive Care Plan, dated 01/10/17, revealed the resident was at risk for abnormal bleeding or hemorrhage related to use of an anticoagulant (blood thinner). Interventions included scheduling lab tests to monitor coagulation factors, monitor resident for signs of bleeding, and report to the physician any signs of abnormal bleeding. Review of Resident #67's INR Monitoring for [MEDICATION NAME] Therapy sheet, for 10/16/17 to 11/17/17, revealed INR was completed on 11/03/17 with a result of 2.2. An INR was completed on 11/17/17, with a result of 4.0. There was no documentation the physician had been notified of the increase in the INR. Review of the U.S. Food and Drug Administration Medication Guide, revised September 2016, revealed patients with [MEDICAL CONDITION] Fibrillation and anticoagulated with [MEDICATION NAME] ([MEDICATION NAME]) should have a target INR of 2.5 (range 2.0 - 3.0). Review of the twenty-four (24) hour report/change of condition report, dated 11/18/17, revealed a note was made to call the physician for Resident #67's INR 4.0 from yesterday. Review of a progress note, for 11/17/17 at 12:02 PM, revealed Resident #67 had been nauseated and had a headache and [MEDICATION NAME] and Tylenol were given. Review of Resident #67's progress notes for 11/17/17, 11/18/17, and 11/19/17, revealed no documentation staff notified the physician or nurse practitioner of the 4.0 INR. Further review of the MAR for 11/17/17 through 11/19/17, revealed [MEDICATION NAME] was administered to Resident #67 after the INR resulted 4.0. Further review of the progress notes from 11/17/17 at 11:40 PM until 11/20/17 at 10:49 AM, revealed no progress notes had been entered and no documentation that Resident #67 was being monitored for signs and symptoms of bleeding due to the increased INR. Review of the progress note for 11/20/17 at 10:49 AM, revealed Licensed Practical Nurse (LPN) #1 was informed by staff that the resident had not eaten or had much to drink over the weekend. LPN #1 assessed Resident #67 and the resident did not respond to verbal or tactile stimuli. The resident laid in the bed, which was not normal for Resident #67. The facility sent Resident #67 to the hospital on [DATE] at 11:30 AM. Review of Resident #67's History and Physical note from the hospital, dated 11/20/17 at 3:28 PM, revealed Resident #67 presented with an altered mental status and increased lethargy over the weekend. A PT/INR was done at 12:18 PM on 11/20/17, and the PT resulted 49.5 with a reference range of 9.6 - 12.0. The INR was 4.3. The urinalysis revealed a trace of occult blood in the urine. Review of the CT of the head revealed a small acute upon chronic left subdural hemorrhage with mild subarachnoid hemorrhage and ten (10) millimeter midline shift. The assessment revealed the [MEDICATION NAME] was supratherapeutic (above therapeutic level) on admission and a reversal agent was given emergently. Review of the physician discharge summary, dated 11/29/17, revealed the discharge [DIAGNOSES REDACTED]. Interview with the UM, on 12/14/17 at 2:45 PM, revealed the third shift nurse usually did the INR and posted on the calendar in the UM's office. The UM revealed most INRs were done weekly but Resident #67 had complained about not liking to be stuck so much that the Nurse Practitioner had noted to do the INR every two (2) weeks; however, she could not find a physician order [REDACTED].#67 was not himself/herself and would not wake up, so the nurse called the physician and got an order to send the resident to the hospital and the resident was admitted with a brain bleed. The UM revealed she could not find any documentation the physician or nurse practitioner had been notified of the 4.0 INR level dated 11/17/17. The UM further revealed the nurse should have called or faxed the physician that was on call with the results of the INR. The UM stated since the INR was elevated, Resident #67 was at high risk of a bleed due to the blood thinner the resident was ordered. The UM stated she could not find a copy of where the INR was faxed to the physician or that the physician was notified of the elevated level. She revealed the physician and the family should have been informed. She stated the night shift nurse should have called the on call physician to inform of the elevated INR level and it should have been put on the INR log and passed along in report, in case the night shift nurse did not call the doctor then the day shift nurse would. She revealed after she reviewed the MAR, the [MEDICATION NAME] had been given 11/17/17 to 11/19/17 to Resident #67. Interview with LPN #4, on 12/14/17 at 3:43 PM, revealed the third shift nurse did the INR and it was usually posted on the calendar in the Unit Manger's (UM) office. LPN #4 stated the results should have been passed along in report and the physician should have been called to see if any new orders were indicated. LPN #4 revealed if the INR was at 4, it posed a risk for Resident #67 of excessive bleeding because the blood would not clot. Interview with LPN #8 via telephone, on 12/14/17 at 5:48 PM, revealed she worked the 11:00 PM to 7:00 AM shift on 11/17/17, but did not recall doing Resident #67's INR as they typically did not do INRs on the weekends. LPN #8 revealed the ideal INR range was around 2.0 to 2.1 and if it were at 4, she would pass it in report for the day shift nurse to call the physician. She further stated there was a physician or nurse practitioner on call but she did not remember calling them. She stated normally the physician or a nurse practitioner was at the facility almost every day, but not on the weekends. LPN #8 revealed a resident was at risk to fall and bleed out if the INR was too high. Interview with LPN #1 via telephone, on 12/14/17 at 6:00 PM, revealed she worked 11/17/17, and did not notice any concerns with Resident #67. However, on Monday 11/20/17, when she returned to work, she noticed Resident #67 was lethargic and mumbling and called the physician who gave an order to send the resident to the hospital. Interview with Certified Nursing Assistant (CNA) #4 via telephone, on 12/14/17 at 5:55 PM, revealed she worked Sunday, 11/19/17, and Resident #67 started to decline and looked like he/she did not feel well and could not hold a cup. She stated she told LPN #8 who said she would put it on the twenty-four (24) hour log. Interview, on 12/14/17 at 6:25 PM, with CNA #5 by telephone, revealed she worked 11/17/17 to 11/19/17 and Resident #67 had slept a lot and had difficulty holding onto a cup, which was not normal for him/her. Interview with the Director of Nursing (DON), on 12/14/17 at 4:00 PM, revealed the third shift nurse normally did the INRs and occasionally the day shift nurse might do them. The DON stated if a INR was 4, the physician should be called immediately by the nurse that did the INR and if not, then the day shift nurse should follow up. The DON further revealed the resident would be at risk for abnormal bleeding and should be monitored for signs and symptoms of bleeding. The DON revealed, after reviewing Resident #67's clinical record, she did not see where the physician had been notified of the elevated INR. The DON revealed they had morning meetings Mondays through Fridays and discussed INR results and she did not recall Resident #67's INR level being discussed on Monday morning. Interview with the Medical Director, on 12/14/17 at 6:20 PM, revealed he did not know if the INR was called into the office or not, as another physician would have followed up on the results. The Medical Director further revealed he would have held the [MEDICATION NAME] for a day or two (2) and rechecked the INR in order to adjust the dose or restart the [MEDICATION NAME].

Based on interview, record review, and facility policy review, it was determined the facility failed to have an effective system to develop a plan of care with goals and interventions related [MEDICAL CONDITION] medication treatment needs for one (1) of three (3) sampled residents, Resident #2. Interview and record review revealed the facility failed to develop a care plan to address Resident #2'[MEDICAL CONDITION] treatment and the resident did not receive the [MEDICAL CONDITION] treatment medication. The facility's failure to have an effective system in place to ensure residents had care plans developed related [MEDICAL CONDITION] treatment medications has caused or is likely to cause serious injury, harm, impairment, or death. The Immediate Jeopardy (IJ) was identified on 03/01/18 and was determined to exist on 11/22/17. The facility was notified on 03/01/18. The facility submitted an acceptable Allegation of Compliance (AoC) on 03/02/18 alleging the removal of Immediate Jeopardy on 03/02/18. The State Survey Agency validated the Immediate Jeopardy was removed on 03/02/18 as alleged, prior to exit on 03/07/18, with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy, Care Plans-Comprehensive, not dated, revealed a person-centered comprehensive care plan that included measurable objectives and timetable to meet the resident's medical, nursing, mental, and psychological needs, would be developed for each resident. The care plan would include how the facility would assist the resident to meet their needs, goals, and preferences. The nurse/Interdisciplinary Team was responsible for the review and updating of the care plan. The care plan should reflect the current status of the resident and be updated with changes in the residents status i.e., when there had been a significant change in the resident's condition, or goals changed, when the desired outcome was not met, or when the resident had been readmitted to the facility from a hospital stay. Each resident had the right to participate in choosing treatment options and would be given the opportunity to participate in the development, review, and revision of their plan of care. Review of Resident #2's closed clinical record revealed the facility originally admitted the resident 10/20/17 and readmitted the resident on 11/21/17, with [DIAGNOSES REDACTED]. In addition, a history of [MEDICAL CONDITION] with a new [DIAGNOSES REDACTED]. Continued review of Resident #2's clinical record revealed a Physician Order, dated 11/21/17, that directed staff to administer Afinitor (medication used to [MEDICAL CONDITION]) ten (10) milligrams, one (1) tablet by mouth daily at 9:00 AM. Review of Resident #2's Interim Admission Care Plan, dated 11/10/17, revealed the resident had two (2) identified problems, one for Pain and the other for Nutrition and Hydration Risk, both related to the resident'[MEDICAL CONDITION] metastasis. However, nursing staff did not develop goals or staff interventions related to the problems. Continued review of Resident #2's plan of care revealed no evidence nursing staff developed an intervention directing staff to administer the physician [MEDICAL CONDITION] treatment medication, Afinitor. Review of Resident #2's Medication Administration Record [REDACTED]. Review of Progress Notes for Resident #2, dated 11/22/17, revealed nursing staff noted the Afinitor was not available for administration. Continued review of nursing documentation revealed nursing did not document a reason on 11/23/17 or 11/24/17, for not administering the Afinitor. Interview with Licensed Practical Nurse (LPN) #5, on 02/06/18 at 2:35 PM, revealed she did not remember developing goals or interventions for Resident #2's [MEDICAL CONDITION] related problems of Pain, and Nutrition and Hydration Risk. She stated nursing staff had twenty-four (24) hours to develop an interim plan of care for newly admitted residents. LPN #5 revealed her role was to initiate the plan upon admission, which included developing care plan interventions for staff to implement. She stated the plan of care directed staff in the care of the resident in order to meet their needs. Interview with LPN #2, on 02/06/18 at 12:13 PM, revealed the purpose of the plan of care was to provide staff with information regarding the resident's care needs. She stated if the Interim Admission Plan of Care did not have goals or interventions, the plan was not fully developed. In addition, LPN #2 stated if the plan did not have interventions for staff to follow, the facility would not meet the resident needs. LPN #2 stated nursing staff should have developed and implemented a plan of care that directed staff to [MEDICAL CONDITION] treatment medication as ordered by the physician. Interview with the Unit Manager of the Blue Unit, on 02/06/18 at 2:55 PM, revealed she had not reviewed Resident #2's Interim Admission Care Plan for completion after his/her admission. She stated the nurse that assessed Resident #2 upon admission was responsible for developing the Interim Admission Plan of Care, which included the development of goals and interventions. The Unit Manager stated if a plan of care did not have interventions, staff would not have the necessary direction to meet the resident's needs. She stated the plan of care should have had an intervention that directed staff to administer [MEDICAL CONDITION] treatment drug Afinitor, per the physician order. She stated the facility did not administer Resident #2's medication on 11/22/17, 11/23/17, or 11/24/17, due to cost. She stated on 11/24/17, the resident's health declined and the facility transferred the resident to the hospital. Interview with the Oncology Physician, on 02/06/18 at 4:00 PM, revealed the facility not administering Afinitor was not in the best interest of Resident #2. He stated the facility transferred Resident #2 to an acute care hospital because the resident experienced a decline while at the facility. Interview with the Interim Director of Nursing (DON), on 02/06/18 at 4:55 PM, revealed the purpose of the plan of care was to direct staff in the care needs of the resident. The DON stated nursing staff should have developed Resident #2's Interim Admission Plan of Care with goals and interventions. She stated leaving blanks on the care plan meant it was incomplete. She stated staff should have included an intervention directing staff to administer the resident'[MEDICAL CONDITION] treatment medication. The DON stated she was not acting as the DON at the time Resident #2 was at the facility and when she began her interim role, she was not informed of any medication issues with Resident #2. Interview with the Administrator, on 02/06/18 at 10:30 AM and 4:00 PM, revealed Resident #2 had a physician's orders [REDACTED]. He stated nursing staff should have developed an Interim Admission Care Plan with goals and interventions related to the administration of [MEDICAL CONDITION] treatment medication because if not, staff would not have the required direction to meet the needs of the resident. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 02/07/18, the Unit Managers (UM), Staff Development Coordinator (SDC), Medical Records Director, and Regional Support Staff (RSS) completed a one-time review of resident admissions from 11/10/17 to 02/07/18, in order to determine compliance with physician orders [REDACTED]. The facility shared the one-time review of admission information with members of the Interdisciplinary Team. 2. The facility assessed all new admits for [MEDICAL CONDITION] treatment medications to determine if the Immediate Jeopardy identified on 02/07/18, could affect them. No additional newly admitted residents were noted [MEDICAL CONDITION] treating medications prescribed. 3. On 02/07/18, the Administrator, Assistant Director of Nursing (ADON), Medical Director, and RSS made the determination policy and procedures, related to the immediate jeopardy, did not require revisions. 4. The UMs, SDC, Administrator, and RSS initiated re-education of the Licensed Nursing Staff, Certified Medication Technicians, and Non-Facility Personnel on 02/07/18, regarding medication administration and notification of the physician, resident, and family of a decision to withhold resident medication. In addition, staff was re-educated on the development and implementation of the baseline care plan, to include goals and interventions. The facility currently employed twelve (12) Licensed Nurses and one (1) Certified Medication Technician. Any Licensed Nurse who had not completed the re-education by 11:59 PM on 03/01/18, would receive the re-education at the time of their next scheduled shift. 5. The SDC would educate newly hired nurses and certified medication technicians during the orientation process. 6. The Director of Nursing (DON), Administrator, ADON, UM, Minimum Data Set (MDS) Coordinator, SDC, or RSS would conduct audits beginning 02/08/18, of new admissions to monitor for the ordering and obtaining of medications, per the physician order, three (3) times a week for eight (8) weeks, then once a week for four (4) weeks, then monthly. Any issues noted by the facility during the auditing process would be immediately corrected with one-on-one re-education and/up to disciplinary action as deemed necessary. 7. The DON, Administrator, ADON, UM, MDS Coordinator, SDC, or RSS would be responsible for conducting audits beginning 02/08/18, regarding compliance with the initiation of the baseline care plan at the time of admission, three (3) times a week for eight (8) weeks, then once a week for four (4) weeks, then monthly. Any issues noted by the facility during the auditing process would be immediately corrected with one-on-one re-education and/up to disciplinary action as deemed necessary. 8. The DON, Administrator, ADON, UM, MDS Coordinator, SDC, or RSS would be responsible for conducting audits beginning 02/08/18, for the provision [MEDICAL CONDITION] treatments as the time of admission three (3) times a week for eight (8) weeks, then once a week for four (4) weeks, then monthly. Any issues noted by the facility during the auditing process would be immediately corrected with one-on-one re-education and/up to disciplinary action as deemed necessary. 9. The Administrator, DON, or RSS would be responsible for reviewing the results of the audits. 10. The Regional Director of Special Projects re-educated the Interdisciplinary Team (IDT) on 02/08/18, regarding administrative roles and responsibilities. The IDT consisted of the Administrator, DON, Admissions, ADON, SDC, UM, Social Services (SS), Business Office Manager (BOM), MDS Coordinator, and Rehabilitation Services Manager (RSM). 11. The facility held an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting on 02/22/18, with the Medical Director, Administrator, DON, ADON, Medical Records, BOM, Maintenance, Admissions, Housekeeping Manager, Rehabilitation Services Manager, and the Regional Director of Clinical Operations to review the statement of deficiencies, corrective actions taken, and results of the audits performed. 12. On 03/01/18, the Regional Vice President of Operations (VPO) reviewed with the Administrator the Administrator Job description and responsibilities. The VPO discussed with the Administrator the role of ensuring resources were available to provide for the needs of the resident, which included medications and other services. 13. On 03/01/18, the Regional Vice President of Operations (VPO) met with the Administrator and the DON to validate the facility's Allegation of Compliance. These meetings would continue weekly until the immediacy of the jeopardy was lifted and substantial compliance was achieved. 14. The facility Administrator would present all findings of the audits to the QAPI committee monthly for three months (3), then quarterly thereafter for further recommendations and follow up. 15. The Administrator would oversee the QAPI committee meeting in conjunction with the DON and Medical Director. The State Survey Agency validated the removal of Immediate Jeopardy on 03/07/18 prior to exit as follows: 1. Interview with the Staff Development Coordinator (SDC), on 03/06/18 at 1:41 PM, and the Unit Manager (UM), on 03/06/18 at 10:20 AM, revealed the facility reviewed resident admission orders [REDACTED]. Interview with the Minimum Data Set (MDS) Coordinator, on 03/06/18 at 9:24 AM, revealed she was on the IDT. She stated the team reviewed the information from the one-time review of resident admissions to determine if the facility had administered medications as ordered and there were no identified issues found from the review. Interview with the Social Services Director (SSD), on 03/06/18 at 10:15 AM, and the Medical Records Director (MRD), on 03/06/18 at 10:00 AM, revealed they were on the Interdisciplinary Team (IDT). The SSD and MRD stated they reviewed the information obtained from the one-time review of resident admissions, from 11/10/17 to 02/07/18, and determined the facility had administered medications as ordered. Record review revealed the facility reviewed resident admission orders [REDACTED]. Review of Unsampled Resident I's medical record revealed the facility admitted the resident on 11/04/17 and readmitted the resident on 01/08/18. The medication orders from the hospital's discharge summary, dated 01/08/18, corresponded with both the medication orders listed on the Physician order [REDACTED]. Review of Unsampled Resident N's medical record revealed the facility admitted the resident on 03/10/17. Medication orders listed on the POS, dated 03/01/18, and the medication orders on the Medication Administration Record [REDACTED]. 2. Interview with the Administrator, on 03/05/18 at 3:00 PM, revealed the facility did not have residents in the facility [MEDICAL CONDITION] treatment medications. Interview with the Director of Nursing (DON), on 03/07/18 at 9:35 AM, revealed the facility did not have a resident in the facility [MEDICAL CONDITION] treatment medications. Review of an untitled typed statement, dated 03/06/18, revealed as of the alleged compliance date of 03/02/18, the facility had not admitted or readmitted residents with orders [MEDICAL CONDITION] related medications. 3. Interview with the Administrator, on 03/06/18 at 8:30 AM, and the Regional Support Staff (RSS), on 03/07/18 at 2:45 PM, revealed the facility reviewed policies and procedures related to Physician Notification, Care Plan Development, and Medication Administration, and determined revisions to the polices were not necessary. 4. Interview with Registered Nurse (RN) #4, on 03/05/18 at 3:00 PM, revealed she was trained on medication, change of condition, and care plans. She stated care plans should be individualized with new information passed on to the CNAs. RN #4 stated she would call the pharmacy if a medication was not available and STAT (immediate) medications would be delivered within one (1) hour. She revealed if she was unable to obtain the medication, the resident's physician and family would be notified. Interview with RN #1, on 03/06/18 at 8:45 AM, revealed she was trained on documentation, updating care plans, and physician notification. She stated the procedure for pre-authorization of medications included contacting the pharmacy and receiving an approval number. She had never experienced an instance where a medication was not approved. Interview with Licensed Practical Nurse (LPN) #7, on 03/06/18 8:30 AM, revealed the facility recently educated her on medication administration, change of condition, and medication changes. She stated she was trained to notify the physician, resident (when applicable), family, and manager any time a resident reacted to, refused, or missed a medication dose and if they had a change in condition. LPN #7 stated she was educated to review the resident care plans each shift, make changes when applicable, and inform her manager if revisions were necessary. Interview with the MDS Coordinator, on 03/06/18 at 9:24 AM, revealed the facility trained her to provide training to the staff on physician, family, and resident notification, medication administration, and care plan development and implementation. Interview with CNA #5, on 03/06/18 at 2:50 PM, revealed she kept a copy of the care plan with her on the floor. She stated the care plans were developed by nursing staff in the care planning meetings when residents were first admitted . If the resident had a change of condition, she stated she would fill out a Stop and Watch form and tell the nurse. The form was then signed by the nurse to prove the CNA informed them of the change. CNA #5 stated the Unit Manager and the nurses kept care plans updated. Review of facility's In-Service Attendance Sheets revealed staff re-education began on 02/07/18, and education continued on 02/08/18, 02/09/18, 02/14/18, 02/16/18, 02/19/18, and 03/01/18. The facility trained Licensed Nursing Staff and Certified Medication Technicians on physician, family, and resident notification, care plan development, and medication administration. Record review revealed the facility used the policy, Medication Administration, dated (MONTH) (YEAR), to re-educate Licensed Nursing Staff and Medication Technicians. Continued review revealed the facility used an undated document, Baseline Care Plan Process, to re-educate the Licensed Nursing Staff. The goal stated the facility would meet newly admitted and/or readmitted resident care needs. During the admission process, staff would complete all required assessments and based on those assessments, would create a care plan for the identified high-risk areas. Review of the Employee Listing Payroll Services document, dated (MONTH) (YEAR), revealed the facility employed twelve (12) licensed nursing staff and one (1) Certified Medication Technician. Review of the facility's In-Service Attendance Sheets, dated 03/04/18, 03/05/18, and 03/06/18, revealed staff assigned to work after 03/02/18, received training prior to their shift. 5. Interview with LPN #6, on 03/05/18 at 3:45 PM, revealed she was an agency nurse and the facility recently educated her regarding physician notification, care plan development, and medication administration prior to her beginning her shift. She stated all new orders required notification of resident and family, and nursing staff must document their notifications. She stated the facility kept a copy of the resident care plans on each medication cart and she signed the plans each shift to show she had reviewed them for potential revisions. Interview with the SDC, on 03/06/18 at 1:41 PM, revealed she scheduled agency staff to come in one (1) hour prior to the beginning of their shift in order for the staff member to receive training on physician, family, and resident notification, care plan development, and medication administration. She stated new hires would receive the training in orientation; however, the facility had not conducted new hire orientation as of yet. 6. Interview with LPN #7, on 03/06/18 at 8:30 AM, revealed she would notify the physician, resident, and family if she could not administer a resident's medication. She stated she readmitted Unsampled Resident I to the facility on [DATE], and after she had processed the admission, her Unit Manager and Corporate Nurses reviewed all the medications and orders for accuracy. She stated the Unit Manager and Corporate Nurses performed the audit of her documentation and did not find any issues. Interview with the DON, on 03/07/18 at 9:35 AM, revealed she assisted with auditing the medical records and found no concerns requiring corrective action. Review of Plan of Correction Auditing Form for Physician Notification, not dated, revealed no new resident admissions had occurred. The facility conducted random medical record audits three (3) times a week to determine compliance with physician notification related to a medication order or compliance with obtaining medication per the physician order. The facility began audits on 02/08/18, and audits continued on 02/09/18, 02/12/18, 02/19/18, 02/21/18, 02/27/18, 03/01/18, and 03/02/18. The facility audited residents' medical records for compliance after re-admission from a hospitalization on [DATE] and 02/14/18. No identified concerns were noted. 7. Interview with the SDC, on 03/06/18 at 1:41 PM, revealed she assisted with conducting audits three (3) times a week and had not identified concerns with care plan audits. Review of Unsampled Resident G's Care Plan, undated, revealed the facility developed and implemented interventions to meet the resident's care needs. Interview with Unsampled Resident G, on 03/06/18 at 2:30 PM, revealed the resident had no concerns with medication administration and staff kept him/her informed of changes in his/her plan of care. Review of a Plan of Correction Auditing Form, not dated, for the initiation of the Baseline Care Plan upon admission, revealed no new resident admissions had occurred. Continued review revealed the facility conducted random medical record audits three (3) times a week, to include residents readmitted after a hospitalization . The facility began the audits on 02/08/18 and continued the audits on 02/10/18, 02/12/18, 02/15/18, 02/19/18, 02/21/18, 02/27/18, 02/27/18, and 03/01/18, to determine compliance with initiation of the Baseline Care Plan development. No identified concerns were noted requiring corrective action. 8. Interview with RN #1, on 03/05/18 at 3:25 PM, revealed management was conducting audits of resident medical records to determine if residents had orders [MEDICAL CONDITION] treatment and to determine if nursing staff administered medications as ordered. She stated she did not know of any resident that had orders [MEDICAL CONDITION] treatment drugs. Interview with the Unit Manager, on 03/06/18 at 10:20 AM, revealed she assisted with conducting audits three (3) times a week and found no concerns that required corrective action. Review of a Plan of Correction Auditing Form, not dated, regarding the provision [MEDICAL CONDITION] treatments per the physician order [REDACTED]. Continued review revealed the facility conducted random audits three (3) times a week of resident medical records to include residents readmitted after a hospitalization . The facility conducted audits on 02/08/18, 02/09/18, 02/10/18, 02/12/18, 02/15/18, 02/19/18, 02/21/18, 02/26/18, 02/27/18, and 03/01/18. No identified concerns were noted which required corrective action. Review of the clinical record for Unsampled Resident G revealed all of the medications listed on the Medication Administration Record [REDACTED]. Continued Review of the MAR indicated [REDACTED]. 9. Interview with the RSS, on 03/07/18 at 2:45 PM, revealed she reviewed the audit forms for completion and for issues needing corrective action. She stated she discussed the findings with the Interdisciplinary Team, which included the Administrator and DON. She stated audits were conducted three (3) times a week as planned, and no issues were identified that required corrective action. Review of a Plan of Correction Auditing Form, not dated, regarding physician notification, baseline care plans, [MEDICAL CONDITION] treatment services revealed the RSS reviewed the audit forms. 10. Interview with the Rehabilitation Services Manager, on 03/06/18 at 11:00 AM, and Social Services, on 03/06/18 at 10:15 AM, revealed the Regional Director of Special Projects re-educated them on their roles and responsibilities in regards to meeting resident care needs. Interview with the Admissions Director, on 03/06/18 at 2:00 PM, and SDC, on 03/06/18 at 1:41 PM, revealed the Regional Director of Special Projects met with the IDT on 02/08/18, to provide re-education regarding the team's roles and responsibility to ensure residents received the care and services ordered by the physician. Interview with the Regional Director of Special Projects, on 03/06/18 at 3:00 PM, revealed he had re-educated the IDT on their administrative roles and responsibilities regarding care plan development, physician, family and resident notification, and medication administration. 11. Interview, on 03/07/18 at 8:03 AM, with the Medical Director revealed he had attended the Ad Hoc Quality Assurance meeting held on 02/22/18. He stated the facility audits were discussed and other actions taken to ensure compliance with medication administration, notification, and care plan implementation. He stated no concerns were identified requiring corrective action. Interview with the Director of Housekeeping, on 03/07/18 at 9:04 AM, and the Medical Records Director, on 03/06/18 at 10:00 AM, revealed they attended the 02/22/18 QAPI committee meeting. They stated the committee discussed the facility's compliance with medication administration, physician notification, and care plan implementation, along with facility audits. They stated no identified concerns were noted. Review of the Ad Hoc Quality Assurance sign in sheet, dated 02/22/18, revealed the Medical Director, Administrator, DON, ADON, Medical Records, BOM, Maintenance, Admissions, Housekeeping Manager, Rehabilitation Services Manager, and the Regional Director of Clinical Operations attended the meeting. 12. Interview with the Administrator, on 03/07/18 at 9:05 AM, revealed the Vice President of Operations (VPO) re-educated him on 03/01/18, regarding his job description and role as an administrator. He stated the VPO instructed him to approve medication, regardless of cost, when pharmacy requested payment approval. He stated the facility must ensure resident's needs were met. Interview with the VPO, on 03/07/18 at 9:26 AM, revealed he re-educated the Administrator on 03/01/18, regarding his job description and responsibilities to ensure resident care needs were met. The VPO stated he instructed the Administrator to approve medication, regardless of cost, when pharmacy requested a payment approval. 13. Interview with the Administrator, on 03/07/18 at 9:05 AM, and the DON, on 03/07/18 at 9:35 AM, revealed the VPO met with them on 03/01/18, to validate the Allegation of Compliance (A[NAME]). They stated the plan was to meet weekly on Thursday until the abatement of the Immediate Jeopardy and substantial compliance was achieved. Interview with the VPO, on 03/07/18 at 9:26 AM, revealed he met with the Administrator and DON on 03/01/18, to validate the facility's compliance with the A[NAME]. He stated he would meet with weekly until the abatement of the immediate jeopardy and substantial compliance was achieved. Review of the Meeting with Administrator and DON form, dated 03/01/18, revealed the VPO met with the Administrator and DON to validate compliance with the A[NAME]. The form stated the VPO would continue to meet with them weekly on Thursday until the abatement of immediate jeopardy and substantial compliance was achieved. 14. Interview with the Administrator, on 03/07/18 at 9:05 AM, and the DON, on 03/07/18 at 9:35 AM, revealed all audits would be presented to the QAPI committee monthly for three (3) months, then quarterly thereafter for further recommendations and follow up. 15. Interview with the Administrator, on 03/07/18 at 9:05 AM, the DON, on 03/07/18 at 9:35 AM, and with the Medical Director, on 03/07/18 at 8:03 AM, revealed they would oversee the QAPI committee process.

