Every finding on record at The Willows at Hamburg

Based on interview, record review, and review of the facility's policy, the facility failed to promptly inform the resident's representative following a fall for 1 of 5 residents sampled for falls, Resident (R) 93. The findings include: Review of the facility's policy titled, Notification of Change in Condition, revised 05/10/2024, revealed the resident representative/provider should be notified of change in condition or diagnostic testing results in a timely manner, and notification attempts should be recorded in the resident's electronic health record (EHR). Review of R93's Face Sheet revealed the facility admitted the resident on 05/21/2026 with diagnoses including intracerebral hemorrhage, disorientation, and atrial fibrillation. Further review revealed R93's primary contact person as Family (F) 1 with a notation she should be contacted at any time and notified of any changes. Review of R93's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 05/25/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of four out of 15, which indicated the resident was severely cognitively impaired. Review of Progress Notes, dated 05/23/2026 at 3:13 AM and written by Licensed Practical Nurse (LPN) 4, revealed R93 experienced an unwitnessed fall on 05/22/2026 at approximately 9:18 PM. However, the resident's representative was not notified until the following morning, 05/23/2026 at approximately 6:35 AM.R93 was no longer present for observation or interview. During an interview with family (F) 1 on 07/08/2026 at 1:09 PM, she stated R93 was admitted to the facility on [DATE] for rehab after she was hospitalized following a stroke. F1 stated on Saturday after R93's admission [DATE]), F1's husband received a phone call at approximately 6:45 AM from LPN4 at the facility who reported R93 was found on the floor, had a suspected fall, but was not injured. F1 stated she was R93's power of attorney (POA) and was listed as the primary contact, but she had not received any calls, her phone showed no missed calls, and there were no recent voicemail messages. F1 further stated her husband handed her the phone, and LPN4 repeated the information that R93 was found on the floor in her room but was not injured. F1 stated she asked the nurse for more details and learned R93 was found on the floor the following evening at around 9:30 PM, but because she was not injured and it was a busy night, notifications were not made until the following morning. F1 stated at that point she drove to the facility, and while she was there, LPN4 came into R93's room, and when she saw F1, she cried and apologized for not calling timely. F1 additionally stated the weekend supervisor, Registered Nurse (RN) 4 directly apologized because she was not notified in a timely manner after R93's fall at the facility. During an interview with LPN1 on 07/09/2026 at 11:21 AM, she stated after an unwitnessed fall, the resident was not left alone and was placed on 15-minute neurological checks because of a potential head injury. LPN1 stated once the resident was stabilized, an Occurrence Note was opened in the electronic health record (EHR), and the representative and provider were notified. When asked if there was a required time frame for notifications, LPN1 stated she did not know if there was a requirement per the facility's policy, but she thought a reasonable time frame for post fall notifications was two to three hours. During an interview with LPN4 on 07/09/2026 at 8:24 PM, she stated the evening R93 fell, she walked into the room, and the resident was sitting upright on the floor. LPN4 stated she assessed R93 for injury, and when nothing was found, she assisted her back to bed. LPN4 additionally stated the resident voiced no pain complaints, and there were no non-verbal signs of pain. LPN4 stated if the resident had experienced an injury she would have called immediately, but since R93 was unharmed, she waited until later. When asked what a reasonable amount of time was before a notification was made, LPN4 stated less than eight hours. LPN4 further stated she learned from the experience that R93's family should have been notified as soon as possible of any changes because they wanted and needed to know what was going on with their loved one. During an interview with the Assistant Director of Health Services (ADHS) on 07/10/2026 at 10:49 AM, she stated if a resident experienced an unwitnessed fall, the resident was immediately assessed for injury, vitals checked, and neuro checks put into place for 72 hours. The ADHS stated if a fall occurred around 9:00 PM, she made notifications that same evening because it was important that representatives and families were notified in a timely manner of any changes with a resident. During an interview on 07/10/2026 at 11:00 AM with RN4, she stated she went to the facility the morning following R93's fall. RN4 stated LPN4 was visibly upset after she made notification to R93's family because they were not happy that they were not contacted the night before. RN4 stated typically if there was a fall with no injury in the middle of the night, family and providers were notified the following morning. When asked if the fall occurred at 9:00 PM, RN4 stated family should have been notified the evening of the fall. RN4 stated she apologized to R93's family on behalf of LPN4. She further stated that notifications were important because families wanted to know of any changes with their family members. During an interview with the Director of Health Services (DHS) on 07/10/2026 at 11:08 AM, she stated she was not present when R93 experienced a fall, but she met with F1 because of concerns with the timeliness of the notification. The DHS stated some of the residents' representatives did not want to be notified in the middle of the night, and some wanted to be notified anytime there was any type of change. When asked about F1's notification preference, the DHS said it was not documented either way. She further stated it was her preference that notifications for an unwitnessed fall were made within a couple of hours after the incident, but she was okay with the end of shift. The DHS stated there were customer service issues from the beginning, R93's representative should have been contacted sooner, and the facility did not meet expectations for R93. During an interview with the Executive Director on 07/10/2026 at 4:15 PM, he stated it was his expectation that notifications of changes were made in a timely manner, and eight hours was not a timely manner. He additionally stated the facility failed to provide proper customer service to R93.

Based on interview, record review, and review of the facility's policy, the facility failed to implement their admissions policy for 1 of 5 residents sampled for admissions, Resident (R) 93.The findings include: Review of the facility's policy titled, admission Policy, revised 07/03/2025, revealed the facility would maintain an admissions policy governing admissions to the facility to ensure fair and impartial admission practices to best serve inquiring customers. Review of Resident (R) 93's Face Sheet revealed the facility admitted the resident on 05/21/2026 with diagnoses including intracerebral hemorrhage, disorientation, and atrial fibrillation. Review of R93's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 05/25/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of four out of 15, which indicated the resident was severely cognitively impaired. Review of R93's admission Observation documentation revealed the resident was admitted on [DATE] at 5:18 PM. Review of R93's electronic health record (EHR) revealed the facility admitted the resident on 05/21/2026 and discharged the resident on 05/27/2026. However, there was no evidence of signed admission paperwork for R93 documented anywhere in the resident's EHR. Resident 93 was no longer present for observation or interview.During an interview with R93's family (F) 1 on 07/08/2026 at 1:09 PM, she stated R93 was admitted to the facility on [DATE] for rehab after she was hospitalized for a stroke. F1 stated she was with the resident at admission and signed two forms, one was a consent to treat, and one was a designated code status. F1 additionally stated she asked at that time about additional admission paperwork but was told not to worry because it would get done. F1 stated she visited her aunt each day at the facility, and each day she asked someone about admission paperwork that should have been signed. She stated after several days, she eventually received the paperwork via email followed by a phone call from the facility that requested the paperwork be signed and returned as soon as possible. F1 stated she informed the caller that she wanted the opportunity to review the admission paperwork before she signed. F1 stated on Tuesday, 05/27/2026, she met with staff at the facility for R93's first resident meeting that discussed care, goals, finances, and other concerns that needed to be addressed. F1 stated the Social Services Director (SSD) was present at the meeting and immediately notified her there was a problem with R93's insurance, her stay was not covered, and there was a balance owed of $6,000. F1 stated she was obviously upset and displayed that in the meeting. F1 further stated the Executive Director (ED) attended the meeting, and after discussions among them all, the ED stated the facility would cover the cost, and R93 was not responsible. F1 stated R93 was discharged home with her that day, but she never signed admission paperwork. During an interview with the Admissions Director (AD) on 07/10/2026 at 9:31 AM, she stated once an admission was known, it was announced to all staff. She stated when the new admission resident arrived, the consent to treat and code status forms were signed immediately. She further stated if a new admission arrived after hours or on a weekend day, someone from nursing obtained signatures for the consent to treat and code status forms. The AD stated the entire admission packet paperwork was completed and signed the day of or the day following admission. She further stated the expectation was that within 48 hours of admission, all admission paperwork was completed and signed. When asked what happened with R93's admission process, she stated the team that processed insurance for new admissions worked remotely and made a mistake when they verified her insurance. The AD stated R93's primary insurance was inactive, and the resident discharged home before admission paperwork was signed. The AD stated she was not sure why R93's paperwork was not presented for signature prior to 05/27/2026. During an interview with the SSD on 07/10/2026 at 9:56 AM, she stated R93 came to the facility for rehab after she suffered a stroke, and the resident's niece was her power of attorney (POA) and responsible party. The SSD stated the facility held R93's initial meeting and discharge at the same time, and the ED, Director of Health Services (DHS), AD, SSD, and F1 were present at the meeting. She stated they discussed insurance status and concerns because there was a co-pay on day one. The SSD stated R93 was discharged home on [DATE], medications were sent to the resident's pharmacy, and F1 told the SSD she would ensure R93's medical appointments were made and home care arranged. During an interview with the Director of Health Services (DHS) on 07/10/2026 at 11:08 AM, she stated if a resident was admitted after hours or on the weekend, nursing ensured a consent to treat form and a code status form were reviewed and signed by the resident or their representative. She additionally stated other than the two forms and reviewing referrals, she was not involved in the admission process. During an interview with the Executive Director on 07/10/2026 at 4:15 PM, he stated it was his expectation admission paperwork was completed, signed, and documented in the resident's chart. He further stated the facility was unsuccessful from a customer service standpoint with R93 from the beginning, and therefore, the facility absorbed the cost, and the resident was not charged.

Based on observation, interview, and review of the facility's policy, the facility failed to store food in a safe manner for 1 of 3 nourishment refrigerators.Observation on 07/10/2026 at 12:00 PM revealed staff stored personal food items in the 200-unit nourishment refrigerator.The findings include:Review of the facility's policy titled, Food Brought Into Facility, dated 11/27/2017, revealed the purpose is to store foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. Food or beverage items are to be stored in such a manner that they are either separate or easily distinguishable from facility food.Observation of the 200-unit nourishment refrigerator on 07/10/2026 at 12:30 PM revealed a large pink lunch bag with no identification, and a salad in a restaurant lunch bag with no name or date.During an interview with Licensed Practical Nurse (LPN) 5 on 07/10/2026 at 1:36 PM, she stated the resident food was labeled with name and date. She stated the staff food was not to be stored in the nourishment refrigerator to prevent possible infection control issues between staff and resident food.During an interview with Registered Nurse (RN) 3 on 07/10/2026 at 1:37 PM, she stated staff food was in the 200-unit refrigerator. She stated staff kept their food in the staff lounge refrigerator to prevent the potential for infection control issues with staff and resident food in the same refrigerator.During an interview with the Director of Health Services on 07/10/2026 at 3:41 PM, she stated that staff should put their food in the break room refrigerator with their name and the date. She stated there would be a potential risk for cross contamination if stored in the nourishment refrigerator because that was for residents only.During an interview with the Executive Director on 07/10/2026 at 4:15 PM, he stated staff were to keep their food in the break room refrigerator to prevent cross contamination.

Based on observation, interview, record review, and review of the facility's documents and policy, the facility failed to maintain essential equipment in safe operating condition, including crash cart supplies and a lock on the storage closet containing oxygen tanks. Observations on [DATE] revealed 1 of 1 crash carts located in the Legacy Memory Care Unit contained an empty oxygen tank, and the Legacy Memory Care Unit oxygen supply room could not be immediately accessed by the Director of the unit due to a faulty keypad lock and the absence of a key to the room on the unit. The findings include:Review of the facility's policy titled, Guidelines for Crash Cart Contents, last review date [DATE], revealed the crash cart should be restocked after use and examined for expired products, a functional suction machine, and that the oxygen tank is full.Review of code status Orders for the current memory care residents revealed that one of the 11 residents was designated as a full code. Review of the facility's document Crash Cart Checklist, undated and electronically signed by LPN2, revealed the night shift was expected to document crash cart audits for supplies and replace them as needed. Review of the initialed Crash Cart Checklist revealed on [DATE] and [DATE], initials did not match the night shift nurse on duty but that of Licensed Practical Nurse (LPN) 2. 1. Observation on [DATE] at 10:27 AM revealed the only crash cart available in the Legacy Memory Care Unit contained an empty oxygen tank. During an immediate interview with LPN2/Assistant Director of Health Services of the Legacy Memory Care Unit, she stated the night shift was responsible for the crash cart check, and she was not sure why it was empty, and she checked it herself. She stated she felt a resident could have turned it on, which would have allowed it to leak out. She stated, if she worked in the evenings, sometimes she would go ahead and check the crash cart. She stated part of her duties included an audit to ensure the crash cart check was done. During an interview with the Director of the Legacy Memory Care Unit on [DATE] at 11:17 AM, she stated she expected staff to monitor and maintain the crash cart, and it included ensuring the oxygen tank was full. She stated she did not feel, however, the empty oxygen tank placed the residents at risk because there were several tanks in the oxygen supply room, also located in the same unit.2. Observation on [DATE] at 11:17 AM with the Director of the Legacy Memory Care Unit, revealed she attempted to show the unit's oxygen supply room. However, a faulty keypad-style lock prevented access. She stated she would have to call maintenance to fix the lock. A keyhole was observed as part of the keypad lock, but the Director stated the key was kept by the maintenance department, and she did not have access to it. During continued interview with the Director of the Legacy Memory Care Unit on [DATE] at 11:17 AM, she stated again she did not feel residents would be in danger because there was a crash cart in the main part of the campus, located in the adjacent building. In addition, she stated she was unaware of any occasion the crash cart had been used in her unit, but in an emergency, the situation of an empty oxygen tank could cause a delay of care that increased the potential for harm. During an interview with the Director of Health Services (DHS) on [DATE] at 4:03 PM, she stated she covered all portions of the campus, including the Legacy Memory Care Unit. She stated she expected the crash carts would be stocked with all necessary supplies, including oxygen. She stated it was the responsibility of the night shift to do this and/or the nurse at the time it was used. She stated the crash cart on the memory care unit was audited by the Assistant Director of the Legacy Memory Care Unit/LPN2. She stated the risk of not having supplies available in the event of an emergency could result in a delay of care and potentially cause harm to a resident. During an interview with the Maintenance Director on [DATE] at 2:58 PM, he stated it was not practical to do a monthly check of the battery-operated locks because it could be checked on Monday and die on Tuesday. He stated a staff member would let him know when the battery was dead, and he would replace the battery as needed. He stated he was notified of this particular lock immediately after the observation by the State Survey Agency (SSA) Surveyor, and the battery was replaced and confirmed to be in working order. He stated he was the one who kept the keys to access these locks, although laundry services had the same type of lock, and the whole unit had to be replaced. He stated, when that happened, the laundry service was provided a key until the replacement was made. During an interview with the Executive Director (ED) on [DATE] at 4:17 PM, he stated he expected all of the crash carts to be checked for appropriate supplies, including a full oxygen tank. He stated he felt a confused resident might have had access to the tank, and the oxygen could have leaked out. As a result of this potential risk, he stated, some changes would be made to decrease accessibility to those residents, such as removing the regulator from the tank so nursing could control its access, and a red pouch with a key would be made available at the Legacy Memory Care Unit so, in the event of an emergent need, the room could be accessed with a key. He stated he felt Cardio-Pulmonary Resuscitation (CPR) would have been the first step, and a patent airway would have to be ensured before application of oxygen would be an issue. He stated, even though the oxygen supply closet was an issue on this occasion, there was another crash cart available in the main building.

Based on observation, interview, and review of the document from the website www.servsafe.com, the facility failed to ensure food was served and stored properly in sanitary conditions. Observation on 08/06/2025 of 1 of 2 kitchens revealed the cook continued to use the cleaning cloth in the production area and did not keep it in the sanitizer bucket during food production. The findings include: Review of the document from the website servsafe.com, Serve Safe National Safety Month titled, Cleaning and Sanitizing Practices that will Prevent Cross-Contamination, dated 09/2012, revealed food-contact surfaces must be both cleaned and sanitized correctly. Per the document, whereas cleaning removed food and other dirt from a surface, sanitizing reduced pathogens on a surface to safe levels. The document stated pathogens could spread to food if equipment had not been cleaned and sanitized correctly. Per the document, that could happen in the following ways: 1) food-contact surfaces were wiped clean rather than being washed, rinsed, and sanitized; and 2) wiping cloths were not stored in a sanitizer solution between uses. Observation on 08/06/2025 at 8:55 AM of the Memory Care kitchen revealed the cook did not have the cleaning cloth in the sanitizer bucket and kept the cloth lying on the counter surface near the food being prepared. The cook continued to wipe the surface of the production area with the same cloth. In an interview with the Dietary Manager on 08/08/2025 at 12:56 PM, she stated the cleaning cloth needed to be in the sanitization water to prevent cross contamination with food. In an interview with the Director of Health Services on 08/08/2025 at 1:01 PM, she stated her expectations were for the cleaning cloths to be kept in the sanitizer bucket during the same food preparation session to prevent cross contamination with food. In an interview with the Executive Director on 08/08/2025 at 1:24 PM, he stated the cleaning cloth needed to be kept in the sanitizer bucket to prevent cross contamination during the food preparation process.

Based on observation, interview, and review of the facility's document, the facility failed to store medications according to the facility's document and regulatory guidelines for 3 of 22 sampled residents, Resident (R) 10, R39, and R61.The findings include: Review of the policies provided to the State Survey Agency (SSA) Surveyor regarding medication storage and labeling of medications revealed they were standard operating procedures from the contracted pharmacy that were specific to pharmacy staff and not to the floor staff of the facility. Review of the facility's document Nurse New Hire Checklist, dated 02/21/2018, revealed a competency checklist that included signing/dating medication upon opening and arranging the drawer of the medication cart based on the routes of medications. Observation of the Thoroughbred medication cart on 08/05/2025 at 2:17 PM revealed R39's opened and undated bottles of liquid protein and Milk of Magnesia (a laxative). Also observed was an opened and undated bottle of Liquid DM cough medication belonging to R10. Several medications were not divided as to the route of administration. Medications for eyes, ears, and topical ointments were combined, separated by resident names instead of the prescribed route. Observation of the Thoroughbred medication room on 08/05/2025 at 2:35 PM revealed multiple medical supplies that had expired. This included an irrigation tray with piston syringe, expired 11/2024; FloQ Swab used to obtain cultures, expired 03/2021; two Accuprism Control Solution for the glucose monitoring machine, expired 06/13/2024 and 02/23/2025; MeSalt Cleansing Dressing with 20% Sodium Chloride, expired 12/28/2024; and two opened and undated bottles of [NAME] plain packing strips. During an interview on 08/05/2025 at 2:40 PM with Licensed Practical Nurse (LPN) 7, she stated she was surprised so many things were out of date. However, she stated while the pharmacy checked for the dates of medications it was the nursing staff's responsibility to check for expiration dates and correct storage of supplies in the medication room. Observation of Calumet medication cart B on 08/05/2025 at 3:14 PM revealed a bottle of liquid chest congestion medication for R 61 without an opened date.During an interview on 08/05/2025 at 3:25 PM with LPN1, she stated it was the facility's policy to date items as they were opened because some medications had different amounts of time that they would be good once they were opened. She stated an expired medication could be less effective or even cause illness, depending on what it was. Observation of the Calumet medication room on 08/05/2025 at 3:34 PM revealed a half bottle of Dermal Wound Cleanser with no date or resident name on top of the treatment cart.During an interview on 08/05/2025 at 3:36 PM, LPN1 stated she was aware the opened items should have a date opened and a resident's name on it. She stated the wound cleanser was a stock item; however, it was not to be a multi-use product. She stated it should be assigned to a resident when it was ordered. She stated the risk of using an individual bottle for multiple residents would be an increased potential of spreading germs, which could cause harm to a resident. During an interview on 08/08/2025 at 11:34 AM with the contracted Pharmacy Account Manager, she stated she came to the facility quarterly, per the facility's policy, to review the carts and medication rooms and to remove expired or discontinued medications. She stated it was not the pharmacy's responsibility to review, remove, or replace medical supplies; that would be the responsibility of the nurses. She stated her last visit to the facility was on 07/02/2025, and a report was sent to the Executive Director, Director of Health Services, and Assistant Director of Health Services. During an interview on 08/07/2025 at 2:15 PM with the Director of Health Services, she stated she expected nurses to label medications with the opened-by date and their initials. She stated that was important, so items were not used after they had expired. She stated different medications had different requirements, and the risk of using expired medications would be loss of efficacy or potential harm to residents.During an interview with the Executive Director on 08/07/2025 at 3:10 PM, he stated he expected staff to follow all of the facility's guidelines and checklists.

