Every finding on record at The Waters of Smyrna, LLC

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure 3 of 4 vulnerable sampled residents (Residents #6, #7, and #18) reviewed for abuse were free from sexual abuse by Resident #10. On an unknown date, Resident #6, who had a Brief Interview of Mental Status (BIMS) score of 15, which indicated no cognitive impairment, and had a diagnosis of Spastic Quadriplegia with Cerebral Palsy, stated Resident #10, who had a BIMS score of 15, which indicated no cognitive impairment, made nonconsensual sexual advances toward her by touching her hair and rubbing her on the thighs without permission. Resident #6 stated Resident #10 continued to rub on her thighs and antagonized her during activities. Resident #6 stated she was fearful and uncomfortable around Resident #10. On an unknown date, Resident #7, who had a BIMS score of 11, which indicated moderate impaired cognition, stated Resident #10 made nonconsensual sexual propositions, grabbed her hand, and rubbed her thighs. Resident #7 stated that she didn't want Resident #10 around her or touching her without permission because he made her feel uncomfortable. On 6/11/2024, Resident #18, who had a BIMS score of 15, which indicated no cognitive impairment, stated that she reported to the Activities Director, Administrator, and Director of Nursing (DON) that Resident #10 came into her room and demanded that she give him a kiss then motioned toward her. Resident #18 stated she yelled for Resident #10 to get out my room. The facility's failure to prevent sexual abuse for Residents #6, #7, and #18 resulted in Immediate Jeopardy (IJ). Immediate Jeopardy (IJ) is 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 and Director of Nursing (DON) were notified of the IJ on 6/14/2024 at 2:00 PM in the Administrator's office. The facility was cited at F-600 at a scope and severity of K, which constitutes Substandard Quality of Care. The Immediate Jeopardy was effective on 2/12/2024 and is ongoing. A partial extended survey was conducted on 6/14/2024 to 6/21/2024. The facility is required to submit a Plan of Correction (POC). The findings include: Review of the facility policy titled, Abuse Prevention Program, dated 10/22/2022 revealed, .It is the policy of this facility to prevent resident abuse, neglect, mistreatment .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 an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect of a resident by a 3rd party .Staff should report their knowledge of allegations without fear of reprisal .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. The Administrator is the Abuse Coordinator .Such reports may be made without fear of retaliation .Upon learning of the report, the Administrator .shall initiate an incident investigation .IF YOU SUSPECT ABUSE .separate the alleged perpetrator and assure all residents safety .Residents who allegedly mistreat another resident will be immediately removed from contact with that resident during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches and placement, considering his or her safety, as well as the safety of the other residents .As part of the social history assessment and MDS [Minimum Data Set] assessment, staff will identify residents with increased vulnerability for abuse, neglect, mistreatment or who have needs and behaviors that might lead to conflict .Through the care planning process, staff will identify any problems .which reduce the chances of mistreatment for these residents .Abuse: the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, mental anguish or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being .Sexual Abuse: Including, but not limited to, sexual harassment, sexual coercion or sexual assault . Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses which included Spastic Quadriplegic Cerebral Palsy, Bipolar Disorder, Aphasia, Anxiety Disorder, and Depression. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #6 revealed a BIMS score of 15 which indicated no cognitive impairment. Further review revealed impairment on one side to the upper extremity (shoulder, elbow, wrist, hand), impairment on both sides of the lower extremity (hip, knee, ankle, foot), and motorized wheelchair used for mobility. Review of the Comprehensive Care Plan dated 4/17/2024 for Resident #6 revealed no interventions were added to address sexual abuse. During observation and interview on 6/12/2024 at 8:02 AM, Resident #6 stated, .I had issues with [Named Resident #10]. [Named Resident #10] keeps rubbing my leg. [Named Resident #10] reaches toward me to hold my hands. I tell him to stop, but he doesn't and just laughs. I don't want another man touching me. He does it to other women. He yells at the staff and other residents all the time. I have reported the incidents to the Administrator and DON, and they told me they were going to handle it by getting [Named Resident #10] transferred. The first incident occurred last summer around June [2023] and continues to happen. Sometimes I don't want to leave my room because [Named Resident #10] makes me feel uncomfortable, and I don't want to be around him. The Administrator and DON keep telling me they are working on doing something about the incidents. I don't want to keep talking about the incidents because I don't want to get kicked out the facility for seeming like I'm causing problems due to reporting the incidents . Review of the medical record for Resident #6 revealed no documentation of Resident #10's sexual abuse until 6/15/2024. Review of the Telemedicine-Psychiatric Periodic Evaluation dated 6/15/2024 for Resident #6 revealed, .[Resident #6] is being seen by request of DON for an incident that occurred with [Resident #10] .DON present during visit .[Resident #6] states she was scared . Review of the Psychiatric Periodic Evaluation dated 6/18/2024 for Resident #6 revealed, . [Resident #6] states she wishes everyone would quit talking about the incident [involving Resident #10] .She states she is worried about retaliation. Discussed with [Resident #6] there would be no retaliation tolerated . Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Polyneuropathy, Parkinson's Disease, Anxiety Disorder, and Dementia. Review of the Quarterly MDS dated [DATE] revealed a BIMS score of 11 which indicated moderate impaired cognition. Review of the Comprehensive Care Plan dated 5/2/2024 revealed no interventions were added to address sexual abuse. During observation and interview on 6/12/2024 at 7:52 AM, Resident #7 stated, .I have had issues with [Named Resident #10]. I don't remember the exact dates. He always reaches to hold my hand. I would slap his hands away. I reported the incident to the Administrator. I am unsure if they are doing anything about it. [Resident #10] says the most inappropriate things sometimes. [Named Resident #10] makes me feel uncomfortable, and I don't want to be around him . Resident #7 was asked if she could share some of the comments Resident #10 had made. Resident #7 stated, .I rather not go into detail about the comments. [Named Resident #10] causes issues all the time during activities by trying to touch on other women and yelling at staff and other residents. [Named Resident #6] is another woman here in the facility that he has touched on. Now, I'm done speaking with you about this situation . Review of the medical record for Resident #7 revealed no documentation of Resident #10's sexual abuse until 6/15/2024. Review of the Telemedicine-Psychiatric Periodic Evaluation dated 6/15/2024 revealed, .[Resident #7] is being seen by request of DON for an incident that occurred with another resident. [Resident #7] stated she doesn't want to talk about the incident . Review of the Psychiatric Periodic Evaluation dated 6/18/2024 revealed, .[Resident #7] states she doesn't want to talk about the incident . Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses which included Chronic Diastolic (Congestive) Heart Failure, Morbid (Severe) Obesity Due to Excess Calories, and Anxiety Disorder. Review of the Quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated no cognitive impairment. Review of the Comprehensive Care Plan dated 5/23/2024 revealed, .[Named Resident #10] has an alteration in behaviors as evidenced by: yelling at staff and others at times. 4/19/23 verbally aggressive with others. 6/8/23 [2023] verbally loud and argumentative with staff and other residents. 2/8/24 [2024] verbally agitated with staff and residents. 2/21/24 [2024] throwing objects out of room into hallway, verbal threats. 3/17/24 [2024] cursing staff, throwing things in room, banging on his garbage can . Further review revealed no interventions were included to address allegations of sexually inappropriate behaviors. During observation and interview on 6/13/2024 at 11:00 AM, Resident #10 stated, .I was sent out yesterday [6/12/2024] because I told [Named Resident #18] to give me a kiss on Tuesday [6/11/2024], and she told on me . Resident #10 was asked if the Administrator or DON had talked to him about the incident. Resident #10 stated, .The Administrator told me to watch my behaviors and conduct . Resident #10 was asked had he had any issues before with residents. Resident #10 smirked and laughed, then stated, .I had a resident report that I was rubbing her hair . Review of the medical record revealed no documentation for Resident #10 regarding sexual abuse or sexual behaviors prior to 6/15/2024. Review of the Telemedicine-Psychiatric Periodic Evaluation dated 6/15/2024 revealed, .[Resident #10] states he doesn't know why he did it. He states he knows better. He states he understands he can be charged with assault. He admits to having touched others [other residents] inappropriately and without consent . Review of the Psychiatric Periodic Evaluation dated 6/18/2024 revealed, .[Resident #10] states he knows what he did was wrong . Review of the medial record revealed Resident #18 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Acute Pyelonephritis, Muscle Wasting and Atrophy Right Shoulder, Weakness, Difficulty in Walking, and Muscle Wasting and Atrophy Left Shoulder. Review of the Quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated no cognitive impairment. Review of the Comprehensive Care Plan dated 5/14/2024 revealed no interventions were added to address allegations of sexual abuse. During observation and interview on 6/12/2024 at 6:35 PM, Resident #18 stated, . [Named Resident #10] came into my room and demanded I give him a kiss. Then, proceeded to come toward me. I yelled for him to get out my room. [Resident #10] looked at me and laughed then left out my room. I will fight him if he tries that again in order to protect myself. I notified the Administrator, DON, and Activities Director of the incident . Review of the medical record for Resident #7 revealed no documentation of Resident #10's sexual abuse until 6/15/2024. Review of the Telemedicine-Psychiatric Periodic Evaluation dated 6/15/2024 revealed, .[Resident #18] states she is bothered by the incident [Resident #10 entered Resident #18's room and asked for a kiss] . Review of the Psychiatric Periodic Evaluation dated 6/18/2024 revealed, .[Resident #18] states she is ready for this to be over with and not being discussed all the time . During an interview on 6/11/2024 at 2:24 PM, the Ombudsman stated, . On 2/12/2024, [Named Residents #6 and #7] reported to me that they were having issues with [Named Resident #10] touching them without permission. Both [Named Resident #6 and #7] stated they had reported the incidents to the Administrator and DON, but the issues with the unwanted touching continues. I spoke with the Administrator and DON regarding what was told to me by [Named Residents #6 and #7]. The facility hadn't put anything in place to address the incidents that were reported to them by the residents [Resident #6 and #7] . During an interview on 6/12/2024 at 9:48 AM, the DON stated, .Last year [2023] I believe there was incident between [Named Residents #6 and #10] about [Named Resident #10] touching [Named Resident #6]'s ponytail. I don't remember anything about [Named Resident #6] being touched inappropriately. The Administrator and I did speak with [Named Resident #10] about being mindful of others personal space and be aware of unwanted touching . During an interview on 6/12/2024 at 11:06 AM, the Administrator stated he was the abuse coordinator. The DON was his backup abuse coordinator. The Administrator stated, .I was aware of the incident between [Named Residents #6 and #10] regarding a ponytail being touched. [Named Resident #6] wanted [Named DON]'s help regarding [Named Resident #10] being rude and antagonizing her. [Named Resident #10]'s behaviors should be care planned. The Ombudsman did speak with me and the DON regarding concerns she about 2 residents [Residents #6 and #7] having issues with [Named Resident #10] . The Administrator was asked what he considers to be sexual abuse. The Administrator stated, .Sexual abuse would be when a staff member or resident touched another resident inappropriately . The Administrator was asked would he consider a resident constantly trying to grab and hold residents' hands or rubbing their legs without permission to be sexual abuse. The Administrator stated, . A resident can consider any touching unwanted . During an interview on 6/12/2024 at 4:16 PM, the Activities Director stated, .I've been having issues with [Named Resident #10] for over a year now. [Named Resident #10] places his hands wherever he can on female residents such as hands, legs, and thigh, then tells them you know you want it. I've witnessed those incidents during activities. Female residents are afraid of him. I report everything that occurs to the Administrator and DON and was told that as long as he doesn't hurt anyone there's nothing they can do .I witnessed [Named Resident #10] putting his hand on and rubbing [Named Resident #7]'s knee. I kept a log of the incidents involving [Named Resident #10] and gave it to the DON in a folder. Resident #10 thinks that touching on the female residents is fun, and he knows that it is wrong. I was told by the Administrator that I can't ask him to leave activities because he has a right to be there. It was also reported to me by [Named Resident #18] that [Named Resident #10] came into her room and demanded he kiss her. [Named Resident #10] has threatened to burn the building down and was looking for matches, and nothing was done. The Administrator and DON are well aware of the issues with [Named Resident #10] . The Activities Director was asked if she reported the incidents involving Resident #10 to any on other than the Administrator and DON, and she stated no. During an interview on 6/13/2024 at 10:50 AM, the Social Services Director (SSD) stated, .I have had concerns brought to me regarding [Named Resident #10] about the things he says and does . The SSD was asked what did he do when the residents' concerns were brought to him. The SSD stated, . By the time I would go speak with [Named Resident #10], [Named Resident #10] would be calm, and there would be no need to intervene . During an interview on 6/13/2024 at 1:00 PM, the DON stated, .[Named Administrator] is the abuse coordinator. I would consider a resident attempting to kiss another resident without permission sex abuse. [Named Resident #10] was sent out last night [6/12/2024] to the hospital for psychological evaluation due to behaviors . The DON was asked what were the behaviors that Resident #10 was exhibiting. The DON stated, .I believe he asked another resident to give him a kiss . The DON was asked when did the incident occur involving the kiss. The DON stated the day before [6/11/2024]. The DON was asked did she consider the incident between Residents #10 and #18 to be sexual abuse. The DON responded, .Yes, I would consider that incident to be sexual abuse . The DON was asked if she had been given a folder by the Activities Director regarding all the incidents and behavior involving Resident #10. The DON stated, .I will go look for it in my office . During an interview on 6/14/2024 at 2:00 PM, the DON stated that she could not find the folder that was given to her by the Activities Directors documenting the incidents and behaviors of Resident #10 during activities.

Based on facility policy review, medical record review, observation, and interview, the facility failed to conduct an investigation and take appropriate corrective actions for 3 of 3 sampled residents (Residents #6, #7, and #18) reviewed for allegations of sexual abuse by Resident #10. On an unknown date, Resident #6, who had a Brief Interview of Mental Status (BIMS) score of 15, which indicated no cognitive impairment, and had a diagnosis of Spastic Quadriplegia with Cerebral Palsy, stated Resident #10, who also had a BIMS score of 15, made nonconsensual sexual advances toward her by touching her hair and rubbing her on the thighs without permission. Resident #6 stated Resident #10 continued to rub on her thighs and antagonized her during activities to the point where she is fearful and uncomfortable around Resident #10. On an unknown date, Resident #7, who had a BIMS score of 11, which indicated moderate cognitive impairment, stated Resident #10 made nonconsensual sexual propositions, grabbed her hand, and rubbed her thighs. Resident #7 stated that she doesn't want Resident #10 around her or touching her without permission because he makes her feel uncomfortable. On 6/11/2024, Resident #18, who had a BIMS score of 15, stated that she reported to the Activities Director, Administrator, and Director of Nursing (DON) that Resident #10 came into her room and demanded that she give him a kiss, then he motioned toward her. Resident #18 stated she yelled for Resident #10 to get out my room. The facility's failure to conduct an investigation and take appropriate corrective actions for sexual abuse for Residents #6, #7, and #18 resulted in Immediate Jeopardy (IJ). Immediate Jeopardy (IJ) is 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 and DON were notified of the IJ on 6/14/2024 at 2:00 PM in the Administrator's office. The facility was cited at F-610 at a scope and severity of K, which constitutes Substandard Quality of Care. The Immediate Jeopardy was effective on 2/12/2024 and is ongoing. A partial extended survey was conducted on 6/14/2024 to 6/21/2024. The facility is required to submit a plan of correction (POC). The findings include: Review of the facility policy titled, Abuse Prevention Program, dated 10/22/2022, revealed, .It is the policy of this facility to prevent resident abuse, neglect, mistreatment .The Administrator is the Abuse Coordinator .Such reports may be made without fear of retaliation. Anonymous reports will also be thoroughly investigated .Upon learning of the report, the Administrator .shall initiate an incident investigation .IF YOU SUSPECT ABUSE .separate the alleged perpetrator and assure all residents safety .All incidents will be documented, whether or not abuse occurred was alleged or suspected .Upon receiving reports of physical or sexual abuse, the Charge Nurse will immediately examine the resident .Any incident or allegation involving abuse or mistreatment will result in an abuse investigation .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. The final investigation report will be completed within the required timeframe .The facility will take steps to prevent mistreatment while the investigation is underway .Residents who allegedly mistreat another resident will be immediately removed from contact with that resident during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches and placement, considering his or her safety, as well as the safety of the other residents .As part of the social history assessment and MDS [Minimum Data Set] assessment, staff will identify residents with increased vulnerability for abuse, neglect, mistreatment or who have needs and behaviors that might lead to conflict .Through the care planning process, staff will identify any problems .which reduce the chances of mistreatment for these residents . Review of the medical revealed Resident #6 was admitted to the facility on [DATE] with diagnoses which included Spastic Quadriplegic Cerebral Palsy, Bipolar Disorder, Aphasia, Anxiety Disorder, and Depression. Review of the Quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated no cognitive impairment. Further review revealed impairment on one side to the upper extremity (shoulder, elbow, wrist, hand), impairment on both sides to the lower extremity (hip, knee, ankle, foot), and a motorized wheelchair used for mobility. Review of the Comprehensive Care Plan dated 4/17/2024 revealed no interventions to address allegations of sexual abuse. During an interview on 6/12/2024 at 8:02 AM, Resident #6 stated, .I had issues with [Named Resident #10]. [Named Resident #10] keeps rubbing my leg. [Named Resident #10] reaches towards me to hold my hands. I tell him to stop, but he doesn't and just laughs. I don't want another man touching me. He does it to other women. I have reported the incidents to the Administrator and DON, and they told me they were going to handle it by getting [Named Resident #10] transferred. The first incident occurred last summer around June and continues to happen. Sometimes I don't want to leave my room because [Named Resident #10] makes me feel uncomfortable, and I don't want to be around him. The Administrator and DON keep telling me they are working on doing something about the incidents. I don't want to keep talking about the incidents because I don't want to get kicked out the facility for seeming like I'm causing problems due to reporting the incidents . Review of a Psychiatric Periodic evaluation dated 6/15/2024 revealed Resident #6 was seen per telemedicine with the DON present regarding the allegation she made of sexual abuse by Resident #10. Resident #6 reported she was scared. Review of a Psychiatric Periodic Evaluation dated 6/18/2024 revealed Resident #6 reported she was worried about retaliation. Resident #6 was reassured there would be no retaliation. The facility was unable to provide an investigation into the allegation of sexual abuse Resident #6 made regarding Resident #10. Review of medical record revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Polyneuropathy, Parkinson's Disease, Anxiety Disorder, and Dementia. Review of the Quarterly MDS dated [DATE] revealed a BIMS score of 11 which indicated moderate impaired cognition. Further review revealed Resident #7 used a manual wheelchair to maneuver. Review of the Comprehensive Care Plan dated 5/2/2024 revealed no interventions to address allegations of sexual abuse. During an interview on 6/12/2024 at 7:52 AM, Resident #7 stated, .I have had issues with [Named Resident #10]. I don't remember the exact dates. He always reaches to hold my hand. I would slap his hands away. I reported the incident to the Administrator. I am unsure if they are doing anything about it. He [Resident #10] says the most inappropriate things sometimes. [Named Resident #10] makes me feel uncomfortable, and I don't want to be around him . Resident #7 was asked if she could share some of the comments Resident #10 made. Resident #7 stated, .I rather not go into detail about the comments. Resident #10 causes issues all the time during activities by trying to touch on other women and yelling at staff and other residents. [Named Resident #6] is another woman here in the facility that he has touched on. Now, I'm done speaking with you about this situation . Review of a Psychiatric Periodic evaluation dated 6/15/2024, revealed Resident #7 was seen per telemedicine by request of the DON regarding the allegation she made of sexual abuse by Resident #10. She stated she doesn't want to talk about the incident [Allegation of sexual abuse by Resident #10]. Review of a Psychiatric Periodic Evaluation dated 6/18/2024 revealed Resident #7 reported that she didn't want to talk about the incident [Allegation of sexual abuse by Resident #10]. The facility was unable to provide an investigation into the allegation of sexual abuse Resident #7 made regarding Resident #10. Review of medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses which included Chronic Diastolic (Congestive) Heart Failure, Morbid (Severe) Obesity Due to Excess Calories, and Anxiety Disorder. Review of the Quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated no cognitive impairment. Review of the Comprehensive Care Plan dated 5/23/2024, revealed Resident #10 exhibited behaviors of yelling at staff and others, verbal aggression, verbally loud and argumentative with staff and residents, verbal agitation with staff and residents, verbal threats, cursing staff, throwing objects into the hallway, throwing things in his room, and banging on his garbage can. Further review revealed no interventions were included to address allegations of sexually inappropriate behaviors. During an interview on 6/13/2024 at 11:00 AM, Resident #10 stated, .I was sent out yesterday [6/12/2024] because I told [Named Resident #18] to give me a kiss on Tuesday [6/11/2024], and she told on me . Resident #10 was asked if the Administrator or DON had talked to him about the incident. Resident #10 stated, .The Administrator told me to watch my behaviors and conduct . Resident #10 was asked had he any issues before with residents. Resident #10 smirked and laughed, then stated, .I had a resident report that I was rubbing her hair . Review of a Psychiatric Periodic Evaluation dated 6/15/2024 revealed Resident #10 was seen per telemedicine with the DON present regarding allegations of sexual abuse by Resident #10 toward Residents #6, #7, and #18. Resident #10 stated he doesn't know why he did it, and he knows better. Resident 10 stated he understands he can be charged with assault, and he admitted to having touched others inappropriately and without their consent. Review of a Psychiatric Periodic Evaluation dated 6/18/2024 revealed Resident #10 stated he knows what he did was wrong. Review of the medial record revealed Resident #18 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Acute Pyelonephritis, Muscle Wasting and Atrophy, Right Shoulder, Weakness, Difficulty in Walking, Depression, Lack of Coordination, and Muscle Wasting and Atrophy, Left Shoulder. Review of the Quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated no cognitive impairment. Review of the Comprehensive Care Plan dated 5/14/2024 revealed no interventions for allegations of sexual abuse. During an interview on 6/12/2024 at 6:35 PM, Resident #18 stated, .[Named Resident #10] came into my room and demanded I give him a kiss. Then, proceeded to come toward me. I yelled for him to get out my room. I will fight him if he tries that again in order to protect myself. I notified the Administrator, DON, and Activities Director of the incident. [Named Resident #10] hadn't done that to me before . Review of a Psychiatric Periodic Evaluation dated 6/15/2024 revealed Resident #18 was bothered by the incident with Resident #10. Review of a Psychiatric Periodic Evaluation dated 6/18/2024 revealed Resident #18 stated she was ready for this to be over with and not to be discussed all the time. The facility was unable to provide an investigation into the allegation of sexual abuse Resident #18 made regarding Resident #10. During an interview on 6/11/2024 at 2:24 PM, the Ombudsman stated, .On 2/12/2024, [Named Residents #6 and #7] reported to me that they were having issues with [Named Resident #10] touching them without permission. Both [Named Residents #6 and #7] stated they had reported the incidents to the Administrator and DON, but the issues with the unwanted touching continues. I spoke with the Administrator and DON regarding what was told to me by [Named Residents #6 and #7]. The facility hadn't put anything in place to address the incidents that were reported to them by the residents [Resident #6 and #7] . During an interview on 6/12/2024 at 9:48 AM, the DON stated, .Last year [2023] I believe there was incident between [Named Residents #6 and #10] about [named Resident #10] touching [Named Resident #6]'s ponytail .The Administrator and I did speak with [Named Resident #10] about being mindful of others personal space and be aware of unwanted touching. That is the only incident I can recall regarding [Named resident #10] . During an interview on 6/12/2024 at 11:06 AM, the Administrator stated he was the abuse coordinator. The DON was his backup abuse coordinator. The Administrator stated, .I was aware of the incident between [Named Residents #6 and #10] regarding a ponytail being touched .[Named Resident #6] wanted [Named DON]'s help regarding [Named Resident #10] being rude and antagonizing her. We did speak with the Ombudsman regarding the incident and [Named Resident #10]'s behaviors. [Named Resident #10]'s behaviors should be care planned. That's the only incident I can recall being reported to me . The Administrator was asked what does he consider to be sexual abuse. The Administrator stated, .Sexual abuse would be when a staff member or resident touched another resident inappropriately . The Administrator was asked would he consider a resident constantly trying to grab and hold residents' hands or rubbing their legs without permission to be sexual abuse. The Administrator stated, .A resident can consider any touching unwanted. We have activities all the time where residents have to interact and touching may occur. Just like when a prayer occurs, residents have to hold hands, and a resident may consider that inappropriate . The Administrator was asked what is the protocol when abuse is reported to him. The Administrator stated, .I follow the abuse policy, make sure the resident is safe, conduct an investigation, and report within 2 hours . The Administrator was asked if the incidents regarding Residents #6 and #7 were investigated, and he stated, No. During an interview on 6/12/2024 at 4:16 PM, the Activities Director stated, .I've been having issues with [Named Resident #10] for over a year now. [Named Resident #10] places his hands wherever he can on female residents such as hands, legs, and thighs. Then tells them you know you want it. I've witnessed those incidents during activities. Female residents are afraid of him. I reported everything that occurred to the Administrator and DON. I was told that as long as he doesn't hurt anyone there's nothing they can do. I tried to put a seating chart in place so that [Named Resident #10] wasn't close to the female residents, but he [Resident #10] didn't like or agree with that .I witnessed [Named Resident #10] putting his hand on and rubbing [Named Resident #7]'s knee. I kept a log of the incidents involving [Named Resident #10] and gave it to the DON in a folder. [Named Resident #10] knows that it is wrong. I was told by the Administrator that I can't ask him to leave activities because he has a right to be there. It was also reported to me by [Named Resident #18] that [Named Resident #10] came into her room and demanded he kiss her. [Named Resident #10] has threatened to burn the building down and was looking for matches, and nothing was done. The Administrator and DON are well aware of the issues with [Named Resident #10] . During an interview on 6/13/2024 at 10:50 AM, the Social Services Director (SSD) stated, .I have had concerns brought to me regarding [Named Resident #10] about the things he says and does. [Named Resident #10] came to me about not liking assigned seating, and I told him [Named Resident #10] that no one could keep him from activities . During an interview on 6/13/2024 at 1:00 PM, the DON stated, .[Named Administrator] is the abuse coordinator. I would consider a resident attempting to kiss another resident without permission sexual abuse. [Named Resident #10] was sent out last night [6/12/2024] to the hospital for psychological evaluation due to behaviors . The DON was asked what type of behavior was Resident #10 sent out for. The DON responded, .I believe it was for attempting to kiss another resident . The DON was asked when did the incident occur involving the kiss. The DON stated the day before [6/11/2024]. The DON was asked if she had been given a folder by the Activities Director regarding all the incidents and behavior involving Resident #10. The DON stated, .I will go look for it in my office . During an interview on 6/14/2024 at 2:00 PM, the DON stated that she could not find the folder that was given to her by the Activities Director documenting the incidents and behaviors of Resident #10 during activities.

Based on facility policy review, medical record review, observation, and interview, the facility failed to provide an environment free from the use of physical restraint used for staff convenience, that unnecessarily inhibited a resident ' s freedom of movement or activity for 1 of 3 (Resident #15) sampled residents reviewed for restraints. The facility also failed to obtain an order for the physical restraint, failed to document the medical symptom for which the restraint was implemented, failed to document less restrictive alternatives were implemented prior to use of the physical restraint, failed to document direct monitoring and supervision provided during use of the restraint, and failed to assess, care plan, and re-evaluate the need for the restraint. On 6/11/2024 and 6/12/2024, multiple observations revealed Resident #15, a vulnerable, severely cognitively impaired resident, sitting in the hallway, in front of the nurse station, in a geriatric chair (a large padded supportive recliner that can be placed in upright position or reclined) with a connected tray table across her lap. Resident #15 was unable to release the connected table and move freely in the chair. On 3/10/2024, Resident #15 sustained a skin tear that was reinjured on 4/6/2024, as a result of being restrained with a table tray, which resulted in an Immediate Jeopardy (IJ) with actual Harm. An Immediate Jeopardy is 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 Interim Administrator, the Regional Nurse Consultant, and the Regional Director of Operations (via telephone) were notified of the Immediate Jeopardy on 6/21/2024 at 6:59 PM in the Administrator's Office. The facility was cited at F604 at a scope and severity of J, which constitutes Substandard Quality of Care. The Immediate Jeopardy was effective 3/10/2024 and is on-going. A partial extended survey was conducted on 6/14/2024 to 6/21/2024. The facility is required to submit a Plan of Correction (POC). The findings include: Review of the facility policy titled, Guidelines for Physical Restraints/Seclusion, dated 5/17/2023, revealed, .It is the policy of the facility to use physical restraint only as a last resort and only after every other alternative to a physical restraint (based on assessment) that seemed to have the potential for being used successfully, has been tried, and has failed. The use of a physical restraint and/or device is to enable and promote functioning at the highest practicable physical, mental, or psychosocial well-being. It will be used only after the resident has been assessed and it has been determined by the IDT [Interdisciplinary Team] that the restraint to be used is the least restrictive and for the least amount of time. A physical restraint is NEVER to be used for staff convenience or for discipline .Use of a physical restraint or device intervention is usually related to .Impaired Cognition and Communication .Decreased Safety Awareness .Impulsive with repeated attempts to stand/transfer without assistance from staff despite education and task segmentation .Unsuccessful attempts to use less restrictive devices .Unavoidable history of falls .Dementia/Alzheimer's .The resident must have a complete order for the restraint which includes the type of restraint and when it is to be applied/released. The restraint order must include the related medical condition. All physical restraints are to [be] released and the resident is to be repositioned at least every 2 hours .If the resident cannot remove the physical restraint device on command-and using the proper technique for removal-the device is considered a physical restraint .Procedure .Complete the initial Physical Restraint Assessment .If a resident is admitted with a physical restraint, a new assessment/order is needed .Review contributing factors such as behaviors/mood/fall risk/medical signs and symptoms/diagnosis/cognition/communication and ADL performance abilities .IDT to evaluate alternatives to physical restraint use and least restrictive interventions for the least amount of time .Explain and document the risk and benefits of treatment options related to physical restraints/devices to the resident as well as the representative/POA [Power of Attorney] .Obtain a detailed and specific doctor ' s order for the physical restraint/device which includes the specific physical restraint/device as well as when it is to be applied and released .Offer sensory stimulation and social interaction at intervals throughout the day with particular emphasis on the restraint release program-must be released at least q [every] 2 hours .Complete a new Physical Restraint/Device Assessment at least quarterly or if there is a change in the resident ' s condition (or if the medical condition for which the physical restraint is being used changes) to see if a lesser restraint can be used-or .discontinuance of the physical restraint if possible .The care plan must reflect the use of the physical restraint-to include medical conditions as well as releasing at least q 2 hours-and skin checks during use at time of application and removal-with nurse to assess skin as indicated .Always try a restraint alternative before using a physical restraint/device . Review of the facility policy titled, GUIDELINES FOR PHYSICIAN ORDERS-(FOLLOWING PHYSICIAN ORDERS), dated 6/18/2023, revealed, .Policy: It is the policy of the facility to follow the orders of the physician .The facility will have orders to provide essential care to the resident, consistent with the resident ' s mental and physical status upon admission .Procedure: 1) c. Routine care to maintain or improve the resident's functional abilities until staff can conduct a comprehensive assessment and develop an interdisciplinary care plan .2) As assessments are completed, orders will be received from the physician to address significant findings of the assessment .4) 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 facility policy titled, Dressing Change, Clean, dated 1/1/2024, revealed, .ASSESSMENT GUIDELINES: General condition of skin .Mobility status .CARE PLAN DOCUMENTATION GUIDELINES .Consider listing possible risks and complications .Identify the cause of the condition . Review of the facility policy titled, Baseline Care Plan Assessment/Comprehensive Care Plans, dated 3/23/2021, revealed, .The Comprehensive Care Plans will be reviewed and updated every quarter at a minimum. The facility may need to review the care plans more often based on changes in the resident's condition and/or newly developed health/psycho-social issues . Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, Anxiety Disorder, and Seizures. Review of the Physician's Orders dated 12/5/2023 to 6/20/2024, revealed Resident #15 had no order for the table tray attached to a geriatric chair. Review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #15 had a Brief Interview of Mental Status (BIMS) score of 2 which indicated severe cognitive impairment. Continued review of the MDS revealed Resident #15 required substantial/maximal assistance to sit to stand, chair/bed to chair transfer, and walking 10 feet was not attempted due to medical conditions or safety concerns. Further review of the MDS revealed Resident #15 was not coded for a restraint. Review of the care plan for Resident #15 revealed, .[12/6/2023] [named Resident #15] has indicated the following daily preferences are important to her; She sits in a [named] geriatric chair for comfort with an activity table provided by son .[3/21/2024] at risk for developing a pressure ulcer and/or alteration in skin integrity due to bowel and bladder incontinence, impaired bed mobility, cognition, and disease process. She requires assistance with bed mobility, transfers, and toileting .[3/10/24] skin tear right lower leg . Continued review revealed no care plan for a restraint to the geriatric chair. Review of the Medication Administration Record (MAR) for Resident #15 dated 3/1/2024 to 3/31/2024, revealed no documentation of a physical restraint. Review of the Treatment Administration Record (TAR) for Resident #15 dated 3/1/2024 to 3/31/2024, revealed no documentation of a physical restraint. Review of the facility progress note dated 3/10/2024 at 1:58 PM, revealed Registered Nurse (RN) OO documented, .INFORMED BY CNA THAT RESIDENT [Resident #15] SUSTAINED SKIN TEAR TO RIGHT LOWER EXTREMITY FROM [named geriatric] CHAIR. ON ASSESSMENT, BLEEDING SKIN TEAR WITH DETACHED SKIN FLAP, 7.5 CM [centimeter] LONG NOTED TO RIGHT LATERAL CALF .AREA WAS CLEANSED WITH WOUND CLEANSER AND COVERED WITH BORDER GAUZE. RP [responsible party] AND WOUND CARE NURSE NOTIFIED . Review of the MAR for Resident #15 dated 4/1/2024 to 4/30/2024, revealed no documentation of a physical restraint. Review of the TAR for Resident #15 dated 4/1/2024 to 4/30/2024, revealed no documentation of a physical restraint. Review of the facility progress note dated 4/6/2024 at 7:23 PM, revealed the DON documented, resident observed anxious/restless while in wheelchair in hall. this nurse observed resident with small amount of dark red blood on lower left outer leg. observed small skin tear in forestated area on resident's leg. resident continuously rubbing leg on parts of [named geriatric] chair d/t [due to] restlessness. resident unaware d/t current cognitive status. Review of the MAR for Resident #15 dated 5/1/2024 to 5/31/2024, revealed no documentation of a physical restraint. Review of the TAR for Resident #15 dated 5/1/2024 to 5/31/2024, revealed no documentation of a physical restraint. Review of the Weekly Wound Evaluation dated 5/8/2024 revealed, .Right lower leg (front) .Skin Tear . Review of the TAR for Resident #15 dated 6/1/2024 to 6/21/2024, revealed no documentation of a physical restraint and documentation that daily treatments were performed on Resident #15's right leg skin tear. Observation at the 100/200 hall at the nurse's station on 6/11/2024 at 9:50 AM, revealed Resident #15 was sitting in a geriatric chair with a connected tray across her. The table tray was without any activity supplies in front of Resident #15. Continued observation revealed Resident #15's left forearm was wrapped with gauze and a bandage was noted to the front of her right leg. Observation at the 100/200 hall at the nurse's station on 6/11/2024 at 10:46 AM, revealed Resident #15 was sitting in a geriatric chair with a connected tray across her. The table tray was without any activity supplies in front of Resident #15. Continued observation revealed Resident #15's left forearm was wrapped with gauze and a bandage was noted to the front of her right leg. Observation in the dining room on 6/11/2024 at 12:22 PM, revealed Resident #15 was sitting in a geriatric chair with a connected tray across her. Resident #15 was delivered her meal on top of the connected tray. Continued observation revealed Resident #15's left forearm was wrapped with gauze and a bandage was noted to the front of her right leg. Observation in the resident's room on 6/11/2024 at 1:20 PM, revealed Resident #15 was brought back out to the nurse ' s station in the geriatric chair with the tray table across her. No activity supplies were observed on the tray table. Continued observation revealed Resident #15's left forearm was wrapped with gauze and a bandage was noted to the front of her right leg. Observation at the 100/200 nurses' station on 6/11/2024 at 2:10 PM, revealed Resident #15 was sitting in the geriatric chair with a piece of paper on her tray table across the resident. Resident #15 was pulling on the tray with both hands and raising her bottom off the seat. Staff failed to respond to Resident #15 pulling on the tray table and raising her bottom off the seat. Resident #15 then laid her head over to rest on the adjacent wall. Continued observation revealed Resident #15's left forearm was wrapped with gauze and a bandage was noted to the front of her right leg. Observation at the 100/200 nurses' station on 6/11/2024 at 2:20 PM, revealed Resident #15 continued to sit in the geriatric chair with a piece of paper on the tray table across the resident. Resident #15 reached for a Certified Nursing Assistant (CNA) walking by and stated, Come on let's go. The CNA patted her hand and walked away. Continued observation revealed Resident #15's left forearm was wrapped with gauze and a bandage was noted to the front of her right leg. Observation in the dining room on 6/11/2024 at 3:00 PM, revealed Resident #15 was sitting in the geriatric chair with a tray table across the resident. Resident #15's tray remained over the resident during a movie. Resident #15 was noted pulling on the tray lifting her buttocks off of the seat. No staff responded to the resident pulling on the tray and lifting her buttocks off of the seat. Continued observation revealed Resident #15's left forearm was wrapped with gauze and a bandage was noted to the front of her right leg. Observation at the 100/200 nurses' station on 6/11/2024 at 4:05 PM, revealed Resident #15 was sitting in the geriatric chair with tray across the resident. Resident #15 scooted the geriatric chair with her feet in a walking motion for two steps. No staff responded to Resident #15 moving the geriatric chair. Continued observation revealed Resident #15's left forearm was wrapped with gauze and a bandage was noted to the front of her right leg. Observation in the resident's room on 6/11/2024 at 4:45 PM, revealed Resident #15 was being pushed in the geriatric chair from her room with a tray table across her. Resident #15 had no activities on her tray in front of her. Continued observation revealed Resident #15's left forearm was wrapped with gauze and a bandage was noted to the front of her right leg. Observation at the 100/200 nurses' station on 6/12/2024 at 11:18 AM, Resident #15 was sitting in her geriatric chair with a tray table across the resident. Resident #15 was sleeping. Continued observation revealed Resident #15's left forearm was wrapped with gauze and a bandage was noted to the front of her right leg. Review of the medical record revealed no documentation for the bandages to Resident #15's left forearm. During an interview on 6/11/2024 at 4:10 PM, CNA F stated, .[Named Resident #15] has been in the [named chair] since I started working here. I [I've] been here about 8 months .she is not able to remove the tray .she will raise herself up in the chair .she needs assistance with walking . CNA F was asked if Resident #15 ever asks to remove the table tray and was she (CNA F) trained on the use of the geriatric chair. CNA F stated, .she doesn ' t ask for it to be removed .I haven't had training on the use of the [named chair] .I don't know of any other residents that use a tray or any pad alarms . During an interview on 6/11/2024 at 4:14 PM, Licensed Practical Nurse (LPN) O stated, .I have been at the facility for 7 months .[Named Resident #15] has had the [named geriatric chair] and tray since I have been here .if the tray is loose, I make sure the tray is secured .She doesn't ask for it to be removed .she can ' t remove it .She will get angry and shake the tray .she is a big fall risk .I would assume the chair and tray was for her safety .she has seizures .I don't see an assessment for the chair or tray .if a resident has behaviors the CNAs don't chart that they just come tell the nurses .I don't see an order for the [named geriatric chair] and tray . During an interview on 6/11/2024 at 4:20 PM, the MDS Coordinator stated, .[Named Resident #15] got the chair a week after she came [admitted to the facility] .she was trying to get up and kept falling and hurting herself .she should have some type of activity on her tray at all times .snacks, magazines, anything to occupy her .she is happy with something to do .she has Alzheimer's .she is a safety risk . The MDS Coordinator was asked what risk factors are present when placing a resident in a geriatric chair with a tray secured over the resident. The MDS Coordinator stated, .it could be considered a restraint, but it helps keep everything in front of her .we do not document when the tray has been released .I have never known of her asking to remove the tray .the Activities of Daily Living (ADL) charting would show when it was released .we haven't done a device assessment . Review of the medical record revealed the ADL charting did not document when the restraint was released. During an interview on 6/12/2024 at 7:52 AM, the Director of Nursing (DON) stated, .I can't say that the staff had any training [related to named geriatric chair] .typically we don't allow that type of chair . The DON was asked if the facility could physically restrain a resident at the family's request, she stated, No. The DON was asked the medical symptom for the physical restraint. The DON stated, .previous falls and behaviors upon admission .it could be seen as a restraint if the resident was not provided food, snacks, magazines, or activities on her tray .It is not used as a restraint if is used for activities . The DON was asked what the benefits of the physical restraint are. The DON stated, .it's keeping her safe, prevented falls .she can't remove the tray .she is always at the nurse's desk and on the get up list first thing in the morning .the staff know the tray has to make 2 sounds to verify it is locked in place . The DON was unable to provide an order, any assessments, consent for the use, or documentation of removal and timing of the release for the physical restraint. During an interview on 6/12/2024 at 8:15 AM, Registered Nurse (RN) X stated, .[Named Resident #15] can't remove the tray .I don't know of any documentation we do on it when it is released .She will shake the tray when she is frustrated, to go to the bathroom . During a telephone interview on 6/12/2024 at 9:07 AM, Family Member (FM) Y stated, .I didn ' t request that chair .it was suggested to me to help decrease her falls .I have been shown on how the tray functions, but nothing was discussed with me about the risk of the chair . FM Y was asked when he visits Resident #15 does she always have activities on her tray. FM Y stated, .it is about a 50/50 .I don ' t think I signed a consent [for a restraint] for the facility .she was having multiple falls .I don ' t know of any injuries she has had related to the chair . During an interview on 6/12/2024 at 4:35 PM, the Activity Director stated, .[Named Resident #15] can't remove the tray .she gets angry and frustrated and will try to climb out of the chair .I don ' t know of any set time to release the tray .I haven't been told to remove it during activities .I never see her without the tray . During an interview on 6/12/2024 at 5:15 PM, LPN W stated, .I don't know why [Named Resident #15] has the tray across her .I would consider that tray a restraint .she can't remove it .I thought nursing homes quit using those [restraints] years ago . During an interview on 6/13/2024 at 9:05 AM, the Physical Therapy Director stated, .today is the first time I have evaluated [Named Resident #15] for a sitting device [Rocking recliner wheelchair that can tilt back 30 degrees] . During an interview on 6/13/2024 at 10:10 AM, the MDS Coordinator was asked why the Quarterly MDS does not reflect the use of a chair that prevents rising. The MDS Coordinator stated, .well, she didn't have the tray on all the time . During a telephone interview on 6/20/2024 at 11:46 PM, the facility Nurse Practitioner (NP) stated a table tray could be placed in front of a resident if the resident had the mental capacity to remove it themselves. When asked if Resident #15 had the mental capacity to remove a tray table, the NP replied, No, Resident #15 does not have the mental capacity to remove a table tray. During an interview on 6/21/2024 at 12:40 PM, the Wound Care Nurse (WCN) stated Resident #15 tried to get up from the geriatric chair with a table tray connected and sustained a skin tear to the front right lower leg on 3/10/2024. The WCN stated the skin tear was healing when Resident #15 reinjured the same skin tear on 4/6/2024 trying to get out of the geriatric chair with the table tray connected. Continued interview revealed the WCN was asked why Resident #15's arm was wrapped with gauze. The WCN replied, There is nothing wrong with her [Resident #15] arm. Some nurse wrapped it because she [Resident #15] had some swelling to her elbow. When asked about the bandage on Resident #15's leg, the WCN replied, Her [Resident #15] skin tear was from the [named] geriatric chair. During an interview on 6/21/2024 at 1:15 PM, the MDS Coordinator stated she could not find any documentation related to an assessment, physician's order, or monitoring of the table tray connected to the geriatric chair of Resident #15.

