Every finding on record at The Waters of Shelbyville, LLC

Based on facility procedure review, medical record review, observations, and interviews, the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice, for 2 of 2 (Residents #3 and #4) residents reviewed. The findings include: Review of the facility's procedure titled, Oxygen Administration, dated 1/1/2020 revealed, .Change humidifier and tubing per facility procedure .At regular intervals, check and clean oxygen equipment, masks, tubing and cannula . Review of the medical record for Resident #3 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease and Atrial Fibrillation. Review of the Annual Minimum Data Set (MDS) assessment for Resident #3 dated 11/7/2023, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Review of the Order Summary Report for Resident #3 revealed and order for, . Oxygen 2/lpm (liters per minute) per NC (nasal cannula) continuous every shift for COPD .Change nebulizer tubing and mask weekly every night shift on Thu [Thursday] .Change oxygen tubing and H20 [water] Nebulizer every week every night shift every Thu . Observation in Resident #3's room on 11/27/2023 at 12:30 PM, revealed Resident #3 lying in bed with oxygen on via nasal cannula at 4 liters per minute (lpm). The humidifier attached to the oxygen concentrator was not dated. A nebulizer mask was hanging on the humidifier bottle that was sitting in a pulled out drawer of the bedside nightstand. The nebulizer mask was undated. During an interview and observation in Resident #3's room on 11/27/2023 at 2:44 PM, the Director Of Nursing (DON) stated the nebulizer mask was not contained in a bag or stored properly. He stated the date on the bag hanging from the concentrator was 11/2/2023. The DON stated the humidifier bottle nor the nebulizer mask were dated. He stated the nebulizer mask and oxygen equipment are to be dated and changed weekly. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses which included Pyogenic Arthritis and Pneumonia. Review of the Quarterly MDS assessment for Resident #4 dated 11/2/2023 revealed a BIMS score of 14, which indicated no cognitive impairment. Review of the Order Summary Report for Resident #4 revealed an order dated 10/26/2023 for Ipratropium-Albuterol Solution (a medication used to dialate the bronchi in the lung to improve breathing) 0.5-2.5 (3)mg (milligram)/3ml (milliliter) 1 vial inhale orally every 6 hours for cough/congestion. Observation in Resident #4's room on 11/27/2023 at 12:45 PM, revealed a nebulizer mask laying on an overbed table not in a bag. The date on the mask was illegible. During an interview and observation in Resident #4's room on 11/27/2023 at 2:46 PM, the DON stated the nebulizer mask was not contained in a bag or stored properly. He stated the nebulizer mask had no date, and it should be dated.

Based on facility policy review, medical record review, observation, and interview, the facility failed to follow MD (Medical Doctor's) orders for 1 of 17 (Resident #3) residents reviewed. The findings include: Review of the facility policy titled, GUIDELINES FOR PHYSICIAN ORDERS--(FOLLOWING PHYSICIAN ORDERS,) dated 6/18/2023, revealed, .It is the policy of the facility to follow the orders of the physician .All physician orders received pertaining to the resident will be implemented and followed throughout the course of the resident's stay in the facility as the orders are received . Review of the medical record for Resident #3 revealed he was admitted on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease and Atrial Fibrillation. Review of the Annual Minimum Data Set (MDS) assessment for Resident #3 dated 11/7/2023, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Review of the Care Plan for Resident #3 revealed, .Focus .is at risk for alteration in respiratory status related to DX [diagnosis] of COPD [Chronic Obstructive Pulmonary Disease], chronic respiratory failure with hypoxia, emphysema .receives oxygen as ordered . Interventions included, .O2 [oxygen] therapy per orders, change 02 tubing per facility protocol and as needed . Review of the Order Summary Report for Resident #3 revealed and order for Oxygen 2/lpm (liters per minute) per NC (nasal cannula) continuous every shift for COPD. Review of the Medication Administration Record (MAR) for Resident #3 dated 11/1/2023-11/30/2023, revealed he was administered oxygen at 2 lpm continuous. Observation in Resident #3's room on 11/27/2023 at 12:30 PM, revealed Resident #3 lying in bed with oxygen on via nasal cannula at 4 lpm. During an interview and observation in Resident #3's room on 11/28/2023 at 11:40 AM, the Regional Nurse Consultant #2 verified the oxygen concentrator was on, attached to Resident #3 via a nasal cannula, and was set to deliver oxygen at 4 lpm. Resident #3 stated, My oxygen has to be on 4 or I can't breathe. Upon review of Resident #3's Physician's Orders, Regional Nurse Consultant #2 confirmed the order was for oxygen at 2 lpm continuous. The Regional Nurse Consultant confirmed the nurses were not following the Physician's Order for Resident #3's oxygen administration.

Based on facility policy review, Facility Reported Investigation (FRI) review, medical record review, and interview, the facility failed to report allegations of abuse within 2 hours for 1 of 3 (Resident #3) sampled residents reviewed for abuse. The findings include: Review of the facility's policy titled, Abuse Prevention Program, dated 1/19/2017, revealed, .It is the policy of this facility to prevent resident abuse, neglect, mistreatment, and misappropriation of resident property. Each resident receives care and services in a person-centered environment in which all individuals are treated as human beings. The following procedures shall be implemented when and employee or agent becomes aware of abuse .or of an allegation of suspected abuse .Employees are required to report any incident, allegation or suspicion of potential abuse, neglect or mistreatment they observe, hear about or suspect to the Administrator or an immediate supervisor .The Administrator of designee utilizing the Incident Reporting System [IRS] will immediately notify the Department of Health by the online system or per direction given by the Department of Health . Review of the FRI #20225168301 revealed on 5/15/2022 Certified Nursing Assistant (CNA) #2 reported to the Director of Nursing (DON), Resident #3 was being pushed down the hall on a shower chair by CNA #3. Resident #3 called for CNA #2 to come to him and Resident #3 stated, This man is in here hitting on me. CNA #3 was immediately sent home. CNA #3 provided a written statement on 5/16/2022 which revealed Resident #3 was yelling, calling CNA #3 names, and while CNA changed his sling to the shower chair he did yell this motherfucker is hitting me, help. CNA #3 revealed Resident #3 has done this before. CNA #3 reported in his statement that Resident #3 was yelling and the door was shut but denied ever hitting the resident. Nursing Supervisor performed skin check on 5/15/2022 which revealed no redness or any type of injury to the resident. Resident #3 denied any pain or any allegations of abuse or injury. Several employees that were working during the allegation were interviewed, all denied hearing the resident say anything about being hit, and Resident #3 did not complain about CNA #3's care. Further review of the Incident Reportable System (IRS) revealed the allegation was reported on 5/16/2022, a day after the DON was made aware of the allegation. Review of the medical record revealed Resident #3 admitted to the facility on [DATE] with diagnoses which included Aphasia, Schizoaffective Disorder, Major Depressive Disorder, Mild Intellectual Disabilities, and Mild Cognitive Impairment. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated severely impaired cognition. During an interview on 2/7/2023 at 12:00 PM, the DON stated, Abuse should be reported to the state agency within 2 hours. The DON confirmed CNA #2 called her on 5/15/2022 and reported Resident #3 was being transferred from room to shower room by CNA #3. During the transfer into the hallway Resident #3 stated, This man is in here hitting on me. During a telephone interview on 2/7/2023 at 1:00 PM, CNA #2 revealed Resident #3 told her that he was hit while CNA #3 was providing him care. CNA #2 stated I called the DON as soon as it happened on 5/15/2022 because I was concerned. During an interview on 2/7/2023 at 2:46 PM, CNA #3 stated, I had given [Named Resident #3] a shower, he did become combative, but that is normal for him. I gave him some space and then completed his care. The next thing I knew the nurse was sending me home because [Named Resident #3] told a CNA I was hitting him. I would never hit a resident. I was sent home immediately on 5/15/2022, and I have never worked at that facility anymore. During an interview on 2/8/2023 at 1:30 PM, DON confirmed allegations of abuse should be reported to the State Agency within 2 hours. The DON confirmed the allegation of abuse was reported to her on 5/15/2022 and confirmed she did not submit the allegation to the state agency until 5/16/2022.

An investigation of complaint #TN 780 conducted on 11/29/2021 at 9:30 AM . Health deficiencies were citied in relation to the complaint investigation #TN 780 under 42 CFR Part 483, Requirements for Long Term Care Facilities. Based on facility policy, medical record review, observations and interviews, the facility failed to provide a COVID-19 vaccination for 1 (Resident #1) of 4 residents reviewed for COVID-19 vaccinations. Review of the facility policy titled, COVID-19 Vaccine/Booster, revised 9/27/21, revealed, .It is the policy of this facility to offer and to make available, (to the best of their ability considering supply and demand and preferences) and administer a Covid-19 vaccine/booster to the residents who reside in the facility . Review of the facility documentation titled, New Covid-19--CDC Requirements, dated May 21, 2021, revealed, .Offering of the COVID-19 Vaccine: The facility is expected to offer and make available, (to the best of their ability considering supply and demand and preferences), approved Covid-19 vaccines to the residents who desire the vaccine and who reside in the facility and the staff who desire the vaccine and who work in the facility .This can be accomplished by filling out the Covid-19 VACCINE INQUIRY WORKSHEET FORM at the onset of resident admissions or for staff as they on-board. If the facility's vaccination process in not able to provide timely vaccinations for residents and/or staff due to lack of supply-efforts must be made and documented as to the facility's actions taken to make arrangements for residents to receive their vaccination(s) from an authorized outside provider. Further staff will be assisted by providing them names or a list of local Covid-19 administration sites. These efforts must be documented. Additionally, the facility must document ongoing efforts to secure vaccine for the facility's Covid-19 vaccination process . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) for Resident #1 dated 02/08/2021, revealed a Brief Interview for Mental Status (BIMS) score of 09, which indicated moderate cognitive impairment. Review of Section GG revealed resident requires partial/moderate assistance with shower/bath. Resident requires Supervision or touching assistance with upper body dressing and substantial/maximal assistance with lower body dressing. Review of the COVID-19 Resident Vaccination Registration Form dated 02/01/2021, revealed The Responsible Party for Resident #1 elected for her to receive the COVID-19 vaccination. Review of the facility documentation of Covid vaccine administration list dated February 2021, revealed Resident #1 was not on the list. Review of the Physician's Orders for Resident #1 revealed there was not an order written [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/29/2021 at 10:24 AM, the Complainant stated that [named Resident #1] was taken by the family to a pharmacy to receive the vaccination. During an interview on 11/29/2021 at 11:01 AM, Family Member #3 revealed that he had signed the consent form for the COVID-19 vaccination when [named Resident #1] was admitted and that to his knowledge, she never received the vaccination. He had been told, but could not remember by whom, that his sister did get both vaccinations and the booster vaccination. He confirmed that he did take her to a local pharmacy for the vaccination in order for her to be admitted to the new facility. During an interview on 11/29/2021 at 2:18 PM, Licensed Practical Nurse (LPN) #1 stated Covid vaccinations are documented in the resident's charts if they receive them. During an interview on 11/29/2021 at 2:30 PM, Registered Nurse (RN) #1 stated that if an admission elects to have the COVID vaccine the DON is notified, and they are put on a list. An outside agency comes to the facility to give the vaccinations. During an interview on 11/29/2021 at 2:45 PM, LPN #2 stated, When a resident request the COVID vaccine, the nurse will notify the DON and she sets up an appointment for them. I think someone from an outside facility give the vaccine. During an interview on 11/29/2021 at 3:48 PM, the DON stated, If someone admits to the facility and wants a Covid vaccine, a vaccination clinic was scheduled. The last couple clinics were set up by the Administrator and Social Services. The prior Assistant Director of Nursing (ADON) set them up before. If a resident wants a vaccination, a Physician's Order is obtained, and they are scheduled with the next clinic. Clinics are set up when residents are on the list. If a resident received Covid vaccine, they're monitored post vaccination. She expects a resident to receive the vaccination before discharge. She confirmed [named] Resident #1 had a signed consent for Covid vaccination in February 2021 and did not receive the vaccine before she was discharged . If resident declined vaccine upon admission and later decided to get it, a new consent is filled out and the resident is set up with the next clinic. She stated she didn't monitor to see if the former ADON ensured the residents received the Covid vaccination. During an interview on 11/29/2021 at 4:15 PM, the Administrator stated that if a resident or responsible party requested a COVID-19 vaccine he expects them to receive the vaccination.

An investigation of complaint TN 780 conducted on 11/29/2021 at 9:30 AM. Health deficiencies were cited in relation to the complaint investigation TN 780 under 42 CFR Part 483, Requirements for Long Term Care Facilities. Based on facility policy, medical record review, observations and interviews, the facility failed to notify the responsible party for 1 (Resident #1) of 4 residents reviewed for notification of room change. Review of the facility's undated policy titled, Transfer and Discharge Policy and Procedure revealed, .if the resident is to transfer within the facility, notice of the transfer is given to the resident/responsible party at least 2 days before relocation except when .the safety of individuals would be endangered; the health of individuals in the facility would be endangered; the resident's health improves sufficiently to allow a more immediate transfer or an immediate transfer is required by the resident's urgent medical needs. Resident/responsible party waives the advanced 2 days' notice . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) for Resident #1 dated 02/08/2021, revealed a Brief Interview for Mental Status (BIMS) score of 09, which indicated moderate cognitive impairment. Review of the Census List for Resident #1 revealed she was admitted to room [ROOM NUMBER]-B on 02/01/2021, room change to 73-B on 02/18/2021 and room change to 38-B on 09/21/2021. Review of the Progress Notes for Resident #1 revealed that on 02/05/2021 the Social Services Director notified the Responsible Party resident would move to a permanent room once the initial quarantine period ended. No documentation indicating notification of room change on 09/21/2021 was noted. During an interview on 11/29/2021 at 10:24 AM, the Complaintant stated there was no notification to her fiance, the Responsible Party regarding the room change. During an interview on 11/29/2021 at 11:01 AM, Family Member #3 confirmed that there was no notification of the room change on 09/21/2021. During an interview on 11/29/2021 at 12:35 PM, the Social Services Director stated, Either myself or the nurse notifies the responsible party of all room transfers. Mostly the nurse in charge of that unit, I haven't done many of notifications lately. During an interview on 11/29/2021 at 2:18 PM, Licensed Practical Nurse (LPN) #1 stated Nurses or housekeeping notify families of resident room changes. When resident's rooms are changed, we would chart it in the progress notes. During an interview on 11/29/2021 at 2:30 PM, Registered Nurse (RN) #1 stated Social Services contacts the family if a resident changes rooms. During an interview on 11/29/2021 at 2:45 PM, LPN #2 stated, If a resident has to be moved to another room, the Social Services person contacts the family. During an interview on 11/29/2021 at 3:48 PM, the DON stated if a resident has a room change, Social Services notified the family of the room change and documented in the progress notes. Room changes are discussed in morning meetings and after the morning meeting, Social Services would notify the family of the room change. She confirmed there was no documentation for room change notification to [named] Resident #1's responsible party. She stated, If it's not documented, it's not done. She stated the policy for transfer is family notification of room change. During an interview on 11/29/2021 at 4:15 PM, the Administrator stated that he did expect the Social Services Director to notify responsible parties when a resident has a room change.

Based on medical record review, policy review, and interview, the facility failed to ensure all weekly weights for new adnissions to the facility were completed as ordered for 1 resident (Resident #1) of 3 residents reviewed for weight loss. The facility census was 57. Findings include: Review of the facility's undated policy titled, S.W.A.T.-Skin Weight Assessment Team, revealed .purpose: to identify residents at nutritional risk for related medical concerns .it is the policy of the facility to assess the nutritional status of each resident .the residents will be monitored by this team effort on a weekly basis .newly admitted resident or readmitted resident has 4 weeks with no concerns . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #1 scored 3 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. No [CONDITION(S)], behaviors, or wandering noted. Extensive, one-person physical assistance was required for bed mobility, locomotion on unit, dressing, eating, and toileting. Extensive, two-person assistance was required for transfers. Review of the Care Plan, dated [DATE], revealed the resident was at risk for developing a transmission-based infection which could result in untoward outcomes with interventions including diet per order; all meals are to be served in his room or in the unit; to encourage by mouth (P.O.) intake; to assist the resident with their meals/snacks as needed; to provide reminders and/or assist him with handwashing before meals and as needed; and to encourage fluids throughout the day unless otherwise. Review of the Hospital History and Physical, dated [DATE], revealed .patient recently diagnosed with COVID-19. Very poor P.O. intake this week. Worsening shortness of breath as well. On arrival air pulse oxygenation in the low 80s . Review of the Dehydration Risk Assessment, dated [DATE], revealed a score of 4. Total score above 8 represents high risk prevention protocol should be initiated immediately and documented on the care plan. Review of the Nutritional Assessment, dated [DATE], revealed .Normal Saline (NS) infusing at 100 ml/hour related to dehydration .current body weight 160 lbs and height 68 inches, by mouth (P.O.) intake ~25% at meals on average .intake does not meet needs .moderate protein calorie malnutrition related to history of weight loss, decreased Po intake, muscle loss, fat loss .recommendation to add house shake three times daily (TID) in effort to increase kcal/protein intake to meet needs .will continue to monitor nutrition parameters. Registered Dietician to follow-up as needed . Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .plan for nasogastric (NG) tube for nutrition . Review of a Nursing Progress Note, dated [DATE] at 6:40 AM, revealed .Certified Nursing Assistant (CNA) reported that resident was unresponsive. Resident without pulse or respiration. Code blue called and initiated. 911 called. Wife at bedside. CPR continued until EMS arrived and took over care of the resident . Review of the Certificate of Death, dated [DATE], revealed the cause of death was Respiratory Arrest, Failure to Thrive, and COVID-19 Infection. Review of the Weight Summary, revealed on [DATE], the resident weighed 160.0. On [DATE], the resident weighed 160.3. There were no additional weights recorded. During interview conducted on [DATE] at 11:52 AM, the Assistant Director of Nursing (ADON) confirmed the facility did not obtain all weekly weights following admission. The ADON verified it is the facility's policy to obtain weekly weights, once weekly for 4 weeks, for all new admissions.

Based on facility policy review, medical record review, and interview, the facility failed to notify 14 Resident Representatives (Residents #5, #7, #11, #12, #13, #15, #18, #19, #25, #26, #31, #32, #38, and #47) of 53 Resident medical records reviewed for changes in the resident's medication regimen regarding the use of [MEDICATION NAME]([MEDICATION NAME]) (a drug used to treat and prevent [DIAGNOSES REDACTED]) for the treatment and prevention of COVID-19. The findings include: Review of the undated facility policy titled, Change in Resident's Condition or Status, showed, .It is the policy of the facility to ensure that attending physician and Representative are notified of changes in the resident's condition or status .4. Except in medical emergencies notification will be made within 24 hours of a change occurring in the resident's condition or status .6. The nurse will record in the resident's medical record any changes in the resident's medical condition or status . Review of the medical record showed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. Review of Resident #5's Order Recap Report dated 11/1/2020 through 11/30/2020, showed, .[MEDICATION NAME] Tablet 200 MG (milligram) ([MEDICATION NAME]) Give 200 mg by mouth two times a day for [MEDICATION NAME] for 15 days .11/21/2020-12/06/2020 . Review of Resident #5's Progress Notes dated 11/8/2020 through 12/7/2020, showed no documentation of Resident Representative notification of the new medication [MEDICATION NAME] ([MEDICATION NAME]). Review of the medical record showed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review showed the Resident had a [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE], showed, Resident #7 had a BIMS score of 15 which indicated no cognitive impairment. Review of Resident #7's Order Recap Report dated 11/1/2020 through 11/30/2020, showed, .[MEDICATION NAME] Tablet 200 MG ([MEDICATION NAME]) Give 200 mg by mouth two times a day for [MEDICATION NAME] for 15 days .11/21/2020-12/06/2020 . Review of Resident #7's Progress Notes dated 11/1/2020 through 12/7/2020, showed no documentation of Resident Representative notification of the new medication [MEDICATION NAME] ([MEDICATION NAME]). Review of the medical record showed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual MDS assessment dated [DATE], showed Resident #11 had a BIMS score of 4 which indicated severe cognitive impairment. Review of Resident #11's Order Recap Report dated 11/1/2020 through 11/30/2020, showed, .11/22/2020 [MEDICATION NAME] Tablet 200 MG ([MEDICATION NAME]) Give 200 mg by mouth one time only for [MEDICATION NAME] until 11/22/2020 AND give 200 mg by mouth two times a day for [MEDICATION NAME] until 12/06/2020 . Review of Resident #11's Progress Notes dated 11/8/2020 through 12/7/2020, showed no documentation of Resident Representative notification of the new medication [MEDICATION NAME] ([MEDICATION NAME]). Review of the medical record showed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE], showed, Resident #12 had a BIMS score of 10 which indicated moderate cognitive impairment. Review of Resident #12's Order Recap Report dated 11/1/2020 through 11/30/2020, showed, .11/22/2020 [MEDICATION NAME] Tablet 200 MG (milligram) ([MEDICATION NAME]) Give 200 mg by mouth two times a day every 15 day(s) for [MEDICATION NAME] for 15 days .11/21/2020-12/06/2020 . Review of Resident #12's Progress Notes dated 11/8/2020 through 12/7/2020, showed no documentation of Resident Representative notification of the new medication [MEDICATION NAME] ([MEDICATION NAME]). Review of the medical record showed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE], showed Resident #13 had a BIMS score of 3 which indicated severe cognitive impairment. Review of Resident #13's Order Recap Report dated 11/1/2020 through 11/30/202, showed, .11/21/2020 [MEDICATION NAME] Tablet 200 MG ([MEDICATION NAME]) Give 200 mg by mouth two times a day every 15 day(s) for [MEDICATION NAME] for 15 days .11/21/2020-12/06/2020 . Review of Resident #13's Progress Notes dated 11/18/2020 through 12/7/2020, showed no documentation of Resident Representative notification of the new medication [MEDICATION NAME] ([MEDICATION NAME]). Review of the medical record showed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE] showed, Resident #15 had a BIMS score of 15 which indicated no cognitive impairment. Review of Resident #15's Order Recap Report dated 11/1/2020 through 11/30/2020, showed, .11/21/2020 [MEDICATION NAME] Tablet 200 MG ([MEDICATION NAME]) Give 200 mg by mouth two times a day every 15 day(s) for [MEDICATION NAME] for 1 day 11/21/2020 through 11/22/2020 AND [MEDICATION NAME] 200 MG ([MEDICATION NAME]) Give 200 mg by mouth two times a day every day for [MEDICATION NAME] for 15 days 11/22/2020-12/7/2020 . Review of Resident #15's Progress Notes dated 11/3/2020 through 12/7/2020, showed no documentation of Resident Representative notification of the new medication [MEDICATION NAME] ([MEDICATION NAME]). Review of the medical record showed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual MDS assessment dated [DATE], showed Resident #16 had a BIMS score of 15 which indicated no cognitive impairment. Review of Resident #16's Order Recap Report dated 11/1/2020 through 11/30/2020, showed, .11/21/2020 [MEDICATION NAME] Tablet 200 MG ([MEDICATION NAME]) Give 200 mg by mouth two times a day for [MEDICATION NAME] for 15 Days .11/21/2020-12/6/2020 . Review of Resident #16's Progress Notes dated 11/19/2020 through 12/6/2020, showed no documentation of Resident Representative notification of the new medication [MEDICATION NAME] ([MEDICATION NAME]). Review of the medical record showed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review showed the resident had a [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE], showed Resident #18 had a BIMS score of 4 which indicated severe cognitive impairment. Review of Resident #18's Order Recap Report dated 11/1/2020 through 11/30/2020, showed, .[MEDICATION NAME] Tablet 200 MG ([MEDICATION NAME]) Give 200 mg by mouth two times a day for [MEDICATION NAME] for 15 days .11/21/2020-12/6/2020 . Review of Resident #18's Progress Notes dated 11/18/2020 through 12/7/2020, showed no documentation of Resident Representative notification of the new medication [MEDICATION NAME] ([MEDICATION NAME]). Review of the medical record showed Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE], showed Resident #19 had a BIMS score of 9 which indicated moderate cognitive impairment. Review of Resident #19's Order Recap Report dated 11/1/2020 through 11/30/2020, showed, .[MEDICATION NAME] Tablet 200 mg by mouth two times a day for [MEDICATION NAME] for 15 Days .11/21/2020-12/06/2020 . Review of Resident #19's Progress Notes dated 11/18/2020 through 12/6/2020, showed no documentation of Resident Representative notification of the new medication [MEDICATION NAME] ([MEDICATION NAME]). Review of the medical record showed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE], showed Resident #25 had a BIMS score of 10 which indicated moderate cognitive impairment. Review of Resident #25's Order Recap Report dated 11/1/2020 through 11/30/2020, showed, .[MEDICATION NAME] Tablet 200 MG ([MEDICATION NAME]) Give 200 mg by mouth two times a day for [MEDICATION NAME] for 15 days .11/21/2020-12/06/2020 . Review of Resident #25's Progress Notes dated 11/19/2020 through 12/06/2020, showed no documentation of Resident Representative notification of the new medication [MEDICATION NAME] ([MEDICATION NAME]). Review of the medical record showed Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review showed Resident #26 had a [DIAGNOSES REDACTED]. Review of Resident #26's Quarterly MDS assessment dated [DATE], showed the resident had a BIMS score of 13 which indicated no cognitive impairment. Review of Resident #26's Order Recap Report dated 11/01/2020 through 11/30/2020, showed, .[MEDICATION NAME] Tablet 200 mg ([MEDICATION NAME]) Give 200 mg by mouth two times a day for [MEDICATION NAME] for 15 days .11/21/2020-12/06/2020 . Review of Resident #26's Progress Notes dated 11/27/2020 through 12/06/2020, showed no documentation of Resident Representative notification of the new medication [MEDICATION NAME] ([MEDICATION NAME]). Review of the medical record showed Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #31's Quarterly MDS assessment dated [DATE], showed the resident had a BIMS score of 15 which indicated no cognitive impairment. Review of Resident #31's Order Recap Report dated 11/1/2020 through 11/30/2020, showed, .[MEDICATION NAME] tablet 200 mg ([MEDICATION NAME]) give one tablet by mouth two times a day for immunity for 15 days .11/21/2020-12/6/2020 . Review of Resident #31's Progress Notes dated 11/1/2020 through 12/7/2020, showed no documentation of Resident Representative notification of the new medication [MEDICATION NAME] ([MEDICATION NAME]). Review of the medical record showed Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #32's Quarterly MDS assessment dated [DATE], showed the resident had a BIMS score of 3 which indicated severe cognitive impairment. Review of Resident #32's Order Recap Report dated 11/1/2020 through 11/30/2020, showed, .[MEDICATION NAME] tablet 200 mg ([MEDICATION NAME]) give one tablet by mouth two times a day for immunity for 15 days .11/21/2020-12/6/2020 . Review of Resident #32's Progress Notes dated 11/1/2020 through 12/7/2020, showed no documentation of Resident Representative notification of the new medication [MEDICATION NAME] ([MEDICATION NAME]). Review of the medical record showed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #38's Quarterly MDS assessment dated [DATE], showed the resident had a BIMS score of 13 which indicated no cognitive impairment. Review of Resident #38's Order Recap Report dated 11/1/2020 through 11/30/2020, showed, .[MEDICATION NAME] tablet 200 mg ([MEDICATION NAME]) give one tablet by mouth two times a day for immunity for 10 days .11/27/2020-12/7/2020 . Review of Resident #38's Progress Notes dated 11/2/2020 through 12/7/2020, showed no documentation of Resident Representative notification of the new medication [MEDICATION NAME] ([MEDICATION NAME]). Review of the medical record showed Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #47's Quarterly MDS assessment dated [DATE], showed the resident had a BIMS score of 3 which indicated severe cognitive impairment. Review of Resident #47's Order Recap Report dated 11/1/2020 through 11/30/2020, showed, .[MEDICATION NAME] tablet 200 mg ([MEDICATION NAME]) give one tablet by mouth two times a day for immunity for 10 days .11/27/2020-12/7/2020 . During a telephone interview on 12/7/2020 at 2:21 PM, Resident #5's Representative confirmed she was not notified by the facility that Resident #5 was ordered the new medication [MEDICATION NAME] ([MEDICATION NAME]). During a telephone interview on 12/8/2020 at 11:30 AM, Resident #7's Representative confirmed she was not notified by the facility that Resident #7 was ordered the new medication [MEDICATION NAME] ([MEDICATION NAME]). During a telephone interview on 12/8/2020 at 12:17 PM, Resident #11's Representative confirmed he was not notified by the facility that Resident #11 was ordered the new medication [MEDICATION NAME] ([MEDICATION NAME]). During a telephone interview on 12/8/2020 at 11:08 AM, Resident #12's Representative confirmed he was not notified by the facility that Resident #12 was ordered the new medication [MEDICATION NAME] ([MEDICATION NAME]). He stated, I have not had a call from the facility. During a telephone interview on 12/8/2020 at 10:57 AM, Resident #13's Representative confirmed he was not notified by the facility that Resident #13 was ordered the new medication [MEDICATION NAME] ([MEDICATION NAME]). He stated, I didn't know she was taking anything for Corona. During a telephone interview on 12/8/2020 at 1:00 PM, Resident #15's Representative confirmed she was not notified by the facility that Resident #15 was ordered the new medication [MEDICATION NAME] ([MEDICATION NAME]). She stated, If they told him, he would not have understood. During a telephone interview on 12/8/2020 at 1:20 PM, Resident #16's Representative confirmed he was not notified by the facility that Resident #16 was ordered the new medication [MEDICATION NAME] ([MEDICATION NAME]). During a telephone interview on 12/8/2020 at 2:15 PM, Resident #18's Representative confirmed he was not notified by the facility that Resident #18 was ordered the new medication [MEDICATION NAME] ([MEDICATION NAME]). During a telephone interview on 12/7/2020 at 4:08 PM, Resident #19's Representative confirmed he was not notified Resident #19 was ordered the new medication [MEDICATION NAME] ([MEDICATION NAME]). During a telephone interview on 12/8/2020 at 11:29 AM, Resident #25's Representative confirmed he was not notified by the facility that Resident #25 was ordered the new medication [MEDICATION NAME] ([MEDICATION NAME]). During an interview on 12/08/2020 at 2:00 PM, Resident #26 confirmed he was not notified by the facility that he was ordered the new medication [MEDICATION NAME] ([MEDICATION NAME]). During an interview on 12/8/2020 at 1:40 PM, Resident #31's Representative confirmed the facility did not notify her of the new medication [MEDICATION NAME] ([MEDICATION NAME]). During an interview on 12/8/2020 at 1:37 PM, Resident #32's Representative confirmed the facility did not notify her of the new medication [MEDICATION NAME] ([MEDICATION NAME]). During an interview on 12/8/2020 at 1:15 PM, Resident #38's Representative confirmed the facility did not notify him of the new medication [MEDICATION NAME] ([MEDICATION NAME]). During an interview on 12/8/2020 at 9:25 AM, Resident #47's Representative confirmed the facility did not notify her of the new medication [MEDICATION NAME] ([MEDICATION NAME]). During an interview on 12/8/2020 at 3:09 PM, the Assistant Director of Nursing stated, The nurses notify the responsible parties of any medication changes or change in condition and document it in the progress notes. If it's not in the progress notes it hasn't been done. During an interview on 12/8/2020 at 5:05 PM the Director of Nursing she stated When you receive a new order or notice a change of condition, family notification is documented in the progress notes if it's a medication; if it's a change in condition you document that on a change of condition assessment in the resident's medical record, so if it's not documented there then it wasn't done.