Based on interview, record review, review of the facility's investigation report, and review of the facility's policies, the facility failed to protect 1 of 8 sampled residents (Resident 7 (R7)) from physical and verbal abuse by Certified Registered Medication Aide (CRMA) 7. Review of the facility's initial Investigation Report and the witness statements from Certified Registered Care Aide 6 (CRCA6), CRCA10, and Licensed Practical Nurse (LPN) 2, revealed that on 06/07/2024 at 5:50 PM, CRCA6 and CRNA10 observed CRMA7 smack R7 across the face, after R7 had knocked CRMA7's glassess off her face. CRCA6's and CRCA10's statements revealed they both heard what sounded like R7's head hitting the wall at the same time as the smack; however, no visible marks were reported or documented. The facility's failure to have an effective system to ensure residents were protected from verbal and physical abuse was likely to cause serious injury, impairment, or death. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 06/21/2024 and determined to exist on 06/07/2024 at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600) at the highest Scope and Severity (S/S) of a J. The facility was notified of the IJ on 06/21/2024. An acceptable Immediate Jeopardy Removal Plan was received on 06/28/2024 and validated before exiting on 07/03/2024. The IJ removal was on 06/15/2024. The deficient practice remained at a S/S of a D following the removal of the immediate jeopardy. The findings include: Review of the facility's policy titled, Abuse Neglect Procedural Guidelines, revised 08/29/2019, stated, Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. irrespective of mental or physical condition. Further review revealed two forms of abuse could be verbal or physical. Per the policy, verbal abuse included the use of oral communication or sounds within hearing distance of the resident, regardless of the resident's age, ability to comprehend, or disability. The policy also stated physical abuse could be with or without injury. Review of the facility's policy titled, Resident Rights Guidelines, revised 05/11/2017, revealed residents had the right to be free from physical and verbal abuse from staff, family, and other residents. Review of R7's Facesheet revealed the facility admitted the resident on 01/05/2024 with diagnoses that included unspecified dementia, pain, and abnormalities in gait and mobility. Review of R7's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 04/05/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3) of fifteen, indicating severe cognitive impairment. Review of the Long Term Care Facility - Self Reporting Incident Form Facility Reported, dated 06/07/2024, revealed the incident between R7 and CRMA7 occurred at 5:50 PM on 06/07/2024. The report revealed this form was submitted to the Office of Inspector General/State Survey Agency (OIG/SSA) on 06/07/2024 at 7:55 PM. Review of the facility's initial Investigation Report, dated 06/07/2024 at 7:55 PM and the witness statements from CRCA6, CRCA 10, and LPN2, revealed that on 06/07/2024 at 5:50 PM, CRCA6 and CRNA10 observed CRMA7 argue and yell at R7 while preventing her from leaving an area at the end of a hall. CRMA7 was observed restraining R7 until she got loose and swung at CRMA7, knocking CRMA7's glasses from her face. CRMA7 smacked R7 across the face, with her hand. CRCA6's and CRCA10's statements revealed they both heard what sounded like R7's head hitting the wall at the same time as the smack. CRCA 6, CRCA 10, and LPN2 stated R7 exhibited increased anxiety and uncontrollable crying but no visible marks were reported or documented. Review of the skin assessment performed by LPN2, dated 06/07/2024, after the incident, revealed the bruising present on R7 could be correlated with labs recently drawn in the anti-cubital area of her left arm, and an old bruise on her right forearm could also be associated to scheduled labs. Review of CRMA7's 06/07/2024 timesheet revealed she clocked out at 6:39 PM, 50 minutes after the facility's report and witness statements indicate the incident occurred. Review of CRMA7's employee file revealed upon hire date in 2014, a previous reprimand was on file regarding her tone when talking to residents. The file revealed CRMA7 was suspended on 06/07/2024 pending an internal investigation of the incident with R7 and was terminated on 06/12/2024. Review of the statement documented by the Administrator and dictated by the Director of Health Services (DHS), dated 06/07/2024, revealed the witnesses CRCA6 and CRCA10 did not see but thought CRMA7 hit R7, and when asked, they stated, I'm not sure and CRMA7 may have hit R7 back. Per the statement, CRCA6 reported she saw CRMA7 get slapped by R7 and possibly saw CRMA7 restrain R7 against the wall. Review of the final Investigation Report, dated 06/12/2024 at 2:05 PM, revealed its findings were inconclusive and stated the written versus oral versions of these events were not the same, and there was no willful infliction of injury resulting in physical or emotional harm. The facility did, however, terminate CRMA 7 based on not following company service standards. Review of a written statement by CRMA7, dated 06/07/2024 at 7:37 PM, revealed R7 was agitated because she wanted to go out, and R7 proceeded to hit, pinch, and knee CRMA7 in the stomach area. She reported that she had R7 in the corner so she would not hurt a resident. CRMA7 reported R7 had her by the wrists, and when R7 let go of them, she knocked the glasses off CRMA7's face. CRMA7 stated, I did not retaliate by hitting her on purpose but if my arm hit her when it raised up to keep her from getting my face.I wasn't going to let her hit me. During an interview on 06/18/2024 at 1:34 PM with R7 and her husband, R7 denied memory of any events where someone had been mean with her, and she was not afraid. R7's spouse stated he recalled hearing about the incident on 06/07/02024, but he had no current concerns. He stated he was glad CRMA7 was no longer at the facility, and he was otherwise happy with his wife's care. During an interview on 06/19/2024 at 10:00 AM with CRMA7, she stated it was near the end of the shift on 06/07/2024 at 5:15 PM to 5:30 PM, when staff heard the door alarm go off. She stated R7 was wandering around and pushing another resident in a wheelchair. She stated R7 told staff they were going home. CRMA7 stated she observed R7 attempting to get a chair-ridden resident out of her wheelchair and push on the exit door, which set off the door alarm. She stated CRCA10 redirected the resident in the wheelchair and she attempted to redirect R7. She stated R7 was already agitated because she was stopped from going out the door. She stated R7 became so agitated that she became physically aggressive toward CRMA7. CRMA7 stated she felt the only way to control the situation was to manually hold R7 off. She stated R7 then got loose and smacked the glasses off her. CRMA7 stated she did not smack R7 in return, but with R7 trying to hit her, it was possible her arms went up to defend herself and she accidentally hit her. CRMA7 could not confirm or deny that she remembered any contact, stating, It all just happened so fast, I don't know. She stated she later saw R7 in the courtyard with other residents. She denied any previous disciplinary action related to staff and patient interaction. CRMA7 stated she received regular, yearly training on abuse. During an interview on 06/18/2024 at 1:11 PM, CRCA10 stated R7 had been pushing another resident around in a wheelchair, but at some point, the residents decided they wanted to go home. She stated R7 went toward the 700 Hall exit door. She stated she heard the door alarm, and she went to the door. CRCA10 stated R7 attempted to exit with the resident she was pushing in the wheelchair. She stated she and CRMA7 attempted to re-direct the residents. CRCA10 stated she got the wheelchair-bound resident out of the immediate area and turned back to R7 and CRMA7. CRCA10 stated she observed CRMA7 holding R7's arms firmly, but then R7 got loose and smacked the glasses off CRMA7's face. She stated then CRMA7 smacked R7's face, and she heard her head make contact with the wall. CRCA10 stated she reinforced verbally for CRMA7 to let R7 go, and CRCA6 went to get the nurse. During an interview on 06/19/2024 at 9:29 AM with CRCA6, she stated she was picking up dishes at the end of dinner and was working with another resident, when CRCA10 went around the corner toward the 700 Hall exit door, near the nurses' station. She stated CRNA10 reported to CRCA6 that she could see CRMA7, in the corner, physically holding R7's arms. She stated, by this time, she had joined CRCA10. She stated R7 got loose and hit the glasses off CRMA7's face. She stated she then saw CRMA7 slap R7 in response and heard R7's head hit the wall. When asked if it might have been a defensive move and the slap was accidental, CRCA6 stated, No, it all happened too fast and there was no time for R7 to have attempted to hit CRMA7 before the slap to R7. CRCA6 was asked about the statement provided by the weekend supervisor and her report that CRCA6 did not have a direct vision of events. CRCA6 stated that was not true. She stated, They have their reasons. CRCA6 stated she and CRCA10 verbally tried to get CRMA7 to just let her go. She stated CRCA10 separated R7 and CRMA7, while CRCA6 got LPN2. During a phone interview on 06/20/2024 at 8:50 AM, LPN2 stated she was at the 700 Hall nurses' station, and R7 was ambulating and pushing another resident around in a wheelchair. She stated the 700 Hall's exit door alarm sounded, and CRMA7 and CRCA10 went to it. She stated R7 became more agitated with CRMA7 as manifested by the raised voices of both R7 and CRMA7. She stated CRCA6 arrived, and CRCA10 took the wheelchair resident away from the area. She stated she could see through a glass window that CRMA7 had her arms extended out and was yelling at R7, and R7 was yelling back. She stated she and CRCA6 separated CRMA7 and R7. She stated she took R7 outside and told CRCA6 to call the DHS, which CRCA6 did at 6:20 PM. She stated R7 was very upset and hard to console for a little while, although R7 could not express why she was upset. She stated the nursing shift ended at 6:30 PM, and LPN2 observed CRMA7 counting her medications on her cart and giving a report to the oncoming shift. LPN2 stated CRMA7 clocked out but remained at the nurses' station desk, on her phone watching a video, after her shift. She stated CRMA7 did leave before LPN2, who clocked out at 7:00 PM (this was verified by LPN2's timesheet). During an interview on 06/21/2024 at 9:25 AM with the DHS and the Corporate Clinical Support present, she stated residents were allowed to wander because staff knew them and tried to anticipate their actions. About the incident on 06/07/2024, she stated she was contacted by CRCA6 at 6:20 PM, and she immediately reported this to the Executive Director. The DHS stated the determining factor in deciding this was not a substantiated case were the witness comments that they thought or didn't hear. The DHS stated she would expect to be notified immediately if there was a concern about abuse. She stated she was content with the chain of events and the timeline as they occurred. During an interview on 06/19/2024 at 9:48 AM with the Executive Director (ED), he stated he was not sure CRMA7 hit R7, or with intent, because he was hearing inconsistencies with the stories from the staff involved. He stated CRMA7 was terminated because she did not rise to the facility's standards. He stated that CRMA7 had received previous disciplinary action related to her tone with other residents.

Based on interview, record review, review of the facility's investigation reports, and review of the facility's policy, the facility failed to ensure its staff implemented the facility's abuse policy regarding immediately providing for the safety of the resident after her allegations of physical and verbal abuse by staff for 1 of 8 sampled residents (Resident #7(R7)). Additionally, review of the facility's policy revealed the policy failed to include guidance to equip staff with the knowledge to be able to communicate and coordinate situations of abuse with the facility's Quality Assurance and Performance Improvement (QAPI) program. On 06/07/2024 at approximately 5:50 PM Certified Resident Care Aide (CRCA) 6 and CRCA10 observed Certified Resident Medication Aide (CRMA) 7 become argumentative and physically aggressive with R7 including, but not limited to, a slap on R7's face. They both could hear what sounded like R7's head hitting the wall at the same time as the smack. CRCA6 contacted the Director of Health Services (DHS) at 6:20 PM. Per review of CRMA7's timesheet, she did not clock out until 6:39 PM. Therefore, CRMA7 was not sent home immediately but remained in the facility approximately 50 minutes after the incident occurred. The facility's failure to have an effective system to ensure residents were protected from verbal and physical abuse by immediately securing the safety of the resident from the alleged perpetrator was likely to cause serious injury, impairment, or death. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 06/21/2024 at CFR 42 483.12 Develop/Implement Abuse/Neglect Policies (F607) at the highest Scope and Severity (S/S) of a J. The IJ was determined to exist on 06/07/2024. The facility was notified of the Immediate Jeopardy on 06/21/2024. An acceptable Immediate Jeopardy Removal Plan was received on 06/28/2024 and validated before exit on 07/03/2024. The IJ removal was on 06/15/2024. The deficient practice remained at a S/S of a D following the removal of the immediate jeopardy so the facility could develop their abuse policy to define how staff would communicate and coordinate situations of abuse with the QAPI program. Refer to F600 The findings include: Review of the facility's policy titled, Abuse, Neglect - Procedural Guidelines, dated 08/29/2019, revealed that for the protection of the resident, upon identifying suspected abuse or neglect, immediately provide for the safety of the resident. This action might include, but was not limited to, suspending the suspected employee pending the outcome of an investigation. Further review revealed the policy failed to address how staff would communicate and coordinate situations of abuse with the QAPI program. Review of the same policy, Abuse, Neglect - Procedural Guidelines, updated 06/19/2024, revealed this version of the policy also failed to address how staff would communicate and coordinate situations of abuse with the QAPI program. Review of the Centers for Medicare and Medicaid (CMS) State Operations Manual (SOM), Appendix PP, 42 CFR 483.12 (b)(4), dated 02/03/2023, revealed the facility's abuse policy should define how staff would communicate and coordinate situations of abuse, neglect, misappropriation of resident property, and exploitation with the QAPI program. Review of the facility's Long Term Care Facility - Self Reporting Incident Form Facility Reported, dated 06/07/2024, revealed the incident between R7 and CRMA7 occurred at 5:50 PM on 06/07/2024. Further review of the report revealed it was submitted to the State Survey Agency (SSA) on 06/07/2024 at 7:55 PM. Review of the facility's initial Investigation Report, dated 06/07/2024 at 7:55 PM, indicated CRMA7 had contact with R7's head after R7 struck her. There was no indication via skin assessment that there was physical injury other than an old bruise on the left bicep. Per the report, the resident was taken for a walk by Licensed Practical Nurse (LPN) 2. The report stated R7 did not recall the event when interviewed by facility staff, immediately after and in the days to follow. Per the report, the Executive Director called the facility to suspend the staff member (on 06/07/2024, no time given), but CRMA7 had already left. Review of CRMA7's 06/07/2024 timesheet, revealed she clocked out at 6:39 PM in the memory care building. During an interview on 06/19/2024 at 9:29 AM with CRCA6, she stated she was picking up dishes at the end of dinner and was working with another resident, when CRCA10 went around the corner toward the 700 Hall exit door, near the nurses' station. She stated CRNA10 reported to CRCA6 that she could see CRMA7, in the corner, physically holding R7's arms. She stated, by this time, she had joined CRCA10. She stated R7 got loose and hit the glasses off CRMA7's face. She stated she then saw CRMA7 slap R7 in response and heard R7's head hit the wall. When asked if it might have been a defensive move and the slap was accidental, CRCA6 stated, No, it all happened too fast and there was no time for R7 to have attempted to hit CRMA7 before the slap to R7. CRCA6 stated she and CRCA10 verbally tried to get CRMA7 to just let her go. She stated CRCA10 separated R7 and CRMA7, while CRCA6 got LPN2. During a phone interview on 06/20/2024 at 8:50 AM, LPN2 stated she was at the 700 Hall nurses' station, and R7 was ambulating and pushing another resident around in a wheelchair. She stated the 700 Hall's exit door alarm sounded, and CRMA7 and CRCA10 went to it. She stated R7 became more agitated with CRMA7 as manifested by the raised voices of both R7 and CRMA7. She stated CRCA6 arrived, and CRCA10 took the wheelchair resident away from the area. She stated she could see through a glass window that CRMA7 had her arms extended out and was yelling at R7, and R7 was yelling back. She stated she and CRCA6 separated CRMA7 and R7. She stated she took R7 outside and told CRCA6 to call the DHS, which CRCA6 did at 6:20 PM. She stated R7 was very upset and hard to console for a little while, although R7 could not express why she was upset. She stated the nursing shift ended at 6:30 PM, and LPN2 observed CRMA7 counting her medications on her cart and giving a report to the oncoming shift. LPN2 stated CRMA7 clocked out but remained at the nurses' station desk, on her phone watching a video, after her shift. She stated CRMA7 did leave before LPN2, who clocked out at 7:00 PM (this was verified by LPN2's timesheet). During an interview with the DHS on 06/21/2024 at 9:25 AM, she stated in the event of any type of abuse, she would expect to be notified immediately if there was a concern about abuse. She stated she was notified at 6:20 PM by CRCA6, approximately 30 minutes after the incident occurred. She stated she was satisfied with the timing of events, and she felt staff contacted her as fast as they were able. The DHS stated she reported the incident to the Executive Director immediately. During an interview with the Corporate Clinical Support Nurse on 07/03/2024 at 11:16 AM, she stated, after an abuse allegation or observation, her expectation was for staff to take action to ensure the resident's safety, separate the alleged perpetrator from the resident, escort the alleged perpetrator out of the building, and immediately report the abuse to the supervisor and/or the Executive Director. She also stated she felt the facility incorporated the components of the QAPI requirement in their abuse investigations. She stated the abuse policy might not detail the exact verbiage of the QAPI requirement but thought other tools that were used facilitated meeting that requirement.

Based on observation, interview, record review, and the facility's job descriptions, it was determined the facility failed to store, prepare, and distribute food in a safe and sanitary manner in accordance with professional standards. Observations, on 05/04/2022 and 05/05/2022, revealed the industrial can opener stem to be in the dish-machine and the base had a build-up of dark, gummy residue. The spice shelf on the preparation table was dusty and the legs of the preparation table had areas of gummy residue. Additional observations revealed the sanitation solution of the red bucket did not attain sufficient sanitation levels of at least two hundred (200) parts per million (PPM), when tested , as recommended by the manufacturer. The findings include: Requests to the Director of Food Services (DFS) for Legacy kitchen cleaning policies revealed there were no actual cleaning policies; there were daily, weekly and monthly cleaning schedules to be completed by each shift per the schedule. The DFS was not able to provide previous completed cleaning schedules as requested nor was he able to provide written education documentation of Legacy kitchen staff. Review of the Cook's Daily Cleaning Schedule, no date, revealed the can opener was to run through the dish machine, but there was no mention of cleaning the base. Additional review revealed the production area, shelves, and spice shelf were to be cleaned daily. Review of the Trilogy Health Services, LLC Manual Sanitation document, no date, revealed the sterilization process was where all microorganisms (bacteria, spores, fungi, viruses) contained on hard surfaces and utensils would be destroyed. Further review revealed the first sanitizer bucket would be made on the morning shift and checked every four (4) hours for efficacy of the sanitizing solution. Additional review revealed if the test strip revealed the solution was below the recommended one-hundred fifty to three hundred (150-300) PPM, the solution was to be re-made and tested for the recommended sanitizing level. In addition, the document directed that the manufacturer's recommended immersion time for the test strip was ten (10) seconds. Review of the DFS Job Description, revised 07/18/2018, revealed he/she was to ensure the Food Service Department (FSD) operated in accordance with current federal, state and local standards, guidelines and regulations. Continued review revealed the DFS was to ensure dietary services be maintained in a clean, safe, and sanitary manner. Additional review of the DFS' job description revealed he/she was responsible for uncompromising levels of cleanliness and safety. Review of the Culinary Support-Regional (CS-R) Job Description, revised 11/07/2017, revealed he/she was to ensure compliance with nutritional, dining and regulatory standards. Additional review revealed he/she was to execute in-service training for specifically identified facility needs. Further review identified he/she was responsible for uncompromising levels of cleanliness and safety. Observations, on 05/04/2022, revealed the industrial can opener stem to be in the dish-machine, clean, and the base had a build-up of dark, gummy residue. The spice shelf on the preparation table was dusty and the legs of the preparation table had areas of dark, gummy residue. Additional observations revealed the utensil drawer had a tray holding serving utensils with gummy residue on the sides and corners of the tray. On 05/04/2022, at 11:42 AM, when Cook #3 was requested by the State Survey Agency (SSA) Surveyor to test the sanitation level of the red sanitation bucket, the cook put the appropriate test strip in the sanitizing solution; however, the cook left the test strip in for three (3) seconds instead of the manufacturer's recommended ten (10) seconds. Cook #3 was not able to relay to the SSA Surveyor what the recommended immersion time was for the sanitizing solution test strip. A repeat test strip was immersed for the recommended ten (10) seconds and did not attain the recommended two hundred (200) PPM to achieve sanitation of the food preparation/work areas. The DFS was notified of the sanitizing solution not meeting parameters. He stated he would have staff hand pour the sanitizing solution into the sanitizing bucket instead of using the pre-mixed method through the faucet. Interview with Cook #1, on 05/04/2022, at 11:47 AM, revealed the can opener was cleaned every shift. The cook had no response when the SSA Surveyor pointed out the gummy residue on the base of the can opener. Continued interview with Cook #1 and Cook #3, revealed there were daily cleaning schedules to be used, but they could not tell the SSA Surveyor where the completed schedules were to be placed nor were they able to say where previous copies would be in the kitchen. Further interview with Cook #1 revealed there were only two (2) dietary staff at any given time in the Legacy kitchen. Observations, on 05/05/2022 at 1:52 PM, with Cook #1, Cook #3, and the DFS, during a walk through inspection, revealed the industrial can opener base remained with the build-up of dark, gummy residue. The spice shelf on the preparation table remained dusty, and the legs of the preparation table continued with areas of dark, gummy residue. Additional observation revealed the sanitizing solution did not meet the recommended PPM sanitation level. Further observation of the dish machine (low temperature-Chlorine) sanitizing cycle revealed it did not meet the required fifty (50) PPM sanitizing level, as specified on the test strip package. Interview with the DFS, on 05/05/2022 at 1:52 PM, revealed to ensure all resident use items were sanitized, he would call the facility's Chemical Representative and request a site visit. He further stated all cooking/serving utensils and all dish/flatware would be hand washed and sanitized prior to the evening meal service. Interview with the Chemical-Beverage Specialist, from an outside contracted company, on 05/06/2022 at 9:52 AM, revealed the mixing valve in the faucet of the three (3) compartment sink that mixed the sanitizer for the sanitation bucket had been clogged, and he replaced the part. Additional interview revealed he performed preventative maintenance monthly. Review of billing statements since 01/2022, verified his statement. Observation of fresh sanitizing solution revealed the test strip indicated the recommended PPM. Interview with the CS-R, on 05/06/2022 at 9:10 AM, revealed he was at the facility approximately two (2) times a week. He defined his role as being a member of the Home Office Support Team that provided field support to facilities. He explained his job duties included doing Quarterly Sanitation Audits, with the facility doing additional audits as needed. He stated his expectation would be for the dietary staff to adhere to all current federal, state, and local standards. Interview with the Executive Director, on 05/06/2022, at 1:05 PM, revealed there had been a breakdown in the Legacy kitchen cleaning process and going forward, the facility was working on solutions to address the observed concerns. Additionally, he stated that he did receive the Sanitation Audits from the CS-R, via email, and would take greater care to ensure he read them. Review of Kitchen Sanitation Audit, dated 03/04/2022, scored at 86.17% and completed by the CS-R, revealed he had identified that the can opener, work table and drawers, and the shelves and table legs needed to be cleaned. Review of Kitchen Sanitation Audit, dated 04/18/2022, scored at 85.06%, and completed by Administrator #1, revealed she had not documented any deficiencies with her Legacy kitchen tour. Interview with Administrator #1, on 05/06/2022, at 12:37 PM, revealed she did not know what she was doing when she did the Legacy kitchen audit on 04/18/2022. Additional interview with the CS-R, after the SSA Surveyor had reviewed the requested Quarterly Sanitation Audits, on 05/06/2022 at 12:50 PM, revealed he had no responsibility to ensure the Sanitation Audit deficiencies were addressed after he sent them to the DFS and Executive Director via email. Continued interview revealed the electronic Sanitation Audit tool used by the facility would automatically score the outcome of the audit, based on the information entered into the system. Additional interview revealed if the system scored the audit at 80% or less, he would complete an audit in two (2) weeks; otherwise, he would continue doing Quarterly audits. Additional interview with the Executive Director, on 05/06/2022, at 10:20 AM, revealed it was his expectation for dietary staff to adhere to all facility dietary policies and procedures concerning cleanliness and safety.