Based on facility policy review, medical record review, observation, and interview, the facility failed to provide sufficient staff to provide care and services in assisting residents to attain or maintain their highest practicable level of physical, mental, and psycho-social well-being for all residents at the facility. The findings include: Review of the facility policy titled, GUIDELINES STANDARD SUPERVISION, dated 5/17/2023, revealed, .6. Staff assignments are based on the resident needs as far as their acuity and their assessment results and their person-centered care planning. Therefore, the requirements of meeting those needs to include physical, emotional, psychosocial, social, and spiritual, will be accomplished by provision of as much hands on care as necessary. Further, supportive services to include staff from various departments in the facility and/or outside resources/vender services will be provided when indicated . Review of the Payroll Based Journal (PBJ) Staffing Data Report (A collection of data used to provide information on staffing levels) for 1/1/2023 to 3/31/2024, revealed, .Metric .One Star Staffing Rating .Result .Triggered .Definition .Triggered = Star Staffing Rating Equals 1 .Metric .Excessively Low Weekend Staffing .Result .Triggered .Definition .Triggered .Submitted Weekend Staffing data is excessively low . Continued review revealed, PBJ Staffing Data Report had triggered for Star Staffing Rating Equal 1 and Submitted Weekend Staffing data is excessively low for 1/1/2023 to 3/31/2023, 4/1/2023 to 6/30/2023, 7/1/2023 to 9/30/2023, and 10/1/2023 to 12/31/2023. Review of the FACILITY ASSESSMENT (designed for the facility to evaluate its resident population and identify the resources needed to provide the necessary services) dated 2/23/2024 revealed an average daily census between 72 and 80 residents. 95% - 100% of all residents required assistance with Activities of Daily Living (ADLs) with 1-2 person physical assistance. Review of the medical records revealed Resident #1 was admitted to the facility on [DATE], with readmission on 12/16/2021, with diagnoses which included Generalized Osteoarthritis, Dysphagia and Major Depressive Disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #1, revealed a Brief Interview for Mental Status (BIMS) score of 00, which indicated severe cognitive impairment. Continued review reveals Resident #1 required extensive assistance with bed mobility, transfers, locomotion on unit, dressing, eating, toilet use, and personal hygiene. Review of the care plan for Resident #1 revealed, . [6/2/2023] has potential for nutritional decline R/T [related to]: varied intakes, confusion/dementia, history of GI bleed .Requires extensive to total assist with meals . Review of the Nursing Home Licensure Checklist dated 6/11/2024, revealed a total of 2.58 Per Patient Day (PPD) for that day. Review of the Daily Scheduled Nursing dated 6/11/2024, revealed four (4) nurses and thee (3) CNAs scheduled for the day. Observation throughout the facility on 6/11/2024 at 9:30 AM, revealed four (4) nurses and three (3) CNAs at the facility. The nurses were passing medications, and the three (3) CNAs were assisting residents with breakfast. Meal carts remained on the halls with untouched trays on them, waiting to be taken to assisted diners. During an interview on 6/12/2024 at 10:02 AM, family member (FM) L stated she had been to the facility several times and Resident #1's meal was on her bedside table with no one assisting her. The staff have not been taking the time to comb Resident #1's hair. Review of medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses which included Chronic Diastolic (Congestive) Heart Failure, Morbid (Severe) Obesity Due to Excess Calories, and Anxiety Disorder. Review of the Quarterly MDS dated [DATE] for Resident #10, revealed a BIMS score of 15, which indicated no cognitive impairment. Continued review revealed Resident #10 required extensive assistance with bed mobility, transfers, locomotion on and off unit, dressing, toilet use, and personal hygiene. During an interview on 6/13/2024 at 11:10 AM, Resident #10 stated the facility needed more staff and had waited up to 45 minutes for assistance. Resident #10 was asked how he knew it took up to 45 minutes to answer the call light. Resident #10 responded, I have four (4) phones and a clock. I know how long I have to wait. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses which included Muscle Wasting and Atrophy, Multiple Sites, Type 2 Diabetes Mellitus without Complications, and Atherosclerotic Heart Disease of Native Coronary Artery. Review of the Admission MDS assessment dated [DATE] for Resident #12, revealed a BIMS score of 11, which indicated moderate cognitive impairment. Continued review revealed Resident #12 required the use of a walker, required partial/moderate assistance with oral hygiene, showers/bath, upper and lower body dressing and putting on and taking off shoes, requires supervision and touch assistance with personal hygiene and required set up assistance with eating. During an interview on 6/12/2024 at 11:09 AM, Resident #12 stated he hardly ever seen a Certified Nursing Assistant (CNA) and sometimes had to wait for his call light to be answered for 45 minutes to an hour. When asked how he knew it took that long to answer the call light, Resident #12 stated, I watch the clock and I have a phone. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses which included Lack of Coordination, Urinary Tract Infection (UTI), and Muscle Wasting and Atrophy. Review of the Admission MDS assessment dated [DATE] for Resident #13, revealed a BIMS score of 15, which indicated no cognitive impairment. Continued review revealed the use of a manual wheelchair, required set up assistance with eating, required partial/moderate assistance with upper/lower body dressing, shower/baths, putting on/taking off footwear, rolling left/right, sit to lying, lying to sit, sit to stand position changes, was frequently incontinent of bladder and always incontinent of bowel. During an interview on 6/12/2024 at 4:44 PM, FM III stated she had come into the facility several times and Resident #13 had been soaked with urine up to her shoulders. FM III stated Resident #13 would get changed between 8:00 PM and 10:00 PM but would not receive anymore care until the next morning. Continued interview revealed the weekend staff was low and the dining room was always closed. During an interview on 6/14/2024 at 1:12 PM, Resident #13 stated, .the facility is always short handed .I don't see anyone all night after they put me to bed .It does no good to put the light on because they will not come .I have to wait to be changed at night until right before the shift changes .sometimes it is only one person on this whole hallway . Review of the medical record revealed Resident #17 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, Anxiety disorder, Adult Failure to thrive, Contracture of Muscle, unspecified lower leg, and Contracture of Muscle, unspecified upper arm. Review of the Quarterly MDS dated [DATE], revealed Resident #17 had a staff interview for mental status which indicated poor short term and long-term memory. Continued review revealed Resident #17 was dependent for oral, personal and toileting hygiene, was dependent for shower/bathing, upper and lower body dressing, and putting on and taking off footwear, and partial/moderate assistance with eating. Review of the Care Plan for Resident #17 revealed, .[11/17/2022] Alteration in nutritional status .He is receiving a mechanically altered diet. He requires extensive assistance with his feeding . Observation on 6/12/2024 at 5:30 PM, Resident #17 was being fed by a CNA at the nurses' station close to the 200 Hallway. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses which included Cerebral Infarction, Hemiplegia and Hemiparesis, and Vascular Dementia. Review of the Quarterly MDS dated [DATE], revealed Resident #19 had a BIMS score of 1, which indicated sever cognitive abilities. Continued review revealed Resident #19 required the use of a wheelchair, required substantial/maximum assistance with eating and upper body dressing, and had been totally dependent with oral, toilet, and personal hygiene, dependence for shower/bath, lower body dressing, and putting on/taking off footwear. Review of the Care Plan for Resident #19 revealed, .[1/10/2022] at risk for Alteration in Nutritional Status . Observation on 6/12/2024 at 5:30 PM, Resident #19 was being fed by a CNA at the nurses' station close to the 200 Hallway. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, Acute and Chronic Respiratory Failure with Hypoxia, and Acute and Chronic Diastolic (Congestive) Heart Failure. Review of the Quarterly MDS assessment dated [DATE] for Resident #20, revealed a BIMS score of 12, which indicated moderate cognitive impairment. During an interview on 6/12/2024 at 8:25 AM, Resident #20 stated her call light was left on for an hour and a half. She stated staff would come in the room and say they would come back but did not. Resident #20 stated, If they tell me they will be back, I expect them to. When asked how Resident #20 knew that she waited for an hour and a half for staff to assist her, she replied, I looked at the clock on the wall and pointed to it. Continued interview revealed, Resident #20 stated the weekends were awful and very short staffed and had to wait for even longer periods of time when she called for assistance. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] with diagnoses which included Muscle Wasting and Atrophy, Multiple Sites, Type 2 Diabetes Mellitus with Hyperglycemia, and Dysphagia, Oropharyngeal Phase. Review of the Quarterly MDS assessment dated [DATE] for Resident #21, revealed a BIMS score of 4 which indicated severe cognitive impairment. Continued review revealed Resident #21 required the use of a wheelchair, required partial/moderate assistance with upper body dressing, substantial/maximal assistance with eating, oral hygiene, shower/bath, lower body dressing, dependent for toileting, putting on/taking off footwear and personal hygiene. Review of the Care Plan for Resident #21 revealed, .[2/6/2023] Alteration in Nutritional Status as evidenced by: [named Resident #21] has a dx [diagnosis] pf CVA [Cerebral Vascular Accident], weakness, dysphagia [difficulty with swallowing]. She is on a modified diet with thickened liquids. Dx: Blind, feeding difficulties and requires assistance with meals . Observation on 6/13/2024 at 5:00 PM, Resident #17 was being fed by a CNA at the nurses' station close to the 200 Hallway. Observation of the facility on 6/11/2024 at 9:30 AM, revealed breakfast carts for all residents remained on the hallways. Residents remained in bed and were not being fed in a timely manner. Continued observation revealed three CNAs for 73 residents in the facility at that time. Observation on 6/11/2024 at 5:30 PM, revealed CNA F standing up, feeding a resident at the end of 100 Hall by the nurse's station. Observation of 200 Hallway on 6/12/2024 at 5:25 PM, revealed assisted diners being fed in the hallway by staff. During an interview on 6/12/2024 at 6:35 PM, CNA Z stated, .The dining room has always been closed for dinner since I been here. I believe it's due to not having enough staff in the building as the day progresses. The management staff is mostly gone so there isn't any extra help to be able to get residents to the dining room and assist with feeding . During an interview on 6/12/2024 at 5:20 PM, CNA F stated she fed in the hallway so she could watch the fall risk patients. When asked if she thought feeding in the hallway was because of a staffing issue, CNA F replied, Yes, it would be. During an interview on 6/14/2024 at 8:45 AM, the Staffing Coordinator was asked how many CNAs were present on the morning of 6/11/2024, the Staffing Coordinator responded, .There were 3 CNAs here . When asked if 3 CNAs would be considered sufficient staff to meet the needs of the residents, the Staffing Coordinator stated, No. During an interview on 6/14/2024 at 11:05 AM, the Administrator was asked about the staffing needs at the facility. When asked how he thought breakfast went on the morning of 6/11/2023, the Administrator stated, I imagine breakfast was rough that morning. During an interview on 6/14/2024 at 11:33 AM, Licensed Practical Nurse (LPN) O stated there were only 3 CNAs in the facility on the morning of 6/11/2024. Continued interview revealed LPN O was asked what a reasonable time for a call light to be answered and she replied, A call light should be answered within 5 minutes. During a telephone interview on 6/18/2024 at 2:50 PM, CNA KK was asked if the night shift had ever worked short before. CNA KK replied, .We have worked with 3 people at night before . When asked if she felt this was enough staff to care for the residents at night, CNA KK replied, No. It makes it very hard to care for all the residents and their needs. During an interview on 6/21/2024 at 10:31 AM, CNA LL stated there were more call outs on the weekend, which made it hard to find staff to come in.

Based on facility policy review, medical record review, and interview, the facility failed to have sufficient staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for 2 (Resident #1 and #15) of 7-sampled residents reviewed. The finding included: Review of the facility policy titled, Baseline Care Plan Assessment/Comprehensive Care Plans, dated [DATE], revealed, .The Comprehensive Care Plans will be reviewed and updated every quarter at a minimum. The facility may need to review the care plans more often based on changes in the resident's condition and/or newly developed health/psycho-social issues . Review of the facility policy titled, Guidelines for Physical Restraints/Seclusion, dated [DATE], revealed, .It is the policy of the facility to use physical restraint only as a last resort and only after every other alternative to a physical restraint (based on assessment) that seemed to have the potential for being used successfully, has been tried, and has failed .A physical restraint is NEVER to be used for staff convenience or for discipline .The resident must have a complete order for the restraint which includes the type of restraint and when it is to be applied/released. The restraint order must include the related medical condition. All physical restraints are to [be] released and the resident is to be repositioned at least every 2 hours .If the resident cannot remove the physical restraint device on command-and using the proper technique for removal-the device is considered a physical restraint .Procedure .Complete the initial Physical Restraint Assessment .Review contributing factors such as behaviors/mood/fall risk/medical signs and symptoms/diagnosis/cognition/communication and ADL performance abilities .IDT to evaluate alternatives to physical restraint use and least restrictive interventions for the least amount of time .Explain and document the risk and benefits of treatment options related to physical restraints/devices to the resident as well as the representative/POA [Power of Attorney] .Obtain a detailed and specific doctor's order for the physical restraint/device which includes the specific physical restraint/device as well as when it is to be applied and released .Complete a new Physical Restraint/Device Assessment at least quarterly or if there is a change in the resident's condition (or if the medical condition for which the physical restraint is being used changes) to see if a lesser restraint can be used .The care plan must reflect the use of the physical restraint-to include medical conditions as well as releasing at least q 2 hours-and skin checks during use at time of application and removal-with nurse to assess skin as indicated . Review of the facility policy titled, GUIDELINES FOR PHYSICIAN ORDERS-(FOLLOWING PHYSICIAN ORDERS), dated [DATE], revealed, .Policy: It is the policy of the facility to follow the orders of the physician .The facility will have orders to provide essential care to the resident, consistent with the resident's mental and physical status upon admission .Procedure: 1) c. Routine care to maintain or improve the resident's functional abilities until staff can conduct a comprehensive assessment and develop an interdisciplinary care plan .2) As assessments are completed, orders will be received from the physician to address significant findings of the assessment .4) 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 Job Description for the Administrator dated [DATE], revealed .reporting to the Governing Body, the Administrator leads and directs the overall operations of the facility in accordance with resident needs, government regulations and company policies so as to maintain quality care for the residents while achieving the facility's business objectives. There are multiple role responsibilities such as: working with management while doing planning for facility operations, conducting rounds to ensure resident needs are being addressed, maintaining working knowledge to ensure compliance with all governmental regulations and company's Quality Assurance Standards and management of turn-over to ensure that adequate staffing through development of recruitment resources, training and education while addressing family and resident satisfaction. The Administrator should also have the ability to identify and respond appropriately to potential behavior outbursts and recognize, remove and/or report potential hazards . Review of the undated Job Description for Director of Nursing (DON) revealed he/she will be under the supervision of the Administrator.The DON has the authority, responsibility and accountability for the functions, activities, and training of the nursing services staff .In the absence of the Administrator, the DON assumes responsibility .Role Responsibilities .knowledge, skills and techniques necessary to care for residents .Ensures that a sufficient number of qualified supervisory and supportive nursing personnel are assigned for each unit/shift to meet the residents needs .makes rounds upon entering the building each day .review all Accidents and Incidents daily and develop an appropriate plan to prevent future accident and incidents . Review of the undated Job Description for Registered Nurse revealed, .POSITION SUMMARY: The Registered Nurse provides direct nursing care to the residents and supervises the day-to-day nursing activities performed by nursing assistants. The person holding this position is delegated the administrative authority, responsibility, and accountability for carrying out the assigned duties and responsibilities in accordance with, current existing federal and state regulations and established company policies and procedures to ensure that the highest degree of quality care is maintained at all times .Role Responsibilities .3. Receives telephone orders from physicians and record on the Physicians' Order Form .Transcribes physician's orders to resident charts, cardex [Kardex], and medication cards, treatment/care plans, as required .5. Charts nurses' notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to the care .Drug Administration .1. Prepares and administers medications as ordered by the physician .8. Reviews medication cards for completeness of information, accuracy in the transcription of the physician's order .9. Notifies the attending physician of automatic stop orders prior to the last dosage being administered . Review of the medical records revealed Resident #1 was admitted to the facility on [DATE] with readmission on [DATE] with diagnoses which included Generalized Osteoarthritis, Dysphagia and Major Depressive Disorder. Continued review revealed Resident #1 was a full code status. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 revealed, a BIMS score of 00 which indicated a severe cognitive impairment. Review of Care Plan for Resident #1 revealed, a care plan with goals and interventions that included Advanced Directives .Full Code status on file . Review of the Progress Notes dated [DATE] at 1:30 PM, the DON documented don notified of resident expiring. call made to daughter to notify her. daughter upset with information given. daughter states that she will be here to see her mother soon. awaiting daughter's arrival for funeral arrangements There was no documentation that the physician had been contacted. During a phone interview on [DATE] at 10:08 AM, FM L was asked when she had been contacted by the facility on [DATE] and she stated she received a call when her (Resident #1) had passed and said that she had not been updated concerning her condition prior to her death on that day. During a phone interview on [DATE] at 12:24 PM, MD HH was asked whether she had received a call regarding a change in Resident #1's condition. After MD HH reviewed her notes, there had been no documentation that the facility had contacted her on that day. MD HH reviewed her schedule and stated she had not rounded that day [[DATE]]. During an interview on [DATE] at 12:35 PM, the Traveling DON for Named Consulting Company reviewed the Code Blue Record for Resident #1. The Traveling DON was asked what the expectation for the nursing staff was when a resident was observed with decreased heart rate and respiration, and no obtainable blood pressure and oxygen saturation. The Traveling DON responded, I would expect the nurse to get orders for oxygen, stay with the patient at the bedside and call 911. The physician should have been contacted immediately. During a phone interview on [DATE] at 1:04 PM, the DON stated if a resident had been found with vitals signs at the level noted in the Code Status form (Pulse of 38, ,d+[DATE] respirations per minute, and unattainable blood pressure and oxygen saturation), she would expect the crash cart to be gotten because a code blue would be imminent. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, Anxiety Disorder, and Seizures. Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. Continued review of the MDS revealed Resident #15 required substantial/maximal assistance to sit to stand, chair/bed to chair transfer, and partial/moderate assistance with walking 10 feet. Continued review of the MDS revealed Resident #15 received an Antipsychotic [medication given for psychosis], Antianxiety [medication given for anxiety], Antidepressant [medication given for depression], and Opioid [medication given for severe pain] over the last 7 days. Review of the Quarterly MDS dated [DATE] revealed Resident #15 had a BIMS score of 2 which indicated severe cognitive impairment. Continued review of the MDS revealed Resident #15 required substantial/maximal assistance to sit to stand, chair/bed to chair transfer, and walking 10 feet was not attempted due to medical conditions or safety concerns. Continued review of the MDS revealed Resident #15 received an Antipsychotic, Antianxiety, Antidepressant, and Opioid over the last 7 days. During a telephone interview on [DATE] at 8:42 AM, Hospice Registered Nurse (RN) V stated she knew of maybe 1 or 2 reported Seizures [Named Resident #15] has had. The Lorazepam order was a standing order Hospice gave for a diagnosis of Seizures. The Lorazepam was a PRN [as needed] order that should have only been given if the resident had a Seizure. The Hospice RN V was asked if she had any concerns with Resident #15's care at the facility. Hospice RN V stated, .Yes, inappropriate use of Lorazepam . RN V stated she had educated the staff that the PRN Lorazepam was for Seizures. Resident #15 would become anxious, and the facility had given her the Lorazepam. During a telephone interview on [DATE] at 9:52 AM, LPN JJJ was asked if she recalled giving Resident #15 Lorazepam. LPN JJJ stated the previous nurse that gave me report said Resident #15 had been shaking a lot. Resident #15 had increased agitation, began puled away from the wall, was shaking, and coming out of the chair. RN V stated she saw Resident #15's behavior changes and she gave the Ativan because she knew it was given for seizures or agitation. RN V stated she was not sure of the seizure protocol, so she gave it [Lorazepam] since she was shaking. RN V stated Resident #15 was care planned for behaviors. Continued interview revealed, RN V did not call the MD and was not sure of that notification protocol. During a telephone interview on [DATE] at 10:07 AM, RN X was asked the reason for giving Resident #15 Ativan. RN X chuckled and replied, I gave it for agitation. That is the only time I would give this medication. When asked about the physician's order that read to give for seizure activity, RN X stated Resident #15 got upset, her hands start shaking, and that was the seizure activity, so we gave it. RN X stated hospice had told staff to do that. Continued interview revealed, RN X stated she had learned since then; the seizure-like activity usually happened when Resident #15 needed to go to the bathroom. Now, staff did that first instead of giving the medicine right away. Further interview revealed RN X was asked if the physician was notified if the resident was having seizure activity. RN X replied, No. I do not notify the physician about the seizures. Hospice said if we have to give her more than 2 or 3 doses a day, then we could give them a call. During a telephone interview on [DATE] at 10:21 AM, the Pharmacist stated Resident #15 had been prescribed Lorazepam 2 mg by the Hospice MD as of [DATE]. When asked what the recommended route for Lorazepam would be related to seizures, the Pharmacist stated it would be hard to give Lorazepam PO [by mouth] during an active seizure. The Pharmacist recommended Lorazepam as an injectable or a cream. Continued interview revealed, the Pharmacist then stated the lorazepam 2 mg injectable would typically be available in the Cubex (a medication dispenser for controlled substances), however there was none available at that time per the Pharmacist. Review of the Physician's Orders dated [DATE] to [DATE], revealed Resident #15 did not have an order for a geriatric chair with a table tray connected. Review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #15 had a Brief Interview of Mental Status (BIMS) score of 2 which indicated severe cognitive impairment. Continued review revealed the MDS for Resident #15 was not coded for a restraint. Review of the care plan for Resident #15 dated [DATE], revealed no care plan for a restraint to the geriatric chair. Review of the Medication Administration Record (MAR) for Resident #15 dated [DATE] to [DATE], revealed no documentation of a physical restraint. Review of the Treatment Administration Record (TAR) for Resident #15 dated [DATE] to [DATE], revealed no documentation of a physical restraint. Review of the Weekly Wound Evaluation dated [DATE] revealed, a skin tear to the front of the right lower leg. Review of the TAR for Resident #15 dated [DATE] to [DATE], revealed no documentation of a physical restraint. Continued review revealed there was no documentation that treatments were performed daily on Resident #15's right leg skin tear. During an interview on [DATE] at 4:14 PM, Licensed Practical Nurse (LPN) O stated Resident #15 had the (named) geriatric chair since she had been working at the facility (7 months). LPN O stated Resident #15 could not remove the restraint from the geriatric chair and had never asked for it to be removed. LPN O stated Resident #15 would get angry and shake the table tray. Continued interview revealed LPN O could not find an assessment or an order for the geriatric chair or the table tray (restraint). During an interview on [DATE] at 4:20 PM, the MDS Coordinator stated, Resident #15 received the geriatric chair with a table tray about a week after she was admitted to the facility. When asked what risk factors were present when placing a resident in a geriatric chair with a tray secured over the resident, the MDS Coordinator stated it could be considered a restraint. Continued interview revealed the MDS Coordinator confirmed there was no documentation when the tray was released or a device assessment. Review of the medical record revealed no documentation of when the restraint was released. During an interview on [DATE] at 7:52 AM, the Director of Nursing (DON) stated, she could not verify staff had been trained related to the geriatric chair with a table tray. The DON stated the facility did not typically allow this type of chair, but the family had requested the geriatric chair with the table tray. The DON was asked if the facility could physically restrain a resident at the family's request and she stated, No. The DON was asked the medical symptom for the physical restraint. The DON stated Resident #15 had previous falls and behaviors upon admission. The DON stated the tray was not used as a restraint if it was used for activities. The DON was asked what the benefits of the physical restraint were. The DON stated the benefit was to keep Resident #15 safe and prevented falls. Continued interview revealed Resident #15 could not remove the table tray. Further interview revealed, the DON was unable to provide an order, any assessments, consent for the use, or documentation of removal and timing of the release for the physical restraint. During an interview on [DATE] at 8:15 AM, Registered Nurse (RN) X stated Resident #15 was unable to remove the tray and she was not aware of any documentation on the tray when it was released. During a telephone interview on [DATE] at 9:07 AM, Family Member (FM) Y stated the geriatric chair with the tray table was suggested to him by the DON. Further interview revealed FM Y did not know of any injuries Resident #15 had related to the chair. During an interview on [DATE] at 5:15 PM, LPN W stated Resident #15 could not remove the tray. During an interview on [DATE] at 9:05 AM, the Physical Therapy Director stated that this day was the first time Resident #15 had ever been evaluated for a sitting device [Rocking recliner wheelchair that can tilt back 30 degrees]. During an interview on [DATE] at 10:10 AM, the MDS Coordinator stated the Quarterly MDS did not reflect the use of a chair that prevented rising because Resident #15 did not have the tray in front of her at all times. During a telephone interview on [DATE] at 11:46 PM, Nurse Practitioner (NP) was asked if a table tray could be considered a restraint. The NP stated if a resident had the mental capacity to remove the tray themselves, it could be placed in front of a resident. When asked if Resident #15 had the mental capacity to remove a tray table, the NP replied, No, Resident #15 does not have the mental capacity to remove a table tray. During an interview on [DATE] at 12:40 PM, the Wound Care Nurse (WCN) stated Resident #15 sustained a skin tear to the front of the right lower leg when she tried to get up from the geriatric chair with a table tray connected. During an interview on [DATE] at 1:15 PM, the MDS Coordinator confirmed she was unable to find any documentation related to an assessment, physician's order, or monitoring of the table tray connected to the geriatric chair of Resident #15. Observation at the ,d+[DATE] nurses' station on [DATE] at 2:10 PM, revealed Resident #15 was sitting in the geriatric chair pulling on the tray with both hands and raising her buttocks off the seat. The staff failed to respond to Resident #15 pulling on the tray table and raising her buttocks off the seat. Observation in the dining room on [DATE] at 3:00 PM, revealed Resident #15 was sitting in the geriatric chair with a tray table across the resident during a movie. Resident #15 was observed pulling on the tray and lifting her buttocks off of the seat. No staff responded to the Resident #15.

47127 Based on facility policy review, temperature log review, observation, and interview, the facility failed to minimize the potential for foodborne illness transmission by not properly cleaning and sanitizing the inner components of the ice machine for 73 of 73 residents. The facility failed to document refrigerator temperatures to ensure the food was kept at a safe level for 3 of 3 nourishment room refrigerators which has the potential to effect all residents. The facility failed to ensure that food was not left in the refrigerator beyond safe to use by dates in all Nourishment Room Refrigerators. The findings included: Review of the undated policy titled Physical Plant-Daily Inspection, revealed, .Refrigerators .Inspect .check for cleanliness and clean if needed and check for proper operation .Ensure a working thermometer is present inside the unit and temperature is taken daily . Review of the policy titled Food Brought into The Facility by Friends/Family/Others [Outside Sources] For Resident Policy, dated 11/28/2016, revealed, .Food/beverages brought in may be stored in the resident ' s personal refrigerator or in the facility ' s appropriate pantry or refrigerator freezer .Foods/beverages that are in the original manufacturer's container when brought in will be labeled appropriately, but will be discarded after the expiration date .Cooked and [prepared foods brought in for resident will .be appropriately labeled and dated when accepted for storage and discarded after 48 hours .All refrigerators in use in the facility have an internal thermometer to monitor temperature .All refrigerators have their internal temps recoded daily . Review of the undated policy titled Ice Machine Preventative Maintenance, revealed .the facility should be checked for proper ice level, if not at satisfactory level, check equipment operation. The facility should also look for any calcium, lime, or algae. Check to ensure it is in a clean and sanitized state. This includes all ice machines throughout the facility including Dietary . Review of (Named Dietetic Solutions) Nutritional Services/Operations Policy Use By Guidelines dated 6/12/2023, revealed, .Foods with a manufacturer's use by date will still require an opened on date once the item is opened . [Named nutritional supplement] opened and refrigerated should be discarded after 4 days and thickened liquid, opened should be refrigerated for no more than 7 days. Observation on 6/11/2024 at 12:14 PM, in the 400 Hall nourishment room, revealed a large bottle of mustard, 2 bottles of mayonnaise, and 1 bottle of ketchup, and 1 bottle of salad dressing were in the refrigerator with no resident name and no open date present. There were 2 open jars of Pure Cranberry juice labeled room [ROOM NUMBER] with no open date present and an opened container of thickened fruit punch with delivery date of 5/7/2024 but no open date or discard by date present. There were 2 unlabeled and undated partially eaten frozen ice cream items in the freezer. The refrigerator temperature log was labeled May 2024 and had two temperatures documented on the 13th and 14th and the remaining dates had no temperatures documented. Observation of the nourishment room between 100 and 200 Hall on 6/11/2024 at 12:20 PM, revealed a bottle of pineapple juice with no open date, an opened container of thickened fruit punch with delivery date of 5/7/2024 and no open/use by date, a bottle of apple juice and thickened tea, both with delivery dates of 4/2/2024 and no open/use by date present, and a container of [Named nutritional supplement] Vanilla Shake with delivery date of 4/30/2024, with no open/use by date present. There were multiple food items in plastic grocery bags with no label, no date and a bag of potatoes with no label and no date. Observation on 6/11/2024, in the 200 Hall nourishment room at 12:35 PM, revealed a container of [Named nutritional supplement] vanilla shake with delivery date of 4/30/2024 and opened Thickened Sweetened Tea with delivery date of 4/2/2024 with no open date. The refrigerator temperature log labeled May 2024 had 1 temperature recorded and 30 days with no temperature recorded. Observation and interview on 6/11/2024 at 1:35 PM, during a walking round with the Dietary Manager (DM), revealed outdated items were identified in 3 of the 3 nourishment rooms which included [Named nutritional supplement], thickened sweet tea, and fruit juice. The Dietary Manager stated those items should not have remained in the refrigerator. The ice machine in the 400 Hall nourishment room contained pink colored debris on the white surface inside the ice machine and this was confirmed present by the DM. Observation and interview on 6/11/2024 at 1:42 PM, was conducted in the Nourishment Room on the 400 Hall with the Director of Nursing (DON). The DON confirmed the debris in the ice machine and stated it should not have been there. Observation and interview on 6/11/2024 at 2:05 PM, revealed the Administrator was present in the 400 Hall nourishment room and the Maintenance Director walked in as well. The Administrator instructed the Maintenance Director to take the ice machine out of service. Observation on 6/14/2024 at 11:10 AM, revealed the refrigerator in the 200 Hall Nourishment Room had an open container of nutritional supplement with delivery date of 4/2/2024, with no open or use by date, and continued to have brown debris in the bottom of the refrigerator. Observation on 6/17/2024 at 10:25 AM, in the nourishment room located between the 100 and 200 Hall, revealed there was an open container of thickened sweet tea with delivery date of 6/2/2024 that had no open date and no use by date. Observation on 6/17/2024 at 10:30 AM, in the nourishment room behind the 200 Hall desk, revealed the brown debris continued to be at the bottom of the refrigerator. Observation on 6/17/2024 at 10:35 AM, revealed in the 400 Hall refrigerator there continued to be 4 opened condiment bottles with no label and no open or use by date on them. The ice scoop was observed in the ice chest. Observation on 6/17/2024 at 11:00 AM, revealed the refrigerator in the 200 Hall Nourishment Room remained soiled with the brown debris at the bottom under the drawers and had not been cleaned.

Based on facility policy review, medical record review, police report review, and interview, the facility failed to report allegations of sexual abuse to the State Survey Agency (SSA) for 3 of 4 (Residents #6, #7, and #18) sampled residents reviewed. On an unknown date, Resident #6, who had a diagnosis of Spastic Quadriplegia with Cerebral Palsy, stated Resident #10 made nonconsensual sexual advances toward her by touching her hair and rubbing her on the thighs without permission. Resident #6 stated Resident #10 continued to rub on her thighs and antagonized her during activities to the point where she is fearful and uncomfortable around Resident #10. On an unknown date, Resident #7 stated Resident #10 made nonconsensual sexual propositions, grabbed her hand, and rubbed her thighs. Resident #7 stated that she doesn't want Resident #10 around her or touching her without permission because he made her feel uncomfortable. On 6/11/2024, Resident #18 stated that she reported to the Activities Director, Administrator, and Director of Nursing (DON) that Resident #10 came into her room and demanded that she give him a kiss then motioned toward her. Resident #18 stated she yelled for Resident #10 to get out my room. The facility also failed to report an allegation of suspected neglect to the SSA for 1 of 4 (Resident #9) sampled residents reviewed. Family Member (FM) ZZ contacted law enforcement and requested they do a welfare check at the skilled nursing facility. When law enforcement arrived at the facility, Resident #9 was tearful and reported an allegation of neglect. Resident #9 alleged she had attempted to contact her nurse Licensed Practical Nurse (LPN) B for needed medications. Resident #9 felt she was not being adequately cared for and did not receive her medication as scheduled. The finding include: Review of the facility policy titled, Abuse Prevention Program, dated 10/22/2022 revealed, .It is the policy of this facility to prevent resident abuse, neglect, mistreatment .The following procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect of a resident by a 3rd party .Staff should report their knowledge of allegations without fear of reprisal .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. The Administrator is the Abuse Coordinator .Such reports may be made without fear of retaliation. Anonymous reports will also be thoroughly investigated .Upon learning of the report, the Administrator .shall initiate an incident investigation .the Administrator or designee utilizing the Incident Reporting System will immediately notify the Department of Health by the online system .All incidents will be documented, whether or not abuse occurred was alleged or suspected .The final investigation report will be completed within the required timeframe . Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses which included Spastic Quadriplegic Cerebral Palsy, Bipolar Disorder, Anxiety Disorder, and Depression. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Review of the Comprehensive Care Plan dated 4/17/2024 revealed no interventions to address allegations of sexual abuse. During an interview on 6/12/2024 at 8:02 AM, Resident #6 stated, .I had issues with [Named Resident #10]. [Named Resident #10] keeps rubbing my leg. [Named Resident #10] reaches towards me to hold my hands. I tell him to stop, but he doesn't and just laughs. I don't want another man touching me. He does it to other women. I have reported the incidents to the Administrator and DON, and they told me they were going to handle it. The first incident occurred last summer around June 2023 and continues to happen . Review of medical record revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Parkinson's Disease, Anxiety Disorder, and Dementia. Review of the Quarterly MDS dated [DATE] revealed a BIMS score of 11 which indicated moderate cognitive impairment. Review of the Comprehensive Care Plan dated 5/2/2024 revealed no interventions to address allegations of sexual abuse. During an interview on 6/12/2024 at 7:52 AM, Resident #7 stated, .I have had issues with [Named Resident #10]. I don't remember the exact dates. He always reaches to hold my hand. I would slap his hands away. I reported the incident to the Administrator. I am unsure if they are doing anything about it . Review of medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses which included Chronic Diastolic (Congestive) Heart Failure, Morbid (Severe) Obesity Due to Excess Calories, and Anxiety Disorder. Review of the Quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated no cognitive impairment. Review of the Comprehensive Care Plan revealed, .[Named Resident #10] has an alteration in behaviors as evidenced by: yelling at staff and others at times. 4/19/23 [4/19/2023] verbally aggressive with others. 6/8/23 [6/8/2023] verbally loud and argumentative with staff and other residents. 2/8/24 [2/8/2024] verbally agitated with staff and residents. 2/21/24 [2/21/2024] throwing objects out of room into hallway, verbal threats. 3/17/24 [3/17/2024] cursing staff, throwing things in room, banging on his garbage can . Further review revealed no appropriate interventions for allegations of inappropriate sexual behaviors. During an interview on 6/13/2024 at 11:00 AM, Resident #10 stated, .I was sent out yesterday [6/12/2024] because I told [Named Resident #18] to give me a kiss on Tuesday [6/11/2024], and she told on me . Resident #10 was asked had he any issues before with residents. Resident #10 smirked and laughed, then stated, .I had a resident report that I was rubbing her hair . Review of the medial record revealed Resident #18 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Muscle Wasting and Atrophy Right Shoulder, Difficulty in Walking, and Muscle Wasting and Atrophy Left Shoulder. Review of the Quarterly MDS dated [DATE] for Resident #18 revealed a BIMS score of 15 which indicated no cognitive impairment. Review of the Comprehensive Care Plan for Resident #18 revealed no interventions for allegations of sexual abuse. During an interview on 6/12/2024 at 6:35 PM, Resident #18 stated, .[Named Resident #10] came into my room and demanded I give him a kiss. Then, proceeded to come toward me. I yelled for him to get out my room.[Resident #10] looked at me and laughed then left out my room. I will fight him if he tries that again in order to protect myself. I notified the Administrator, DON, and Activities Director of the incident . During an interview on 6/11/2024 at 2:24 PM, The Ombudsman stated, .On 2/12/2024, [Named Residents #6 and #7] reported to me that they were having issues with [Named Resident #10] touching them without permission. Both [Named Residents #6 and #7] stated they had reported the incidents to the Adminitsrator and DON, but the issues with the unwanted touching continue. I spoke with the Administrator and DON regarding what was disclosed to me by [Named Residents #6 and #7]. The facility hadn't put anything in place to address the incidents that were reported to them by the residents [Named Resident #6 and #7]. The Administrator and DON also stated that the incidents weren't reported to the state . During an interview on 6/12/2024 at 9:48 AM, The DON stated, .Last year [2023] I believe there was incident between [Named Residents #6 and #10] about [named Resident #10] touching [Named Resident #6]'s ponytail. That is the only incident I can recall regarding [Named resident #10]. The incident wasn't reported to the state . During an interview on 6/12/2024 at 11:06 AM, the Administrator stated he was the abuse coordinator. The DON was his backup abuse coordinator. The Administrator stated, .I was aware of the incident between [Named Residents #6 and #10] regarding a ponytail being touched .[Named Resident #6] wanted [Named DON]'s help regarding [Named Resident #10] being rude and antagonizing her. The Ombudsman did inform me and the DON regarding [Named Resident #10]'s behaviors [sexual] toward [Named Residents #6 and #7]. [Named Resident #10]'s behaviors should be care planned. The Ombudsman did speak with me and the DON regarding concerns she had about 2 residents [Named Residents #6 and #7] having issues with [Named Resident #10] . The Administrator was asked what is the protocol when abuse is reported to him. The Administrator stated, .I follow the abuse policy, make sure the resident is safe, conduct an investigation, and report within 2 hours . The Administrator was asked if the incidents regarding Residents #6 and #7 were reported, and he stated no. During an interview on 6/12/2024 at 4:16 PM, the Activities Director stated, .I've been having issues with [Named Resident #10] for over a year now. During activities, he over talks residents and becomes very combative. [Named Resident #10] places his hands wherever he can on female residents such as hands, legs, and thighs. Then tells them you know you want it. I've witnessed those incidents during activities. Female residents are afraid of him. I reported everything that occurred to the Administrator and DON. I was told that as long as he doesn't hurt anyone there's nothing they can do. I witnessed [Named Resident #10] putting his hand on and rubbing [Named Resident #7]'s knee. I kept a log of the incidents involving [Named Resident #10] and gave it to the DON in a folder. I was told by the Administrator that I can't ask him to leave activities because he has a right to be there. It was also reported to me by [Named Resident #18] that [Named Resident #10] came into her room and demanded he kiss her. The Administrator and DON are well aware of the issues with [Named Resident #10] . During an interview on 6/13/2024 at 1:00 PM, the DON stated, .[Named Administrator] is the abuse coordinator. I would consider a resident attempting to kiss another resident without permission sexual abuse. [Named Resident #10] was sent out last night [6/12/2024] to the hospital for psychological evaluation due to behaviors . The DON was asked what type of behavior Resident #10 was sent out for. The DON responded, .I believe it was for attempting to kiss another resident . The DON was asked when did the incident occur involving the kiss. The DON stated the day before [6/11/2024]. The DON was asked if she would consider that a reportable incident. The DON stated, .Yes, the incident between [Named Resident #10 and #18] would be considered a reportable incident, but it was not reported to the state . Review of medical records revealed Resident #9 was admitted to the facility on [DATE] with readmission on 5/25/2024 with diagnoses which included End Stage Renal Disease, Dependence on Renal Dialysis, Acquired Absence of Right Leg Above the Knee, and Type 1 Diabetes Mellitus. Review of the Admission MDS assessment dated [DATE], revealed Resident #9 had a BIMS score was 15 which indicated no cognitive impairment. Continued review revealed Resident #9 requires the use of a wheelchair, had been occasionally incontinent of Bowel and Bladder, had a surgical wound, and required dialysis. Review of the undated Care Plan for Resident #9 revealed, Resident #9 was .at risk for an alteration in comfort related to diabetic polyneuropathy, chronic pain and Right AKA (above the knee amputation) .4/12/2024 surgical wound to right AKA .impaired visual function .legally blind . Review of the police report dated 4/29/2024 at 4:18 AM, revealed Resident #9 submitted a report alleging neglect of an Elderly or Vulnerable Adult.On 4/29/2024 Family Member (FM) ZZ called local law enforcement related to a welfare check at [named facility's address]. Resident #9 was crying .she feared retaliation from staff for speaking out against them [the staff]. Named Resident #9 attempted to contact her nurse [LPN B] started at midnight and she was not available no one else could access the medication. The nurse appeared shortly after the police had arrived at the facility .Resident #9 alleged the facility was the cause of her lower limb amputation . During an interview on 6/20/2024 at 12:24 PM, the Nurse Practitioner (NP) stated Resident #9 was a medically complex resident. Resident #9 was a brittle Diabetic, required dialysis and has had an amputation. Resident #9 psychologically had concerns with depression, anxiety and a lack of social support. The NP remembers being told about a time when Resident #9 had not been given her medication on the night shift but did not recall any pertinent details. During an interview on 6/17/2024 at 3:20 PM, LPN B stated Resident #9 had prescription for Vistaril (medication has been used for anxiety, nausea, vomiting and itching) that was requested more often than prescribed. LPN B said the technicians were intercepting Resident #9's phone calls for her because the medication was not available. LPN B stated the prescription had been changed from every 4 hours and Resident #9 was still requesting it be given that often. During an interview on 6/18/2024 at 10:00 AM. The Regional Director of Operations (RDO) stated he had reviewed the police report initiated by Resident #9 and noticed there was an allegation of neglect. The RDO stated the allegation should have been reported to the SSA within the 2-hour window. The RDO confirmed the allegation was not reported.

Based on facility policy review, medical record review, observation, and interview, the facility failed to assure that a resident received an accurate assessment by staff qualified to assess relevant care areas for 1 of 1 (Resident #15) sampled residents reviewed. The findings include: Review of the Resident Assessment Instrument (RAI) (a means of ensuring that residents receive the highest quality of care and can maintain the highest quality of life) dated 10/2023, revealed .Intent: The intent of this section is to record the frequency that the resident was restrained by any of the listed devices or an alarm was used, at any time during the day or night, during the 7- day look-back period. Assessors will evaluate whether or not a device meets the definition of a physical restraint or an alarm and code only the devices that meet the definitions in the appropriate categories .Proper interpretation of the physical restraint definition is necessary to understand if nursing homes are accurately assessing manual methods or physical or mechanical devices, materials or equipment as physical restraints and meeting the federal requirements for restraint use .The regulation specifically states, 'The resident has the right to be free from any physical or chemical restraints imposed for the purposes of discipline or convenience and not required to treat the resident's medical symptoms' (42 CFR 483.10(e)(1) and 483.12) .Prior to using any physical restraint, the nursing home must assess the resident to properly identify the resident's needs and the medical symptom(s) that the restraint is being employed to address. If a physical restraint is needed to treat the resident's medical symptom(s), the nursing home is responsible for assessing the appropriateness of that restraint .Residents who are cognitively impaired are at a higher risk of entrapment and injury or death caused by physical restraints. It is vital that physical restraints used on this population be carefully considered and monitored .When the interdisciplinary team determines that the use of physical restraints is the appropriate course of action, and there is a signed physician order that gives the medical symptom supporting the use of the restraint, the least restrictive manual method or physical or mechanical device, material or equipment that will meet the resident's needs must be selected .Steps for Assessment 1. Review the resident's medical record (e.g., physician orders, nurses' notes, nursing assistant documentation) to determine if physical restraints were used during the 7-day look-back period .2. Consult the nursing staff to determine the resident's cognitive and physical status/limitations .3. observe the resident to determine the effect the restraint has on the resident's normal function .4.Evaluate whether the resident can easily and voluntarily remove any manual method or physical or mechanical device, material, or equipment attached or adjacent to their body .5. Any manual method or physical or mechanical device, material or equipment should be classified as a restraint only when it meets the criteria of the physical restraint definition .6. Determine if the manual method or physical or mechanical device, material, or equipment meets the definition of a physical restraint as clarified .After determining whether or not an item listed in (P0100) is a physical restraint and was used during the 7-day look-back period, code the frequency of use . The facility uses the RAI manual in the place of a MDS policy. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, Anxiety Disorder, and Seizures. Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. Review of the Quarterly MDS dated [DATE] revealed Resident #15 had a BIMS score of 2 which indicated severe cognitive impairment. Continued review of the MDS revealed Resident #15 was not coded for a restraint. Review of the Care plan dated 12/5/2024, revealed, .Interventions .1/13/2024 Have resident up in [Named chair] with activity table when awake near nurses [nurses'] station for closer observation . The care plan does not reflect the use of the physical restraint, the medical condition for the use, or when the restraint will be released as noted per the facility policy. Observation on 100/200 hall at the nurse's station on 6/11/2024 at 9:50 AM, 10:46 AM, 12:22 PM, 2:10 PM, 2:20 PM, 3:00 PM, 4:04 PM, and 4:45 PM revealed Resident #15 was sitting in a geriatric chair (a large padded supportive recliner that can be placed in upright position or reclined) with a connected tray across her. Observation at the 100/200 hall nurses' station on 6/12/2024 at 11:18 AM, revealed Resident #15 was sitting in the hallway in a geriatric chair with a tray across her. Resident #15 was unable to release the table tray and get up out of the geriatric chair without assistance. During an interview on 6/11/2024 at 4:20 PM, the MDS Coordinator stated Resident #15 received the geriatric chair a week after she came to the facility. The MDS Coordinator was asked what were the risk factors when placing Resident #15 in a geriatric chair with a tray secured over her. The MDS Coordinator stated, .it could be considered a restraint . The MDS Coordinator stated no one documented the tray had been released and had never known of her (Resident #15) asking to remove the tray. Continued interview revealed the facility had not completed a device assessment. During an interview on 6/12/2024 at 7:52 AM, the Director of Nursing (DON) was asked if the facility could physically restrain a resident at the family's request. The DON stated, No. The DON was then asked the medical symptom for the physical restraint. The DON stated Resident #15 had the geriatric chair for previous falls and behaviors upon admission. The DON was asked what the benefits of the physical restraint are. The DON stated it was for keeping Resident #15 safe and prevent falls. Further interview revealed the DON was unable to provide a physician's order, any assessments, consent for the use, or documentation of removal and timing of the release for the physical restraint. During an interview on 6/13/2024 at 10:10 AM, the MDS Coordinator was asked why the Quarterly MDS does not reflect the use of a chair that prevented Resident #15 from rising. The MDS Coordinator stated, .well she didn't have the tray on all the time . During an interview on 6/21/2024 at 1:15 PM, the MDS Coordinator stated she could not find any documentation related to an assessment, physician's order, or monitoring of the table tray connected to the geriatric chair of Resident #15. When asked if she went out to do the assessment of the restraint, the MDS Coordinator stated, I do not go out myself to do the assessment, I go by what is charted. During an interview on 6/21/2024 at 4:05 PM, the Regional [NAME] President (RVP) Clinical Services stated the facility did not have a MDS policy and the coordinator should follow the RAI manual for the MDS.

Based on facility policy review, medical record review, and interview, the facility failed to implement a comprehensive person-centered care plan with appropriate interventions for 5 of 6 (Residents #6, #7, #10, #15, and #18) sampled residents reviewed. The findings include: Review of the facility policy titled, Baseline Care Plan Assessment/Comprehensive Care Plans, revised 3/21/2021, revealed .The Comprehensive Care Plan will be reviewed and updated every quarter at a minimum. The facility may need to review the care plans more often based on changes in the resident's condition and/or newly developed health/psycho-social issues . Review of the facility policy titled, Guidelines for Physical Restraints/Seclusion, dated 5/17/2023, revealed, .The care plan must reflect the use of the physical restraint-to include medical conditions as well as releasing at least q 2 hours-and skin checks during use at time of application and removal-with nurse to assess skin as indicated . Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses which included Spastic Quadriplegia Cerebral Palsy, Bipolar Disorder, Aphasia, Anxiety Disorder, and Depression. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #6 revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Review of the Comprehensive Care Plan dated 4/17/2024 for Resident #6 revealed no interventions were added to address sexual abuse when Resident #10 touched Resident #6's hair and rubbed her thigh without permission. During an interview on 6/12/2024 at 8:02 AM, Resident #6 stated she had issues with [Named Resident #10]. [Named Resident #10] keeps rubbing her leg. [Named Resident #10] reaches toward her to hold her hands. She stated she would tell him to stop, but he doesn't and just laughs. She stated she doesn't want another man touching her. He does it to other women. She stated that she reported the incidents to the Administrator and DON, and they told her they were going to handle it by getting [Named Resident #10] transferred. The first incident occurred last summer around June [2023] and continues to happen. Resident #6 stated she doesn't want to leave her room because [Named Resident #10] makes her feel uncomfortable, and she doesn't want to be around him. The Administrator and DON keep telling her they are working on doing something about the incidents. Resident #6 stated she doesn't want to keep talking about the incidents because she doesn't want to get kicked out the facility for seeming like she is causing problems due to reporting the incidents. Review of medical record revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Polyneuropathy, Parkinson's Disease, Anxiety Disorder, and Dementia. Review of the Quarterly MDS dated [DATE] revealed a BIMS score of 11 which indicated moderate cognitive impairment. Review of the Comprehensive Care Plan dated 5/2/2024 revealed no interventions were added to address sexual abuse when Resident #10 made nonconsensual sexual propositions with Resident #7, grabbed her hand, and rubbed her thighs. During an interview on 6/12/2024 at 7:52 AM, Resident #7 stated that she has had issues with [Named Resident #10]. Resident #7 stated that she doesn't remember the exact dates. Resident #6 stated [Named Resident #10] always reaches to hold her hand. She stated she would slap his hands away. Resident #7 stated that she reported the incident to the Administrator. Resident #7 stated she is unsure if they are doing anything about it. Resident #7 stated that [Resident #10] says the most inappropriate things sometimes, and that [Named Resident #10] makes her feel uncomfortable, and she doesn't want to be around him . Resident #7 was asked if she could share some of the comments Resident #10 had made. Resident #7 stated she would rather not go into detail about the comments. Resident #6 stated that [Named Resident #10] causes issues all the time during activities by trying to touch on other women and yelling at staff and other residents. Resident #7 stated that [Named Resident #6] is another woman here in the facility that Resident #10 has touched on. Review of medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses which included Chronic Diastolic (Congestive) Heart Failure, Morbid (Severe) Obesity Due to Excess Calories, and Anxiety Disorder. Review of the Quarterly MDS dated [DATE] for Resident #10 revealed a BIMS score of 15 which indicated no cognitive impairment. Review of the Comprehensive Care Plan for Resident #10 revealed, .[Named Resident #10] has an alteration in behaviors as evidenced by: yelling at staff and others at times. 4/19/23 [2023] verbally aggressive with others. 6/8/23 [2023] verbally loud and argumentative with staff and other residents. 2/8/24 [2024] verbally agitated with staff and residents. 2/21/24 [2024] throwing objects out of room into hallway, verbal threats. 3/17/24 [2024] cursing staff, throwing things in room, banging on his garbage can . Further review revealed no interventions for allegations of sexual abuse. During an interview on 6/13/2024 at 11:00 AM, Resident #10 stated, .I was sent out yesterday [6/12/2024] because I told [Named Resident #18] to give me a kiss on Tuesday [6/11/2024], and she told on me . Resident #10 was asked had he any issues before with residents. Resident #10 smirked and laughed, then stated, .I had a resident report that I was rubbing her hair . During an interview on 6/12/2024 at 11:06 AM, the Administrator stated [Named Resident #10]'s behaviors should be care planned. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, Anxiety Disorder, and Seizures. Review of the Admission MDS dated [DATE] revealed Resident #15 had a BIMS score of 3 which indicated severe cognitive impairment. Review of the Quarterly MDS dated [DATE] revealed Resident #15 had a BIMS score of 2 which indicated severe cognitive impairment. Continued review of the MDS revealed Resident #15 was not coded for a physical restraint (table tray). Review of the care plan revealed, .Interventions .[1/13/2024] Have resident up in [Named chair] with activity table when awake near nurses [nurse's] station for closer observation . The care plan did not reflect the use of the physical restraint, the medical condition for the use or when the restraint will be released as noted per the facility policy. During an interview on 6/11/2024 at 4:20 PM, the MDS Coordinator stated Resident #15 received the geriatric chair a week after she admitted into the facility. Resident #15 was trying to get up and kept falling. The MDS Coordinator was asked what risk factors are present when placing a resident in a geriatric chair with a tray secured over the resident. The MDS Coordinator stated the tray could be considered a restraint. During an interview on 6/12/2024 at 7:52 AM, the Director of Nursing (DON) stated the family requested for the table tray for Resident #15. The DON was asked if the facility could physically restrain a resident at the family's request, she stated, No. The DON was asked the medical symptom for the physical restraint. The DON stated it was for previous falls and behaviors upon admission. The DON was asked what the benefits of the physical restraint are. The DON stated to keep the resident safe and prevent falls. The DON was unable to provide an order, any assessments, consent for the use, or documentation of removal and timing of the release for the physical restraint. During an interview on 6/13/2024 at 9:05 AM, the Physical Therapy Director stated, .today is the first time I have evaluated [Named Resident #15] for a sitting device . During an interview on 6/13/2024 at 10:10 AM, the MDS Coordinator was asked why the Quarterly MDS does not reflect the use of a chair that prevents rising. The MDS Coordinator stated she did not have the table tray on at all times. Further interview revealed the MDS Coordinator could not find any documentation related to an assessment, monitor for a table tray or a physician's order for the table tray connected to the geriatric chair. Further interview revealed, the MDS Coordinator admitted Resident #15 had the geriatric chair with the tray table since approximately one week after she admitted . When asked if she went out to do the assessment of the restraint, the MDS Coordinator stated, I do not go out myself to do the assessment, I go by what is charted. Observation on 100/200 hall at the nurse's station on 6/11/2024 at 9:50 AM, 10:46 AM, 12:22 PM, 2:10 PM, 2:20 PM, 3:00 PM, 4:04 PM, and 4:45 PM revealed Resident #15 was sitting in a geriatric chair (a large padded supportive recliner that can be placed in upright position or reclined) with a connected tray across her. Observation at the 100/200 nurses' station on 6/12/2024 at 11:18 AM, Resident #15 was sitting in her geriatric chair with tray across the resident. Review of the medial record revealed Resident #18 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Muscle Wasting and Atrophy Right Shoulder, Difficulty in Walking, and Muscle Wasting and Atrophy Left Shoulder. Review of the Quarterly MDS dated [DATE] revealed Resident #18 had a BIMS score of 15 which indicated no cognitive impairment. Review of the Comprehensive Care Plan dated 5/14/2024 revealed no interventions were added to address allegations of sexual abuse when Resident #10 attempted to kiss Resident #18. During an interview on 6/12/2024 at 6:35 PM, Resident #18 stated, .[Named Resident #10] came into my room and demanded I give him a kiss. Then, he proceeded to come toward me. I yelled for him to get out my room. [Resident #10] looked at me and laughed then left out my room. I will fight him if he tries that again in order to protect myself. I notified the Administrator, DON, and Activities Director of the incident .

