Signature Healthcare Of Erin

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure medications were properly stored when expired and outdated medications were found on 3 of 7 medication storage carts. The facility policy titled, "Storage of Medication," dated 1/2025, stated that medications and biologicals are stored properly to keep their integrity and support safe, effective drug administration, and that outdated medications are immediately removed from stock and disposed of according to medication disposal procedures. During observation and interview, expired medications were identified on multiple carts. On the Brandywood Hall Treatment Cart, an LPN confirmed that Resident #29's Ketoconazole shampoo 2% and Resident #94's Ketoconazole shampoo 2% were both expired in 2/2026. On the Reflections Hall Treatment Cart, a bottle of Packing Strip with an expiration date of 3/2025 was present, and an LPN stated it should have been discarded before the expiration date. On Reflections Hall Med Cart 1, a bottle of Fiber Laxative with an expiration date of 2/2026 was found on the cart, and an LPN stated it should be discarded. The DON stated medications should be discarded when no longer needed and by the expiration date, and that nurses, administrative staff, and the pharmacist were responsible for checking medication and treatment carts for expired medications.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure food was distributed in a manner to prevent the spread of infection when staff handled residents’ food with bare hands during dining room observations. The facility policy titled, INFECTION CONTROL OVERVIEW & POLICY, dated 9/5/2017, stated that hand hygiene is required to reduce the spread of infection and prevent cross-contamination, and that food must be properly handled, processed, and transported to minimize possible contamination. It also stated that hand hygiene is required before handling food. During dining observations in the secured dining room, the Housekeeping Director removed a resident’s sandwich and cookie from plastic bags with bare hands and placed them on the resident’s plate without performing hand hygiene or using gloves. In separate observations, CNA E assisted one resident with a sandwich using bare hands, scratched her head while assisting the resident to eat, and did not perform hand hygiene or use gloved hands when touching the resident’s food. CNA E also picked up another resident’s sandwich with bare hands and gave it to the resident without performing hand hygiene or using gloves. When asked, CNA E stated she should not touch resident food with bare hands, the Housekeeping Director stated, "Probably not," and the Administrator stated staff should not touch residents’ food with bare hands.

Penalty

Inspection fine: $147,898

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure residents' rights to be free from misappropriation of controlled narcotics for seven residents. Specifically, the facility did not account for a significant number of narcotic tablets, including Oxycodone and Hydrocodone, for these residents. The missing medications were discovered through a review of pharmacy delivery records, controlled substance count sheets, and controlled drug record sheets. Interviews with staff revealed inconsistencies and lapses in the proper documentation and verification processes for controlled substances. Resident #1 had 48 tablets of Oxycodone 10 mg missing, and the DON could not explain discrepancies in the controlled substance count sheet. Resident #2 had 61 tablets of Oxycodone 5 mg missing, and the controlled drug record sheet for this resident was removed and could not be located. Interviews with staff indicated that proper procedures for witnessing and documenting the removal of controlled substances were not followed. Similar issues were found for Residents #5, #6, #7, #8, and #9, with varying amounts of Hydrocodone and Oxycodone tablets unaccounted for. The facility's failure to properly handle, store, and document controlled medications resulted in Immediate Jeopardy for the affected residents. The DON confirmed that the missing narcotic tablets for these residents could not be accounted for due to missing narcotic sheets and medication cards that were improperly removed from the medication cart. This deficiency highlights significant lapses in the facility's controlled medication management and documentation processes.

