Every finding on record at Tahoe Forest Hospital D/P SNF

Based on observation, interview, and record review, the facility failed to ensure proper labeling and storage of medications and biologicals for a census of 31 residents, when:1. Opened and unlabeled insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) pens were found in medication cart 1;2. Expired Coronavirus disease 2019 (COVID 19; an infectious disease that causes respiratory illness) test kits were found inside the medication storage room; and3. A metered dose inhaler (MDI, puffer handheld pressurized device delivers measured amount of medication to the lungs) with no name and use by date was available for use inside medication cart 2.These failures decreased the facility's potential to safely store medications.Findings:1. During a concurrent observation and interview on 2/9/26 at 10:16 a.m. with Licensed Nurse (LN) 3, medication cart 1 was inspected. LN 3 confirmed two unlabeled insulin pens were stored in the top drawer of the medication cart. LN 3 stated she was unsure which resident the insulin pens belonged to because they had no pharmacy labels attached.During an interview on 2/10/26 at 2:02 p.m. with the Pharmacy Consultant (PC), PC stated prescribed medications should have pharmacy labels to ensure residents were provided with the correct medications and were within their expiration date.2. During a concurrent observation and interview on 2/9/26 at 2:45 p.m. with LN 5, the medication storage room was inspected. LN 5 confirmed thirty-eight boxes of COVID 19 test kits, each with an expiration date of 3/13/25, were stored inside the Infection Preventionist (IP) cart within the medication storage area.During a concurrent observation and interview on 2/10/26 at 1:49 p.m. with the IP, IP stated the COVID 19 test kits were all expired and should have been discarded. IP further stated using expired test kits could result in inaccurate staff results.3. During a concurrent observation and interview on 2/10/26 at 1:53 p.m. with LN 4, medication cart 2 was inspected. LN 4 confirmed an MDI with no name and use by date was available for resident use inside the cart. LN 4 stated the MDI should have proper labeling to make sure the medication was for the right resident and was not expired.During an interview on 2/12/26 at 10 a.m. with the Director of Nursing - Hospital District (DON HD), DON HD stated medications should have been labeled properly at least with the resident's name and expired medications should have been disposed of according to the facility's policy.A review of the facility's policy titled, Single and Multi-Dose Medications and Expirations in Clinical Area, APH-28, revised in 4/2025, indicated, Insulin pens . once opened shall be labeled with a beyond use date of a maximum 28 days post entry and two patient identifiers . Vaccines . should be inspected for viability prior to vaccination . vaccines may be discarded per the manufacturer's expiration which is usually the expiration date printed on the FDA packaging.A review of the facility's policy titled, ECC Delivery Process, Medication Labels, AEP-79, revised in 4/2024, indicated, Labels are permanently affixed to the outside of the prescription unit dose . The resident's name . must be maintained directly on the actual product .

Based on interview and record review, the facility failed to ensure the Pharmacy Consultant's (PC) recommendations were followed for three of 13 sampled residents (Resident 2, Resident 9 and Resident 12), when Resident 2, Resident 9 and Resident 12's monthly medication regimen reviews (MRRs) for December 2025 and January 2026 were not reviewed by the attending physician.This failure decreased the facility's potential to prevent the residents' unnecessary medication use and experiencing of adverse drug reactions.Findings: 1. A review of Resident 2's Record of Admission, indicated he was admitted to the facility on [DATE] with diagnoses including diabetic polyneuropathy (a progressive type of nerve damage caused by long-term high blood sugar, causing burning or pain), traumatic brain injury (an acquired injury to the brain caused by external physical force), and gastroesophageal reflux disease with esophagitis (GERD-a serious form of acid reflux in which stomach contents flow back into the esophagus, irritating its lining). A review of Resident 2's Physician Orders, indicated he was prescribed the following medications on 7/24/25: -pregabalin (treats neuropathic pain) 25 milligrams (mg; a unit of measure) every 12 hours for peripheral neuropathy, -clopidogrel hydrogen sulfate (reduces the risk of stroke and heart attack) 75 mg daily for cerebrovascular accident (stroke), and -pantoprazole sodium (treats excess stomach acid and erosive esophagitis) 40 mg daily for GERD. A review of a facility document titled, Consultant Pharmacist's MRR: Note to Attending Physician/Prescriber, dated 12/31/25, indicated there was no response to CP's recommendation for dose reduction and medication replacement regarding Resident 2's use of clopidogrel and pantoprazole. A review of a facility document titled, Consultant Pharmacist's MRR: Note to Attending Physician/Prescriber, dated 2/2/26, indicated there was no response to CP's recommendation for discontinuation of Resident 2's pregabalin. During an interview on 2/12/26 at 11:15 a.m. with the Director of Nursing-Hospital District (DON HD), DON HD stated the MRRs were incomplete for the months of December 2025 and January 2026 because there was no documented response to CP's medication recommendations. DON HD further stated he was unable to locate further documentation for these MRR months. 2. A review of Resident 9's Record of Admission, indicated Resident 9 was admitted to the facility in October 2020 with diagnoses including congestive heart failure (heart cannot pump enough blood throughout the body) and dementia with behavioral disturbance (a progressive state of decline in mental abilities). A review of Resident 9's physician order, dated 6/19/25, indicated an order for quetiapine (medication used to treat psychosis [a severe mental condition in which thought, and emotions are so affected that contact is lost with reality] and major depression [feeling of sadness]) 75 mg oral three times daily for psychosis. A review of Resident 9's MRR PC recommendation, dated 12/31/25, indicated Resident 9 was taking quetiapine and was due for a gradual dose reduction attempt. The MRR was not signed by the physician. 3. A review of Resident 12's Record of Admission, indicated Resident 12 was admitted to the facility in October 2013 with diagnoses including congestive heart failure and chronic kidney disease. A review of Resident 12's physician order, dated 8/4/23, indicated an order for furosemide (medication to treat excess fluid) 20 mg oral once daily for edema (swelling cause by excess fluid) and spironolactone (medication to treat excess fluid and high blood pressure) 25 mg oral once daily for hypertension (HTN - high blood pressure). A review of Resident 12's MRR PC recommendation, dated 12/31/25, indicated Resident 12 was taking diuretics (medications to remove excess fluid) and the recommendation was to monitor for any possible electrolyte imbalance, and redo all labs if necessary. MRR further indicated if Resident 12's fluid retention (excess fluid) improved then to consider discontinuing the medication. The MRR was not signed by the physician During a concurrent interview and record review on 2/12/26 at 10:34 a.m. with DONHD, Resident 9 and Resident 12's MRRs were reviewed. DONHD confirmed the MRRs were not signed and stated he could not find any documentation of the MRR recommendations being reviewed and implemented by the physician. DONHD further stated reviewing the MRR was needed to help prevent the residents from receiving unnecessary medications. A review of the facility's procedure titled, ECC Monitoring; Drug Regimen Review (Monthly Report), AEP-97, revised April 2024, indicated, Absence of regular and timely review of medication regimens increases the risk for medication-related adverse events and patient harm. The procedure further indicated, Physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing.

Based on observation, interview, and record review, the facility failed to follow professional standards for food service safety for a census of 31 residents, when:Cook (CK) 1 was observed without a beard restraint (facial hair covering) in the kitchen, andOutdated food items were found in the residents' fridge.These failures decreased the facility's potential to prevent food contamination and illnesses among vulnerable residents.Findings: 1.During a concurrent observation and interview on 2/9/26 at 8:30 a.m. with CK 1, CK 1 was observed in the kitchen without wearing a beard restraint. CK 1 stated he normally did not wear a beard restraint.During an interview on 2/9/26 at 8:50 a.m. with the Executive Chef (EC), EC confirmed CK 1 was not wearing a beard restraint and stated he should have put one on.During a concurrent interview and record review on 2/11/26 at 1:14 p.m. with the Dietary Director (DD), the 2022 Food Code (FC -guidelines for safety and protection of foods) was reviewed. DD stated she agreed with the FC guidelines and expected staff to follow the guidelines.A review of the Food and Drug Administration 2022 Food Code section 2-402.11, dated 1/18/23, indicated, Hair restraints - food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment and utensils .A review of the facility's policy and procedure (P&P) titled, Dietary Staff Dress Code, revised 1/2025, indicated, The risk of not following staff dress code is a violation of . food code and potential of contaminating food. 2. During a concurrent observation and interview on 2/12/26 at 9:25 a.m. with Licensed Nurse (LN) 1, the residents' refrigerator at station two was observed, the following were found: - One clear bag containing several pouches of single serve thousand island dressing with a use by date of 12/25/25,- One clear bag containing several pouches of single serve ranch dressing with a use by date of 1/16/26, and- One clear undated bag containing several containers of single serve low-fat cream cheese.LN 1 confirmed all findings and stated she would consider all those items expired and should be disposed. LN 1 further stated residents could potentially get ill from using outdated foods.During an interview on 2/12/26 at 12:15 p.m. with the DD, DD confirmed the items were outdated and stated outdated food items should have been removed from the fridge, because they can cause a food borne illness among residents if used.A review of the facility's P&P titled, Food Storage, revised 12/2023, indicated, Refrigerator Storage - All refrigerated and frozen food shall be dated . discard any product of questionable quality and if past use by date.

Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for one of 13 sampled residents (Resident 7), when Resident 7's care plan did indicate the use of safety lap belt due to fall risk.This failure decreased the facility's potential to address Resident 7's specific health care needs.Findings:A review of Resident 7's Record of Admission, indicated she was admitted to the facility on [DATE] with diagnoses including multiple sclerosis (a chronic condition where the immune system damages the protective covering of nerve cells, causing muscle weakness and coordination problems) and blindness. A review of Resident 7's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 12/10/25, indicated she had a Brief Interview for Mental Status score (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) of 15 out of 15 with intact memory.During a concurrent observation and interview on 2/9/26 at 11:05 a.m. with Resident 7 in her wheelchair, Resident 7 had a lap belt fastened across her thighs. Resident 7 stated she fell out of her wheelchair many times and the lap belt protected her from falling.During an interview on 2/11/26 at 9:51 a.m. with Resident 7, Resident 7 stated she worn the belt since 2025 and verbally consented to the facility that she wanted to use it on a long-term basis.A review of Resident 7's progress note, dated 11/28/25, indicated the physician approved Resident 7's use of belt for wheelchair.A review of Resident 7's Plan of Care, dated 9/18/22, indicated, Resident 7 was at risk for falls due to progressive multiple sclerosis with functional decline and history of falls at home. Resident 7's care plan did not indicate the use of the lap belt.During an interview on 2/11/26 at 12:34 p.m. with Registered Nurse Supervisor (RNS) 1, RNS 1 stated the facility missed inputting necessary documentation for Resident 7's lap belt after they determined the trial for the lap belt was successful. RNS 1 further stated no one would know how long Resident 7 had been wearing it or how she was to use it, which could lead to safety issues.A review of the facility's policy titled, Extended Nursing Admit Assessment-Reassessment and Documentation, DECC-010, revised September 2025, indicated, The care plan shall be . updated as indicated for change in condition, onset of new problems and resolution of current problems.

Based on observation, interview, and record review, the facility failed to ensure one of 13 sampled residents (Resident 11) was safe from falling, when Resident 11's bed headrail was not in place as ordered.This failure increased Resident 11's risk to fall and injure himself.Findings:A review of Resident 11's Record of Admission, indicated he was admitted to the facility on [DATE] with a diagnosis of vascular dementia (cognitive decline caused by reduced blood flow to the brain).A review of Resident 11's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 11/4/25, indicated he had a Brief Interview for Mental Status score (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) of one out of 15 with severely impaired memory.A review of a facility document titled, Fall Risk Evaluation, dated 2/7/26, indicated Resident 11 was at risk for falling.A review of Resident 11's Physician Orders, dated 10/26/23, indicated both his bed's head siderails were to be placed in the up position.During an observation on 2/9/26 at 11:28 a.m. Resident 11 was awake and lying in bed diagonally, with his legs on the right edge of the bed. Resident 11's right headrail was in the down position. He waved but did not talk when prompted. A four-wheel walker was near his bed. During a concurrent observation and interview on 2/9/26 at 11:35 a.m. with Certified Nursing Assistant (CNA) 1 in Resident 11's room, CNA 1 stated due to his severe memory problems, Resident 11 had a position change alarm on his bed in addition to head siderails in the up position because he was prone to wander and tended to fall. CNA 1 stated Resident 11 was supposed to have both headrails up and that someone forgot to put the right headrail up.During an interview on 2/11/26 at 10:26 a.m. with Licensed Nurse (LN) 1, LN 1 stated Resident 11 had a history of falling when attempting to get out of his bed, was very confused and did not use his call light, so there was a concern of falling from his bed. LN 1 also stated both headrails should have been up when the resident was in his bed to coincide with current physician orders. LN 1 further stated if one headrail was down then it could cause Resident 11 to fall and injure himself.During an interview on 2/11/26 at 11:25 a.m. with RN Supervisor (RNS) 1, RNS 1 confirmed that Resident 7 had orders for bilateral headrails.A review of the facility's policy titled, ECC [Extended Care Center] Structures Standards, DECC-061, revised September 2025, indicated one of the facility's objectives was To provide an environment that will be conducive to maintaining resident comfort, dignity, and safety. The policy further indicated, Side rails are to be used as indicated on the resident Care Plan.

Based on observation, interview, and record review, the facility failed to provide services according to professional standards of quality for two of 13 sampled residents (Resident 7 and Resident 8), when:1. A wheelchair lap belt was used for Resident 7 without a physician's written order; and 2. Omeprazole (a medication that reduces stomach acid production) was not administered to Resident 8 as prescribed.These failures decreased the facility's potential to follow the residents' physician orders.Findings: 1. A review of Resident 7's Record of Admission, indicated she was admitted to the facility on [DATE] with diagnoses including multiple sclerosis (a chronic condition where the immune system damages the protective covering of nerve cells, causing muscle weakness and coordination problems) and blindness. A review of Resident 7's Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 12/10/25, indicated she had a Brief Interview for Mental Status score (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) of 15 out of 15 with intact memory. A review of a facility document titled, Fall Risk Evaluation, dated 2/3/26, indicated Resident 7 was at risk for falling. During a concurrent observation and interview on 2/9/26 at 11:05 a.m. with Resident 7 in her wheelchair, Resident 7 had a lap belt fastened across her thighs. Resident 7 stated she fell out of her wheelchair many times and the lap belt protected her from falling. During an interview on 2/11/26 at 9:51 a.m. with Resident 7, Resident 7 stated she had the belt on her wheelchair since 2025. During a concurrent observation and interview on 2/11/26 at 10:21 a.m. with Licensed Nurse (LN) 1, LN 1 stated Resident 7 had problems with sliding out of her wheelchair onto the floor. LN 1 further stated the lap belt helped her in preventing falls and was not aware of an order for the lap belt. A review of Resident 7's progress note, dated 11/28/25, indicated the physician approved the resident's use of a belt for her wheelchair. A review of Resident 7's Physician Orders, dated 2/11/26, indicated no written order had been entered for the wheelchair lap belt. During a concurrent interview and record review on 2/11/26 at 12:34 p.m. with Registered Nurse Supervisor (RNS) 1, Resident 7's physician's orders were reviewed. RNS 1 confirmed the lap belt order was missing and stated no one would know how long Resident 7 had been wearing it or how she was to use it, which could lead to safety issues. A review of the facility's policy titled, ECC [Extended Care Center] Structures Standards, DECC-061, revised September 2025, indicated, It is mandatory that all admitted residents have Physician orders. The nursing staff must have adequate medical direction and support . These orders must include . Activity, Medications/Treatment . 2. A review of Resident 8's Record of Admission, indicated she was admitted to the facility in October 2024 with a diagnosis of symptomatic gastroesophageal reflux disease (GERD, chronic condition where stomach acid flows back into the esophagus causing irritation). A review of Resident 8's Physician Orders, dated 8/12/25, indicated an order for omeprazole 20 milligrams (mg, a unit of measurement) was to be given daily in morning for GERD. During an observation on 2/10/26 at 8:29 a.m., LN 4 was observed during medication pass. LN 4 gave Resident 8 a slice of bread then passed her morning medications. Resident 8 ate the slice of bread before taking her medications including omeprazole. During an interview on 2/10/26 at 1:53 p.m. with LN 4, LN 4 confirmed she administered omeprazole to Resident 8 along with other morning medications after eating a piece of bread. LN 4 stated omeprazole should have been given separately before the meal as indicated on the medication's bubble pack. During an interview on 2/10/26 at 2:02 p.m. with the Pharmacy Consultant (PC), PC stated omeprazole should have been given before meals as indicated on the medication bubble pack. PC further stated staff should have followed the instructions indicated as prescribed by the doctor to ensure the medication achieved its maximum effectiveness and assisted residents with their symptoms. A review of the facility's policy titled, ECC Monitoring Standard Medication Administration times AEP-110, revised in 4/2024, indicated, Medications that require special times to be scheduled will be accommodated based on pharmacology needs . oral proton pump inhibitor like omeprazole defaults to Q AM AC (before meals) at 6 a.m.

Based on observation, interview, and record review, the facility failed to follow proper infection control measures for one of 13 sampled residents (Resident 3), when a housekeeper (HK) did not wear the required personal protective equipment (PPE, any gear to protect your body from germs, hazardous chemicals in a medical setting like gloves, gowns, and masks) while cleaning a room on Enhanced Barrier Precaution (EBP, an infection control method).This failure decreased the facility's potential to prevent the spread of infection among vulnerable residents.Findings:A review of Resident 3's Record of Admission, indicated he was admitted to the facility in August 2023 with a diagnosis of urinary retention.A review of Resident 3's Physician Orders, dated 11/2/25, indicated an order for the insertion of a urinary catheter due to urine retention.During a concurrent observation and interview on 2/9/26 at 9:35 a.m. with HK, HK was observed cleaning inside Resident 3's room without wearing a gown. HK confirmed she was not wearing a gown because there was no sign indicating that Resident 3 was on EBP which required the use of a gown while cleaning.During a concurrent observation and interview on 2/10/26 at 8:40 a.m. with Licensed Nurse (LN) 3, LN 3 confirmed Resident 3 had an orange magnet by the door, a signage indicating he was on EBP due to the use of a urinary catheter.During an interview on 2/10/26 at 2 p.m. with the Infection Preventionist (IP), IP expected staff to follow proper infection prevention and control practices before entering a room on any precautions to prevent the spread of infection in the facility and placing residents at risk.A review of the facility's policy titled, ECC Enhanced Barrier (Enhanced Standard) Precautions, DECC-1502, revised in 11/2025, indicated, Enhanced Barrier Precautions (also known as Enhanced Standard Precautions) are designed to reduce transmission of resistant organisms . Implement Enhanced Barrier Precautions on those residents who . are at risk of transmitting and/or contracting MDROs [Multidrug-resistant organisms; a germ that is resistant to many antibiotics]. Residents who have indwelling medical devices . including foley catheters . Use of PPE such as gowns and gloves is one component of Standard Precautions . along environmental cleaning and disinfection . activities that provide opportunities for transfers of MDROs to staff hands and clothing.

