**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. a. Review of the medical record for Resident #63 revealed the facility admitted the resident on 06/25/19 with diagnoses that included Seizure, Debility, Acute Renal Failure, and Hypertension. Review of the MDS dated [DATE] revealed the resident had a BIMS score of eight (8), which indicated the resident was cognitively impaired but interviewable. Further review of the medical record for Resident #63 revealed Physician's Orders for Phenobarbital 64.8 milligrams (mg), one tablet by mouth twice daily for seizures. The medication was scheduled to be administered at 10:00 AM and 10:00 PM; and Depakote 500 mg, one tablet by mouth three (3) times per day, used to treat seizures, was scheduled for 10:00 AM, 2:00 PM, and 10:00 PM. Review of the Medication Administration Record (MAR) dated 08/26/19, revealed the medications had not been initialed as being administered for the 10:00 PM dose. Review of the schedule and time card documentation revealed Registered Nurse (RN) #1 was responsible for administering the resident's 10:00 PM medications on 08/26/19. Interview with Resident #63 on 09/12/19 at 10:57 AM revealed he/she had missed a nighttime dose of medication a few weeks ago. Resident #63 stated he/she did not know the name of the medicine, but it helps him/her sleep. The resident stated he/she was unsure of the nurse's name that worked that night. Continued interview revealed the resident did not tell anyone about it, but this (omitted medications) had occurred several times. b. Review of the medical record for Resident #9 revealed the facility admitted the resident on 05/30/19 with diagnoses that included Neurologic pain, Hypertension, Obstructive Pulmonary Disease, and Heart failure. Review of the MDS dated [DATE], revealed the facility assessed the resident to have a BIMS score of 15, which indicated the resident was interviewable. Further review of the medical record for Resident #9 revealed a physician's order for Lopressor 12.5 mg, one tablet by mouth twice daily, used to treat high blood pressure, scheduled for 10:00 AM and 10:00 PM. Interview with Resident #9 on 09/11/19 at 1:55 PM revealed he/she had missed the scheduled nighttime medication a few weeks ago. The resident stated he/she did not recall the date, or who the nurse was working that evening. Review of the MAR revealed no documentation that the resident's Lopressor had been administered for the evening shift on 08/26/19. Review of the schedule and timecard revealed RN #1 was responsible for administering Resident #9's medications on 08/26/19. Phone interview with RN #1 on 09/10/19 at 2:10 PM revealed she had started working at the facility on 05/28/19. RN #1 stated she was hired as a weekend supervisor. The RN stated she spent four (4) days doing paperwork and watching videos. RN #1 indicated she was scheduled to work with another nurse during the second week she was employed. However, when she arrived at work the nurse she was scheduled with for orientation has resigned and she was asked to work the floor independently. RN #1 stated she was not familiar with the residents and did not know the routine for passing the medications. RN #1 further stated she was not aware that the facility has two (2) Medication Administration Records (MARs) on each unit, one for the medication aide to use and the other MAR for the nurse to use. RN #1 stated she had only made one medication error. Per the RN, she administered Resident #64 medication that belonged to Resident #66. The RN stated she had no additional training after the error and was just advised by the DON to follow the five (5) rights of medication administration. RN#1 stated she had not been observed by the DON or other administrative staff during a medication pass. RN #1 stated just human error when I made this mistake referencing the medication error. RN #1 denied that she failed to administer scheduled medications to Resident #9 and Resident #63. On 09/10/19 at 6:05 PM, interview with LPN #2 revealed she worked 6:00 PM to 6:00 AM on 08/26/19. Per LPN #2, RN #1 was working when she arrived and worked until 10:00 PM, at which time LPN #2 counted narcotics with RN #1. LPN #2 stated that RN #1 did not report any problems with residents refusing medication, or that any scheduled medications had not been administered. LPN #2 stated when she counted narcotics with RN #1, the count was correct. LPN #2 stated that during her morning medication pass she discovered that Resident #9's scheduled dose of Lopressor was not signed out as administered on 08/26/19 for the 10:00 PM dose. LPN #2 also stated Resident #63's 10:00 PM dose of Phenobarbital and Depakote had not been signed out as administered for 08/26/19 on the MAR, nor on the Controlled Drug Sheet. LPN #2 stated she notified the DON of this and the DON stated, I will look into this. The LPN stated the DON did not give her any directive regarding this matter and she was not advised of the outcome. LPN #2 stated when a medication was held or omitted the nurse should circle her initials and document a reason for the omission on the back of the MAR. LPN #2 stated that Resident #63 did not have any concerns or complaints. Per the LPN, she did not complete a medication error report for Resident #63 or Resident #9. Interview with the DON on 09/12/19 at 11:35 AM revealed the DON was not aware of any issues regarding missed or omitted medication. The DON was advised that on 08/26/19 Resident #9's and Resident #63's MARs indicated the 10:00 PM medications were not signed as being administered. The DON stated she was not aware of these errors. Continued interview revealed the DON acknowledged the doctor and family should have been notified and a medication error report completed. Per the DON, the expectation was that when a medication was omitted the nurse would circle her initials on the MAR and document a reason indicating why the medication was not given. The DON acknowledged that missing scheduled medications could have an adverse impact on the resident. She further stated she did not monitor the MAR or the Controlled Drug Count sheet to ensure medications were administered as ordered. The DON stated that RN #1 had no additional training on medication administration and medication errors. The DON stated she has not evaluated RN #1's ability to safely administer and document medication. Continued interview revealed she did not realize that all these problems were occurring. ***The facility alleged the following was implemented to remove the Immediate Jeopardy as of 09/19/19: 1. On 09/13/19, a Quality Improvement meeting was conducted after the Immediate Jeopardy (IJ) was communicated to the facility. The purpose was to develop an improvement plan to address the IJ deficiencies, and monitor guidelines to ensure compliance was maintained. This meeting was attended by the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC), and an RN Nurse Consultant. 2. On 09/14/19, the facility's Medical Director was made aware of the Immediate Jeopardy and advised of the improvement plan, by the DON. He had no concerns or additions to the plan. 3. On 09/16/19, a follow-up QI meeting was conducted to review the progress on the 09/13/19 plan. A review of all items completed and the monitoring plan was completed. There were no additional recommendations at this time. Those in attendance were the Administrator, DON, ADON, RN Consultant, and Medical Director via phone. 4. Nurse #1 has not worked in the facility since 09/08/19, and is no longer employed by the facility effective 09/16/19. 5. On 09/16/19, Nurse #2 received education regarding physician notification, which included that the physician must be notified if there was a question of whether a resident had received their medication or had their blood sugar evaluated. 6. On 09/14/19, the ADON completed an audit of 100% of the in-house residents' August and September 2019 Medication Administration Records (MARs). This audit was to identify medications that were not documented as administered on the MAR and medications with multiple days of refusals. The findings included that over 50% of the MARs were missing documentation to support that medications had been administered. 7. On 09/14/19, the DON completed interviews with all residents with a BIMS score above eight (8), except one resident who was not feeling well. Residents were asked about concerns with how and when medications were administered. One resident stated he/she did not know why he/she received each medication and why medications were not consistently given at the same time each day. This resident was provided education, by the staff nurse, on his/her medications and the two (2) hour window for administering medications. On 09/15/19, the ADON completed an interview with the resident who was not feeling well on 09/14/19. The resident had no concerns with how and when medications were administered. 8. On 09/15/19, the ADON and SDC completed nursing assessments on all residents with a BIMS score of eight (8) or below. This assessment included Vital Signs and Lung and Bowel assessments. Two (2) residents were noted with a concern. One resident had an oxygen (O2) saturation of 82%, the MD was notified, and orders for oxygen at 2 Liters and chest x-ray were received. Oxygen was applied and his/her O2 saturation was 94%. One resident had an erratic pulse. The MD was notified and ordered a STAT EKG. The resident has a diagnosis of A-fib. Both residents were asymptomatic at the time. 9. On 09/13/19, the Staff Development Coordinator began education with all licensed nurses and Kentucky Medication Aides (KMAs) regarding the six (6) rights of medication administration. These included Right Resident, Right Medication, Right Dose, Right Time, Right Route, and Right Documentation. This education also included what to do if an order was not legible, or if a medication was unavailable. On 09/14/19, this education was continued by the Director of Nursing (DON), and will continue until all licensed nurses and KMAs have completed the education. No licensed nurse or KMA will work after 09/16/19, without completing this education. As of 09/18/19, 85% of the licensed nurses and KMAs have completed this education. Beginning 09/17/19 a posttest will be completed by all licensed nurses and KMAs. The quiz will cover both medication administration and physician notification and competency validation for licensed nurses and KMA will be determined by a written test. Any licensed nurse or KMA not completing the posttest by 09/18/19, will complete it prior to returning to the floor to work. Any licensed nurse or KMA not scoring 100% will receive additional education. On 09/14/19, the education was expanded to include additional medication administration information, including documentation of medications. Licensed nurses and KMAs completing the education on 09/13/19 were provided this additional education. This education was initiated by the Director of Nursing (DON), and will be continued by the DON, ADON, or SDC until all licensed nurses and KMAs have completed the education. No licensed nurse of KMA will work after 09/16/19, without completing this education. As of 09/18/19, 85% of the licensed nurses and KMAs have completed this education. Beginning 09/17/19, a posttest will be completed by all licensed nurses and KMAs. The quiz will cover both medication administration and physician notification and licensed nurses and KMAs will validate competency by a posttest. Any licensed nurse or KMA not completing the posttest by 09/18/19 will complete it prior to returning to the floor to work. Any licensed nurse or KMA not scoring 100% will receive additional education. 