Removal Plan

• Resident #6 discharged from the facility. Charges to his insurance was reversed and charged to the facility.
• Resident #1 was assessed for pain, no pain was noted and current residents #1, #5, #8 and #9 were assessed for pain by the DON. No pain was noted.
• Controlled medications were reconciled on every medication cart by the DON.
• The pharmacy was informed of the missing medications for residents #1, #5, #8, and #9. The charges to their insurance for their medications were reversed and charged to the facility.
• The DON and SCC conducted interviews with licensed staff to inquire if they had knowledge of controlled medication unaccounted for or if they had suspicion of anyone working while impaired.
• The DON and SCC began auditing the Controlled Medication delivery logs for Resident #1 to ensure all deliveries were added to carts #1 and #2 on Hall #3.
• The DON and SCC began auditing the Controlled Drug Records for residents that were recently discharged or deceased from Hall #3. An audit of controlled medication logs was conducted for every resident in the facility with an order for a controlled medication to determine if other nurses/residents were involved. This was performed by the DON and SCC. Hall #3 was the only hall identified with controlled medications unaccounted for. Any findings were reported to the legal and regulatory authorities: Health Facilities Commission, TN Regional Office; TN Bureau of Investigation; Police Department, Ombudsman and APS.
• The affected residents with a BIMS of 8 or greater were interviewed by the DON, and all stated they received their pain medications, and all denied pain.
• The affected resident with a BIMS less than 8 was assessed for pain by the DON, there was no complaint or signs of pain.
• Pain assessments were completed for all residents on Hall #3 by the nurse managers to determine if any had uncontrolled pain. There were no residents experiencing uncontrolled pain.
• The nurse managers interviewed residents on Hall #3 with a BIMS equal or greater than 8 to determine if their pain is controlled and as needed (PRN) medications had been administered when requested. All stated their pain is controlled and they receive their PRN medications when requested.
• The DON reviewed documented pain levels for uncontrolled pain. No one had uncontrolled pain levels.
• One nurse was suspended due to reasonable suspicion and remains suspended. This nurse was reported to the Tennessee (TN) Board of Nursing. The TN Bureau of Investigation is continuing the investigation.
• A root cause analysis was conducted. It was determined that the nurse did not follow the process for removing controlled medications; obtaining a witness to verify the removal of controlled medications. The process was changed to prevent the nurses/medication aides from removing completed medication cards or discontinued medication cards. The DON or Unit Managers will remove controlled medications from the medication cart; completed medication cards/sheets and discontinued medication cards/sheets.
• A root cause analysis was conducted. It was determined the excess controlled medication cards/sheets did not need to be on the medication cart. A cabinet with 2 locks was secured in the medication room for overflow-controlled medications and a new form was developed, Controlled Substance Overflow Sheet, to record the addition and removal of controlled medication to that cabinet.
• Education was conducted by the Director of Nursing (DON) and Staff Development Coordinator (SDC) with all staff on the Abuse and Misappropriation Policy. Any staff/agency staff who were not educated will be before working their next shift.
• Education was conducted by the DON and SDC with all licensed staff and Medication Aides on the Controlled Medication Policy and process changes for counting/receiving/removing controlled medication. Any staff/agency staff who were not educated will be educated prior to working their next shift.
• Two nurses will verify the pharmacy delivery manifests for controlled medications in the presence of the driver. Once the quantity has been verified, they will sign the pharmacy delivery manifest. Two nurses will sign the Controlled Drug Record sheet and indicate the total quantity for the prescription (RX) number and the number of medication units, i.e. tablets, on the Controlled Drug Record sheet. Once the quantities are verified the two nurses will add the controlled medications to the medication cart and sign them into the Controlled Substance Record sheet.