Based on facility policy review, facility documentation review, medical record review, observation and interview the facility failed to provide adequate supervision to prevent elopement for 1 resident (#68) of 5 residents reviewed who were wander/elopement (Residents who have a history of leaving or trying to leave the facility, or have wandered or have the potential to wander into unsafe areas) risks resulting in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator was informed of the Immediate Jeopardy (IJ) on 11/5/19 at 6:50 PM in his office. An extended survey was conducted from 11/5/19 to 11/6/19. F-689 was cited at a scope and severity of [NAME] F-689 J is Substandard Quality of Care. The Immediate Jeopardy was effective from 7/27/19 through 8/20/19. The facilities corrective action plan, which removed the IJ, was received and the corrective actions were validated onsite on 11/6/19 F-689 was cited at a scope and severity of J as past noncompliance. The facility is not required to submit a plan of correction for F-689 [NAME] The findings include: Review of the facility policy, Missing Residents and Elopement, dated 8/1/16 revealed .It is the policy of this facility that all residents are provided adequate supervision to meet each resident's personal care needs .All residents will be assessed for behaviors or conditions that put them at risk of elopement .All resident's assessed to be at risk of elopement will have this issue addressed in their plan of care .Residents that are at risk of elopement will be provided at least one of the following safety precautions: staff supervision of facility exits either directly or by video camera .door alarms on facility exits .a personal safety device that notifies facility staff when the resident has left the facility without supervision .all personal safety devices, door alarms and video cameras will be tested and document weekly .at no time will any door alarm or personal safety device be deactivated without direct supervision of the exit .Potential safety hazards on the exterior of the facility shall be identified such as wooded areas, water hazards, and busy roads .Should an alarm on one of the exits to the outside of the facility sound, staff will immediately respond to determine the cause of the alarm . Medical record review revealed Resident #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #68's hospital records dated 7/15/19 revealed approximately 1 week prior to the hospitalization , and susequent admission into the facility the resident had wandered from his home, became lost in the woods and sustained rib fractures. Medical record review of Resident #68's 5 day Minimum Data Set ((MDS) dated [DATE] and Discharge MDS dated [DATE] revealed the resident had a Brief Interview of Mental Status Score of 4 indicating the resident had severe cognitive impairment. Continued review revealed the resident wandered daily. Medical record review of Resident #68's comprehensive care plan dated 7/26/19 revealed the resident was high risk for elopement and wandering. Continued review revealed .roam alert bracelet was applied to resident to reduce risk of elopement .monitor resident location with frequent visual checks .monitor doors when staff and visitors come and go . Continued review revealed the resident was at risk for falls. Medical record review of Resident #68's progress notes dated 7/26/19 through 8/6/19 revealed the resident wandered in and out of resident rooms. Medical record review of Resident #68's Elopement Risk Review dated 7/26/19 revealed .the resident had a history of [REDACTED].hangs around facility exits and/or stairways .responds poorly to staff re-direction when roaming into areas that are 'off limits' or unauthorized .has the physical ability to leave the building .becomes agitated, confused and/or disoriented or displays consistently poor judgement (would not be able to safely care for him/herself outside the facility) .at risk to elope and should be placed on the Elopement Risk Protocol .Resident has a history of trying to elope, he does not do redirection to (too) easily from staff . Medical record review of Resident #68's Wandering Risk assessment dated [DATE] revealed .Resident is cognitively impaired with poor decision making .resident is alert but non-compliant with facility protocols regarding leaving the unit .unauthorized opening doors to the outside without regard to their personal safety .lingering around exit doors, attempting to exit with visitors without authorization .displays behaviors, body language, indicating an elopement may be forthcoming . Medical record review of Resident #68's Fall Risk Review dated 7/26/19 revealed the resident was at risk for falls related to [MEDICAL CONDITION] and Dementia. Review of the facility's investigation for Resident #68 dated 7/27/19 revealed the resident exited the building through the front door of the facility. Interview with Licensed Practical Nurse (LPN) #5 on 11/5/19 at 4:19 PM in the conference room revealed she was working on 7/27/19 when Resident #68 exited the facility out the front entrance door. Continued interview revealed I was on the hallway and a 'tech' (Certified Nursing Assistant (CNA) # 6) came out of room [ROOM NUMBER] and yelled at us that (named resident) was outside. Telephone interview with LPN #6 on 11/5/19 at 4:48 PM revealed I was on the hall at the time he was visiting with family in the dining room. One of the CNA's saw him outside through another resident's window; she came out and told me he was outside so I went out to get him and bring him back inside. I was just concerned about getting the resident to safety. Telephone interview with CNA #6 on 11/5/19 at 5:01 PM confirmed I saw him walking outside in the parking lot out of room [ROOM NUMBER]'s window. I first thought his daughter was with him then when I looked again I realized she wasn't, nobody was; I came out of the room and yelled at other staff that (named resident) was in the parking lot. Observation on 11/5/19 at 5:10 PM from room [ROOM NUMBER]'s window revealed the inability to view the front entrance area of the building. Continued observation revealed the ability to view the side parking lot and the 4 lane highway. Telephone interview with Resident #68's family member on 11/6/19 at 2:42 PM revealed I was there, I had gone to the bathroom and when I came out he (Resident #68) was not where I left him, so I started looking for him. I walked all the hallways even looking in rooms to see if he was there. Continued interview revealed I walked around the building for approximately 10 minutes or so; then when I got to Station 1 (nurses' station 1) the staff started yelling 'he's outside' and then everybody started running toward the front door so I went too. When I got to the front door I saw him. He was already down to the road, fixing to get on the road. Interview with the Director of Nursing (DON) on 11/5/19 at 5:38 PM at the front entrance door revealed the DON confirmed Resident #68 was not safe outside. The facility's corrective action plan included the following: 1. On 7/27/19 Resident #68 was brought back into the facility by staff members without injury. A head to toe assessment was competed on Resident #68. The resident was placed on 1:1 staff monitoring. Education and Elopement Training was administered to staff. Confirmed placement and function of residents with wanderguards (Alarm bands placed on residents at risk for exiting the facility which alarms once the resident nears the exit doors) was completed on 7/27/19. The facility completed 100% of Elopement assessments on all residents on 7/27/19. Maintenance Director immediately reviewed all doors on 7/27/19. 2. Elopement drill was completed on 8/8/19. Elopement plans reviewed at an adhoc Quality Performance Improvement (QAPI) meeting on 8/20/19. 3. All residents facility wide had their assessments for elopement risk reviewed for accuracy. The surveyors verified the facility's corrective action plan as follows: 1. The surveyors interviewed staff to confirm the resident was brought back inside the facility to safety and placed on 1:1 monitoring. The surveyors verified a skin assessment was completed on Resident #68 with no skin issues identified. The surveyors reviewed the maintenance log for the functioning of the door alarm system on 7/27/19. The surveyors interviewed random staff concerning elopement in-services on 7/27/19 and what the procedures were for door alarms sounding and what they would do when an alarm sounds. The surveyors reviewed the facility's investigation dated 7/27/19. The surveyors checked the door alarms and the staff responded to the alarms immediately. 2. The surveyors Varified the facility elopement drill dated 8/8/19 and the adhoc Qapi meeting minutes. 3.The surveyors varified elopement risk assessments on all residents who resided in the facility on 7/27/19.

Based on facility policy review, observation and interview, the facility failed to ensure food was served under sanitary conditions when a male dietary employee with visible facial hair was observed working on the tray line without wearing a beard guard on 1 of 4 observations having plated the first 22 trays of the noon meal. The facility also failed to store foods in a safe and sanitary manner as evidenced by expired foods brought in by family in 2 of 2 nourishment rooms observed. The findings include: Facility policy review, Code of Dress and Personal Appearance, dated (YEAR), revealed .Hairnets, hair restraints, and beard guards shall be worn .Personal hygiene guidelines will be followed to ensure safe food production and service . Observation of the noon meal on [DATE] at 11:58 AM in the dietary department revealed 1 male dietary employee working on the resident's tray line with visible facial hair and not wearing a beard guard. Continued observation revealed 22 plated trays had already been served in the dining room. Interview with the Assistant Dietary Manager on [DATE] at 12:00 PM in the dietary department confirmed the male employee failed to wear a beard guard to cover visible facial hair while plating food on the tray line. Facility policy review, Use and Storage of Food Brought in by Family or Visitors, revised ,[DATE], revealed .All food items that are already prepared by the family or visitors brought in must be labeled with content and dated .the prepared food must be consumed by the resident within 3 days .if not consumed in 3 days, food will be thrown away by facility staff . Observation and interview with the Assistant Dietary Manager on [DATE] at 3:40 PM in the station 1 nourishment room confirmed pureed unsweetened orange juice (6) 5.5 fluid ounce cans expired (MONTH) 2019. Continued observation in the station 2 nourishment room confirmed cantaloupe, 16 ounce (OZ) container expired [DATE] and a large bag containing multiple plastic containers of food dated [DATE] were past the 3 day window for use. Interview with Licensed Practical Nurse #6 on [DATE] at 4:00 PM at the station 2 nursing station when asked who is responsible to check for expired foods in the nourishment room she confirmed the nurses and Certified Nursing Assistants check for expiration dates and monitor foods brought in from families. Foods from families are to be labeled and dated and thrown away after 3 days from the date brought in. Interview with the Director of Nursing (DON) on [DATE] at 4:25 PM in the hallway outside of the Bedford Corner conference room, confirmed, she would not expect to find expired foods in the nourishment rooms. The DON also confirmed she expected the nursing staff and the dietary staff to check the nourishment rooms daily for expired food.

Based on facility policy review, medical record review, observation and interview the facility failed to ensure dignity for 1 resident (#54) of 7 residents reviewed with urinary catheters. The findings include: Facility policy review Dignity, undated, revealed .Urinary drainage bags will be covered unless residents are in their rooms, at which time the bag will be placed so as not to be visible from the hall if at all possible . Medical record review revealed Resident #54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #54's Quarterly Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview of Mental Status score of 13 indicating the resident was cognitively intact. Continued review revealed the resident had an indwelling catheter. Medical record review of Resident #54's comprehensive care plan revealed the resident had a suprapubic catheter. Observation on 11/5/19 at 8:06 AM in Resident #54's room revealed the resident lying in bed with a catheter drainage bag not covered and visible from the doorway. Observation on 11/5/19 at 9:44 AM revealed the resident in bed with an uncovered catheter drainage bag on the right side of the bed facing the door. Observation and interview on 11/5/19 at 9:46 AM with Certified Nursing Assistant #1 in Resident #54's door way confirmed the resident's catheter drainage bag was visible from the hall and not covered with a dignity bag. Continued interview when asked the procedure for catheter drainage bag placement she stated, we turn and reposition residents every 2 hours and if they have a catheter then we place the catheter bag to whichever side the resident is turned to; I just turned her and placed her bag on her right side facing the door. Observation and interview on 11/5/19 at 9:50 AM with Registered Nurse #1 in Resident #54's room confirmed the resident's catheter drainage bag was facing the hallway and not covered with a dignity bag. Continued interview when asked what was the procedure for covering a resident's catheter bag she confirmed catheter bags are to be covered with a dignity bag at all times and I don't see one on hers. Observation and interview on 11/5/19 at 9:52 AM with the Director of Nursing in the hallway outside of Resident #54's room confirmed the resident's catheter drainage bag was not covered with a dignity bag. Continued interview she confirmed catheter bags were to be covered with dignity bags at all times; I can see hers through the crack from the door and it's not covered.

Based on facility policy review, medical record review and interview, the facility failed to meet professional standards of practice when the facility failed to obtain a lab that was ordered for 1 resident (#11) of 28 residents reviewed. The findings include: Facility policy review, Physcian Orders-(Following Physican Orders), undated, revealed .It is the policy of the facility to follow the orders of the physician .As assessments are completed, orders will be received from the physician to address significant findings of the assessments . Medical record review revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician order [REDACTED]. Medical record review of Resident #11's lab report revealed the last HbA1c was obtained on 6/4/19. Medical record review revealed Resident #11 did not have the HbA1c obtained for (MONTH) 2019 per the physicians order. Interview with the Director of Nursing on 11/5/19 at 4:15 PM in her office confirmed the HbA1c lab for Resident #11 was not obtained for (MONTH) 2019.

Based on medical record review, narcotic log review, and interview the facility failed to provide a system of medication records that enables periodic accurate reconciliation and accounting for controlled substances for 2 residents (#1 and #2) of 7 residents reviewed. The findings include: Medical record review revealed Resident #1 was admitted [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Medication Administration Record [REDACTED]. Review of the narcotic log sheets dated 2/2019 and 5/14/19 revealed [MEDICATION NAME] (an orally administered narcotic controlled substance for severe pain) was signed out 41 times. Continued review revealed 32 narcotic log sign-outs for [MEDICATION NAME] were not reflected on the MAR indicated [REDACTED] Medical record review revealed Resident #2 was admitted [DATE] and discharged [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Medication Administration Record [REDACTED]. Review of the narcotic log sheets dated 4/2019 and 5/15/19 revealed [MEDICATION NAME] was signed out 17 times. Continued review revealed 10 narcotic log sign-outs for [MEDICATION NAME] were not reflected on the MAR indicated [REDACTED] Telephone interview with the Pharmacist on 6/25/19 at 10:23 AM confirmed an audit done by the Pharmacist, the DON, and the ADON revealed some nurses were sporadic in making entries appropriately and timely to the MAR. Interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 6/26/19 at 2:30 PM in the chapel confirmed the narcotics logs and MARs dated 2/2019 to 5/15/19 for Resident #1 and Resident #2 had inconsistencies. Continued interview revealed the DON confirmed the MARs for Resident #1 and Resident #2 had omissions on the MARs dated 2/2019 to 5/15/19.

Based on medical record review, narcotic log review, and interview the facility failed to show nursing competency in medication administration documentation for 2 residents (#1 and #2) of 7 residents reviewed. The findings include: Medical record review revealed Resident #1 was admitted [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Medication Administration Record [REDACTED]. Review of the narcotic log sheets dated 2/2019 and 5/14/19 revealed [MEDICATION NAME] (an orally administered narcotic controlled substance for severe pain) was signed out 41 times. Continued review revealed 32 narcotic log sign-outs for [MEDICATION NAME] were not reflected on the MAR indicated [REDACTED] Medical record review revealed Resident #2 was admitted [DATE] and discharged [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Medication Administration Record [REDACTED]. Review of the narcotic log sheets dated 4/2019 and 5/15/19 revealed [MEDICATION NAME] was signed out 17 times. Continued review revealed 10 narcotic log sign-outs for [MEDICATION NAME] were not reflected on the MAR indicated [REDACTED] Interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 6/26/19 at 2:30 PM in the chapel confirmed the narcotics logs and MARs dated 2/2019 to 5/15/19 for Resident #1 and Resident #2 had inconsistencies. Continued interview revealed the DON confirmed the MARs for Resident #1 and Resident #2 had omissions on the MARs dated 2/2019 to 5/15/19.

Based on facility policy review, medical record review, observation and interview, the facility failed to administer the rate of a tube feeding as ordered and failed to administer the tube feeding as ordered for 1 Resident (#26) of 5 residents receiving tube feeding. The findings include: Review of an undated facility policy, Enteral Tube Medication Administration revealed, .Verify physician's orders [REDACTED]. Medical record review revealed Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].Enteral Feed every day and night shift [MEDICATION NAME] 2.0 (enteral formula) @ (at) 40 ml/hr (milliters per hour) x (times) 25 hours turn on at 0000 (12 AM) turn off at 2200 (10 PM) (May use [MEDICATION NAME] 1.5 (enteral formula) until [MEDICATION NAME] 2.0 available) H20 (water) auto flush via percutaneous endoscopic gastrostomy (peg tube) @ 30 ml/hr x 22 hours/day Turn on @ 0000 Turn off @ 2200, start 11/21/2018 22:00 . Observation on 12/3/18 at 9:37 AM, and 3:47 PM revealed Resident #26 was administered [MEDICATION NAME] 2.0 tube feeding at 50 ml/hr instead of 40 ml/hr as ordered. Observation on 12/3/18 at 12:08 PM, 3:24 PM and on 12/4/18 at 7:46 AM revealed Resident #26 was not receiving the tube feeding as ordered from 12 AM to 10 PM. Observation and interview with Licensed Practical Nurse (LPN) #4 on 12/4/18 at 4:53 PM on the station 1 hall revealed Resident #26 was receiving the tube feeding at 50 ml/hr. Further interview when asked if the enteral order was changed?, LPN #4 stated .if it had been changed they haven't changed it in the medical record . Further interview confirmed the enteral feeding order had been changed to 40 ml/hr on 11/21/18. Further interview confirmed .sometimes he's sitting out of his room and he would be off the tube feeding .

Based on medical record review and interview, the facility failed to provide monitoring related to performing Abnormal Involuntary Movement Scale (AIMS) assessments in a timely manner for 1 Resident (#4) of 27 residents receiving Anti-Psychotic medications. The findings include: Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].[MEDICATION NAME] 25 milligrams (mg) by mouth twice a day . Medical record review revealed the last AIMS performed for Resident #4 was completed on 10/24/17. Interview with the Director of Nursing on 12/5/18 at 3:48 PM in her office confirmed Resident #4 did not have an AIMS completed since (MONTH) (YEAR). She stated, I know they are to be done quarterly by the nurses, we have a breakdown.

Based on facility policy review, review of facility documents, medical record review and interview, the facility failed to revise care plans for 2 Residents (#26 and #44) of 31 residents reviewed. The findings include: Review of an undated facility policy, Care Plan Review, revealed .all residents receive a review of the Plan of Care by the Interdisciplinary Team at least quarterly . Review of the facility's undated Daily Clinical Control Quality Improvement Meeting form revealed .care plan updates as appropriate . Medical record review revealed Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].Enteral Feed every day and night shift [MEDICATION NAME] 2.0 (enteral formula) @ (at) 40 ml/hr (milliters per hour) x (times) 25 hours turn on at 0000 (12 AM) turn off at 2200 (10 PM) (May use [MEDICATION NAME] 1.5 (enteral formula) until [MEDICATION NAME] 2.0 available) H20 (water) auto flush via (by) percutaneous endoscopic gastrostomy peg tube ([DEVICE])@ 30 ml/hr x 22 hours/day. Turn on @ 0000 Turn off @ 2200, start [DATE] 22:00 . Medical record review of the Care Plan revealed .(resident) is NPO (nothing by mouth) and is receiving tube feedings x 20 hours with auto H2O flush per pump. He has a 16 french [DEVICE] with a 20 ml bulb. He is given [MEDICATION NAME] 2.0 @ 50 ml/hr (hour) x 22 hours turn on at 0000 turn off at 2200 (May use [MEDICATION NAME] 1.5 until [MEDICATION NAME] 2.0 available) H20 auto flush via peg tube ([DEVICE]) @ 30 ml/hr x 22 hours/day. Turn on @ 0000. Turn off @ 2200. He is monitored for residual and placement of [DEVICE] every shift and PRN (as needed) . Interview with Registered Nurse #1 on [DATE] at 5:52 PM at station 1 revealed the update of the resident Care Plans are part of the SWAT (Skin And Weight Assessment Team) team and the different departments are delegated to put in a note or change the order. Further interview confirmed the facility failed to update the Care Plan to reflect a change. Medical record review revealed the facility admitted Resident #44 on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #44's Tennessee Physician order [REDACTED].Do Not Attempt Resuscitation (DNR/no cardiopulmonary resuscitation (CPR)), limited additional interventions no artificial nutrition by tube, no intubation . Review of a physician's orders [REDACTED].DNR with limited interventions. Do not intubate. No mechanical life sustaining measures . Review of the comprehensive care plan dated [DATE] and revised on [DATE] revealed .Full Code/CPR, limited interventions, no artificial nutrition by tube, do not intubate . Interview with the Director of Nursing (DON) on [DATE] at 9:59 AM in her office revealed physician orders [REDACTED]. Further interview with the DON revealed the Minimum Data Set (MDS) Coordinator was responsible for updating the care plans. The DON reviewed the physician order [REDACTED].#44 and stated Yep it's not updated. Interview with the MDS Coordinator on [DATE] at 10:07 AM in her office confirmed physician orders [REDACTED]. Further interview with the MDS Coordinator confirmed Resident #44's care plan was not updated. She stated It should have been updated when the orders were received.

Based on facility policy review, medical record review, review of facility documentation and interview, the facility staff failed to report a suspicion/allegation of abuse to the administrator for 1 of 3 residents (Resident #1) reviewed for abuse. The findings include: Review of the facility policy, Abuse Prevention Program, updated 1/19/17, revealed .It is the policy of this facility to prevent abuse .The following Procedures shall be implemented when an employee or agent becomes aware of abuse .or of an allegation of suspected abuse .Procedure .Abuse Reporting .This facility will not tolerate abuse .by anyone, including staff members .All alleged violations involving .abuse .MUST be reported to the Administrator and Director of Nursing. The Administrator is the Abuse Coordinator .the person(s) observing the incident of resident abuse or suspected resident abuse must IMMEDIATELY report such incidents to the Charge Nurse, regardless of the time lapse since the incident occurred. The Charge Nurse will immediately report the incident to the Administrator .The Charge Nurse must complete an incident report and obtain written, signed and dated statement from the person reporting the incident. A completed copy of the incident report and written statements from witnesses, if any, will be provided to the Administrator .within twenty-four (24) hours of the occurrence of such incident .Identification .Employees are required to report any incident, allegation or suspicion of potential abuse .to the Administrator or an immediate supervisor who will immediately report the allegation to the Administrator .All residents, visitors, volunteers, family members or others are encouraged to report their concerns or suspected incidents of potential abuse .to the Administrator or an immediate supervisor who will immediately report the allegation to the Administrator .Supervisors will immediately inform the Administrator or in absence of the Administrator, the person in charge of the facility of all reports of incidents, allegations or suspicion of potential mistreatment. Upon learning of the report, the Administrator or .the person in charge of the facility shall initiate an incident investigation Investigation .For any incident involving suspicion of abuse .the Administrator or person appointed .will gather further facts prior to making a determination conduct an abuse investigation .Once the Administrator or designee determines there is a reasonable cause for suspected abuse, the Administrator or designee will investigate the allegation The final report shall include facts determined during the process of the investigation, review of the medical records, personnel files and interview of witnesses. The final investigation shall also include a conclusion of the investigation based on known facts . Medical record review revealed Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum (MDS) data set [DATE] revealed Resident #1 had minimal difficulty hearing, had clear speech, could make herself understood, could understand others; scored 9 out of 15 on the Brief Interview for Mental Status, indicating moderate cognitive impairment; exhibited no [MEDICAL CONDITIONS], or behaviors; exhibited feeling down/depressed 2-6 days of the review period; exhibited little interest/pleasure, sleep issue, and concentration issue for 7-11 days of the review period; exhibited change in energy for 12-14 days of the review period; required extensive 2+ person assistance for bed mobility, dressing, toileting; total dependence with 2+ person assistance for transfers, hygiene and bathing; was always incontinent bowel and bladder; and received antianxiety, antidepressant and diuretic medication for 7 days of the review period. Review of the staffing assignments for 9/15/18 for the 7:00 PM to 7:00 AM shift revealed Certified Nurse Aide (CNA) #1, #2, #3, #4, #6; Registered Nurse (RN) #2, and Licensed Practical Nurse (LPN) #1 were on duty. Review of the facility documentation revealed staff had written statements or responses to questionnaires regarding the 9/16/18 allegation of abuse. Review of the facility Abuse Questionnaire completed by Resident #1 dated 9/17/18 revealed .Has staff, a resident or anyone else here abused you, this includes verbal, physical, financial or sexual abuse? .Yes. If Yes, ask who the abuser was, what happened, when it occurred, where it happened, and how often .'I got hit several times. Big hands, big fists.' Further review revealed the person had 'Short hair (blonde) large in posture. Hit her in her head, hit face. Chest hit her with a big hand & fist hit her hand several times happened-several months ago. did not happen Sat. (Saturday) or Friday-happened 6 mo (months) ago happened at night.' When asked Did you tell staff? Yes. Who did you tell? Told friends-Told nurses. Also included in the Questionnaire was a diagram of a person with No new bruises anywhere else. Review of the facility documentation included the statement written by CNA #1 revealed .When I entered the room the tech (CNA #2) was turning patient (Resident #1) trying to clean her, the patient was yelling at tech to get away from her. The patient told me the tech was being rough with her and hurting her. The tech begin to argue with patient saying she didn't do anything to her. The patient became more agitated and told the tech if she hits her again she will get out of bed and whoop her . Review of the facility documentation included the statement written by RN #2 revealed .CNA (#2) came to desk to ask other CNA (#1) for assist (with) pt (patient/Resident #1) because she was agitated. After CNA's provided care this nurse went in to (check) on pt. Pt agitated .Asked pt what was wrong pt stated 'I don't want her in here ever again' (described CNA #2). Asked pt why she didn't want her in there. Pt stated ' .she (CNA #2) just starts bossing me around-saying do this, do that, roll over .and if she ever hits me I'm gong to knock her block-off .' Asked pt has she ever hurt her. Pt stated 'No, but she doesn't have to be so bossy, I'm not going to put up with that, I don't want her in here anymore, she is just rough and rude' . Review of the facility documentation included thestatement written by RN #1 dated 9/17/18 revealed .(Resident #1's) daughter approached me in the hallway with a concern. Her mother had told her Saturday night there was a tech (CNA) smacking on her. She said it was a fat tech and that she kept smacking her. I did report immediately to ADON (Assistant Director of Nursing) /Abuse Coordinator (Administrator) @ (at) which time immediate actions were taken . Telephone interview with CNA #1 on 9/24/18 at 11:47 AM revealed .I was charting at the nursing station when (CNA #2) came up to me and said (Resident #1) was agitated and she needed help .I walked down with her .and resident said 'You're rough with me, you hurt me' and (CNA #2) stepped back. Resident talk with me calm like and said (CNA #2) 'rough, hurt me' and 'I'll get out of bed if she hurts me again' and 'If you ever hit me again I'll whoop your ass.' (CNA #2) said 'I never hit you, just took care of you and cleaned you up.' They argued back and forth 'You hit me, no I didn't hit you' .I went to the nursing station and (CNA #2) there and said she already told the nurse what happened . Telephone interview with CNA #2 on 9/24/18 at 12:16 PM revealed .(Resident #1) was agitated .she was cursing, aggressive, combative, and not cooperative .so I went to the Charge Nurse (RN #2) and tell her what was going on and ask if another tech (CNA #1) to help me. The resident could be heard hollering .Both (CNA #1) and I went into the room .the resident turned over the bedside table onto herself in bed and all the stuff on it went everywhere, on her, on the floor, in the bed. It was a mess and resident agitated made it worse .She was hollering about being abused and I told her no one doing that or anything like that to her . Resident kept saying she was being abused .I went straight to nurse and told her resident said I was hitting her . Telephone interview with RN #2 on 9/24/18 at 4:38 PM and 5:28 PM revealed .around 2:00-3:00 AM, I think, (CNA #2) was doing rounds and came up to the desk and asked (CNA #1) to help her because (Resident #1) being agitated .After care (to Resident #1) both (CNAs) came out and told me about resident's statement .to (CNA #1) that (CNA #2) slapped her .I said I would go and talk with (Resident #1) myself. She was agitated. She never told me (CNA #2) hit her. I asked her if (CNA #2) had been hurt her and she 'no, just hateful, comes in here looking like a bulldog.' (Resident #1) said 'if she (CNA #2) does I'll knock her block off.' (Resident #1) did not tell me (CNA #2) hurt her in any way .(Resident #1) described (CNA #2) as 'blonde, bigger older lady.' She never said (CNA #2) hit her . Further interview revealed when asked why she did not report the allegation to the Administrator or the Director of Nursing the RN stated .She (Resident #1) never said (CNA #2) hit her to me. Said she was rough and rude and I took that to mean bossy. I personally felt no harm came out of it. I did full body check and no marks except her usual stuff, nothing new . Interview with the Administrator on 9/25/8 at 11:15 AM in the conference room when asked if (RN #2) was to report the allegation/suspicion of abuse alleged involving Resident #1 on 9/16/18 to the Administrator or designee, the Administrator stated .should have been reported to me the morning of 9/16/18 .