10. On 09/16/19, the attending physician was notified, in writing, by the Administrator of the medication omissions for Residents #3, #13, #19, #41, #42, #53, #72, and #86. No new orders were received. On 09/16/19, the attending physicians were notified that there were additional residents without documentation to support that medications had been administered as ordered. The notification was hand delivered, in writing, by the Administrator, and the attending physicians were made aware that the MARs were available for their review. 11. On 09/14/19, the DON initiated education regarding physician notification. This education included the attending physician must be notified anytime a medication was not given as ordered, unless a resident was refusing. If the resident was refusing medications routinely, the physician should be notified. a) This education will be continued by the DON, ADON, or SDC until all licensed nurses and KMAs have completed the education. No licensed nurse or KMA will work after 09/16/19, without completing this education. As of 09/18/19, 85% of the licensed nurses and KMAs have completed this education. b) Beginning on 09/17/19, a posttest will be completed by all licensed nurses and KMAs. The quiz will cover both medication administration and physician notification and competency validation for licensed nurses and KMA will be a posttest. Any licensed nurse or KMA not completing the posttest by 09/18/19 will complete it prior to returning to the floor to work. Any licensed nurse or KMA not scoring 100% will receive additional education. 12. After 09/16/19, no licensed nurse or Kentucky Medication Aide (KMA) will be allowed to leave at the end of their shift until their MAR has been audited by the DON, ADON, SDC, or MDS Nurse. The audit is to ensure all medications have the appropriate documentation completed with physician notification, as indicated. Any concerns regarding documentation of physician notification will be addressed at the time of the audit, and reported to the DON or Administrator for review in the morning Interdisciplinary Team (IDT) meeting. a) In addition, each off-going licensed Nurse or KMA will be asked to sign a statement at the end of their shift to ensure no resident has expressed concerns regarding their medication administration. This statement will include if any concerns were expressed and to whom the concern was reported to if one was expressed. Any resident concerns regarding medication administration will be reported to the DON or Administrator for review at the morning IDT meeting. b) This audit, and statement, will continue at every shift change until Jeopardy is abated and an acceptable Plan of Correction is in place. The results of these audits will be reviewed in the weekly QAPI/IDT meeting on Fridays, beginning 09/20/19. 13. On 09/14/19, an RN Nurse Consultant observed a medication pass with the DON and one with the Assistant Director of Nursing (ADON). The purpose of this observation was to ensure the competency of the DON and ADON to administer medications. The CMS (The Centers for Medicare and Medicaid) Medication Administration Observation Care Path was used for these observations. These passes included insulin administration, the DON's medication pass included G-tube (gastrointestinal) administration. Both the DON and ADON completed the medication pass without concerns. On 09/14/19, an RN Nurse Consultant and the DON began medication administration observations with all licensed nurses and KMAs. The purpose of this observation was to ensure the competency of the licensed nurse or KMA to administer medications. Concerns were addressed with each licensed nurse or KMA at the time of the observation. As of 09/18/19, 85% of the licensed nurses and KMAs have a medication administration observation completed. 14. After 09/16/19, night shift, the DON, ADON or SDC will begin observing (auditing) all licensed nurses and KMAs administering medications daily. The purpose of the audit is to ensure the licensed nurse's or KMA's competency to administer medications. The CMS Medication Administration Observation Care Path will be used for these audits. These audits will take place on various shift and days of the week, including weekends. Any concerns will be addressed with the nurse at the time of the observation. Concerns regarding medication administration will be reported to the DON or Administrator for review at the morning IDT meeting. These observations will continue until Jeopardy is abated, then decrease to observation of half of the licensed nurses and KMAs administering medications daily until an acceptable Plan of Correction is in place. The results of these audits will be reviewed in the weekly QAPI/IDT meeting on Fridays, beginning 09/20/19. A record will be kept to track and offer opportunities to observe each licensed nurse and KMA with various types of medications, as permitted by their training, including oral, injections, G-tubes, eye drops, inhalers, crushed etc. 15. After 09/16/19, night shift, the DON, ADON, SDC, MDS Nurses, Social Services Director or Activities Director will begin interviewing six (6) random residents with a BIMS of nine (9) or above weekly to ensure they have no concerns related to when or how their medications are to be administered. Any concerns regarding medication administration will be reported to the DON or Administrator for review at the morning IDT meeting. These interviews will continue until Jeopardy is abated and an acceptable Plan of Correction is in place. The results of these audits will be reviewed in the weekly QAPI/IDT meeting on Fridays, beginning 09/20/19. 16. Beginning the week of 09/16/19, an RN Consultant will be at the facility to provide oversight of the implementation of the QI improvement plan addressing the Immediate Jeopardy. The RN Consultant visits will continue, at least three (3) days per week until Jeopardy is abated, and then at least weekly, until an acceptable Plan of Correction is in place. An RN Consultant may complete any audit in place of the assigned auditor. 17. A DON, ADON, SDC, or MDS Nurse from a sister facility may assist with monitoring, to include MAR audits, staff interviews, resident interviews, and medication administration observations, to ensure evidence is provided that they have successfully completed a medication administration audit in the past six (6) months. ****The State Survey Agency verified the facility implemented the following actions and that Immediate Jeopardy was removed on 09/19/19, as alleged by the facility: 1. Review of Minutes revealed a Quality Improvement (QI) meeting was conducted on 09/13/19 and the minutes were signed by the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC) and a Registered Nurse (RN) Consultant. Interviews on 09/25/19 with the Administrator, at 10:30 AM, the DON at 10:05 AM, the ADON at 10:00 AM, and the SDC at 10:16 AM, revealed they had attended the QA meetings dated 09/13/19, 09/16/19, and 09/20/19. 2. A statement written by the Director of Nursing was presented detailing she had informed the Medical Director, on 09/14/19 of the Immediate Jeopardy and the current plan of correction. Interview with the DON, on 09/25/19 at 10:05 AM, revealed she had phoned the Medical Director on 09/14/19 and informed him what the Immediate Jeopardy was related to and the plan per the QA committee. 3. Review of QI meeting minutes revealed a meeting was held on 09/16/19 with documentation that the plan of correction would continue. The attendees included the Administrator, DON, SDC, RN Consultant, and ADON. Interview with the ADON on 09/25 19 at 10:00 AM, the DON at 10:05 AM, the SDC at 10:16 AM, the Administrator at 10:30 AM, and the RN Nurse Consultant at 9:16 AM revealed they all had attended the QI meetings and had signed the QI form. 4. Review of the Disciplinary Warning Notice for RN #1, dated 09/16/19 revealed the notice stated RN #1 was terminated effective immediately, and signed by the DON. The documentation revealed the RN refused to sign the notice. 5. Review of the Complete In-service Training Report, dated 09/16/19, for Licensed Practical Nurse (LPN) #1 revealed the education provided included training on notification of the physician when there was a question related to the administration of medication or whether or not a resident received a medication as ordered. The training also included specific verbage related to insulin administration and physician notification. Interview with LPN #1 on 09/25/19 at 4:50 PM, revealed she did receive training regarding physician notification on 09/16/19. She stated she was educated to notify the physician whenever a medication was not administered and that insulin could not be held without an order, if the resident's blood sugar was low. 6. Review of a statement signed by the ADON, dated 09/14/19, revealed that an audit of all residents' August and September 2019 Medication Administration Records (MAR) had been conducted. The review also included a copy of all MARs reviewed and highlighted areas that revealed discrepancy or incomplete documentation. Interview with the ADON, on 09/25/19 at 10:00 AM, revealed she conducted the MAR audits as stated and any concerns were addressed. 7. Review of documentation revealed a medication questionnaire was used for interviews of all residents with a Brief Interview Mental Status (BIMS) score above eight (8). All questionnaires were dated 09/14/19 and were signed by the DON. One (1) resident had declined the interview on 09/14/19; however, the ADON conducted the interview with the resident on 09/15/19. Interview with the DON on 09/25/19 at 10:05 AM, revealed she conducted the interviews on 09/14/19 and 09/15/19 for all residents with a BIMS score above eight (8). She also stated she had the opportunity to educate some of the residents who had concerns, which included Resident #43, Resident #25, and Resident #24. Interview with Resident #25, on 09/25/19 at 8:15 AM, revealed he/she had concerns with some medications, staff educated him/her, and he/she was satisfied with the explanation. Interview with Resident #24, on 09/25/19 at 8:20 AM, revealed the resident could not remember the discussion related to medications. Interview with Resident #43, on 09/25/19 at 8:25 AM, revealed he/she was educated, but stated he/she still got confused when some medicines had different names. 8. Review of assessment documentation revealed assessments for all resident with a BIMS of eight (8) or less were completed on 09/15/19 by the ADON or the SDC. Interview with the ADON on 09/25/19 at 10:00 AM, revealed an assessment was performed on all residents with a BIMS of eight (8) or lower. Physicians were contacted with all concerns and they were addressed. 9. Review of education documentation revealed staff were trained regarding the six (6) rights of medication administration. A sign in sheet was available with nurses and KMAs who attended on 09/13/19. There was documented evidence of continued education by the DON and the SDC. Each nurse and KMA employed by the facility was on a roster and was checked off as education was provided in each of the areas. Interview with the SDC, on 09/25/19 at 10:16 AM, revealed on 09/13/19 she immediately educated the nurses and KMAs on the six (6) rights of medication administration as well as documentation on the MAR. She stated that education would continue daily until all nurses and KMAs had received the education. She also stated no nurse or KMA would be permitted to work the floor to administer medications until all education was provided and had scored 100% on the posttest. Interview with the DON, on 09/25/19 at 10:05 AM, revealed she initiated education on 09/14/19 that included additional medication information and accurate documentation on the MAR. She stated the education had continued daily and no nurse or KMA was allowed to work and administer medications until they had received all the education provided and passed the posttest with a score of 100%. Interviews on 09/25/19 with KMA #3 at 8:10 AM, RN #2 at 8:30 AM, RN #4 at 8:45 AM, LPN #8 at 8:54 AM, LPN #5 at 9:00 AM, LPN #4 at 9:10 AM, LPN #13 at 10:40 AM and LPN #1 at 4:50 PM revealed they all had received training on the six (6) rights of medication administration and documentation on the MAR. A posttest was completed after the training. 