• The Unit Managers will audit the pharmacy delivery manifests, daily, to verify controlled medications and Controlled Drug Record Sheets were added to the Controlled Substance Count Sheet and for count accuracy.
• The DON/UM will remove all controlled medications with a witness (empty and discontinued) from the medication cart, reconcile the Controlled Substance Count Sheets and compare the Controlled Substance Count Sheets to the Controlled Drug Records as they are removed from the cart to be secured for destruction. No one will remove controlled medication card/sheets without the DON/UM witnessing. This process, along with the process in #5 above, will prevent the ability to remove a count sheet and medication card without being discovered.
• A secured cabinet with 2 locks was placed in the Four Seasons (hall #2) medication storage room. Overflow of controlled medications will be stored in the secured cabinet. The cabinet has 2 locks with 2 separate keys that are assigned to 2 different licensed nurses (the DON and SDC). The DON and SDC will access the controlled medication cabinet as needed: when multiple cards/sheets are delivered and as the nurses need medications due to running out on the cart. The carts will be checked at the end of the day and before the weekend to ensure the residents will not miss a dose of their controlled medication. The transaction will be recorded on the Controlled Substance Overflow sheet. There will not be a key to this cabinet on any other key ring. In the event the DON or SDC are not in the facility, the DON will designate a Clinical Manager to hold one key.
• The licensed nurses/medication aides were educated by the DON, SDC or UM. Any licensed staff including agency nurses that were not educated will be before their next shift.
• An Ad Hoc QAPI was held via phone, with Corporate Leadership, SCC, Pharmacy President (VP) Strategic Accounts, and the Medical Director to discuss new findings and ongoing investigation.
• An Ad Hoc QAPI was held with Corporate Leaders to discuss audit findings, via phone.
• An Ad HOC QAPI was held with the Medical Director to discuss the event and plan of correction.
• An Ad HOC QAPI was held with the Medical Director, to discuss implementation of a secured overflow cabinet for controlled medications, the process for accessing the cabinet and the recording of adding/removing controlled medications. This new process will be discussed in QAPI meetings to ensure compliance and determine any changes that may be warranted.
• The Clinical Interdisciplinary Team (IDT) will audit every scheduled nurse at shift change for accuracy of the count process daily for two weeks then, weekly times (x) 2 weeks, then monthly x 2 months, then quarterly thereafter.
• The DON/Unit Manager (UM) will audit the medication carts to ensure discontinued/completed controlled medications have been removed from the cart and the Controlled Medication Count Sheet accurately records the removal 5 times per week x 2 weeks then, 3 times per week x 2 weeks then, 2 times monthly x 2 months.
• The DON will conduct random audits of the Pharmacy Delivery Report to ensure the delivered controlled medications were accurately added to the medication carts and Controlled Substance Count Sheets; 5 deliveries per week x 2 weeks then, 3 deliveries per week x 2 weeks then, 3 deliveries per month x 2 months.
• The Quality Assurance (QA) Team will review staff education and QA audits for completion and accuracy. Findings of audits will be reported to the QAPI Committee which includes the Administrator, DON, Unit Managers, SDC, Social Services Director, Maintenance Director, Dietary Manager, Life Enrichment Director, Rehab Manager, and Medical Director. The QAPI meetings will be held weekly for 4 weeks then, 2 times per month for the next 30 days then, monthly thereafter or until the QAPI Committee determines substantial compliance has been achieved. The QAPI Committee reserves the right to modify or extend monitoring times according to outcomes.
• Regional oversite has been in place daily. The Senior (Sr.) Signature State Care Consultant has been in the facility assisting with interviews, education, audits, process changes, attending Ad Hoc QAPI meetings and oversight of compliance with process changes. Regional oversite has occurred onsite or by phone from the Sr. Signature State Care Consultant, the Regional VP of Clinical Operations, or the Regional VP of Operations. The Regional team has collaborated with the facility team on process changes and attended Ad HOC QAPI meetings via phone to discuss audit findings and develop a plan of correction.