Based on interview, record review, and facility policy review, it was determined the facility failed to have an effective system to develop a plan of care with goals and interventions related [MEDICAL CONDITION] medication treatment needs for one (1) of three (3) sampled residents, Resident #2. Interview and record review revealed the facility failed to develop a care plan to address Resident #2'[MEDICAL CONDITION] treatment and the resident did not receive the [MEDICAL CONDITION] treatment medication. The facility's failure to have an effective system in place to ensure residents had care plans developed related [MEDICAL CONDITION] treatment medications has caused or is likely to cause serious injury, harm, impairment, or death. The Immediate Jeopardy (IJ) was identified on 03/01/18 and was determined to exist on 11/22/17. The facility was notified on 03/01/18. The facility submitted an acceptable Allegation of Compliance (AoC) on 03/02/18 alleging the removal of Immediate Jeopardy on 03/02/18. The State Survey Agency validated the Immediate Jeopardy was removed on 03/02/18 as alleged, prior to exit on 03/07/18, with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy, Care Plans-Comprehensive, not dated, revealed a person-centered comprehensive care plan that included measurable objectives and timetable to meet the resident's medical, nursing, mental, and psychological needs, would be developed for each resident. The care plan would include how the facility would assist the resident to meet their needs, goals, and preferences. The nurse/Interdisciplinary Team was responsible for the review and updating of the care plan. The care plan should reflect the current status of the resident and be updated with changes in the residents status i.e., when there had been a significant change in the resident's condition, or goals changed, when the desired outcome was not met, or when the resident had been readmitted to the facility from a hospital stay. Each resident had the right to participate in choosing treatment options and would be given the opportunity to participate in the development, review, and revision of their plan of care. Review of Resident #2's closed clinical record revealed the facility originally admitted the resident 10/20/17 and readmitted the resident on 11/21/17, with [DIAGNOSES REDACTED]. In addition, a history of [MEDICAL CONDITION] with a new [DIAGNOSES REDACTED]. Continued review of Resident #2's clinical record revealed a Physician Order, dated 11/21/17, that directed staff to administer Afinitor (medication used to [MEDICAL CONDITION]) ten (10) milligrams, one (1) tablet by mouth daily at 9:00 AM. Review of Resident #2's Interim Admission Care Plan, dated 11/10/17, revealed the resident had two (2) identified problems, one for Pain and the other for Nutrition and Hydration Risk, both related to the resident'[MEDICAL CONDITION] metastasis. However, nursing staff did not develop goals or staff interventions related to the problems. Continued review of Resident #2's plan of care revealed no evidence nursing staff developed an intervention directing staff to administer the physician [MEDICAL CONDITION] treatment medication, Afinitor. Review of Resident #2's Medication Administration Record [REDACTED]. Review of Progress Notes for Resident #2, dated 11/22/17, revealed nursing staff noted the Afinitor was not available for administration. Continued review of nursing documentation revealed nursing did not document a reason on 11/23/17 or 11/24/17, for not administering the Afinitor. Interview with Licensed Practical Nurse (LPN) #5, on 02/06/18 at 2:35 PM, revealed she did not remember developing goals or interventions for Resident #2's [MEDICAL CONDITION] related problems of Pain, and Nutrition and Hydration Risk. She stated nursing staff had twenty-four (24) hours to develop an interim plan of care for newly admitted residents. LPN #5 revealed her role was to initiate the plan upon admission, which included developing care plan interventions for staff to implement. She stated the plan of care directed staff in the care of the resident in order to meet their needs. Interview with LPN #2, on 02/06/18 at 12:13 PM, revealed the purpose of the plan of care was to provide staff with information regarding the resident's care needs. She stated if the Interim Admission Plan of Care did not have goals or interventions, the plan was not fully developed. In addition, LPN #2 stated if the plan did not have interventions for staff to follow, the facility would not meet the resident needs. LPN #2 stated nursing staff should have developed and implemented a plan of care that directed staff to [MEDICAL CONDITION] treatment medication as ordered by the physician. Interview with the Unit Manager of the Blue Unit, on 02/06/18 at 2:55 PM, revealed she had not reviewed Resident #2's Interim Admission Care Plan for completion after his/her admission. She stated the nurse that assessed Resident #2 upon admission was responsible for developing the Interim Admission Plan of Care, which included the development of goals and interventions. The Unit Manager stated if a plan of care did not have interventions, staff would not have the necessary direction to meet the resident's needs. She stated the plan of care should have had an intervention that directed staff to administer [MEDICAL CONDITION] treatment drug Afinitor, per the physician order. She stated the facility did not administer Resident #2's medication on 11/22/17, 11/23/17, or 11/24/17, due to cost. She stated on 11/24/17, the resident's health declined and the facility transferred the resident to the hospital. Interview with the Oncology Physician, on 02/06/18 at 4:00 PM, revealed the facility not administering Afinitor was not in the best interest of Resident #2. He stated the facility transferred Resident #2 to an acute care hospital because the resident experienced a decline while at the facility. Interview with the Interim Director of Nursing (DON), on 02/06/18 at 4:55 PM, revealed the purpose of the plan of care was to direct staff in the care needs of the resident. The DON stated nursing staff should have developed Resident #2's Interim Admission Plan of Care with goals and interventions. She stated leaving blanks on the care plan meant it was incomplete. She stated staff should have included an intervention directing staff to administer the resident'[MEDICAL CONDITION] treatment medication. The DON stated she was not acting as the DON at the time Resident #2 was at the facility and when she began her interim role, she was not informed of any medication issues with Resident #2. Interview with the Administrator, on 02/06/18 at 10:30 AM and 4:00 PM, revealed Resident #2 had a physician's orders [REDACTED]. He stated nursing staff should have developed an Interim Admission Care Plan with goals and interventions related to the administration of [MEDICAL CONDITION] treatment medication because if not, staff would not have the required direction to meet the needs of the resident. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 02/07/18, the Unit Managers (UM), Staff Development Coordinator (SDC), Medical Records Director, and Regional Support Staff (RSS) completed a one-time review of resident admissions from 11/10/17 to 02/07/18, in order to determine compliance with physician orders [REDACTED]. The facility shared the one-time review of admission information with members of the Interdisciplinary Team. 2. The facility assessed all new admits for [MEDICAL CONDITION] treatment medications to determine if the Immediate Jeopardy identified on 02/07/18, could affect them. No additional newly admitted residents were noted [MEDICAL CONDITION] treating medications prescribed. 3. On 02/07/18, the Administrator, Assistant Director of Nursing (ADON), Medical Director, and RSS made the determination policy and procedures, related to the immediate jeopardy, did not require revisions. 4. The UMs, SDC, Administrator, and RSS initiated re-education of the Licensed Nursing Staff, Certified Medication Technicians, and Non-Facility Personnel on 02/07/18, regarding medication administration and notification of the physician, resident, and family of a decision to withhold resident medication. In addition, staff was re-educated on the development and implementation of the baseline care plan, to include goals and interventions. The facility currently employed twelve (12) Licensed Nurses and one (1) Certified Medication Technician. Any Licensed Nurse who had not completed the re-education by 11:59 PM on 03/01/18, would receive the re-education at the time of their next scheduled shift. 5. The SDC would educate newly hired nurses and certified medication technicians during the orientation process. 6. The Director of Nursing (DON), Administrator, ADON, UM, Minimum Data Set (MDS) Coordinator, SDC, or RSS would conduct audits beginning 02/08/18, of new admissions to monitor for the ordering and obtaining of medications, per the physician order, three (3) times a week for eight (8) weeks, then once a week for four (4) weeks, then monthly. Any issues noted by the facility during the auditing process would be immediately corrected with one-on-one re-education and/up to disciplinary action as deemed necessary. 7. The DON, Administrator, ADON, UM, MDS Coordinator, SDC, or RSS would be responsible for conducting audits beginning 02/08/18, regarding compliance with the initiation of the baseline care plan at the time of admission, three (3) times a week for eight (8) weeks, then once a week for four (4) weeks, then monthly. Any issues noted by the facility during the auditing process would be immediately corrected with one-on-one re-education and/up to disciplinary action as deemed necessary. 8. The DON, Administrator, ADON, UM, MDS Coordinator, SDC, or RSS would be responsible for conducting audits beginning 02/08/18, for the provision [MEDICAL CONDITION] treatments as the time of admission three (3) times a week for eight (8) weeks, then once a week for four (4) weeks, then monthly. Any issues noted by the facility during the auditing process would be immediately corrected with one-on-one re-education and/up to disciplinary action as deemed necessary. 9. The Administrator, DON, or RSS would be responsible for reviewing the results of the audits. 10. The Regional Director of Special Projects re-educated the Interdisciplinary Team (IDT) on 02/08/18, regarding administrative roles and responsibilities. The IDT consisted of the Administrator, DON, Admissions, ADON, SDC, UM, Social Services (SS), Business Office Manager (BOM), MDS Coordinator, and Rehabilitation Services Manager (RSM). 11. The facility held an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting on 02/22/18, with the Medical Director, Administrator, DON, ADON, Medical Records, BOM, Maintenance, Admissions, Housekeeping Manager, Rehabilitation Services Manager, and the Regional Director of Clinical Operations to review the statement of deficiencies, corrective actions taken, and results of the audits performed. 12. On 03/01/18, the Regional Vice President of Operations (VPO) reviewed with the Administrator the Administrator Job description and responsibilities. The VPO discussed with the Administrator the role of ensuring resources were available to provide for the needs of the resident, which included medications and other services. 13. On 03/01/18, the Regional Vice President of Operations (VPO) met with the Administrator and the DON to validate the facility's Allegation of Compliance. These meetings would continue weekly until the immediacy of the jeopardy was lifted and substantial compliance was achieved. 14. The facility Administrator would present all findings of the audits to the QAPI committee monthly for three months (3), then quarterly thereafter for further recommendations and follow up. 15. The Administrator would oversee the QAPI committee meeting in conjunction with the DON and Medical Director. The State Survey Agency validated the removal of Immediate Jeopardy on 03/07/18 prior to exit as follows: 1. Interview with the Staff Development Coordinator (SDC), on 03/06/18 at 1:41 PM, and the Unit Manager (UM), on 03/06/18 at 10:20 AM, revealed the facility reviewed resident admission orders [REDACTED]. Interview with the Minimum Data Set (MDS) Coordinator, on 03/06/18 at 9:24 AM, revealed she was on the IDT. She stated the team reviewed the information from the one-time review of resident admissions to determine if the facility had administered medications as ordered and there were no identified issues found from the review. Interview with the Social Services Director (SSD), on 03/06/18 at 10:15 AM, and the Medical Records Director (MRD), on 03/06/18 at 10:00 AM, revealed they were on the Interdisciplinary Team (IDT). The SSD and MRD stated they reviewed the information obtained from the one-time review of resident admissions, from 11/10/17 to 02/07/18, and determined the facility had administered medications as ordered. Record review revealed the facility reviewed resident admission orders [REDACTED]. Review of Unsampled Resident I's medical record revealed the facility admitted the resident on 11/04/17 and readmitted the resident on 01/08/18. The medication orders from the hospital's discharge summary, dated 01/08/18, corresponded with both the medication orders listed on the Physician order [REDACTED]. Review of Unsampled Resident N's medical record revealed the facility admitted the resident on 03/10/17. Medication orders listed on the POS, dated 03/01/18, and the medication orders on the Medication Administration Record [REDACTED]. 2. Interview with the Administrator, on 03/05/18 at 3:00 PM, revealed the facility did not have residents in the facility [MEDICAL CONDITION] treatment medications. Interview with the Director of Nursing (DON), on 03/07/18 at 9:35 AM, revealed the facility did not have a resident in the facility [MEDICAL CONDITION] treatment medications. Review of an untitled typed statement, dated 03/06/18, revealed as of the alleged compliance date of 03/02/18, the facility had not admitted or readmitted residents with orders [MEDICAL CONDITION] related medications. 3. Interview with the Administrator, on 03/06/18 at 8:30 AM, and the Regional Support Staff (RSS), on 03/07/18 at 2:45 PM, revealed the facility reviewed policies and procedures related to Physician Notification, Care Plan Development, and Medication Administration, and determined revisions to the polices were not necessary. 4. Interview with Registered Nurse (RN) #4, on 03/05/18 at 3:00 PM, revealed she was trained on medication, change of condition, and care plans. She stated care plans should be individualized with new information passed on to the CNAs. RN #4 stated she would call the pharmacy if a medication was not available and STAT (immediate) medications would be delivered within one (1) hour. She revealed if she was unable to obtain the medication, the resident's physician and family would be notified. Interview with RN #1, on 03/06/18 at 8:45 AM, revealed she was trained on documentation, updating care plans, and physician notification. She stated the procedure for pre-authorization of medications included contacting the pharmacy and receiving an approval number. She had never experienced an instance where a medication was not approved. Interview with Licensed Practical Nurse (LPN) #7, on 03/06/18 8:30 AM, revealed the facility recently educated her on medication administration, change of condition, and medication changes. She stated she was trained to notify the physician, resident (when applicable), family, and manager any time a resident reacted to, refused, or missed a medication dose and if they had a change in condition. LPN #7 stated she was educated to review the resident care plans each shift, make changes when applicable, and inform her manager if revisions were necessary. Interview with the MDS Coordinator, on 03/06/18 at 9:24 AM, revealed the facility trained her to provide training to the staff on physician, family, and resident notification, medication administration, and care plan development and implementation. Interview with CNA #5, on 03/06/18 at 2:50 PM, revealed she kept a copy of the care plan with her on the floor. She stated the care plans were developed by nursing staff in the care planning meetings when residents were first admitted . If the resident had a change of condition, she stated she would fill out a Stop and Watch form and tell the nurse. The form was then signed by the nurse to prove the CNA informed them of the change. CNA #5 stated the Unit Manager and the nurses kept care plans updated. Review of facility's In-Service Attendance Sheets revealed staff re-education began on 02/07/18, and education continued on 02/08/18, 02/09/18, 02/14/18, 02/16/18, 02/19/18, and 03/01/18. The facility trained Licensed Nursing Staff and Certified Medication Technicians on physician, family, and resident notification, care plan development, and medication administration. Record review revealed the facility used the policy, Medication Administration, dated (MONTH) (YEAR), to re-educate Licensed Nursing Staff and Medication Technicians. Continued review revealed the facility used an undated document, Baseline Care Plan Process, to re-educate the Licensed Nursing Staff. The goal stated the facility would meet newly admitted and/or readmitted resident care needs. During the admission process, staff would complete all required assessments and based on those assessments, would create a care plan for the identified high-risk areas. Review of the Employee Listing Payroll Services document, dated (MONTH) (YEAR), revealed the facility employed twelve (12) licensed nursing staff and one (1) Certified Medication Technician. Review of the facility's In-Service Attendance Sheets, dated 03/04/18, 03/05/18, and 03/06/18, revealed staff assigned to work after 03/02/18, received training prior to their shift. 5. Interview with LPN #6, on 03/05/18 at 3:45 PM, revealed she was an agency nurse and the facility recently educated her regarding physician notification, care plan development, and medication administration prior to her beginning her shift. She stated all new orders required notification of resident and family, and nursing staff must document their notifications. She stated the facility kept a copy of the resident care plans on each medication cart and she signed the plans each shift to show she had reviewed them for potential revisions. Interview with the SDC, on 03/06/18 at 1:41 PM, revealed she scheduled agency staff to come in one (1) hour prior to the beginning of their shift in order for the staff member to receive training on physician, family, and resident notification, care plan development, and medication administration. She stated new hires would receive the training in orientation; however, the facility had not conducted new hire orientation as of yet. 6. Interview with LPN #7, on 03/06/18 at 8:30 AM, revealed she would notify the physician, resident, and family if she could not administer a resident's medication. She stated she readmitted Unsampled Resident I to the facility on [DATE], and after she had processed the admission, her Unit Manager and Corporate Nurses reviewed all the medications and orders for accuracy. She stated the Unit Manager and Corporate Nurses performed the audit of her documentation and did not find any issues. Interview with the DON, on 03/07/18 at 9:35 AM, revealed she assisted with auditing the medical records and found no concerns requiring corrective action. Review of Plan of Correction Auditing Form for Physician Notification, not dated, revealed no new resident admissions had occurred. The facility conducted random medical record audits three (3) times a week to determine compliance with physician notification related to a medication order or compliance with obtaining medication per the physician order. The facility began audits on 02/08/18, and audits continued on 02/09/18, 02/12/18, 02/19/18, 02/21/18, 02/27/18, 03/01/18, and 03/02/18. The facility audited residents' medical records for compliance after re-admission from a hospitalization on [DATE] and 02/14/18. No identified concerns were noted. 7. Interview with the SDC, on 03/06/18 at 1:41 PM, revealed she assisted with conducting audits three (3) times a week and had not identified concerns with care plan audits. Review of Unsampled Resident G's Care Plan, undated, revealed the facility developed and implemented interventions to meet the resident's care needs. Interview with Unsampled Resident G, on 03/06/18 at 2:30 PM, revealed the resident had no concerns with medication administration and staff kept him/her informed of changes in his/her plan of care. Review of a Plan of Correction Auditing Form, not dated, for the initiation of the Baseline Care Plan upon admission, revealed no new resident admissions had occurred. Continued review revealed the facility conducted random medical record audits three (3) times a week, to include residents readmitted after a hospitalization . The facility began the audits on 02/08/18 and continued the audits on 02/10/18, 02/12/18, 02/15/18, 02/19/18, 02/21/18, 02/27/18, 02/27/18, and 03/01/18, to determine compliance with initiation of the Baseline Care Plan development. No identified concerns were noted requiring corrective action. 8. Interview with RN #1, on 03/05/18 at 3:25 PM, revealed management was conducting audits of resident medical records to determine if residents had orders [MEDICAL CONDITION] treatment and to determine if nursing staff administered medications as ordered. She stated she did not know of any resident that had orders [MEDICAL CONDITION] treatment drugs. Interview with the Unit Manager, on 03/06/18 at 10:20 AM, revealed she assisted with conducting audits three (3) times a week and found no concerns that required corrective action. Review of a Plan of Correction Auditing Form, not dated, regarding the provision [MEDICAL CONDITION] treatments per the physician order [REDACTED]. Continued review revealed the facility conducted random audits three (3) times a week of resident medical records to include residents readmitted after a hospitalization . The facility conducted audits on 02/08/18, 02/09/18, 02/10/18, 02/12/18, 02/15/18, 02/19/18, 02/21/18, 02/26/18, 02/27/18, and 03/01/18. No identified concerns were noted which required corrective action. Review of the clinical record for Unsampled Resident G revealed all of the medications listed on the Medication Administration Record [REDACTED]. Continued Review of the MAR indicated [REDACTED]. 9. Interview with the RSS, on 03/07/18 at 2:45 PM, revealed she reviewed the audit forms for completion and for issues needing corrective action. She stated she discussed the findings with the Interdisciplinary Team, which included the Administrator and DON. She stated audits were conducted three (3) times a week as planned, and no issues were identified that required corrective action. Review of a Plan of Correction Auditing Form, not dated, regarding physician notification, baseline care plans, [MEDICAL CONDITION] treatment services revealed the RSS reviewed the audit forms. 10. Interview with the Rehabilitation Services Manager, on 03/06/18 at 11:00 AM, and Social Services, on 03/06/18 at 10:15 AM, revealed the Regional Director of Special Projects re-educated them on their roles and responsibilities in regards to meeting resident care needs. Interview with the Admissions Director, on 03/06/18 at 2:00 PM, and SDC, on 03/06/18 at 1:41 PM, revealed the Regional Director of Special Projects met with the IDT on 02/08/18, to provide re-education regarding the team's roles and responsibility to ensure residents received the care and services ordered by the physician. Interview with the Regional Director of Special Projects, on 03/06/18 at 3:00 PM, revealed he had re-educated the IDT on their administrative roles and responsibilities regarding care plan development, physician, family and resident notification, and medication administration. 11. Interview, on 03/07/18 at 8:03 AM, with the Medical Director revealed he had attended the Ad Hoc Quality Assurance meeting held on 02/22/18. He stated the facility audits were discussed and other actions taken to ensure compliance with medication administration, notification, and care plan implementation. He stated no concerns were identified requiring corrective action. Interview with the Director of Housekeeping, on 03/07/18 at 9:04 AM, and the Medical Records Director, on 03/06/18 at 10:00 AM, revealed they attended the 02/22/18 QAPI committee meeting. They stated the committee discussed the facility's compliance with medication administration, physician notification, and care plan implementation, along with facility audits. They stated no identified concerns were noted. Review of the Ad Hoc Quality Assurance sign in sheet, dated 02/22/18, revealed the Medical Director, Administrator, DON, ADON, Medical Records, BOM, Maintenance, Admissions, Housekeeping Manager, Rehabilitation Services Manager, and the Regional Director of Clinical Operations attended the meeting. 12. Interview with the Administrator, on 03/07/18 at 9:05 AM, revealed the Vice President of Operations (VPO) re-educated him on 03/01/18, regarding his job description and role as an administrator. He stated the VPO instructed him to approve medication, regardless of cost, when pharmacy requested payment approval. He stated the facility must ensure resident's needs were met. Interview with the VPO, on 03/07/18 at 9:26 AM, revealed he re-educated the Administrator on 03/01/18, regarding his job description and responsibilities to ensure resident care needs were met. The VPO stated he instructed the Administrator to approve medication, regardless of cost, when pharmacy requested a payment approval. 13. Interview with the Administrator, on 03/07/18 at 9:05 AM, and the DON, on 03/07/18 at 9:35 AM, revealed the VPO met with them on 03/01/18, to validate the Allegation of Compliance (A[NAME]). They stated the plan was to meet weekly on Thursday until the abatement of the Immediate Jeopardy and substantial compliance was achieved. Interview with the VPO, on 03/07/18 at 9:26 AM, revealed he met with the Administrator and DON on 03/01/18, to validate the facility's compliance with the A[NAME]. He stated he would meet with weekly until the abatement of the immediate jeopardy and substantial compliance was achieved. Review of the Meeting with Administrator and DON form, dated 03/01/18, revealed the VPO met with the Administrator and DON to validate compliance with the A[NAME]. The form stated the VPO would continue to meet with them weekly on Thursday until the abatement of immediate jeopardy and substantial compliance was achieved. 14. Interview with the Administrator, on 03/07/18 at 9:05 AM, and the DON, on 03/07/18 at 9:35 AM, revealed all audits would be presented to the QAPI committee monthly for three (3) months, then quarterly thereafter for further recommendations and follow up. 15. Interview with the Administrator, on 03/07/18 at 9:05 AM, the DON, on 03/07/18 at 9:35 AM, and with the Medical Director, on 03/07/18 at 8:03 AM, revealed they would oversee the QAPI committee process.