Based on facility policy review, medical record review, and interview, the facility failed to follow physician's orders and ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 3 (Resident #15) residents reviewed. The findings include: Review of the facility's policy titled, GUIDELINES FOR PHYSICIAN ORDERS--(FOLLOWING PHYSICIAN ORDERS), dated 6/18/2023, revealed .Policy .It is the policy of the facility to follow the orders of the physician .Procedure .4) All physician orders received pertaining to the resident will be implemented and followed throughout the course of the resident's dtay in the facility as the orders are received . Review of the facility's undated policy titled, Medication Administration, revealed .Purpose: To ensure that resident medications are administrered in a timely manner and documentation is completed to substantiate administration . Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, Anxiety Disorder, and Seizures. Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. Continued review of the MDS revealed Resident #15 received an Antipsychotic [medication given for psychosis], Antianxiety [medication given for anxiety], Antidepressant [medication given for depression], and Opioid [medication given for severe pain] over the last 7 days. Review of the Quarterly MDS dated [DATE] revealed Resident #15 had a BIMS score of 2 which indicated severe cognitive impairment. Continued review of the MDS revealed Resident #15 received an Antipsychotic, Antianxiety, Antidepressant, and Opioid over the last 7 days. Review of the Medication Administration Record (MAR) dated 4/1/2024 - 4/30/2024 revealed an order for Lorazepam oral tablet 2 mg (milligram) give 1 tablet by mouth as needed for seizures, may give x 3 doses for seizure activity. Continued review of the MAR revealed Resident #15 received Lorazepam on 4/1/2024, 4/2/2024, 4/5/2024, 4/6/2024, 4/15/2024, and 4/19/2024. Review of the Progress Notes from 4/1/2024 to 4/30/2024 for Resident #15 revealed no documentation of seizure activity for the use of the Lorazepam. Review of the Progress Notes dated 4/4/2024 revealed, .resident observed anxious/restless in . chair in hall .resident unaware d/t current cognitive status . Review of the care plan dated 12/5/2023, revealed .Focus .Alteration in comfort related to .dx [diagnoses] includes seizures, anxiety .Focus .diagnosis of seizure disorder and is as [at] risk or [of] injury .Interventions .Observe for seizure activity .Staff to monitor for changes in level consciousness .Stay with resident if seizure activity occurs . Review of the MAR dated 5/1/2024 - 5/31/2024 revealed an order for Lorazepam oral tablet 2 mg give 1 tablet by mouth as needed for seizures, may give x 3 doses for seizure activity. Continued review of the MAR revealed Resident #15 received Lorazepam on 5/23/2024, 5/25/2024, 5/29/2024, 5/30/2024, and 5/31/2024. Review of the Progress Notes from 5/1/2024 to 5/31/2024 for Resident #15 revealed no documentation of seizure activity for the use of the Lorazepam. Continued review of the Progress Notes revealed, .5/23/2024 13:43 [1:43 PM] .Medication Administration .Lorazepam Oral Tablet 2 MG Give 1 tablet by mouth as needed for seizures May give x 3 doses for seizures activity .Pt [Patient] agitated pulling on staff and chair .5/29/2024 12:13 [PM] .Medication Administration .Lorazepam Oral Tablet 2 MG Give 1 tablet by mouth as needed for seizures .Pt agitated and trying to get out of chair hollering at staff .5/31/2024 13:12 [1:12 PM] .Medication Administration .Lorazepam Oral Tablet 2 MG Give 1 tablet by mouth as needed for seizures May give x 3 doses for seizures May give x 3 doses for seizures activity .Pt restless and pulling at chair and calling out . Review of the Progress Notes from 5/1/2024 to 5/31/2024 revealed no documentation of seizure activity for the use of the Lorazepam. Review of the MAR dated 6/1/2024 - 6/12/2024 revealed an order for Lorazepam oral tablet 2 mg give 1 tablet by mouth as needed for seizures, may give x 3 doses for seizure activity. Continued review of the MAR revealed Resident #15 received Lorazepam on 6/3/2024, 6/5/2024, 6/7/2024, 6/9/2024, 6/11/2024, and 6/12/2024. Review of the Progress Notes revealed 6/3/2024, .Lorazepam Oral Tablet 2 MG .pt [patient] showing signs of anixety [anxiety] .6/5/2024 .Lorazepam Oral Tablet 2 MG .Pt pulling at other Patients trying to get out of chair .6/7/2024 .Lorazepam Oral Table 2 MG . Resident anxious . Review of the care plan dated 12/5/2023, revealed .Focus .Alteration in comfort related to .dx [diagnoses] includes seizures, anxiety .diagnosis of seizure disorder and is as [at] risk or [of] injury .Interventions .Observe for seizure activity .Staff to monitor for changes in level consciousness .Stay with resident if seizure activity occurs . Review of the Progress Notes from 6/1/2024 to 6/12/2024 for Resident #15 revealed no documentation of seizure activity for the use of the Lorazepam. Review of the Progress Notes revealed 6/7/2024, .Lorazepam Oral Tablet 2 MG . Resident anxious . Continued review of the Progress Notes revealed on 6/9/2024, 6/11/2024, and 6/12/2024 Lorazepam was given, the Notes did not reveal any seizure activity. During a telephone interview on 6/14/2024 at 8:42 AM, Hospice Registered Nurse (RN) V stated, .I know of maybe 1 or 2 reported Seizures [Named Resident #15] has had .the Lorazepam order she has a standing order Hospice gives if a resident has a diagnosis of Seizures .it is a PRN [as needed] order and should only be given if the resident has a Seizure . The Hospice RN V was asked if she had any concerns with Resident #15's care at the facility. Hospice RN V stated, .Yes, inappropriate use of Lorazepam .I have educated the staff that the PRN Lorazepam is for Seizures .[Named Resident #15] will become anxious, and the facility has given her the Lorazepam . During a telephone interview on 6/18/2024 at 9:52 AM, Licensed Practical Nurse (LPN) JJJ was asked if she recalled giving Resident #15 Lorazepam. LPN JJJ stated, .It was change of shift .the nurse that gave me report said she [Resident #15] had been shaking a lot .I checked to see if she needed to go to the bathroom .took her [Resident #15] myself .put her back in the [named] geriatric chair .she became agitated .she began pulling away from the wall .increased agitation .I saw her behavior change .I gave the Ativan .she was shaking and coming out of the chair .I wasn't sure of the seizure protocol, so I gave it since she was shaking .she was care planned for behaviors .I did not call the MD .I wasn't sure of that protocol .I just knew it was given for seizures or agitation . During a telephone interview on 6/18/2024 at 10:07 AM, RN X was asked the reason for giving Resident #15 Ativan. RN X chuckled and replied, I gave it for agitation. That is the only time I would give this medication. When asked about the physician's order that read to give for seizure activity, RN X replied, [Named Resident #15] gets upset and her hands start shaking. That is the seizure activity, and that's when we give it. That's what hospice told me to do. I have learned since then; the activity usually happens when she needs to go to the bathroom. Now we do that first instead of giving the medicine right away. RN X was asked if the physician was notified if the resident was having seizure activity. RN X replied, No. I do not notify the physician about the seizures. Hospice said if we have to give her more than 2 or 3 doses a day, then we could give them a call. During a telephone interview on 6/18/2024 at 10:21 AM, the Pharmacist stated Resident #15 had an order for Lorazepam since 12/5/2023 and was prescribed by Hospice MD. When asked what the recommended mode of transmission for lorazepam would be related to seizures, the Pharmacist replied, .For seizures, generally it is injectable or cream. It would be hard to give a patient a PO [by mouth] lorazepam if they were having a seizure . The Pharmacist then stated the lorazepam 2 mg injectable would typically be available in the Cubex (a medication dispenser for controlled substances), however there was none available at that time per the Pharmacist. During a telephone interview on 6/18/2024 at 11:45 AM, the Hospice Medical Doctor [MD] stated she did order Lorazepam 2 mg for seizures but would be concerned if the nurses are not charting seizure activity when giving this medication. Continued interview revealed Resident #15 should have 3 active orders for Lorazepam. One for 2 mg for seizure activity, one for 2 mg for agitation, and one for 0.5 mg BID. During a telephone interview on 6/18/2024 at 2:50 PM, MD FF stated he signed off on some of the hospice orders. MD FF was asked if he felt lorazepam 2 mg PO was the correct mode of transmission for a resident with seizures. MD FF replied, .The lorazepam PO can be given after the seizure is over and not during the active phase . When asked if staff consistently charted 0 for a pain level, would prn pain meds need to be given. MD FF stated, If it consistently a 0, then no. However, if they are without the pain medication, the pain could come back and potentially become worse. The pain meds keep the patient comfortable. During a telephone interview on 6/20/2024, the facility Nurse Practitioner [NP] stated she was not notified about Resident #15's seizure activity, but the nurses would also call hospice for any concerns or request. When asked about giving Ativan 2 mg PO for seizures, the NP stated, Not for active seizures. It should be given IM in my professional opinion.

Based on facility policy review, observations, and interviews, the facility failed to ensure a safe and clean environment in 32 of 51 residents' rooms (101, 102, 103, 104, 105, 106, 110, 113, 201, 203, 204, 205, 208, 210, 211, 212, 213, 214, 301, 302, 306, 307, 308, 309, 311, 314, 403, 405, 406, 407, 409, 411) observed. The findings include: Review of the policy titled, General Cleaning Policies and Procedures, revealed, .To provide a clean, attractive and safe environment for residents, visitors, and staff .Remove general waste from the resident's room .Clean and disinfect the room furnishings .Clean bedside commodes, toilet, handrails, nurse call and cord, light switch and cover plate, safety bar, toilet paper holder, light cover, door frame, and door knobs .Clean and refill soap dispensers .Clean and refill the paper towel and toilet paper dispenser .Clean and reline the waste containers .Wet mop the resident room and bathroom floors .Clean and sanitize toilets . An observation on 8/14/2023 at 11:27 AM, in room [ROOM NUMBER], revealed dried debris on the floor and in the bathroom. An observation on 8/14/2023 at 11:27 AM, in room [ROOM NUMBER], revealed debris on floor and no hand sanitizer in dispenser. An observation on 8/14/2023 at 11:29 AM, in room [ROOM NUMBER], revealed dried debris on the floor and in the bathroom. An observation on 8/14/2023 at 11:32 AM, in room [ROOM NUMBER], revealed dried debris on the floor and in the bathroom. An observation on 8/14/2023 at 11:32 AM, in room [ROOM NUMBER], revealed used paper towels on the floor in the bathroom, a bag of laundry on the bathroom floor, and two spots of a dried red substance on the floor. An observation on 8/14/2023 at 11:35 AM, in room [ROOM NUMBER], revealed dried debris on the floor. An observation on 8/14/2023 at 11:35 AM, in room [ROOM NUMBER], revealed dark dried spots on the floor. An observation on 8/14/2023 at 11:37 AM, in room [ROOM NUMBER], revealed dried debris on the floor. An observation on 8/14/2023 at 11:40 AM, in room [ROOM NUMBER], revealed there was no hand sanitizer in the dispenser. An observation on 8/14/2023 at 11:40 AM, in room [ROOM NUMBER], revealed no toilet paper in bathroom and no hand sanitizer in dispenser. An observation on 8/14/2023 at 11:42 AM, in room [ROOM NUMBER], revealed a foul odor. An observation on 8/14/2023 at 11:42 AM, in room [ROOM NUMBER], revealed dried debris on the floor. An observation on 8/14/2023 at 11:46 AM, In room [ROOM NUMBER], revealed no trash bags in the trash cans and no hand sanitizer in the dispenser. An observation on 8/14/2023 at 11:50 AM, 300 Hall shower room had soiled gloves and used washcloths on the floor. An observation on 8/14/2023 at 11:51 AM, in room [ROOM NUMBER], revealed dark colored dried debris on B side of the room, a foul odor on the A side of the room and soiled linen present in bathroom and no toilet paper present. An observation on 8/14/2023 at 11:51 AM, revealed no hand sanitizer in Rooms 201, 204, 309, and 407. An observation on 8/14/2023 at 11:54 AM, in room [ROOM NUMBER] revealed loose dry debris on the floor and stained tiles. An observation on 8/14/2023 at 11:56 AM, in room [ROOM NUMBER], a graduate was unlabeled and unbagged in the bathroom and no hand sanitizer was in the dispenser. An observation on 8/14/2023 at 11:58 AM, in room [ROOM NUMBER], a graduate was unlabeled and unbagged in the bathroom. An observation on 8/14/2023 at 12:00 PM, in room [ROOM NUMBER], revealed debris on the floor and a bathroom with dried brown debris down the side of the toilet. An observations on 8/14/2023 at 12:00 PM, in room [ROOM NUMBER], revealed no gloves in the room, the uncovered positioning wedge was on the floor, A side had food on the floor, and there was no hand sanitizer. An observation on 8/14/2023 at 12:03 PM, in room [ROOM NUMBER], revealed there was no hand sanitizer. An observation on 8/14/2023 at 12:04 PM, in room [ROOM NUMBER], revealed dried debris on the floor of the bathroom. An observation on 8/14/2023 at 12:04 PM, in room [ROOM NUMBER], revealed there was no hand sanitizer. An observation on 8/14/2023 at 12:05 PM, in room [ROOM NUMBER], revealed there was no hand sanitizer. An observation on 8/14/2023 at 12:07 PM, in room [ROOM NUMBER], revealed there was no hand sanitizer. An observation on 8/14/2023 at 12:08 PM, in room [ROOM NUMBER], revealed dried debris on the floor and no hand sanitizer in the dispenser. An observation on 8/14/2023 at 12:43 PM, in room [ROOM NUMBER], revealed debris on the floor of the bathroom. An observation on 8/14/2023 at 12:45 PM, in room [ROOM NUMBER], revealed dried debris on the bathroom floor. An observation on 8/14/2023 at 12:48 PM, in room [ROOM NUMBER], revealed dried debris and food on the floor. An observation on 8/14/2023 at 12:55 PM, in room [ROOM NUMBER], revealed dried debris on the floor. An observation on 8/14/2023 at 1:00 PM, in room [ROOM NUMBER], revealed debris on the floor. An observation on 8/14/2023 at 1:05 PM, in room [ROOM NUMBER], revealed debris on the floor. An observation on 8/14/2023 at 1:12 PM, in room [ROOM NUMBER], revealed dried brown debris in the bathroom on the toilet. An observation on 8/14/2023 at 1:17 PM, in room [ROOM NUMBER], revealed debris on the floor. An observation on 8/14/2023 at 1:20 PM, in room [ROOM NUMBER], revealed food on the floor. During an interview on 8/14/2023 at 1:43 PM, the Assistant Director of Nursing (ADON) confirmed room [ROOM NUMBER] was dirty with dried brown debris on the toilet. Continued interview revealed the ADON stated this is not an acceptable practice for nursing home standards. An observation on 100 Hall on 8/14/2023 at 2:23 PM, revealed residents' rooms with dried debris on floor. An observation on 200 Hall on 8/14/2023 at 2:35 PM, revealed residents' rooms with dried debris on floor and in bathroom. An observation on 8/14/2023 at 2:38 PM, in room [ROOM NUMBER], revealed candy, an empty medicine cup, and dark dried substance on the floor. Further observation revealed no hand sanitizer in dispenser. During an interview on 8/14/2023 at 2:46 PM, the Director of Nursing (DON) confirmed there was an issue with an understaffed housekeeping department and the resident rooms should have already been cleaned. During an interview on 8/14/2023 at 3:03 PM, the Housekeeper stated the housekeeping department was understaffed and currently had only two staff members. She stated the two housekeepers had two halls each and did laundry too. Continued interview revealed the Housekeeper stated the housekeepers were responsible for toilet paper, paper towels, and soap in resident rooms. During an interview on 8/14/2023 at 3:55 PM, CNA #2 stated that during her rounds at the start of her shift, at the facility, on this day, she observed a soiled brief, with dried debris present, stuck to the floor in room [ROOM NUMBER] on the B side of the room. She stated there was also brown debris present on the bed and a soiled chuck present in the wheelchair. During an interview on 8/15/2023 at 1:46 PM, the DON confirmed the resident rooms were not cleaned the way they should be due to being short staffed in housekeeping.

Based on facility policy review, record review, observation, and interview, the facility failed to provide wound and skin care for 1 of 3 sampled residents (Resident #1), which resulted in actual harm (surgical debridement of skin due to maggot infestation). The findings include: Review of the facility's undated policy titled, Abuse Prevention Program revealed .It is the policy of this facility to prohibit and prevent resident abuse, neglect, mistreatment, and misappropriation of resident property and a crime against a resident in the facility . Review of the facility's undated policy titled, Resident Rights revealed .As a resident of this facility, you have the right to a dignified existence and to communicate with individuals and representatives of choice. The facility will protect and promote your rights . Review of the facility's undated policy titled, Skin and Weight Assessment Team revealed, .To identify those residents at nutritional risks for related medical conditions .aggressively review and address those residents exhibiting significant weight changes and skin breakdown . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Cellulitis of the Left Toe, Morbid (severe) Obesity Due to Excess Calories, Type 2 Diabetes Mellitus without Complications, and Lymphedema, Not Elsewhere Classified. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored 15 on the BIMS which indicated high cognitive functioning. The MDS also revealed Resident #1 required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. The MDS also revealed Resident #2 required use of a wheelchair for mobility. Review of the Comprehensive Care Plan dated 9/15/2022 for Resident #1 revealed a person-centered individualized care plan that included assistance with bed mobility, at risk for falls, self-care deficit, difficulty in transferring, lesions on his back/legs/buttocks/groin that require creams and medicated powders at times, and at risk for skin breakdown due to incontinence. Review of Nursing Progress Notes for Resident #1 dated 9/15/2022 and 9/22/2022 revealed, .no skin issues noted . Review of the Admission Progress/History and Physical note dated 9/19/2022 for Residnet #1 revealed, .His significant edema has caused multiple hypertrophic skin (a thick raised scar caused by cutaneous injury or irritation) gross throughout .Dry scaly skin with multiple areas of lichenification (thick, leathery skin, giving the skin a leathery bark-like appearance) specifically posterior legs under pannus (occurs when extra skin and fat deposits hang from the stomach or belly area on the abdomen) laterally . Review of the Operative Notes for Resident #1 date 9/25/2022 revealed, .Surgical debridement of right upper wound .Surgical debridement of right lower wound .with lichenification of his right lateral area with signs of infection and intradermal (within the skin) maggots . Review of the hospital discharge date d 10/3/2022 revealed, Admission Diagnosis: maggot wounds Discharge diagnosis: Acute on chronic right flank/abdominal wound with maggot infestation S/p [status post] surgical debridement of right upper and lower wound 9/25/2022 .Patient .male with .CHF [Congestive Heart Failure] .lymphedema, DM [Diabetes Mellitus] .obesity who came into the ER [emergency room ] due to wound check .Per patient he has a chronic pressure wound in the right flank and yesterday was having some itching and biting like pain .Per patient he has had three similar episodes over the past few years . During an observation in Resident #1's room on 10/4/2022 at 9:55 AM, the Unit Manager performed wound care to two surgical areas of his right hip with the assistance of License Practical Nurse (LPN) #2. The Unit Manager lifted Resident #1's right leg up and placed her hand to his side to assist resident onto his left side. Resident #1 was able to grab the side rail with his right hand but unable to turn without assistance from the Unit Manager. The Unit Manager provided wound care per physician orders and followed infection control during the care. Resident #1 screamed throughout the care of the two wounds with noted tears going down resident's cheek. The Unit Manager stated, We did provide pain medication prior to the wound care. The Nurse Practitioner [NP] also entered room during wound care and Unit Manager asked for extra pain medication post wound care since resident was experiencing pain. The NP stated, Yes, I will take care of that. The NP then left the room. The Unit Manager stated, I will show you his left side that is how this area looked prior to his surgery. The Unit Manager assisted Resident #1 onto his back. Resident #1's abdomen was very large and skin to skin contact was noted with abdominal weight laying onto both of his upper thighs and protruding over both of his hips. The Unit Manager held his abdominal fold up to reveal a large crusted raised black area over the top of his left leg and hip. The Unit Manager palpated this area which revealed dark, thick skin with warty overgrowths and creases which revealed thin slits in the skin that are opened. During an interview on 10/3/2022 at 3:32 PM with the Wound Care Nurse, she stated that she provided wound care for Resident #1. Wound Care Nurse stated Resident #1 had no open wounds, but he did have a lymphedema on his left and right hip. She stated, it looked like warts built up on the lymphedema and was very moist with drainage. She stated, I provided daily wound care to the resident and could have mistaken the maggots for yeast. The Wound Care Nurse stated that the Nurse Practitioner (NP) told her that it takes about 14 days for maggots to incubate, and that the resident was on his 13th day. The Wound Care Nurse was asked about documentation of wound care for Resdient #1. The Wound Care Nurse confirmed she was unable to find any documenation of wounds or wound care for Resident #1. During an interview in Resident #1's room post wound care procedure on 10/4/2022 at 10:25 AM, he revealed post his surgery at the hospital he cried so loud and long after the surgery and stated, It was so painful. Resident #1 stated, I had one good bath on day shift, she took good care of me, I think it was either Wednesday or Thursday after I admitted . Resident #1 was able to recall that Certified Nursing Assistant's (CNA) name and we verified that she did provide him care prior to hospitalization . Resident #1 stated, I never got washed up, I did ask a tech to clean me up, she never came back. I even asked the staff about just AM routine care, but I never got it. The nurses didn't assess my skin the day I admitted and never provided routine care to my abdominal folds. I know these areas have a lot of moisture, so I always ask for pillowcases to be placed in these skin folds. He further stated, I think it was around Sunday, my right side felt sweaty and sticky, so I stuck my hand down there to wipe the moisture away and when I brought my hand up something fell off my hand. It was a maggot. Resident #1 stated, I know what they look like I have had them before, so I turned on my light and a CNA came in the room looks at it, said OK I will be right back, next thing I know the Paramedics were here to take me to the hospital. The nurse never came into the room to look at it before I left. Then I got at the hospital the doctor says you're going to the operating room; we will not know what is going on until we remove the infected area. He said he seen the maggots. Resident #1 stated, I seen a fly, that is how it goes, not cleaning me up, not keeping the skin protected, not cleaning the wounds then eventually it will find entry then the maggots happen. Resident #1 confirmed he has been on an air loss mattress in the past but in the hospital, it was accidently turned off, he was in gulfed by the mattress so now he refuses to use one. Resident #1 confirmed he was not repositioned every two hours at the facility. He stated, I done the best I could to move a little in the bed. During an interview on 10/4/2022 at 11:29 AM with the NP, she revealed resident expressed pain on 9/16/2022. She stated that she asked the one of the nurses to change Resident #1's pain medications back to scheduled, but she doesn't remember the nurse she had spoken to. She stated, The resident's skin was very dry and scaly and looked as if it needed hygiene. It looked like he had not had a shower in days. She stated, There were no medications prescribed for open wounds and that there was no skin breakdown when she seen the resident. NP stated, I was the one who sent him to hospital once the CNA made me aware of the maggots. I saw no open wounds when I seen him. She stated the lymphedema had no weeping but that maggots could have been there previously deep in the crevasses. The NP stated, I told the Wound Care Nurse that the resident needed a shower to cleanse the skin. During an interview on 10/4/2022 at 12:39 PM with the CNA #2, revealed he had provided care for Resident #1. CNA #2 stated that he had washed resident up by washing under his arms and chest. CNA #2 confirmed he did not give Resident #1 a shower or roll him over to do a skin check. CNA stated that it would take about 4 to 5 people to turn resident. CNA #2 also stated Resident #1's bed was too small when he admitted . During an interview on 10/4/2022 at 2:10 PM with the Director of Nursing (DON) and the Corporate Director of Nursing (CDON), the DON stated that she looked over the admission paperwork for Resident #1. The DON stated she didn't see notes on wound care. The DON confirmed she expected her staff to access any skin conditions and document it. She stated she expects any skin issues to be reported to the nurse on duty or to her. The DON confirmed that it was documented that the Wound Care Nurse and CNA had given Resident #1 a full bath one time. The DON stated that she expects her staff to chart baths and what type of bath was given. The DON stated Resident #1 never complained about pain to her. The DON also confirmed, I never checked the resident's skin.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to check residents every 2 hours and provide care as needed for incontinent episodes in 3 of 7 sampled residents (Residents#1, #2, and #6) reviewed. The findings include: Review of the facility's undated policy titled, Incontinence Care, revealed .It is the policy of the facility to ensure that residents receive as much assistance as needed for cleansing the perineum and buttocks after an Incontinent episode or with routine daily care. Frequency depends on bladder diary results and/or routine minimal q (every) 2 hour checks as well as care planning . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Cellulitis of the Left Toe, Morbid (severe) Obesity Due to Excess Calories, Type 2 Diabetes Mellitus Without Complications, and Lymphedema, Not Elsewhere Classified. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored 15 on the Brief Interview for Mental Status (BIMS) which indicated high cognitive functioning. The MDS also revealed Resident #1 required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. The MDS also revealed Resident #2 required use of a wheelchair for mobility. Review of the Comprehensive Care Plan dated 9/15/2022 for Resident #1 revealed a person-centered individualized care plan that included assistance with bed mobility, at risk for falls, self-care deficit, difficulty in transferring, lesions on his back/legs/buttocks/groin that require creams and medicated powders at times, and at risk for skin breakdown due to incontinence. During an observation in Resident #1's room on 10/4/2022 at 9:55 AM, the Unit Manager performed wound care to two surgical areas of his right hip with the assistance of License Practical Nurse (LPN) #2. The Unit Manager lifted Resident #1's right leg up and placed her hand to his side to assist resident onto his left side. Resident #1 was able to grab the side rail with his right hand but unable to turn without assistance from the Unit Manager. During an interview in Resident #1's room after wound care procedure on 10/4/2022 at 10:25 AM, he revealed after his surgery at the hospital he cried so loud and long after the surgery and stated, It was so painful. Resident #1 stated, I never got washed up. I even asked the staff about just AM routine care, but I never got it. Resident #1 confirmed he was not given incontinence care and repositioned every two hours at the facility. He stated, I done the best I could to move a little in the bed. During an interview on 10/4/2022 at 11:29 AM, the Nurse Practitioner (NP) stated, I saw Resident #1 on 9/16/2022. The resident's skin was very dry and scaly and looked as if it needed hygiene. It looked like he had not had a shower in days . The NP stated, I told the Wound Care Nurse that the resident needed a shower to cleanse the skin. During an interview on 10/4/2022 at 12:39 PM, CNA #2 revealed, he had provided care for Resident #1. CNA #2 stated that he had washed resident up by washing under his arms and chest. CNA #2 confirmed he did not give Resident #1 a shower or roll him over to do a skin check. CNA stated that it would take about 4 to 5 people to turn resident. CNA #2 also stated Resident #1's bed was too small for the resident at the time. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included Cerebral Infarction, and Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side. Review of the Quarterly MDS assessment dated ,d+[DATE], revealed Resident #2 had a BIMS score of 15 indicating no cognitive impairment. Continued review revealed Resident #2 required supervision with eating, extensive assistance for bed mobility, toileting, personal hygiene, total dependence for bathing, at risk for developing Pressure Ulcer/Injuries, with treatments of pressure reducing device for chair, pressure reducing device for bed, turning/repositioning program, and always incontinent of bladder and bowel. Review of Resident #2's Comprehensive Care Plan dated 7/25/2022, revised as needed, revealed a person-centered individualized care plan that included plans with interventions for Bed Mobility ., Risk for Pressure Ulcer, ADL's [activities of daily living] Self-care deficit ., Urinary Incontinence . with intervention of Check residents Q2-3 hrs [hours]and PRN [as needed] for incontinent episodes, Alteration in skin integrity ., and Alteration in elimination due to bowel incontinence . with intervention provide incontinence care after incontinence episodes PRN. Review of Resident #2's ADLs Reports from 7/2022 to 10/2/2022 revealed care was not provided per facility policy every 2 hours. Continued review revealed on 10/2/2022 Resident #2 received care at 5:40 AM, 13:29 PM with no other Toileting care documented. Review of Resident #2's Weekly Wound Evaluation -V2 dated 9/9/2022 and 9/15/2022 revealed a rash on left and right buttocks wound that was identified 9/7/2022 with the additional description of Moisture Associated Skin Damage (MASD) with the prevention intervention of specific turning and repositioning program. During an interview on 10/3/2022 at 3:15 PM the Director of Nursing (DON) in her office stated the policy is that residents are checked every two hours for toileting and turning. The DON stated the process is the nurses go behind the CNAs to ensure residents are checked every 2 hours, turned and toileted and the CNAs document the care in the computer on the Plan of Care (POC). The DON reviewed the POC for Resident #2 which revealed, documentation on 10/2/2022 at 5:40 AM and 1:29 PM with no other entries for that day documented. The DON was asked if Resident #2 was not given care between 1:29 PM and 4:25 PM when she was transported back to the hospital. DON stated, That's what it looks like. The Corporate DON was in the office and confirmed only two entries were documented on 10/2/2022 for toilet use, and personal hygiene. During an interview on 10/3/2022 at 3:30 PM, at the 100 Hall Nurses Station, Licensed Practical Nurse (LPN) #1 confirmed the facility policy was residents are to be turned and offered toileting every two hours. She stated the CNAs document care given in the computer and she sees the CNA's go down the hall checking on residents. During an interview on 10/3/2022 at 3:35 PM, at the 100 Hall CNA #1 confirmed the facility policy is to check residents every two hours, offer turning, repositioning, and toileting. CNA #1 stated Residents are also assisted with toileting when they request it. I am assigned 10 to 13 residents on average and have enough time to complete my work. During a phone interview on 10/4/2022 with Family Member #1 daughter stated over the weekend on Saturday 10/1/2022 and Sunday 10/2/2022 around 3:00 PM to 4:00 PM There was not a nurse to be found. I stood at the nurse's desk for 15 to 20 minutes trying to get someone to change my mother. She stated her mother has been left lying in urine and feces for hours and she believes the facility is short staffed on the weekend. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses which included Urinary Tract Infection (UTI), Muscled Wasting and Atrophy, Malaise, and Lack of Coordination. Review of the Admission MDS assessment dated [DATE], revealed Resident #6 had a BIMS score of 15 which indicated intact cognitive abilities. Continued review of the MDS revealed Resident #6 required extensive assistance of 2 people for bed mobility, transfers, toileting, and required 1 assist with bathing. Review of Resident #6's ADL Report revealed toileting care given two times on 9/28/2022, two times on 9/29/2022, one time on 9/30/2022, three times on 10/1/2022, three times on 10/2/2022, and three times on 10/3/2022. Continued review of the ADL Report revealed personal hygiene was given three times on 9/28/2022, zero times on 9/29/2022, zero times on 9/30/2022, three times on 10/1/2022, three times on 10/2/2022, and three times on 10/3/2022. Further review of the ADL report revealed no baths were given from 9/28/2022 to 10/3/2022. Review of the staffing percentage sheet for the past 2 weeks revealed no concerns. Staffing was maintained at 3.03% at the highest and 2.4% at the lowest. During an observation and interview in Resident #6's room on 10/4/2022 at 8:30 AM, Resident #6 stated, I can get up to go to the bathroom when therapy helps me but other times, I use my brief. Recently I was left wet for over an hour. During an interview on 10/4/2022 at 9:30 AM, DON reviewed ADL Report for Resident #6 and confirmed she did not receive incontinence care every two hours.

Based on facility policy review, medical record review, observation, and interview, the facility failed to provide Activities of Daily Living (ADL) care for 8 of 39 sampled residents (Residents #2, #11, #18, #47, #52, #54, #55, #58, and #111) reviewed. The findings include: Review of the facility's undated policy titled, Activities of Daily Living (Routine Care), revealed, .Residents are given routine daily care and HS [bedtime] care by a C.N.A. [Certified Nursing Assistant] or a Nurse to promote hygiene, provide comfort and provide a homelike environment. ADL care is provided throughout the day, evening and night as care planned and/or as needed .ADL care of the resident includes: Assisting the resident in personal care such as bathing, showering, dressing, eating, hair care, oral care, nail care, appropriate skin care .Providing privacy and personal space . Review of the facility's undated policy titled, Incontinence Care, revealed, .It is the policy of the facility to ensure that resident's receive as much assistance as needed for cleansing the perineum and buttocks after an incontinent episode or with routine daily care. Frequency depends on bladder diary results and/or routine minimal q [every] 2 hour checks as well as care planning . Review of the facility's undated policy titled, Oral Hygiene and Denture Care, revealed, .It is the policy of the facility to assist the residents as much as necessary to see that they have good oral hygiene. This includes removing food and debris from their teeth and mouth . Review of the medical record for Resident #2 revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment for Resident #2 dated 8/4/2022, revealed a Brief Interview for Mental Status (BIMS) assessment score of 15, which indicated no cognitive impairment. Continued review revealed she required extensive assistance for toilet use and personal hygiene. Continued review revealed she was always incontinent of bowel and bladder. Review of the Care Plan for Resident #2 revealed assessments/problems, goals, and interventions for, .Self care deficit related to: obesity, pain, right shoulder total reverse, she requires extensive assistance with bed mobility, transfers, toileting, and meals, r/t [related to] altered ROM [range of motion] and weight bearing status .Assist to bathroom as needed. Provide incontinence care as indicated . Review of the medical record for Resident #11 revealed he was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment for Resident #11 dated 5/26/2022, revealed a BIMS score of 00, which indicated severe cognitive impairment. Continued review revealed he required extensive assistance of 1-2 persons for bed mobility, transfers, dressing, toilet use, personal hygiene, and total dependence for bathing and eating. Review of the Care Plan for Resident #11 revealed assessments/problems, goals, and interventions for, .Self care deficit related to : [Named resident] has altered functional ability he requires extensive to total services all mobility related tasks .Oral care daily and as needed . Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS dated [DATE], revealed Resident #18 required extensive assistance of 2 staff for bed mobility, dressing, toileting, personal hygiene, and total assistance required for bathing. Review of the Care Plan for Resident #18 revealed assessments/problems, goals, and interventions for, .Self care deficit related to : [Named resident] requires extensive assist with bed mobility, grooming, eating, and transfers .bowel incontinence .provide incontinence care after incontinence episodes .prn[as needed] . Review of the medical record for Resident #47 revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment for Resident #47 dated 7/19/2022, revealed she had a BIMS score of 15, which indicated no cognitive impairment. Continued review revealed she required extensive assistance for toileting and hygiene. Continued review revealed she is always incontinent of bowel and bladder. Review of the Care Plan for Resident #47 revealed assessments/problems, goals, and interventions for, .Self care deficit related to: [Named resident] requires extensive assistance for her bed mobility, transfers, toileting and bathing needs. She has back pain, Parkinson disease .Provide incontinence care as indicated .Alteration in elimination due to bowel incontinence. [Named resident] is frequently incontinent of bowel and bladder requires staff with all toileting and hygiene needs .Provide incontinence care after incontinence episodes PRN . Review of the medical record for Resident #52 revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 5-day MDS assessment dated [DATE], revealed Resident #52 had a BIMS score of 15, which indicated no cognitive impairment. Continued review revealed she required extensive assistance with bed mobility, transfer, dressing, toilet use, personal hygiene, total dependence with bathing, and supervision with eating. Continued review revealed she is frequently incontinent of bladder and always incontinent of bowel. Review of the Care Plan for Resident #52 revealed care plans which included ADLs related to self care deficit. Review of the medical record revealed Resident #54 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment dated [DATE] revealed Resident #54 had a BIMS score of 15, which indicated no cognitive impairment. Continued review revealed the resident required supervision to total dependence with all ADLs. Continued review revealed Resident #54 was always incontinent of bowel and bladder. Review of the Comprehensive Care Plan for Resident #54 revealed care plans which included ADLs related to self-care deficit. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the shower records for Resident #55 revealed he was scheduled to be given showers on Tuesday, Thursday, Saturday, and as requested during the second shift. Continued review revealed the resident was not given his scheduled shower on Saturday 8/6/2022. Review of the medical record revealed Resident #58 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual MDS assessment dated [DATE] revealed Resident #58 had a BIMS score 13 which indicated the resident was cognitively intact. Continued review revealed the resident required supervision to total dependence with all ADLs. Resident #58 was occasionally incontinent of bladder and continent of bowel. Review of the Comprehensive Care Plan for Resident #58 revealed care plans which included difficulty with transfers and ADLs related to self-care deficit. Review of the medical record revealed Resident #111 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission MDS assessment dated [DATE] revealed Resident #111 had a BIMS score of 15 indicating no cognitive impairment. Continued review revealed Resident #111 required extensive assistance with bathing with two staff. Review of Resident #111's care plan dated 8/9/2022 revealed .Self care deficit related to dx [diganosis]: fx [fracture] femur, [CONDITION(S)]. Requires extensive assistance with bed mobility, toileting, transfers, dressing. Shower 2-3 times a week and as needed . Review of the Bathing Activities dated 7/2022 revealed Resident #111 had one doumented bed bath on 7/12/2022 on the 7 AM to 3 PM shift. Review of Occupational Therapy (OT) Notes dated 7/13/2022 revealed Resident #111 was assisted with a light bath by the Occupational Therapist. Review of the OT Notes dated 7/20/2022 revealed Resident #111 was assisted with a shower by the Occupational Therapist. Observation and interview in room [ROOM NUMBER] B on 8/8/2022 at 10:35 AM, revealed Resident #54 in bed with a personal gown on. There was a strong odor of urine present in the room. She stated she was waiting for the CNA to come back to change her because she was wet. She stated she had put on her call light and the CNA came in, cut the light off, and told her she would be right back. She stated the staff sometimes takes up to 2 to 4 hours at night to answer her call light. She stated the weekends are worse. She stated she had told the nurse about the call lights and the nurse told her they were short staffed. During an observation and interview in Resident #2's room on 8/8/2022 at 10:42 AM, she stated she she was wet with urine and has been waiting all morning to be changed, The room had a strong smell of urine. During an observation and interview in Resident #47's room on 8/8/2022 at 10:45 AM, revealed a strong odor of urine. Resident #47 stated, I put my call light on at 6:30 (AM) this morning so I could be changed, and they haven't come in yet. I am soaking wet. Observation in Resident #11's room on 8/8/2022 at 11:09 AM, 2:23 PM and again on 8/9/2022 at 7:07 AM, and 9:33 AM, revealed he had white/tan dried crusty substance on his lips. Observation and interview in Resident #55's room on 8/8/2022 at 11:26 AM, Resident #55 stated he had been requesting to get a shower since 8/4/2022. Resident #55 then pushed his call light, and the Administrator answered and told Resident #55 that he would send a tech down to let him know when he would be getting a shower. Observation and interview in room [ROOM NUMBER] on 8/8/2022 at 12:00 PM, revealed, Resident #52 sitting in a wheelchair (wc) at bedside. The resident had a strong odor of urine. She stated she had been brought back to her room about an hour ago by therapy. She stated she told CNA #3 at that time she needed to use the bedpan. She stated CNA #3 told her she would be back to help her, and she had not been back. She stated the staff often cuts off her call light and says they will be back, only to not come back to help. She stated she will urinate in her brief before anyone comes back. She stated she had complained to the nurse many times about the call lights and staff not providing assistance. Observation on 8/8/2022 at 12:20 PM, revealed Resident #52 told the Director of Nursing (DON), who was in the room delivering a lunch tray to A bed, that she had to be changed. The DON told the resident she would let the CNA know and they would be back in to change her before she eats. The Assistant Director of Nursing (ADON) then delivered the resident's lunch tray and the resident shrugged her shoulders and stated I guess I will have to wait. Observation and interview on 8/8/2022 at 12:44 PM and 3:41 PM, with Resident #55, he stated he had not received his shower as he had requested. Observation and interview on 8/8/2022 at 1:30 PM, revealed CNA #3 was in Resident #52's room making the bed and Resident #52 was sitting in her wheelchair at bedside. Resident #52 stated she had not been changed since coming back from therapy. CNA #3 stated she was going to change the resident after making the bed. Resident #52 stated she has to wait over an hour most of the time to be changed. During an observation of medication administration with Licensed Practical Nurse #2 on 8/9/2022 at 9:50 AM, Resident #18 was found to have a soiled gown and pad that had soaked onto the left arm of her gown. Resident #18's incontinent pad was covered with a large amount of black wet substance, with a large light brown ring around the parameters of the pad. LPN #2 stated, Oh no, she has to have a shower, she is in a mess. The DON was asked to come to the room and at 10:00 AM she confirmed the resident should not be in this kind of condition. LPN #2 raised Resident #18's cloth pad which revealed a brown dried ring on the fitted sheet under the incontinent pad. Resident #18's room had a foul odor and 4 flies were on the resident and 3 other flies were noted on her roommate. During an interview in room [ROOM NUMBER] A on 8/8/2022 at 10:22 AM, Resident #58 stated she required assistance with the use of a bedside commode (BSC). She stated she calls the CNA to empty the BSC after she finishes using the bathroom. She stated there are times when she had to call for assistance with transfering to the BSC. She stated staff often took hours to come in and empty the BSC. She stated she had been incontinent on a few occasions because she needed help getting to the BSC and staff took too long to answer her call light. During an interview on 8/8/2022 at 10:40 AM, CNA #3 stated she did turn off the call light in room [ROOM NUMBER] B. She stated she told the resident she would be back after completing care for another resident. During an interview in Resident #2's room on 8/8/2022 at 12:25 PM, she stated, I finally got changed after 4 1/2 hours of waiting. During an interview on 8/8/2022 at 12:43 PM, Resident #54's family member #3 stated she came in to visit at 11:00 AM today. She stated Resident #54 was soaked in urine and the bed was wet needing a complete linen change. She stated the resident had feces dried on her and her brief. She stated she put the call light on and the Human Resource person assisted her in changing the resident and her linens. She stated the Human Resource person told her she would speak to the DON about the poor care. She stated she had talked to the nurse about her concerns with pericare and some of the CNAs. She stated she was here to visit on 8/5/2022 early and the resident put on her call light several times to be changed. She stated the nurse came in and turned off the call light multiple times and told her she would let the CNA know. She stated it was just before shift change at 2:30 PM before anyone came in to assist her. During an interview on 8/8/2022 at 2:22 PM, the Human Resource person stated she had an active CNA license, and she helped familiy member #3 clean up Resident #54. She stated the resident had feces that looked dry and had saturated her brief and had to have her bed changed. She stated Resident #54's family member explained to her that the resident had waited all night to be changed. She stated she told the Assistant Director of Nursing (ADON) about the situation. During an interview on 8/8/2022 at 2:23 PM in Resident #11's room, the DON confirmed the resident had white/tan dried crusty substance on his lips. When asked if he had mouth care performed that day, she stated, It looks like he hasn't had mouth care today, and he certainly should have. During a telephone interview on 8/8/2022 at 7:24 PM, the Complainant stated Resident #111 was only given a shower one time during her stay at the facility. During an interview on 8/9/2022 at 7:11 AM with LPN #1, she confirmed Resident #11 had white/tan dried crusty substance on his lips. During an interview on 8/9/2022 at 2:45 PM, the ADON stated she expected call lights to be answered in a timely manner. She stated residents should not have to wait hours to have a call light answered. During an interview on 8/9/2022 at 4:00 PM, the Staffing Coordinator confirmed residents were to receive showers 3 times a week and were to receive bed baths on the days they do not receive showers. Continued interview she stated staff were to notify the Registered Nurse (RN) to document any refusals. During an interview on 8/9/2022 at 5:12 PM, CNA #2 confirmed residents were to receive showers 3 times a week and were to receive bed baths on the days they do not receive showers. Continued interview she stated the RN would be notified to document any refusals. During an interview on 8/10/2022 at 10:27 AM the DON reviewed Resident #55's bathing sheets and confirmed Resident #55 did not receive a scheduled shower on 8/6/2022. During an interview on 8/10/2022 at 1:28 PM with the DON confirmed, If a resident is incontinent of urine or bowel, they should be provided incontinent care within a reasonable amount of time, like 15 minutes. She confirmed a resident should never go 4 1/2 hours without being provided incontinent care. During an interview on 8/9/2022 at 3:35 PM, the DON stated Resident #111 had assistance with showers by the Occupational Therapist. She confirmed the Resident could have either a shower or bed bath 3 days a week and on the days she was not scheduled for shower or bed bath the resident she could clean herself such as wash her face and wash certain body parts. The DON stated We don't do bed baths when they are not scheduled for a shower. Review of the undated facility policy titled, Incontinence Care, revealed, .Policy of the facility to ensure that residents receive as much assistance as needed for cleansing the perineum and buttocks after an incontinent episode or with routine daily care .Frequency depends on bladder diary results and/or routine minimal q [every] 2 hour checks . Review of the medical record revealed Resident #58 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual MDS assessment dated [DATE] revealed Resident #58 had a BIMS score 13 which indicated cognitively intact. Continued review revealed the resident required supervision to total dependence of one to two person physical assist with all ADLs. Resident #58 was occasionally incontinent of bladder and continent of bowel. Review of the Comprehensive Care Plan for Resident #58 revealed care plans which included difficulty with transfers and ADLs related to self-care deficit. Review of the medical record revealed Resident #54 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 had a BIMS score of 15, which indicated no cognitive impairment. Continued review revealed the resident required supervision to total dependence of one to two person physical assist with all ADLs. Resident #54 was always incontinent of bowel and bladder. Review of the Comprehensive Care Plan for Resident #54 revealed care plans which included ADLs related to self-care deficit. Review of the medical record for Resident #52 revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #52 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Continued review revealed she required extensive assistance with bed mobility, transfer, dressing, toilet use, personal hygiene, total dependence with bathing and supervision with eating. Continued review revealed she is frequently incontinent of bladder and always incontinent of bowel. Review of the Care Plan for Resident #52 revealed care plans which included ADLs (Activities of Daily Living) related to self care deficit. Observation and interview in room [ROOM NUMBER] on 08/08/22 at 12:00 PM, revealed, Resident #52 sitting in a wheelchair (wc)at bedside. The resident had a strong odor of urine. She stated she had been brought back to her room about an hour ago by therapy. She stated she told the CNA #3 at that time she needed to use the bedpan. She stated CNA #3 told her she would be back to help her, and she had not been back. She stated the staff often cuts off her call light and says they will be back, only to not come back to help. She stated she will urinate in her brief before anyone comes back, and it makes her angry as hell. She stated she had com plained to the nurse many times about the call lights and staff not providing assistance. Observation on 8/8/2022 at 12:20 PM, revealed Resident #52 told the DON, who was in the room delivering a lunch tray to A bed, that she had to be changed. The DON told the resident she would let the CNA know and they would be back in to change her before she eats. The ADON then delivered the resident's lunch tray and the resident shrugged her shoulders and stated I guess I will have to wait. Observation and interview on 8/8/2022 at 1:30 PM, revealed CNA #3 in room making the bed and Resident #52 sitting in wc at bedside. Resident stated she had not been changed since coming back from therapy. CNA #3 stated she was going to change the resident after making the bed. Resident #52 stated she has to wait over an hour most of the time to be changed. During an interview in room [ROOM NUMBER] A on 08/08/22 at 10:22 AM, Resident #58 stated she required assistance with the use of a bedside commode (BSC). She stated she calls the CNA to empty the BSC after she finishes using the bathroom. She stated there are times when she had to call for assistance with transfering to the BSC. She stated staff often took hours to come in and empty the BSC. She stated she had been incontinent on a few occasions because she needed help getting to the BSC and staff took too long to answer her call light. Observation and interview in room [ROOM NUMBER] B on 08/08/22 at 10:35 AM, revealed Resident #54 in bed with a personal gown on. There was a strong odor of urine present in the room. She stated she was waiting for the CNA to come back to change her because she was wet. She stated she had put on her call light and the CNA came in, cut the light off, and told her she would be right back. She stated the staff sometimes takes up to 2 to 4 hours at night to answer her call light. She states the weekends are worse. She stated had told the nurse about the call lights and the nurse told her they were short staffed. During an interview on 8/8/2022 at 10:40 AM, CNA #3 stated she did turn off the call light in room [ROOM NUMBER] B. She stated she told the resident she would be back after completing care for another resident. During an interview on 8/8/22 at 12:43 PM, family member #3 stated she came in to visit at 11:00 AM today. She stated Resident #54 was soaked in urine and the bed was wet needing a complete linen change. She stated the resident had feces dried on her and her brief. She stated she put the call light on and the Human Resource person assisted her in changing the resident and her linens. She stated the Human Resource person told her she would speak to the DON about the poor care. She stated she had talked to the nurse, about her concerns with pericare and some of the CNA's. She stated she was here to visit on 8/5/2022 early and the resident put on her call light several times to be changed. She stated the nurse came in and turned off the call light multiple times and told her she would let the CNA know. She stated it was just before shift change at 2:30 PM before anyone came in to assist her. During an interview on 8/8/22 2:22 PM, the Human Resource person stated she had an active CNA license, and she helped familiy member #3 clean up Resident #54. She stated the resident had feces that looked dry and had saturated her brief and had to have her bed changed. She stated the daughter explained to her that the resident had waited all night to be changed. She stated she told the ADON about the situation. During an interview on 8/9/2022 at 2:45 PM, the Assistant Director of Nursing (ADON) stated she expected call lights to be answered in a timely manner. She stated residents should not have to wait hours to have a call light answered. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the shower records for Resident #55 revealed he was scheduled to be given showers on Tuesday, Thursday, Saturday, and as requested during the second shift. Continued review revealed the resident was not given his scheduled shower on Saturday 8/6/2022. Observation and interview in Resident #55's room on 8/8/2022 at 11:26 AM, Resident #55 stated he had been requesting to get a shower since 8/4/2022. Resident #55 then pushed his call light, and the Administrator answered and told Resident #55 that he would send a tech down to let him know when he would be getting a shower. Observation and interview on 8/8/2022 at 12:44 PM and 3:41 PM, with Resident #55, he stated he had not received his shower as he had requested. During an interview on 8/9/2022 at 4:00 PM, the Staffing Coordinator confirmed residents were to receive showers 3 times a week and were to receive bed baths on the days they do not receive showers. Continued interview she stated staff were to notify the Registered Nurse (RN) to document any refusals. During an interview on 8/9/2022 at 5:12 PM, the Certified Nurse Aide (CNA) #2 confirmed residents were to receive showers 3 times a week and were to receive bed baths on the days they do not receive showers. Continued interview she stated the Registered Nurse (RN) would be notified to document any refusals. During an interview on 8/10/2022 at 10:27 AM the Director of Nursing (DON) reviewed Resident #55's bathing sheets and confirmed Resident #55 did not receive a scheduled shower on 8/6/2022.