Penalty

Inspection fine: $147,898

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to have a system of recording, accurate reconciliation, and accounting for all controlled medications, leading to the loss or potential diversion of controlled medications for seven residents. The medication nurse discovered that a resident's Fentanyl transdermal patch had been tampered with, but no actions were taken at that time. Later, it was found that two residents' Fentanyl patches had been tampered with, indicating possible diversion of the prescribed controlled medication for pain control. The facility did not test or seek expert identification for the tampered Fentanyl patches, and the narcotic count reconciliations for Oxycodone and Hydrocodone were found to be inaccurate, with a total of 509 tablets missing and unaccounted for. The facility's policy required a controlled medication accountability record to be prepared when receiving or checking in Schedule II, III, IV, or V medications, and a physical inventory of all controlled medication to be conducted by two staff members at each shift change. However, the facility failed to ensure that these procedures were followed. The Pharmacy manifest sheets for the delivery of Fentanyl patches and other controlled medications were not signed by a nurse to verify receipt, and the controlled medication accountability records were not accurately maintained. Additionally, the facility did not promptly identify the loss or potential diversion of controlled medications, and the extent of the loss was not timely determined. Interviews with staff revealed that the process for signing the Pharmacy manifest sheets and the controlled medication accountability records was not consistently followed. The DON and other staff members acknowledged that the required procedures were not always adhered to, and the facility's investigation confirmed that multiple narcotic sheets and medication cards were missing. The facility's failure to maintain accurate records and promptly identify and address the loss or potential diversion of controlled medications resulted in Immediate Jeopardy for the affected residents.

Removal Plan

• A reconciliation of controlled medications was initiated for every resident with an order for a controlled medication verifying the disposition of the controlled medications. This was performed by the DON and Regional Signature Care Consultant (SCC). Hall #3 was the only hall identified with controlled medications unaccounted for. Any findings of misappropriation or diversion were reported to appropriate legal and regulatory entities: Health Facilities Commission, Tennessee (TN) Regional Office; TN Bureau of Investigations; Police Department, Ombudsman and Adult Protective Services (APS).
• The DON and SCC reviewed all delivery manifests to ensure all narcotics delivered and signed in by the alleged nurse were added to the narcotic count and narcotic box on the medication cart. Any findings of misappropriation or diversion were reported to appropriate legal and regulatory entities.
• The affected residents with a BIMS of 8 or greater were interviewed by the DON, and all stated they received their pain medications, and all denied increased pain.
• The affected resident with a BIMS of less than 8 was assessed for pain by the DON, there were no complaints or signs of increased pain.
• All residents on hall #3 were assessed for pain by the Unit Managers. No one complained of pain.
• Hall #3 was the only hall identified with controlled medications unaccounted for.
• A secured cabinet with 2 locks was placed in the Four Seasons Medication storage room.
• Overflow of controlled medications will be stored in the secured cabinet. The cabinet has 2 locks with 2 separate keys that are assigned to 2 different licensed nurses. The DON and a witness will access the controlled medications and record transactions on a medication reconciliation record.
• A root cause analysis was conducted. It was determined that the nurse did not follow the process for removing controlled medications; obtaining a witness to verify the removal of controlled medications. This process was changed to prevent the nurses/medication technicians from removing completed medication cards or discontinued medication cards. The DON or Unit Managers (UM) will remove controlled medications from the medication cart; completed medication cards/sheets and discontinued medication cards/sheets.
• Education was conducted by the DON and Staff Development Coordinator (SDC) with all staff on the Abuse and Misappropriation Policy. Any staff/agency staff who were not educated will be educated.

Penalty

Inspection fine: $147,898

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident was free from significant medication errors. Specifically, Resident #2's orders for Fentanyl were erroneously changed from being administered every 3 days to being administered daily. As a result, Resident #2 was administered Fentanyl patches daily for three consecutive days, contrary to the prescribed order of every 72 hours. This error had the potential to cause serious adverse outcomes, including overdose and death, placing Resident #2 in Immediate Jeopardy. Resident #2 was admitted with multiple diagnoses, including Rheumatoid Arthritis, Pain Unspecified, and Type 2 Diabetes. The resident had a Brief Interview for Mental Status score indicating no cognitive impairment. The medical record revealed that the resident had a physician's order for Fentanyl patches to be applied every 72 hours. However, due to a transcription error, the order was entered into the facility's electronic system as a daily administration. This error was not caught by the nursing staff, who administered the patches daily. Interviews with the Director of Nursing, Nurse Practitioner, and Licensed Practical Nurses revealed that there were multiple points where the error could have been identified and corrected. The NP stated that the intention was to increase the Fentanyl dosage but maintain the 72-hour interval. However, the order was incorrectly entered into the electronic system and not questioned by the verifying nurse. The LPNs involved admitted to noticing the discrepancy but failed to clarify the order with the NP or DON. This series of actions and inactions led to the inappropriate administration of the medication, ultimately resulting in the resident's death.