Based on facility policy review, medical record review, review of facility documentation and interview, the facility staff failed to thoroughly investigate a suspicion/allegation of abuse to the Administrator or designee for 1 of 3 residents (Resident #1) reviewed for abuse. The findings include: Review of the facility policy, Abuse Prevention Program, updated 1/19/17, revealed .It is the policy of this facility to prevent abuse .The following Procedures shall be implemented when an employee or agent becomes aware of abuse .or of an allegation of suspected abuse .Procedure .The Charge Nurse must complete an incident report and obtain written, signed and dated statement from the person reporting the incident. A completed copy of the incident report and written statements from witnesses, if any, will be provided to the Administrator .within twenty-four (24) hours of the occurrence of such incident .Upon learning of the report, the Administrator or .the person in charge of the facility shall initiate an incident investigation Investigation .For any incident involving suspicion of abuse .the Administrator or person appointed .will gather further facts prior to making a determination conduct an abuse investigation .Once the Administrator or designee determines there is a reasonable cause for suspected abuse, the Administrator or designee will investigate the allegation The final report shall include facts determined during the process of the investigation, review of the medical records, personnel files and interview of witnesses. The final investigation shall also include a conclusion of the investigation based on known facts . Medical record review revealed Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum (MDS) data set [DATE] revealed Resident #1 had minimal difficulty hearing, had clear speech, could make herself understood, could understand others; scored 9 out of 15 on the Brief Interview for Mental Status, indicating moderate cognitive impairment; exhibited no [MEDICAL CONDITIONS], or behaviors; exhibited feeling down/depressed 2-6 days of the review period; exhibited little interest/pleasure, sleep issue, and concentration issue for 7-11 days of the review period; exhibited change in energy for 12-14 days of the review period; required extensive 2+ person assistance for bed mobility, dressing, toileting; total dependence with 2+ person assistance for transfers, hygiene and bathing; was always incontinent bowel and bladder; and received antianxiety, antidepressant and diuretic medication for 7 days of the review period. Medical record review of the Physician Orders revealed the following: From 6/23/18 to the present [MEDICATION NAME] HCL ER ([MEDICATION NAME]-antidepressant) 150 milligrams by mouth 1 time a day for depression. On 8/13/18 [MEDICATION NAME] ([MEDICATION NAME]-antianxiety) 0.5 milligrams by mouth 3 times a day for anxiety. On 8/19/18 Discontinue [MEDICATION NAME] 0.5 milligrams by mouth 3 times a day for anxiety. On 8/19/18 Restore [MEDICATION NAME] back to 1 milligram by mouth three times daily, note in chart GDR (Gradual Dose Reduction) failure. On 8/20/18 [MEDICATION NAME] 1 milligram by mouth three times a day related to anxiety disorder. Medical record review of the (MONTH) and (MONTH) (YEAR) Medication Administration Records revealed the medications noted above were administered as ordered. Behavior monitoring for the antianxiety mediation was done every shift with no documentation of a behavior during (MONTH) and (MONTH) (YEAR). Medical record review of the physician orders dated 9/12/18 revealed .Check UA (urinalysis) . Medical record review of the Urinalysis, Culture and Sensitivity laboratory results dated [DATE] the UA revealed .SL (slightly) cloudy .Many Bacteria . indicating possible urinary tract infection. Further review revealed on 9/15/18 the Culture and Sensitively result .Escherichia Coli (EColi) and Extended Spectrum B-Lactamase (ESBL) . indication the resident had a urinary tract infection requiring contact isolation. Medical record review of the physician orders dated 9/13/18 revealed .Contact Isolation for ESBL until antibiotics complete . Further review of the physician orders dated 9/16/18 revealed [MEDICATION NAME] (antibiotic) 100 milligrams by mouth two times daily times 10 days for Urinary Tract Infection. Medical record review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The facility reported an allegation of abuse occurring on 9/15/18 at 1:00 AM involving Resident #1 and a staff member. Review of the staffing assignments for 9/15/18 for the 7:00 PM to 7:00 AM shift revealed Certified Nurse Aide (CNA) #1, #2, #3, #4, #6; Registered Nurse (RN) #2, and Licensed Practical Nurse (LPN) #1 were on duty. Review of the facility documentation revealed Resident #1 had responded to a questionnaire regarding the 9/16/18 allegation of abuse. Review of the facility Abuse Questionnaire completed by Resident #1 dated 9/17/18 revealed .Has staff, a resident or anyone else here abused you, this includes verbal, physical, financial or sexual abuse? .Yes. If Yes, ask who the abuser was, what happened, when it occurred, where it happened, and how often .'I got hit several times. Big hands, big fists.' Further review revealed the person had 'Short hair (blonde) large in posture. Hit her in her head, hit face. Chest hit her with a big hand & fist hit her hand several times happened-several months ago. did not happen Sat. (Saturday) or Friday-happened 6 mo (months) ago happened at night.' When asked Did you tell staff? Yes. Who did you tell? Told friends-Told nurses. Also included in the Questionnaire was a diagram of a person with No new bruises anywhere else. Review of facility documentation of the statement written by CNA #1 revealed .When I entered the room the tech (CNA #2) was turning patient (Resident #1) trying to clean her, the patient was yelling at tech to get away from her. The patient told me the tech was being rough with her and hurting her. The tech begin to argue with patient saying she didn't do anything to her. The patient became more agitated and told the tech if she hits her again she will get out of bed and whoop her . Review of the undated staff questionnaire completed by CNA #1 after the 9/16/18 event asking Do you know of any abuse? had NO. Review of facility documentation included the email dated 9/18/18 from CNA #2 to the facility revealed On Saturday the 15th of (MONTH) as I was giving care to (Resident #1) she was very agitated and aggressive, cursing and smaking (sic) at me refusing care and knocking her bedside table over all on table stuff was in floor (Resident #1) had been digging and playing in her bm (bowel movement) was trying to get out. Of bed I went immediately to the charge nurse (RN #2) and told her what was going on and ask the other tech (CNA #1) could she help me attend to (Resident #1) she agreed then the nurse asked us to switch patient and I did so. Further review revealed no interview with CNA #2. Review of facility documentation of the statement written by RN #2 revealed .CNA (#2) came to desk to ask other CNA (#1) for assist (with) pt (patient/Resident #1) because she was agitated. After CNA's provided care this nurse went in to (check) on pt. Pt agitated .Asked pt what was wrong pt stated 'I don't want her in here ever again' (described CNA #2). Asked pt why she didn't want her in there. Pt stated ' .she (CNA #2) just starts bossing me around-saying do this, do that, roll over .and if she ever hits me I'm gong to knock her block-off .' Asked pt has she ever hurt her. Pt stated 'No, but she doesn't have to be so bossy, I'm not going to put up with that, I don't want her in here anymore, she is just rough and rude' . Review of the staff questionnaire completed by RN #2 dated 9/18/18 asking Do you know of any abuse? had NO. Review of facility documentation of the statement written by RN #1 dated 9/17/18 revealed .(Resident #1's) daughter approached me in the hallway with a concern. Her mother had told her Saturday night there was a tech (CNA) smacking on her. She said it was a fat tech and that she kept smacking her. I did report immediately to ADON (Assistant Director of Nursing) /Abuse Coordinator (Administrator) @ (at) which time immediate actions were taken . Review of facility documentation of the undated staff questionnaire completed after the 9/16/18 event by CNA #3, #4, #6, and LPN #1 asking Do you know of any abuse? had NO. Telephone interview with CNA #1 on 9/24/18 at 11:47 AM revealed .I was charting at the nursing station when (CNA #2) came up to me and said (Resident #1) was agitated and she needed help .I walked down with her .and resident said 'You're rough with me, you hurt me' and (CNA #2) stepped back. Resident talk with me calm like and said (CNA #2) 'rough, hurt me' and 'I'll get out of bed if she hurts me again' and 'If you ever hit me again I'll whoop your ass.' (CNA #2) said 'I never hit you, just took care of you and cleaned you up.' They argued back and forth 'You hit me, no I didn't hit you' .I went to the nursing station and (CNA #2) there and said she already told the nurse what happened . Telephone interview with CNA #2 on 9/24/18 at 12:16 PM revealed .(Resident #1) was agitated .she was cursing, aggressive, combative, and not cooperative .so I went to the Charge Nurse (RN #2) and tell her what was going on and ask if another tech (CNA #1) to help me. The resident could be heard hollering .Both (CNA #1) and I went into the room .the resident turned over the bedside table onto herself in bed and all the stuff on it went everywhere, on her, on the floor, in the bed. It was a mess and resident agitated made it worse .She was hollering about being abused and I told her no one doing that or anything like that to her . Resident kept saying she was being abused .I went straight to nurse and told her resident said I was hitting her . Telephone interview with RN #2 on 9/24/18 at 4:38 PM and 5:28 PM revealed .around 2:00-3:00 AM, I think, (CNA #2) was doing rounds and came up to the desk and asked (CNA #1) to help her because (Resident #1) being agitated .After care (to Resident #1) both (CNAs) came out and told me about resident's statement .to (CNA #1) that (CNA #2) slapped her .I said I would go and talk with (Resident #1) myself. She was agitated. She never told me (CNA #2) hit her. I asked her if (CNA #2) had been hurt her and she 'no, just hateful, comes in here looking like a bulldog.' (Resident #1) said 'if she (CNA #2) does I'll knock her block off.' (Resident #1) did not tell me (CNA #2) hurt her in any way .(Resident #1) described (CNA #2) as 'blonde, bigger older lady.' She never said (CNA #2) hit her . Further interview revealed when asked why she did not report the allegation to the Administrator or the Director of Nursing the RN stated .She (Resident #1) never said (CNA #2) hit her to me. Said she was rough and rude and I took that to mean bossy. I personally felt no harm came out of it. I did full body check and no marks except her usual stuff, nothing new . Interview with Resident #1's daughter on 9/24/18 at 3:23 PM in the conference room revealed Resident #1 .complained of lady for past couple of weeks. Said 'she (Resident #1) didn't like her (CNA #2), (CNA #2) was rough with me, argues with me, I might have wanted something and press the call light and lady (CNA #2) comes in argues with me and turns call light off and leaves.' (Resident #1) said one night the CNA (#2) stuck her head in the door and said 'I heard you were talking about me, you need to stop talking about me.' I told Mom they don't need to be arguing with you and you not argue with them. She has dementia. This went on for a couple of weeks, then she calmed down for a week. Sunday I was here and she said '(CNA #2) slapped her and was rough with me last night . I told her 'Mom, tell me the truth, are you sure? Why would she slap you?' Mom said 'she was rough with me, I told her to stop and she slapped me. She's rough with me when she changes me and I don't like it.' I told her to tell me the truth and she said the same thing again. I told her it was Sunday and I can't do anything today. I checked her skin and there were no marks on her face. I checked her skin the next day but she bruises all the time anyway. I couldn't go by that .Mom told me was a heavy set red head .I ran into RN #1 up front .When I said a red head to RN #1 she didn't know that person name either. RN #1 said she would take care of it right now. RN #1 went to the Administrator and came back to me and the Administrator and ADON (Assistant Director of Nursing) .talked . Review of the facility documentation regarding the allegation of abuse on 9/16/18 revealed no evidence the UA was considered, the [MEDICAL CONDITION] medications adjusted in 8/2018 were considered, failed to have interview with staff on duty on 9/16/18 at 1:00 AM to 3:00 AM addressing the allegation, failed to have an interview with the alleged perpetrator and residents in the vicinity of the Resident #1, failed to have documentation of Resident #1's multiple interviews with different information, failed to have an interview with the family member reporting the allegation on 9/17/18 and clarifying the details, and failed to clarify why RN #2, CNA #1 and #2 answered No to the employee questionnaire asking Do you know of any abuse? Interview with the Administrator on 9/25/8 at 1:15 PM in the conference room when asked if the facility had the multiple interviews with the resident with different versions of the event, he stated No; if they had the staff interviews of all on duty and clarification of discrepancies, he stated No, but see where should have; if there was an interview with the reporting family member for clarification of information, he stated No; if there were interviews with residents in the vicinity of the event for information, he said No; for there was a medication review considering [MEDICAL CONDITION] medication had recently been changed, he said NO; and if the laboratory results of urinary tract infection was considered to contribute, he said NO.

Based on medical record review, review of the facility investigation, and interview the facility failed to intervene and protect from abuse 1 (#2) of 4 sampled residents. The findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 1/19/18 Quarterly Minimum Data Set (MDS) revealed Resident #1 was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 8 of 15. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #2 was cognitively intact with a BIMS score of 15 of 15. Review of the facility investigation revealed on 1/28/18 Resident #1 and Resident #2 were together outside of the Bedford Corner dining room. Continued review revealed staff heard Resident #2 state loudly Resident #1 was going to hit (Resident #2). Continued review revealed three staff, including Certified Nurse Assistant (CNA) #1 rushed to reach Resident #1 and Resident #2 to separate them. Further review revealed Resident #1 struck Resident #2 in the chest/upper arm area 3 times before the staff reached Resident #1 and #2. Continued review revealed Resident #1 and Resident #2 were examined for injury and Resident #2 was found to have a hand print mark on her right breast. Interview with CNA #1 on 2/27/18 at 5:05 PM at Nurse Station 1 revealed she had witnessed the altercation between Resident #1 and Resident #2 on 1/28/18. Continued interview revealed CNA #1, just prior to the altercation, had walked through the Bedford Corner dining room and observed and heard Resident #1 and Resident #2 bickering. Continued interview revealed CNA #1 had told Resident #1 and Resident #2 to stop bickering and to separate from one another. Continued interview revealed she left Resident #1 and Resident #2 before ensuring they had separated and she continued down the hallway. Continued interview revealed she heard Resident #2 state Resident #1 was trying to hit (Resident #2). Continued interview revealed she turned and saw Resident #1 strike Resident #2 three times before staff could separate the two residents. Interview with the Director of Nursing (DON) on 2/28/18 at 8:45 AM in the conference room revealed the staff was expected to immediately separate residents who were engaged in any type of altercation. Continued interview confirmed CNA #1 failed to separate Resident #1 and Resident #2 when she witnessed the two residents arguing. Continued interview revealed the facility's failure to separate Resident #1 and Resident #2 resulted in failure to protect Resident #2 from physical abuse from Resident #1.

Based on review of facility policy, medical record review, review of a facility investigation, observation, and interview, the facility failed to prevent an accident resulting in an arm fracture for 1 resident (#66), and failed to prevent elopement for 1 resident (#77) of 14 residents reviewed. The facility's failure resulted in HARM for Resident #66. The findings included: Review of facility policy, Accidents/Incidents, dated 1/1989 revealed, .any accidents/incidents involving Residents .are immediately reported to the charge nurse or immediate supervisor. All accidents/incidents involving Residents are evaluated by the charge nurse who, in consultation with the attending physician, determines the appropriate interventions . Review of facility policy, Gait Belt, dated 7/2007 revealed, .to prevent injury to the resident or staff while ambulating the resident and to provide an additional sense of security for the resident . Medical record review revealed Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #66 was cognitively impaired, rarely understood, required extensive assist of 2 people for transfers, and was mobile in a wheelchair per self. Continued review revealed [DIAGNOSES REDACTED]. Medical record review of Nurses Notes dated 10/27/17 at 8:30 PM revealed LPN #6 was called to the resident's room by the Certified Nurse Aide (CNA) #5 to look at a bruise and swelling of Resident #66's right arm and shoulder. Continued review revealed a Physician's Telephone Order was obtained by the Licensed Practical Nurse (LPN) #6 for an x-ray of the Resident's right arm and shoulder. LPN #6 applied ice to the area and notified Resident #66 responsible party. Medical record review of an x-ray report dated 10/28/17 at 3:40 PM revealed an acute [MEDICATION NAME] humeral metaphysis with slight medial displacement of the distal fracture fragment (fracture occurring at a ninety degree angle in relation to the long bone of the upper arm and near the shoulder joint). Continued review of the x-ray report dated 10/28/17 revealed the humerus and shoulder demonstrated generalized osteopenic (the bone density is more like a honeycomb than solid). Telephone interview with CNA #4 on 12/6/17 at 1:30 PM revealed, I found the bruise on his arm around 11:00 AM on 10/27/17 and told the nurse. Further interview revealed when asked how Resident #66 is transferred the CNA replied, now we use a lift but before we didn't. Further interview revealed when asked if the Nurse Aids used a gait belt to transfer Resident #66 before the injury she replied, No. We just supported his arms. Observation of Resident #66 on 12/4/17 at 1:30 PM in his room revealed the resident was wearing a right arm sling, lying in bed with yellow discoloration to visible aspect of right upper outer arm. Review of the facility Root Cause Analysis worksheet, dated 11/1/17, revealed the root cause of Resident #66's humerus fracture was due to .lack of education and training with system cause of the arm fracture listed as transferring . Interview with the Director of Nursing (DON) in the conference room on 12/6/17 at 4:38 PM revealed she stated, We do not have a transfer policy or written protocol, we just teach them how to use a gait belt and they come to us if they have any questions. Interview with the Assistant Director of Nursing (ADON) on 12/6/17 at 2:00 PM in the conference room, when asked if the fracture was avoidable she stated, Yes I feel the fracture could have been prevented if the staff had been better trained, for instance, if they had been using a gait belt instead of steadying the resident by his arms it could have taken some of the pressure off of his shoulder. Continued interview confirmed .the facility failed to provide adequate transfer training which resulted in the fracture for Resident #66 and actual Harm . Review of facility policy, Resident Elopement Policy, undated revealed .personnel who have residents under their care are responsible for knowing the location of those residents, and in the case of a missing resident ensuring appropriate action is taken. Medical record review revealed Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Admission MDS dated [DATE] revealed Resident #77 had a Brief Interview for Mental Status (BIMS) of 3 indicating severe cognitive impairment and required extensive assistance in transfers, eating, and hygiene and used a wheelchair for locomotion. Medical record review of an Elopement Risk Review dated 11/3/17 revealed the resident was not at risk for elopement. Medical record review of the Nurses Notes dated 11/7/17 at 11:19 PM revealed, .resident exited the garden room door and tipped his wheelchair off the sidewalk .noted by Dietary staff and LPN to be in the grass lying on his right side with the wheelchair tipped over in the grass as well. Small dime sized skin tear noted to back of left hand near his knuckles . Review of a facility investigation and witness statements revealed Resident #77 was last seen inside the facility on 11/7/17 at 6:50 PM after supper. Further review revealed, between 7:15 PM and 7:30 PM the LPN was unable to find the resident and began searching the resident rooms. At 7:45 PM staff began searching outside for the resident, and Resident #77 was found outside the facility lying on the ground at 8:15 PM, .with his wheelchair flipped over on its side . Further review of witness statements revealed, .We found him (Resident #66) outside, flipped over in his chair laying in the grass, wet, he was a little scraped up . Interview with the Maintenance Director on 12/4/17 at 3:45 PM in the garden room revealed, .I was called to the facility after hours and found the garden room exit door not to be functioning properly .I removed the electrical cover and noticed the wiring was corroded and there was moisture on the cover .I cleaned the corrosion and dried up the moisture .The area above the door was caulked and the door began to work properly .sign in sheets were made and the door was checked every fifteen minutes .then weekly .I ordered new mag locks and they were installed .'' Observation on 12/4/17 with the Maintanance Director present revealed all the exit doors functioned correctly. Further review revealed all wandergaurd alarms at exit doors functioned correctly. Interview with the Assistant Director of Nursing (ADON) on 12/6/17 at 2:15 PM in the conference room confirmed, that night the whole door malfunctioned.

Based on review of medication error reports, reference review of "Sorensen and Luckmann's Basic Nursing", medical record review, hospital medical record review, observation and interview, it was determined the facility's Quality Assessment (QA) and assurance committee failed to establish and implement a method of identifying concerns, identified and implement plans of actions to correct identified concerns of medication and transcription errors; ensure residents were not administered unnecessary medications; residents were free of significant medication errors; the physician was notified of critical laboratory results and change in resident conditions; physician orders [REDACTED].#4, 61, 62 and 135) sampled residents. The failure of the QA committee to identify and address the concerns identified resulted in immediate jeopardy, a situation in which the provider's noncompliance has caused, or is likely to cause serious injury, harm, impairment or death for Residents #62 and 135. A meeting was conducted in the conference room on 6/11/14 at 7:34 PM with the Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) when they were informed of the immediate jeopardy. The Immediate Jeopardy effective date is 6/11/14, and is ongoing. The facility provided an acceptable Allegation of Compliance on June 27, 2014, and a revisit on July 2, 2014 revealed the corrective actions implemented on June 27, 2014 removed the Immediate Jeopardy. Noncompliance for F520 continues at a "D" level citation. The facility is required to submit a Plan of Correction. The findings included: 1. The facility provided a total of six medication error reports since May 2013. Two of the 6 medication error reports were documented as transcription errors as follows: a. Resident #4 - 12/19/13 - "...Medication ([MEDICATION NAME] (antibiotic used to treat urinary tract infections) 100 milligrams (mg)) ordered for 21 doses transcribed for 21 days... received 38 doses..." b. Resident #62 - 4/25/14 - "...during med (medication) pass noted cassette for Zaroxlyn (diuretic/water pill) in med cart but not on MAR. looked in resident chart noted ordered received on 4 (3/24/14) to (symbol for increase) Zaroxlyn to 5mg. order was not transcribed to new MAR for month of April (2014)..." 2. During an interview in the conference room on 6/14/14 beginning at 11:15 AM, the Administrator was asked if QA committee had discussed the following quality issues: a. Medication Errors / Transcription Errors: The Administrator stated, "We pulled the ones since May of last year (2013)... they were all different..." The failure of the facility to recognize a trend in medication transcription errors resulted in significant medication errors for resident #62 and medications administered for a excessive duration resulting in actual harm for Resident #4. b. Notification of the physician related to abnormal or critical high test results / change of resident status: The Administrator stated, "I would have to look back we report on lots of things..." c. Signing of physician orders [REDACTED]. The Administrator stated, "Not that I'm aware of." d. Physician visits and signing of physician orders: The Administrator stated, "Don't recall any issues..." e. Maintaining accurate medical records: The Administrator stated, "Not since I've been here." f. Kitchen Sanitation: The Administrator stated, "The Dietary Manager attends. Not since I've been here (October 2013)." g. Running out of food: The Administrator stated, "Nothing identified." h. Emergency Food Supply: The Administrator stated, "Nothing identified." The facility did not have a system where information from the audit process was brought to the attention of the full QA committee to address identified issues. 3. The facility's QA committee failed to address identified issues such as medication/transcription errors, timely notification of the physician of critical laboratory results and change in the residents status, signing and dating physician orders, and maintaining complete and accurate medical records. Refer to F157, F281, F329, F333, F386, F501, F505, F507, and F514. Validation of the Credible Allegation of Compliance was accomplished on-site July 2, 2014 through review of facility documents and interviews with the administrator and medical director. The facility provided evidence with sign-in sheets for Performance Improvement (PI) meetings on 6/16/14, 6/23/14 and 6/27/14. The minutes documented identification of problems and actions taken related to the IJ deficiencies. All department heads and attending physicians were in attendance, along with the Medical Director in 2 of the 3 meetings (He was out of the country for the meeting on 6/16/14). The immediate issues identified medication transcription errors, unnecessary medications, medication errors, notification of abnormal/critical lab results, changes in resident conditions to the physicians, signing and dating physician orders, and assurance that all medical records were complete and accurate. New policies and procedures were discussed, written and implemented to ensure accuracy for the above issues. Audits were done, and results were discussed in the PI meetings to ensure compliance with new policies and procedures. In-services were completed and are ongoing for new hires regarding new policies and procedures. The facility provided evidence with new policy and procedures for Charting and Documentation - Telephone/Verbal order transcription, MD signing and dating orders, Shift-to-Shift MSAR/TAR Audit, Admission/Readmission orders [REDACTED]. An interview with the Administrator was conducted on 7/2/14. The Administrator verified the PI meetings are being held weekly at this time. The Administrator verified that there has been significant improvement in how the team interacts and brainstorms to come up with process improvement initiatives that impact overall resident care and safety. An interview with the Medical Director was conducted on 7/2/14. The Medical Director verbalized that he attends 100% of the PI meetings. He verbalized the understanding of the facility policy regarding the 10 time frame for physician signatures. He verbalized he is engaged and involved with all aspects of care delivery for the residents. He verbalized he feels there has been a solid improvement since the changes have been implemented. The facility will remain out of compliance at a Scope and Severity level "D" an isolated deficient practice that constitutes no actual harm with potential for more than minimal harm, that is not Immediate Jeopardy, until it provides an acceptable plan of correction.

Based on review of medication error reports, reference review of "Sorensen and Luckmann's Basic Nursing", medical record review, hospital medical record review, observation and interview, it was determined the facility's Quality Assessment (QA) and assurance committee failed to establish and implement a method of identifying concerns, identified and implement plans of actions to correct identified concerns of medication and transcription errors; ensure residents were not administered unnecessary medications; residents were free of significant medication errors; the physician was notified of critical laboratory results and change in resident conditions; physician orders [REDACTED].#4, 61, 62 and 135) sampled residents. The failure of the QA committee to identify and address the concerns identified resulted in immediate jeopardy, a situation in which the provider's noncompliance has caused, or is likely to cause serious injury, harm, impairment or death for Residents #62 and 135. A meeting was conducted in the conference room on 6/11/14 at 7:34 PM with the Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) when they were informed of the immediate jeopardy. The Immediate Jeopardy effective date is 6/11/14, and is ongoing. The findings included: 1. The facility provided a total of six medication error reports since May 2013. Two of the 6 medication error reports were documented as transcription errors as follows: a. Resident #4 - 12/19/13 - "...Medication ([MEDICATION NAME] (antibiotic used to treat urinary tract infections) 100 milligrams (mg)) ordered for 21 doses transcribed for 21 days... received 38 doses..." b. Resident #62 - 4/25/14 - "...during med (medication) pass noted cassette for Zaroxlyn (diuretic/water pill) in med cart but not on MAR. looked in resident chart noted ordered received on 4 (3/24/14) to (symbol for increase) Zaroxlyn to 5mg. order was not transcribed to new MAR for month of April (2014)..." 2. During an interview in the conference room on 6/14/14 beginning at 11:15 AM, the Administrator was asked if QA committee had discussed the following quality issues: a. Medication Errors / Transcription Errors: The Administrator stated, "We pulled the ones since May of last year (2013)... they were all different..." The failure of the facility to recognize a trend in medication transcription errors resulted in significant medication errors for resident #62 and medications administered for a excessive duration resulting in actual harm for Resident #4. b. Notification of the physician related to abnormal or critical high test results / change of resident status: The Administrator stated, "I would have to look back we report on lots of things..." c. Signing of physician orders [REDACTED]. The Administrator stated, "Not that I'm aware of." d. Physician visits and signing of physician orders: The Administrator stated, "Don't recall any issues..." e. Maintaining accurate medical records: The Administrator stated, "Not since I've been here." f. Kitchen Sanitation: The Administrator stated, "The Dietary Manager attends. Not since I've been here (October 2013)." g. Running out of food: The Administrator stated, "Nothing identified." h. Emergency Food Supply: The Administrator stated, "Nothing identified." The facility did not have a system where information from the audit process was brought to the attention of the full QA committee to address identified issues. 3. The facility's QA committee failed to address identified issues such as medication/transcription errors, timely notification of the physician of critical laboratory results and change in the residents status, signing and dating physician orders, and maintaining complete and accurate medical records. Refer to F157, F281, F329, F333, F386, F501, F505, F507, and F514.