Based on observation, interview, record review, review of the manufacturer's directions for use, and review of the facility's policies and procedures, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent and control the development and transmission of communicable diseases and to implement interventions per the Centers for Medicare and Medicaid Services (CMS), the Centers for Disease Control and Prevention (CDC), and the Kentucky Department for Public Health (Health Department) state guidelines for COVID-19. Observation of medication administration for Resident #8, on 05/03/2022, with Kentucky Medication Aide (KMA) #1 revealed improper handling of medication before administration, per mouth (PO). Additional observations of medication administration for Resident #37, on 05/03/2022, with KMA #1 revealed improper glucometer cleaning and disinfection before and after use. Further observations, on 05/04/2022, revealed laundry staff separating laundry without wearing appropriate Personal Protective Equipment (PPE). Continued observations, on 05/04/2022, in the laundry room, revealed the doors between the designated clean laundry area and the dirty laundry area was open. The findings include: Review of the facility's policy titled, Infection Prevention and Control Program (IPCP), revised 11/10/2019 revealed the facility was to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Review of the facility's policy titled, Preparation and General Guidelines, revised November 2018, revealed medications should be administered as prescribed in accordance with good nursing principles and practice. Additionally, personnel authorized to administer medications should do so only after they had been properly oriented to the facility's medication distribution system, including handling and administration. Further, gloves would be worn when administering medications when necessary. Review of the facility's policy titled, Glucometer, Standard Operating Procedure, revised 09/17/2018, revealed guidelines for performance of blood glucose monitoring and glucometer maintenance. Additionally, appropriate infection control technique should be followed during testing procedures. Further, the glucometer machine should be cleaned between residents according to manufacture recommendations as needed. Review of the facility's procedure titled, Cleaning of Accu-Check Meter, undated, revealed before and after each use, the meter should be cleaned with purple or yellow top wipes. Two (2) wipes should be used; one (1) to clean, and one (1) to disinfect. Additionally, with the first wipe, the whole meter (front and back) should be cleaned, horizontally three (3) times and vertically three (3) times, before discarding the wipe. Continued review revealed with the second wipe, the whole meter (front and back) should be cleaned, horizontally three (3) times and vertically three (3) times, before discarding the wipe. Further, the meter should be placed on a clean, dry surface such as a paper towel. Per procedure, the dry time was dependent on the product used, manufacture recommendations; Purple top wipes required two (2) minute dry time and Yellow top wipes required four (4) minute dry time. Review of Professional Disposables International (PDI) Incorporated, website https://pdihc.com/, dated 2022, revealed Sani-Cloth Germicidal Disposable Wipes could be used on hard nonporous surfaces such as blood glucose meters (glucometers) and were effective against bloodborne pathogens. Additionally, Sani-Cloths required three (3) minute continuous wet contact with medical devices and complete air-dry time to be an effective disinfection per manufacture guidelines. Review of PDI, Sani-Cloth Germicidal Disposable Wipes label (Gray top), with no date, revealed to disinfect unfold a clean wipe and thoroughly wet the surface. Additional instruction included ensuring the surface to remain wet for three (3) minutes for adequate efficiency. Further, the surface should completely air dry. Review of the facility's procedure titled, Laundry Operations, revised 02/05/2019, revealed guidelines for laundry operations; laundry was a daily task. Additional review revealed when laundry was sorted and placed in the washer, PPE should be worn. Further, the Director of Environmental Services ensured all day tasks were completed daily. Interview with the Director of Environmental Services, on 05/04/2022 at 2:55 PM, revealed the facility did not have a laundry policy on infection control specific to the door being closed to separate the clean area from the dirty area in the laundry rooms. Review of KMA #1's Annual Training record, revealed she competed Medication Administration: Avoiding Common Areas, on 10/06/2021. Further, she completed a Geriatric Care Competency check list, on 06/15/2021. Review of Garment Service Technician #1's Annual Training record, revealed she completed Standard Precautions, Including Infection Control and Bloodborne Pathogens, on 01/21/2022. 1. Review of Resident #8's medical record revealed the facility admitted the resident, on 10/22/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #8's Quarterly Minimum Data Set (MDS) Assessment, dated 01/26/2022, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fourteen (14) indicating intact cognition. Additional review revealed the resident had no pain and received seven (7) days of opioid medication. Review of Resident #8's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #8's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of medication administration for Resident #8, on 05/03/2022 at 3:57 PM, by KMA #1 revealed the KMA held the medication ([MEDICATION(S)]) skid above a plastic medication chart and attempted to pop the medication into the cup; however, the medication missed the plastic medication cup and fell on top of the medication cart. Additional observation revealed KMA #1 picked up the medication from the top of the medication cart with her bare hands and placed it into the medication cup. Further observation revealed KMA #1 stuck her ring finger and thumb into the medication cup and pushed the medication around the medication cup trying to get a piece of paper (from the back of the medication skid) out of the medication cup. Continued observation revealed KMA #1 administered the contaminated medication to Resident #8. Interview with KMA #1, on 05/03/2022 at 3:57 PM, revealed she had worked at the facility for seven (7) years and as a KMA for two (2) years. Per interview, she was not sure if she should wear gloves when preparing medications for administration or if it was okay for her to touch medication with her bare hands. Additionally, she did not think touching medications with her bare hands was a breach of infection control. Further, she stated she had been provided education on how to properly handle medication. Interview with Registered Nurse (RN) #1, on 05/03/2022 at 3:57 PM, revealed KMA #1 should not have touched Resident #8's medication with her bare hands. Further, touching the medication with her bare hands contaminated the medication with germs. Further interview revealed staff should not touch pills with their bare hands to ensure the medications were not dirty and to maintain infection control; it was a standard of practice. 2. The facility admitted Resident #37, on 12/22/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #37's Quarterly Minimum Data Set (MDS) Assessment, dated 03/30/2022, revealed the facility assessed the resident to have a BIMS score of fourteen (14) indicating intact cognition. Additional review revealed the resident had received seven (7) day of insulin (lowers blood sugar levels) injections. Review of Resident #37's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #37's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of medication administration, for Resident #37, on 05/03/2022 at 4:03 PM, by KMA #1, revealed the KMA gathered Sani-Clothes (Gray top) from the medication room, a plastic pencil box from the medication cart, containing a glucometer; multiple lancets; alcohol pads; and the test strip bottle. The KMA placed the gathered items on the top of the medication cart without preparing a clean area. Observation revealed the KMA used hand sanitizer on her hands and donned (put on) gloves and removed one (1) Sani-Cloth from the gray top container. The KMA then rubbed the cloth over the front and back of the glucometer once and laid the glucometer on the medication cart and placed the Sani-Cloth in the trash. She doffed (removed) her gloves, donned a new pair of gloves, and immediately added a test strip to the wet glucometer. Continued observation revealed she performed a finger stick blood glucose check on Resident #37 and discarded the lancet and test strip in the sharps box on the side of the medication cart. Further observation revealed she laid the dirty glucometer on the medication cart and again obtained one (1) Sani-Wipe from the gray top container and wiped the front and back of the glucometer; she placed the wet glucometer into the plastic pencil box while wet, with multiple lancets and the test strip bottle and placed it back into the medication cart. Interview with KMA #1, on 05/03/2022 at 4:05 PM, revealed she had been provided training on how to properly clean a glucometer. Per interview, the glucometer should be wiped thoroughly with a Sani-Cloth before and after each use. Additionally, she was not aware of the time the glucometer should remain wet. Further, she stated the glucometer air dried fast. Continued interview revealed it was important for the glucometer to be clean to maintain infection control. Interview with RN #1, on 05/03/2022 at 4:18 PM, revealed she had worked in the facility for four (4) years. Per interview, glucometers should be cleaned with a Sani-Cloth thoroughly before and after use. Additionally, the surface of the glucometer should be wet for five (5) minutes, while it rested on a clean wipe or paper towel and air dried. Continued interview revealed it was important to clean the glucometer properly to ensure germs were not cross contaminated and to maintain infection control. Further, she stated staff were provided competency training on cleaning glucometers during annual training. RN #1 stated two (2) residents had orders for finger stick blood glucose checks on the hallway. 3. Observations of the laundry rooms, on 05/04/2022 at 1:15 PM, revealed the door between the clean linen room into the washer/dryer room was open, with a handwritten Post It note taped to each side above the doorknob; Keep Door Closed. Clean linens were folded uncovered on the shelves and in totes, and resident clothing was hanging uncovered on rolling racks. Additional observations revealed the door between the washer/dryer room and the dirty/soiled laundry room was also open. Garment Service Technician #1 was noted in the dirty/soiled laundry room separating colors and white linens from the dining room. She was wearing a surgical mask and gloves only. Her clothing was touching the soiled linens and the soiled linen cart as she sorted. Further, trash and food were mixed with the soiled linens she was separating. Interview with Garment Service Technician #1, on 05/04/2022 at 1:18 PM, revealed she had worked at the facility for five (5) years. Per interview, she had received training on infection control, to include cross contamination, COVID, and PPE; at least two (2) to three (3) times a year. Additionally, she stated it was important to follow training/policy for infection control, and she should have worn a gown and eye protection when sorting dirty linens. Interview with the Director of Environmental Services, on 05/04/2022 at 1:20 PM, revealed she had worked at the facility for five (5) years and was in the facility four (4) days a week. Per interview, Garment Service Technician #1 should have had appropriate PPE on in the dirty laundry room, while separating linens; gown, gloves, and eye protection to ensure her clothing was not contaminated and carried into the clean areas of the laundry. Additionally, she stated staff was educated on infection control, cross contamination, and PPE annually and as needed. Continued interview revealed she rounded through the laundry rooms three (3) to four (4) times a day and had not identified any concerns with infection control in the laundry. Further, she stated the doors that separated the clean areas from the dirty areas in the laundry should always be closed to maintain infection control. The Director stated she wrote the Post It note, Keep Door Closed, over a year ago, because she noticed staff was not consistently pulling the clean linen door closed, and it was open into the dirty areas; however, she did not implement actions to correct the issues other than taping a note to the door. Interview with the Senior Director of Plant Operations, on 05/04/22 at 2:25 PM, revealed he had been in the role for twelve (12) years, and was at the facility once a month. Additionally, he had not identified that there were any issues with the door between clean and dirty laundry no being closed to maintain infection control. Further, he stated his observations were that the door was usually closed, and he recalled there had always been a hand-written note by the Director of Environmental Services, on the door that read Keep Door Closed; however, he did not identify this as a concern. Continued observations, on 05/04/2022 at 2:25 PM, revealed the door between the clean linen laundry room and the washer/dryer room had been changed to a self-closing door. Interview with the Assistant Director of Health Services (DHS)/Infection Preventionist (IP), on 05/05/22 at 3:04 PM, revealed she had been in the role for two (2) years and prior was a night shift nurse at the facility. Per interview, she expected nursing staff (nurses and KMA's) to maintain infection control practices while handling medication, when preparing medications and during administration. She stated she expected nurses and KMA's to wear gloves, when necessary, when preparing medications for administration and not to handle medications with their bare hands. Additional interview revealed the facility's policy related to cleaning and disinfecting glucometers should be followed by nursing staff to reduce the risk of cross contamination. Per interview, the facility had not identified any concerns with infection control/handling medications during medication administration; however, the facility had not utilized a medication administration audit to ensure preparing medications was performed appropriately. She stated she expected the nursing staff to clean and disinfect the glucometer before use and in between use on each resident. She stated glucometers should be disinfected by using Sani-Cloths per the manufacturer's guidelines. The IP Nurse stated it was important to decrease the cross-contamination risk. She stated nursing staff received annual competency training on medication administration and glucometer cleaning and disinfection, and she had not identified any concerns with glucometer cleaning and disinfection. Further interview with the IP Nurse revealed she expected laundry workers to wear PPE as necessary when handling and separating dirty linens and to ensure the barrier (door) between the dirty and clean areas in the laundry room was closed. Continued interview revealed the laundry policy(s) and infection control standards should be followed by laundry staff to reduce the risk for cross contamination. She stated she did not audit laundry related to infection control and was unaware of a formal infection control audit completed by laundry supervisors related to infection control. The IP Nurse stated she was not aware if laundry staff received annual infection control training. Interview with the Executive Director (ED), on 05/05/2022 at 3:27 PM, revealed he expected the facility's infection control policy(s) and procedure guidelines to be followed by everyone in the facility. Additionally, he expected the IP nurse and facility leadership to maintain ongoing monitoring throughout the building. The ED stated the facility had not identified any concerns with infection control practices in the facility. Further, he explained he expected infection control to be maintained per the facility's policy(s) to decrease cross-contamination, while preparing medication for administration. In addition, he stated glucometers should be cleaned and disinfected between use on residents and laundry staff should wear PPE and ensure doors were closed between clean and dirty areas in the laundry room. Interview with The Director of Health Services (DHS), on 05/05/2022 at 3:59 PM, revealed she had worked at the facility for one (1) month. She stated she expected the facility's policies related to medication administration/handling medications and glucometer cleaning and disinfecting always to be followed. Additionally, she stated she expected nursing staff to prepare medications for administration and don gloves per standards of practice. Continued interview revealed it was important to maintain infection control practices related to gloves and hand hygiene to decrease the risk of cross contamination. Further, she stated she expected staff to clean glucometers prior to use and after each use with residents, per the facility's policy and manufacturer's recommendations. The DHS explained it was important to ensure infection control was maintained with medical devices to reduce the spread of communicable disease. Continued interview with the DHS, on 05/05/2022 at 3:59 PM, revealed she expected the facility's policies related to infection control and wearing PPE while handling soiled linens to be followed. Additionally, she stated she expected the door to be closed between the clean and dirty areas in the laundry. Further, the DHS stated it was important to maintain infection control practices in laundry to decrease the risk of cross contamination.

Based on observation, interview and review of the facility's Policy, it was determined the facility failed to prepare and serve food under sanitary conditions for thirty-two (32) of thirty-two (32) residents in the Legacy Dining Room. Observation during the lunch meal, on 08/20/19, revealed a State Registered Nurse Aide (SRNA) holding a large serving bowl next to her person touching her apron with her full arms encircling the food bowl. Observation during the lunch meal, on 08/21/19, revealed the Legacy Neighborhood Director (LND), holding a large serving bowl on her hip in direct contact with her personal clothing. The findings include: Review of the facility's Policy titled, Legacy Family Style Dining Standard, effective 11/07/18, addresses using colored plates to improve appetite and meal identification, serving food family-style from larger, colored platters and to serve the resident from the left; however, there is no documented evidence the policy addressed infection control and cross contamination when serving food. Interview with the Director of Nursing, on 08/22/19 at 4:22 PM, revealed the facility did not have a policy related to infection control and cross contamination when serving food. Observation of the Legacy Neighborhood dining room meal service, on 08/20/19 at 12:10 PM to 12:25 PM, revealed SRNA #1 serving the lunch meal home-style holding a large bowl next to her body touching her apron and personal clothing. Continued observation revealed her arms were encircling the large bowl pressing the bowl against her person. Further observation revealed the bowl contained the ham/pineapple entrée for all thirty-two (32) residents dining. Additional observation revealed the bowl was removed from her body each time she arrived at a dining table to spoon the entrée onto the resident plates and replaced back against her body after serving the entree. Observation, on 08/21/19 at 12:02 PM, revealed the Legacy Neighborhood Director (LND) serving the lunch meal home-style holding a large serving bowl containing the lunch entrée next to her body at her hip level with the bowl touching her personal clothing. Continue observation revealed the LND was observed, at 12:09 PM and 12:11 PM, again holding the large serving bowl next to her body at her hip level with the serving bowl touching her personal clothing. Interview with SRNA #1, on 08/22/19 at 1:45 PM, revealed she was holding the large serving bowl next to her body and was unaware that was an issue since she was wearing an apron. Further interview revealed it was the facility's policy to serve the meals family style; however, the bowls get heavy and it was a way to secure the large bowl. Continued interview with SRNA #1 revealed it was difficult to carry the large bowl around to serve and it would be more comfortable if it were to have been on a cart. Interview with the Legacy Neighborhood Directory, on 08/22/19 at 1:53 PM, revealed she was aware holding a food bowl next to her person could have been an infection control issue and physical cross contamination of bacteria from the server or server's clothing to the food. Continued interview revealed the aprons were put on prior to the meal, before we serve salad for protection. Further interview revealed in the future, staff will be encouraged to hold the bowls away from their bodies. She stated we may modify the family style serving method we are using. Interview with the Director of Nursing, on 08/22/19 at 4:22 PM, revealed holding food bowls next to staff's bodies was an infection control issue and potential cross contamination of food. She stated the bowls are heavy; we may need to look at a more ergonomic way to serve the food. Continued interview revealed the facility's Policy does not detail how to serve food; however, holding food bowls next to the staff clothing was not acceptable. Further interview revealed it was her expectation for the staff to hold bowls of food away from their body even if they are wearing an apron. Interview with the Executive Director, on 08/22/19 at 4:32 PM, revealed there was not a difference in serving food on the service line and serving food in the dining room. Continued interview revealed, it was his understanding that in this industry (Skilled Nursing Home and Personal Care Home), staff should not hold food bowls next to their body. Per the definition of the regulatory guidelines, it could be an infection control issue. Per interview, he has not reviewed the facility's policy on the exact guidelines; however, he would expect staff to follow the facility's policy to ensure good infection control.

Based on interview and record review, it was determined the facility failed to ensure a Registered Nurse (RN) was available eight (8) hours per day, seven (7) days per week. The facility failed to meet this requirement for four (4) twenty four (24) hour periods, for the review period 07/01/18 through 10/09/18. The findings include: Interview with the Director of Health Services (DHS), on 10/09/18 at 8:30 AM, revealed the facility did not have a staffing policy. Review of Health Services Research from (MONTH) 2008, revealed Registered Nurse staffing was likely to decrease adverse outcomes in skilled nursing facilities, in particular pressure ulcers and urinary tract infections. Review of the Center for Medicare Advocacy,More Nurses in Nursing Homes Would Mean Fewer Patients Headed to the Hospital, undated, revealed inadequate nurse staffing is a primary contributor to re-hospitalization . Further, more Registered Nurses, Physicians, and Advance Practice Registered Nurses in a facility resulted in an eleven percent (11%) decrease in hospitalization s. Review of the facility nursing schedules titled, Nursing Skilled Daily Attendance Report, revealed a Registered Nurse (RN) was not available in the facility for eight (8) hours on 07/01/18, 07/29/18, 09/01/18, and 09/02/18. Further review revealed the RN who usually worked the weekends was scheduled off based on request 07/01/18 and 07/29/18. On 09/01/18 and 09/02,18, RN #1 was also scheduled off based upon request. Review of the facility List of Absences 07/01/18-10/09/18, revealed no unplanned RN absences occurred on 07/01/18, 07/29/18, 09/01/18, or 09/02/18. Review of the (YEAR) Weekstart Manager schedule (an on call administrative manager schedule used by the facility), revealed on 07/01/18 the Business Office Manager was covering the weekend for non-nursing issues. Further, on 07/29/18, Plant Operations was the management representative on call. Non-nursing management staff was assigned to the facility on [DATE] and 09/02/18 as well, with no RN assigned to work in the facility for eight (8) hours. Review of the facility (YEAR) On-Call Schedule for Nursing Management, revealed there was no RN on call for the facility for eight (8) hours on 07/29/18, 09/01/18, and 09/02/18. On 07/01/18, the Assistant Director of Nursing (ADON) was the nurse on call for the facility. There was no documentation of the ADON's presence in the facility on 07/01/18. Interview on 10/09/18 at 11:45 AM, with RN #3, revealed weekends were usually staffed with Licensed Practical Nurses (LPNs). She stated she did not know how weekend RN coverage was arranged. She further stated she worked weekends on occasion when scheduled. Interview with LPN #1, on 10/09/18 at 1:30 PM, revealed she usually worked when a RN was in the building. However, after review of the Nursing Skilled Daily Attendance Report for 09/01/18 and 09/02/18, she stated she worked twelve (12) hour shifts on both days with no RN available in the facility. Interview with the Scheduler, on 10/09/18 at 1:53 PM, revealed she was responsible for creating the nursing schedules and providing for absentee coverage during the business week. Per interview, on weekends, the nurse manager on call assumed responsibility for unplanned absence (call in) coverage. She stated she did not rely on agency for scheduling; either staff picked up additional shifts or she relied on some PRN (as needed) staff. Continued interview revealed the Nurse Managers or RN floor nurse provided the RN coverage for eight (8) hours each day during weekdays. The scheduler stated weekend RN coverage occurred when an RN was scheduled for a shift or when a RN Manager worked eight (8) hours in the facility. She stated she had not scheduled an eight (8) hour RN shift for 07/01/18, 07/29/18, 09/01/18, or 09/02/18. She further stated when no RN was in the building, staff relied on the DON or the nursing call schedule for direction or consultation as needed. Interview with the Assistant Director of Nursing (ADON), on 10/09/18 at 2:17 PM, revealed the scheduler created and maintained the daily nursing schedule. She stated the scheduler managed time off requests and unplanned absence from the facility. She further stated if no RN was in the building, the nursing staff would rely on the nursing call schedule for RN assistance. Continued interview revealed on 07/01/18, the Personal Care Unit had a RN on duty who also covered for skilled nursing. However, she stated the Personal Care RN was only in the building for six (6) hours in the twenty four (24) hour period. (The Personal Care RN covered the hours from midnight until 6:00 AM.) The ADON stated all managers were assigned a weekend day to come to the facility and work. She acknowledged manager coverage could be nursing or non-nursing management staff; thus, non-nursing management did not meet the requirement for an eight (8) hour RN presence in the facility. Interview with the Director of Health Services (Director of Nursing), on 10/09/18 at 2:45 PM, revealed the scheduler prepared the nursing schedules. She stated if no RN was in the building on the weekend, staff would rely on the nursing management call schedule for assistance as needed. She further stated she was always available to staff by telephone. The Director stated no RN was in the building for eight (8) hours on 07/29/18, 09/01/18, and 09/02/18, and during this time, the nursing staff relied on the Nursing Management Call Schedule for assistance. Further, she stated on 07/01/18, the Personal Care RN covered six (6) of the eight (8) required RN work hours. Interview with the Acting Administrator, on 10/09/18 at 3:10 PM, revealed if no RN was in the building, nursing management rotated call for the facility and were available by telephone. The Administrator stated the nursing schedules were prepared and maintained by the scheduler. Further interview revealed a RN should be in the building eight (8) hours per day, seven (7) day a week in order to provide expertise and ensure high quality of care for residents.

