Every finding on record at Ahoskie Health and Rehabilitation Center

Based on observation, record review and staff interviews, the facility failed to update the resident's code status information when Resident #12's Responsible Party requested a change from do not resuscitate to full code. This was for 1 of 4 residents reviewed for advanced directives (Resident #12).The findings included:Resident #12 was admitted to the facility on [DATE].Resident #12's care plan revised 3/19/25 revealed he had a goal status of do not resuscitate.Resident #12's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 was assessed as being severely cognitively impaired.Review of a care plan meeting note dated 11/25/25 written by the MDS Nurse indicated Resident #12's responsible party stated she would like to change Resident #12's code status from do not resuscitate to full code.An attempt to contact Resident #12's responsible party was not successful on 12/18/25 at 9:39 AM.An observation of Resident #12's electronic medical record showed on the communication bar a code status icon that read do not resuscitate (DNR). On 12/15/25 at 10:47 AM an interview was conducted with the MDS Nurse who stated to locate a resident's code status she would check the medical record for the status. She reported Resident #12's code status was do not resuscitate after checking Resident #12's medical record during the interview.A follow up interview was conducted with the MDS Nurse on 12/18/25 at 10:37 AM who stated she reported to the Social Worker and the former Director of Nursing that Resident #12's responsible party requested Resident #12's code status be changed from a DNR to a full code. The MDS Nurse was unable to recall the specific date she reported this information to the Social Worker and the former Director of Nursing. She reported she recalled the care plan meeting on 11/25/25 and wrote the care plan meeting note. The MDS Nurse reported the facility Social Worker was responsible for filling out the documents for the code status change.An interview was conducted on 12/15/25 at 2:33 P.M with the facility Social Worker (SW). During the interview the SW stated when a resident's code status was updated after admission, she was responsible for changing and updating the code status on the communication bar and within the electronic medical record. She indicated she was not present when Resident 12's responsible party requested his code status be changed. The SW stated the MDS Nurse wrote the care plan meeting note but the code status was not changed. She did not recall the MDS Nurse telling her about the request for a code status change for Resident #12.An interview was conducted on 12/18/25 at 11:00 A.M with the Administrator. She stated Resident #12's code status should have been changed when Resident #12's responsible party requested it be changed from do not resuscitate to full code and the SW should have ensured Resident #12's code status was changed. The Administrator reported this was an oversight.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set Assessments (MDS) for 2 of 32 residents whose MDS assessments were reviewed for accuracy (Resident #22, and Resident #25). The findings included: 1. Resident #22 was admitted to the facility on [DATE] with diagnoses that included intellectual disabilities, schizophreniform disorder, depression, anxiety and dementia. Review of Resident #22's electronic health record revealed a Preadmission Screening and Resident Review (PASRR, a federal requirement for Medicaid-certified nursing facilities to assess individuals for serious mental illness) was completed prior to his admission and indicated Resident #22 was screened as Level II determination (a comprehensive evaluation conducted to assess the needs of individuals identified as having serious mental illness or intellectual disabilities, ensuring they received appropriate care and services in the nursing home) with no end date. A review of Resident #22's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was not coded as having a Level II PASRR determination. The MDS documented diagnoses including dementia, depression, anxiety disorder and schizophrenia. In an interview on 12/18/25 at 10:34 AM the MDS Nurse stated that Resident #22 should have been coded on the MDS for a Level II PASRR determination. She indicated it was an oversight. 2. Resident #25 was admitted to the facility on [DATE] with diagnoses that included depression, schizoaffective disorder, dementia and psychosis. Review of Resident #25's electronic health record revealed a Preadmission Screening and Resident Review (PASRR, a federal requirement for Medicaid-certified nursing facilities to assess individuals for serious mental illness) was completed on 10/05/23 and indicated Resident #25 was screened as Level II determination (a comprehensive evaluation conducted to assess the needs of individuals identified as having serious mental illness or intellectual disabilities, ensuring they received appropriate care and services in the nursing home) with no end date. A review of Resident #25's care plan dated 12/21/23 revealed a plan for Level II PASRR recommendations related to serious mental illness diagnoses of schizoaffective disorder, dementia and psychosis. The goal for the plan of care was that the Resident would receive recommended care and/or services as determined appropriate by Level II PASRR through next review. Interventions included continuing to adjust and meet activities of daily living (ADL) needs. Provide occupational therapy, physical therapy and restorative nursing to be provided as needed. A review of Resident #25's annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was not coded as having a Level II PASRR determination. The MDS documented diagnoses including dementia, depression, psychotic disorder and schizophrenia. In an interview on 12/17/25 at 10:11 AM the MDS Nurse stated that Resident #25 should have been coded on the MDS for a Level II PASRR determination. She indicated it was an oversight.

Based on observation, record review and staff interviews, the facility failed to secure the indwelling urinary catheter tubing to prevent tugging or pulling for 1 of 1 resident reviewed for indwelling urinary catheter (Resident #11).The findings included:Resident #11 was admitted to the facility on [DATE] with diagnoses that included bladder rupture and urinary retention.The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 was cognitively intact. She was coded as having an indwelling urinary catheter.A Physicians' Order dated 12/16/25 indicated Resident #11 had an indwelling urinary catheter for urinary retention.An observation was conducted on 12/17/25 at 10:22 AM of Nurse Aide #2 performing catheter care for Resident #11. The indwelling catheter tubing had no securement device to prevent pulling of the catheter tubing. There was no tension on the catheter tubing during observation.An interview was conducted with Nurse Aide #2 on 12/17/25 at 10:30 AM. NA #2 stated she was assigned to Resident #11 and had provided care for this resident. NA #2 stated the nurse caring for the resident was responsible for making sure the indwelling catheter tubing had a securement device.An interview was conducted with Resident #11 on 12/17/25 at 11:22 AM. Resident #11 stated that staff did not consistently place a securement device on her indwelling urinary catheter. During an interview with Nurse #1 on 12/18/25 at 10:44 AM, she stated that the nurse was responsible for making sure residents had a securement device on urinary catheter tubing. Nurse #1 stated the nurse aide usually informed the nurse if the securement device was missing or soiled.An interview was conducted with the Director of Nursing (DON) on 12/18/25 at 12:36 PM The DON stated the nurse aide, or nurse could apply the securement device for the urinary catheter. The DON stated that she expected that indwelling urinary catheter would have a securement device in place.During an interview with the Administrator on 12/18/25 at 1:00 PM, the Administrator stated she expected that staff would have placed a urinary catheter securement device and checked for placement each shift.

Based on record review and staff interviews, the facility failed to ensure a resident receiving dialysis had a physician's order for dialysis for 1 of 2 sampled residents reviewed for dialysis (Resident #6). The findings included:Resident #6 was admitted to the facility on [DATE] with diagnoses including end-stage renal disease requiring dialysis.The resident's care plan, last updated on 10/21/24, documented chronic renal failure and the potential for complications related to hemodialysis. Interventions included:- Communicating with the dialysis center regarding medications, diet, and lab results.- Coordinating care with the dialysis center.- Monitoring the shunt site daily and as needed for signs of infection, pain, or bleeding.- Notifying the physician of absence of thrill or bruit.Review of a hospital note dated 11/18/25 revealed that Resident #6 was hospitalized on [DATE] for a critical procedure for patients requiring long-term dialysis access. The resident continued receiving hemodialysis.Upon readmission to the facility on [DATE], the physician's orders did not include dialysis services.The Minimum Data Set, dated [DATE] coded the resident as having end-stage renal disease and receiving dialysis services.During an interview on 12/18/25 at 11:17 AM, the [NAME] Annex Unit Manager confirmed there was no dialysis order in the chart following the resident's return from the hospital. She stated the order was not reinstated after readmission.In an interview on 12/18/25 at 11:34 AM, the Director of Nursing reported she was unaware that the dialysis order was missing and acknowledged staff likely failed to re-enter the order upon readmission.In an interview on 12/18/25 at 11:32 AM, the Administrator stated the dialysis order should have been immediately reinstated after the resident's return from the hospital.

Based on record review, and staff interviews, the facility failed to monitor the North Carolina (NC) Nurse Aide (NA) Registry to ensure 1 of 6 nurse aides employed at the facility remained listed on the NC Nurse Aide Registry with an active Nurse Aide I certification (NA#1).The findings included:A review of Nurse Aide #1's employment record reported a hired date as [DATE]. The Nurse Aide Registry Verification form revealed the facility requested verification of Nurse Aide #1's certification on [DATE] and the NA's certification was current.During an interview with the Nurse Aide Registry Representative on [DATE] at 10:38 am, she stated NA #1's Nurse Aide I Registry expired on [DATE]. She stated NA #1's Nurse Aide registry was submitted and processed on [DATE].A review of NA #1's time sheet since [DATE] listed NA #1 worked the following dates:On [DATE] at 06:59 am to 07:01 pm as a Nurse AideOn [DATE] at 06:54 am to 07:01 pm as a Nurse AideOn [DATE] at 07:14 am to 07:04 pm as a Nurse AideOn [DATE] at 07:08 am to 07:00 pm as a Nurse AideOn [DATE] at 07:09 am to 07:01 pm as a Nurse AideOn [DATE] at 07:00 am to 07:02 pm as a Nurse AideOn [DATE] at 07:00 am to 07:01 pm as a Nurse AideOn [DATE] at 07:15 am to 07:01 pm as a Nurse AideOn [DATE] at 06:56 am to 07:03 pm as a Nurse AideOn [DATE] at 06:54 am to 07:04 pm as a Nurse AideOn [DATE] at 06:54 am to 06:54 pm as a Nurse AideOn [DATE] at 06:53 am to 06:56 pm as a Nurse AideOn [DATE] at 06:52 am to 01:28 pm as a Nurse AideOn [DATE] at 06:55 am to 07:00 pm as a Nurse AideOn [DATE] at 06:53 am to 06:55 pm as a Nurse AideOn [DATE] at 06:55 am to 06:57 pm as a Nurse AideOn [DATE] at 06:54 am to 07:03 pm as a Nurse AideOn [DATE] at 06:53 am to 06:56 pm as a Nurse AideOn [DATE] at 06:54 am to 07:06 pm as a Nurse AideOn [DATE] at 06:55 am to 07:05 pm as a Nurse AideOn [DATE] at 07:03 am to 07:07 pm as a Nurse AideOn [DATE] at 06:56 am to 07:01 pm as a Nurse AideOn [DATE] at 06:59 am to 07:01 pm as a Nurse AideOn [DATE] at 06:54 am to 07:05 pm as a Nurse AideOn [DATE] at 07:09 am to 07:00 pm as a Nurse AideOn [DATE] at 06:53 am to 07:08 pm as a Nurse AideOn [DATE] at 07:05 am to 07:06 pm as a Nurse AideOn [DATE] at 06:54 am to 07:02 pm as a Nurse AideOn [DATE] at 06:57 am to 06:59 pm as a Nurse AideOn [DATE] at 06:52 am to 07:04 pm as a Nurse AideOn [DATE] at 06:53 am to 06:59 pm as a Nurse AideOn [DATE] at 06:55 am to 07:01 pm as a Nurse AideOn [DATE] at 06:57 am to 06:59 pm as a Nurse AideOn [DATE] at 07:09 am to 06:58 pm as a Nurse AideOn [DATE] at 07:00 am to 07:01 pm as a Nurse AideOn [DATE] at 07:05 am to 07:06 pm as a Nurse AideOn [DATE] at 07:01 am to 07:00 pm as a Nurse AideOn [DATE] at 07:03 am to 06:59 pm as a Nurse AideOn [DATE] at 07:11 am to 07:05 pm as a Nurse AideOn [DATE] at 06:53 am to 06:58 pm as a Nurse AideOn [DATE] at 06:54 am to 07:02 pm as a Nurse AideOn [DATE] at 06:59 am to 07:00 pm as a Nurse AideOn [DATE] at 07:00 am to 07:00 pm as a Nurse AideOn [DATE] at 07:00 am to 07:00 pm as a Nurse AideOn [DATE] at 07:00 am to 07:00 pm as a Nurse AideOn [DATE] at 07:00 am to 07:00 pm as a Nurse AideOn [DATE] at 06:59 am to 07:02 pm as a Nurse AideOn [DATE] at 06:59 am to 07:00 pm as a Nurse AideOn [DATE] at 06:50 am to 06:58 pm as a Nurse AideOn [DATE] at 06:54 am to 06:58 pm as a Nurse AideOn [DATE] at 06:53 am to 07:00 pm as a Nurse AideOn [DATE] at 06:53 am to 07:01 pm as a Nurse AideOn [DATE] at 06:55 am to 07:01 pm as a Nurse AideOn [DATE] at 06:52 am to 07:09 pm as a Nurse AideOn [DATE] at 06:58 am to 03:32 pm as a Nurse AideDuring an interview with Nurse Aide #1 on [DATE] at 10:32 AM, she stated that her Nurse Aide certification had expired at the end of August. NA #1 stated she was not aware that her certification had expired because she did not receive any notification via mail or email. NA #1 stated she had worked about a month when she found out that her Nurse Aide certification had expired. NA #1 stated that she completed the necessary online forms and got the nurse to sign off. NA #1 reported this was close to the end of [DATE].An interview was conducted with Nurse Manager #1 on [DATE] at 11:04 PM. Nurse Manager #1 stated she had signed off electronically on NA #1's Nurse Aide Registry renewal form the end of [DATE].A follow up phone call was made to the Nurse Aide Registry Representative on [DATE]. She stated the process was for the Nurse Aide to complete their section of the electronic Nurse Aide Registry renewal form. The Nurse Aide Registry Representative stated once the Nurse Aide completed her section, she would then notify the Registered Nurse (RN) to go in and fill out her section on the renewal form. The Nurse Aide Registry Representative added that if the RN waited longer than 7 days to complete her section, the renewal form would reset, and the process would restart and the Nurse Aide had to resubmit her section. The Nurse Aide Registry Representative further stated that Nurse Aides were to check the system to see when the Nurse Aide Registry renewal was effective.On [DATE] at 12:33 PM an interview was conducted with the Human Resources (HR) Director. The HR Director stated she was responsible for reviewing the Nurse Aide Registry verifications. The HR Director stated she reviewed all Nurse Aide Registry verifications every six months. She stated that it was human error that she had missed that NA #1's Nurse Aide certification had expired.During an interview with the Administrator on [DATE] at 12:28 PM, she stated the HR Director was responsible for notifying staff that their Nurse Aide Registry renewal was due before the end of the month. She stated NA #1's certification expiration was an oversight.