Based on facility policy review, observation, and interview, the Dietary Department failed to label, date, dispose of expired food, and failed to maintain dietary equipment in a sanitary manner on 2 of 5 observations. The findings include: Review of the facility's policy titled, Storage Periods, Use-By Guidelines, dated [DATE], revealed, .Food will be stored properly and used within the appropriate time period to ensure safe and high quality food is served .In some cases, [named Dietetic Solutions] guideline is for 3 days. Expired Food items will be disposed of . Review of the facility's policy titled, Food Storage, dated [DATE], revealed, .Food is stored and prepared in a clean safe sanitary manner that complies with state and federal guidelines . Review of the facility's policy titled, Cleaning Rotation, dated 2017, revealed, .Equipment and utensils will be cleaned according to the following guidelines, or manufacturer's instructions .Items cleaned daily: stove top, grill, exterior of large appliances . Observation in the Dietary Department on [DATE] at 9:55 AM, with the Certified Dietary Manager (CDM), revealed one full pitcher of fruit punch dated [DATE]-[DATE], ,d+[DATE] opened and unlabeled 16.9 ounce bottle of water, ,d+[DATE] pound bag of salad mix with ,d+[DATE] bag full of brown contents dated [DATE], ,d+[DATE] gallon of chocolate milk that was ,d+[DATE] full, expiration date [DATE], ,d+[DATE] canister full of pimento cheese dated [DATE] with use by date [DATE], 2 boiled eggs in a bowl unlabeled and undated, 1 small bowl of peaches unlabeled and undated, and ,d+[DATE] container full of white beans dated [DATE]. During an interview on [DATE] at 10:00 AM, the CDM confirmed the fruit punch, opened bottle of water, 5 pound bag of salad mix, chocolate milk, pimento cheese, eggs, peaches, and white beans were to be labeled and/or discarded by the specified dates or 3 days after opened/prepared. Observation in the Dietary Department on [DATE] at 10:10 AM and 12:05 PM, with the CDM, revealed the stove drip pan had a moderate amount of dark tan and black debris. During an interview on [DATE] at 10:11 AM, the CDM confirmed the stove drip pan had a moderate amount of dark tan and black debris. She stated the drip pan needed to be cleaned and did not know when the drip pan was last cleaned. Observation in the Dietary Department on [DATE] at 10:10 AM and 12:08 PM, with the CDM, revealed moderate amount of dried tan debris on the right side and top of the steamer, on the grill, backsplash behind the grill, stove, large backsplash on the right side of the stove and 11 large baking pans with moderate amount of dark tan debris and one stove rack sitting on the floor. During an interview on [DATE] at 12:10 PM, the CDM confirmed a large amount of dried tan debris on the right side and top of the steamer, on the grill, backsplash behind the grill, stove, large backsplash on the right side of the stove and 11 large baking pans with moderate amount of dark tan debris and the stove rack was sitting in the floor. She stated, The whole kitchen needed to be cleaned.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to promote and protect the dignity of 1 of 39 sampled residents (Resident #2) reviewed. The findings include: Review of the facility's undated policy titled, Resident Rights, revealed, .As a resident of this facility, you have the right to a dignified existence and to communicate with individuals and representatives of choice .The facility must care for you in a manner and environment that enhances or promotes your quality of life .The facility will treat you with dignity and respect in full recognition of your individuality .You have the right to receive services with reasonable accommodations to individual needs and interests .The facility must provide a safe, clean, comfortable, home-like environment, allowing you the opportunity to use your personal belongings to the extent possible .The facility will provide housekeeping and maintenance services . Review of the medical record for Resident #2 revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment for Resident #2 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Continued review revealed she required extensive assistance for transfer, toileting and hygiene. Review of the Care Plan for Resident #2 revealed, .Self care deficit related to: obesity, pain .she requires extensive assistance with bed mobility, transfers, toileting . Observation on 8/9/2022 at 7:15 AM, Certified Nursing Assistant (CNA) #1 provided incontinent/peri care for Resident #2, and did not pull the privacy curtain, nor close the door to the room. Several staff members, residents and visitors were observed passing by the room in the hallway. During an interview on 8/9/2022 at 7:30 AM with CNA #1, she confirmed she did not provide privacy for Resident #35 while performing incontinent care. She stated, I should have pulled the curtain and closed the door. During an interview on 8/9/2022 at 8:57 AM with the Director Of Nursing, she confirmed the staff must provide privacy when performing incontinent care for the residents by pulling the curtain and closing the room door.

Based on facility policy review, medical record review, and interview, the facility failed to notify the physician when a resident refused gastrostomy supplemental feeding, blood glucose checks, and medication for 1 of 39 sampled residents (Resident #20) reviewed; the facility also failed to notify the family of a Resident to Resident interaction for 1 of 39 sampled residents (Resident #211) reviewed. The findings include: Review of the facility's undated policy titled, Change in Resident's Condition or Status, revealed, .it is the policy of the facility to ensure that the resident's attending physician and Representative are notified of changes in the resident's condition or status .resident is involved in an abuse situation or an allegation of abuse .a need to alter the resident's treatment plan significantly .resident repeatedly refuses treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .the nurse will notify the resident's representative when .abuse situations or allegations of abuse . Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Continued review of the MDS revealed Resident #20 required extensive assistance with Activities of Daily Living (ADL). Review of Resident #20's July and August 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of Resident #20's July and August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 8/10/2022 at 3:05 PM, the Director of Nursing (DON) reviewed Resident #20's medical record and confirmed she was unable to find any notifications to the Physician of the resident's refusals. Review of the medical record for Resident #16 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission MDS assessment dated [DATE] revealed Resident #16 had a BIMS score of 3, which indicated severe cognitive impairment. Review of the medical record for Resident # 211 revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment dated [DATE], revealed Resident #211 had a BIMS score of 8, which indicated moderate cognitive impairment. During a telephone interview on 8/9/2022 at 3:05 PM, Registered Nurse (RN) #1 stated she had notified Resident #16's family member about finding her in bed with Resident #211, but she did not notify Resident #211's family. During a telephone interview on 8/9/2022 at 4:33 PM, Resident #211's responsible party (family member #4) stated she had not been notified of any occurrences involving another resident being found in Resident #211's bed. She stated the resident was sent to the hospital on 8/2/2022 and the facility called her to let her know but no one told her about the incident. During an interview on 8/10/2022 at 7:15 PM, the Assistant Director of Nursing (ADON) stated there was no documentation in Resident #211's records to indicate the family was notified about Resident #16 being found in Resident #211's bed on 7/31/2022. She confirmed the family/responsible party should have been notified of the occurrence.

Based on facility policy review, observation, and interview, the facility failed to maintain patient confidentiality related to a computer screen open with resident health information in view with no staff in attendance. The findings include: Review of the undated facility policy titled, What Is HIPAA [Health Insurance Portability and Accountability Act of 1996] revealed, .It shall be the policy of the facility to protect and safeguard the PHI (Protected Health Information) created, acquired and maintained in accordance with the Privacy Regulation pursuant to the HIPAA . Observation of the 200 Hall medication cart on 8/8/2022 at 2:40 PM, revealed residents' heath information was displayed on the computer screen on the medication cart with no staff in attendance. Observation of the 200 Hall on 8/8/2022 at 2:43 PM, revealed 2 EMS (Emergency Medical Service) personnel and 2 facility staff walked by the 200 Hall medication cart with the computer screen open with residents' identifiable information in view. During an interview on 8/8/2022 at 2:43 PM, Licensed Practical Nurse (LPN) #2 confirmed she left the 200 Hall medication cart with the computer screen open with resident identifiable information in view. During an interview on 8/8/2022 at 2:45 PM, the Director of Nursing stated, Computer screens should be locked to protect the resident's health information.

Based on facility policy review, observation, and interview, the facility failed to promote a clean and sanitary homelike environment for 1 of 39 sampled residents (Resident #22). The findings include: Review of the facility's undated policy titled, General Cleaning Policies and Procedures, Resident Room-Clean, revealed, .Bedside tables-scrub all surfaces of the table including legs, base, stand, table top, and bottom . Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses which included Interstitial Pulmonary Disease, Hypertensive Heart Disease without Heart Failure and Atrioventricular Block. Observation in Resident #22's room on 8/8/2022 at 10:10 AM, 12:43 PM, and 2:41 PM, and again on 8/9/2022 at 12:29 PM and 12:36 PM revealed several flies on Resident #22's left shoulder and flying around the room. Continued observation revealed an bedside table with dark dried debris at the base of the table. Observation and interview on 8/9/2022 at 12:36 PM in Resident #22's room in the presence of Housekeeper #1, Housekeeper #2, and the Housekeeping Supervisor, all 3 confirmed there were flies in the room and dark dried debris to the base of bedside table.

Based on facility policy review, record review, and interview, the facility failed to report a resident to resident interaction incident to the State Agency within the required time for Resident #16 and #211. The findings include: Review of the facility policy titled, Abuse Prevention Program, revealed, .It is the policy of this facility to prevent resident abuse, neglect, mistreatment and misappropriation of resident property .The following procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect of a resident by a 3rd party .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 who will immediately report the allegation to the Administrator .Supervisors shall immediately inform the Administrator or in the 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, the person in charge of the facility shall initiate an incident investigation .All personnel must promptly report any incident or suspected incident of resident abuse, mistreatment or neglect, including injuries of unknown origin . Review of the medical record for Resident #16 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #16 revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Review of the progress notes for Resident #16 revealed, .7/31/2022 06:54 .Res [resident] was awake .Found her in [named Resident] #211's bed with other res .res just started fighting .hitting CNA [Certified Nursing Assistant] with both fists .Police came with EMT [Emergency Management Transportation]. Review of the medical record for Resident #211 revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment dated [DATE], revealed Resident #211 had a BIMS score of 8, which indicated moderate cognitive impairment. During an interview on 8/8/2022 at 3:24 PM, Resident #16's responsible party (family member #4) stated she had received a phone call about Resident #16 getting into bed and cuddling with another female resident. She stated she was informed Resident #16 became combative with the CNA when she tried to get her out of the bed and had to be sent to the ER to get her calmed down. She stated the next night at the facility, the resident was found in another bed and became combative again. She stated the resident had to be sent back to the ER again for her behavior. During a telephone interview on 8/9/2022 at 3:05 PM, Registered Nurse (RN) #1 stated Resident #16 wanders into rooms and has to be redirected frequently. She stated she had gotten into beds before and had to be redirected. She stated she was notified by the CNA on 7/31/2022 that Resident #16 had been found in bed with Resident #211. She stated Resident #16 became combative and attacked the CNA when she attempted to assist her out of the other resident's bed. She stated she notified the Director of Nursing (DON) and was told to send her out to the emergency room (ER). She stated the resident was sent to the ER and returned later that morning. During an interview on 8/10/2022 at 4:49 PM, the DON confirmed she had not reported the incident to the State Agency. During an interview on 8/10/2022 at 5:22 PM, the Administrator stated he was the abuse coordinator. He stated the facility did not report the occurrence between Resident #16 and Resident #211 to the State Agency.

Based on medical record review, facility documentation review and interview, the facility failed to prevent an injury during resident care for 1(Resident #1) of 2 residents reviewed for falls. This failure resulted in a Right Humerus Fracture (upper arm bone), 2 skin tears to the right forearm and a swollen discolored area to the right forehead, causing Harm to Resident #1. The findings include: Review of the medical record showed Resident #1 was admitted to the facility on [DATE], with readmission on 8/1/2019, with [DIAGNOSES REDACTED]. Review of the of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #1had a Brief Interview of Mental Status (BIMS) score of 00 indicating the resident was severely cognitively impaired. Continued review revealed the resident required extensive assistance with a 2 person physical assistance for bed mobility, transfers, toilet use and dressing. Review of the Annual Comprehensive Assessment MDS assessment dated [DATE] showed Resident #1 had a BIMS score of 02 indicating the resident was severely cognitively impaired. Continued review revealed the resident required extensive assistance with a 2 person physical assistance for bed mobility, transfers, toilet use and dressing. Review of the Fall Risk Review form dated 6/2/2020 showed Resident #1 had a total score of 12 which represents a high risk for falls. Review of the Nursing Progress Notes dated 6/2/2020 at 10:33 AM showed .Upon entering room resident was observed laying on her right side with her right arm underneath her .Resident crying, c/o (complained of) right shoulder pain .During transfer from floor to stretcher, 2 skin tears noted to right forearm as well as swollen discolored area noted to right forehead . Review of the Nurse Practitioner (NP) #1 Progress Notes dated 6/3/2020 showed .After a fall yesterday (named Resident #1) was sent to the hospital for evaluation .Nondisplaced oblique fracture of shaft of humerus, right arm .with routine healing no surgical intervention, returned with sling to right arm for supportive care . Review of a Witness Statement dated 6/17/2020, showed Certified Nursing Assistant (CNA) #1 stated .was almost done, had just helped her change and was re-adjusting pad. Rolled away from me when I noticed her legs falling off far side of bed . Review of the Resident Incident Report dated 6/19/2020 showed on 6/2/2020 .CNA #1 was assisting resident in bed and was adjusting residents' cloth pad when legs of resident slipped off the far side of her mattress and the resident proceeded to fall OOB (out of bed) .The resident sustained [REDACTED]. During an interview on 6/23/2020 at 12:53 PM CNA #2, stated, We get shift report each day and (named CNA #1) should have gotten details for Resident #1's care needs before accepting the patients. During a telephone interview on 6/23/2020 at 2:42 PM CNA #1 described the events of Resident #1's fall on 6/2/2020. CNA #1 stated she was pulling the pad underneath the resident when Resident #1 kicked her feet out which caused the resident to fall off the left side of the bed landing on her right side on the floor. During continued interview CNA #1 stated she left to notify Licensed Practical Nurse (LPN) #1 who assessed the resident; notified the physician; and received an order to transfer Resident #1 to the ER (Emergency Department) for evaluation. During continued interview CNA #1 stated she assumed the resident was a one person assist due to the resident's size and she did not look at the Care Plan or Kardex (resident treatment plan) before assisting Resident #1. During an interview on 6/23/2020 at 2:54 PM LPN #2 she described the events of Resident #1's fall on 6/2/2020. She stated CNA #1 reported the fall. The resident was lying on the her right side on the floor on the left side of the bed and her head was at the foot of the bed. LPN #2 stated she assessed Resident #1 who was crying and complaining about her right arm. LPN #2 stated CNA #1 reported .she was rolling the resident over in the bed and she just kept rolling . During further interview LPN #2 confirmed Resident #1 was a 2 person assist. During an interview on 6/24/2020 at 11:30 AM MDS Coordinator #1 confirmed resident Care Plans are generated from the residents' MDS assessments. During an interview on 6/24/2020 at 4:30 PM, the Administrator and the Director of Nursing (DON) confirmed they would expect the CNAs to look at the residents' Care Plans and Kardexes before caring for residents.

Based on facility policy review, medical record review, observation, and interview, the facility failed to prevent abuse by 3 residents (#13, #15, #31) who were perpetrators; failed to provide a safe environment for 9 residents (#14, #16, #21, #26, #27, #28, #29, #30, #31) who were victims; and failed to ensure the safety of an unknown number of other potential victims whom the facility could not identify of 16 residents reviewed for abuse. The facility's failure resulted in Immediate Jeopardy (a situation in which the provider's non-compliance 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 notified of the Immediate Jeopardy on 1/16/18 at 2:10 PM in the conference room. The Immediate Jeopardy was effective on 8/15/17 and is ongoing. The findings included: Review of facility policy, Abuse Prevention Program dated 1/19/17, revealed .It is the policy of this facility to prevent resident abuse, neglect, mistreatment, and misappropriation of resident property .All alleged violations MUST be reported to the Administrator and Director of Nursing (DON) .After notification of alleged abuse or neglect the Administrator or person in charge of the facility shall immediately commence an investigation of the incident reported . Medical record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #15 scored 1 on the Brief Interview for Mental Status (BIMS) indicating he was severely cognitively impaired. Continued review of the MDS revealed Resident #15 required extensive assistance with transfers, dressing, grooming, and bathing. Further review of the MDS revealed Resident #15 displayed no behaviors, either physical or verbal, toward others; had no wandering; and had no resistance to care. Medical record review of the Comprehensive Care Plan dated 6/13/17 revealed Resident #15 was at risk for increasing confusion secondary to [MEDICAL CONDITION] and Agitation. Continued review of the Care Plan revealed interventions included: explain all procedures; use simple commands; pleasant calm interaction with resident; provide prompting and cueing as needed; observe for signs of frustration and anxiety; involve in small groups; reality orientation as needed. Continued review of the Care Plan dated 6/13/17 revealed Resident #15 had [MEDICAL CONDITION] medication use to help manage and alleviate [MEDICAL CONDITION], history of aggression, and depression related to a [DIAGNOSES REDACTED]. Resident has episodes of wandering into others' rooms at times. Further review revealed interventions included: carry out medication management regime as prescribed; observe for side effects and complication; offer behavioral counseling and intervention to help resident cope with mood and/or behavioral distress and dysfunction. Medical record review of Resident #15's Progress Notes included the following information: Medical record review of Progress Notes dated 8/5/17 revealed there were multiple aggressive behaviors noted today. Witnessed going into another patient's room and hit her . Medical record review of Progress Notes revealed a late entry on 9/3/17 for 9/2/17 which stated, .Reported to this nurse that resident hit at a family member and a resident . Medical record review of Progress Notes dated 9/3/17, revealed the .Resident hit resident in (room number) twice this AM . Medical record review of Progress Notes dated 9/24/17 revealed multiple entries including: 9/24/17 Resident has hit another resident, chased a family member, attempting to hit her, and hit two staff members, and groped breasts of another incapacitated resident. 9/24 .He was witnessed by another resident groping the breasts of an incapacitated resident who is unable to speak or remove herself from the situation .C Wing Nurse reported to this nurse that he kicked another resident. 9/24/17 11:30 AM .Resident was exhibiting repeated intrusive behaviors, wandering in and other of other resident's rooms .attempting to touch other residents . Medical record review of Progress Notes dated 9/24/17 revealed .at 11:09 AM resident hit another resident, chased a family member attempting to hit her, hit 2 staff members; and groped breasts of an incapacitated resident . Continued review of Progress Notes at 11:12 AM revealed .he was witnessed by another resident groping the breasts of an another incapacitated resident who is unable to speak or remove herself from the situation .C wing nurse reported to this nurse that he kicked another resident . Further review of Progress Notes at 11:30 AM revealed Resident #15 was .exhibiting repeated intrusive behaviors, wandering in and out of other residents' rooms .attempting to touch other residents . Medical record review revealed Resident #15 was sent to the hospital on [DATE] and returned to the facility on [DATE] with no changes in medications or new orders. Medical record review of Progress Notes dated 12/18/17 revealed Resident #15 went up to Resident #16 in the hallway and punched her in the left cheek. Continued review revealed Resident #15 was sent to the hospital on [DATE] through 1/8/18. Interview with the DON on 1/8/18 at 4:10 PM in the conference room revealed Resident #15 had a history of [REDACTED].#15 returned to the facility after being gone a month and .he was doped up, really lethargic beyond his normal . Further interview revealed the resident underwent [REDACTED]. Continued interview revealed Resident #15 went about 2 weeks without any behaviors then just .out and hit another resident . Further interview revealed the facility sent the resident to the hospital on [DATE] but they sent him back stating he did not need treatment. Continued interview revealed upon the resident's return to the facility the DON sent him out to another hospital and this psychiatric hospital was now trying to transfer him back to the facility. Continued interview revealed she did not think it was safe for the resident to return to the facility and she would have to provide 1:1 supervision for the next 72 hours if he came back .to see if we can keep him here while keeping others safe . Further interview on 1/9/18 revealed Resident #15 returned to the facility the previous evening and was placed on 1:1 supervision. Observation of Resident #15 on 1/10/18 at 12:55 PM revealed the resident asleep in his bed. Certified Nurse Aide (CNA) #4 was present in the room and stated he was providing 1:1 supervision of the resident who had just been readmitted from the hospital the previous evening. CNA #4 also stated Resident #15 had displayed 1-2 behaviors of aggression and punched the CNA while he was being showered on the same day. Interview with CNA #2 on 1/11/18 at 11:28 AM in the break room revealed Resident #15 .punched people randomly. He would be sitting there minding his own business and would just hit out . Continued interview revealed the staff tried to keep Resident #15 away from certain people and would just remove him from the area. Further interview revealed there were no specific interventions in place except to remove him from the area. Interview with CNA #3 on 1/11/18 at 11:52 AM in the break room revealed .I've seen him hitting others. He rolls up to somebody and stares into their face. He actually kicked a family. The only thing to prevent it is to keep an eye on him. If you see him rolling up to somebody, redirect him . Interview with Corporate Consultant #1 on 1/10/18 at 9:20 AM at the C-wing nurses' station, revealed there were no investigations for the incidents on 8/5/17, 9/2/17, 9/3/17, and 9/24/17. Continued interview confirmed for each allegation of resident-to-resident abuse a full investigation should be conducted to determine if the allegation was substantiated in order to plan interventions to protect residents; put these interventions in place immediately; and prevent further abuse. Medical record review revealed Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission MDS revealed Resident #31 had periodic confusion related to Dementia. Continued review revealed the resident had no behaviors during the assessment period. Medical record review of Progress Notes dated 6/3/17 revealed Resident #31 was involved in an incident of .physical aggression towards another resident . No specifics of this incident, which resulted in Resident #31 being hospitalized for [REDACTED]. Medical record review of Progress Notes dated 9/16/17 revealed Resident #31 was observed in the dining room with .her hand held back at another resident and the second resident stated Resident #31 hit her. When this nurse asked the resident if she hit her she held her hand up and said in the nose, in the nose, just once, just once. Will send resident to ER (emergency room ) for psych (psychiatric) evaluation . Medical record review of Progress Notes dated 9/21/17 revealed Resident #31 was reported to .have slapped a male patient who had been invading the space of other individuals all afternoon. Patient was in dining room eating supper. Both patients were separated several times. Resident (#31) sent to ER for evaluation . Medical record review of Progress Notes dated 12/22/17 revealed Resident #31 slapped another resident in the face. When Resident #31 was asked what happened stated .I didn't hit her; she hit me . A witness stated Resident #31 slapped the other resident. Resident #31 was transferred to the hospital until 1/3/18. Interview with the DON on 1/15/18 at 3:10 PM in the conference room revealed she was unable to find an investigation for the incidents. Continued interview revealed they just sent Resident #31 out to the hospital each time. Telephone interview with Registered Nurse (RN) #2 on 1/16/18 at 12:05 PM revealed RN #2 did not report this incident as abuse because .I considered it a behavior problem. Not an abuse problem. Abuse needs to be purposeful. If you have psychiatric problems the residents can't be held to the same behaviors as someone who doesn't. Abuse is intentional, trying to hurt someone . Continued interview revealed RN #2 stated We need additional eyes to redirect these residents. More staff would always be helpful. It would be useful to prevent future resident to resident altercations. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #13 scored 2 on the BIMS indicating he was severely cognitively impaired. Continued review of the MDS revealed the resident required extensive assistance with transfers, dressing, grooming, and bathing. Review of the facility investigation revealed a Witness Explanation of Incident dated 8/15/17 revealed a witness statement .a male resident alerted me there was an emergency in the dining room, that he is playing with her (female genitalia). I went to the dining room and (Resident #13) had his right hand up the pants of a female resident (Resident #14). She was motioning him to keep coming and was patting her private area. This nurse removed (Resident #13) from the area . Review of a facility investigation dated 11/5/17 revealed Resident #13 was seen fondling a female resident's breast (Resident #21) while she was sleeping in her wheelchair. Continued review revealed Resident #13 was removed from the area and sent to the hospital on [DATE]. Further review revealed on return from the hospital Resident #13 was started on [MEDICATION NAME] Acetate (a female hormone used to reduce sexual behaviors) to be given daily for inappropriate sexual behavior. Medical record review of Medication Administration Records for December 2017 and January 2018 revealed Resident #13 refused his medication on 5 different days. Interview with the DON on 1/8/18 at 2:25 PM in the conference room revealed Resident #13 had a long history of liking the ladies. Continued interview revealed he was sent to the hospital after his incidents of sexual contact with female residents and finally he went to a psychiatric hospital where they started him on medication to decrease his sexual urges. Further interview confirmed Resident #13 had several episodes of unwanted sexual contact with female residents. Interview with Licensed Practical Nurse (LPN) #3 on 1/9/18 at 11:20 AM on the 200 hall revealed (Resident #14) used to live on the same hall as Resident #13 however she had been moved to another hall. Continued interview revealed Resident #14 had been moved back to the unit where Resident #13 resided and LPN #1 felt It was a terrible idea since (Resident #14) had been moved to decrease repeated sexual contact with (Resident #13). Observation on 1/9/18 at 11:28 AM revealed Resident #14 was residing 4 rooms away from Resident #13. Additional interview with the DON on 1/9/18 at 12:20 PM at the 100 hall nurses' station revealed she was not aware Resident #13 was spending time up and around the facility in his wheelchair. F-600 resulted in Substandard Quality of Care.

Based on review of facility policy, medical record review, facility investigation review, observation, and interview, the Administrator failed to administer the facility in a manner to provide adequate supervision to prevent unsafe wandering and elopement from the facility for 1 resident (#6) who was an elopement risk; failed to provide adequate supervision for 1 resident (#13) with multiple incidents of inappropriate sexual contact toward other residents; failed to provide supervision to 2 resident (#15, #31) with multiple incidents of physical abuse toward other residents. The administrator's failure to provide supervision and keep residents safe placed the residents 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 findings included: Resident #6 eloped from the facility on 10/14/17 and staff were unaware of the resident's absence until notified via phone that the resident had been found by the local police. During this elopement, the resident was gone for an hour and crossed a 3-lane road with a speed limit of 35 miles per hour. The facility failed to conduct a thorough investigation and could not provide evidence to verify how the elopement had occurred. There was no evidence that the facility systematically examined all possible root causes, or came to a determination as to why the facility's supervision had not been adequate to prevent the elopement. Facility systems for monitoring of wanderguard placement, and functioning of the alarm system were not implemented in a manner to prevent elopements. This resident also allegedly eloped from the facility on 10/18/17. Resident #15 and Resident #31 were witnessed to hit, punch, grope an incapacitated resident's breast, and/or slap multiple other residents without provocation. Resident #13 was observed to be involved in multiple incidents of resident-to-resident abuse, including physical abuse where he hit another resident and/or touched a female resident (Resident #21) who did not have the cognitive ability to form consent to being touched in a sexual manner. The administrator failed to assure that each instance of abuse that was either alleged to have occurred or witnessed was thoroughly investigated, with the facility identifying the victim, determining possible root cause of the incident, care planning, and providing needed supervision to prevent further instances of resident to abuse. An interview was conducted with the Interim Administrator on 1/10/18 at 4:02 PM in his office. He stated that the facility did not have a copy of the video recording from 10/14/17, and one could no longer be located due to retention time of the tapes. He stated the elopement should have been thoroughly investigated, as well as reported to the State Survey Agency (SSA). The Administrator related that a complete investigation should have included witness statements, a review and documentation of the security video tape, and a copy of the police report. In addition, he related there should have been analysis of all the facts learned in the investigation, with a determination as to the root cause of the elopement to prevent further incidents. Further interview with the Interim Administrator revealed because he was not working at the facility at the time of the incident, he did not know why this had not occurred. The Administrator was notified of the Immediate Jeopardy on 1/16/18 at 2:10 PM in the conference room. The Immediate Jeopardy was effective from 8/15/17 and is ongoing. Refer to F-600, F-689

Based on review of facility policy, medical record review, facility investigation review, observation, and interview, the facility's governing body failed to ensure adequate supervision was provided to prevent unsafe wandering and elopement from the facility for 1 resident (#6) who was an elopement risk; failed to ensure adequate supervision was provided for 1 resident (#13) with multiple incidents of inappropriate sexual contact toward other residents; failed to ensure adequate supervision was provided to 2 residents (#15, #31) with multiple incidents of physical abuse toward other residents. The governing body's failure to ensure supervision was provided and victims were protected placed residents 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 findings included: Resident #6 eloped from the facility on 10/14/17 and staff were unaware of the resident's absence until notified via phone that the resident had been found by the local police. During this elopement, the resident was gone for an hour and crossed a 3-lane road with a speed limit of 35 miles per hour. The facility failed to conduct a thorough investigation and could not provide evidence to verify how the elopement had occurred. There was no evidence that the facility systematically examined all possible root causes, or came to a determination as to why the facility's supervision had not been adequate to prevent the elopement. Facility systems for monitoring of wanderguard placement, and functioning of the alarm system were not implemented in a manner to prevent elopements. This resident also eloped from the facility on 10/18/17. Resident #15 and Resident #31 were witnessed to hit, punch, and/or slap multiple other residents without provocation. Resident #13 was observed to be involved in multiple incidents of resident-to-resident abuse, including physical abuse where he hit another resident and/or touched a female resident (Resident #21) who did not have the cognitive ability to form consent to being touched in a sexual manner. The facility failed to assure that each instance of abuse that was either alleged to have occurred or witnessed was thoroughly investigated, with the facility identifying the victim, determining possible root cause of the incident, care planning, and providing needed supervision to prevent further instances of resident to abuse. The Administrator was notified of the Immediate Jeopardy on 1/16/18 at 2:10 PM in the conference room. The Immediate Jeopardy was effective from 8/15/17 and is ongoing. Refer to F-600. Refer to F-689.

Based on facility policy review, medical record review, facility investigation review, and observation, the facility's Quality Assurance (QA) Committee failed to assess and monitor behavior in and elopement from the facility; failed to identify the root cause of incidents; and failed to develop a plan with interventions to prevent abuse and elopement and protect victims of abuse. The facility's QA Committee failure residents 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 Administrator was notified of the Immediate Jeopardy on 1/16/18 at 2:10 PM in the conference room. The findings included: Resident #6 eloped from the facility on 10/14/17 and staff were unaware of the resident's absence until notified via phone that the resident had been found by the local police. During this elopement, the resident was gone for an hour and crossed a 3-lane road with a speed limit of 35 miles per hour. The facility failed to conduct a thorough investigation and could not provide evidence to verify how the elopement had occurred; examined all possible root causes; or came to a determination as to why the facility's supervision had not been adequate to prevent the elopement. Facility systems for monitoring of wanderguard placement, and functioning of the alarm system were not implemented in a manner to prevent elopements. This resident also allegedly eloped from the facility on 10/18/17. Resident #13 was observed to be involved in multiple incidents of resident-to-resident abuse, including physical abuse where he hit another resident and/or touched a female resident (Resident #21) who did not have the cognitive ability to form consent to being touched in a sexual manner. Residents #15 and #31 were involved with physical abuse of other residents. The facility failed to assure that each instance of abuse that was either alleged to have occurred or witnessed was thoroughly investigated, with the facility identifying the victim, determining possible root cause of the incident, care planning, and providing needed supervision to prevent further instances of resident to resident abuse. There was no evidence the QA Committee systematically assessed and investigated incidents; developed a corrective action plan to prevent future occurrences; or engaged in continued monitoring of circumstances surrounding the incidents. Refer to F-600. Refer to F-689.

Based on review of facility policy, medical record review, facility investigation review, video review, review of maintenance records, review of alarm company records, observation, and interview the facility failed to ensure each resident received the necessary supervision to prevent elopements from the facility for 2 residents (#6, #23) of 2 discharged residents who eloped from the facility and 7 residents (#16, #26, #27, #28, #29, #30, #31) of 7 residents assessed to be an elopement risk. The facility's failure resulted in Immediate Jeopardy (a situation in which the provider's non-compliance 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 notified of the Immediate Jeopardy on 1/16/18 at 2:10 PM in the conference room. The immediate Jeopardy was effective 8/15/17 and is ongoing. F-689 resulted in Substandard Quality of Care. The findings included: Review of facility policy Elopement, issued 7/1/11, revealed . Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e. an order for [REDACTED].The interdisciplinary notes contain all attempts to elope and efforts and results in locating the resident and who was notified .Ensure all entries are time specific to reflect the responsiveness and timeliness of actions taken by the staff to locate and assess the resident. Document that resident's bracelet alarm/device is in place .When door alarms are in place, they are tested daily by maintenance. The results of the tests are them recorded on designated log. Only the CEO (Chief Executive Officer) may authorize disabling the alarm system and is responsible for the method of monitoring for residents' safety and resetting the alarm . Review of facility policy Missing Resident revised 3/10, revealed .When a door alarm sounds, facility staff will go to the door that is emitting the alarm, and they will go outside the building and search the property for any missing residents. At the same time, other facility staff will immediately do a head count of all residents to check for any missing residents . Medical record review revealed Resident #6 was admitted to the facility on [DATE] for long term care with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had severe cognitive impairment, based on a Brief Interview for Mental Status (BIMS) score of 3/15. Continued review of the MDS revealed the resident had delusions, required supervision with ambulation, and wandered daily. Further review of the MDS revealed the resident's behavior of daily wandering did not place her at significant risk of getting to a potentially dangerous location, and did not significantly intrude on the privacy of others. Medical record review of Nursing Progress Note dated 9/21/17, revealed the resident .is alert with confusion. Ambulates independently. Resident confused as to why she is here. Asks random questions and makes random statements. Resident is pleasantly confused and redirected as needed. Resident ambulates independently .Wanderguard placed to body rt (related to) confusion and wandering . Medical record review of an Elopement Risk Review completed on 9/21/17 found the resident was at risk for elopement and should be care planned. Risk factors included her [DIAGNOSES REDACTED].hangs around facility exits . a physical ability to leave the building, and confusion and/or disorientation or displaying consistently poor judgement. Medical record review of a Care Plan, initiated on 9/22/17, revealed approaches including a wanderguard as ordered by the physician on 9/21/17. Medical record review of Progress Notes for Resident #6 revealed the following: 9/22/17 - She has a wanderguard and does attempt to go home often so far. 9/23/17 - (Late entry) Informed that resident was on another wing and entered another resident's room was standing next to the bed holding scissors. 10/12/17 - Resident's wanderguard was found on bed inside socks. New wanderguard placed to left ankle. Continued review of a Progress Note dated 10/14/17 revealed , .received a call from (another long term care facility)across the street reporting Police Department had a confused pt (patient) there who was found walking down the street. Pt reported her name was (name). I asked to speak with the police officer and told him she was one of our residents. Officer (name) returned resident in ambulatory condition. While testing the wanderguard resident's daughter came in so she was notified of occurrence. Management made aware of occurrence as well . Further review of the Progress Notes revealed, the resident was placed on 15 minute checks and the wanderguard continued to be in place. Review of a copy of the police report revealed that a call was received on 10/14/17 at 10:14:07 AM from a local car dealer located on the same road as the nursing facility. Continued review of the report revealed the .Caller advised of an elderly female who has come inside the business pushing a pink Disney stroller with 2 dolls in it. The female keeps calling the dolls her babies and was asking for the location of an address. The caller advised she seems very disoriented and confused. The caller believes she may have come from one of the nursing homes in the area . The police were dispatched to the car lot where they took possession of the resident. Review of the Police Radio Log and Event Notes Addendum revealed that the police tried 2 other nursing homes to see if the woman resided there, before finally identifying she was a resident of this facility when they brought her back to the building at 10:40 AM. An observation was made on 1/10/18 at 9:00 AM of the distance the resident covered from the back door of the facility to the entrance of the car lot office. Her elopement covered .2 miles in which she crossed a 3-lane road with a speed limit of 35 miles/hour. Further observation revealed additional hazards in the area included a 6-lane road and train track crossing within .3 miles of the facility. Based on the untitled paper provided by the DON as well as the police report, Resident #6 was gone from the facility for 1 hour, between 9:39 AM until 10:40 AM when the police ultimately returned her to the building. Interview with the Director of Nursing (DON) on 1/10/18 at 7:30 AM in the conference room revealed the DON provided documentation which she stated was the facility's complete elopement investigation. Continued interview revealed review of the facility investigation file confirmed on 10/14/17, the facility Received a call from (another nursing home) across the street reporting that Police Department had a confused pt there that was found walking down the street. Pt reported her name was (Resident #6's name). I asked to speak to with the police officer and told him that she was one of our residents and they returned her to the facility .Resident pleasantly confused and unable to elaborate on what happened. Further review of the incident report, no injuries were observed, and upon return to the facility, the resident's wanderguard in place and working order. Continued review of the facility investigation revealed it included multiple factors which the resident displayed, including confusion, being impulsive and resistant to care, impaired memory, decreased safety awareness and agitation/anxiety. Further review of the Elopement Investigation Report provided by the DON confirmed a thorough investigation was not conducted at the time of the elopement. Continued review revealed the facility investigation provided by the DON contained only 3 items that were documented as having been made at the time of the 10/14/17 elopement - the incident report, documentation of 15 minute rounds for 4 days after the elopement, and documentation of checks of other resident's wanderguards. Further review revealed all other information in the investigation file was printed on 1/8/18 between 10:30 PM - 10:50 PM; approximately 10 hours after the complaint survey was initiated and requests for investigation of the elopement were first made. Continued review revealed the additional information printed on 1/8/18 and added to the facility investigation included a copy of the resident's Progress Notes since admission, her physician orders, and Medication Administration Record. Further review revealed there was no evidence the facility had investigated and determined how the resident eloped from the facility and there was no evidence of witness statement from staff, residents, or visitors who were present at the time of the elopement and who might have knowledge of the incident. Continued review revealed there was no evidence the facility reviewed its staffing or investigated why staff were unaware of the resident's elopement until they were notified of the incident by local police. Further review revealed there was no evidence that the facility's investigation included a review of why the wanderguard system had not been effective in preventing the elopement. Continued review revealed although observation during initial tour of the facility on 1/8/18 at 11:00 AM revealed the facility employed a camera system, there was no evidence the video for the day of the elopement had been reviewed and there was no evidence that the facility concluded as to how the elopement occurred, or that corrective actions were implemented to prevent further elopements. Interview with the Maintenance Supervisor at the C Wing Nurses Station on 1/10/18 at 9:31 AM revealed he was aware of the circumstances of Resident #6's elopement. He stated, She went out the door by C Wing. It happened on a weekend. The Maintenance Supervisor stated the resident followed a staff who was pulling a laundry cart out the back door. He added that the staff didn't see her going out behind them. He named the employee, who he said had quit 2-3 days prior to this interview. He stated he thought the resident's wanderguard sounded when she went out the door; however, the laundry employee who was pulling the cart didn't notice it because she was going into the laundry room outside this door and could not hear the alarm in the laundry. He reiterated the laundry employee, just didn't see her get out. The Maintenance Supervisor stated that it appears someone came to the door, but since they didn't see anyone they just turned the alarm off. At 9:40 AM on 1/10/18, the Maintenance Supervisor demonstrated how he tested the wanderguard system, using the C-Wing door through which the resident eloped as an example. He showed when the maglock door was closed and a wanderguard device came within distance, the door would not open, and a chime went off. The Maintenance Supervisor then demonstrated if there was no wanderguard close to the door, a code could be entered into the keypad on the wall next to the door and the maglock door could be opened. Observation during this demonstration revealed if a person with a wanderguard came within the radius of the alarm system while the door was already open, the chiming noise would sound, and could only be turned off via a different alarm pad, which was located on the wall across from the nurse's station. During this interview, the Maintenance Supervisor repeatedly stated the method he demonstrated (testing the door when it was both closed and open) was how he tested the wanderguard system on a daily basis, both before and after this elopement. During this interview on 1/10/18, the Maintenance Supervisor provided documentation of wanderguard/door checks. Review of these records revealed he had documented the wanderguard system at the door through which Resident #6 eloped was functioning correctly on 10/14/17, the day of the elopement. Interview with the Director of Nursing (DON) on 1/10/18 at 12:15 PM in the conference room revealed the facility could not initially figure out how Resident #6 got out of the building on 10/14/17 because she was wearing a wanderguard. Continued interview revealed the DON stated they finally determined the resident had followed a laundry worker out of a door while the employee was pulling a large tub through the door to take it outside to the laundry. Further interview with the DON revealed the employee should have turned around and checked to make sure no one was behind, but she didn't. The DON confirmed the resident had eloped off the property and staff were unaware she was missing until they were contacted by the police. The DON added that she did not think the back-door alarm chimed when the resident went through it, stating, I'm pretty sure something was wrong with the door. Continued interview revealed she stated the wanderguard alarm should have chimed when the resident went through the door which had previously been opened by the laundry employee. Further interview revealed the DON stated they had contacted the alarm company to fix the problem and when they came out on 10/18/17, they found, It didn't ding. Continued interview revealed the DON stated she was not sure, but she thought staff had previously disengaged the alarm so it would not constantly chime as ambulance staff routinely used this door. Further interview revealed the DON stated prior to the elopement, the facility had not identified the wanderguard alarm was not chiming if the door had already been opened via use of the key pad. Continued interview revealed she stated, That's not a standard we would check during routine checks. and added, I'm sure the (Maintenance Director) changed how he was checking to make sure it was dinging since Resident #6's elopement. Further interview with the DON on 1/10/18 confirmed no witness statements had been completed as a part of this investigation. Continued interview revealed she stated the previous administrator looked at the camera system, because we could not figure out how she got out with the wanderguard on. Further interview revealed the DON related the previous Administrator had been the person responsible for the investigation regarding possible malfunctions of the equipment; however, she had no evidence as to anything he had done as part of his investigation. When asked for any additional investigative information, she stated, This is all I have. The DON added the previous administrator might have had more information, but we can't find anything else. Based on the DON's statement, an additional interview was conducted with the Maintenance Supervisor on 1/10/18 at 12:50 PM in the 300 Hall. He reiterated he had always checked the chiming of the wanderguard while the door was open/disengaged via use of the key pad. He reviewed the 10/17 daily documentation of door checks and confirmed that on 10/14/17 (the day of Resident #6's elopement) he had checked the wanderguard system and it was functioning properly. He confirmed the DON's statement that the alarm company had been at the facility on 10/18/17; however, he continued, it was not because of any problems with the wanderguard system on the back door from which Resident #6 eloped. Instead, he stated, the alarm company was there on 10/18/17 because the front door wanderguard system was not working. He stated it was absolutely a nurse who had turned off the wanderguard chime, because they did not see anyone in the area after Resident #6 exited through the open door where the laundry employee was bringing out her cart. An interview was conducted with the Interim Administrator on 1/10/18 at 4:02 PM in his office. He stated that the facility did not have a copy of the video recording from 10/14/17, and one could no longer be located due to retention time of the tapes. He stated the elopement should have been thoroughly investigated, as well as reported to the State Survey Agency (SSA). The Administrator related that a complete investigation should have included witness statements, a review and documentation of the security video tape, and a copy of the police report. In addition, he related there should have been analysis of all the facts learned in the investigation, with a determination as to the root cause of the elopement to prevent further incidents. Further interview with the Interim Administrator revealed because he was not working at the facility at the time of the incident, he did not know why this had not occurred. An additional interview was conducted on 1/10/18 at 4:45 PM with the Maintenance Supervisor in his office. He stated, I was wrong, and retracted his initial statement that there had been nothing wrong with the back door. He stated the alarm company had worked on both the front and back doors on 10/18/17, and there had been a problem with the alarm on the back-door sounding. He was asked to explain his previous statement (that the 10/18/17 visit was for the front door, only) and he stated he had called the alarm company since his previous statement, and they told him they had also worked on the back door on that visit. Further interview with the Maintenance Supervisor revealed, I just don't know whether or not the wanderguard alarm had sounded at the time that Resident #6 eloped on 10/14/17. During an additional interview on 1/10/18 at 5:08 PM at the Nurse's Station by the C-Wing Nurse's Station, in the presence of the DON, the Maintenance Supervisor provided more information which conflicted with his previous statements. The Maintenance Supervisor related he had spoken to the DON and now I believe the alarm wasn't working right. During this interview, he now stated the wanderguard alarm did not chime when the resident went through the door. The Maintenance Director could provide no explanation as to why he initially stated the wanderguard system had chimed when the resident exited the building and a nurse turned if off without looking to see if a resident was missing. An additional interview was conducted with the Maintenance Supervisor in the conference room on 1/10/18 at 5:10 PM. During this interview, the Maintenance Supervisor also contradicted information he had previously provided about the daily testing of the wanderguard system. The Maintenance Supervisor now acknowledged he did not check to see if the wanderguard alarm chimed when the door was already opened. He stated the only step in his daily check of the system consisted of using a wanderguard device which was kept in his clipboard to see if the wanderguard system locked and sounded at each closed exit door in the facility. He stated, As soon as I walk up and it chimes, locks, I move on. He confirmed even after Resident #6's elopement, he did not change the system check to assure that the wanderguard system chimed when the door had already been opened by someone using the code pad. The Maintenance Supervisor related, I didn't see the need to do a check of the chime when the door was open because, It was fixed. Further interview revealed he had not added these checks to his daily monitoring of the equipment, because, It would take 2 people to actually check to see if the chime goes off after the door is opened. Interview with Laundry Employee (LE) #1 by telephone on 1/10/18 at 8:22 PM revealed she stated she was aware Resident #6 was an elopement risk, and had got out a couple of times, including on 10/14/17, when the resident eloped, crossed the road in front of the facility and was found at a local car lot. Continued interview revealed she stated, They said I let her out, but I didn't let her out. She did not follow me out. Further interview revealed LE #1 stated as she was taking her laundry cart out of the door, I heard her say, Hold on, I'm coming and she stated because she knew Resident #6 was an elopement risk, she made sure the resident did not follow her out the open door. Continued interview revealed LE #1 stated, I looked - there was no one behind me when I closed the door. I made sure the door was shut completely and locked before I put the big long cart in the laundry room. Further interview revealed she noted When I heard her saying there was a man behind her. I think he was the one who let her out. Further interview revealed LE #1 stated she did not know the man, who was a family member/visitor. Continued interview revealed she added she never heard an alarm sound when the resident exited the building as she had immediately entered the laundry room and closed the door. Further interview revealed LE #1 stated the previous Administrator told her the facility came to the conclusion she let her out. Continued interview revealed she was certain this is not what happened and LE #1 stated she was aware the facility had a camera system and repeatedly asked to see the tape made at the time of elopement, but they would not let me. Further interview revealed she stated she was never asked to write a witness statement at the time of the elopement and added, I would have been glad to. I would have told them the same thing I'm telling you. Observation with the Interim Administrator and DON on 1/11/18 at 7:38 AM in the Administrator's office revealed that the facility's camera system was not positioned to show the inside of the door from which Resident #6 eloped. Observation of the camera screens and interview with the both the Administrator and DON revealed the doorway from which the resident eloped was around a corner and out of visual range of the camera. In addition, the key pad used to open this door also could not be visualized on the camera. The DON pointed out another camera was placed outside the facility and covered the area after the resident came out the door; however, she confirmed, the outside video did not cover the inside area of the facility to show the activity prior to the elopement. Further interview with the DON on 1/11/18 at 7:38 AM in the Administrator's office revealed she couldn't swear she saw the video of the 10/14/17 elopement but thought she probably did because she would have been the staff to operate the video playback for the previous administrator. Continued interview revealed she stated, If there had been someone else, we would have noted it. Further interview revealed during this interview, the DON stated the Maintenance Supervisor was confused - He should have stated he wasn't sure, rather than stating that a nurse turned off the alarm. Continued interview revealed she stated, It took us a couple of days to figure out what happened - he and I went to all the doors and finally figured out the wanderguard alarm didn't chime when the code had been entered and the door was already open. That's why we called (alarm repair company name). Further interview revealed she stated the facility had invoices to show the alarm company came to repair the alarm at the back door through which Resident #6 eloped, and during this visit, the repair company had also worked on the front door to widen the sensor field for the wanderguard. Review of an alarm company invoice dated 10/18/17 (4 days after the elopement) revealed that Upon arrival, troubleshot issues with Wonderguard (Wanderguard) system. Repaired and tested for proper operation. Interview with the alarm repair technician by telephone on 1/11/18 at 8:10 AM revealed the 10/18/17 repair call was not related to the back door through which the resident eloped. Continued interview revealed he stated he was called in on 10/18/17 because the front door of the facility wasn't locking like it was supposed to. Further interview revealed he stated after repairing the front door, he reconfigured all doors in the facility so when someone with a wanderguard approached the door, it overrode the code buttons for the maglocks on the door. Continued interview revealed he was not told there were any problems with the back-door alarm not chiming, and stated, The only reason I worked on any doors beside the front one was to standardize all of them to the same code. Interview with the DON on 1/11/18 at 1:50 PM in the conference room, revealed in response to the survey team's investigation, the facility had continued to search for evidence regarding Resident #6's elopement on 10/14/17. She stated they had found a piece of paper in the Administrator's office about the elopement. She said this unsigned piece of paper indicated the previous administrator had reviewed the tape showing the resident's elopement. Review of this piece of paper revealed it stated: 10/14. 9:39:39 (Name of Laundry Employee #1) 9:40:01 (Name of Resident #6.) 9:40:38 AM Man. Interview with the DON revealed when informed that this information corresponded to Laundry Employee #1's statement she had seen a man behind Resident #6, and thought he could have let her out, the DON then asked, Have you considered (Laundry Employee Name) might not be telling the truth? However, the DON then confirmed, she had no contemporaneous witness statements from the employee, as well as anyone else, to validate that the facility had determined the actual facts surrounding the resident's elopement. She confirmed the camera system did not record sound, and the unsigned piece of paper which she had provided did not address whether the wanderguard system's alarm had sounded at the time of the resident's elopement. Review of Resident #6's Comprehensive Care Plan for elopement risk, initiated 9/22/17, revealed in addition to the 10/14/17 elopement, the resident also exited building 10/18/17 - returned to building safely by staff no injuries. However, review of the portions of the clinical record which the facility could locate revealed no evidence of this incident. The following Progress Notes were documented for 10/18/17: 3:12 AM - Resident up without assistance. Encouraged to rest in bed. Wanderguard in place. 2:28 PM, - Medication administration notes. 8:56 PM - Resident sitting up feeding self dinner .wander guard in place and working. 9:47 PM - Medication administration notes. None of the Progress Notes for 10/18/17 indicated that the resident exited the building and required staff intervention to return her to the facility. Interview with the DON on 1/9/18 at 4:15 PM in the conference room confirmed the resident had been able to get out of the facility at least one other time. Continued interview revealed she stated in the incident, two little girls who were the children of staff, had let her out of a door and the DON stated this was not considered an elopement as the resident was always in staff view and was returned inside the facility without issue. Further interview revealed the DON could not recall the names of the children who had allowed the resident to leave the facility, or verify the staff who had allegedly had the resident in view and the DON could also not verify the date of this incident and it could not be determined if it was the same incident referenced on the care plan (10/18/17), or was, in fact, a separate incident. Continued interview revealed the DON stated she would provide any documentation on the incident that she could find. However, as of 2:45 PM on 1/11/18, no further information about this undocumented incident had been provided, and the facility failed to provide evidence it had been investigated. Interview on 1/10/18 at 4:20 PM with the Business Manager revealed and she related that she was the only staff who sat in the front office who would have been able to see if the resident was out in the front of the facility; however, she was unaware of any such incidents and stated, No, I never saw her. Further review of Resident #6's Comprehensive Care Plan revealed from 9/22/17, staff were to check the placement of the wanderguard. Review of a 9/22/17 physician's orders [REDACTED]. The physician's orders [REDACTED]. Review of the Treatment Administration Record (TAR) for September 2017 revealed no evidence of monitoring of the wanderguard placement and function on 5/18 required observations. There was no evidence of monitoring of the wanderguard placement and function on 21 of 62 required observations in October 2017. There was no evidence of monitoring of the wanderguard placement and function on 8 of 25 required observations in November, prior to her discharge on 11/13/17. Interview with the Assistant Director of Nursing (ADON) on 1/11/18 at 1:50 PM in the conference room revealed she believed staff had checked for the wanderguard's placement and function but had just not documented their findings. However, she could provide no other evidence to verify the wanderguard had been checked in accordance with the physician's orders [REDACTED].>Review of maintenance records revealed the wanderguard system/alarm/doors were not consistently tested on a daily basis. There was no evidence the wanderguard system/doors were checked on 7 of 30 days in September 2017, 6 of 31 days in October 2017, 8 of 30 days in November 2017, or 9 of 31 days in December 2017. The facility provided the record for January 2018 on 1/15/18 which showed there was no evidence the system had been checked on 3 of 15 days that month. Interview with the Maintenance Supervisor on 1/15/18 at 10:33 AM at the 100 Hall Door confirmed the system was to be checked on a daily basis. He stated he was the only maintenance person and was not sure who checked the doors and alarm system on days which he did not work. An interview was conducted with the Interim Administrator on 1/15/18 at 12:15 PM at the 100 Hall Nurses Station. During this interview, the Administrator was asked who was designated to check the wanderguard alarm system/doors on the days when the Maintenance Supervisor was not present. The Administrator responded he had not assigned anyone to check the doors on these day, and stated, That's a fallacy - they don't need to be checked every day. The Interim Administrator indicated he was unaware of the facility policy that called for daily checks of the system. Additional interview with the Interim Administrator on 1/15/18 at 12:20 PM in the central hall revealed he had just reviewed the policy and confirmed it stated the checks would be completed daily by maintenance. Interviews revealed even after being made aware by the survey team of concerns about how the wanderguard/alarm system/doors were checked, the facility failed to assure that all components of the system were operating correctly when they performed maintenance checks. Interview with the Administrator on 1/15/18 at 12:35 PM in the front hall revealed when the Maintenance Supervisor was not working on the weekend, the Weekend Manager was responsible for checking the wanderguard system. Interview on 1/15/18 at 12:38 PM with the Dietary Supervisor in the front hall confirmed she had been the Weekend Manager who did the checks the previous weekend. She explained her system and how she performed the checks each day when she was responsible. Continued interview revealed she was not checking the alarm system to see if the wanderguard chimed when the door was already open and a wanderguard came within the vicinity. Further interview revealed she stated she only checked to see if the wanderguard locked the closed door and chimed, and was unaware of the second step to verify that the chime also worked if the door was already open. Continued interview revealed she confirmed she was not doing this step in her system checks, stating, I have never done that. Additional interview with the Interim Administrator on 1/15/18 at 12:40 PM in his office, revealed although one of the theories offered related to Resident #6's elopement was the wanderguard alarm had not chimed when the resident went out the open back door which the laundry staff ha (TRUNCATED)