Based on observation, interview, record review, review of the facility's policies, and review of the Centers for Disease Control (CDC) guidelines, it was determined the facility failed to establish and maintain an infection control program designed to ensure a safe environment and to help prevent the transmission of infection for four (4) of seventeen (17) sampled residents (Resident #10, #28, #30 and #41). Observation on 08/01/18 and 08/02/18, revealed State Registered Nurse Aides (SRNAs) failed to perform proper hand hygiene and glove usage prior to and after performing pericare/incontinence care for Residents #10, #28, #30 and #41. The findings include: Review of the facility Policy titled, Guideline for Handwashing/Hand Hygiene, revised 02/09/17, revealed hand hygiene was the single most important factor in preventing the transmission of infections. Review of the facility Policy titled, Standard Precaution Guidelines, revised 05/11/16, revealed the use of standard precautions was necessary to prevent the spread of infections. Review of the facility Policy titled, Perineal Care for the Incontinent Guideline, revised 11/09/17, revealed staff were to pay particular attention to infection prevention and control techniques when performing peri-care. Review of CDC Guidelines titled, Introduction to Hand Hygiene, When and How to Wear Gloves, undated, revealed gloves should be changed when moving from a contaminated site to a clean site. Continued review of the guidelines revealed failure to remove soiled gloves after caring for a patient could lead to the spread of potentially deadly germs. 1. Review of Resident #10's Medical Record revealed the facility readmitted the resident on 05/01/18, with [DIAGNOSES REDACTED]. Observation on 08/01/18 at 10:00 AM, revealed SRNA #1 assisted Resident #10 to the toilet; pulled the resident's pants down; and left the resident on the toilet. SRNA #1 then removed her gloves, but did not perform hand hygiene after removing the soiled gloves. SRNA #1 proceeded to retrieve the resident's clothes from the closet and drawers. SRNA #1 then without performing hand hygiene, donned clean gloves and assisted the resident to stand; performed pericare/perineal care; and placed a new brief on the resident. SRNA #1 then with the same soiled gloves, dressed the resident, and assisted the resident to the wheelchair. She then removed the soiled gloves and washed her hands. Interview with SRNA #1 on 8/02/18 at 12:00 PM, revealed she had been employed by the facility for three (3) years. Per interview, hand hygiene should be performed prior to and after performing peri-care/incontinence care. Further interview revealed hand hygiene should be performed anytime soiled gloves were removed. Continued interview revealed this was important for infection control and for the safety of the resident. Per interview, the facility provided education at orientation, and annually for hand hygiene and perineal care. Interview on 8/02/18 at 4:43 PM, with Licensed Practical Nurse (LPN) #2, who was assigned to Resident #10, revealed she had been employed by the facility for three (3) years. Per interview, it was her expectation SRNAs follow policy related to hand hygiene and peri-care/perineal care. Continued interview revealed this was important to prevent cross contamination and infection for residents and staff. 2. Review of Resident #30's Medical Record revealed the facility admitted the resident on 09/03/16 with [DIAGNOSES REDACTED]. Observation on 08/01/18 at 1:20 PM, revealed SRNA #5 completed peri-care, and with the same soiled gloves proceeded to pull up the resident's blanket, and pick up the resident's cup and give the resident a drink of water. SRNA #5 then performed hand hygiene prior to exiting the room. Interview on 08/02/18 at 1:56 PM, with SRNA #5, revealed staff should wash their hands prior to and after peri-care/incontinence care and anytime you get your gloves dirty. Further interview revealed it was important to wash hands to prevent transferring germs after providing peri-care and prior to touching other items in the room such as the resident's blanket or cup. 3. Review of Resident #41's Medical Record revealed the facility admitted the resident on 02/06/18 with [DIAGNOSES REDACTED]. Observation of peri-care/perineal care for Resident #41, on 08/01/18 at 3:27 PM, revealed SRNA #2 performed hand hygiene, donned clean gloves, and performed peri-care/perineal care using peri-care wipes and peri-care spray cleanser. Upon completion of the perineal care and prior to removing soiled gloves, she picked up the clean package of peri- care wipes and the bottle of peri-care cleanser, placed them in a drawer, and rearranged the bed linens. SRNA #2 then removed the soiled gloves and performed hand hygiene. Review of the Caregiver Annual Competency Evaluation for State Registered Nursing Assistant (SRNA) #2, dated 03/23/18, revealed skills and techniques for peri-care and handwashing were checked as completed. Interview with SRNA #2, on 08/01/18 at 3:35 PM, revealed soiled gloves were to be removed prior to contact with clean surfaces. SRNA #2 stated she forgot to take off the soiled gloves after providing peri-care and before touching the clean package of wipes and bottle of peri-care cleanser. She further stated she knew she should have taken off her soiled gloves and washed her hands at the conclusion of peri-care to prevent cross contamination. Interview with LPN #1, on 08/02/18 at 2:28 PM, who was assigned to Resident #41's unit, revealed after performing peri-care, staff was to remove soiled gloves prior to touching clean surfaces. She stated SRNAs were educated about correct peri-care techniques during orientation and at least annually. She further stated although she was unaware of any routine audits performed to ascertain compliance with the peri-care procedure, she observed peri-care on her unit when the opportunity arose. LPN #1 stated SRNA #2 had been on her unit for approximately one (1) month. She stated correct glove use and hand hygiene were important components of infection control. 4. Review of Resident #28's Medical Record revealed the facility admitted the resident on 07/17/13 with [DIAGNOSES REDACTED]. Observation of pericare/incontinence care for Resident #28, on 08/02/18 at 1:28 PM, revealed SRNA #5 and SRNA #6 washed their hands and applied gloves prior to starting pericare/incontinence care. Continued observation revealed after the completion of incontinence care, SRNA#5 and SRNA #6 removed their gloves; however, failed to perform hand hygiene prior to lowering the resident's bed using the bed controller; assisting the resident back to his/her wheelchair; and touching the resident's wheelchair handles. Additional observation revealed after the resident was assisted back into the wheelchair, SRNA #5 and SRNA #6 washed their hands and then wheeled the resident out of the room. Interview on 08/02/18 at 1:56 PM, with SRNA #5 and SRNA #6, revealed they should have removed their gloves and washed their hands after performing peri-care/incontinence care and prior to touching items in the resident's room. Interview with the Staff Development Coordinator, on 8/02/18 at 2:45 PM, revealed she had been employed by the facility for three (3) years. Per interview, SRNAs receive training on hand hygiene and peri-care/perineal care upon orientation and have annual competencies related to basic skills with hand washing and peri-care addressed. Further interview revealed random audits of staff providing care to check for proper hand hygiene was performed periodically. Per interview, all staff was to perform hand hygiene and perineal care per policy to prevent cross contamination to residents and staff. Interview with the Assistant Director of Health Services on 08/02/18 at 2:57 PM, revealed she was responsible for the facility's infection control program. She stated all SRNAs receive education regarding hand hygiene and glove use during initial orientation, during annual education, and whenever a need was identified. Continued interview revealed correct hand hygiene and glove usage technique was a key component of infection control and was important for the overall health of residents and staff. Interview with the Director of Health Services, on 08/02/18 at 3:23 PM, revealed it was her expectation for staff to adhere to infection control practices for the prevention of disease transmission in the facility. She stated new staff were educated regarding hand hygiene, peri-care, and use of gloves upon hire and at least annually. She further stated SRNAs were assigned hand hygiene modules in the computer to complete as part of the educational process and were evaluated for hand hygiene and peri-care skills using a competency tool. Continued interview revealed although no routine peri- care audits were currently being done, she relied on her nursing management team to assist in monitoring and educating staff on infection control practices to ensure control of disease transmission. Post Survey telephone interview with the Administrator, on 08/03/18 at 10:06 AM, revealed it was his expectation for the nursing management team to ensure compliance with infection control practices for the purpose of preventing disease transmission.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to immediately inform the resident, consult with the resident's physician and notify the resident's representative when there was an accident involving the resident which resulted in injury and had the potential to required physician intervention for one (1) of four (4) sampled resident, Resident #1. The findings include: Review of the facility's Notification of Change in Condition policy, reviewed 05/23/18, revealed the purpose was to ensure appropriate individuals were notified of a change in condition. Per the policy, the facility must inform the resident, consult with the resident's physician and if known notify the resident's legal representative when an accident involving the resident which resulted in an injury and had the potential for requiring physician intervention. The physician should be notified immediately of a fall with significant injury (i.e. suspecting a fracture). Further review revealed, the responsible party should be notified of change in condition or diagnostic testing results in a timely manner. Review of the facility's Fall Management Program Guidelines, reviewed 05/22/18, revealed the purpose was to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures. Further review revealed, a fall was considered to be an unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force. Per the facility's policy/guidelines, unless there was evidence suggesting otherwise, when a resident was found on the floor, a fall was considered to have occurred. Continued review revealed, should a resident experience a fall, the nurse shall complete the Fall Event report which included an investigation into the circumstances surrounding the fall to determine the cause, a reassessment to identify possible contributing factors, interventions to reduce risk of repeat episodes and a review by the Interdisciplinary Team (IDT) to evaluate thoroughness of the investigation and appropriateness of the interventions. Further review revealed, the attending physician, medical director (should attending physician be unavailable) and the responsible party should be notified. The resident care plan should be updated to reflect any new or change in interventions. Per the policy/guidelines, nursing staff would monitor and document continued resident response and effectiveness of interventions for seventy-two (72) hours. Review of Resident #1's medical record revealed, he/she was admitted by the facility on 04/20/18 with [DIAGNOSES REDACTED]. Review of Resident #1's Admission Minimum Data Set (MDS) Assessment, dated 04/27/18, revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status (BIMS) score of six (6) out of fifteen (15), indicating severe cognitive impairment. Continued review revealed, the facility assessed Resident #1 to require extensive two (2) person physical assist with bed mobility, transfers, locomotion on the unit, dressing, toilet use and personal hygiene. Per the MDS, Resident #1 was also frequently incontinent of bladder and occasionally incontinent of bowel. Further review revealed, Resident #1 did not require the use of bed rails or alarms. Review of Resident #1's admission fall risk assessment, dated 04/20/18, revealed Resident #1 had a fall in the last month prior to admission to the facility and used a wheelchair for mobility. Review of Resident #1's comprehensive care plan, dated 04/30/18, revealed the facility assessed Resident #1 as being at risk for falls. The goal was Resident #1 would remain free from falls with major injury. Interventions in place included: to keep the call light in reach, keep personal items and frequently used items within reach, providing non-skid footwear, and two person assist with transfers as needed. Review of nurse's notes for Resident #1, dated 06/03/18 at 10:15 PM, written by Licensed Practical Nurse (LPN) #2, revealed Resident #1 complained of left hip pain and was unable to perform range of motion. LPN#2 obtained an order for [REDACTED].#1 revealed, a mobile X-Ray service arrived at 11:02 PM to perform an x-ray of Resident #1's left hip and left lower extremity. Further review revealed, no documented evidence Resident #1 had sustained a fall on 06/03/18. Review of the Radiology Report, dated 06/04/18 at 3:20 AM, revealed Resident #1 had an acute [MEDICAL CONDITION] superior and inferior rami (located in the pelvis). Review of the facility's investigation revealed, the facility initiated the investigation on 06/05/18 due to an injury of unknown origin. Further review of the facility's investigation revealed, on 06/03/18 at approximately 10:15 PM, Resident #1 complained of pain. LPN #2 administered pain medication for the complaint of pain as well as called the doctor to obtain an order for [REDACTED].#1 and SRNA #2. Per the statements, on 06/03/18, SRNA #1 and SRNA #2 found Resident #1 sitting on the floor of his/her bathroom with his/her walker nearby after he/she had sustained a fall. Per the statements, the SRNA's reported the incident to Licensed (LPN) #1 who instructed SRNA #1 and SRNA #2 to put Resident #1 in his/her recliner chair. SRNA #1 reported, LPN #1 told SRNA #1 and SRNA #2 that she was not going to fill out the incident report because it appeared there was nothing wrong with Resident #1. Additional review of the investigation report revealed, a statement from Licensed Practical Nurse (LPN) #1, dated 06/06/18 at 4:20 PM, unsigned, revealed she initially claimed Resident #1's injury occurred as a result of being assisted onto the toilet. Per the report, when the facility advised LPN #1 that SRNA #1 and SRNA #2 reported on 06/03/18, they found Resident #1 in the bathroom on the floor, LPN #1 confirmed Resident #1 did fall. When asked why she didn't report the fall, LPN #1 stated Resident #1 didn't appear to be hurt. The final report of the facility's investigation, dated 06/11/18, revealed Resident #1 had sustained a fall on 06/03/18 and his/her injury was a result of that fall. Interview with SRNA #2, on 06/27/18 at 10:28 AM, revealed she had worked from 2:00 PM to 10:00 PM on 06/03/18. Continued interview revealed, she and SRNA #1 were responding to another resident's call light when they noticed Resident #1 was not sitting in his/her chair. Per interview, SRNA #1 and SRNA #2 entered Resident #1's room and did not see him/her so they decided to look in Resident #1's bathroom. Upon looking into Resident #1's bathroom, they found him/her on the floor of the bathroom sitting on his/her bottom. Per interview, SRNA #1 instructed SRNA #2 to stay with Resident #1 while SRNA #1 went to get the nurse. SRNA #1 and LPN #1 came back into the bathroom and LPN #1 instructed SRNA #1 and SRNA #2 to pick him/her up and assist him/her back into his/her recliner chair. Further interview revealed, once Resident #1 was back in his/her recliner, LPN #1 stated that she was not going to fill out an Incident Report. SRNA #2 was unable to recall the reason LPN #1 gave for not filling out the incident report. Interview with Licensed Practical Nurse (LPN) #1, on 06/26/18 at 3:32 PM, revealed she had been employed at the facility for 2 years and worked 6:00 AM to 6:00 PM on 06/03/18. Per interview, LPN #1 was the primary nurse for Resident #1 on 06/03/18. LPN #1 stated, on 06/03/18, she was administering another resident's medications around 2:30 PM when SRNA #1 came and got her, saying that Resident #1 was on the floor in the bathroom. LPN #1 stated, she assessed Resident #1 upon her arrival and found Resident #1 without obvious injury. After assessing Resident #1, LPN #1 instructed SRNA #1 and SRNA #2 to assist Resident #1 back into his/her recliner chair. LPN #1 stated, Resident #1 walked 4 or 5 steps back to the recliner with no complaints of pain. LPN #1 stated, she did not fill out an incident report for Resident #1's fall nor did she document the post-fall physical assessment because I was in the middle of med pass and was too busy to fill it out. Per interview, LPN #1 stated she should have filled out the incident report and documented her assessment of Resident #1. LPN #1 stated, the importance of documenting an incident, such as a fall, was to ensure other staff were up to date on the resident's status and the care they need to receive. LPN #1 further stated, she did not notify Resident #1's physician nor did she notify Resident #1's representative because she was too busy. LPN #1 stated she should have notified both the physician and the resident representative. LPN #1 stated it was important to notify the physician in case they wanted to give new orders and it was important to notify the representative so they could be kept up to date on the care and status of the resident. Interview with LPN #2, on 06/27/18 at 3:35 PM, revealed she has been employed at the facility for one and a half years and worked 6:00 PM to 6:00 AM on the 06/03/18. LPN #2 stated, she did not receive any information in the shift report that Resident #1 had fallen earlier in the day. LPN #2 stated, Resident #1 was sitting in his/her chair when she started her shift at 6:00 PM on 06/03/18. LPN #2 stated, Resident #1 complained of pain at approximately 6:30 PM and received a pain pill. LPN #2 stated, Resident #1 again complained of pain when being assisted to bed at approximately 10:15 PM. LPN #2 stated, upon her assessment, Resident #1 was unable to perform range of motion using the left lower extremity and was unable to bear weight on the left lower extremity once being assisted into bed. LPN #2 stated, she called the attending physician at approximately 10:30 PM, after Resident #1 was assisted to bed and obtained an order for [REDACTED].#2 stated, the x-ray was taken at approximately 11:00 PM. LPN #2 stated, Resident #1's daughter was in the room when Resident #1 was being assisted into bed and was aware of the order for an x-ray. LPN #2 stated, the results of the x-ray arrived by fax at approximately 4:00 AM. Continued interview revealed, LPN #2 called the physician and left a message requesting a call to relay the results of the x-ray. LPN #2 stated, when she left at approximately 6:00 AM the physician had not called back to receive the x-ray results. Interview with Advance Practice Registered Nurse (APRN), on 06/27/18 at 3:46 PM, revealed it was her expectation that staff always notify us of any fall. Continued interview revealed, it was important that staff report all falls especially geriatric falls because older people were more prone to injury than a younger person and so she and/or the attending physician could give new orders if required. Further interview revealed, any geriatric fall should be reported, even if they slide down or are eased to the floor. The APRN stated, neither she nor the attending physician were notified of a fall on 06/03/18 but were notified a few days later. Interview with the Director of Health Services (DHS), on 06/27/18 at 2:14 PM, revealed it was her expectation that SRNA's notify the nurse immediately if they find a resident on the floor. It is also her expectation that nurses would assess the resident, fill out a fall event report, notify the physician and resident representative immediately after ensuring the safety of the resident as outlined in the facility policy. Per interview, she was not notified of Resident #1's fall until 06/06/18, during the facility's investigation, SRNA #1 and SRNA #2 came to her office and advised her about the fall. Additional interview revealed, SRNA #1 and SRNA #2 reported to her they found Resident #1 on the floor of his/her bathroom on 06/03/18 and got LPN #1. Per interview, SRNA #1 and SRNA #2 told her that LPN #1 stated she was not going to fill out a fall event since the resident did not appear hurt and instructed SRNA #1 and SRNA #2 to keep it (the fall) quiet. Continued interview revealed, LPN #1 should have assessed Resident #1, gotten the resident to a safe position, filled out the fall event, and notified the physician and the family of Resident #1's fall. Further interview revealed, all staff were educated on the policy and procedure for reporting falls on hire and periodically as needed. Interview with the Executive Director (ED), on 06/27/18 at 3:56 PM, Resident #1's daughter suspected the resident had sustained a fall and requested an investigation. The ED stated, he told Resident #1's daughter there was no documentation of a fall, so a fall was unlikely; however, the facility initiated an investigation at her insistence. Per the ED, the facility initiated their investigation into the fall on 06/05/18. Further interview revealed, the facility was not notified of the fall until 06/06/18. Additional interview revealed, on 06/06/18 SRNA #1 and SRNA #2 went to the DHS and reported there was a fall on 06/03/18. Per interview, the physician was notified of the fall on 06/06/18 once it was known that there was a fall and the care plan was updated accordingly. Per interview, it was his expectation that SRNAs report any fall to the nurse immediately. Per interview, it was also his expectation that the nurse would assess the resident, document a fall event, notify the physician, and notify the family of the resident. Continued interview revealed, it was important to notify the physician to let them know what had happened and they could determine if the resident needed to be sent to the ER, required a new order, or needed pain medication adjusted for the fall. ED stated, this notification was not performed by the initial nurse. The ED stated, SRNA #1, SRNA #2, and LPN #1 were terminated as a result of this incident.