Based on observations, manufacturers' instructions, and staff and Pharmacy Consultant interviews, the facility failed to remove one (1) multi-dose insulin injector pen that was expired and 2 bottles of expired eye drops in 1 of 4 medication carts (East Annex Medication Cart #1) reviewed for medication storage and labeling.The findings included: The manufacturer's instructions for insulin lispro injector pen stated it should be discarded 28 days after opening. The manufacturer's instructions for latanoprost solution (eye drop used to treat glaucoma) stated once the bottle was opened it could be used for 6 weeks. The manufacturer's instructions for dorzol/timolol solution (eye drop used to treat glaucoma) stated once bottle was opened it should be discarded 28 days after opening. An observation of the East Annex medication cart #1 on 12/17/25 at 2:09 pm revealed one (1) insulin lispro injector pen that was open which had an opened date of 11/3/25, one (1) bottle of latanoprost solution 0.05 percent (%) which had an opened date of 10/29/25 with an expiration date handwritten on the bottle of 12/10/25, and one (1) bottle of dorzol/timolol solution which had an opened date of 11/13/25 and an expiration date handwritten on the bottle of 12/11/25. During an interview with Nurse #2 during the medication cart observation on 12/17/25 at 2:09 pm she stated the insulin pen should have been removed after 28 days and the eye drops should have been discarded on the expiration dates written on the bottles. During a phone interview with the Pharmacy Consultant on 12/17/25 at 4:53 pm, he stated the insulin pen should have been discarded 28 days after opening, the latanoprost eye drops should have been discarded 6 weeks after opening and the dorzol/timolol eye drops should have been discarded 28 days after opening. During an interview with the Director of Nursing (DON) on 12/18/25 at 11:55 am, she explained the Unit Managers and floor nurses were responsible for checking the medication carts for expired medications on a daily basis and discard any expired medications. The DON further stated her expectations of the nursing staff were to check the medication carts daily and remove any expired medications. During an interview with the Administrator on 12/18/25 at 12:04 pm, she stated her expectations were the nursing staff would check the medication carts daily and have no expired medications in the medication carts.

Based on observations and staff interviews, the facility failed to maintain 1 of 2 nourishment room refrigerators and freezer clean, and in a sanitary manner to prevent cross contamination by failing to clean up spills (South Unit refrigerator). The findings included:On 12/17/25 at 11:17 AM the South Unit nourishment refrigerator was observed with the South Unit Nurse. The clear refrigerator drawers were noted with small, dried food particles and there was a brown sticky substance spilled on the bottom shelf of the freezer section. The South Unit Nurse indicated during the observation she was not aware who was responsible for cleaning the refrigerator.A second observation of the South Unit nourishment room, on 12/18/25 at 10:36 AM revealed the refrigerator and freezer were in the same condition.In an interview on 12/18/25 at 10:25 AM Housekeeper #1 stated that she was assigned to clean the South Unit refrigerator once a week and had not looked at or cleaned the freezer that week. In an interview on 12/18/25 at 11:29 AM the Administrator stated the dietary department was responsible for cleaning the nourishment room refrigerators and she expected them to be clean.

Based on record reviews and staff interviews, the facility failed to develop a person-centered care plan in the areas of antipsychotic medication use (Resident #8), and preferred activities (Resident #109) for 2 of 32 residents whose care plans were reviewed.The findings included: 1. Resident #8 was admitted to the facility on [DATE] with diagnoses that included vascular dementia with psychotic disturbance. Review of Resident #8's December 2025 physician's orders revealed a medication order dated 07/22/25 for olanzapine (antipsychotic medication) 5 milligrams (mg) one (1) tablet every 12 hours for psychotic disorder. Review of Resident #8's current comprehensive care plan last reviewed on 10/24/25 did not reveal a care plan focus area related to receiving an antipsychotic medication. Resident #8's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired and was coded for antipsychotic medication use. Review of Resident #8's December 2025 medication administration record for the period of 12/01/25 through 12/17/25 revealed Resident #8 received olanzapine 5mg one (1) tablet every 12 hours as prescribed. An interview was completed with the MDS Nurse on 12/18/25 at 12:06 pm who revealed she was responsible for the development of resident care plans. The MDS Nurse stated Resident #8 should have had an antipsychotic medication care plan with interventions in place. The MDS Nurse stated the missing care plan was due to an oversight. An interview was completed on 12/18/25 at 12:33 pm with the Director of Nursing (DON). The DON revealed the MDS Nurse was responsible for resident care plans. The DON stated resident care plans were reviewed during care plan meetings and Resident #8 should have had a care plan initiated for antipsychotic medication use when the medication was prescribed. An interview was completed with the Administrator on 12/18/25 at 12:41 pm. The Administrator revealed the MDS Nurse was responsible for reviewing and developing residents' comprehensive care plans. The Administrator stated the MDS Nurse was responsible for developing Resident #8's care plan for antipsychotic medication use. The Administrator revealed the care plan was missed due to an oversight by the MDS Nurse. 2. Resident #109 was admitted to the facility on [DATE] with diagnoses that included vascular dementia. Resident #109's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired. The assessment revealed it was very important for Resident #109 to listen to music, participate in groups, participate in favorite activities, and participate in religious services. A progress note dated 10/26/25 revealed Resident #109 was taken from the dementia care unit to the main unit to attend a religious service. Review of Resident #109's current comprehensive care plan last reviewed on 10/28/25 did not reveal a care plan focus area related to activities. An interview was conducted with Nurse Aide #1 on 12/17/25 at 2:34 PM who stated Resident #109 frequently attended activities on the dementia care unit. An interview was completed with the Activities Director on 12/18/25 at 9:58 AM who revealed she was responsible for the development of resident care plans related to activities and residents should have a focus related to activities on their care plan. She reported that sometimes the MDS Nurse ensured there was a focus related to activities on resident care plans. She stated it was an oversight that activities was not included in the comprehensive care plan. During an interview with the MDS Nurse on 12/18/25 at 10:32 AM she stated sometimes she assisted the Activities Director and placed a focus related to activities on resident care plans, but it was the Activities Director's responsibility to ensure this was completed. She reported that if she noticed there was not a focus related to activities on the care plan, she would place one. She stated she was not aware that Resident #109 did not have a focus related to activities on her care plan. An interview was completed with the Administrator on 12/18/25 at 11:00 AM. The Administrator revealed the Activities Director was responsible for developing residents' comprehensive care plans related to activities. The Administrator revealed the focus of activities on the care plan was missed due to an oversight by the Activities Director.

Based on record review and staff interviews, the facility failed to ensure accurate daily staff nursing postings for 13 of 30 days reviewed for accurate nurse staffing information (11/17/25, 11/18/25, 11/21/25, 11/22/25, 11/23/25, 11/24/25, 11/27/25, 11/29/25, 11/30/25, 12/2/25, 12/11/25, 12/12/25 and 12/13/25).The findings included:The daily staff nursing postings from 11/15/25 through 12/15/25 did not include the resident census on 11/17/25, 11/18/25, 11/21/25, 11/22/25, 11/23/25, 11/24/25, 11/27/25, 11/29/25, 11/30/25, 12/2/25, 12/11/25, 12/12/25 and 12/13/25.An interview conducted with the Director of Nursing (DON) on 12/18/25 at 12:11 PM revealed she was responsible for updating the daily nurse staffing information postings. The DON stated the daily nurse staffing posting was usually filled out the previous evening and updated with the current daily census after the morning clinical meeting. The DON stated that Unit Manager #2 was responsible for updating the census on the weekends and the daily nurse staffing postings had been overlooked by the Unit Manager on the days it was not updated.An interview conducted with the Administrator on 12/18/15 at 12:54 PM revealed she expected that the daily staff posting would be completed to include the resident census.

Based on record review and staff interview the facility failed to designate a full-time Director of Nursing (DON) for the Skilled Nursing Facility (SNF) when the current DON went out on family medical leave. The findings included: During an interview with the Administrator on 9/23/24 at 9:53 AM, the Administrator explained that the Director of Nursing (DON) was out due to having surgery. She stated the DON had been available by phone when unable to physically be in the building due to these issues. The Administrator stated on 9/16/24 the DON had planned surgery and took medical leave at that time. The Administrator stated that the Staff Development Coordinator who was a registered nurse (RN) was the contact person for nursing-related questions. During an interview with the Staff Development Coordinator (SDC) on 9/24/24 at 2:48 PM, she stated she shared on call duty with the Wound nurse. The SDC reported staff would call her with nursing related questions after hours during her on call day. The Staff Development Coordinator stated she had not been informed that she was the DON designee. During a follow up interview with the Administrator on 9/26/24 at 9:17 AM, she stated she did not appoint an interim DON when the DON went out for surgery on 9/16/24. The Administrator stated on 9/25/24 the SDC was appointed as the interim DON.

