Every finding on record at St Andrews Bay Skilled Nursing and Rehabilitation

Based on observation, record review, interview, and policy review, the facility failed to provide adequate and appropriate treatment and services related to the management of an indwelling urinary catheter to prevent urinary tract infection and hospitalization for 1 of 1 resident reviewed for urinary catheter care (Resident #112).The findings included:During tours of the facility conducted on 09/01/2026 at 8:47 AM, 2:40 PM, and 4:13 PM, it was observed that Resident #112's urinary catheter drainage bag was dated 08/15/2026 (Photographic evidence obtained). An interview was attempted with Resident #112 on 08/31/2026 at 12:45 PM to discuss if he had any concerns with the care of his urinary catheter, but the resident refused interview at the time.Review of Resident #112's medical record revealed he was initially admitted to the facility on [DATE] with an indwelling urinary catheter in place. Resident #112 had a medical history significant for benign prostatic hyperplasia (BPH), diabetes, and sepsis.Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #112 had a Brief Interview for Mental Status (BIMS) score of 10, indicating he had moderate cognitive impairment. This MDS documented that Resident #112 was dependent on facility staff for toileting and hygiene needs and that he required maximal assistance from staff for showering and bathing and for upper and lower body care. The MDS also documented the presence of Resident #112's indwelling urinary catheter.Review of physician orders revealed there were no orders implemented for urinary catheter care during Resident #112's admission on [DATE].Further review of Resident #112's record revealed he was discharged from the facility and admitted to a hospital on [DATE] due to sepsis (an infection in his blood and urine). Resident #112 remained hospitalized until 08/28/2026 when he was readmitted to the facility. Upon readmission, it was noted that no urinary catheter-related orders were implemented.Review of Resident #112's Care Plans revealed there were no care plans put in place regarding the care of the urinary catheter during either admission - 05/26/26 to 08/13/26 or 08/28/26 to present.Review of a Progress Note written by the Advanced Registered Nurse Practitioner on 08/31/2026 documented that Resident #112 had experienced a hospitalization for bacteremia and urinary tract infection. The progress note documented that Resident #112 had been treated with antibiotics and was able to return to the facility after 15 days in the hospital.Review of the Certified Nursing Assistant Care Task for the documentation of Resident #112's catheter/toileting revealed that during his stay at the facility, this task had been documented on 08/07/2026, 08/08/2026, 08/10/2026, 08/13/2026, and 08/14/2026.Review of the Care Area Assessment (CAA) for Urinary Incontinence and Indwelling Catheter revealed Resident #112 had been identified as being at risk for developing complications due to the long-term use of a urinary catheter. The CAA identified care-planning objectives to avoid complications and minimize risks and documented that the resident would not develop complications associated with catheter usage through the next review. The CAA additionally identified that referral to Urology was warranted. However, it was noted that Resident #112 had no physician order for a urology referral or consultation.An interview was conducted on 09/02/2026 at 11:58 AM with Staff A, Licensed Practical Nurse (LPN). Staff A confirmed that Resident #112 was admitted to the facility with a urinary catheter in place on 05/26/2026. Staff A stated that urinary catheter care was to be documented by nursing staff in tasks daily. Upon review of Resident #112's record, Staff A confirmed she could not locate any documented catheter care from 05/26/2026 to 08/10/2026. Staff A further stated she could not find any indication for the urinary catheter or a referral for urology.An interview was conducted on 09/02/2026 at 12:20PM with Staff B, LPN. Staff B confirmed she was assigned to provide care to Resident #112 that day. Staff B stated that urinary catheters should be emptied throughout each shift and that urinary catheter care should be performed every day and as ordered by the physician. Staff B further stated that care for catheters was documented by staff in tasks for the individual resident in their record.An interview was conducted on 09/03/2026 at 9:33 AM with the facility's Director of Nursing (DON). The DON stated that urinary catheter care was expected to be completed daily in accordance with the facility policy and that staff were expected to follow the policy and physician orders for catheter care. The DON independently reviewed Resident #112's record and confirmed the only documentation she could locate for urinary catheter care was on 08/07/2026, 08/08/2026, 08/10/2026, 08/13/2026, and 08/14/2026.Review of the facility's policy titled Catheter Care, last revised date 01/06/2023, stated, Catheter care will be performed every shift and as needed by nursing personnel.

Based upon observations and interviews, the facility failed to post the daily staffing information in a manner that was readily available to staff, residents, and visitors for 3 out of 4 consecutive days.The findings include:An observation of the daily staffing data posted for public view was conducted on 08/31/2026 at 11:30 AM and again at 03:00 PM. The staffing data displayed was dated 08/30/2026, indicating that the information was not updated for the current day.On 09/01/2026, observations were conducted of the staffing data at 08:15 AM, 11:30 AM, 02:15 PM, and 04:30 PM. The information posted remained dated 08/31/2026, again reflecting failure to update the daily staffing posted.On 09/02/2026, observations were conducted of the posted staffing data at 08:00 AM and 11:00 AM. The staffing data posted was dated for 09/01/2026, confirming the continued pattern of posting the previous-day information.An interview was conducted with the Administrator and the Regional Clinical Director on 09/02/2026 at 11:35 AM. The Administrator confirms she is responsible for posting the staffing data daily. The Administrator stated, Staffing data is posted from the verified hours that was worked the previous day. That is how I was trained and that is how we did it in Colorado. The Regional Clinical Director confirmed the staffing data is required to be posted for each day and not from the previous day's verified hours.

Based upon observations, interviews, and record reviews, the facility failed to provide Activities of Daily Living (ADLs) to maintain or improve abilities and choices for 5 out of 10 residents reviewed. (Resident #1, #6, #8, #9, #10)The findings include:On 2/23/26 at 10:15 AM, a tour of the facility was conducted. The following observations were made:Resident #6's room door was open and no privacy curtain was in use. The resident was lying in bed awake screaming I'm hurting. Resident #6 appeared unshaven and his hair was unkempt. He appeared to be restless moving in bed from side to side while rubbing his right and left lower legs. He did not have any clothes on except for an incontinence brief. He did not have any sheets or blankets over him. His room had a notable strong smell of urine.Resident #9 was lying in bed with the head of the bed elevated at a 45-degree angle. His eyes were closed, he appeared unshaven with notable facial hair, and his hair appeared unkempt and ungroomed.Resident #8's room has a notable strong smell of urine. She stated, I have been waiting on someone to come change me, someone came in and stated they will get someone, but no one has come yet. Resident #10's room had a strong smell of urine upon entering. She stated, I have been waiting to get changed, they haven't come yet, I pressed my call light, they are shorthanded, it depends on the time of day on how long it takes them to answer the call light, usually more than 30-45 minutes. An interview was conducted with Resident #1 on 2/23/26 at 02:00 pm. Resident #1 stated, I have to go to the bathroom now, and that's why I have been sitting at the nurses desk waiting for someone to help me. It takes the staff a while to answer my call light, it's been over 30 minutes and a couple of times an hour.On 2/24/26 at 09:00 am, follow up observations and interviews were conducted throughout the facility.Resident #6 was lying in bed. A hospital gown was covering him, facial hair was noted, and his hair was unkempt and ungroomed.Resident #9 appeared to have facial hair and the hair on his head was unkempt. During an interview, he stated, I have not had a shower since I have been here. I have been here 2 weeks now, and they haven't let me shave. They gave me a sponge bath, but I prefer to get up and get a shower. A record review was conducted for Resident #1 on 2/23/26 at 1:00 pm. She was admitted to the facility on [DATE] with the following diagnoses: Cerebral vascular Incident with hemiplegia to the right side, urinary tract infection, Chronic obstructive pulmonary disease, and hypertensive heart disease. A minimum data set (MDS) was completed with assessment reference date on 1/12/26 revealed she requires partial to maximal assistance with activities of daily living (ADLs).A record review of was conducted on 2/24/26 at 03:15 pm for Resident #6. He was admitted to facility on 2/19/26 with the following diagnoses: displaced fracture of left femur, unspecified dementia, hypertensive heart disease, hyperlipidemia, need for assistance with personal care, Post-traumatic stress disorder, and anxiety disorder. Review of hygiene documentation revealed that, since his admission, Resident #6 had not received a bath. A skilled nurses note dated 2/20/26 demonstrated that Resident #6 is dependent on staff for all ADLs and is incontinent of bowel and bladder function. A review of therapy notes indicates, dated 2/20/26, Resident #6 presents with severe cognitive-communication impairment impacting comprehension, expressive reliability, safety awareness, and functional task completion. Occupational Therapy states that the patient currently demonstrates behaviors, severe cognitive impairment and mobility due to left lower extremity fracture and pain. Physical therapy evaluation states he is alert and disoriented, high risk of falls, weakness to bilateral lower extremities. A record review of Resident #8 reveals she was admitted to facility on 11/4/25 with the following diagnoses: Type 2 diabetes, Fracture of left patella and left toes, Multiple Myeloma, Hypertensive heart disease, and Cirrhosis of the liver. A minimum data set (MDS) assessment with the assessment reference date of 2/19/26 revealed an impairment to one side lower extremity, requiring a wheelchair for mobility, limited to moderate assistance neededfor ADLs and is frequently incontinent of bowel and bladder function. A plan of care was initiated for ADL self - care deficit related to impaired mobility and is at risk for complications due to incontinence of urine and bowel.A record review of Resident #9 revealed he was admitted to the facility on [DATE] with diagnoses of non-displaced fracture of lateral malleolus of left Fibula, urinary tract infection, metabolic encephalopathy, heart disease, and need for assistance with personal care. A MDS assessment was completed on 1/31/26, indicating moderate to dependent assistance from staff to perform ADLs. A plan of care was initiated for ADL self-care deficit related to left ankle fracture and that he is at risk for complications due to incontinent episodes of urine and bowel. Upon reviewing CNA documentation of bathing task, Resident 9 received a bed bath on 2/21/26, 2/18/26, 2/14/26, 2/10/26, 2/7/26, 2/3/26, and 1/31/26, but has not received a shower as requested.A record review of Resident #10 revealed she was admitted to facility on 4/4/22 with the following diagnoses: hypertensive heart disease, personal history of transient ischemic attack (TIA) and cerebral infarction. A MDS assessment from 12/31/25 revealed that she utilizes a wheelchair for mobility due to impairment to one side of lower extremities and requires maximal assistance from staff to perform ADLs and is always incontinent of bowel and bladder function. A plan of care was initiated for decreased ability to perform ADLs, prefers not to be woken up at night for incontinent care.On 2/24/26 at 11:15 AM, an interview was conducted with Staff D, a Registered Nurse (RN), who states, [Resident #1] got changed on a regular basis during my shift, I can't say about the other shift. I work, day shift 7 am - 3 pm. But I will tell you this, the CNAs do not provide proper care, they don't make their rounds like they are supposed to. I have written several CNAs up on a disciplinary form, but nothing happens and nothing changes. The staff needs to provide better care to the residents. I have voiced my concerns and complaints to management but like I said nothing changes. Yes, sometimes we do work short staff.A interview with the Director of Nursing (DON) was conducted on 2/24/26 at 02:00 pm. She stated, Yes there have been several grievances filed in regard to call lights and care not being given in a timely manner. But we have done training with the staff. We have done call light audits to ensure that they are being answered and interviewed residents to ensure that call lights were being answered. As far as the education and training for care not being done, I have spoken to the staff but did not do any formal training. I can't give you anything on paper to confirm that. When asked to explain what her expectations are of her staff and she stated,Care should be done every two hours and as needed, more often if residents require it and call lights should be answered in a timely manner with 5-10 minutes.A review of facility policy for Incontinence was completed on 2/24/26 at 10:15 AM demonstrates, it is the policy of the facility to ensure that residents receive care and services to promote urinary continence of it residents.

Based upon observations, interviews, and record reviews, the facility failed to ensure call lights were placed within reach of dependent residents while in their rooms for 12 out of 116 resident beds observed. (Rooms 115, 207, 208 (both A and B beds), 212, 213, 215, 302, 303, 308, 402, and 409)The findings include:A tour of the facility was conducted on 02/23/26 at 10:15 AM and revealed the following call light issues:In room [ROOM NUMBER], the call light was fastened with a red plastic clip hanging in between the bed and bedside dresser, out of reach of the resident lying in bed. In room [ROOM NUMBER], the call light was wrapped around a wheelchair handle hanging near the floor, out of reach of the resident lying in bed.In room [ROOM NUMBER], the call light for the A bed was hanging on the wall, out of reach of the resident. The call light for the B bed was lying on the floor at the head of the bed, out of reach of the resident lying in bed.In room [ROOM NUMBER], the call light was lying on the floor out of the reach of the resident lying in bed.In room [ROOM NUMBER], the call light was hanging from the wall, out of reach of the resident lying in bed.In room [ROOM NUMBER], the call light was observed lying on the floor out of reach of the resident lying in bed.In room [ROOM NUMBER] , the resident was sitting up in the wheelchair between his bed and window, the call light was clipped to the privacy curtain out of reach of him. (photographic evidence obtained of all call lights)An interview was conducted with Resident #1 on 02/23/26 at 02;00 PM. The resident stated, I will press the call light button for assistance, sometimes no one comes, and there are times when they will come in turn off the light, then states I'll be right back. But they never come back. A lot of the times I will sit out in the hallway or at the nursing station to get someone to help me as they walk by. I see staff on their phones playing games. It takes the staff a while to answer my call light, it's been over 30 minutes and a couple of times an hour.An interview was conducted with Resident #7 on 2/23/26 at 11:00 AM. The resident stated, sometimes the staff doesn't even come when you turn your call light on, if they do come, it's too late and I have already soiled myself.An interview was then conducted with Resident #10, who stated, I have been waiting to get changed, they haven't come yet, I pressed my call light, they are shorthanded, it depends on the time of day on how long it takes them to answer the call light, usually more than 30-45 minutes. During the tour on 300 hallway on 2/23/26 at 11:27 AM, it was observed that a call light was turned on and making a beeping noise. Several staff members were observed sitting at the nurses' station desk, a nurse was standing at the end of the hallway next to the medication cart, and several staff members passed by the room with the call light on at 11:40 AM. At 11:45 AM, the nurse standing at the end of 300 hallway approached and stated, I don't want you to think I am ignoring the light, but I am trying to finish up some stuff before I go in the room, the resident wants her phone plugged in to charge.On 02/24/26 at 09:00 AM, a tour was completed and the rooms were monitored and observed for call lights in reach of residents. It was observed that the call lights from rooms 212, 215, 207, 208, 302, 303, 308, and 409 were lying on the floor out of the residents' reach while the residents were lying in bed.A record review was conducted of facility grievances on 2/23/26 at 1:30 pm. A resident council meeting was held on 11/28/25 with eight grievances filed by residents consisting of concerns including staff on their phones in the hallway and call lights not being answered in a timely manner. A resident council meeting was held on 12/31/25 had twelve grievances filed by residents with concerns with call lights not being answered in a timely manner and residents not being changed in a timely manner after incontinent episodes. A resident council meeting was conducted by facility on 1/31/26, with seven grievances filed by residents with concerns of call lights not being answered in a timely manner and residents are not being changed in a timely manner after incontinent episodes. (photographic evidence obtained)An interview with the Social Services Director was performed on 02/24/2026 at 01:30 PM by phone. She stated there have been several grievances filed in regard to call lights not being answered in a timely manner, residents not being changed in a timely manner, and some staff issues. All of those have been addressed with education and audits for call lights. If it involved a staff member in particular nursing, the Director of Nursing (DON) handled that on a 1:1 interaction.An interview with the Director of Nurses (DON) was conducted on 2/24/26 at 02:00 PM. She stated yes there have been several grievances filed in regard to call lights and care not being given in a timely manner. But we have done training with the staff. We have done call light audits to ensure that they are being answered and interviewed residents to ensure that call lights were being answered. As far as the education and training for care not being done, I have spoken to the staff but did not do any formal training. I can't give you anything on paper to confirm that. Asked DON to explain what her expectations are of her staff and she stated, care should be done every two hours and as needed, more often if residents require it and call lights should be answered in a timely manner with 5-10 minutes. I have done education and training in the town hall meetings in regard to call lights. I also expect if the CNAs are tied up in a resident's room, I expect my managers and nurses to assist with answering call lights.On 2/24/26 at 10:15 AM, a review of facility policy titled Call Lights: Accessibility and Timely response date implemented 11/2020 date revised 7/19/22 reveals the purpose of this policy is to assure the facility is adequately equipped with a call at each residents bedside, toilet, and bathing facility to allow residents to call for assistance. All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light. Staff will ensure the call light is within reach of resident and secured, as needed. The call system will be accessible to residents while in their bed, or other sleeping accommodations within the residents' room.