Based on policy review, review of medication error reports, medical record review, and interview, it was determined the facility failed to maintain clinical records on each resident in accordance with accepted professional standards and practices to ensure the record was complete and accurate for 3 of 35 (Residents #135, 4 and 61) sampled residents. The facility failed to ensure the medication regimen was transcribed accurately, failed to ensure medications administered were documented on the medication administration record (MAR) and the facility failed to ensure the physician signed orders timely and dated the signature. The inaccuracy of the medication transcriptions resulted in Resident #135 receiving the wrong medications and not receiving all of his prescribed medications for three days which resulted in the resident having a hospitalization due to adverse consequences of medications as evidenced by [MEDICAL CONDITION] activity, severely low blood sugars, elevated potassium, creatinine and blood urea nitrogen levels which indicated Dehydration and Acute [MEDICAL CONDITION]. This resulted in immediate jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). A meeting was conducted in the conference room on 6/11/14 at 7:34 PM, with the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) at which time they were informed of the immediate jeopardy (IJ). The Immediate Jeopardy effective date is 6/11/14, and is ongoing. The findings included: 1. Review of the facility's general policies documented, "...PHYSICIAN'S ORDERS... All medications and treatments administered to the Resident must be ordered by the attending physician. Such orders must be in writing and signed and dated by the prescribing physician. All orders must be recorded on the Resident's Physician Order Sheet located in the Resident's clinical record... Medications... or any treatment cannot be administered to the Resident without written approval from the attending physician..." Review of the facility's charting and documentation policy documented, "...Medication Administration... Documentation pertaining to medication administration includes... Date and time medication administered... Document on the Medication Administration Record (MAR) as the medications are administered... Signature and title of person recording the data..." Review of the facility's medication administration record: transcription of Doctor's orders and documentation policy documented, "...TRANSCRIPTION PROCEDURE... Transcribe Physician's written orders to MAR exactly as written... When transcribing a "discontinue" order, write in "last dose 9 PM" (or other appropriate time), "X" out remaining spaces, and hi-light with yellow marker... DOCUMENTATION PROCEDURE... Document each dose of medication at the time of administration by placing your initials in the block corresponding to the correct drug, date, and time..." 2. Medical record review for Resident #135 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the hospital Physician Discharge Med (medication) Reconciliation signed by the physician on 5/17/13 and faxed to facility on "5/17/13 at 08:26AM" documented the following medications be continued at the facility for Resident #135: "[MEDICATION NAME] HCL ([MEDICATION NAME]) 100 mg (milligrams) po (by mouth) daily, [MEDICATION NAME] 10 mg rectal daily prn, Polyethylene [MEDICATION NAME] 17 GM (grams) po daily, Dissolve in 8 OZ (ounces) H2O (water) or juice before Giving, Zinc Oxide 12% (percent) & (and) Dimethicone 1% 1 application topical twice a day, Zinc Oxide 12 % & Demethicone 1% 1 application topical as needed PRN, Groin Excoriation, [MEDICATION NAME] 2.5 mg. po daily, Tamsulosin HCL 0.4 mg po daily Take 30 minutes after the same meal each day, and [MEDICATION NAME] 20 mg po Each Night at Bedtime." These medications treated heart rate, constipation, bowel regularity, skin irritation, hypertension, prostate enlargement, and cholesterol. Further review of Resident #135's medical record revealed additional hospital Discharge Medication Reconciliation forms signed by a different physician and fax dated to the facility on "May.8.2013 10:49AM" contained the name of Referral Resident #1 and documented the following medications: [REDACTED]." These medications treated gout, [MEDICAL CONDITION], stool softener, iron supplement, diuretic, diabetes treatment, [MEDICAL CONDITIONS] disorder, hypertension, multivitamin supplement, vitamin D deficiency, reflux, [MEDICAL CONDITION] hormone levels, potassium supplement, chest pain, constipation and high blood phosphorus levels for patients on [MEDICAL TREATMENT]. Review of the handwritten transcribed admission orders [REDACTED]. These orders were signed "Transcribed by (Nurse #1)." These orders had not been signed by the physician. These medications treated cholesterol, bowel regularity, gout, [MEDICAL CONDITION], stool softener, iron supplement, diuretic, diabetes treatment, [MEDICAL CONDITIONS] disorder, hypertension, multivitamin supplement, vitamin D deficiency, reflux, [MEDICAL CONDITION] hormone levels, potassium supplement, chest pain, constipation and high blood phosphorus levels for patients on [MEDICAL TREATMENT]. Review of Resident #135's May 2013 MAR revealed Resident #135 received the following medications by error from 5/17/13 through 5/20/13: [MEDICATION NAME], Polyethylene [MEDICATION NAME], ASA, [MEDICATION NAME], [MEDICATION NAME], Imdur, [MEDICATION NAME], MVI, Vitamin D, [MEDICATION NAME], Potassium Chloride, [MEDICATION NAME], Senna, [MEDICATION NAME] and [MEDICATION NAME]. The inaccurate transcriptions of orders resulted in the resident receiving medications that were not ordered for him. Nurses note for resident #135 documented the following: a. 5/20/13 at 1:15 PM - "Notified by P.T. (Physical Therapist) that resident was saying "I'm going to die", observed resident up in w/c (wheelchair) in PT room holding lower abd (abdomen)..." 5/20/13 at 1:20 PM - "called to resident room per PT stating resident was jerking, uncontrolled movements... observed resident ^ (up) in w/c with jerking movements and tremors to arms..." 5/20/13 at 1:30 PM - "...accucheck (test for blood sugar (BS)) registered 38 (normal reference range 70 to 110 milligrams per deciliter (mg/dl)) glucagan ([MEDICATION NAME] medication for blood sugar) 1 mg (milligram) administered to R (right) thigh... responding to name but unable to follow commands BS rechecked @ (at) 140 (PM) FS (fingerstick test for blood sugar) 29... instructed tx (treatment) nurse to get 2nd [MEDICATION NAME]." 5/20/13 at 2:00 PM - "Glucogon ([MEDICATION NAME]) 1 mg administered..." During an interview in the conference room on 6/10/14 at 1:40 PM, the DON was asked about the medication errors and stated, "...It was a medication error, the wrong residents medications were transcribed on his (Resident #135's) MARs..." During an interview in the conference room on 6/11/14 at 12:15 PM, Nurse #1 was asked about the transcription errors and stated, "...I didn't look at the names... way past an error for me... When (named DON) called me into the office she asked me to sign the orders. I signed them as transcribed by me." During a telephone interview on 6/13/14 at 8:10 AM, Nurse #7 was asked about the order transcription errors for Resident #135. Nurse #7 stated, "I worked nights, back then, we took the hospital discharge orders and rewrote the medications and orders on the facility order sheet for admissions. We hand wrote the medications, those orders had been written by another nurse. I added the lift code and bathing method to those admission orders [REDACTED]. The sheets were crazy. I was taught if I wrote an order to sign it, so I signed the orders (named physician / Nurse #7) that is what we did back then. The RBVO is "read back verbal order." No, I did not contact (named physician) about the bathing and lift code we actually had standing orders we used for those. No, I did not read back those admission orders [REDACTED] The facility failed to transcribe medication orders accurately and correctly for Resident #135. During a telephone interview in the conference room on 6/12/14 at 4:00 PM, Pharmacist #1 was asked to describe his involvement in the medication errors for Resident #135. Pharmacist #1 stated, "I was in the building that day (when Resident #135 was in crisis) doing pharmacy reviews. The DON came to me that afternoon, I would say around 3:00 PM and ask me to check (named Resident #135) medications to see what could be causing his low blood sugars. I reviewed the meds and determined the [MEDICATION NAME] could be causing it, she took the chart and was reviewing it in the room behind the desk and that is when she discovered the medication errors. Another resident's medications had been transcribed as (named Resident #135"s). She (the DON) also found further in the chart (named Resident #135's) correct medications ordered. She came to me and asked me to review med errors for possible adverse effects. I did a review and made recommendations. The DON shared these with the PA (Physician Assistant) via telephone conference." Pharmacist #1 was asked if he had recommended the [MEDICATION NAME] injections for the low blood sugars on 5/20/13. Pharmacist #1 stated, "No, they (nurses) had already addressed the low blood sugar issue, that had already been done." Review of Resident #135's admission physician orders revealed the hand transcribed admission orders [REDACTED]. There was a RBTO dated 5/18/13 for Physical Therapy services clarification had not been signed by the physician. In addition there was a RBTO dated 5/20/13 at 3:00 PM that documented accucheck orders, [MEDICATION NAME] orders, laboratory tests, electrocardiogram, push fluids and to reconcile medication profile that had not been signed by a physician. There was a RBTO dated 5/20/13 at 3:00 PM that documented to discontinue all previous medications and to start medication [MEDICATION NAME] HCL, [MEDICATION NAME], Tamsulosin HCL Zinc Oxide topical and see new admission orders [REDACTED] During an interview in the conference room on 6/11/14 at 6:15 PM, the DON was asked about Resident #135's orders not being signed. The DON verified the orders were not signed and stated, "Orders are suppose to be signed every 30 days for POS (physician order sheets), physician is to sign telephone orders the next time they are in the building. Can have up to 30 days for RBTO orders." The DON was asked about the documentation of glucagan being administered and not being on Resident #135's MAR. The DON stated, "It ([MEDICATION NAME]) was given a total of 3 times but can't find it on the MARs. Nurses are suppose to sign and initial MARS. I would expect nurse to document that it was given." During an interview in the conference room on 6/12/14 at 8:50 AM, the PA was asked about signing orders. The PA stated, "I try to sign orders the next day. I am here Monday through Friday." The PA was shown the orders and asked if he remembered the orders dated 5/17/13 at 3:00 PM that documented RBTO to him. The PA stated, "Don't know specifically. No, they (nurses) would have notified us... I do not know why these orders are not signed... I really can't say I remember giving those orders..." During an interview in the conference room on 6/13/14 at 7:45 AM, the DON was shown the unsigned orders that were dated 5/17/13, 5/18/13, and 5/20/13. The DON stated, " Yes, (nodding affirmative) they are not signed. Only thing I can say is right after that happened we had the chart auditing it and trying to determine what happened. We have no problems with PA signing orders timely, (Named attending physician and medical director) is in other facilities and we have problems at times with him signing timely. I expect recertifications to be signed within 30 days and telephone orders to be signed within 5 days or on the next visit. We do have a medical records person." During an interview in the conference room on 6/13/14 at 7:55 AM, the Medical Records Clerk Nurse #8 was asked about the process for getting orders signed. The Medical Records Clerk Nurse #8 stated, "I take the charts out and bind them up and hold them until the doctors signs and I put them in the record." The Medical Records Clerk Nurse #8 was asked if she reviews the closed charts for unsigned orders. The Medical Records Clerk Nurse #8 stated, "No, not usually." On 6/13/14 at 7:56 AM, the DON came into the conference room and requested Resident #135's chart. The DON stated, "The PA is here and I need to get him to sign all those orders." Medical Records Clerk Nurse #8 took Resident #135's chart with her and stated "I will bring it right back." On 6/13/14 at 8:35 AM, Medical Records Clerk (Nurse #8) returned Resident #135's chart. Review of the orders dated 5/17/13, 5/18/13, and 5/20/13 were observed to now be signed by the PA but the signature had not been dated. During an interview in the conference room on 6/13/14 at 9:01 AM, the DON was shown the telephone/verbal orders dated 5/17/13, 5/18/13, and 5/20/13 that had now been signed by the PA. The DON was asked if the PA had signed the orders today. The DON stated, "Yes, he signed those orders today, that is his signature." The DON was asked if his signature was dated. The DON stated, "No, he did not date them." During a telephone interview in the conference room on 6/13/14 at 9:55 AM, the PA was asked if he had signed orders on Resident #135 today. The PA stated, "Yes, I signed those orders this morning. There was 4 or 5 of them. I signed orders for therapies, [MEDICATION NAME]" The PA was asked why he did not date his signature. the PA stated, "I just forgot to date the orders, but yes I did sign them this morning." The facility failed to ensure that physician orders were signed by the physician or physician assistant timely and dated when signed for Resident #135. The facility's failure to ensure the medication regimen was transcribed accurately, ensure the physician signed orders timely and signatures were dated and ensure nurses document medications given on the MAR resulted in IJ for Resident #135 who received the wrong medications and did not receive all of his prescribed medications for three days which resulted in the resident being hospitalized due to adverse consequences of medications as evidenced by [MEDICAL CONDITION] activity, severely low blood sugars, elevated potassium, elevated creatinine and blood urea nitrogen levels which indicated Dehydration and Acute [MEDICAL CONDITION]. 4. Medical record review for Resident #4 documented an admission date of [DATE] and [DIAGNOSES REDACTED]. a. Review of a physician's order dated 11/30/13, documented, "...Start [MEDICATION NAME] 100 mg (milligrams) po (by mouth) bid (twice daily) x (times) 21 doses..." Review of Resident #4's December 2013 MAR documented Resident #4 received a total of 37 doses of [MEDICATION NAME] 100 mg from 12/1/13 through 12/19/13. Review of a medication error report for Resident #4 dated 12/19/13 documented, "...Explanation... medication error was made: Medication ordered for 21 doses transcribed for 21 days... What has the actual effect of the error, if any, made on the resident... skin redness/irritation... [MEDICATION NAME] cream ordered..." Review of a physician telephone order dated 12/21/13 Resident #4 documented, "[MEDICATION NAME] cream to (right) side of neck/cheek BID (twice daily) X (times) 10 days... INDICATION... Red/heat Irritation..." During an interview in the conference room on 6/14/14 at 9:50 AM, the DON was asked about the discrepancy between the MAR and the physician's order for the [MEDICATION NAME] for Resident #4. The DON stated, "That was a med (medication) error. It should have been 21 doses..." The DON was asked to clarify the [MEDICATION NAME] for Resident #4 should have been 21 doses instead given for 21 days. The DON nodded her head in agreement and stated "Mmm Hmmm." b. Review of Resident #4's physician's orders dated 2/22/14 documented, "[MEDICATION NAME] 5MG... TAKE 1 TABLET BY MOUTH TWICE DAILY. (OAB (Overactive Bladder))... [MEDICATION NAME] 24mcg (micrograms)... TAKE 1 CAPSULE BY MOUTH TWICE DAILY... (CONSTIPATION)... ZAFIRLUKAST 20MG... TAKE 1 TABLET BY MOUTH TWICE DAILY (ASTHMA)... [MEDICATION NAME] 10MG... TAKE 1 TABLET BY MOUTH THREE TIMES DAILY (GERD (Gastro [MEDICAL CONDITION] Reflux Disease))... [MEDICATION NAME] TABLET... TAKE 1 TABLET BY MOUTH THREE TIMES DAILY... (FLATULENCE)... [MEDICATION NAME] HCL ([MEDICATION NAME]) 4 MG... TAKE 1 TABLET (s) BY MOUTH 5 TIMES A DAY (MUSCLE SPASMS)..." Review of Resident #4's March 2014 MAR dated 3/1/14 through 3/31/14 revealed the nurse failed to document the 5PM doses of [MEDICATION NAME], Zafirlukast, or [MEDICATION NAME] on 3/21/14. The nurse failed to initial the MAR for that time. Additionally, there was no initials on the MAR that the 4PM doses of [MEDICATION NAME] or [MEDICATION NAME] had been administered on 3/21/14. There were no nurse initials on the MAR that the 4 PM doses of [MEDICATION NAME] had been administered on 3/24/14, 3/25/14, or 3/28/14. During an interview in the conference room on 6/14/14 at 8:45 AM, the DON stated, "The nurse didn't initial... it (the nurse's initials) would be circled if it was not given..." The DON confirmed the nurses failed to initial the MAR when giving the medications. c. Review of Resident #4's physician's orders dated 4/1/14 documented, "...POLYETHYLENE [MEDICATION NAME] POWDER... MIX 17GM (grams)... IN 8OZ (ounces) OF LIQUID AND TAKE BY MOUTH DAILY... (CONSTIPATION)..." Review of a telephone physician's order dated 4/8/14 documented, "..D/C (discontinue) [MEDICATION NAME]" Review of Resident #4's April 2014 MAR dated 4/1/14 through 4/30/14 revealed the nurses failed to initial that [MEDICATION NAME] was given from 4/1/14 through 4/7/14. During an interview in the conference room on 6/14/14 at 8:55 AM, the DON was asked about the nurses not initialing the [MEDICATION NAME] on 4/1/14 through 4/7/14. The DON stated, The nurses failed to initial that is was given. d. Review of Resident #4's physician's orders dated 4/1/14 documented, "[MEDICATION NAME] HCl ([MEDICATION NAME]) 4 MG... TAKE 1 TABLET (s) BY MOUTH 5 TIMES A DAY (MUSCLE SPASMS)..." Review of Resident #4's April 2014 MAR dated 4/1/14 through 4/30/14 revealed the nurse failed to initial the 4 PM dose of [MEDICATION NAME] on 4/5/14 and 4/6/14. During an interview in the conference room on 6/14/14 at 8:55 AM, the DON was asked about the nurse not initialing the [MEDICATION NAME] on 4/5/14 and 4/6/14 at 4 PM. The DON stated, The failed to initial it. e. Review of Resident #4's physician's orders dated 4/1/14 documented, "[MEDICATION NAME] 0.5 MG... TAKE ? TABLET BY MOUTH ONCE DAILY. FOR [MEDICAL CONDITION]" Review of Resident #4's April 2014 MAR for 4/1/14 through 4/30/14 revealed [MEDICATION NAME] was not initialed as given on 4/2/14. Review of a "CONTROLLED SUBSTANCES" document for Resident #4 documented that [MEDICATION NAME] 0.5mg 1/2 tablet was administered to Resident #4 on 4/2/14. During an interview in the conference room on 6/14/14 at 8:55 AM, the DON confirmed the absence of nurse initials on the MAR that [MEDICATION NAME] had been administered as scheduled on 4/2/14 it was just not initialed on the MAR. f. Review of a physician's telephone order dated 4/29/14 for Resident #4 documented, "...D/C (discontinued) [MEDICATION NAME]" Review of Resident #4's MAR for 5/1/14 through 5/31/14 documented that [MEDICATION NAME] was administered to Resident #4 on 5/1/14 at 8 AM. During an interview in the conference room on 6/14/14 at 8:55 AM, the DON was asked why the nurse initialed the [MEDICATION NAME] as having been given on 5/1/14 after it was discontinued on 4/29/14. The DON stated, "I'm thinking the drug was DC'd, and the nurse initialed it and yellowed it out to show that it was DC'd..." 5. Review of facility's blood glucose monitoring policy documented, "...Procedure: 1. Obtain and verify physician order... 19. Document on Medication Administration Record (MAR)... with results..." Medical record review for Resident #61 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #61's physician's orders dated 5/23/14 documented, "...SSI (sliding scale insulin)... AC (before meals) and HS (hour of sleep)..." There were no physician orders in the medical record for the SSI. The DON provided a copy of the facility's protocol for sliding scale insulin. The form was signed by the named physician but did not include the name of the resident or the date. During an interview in the conference room on 6/11/14 at 3:30 PM, the DON was asked about the sliding scale insulin orders for Resident #61. The DON stated, "They (the orders) are kept in the accucheck book. When a resident is admitted , the nurses get this form from the communication book to write the orders." The DON was asked why the orders for the SSI were not filed in the medical record. The DON stated, "That's the way it was when I came here." The facility failed to ensure Resident #61's medical record was complete and accurately documented.

Based on medical record review and interview, it was determined the facility failed to ensure laboratory test results of a basic metabolic panel (BMP) was available for clinical management for 1 of 35 (Resident #62) sampled residents. The failure of the facility to ensure abnormal and critical laboratory test results were available and in the medical record resulted in immediate jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident), A meeting was conducted in the conference room on 6/11/14 at 7:34 PM, with the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) at which time they were informed of the immediate jeopardy (IJ). The IJ is ongoing. The findings included: Medical record review for Resident #62 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician order [REDACTED]. There was no evidence in the medical record the BMP ordered to be repeated in 1 week was drawn as ordered. The ADON called the laboratory and the results of the BMP drawn on 6/4/14 was faxed to the facility. Review of the BMP, provided by the ADON, dated 6/4/14 documented, "...CREATININE, SERUM... 2.3... H (high)... (normal) Reference Range... 0.7-1.2... BUN...71... CH (critically high)... (normal reference range 7-22 milligrams per deciliter)." During an interview in the conference room on 6/14/14 at 9:25 AM, the ADON brought in the BMP for Resident #62 and stated, "Had to have it faxed over, wasn't in the chart or the book (laboratory book)..." The ADON was asked how the physician is notified of abnormal and critical high laboratory results. The ADON stated "...it depends... labs (laboratory) goes in the lab book and chart... usually... the doctor signs it and puts the lab in the chart..." The ADON was asked how do you know the physician was notified of the abnormal or critical high laboratory results. The ADON stated, "(Physician) signs the lab." The ADON was asked if the BMP that was done 6/4/14 was signed by the physician. The ADON stated, "No." The facility failed to ensure laboratory test results were available in the medical record. Resident #62 has a [DIAGNOSES REDACTED]. The failure of the facility ensure the physician was aware of the abnormal serum creatinine level, which if elevated signifies impaired kidney function and a critical high BUN level of 71, which if more than 20 may indicate that the kidneys are not working at full strength placed Resident #62 in IJ.

Based on policy review, hospital record review, medical record review, and interview, it was determined the facility failed to promptly notify the physician of abnormal, critical low, and critical high laboratory results for 2 of 35 (Residents #135 and 62) sampled residents. The facility failed to promptly notify the physician of critical low blood sugar results for Resident #135 which resulted in a hospitalization due to adverse consequences from medications and failed to promptly notify the physician of an abnormal and critical high laboratory test result related to kidney function for Resident #62, which resulted in immediate jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). A meeting was conducted in the conference room on 6/11/14 at 7:34 PM, with the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) at which time they were informed of the immediate jeopardy (IJ). The IJ is ongoing. The findings included: 1. Review of facility's notification to the Physician policy documented, "Policy: It is the policy of this facility to promptly notify the Resident's physician of changes in the Resident's condition and/or status. Procedure: The nurse will notify the Resident's attending physician when... 5. Any condition, lab report... 7. critical information will be called to the Resident's attending physician promptly... 9. The nurse will record in the Resident's medical record any changes in the Resident's condition or status (to include physician notification)." 2. Medical record review for Resident #135 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #135's nurses note documented the following: a. 5/20/13 at 1:15 PM - "Notified by P.T. (Physical Therapist) that resident was saying "I'm going to die", observed resident up in w/c (wheelchair) in PT room holding lower abd (abdomen)..." b. 5/20/13 at 1:20 PM - "called to resident room per PT stating resident was jerking, uncontrolled movements... observed resident ^ (up) in w/c with jerking movements and tremors to arms..." 5/20/13 at 1:30 PM - "...accucheck (test for blood sugar (BS)) registered 38 (BS normal range 70 to 110 milligrams per deciliter (mg/dl)) glucagan (medication for blood sugar) 1 mg (milligram) administered to R (right) thigh... responding to name but unable to follow commands BS rechecked @ 140 (1:40 PM) FS (fingerstick test for blood sugar) 29... instructed tx (treatment) nurse to get 2nd [MEDICATION NAME]." "5/20 at 2P" - "Glucogon 1 mg administered..." "5/20/13 @ (at) 0300pm (3:00 PM)" - "...MD/PA (Medical Doctor and Physician Assistant) & (and) family notified..." The physician was not promptly notified of the residents critically low blood sugars. The facility did not notify the MD/PA until an hour and 30 minutes after the first accucheck result. During an interview in the conference room on 6/12/14 at 12:45 PM, the DON stated, "We don't have a policy for [DIAGNOSES REDACTED]. Don't have a standing order addressing [DIAGNOSES REDACTED]. We chart by exception, nurses suppose to assess signs and symptoms and notify physician to address low blood sugars." Review of Resident #135's hospital inpatient History and Physical dated 5/21/13 and signed by physician documented, "...A transcription error lead to pt. (patient) getting [MEDICATION NAME] and K+ (potassium) that were another patients meds (medications)... investigation discovered the med(medication) error and critical labs were K+ 6.7 (K+ normal range is 3.6- (to) 5.3 mEq/L (milliequilivants per liter), glucose as low as 19 (glucose normal range is 70-110 milligrams per deciliter (mg/dl)), BUN (blood urea nitrogen) /CR (creatinine) 126/6.6 (normal BUN range is 7-22 mg/dl / normal creatinine range is 0.5-1.5 mg/dL)... admitting [DIAGNOSES REDACTED]. The facility failed to promptly notify the Physician of critically low blood glucose results which placed Resident #135 in IJ. 3. Medical record review for Resident #62 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician order [REDACTED]. Review of the BMP, provided by the ADON, dated 6/4/14 documented, "...CREATININE, SERUM... 2.3... H (high)... Reference Range... 0.7 - 1.2... BUN...71... CH (critically high)..." The facility was unable to provide documentation the physician was notified of the abnormal serum creatinine and critical high BUN level results on 6/4/14. During an interview in the conference room on 6/14/14 at 9:25 AM, the ADON asked how the physician is notified of abnormal and critical high laboratory results. The ADON stated "...it depends... labs (laboratory) goes in the lab book and chart... usually... the doctor signs it and puts the lab in the chart..." The ADON was asked how do you know the physician was notified of the abnormal or critical high laboratory results. The ADON stated, "(Physician) signs the lab." The ADON was asked if the BMP that was done 6/4/14 was signed by the physician. The ADON stated, "No." The facility failed to notify the physician of an abnormal serum creatinine level, which if elevated signifies impaired kidney function and a critical high BUN level of 71, which if more than 20 may indicate that the kidneys are not working at full strength. The failure of the facility to promptly notify the physician of an abnormal and a critical high laboratory results related to kidney function for a resident with a [DIAGNOSES REDACTED].#62 in IJ.