Based on interview, record review and review of the facility's policies, it was determined the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (1) of four (4) sampled residents, Resident #1. The findings include: Review of Lippincott's Manual of Nursing Practice, 9th Edition, Chapter 2, Standards of Practice revealed, the practice of professional nursing had standards of practice setting minimum levels of acceptable performance for which its practitioners were accountable. Standards and parameters typically consist of a simple, realistic series of steps that would be applicable given the same or similar clinical scenario. Continued review revealed, a deviation from the protocol should be documented in the patient's chart with clear, concise statements of the nurse's decisions, actions, and reasons for the care provided, including any apparent deviation. This should be done at the time the care was rendered because passage of time may lead to a less than accurate recollection of the specific event. Further review revealed, the standards of care for professional nursing include assessment, diagnosis, outcome identification, planning, implementation, and evaluation. Review of the facility's Comprehensive Care Plan Guidelines, reviewed 05/22/18, revealed the purpose was to ensure appropriateness of services and communication that would meet the resident's needs, severity/stability of conditions, impairment, disability, or disease in accordance with state and federal guidelines. Continued review revealed, care plan interventions should be reflective of risk areas or disease processes that impact the individual resident. Per the guidelines, should new identified areas of concern arise during the resident's stay, they should be addressed on the care plan. Further review revealed, the comprehensive care plan should be revised to reflect changes in the resident's condition as they occur. Review of the facility's Fall Management Program Guidelines, reviewed 05/22/18, revealed the purpose was to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures. Further review revealed, a fall was considered to be an unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force. Unless there was evidence suggesting otherwise, when a resident was found on the floor, a fall was considered to have occurred. Continued review revealed, should a resident experience a fall, the nurse shall complete the Fall Event report which included an investigation into the circumstances surrounding the fall to determine the cause, a reassessment to identify possible contributing factors, interventions to reduce risk of repeat episodes and a review by the Interdisciplinary Team (IDT) to evaluate thoroughness of the investigation and appropriateness of the interventions. Additional review revealed, the attending physician, medical director (in the absence of the attending physician), and the responsible party should be notified. The resident care plan should be updated to reflect any new or change in interventions. Nursing staff would monitor and document continued resident response and effectiveness of interventions for seventy-two (72) hours. Review of the facility's Notification of Change in Condition policy, reviewed 05/23/18, revealed the purpose was to ensure appropriate individuals were notified of a change in condition. Continued review revealed, the facility must inform the resident, consult with the resident's physician and if known notify the resident's legal representative when an accident involving the resident which results in an injury and had the potential for requiring physician intervention. Per the policy, the physician should be notified immediately of a fall with significant injury (i.e. suspecting a fracture). Further review revealed, the responsible party should be notified of change in condition or diagnostic testing results in a timely manner. Review of Resident #1's medical record revealed he/she was admitted by the facility, on 04/20/18, with [DIAGNOSES REDACTED]. Review of Resident #1's Admission Minimum Data Set (MDS) Assessment, dated 04/27/18 revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status (BIMS) score of six (6) out of fifteen (15), indicating severe cognitive impairment. Continued review revealed, the facility assessed Resident #1 to require extensive two (2) person physical assist with bed mobility, transfers, locomotion on the unit, dressing, toilet use and personal hygiene. Resident #1 was also assessed by the facility to be frequently incontinent of bladder and occasionally incontinent of bowel. Further review revealed, Resident #1 was not assessed to require the use of bed rails or alarms. Review of Resident #1's comprehensive care plan, dated 04/30/18, revealed the facility assessed Resident #1 as being at risk for falls. Continued review revealed, the goal was that Resident #1 would remain free from falls with major injury. Interventions in place included: keeping the call light in reach, keeping personal items and frequently used items within reach, providing non-skid footwear, assure the floor was free of liquids and foreign objects, encourage/assist resident to assume a standing position slowly, therapy evaluation and treat as needed and two (2) person assist with transfers. Review of Resident #1's Admission Fall Risk Assessment, dated 04/20/18, revealed Resident #1 had a fall in the last month prior to admission to the facility and used a wheelchair for mobility. Review of Nurse's Notes for Resident #1, dated 06/03/18 at 10:15 PM, written by Licensed Practical Nurse (LPN) #2 revealed, Resident #1 complained of left hip pain and was unable to perform range of motion. Continued review revealed, LPN#2 obtained an order for [REDACTED].#1 revealed, a mobile x-ray service arrived at 11:02 PM, to perform an x-ray of Resident #1's left hip and left lower extremity. Additional review revealed, no documented evidence dated 06/03/18, Resident #1 sustained a fall on 06/03/18. Review of the Radiology Report, dated 06/04/18 at 3:20 AM, for Resident #1's left hip and left lower extremity revealed Resident #1 had an acute fracture of left superior and inferior rami (located in the pelvis). Review of the facility's investigation revealed, the facility initiated the investigation on 06/05/18 due to an injury of unknown origin. Further review of the facility's investigation revealed, on 06/03/18 at approximately 10:15 PM, Resident #1 complained of pain. LPN #2 administered pain medication for the complaint of pain as well as called the doctor to obtain an order for [REDACTED].#1 and SRNA #2. Per the statements, on 06/03/18, SRNA #1 and SRNA #2 found Resident #1 sitting on the floor of his/her bathroom with his/her walker nearby after he/she had sustained a fall. Per the statements, the SRNA's reported the incident to Licensed (LPN) #1 who instructed SRNA #1 and SRNA #2 to put Resident #1 in his/her recliner chair. SRNA #1 reported, LPN #1 told SRNA #1 and SRNA #2 that she was not going to fill out the incident report because it appeared there was nothing wrong with Resident #1. Additional review of the investigation report revealed, a statement from Licensed Practical Nurse (LPN) #1, dated 06/06/18 at 4:20 PM, unsigned, revealed she initially claimed Resident #1's injury occurred as a result of being assisted onto the toilet. Per the report, when the facility advised LPN #1 that SRNA #1 and SRNA #2 reported on 06/03/18, they found Resident #1 in the bathroom on the floor, LPN #1 confirmed Resident #1 did fall. When asked why she didn't report the fall, LPN #1 stated Resident #1 didn't appear to be hurt. The final report of the facility's investigation, dated 06/11/18, revealed Resident #1 had sustained a fall on 06/03/18 and his/her injury was a result of that fall. Interview with SRNA #2, on 06/27/18 at 10:28 AM, revealed she had worked from 2:00 PM to 10:00 PM on 06/03/18. Continued interview revealed, she and SRNA #1 were responding to another resident's call light when they noticed Resident #1 was not sitting in his/her chair. Per interview, SRNA #1 and SRNA #2 entered Resident #1's room and did not see him/her so they decided to look in Resident #1's bathroom. Upon looking into Resident #1's bathroom, they found him/her on the floor of the bathroom sitting on his/her bottom. Per interview, SRNA #1 instructed SRNA #2 to stay with Resident #1 while SRNA #1 went to get the nurse. SRNA #1 and LPN #1 came back into the bathroom and LPN #1 instructed SRNA #1 and SRNA #2 to pick him/her up and assist him/her back into his/her recliner chair. Further interview revealed, once Resident #1 was back in his/her recliner, LPN #1 stated that she was not going to fill out an Incident Report. SRNA #2 was unable to recall the reason LPN #1 gave for not filling out the incident report. Interview with Licensed Practical Nurse (LPN) #1, on 6/26/18 at 3:32 PM, revealed she had been employed at the facility for 2 years and worked 6:00 AM to 6:00 PM on 06/03/18. LPN #1 stated that she was administering another resident's medications around 2:30 PM, when SRNA #1 came and got her, saying that Resident #1 was on the floor in the bathroom. LPN #1 stated she assessed Resident #1 upon her arrival and found Resident #1 without obvious injury. After assessing Resident #1, LPN #1 instructed SRNA #1 and SRNA #2 to assist Resident #1 back into his/her recliner chair. LPN #1 stated that Resident #1 walked 4 or 5 steps back to the recliner with no complaints of pain. LPN #1 stated she did not fill out an incident report for Resident #1's fall nor did she document the post-fall physical assessment because I was in the middle of med pass and was too busy to fill it out. LPN #1 stated she asked the resident several times throughout the rest of the shift if he/she was in pain and he/she said no; however, she did not document this in Resident #1's nurses notes. Further interview revealed, she did not notify Resident #1's physician or responsible party of the fall because she was too busy. Per interview, she should have filled out the incident report, documented her assessment of Resident #1, notified the physician and the resident's representative. LPN #1 stated, the importance of documenting an incident, such as a fall, was to ensure other staff were up to date on the resident's status and to be able to provide appropriate care to the resident. LPN #1 stated, it was important to notify the physician in case they wanted to give new orders and it was important to notify the representative so they could be kept up to date on the care and status of the resident. Interview with LPN #2, on 06/27/18 at 3:35 PM, revealed she had been employed at the facility for one and a half years and worked 6:00 PM to 6:00 AM on the 06/03/18. LPN #2 stated, she did not receive any information in the shift report provided by LPN #1, that Resident #1 had fallen earlier in the day. LPN #2 stated, Resident #1 was sitting in his/her chair when she started her shift at 6:00 PM on 06/03/18. LPN #2 stated, Resident #1 complained of pain at approximately 6:30 PM and received a pain pill. LPN #2 stated, Resident #1 again complained of pain when being assisted to bed at approximately 10:15 PM. LPN #2 stated, upon her assessment, Resident #1 was unable to perform range of motion using the left lower extremity and was unable to bear weight on the left lower extremity while being assisted into bed. LPN #2 stated, she called the attending physician at approximately 10:30 PM, after Resident #1 was assisted to bed and obtained an order for [REDACTED].#2 stated, the x-ray was taken at approximately 11:00 PM. Further interview revealed, Resident #1's daughter was in the room when Resident #1 was being assisted into bed and was aware of the order for an x-ray. LPN #2 stated, the results of the x-ray arrived by facsimile at approximately 4:00 AM on 06/04/18. Continued interview revealed, LPN #2 called the physician and left a message requesting a return call to relay the results of the x-ray. LPN #2 stated, when she left at approximately 6:00 AM, on 06/04/18, the physician had not called back to receive the x-ray results. Interview with Advance Practice Registered Nurse (APRN), on 06/27/18 at 3:46 PM, revealed it was her expectation that staff always notify us of any fall. Continued interview it was important for staff to report all falls, especially geriatric falls because older people were more prone to injury than a younger person and so she and/or the attending physician could give new orders if required. Per interview, any geriatric fall should be reported, even if they slide down or are eased to the floor. Further interview revealed, neither she nor the attending physician were notified of Resident #1's fall on 06/03/18 but were notified a few days later. Interview with the Director of Health Services (DHS), on 06/27/18 at 2:14 PM, revealed it was her expectation that SRNAs notify the nurse immediately if they find a resident on the floor. It is also her expectation that nurses would assess the resident, complete a fall event report, notify the physician and resident representative immediately after ensuring the safety of the resident as outlined in the facility policy. Per interview, she was notified of the fall on 06/06/18, when SRNA #1 and SRNA #2 reported the fall Resident #1 sustained on 06/03/18. Continued interview revealed, SRNA #1 and SRNA #2 told her that LPN #1 stated, she was not going to fill out a fall since the resident did not appear hurt and instructed SRNA #1 and SRNA #2 to keep it (the fall) quiet. Further interview revealed, LPN #1 should have assessed the resident, gotten Resident #1 to a safe position, filled out the fall event, and notified the physician and the family of Resident #1. The DHS stated, all staff were educated on the policy and procedure for reporting falls on hire and periodically as needed. Additional interview revealed, the care provided to Resident #1 by LPN #1 did not meet the standards of nursing practice and was not an acceptable quality of care. Interview with the Executive Director (ED), on 06/27/18 at 3:56 PM, Resident #1's daughter suspected the resident had sustained a fall and requested an investigation. The ED stated, he told Resident #1's daughter there was no documentation of a fall, so a fall was unlikely; however, the facility initiated an investigation at her insistence. Per the ED, the facility initiated their investigation into the fall on 06/05/18. Further interview revealed, the facility was not notified of the fall until 06/06/18. Additional interview revealed, on 06/06/18 SRNA #1 and SRNA #2 went to the DHS and reported there was a fall on 06/03/18. Per interview, the physician was notified of the fall on 06/06/18 once it was known that there was a fall and the care plan was updated accordingly. Per interview, it was his expectation that SRNAs report any fall to the nurse immediately. Per interview, it was also his expectation that the nurse would assess the resident, document a fall event, notify the physician, and notify the family of the resident. Continued interview revealed, it was important to notify the physician to let them know what had happened and they could determine if the resident needed to be sent to the ER, required a new order, or needed pain medication adjusted for the fall. ED stated, this notification was not performed by the initial nurse. Per interview, the care provided to Resident #1 by LPN #1 did not meet the standards of nursing practice nor was it care of an acceptable quality. The ED stated, SRNA #1, SRNA #2, and LPN #1 were terminated as a result of this incident.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (1) of four (4) sampled residents, Resident #1. The findings include: Review of Lippincott's Manual of Nursing Practice, 9th Edition, Chapter 2, Standards of Practice revealed, the practice of professional nursing had standards of practice setting minimum levels of acceptable performance for which its practitioners were accountable. Standards and parameters typically consist of a simple, realistic series of steps that would be applicable given the same or similar clinical scenario. A deviation from the protocol should be documented in the patient's chart with clear, concise statements of the nurse's decisions, actions, and reasons for the care provided, including any apparent deviation. This should be done at the time the care was rendered because passage of time may lead to a less than accurate recollection of the specific event. The standards of care for professional nursing include assessment, diagnosis, outcome identification, planning, implementation, and evaluation. Review of the facility's Comprehensive Care Plan Guidelines, reviewed 05/22/18, revealed the purpose was to ensure appropriateness of services and communication that would meet the resident's needs, severity/stability of conditions, impairment, disability, or disease in accordance with state and federal guidelines. Continued review revealed, care plan interventions should be reflective of risk areas or disease processes that impact the individual resident. Should new identified areas of concern arise during the resident's stay, they should be addressed on the care plan. The comprehensive care plan should be revised to reflect changes in the resident's condition as they occur. Review of the facility's Fall Management Program Guidelines, reviewed 05/22/18, revealed the purpose was to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures. Further review revealed, a fall was considered to be an unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force. Unless there was evidence suggesting otherwise, when a resident was found on the floor, a fall was considered to have occurred. Continued review revealed, should a resident experience a fall, the nurse shall complete the Fall Event report which included an investigation into the circumstances surrounding the fall to determine the cause, a reassessment to identify possible contributing factors, interventions to reduce the risk of repeat episodes and a review by the Interdisciplinary Team (IDT) to evaluate thoroughness of the investigation and appropriateness of the interventions. Further review revealed, the attending physician (medical director in the absence of the attending physician) and the responsible party should be notified. The resident care plan should be updated to reflect any new or change in interventions. Nursing staff would monitor and document continued resident response and effectiveness of interventions for seventy-two (72) hours. Review of the facility's Notification of Change in Condition policy, reviewed 05/23/18, revealed the purpose was to ensure appropriate individuals were notified of a change in condition. The facility must inform the resident, consult with the resident's physician and if known, notify the resident's legal representative when an accident involving the resident which resulted in an injury and had the potential to require a physician intervention. The physician should be notified immediately of a fall with significant injury (i.e. suspecting a fracture). Further review revealed, the responsible party should be notified of change in condition or diagnostic testing results in a timely manner. Review of Resident #1's medical record revealed, he/she was admitted by the facility, on 4/20/18, with [DIAGNOSES REDACTED]. Review of Resident #1's Admission Minimum Data Set (MDS) Assessment, dated 04/27/18, revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status (BIMS) score of six (6) out of fifteen (15), indicating severe cognitive impairment. Continued review revealed, the facility assessed Resident #1 to require extensive two (2) person physical assist with bed mobility, transfers, locomotion on the unit, dressing, toilet use and personal hygiene. Resident #1 was also assessed by the facility to be frequently incontinent of bladder and occasionally incontinent of bowel. Further review revealed, Resident #1 was not assessed to require the use of bed rails or alarms. Review of Resident #1's admission fall risk assessment, dated 04/20/18, revealed Resident #1 had a fall in the month prior to admission to the facility and used a wheelchair for mobility. Review of Resident #1's comprehensive care plan, dated 04/30/18, revealed the facility assessed Resident #1 as being at risk for falls. The goal was that Resident #1 would remain free from falls with major injury. Interventions in place included: keeping the call light in reach, keeping personal items and frequently used items within reach, providing non-skid footwear,assure the floor was free of liquids and foreign objects, encourage/assist resident to assume a standing position slowly, therapy evaluation and treatment as needed, and two (2) person assist with transfers. Review of Nurse's Notes for Resident #1, dated 06/03/18 at 10:15 PM, written by Licensed Practical Nurse (LPN) #2 revealed, Resident #1 complained of left hip pain and was unable to perform range of motion. Continued review revealed, LPN#2 obtained an order for [REDACTED].#1 revealed, a mobile x-ray service arrived at 11:02 PM, to perform an x-ray of Resident #1's left hip and left lower extremity. Additional review revealed, no documented evidence dated 06/03/18, Resident #1 sustained a fall on 06/03/18. Review of a Radiology Report, dated 6/4/18 at 3:20 AM, for Resident #1's left hip and left lower extremity revealed, Resident #1 had an acute [MEDICAL CONDITION] superior and inferior rami (located in the pelvis). Review of the facility's investigation revealed, the facility initiated the investigation on 06/05/18 due to an injury of unknown origin. Further review of the facility's investigation revealed, on 06/03/18 at approximately 10:15 PM, Resident #1 complained of pain. LPN #2 administered pain medication for the complaint of pain as well as called the doctor to obtain an order for [REDACTED].#1 and SRNA #2. Per the statements, on 06/03/18, SRNA #1 and SRNA #2 found Resident #1 sitting on the floor of his/her bathroom with his/her walker nearby after he/she had sustained a fall. Per the statements, the SRNA's reported the incident to Licensed (LPN) #1 who instructed SRNA #1 and SRNA #2 to put Resident #1 in his/her recliner chair. SRNA #1 reported, LPN #1 told SRNA #1 and SRNA #2 that she was not going to fill out the incident report because it appeared there was nothing wrong with Resident #1. Additional review of the investigation report revealed, a statement from Licensed Practical Nurse (LPN) #1, dated 06/06/18 at 4:20 PM, unsigned, stating she initially claimed Resident #1's injury occurred as a result of being assisted onto the toilet. Per the report, when the facility advised LPN #1 that SRNA #1 and SRNA #2 reported on 06/03/18, they found Resident #1 in the bathroom on the floor, LPN #1 confirmed Resident #1 did fall. Per the report, when asked why she didn't report the fall, LPN #1 stated Resident #1 didn't appear to be hurt. The final report of the facility's investigation, dated 06/11/18, revealed Resident #1 had sustained a fall on 06/03/18 and his/her injury was a result of that fall. Interview with SRNA #2, on 06/27/18 at 10:28 AM, revealed she had worked from 2:00 PM to 10:00 PM on 06/03/18. Continued interview revealed, she and SRNA #1 were responding to another resident's call light when they noticed Resident #1 was not sitting in his/her chair. Per interview, SRNA #1 and SRNA #2 entered Resident #1's room and did not see him/her so they decided to look in Resident #1's bathroom. Upon looking into Resident #1's bathroom, they found him/her on the floor of the bathroom sitting on his/her bottom. Per interview, SRNA #1 instructed SRNA #2 to stay with Resident #1 while SRNA #1 went to get the nurse. SRNA #1 and LPN #1 came back into the bathroom and LPN #1 instructed SRNA #1 and SRNA #2 to pick him/her up and assist him/her back into his/her recliner chair. Further interview revealed, once Resident #1 was back in his/her recliner, LPN #1 stated that she was not going to fill out an Incident Report. SRNA #2 was unable to recall the reason LPN #1 gave for not filling out the incident report. Interview with Licensed Practical Nurse (LPN) #1, on 6/26/18 at 3:32 PM, revealed she had been employed at the facility for 2 years and worked 6:00 AM to 6:00 PM on 06/03/18. LPN #1 stated that she was administering another resident's medications around 2:30 PM, when SRNA #1 came and got her, saying that Resident #1 was on the floor in the bathroom. LPN #1 stated she assessed Resident #1 upon her arrival and found Resident #1 without obvious injury. After assessing Resident #1, LPN #1 instructed SRNA #1 and SRNA #2 to assist Resident #1 back into his/her recliner chair. LPN #1 stated that Resident #1 walked 4 or 5 steps back to the recliner with no complaints of pain. LPN #1 stated she did not fill out an incident report for Resident #1's fall nor did she document the post-fall physical assessment because I was in the middle of med pass and was too busy to fill it out. LPN #1 stated she asked the resident several times throughout the rest of the shift if he/she was in pain and he/she said no; however, she did not document this in Resident #1's nurse's notes. Further interview revealed, she did not notify Resident #1's physician or responsible party of the fall because she was too busy. Per interview, she should have filled out the incident report, documented her assessment of Resident #1, notified the physician and the resident's representative. LPN #1 stated, the importance of documenting an incident, such as a fall, was to ensure other staff were up to date on the resident's status and to be able to provide appropriate care to the resident. LPN #1 stated, it was important to notify the physician in case they wanted to give new orders and it was important to notify the representative so they could be kept up to date on the care and status of the resident. Interview with LPN #2, on 6/27/18 at 3:35 PM, revealed she had been employed at the facility for one and a half years and worked 6:00 PM to 6:00 AM on the 06/03/18. LPN #2 stated, she did not receive any information in the shift report provided by LPN #1, that Resident #1 had fallen earlier in the day. LPN #2 stated, Resident #1 was sitting in his/her chair when she started her shift at 6:00 PM on 06/03/18. LPN #2 stated, Resident #1 complained of pain at approximately 6:30 PM and received a pain pill. LPN #2 stated, Resident #1 again complained of pain when being assisted to bed at approximately 10:15 PM. LPN #2 stated, upon her assessment, Resident #1 was unable to perform range of motion using the left lower extremity and was unable to bear weight on the left lower extremity while being assisted into bed. LPN #2 stated, she called the attending physician at approximately 10:30 PM, after Resident #1 was assisted to bed and obtained an order for [REDACTED].#2 stated, the x-ray was taken at approximately 11:00 PM. Further interview revealed, Resident #1's daughter was in the room when Resident #1 was being assisted into bed and was aware of the order for an x-ray. LPN #2 stated, the results of the x-ray arrived by facsimile at approximately 4:00 AM on 06/04/18. Continued interview revealed, LPN #2 called the physician and left a message requesting a return call to relay the results of the x-ray. LPN #2 stated, when she left at approximately 6:00 AM, on 06/04/18, the physician had not called back to receive the x-ray results. Interview with Advance Practice Registered Nurse (APRN), on 6/27/18 at 3:46 PM, revealed it was her expectation that staff always notify us of any fall. Per interview, it was important that staff report all falls especially geriatric falls because older people were more prone to injury than a younger person and so she and/or the attending physician could give new orders if required. Continued interview revealed, any geriatric fall should be reported, even if they slide down or are eased to the floor. Further interview revealed, neither she nor the attending physician were notified of Resident #1's fall on 6/3/18 but were notified a few days later. Interview with the Director of Health Services (DHS), on 06/27/18 at 2:14 PM, revealed it was her expectation that SRNAs notify the nurse immediately if they find a resident on the floor. It was also her expectation that nurses would assess the resident after a fall, complete a Fall Event report, notify the physician and resident representative immediately after ensuring the safety of the resident as outlined in the facility policy. Per interview, she was notified of the fall on 06/06/18, when SRNA #1 and SRNA #2 reported the fall Resident #1 sustained on 06/03/18. Continued interview revealed, SRNA #1 and SRNA #2 told her that LPN #1 stated, she was not going to fill out a Fall Event form, since the resident did not appear hurt and instructed SRNA #1 and SRNA #2 to keep it (the fall) quiet. Further interview revealed, LPN #1 should have assessed the resident, gotten Resident #1 to a safe position, filled out the Fall Event form, and notified the physician and the family of Resident #1. The DHS stated, all staff were educated on the policy and procedure for reporting falls on hire and periodically as needed. Additional interview revealed, the care provided to Resident #1 by LPN #1 did not meet the standards of nursing practice and was not an acceptable quality of care. Interview with the Executive Director (ED), on 06/27/18 at 3:56 PM, revealed Resident #1's daughter suspected the resident had sustained a fall and requested an investigation. The ED stated, he told Resident #1's daughter there was no documentation of a fall, so a fall was unlikely; however, the facility initiated an investigation at her insistence. Per the ED, the facility initiated their investigation into the fall on 06/05/18. Further interview revealed, the facility was not notified of the fall until 06/06/18. Additional interview revealed, on 06/06/18, SRNA #1 and SRNA #2 went to the DHS and reported there was a fall on 06/03/18. Per interview, the physician was notified of the fall on 06/06/18, once it was known that there was a fall, the care plan was updated accordingly. Per interview, it was his expectation that SRNAs report any fall to the nurse immediately. Per interview, it was also his expectation that the nurse would assess the resident, document a fall event, notify the physician, and notify the family of the resident. Continued interview revealed, it was important to notify the physician to let them know what had happened and they could determine if the resident needed to be sent to the ER, required a new order, or needed pain medication adjusted for the fall. The ED stated, this notification was not performed by the initial nurse. Per interview, the care provided to Resident #1 by LPN #1 did not meet the standards of nursing practice nor was it care of an acceptable quality. The ED stated, SRNA #1, SRNA #2, and LPN #1 were terminated as a result of this incident.

Based on observation and interviews, it was determined the facility failed to ensure the residents environment was free from accidents and hazards related to observation of six (6) wooden handrails with rough and splintered wood. The findings include: The facility policy on preventative maintenance was requested however, the facility does not have a specific policy on preventative building maintenance. Observation on 07/06/07 at 09:45 AM revealed rough and splintered wood handrails in the Thoroughbred Unit by Room 302, Room 306 and in the hallway by the courtyard. Additionally, rough and splintered wood handrails were noted in the hallway by the Sunroom. Observation on 07/07/17 at 01:45 PM noted rough and splintered handrails in the Calumet Unit by Room 215 and by the Dining Room entrance. Interview with Director of Plant Operations on 07/06/17 at 2:00 PM revealed he had been at the current position for two (2) months; however, he had been employed by facility for over a year. Further interview revealed any staff member could put in a work order for handrail repair but he had not received a work order to repair any handrails. He further stated although the facility did not have a written policy for preventative maintenance, monthly handrail checks were part of the TELS computer maintenance program the facility used and part of his monthly assigned duties. He was unable to state when the handrails had become damaged on the Thoroughbred, Calumet Units or in front of the Dining Room or Sunroom. He was unable to show documentation on the TELS computer program of the last date he had checked the handrails for monthly checks. He stated that it had been done for the month of June, 2017 but could provide no documented evidence of a specific date. Continued interview on 07/07/17 at 02:00 PM revealed the condition of the handrails was important related for the safety of the residents to protect their skin integrity and for them to use the handrails to propel themselves safely. Interview with the Administrator on 07/06/17 at 4:00 PM revealed although there was not a preventative maintenance policy, the Administrator and the Director of Plant Operations made environmental rounds of the facility on Fridays to tour the facility and focus on any issues. Further interview revealed the facility was currently trying to hire a part time assistant to help the Director of Plant Operations with maintenance tasks but as of the time of this survey the Director of Plant Operations was the only Maintenance person and was also the head of Housekeeping. The Administrator did not know why the rough and splintered handrails had not been found on the weekly rounds. Continued interview on 07/07/17 at 02:00 PM revealed the condition of the handrails was important related for the safety of the residents to protect their skin and the splintered handrails could cause injury to a resident's hand.

Based on observation, interview and review of the facility's policy, it was determined the facility failed to ensure food was dated with open dates prior to storing. Observation during the initial tour of the kitchen on 07/05/17 at 09:15 AM, revealed foods in the freezer were not labeled with an open date prior to placing the open containers back into the freezer. The findings include: Review of the facility's policy titled Food Labeling and Dating Policy effective date 05/31/16, revealed any food product removed from its original container, has a broken seal, has been processed in any way must have a label with item name, date and time labeled, use by date, and initials of person labeling the item. Observation during initial tour of the kitchen on 07/05/17 at 9:15 AM, revealed a box with multiple frozen Bread Sticks delivery date 06/13/17 with the seal broken and no open date/label; a box of Rich's frozen Yeast Dough (multiple) with delivery date of 06/12/17 with the seal broken and no open date/label; a box of GFS frozen Green Peas with a delivery date of 06/23/17 with the seal broken, and no open date/label; a box of frozen Cauliflower Florets with a delivery date of 06/05/17 with the seal broken (open bag), and no open date/label; a box of Kitchen Essentials frozen Mixed Vegetables with a delivery date of 06/23/17, with the seal broken and no open date/label; and a box of Rich's Cream Puff Shells (multiple) with a delivery date 05/16/17, that was open and had no date/label. Interview with Food Services Associate on 07/07/17 at 2:28 PM, revealed delivered foods are to be labeled with name, delivery date, and time and then dated when opened because if foods were kept too long they may make a resident sick. Interview with Director of Dining Services on 07/06/17 at 8:40 AM, revealed he/she was initially not aware of the policy. The Director of Dining Service stated he/she never thought of frozen foods expiring because they were cooked and the temperature was checked prior to serving; however, the facility should follow the policies. Interview with the Executive Director on 07/07/17 at 4:20 PM, revealed his/her expectation regarding food labeling was that open foods be labeled with a use by date. She further stated correct food labeling allows dietary staff to know when foods expire, and knowing expiration dates would eliminate foodborne illness.

Based on observations, interviews and review of the facility's policy, it was determined that the facility failed to ensure the development of a comprehensive care plan for one (1) of fifteen (15) sampled residents (Resident #9). Review of Resident #9's Comprehensive Care Plan revealed that although the resident was admitted to the facility with an order for [REDACTED]. The findings include: Review of the facility's policy titled Guidelines for Pain Observation and Management revised date 05/23/17, revealed procedures include: (1) Initiate a plan of care related to chronic, acute, or breakthrough pain; (2) Implement the care plan approaches to assist with pain management; and (3) Evaluate the effectiveness of pain management interventions and modify as indicated. Review of the medical records revealed Resident #9 was admitted by the facility on 12/30/16 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) for Resident #9 dated 01/06/17, revealed that although pain did not trigger for the Care Area Assessment (CAA), Section J0300 and J0400 revealed that pain was occasionally present. Review of the Medication Administration Record [REDACTED]. Review of the Comprehensive Care Plan for Resident #9, with the latest care conference date of 01/17/17, revealed no documented evidence the facility developed a care plan related to Resident #9's pain and use of pain medication. Interview with Licensed Practical Nurse (LPN) #2 on 07/07/17 at 2:30 PM, revealed residents' pain was assessed at the beginning of each shift, any time they complain of pain, or have non-verbal behaviors that could indicate pain; however, the only area in the medical record to chart pain assessment is for as needed (prn) pain medications on the MAR, the beginning of shift assessment, or on Medicare Skilled Nursing Assessments. Further interview revealed that LPN #2 agreed that Resident #9 should have a care plan for pain and the use of pain medications. Interview with the Campus Assessment Support Staff on 07/07/17 at 2:45 PM, revealed a resident whom has a [MEDICATION NAME] Patch and prn [MEDICATION NAME] ordered, should have pain included in the Comprehensive Care Plan (CCP). Further interview revealed that pain assessment was not included in the scheduled pain medication order set. Interview with the Director of Health Services (DHS) on 07/07/17 at 4:04 PM, revealed her/his expectations regarding resident pain assessments was that pain assessments would be completed on admission, quarterly, and with any significant change. Further interview revealed there were several places in the electronic medical record for nurses to document pain assessment which included the quarterly assessment form in the Matrix, a nursing progress note, during administration of an ordered prn medication, or a nurse can initiate a pain event if there was new pain. Additional interview also revealed that pain should be included on the care plan if the resident has pain medications ordered, even if it is not triggered on the CAA, so that all staff was aware. In addition, a resident's pain needed to be assessed (if on a pain patch) and the resident should be monitored for potential side effects or adverse effects of the medication. Interview with the Executive Director on 07/07/17 at 4:20 PM, revealed the following: 1) If a resident is having pain, it should be assessed; 2) If a resident has scheduled pain medication ordered, they must be assessed either verbally or nonverbally; and 3) All residents should have a care plan that addresses all of their needs, the care plans are reviewed during morning meeting, and the CCP should match the MDS and the Certified Nursing Assistant (CNA) care plan.