10. Reviewed letters addressed to the physicians for Residents #3, #13, #19, #41, #42, #53, #72, and #86 related to omission of medications. Additional residents were added to the notifications as a result of the 09/14/19 audit. Each letter included the names of the specific residents under the care of that physician and the medications believed to have been omitted. Interview with the Administrator, on 09/25/19 at 10:30 AM, revealed he had hand delivered each of the letters to the physicians' offices. He further stated he had received no questions or concerns from the physicians. Interviews with Medical Doctor (MD) #4 on 09/25/19, at 9:24 AM and MD #3 at 11:06 AM, revealed both had received letters detailing the possible omission of medications on their residents and had no further concerns or questions 11. Review of the Allegation of Compliance information revealed training, dated 09/14/19, on physician notification was initiated by the DON. The information also included a sign in sheet of staff that attended and dated. All nurses and Kentucky Medication Aides (KMA) employed by the facility had documentation of when they were provided the education. This education had been provided on an ongoing basis since 09/14/19. Interview with the DON, on 09/25/19 at 10:05 AM, revealed she initiated education on physician notification on 09/14/19. She stated the training included the six (6) rights of medication administration, medication error process, and accurate documentation of the MAR. Interviews on 09/25/19 with KMA #3 at 8:10 AM, RN #2 at 8:30 AM, RN #4 at 8:45 AM, LPN #8 at 8:54 AM, LPN #5 at 9:00 AM, LPN #4 at 9:10 AM, LPN #13 at 10:40 AM and LPN #1 at 4:50 PM revealed they all had received training regarding notification of the physician anytime a medication was not administered as ordered. The interviews also revealed the staff had completed a posttest and had to make 100% to pass. Interview with the Staff Development Coordinator (SDC), on 09/25/19 at 10:16 AM, revealed she had been educating nurses and KMA's on physician notification related to medications. 12. (a) Review of the Allegation of Compliance evidence revealed audits of MARS, dated 09/16/19 to 09/24/19. These audits were performed at the end of each shift, by the DON, ADON, SDC, or MDS Nurse, for each nurse or KMA who had administered medications during the shift. The audit ensured all medications had the appropriate documentation with physician notification as indicated. The audit also contained a statement, signed by the nurse or KMA, as to whether or not a resident had voiced any concerns or complaints regarding their medications during the shift. Interviews on 09/25/19 with KMA #3 at 8:10 AM, RN #2 at 8:30 AM, RN #4 at 8:45 AM, LPN #8 at 8:54 AM, LPN #5 at 9:00 AM, LPN #4 at 9:10 AM, LPN #13 at 10:40 AM and LPN #1 at 4:50 PM revealed residents' MARs were audited at the end of the shift and each had to sign a statement related to any resident concerns about medications. (b) Review of the 09/20/19 QA/QI meeting revealed the every shift audits were completed and reviewed in the QA/QI meeting. Interview with the ADON on 09/25 19 at 10 AM, the DON at 10:05 AM, the SDC at 10:16 AM, the Administrator at 10:30 AM and the RN Nurse Consultant at 9:16 AM revealed they all had attended the QA meetings and had signed the QA form. 13. The AOC evidence revealed a check off form, CMS Medication Administration Observation Care Path, was used by the RN Nurse Consultant on 09/14/19, to ensure the competency of the DON and the ADON to administer medications. Interview with the DON, on 09/25/19 at 10:05 AM, revealed an RN Nurse Consultant performed her medication administration competency. 14. Review of the AOC evidence revealed observations of nurses and KMA's on a daily basis using the CMS Medication Administration Observation Care Path, dated from 09/14/19 up through 09/24/19. Interviews with KMA #3 on 09/25/19 at 8:10 AM, RN #4 at 8:45 AM, LPN #8 at 8:54 AM, LPN #5 at 9 AM, LPN #13 at 10:40 AM and LPN #1 at 4:50 PM revealed they had been observed daily, and sometimes multiple times a day, administering medications. 15. The AOC evidence revealed six (6) resident interviews, dated 09/18/19, and seven (7) resident interviews, dated 09/23/19 performed by one of the management team. The questionnaires were related to any medication concerns the residents may have. Interview with the ADON, on 09/25/19 at 10 AM, revealed no concerns had been voiced with resident interviews. She also stated the audits of and interview results were reviewed at the 09/20/19 QA meeting. Interview with the Administrator, on 09/25/19 at 10:30 AM, revealed during the QA meeting, dated 09/20/19, results of audits and competencies, and resident interviews were reviewed. These will continue to be monitored these on a weekly basis. 16. Interview with the RN Nurse Consultant on 09/25/19 at 9:16 AM, revealed since 09/13/19, she had been present in the facility every day except for 09/21/19 and 09/22/19. 17. Interview with the DON, on 09/25/19 at 10:05 AM, revealed a sister facility's DON and SDC had assisted the facility with audits during the week of 09/16/19. Based on interview, record review, and review of the facility's policy for medication administration it was determined the facility failed to ensure three (3) of twenty-two (22) sampled residents (Residents #9, #63, and #80) were free of significant medication errors. On 08/26/19, the facility failed to administer Lopressor (used to treat high blood pressure) to Resident #9 as ordered, and failed to administer Phenobarbital (used to treat seizures) and Depakote (used to treat seizures) to Resident #63 as ordered. The facility failed to obtain and administer the medication Diulo (a medication to help the kidneys remove fluid) to Resident #80 daily on 09/02/19-09/04/19. The resident was congested and voiced complaints of being short of breath due to edema and was treated at the facility. Refer to F726. The facility's failure to ensure residents were free from significant medications errors has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/13/19 and was determined to exist on 08/19/19 at 42 CFR 483.10 Resident Rights (F580-K), 42 CFR 483.35 Nursing Services (F726-K), and 42 CFR 483.45 Pharmacy Services (F760-J). The facility was notified of the Immediate Jeopardy on 09/13/19. An acceptable Allegation of Compliance was received on 09/18/19, which alleged removal of the Immediate Jeopardy on 09/19/19. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on 09/19/19, prior to exit on 09/25/19, which lowered the scope and severity to E level at 42 CFR 483.10 Resident Rights (F580) and 42 CFR 483.35 Nursing Services (F726) and to D level at 42 CFR 483.45 Pharmacy Services (F760) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Interview with the Director of Nursing (DON) on 09/12/19 at 11:25 AM revealed the facility did not have a written policy for obtaining medications from the pharmacy, but the facility's procedure was for a copy of the Physician's Orders to be faxed to the pharmacy and the pharmacy to deliver the medications. Review of the Medication Administration policy, not dated, revealed, All medication errors shall be described in detail on a Medication Error Report which shall be filed with the Director of Nursing (DON). The facility's medication error report shall be completed in detail, making every possible effort to describe the discrepancy thoroughly; suggestion should be made as to how such discrepancy could be avoided in the future. A review of the medical record for Resident #80 revealed the facility admitted the reside[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policy it was determined the facility failed to immediately notify the physician of omitted medications and/or medication errors for twelve (12) of twenty-two (22) sampled residents (Resident #3, #9, #13, #19, #28, #41, #42, #47, #63, #66, #72, and #86). Seven residents (Residents #3, #13, #19, #41, #42, #72, and #86), who were alert and oriented, all alleged they did not receive medications as ordered on the evening of 08/19/19. RN #1 was responsible for administering medications for these residents on 08/19/19. Although the residents' complaints were reported to administrative staff (DON and Administrator), the facility failed to report the medication errors to the residents' physicians. Resident #66 also reported that he/she did not receive his/her medications on the evening of 08/26/19. In addtion, RN #1 failed to administer three (3) residents (Residents #63, #47, and #9) their 10:00 PM medications on 08/26/19. Again, the facility failed to ensure the residents' physicians were notified of the medication errors. Resident #28 reported to at least three (3) facility staff members that staff had failed to administer his/her medications. RN #1 failed to administer the resident's pain medication on 08/25/19 and the medication error was reported to administrative staff (Assistant Director of Nursing and Director of Nursing); however, the facility failed to notify Resident #28's physician of the medication error. The facility's failure to immediately report the alleged omission of ordered medications for residents (Resident #3, #9, #13, #19, #28, #41, #42, #47, #63, #66, #72, and #86) has caused or is likely to cause serious harm, injury, impairment, or death to a resident. Immediate Jeopardy was identified on 09/13/19 and was determined to exist on 08/19/19 at 42 CFR 483.10 Resident Rights (F580-K), 42 CFR 483.35 Nursing Services (F726-K) and 42 CFR 483.45 Pharmacy Services (F760-J). The facility was notified of the Immediate Jeopardy on 09/13/19. An acceptable Allegation of Compliance was received on 09/18/19, which alleged removal of the Immediate Jeopardy on 09/19/19. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on 09/19/19, prior to exit on 09/25/19, which lowered the scope and severity to E level at 42 CFR 483.10 Resident Rights (F580) and 42 CFR 483.35 Nursing Services (F726) and to D level at 42 CFR 483.45 Pharmacy Services (F760) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy, Notification of Physician for Change in Resident's Condition, dated August 2012, revealed the facility was to notify the physician when a significant change in a resident's condition occurred with documentation contained in the medical record. Review of the Medication Administration policy, not dated, revealed, All medication errors shall be described in detail on a Medication Error Report which shall be filed with the Director of Nursing (DON). Continued review revealed the facility's medication error report shall be completed in detail, making every possible effort to describe the discrepancy thoroughly; suggestion should be made as to how such discrepancy could be avoided in the future. The attending physician shall be notified immediately of significant medication errors. 