Based on observation, interview, and record review, the facility failed to ensure that their food was safe for resident consumption when 10 cartons of milk and a jar of mustard were expired and available for use. This had the potential for the residents to receive sour milk and subject them to food-borne illness. Findings: A review of the facility's policy titled, Refrigerated Storage Life of Foods indicated that the storage life for milk, half and half, heavy cream, and cottage cheese was seven days and that the expiration date on the package should be followed. Similarly, the policy indicated that the storage for condiments including mustard was, six months from opening date or expiration date. A review of the facility's policy titled, Food Storage, DNS-503, revised ,d+[DATE], indicated that dry storage foods should be used, according to the expiration date such that products expiring soonest are used first. During a concurrent observation and interview with the Executive Chef (EC) A, on [DATE] at 8:51 AM, 10 cartons of milk were observed with an expiration date of [DATE], and a jar of [NAME] Mustard was dated with an expiration date of [DATE]. EC A confirmed that the milk and mustard were outdated and should not be used.

The facility failed to prevent abuse of Resident 1 by Certified Nursing Assistant 1 (CNA 1) when CNA 1 was heard being verbally inappropriate with Resident 1. CNA 1's actions create potential feelings of embarrassment and mood changes in Resident 1 which can lead to adverse clinical outcomes. Findings: Resident 1 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's BIMS was 14 on 3/24/2021 indicating normal mental function. On 4/28/2021 at 9:30 AM, the Activities Coordinator (AC) was interviewed regarding observed interactions between CNA 1 and Resident 1 on 4/22/2021. The AC stated she heard CNA 1 ask Resident 1 .are you going to start your[OBSCENITY] The AC also affirmed documenting CNA 1 calling Resident 1 a big baby. The AC stated Resident 1 started to cry after CNA 1 had made those statements. Resident 1 remained tearful as the AC attempted to console her. On 4/28/2021 at 10:00 AM the Director of Nursing (DON) was interviewed regarding CNA 1's verbal abuse of Resident 1. The DON stated CNA 1 was counseled in Human Resources . The staff is being supportive of Resident 1 because of psychological sensitivity.

Based on interview and record review, the facility failed to prevent abuse for one of three sampled residents (Resident 1) when Resident 1 reported being roughed up by Certified Nursing Assistant (CNA) 1. This failure has the potential for Resident 1 to have increased anxiety and fear, and to lead to negative clinical outcomes. Findings: A review of the facility's policy and procedure titled, ECC Abuse; Prevention of, last revised 01/2020, indicated that Each resident has the right to be free from verbal, sexual, physical, and mental abuse . Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers . On 12/02/2020 at 2:20 PM during a concurrent record review and interview Registered Nurse (RN) 1 stated that Resident 1 reported during care that CNA 1 abused him. RN 1 also stated Resident 1 repeated that information to the police when the incident was reported as required by policy. RN 1 also confirmed the Social Worker (SW 1) had received the initial report from Resident 1. On 12/03/2020 at 8:30 AM during a concurrent interview and record review with SW 1, the reported abuse of Resident 1 was discussed. SW 1 stated I heard of the abuse after the fact. After I talked to him and explained what abuse was and that could include rough handling or feeling like you have been handled roughly that is abuse. So, when he said, Yes, it was abuse that is when I reported it. A review of an Interdisciplinary Progress Note, dated 6/18/20 at 11:56 pm, indicated Resident 1 reported to SW 1 that he was roughed up and abused by CNA 1 on Friday 6/5. Resident 1 stated that he no longer wants this particular CNA to provide care for him. On 12/03/2020 at 9:15 AM the Director of Nursing (DON) was interviewed. The DON stated, Yes it was reported by the Social Worker because she is the one he told. From his words we determined it was abuse and it was reported.

Based on interview and record review the facility failed to issue a bed hold notice to the Responsible Party (RP) of Resident 1(R1) when he was sent to the Hospital emergency room (ER) on 4/20/2020. Failure to issue a bed hold notice during any transfer can lead to questions, concerns and anxieties associated with the discharge from the ER when the resident previously required supervision and the provision of skilled nursing care. Findings include: Resident 1 (R1) is a [AGE] year old male admitted to facility on 08/30/2017. Some of his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident lived at the skilled nursing facility and shared a room with his wife. The son is the Responsible Party (RP) for the resident. Review of the most recent quarterly and annual comprehensive assessments show he has a Brief Interview of Mental Status score of 3 - 4 indicating severe cognitive impairment. Additional record review of the initial admission comprehensive assessment does not reflect behaviors. During an interview with the Director of Nurses on 09/03/2020, she acknowledged there was no documentation of behaviors occurring at the departing skilled nursing facility prior to admission. The quarterly comprehensive assessment dated [DATE] indicates verbal behaviors directed towards others occurring 1-3 days during the observation period. The initial, quarterly (03/10/2020) and annual comprehensive assessments (09/10/2019) do not reflect active discharge planning. Further record review of the Interdisciplinary Progress Notes dated 04/20/2020 (timed at 7AM) indicate, .informed by RN (Registered Nurse) Supervisor that R1 had just elbowed Certified Nursing Assistant CNA in the back and was still upset and swearing. Plan was to call security and have R1 escorted to the ER (emergency room ) and transfer to ER due to physical abuse to CNA. The Discharge Summary for R1 associated with the transfer to the ER dated 04/20/2020 was reviewed on 09/03/2020 and it indicates, On 04/20/2020, after 2 such episodes including aggressive behaviors toward staff and another resident, patient (R1) was transferred to Tahoe Forest Hospital emergency room . His Son was informed that his father would not be able to return to our unit and that other arrangements for placement would be pursued. Further care will be provided by the staff at Tahoe Forest Hospital emergency room and discharge from there and placement to another facility will be determined at a future date. On 09/03/2020, reviewed the facility policy titled ECC (Extended Care Center) Bedhold. The purpose of the bedhold policy is to ensure the residents with MediCAL are entitled to have their bed in the ECC held in the event they need acute hospitalization or are on a therapeutic leave or on an entitled leave from the facility. The document further delineates It is the policy of this facility to notify resident and family members or legal representative the duration of the bed hold period when a resident requires transfer to a hospital or a therapeutic leave. The procedure indicates at the time of transfer out to acute stay: Notice of Transfer or Discharge form completed. Once copy to chart, once copy to resident/resident representative and one faxed to local ombudsman. During a telephone interview with the RP on 09/10/2020. He denied receiving any documentation associated with a possible bedhold with the transfer of R1 to the ER. The son continued stating .They (the ECC) Had no intentions of taking my dad back. When I went to visited him in the ER at near 2:30PM I was informed he was discharged from the nursing home.

Based on interview and record review the facility failed to develop and implement an effective discharge planning process that focuses on the resident's (R1) needs. Failure to generate and implement a discharge plan that focuses on the resident goals and needs could potentially lead to delays in discharge, readmission or a prolonged hospital stay. Findings include: Resident 1 is a [AGE] year old male admitted to facility on 08/30/2017. Some of his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident lived at the skilled nursing facility and shared a room with his wife. The son is the Responsible Party (RP) for the resident. The review of the most recent quarterly and annual comprehensive assessments show he has a Brief Interview of Mental Status score of 3 - 4 indicating severe cognitive impairment. The initial, quarterly (03/10/2020) and annual comprehensive assessments (09/10/2019) do not reflect an anticipated discharge. Further review of the Interdisciplinary Progress Notes dated 04/20/2020 and timed at 7AM indicate, .informed by RN (Registered Nurse) Supervisor that R1 had just elbowed (Certified Nursing Assistant) CNA in the back and was still upset and swearing. Plan was to call security and have R1 escorted to the ER (emergency room ) and transfer to ER due to physical abuse to CNA. The Discharge Summary for R1 associated with the transfer dated 04/20/2020 was reviewed on 09/03/2020 and it indicates, On 04/20/2020, after 2 such episodes including aggressive behaviors toward staff and another resident, patient (R1) was transferred to Tahoe Forest Hospital emergency room . His son was informed that his father would not be able to return to our unit and that other arrangements for placement would be pursued. Further care will be provided by the staff at Tahoe Forest Hospital emergency room and discharge from there and placement to another facility will be determined at a future date. During an interview with Staff 14 on 09/01/2020 at 3PM, she described the incident that occurred on 4/20/2020. On that day, another CNA (who no longer works at the facility) and I were getting up Resident 2 (R2). R2 was one of the residents assigned to me for that day. R1 had been out of the room getting bottled water and ice while we were getting up R2. When R1 returned he started cussing at both of us CNAs and he elbowed me on right side of her back. CNA 14 stated she questioned R1 asking him Why did you do that? then she stepped out of the room and reported the incident to her supervisor. CNA 14 stated she was never informed or advised not to provide care the R1 or R2. CNA 14 reported she got along well with R2. An additional interview with the RP occurred on 09/10/2020 near 1:45PM. During that interview, he acknowledged attending several care conferences regarding R1. He continued stating the facility failed to implement the care plan by failing to keep those people who trigger R1 from being around or in his room/area. He denied being informed the care conferences were Discharge Planning meetings. He denied knowledge of a discharge goal. Requested RP1 to describe what a discharge goal could have possibly been. RP1 indicated he would like to keep the family together at one facility until the end of life. He answered additional questions regarding the transfer and eventual discharge of R1 from theER on [DATE]. He further acknowledged he had visited several other care facilities but had not made specific arrangements nor committed to specific agreements with other individuals or facilities regarding the safe transition of care. He denied having the capability or capacity to provide continuous supervision and custodial care for R1. On 04/20/2020, ER Staff informed him of the discharge from the Extended Care Center. He was also informed him of the discharge from the ER and that he needed to come pick up R1. On 09/03/2020, reviewed the facility policy titled Transfers and Discharges states Transfer is moving the resident from the facility to another legally responsible institutional setting, while discharge is moving the resident to a non-institutional setting when the releasing facility ceases to be responsible for the resident's care. The Resident Rights policy with an approval date of 07/2019 was reviewed on 09/03/2020. The identified purpose of the policy is to Provide guidelines for maintaining and upholding the resident's rights while living in the Extended Care Center. Within the section of the policy addressing Transfer and Discharge the policy states 4. We will provide preparation and orientation to residents prior to transfer or discharge in order to ensure a safe and orderly transition from our facility. 5. We will not transfer a resident to a hospital or allow a resident to go on therapeutic leave without first providing written information to the resident and a family member or legal representative specifying the applicable bed hold policy, i.e., the period of time (if any) during which the resident is permitted to return and resume residence in the facility after hospitalization or therapeutic leave. During an interview with the DON on 09/10/2020 near 3:30PM she acknowledged there was no discharge nursing care plan associated with the emergent transfer and eventual discharge from the skilled nursing facility to theER on [DATE]. During an interview with RP1 on 09/10/2020 near 2PM he reported R1 was still in the Hospital Medical-Surgical Unit and to his knowledge, he was not aware of any outburst/behaviors. The plan of care titled Trans/DC (discharge) dated 02/24/2020 had been generated but had not been fully operationalized when R1 was transferred and discharged to the ER. The goal of the aforementioned care plan to work on a safe placement for R1 while maintaining safe environment for R1 and current facility residents.