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure care and treatment services [MEDICAL CONDITION] was provided for one (1) of three (3) sampled residents, Resident #2. Resident #2 had a physician order, dated [DATE], to receive Afinitor (cancer treatment medication); however, the facility made the decision to put a hold on the medication due to the cost. The facility failed to inform the physician of the cost in order to determine if another medication could be substituted, resulting in [MEDICAL CONDITION] treatment medication not being administered to the resident. On [DATE], Resident #2 experienced a decline while at the nursing facility, which required a transfer to an acute care hospital. The resident expired on [DATE] due to [MEDICAL CONDITION], Hepatic Failure, Acute [MEDICAL CONDITION], and Metastatic [MEDICAL CONDITION]. The facility's failure to have an effective system in place to ensure the resident's choice to [MEDICAL CONDITION] treatment medications has caused or is likely to cause serious injury, harm, impairment, or death. The Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE]. The facility was notified on [DATE]. The facility submitted an acceptable Allegation of Compliance (AoC) on [DATE] alleging the removal of Immediate Jeopardy on [DATE]. The State Survey Agency validated the Immediate Jeopardy was removed on [DATE] as alleged, prior to exit on [DATE], with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy, Ordering and Receiving Medications, dated (MONTH) 2010, revealed medications and related products were received from the provider pharmacy on a timely basis. If the resident's first dose of medication was scheduled to be given before the next regularly scheduled pharmacy delivery, staff should telephone or transmit the medication orders to the pharmacy immediately upon receipt. Staff was to inform the pharmacy of the need for prompt delivery. Timely delivery of new medication orders was required so that medication administration was not delayed. Staff would promptly report discrepancies and omissions to the issuing pharmacy and the charge nurse or supervisor. Review of the facility's policy, Resident Rights, not dated, revealed the resident had the right to participate in healthcare decisions and care planning. Review of the facility's policy, Care Plans-Comprehensive, not dated, revealed each resident had the right to participate in choosing treatment options and would be given the opportunity to participate in the development, review, and revision of their plan of care. Review of Resident #2's closed clinical record revealed the facility originally admitted the resident [DATE] and readmitted the resident on [DATE], with [DIAGNOSES REDACTED]. In addition, a history of [MEDICAL CONDITION] with a new [DIAGNOSES REDACTED]. Review of Resident #1's admission Minimum Data Set, dated dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status score of fifteen (15) out of fifteen (15) and determined the resident interviewable. Review of Resident #2's Physician Order, dated [DATE], revealed the physician ordered Afinitor 10 milligrams, one (1) tablet administered by mouth daily at 9:00 AM. However, review of Resident #2's Medication Administration Record [REDACTED]. Review of Resident #2's Interim Admission Care Plan, dated [DATE], revealed nursing staff did not develop goals or staff interventions related to the resident'[MEDICAL CONDITION] metastasis. Continued review of Resident #2's Interim Admission plan of care revealed no evidence nursing staff developed interventions directing staff to administer the physician ordered medication, Afinitor, to ensure the resident'[MEDICAL CONDITION] treatment needs were met. Interview, on [DATE] at 4:00 PM, with the Oncology Physician, revealed Resident #2 experienced a decline while at the nursing facility, which required a transfer to an acute care hospital. He stated it was not in the best interest of Resident #2 for the facility not to administer [MEDICAL CONDITION] treatment medication, Afinitor. He stated after hospitalization , the resident rapidly expired from [MEDICAL CONDITION]. Interview with Licensed Practical Nurse (LPN) #2, on [DATE] at 12:13 PM, revealed on [DATE], Resident #2 returned to the facility after hospitalization with medication orders including Afinitor, [MEDICAL CONDITION] treatment drug. She stated she obtained orders, from the facility's physician, that included the Afinitor, and sent the orders to the pharmacy. LPN #2 stated the pharmacy informed her the Director of Nursing must approve the Afinitor prior to delivery due to the cost of the medication. She stated the Unit Manager told her the facility was not going to approve the medication due to the cost, as the cost was eight thousand dollars ($8,000) for a fourteen (14) day supply. The facility did not notify Resident #2 or the physician of the decision not to approve the delivery/administration of the medication. Interview with the Pharmacist, on [DATE] at 10:30 AM, revealed on [DATE], the facility sent an order to the pharmacy for Resident #2's Afinitor. She stated due to the resident's insurance coverage, a seven (7) day supply of the Afinitor would cost the facility four thousand one hundred and forty-five dollars ($4145). The Pharmacist stated due to the cost, there was required approval needed from the Director of Nursing prior to delivery. She stated the pharmacy did not deliver Afinitor to the facility because the Interim Director of Nursing canceled the prescription. Attempted interview with the Interim Director of Nursing at the time Resident #2 was in the facility, on [DATE] at 3:38 PM and [DATE] at 12:59 PM, via telephone, was unsuccessful. Interview with the Unit Manager of the Blue Unit where the resident resided, on [DATE] at 2:55 PM, revealed she identified on [DATE], three (3) days after the medication had been ordered, Resident #2's Afinitor was not available and she informed the resident on [DATE], the facility had not administered the Afinitor to him/her as ordered by the Oncologist. The Unit Manager stated the resident told her he/she wanted to fight [MEDICAL CONDITION] and thought the facility was administering [MEDICAL CONDITION] treatment drug. The Unit Manager stated she spoke with the Administrator on [DATE], and was told the medication was too expensive to order and the facility would try to contact the Oncology Physician regarding the medication on [DATE], six (6) days after the medication had been ordered. She stated she tried to get an approval for a three (3) or four (4) day supply of the Afinitor; however, the Administrator denied the request because five hundred dollars ($500) to eight hundred dollars ($800) per pill would be charged to the facility. She stated the Administrator told her to contact the physician to see if there was another less expensive medication to treat Resident #2'[MEDICAL CONDITION]. However, when she went back to the unit, Resident #2 was not feeling well and requested a transfer to the hospital. The Unit Manager stated the facility did not administer the Afinitor on [DATE], [DATE], or [DATE], and in order to meet resident care needs, the facility should had administered the medication as ordered. Interview, on [DATE] at 4:55 PM, with the Interim Director of Nursing (DON), revealed she was not the DON during Resident #2's stay at the facility. The DON stated she was not aware of the incident regarding Resident #2's Afinitor medication denial. The DON stated if a physician ordered a medication that was not part of the facility's formulary and required her approval, she would call the physician to determine if another medication could be substituted, and if not, she would approve the medication. The DON stated it was important for the facility to take care of residents' cancer treatment needs, regardless of medication cost. Interview with the Administrator, on [DATE] at 10:30 AM and 4:00 PM, revealed he called the pharmacist to determine if Resident #2'[MEDICAL CONDITION] treatment medication, Afinitor, was on the facility's formulary for covered medications, and found out it was not and he decided to put a hold order on the medication due to cost. He stated it was Thanksgiving holiday week and he chose to wait until [DATE], to contact the Oncologist to seek further direction. The Administrator stated he went to Resident #2's unit on [DATE], after staff raised questions regarding the availability of the Afinitor; however, he did not inform staff at that time the facility did not approve the medication for delivery due to cost, nor did he instruct staff to call the physician to inform him the medication was not available and seek further direction. He stated he was not opposed to the request for a three (3) to four (4) day supply; however, he made the decision to wait until [DATE], due to the holiday week, to determine if the insurance company would cover more of the cost. According to the Administrator, he was ultimately responsible for the care and services the residents received in the facility. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], the Unit Managers (UM), Staff Development Coordinator (SDC), Medical Records Director, and Regional Support Staff (RSS) completed a one-time review of resident admissions from [DATE] to [DATE], in order to determine compliance with physician orders [REDACTED]. The facility shared the one-time review of admission information with members of the Interdisciplinary Team. 2. The facility assessed all new admits for [MEDICAL CONDITION] treatment medications to determine if the Immediate Jeopardy identified on [DATE], could affect them. No additional newly admitted residents were noted [MEDICAL CONDITION] treating medications prescribed. 3. On [DATE], the Administrator, Assistant Director of Nursing (ADON), Medical Director, and RSS made the determination policy and procedures, related to the immediate jeopardy, did not require revisions. 4. The UMs, SDC, Administrator, and RSS initiated re-education of the Licensed Nursing Staff, Certified Medication Technicians, and Non-Facility Personnel on [DATE], regarding medication administration and notification of the physician, resident, and family of a decision to withhold resident medication. In addition, staff was re-educated on the development and implementation of the baseline care plan, to include goals and interventions. The facility currently employed twelve (12) Licensed Nurses and one (1) Certified Medication Technician. Any Licensed Nurse who had not completed the re-education by 11:59 PM on [DATE], would receive the re-education at the time of their next scheduled shift. 5. The SDC would educate newly hired nurses and certified medication technicians during the orientation process. 6. The Director of Nursing (DON), Administrator, ADON, UM, Minimum Data Set (MDS) Coordinator, SDC, or RSS would conduct audits beginning [DATE], of new admissions to monitor for the ordering and obtaining of medications, per the physician order, three (3) times a week for eight (8) weeks, then once a week for four (4) weeks, then monthly. Any issues noted by the facility during the auditing process would be immediately corrected with one-on-one re-education and/up to disciplinary action as deemed necessary. 7. The DON, Administrator, ADON, UM, MDS Coordinator, SDC, or RSS would be responsible for conducting audits beginning [DATE], regarding compliance with the initiation of the baseline care plan at the time of admission, three (3) times a week for eight (8) weeks, then once a week for four (4) weeks, then monthly. Any issues noted by the facility during the auditing process would be immediately corrected with one-on-one re-education and/up to disciplinary action as deemed necessary. 8. The DON, Administrator, ADON, UM, MDS Coordinator, SDC, or RSS would be responsible for conducting audits beginning [DATE], for the provision [MEDICAL CONDITION] treatments as the time of admission three (3) times a week for eight (8) weeks, then once a week for four (4) weeks, then monthly. Any issues noted by the facility during the auditing process would be immediately corrected with one-on-one re-education and/up to disciplinary action as deemed necessary. 9. The Administrator, DON, or RSS would be responsible for reviewing the results of the audits. 10. The Regional Director of Special Projects re-educated the Interdisciplinary Team (IDT) on [DATE], regarding administrative roles and responsibilities. The IDT consisted of the Administrator, DON, Admissions, ADON, SDC, UM, Social Services (SS), Business Office Manager (BOM), MDS Coordinator, and Rehabilitation Services Manager (RSM). 11. The facility held an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting on [DATE], with the Medical Director, Administrator, DON, ADON, Medical Records, BOM, Maintenance, Admissions, Housekeeping Manager, Rehabilitation Services Manager, and the Regional Director of Clinical Operations to review the statement of deficiencies, corrective actions taken, and results of the audits performed. 12. On [DATE], the Regional Vice President of Operations (VPO) reviewed with the Administrator the Administrator Job description and responsibilities. The VPO discussed with the Administrator the role of ensuring resources were available to provide for the needs of the resident, which included medications and other services. 13. On [DATE], the Regional Vice President of Operations (VPO) met with the Administrator and the DON to validate the facility's Allegation of Compliance. These meetings would continue weekly until the immediacy of the jeopardy was lifted and substantial compliance was achieved. 14. The facility Administrator would present all findings of the audits to the QAPI committee monthly for three months (3), then quarterly thereafter for further recommendations and follow up. 15. The Administrator would oversee the QAPI committee meeting in conjunction with the DON and Medical Director. The State Survey Agency validated the removal of Immediate Jeopardy on [DATE] prior to exit as follows: 1. Interview with the Staff Development Coordinator (SDC), on [DATE] at 1:41 PM, and the Unit Manager (UM), on [DATE] at 10:20 AM, revealed the facility reviewed resident admission orders [REDACTED]. Interview with the Minimum Data Set (MDS) Coordinator, on [DATE] at 9:24 AM, revealed she was on the IDT. She stated the team reviewed the information from the one-time review of resident admissions to determine if the facility had administered medications as ordered and there were no identified issues found from the review. Interview with the Social Services Director (SSD), on [DATE] at 10:15 AM, and the Medical Records Director (MRD), on [DATE] at 10:00 AM, revealed they were on the Interdisciplinary Team (IDT). The SSD and MRD stated they reviewed the information obtained from the one-time review of resident admissions, from [DATE] to [DATE], and determined the facility had administered medications as ordered. Record review revealed the facility reviewed resident admission orders [REDACTED]. Review of Unsampled Resident I's medical record revealed the facility admitted the resident on [DATE] and readmitted the resident on [DATE]. The medication orders from the hospital's discharge summary, dated [DATE], corresponded with both the medication orders listed on the Physician order [REDACTED]. Review of Unsampled Resident N's medical record revealed the facility admitted the resident on [DATE]. Medication orders listed on the POS, dated [DATE], and the medication orders on the Medication Administration Record [REDACTED]. 2. Interview with the Administrator, on [DATE] at 3:00 PM, revealed the facility did not have residents in the facility [MEDICAL CONDITION] treatment medications. Interview with the Director of Nursing (DON), on [DATE] at 9:35 AM, revealed the facility did not have a resident in the facility [MEDICAL CONDITION] treatment medications. Review of an untitled typed statement, dated [DATE], revealed as of the alleged compliance date of [DATE], the facility had not admitted or readmitted residents with orders [MEDICAL CONDITION] related medications. 3. Interview with the Administrator, on [DATE] at 8:30 AM, and the Regional Support Staff (RSS), on [DATE] at 2:45 PM, revealed the facility reviewed policies and procedures related to Physician Notification, Care Plan Development, and Medication Administration, and determined revisions to the polices were not necessary. 4. Interview with Registered Nurse (RN) #4, on [DATE] at 3:00 PM, revealed she was trained on medication, change of condition, and care plans. She stated care plans should be individualized with new information passed on to the CNAs. RN #4 stated she would call the pharmacy if a medication was not available and STAT (immediate) medications would be delivered within one (1) hour. She revealed if she was unable to obtain the medication, the resident's physician and family would be notified. Interview with RN #1, on [DATE] at 8:45 AM, revealed she was trained on documentation, updating care plans, and physician notification. She stated the procedure for pre-authorization of medications included contacting the pharmacy and receiving an approval number. She had never experienced an instance where a medication was not approved. Interview with Licensed Practical Nurse (LPN) #7, on [DATE] 8:30 AM, revealed the facility recently educated her on medication administration, change of condition, and medication changes. She stated she was trained to notify the physician, resident (when applicable), family, and manager any time a resident reacted to, refused, or missed a medication dose and if they had a change in condition. LPN #7 stated she was educated to review the resident care plans each shift, make changes when applicable, and inform her manager if revisions were necessary. Interview with the MDS Coordinator, on [DATE] at 9:24 AM, revealed the facility trained her to provide training to the staff on physician, family, and resident notification, medication administration, and care plan development and implementation. Interview with CNA #5, on [DATE] at 2:50 PM, revealed she kept a copy of the care plan with her on the floor. She stated the care plans were developed by nursing staff in the care planning meetings when residents were first admitted . If the resident had a change of condition, she stated she would fill out a Stop and Watch form and tell the nurse. The form was then signed by the nurse to prove the CNA informed them of the change. CNA #5 stated the Unit Manager and the nurses kept care plans updated. Review of facility's In-Service Attendance Sheets revealed staff re-education began on [DATE], and education continued on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The facility trained Licensed Nursing Staff and Certified Medication Technicians on physician, family, and resident notification, care plan development, and medication administration. Record review revealed the facility used the policy, Medication Administration, dated (MONTH) (YEAR), to re-educate Licensed Nursing Staff and Medication Technicians. Continued review revealed the facility used an undated document, Baseline Care Plan Process, to re-educate the Licensed Nursing Staff. The goal stated the facility would meet newly admitted and/or readmitted resident care needs. During the admission process, staff would complete all required assessments and based on those assessments, would create a care plan for the identified high-risk areas. Review of the Employee Listing Payroll Services document, dated (MONTH) (YEAR), revealed the facility employed twelve (12) licensed nursing staff and one (1) Certified Medication Technician. Review of the facility's In-Service Attendance Sheets, dated [DATE], [DATE], and [DATE], revealed staff assigned to work after [DATE], received training prior to their shift. 5. Interview with LPN #6, on [DATE] at 3:45 PM, revealed she was an agency nurse and the facility recently educated her regarding physician notification, care plan development, and medication administration prior to her beginning her shift. She stated all new orders required notification of resident and family, and nursing staff must document their notifications. She stated the facility kept a copy of the resident care plans on each medication cart and she signed the plans each shift to show she had reviewed them for potential revisions. Interview with the SDC, on [DATE] at 1:41 PM, revealed she scheduled agency staff to come in one (1) hour prior to the beginning of their shift in order for the staff member to receive training on physician, family, and resident notification, care plan development, and medication administration. She stated new hires would receive the training in orientation; however, the facility had not conducted new hire orientation as of yet. 6. Interview with LPN #7, on [DATE] at 8:30 AM, revealed she would notify the physician, resident, and family if she could not administer a resident's medication. She stated she readmitted Unsampled Resident I to the facility on [DATE], and after she had processed the admission, her Unit Manager and Corporate Nurses reviewed all the medications and orders for accuracy. She stated the Unit Manager and Corporate Nurses performed the audit of her documentation and did not find any issues. Interview with the DON, on [DATE] at 9:35 AM, revealed she assisted with auditing the medical records and found no concerns requiring corrective action. Review of Plan of Correction Auditing Form for Physician Notification, not dated, revealed no new resident admissions had occurred. The facility conducted random medical record audits three (3) times a week to determine compliance with physician notification related to a medication order or compliance with obtaining medication per the physician order. The facility began audits on [DATE], and audits continued on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The facility audited residents' medical records for compliance after re-admission from a hospitalization on [DATE] and [DATE]. No identified concerns were noted. 7. Interview with the SDC, on [DATE] at 1:41 PM, revealed she assisted with conducting audits three (3) times a week and had not identified concerns with care plan audits. Review of Unsampled Resident G's Care Plan, undated, revealed the facility developed and implemented interventions to meet the resident's care needs. Interview with Unsampled Resident G, on [DATE] at 2:30 PM, revealed the resident had no concerns with medication administration and staff kept him/her informed of changes in his/her plan of care. Review of a Plan of Correction Auditing Form, not dated, for the initiation of the Baseline Care Plan upon admission, revealed no new resident admissions had occurred. Continued review revealed the facility conducted random medical record audits three (3) times a week, to include residents readmitted after a hospitalization . The facility began the audits on [DATE] and continued the audits on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], to determine compliance with initiation of the Baseline Care Plan development. No identified concerns were noted requiring corrective action. 8. Interview with RN #1, on [DATE] at 3:25 PM, revealed management was conducting audits of resident medical records to determine if residents had orders [MEDICAL CONDITION] treatment and to determine if nursing staff administered medications as ordered. She stated she did not know of any resident that had orders [MEDICAL CONDITION] treatment drugs. Interview with the Unit Manager, on [DATE] at 10:20 AM, revealed she assisted with conducting audits three (3) times a week and found no concerns that required corrective action. Review of a Plan of Correction Auditing Form, not dated, regarding the provision [MEDICAL CONDITION] treatments per the physician order [REDACTED]. Continued review revealed the facility conducted random audits three (3) times a week of resident medical records to include residents readmitted after a hospitalization . The facility conducted audits on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. No identified concerns were noted which required corrective action. Review of the clinical record for Unsampled Resident G revealed all of the medications listed on the Medication Administration Record [REDACTED]. Continued Review of the MAR indicated [REDACTED]. 9. Interview with the RSS, on [DATE] at 2:45 PM, revealed she reviewed the audit forms for completion and for issues needing corrective action. She stated she discussed the findings with the Interdisciplinary Team, which included the Administrator and DON. She stated audits were conducted three (3) times a week as planned, and no issues were identified that required corrective action. Review of a Plan of Correction Auditing Form, not dated, regarding physician notification, baseline care plans, [MEDICAL CONDITION] treatment services revealed the RSS reviewed the audit forms. 10. Interview with the Rehabilitation Services Manager, on [DATE] at 11:00 AM, and Social Services, on [DATE] at 10:15 AM, revealed the Regional Director of Special Projects re-educated them on their roles and responsibilities in regards to meeting resident care needs. Interview with the Admissions Director, on [DATE] at 2:00 PM, and SDC, on [DATE] at 1:41 PM, revealed the Regional Director of Special Projects met with the IDT on [DATE], to provide re-education regarding the team's roles and responsibility to ensure residents received the care and services ordered by the physician. Interview with the Regional Director of Special Projects, on [DATE] at 3:00 PM, revealed he had re-educated the IDT on their administrative roles and responsibilities regarding care plan development, physician, family and resident notification, and medication administration. 11. Interview, on [DATE] at 8:03 AM, with the Medical Director revealed he had attended the Ad Hoc Quality Assurance meeting held on [DATE]. He stated the facility audits were discussed and other actions taken to ensure compliance with medication administration, notification, and care plan implementation. He stated no concerns were identified requiring corrective action. Interview with the Director of Housekeeping, on [DATE] at 9:04 AM, and the Medical Records Director, on [DATE] at 10:00 AM, revealed they attended the [DATE] QAPI committee meeting. They stated the committee discussed the facility's compliance with medication administration, physician notification, and care plan implementation, along with facility audits. They stated no identified concerns were noted. Review of the Ad Hoc Quality Assurance sign in sheet, dated [DATE], revealed the Medical Director, Administrator, DON, ADON, Medical Records, BOM, Maintenance, Admissions, Housekeeping Manager, Rehabilitation Services Manager, and the Regional Director of Clinical Operations attended the meeting. 12. Interview with the Administrator, on [DATE] at 9:05 AM, revealed the Vice President of Operations (VPO) re-educated him on [DATE], regarding his job description and role as an administrator. He stated the VPO instructed him to approve medication, regardless of cost, when pharmacy requested payment approval. He stated the facility must ensure resident's needs were met. Interview with the VPO, on [DATE] at 9:26 AM, revealed he re-educated the Administrator on [DATE], regarding his job description and responsibilities to ensure resident care needs were met. The VPO stated he instructed the Administrator to approve medication, regardless of cost, when pharmacy requested a payment approval. 13. Interview with the Administrator, on [DATE] at 9:05 AM, and the DON, on [DATE] at 9:35 AM, revealed the VPO met with them on [DATE], to validate the Allegation of Compliance (A[NAME]). They stated the plan was to meet weekly on Thursday until the abatement of the Immediate Jeopardy and substantial compliance was achieved. Interview with the VPO, on [DATE] at 9:26 AM, revealed he met with the Administrator and DON on [DATE], to validate the facility's compliance with the A[NAME]. He stated he would meet with weekly until the abatement of the immediate jeopardy and substantial compliance was achieved. Review of the Meeting with Administrator and DON form, dated [DATE], revealed the VPO met with the Administrator and DON to validate compliance with the A[NAME]. The form stated the VPO would continue to meet with them weekly on Thursday until the abatement of immediate jeopardy and substantial compliance was achieved. 14. Interview with the Administrator, on [DATE] at 9:05 AM, and the DON, on [DATE] at 9:35 AM, revealed all audits would be presented to the QAPI committee monthly for three (3) months, then quarterly thereafter for further recommendations and follow up. 15. Interview with the Administrator, on [DATE] at 9:05 AM, the DON, on [DATE] at 9:35 AM, and with the Medical Director, on [DATE] at 8:03 AM, revealed they would oversee the QAPI committee process.