1. Seven residents (Residents #3, #13, #19, #41, #42, #72, and # 86), who were alert and oriented, all alleged they did not receive medications as ordered on the evening of 08/19/19. An interview on 09/10/19 at 12:14 PM with LPN #1 revealed RN #1 had helped with medication administration on the East Unit (short hall) on the evening of 08/19/19. Per LPN #1, the RN left sometime around 10:00 PM. The LPN stated that at around 9:30 PM, Resident #41 stated he/she was ready to take his/her medication for the night. When RN #1 was informed of this, she stated she had already administered the resident's medication. LPN #1 stated Resident #41 was told what the nurse had stated and the resident replied that he/she had not received the medication. Resident #42 then asked the LPN when he/she would receive the rest of his/her medication. Per LPN #1, Resident #42 stated he/she had only received one pill and the RN had informed him/her she did not have the right cart to give the rest of the resident's medication. The LPN further stated Resident #72 asked when someone was going to perform his/her finger stick blood sugar and that he/she felt funny. LPN #1 stated the MAR for Resident #72 revealed the finger stick blood sugar had been performed with a reading of 130. LPN #1 stated she checked the MARs of Residents #13 and #19 and discovered Resident #13's fingerstick blood sugar was also documented as 130 and Resident #19 had no finger stick blood sugar documented and the ordered Levemir (long-acting insulin) had not been administered. The LPN stated she did another finger stick blood sugar on Resident #13 and it was 297. LPN #1 stated she continued to review the MARs of the residents on the East short hall and discovered Residents #3 and #86 had no initials in the space on the MAR that would have indicated their evening medications were administered as ordered. Per the LPN, she notified the Assistant Director of Nursing (ADON), who was in the facility working on the [NAME] Unit, of all the allegations and MAR inaccuracies. Per the LPN, the DON was also made aware of the incidents by the ADON on 08/20/19 and she was told the DON had handled the situation. Interview with RN #1 on 09/13/19 at 3:39 PM, revealed she remembered it took a long time to complete the medication pass on 08/19/19 because she was not familiar with the hall. She further stated the two (2) book MAR system means you have to go back and forth. The RN also stated she did not remember ever being spoken to regarding allegations on 08/19/19. Interview with the DON on 09/10/19 at 3:07 PM, revealed she spoke to RN #1 the next day following the incidents on 08/19/19. She also stated she spoke to the residents on the hall and that no medication error forms were completed nor were the residents' physicians contacted. The DON stated she just did not think about doing that. Review of the Progress Notes for Residents #3, #13, #19, #41, #42, #72, and #86 for 08/19/19 and 08/20/19 did not reveal any documentation of physician notification regarding the residents' alleged medication omissions. Interview on 09/13/19 with MD (Medical Doctor) #1 at 3:00 PM and MD #2 at 3:05 PM revealed neither had been contacted related to medication errors involving their residents. The doctors stated they would expect to be notified of any resident medication errors. 2. Review of the medical record for Resident #66 revealed the facility admitted the resident on 08/09/19 with diagnoses that included Cerebral Infarction, Type 2 Diabetes, Peripheral Vascular Disease, and Chronic Kidney Disease. Review of the MDS dated [DATE] revealed the facility assessed the resident to have a BIMS score of 15, which indicated the resident was interviewable. Review of a Grievance filed by Resident #66 on 08/29/19 revealed the resident had reported to the Social Services Director that on 08/26/19, the nurse on duty did not give his/her medicine and failed to do a finger stick blood sugar and administer his/her insulin. Record review revealed Resident #66 was discharged from the facility on 09/04/19. Unsuccessful attempts were made to contact the resident by phone. Interview with the Social Services Director (SSD) on 09/13/19 at 2:37 PM revealed on 08/29/19, Resident #66 reported that he/she did not receive his/her medications on 08/26/19. The SSD stated she reported the medication error to the Administrator. Interview with the Administrator on 09/13/19 at 5:03 PM revealed he spoke with the Director of Nursing (DON) regarding the resident not receiving medication as ordered, and the DON assured him that she had taken care of the concern. However, an interview with the DON on 09/10/19 at 2:56 PM revealed Resident #66's physician should have been contacted related to the medication error with the resident's insulin, but she did not ensure the physician was notified. 3. Review of the medical record for Resident #63 revealed the facility admitted the resident on 06/25/19 with diagnoses that included Seizure, Debility, Acute Renal Failure, and Hypertension. Review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of eight (8), which indicates the resident was cognitively impaired, but interviewable. Further review of the medical record for Resident #63 revealed a Physician's Order for Phenobarbital (an anticonvulsant) 64.8 mg (milligrams), one tablet by mouth twice daily for Seizures, scheduled to be administered at 10:00 AM and 10:00 PM. Further review revealed an order for Depakote 500 mg, one tablet by mouth three times per day, used to treat Seizures, scheduled for 10:00 AM, 2:00 PM, and 10:00 PM. Review of the Medication Administration Record (MAR) dated 08/26/19 revealed the resident's 10:00 PM dose of Phenobarbital and Depakote had not been initialed as being administered. Interview with Resident #63 on 09/12/19 at 10:57 AM revealed the nurse on duty had failed to administer his/her scheduled medication at bedtime. However, the resident could not remember the exact date. Resident #63 stated the medication was to help him/her sleep and he/she had not slept at all that night. Continued interview with Resident #63 revealed the resident reported the omitted medications the following day, but he/she could not remember the nurse's name that he/she reported it to. On 09/10/19 at 6:05 PM, interview with LPN #2 revealed she worked 6:00 PM to 6:00 AM on 08/26/19. Per LPN #2, RN #1 was working when she arrived and worked until 10:00 PM, at which time LPN #2 counted narcotics with RN #1. LPN #2 stated that RN #1 did not report any problems with residents refusing medication, or that any scheduled medications had not been administered. LPN #2 stated Resident #63's 10:00 PM dose of Phenobarbital and Depakote had not been signed out as administered for 08/26/19 on the MAR, nor on the Controlled Drug Sheet. LPN #2 stated she notified the DON of this and the DON stated, I will look into this. Per the LPN, she did not call the resident's physician related to the medication error for Resident #63. 4. Review of the medical record for Resident #47 revealed the facility admitted the resident on 08/17/18 with diagnoses that included Arthritis, Alzheimer's disease, Gastroesophageal Reflux Disease, and Hypothyroidism. Review of the MDS dated [DATE] revealed the facility assessed the resident to have a BIMS score of 99, which indicated the resident was not interviewable. Review of the medical record for Resident #47 revealed a Physician's Order dated 08/01/19 through 08/31/19 for Hydrocodone/APAP (controlled pain medication) tablet 5-325, one tablet by mouth twice daily. The medication was scheduled at 10:00 AM and 10:00 PM. However, review of the MAR dated 08/26/19 revealed the 10:00 PM dose was not signed out. In addition, review of the Controlled Substance Receipt/Count Sheet dated 08/26/19 revealed the 10:00 PM dosage of medication had not been administered to the resident on 08/26/19. On 09/10/19 at 6:05 PM, interview with LPN #2 revealed she worked 6:00 PM to 6:00 AM on 08/26/19. LPN #2 stated she received report from the offgoing nurse, RN #1, around 10:00 PM on 08/26/19. LPN #2 stated that RN #1 did not report any problems with residents refusing medication, or that any scheduled medications had not been administered. LPN #2 stated that during her morning medication pass she discovered that Resident #47's scheduled dose of Hydrocodone/APAP on 08/26/19 at 10:00 PM had not been signed as administered on the MAR or signed out on the Controlled Drug Sheet. LPN #2 stated she informed the DON of this when she arrived at the facility but failed to contact the physician of the medication error. 5. Review of the medical record for Resident #9 revealed the facility admitted the resident on 05/30/19 with diagnoses that included Neurologic pain, Hypertension, Obstructive Pulmonary Disease, and Heart Failure. Review of the MDS dated [DATE], revealed the facility assessed the resident to have a BIMS score of 15, which indicated the resident was interviewable. Interview with Resident #9 on 09/11/19 at 1:55 PM revealed his/her scheduled nighttime medication was missed/omitted a few weeks ago. The resident stated he/she did not recall the date, or the nurse working. Resident #9 stated he/she did not sleep at all that night, and further stated that the medication was for my nerves. Review of the medical record for Resident #9 revealed an order for Hydrocodone/APAP 7.5-325, one tablet by mouth three times per day, scheduled for 10:00 AM, 4:00 PM, and 10:00 PM, and Xanax 0.25 mg, one tablet by mouth three times per day, scheduled for 10:00 AM, 4:00 PM, and 10:00 PM. Review of the MAR and the Controlled Substance Receipt/Count Sheet for 08/26/19 revealed the medications were not signed out for the 10:00 PM dose. On 09/10/19 at 6:05 PM, interview with LPN #2 revealed she worked 6:00 PM to 6:00 AM on 08/26/19. The LPN stated she received report from the offgoing nurse, RN #1, around 10:00 PM on 08/26/19. LPN #2 stated that RN #1 did not report any problems with residents refusing medication, or that any scheduled medications had not been administered. LPN #2 stated that during her morning medication pass she discovered that Resident #9's scheduled dose of Hydrocodone/APAP, Xanax, and Neurontin had not been signed out on the MAR or on the controlled drug sheet. LPN #2 stated she informed the DON of this when she arrived at the facility. Per the LPN, she had not contacted the resident's physician related to the medication error. Interview with the DON on 09/10/19 at 2:56 PM revealed she did not recall any reports that Resident #47 or Resident #9 had not received their scheduled medication. The DON stated when a medication error occurs, the resident's physician should be notified. 6. Medical record review for Resident #28 revealed the facility admitted the resident on 01/22/18 with diagnoses that included Pain, Shortness of Breath, Major Depression, and Sepsis. Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score was eight (8) indicating the resident was cognitively impaired, but was interviewable. Interview with Resident #28 on 09/10/19 at 12:23 PM revealed he/she missed his/her medication for several days; was unable to state the exact dates. Resident #28 stated he/she felt funny and didn't rest well and had pain because of not receiving his/her medication. Review of the medical record for Resident #28 revealed a Physician's Order for Hydrocodone/APAP 7.5/325, one (1) tablet by mouth twice daily. Review of the resident's Medication Administration Record (MAR) revealed the medication was scheduled for 10:00 AM and 10:00 PM. Review of the MAR dated 08/25/19 revealed RN #1's initials were circled with no documented evidence indicating why the medication was not administered. Interview with Kentucky Medication Aide (KMA) #1 on 09/10/19 at 11:20 AM revealed Resident #28 reported that he/she did not receive his/her nighttime medication for three (3) days (unable to recall the date). KMA #1 stated she immediately reported the medication errors to LPN #2. Interview on 09/10/19 at 6:05 PM with LPN #2 revealed on 08/26/19, KMA #1 reported that Resident #28 had complained of not getting his/her medications for the past three (3) days. LPN #2 stated she reviewed Resident #28's MAR and discovered several areas that had not been initialed. The LPN stated she did notify the DON of the resident's complaint of missed medications when she discovered the error, but she was not directed by the DON to take any action. The resident's physician was not notified regarding the medication error. Interview with the SSD, who also is a KMA, on 09/13/19 at 2:37 PM revealed the SSD had worked on 08/25/19, on the 2 PM-10 PM shift as a KMA. The SSD was assigned to pass medication. The SSD stated that Resident #28 reported that he/she had not received his/her scheduled morning medication. The SSD stated she reviewed the Controlled Drug Sign Sheet and discovered the morning dose of Hydrocodone/APAP was not signed out. However, the scheduled 10:00 AM dose was signed out on the MAR indicating the medication had been administered. The SSD stated that RN #1 was assigned to pass the morning medicine on 08/25/19. She further stated that she questioned RN #1 about why the narcotic was not signed out on the controlled drug log. However, RN #1 did not respond to the question. The SSD stated that later in the shift she checked Resident #28's MAR again and the 08/25/19 10:00 AM dose of Hydrocodone/APAP had been circled, indicating not given. The SSD stated she reported the medication error to the DON. Further review revealed no documented evidence that Resident #28's physician was contacted related to the medication error. Interview with the DON on 09/10/19 at 2:56 PM revealed she did not recall anyone reporting that Resident #28's medications were omitted. The DON further reported the facility had no system in place to monitor residents' MARs for completion or to ensure the physician was notified when medications were not administered as ordered. ***The facility alleged the following was implemented to remove the Immediate Jeopardy as of 09/19/19: 1. On 09/13/19, a Quality Improvement meeting was conducted after the Immediate Jeopardy (IJ) was communicated to the facility. The purpose was to develop an improvement plan to address the IJ deficiencies, and monitor guidelines to ensure compliance was maintained. This meeting was attended by the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC), and an RN Nurse Consultant. 2. On 09/14/19, the facility's Medical Director was made aware of the Immediate Jeopardy and advised of the improvement plan, by the DON. He had no concerns or additions to the plan. 3. On 09/16/19, a follow-up QI meeting was conducted to review the progress on the 09/13/19 plan. A review of all items completed and the monitoring plan was completed. There were no additional recommendations at this time. Those in attendance were the Administrator, DON, ADON, RN Consultant, and Medical Director via phone. 4. Nurse #1 has not worked in the facility since 09/08/19, and is no longer employed by the facility effective 09/16/19. 5. On 09/16/19, Nurse #2 received education regarding physician notification, which included that the physician must be notified if there was a question of whether a resident had received their medication or had their blood sugar evaluated. 6. On 09/14/19, the ADON completed an audit of 100% of the in-house residents' August and September 2019 Medication Administration Records (MARs). This audit was to identify medications that were not documented as administered on the MAR and medications with multiple days of refusals. The findings included that over 50% of the MARs were missing documentation to support that medications had been administered. 7. On 09/14/19, the DON completed interviews with all residents with a BIMS score above eight (8), except one resident who was not feeling well. Residents were asked about concerns with how and when medications were administered. One resident stated he/she did not know why he/she received each medication and why medications were not consistently given at the same time each day. This resident was provided education, by the staff nurse, on his/her medications and the two (2) hour window for administering medications. On 09/15/19, the ADON completed an interview with the resident who was not feeling well on 09/14/19. The resident had no concerns with how and when medications were administered. 8. On 09/15/19, the ADON and SDC completed nursing assessments on all residents with a BIMS score of eight (8) or below. This assessment included Vital Signs and Lung and Bowel assessments. Two (2) residents were noted with a concern. One resident had an oxygen (O2) saturation of 82%, the MD was notified, and orders for oxygen at 2 Liters and chest x-ray were received. Oxygen was applied and his/her O2 saturation was 94%. One resident had an erratic pulse. The MD was notified and ordered a STAT EKG. The resident has a diagnosis of A-fib. Both residents were asymptomatic at the time. 9. On 09/13/19, the Staff Development Coordinator began education with all licensed nurses and Kentucky Medication Aides (KMAs) regarding the six (6) rights of medication administration. These included Right Resident, Right Medication, Right Dose, Right Time, Right Route, and Right Documentation. This education also included what to do if an order was not legible, or if a medication was unavailable. On 09/14/19, this education was continued by the Director of Nursing (DON), and will continue until all licensed nurses and KMAs have completed the education. No licensed nurse or KMA will work after 09/16/19, without completing this education. As of 09/18/19, 85% of the licensed nurses and KMAs have completed this education. Beginning 09/17/19 a posttest will be completed by all licensed nurses and KMAs. The quiz will cover both medication administration and physician notification and competency validation for licensed nurses and KMA will be determined by a written test. Any licensed nurse or KMA not completing the posttest by 09/18/19, will complete it prior to returning to the floor to work. Any licensed nurse or KMA not scoring 100% will receive additional education. On 09/14/19, the education was expanded to include additional medication administration information, including documentation of medications. Licensed nurses and KMAs completing the education on 09/13/19 were provided this additional education. This education was initiated by the Director of Nursing (DON), and will be continued by the DON, ADON, or SDC until all licensed nurses and KMAs have completed the education. No licensed nurse of KMA will work after 09/16/19, without completing this education. As of 09/18/19, 85% of the licensed nurses and KMAs have completed this education. Beginning 09/17/19, a posttest will be completed by all licensed nurses and KMAs. The quiz will cover both medication administration and physician notification and licensed nurses and KMAs will validate competency by a posttest. Any licensed nurse or KMA not completing the posttest by 09/18/19 will complete it prior to returning to the floor to work. Any licensed nurse or KMA not scoring 100% will receive additional education. 10. On 09/16/19, the attending physician was notified, in writing, by the Administrator of the medication omissions for Residents #3, #13, #19, #41, #42, #53, #72, and #86. No new orders were received. On 09/16/19, the attending physicians were notified that there were additional residents without documentation to support that medications had been administered as ordered. The notification was hand delivered, in writing, by the Administrator, and the attending physicians were made aware that the MARs were available for their review. 11. On 09/14/19, the DON initiated education regarding physician notification. This education included the attending physician must be notified anytime a medication was not given as ordered, unless a resident was refusing. If the resident was refusing medications routinely, the physician should be notified. a) This education will be continued by the DON, ADON, or SDC until all licensed nurses and KMAs have completed the education. No licensed nurse or KMA will work after 09/16/19, without completing this education. As of 09/18/19, 85% of the licensed nurses and KMAs have completed this education. b) Beginning on 09/17/19, a posttest will be completed by all licensed nurses and KMAs. The quiz will cover both medication administration and physician notification and competency validation for licensed nurses and KMA will be a posttest. Any licensed nurse or KMA not completing the posttest by 09/18/19 will complete it prior to returning to the floor to work. Any licensed nurse or KMA not scoring 100% will receive additional education. 12. After 09/16/19, no licensed nurse or Kentucky Medication Aide (KMA) will be allowed to leave at the end of their shift until their MAR has been audited by the DON, ADON, SDC, or MDS Nurse. The audit is to ensure all medications have the appropriate documentation completed with physician notification, as indicated. Any concerns regarding documentation of physician notification will be addressed at the time of the audit, and reported to the DON or Administrator for review in the morning Interdisciplinary Team (IDT) meeting. a) In addition, each off-going licensed Nurse or KMA will be asked to sign a statement at the end of their shift to ensure no resident has expressed concerns regarding their medication administration. This statement will include if any concerns were expressed and to whom the concern was reported to if one was expressed. Any resident concerns regarding medication administration will be reported to the DON or Administrator for review at the morning IDT meeting. b) This audit, and statement, will continue at every shift change until Jeopardy is abated and an acceptable Plan of Correction is in place. The results of these audits will be reviewed in the weekly QAPI/IDT meeting on Fridays, beginning 09/20/19. 13. On 09/14/19, an RN Nurse Consultant observed a medication pass with the DON and one with the Assistant Director of Nursing (ADON). The purpose of this observation was to ensure the competency of the DON and ADON to administer medications. The CMS (The Centers for Medicare and Medicaid) Medication Administration Observation Care Path was used for these observations. These passes included insulin administration, the DON's medication pass included G-tube (gastrointestinal) administration. Both the DON and ADON completed the medication pass without concerns. On 09/14/19, an RN Nurse Consultant and the DON began medication administration observations with all licensed nurses and KMAs. The purpose of this observation was to ensure the competency of the licensed nurse or KMA to administer medications. Concerns were addressed with each licensed nurse or KMA at the time of the observation. As of 09/18/19, 85% of the licensed nurses and KMAs have a medication administration observation completed. 14. After 09/16/19, night shift, the DON, ADON or SDC will begin observing (auditing) all licensed nurses and KMAs administering medications daily. The purpose of the audit is to ensure the licensed nurse's or KMA's competency to administer medications. The CMS Medication Administration Observation Care Path will be used for these audits. These audits will take place on various shift and days of the week, including weekends. Any concerns will be addressed with the nurse at the time of the observation. Concerns regarding medication administration will be reported to the DON or Administrator for review at the morning IDT meeting. These observations will continue until Jeopardy is abated, then decrease to observation of half of the licensed nurses and KMAs administering medications daily until an acceptable Plan of Correction is in place. The results of these audits will be reviewed in the weekly QAPI/IDT meeting on Fridays, beginning 09/20/19. A record will be kept to track and offer opportunities to observe each licensed nurse and KMA with various types of medications, as permitted by their training, including oral, injections, G-tubes, eye drops, inhalers, crushed etc. 15. After 09/16/19, night shift, the DON, ADON, SDC, MDS Nurses, Social Services Director or Activities Director will begin interviewing six (6) random residents with a BIMS of nine (9) or above weekly to ensure they have no concerns related to when or how their medications are to be administered. Any concerns regarding medication administration will be reported to the DON or Administrator for review at the morning IDT meeting. These interviews will continue until Jeopardy is abated and an acceptable Plan of Correction is in place. The results of these audits will be reviewed in the weekly QAPI/IDT meeting on Fridays, beginning 09/20/19. 