Based on observation, interview, and review of facility policy, it was determined the facility failed to store food under sanitary conditions. During initial tour on 06/28/16 at 10:15 AM a refrigerator shared by the 100 Unit, 200 Unit, and 300 Unit was found to have unlabeled and undated food items, as well as expired food items. Further observation revealed the refrigerator Temperature Log for the refrigerator shared by the three (3) units had not been maintained since 06/14/16. Then findings include: Review of the facility policy, titled Food Labeling and Dating Policy, undated, revealed all food items were to be labeled and dated, and any product removed from it's original container must also be initialed by the person labeling the item. Observation during initial tour on 06/28/16 at 10:15 AM revealed a refrigerator in the Keeneland Cafe area of the facility shared by the 100 Unit, 200 Unit, and 300 Unit, contained a plastic McDonalds bag containing what appeared to be a breaded chicken salad with no label or date, and a small box labeled Puccini's with a room number, but no date containing three (3) pieces of a personal pizza, on the top shelf. Just beneath the McDonalds bag was an unopened plastic cake container with a white frosted birthday cake covered with cherries, with a date of 06/10/16 and a note which read please help yourself. A chicken biscuit in a clear plastic wrapper with no label or date, was also on the second shelf from the top. The doorway of the refrigerator contained a single serving plastic container of what appeared to be whipped cream with cherries desert, which was not labeled or dated and a single serving glass bowl of what appeared to be cottage cheese, covered with plastic wrap, with no label or date. Review of the refrigerator Temperature Log, on 06/28/16 at 10:15 AM, in the Keeneland Cafe area, revealed the refrigerator temperatures for the refrigerator shared by the three (3) units had not been consistently documented since 06/14/16. Interview with Registered Nurse (RN) #1, on 06/28/16 at 10:34 AM, revealed she believed night shift was responsible for checking the refrigerator temperatures and that activities staff were responsible for maintaining the refrigerator. Interview with the Life Enrichment Director on 06/28/16 at 10:39 AM revealed housekeeping was responsible for cleaning the area, and she wasn't certain who was responsible for the refrigerator or for maintaining the temperature log. She revealed activities sometimes used the counter space and the stove, but any items they used in the activities program were stored in the kitchen by dietary staff. Interview with the Director of Food Services (DFS), on 06/28/16 at 10:50 AM, revealed it was dietary's responsibility to maintain the refrigerator, although it was open to residents. He revealed it was important to ensure the refrigerator temperatures were checked and documented because food items could spoil if stored at incorrect temperatures, and residents could get sick if eating spoiled food. He further stated food items needed to be labeled and dated in order to know how long the items had been stored, and residents could get sick if outdated food items. In a further interview with the DFS, on 06/28/16 at 3:03 PM, he revealed maintaining the Keeneland Cafe refrigerator had fallen by the wayside. He stated it was dietary's responsibility to maintain the temperature log as well as food items in the refrigerator. Interview with the Director of Post Acute Services (DPAS) on 06/29/16 at 3:16 PM, revealed temperatures should be maintained and food items should be stored according to regulation. She revealed she wasn't certain why it hadn't been done.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure the Physician and the resident's Power of Attorney (POA) were notified in a timely manner, for one (1) of six (6) sampled residents, (Resident #1). The facility failed to immediately notify the Physician and the POA for Resident #1, after Resident #1 received the wrong medications on 02/02/13. In addition, when the Nurse Practitioner was initially notified, she was given insufficient information regarding the medications Resident #1 was given, therefore delaying Resident #1 being sent to the hospital. On 02/02/13 at approximately 9:00 AM, Registered Nurse (RN) #1 administered Resident #2's medications to Resident #1, which included [MEDICATION NAME] HCL (a medication given for [MEDICAL CONDITION] Fibrillation), Tramadal (a controlled medication given for mild to moderate pain), [MEDICATION NAME] (a medication given for Hypertension (HTN), [MEDICATION NAME] (a medication given for nerve pain),[MEDICATION NAME](a medication given for HTN), [MEDICATION NAME] (a medication given for HTN), [MEDICATION NAME] (a controlled medication given for anxiety), and Levumir (a long acting insulin) 25 Units Subcutaneous. Interview and record review revealed the significant medication error was identified at approximately 9:45 AM after a change in Resident #1's alertness was noted by the resident's sitter. On 02/02/13 at 11:30 AM, Resident #1 was transferred to the hospital by Emergency Medical Services and admitted to the Intensive Care Unit (ICU) with a [DIAGNOSES REDACTED]. The resident was hospitalized for [REDACTED]. Interview with the Nurse Practitioner revealed she had been notified at approximately 10:00 AM of the medication error; however, she was not given the entire list of medications Resident #1 had received nor had she been given vital signs taken after the medication error had occurred. She further stated at approximately 11:00 AM, LPN #1 sent her a text stating Resident #1's blood pressure (BP) had dropped and he/she had became increasingly lethargic, and the family had requested Resident #1 be sent to the hospital. She stated she gave LPN #1 the order to send Resident #1 to the hospital at that time; however, had she been given the correct information the first time LPN #1 notified her at 10:00 AM, she would have sent Resident #1 to the hospital immediately. Interview with the POA revealed the facility did not notify her of the incorrect medications given to Resident #1; she was notified by Resident #1's sitter. The facility's failure to ensure an effective system was in place to ensure timely Physician and responsible party notification of a change in condition, which was likely to cause a risk for serious injury, harm, or impairment or death. The Immediate Jeopardy was identified on 02/09/13, and was determined to exist on 02/02/13. The facility was notified of the Immediate Jeopardy on 02/09/13. The facility provided an acceptable Allegation of Compliance (AOC) on 02/14/13, with the facility alleging removal of the Immediate Jeopardy on 02/14/13. The Immediate Jeopardy was verified to be removed on 02/15/13, with remaining non-compliance at 42 CFR 483.10 Resident Rights, F-157 at a S/S of a "D" while the facility develops and implements the facility's Plan of Correction (POC) and the facility's Quality Assurance Program continues to monitor to ensure the Physicians and the residents' responsible party are notified in a timely manner of any changes in conditions. The findings include: Review of the facility policy titled, "Guidelines for Medication Error Reporting", dated 11/2010, revealed in the event of a medication error, nursing personnel should first take whatever immediate action is necessary to protect the resident's safety and welfare, and notify the Physician promptly of the error. Further review revealed, nursing staff should also notify the resident's responsible party. Review of the Medication Error Circumstance, Assessment and Intervention sheet, dated 02/02/13 at 8:00 AM, revealed Resident #1 received the wrong medication. Further review revealed, the section staff was to write the name and dose of the wrong medication, LPN #1 had written "see the MAR" for Resident #2. Further review revealed LPN #1 wrote Resident #1 was sedated and had a low blood pressure, and was lethargic. Review of the Fire and Emergency Services report, dated 02/02/13, revealed at 11:30 AM they arrived at the facility. Further review revealed the facility had reported Resident #1 was mistakenly given another resident's medications at 9:00 AM, which included [MEDICATION NAME] 30 mg and long acting insulin. It was further reported Resident #1 demonstrated a decreased level of consciousness and had a decreased blood pressure from his/her baseline, and the resident was placed in a modified trendelenburg position. Further review revealed Resident #1's blood pressure was 82/40 and heart rate of fifty-six (56), upon Emergency Medical Service (EMS) arrival and upon arrival to the hospital, Resident #1's blood pressure was 78/30 and a heart rate of fifty (50). Review of the hospital records, dated 02/02/13, revealed Resident #1 received [MEDICATION NAME] (prevents or reverses the effects of opioids including respiratory depression, sedation and [MEDICAL CONDITION]) 1 MG and 400 Milliliters (ML) of normal saline via Intravenous Infusion (IV) in the ambulance in route to the hospital. Resident #1 was started on a [MEDICATION NAME] drip (Suddenly Serious Symptoms of Heart Failure, Decrease in the Amount of Work the Heart Does, Sudden Drop in Blood Pressure) which was titrated from 3 MG to 12 MG to maintain Resident #1's blood pressure. Further review revealed Resident #1 showed [MEDICAL CONDITION] Fibrillation on the cardiac monitor; the resident's oxygen saturation dropped to eighty-nine (89) percent, and he/she was placed on a non-rebreather at ten (10) liters of oxygen. Record review revealed Resident #1's blood sugar was 119 when he/she first arrived to the Emergency Department at 11:50 AM and at 2:30 PM his/her blood sugar had dropped to ninety-three (93). The resident was admitted to the Intensive Care Unit (ICU) with a [DIAGNOSES REDACTED]. Review of Resident #1's medical chart revealed the facility admitted Resident #1 on 01/13/13 with [DIAGNOSES REDACTED]. Review of the admission Minimal Data Set (MDS) Assessment, dated 01/25/13, revealed the facility assessed Resident #1 as having a Brief Interview for Mental Status (BIMS) of three (3) out of fifteen (15), indicating the resident was cognitively impaired. Interview on 02/08/13 at 3:30 PM with Resident #1's roommate, Resident #3, whom the facility had assessed being cognitive intact with a BIMS of 15, revealed on 02/02/13 he/she went to the bathroom at approximately 9:00 AM. Resident #3 stated he/she overheard the nurse tell Resident #1 she was going to give the resident an insulin shot and his/her other medications. She further stated it was about 9:45 AM, when Resident #1's sitter arrived at the facility and she asked the sitter if Resident #1 took insulin shots because he/she had overheard the nurse tell Resident #1 she was going to give him/her an insulin shot. Interview with Resident #1's sitter, on 02/08/13 at 5:30 PM, revealed she arrived at the facility at approximately 9:45 AM on 02/02/13. She stated as soon as she walked in the room, Resident #3 asked her if Resident #1 took insulin shots because he/she had overheard the nurse tell Resident #1 she was going to give him/her an insulin shot. She stated she had gone out into the hall way and asked LPN #1 if she had given Resident #1 an insulin shot, and it was approximately ten (10) minutes later when LPN #1 came to the room and stated Resident #1 had received an insulin shot. Further interview revealed, she was the one who notified Resident #1's POA about the medication error as well as the change in Resident #1's condition. Interview with Resident #1's daughter, on 02/08/13 at 6:00 PM, revealed Resident #1's sitter called her at approximately 10:00 AM and informed her Resident #1 had received an insulin shot. She stated the sitter was the only person who called her related to the medication error and the change in condition. Interview with RN #1, on 02/09/13 at 10:00 AM, revealed 02/02/13, at approximately 9:00 AM she entered Resident #1's room without looking at the name on the door, and proceeded to administer Resident #2's medications to Resident #1, without asking Resident #1 what his/her name was. She stated she could not recall how long it was before LPN #1 came to her and asked if she had given Resident #1 an insulin shot, but this was when they realized the medication error had occurred. She stated LPN #1 took over and instructed her to bring her a set of vital signs. She stated the Certified Nursing Assistants (CNA) had taken Resident #1's vital signs prior to the medication administration (approximately 8:00 AM), and these were the vital signs given to the Nurse Practitioner when she was notified by LPN #1 at approximately 9:45 AM. She further stated she should have taken a new set of vital signs before calling the Nurse Practitioner. She stated everything happened so fast and she could not remember exactly when Resident #1's vital signs were taken or when the POA was notified. She further stated the Nurse Practitioner should have been given the entire list of medications Resident #1 received and the POA should have been notified by the nursing staff. Interview with LPN #1, on 02/09/13 at 11:00 AM, revealed she was going to answer the call light in Resident #1's room when Resident #1's sitter asked her if Resident #1 had received an insulin shot. She stated she asked RN #1 if she had given Resident #1 an insulin shot and at this time RN #1 stated she had given Resident #2 his/her medications, and it was at this time they realized she had given Resident #1 all of Resident #2's morning medications. She stated she thought RN #1 had taken Resident #1's vital signs after they had discovered he/she had received the wrong medications. She stated she notified the Director of Health Services (DHS) of the medication error and then she sent the Nurse Practitioner a text stating Resident #1 had been given Resident #2's medications. She stated she then called the Nurse Practitioner and reported to her the medications Resident #1 received and the vital signs that RN #1 had given her. She stated she thought she had given the entire list of medications administered to Resident #1 to the Nurse Practitioner; however, she could not say for sure. Further interview revealed, LPN #1 could not give any of the times in which she notified the Nurse Practitioner and performed an assessment of Resident #1, which she said included blood sugar check and vital signs check; however, there was no documented evidence of the notification or any type of assessments in Resident #1's medical record. Further interview revealed, at no time did LPN #1 call Resident #1's POA, but had been handed the sitter's cell phone when the POA requested to speak with her. She further stated she should have called the POA before that time. Interview with the DHS, on 02/09/13 at 9:00 PM, revealed LPN #1 called her at home and reported to her Resident #1 had received all of Resident #2's medications, as soon as the medication error was identified, which was at approximately 10:00 AM, and she came straight to the facility. Further interview revealed, when a nurse calls a physician about a medication error, the nurse should have named all of the medications the resident received as well as give vital signs taken after the medication error occurred. She further stated after a medication error has occurs and the Physician has been notified, staff should have notified the resident's POA. Interview with the Nurse Practitioner, on 02/11/13 at 9:55 AM, revealed on 02/02/13 at approximately 10:00 AM she received a text from the facility stating Resident #1 had received two (2) blood pressure medications he/she did not normally take and a slow acting insulin, and the vital signs the nurse gave her was normal; therefore, she was not concerned. She stated she gave an order to monitor Resident #1's vital signs every hour for four (4) hours and then every four (4) hours for twenty-four (24) hours, and to check his/her blood sugar before lunch, dinner, and before bed time. She stated she was not notified of any changes in Resident #1's condition until approximately 11:00 AM, when she received a text from the facility stating Resident #1's blood pressure had dropped and the daughter was wanting the resident sent to the hospital. She stated had she been informed of all of the medications Resident #1 had received and been given the first set of vital signs taken after the medication error occurred (which were B/P of 79/38, Respirations of 16 and Heart Rate of 80), she would have given the order to send Resident #1 out right then. She further stated at no time did LPN #1 state Resident #1 had received all of Resident #2's medications. She further stated she did not feel she was completely informed of the medication error and the change in Resident #1's status, and she was not notified in a timely manner considering the error occurred at approximately 9:00 AM and the first text she received was approximately 10:00 AM. Review of the Physician Orders, dated 02/02/12 at 9:45 AM, revealed a telephone order to monitor Resident #1's vital signs every four (4) hours for twenty-four (24) hours and to test Resident #1's blood sugar before lunch, dinner, and bed time. Further review of the Physician Orders, dated 02/02/13 at 11:00 AM, revealed a telephone order from the Nurse Practitioner to send Resident #1 to the hospital. Interview with Resident #1's Primary Physician/Medical Director, on 02/11/13 at 10:05 AM, revealed had he been made aware of all the medications Resident #1 was given, he would have given the order to send the resident to the hospital at that time. The facility provided an acceptable AOC on 02/14/13 that alleged the removal of the IJ was effective on 02/14/13. Review of the AOC revealed the facility implemented the following: All residents, including Resident #1 were observed by the DHS on 02/02/13 for any signs and symptoms different from their baseline. The DHS interviewed all licensed staff on duty on 02/02/13 to confirm no other residents had experienced an inadvertent medication error and that none were exhibiting an signs of symptoms different from their normal baseline. On 02/02/13 the DHS ensured that RN #1 did not administer any additional medications following the medication error and initiated an investigation related to the medication error. In addition, on 02/02/13, the DHS conducted a 100% review of all current residents' clinical records to verify that all methods of resident identification: photos on MAR/TAR, name on door and name on MAR/TAR were present. The DHS, Clinical Campus Support (CCS), Assistant Director of Health Service (ADHS), and the DHS, initiated in-service education on 02/10/13 at 12:00 PM and completed on 02/11/13 at 2:00 PM. This in-service for all licensed nurses included the following: 1) "Specific Medication Administration Procedures" to include noting the correct time, dose, route, medication, and resident identification. 2) "Specific Medication Administration Procedures" related to identification of correct resident. This included discussion of all available identification resources for resident identification including verifying residents names on the door, MAR/TAR, review of the photo, have resident tell the nurse their name or have another facility personnel identify the resident. 3) A "Specific Medication Administration Clinical Competency" was completed on all nurses with a mock resident demonstration using at least two (2) forms of identification prior to medication administration. On 02/11/13 the nurses were also observed while completing their medication pass and this is on going. 4) Assessment, monitoring, and documentation requirements on the evening that a medication error occurred. This included the nurses being given a hypothetical medication error scenario and having them complete "mock" timely Physician notification, assessment and monitoring documentation and "Medpass Error Prevention Post Test", in order to validate skill competency. 5) Discussion/Review of the facility policy and procedure for timely Physician Notification was reviewed. This included discussion of critical labs, normal labs, and resident change of condition. In-service education provided related to maintaining complete and accurate clinical records to include documentation of medication errors. The "Medication Error Circumstance Assessment and Intervention Forms" had been modified to accommodate frequent vital sign documentation. A Quality Assurance (QA) discussion was conducted on 02/11/13 at 9:00 AM to discuss the details of the action items contained in the AOC. The Executive Director (ED), DHS, ADHS, Consultant Pharmacist, Advanced Practice Registered Nurse (APRN), and CCS were present. The ED via phone with Medical Director discussed the action items that were put into place. The "Documentation Audit Tool" was be used to audit 100% of resident clinical records for accuracy until abatement was achieved. This audit was conducted by the DHS, ADHS, Medical records nurse, and CCS. This audit focused on timely and thorough notification of the Physician and POA and documentation. This audit tool was used to conduct audits on 100% of resident clinical records on 02/13/13 with no errors noted. The QA committee will review results of all audits weekly until substantial compliance is obtained. The Committee will monitor the effectiveness and compliance with the plan and update and develop plans of action related to any and all problems identified though audits. The results of the above will be tracked and trended with follow up actions or education for staff completed as necessary. The Medical Director if unavailable in person will review the progress by phone with the Administrator on a weekly basis (Wednesday). The State Survey Agency validated the implementation of the facility's AOC as follows: Interviews with licensed nursing staff on 02/15/13 at 8:00 AM with LPN #6, at 8:15 AM with LPN #7, at 9:00 AM with LPN #8, at 9:15 AM with RN #2, at 9:30 AM with LPN #2, at 10:00 AM with LPN #3, at 1:40 PM with LPN #9, at 2:00 PM with RN #3, at 2:30 PM with LPN #4, and at 3:00 PM with LPN #5 revealed they all attended in-services which covered: "Specific Medication Administration Procedures" which included noting the correct time, dose, route, medication, and resident identification. "Specific Medication Administration Procedures" related to identification of correct resident, including discussions on all of the acceptable identification methods, including verifying residents names on the door, MAR/TAR, review of the photo, have resident tell the nurse their name or have another facility personnel identify the resident. Further interview revealed all nurses interviewed had completed a medication administration competency, which consisted of a mock resident demonstration using at least two (2) forms of identification prior to medication administration, and were observed by the DHS or the ADNS completing their medication pass before they were able to accept the keys to a medication cart on the floor. Further interview revealed staff was in-serviced on the assessment, monitoring, and documentation requirements in the event of a medication error, which included the nurses being given a hypothetical medication error scenario and having to complete a "mock" timely Physician and POA/family notification, assessment and monitoring documentation, and then each nurse had to take and pass a medication error prevention post test in order to validate skill competency. Further interview revealed, all nurses interviewed participated in a discussion and review discussion of the facility policy and procedures for timely Physician and POA/family notification, which included discussion of critical labs, normal labs, and resident change of condition, education related to maintaining complete and accurate clinical records to include documentation of medication errors, and review of the new "Medication Error Circumstance Assessment and Intervention Forms". Review of the in-service sign in sheet revealed all nursing staff attended all in-services provided. Interview with DHS, on 02/15/13 at 3:00 PM, revealed she had participated in all the in-services provided to all licensed nursing staff and had conducted a hypothetical medication error scenario with all licensed nursing staff and completed a "mock" timely Physician and POA/family notification, assessment and monitoring documentation scenario. She further stated she also conducted a "mock" medication administration scenario with each licensed nursing staff, prior to observing each licensed nursing staff administer medications to actual residents. She further stated no licensed nursing staff had been allowed to take the medication cart prior to completing these tasks. Further interview revealed, she had conducted audits using the "Documentation Audit Tool" to audit 100% of resident clinical records for accuracy, and on the timely and thorough notification of the Physician and POA/family, and documentation. She further stated she had attended the QA meeting when all the components of the AOC were discussed and recommendations were made. Interview with the ED, on 02/15/13 at 3:30 PM, revealed he had participated in the development of the AOC and the implementation of the AOC. He further stated he had also assisted in the "Documentation Audit Tool" which was done on 100% of resident clinical records, as well as observed the licensed nursing staff administer medications to the residents. He further stated he had attended the QA meeting when all of the components of the AOC were discussed and recommendations made, and he had also contacted the Medical Director for his input on the AOC as well as communicated with him via phone during the QA meeting. He further stated that each morning, during the morning stand up meetings attended by all department heads, the results of the audits were reviewed by all in attendance. Interview with the Medical Director, on 02/15/13 at 4:30 PM, revealed he had been included in the completion of the AOC and had given his input and had approved the AOC. He further stated the ED had remained in contact with him via the telephone with all aspects of the implementation of the AOC and during the QA meeting when the results of the AOC and the audits were discussed.