Removal Plan

• A Medical Record review was conducted by the Director of Nursing to identify residents who have active orders for Fentanyl Transdermal patches to ensure the order was transcribed correctly.
• An audit of medications in the medication carts was conducted by the Clinical Interdisciplinary Team (IDT) to ensure the labels on the medication cards match the order in Matrix Care.
• A root cause analysis was conducted by the Clinical Interdisciplinary Team.
• The Nurse Practitioner was educated by the Signature State Care Consultant and the Director of Nursing on Order Entry in Matrix Care.
• The Nurse Practitioner attended an on-line Matrix Care Provider Training.
• The Director of Nursing educated the Unit Manager #2 to ensure the order is transcribed accurately and clarify any discrepancies with the provider before verifying the order.
• Unit Managers #1, #2, and #3 and licensed nurses were educated to verify orders for accuracy before activating them and to clarify any discrepancies with the providers.
• All licensed staff were educated by the Director of Nursing to ensure the label on the medication card matches the medication order in MatrixCare and to call the provider to clarify any discrepancies.
• An Ad Hoc QAPI was held with the Leadership Team and Medical Director to discuss the incident, the investigation outcome and discuss the Plan of Correction.
• The DON or Unit Manager will verify the medication card labels match the order in Matrix Care for 5 days per week for 1 week then, 3 times per week for 3 weeks then, 1 time per week for 1 month.
• A pharmacy nurse consultant will audit all medication carts to ensure the labels on the medication cards match the order in MatrixCare until the QAPI team determines compliance.
• Findings of audits will be reported to the QAPI Committee which consists of the Administrator, Director of Nursing, Unit Managers, Staff Development Coordinator, Social Services Director, Maintenance Director, Dietary Manager, Life Enrichment Director, Rehab Manager, and Medical Director.
• QAPI meetings will be held weekly for 4 weeks, then 2 times per month for the next 30 days, then monthly thereafter until the QAPI Committee determines substantial compliance.
• Regional oversite has been in place daily since the date Misappropriation of Resident Property was reported to Health Facilities Commission regarding Transdermal Fentanyl Patches.
• The Senior (Sr.) Signature State Care Consultant has been in the facility assisting with interviews, audits, education, process changes, attending QAPI meetings, and oversight of compliance with process changes.
• Regional oversite has occurred onsite or by phone from the Sr. State Signature Care Consultant, the Regional President of Clinical Operations, or the Regional President of Operations.
• The Regional team has collaborated with the facility team on process changes and attended Ad HOC QAPI meetings via phone to discuss audit findings and develop a plan of correction.

Penalty

Inspection fine: $147,898

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide effective pain management for a resident with severe cognitive impairment and multiple fractures. The resident, who had a history of falling and severe cognitive impairment, was found on the floor complaining of hip pain. Despite a physician's standing order for Tylenol, the medication was not effective in managing the resident's pain. The resident continued to complain of pain, and no additional imaging was performed until the family requested it eight days later. The delayed imaging revealed a displaced comminuted fracture involving the distal femur, which required surgical intervention. The medical records show that the resident's pain was not adequately addressed despite multiple complaints and signs of severe pain, such as yelling and grimacing. The resident's pain was documented as being as high as 10/10 on the pain scale, and the Tylenol administered was noted to be only slightly effective. The facility staff failed to notify the physician promptly about the resident's continued pain and did not escalate pain management measures in a timely manner. Interviews with facility staff revealed that they were aware of the resident's pain but did not take appropriate actions to manage it effectively. The primary physician was not notified immediately of the resident's increased pain, and the standing order for Tylenol was not sufficient to manage the resident's severe pain. The resident was eventually given Tramadol, but only after several days of inadequate pain management. The delay in appropriate pain management and imaging resulted in actual harm to the resident, who required surgical intervention for the fractures discovered.