Based on interview, review of the pharmacy agreement with the facility, review of the agreement with the pharmacy consultant and the facility, and medical record review, the facility's contracted pharmacy failed to provide prescribed medication for five residents (#3, #19, #14, #1, #10); and failed to accurately transcribe medications on the admission/monthly physician's orders [REDACTED].#19, #14, #26 #13, #24, #29) of thirty-one residents reviewed. The facility's contracted pharmacy and the facility's systemic failure to compare/reconcile medications with physician orders [REDACTED]. The Administrator, Regional Administrator Consultant, Assistant Director of Nursing, Nurse Consultant #1/Acting Director of Nursing, Nurse Consultant #2, Nurse Consultant #3, Vice-President of Client Operations, and Medical Director #1 were informed of the Immediate Jeopardy on April 24, 2014, at 10:55 a.m., in the Conference Room. The Immediate Jeopardy was effective March 14, 2014, and is ongoing. An extended survey was conducted on April 24, 2014. Substandard Quality of Care was cited at F224-J, F309-J, and F333-L. The findings included: Interview with the Director of Nursing and Nurse Consultant #1, on April 15, 2014, at 2:45 p.m., in the conference room, revealed the the hospital discharge medication reports were delivered to the facility. Further interview revealed the facility faxed the hospital discharge medication report to the pharmacy. Further interview revealed the pharmacy generated the facility physician medication orders and the MAR. Further interview revealed the pharmacy delivered the facility admission physician orders [REDACTED]. Further interview confirmed the facility physician orders [REDACTED]. Review of the agreement between the pharmacy and the facility, dated June 2011, revealed the "Duties and Obligations of the Pharmacy" included: "...support and delivery of medications to the facility (twenty-four hours per day, seven days per week)...Medication Administration records...physician order [REDACTED]. Review of the agreement with the pharmacy consultant and the facility dated June 2011, revealed "Responsibilities and Functions"...the "Consultant agrees to:...Complete monthly patient medication reviews...Participate in Quality Assurance Committee Meetings and provide administrative/professional guidance to administrative staff for the development and implementation..." Medical record review of resident #3 revealed the hospital discharge medication report including the six medication of Coumadin (blood thinner), Lipitor (statin drug for cholesterol management), Coreg medication to regulate heart rate), Digoxin medication to slow heart rate and control rhythm), Cardizem medication to control heart rate and blood pressure), and Lisinopril (medication to control high blood pressure). Medical record review revealed the pharmacy failed to transcribe the six medications onto the facility admission physician orders [REDACTED].#3 in Immediate Jeopardy. Medical record review of resident #19, receiving dialysis treatment three days per week, revealed the March 2014, hospital discharge medications did not include PhosLo (Calcium Acetate-used to bind the phosphorus in the body to decrease the level of the phosphorus in the blood) and Crestor (an antistatin medication to lower cholesterol) at 20 milligrams (mg). Further review of the hospital discharge medications revealed Mirtazapine (antidepressant medication) and Protonix (medication to control stomach acid) were included. Medical record review of the March 2014, facility admission physician medication order revealed the pharmacy incorrectly included the PhosLo and Crestor 20 mg (although they were not ordered) onto the forms. Further review of the facility admission physician medication order revealed the pharmacy failed to transcribe the Mirtazapine and Protonix (although they were ordered) onto the forms. Medical record review of the facility March 2014 MAR indicated [REDACTED]. The failure of the pharmacy to accurately transcribe and provide medication placed resident #19 in Immediate Jeopardy. Medical record review for resident #14 revealed the hospital discharge medications included Gabapentin 800 milligrams (mg). Medical record review of the facility readmission medication orders and the MAR indicated [REDACTED]. Medical record review for resident #1 revealed the hospital discharge medications included Metoprolol (medication to control blood pressure). Medical record review of the facility admission physician orders [REDACTED]. Medical record review for resident #10 revealed the hospital discharge medications included lubricating top jelly bacteriostatic. Medical record review of the facility admission physician orders [REDACTED]. Interview with Pharmacist #1, on April 22, 2014, at 1:25 p.m., in the Conference Room, confirmed the lubricating jelly was "...a blatant omission by pharmacy..." and failed to provide the medication. Medical record review for resident #26 revealed the hospital discharge medications included Tylenol (medication for control of pain/fever) with no specified frequency of administration. Medical record review of the facility admission physician orders [REDACTED]. Interview with Pharmacist #1 confirmed the attempt and failure to obtain a clarification order prior to providing the facility with the physician orders [REDACTED]. Medical record review of resident #13 revealed the February 2014 hospital discharge medications included a cranberry supplement. Medical record review of the facility admission physician order [REDACTED]. Medical record review of the March 2014 hospital discharge medications included Aspirin and a cranberry supplement. Medical record review of the facility admission physician order [REDACTED]. Medical record review for resident #24 revealed the hospital discharge medications included Melatonin (herbal medication prescribed for sleep) at 4 mg, Latuda (an atypical antipsychotic medication prescribed for anxiety) at 20 mg twice daily and Latuda 10 mg as needed. Medical record review of the facility admission physician order [REDACTED]. Medical record review of the facility admission physician order [REDACTED]. Medical record review for resident #29 revealed the hospital discharge medications included Gabapentin (medication used to treat pain and anxiety) and Metoclopramide (medication to aid in stomach emptying). Medical record review of the facility admission physician order [REDACTED]. Interview with Pharmacist #1 on April 22, 2014, at 1:25 a.m., in the conference room, revealed the facility identified a breakdown in communication between the pharmacy and the facility in early April. Further interview confirmed prior to the last Performance Improvement meeting held April 10, 2014, the pharmacy did not compare/reconcile hospital discharge medication to the facility admission physician orders [REDACTED].(to provide medications prescribed)..." Refer to F157-J, F224-K, F281-L, F309-J, F333-L. C/0 #

Based on interview, review of the pharmacy agreement with the facility, review of the agreement with the pharmacy consultant and the facility, and medical record review, the facility's contracted pharmacy failed to provide prescribed medication for five residents (#3, #19, #14, #1, #10); and failed to accurately transcribe medications on the admission/monthly physician's orders [REDACTED].#19, #14, #26 #13, #24, #29) of thirty-one residents reviewed. The facility's contracted pharmacy and the facility's systemic failure to compare/reconcile medications with physician orders [REDACTED]. The Administrator, Regional Administrator Consultant, Assistant Director of Nursing, Nurse Consultant #1/Acting Director of Nursing, Nurse Consultant #2, Nurse Consultant #3, Vice-President of Client Operations, and Medical Director #1 were informed of the Immediate Jeopardy on April 24, 2014, at 10:55 a.m., in the Conference Room. The Immediate Jeopardy was effective March 14, 2014, and was ongoing. An extended survey was conducted on April 24, 2014. Substandard Quality of Care was cited at F224-K, F309-K, and F333-L. The facility provided an acceptable Allegation of Compliance on May 8, 2014, and a revist on May 13, 2014, and May 14, 2014, revealed the corrective actions implemented on May 2, 2014, removed the immediacy of the jeopardy. Noncompliance for F-425 continues at a "F" level citation for the facility's monitoring the effectiveness of corrective actions in order to ensure sustained compliance and evaluation of the processes by the Quality Assurance Committee. The findings included: Interview with the Director of Nursing and Nurse Consultant #1, on April 15, 2014, at 2:45 p.m., in the conference room, revealed the the hospital discharge medication reports were delivered to the facility. Further interview revealed the facility faxed the hospital discharge medication report to the pharmacy. Further interview revealed the pharmacy generated the facility physician medication orders and the MAR. Further interview revealed the pharmacy delivered the facility admission physician orders [REDACTED]. Further interview confirmed the facility physician orders [REDACTED]. Review of the agreement between the pharmacy and the facility, dated June 2011, revealed the "Duties and Obligations of the Pharmacy" included: "...support and delivery of medications to the facility (twenty-four hours per day, seven days per week)...Medication Administration records...physician order [REDACTED]. Review of the agreement with the pharmacy consultant and the facility dated June 2011, revealed "Responsibilities and Functions"...the "Consultant agrees to:...Complete monthly patient medication reviews...Participate in Quality Assurance Committee Meetings and provide administrative/professional guidance to administrative staff for the development and implementation..." Medical record review of resident #3 revealed the hospital discharge medication report including the six medication of Coumadin (blood thinner), Lipitor (statin drug for cholesterol management), Coreg medication to regulate heart rate), Digoxin medication to slow heart rate and control rhythm), Cardizem medication to control heart rate and blood pressure), and Lisinopril (medication to control high blood pressure). Medical record review revealed the pharmacy failed to transcribe the six medications onto the facility admission physician orders [REDACTED].#3 in Immediate Jeopardy. Medical record review of resident #19, receiving dialysis treatment three days per week, revealed the March 2014, hospital discharge medications did not include PhosLo (Calcium Acetate-used to bind the phosphorus in the body to decrease the level of the phosphorus in the blood) and Crestor (an antistatin medication to lower cholesterol) at 20 milligrams (mg). Further review of the hospital discharge medications revealed Mirtazapine (antidepressant medication) and Protonix (medication to control stomach acid) were included. Medical record review of the March 2014, facility admission physician medication order revealed the pharmacy incorrectly included the PhosLo and Crestor 20 mg (although they were not ordered) onto the forms. Further review of the facility admission physician medication order revealed the pharmacy failed to transcribe the Mirtazapine and Protonix (although they were ordered) onto the forms. Medical record review of the facility March 2014 MAR indicated [REDACTED]. The failure of the pharmacy to accurately transcribe and provide medication placed resident #19 in Immediate Jeopardy. Medical record review for resident #14 revealed the hospital discharge medications included Gabapentin 800 milligrams (mg). Medical record review of the facility readmission medication orders and the MAR indicated [REDACTED]. Medical record review for resident #1 revealed the hospital discharge medications included Metoprolol (medication to control blood pressure). Medical record review of the facility admission physician orders [REDACTED]. Medical record review for resident #10 revealed the hospital discharge medications included lubricating top jelly bacteriostatic. Medical record review of the facility admission physician orders [REDACTED]. Interview with Pharmacist #1, on April 22, 2014, at 1:25 p.m., in the Conference Room, confirmed the lubricating jelly was "...a blatant omission by pharmacy..." and failed to provide the medication. Medical record review for resident #26 revealed the hospital discharge medications included Tylenol (medication for control of pain/fever) with no specified frequency of administration. Medical record review of the facility admission physician orders [REDACTED]. Interview with Pharmacist #1 confirmed the attempt and failure to obtain a clarification order prior to providing the facility with the physician orders [REDACTED]. Medical record review of resident #13 revealed the February 2014 hospital discharge medications included a cranberry supplement. Medical record review of the facility admission physician order [REDACTED]. Medical record review of the March 2014 hospital discharge medications included Aspirin and a cranberry supplement. Medical record review of the facility admission physician order [REDACTED]. Medical record review for resident #24 revealed the hospital discharge medications included Melatonin (herbal medication prescribed for sleep) at 4 mg, Latuda (an atypical antipsychotic medication prescribed for anxiety) at 20 mg twice daily and Latuda 10 mg as needed. Medical record review of the facility admission physician order [REDACTED]. Medical record review of the facility admission physician order [REDACTED]. Medical record review for resident #29 revealed the hospital discharge medications included Gabapentin (medication used to treat pain and anxiety) and Metoclopramide (medication to aid in stomach emptying). Medical record review of the facility admission physician order [REDACTED]. Interview with Pharmacist #1 on April 22, 2014, at 1:25 a.m., in the conference room, revealed the facility identified a breakdown in communication between the pharmacy and the facility in early April. Further interview confirmed prior to the last Performance Improvement meeting held April 10, 2014, the pharmacy did not compare/reconcile hospital discharge medication to the facility admission physician orders [REDACTED].(to provide medications prescribed)..." Refer to F157-J, F224-K, F281-L, F309-J, F333-L. Validation of the Credible Allegation of Compliance was accomplished on-site on May 13, 2014, and May 14, 2014, through medical record reviews, review of facility documents, and interviews with Nursing and Administrative Staff. The facility provided evidence of audits of reconciliation of admission/re-admission orders [REDACTED]. The facility provided documentation of an emergency Performance Improvement Meeting held on April 28, 2014, to discuss the new admission/readmission medication reconcilation process, pharmacy process, and physician notification process. Interviews with Nursing Staff on all shifts May 13-14, 2014, throughout the facility, revealed the nursing staff had been in-serviced on the protocol for new admission/readmission medication order reconciliation, pharmacy protocol, medication errors, and physician standing orders. Interview on May 13, 2014, at 9:50 a.m., with the Pharmacist, in the conference room, revealed all medication orders were entered by a pharmacy technician, at pharmacy office #1, then the medication orders were checked by the Pharmacist at pharmacy office #1, and the Pharmacist at pharmacy office #2 would provide a second check to ensure the physician orders [REDACTED]. Continued interview revealed a new fax sheet with a barcode had been implemented to ensure new admission/re-admission orders [REDACTED]. Continued interview revealed all new orders were checked the next day on-site by pharmacy services. Continued interview confirmed the four pharmacy staff members had received in-service education on the new procedures. The facility will remain out of compliance at a Scope and Severity level "F" a 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 and corrective actions are verified onsite.. C/0 #

Based on medical record review, review of facility Plan of Correction, facility policy review, and interview, the facility failed to be administered in a manner to ensure physician's orders [REDACTED].#1, #3, #10, #13, #14, #19, #24, #26, #28, #29, #30), failed to administer medications as ordered resulting in neglect of one resident (#3), failed to ensure quality of care for eight residents (#1, #3, #10, #13, #14, #19, #24, #29), failed to ensure the facility was free from significant medication errors for one resident (#3), and failed to ensure implemented interventions addressed during Performance Improvement were effective. The facility personnel failed to identify significant medication errors when completing medication audit. The facility's failure to ensure physician's orders [REDACTED].#3, #19, and #14 (a situation in the provider's noncompliance with one or more requirements of participation has caused, or was likely to cause, serious injury, harm impairment or death), and potentially for all residents in the facility. The Administrator, Regional Administrator Consultant, Assistant Director of Nursing, Nurse Consultant #1/Acting Director of Nursing, Nurse Consultant #2, Nurse Consultant #3, Vice-President of Client Operations, and Medical Director #1 were informed of the Immediate Jeopardy on April 24, 2014, at 10:55 a.m., in the Conference Room. The Immediate Jeopardy was effective March 14, 2014, and is ongoing. An extended survey was conducted on April 24, 2014. Substandard Quality of Care was cited at F224-J, F309-J, and F333-L. The findings included: Review of facility Plan of Correction (facility's own, internal corrective action plan), completed by the Director of Nursing (DON) on April 2, 2014, in response to the discovery of the significant medication errors of resident #3, revealed the facility became aware of medications which were being omitted from the hospital discharge records when reconciled with the facility's admission medication orders and Medication Records (MARs) sent from the pharmacy. Continued review revealed a Plan of Correction was instituted by the DON which stated the facility would complete a 100 % (percent) audit of all active residents by conducting a reconciliation with the MARs and the Physician Orders. Continued review revealed the Plan of Correction was to provide education of all Licensed Nursing Staff of the new system to be instituted requiring two nurses to double check the hospital discharge orders with the physician's orders [REDACTED]. to the facility. Continued review revealed each physician order, after a resident's admission to the facility, was to be verified by nursing administration "...the following business day..." Continued review of The Plan of Correction revealed the plan was ongoing with each new admission and physician order. Interview with the DON and Nurse Consultant #1 on April 17, 2014, at 2:55 p.m., in the Conference Room, confirmed the audit was completed per the Plan of Correction dated April 2, 2014, of all residents in the facility. Continued interview confirmed Nurse Consultant #1 emailed the results of the audit to the DON on April 4, 2014. Further interview confirmed both the DON and Nurse Consultant #1 were aware of the results of the audit which documented resident #19 was receiving medications which had not been ordered on admission, and were aware resident #19 was not receiving other medications which had been ordered. Continued interview confirmed both the DON and Nurse Consultant #1 failed to follow-up on the audit as of the time of the interview on April 17, 2014. Interview with the Administrator on April 21, 2014, at 9:40 a.m., in the Conference Room, confirmed the Administrator was also notified by email on April 4, 2014, of the results of the chart audits. Continued interview with the Administrator confirmed the Administrator also failed to follow-up on the results of the audit and was aware the medication errors had been identified. Further interview confirmed no action had been taken by Nursing Administration Staff or the Administrator to address the audit concerns. Further interview confirmed the Administrator had participated in the last Performance Improvement meeting on April 10, 2014, and "...talked about reconciliations..." Further interview confirmed facility management had identified the issues with medication reconiliation processes and had developed Plan of Correction on April 2, 2014. Continued interview confirmed the Administrator had "...discussions..." with the pharmacy related to the medication errors which had occurred. Further interview confirmed no new plan had been put in place since the original Plan of Correction presented by the DON on April 2, 2014. Refer to F157-J, F224-K, F281-L, F309-K, F333-L, F425-L C/0 #

Based on medical record review, review of facility Plan of Correction, facility policy review, and interview, the facility failed to be administered in a manner to ensure physician's orders [REDACTED].#1, #3, #10, #13, #14, #19, #24, #26, #28, #29, #30), failed to administer medications as ordered resulting in neglect of one resident (#3), failed to ensure quality of care for eight residents (#1, #3, #10, #13, #14, #19, #24, #29), failed to ensure the facility was free from significant medication errors for one resident (#3), and failed to ensure implemented interventions addressed during Performance Improvement were effective. The facility personnel failed to identify significant medication errors when completing medication audit. The facility's failure to ensure physician's orders [REDACTED].#3, #19, and #14 (a situation in the provider's noncompliance with one or more requirements of participation has caused, or was likely to cause, serious injury, harm impairment or death), and potentially for all residents in the facility. The Administrator, Regional Administrator Consultant, Assistant Director of Nursing, Nurse Consultant #1/Acting Director of Nursing, Nurse Consultant #2, Nurse Consultant #3, Vice-President of Client Operations, and Medical Director #1 were informed of the Immediate Jeopardy on April 24, 2014, at 10:55 a.m., in the Conference Room. The Immediate Jeopardy was effective March 14, 2014, and was ongoing. An extended survey was conducted on April 24, 2014. Substandard Quality of Care was cited at F224-K, F309-K, and F333-L. The facility provided an acceptable Allegation of Compliance on May 8, 2014, and a revist on May 13, 2014, and May 14, 2014, revealed the corrective actions implemented on May 2, 2014, removed the Immediacy of the Jeopardy. Noncompliance for F-490 continues at a "F" level citation for the facility's monitoring the effectiveness of corrective actions in order to ensure sustained compliance and evaluation of the processes by the Quality Assurance Committee. The findings included: Review of facility Plan of Correction (facility's own, internal corrective action plan), completed by the Director of Nursing (DON) on April 2, 2014, in response to the discovery of the significant medication errors of resident #3, revealed the facility became aware of medications which were being omitted from the hospital discharge records when reconciled with the facility's admission medication orders and Medication Records (MARs) sent from the pharmacy. Continued review revealed a Plan of Correction was instituted by the DON which stated the facility would complete a 100 % (percent) audit of all active residents by conducting a reconciliation with the MARs and the Physician Orders. Continued review revealed the Plan of Correction was to provide education of all Licensed Nursing Staff of the new system to be instituted requiring two nurses to double check the hospital discharge orders with the physician's orders [REDACTED]. to the facility. Continued review revealed each physician order, after a resident's admission to the facility, was to be verified by nursing administration "...the following business day..." Continued review of The Plan of Correction revealed the plan was ongoing with each new admission and physician order. Interview with the DON and Nurse Consultant #1 on April 17, 2014, at 2:55 p.m., in the Conference Room, confirmed the audit was completed per the Plan of Correction dated April 2, 2014, of all residents in the facility. Continued interview confirmed Nurse Consultant #1 emailed the results of the audit to the DON on April 4, 2014. Further interview confirmed both the DON and Nurse Consultant #1 were aware of the results of the audit which documented resident #19 was receiving medications which had not been ordered on admission, and were aware resident #19 was not receiving other medications which had been ordered. Continued interview confirmed both the DON and Nurse Consultant #1 failed to follow-up on the audit as of the time of the interview on April 17, 2014. Interview with the Administrator on April 21, 2014, at 9:40 a.m., in the Conference Room, confirmed the Administrator was also notified by email on April 4, 2014, of the results of the chart audits. Continued interview with the Administrator confirmed the Administrator also failed to follow-up on the results of the audit and was aware the medication errors had been identified. Further interview confirmed no action had been taken by Nursing Administration Staff or the Administrator to address the audit concerns. Further interview confirmed the Administrator had participated in the last Performance Improvement meeting on April 10, 2014, and "...talked about reconciliations..." Further interview confirmed facility management had identified the issues with medication reconiliation processes and had developed Plan of Correction on April 2, 2014. Continued interview confirmed the Administrator had "...discussions..." with the pharmacy related to the medication errors which had occurred. Further interview confirmed no new plan had been put in place since the original Plan of Correction presented by the DON on April 2, 2014. Refer to F157-J, F224-K, F281-L, F309-K, F333-L, F425-L Validation of the Credible Allegation of Compliance was accomplished on-site on May 13, 2014, and May 14, 2014, through medical record reviews, review of facility documents, and interviews with Nursing and Administrative Staff. The facility provided evidence of audits of reconciliation of admission/re-admission orders [REDACTED]. The facility provided documentation of an emergency Performance Improvement Meeting held on April 28, 2014, to discuss the new admission/readmission medication reconcilation process, pharmacy process, and physician notification process. Interviews with Nursing Staff on all shifts May 13-14, 2014, throughout the facility, revealed the nursing staff had been in-serviced on the protocol for new admission/readmission medication order reconciliation, pharmacy protocol, medication errors, and physician standing orders. Interview with the Administrator on May 14, 2014, at 8:40 a.m., in the conference room, revealed the facility leadership group, the Director of Nursing, and the Medical Director, reviewed the findings of the survey and implemented follow-up audit measures to ensure compliance with corrective actions with initiating a Performance Improvement Committee. The facility will remain out of compliance at a Scope and Severity level "F" a 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 and corrective actions are verified onsite. C/0 #

Based on review of Co-Medical Director Agreements, and interview, the facility failed to ensure one medical director was designated to be responsible and accountable for oversight of resident care policies, procedures and services. The failure of the facility to appoint one medical director resulted in inaccurate medication administration procedures that placed three residents (#3, #14, #19) of thirty-one residents reviewed in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death), and placed any resident who receives medications at risk. The Administrator, Regional Administrator Consultant, Assistant Director of Nursing, Nurse Consultant #1/Acting Director of Nursing, Nurse Consultant #2, Nurse Consultant #3, Vice-President of Client Operations, and Medical Director #1 were informed of the Immediate Jeopardy on April 24, 2014, at 10:55 a.m., in the Conference Room. The Immediate Jeopardy was effective March 14, 2014, and is ongoing. An extended survey was conducted on April 24, 2014. Substandard Quality of Care was cited at F224-J, F309-J, and F333-L. The findings included: Review of the facility's Medical Director Agreement revealed the facility had three co-medical directors, not one. Review of Co-Medical Director Agreement signed and dated November 14, 2012, by Medical Director #2, revealed, "...Services of Physicians...As Co-Medical Director of facility, Physician shall perform those duties and responsibilities set forth in Addendum A, atttached hereto...together with all other services to be provided by Physician hereunder, the 'Services'..." Further review revealed, "...Coordination of medical care in Facility...(iii) Facility's quality assurance program on a quarterly basis..." Continued review revealed, "...Addendum A...provides that medical directors are responsible for...implementation of resident care policies and the coordination of medical care in the facility...'Resident care policies' include admissions, transfers and discharges...It also includes having a significant role in overseeing the overall clinical care of residents to ensure to the extent possible that care is adequate...When the medical director identifies or receives a report of possible inadequate medical care, including drug irregularities, (Medical Director), is responsible for evaluating the situation and taking appropiate steps to try to correct the problem...A medical director whose sole function is to approve resident care policies does not meet this requirement..." Interview with Medical Director #2 on April 21, 2014, at 11:52 a.m., in the Conference Room, revealed "...was at the last Performance Improvement meeting (April 10, 2014)...don't remember specifics...talked about changing processes...and issue with medications...I would expect something to happen...Not sure of specifics...Not aware of the what checks and balances in place...Not aware of what pharmacy has or had in place to correct issues... " Review of Co-Medical Director Agreement signed and dated March 22, 2013, by Medical Director #3, revealed, "...Services of Physicians...As Co-Medical Director of facility, Physician shall perform those duties and responsibilities set forth in Addendum A, atttached hereto...together with all other services to be provided by Physician hereunder, the 'Services'..." Further review revealed, "...Coordination of medical care in Facility...(iii) Facility's quality assurance program on a quarterly basis..." Continued review revealed, "...Addendum A...provides that medical directors are responsible for...implementation of resident care policies and the coordination of medical care in the facility...'Resident care policies' include admissions, transfers and discharges...It also includes having a significant role in overseeing the overall clinical care of residents to ensure to the extent possible that care is adequate...When the medical director identifies or receives a report of possible inadequate medical care, including drug irregularities, (Medical Director), is responsible for evaluating the situation and taking appropiate steps to try to correct the problem...A medical director whose sole function is to approve resident care policies does not meet this requirement..." Interview with Medical Director #3 on April 22, 2014, at 9:30 a.m., in the Conference Room, revealed "...was not at last Performance Improvement meeting (April 10, 2014)...was aware was working on issue of confusing hospital discharge orders due to multiple sets provided to the facility...The administrator has not as yet approached (Medical Director #3) to address the issue..." In summary, the facility's failure to designate only one physician as Medical Director resulted in no one (of the three co-medical directors) soley accountable to ensure implementation of resident care policies and the coordination of medical care in the facility, including accurrate medication administration. Refer to F157-J, F224-K, F281-L, F309-K, F333-L, F425-L, F490-L C/0 #

Based on review of Co-Medical Director Agreements, and interview, the facility failed to ensure one medical director was designated to be responsible and accountable for oversight of resident care policies, procedures and services. The failure of the facility to appoint one medical director resulted in inaccurate medication administration procedures that placed three residents (#3, #14, #19) of thirty-one residents reviewed in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death), and placed any resident who receives medications at risk. The Administrator, Regional Administrator Consultant, Assistant Director of Nursing, Nurse Consultant #1/Acting Director of Nursing, Nurse Consultant #2, Nurse Consultant #3, Vice-President of Client Operations, and Medical Director #1 were informed of the Immediate Jeopardy on April 24, 2014, at 10:55 a.m., in the Conference Room. The Immediate Jeopardy was effective March 14, 2014, and was ongoing. An extended survey was conducted on April 24, 2014. Substandard Quality of Care was cited at F224-K, F309-K, and F333-L. The facility provided an acceptable Allegation of Compliance on May 8, 2014, and a revist on May 13, 2014, and May 14, 2014, revealed the corrective actions implemented on May 2, 2014, removed the Immediacy of the Jeopardy. Noncompliance for F-501 continues at a "F" level citation for the facility's monitoring the effectiveness of corrective actions in order to ensure sustained compliance and evaluation of the processes by the Quality Assurance Committee. The findings included: Review of the facility's Medical Director Agreement revealed the facility had three co-medical directors, not one. Review of Co-Medical Director Agreement signed and dated November 14, 2012, by Medical Director #2, revealed, "...Services of Physicians...As Co-Medical Director of facility, Physician shall perform those duties and responsibilities set forth in Addendum A, atttached hereto...together with all other services to be provided by Physician hereunder, the 'Services'..." Further review revealed, "...Coordination of medical care in Facility...(iii) Facility's quality assurance program on a quarterly basis..." Continued review revealed, "...Addendum A...provides that medical directors are responsible for...implementation of resident care policies and the coordination of medical care in the facility...'Resident care policies' include admissions, transfers and discharges...It also includes having a significant role in overseeing the overall clinical care of residents to ensure to the extent possible that care is adequate...When the medical director identifies or receives a report of possible inadequate medical care, including drug irregularities, (Medical Director), is responsible for evaluating the situation and taking appropiate steps to try to correct the problem...A medical director whose sole function is to approve resident care policies does not meet this requirement..." Interview with Medical Director #2 on April 21, 2014, at 11:52 a.m., in the Conference Room, revealed "...was at the last Performance Improvement meeting (April 10, 2014)...don't remember specifics...talked about changing processes...and issue with medications...I would expect something to happen...Not sure of specifics...Not aware of the what checks and balances in place...Not aware of what pharmacy has or had in place to correct issues... " Review of Co-Medical Director Agreement signed and dated March 22, 2013, by Medical Director #3, revealed, "...Services of Physicians...As Co-Medical Director of facility, Physician shall perform those duties and responsibilities set forth in Addendum A, atttached hereto...together with all other services to be provided by Physician hereunder, the 'Services'..." Further review revealed, "...Coordination of medical care in Facility...(iii) Facility's quality assurance program on a quarterly basis..." Continued review revealed, "...Addendum A...provides that medical directors are responsible for...implementation of resident care policies and the coordination of medical care in the facility...'Resident care policies' include admissions, transfers and discharges...It also includes having a significant role in overseeing the overall clinical care of residents to ensure to the extent possible that care is adequate...When the medical director identifies or receives a report of possible inadequate medical care, including drug irregularities, (Medical Director), is responsible for evaluating the situation and taking appropiate steps to try to correct the problem...A medical director whose sole function is to approve resident care policies does not meet this requirement..." Interview with Medical Director #3 on April 22, 2014, at 9:30 a.m., in the Conference Room, revealed "...was not at last Performance Improvement meeting (April 10, 2014)...was aware was working on issue of confusing hospital discharge orders due to multiple sets provided to the facility...The administrator has not as yet approached (Medical Director #3) to address the issue..." In summary, the facility's failure to designate only one physician as Medical Director resulted in no one (of the three co-medical directors) soley accountable to ensure implementation of resident care policies and the coordination of medical care in the facility, including accurrate medication administration. Refer to F157-J, F224-K, F281-L, F309-K, F333-L, F425-L, F490-L Validation of the Credible Allegation of Compliance was accomplished on-site on May 13, 2014, and May 14, 2014, through review of facility documents, interviews with Nursing and Administrative Staff, and the Medical Director. The facility provided evidence of audits of reconciliation of admission/re-admission orders [REDACTED]. The facility provided documentation of an emergency Performance Improvement Meeting held on April 28, 2014, to discuss the new admission/readmission medication reconcilation process, pharmacy process, and physician notification process. Interviews with Nursing Staff on all shifts May 13-14, 2014, throughout the facility, revealed the nursing staff had been in-serviced on the protocol for new admission/readmission medication order reconciliation, pharmacy protocol, medication errors, and physician standing orders. Telephone interview on May 13, 2014, at 2:30 p.m., with the Medical Director revealed the facility had three physician's with admitting priviledges. Continued interview revealed the Medical Director assisted the facility with implementation and approval of protocols for resident care and to remove the Immediate Jeopardy. Continued interview revealed the Medical Director and the other attending physicians communicated facility procedures during the Performance Improvement meetings, and discussed ways to address quality of care issues. The facility will remain out of compliance at a Scope and Severity level "F" a deficient practice that constitutes no actual harm with potential for minimal harm, that is not Immediate Jeopardy until it provides an acceptable plan of correction and corrective actions are verified onsite. C/0 #

Based on review of Medication Review 3 Month review, review of Timeline of Events, review of New Admission/Readmission Audts, medical record review, review of facility policy, review of facility Performance Improvement Committee Agenda and Minutes, and interview, the facility failed to develop a plan of action related to the failure to follow physician's orders [REDACTED].#1, #3, #10, #13, #14, #19, #24, #26, #28, #29, #30); failure to administer medications as ordered resulting in neglect for two residents (#3, #19); failure to ensure quality of care for eight residents (#1,#3, #10, #13, #14,#19, #24, #29); failure to ensure the facility was free from significant medication errors for two residents (#3, #14); failure to ensure the hospital medication discharge orders and the facility admission medication orders (physician's orders [REDACTED].#3, #10, #13, #19, #24, #26, #29) of the thirty-one residents reviewed. The facility's failure to ensure the physician's orders [REDACTED]. [REDACTED].#3, #14, #19) of thirty-one residents reviewed. The systems failure had the potential to place all residents in the facility who received medications in Immediate Jeopardy. The Administrator, Regional Administrator Consultant, Assistant Director of Nursing, Nurse Consultant #1/Acting Director of Nursing, Nurse Consultant #2, Nurse Consultant #3, Vice-President of Client Operations, and Medical Director #1 were informed of the Immediate Jeopardy on April 24, 2014, at 10:55 a.m., in the Conference Room. The Immediate Jeopardy was effective March 14, 2014, and is ongoing. Substandard Quality of Care was cited under F224-J, F309-J, and F333-L. An extended survey was conducted on April 24, 2014. The findings included: Review of facility Plan of Correction (facility's own internal corrective action plan), completed by the Director of Nursing (DON) on April 2, 2014, in response to the DON's discovery of the significant medication errors for resident #3 revealed, the facility had became aware of medications which were being omitted from the hospital discharge records when reconciled with the facility's admission medication orders and Medication Records (MARS) sent from the pharmacy. Continued review revealed the April 2, 2014, Plan of Correction was developed by the DON which stated the facility would complete a 100 % (percent) audit of all active residents by conducting a reconciliation with the MARs and the Physician Orders. Continued review revealed the Plan of Correction was to provide education of all Licensed Nursing Staff on the new system to be initiated requiring two nurses to double check the hospital discharge orders with the physician's orders [REDACTED]. or readmission to the facility. Continued review revealed each physician order, after a resident's admission to the facility, was to be verified by nursing administration "...the following business day..." Continued review of the Plan of Correction revealed the plan was ongoing with each new admission and physician order. Review of Performance Improvement Meeting Minutes, dated April 10, 2014, revealed the DON, Administrator, Assistant Director of Nursing (ADON), Pharmacist #1, Medical Director #2, Medical Director #1, as well as other facility staff attended the April 10, 2014, Performance Improvement meeting (Quality Assurance). Continued review revealed, "...Issue resident admitted , pharmacy only received 3 of the pages...Resolution plan...1. All orders faxed and both nurses' sign and fax confirmation and name of pharmacist who received the fax. 2. When medication arrive 2 nurses will check the POS (physician's orders [REDACTED]. Pharmacy is currently making changes with their system to alleviate any further problems. Nurses are also being educated with this new process..." Further review of the Performance Improvement Meeting Minutes revealed the facility did not address the results of the New Admission/Readmission Audits which had been completed by the DON which had identified continued problems with medication reconcilation processes. Interview with the DON and Nurse Consultant #1 on April 17, 2014, in the Conference Room, confirmed the audit was completed per the Plan of Correction dated April 2, 2014, of all residents in the facility. Further interview confirmed both the DON and Nurse Consultant #1 participated in Quality Assurrance meetings. Continued interview confirmed Nurse Consultant #1 emailed the results of the audit to the DON on April 4, 2014. Further interview confirmed both the DON and Nurse Consultant #1 were aware of the results of the audit which documented resident #19 was receiving medications which had not been ordered on admission, and were aware resident #19 was not receiving other medications which had been ordered. Continued interview confirmed both the DON and the Nurse Consultant #1 failed to follow-up on the audit until informed by the surveyor of the on-going medication errors during the interview on April 17, 2014. Interview with the Administrator on April 21, 2014, at 9:40 a.m., in the Conference Room, confirmed the Administrator was also notified by email on April 4, 2014, of the results of the chart audits. Continued interview with the Administrator confirmed the Administrator also failed to follow-up on the results of the audit and was aware the medication errors had been identified. Further interview confirmed no action had been taken by Nursing Administration Staff or the Administrator to address the audit concerns. Further interview confirmed the Administrator had participated in the last Performance Improvement meeting on April 10, 2014, and "...talked about reconciliations..." Continued interview confirmed the Administrator had "...discussions..." with the pharmacy related to the medication errors which had occurred. Further interview confirmed no new plan had been put in place since the original Plan of Correction presented by the DON on April 2, 2014. Interview with Medical Director #2 on April 21, 2014, at 11:52 a.m., in the Conference Room, revealed "...was at the last Performance Improvement meeting (April 10, 2014)...don't remember specifics...talked about changing processes...and issue with medications...I would expect something to happen...Not sure of specifics...Not aware of what the checks and balances were in place...Not aware of what pharmacy has or had in place to correct issues..." Interview with Medical Director #3 on April 22, 2014, at 9:30 a.m., in the conference room, revealed "...was not at last Performance Improvement meeting (April 10, 2014)...was aware was working on issue of confusing hospital discharge orders due to multiple sets provided to the facility...The administrator has not as yet approached (Medical Director #3) to address the issue..." Interview with Pharmacist #1 April 22, at 1:25 p.m., in the Conference Room, confirmed the pharmacist attended the last Performance Improvement meeting on April 10, 2014. Continued interview with Pharmacist #1 confirmed the pharmacist was aware of the medication reconciliation issues, and confirmed was aware of the Plan of Correction processes which had been instituted. Further interview confirmed the pharmacy had instituted an internal process to correct medication reconciliation issues. Continued interview confirmed Pharmacist #1 or Pharmacist #2 were to audit all resident's hospital discharge orders with the physician's orders [REDACTED]. Refer to F157-J, F224-K, F281-L, F309-K, F333-L, F425-L, F490-L, F501-L C/0 #

Based on review of Medication Review 3 Month review, review of Timeline of Events, review of New Admission/Readmission Audts, medical record review, review of facility policy, review of facility Performance Improvement Committee Agenda and Minutes, and interview, the facility failed to develop a plan of action related to the failure to follow physician's orders [REDACTED].#1, #3, #10, #13, #14, #19, #24, #26, #28, #29, #30); failure to administer medications as ordered resulting in neglect for two residents (#3, #19); failure to ensure quality of care for eight residents (#1,#3, #10, #13, #14,#19, #24, #29); failure to ensure the facility was free from significant medication errors for two residents (#3, #14); failure to ensure the hospital medication discharge orders and the facility admission medication orders (physician's orders [REDACTED].#3, #10, #13, #19, #24, #26, #29) of the thirty-one residents reviewed. The facility's failure to ensure the physician's orders [REDACTED]. [REDACTED].#3, #14, #19) of thirty-one residents reviewed. The systems failure had the potential to place all residents in the facility who received medications in Immediate Jeopardy. The Administrator, Regional Administrator Consultant, Assistant Director of Nursing, Nurse Consultant #1/Acting Director of Nursing, Nurse Consultant #2, Nurse Consultant #3, Vice-President of Client Operations, and Medical Director #1 were informed of the Immediate Jeopardy on April 24, 2014, at 10:55 a.m., in the Conference Room. The Immediate Jeopardy was effective March 14, 2014, and was ongoing. Substandard Quality of Care was cited under F224-K, F309-K, and F333-L. An extended survey was conducted on April 24, 2014. The facility provided an acceptable Allegation of Compliance on May 8, 2014, and a revist on May 13, 2014, and May 14, 2014, revealed the corrective actions implemented on May 2, 2014, removed the Immediacy of the Jeopardy. Noncompliance for F-520 continues at a "F" level citation for the facility's monitoring the effectiveness of corrective actions in order to ensure sustained compliance and evaluation of the processes by the Quality Assurance Committee. The findings included: Review of the facility's Plan of Correction (facility's own internal corrective action plan), completed by the Director of Nursing (DON) on April 2, 2014, in response to the DON's discovery of the significant medication errors for resident #3 revealed, the facility had became aware of medications which were being omitted from the hospital discharge records when reconciled with the facility's admission medication orders and Medication Records (MARs) sent from the pharmacy. Continued review revealed the April 2, 2014, Plan of Correction was developed by the DON which stated the facility would complete a 100 % (percent) audit of all active residents by conducting a reconciliation with the MARs and the Physician Orders. Continued review revealed the Plan of Correction was to provide education of all Licensed Nursing Staff on the new system to be initiated requiring two nurses to double check the hospital discharge orders with the physician's orders [REDACTED]. or readmission to the facility. Continued review revealed each physician order, after a resident's admission to the facility, was to be verified by nursing administration "...the following business day..." Continued review of the Plan of Correction revealed the plan was ongoing with each new admission and physician order. Review of Performance Improvement Meeting Minutes, dated April 10, 2014, revealed the DON, Administrator, Assistant Director of Nursing (ADON), Pharmacist #1, Medical Director #2, Medical Director #1, as well as other facility staff attended the April 10, 2014, Performance Improvement meeting (Quality Assurance). Continued review revealed, "...Issue resident admitted , pharmacy only received 3 of the pages...Resolution plan...1. All orders faxed and both nurses' sign and fax confirmation and name of pharmacist who received the fax. 2. When medication arrive 2 nurses will check the POS (physician's orders [REDACTED]. Pharmacy is currently making changes with their system to alleviate any further problems. Nurses are also being educated with this new process..." Further review of the Performance Improvement Meeting Minutes revealed the facility did not address the results of the New Admission/Readmission Audits which had been completed by the DON which had identified continued problems with medication reconcilation processes. Interview with the DON and Nurse Consultant #1 on April 17, 2014, in the Conference Room, confirmed the audit was completed per the Plan of Correction dated April 2, 2014, of all residents in the facility. Further interview confirmed both the DON and Nurse Consultant #1 participated in Quality Assurrance meetings. Continued interview confirmed Nurse Consultant #1 emailed the results of the audit to the DON on April 4, 2014. Further interview confirmed both the DON and Nurse Consultant #1 were aware of the results of the audit which documented resident #19 was receiving medications which had not been ordered on admission, and were aware resident #19 was not receiving other medications which had been ordered. Continued interview confirmed both the DON and the Nurse Consultant #1 failed to follow-up on the audit until informed by the surveyor of the on-going medication errors during the interview on April 17, 2014. Interview with the Administrator on April 21, 2014, at 9:40 a.m., in the Conference Room, confirmed the Administrator was also notified by email on April 4, 2014, of the results of the chart audits. Continued interview with the Administrator confirmed the Administrator also failed to follow-up on the results of the audit and was aware the medication errors had been identified. Further interview confirmed no action had been taken by Nursing Administration Staff or the Administrator to address the audit concerns. Further interview confirmed the Administrator had participated in the last Performance Improvement meeting on April 10, 2014, and "...talked about reconciliations..." Continued interview confirmed the Administrator had "...discussions..." with the pharmacy related to the medication errors which had occurred. Further interview confirmed no new plan had been put in place since the original Plan of Correction presented by the DON on April 2, 2014. Interview with Medical Director #2 on April 21, 2014, at 11:52 a.m., in the Conference Room, revealed "...was at the last Performance Improvement meeting (April 10, 2014)...don't remember specifics...talked about changing processes...and issue with medications...I would expect something to happen...Not sure of specifics...Not aware of what the checks and balances were in place...Not aware of what pharmacy has or had in place to correct issues..." Interview with Medical Director #3 on April 22, 2014, at 9:30 a.m., in the conference room, revealed "...was not at last Performance Improvement meeting (April 10, 2014)...was aware was working on issue of confusing hospital discharge orders due to multiple sets provided to the facility...The administrator has not as yet approached (Medical Director #3) to address the issue..." Interview with Pharmacist #1 April 22, at 1:25 p.m., in the Conference Room, confirmed the pharmacist attended the last Performance Improvement meeting on April 10, 2014. Continued interview with Pharmacist #1 confirmed the pharmacist was aware of the medication reconciliation issues, and confirmed was aware of the Plan of Correction processes which had been instituted. Further interview confirmed the pharmacy had instituted an internal process to correct medication reconciliation issues. Continued interview confirmed Pharmacist #1 or Pharmacist #2 were to audit all resident's hospital discharge orders with the physician's orders [REDACTED]. Refer to F157-J, F224-K, F281-L, F309-K, F333-L, F425-L, F490-L, F501-L Validation of the Credible Allegation of Compliance was accomplished on-site on May 13, 2014, and May 14, 2014, through medical record reviews, review of facility documents, and interviews with Nursing and Administrative Staff. The facility provided evidence of audits of reconciliation of admission/re-admission orders [REDACTED]. The facility provided documentation of an emergency Performance Improvement Meeting held on April 28, 2014, to discuss the new admission/readmission medication reconcilation process, pharmacy process, and physician notification process. and provided evidence of establishing a Performance Improvement Committee which will meet monthly for three consecutive months. The medication error audits, admission/readmission orders [REDACTED]. Interviews with Nursing Staff on all shifts May 13-14, 2014, revealed the nursing staff had been in-serviced on the protocol for new admission/readmission medication order reconciliation, pharmacy protocol, medication errors, and physician standing orders. The facility will remain out of compliance at a Scope and Severity level "F" a 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 and corrective actions are verified onsite. C/0 #