Based upon interviews and record reviews, the facility failed to ensure 1 of 3 residents reviewed for wound care received ongoing monitoring and treatment for wound care to prevent worsening and new pressure ulcers from occurring, initiate treatment orders on admission, and monitor bruising to left lower abdomen, left groin and thigh that resulted in worsening of wounds and bruising. (Resident #1)The findings include:On 2/23/26 at 2:00 pm, an interview was conducted with Resident #1 who revealed upon admission on [DATE] that she did not have any wounds except on her sacral area but now she has a wound on her heel.A record review was conducted on 2/23/26 for Resident #1. She was admitted to the facility on [DATE] with one unstageable pressure ulcer injury presenting as SDTI (suspected deep tissue injury).A progress note dated 1/6/26 titled Skin Note revealed Resident #1 had extensive bruising to her left abdomen that was deep purple in color extending to her back shoulder blade, bruising to her right lower abdomen, left thigh from her groin to knee, dark purple in color, and an old area on her sacrum that was not opened at this time, her right and left arm swelling, and a callous to the bottom of her right foot near her great toe. Upon further review, progress notes dated 1/7/26, 1/8/26, 1/10/26, 1/12/26, 1/13/26, 1/14/26, and 1/15/26 revealed Resident #1 having skin that is warm, dry, and intact with no wounds present. A weekly skin evaluation was completed on 1/12/26 revealed Resident #1's skin was intact. (photographic evidence obtained)An interview was conducted with Staff Member D, Registered Nurse (RN), on 2/24/26 at 11:15 AM. She confirmed that she completed the admission on Resident #1 and that, when admitted , Resident #1 only had an old site from a wound on sacrum that was not opened.A review of Resident #1's wound care notes from the physician dated 1/13/26 revealed that Resident #1 presented with wounds to her right heel and sacral area. An unstageable DTI (deep tissue injury) of the right heel measuring 1.3 cm x 2.1 cm with an undetermined depth; skin intact with purple, maroon discoloration. A new order was initiated to skin prep area once a day and as needed. An unstageable DTI to the sacrum measures 5.1 cm x 4.7 x 0.1 cm with an order for hydrocolloid sheet apply three times a week and as needed was also noted.The medication administration record and treatment sheet showed orders were initiated on 1/14/26 to apply skin prep to right heel every day and to cleanse the sacral wound with normal saline (NS), skin prep area and apply hydrocolloid dressing three times a week every day shift. A plan of care was revised on 1/14/26 indicating Resident #1 is at risk for skin breakdown related to her right heel and sacral area.On 1/17/26, progress notes and change of condition assessments were initiated for Resident #1 due to complaints of pain to the abdominal area. Hospital medical records revealed Resident #1 was admitted to the hospital for abdominal pain for 3 days and a hematoma PSOAS muscle abscess (PSOAS muscle is a long ribbon shaped muscle, starting at the lower back and extending through the pelvis to the top of the femur. A hematoma PSOAS is a collection of blood within the muscle compartment often associated with trauma, bleeding disorders, or anticoagulant therapy.)Upon further review of the medication administration record on 02/23/26, Resident #1 was receiving anticoagulant medication. The medical record revealed that Resident #1 was re-admitted to facility on 1/23/26 with skin issues noted as follows: midline present to left upper arm, bruising to left hip and abdomen area, scattered bruising to right forearm, an open area to sacrum and DTI (deep tissue injury) to right heel. A revision of Resident #1's plan of care was initiated for being at risk for skin breakdown related to right heel and sacral wound. Physician orders were initiated on 1/24/26 for wound care to apply skin prep to right heel every day shift and as needed; sacral wound, cleanse with NS (normal saline), skin prep area, apply hydrocolloid dressing every day shift and as needed for wound healing. Resident 1 was seen by wound care physician on 02/17/26 indicating a unstageable wound to the right heel measuring 2.4cm x 2.7 cm x undetermined depth skin intact with purple, maroon discoloration. Sacral wound resolved, healed. On 2/24/26 at 10:15 am a review of facility's policy and procedures for wound management demonstrates the purpose of this policy is to assist the facility in the care, services, and documentation related to the occurrence, treatment, and prevention of pressure as well as non-pressure related wounds. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. The effectiveness of treatments will be monitored through ongoing assessment .

Based on record review, staff interviews, and policy review, the facility failed to ensure that the consultant pharmacist identified and reported irregularities related to the long-term use of an anti-psychotic medication and thyroid medication for 1 of 5 sampled residents reviewed for unnecessary medications. (Resident #20) The findings include: Resident #20's medical record revealed the resident was admitted to the facility on [DATE] with a diagnosis of Diabetes Mellitus. The current physician's orders revealed the resident received Levothyroxine Sodium 50 mcg (thyroid medication) by mouth daily for hypothyroidism since 6/16/23 and Abilify 15 mg tablet (anti-psychotic medication) orally daily for bipolar disorder with an original start date for the medication of 11/15/22. The record revealed no current physician's orders for laboratory testing related to these medications. The physician's order history revealed no laboratory tests had ever been ordered to check the resident's thyroid stimulating hormone (TSH) or free T4 (a test to assess thyroid function and the levels of the active thyroid hormone) since the resident had started the Levothyroxine Sodium in 2023. Additionally, no physician's orders to routinely monitor the resident's fasting blood glucose related to the use of Abilify. The most recent laboratory data in the resident's record was from a hospital visit on 2/8/24. The result of the laboratory data on 2/8/24 revealed the resident's glucose was abnormal. The last 12 months of consultant pharmacist medication regimen reviews (5/2024- 4/2025) revealed no recommendation to assess a TSH, free T4, or fasting blood glucose related to the use of the Levothyroxine Sodium and Abilify. The package insert manufacturer information for Abilify tablets accessed at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2025/021436s046s050lbl pdf#page=66 on 5/22/25 at 2:40 PM revealed the following: Patients with an established diagnosis of diabetes mellitus who are started on atypical antipsychotics should be monitored regularly for worsening of glucose control. Patients with risk factors for diabetes mellitus (e.g., obesity, family history of diabetes) who are starting treatment with atypical antipsychotics should undergo fasting blood glucose testing at the beginning of treatment and periodically during treatment. Any patient treated with atypical antipsychotics should be monitored for symptoms of hyperglycemia including polydipsia, polyuria, polyphagia, and weakness. Patients who develop symptoms of hyperglycemia during treatment with atypical antipsychotics should undergo fasting blood glucose testing. In some cases, hyperglycemia has resolved when the atypical antipsychotic was discontinued; however, some patients required continuation of anti-diabetic treatment despite discontinuation of the suspect drug. An interview was conducted with the Director of Nursing (DON) on 5/21/25 at 3:57 PM. The DON stated the provider was ordering stat laboratory testing and she would attempt to obtain the blood sample. The DON confirmed there was no other evidence of laboratory testing completed for the resident. A telephone interview was conducted with the Consultant Pharmacist on 5/22/25 at 9:23 AM. He stated nothing really comes to mind for any laboratory testing that should be completed for the long-term use of Abilify, but he would look it up. He would expect at least an annual TSH and T4 test with the use of Levothyroxine. He then stated he was not aware of any recommended laboratory tests to be conducted routinely with the use of Abilify. The facility's policy for Consultant Pharmacist Reports IIIA1: Medication Regimen Review (May 2022) states, The consultant pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least monthly. The medication regimen review (MRR) includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and preventing or minimizing adverse consequences related to medication therapy. The MRR also involves a thorough review of the resident records and may include collaboration with other members of the interdisciplinary team, collaboration with the resident, family members or other resident representatives. MRR also involves reporting of findings with recommendations for improvement. All findings and recommendations are reported to the director of nursing and the attending physician, the medical director and the administrator.

Based on observation, interview, record review the facility failed to implement the care plan of 1 of 27 sampled residents. (Resident #89) The findings include: Observations: On 02/12/2024 at 07:15 PM, an observation was made of Resident #89 lying in bed on his back with the head of his bed elevated at a 30-degree angle. On 02/13/2024 at 09:00 AM, Resident #89 was observed lying on his back with his head turned to right side. No wedge or extra pillow was observed to be on the bed. On 02/13/2024 at 11:30 AM, an observation was made of Resident #89 lying in bed on his back with his head straight. On 02/13/2024 at 03:12 PM, an observation of Resident #89 was made lying on his back with the head of the bed elevated. This was an indication that the resident had been pulled up in bed. He was still lying on his back. On 2/14/2024 at 10:10 AM, an observation of Resident #89 revealed him lying in bed on his back. On 02/14/2024 at 11:24 AM, Resident #89 was observed lying on his back with no pillow or wedge on the bed. On 02/15/24 at 09:36 AM, Resident #89 was observed lying on his back in bed with the head of bed elevated. Record review: On approximately 02/14/2024, a record review was conducted for Resident #89. Resident #89 had a care plan initiated for bed mobility on 05/24/2023 indicating that Resident #89 required assistance by 2 staff to turn and reposition in bed every 2 hours and as needed due to a diagnosis of Hemiplegia and Hemiparesis Cerebral Infarction affecting left non dominant side that had impaired his mobility. Interviews: On 02/14/2024 at 02:49 PM, an interview was conducted with Certified Nurse Assistant (CNA) F. She explained she tries to do frequent checks on Resident #89 since he can't reposition himself, and he is often soiled. She indicated that she had not turned Resident #89 at all today. On 02/15/2024 at approximately 09:40 AM, an interview was conducted with Licensed Practical Nurse (LPN) E. LPN E explained she asked the CNA about Resident #89 being turned yesterday. She indicated that the CNA's place a pillow under the resident. On 02/25/2024 at 10:15 AM, the Director of Nursing was interviewed. She stated that documentation should be in the Electronic Health Record indicating where staff are turning residents and that staff should be using a wedge or pillow every 2 hours. She acknowledged that Resident #89 had not been positioned as ordered. She did state that Certified Nurse Assistants are trained on care plans and positioning upon hire.

Based on resident interview, record reviews, staff interviews, and facility policy review, the facility failed to ensure complete and accurate medical records for 1 of 1 residents sampled for pain management. The findings include: On 2/12/24 at 7:38 PM, an interview was conducted with Resident #21. During the interview, the resident was grimacing and indicated that she had constant paint of a level of 8-9 out of 10 (on a scale of 0 being no pain and 10 being the worst pain). She further stated the last time she received pain medication was 4:00 PM that day. A review of Resident #21's medical record was conducted. A physician's order stated to receive oxycodone (a controlled pain medication) 7.5 mg 1 tablet every 4 hours as needed for acute pain. A review of the resident's Medication Administration Record (MAR) revealed the resident received 14 doses of 1 tablet oxycodone. A review of the resident's narcotic controlled record sheet revealed oxycodone had been documented as pulled 17 times, totaling 17 tablets. There was 1 pill left inside the bottle of a total of 18. On 2/14/24 at 9:14 AM, an interview was conducted with Staff B, a Licensed Practical Nurse (LPN). She reviewed Resident #21's MAR and compared this with the narcotic sheet for oxycodone and verified the amount of pills recorded on the narcotic record sheet and the amount of pills recorded on the MAR did not match. She stated the facility's protocol was to notify the unit manager when a discrepancy occurs. On 2/14/24 at 11:38 AM, an interview was conducted with Director of Nursing (DON). The DON reviewed Resident # 21's narcotic sheet for oxycodone as well as Resident # 21's MAR and stated she was not aware of that discrepancy until this moment. A review of the facility's policy titled Medication Administration (revised 10/23) was conducted. The policy stated, Sign MAR after administration, If medication is a controlled substance, sign narcotic book , and correct any discrepancies and report to nurse manager.

Based on observations, interviews, and record reviews the facility failed to provide nail care to dependent residents for 2 of 6 residents sampled for Activities for Daily Living (ADL) residents, (Residents #309 and #46). The findings include: Resident #309 An observation was made of resident #309 on 11/1/22 at approximately 12:10 PM. The resident was observed lying in bed, observed multiple long fingernails with brown matter under the nails. An additional observation was made on 11/1/22 at approximately 4:06 PM. The resident's family member was at the bedside and noted the fingernails continued to be long, and dirty, and stated she wants the nails to be trimmed, but doesn't know how to get that done. The fingernail on the forefinger of the right hand was broken to the quick. The family member lifted the sheet to expose the resident's feet. The toenails on both feet were long, thick and yellow and the nails on the left 2nd and 3rd toes were rolled under, embedded in the skin. The nail on the left 5th toe was long, thick, and yellow. Additional observations were made on 11/2/22 at 8:19 AM, 11/2/22 at 9:45 AM, which revealed continued long, dirty nails. A review of record revealed a brief interview for mental status (BIMS) score of 3, which indicates severely impaired cognition. On 11/2/22 at approximately 9:12 AM, an interview was conducted with staff O, certified nursing assistant, (CNA) who stated she was assigned to the resident for the day and stated when she notices a resident's nails are long, she will cut the nails, including the toenails if the resident is not a diabetic. She stated she was not aware of the resident's long nails. On 11/02/22 at approximately 10:00 AM, an observation of the resident and an interview with staff H, Licensed Practical Nurse, (LPN) was conducted. Staff H stated the expectation is that resident's nails are cleaned when they are given a bath, or when needed, and the fingernails should be trimmed to the tip of the finger, unless the resident is diabetic, then the nurse must trim the fingernails. She further stated the CNAs are not allowed to trim the toenails at all. Staff H observed the nails in the surveyor's presence and confirmed the 5th digit on the right hand had brown matter under the nail, and measured the nail as 0.5 centimeters (cm) past the tip of the finger, the left thumb nail had brown matter under the nail, was jagged and measured 0.5 cm beyond the tip of the finger, the forefinger of the left hand was greater than 0.5 cm beyond the end of the fingertip. Staff H confirmed the right great toe was greater than 0.5 cm beyond the tip of the toe, the nail on the 3rd digit on the right foot was curled under and was embedded in the skin at the upper back of the toe, the great toe on the left great toe was greater than 0.5 cm beyond the tip of the toe, and the nails on the 2nd and 3rd digits of the left foot were curled under and embedded into the upper back of the toe. An interview was conducted with the Director of Nurses, (DON) on 11/2/22 at approximately 11:01 AM, who confirmed resident's nails should be trimmed during the bath unless a diabetic, then the nurse should trim them. White, [NAME] Resident #46 An observation was made of resident #46 on 11/1/22 at approximately 12:15 PM. The resident was observed lying in bed, observed multiple long fingernails with brown matter under the nails. Additional observations were made 11/01/22 at 4:06 PM, 11/02/22 at 9:05 AM, and 11/02/22. A review of medical record revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/2/22 at approximately 10:30 AM, an observation of the resident and an interview with staff H, Licensed Practical Nurse, (LPN) was conducted. She measured the fingernails and confirmed brown matter under the nails. Measurements included left thumb was 0.5 cm beyond the tip of the finger, left middle finger 0.5 cm beyond the tip of finger and the little finger or pinkie was 1.0 cm beyond the tip of finger. Right index finger was 1.0 cm beyond the tip of finger, right middle finger was 0.5 cm beyond the tip of finger and right pinkie was 1.0 cm beyond the tip of finger. Review of policy titled Nail care implemented on 5/1/21 revealed routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. The policy further states routine nail care, to include trimming and filing will be provided. Nail care will be provided between scheduled occasion as the need arises.