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure care and treatment services [MEDICAL CONDITION] was provided for one (1) of three (3) sampled residents, Resident #2. Resident #2 had a physician order, dated [DATE], to receive Afinitor (cancer treatment medication); however, the facility made the decision to put a hold on the medication due to the cost. The facility failed to inform the physician of the cost in order to determine if another medication could be substituted, resulting in [MEDICAL CONDITION] treatment medication not being administered to the resident. On [DATE], Resident #2 experienced a decline while at the nursing facility, which required a transfer to an acute care hospital. The resident expired on [DATE] due to [MEDICAL CONDITION], Hepatic Failure, Acute [MEDICAL CONDITION], and Metastatic [MEDICAL CONDITION]. The facility's failure to have an effective system in place to ensure the resident's choice to [MEDICAL CONDITION] treatment medications has caused or is likely to cause serious injury, harm, impairment, or death. The Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE]. The facility was notified on [DATE]. The facility submitted an acceptable Allegation of Compliance (AoC) on [DATE] alleging the removal of Immediate Jeopardy on [DATE]. The State Survey Agency validated the Immediate Jeopardy was removed on [DATE] as alleged, prior to exit on [DATE], with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy, Ordering and Receiving Medications, dated (MONTH) 2010, revealed medications and related products were received from the provider pharmacy on a timely basis. If the resident's first dose of medication was scheduled to be given before the next regularly scheduled pharmacy delivery, staff should telephone or transmit the medication orders to the pharmacy immediately upon receipt. Staff was to inform the pharmacy of the need for prompt delivery. Timely delivery of new medication orders was required so that medication administration was not delayed. Staff would promptly report discrepancies and omissions to the issuing pharmacy and the charge nurse or supervisor. Review of the facility's policy, Resident Rights, not dated, revealed the resident had the right to participate in healthcare decisions and care planning. Review of the facility's policy, Care Plans-Comprehensive, not dated, revealed each resident had the right to participate in choosing treatment options and would be given the opportunity to participate in the development, review, and revision of their plan of care. Review of Resident #2's closed clinical record revealed the facility originally admitted the resident [DATE] and readmitted the resident on [DATE], with [DIAGNOSES REDACTED]. In addition, a history of [MEDICAL CONDITION] with a new [DIAGNOSES REDACTED]. Review of Resident #1's admission Minimum Data Set, dated dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status score of fifteen (15) out of fifteen (15) and determined the resident interviewable. Review of Resident #2's Physician Order, dated [DATE], revealed the physician ordered Afinitor 10 milligrams, one (1) tablet administered by mouth daily at 9:00 AM. However, review of Resident #2's Medication Administration Record [REDACTED]. Review of Resident #2's Interim Admission Care Plan, dated [DATE], revealed nursing staff did not develop goals or staff interventions related to the resident'[MEDICAL CONDITION] metastasis. Continued review of Resident #2's Interim Admission plan of care revealed no evidence nursing staff developed interventions directing staff to administer the physician ordered medication, Afinitor, to ensure the resident'[MEDICAL CONDITION] treatment needs were met. Interview, on [DATE] at 4:00 PM, with the Oncology Physician, revealed Resident #2 experienced a decline while at the nursing facility, which required a transfer to an acute care hospital. He stated it was not in the best interest of Resident #2 for the facility not to administer [MEDICAL CONDITION] treatment medication, Afinitor. He stated after hospitalization , the resident rapidly expired from [MEDICAL CONDITION]. Interview with Licensed Practical Nurse (LPN) #2, on [DATE] at 12:13 PM, revealed on [DATE], Resident #2 returned to the facility after hospitalization with medication orders including Afinitor, [MEDICAL CONDITION] treatment drug. She stated she obtained orders, from the facility's physician, that included the Afinitor, and sent the orders to the pharmacy. LPN #2 stated the pharmacy informed her the Director of Nursing must approve the Afinitor prior to delivery due to the cost of the medication. She stated the Unit Manager told her the facility was not going to approve the medication due to the cost, as the cost was eight thousand dollars ($8,000) for a fourteen (14) day supply. The facility did not notify Resident #2 or the physician of the decision not to approve the delivery/administration of the medication. Interview with the Pharmacist, on [DATE] at 10:30 AM, revealed on [DATE], the facility sent an order to the pharmacy for Resident #2's Afinitor. She stated due to the resident's insurance coverage, a seven (7) day supply of the Afinitor would cost the facility four thousand one hundred and forty-five dollars ($4145). The Pharmacist stated due to the cost, there was required approval needed from the Director of Nursing prior to delivery. She stated the pharmacy did not deliver Afinitor to the facility because the Interim Director of Nursing canceled the prescription. Attempted interview with the Interim Director of Nursing at the time Resident #2 was in the facility, on [DATE] at 3:38 PM and [DATE] at 12:59 PM, via telephone, was unsuccessful. Interview with the Unit Manager of the Blue Unit where the resident resided, on [DATE] at 2:55 PM, revealed she identified on [DATE], three (3) days after the medication had been ordered, Resident #2's Afinitor was not available and she informed the resident on [DATE], the facility had not administered the Afinitor to him/her as ordered by the Oncologist. The Unit Manager stated the resident told her he/she wanted to fight [MEDICAL CONDITION] and thought the facility was administering [MEDICAL CONDITION] treatment drug. The Unit Manager stated she spoke with the Administrator on [DATE], and was told the medication was too expensive to order and the facility would try to contact the Oncology Physician regarding the medication on [DATE], six (6) days after the medication had been ordered. She stated she tried to get an approval for a three (3) or four (4) day supply of the Afinitor; however, the Administrator denied the request because five hundred dollars ($500) to eight hundred dollars ($800) per pill would be charged to the facility. She stated the Administrator told her to contact the physician to see if there was another less expensive medication to treat Resident #2'[MEDICAL CONDITION]. However, when she went back to the unit, Resident #2 was not feeling well and requested a transfer to the hospital. The Unit Manager stated the facility did not administer the Afinitor on [DATE], [DATE], or [DATE], and in order to meet resident care needs, the facility should had administered the medication as ordered. Interview, on [DATE] at 4:55 PM, with the Interim Director of Nursing (DON), revealed she was not the DON during Resident #2's stay at the facility. The DON stated she was not aware of the incident regarding Resident #2's Afinitor medication denial. The DON stated if a physician ordered a medication that was not part of the facility's formulary and required her approval, she would call the physician to determine if another medication could be substituted, and if not, she would approve the medication. The DON stated it was important for the facility to take care of residents' cancer treatment needs, regardless of medication cost. Interview with the Administrator, on [DATE] at 10:30 AM and 4:00 PM, revealed he called the pharmacist to determine if Resident #2'[MEDICAL CONDITION] treatment medication, Afinitor, was on the facility's formulary for covered medications, and found out it was not and he decided to put a hold order on the medication due to cost. He stated it was Thanksgiving holiday week and he chose to wait until [DATE], to contact the Oncologist to seek further direction. The Administrator stated he went to Resident #2's unit on [DATE], after staff raised questions regarding the availability of the Afinitor; however, he did not inform staff at that time the facility did not approve the medication for delivery due to cost, nor did he instruct staff to call the physician to inform him the medication was not available and seek further direction. He stated he was not opposed to the request for a three (3) to four (4) day supply; however, he made the decision to wait until [DATE], due to the holiday week, to determine if the insurance company would cover more of the cost. According to the Administrator, he was ultimately responsible for the care and services the residents received in the facility. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], the Unit Managers (UM), Staff Development Coordinator (SDC), Medical Records Director, and Regional Support Staff (RSS) completed a one-time review of resident admissions from [DATE] to [DATE], in order to determine compliance with physician orders [REDACTED]. The facility shared the one-time review of admission information with members of the Interdisciplinary Team. 2. The facility assessed all new admits for [MEDICAL CONDITION] treatment medications to determine if the Immediate Jeopardy identified on [DATE], could affect them. No additional newly admitted residents were noted [MEDICAL CONDITION] treating medications prescribed. 3. On [DATE], the Administrator, Assistant Director of Nursing (ADON), Medical Director, and RSS made the determination policy and procedures, related to the immediate jeopardy, did not require revisions. 4. The UMs, SDC, Administrator, and RSS initiated re-education of the Licensed Nursing Staff, Certified Medication Technicians, and Non-Facility Personnel on [DATE], regarding medication administration and notification of the physician, resident, and family of a decision to withhold resident medication. In addition, staff was re-educated on the development and implementation of the baseline care plan, to include goals and interventions. The facility currently employed twelve (12) Licensed Nurses and one (1) Certified Medication Technician. Any Licensed Nurse who had not completed the re-education by 11:59 PM on [DATE], would receive the re-education at the time of their next scheduled shift. 5. The SDC would educate newly hired nurses and certified medication technicians during the orientation process. 6. The Director of Nursing (DON), Administrator, ADON, UM, Minimum Data Set (MDS) Coordinator, SDC, or RSS would conduct audits beginning [DATE], of new admissions to monitor for the ordering and obtaining of medications, per the physician order, three (3) times a week for eight (8) weeks, then once a week for four (4) weeks, then monthly. Any issues noted by the facility during the auditing process would be immediately corrected with one-on-one re-education and/up to disciplinary action as deemed necessary. 7. The DON, Administrator, ADON, UM, MDS Coordinator, SDC, or RSS would be responsible for conducting audits beginning [DATE], regarding compliance with the initiation of the baseline care plan at the time of admission, three (3) times a week for eight (8) weeks, then once a week for four (4) weeks, then monthly. Any issues noted by the facility during the auditing process would be immediately corrected with one-on-one re-education and/up to disciplinary action as deemed necessary. 8. The DON, Administrator, ADON, UM, MDS Coordinator, SDC, or RSS would be responsible for conducting audits beginning [DATE], for the provision [MEDICAL CONDITION] treatments as the time of admission three (3) times a week for eight (8) weeks, then once a week for four (4) weeks, then monthly. Any issues noted by the facility during the auditing process would be immediately corrected with one-on-one re-education and/up to disciplinary action as deemed necessary. 9. The Administrator, DON, or RSS would be responsible for reviewing the results of the audits. 10. The Regional Director of Special Projects re-educated the Interdisciplinary Team (IDT) on [DATE], regarding administrative roles and responsibilities. The IDT consisted of the Administrator, DON, Admissions, ADON, SDC, UM, Social Services (SS), Business Office Manager (BOM), MDS Coordinator, and Rehabilitation Services Manager (RSM). 11. The facility held an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting on [DATE], with the Medical Director, Administrator, DON, ADON, Medical Records, BOM, Maintenance, Admissions, Housekeeping Manager, Rehabilitation Services Manager, and the Regional Director of Clinical Operations to review the statement of deficiencies, corrective actions taken, and results of the audits performed. 12. On [DATE], the Regional Vice President of Operations (VPO) reviewed with the Administrator the Administrator Job description and responsibilities. The VPO discussed with the Administrator the role of ensuring resources were available to provide for the needs of the resident, which included medications and other services. 13. On [DATE], the Regional Vice President of Operations (VPO) met with the Administrator and the DON to validate the facility's Allegation of Compliance. These meetings would continue weekly until the immediacy of the jeopardy was lifted and substantial compliance was achieved. 14. The facility Administrator would present all findings of the audits to the QAPI committee monthly for three months (3), then quarterly thereafter for further recommendations and follow up. 15. The Administrator would oversee the QAPI committee meeting in conjunction with the DON and Medical Director. The State Survey Agency validated the removal of Immediate Jeopardy on [DATE] prior to exit as follows: 1. Interview with the Staff Development Coordinator (SDC), on [DATE] at 1:41 PM, and the Unit Manager (UM), on [DATE] at 10:20 AM, revealed the facility reviewed resident admission orders [REDACTED]. Interview with the Minimum Data Set (MDS) Coordinator, on [DATE] at 9:24 AM, revealed she was on the IDT. She stated the team reviewed the information from the one-time review of resident admissions to determine if the facility had administered medications as ordered and there were no identified issues found from the review. Interview with the Social Services Director (SSD), on [DATE] at 10:15 AM, and the Medical Records Director (MRD), on [DATE] at 10:00 AM, revealed they were on the Interdisciplinary Team (IDT). The SSD and MRD stated they reviewed the information obtained from the one-time review of resident admissions, from [DATE] to [DATE], and determined the facility had administered medications as ordered. Record review revealed the facility reviewed resident admission orders [REDACTED]. Review of Unsampled Resident I's medical record revealed the facility admitted the resident on [DATE] and readmitted the resident on [DATE]. The medication orders from the hospital's discharge summary, dated [DATE], corresponded with both the medication orders listed on the Physician order [REDACTED]. Review of Unsampled Resident N's medical record revealed the facility admitted the resident on [DATE]. Medication orders listed on the POS, dated [DATE], and the medication orders on the Medication Administration Record [REDACTED]. 2. Interview with the Administrator, on [DATE] at 3:00 PM, revealed the facility did not have residents in the facility [MEDICAL CONDITION] treatment medications. Interview with the Director of Nursing (DON), on [DATE] at 9:35 AM, revealed the facility did not have a resident in the facility [MEDICAL CONDITION] treatment medications. Review of an untitled typed statement, dated [DATE], revealed as of the alleged compliance date of [DATE], the facility had not admitted or readmitted residents with orders [MEDICAL CONDITION] related medications. 3. Interview with the Administrator, on [DATE] at 8:30 AM, and the Regional Support Staff (RSS), on [DATE] at 2:45 PM, revealed the facility reviewed policies and procedures related to Physician Notification, Care Plan Development, and Medication Administration, and determined revisions to the polices were not necessary. 4. Interview with Registered Nurse (RN) #4, on [DATE] at 3:00 PM, revealed she was trained on medication, change of condition, and care plans. She stated care plans should be individualized with new information passed on to the CNAs. RN #4 stated she would call the pharmacy if a medication was not available and STAT (immediate) medications would be delivered within one (1) hour. She revealed if she was unable to obtain the medication, the resident's physician and family would be notified. Interview with RN #1, on [DATE] at 8:45 AM, revealed she was trained on documentation, updating care plans, and physician notification. She stated the procedure for pre-authorization of medications included contacting the pharmacy and receiving an approval number. She had never experienced an instance where a medication was not approved. Interview with Licensed Practical Nurse (LPN) #7, on [DATE] 8:30 AM, revealed the facility recently educated her on medication administration, change of condition, and medication changes. She stated she was trained to notify the physician, resident (when applicable), family, and manager any time a resident reacted to, refused, or missed a medication dose and if they had a change in condition. LPN #7 stated she was educated to review the resident care plans each shift, make changes when applicable, and inform her manager if revisions were necessary. Interview with the MDS Coordinator, on [DATE] at 9:24 AM, revealed the facility trained her to provide training to the staff on physician, family, and resident notification, medication administration, and care plan development and implementation. Interview with CNA #5, on [DATE] at 2:50 PM, revealed she kept a copy of the care plan with her on the floor. She stated the care plans were developed by nursing staff in the care planning meetings when residents were first admitted . If the resident had a change of condition, she stated she would fill out a Stop and Watch form and tell the nurse. The form was then signed by the nurse to prove the CNA informed them of the change. CNA #5 stated the Unit Manager and the nurses kept care plans updated. Review of facility's In-Service Attendance Sheets revealed staff re-education began on [DATE], and education continued on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The facility trained Licensed Nursing Staff and Certified Medication Technicians on physician, family, and resident notification, care plan development, and medication administration. Record review revealed the facility used the policy, Medication Administration, dated (MONTH) (YEAR), to re-educate Licensed Nursing Staff and Medication Technicians. Continued review revealed the facility used an undated document, Baseline Care Plan Process, to re-educate the Licensed Nursing Staff. The goal stated the facility would meet newly admitted and/or readmitted resident care needs. During the admission process, staff would complete all required assessments and based on those assessments, would create a care plan for the identified high-risk areas. Review of the Employee Listing Payroll Services document, dated (MONTH) (YEAR), revealed the facility employed twelve (12) licensed nursing staff and one (1) Certified Medication Technician. Review of the facility's In-Service Attendance Sheets, dated [DATE], [DATE], and [DATE], revealed staff assigned to work after [DATE], received training prior to their shift. 5. Interview with LPN #6, on [DATE] at 3:45 PM, revealed she was an agency nurse and the facility recently educated her regarding physician notification, care plan development, and medication administration prior to her beginning her shift. She stated all new orders required notification of resident and family, and nursing staff must document their notifications. She stated the facility kept a copy of the resident care plans on each medication cart and she signed the plans each shift to show she had reviewed them for potential revisions. Interview with the SDC, on [DATE] at 1:41 PM, revealed she scheduled agency staff to come in one (1) hour prior to the beginning of their shift in order for the staff member to receive training on physician, family, and resident notification, care plan development, and medication administration. She stated new hires would receive the training in orientation; however, the facility had not conducted new hire orientation as of yet. 6. Interview with LPN #7, on [DATE] at 8:30 AM, revealed she would notify the physician, resident, and family if she could not administer a resident's medication. She stated she readmitted Unsampled Resident I to the facility on [DATE], and after she had processed the admission, her Unit Manager and Corporate Nurses reviewed all the medications and orders for accuracy. She stated the Unit Manager and Corporate Nurses performed the audit of her documentation and did not find any issues. Interview with the DON, on [DATE] at 9:35 AM, revealed she assisted with auditing the medical records and found no concerns requiring corrective action. Review of Plan of Correction Auditing Form for Physician Notification, not dated, revealed no new resident admissions had occurred. The facility conducted random medical record audits three (3) times a week to determine compliance with physician notification related to a medication order or compliance with obtaining medication per the physician order. The facility began audits on [DATE], and audits continued on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The facility audited residents' medical records for compliance after re-admission from a hospitalization on [DATE] and [DATE]. No identified concerns were noted. 7. Interview with the SDC, on [DATE] at 1:41 PM, revealed she assisted with conducting audits three (3) times a week and had not identified concerns with care plan audits. Review of Unsampled Resident G's Care Plan, undated, revealed the facility developed and implemented interventions to meet the resident's care needs. Interview with Unsampled Resident G, on [DATE] at 2:30 PM, revealed the resident had no concerns with medication administration and staff kept him/her informed of changes in his/her plan of care. Review of a Plan of Correction Auditing Form, not dated, for the initiation of the Baseline Care Plan upon admission, revealed no new resident admissions had occurred. Continued review revealed the facility conducted random medical record audits three (3) times a week, to include residents readmitted after a hospitalization . The facility began the audits on [DATE] and continued the audits on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], to determine compliance with initiation of the Baseline Care Plan development. No identified concerns were noted requiring corrective action. 8. Interview with RN #1, on [DATE] at 3:25 PM, revealed management was conducting audits of resident medical records to determine if residents had orders [MEDICAL CONDITION] treatment and to determine if nursing staff administered medications as ordered. She stated she did not know of any resident that had orders [MEDICAL CONDITION] treatment drugs. Interview with the Unit Manager, on [DATE] at 10:20 AM, revealed she assisted with conducting audits three (3) times a week and found no concerns that required corrective action. Review of a Plan of Correction Auditing Form, not dated, regarding the provision [MEDICAL CONDITION] treatments per the physician order [REDACTED]. Continued review revealed the facility conducted random audits three (3) times a week of resident medical records to include residents readmitted after a hospitalization . The facility conducted audits on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. No identified concerns were noted which required corrective action. Review of the clinical record for Unsampled Resident G revealed all of the medications listed on the Medication Administration Record [REDACTED]. Continued Review of the MAR indicated [REDACTED]. 9. Interview with the RSS, on [DATE] at 2:45 PM, revealed she reviewed the audit forms for completion and for issues needing corrective action. She stated she discussed the findings with the Interdisciplinary Team, which included the Administrator and DON. She stated audits were conducted three (3) times a week as planned, and no issues were identified that required corrective action. Review of a Plan of Correction Auditing Form, not dated, regarding physician notification, baseline care plans, [MEDICAL CONDITION] treatment services revealed the RSS reviewed the audit forms. 10. Interview with the Rehabilitation Services Manager, on [DATE] at 11:00 AM, and Social Services, on [DATE] at 10:15 AM, revealed the Regional Director of Special Projects re-educated them on their roles and responsibilities in regards to meeting resident care needs. Interview with the Admissions Director, on [DATE] at 2:00 PM, and SDC, on [DATE] at 1:41 PM, revealed the Regional Director of Special Projects met with the IDT on [DATE], to provide re-education regarding the team's roles and responsibility to ensure residents received the care and services ordered by the physician. Interview with the Regional Director of Special Projects, on [DATE] at 3:00 PM, revealed he had re-educated the IDT on their administrative roles and responsibilities regarding care plan development, physician, family and resident notification, and medication administration. 11. Interview, on [DATE] at 8:03 AM, with the Medical Director revealed he had attended the Ad Hoc Quality Assurance meeting held on [DATE]. He stated the facility audits were discussed and other actions taken to ensure compliance with medication administration, notification, and care plan implementation. He stated no concerns were identified requiring corrective action. Interview with the Director of Housekeeping, on [DATE] at 9:04 AM, and the Medical Records Director, on [DATE] at 10:00 AM, revealed they attended the [DATE] QAPI committee meeting. They stated the committee discussed the facility's compliance with medication administration, physician notification, and care plan implementation, along with facility audits. They stated no identified concerns were noted. Review of the Ad Hoc Quality Assurance sign in sheet, dated [DATE], revealed the Medical Director, Administrator, DON, ADON, Medical Records, BOM, Maintenance, Admissions, Housekeeping Manager, Rehabilitation Services Manager, and the Regional Director of Clinical Operations attended the meeting. 12. Interview with the Administrator, on [DATE] at 9:05 AM, revealed the Vice President of Operations (VPO) re-educated him on [DATE], regarding his job description and role as an administrator. He stated the VPO instructed him to approve medication, regardless of cost, when pharmacy requested payment approval. He stated the facility must ensure resident's needs were met. Interview with the VPO, on [DATE] at 9:26 AM, revealed he re-educated the Administrator on [DATE], regarding his job description and responsibilities to ensure resident care needs were met. The VPO stated he instructed the Administrator to approve medication, regardless of cost, when pharmacy requested a payment approval. 13. Interview with the Administrator, on [DATE] at 9:05 AM, and the DON, on [DATE] at 9:35 AM, revealed the VPO met with them on [DATE], to validate the Allegation of Compliance (A[NAME]). They stated the plan was to meet weekly on Thursday until the abatement of the Immediate Jeopardy and substantial compliance was achieved. Interview with the VPO, on [DATE] at 9:26 AM, revealed he met with the Administrator and DON on [DATE], to validate the facility's compliance with the A[NAME]. He stated he would meet with weekly until the abatement of the immediate jeopardy and substantial compliance was achieved. Review of the Meeting with Administrator and DON form, dated [DATE], revealed the VPO met with the Administrator and DON to validate compliance with the A[NAME]. The form stated the VPO would continue to meet with them weekly on Thursday until the abatement of immediate jeopardy and substantial compliance was achieved. 14. Interview with the Administrator, on [DATE] at 9:05 AM, and the DON, on [DATE] at 9:35 AM, revealed all audits would be presented to the QAPI committee monthly for three (3) months, then quarterly thereafter for further recommendations and follow up. 15. Interview with the Administrator, on [DATE] at 9:05 AM, the DON, on [DATE] at 9:35 AM, and with the Medical Director, on [DATE] at 8:03 AM, revealed they would oversee the QAPI committee process.