Based on medical record review, review of a facility investigation, and interview the facility failed to ensure one resident (#3) received ordered medications for 15 days following a hospital stay, resulting in rehospitalization in critical condition, of thirty-one residents reviewed. The facility's failure to administer prescribed medications resulted in neglect. The facility's neglect of the resident placed resident #3 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 systemic failure to ensure post-hospital discharge orders were reconciled with facility admission orders [REDACTED]. The Administrator, Regional Administrator Consultant, Assistant Director of Nursing, Nurse Consultant #1/Acting Director of Nursing, Nurse Consultant #2, Nurse Consultant #3, Vice-President of Client Operations, and Medical Director #1 were informed of the Immediate Jeopardy on April 24, 2014, at 10:55 a.m., in the Conference Room. The Immediate Jeopardy was effective March 14, 2014, and is ongoing. An extended survey was conducted on April 24, 2014. The findings included: Resident #3 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the hospital Discharge Med (Medication) Rec (Reconciliation) form dated March 14, 2014, revealed the hospital Discharge Med Rec form contained a total of 6 pages of medications ordered for the resident upon discharge from the hospital and readmission to the facility. Continued review revealed the Discharge Med Rec form for pages 1 and 2 included physician's orders [REDACTED]. once per day, [MEDICATION NAME] (heart medication to control heart rate and blood pressure) 120 mg once per day, and [MEDICATION NAME] (medication to control high blood pressure) 10 mg once per day. Medical record review of physician's orders [REDACTED]. Medical record review of the Medication Record (form used to document medication administration: MAR) dated March 14, 2014, through March 31, 2014, revealed two pages of medications, neither of which included the [MEDICATION NAME], [MEDICATION NAME], and [MEDICATION NAME]. Medical record review of a nurse's note dated March 30, 2014, revealed, "...Late entry for 3/28/14. At approx. (approximately) 3 p.m. this nurse was called to resident room to assess resident. Resident in bed with eyes closed, shaking et (and) c/o (complained of) being cold. Resident alert et responsive. Vital signs T (temperature) 100.8 orally, P (pulse) 138 (normal range 60-100), R (respirations) 27, B/P (blood pressure) 156/92, O2 (oxygen) 78 % (percent) via (by) nc (nasal cannula) at 3 LPM (liters per minute). This nurse instructed patient to breathe in through nose et out through mouth. O2 increased to 83%. Nurse applied a non-rebreather oxygen mask et O2 increased to 86-92% fluctuating. Nurse notified MD (medical doctor) of pt (patient) status et N/O (new order) to send to ER (emergency room ) for eval (evaluation) et tx (treatment)..." Continued review revealed, "...late entry for 3/29/14 5 pm. ER staff called et stated they needed a copy of resident's MAR. This nurse faxed MAR indicated [REDACTED]. No new [DIAGNOSES REDACTED]. This nurse was informed that diagnostic testing was still being performed..." Medical record review of a nurse's note dated April 8, 2014, timed 2:49 p.m., and signed by the Director of Nursing (DON) revealed, "...Upon chart review it is noted on the late entry dated 3-30-14 @ (at) 730 a.m., (the note is for 3-28-14) the date for the late entry is incorrect and is actually for 3-29-14 which is when this resident was transferred to the ER for further eval and treatment..." Medical record review of emergency room Provider Report dated March 29, 2014, revealed the resident was evaluated in the emergency room . Continued review of the emergency room Provider Report revealed the resident had complained of shortness of breath and "...pt recently diagnosed with [REDACTED]. Further review revealed the resident's vital signs were documented as blood pressure 150/50, temperature 100.3, pulse 67, and respirations 20 at 4:06 p.m. Continued review revealed, "...Cardiovascular: normal heart sounds, [MEDICAL CONDITION](heart rate over 100), irregularly irregular..." Further review revealed the resident's vital signs were documented at 5:58 p.m. "...b/p 131/80, pulse 154, resp (respirations) 26, and temp 100.3..." Medical record review of emergency room lab report dated March 29, 2014, revealed the resident's level of the [MEDICATION NAME] medication was reported as "...< (less than) 0.2 L (low)..." Continued review of the emergency room report revealed the resident had an Electrocardiogram (EKG, diagnostic test to evaluate heart rate, rhythm, and electrical pulses). Further review revealed the results of the heart monitoring test was "...A-Fib ([MEDICAL CONDITION] Fibrillation) with RVR (rapid ventricular response) ..." indicating the resident's heart rate and rhythm were abnormal. Continued review revealed, "...Clinical Impression: Primary Impression: Pneumonia...Secondary Impressions: AFib, [MEDICAL CONDITIONS]..." Further review revealed the resident was admitted to the hospital for further treatment. Medical record review of Consulting Physician #1's note dated March 29, 2014, revealed the resident was seen by a consulting physician in the hospital. Review of the record revealed, "...Reason for Consultation: [MEDICAL CONDITION]..." Further review revealed the resident "...was found to be in [MEDICAL CONDITION] with a ventricular rate around 170...(resident) has history of chronic [MEDICAL CONDITION], chronic heart failure, and had a stroke in September 2012...Currently (resident) is on long term oral anticoagulation ([MEDICATION NAME])..." Further review of Consulting Physician #1's note revealed, "...Diagnostic Studies: (Resident's) EKG shows [MEDICAL CONDITION] with a ventricular rate around 185, low voltage, and poor R-wave progression..." Continued review of the consultation note revealed, "...Impression: 1. [MEDICAL CONDITION] 2. Acute...chronic heart failure..." Medical record review of Consulting Physician #2's note dated March 29, 2014, revealed, "...Assessment and Plan: 1. [MEDICAL CONDITION] with rapid ventricular response. Continue [MEDICATION NAME] drip initiated in the emergency room ...2. Pneumonia...5. Subtherapeutic [MEDICATION NAME] level. We will load the patient with [MEDICATION NAME] repeat level in the morning hours with further orders to follow..." Medical record review of Hospitalist Physician's Progress Note dated March 30, 2014, revealed, "...Subjective: The patient was noted to have persistent [MEDICAL CONDITION] with rapid ventricular response despite [MEDICATION NAME] drip. (Resident) was also noted to have [MEDICAL CONDITION] (a decreased level of oxygen in the blood)...The patient was also note (noted) to have some decreased responsiveness and (resident) was...transferred to the intensive care unit (ICU)..." Continued review of the physician's progress note revealed, "...Assessment and Plan: The patient is a [AGE] year old (resident) admitted to the hospital with [REDACTED]. [MEDICAL CONDITION] with rapid ventricular response. Heart rate is improving. Continue [MEDICATION NAME]" Medical record review of Consulting Physician #3's note dated March 30, 2014, revealed, "...(Resident) also has [MEDICAL CONDITION] with rapid ventricular rate. (Resident) was transferred to ICU this morning because of [MEDICAL CONDITION] and also because of persistent [MEDICAL CONDITION] with rapid rate..." Continued review revealed, "...Impression: 1...Acute [MEDICAL CONDITION] 2. Pneumonia 3. [MEDICAL CONDITION] 4. [MEDICAL CONDITION]...Recommendations: 1. Agree with transfer to intensive care unit...7. Continue care in the ICU, critically ill..." Medical record review of the hospital Discharge Summary by Hospitalist Physician dated March 31, 2014, revealed, "...Hospital course: The patient was admitted and started on [MEDICATION NAME] drip...The patient did have a subtherapeutic [MEDICATION NAME] level and the patient was loaded with [MEDICATION NAME]. The patient was noted to have persistent [MEDICAL CONDITION] with rapid ventricular response despite the [MEDICATION NAME] drip...The patient was transferred to the intensive care unit...Plan for this patient: 1. Pneumonia is improving...3. [MEDICAL CONDITION] with rapid ventricular response, heart rate is rate controlled, [MEDICATION NAME] drip has been off for over 24 hours. The patient will be discharged back to nursing home today..." Review of Timeline of Events dated April 1, 2014, and signed by the DON, revealed, "...Timeline of Events...During MAR indicated [REDACTED]. Upon investigation, it appears that resident (#3)...did not receive (resident's) scheduled [MEDICATION NAME], [MEDICATION NAME] or [MEDICATION NAME] since (resident) was readmitted to (facility) on 3/14/14..." Continued review of Timeline of Events revealed when the resident was readmitted to the facility on [DATE], the resident's hospital discharge orders were faxed to the pharmacy. Further review of Timeline of Events revealed the facility's investigation determined the pharmacy received only pages 3, 4, 5, and 6 of a total of six pages. Continued review revealed the pharmacy did not receive pages 1 and 2 which consisted of the orders for the resident's [MEDICATION NAME], [MEDICATION NAME], and [MEDICATION NAME]. Interview with the DON and Nurse Consultant #1 on April 15, 2014, at 2:45 p.m., in the Conference Room, revealed the DON's investigation of the medication errors revealed the nurse who faxed the resident's discharge orders from the hospital to the pharmacy did not verify with the pharmacy how many pages the pharmacy had received. Continued interview revealed when the resident's medications arrived from the pharmacy, the nurse matched the medications with the Physician order [REDACTED]. Further interview with the DON and Nurse Consultant #1 confirmed resident #3 did not receive six ordered medications ([MEDICATION NAME], [MEDICATION NAME]) from the time of the resident's admission to the facility on [DATE], until the resident's discharge to the hospital on March 29, 2014 (a total of 15 days). Further interview with the DON and Nurse Consultant #1 confirmed the facility's failure to reconcile the resident's hospital discharge orders with the facility's admission orders [REDACTED]. Interview with the DON on April 16, 2014, at 12:40 p.m., in the Conference Room, confirmed the DON had questioned the admitting nurse of resident #3 about the resident not being admitted from the hospital with [MEDICATION NAME] orders. Continued interview with the DON confirmed the DON also did not reconcile the hospital discharge orders with the facility's admission orders [REDACTED]. Interview with Hospitalist Physician #1 on April 21, 2014, at 10:26 a.m., by phone, confirmed the physician was one of resident #3's treating physicians. Further interview revealed, "...I would say the fact that (resident) did not receive medications led to the (resident's) hospitalization ..." Continued interview confirmed the resident's [MEDICATION NAME] level "...was very low...", subtherapeutic, and confirmed the resident was "...critically ill..." necessitating the resident's transfer to the Intensive Care Unit (ICU). Further interview with Hospitalist Physician #1 confirmed when resident #3 was administered the resident's ordered medications (specifically [MEDICATION NAME] and [MEDICATION NAME]) the resident improved, and was able to be discharged back to the facility. Interviews conducted with the DON and Nurse Consultant #1 during the course of the survey confirmed there was not a consistent medication reconciliation process in place for nursing staff to utilize when a resident was admitted /readmitted to the facility which resulted in the failure to provide six medications, therefore neglect, to resident #3. C/O #

Based on medical record review, review of a facility investigation, and interview the facility failed to ensure one resident (#3) received ordered medications for 15 days following a hospital stay, resulting in rehospitalization in critical condition, of thirty-one residents reviewed. The facility's failure to administer prescribed medications resulted in neglect. The facility's neglect of the resident placed resident #3 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 systemic failure to ensure post-hospital discharge orders were reconciled with facility admission orders [REDACTED]. The Administrator, Regional Administrator Consultant, Assistant Director of Nursing, Nurse Consultant #1/Acting Director of Nursing, Nurse Consultant #2, Nurse Consultant #3, Vice-President of Client Operations, and Medical Director #1 were informed of the Immediate Jeopardy on April 24, 2014, at 10:55 a.m., in the Conference Room. The Immediate Jeopardy was effective March 14, 2014, and was ongoing. An extended survey was conducted on April 24, 2014. The facility provided an acceptable Allegation of Compliance on May 8, 2014, and a revisit on May 13, 2014, and May 14, 2014, revealed the corrective actions implemented on May 2, 2014, removed the Immediacy of the Jeopardy. Noncompliance for F224 continues at "E" level citation for the facility's monitoring the effectiveness of corrective actions in order to ensure sustained compliance and evaluation of the processes by the Quality Assurance Committee. The findings included: Resident #3 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the hospital Discharge Med (Medication) Rec (Reconciliation) form dated March 14, 2014, revealed the hospital Discharge Med Rec form contained a total of 6 pages of medications ordered for the resident upon discharge from the hospital and readmission to the facility. Continued review revealed the Discharge Med Rec form for pages 1 and 2 included physician's orders [REDACTED]. once per day, [MEDICATION NAME] (heart medication to control heart rate and blood pressure) 120 mg once per day, and [MEDICATION NAME] (medication to control high blood pressure) 10 mg once per day. Medical record review of physician's orders [REDACTED]. Medical record review of the Medication Record (form used to document medication administration: MAR) dated March 14, 2014, through March 31, 2014, revealed two pages of medications, neither of which included the [MEDICATION NAME], [MEDICATION NAME], and [MEDICATION NAME]. Medical record review of a nurse's note dated March 30, 2014, revealed, "...Late entry for 3/28/14. At approx. (approximately) 3 p.m. this nurse was called to resident room to assess resident. Resident in bed with eyes closed, shaking et (and) c/o (complained of) being cold. Resident alert et responsive. Vital signs T (temperature) 100.8 orally, P (pulse) 138 (normal range 60-100), R (respirations) 27, B/P (blood pressure) 156/92, O2 (oxygen) 78 % (percent) via (by) nc (nasal cannula) at 3 LPM (liters per minute). This nurse instructed patient to breathe in through nose et out through mouth. O2 increased to 83%. Nurse applied a non-rebreather oxygen mask et O2 increased to 86-92% fluctuating. Nurse notified MD (medical doctor) of pt (patient) status et N/O (new order) to send to ER (emergency room ) for eval (evaluation) et tx (treatment)..." Continued review revealed, "...late entry for 3/29/14 5 pm. ER staff called et stated they needed a copy of resident's MAR. This nurse faxed MAR indicated [REDACTED]. No new [DIAGNOSES REDACTED]. This nurse was informed that diagnostic testing was still being performed..." Medical record review of a nurse's note dated April 8, 2014, timed 2:49 p.m., and signed by the Director of Nursing (DON) revealed, "...Upon chart review it is noted on the late entry dated 3-30-14 @ (at) 730 a.m., (the note is for 3-28-14) the date for the late entry is incorrect and is actually for 3-29-14 which is when this resident was transferred to the ER for further eval and treatment..." Medical record review of emergency room Provider Report dated March 29, 2014, revealed the resident was evaluated in the emergency room . Continued review of the emergency room Provider Report revealed the resident had complained of shortness of breath and "...pt recently diagnosed with [REDACTED]. Further review revealed the resident's vital signs were documented as blood pressure 150/50, temperature 100.3, pulse 67, and respirations 20 at 4:06 p.m. Continued review revealed, "...Cardiovascular: normal heart sounds, [MEDICAL CONDITION](heart rate over 100), irregularly irregular..." Further review revealed the resident's vital signs were documented at 5:58 p.m. "...b/p 131/80, pulse 154, resp (respirations) 26, and temp 100.3..." Medical record review of emergency room lab report dated March 29, 2014, revealed the resident's level of the [MEDICATION NAME] medication was reported as "...< (less than) 0.2 L (low)..." Continued review of the emergency room report revealed the resident had an Electrocardiogram (EKG, diagnostic test to evaluate heart rate, rhythm, and electrical pulses). Further review revealed the results of the heart monitoring test was "...A-Fib ([MEDICAL CONDITION] Fibrillation) with RVR (rapid ventricular response) ..." indicating the resident's heart rate and rhythm were abnormal. Continued review revealed, "...Clinical Impression: Primary Impression: Pneumonia...Secondary Impressions: AFib, [MEDICAL CONDITIONS]..." Further review revealed the resident was admitted to the hospital for further treatment. Medical record review of Consulting Physician #1's note dated March 29, 2014, revealed the resident was seen by a consulting physician in the hospital. Review of the record revealed, "...Reason for Consultation: [MEDICAL CONDITION]..." Further review revealed the resident "...was found to be in [MEDICAL CONDITION] with a ventricular rate around 170...(resident) has history of chronic [MEDICAL CONDITION], chronic heart failure, and had a stroke in September 2012...Currently (resident) is on long term oral anticoagulation ([MEDICATION NAME])..." Further review of Consulting Physician #1's note revealed, "...Diagnostic Studies: (Resident's) EKG shows [MEDICAL CONDITION] with a ventricular rate around 185, low voltage, and poor R-wave progression..." Continued review of the consultation note revealed, "...Impression: 1. [MEDICAL CONDITION] 2. Acute...chronic heart failure..." Medical record review of Consulting Physician #2's note dated March 29, 2014, revealed, "...Assessment and Plan: 1. [MEDICAL CONDITION] with rapid ventricular response. Continue [MEDICATION NAME] drip initiated in the emergency room ...2. Pneumonia...5. Subtherapeutic [MEDICATION NAME] level. We will load the patient with [MEDICATION NAME] repeat level in the morning hours with further orders to follow..." Medical record review of Hospitalist Physician's Progress Note dated March 30, 2014, revealed, "...Subjective: The patient was noted to have persistent [MEDICAL CONDITION] with rapid ventricular response despite [MEDICATION NAME] drip. (Resident) was also noted to have [MEDICAL CONDITION] (a decreased level of oxygen in the blood)...The patient was also note (noted) to have some decreased responsiveness and (resident) was...transferred to the intensive care unit (ICU)..." Continued review of the physician's progress note revealed, "...Assessment and Plan: The patient is a [AGE] year old (resident) admitted to the hospital with [REDACTED]. [MEDICAL CONDITION] with rapid ventricular response. Heart rate is improving. Continue [MEDICATION NAME]" Medical record review of Consulting Physician #3's note dated March 30, 2014, revealed, "...(Resident) also has [MEDICAL CONDITION] with rapid ventricular rate. (Resident) was transferred to ICU this morning because of [MEDICAL CONDITION] and also because of persistent [MEDICAL CONDITION] with rapid rate..." Continued review revealed, "...Impression: 1...Acute [MEDICAL CONDITION] 2. Pneumonia 3. [MEDICAL CONDITION] 4. [MEDICAL CONDITION]...Recommendations: 1. Agree with transfer to intensive care unit...7. Continue care in the ICU, critically ill..." Medical record review of the hospital Discharge Summary by Hospitalist Physician dated March 31, 2014, revealed, "...Hospital course: The patient was admitted and started on [MEDICATION NAME] drip...The patient did have a subtherapeutic [MEDICATION NAME] level and the patient was loaded with [MEDICATION NAME]. The patient was noted to have persistent [MEDICAL CONDITION] with rapid ventricular response despite the [MEDICATION NAME] drip...The patient was transferred to the intensive care unit...Plan for this patient: 1. Pneumonia is improving...3. [MEDICAL CONDITION] with rapid ventricular response, heart rate is rate controlled, [MEDICATION NAME] drip has been off for over 24 hours. The patient will be discharged back to nursing home today..." Review of Timeline of Events dated April 1, 2014, and signed by the DON, revealed, "...Timeline of Events...During MAR indicated [REDACTED]. Upon investigation, it appears that resident (#3)...did not receive (resident's) scheduled [MEDICATION NAME], [MEDICATION NAME] or [MEDICATION NAME] since (resident) was readmitted to (facility) on 3/14/14..." Continued review of Timeline of Events revealed when the resident was readmitted to the facility on [DATE], the resident's hospital discharge orders were faxed to the pharmacy. Further review of Timeline of Events revealed the facility's investigation determined the pharmacy received only pages 3, 4, 5, and 6 of a total of six pages. Continued review revealed the pharmacy did not receive pages 1 and 2 which consisted of the orders for the resident's [MEDICATION NAME], [MEDICATION NAME], and [MEDICATION NAME]. Interview with the DON and Nurse Consultant #1 on April 15, 2014, at 2:45 p.m., in the Conference Room, revealed the DON's investigation of the medication errors revealed the nurse who faxed the resident's discharge orders from the hospital to the pharmacy did not verify with the pharmacy how many pages the pharmacy had received. Continued interview revealed when the resident's medications arrived from the pharmacy, the nurse matched the medications with the Physician order [REDACTED]. Further interview with the DON and Nurse Consultant #1 confirmed resident #3 did not receive six ordered medications ([MEDICATION NAME], [MEDICATION NAME]) from the time of the resident's admission to the facility on [DATE], until the resident's discharge to the hospital on March 29, 2014 (a total of 15 days). Further interview with the DON and Nurse Consultant #1 confirmed the facility's failure to reconcile the resident's hospital discharge orders with the facility's admission orders [REDACTED]. Interview with the DON on April 16, 2014, at 12:40 p.m., in the Conference Room, confirmed the DON had questioned the admitting nurse of resident #3 about the resident not being admitted from the hospital with [MEDICATION NAME] orders. Continued interview with the DON confirmed the DON also did not reconcile the hospital discharge orders with the facility's admission orders [REDACTED]. Interview with Hospitalist Physician #1 on April 21, 2014, at 10:26 a.m., by phone, confirmed the physician was one of resident #3's treating physicians. Further interview revealed, "...I would say the fact that (resident) did not receive medications led to the (resident's) hospitalization ..." Continued interview confirmed the resident's [MEDICATION NAME] level "...was very low...", subtherapeutic, and confirmed the resident was "...critically ill..." necessitating the resident's transfer to the Intensive Care Unit (ICU). Further interview with Hospitalist Physician #1 confirmed when resident #3 was administered the resident's ordered medications (specifically [MEDICATION NAME] and [MEDICATION NAME]) the resident improved, and was able to be discharged back to the facility. Interviews conducted with the DON and Nurse Consultant #1 during the course of the survey confirmed there was not a consistent medication reconciliation process in place for nursing staff to utilize when a resident was admitted /readmitted to the facility which resulted in the failure to provide six medications, therefore neglect, to resident #3. C/O # Validation of the Credible Allegation of Compliance was accomplished on-site on May 13, 2014, and May 14, 2014, through medical record reviews, review of facility documents, and interviews with Nursing and Administrative Staff. The facility provided evidence of audits of reconciliation of admission/re-admission orders [REDACTED]. The facility provided documentation of an emergency Performance Improvement Meeting held on April 28, 2014, to discuss the new admission/readmission medication reconcilation process, pharmacy process, and physician notification process and provided evidence of establishing a Performance Improvement Committee to address the system failure for accurate medication verification, delivery and administration. Medical record review of the closed chart of resident #3 revealed the resident's Physician order [REDACTED]. Resident #3 was discharged from the facility on April 1, 2014. Medical record review of resident #33 revealed the resident was readmitted to the facility on [DATE]. Continued review of the physician orders [REDACTED]. Medical record review of the Medication Administration Record [REDACTED]. Interviews with Nursing Staff on all shifts May 13-14, 2014, throughout the facility, revealed the nursing staff had been in-serviced on the protocol for new admission/readmission medication order reconciliation, pharmacy protocol, medication errors, and physician standing orders. The facility will remain out of compliance at a Scope and Severity level "E" a pattern of 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, and the corrective actions are verified onsite.

Based on medical record review, review of Timeline of Events, review of Medication 3 Month Review, review of New Admission/Readmission Audits, and interview the facility failed to provide a system of quality of care to ensure any resident admitted or readmitted to the facility with hospital discharge physician's orders [REDACTED]. The facility's failure to provide quality of care resulted in one resident (#3) requiring re-hospitalization in critical condition, and resulted in seven residents (#19, #14 #24, #29, #13, #1, #10) receiving multiple medication errors, of thirty-one residents reviewed. The facility's failure to reconcile hosptial discharge/facility admission orders [REDACTED] The Administrator, Regional Administrator Consultant, Assistant Director of Nursing, Nurse Consultant #1/Acting Director of Nursing, Nurse Consultant #2, Nurse Consultant #3, Vice-President of Client Operations, and Medical Director #1 were informed of the Immediate Jeopardy on April 24, 2014, at 10:55 a.m., in the Conference Room. The Immediate Jeopardy was effective March 14, 2014, and is ongoing. An extended survey was conducted on April 24, 2014. Substandard Quality of Care was cited under F309-J The findings included: Resident #3 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the hospital Discharge Med (Medication) Rec (Reconciliation) form dated March 14, 2014, revealed the hospital Discharge Med Rec form contained a total of 6 pages of medications ordered for resident #3 upon discharge from the hospital and readmission to the facility. Continued review revealed the Discharge Med Rec form for pages 1 and 2 included physician's orders [REDACTED]. once per day, [MEDICATION NAME] (heart medication to control heart rate and blood pressure) 120 mg once per day, and [MEDICATION NAME] (medication to control high blood pressure) 10 mg once per day. Medical record review of physician's orders [REDACTED]. Medical record review of the Medication Record (form used to document medication administration: MAR) dated March 14, 2014, through March 31, 2014, revealed two pages of medications, neither of which included the [MEDICATION NAME], [MEDICATION NAME], and [MEDICATION NAME] for resident #3. Medical record review of a nurse's note dated March 30, 2014, revealed, "...Late entry for 3/28/14. At approx. (approximately) 3 p.m. this nurse was called to resident room to assess resident. Resident (#3) in bed with eyes closed, shaking et (and) c/o (complained of) being cold. Resident alert et responsive. Vital signs T (temperature) 100.8 orally, P (pulse) 138 (normal range 60-100), R (respirations) 27, B/P (blood pressure) 156/92, O2 (oxygen) 78 % (percent) via (by) nc (nasal cannula) at 3 LPM (liters per minute). This nurse instructed patient to breathe in through nose et out through mouth. O2 increased to 83%. Nurse applied a non-rebreather oxygen mask et O2 increased to 86-92% fluctuating. Nurse notified MD (medical doctor) of pt (patient) status et N/O (new order) to send to ER (emergency room ) for eval (evaluation) et tx (treatment)..." Continued review revealed, "...late entry for 3/29/14 5 pm. ER staff called et stated they needed a copy of resident's MAR. This nurse faxed MAR indicated [REDACTED]. No new [DIAGNOSES REDACTED]. This nurse was informed that diagnostic testing was still being performed..." Medical record review of a nurse's note dated April 8, 2014, timed 2:49 p.m., and signed by the Director of Nursing (DON) revealed, "...Upon chart review it is noted on the late entry dated 3-30-14 @ (at) 730 a.m., (the note is for 3-28-14) the date for the late entry is incorrect and is actually for 3-29-14 which is when this resident (#3) was transferred to the ER for further eval and treatment..." Medical record review of emergency room Provider Report dated March 29, 2014, revealed resident #3 was evaluated in the emergency room . Continued review of the emergency room Provider Report revealed the resident had complained of shortness of breath and "...pt recently diagnosed with [REDACTED]. Further review revealed the resident's vital signs were documented as blood pressure 150/50, temperature 100.3, pulse 67, and respirations 20 at 4:06 p.m. Continued review revealed, "...Cardiovascular: normal heart sounds, [MEDICAL CONDITION](heart rate over 100), irregularly irregular..." Further review revealed the resident's vital signs were documented at 5:58 p.m. "...b/p 131/80, pulse 154, resp (respirations) 26, and temp 100.3..." Medical record review of emergency room lab report dated March 29, 2014, revealed resident #3's level of the [MEDICATION NAME] medication was reported as "...< (less than) 0.2 L (low)..." Continued review of the emergency room report revealed the resident had an Electrocardiogram (EKG, diagnostic test to evaluate heart rate, rhythm, and electrical pulses). Further review revealed the results of the heart monitoring test was "...A-Fib ([MEDICAL CONDITION] Fibrillation) with RVR (rapid ventricular response)..." indicating the resident's heart rate and rhythm were abnormal. Continued review revealed, "...Clinical Impression: Primary Impression: Pneumonia...Secondary Impressions: AFib, [MEDICAL CONDITIONS]..." Further review revealed the resident was admitted to the hospital for further treatment. Medical record review of Consulting Physician #1's note dated March 29, 2014, revealed resident #3 was seen by a consulting physician in the hospital. Review of the record revealed, "...Reason for Consultation: [MEDICAL CONDITION]..." Further review revealed the resident "...was found to be in [MEDICAL CONDITION] with a ventricular rate around 170...(resident) has history of chronic [MEDICAL CONDITION], chronic heart failure, and had a stroke in September 2012...Currently (resident) is on long term oral anticoagulation ([MEDICATION NAME])..." Further review of Consulting Physician #1's note revealed, "...Diagnostic Studies: (Resident's) EKG shows [MEDICAL CONDITION] with a ventricular rate around 185, low voltage, and poor R-wave progression..." Continued review of the consultation note revealed, "...Impression: 1. [MEDICAL CONDITION] 2. Acute...chronic heart failure..." Medical record review of Consulting Physician #2's note dated March 29, 2014, revealed, "...Assessment and Plan: 1. [MEDICAL CONDITION] with rapid ventricular response. Continue [MEDICATION NAME] drip initiated in the emergency room ...2. Pneumonia...5. Subtherapeutic [MEDICATION NAME] level. We will load the patient with [MEDICATION NAME] ...and repeat level in the morning hours with further orders to follow..." Medical record review of Hospitalist Physician's Progress Note dated March 30, 2014, revealed, "...Subjective: The patient (resident #3) was noted to have persistent [MEDICAL CONDITION] with rapid ventricular response despite [MEDICATION NAME] drip. (Resident) was also noted to have [MEDICAL CONDITION] ( a decreased level of oxygen in the blood)...The patient was also note (noted) to have some decreased responsiveness and (resident) was...transferred to the intensive care unit (ICU)..." Continued review of the physician's progress note revealed, "...Assessment and Plan: The patient is a [AGE] year old (resident) admitted to the hospital with [REDACTED]. [MEDICAL CONDITION] with rapid ventricular response. Heart rate is improving. Continue [MEDICATION NAME]" Medical record review of Consulting Physician #3's note dated March 30, 2014, revealed, "...(Resident #3) also has [MEDICAL CONDITION] with rapid ventricular rate. (Resident) was transferred to ICU this morning because of [MEDICAL CONDITION] and also because of persistent [MEDICAL CONDITION] with rapid rate..." Continued review revealed, "...Impression: 1...Acute [MEDICAL CONDITION] 2. Pneumonia 3. [MEDICAL CONDITION] 4. [MEDICAL CONDITION]...Recommendations: 1. Agree with transfer to intensive care unit ...7. Continue care in the ICU, critically ill..." Medical record review of the hospital Discharge Summary by Hospitalist Physician dated March 31, 2014, revealed, "...Hospital course: The patient (resident #3) was admitted and started on [MEDICATION NAME] drip...The patient did have a subtherapeutic [MEDICATION NAME] level and the patient was loaded with [MEDICATION NAME]. The patient was noted to have persistent [MEDICAL CONDITION] with rapid ventricular response despite the [MEDICATION NAME] drip...The patient was transferred to the intensive care unit...Plan for this patient: 1. Pneumonia is improving...3. [MEDICAL CONDITION] with rapid ventricular response, heart rate is rate controlled, [MEDICATION NAME] drip has been off for over 24 hours. The patient will be discharged back to nursing home today..." Review of Timeline of Events dated April 1, 2014, and signed by the DON, revealed, "...Timeline of Events...During MAR indicated [REDACTED]. Upon investigation, it appears that resident (#3)...did not receive (resident's) scheduled [MEDICATION NAME], [MEDICATION NAME] or [MEDICATION NAME] since (resident) was readmitted to (facility) on 3/14/14..." Continued review of Timeline of Events revealed when the resident was readmitted to the facility on [DATE], the resident's hospital discharge orders were faxed to the pharmacy. Further review of Timeline of Events revealed the facility's investigation determined the pharmacy received only pages 3, 4, 5, and 6 of a total of six pages. Continued review revealed the pharmacy did not receive pages 1 and 2 which consisted of the orders for the resident's [MEDICATION NAME], [MEDICATION NAME], and [MEDICATION NAME]. Interview with the DON and Nurse Consultant #1 on April 15, 2014, at 2:45 p.m., in the Conference Room, revealed the DON's investigation of the medication errors revealed the nurse who faxed the resident's discharge orders from the hospital to the pharmacy did not verify with the pharmacy how many pages the pharmacy had received. Continued interview revealed when the resident's medications arrived from the pharmacy, the nurse matched the medications with the Physician order [REDACTED]. Further interview with the DON and Nurse Consultant #1 confirmed resident #3 did not receive six ordered medications ([MEDICATION NAME], [MEDICATION NAME]) from the time of the resident's admission to the facility on [DATE], until the resident's discharge to the hospital on March 29, 2014 (a total of 15 days). Further interview with the DON and Nurse Consultant #1 confirmed the facility's failure to reconcile the resident's hospital discharge orders with the facility's admission orders [REDACTED]. Interview with the DON on April 16, 2014, at 12:40 p.m., in the Conference Room, confirmed the DON had questioned the admitting nurse of resident #3 about the resident not being admitted from the hospital with [MEDICATION NAME] orders. Continued interview with the DON confirmed the DON also did not reconcile the hospital discharge orders with the facility's admission orders [REDACTED]. Interview with Hospitalist Physician #1 on April 21, 2014, at 10:26 a.m., by phone, confirmed the physician was one of resident #3's treating physicians. Further interview revealed, "...I would say the fact that (resident) did not receive medications led to the (resident's) hospitalization ..." Continued interview confirmed the resident's [MEDICATION NAME] level "...was very low...", subtherapeutic, and confirmed the resident was "...critically ill..." necessitating the resident's transfer to the Intensive Care Unit (ICU). Further interview with Hospitalist Physician #1 confirmed when resident #3 was administered the resident's ordered medications (specifically [MEDICATION NAME] and [MEDICATION NAME]) the resident improved, and was able to be discharged back to the facility. The facility nursing staff's failure to reconcile hospital discharge orders with facility admission orders [REDACTED]. The facility's failure to ensure the resident received prescribed medications placed resident #3 in Immediate Jeopardy. Resident #19 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the hospital Discharge Med Rec form dated March 27, 2014, revealed no order for Phoslo (Calcium Acetate) 667 mg, a medication used to bind with phosphorus in the body to decrease the level of phosphorus in the blood). Continued review also revealed no order for [MEDICATION NAME] 20 mg (an antistatin medication used to lower cholesterol). Further review of the Discharge Med Rec form revealed orders for [MEDICATION NAME] 7.5 mg (an antidepressant medication) and [MEDICATION NAME] 40 mg (a stomach medication used to control acid in the stomach). Medical record review of physician's orders [REDACTED]. [REDACTED]. Medical record review of the dated March 27, 2014, through March 31, 2014, revealed resident #19 received both Calcium Acetate and [MEDICATION NAME] March 28, 2014, through March 31, 2014. Continued review of the MAR indicated [REDACTED]. Medical record review of the April 1, 2014, through April 31, 2014, physician's orders [REDACTED]. Continued review of the physician's orders [REDACTED]. Further review of the April physician's orders [REDACTED]. Further review of the April physician's orders [REDACTED]. Therefore resident #19 continued to be administered two medications without an order (Calcium Acetate and [MEDICATION NAME]), and failed to be administered two medications ([MEDICATION NAME] and [MEDICATION NAME]) which had been ordered by the discharging hospital from March 27, 2014, through April 17, 2014. Medical record review of Medication Reviews 3 Month Review dated April 4, 2014, revealed "...(Facility) Medication Reviews 3 Month Review...3-27-14 re-admit... pharmacy [MEDICATION NAME][MEDICATION NAME] ([MEDICATION NAME]), the pharmacy also added [MEDICATION NAME] and Phoslo (Calcium Acetate) without an order. This was not caught by nursing. The April POS (physician's orders [REDACTED].#1 to the Director of Nursing (DON) and Administrator on April 4, 2014. Interview with the DON and Nurse Consultant #1 on April 17, 2014, at 2:55 p.m., in the Conference Room, confirmed the resident's March 2014 and April 2014 physician's orders [REDACTED]. Continued interview confirmed the resident continued to receive discontinued medications, PhosLo (Calcium Acetate) and [MEDICATION NAME] without a physician's orders [REDACTED]. Further interview confirmed both the DON and Nurse Consultant #1 became aware the resident was receiving medications that were not ordered, and became aware the resident was not receiving ordered medications on April 4, 2014, and confirmed both neglected to correct the medication errors, and the resident continued to receive Calcium Acetate and [MEDICATION NAME] without physician orders, and did not receive ordered medications, [MEDICATION NAME] and [MEDICATION NAME], through April 17, 2014. The failure of the facility nursing staff to accurately reconcile hospital discharge orders with facility admission orders [REDACTED]. Resident #14 was admitted to the facility on [DATE], discharged to the hospital on April 1, 2014, related to care for a cyst, and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician order [REDACTED]. Medical record review revealed no documentation of the monitoring of the blood sugar level before the supper meal on March 31, 2014. Medical record review of the hospital Discharge Med Rec dated April 10, 2014, for the facility readmission on April 11, 2014, revealed an order for [REDACTED].< (less than) 60 give snack & (and) recheck in 30 minutes. If recheck still <60 give [MEDICATION NAME] UD (Unit Dose); 251-300= 4 units (give 4 units); 301-350=6 units; 351-400=8 units; 401-450= 10 units; Recheck in 1HR (hour) using above sliding scale if BG (Blood Glucose) > (greater than) 300; >450= (means) call MD (physician) for orders recheck in 1 HR or per MD..." Further review of the readmission orders [REDACTED] Medical record review of the Diabetic Medication Administration Record [REDACTED] 1. April 18, 2014, at 5:00 p.m. the accucheck was 253 and no documentation of the insulin administration (should have administered 4 units); 2. April 19, 2014, at 5:00 p.m. the accucheck was 301 and no insulin administration (should have administered 6 units); 3. April 19, 2014, at 9:00 p.m. no accucheck was obtained; 4. April 20, 2014, at 11:00 a.m. the accucheck was 305 and no insulin administration (should have administered 6 units); 5. April 21, 2014, before the breakfast meal, no accucheck was obtained; and on 6. April 23, 2014, at "6A (6:00 a.m.)" no accucheck was obtained. Interview with Licensed Practical Nurse (LPN) #1 assigned to resident #14, on April 21, 2014, at 11:15 a.m., on the 100 hall revealed "...the night nurse (7:00 p.m. to 7:00 a.m. shift) obtains the blood sugar..." Further interview confirmed the blood sugar level for April 21, 2014, at 6:00 a.m. was not documented on the Diabetic Medication Administration Record. Interview with Nurse Consultant #1/Acting Director of Nursing, on April 21, 2014, at 11:38 a.m., in the Conference Room confirmed the blood sugar level and the insulin administration when the blood sugar was elevated was to be documented on the Diabetic Medication Administration Record. Further interview and review of the April 2014 Diabetic Medication Administration Record [REDACTED]. Interview with Medical Director #2, on April 21, 2014, at 11:52 a.m., in the Conference Room confirmed "...expect (resident #14) should have gotten sliding scale (insulin) per order (when blood sugar elevated)..." Interview with LPN #5, on April 23, 2014, at 7:45 a.m., at the 200/300 nursing station, and Nurse Consultant #1/Acting Director of Nursing present, confirmed LPN #5 had been responsible for resident #14 during the 7:00 p.m.-7:00 a.m. shift and had not obtained the blood sugar level the morning of April 23, 2014. Interview with LPN #4, and observation on April 23, 2014, at 7:50 a.m., and Nurse Consultant #1/Acting Director of Nursing present, outside the room of resident #14, confirmed LPN #4 was responsible for resident #14 for the 7:00 a.m.-7:00 p.m. shift, and had not obtained the blood sugar the morning of April 23, 2014. When LPN #4 was asked which shift was responsible to obtain the morning blood sugar LPN #4 stated "...the night shift (7:00 p.m.-7:00 a.m.) does it." Further interview with the Nurse Consultant #1/Acting Director of Nursing revealed this surveyor "...got to (LPN #4) before the Nurse Consultant #1/Acting Director of Nursing could in-service (LPN #4) (on the change in the accucheck time before the breakfast meal)..." Interview with Nurse Consultant #1, on April 23, 2014, at 1:20 p.m., in the Conference Room, confrmed the facility had failed to inservice LPN #4 regarding the change in the accucheck time from 6:00 a.m. to 7:00 a.m. Interview with LPN #8 and Nurse Consultant #2, on April 24, 2014, at 10:15 a.m., at the 100/200 nursing station, confirmed resident #14 had been admitted on [DATE], at 2:50 p.m. and had been discharged before breakfast on April 1, 2014. Further interview confirmed the accucheck for March 31, 2014, at 5:00 p.m. was not obtained. The facility's nursing staff failure to monitor the blood sugar level and the nursing staffs failure to administer the prescribed insulin when the blood sugar was elevated placed resident #14 in Immediate Jeopardy. Review of the hospital Discharge Medication Reconciliation dated April 10, 2014, for the facility readmission on April 11, 2014, for resident #14 included an order for [REDACTED]. Medical record review of the facility readmission orders [REDACTED]. Interview with Nurse Consultant #1, on April 17, 2014, at 2:20 p.m., in the Conference Room, confirmed the facility nursing staff had failed to reconcile the hospital discharge medications with the facility readmission orders [REDACTED]#14. Interview with Pharmacist #1 on April 22, 2014, at 1:25 a.m., in the conference room, , revealed the facility identified a breakdown in communication between the pharmacy and the facility in early April. Further interview revealed prior to the last Performance Improvement meeting held April 10, 2014, the pharmacy did not compare/reconcile hospital discharge medication to the facility admission physician orders. Further interview revealed "...assumed orders verified prior to contact with (pharmacy) or that the nursing facility made a clarification order prior to contacting the (Pharmacy)..." Resident #24 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the hospital discharge orders dated April 2, 2014, revealed a medication order for "[MEDICATION NAME] (herbal medication prescribed for sleep) 4 mg daily at 1800 (6:00 p.m.)[MEDICATION NAME] ( an atypical antipsychotic medication prescribed for anxiety) 20 mg Twice daily with [MEDICATION NAME] 10 mg every 6 hours as needed...for anxiety..." Medical record review of the physician's orders [REDACTED]." Continued review of the Physician order [REDACTED]. Medical record review of the MAR indicated [REDACTED]. Continued review of the MAR indicated [REDACTED]. Further review revealed the resident was administered [MEDICATION NAME] 20 mg twice a day from April 3, 2014, through April 8, 2014, and was administered [MEDICATION NAME] 10 mg April 4, 2014, through April 7, 2014, one time daily . Review of the facility documentation entitled New Admission/Readmission Audits dated April 3, 2014, revealed resident #24's admission orders [REDACTED]. Interview with Nurse Consultant #1/Acting DON on April 21, 2014, at 4:05 p.m., in the Conference Room, confirmed the Physician order [REDACTED]. Further interview confirmed the resident was administered the wrong dose of [MEDICATION NAME] from April 2, 2014, through April 20, 2014. Continued interview confirmed the MAR indicated [REDACTED]. Further interview confirmed [MEDICATION NAME] was not on the physician's orders [REDACTED].#1/Acting DON confirmed the resident's hospital discharge orders and admission orders [REDACTED]. Continued interview confirmed the resident's medications continued to be incorrect after the audit and the facility had failed to provided quality of care standards with medication administration. Resident #29 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of hospital discharge orders dated April 14, 2014, revealed an order for [REDACTED]. Medical record review of the physician's orders [REDACTED]. Continued review revealed a physician's orders [REDACTED]. Medical record review of the MAR indicated [REDACTED]. Continued review revealed [MEDICATION NAME] was on the MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. Medical record review of the Telephone order/Clarification order dated April 18, 2014, revealed a clarification order for [MEDICATION NAME] 600 mg three times daily, related to the medication being on the MAR but not on the physician's orders [REDACTED]. Review of facility documentation entitled New Admission/Readmission Audits dated and initialed by the DON on April 15, 2014, revealed the resident's chart was audited for medication reconciliation accuracy and completed. Interview with Nurse Consultant #1/Acting DON on April 22, 2014, at 1:07 p.m., in the Conference Room, confirmed the hospital discharge order for [MEDICATION NAME] was not included on the physician's orders [REDACTED]. Continued interview confirmed the medication was handwritten on the MAR for April and the resident was administered the medication without an order from April 15, 2014, through April 22, 2014. Continued interview confirmed the resident's hospital discharge orders and physician's orders [REDACTED]. Continued interview with Nurse Consultant #1/Acting DON confirmed the resident's chart had been listed as audited and initialed as compl