Based on observation, record review, staff interviews, and policy review the facility failed to provide physician ordered treatment to prevent complications of enteral feeding tubes for 1 of 2 sampled residents with enteral feeding tubes. (resident #62) The findings include: Observations of resident #62's Percutaneous Endoscopic Gastrostomy (PEG) tube insertion site were conducted on 10/31/22 at 2:45 PM and 4:21 PM. The dressing on the tube site was observed to be dated 10/27/22 and the resident stated it was supposed to be changed daily. The Director of Nursing (DON) observed the tube site dressing on 10/31/22 at 4:21 PM, and confirmed the dressing on the tube site was dated 10/27/22. A PEG tube is a tube surgically placed into the stomach through the abdominal wall that allows for liquid food to be given. Review of resident #62's electronic medical record revealed a current physician treatment order dated 10/26/21 stating cleanse peg tube site with warm, soapy water once daily and pat dry, apply split sponge to site and secure with tape every day and as needed every night shift. Review of the treatment administration record (TAR) for October 2022 revealed the treatment was signed as completed by nursing staff on October 28, 29, and 30, 2022 and no refusals were documented. The TAR revealed employee B, Licensed Practical Nurse (LPN) signed the treatment was completed on 10/28/22 and employee C, LPN signed the treatment was completed on 10/29/22 and 10/30/22. A telephone interview was conducted with employee B, LPN, on 11/1/22 at 2:52 PM. Employee B, stated the treatment was overlooked and an error. A telephone interview was conducted with employee C, LPN, on 11/1/22 at 3:10 PM. Employee C verified her initials on the treatment record and stated she did not complete a dressing change for resident #62. Review of the facility policy regarding Care of Feeding Tubes (implemented 5/1/21) revealed it is a policy of the facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Direction for staff on how to provide the following care will be provided examination and cleaning of the insertion site in order to identify, lessen, or resolve possible skin irritation and local infection.

Based on observation, staff interview, and policy review the facility failed to ensure staff serve food in a sanitary manner during 1 of 2 dining observations. (lunch 10/31/22) The findings include: An observation of the lunch meal was conducted on 10/31/22 at 11:40 AM. Employee A, Certified Nursing Assistant (CNA) was observed to serve a resident a bowl of soup, and touched the eating end of a spoon before handing the spoon to the resident. At 11:45 AM, Employee A, CNA, touched her surgical face mask with her bare hand and pulled it down while speaking to a resident. Employee A then used the same bare hand to serve soup to a resident and did not wash or sanitize her hands after touching her face. An interview was conducted with Employee A on 10/31/22 at 2:30 PM. She stated she had received training regarding safe food handling and should not touch the end of the utensil the resident eats with. She also confirmed she should wash or sanitize her hands after touching her face or mask before serving food. Review of the facility policy regarding Dietary/Food Handling (revised April 2001) revealed food handlers must wash their hands after personal body functions and before handling any food surfaces.

Based on observations, interviews and record review, the facility failed to ensure residents who required assistance with eating/dining received restorative dining services for 1 of 1 resident sampled for weight loss. (Resident #38) The findings include: An observation on 11/01/22 at approximately 8:45 AM, revealed that Resident #38 was observed in her room sitting up in the wheelchair with a sling under her. There was a breakfast tray sitting in front of the resident still covered. She was not eating her breakfast. The bedside table and food were not near the resident. A follow up observation was conducted on 11/01/22 at 9:11 AM, during which staff member Q, Certified Nursing Assistant (CNA) was in the room and brushing the resident #38's hair. The breakfast tray and bedside table were still sitting in the same position as the earlier observation. The surveyor lifted the lid to the breakfast tray to identify what food had been eaten. No food had been consumed from the plate. The CNA then reached over to the bedside table and handed the resident a glass of what appeared to be the ordered vanilla shake. The CNA stated, She will not eat if we give her the shake. A record review was conducted for resident #38 which revealed she had a 29-pound weight loss over the last 4 months, per the facility's weight documentation on 6/22/22 the resident weight 129 pounds, there was no weights for July, on 8/23/22 - 101.2 pounds, on 9/8/22 - 101 pounds, 9/15/22 - 99 pounds, 9/22/22 - 99.4 pounds, 10/4/22 - 98 pounds, 10/18/22 - 99.4 pounds, and on 10/25/22 - 100 pounds. A review of Resident #38's care plan dated 4/22/22 and revised on 10/24/22 revealed a focus area regarding risk for weight variance related to therapeutic diet, mechanically altered diet, [CONDITION(S)] and thickened liquids. The resident was to have her trays set up with supervision and cueing and to assist with meals as needed. The resident was to participate in Restorative Dining and needed to be up and in dining room before 11:30. She required extensive assist with eating dated on the 10/24/2022 care plan. Further review of the care plan revealed the goal for Resident #38 was to have no significant weight loss of 5% in 30 days or 7.5 % in 90 days (revised 5/5/22). Care plan interventions dated 8/26/22 restorative dining as ordered. The resident was to have her trays set up with supervision and cueing and to assist with meals as needed. A review of the resident's dietary orders dated 5/24/22 revealed she was to be on a consistent carbohydrate diet with pureed texture, nectar consistency, and fortified foods for additional calories. An order dated 10/21/22 added supplements that included a vanilla house shake two times a day. She was referred to speech therapy on 8/17/22 with documented concerns of takes two hours to feed and will not open mouth wide enough to eat. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #38 had a brief interview for mental status (BIMS) score of 06, indicating severe cognitive impairment. She required supervision and assistance for eating. The resident was non-ambulatory and used a wheelchair for mobility. The resident was to have a mechanically and therapeutic altered diet. Resident #38 had a Significant Change MDS assessment dated [DATE]. The Significant Change MDS indicated weight loss and a current weight of 99 pounds, had lost 10% of her body weight. And that she was a Restorative Dining participant. An interview was conducted on 10/31/22 at approximately 12:11 PM, staff member P, CNA. She stated, It is hit or miss when the food gets here and when the residents are brought down to us. Sometimes everyone is here for meals and sometimes they are not. It is hit or miss. An interview was conducted on 11/01/22 at approximately 9:00 AM, with the Restorative Manager. The Restorative Manager stated she did ask staff S, Licensed Practical Nurse (LPN) to make sure the residents were up this morning for breakfast and brought to the restorative dining area. She stated that no residents were brought to restorative dining. She stated she had approximately six residents in restorative dining. The Restorative Manager stated, She just did not bring them down there like I asked her. An interview was conducted on 11/01/22 at approximately 9:38 AM, staff member T, LPN, who stated, The Restorative Dining residents are supposed to be up by 7 AM daily. The night shift is supposed to have them up. We do have a problem with them doing that. An interview was conducted on 11/02/22 9:51 AM, with the Director of Nursing (DON). She stated there are approximately 6-7 in Restorative Dining. I was just made aware that none of them were up for restorative dining this morning. Our restorative program for Resident # 38 is to cue her to eat. We want to keep our residents as independent as possible, as far as eating. The DON stated that the night shift staff were to get the restorative residents up by 7 AM and that a recent staff meeting had been conducted regarding the need for the Restorative Dining residents to be up and in the dining area by the specified time. The DON stated, I will be addressing this on a different level as far as getting the residents up for restorative dining. An interview was conducted on 11/02/22 at approximately 3:30 PM, with staff member V, Dietician. Staff member V stated there was a list of residents with weight loss and that Resident #38 was to participate in Restorative Services and be supervised by the staff during her meals.

Based on observation, staff interviews, and policy review the facility failed to ensure resident personal hygiene items were stored in a sanitary manner for 1 of 20 sampled residents (resident #60) and failed to maintain the main dining room glass exterior door in a safe manner. The findings include: Resident #60 Observations of resident #60's shared bathroom were conducted on 10/31/22 at 12:51 PM, 11/1/22 at 2:32 PM, 11/3/22 at 9:01 AM, and 11/3/22 at 11:20 AM. A blue toothbrush was observed to be in an open emesis basin on top of the sink and was not labeled or in a storage container and a urine collection hat was observed in the floor. The urine collection hat was not labeled or stored in a bag or storage container. (Photographic evidence obtained.) An interview was conducted with Employee D, Certified Nursing Assistant (CNA) on 11/3/22 at 11:20 AM. She observed the toothbrush and urine collection hat. She stated resident #60 had indicated the blue toothbrush was her toothbrush. Employee D stated she had worked in the facility for about 2 months and she did not know how the items were supposed to be stored. An interview was conducted with the Director of Nursing (DON) on 11/3/22 at 11:32 AM. The DON stated resident #60 was not care planned for refusals to properly store personal items. Review of the facility policy regarding Resident Personal Belongings (implemented 5/1/21) revealed the facility will ensure resident belongings are kept in a neat and orderly fashion and maintained in each resident's room. Main Dining Room Glass On 10/31/22 at 11:40 AM, an observation of the dining room glass exit door revealed the glass was cracked the entire length of the 2 window panes. (Photographic evidence obtained.) An interview was conducted with the Administrator on 11/3/22 at 10:23 AM. The Administrator stated this must have happened last Thursday when the yard maintenance was being done.

Based on observation, record review, interview, and policy review, the facility failed to ensure an assessment by the Interdisciplinary Team (IDT) for the clinical appropriateness to self-administer a medication was completed for 1 of 5 residents sampled for unnecessary medications (#69). The findings include: On 8/11/21 at approximately 8:40 AM, 2 medications were observed on resident #69's overbed table. The facility nurse was not in the room. The medication observed was [MEDICATION(S)] (an anticonvulsant) capsule 300 mg (milligram) and approximately 15 cc (cubic centimeters) of a white liquid substance, the resident stated was for gas. She stated she planned to take the medication after she returned from her smoke break. On 8/11/21 at approximately 8:56 AM, an interview was conducted with Staff A , a Licensed Practical Nurse, (LPN). Staff A revealed the medications that were found in the room were left by the nurse on the previous shift and it was not acceptable to leave medications on the bedside table. A review of resident #69's medical record was completed. The record review failed to reveal an assessment of resident #69's capacity to self-administer medications and failed to reveal a care plan for self-administration of medication and failed to reveal a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] On 8/11/21 at approximately 9:40 AM, an interview was conducted with the Director of Nursing (DON) who confirmed that resident #69 was not assessed to self-administer medications. The DON confirmed any resident who wants to self-administer medications would require the IDT to first review the request and would then require inclusion on the Care Plan prior to the resident self-administering medication. On 8/11/21 a review of the policy, IIA10 Self-administration of Medication, last revised on 01/18, revealed the resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely.

Based on observation, record reviews and interviews, the facility failed to implement the plan of care for 1 of 5 (#86) residents sampled for unnecessary medications and 1 of 2 (#21) residents sampled for position, mobility. The findings include: Resident #86 On 8/10/21 a record review was conducted for resident #86. The plan of care included interventions for monitoring for behaviors and side effects related to use of [CONDITION(S)] drugs and for the use of anticoagulant therapies. The care plan was initiated on 7/19/21. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's drug regimen included Trazadone, an antidepressant, 50 milligrams (MG) by mouth at night daily. [MEDICATION(S)], an anticoagulant that helps to prevent blood clots, 50 MG subcutaneous injection twice daily. On 08/10/21 at approximately 2:12 PM, an interview was conducted with the Director of Nursing ( DON) who verbally agreed there was no order for monitoring for side effects for medications and stated there was no monitoring for side effects or behaviors on the MAR/TAR. The DON stated she did not know how it was missed but would correct it and conduct audits to ensure all residents on high risk medications had orders for monitoring for adverse effects and for behaviors. Resident #21 A review of the care plan for Resident #21, dated 5/7/2020, with a review date of 9/7/2021, revealed recommended that Offloading boots (pressure redistribution foot devices for patients at-risk for diabetic foot conditions) be applied to Resident #21 while in bed. A review of the order summary dated 8/12/2021 revealed no orders to discontinue use of the offloading boots. A review of the nurse progress notes from 8/2/2021 through 8/11/2021 revealed no documentation that Resident #21 had refused to wear the offloading boots. Review of the resident's recorded revealed she had active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/10/21 at approximately 3:25 PM, an observation of Resident #21 was made. She was in bed without the offloading boots on her feet. Resident #21 was asked, Do you ever wear padded booties on your feet while in bed?. She replied: No, they are supposed to be getting me some kind of splints. The surveyor asked if she would wear the protective boots to help keep pressure off her feet while in the bed. Resident #21 replied: Yes. On 8/11/2021 at approximately 2:35 PM, an interview was conducted with the Assistant Director of Nursing (ADON) regarding use of offloading boots for Resident #21. She was notified of the observations made of Resident #21 in bed without offloading boots as recommended by the care plan. The ADON explained that she would check the care plan and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/11/2021 at approximately 3:00 PM, a follow up observation was made of Resident #21 in bed without the Offloading boots. On 8/11/2021 at approximately 3:21 PM, an interview was conducted with Staff Member C, Certified Nursing Assistant (CNA,) in the room of Resident #21. Resident #21 was in bed without the offloading boots in place. Staff Member C, CNA, was asked about the location of the offloading boots that were recommended in the care plan. She responded by explaining that the boots are kept in her closet. She explained that they do not apply the boots to Resident #21 any longer and that it had been a few months since they were used. On 8/12/21 at approximately 10:11 AM, an interview was conducted with the ADON regarding use of offloading boots for Resident #21. She explained that she did not find an order to discontinue using the boots. She explained that the resident had previously been refusing to wear the boots. The surveyor notified the ADON that during an earlier interview Resident #21 had expressed that she would wear the boots while in the bed. The ADON explained that she was not aware that Resident #21 was agreeable to wearing the boots. She explained that they will check with Resident #21 and proceed if she agrees to wear the boots.