Based on review of the medical director agreement, reference review of Sorensen and Luckmann's Basic Nursing A Psychophysiologic Approach, policy review, review of Quality Assurance (QA) attendance sheets, medical record review, review of medication error reports and interview, it was determined the medical director failed to coordinate medical care in the facility, provide clinical guidance and oversight, assist in identifying, and addressed medical and clinical concerns of resident care, assisted in development, implementation, and evaluation of resident care policies and procedures that reflect current standard of practice in the facility and failed to ensure that physician orders [REDACTED].#135, 62 and 4) residents, which resulted in immediate jeopardy requiring hospitalization due to adverse consequences of medications (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The facility's failure to transcribe medications correctly onto the MAR resulted in significant medication errors of omission of Zaroxlyn prescribed for [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] which resulted in an IJ for Resident #62. The facility's failure to ensure drugs were not administered for an excessive duration resulted in actual harm when Resident #4 exhibited skin redness and irritation, requiring the treatment intervention of [MEDICATION NAME] cream. A meeting was conducted in the conference room on 6/11/14 at 7:34 PM with the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) when they were informed of the immediate jeopardy. The IJ is ongoing. The facility provided an acceptable Allegation of Compliance on June 27, 2014, and a revisit on July 2, 2014 revealed the corrective actions implemented on June 27, 2014 removed the Immediate Jeopardy. Noncompliance for F501 continues at a "D" level citation. The facility is required to submit a Plan of Correction. The findings included: 1. Review of Medical Director Agreement documented, "...4. Services of Physicians... providing physician input and medical decision support... regarding the following: (i) Implementation of resident care policies; (ii) coordination of medical care in Facility... (iii) Facility's quality assurance program... (e) Physician shall at all times render Services in a competent, professional, and ethical manner, in accordance with prevailing standards of medical practice..." 2. Review of Sorensen and Luckmann's Basic Nursing A Psychophysiologic Approach, Third Edition, Chapter 46, pages 1257, 1258, 1259, and 1262 documented, "...physicians are legally responsible for ordering medications, nurses are responsible for assessing the client... and providing the physician with data that assist in the [DIAGNOSES REDACTED]. This verification prevents errors in communication..." 3. Review of the facility's general policies documented, "physician's orders [REDACTED]. Such orders must be in writing and signed and dated by the prescribing physician. All orders must be recorded on the Resident's Physician order [REDACTED]. Phone orders must be recorded by the licensed nurse receiving them and must be counter signed by the prescribing physician within forty-eight (48) hours of issuing the order... Medications... or any treatment cannot be administered to the Resident without written approval from the attending physician." 4. The facility failed to promptly notify the physician of the onset of [MEDICAL CONDITION] activity and critical low blood sugar results which resulted in Resident #135 being hospitalized due to adverse consequences of medications. The facility failed to ensure the medication regimen was transcribed accurately on admission and failed to ensure diagnostic tests and administration of medication were ordered by the physician prior to being done/given to Resident #135 and medications given were documented on the medication administration record (MAR). The facility failed to ensure the physician signed orders timely, dated their signature at the time of signing verifying the orders for Resident #135. Resident #135 received the wrong medications and did not receive all of his prescribed medications for three days which resulted in the resident being hospitalized due to adverse consequences of medications as evidenced by [MEDICAL CONDITION] activity, severely low blood sugars, elevated potassium, elevated creatinine and blood urea nitrogen levels which indicated Dehydration and Acute [MEDICAL CONDITION]. The medical director failed to ensure that physician orders [REDACTED]. This PA is the Medical Director's PA. Refer to F157, F281, F329, F333 and F386. 5. The facility's failure to transcribe medications correctly onto the MAR resulted in significant medication errors of omission of Zaroxlyn prescribed for [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] which resulted in an IJ for Resident #62. Refer to F281 and F333. 6. The facility's failure to ensure drugs were not administered for an excessive duration resulted in actual harm when Resident #4 exhibited skin redness and irritation, requiring the treatment intervention of [MEDICATION NAME] cream. Refer to F281, F329 and F333. 7. Review of the monthly QA sign in sheets beginning in May 2013 through May 2014 documented the Medical Director had signed as attending the meetings on 7/19/13, 12/20/13, 3/14/14, and 5/23/14. There was no documentation of Quality Assurance / Performance Improvement information was discussed with the medical director from other meetings. The medication error involving Resident #135 had occurred in May 2013. There was no documentation the Medical Director had provided clinical guidance and oversight, assisted in identifying, and addressing medical and clinical concerns of resident care, assisted in development, implementation, and evaluation of resident care policies and procedures to address medication or transcription errors. During a telephone interview in the conference room on 6/11/14 at 12:30 PM, the Medical Director was asked about his involvement in QA. the Medical Director stated, "I attend about 2/3rds of the QA meetings." The Medical Director was asked if medication transcription errors were discussed. The Medical Director stated, "I can't recall if medication error was discussed. I work at 3 different (nursing) homes." During an interview in the conference room on 6/11/14 at 3:35 PM, the DON was asked if routine, telephone or verbal orders had been looked at in QA. The DON stated, "No." The DON was asked about the participation of the Medical Director in the QA process. The DON stated, "We meet monthly he comes every other month." During an interview in the conference room on 6/14/14 at 11:30 AM, the DON was asked about verification the Medical Director was updated on QA issues and studies. The DON stated, "He (Medical Director) signs the QA sign in sheet that is how he agrees to things." Refer to F520. Validation of the Credible Allegation of Compliance was accomplished on-site July 2, 2014 through review of facility documents and interviews with the medical director. The facility provided evidence of a new policy and procedure requiring physicians to sign and date all orders within 10 days. The Medical Director signed and approved the new policy. The facility provided evidence of a new policy and procedure for care of a resident experiencing [MEDICAL CONDITION]. The Medical Director signed and approved the new policy. The facility provided evidence to ensure all current medical charts were audited to ensure all orders were signed and dated by the physician. The facility provided evidence of auditing logs to ensure all admission/readmission documentation is complete. The facility provided evidence of a new policy/procedure to ensure accuracy in monthly medication reconciliation. The facility provided evidence of in-service training with sign-in sheets for physicians and the physician's assistant during a Focus Performance Improvement Committee Meeting (FPIC) on 6/16/14. The Medical Director was in-serviced on 6/23/14 during a second FPIC meeting. There was an third FPIC meeting on 6/27/14. The department heads were in attendance for each of these meetings, as well as attending physicians and pharmacy consultant and pharmacist. An interview with the Medical Director was conducted on 7/2/14. The Medical Director verbalized that he attends 100 percent (%) of the PI meetings. He verbalized the understanding of the facility policy regarding the 10 time frame for physician signatures. He verbalized he is engaged and involved with all aspects of care delivery for the residents. He verbalized he feels there has been a solid improvement since the changes have been implemented. The facility will remain out of compliance at a Scope and Severity level "D" an isolated deficient practice that constitutes no actual harm with potential for more than minimal harm, that is not Immediate Jeopardy, until it provides an acceptable plan of correction.

Based on review of the medical director agreement, reference review of Sorensen and Luckmann's Basic Nursing A Psychophysiologic Approach, policy review, review of Quality Assurance (QA) attendance sheets, medical record review, review of medication error reports and interview, it was determined the medical director failed to coordinate medical care in the facility, provide clinical guidance and oversight, assist in identifying, and addressed medical and clinical concerns of resident care, assisted in development, implementation, and evaluation of resident care policies and procedures that reflect current standard of practice in the facility and failed to ensure that physician orders [REDACTED].#135, 62 and 4) residents, which resulted in immediate jeopardy requiring hospitalization due to adverse consequences of medications (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The facility's failure to transcribe medications correctly onto the MAR resulted in significant medication errors of omission of Zaroxlyn prescribed for [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] which resulted in an IJ for Resident #62. The facility's failure to ensure drugs were not administered for an excessive duration resulted in actual harm when Resident #4 exhibited skin redness and irritation, requiring the treatment intervention of [MEDICATION NAME] cream. A meeting was conducted in the conference room on 6/11/14 at 7:34 PM with the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) when they were informed of the immediate jeopardy. The IJ is ongoing. The findings included: 1. Review of Medical Director Agreement documented, "...4. Services of Physicians... providing physician input and medical decision support... regarding the following: (i) Implementation of resident care policies; (ii) coordination of medical care in Facility... (iii) Facility's quality assurance program... (e) Physician shall at all times render Services in a competent, professional, and ethical manner, in accordance with prevailing standards of medical practice..." 2. Review of Sorensen and Luckmann's Basic Nursing A Psychophysiologic Approach, Third Edition, Chapter 46, pages 1257, 1258, 1259, and 1262 documented, "...physicians are legally responsible for ordering medications, nurses are responsible for assessing the client... and providing the physician with data that assist in the [DIAGNOSES REDACTED]. This verification prevents errors in communication..." 3. Review of the facility's general policies documented, "physician's orders [REDACTED]. Such orders must be in writing and signed and dated by the prescribing physician. All orders must be recorded on the Resident's Physician order [REDACTED]. Phone orders must be recorded by the licensed nurse receiving them and must be counter signed by the prescribing physician within forty-eight (48) hours of issuing the order... Medications... or any treatment cannot be administered to the Resident without written approval from the attending physician." 4. The facility failed to promptly notify the physician of the onset of [MEDICAL CONDITION] activity and critical low blood sugar results which resulted in Resident #135 being hospitalized due to adverse consequences of medications. The facility failed to ensure the medication regimen was transcribed accurately on admission and failed to ensure diagnostic tests and administration of medication were ordered by the physician prior to being done/given to Resident #135 and medications given were documented on the medication administration record (MAR). The facility failed to ensure the physician signed orders timely, dated their signature at the time of signing verifying the orders for Resident #135. Resident #135 received the wrong medications and did not receive all of his prescribed medications for three days which resulted in the resident being hospitalized due to adverse consequences of medications as evidenced by [MEDICAL CONDITION] activity, severely low blood sugars, elevated potassium, elevated creatinine and blood urea nitrogen levels which indicated Dehydration and Acute [MEDICAL CONDITION]. The medical director failed to ensure that physician orders [REDACTED]. This PA is the Medical Director's PA. Refer to F157, F281, F329, F333 and F386. 5. The facility's failure to transcribe medications correctly onto the MAR resulted in significant medication errors of omission of Zaroxlyn prescribed for [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] which resulted in an IJ for Resident #62. Refer to F281 and F333. 6. The facility's failure to ensure drugs were not administered for an excessive duration resulted in actual harm when Resident #4 exhibited skin redness and irritation, requiring the treatment intervention of [MEDICATION NAME] cream. Refer to F281, F329 and F333. 7. Review of the monthly QA sign in sheets beginning in May 2013 through May 2014 documented the Medical Director had signed as attending the meetings on 7/19/13, 12/20/13, 3/14/14, and 5/23/14. There was no documentation of Quality Assurance / Performance Improvement information was discussed with the medical director from other meetings. The medication error involving Resident #135 had occurred in May 2013. There was no documentation the Medical Director had provided clinical guidance and oversight, assisted in identifying, and addressing medical and clinical concerns of resident care, assisted in development, implementation, and evaluation of resident care policies and procedures to address medication or transcription errors. During a telephone interview in the conference room on 6/11/14 at 12:30 PM, the Medical Director was asked about his involvement in QA. the Medical Director stated, "I attend about 2/3rds of the QA meetings." The Medical Director was asked if medication transcription errors were discussed. The Medical Director stated, "I can't recall if medication error was discussed. I work at 3 different (nursing) homes." During an interview in the conference room on 6/11/14 at 3:35 PM, the DON was asked if routine, telephone or verbal orders had been looked at in QA. The DON stated, "No." The DON was asked about the participation of the Medical Director in the QA process. The DON stated, "We meet monthly he comes every other month." During an interview in the conference room on 6/14/14 at 11:30 AM, the DON was asked about verification the Medical Director was updated on QA issues and studies. The DON stated, "He (Medical Director) signs the QA sign in sheet that is how he agrees to things." Refer to F520.

Based on policy review, medical record review, review of medication error report, observation, and interview, it was determined the facility failed to ensure 3 of 35 (Residents #135, 62 and 4) sampled residents were free of significant medication errors. The failure of the facility to ensure Resident #135's drug regimen was correct resulted in immediate jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) when Resident #135 received the wrong medications and did not receive all of his prescribed medications for three days, which resulted in the resident being hospitalized due to having adverse consequences of medications as evidenced by [MEDICAL CONDITION] activity, severely low blood sugars, elevated potassium, creatinine and blood urea nitrogen levels which indicated Dehydration and Acute [MEDICAL CONDITION]. The facility's failure to transcribe medications correctly onto the Medication Administration Record (MAR) resulted in significant medication errors of omission of Zaroxlyn prescribed for [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] resulted in an IJ for Resident #62. The facility's failure to ensure drugs were not administered for an excessive duration period of time resulted in actual harm when Resident #4 exhibited skin redness and irritation, requiring the treatment intervention of [MEDICATION NAME] cream. A meeting was conducted in the conference room on 6/11/14 at 7:34 PM with the Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) when they were informed of the immediate jeopardy. The IJ is ongoing. The IJ for F333-J constitutes substandard quality of care. An extended survey was conducted on 6/13/14 through 6/14/14. The Facility provided an acceptable Allegation of Compliance on June 27, 2014, and a revisit on July 2, 2014 revealed the corrective actions implemented on June 27, 2014 removed the Immediate Jeopardy. Noncompliance for F333 continues at a "D" level citation. The facility is required to submit a Plan of Correction. The findings included: 1. Review of the facility's general policies documented, "physician's orders [REDACTED]. Such orders must be in writing and signed and dated by the prescribing physician... All orders must be recorded on the Resident's Physician order [REDACTED]. Phone orders must be recorded by the licensed nurse receiving them and must be counter signed by the prescribing physician within forty-eight (48) hours of issuing the order... Medications... or any treatment cannot be administered to the Resident without written approval from the attending physician." 2. Medical record review for Resident #135 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #135's hospital physician discharge medication reconciliation signed by physician on 5/17/13 and faxed to facility on "5/17/13 at 08:26AM" documented the following medications be continued at the facility for Resident #135: "[MEDICATION NAME] HCL ([MEDICATION NAME]) 100 mg (milligrams) po (by mouth) daily, [MEDICATION NAME] 10 mg rectal daily prn (as needed), Polyethylene [MEDICATION NAME] 17 GM (grams) po daily, Dissolve in 8 OZ (ounces) H2O (water) or juice before Giving, Zinc Oxide 12% (percent) & (and) Dimethicone 1% 1 application topical twice a day, Zinc Oxide 12 % & Demethicone 1% 1 application topical as needed PRN, Groin Excoriation, [MEDICATION NAME] 2.5 mg. po daily, Tamsulosin HCL 0.4 mg po daily Take 30 minutes after the same meal each day, and [MEDICATION NAME] 20 mg po Each Night at Bedtime." These medications treated heart rate, constipation, bowel regularity, skin irritation, hypertension, prostate enlargement, and cholesterol. Further review of Resident #135's medical record revealed additional hospital discharge medication reconciliation forms signed by a different physician and fax dated to the facility on "May.8.2013 10:49AM" containing the name of Referral Resident #1 and documented the following medications: [REDACTED]." These medications treated gout, [MEDICAL CONDITION], stool softener, iron supplement, diuretic, diabetes treatment, [MEDICAL CONDITIONS] disorder, hypertension, multivitamin supplement, vitamin D deficiency, reflux, [MEDICAL CONDITION] hormone levels, potassium supplement, chest pain, constipation and high blood phosphorus levels for patients on [MEDICAL TREATMENT]. Review of Resident #135's handwritten transcribed admission orders [REDACTED]. These orders were signed "Transcribed by (Nurse #1)." These admission orders [REDACTED]. Review of Resident #135's May 2013 medication administration records (MAR) documented Resident #135 received the following medications by error from 5/17/13 through 5/20/13: [MEDICATION NAME], Polyethylene [MEDICATION NAME], ASA, [MEDICATION NAME], [MEDICATION NAME], Imdur, [MEDICATION NAME], MVI, Vitamin D, [MEDICATION NAME], Potassium Chloride, [MEDICATION NAME], Senna, [MEDICATION NAME], and [MEDICATION NAME] per above orders. This resulted in significant medication errors from 5/17/13 through 5/20/14. There was no documentation on the May 2013 MAR that Resident #135's received the following medications prescribed by the physician: "[MEDICATION NAME] HCL ([MEDICATION NAME]) 100 mg (milligrams) po daily, [MEDICATION NAME] 10 mg rectal daily prn, Zinc Oxide 12% & Dimethicone 1% 1 application topical twice a day, Zinc Oxide 12% & Demethicone 1% 1 application topical as needed PRN, Groin Excoriation, [MEDICATION NAME] 2.5 mg. po daily, and Tamsulosin HCL 0.4 mg po daily Take 30 minutes after the same meal each day. The failure to receive these medications as ordered resulted in significant medications errors for Resident #135. Nurses note for Resident #135 documented the following: a. 5/20/13 at 1:15 PM - "Notified by P.T. (Physical Therapist) that resident was saying "I'm going to die", observed resident up in w/c (wheelchair) in PT room holding lower abd (abdomen)... instructed CNA (Certified Nursing Assistant) to assist resident to room and assist to toliet and prep (prepare) for lunch." 5/20/13 at 1:20 PM - "called to resident room per PT stating resident was jerking, uncontrolled movements... observed resident ^ (up) in w/c with jerking movements and tremors to arms..." 5/20/13 at 1:30 PM - "...accucheck (test for blood sugar) registered 38 blood sugar (BS) (normal reference range 70 to 110 milligrams per deciliter (mg/dl)) glucagan ([MEDICATION NAME] medication for low blood sugars) 1 mg (milligram) administered to R (right) thigh... responding to name but unable to follow commands BS rechecked @ (at) 140 (PM) FS (fingerstick) (test for blood sugars) 29... instructed tx (treatment) nurse to get 2nd [MEDICATION NAME]." 5/20/13 at 2:00 PM - "Glucogon 1 mg administered, rechecked BS 56 tremors & jerking decreased and not noted..." 5/20/13 at 5:57 PM - "...BS 37... administered [MEDICATION NAME] 1 gm IM (intramuscular)..." 5/201/13 at 7:15 PM - "call received from lab (laboratory) with critical values K+ 6.6 (potassium), creatinine 6.6 BUN (blood urea nitrogen) 121 glucose 32..." The K+ normal reference range is 3.6 to (-) 5.3 milliequivalant per liter (mEq/L), glucose normal reference range is 70-110 milligrams per deciliter (mg/dl), blood urea nitrogen (BUN) normal reference range is 7-22 mg/dl and creatinine normal reference range is 0.5-1.5 mg/dL. During an interview in the conference room on 6/10/14 at 1:40 PM, the DON was asked about the medication errors from 5/17-20/13. The DON stated, "What happened was his (Resident #135's) referral came in the same day as another man (Referral Resident #1) on 5/8/13. We did not admit the other resident referral (Referral Resident #1) and when (named Resident #135) arrived for admission the other man's information had gotten mixed into (named Resident #135's record). He (Resident #135) was admitted on a Friday (5/17/13), on Monday (5/20/13) his blood sugar got low. I started to review his file. Called the pharmacy consultant who came to review. In the meantime, I called his daughter in law who is a nurse... I was going over his record and asked about how long and severe his diabetes was and she (daughter in law) told me he did not have diabetes... When I reviewed his record that is when I found the other referrals (Referral Resident #1's) information and medicine orders. The pharmacist and myself reviewed the record. We determined there had been medication errors. We called the physician. He ordered lab work which was gotten. We had already given the resident something to increase his blood sugar... We watched him the rest of the day... Later about 7 to 8 PM the nurses called me to report labs were back and critical. I instructed them to notify the physician and transfer to ER (emergency room ) which they did. It was a medication error, the wrong residents medications were transcribed on his (Resident #135's) MARs..." The failure of the facility to ensure Resident #135's drug regimen was correct resulted in a significant medication error and IJ when Resident #135 received the wrong medications and did not receive all of his prescribed medications for three days, which resulted in the resident being hospitalized due to having adverse consequences of medications as evidenced by [MEDICAL CONDITION] activity, severely low blood sugars, elevated potassium, creatinine and blood urea nitrogen levels which indicated Dehydration and Acute [MEDICAL CONDITION]. 3. Medical record review for Resident #62 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of Resident #62's April 2014 MAR revealed there was no documentation Resident #62 received Zaroxlyn 5 mg qd from 4/1/14 through 4/24/14. Resident #62 did not receive Zanoxlyn 5 mg until 4/25/14. Review of the facility's medication error report dated 4/25/14 for Resident #62 documented, "...Date of Error 4 (4/1/14) - 4 (4/25/14)... during med (medication) pass noted cassette for Zaroxlyn in med cart but not on the MAR. looked in resident chart noted ordered received on 4 (3/24/14) to (symbol for increase) to Zaroxlyn to 5 mg. order was not transcribed to new MAR's for month of April... What has the actual effect of the error, if any, made on the resident?... continues to have [MEDICAL CONDITION] to BLE (bilateral lower extremities)..." Observations in Resident #62's room on 6/13/14 at 2:45 PM, revealed Resident #62 sitting in wheelchair with both feet elevated with bilateral [MEDICAL CONDITION] noted in the ankles. During an interview in Resident #62's room on 6/13/14 at 2:45 PM, Resident #62 stated, "(Both feet) ...are swollen..." During an interview in the conference room on 6/13/14 at 4:45 PM, the DON was asked about the medication error report for Resident #62 that was reported on 4/25/14. The DON stated, "The Zaroxlyn did not get transcribed for the month of April (2014). The DON was asked how long Resident #62 did not receive the Zaroxlyn 5 mg as ordered by the physician. The DON stated, "30 days." The facility's failure to administer Zanoxlyn as ordered resulted in significant medication errors of omission. Zaroxlyn was prescribed for [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] from April 1, 2014 through April 24, 2014. The facility's failure to ensure Resident #62 was free from significant medication errors resulted in IJ. 4. Medical record review for Resident #4 documented an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].#4 documented, "...Start [MEDICATION NAME] 100 mg (milligrams) po (by mouth) bid (twice daily) x (times) 21 doses... " Review of Resident #4's MAR dated 12/1/13 through 12/31/13 documented a total of 37 doses of [MEDICATION NAME] 100 mg being administered to Resident #4 from 12/1/13 through 12/19/13. Review of a medication error report for Resident #4 dated 12/19/13 documented, "...Explanation... medication error was made: Medication ordered for 21 doses transcribed for 21 days... What has the actual effect of the error, if any, made on the resident... skin redness / irritation... [MEDICATION NAME] cream ordered..." During an interview in the conference room on 6/14/14 at 9:50 AM, the DON was asked about the discrepancy between the MAR and the physician's orders [REDACTED].#4. The DON stated, "That was a med (medication) error. It should have been 21 doses..." The DON was asked to clarify that it should have been 21 doses instead of 21 days. The DON nodded head in agreement and stated "Mmm Hmmm." The facility's failure to ensure drugs were not administered for an excessive duration period of time resulted significant medication errors and actual harm when Resident #4 exhibited skin redness and irritation, requiring the treatment intervention of [MEDICATION NAME] cream. Validation of the Credible Allegation of Compliance was accomplished on-site July 2, 2014 through medical record review, review of facility documents and interviews with licensed staff. Resident #135 was discharged from the facility on 5/20/13 The facility provided evidence of pharmacy auditing logs to ensure orders were current and carried over to the next months Physician order [REDACTED]. The facility provided evidence of a new admission process to ensure physician orders [REDACTED]. The process includes a new Admission Checklist for all disciplines involved in an admission / readmission to be filled out. The facility provided evidence to ensure all current medical charts were audited to ensure all orders were signed and dated by the physician. The facility provided evidence of auditing logs to ensure all admission/readmission documentation is complete. The facility provided evidence of a new policy/procedure to ensure accuracy in monthly medication reconciliation. The facility provided evidence of in-service training with sign-in sheets for licensed staff on the procedure to ensure accuracy in monthly medication reconciliation, as well as telephone/verbal order verification and transcription. The facility provided evidence of every-shift auditing logs by 2 charge nurses to ensure no omissions were on the Medical Record Administration Sheets. The facility provided evidence of "RECORD OF CONVERSATION" forms for 5 nurses that were counseled regarding medication errors, transcription errors, documentation and reconciliation. Medical record review for Resident #1 documented a completed "Check-off Sheet for Admissions/Re-Admissions", Physician order [REDACTED]. The POS dated July, 2014 was signed and verified by 2 nurses and the original POS was in the MD notification binder waiting for a date and signature by the MD. All telephone orders up to 6/26/14 were signed and dated by the MD. Three telephone orders dated 6/28, 6/29, and 6/30 are in the MD binder waiting for a date and signature by the MD. The June and July, 2014 MARS were signed and dated by 2 nurses. Medical record review for Resident #2 documented a completed "Check-off Sheet for Admissions/Re-Admissions", Physician order [REDACTED]. All telephone orders were signed and dated by the MD. The June and July MARs were signed and dated by 2 nurses. Medical record review for Resident #4 documented a Physician order [REDACTED]. The MAR dated July, 2014 was signed and verified by 2 nurses. All telephone orders were signed and dated by the MD. An order clarification dated 6/20/14 was verified on the June, 2014 MAR and POS and was signed and verified by 2 nurses. Medical record review for Resident #61 documented a Physician order [REDACTED]. The MAR dated June and July, 2014 was signed and verified by 2 nurses. An order clarification dated 6/26/14 was verified on the June and July, 2014 MARs and signed and dated by the MD. Medical record review for Resident #62 documented a Physician order [REDACTED]. A physician order [REDACTED]. The MAR and July, 2014 POS was transcribed with the order, signed and dated by 2 nurses. Observations of medication administration revealed there were no medication errors. Interviews with licensed staff were conducted on 7/2/14 in the facility. Licensed staff verbalized the process to ensure orders were current and carried over to the next months Physician order [REDACTED]. An interview with the ADON was conducted on 7/2/14. The ADON verbalized the process that would be utilized for new hire training regarding order processing, monthly MAR reconciliation, admission/readmission process, every shift auditing of MARS, verbal/telephone order processing and the process and importance of receiving all lab results being accessible in the medical record, and prompt notification to the attending physician of all abnormal and critical lab values. The facility will remain out of compliance at a Scope and Severity level "D" an isolated deficient practice that constitutes no actual harm with potential for more than minimal harm, that is not Immediate Jeopardy, until it provides an acceptable plan of correction.