16. Beginning the week of 09/16/19, an RN Consultant will be at the facility to provide oversight of the implementation of the QI improvement plan addressing the Immediate Jeopardy. The RN Consultant visits will continue, at least three (3) days per week until Jeopardy is abated, and then at least weekly, until an acceptable Plan of Correction is in place. An RN Consultant may complete any audit in place of the assigned auditor. 17. A DON, ADON, SDC, or MDS Nurse from a sister facility may assist with monitoring, to include MAR audits, staff interviews, resident interviews, and medication administration observations, to ensure evidence is provided that they have successfully completed a medication administration audit in the past six (6) months. ****The State Survey Agency verified the facility implemented the following actions and that Immediate Jeopardy was removed on 09/19/19, as alleged by the facility: 1. Review of Minutes revealed a Quality Improvement (QI) meeting was conducted on 09/13/19 and the minutes were signed by the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC) and a Registered Nurse (RN) Consultant. Interviews on 09/25/19 with the Administrator, at 10:30 AM, the DON at 10:05 AM, the ADON at 10:00 AM, and the SDC at 10:16 AM, revealed they had attended the QA meetings dated 09/13/19, 09/16/19, and 09/20/19. 2. A statement written by the Director of Nursing was presented detailing she had informed the Medical Director, on 09/14/19 of the Immediate Jeopardy and the current plan of correction. Interview with the DON, on 09/25/19 at 10:05 AM, revealed she had phoned the Medical Director on 09/14/19 and informed him what the Immediate Jeopardy was related to and the plan per the QA committee. 3. Review of QI meeting minutes revealed a meeting was held on 09/16/19 with documentation that the plan of correction would continue. The attendees included the Administrator, DON, SDC, RN Consultant, and ADON. Interview with the ADON on 09/25 19 at 10:00 AM, the DON at 10:05 AM, the SDC at 10:16 AM, the Administrator at 10:30 AM, and the RN Nurse Consultant at 9:16 AM revealed they all had attended the QI meetings and had signed the QI form. 4. Review of the Disciplinary Warning Notice for RN #1, dated 09/16/19 revealed the notice stated RN #1 was terminated effective immediately, and signed by the DON. The documentation revealed the RN refused to sign the notice. 5. Review of the Complete In-service Training Report, dated 09/16/19, for Licensed Practical Nurse (LPN) #1 revealed the education provided included training on notification of the physician when there was a question related to the administration of medication or whether or not a resident received a medication as ordered. The training also included specific verbage related to insulin administration and physician notification. Interview with LPN #1 on 09/25/19 at 4:50 PM, revealed she did receive training regarding physician notification on 09/16/19. She stated she was educated to notify the physician whenever a medication was not administered and that insulin could not be held without an order, if the resident's blood sugar was low. 6. Review of a statement signed by the ADON, dated 09/14/19, revealed that an audit of all residents' August and September 2019 Medication Administration Records (MAR) had been conducted. 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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** ***The facility alleged the following was implemented to remove the Immediate Jeopardy as of 09/19/19: 1. On 09/13/19, a Quality Improvement meeting was conducted after the Immediate Jeopardy (IJ) was communicated to the facility. The purpose was to develop an improvement plan to address the IJ deficiencies, and monitor guidelines to ensure compliance was maintained. This meeting was attended by the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC), and an RN Nurse Consultant. 2. On 09/14/19, the facility's Medical Director was made aware of the Immediate Jeopardy and advised of the improvement plan, by the DON. He had no concerns or additions to the plan. 3. On 09/16/19, a follow-up QI meeting was conducted to review the progress on the 09/13/19 plan. A review of all items completed and the monitoring plan was completed. There were no additional recommendations at this time. Those in attendance were the Administrator, DON, ADON, RN Consultant, and Medical Director via phone. 4. Nurse #1 has not worked in the facility since 09/08/19, and is no longer employed by the facility effective 09/16/19. 5. On 09/16/19, Nurse #2 received education regarding physician notification, which included that the physician must be notified if there was a question of whether a resident had received their medication or had their blood sugar evaluated. 6. On 09/14/19, the ADON completed an audit of 100% of the in-house residents' August and September 2019 Medication Administration Records (MARs). This audit was to identify medications that were not documented as administered on the MAR and medications with multiple days of refusals. The findings included that over 50% of the MARs were missing documentation to support that medications had been administered. 7. On 09/14/19, the DON completed interviews with all residents with a BIMS score above eight (8), except one resident who was not feeling well. Residents were asked about concerns with how and when medications were administered. One resident stated he/she did not know why he/she received each medication and why medications were not consistently given at the same time each day. This resident was provided education, by the staff nurse, on his/her medications and the two (2) hour window for administering medications. On 09/15/19, the ADON completed an interview with the resident who was not feeling well on 09/14/19. The resident had no concerns with how and when medications were administered. 8. On 09/15/19, the ADON and SDC completed nursing assessments on all residents with a BIMS score of eight (8) or below. This assessment included Vital Signs and Lung and Bowel assessments. Two (2) residents were noted with a concern. One resident had an oxygen (O2) saturation of 82%, the MD was notified, and orders for oxygen at 2 Liters and chest x-ray were received. Oxygen was applied and his/her O2 saturation was 94%. One resident had an erratic pulse. The MD was notified and ordered a STAT EKG. The resident has a diagnosis of A-fib. Both residents were asymptomatic at the time. 9. On 09/13/19, the Staff Development Coordinator began education with all licensed nurses and Kentucky Medication Aides (KMAs) regarding the six (6) rights of medication administration. These included Right Resident, Right Medication, Right Dose, Right Time, Right Route, and Right Documentation. This education also included what to do if an order was not legible, or if a medication was unavailable. On 09/14/19, this education was continued by the Director of Nursing (DON), and will continue until all licensed nurses and KMAs have completed the education. No licensed nurse or KMA will work after 09/16/19, without completing this education. As of 09/18/19, 85% of the licensed nurses and KMAs have completed this education. Beginning 09/17/19 a posttest will be completed by all licensed nurses and KMAs. The quiz will cover both medication administration and physician notification and competency validation for licensed nurses and KMA will be determined by a written test. Any licensed nurse or KMA not completing the posttest by 09/18/19, will complete it prior to returning to the floor to work. Any licensed nurse or KMA not scoring 100% will receive additional education. On 09/14/19, the education was expanded to include additional medication administration information, including documentation of medications. Licensed nurses and KMAs completing the education on 09/13/19 were provided this additional education. This education was initiated by the Director of Nursing (DON), and will be continued by the DON, ADON, or SDC until all licensed nurses and KMAs have completed the education. No licensed nurse of KMA will work after 09/16/19, without completing this education. As of 09/18/19, 85% of the licensed nurses and KMAs have completed this education. Beginning 09/17/19, a posttest will be completed by all licensed nurses and KMAs. The quiz will cover both medication administration and physician notification and licensed nurses and KMAs will validate competency by a posttest. Any licensed nurse or KMA not completing the posttest by 09/18/19 will complete it prior to returning to the floor to work. Any licensed nurse or KMA not scoring 100% will receive additional education. 10. On 09/16/19, the attending physician was notified, in writing, by the Administrator of the medication omissions for Residents #3, #13, #19, #41, #42, #53, #72, and #86. No new orders were received. On 09/16/19, the attending physicians were notified that there were additional residents without documentation to support that medications had been administered as ordered. The notification was hand delivered, in writing, by the Administrator, and the attending physicians were made aware that the MARs were available for their review. 11. On 09/14/19, the DON initiated education regarding physician notification. This education included the attending physician must be notified anytime a medication was not given as ordered, unless a resident was refusing. If the resident was refusing medications routinely, the physician should be notified. a) This education will be continued by the DON, ADON, or SDC until all licensed nurses and KMAs have completed the education. No licensed nurse or KMA will work after 09/16/19, without completing this education. As of 09/18/19, 85% of the licensed nurses and KMAs have completed this education. b) Beginning on 09/17/19, a posttest will be completed by all licensed nurses and KMAs. The quiz will cover both medication administration and physician notification and competency validation for licensed nurses and KMA will be a posttest. Any licensed nurse or KMA not completing the posttest by 09/18/19 will complete it prior to returning to the floor to work. Any licensed nurse or KMA not scoring 100% will receive additional education. 12. After 09/16/19, no licensed nurse or Kentucky Medication Aide (KMA) will be allowed to leave at the end of their shift until their MAR has been audited by the DON, ADON, SDC, or MDS Nurse. The audit is to ensure all medications have the appropriate documentation completed with physician notification, as indicated. Any concerns regarding documentation of physician notification will be addressed at the time of the audit, and reported to the DON or Administrator for review in the morning Interdisciplinary Team (IDT) meeting. a) In addition, each off-going licensed Nurse or KMA will be asked to sign a statement at the end of their shift to ensure no resident has expressed concerns regarding their medication administration. This statement will include if any concerns were expressed and to whom the concern was reported to if one was expressed. Any resident concerns regarding medication administration will be reported to the DON or Administrator for review at the morning IDT meeting. b) This audit, and statement, will continue at every shift change until Jeopardy is abated and an acceptable Plan of Correction is in place. The results of these audits will be reviewed in the weekly QAPI/IDT meeting on Fridays, beginning 09/20/19. 