Based on observation, interview and record review the facility failed to apply splints for 1 of 2 residents reviewed for mobility, (Resident #62). The findings include: An interview and observation was conducted with resident #62 on 08/09/21 at 3:12 PM, during which the resident indicated that staff were not putting her hand splints on her. She states she has asked in the past and the splints were still not applied. During the interview the resident pointed to a bag on the back of her wheelchair that contained the splints. A record review was conducted of resident #62 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review was conducted of the medication and treatment records for the month of August, no evidence was found to instruct staff to apply splints for resident #62. An interview was conducted with the Director of Nursing (DON) on 08/10/21 at 3:58 PM, she stated that there is no documentation in the computer system that splints have been put on for this resident for the past 10 days. If it is not in the computer system, it does not alert staff to put them on. She stated she is unsure if the splints have been applied. An interview was conducted with resident #62 on 08/11/21 at 9:26 AM, the resident stated no staff came in to apply or offered to apply the splints to her hands yesterday evening or during the night.

Based on observations, interviews and facility documentation, the facility failed to identify and ensure resident rooms were maintained in good condition for 3 of 14 rooms on the 300 hall. (Rooms 302, 306 and 313) The findings include: On 02/02/2020 and 02/03/2020, resident rooms along the 300 hall were toured and inspected. Observation in rooms 302, 306 and 313 found that the walls at the head of the beds were shredded and not maintained in a good condition. (photographic evidence obtained) On 02/05/2020 at approximately 1:05 PM, an interview was conducted with Staff Member B, the Maintenance Director, and the facility's Administrator. They were asked to present documentation to support resident room repairs that were up and coming. Staff Member B stated they were currently revamping the bathrooms and they had made a list of rooms that needed painting and which ones still needed the bathrooms repaired. Presented was a list with resident room numbers. They had highlighted the rooms that had been completed. Of the 62 resident rooms in the facility, five rooms had been completed (rooms 309, 414,102, 106, 113 & 211) and seven rooms that were noted to be okay, (Rooms 118, 200, 202, 203, 204, 205 and 417). The walls in the three rooms observed (302, 306 & 313) failed to be identified with maintenance issues.

Based on interview and clinical record review, the facility failed to include the minimum healthcare information necessary to properly care for a resident regarding physician orders [REDACTED]. (Resident #306) The findings include: A clinical record review was conducted for resident #306 on 02/04/2020 and revealed an admission date of [DATE]. Review of the resident's physician orders [REDACTED]. Chronic Obstructive [MEDICAL CONDITION] Disorder ([MEDICAL CONDITION]) and orders dated 01/17/2020 to administer continuous oxygen (O2) at 2 liters per minute via nasal cannula for a [DIAGNOSES REDACTED]. Review of resident #306's baseline care plan did not indicate the use of any of the aforementioned medications, therapies, or monitoring. An interview was conducted with the DON on 02/06/20 at 08:17 AM. The DON was informed that resident #306 was admitted with anticoagulant, antibiotic, and O2 orders, which require monitoring. When asked if those items should have been indicated on his baseline care plan, she replied, Yes, once they were identified they should've been added to the care plan.

Based on observation, staff and resident interview and clinical record review, the facility failed to provide appropriate health care by not providing wound care or dressing changes per order for 1 of 3 residents sampled for non-pressure skin conditions. (Resident #306) The findings include: In an interview on 02/03/2020 at approximately 01:00 PM, resident #306 revealed that he was recently admitted following the amputation of all five toes on his left foot. He expressed concern about some discoloration he observed on the ball of his left foot. He stated he felt like the facility should be doing more to monitor his foot and stated that the dressing had only been changed twice since he'd been at the facility. Review of the resident's clinical record revealed he was admitted from the hospital 01/16/2020 status [REDACTED]. Will contact surgeon for instructions on dressing removal and changes. The second and last wound assessment performed by the ADON was dated 01/22/20 and described the wound as 100% eschar tissue measuring 1.50 cm x 9.50 cm x 0.00 cm. It also noted the presence of 10 sutures/staples, which were intact and a closed, healing incision area. It was noted that the physician was notified of the findings on 01/22/20 and new orders were received on 01/23/20 to cleanse wound to left foot amputation site with saline, apply dry dressing with kerlix and ace wrap once a day. Review of the resident's (MONTH) Treatment Administration Record revealed the dressing was changed on the 3-11 shift 01/25/20. The order was discontinued on 01/26/20 when the resident was transferred to the hospital. The resident returned to the facility on [DATE]. Review of resident #306's active treatment orders on 02/05/20 revealed no order related to the wound or dressing changes. An interview was conducted 02/05/20 at approximately 10:00 AM with the ADON. When asked how often staff are supposed to be monitoring and providing care to the resident's left foot she replied, Q (every) day. When informed that no wound or dressing change orders could be located in the resident's record, she replied I guess I just failed to make him a new sheet. I don't see where we re-instated his orders. The ADON agreed to be observed performing the dressing change later that day since it hadn't been done since he was readmitted [DATE]. On 02/05/20 at 02:20 PM the ADON was observed providing skin care to resident #306's left foot wound. Currently there is not a date on the dressing. When asked if staff normally date the dressings she replied, Yes. The ADON confirmed that the current dressing was not dated. When asked if the dressing was done yesterday, she replied, No, he was out of the room all day. I did not get to do it. The ADON completed the dressing change using technique in accordance with current best practice. Sutures are all intact over the incision. The incision is intact. The dressing is clean and dry. There is no drainage present on the dressing or around the wound. There are no symptoms of infection. The suture line area was cleansed with normal saline. According to the ADON, he has an appointment Monday to see the surgeon for follow up. During the observation resident #306 stated, My dressing has only been changed two times since I've been here.

Based on observations, interviews and review of the facility's policy and procedure, the facility failed to ensure hand hygiene and other infection control measures were implemented prior and during medication Adminsitration for 1 of 5 staff members observed. (Staff Member A) The findings include: On 02/05/2020 beginning at 8:35 AM, medication administration was observed with Staff Member A, a Licensed Practical Nurse. Staff Member A failed to perform hand hygiene after completing medication Adminsitration for the previous resident. The staff nurse proceeded to retrieve 4 medication cards, and popped out 1 pill from each card into his hand and then placed in the medication cup. The medications were administered to Resident #54. The resident requested Tylenol. Without performing hand-hygiene, Staff Member A, opened a bottle of [MEDICATION NAME] shook-out 2 caplets into the medication cup and administered to the resident. Without performing hand-hygiene, Staff Member A began to retrieve medications for Resident #80. Staff Member A retrieved 5 medications cards and 2 bottles of medication from the medication cart. He popped each pill into his hand and placed in the medication cup. He then opened each bottle of medication and shook the medication into his hand and placed in the cup. The medication was then administered to Resident #80. The staff nurse failed to perform hand-hygiene. Review of the facility's policy and procedure entitled Handwashing/Hand Hygiene, indicates 5. Employees must wash their hands for at least (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: c. Before and after direct resident contact (for which hand hygiene) is indicated by acceptable professional practice.

Based on observation of insulin administration, staff interviews, closed and open clinical record review, and policy review, the facility failed to ensure 8 of 33 residents sampled for insulin review were free from neglectful medication administration practices by facility staff (#5, #6, #13, #14, #19, #23, #24, & #32) A nurse failed to report a significant insulin medication error for 5 days resulting in a [DIAGNOSES REDACTED].#33. The facility failed to ensure a sufficient corrective action plan was developed and implemented to correct negligent nursing practices related to blood glucose monitoring and insulin administration resulting in significant insulin medication errors for resident #19 and #23 and a failure to prevent blood glucose monitoring and insulin dosage issues for 6 of 32 current residents (#5, #6, #13, #14, #24, & #32) within the facility receiving diabetic monitoring and treatment. The situation resulted in a finding of immediate jeopardy. The facility's Administrator, the Administrator in Training and the Director of Nursing were notified of the findings of Immediate Jeopardy on (MONTH) 10, 2019 at approximately 10:45 AM. The Immediate Jeopardy was removed on (MONTH) 11, 2019 at 4:30 PM when the facility provided evidence of immediate corrective actions. The deficient practice remains at a scope and severity level of a D. Cross reference F684 and F760. The findings included: Review of a facility submitted abuse report for resident #33, dated 11/20/18, revealed that on 11/15/18, during evening medication pass, staff member A, an LPN, entered a resident room with medications for residents #33 (A bed) and resident #16 (B bed). The medications taken into the residents' room included 28 units of the long acting insulin [MEDICATION NAME], which was scheduled to be administered at 4:30 PM for resident #16 in B bed; however, the nurse injected the insulin subcutaneously into resident #33 in A bed. Per the investigation conducted by the facility, at the time of administration, the resident stated, what shot? and the nurse realized her mistake. The nurse reported she checked the resident's blood sugar and found it to be 126mg/dl (milligrams per deciliter), which is within normal range, so she did not report the incident. On 11/16/18, resident #33 was transferred to the hospital at 9:50 AM for being unresponsive to verbal or painful stimuli with stroke like symptoms. The resident's extremities were rigid, pupils nonresponsive and vital signs were blood pressure 205/83mgHG (millimeter of mercury), heart rate of 60 beats per minute, respiratory rate of 20 breaths per minute, and a temperature of 97.6F (Farenheit). Resident #33 was subsequently admitted to the hospital with [REDACTED]. The resident had no history of diabetes or orders to receive insulin. The nurse returned to the facility on [DATE], 5 days after the incident and reported her mistake to the supervisor. On 11/20/18 the nurse involved in the incident was terminated. On 11/22/18 resident #33 passed away. On 1/9/19 at approximately 6:40 AM, observation was made of medication administration with Licensed Practical Nurse (LPN) staff member E. During this observation, the nurse was observed to administer insulin to resident #23 using a newly opened insulin pen prescribed for resident #25, though the appropriate type and dose of insulin was administered. This was verified via an interview with LPN C who verified the insulin on the insulin verification form with LPN E. On 11/20/18, the facility, in response to the incident with resident #33, instituted a Performance Improvement Plan (PIP). The PIP included medication administration observations, which focused on proper medication preparations and resident identification, a nursing in-service on diabetes management, including short versus long acting insulin, physician notification and incident reporting. The PIP also involved a 100% review of residents with insulin orders for appropriateness, and an insulin administration test for nurse competency. All areas of the PIP were noted to have an Actual Completion Date ranging from 11/20/18 to 11/30/18 with two areas noted to be ongoing, which included resident pictures on the MAR for appropriate identification as well as residents' name being correct on their name plates outside their rooms. Observations of staff administering insulin were not included in the PIP, and the Director of Nursing (DON) reported on 1/9/19 that she and the Assistant Director of Nursing (ADON) observed medication pass but did not focus on insulin. On 12/4/18, the facility also instituted a PIP related to nurse training, orientation, and skills validations when they discovered these were not being completed for new hires, including the nurse involved in the incident on 11/15/18, nor annually for existing staff. The focus of the PIP was to correct the training and skills competency issues for new hires, but did not include any action to be taken for existing staff in the facility. In a discussion with the DON on 01/09/19, regarding the PIP, she was asked if staff currently working in the facility were included in the plan and she stated, not at this time. Review of the orientation sign-in sheets for (MONTH) 20th, 21st and 31st found that of the 11 new employees listed, only nurses G, H & I had skills checklists that were either in progress or completed. According to review of a report from the facility's consultant pharmacy, on 12/7/18 at 4:50 AM, a nurse consultant from the pharmacy conducted an observation of the morning medication administration with facility nursing staff. The nurse consultant's documentation supported that during this observation, staff member D, an LPN, gave 25 units of the short acting insulin Humalog instead of the long acting insulin [MEDICATION NAME] that was ordered by the physician for resident #19. This incident occurred after the training and other interventions put in place as a result of the death of resident #33. As a result of this observation by the nurse consultant, the facility instituted a 2 nurse verification process for all insulin administration. Each medication cart was provided a red three ring binder that housed an insulin verification form that stated nurses were to have a co-signature before giving sliding scale or routine insulin. On 1/9/19, review of the insulin verification forms on all 5 facility medication carts was conducted and revealed the 2 nurse verification process instituted by the facility was not being executed by the facility nursing staff. Review of the forms on the 100 hall and 200 hall medication cart showed the procedure was only documented for 4 of 10 insulin administrations. The 300 hall cart had only 3 of 8 insulin administrations verified by 2 nurses and the 400 hall cart had 6 of 11 insulin opportunities verified by a second nurse. On 1/10/19, a record review was conducted for all 32 residents in the facility receiving some type of insulin. This review covered the 5 week period of the facility's PIP starting (MONTH) 7, (YEAR) and ending (MONTH) 1, 2019. The review revealed concerns with diabetic monitoring and treatment as follows: Resident #5 had a physician order [REDACTED]. Review of the MAR for (MONTH) 1 - 10, 2019 revealed the order was not consistently followed. At lunchtime on (MONTH) 1 & 2, nursing documented that none of the meal was consumed, but the 5 units of insulin was given. Resident # 6 had an order to call the physician for blood sugars greater than 400mg/dl. Review of the MAR for resident #6 revealed blood sugars documented as high on (MONTH) 14th and on (MONTH) 4th with no documentation that the physician was notified. Resident #13 had an order to call the physician for blood sugars less than 60mg/dl or greater than 400mg/dl. Review of the resident's MAR indicated [REDACTED]. and also revealed the nurses were not administering the appropriate amounts of insulin to the resident based on the physician ordered sliding scale. The ordered sliding scale stated that for readings of 151mg/dl to 200mg/dl the resident should receive 2 units of insulin coverage, for readings of 201mg/dl to 250mg/dl the resident should receive 4 units of insulin and readings of 251mg/dl to 300mg/dl should result in the administration of 6 units of insulin for the resident. On 12/1/18 the resident was documented as having a blood glucose reading of 219mg/dl with 2 units of insulin instead of the ordered 4 units. On 12/2/18 the resident's reading was documented as 227mg/dl with 2 units of coverage instead of ordered 4 units. On 12/3/18 the reading was documented as 232mg/dl with 2 units of coverage instead of 4 ordered. On 12/4/18 reading was documented as 234mg/dl with 2 units of coverage instead of ordered 4 units. On 12/6/18 the reading was documented as 182mg/dl with 1 unit of insulin given instead of 2 units ordered. On 12/7/18 the reading was 199mg/dl with 1 unit of coverage instead of 2 units ordered. On 12/8/18 the reading was 190mg/dl with 1 unit of coverage provided instead of 2 units ordered. On 12/9/18 the reading was 232mg/dl with 2 units of coverage instead of 4 units ordered and on 12/10/18 the reading was 265mg/dl with 3 units of insulin given instead of ordered 6 units. Resident #14 had an order for [REDACTED]. Resident #24 had an order for [REDACTED]. Resident #32 had an order for [REDACTED]. On 1/10/19 at approximately 1:00 PM, an interview was conducted with the facility's consultant pharmacist who stated that even insulin given 1 unit off could cause harm to a resident. Review of the facility's policy on Abuse and Neglect, undated, revealed a statement that the facility would make efforts to protect any and all residents after alleged abuse, neglect and/or exploitation. Review of their policy on Medication Administration, dated (MONTH) (YEAR), revealed that medications were to be administered as prescribed and in accordance with manufactures' specifications, and good nursing principles. It further stated that prior to administration, the nurse should review and confirm MEDICATION ORDERS FOR [REDACTED]. It also stated medications supplied for one resident were never to be administered to another resident. The immediate jeopardy was removed onsite after the receipt of the allegation of compliance and verification of corrective actions. The facility placed an immediate moratorium on new admissions who require insulin. The facility conducted an immediate retraining of nursing staff regarding insulin administration, the 10 rights of medication administration, blood sugar monitoring, and physician notification regarding high and low blood sugar readings. All nurses not immediately available were to be educated prior to starting their next shift. The facility implemented a 2 person insulin validation system where a supervisor on every shift was designated to verify insulin prior to administration. Nursing staff were trained in the validation system. All nurses not immediately available were to be educated prior to starting their next shift. The facility immediately discarded the insulin pen that was used on the incorrect resident to prevent cross-contamination.