Based on policy review, medical record review, review of medication error report, observation, and interview, it was determined the facility failed to ensure 3 of 35 (Residents #135, 62 and 4) sampled residents were free of significant medication errors. The failure of the facility to ensure Resident #135's drug regimen was correct resulted in immediate jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) when Resident #135 received the wrong medications and did not receive all of his prescribed medications for three days, which resulted in the resident being hospitalized due to having adverse consequences of medications as evidenced by [MEDICAL CONDITION] activity, severely low blood sugars, elevated potassium, creatinine and blood urea nitrogen levels which indicated Dehydration and Acute [MEDICAL CONDITION]. The facility's failure to transcribe medications correctly onto the Medication Administration Record (MAR) resulted in significant medication errors of omission of Zaroxlyn prescribed for [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] resulted in an IJ for Resident #62. The facility's failure to ensure drugs were not administered for an excessive duration period of time resulted in actual harm when Resident #4 exhibited skin redness and irritation, requiring the treatment intervention of [MEDICATION NAME] cream. A meeting was conducted in the conference room on 6/11/14 at 7:34 PM with the Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) when they were informed of the immediate jeopardy. The IJ is ongoing. The IJ for F333-J constitutes substandard quality of care. An extended survey was conducted on 6/13/14 through 6/14/14. The findings included: 1. Review of the facility's general policies documented, "physician's orders [REDACTED]. Such orders must be in writing and signed and dated by the prescribing physician... All orders must be recorded on the Resident's Physician order [REDACTED]. Phone orders must be recorded by the licensed nurse receiving them and must be counter signed by the prescribing physician within forty-eight (48) hours of issuing the order... Medications... or any treatment cannot be administered to the Resident without written approval from the attending physician." 2. Medical record review for Resident #135 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #135's hospital physician discharge medication reconciliation signed by physician on 5/17/13 and faxed to facility on "5/17/13 at 08:26AM" documented the following medications be continued at the facility for Resident #135: "[MEDICATION NAME] HCL ([MEDICATION NAME]) 100 mg (milligrams) po (by mouth) daily, [MEDICATION NAME] 10 mg rectal daily prn (as needed), Polyethylene [MEDICATION NAME] 17 GM (grams) po daily, Dissolve in 8 OZ (ounces) H2O (water) or juice before Giving, Zinc Oxide 12% (percent) & (and) Dimethicone 1% 1 application topical twice a day, Zinc Oxide 12 % & Demethicone 1% 1 application topical as needed PRN, Groin Excoriation, [MEDICATION NAME] 2.5 mg. po daily, Tamsulosin HCL 0.4 mg po daily Take 30 minutes after the same meal each day, and [MEDICATION NAME] 20 mg po Each Night at Bedtime." These medications treated heart rate, constipation, bowel regularity, skin irritation, hypertension, prostate enlargement, and cholesterol. Further review of Resident #135's medical record revealed additional hospital discharge medication reconciliation forms signed by a different physician and fax dated to the facility on "May.8.2013 10:49AM" containing the name of Referral Resident #1 and documented the following medications: [REDACTED]." These medications treated gout, [MEDICAL CONDITION], stool softener, iron supplement, diuretic, diabetes treatment, [MEDICAL CONDITIONS] disorder, hypertension, multivitamin supplement, vitamin D deficiency, reflux, [MEDICAL CONDITION] hormone levels, potassium supplement, chest pain, constipation and high blood phosphorus levels for patients on [MEDICAL TREATMENT]. Review of Resident #135's handwritten transcribed admission orders [REDACTED]. These orders were signed "Transcribed by (Nurse #1)." These admission orders [REDACTED]. Review of Resident #135's May 2013 medication administration records (MAR) documented Resident #135 received the following medications by error from 5/17/13 through 5/20/13: [MEDICATION NAME], Polyethylene [MEDICATION NAME], ASA, [MEDICATION NAME], [MEDICATION NAME], Imdur, [MEDICATION NAME], MVI, Vitamin D, [MEDICATION NAME], Potassium Chloride, [MEDICATION NAME], Senna, [MEDICATION NAME], and [MEDICATION NAME] per above orders. This resulted in significant medication errors from 5/17/13 through 5/20/14. There was no documentation on the May 2013 MAR that Resident #135's received the following medications prescribed by the physician: "[MEDICATION NAME] HCL ([MEDICATION NAME]) 100 mg (milligrams) po daily, [MEDICATION NAME] 10 mg rectal daily prn, Zinc Oxide 12% & Dimethicone 1% 1 application topical twice a day, Zinc Oxide 12% & Demethicone 1% 1 application topical as needed PRN, Groin Excoriation, [MEDICATION NAME] 2.5 mg. po daily, and Tamsulosin HCL 0.4 mg po daily Take 30 minutes after the same meal each day. The failure to receive these medications as ordered resulted in significant medications errors for Resident #135. Nurses note for Resident #135 documented the following: a. 5/20/13 at 1:15 PM - "Notified by P.T. (Physical Therapist) that resident was saying "I'm going to die", observed resident up in w/c (wheelchair) in PT room holding lower abd (abdomen)... instructed CNA (Certified Nursing Assistant) to assist resident to room and assist to toliet and prep (prepare) for lunch." 5/20/13 at 1:20 PM - "called to resident room per PT stating resident was jerking, uncontrolled movements... observed resident ^ (up) in w/c with jerking movements and tremors to arms..." 5/20/13 at 1:30 PM - "...accucheck (test for blood sugar) registered 38 blood sugar (BS) (normal reference range 70 to 110 milligrams per deciliter (mg/dl)) glucagan ([MEDICATION NAME] medication for low blood sugars) 1 mg (milligram) administered to R (right) thigh... responding to name but unable to follow commands BS rechecked @ (at) 140 (PM) FS (fingerstick) (test for blood sugars) 29... instructed tx (treatment) nurse to get 2nd [MEDICATION NAME]." 5/20/13 at 2:00 PM - "Glucogon 1 mg administered, rechecked BS 56 tremors & jerking decreased and not noted..." 5/20/13 at 5:57 PM - "...BS 37... administered [MEDICATION NAME] 1 gm IM (intramuscular)..." 5/201/13 at 7:15 PM - "call received from lab (laboratory) with critical values K+ 6.6 (potassium), creatinine 6.6 BUN (blood urea nitrogen) 121 glucose 32..." The K+ normal reference range is 3.6 to (-) 5.3 milliequivalant per liter (mEq/L), glucose normal reference range is 70-110 milligrams per deciliter (mg/dl), blood urea nitrogen (BUN) normal reference range is 7-22 mg/dl and creatinine normal reference range is 0.5-1.5 mg/dL. During an interview in the conference room on 6/10/14 at 1:40 PM, the DON was asked about the medication errors from 5/17-20/13. The DON stated, "What happened was his (Resident #135's) referral came in the same day as another man (Referral Resident #1) on 5/8/13. We did not admit the other resident referral (Referral Resident #1) and when (named Resident #135) arrived for admission the other man's information had gotten mixed into (named Resident #135's record). He (Resident #135) was admitted on a Friday (5/17/13), on Monday (5/20/13) his blood sugar got low. I started to review his file. Called the pharmacy consultant who came to review. In the meantime, I called his daughter in law who is a nurse... I was going over his record and asked about how long and severe his diabetes was and she (daughter in law) told me he did not have diabetes... When I reviewed his record that is when I found the other referrals (Referral Resident #1's) information and medicine orders. The pharmacist and myself reviewed the record. We determined there had been medication errors. We called the physician. He ordered lab work which was gotten. We had already given the resident something to increase his blood sugar... We watched him the rest of the day... Later about 7 to 8 PM the nurses called me to report labs were back and critical. I instructed them to notify the physician and transfer to ER (emergency room ) which they did. It was a medication error, the wrong residents medications were transcribed on his (Resident #135's) MARs..." The failure of the facility to ensure Resident #135's drug regimen was correct resulted in a significant medication error and IJ when Resident #135 received the wrong medications and did not receive all of his prescribed medications for three days, which resulted in the resident being hospitalized due to having adverse consequences of medications as evidenced by [MEDICAL CONDITION] activity, severely low blood sugars, elevated potassium, creatinine and blood urea nitrogen levels which indicated Dehydration and Acute [MEDICAL CONDITION]. 3. Medical record review for Resident #62 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of Resident #62's April 2014 MAR revealed there was no documentation Resident #62 received Zaroxlyn 5 mg qd from 4/1/14 through 4/24/14. Resident #62 did not receive Zanoxlyn 5 mg until 4/25/14. Review of the facility's medication error report dated 4/25/14 for Resident #62 documented, "...Date of Error 4 (4/1/14) - 4 (4/25/14)... during med (medication) pass noted cassette for Zaroxlyn in med cart but not on the MAR. looked in resident chart noted ordered received on 4 (3/24/14) to (symbol for increase) to Zaroxlyn to 5 mg. order was not transcribed to new MAR's for month of April... What has the actual effect of the error, if any, made on the resident?... continues to have [MEDICAL CONDITION] to BLE (bilateral lower extremities)..." Observations in Resident #62's room on 6/13/14 at 2:45 PM, revealed Resident #62 sitting in wheelchair with both feet elevated with bilateral [MEDICAL CONDITION] noted in the ankles. During an interview in Resident #62's room on 6/13/14 at 2:45 PM, Resident #62 stated, "(Both feet) ...are swollen..." During an interview in the conference room on 6/13/14 at 4:45 PM, the DON was asked about the medication error report for Resident #62 that was reported on 4/25/14. The DON stated, "The Zaroxlyn did not get transcribed for the month of April (2014). The DON was asked how long Resident #62 did not receive the Zaroxlyn 5 mg as ordered by the physician. The DON stated, "30 days." The facility's failure to administer Zanoxlyn as ordered resulted in significant medication errors of omission. Zaroxlyn was prescribed for [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] from April 1, 2014 through April 24, 2014. The facility's failure to ensure Resident #62 was free from significant medication errors resulted in IJ. 4. Medical record review for Resident #4 documented an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].#4 documented, "...Start [MEDICATION NAME] 100 mg (milligrams) po (by mouth) bid (twice daily) x (times) 21 doses... " Review of Resident #4's MAR dated 12/1/13 through 12/31/13 documented a total of 37 doses of [MEDICATION NAME] 100 mg being administered to Resident #4 from 12/1/13 through 12/19/13. Review of a medication error report for Resident #4 dated 12/19/13 documented, "...Explanation... medication error was made: Medication ordered for 21 doses transcribed for 21 days... What has the actual effect of the error, if any, made on the resident... skin redness / irritation... [MEDICATION NAME] cream ordered..." During an interview in the conference room on 6/14/14 at 9:50 AM, the DON was asked about the discrepancy between the MAR and the physician's orders [REDACTED].#4. The DON stated, "That was a med (medication) error. It should have been 21 doses..." The DON was asked to clarify that it should have been 21 doses instead of 21 days. The DON nodded head in agreement and stated "Mmm Hmmm." The facility's failure to ensure drugs were not administered for an excessive duration period of time resulted significant medication errors and actual harm when Resident #4 exhibited skin redness and irritation, requiring the treatment intervention of [MEDICATION NAME] cream.

Based on policy review, hospital record review, medical record review, medication error review, and interview, it was determined the facility failed to ensure drug regimens were accurate and had adequate indications for use for 2 of 35 (Residents #135 and 4) sampled residents. The failure of the facility to ensure Resident #135's drug regimen was correct with adequate indications for medications resulted in Resident #135 receiving the wrong medications and did not receive all of his prescribed medications for three days which resulted in the resident being hospitalized due to adverse consequences of the medications as evidenced by [MEDICAL CONDITION] activity, severely low blood sugars, elevated potassium, creatinine and blood urea nitrogen levels which indicated Dehydration and Acute [MEDICAL CONDITION] and immediate jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The facility's failure to ensure drugs were not administered for an excessive duration of time resulted in actual harm when Resident #4 exhibited skin redness and irritation, requiring the treatment intervention of [MEDICATION NAME] cream. A meeting was conducted in the conference room on 6/11/14 at 7:34 PM with the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) and they were informed of the immediate jeopardy. The IJ is ongoing. The IJ for F329-J constitutes substandard quality of care. An extended survey was conducted on 6/13/14 through 6/14/14. The findings included: 1. Review of the facility's Admissions (Effective Date: 1/89, Date Revised...8/12) policy documented "Objectives: To provide uniform guidelines for admission... To complete appropriate records accurately. Policy: A written order from the Resident's attending physician is required for admission. The following data must be obtained prior to or at the time of admission... 3. Doctor's orders..." Review of facility's Medication Administration Record: Transcription of Doctors Orders and Documentation policy documented, "Objective: To maintain accurate Medication Administration Record (MAR) for permanent placement in legal clinical record... Transcription Procedure: 1. Transcribe Physician's written orders to MAR exactly as written. 2. Insure that MAR contains Resident's name, room/bed number, attending physician's name. 3. Insure that transcription contains: a. Name of drug... f. Date and time of transcription g. Initials of person transcribing... 4. After order has been transcribed, write the date and time and sign the physician's orders [REDACTED]. Document each dose of medication at the time of administration by placing your initials in the block corresponding to the correct drug, date and time... 3. When charting PRN (as needed) medications, place initials in block corresponding to correct date and time. Then go to space provided on reverse side of MAR to document narratively which PRN medication was given, the dosage given, the route of administration, site of injection (if applicable) and reason for giving medication. 4. Following administration of a PRN drug, assess the Resident for effectiveness of medication, and document." Review of the facility's general policies documented, "physician's orders [REDACTED]. Such orders must be in writing and signed and dated by the prescribing physician. All orders must be recorded on the Resident's Physician order [REDACTED]. Phone orders must be recorded by the licensed nurse receiving them and must be counter signed by the prescribing physician within forty-eight (48) hours of issuing the order... Medications... or any treatment cannot be administered to the Resident without written approval from the attending physician." 2. Medical record review for Resident #135 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of hospital Physician Discharge Medication Reconciliation signed by physician on 5/17/13 and faxed to facility on "5/17/13 at 08:26AM" documented the following medications be continued at the facility for Resident #135: "[MEDICATION NAME] HCL ([MEDICATION NAME]) 100 mg (milligrams) po (by mouth) daily, [MEDICATION NAME] 10 mg rectal daily prn (as needed), Polyethylene [MEDICATION NAME] 17 GM (grams) po (by mouth) daily, Dissolve in 8 OZ (ounces) H2O (water) or juice before Giving, Zinc Oxide 12% (percent) & (and) Dimethicone 1% 1 application topical twice a day, Zinc Oxide 12% & Demethicone 1% 1 application topical as needed PRN, Groin Excoriation, [MEDICATION NAME] 2.5 mg. po daily, Tamsulosin HCL 0.4 mg po daily Take 30 minutes after the same meal each day, and [MEDICATION NAME] 20 mg po Each Night at Bedtime." These medications treated heart rate, constipation, bowel regularity, skin irritation, hypertension, prostate enlargement, and cholesterol. Further review of Resident #135's medical record revealed additional hospital Discharge Medication Reconciliation forms signed by a different physician and fax dated to the facility on "May.8.2013 10:49AM" containing the name of Referral Resident #1 and documented the following medications: [REDACTED]." These medications treated gout, [MEDICAL CONDITION], stool softener, iron supplement, diuretic, diabetes treatment, [MEDICAL CONDITIONS] disorder, hypertension, multivitamin supplement, vitamin D deficiency, reflux, [MEDICAL CONDITION] hormone levels, potassium supplement, chest pain, constipation and high blood phosphorus levels for patients on [MEDICAL TREATMENT]. Review of the handwritten transcribed admission orders [REDACTED]. These orders were signed "Transcribed by (Nurse #1)." These medications treated cholesterol, bowel regularity, gout, [MEDICAL CONDITION], stool softener, iron supplement, diuretic, diabetes treatment, [MEDICAL CONDITIONS] disorder, hypertension, multivitamin supplement, vitamin D deficiency, reflux, [MEDICAL CONDITION] hormone levels, potassium supplement, chest pain, constipation and high blood phosphorus levels for patients on [MEDICAL TREATMENT]. Review of Resident #135's May 2013 MAR revealed Resident #135 received the following medications by error from 5/17/13 through 5/20/13: [MEDICATION NAME], Polyethylene [MEDICATION NAME], ASA, [MEDICATION NAME], [MEDICATION NAME], Imdur, [MEDICATION NAME], MVI, Vitamin D, [MEDICATION NAME], Potassium Chloride, [MEDICATION NAME], Senna, [MEDICATION NAME], and [MEDICATION NAME] per above orders. Resident #135's nurses note documented the following: a. 5/20/13 at 1:15 PM - " Notified by P.T. (Physical Therapist) that resident was saying "I'm going to die", observed resident up in w/c (wheelchair) in PT room holding lower abd (abdomen)... instructed CNA (Certified Nursing Assistant) to assist resident to room and assist to toliet and prep (prepare) for lunch." b. 5/20/13 at 1:20 PM - "called to resident room per PT stating resident was jerking, uncontrolled movements... observed resident ^ (up) in w/c with jerking movements and tremors to arms..." 5/20/13 at 1:30 PM - "...accucheck (test for blood sugar) registered 38 (blood sugar (BS) normal reference range 70 to 110 milligrams per deciliter (mg/dl)) glucagan ([MEDICATION NAME] medication for low blood sugar) 1 mg (milligram) administered to R (right) thigh... responding to name but unable to follow commands BS rechecked @ (at) 140 (PM) FS (fingerstick test for blood sugar) 29... instructed tx (treatment) nurse to get 2nd [MEDICATION NAME]." "5/20 at 2P" - "Glucogon ([MEDICATION NAME]) 1 mg administered, rechecked BS 56 tremors & (and) jerking decreased and not noted..." 5/20/13 at 3:00 PM - "...MD/PA (Medical Doctor and Physician Assistant) & family notified see... MD orders" 5/20/13 at 5:57 PM - "...BS 37... administered [MEDICATION NAME] 1 gm IM (intramuscular)" 5/20/13 at 7:15 PM - "call received from lab (laboratory) with critical values K+ (potassium) 6.6, creatinine 6.6 BUN (blood urea nitrogen) 121 glucose 32..." 5/20/13 at 755 PM - "called 911 relayed critical lab values and need for ER (emergency room ) eval (evaluation)..." Review of Resident #135's hospital laboratory results dated [DATE] (prior to admission to this facility) documented: Potassium 4.2 milliequivalant per liter (mEq/L) with normal reference range 3.6 to (-) 5.3 mEq/L, Glucose 111 milligrams per deciliter (mg/dl) with normal reference range 70-110 mg/dl, blood urea nitrogen (BUN) 32 mg/dl with normal reference range 7-22 mg/dl, and Creatinine 2.2 mg/dl with normal reference range of 0.5-1.5 mg/dL. The laboratory results collected on 5/20/13 at 5:00 PM documented the following critical values: Potassium 6.6 critical high, Glucose 32 critical low, BUN 121 critical high, and Creatinine 6.6 critical high. During an interview in the conference room on 6/10/14 at 1:40 PM, the DON was asked about Resident #135's drug transcription errors. The DON stated, "What happened was his (Resident #135's) referral came in the same day as another man (Referral Resident #1) on 5/8/13. We did not admit the other resident referral and when (named Resident #135) arrived for admission the other man's (Referral Resident #1's) information had gotten mixed into (named Resident #135 record). He (Resident #135) was admitted on a Friday (5/17/13), on Monday (5/20/14) his blood sugar got low. I started to review his (Resident #135's) file. Called the pharmacy consultant who came to review. In the meantime, I called his daughter in law who is a nurse... I was going over his record and asked about how long and severe his diabetes was and she (Resident #135's daughter in law) told me he did not have diabetes. I told her I would review the matter and call her back. When I reviewed his (Resident #135's) record that is when I found the other referral's (Referral Resident #1's) information and medicine orders (in Resident #135's medical record). The pharmacist and myself reviewed the (Resident #135) record. We determined there had been medication errors. We called the physician, he ordered lab work which was gotten. We had already given the resident (#135) something to increase his blood sugar... We watched him the rest of the day... Later about 7 to 8 PM the nurses called me to report labs were back and critical. I instructed them to notify the physician and transfer to ER which they did. It was a medication error, the wrong residents medications were transcribed on his (Resident #135's) MARs..." During an interview in the conference room on 6/11/14 at 7:30 AM, the Admissions Coordinator was asked about the drug transcription errors. The Admissions Coordinator stated, "I was the one who took (named Resident #135's) referral, his referral came through the fax machine... We tried to pinpoint what happened and think it happen during the faxing process... not sure that happened... either that or got mixed up on the desk." During an interview in the conference room on 6/11/14 at 10:45 AM, the DON was asked about pharmacy services involvement in the drug errors. The DON stated, "The pharmacy got and filled the orders the nurse had transcribed." During an interview in the conference room on 6/11/14 at 12:15 PM, Nurse #1 was asked about the drug transcription errors. Nurse #1 stated, "What happened was the DON called me, we were getting 2 to 3 admissions and asked if I could I help with MARs and orders. I said sure. I went to station 2 and (named DON) gave me a pack of orders and said here is his (Resident #135's) orders. I went and transcribed about 3 of the medications... when someone, can't remember who said here's the rest of his orders. Back then we had to rewrite the orders. I make marks to show what I've done. They gave me the orders and they were much easier to read. I assumed they all belonged to him (Resident #135). I didn't look at the names. I don't sign anything. I didn't sign those orders. The hall nurse was supposed to double check and sign off on the orders... It was the next day or so, can't remember when, (named DON) brought the orders to me and asked if anything was wrong with the orders... This was horrendous- way past an error for me... When (named DON) called me into the office she asked me to sign the orders. I signed them as transcribed by me." During a telephone interview in the conference room on 6/11/14 at 12:30 PM, Resident #135's attending physician, who is also the facility's medical director, was asked when he was made aware of the drug errors involving Resident #135. Resident #135's physician stated, "Can't recall when, maybe May 21st. I am looking at the hospital report. I ordered him to theER on [DATE]th, hospital report states he was admitted on the 21st." The physician was asked to describe Resident #135's condition upon arrival in ER and stated, "...He had critical labs, not safe numbers to be at..." During an telephone interview in the conference room on 6/12/14 at 2:05 PM, Physical Therapist (PT) #1 was asked to describe the incident involving Resident #135. PT #1 stated, "I remember that incident well. (Named Resident #135) had been in our department earlier and was repeatedly saying he was dying. (Resident #135) pointed to lower abdomen when I asked him if he was in pain. We went and told his nurse and a CNA came and got him. Later I went to his room, when I entered he was up in the wheelchair, was actively having [MEDICAL CONDITION] activity. It was a mess he was thrashing around, food was strewn all over... I ran to get his nurse... I told her you have to come now, it is an emergency. We both went to his room. He was slumped over in his chair still having [MEDICAL CONDITION] activity. She (Nurse #4) left to check his chart and told me to get someone to help me get him in bed. I got (named CNA #1)... We put him (Resident #135) to bed. He was having [MEDICAL CONDITION] the entire time. I ran to get more help and when I returned she (CNA #1) told me she had removed a ball of food from his mouth. The nurse (#4) came back with oxygen... the room had gotten crowded so I left." During a telephone interview in the conference room on 6/12/14 at 4:00 PM, Pharmacist #1 was asked to describe his involvement in the incident with Resident #135. Pharmacist #1 stated, "I am their consulting pharmacist. I was in the building that day doing pharmacy reviews. The DON came to me that afternoon, I would say around 3:00 PM and ask me to check (named Resident #135) medications to see what could be causing his low blood sugars. I reviewed the meds and determined the [MEDICATION NAME] could be causing it. She (the DON) took the chart and was reviewing it in the room behind the desk and that is when she discovered the medication errors. Another resident's (Referral Resident #1) medications had been transcribed as (named Resident #135's). She (the DON) also found in the chart (named Resident #135's) correct medications ordered. She (the DON) came to me and asked me to review med errors for possible adverse effects... I did a review and made recommendations. I recommended the labs, food, fluids, and additional blood sugar checks. The DON shared these with the PA via telephone conference." Pharmacist #1 was asked if he had recommended the [MEDICATION NAME] injections for the low blood sugars. Pharmacist #1 stated, "No, they (nurses) had already addressed the low blood sugar issue. That had already been done..." During an interview in the conference room on 6/13/14 at 9:25 AM, Nurse #2 was asked about the medication transcription errors. Nurse #2 stated, "I was the "second" nurse to check and sign off the admission orders [REDACTED]. I did not notice that the hospital orders had a different name on them. I was going to take the orders to (named Nurse #1) to sign before I signed, but I got busy and then (named Nurse #1) was gone." During an interview in the conference room on 6/13/14 at 10:00 AM, Nurse #5 was asked about the incident with Resident #135. Nurse #5 stated, "I remember the incident. (Named DON) told me I was getting two new admissions and the paperwork would be done for me. I did the vitals and assessment on (named Resident #135) when he arrived. All the orders and MARS were already filled out. I gave him his medications per MAR that evening, finished my shift... did not know about the medication error until (named DON) called me in for my statement." Review of Resident #135's hospital emergency room record dated 5/20/13 documented, "Chief complaint--Altered Lab Values... Clinical Impression: 1. Toxic Ingestion, 2. GIVEN WRONG PATIENTS MED FOR 3 DAYS, 3. [MEDICAL CONDITION] (high potassium)..." Review of Resident #135's hospital inpatient History and Physical dated 5/21/13 and signed by physician documented, "...A transcription error lead to pt. (patient) getting [MEDICATION NAME] and K+ that were another patients meds (medications)... investigation discovered the med error and critical labs were K+ 6.7, glucose as low as 19, BUN/CR 126/6.6... admitting [DIAGNOSES REDACTED]. The failure of the facility to ensure Resident #135's drug regimen was correct with adequate indications for medications resulted in IJ. Resident #135 received the wrong medications and did not receive all of his prescribed medications for three days which resulted in the resident being hospitalized due to adverse consequences of the medications as evidenced by [MEDICAL CONDITION] activity, severely low blood sugars, elevated potassium, creatinine and blood urea nitrogen levels which indicated Dehydration and Acute [MEDICAL CONDITION]. 5. Medical record review for Resident #4 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of Resident #4's MAR dated 12/1/13 through 12/31/13 documented a total of 37 doses of [MEDICATION NAME] 100 mg was administered to Resident #4 from 12/1/13 through 12/19/13. Review of a medication error report dated 12/19/13, documented, "...Explanation... medication error was made: Medication ordered for 21 doses transcribed for 21 days... What has the actual effect of the error, if any, made on the resident... skin redness/irritation... [MEDICATION NAME] cream ordered..." During an interview in the conference room on 6/14/14 at 9:50 AM, the DON was asked about the discrepancy between the MAR and the physician's orders [REDACTED].#4. The DON stated, "That was a med (medication) error. It should have been 21 doses." The DON was asked to clarify that it should have been 21 doses instead of 21 days. The DON nodded her head in agreement and stated, "Mmm Hmmm." The facility's failure to ensure drugs were not administered for an excessive duration period of time resulted in actual harm when Resident #4 exhibited skin redness and irritation, requiring treatment intervention of [MEDICATION NAME] cream.