Based on medical record review, review of Timeline of Events, review of Medication 3 Month Review, review of New Admission/Readmission Audits, and interview the facility failed to provide a system of quality of care to ensure any resident admitted or readmitted to the facility with hospital discharge physician's orders [REDACTED]. The facility's failure to provide quality of care resulted in one resident (#3) requiring re-hospitalization in critical condition, and resulted in seven residents (#19, #14 #24, #29, #13, #1, #10) receiving multiple medication errors, of thirty-one residents reviewed. The facility's failure to reconcile hosptial discharge/facility admission orders [REDACTED] The Administrator, Regional Administrator Consultant, Assistant Director of Nursing, Nurse Consultant #1/Acting Director of Nursing, Nurse Consultant #2, Nurse Consultant #3, Vice-President of Client Operations, and Medical Director #1 were informed of the Immediate Jeopardy on April 24, 2014, at 10:55 a.m., in the Conference Room. The Immediate Jeopardy was effective March 14, 2014, and was ongoing. An extended survey was conducted on April 24, 2014. Substandard Quality of Care was cited under F309-K The facility provided an acceptable Allegation of Compliance on May 8, 2014, and a revist on May 13, 2014, and May 14, 2014, revealed the corrective actions implemented on May 2, 2014, removed the Immediacy of the Jeopardy. Noncompliance for F-309 continues at a "E" level citation for the facility's monitoring the effectiveness of corrective actions in order to ensure sustained compliance and evaluation of the processes by the Quality Assurance Committee. The findings included: Resident #3 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the hospital Discharge Med (Medication) Rec (Reconciliation) form dated March 14, 2014, revealed the hospital Discharge Med Rec form contained a total of 6 pages of medications ordered for resident #3 upon discharge from the hospital and readmission to the facility. Continued review revealed the Discharge Med Rec form for pages 1 and 2 included physician's orders [REDACTED]. once per day, [MEDICATION NAME] (heart medication to control heart rate and blood pressure) 120 mg once per day, and [MEDICATION NAME] (medication to control high blood pressure) 10 mg once per day. Medical record review of physician's orders [REDACTED]. Medical record review of the Medication Record (form used to document medication administration: MAR) dated March 14, 2014, through March 31, 2014, revealed two pages of medications, neither of which included the [MEDICATION NAME], [MEDICATION NAME], and [MEDICATION NAME] for resident #3. Medical record review of a nurse's note dated March 30, 2014, revealed, "...Late entry for 3/28/14. At approx. (approximately) 3 p.m. this nurse was called to resident room to assess resident. Resident (#3) in bed with eyes closed, shaking et (and) c/o (complained of) being cold. Resident alert et responsive. Vital signs T (temperature) 100.8 orally, P (pulse) 138 (normal range 60-100), R (respirations) 27, B/P (blood pressure) 156/92, O2 (oxygen) 78 % (percent) via (by) nc (nasal cannula) at 3 LPM (liters per minute). This nurse instructed patient to breathe in through nose et out through mouth. O2 increased to 83%. Nurse applied a non-rebreather oxygen mask et O2 increased to 86-92% fluctuating. Nurse notified MD (medical doctor) of pt (patient) status et N/O (new order) to send to ER (emergency room ) for eval (evaluation) et tx (treatment)..." Continued review revealed, "...late entry for 3/29/14 5 pm. ER staff called et stated they needed a copy of resident's MAR. This nurse faxed MAR indicated [REDACTED]. No new [DIAGNOSES REDACTED]. This nurse was informed that diagnostic testing was still being performed..." Medical record review of a nurse's note dated April 8, 2014, timed 2:49 p.m., and signed by the Director of Nursing (DON) revealed, "...Upon chart review it is noted on the late entry dated 3-30-14 @ (at) 730 a.m., (the note is for 3-28-14) the date for the late entry is incorrect and is actually for 3-29-14 which is when this resident (#3) was transferred to the ER for further eval and treatment..." Medical record review of emergency room Provider Report dated March 29, 2014, revealed resident #3 was evaluated in the emergency room . Continued review of the emergency room Provider Report revealed the resident had complained of shortness of breath and "...pt recently diagnosed with [REDACTED]. Further review revealed the resident's vital signs were documented as blood pressure 150/50, temperature 100.3, pulse 67, and respirations 20 at 4:06 p.m. Continued review revealed, "...Cardiovascular: normal heart sounds, [MEDICAL CONDITION](heart rate over 100), irregularly irregular..." Further review revealed the resident's vital signs were documented at 5:58 p.m. "...b/p 131/80, pulse 154, resp (respirations) 26, and temp 100.3..." Medical record review of emergency room lab report dated March 29, 2014, revealed resident #3's level of the [MEDICATION NAME] medication was reported as "...< (less than) 0.2 L (low)..." Continued review of the emergency room report revealed the resident had an Electrocardiogram (EKG, diagnostic test to evaluate heart rate, rhythm, and electrical pulses). Further review revealed the results of the heart monitoring test was "...A-Fib ([MEDICAL CONDITION] Fibrillation) with RVR (rapid ventricular response)..." indicating the resident's heart rate and rhythm were abnormal. Continued review revealed, "...Clinical Impression: Primary Impression: Pneumonia...Secondary Impressions: AFib, [MEDICAL CONDITIONS]..." Further review revealed the resident was admitted to the hospital for further treatment. Medical record review of Consulting Physician #1's note dated March 29, 2014, revealed resident #3 was seen by a consulting physician in the hospital. Review of the record revealed, "...Reason for Consultation: [MEDICAL CONDITION]..." Further review revealed the resident "...was found to be in [MEDICAL CONDITION] with a ventricular rate around 170...(resident) has history of chronic [MEDICAL CONDITION], chronic heart failure, and had a stroke in September 2012...Currently (resident) is on long term oral anticoagulation ([MEDICATION NAME])..." Further review of Consulting Physician #1's note revealed, "...Diagnostic Studies: (Resident's) EKG shows [MEDICAL CONDITION] with a ventricular rate around 185, low voltage, and poor R-wave progression..." Continued review of the consultation note revealed, "...Impression: 1. [MEDICAL CONDITION] 2. Acute...chronic heart failure..." Medical record review of Consulting Physician #2's note dated March 29, 2014, revealed, "...Assessment and Plan: 1. [MEDICAL CONDITION] with rapid ventricular response. Continue [MEDICATION NAME] drip initiated in the emergency room ...2. Pneumonia...5. Subtherapeutic [MEDICATION NAME] level. We will load the patient with [MEDICATION NAME] ...and repeat level in the morning hours with further orders to follow..." Medical record review of Hospitalist Physician's Progress Note dated March 30, 2014, revealed, "...Subjective: The patient (resident #3) was noted to have persistent [MEDICAL CONDITION] with rapid ventricular response despite [MEDICATION NAME] drip. (Resident) was also noted to have [MEDICAL CONDITION] ( a decreased level of oxygen in the blood)...The patient was also note (noted) to have some decreased responsiveness and (resident) was...transferred to the intensive care unit (ICU)..." Continued review of the physician's progress note revealed, "...Assessment and Plan: The patient is a [AGE] year old (resident) admitted to the hospital with [REDACTED]. [MEDICAL CONDITION] with rapid ventricular response. Heart rate is improving. Continue [MEDICATION NAME]" Medical record review of Consulting Physician #3's note dated March 30, 2014, revealed, "...(Resident #3) also has [MEDICAL CONDITION] with rapid ventricular rate. (Resident) was transferred to ICU this morning because of [MEDICAL CONDITION] and also because of persistent [MEDICAL CONDITION] with rapid rate..." Continued review revealed, "...Impression: 1...Acute [MEDICAL CONDITION] 2. Pneumonia 3. [MEDICAL CONDITION] 4. [MEDICAL CONDITION]...Recommendations: 1. Agree with transfer to intensive care unit ...7. Continue care in the ICU, critically ill..." Medical record review of the hospital Discharge Summary by Hospitalist Physician dated March 31, 2014, revealed, "...Hospital course: The patient (resident #3) was admitted and started on [MEDICATION NAME] drip...The patient did have a subtherapeutic [MEDICATION NAME] level and the patient was loaded with [MEDICATION NAME]. The patient was noted to have persistent [MEDICAL CONDITION] with rapid ventricular response despite the [MEDICATION NAME] drip...The patient was transferred to the intensive care unit...Plan for this patient: 1. Pneumonia is improving...3. [MEDICAL CONDITION] with rapid ventricular response, heart rate is rate controlled, [MEDICATION NAME] drip has been off for over 24 hours. The patient will be discharged back to nursing home today..." Review of Timeline of Events dated April 1, 2014, and signed by the DON, revealed, "...Timeline of Events...During MAR indicated [REDACTED]. Upon investigation, it appears that resident (#3)...did not receive (resident's) scheduled [MEDICATION NAME], [MEDICATION NAME] or [MEDICATION NAME] since (resident) was readmitted to (facility) on 3/14/14..." Continued review of Timeline of Events revealed when the resident was readmitted to the facility on [DATE], the resident's hospital discharge orders were faxed to the pharmacy. Further review of Timeline of Events revealed the facility's investigation determined the pharmacy received only pages 3, 4, 5, and 6 of a total of six pages. Continued review revealed the pharmacy did not receive pages 1 and 2 which consisted of the orders for the resident's [MEDICATION NAME], [MEDICATION NAME], and [MEDICATION NAME]. Interview with the DON and Nurse Consultant #1 on April 15, 2014, at 2:45 p.m., in the Conference Room, revealed the DON's investigation of the medication errors revealed the nurse who faxed the resident's discharge orders from the hospital to the pharmacy did not verify with the pharmacy how many pages the pharmacy had received. Continued interview revealed when the resident's medications arrived from the pharmacy, the nurse matched the medications with the Physician order [REDACTED]. Further interview with the DON and Nurse Consultant #1 confirmed resident #3 did not receive six ordered medications ([MEDICATION NAME], [MEDICATION NAME]) from the time of the resident's admission to the facility on [DATE], until the resident's discharge to the hospital on March 29, 2014 (a total of 15 days). Further interview with the DON and Nurse Consultant #1 confirmed the facility's failure to reconcile the resident's hospital discharge orders with the facility's admission orders [REDACTED]. Interview with the DON on April 16, 2014, at 12:40 p.m., in the Conference Room, confirmed the DON had questioned the admitting nurse of resident #3 about the resident not being admitted from the hospital with [MEDICATION NAME] orders. Continued interview with the DON confirmed the DON also did not reconcile the hospital discharge orders with the facility's admission orders [REDACTED]. Interview with Hospitalist Physician #1 on April 21, 2014, at 10:26 a.m., by phone, confirmed the physician was one of resident #3's treating physicians. Further interview revealed, "...I would say the fact that (resident) did not receive medications led to the (resident's) hospitalization ..." Continued interview confirmed the resident's [MEDICATION NAME] level "...was very low...", subtherapeutic, and confirmed the resident was "...critically ill..." necessitating the resident's transfer to the Intensive Care Unit (ICU). Further interview with Hospitalist Physician #1 confirmed when resident #3 was administered the resident's ordered medications (specifically [MEDICATION NAME] and [MEDICATION NAME]) the resident improved, and was able to be discharged back to the facility. The facility nursing staff's failure to reconcile hospital discharge orders with facility admission orders [REDACTED]. The facility's failure to ensure the resident received prescribed medications placed resident #3 in Immediate Jeopardy. Resident #19 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the hospital Discharge Med Rec form dated March 27, 2014, revealed no order for Phoslo (Calcium Acetate) 667 mg, a medication used to bind with phosphorus in the body to decrease the level of phosphorus in the blood). Continued review also revealed no order for [MEDICATION NAME] 20 mg (an antistatin medication used to lower cholesterol). Further review of the Discharge Med Rec form revealed orders for [MEDICATION NAME] 7.5 mg (an antidepressant medication) and [MEDICATION NAME] 40 mg (a stomach medication used to control acid in the stomach). Medical record review of physician's orders [REDACTED]. [REDACTED]. Medical record review of the dated March 27, 2014, through March 31, 2014, revealed resident #19 received both Calcium Acetate and [MEDICATION NAME] March 28, 2014, through March 31, 2014. Continued review of the MAR indicated [REDACTED]. Medical record review of the April 1, 2014, through April 31, 2014, physician's orders [REDACTED]. Continued review of the physician's orders [REDACTED]. Further review of the April physician's orders [REDACTED]. Further review of the April physician's orders [REDACTED]. Therefore resident #19 continued to be administered two medications without an order (Calcium Acetate and [MEDICATION NAME]), and failed to be administered two medications ([MEDICATION NAME] and [MEDICATION NAME]) which had been ordered by the discharging hospital from March 27, 2014, through April 17, 2014. Medical record review of Medication Reviews 3 Month Review dated April 4, 2014, revealed "...(Facility) Medication Reviews 3 Month Review...3-27-14 re-admit... pharmacy [MEDICATION NAME][MEDICATION NAME] ([MEDICATION NAME]), the pharmacy also added [MEDICATION NAME] and Phoslo (Calcium Acetate) without an order. This was not caught by nursing. The April POS (physician's orders [REDACTED].#1 to the Director of Nursing (DON) and Administrator on April 4, 2014. Interview with the DON and Nurse Consultant #1 on April 17, 2014, at 2:55 p.m., in the Conference Room, confirmed the resident's March 2014 and April 2014 physician's orders [REDACTED]. Continued interview confirmed the resident continued to receive discontinued medications, PhosLo (Calcium Acetate) and [MEDICATION NAME] without a physician's orders [REDACTED]. Further interview confirmed both the DON and Nurse Consultant #1 became aware the resident was receiving medications that were not ordered, and became aware the resident was not receiving ordered medications on April 4, 2014, and confirmed both neglected to correct the medication errors, and the resident continued to receive Calcium Acetate and [MEDICATION NAME] without physician orders, and did not receive ordered medications, [MEDICATION NAME] and [MEDICATION NAME], through April 17, 2014. The failure of the facility nursing staff to accurately reconcile hospital discharge orders with facility admission orders [REDACTED]. Resident #14 was admitted to the facility on [DATE], discharged to the hospital on April 1, 2014, related to care for a cyst, and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician order [REDACTED]. Medical record review revealed no documentation of the monitoring of the blood sugar level before the supper meal on March 31, 2014. Medical record review of the hospital Discharge Med Rec dated April 10, 2014, for the facility readmission on April 11, 2014, revealed an order for [REDACTED].< (less than) 60 give snack & (and) recheck in 30 minutes. If recheck still <60 give [MEDICATION NAME] UD (Unit Dose); 251-300= 4 units (give 4 units); 301-350=6 units; 351-400=8 units; 401-450= 10 units; Recheck in 1HR (hour) using above sliding scale if BG (Blood Glucose) > (greater than) 300; >450= (means) call MD (physician) for orders recheck in 1 HR or per MD..." Further review of the readmission orders [REDACTED] Medical record review of the Diabetic Medication Administration Record [REDACTED] 1. April 18, 2014, at 5:00 p.m. the accucheck was 253 and no documentation of the insulin administration (should have administered 4 units); 2. April 19, 2014, at 5:00 p.m. the accucheck was 301 and no insulin administration (should have administered 6 units); 3. April 19, 2014, at 9:00 p.m. no accucheck was obtained; 4. April 20, 2014, at 11:00 a.m. the accucheck was 305 and no insulin administration (should have administered 6 units); 5. April 21, 2014, before the breakfast meal, no accucheck was obtained; and on 6. April 23, 2014, at "6A (6:00 a.m.)" no accucheck was obtained. Interview with Licensed Practical Nurse (LPN) #1 assigned to resident #14, on April 21, 2014, at 11:15 a.m., on the 100 hall revealed "...the night nurse (7:00 p.m. to 7:00 a.m. shift) obtains the blood sugar..." Further interview confirmed the blood sugar level for April 21, 2014, at 6:00 a.m. was not documented on the Diabetic Medication Administration Record. Interview with Nurse Consultant #1/Acting Director of Nursing, on April 21, 2014, at 11:38 a.m., in the Conference Room confirmed the blood sugar level and the insulin administration when the blood sugar was elevated was to be documented on the Diabetic Medication Administration Record. Further interview and review of the April 2014 Diabetic Medication Administration Record [REDACTED]. Interview with Medical Director #2, on April 21, 2014, at 11:52 a.m., in the Conference Room confirmed "...expect (resident #14) should have gotten sliding scale (insulin) per order (when blood sugar elevated)..." Interview with LPN #5, on April 23, 2014, at 7:45 a.m., at the 200/300 nursing station, and Nurse Consultant #1/Acting Director of Nursing present, confirmed LPN #5 had been responsible for resident #14 during the 7:00 p.m.-7:00 a.m. shift and had not obtained the blood sugar level the morning of April 23, 2014. Interview with LPN #4, and observation on April 23, 2014, at 7:50 a.m., and Nurse Consultant #1/Acting Director of Nursing present, outside the room of resident #14, confirmed LPN #4 was responsible for resident #14 for the 7:00 a.m.-7:00 p.m. shift, and had not obtained the blood sugar the morning of April 23, 2014. When LPN #4 was asked which shift was responsible to obtain the morning blood sugar LPN #4 stated "...the night shift (7:00 p.m.-7:00 a.m.) does it." Further interview with the Nurse Consultant #1/Acting Director of Nursing revealed this surveyor "...got to (LPN #4) before the Nurse Consultant #1/Acting Director of Nursing could in-service (LPN #4) (on the change in the accucheck time before the breakfast meal)..." Interview with Nurse Consultant #1, on April 23, 2014, at 1:20 p.m., in the Conference Room, confrmed the facility had failed to inservice LPN #4 regarding the change in the accucheck time from 6:00 a.m. to 7:00 a.m. Interview with LPN #8 and Nurse Consultant #2, on April 24, 2014, at 10:15 a.m., at the 100/200 nursing station, confirmed resident #14 had been admitted on [DATE], at 2:50 p.m. and had been discharged before breakfast on April 1, 2014. Further interview confirmed the accucheck for March 31, 2014, at 5:00 p.m. was not obtained. The facility's nursing staff failure to monitor the blood sugar level and the nursing staffs failure to administer the prescribed insulin when the blood sugar was elevated placed resident #14 in Immediate Jeopardy. Review of the hospital Discharge Medication Reconciliation dated April 10, 2014, for the facility readmission on April 11, 2014, for resident #14 included an order for [REDACTED]. Medical record review of the facility readmission orders [REDACTED]. Interview with Nurse Consultant #1, on April 17, 2014, at 2:20 p.m., in the Conference Room, confirmed the facility nursing staff had failed to reconcile the hospital discharge medications with the facility readmission orders [REDACTED]#14. Interview with Pharmacist #1 on April 22, 2014, at 1:25 a.m., in the conference room, , revealed the facility identified a breakdown in communication between the pharmacy and the facility in early April. Further interview revealed prior to the last Performance Improvement meeting held April 10, 2014, the pharmacy did not compare/reconcile hospital discharge medication to the facility admission physician orders. Further interview revealed "...assumed orders verified prior to contact with (pharmacy) or that the nursing facility made a clarification order prior to contacting the (Pharmacy)..." Resident #24 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the hospital discharge orders dated April 2, 2014, revealed a medication order for "[MEDICATION NAME] (herbal medication prescribed for sleep) 4 mg daily at 1800 (6:00 p.m.)[MEDICATION NAME] ( an atypical antipsychotic medication prescribed for anxiety) 20 mg Twice daily with [MEDICATION NAME] 10 mg every 6 hours as needed...for anxiety..." Medical record review of the physician's orders [REDACTED]." Continued review of the Physician order [REDACTED]. Medical record review of the MAR indicated [REDACTED]. Continued review of the MAR indicated [REDACTED]. Further review revealed the resident was administered [MEDICATION NAME] 20 mg twice a day from April 3, 2014, through April 8, 2014, and was administered [MEDICATION NAME] 10 mg April 4, 2014, through April 7, 2014, one time daily . Review of the facility documentation entitled New Admission/Readmission Audits dated April 3, 2014, revealed resident #24's admission orders [REDACTED]. Interview with Nurse Consultant #1/Acting DON on April 21, 2014, at 4:05 p.m., in the Conference Room, confirmed the Physician order [REDACTED]. Further interview confirmed the resident was administered the wrong dose of [MEDICATION NAME] from April 2, 2014, through April 20, 2014. Continued interview confirmed the MAR indicated [REDACTED]. Further interview confirmed [MEDICATION NAME] was not on the physician's orders [REDACTED].#1/Acting DON confirmed the resident's hospital discharge orders and admission orders [REDACTED]. Continued interview confirmed the resident's medications continued to be incorrect after the audit and the facility had failed to provided quality of care standards with medication administration. Resident #29 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of hospital discharge orders dated April 14, 2014, revealed an order for [REDACTED]. Medical record review of the physician's orders [REDACTED]. Continued review revealed a physician's orders [REDACTED]. Medical record review of the MAR indicated [REDACTED]. Continued review revealed [MEDICATION NAME] was on the MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. Medical record review of the Telephone order/Clarification order dated April 18, 2014, revealed a clarification order for [MEDICATION NAME] 600 mg three times daily, related to the medication being on the MAR but not on the physician's orders [REDACTED]. Review of facility documentation entitled New Admission/Readmission Audits dated and initialed by the DON on April 15, 2014, revealed the resident's chart was audited for medication reconciliation accuracy and completed. Interview with Nurse Consultant #1/Acting DON on April 22, 2014, at 1:07 p.m., in the Conference Room, confirmed the hospital discharge order for [MEDICATION NAME] was not included on the physician's orders [REDACTED]. Continued interview confirmed the medication was handwritten on the MAR for April and the resident was administered the medication without an order from April 15, 2014, through April 22, 2014. Continued interview confirmed the resident's hospital discharge orders and physician's orders [REDACTED].

Based on medical record review, review of Medication Reviews/3 Month Reviews, review of facility policy, and interview, the facility failed to notify the physician of medication errors for one resident (#19) of thirty-one sampled residents. The findings included: Resident #19 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed Resident #19 received [MEDICAL TREATMENT] treatment three days per week for [MEDICAL CONDITION]. Medical record review of the hospital Discharge Med (Medical) Rec (Record) form dated March 27, 2014, revealed no order for Phoslo (Calcium Acetate) 667 mg (milligrams), a medication used to bind with phosphorus in the body to decrease the level of phosphorus in the blood. Continued review also revealed no order for [MEDICATION NAME] 20 mg (an antistatin medication used to lower cholesterol). Further review of the Discharge Med Rec form revealed orders for [MEDICATION NAME] 7.5 mg (an antidepressant medication) and [MEDICATION NAME] 40 mg (a stomach medication used to control acid in the stomach). Medical record review of physician's orders [REDACTED]. [REDACTED]. Medical record review of the Medication Administration Records (MARS) dated March 27, 2014, through March 31, 2014, revealed the resident received both Calcium Acetate and [MEDICATION NAME] March 28, 2014, through March 31, 2014. Continued review of the MAR indicated [REDACTED]. Medical record review of the April 1, 2014, through April 31, 2014, physician's orders [REDACTED]. Continued review of the physician's orders [REDACTED]. Further review of the April physician's orders [REDACTED]. Further review of the April physician's orders [REDACTED]. Therefore resident #19 continued to be administered 2 medications without an order (Calcium Acetate and [MEDICATION NAME]), and failed to be administered 2 medications ([MEDICATION NAME] and [MEDICATION NAME]) which had been ordered by the discharging hospital from March 27, 2014, through April 17, 2014. Medical record review of Medication Reviews 3 Month Review dated April 4, 2014, revealed "...(Facility) Medication Reviews 3 Month Review...3-27-14 re-admit...pharmacy [MEDICATION NAME][MEDICATION NAME] ([MEDICATION NAME]), the pharmacy also added [MEDICATION NAME] and Phoslo (Calcium Acetate) without an order. This was not caught by nursing. The April POS (physician's orders [REDACTED].#1 to the Director of Nursing (DON) and Administrator on April 4, 2014. Interview with the DON and Nurse Consultant #1 on April 17, 2014, at 2:55 p.m., in the Conference Room, confirmed the resident's March 2014, and April 2014, physician's orders [REDACTED]. Continued interview confirmed the resident continued to receive discontinued medications, PhosLo (Calcium Acetate) and [MEDICATION NAME] without a physician's orders [REDACTED]. Further interview confirmed both the DON and Nurse Consultant #1 became aware the resident was receiving medications that were not ordered, and became aware the resident was not receiving ordered medications on April 4, 2014, and confirmed both had neglected to correct the medication errors, and the resident continued to receive Calcium Acetate and [MEDICATION NAME] without physician orders, and did not receive ordered medications, [MEDICATION NAME] and [MEDICATION NAME], through April 17, 2014. Interview with Nurse Consultant #1 on April 24, 2014, at 9:10 a.m., in the Conference Room, confirmed neither the Nurse Consultant or DON had contacted the resident's [MEDICAL TREATMENT] Physician to inform the physician of the medication errors. Interview with the [MEDICAL TREATMENT] Physician on April 24, 2014, at 2:20 p.m., by phone, confirmed the physician had not been contacted by the facility regarding the resident's medication errors.

Based on medical record review, review of Medication Reviews/3 Month Reviews, review of facility policy, and interview, the facility failed to notify the physician of medication errors for one resident (#19) of thirty-one sampled residents. The facility provided an acceptable Allegation of Compliance on May 8, 2014, and a revist on May 13, 2014, and May 14, 2014, revealed the corrective actions implemented on May 2, 2014, removed the immediacy of the jeopardy. Noncompliance for F-157 continues at a "D" level citation for the facility's monitoring the effectiveness of corrective actions in order to ensure sustained compliance and evaluation of the processes by the Quality Assurance Committee. The findings included: Resident #19 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed Resident #19 received [MEDICAL TREATMENT] treatment three days per week for [MEDICAL CONDITION]. Medical record review of the hospital Discharge Med (Medical) Rec (Record) form dated March 27, 2014, revealed no order for Phoslo (Calcium Acetate) 667 mg (milligrams), a medication used to bind with phosphorus in the body to decrease the level of phosphorus in the blood. Continued review also revealed no order for [MEDICATION NAME] 20 mg (an antistatin medication used to lower cholesterol). Further review of the Discharge Med Rec form revealed orders for [MEDICATION NAME] 7.5 mg (an antidepressant medication) and [MEDICATION NAME] 40 mg (a stomach medication used to control acid in the stomach). Medical record review of physician's orders [REDACTED]. [REDACTED]. Medical record review of the Medication Administration Records (MARS) dated March 27, 2014, through March 31, 2014, revealed the resident received both Calcium Acetate and [MEDICATION NAME] March 28, 2014, through March 31, 2014. Continued review of the MAR indicated [REDACTED]. Medical record review of the April 1, 2014, through April 31, 2014, physician's orders [REDACTED]. Continued review of the physician's orders [REDACTED]. Further review of the April physician's orders [REDACTED]. Further review of the April physician's orders [REDACTED]. Therefore resident #19 continued to be administered 2 medications without an order (Calcium Acetate and [MEDICATION NAME]), and failed to be administered 2 medications ([MEDICATION NAME] and [MEDICATION NAME]) which had been ordered by the discharging hospital from March 27, 2014, through April 17, 2014. Medical record review of Medication Reviews 3 Month Review dated April 4, 2014, revealed "...(Facility) Medication Reviews 3 Month Review...3-27-14 re-admit...pharmacy [MEDICATION NAME][MEDICATION NAME] ([MEDICATION NAME]), the pharmacy also added [MEDICATION NAME] and Phoslo (Calcium Acetate) without an order. This was not caught by nursing. The April POS (physician's orders [REDACTED].#1 to the Director of Nursing (DON) and Administrator on April 4, 2014. Interview with the DON and Nurse Consultant #1 on April 17, 2014, at 2:55 p.m., in the Conference Room, confirmed the resident's March 2014, and April 2014, physician's orders [REDACTED]. Continued interview confirmed the resident continued to receive discontinued medications, PhosLo (Calcium Acetate) and [MEDICATION NAME] without a physician's orders [REDACTED]. Further interview confirmed both the DON and Nurse Consultant #1 became aware the resident was receiving medications that were not ordered, and became aware the resident was not receiving ordered medications on April 4, 2014, and confirmed both had neglected to correct the medication errors, and the resident continued to receive Calcium Acetate and [MEDICATION NAME] without physician orders, and did not receive ordered medications, [MEDICATION NAME] and [MEDICATION NAME], through April 17, 2014. Interview with Nurse Consultant #1 on April 24, 2014, at 9:10 a.m., in the Conference Room, confirmed neither the Nurse Consultant or DON had contacted the resident's [MEDICAL TREATMENT] Physician to inform the physician of the medication errors. Interview with the [MEDICAL TREATMENT] Physician on April 24, 2014, at 2:20 p.m., by phone, confirmed the physician had not been contacted by the facility regarding the resident's medication errors. Validation of the Credible Allegation of Compliance was accomplished on-site on May 13, 2014, and May 14, 2014, through medical record reviews, review of facility documents, and interviews with Nursing and Administrative Staff. Medical record review of Resident #19's nursing notes dated April 25, 2014, revealed the Interim Director of Nursing, notified the [MEDICAL TREATMENT] physician and the resident's responsible party of the medication errors. Medical record review of resident #33 revealed the resident was readmitted to the facility on [DATE]. Continued review of the physician orders [REDACTED]. Medical record review of the Medication Administration Record [REDACTED]. The facility provided evidence of audits of reconciliation of admission/re-admission orders [REDACTED]. The facility provided documentation of an emergency Performance Improvement Meeting held on April 28, 2014, to discuss the new admission/readmission medication reconcilation process, pharmacy process, and physician notification process and establish a plan to ensure physician notification for clarification of medication orders and medication errors. Interviews with Nursing Staff on all shifts May 13-14, 2014, throughout the facility, revealed the nursing staff had been in-serviced on the protocol for new admission/readmission medication order reconciliation, pharmacy protocol, medication errors, and physician standing orders. The facility will remain out of compliance at a Scope and Severity level "D" a 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 and corrections are verified on-site..

Based on medical record review, review of Timeline of Events, and interview, the facility failed to reconcile hospital discharge orders with facility admission orders [REDACTED]. The failure of the facility to reconcile the medication orders placed resident #3 in Immediate Jeopardy, and the facility's failure to monitor and administer insulin as ordered, placed resident #14 in Immediate Jeopardy (a situation in which the facility'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, Regional Administrator Consultant, Assistant Director of Nursing, Nurse Consultant #1/Acting Director of Nursing, Nurse Consultant #2, Nurse Consultant #3, Vice-President of Client Operations, and Medical Director #1 were informed of the Immediate Jeopardy on April 24, 2014, at 10:55 a.m., in the Conference Room. The Immediate Jeopardy was effective March 14, 2014, and was ongoing. An extended survey was conducted on April 24, 2014. Substandard Quality of Care was cited at F333-L. The facility provided an acceptable Allegation of Compliance on May 8, 2014, and a revist on May 13, 2014, and May 14, 2014, revealed the corrective actions implemented on May 2, 2014, removed the Immediacy of the Jeopardy. Noncompliance for F-333 continues at a "F" level citation for the facility's monitoring the effectiveness of corrective actions in order to ensure sustained compliance and evaluation of the processes by the Quality Assurance Committee. The findings included: Resident #3 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the hospital Discharge Med (Medication) Rec (Reconciliation) form dated March 14, 2014, revealed the hospital Discharge Med Rec form contained a total of 6 pages of medications ordered for the resident upon discharge from the hospital and readmission to the facility. Continued review revealed the Discharge Med Rec form for pages 1 and 2 included physician's orders [REDACTED]. once per day, [MEDICATION NAME] (heart medication to control heart rate and blood pressure) 120 mg once per day, and [MEDICATION NAME] (medication to control high blood pressure) 10 mg once per day. Medical record review of physician's orders [REDACTED]. Medical record review of the Medication Record (form used to document medication administration: MAR) dated March 14, 2014, through March 31, 2014, revealed two pages of medications, neither of which included the [MEDICATION NAME], [MEDICATION NAME], and [MEDICATION NAME]. Medical record review of nurse's note dated March 30, 2014, (documented incorrectly, the actual date of event is March 29, 2014, as documented in a late entry note by the DON on April 8, 2014), revealed the resident was transferred to the hospital to be evaluated and treated in the emergency room . Medical record review of emergency room notes, and physician's progress notes dated March 29, 2014, revealed resident #3 was treated in the emergency department for [MEDICAL CONDITION] Fibrillation. Continued review revealed emergency room lab reports which documented the resident's [MEDICATION NAME] level was "< 0.2 L", subtherapeutic. Further review revealed the resident was documented as "critically ill" and was admitted to the Intensive Care Unit (ICU) of the hospital. Medical record review of a physician's discharge summary dated March 31, 2014, revealed the resident was stabilized in the ICU after the resident received [MEDICATION NAME] and [MEDICATION NAME] (two of the medications which had been omitted from the facility's physician's orders [REDACTED]. Interview with Hospitalist Physician #1 on April 21, 2014, at 10:26 a.m., by phone, confirmed the Physician was the resident's treating physician in the hospital. Continued interview confirmed the resident's [MEDICATION NAME] "was very low" and the resident was "critically ill" when admitted to the ICU. Further interview confirmed when the resident was administered [MEDICATION NAME] and [MEDICATION NAME] the resident was stabilized and able to be discharged back to the facility. Further interview revealed, "...I would say the fact that (resident) did not receive medications ([MEDICATION NAME]) led to the resident's hospitalization ..." Review of Timeline of Events dated April 1, 2014, and signed by the DON, revealed, "...Timeline of Events...During MAR indicated [REDACTED]. Upon investigation, it appears that resident (#3)...did not receive (resident's) scheduled [MEDICATION NAME], [MEDICATION NAME] or [MEDICATION NAME] since (resident) was readmitted to (facility) on 3/14/14..." Continued review of Timeline of Events revealed when the resident was readmitted to the facility on [DATE], the resident's hospital discharge orders were faxed to the pharmacy. Further review of Timeline of Events revealed the facility's investigation determined the pharmacy received only pages 3, 4, 5, and 6 of a total of six pages. Continued review revealed the pharmacy did not receive pages 1 and 2 which consisted of the orders for the resident's [MEDICATION NAME], [MEDICATION NAME], and [MEDICATION NAME]. Interview with the DON and Nurse Consultant #1 on April 15, 2014, at 2:45 p.m., in the Conference Room, revealed the DON's investigation of the medication errors revealed the nurse who faxed the resident's discharge orders from the hospital to the pharmacy did not verify with the pharmacy how many pages the pharmacy had received. Continued interview revealed when the resident's medications arrived from the pharmacy, the nurse matched the medications with the Physician order [REDACTED]. Further interview with the DON and Nurse Consultant #1 confirmed resident #3 did not receive six ordered medications ([MEDICATION NAME], [MEDICATION NAME]) from the time of the resident's admission to the facility on [DATE], until the resident's discharge to the hospital on March 29, 2014 (a total of 15 days). Further interview with the DON and Nurse Consultant #1 confirmed the facility's failure to reconcile the resident's hospital discharge orders with the facility's admission orders [REDACTED]. The facility's failure to reconcile hospital discharge orders with facility admission orders [REDACTED]. The facility's failure to ensure the resident was free from significant medication errors resulted in Immediate Jeopardy for resident #3. Resident #14 was admitted to the facility on [DATE], discharged to the hospital on April 1, 2014, related to care for a cyst, and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician order [REDACTED]. Medical record review revealed no documentation of the monitoring of the blood sugar level before supper for March 31, 2014. Medical record review of the hospital Discharge Med Rec dated April 10, 2014, for the facility readmission on April 11, 2014, revealed an order for [REDACTED].< (less than) 60 give snack & (and) recheck in 30 minutes. If recheck still <60 give [MEDICATION NAME] UD (Unit Dose); 251-300= 4 units (give 4 units); 301-350=6 units; 351-400=8 units; 401-450= 10 units; Recheck in 1HR (hour) using above sliding scale if BG (Blood Glucose) > (greater than) 300; >450= (means) call MD (physician) for orders recheck in 1 HR or per MD..." Further review of the readmission orders [REDACTED] Medical record review of the Diabetic Medication Administration Record [REDACTED] 1. April 18, 2014, at 5:00 p.m. the accucheck was 253 and no insulin administration (should have administered 4 units); 2. April 19, 2014, at 5:00 p.m. the accucheck was 301 and no insulin administration (should have administered 6 units); 3. April 19, 2014, at 9:00 p.m. no accucheck was obtained; 4. April 20, 2014, at 11:00 a.m. the accucheck was 305 and no insulin administration (should have administered 6 units); 5. April 21, 2014, before the breakfast meal, no accucheck was obtained; and on 6. April 23, 2014, at "6A (6:00 a.m.)" no accucheck was obtained. Interview with Licensed Practical Nurse (LPN) #1 assigned to resident #14, on April 21, 2014, at 11:15 a.m., on the 100 hall revealed "...the night nurse (7:00 p.m. to 7:00 a.m. shift) obtains the blood sugar..." Further interview confirmed LPN #1 was not aware of the blood sugar result for 6:00 a.m. on April 21, 2014. Further interview confirmed the blood sugar level for April 21, 2014, at 6:00 a.m. was not documented on the Diabetic Medication Administration Record. Interview with Nurse Consultant #1/Acting Director of Nursing, on April 21, 2014, at 11:38 a.m., in the Conference Room confirmed the blood sugar level and the insulin administration when the blood sugar was elevated was to be documented on the Diabetic Medication Administration Record. Further interview confirmed the April 2014, Diabetic Medication Administration Record [REDACTED]. Further interview confirmed the insulin should have been administered and the number of units administered was to be documented on April 18 and 19, 2014, at 5:00 p.m. and on April 20, 2014, at 11:00 a.m. due to the elevated accucheck results. Interview with Medical Director #2, on April 21, 2014, at 11:52 a.m., in the Conference Room confirmed "...expect (resident #14) should have gotten sliding scale (insulin) per order (when blood sugar elevated)..." Interview with LPN #5, on April 23, 2014, at 7:45 a.m., at the 200/300 nursing station, and Nurse Consultant #1/Acting Director of Nursing present, confirmed LPN #5 had been responsible for resident #14 during the 7:00 p.m.-7:00 a.m. shift and had not obtained the blood sugar level for the morning of April 23, 2014. Interview with LPN #4, and observation on April 23, 2014, at 7:50 a.m., and Nurse Consultant #1/Acting Director of Nursing present, outside the room of resident #14, confirmed LPN #4 was responsible for resident #14 for the 7:00 a.m.-7:00 p.m. shift and had not obtained the blood sugar level for the morning of April 23, 2014. When LPN #4 was asked if the blood sugar had been obtained this nurse stated "No, the night shift (7:00 p.m.-7:00 a.m.) does it." Interview with LPN #8 and Nurse Consultant #2, on April 24, 2014, at 10:15 a.m., at the 100/200 nursing station, confirmed the resident had been admitted on [DATE], at 2:50 p.m. and had been discharged before breakfast on April 1, 2014. Further interview confirmed the accucheck for March 31, 2014, at 5:00 p.m. was not obtained. The facility's failure to monitor the blood sugar level and the failure to administer the prescribed insulin when the blood sugar was elevated resulted in significant medication errors and placed resident #14 in Immediate Jeopardy. Validation of the Credible Allegation of Compliance was accomplished on-site on May 13, 2014, and May 14, 2014, through medical record reviews, review of facility documents, and interviews with Nursing and Administrative Staff. Medical record review of the closed chart of resident #3 revealed the resident's Physician order [REDACTED]. Resident #3 was discharged from the facility on April 1, 2014. Medical record review of resident #33 revealed the resident was readmitted to the facility on [DATE]. Continued review of the physician orders [REDACTED]. Medical record review of the Medication Administration Record [REDACTED]. The facility provided evidence of audits of reconciliation of admission/re-admission orders [REDACTED]. The facility provided documentation of an emergency Performance Improvement Meeting held on April 28, 2014, to discuss the new admission/readmission medication reconcilation process, pharmacy process, and physician notification process and provided evidence of establishing a Performance Improvement Committee. Interviews with Nursing Staff on all shifts May 13-14, 2014, throughout the facility, revealed the nursing staff had been in-serviced on the protocol for new admission/readmission medication order reconciliation, pharmacy protocol, medication errors, and physician standing orders. The facility will remain out of compliance at a Scope and Severity level "F" a 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 and corrective actions are verified onsite.. C/O #

Based on interview, review of the pharmacy agreement with the facility, review of the agreement with the pharmacy consultant and the facility, and medical record review, the facility's contracted pharmacy failed to provide prescribed medication for five residents (#3, #19, #14, #1, #10); and failed to accurately transcribe medications on the admission/monthly physician's orders [REDACTED].#19, #14, #26 #13, #24, #29) of thirty-one residents reviewed. The facility's contracted pharmacy and the facility's systemic failure to compare/reconcile medications with physician orders [REDACTED]. The Administrator, Regional Administrator Consultant, Assistant Director of Nursing, Nurse Consultant #1/Acting Director of Nursing, Nurse Consultant #2, Nurse Consultant #3, Vice-President of Client Operations, and Medical Director #1 were informed of the Immediate Jeopardy on April 24, 2014, at 10:55 a.m., in the Conference Room. The Immediate Jeopardy was effective March 14, 2014, and is ongoing. An extended survey was conducted on April 24, 2014. Substandard Quality of Care was cited at F224-J, F309-J, and F333-L. The findings included: Interview with the Director of Nursing and Nurse Consultant #1, on April 15, 2014, at 2:45 p.m., in the conference room, revealed the the hospital discharge medication reports were delivered to the facility. Further interview revealed the facility faxed the hospital discharge medication report to the pharmacy. Further interview revealed the pharmacy generated the facility physician medication orders and the MAR. Further interview revealed the pharmacy delivered the facility admission physician orders [REDACTED]. Further interview confirmed the facility physician orders [REDACTED]. Review of the agreement between the pharmacy and the facility, dated June 2011, revealed the Duties and Obligations of the Pharmacy included: .support and delivery of medications to the facility (twenty-four hours per day, seven days per week).Medication Administration records.physician order [REDACTED].>Review of the agreement with the pharmacy consultant and the facility dated June 2011, revealed Responsibilities and Functions.the Consultant agrees to:.Complete monthly patient medication reviews.Participate in Quality Assurance Committee Meetings and provide administrative/professional guidance to administrative staff for the development and implementation. Medical record review of resident #3 revealed the hospital discharge medication report including the six medication of Coumadin (blood thinner), Lipitor (statin drug for cholesterol management), Coreg medication to regulate heart rate), Digoxin medication to slow heart rate and control rhythm), Cardizem medication to control heart rate and blood pressure), and Lisinopril (medication to control high blood pressure). Medical record review revealed the pharmacy failed to transcribe the six medications onto the facility admission physician orders [REDACTED].#3 in Immediate Jeopardy. Medical record review of resident #19, receiving dialysis treatment three days per week, revealed the March 2014, hospital discharge medications did not include PhosLo (Calcium Acetate-used to bind the phosphorus in the body to decrease the level of the phosphorus in the blood) and Crestor (an antistatin medication to lower cholesterol) at 20 milligrams (mg). Further review of the hospital discharge medications revealed Mirtazapine (antidepressant medication) and Protonix (medication to control stomach acid) were included. Medical record review of the March 2014, facility admission physician medication order revealed the pharmacy incorrectly included the PhosLo and Crestor 20 mg (although they were not ordered) onto the forms. Further review of the facility admission physician medication order revealed the pharmacy failed to transcribe the Mirtazapine and Protonix (although they were ordered) onto the forms. Medical record review of the facility March 2014 MAR indicated [REDACTED]. The failure of the pharmacy to accurately transcribe and provide medication placed resident #19 in Immediate Jeopardy. Medical record review for resident #14 revealed the hospital discharge medications included Gabapentin 800 milligrams (mg). Medical record review of the facility readmission medication orders and the MAR indicated [REDACTED]. Medical record review for resident #1 revealed the hospital discharge medications included Metoprolol (medication to control blood pressure). Medical record review of the facility admission physician orders [REDACTED]. Medical record review for resident #10 revealed the hospital discharge medications included lubricating top jelly bacteriostatic. Medical record review of the facility admission physician orders [REDACTED]. Interview with Pharmacist #1, on April 22, 2014, at 1:25 p.m., in the Conference Room, confirmed the lubricating jelly was .a blatant omission by pharmacy. and failed to provide the medication. Medical record review for resident #26 revealed the hospital discharge medications included Tylenol (medication for control of pain/fever) with no specified frequency of administration. Medical record review of the facility admission physician orders [REDACTED]. Interview with Pharmacist #1 confirmed the attempt and failure to obtain a clarification order prior to providing the facility with the physician orders [REDACTED]. Medical record review of resident #13 revealed the February 2014 hospital discharge medications included a cranberry supplement. Medical record review of the facility admission physician order [REDACTED]. Medical record review of the March 2014 hospital discharge medications included Aspirin and a cranberry supplement. Medical record review of the facility admission physician order [REDACTED]. Medical record review for resident #24 revealed the hospital discharge medications included Melatonin (herbal medication prescribed for sleep) at 4 mg, Latuda (an atypical antipsychotic medication prescribed for anxiety) at 20 mg twice daily and Latuda 10 mg as needed. Medical record review of the facility admission physician order [REDACTED]. Medical record review of the facility admission physician order [REDACTED]. Medical record review for resident #29 revealed the hospital discharge medications included Gabapentin (medication used to treat pain and anxiety) and Metoclopramide (medication to aid in stomach emptying). Medical record review of the facility admission physician order [REDACTED]. Interview with Pharmacist #1 on April 22, 2014, at 1:25 a.m., in the conference room, revealed the facility identified a breakdown in communication between the pharmacy and the facility in early April. Further interview confirmed prior to the last Performance Improvement meeting held April 10, 2014, the pharmacy did not compare/reconcile hospital discharge medication to the facility admission physician orders [REDACTED].(to provide medications prescribed). Refer to F157-J, F224-K, F281-L, F309-J, F333-L. C/0 #

Based on medical record review, review of facility Plan of Correction, facility policy review, and interview, the facility failed to be administered in a manner to ensure physician's orders [REDACTED].#1, #3, #10, #13, #14, #19, #24, #26, #28, #29, #30), failed to administer medications as ordered resulting in neglect of one resident (#3), failed to ensure quality of care for eight residents (#1, #3, #10, #13, #14, #19, #24, #29), failed to ensure the facility was free from significant medication errors for one resident (#3), and failed to ensure implemented interventions addressed during Performance Improvement were effective. The facility personnel failed to identify significant medication errors when completing medication audit. The facility's failure to ensure physician's orders [REDACTED].#3, #19, and #14 (a situation in the provider's noncompliance with one or more requirements of participation has caused, or was likely to cause, serious injury, harm impairment or death), and potentially for all residents in the facility. The Administrator, Regional Administrator Consultant, Assistant Director of Nursing, Nurse Consultant #1/Acting Director of Nursing, Nurse Consultant #2, Nurse Consultant #3, Vice-President of Client Operations, and Medical Director #1 were informed of the Immediate Jeopardy on April 24, 2014, at 10:55 a.m., in the Conference Room. The Immediate Jeopardy was effective March 14, 2014, and is ongoing. An extended survey was conducted on April 24, 2014. Substandard Quality of Care was cited at F224-J, F309-J, and F333-L. The findings included: Review of facility Plan of Correction (facility's own, internal corrective action plan), completed by the Director of Nursing (DON) on April 2, 2014, in response to the discovery of the significant medication errors of resident #3, revealed the facility became aware of medications which were being omitted from the hospital discharge records when reconciled with the facility's admission medication orders and Medication Records (MARs) sent from the pharmacy. Continued review revealed a Plan of Correction was instituted by the DON which stated the facility would complete a 100 % (percent) audit of all active residents by conducting a reconciliation with the MARs and the Physician Orders. Continued review revealed the Plan of Correction was to provide education of all Licensed Nursing Staff of the new system to be instituted requiring two nurses to double check the hospital discharge orders with the physician's orders [REDACTED]. to the facility. Continued review revealed each physician order, after a resident's admission to the facility, was to be verified by nursing administration .the following business day. Continued review of The Plan of Correction revealed the plan was ongoing with each new admission and physician order. Interview with the DON and Nurse Consultant #1 on April 17, 2014, at 2:55 p.m., in the Conference Room, confirmed the audit was completed per the Plan of Correction dated April 2, 2014, of all residents in the facility. Continued interview confirmed Nurse Consultant #1 emailed the results of the audit to the DON on April 4, 2014. Further interview confirmed both the DON and Nurse Consultant #1 were aware of the results of the audit which documented resident #19 was receiving medications which had not been ordered on admission, and were aware resident #19 was not receiving other medications which had been ordered. Continued interview confirmed both the DON and Nurse Consultant #1 failed to follow-up on the audit as of the time of the interview on April 17, 2014. Interview with the Administrator on April 21, 2014, at 9:40 a.m., in the Conference Room, confirmed the Administrator was also notified by email on April 4, 2014, of the results of the chart audits. Continued interview with the Administrator confirmed the Administrator also failed to follow-up on the results of the audit and was aware the medication errors had been identified. Further interview confirmed no action had been taken by Nursing Administration Staff or the Administrator to address the audit concerns. Further interview confirmed the Administrator had participated in the last Performance Improvement meeting on April 10, 2014, and .talked about reconciliations. Further interview confirmed facility management had identified the issues with medication reconiliation processes and had developed Plan of Correction on April 2, 2014. Continued interview confirmed the Administrator had .discussions. with the pharmacy related to the medication errors which had occurred. Further interview confirmed no new plan had been put in place since the original Plan of Correction presented by the DON on April 2, 2014. Refer to F157-J, F224-K, F281-L, F309-K, F333-L, F425-L C/0 #

Based on review of Co-Medical Director Agreements, and interview, the facility failed to ensure one medical director was designated to be responsible and accountable for oversight of resident care policies, procedures and services. The failure of the facility to appoint one medical director resulted in inaccurate medication administration procedures that placed three residents (#3, #14, #19) of thirty-one residents reviewed in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death), and placed any resident who receives medications at risk. The Administrator, Regional Administrator Consultant, Assistant Director of Nursing, Nurse Consultant #1/Acting Director of Nursing, Nurse Consultant #2, Nurse Consultant #3, Vice-President of Client Operations, and Medical Director #1 were informed of the Immediate Jeopardy on April 24, 2014, at 10:55 a.m., in the Conference Room. The Immediate Jeopardy was effective March 14, 2014, and is ongoing. An extended survey was conducted on April 24, 2014. Substandard Quality of Care was cited at F224-J, F309-J, and F333-L. The findings included: Review of the facility's Medical Director Agreement revealed the facility had three co-medical directors, not one. Review of Co-Medical Director Agreement signed and dated November 14, 2012, by Medical Director #2, revealed, .Services of Physicians.As Co-Medical Director of facility, Physician shall perform those duties and responsibilities set forth in Addendum A, atttached hereto.together with all other services to be provided by Physician hereunder, the 'Services'. Further review revealed, .Coordination of medical care in Facility.(iii) Facility's quality assurance program on a quarterly basis. Continued review revealed, .Addendum A.provides that medical directors are responsible for.implementation of resident care policies and the coordination of medical care in the facility.'Resident care policies' include admissions, transfers and discharges.It also includes having a significant role in overseeing the overall clinical care of residents to ensure to the extent possible that care is adequate.When the medical director identifies or receives a report of possible inadequate medical care, including drug irregularities, (Medical Director), is responsible for evaluating the situation and taking appropiate steps to try to correct the problem.A medical director whose sole function is to approve resident care policies does not meet this requirement. Interview with Medical Director #2 on April 21, 2014, at 11:52 a.m., in the Conference Room, revealed .was at the last Performance Improvement meeting (April 10, 2014).don't remember specifics.talked about changing processes.and issue with medications.I would expect something to happen.Not sure of specifics.Not aware of the what checks and balances in place.Not aware of what pharmacy has or had in place to correct issues. Review of Co-Medical Director Agreement signed and dated March 22, 2013, by Medical Director #3, revealed, .Services of Physicians.As Co-Medical Director of facility, Physician shall perform those duties and responsibilities set forth in Addendum A, atttached hereto.together with all other services to be provided by Physician hereunder, the 'Services'. Further review revealed, .Coordination of medical care in Facility.(iii) Facility's quality assurance program on a quarterly basis. Continued review revealed, .Addendum A.provides that medical directors are responsible for.implementation of resident care policies and the coordination of medical care in the facility.'Resident care policies' include admissions, transfers and discharges.It also includes having a significant role in overseeing the overall clinical care of residents to ensure to the extent possible that care is adequate.When the medical director identifies or receives a report of possible inadequate medical care, including drug irregularities, (Medical Director), is responsible for evaluating the situation and taking appropiate steps to try to correct the problem.A medical director whose sole function is to approve resident care policies does not meet this requirement. Interview with Medical Director #3 on April 22, 2014, at 9:30 a.m., in the Conference Room, revealed .was not at last Performance Improvement meeting (April 10, 2014).was aware was working on issue of confusing hospital discharge orders due to multiple sets provided to the facility.The administrator has not as yet approached (Medical Director #3) to address the issue. In summary, the facility's failure to designate only one physician as Medical Director resulted in no one (of the three co-medical directors) soley accountable to ensure implementation of resident care policies and the coordination of medical care in the facility, including accurrate medication administration. Refer to F157-J, F224-K, F281-L, F309-K, F333-L, F425-L, F490-L C/0 #