Based on interview, record review, and review of the facility's policy, it was determined the facility's administration failed to have an effective system in place to ensure resources were effectively utilized to provide care and services related to the administration [MEDICAL CONDITION] treatment medications for one (1) of three (3) sampled residents, Resident #2. Interviews revealed the facility did not administer Resident #2 his/her physician ordered medication because of the expense and did not notify the physician or resident that the medication was withheld. Resident #2 experienced a decline while at the nursing facility, which required a transfer to an acute care hospital on [DATE] where the resident expired on [DATE] due to [MEDICAL CONDITION], Hepatic Failure, Acute [MEDICAL CONDITION], and Metastatic [MEDICAL CONDITION]. The facility's failure to have an effective system in place to ensure the facility administered care and services effectively has caused or is likely to cause serious injury, harm, impairment, or death. The Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE]. The facility was notified on [DATE]. The facility submitted an acceptable Allegation of Compliance (AoC) on [DATE] alleging the removal of Immediate Jeopardy on [DATE]. The State Survey Agency validated the Immediate Jeopardy was removed on [DATE] as alleged, prior to exit on [DATE], with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the Administrator's Job Description, dated (MONTH) 2011, revealed the Administrator would lead and direct the overall operations of the facility in accordance with customer needs, government regulations, and company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives. Essential duties and responsibilities included overseeing regular rounds to monitor delivery of nursing care, operation of support department, cleanliness and appearance of the facility, morale of staff, and ensure resident needs were addressed. Review of Resident #2's closed clinical record revealed a physician's orders [REDACTED]. However, review of Resident #2's Medication Administration Record [REDACTED]. Interview, on [DATE] at 12:13 PM, with Licensed Practical Nurse (LPN) #2 revealed on [DATE], Resident #2 returned to the facility after hospitalization with medication orders including Afinitor. She stated the Unit Manager told her the facility was not going to approve the medication due to the cost. Interview, on [DATE] at 10:30 AM, with the Pharmacist revealed the Interim Director of Nursing canceled the prescription and the pharmacy did not deliver Afinitor to the facility. Interview, on [DATE] at 2:55 PM, with the Unit Manager (UM) of the Blue Unit revealed she spoke with the Administrator on [DATE], and he said the medication was too expensive to order. Per interview, she tried to get an approval for a three (3) or four (4) day supply of the Afinitor; however, the Administrator denied the request. Interview, on [DATE] at 10:30 AM and 4:00 PM, with the Administrator revealed he put a hold on the medication due to the cost. He chose to wait until [DATE], to contact the Oncologist to seek further direction because it was the Thanksgiving holiday week. The Administrator stated he did not inform staff he did not approve the medication due to cost, nor did he instruct staff to call the physician to seek further direction. According to the Administrator, he was ultimately responsible for the care and services the residents received in the facility. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], the Unit Managers (UM), Staff Development Coordinator (SDC), Medical Records Director, and Regional Support Staff (RSS) completed a one-time review of resident admissions from [DATE] to [DATE], in order to determine compliance with physician orders [REDACTED]. The facility shared the one-time review of admission information with members of the Interdisciplinary Team. 2. The facility assessed all new admits for [MEDICAL CONDITION] treatment medications to determine if the Immediate Jeopardy identified on [DATE], could affect them. No additional newly admitted residents were noted [MEDICAL CONDITION] treating medications prescribed. 3. On [DATE], the Administrator, Assistant Director of Nursing (ADON), Medical Director, and RSS made the determination policy and procedures, related to the immediate jeopardy, did not require revisions. 4. The UMs, SDC, Administrator, and RSS initiated re-education of the Licensed Nursing Staff, Certified Medication Technicians, and Non-Facility Personnel on [DATE], regarding medication administration and notification of the physician, resident, and family of a decision to withhold resident medication. In addition, staff was re-educated on the development and implementation of the baseline care plan, to include goals and interventions. The facility currently employed twelve (12) Licensed Nurses and one (1) Certified Medication Technician. Any Licensed Nurse who had not completed the re-education by 11:59 PM on [DATE], would receive the re-education at the time of their next scheduled shift. 5. The SDC would educate newly hired nurses and certified medication technicians during the orientation process. 6. The Director of Nursing (DON), Administrator, ADON, UM, Minimum Data Set (MDS) Coordinator, SDC, or RSS would conduct audits beginning [DATE], of new admissions to monitor for the ordering and obtaining of medications, per the physician order, three (3) times a week for eight (8) weeks, then once a week for four (4) weeks, then monthly. Any issues noted by the facility during the auditing process would be immediately corrected with one-on-one re-education and/up to disciplinary action as deemed necessary. 7. The DON, Administrator, ADON, UM, MDS Coordinator, SDC, or RSS would be responsible for conducting audits beginning [DATE], regarding compliance with the initiation of the baseline care plan at the time of admission, three (3) times a week for eight (8) weeks, then once a week for four (4) weeks, then monthly. Any issues noted by the facility during the auditing process would be immediately corrected with one-on-one re-education and/up to disciplinary action as deemed necessary. 8. The DON, Administrator, ADON, UM, MDS Coordinator, SDC, or RSS would be responsible for conducting audits beginning [DATE], for the provision [MEDICAL CONDITION] treatments as the time of admission three (3) times a week for eight (8) weeks, then once a week for four (4) weeks, then monthly. Any issues noted by the facility during the auditing process would be immediately corrected with one-on-one re-education and/up to disciplinary action as deemed necessary. 9. The Administrator, DON, or RSS would be responsible for reviewing the results of the audits. 10. The Regional Director of Special Projects re-educated the Interdisciplinary Team (IDT) on [DATE], regarding administrative roles and responsibilities. The IDT consisted of the Administrator, DON, Admissions, ADON, SDC, UM, Social Services (SS), Business Office Manager (BOM), MDS Coordinator, and Rehabilitation Services Manager (RSM). 11. The facility held an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting on [DATE], with the Medical Director, Administrator, DON, ADON, Medical Records, BOM, Maintenance, Admissions, Housekeeping Manager, Rehabilitation Services Manager, and the Regional Director of Clinical Operations to review the statement of deficiencies, corrective actions taken, and results of the audits performed. 12. On [DATE], the Regional Vice President of Operations (VPO) reviewed with the Administrator the Administrator Job description and responsibilities. The VPO discussed with the Administrator the role of ensuring resources were available to provide for the needs of the resident, which included medications and other services. 13. On [DATE], the Regional Vice President of Operations (VPO) met with the Administrator and the DON to validate the facility's Allegation of Compliance. These meetings would continue weekly until the immediacy of the jeopardy was lifted and substantial compliance was achieved. 14. The facility Administrator would present all findings of the audits to the QAPI committee monthly for three months (3), then quarterly thereafter for further recommendations and follow up. 15. The Administrator would oversee the QAPI committee meeting in conjunction with the DON and Medical Director. The State Survey Agency validated the removal of Immediate Jeopardy on [DATE] prior to exit as follows: 1. Interview with the Staff Development Coordinator (SDC), on [DATE] at 1:41 PM, and the Unit Manager (UM), on [DATE] at 10:20 AM, revealed the facility reviewed resident admission orders [REDACTED]. Interview with the Minimum Data Set (MDS) Coordinator, on [DATE] at 9:24 AM, revealed she was on the IDT. She stated the team reviewed the information from the one-time review of resident admissions to determine if the facility had administered medications as ordered and there were no identified issues found from the review. Interview with the Social Services Director (SSD), on [DATE] at 10:15 AM, and the Medical Records Director (MRD), on [DATE] at 10:00 AM, revealed they were on the Interdisciplinary Team (IDT). The SSD and MRD stated they reviewed the information obtained from the one-time review of resident admissions, from [DATE] to [DATE], and determined the facility had administered medications as ordered. Record review revealed the facility reviewed resident admission orders [REDACTED]. Review of Unsampled Resident I's medical record revealed the facility admitted the resident on [DATE] and readmitted the resident on [DATE]. The medication orders from the hospital's discharge summary, dated [DATE], corresponded with both the medication orders listed on the Physician order [REDACTED]. Review of Unsampled Resident N's medical record revealed the facility admitted the resident on [DATE]. Medication orders listed on the POS, dated [DATE], and the medication orders on the Medication Administration Record [REDACTED]. 2. Interview with the Administrator, on [DATE] at 3:00 PM, revealed the facility did not have residents in the facility [MEDICAL CONDITION] treatment medications. Interview with the Director of Nursing (DON), on [DATE] at 9:35 AM, revealed the facility did not have a resident in the facility [MEDICAL CONDITION] treatment medications. Review of an untitled typed statement, dated [DATE], revealed as of the alleged compliance date of [DATE], the facility had not admitted or readmitted residents with orders [MEDICAL CONDITION] related medications. 3. Interview with the Administrator, on [DATE] at 8:30 AM, and the Regional Support Staff (RSS), on [DATE] at 2:45 PM, revealed the facility reviewed policies and procedures related to Physician Notification, Care Plan Development, and Medication Administration, and determined revisions to the polices were not necessary. 4. Interview with Registered Nurse (RN) #4, on [DATE] at 3:00 PM, revealed she was trained on medication, change of condition, and care plans. She stated care plans should be individualized with new information passed on to the CNAs. RN #4 stated she would call the pharmacy if a medication was not available and STAT (immediate) medications would be delivered within one (1) hour. She revealed if she was unable to obtain the medication, the resident's physician and family would be notified. Interview with RN #1, on [DATE] at 8:45 AM, revealed she was trained on documentation, updating care plans, and physician notification. She stated the procedure for pre-authorization of medications included contacting the pharmacy and receiving an approval number. She had never experienced an instance where a medication was not approved. Interview with Licensed Practical Nurse (LPN) #7, on [DATE] 8:30 AM, revealed the facility recently educated her on medication administration, change of condition, and medication changes. She stated she was trained to notify the physician, resident (when applicable), family, and manager any time a resident reacted to, refused, or missed a medication dose and if they had a change in condition. LPN #7 stated she was educated to review the resident care plans each shift, make changes when applicable, and inform her manager if revisions were necessary. Interview with the MDS Coordinator, on [DATE] at 9:24 AM, revealed the facility trained her to provide training to the staff on physician, family, and resident notification, medication administration, and care plan development and implementation. Interview with CNA #5, on [DATE] at 2:50 PM, revealed she kept a copy of the care plan with her on the floor. She stated the care plans were developed by nursing staff in the care planning meetings when residents were first admitted . If the resident had a change of condition, she stated she would fill out a Stop and Watch form and tell the nurse. The form was then signed by the nurse to prove the CNA informed them of the change. CNA #5 stated the Unit Manager and the nurses kept care plans updated. Review of facility's In-Service Attendance Sheets revealed staff re-education began on [DATE], and education continued on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The facility trained Licensed Nursing Staff and Certified Medication Technicians on physician, family, and resident notification, care plan development, and medication administration. Record review revealed the facility used the policy, Medication Administration, dated (MONTH) (YEAR), to re-educate Licensed Nursing Staff and Medication Technicians. Continued review revealed the facility used an undated document, Baseline Care Plan Process, to re-educate the Licensed Nursing Staff. The goal stated the facility would meet newly admitted and/or readmitted resident care needs. During the admission process, staff would complete all required assessments and based on those assessments, would create a care plan for the identified high-risk areas. Review of the Employee Listing Payroll Services document, dated (MONTH) (YEAR), revealed the facility employed twelve (12) licensed nursing staff and one (1) Certified Medication Technician. Review of the facility's In-Service Attendance Sheets, dated [DATE], [DATE], and [DATE], revealed staff assigned to work after [DATE], received training prior to their shift. 5. Interview with LPN #6, on [DATE] at 3:45 PM, revealed she was an agency nurse and the facility recently educated her regarding physician notification, care plan development, and medication administration prior to her beginning her shift. She stated all new orders required notification of resident and family, and nursing staff must document their notifications. She stated the facility kept a copy of the resident care plans on each medication cart and she signed the plans each shift to show she had reviewed them for potential revisions. Interview with the SDC, on [DATE] at 1:41 PM, revealed she scheduled agency staff to come in one (1) hour prior to the beginning of their shift in order for the staff member to receive training on physician, family, and resident notification, care plan development, and medication administration. She stated new hires would receive the training in orientation; however, the facility had not conducted new hire orientation as of yet. 6. Interview with LPN #7, on [DATE] at 8:30 AM, revealed she would notify the physician, resident, and family if she could not administer a resident's medication. She stated she readmitted Unsampled Resident I to the facility on [DATE], and after she had processed the admission, her Unit Manager and Corporate Nurses reviewed all the medications and orders for accuracy. She stated the Unit Manager and Corporate Nurses performed the audit of her documentation and did not find any issues. Interview with the DON, on [DATE] at 9:35 AM, revealed she assisted with auditing the medical records and found no concerns requiring corrective action. Review of Plan of Correction Auditing Form for Physician Notification, not dated, revealed no new resident admissions had occurred. The facility conducted random medical record audits three (3) times a week to determine compliance with physician notification related to a medication order or compliance with obtaining medication per the physician order. The facility began audits on [DATE], and audits continued on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The facility audited residents' medical records for compliance after re-admission from a hospitalization on [DATE] and [DATE]. No identified concerns were noted. 7. Interview with the SDC, on [DATE] at 1:41 PM, revealed she assisted with conducting audits three (3) times a week and had not identified concerns with care plan audits. Review of Unsampled Resident G's Care Plan, undated, revealed the facility developed and implemented interventions to meet the resident's care needs. Interview with Unsampled Resident G, on [DATE] at 2:30 PM, revealed the resident had no concerns with medication administration and staff kept him/her informed of changes in his/her plan of care. Review of a Plan of Correction Auditing Form, not dated, for the initiation of the Baseline Care Plan upon admission, revealed no new resident admissions had occurred. Continued review revealed the facility conducted random medical record audits three (3) times a week, to include residents readmitted after a hospitalization . The facility began the audits on [DATE] and continued the audits on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], to determine compliance with initiation of the Baseline Care Plan development. No identified concerns were noted requiring corrective action. 8. Interview with RN #1, on [DATE] at 3:25 PM, revealed management was conducting audits of resident medical records to determine if residents had orders [MEDICAL CONDITION] treatment and to determine if nursing staff administered medications as ordered. She stated she did not know of any resident that had orders [MEDICAL CONDITION] treatment drugs. Interview with the Unit Manager, on [DATE] at 10:20 AM, revealed she assisted with conducting audits three (3) times a week and found no concerns that required corrective action. Review of a Plan of Correction Auditing Form, not dated, regarding the provision [MEDICAL CONDITION] treatments per the physician order [REDACTED]. Continued review revealed the facility conducted random audits three (3) times a week of resident medical records to include residents readmitted after a hospitalization . The facility conducted audits on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. No identified concerns were noted which required corrective action. Review of the clinical record for Unsampled Resident G revealed all of the medications listed on the Medication Administration Record [REDACTED]. Continued Review of the MAR indicated [REDACTED]. 9. Interview with the RSS, on [DATE] at 2:45 PM, revealed she reviewed the audit forms for completion and for issues needing corrective action. She stated she discussed the findings with the Interdisciplinary Team, which included the Administrator and DON. She stated audits were conducted three (3) times a week as planned, and no issues were identified that required corrective action. Review of a Plan of Correction Auditing Form, not dated, regarding physician notification, baseline care plans, [MEDICAL CONDITION] treatment services revealed the RSS reviewed the audit forms. 10. Interview with the Rehabilitation Services Manager, on [DATE] at 11:00 AM, and Social Services, on [DATE] at 10:15 AM, revealed the Regional Director of Special Projects re-educated them on their roles and responsibilities in regards to meeting resident care needs. Interview with the Admissions Director, on [DATE] at 2:00 PM, and SDC, on [DATE] at 1:41 PM, revealed the Regional Director of Special Projects met with the IDT on [DATE], to provide re-education regarding the team's roles and responsibility to ensure residents received the care and services ordered by the physician. Interview with the Regional Director of Special Projects, on [DATE] at 3:00 PM, revealed he had re-educated the IDT on their administrative roles and responsibilities regarding care plan development, physician, family and resident notification, and medication administration. 11. Interview, on [DATE] at 8:03 AM, with the Medical Director revealed he had attended the Ad Hoc Quality Assurance meeting held on [DATE]. He stated the facility audits were discussed and other actions taken to ensure compliance with medication administration, notification, and care plan implementation. He stated no concerns were identified requiring corrective action. Interview with the Director of Housekeeping, on [DATE] at 9:04 AM, and the Medical Records Director, on [DATE] at 10:00 AM, revealed they attended the [DATE] QAPI committee meeting. They stated the committee discussed the facility's compliance with medication administration, physician notification, and care plan implementation, along with facility audits. They stated no identified concerns were noted. Review of the Ad Hoc Quality Assurance sign in sheet, dated [DATE], revealed the Medical Director, Administrator, DON, ADON, Medical Records, BOM, Maintenance, Admissions, Housekeeping Manager, Rehabilitation Services Manager, and the Regional Director of Clinical Operations attended the meeting. 12. Interview with the Administrator, on [DATE] at 9:05 AM, revealed the Vice President of Operations (VPO) re-educated him on [DATE], regarding his job description and role as an administrator. He stated the VPO instructed him to approve medication, regardless of cost, when pharmacy requested payment approval. He stated the facility must ensure resident's needs were met. Interview with the VPO, on [DATE] at 9:26 AM, revealed he re-educated the Administrator on [DATE], regarding his job description and responsibilities to ensure resident care needs were met. The VPO stated he instructed the Administrator to approve medication, regardless of cost, when pharmacy requested a payment approval. 13. Interview with the Administrator, on [DATE] at 9:05 AM, and the DON, on [DATE] at 9:35 AM, revealed the VPO met with them on [DATE], to validate the Allegation of Compliance (A[NAME]). They stated the plan was to meet weekly on Thursday until the abatement of the Immediate Jeopardy and substantial compliance was achieved. Interview with the VPO, on [DATE] at 9:26 AM, revealed he met with the Administrator and DON on [DATE], to validate the facility's compliance with the A[NAME]. He stated he would meet with weekly until the abatement of the immediate jeopardy and substantial compliance was achieved. Review of the Meeting with Administrator and DON form, dated [DATE], revealed the VPO met with the Administrator and DON to validate compliance with the A[NAME]. The form stated the VPO would continue to meet with them weekly on Thursday until the abatement of immediate jeopardy and substantial compliance was achieved. 14. Interview with the Administrator, on [DATE] at 9:05 AM, and the DON, on [DATE] at 9:35 AM, revealed all audits would be presented to the QAPI committee monthly for three (3) months, then quarterly thereafter for further recommendations and follow up. 15. Interview with the Administrator, on [DATE] at 9:05 AM, the DON, on [DATE] at 9:35 AM, and with the Medical Director, on [DATE] at 8:03 AM, revealed they would oversee the QAPI committee process.

Based on interview, record review, and review of the facility's policy, it was determined the facility's administration failed to have an effective system in place to ensure resources were effectively utilized to provide care and services related to the administration [MEDICAL CONDITION] treatment medications for one (1) of three (3) sampled residents, Resident #2. Interviews revealed the facility did not administer Resident #2 his/her physician ordered medication because of the expense and did not notify the physician or resident that the medication was withheld. Resident #2 experienced a decline while at the nursing facility, which required a transfer to an acute care hospital on [DATE] where the resident expired on [DATE] due to [MEDICAL CONDITION], Hepatic Failure, Acute [MEDICAL CONDITION], and Metastatic [MEDICAL CONDITION]. The facility's failure to have an effective system in place to ensure the facility administered care and services effectively has caused or is likely to cause serious injury, harm, impairment, or death. The Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE]. The facility was notified on [DATE]. The facility submitted an acceptable Allegation of Compliance (AoC) on [DATE] alleging the removal of Immediate Jeopardy on [DATE]. The State Survey Agency validated the Immediate Jeopardy was removed on [DATE] as alleged, prior to exit on [DATE], with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the Administrator's Job Description, dated (MONTH) 2011, revealed the Administrator would lead and direct the overall operations of the facility in accordance with customer needs, government regulations, and company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives. Essential duties and responsibilities included overseeing regular rounds to monitor delivery of nursing care, operation of support department, cleanliness and appearance of the facility, morale of staff, and ensure resident needs were addressed. Review of Resident #2's closed clinical record revealed a physician's orders [REDACTED]. However, review of Resident #2's Medication Administration Record [REDACTED]. Interview, on [DATE] at 12:13 PM, with Licensed Practical Nurse (LPN) #2 revealed on [DATE], Resident #2 returned to the facility after hospitalization with medication orders including Afinitor. She stated the Unit Manager told her the facility was not going to approve the medication due to the cost. Interview, on [DATE] at 10:30 AM, with the Pharmacist revealed the Interim Director of Nursing canceled the prescription and the pharmacy did not deliver Afinitor to the facility. Interview, on [DATE] at 2:55 PM, with the Unit Manager (UM) of the Blue Unit revealed she spoke with the Administrator on [DATE], and he said the medication was too expensive to order. Per interview, she tried to get an approval for a three (3) or four (4) day supply of the Afinitor; however, the Administrator denied the request. Interview, on [DATE] at 10:30 AM and 4:00 PM, with the Administrator revealed he put a hold on the medication due to the cost. He chose to wait until [DATE], to contact the Oncologist to seek further direction because it was the Thanksgiving holiday week. The Administrator stated he did not inform staff he did not approve the medication due to cost, nor did he instruct staff to call the physician to seek further direction. According to the Administrator, he was ultimately responsible for the care and services the residents received in the facility. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], the Unit Managers (UM), Staff Development Coordinator (SDC), Medical Records Director, and Regional Support Staff (RSS) completed a one-time review of resident admissions from [DATE] to [DATE], in order to determine compliance with physician orders [REDACTED]. The facility shared the one-time review of admission information with members of the Interdisciplinary Team. 2. The facility assessed all new admits for [MEDICAL CONDITION] treatment medications to determine if the Immediate Jeopardy identified on [DATE], could affect them. No additional newly admitted residents were noted [MEDICAL CONDITION] treating medications prescribed. 3. On [DATE], the Administrator, Assistant Director of Nursing (ADON), Medical Director, and RSS made the determination policy and procedures, related to the immediate jeopardy, did not require revisions. 4. The UMs, SDC, Administrator, and RSS initiated re-education of the Licensed Nursing Staff, Certified Medication Technicians, and Non-Facility Personnel on [DATE], regarding medication administration and notification of the physician, resident, and family of a decision to withhold resident medication. In addition, staff was re-educated on the development and implementation of the baseline care plan, to include goals and interventions. The facility currently employed twelve (12) Licensed Nurses and one (1) Certified Medication Technician. Any Licensed Nurse who had not completed the re-education by 11:59 PM on [DATE], would receive the re-education at the time of their next scheduled shift. 5. The SDC would educate newly hired nurses and certified medication technicians during the orientation process. 6. The Director of Nursing (DON), Administrator, ADON, UM, Minimum Data Set (MDS) Coordinator, SDC, or RSS would conduct audits beginning [DATE], of new admissions to monitor for the ordering and obtaining of medications, per the physician order, three (3) times a week for eight (8) weeks, then once a week for four (4) weeks, then monthly. Any issues noted by the facility during the auditing process would be immediately corrected with one-on-one re-education and/up to disciplinary action as deemed necessary. 7. The DON, Administrator, ADON, UM, MDS Coordinator, SDC, or RSS would be responsible for conducting audits beginning [DATE], regarding compliance with the initiation of the baseline care plan at the time of admission, three (3) times a week for eight (8) weeks, then once a week for four (4) weeks, then monthly. Any issues noted by the facility during the auditing process would be immediately corrected with one-on-one re-education and/up to disciplinary action as deemed necessary. 8. The DON, Administrator, ADON, UM, MDS Coordinator, SDC, or RSS would be responsible for conducting audits beginning [DATE], for the provision [MEDICAL CONDITION] treatments as the time of admission three (3) times a week for eight (8) weeks, then once a week for four (4) weeks, then monthly. Any issues noted by the facility during the auditing process would be immediately corrected with one-on-one re-education and/up to disciplinary action as deemed necessary. 9. The Administrator, DON, or RSS would be responsible for reviewing the results of the audits. 10. The Regional Director of Special Projects re-educated the Interdisciplinary Team (IDT) on [DATE], regarding administrative roles and responsibilities. The IDT consisted of the Administrator, DON, Admissions, ADON, SDC, UM, Social Services (SS), Business Office Manager (BOM), MDS Coordinator, and Rehabilitation Services Manager (RSM). 11. The facility held an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting on [DATE], with the Medical Director, Administrator, DON, ADON, Medical Records, BOM, Maintenance, Admissions, Housekeeping Manager, Rehabilitation Services Manager, and the Regional Director of Clinical Operations to review the statement of deficiencies, corrective actions taken, and results of the audits performed. 12. On [DATE], the Regional Vice President of Operations (VPO) reviewed with the Administrator the Administrator Job description and responsibilities. The VPO discussed with the Administrator the role of ensuring resources were available to provide for the needs of the resident, which included medications and other services. 13. On [DATE], the Regional Vice President of Operations (VPO) met with the Administrator and the DON to validate the facility's Allegation of Compliance. These meetings would continue weekly until the immediacy of the jeopardy was lifted and substantial compliance was achieved. 14. The facility Administrator would present all findings of the audits to the QAPI committee monthly for three months (3), then quarterly thereafter for further recommendations and follow up. 15. The Administrator would oversee the QAPI committee meeting in conjunction with the DON and Medical Director. The State Survey Agency validated the removal of Immediate Jeopardy on [DATE] prior to exit as follows: 1. Interview with the Staff Development Coordinator (SDC), on [DATE] at 1:41 PM, and the Unit Manager (UM), on [DATE] at 10:20 AM, revealed the facility reviewed resident admission orders [REDACTED]. Interview with the Minimum Data Set (MDS) Coordinator, on [DATE] at 9:24 AM, revealed she was on the IDT. She stated the team reviewed the information from the one-time review of resident admissions to determine if the facility had administered medications as ordered and there were no identified issues found from the review. Interview with the Social Services Director (SSD), on [DATE] at 10:15 AM, and the Medical Records Director (MRD), on [DATE] at 10:00 AM, revealed they were on the Interdisciplinary Team (IDT). The SSD and MRD stated they reviewed the information obtained from the one-time review of resident admissions, from [DATE] to [DATE], and determined the facility had administered medications as ordered. Record review revealed the facility reviewed resident admission orders [REDACTED]. Review of Unsampled Resident I's medical record revealed the facility admitted the resident on [DATE] and readmitted the resident on [DATE]. The medication orders from the hospital's discharge summary, dated [DATE], corresponded with both the medication orders listed on the Physician order [REDACTED]. Review of Unsampled Resident N's medical record revealed the facility admitted the resident on [DATE]. Medication orders listed on the POS, dated [DATE], and the medication orders on the Medication Administration Record [REDACTED]. 2. Interview with the Administrator, on [DATE] at 3:00 PM, revealed the facility did not have residents in the facility [MEDICAL CONDITION] treatment medications. Interview with the Director of Nursing (DON), on [DATE] at 9:35 AM, revealed the facility did not have a resident in the facility [MEDICAL CONDITION] treatment medications. Review of an untitled typed statement, dated [DATE], revealed as of the alleged compliance date of [DATE], the facility had not admitted or readmitted residents with orders [MEDICAL CONDITION] related medications. 3. Interview with the Administrator, on [DATE] at 8:30 AM, and the Regional Support Staff (RSS), on [DATE] at 2:45 PM, revealed the facility reviewed policies and procedures related to Physician Notification, Care Plan Development, and Medication Administration, and determined revisions to the polices were not necessary. 