Based on policy review, reference review of "Sorensen and Luckmann's Basic Nursing", medical record review, and interview, it was determined the facility failed to ensure services provided to 3 of 35 (Resident #135, 62 and 4) sampled residents met professional standards of quality. The facility failed to ensure the medication regimen was transcribed accurately on admission and failed to ensure diagnostic tests and administration of medication were ordered by the physician prior to being done/given to Resident #135 and medications given were documented on the medication administration record (MAR). The facility failed to ensure the physician signed orders timely, dated their signature at the time of signing verifying the orders for Resident #135. Resident #135 received the wrong medications and did not receive all of his prescribed medications for three days which resulted in the resident being hospitalized due to adverse consequences of medications as evidenced by [MEDICAL CONDITION] activity, severely low blood sugars, elevated potassium, elevated creatinine and blood urea nitrogen levels which indicated Dehydration and Acute [MEDICAL CONDITION]. This resulted in immediate jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The facility's failure to transcribe medications correctly onto the MAR resulted in significant medication errors of omission of Zaroxlyn prescribed for [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] which resulted in an IJ for Resident #62. The facility's failure to ensure drugs were not administered for an excessive duration resulted in actual harm when Resident #4 exhibited skin redness and irritation, requiring the treatment intervention of [MEDICATION NAME] cream. A meeting was conducted in the conference room on 6/11/14 at 7:34 PM, with the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) when they were informed of the immediate jeopardy (IJ). The IJ is ongoing. The facility provided an acceptable Allegation of Compliance on June 27, 2014, and a revisit on July 2, 2014 revealed the corrective actions implemented on June 27, 2014 removed the Immediate Jeopardy. Noncompliance for F281 continues at a "D" level citation. The facility is required to submit a Plan of Correction. The findings included: 1. Review of facility's general policies documented, "physician's orders [REDACTED]. Such orders must be in writing and signed and dated by the prescribing physician. All orders must be recorded on the Resident's Physician order [REDACTED]. Phone orders must be recorded by the licensed nurse receiving them and must be counter signed by the prescribing physician within forty-eight (48) hours of issuing the order... Medications... or any treatment cannot be administered to the Resident without written approval from the attending physician." Review of facility's medication administration record: transcription of doctors orders and documentation policy documented, "Objective: To maintain accurate Medication Administration Record (MAR) for permanent placement in legal clinical record... Transcription Procedure: 1. Transcribe Physician's written orders to MAR exactly as written. 2. Insure that MAR contains Resident's name, room/bed number, attending physician's name. 3. Insure that transcription contains: a. Name of drug... f. Date and time of transcription g. Initials of person transcribing... 4. After order has been transcribed, write the date and time and sign the physician's orders [REDACTED]. Document each dose of medication at the time of administration by placing your initials in the block corresponding to the correct drug, date and time... 3. When charting PRN (as needed) medications, place initials in block corresponding to correct date and time. Then go to space provided on reverse side of MAR to document narratively which PRN medication was given, the dosage given, the route of administration, site of injection (if applicable) and reason for giving medication. 4. Following administration of a PRN drug, assess the Resident for effectiveness of medication, and document." Review of the facility's charting and documentation policy documented, "Medication Administration: 1. Documentation pertaining to medication administration includes: Date and time medication administered. Name and strength of medication and how administered... Document on the Medication Administration Record (MAR) as the medications are administered... Signature and title of person recording the data... Reason(s) for prn administration and its effects on the Resident." Review of the facility's "physician's orders [REDACTED].. Only a physician... may order drugs for any Resident... All orders for medications shall be in writing. A verbal order shall be considered to be in writing if dictated to a licensed nurse... and signed by the responsible practitioner. Telephone/Verbal Orders... When receiving a verbal or telephone order, the nurse is to write the order on the order form as it is being given. The nurse must then read the order back to the practitioner for verification. At the bottom of the order, the nurse will write RBTO (Read Back Telephone Order) or RBVO (Read Back Verbal Order) to indicate the order was verified. The original telephone order requires the physician's signature within five (5) days or on the next visit to the facility..." 2. Review of Sorensen and Luckmann's Basic Nursing A Psychophysiologic Approach, Third Edition, Chapter 46, pages 1257, 1258, 1259, and 1262 documented, "...physicians are legally responsible for ordering medications, nurses are responsible for assessing the client (resident)... and providing the physician with data that assist in the [DIAGNOSES REDACTED]. This verification prevents errors in communication..." 3. Medical record review for Resident #135 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the hospital Physician Discharge Med (medication) Reconciliation signed by the physician on 5/17/13 and faxed to the facility on "5/17/13 at 08:26AM" documented the following medications be continued at the facility for Resident #135: "[MEDICATION NAME] HCL ([MEDICATION NAME]) 100 mg (milligrams) po (by mouth) daily, [MEDICATION NAME] 10 mg rectal daily prn, Polyethylene [MEDICATION NAME] 17 GM (grams) po daily, Dissolve in 8 OZ (ounces) H2O (water) or juice before Giving, Zinc Oxide 12% (percent) & (and) Dimethicone 1% 1 application topical twice a day, Zinc Oxide 12% & Demethicone 1% 1 application topical as needed PRN, Groin Excoriation, [MEDICATION NAME] 2.5 mg. po daily, Tamsulosin HCL 0.4 mg po daily Take 30 minutes after the same meal each day, and [MEDICATION NAME] 20 mg po Each Night at Bedtime." These medications treated heart rate, constipation, bowel regularity, skin irritation, hypertension, prostate enlargement and cholesterol. Further review of Resident #135's medical record revealed additional Discharge Medication Reconciliation forms signed by a different physician and fax dated to the facility on "May.8.2013 10:49AM" contained the name of Referral Resident #1 and documented the following medications: [REDACTED]." These medications treated gout, [MEDICAL CONDITION], stool softener, iron supplement, diuretic, diabetes treatment, [MEDICAL CONDITIONS] disorder, hypertension, multivitamin supplement, vitamin D deficiency, reflux, [MEDICAL CONDITION] hormone levels, potassium supplement, chest pain, constipation and high blood phosphorus levels for patients on [MEDICAL TREATMENT]. Review of the handwritten transcribed admission orders [REDACTED]. These orders were signed "Transcribed by (Nurse #1)." These orders had not been signed by the physician. These medications treated cholesterol, bowel regularity, gout, [MEDICAL CONDITION], stool softener, iron supplement, diuretic, diabetes treatment, [MEDICAL CONDITIONS] disorder, hypertension, multivitamin supplement, vitamin D deficiency, reflux, [MEDICAL CONDITION] hormone levels, potassium supplement, chest pain, constipation and high blood phosphorus levels for patients on [MEDICAL TREATMENT]. Review of Resident #135's May 2013 MAR revealed Resident #135 received the following medications by error from 5/17/13 through 5/20/13: [MEDICATION NAME], Polyethylene [MEDICATION NAME], ASA, [MEDICATION NAME], [MEDICATION NAME], Imdur, [MEDICATION NAME], MVI, Vitamin D, [MEDICATION NAME], Potassium Chloride, [MEDICATION NAME], Senna, [MEDICATION NAME] and [MEDICATION NAME]. There was no documentation on the MAR that Resident #135 received the following medications prescribed by the physician: "[MEDICATION NAME] HCL 100 mg po daily, [MEDICATION NAME] 10 mg rectal daily prn, Zinc Oxide 12% & Dimethicone 1% 1 application topical twice a day, Zinc Oxide 12 % & Demethicone 1% 1 application topical as needed PRN, Groin Excoriation, [MEDICATION NAME] 2.5 mg. po daily, and Tamsulosin HCL 0.4 mg po daily Take 30 minutes after the same meal each day as ordered. During an interview in the conference room on 6/10/14 at 1:40 PM, the DON was asked about the medication errors. The DON stated, "What happened was his (Resident #135's) referral came in the same day as another man (Referral Resident #1) on 5/8/13. We did not admit the other resident referral and when (named Resident #135) arrived for admission the other man's (Referral Resident #1) information had gotten mixed into (named Resident #135's record). He (Resident #135) was admitted on a Friday (5/17/13), on Monday (5/20/13) his blood sugar got low. I started to review his file (5/20/13)... that is when I found the other referral's (Referral Resident #1's) information and medicine orders (in Resident #135's record). The pharmacist and myself reviewed the (Resident #135's) record. We determined there had been medication errors, we called the physician. He (the attending physician) ordered lab work which was gotten. We had already given the resident something to increase his blood sugar... Later about 7 to 8 PM the nurses called me to report labs were back and critical... It was a medication error, the wrong residents medications were transcribed on his (Resident #135's) MARs..." During an interview in the conference room on 6/11/14 at 12:15 PM, Nurse #1 was asked about the transcription errors. Nurse #1 stated, "What happened was the DON called me, we were getting 2 to 3 admissions and asked if I could help with MARs and orders. I said sure. I went to station 2 and (named DON) gave me a pack of orders and said here is his (Resident #135's) orders. I went and transcribed about 3 of the medications... when someone, can't remember who said here's the rest of his orders. Back then we had to rewrite the orders. I make marks (on the orders) to show what I've done. They gave me the orders (which were for Referral Resident #1) and they (orders) were much easier to read. I assumed they all belonged to him (Resident #135). I didn't look at the names. I don't sign anything. I didn't sign those orders. The hall nurse was supposed to double check and sign off on the orders... It was the next day or so, can't remember when, (named DON) brought the orders to me and asked if anything was wrong with the orders... way past an error for me... When (named DON) called me into the office she asked me to sign the orders. I signed them as transcribed by me." During a telephone interview on 6/13/14 at 8:10 AM, Nurse #7 was asked about the order transcription errors for Resident #135. Nurse #7 stated, "I worked nights, back then, we took the hospital discharge orders and rewrote the medications and orders on the facility order sheet for admissions. We hand wrote the medications, those orders had been written by another nurse. I added the lift code and bathing method to those admission orders [REDACTED]. The sheets were crazy. I was taught if I wrote an order to sign it, so I signed the orders (named physician / Nurse #7) that is what we did back then. The RBVO is "read back verbal order." No, I did not contact (named physician) about the bathing and lift code we actually had standing orders we used for those. No, I did not read back those admission orders [REDACTED] The facility failed to transcribe medication orders accurately, failed to follow their policy for read back verbal order and read back telephone order, and failed to ensure nurses signed physician orders [REDACTED].#135. Resident #135's nurses note documented the following: a. 5/20/13 at 1:15 PM - "Notified by P.T. (Physical Therapist) that resident was saying "I'm going to die", observed resident up in w/c (wheelchair) in PT room holding lower abd (abdomen)..." b. 5/20/13 at 1:20 PM - "called to resident room per PT stating resident was jerking, uncontrolled movements... observed resident ^ (up) in w/c with jerking movements and tremors to arms..." 5/20/13 at 1:30 PM - "...accucheck (test for blood sugar (BS)) registered 38 (normal reference range 70 to 110 milligrams per deciliter (mg/dl)) glucagan (medication for low blood sugar) 1 mg (milligram) administered to R (right) thigh... responding to name but unable to follow commands BS rechecked @ (at) 140 (1:40) FS (fingerstick test for blood sugar) 29... instructed tx (treatment) nurse to get 2nd [MEDICATION NAME]." "5/20 at 2P" - "Glucogon ([MEDICATION NAME]) 1 mg administered..." During an interview in the conference room on 6/10/14 at 1:40 PM the DON was asked about the medication errors for Resident #135. The DON stated, "He (Resident #135) was admitted on Friday (5/17/13), on Monday (5/20/13) his blood sugar got low. I started to review his (Resident #135) file... that is when I found the other referrals (Referral Resident #1's) information and medicine orders. The pharmacist and myself reviewed the record. We determined there had been medication errors... We had already given the resident something to increase his blood sugar..." During a telephone interview in the conference room on 6/11/14 at 12:30 PM, Resident #135's attending physician, who is also the facility's medical director, was asked when he was made aware of the medication errors/change in condition involving Resident #135. Resident #135's physician stated, "Can't recall when. Maybe May 21st, I am looking at the hospital report I ordered him to the ER (emergency room ) on May 20th..." During an interview in the conference room on 6/12/14 at 9:05 AM, Certified Nursing Assistant (CNA) #2 was asked about Resident #135's condition on 5/20/13. CNA #2 stated, "Yes, I remember this just like it was yesterday. (Named Resident #135) was in bed having uncontrollable jerking. I got his vital signs, the nurse did an assessment, he was jerking and mumbling. (Named Nurse #4) went to review his chart, came back and told us to give him sugar and orange juice. She (Nurse #4) gave him a shot ([MEDICATION NAME]). Then (named DON) came in and told us to get more orange juice and peanut butter... (Named Nurse #4) gave him that shot ([MEDICATION NAME]) within 15 minutes of the jerking starting." During an interview in the conference room on 6/12/14 at 12:45 PM, the DON stated, "We don't have a policy for [DIAGNOSES REDACTED], don't have a standing order addressing [DIAGNOSES REDACTED], we chart by exception, nurses suppose to assess signs/symptoms and notify physician to address low blood sugars." During a telephone interview in the conference room on 6/12/14 at 4:00 PM, Pharmacist #1 was asked to describe his involvement in the medication errors for Resident #135. Pharmacist #1 stated, "I was in the building that day (when Resident #135 was in crisis) doing pharmacy reviews. The DON came to me that afternoon. I would say around 3 PM and ask me to check (named Resident #135) medications to see what could be causing his low blood sugars. I reviewed the meds and determined the [MEDICATION NAME] could be causing it. She (DON) took the chart and was reviewing it in the room behind the desk and that is when she discovered the medication errors. Another resident's medications had been transcribed as (named Resident #135's). She (the DON) also found further in the chart (named Resident #135's) correct medications ordered. She came to me and asked me to review med errors for possible adverse effects. I did a review and made recommendations. The DON shared these with the PA (Physician Assistant) via telephone conference." Pharmacist #1 was asked if he had recommended the [MEDICATION NAME] injections for the low blood sugars on 5/20/13. Pharmacist #1 stated, "No, they (nurses) had already addressed the low blood sugar issue, that had already been done." Review of Resident #135's admission physician orders [REDACTED]. There was a RBTO dated 5/18/13 for Physical Therapy services clarification had not been signed by the physician. In addition there was a RBTO dated 5/20/13 at 3:00 PM that documented accucheck orders, [MEDICATION NAME] orders, laboratory tests, electrocardiogram, push fluids and to reconcile medication profile that had not been signed by a physician. There was a RBTO dated 5/20/13 at 3:00 PM that documented to discontinue all previous medications and to start medication [MEDICATION NAME] HCL, [MEDICATION NAME], Tamsulosin HCL Zinc Oxide topical and see new admission orders [REDACTED]. During an interview in the conference room on 6/11/14 at 3:35 PM, the DON was asked about routine and/or verbal orders. The DON stated, "Nurses are to read back to doctor, then transcribe to POS (Physician order [REDACTED]. During an interview in the conference room on 6/11/14 at 6:15 PM, the DON was asked about Resident #135's orders not being signed. The DON verified the orders were not signed and stated, "Orders are suppose to be signed every 30 days for POS, physician is to sign telephone orders the next time they are in the building. Can have up to 30 days for RBTO orders." The DON was asked about the documentation of glucagan being administered and not being on Resident #135's MAR. The DON stated, "It ([MEDICATION NAME]) was given a total of 3 times but can't find it on the MARs. Nurses are suppose to sign and initial MARS. I would expect nurse to document that it was given." During an interview in the conference room on 6/12/14 at 8:50 AM, the PA was asked about signing orders. The PA stated, "I try to sign orders the next day. I am here Monday through Friday." The PA was shown the orders and asked if he remembered the orders dated 5/17/13 at 3:00 PM that documented RBTO to him. The PA stated, "Don't know specifically. No, they (nurses) would have notified us... I do not know why these orders are not signed... I really can't say I remember giving those orders..." During an interview in the conference room on 6/13/14 at 7:45 AM, the DON was shown the unsigned orders that were dated 5/17/13, 5/18/13, and 5/20/13. The DON stated, "Yes, (nodding affirmative) they are not signed. Only thing I can say is right after that happened we had the chart auditing it and trying to determine what happened. We have no problems with PA signing orders timely, (Named attending physician/medical director) is in other facilities and we have problems at times with him signing timely. I expect recertifications to be signed within 30 days and telephone orders to be signed within 5 days or on the next visit. We do have a medical records person." During an interview in the conference room on 6/13/14 at 7:55 AM, the Medical Records Clerk Nurse #8 was asked about the process for getting orders signed on closed medical records. The Medical Records Clerk Nurse #8 stated, "I take the charts out and bind them up and hold them until the doctors signs and I put them in the record." The Medical Records Clerk Nurse #8 was asked if she reviews the chart for unsigned orders. The Medical Records Clerk Nurse #8 stated, "No, not usually." On 6/13/14 at 7:56 AM, the DON came into the conference room and requested Resident #135's chart. The DON stated, "The PA is here and I need to get him to sign all those orders." Medical Records Clerk Nurse #8 took Resident #135's chart with her and stated "I will bring it right back." On 6/13/14 at 8:35 AM, Medical Records Clerk Nurse #8 returned Resident #135's chart. Review of the orders dated 5/17/13, 5/18/13, and 5/20/13 were observed to now be signed by the PA but the signature had not been dated. During an interview in the conference room on 6/13/14 at 9:01 AM, the DON was shown the telephone/verbal orders dated 5/17/13, 5/18/13, and 5/20/13 that had now been signed by the PA. The DON was asked if the PA had signed the orders today. The DON stated, "Yes, he signed those orders today, that is his signature." The DON was asked if his signature was dated. The DON stated, "No, he did not date them." During a telephone interview in the conference room on 6/13/14 at 9:55 AM, the PA was asked if he had signed orders on Resident #135 today. The PA stated, "Yes, I signed those orders this morning. There was 4 or 5 of them. I signed orders for therapies, [MEDICATION NAME]" The PA was asked why he did not date his signature. The PA stated, "I just forgot to date the orders, but yes I did sign them this morning." The facility failed to ensure the physician orders [REDACTED].#135. The facility failed to ensure the standard of practice and policy were followed to ensure the medication regimen was accurate, ensure diagnostic tests and administration of medication was ordered by the physician prior to being done/given, ensure the physician timely signed and dated orders, and ensure that nurses document medications given on the MAR. Resident #135 received the wrong medications and did not receive all of his prescribed medications for three days which resulted in the resident being hospitalized due to adverse consequences of medications as evidenced by [MEDICAL CONDITION] activity, severely low blood sugars, elevated potassium, elevated creatinine and blood urea nitrogen levels which indicated Dehydration and Acute [MEDICAL CONDITION] which resulted in IJ. 4. Medical record review for Resident #62 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of Resident #62's April 2014 MAR revealed there was no documentation Resident #62 received Zaroxlyn 5 mg qd from 4/1/14 through 4/24/14. Resident #62 did not receive Zanoxlyn 5 mg until 4/25/14. Review of the facility's medication error report dated 4/25/14 for Resident #62 documented, "...Date of Error 4 (4/1/14) - 4 (4/25/14)... during med (medication) pass noted cassette for Zaroxlyn in med cart but not on the MAR. looked in resident chart noted ordered received on 4 (3/24/14) to (symbol for increase) to Zaroxlyn to 5 mg. order was not transcribed to new MAR's for month of April... What has the actual effect of the error, if any, made on the resident?... continues to have [MEDICAL CONDITION] to BLE (bilateral lower extremities)..." During an interview in the conference room on 6/13/14 at 4:45 PM, the DON was asked about the medication error report for Resident #62 that was reported on 4/25/14. The DON stated, "The Zaroxlyn did not get transcribed for the month of April (2014). The DON was asked how long Resident #62 did not receive the Zaroxlyn 5 mg as ordered by the physician. The DON stated, "30 days." The facility's failure to administer Zanoxlyn as ordered resulted in significant medication errors of omission. Zaroxlyn was prescribed for [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] from April 1, 2014 through April 24, 2014. The facility's failure to transcribe medications correctly onto the MAR resulted in significant medication errors of omission of Zaroxlyn prescribed for [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] which resulted in an IJ for Resident #62. 5. Medical record review for Resident #4 documented an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].#4 documented, "...Start [MEDICATION NAME] 100 mg (milligrams) po (by mouth) bid (twice daily) x (times) 21 doses... " The MAR for Resident #4 dated 12/1/13 through 12/31/13 documented a total of 37 doses of [MEDICATION NAME] 100 mg had been administered to Resident #4. Review of a medication error report for Resident #4 dated 12/19/13 documented, "...Explanation... medication error was made: Medication ordered for 21 doses transcribed for 21 days... What has the actual effect of the error, if any, made on the resident... skin redness / irritation... [MEDICATION NAME] cream ordered..." Review of a physician telephone order dated 12/21/13 Resident #4 documented, "[MEDICATION NAME] cream to (right) side of neck/cheek BID (twice daily) X (times) 10 days... INDICATION... Red/heat Irritation..." During an interview in the conference room on 6/14/14 at 9:50 AM, the DON was asked about the discrepancy between the MAR and the physician's orders [REDACTED].#4. The DON stated, "That was a med (medication) error. It should have been 21 doses..." The DON was asked to clarify that it should have been 21 doses instead of 21 days. The DON nodded head in agreement and stated "Mmm Hmmm." The facility's failure to ensure drugs were not administered for an excessive duration resulted in actual harm when Resident #4 exhibited skin redness and irritation, required medical treatment. Validation of the Credible Allegation of Compliance was accomplished on-site July 2, 2014 through medical record review, review of facility documents and interviews with licensed staff. The facility provided evidence to ensure all current medical charts were audited to ensure all orders were signed and dated by the physician. The facility provided evidence of pharmacy auditing logs to ensure orders were current and carried over to the next months Physician order [REDACTED]. The facility provided evidence of a new admission process to ensure physician orders [REDACTED]. The process includes a new Admission Checklist for all disciplines involved in an admission/readmission to be filled out. The facility provided evidence of auditing logs to ensure all admission/readmission documentation is complete. The facility provided evidence of a new policy/procedure to ensure accuracy in monthly medication reconciliation. The facility provided evidence of in-service training with sign-in sheets for licensed staff on the procedure to ensure accuracy in monthly medication reconciliation, as well as telephone/verbal order verification and transcription. The facility provided evidence of every-shift auditing logs by 2 charge nurses to ensure no omissions were on the Medical Record Administration Sheets. The facility provided evidence of "RECORD OF CONVERSATION" forms for 5 nurses that were counseled regarding medication errors, transcription errors, documentation and reconciliation. Medical record review for Resident #1 documented a completed "Check-off Sheet for Admissions/Re-Admissions", Physician order [REDACTED]. The POS dated July, 2014 was signed and verified by 2 nurses and the original POS was in the MD notification binder waiting for a date and signature by the MD. All telephone orders up to 6/26/14 were signed and dated by the MD. Three telephone orders dated 6/28, 6/29, and 6/30 are in the MD binder waiting for a date and signature by the MD. The June and July, 2014 MARS were signed and dated by 2 nurses. Medical record review for Resident #2 documented a completed "Check-off Sheet for Admissions/Re-Admissions", Physician order [REDACTED]. All telephone orders were signed and dated by the MD. The June and July MARs were signed and dated by 2 nurses. Medical record review for Resident #4 documented a Physician order [REDACTED]. The MAR dated July, 2014 was signed and verified by 2 nurses. All telephone orders were signed and dated by the MD. An order clarification dated 6/20/14 was verified on the June, 2014 MAR and POS and was signed and verified by 2 nurses. Medical record review for Resident #61 documented a Physician order [REDACTED]. The MAR dated June and July, 2014 was

Based on policy review, reference review of "Sorensen and Luckmann's Basic Nursing", medical record review, and interview, it was determined the facility failed to ensure services provided to 3 of 35 (Resident #135, 62 and 4) sampled residents met professional standards of quality. The facility failed to ensure the medication regimen was transcribed accurately on admission and failed to ensure diagnostic tests and administration of medication were ordered by the physician prior to being done/given to Resident #135 and medications given were documented on the medication administration record (MAR). The facility failed to ensure the physician signed orders timely, dated their signature at the time of signing verifying the orders for Resident #135. Resident #135 received the wrong medications and did not receive all of his prescribed medications for three days which resulted in the resident being hospitalized due to adverse consequences of medications as evidenced by [MEDICAL CONDITION] activity, severely low blood sugars, elevated potassium, elevated creatinine and blood urea nitrogen levels which indicated Dehydration and Acute [MEDICAL CONDITION]. This resulted in immediate jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The facility's failure to transcribe medications correctly onto the MAR resulted in significant medication errors of omission of Zaroxlyn prescribed for [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] which resulted in an IJ for Resident #62. The facility's failure to ensure drugs were not administered for an excessive duration resulted in actual harm when Resident #4 exhibited skin redness and irritation, requiring the treatment intervention of [MEDICATION NAME] cream. A meeting was conducted in the conference room on 6/11/14 at 7:34 PM, with the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) when they were informed of the immediate jeopardy (IJ). The IJ is ongoing. The findings included: 1. Review of facility's general policies documented, "physician's orders [REDACTED]. Such orders must be in writing and signed and dated by the prescribing physician. All orders must be recorded on the Resident's Physician order [REDACTED]. Phone orders must be recorded by the licensed nurse receiving them and must be counter signed by the prescribing physician within forty-eight (48) hours of issuing the order... Medications... or any treatment cannot be administered to the Resident without written approval from the attending physician." Review of facility's medication administration record: transcription of doctors orders and documentation policy documented, "Objective: To maintain accurate Medication Administration Record (MAR) for permanent placement in legal clinical record... Transcription Procedure: 1. Transcribe Physician's written orders to MAR exactly as written. 2. Insure that MAR contains Resident's name, room/bed number, attending physician's name. 3. Insure that transcription contains: a. Name of drug... f. Date and time of transcription g. Initials of person transcribing... 4. After order has been transcribed, write the date and time and sign the physician's orders [REDACTED]. Document each dose of medication at the time of administration by placing your initials in the block corresponding to the correct drug, date and time... 3. When charting PRN (as needed) medications, place initials in block corresponding to correct date and time. Then go to space provided on reverse side of MAR to document narratively which PRN medication was given, the dosage given, the route of administration, site of injection (if applicable) and reason for giving medication. 4. Following administration of a PRN drug, assess the Resident for effectiveness of medication, and document." Review of the facility's charting and documentation policy documented, "Medication Administration: 1. Documentation pertaining to medication administration includes: Date and time medication administered. Name and strength of medication and how administered... Document on the Medication Administration Record (MAR) as the medications are administered... Signature and title of person recording the data... Reason(s) for prn administration and its effects on the Resident." Review of the facility's "physician's orders [REDACTED].. Only a physician... may order drugs for any Resident... All orders for medications shall be in writing. A verbal order shall be considered to be in writing if dictated to a licensed nurse... and signed by the responsible practitioner. Telephone/Verbal Orders... When receiving a verbal or telephone order, the nurse is to write the order on the order form as it is being given. The nurse must then read the order back to the practitioner for verification. At the bottom of the order, the nurse will write RBTO (Read Back Telephone Order) or RBVO (Read Back Verbal Order) to indicate the order was verified. The original telephone order requires the physician's signature within five (5) days or on the next visit to the facility..." 2. Review of Sorensen and Luckmann's Basic Nursing A Psychophysiologic Approach, Third Edition, Chapter 46, pages 1257, 1258, 1259, and 1262 documented, "...physicians are legally responsible for ordering medications, nurses are responsible for assessing the client (resident)... and providing the physician with data that assist in the [DIAGNOSES REDACTED]. This verification prevents errors in communication..." 3. Medical record review for Resident #135 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the hospital Physician Discharge Med (medication) Reconciliation signed by the physician on 5/17/13 and faxed to the facility on "5/17/13 at 08:26AM" documented the following medications be continued at the facility for Resident #135: "[MEDICATION NAME] HCL ([MEDICATION NAME]) 100 mg (milligrams) po (by mouth) daily, [MEDICATION NAME] 10 mg rectal daily prn, Polyethylene [MEDICATION NAME] 17 GM (grams) po daily, Dissolve in 8 OZ (ounces) H2O (water) or juice before Giving, Zinc Oxide 12% (percent) & (and) Dimethicone 1% 1 application topical twice a day, Zinc Oxide 12% & Demethicone 1% 1 application topical as needed PRN, Groin Excoriation, [MEDICATION NAME] 2.5 mg. po daily, Tamsulosin HCL 0.4 mg po daily Take 30 minutes after the same meal each day, and [MEDICATION NAME] 20 mg po Each Night at Bedtime." These medications treated heart rate, constipation, bowel regularity, skin irritation, hypertension, prostate enlargement and cholesterol. Further review of Resident #135's medical record revealed additional Discharge Medication Reconciliation forms signed by a different physician and fax dated to the facility on "May.8.2013 10:49AM" contained the name of Referral Resident #1 and documented the following medications: [REDACTED]." These medications treated gout, [MEDICAL CONDITION], stool softener, iron supplement, diuretic, diabetes treatment, [MEDICAL CONDITIONS] disorder, hypertension, multivitamin supplement, vitamin D deficiency, reflux, [MEDICAL CONDITION] hormone levels, potassium supplement, chest pain, constipation and high blood phosphorus levels for patients on [MEDICAL TREATMENT]. Review of the handwritten transcribed admission orders [REDACTED]. These orders were signed "Transcribed by (Nurse #1)." These orders had not been signed by the physician. These medications treated cholesterol, bowel regularity, gout, [MEDICAL CONDITION], stool softener, iron supplement, diuretic, diabetes treatment, [MEDICAL CONDITIONS] disorder, hypertension, multivitamin supplement, vitamin D deficiency, reflux, [MEDICAL CONDITION] hormone levels, potassium supplement, chest pain, constipation and high blood phosphorus levels for patients on [MEDICAL TREATMENT]. Review of Resident #135's May 2013 MAR revealed Resident #135 received the following medications by error from 5/17/13 through 5/20/13: [MEDICATION NAME], Polyethylene [MEDICATION NAME], ASA, [MEDICATION NAME], [MEDICATION NAME], Imdur, [MEDICATION NAME], MVI, Vitamin D, [MEDICATION NAME], Potassium Chloride, [MEDICATION NAME], Senna, [MEDICATION NAME] and [MEDICATION NAME]. There was no documentation on the MAR that Resident #135 received the following medications prescribed by the physician: "[MEDICATION NAME] HCL 100 mg po daily, [MEDICATION NAME] 10 mg rectal daily prn, Zinc Oxide 12% & Dimethicone 1% 1 application topical twice a day, Zinc Oxide 12 % & Demethicone 1% 1 application topical as needed PRN, Groin Excoriation, [MEDICATION NAME] 2.5 mg. po daily, and Tamsulosin HCL 0.4 mg po daily Take 30 minutes after the same meal each day as ordered. During an interview in the conference room on 6/10/14 at 1:40 PM, the DON was asked about the medication errors. The DON stated, "What happened was his (Resident #135's) referral came in the same day as another man (Referral Resident #1) on 5/8/13. We did not admit the other resident referral and when (named Resident #135) arrived for admission the other man's (Referral Resident #1) information had gotten mixed into (named Resident #135's record). He (Resident #135) was admitted on a Friday (5/17/13), on Monday (5/20/13) his blood sugar got low. I started to review his file (5/20/13)... that is when I found the other referral's (Referral Resident #1's) information and medicine orders (in Resident #135's record). The pharmacist and myself reviewed the (Resident #135's) record. We determined there had been medication errors, we called the physician. He (the attending physician) ordered lab work which was gotten. We had already given the resident something to increase his blood sugar... Later about 7 to 8 PM the nurses called me to report labs were back and critical... It was a medication error, the wrong residents medications were transcribed on his (Resident #135's) MARs..." During an interview in the conference room on 6/11/14 at 12:15 PM, Nurse #1 was asked about the transcription errors. Nurse #1 stated, "What happened was the DON called me, we were getting 2 to 3 admissions and asked if I could help with MARs and orders. I said sure. I went to station 2 and (named DON) gave me a pack of orders and said here is his (Resident #135's) orders. I went and transcribed about 3 of the medications... when someone, can't remember who said here's the rest of his orders. Back then we had to rewrite the orders. I make marks (on the orders) to show what I've done. They gave me the orders (which were for Referral Resident #1) and they (orders) were much easier to read. I assumed they all belonged to him (Resident #135). I didn't look at the names. I don't sign anything. I didn't sign those orders. The hall nurse was supposed to double check and sign off on the orders... It was the next day or so, can't remember when, (named DON) brought the orders to me and asked if anything was wrong with the orders... way past an error for me... When (named DON) called me into the office she asked me to sign the orders. I signed them as transcribed by me." During a telephone interview on 6/13/14 at 8:10 AM, Nurse #7 was asked about the order transcription errors for Resident #135. Nurse #7 stated, "I worked nights, back then, we took the hospital discharge orders and rewrote the medications and orders on the facility order sheet for admissions. We hand wrote the medications, those orders had been written by another nurse. I added the lift code and bathing method to those admission orders [REDACTED]. The sheets were crazy. I was taught if I wrote an order to sign it, so I signed the orders (named physician / Nurse #7) that is what we did back then. The RBVO is "read back verbal order." No, I did not contact (named physician) about the bathing and lift code we actually had standing orders we used for those. No, I did not read back those admission orders [REDACTED] The facility failed to transcribe medication orders accurately, failed to follow their policy for read back verbal order and read back telephone order, and failed to ensure nurses signed physician orders [REDACTED].#135. Resident #135's nurses note documented the following: a. 5/20/13 at 1:15 PM - "Notified by P.T. (Physical Therapist) that resident was saying "I'm going to die", observed resident up in w/c (wheelchair) in PT room holding lower abd (abdomen)..." b. 5/20/13 at 1:20 PM - "called to resident room per PT stating resident was jerking, uncontrolled movements... observed resident ^ (up) in w/c with jerking movements and tremors to arms..." 5/20/13 at 1:30 PM - "...accucheck (test for blood sugar (BS)) registered 38 (normal reference range 70 to 110 milligrams per deciliter (mg/dl)) glucagan (medication for low blood sugar) 1 mg (milligram) administered to R (right) thigh... responding to name but unable to follow commands BS rechecked @ (at) 140 (1:40) FS (fingerstick test for blood sugar) 29... instructed tx (treatment) nurse to get 2nd [MEDICATION NAME]." "5/20 at 2P" - "Glucogon ([MEDICATION NAME]) 1 mg administered..." During an interview in the conference room on 6/10/14 at 1:40 PM the DON was asked about the medication errors for Resident #135. The DON stated, "He (Resident #135) was admitted on Friday (5/17/13), on Monday (5/20/13) his blood sugar got low. I started to review his (Resident #135) file... that is when I found the other referrals (Referral Resident #1's) information and medicine orders. The pharmacist and myself reviewed the record. We determined there had been medication errors... We had already given the resident something to increase his blood sugar..." During a telephone interview in the conference room on 6/11/14 at 12:30 PM, Resident #135's attending physician, who is also the facility's medical director, was asked when he was made aware of the medication errors/change in condition involving Resident #135. Resident #135's physician stated, "Can't recall when. Maybe May 21st, I am looking at the hospital report I ordered him to the ER (emergency room ) on May 20th..." During an interview in the conference room on 6/12/14 at 9:05 AM, Certified Nursing Assistant (CNA) #2 was asked about Resident #135's condition on 5/20/13. CNA #2 stated, "Yes, I remember this just like it was yesterday. (Named Resident #135) was in bed having uncontrollable jerking. I got his vital signs, the nurse did an assessment, he was jerking and mumbling. (Named Nurse #4) went to review his chart, came back and told us to give him sugar and orange juice. She (Nurse #4) gave him a shot ([MEDICATION NAME]). Then (named DON) came in and told us to get more orange juice and peanut butter... (Named Nurse #4) gave him that shot ([MEDICATION NAME]) within 15 minutes of the jerking starting." During an interview in the conference room on 6/12/14 at 12:45 PM, the DON stated, "We don't have a policy for [DIAGNOSES REDACTED], don't have a standing order addressing [DIAGNOSES REDACTED], we chart by exception, nurses suppose to assess signs/symptoms and notify physician to address low blood sugars." During a telephone interview in the conference room on 6/12/14 at 4:00 PM, Pharmacist #1 was asked to describe his involvement in the medication errors for Resident #135. Pharmacist #1 stated, "I was in the building that day (when Resident #135 was in crisis) doing pharmacy reviews. The DON came to me that afternoon. I would say around 3 PM and ask me to check (named Resident #135) medications to see what could be causing his low blood sugars. I reviewed the meds and determined the [MEDICATION NAME] could be causing it. She (DON) took the chart and was reviewing it in the room behind the desk and that is when she discovered the medication errors. Another resident's medications had been transcribed as (named Resident #135's). She (the DON) also found further in the chart (named Resident #135's) correct medications ordered. She came to me and asked me to review med errors for possible adverse effects. I did a review and made recommendations. The DON shared these with the PA (Physician Assistant) via telephone conference." Pharmacist #1 was asked if he had recommended the [MEDICATION NAME] injections for the low blood sugars on 5/20/13. Pharmacist #1 stated, "No, they (nurses) had already addressed the low blood sugar issue, that had already been done." Review of Resident #135's admission physician orders [REDACTED]. There was a RBTO dated 5/18/13 for Physical Therapy services clarification had not been signed by the physician. In addition there was a RBTO dated 5/20/13 at 3:00 PM that documented accucheck orders, [MEDICATION NAME] orders, laboratory tests, electrocardiogram, push fluids and to reconcile medication profile that had not been signed by a physician. There was a RBTO dated 5/20/13 at 3:00 PM that documented to discontinue all previous medications and to start medication [MEDICATION NAME] HCL, [MEDICATION NAME], Tamsulosin HCL Zinc Oxide topical and see new admission orders [REDACTED]. During an interview in the conference room on 6/11/14 at 3:35 PM, the DON was asked about routine and/or verbal orders. The DON stated, "Nurses are to read back to doctor, then transcribe to POS (Physician order [REDACTED]. During an interview in the conference room on 6/11/14 at 6:15 PM, the DON was asked about Resident #135's orders not being signed. The DON verified the orders were not signed and stated, "Orders are suppose to be signed every 30 days for POS, physician is to sign telephone orders the next time they are in the building. Can have up to 30 days for RBTO orders." The DON was asked about the documentation of glucagan being administered and not being on Resident #135's MAR. The DON stated, "It ([MEDICATION NAME]) was given a total of 3 times but can't find it on the MARs. Nurses are suppose to sign and initial MARS. I would expect nurse to document that it was given." During an interview in the conference room on 6/12/14 at 8:50 AM, the PA was asked about signing orders. The PA stated, "I try to sign orders the next day. I am here Monday through Friday." The PA was shown the orders and asked if he remembered the orders dated 5/17/13 at 3:00 PM that documented RBTO to him. The PA stated, "Don't know specifically. No, they (nurses) would have notified us... I do not know why these orders are not signed... I really can't say I remember giving those orders..." During an interview in the conference room on 6/13/14 at 7:45 AM, the DON was shown the unsigned orders that were dated 5/17/13, 5/18/13, and 5/20/13. The DON stated, "Yes, (nodding affirmative) they are not signed. Only thing I can say is right after that happened we had the chart auditing it and trying to determine what happened. We have no problems with PA signing orders timely, (Named attending physician/medical director) is in other facilities and we have problems at times with him signing timely. I expect recertifications to be signed within 30 days and telephone orders to be signed within 5 days or on the next visit. We do have a medical records person." During an interview in the conference room on 6/13/14 at 7:55 AM, the Medical Records Clerk Nurse #8 was asked about the process for getting orders signed on closed medical records. The Medical Records Clerk Nurse #8 stated, "I take the charts out and bind them up and hold them until the doctors signs and I put them in the record." The Medical Records Clerk Nurse #8 was asked if she reviews the chart for unsigned orders. The Medical Records Clerk Nurse #8 stated, "No, not usually." On 6/13/14 at 7:56 AM, the DON came into the conference room and requested Resident #135's chart. The DON stated, "The PA is here and I need to get him to sign all those orders." Medical Records Clerk Nurse #8 took Resident #135's chart with her and stated "I will bring it right back." On 6/13/14 at 8:35 AM, Medical Records Clerk Nurse #8 returned Resident #135's chart. Review of the orders dated 5/17/13, 5/18/13, and 5/20/13 were observed to now be signed by the PA but the signature had not been dated. During an interview in the conference room on 6/13/14 at 9:01 AM, the DON was shown the telephone/verbal orders dated 5/17/13, 5/18/13, and 5/20/13 that had now been signed by the PA. The DON was asked if the PA had signed the orders today. The DON stated, "Yes, he signed those orders today, that is his signature." The DON was asked if his signature was dated. The DON stated, "No, he did not date them." During a telephone interview in the conference room on 6/13/14 at 9:55 AM, the PA was asked if he had signed orders on Resident #135 today. The PA stated, "Yes, I signed those orders this morning. There was 4 or 5 of them. I signed orders for therapies, [MEDICATION NAME]" The PA was asked why he did not date his signature. The PA stated, "I just forgot to date the orders, but yes I did sign them this morning." The facility failed to ensure the physician orders [REDACTED].#135. The facility failed to ensure the standard of practice and policy were followed to ensure the medication regimen was accurate, ensure diagnostic tests and administration of medication was ordered by the physician prior to being done/given, ensure the physician timely signed and dated orders, and ensure that nurses document medications given on the MAR. Resident #135 received the wrong medications and did not receive all of his prescribed medications for three days which resulted in the resident being hospitalized due to adverse consequences of medications as evidenced by [MEDICAL CONDITION] activity, severely low blood sugars, elevated potassium, elevated creatinine and blood urea nitrogen levels which indicated Dehydration and Acute [MEDICAL CONDITION] which resulted in IJ. 4. Medical record review for Resident #62 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of Resident #62's April 2014 MAR revealed there was no documentation Resident #62 received Zaroxlyn 5 mg qd from 4/1/14 through 4/24/14. Resident #62 did not receive Zanoxlyn 5 mg until 4/25/14. Review of the facility's medication error report dated 4/25/14 for Resident #62 documented, "...Date of Error 4 (4/1/14) - 4 (4/25/14)... during med (medication) pass noted cassette for Zaroxlyn in med cart but not on the MAR. looked in resident chart noted ordered received on 4 (3/24/14) to (symbol for increase) to Zaroxlyn to 5 mg. order was not transcribed to new MAR's for month of April... What has the actual effect of the error, if any, made on the resident?... continues to have [MEDICAL CONDITION] to BLE (bilateral lower extremities)..." During an interview in the conference room on 6/13/14 at 4:45 PM, the DON was asked about the medication error report for Resident #62 that was reported on 4/25/14. The DON stated, "The Zaroxlyn did not get transcribed for the month of April (2014). The DON was asked how long Resident #62 did not receive the Zaroxlyn 5 mg as ordered by the physician. The DON stated, "30 days." The facility's failure to administer Zanoxlyn as ordered resulted in significant medication errors of omission. Zaroxlyn was prescribed for [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] from April 1, 2014 through April 24, 2014. The facility's failure to transcribe medications correctly onto the MAR resulted in significant medication errors of omission of Zaroxlyn prescribed for [MEDICAL CONDITION] secondary to [MEDICAL CONDITION] which resulted in an IJ for Resident #62. 5. Medical record review for Resident #4 documented an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].#4 documented, "...Start [MEDICATION NAME] 100 mg (milligrams) po (by mouth) bid (twice daily) x (times) 21 doses... " The MAR for Resident #4 dated 12/1/13 through 12/31/13 documented a total of 37 doses of [MEDICATION NAME] 100 mg had been administered to Resident #4. Review of a medication error report for Resident #4 dated 12/19/13 documented, "...Explanation... medication error was made: Medication ordered for 21 doses transcribed for 21 days... What has the actual effect of the error, if any, made on the resident... skin redness / irritation... [MEDICATION NAME] cream ordered..." Review of a physician telephone order dated 12/21/13 Resident #4 documented, "[MEDICATION NAME] cream to (right) side of neck/cheek BID (twice daily) X (times) 10 days... INDICATION... Red/heat Irritation..." During an interview in the conference room on 6/14/14 at 9:50 AM, the DON was asked about the discrepancy between the MAR and the physician's orders [REDACTED].#4. The DON stated, "That was a med (medication) error. It should have been 21 doses..." The DON was asked to clarify that it should have been 21 doses instead of 21 days. The DON nodded head in agreement and stated "Mmm Hmmm." The facility's failure to ensure drugs were not administered for an excessive duration resulted in actual harm when Resident #4 exhibited skin redness and irritation, required medical treatment.