Based on interview and record review the facility failed to permit Resident 1 to return to the skilled nursing facility after a transfer /discharge to a hospital emergency room (ER). Failure to allow a resident to return after a transfer/discharge to an emergency room could potentially contribute to stress and anxieties for any cognitively intact resident or resident representative. Finding include: Resident 1 (R1) is a [AGE] year old male admitted to facility on 08/30/2017. Some of his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident lived at the skilled nursing facility and shared a room with his wife. The son is the Responsible Party (RP) for the resident. The review of the most recent quarterly and annual comprehensive assessments show he has a Brief Interview of Mental Status score of 3 - 4 indicating severe cognitive impairment. Additional record review of the initial admission comprehensive assessment does not reflect behaviors. During an interview with the Director of Nurses on 09/03/2020, she acknowledged there was no documentation of behaviors occurring at the departing skilled nursing facility prior to admission. The quarterly comprehensive assessment dated [DATE] indicates verbal behaviors directed towards others occurring 1-3 days during the observation period. The initial, quarterly (03/10/2020) and annual comprehensive assessments (09/10/2019) do not reflect an anticipated discharge. Further review of the Interdisciplinary Progress Notes dated 04/20/2020 (and timed at 7AM) indicate, .informed by RN (Registered Nurse) Supervisor that R1 had just elbowed (Certified Nursing Assistant) CNA in the back and was still upset and swearing. Plan was to call security and have R1 escorted to the ER (emergency room ) and transfer to ER due to physical abuse to CNA. The Discharge Summary for R1 associated with the transfer dated 04/20/2020 was reviewed on 09/03/2020 and it indicates, On 04/02/2020, after 2 such episodes including aggressive behaviors toward staff and another resident, patient (R1) was transferred to Tahoe Forest Hospital emergency room . His Son was informed that his father would not be able to return to our unit and that other arrangements for placement would be pursued. Further care will be provided by the staff at Tahoe Forest Hospital emergency room and discharge from there and placement to another facility will be determined at a future date. The Resident Rights policy (with an approval date of 07/2019) was reviewed on 09/03/2020. The identified purpose of the policy is to Provide guidelines for maintaining and upholding the resident's rights while living in the Extended Care Center. Within the section of the policy addressing Transfer and Discharge the policy states 1. We will not transfer or discharge a resident without first providing reasonable notice. We will notify the resident and, if known, a family member or legal representative of the resident, of the transfer or discharge and the reasons. Our notice will be given at least thirty (30) days before transfer or discharge. 2. We reserve the right to transfer or discharge a resident on shorter notice when: . (the facility provides of list of reasons outlined as items a. thru i.). Item i. states A reminder that our action may be appealed to an appropriate State agency. The name, address and telephone number of the State Long-Term Care Ombudsman. 4. We will provide preparation and orientation to residents prior to transfer or discharge in order to ensure a safe and orderly transition from our facility. 5. We will not transfer a resident to a hospital or allow a resident to go on therapeutic leave without first providing written information to the resident and a family member or legal representative specifying the applicable bed hold policy, i.e., the period of time (if any) during which the resident is permitted to return and resume residence in the facility after hospitalization or therapeutic leave. 6. If a resident's hospitalization or therapeutic leave exceeds the State-approved bed hold period (if any), and the resident continues to require the services of the facility after hospitalization or therapeutic leave and is eligible for Medicaid nursing facility services, such resident shall be readmitted to our facility as soon as a bed in a semi-private room becomes available. Review of the facility policy titled Transfers and Discharges states Transfer is moving the resident from the facility to another legally responsible institutional setting, while discharge is moving the resident to a non-institutional setting when the releasing facility ceases to be responsible for the resident's care. On 09/10/2020 reviewed the Department of Health Care Services, report titled Refusal to Readmit Appeal dated 5/15/2020, the document references the appeal is granted. The facility must immediately offer to readmit Resident 1 to his former bed. Should the Resident's former bed be unavailable, the facility shall offer resident readmission to the first available male bed appropriate to his needs. During a telephone interview with the RP on 09/10/2020. The RP continued stating .They (the ECC) had no intentions of taking my dad back. When I went to visited him in the ER at near 2:30PM I was informed he was discharged from the nursing home. During the same interview, RP reported R1 was still in the Hospital Medical-Surgical Unit and to his knowledge he was not aware of any outburst or behaviors. During a telephone interview with the Director of Nurses on 09/10/2020 she acknowledged R1 was initially transferred to the ER and ultimately discharged from the skilled nursing facility to the ER. She reported she became aware of the appeal on or near the 10th day after discharge (past the bed hold window) and no consideration for readmission had occurred. She stated it had been determined that R1 would not be readmitted related to his behaviors.

Based on interview and record review, the facility failed to provide Resident 1's Family Member (FM) 1 with a written notice of bed hold before Resident 1 was transferred to a local acute care hospital that explained the duration of the bed hold and addressed permitting the return of the resident to the first available bed. This failure resulted in the Resident 1's representative to not know Resident 1's right of being allowed to return to the facility when discharged from the emergency room . Findings: A review of Resident 1's Transfer Summary (TS) dated 4/22/20 indicated he was admitted to the facility on [DATE] [DIAGNOSES REDACTED]. He also has additional problems with coordination. The assessment indicated, Long-term care admission for custodial care due to cognitive and memory deficits. The facility's BIMS test (a Brief Interview for Mental Status that is used to get a quick snapshot of how well a resident is functioning cognitively), dated 3/10/20, indicated Resident 1 had a BIMS score of 4 indicating his cognition was severely impaired. An Interdisciplinary Team Progress Note (IDT) dated 4/20/20 at 7:09 am was reviewed. According to the documentation, Night shift Certified Nurse Assistant (CNA) was assisting Resident 3 in getting up, Resident 1 was out of the room filing water cups. Assistance was required with initial transfer and Day CNA came in to help. Resident 1 returned to the room during the transfer, was agitated and used bad language, set down water cups and elbowed CNA in the back. Director of Nurses (DON) notified, decision made to transfer resident to emergency room (ER) for further evaluation, security and nursing supervisors escorted without incident. Verbal report given to ER nurses along with paper chart. An IDT Note dated 4/20/20 at 10:30 am indicated Resident 1 and 3's Representative is here to see Residents 1 and 3 at window and would like to drop off some mints. Met FM 1 outside facility with Registered Nurse (RN) Supervisor. Took mints for Resident 3 and told FM 1 that Resident 1 was not in our facility anymore and he was transferred to the ER (emergency room ) this morning for striking a staff member. FM 1 was advised to visit with Resident 3 at window and then go to ER and check on situation there. The facility's policy and procedure (P&P) titled, ECC Bed-hold, dated 5/2020, was reviewed. It indicated, It is the policy of this facility to notify resident and family members or legal representative the duration of the bed hold period when a resident requires transfer to a hospital or a therapeutic leave. At the time of transfer out to acute stay notice of transfer or discharge form completed. One copy to chart, one copy to resident/resident representative and one faxed to local ombudsman. In case of emergency, notice can be given within 24 hours. During a review of Resident 1's clinical record dated April and May 2020, there was no documentation found regarding written notification to FM 1 for the bed-hold. During an interview on 4/22/20 at 10:00 a.m., with FM 1 and the Ombudsman (an official, usually appointed by the government, who advocates on behalf of their residents), they confirmed they did not receive a copy of the written notification from the facility regarding the bed-hold, or refusal to readmit Resident 1. Resident 1's Representative stated they were very upset that the facility was refusing to readmit Resident 1.

Based on interview and record review, the facility discharged Resident 1 to the hospital's emergency room without developing and implementing an effective and safe discharge plan to ensure a smooth and safe discharge to a facility that met Resident 1's needs for long term care placement. This failure resulted in Resident 1 being discharged to an emergency room for a prolonged hospitalization , since 4/20/20, in which no arrangements for permanent placement had been developed. Findings: A review of Resident 1's clinical record indicated he was originally admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The assessment indicated, Long-term care admission for custodial care due to cognitive and memory deficits. A review of the facility's Minimum Data Set (MDS, an assessment tool), dated 3/10/20, indicated Resident 1's Brief Interview for Mental Status was 4, indicating he had severe cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). During a concurrent interview and record review, on 4/24/20, at 2:00 p.m., with Medical Doctor (MD), Resident 1's Transfer Summery (TS), dated 4/22/20 was reviewed. The TS indicated, Family Member (FM) 1 was informed that Resident 1 was transferred to the emergency room and would not be able to return to the Skilled Nursing Facility other arrangements for placement would be pursued. Further care will be provided by the staff at the local hospital and placement to another facility will be determined at a future date. MD confirmed there was no discharge plan in place for Resident 1. During an interview on 4/22/20, at 10:00 a.m., with FM 1, FM 1 stated, the facility discharged Resident 1 without a plan or place for him to go to, so they sent him to the emergency room at the local hospital. During a concurrent interview and record review on 4/22/20, at 11:36 a.m., with Director of Nursing (DON), Resident 1's clinical record was reviewed. The clinical record did not have a safe discharge plan in place for Resident 1. DON confirmed there was no discharge plan. During an interview on 4/22/20, at 1:15 pm, with the Social Services Director (SSD), SSD stated, we discharged Resident 1, he is not coming back, and we informed FM 1 when he came to see Resident 3. SSD confirmed the facility packed up all his belongings and were not going to readmit Resident 1. During a phone interview on 4/24/20, at 2:40 p.m., with the Clinical Nursing Officer (CNO), the CNO stated, there was no documentation in the clinical record, of a safe and effective discharge plan in place for Resident 1. During an interview on 5/13/20, at 12:10 p.m., with Certified Nurse Assistant (CNA) C, CNA C stated, the facility packed all his stuff up and told us he was not coming back. During a review of Resident 1's MDS Section Q0400, dated 04/20/20, the MDS indicated, Resident 1 did not have an active discharge plan in place.