4. Interview with Registered Nurse (RN) #4, on [DATE] at 3:00 PM, revealed she was trained on medication, change of condition, and care plans. She stated care plans should be individualized with new information passed on to the CNAs. RN #4 stated she would call the pharmacy if a medication was not available and STAT (immediate) medications would be delivered within one (1) hour. She revealed if she was unable to obtain the medication, the resident's physician and family would be notified. Interview with RN #1, on [DATE] at 8:45 AM, revealed she was trained on documentation, updating care plans, and physician notification. She stated the procedure for pre-authorization of medications included contacting the pharmacy and receiving an approval number. She had never experienced an instance where a medication was not approved. Interview with Licensed Practical Nurse (LPN) #7, on [DATE] 8:30 AM, revealed the facility recently educated her on medication administration, change of condition, and medication changes. She stated she was trained to notify the physician, resident (when applicable), family, and manager any time a resident reacted to, refused, or missed a medication dose and if they had a change in condition. LPN #7 stated she was educated to review the resident care plans each shift, make changes when applicable, and inform her manager if revisions were necessary. Interview with the MDS Coordinator, on [DATE] at 9:24 AM, revealed the facility trained her to provide training to the staff on physician, family, and resident notification, medication administration, and care plan development and implementation. Interview with CNA #5, on [DATE] at 2:50 PM, revealed she kept a copy of the care plan with her on the floor. She stated the care plans were developed by nursing staff in the care planning meetings when residents were first admitted . If the resident had a change of condition, she stated she would fill out a Stop and Watch form and tell the nurse. The form was then signed by the nurse to prove the CNA informed them of the change. CNA #5 stated the Unit Manager and the nurses kept care plans updated. Review of facility's In-Service Attendance Sheets revealed staff re-education began on [DATE], and education continued on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The facility trained Licensed Nursing Staff and Certified Medication Technicians on physician, family, and resident notification, care plan development, and medication administration. Record review revealed the facility used the policy, Medication Administration, dated (MONTH) (YEAR), to re-educate Licensed Nursing Staff and Medication Technicians. Continued review revealed the facility used an undated document, Baseline Care Plan Process, to re-educate the Licensed Nursing Staff. The goal stated the facility would meet newly admitted and/or readmitted resident care needs. During the admission process, staff would complete all required assessments and based on those assessments, would create a care plan for the identified high-risk areas. Review of the Employee Listing Payroll Services document, dated (MONTH) (YEAR), revealed the facility employed twelve (12) licensed nursing staff and one (1) Certified Medication Technician. Review of the facility's In-Service Attendance Sheets, dated [DATE], [DATE], and [DATE], revealed staff assigned to work after [DATE], received training prior to their shift. 5. Interview with LPN #6, on [DATE] at 3:45 PM, revealed she was an agency nurse and the facility recently educated her regarding physician notification, care plan development, and medication administration prior to her beginning her shift. She stated all new orders required notification of resident and family, and nursing staff must document their notifications. She stated the facility kept a copy of the resident care plans on each medication cart and she signed the plans each shift to show she had reviewed them for potential revisions. Interview with the SDC, on [DATE] at 1:41 PM, revealed she scheduled agency staff to come in one (1) hour prior to the beginning of their shift in order for the staff member to receive training on physician, family, and resident notification, care plan development, and medication administration. She stated new hires would receive the training in orientation; however, the facility had not conducted new hire orientation as of yet. 6. Interview with LPN #7, on [DATE] at 8:30 AM, revealed she would notify the physician, resident, and family if she could not administer a resident's medication. She stated she readmitted Unsampled Resident I to the facility on [DATE], and after she had processed the admission, her Unit Manager and Corporate Nurses reviewed all the medications and orders for accuracy. She stated the Unit Manager and Corporate Nurses performed the audit of her documentation and did not find any issues. Interview with the DON, on [DATE] at 9:35 AM, revealed she assisted with auditing the medical records and found no concerns requiring corrective action. Review of Plan of Correction Auditing Form for Physician Notification, not dated, revealed no new resident admissions had occurred. The facility conducted random medical record audits three (3) times a week to determine compliance with physician notification related to a medication order or compliance with obtaining medication per the physician order. The facility began audits on [DATE], and audits continued on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The facility audited residents' medical records for compliance after re-admission from a hospitalization on [DATE] and [DATE]. No identified concerns were noted. 7. Interview with the SDC, on [DATE] at 1:41 PM, revealed she assisted with conducting audits three (3) times a week and had not identified concerns with care plan audits. Review of Unsampled Resident G's Care Plan, undated, revealed the facility developed and implemented interventions to meet the resident's care needs. Interview with Unsampled Resident G, on [DATE] at 2:30 PM, revealed the resident had no concerns with medication administration and staff kept him/her informed of changes in his/her plan of care. Review of a Plan of Correction Auditing Form, not dated, for the initiation of the Baseline Care Plan upon admission, revealed no new resident admissions had occurred. Continued review revealed the facility conducted random medical record audits three (3) times a week, to include residents readmitted after a hospitalization . The facility began the audits on [DATE] and continued the audits on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], to determine compliance with initiation of the Baseline Care Plan development. No identified concerns were noted requiring corrective action. 8. Interview with RN #1, on [DATE] at 3:25 PM, revealed management was conducting audits of resident medical records to determine if residents had orders [MEDICAL CONDITION] treatment and to determine if nursing staff administered medications as ordered. She stated she did not know of any resident that had orders [MEDICAL CONDITION] treatment drugs. Interview with the Unit Manager, on [DATE] at 10:20 AM, revealed she assisted with conducting audits three (3) times a week and found no concerns that required corrective action. Review of a Plan of Correction Auditing Form, not dated, regarding the provision [MEDICAL CONDITION] treatments per the physician order [REDACTED]. Continued review revealed the facility conducted random audits three (3) times a week of resident medical records to include residents readmitted after a hospitalization . The facility conducted audits on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. No identified concerns were noted which required corrective action. Review of the clinical record for Unsampled Resident G revealed all of the medications listed on the Medication Administration Record [REDACTED]. Continued Review of the MAR indicated [REDACTED]. 9. Interview with the RSS, on [DATE] at 2:45 PM, revealed she reviewed the audit forms for completion and for issues needing corrective action. She stated she discussed the findings with the Interdisciplinary Team, which included the Administrator and DON. She stated audits were conducted three (3) times a week as planned, and no issues were identified that required corrective action. Review of a Plan of Correction Auditing Form, not dated, regarding physician notification, baseline care plans, [MEDICAL CONDITION] treatment services revealed the RSS reviewed the audit forms. 10. Interview with the Rehabilitation Services Manager, on [DATE] at 11:00 AM, and Social Services, on [DATE] at 10:15 AM, revealed the Regional Director of Special Projects re-educated them on their roles and responsibilities in regards to meeting resident care needs. Interview with the Admissions Director, on [DATE] at 2:00 PM, and SDC, on [DATE] at 1:41 PM, revealed the Regional Director of Special Projects met with the IDT on [DATE], to provide re-education regarding the team's roles and responsibility to ensure residents received the care and services ordered by the physician. Interview with the Regional Director of Special Projects, on [DATE] at 3:00 PM, revealed he had re-educated the IDT on their administrative roles and responsibilities regarding care plan development, physician, family and resident notification, and medication administration. 11. Interview, on [DATE] at 8:03 AM, with the Medical Director revealed he had attended the Ad Hoc Quality Assurance meeting held on [DATE]. He stated the facility audits were discussed and other actions taken to ensure compliance with medication administration, notification, and care plan implementation. He stated no concerns were identified requiring corrective action. Interview with the Director of Housekeeping, on [DATE] at 9:04 AM, and the Medical Records Director, on [DATE] at 10:00 AM, revealed they attended the [DATE] QAPI committee meeting. They stated the committee discussed the facility's compliance with medication administration, physician notification, and care plan implementation, along with facility audits. They stated no identified concerns were noted. Review of the Ad Hoc Quality Assurance sign in sheet, dated [DATE], revealed the Medical Director, Administrator, DON, ADON, Medical Records, BOM, Maintenance, Admissions, Housekeeping Manager, Rehabilitation Services Manager, and the Regional Director of Clinical Operations attended the meeting. 12. Interview with the Administrator, on [DATE] at 9:05 AM, revealed the Vice President of Operations (VPO) re-educated him on [DATE], regarding his job description and role as an administrator. He stated the VPO instructed him to approve medication, regardless of cost, when pharmacy requested payment approval. He stated the facility must ensure resident's needs were met. Interview with the VPO, on [DATE] at 9:26 AM, revealed he re-educated the Administrator on [DATE], regarding his job description and responsibilities to ensure resident care needs were met. The VPO stated he instructed the Administrator to approve medication, regardless of cost, when pharmacy requested a payment approval. 13. Interview with the Administrator, on [DATE] at 9:05 AM, and the DON, on [DATE] at 9:35 AM, revealed the VPO met with them on [DATE], to validate the Allegation of Compliance (A[NAME]). They stated the plan was to meet weekly on Thursday until the abatement of the Immediate Jeopardy and substantial compliance was achieved. Interview with the VPO, on [DATE] at 9:26 AM, revealed he met with the Administrator and DON on [DATE], to validate the facility's compliance with the A[NAME]. He stated he would meet with weekly until the abatement of the immediate jeopardy and substantial compliance was achieved. Review of the Meeting with Administrator and DON form, dated [DATE], revealed the VPO met with the Administrator and DON to validate compliance with the A[NAME]. The form stated the VPO would continue to meet with them weekly on Thursday until the abatement of immediate jeopardy and substantial compliance was achieved. 14. Interview with the Administrator, on [DATE] at 9:05 AM, and the DON, on [DATE] at 9:35 AM, revealed all audits would be presented to the QAPI committee monthly for three (3) months, then quarterly thereafter for further recommendations and follow up. 15. Interview with the Administrator, on [DATE] at 9:05 AM, the DON, on [DATE] at 9:35 AM, and with the Medical Director, on [DATE] at 8:03 AM, revealed they would oversee the QAPI committee process.

Based on observation, interview, record review, review of the facility's policy, and review of the U.S. Food and Drug Administration Medication Guide, it was determined the facility failed to implement the care plan for one (1) of eighteen (18) sampled residents, Resident #67. The facility's care plan for Resident #67 directed staff to report abnormal laboratory results to the physician. The facility obtained an abnormal International Normalized Ration (INR) result and did not notify the physician timely, which resulted in Resident #67's decline and subsequent hospitalization . The findings include: Review of the facility policy Care Plans - Comprehensive, undated, revealed the facility would implement the care plan interventions after consideration of the resident's problem areas and their causes. Interventions addressed the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers. The interventions would reflect action, treatment, or procedure to meet the objectives toward achieving the resident goals. Review of the facility's undated PT/INR Testing Policy revealed the purpose of the testing was to evaluate resident's INR levels to determine effectiveness of [MEDICATION NAME] therapy and to reduce the risk of adverse events that may be associated with anticoagulation therapy. The date and time the PT/INR was done was to be recorded in the medical record. The name and title of the individual who performed the procedure were to be documented in the medical record. The PT/INR results and interventions done, and physician and family notification, if any, were to be documented in the medical record. The policy revealed unexpected results or results outside of the INR target range was to be reported to the charge nurse and physician; however, the policy did not indicate the INR target range. Review of the facility's undated PT/INR Results Protocol revealed licensed nurses were to notify the physician of PT/INR results and respond with any new orders or to maintain current medication dose. The attending physician or nurse practitioner would then review at the next visit. Review of facility clinical record for Resident #67 revealed the facility admitted the resident on 12/28/16, and readmitted the resident on 07/01/17, with [DIAGNOSES REDACTED]. Review of Resident #67's annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed him/her with a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15) and determined the resident was interviewable. The resident had a [DIAGNOSES REDACTED]. Review of Resident #67's Comprehensive Care Plan, dated 01/10/17, revealed the resident was at risk for abnormal bleeding or hemorrhage related to use of an anticoagulant (blood thinner). Interventions included scheduling lab tests to monitor coagulation factors. The care plan also revealed Resident # 67 had actual/potential cardiovascular problems related to [MEDICAL CONDITION] Fibrillation and interventions included scheduling lab tests per physician order, and reporting abnormal results to the physician. Review of Resident #67's Medication Administration Record [REDACTED]. Review of Resident #67's INR Monitoring for [MEDICATION NAME] Therapy sheet, from 10/16/17 to 11/17/17, revealed an INR was obtained on 11/03/17 with a result of 2.2. An INR was obtained on 11/17/17, with a result of 4.0. There was no documentation the physician had been notified of the increase in the INR. Review of the U.S. Food and Drug Administration Medication Guide, revised September 2016, revealed patients with [MEDICAL CONDITION] Fibrillation and anticoagulated with [MEDICATION NAME] ([MEDICATION NAME]) should have a target INR of 2.5 (range 2.0 - 3.0). Review of the facility's Twenty-Four (24) Hour Report/Change of Condition Report, dated 11/18/17, revealed a note was made to call the physician for Resident #67's INR of 4.0 from yesterday (11/17/18). Review of Resident #67's Progress Notes, dated 11/17/17, 11/18/17, and 11/19/17, revealed no documentation staff notified the physician or nurse practitioner of the 4.0 INR. Further review of Resident #67's MAR for 11/17/17 through 11/19/17, revealed [MEDICATION NAME] was administered to the resident after the INR resulted 4.0. Further review of Resident #67's Progress Notes, dated 11/20/17 at 10:49 AM, revealed Licensed Practical Nurse (LPN) #1 was informed by staff that the resident had not eaten or had much to drink over the weekend. LPN #1 assessed Resident #67 and the resident did not respond to verbal or tactile stimuli. The resident laid in the bed, which was not normal for Resident #67. The facility sent Resident #67 to the hospital on [DATE] at 11:30 AM. Further review of the clinical record for Resident #67 revealed the resident had a hospital stay from 11/20/17 to 11/29/17. Review of Resident #67's History and Physical note from the hospital, dated 11/20/17 at 3:28 PM, revealed Resident #67 presented with an altered mental status and increased lethargy over the weekend. A PT/INR was done at 12:18 PM on 11/20/17, and the PT resulted 49.5 with a reference range of 9.6 - 12.0. The INR was 4.3. The urinalysis revealed a trace of occult blood in the urine. Review of the CT of the head revealed a small acute upon chronic left subdural hemorrhage with mild subarachnoid hemorrhage and ten (10) millimeter midline shift. The assessment revealed the [MEDICATION NAME] was supratherapeutic (above therapeutic level) on admission and a reversal agent was given emergently. Review of the physician discharge summary, dated 11/29/17, revealed the discharge [DIAGNOSES REDACTED]. Observation of Resident #67, on 12/12/17 at 8:56 AM, revealed the resident lying in bed. Interview, on 12/12/17 at 8:56 AM, with Resident #67, revealed he/she had a decline in function because of health reasons. Resident #67 stated he/she had been in the hospital for a few days and had only been back to the facility a couple of weeks and received physical and occupational therapy since the return to the facility. Post survey interview with the Unit Manager (UM), on 01/22/18 at 2:00 PM, revealed she was the UM on the unit where Resident #67 resided, on 11/17/17. She reported it was her expectation that nursing staff, Management, the MDS Nurse, the Director of Nursing (DON), and Social Workers follow the care plan and Certified Nursing Assistants (CNAs) had their own resident care plans. She explained care plans helped to ensure resident problems, care, and goals were addressed by the team. She also stated nursing staff monitored the implementation of the care plans by discussing resident changes of condition, new orders/treatments, and review the MAR indicated [REDACTED]. She explained the facility's practice was for third (3rd) shift nurses to pass abnormal laboratory results to first (1st) shift nurses, who would call the physician. She also stated nursing staff did not follow Resident #67's care plan, which could result in serious and/or dangerous consequences. Lastly, the UM stated Resident #67 was on a blood thinner and he/she could have bled. Post survey interview with LPN #1, on 01/22/18 at 3:41 PM, revealed care plans represented the needs of individual residents. She stated she had not read Resident #67's care plan because she did not have enough time. She explained nurses, CNAs, and anyone else listed on the care plans were responsible for following the plan. She stated abnormal laboratory information was passed along in report to the day shift nurse to call the physician, which was their practice; however, she was not sure if the practice was written anywhere. According to LPN #1, when staff did not follow care plans, residents' health was at risk. Post survey interview with Registered Nurse (RN) #3, on 01/29/18 at 8:45 AM, revealed she had been the DON for the last three (3) weeks. She stated an individualized plan of care provided staff an outline of the resident's needs. Nursing staff and all other disciplines mentioned in the care plan followed it, but only nursing staff added or removed items on the care plan. She explained charge nurses, UMs, department heads, and the DON monitored the implementation of the care plan. The implementation was monitored during the UM's two (2) hour rounds. All resident charts and changes of condition were reviewed daily in morning meeting and demonstrated care plan implementation. She stated she reviewed the facility's care plan for Resident #67 and the nurses did not follow it. Lastly, RN #3 stated if care plans were not followed, and physicians were not called for abnormal lab values related to [MEDICATION NAME], there could be gastrointestinal, subdermal, and/or subdural bleeding. Post survey interview with LPN #8, on 01/29/18 at 9:54 AM, revealed care plans were individualized plans and everyone taking care of the resident should follow it. She went on to state the UM, DON, and the nurses were responsible for ensuring CNAs were implementing the care plans. The UM monitored other staff when out on the floor and they ensured nurses were reviewing the care plans with the CNAs. She stated she was unsure how the nurses were monitored. She stated she could not specifically recall Resident #67's care plan. The nurse stated she wrote Resident #67's abnormal INR value on the calendar and twenty-four (24) hour report and told LPN #1 on the morning of 11/17/17. She stated resident's health and life would be at risk if staff did not follow the care plan.

Based on interview, record review, and facility policy review, it was determined the facility failed to follow the care plan for one (1) of four (4) sampled residents, Resident #2. Resident #2's care plan included an intervention to transfer the resident with a mechanical lift and assist of (2) persons; however, Certified Nursing Assistant (CNA) #5 transferred the resident by herself and the resident fell out of the lift sling and sustained a [MEDICAL CONDITION]. The findings include: Review of the facility's policy, Care Plans - Comprehensive, undated, revealed an individualized comprehensive care plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs were developed for each resident. Each resident care plan was designed to incorporate identified problem areas, incorporate risk factors associated with identified problems, and aid in preventing or reducing declines in the resident's functional status and/or functional level. Review of the facility's policy, Safety and Supervision of Resident, undated, revealed resident safety, supervision, and assistance to prevent accidents were facility-wide priorities. Implementing interventions to reduce accident risks and hazards shall include ensuring that interventions were implemented correctly and consistently. Review of the facility's policy, Resident Lift, undated, revealed residents who were unable to transfer themselves independently or with minimum assistance shall be transferred safely with a lift. The policy revealed at least two (2) trained staff were needed to transfer a resident when using a lift. Review of a facility investigation, dated 09/28/17, revealed on 09/25/17, CNA #5 transferred Resident #2 from the chair to the bed using a mechanical lift. The strap of the sling came off its post and the resident fell to the floor. The facility determined CNA #5 failed to follow the resident's care plan in providing two (2) person assistance during a mechanical lift transfer. The resident suffered a left hip and femur fracture. Review of Resident #2's closed clinical record revealed the facility admitted the resident on 03/17/17, with [DIAGNOSES REDACTED]. Review of Resident #2's quarterly Minimum Data Set, dated dated [DATE], revealed the facility assessed the resident was rarely/never understood and required extensive assistance of two (2) persons for transfer. Review of a Situation, Background, Appearance, and Review (SBAR) Communication Form, dated 09/25/17, revealed Resident #2 sustained a fall during a transfer with a mechanical lift. Review of a facility Event Report, dated 09/25/17 at 7:45 PM, revealed the CNA was lifting the resident with a lift and it malfunctioned and the resident fell approximately four (4) feet. Review of the hospital Physician's Progress Note, dated 10/02/17, for Resident #2, revealed he/she was admitted with [DIAGNOSES REDACTED]. Review of Resident #2's Comprehensive Care Plan, dated 03/30/17, revealed the resident had a self care deficit related to multiple contractures, weakness, and dementia and a two (2) person lift was required during transfers. Review of Resident #2's CNA Care Plan, not dated, revealed the resident was transferred by mechanical lift with the assist of two (2) persons. Interview with CNA #5, on 10/04/17 at 3:16 PM, revealed she attempted to transfer Resident #2 to bed unassisted with a mechanical lift on 09/25/17, because she could not find any help. She stated as she was moving the lift toward the bed, she heard the resident slip and before she got to the front of the lift, the resident slid out of the sling. The CNA further revealed the facility trained her that two (2) persons were required for transfers with a mechanical lift to ensure resident safety and prevent a fall. The CNA revealed she did not follow Resident #2's care plan for the transfer with a lift. Review of the Green Unit Daily Staffing Worksheet, dated 09/25/17, revealed there was one (1) Registered Nurse (RN), one (1) Licensed Practical Nurse (LPN), one (1) Certified Medication Technician (CMT), and six (6) CNA's assigned to the Green unit for the 3:00 PM to 11:00 PM shift. Interview with RN #1, on 10/04/17 at 1:56 PM, revealed she had returned to the unit from break when staff notified her Resident #2 had fallen. The RN stated she entered the resident's room and observed the resident lying on the floor with his/her neck positioned over the base of the lift and the lift pad hanging approximately four (4) to five (5) feet off the ground. The nurse stated she assessed the resident and activated emergency medical services (911). RN #1 stated CNA #5 reported she had attempted to use the mechanical lift alone and the resident slid out of the lift pad. She further revealed CNA #5 had not followed Resident #2's care plan for transfers. RN #1 stated the Green Unit was adequately staffed on the day of the incident. Interview with the CMT, on 10/04/17 at 2:16 PM, revealed she was passing medications on 09/25/17 when she heard a scream. The CMT revealed she entered Resident #2's room, observed the resident lying on the floor next to the lift, and CNA #5 standing next to him/her. The CMT revealed she then yelled for RN #1 to come to the resident's room. The CMT revealed she had been trained that two (2) persons were required at all times for transfers with a mechanical lift to ensure resident safety. Interview with the Plant Operations Director, on 10/04/17 at 2:10 PM, revealed he inspected all mechanical lifts every week and documented problems in the computer log. He stated after the incident with Resident #2, he inspected the lift and found no problems. He stated housekeeping inspected the lift slings. Review of the Mechanical Lift Inspection log, dated 09/15/17 and 09/22/17, revealed no documented problems with the condition of the lifts. Interview with the Director of Housekeeping, on 10/04/17 at 2:36 PM, revealed the lift slings were inspected for holes, tears, and missing buckles. She stated the slings were inspected if staff sent them to be washed and not a lot of the slings came through laundry to be washed. Review of the Lift Sling Tracking log, for (MONTH) (YEAR), revealed sling #20 was inspected on 09/06/17 and in new condition, sling #21 was inspected on 09/16/17 and in good condition, and sling #23 was inspected on 09/24/17 and in good condition. Interview with CNA #6, on 10/04/17 at 4:00 PM, revealed she was walking down the hallway on 09/25/17 when she heard CNA #5 scream. She stated she entered Resident #2's room and observed the resident lying on the floor and the lift pad hanging from the mechanical lift. The CNA stated two (2) people were required for resident transfers with mechanical lifts to ensure resident safety. She stated she had been trained that one (1) person worked the lift while the other person held onto the resident. Interview with RN #2, on 10/05/17 at 9:24 AM, revealed she monitored CNAs following resident care plans while she was out on the unit and in resident rooms when the CNAs were providing care. Interview with the Director of Nursing (DON), on 10/05/17 at 10:29 AM, revealed she was not aware of concerns regarding CNA #5 using lifts prior to Resident #2's incident. She stated a mechanical lift required two (2) people to ensure resident safety. The DON stated CNA #5 did not follow Resident #2's care plan for transfers using a lift. Interview with the Administrator, on 10/05/17 at 11:16 AM, revealed he was not aware of any concerns regarding the improper use of mechanical lifts. The Administrator revealed CNA #5 failed to follow Resident #2's care plan for two (2) person assist during transfers to ensure the resident's safety.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of four (4) sampled residents, Resident #2, was free from accidents. The facility determined Resident #2 required a mechanical lift with two (2) person assist for transfers; however, Certified Nursing Assistant (CNA) #5 transferred the resident alone using a lift, which resulted in the resident sustaining a fall and a hip fracture. The findings include: Review of the facility's policy, Safety and Supervision of Resident, undated, revealed resident safety, supervision, and assistance to prevent accidents were facility-wide priorities. Implementing interventions to reduce accident risks and hazards shall include ensuring interventions were implemented correctly and consistently. Review of the facility's policy, Resident Lift, undated, revealed residents who were unable to transfer themselves independently or with minimum assistance shall be transferred safely with a lift. At least two (2) trained staff was needed to transfer a resident when using a lift. Review of a facility investigation, dated 09/28/17, revealed on 09/25/17, CNA #5 transferred Resident #2 from the chair to the bed using a mechanical lift. The strap of the sling came off its post and the resident fell to the floor. The facility determined CNA #5 failed to follow the resident's care plan in providing two (2) person assistance during a mechanical lift transfer. The resident suffered a left hip and femur fracture. Review of Resident #2's closed clinical record revealed the facility admitted the resident on 03/17/17, with [DIAGNOSES REDACTED]. Review of Resident #2's quarterly Minimum Data Set (MDS), date 07/12/17, revealed the facility assessed the resident was rarely/never understood and required extensive assistance of two (2) persons for bed mobility and transfer. Review of a Situation, Background, Appearance, and Review (SBAR) Communication Form, dated 09/25/17, revealed Resident #2 sustained a fall during a transfer with a mechanical lift. The resident was transported to the hospital emergency room for evaluation. Review of a facility Event Report, dated 09/25/17 at 7:45 PM, revealed the CNA was lifting the resident with a lift and it malfunctioned and the resident fell approximately four (4) feet. Review of the hospital Physician's Progress Note, dated 10/02/17, for Resident #2, revealed he/she was admitted with [DIAGNOSES REDACTED]. Review of Resident #2's Comprehensive Care Plan, dated 03/30/17, revealed the resident had a self care deficit related to multiple contractures, weakness, and dementia and a two (2) person lift was required during transfers. Review of Resident #2's CNA Care Plan, not dated, revealed the resident was transferred by mechanical lift with the assist of two (2) persons. Interview with CNA #5, on 10/04/17 at 3:16 PM, revealed she attempted to transfer Resident #2 to bed unassisted with a mechanical lift on 09/25/17, because she could not find any help. She stated as she pushed the lift towards the bed, she heard the resident slip and before she got to the front of the lift, the resident slid out of the sling. The CNA stated the facility trained her that two (2) persons were required for transfers with a mechanical lift to ensure resident safety and prevent a fall. Review of the Green Unit Daily Staffing Worksheet, dated 09/25/17, revealed there was one (1) Registered Nurse (RN), one (1) Licensed Practical Nurse (LPN), one (1) Certified Medication Technician (CMT), and six (6) CNAs assigned to the Green unit for the 3:00 PM to 11:00 PM shift. Interview with RN #1, on 10/04/17 at 1:56 PM, revealed she returned to the unit from break when staff notified her Resident #2 had fallen. The RN stated she entered the resident's room and observed the resident lying on the floor with his/her neck positioned over the base of the lift and the lift pad hanging approximately four (4) to five (5) feet off the ground. RN #1 stated she assessed the resident and activated emergency medical services (911). The RN stated CNA #5 said she attempted to use the mechanical lift alone and the resident slid out of the lift pad. RN #1 stated the Green Unit was adequately staffed on the day of the incident. Interview with the CMT, on 10/04/17 at 2:16 PM, revealed she was passing medications on 09/25/17, when she heard a scream. The CMT entered Resident #2's room, observed the resident lying on the floor next to the lift, and CNA #5 standing next to him/her. The CMT stated she then yelled for RN #1 to come to the resident's room. The CMT revealed two (2) persons were required at all times for transfers with a mechanical lift to ensure resident safety and the facility had trained her on that requirement. Interview with CNA #6, on 10/04/17 at 4:00 PM, revealed on 09/25/17, she was walking down the hallway when she heard CNA #5 scream. She entered Resident #2's room and observed the resident lying on the floor and the lift pad hanging from the mechanical lift. The CNA stated two (2) people were required for resident transfers with mechanical lifts to ensure resident safety. She had been trained that one (1) person was to work the lift while the other person held onto the resident. Interview with the Plant Operations Director, on 10/04/17 at 2:10 PM, revealed he inspected all mechanical lifts every week and documented problems in the computer log. He stated after the incident with Resident #2, he inspected the lift and found no problems. He stated housekeeping inspected the lift slings. Review of the Mechanical Lift Inspection log, dated 09/15/17 and 09/22/17, revealed no documented problems with the condition of the lifts. Interview with the Director of Housekeeping, on 10/04/17 at 2:36 PM, revealed the lift slings were inspected for holes, tears, and missing buckles. She stated the slings were inspected if staff sent them to be washed and not a lot of the slings came through laundry to be washed. Review of the Lift Sling Tracking log, for (MONTH) (YEAR), revealed sling #20 was inspected on 09/06/17 and in new condition, sling #21 was inspected on 09/16/17 and in good condition, and sling #23 was inspected on 09/24/17 and in good condition. Interview with RN #2, on 10/05/17 at 9:24 AM, revealed she monitored CNAs using lifts if she happened to be in the room when the CNAs were providing care. The RN stated prior to the incident with Resident #2, Resident #4 reported CNA #5 had transferred him/her with a mechanical lift without assistance and the CNA was re-educated on the correct procedure for transfers using a lift. Review of Resident #4's quarterly MDS, dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status score of twelve (12) out of fifteen (15) and determined the resident interviewable. Interview with Resident #4, on 10/05/17 at 9:55 AM, revealed a CNA had transferred him/her with a mechanical lift without the assistance of a second person. The resident further stated the incident happened a long time ago and he/she was unable to recall the name of the CNA. Interview with the Director of Nursing (DON), on 10/05/17 at 10:29 AM, revealed there were no identified concerns regarding staff use of the mechanical lifts prior to the incident with Resident #2. The DON stated there should be two (2) people for transfers with mechanical lift to ensure resident safety and CNA #5 did not follow the correct procedure for using the lift. Interview with the Administrator, on 10/05/17 at 11:16 AM, revealed he was not aware of any concerns regarding the improper use of mechanical lifts. The Administrator revealed CNA #5 failed to follow the correct procedure for use of the mechanical lift to ensure the resident's safety and reduce the risk of an accident.