Based on policy review, hospital record review, medical record review, and interview, it was determined the facility failed to promptly notify the physician of a significant change in status for 1 of 35 (Residents #135) sampled residents of the 43 residents included in stage 2 review. The facility failed to promptly notify the physician of the onset of [MEDICAL CONDITION] activity and critical low blood sugar results which resulted in Resident #135 being hospitalized due to adverse consequences of medications, which resulted in immediate jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident.) A meeting was conducted in the conference room on 6/11/14 at 7:34 PM, with the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) at which time they were informed of the immediate jeopardy (IJ). The IJ is ongoing. The facility provided an acceptable Allegation of Compliance on June 27, 2014, and a revisit on July 2, 2014 revealed the corrective actions implemented on June 27, 2014 removed the Immediate Jeopardy. Noncompliance for F157 continues at a "D" level citation. The facility is required to submit a Plan of Correction. The findings included: Review of facility's policy for notification to the Physician documented, "Policy: It is the policy of this facility to promptly notify the Resident's physician of changes in the Resident's condition and/or status. Procedure: The nurse will notify the Resident's attending physician when... 2. There is a significant change in the Resident's... status... 5. Any condition... or any other information is deemed necessary by the Resident's nurse... 7. critical information will be called to the Resident's attending physician promptly... 9. The nurse will record in the Resident's medical record any changes in the Resident's condition or status (to include physician notification)." Medical record review for Resident #135 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #135's nurses note documented the following: a. 5/20/13 at 1:15 PM - "Notified by P.T. (Physical Therapist) that resident was saying "I'm going to die", observed resident up in w/c (wheelchair) in PT room holding lower abd (abdomen)..." b. 5/20/13 at 1:20 PM - "called to resident room per PT stating resident was jerking, uncontrolled movements... observed resident ^ (up) in w/c with jerking movements and tremors to arms..." 5/20/13 at 1:30 PM - "...accucheck (test for blood sugar (BS)) registered 38 (glucose normal range is 70 to (-) 110 milligrams per deciliter (mg/dl)) [MEDICATION NAME] (medication for low blood sugar) 1 mg (milligram) administered to R (right) thigh... responding to name but unable to follow commands BS rechecked @ (at) 140 (1:40 PM) FS (fingerstick test for blood sugar) 29... instructed tx (treatment) nurse to get 2nd [MEDICATION NAME]." "5/20 at 2P" - "Glucogon ([MEDICATION NAME]) 1 mg administered..." "5/20/13 @ (at) 0300pm (3:00 PM)" - "...MD/PA (Medical Doctor and Physician Assistant) & (and) family notified..." The physician was not promptly notified of the residents [MEDICAL CONDITION] activity and the critically low blood sugars. The facility did not notify the MD/PA until an hour and 40 minutes after the onset of the [MEDICAL CONDITION] activity. During an interview in the conference room on 6/10/14 at 1:40 PM, the DON was asked about the above incident documented in the nurses notes. The DON stated, "He (Resident #135) was admitted on Friday (5/17/13). On Monday (5/20/13) his blood sugar got low. I started to review his file (5/20/13), called the pharmacy consultant who came to review, in the meantime, I called his daughter in law who is a nurse... I was going over his record and asked about how long and severe his diabetes was and she (daughter in law) told me he did not have diabetes. I told her I would review the matter and call her back... that is when I found the other referral's (Referral Resident #1's) information and medicine orders (included in Resident #135's medical record)... We had already given the resident something to increase his blood sugar..." During a telephone interview in the conference room on 6/11/14 at 12:30 PM, Resident #135's attending physician, who is also the facility's medical director, was asked when was he made aware of Resident #135's change in condition. Resident #135's attending physician stated, "Can't recall when, maybe May 21st (2013). I am looking at the hospital report. I ordered him to the ER (emergency room ) on May 20th (2013)..." During an interview in the conference room on 6/12/14 at 9:05 AM, Certified Nursing Assistant (CNA) #2 was asked about Resident #135's condition on 5/20/13. CNA #2 stated, "Yes, I remember this just like it was yesterday. (Named Resident #135) was in bed having uncontrollable jerking. I got his vital signs, the nurse did an assessment, he was jerking and mumbling. (Named Nurse #4) went to review his chart, came back and told us to give him sugar and orange juice. She (Nurse #4) gave him a shot ([MEDICATION NAME]). Then (named DON) came in and told us to get more orange juice and peanut butter... (Named Nurse #4) gave him that shot ([MEDICATION NAME]) within 15 minutes of the jerking starting." During an interview in the conference room on 6/12/14 at 12:45 PM, the DON stated, "We don't have a policy for [DIAGNOSES REDACTED]. Don't have a standing order addressing [DIAGNOSES REDACTED]. We chart by exception, nurses suppose to assess signs and symptoms and notify physician to address low blood sugars." During an interview in the conference room on 6/13/14 at 8:20 AM, the Regional Nurse Consultant stated, "We do not have a policy for [MEDICAL CONDITION]." Review of the hospital emergency room record dated 5/20/13 for Resident #135 documented, "...Chief complaint--Altered Lab Values... Clinical Impression: 1. Toxic Ingestion, 2. GIVEN WRONG PATIENTS MED (medications) FOR 3 DAYS, 3. [MEDICAL CONDITION] (high potassium)..." Review of Resident #135's hospital inpatient History and Physical dated 5/21/13 and signed by physician documented, "...A transcription error lead to pt. (patient) getting [MEDICATION NAME] and K+ (potassium) that were another patients meds (medications)... investigation discovered the med (medication) error and critical labs were K+ 6.7 (K+ normal range is 3.6 - (to) 5.3 mEq/L (milliequilivants per liter), glucose as low as 19, BUN (blood urea nitrogen) /CR (creatinine) 126/6.6 (normal BUN range is 7-22 mg/dl and normal creatinine range is 0.5-1.5 mg/dL)... admitting [DIAGNOSES REDACTED]. The facility failed to promptly notify the physician of the change of condition of the [MEDICAL CONDITION] activity and critical low glucose levels, which resulted in IJ. Validation of the Credible Allegation of Compliance was accomplished on-site July 2, 2014 through medical record review, review of facility documents and interviews with licensed staff. The facility provided evidence of auditing logs to ensure all notification of laboratory results were reported to the attending physician and follow-up occurred. The facility provided evidence of in-service training with sign-in sheets for licensed staff on the importance of notifying the attending physician immediately for a change/decline in condition, critical lab values, and review of the new policy for care of a resident with [MEDICAL CONDITION] activity. Medical record review for Resident #1 documented an abnormal lab value on 6/23/14. MD was notified and signed the lab result on 6/24/14. Medical record review for Resident #61 documented an abnormal lab value on 6/25/14. The MD was notified on 6/25/14. The Physician Assistant signed the lab result on 6/26/14 Medical record review for Resident #62 documented a critical lab value on 6/26/14. MD was notified on 6/26/14 and signed the lab result on 6/26/14. A copy of the lab result was in the DON communication binder. Interviews with licensed staff were conducted on 7/2/14 in the facility. Licensed staff verbalized the process for obtaining lab results, the importance of notifying the attending physician, and proper documentation regarding the communication with the attending physician. The facility will remain out of compliance at a Scope and Severity level "D" an isolated deficient practice that constitutes no actual harm with potential for more than minimal harm, that is not Immediate Jeopardy, until it provides an acceptable plan of correction.

Based on policy review, hospital record review, medical record review, and interview, it was determined the facility failed to promptly notify the physician of a significant change in status for 1 of 35 (Residents #135) sampled residents of the 43 residents included in stage 2 review. The facility failed to promptly notify the physician of the onset of [MEDICAL CONDITION] activity and critical low blood sugar results which resulted in Resident #135 being hospitalized due to adverse consequences of medications, which resulted in immediate jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident.) A meeting was conducted in the conference room on 6/11/14 at 7:34 PM, with the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) at which time they were informed of the immediate jeopardy (IJ). The IJ is ongoing. The findings included: Review of facility's policy for notification to the Physician documented, "Policy: It is the policy of this facility to promptly notify the Resident's physician of changes in the Resident's condition and/or status. Procedure: The nurse will notify the Resident's attending physician when... 2. There is a significant change in the Resident's... status... 5. Any condition... or any other information is deemed necessary by the Resident's nurse... 7. critical information will be called to the Resident's attending physician promptly... 9. The nurse will record in the Resident's medical record any changes in the Resident's condition or status (to include physician notification)." Medical record review for Resident #135 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #135's nurses note documented the following: a. 5/20/13 at 1:15 PM - "Notified by P.T. (Physical Therapist) that resident was saying "I'm going to die", observed resident up in w/c (wheelchair) in PT room holding lower abd (abdomen)..." b. 5/20/13 at 1:20 PM - "called to resident room per PT stating resident was jerking, uncontrolled movements... observed resident ^ (up) in w/c with jerking movements and tremors to arms..." 5/20/13 at 1:30 PM - "...accucheck (test for blood sugar (BS)) registered 38 (glucose normal range is 70 to (-) 110 milligrams per deciliter (mg/dl)) [MEDICATION NAME] (medication for low blood sugar) 1 mg (milligram) administered to R (right) thigh... responding to name but unable to follow commands BS rechecked @ (at) 140 (1:40 PM) FS (fingerstick test for blood sugar) 29... instructed tx (treatment) nurse to get 2nd [MEDICATION NAME]." "5/20 at 2P" - "Glucogon ([MEDICATION NAME]) 1 mg administered..." "5/20/13 @ (at) 0300pm (3:00 PM)" - "...MD/PA (Medical Doctor and Physician Assistant) & (and) family notified..." The physician was not promptly notified of the residents [MEDICAL CONDITION] activity and the critically low blood sugars. The facility did not notify the MD/PA until an hour and 40 minutes after the onset of the [MEDICAL CONDITION] activity. During an interview in the conference room on 6/10/14 at 1:40 PM, the DON was asked about the above incident documented in the nurses notes. The DON stated, "He (Resident #135) was admitted on Friday (5/17/13). On Monday (5/20/13) his blood sugar got low. I started to review his file (5/20/13), called the pharmacy consultant who came to review, in the meantime, I called his daughter in law who is a nurse... I was going over his record and asked about how long and severe his diabetes was and she (daughter in law) told me he did not have diabetes. I told her I would review the matter and call her back... that is when I found the other referral's (Referral Resident #1's) information and medicine orders (included in Resident #135's medical record)... We had already given the resident something to increase his blood sugar..." During a telephone interview in the conference room on 6/11/14 at 12:30 PM, Resident #135's attending physician, who is also the facility's medical director, was asked when was he made aware of Resident #135's change in condition. Resident #135's attending physician stated, "Can't recall when, maybe May 21st (2013). I am looking at the hospital report. I ordered him to the ER (emergency room ) on May 20th (2013)..." During an interview in the conference room on 6/12/14 at 9:05 AM, Certified Nursing Assistant (CNA) #2 was asked about Resident #135's condition on 5/20/13. CNA #2 stated, "Yes, I remember this just like it was yesterday. (Named Resident #135) was in bed having uncontrollable jerking. I got his vital signs, the nurse did an assessment, he was jerking and mumbling. (Named Nurse #4) went to review his chart, came back and told us to give him sugar and orange juice. She (Nurse #4) gave him a shot ([MEDICATION NAME]). Then (named DON) came in and told us to get more orange juice and peanut butter... (Named Nurse #4) gave him that shot ([MEDICATION NAME]) within 15 minutes of the jerking starting." During an interview in the conference room on 6/12/14 at 12:45 PM, the DON stated, "We don't have a policy for [DIAGNOSES REDACTED]. Don't have a standing order addressing [DIAGNOSES REDACTED]. We chart by exception, nurses suppose to assess signs and symptoms and notify physician to address low blood sugars." During an interview in the conference room on 6/13/14 at 8:20 AM, the Regional Nurse Consultant stated, "We do not have a policy for [MEDICAL CONDITION]." Review of the hospital emergency room record dated 5/20/13 for Resident #135 documented, "...Chief complaint--Altered Lab Values... Clinical Impression: 1. Toxic Ingestion, 2. GIVEN WRONG PATIENTS MED (medications) FOR 3 DAYS, 3. [MEDICAL CONDITION] (high potassium)..." Review of Resident #135's hospital inpatient History and Physical dated 5/21/13 and signed by physician documented, "...A transcription error lead to pt. (patient) getting [MEDICATION NAME] and K+ (potassium) that were another patients meds (medications)... investigation discovered the med (medication) error and critical labs were K+ 6.7 (K+ normal range is 3.6 - (to) 5.3 mEq/L (milliequilivants per liter), glucose as low as 19, BUN (blood urea nitrogen) /CR (creatinine) 126/6.6 (normal BUN range is 7-22 mg/dl and normal creatinine range is 0.5-1.5 mg/dL)... admitting [DIAGNOSES REDACTED]. The facility failed to promptly notify the physician of the change of condition of the [MEDICAL CONDITION] activity and critical low glucose levels, which resulted in IJ.

Based on policy review, reference review of "Sorensen and Luckmann's Basic Nursing", medical record review, and interview, it was determined the facility failed to ensure physician's signed orders timely and documented the date of their signature to verify the orders for 1 of 35 (Resident #135) sampled residents of the 43 residents included in the stage 2 review. The admission orders [REDACTED]. The facility failed to verify medication orders with the physician. The failure to verify the medication orders resulted in an immediate jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) when Resident #135 sustained multiple medication errors and was hospitalized due to adverse consequences of the medications. A meeting was conducted in the conference room on 6/11/14 at 7:34 PM with the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) when they were informed of the immediate jeopardy. The IJ is ongoing. The findings included: 1. Review of facility's general policies documented, "Physician's Orders: All medications and treatments administered to the Resident must be ordered by the attending physician. Such orders must be in writing and signed and dated by the prescribing physician. All orders must be recorded on the Resident's Physician Order Sheet located in the Resident's clinical record. Phone orders must be recorded by the licensed nurse receiving them and must be counter signed by the prescribing physician within forty-eight (48) hours of issuing the order... Medications... or any treatment cannot be administered to the Resident without written approval from the attending physician." Review of the facility's "Physician's Orders" policy documented, "Policy... Only a physician... may order drugs for any Resident... All orders for medications shall be in writing. A verbal order shall be considered to be in writing if dictated to a licensed nurse... and signed by the responsible practitioner. Telephone/Verbal Orders... When receiving a verbal or telephone order, the nurse is to write the order on the order form as it is being given. The nurse must then read the order back to the practitioner for verification. At the bottom of the order, the nurse will write RBTO (Read Back Telephone Order) or RBVO (Read Back Verbal Order) to indicate the order was verified. The original telephone order requires the physician's signature within five (5) days or on the next visit to the facility..." 2. Reference review of Sorensen and Luckmann's Basic Nursing A Psychophysiologic Approach, Third Edition, Chapter 46, pages 1257, 1258, 1259, and 1262 documented, "...physicians are legally responsible for ordering medications, nurses are responsible for assessing the client... and providing the physician with data that assist in the [DIAGNOSES REDACTED]. This verification prevents errors in communication..." 3. Medical record review for Resident #135 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the handwritten transcribed admission orders [REDACTED]. These orders were signed "Transcribed by (Nurse #1)." There was no physician signature on these orders. These medications treated cholesterol, bowel regularity, gout, [MEDICAL CONDITION], stool softener, iron supplement, diuretic, diabetes treatment, [MEDICAL CONDITIONS] disorder, hypertension, multivitamin supplement, vitamin D deficiency, reflux, [MEDICAL CONDITION] hormone levels, potassium supplement, chest pain, constipation and high blood phosphorus levels for patients on [MEDICAL TREATMENT]. Review of Resident #135's physician telephone orders revealed there were 3 read back telephone order (RBTO) dated 5/17/13 for Occupational Therapy services, Speech Therapy services, and clarification order for enzyme digest [MEDICATION NAME] 800 milligram (mg) by mouth (PO) three times daily that had not been signed by a physician as of 6/13/14. There was a RBTO dated 5/18/13 for Physical Therapy services clarification that had not been signed by the physician as of 6/13/14. In addition there was a RBTO dated 5/20/13 at 3:00 PM that documented accucheck (test for blood sugar) orders, [MEDICATION NAME] (medication for low blood sugar) orders, laboratory tests, electrocardiogram, push fluids and to reconcile medication profile that had not been signed by a physician. There was a RBTO dated 5/20/13 at 3:00 PM that documented to discontinue all previous medications and to start medication [MEDICATION NAME] (HCL), [MEDICATION NAME], Tamsulosin HCL, (Zinc Oxide topical and see new admission orders [REDACTED]. During an interview in the conference room on 6/11/14 at 6:15 PM, the DON was asked about Resident #135's orders not being signed. The DON verified the orders were not signed and stated, "Orders are suppose to be signed every 30 days for POS (physician order sheet). Physician is to sign telephone orders the next time they are in the building. Can have up to 30 days for RBTO orders..." During an interview in the conference room on 6/12/14 at 8:50 AM, the PA was asked about signing orders. The PA stated, "I try to sign orders the next day. I am here Monday through Friday." The PA was shown Resident #135's orders and asked if he remembered the orders dated 5/17/13 at 3:00 PM that documented RBTO to him. The PA stated, "Don't know specifically. No, they would have notified us... I do not know why these orders are not signed... I really can't say I remember giving those orders..." During an interview in the conference room on 6/13/14 at 7:45 AM, the DON was shown Resident #135's unsigned orders that were dated 5/17/13, 5/18/13, and 5/20/13. The DON stated, "Yes, (nodding affirmative) they are not signed. Only thing I can say is right after that happened we had the chart auditing it and trying to determine what happened. We have no problems with PA signing orders timely. (Named attending physician and medical director) is in other facilities and we have problems at times with him signing timely. I expect recertifications to be signed within 30 days and telephone orders to be signed within 5 days or on the next visit. We do have a medical records person." During an interview in the conference room on 6/13/14 at 7:55 AM, the Medical Record Clerk Nurse #8 was asked about process for getting orders signed. Medical Record Clerk Nurse #8 stated, "I take the charts out and bind them up and hold them until the doctor signs and I put them in the record." Medical Record Clerk Nurse #8 was asked if she reviews the chart for unsigned orders. Medical Record Clerk Nurse #8 stated, "No, not usually." In the conference room on 6/13/14 at 7:56 AM, the DON requested to have Resident #135's chart. The DON stated, "The PA is here and I need to get him to sign all those orders." The Medical Records Clerk Nurse #8 took the chart with her and stated, "I will bring it right back." On 6/13/14 at 8:35 AM the Medical Records Clerk Nurse #8 returned Resident #135's chart. Review of Resident #135's orders dated 5/17/13, 5/18/13 and 5/20/13 were observed to be signed by PA but had not been dated. During an interview in the conference room on 6/13/14 at 9:01 AM, the DON was shown the telephone / verbal orders dated 5/17/13, 5/18/13 and 5/20/13 signed by PA. The DON was asked if the PA signed the orders today. The DON stated, "Yes, he signed those orders today. That is his signature." The DON was asked if the PA's signature was dated. The DON stated, "No, he (PA) did not date them." During a telephone interview in the conference room on 6/13/14 at 9:55 AM, the PA was asked if he had signed orders on Resident #135 today. The PA stated, "Yes, I signed those orders this morning. There was 4 or 5 of them. I signed orders for therapies, [MEDICATION NAME]" The PA was asked why he did not date his signature. The PA stated, "I just forgot to date the orders. Yes I did sign them this morning." The facility failed to ensure physician orders were signed and dated by the physician or physician assistant timely for Resident #135. The facility's failure to ensure the medication regimen was transcribed accurately and ensure the physician signed and dated orders timely resulted in those orders not being verified by the physician. Resident #135 received the wrong medications and did not receive all of his prescribed medications for three days which resulted in the resident being hospitalized for [REDACTED].