Based on record review, staff interviews, and Consultant Pharmacist interview, the facility failed to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for residents receiving an antipsychotic medication, which is used for medication monitoring of side effects of antipsychotic medication for 3 of 5 residents reviewed for unnecessary medications (Resident #7, Resident #62, and Resident #57). The findings included: 1. Resident #7 was admitted to the facility on [DATE] with diagnoses which included dementia with behaviors. Resident #7 had an active physician order dated 4/20/24 for quetiapine fumarate oral tablet (an antipsychotic medication) 25 milligrams (mg) give one tablet by mouth one time a day for dementia with behaviors. Resident #7 had an active physician order dated 4/22/24 for quetiapine fumarate oral tablet 50 mg at bedtime for behaviors. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #7 had moderate cognitive impairment and was not coded for behaviors. Resident #7 was coded for antipsychotic medications for 7 of the 7 days during the assessment period. Resident #7 had a care plan last reviewed on 7/26/24 for use of psychotropic mediations related to dementia and behavior management with interventions to administer psychotropic medication as ordered by the physician, and to monitor for adverse reactions. A review of Resident #7's electronic medical record from 4/20/24 through 9/25/24 revealed no documentation regarding the completion of an AIMS assessment since the antipsychotic medication had been started. The AIMS assessment was utilized to detect Tardive Dyskinesia (involuntary repetitive movements which occurs following treatment with medication) in residents prescribed antipsychotic medications. A telephone interview was conducted on 9/25/24 at 12:33 pm with the Consultant Pharmacist who revealed the facility was required to complete an AIMS assessment on all residents that were prescribed an antipsychotic medication upon initiation of the medication and every 6 months thereafter. The Consultant Pharmacist stated the facility was responsible to ensure the AIMS assessment was completed as required for Resident #7 when the antipsychotic medication was started. An interview was conducted on 9/26/24 at 10:08 am with the Interim Director of Nursing (DON) who revealed Resident #7 was required to have an AIMS assessment for the antipsychotic medication when it was started. The Interim DON stated the medication orders were reviewed in the daily clinical meeting and the need for Resident #7's initial baseline AIMS assessment should have been identified during those meetings. During an interview on 9/26/24 at 12:20 pm the Administrator stated the AIMS assessment was missed due to a breakdown in their process and communication. 2. Resident #62 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease with early onset and major depressive disorder. Review of the Psychiatric Provider visit note dated 12/11/23 revealed Resident #62 was recommended to start olanzapine (an antipsychotic medication) 2.5 milligrams (mg) tablet at bedtime for mood instability related to dementia. Resident #62 had an active physician order dated 12/14/23 for olanzapine 2.5 mg at bedtime for mood instability related to dementia. Review of Resident #62's electronic medical record revealed an AIMS assessment was completed on 1/25/24 for the start of the olanzapine medication. The AIMS assessment was utilized to detect Tardive Dyskinesia (involuntary repetitive movements which occurs following treatment with medication) in residents prescribed antipsychotic medications. Further review of Resident #62's electronic medical record 2/01/24 through 9/25/24 revealed no documentation regarding the completion of an AIMS assessment since the baseline AIMS assessment was completed for the antipsychotic medication on 1/25/24. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #62 had moderate cognitive impairment and was coded for rejection of care for 1-3 days during the 7-day look back period. Resident #62 was coded for antipsychotic medications for 7 of the 7 days during the assessment period. Review of Resident #62's care plan last reviewed on 8/13/24 revealed no care plan in place for use of an antipsychotic medication. A telephone interview was conducted on 9/25/24 at 12:33 pm with the Consultant Pharmacist who revealed the facility was required to complete an AIMS assessment on all residents that were prescribed an antipsychotic medication upon initiation of the medication and every 6 months thereafter. The Consultant Pharmacist stated he would have expected for the facility to have completed another AIMS assessment for Resident #62's antipsychotic medication within 6 months of the initial assessment. An interview was conducted on 9/26/24 at 10:08 am with the Interim Director of Nursing (DON) who revealed an AIMS assessment for the antipsychotic medication was required when the medication was started and then quarterly thereafter. The Interim DON stated the AIMS assessments were reviewed in the daily clinical meeting and the need for Resident #62's next AIMS assessment should have been identified during those meetings. The Interim DON was unable to recall if Resident #62's AIMS assessments due dates were discussed during the meetings. During an interview on 9/26/24 at 12:20 pm the Administrator stated the AIMS assessment was missed due to a breakdown in their process and communication. 41772 3. Resident #57 was admitted on [DATE] with diagnoses that included anxiety disorder and dementia with behavioral disturbance. A review of the physician's orders revealed an order for Olanzapine10 (milligrams) MG (an antipsychotic medication used to regulate behaviors)-Give 1 tablet by mouth at bedtime for mood instability and hallucinations dated 1/17/23. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #57 was cognitively intact and was not coded for behaviors. Resident #57 was coded for antipsychotic medications for 7 of the 7 days during the assessment period. Review of Resident # 57's electronic medical record from 8/10/23 to 9/26/24 revealed no documentation regarding the completion of an AIMS assessment. Review of the care plan last reviewed on 7/10/24 revealed Resident #57 used psychotropic medications due to hallucinations. The interventions included administering psychotropic medications as ordered by physician and monitoring for side effects. Further review of the care plan revealed Resident #57 exhibited behaviors of pulling off clothes, making inappropriate remarks to staff, and loud yelling. The interventions included approach/speak to resident in a calm manner, divert attention, and intervene as necessary to protect the rights and safety of others. A telephone interview was conducted on 9/25/24 at 12:33 pm with the Consultant Pharmacist who revealed the facility was required to complete an AIMS assessment on all residents that were prescribed an antipsychotic medication upon initiation of the medication and every 6 months thereafter. The Consultant Pharmacist stated Resident #57 had been overlooked and the facility was responsible for completing the AIMS assessment once Resident #57 was started on the antipsychotic medication. An interview was conducted with the Senior [NAME] President of Clinical Operations on 09/26/24 at 11:09 AM. The Senior VP stated AIMS should be completed every 6 months for residents who are on antipsychotic medications. She further stated the AIMS assessments were to be reviewed during the at-risk meetings which involved the interdisciplinary team. During an interview on 9/26/24 at 12:20 pm the Administrator stated the AIMS assessment was missed due to a breakdown in their process and communication.

Based on record review, staff interviews, and Medical Director interview, the facility failed to hold a blood pressure medication as ordered by the physician when the blood pressure was above the parameter for 1 of 1 resident reviewed for a significant medication error (Resident #101). The findings included: Resident #101 was admitted to the facility on [DATE] with diagnoses which included hypertension, heart failure, and atrial fibrillation. A physician order dated 3/18/24 for midodrine (a medication used to treat low blood pressure) 5 milligram (mg) tablet by mouth three times a day for hypotension (low blood pressure). Hold for systolic blood pressure (SBP) greater than 120 millimeters of mercury (mmHg). Review of the Medication Administration Record for July 2024 revealed Resident #101 was administered midodrine 15 times with the SBP greater than 120 mmHg. The MAR report revealed the following dates, times, and blood pressure readings: 7/1/24 at 8:00 am SBP was 134 mmHg and was administered by Nurse #1. 7/1/24 at 12 pm SBP was 142 mmHg and was administered by Nurse #1. 7/1/24 at 4:00 pm SBP was 138 mmHg and was administered by Nurse #1. 7/2/24 at 8:00 am SBP was 138 mmHg and was administered by Nurse #7. 7/2/24 at 12 pm SBP was 138 mmHg and was administered by Nurse #7. 7/2/24 at 4:00 pm SBP was 133 mmHg and was administered by Nurse #7. 7/6/24 at 4:00 pm SBP was 130 mmHg and was administered by Nurse #6. 7/11/24 at 8:00 am SBP was 124 mmHg and was administered by Nurse #4. 7/11/24 at 12:00 pm SBP was 124 mmHg and was administered by Nurse #4. 7/18/24 at 12:00 pm SBP was 128 mmHg and was administered by Nurse #8. 7/22/24 at 8:00 am SBP was 139 mmHg and was administered by Nurse #8. 7/27/24 at 4:00 pm SBP was 122 mmHg and was administered by Nurse #1. 7/28/24 at 8:00 am SBP was 142 mmHg and was administered by Nurse #1. 7/28/24 at 12:00 pm SBP was 136 mmHg and was administered by Nurse #1. 7/28/24 at 4:00 pm SBP was 124 mmHg and was administered by Nurse #1. Review of the Medication Administration Record for August 2024 revealed Resident #101 was administered midodrine 5 times with the SBP greater than 120 mmHg. The MAR report revealed the following dates, times, and blood pressure readings: 8/9/24 at 4:00 pm SBP was 128 mmHg and was administered by Nurse #5. 8/10/24 at 12:00 pm SBP was 124 mmHg and was administered by Nurse #5. 8/12/24 at12:00 pm SBP was 127 mmHg and was administered by Nurse #5. 8/20/24 at 12:00 pm SBP was 124 mmHg and was administered by Nurse #5. 8/23/24 at 12:00 pm SBP was 124 mmHg and was administered by Nurse #5. Review of the nursing progress notes from July 2024 through August 2024 revealed no identified concerns related to the midodrine being administered to Resident #101 outside of the physician order parameters. An attempt to conduct a telephone interview with Nurse #8 on 9/25/24 at 1:15 pm was unsuccessful. An attempt to conduct a telephone interview with Nurse #7 on 9/25/24 at 1:59 pm was unsuccessful. During a telephone interview on 9/25/24 at 2:06 pm with Nurse #5 confirmed she worked at the facility on the dates the medication was signed out on the MAR. She revealed she normally checked Resident #101's blood pressure before she gave her midodrine and she recalled Resident #101's SBP normally being lower than order parameter. Nurse #5 reported the medication should have been held based on the SBP that was documented. Nurse #5 stated she cannot say what happened and why the medication was given. An attempt to conduct a telephone interview with Nurse #6 on 9/25/24 at 2:15 pm was unsuccessful. A telephone interview was conducted on 9/25/24 at 2:23 pm with Nurse #4 who revealed when a blood pressure medication had a parameter to hold a blood pressure was supposed to be obtained prior to administration of the medication. Nurse #4 stated she did not recall the particular dates she was assigned to Resident #101, but she stated the midodrine should have been held if the SBP was greater than 120 mmHg. Nurse #4 could not say why she gave the medication. A telephone interview was conducted on 9/25/24 at 6:00 pm with Nurse #1 who revealed she did not recall Resident #101or the specific dates to respond to the questions. Nurse #1 stated that in general if a blood pressure medication had a parameter, she would have obtained the blood pressure prior to giving the medication and documented the blood pressure when she signed out the medication. Nurse #1 stated if she documented that she administered the medication she would not be able to say what happened and why she would have given the medication. An interview was conducted on 9/25/24 at 1:01 pm with the Nurse Practitioner who revealed she had only been at the facility for a few weeks and was unable to answer the questions regarding Resident #101. An attempt to conduct a telephone interview with the Medical Doctor who was assigned to Resident #101 on 9/26/24 at 11:39 am was unsuccessful. A telephone interview was conducted on 9/26/24 at 1:50 pm with the Medical Director who revealed Resident #101's midodrine was ordered with a parameter to keep the blood pressure from going too low. The Medical Director stated the risk associated with the midodrine being administered outside of the SBP parameter could have increased her blood pressure to an unsafe level which is why a parameter was placed on specific orders. The Medical Director stated Resident #101's midodrine should not have been administered when the SBP was greater than 120 mmHg. An interview was conducted on 9/26/24 at 9:58 am with the Interim Director of Nursing (DON) who revealed nurses were educated regarding medication administration including to hold medications when outside of an order parameter. The Interim DON stated nurses were to check the blood pressure prior to the medication being administered. The Interim DON stated the Nurses should not have administered Resident #101's midodrine when the SBP was greater than the parameter of the physician order.

Based on record review and staff interviews, the facility failed to accurately document the administration of 14 doses of blood pressure medication in the medical record for 1 of 1 resident reviewed for a significant medication error (Resident #101). The findings included: Resident #101 was admitted to the facility on [DATE] with diagnoses which included hypertension, heart failure, and atrial fibrillation. A physician order dated 3/18/24 for midodrine (a medication used to treat low blood pressure) 5 milligram (mg) tablet by mouth three times a day for hypotension (low blood pressure). Hold for systolic blood pressure (SBP) greater than 120 millimeters of mercury (mmHg). Review of the Medication Administration Record for July 2024 revealed Resident #101's midodrine was documented as administered 2 times with the SBP greater than 120 mmHg. The MAR report revealed the following dates, times, and blood pressure readings: 7/4/24 at 4:00 pm SBP was 132 mmHg and was documented as administered by Nurse #3. 7/10/24 at 4:00 pm SBP was 128 mmHg and was documented as administered by Nurse #3. Review of the Medication Administration Record for August 2024 revealed Resident #101's midodrine was documented as administered 8 times with the SBP greater than 120 mmHg. The MAR report revealed the following dates, times, and blood pressure readings: 8/2/24 at 12:00 pm SBP was 128 mmHg and was documented as administered by Nurse #3. 8/8/24 at 12:00 pm SBP was 132 mmHg and was documented as administered by Nurse #2. 8/14/24 at 12:00 pm SBP was 122 mmHg and was documented as administered by Nurse #2. 8/17/24 at 12:00 pm SBP was 124 mmHg and was documented as administered by Nurse #2. 8/21/24 at 8:00 am SBP was 132 mmHg and was documented as administered by Nurse #2. 8/22/24 at 12:00 pm SBP was 122 mmHg and was documented as administered by Nurse #2. 8/28/24 at 8:00 am SBP was 122 mmHg and was documented as administered by Nurse #2. 8/31/24 at 4:00 pm SBP was 124 mmHg and was documented as administered by Nurse #2. Review of the Medication Administration Record for September 2024 revealed Resident #101's midodrine was documented as administered 4 times with the SBP greater than 120 mmHg. The MAR report revealed the following dates, times, and blood pressure readings: 9/1/24 at 12:00 pm SBP was 122 mmHg and was documented as administered by Nurse #2. 9/11/24 at 4:00 pm SBP was 122 mmHg and was documented as administered by Nurse #2. 9/15/24 at 12:00 pm SBP was 122 mmHg and was documented as administered by Nurse #2. 9/19/24 at 4:00 pm SBP was 121 mmHg and was documented as administered by Nurse #2. An interview was conducted on 9/25/24 at 1:01 pm with Nurse #2 who revealed when a physician order had a parameter to hold the medication the order required a blood pressure to be obtained and documented on the Medication Administration Record (MAR). Nurse #2 stated she did not believe she administered the midodrine medication to Resident #101 on the dates noted because she always paid attention to the medication order. Nurse #2 stated does not think she gave the medication outside the parameter because she knows Resident #101 well. An interview was conducted on 9/25/24 at 1:09 pm with Nurse # 3 who revealed she checked Resident #101's blood pressure prior to administering the midodrine medication and would enter the blood pressure when she documented the medication as administered. Nurse #3 stated it may have been a documentation mistake, but she did not think she would have administered Resident #101's midodrine medication outside of the parameter. An interview was conducted with the Interim Director of Nursing (DON) on 9/26/24 at 9:58 am who revealed all nursing staff were provided education during orientation and random medication pass observations throughout the year to ensure medications were being administered correctly. The Interim DON stated the education included documentation of the medications administered.