Based on review of Medication Review 3 Month review, review of Timeline of Events, review of New Admission/Readmission Audts, medical record review, review of facility policy, review of facility Performance Improvement Committee Agenda and Minutes, and interview, the facility failed to develop a plan of action related to the failure to follow physician's orders [REDACTED].#1, #3, #10, #13, #14, #19, #24, #26, #28, #29, #30); failure to administer medications as ordered resulting in neglect for two residents (#3, #19); failure to ensure quality of care for eight residents (#1,#3, #10, #13, #14,#19, #24, #29); failure to ensure the facility was free from significant medication errors for two residents (#3, #14); failure to ensure the hospital medication discharge orders and the facility admission medication orders (physician's orders [REDACTED].#3, #10, #13, #19, #24, #26, #29) of the thirty-one residents reviewed. The facility's failure to ensure the physician's orders [REDACTED]. [REDACTED].#3, #14, #19) of thirty-one residents reviewed. The systems failure had the potential to place all residents in the facility who received medications in Immediate Jeopardy. The Administrator, Regional Administrator Consultant, Assistant Director of Nursing, Nurse Consultant #1/Acting Director of Nursing, Nurse Consultant #2, Nurse Consultant #3, Vice-President of Client Operations, and Medical Director #1 were informed of the Immediate Jeopardy on April 24, 2014, at 10:55 a.m., in the Conference Room. The Immediate Jeopardy was effective March 14, 2014, and is ongoing. Substandard Quality of Care was cited under F224-J, F309-J, and F333-L. An extended survey was conducted on April 24, 2014. The findings included: Review of facility Plan of Correction (facility's own internal corrective action plan), completed by the Director of Nursing (DON) on April 2, 2014, in response to the DON's discovery of the significant medication errors for resident #3 revealed, the facility had became aware of medications which were being omitted from the hospital discharge records when reconciled with the facility's admission medication orders and Medication Records (MARS) sent from the pharmacy. Continued review revealed the April 2, 2014, Plan of Correction was developed by the DON which stated the facility would complete a 100 % (percent) audit of all active residents by conducting a reconciliation with the MARs and the Physician Orders. Continued review revealed the Plan of Correction was to provide education of all Licensed Nursing Staff on the new system to be initiated requiring two nurses to double check the hospital discharge orders with the physician's orders [REDACTED]. or readmission to the facility. Continued review revealed each physician order, after a resident's admission to the facility, was to be verified by nursing administration .the following business day. Continued review of the Plan of Correction revealed the plan was ongoing with each new admission and physician order. Review of Performance Improvement Meeting Minutes, dated April 10, 2014, revealed the DON, Administrator, Assistant Director of Nursing (ADON), Pharmacist #1, Medical Director #2, Medical Director #1, as well as other facility staff attended the April 10, 2014, Performance Improvement meeting (Quality Assurance). Continued review revealed, .Issue resident admitted , pharmacy only received 3 of the pages.Resolution plan.1. All orders faxed and both nurses' sign and fax confirmation and name of pharmacist who received the fax. 2. When medication arrive 2 nurses will check the POS (physician's orders [REDACTED]. Pharmacy is currently making changes with their system to alleviate any further problems. Nurses are also being educated with this new process. Further review of the Performance Improvement Meeting Minutes revealed the facility did not address the results of the New Admission/Readmission Audits which had been completed by the DON which had identified continued problems with medication reconcilation processes. Interview with the DON and Nurse Consultant #1 on April 17, 2014, in the Conference Room, confirmed the audit was completed per the Plan of Correction dated April 2, 2014, of all residents in the facility. Further interview confirmed both the DON and Nurse Consultant #1 participated in Quality Assurrance meetings. Continued interview confirmed Nurse Consultant #1 emailed the results of the audit to the DON on April 4, 2014. Further interview confirmed both the DON and Nurse Consultant #1 were aware of the results of the audit which documented resident #19 was receiving medications which had not been ordered on admission, and were aware resident #19 was not receiving other medications which had been ordered. Continued interview confirmed both the DON and the Nurse Consultant #1 failed to follow-up on the audit until informed by the surveyor of the on-going medication errors during the interview on April 17, 2014. Interview with the Administrator on April 21, 2014, at 9:40 a.m., in the Conference Room, confirmed the Administrator was also notified by email on April 4, 2014, of the results of the chart audits. Continued interview with the Administrator confirmed the Administrator also failed to follow-up on the results of the audit and was aware the medication errors had been identified. Further interview confirmed no action had been taken by Nursing Administration Staff or the Administrator to address the audit concerns. Further interview confirmed the Administrator had participated in the last Performance Improvement meeting on April 10, 2014, and .talked about reconciliations. Continued interview confirmed the Administrator had .discussions. with the pharmacy related to the medication errors which had occurred. Further interview confirmed no new plan had been put in place since the original Plan of Correction presented by the DON on April 2, 2014. Interview with Medical Director #2 on April 21, 2014, at 11:52 a.m., in the Conference Room, revealed .was at the last Performance Improvement meeting (April 10, 2014).don't remember specifics.talked about changing processes.and issue with medications.I would expect something to happen.Not sure of specifics.Not aware of what the checks and balances were in place.Not aware of what pharmacy has or had in place to correct issues. Interview with Medical Director #3 on April 22, 2014, at 9:30 a.m., in the conference room, revealed .was not at last Performance Improvement meeting (April 10, 2014).was aware was working on issue of confusing hospital discharge orders due to multiple sets provided to the facility.The administrator has not as yet approached (Medical Director #3) to address the issue. Interview with Pharmacist #1 April 22, at 1:25 p.m., in the Conference Room, confirmed the pharmacist attended the last Performance Improvement meeting on April 10, 2014. Continued interview with Pharmacist #1 confirmed the pharmacist was aware of the medication reconciliation issues, and confirmed was aware of the Plan of Correction processes which had been instituted. Further interview confirmed the pharmacy had instituted an internal process to correct medication reconciliation issues. Continued interview confirmed Pharmacist #1 or Pharmacist #2 were to audit all resident's hospital discharge orders with the physician's orders [REDACTED]. Refer to F157-J, F224-K, F281-L, F309-K, F333-L, F425-L, F490-L, F501-L C/0 #

Based on medical record review, review of a facility investigation, and interview the facility failed to ensure one resident (#3) received ordered medications for 15 days following a hospital stay, resulting in rehospitalization in critical condition, of thirty-one residents reviewed. The facility's failure to administer prescribed medications resulted in neglect. The facility's neglect of the resident placed resident #3 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 systemic failure to ensure post-hospital discharge orders were reconciled with facility admission orders [REDACTED]. The Administrator, Regional Administrator Consultant, Assistant Director of Nursing, Nurse Consultant #1/Acting Director of Nursing, Nurse Consultant #2, Nurse Consultant #3, Vice-President of Client Operations, and Medical Director #1 were informed of the Immediate Jeopardy on April 24, 2014, at 10:55 a.m., in the Conference Room. The Immediate Jeopardy was effective March 14, 2014, and is ongoing. An extended survey was conducted on April 24, 2014. The findings included: Resident #3 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the hospital Discharge Med (Medication) Rec (Reconciliation) form dated March 14, 2014, revealed the hospital Discharge Med Rec form contained a total of 6 pages of medications ordered for the resident upon discharge from the hospital and readmission to the facility. Continued review revealed the Discharge Med Rec form for pages 1 and 2 included physician's orders [REDACTED]. once per day, [MEDICATION NAME] (heart medication to control heart rate and blood pressure) 120 mg once per day, and [MEDICATION NAME] (medication to control high blood pressure) 10 mg once per day. Medical record review of physician's orders [REDACTED]. Medical record review of the Medication Record (form used to document medication administration: MAR) dated March 14, 2014, through March 31, 2014, revealed two pages of medications, neither of which included the [MEDICATION NAME], [MEDICATION NAME], and [MEDICATION NAME]. Medical record review of a nurse's note dated March 30, 2014, revealed, .Late entry for 3/28/14. At approx. (approximately) 3 p.m. this nurse was called to resident room to assess resident. Resident in bed with eyes closed, shaking et (and) c/o (complained of) being cold. Resident alert et responsive. Vital signs T (temperature) 100.8 orally, P (pulse) 138 (normal range 60-100), R (respirations) 27, B/P (blood pressure) 156/92, O2 (oxygen) 78 % (percent) via (by) nc (nasal cannula) at 3 LPM (liters per minute). This nurse instructed patient to breathe in through nose et out through mouth. O2 increased to 83%. Nurse applied a non-rebreather oxygen mask et O2 increased to 86-92% fluctuating. Nurse notified MD (medical doctor) of pt (patient) status et N/O (new order) to send to ER (emergency room ) for eval (evaluation) et tx (treatment). Continued review revealed, .late entry for 3/29/14 5 pm. ER staff called et stated they needed a copy of resident's MAR. This nurse faxed MAR indicated [REDACTED]. No new [DIAGNOSES REDACTED]. This nurse was informed that diagnostic testing was still being performed. Medical record review of a nurse's note dated April 8, 2014, timed 2:49 p.m., and signed by the Director of Nursing (DON) revealed, .Upon chart review it is noted on the late entry dated 3-30-14 @ (at) 730 a.m., (the note is for 3-28-14) the date for the late entry is incorrect and is actually for 3-29-14 which is when this resident was transferred to the ER for further eval and treatment. Medical record review of emergency room Provider Report dated March 29, 2014, revealed the resident was evaluated in the emergency room . Continued review of the emergency room Provider Report revealed the resident had complained of shortness of breath and .pt recently diagnosed with [REDACTED]. Further review revealed the resident's vital signs were documented as blood pressure 150/50, temperature 100.3, pulse 67, and respirations 20 at 4:06 p.m. Continued review revealed, .Cardiovascular: normal heart sounds, [MEDICAL CONDITION](heart rate over 100), irregularly irregular. Further review revealed the resident's vital signs were documented at 5:58 p.m.b/p 131/80, pulse 154, resp (respirations) 26, and temp 100.3. Medical record review of emergency room lab report dated March 29, 2014, revealed the resident's level of the [MEDICATION NAME] medication was reported as .< (less than) 0.2 L (low). Continued review of the emergency room report revealed the resident had an Electrocardiogram (EKG, diagnostic test to evaluate heart rate, rhythm, and electrical pulses). Further review revealed the results of the heart monitoring test was .A-Fib ([MEDICAL CONDITION] Fibrillation) with RVR (rapid ventricular response) . indicating the resident's heart rate and rhythm were abnormal. Continued review revealed, .Clinical Impression: Primary Impression: Pneumonia.Secondary Impressions: AFib, [MEDICAL CONDITIONS]. Further review revealed the resident was admitted to the hospital for further treatment. Medical record review of Consulting Physician #1's note dated March 29, 2014, revealed the resident was seen by a consulting physician in the hospital. Review of the record revealed, .Reason for Consultation: [MEDICAL CONDITION]. Further review revealed the resident .was found to be in [MEDICAL CONDITION] with a ventricular rate around 170.(resident) has history of chronic [MEDICAL CONDITION], chronic heart failure, and had a stroke in September 2012.Currently (resident) is on long term oral anticoagulation ([MEDICATION NAME]). Further review of Consulting Physician #1's note revealed, .Diagnostic Studies: (Resident's) EKG shows [MEDICAL CONDITION] with a ventricular rate around 185, low voltage, and poor R-wave progression. Continued review of the consultation note revealed, .Impression: 1. [MEDICAL CONDITION] 2. Acute.chronic heart failure. Medical record review of Consulting Physician #2's note dated March 29, 2014, revealed, .Assessment and Plan: 1. [MEDICAL CONDITION] with rapid ventricular response. Continue [MEDICATION NAME] drip initiated in the emergency room .2. Pneumonia.5. Subtherapeutic [MEDICATION NAME] level. We will load the patient with [MEDICATION NAME] repeat level in the morning hours with further orders to follow. Medical record review of Hospitalist Physician's Progress Note dated March 30, 2014, revealed, .Subjective: The patient was noted to have persistent [MEDICAL CONDITION] with rapid ventricular response despite [MEDICATION NAME] drip. (Resident) was also noted to have [MEDICAL CONDITION] (a decreased level of oxygen in the blood).The patient was also note (noted) to have some decreased responsiveness and (resident) was.transferred to the intensive care unit (ICU). Continued review of the physician's progress note revealed, .Assessment and Plan: The patient is a [AGE] year old (resident) admitted to the hospital with [REDACTED]. [MEDICAL CONDITION] with rapid ventricular response. Heart rate is improving. Continue [MEDICATION NAME] Medical record review of Consulting Physician #3's note dated March 30, 2014, revealed, .(Resident) also has [MEDICAL CONDITION] with rapid ventricular rate. (Resident) was transferred to ICU this morning because of [MEDICAL CONDITION] and also because of persistent [MEDICAL CONDITION] with rapid rate. Continued review revealed, .Impression: 1.Acute [MEDICAL CONDITION] 2. Pneumonia 3. [MEDICAL CONDITION] 4. [MEDICAL CONDITION].Recommendations: 1. Agree with transfer to intensive care unit.7. Continue care in the ICU, critically ill. Medical record review of the hospital Discharge Summary by Hospitalist Physician dated March 31, 2014, revealed, .Hospital course: The patient was admitted and started on [MEDICATION NAME] drip.The patient did have a subtherapeutic [MEDICATION NAME] level and the patient was loaded with [MEDICATION NAME]. The patient was noted to have persistent [MEDICAL CONDITION] with rapid ventricular response despite the [MEDICATION NAME] drip.The patient was transferred to the intensive care unit.Plan for this patient: 1. Pneumonia is improving.3. [MEDICAL CONDITION] with rapid ventricular response, heart rate is rate controlled, [MEDICATION NAME] drip has been off for over 24 hours. The patient will be discharged back to nursing home today. Review of Timeline of Events dated April 1, 2014, and signed by the DON, revealed, .Timeline of Events.During MAR indicated [REDACTED]. Upon investigation, it appears that resident (#3).did not receive (resident's) scheduled [MEDICATION NAME], [MEDICATION NAME] or [MEDICATION NAME] since (resident) was readmitted to (facility) on 3/14/14. Continued review of Timeline of Events revealed when the resident was readmitted to the facility on [DATE], the resident's hospital discharge orders were faxed to the pharmacy. Further review of Timeline of Events revealed the facility's investigation determined the pharmacy received only pages 3, 4, 5, and 6 of a total of six pages. Continued review revealed the pharmacy did not receive pages 1 and 2 which consisted of the orders for the resident's [MEDICATION NAME], [MEDICATION NAME], and [MEDICATION NAME]. Interview with the DON and Nurse Consultant #1 on April 15, 2014, at 2:45 p.m., in the Conference Room, revealed the DON's investigation of the medication errors revealed the nurse who faxed the resident's discharge orders from the hospital to the pharmacy did not verify with the pharmacy how many pages the pharmacy had received. Continued interview revealed when the resident's medications arrived from the pharmacy, the nurse matched the medications with the Physician order [REDACTED]. Further interview with the DON and Nurse Consultant #1 confirmed resident #3 did not receive six ordered medications ([MEDICATION NAME], [MEDICATION NAME]) from the time of the resident's admission to the facility on [DATE], until the resident's discharge to the hospital on March 29, 2014 (a total of 15 days). Further interview with the DON and Nurse Consultant #1 confirmed the facility's failure to reconcile the resident's hospital discharge orders with the facility's admission orders [REDACTED]. Interview with the DON on April 16, 2014, at 12:40 p.m., in the Conference Room, confirmed the DON had questioned the admitting nurse of resident #3 about the resident not being admitted from the hospital with [MEDICATION NAME] orders. Continued interview with the DON confirmed the DON also did not reconcile the hospital discharge orders with the facility's admission orders [REDACTED]. Interview with Hospitalist Physician #1 on April 21, 2014, at 10:26 a.m., by phone, confirmed the physician was one of resident #3's treating physicians. Further interview revealed, .I would say the fact that (resident) did not receive medications led to the (resident's) hospitalization . Continued interview confirmed the resident's [MEDICATION NAME] level .was very low., subtherapeutic, and confirmed the resident was .critically ill. necessitating the resident's transfer to the Intensive Care Unit (ICU). Further interview with Hospitalist Physician #1 confirmed when resident #3 was administered the resident's ordered medications (specifically [MEDICATION NAME] and [MEDICATION NAME]) the resident improved, and was able to be discharged back to the facility. Interviews conducted with the DON and Nurse Consultant #1 during the course of the survey confirmed there was not a consistent medication reconciliation process in place for nursing staff to utilize when a resident was admitted /readmitted to the facility which resulted in the failure to provide six medications, therefore neglect, to resident #3. C/O #

Based on medical record review, review of Timeline of Events, review of Medication 3 Month Review, review of New Admission/Readmission Audits, and interview the facility failed to provide a system of quality of care to ensure any resident admitted or readmitted to the facility with hospital discharge physician's orders [REDACTED]. The facility's failure to provide quality of care resulted in one resident (#3) requiring re-hospitalization in critical condition, and resulted in seven residents (#19, #14 #24, #29, #13, #1, #10) receiving multiple medication errors, of thirty-one residents reviewed. The facility's failure to reconcile hosptial discharge/facility admission orders [REDACTED] The Administrator, Regional Administrator Consultant, Assistant Director of Nursing, Nurse Consultant #1/Acting Director of Nursing, Nurse Consultant #2, Nurse Consultant #3, Vice-President of Client Operations, and Medical Director #1 were informed of the Immediate Jeopardy on April 24, 2014, at 10:55 a.m., in the Conference Room. The Immediate Jeopardy was effective March 14, 2014, and is ongoing. An extended survey was conducted on April 24, 2014. Substandard Quality of Care was cited under F309-J The findings included: Resident #3 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the hospital Discharge Med (Medication) Rec (Reconciliation) form dated March 14, 2014, revealed the hospital Discharge Med Rec form contained a total of 6 pages of medications ordered for resident #3 upon discharge from the hospital and readmission to the facility. Continued review revealed the Discharge Med Rec form for pages 1 and 2 included physician's orders [REDACTED]. once per day, [MEDICATION NAME] (heart medication to control heart rate and blood pressure) 120 mg once per day, and [MEDICATION NAME] (medication to control high blood pressure) 10 mg once per day. Medical record review of physician's orders [REDACTED]. Medical record review of the Medication Record (form used to document medication administration: MAR) dated March 14, 2014, through March 31, 2014, revealed two pages of medications, neither of which included the [MEDICATION NAME], [MEDICATION NAME], and [MEDICATION NAME] for resident #3. Medical record review of a nurse's note dated March 30, 2014, revealed, .Late entry for 3/28/14. At approx. (approximately) 3 p.m. this nurse was called to resident room to assess resident. Resident (#3) in bed with eyes closed, shaking et (and) c/o (complained of) being cold. Resident alert et responsive. Vital signs T (temperature) 100.8 orally, P (pulse) 138 (normal range 60-100), R (respirations) 27, B/P (blood pressure) 156/92, O2 (oxygen) 78 % (percent) via (by) nc (nasal cannula) at 3 LPM (liters per minute). This nurse instructed patient to breathe in through nose et out through mouth. O2 increased to 83%. Nurse applied a non-rebreather oxygen mask et O2 increased to 86-92% fluctuating. Nurse notified MD (medical doctor) of pt (patient) status et N/O (new order) to send to ER (emergency room ) for eval (evaluation) et tx (treatment). Continued review revealed, .late entry for 3/29/14 5 pm. ER staff called et stated they needed a copy of resident's MAR. This nurse faxed MAR indicated [REDACTED]. No new [DIAGNOSES REDACTED]. This nurse was informed that diagnostic testing was still being performed. Medical record review of a nurse's note dated April 8, 2014, timed 2:49 p.m., and signed by the Director of Nursing (DON) revealed, .Upon chart review it is noted on the late entry dated 3-30-14 @ (at) 730 a.m., (the note is for 3-28-14) the date for the late entry is incorrect and is actually for 3-29-14 which is when this resident (#3) was transferred to the ER for further eval and treatment. Medical record review of emergency room Provider Report dated March 29, 2014, revealed resident #3 was evaluated in the emergency room . Continued review of the emergency room Provider Report revealed the resident had complained of shortness of breath and .pt recently diagnosed with [REDACTED]. Further review revealed the resident's vital signs were documented as blood pressure 150/50, temperature 100.3, pulse 67, and respirations 20 at 4:06 p.m. Continued review revealed, .Cardiovascular: normal heart sounds, [MEDICAL CONDITION](heart rate over 100), irregularly irregular. Further review revealed the resident's vital signs were documented at 5:58 p.m.b/p 131/80, pulse 154, resp (respirations) 26, and temp 100.3. Medical record review of emergency room lab report dated March 29, 2014, revealed resident #3's level of the [MEDICATION NAME] medication was reported as .< (less than) 0.2 L (low). Continued review of the emergency room report revealed the resident had an Electrocardiogram (EKG, diagnostic test to evaluate heart rate, rhythm, and electrical pulses). Further review revealed the results of the heart monitoring test was .A-Fib ([MEDICAL CONDITION] Fibrillation) with RVR (rapid ventricular response). indicating the resident's heart rate and rhythm were abnormal. Continued review revealed, .Clinical Impression: Primary Impression: Pneumonia.Secondary Impressions: AFib, [MEDICAL CONDITIONS]. Further review revealed the resident was admitted to the hospital for further treatment. Medical record review of Consulting Physician #1's note dated March 29, 2014, revealed resident #3 was seen by a consulting physician in the hospital. Review of the record revealed, .Reason for Consultation: [MEDICAL CONDITION]. Further review revealed the resident .was found to be in [MEDICAL CONDITION] with a ventricular rate around 170.(resident) has history of chronic [MEDICAL CONDITION], chronic heart failure, and had a stroke in September 2012.Currently (resident) is on long term oral anticoagulation ([MEDICATION NAME]). Further review of Consulting Physician #1's note revealed, .Diagnostic Studies: (Resident's) EKG shows [MEDICAL CONDITION] with a ventricular rate around 185, low voltage, and poor R-wave progression. Continued review of the consultation note revealed, .Impression: 1. [MEDICAL CONDITION] 2. Acute.chronic heart failure. Medical record review of Consulting Physician #2's note dated March 29, 2014, revealed, .Assessment and Plan: 1. [MEDICAL CONDITION] with rapid ventricular response. Continue [MEDICATION NAME] drip initiated in the emergency room .2. Pneumonia.5. Subtherapeutic [MEDICATION NAME] level. We will load the patient with [MEDICATION NAME] .and repeat level in the morning hours with further orders to follow. Medical record review of Hospitalist Physician's Progress Note dated March 30, 2014, revealed, .Subjective: The patient (resident #3) was noted to have persistent [MEDICAL CONDITION] with rapid ventricular response despite [MEDICATION NAME] drip. (Resident) was also noted to have [MEDICAL CONDITION] ( a decreased level of oxygen in the blood).The patient was also note (noted) to have some decreased responsiveness and (resident) was.transferred to the intensive care unit (ICU). Continued review of the physician's progress note revealed, .Assessment and Plan: The patient is a [AGE] year old (resident) admitted to the hospital with [REDACTED]. [MEDICAL CONDITION] with rapid ventricular response. Heart rate is improving. Continue [MEDICATION NAME] Medical record review of Consulting Physician #3's note dated March 30, 2014, revealed, .(Resident #3) also has [MEDICAL CONDITION] with rapid ventricular rate. (Resident) was transferred to ICU this morning because of [MEDICAL CONDITION] and also because of persistent [MEDICAL CONDITION] with rapid rate. Continued review revealed, .Impression: 1.Acute [MEDICAL CONDITION] 2. Pneumonia 3. [MEDICAL CONDITION] 4. [MEDICAL CONDITION].Recommendations: 1. Agree with transfer to intensive care unit .7. Continue care in the ICU, critically ill. Medical record review of the hospital Discharge Summary by Hospitalist Physician dated March 31, 2014, revealed, .Hospital course: The patient (resident #3) was admitted and started on [MEDICATION NAME] drip.The patient did have a subtherapeutic [MEDICATION NAME] level and the patient was loaded with [MEDICATION NAME]. The patient was noted to have persistent [MEDICAL CONDITION] with rapid ventricular response despite the [MEDICATION NAME] drip.The patient was transferred to the intensive care unit.Plan for this patient: 1. Pneumonia is improving.3. [MEDICAL CONDITION] with rapid ventricular response, heart rate is rate controlled, [MEDICATION NAME] drip has been off for over 24 hours. The patient will be discharged back to nursing home today. Review of Timeline of Events dated April 1, 2014, and signed by the DON, revealed, .Timeline of Events.During MAR indicated [REDACTED]. Upon investigation, it appears that resident (#3).did not receive (resident's) scheduled [MEDICATION NAME], [MEDICATION NAME] or [MEDICATION NAME] since (resident) was readmitted to (facility) on 3/14/14. Continued review of Timeline of Events revealed when the resident was readmitted to the facility on [DATE], the resident's hospital discharge orders were faxed to the pharmacy. Further review of Timeline of Events revealed the facility's investigation determined the pharmacy received only pages 3, 4, 5, and 6 of a total of six pages. Continued review revealed the pharmacy did not receive pages 1 and 2 which consisted of the orders for the resident's [MEDICATION NAME], [MEDICATION NAME], and [MEDICATION NAME]. Interview with the DON and Nurse Consultant #1 on April 15, 2014, at 2:45 p.m., in the Conference Room, revealed the DON's investigation of the medication errors revealed the nurse who faxed the resident's discharge orders from the hospital to the pharmacy did not verify with the pharmacy how many pages the pharmacy had received. Continued interview revealed when the resident's medications arrived from the pharmacy, the nurse matched the medications with the Physician order [REDACTED]. Further interview with the DON and Nurse Consultant #1 confirmed resident #3 did not receive six ordered medications ([MEDICATION NAME], [MEDICATION NAME]) from the time of the resident's admission to the facility on [DATE], until the resident's discharge to the hospital on March 29, 2014 (a total of 15 days). Further interview with the DON and Nurse Consultant #1 confirmed the facility's failure to reconcile the resident's hospital discharge orders with the facility's admission orders [REDACTED]. Interview with the DON on April 16, 2014, at 12:40 p.m., in the Conference Room, confirmed the DON had questioned the admitting nurse of resident #3 about the resident not being admitted from the hospital with [MEDICATION NAME] orders. Continued interview with the DON confirmed the DON also did not reconcile the hospital discharge orders with the facility's admission orders [REDACTED]. Interview with Hospitalist Physician #1 on April 21, 2014, at 10:26 a.m., by phone, confirmed the physician was one of resident #3's treating physicians. Further interview revealed, .I would say the fact that (resident) did not receive medications led to the (resident's) hospitalization . Continued interview confirmed the resident's [MEDICATION NAME] level .was very low., subtherapeutic, and confirmed the resident was .critically ill. necessitating the resident's transfer to the Intensive Care Unit (ICU). Further interview with Hospitalist Physician #1 confirmed when resident #3 was administered the resident's ordered medications (specifically [MEDICATION NAME] and [MEDICATION NAME]) the resident improved, and was able to be discharged back to the facility. The facility nursing staff's failure to reconcile hospital discharge orders with facility admission orders [REDACTED]. The facility's failure to ensure the resident received prescribed medications placed resident #3 in Immediate Jeopardy. Resident #19 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the hospital Discharge Med Rec form dated March 27, 2014, revealed no order for Phoslo (Calcium Acetate) 667 mg, a medication used to bind with phosphorus in the body to decrease the level of phosphorus in the blood). Continued review also revealed no order for [MEDICATION NAME] 20 mg (an antistatin medication used to lower cholesterol). Further review of the Discharge Med Rec form revealed orders for [MEDICATION NAME] 7.5 mg (an antidepressant medication) and [MEDICATION NAME] 40 mg (a stomach medication used to control acid in the stomach). Medical record review of physician's orders [REDACTED]. [REDACTED]. Medical record review of the dated March 27, 2014, through March 31, 2014, revealed resident #19 received both Calcium Acetate and [MEDICATION NAME] March 28, 2014, through March 31, 2014. Continued review of the MAR indicated [REDACTED]. Medical record review of the April 1, 2014, through April 31, 2014, physician's orders [REDACTED]. Continued review of the physician's orders [REDACTED]. Further review of the April physician's orders [REDACTED]. Further review of the April physician's orders [REDACTED]. Therefore resident #19 continued to be administered two medications without an order (Calcium Acetate and [MEDICATION NAME]), and failed to be administered two medications ([MEDICATION NAME] and [MEDICATION NAME]) which had been ordered by the discharging hospital from March 27, 2014, through April 17, 2014. Medical record review of Medication Reviews 3 Month Review dated April 4, 2014, revealed .(Facility) Medication Reviews 3 Month Review.3-27-14 re-admit. pharmacy [MEDICATION NAME][MEDICATION NAME] ([MEDICATION NAME]), the pharmacy also added [MEDICATION NAME] and Phoslo (Calcium Acetate) without an order. This was not caught by nursing. The April POS (physician's orders [REDACTED].#1 to the Director of Nursing (DON) and Administrator on April 4, 2014. Interview with the DON and Nurse Consultant #1 on April 17, 2014, at 2:55 p.m., in the Conference Room, confirmed the resident's March 2014 and April 2014 physician's orders [REDACTED]. Continued interview confirmed the resident continued to receive discontinued medications, PhosLo (Calcium Acetate) and [MEDICATION NAME] without a physician's orders [REDACTED]. Further interview confirmed both the DON and Nurse Consultant #1 became aware the resident was receiving medications that were not ordered, and became aware the resident was not receiving ordered medications on April 4, 2014, and confirmed both neglected to correct the medication errors, and the resident continued to receive Calcium Acetate and [MEDICATION NAME] without physician orders, and did not receive ordered medications, [MEDICATION NAME] and [MEDICATION NAME], through April 17, 2014. The failure of the facility nursing staff to accurately reconcile hospital discharge orders with facility admission orders [REDACTED]. Resident #14 was admitted to the facility on [DATE], discharged to the hospital on April 1, 2014, related to care for a cyst, and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the physician order [REDACTED]. Medical record review revealed no documentation of the monitoring of the blood sugar level before the supper meal on March 31, 2014. Medical record review of the hospital Discharge Med Rec dated April 10, 2014, for the facility readmission on April 11, 2014, revealed an order for [REDACTED].< (less than) 60 give snack & (and) recheck in 30 minutes. If recheck still <60 give [MEDICATION NAME] UD (Unit Dose); 251-300= 4 units (give 4 units); 301-350=6 units; 351-400=8 units; 401-450= 10 units; Recheck in 1HR (hour) using above sliding scale if BG (Blood Glucose) > (greater than) 300; >450= (means) call MD (physician) for orders recheck in 1 HR or per MD. Further review of the readmission orders [REDACTED] Medical record review of the Diabetic Medication Administration Record [REDACTED] 1. April 18, 2014, at 5:00 p.m. the accucheck was 253 and no documentation of the insulin administration (should have administered 4 units); 2. April 19, 2014, at 5:00 p.m. the accucheck was 301 and no insulin administration (should have administered 6 units); 3. April 19, 2014, at 9:00 p.m. no accucheck was obtained; 4. April 20, 2014, at 11:00 a.m. the accucheck was 305 and no insulin administration (should have administered 6 units); 5. April 21, 2014, before the breakfast meal, no accucheck was obtained; and on 6. April 23, 2014, at 6A (6:00 a.m.) no accucheck was obtained. Interview with Licensed Practical Nurse (LPN) #1 assigned to resident #14, on April 21, 2014, at 11:15 a.m., on the 100 hall revealed .the night nurse (7:00 p.m. to 7:00 a.m. shift) obtains the blood sugar. Further interview confirmed the blood sugar level for April 21, 2014, at 6:00 a.m. was not documented on the Diabetic Medication Administration Record. Interview with Nurse Consultant #1/Acting Director of Nursing, on April 21, 2014, at 11:38 a.m., in the Conference Room confirmed the blood sugar level and the insulin administration when the blood sugar was elevated was to be documented on the Diabetic Medication Administration Record. Further interview and review of the April 2014 Diabetic Medication Administration Record [REDACTED]. Interview with Medical Director #2, on April 21, 2014, at 11:52 a.m., in the Conference Room confirmed .expect (resident #14) should have gotten sliding scale (insulin) per order (when blood sugar elevated). Interview with LPN #5, on April 23, 2014, at 7:45 a.m., at the 200/300 nursing station, and Nurse Consultant #1/Acting Director of Nursing present, confirmed LPN #5 had been responsible for resident #14 during the 7:00 p.m.-7:00 a.m. shift and had not obtained the blood sugar level the morning of April 23, 2014. Interview with LPN #4, and observation on April 23, 2014, at 7:50 a.m., and Nurse Consultant #1/Acting Director of Nursing present, outside the room of resident #14, confirmed LPN #4 was responsible for resident #14 for the 7:00 a.m.-7:00 p.m. shift, and had not obtained the blood sugar the morning of April 23, 2014. When LPN #4 was asked which shift was responsible to obtain the morning blood sugar LPN #4 stated .the night shift (7:00 p.m.-7:00 a.m.) does it. Further interview with the Nurse Consultant #1/Acting Director of Nursing revealed this surveyor .got to (LPN #4) before the Nurse Consultant #1/Acting Director of Nursing could in-service (LPN #4) (on the change in the accucheck time before the breakfast meal). Interview with Nurse Consultant #1, on April 23, 2014, at 1:20 p.m., in the Conference Room, confrmed the facility had failed to inservice LPN #4 regarding the change in the accucheck time from 6:00 a.m. to 7:00 a.m. Interview with LPN #8 and Nurse Consultant #2, on April 24, 2014, at 10:15 a.m., at the 100/200 nursing station, confirmed resident #14 had been admitted on [DATE], at 2:50 p.m. and had been discharged before breakfast on April 1, 2014. Further interview confirmed the accucheck for March 31, 2014, at 5:00 p.m. was not obtained. The facility's nursing staff failure to monitor the blood sugar level and the nursing staffs failure to administer the prescribed insulin when the blood sugar was elevated placed resident #14 in Immediate Jeopardy. Review of the hospital Discharge Medication Reconciliation dated April 10, 2014, for the facility readmission on April 11, 2014, for resident #14 included an order for [REDACTED]. Medical record review of the facility readmission orders [REDACTED]. Interview with Nurse Consultant #1, on April 17, 2014, at 2:20 p.m., in the Conference Room, confirmed the facility nursing staff had failed to reconcile the hospital discharge medications with the facility readmission orders [REDACTED]#14. Interview with Pharmacist #1 on April 22, 2014, at 1:25 a.m., in the conference room, , revealed the facility identified a breakdown in communication between the pharmacy and the facility in early April. Further interview revealed prior to the last Performance Improvement meeting held April 10, 2014, the pharmacy did not compare/reconcile hospital discharge medication to the facility admission physician orders. Further interview revealed .assumed orders verified prior to contact with (pharmacy) or that the nursing facility made a clarification order prior to contacting the (Pharmacy). Resident #24 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the hospital discharge orders dated April 2, 2014, revealed a medication order for [MEDICATION NAME] (herbal medication prescribed for sleep) 4 mg daily at 1800 (6:00 p.m.)[MEDICATION NAME] ( an atypical antipsychotic medication prescribed for anxiety) 20 mg Twice daily with [MEDICATION NAME] 10 mg every 6 hours as needed.for anxiety. Medical record review of the physician's orders [REDACTED]. Continued review of the Physician order [REDACTED]. Medical record review of the MAR indicated [REDACTED]. Continued review of the MAR indicated [REDACTED]. Further review revealed the resident was administered [MEDICATION NAME] 20 mg twice a day from April 3, 2014, through April 8, 2014, and was administered [MEDICATION NAME] 10 mg April 4, 2014, through April 7, 2014, one time daily . Review of the facility documentation entitled New Admission/Readmission Audits dated April 3, 2014, revealed resident #24's admission orders [REDACTED]. Interview with Nurse Consultant #1/Acting DON on April 21, 2014, at 4:05 p.m., in the Conference Room, confirmed the Physician order [REDACTED]. Further interview confirmed the resident was administered the wrong dose of [MEDICATION NAME] from April 2, 2014, through April 20, 2014. Continued interview confirmed the MAR indicated [REDACTED]. Further interview confirmed [MEDICATION NAME] was not on the physician's orders [REDACTED].#1/Acting DON confirmed the resident's hospital discharge orders and admission orders [REDACTED]. Continued interview confirmed the resident's medications continued to be incorrect after the audit and the facility had failed to provided quality of care standards with medication administration. Resident #29 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of hospital discharge orders dated April 14, 2014, revealed an order for [REDACTED].>Medical record review of the physician's orders [REDACTED]. Continued review revealed a physician's orders [REDACTED]. Medical record review of the MAR indicated [REDACTED]. Continued review revealed [MEDICATION NAME] was on the MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. Medical record review of the Telephone order/Clarification order dated April 18, 2014, revealed a clarification order for [MEDICATION NAME] 600 mg three times daily, related to the medication being on the MAR but not on the physician's orders [REDACTED]. Review of facility documentation entitled New Admission/Readmission Audits dated and initialed by the DON on April 15, 2014, revealed the resident's chart was audited for medication reconciliation accuracy and completed. Interview with Nurse Consultant #1/Acting DON on April 22, 2014, at 1:07 p.m., in the Conference Room, confirmed the hospital discharge order for [MEDICATION NAME] was not included on the physician's orders [REDACTED]. Continued interview confirmed the medication was handwritten on the MAR for April and the resident was administered the medication without an order from April 15, 2014, through April 22, 2014. Continued interview confirmed the resident's hospital discharge orders and physician's orders [REDACTED]. Continued interview with Nurse Consultant #1/Acting DON confirmed the resident's cha

Based on medical record review, review of Medication Reviews/3 Month Reviews, review of facility policy, and interview, the facility failed to notify the physician of medication errors for one resident (#19) of thirty-one sampled residents. The findings included: Resident #19 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review revealed Resident #19 received [MEDICAL TREATMENT] treatment three days per week for [MEDICAL CONDITION]. Medical record review of the hospital Discharge Med (Medical) Rec (Record) form dated March 27, 2014, revealed no order for Phoslo (Calcium Acetate) 667 mg (milligrams), a medication used to bind with phosphorus in the body to decrease the level of phosphorus in the blood. Continued review also revealed no order for [MEDICATION NAME] 20 mg (an antistatin medication used to lower cholesterol). Further review of the Discharge Med Rec form revealed orders for [MEDICATION NAME] 7.5 mg (an antidepressant medication) and [MEDICATION NAME] 40 mg (a stomach medication used to control acid in the stomach). Medical record review of physician's orders [REDACTED]. [REDACTED]. Medical record review of the Medication Administration Records (MARS) dated March 27, 2014, through March 31, 2014, revealed the resident received both Calcium Acetate and [MEDICATION NAME] March 28, 2014, through March 31, 2014. Continued review of the MAR indicated [REDACTED]. Medical record review of the April 1, 2014, through April 31, 2014, physician's orders [REDACTED]. Continued review of the physician's orders [REDACTED]. Further review of the April physician's orders [REDACTED]. Further review of the April physician's orders [REDACTED]. Therefore resident #19 continued to be administered 2 medications without an order (Calcium Acetate and [MEDICATION NAME]), and failed to be administered 2 medications ([MEDICATION NAME] and [MEDICATION NAME]) which had been ordered by the discharging hospital from March 27, 2014, through April 17, 2014. Medical record review of Medication Reviews 3 Month Review dated April 4, 2014, revealed .(Facility) Medication Reviews 3 Month Review.3-27-14 re-admit.pharmacy [MEDICATION NAME][MEDICATION NAME] ([MEDICATION NAME]), the pharmacy also added [MEDICATION NAME] and Phoslo (Calcium Acetate) without an order. This was not caught by nursing. The April POS (physician's orders [REDACTED].#1 to the Director of Nursing (DON) and Administrator on April 4, 2014. Interview with the DON and Nurse Consultant #1 on April 17, 2014, at 2:55 p.m., in the Conference Room, confirmed the resident's March 2014, and April 2014, physician's orders [REDACTED]. Continued interview confirmed the resident continued to receive discontinued medications, PhosLo (Calcium Acetate) and [MEDICATION NAME] without a physician's orders [REDACTED]. Further interview confirmed both the DON and Nurse Consultant #1 became aware the resident was receiving medications that were not ordered, and became aware the resident was not receiving ordered medications on April 4, 2014, and confirmed both had neglected to correct the medication errors, and the resident continued to receive Calcium Acetate and [MEDICATION NAME] without physician orders, and did not receive ordered medications, [MEDICATION NAME] and [MEDICATION NAME], through April 17, 2014. Interview with Nurse Consultant #1 on April 24, 2014, at 9:10 a.m., in the Conference Room, confirmed neither the Nurse Consultant or DON had contacted the resident's [MEDICAL TREATMENT] Physician to inform the physician of the medication errors. Interview with the [MEDICAL TREATMENT] Physician on April 24, 2014, at 2:20 p.m., by phone, confirmed the physician had not been contacted by the facility regarding the resident's medication errors.

Based on medical record review, review of facility documentation, review of facility policy, and interview, the facility failed to provide supervision for a wandering resident (#106) which resulted in a fall with injury for one resident (#109) of three residents reviewed for falls of 32 sampled residents. The facility's failure to monitor and supervise resident #106 resulted in harm to resident #109. The findings included: Resident #106 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a nurse note dated November 24, 2013, revealed, "...resident finally resting quietly in bed...alert with confusion...Propels self in wc (wheelchair)....Earlier in shift client going in other resident's rooms ..." Medical record review of 30 day Minimum Data Set (MDS) dated [DATE], revealed the resident was severely cognitively impaired, exhibited behavioral symptoms, and required extensive assistance with all Activities of Daily Living. Medical record review of a nurse note dated December 11, 2013, revealed, "...remains awake/alert with confusion-not easily redirected, self propels in w/c wanders throughout the facility..." Medical record review of a nurse note dated December 24, 2013, revealed, "...the nurse had prepared resident's med (medication) and was about to administer when (nurse) noticed (the resident) was 'out of pocket'- the nurse had seen this resident approx. (approximately) 20 min (minutes) prior to this time...a search began for the resident who was found in an empty room in the restroom...(resident) is not a candidate for redirection at present time-Psyche (psychiatric) services to consult-resident placed on Q (every) 30 minute checks-Wanderguard (a small wrist or ankle bracelet placed on the resident that sends an alarm to facility staff when a resident attempts to exit a facility)..." Medical record review of the resident's care plan, updated December 24, 2013, revealed, "...Wandering in other rooms..." with interventions to include "...Inform nursing of any behaviors noticed ...invite resident to an activity...wanderguard and 30 min (minute) checks by nursing staff..." Medical record review of the resident's Kardex, undated, revealed, "...likes to shuffle papers or read news...remain on 30 min checks for safety...offer alternative activity if wander in w/c..." Medical record review of a physician telephone order dated December 24, 2013, revealed, "...resident to remain on 30 min checks by nursing with documentation on MAR (medication administration record)...Place wanderguard on resident..." Medical record review of a nurse note dated January 13, 2014, revealed, "...(resident #106) usually in (resident #106's) wheelchair riding in all hallways-going into other resident's room; tonight (resident #106) went into another resident's (#109) room and would not leave...the other resident tried to move the resident...(resident #109) fell causing a laceration to forehead..." Interview with the Licensed Psychological Examiner (LPE), on February 3, 2014, at 1:54 p.m., in the conference room, revealed the LPE was familiar with resident #106 and the resident's history of wandering. Continued interview with the LPE revealed the LPE had made oral recommendations for " ...increased supervision" of resident #106 to a staff nurse after a routine assessment of the resident, but could not recall when, or to whom that recommendation was made. Further interview confirmed the LPE was not aware of a nurse's note written by the DON on December 24, 2013, which documented persistent wandering, agitation, and near elopement of the resident. Interview with the Administrator on February 3, 2014, at 4:30 p.m., in the conference room, revealed the Administrator was aware of the December 24, 2013, incident when resident #106 was unable to be located in the facility. Continued interview with the Administrator revealed the Administrator considered the incident an "...elopement risk only..." and was not made aware resident #106 continued to wander in other resident's rooms after December 24, 2013. Interview with the facility Medical Director on February 4, 2014, at 9:50 a.m., in the conference room, revealed the Medical Director was the attending physician for resident #106, and was aware of the resident's history of wandering. Resident #109 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. Continued review of the MDS revealed the resident was independent with walking requiring no help or staff oversight. Medical record review of a Fall Risk Evaluation dated November 1, 2013, revealed the resident was a high risk for falls. Medical record review of the resident's care plan revealed, "...Resident is at risk for falls and or injuries related to having a fall before admission..." Continued review of the resident's care plan revealed interventions to prevent falls "...Ensure call light is available and answered promptly..." Medical record review of a nurse note dated January 13, 2014, revealed, "...(resident #109) fell after another resident rolled into (resident #109's) room, after (resident #109) tried to remove other resident x (times) 3, the other resident tried to hit (resident #109) x 3 (did not connect) (Resident #109) fell on face in the hallway and sustained a laceration to forehead. Pressure dsg (dressing) applied to forehead..." Medical record review of an emergency room hospital report dated January 13, 2014, revealed, "...head injury...tripped over wheelchair striking rt (right) forehead..." Continued review of the hospital emergency room report revealed the resident had a laceration to the forehead measuring three centimeters "...multiple lacerations (somewhat Z shaped) to rt forehead with swelling and contusion..." Further review of the emergency room report revealed the resident's laceration required ten sutures to the forehead. Continued review of the medical record revealed resident #109 returned to the facility at 11:30 P.M. on January 13, 2014. Further review revealed the resident had new orders for as needed pain medication , was prescribed an oral antibiotic for ten days, and required monitoring of neurological status. Medical record review of a nurse note dated January 16, 2014, revealed, "...Bruising noted to right eye. Sutures to head clean, dry, intact..." Review of facility documentation revealed, "...(resident #106) entered another resident's (#109) room x 3 on the last entry (resident #106) was punching/slapping at the other resident. The other resident (#109) tripped and fell causing a laceration..." Continued review revealed, "...one resident caused another to fall by virtue of being in the room..." Continued review of facility documentation revealed, "...(resident #106) rolled into (resident #109) (resident #109) told (resident #106) to leave (resident #106) left and returned. (resident #109) again pushed (resident #106) back out...(resident #109) again pushed (resident #106) in (resident #106's wheelchair) into the hall and tripped on the wheelchair wheels causing (resident #109) to fall..." Interview with Licensed Practical Nurse (LPN) #3 on January 27, 2014, at 4:56 p.m., in the 100-200 Hallway, revealed the LPN was on shift and in charge of the care of the resident on January 13, 2014. Continued interview revealed the LPN was aware of the history of the other resident wandering throughout the facility and into other resident's rooms. Continued interview confirmed resident #106 had entered resident #109's room on three separate occasions on January 13, 2014. Continued interview confirmed when resident #106 had entered resident #109's room on the third occasion, resident #109 had attempted to remove resident #106 from resident #109's room and became tangled in resident #106's wheelchair and "...fell flat on his face..." Further interview with LPN #3 confirmed resident #106 "...goes in and out of other resident's rooms all the time..." Interview with LPN #3 on January 28, 2014, at 3:20 p.m., in the Conference Room, confirmed the LPN had been alerted by another resident that resident #106 had gone into the resident's room on two separate occasions before the last time resident #106 had entered resident #109's room which resulted in resident #109 attempting to remove resident #106 and fell . Further interview confirmed no staff had attempted to remove resident #106 from resident #109's room before resident #106 entered resident #109's room for the third time. Interview with LPN #4 on January 28, 2014, at 8:00 a.m., at the 100-200 Nurse Station, revealed the LPN was aware of resident #106's history of wandering in and out of other resident's rooms. Continued interview with LPN #4 revealed resident #106 is "...easily redirectable back to the hall...I just try to watch and redirect (the resident)..." Interview with LPN #5 on January 28, 2014, at 8:00 a.m., at the 100-200 Nurse Station, revealed the LPN was aware of resident #106's history of wandering in and out of other resident's rooms, and the staff utilized redirection to remove the resident from other resident's rooms. Interview with Certified Nurse Assistant (CNA #2) on January 28, 2013, at the 100-200 Nurse Station, confirmed the CNA was aware of resident #106's history of wandering into other resident's rooms. Continued interview confirmed the CNA utilized redirection to remove the resident from other resident's rooms. Interview with LPN #3 on January 28, 2014, at 3:20 p.m., in the Conference Room, confirmed the LPN had been made aware resident #106 had entered resident #109's room on two separate occasions by resident #106, before resident #109 got out of bed and attempted to remove resident #106 from resident #109's room. Continued interview with LPN #3 revealed, "...just continue to redirect (resident #106)..." Further interview with LPN #3 confirmed resident #106 continued to wander throughout the facility, and continued to wander into other resident's rooms. Interview with CNA #3 on January 29, 2014, by phone, revealed the CNA was working the night resident #109 fell . Continued interview revealed the CNA was not aware of resident #106 entering resident #109's room until the CNA heard (resident #109) fall. Further interview confirmed resident #106 "...goes in and out of everyone's room all the time...it won't be ten minutes until (resident #106) is in someone else's room...we hear people holler all the time..." Interview with the Director of Nursing (DON) on January 28, 2014, at 3:30 p.m., in the Conference Room confirmed resident #109 had a fall as the result of resident #106 entering resident #109's room multiple times on January 13, 2014. Further interview with the DON confirmed resident #109 was harmed as a result of the facility's failure to monitor and supervise resident #106. Complaint #