Based on interview and record review, the facility failed to implement Resident 1's care plan that directed staff to monitor Residents 1 and Resident 2 to keep them apart, and to prevent CNA B from caring for Resident 1 because CNA B triggered resident 1's bad behavior. These failures resulted in Resident 1 physically abusing resident 2 and put CNA B at risk for injury. Findings: A review of Resident 1's clinical record indicated he was originally admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of the facility's Minimum Data Set (MDS, an assessment tool), dated 3/10/20, indicated Resident 1's Brief Interview for Mental Status was 4, indicating he had severe cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 1 required Long-term care admission for custodial care due to cognitive and memory deficits. A review of Resident 1's Transfer Summary (TS) dated 04/22/20 indicated he was admitted to the facility on [DATE] [DIAGNOSES REDACTED]. He also has additional problems with coordination. The assessment indicated, Long-term care admission for custodial care due to cognitive and memory deficits. During a review of Resident 1's Interdisciplinary Progress Notes (IDT), dated 2/24/20, the IDT Notes indicated, the goal for Resident 1 is to remain separated from Resident 2. During a review of the facility's policy and procedure (P&P) titled, Nursing Admit Assessment-reassessment and Documentation, DECC-010, dated 2020, the P&P indicated, the care plan should be finalized in accordance with the Resident Assessment Instrument (RAI) Resident Assessment Instrument (RAI) (a tool that helps facility staff to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan). The RAI indicated, facilities are responsible for assessing and addressing all care issues, including monitoring each resident's condition and responding with appropriate interventions. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The information gleaned from the assessment should be used to determine why the resident's behavioral symptoms are problematic in contrast to a variant of normal, whether and to what extent behavior places the resident or others at risk for harm, and any related contributing and/or risk factors. During an interview on 04/22/20 at 1:15 p.m., with Social Services Director (SSD), SSD stated, stated, the care plans are part of their Interdisciplinary Progress Notes (IDT) progress notes. In the IDT progress notes they chart the problem, goal and plan. During a concurrent interview and record review, on 4/22/20 at 11:33 a.m., with Director of Nursing (DON), Resident 1's Care Team Notes (CTN) dated March 4, 2020 was reviewed. The CTN indicated, the facility was supposed to implement several interventions: to reduce triggers: 1) Certified Nurse Assistant (CNA) B will not provide care for either Resident 1 or his spouse, 2) have a written plan in place in case of another aggressive incident and staff will continue to round and monitor to minimize interactions with trigger people or situations. DON confirmed CNA B was supposed to be removed from providing care for Resident 1. During a concurrent interview and record review, on 4/24/20, at 2:00 p.m., with the Medical Doctor (MD), Resident 1's History and Physical (H&P), dated April 2020 was reviewed. The H&P indicated, the facility was to remove staff members from providing care to him, members that he disliked or became aggressive with. MD confirmed CNA B was a trigger for Resident 1. During an interview on 4/28/20, at 2:44 p.m., with Certified Nurse Assistant (CNA) B, CNA B stated, I was never told not go into Resident 1's room. CNA B also said she was not aware that at the care conference the facility told Resident 1's son that she would not go in the room. During an interview on 5/13/20, at 12:10 p.m., with CNA C, CNA C stated, we are not able to be with Resident 1 all the time and sometimes things get missed, for example, when they pass each other in the hall way. CNA C confirmed that they were not told they needed to keep Resident 1 separated from Resident 2 when they were in the hall way at the same time. During an interview on 5/13/20, at 1:32 p.m., with Registered Nurse (RN) A, RN A stated, Resident 1 was independent and roamed the hall ways whenever he wanted. Due to his independence they were not able to watch him all the time. During an interview on 5/13/20, at 2:10 p.m., with the Activities Assistant (AA), AA stated, she was not aware Resident 1 needed to be kept separated from Resident 2 when they were going to and from the dining room per his care plan. AA confirmed Resident 1 and Resident 2 were found in the dining room on several different occasions alone. AA said Resident 2 is often going up and down the hall way in front of Resident 1's room unsupervised. During an interview on 5/19/20, at 1:22 p.m., with CNA D, CNA D stated, every morning her and CNA B would team up together to get residents up for breakfast, including Resident 1 and his spouse. CNA D confirmed she was never told CNA B could not help her. During a review of Resident 1's IDT, dated February, March, and April 2020 indicated, seven out of 29 days in February 28 out of 31 days in March, and in April 19th, Resident 1 will remain separated from Resident 2. During a review of Resident 1's IDT Notes, dated February 12, 2020, the IDT Notes indicated, CNA B has removed herself from caring for his or his spouse. When she is assigned to the team with that room, she trades with another team member and cares for different resident room. During a review of Resident 1's Plan of Care (PC), dated February 23,2020, the PC indicated, Resident 1 will be monitored in activities and while Resident 2 is present and completing her usual tasks of choice.

Based on interview and record review, The facility failed to permit Resident 1 to return to the facility, during the bed-hold period and after a discharge appealed was granted, for care and services after discharge to the emergency room (ER) by the facility for evaluation due to being combative and refusing care. These failures violated Resident 1's rights to return to the facility where a family member is a resident and resulted in Resident 1's prolonged hospitalization in a local General Acute Care Hospital since 4/20/20. Findings: The clinical record for Resident 1 was reviewed and indicated that Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A document titled History & Physical dated 2/13/20 and a document titled Progress Note dated 3/11/20, both indicated that resident 1 was admitted for , Long-term care admission for custodial care due to cognitive and memory deficits. The facility's Brief Interview for Mental Status test (BIMS used to get a quick summary of a resident's immediate cognitive functioning) dated 3/10/20 indicated Resident 1 had a BIMS score of four indicating his cognition was severely impaired. The facility's policy and procedure titled, ECC Bed-hold, dated 05/2020, was reviewed and indicated under the heading Policy - It is the policy of this facility to notify resident and family members or legal representative the duration of the bed hold period when a resident requires transfer to a hospital or a therapeutic leave. Under the heading Procedure the policy further indicated, At the time of Transfer . one copy to resident/resident representative and one faxed to local ombudsman. In case of emergency, notice can be given within 24 hours. The facility is required to permit residents to return to the facility immediately to the first available bed. In the event that the resident does not return by the seventh day, the resident is officially discharged The resident may be readmitted , if they desire, upon the first bed availability. The facility's policy and procedure titled, ECC Transfers and Discharges dated 06/2020, was reviewed and indicated under the heading Policy - Transfer is moving the resident from the facility to another legally responsible institution setting, while discharge is moving the resident to a non-institutional setting when the releasing facility ceases to be responsible for the resident's care. Under the heading Procedure the policy indicated, The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility A report titled Refusal to Readmit Appeal dated 5/15/20 indicated that the facility must immediately offer to readmit Resident 1 to his former bed Should Resident's former bed be unavailable, the facility shall offer resident readmission to the first available male bed. The clinical record for Resident 1 was reviewed. An Interdisciplinary Progress Note, dated 4/20/20 at 7:09 am, indicated that a Night shift Certified Nurse Assistant (CNA) E was assisting Resident 3 in getting up. Resident 1 was out of the room filling water cups. CNA E required assistance with the initial transfer of Resident 3 and CNA B came in to help. Resident 1 returned to the room while the two CNAs were transferring Resident 3 to a wheelchair and was agitated and used bad language. Resident 1 set down the water cups and elbowed CNA in the back. The Director of Nurses (DON) was notified and a decision made to transfer Resident 1 to the emergency room (ER) for further evaluation, security and nursing supervisors escorted Resident 1 to the ER without incident. A Verbal report was given to ER nurses along with the paper chart. The clinical record for Resident 1 was reviewed. An Interdisciplinary Progress (IDT) Note, dated 4/20/20 at 10:30 am, indicated that Family Member (FM) 1 was told that Resident 1 was no longer in the facility and that he was transferred to the ER (emergency room ) this morning for striking a staff member. FM 1 was advised check on situation at the ER. During an interview on 4/22/20, at 10:00 am, FM 1 stated, that he was upset the ER at Local General Acute Care Hospital called him up and told him Resident 1 was being discharged and he needed to come pick him up from the ER. FM 1 refused to pick Resident 1 up and told them (the ER) he was unable to take care of Resident 1 at home. FM 1 stated that due to his traveling for work, it would not be safe for Resident 1 to be there. FM 1 also voiced his concerns regarding separating Resident 1 and a family member that was also a resident at the facility. FM 1 did not want to separate them after [AGE] years of marriage; three of those years living at the facility together and that he wanted Resident 1 to go back. When the facility told FM 1, that Resident 1 could not come back FM 1 was very upset and did not understand why, Out of the blue the facility would do this. FM 1 was also upset because the facility wanted him to pick up Resident 1 without there being a safe plan in place and FM 1 stated, How can they do that? FM 1 stated that he found out Resident 1 had been transferred when he came to see Resident 1 and bring him snacks. That was when the facility informed him that Resident 1 was transferred to the hospital the day before. FM 1 stated that his the other family member living in the facility with Resident 1 had called him up crying, stating the facility had packed all Resident 1's things up and sent them to the hospital with Resident 1. During an interview on 04/22/20 at 10:00 am, Family Member (FM) 1 and the Ombudsman (an official, usually appointed by the government, who advocates on behalf of residents) confirmed that the facility had informed them (FM 1 and Ombudsman) that they (the facility) had given Resident 1 a 30-day notice. FM 1 and the Ombudsman stated that they had never received a copy of the written notification from the facility regarding the bed-hold, or refusal to readmit Resident 1. FM 1 stated he was very upset that the facility was refusing to readmit Resident 1. During a concurrent interview and record review on 04/22/20, at 11:36 a.m., with Director of Nursing (DON), Resident 1's IDT was reviewed. The IDT indicated that the DON informed the Ombudsman and FM 1 they were not readmitting Resident 1 back to the facility. The DON confirmed that Resident 1 had been discharged to the emergency room and the facility was allowing him to return. During an interview on 04/22/20, at 1:15 pm, the Social Services Director (SSD) stated that Resident 1 was discharged and he is not coming back, and we informed the FM 1 when he came to see Resident 3. SSD confirmed the facility packed up all Resident 1's belongings and were not going to readmit Resident 1 back in to the facility. The clinical record for Resident 1 was reviewed. A document titled, Transfer Summery (TS), dated 04/22/20, was reviewed. The TS indicated, that FM 1 was informed that Resident 1 was transferred to the emergency room and would not be able to return to the Skilled Nursing Facility, other arrangements for placement would be pursued. Further care would be provided by the staff at the local General Acute Care Hospital and placement to another facility would be determined at a future date. During a concurrent interview on 04/24/20, at 2:00 pm, the facility's Medical Doctor confirmed that there was no discharge plan in place for Resident 1. During an interview on 05/13/20, at 12:10 pm, CNA C stated that the facility had packed up all of Resident 1's belongings and told us he (Resident 1) was not coming back. During an interview on 5/16/20, at 7:00 am, FM 1 stated, he had won the discharge appeal however, the facility still refused to readmit Resident 1 back to the facility. The facility failed to permit Resident 1 to return to the facility for care and services after discharge to the emergency room (ER) for evaluation due to being combative and refusing care. This failure violated Resident 1's right to return to the facility where a family member is a resident and resulted in Resident 1's prolonged hospitalization in a local General Acute Care Hospital since 4/20/20. This violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to a patient.