Based on observation of insulin administration, staff interviews, closed and open clinical record review, and policy review, the facility failed to provide quality care related to insulin administration and diabetes management for 9 of 33 residents sampled for insulin review. A nurse failed to report an insulin medication error resulting in the death of resident #33. A wrong insulin medication error was identified by the facility for resident #19 during evaluation of corrective actions. Resident #23 was observed to receive insulin from resident #25's insulin pen during medication pass observation. Record review revealed that high and low blood sugar levels were not consistently reported to the physician, or sliding scale orders were not accurately followed for 6 of 32 current residents in the facility receiving diabetes management (#5, #6, #13, #14, #24, & #32). The situation resulted in a finding of immediate jeopardy. The facility's Administrator, the Administrator in Training and the Director of Nursing were notified of the findings of Immediate Jeopardy on (MONTH) 10, 2019 at approximately 10:45 AM. The Immediate Jeopardy was removed on (MONTH) 11, 2019 at 4:30 PM when the facility provided evidence of immediate corrective actions. The deficient practice remains at a scope and severity level of a D. Cross reference to F600, F726, F760, F835 and F867. Findings included: Review of a facility submitted abuse report for resident #33, dated 11/20/18, revealed that on 11/15/18, during evening medication pass, staff member A, an LPN, entered a resident room with medications for residents #33 (A bed) and resident #16 (B bed). The medications taken into the residents' room included 28 units of the long acting insulin [MEDICATION NAME], which was scheduled to be administered at 4:30 PM for resident #16 in B bed; however, the nurse injected the insulin subcutaneously into resident #33 in A bed. Per the investigation conducted by the facility, at the time of administration, the resident stated, what shot? and the nurse realized her mistake. The nurse reported she checked the resident's blood sugar and found it to be 126mg/dl (milligrams per deciliter), which is within normal range, so she did not report the incident. On 11/16/18, resident #33 was transferred to the hospital at 9:50 AM for being unresponsive to verbal or painful stimuli with stroke like symptoms. The resident's extremities were rigid, pupils nonresponsive and vital signs were blood pressure 205/83mgHG (millimeter of mercury), heart rate of 60 beats per minute, respiratory rate of 20 breaths per minute, and a temperature of 97.6F (Farenheit). Resident #33 was subsequently admitted to the hospital with [REDACTED]. The resident had no history of diabetes or orders to receive insulin. The nurse returned to the facility on [DATE], 5 days after the incident and reported her mistake to the supervisor. On 11/22/18 resident #33 passed away. On 11/20/18, the facility, in response to the incident with resident #33, instituted a Performance Improvement Plan (PIP). The PIP included medication administration observations, which focused on proper medication preparations and resident identification, a nursing in-service on diabetes management, including short versus long acting insulin, physician notification and incident reporting. The PIP also involved a 100% review of residents with insulin orders for appropriateness, and an insulin administration test for nurse competency. All areas of the PIP were noted to have an Actual Completion Date ranging from 11/20/18 to 11/30/18 with two areas noted to be ongoing, which included resident pictures on the MAR for appropriate identification as well as residents' name being correct on their name plates outside their rooms. Observations of staff administering insulin were not included in the PIP, and the Director of Nursing (DON) reported on 1/9/19 that she and the Assistant Director of Nursing (ADON) observed medication pass but did not focus on insulin. On 12/4/18, the facility also instituted a PIP related to nurse training, orientation, and skills validations when they discovered these were not being completed for new hires, including the nurse involved in the incident on 11/15/18, nor annually for existing staff. The focus of the PIP was to correct the training and skills competency issues for new hires, but did not include any action to be taken for existing staff in the facility. In a discussion with the DON on 01/09/19, regarding the PIP, she was asked if staff currently working in the facility were included in the plan and she stated, not at this time. Review of the orientation sign-in sheets for (MONTH) 20th, 21st and 31st found that of the 11 new employees listed, only staff G, H & I had skills checklists that were either in progress or completed. According to review of a report from the facility's consultant pharmacy, on 12/7/18 at 4:50 AM, a nurse consultant from the pharmacy conducted an observation of the morning medication administration with facility nursing staff. The nurse consultant's documentation supported that during this observation, staff member D, an LPN, gave 25 units of the short acting insulin Humalog instead of the long acting insulin [MEDICATION NAME] that was ordered by the physician for resident #19. This incident occurred after the training and other interventions put in place as a result of the death of resident #33. As a result of this observation by the nurse consultant, the facility instituted a 2 nurse verification process for all insulin administration. Each medication cart was provided a red three ring binder that housed an insulin verification form that stated nurses were to have a co-signature before giving sliding scale or routine insulin. On 1/9/19, review of the insulin verification forms on all 5 facility medication carts was conducted and revealed the 2 nurse verification process instituted by the facility was not being executed by the facility nursing staff. Review of the forms on the 100 hall and 200 hall medication cart showed the procedure was only documented for 4 of 10 insulin administrations. The 300 hall cart had only 3 of 8 insulin administrations verified by 2 nurses and the 400 hall cart had 6 of 11 insulin opportunities verified by a second nurse. On 1/9/19 at approximately 6:40 AM, observation was made of medication administration with Licensed Practical Nurse (LPN) staff member E. During this observation, the nurse was observed to administer insulin to resident #23 using a newly opened insulin pen prescribed for resident #25, though the appropriate type and dose of insulin was administered. This was verified via an interview with staff member C who verified the insulin on the insulin verification form with staff member E. On 1/10/19, a record review was conducted for all 32 current residents in the facility receiving some type of insulin. This review covered the 5 week period of the facility's PIP starting (MONTH) 7, (YEAR) and ending (MONTH) 1, 2019. The review revealed concerns with diabetic monitoring and treatment as follows: Resident #5 had a physician order to receive [MEDICATION NAME] 5 units after lunch and 4 units after dinner with a note to hold the insulin for blood glucose readings less than 100 or if the resident's meal was not consumed. Review of the MAR for (MONTH) 1 - 10, 2019 revealed the order was not consistently followed. At lunchtime on (MONTH) 1 & 2, nursing documented that none of the meal was consumed, but the 5 units of insulin was given. Resident # 6 had an order to call the physician for blood sugars greater than 400mg/dl. Review of the MAR for resident #6 revealed blood sugars documented as high on (MONTH) 14th and on (MONTH) 4th with no documentation that the physician was notified. Resident #13 had an order to call the physician for blood sugars less than 60mg/dl or greater than 400mg/dl. Review of the resident's MAR indicated [REDACTED]. and also revealed the nurses were not administering the appropriate amounts of insulin to the resident based on the physician ordered sliding scale. The ordered sliding scale stated that for readings of 151mg/dl to 200mg/dl the resident should receive 2 units of insulin coverage, for readings of 201mg/dl to 250mg/dl the resident should receive 4 units of insulin and readings of 251mg/dl to 300mg/dl should result in the administration of 6 units of insulin for the resident. On 12/1/18 the resident was documented as having a blood glucose reading of 219mg/dl with 2 units of insulin instead of the ordered 4 units. On 12/2/18 the resident's reading was documented as 227mg/dl with 2 units of coverage instead of ordered 4 units. On 12/3/18 the reading was documented as 232mg/dl with 2 units of coverage instead of 4 ordered. On 12/4/18 reading was documented as 234mg/dl with 2 units of coverage instead of ordered 4 units. On 12/6/18 the reading was documented as 182mg/dl with 1 unit of insulin given instead of 2 units ordered. On 12/7/18 the reading was 199mg/dl with 1 unit of coverage instead of 2 units ordered. On 12/8/18 the reading was 190mg/dl with 1 unit of coverage provided instead of 2 units ordered. On 12/9/18 the reading was 232mg/dl with 2 units of coverage instead of 4 units ordered and on 12/10/18 the reading was 265mg/dl with 3 units of insulin given instead of ordered 6 units. Resident #14 had an order for [REDACTED]. Resident #24 had an order for [REDACTED]. Resident #32 had an order for [REDACTED]. An interview conducted with the DON on 1/10/19 at approximately 3:15 PM in the presence of the interim administrator and the administrator in training. During the interview the DON was asked what the indications of low or 'high on the glucometer meant. She stated she was not sure and would need to look on the manufactures instruction booklet. She attempted to locate the booklet and was unable to do so. The administrator in training was able to pull the information from the manufactures website and stated that the indication for low was a blood sugar less than 20 and high was a blood sugar greater than 600. When asked if these readings would require a phone call to the physician or the nurse practitioner, she stated yes and activation of the diabetic protocol created after resident #33's death. Review of the facility policy 'Medication Administration General Guidelines' dated (MONTH) (YEAR), revealed that medications were to be administered as prescribed and in accordance with manufactures' specifications, and good nursing principles. It further stated that prior to administration, the nurse should review and confirm MEDICATION ORDERS FOR [REDACTED]. It also stated medications supplied for one resident were never to be administered to another resident. The immediate jeopardy was removed onsite after the receipt of the allegation of compliance and verification of corrective actions. The facility placed an immediate moratorium on new admissions who require insulin. The facility conducted an immediate retraining of nursing staff regarding insulin administration, the 10 rights of medication administration, blood sugar monitoring, and physician notification regarding high and low blood sugar readings. All nurses not immediately available were to be educated prior to starting their next shift. The facility implemented a 2 person insulin validation system where a supervisor on every shift was designated to verify insulin prior to administration. Nursing staff were trained in the validation system. All nurses not immediately available were to be educated prior to starting their next shift. The facility immediately discarded the insulin pen that was used on the incorrect resident to prevent cross-contamination.

Based on observation of insulin administration, staff interviews, and clinical record review, the facility failed to ensure nursing staff had appropriate training and competency evaluation with diabetes management, including blood glucose monitoring and insulin administration for 9 of 33 residents sampled for insulin review. This failure resulted in the death of resident #33, significant medication errors for residents #19 and #23, and continued risk of injury to 6 of 32 current residents in the facility receiving diabetes management (#5, #6, #13, #14, #24, & #32). The situation resulted in a finding of immediate jeopardy. The facility's Administrator, the Administrator in Training and the Director of Nursing were notified of the findings of Immediate Jeopardy on (MONTH) 10, 2019 at approximately 10:45 AM. The Immediate Jeopardy was removed on (MONTH) 11, 2019 at 4:30 PM when the facility provided evidence of immediate corrective actions. The deficient practice remains at a scope and severity level of a D. Cross reference to F600, F684 and F760. Findings included: Review of a facility submitted abuse report for resident #33, dated 11/20/18, revealed that on 11/15/18, during evening medication pass, staff member A, an LPN, entered a resident room with medications for residents #33 (A bed) and resident #16 (B bed). The medications taken into the residents' room included 28 units of the long acting insulin [MEDICATION NAME], which was scheduled to be administered at 4:30 PM for resident #16 in B bed; however, the nurse injected the insulin subcutaneously into resident #33 in A bed. Per the investigation conducted by the facility, at the time of administration, the resident stated, what shot? and the nurse realized her mistake. The nurse reported she checked the resident's blood sugar and found it to be 126mg/dl (milligrams per deciliter), which is within normal range, so she did not report the incident. On 11/16/18, resident #33 was transferred to the hospital at 9:50 AM for being unresponsive to verbal or painful stimuli with stroke like symptoms. The resident's extremities were rigid, pupils nonresponsive and vital signs were blood pressure 205/83mgHG (millimeter of mercury), heart rate of 60 beats per minute, respiratory rate of 20 breaths per minute, and a temperature of 97.6F (Farenheit). Resident #33 was subsequently admitted to the hospital with [REDACTED]. The resident had no history of diabetes or orders to receive insulin. The nurse returned to the facility on [DATE], 5 days after the incident and reported her mistake to the supervisor. On 11/22/18 resident #33 passed away. On 12/4/18, the facility instituted a Performance Improvement Plan (PIP) related to nurse training, orientation, and skills validations when they discovered these were not being completed for new hires, including the nurse involved in the incident on 11/15/18, nor annually for existing staff. The focus of the PIP was to correct the training and skills competency issues for new hires, but did not include any action to be taken for existing staff in the facility. In a discussion with the DON on 01/09/19, regarding the PIP, she was asked if staff currently working in the facility were included in the plan and she stated, not at this time. Review of the orientation sign-in sheets for (MONTH) 20th, 21st and 31st found that of the 11 new employees listed, only staff G, H & I had skills checklists that were either in progress or completed. On 1/10/19, a record review was conducted for all 32 current residents in the facility receiving some type of insulin. This review covered the 5 week period of the facility's PIP starting (MONTH) 7, (YEAR) and ending (MONTH) 1, 2019. The review revealed a failure to notify the physician and/or implement diabetes management protocols regarding high and/or low blood sugar readings for residents #6, 14, 24, and 32, and a failure to consistently implement physician orders [REDACTED].#5 & 13. Please see F684 and F760 for additional information. According to review of a report from the facility's consultant pharmacy, on 12/7/18 at 4:50 AM, a nurse consultant from the pharmacy conducted an observation of the morning medication administration with facility nursing staff. The nurse consultant's documentation supported that during this observation, staff member D, a Licensed Practical Nurse (LPN), gave 25 units of the short acting insulin Humalog instead of the long acting insulin [MEDICATION NAME] that was ordered by the physician for resident #19. This incident occurred after the training and other interventions put in place as a result of the death of resident #33. On 1/9/19 at approximately 6:40 AM, observation was made of medication administration with Licensed Practical Nurse (LPN) staff member E. During this observation, the nurse was observed to administer insulin to resident #23 using a newly opened insulin pen prescribed for resident #25, though the appropriate type and dose of insulin was administered. This was verified via an interview with staff member C who verified the insulin on the insulin verification form with staff member E. A review of the personnel records for the staff involved in these incidents revealed that the nurses (staff members A and D) were newly hired LPNs both starting employment at the facility in (MONTH) (YEAR). The review revealed that neither of the nurses had nursing skills validations conducted prior to being assigned patient care nor documentation of orientation attendance. Review of staff member A's on-line training found no evidence that she had completed classes related to incident reporting, resident rights, or Abuse/Neglect. Review of staff member D's on-line training found no evidence that she had completed classes related to medication administration until after the incident on 12/7/18. An interview conducted with LPN staff member J on 1/11/19 at approximately 2:00 PM revealed she helped train new hires all the time and had worked with several over the last 6 months. She stated she remembered working with staff member A when she was a new nurse but could not remember how long she had worked with her. She stated the normal orientation is for three days with the first day being the new hire observing her pass medications, the second day she allows the new hire to pass medications at the 1:00 PM med pass independently and on the third day she allows the new staff member to pass medications on all residents assigned to them and she is there if the new hire has questions. She stated that any employee can request additional orientation days; however, she cannot recall if staff member A had requested this. She stated she did not complete any forms or skills validation sheets for any staff members in training. The administrator stated on 1/09/19 at approximately 11:00 AM that orientation and skills validation were done per federal regulations and that there was no formal policy for staff orientation or annual skills review. At this same time, the Director of Nursing (DON) was asked about the lack of annual skills verification and stated they had not been completed since (YEAR). The facility was asked to provide the policies related to new employee orientation, annual skills review, and competencies for nursing staff. The facility was unable to produce such policies by the end of the survey on 1/11/19. The immediate jeopardy was removed onsite after the receipt of the allegation of compliance and verification of corrective actions. The facility placed an immediate moratorium on new admissions who require insulin. The facility conducted an immediate retraining of nursing staff regarding insulin administration, the 10 rights of medication administration, blood sugar monitoring, and physician notification regarding high and low blood sugar readings. All nurses not immediately available were to be educated prior to starting their next shift. The facility implemented a 2 person insulin validation system where a supervisor on every shift was designated to verify insulin prior to administration. Nursing staff were trained in the validation system. All nurses not immediately available were to be educated prior to starting their next shift. The facility immediately discarded the insulin pen that was used on the incorrect resident to prevent cross-contamination.