Based on interview, record review and facility policy review and review of the facility's incident report, it was determined the facility failed to have an effective system to ensure the development of an interim care plan to meet the needs of a newly admitted resident to reduce the risk of elopement for one (1) of nineteen (19) sampled residents, Resident #7. On 08/19/15, Resident #7 eloped from the facility without staff knowledge. An employee of the facility was walking to the bus stop on a busy two-lane road after completing his shift and observed the resident sitting in a wheelchair and attempting to cross a busy two-lane road approximately 0.4 miles from the facility. The temperature was eighty-six (86) degrees Fahrenheit (F) with intermittent clouds and a breeze up to fourteen (14) miles per hour. The resident was wearing an orange shirt, bib overalls, a hat, and sneakers. The resident was returned to the facility at approximately 3:30 PM and assessed with [REDACTED]. The facility's failure to ensure a care plan was developed to direct staff in the monitoring of a newly admitted resident with exit seeking behavior has caused or is likely to cause serous injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 08/27/15 and determined to exist on 08/19/15. The facility was notified of the Immediate Jeopardy on 08/27/15. The facility provided an acceptable allegation of compliance (AOC) on 09/02/15 alleging compliance on 08/29/15. The State Survey Agency validated the removal of Immediate Jeopardy on 08/29/15 as alleged prior to exit on 09/10/15. The scope and severity was lowered to a D while the facility implements the Plan of Correction and the facility's Quality Assurance monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy regarding Elopement, dated 02/18/09, revealed the facility would assess all residents for elopement risk upon admission, between day three (3) and day seven (7), between day thirty (30) and day forty-five (45), quarterly and with any significant change in Activities of Daily Living (ADL) function or cognitive function. The facility would use the Elopement Risk Assessment. The elopement risk assessment would indicate a resident had an increased risk for elopement if the facility determined the answer to two (2) or more of the five (5) questions on the assessment was a YES. The assessment further stated if a resident had two (2) or more Yes answers and the facility determined the resident was not at risk for elopement, the facility would provide rationale. If the assessment determined the resident was at risk for elopement, the facility would develop a care plan to include interventions such as increased monitoring, use of one-on-one services, bed alarms, code alerts, and activity programs. The policy further stated the facility should develop a plan to eliminate or reduce the risk of elopement. Interview with the Administrator, on 08/27/15 at 4:07 PM, revealed the facility used the Resident Assessment Instrument (RAI) Manual for the development and revision of initial and interim care plans. The Administrator provided a printout of a power point presentation the facility used to train staff on care plan development and updating. Review of the Resident Assessment Instrument (RAI) manual, Minimum Data Set (MDS), Chapter 4, page revealed a good assessment is the starting point for good clinical problem solving, decision making, and for the creation of a sound care plan. The manual revealed the facility should have collected information that was needed to identify an individual's strengths and risks by obtaining a personal and medical history. The facility would identify the resident's prior wandering behaviors and determined whether those behaviors put the resident at significant risk of getting into potentially dangerous situations/places. The facility would identify any current consequences of the individual's situation and defined significant risk factors. The facility would implement interventions to address the individual's concerns and risks. Review of the facility's Power Point presentation titled Care Planning, 04/08/13, revealed the facility identified three (3) types of care plans: the initial care plan; the comprehensive care plan; and, the acute care plan. The facility would initiate the standard template with admission and complete it within twenty-four (24) hours. The standard template served as the initial care plan and the nurse aide care sheet. When building a care plan, the facility used assessments including the elopement assessment. Review of the facility's Combined Incident Report/Final Report, dated 08/20/15, revealed on 08/19/15 the Administrator had observed Resident #7 walking in the facility around 3:05 PM on 08/19/15. At approximately 3:30 PM, an employee walking toward the bus stop observed the resident headed toward the bus stop and brought the resident back to the facility. Review of the document further revealed on 08/20/15 the facility discovered Resident #7 had a history of [REDACTED]. The POA informed the facility the resident had a history of [REDACTED]. Interview with the Admissions Director, on 08/27/15 at 1:35 PM, revealed she did not specifically ask Resident #7 or the resident's Power of Attorney (POA) if the resident had a history of [REDACTED]. However, the facility did not utilize a pre-admission assessment for residents moving from their homes. The Admissions Director stated she conducted the admission with Resident #7 and the resident's POA on the evening of 08/17/15. The Admissions Director explained to the POA that the facility had limitations concerning elopements in that the facility did not have a locked Memory Care Unit. The Admissions Director further stated she did not ask the POA if the resident had a history of [REDACTED]. She stated the POA did not disclose any information regarding whether or not the resident had a history of [REDACTED]. Review of the clinical record for Resident #7 revealed the facility admitted the resident on 08/17/15 with [DIAGNOSES REDACTED]. Review of the Brief Interview for Mental Status (BIMS), dated 08/18/15, revealed the facility assessed the resident to have a BIMS score of six (6) of fifteen (15) indicating the resident was not interviewable and had moderate cognitive impairment. Review of the Nursing Observations Assessment, dated 08/17/15 at 4:12 PM, revealed the facility admitted Resident #7 from home by wheelchair. The resident was accompanied by his/her spouse/POA. The resident had a history of [REDACTED]. The resident was alert, but had impaired memory. The assessment stated the resident and the resident's POA stated the resident was able to ambulate independently without the assistance of any device. The assessment further stated the resident's POA was present during the admission process. Review of the Elopement Risk Screen, dated 08/17/15, revealed the facility assessed Resident #7 as not at risk for elopement. The facility completed the Elopement Risk Screen upon admission of the resident to the facility. The screen consisted of five (5) questions. The nurse marked the assessment with three (3) yes answers and two (2) no answers. The assessment stated the resident did not wander and did not have a history of elopement. The screen stated at the bottom of the assessment that two (2) or more YES answers indicated possible risk for elopement. It further stated if a resident had two (2) or more YES answers and nursing determined the resident was not at risk, nursing would provide a rationale. The nurse completing the assessment documented, the resident was currently alert and oriented, was here to get stronger, for return to home with the spouse and there was no risk for elopement at this time. Interview with the MDS Coordinator, on 08/27/15 at 1:50 PM, revealed the Unit Managers were responsible for completing the initial one page care plan when a resident was admitted to the facility. MDS reviewed the initial care plan and created the hand written interim care plan for the resident. Afterwards, any Nurse or Nurse Manager could update the interim care plan. Interview with the Green House Supervisor, on 8/27/15 at 2:40 PM, revealed she did not include elopement risk on the interim care plan for Resident #7. The Green House Supervisor completed the intake assessments, including the elopement screen, and the interim care plan. She did not assess Resident #7 as an elopement risk and therefore did not place elopement risk on the interim care plan. The Green House Supervisor completed the initial elopement evaluation and did not ask Resident #7 or the resident's POA if the resident had a history of [REDACTED]. Review of the Interim Care Plan for Resident #7, dated 08/17/15, revealed the facility placed no interventions identifying or reducing the elopement risk on the resident's Interim Care Plan. Review of the Physician's Telephone Orders for Resident #7, dated 08/19/15, revealed the facility received an order to place a code alert to the resident's ankle. The order included instruction for staff to check the placement of the code alert bracelet every hour. However, review of the Interim Care Plan for Resident #7, dated 08/18/15, revealed an interim care plan for elopement was not developed until 08/20/15, three (3) days after admission and two (2) days after the elopement. Interventions in the care plan included staff to check placement of the code alert per physician's orders [REDACTED]. Interview with RN #1, on 08/26/15 at 11:05 AM, revealed the morning of 08/19/15, RN #1 observed the resident gathering his/her belongings. She also observed the resident walking throughout the facility with no walker and the resident stated he/she was looking for their truck. RN #1 stated she consulted with the Assistant Unit Manager and placed a code alert bracelet on Resident #7's wrist; but did not develop an interim care plan for elopement. Interview with the Blue Assistant Unit Manager, on 08/26/15 at 3:20 PM, revealed RN #1 informed her of Resident #7's increased exit seeking behaviors. RN #1 placed a code alert bracelet on the resident due to the resident wandering the facility and looking for his/her truck. The Assistant Unit Manager stated she was the acting supervisor for the nurses on the floor, but did not ensure the RN for Resident #7 developed an interim care plan for elopement. The Assistant Unit Manager stated she did not communicate the increased exit seeking behaviors with other staff and did not add any increased supervision to ensure the safety of the resident. Interview with the Director of Nursing (DON), on 08/27/15 at 2:18 PM, revealed the facility did not develop and interim care plan for Resident #7 after becoming aware of an increased elopement risk. The DON stated because nursing had already placed the code alert on the resident, she assumed the nursing staff had completed other requirements, such as placing it on the care plan. The DON stated she did not check until after the resident eloped later on that afternoon. Interview with the Administrator, on 08/27/15 at 4:07 PM, revealed the facility did not care plan Resident #7 for increased risk for elopement due to not performing a thorough assessment to determine Resident #7 was at increased risk for elopement. Part of completing the elopement assessment included staff asking family about elopement risk. The facility did not identify Resident #7 as an elopement risk until 08/19/15. Admissions addressed elopement risks with the family; however, they were not required to ask the family if the resident had a history of [REDACTED]. Interview with Resident #7's POA, on 08/25/15 at 1:45 PM, revealed the facility did not ask the POA about elopement concerns, precautions, or interventions prior to the resident eloping from the facility. The facility took the following actions to remove the Immediate Jeopardy: 1. The Elopement Policy was reviewed by the Administrator, Director of Nursing (DON), Unit Managers, Corporate staff and Medical Director on 08/28/15. The Elopement Policy required: residents to be screened upon admission/readmission, between day three (3) and seven (7), between day thirty (30) and forty-five (45), quarterly and with any significant change. Residents identified at risk for elopement would have a care plan developed to eliminate or reduce the risk of elopement. The facility would maintain a list of all residents identified at risk for elopement at the reception area and in each Medication Administration Record (MAR). If a Code Alert bracelet was utilized, placement was checked every shift and function was checked no less than weekly. All monitored doors would be checked not less than weekly for function. 2. All current ninety-four (94) residents' Elopement Risk Screens were reviewed to ensure accurate and timely assessments and the care plans and nurse aide care plans for the twelve (12) residents identified at risk for elopement were reviewed to ensure all appropriate interventions were in place, on 08/27/15 by the Staff Development Nurse, the Minimum Data Set (MDS) nurse, the Assistant Director of Nursing (ADON) and Unit Mangers. All were determined to be correct with exception of one care plan. It was determined all newly admitted residents would have an Elopement Risk Screen completed by the admitting nurse and the Elopement Risk Screen would be reviewed by the Director of Nursing, Unit Manager or House Supervisor to ensure accurate screening to begin 08/27/15 and continue for three (3) months. In addition, the Unit Managers and Assistant Managers verified the list of residents identified at risk for elopement was on each MAR and at the reception area on 08/27/15. On 08/28/15, the MARs and Treatment Administration Records (TARs) were checked by the DON retroactively to 08/01/15 for the twelve (12) residents identified as at risk for elopement to ensure all placement and function checks were completed. 3. The Administrator completed a review of all exterior door function checks on 08/27/15 for the past sixty (60) days to ensure the policy was followed. 4. On 08/28/15 a Quality Assurance (QA) meeting was held with the Medical Director, Corporate Consultant, Vice President of Operations, Administrator, DON and Unit Managers to review the Immediate Jeopardy (IJ) notification and the process and interventions to remove the IJ, review of facility policy and actions currently underway in regards education and audits. All in attendance at the meeting voiced understanding and agreement with the plan with no additional recommendations made. It was determined at the meeting all audits would be reported to a QA subcommittee that would meet no less than monthly for six (6) months and then no less than quarterly to ensure sustained compliance. 5. Re-education on the Elopement Policy, Elopement Risk Screen, Behavioral Indicators for Exit Seeking Behavior and interventions to address exit seeking behavior was initiated on 08/27/15 and concluded on 08/28/15 for staff. No staff would be allowed to work until re-educated. The re-education included a pre and post test and was completed by the Administrator, DON, and Administrative Nurses to include MDS, Staff Development, House Supervisor, Unit Managers and Assistant Unit Managers. The facility did not utilize agency staff but did utilize contract therapy staff. All regular contract therapy staff had been trained on 08/28/15 and no as needed (prn) contract staff would be allowed to work until re-educated. 6. On 08/28/15 education on the Elopement Policy, Elopement Risk Screen, Behavioral Indicators for Exit Seeking Behavior and Interventions to address exit seeking behaviors was added to the new hire orientation by the Staff Development Coordinator and that education would be repeated no less than annually by administrative nurses including Staff Development, the Administrator, DON, ADON and Unit Managers. 7. Audits on Elopement Risk Screens, MAR, TAR, Care Plans and Nurse Aide Care Plans were to be done daily for seven (7) days, then weekly for three (3) weeks, then monthly for twelve (12) months to ensure accuracy and timeliness of the screens and placement and function checks with audits initiated on 08/28/15. Audits of all exterior door checks initiated on 08/28/15 are to be done weekly for three (3) months then monthly for twelve (12) months. Audit of review of new Elopement Risk Screens to be done weekly for three (3) months and was initiated on 08/28/15. Audits of education for newly hired employees to be completed weekly for twelve (12) months were initiated on 08/28/15. Audit of list at reception area and on MAR of all residents at risk for elopement to be completed weekly for three (3) weeks and then monthly for twelve (12) months were initiated on 08/28/15. The State Survey Agency validated the implementation of the acceptable AOC as follows: 1. Review of the facility Elopement Policy on 09/10/15 revealed it contained all points as alleged. Interview with the Administrator, on 09/10/15 at 8:58 AM, the Director of Nursing (DON), on 09/10/15 at 9:25 AM, the Unit Manager, on 09/10/15 at 9:40 AM, the Blue Unit Manager, on 09/10/15 at 10:04 AM, the Vice President of Operations, on 09/10/15 at 10:25 AM via telephone, the Corporate Consultant, on 09/10/15 at 10:35 AM and the Medical Director, on 09/10/15 at 8:45 AM revealed they had reviewed the facility's Elopement Policy as alleged on 08/28/15. 2. Review of the clinical records for sampled Residents' #20, #21, #22 and #23, who were assessed as elopement risks, revealed all had accurate, timely Elopement Risk Screens and appropriate interventions in place on their care plans and nurse aide care plans. Review of the MARs and TARs for Residents #20, #21, #22 and #23 revealed they had all placement and function checks completed for their Code Alert Bracelets documented back to 08/01/15. Interview with the Staff Development Nurse, on 09/10/15 at 9:45 AM, the Green Unit Nurse Manager, on 09/10/15 at 9:40 AM, and the Blue Unit Nurse Manager, on 09/10/15 at 10:04 AM, revealed they were all involved in an audit of the ninety-four (94) residents' (census as of 08/27/15) Elopement Risk Screens on 08/27/15 to ensure accurate and timely assessments. In addition, the Staff Development nurse, the Green Unit Nurse Manager, the Blue Unit Nurse Manager, the Green Unit Assistant Manager, on 09/10/15 at 9:10 AM and the Blue Unit Assistant Manager, on 09/10/15 at 9:58 AM, all revealed they participated in reviewing the care plans and the nurse aide care plans to ensure appropriate interventions were in place on 08/27/15 for risk of elopement. Further interview with the Green Unit Nurse Manager, the Blue Unit Nurse Manager, the Green Unit Assistant Manager, on 09/10/15 at 9:10 AM and the Blue Unit Assistant Manager, on 09/10/15 at 9:58 AM, all revealed they verified the list of residents identified at risk for elopement was on each MAR and at the reception area on 08/27/15. Interview with the DON, on 09/10/15 at 9:25 AM, the Green Unit Nurse Manager, on 09/10/15 at 9:40 AM, the Blue Unit Nurse Manager, on 09/10/15 at 10:04 AM, and an RN Supervisor, on 09/10/15 at 12:30 PM, revealed they understood they were to review the Elopement Risk Screen completed for all newly admitted residents. No residents had been newly admitted . 3. Review of exterior door function checks revealed they had been completed for sixty (60) days prior to 8/27/15 per the facility policy. Interview with Maintenance Staff #1 and Maintenance Staff #2, on 09/10/15 at 10:15 AM, revealed they had been completing the door function checks per the facility policy for the sixty (60) days prior to 08/27/15 and were continuing to do so. They indicated they had and would continue to provide computer generated print-outs of the door checks to the Administrator. Interview with the Administrator, on 09/10/15 at 9:10 AM, revealed she did receive and was continuing to receive the door function checks from the Maintenance personnel and she was conducting an audit of those function checks as evidenced by her signature and date reviewed on the computer print-outs for the door checks. Observation of the exterior doors on the Blue Unit, the 600 hallway, the Blue Unit dining room, the main dining room, the back door by the kitchen, the Green Unit dining room, the 300 hallway and the 200 hallway, on 09/10/15 from 8:25 AM - 9:15 AM, revealed all alarms operational per policy. 4. Review of the Quality Assurance (QA) Meeting signature sheet revealed a meeting was held on 08/28/15 to review the Immediate Jeopardy (IJ) Notification, the process to remove the IJ, review of the facility Elopement Policy and actions to be taken in regard education and audits. Telephone interview with the Vice President of Operations, on 09/10/15 at 10:25 AM, and the Corporate Consultant, on 09/10/15 at 10:35 AM revealed they had been present in the QA Meeting held on 08/27/15 at the facility and it was decided all audits would be reported to a QA subcommittee which would meet no less than monthly for six (6) months and then no less than quarterly to ensure sustained compliance. Interview with the Administrator, on 09/10/15 at 8:58 AM, revealed she had been present in the QA Meeting held on 09/10/15 to discuss the U. Interview with the Director of Nursing (DON), on 09/10/15 at 9:25 AM, revealed she had been present in the QA Meeting held on 09/10/15 to discuss the IJ and interview with the Blue and Green Unit Managers, on 09/10/15 at 9:40 AM and 10:04 AM, revealed they had also been present in that QA Meeting. Interview with the Medical Director, on 09/10/15 at 8:45 AM, revealed he had been present at the QA Meeting to review the IJ Notification, the process to remove the I.), review of the facility Elopement Policy and actions to be taken in regard education and audits. 5. Telephone interview with the Vice President of Operations, on 09/10/15 at 10:25 AM, and the Corporate Consultant, on 09/10/15 at 10:35 AM revealed they held a meeting on 08/27/15 to re¿educate the administrative staff of the facility on the Elopement Policy, the Elopement Risk Screen, behavioral indicators for exit seeking behavior and interventions to address exit seeking behaviors. Interview with the Administrator, on 09/10/15 at 8:58 AM, the DON, on 09/10/15 at 9:25 AM, the Green Unit Manager, on 09/10/15 a 9:40 AM, the Blue Unit Manager, on 09/10/15 at 10:04 AM, the Staff Development Nurse, on 09/10/15 at 9:45 AM, the Blue Unit Assistant Nurse Manager, on 09/10/15 at 9:58 AM, the Green Unit Assistant Nurse Manager, on 09/10/15 at 9:10 AM, and the RN Supervisor, on 09/10/15 at 12:30 PM, revealed they had received re-education on the Elopement Policy, the Elopement Risk Screen, behavioral indicators for exit seeking behaviors and interventions to address exit seeking behaviors by the Vice President of Operations and the Corporate Consultant on 08/27/15 and prior to the administrative staff giving any re-training to the other facility staff. They all indicated they participated in re-training the other facility staff ending on 08/28/15 and indicated no staff would be allowed to work until they had received the re-training. 6. Interview with the Staff Development Nurse, on 09/10/15 at 9:45 AM, revealed she had done most of the staff re-training beginning on 08/27/15 and ending on 08/28/15 and she had added training on the Elopement Policy, the Elopement Risk Screen, behavioral indicators for exit seeking behavior and interventions to address exit seeking behaviors to the new hire orientation and that training would be repeated for facility staff no less than annually by administrative nurses. Review of the new hire orientation documents revealed the training had been added to the content by the Staff Development Nurse as alleged. 7. Audits on Elopement Risk Screens, MARs, TARs, Care Plans and Nurse Aide Care Plans, exterior door checks, education of newly hired employees, and the audit of the list of residents at risk of elopement kept at the reception area and on the MARs for those residents completed by 09/10/15 were reviewed and were completed as alleged. Interview with the DON, on 09/10/15 at 9:25 AM, the Green Unit Manager, on 09/10/15 at 9:40 AM, the Blue Unit Manager, on 09/10/15 at 10:04 AM, the Staff Development Nurse, on 09/10/15 at 9:45 AM, the Blue Unit Assistant Nurse Manager, on 09/10/15 at 9:58 AM, the Green Unit Assistant Nurse Manager, on 09/10/15 at 9:10 AM, revealed they were involved in doing audits of the list of residents at risk of elopement kept at the reception area and on the MARs and TARs and of their Elopement Risk Assessments, care plans and nurse aide care plans and submit those audits to the Administrator. Interview with Maintenance #1 and Maintenance #2, on 09/10/15 at 10:15 AM, revealed they had been completing the door function checks per the facility policy and submit those checks to the Administrator as alleged. Interview with the Administrator, on 09/10/15 at 8:58 AM, revealed she received all audits to date and reviewed them and will continue to do so to ensure sustained compliance.