Based on record review, staff interviews, and resident interview, the facility failed to hold a care plan meeting or invite the resident to participate in the care planning process for 1 of 22 residents whose care plans were reviewed (Resident #62). The findings included: Resident #62 was admitted to the facility on [DATE]. Review of the Multidisciplinary Care Conference assessment dated [DATE] revealed a quarterly care plan meeting was conducted for Resident #62. Review of the Multidisciplinary Care Conference assessment dated [DATE] revealed a quarterly care plan meeting was conducted for Resident #62. Review of the Multidisciplinary Care Conference assessment dated [DATE] revealed a quarterly care plan meeting was conducted for Resident #62. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #62 had moderate cognitive impairment. Resident #62 was coded for active participation in the assessment and goal setting. Review of Resident #62's electronic medical record revealed no documentation that a care plan meeting was held or that Resident #62 was invited to participate in a care plan meeting during the time between the 11/28/23 and 7/02/24 care plan meetings. During an interview with Resident #62 on 9/23/24 at 10:16 am, Resident #62 reported she was unable to recall the last time she had a care plan meeting, but she wanted to be involved with her care plan meetings. An interview was conducted on 9/24/24 at 1:05 pm with the Director of Social Services who revealed she was responsible to invite the resident and/or the Responsible Party (RP) to participate in the quarterly care plan meetings. She stated she personally invited the residents to participate in the quarterly care plan meetings when they were scheduled. The Director of Social Services reported she was unable to locate any documentation that a care plan meeting was held for Resident #62 between the 11/28/23 and 7/02/24 care plan meetings but she stated there should have been one held during that time frame. An interview was conducted with MDS Nurse #2 on 9/24/24 at 1:14 pm who revealed the long-term resident care plan meetings were held quarterly (every 3 months). MDS Nurse #2 stated MDS Nurse #1 created a care plan meeting calendar and would give the calendar to the Director of Social Services to schedule the resident care plan meeting. MDS Nurse #2 stated Resident #62 should have had a care plan meeting between the 11/28/23 and 7/02/24 care plan meetings but she was unable to locate any documentation that the meeting was scheduled or completed. During an interview on 9/26/24 at 10:32 am with MDS Nurse #1 she revealed she was responsible to create a care plan meeting calendar based on the resident assessment dates which were every 3 months for long-term care residents. She stated she created the care plan meeting calendar that noted the residents that required a care plan meeting to be scheduled for a particular month. MDS Nurse #1 stated she gave the calendar of residents that required a care plan meeting to the Director of Social Services to schedule and invite the resident to the care plan meeting. MDS Nurse #1 stated Resident #62 should have been on the calendar to have a care plan meeting sometime around the March 2024 time frame for her next care plan meeting after the 11/28/23 care plan meeting. MDS Nurse #1 was unable to locate the care plan meeting calendar to confirm Resident #62 was listed to have the meeting scheduled, but she stated she thought Resident #62's name was listed. A follow-up interview was conducted on 9/26/24 at 12:21 pm with the Director of Social Services who revealed if Resident #62 was listed on the care plan meeting calendar created by MDS Nurse #1 she would have scheduled a care plan meeting to be held. The Director of Social Services stated Resident #62 should have had a care plan meeting scheduled sometime between the end of February 2024 through early March 2024 based on the last care plan meeting date, but she must not have been on the care plan calendar list provided by MDS Nurse #1. An interview was conducted on 9/26/24 at 12:43 pm with the Administrator who revealed MDS Nurse #1 was responsible to ensure the care plan meeting calendar was completed accurately and communicated appropriately to the Director of Social Services to create the schedule.

Based on observation, record review, and staff and resident interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of a pressure reducing surface for pressure ulcer (Resident #7) and the use of a continuous positive airway pressure (CPAP) machine (Resident #95) for 2 of 22 residents whose MDS assessments were reviewed. The findings included: 1. Resident #7 was admitted to the facility on [DATE]. Resident #7 had an active physician order dated 4/19/24 for a standard pressure ulcer redistribution mattress. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #7 had moderate cognitive impairment and was coded for an unhealed, unstageable (due to coverage of the wound bed by slough and/or eschar) pressure ulcer. Resident # 7 was not coded for a pressure reducing surface for bed. An interview was conducted on 9/24/24 at 3:19 pm with MDS Nurse #2 who completed Resident #7's MDS quarterly assessment. MDS Nurse #2 confirmed Resident #7 had a physician order for the standard pressure ulcer redistribution mattress and stated Resident #7's mattress was a pressure reducing surface for the bed. MDS Nurse #2 stated she should have coded the mattress as a pressure reducing surface for bed for Resident #7's quarterly assessment. During an interview on 09/26/24 at 12:38 pm with the Administrator she revealed the MDS Nurse was responsible to code Resident #7's MDS assessment accurately. 2. Resident #95 was admitted to the facility on [DATE] with diagnoses which included obstructive sleep apnea and acute respiratory failure with hypoxia. Resident #95 was noted to be discharged to the hospital on 8/19/24 and returned to the facility on [DATE]. Resident #95 had a care plan initiated on 2/02/24 for oxygen therapy related to continuous positive airway pressure (CPAP) related to obstructive sleep apnea with an intervention to encourage to wear the CPAP as ordered by the physician. Resident #95 had an active physician order dated 8/26/24 for CPAP machine to apply at bedtime and remove when awake for sleep apnea. Review of the medication administration record for the month of August 2024 revealed Resident #95 used the CPAP machine as ordered with the exception of 8/28/24 which was noted as refused. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #95 was cognitively intact and was not coded for use of a CPAP machine. An observation and interview were conducted on 9/23/24 at 10:24 am with Resident #95 who had a CPAP machine located on the bedside table. Resident #95 revealed she had the CPAP machine for a long time and did use it at night while sleeping. An interview was conducted on 9/24/24 at 1:31 pm with MDS Nurse #1 who revealed if Resident #95 used the CPAP it should have been coded on the assessment. MDS Nurse #1 stated she reviewed the MDS assessment, and she did not have the option to answer the question regarding Resident #95's CPAP use. A follow-up interview was conducted with MDS Nurse #1 on 9/24/24 at 3:10 pm who revealed she reviewed the Resident Assessment Instrument (manual used for completing the MDS assessments) and she found that in order to code Resident #95's CPAP she had to choose yes to mechanical ventilation first. MDS Nurse #1 stated she was not aware she had to answer the mechanical ventilation area first in order to accurately code Resident #95 for use of the CPAP. During an interview on 09/26/24 at 12:38 pm with the Administrator she revealed the MDS Nurse was responsible to code Resident #95's MDS assessment accurately.

Based on record review, staff interviews, and resident interview, the facility failed to revise the care plan in the area of antipsychotic medication use (Resident #62) and risk for pain (Resident #101) for 2 of 22 residents reviewed for care plan revision. The findings included: 1. Resident #62 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, major depressive disorder, and cognitive communication deficit. Review of the Psychiatric Provider visit note dated 12/11/23 revealed Resident #62 was recommended to start olanzapine (an antipsychotic medication) 2.5 milligrams (mg) tablet at bedtime for mood instability related to dementia. Resident #62 had an active physician order dated 12/14/23 for olanzapine 2.5 mg at bedtime for mood instability related to dementia. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #62 had moderate cognitive impairment and was coded for rejection of care for 1-3 days during the 7-day look back period. Resident #62 was coded for antipsychotic medications for 7 of the 7 days during the assessment period. Review of Resident #62's care plan last reviewed on 8/13/24 revealed no care plan in place for use of an antipsychotic medication. An interview was conducted on 9/26/24 at 10:08 am with the Interim Director of Nursing (DON) who revealed care plan revisions were completed by the MDS Nurse. During an interview on 9/26/24 at 10:20 am MDS Nurse #2 revealed the MDS Nurses were responsible to update resident care plans. MDS Nurse #2 stated the normal process was the new medication would be discussed in the clinical meeting by nursing and she would revise the care plan during the meeting. MDS Nurse #2 stated had the new medication been discussed at the clinical meeting by nursing she would have revised Resident #62's care plan, but she did not recall the new medication being discussed. An interview was conducted on 9/26/24 at 10:35 am with MDS Nurse #1 who revealed Resident #62's antipsychotic medication required a care plan. MDS Nurse #1 stated she normally did not revise resident care plans because it was MDS Nurse #2's responsibility. MDS Nurse #1 stated the care plan should have been revised by MDS Nurse #2 when Resident #62's antipsychotic medication was started. An interview with the Administrator was conducted on 9/26/24 at 12:46 pm who revealed she expected resident care plans to be revised as needed. 2. Resident #101 was admitted to the facility on [DATE] with diagnoses which included Parkinsonism (clinical syndrome characterized by tremor, slow movement, and rigidity). Resident #101 had an active physician order dated 3/02/24 for meloxicam (a nonsteroidal medication used to treat arthritis) tablet 7.5 milligram (mg) one time a day for chronic pain. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #101 had moderate cognitive impairment and was coded for a stage 3 pressure ulcer. Resident #101 was coded for use of scheduled pain medication. Review of Resident #101's care plan last reviewed on 7/24/24 revealed no care plan was in place for pain management. Review of the medication administration record (MAR) for August 2024 through September 2024 revealed Resident #101 was administered the meloxicam medication as ordered. An interview was conducted with Resident #101 on 9/23/24 at 12:39 pm who reported she often had aching pain to her right arm. Resident #101 stated she did report the pain when it starts to the nurses, but she was not sure if they gave her pain medication. An interview was conducted with Nurse #2 on 9/24/24 at 2:03 pm who revealed Resident #101 was on a scheduled pain medication that was administered every morning, and she had not reported right arm pain to her in the past. An interview was conducted on 9/26/24 at 10:08 am with the Interim Director of Nursing (DON) who revealed the MDS Nurses were responsible for resident care plans. During an interview on 9/26/24 at 10:15 am with MDS Nurse #2 she revealed Resident #101 was not taking a lot of pain medication and did not report a pain presence when she completed her assessment, so she did start a pain management care plan. MDS Nurse #2 stated she could have entered a risk for pain care plan, but she did not revise Resident #101's care plan when the meloxicam medication was ordered. An interview was conducted on 9/26/24 at 10:35 am with MDS Nurse #1 who revealed Resident #101 should have had a care plan in place for pain related to her scheduled pain medication and the stage 3 pressure ulcer. MDS Nurse #1 stated she normally did not revise resident care plans because it was MDS Nurse #2's responsibility. MDS Nurse #1 stated the care plan should have been revised by MDS Nurse #2 when Resident #101's pain medication was started. An interview with the Administrator was conducted on 9/26/24 at 12:46 pm who revealed she expected resident care plans to be revised as needed.

Based on record review, staff interview and Consultant Pharmacist interview, the Pharmacist failed to identify and report a medication irregularity when an Abnormal Involuntary Movement Scale (AIMS) assessment was not initiated for Olanzapine (antipsychotic medication used to regulate behaviors) or 1 of 4 residents reviewed for unnecessary medications (Resident #57). The findings included: Resident #57 was admitted on [DATE] with diagnoses that included anxiety disorder and dementia with behavioral disturbance. A review of the physician's orders revealed an order for Olanzapine 10 MG (milligrams) (an antipsychotic medication used to regulate behaviors)- Give 1 tablet by mouth at bedtime for mood instability and hallucinations dated 1/17/23. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #57 was cognitively intact and was not coded for behaviors. Resident #57 was coded for antipsychotic medications for 7 of the 7 days during the assessment period. Review of Resident #57's electronic medical record from 8/10/23 to 9/26/24 revealed no documentation regarding the completion of an AIMS assessment. Review of the Monthly Medication Regimen (MRR) for Resident #57 revealed the Pharmacy Consultant reviews were completed on the following days: 9/17/23, 10/17/23, 11/8/23, 12/18/23, 1/22/24, 2/25/24, 3/24/24, 4/23/24, 5/22/24, 6/16/24, 7/23/24, and 8/22/24. There were no recommendations made by the Consultant Pharmacist for completion of an AIMS assessment. Review of the care plan last reviewed on 7/10/24 revealed Resident #57 used psychotropic medications due to hallucinations. The interventions included administering psychotropic medications as ordered by physician and monitoring for side effects. Further review of the care plan revealed Resident #57 exhibited behaviors of pulling off clothes, making inappropriate remarks to staff, and loud yelling. The interventions included approach/speak to resident in a calm manner, divert attention, and intervene as necessary to protect the rights and safety of others. A telephone interview was conducted on 9/25/24 at 12:33 pm with the Consultant Pharmacist who revealed the facility was required to complete an AIMS assessment on all residents that were prescribed an antipsychotic medication upon initiation of the medication and every 6 months thereafter. The Consultant Pharmacist stated Resident #57 had been overlooked and the facility was responsible for completing the AIMS assessment once Resident #57 was started on the antipsychotic medication. An interview was conducted with the Senior [NAME] President of Clinical Operations on 09/26/24 at 11:09 AM. The Senior VP stated AIMS should be completed every 6 months for residents who are on antipsychotic medications. She further stated the AIMS assessments were to be reviewed during the at-risk meetings which involved the interdisciplinary team. During an interview on 9/26/24 at 12:20 pm the Administrator stated the AIMS assessment was missed due to a breakdown in their process and communication.