Based on interview, and record review, the facility failed to protect one of two sampled residents (Resident 2) from physical abuse, when Resident 1 punched Resident 2 in the back. This failure resulted in emotional distress and had the potential to cause pain and suffering resulting in potential adverse clinical outcomes. Findings: A review of Resident 2's Progress Note (PN) dated 4/08/20, indicated, she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's Transfer Summary (TS) dated 4/22/20 indicated he was admitted to the facility on [DATE] [DIAGNOSES REDACTED]. He also has additional problems with coordination. The assessment indicated, Long-term care admission for custodial care due to cognitive and memory deficits. The facility's policy titled, ECC Abuse Prevention of, dated 5/2020, was reviewed and indicated that each resident has the right to be free from verbal, sexual, physical and mental abuse. All residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants, or volunteers. During a review of Resident 1's Interdisciplinary Team (IDT) notes, dated February, March, and April 2020 indicated, seven out of 29 days in February 28 out of 31 days in March, and on April 19th, Resident 1 will remain separated from Resident 2. During a concurrent interview and record review on 4/22/20 at 11:36 a.m., with Director of Nurses (DON), Resident 1's Interdisciplinary Progress Note (IDT, a team that works together to provide the greatest benefit for the Resident) dated 4/19/20 at 07:34 a.m., was reviewed. The IDT note indicated Resident 1 and Resident 2 were in the dining room together alone and Resident 2 punched Resident 1 in the back. DON confirmed they should not have been in the dining room alone. During an interview on 4/22/20 at 1:15 p.m., the Social Services Director (SSD) stated, the care plans are part of their IDT progress notes. In the IDT progress notes they chart the problems, goals and plans. During a concurrent interview and record review on 4/23/20 at 2:44 p.m., with Certified Nurse Assistant (CNA) B, Resident 1's facility's report dated 4/4/20 at 6:28 p.m., was reviewed. The facility's report indicated, on 4/4/20 at 6:28 p.m., Resident 2 came out of dining room yelling and crying, he punched me in the back! CNA B confirmed, Resident 1 and Resident 2 were in the dining room alone and they should not have been. During a concurrent interview and record review on 4/22/20, at 2:00 p.m., with the MD, Resident 1's Care Plan Conference (CPC) was reviewed, the CPC indicated, Resident 1 had physically abused Resident 2 on 12/14/19, 2/23/20 in the dining room and 4/19/20 in the hall way in front of the dining room. MD confirmed Resident 1 should not be left alone with Resident 2. During an interview on 5/13/20 at 9:00 a.m., with CNA C, CNA C stated, we are not able to be with them all the time due to not enough staff. We try to keep a watch out for Resident 2 when she is out of her room but, sometimes they were all busy helping other residents and things got missed. CNA C confirmed she was not told Resident 1 and Resident 2 could not be in hall or dining room alone together. During an interview on 5/13/20 at 11:30 a.m., with Resident 2, Resident 2 stated, I was leaving the dining room and Resident 1 punched me in the back. Resident 2 also stated, Resident 1 is always mean to me whenever I pass him in the hallway or dining room. During an interview on 5/13/20 at 2:10 p.m., with Activities Assistant (AA), AA stated, she was unaware the Resident 1 and Resident 2 had to be kept separate when they were out of their rooms. AA also stated Resident 1 and Resident 2 went around the facility independently and it seemed Resident 2 would physically abuse Resident 1 when no one was around. AA confirmed Resident 1 has been physically abused by Resident 2 multiple times. During an interview on 5/19/20 at 1:22 p.m., with CNA D, CNA D stated, she was never told Resident 1 and Resident 2 had to be away from each other while in the hall way and dining room. CNA D also stated when we would go into the dining room in the afternoons and help when we could, but it was impossible to watch them all the time. During an interview on 5/13/20 at 1:32 p.m., with Registered Nurse (RN) A, RN A stated they were not able to keep an eye on Resident 1 or Resident 2 all the time. RN A stated the altercations seem to happen in the hall when no one is around. RN A confirmed she was not told Resident 1 and Resident 2 could not be in the hall way by themselves. During a review of Resident 1's Care Team Notes (CT), dated 3/4/20, the CT indicated, the facility will implement interventions: 1. To reduce triggers: CNA B will not provide care for either Resident 1 or Resident 3. 2. Staff will continue to round and monitor to minimize interactions with trigger situations or people.

Based on interview, and record review, the facility failed to prevent verbal and physical abuse from occurring to one of two sampled residents (Resident 1) when, Resident 2 yelled at Resident 1, and then struck Resident 1 in the neck with a stack of bingo cards. This failure resulted in Resident 1 being afraid, tearful, and had the potential to lead to isolation, and depression. Findings: Resident 1's clinical record was reviewed, and indicated that she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 1's most recent Minimum Data Set (MDS, a standardized resident assessment) dated 12/14/19, indicated Resident 1 had intact cognition. Resident 2's clinical record was reviewed, and indicated that he was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 2's most recent MDS, dated [DATE], indicated that Resident 2 had severe cognition impairments. During an interview, on 3/4/20, at 8:44 am, with Resident 1, Resident 1 said, when Resident 2 is around she does not like to go into the dining room for activities because he yells mean things to her. Resident 1 also said he swung a stack of bingo cards and hit her in the neck. During an interview, on 3/4/20, at 9:33 am, with the Activities Coordinator (ACC), it was reported that Resident 1 was going through the bingo cards and picking out the one she liked. Then another resident approached her and Resident 1 grabbed a second card and handed it to him. Resident 2 saw this and started gathering up all the bingo cards, while yelling at Resident 1, You only get one! Then Resident 2 swung the stack of bingo cards at Resident 1 hitting her in the neck, while yelling, Get out of here, you don't belong here! At which point, Resident 1 started to cry. She told me Resident 2 always says mean things to her. The ACC also said, whenever Resident 2 comes into the dining room and Resident 1 is in there, Resident 1 gets scared and tells her, Oh no, here he comes. The ACC said, Resident 2 has yelled at Resident 1 at least five times since, and that no one deserves to be verbally or physically mistreated in their own home. During an interview, on 3/4/20, at 11:00 am, with Director of Nursing (DON), she said, Resident 2 yells, get out, you don't belong here, go away, at Resident 1 every time he sees her. The DON also said, even though we increased our staffing during activities Resident 2 still will yell at Resident 1, and then stated, I don't have the staff to make him a 1:1. Resident 2's Care Plan Conference Notes (CPCN), dated 3/4/20, were reviewed and indicated that he had exhibited multiple instances of behaviors. Resident 2's first incident was aggressive behavior towards his wife. The second was punching an aide in the face. The third was Resident 2's first reported physical aggression toward Resident 1 after dinner. The fourth incident was the second physical incident with Resident 1. The facility's policy titled, ECC Abuse Prevention of, dated 1/2020, was reviewed and indicated that each resident has the right to be free from verbal, sexual, physical and mental abuse. All residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants, or volunteers.