Based on observation, interview, record review, policy review and review of the facility's incident reports, it was determined the facility failed to have an effective system to provide adequate supervision to prevent the elopement of one (1) of nineteen (19) sampled residents, Resident #7. On 08/19/15, Resident #7 eloped from the facility without staff knowledge. An employee of the facility was walking to the bus stop on a busy two-lane road after completing his shift and observed the resident sitting in a wheelchair and attempting to cross a busy two-lane road approximately 0.4 miles from the facility. The temperature was eighty-six (86) degrees Fahrenheit (F) with intermittent clouds and a breeze up to fourteen (14) miles per hour. The resident was wearing an orange shirt, bib overalls, a hat, and sneakers. The resident was returned to the facility at approximately 3:30 PM and assessed with [REDACTED]. The facility's failure to ensure adequate supervision was provided to prevent the elopement of a newly admitted resident with a history of elopement has caused or is likely to cause serous injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 08/27/15 and determined to exist on 08/19/15. The facility was notified of the Immediate Jeopardy on 08/27/15. The facility provided an acceptable allegation of compliance (AOC) on 09/02/15 alleging compliance on 08/29/15. The State Survey Agency validated the removal of Immediate Jeopardy on 08/29/15 as alleged prior to exit on 09/10/15. The scope and severity was lowered to a D while the facility implements the Plan of Correction and the facility's Quality Assurance monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled Elopement, dated 02/18/09, revealed the facility would assess all residents for elopement risk upon admission and with any significant change in Activities of Daily Living (ADL) function or cognitive function. The facility would use the Elopement Risk Assessment. The Elopement Risk Assessment would indicate a resident had an increased risk for elopement if the facility determined the answer to two (2) or more of the five (5) questions on the assessment was a Yes. The assessment further stated if a resident had two (2) or more Yes answers and the facility determined the resident was not at risk for elopement, the facility would provide a rationale. If the assessment determined the resident was at risk for elopement, the facility would develop a care plan to include interventions such as increased monitoring, use of one-on-one services, bed alarms, code alerts, and activity programs. The policy further stated the facility should develop a plan to eliminate or reduce the risk of elopement. Review of the clinical record for Resident #7 revealed the facility admitted the resident on 08/17/15 with [DIAGNOSES REDACTED]. Review of the Nursing Observations Assessment, dated 08/17/15 at 4:12 PM, revealed the facility admitted Resident #7 from home by wheelchair. The resident was accompanied by his/her spouse/Power of Attorney (POA). The resident had a history of [REDACTED]. The resident was alert, but had impaired memory. The assessment stated the resident and the resident's POA said Resident #7 was able to ambulate independently without the assistance of any device. Review of the Elopement Risk Screen, dated 08/17/15, revealed the Green House Unit Supervisor completed the Elopement Risk Screen upon admission of Resident #7 to the facility. The screen consisted of five (5) questions. The nurse marked YES to the first question stating the resident was physically able to leave the facility on his/her own. The nurse marked YES to the second question stating the resident was a new admission. The nurse marked YES to the third question stating the resident exhibited periods of confusion. The nurse marked NO to the fourth question indicating the resident did not have a history of leaving the facility or the home. The nurse marked NO to the last question indicating the resident did not exhibit periods of pacing, agitation, or wandering. The screen stated at the bottom of the assessment that two (2) or more YES answers indicated possible risk for elopement. It further stated if a resident had two (2) or more YES answers, and nursing determined the resident was not at risk, nursing would provide a rationale. The nurse completing the assessment documented, Resident is currently alert and oriented, states that (he/she) is here to get stronger, so that he/she can return home with spouse. 0 risk for elopement at this time. Interview with the Green House Unit Supervisor, on 08/27/15 at 2:40 PM, revealed she completed the initial elopement evaluation and did not ask Resident #7 or the resident's POA if the resident had a history of [REDACTED]. The Green House Unit Supervisor stated she did ask the resident if he was planning to leave the facility. The resident replied saying he/she was there to get better. The Green House Unit Supervisor also stated the resident was able to say where he/she was and what day it was. Therefore, despite the three (3) YES answers on the Elopement Risk Screen, the Green House Unit Supervisor stated at the time she did not believe the resident was at risk for elopement. The Green House Unit Supervisor stated she did not directly ask the resident or his/her POA if the resident had any prior history of elopement. Review of the Initial Care Plan for Resident #7, dated 08/17/15, revealed the facility placed no interventions identifying or reducing the elopement risk on the resident's Initial Care Plan. Review of the Brief Interview for Mental Status (BIMS), 08/18/15, revealed the facility assessed the resident to have a BIMS score of six (6) of fifteen (15) indicating the resident was not interviewable and had moderate cognitive impairment. Review of the facility's Combined Incident Report/Final Report, dated 08/20/15, revealed the Administrator observed Resident #7 walking down the 400 Hall of the facility around 3:05 PM on 08/19/15. At approximately 3:30 PM, an employee walking toward the bus stop observed the resident headed toward the bus stop and brought the resident back to the facility. Interview with the Dietary Aid, on 08/26/15 at 2:15 PM, revealed the Dietary Aid discovered Resident #7 crossing a busy two-lane road unattended on 08/19/15 a little after 3:00 PM. The Dietary Aid stated his shift ended at 3:00 PM and he was heading toward the bus stop when he realized he had forgotten something and returned to the facility. Then he proceeded to the bus stop where he observed an elderly person sitting in a wheelchair and self-propelled across the two-lane road. The Dietary Aid approached the elderly person and recognized him/her as Resident #7. He told the resident that he had to take him/her back to the facility. The resident resisted some by placing his/her hands on the armrests as if to stand-up and by pushing back into the chair. The Dietary Aid told the resident that he/she must sit down and the resident stopped resisting. Resident #7 told the Dietary Aid that he/she just wanted to go outside and get some fresh air. He stated the resident was wearing an orange shirt, bib overalls, a hat, and sneakers. Interview with the Physical Therapist Assistant (PTA), on 08/26/15 at 2:45 PM, revealed the resident had exhibited exit-seeking behaviors prior to 08/19/15. The PTA stated Resident #7 packed up his/her belongings every day as if to leave the facility. This behavior started the first day the resident was at the facility. The resident also talked about needing to get to his/her truck on the first day at the facility. However, per interview she did not report these behaviors to nursing staff. The PTA stated she did not identify these actions as elopement risks because the actions were similar to other residents at the facility who would often discuss their past lives as if it were the present. Interview with Certified Nursing Assistant (CNA) #1, on 08/26/15 at 3:05 PM, revealed Resident #7 had been exit seeking on 08/18/15, the day before he/she eloped from the facility. CNA #1 stated on the morning of 08/18/15 Resident #7 met her at the door and asked the CNA to help find his/her truck. The CNA stated she did inform the nurse of the resident's exit seeking behaviors, but was unaware of what actions nursing took to protect the resident. Interview with Blue House Unit Manager, on 08/26/15 at 3:30 PM, revealed Resident #7 discussed wanting to leave the facility prior to 08/19/15. The Blue House Unit Manager stated Resident #7 began saying he/she needed to go home and cut the grass on 08/18/15, the day prior to the elopement. The Blue House Unit Manager stated he did not consider these statements as exit seeking and did not report the statements about wanting to leave the facility. Interview with Registered Nurse (RN) #1, on 08/26/15 at 11:05 AM, revealed on the morning of 08/19/15, RN #1 observed the resident gathering his/her belongings. She also observed the resident walking throughout the facility with no walker. The resident told the RN that he/she was looking for their truck. RN #1 stated she consulted with the Assistant Unit Manager and placed a code alert bracelet on Resident #7's wrist the morning of 08/19/15. RN #1 stated she did not remember documenting the placement of the code alert bracelet in the nurses' notes. RN #1 also stated she did not call the physician for an order for [REDACTED]. After placing the code alert bracelet, RN #1 informed the CNA, but did not put in place a specific increment of time or check-list in which to increase supervision. She stated the resident was out of the room and walking around the facility more that day; however, she did not notify staff about the resident's increased walking. RN #1 did not update the Care Plan to address elopement risk or include elopement risk interventions. She stated she thought the supervisor would update the care plan after completing an elopement risk assessment. RN #1 revealed she last observed Resident #7 when she provided care between 1:00 PM and 1:30 PM on 08/19/15. Continued interview with CNA #1, on 08/26/15 at 3:05 PM, revealed on 08/19/15, RN #1 informally and verbally told the CNA to check on Resident #7 more often and that the resident had a code alert bracelet. The CNA stated she was not told how often to check on the resident. CNA #1 stated her last observation of Resident #7 on 08/19/15 was approximately 2:30 PM when she gave the resident a soda. Interview with Assistant Unit Manager (AUM), on 08/26/15 at 11:20 PM, revealed she was the acting supervisor for the nurses on the floor on 08/19/15. She did not notify staff, document, or increase supervision of Resident #7 after RN #1 reported the resident exhibited increased exit seeking behaviors on the morning of 08/19/15. Pre interview, RN #1 placed a code alert bracelet on the resident due to the resident wandering the facility and looking for his/her truck. The Assistant Unit Manager stated for the safety of the resident, a nurse might place a code alert bracelet on a resident first, and then obtain a physician's orders [REDACTED].#7 made a notation on the care plan or in the nurse's notes of the addition of the code alert bracelet. Additionally, the Assistant Unit Manager on duty was responsible for completing a new Elopement Risk Assessment, however, she did not complete the assessment during the shift. Interview with the Director of Nursing (DON), on 08/27/15 at 2:18 PM, revealed Resident #7 had walked out of the facility on the morning of 08/19/15 while wearing a code alert bracelet. Per interview, at 7:30 AM on the morning of 08/19/15 she observed Resident #7 pushing his/her wheelchair with his/her belongings in the seat of the wheelchair. She stated the resident was wearing the code alert; walked out the front door; and, met a facility manager, who then walked around outside with the resident. However, the facility did not increase supervision or complete an elopement assessment at that time. Further interview with the AUM, on 08/26/15 at 11:20 PM revealed she went to the morning meeting, Interdisciplinary Team (IDT) meeting; however, she did not discuss Resident #7's new alarm or the exit seeking behaviors with staff in the IDT meeting. The AUM stated she had left the floor to attend meetings and returned to the floor around noon. At that time, she stated she was doing several other tasks and did not return to the subject of Resident #7's elopement risk. Further interview with the Blue Unit Manager, on 08/27/15 at 9:50 AM, revealed she attended the morning meeting and discussed Resident #7's exit seeking behaviors. However, in the meeting, nursing did not state they had placed the code alert bracelet on the resident just that morning. The facility did not discuss increasing supervision for Resident #7 at this meeting. Further interview with the DON, on 08/27/15 at 2:18 PM, revealed in the morning meeting on 08/19/15, staff discussed the resident's exit seeking behaviors; that the resident was wearing a code alert bracelet; and, that nursing would monitor the resident. However, interviews with staff said this was not discussed during the meeting. Review of the Nursing Notes, dated 08/19/15 at 3:46 PM, revealed an employee found Resident #7 by a bus stop. In the note, the nurse stated the resident was not wearing the code alert bracelet. Nursing found the bracelet in one of the resident's bags. The facility informed the Physician and the resident's family. At the time of the resident's return to the facility, the resident was stating he/she was looking for their truck. Interview with the Blue House Unit Manager, on 08/27/15 at 9:50 AM, revealed she was at the facility when the Dietary Aid returned Resident #7 to the facility. The resident was not wearing a code alert bracelet when he/she returned. Nursing staff found the bracelet in the resident's room among his/her other belongings. The Blue Unit Manager placed a new code alert bracelet on the resident's ankle. Review of the Physician's Telephone Orders for Resident #7, dated 08/19/15, revealed the facility received an order to place a code alert to the resident's ankle. The order included instruction for staff to check the placement of the code alert bracelet every hour. However, review of the Medication Administration Record (MAR), dated 08/17/15 through 08/31/15, revealed the facility did not begin checking the resident to ensure the code alert bracelet was in place until 08/20/15 at 7:00 AM. Further review of the resident's clinical record revealed a Nursing Note, dated 08/20/15 at 4:11 PM, stating a CNA found a piece of the code alert on the resident's floor. The code alert was still in place at that time. Review of the Nursing Notes, 08/19/15 at 10:30 PM, revealed the Blue House Unit Supervisor discovered Resident #7 in his/her room without wearing the code alert bracelet. He asked the nurse who stated he/she had cut off the code alert bracelet with a pair of toenail clippers. The Blue House Unit Supervisor placed a new code alert on the resident's left ankle. Interview with Licensed Practical Nurse (LPN) #1, on 08/27/15 at 3:00 PM, revealed the LPN discovered Resident #7 was not wearing the second code alert bracelet at 10:00 PM on 08/19/15. The LPN reported she had checked on the resident at approximately 9:30 PM and the resident was wearing the code alert bracelet on his/her ankle. LPN #1 stated the CNA informed her Resident #7 was not wearing the code alert bracelet at approximately 10:00 PM. LPN #1 asked Resident #7 what he/she had in their pocket and the resident pulled out two (2) pair of nail clippers. Nursing staff found the second code alert bracelet in the resident's room and it appeared someone had cut the bracelet in a V shape. The LPN placed a new code alert bracelet on the resident's ankle. Review of the Physician's Telephone Orders for Resident #7, dated 08/20/15, revealed the physician ordered nursing staff to place a code alert device on the resident's wheel chair. Further review of the facility's Combined Incident Report/Final Report, dated 08/20/15, revealed the facility called the resident's Power of Attorney (POA) who informed the facility the resident might have a pocket knife. Employees searched and found a pocket knife and the intact code alert bracelet in the resident's room. The POA also informed the facility the resident had been looking for his/her truck, which the family sold years ago. Nursing placed Resident #7 on increased supervision for nursing to check the code alert every hour. Later in the evening, nursing staff found two (2) nail clippers in the resident's room. Review of the document further revealed that on 08/20/15 the facility discovered Resident #7 had a history of [REDACTED]. The POA informed the facility he/she had a history of [REDACTED]. The document stated the facility did not know about the elopement history at the time of admission. Further interview with the Blue House Unit Manager, on 08/27/15 at 9:50 AM, revealed she talked with the resident's POA who stated the resident might have a pocket knife. Further search of the resident's belongings revealed a pocket knife and two (2) pair of nail clippers. The facility discussed Resident #7's exit seeking behaviors and elopement in morning meeting on 08/20/15. At this time, nursing staff initiated one (1) hour visual checks of the resident to ensure the resident's safety and placement of the code alert bracelet. Nursing staff also updated the resident's care plan and CNA care sheet on 08/20/15. Review of the Interim Care Plan for Resident #7, dated 08/18/15, revealed on 08/20/15 the facility updated the resident's care plan to include elopement interventions. Interventions in the care plan included staff to check placement of the code alert per physician's orders [REDACTED]. Interview with the Administrator, on 08/27/15 at 4:07 PM, revealed Admissions addressed elopement risks with the family; however, they were not required to ask the family if the resident had a history of [REDACTED]. Interview with the Admissions Director, on 08/27/15 at 1:35 PM, revealed she did not specifically ask Resident #7 or the resident's POA if the resident had a history of [REDACTED]. She stated the facility had liaisons who conducted a pre-admission assessment with residents who moved to the facility directly from the hospital. However, the facility did not utilize a pre-admission assessment for residents moving from their homes. The Admissions Director stated she conducted the admission with Resident #7 with the resident's POA present on the evening of 08/17/15. The Admissions Director explained to the POA that the facility had limitations concerning elopements in that the facility did not have a locked memory care unit. The Admissions Director further stated she did not ask the POA if the resident had a history of [REDACTED]. She stated the POA did not disclose any information regarding whether or not the resident had a history of [REDACTED]. Interview with Resident #7's Power Of Attorney (POA), on 08/25/15 at 1:45 PM, revealed the facility did not ask the POA about elopement concerns, precautions, or interventions prior to the resident eloping from the facility. The POA stated the facility admitted Resident #7 from home for short-term rehab following surgery to his/her carotid artery. The POA further stated the resident had Dementia that included short-term memory loss and did not remember eloping from the facility on 08/19/15. The resident presented well in the moment, but may not remember what was going on earlier in the day. The POA stated the resident was often confused. The POA visited with the resident on 08/19/15 during the day and the facility did not discuss elopement concerns with the POA at the time of the visit. The facility called the POA after the resident eloped from the facility on the afternoon of 08/19/15. Observation and interview with Resident #7, on 08/25/15 at 1:45 PM, revealed the resident was able to answer yes/no questions by nodding or shaking his/her head. Resident #7 had no memory of having eloped from the facility on 08/19/15. The facility took the following actions to remove the Immediate Jeopardy: 1. The Elopement Policy was reviewed by the Administrator, Director of Nursing (DON), Unit Managers, Corporate staff and Medical Director on 08/28/15. The Elopement Policy required: residents to be screened upon admission/readmission, between day three (3) and seven (7), between day thirty (30) and forty-five (45), quarterly and with any significant change. Residents identified at risk for elopement would have a care plan developed to eliminate or reduce the risk of elopement. The facility would maintain a list of all residents identified at risk for elopement at the reception area and in each Medication Administration Record (MAR). If a Code Alert bracelet was utilized, placement was checked every shift and function was checked no less than weekly. All monitored doors would be checked not less than weekly for function. 2. All current ninety-four (94) residents' Elopement Risk Screens were reviewed to ensure accurate and timely assessments and the care plans and nurse aide care plans for the twelve (12) residents identified at risk for elopement were reviewed to ensure all appropriate interventions were in place, on 08/27/15 by the Staff Development Nurse, the Minimum Data Set (MDS) nurse, the Assistant Director of Nursing (ADON) and Unit Mangers. All were determined to be correct with exception of one care plan. It was determined all newly admitted residents would have an Elopement Risk Screen completed by the admitting nurse and the Elopement Risk Screen would be reviewed by the Director of Nursing, Unit Manager or House Supervisor to ensure accurate screening to begin 08/27/15 and continue for three (3) months. In addition, the Unit Managers and Assistant Managers verified the list of residents identified at risk for elopement was on each MAR and at the reception area on 08/27/15. On 08/28/15, the MARs and Treatment Administration Records (TARs) were checked by the DON retroactively to 08/01/15 for the twelve (12) residents identified as at risk for elopement to ensure all placement and function checks were completed. 3. The Administrator completed a review of all exterior door function checks on 08/27/15 for the past sixty (60) days to ensure the policy was followed. 4. On 08/28/15 a Quality Assurance (QA) meeting was held with the Medical Director, Corporate Consultant, Vice President of Operations, Administrator, DON and Unit Managers to review the Immediate Jeopardy (IJ) notification and the process and interventions to remove the IJ, review of facility policy and actions currently underway in regards education and audits. All in attendance at the meeting voiced understanding and agreement with the plan with no additional recommendations made. It was determined at the meeting all audits would be reported to a QA subcommittee that would meet no less than monthly for six (6) months and then no less than quarterly to ensure sustained compliance. 5. Re-education on the Elopement Policy, Elopement Risk Screen, Behavioral Indicators for Exit Seeking Behavior and interventions to address exit seeking behavior was initiated on 08/27/15 and concluded on 08/28/15 for staff. No staff would be allowed to work until re-educated. The re-education included a pre and post test and was completed by the Administrator, DON, and Administrative Nurses to include MDS, Staff Development, House Supervisor, Unit Managers and Assistant Unit Managers. The facility did not utilize agency staff but did utilize contract therapy staff. All regular contract therapy staff had been trained on 08/28/15 and no as needed (prn) contract staff would be allowed to work until re-educated. 6. On 08/28/15 education on the Elopement Policy, Elopement Risk Screen, Behavioral Indicators for Exit Seeking Behavior and Interventions to address exit seeking behaviors was added to the new hire orientation by the Staff Development Coordinator and that education would be repeated no less than annually by administrative nurses including Staff Development, the Administrator, DON, ADON and Unit Managers. 7. Audits on Elopement Risk Screens, MAR, TAR, Care Plans and Nurse Aide Care Plans were to be done daily for seven (7) days, then weekly for three (3) weeks, then monthly for twelve (12) months to ensure accuracy and timeliness of the screens and placement and function checks with audits initiated on 08/28/15. Audits of all exterior door checks initiated on 08/28/15 are to be done weekly for three (3) months then monthly for twelve (12) months. Audit of review of new Elopement Risk Screens to be done weekly for three (3) months and was initiated on 08/28/15. Audits of education for newly hired employees to be completed weekly for twelve (12) months were initiated on 08/28/15. Audit of list at reception area and on MAR of all residents at risk for elopement to be completed weekly for three (3) weeks and then monthly for twelve (12) months were initiated on 08/28/15. The State Survey Agency validated the implementation of the acceptable AOC as follows: 1. Review of the facility Elopement Policy on 09/10/15 revealed it contained all points as alleged. Interview with the Administrator, on 09/10/15 at 8:58 AM, the Director of Nursing (DON), on 09/10/15 at 9:25 AM, the Unit Manager, on 09/10/15 at 9:40 AM, the Blue Unit Manager, on 09/10/15 at 10:04 AM, the Vice President of Operations, on 09/10/15 at 10:25 AM via telephone, the Corporate Consultant, on 09/10/15 at 10:35 AM and the Medical Director, on 09/10/15 at 8:45 AM revealed they had reviewed the facility's Elopement Policy as alleged on 08/28/15. 2. Review of the clinical records for sampled Residents' #20, #21, #22 and #23, who were assessed as elopement risks, revealed all had accurate, timely Elopement Risk Screens and appropriate interventions in place on their care plans and nurse aide care plans. Review of the MARs and TARs for Residents #20, #21, #22 and #23 revealed they had all placement and function checks completed for their Code Alert Bracelets documented back to 08/01/15. Interview with the Staff Development Nurse, on 09/10/15 at 9:45 AM, the Green Unit Nurse Manager, on 09/10/15 at 9:40 AM, and the Blue Unit Nurse Manager, on 09/10/15 at 10:04 AM, revealed they were all involved in an audit of the ninety-four (94) residents' (census as of 08/27/15) Elopement Risk Screens on 08/27/15 to ensure accurate and timely assessments. In addition, the Staff Development nurse, the Green Unit Nurse Manager, the Blue Unit Nurse Manager, the Green Unit Assistant Manager, on 09/10/15 at 9:10 AM and the Blue Unit Assistant Manager, on 09/10/15 at 9:58 AM, all revealed they participated in reviewing the care plans and the nurse aide care plans to ensure appropriate interventions were in place on 08/27/15 for risk of elopement. Further interview with the Green Unit Nurse Manager, the Blue Unit Nurse Manager, the Green Unit Assistant Manager, on 09/10/15 at 9:10 AM and the Blue Unit Assistant Manager, on 09/10/15 at 9:58 AM, all revealed they verified the list of residents identified at risk for elopement was on each MAR and at the reception area on 08/27/15. Interview with the DON, on 09/10/15 at 9:25 AM, the Green Unit Nurse Manager, on 09/10/15 at 9:40 AM, the Blue Unit Nurse Manager, on 09/10/15 at 10:04 AM, and an RN Supervisor, on 09/10/15 at 12:30 PM, revealed they understood they were to review the Elopement Risk Screen completed for all newly admitted residents. No residents had been newly admitted . 3. Review of exterior door function checks revealed they had been completed for sixty (60) days prior to 8/27/15 per the facility policy. Interview with Maintenance Staff #1 and Maintenance Staff #2, on 09/10/15 at 10:15 AM, revealed they had been completing the door function checks per the facility policy for the sixty (60) days prior to 08/27/15 and were continuing to do so. They indicated they had and would continue to provide computer generated print-outs of the door checks to the Administrator. Interview with the Administrator, on 09/10/15 at 9:10 AM, revealed she did receive and was continuing to receive the door function checks from the Maintenance personnel and she was conducting an audit of those function checks as evidenced by her signature and date reviewed on the computer print-outs for the door checks. Observation of the exterior doors on the Blue Unit, the 600 hallway, the Blue Unit dining room, the main dining room, the back door by the kitchen, the Green Unit dining room, the 300 hallway and the 200 hallway, on 09/10/15 from 8:25 AM - 9:15 AM, revealed all alarms operational per policy. 4. Review of the Quality Assurance (QA) Meeting signature sheet revealed a meeting was held on 08/28/15 to review the Immediate Jeopardy (IJ) Notification, the process to remove the IJ, review of the facility Elopement Policy and actions to be taken in regard education and audits. Telephone interview with the Vice President of Operations, on 09/10/15 at 10:25 AM, and the Corporate Consultant, on 09/10/15 at 10:35 AM revealed they had been present in the QA Meeting held on 08/27/15 at the facility and it was decided all audits would be reported to a QA subcommittee which would meet no less than monthly for six (6) months and then no less than quarterly to ensure sustained compliance. Interview with the Administrator, on 09/10/15 at 8:58 AM, revealed she had been present in the QA Meeting held on 09/10/15 to discuss the U. Interview with the Director of Nursing (DON), on 09/10/15 at 9:25 AM, revealed she had been present in the QA Meeting held on 09/10/15 to discuss the IJ and interview with the Blue and Green Unit Managers, on 09/10/15 at 9:40 AM and 10:04 AM, revealed they had also been present in that QA Meeting. Interview with the Medical Director, on 09/10/15 at 8:45 AM, revealed he had been present at the QA Meeting to review the IJ Notification, the process to remove the I.), review of the facility Elopement Policy and actions to be taken in regard education and audits. 5. Telephone interview with the Vice President of Operations, on 09/10/15 at 10:25 AM, and the Corporate Consultant, on 09/10/15 at 10:35 AM revealed they held a meeting on 08/27/15 to re¿educate the administrative staff of the facility on the Elopement Policy, the Elopement Risk Screen, behavioral indicators for exit seeking behavior and interventions to address exit seeking behaviors. Interview with the Administrator, on 09/10/15 at 8:58 AM, the DON, on 09/10/15 at 9:25 AM, the Green Unit Manager, on 09/10/15 a 9:40 AM, the Blue Unit Manager, on 09/10/15 at 10:04 AM, the Staff Development Nurse, on 09/10/15 at 9:45 AM, the Blue Unit Assistant Nurse Manager, on 09/10/15 at 9:58 AM, the Green Unit Assistant Nurse Manager, on 09/10/15 at 9:10 AM, and the RN Supervisor, on 09/10/15 at 12:30 PM, revealed they had received re-education on the Elopement Policy, the Elopement Risk Screen, behavioral indicators for exit seeking behaviors and interventions to addre