Based on observations, record review, and interviews with resident, Speech Language Pathologist, Registered Dietitian, and staff, the facility failed to honor food preferences for 1 of 4 residents reviewed for preferences (Resident #66). The findings included: Resident #66 was readmitted to the facility on [DATE]. Diagnoses included severe protein calorie malnutrition, failure to thrive, diabetes, and dysphagia. An admission Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #66 with adequate hearing/vision, understood, understands, clear speech, severely impaired cognition. A diet order for Resident #66 dated 9/15/23 recorded a regular diet with mechanical soft ground meat texture on a sectioned plate with thin liquids, and double portions. Review of Diet Order and Communication form dated 9/15/24 for Resident #66 revealed a new diet order that included mechanically altered level 2, thin liquids, and double portions on a sectioned plate. A Nutritional Review dated 9/20/24, completed by the Registered Dietitian (RD), recorded Resident #66 for a regular, mechanical soft, ground meat texture; double portions diet order. Her intake varied from 25-75% consumption of meals. She had a wound noted to the right buttocks. The current diet order met nutritional requirements, but Resident #66 had variable intake. Wound healing interventions needed. Resident #66 was interviewed on 9/24/24 at 8:36 AM. She stated that she was supposed to receive double portions at meals but had yet to receive. During an observation on 9/25/24 at 8:52 AM, Resident #66 did not receive double portions of food items on breakfast meal tray, including eggs and oatmeal. The meal ticket did not include the details of double portions. During an observation on 9/25/24 at 12:58 PM, Resident #66 did not receive double portions of food items on the lunch meal tray, including ground meat, rice, and creamed corn. The meal ticket did not include the details of double portions. The Dietary Manager (DM) was interviewed on 9/25/24 at 1:05 PM. She revealed that all diet order changes were communicated with a Diet Order and Communication form from the nurse on duty. She stated she was not notified that the order change on 9/15/24 included double portions. The DM indicated that Resident #66 ate a lot of snacks/cookies and drank fluids, but she did not eat most of her meals. During an interview with the Speech Language Pathologist (SLP) on 9/25/24 at 2:13 PM, she revealed that if she initiated a diet change for a resident, a copy would be given to the Director of Rehab, the RD, and the nurse on duty. The SLP stated that Resident #66 asked for double portions on 9/15/24 because she was still hungry after meals. So, the SLP gave the Diet Order and Communication form to kitchen staff (names unknown) and the nurse on duty assigned to Resident #66. An interview was conducted with the RD on 9/25/24 at 2:47 PM. She revealed that she was aware of Resident #66's double portions diet order, but the description seemed vague and left a lot of room for interpretation. The RD indicated she needed to clarify the double portions order with the SLP as to double protein or double entrees. The interview further reveaked if Resident #66 requested more food and was included in the diet order, then she should receive double portions. Nurse #10 was interviewed on 9/25/24 at 3:32 PM. She revealed that when she was given a Diet Order and Communication form, she would take it to the kitchen. Nurse #10 stated she could not recall if she was given a Diet Order and Communication form from the SLP on 9/15/24. During an interview with the Senior [NAME] President of Operations on 9/25/24 at 3:25 PM, she revealed that the RD told her Resident #66's request for double portions was considered a preference. If the DM was not in the building when a food preference/dietary change was made, then there needed to be a process in place to ensure clear communication. She stated she would expect any changes to a dietary order or food preference to be fulfilled and carried out. The Administrator was interviewed on 9/26/24 at 8:49 AM. She revealed that Resident #66 asked for double portions, and dietary staff should have been alerted to the change and provided her preference at meals.

Based on record review and staff interviews, the facility failed to develop a care plan that addressed dementia care for 1 of 3 residents reviewed for comprehensive care plans (Resident #39). The findings included: Resident #39 was admitted to the facility on [DATE] with diagnoses that included Dementia and Insomnia. Review of Resident #39's care plan updated on 8/7/2024 revealed a focus area for dementia was not reflected in the care plan. A review of Resident #39's Nursing progress note dated 9/21/2024 at 11:18 P.M. revealed the resident refused the previous shift nurse to complete wound care. In an interview with Nurse #12 on 9/25/2024 at 12:03 P.M. she revealed Resident #39 had behaviors which included refusing wound care and medications or forcing his way to the smoking area outside smoking times. During an interview with MDS Nurse #2 on 9/24/2024 at 12:10 P.M. she revealed it was her responsibility to ensure the diagnosis of Dementia was care planned. She further revealed the error of not updating the care plan was an oversite on her part. An interview was conducted with the Administrator on 9/25/2024 at 9:19 A.M. She revealed it was the responsibility of the Director of Nursing to ensure the care plans accurately reflected the resident's condition and diagnosis.

Based on record review, staff and pharmacy interviews, the facility failed to complete the shift change inventory sheet consistently and accurately for 4 of 7 medication carts reviewed. Findings included: Review of the policy for Narcotic Reconciliation Protocol provided by the facility dated 5/30/23 stated in part: - The Director of Nursing or Nurse Manager shall reconcile narcotics monthly on or before the 15th of each month. - The reconciliation audit will include review of each narcotic book for shift count, narcotic count, narcotic page count and that the narcotics are stored with a double lock and key system. - Narcotic Management includes: o Assuring the Narcotic Shift Count is performed. 1 a. Review of the [NAME] Annex #1 medication cart with Nurse #3 revealed the Shift Change Controlled Substance Inventory Count sheet from 7/17/23 7:00 AM - 8/9/23 7:00 AM were missing the following entries: - 7 of 90 controlled substance card counts were not completed - 3 of 45 nurse signatures for coming on duty were missing - 3 of 45 nurse's signatures for going off duty were missing An interview was conducted with Nurse #3 on 8/9/23 at 1:18 PM. She revealed that all narcotics were stored in the medication cart unless they needed to be refrigerated. At the start of a shift, the departing and oncoming nurses counted and signed off on the shift change inventory sheet. Nurse #3 indicated that if the departing nurse did not count or sign the sheet, then she would have notified the Unit Manager or Director of Nursing (DON). She stated that every date and shift needed to be signed and counted. Nurse #3 revealed that she stated she did not write down the count of narcotics on 8/4/23 because it was a mistake. b. Review of the [NAME] Annex #2 medication cart with Nurse #6 revealed the Shift Change Controlled Substance Inventory Count sheet from 7/20/23 7:00 PM - 8/9/23 7:00 AM were missing the following entries: - 8 of 78 controlled substance card counts were not completed - 1 of 39 nurse signatures for coming on duty were missing - 5 of 39 nurse's signatures for going off duty were missing Nurse #6 was interviewed on 8/9/23 at 1:36 PM, and she revealed that she forgot to sign as the going off duty nurse on 7/31/23 when she finished her shift. c. Review of the East Annex #2 medication cart with Nurse #5 revealed the Shift Change Controlled Substance Inventory Count sheet from 6/27/23 7:00 AM - 8/9/23 7:00 AM were missing the following entries: - 18 of 172 controlled substance card counts were not completed - 1 of 86 nurse signatures for coming on duty were missing - 6 of 86 nurse's signatures for going off duty were missing An interview was conducted on 8/9/23 at 3:26 PM with Nurse #5. She revealed that when she started a shift, she counted all of the controlled substance cards and sheets to make sure they aligned with the departing nurse's information. At the end of her shift, she counted the cards and sheets again with the oncoming nurse. Nurse #5 stated there was never a time when she did not sign the shift change controlled substance inventory count sheet because her signature verified that the count was correct. d. Review of the East Hall #2 medication cart with Nurse #4 revealed the Shift Change Controlled Substance Inventory Count sheet from 7/2/23 7:00 PM - 8/9/23 7:00 AM were missing the following entries: - 5 of 104 controlled substance card counts were not completed - 3 of 52 nurse's signatures for going off duty were missing An interview was conducted with Nurse #4 on 8/9/23 at 3:09 PM. Nurse #4 stated the controlled substances were counted when she came in for her shift to make sure the number of sheets and cards were correct and was the same as the departing nurse. The same process was followed for when she completed a shift as well. Nurse #4 indicated there was never a time that she did not sign it, unless it was incorrect, but she had not yet experienced that. If there was an issue with the inventory sheet, then she would notify the Unit Manager. The Unit Manager was interviewed on 8/9/23 at 1:58 PM. He revealed that nurses were expected to count off the total number of cards and sheets with a signature when they arrive for their shift and when they finish their shift. If there was not a signature, then nurses were expected to come back to the facility and make sure the shift change inventory sheet was signed. The Unit Manager indicated that the narcotic books were checked by him every 15th day of the month to make sure they were completed correctly. However, he stated he took the Unit Manager position one week ago, and before then, the responsibility was assigned to the Assistant Director of Nursing (ADON) and DON. A phone interview was conducted with the Pharmacist on 8/9/23 at 2:59 PM. He revealed that he performed random audit narcotic card counts when he was in the building monthly. However, nursing staff were responsible for the day-to-day reconciliation and should be counted at every shift change. During an interview with the ADON on 8/10/23 at 8:43 AM, she revealed that nurses were expected to count the controlled substance sheets/cards and ensure the narcotic book reconciled with the medication cart at the start and end of each shift. If there was an issue, nursing staff needed to make the correction before they left from their shift. The ADON indicated the narcotics book was reviewed on the 15th of each month by the DON or Nurse Manager to make sure that the shift change inventory sheets were signed off properly. If there were any missing entries, then the ADON stated she would find out who was working that shift and have them sign. The DON was interviewed on 8/10/23 at 9:02 AM. She revealed nurses were expected to count and sign the shift change inventory sheet at the beginning and end of every shift. if there was a discrepancy with the shift change inventory sheets, then she should have been notified immediately. The DON stated that she or the Unit Manager monitor and audit the shift change sheets on the 15th of every month. She indicated that the missing entries might have been caused by nursing staff were ready to leave work and perhaps forgot to sign. An interview with the Administrator was conducted on 8/10/23 at 9:20 AM. She revealed the oncoming nurse was expected to count and sign the shift change inventory sheet, as well as the off going nurse. The facility protocol was for the DON or Nurse Manager to monitor the controlled substances form on or before the 15th of every month. The Administrator indicated that education and auditing needed to be put in place.