Based on interview, and record review, the facility failed to protect Resident 1 from abuse, when a staff allegedly touched Resident 1 in a sexual manner. This failure had the potential for Resident 1 to experience emotional distress, anguish, and negative clinical outcomes. Findings: On 1/14/20, the facility reported to the Department that Resident 4 had witnessed Certified Nursing Assistant (CNA) A touching Resident 1's breast in a possibly sexually inappropriate manner. Resident 4 had not immediately reported this to staff, but the facility did immediately report this allegation, once they were made aware of it. Resident 1's medical record was reviewed on 1/22/20. Resident 1 was admitted on [DATE], with [DIAGNOSES REDACTED]. According to Resident 1's record, she is able to communicate appropriate responses to questions by looking downwards to indicate no and upwards to indicate yes. On 1/4/20 Resident 1 had an assessment of her mental abilities known as a Brief Interview for Mental Status (BIMS) with a score of 15 (indicating no mental impairment). Resident 1's record indicated that she participates in off campus social activities, and is able to communicate her needs with others. Resident 4's medical record was reviewed on 1/22/20. Resident 4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 12/11/19, Resident 4 was administered the BIMS which resulted in a score of 12, indicating mild impairment of mental function. Resident 4's record had no indications of memory recall problems. During an interview, on 1/22/20 at 10:45 am, Resident 4 reported observing CNA A inappropriately grabbing Resident 1's breast and twisting her nipples. Resident 4 had asked what CNA A was doing, prior to leaving the room. Resident 4 stated that she was shocked, at what she had seen, so much so, that I didn't know what to do. Resident 4 stated that she felt bad that she had not come forward and reported what she had observed sooner. During a concurrent observation, and interview, on 1/22/20 at 12:40 pm, Resident 1 was interviewed in the privacy of her room with the supportive presence of the Director of Nursing (DON). Resident 1 appeared in cheerful spirits at the beginning of the interview. Resident 1 looked up sharply and opened her mouth when asked if someone had touched her where they should not. When asked if the touching was on her chest Resident 1 looked up, closing her eyes. Resident 1 became tense and opened her mouth while looking upward when asked if her breasts were touched. Resident 1 appeared distressed by the recollection of the incident and was reassured by the DON that she was safe. When asked if it was CNA A that did the touching Resident 1 became tense again opening her mouth while looking up and moving her left arm about quickly. The facility's policy titled, Abuse - Prevention, Screening, and Training dated 7/18, was reviewed and indicated that this facility does not condone any form of resident abuse. This policy defined abuse as the willful and deliberate infliction of injury. Sexual abuse is defined as non-consensual sexual contact of any type, sexual harassment, sexual coercion, or sexual assault.