Based on interview, record review, and review of the facility policy, it was determined the facility failed to have an effective system to ensure services provided met professional standards for one (1) of six (6) sampled residents, (Resident #1). The facility failed to ensure staff completed their Job Specific Orientation Checklist, prior to administering medications to residents, per facility policy. Review of Registered Nurse (RN) #1 Job Orientation Checklist, not dated, revealed Licensed Practical Nurse (LPN) #1's initials were next to the task of administering oral medications, performing a subcutaneous injection, and performing an accu-check. However, interview with LPN #1 revealed she had never observed RN #1 administer any route of medication and she did not remember initialing the Job Specific Orientation Checklist. On 02/02/13 at approximately 9:00 AM, Registered Nurse (RN) #1 administered Resident #2's medications to Resident #1, which included [MEDICATION NAME] HCL (a medication given for [MEDICAL CONDITION] Fibrillation), Tramadal (a controlled medication given for mild to moderate pain), [MEDICATION NAME] (a medication given for Hypertension (HTN), [MEDICATION NAME] (a medication given for nerve pain),[MEDICATION NAME](a medication given for HTN), [MEDICATION NAME] (a medication given for HTN), [MEDICATION NAME] (a controlled medication given for anxiety), and Levumir (a long acting insulin) 25 Units Subcutaneous. Interview revealed RN #1 did not look at the name on the door before she entered Resident #1's room, and she did not ask the resident his/her name before administering the medications to Resident #1. Staff interviews revealed RN #1 had not been observed administering medications by any of her mentors prior to her administering medications to residents on 02/02/13, per facility policy. Interviews further revealed, LPN #1 was to be observing RN #1 administer medications on 02/02/13; however, she left the unit and never observed RN #1 administer any medications. Interview and record review revealed the significant medication error was identified at approximately 9:45 AM after a change in Resident #1's alertness was noted by the resident's sitter. On 02/02/13 at 11:30 AM, Resident #1 was transferred to the hospital by Emergency Medical Services and admitted to the Intensive Care Unit (ICU) with a [DIAGNOSES REDACTED]. The resident was hospitalized for [REDACTED]. The facility further failed to timely inform the Physician of all the medications Resident #1 received when RN #1 administered Resident #2's medications to Resident #1, which delayed emergency treatment for [REDACTED].#1 and check his/her blood sugar after he/she received the wrong medications, including a long acting insulin, using professional standards. Review of the medical records revealed no documented evidence assessments were performed on Resident #1 except for vital signs, which were documented but not timed. The facility's failure to ensure services provided met professional standards was likely to cause a risk for serious injury, harm, impairment or death. The Immediate Jeopardy was identified on 02/09/13, and was determined to exist on 02/02/13. The facility was notified of the Immediate Jeopardy on 02/09/13. The facility provided an acceptable Allegation of Compliance (AOC) on 02/14/13, with the facility alleging removal of the Immediate Jeopardy on 02/14/13. The Immediate Jeopardy was verified to be removed on 02/15/13 with remaining non-compliance at 42 CFR 483.20 Resident Assessment, F-281 at a S/S of a "D" while the facility develops and implements the Plan of Correction (POC) and the facility's Quality Assurance program continues to monitor to ensure the residents receive care and service that meet professional standards of practice. The findings include: Review of the facility's policy, titled "Nursing Services-Licensed Staff", dated 10/13/2008, revealed all residents' safety would be maintained as much as possible through risk assessments, preventive interventions, monitoring, and education. Further review revealed, timely and correct completion of required documentation was not negotiable and must be kept up to date at all times to provide a record of care and service delivery and meet regulatory requirements. Further review revealed, staff was to provide communication to the Physician and responsible party to keep them abreast of condition changes and serviced delivered. Review of the facility's policy, titled "Preparation and General Guidelines", dated 02/01/10, revealed under the documentation section, the staff who administered the medication should document on the resident's Medication Administration Record (MAR) directly after the medication was given. Further review revealed the resident's MAR was initialed by the person administering the medication, in the space provided under the date, and on the line for the specific medication dose administered. Further review revealed, medications were administered in accordance with the written order of the attending Physician, and were administered without unnecessary interruption, and staff was to identify the resident before the medication was administered, using one of these forms of identifications: A) Checking the identification band. B) Checking the photograph. C) Calling the resident by name. D) If necessary, verifying resident identification with other facility personnel. Review of the facility's policy, titled "Guidelines for Medication Error Reporting", dated 11/2010, revealed staff was to document a description of the error, name of the Physician and time notified, and the Physician's subsequent orders, in the resident's clinical record. Review of the Board of Nursing Standards of Practice, used by the facility, revealed under KRS 314.011 Licensed Nurses were to be able to observe, record, and report untoward reactions and side effects of drug therapy. Interview with the Executive Director (ED), on 02/15/13 at 10:00 AM, revealed the facility used the Lippincott Standards of Nursing Practice, the Briggs Standards of Nursing Practice, the Board of Nursing Standards of Practice, the Regulatory Standards of Practice, Taber's Medical Dictionary, and the PCA Pharmacy as sources for standards of nursing and professional standards. Review of RN #1's Job Specific Orientation Checklist, not dated, revealed LPN #1's initials next to Medication Administration on day two (2) of oral medications, Subcutaneous Injections, and Accu-Checks, not dated. Interview with LPN #1, on 02/09/13 at 8:00 PM, revealed she did not recall signing off on the Job Specific Orientation Checklist for RN #1. Interview with LPN #10, on 02/09/13 at 12:20 PM, revealed she worked with RN #1 on 02/01/13, which was RN #1's first day on the floor. She stated at no time did she observe RN #1 administer any oral medications nor had she observed RN #1 give any types of injections nor accu-checks. She further stated as a mentor, she had been trained to observe a new orientee when they administered any form of medication on their first and their second day on the floor, and then after the second day it would be up to the mentor and the orientee if they needed further one (1) on one (1) with the mentor when administering medications. Interview with LPN #1, on 02/08/12 at 3:30 PM, revealed she was assigned as RN #1's mentor on 02/02/13. She stated RN #1 had told her it was her third (3) day on the floor; therefore, she left the unit and did not observe RN #1 administer any medications. She further stated she could not recall a picture of Resident #1 on the MAR. Interview with RN #1, on 02/09/13 at 9:30 AM, revealed on 02/02/13 LPN #1 had not observed her administering medications prior to leaving the unit. She further stated she did not recall a picture of Resident #1 on the MAR; however, she stated she did not look at the pictures when administering medications, she would look at the names on the MAR and the names on the doors. She further stated she did not look at the name on the door before entering Resident #1's room and prior to administering the medications she stated Resident #2's name and when Resident #1 smiled she assumed he/she was Resident #2. She further stated this had been the first time she had worked on this hall and was not familiar with the resident's and she should have asked Resident #1 his/her name prior to administering the medications. Further interview revealed, the blood pressure reading 140/62 had been taken prior to the medication error. Interview with the Director of Health Services (DHS), on 02/09/13 at 8:45 PM, revealed she had been under the assumption that LPN #1 had observed RN #1 administer medications prior to leaving the unit to go to the dinning room. She further stated before an orientee administered medications alone, they must first be observed by a mentor administering medications. She further stated she was unable to locate a photograph of Resident #1. She further stated, stating a resident's name was not an appropriate identifier for staff to use prior to administering a medication, and staff were to use at least two (2) of the approved identifiers prior to administering a medication, and RN #1 had not used two (2) acceptable identifiers prior to administering medications to Resident #1. Further interview revealed, she had observed RN #1 administer medications; however, she was unable to say when she had observed RN #1 administer medications and to which resident's she had observed RN #1 administer medications to. Review of Resident #2's MAR, dated 02/02/13, revealed RN #1 signed out [MEDICATION NAME] HCL (a medication given for [MEDICAL CONDITION] Fibrillation) 225 milligrams (MG) per oral (PO), Tramadal (a controlled medication given for mild to moderate pain) 50 MG two (2) tablets PO, [MEDICATION NAME] (a medication given for Hypertension (HTN)) 12.5 MG PO, [MEDICATION NAME] (a medication given for nerve pain) 600 MG PO,[MEDICATION NAME](a medication given for HTN) 15 MG PO, [MEDICATION NAME] (a medication given for HTN) 15 MG PO, [MEDICATION NAME] (a controlled medication given for anxiety) 0.5 MG PO, and Levumir (a long acting insulin) 25 Units Subcutaneous. Interview with RN #1, on 02/09/13 at 9:30 AM, revealed she gave Resident #1 all of Resident #2's morning medications. She further stated once the medication error was discovered, LPN #1 was the one who notified the on call Physician. Interview with LPN #1, on 02/08/13 at 4:30 PM, revealed after the medication error was discovered she notified the Nurse Practitioner who was on call and reported Resident #1 had received Resident #2's morning medications. She further stated she thought she had told the Nurse Practitioner every medication Resident #1 had received. She further stated the vital signs given to the Nurse Practitioner had been given to her by RN #1, and she had assumed the vital signs had been taken after the medication error had occurred. She further stated once the medication error had been identified, she and RN #1 assessed Resident #1 and placed him/her in a modified Trendelenburg position and checked Resident #1's blood sugar, she stated at this time Resident #1 was alert and oriented and his/her vital signs were within normal limits. Review of Resident #1's medical record revealed no documented blood sugar nor any documentation of assessments performed or interventions put into place. LPN #1 stated she must not have documented the blood sugar and she could not recall who had taken the vital signs or when the vital signs had been take. She further stated she had not documented in the Nurses Notes any of the assessments done on Resident #1 nor had she documented any of the interventions that were put into place. Further interview revealed, a member of the staff was in the room with Resident #1 at all times; however, she could not remember who had been in the room and when they had been in the room. Interview with Resident #1's sitter, on 02/08/13 at 5:30 PM, revealed she could not remember the names of the staff who were in Resident #1's room; however, she could say there had been long periods of times where a staff member was not in the room. She stated she could recall three (3) times staff had taken Resident #1's vital signs but she could not recall anyone testing Resident #1's blood sugar. Further interview revealed, the only time she left Resident #1's room was when she went out into the hallway to ask LPN #1 if she had given Resident #1 an insulin shot. Interview with the Nurse Practitioner, on 02/11/13 at 9:55 AM, revealed on 02/02/13 at approximately 10:00 AM she received a text from the facility stating Resident #1 had received two (2) blood pressure medications he/she did not normally take and a slow acting insulin, and his/her blood pressure was 140/62; therefore, she was not concerned. She stated she gave an order to monitor Resident #1's vital signs every hour for four (4) hours and then every four (4) hours for twenty-four (24) hours, and to check his/her blood sugar before lunch, dinner, and before bed time. She stated she was not notified of any changes in Resident #1's condition until approximately 11:00 AM, when she received a text from the facility stating Resident #1's blood pressure had dropped and the daughter was wanting the resident sent to the hospital. Further interview revealed, had she been given the correct list of medications Resident #1 had received and been given the first set of vital signs taken after the medication error occurred (blood pressure of 79/38, heart rate of 80 and respirations of 16) she would have given the order to send Resident #1 out right then. She further stated at no time did LPN #1 state Resident #1 had received all of Resident #2's medications. She further stated she did not feel she was completely informed of the medication error and of the change in Resident #1's status. Review of the Physician Orders, dated 02/02/12 at 9:45 AM, revealed a telephone order to monitor Resident #1's vital signs every four (4) hours for twenty-four (24) hours and to test Resident #1's blood sugar before lunch, dinner, and bed time. Review of the Vital Sign form, dated 02/02/12 with no time documented, revealed Resident #1's vital signs were: blood pressure 140/62, heart rate sixty-six (66), oxygen saturation of ninety-four (94) percent on three (3) liters of oxygen; blood pressure 78/38, heart rate eighty (80), oxygen saturation of eighty-nine (89) percent on three (3) liters of oxygen. Review of the Nurse Notes, dated 02/02/13 but not timed, revealed Licensed Practical Nurse (LPN) #1 documented Resident #1 had a blood pressure of 79/38 a heart rate of eighty (80) and respirations of sixteen (16). It stated the resident was lethargic and was being transferred to the hospital. Review of the Transfer Form, dated 02/02/13 at 11:30 AM, revealed Resident #1 had a blood pressure of 81/38, heart rate of fifty-eight (58), respirations of fourteen (14). Interview with the Medical Director, on 02/11/13 at 10:05 AM, revealed had he been made aware of all the medications Resident #1 was given, he would have given the order to send the resident to the hospital when first notified of the medication error. He further stated, he would expect a new orientee would be monitored by an experienced staff when administering medications on their second day. Review of the Hospital records, dated 02/02/13, revealed Resident #1 received [MEDICATION NAME] (prevents or reverses the effects of opioids including respiratory depression, sedation and [MEDICAL CONDITION]) 1 MG and 400 Milliliters of normal saline via Intravenous Infusion (IV) in the ambulance in route to the hospital. Further review revealed Resident #1 was started on a [MEDICATION NAME] drip (Suddenly Serious Symptoms of Heart Failure, Decrease in the Amount of Work the Heart Does, Sudden Drop in Blood Pressure) which was titrated from 3 MG to 12 MG to maintain Resident #1's blood pressure. Further review revealed Resident #1 showed [MEDICAL CONDITION] Fibrillation on the cardiac monitor. Further review revealed Resident #1 was admitted to the Intensive Care Unit (ICU). The facility provided an acceptable AOC on 02/14/13 that alleged the removal of the IJ was effective on 02/14/13. Review of the AOC revealed the facility implemented the following: All residents, including Resident #1 were observed by the DHS on 02/02/13 for any signs and symptoms different from their baseline. The DHS interviewed all licensed staff on duty on 02/02/13 to confirm no other residents had experienced an inadvertent medication error and that none were exhibiting an signs of symptoms different from their normal baseline. On 02/02/13 the DHS ensured that RN #1 did not administer any additional medications following the medication error and initiated an investigation related to the medication error. In addition, on 02/02/13, the DHS conducted a 100% review of all current residents' clinical records to verify that all methods of resident identification: photos on MAR/TAR, name on door and name on MAR/TAR were present. The DHS, Clinical Campus Support (CCS), Assistant Director of Health Service (ADHS), and the DHS, initiated in-service education on 02/10/13 at 12:00 PM and completed on 02/11/13 at 2:00 PM. This in-service for all licensed nurses included the following: 1) "Specific Medication Administration Procedures" to include noting the correct time, dose, route, medication, and resident identification. 2) "Specific Medication Administration Procedures" related to identification of correct resident. This included discussion of all available identification resources for resident identification including verifying residents names on the door, MAR/TAR, review of the photo, have resident tell the nurse their name or have another facility personnel identify the resident. 3) A "Specific Medication Administration Clinical Competency" was completed on all nurses with a mock resident demonstration using at least two (2) forms of identification prior to medication administration. On 02/11/13 the nurses were also observed while completing their medication pass and this is on going. 4) Assessment, monitoring, and documentation requirements on the evening that a medication error occurred. This included the nurses being given a hypothetical medication error scenario and having them complete "mock" timely Physician notification, assessment and monitoring documentation and "Medpass Error Prevention Post Test", in order to validate skill competency. 5) Discussion/Review of the facility policy and procedure for timely Physician Notification was reviewed. This included discussion of critical labs, normal labs, and resident change of condition. In-service education provided related to maintaining complete and accurate clinical records to include documentation of medication errors. The "Medication Error Circumstance Assessment and Intervention Forms" had been modified to accommodate frequent vital sign documentation. A Quality Assurance (QA) discussion was conducted on 02/11/13 at 9:00 AM to discuss the details of the action items contained in the AOC. The Executive Director (ED), DHS, Assistant Director of Nursing Services (ADHS), Consultant Pharmacist, Advanced Practice Registered Nurse (APRN), and CCS were present. The ED via phone with Medical Director discussed the action items that were put into place. The "Documentation Audit Tool" was be used to audit 100% of resident clinical records for accuracy until abatement was achieved. This audit was conducted by the DHS, ADHS, Medical records nurse, and CCS. This audit focused on timely and thorough notification of the Physician and POA and documentation. This audit tool was used to conduct audits on 100% of resident clinical records on 02/13/13 with no errors noted. The QA committee will review results of all audits weekly until substantial compliance is obtained. The Committee will monitor the effectiveness and compliance with the plan and update and develop plans of action related to any and all problems identified though audits. The results of the above will be tracked and trended with follow up actions or education for staff completed as necessary. The Medical Director if unavailable in person will review the progress by phone with the Administrator on a weekly basis (Wednesday). The State Survey Agency validated the implementation of the facility's AOC as follows: Interviews with licensed nursing staff on 02/15/13 at 8:00 AM with LPN #6, at 8:15 AM with LPN #7, at 9:00 AM with LPN #8, at 9:15 AM with RN #2, at 9:30 AM with LPN #2, at 10:00 AM with LPN #3, at 1:40 PM with LPN #9, at 2:00 PM with RN #3, at 2:30 PM with LPN #4, and at 3:00 PM with LPN #5 revealed they all attended in-services which covered: "Specific Medication Administration Procedures" which included noting the correct time, dose, route, medication, and resident identification. "Specific Medication Administration Procedures" related to identification of correct resident, including discussions on all of the acceptable identification methods, including verifying residents names on the door, MAR/TAR, review of the photo, have resident tell the nurse their name or have another facility personnel identify the resident. Further interview revealed all nurses interviewed had completed a medication administration competency, which consisted of a mock resident demonstration using at least two (2) forms of identification prior to medication administration, and were observed by the DHS or the ADHS completing their medication pass before they were able to accept the keys to a medication cart on the floor. Further interview revealed staff was in-serviced on the assessment, monitoring, and documentation requirements in the event of a medication error, which included the nurses being given a hypothetical medication error scenario and having to complete a "mock" timely Physician and POA/family notification, assessment and monitoring documentation, and then each nurse had to take and pass a medication error prevention post test in order to validate skill competency. Further interview revealed, all nurses interviewed participated in a discussion and review discussion of the facility policy and procedures for timely Physician and POA/family notification, which included discussion of critical labs, normal labs, and resident change of condition, education related to maintaining complete and accurate clinical records to include documentation of medication errors, and review of the new "Medication Error Circumstance Assessment and Intervention Forms". Review of the in-service sign in sheet revealed all nursing staff attended all in-services provided. Interview with DHS, on 02/15/13 at 3:00 PM, revealed she had participated in all the in-services provided to all licensed nursing staff and had conducted a hypothetical medication error scenario with all licensed nursing staff and completed a "mock" timely Physician and POA/family notification, assessment and monitoring documentation scenario. She further stated she also conducted a "mock" medication administration scenario with each licensed nursing staff, prior to observing each licensed nursing staff administer medications to actual residents. She further stated no licensed nursing staff had been allowed to take the medication cart prior to completing these tasks. Further interview revealed, she had conducted audits using the "Documentation Audit Tool" to audit 100% of resident clinical records for accuracy, and on the timely and thorough notification of the Physician and POA/family, and documentation. She further stated she had attended the QA meeting when all the components of the AOC were discussed and recommendations were made. Interview with the Executive Director (ED), on 02/15/13 at 3:30 PM, revealed he had participated in the development of the AOC and the implementation of the AOC. He further stated he had also assisted in the "Documentation Audit Tool" which was done on 100% of resident clinical records, as well as observed the licensed nursing staff administer medications to the residents. He further stated he had attended the QA meeting when all of the components of the AOC were discussed and recommendations made, and he had also contacted the Medical Director for his input on the AOC as well as communicated with him via phone during the QA meeting. He further stated that each morning, during the morning stand up meetings attended by all department heads, the results of the audits were reviewed by all in attendance. Interview with the Medical Director, on 02/15/13 at 4:30 PM, revealed he had been included in the completion of the AOC and had given his input and had approved the AOC. He further stated the ED had remained in contact with him via the telephone with all aspects of the implementation of the AOC and during the QA meeting when the results of the AOC and the audits were discussed.