Based on record review and physician and staff interviews, the facility neglected to protect the residents' right to be free from abuse when Resident #29 physically abused Residents #39 and #53. Resident #53 sustained injuries that required emergency room evaluation. This was for 1 of 1 resident (Resident #29) reviewed for resident-to-resident abuse. Immediate Jeopardy began on 11/08/21 when the facility failed to implement effective interventions to protect residents from the physical abuse of Resident #29 resulting in the resident placing Resident #53 in a headlock and pulling her to the floor. Immediate Jeopardy was removed on 1/30/22 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity of E (no actual harm with a potential for minimum harm that is not Immediate Jeopardy) to ensure the monitoring of the systems put into place and to complete facility employee and agency in-services, orientation and training. The findings included: Resident #29 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A nurse's note dated 9/20/21 revealed Resident #29 yelled at another resident for being in his room and told him if he did not get out, he was going to make him get out. An entry on Resident #29's care plan dated 9/20/21 revealed the resident had a behavior problem (yelling at another resident and being rude and cursing at staff). The goal was for the resident to not harm self or others through the review date (1/31/22). The interventions included to intervene as necessary to protect the rights and safety of others; approach/speak in a calm manner; divert attention and remove from the situation and take to an alternate location as needed. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 had severe cognitive impairment and verbal behavioral symptoms directed towards others on 1-3 days during the lookback period. The MDS noted the resident was independent with transfers and ambulation in his room, in the corridor and on the unit. A nurse's note completed by Nurse #6 dated 11/8/21 at 7:58 PM revealed Resident #29 displayed aggressive behavior against another resident this shift. Resident found standing over a female resident (Resident #53) with her in a headlock position and pulled her onto the floor. This writer separated the two residents and explained to him that it was not okay for him to do that. Resident's previous behaviors have shown no signs of this as a potential incident, seemingly unpredictable and unavoidable. Will continue to monitor resident for behaviors and will inform oncoming shift. (Resident #53's 10/13/21 MDS indicated her cognition was moderately impaired and she had verbal behaviors on 1 to 3 days during the review period.) On 2/1/22 at 9:52 AM an interview was conducted with Nurse #6 who stated on 11/8/21 she heard Resident #53 saying: Get off me. Nurse #6 further stated Resident #29 was behind Resident #53 and had his arm around her neck and pulled her to the floor. Nurse #6 stated another staff member helped her separate the two residents. Nurse #6 further stated there were no injuries for either resident. Nurse #6 stated she called the families of Resident #29 and Resident #53 and reported the incident to the previous Director of Nursing (DON). Nurse #6 stated she called the Medical Director who was the physician for Resident #53 and Physician #1 for Resident #29. An entry on the care plan dated 11/9/21 noted the resident was physically aggressive (putting a resident in a headlock) related to dementia. The interventions included monitor and document and report as needed any signs or symptoms of resident posing danger to self and others. Psychiatry consult as indicated and put stop sign on the outside of the resident's room to deter other residents from entering his room. A progress note completed by Nurse #3 dated 12/23/21 at 1:55 AM noted the nurse received report of a resident-to-resident situation occurring in the dining room with this resident (Resident #29) grabbing Resident #39 by the throat because he thought the resident was taking his food tray. Nurse #3 indicated this was communicated to her by the Med Aide on duty. Residents were noted to currently both be in bed with monitoring being done by staff. (Resident #39's 10/28/21 MDS indicated severely impaired cognition and no behavioral symptoms.) On 1/27/22 at 1:00 PM an interview was conducted with the Medication (Med) Aide #1 that was working on 12/23/21 when Resident #29 put his hands on the throat of Resident #39 in the dining room. Med Aide #1 stated she was setting up a supper tray for Resident #39 and Resident #29 thought the resident was getting his meal tray and he put both his hands around Resident #39's throat and she stopped him from going any further. Med Aide #1 stated that Resident #29 would get very upset if any of the residents started to go toward his room and would say that it was his room, and no one could go in there. On 2/2/22 at 9:08 AM a follow up interview was conducted with Med Aide #1. She stated on 12/23/21 when the incident occurred between Resident #29 and Resident #39 during the supper meal, she reported it to the nurse supervising her that evening. She was unable to recall who the nurse was or the time of the report. There were no new care plan interventions implemented after the 12/23/21 incident. A nurse's note completed by Nurse #1 dated 1/23/22 at 11:02 PM revealed Resident #53 was yelling help while in another resident's room. The Nursing Assistant (NA) found Resident #53 on the floor behind the door and Resident #29 was standing over Resident #53 attempting to hit her with a chair and kicked her. The assessment revealed Resident #53 had a knot on the left side of her head and a busted lip with a deep gash. 911 was called and Resident #53 was taken to the Emergency Department (ED) for evaluation. On 1/27/22 at 10:51 AM an interview was conducted with Nursing Assistant (NA) #1 who was working on the SCU on 1/23/22. NA #1 stated that Nurse #1 told her she would be back in a few minutes and left the unit and she was the only staff on the unit. NA #1 stated she was in a room where 2 residents were trying to get out of bed, and she was trying to keep them from falling. NA #1 further stated there were 2 male residents trying to get out of the door to the unit and then she heard someone saying, Help me. Help me. He's going to kill me. NA #1 stated she went to the room of Resident #29 and observed Resident #53 on the floor and there was blood on the floor. NA #1 stated she had no choice but to leave the room and went to the door to the unit and called down the hall to Nurse #2 that she needed help. NA #1 stated she and Nurse #2 went back to the room and she observed Resident #53 on the floor and Resident #29 was holding a wooden chair over her and she told him he better not do that and he dropped the chair and kicked Resident #53 in the head and stated to get this (racial slur) out of his room. NA #1 stated she and Nurse #2 got the resident up and sat her in a chair and cleaned her up. NA #1 further stated Resident #29 was very angry and she had never seen him like this. NA #1 stated they had one Med Aide or Nurse and one NA on the unit and this was not enough staff to monitor the residents on the SCU. On 1/27/22 at 5:01 PM an interview was conducted with Nurse #2 who responded to NA #1's call for help on the night of 1/23/22. Nurse #2 stated NA #1 came on the hall next to the SCU and was hollering for help and when she got to the room, Resident #53 was standing in the doorway arguing and saying to get her out of his room. Nurse #2 stated that Resident #3 (a resident that resided in the room across the hall from Resident #29) was in his wheelchair at the door to keep Resident #29 from getting back in his room and Resident #53 was on the floor crying and had blood on her clothing and on the floor. Nurse #2 further stated they tried to calm Resident #29 and directed him to the dining room to sit down but he sat down for a second and came back to the room and said to get her out of his room. Nurse #2 stated they were trying to get him back to the dining room and another resident was trying to get out of the door to the unit and she and NA #1 got Resident #53 up off the floor to sit in a chair. Nurse #2 stated NA #1 told her that Resident #29 hit Resident #53 with the chair and knocked her to the floor. Nurse #2 stated she called the Director of Nursing (DON) for extra hands, and they sent Resident #53 to the hospital. Nurse #2 further stated the DON told her to make sure to document what had happened and to call the family and the doctor. She stated by this time Nurse #1 had returned to the unit and stated she would call the doctor and the family. Nurse #2 was asked about the staffing on the SCU, and she stated there was one nurse or med aide and one NA and this was not enough staff for the unit. Nurse #2 further stated there had been issues with residents on the SCU getting out of the unit and onto the general population unit and that traffic control was the main issue. She explained that there were a few residents that got up all the time but were not steady and some residents would walk the hall at night and try to get out of the unit and some residents would wander into other resident's rooms which was what happened on the night of 1/23/22. On 1/27/22 at 11:23 AM an interview was conducted with the Interim Director of Nursing (DON) who stated she received a phone call on 1/23/22 around 9:00 PM from Nurse #2 who told her about a situation between Resident #29 and Resident #53. The DON stated she called the Administrator to let her know what was going on. The DON stated the Administrator told them to call the physician and the family. The DON further stated at that time she received a text that the police were on the way to the facility, and she called the Administrator back and was told to keep the residents separated and do 15-minute checks on the two residents and she (Administrator) would deal with it in the morning. The DON stated she did not work on Monday (1/24/22) so she did not know what action was taken the next morning. Review of the ED Record for Resident #53 dated 1/23/22 noted the resident was assaulted by another resident at the facility. Emergency Medical Technicians (EMT) reported resident was hit in the face with a wooden chair. The physical exam noted a lip laceration of the right upper lip and nasal swelling. Exam positive for neck pain at cervical back and laterally of the neck with signs of trauma and tenderness present. Pain with movement. Normal range or motion. A CAT (Computed Tomography) scan of the head was negative and showed a small Right Malar (cheek) contusion. A CAT scan of the cervical spine showed a small right malar (cheek) contusion. A CAT scan uses special x-ray equipment to help assess head injuries. Review of the police report dated 1/23/22 revealed a call was received regarding an assault on a female at the skilled nursing facility. The Nurse explained they would like the male resident (Resident #29) to be involuntarily committed. The report revealed that because of the resident's medical issues, the officer could not take the resident into custody. The female resident was picked up by EMS (Emergency Medical Services). The report indicated he advised the staff they could speak with the magistrate regarding the request for involuntary commitment orders. The case was closed. A Skin/Wound note completed by Nurse #5 dated 1/25/21 at 8:40 AM revealed Resident #53 had a bruise along the bridge of her nose that measured 4 centimeters (cm) by 3 cm along with an abrasion that was 2.3 cm by 0.1 cm. The resident was noted to be sniffling during the examination and the resident was asked if she had a cold and the resident stated: No, that man hit me across my nose. The right upper lip was swollen with abrasion 3.7 cm by 2.5 cm. An interview was conducted on 1/27/22 at 4:10 PM with the Medical Director (MD) who cared for Resident #53 in the facility. The MD stated he had been notified (on 1/25/22) of the incident between Resident #29 and Resident #53 and had not seen Resident #53 since the incident on 1/23/22. On 1/27/22 at 5:30 PM an interview was conducted with Physician #1 who cared for Resident #29 in the facility. The Physician stated Resident #29 had another resident (Resident #53) in a headlock several months ago and they were separated. Physician #1 stated he had not heard of any other issues with Resident #29 since that time and was not notified of an incident with this resident on 1/23/22. On 1/27/22 at 6:04 AM an interview was conducted with Nurse #3 who worked on the night shift in the Secure Care Unit (SCU). Nurse #3 stated if anyone went toward the room of Resident #29, he would get very upset. Nurse #3 further stated a Velcro STOP sign was put across his door and this had been somewhat effective but when Resident #29 came out of his room he would often forget to reattach the STOP sign in front of the door. On 1/28/22 at 9:20 AM an interview was conducted with Med Aide #2 who stated Resident #29 would get very upset if anyone went in his room and had been aggressive a number of times with other residents and she had expressed a concern to the previous Director of Nursing that Resident #29 was going to hurt someone. On 1/28/22 at 9:30 AM Nurse #17 stated in an interview that Resident #29's behaviors have escalated verbally and physically over the last couple of months. Nurse #17 further stated they have morning hall meetings, and the Administrator attended these meetings and the staff have expressed concerns during these meetings that Resident #29 was going to hurt somebody, and that he did not need to be on the SCU. Nurse #17 stated the staffing on the SCU was not adequate and the staff have expressed this concern to the Administrator but they were told that one Nurse or Med Aide and one NA was adequate staffing for the unit. On 1/27/22 at 11:58 AM an interview was conducted