Based on staff interview and record review, the facility failed to ensure that eight of 14 sampled residents (Residents 2, 3, 5, 6, 7, 11, 12, and 13) and three residents outside the sample (Residents 15, 16, and 17) were free from the risk for significant medication errors and related adverse outcomes, and that medications were administered, as ordered by the physician. 1. For Resident 6, two physician orders [REDACTED]. The monthly physician's recapitulated (recap) orders (a list of all medication and treatment orders) for June and July 2012 contained errors: The Insulin order dates were discrepant and times of when to give insulin had been changed on both orders, from a specific time to "every day." One of the insulin orders was recapped with information not included in the original physician's orders [REDACTED]. These medication transcription and recap errors had not been detected by the facility and occurred for 6 weeks. These failures placed Resident 6 at unnecessary risk for significant medication errors by potentially receiving the wrong doses of insulin at the wrong time and not receiving Artificial Saliva as necessary, which could result in adverse outcomes such a oral complications of chronic dry mouth that includes gum and tooth disease, and loss of teeth and coma/death from abnormal blood sugar levels. 2. Medication orders were not correctly transcribed from the original physicians' orders into the EHR for 7 of 14 sampled residents (Residents 2, 3, 5, 7, 11, 12, and 13) and 3 residents outside the sample (Residents 15, 16, and 17), resulting in Resident 11 receiving an incorrect medication and the other residents' records containing incorrect order dates, doses/strengths, forms of the drug, amounts and frequencies, routes (oral, injection or topical) and omitted medications in the monthly physicians' recap orders and MAR's. a. Resident 11 received an incorrect medication, which can result in medication side effects and complications from receiving the wrong drug. b. Resident 3's medications had the wrong date on the physician's orders [REDACTED]. c. Resident 5 had omitted PRN cough medications on the recap physician orders [REDACTED]. d. The facility did not clarify the form of a drug for a resident with the feeding tube, Resident 15, which could result in a change absorption of the drug or clog a feeding tube. e. The facility did not clarify a medication frequency when missing on the original order for Resident 16, and another order for medication included additional information that was not part of the original physician's orders [REDACTED]. f. Resident 7's pain medication did not reflect a change in the order to decrease the amount of pain medication putting the resident at risk to be over sedated or overdosed. A blood pressure (BP) medication order date was incorrect which does not reflect the correct length of time a medication has been given to control his BP. g. The facility did not clarify the form of a drug for Resident 2, and the available amount of the drug that could be given exceeded the recommended daily dose, putting the resident at risk for complications including liver failure. h. Resident 12's order for pain medication was incorrectly transcribed resulting in a reduced amount of pain medication that was available to control Resident 12's pain. i. Resident 17 had multiple errors in transcription omitting physician's instructions and the correct dates when medication had been ordered. j. Resident 13 received the incorrect dosage of a medication, contributing in increased lab values, that were out of normal range. 3. The facility failed to ensure that all residents were free from risk of significant medication errors by failing to have an established policy and procedure to ensure a pharmaceutical services system for accurate medication administration and that staff were trained and competent to conduct medication transcription, recap, and EHR entry procedures. (Refer to F425). All Residents in the facility were at risk for complications from potential significant medication errors which can cause harm and jeopardize the residents' health and safety and lead to severe adverse outcomes, including death. Due to the facility's failure to ensure that residents were free from risk for significant medication errors, provided medications in accordance with physicians orders, and failure to identify if Physicians Orders were correctly transcribed, Medication Administration Records and Physicians Recapitulated Orders were accurate and correct, an Immediately Jeopardy was declared on 7/12/12 at 8 pm, with the Director of Nurses (DON), Chief Nursing officer (CNO), and Chief Operating Officer (COO). Findings: 1. On 7/12/12 Resident 6's record was reviewed. Resident 6 was re-admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. a. physician's orders [REDACTED]. Decrease HS (bedtime) dose of [MEDICATION NAME] to 8 units sq daily." The June 2012 and July 2012 monthly physician's orders [REDACTED]. "5/25/12 [MEDICATION NAME] 10 units sub-q daily. " 5/30/12 [MEDICATION NAME] 8 units sub-q daily FYI: 10 units given at 0900." The order date of one of the Insulin orders had been changed to a different order date (from 5/25 to 5/30/12). The recapped order for [MEDICATION NAME] 8 units sq daily did not specify bedtime administration, in accordance with the original physician's orders [REDACTED]. The date of when a medication is actually ordered is important in determining the length of time a resident has received a medication, if the medication has been therapeutic, and if a medication requires any changes. On 7/12/12 at 3:30 pm, a concurrent review of Resident 6's July 2012 MAR was reviewed with Registered Nurse A. She stated that the order for insulin was confusing the way it had been recorded on the July 2012 MAR and stated that the "FYI" addendum with the [MEDICATION NAME] 8 units made it more difficult to understand the order and when to give the medication. b. Resident 6 had a physician's orders [REDACTED]." The June 2012 and July 2012 month physician's orders [REDACTED]. Give before breakfast and bedtime." The order on the recapitulated orders and the MAR were not correct and did not reflect the current physician's orders [REDACTED]. Artificial Saliva was incorrectly entered into the EHR as a PRN (as needed) order, and therefore, had the potential to not be administered in accordance with the physician's orders [REDACTED]. 2a. Resident 11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 6/28/10, the physician ordered Vitamin D (a supplement for bones) 1000 IU (a measurement) daily. On 8/1/10 the physician ordered [MEDICATION NAME] (calcium supplement with 500 mg) one tab twice daily, and continue the Vitamin D. The September 2010 physician's monthly recap orders and MAR included: 1. [MEDICATION NAME] D (calcium 500 mg and Vitamin D 600 IU) one tablet twice daily, and 2. Vitamin D 1000 IU daily. The facility continued to administer [MEDICATION NAME] D to Resident 11, and did not follow the original physician's orders [REDACTED]. Resident 11 continued to receive [MEDICATION NAME] D without a specific physicians order for almost two years. b. Resident 3 had been admitted to the facility several times over the years. He was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Medication Recapitulation Orders demonstrated that all of Resident 3's medication orders were dated 11/26/11 with the exception of medications in his bowel regime, which were dated 4/5/05. c. Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/16/12, the physician ordered [MEDICATION NAME] A-C (cough medication with [MEDICATION NAME]) 5 cubic centimeter (cc) four times a day as needed for cough, or 10 cc prn, if 5 cc not effective for cough. The July 2012 monthly physician's recap orders did not include the above order for [MEDICATION NAME] A-C, the order had been omitted. On 6/1/12 the physician ordered Tylenol 500 mg orally three times daily for hip pain. The July 2012 monthly physician's recap orders did not include the new order for Tylenol. However, the July 2012 MAR did include the new order for Tylenol. d. Resident 15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The July 2012 Physician's monthly recap orders included an order, dated 6/1/12, for [MEDICATION NAME] 400 mg per GT (tube inserted into the stomach through the abdomen for food and medications) prn every four hours for moderate pain. The recap order did not include specific instructions for the form (liquid or pills) of medication to be given by GT, and the facility had not clarified the order. Medications given by GT need to be in appropriate doseage form to ensure the appropriate absorption and reduce the potential for blocking or clogging the GT. e. Resident 16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The July 2012 Physician's monthly recap orders included the following: a. An order, dated 5/5/12, read, "[MEDICATION NAME] 5 mg oral PRN if 0900 (9 am) SBP (systolic, top number of a BP) is greater that 160. Give additional dose at 1500 (3 pm)." After the pharmacy audit, the order was corrected on the July 2012 recap to read, "[MEDICATION NAME] 5 mg oral every PM PRN, if 0900 SBP is greater than 160." An order, dated 5/4/12, read, [MEDICATION NAME] (anxiety medication) 0.125 mg oral PRN anxiety. The order did not include the frequency to give the medication. After the pharmacy audit, the order on the July 2012 recap to read, "[MEDICATION NAME] .125 mg oral TID (three times daily) PRN anxiety." f. Resident 7 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 5/18/12, the physician ordered "[MEDICATION NAME] IR (immediate release potent narcotic pain medication) 5 milligrams (mg) two tabs orally as needed (prn moderate pain." On 5/21/12 the physician ordered to "decrease [MEDICATION NAME] to 5 milligrams (mg) orally every eight hours prn pain." The July 2012 physicians recap orders did not included the new order, dated 5/21/12, and still reflected the previous order, dated 5/18/12. The new order to decrease [MEDICATION NAME] had not been included on the monthly physician's orders [REDACTED]. On 5/30/12 the physician ordered [MEDICATION NAME] (blood pressure medication) 25 mg twice daily. The July 2012 monthly physician's recap order listed that the medication was ordered 6/19/12, not 5/20/12. g. Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 2 also had a feeding tube through which she received fluid, nutrition, and her medications. Review of the July 2012 Medication Recapitulation Orders noted that physician's orders [REDACTED]. No form of the medication was documented. On 5/29/12, another order for [MEDICATION NAME] 650 mg liquid per PEG tube 3 times a day was ordered. If all doses were ingested in a 24 hour period, the total amount would be 4550 mg which exceeded the manufacturer's recommended daily dose of 4 grams in a 24 hour period. h. Resident 12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the July 2012 Medication Recapitulation Orders noted that [MEDICATION NAME] 5/325 (1) tablet orally every 4 hours, as needed, for moderate pain was ordered on [DATE]. On 7/11/12, the physician ordered [MEDICATION NAME] 5/325 1 or 2 tabs orally every 4 hours, as needed, for pain. The Licensed Nurse clarified the order with the physician to read [MEDICATION NAME] 5/325 1 or 2 orally every 4 hours for pain; 1 tablet orally for mild to moderate pain; 2 tablets orally for severe pain. This order was not transcribed onto the July 2012 MAR; licensed nursing staff continued to observe the order for one [MEDICATION NAME] tablet only. Review of the Nurse's Medication Notes revealed that Resident 12 complained of pain ranging between 3 to 7 on a scale of 10, nine times between 7/6/12 - 7/12/12; four complaints of pain occurred in one day and three in another. Resident 12 was medicated with one [MEDICATION NAME] 5/325 tablet for each complaint of pain. Absence of the 7/11/12 [MEDICATION NAME] clarification on the MAR (including two tablets for severe pain) had the potential for not adequately addressing Resident 12's pain. i. Resident 17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The following medication errors were noted in the transcription of these medications to the July 2012 Medication Recapitulation Orders: 1. EC ([MEDICATION NAME]-coated) was missing from the order for Aspirin 325mg orally daily. 2. The descriptor "mild" was omitted from the order for [MEDICATION NAME] DM 1 tsp orally, as needed, for congestion cough. 3. The descriptor "moderate" was omitted from the order for [MEDICATION NAME] DM 2 tsp orally, as needed, for congestion cough. 4. The descriptor "moderate" was omitted from the order for [MEDICATION NAME] (brand name for [MEDICATION NAME], a potent pain medicaiton) 1ml, 20 mg/ml orally, as needed, for pain. 5. The descriptor "severe" was omitted from the order for [MEDICATION NAME] 2ml, 20 mg/ml orally, as needed for pain. 6. The order for [MEDICATION NAME] (a blood pressure medication) 40mg orally twice a day contained the wrong original order date. The listed date was 9/10/08; the correct date was 7/30/11. 7. The order for [MEDICATION NAME] lotion was written as, "apply a small amount topical daily." The correct order read: Apply to bilateral lower extremities daily, as needed, for dry skin (8/14/11). j. Resident 13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/6/12, [MEDICATION NAME] 200 mg orally daily was ordered by the physician. The order was transcribed as [MEDICATION NAME] 100mg orally daily on the July 2012 Medication Recapitulation Orders and the MAR. Lab values for [MEDICATION NAME] on 6/27/12 showed a result of 42 (range 8-30). An order to discontinue the medication was obtained by the pharmacist on 7/16/12. The EC ([MEDICATION NAME]-coated) was missing from the order for Aspirin 325 mg orally daily. [MEDICATION NAME] coating of Aspirin promotes dissolution of the product in the intestines, preventing potential irritation and bleeding in the stomach. In an interview and concurrent record review with the DON and RN B at 7/12/12 at 5:10 pm, both stated that the current system for entering a physician's orders [REDACTED]. The DON stated that each month different staff (nurses and a ward clerk) would help complete entering the monthly physician's orders [REDACTED]. On 7/12/12 at 6:45 pm, the DON stated that the facility did not have a policy and procedure that instructed staff how to enter resident's information and physicians orders into the residents EHR or how to perform the monthly recap of physician' orders and that the current problems reviewed above had been a problem for years. She acknowledged that Resident 6's physician's orders [REDACTED]. Due to a systems failure that placed all residents in the facility at risk for significant medication errors which can cause harm, jeopardize the resident's health and safety, and can lead to severe adverse outcomes including death, an Immediately Jeopardy was declared on 7/12/12 at 8 pm, with the Director of Nurses (DON), Chief Nursing officer (CNO), and Chief Operating Officer (COO). In an interview with the Pharmacy Director and the COO on 7/13/12 at 10 am, they stated that the staff lacked knowledge and had not been trained on how to accurately enter physician's orders [REDACTED]. On 7/13/12, the DON, CNO and COO presented two immediate plans of corrective action which were not accepted by the survey team and the IJ continued. At 4:15 pm, a third plan was presented to and accepted by the survey team which included: Corrective action for Resident 6 who was identified to have incorrect physician' orders; By 7/16/12 at midnight, all residents electronic health record (EHR) and MAR will be verified against the original written order. If discrepancies are noted, the EHR will be updated to reflect the order date and accuracy of the order. A second licensed professional will verify the accuracy of again the original order. All discrepancies (errors) will be documented; The director of pharmacy will coordinate pharmacy services with the SNF with weekly meetings with pharmacy consultant and Administrative Director to ensure compliance for three months; Systems review and revisions will occur to assure elimination of the actual and potential for significant medication errors for each resident by 7/13/12; Medication order verification will be conducted by a pharmacist within 24 hours of entry into the EHR. Orders will be clarified, if needed, by a nurse or pharmacist. New orders to the MAR will be verified by a second licensed health professional and initialed. The nurse will date, time, and note the orders when transcribed. Orders transcribed into the EHR (Accucare) will be verified by a second licensed health professional. Daily, the Night Nurse will verify that new orders are accurately entered on the MAR. New orders will remain flagged until entered into the EHR. Monthly, all new physicians orders will be recapped against the EHR and the MAR for accuracy by nursing staff; Policy and procedures will be developed and approved by 7/13/12; Education of the new policy and procedures will occur at change of shift and cover: Physician order [REDACTED]. The facility's pharmacist will review policies and procedures at the staff meeting. Competition date 7/24/12. Monthly, the pharmacist will review the results of the ongoing audit and educate staff to policy and procedures, completion by 10/31/12; The Director of Pharmacy will provide one-on-one training for each pharmacist, focused on medication order verification and clarification of medication order policies. Completion date 7/16/12; The plan of correction will be implemented, evaluated, and integrated in the facility's quality assurance system. While the survey team accepted the above corrective action plan, daily State monitoring occurred on 7/14 through 7/16/12 to ensure plan implementation, and the IJ was not lifted. On 7/17/12, the survey team reviewed a sample of resident records to ensure that all residents electronic health records (EHR, in Accucare) and MARs were verified against the original physician's written order. It was determined that all medications had not been verified, and the IJ remained unabated. On 7/18/12, the survey team again reviewed a sample of nine residents, and was able to see evidence that the facility had recapitulated physician's orders [REDACTED]. The facility provided evidence that all discrepancies (errors) that were identified were documented during the process of two audits. The first audit (Audit One) was performed with Licensed Nurses and Pharmacists, errors were identified and corrected. The second audit (Audit Two) was completed by two pharmacists (COO and the Director of Pharmacy) and was a re-review of the same records. In an interview and current record review with the COO and the CNO on 7/18/12 at 10 am, the following information had been identified by the facility from the audits of the residents physicians' orders: 1) Audit One (conducted by facility licensed nurses and pharmacists on 7/15/12) reviewed 475 orders (this included orders that required to be listed as multiple orders, called "break out orders") and detected the following errors on the recapitulated physician's orders [REDACTED]. a. 0 wrong medications b. 168 order dates c. Three dose/strength d. Two forms of drug e. Seven S.I.G. (frequency and when to give medications) f. One omitted medication. 2) Audit Two (conducted by a team of facility pharmacists on 7/16/12) found and reviewed 489 orders and detected the following errors on the recapitulated physician's orders [REDACTED]. a. Wrong medication b. 44 order dates c. One dose/strength d. One form of drug e. Eleven S.I.G. f. Three omitted medications On 7/18/12 at 10 am, the COO and the PD confirmed that the process in which medications were transcribed into the EHR, that created monthly recap physician's orders [REDACTED]. The COO stated that the EHR system was reviewed, and it was determined that staff, both nursing and the ward clerk, had not been trained in the specific process to accurately enter physician's orders [REDACTED]. The COO stated that pharmacy oversight had been lacking to ensure that residents received the appropriate medications, as ordered by the physician. On 7/18/12 from 1 pm to 4 pm, a review of the July 2012 Medication Recapitulation Orders was conducted with both the PD and COO who verified the above findings. On 7/18/12 at 5 pm, the IJ was abated with the COO, PD, CNO, and the DON.