Based on observation of insulin administration, staff interviews, clinical record review and policy review, the facility failed to ensure residents were free of significant medication errors regarding diabetes management and insulin administration. Significant insulin medication errors were identified for 3 of 33 residents sampled for insulin review, (#13, #23 and #33). A nurse failed to report an insulin medication error resulting in the death of resident #33. A wrong insulin medication error was identified by the facility for resident #19 during evaluation of corrective actions. Resident #23 was observed to receive insulin from resident #25's insulin pen during medication pass observation. There were 32 current residents in the facility receiving diabetes management. The situation resulted in a finding of immediate jeopardy. The facility's Administrator, the Administrator in Training and the Director of Nursing were notified of the findings of Immediate Jeopardy on (MONTH) 10, 2019 at approximately 10:45 AM. The Immediate Jeopardy was removed on (MONTH) 11, 2019 at 4:30 PM when the facility provided evidence of immediate corrective actions. The deficient practice remains at a scope and severity level of a D. Cross reference to F600, F684, F726, F835 and F867. Findings included: Review of a facility submitted abuse report for resident #33, dated 11/20/18, revealed that on 11/15/18, during evening medication pass, staff member A, an LPN, entered a resident room with medications for residents #33 (A bed) and resident #16 (B bed). The medications taken into the residents' room included 28 units of the long acting insulin [MEDICATION NAME], which was scheduled to be administered at 4:30 PM for resident #16 in B bed; however, the nurse injected the insulin subcutaneously into resident #33 in A bed. Per the investigation conducted by the facility, at the time of administration, the resident stated, what shot? and the nurse realized her mistake. The nurse reported she checked the resident's blood sugar and found it to be 126mg/dl (milligrams per deciliter), which is within normal range, so she did not report the incident. On 11/16/18, resident #33 was transferred to the hospital at 9:50 AM for being unresponsive to verbal or painful stimuli with stroke like symptoms. The resident's extremities were rigid, pupils nonresponsive and vital signs were blood pressure 205/83mgHG (millimeter of mercury), heart rate of 60 beats per minute, respiratory rate of 20 breaths per minute, and a temperature of 97.6F (Farenheit). Resident #33 was subsequently admitted to the hospital with [REDACTED].The resident had no history of diabetes or orders to receive insulin. The nurse returned to the facility on [DATE], 5 days after the incident and reported her mistake to the supervisor. On 11/22/18 resident #33 passed away. On 11/20/18, the facility, in response to the incident with resident #33, instituted a Performance Improvement Plan (PIP). The PIP included medication administration observations, which focused on proper medication preparations and resident identification, a nursing in-service on diabetes management, including short versus long acting insulin, physician notification and incident reporting. The PIP also involved a 100% review of residents with insulin orders for appropriateness, and an insulin administration test for nurse competency. All areas of the PIP were noted to have an Actual Completion Date ranging from 11/20/18 to 11/30/18 with two areas noted to be ongoing, which included resident pictures on the MAR for appropriate identification as well as residents' name being correct on their name plates outside their rooms. Observations of staff administering insulin were not included in the PIP, and the Director of Nursing (DON) reported on 1/9/19 that she and the Assistant Director of Nursing (ADON) observed medication pass but did not focus on insulin. On 12/4/18, the facility also instituted a PIP related to nurse training, orientation, and skills validations when they discovered these were not being completed for new hires, including the nurse involved in the incident on 11/15/18, nor annually for existing staff. The focus of the PIP was to correct the training and skills competency issues for new hires, but did not include any action to be taken for existing staff in the facility. In a discussion with the DON on 01/09/19, regarding the PIP, she was asked if staff currently working in the facility were included in the plan and she stated, not at this time. Review of the orientation sign-in sheets for (MONTH) 20th, 21st and 31st found that of the 11 new employees listed, only staff G, H & I had skills checklists that were either in progress or completed. According to review of a report from the facility's consultant pharmacy, on 12/7/18 at 4:50 AM, a nurse consultant from the pharmacy conducted an observation of the morning medication administration with facility nursing staff. The nurse consultant's documentation supported that during this observation, staff member D, an LPN, gave 25 units of the short acting insulin Humalog instead of the long acting insulin [MEDICATION NAME] that was ordered by the physician for resident #19. This incident occurred after the training and other interventions put in place as a result of the death of resident #33. As a result of this observation by the nurse consultant, the facility instituted a 2 nurse verification process for all insulin administration. Each medication cart was provided a red three ring binder that housed an insulin verification form that stated nurses were to have a co-signature before giving sliding scale or routine insulin. On 1/9/19, review of the insulin verification forms on all 5 facility medication carts was conducted and revealed the 2 nurse verification process instituted by the facility was not being executed by the facility nursing staff. Review of the forms on the 100 hall and 200 hall medication cart showed the procedure was only documented for 4 of 10 insulin administrations. The 300 hall cart had only 3 of 8 insulin administrations verified by 2 nurses and the 400 hall cart had 6 of 11 insulin opportunities verified by a second nurse. On 1/9/19 at approximately 6:40 AM, observation was made of medication administration with Licensed Practical Nurse (LPN) staff member E. During this observation, the nurse was observed to administer insulin to resident #23 using a newly opened insulin pen prescribed for resident #25, though the appropriate type and dose of insulin was administered. This was verified via an interview with staff member C who verified the insulin on the insulin verification form with staff member E. An interview conducted with LPN staff member J on 1/11/19 at approximately 2:00 PM revealed she helped train new hires all the time and had worked with several over the last 6 months. She stated she remembered working with staff member A when she was a new nurse but could not remember how long she had worked with her. She stated the normal orientation is for three days with the first day being the new hire observing her pass medications, the second day she allows the new hire to pass medications at the 1:00 PM med pass independently and on the third day she allows the new staff member to pass medications on all residents assigned to them and she is there if the new hire has questions. She stated that any employee can request additional orientation days; however, she cannot recall if staff member A had requested this. She stated she did not complete any forms or skills validation sheets for any staff members in training. The administrator stated on 1/09/19 at approximately 11:00 AM that orientation and skills validation were done per federal regulations and that there was no formal policy for staff orientation or annual skills review. At this same time, the Director of Nursing (DON) was asked about the lack of annual skills verification and stated they had not been completed since (YEAR). The facility was asked to provide the policies related to new employee orientation, annual skills review, and competencies for nursing staff. The facility was unable to produce such policies by the end of the survey on 1/11/19. Review of the facility policy 'Medication Administration General Guidelines' dated (MONTH) (YEAR), revealed that medications were to be administered as prescribed and in accordance with manufactures' specifications, and good nursing principles. It further stated that prior to administration, the nurse should review and confirm MEDICATION ORDERS FOR [REDACTED]. It also stated medications supplied for one resident were never to be administered to another resident. The immediate jeopardy was removed onsite after the receipt of the allegation of compliance and verification of corrective actions. The facility placed an immediate moratorium on new admissions who require insulin. The facility conducted an immediate retraining of nursing staff regarding insulin administration, the 10 rights of medication administration, blood sugar monitoring, and physician notification regarding high and low blood sugar readings. All nurses not immediately available were to be educated prior to starting their next shift. The facility implemented a 2 person insulin validation system where a supervisor on every shift was designated to verify insulin prior to administration. Nursing staff were trained in the validation system. All nurses not immediately available were to be educated prior to starting their next shift. The facility immediately discarded the insulin pen that was used on the incorrect resident to prevent cross-contamination.

Based on observation of insulin administration, staff interviews, clinical record review and policy review, the facility failed to be administered in a manner that ensured the well being of all residents. Administrative staff developed a corrective action plan following a significant insulin medication error and subsequent death of resident #33. The administrative staff failed to ensure corrective action plans for issues identified were fully and consistently implemented. The facility failed to ensure nursing staff had appropriate training and competency evaluation with diabetes management and insulin administration. This failure resulted in significant medication errors for residents #19 and #23, and continued risk of injury to 6 of 32 current residents in the facility receiving diabetes management (#5, #6, #13, #14, #24, & #32). The situation resulted in a finding of immediate jeopardy. The facility's Administrator, the Administrator in Training and the Director of Nursing were notified of the findings of Immediate Jeopardy on (MONTH) 10, 2019 at approximately 10:45 AM. The Immediate Jeopardy was removed on (MONTH) 11, 2019 at 4:30 PM when the facility provided evidence of immediate corrective actions. The deficient practice remains at a scope and severity level of a D. Cross reference to F600, F684, F726, and F760. The findings include: Review of a facility submitted abuse report for resident #33, dated 11/20/18, revealed that on 11/15/18, during evening medication pass, staff member A, an LPN, entered a resident room with medications for residents #33 (A bed) and resident #16 (B bed). The medications taken into the residents' room included 28 units of the long acting insulin [MEDICATION NAME], which was scheduled to be administered at 4:30 PM for resident #16 in B bed; however, the nurse injected the insulin subcutaneously into resident #33 in A bed. The next morning, on 11/16/18, resident #33 was transferred to the hospital at 9:50 AM for being unresponsive to verbal or painful stimuli with stroke like symptoms. Resident #33 was subsequently admitted to the hospital with [REDACTED]. The resident had no history of diabetes or orders to receive insulin. The nurse returned to the facility on [DATE], 5 days after the incident and reported her mistake to the supervisor. On 11/20/18 the nurse involved in the incident was terminated. On 11/22/18 resident #33 passed away. On 11/20/18, the facility, in response to the incident with resident #33, instituted a Performance Improvement Plan (PIP). The PIP included medication administration observations, which focused on proper medication preparations and resident identification, a nursing in-service on diabetes management, including short versus long acting insulin, physician notification and incident reporting. The PIP also involved a 100% review of residents with insulin orders for appropriateness, and an insulin administration test for nurse competency. All areas of the PIP were noted to have an Actual Completion Date ranging from 11/20/18 to 11/30/18 with two areas noted to be ongoing, which included resident pictures on the MAR for appropriate identification as well as residents' name being correct on their name plates outside their rooms. Observations of staff administering insulin were not included in the PIP, and the Director of Nursing (DON) reported on 1/9/19 that she and the Assistant Director of Nursing (ADON) observed medication pass but did NOT focus on insulin. On 12/4/18, the facility also instituted a PIP related to nurse training, orientation, and skills validations when they discovered these were not being completed for new hires, including the nurse involved in the incident on 11/15/18, nor annually for existing staff. The focus of the PIP was to correct the training and skills competency issues for new hires, but did not include any action to be taken for existing staff in the facility. In a discussion with the DON on 01/09/19, regarding the PIP, she was asked if staff currently working in the facility were included in the plan and she stated, not at this time. Review of the orientation sign-in sheets for (MONTH) 20th, 21st and 31st found that of the 11 new employees listed, only staff G, H & I had skills checklists that were either in progress or completed. According to review of a report from the facility's consultant pharmacy, on 12/7/18 at 4:50 AM, a nurse consultant from the pharmacy conducted an observation of the morning medication administration with facility nursing staff. The nurse consultant's documentation supported that during this observation, staff member D, an LPN, gave 25 units of the short acting insulin Humalog instead of the long acting insulin [MEDICATION NAME] that was ordered by the physician for resident #19. As a result of this observation by the nurse consultant, the facility revised their PIP and instituted a 2 nurse verification process for all insulin administration. Each medication cart was provided a red three ring binder that housed an insulin verification form that stated nurses were to have a co-signature before giving sliding scale or routine insulin. On 1/9/19, review of the insulin verification forms on all 5 facility medication carts was conducted and revealed the 2 nurse verification process instituted by the facility was not being executed by the facility nursing staff. Review of the forms on the 100 hall and 200 hall medication cart showed the procedure was only documented for 4 of 10 insulin administrations. The 300 hall cart had only 3 of 8 insulin administrations verified by 2 nurses and the 400 hall cart had 6 of 11 insulin opportunities verified by a second nurse. On 1/9/19 at approximately 6:40 AM, observation was made of medication administration with Licensed Practical Nurse (LPN) staff member E. During this observation, the nurse was observed to administer insulin to resident #23 using a newly opened insulin pen prescribed for resident #25, though the appropriate type and dose of insulin was administered. A review of all 22 current residents on routine insulin and 10 additional residents on sliding scale insulin (for a total of 32 at the time of the survey) was conducted. The review revealed a failure to notify the physician and/or implement diabetes management protocols regarding high and/or low blood sugar readings for residents #6, 14, 24, and 32, and a failure to consistently implement physician orders regarding sliding scale or holding insulin for resident #5 & 13. Please see F684 and F760 for additional information. On 1/11/19 at approximately 1:00 PM the Administrator in Training provided a typed document that he stated was a summary of the QA Committee meeting held on 12/4/18. The document found the following Incidents for past two months and current month of (MONTH) were reviewed to ensure follow-up was completed, system now in compliance the note continues on to say initiated Clinical QAPI and weekly QA/Risk meetings per our processes to ensure accuracy and follow was completed, system is in compliance. Labs, anticoagulants, Insulin/Accuchecks were reviewed to ensure follow-up complete. The facility was asked to provide policies related to new employee orientation, annual skills review, and competencies for nursing staff. The facility was unable to produce such policies by the end of the survey on 1/11/19. The administrator stated on 1/09/19 at approximately 11:00 AM that orientation and skills validation are done per federal regulations and that there is no formal policy for staff orientation or annual skills review. At this same time the DON (Director of Nursing) was asked about the lack of annual skills verification to which she stated that she has attempted to find evidence of staff reviews but has been unable to do so for (YEAR). She stated she can easily trace these as being done prior to (YEAR) however they have not been completed since (YEAR). She also stated that prior to her start of employment in (MONTH) she has been unable to find evidence of new employee orientation or skills validations. She stated that she developed an Action Plan after realizing these were not being done on 12/4/18 with the intention to address new employees only. She has not reviewed current employees and the Action Plan does not address current employees' only new hires moving forward. Review of the POS [REDACTED]. Essential functions of the position include ensure excellent care for residents is maintained by overseeing and monitoring patient care services delivered works with and supervises personnel in facility by providing opportunities for instruction, guidance, and counseling as necessary to ensure complete understanding of responsibilities. Review of the POS [REDACTED]. Ensures the orientation and training of nursing services personnel Ensures nursing department compliance with federal, state and local regulations and implementation of nursing programs. Monitors the facility's survey reports and assist in developing plans of action to correct potential or identified problems areas. Review of the facility policy 'Medication Administration General Guidelines' dated (MONTH) (YEAR), revealed that medications were to be administered as prescribed and in accordance with manufactures' specifications, and good nursing principles. It further stated that prior to administration, the nurse should review and confirm MEDICATION ORDERS FOR [REDACTED]. It also stated medications supplied for one resident were never to be administered to another resident. The immediate jeopardy was removed onsite after the receipt of the allegation of compliance and verification of corrective actions. The facility placed an immediate moratorium on new admissions who require insulin. The facility conducted an immediate retraining of nursing staff regarding insulin administration, the 10 rights of medication administration, blood sugar monitoring, and physician notification regarding high and low blood sugar readings. All nurses not immediately available were to be educated prior to starting their next shift. The facility implemented a 2 person insulin validation system where a supervisor on every shift was designated to verify insulin prior to administration. Nursing staff were trained in the validation system. All nurses not immediately available were to be educated prior to starting their next shift. The facility immediately discarded the insulin pen that was used on the incorrect resident to prevent cross-contamination.