with the Administrator who stated Resident #53 had a fall on 1/22/22 and busted her lip and had an abrasion. The Administrator further stated the next day (1/23/22) Resident #29 and Resident #53 had an interaction and she was in the midst of that investigation now. The Administrator stated that NA #1 was in another room and heard someone needed help and found Resident #29 holding a chair and believed Resident #53 was hit with the chair. The Administrator further stated it seemed to her if he hit her with a chair, she would have had other injuries and the NA assumed the resident was hit with the chair. The Administrator stated Resident #29 was moved off the unit the next morning. The Administrator further stated she interviewed both residents after the 11/8/21 incident and one resident resided on one end of the hall and the other resident resided on the other end of the hall and when she interviewed them, neither of the residents had any recollection of the event on 11/8/21. The Administrator stated head to toe assessments were done, statements were obtained, and the Physician and the families had been notified and the Nurse Practitioner reviewed both residents. The Administrator stated she was not aware that Resident #29 had kicked Resident #53 in the head during the incident on 1/23/22. The Administrator stated the police were notified and the family did not choose to press charges. The Administrator stated the STOP sign on the door was an intervention as a result of the 11/8/21 incident. The Administrator stated there had been concerns from the staff about the staffing on the SCU and that she believed two staff members for 13 residents on the SCU was adequate. The Administrator stated when one of the staff took a meal break there was still one person on the unit and if there was an issue, they should call for additional help. The Administrator stated she thought the incident on 11/8/21 was an isolated incident and she was not aware of the incident on 12/23/21. The Administrator was notified of the Immediate Jeopardy at F600 on 1/28/22 at 1:32 PM. The facility provided a credible allegation of Immediate Jeopardy removal on 1/30/22. The allegation of Immediate Jeopardy removal indicated: Credible Allegation of Immediate Jeopardy Removal: Resident #29 displayed aggressive behaviors against Resident #53 on 11/8/2021. Resident #29 was found standing over Resident #53 with her in a headlock position and pulled her onto the floor. Nurse #6 separated the two residents and explained to Resident #29 that it was not okay for him to do that. Resident #53 did not have any injuries related to this incident. Resident #29's care plan was updated on 11/9/2021 and noted the resident was physically aggressive (putting a resident in a headlock) related to dementia. The physician was notified on 11/8/2021 of incident. Resident #29 and Resident #53 were evaluated by the Nurse Practitioner on 11/9/2021. Medication changes were made for Resident #29 due to his behavior change; therefore, a psychiatric evaluation was not obtained. The initial report was submitted to the State Survey Agency on 11/8/2021 and final investigation finding submitted on 11/12/2021. The police were not notified of this incident. The interventions included to monitor Resident #29, document and report as needed any signs or symptoms of resident posing danger to self and others. Additionally, facility to obtain as indicated and put stop sign on the outside of the resident's room to deter other residents from entering his room. Resident #29 displayed aggressive behavior on 12/23/2021 against Resident #39. Both residents were in the dining room when Resident #29 grabbed Resident #39 by the throat because he thought Resident #39 was taking his food tray. The residents were immediately separated by staff and increased monitoring (increase in frequency of being aware of his whereabouts, needs and behavior) was initiated and remained in place for the duration of the shift without further behaviors exhibited by the resident. A 24-hour reportable was not submitted to the State Survey Agency by the facility nor were the police notified at the time of the incident. For compliance purposes, a 24-hour report was sent to the State Survey Agency by the Regional Director of Operations on 1/29/2022 @ 3pm. Police were contacted on 1/29/2022 @ 10:30pm. Physician was notified of the incident on 1/28/2022 @ 1pm by the Administrator. The final investigation (5-day report) will be concluded and sent to the State Survey Agency. Resident #29 displayed aggressive behavior on 1/23/2022 against Resident #53. NA #1 stated that Nurse #1 told her she would be back in a few minutes and left the unit and she was the only staff on the floor. The NA stated she was in a room where 2 residents were trying to get out of bed, and she was trying to keep them from falling. The NA further stated there were 2 male residents trying to get out of the door to the unit and then she heard someone saying, Help me. Help me. He's going to kill me. The NA stated she went to the room of Resident #29 and observed Resident #53 on the floor and there was blood on the floor. The NA stated she had no choice but to leave the room and went to the door to the unit and called down the hall to Nurse #2 that she needed help. The NA stated she and Nurse #2 went back to the room and she observed Resident #53 on the floor and Resident #29 was holding a wooden chair over her and she told him he better not do that and he dropped the chair and kicked Resident #53 in the head and stated to get this (racial slur) out of his room. The police were immediately notified of the incident on 1/23/2022. The physician was made aware by the Social Worker on 1/25/2022. Resident #53 was sent to the emergency room for evaluation. The emergency room (ER) Record for Resident #53 dated 1/23/22 noted the resident was assaulted by another resident at the facility. The physical exam noted a lip laceration of the right upper lip and nasal swelling. Exam positive for neck pain at cervical back and laterally of the neck with signs of trauma and tenderness present. Pain with movement. Normal range or motion. A CAT scan of the head was negative and showed a small Right Malar (cheek) contusion. A CAT scan of the cervical spine showed a small right malar (cheek) contusion. Of note, Resident #53 had the above noted injuries when she arrived to theER on [DATE]. These injuries were sustained from an unwitnessed fall on 1/22/22. According to the ER report dated 1/22/22, Resident #53 arrived to the ER after sustaining an unwitnessed fall. Resident #53 had her upper lip sutured by the ER Physician and she tolerated the procedure well. Administrator submitted 24-hour reportable to the State Survey Agency on 1/24/22 and initiated investigation; although, incident occurred 1/23/22. The police were immediately notified of the incident on 1/23/2022. Because all residents are at risk when the facility fails to protect residents from being physically abused by other residents, the following plan has been formulated to address this issue: On 1/23/2022 at approximately 9:30pm (21:30) Resident #29 was placed on 1:1 staff supervision until seen by Psychiatry and deemed safe to remove from 1:1 supervision. Further, a care conference was held on 1/28/2022 with the facility Interdisciplinary Team (IDT) to include the Administrator, Director of Nursing, Social Worker and Resident #29's Responsible Party. The Psychiatrist and Medical Director were notified of the care conference by the Social Worker but unable to attend. The purpose of the care conference was to discuss on-going medication management and alternate interventions to manage residents' aggressive behavior towards others. On 1/28/2022, the plan of care was reviewed and revised by the IDT for Resident #29 to protect all residents at risk. This plan of care includes the following: 1:1 supervision until seen by psychiatry and deemed safe to remove from 1:1 supervision; intervene to protect the safety of others; remove from situation and take to alternate location as needed; monitor behavior episodes and attempt to determine underlying cause with consideration of location, triggers, time of day, persons involved and situations; document behaviors, potential causes and what de-escalates the behavior, stop sign on door of Resident #29 room to deter other residents from wandering into Resident #29 room. On 1/28/2022, an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held by facility IDT (department heads), Regional Clinical Consultant and Regional Director of Operations on 1/28/2022 to review the behavioral management policy to ensure it included strategies to manage residents' behaviors toward others. Additionally, the committee discussed the incident(s) involving Resident #29 and developed an immediate action plan based upon root cause analysis to address and remove immediate and future risk potential. Based upon root cause analysis of each incident, Resident #29's primary trigger is individuals invading his personal space and his inability to make sound response decisions secondary to his cognition status and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/28/2022, the administrative staff which includes the Administrator, Director of Nursing were educated by the Regional Director of Operations and the Regional Director of Clinical Services on responding to emergency situations such as physical abuse. This education will include strategies for prevention of physical abuse and identifying the likelihood based upon resident assessments and any exhibited behaviors. Beginning 1/26/2022, current facility and agency staff on each shift, including Nursing, Activities, Social Work, Dietary, housekeeping and maintenance, will be re-educated by the Regional Director of Nursing and/or Administrator on F600 and the Prevention of Abuse or/and Neglect. The education will be communicated verbally and telephonically by the Director of Nursing. Written education will be available for review prior to the staff member working their assigned shift. Assistant Director of Nursing will utilize a master employee list to track completion of education. No staff will be allowed to work until education is completed. Education will also be included during orientation for newly hired staff. Beginning 1/28/2022, all staff will be educated by the Director of Nursing on the facility behavioral management policy to include managing resident behaviors and prevention of resident-to-resident altercations. This will include identifying contributing factors such as situational, physical environment, and organizational factors. An emphasis will be placed upon ensuring supervision of residents to aid in preventing physical assault between residents. If the resident is displaying aggressive behaviors towards others, the resident will be monitored closely which will include 1 to 1 observation if the resident continues to have behaviors. If the resident continues to have aggressive behaviors towards others despite facility interventions, the facility will transfer the resident (including Resident #29) to the hospital for an immediate psychological evaluation to protect risk to others. The education will be communicated verbally and telephonically by the Director of Nursing. Written education will be available for review prior to the staff member working their assigned shift. will utilize a master employee list to track completion of education. No staff will be allowed to work until education is completed. Education will also be included during orientation for newly hired staff. On 1/28/2022, the Administrator and Social Worker completed an audit for F600 via abuse questionnaire with cognitively intact residents and the Licensed Nurses completed body audits on cognitively impaired residents to ensure other residents are free from abuse, including resident-to-resident. No additional concerns identified. On 1/28/2022, the Administrator and Director of Nursing reviewed with the IDT, Licensed Nurses and Nurse Aides all residents on the secure unit with behaviors that could potentially affect the safety of other residents. Those identified as not currently having psychiatry services were referred to psychiatrist for consult and medication review. Effective 1/28/2022, the facility Administrator, Director of Nursing, Social Worker and Charge Nurse will perform facility tours (including off shifts and weekends) daily of the memory unit to observe for any residents with behaviors which would need additional interventions. Additionally, the Administrator and Director of Nursing will monitor staffing levels every shift (including coverage during breaks and lunches) on the memory care unit to ensure adequate staff to provide supervision to residents to prevent physical abuse. Effective 1/28/2022, the facility Administrator will conduct questionnaires weekly with Licensed Staff and Nurse Aides related to how to respond to residents with physical behaviors and interventions. Effective 1/28/2022, the Administrator and Director of Nursing will be ultimately responsible to ensure implementation of this immediate jeopardy removal for this alleged noncompliance. Alleged date of IJ Removal: 1/30/22 On 1/31/22 the Credible Allegation of Immediate Jeopardy removal was validated by onsite verification. Multiple interviews were conducted with regular staff as well as agency staff who stated they had received education on abuse and neglect and examples of each were included in the training. The staff stated the education included who to notify if abuse was suspected and the requirements of notification to the DON, Administrator, state agency and law enforcement. The staff stated the education also included prevention of resident-to-resident abuse. Verification of this education for staff was completed on 1/30/22 and the facility's Immediate Jeopardy removal date of 1/30/22 was validated.