Based on interview, record review, review of the facility policy and Medication Error Circumstance, Assessment and Intervention sheet, and review of the hospital records, it was determined the facility failed to have an effective system to ensure all resident's were free of significant medication errors for one (1) of six (6) samples resident's (Resident #1). On 02/02/13 at approximately 9:00 AM, Registered Nurse (RN) #1 administered Resident #2's medications to Resident #1, which included [MEDICATION NAME] HCL (a medication given for [MEDICAL CONDITION] Fibrillation), Tramadal (a controlled medication given for mild to moderate pain), [MEDICATION NAME] (a medication given for Hypertension (HTN), [MEDICATION NAME] (a medication given for nerve pain),[MEDICATION NAME](a medication given for HTN), [MEDICATION NAME] (a medication given for HTN), [MEDICATION NAME] (a controlled medication given for anxiety), and Levumir (a long acting insulin) 25 Units Subcutaneous. Interview revealed RN #1 did not look at the name on the door before she entered Resident #1's room, and she did not ask the resident his/her name before administering the medications to Resident #1. Interview and record review revealed the significant medication error was identified at approximately 9:45 AM after a change in Resident #1's alertness was noted by the resident's sitter. On 02/02/13 at 11:30 AM, Resident #1 was transferred to the hospital by Emergency Medical Services and admitted to the Intensive Care Unit (ICU) with a [DIAGNOSES REDACTED]. The resident was hospitalized for [REDACTED]. Based on the above findings it was determined the facility's failure to ensure residents remained free of significant medication errors was likely to cause risk for serious injury, harm, impairment or death. The Immediate Jeopardy (IJ) was identified on 02/09/13, and was determined to of existed on 02/02/13. The facility was notified of the IJ on 02/09/13. The facility provided an acceptable Allegation of Compliance (AOC) on 02/14/13, with the facility alleging removal of the Immediate Jeopardy on 02/14/13. The Immediate Jeopardy was verified to be removed on 02/15/13 with remaining non-compliance at 42 CFR 483.25 Quality of Care, F-333 at a S/S of a "D" while the facility develops and implements the Plan of Correction (POC) and the facility's Quality Assurance program continues to monitor to ensure the residents are free from significant medication errors. The finding included: Review of the facility's policy, titled "Specific Medication Administration Procedures", dated 02/01/2010, revealed staff was to identify residents using two (2) identification methods before administering medications. Review of the facility's policy, titled "Preparation and General Guidelines", dated 02/01/10, revealed under the documentation section, the staff who administered the medication should document on the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further review revealed the resident's MAR indicated [REDACTED]. Further review revealed, medications were administered in accordance with the written order of the attending Physician, and were administered without unnecessary interruption, and staff was to identify the resident before the medication was administered, using one of these forms of identifications: A) Checking the identification band. B) Checking the photograph. C) Calling the resident by name. D) If necessary, verifying resident identification with other facility personnel. Review of the facility's policy, titled "Nursing Services-Licensed Staff", dated 10/13/2008, revealed resident's would receive the correct medications, type, dosage, and route at the appropriate times. Review of the Medication Error Circumstance, Assessment and Intervention sheet, dated 02/02/13 at 8:00 AM, revealed Resident #1 received the wrong medication. Further review revealed, the section staff was to write the name and dose of the wrong medication, LPN #1 had written "see the MAR" for Resident #2. Further review revealed LPN #1 wrote Resident #1 was sedated and had a low blood pressure, and was lethargic. Review of the Fire and Emergency Services report, dated 02/02/13, revealed at 11:30 AM they arrived at the facility. Further review revealed the facility had reported Resident #1 was mistakenly given another resident's medications at 9:00 AM, which included [MEDICATION NAME] 30 mg and long acting insulin. It was further reported Resident #1 demonstrated a decreased level of consciousness and had a decreased blood pressure from his/her baseline, and the resident was placed in a modified trendelenburg position. Further review revealed Resident #1's blood pressure was 82/40 and heart rate of fifty-six (56), upon Emergency Medical Service (EMS) arrival and upon arrival to the hospital, Resident #1's blood pressure was 78/30 and a heart rate of fifty (50). Review of the hospital records, dated 02/02/13, revealed Resident #1 received [MEDICATION NAME] (prevents or reverses the effects of opioids including respiratory depression, sedation and [MEDICAL CONDITION]) 1 MG and 400 Milliliters (ML) of normal saline via Intravenous Infusion (IV) in the ambulance in route to the hospital. Resident #1 was started on a [MEDICATION NAME] drip (Suddenly Serious Symptoms of Heart Failure, Decrease in the Amount of Work the Heart Does, Sudden Drop in Blood Pressure) which was titrated from 3 MG to 12 MG to maintain Resident #1's blood pressure. Further review revealed Resident #1 showed [MEDICAL CONDITION] Fibrillation on the cardiac monitor; the resident's oxygen saturation dropped to eighty-nine (89) percent, and he/she was placed on a non-rebreather at ten (10) liters of oxygen. Record review revealed Resident #1's blood sugar was 119 when he/she first arrived to the Emergency Department at 11:50 AM and at 2:30 PM his/her blood sugar had dropped to ninety-three (93). The resident was admitted to the Intensive Care Unit (ICU) with a [DIAGNOSES REDACTED]. Record review revealed the facility admitted Resident #1 on 01/13/13 with [DIAGNOSES REDACTED]. Review of the Admission Minimal Data Set (MDS) Assessment, dated 01/25/13, revealed the facility assessed Resident #1 had a Brief Interview for Mental Status (BIMS) of three (3), which indicated the resident was cognitively impaired. Review of Resident #1's Comprehensive Care Plan, dated 01/30/13, revealed Resident #1 had a Care Plan for communication, which stated Resident #1 suffered from Dementia with behavior disturbance which caused the resident to have difficulty understanding and being understood. Further review revealed, Resident #1 would miss some parts/intents of messages at times and required simple, direct communication. Interview on 02/08/13 at 3:30 PM with Resident #1's roommate, Resident #3, whom the facility had assessed being cognitive intact with a BIMS of 15, revealed on 02/02/13 at approximately 9:00 AM while Resident #3 was in the bathroom, he/she overheard the nurse tell Resident #1 she was going to give the resident an insulin shot and his/her other medications. Resident #3 further stated he/she thought this was strange because he/she had never seen Resident #1 receive an insulin shot or heard Resident #1's family say he/she had "sugar". She further stated it was about 9:45 AM, when Resident #1's sitter arrived at the facility and she asked the sitter if Resident #1 received insulin shots because he/she had overheard the nurse tell Resident #1 she was going to give him/her an insulin shot. She further stated the sitter stated Resident #1 did not receive insulin shots. Interview with Resident #1's sitter, on 02/08/13 at 5:30 PM, revealed she arrived at the facility at approximately 9:45 AM on 02/02/13. She stated Resident #3 asked her if Resident #1 took insulin shots because he/she had overheard the nurse tell Resident #1 she was going to give him/her an insulin shot. She stated it was at this time she looked down and saw an alcohol swab in Resident #1's trash can and it had blood on it. She stated she went out into the hall way and asked LPN #1 if she had given Resident #1 an insulin shot. She stated LPN #1 stated she had not administered the medications but would ask the nurse who had. She further stated approximately five (5) minutes later LPN #1 came into Resident #1's room and stated Resident #1 had received an insulin shot. She stated at that time Resident #1 became more lethargic, unable to hold his/her head up and kept his/her eyes open. She stated she asked LPN #1 to help her get Resident #1 into the bed and LPN #1 assisted her with Resident #1. She further stated, after Resident #1 was back in his/her bed, RN #1 came into the room and stated Resident #1 had also received a "nerve pill", and proceeded to take Resident #1's vital signs, and then she stated Resident #1's blood pressure was very low. Interview with Resident #1's daughter, on 02/08/13 at 6:00 PM, revealed Resident #1's sitter called her at approximately 10:00 AM and informed her Resident #1 had received an insulin shot. She stated she had been on the phone with the sitter when she heard the nurse say Resident #1's blood pressure had dropped. She asked to speak to the nurse, and asked the nurse if she had called 911 and when the nurse stated she had not, Resident #1's daughter told her she needed to hang up the phone and she wanted 911 called immediately and the resident sent out as soon as possible. She further stated she arrived at the facility at around 11:15 AM and Resident #1 was in the bed with his/her eyes closed, mouth gaped open, and non-responsive. Interview with RN #1, on 02/09/13 at 10:00 AM, revealed 02/02/13 was her second day on the floor, and she was administering medications by herself. She stated she had the MAR indicated [REDACTED]. She stated at approximately 9:00 AM she entered Resident #1's room without looking at the name on the door, calling the resident's name, or identifying the resident, and proceeded to administer Resident #2's medications to Resident #1. She stated she was not for sure how long it was before LPN #1 came to her and asked if she had given Resident #1 an insulin shot, but this was when they realized the medication error had occurred. Review of Resident #2's MAR, dated 02/2013, revealed Resident #2 was prescribed the following: [MEDICATION NAME] HCL (a medication given for [MEDICAL CONDITION] Fibrillation) 225 milligrams (MG) per oral (PO), Tramadal (a controlled medication given for mild to moderate pain) 50 MG two (2) tablets PO, [MEDICATION NAME] (a medication given for Hypertension (HTN)) 12.5 MG PO, [MEDICATION NAME] (a medication given for nerve pain) 600 MG PO,[MEDICATION NAME](a medication given for HTN) 15 MG PO, [MEDICATION NAME] (a medication given for HTN) 15 MG PO, [MEDICATION NAME] (a controlled medication given for anxiety) 0.5 MG PO, and Levumir (a long acting insulin) 25 Units Subcutaneous. Interview with LPN #1, 02/09/13 at 11:30 AM, revealed on 02/02/13 at approximately 9:45 AM she was going to answer a call light in Resident #1's room when Resident #1's sitter asked her if Resident #1 had received an insulin shot. She stated she asked RN #1 if she had given Resident #1 an insulin shot and at this time RN #1 stated she had given Resident #2 his/her medications, and it was at this time they realized she had given Resident #1 all of Resident #2's morning medications. She stated she notified the Director of Nursing Services (DNS) of the medication error and then she sent the Nurse Practitioner a text stating Resident #1 had been given Resident #2's medications. She further stated at approximately 11:00 AM she text the Nurse Practitioner and informed her Resident #1's blood pressure had dropped and the POA wanted him/her sent to the hospital and she stated she was given the order to send the resident to the hospital and she immediately picked up the red phone, which is a direct line to dispatch, and they took her information and stated they would send an ambulance right away. Further interview revealed Resident #1 had become increasingly lethargic and his/her blood pressure had dropped to 78/38 with a heart rate of sixty-six (66). Interview with the Nurse Practitioner, on 02/11/13 at 9:55 AM, revealed on 02/02/13 at approximately 10:00 AM she received a text from the facility stating Resident #1 had received two (2) blood pressure medications he/she did not normally take and a slow acting insulin; however, the vital signs the nurse gave her were normal; therefore, she was not concerned. She stated she gave an order to monitor Resident #1's vital signs every hour for four (4) hours and then every four (4) hours for twenty-four (24) hours, and to check his/her blood sugar before lunch, dinner, and before bed time. She stated she was not notified of any changes in Resident #1's condition until approximately 11:00 AM, when she received a text from the facility stating Resident #1's blood pressure had dropped and the daughter was wanting the resident sent to the hospital. She stated had she been given the correct list of medications Resident #1 had received and been given the first set of vital signs taken after the medication error occurred, she would have given the order to send Resident #1 out right then. She further stated at no time did LPN #1 state Resident #1 had received all of Resident #2's medications. She further stated she did not feel she was completely informed of the medication error and the change in Resident #1's status. Review of the Vital Sign and Weight Record sheet, dated 02/02/12 with no time documented, revealed Resident #1's vital signs were: blood pressure 140/62, heart rate sixty-six (66), oxygen saturation of ninety-four (94) percent on three (3) liters of oxygen; blood pressure 78/38, heart rate eighty (80), oxygen saturation of eighty-nine (89) percent on three (3) liters of oxygen. Interview with the DNS, on 02/09/13 at 9:00 PM, revealed LPN #1 called her at home and reported to her Resident #1 had received all of Resident #2's medications, as soon as the medication error was identified, which was at approximately 10:00 AM. She stated that all residents had vital signs taken every shift; therefore, there was no other vital signs taken after the medication error occurred. Further interview revealed staff should always use two (2) approved identifiers before administering medications to a resident and RN #1 did not use two (2) approved identifiers prior to administering the medications. Per interview, RN #1 stating a resident's name versus asking the resident to state his/her name, was not appropriate considering she was not familiar with the residents. Interview with the Executive Director (ED), on 02/09/13 at 3:30 PM, revealed if a nurse was not familiar with the residents, stating the residents' name versus asking the resident to give their name, would not have been an appropriate identifier to use prior to administering medications. The facility provided an acceptable AOC on 02/14/13 that alleged the removal of the IJ was effective on 02/14/13. Review of the AOC revealed the facility implemented the following: All residents, including Resident #1 were observed by the DHS on 02/02/13 for any signs and symptoms different from their baseline. The DHS interviewed all licensed staff on duty on 02/02/13 to confirm no other residents had experienced an inadvertent medication error and that none were exhibiting an signs of symptoms different from their normal baseline. On 02/02/13 the DHS ensured that RN #1 did not administer any additional medications following the medication error and initiated an investigation related to the medication error. In addition, on 02/02/13, the DHS conducted a 100% review of all current residents' clinical records to verify that all methods of resident identification: photos on MAR/TAR, name on door and name on MAR/TAR were present. The DHS, Clinical Campus Support (CCS), Assistant Director of Health Service (ADHS), and the DHS, initiated in-service education on 02/10/13 at 12:00 PM and completed on 02/11/13 at 2:00 PM. This in-service for all licensed nurses included the following: 1) "Specific Medication Administration Procedures" to include noting the correct time, dose, route, medication, and resident identification. 2) "Specific Medication Administration Procedures" related to identification of correct resident. This included discussion of all available identification resources for resident identification including verifying residents names on the door, MAR/TAR, review of the photo, have resident tell the nurse their name or have another facility personnel identify the resident. 3) A "Specific Medication Administration Clinical Competency" was completed on all nurses with a mock resident demonstration using at least two (2) forms of identification prior to medication administration. On 02/11/13 the nurses were also observed while completing their medication pass and this is on going. 4) Assessment, monitoring, and documentation requirements on the evening that a medication error occurred. This included the nurses being given a hypothetical medication error scenario and having them complete "mock" timely Physician notification, assessment and monitoring documentation and "Medpass Error Prevention Post Test", in order to validate skill competency. 5) Discussion/Review of the facility policy and procedure for timely Physician Notification was reviewed. This included discussion of critical labs, normal labs, and resident change of condition. In-service education provided related to maintaining complete and accurate clinical records to include documentation of medication errors. The "Medication Error Circumstance Assessment and Intervention Forms" had been modified to accommodate frequent vital sign documentation. A Quality Assurance (QA) discussion was conducted on 02/11/13 at 9:00 AM to discuss the details of the action items contained in the AOC. The Executive Director (ED), DNS, Assistant Director of Nursing Services (ADHS), Consultant Pharmacist, Advanced Practice Registered Nurse (APRN), and CCS were present. The ED via phone with Medical Director discussed the action items that were put into place. The "Documentation Audit Tool" was be used to audit 100% of resident clinical records for accuracy until abatement was achieved. This audit was conducted by the DHS, ADHS, Medical records nurse, and CCS. This audit focused on timely and thorough notification of the Physician and POA and documentation. This audit tool was used to conduct audits on 100% of resident clinical records on 02/13/13 with no errors noted. The QA committee will review results of all audits weekly until substantial compliance is obtained. The Committee will monitor the effectiveness and compliance with the plan and update and develop plans of action related to any and all problems identified though audits. The results of the above will be tracked and trended with follow up actions or education for staff completed as necessary. The Medical Director if unavailable in person will review the progress by phone with the Administrator on a weekly basis (Wednesday). The State Survey Agency validated the implementation of the facility's AOC as follows: Interviews with licensed nursing staff on 02/15/13 at 8:00 AM with LPN #6, at 8:15 AM with LPN #7, at 9:00 AM with LPN #8, at 9:15 AM with RN #2, at 9:30 AM with LPN #2, at 10:00 AM with LPN #3, at 1:40 PM with LPN #9, at 2:00 PM with RN #3, at 2:30 PM with LPN #4, and at 3:00 PM with LPN #5 revealed they all attended in-services which covered: "Specific Medication Administration Procedures" which included noting the correct time, dose, route, medication, and resident identification. "Specific Medication Administration Procedures" related to identification of correct resident, including discussions on all of the acceptable identification methods, including verifying residents names on the door, MAR/TAR, review of the photo, have resident tell the nurse their name or have another facility personnel identify the resident. Further interview revealed all nurses interviewed had completed a medication administration competency, which consisted of a mock resident demonstration using at least two (2) forms of identification prior to medication administration, and were observed by the DNS or the ADNS completing their medication pass before they were able to accept the keys to a medication cart on the floor. Further interview revealed staff was in-serviced on the assessment, monitoring, and documentation requirements in the event of a medication error, which included the nurses being given a hypothetical medication error scenario and having to complete a "mock" timely Physician and POA/family notification, assessment and monitoring documentation, and then each nurse had to take and pass a medication error prevention post test in order to validate skill competency. Further interview revealed, all nurses interviewed participated in a discussion and review discussion of the facility policy and procedures for timely Physician and POA/family notification, which included discussion of critical labs, normal labs, and resident change of condition, education related to maintaining complete and accurate clinical records to include documentation of medication errors, and review of the new "Medication Error Circumstance Assessment and Intervention Forms". Review of the in-service sign in sheet revealed all nursing staff attended all in-services provided. Interview with DNS, on 02/15/13 at 3:00 PM, revealed she had participated in all the in-services provided to all licensed nursing staff and had conducted a hypothetical medication error scenario with all licensed nursing staff and completed a "mock" timely Physician and POA/family notification, assessment and monitoring documentation scenario. She further stated she also conducted a "mock" medication administration scenario with each licensed nursing staff, prior to observing each licensed nursing staff administer medications to actual residents. She further stated no licensed nursing staff had been allowed to take the medication cart prior to completing these tasks. Further interview revealed, she had conducted audits using the "Documentation Audit Tool" to audit 100% of resident clinical records for accuracy, and on the timely and thorough notification of the Physician and POA/family, and documentation. She further stated she had attended the QA meeting when all the components of the AOC were discussed and recommendations were made. Interview with the Executive Director (ED), on 02/15/13 at 3:30 PM, revealed he had participated in the development of the AOC and the implementation of the AOC. He further stated he had also assisted in the "Documentation Audit Tool" which was done on 100% of resident clinical records, as well as observed the licensed nursing staff administer medications to the residents. He further stated he had attended the QA meeting when all of the components of the AOC were discussed and recommendations made, and he had also contacted the Medical Director for his input on the AOC as well as communicated with him via phone during the QA meeting. He further stated that each morning, during the morning stand up meetings attended by all department heads, the results of the audits were reviewed by all in attendance. Interview with the Medical Director, on 02/15/13 at 4:30 PM, revealed he had been included in the completion of the AOC and had given his input and had approved the AOC. He further stated the ED had remained in contact with him via the telephone with all aspects of the implementation of the AOC and during the QA meeting when the results of the AOC and the audits were discussed.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system to ensure clinical records were maintained in accordance with accepted professional standards and practices for two (2) of six (6) sampled residents, (Resident #1 and Resident #2). On 02/02/13 at approximately 9:00 AM, Registered Nurse (RN) #1 administered Resident #2's medications to Resident #1. Interview and record review revealed the significant medication error was identified at approximately 9:45 AM after a change in Resident #1's alertness was noted by the resident's sitter. On 02/02/13 at 11:30 AM, Resident #1 was transferred to the hospital by Emergency Medical Services and admitted to the Intensive Care Unit (ICU) with a [DIAGNOSES REDACTED]. The resident was hospitalized for [REDACTED]. The facility failed to ensure the clinical record contained documentation of times vital signs were taken for Resident #1 on 02/02/13, per physician orders, as well as documented evidence of assessments performed on Resident #1 after he/she had been given the wrong medications and exhibited a change in condition. Record review and interview revealed the facility also failed to ensure staff accurately documented the times medications were administered and their initials on the Medication Administration Records (MAR) for Resident #1 and Resident #2, as well as on the narcotic sign out sheet for Resident #2. Based on the above findings it was determined the facility's failure to ensure a system was in place to ensure clinical records were maintained in accordance with accepted professional standards and practices and was likely to cause risk for serious injury, harm, impairment or death. The Immediate Jeopardy (IJ) was identified on 02/09/13, and was determined to of existed on 02/02/13. The facility was notified of the IJ on 02/09/13. The facility provided an acceptable Allegation of Compliance (AOC) on 02/14/13, with the facility alleging removal of the Immediate Jeopardy on 02/14/13. The Immediate Jeopardy was verified to be removed on 02/15/13, with remaining non-compliance at 42 CFR 483.75 Administration, F-514 at a S/S of a "D" while the facility develops and implements the Plan of Correction (POC) and the facility's Quality Assurance program continues to monitor to ensure clinical records on each resident are maintained in accordance with accepted professional standards of practice and that the clinical records are accurately documented. The findings include: Review of the facility policy, titled "Nursing Services-Licensed Staff", dated 10/13/08, revealed timely and correct completion of required documentation was not negotiable and must be kept up to date at all times to provide a record of care and service delivery and meet regulatory requirements. Review of facility's policy titled "Medication Administration Times Procedural Guidelines", (no date) revealed the nurse administering the medications shall record the time the medication was administered along with his/her initials. 1. Record review revealed the facility admitted Resident #1 on 01/13/13 with [DIAGNOSES REDACTED]. Review of Resident Admission Minimal Data Set (MDS) Assessment, dated 01/25/13, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) of three (3) out of fifteen (15), which meant the resident was cognitively impaired. Interview with RN #1, on 02/09/13 at 9:30 AM, revealed on 02/02/13 at approximately 9:00 AM she administered Resident #2's medications to Resident #1. She stated she could not remember who assessed Resident #1 after the medication error occurred nor could she remember when Resident #1's vital signs had been taken. She stated everything happened so fast, and after review of the medical records, she was still unable to say what type of assessments were done and when, as well as what time vital signs were taken and by whom. Review of Resident #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Interview with LPN #1, on 02/09/13 at 9:30 AM, revealed if initials on a MAR indicated [REDACTED]. She further stated she had not documented in the nurses notes about Resident #1 not receiving his/her medications, but she should have documented the medication error in the nurses notes, as per the facility's policy. Interview with LPN #1, on 02/08/13 at 3:30 PM, revealed she thought she had come back to the unit from the dining room at approximately 9:45 AM; however, she was unable to say for sure. She further stated after she discovered Resident #1 had received Resident #2's medications, she assessed Resident #1; however, after review of the medical record she was unable to say when she assessed Resident #1 and when his/her vital signs had been taken. She stated Resident #1 was never left alone after the medication error had been identified; however, she was unable to say who was with Resident #1 and when. Interview with LPN #1, on 02/08/13 at 3:30 PM, revealed she had documented the incident on the Medication Error Circumstance Assessment and Intervention form. She further stated there was not a place on the Medication Error Circumstance Assessment and Intervention form to document all of the vital signs which had been taken, and there was not a place to document the assessments performed. She further stated she should have documented in the Nurses Notes what assessments were done as well as the times the vital signs were taken. Further interview revealed, LPN #1 was unable to remember what times Resident #1's vital signs were taken or who had taken Resident #1's vital signs after the medication error occurred. She further stated she also could not remember who had performed the assessments on Resident #1 after he/she had received the wrong medications, but whoever did the assessment should have documented those assessments. Further interview revealed, LPN #1 stated she had taken Resident #1's blood sugar; however, there was no documented evidence a blood sugar had been obtained. Interview with Registered Nurse (RN) #1, on 02/09/13 at 10:00 AM, revealed she had not documented any assessments done on Resident #1 after she gave him/her the wrong medications. She further stated she knew Resident #1's vital signs had been taken; however, she did not know who had taken the vital signs or when. She further stated she should have documented the assessments she did on Resident #1 and she should have documented the vital signs and the time they were taken. She stated at no time was Resident #1 left alone; however, she was unable to say who was in the room with Resident #1 and when. Interview with the Nurse Practitioner, on 02/11/13 at 09:55 AM, revealed on 02/02/13 at approximately 10:00 AM she received a text from the facility stating Resident #1 had received two (2) blood pressure medications he/she did not normally take and a slow acting insulin, and the vital signs the nurse gave her were normal; therefore, she was not concerned. She stated she gave an order to monitor Resident #1's vital signs every hour for four (4) hours and then every four (4) hours for twenty-four (24) hours, and to check his/her blood sugar before lunch, dinner, and before bed time. However, review of the Physician Orders, dated 02/02/13, revealed at 09:45 AM, LPN #1 wrote an order for [REDACTED]. Further review revealed on 02/02/13 at 11:00 AM, LPN #1 wrote an order to send Resident #1 to the hospital. Further review revealed no Physician's signature on either order and no Physician's name was documented on either order by LPN #1. Review of the Vital Signs Record, dated 02/02/13 no time documented, revealed Resident #1 had two (2) sets of vital signs documented; however, there was no time documented. Review of the Nurse Notes, dated 02/02/13 at 10:00 AM, revealed Licensed Practical Nurse (LPN) #1 documented Resident #1 had a blood pressure of 79/38 a heart rate of eighty (80) and respirations of sixteen (16). Interview with LPN #1, on 02/08/13 at 3:30 PM, revealed she should have written the Nurse Practitioners name on the order. She further stated she had not written the times on the orders and was not aware of who wrote the times on the orders. Further interview revealed she thought the Nurse Practitioner had given the order to check Resident #1's vital signs as she wrote in the order, but she might have misunderstood. Interview with the DNS, on 02/09/13 at 9:00 PM, revealed LPN #1 called her at home and reported to her Resident #1 had received all of Resident #2's medications, as soon as the medication error was identified, which was at approximately 10:00 AM and she went straight to the facility. Further interview revealed, staff was to document the medication error and the assessments on the Medication Error Circumstance Assessment and Intervention form. After review of the Medication Error Circumstance Assessment and Intervention form and the Nurses Notes, she stated LPN #1 should have documented further what assessments had been done and the times the vital signs had been taken. 2. Review of medical record for Resident #2 revealed the facility admitted the resident on 12/30/12, with [DIAGNOSES REDACTED]. Review of Resident #2's Physician's Orders, starting 02/01/13 and ending 02/28/13, revealed the following medications: [REDACTED] (pain relief) 600 mg, one tablet orally, twice a day, [MEDICATION NAME] (for HTN) 30 mg tablet, ? tablet orally twice a day, [MEDICATION NAME] (for [MEDICAL CONDITION]) 175 Microgram (MCG) tablet once daily, [MEDICATION NAME] (for HTN) 30 mg tablet, ? tablet twice a day, [MEDICATION NAME] (narcotic anxiety medication) 0.5 mg, one tablet to be given three times a day at 09:00 AM, [MEDICATION NAME] (to stimulate appetite) 40 mg/milliliter (ml) liquid, 10 ml, Multivitamin given daily for dietary supplement, Oyst-Cal 500+D (calcium and vitamin D combination) 200 International Units (IU), 2 tablets (400 IU) once a day for treatment of [REDACTED]. as needed for [MEDICAL CONDITION]. Interview with RN #1, on 02/09/13 at 09:30 AM, revealed she had mistakenly administered all of Resident #2's medication to Resident #1, including checking finger stick blood sugar, injecting insulin, and administration of controlled medications, the morning of 02/02/13. RN #1 further stated she did not administer any medications to Resident #2. Interview with LPN #1, on 02/08/13 at 3:15 PM, revealed RN #1 did not administer any other medications nor perform treatments once discovering the medication error. Further, LPN#1 stated she administered all of Resident #2's medications "once everything calmed down", indicating after Resident #1 left the facility via ambulance to hospital. Review of Emergency Medical Services (EMS) run sheet, dated 02/02/13, revealed Resident #1 left facility at 11:45 AM. Review of Resident #2's MAR, for February 2013, revealed all of Resident #2's medications were documented as being administered at 9:00 AM on 02/02/13, with initials of what appeared to be those of RN #1. Further, Resident #2's MAR indicated [REDACTED]'s initials. Review of the Controlled Drug Record (Controlled substances are any drug or therapeutic agent with a potential for abuse or addiction which is held under strict government control) for Resident #2, revealed RN #1 documented she administered doses of controlled medications [MEDICATION NAME] and [MEDICATION NAME] on 02/02/13 at 9:00 AM, which, as previously stated, was given to Resident #1. However, further review of Controlled Drug Record (CDR) revealed no other doses of controlled medication [MEDICATION NAME] and [MEDICATION NAME] were signed out as administered to Resident #2 until Resident #2 received his/her next dose of [MEDICATION NAME] documented on 02/02/13 at 6:00 PM, and [MEDICATION NAME] documented on 02/02/13 at 10:00 PM. Interview with the DHS, on 02/13/13 at 3:15 PM, revealed she was not able to identify her nursing staff's initials responsible for administering the morning medications as recorded on Resident #2's MAR indicated [REDACTED]. Additionally, the DNS was unable to provide a current, up to date, Master Signature Log of nursing staff which identified the individuals by printed name, signature, initials, and license designation. Further, the DNS stated the CDR, which was verified by both the off going and on coming nurses at the end of each shift for accuracy, was not a definite measure to indicate whether a controlled medication was administered or not, and felt verbal verification from the nurses involved would be a better measure to determine whether or not controlled medications were administered. The facility provided an acceptable AOC on 02/14/13 that alleged the removal of the IJ was effective on 02/14/13. Review of the AOC revealed the facility implemented the following: All residents, including Resident #1 were observed by the DHS on 02/02/13 for any signs and symptoms different from their baseline. The DHS interviewed all licensed staff on duty on 02/02/13 to confirm no other residents had experienced an inadvertent medication error and that none were exhibiting an signs of symptoms different from their normal baseline. On 02/02/13 the DHS ensured that RN #1 did not administer any additional medications following the medication error and initiated an investigation related to the medication error. In addition, on 02/02/13, the DHS conducted a 100% review of all current residents' clinical records to verify that all methods of resident identification: photos on MAR/TAR, name on door and name on MAR/TAR were present. The DHS, Clinical Campus Support (CCS), Assistant Director of Health Service (ADHS), and the DHS, initiated in-service education on 02/10/13 at 12:00 PM and completed on 02/11/13 at 2:00 PM. This in-service for all licensed nurses included the following: 1) "Specific Medication Administration Procedures" to include noting the correct time, dose, route, medication, and resident identification. 2) "Specific Medication Administration Procedures" related to identification of correct resident. This included discussion of all available identification resources for resident identification including verifying residents names on the door, MAR/TAR, review of the photo, have resident tell the nurse their name or have another facility personnel identify the resident. 3) A "Specific Medication Administration Clinical Competency" was completed on all nurses with a mock resident demonstration using at least two (2) forms of identification prior to medication administration. On 02/11/13 the nurses were also observed while completing their medication pass and this is on going. 4) Assessment, monitoring, and documentation requirements was the evening that a medication error occurred. This included the nurses being given a hypothetical medication error scenario and having them complete "mock" timely Physician notification, assessment and monitoring documentation and "Medpass Error Prevention Post Test", in order to validate skill competency. 5) Discussion/Review of the facility policy and procedure for timely Physician Notification was reviewed. This included discussion of critical labs, normal labs, and resident change of condition. In-service education provided related to maintaining complete and accurate clinical records to include documentation of medication errors. The "Medication Error Circumstance Assessment and Intervention Forms" had been modified to accommodate frequent vital sign documentation. A Quality Assurance (QA) discussion was conducted on 02/11/13 at 9:00 AM to discuss the details of the action items contained in the AOC. The Executive Director (ED), DNS, Assistant Director of Nursing Services (ADHS), Consultant Pharmacist, Advanced Practice Registered Nurse (APRN), and CCS were present. The ED via phone with Medical Director discussed the action items that were put into place. The "Documentation Audit Tool" was be used to audit 100% of resident clinical records for accuracy until abatement was achieved. This audit was conducted by the DHS, ADHS, Medical records nurse, and CCS. This audit focused on timely and thorough notification of the Physician and POA and documentation. This audit tool was used to conduct audits on 100% of resident clinical records on 02/13/13 with no errors noted. The QA committee will review results of all audits weekly until substantial compliance is obtained. The Committee will monitor the effectiveness and compliance with the plan and update and develop plans of action related to any and all problems identified though audits. The results of the above will be tracked and trended with follow up actions or education for staff completed as necessary. The Medical Director if unavailable in person will review the progress by phone with the Administrator on a weekly basis (Wednesday). The State Survey Agency validated the implementation of the facility's AOC as follows: Interviews with licensed nursing staff on 02/15/13 at 8:00 AM with LPN #6, at 8:15 AM with LPN #7, at 9:00 AM with LPN #8, at 9:15 AM with RN #2, at 9:30 AM with LPN #2, at 10:00 AM with LPN #3, at 1:40 PM with LPN #9, at 2:00 PM with RN #3, at 2:30 PM with LPN #4, and at 3:00 PM with LPN #5 revealed they all attended in-services which covered: "Specific Medication Administration Procedures" which included noting the correct time, dose, route, medication, and resident identification. "Specific Medication Administration Procedures" related to identification of correct resident, including discussions on all of the acceptable identification methods, including verifying residents names on the door, MAR/TAR, review of the photo, have resident tell the nurse their name or have another facility personnel identify the resident. Further interview revealed all nurses interviewed had completed a medication administration competency, which consisted of a mock resident demonstration using at least two (2) forms of identification prior to medication administration, and were observed by the DNS or the ADNS completing their medication pass before they were able to accept the keys to a medication cart on the floor. Further interview revealed staff was in-serviced on the assessment, monitoring, and documentation requirements in the event of a medication error, which included the nurses being given a hypothetical medication error scenario and having to complete a "mock" timely Physician and POA/family notification, assessment and monitoring documentation, and then each nurse had to take and pass a medication error prevention post test in order to validate skill competency. Further interview revealed, all nurses interviewed participated in a discussion and review discussion of the facility policy and procedures for timely Physician and POA/family notification, which included discussion of critical labs, normal labs, and resident change of condition, education related to maintaining complete and accurate clinical records to include documentation of medication errors, and review of the new "Medication Error Circumstance Assessment and Intervention Forms". Review of the in-service sign in sheet revealed all nursing staff attended all in-services provided. Interview with DNS, on 02/15/13 at 3:00 PM, revealed she had participated in all the in-services provided to all licensed nursing staff and had conducted a hypothetical medication error scenario with all licensed nursing staff and completed a "mock" timely Physician and POA/family notification, assessment and monitoring documentation scenario. She further stated she also conducted a "mock" medication administration scenario with each licensed nursing staff, prior to observing each licensed nursing staff administer medications to actual residents. She further stated no licensed nursing staff had been allowed to take the medication cart prior to completing these tasks. Further interview revealed, she had conducted audits using the "Documentation Audit Tool" to audit 100% of resident clinical records for accuracy, and on the timely and thorough notification of the Physician and POA/family, and documentation. She further stated she had attended the QA meeting when all the components of the AOC were discussed and recommendations were made. Interview with the Executive Director (ED), on 02/15/13 at 3:30 PM, revealed he had participated in the development of the AOC and the implementation of the AOC. He further stated he had also assisted in the "Documentation Audit Tool" which was done on 100% of resident clinical records, as well as observed the licensed nursing staff administer medications to the residents. He further stated he had attended the QA meeting when all of the components of the AOC were discussed and recommendations made, and he had also contacted the Medical Director for his input on the AOC as well as communicated with him via phone during the QA meeting. He further stated that each morning, during the morning stand up meetings attended by all department heads, the results of the audits were reviewed by all in attendance. Interview with the Medical Director, on 02/15/13 at 4:30 PM, revealed he had been included in the completion of the AOC and had given his input and had approved the AOC. He further stated the ED had remained in contact with him via the telephone with all aspects of the implementation of the AOC and during the QA meeting when the results of the AOC and the audits were discussed.