Based on observation of insulin administration, staff interviews, closed and open clinical record review, and policy review, the facility failed to ensure corrective action plans were fully and consistently implemented to correct identified process failures regarding diabetes management including insulin medication errors. The quality assurance (QA) committee developed a corrective action plan following a significant insulin medication error and subsequent death of resident #33. The QA committee failed to ensure corrective actions requiring 2 person verification were being fully implemented and failed to ensure nursing staff had appropriate training and competency evaluations with diabetes management and insulin administration. This failure resulted in significant medication errors for residents #19 and #23, and continued risk of injury to 6 of 32 current residents in the facility receiving diabetes management (#5, #6, #13, #14, #24, & #32). The situation resulted in a finding of immediate jeopardy. The facility's Administrator, the Administrator in Training and the Director of Nursing were notified of the findings of Immediate Jeopardy on (MONTH) 10, 2019 at approximately 10:45 AM. The Immediate Jeopardy was removed on (MONTH) 11, 2019 at 4:30 PM when the facility provided evidence of immediate corrective actions. The deficient practice remains at a scope and severity level of a D. Cross reference to F600, F684, F726 and F760. Findings included: Review of a facility submitted abuse report for resident #33, dated 11/20/18, revealed that on 11/15/18, during evening medication pass, staff member A, an LPN, entered a resident room with medications for residents #33 (A bed) and resident #16 (B bed). The medications taken into the residents' room included 28 units of the long acting insulin [MEDICATION NAME], which was scheduled to be administered at 4:30 PM for resident #16 in B bed; however, the nurse injected the insulin subcutaneously into resident #33 in A bed. Per the investigation conducted by the facility, at the time of administration, the resident stated, what shot? and the nurse realized her mistake. The nurse reported she checked the resident's blood sugar and found it to be 126mg/dl (milligrams per deciliter), which is within normal range, so she did not report the incident. On 11/16/18, resident #33 was transferred to the hospital at 9:50 AM for being unresponsive to verbal or painful stimuli with stroke like symptoms. The resident's extremities were rigid, pupils nonresponsive and vital signs were blood pressure 205/83mgHG (millimeter of mercury), heart rate of 60 beats per minute, respiratory rate of 20 breaths per minute, and a temperature of 97.6F (Farenheit). Resident #33 was subsequently admitted to the hospital with [REDACTED]. The resident had no history of diabetes or orders to receive insulin. The nurse returned to the facility on [DATE], 5 days after the incident and reported her mistake to the supervisor. On 11/22/18 resident #33 passed away. On 11/20/18, the facility, in response to the incident with resident #33, instituted a Performance Improvement Plan (PIP). The PIP included medication administration observations, which focused on proper medication preparations and resident identification, a nursing in-service on diabetes management, including short versus long acting insulin, physician notification and incident reporting. The PIP also involved a 100% review of residents with insulin orders for appropriateness, and an insulin administration test for nurse competency. All areas of the PIP were noted to have an Actual Completion Date ranging from 11/20/18 to 11/30/18 with two areas noted to be ongoing, which included resident pictures on the MAR for appropriate identification as well as residents' name being correct on their name plates outside their rooms. Observations of staff administering insulin were not included in the PIP, and the Director of Nursing (DON) reported on 1/9/19 at about 11:00am that she and the Assistant Director of Nursing (ADON) observed medication pass but did not focus on insulin. On 12/4/18, the facility also instituted a PIP related to nurse training, orientation, and skills validations when they discovered these were not being completed for new hires, including the nurse involved in the incident on 11/15/18, nor annually for existing staff. The focus of the PIP was to correct the training and skills competency issues for new hires, but did not include any action to be taken for existing staff in the facility. In a discussion with the DON on 01/09/19, regarding the PIP, she was asked if staff currently working in the facility were included in the plan and she stated, not at this time. Review of the orientation sign-in sheets for (MONTH) 20th, 21st and 31st found that of the 11 new employees listed, only nurses G, H & I had skills checklists that were either in progress or completed. According to review of a report from the facility's consultant pharmacy, on 12/7/18 at 4:50 AM, a nurse consultant from the pharmacy conducted an observation of the morning medication administration with facility nursing staff. The nurse consultant's documentation supported that during this observation, staff member D, an LPN, gave 25 units of the short acting insulin Humalog instead of the long acting insulin [MEDICATION NAME] that was ordered by the physician for resident #19. This incident occurred after the training and other interventions put in place as a result of the death of resident #33. As a result of this observation by the nurse consultant, the facility instituted a 2 nurse verification process for all insulin administration. Each medication cart was provided a red three ring binder that housed an insulin verification form that stated nurses were to have a co-signature before giving sliding scale or routine insulin. On 1/9/19, review of the insulin verification forms on all 5 facility medication carts was conducted and revealed the 2 nurse verification process instituted by the facility was not being executed by the facility nursing staff. Review of the forms on the 100 hall and 200 hall medication cart showed the procedure was only documented for 4 of 10 insulin administrations. The 300 hall cart had only 3 of 8 insulin administrations verified by 2 nurses and the 400 hall cart had 6 of 11 insulin opportunities verified by a second nurse. On 1/9/19 at approximately 6:40 AM, observation was made of medication administration with Licensed Practical Nurse (LPN) staff member E. During this observation, the nurse was observed to administer insulin to resident #23 using a newly opened insulin pen prescribed for resident #25, though the appropriate type and dose of insulin was administered. This was verified via an interview with staff member C who verified the insulin on the insulin verification form with staff member E. A review of all 22 current residents on routine insulin and 10 additional residents on sliding scale insulin (for a total of 32 at the time of the survey) was conducted. The review revealed a failure to notify the physician and/or implement diabetes management protocols regarding high and/or low blood sugar readings for residents #6, 14, 24, and 32, and a failure to consistently implement physician orders regarding sliding scale or holding insulin for resident #5 & 13. Please see F684 and F760 for additional information. On 1/11/19 at approximately 1:00 PM the Administrator in Training provided a typed document that he stated was a summary of the QA Committee meeting held on 12/4/18. The document found the following Incidents for past two months and current month of (MONTH) were reviewed to ensure follow-up was completed, system now in compliance the note continues on to say initiated Clinical QAPI and weekly QA/Risk meetings per our processes to ensure accuracy and follow was completed, system is in compliance. Labs, anticoagulants, Insulin/Accuchecks were reviewed to ensure follow-up complete. The facility was asked to provide policies related to new employee orientation, annual skills review, and competencies for nursing staff. The facility was unable to produce such policies by the end of the survey on 1/11/19. The administrator stated on 1/09/19 at approximately 11:00 AM that orientation and skills validation are done per federal regulations and that there is no formal policy for staff orientation or annual skills review. At this same time the DON (Director of Nursing) was asked about the lack of annual skills verification to which she stated that she has attempted to find evidence of staff reviews but has been unable to do so for (YEAR). She stated she can easily trace these as being done prior to (YEAR) however they have not been completed since (YEAR). She also stated that prior to her start of employment in (MONTH) she has been unable to find evidence of new employee orientation or skills validations. She stated that she developed an Action Plan after realizing these were not being done on 12/4/18 with the intention to address new employees only. She has not reviewed current employees and the Action Plan does not address current employees' only new hires moving forward. Review of the facility policy 'Medication Administration General Guidelines' dated (MONTH) (YEAR), revealed that medications were to be administered as prescribed and in accordance with manufactures' specifications, and good nursing principles. It further stated that prior to administration, the nurse should review and confirm MEDICATION ORDERS FOR [REDACTED]. It also stated medications supplied for one resident were never to be administered to another resident. The immediate jeopardy was removed onsite after the receipt of the allegation of compliance and verification of corrective actions. The facility placed an immediate moratorium on new admissions who require insulin. The facility conducted an immediate retraining of nursing staff regarding insulin administration, the 10 rights of medication administration, blood sugar monitoring, and physician notification regarding high and low blood sugar readings. All nurses not immediately available were to be educated prior to starting their next shift. The facility implemented a 2 person insulin validation system where a supervisor on every shift was designated to verify insulin prior to administration. Nursing staff were trained in the validation system. All nurses not immediately available were to be educated prior to starting their next shift. The facility immediately discarded the insulin pen that was used on the incorrect resident to prevent cross-contamination.

Based on medication pass observation, medication record review, plan of correction review and staff interview, the facility failed to implement an effective Quality Assurance Program to implement action plans developed to address a significant medication error related to the administration of [MEDICATION NAME]. During a follow-up medication pass, another [MEDICATION NAME] medication error was identified for the same resident (#140). Resident #140 had not been administered [MEDICATION NAME] in 12 days. The facility identified 11 current residents receiving [MEDICATION NAME] therapy. An audit of all 11 charts was conducted the morning of 9/13/12. Two other [MEDICATION NAME] dosing errors were identified (#17 and #249). In addition, a [MEDICATION NAME] (another blood thinner) error was identified for Resident #244. The failure of the Action Plan to prevent a second significant medication error for the same medication being administered to the same resident, and the identification of three other documented medication dosing errors for 4 of 12 residents led to a finding of Immediate Jeopardy with the Quality Assurance process. The facility was informed of the finding of immediate jeopardy on 9/13/12. The facility immediately began developing an action plan to abate the jeopardy. Immediate Jeopardy was ongoing at the time of exit. Cross reference F333. The findings: On 8/7/12, during a complaint survey, a medication pass observation was conducted for Resident #140. Resident #140 was ordered 8mg of [MEDICATION NAME] daily, but was only administered 4mg of [MEDICATION NAME]. The facility developed a Plan of Correction to address this significant medication dosage error. The Plan of Correction included: - Immediate MAR (Medication administration Record) audit of [MEDICATION NAME] physician orders [REDACTED]. - Random audits of d MARS by Unit Manager (UM) or designee daily x 7 days then weekly x 8 weeks. Nurses to be observed by UM/designee for medication observation and medication competency testing. Results of audit will be reported at QA (Quality Assurance) meeting x 3 Months for review and recommendations. On 9/10/12 a current list of all residents receiving [MEDICATION NAME] therapy was requested. The facility provided a list of 11 resident names, one of which was Resident #140 (who had previously been cited for a [MEDICATION NAME] dosing error). On 9/12/12 at approximately 4:30pm, a Medication Pass Observation was again conducted for Resident #140. There were current Physician orders [REDACTED]. This medication was not observed to be given. Upon further record review, it was determined that the order for [MEDICATION NAME] 6mg daily (which had been written on 8/7/12, renewed on 8/29/12 and remained current) had been omitted from both the September Physician order [REDACTED]. Resident #140 was sent out to the emergency room the evening of 9/12/12. The emergency room record documentation was reviewed. Resident #140's [MEDICATION NAME] INR was only 1.6. This was barely above the normal reference range of 0.9 to 1.3, and well below the therapeutic reference range for people taking [MEDICATION NAME] (2.0 to 3.0 for basic "blood-thinning" needs and 2.5 - 3.5 for people who have a high risk of clot formation). In order to prevent a blood clot and possible stroke, the emergency room physician ordered a [MEDICATION NAME] drip (fast acting blood thinner) and a stat (immediate) order of [MEDICATION NAME] 10 mg orally. Resident #140 was sent back to the facility with instructions: while bridging [MEDICATION NAME] use [MEDICATION NAME] 100 mg subcutaneously twice daily, resume [MEDICATION NAME] and use [MEDICATION NAME] until INR is therapeutic at 2.5 to 3. A further review of the resident's clinical record revealed that Resident #140 took [MEDICATION NAME] ([MEDICATION NAME]) because he had an aortic valve replacement, [MEDICAL CONDITION] and has a history of a stroke. These [DIAGNOSES REDACTED]. On 9/13/12 at approximately 2:18pm, an interview was conducted with the Medical Director. The Medical Director stated that the INR target range was 2.5 - 3.5 for patients with aortic valve replacement. He confirmed the [DIAGNOSES REDACTED]. The medical director affirmed that he would be involved in the solution and the process to ensure that this type of medication error was not repeated. The facility was in the process of developing and implementing a new process and retraining staff. "I will be actively involved". An interview with the Regional Nurse Consultant, the Administrator, the Director of Nurses (DON) and the Risk Manager on their Quality Assurance (QA) Committee process was conducted on 9/14/12 at approximately 2:43pm. They confirmed that an action plan had been developed by the QA committee related to the [MEDICATION NAME] dosing error identified on 8/7/12. They confirmed that they had been implementing their action plan which included a weekly MAR indicated [REDACTED]. These audits were conducted with concurrent review. They also conducted random medication pass audits with the Unit Managers and pharmacy. The staff attributed the continued medication administration errors to staff change over. There had been a lot of change-over and inconsistent staff. The DON, the unit managers, the Risk Manager and many of the nurses were newly hired. They have developed a new action plan to address the continued problems with medication administration.