13. On 09/14/19, an RN Nurse Consultant observed a medication pass with the DON and one with the Assistant Director of Nursing (ADON). The purpose of this observation was to ensure the competency of the DON and ADON to administer medications. The CMS (The Centers for Medicare and Medicaid) Medication Administration Observation Care Path was used for these observations. These passes included insulin administration, the DON's medication pass included G-tube (gastrointestinal) administration. Both the DON and ADON completed the medication pass without concerns. On 09/14/19, an RN Nurse Consultant and the DON began medication administration observations with all licensed nurses and KMAs. The purpose of this observation was to ensure the competency of the licensed nurse or KMA to administer medications. Concerns were addressed with each licensed nurse or KMA at the time of the observation. As of 09/18/19, 85% of the licensed nurses and KMAs have a medication administration observation completed. 14. After 09/16/19, night shift, the DON, ADON or SDC will begin observing (auditing) all licensed nurses and KMAs administering medications daily. The purpose of the audit is to ensure the licensed nurse's or KMA's competency to administer medications. The CMS Medication Administration Observation Care Path will be used for these audits. These audits will take place on various shift and days of the week, including weekends. Any concerns will be addressed with the nurse at the time of the observation. Concerns regarding medication administration will be reported to the DON or Administrator for review at the morning IDT meeting. These observations will continue until Jeopardy is abated, then decrease to observation of half of the licensed nurses and KMAs administering medications daily until an acceptable Plan of Correction is in place. The results of these audits will be reviewed in the weekly QAPI/IDT meeting on Fridays, beginning 09/20/19. A record will be kept to track and offer opportunities to observe each licensed nurse and KMA with various types of medications, as permitted by their training, including oral, injections, G-tubes, eye drops, inhalers, crushed etc. 15. After 09/16/19, night shift, the DON, ADON, SDC, MDS Nurses, Social Services Director or Activities Director will begin interviewing six (6) random residents with a BIMS of nine (9) or above weekly to ensure they have no concerns related to when or how their medications are to be administered. Any concerns regarding medication administration will be reported to the DON or Administrator for review at the morning IDT meeting. These interviews will continue until Jeopardy is abated and an acceptable Plan of Correction is in place. The results of these audits will be reviewed in the weekly QAPI/IDT meeting on Fridays, beginning 09/20/19. 16. Beginning the week of 09/16/19, an RN Consultant will be at the facility to provide oversight of the implementation of the QI improvement plan addressing the Immediate Jeopardy. The RN Consultant visits will continue, at least three (3) days per week until Jeopardy is abated, and then at least weekly, until an acceptable Plan of Correction is in place. An RN Consultant may complete any audit in place of the assigned auditor. 17. A DON, ADON, SDC, or MDS Nurse from a sister facility may assist with monitoring, to include MAR audits, staff interviews, resident interviews, and medication administration observations, to ensure evidence is provided that they have successfully completed a medication administration audit in the past six (6) months. ****The State Survey Agency verified the facility implemented the following actions and that Immediate Jeopardy was removed on 09/19/19, as alleged by the facility: 1. Review of Minutes revealed a Quality Improvement (QI) meeting was conducted on 09/13/19 and the minutes were signed by the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC) and a Registered Nurse (RN) Consultant. Interviews on 09/25/19 with the Administrator, at 10:30 AM, the DON at 10:05 AM, the ADON at 10:00 AM, and the SDC at 10:16 AM, revealed they had attended the QA meetings dated 09/13/19, 09/16/19, and 09/20/19. 2. A statement written by the Director of Nursing was presented detailing she had informed the Medical Director, on 09/14/19 of the Immediate Jeopardy and the current plan of correction. Interview with the DON, on 09/25/19 at 10:05 AM, revealed she had phoned the Medical Director on 09/14/19 and informed him what the Immediate Jeopardy was related to and the plan per the QA committee. 3. Review of QI meeting minutes revealed a meeting was held on 09/16/19 with documentation that the plan of correction would continue. The attendees included the Administrator, DON, SDC, RN Consultant, and ADON. Interview with the ADON on 09/25 19 at 10:00 AM, the DON at 10:05 AM, the SDC at 10:16 AM, the Administrator at 10:30 AM, and the RN Nurse Consultant at 9:16 AM revealed they all had attended the QI meetings and had signed the QI form. 4. Review of the Disciplinary Warning Notice for RN #1, dated 09/16/19 revealed the notice stated RN #1 was terminated effective immediately, and signed by the DON. The documentation revealed the RN refused to sign the notice. 5. Review of the Complete In-service Training Report, dated 09/16/19, for Licensed Practical Nurse (LPN) #1 revealed the education provided included training on notification of the physician when there was a question related to the administration of medication or whether or not a resident received a medication as ordered. The training also included specific verbage related to insulin administration and physician notification. Interview with LPN #1 on 09/25/19 at 4:50 PM, revealed she did receive training regarding physician notification on 09/16/19. She stated she was educated to notify the physician whenever a medication was not administered and that insulin could not be held without an order, if the resident's blood sugar was low. 6. Review of a statement signed by the ADON, dated 09/14/19, revealed that an audit of all residents' August and September 2019 Medication Administration Records (MAR) had been conducted. The review also included a copy of all MARs reviewed and highlighted areas that revealed discrepancy or incomplete documentation. Interview with the ADON, on 09/25/19 at 10:00 AM, revealed she conducted the MAR audits as stated and any concerns were addressed. 7. Review of documentation revealed a medication questionnaire was used for interviews of all residents with a Brief Interview Mental Status (BIMS) score above eight (8). All questionnaires were dated 09/14/19 and were signed by the DON. One (1) resident had declined the interview on 09/14/19; however, the ADON conducted the interview with the resident on 09/15/19. Interview with the DON on 09/25/19 at 10:05 AM, revealed she conducted the interviews on 09/14/19 and 09/15/19 for all residents with a BIMS score above eight (8). She also stated she had the opportunity to educate some of the residents who had concerns, which included Resident #43, Resident #25, and Resident #24. Interview with Resident #25, on 09/25/19 at 8:15 AM, revealed he/she had concerns with some medications, staff educated him/her, and he/she was satisfied with the explanation. Interview with Resident #24, on 09/25/19 at 8:20 AM, revealed the resident could not remember the discussion related to medications. Interview with Resident #43, on 09/25/19 at 8:25 AM, revealed he/she was educated, but stated he/she still got confused when some medicines had different names. 8. Review of assessment documentation revealed assessments for all resident with a BIMS of eight (8) or less were completed on 09/15/19 by the ADON or the SDC. Interview with the ADON on 09/25/19 at 10:00 AM, revealed an assessment was performed on all residents with a BIMS of eight (8) or lower. Physicians were contacted with all concerns and they were addressed. 9. Review of education documentation revealed staff were trained regarding the six (6) rights of medication administration. A sign in sheet was available with nurses and KMAs who attended on 09/13/19. There was documented evidence of continued education by the DON and the SDC. Each nurse and KMA employed by the facility was on a roster and was checked off as education was provided in each of the areas. Interview with the SDC, on 09/25/19 at 10:16 AM, revealed on 09/13/19 she immediately educated the nurses and KMAs on the six (6) rights of medication administration as well as documentation on the MAR. She stated that education would continue daily until all nurses and KMAs had received the education. She also stated no nurse or KMA would be permitted to work the floor to administer medications until all education was provided and had scored 100% on the posttest. Interview with the DON, on 09/25/19 at 10:05 AM, revealed she initiated education on 09/14/19 that included additional medication information and accurate documentation on the MAR. She stated the education had continued daily and no nurse or KMA was allowed to work and administer medications until they had received all the education provided and passed the posttest with a score of 100%. Interviews on 09/25/19 with KMA #3 at 8:10 AM, RN #2 at 8:30 AM, RN #4 at 8:45 AM, LPN #8 at 8:54 AM, LPN #5 at 9:00 AM, LPN #4 at 9:10 AM, LPN #13 at 10:40 AM and LPN #1 at 4:50 PM revealed they all had received training on the six (6) rights of medication administration and documentation on the MAR. A posttest was completed after the training. 10. Reviewed letters addressed to the physicians for Residents #3, #13, #19, #41, #42, #53, #72, and #86 related to omission of medications. Additional residents were added to the notifications as a result of the 09/14/19 audit. Each letter included the names of the specific residents under the care of that physician and the medications believed to have been omitted. Interview with the Administrator, on 09/25/19 at 10:30 AM, revealed he had hand delivered each of the letters to the physicians' offices. He further stated he had received no questions or concerns from the physicians. Interviews with Medical Doctor (MD) #4 on 09/25/19, at 9:24 AM and MD #3 at 11:06 AM, revealed both had received letters detailing the possible omission of medications on their residents and had no further concerns or questions 11. Review of the Allegation of Compliance information revealed training, dated 09/14/19, on physician notification was initiated by the DON. The information also included a sign in sheet of staff that attended and dated. All nurses and Kentucky Medication Aides (KMA) employed by the facility had documentation of when they were provided the education. This education had been provided on an ongoing basis since 09/14/19. Interview with the DON, on 09/25/19 at 10:05 AM, revealed she initiated education on physician notification on 09/14/19. She stated the training included the six (6) rights of medication administration, medication error process, and accurate documentation of the MAR. Interviews on 09/25/19 with KMA #3 at 8:10 AM, RN #2 at 8:30 AM, RN #4 at 8:45 AM, LPN #8 at 8:54 AM, LPN #5 at 9:00 AM, LPN #4 at 9:10 AM, LPN #13 at 10:40 AM and LPN #1 at 4:50 PM revealed they all had received training regarding notification of the physician anytime a medication was not administered as ordered. The interviews also revealed the staff had completed a posttest and had to make 100% to pass. Interview with the Staff Development Coordinator (SDC), on 09/25/19 at 10:16 AM, revealed she had been educating nurses and KMA's on physician notification related to medications. 12. (a) Review of the Allegation of Compliance evidence revealed audits of MARS, dated 09/16/19 to 09/24/19. These audits were performed at the end of each shift, by the DON, ADON, SDC, or MDS Nurse, for each nurse or KMA who had administered medications during the shift. The audit ensured all medications had the appropriate documentation with physician notification as indicated. The audit also contained a statement, signed by the nurse or KMA, as to whether or not a resident had voiced any concerns or complaints regarding their medications during the shift. Interviews on 09/25/19 with KMA #3 at 8:10 AM, RN #2 at 8:30 AM, RN #4 at 8:45 AM, LPN #8 at 8:54 AM, LPN #5 at 9:00 AM, LPN #4 at 9:10 AM, LPN #13 at 10:40 AM and LPN #1 at 4:50 PM revealed residents' MARs were audited at the end of the shift and each had to sign a statement related to any resident concerns about medications. (b) Review of the 09/20/19 QA/QI meeting revealed the every shift audits were completed and reviewed in the QA/QI meeting. Interview with the ADON on 09/25 19 at 10 AM, the DON at 10:05 AM, the SDC at 10:16 AM, the Administrator at 10:30 AM and the RN Nurse Consultant at 9:16 AM revealed they all had attended the QA meetings and had signed the QA form. 13. The AOC evidence revealed a check off form, CMS Medication Administration Observation Care Path, was used by the RN Nurse Consultant on 09/14/19, to ensure the competency of the DON and the ADON to administer medications. Interview with the DON, on 09/25/19 at 10:05 AM, revealed an RN Nurse Consultant performed her medication administration competency. 14. Review of the AOC evidence revealed observations of nurses and KMA's on a daily basis using the CMS Medication Administration Observation Care Path, dated from 09/14/19 up through 09/24/19. Interviews with KMA #3 on 09/25/19 at 8:10 AM, RN #4 at 8:45 AM, LPN #8 at 8:54 AM, LPN #5 at 9 AM, LPN #13 at 10:40 AM and LPN #1 at 4:50 PM revealed they had been observed daily, and sometimes multiple times a day, administering medications. 15. The AOC evidence revealed six (6) resident interviews, dated 09/18/19, and seven (7) resident interviews, dated 09/23/19 performed by one of the management team. The questionnaires were related to any medication concerns the residents may have. Interview with the ADON, on 09/25/19 at 10 AM, revealed no concerns had been voiced with resident interviews. She also stated the audits of and interview results were reviewed at the 09/20/19 QA meeting. Interview with the Administrator, on 09/25/19 at 10:30 AM, revealed during the QA meeting, dated 09/20/19, results of audits and competencies, and resident interviews were reviewed. These will continue to be monitored these on a weekly basis. 16. Interview with the RN Nurse Consultant on 09/25/19 at 9:16 AM, revealed since 09/13/19, she had been present in the facility every day except for 09/21/19 and 09/22/19. 17. Interview with the DON, on 09/25/19 at 10:05 AM, revealed a sister facility's DON and SDC had assisted the facility with audits during the week of 09/16/19. Based on interview, record review, and policy review, it was determined the facility failed to ensure nursing staff (Registered Nurse #1) had appropriate competencies and skills to safely administer medications to residents. The facility failed to evaluate the competency and skill level of Registered Nurse (RN) #1 when she was hired (05/28/19), during the orientation process, or after being notified of medication errors made by RN #1. On 07/07/19, RN #1 argued with Resident #10 that the resident did not have medication due when the resident requested scheduled medications. The RN was not aware that Medication Administration Records (MAR) for oral medications was kept in a different book, on a different medication cart, until another nurse explained the facility's process for administering medications. The incident was reported to the Director of Nursing (DON) and Administrator; however, no actions related to assessing RN #1's competency to give medication was completed. On the evening of 08/19/19, RN #1 was responsible for administering medications for seven (7) residents (Residents #3, #13, #19, #41, #42, #72, and #86). Even though RN #1 documented that Residents #13, #19, #41, #42, and #72's medications were administered, Residents #41, #42, and #72 reported that they did not receive medications. In addition, there was no documented evidence that Residents #3 and #86 received their evening medications on 08/19/19. The residents' complaints were reported to administrative staff (the DON and Administrator); however, no actions were taken to ensure the RN's competency. RN #1 failed to administer three (3) residents' (Residents #63, #47, and #9) 10:00 PM narcotic pain medication, antianxiety, and/or antiseizure medications on 08/26/19. In addition, RN #1 documented that Resident #66's blood sugar was obtained and insulin was administered. However, Resident #66 reported that he/she did not receive insulin and the RN did not check his/her blood sugar on the evening of 08/26/19. Again, the facility failed to ensure Nurse #1 was competent to administer medications. Further, Resident #28 reported that facility staff had failed to administer his/her medications. Staff determined that RN #1 failed to document that the resident's narcotic pain medication was administered on 08/25/19. Staff stated they reported the medication error to administrative staff (Assistant DON and DON); however, again, the facility did not evaluate RN #1's competency to administer medications. On an unknown date, Resident #77 reported to the Assistant Director of Nursing (ADON) that RN #1 attempted to administer an insulin injection. However, the resident did not have an order for Insulin. Resident #77 stopped the nurse from administering the medication and stated the DON was aware. However, the facility took no action to ensure RN #1 was competent to administer medications. In addition, on 09/10/19, RN #1 failed to administer medication to the right resident. RN #1 administered Klonopin (treats seizures) medication to Resident #64; this medication was not ordered for this resident, but was ordered for Resident #63. The facility's failure to ensure nursing staff had the appropriate competencies and skills to safely administer medications to residents has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/13/19 and was determined to exist on 08/19/19 at 42 CFR 483.10 Resident Rights (F580-K), 42 CFR 483.35 Nursing Services (F726-K), and 42 CFR 483.45 Pharmacy Services (F760-J). The facility was notified of the Immediate Jeopardy on 09/13/19. An acceptable Allegation of Compliance was received on 09/18/19, which alleged removal of the Immediate Jeopardy on 09/19/19. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on 09/19/19, prior to exit on 09/25/19, which lowered the scope and severity to E level at 42 CFR 483.10 Resident Rights (F580) and 42 CFR 483.35 Nursing Services (F726) and to D level at 42 CFR 483.45 Pharmacy Services (F760) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's Medication Administration policy, not dated, revealed, All medication errors shall be described in detail on a Medication Error Report which shall be filed with the Director of Nursing (DON). The facility's medication error report shall be completed in detail, making every possible effort to describe the discrepancy thoroughly; suggestion should be made as to how such discrepancy could be avoided in the future. Interview with the facility's former Administrator on 09/12/19 at 2:16 PM, revealed the facility did not have a written policy on orientation/competency for nursing staff. However, the facility's process was for new employees to be given a skills check-off list to complete during the orientation process. When the check-off list was completed, the employee was to give the check-off list back to the Staff Development Coordinator and the Staff Development Coordinator was responsible for taking it to the Personnel Department to file in the employee's personnel file. According to the interview, the Staff Development Coordinator that was at the facility when RN #1 had orientation was no longer employed at the facility. Review of the facility's new hire orientation packet revealed an RN orientation skills checklist that included medication preparations and medication administration documentation. The assessment included a staff competency checklist for licensed nurse orientation. Per the checklist, the preceptor would evaluate the skills of the licensed nurse and indicate the completion date and the observer's initials. Review of RN #1's personnel record revealed a hire date of 05/28/19. The file did not contain RN #1's competency checklist that should be completed for each new employee. The personnel file contained no work performance concerns or counseling. 1. Review of the medical record revealed the facility admitted Resident #10 on 03/27/15, with diagnoses that included Coronary Artery Disease, Heart Failure, Anxiety Disorder, ST-Elevation Myocardial Infarction of unspecified site, Type 2 Diabetes Mellitus, Hypertension, Pain-unspecified, and Unspecified Acquired Deformity of the Left Lower Leg. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact. The MDS also revealed the resident was independent for the tasks of bed mobility, transfer, and dressing and used a walker or wheelchair for mobility. Review of the Medication Administration Record (MAR) for Resident #10, dated 07/01/19 through 07/31/19, revealed the resident had the medication Hydrocodone with Acetaminophen (controlled narcotic pain medication) ordered to be administered four (4) times a day. The MAR also revealed the scheduled times of 6:00 AM, 12:00 PM, 6:00 PM, and 12:00 AM. Further review of the MAR revealed the resident had an order for a sleeping medication, Trazadone fifty (50) milligrams, which could be administered at hour of sleep (HS), if needed for insomnia. Interview with Resident #10 on 09/09/19 at 12:59 PM, revealed he/she had an issue on 07/07/19 regarding receiving his/her ordered medication at midnight. The resident stated, I asked for my pain pill and my sleeping pill and was told (by RN #1) that they were not ordered for me. Interview with Licensed Practical Nurse (LPN) #2 on 09/10/19 at 6:26 PM, revealed she was alerted by a State Registered Nurse Aide (SRNA) on 07/07/19, regarding an incident between RN #1 and Resident #10. She stated the resident was upset because RN #10 stated he/she did not have the medications ordered that the resident had requested. The LPN stated she reviewed the MAR and discovered the resident did have the medications ordered and showed this to RN #1. She stated the RN had been reviewing the wrong MAR for the resident's medications. RN #1 was looking at the nurses MAR which did not have the oral medications Resident #10 had requested. LPN #2 stated after explaining that Medication Aides had a MAR with oral medications, RN #1 then realized that the resident did have medication to be administered, and was preparing to administer the medications to the resident when she returned to her unit. Interview with RN #1 on 09/10/19 at 2:15 PM, revealed Resident #10's medications were in two (2) separate medication books. RN #1 further stated the ADON did come to the facility that night, but she did not remember receiving any particular instructions or any training regarding residents' MARs after the incident. 2. According to an Interview with LPN #1, on 09/10/19 at 12:14 and 12:23 PM, seven (7) residents (Residents #3, #13, #19, #41, #42, #72, a[TRUNCATED]