Based on observation, staff interview, resident interview, clinical record review and policy review the facility failed to implement the plan of care for 1 of 1 sampled residents observed during the tour (#3) and 1 of 8 sampled residents receiving [MEDICATION NAME]. (#12) The findings include: 1. An observation of resident #3 was conducted on 8/6/2012 at approximately 9:15 AM. The resident was in bed. The surveyor observed 2 [MEDICATION NAME]es on the bedside table next to the bed. The resident stated she had asked the nurse to leave the patches on the table. The [MEDICATION NAME]es were dated 8/6/12 6 AM. An interview was conducted with employee A (a Licensed Practical Nurse) on 8/6/2012 at approximately 9:22 AM at the bedside of resident #3. Employee A confirmed the patches on the bedside table were medication, stated she was not aware they were left on the table and the staff were not supposed to leave medications at the bedside. Review of resident #3's clinical record was conducted on 8/6/2012. The record revealed a current plan of care dated 3/14/2012 for altered comfort related to left knee pain, chronic pai[DIAGNOSES REDACTED] and chronic constipation. The approaches included meds as ordered by nursing staff and topical [MEDICATION NAME] as ordered by nursing staff. The record contained a current physician order [REDACTED]. 2. An observation of medication pass with employee B (a Licensed Practical Nurse) was conducted on 8/6/2012 at approximately 4:56 PM for resident #12. Employee B administered [MEDICATION NAME] 4 mg to resident #12. The label on the medication stated to administer two (2) 4 mg tablets of [MEDICATION NAME] for a total dose of 8 mg. Review of resident #12's clinical record was conducted on 8/6/2012 after observing the medication pass. The current physician orders [REDACTED]. The MAR indicated [REDACTED]. The record revealed a current plan of care last updated on 6/26/2012 for risk of adverse bleeding secondary to the use of [MEDICATION NAME] for the treatment of [REDACTED]. An interview was conducted with employee B on 8/6/2012 at approximately 5:22 PM. Employee B confirmed she administered [MEDICATION NAME] 4 mg instead of the ordered 8 mg to resident #12 and stated she would go and give the other 4 mg. An interview was conducted with the Advanced Registered Nurse Practitioner (ARNP) on 8/7/2012 at approximately 10:11 AM. The ARNP stated resident #12 received [MEDICATION NAME] due to [MEDICAL CONDITION] and aortic valve replacement. She stated they have had some difficulty regulating the medication level due to recent [MEDICATION NAME] toxicity and the 2 medications can interact. The facility policy for Medication Administration (section 7.1) was reviewed on 8/7/2012. The policy stated medications are to be administered at the time they are prepared and in accordance with the written orders of the prescriber. The following is an excerpt from the U.S. National Library of Medicine at www.ncbi.nlm.nih.gov: Last reviewed September 1, 2010 [MEDICATION NAME] ([MEDICATION NAME]) [MEDICATION NAME] is used to prevent blood clots from forming or growing larger in your blood and blood vessels. It is prescribed for people with certain types of irregular heartbeat, people with prosthetic (replacement or mechanical) heart valves, and people who have suffered a [MEDICAL CONDITION]. [MEDICATION NAME] is also used to treat or prevent venous [MEDICAL CONDITION] (swelling and blood clot in a vein) and [MEDICAL CONDITION] embolism (a blood clot in the lung). [MEDICATION NAME] is in a class of medications called anticoagulants ('blood thinners'). It works by decreasing the clotting ability of the blood. [MEDICATION NAME] comes as a tablet to take by mouth. It is usually taken once a day with or without food. Take [MEDICATION NAME] at around the same time every day. Follow the directions on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Take [MEDICATION NAME] exactly as directed. Do not take more or less of it or take it more often than prescribed by your doctor.

Based on observation, staff interview, resident interview, clinical record review and policy review the facility failed to implement the plan of care for 1 of 11 sampled residents observed during medication pass who was receiving [MEDICATION NAME]. ( resident #140) Resident #140 was observed for Medication Pass on 9/12/12 about 4:30 pm. The nurse administered [MEDICATION NAME] 750 mg two tablets (1500 mg) by mouth (po); [MEDICATION NAME] 300 mg one capsule po; Senna laxative two 8.6 mg tablets po and [MEDICATION NAME] one 500 mg tablet and one 250 mg tablet = 750 mg po. It was observed that the nurse did not administer [MEDICATION NAME]. The Physician Order Sheet (POS) and Medication Administration Record (MAR) were reviewed for September 2012. [MEDICATION NAME] was not listed on either document. A review of the telephone physician order sheet revealed an order written [REDACTED].#2 - Start [MEDICATION NAME] 6 mg one tablet daily on 8/8/12. There were no orders to discontinue the [MEDICATION NAME]. On 9/12/12 about 5:15pm the Licensed Practical Nurse (LPN) Unit Manager (Employee B) was asked if Resident 140's [MEDICATION NAME] was discontinued. The Unit Manager checked the telephone orders, MAR for August and September, and the POS for August and September. She then stated, "No it has not been discontinued". She verified that the [MEDICATION NAME] ([MEDICATION NAME]) order had been omitted from the September 2012 POS and MAR and the resident had not received [MEDICATION NAME] from September 1 to September 12. Review of the medical record for resident #140 revealed a care plan last updated on 6/26/2012 for risk of adverse bleeding secondary to the use of [MEDICATION NAME] for the treatment of [REDACTED]. Review of the facility policy for Medication Administration (section 7.1) stated medications are to be administered at the time they are prepared and in accordance with the written orders of the prescriber.

Based on observation, staff interviews, clinical record review and policy review the facility failed to ensure residents were free from significant medication errors for 1 of 8 sampled residents receiving [MEDICATION NAME] therapy. (#12) The findings include: An observation of medication pass with employee B (a Licensed Practical Nurse) was conducted on 8/6/2012 at approximately 4:56 PM for resident #12. Employee B administered [MEDICATION NAME] 4 mg to resident #12. The label on the medication stated to administer two (2) 4 mg tablets of [MEDICATION NAME], for a total dose of 8 mg. Review of resident #12's clinical record was conducted on 8/6/2012 after observing the medication pass. The current physician orders [REDACTED]. The MAR indicated [REDACTED]. The record revealed a current plan of care last updated on 6/26/2012 for risk of adverse bleeding secondary to the use of [MEDICATION NAME] for the treatment of [REDACTED]. An interview was conducted with employee B on 8/6/2012 at approximately 5:22 PM. Employee B confirmed she administered [MEDICATION NAME] 4 mg instead of the ordered 8 mg to resident #12 and stated she would go and give the other 4 mg. An interview was conducted with the Advanced Registered Nurse Practitioner (ARNP) on 8/7/2012 at approximately 10:11 AM. The ARNP stated resident #12 received [MEDICATION NAME] due to [MEDICAL CONDITION] and aortic valve replacement. She stated they have had some difficulty regulating the medication level due to recent [MEDICATION NAME] toxicity and the 2 medications can interact. The facility policy for Medication Administration (section 7.1) was reviewed on 8/7/2012. The policy stated medications are to be administered at the time they are prepared and in accordance with the written orders of the prescriber. The following is an excerpt from the U.S. National Library of Medicine at www.ncbi.nlm.nih.gov: Last reviewed September 1, 2010 [MEDICATION NAME] ([MEDICATION NAME]) [MEDICATION NAME] is used to prevent blood clots from forming or growing larger in your blood and blood vessels. It is prescribed for people with certain types of irregular heartbeat, people with prosthetic (replacement or mechanical) heart valves, and people who have suffered a [MEDICAL CONDITION]. [MEDICATION NAME] is also used to treat or prevent venous [MEDICAL CONDITION] (swelling and blood clot in a vein) and [MEDICAL CONDITION] embolism (a blood clot in the lung). [MEDICATION NAME] is in a class of medications called anticoagulants ('blood thinners'). It works by decreasing the clotting ability of the blood. [MEDICATION NAME] comes as a tablet to take by mouth. It is usually taken once a day with or without food. Take [MEDICATION NAME] at around the same time every day. Follow the directions on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Take [MEDICATION NAME] exactly as directed. Do not take more or less of it or take it more often than prescribed by your doctor.

Based on observation of medication pass, staff interviews, clinical record reviews and policy reviews, the facility failed to administer medications in accordance with physician orders [REDACTED]. The facility failed to administer [MEDICATION NAME] medication as ordered for 1 of 11 sampled residents during medication pass observation (resident #140). Further record review revealed that the facility failed to administer [MEDICATION NAME] to Resident #140 for 12 days. The facility also documented the administration of 1 dose of a discontinued medication, [MEDICATION NAME], for 1 of 10 sampled residents during unnecessary medication review (Resident #244). The facility failed to appropriately transcribe and document [MEDICATION NAME] orders and administration for 2 of 11(#17,and #249) sampled residents receiving [MEDICATION NAME]. The survey team expanded the [MEDICATION NAME] orders and administration to include all 11 residents identified by the facility as receiving [MEDICATION NAME] therapy. The facility failure to administer [MEDICATION NAME] and [MEDICATION NAME] in accordance with physician orders [REDACTED]. The facility was informed of the finding of immediate jeopardy on 9/13/12. The findings are: 1. At the request of the team-leader on 9/10/12, the facility had provided a list of all residents receiving [MEDICATION NAME]. The list contained 11 names, one of which was Resident #140 (who had previously been cited for a [MEDICATION NAME] dosing error during the complaint survey of August 7, 2012). Resident #140 was observed for Medication Pass on 9/12/12 about 4:30 pm. The nurse administered [MEDICATION NAME] 750 mg two tablets (1500 mg) by mouth (po); [MEDICATION NAME] 300 mg one capsule po; Senna laxative two 8.6 mg tablets po and [MEDICATION NAME] one 500 mg tablet and one 250 mg tablet = 750 mg po. It was observed that the nurse did not administer [MEDICATION NAME]. The Physician order [REDACTED]. [MEDICATION NAME] was not listed on either document. A review of the telephone physician order [REDACTED].#2 - Start [MEDICATION NAME] 6 mg one tablet daily on 8/8/12. There were no orders to discontinue the [MEDICATION NAME]. On 9/12/12 about 5:15pm the Licensed Practical Nurse (LPN) Unit Manager (Employee B) was asked if Resident 140's [MEDICATION NAME] was discontinued. The Unit Manager checked the telephone orders, MAR for August and September, and the POS for August and September. She then stated, "No it has not been discontinued". She verified that the [MEDICATION NAME] ([MEDICATION NAME]) order had been omitted from the September 2012 POS and MAR and the resident had not received [MEDICATION NAME] from September 1 to September 12. An interview was conducted with the Administrator and the Director of Nursing (DON) on 9/12/12 about 5:30 pm. They indicated the resident would receive lab work immediately for PT ([MEDICATION NAME] time) and INR (International Ratio) to determine how this omission had affected the resident. A follow-up interview was conducted with the Administrator and the DON on 9/13/12 about 8:00 am. They indicated that Resident #140, his family and physician were notified of the omission. He was sent to the emergency room (ER) for evaluation of his medical condition last evening. He has returned to the facility. A request was made to review the assessment and results of his lab results while in the ER. The emergency room record provided by the facility on 9/13/12 indicated that Resident #140's PT was 15.9. This was barely above the normal reference range of 9.4-12.7 (the range for people not taking [MEDICATION NAME] Blood thinners). His [MEDICATION NAME] INR was 1.6. This was barely above the normal reference range of 0.9 to 1.3, and well below the therapeutic reference range for people taking [MEDICATION NAME] (2.0 to 3.0 for basic "blood-thinning" needs and 2.5 - 3.5 for people who have a high risk of clot formation). The resident was given the following medications: [REDACTED]. He was sent back to the facility with instructions: while bridging [MEDICATION NAME] use [MEDICATION NAME] 100 mg subcutaneously twice daily, resume [MEDICATION NAME] and use [MEDICATION NAME] until INR is therapeutic at 2.5 to 3.0. A further review of the resident's clinical record revealed that Resident #140 takes [MEDICATION NAME] ([MEDICATION NAME]) because he has an aortic valve replacement, [MEDICAL CONDITION] and history of a previous stroke. The September 2012 MAR and POS revealed he has conflicting current orders for laboratory monitoring of PT/INR. One order has a start date of 11/21/11 for PT/INR every Monday for [MEDICAL CONDITION], and the other order dated 5/23/12 is for PT/INR every other week for heart valve replacement. Additionally, on 8/29/12, the Advanced Registered Nurse Practitioner (ARNP) ordered a PT/INR every Monday. This order was written on a lab report dated 8/29/12. Record review revealed that his order had not been transcribed to the POS, telephone order sheet or the MAR. On 9/13/12 about 10:45am, the telephone orders were reviewed with the LPN Unit Manager (Employee B). A review of the telephone orders failed to reveal an order for [REDACTED]. The Unit Manager (Employee B) verified the PT/INR was not done on 9/10/12 per the written order from the INR lab report dated 8/29/12. Employee B verified that the ARNP wrote an order on the sheet: " Continue [MEDICATION NAME] therapy 6 mg per day. PT/INR every Monday " . No PT/INR was obtained on Monday, 9/10/12. The most recent PT/INR in the patient ' s record was dated 9/03/12. A follow-up interview was conducted with the Administrator on 9/13/12 about 10:25am regarding the ARNPs order written on the PT/INR lab report. The Administrator indicated that this type of order would be verified by the nurse and transcribed to a physician order [REDACTED]. The last INR performed was on 9/3/12. The Medical Director and physician for Resident #140 was interviewed on 9/13/12 about 2:15 pm. He was asked what his PT/INR target range was for residents having an aortic valve replacement. He stated, "I would like to keep it between 2.5 to 3.5". He also confirmed that the expectation was that all physician and ARNP orders, including those written on laboratory and X-ray result forms, would be followed. (Note lab results from the PT/INR from theER on [DATE] indicate Resident 140's INR was 1.6, well below the stated range). 2. Review of resident #244's record was conducted on 9/13/2012. The record revealed a physician's clarification order dated 9/5/2012 stating to discontinue [MEDICATION NAME] as of 9/3/2012. The Medication Administration Record (MAR) was reviewed on 9/13/2012. The MAR revealed the [MEDICATION NAME] was administered on 9/9/2012, six days after it was discontinued. The policy for administering medications was reviewed on 9/14/2012. The policy stated medications must be administered in accordance with the orders. 3. Review of resident #17's record was conducted on 9/13/2012. The record revealed a physician order [REDACTED]. The Medication Administration Record revealed the nurse administered [MEDICATION NAME] 3 mg by mouth at 5 PM on 9/10/2012 to resident #17. The MAR also revealed the same nurse administered [MEDICATION NAME] 6 mg by mouth at 5 PM on 9/10/2012 to resident #17. This would equal a total of 9 mg administered on 9/10/2012. An interview was conducted with Employee N (a Registered Nurse) on 9/13/2012 at approximately 1:05 PM. The Registered Nurse confirmed the signatures on the MAR were her signatures for both doses of [MEDICATION NAME] on 9/10/2012. She stated she signed the [MEDICATION NAME] 3 mg dose on 9/10/2012 in error because it looked like a hole in the MAR. The facility policy for Documentation of Medication Administration was reviewed on 9/14/2012. The policy stated administration of medication must be documented immediately after it is given. 4. Review of resident #249's record was conducted on 9/13/2012. The record revealed a physician order [REDACTED]. The previously ordered dose of [MEDICATION NAME] was 4 mg by mouth every day at 5 PM. The Medication Administration Record (MAR) revealed a current order (not discontinued) for [MEDICATION NAME] 4 mg by mouth every day at 5 PM. The MAR also revealed a current order for [MEDICATION NAME] 4.5 mg by mouth every day at 5 PM to start on 9/13/2012. Both doses of [MEDICATION NAME] remained on the MAR as current orders which created the potential for the resident to receive a total of 8.5 mg in one day. An interview was conducted with the Director of Nursing (DON) on 9/13/2012 at approximately 9:50 AM. The DON stated the order was received after 5 PM on 9/12/2012 when the 4 mg of [MEDICATION NAME] was administered instead of 4.5 mg. The facility policy for Discontinued Medications was reviewed on 9/14/2012. The policy stated a practitioner's order to discontinue a resident's medication must be documented in the resident's clinical record and on the medication administration record.