Based on record review, staff interview and observation, the facility failed to provide supervision to prevent residents with severe cognitive impairment who displayed exit seeking behaviors from exiting the facility unsupervised for 2 of 2 residents (Resident #21, Resident #29) reviewed for wandering behavior. The facility also failed to implement 1 to 1 supervision for Resident #29. Immediate jeopardy began for Resident #21 on 1/11/22 when he exited the facility unsupervised and was observed by police near a local gas station approximately 0.75 miles from the facility at night. Immediate Jeopardy began for Resident #29 on 1/29/22 when he exited the facility unsupervised while he was supposed to be on 1 to 1 staff supervision. Immediate Jeopardy was removed on 2/2/22 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity of E (no actual harm with a potential for minimum harm that is not Immediate Jeopardy) to ensure the monitoring of the systems put into place and to complete facility employee and agency in-services, orientation, and training. The findings included: 1. Resident #21 was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)] with behavioral disturbance and difficulty in walking. The Admission Minimum Data Set (MDS) dated [DATE] indicated Resident #21's cognition was severely impaired. Resident #21 exhibited wandering behavior 1 to 3 days of the 7 days look back period. Resident #21 required supervision with one person assist for ambulation. Resident #21 received antipsychotic medication 6 of the 7 days during the MDS look back period. Review of a behavior note dated 11/5/21 indicated that staff tried to redirect Resident #21 several times from going in other resident's rooms. Resident #21 became aggressive, grabbed staff arm, and scratched staff leaving open scratches to their arms. A care plan dated 11/5/21 revealed a focus of elopement risk/wanderer ([CONDITION(S)]) related to disorientation to place and attempts to leave facility unattended. The goal was for Resident #21 not to leave facility unattended through the review date. The interventions included: -Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. -Ensure that the area that resident wanders in is safe. -Report to MD changes in resident behavior. Review of the medical record revealed that Resident #21 was transferred to the facility from a sister facility due to his exit seeking behavior and need for a special care unit. Review of a nursing note dated 1/6/2022 revealed Resident #21 was transferred from the SCU (Special Care Unit) to the COVID unit on 1/6/22. Resident #21's care plan revealed no new interventions were implemented related to wandering/exit seeking when he was moved from the secured unit to the COVID unit. On 1/27/22 at 8:30 AM an observation was conducted of the COVID unit. The COVID unit had one closed door at the front of the unit that led to the general population units. This door at the front of the unit did not alarm when opened. The COVID unit had one exit door at the end of the unit that led to the exterior of the building. This door alarmed when pushed on and required a numerical code to be entered for the alarm to stop. An interview was conducted with NA #4 on 1/27/22 at 11:30 AM. NA #4 revealed that she had worked the 7:00 AM to 3:00 PM on 1/11/22. NA #4 stated she was aware of Resident #21's exit seeking behaviors when he was moved to the COVID unit. NA #4 stated Resident #21 regularly came out of his room and walked the hallway and was redirected back to his room. NA #4 stated that she would try to figure out what Resident #21 was looking for and would attempt to assist him. NA #4 stated Resident #21 could be easily redirected. She stated that Resident #21 had not displayed any aggressive behaviors towards her. NA #4 indicated there was malfunction on the exit door at the back of the unit on 1/11/22. She explained the door opened as soon as pushed and the alarm went off instead of waiting the normal 15 seconds before the door lock released and the door opened. NA #4 stated she was made aware of the issue with the doors locking by Nurse #8. An interview was conducted with Nurse #8 on 1/27/22 at 11:38 AM. Nurse #8 stated that she had worked with Resident #21 on 1/11/22 from 7:00 AM to 7:00 PM. Nurse #8 stated Resident #21 was up walking around the unit and stated he wanted to leave. Nurse #8 stated that she walked Resident #21 back to his room. Nurse #8 stated Resident #21 had opened the door at the front of the COVID unit (led to another unit in the facility and was not alarmed) and when she called his name he turned around and headed back inside the unit. Nurse #8 stated that she reported to Nurse #7 about Resident #21 trying to go out the COVID unit front door. Nurse #8 stated she was made aware of Resident #21's exit seeking behaviors when he was moved to the COVID unit. Nurse #8 stated the staff would redirect Resident #21 when he started walking in the hallway. Nurse #8 stated that she last saw Resident #21 at approximately 7:20 PM and he was on the bed in his room. Nurse #8 stated she was made aware that the lock on the exit door at the end of the COVID unit (that led to the exterior of the facility) was not working correctly during report with Nurse #7 on 1/11/22. Nurse #8 explained that the door would open as soon as pushed on and the alarm went off instead of waiting the normal 15 seconds before the door released and would open. An interview was conducted with NA #3 on 1/28/22 at 9:23 AM. NA #3 stated she was made aware that Resident #21 had exit seeking behaviors when he was moved to the COVID unit. She indicated staff would redirect Resident #21 to his room. NA #3 stated Resident #21 would wander up and down the hallway and try to push open the exit doors. She spoke about the COVID unit reporting that staff regularly used the door at the end of the unit to enter and exit the facility. She indicated the door alarmed when it was opened. She explained that the alarm system panel was in another area of the building and staff on the COVID unit could not view the panel to see which location alarm was sounding, but they could punch in a code at the COVID unit exit door to turn the alarm off. NA #3 stated that she was made aware by Nurse #8 that there was a malfunction with the exit doors on 1/11/22 causing the door to open and alarm as soon as it pushed on instead of waiting the 15 seconds before the door released and would open. NA #3 stated that she recalled seeing Resident #21 in his room after dinner on 1/11/22 because she picked up his tray. She stated Resident #21 was laying on his bed with a plaid shirt, pants, and socks on. The NA stated he had a pair of flip flops on the floor at the bedside. NA #3 stated Resident #21 had attempted to exit the COVID unit through the front door on 1/11/22 just before 7:00 PM. The NA stated that Nurse #8 assisted Resident #21 back to his room. NA #3 stated Nurse #7 came in at approximately 7:30 PM. She stated she heard an alarm when Nurse #7 came in and the nurse punched in the code to turn off the alarm. NA#3 stated at that time she was in the clean room (a room that is free of contamination) which was located 2 doors from the COVID unit exit door and did not see anyone pass the door during that time. NA#3 stated at approximately 7:40 PM Nurse #8 exited the building at the end of the COVID unit and the alarm did not go off. She revealed she did not report to anyone that the alarm didn't sound at when Nurse #8 left. NA #3 stated Nurse #7 left the facility through the COVID unit back door and stated she was going to get something to eat at approximately 7:45 PM and the alarm went off when she exited. NA #3 stated she after Nurse #7 left (approximately 7:45 PM) she was the only staff on the COVID unit until NA #5 came in. NA #3 reported that she heard the alarm go off for the COVID unit back door at approximately 8:00 PM when NA #5 came in. NA #3 stated that she and NA #5 were on the hall because Nurse #7 had not returned from getting her food. NA #3 stated she heard the COVID unit back door alarm at approximately 8:20 PM when Nurse #7 came back from getting her lunch. NA #3 stated Nurse #7 went back out the COVID unit back door to get her computer and a bag. She stated Nurse #7 brought her belongings in and went inside the clean room to place them down. NA #3 stated Nurse #7 returned to the door and punched in the code to turn off the alarm. NA #3 stated she went to lunch at approximately 8:30 PM. NA #3 stated she did not know that Resident #21 was not in the building. Review of the 911 Communications Report dated 1/11/22 at 8:04 PM revealed that Resident #21 was seen walking in the middle of the road wearing grey sweatpants and blue shirt. The report further revealed Resident #21 had exited the facility from the COVID unit at the back of facility. A review of the weather conditions per Local Condition's website (www.localconditions.com) for Ahoskie's weather history indicated the temperature on 1/11/22 at 7:35 PM was 24 degrees Fahrenheit, 69 % humidity and there was no precipitation. An interview was conducted with the receptionist on 1/28/22 at 9:32 AM. The receptionist revealed that she received a phone call from a local police officer on 1/11/22 at approximately 8:00 PM. She stated that the police officer asked her if the facility had a resident by Resident #21's name. The receptionist stated that she reviewed the resident census and stated that there was a resident that resided there with that name. The receptionist reported that the officer told her Resident #21 was out at a local service station. She stated the officer informed her that the precinct received a call about a suspicious person. The receptionist stated that she placed the officer on hold and called the COVID unit and spoke to Nurse #7. The receptionist stated that she asked Nurse #7 if Resident #21 was in his room. The nurse stated that she would look, and Resident #21 was not in his room. The receptionist stated that officer did not bring Resident #21 to the front door, so she did not see him when he returned. An interview was attempted with the local police officer who contacted the facility, but he was unable to be reached. An interview was conducted with Nurse #7 on 1/28/22 at 7:15 AM. Nurse #7 stated she received a call on 1/11/22 at approximately 8:30 PM to pick up the COVID unit cell phone. Nurse #7 stated that she spoke with someone, unable to recall who she spoke with, who told her they had Resident #21. Nurse #7 stated she did not know what time Resident #21 had gone out the door. Nurse #7 stated that when you hear an alarm sounding, there is no way to see which door the alarm is sounding for. Nurse #7 stated that she did not see anyone leave out the building and she parked in the back of the facility near the COVID exit door. Nurse #7 stated Resident #21 was wearing blue shirt and grey sweatpants when the police brought him back to the facility. She was unsure of whether Resident #21 had on a long sleeved or short sleeved shirt. Nurse #7 stated she was not sure if Resident #21 was wearing shoes. Nurse #7 stated that she was told that Resident #21 was found down by the gas station. Nurse #7 stated that the DON called her and informed her of what to do for Resident #21. A head-to-toe assessment was conducted, and Resident #21 had a scrape to his knee but no other injuries. Nurse #7 stated that he was placed on 15-minute watch for his safety. Review of a nursing note dated 1/12/22 at 7:11 AM revealed Resident #21 returned to the facility at 8:30 PM on 01/11/22. A full head to toe assessment was performed by Nurse #8 and Resident #21 was placed on 15-minute checks to ensure safety. Resident #21's vital signs were within normal limits. Resident #21's temperature was 97.4 and he had a small scrape to his left knee which was cleaned and required no dressing. Resident #21 remained on isolation for COVID. An interview was conducted with the DON on 1/27/22 at 9:40 AM. The DON stated that she was made aware of an issue with the locking of the exit doors on Sunday night 1/9/22. Staff reported that the alarm would sound when the door was pushed on and immediately opened instead of waiting the normal 15 seconds before you could open the exit door. The DON stated that the staff that work in the COVID unit were to use this exit to go in and out the unit. She indicated staff were trained to look to see who was at or around the door when the alarm sounded The DON stated that on 1/11/22 Receptionist #1 called her and stated the police had found Resident #21 and bought him back to the facility. The DON stated that she was not told where Resident #21 was when the police found him. The DON stated she was never notified that the COVID unit exit door opened without alarming at approximately 7:40 PM that evening (1/11/22) and indicated the staff should have reported any issues with the doors to maintenance and herself. The DON stated Resident #21was admitted to the special care unit (secured unit) because of his exit seeking behaviors. She revealed when he was transferred to the COVID unit (1/6/22) there no increase to the frequency of monitoring for Resident #21 was transferred. An interview was conducted on 1/26/22 at 4:11 PM with Maintenance Director. The Maintenance Director stated that the recent cold weather had caused the alarm system circuit board to burn up. He stated beginning on 1/9/22 the exit doors would continue to alarm but would open immediately instead of locking and waiting the 15 seconds for release per the egress code. The Maintenance Director stated that all staff including the DON and Administrator were made aware of the issue with the locking mechanism on the door. The staff were completing Firewatch every 30 minutes until the locking mechanism was fixed. The Maintenance Director stated the staff should have reported any issues with the doors to maintenance and he was never notified that the door opened without alarming at approximately 7:40 PM on 1/11/22. The Maintenance Director stated that he was called at 1/11/22 at 9:18 PM to come in to look at the doors and all alarms were working. The Director reported that Resident #21 was back in the building at that time. An interview was conducted with the Administrator on 1/27/22 at 1:11 PM. The Administrator stated that Resident #21 resided on the secured unit when he was admitted in October. She stated that Resident #21 was transferred from a sister facility due to his wandering behavior and the need for a locked unit. The Administrator stated that she was aware the exit door latch time had decreased from 15 seconds to 2 seconds on 1/9/22. The Administrator stated staff were to check the doors every 30 minutes and place the findings on the Firewatch log (checks every 30 minute). The Administrator stated that she had not been made aware that Resident #21 had exhibited exit seeking behaviors during the day shift on 1/11/22. The Administrator stated staff should have reported Resident #21's exit seeking behavior to the DON and placed Resident #21 on more frequent observations. The Administrator stated she was made aware of Resident #21's elopement at approximately 8:30 PM when the staff notified her that the police were bringing him back to the facility. She indicated that a head-to-toe assessment was completed on Resident #21 and there was no injury. The Administrator stated that Maintenance Director came out to the facility to verify that the alarm was working. She stated that she remained on the telephone while the Maintenance Director walked and checked each door and there were no identified issues with the alarm 2. Resident #29 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance. The Quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #29's cognition was severely impaired. Resident #29 did not exhibit wandering behavior during the look back period. Resident #29 was independent with ambulation and used a walker as mobility device. A care plan updated 6/8/21 and currently in place revealed a focus of elopement risk related to disoriented to place, dementia with behavioral disturbances, and wandering. The goal was for Resident #29 will not leave facility unattended and his safety will be maintained through the review date. The interventions included: distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or book. Documentation of behavior observations, including wandering/pacing/exit seeking for Resident #29 were ordered by the physician for every shift on 10/21/21. Review of a behavior note dated 12/14/21 indicated that staff tried to redirect Resident #29 away from an exit door he opened setting off the alarm. Resident #29 became aggressive, swung at the staff member with his hand and then his walker. Resident #29 was moved from the secured memory care unit to a general hall on 1/24/22 after a resident-to-resident altercation per the medical record. There were no new interventions related to wandering implemented when he was moved to the unsecured unit. On 1/28/22 Resident #29 was placed on 1:1 monitoring after he became combative with staff. Review of a nursing note dated 1/29/22 at 8:26 AM by Nurse #9 revealed Resident #29 was noted to have walked out of the facility's front door after staff and redirected back inside. Physician #1, interim DON, responsible party (RP) and the Administrator were notified. A review of the weather conditions per Local Condition's website (www.localconditions.com) for Ahoskie's weather history indicated the temperature on 1/29/22 at 7:35 AM was 31 degrees Fahrenheit, 83% humidity and there was no precipitation. An interview was conducted with Nurse #1 on 1/31/22 at 2:50 PM, and she stated she was in the front lobby speaking to Receptionist #1 on the morning of 1/29/22 (time unknown). Receptionist #1 stated she was going to try to wait for the oncoming receptionist to relieve her from supervising Resident #29. Nurse #1 stated she did not agree that she would watch Resident #29 because the NA she was working with was pulled to another unit due to insufficient staffing. When Nurse #1 left the lobby to go back to her unit, Receptionist #1 and Resident #29 were in the lobby (time unknown). Receptionist #1 was interviewed on 1/31/22 at 2:46 PM, and she revealed she was asked to stay over Friday night (1/28/22) by the Administrator to monitor Resident #29 1 on 1 but was not instructed when to stay until or who was to relieve her. She stated Nurse #1 agreed to watch Resident #29 when she left the building at 6:30 AM. She stated that was the last time she saw him sitting in the front lobby. Nurse #10 was interviewed on 2/1/22 at 11:30 AM, and he revealed he worked the overnight shift on 1/28/22. He stated Resident #29 had been fighting with staff on the evening of 1/28/22 and was now on 1:1 monitoring. Nurse #10 further stated he last saw Resident #29 in the front lobby when he left the building at 7:30 AM on 1/29/22 and did not remember seeing Receptionist #1 with him. When Nurse #10 needed to leave the building without a receptionist present, he used the code to unlock the front door and pushed the door himself without using the automated release button. The front door was secured with a code. He stated he was certain there was no one behind him when he walked out because he stood out in front of the building when he left and took a picture of his schedule to send to his agency. Nurse #10 indicated his car was parked in front of the building. An interview was conducted with Nurse #9 on 1/31/22 at 11:21 AM, and she revealed after she received report for the morning shift of 1/29/22 and checked on her residents, which included #29, she walked toward the lobby to locate Resident #29. At that time, NA #5 was escorting him back into the building, and she did not know how long he was out of the building. Nurse #9 stated she performed a skin check on him but did not document the assessment. She contacted the Administrator immediately after Resident #29 returned (time unknown) and was told Receptionist #1 was assigned to monitor him 1:1. She stated Receptionist #1 had already left the facility, and she was unsure if the oncoming receptionist had arrived. During an interview with nurse aide (NA) #5 on 1/31/22 at 11:41 AM, she revealed she was late to work and arrived at the facility at 7:30 AM on 1/29/22. She stated she observed Resident #29 walking alone down the sidewalk in front of the building where cars park on the street just in front of the parking lot. He was walking towards the main road, and she met him while she was in her vehicle after recognizing him. NA #5 stated he was not wearing a jacket, but he was wearing long sleeves, pants, and shoes. She indicated it was cold outside and he appeared cold. He also seemed agitated when she instructed him to come inside, he slammed his walker down on the ground and that is when she called the facility's main number. No one answered the phone, so she contacted the Director of Nursing (DON) directly who came outside to help her. NA #5 was only with him a few minutes from the time she arrived to when Resident #29 was escorted back inside. NA #5 stated she was not sure how Resident #29 got out of the building, and the front door was always locked. During an interview with the DON on 1/31/at 12:58 PM, she revealed that she was made aware of Resident #29 needing 1:1 supervision indefinitely by the Administrator on 1/28/22 at 6:00 PM. She stated she arrived to work at 7:00 AM on 1/29/22 but forgot to clock in. When she used the punch clock in the lobby at 7:27 AM, she saw Resident #29 in the lobby. The interview continued on 1/31/22 at 6:17 PM, and the DON stated she did not see a 1:1 monitoring partner with him. Receptionist #1 was assigned to monitor Resident #29, but she left at 6:30 AM before the oncoming receptionist arrived. She further stated Receptionist #1 was supposed to stay with Resident #29 until someone relieved her, but she did not know who that person should have been. She then went back to her hall assignment to give Nurse #10 report and was contacted by NA #5 at 7:36 AM via telephone that Resident #29 was outside by himself. She then went to the front lobby and saw NA #5 and Resident #29 entering the front door. Nurse #9 was assigned to provide care for Resident #29, who was also present in the lobby at this time. An interview was conducted with the Administrator on 1/31/22 at 2:01 PM, and she revealed Resident #29 was placed on 1:1 monitoring Friday evening (1/28/22) at 6:00 PM. She stated Receptionist #1 accepted the supervision assignment and was willing to stay through the night until Resident #29 was handed off to the oncoming receptionist. The Administrator stated she was supposed to stay until she handed him off to the oncoming receptionist. The Administrator stated she was notified by Nurse #9 at 7:49 AM about Resident #29's elopement. She was told there were no nurse aides on duty on East Hall, the hall Resident #29 resided on, for the first shift which began at 7:00 AM. She stated she then called the DON at 7:56 AM. The Administrator stated Nurse #10 left the building after his shift ended and may have left the door open when Resident #29 got out. The Corporate Consultant was notified of immediate jeopardy on 1/31/22 at 7:08 PM. The facility provided the following Credible Allegation of immediate jeopardy removal. Beginning 2/1/22, the Director of Nursing and Regional Director of Nursing completed elopement education with all current facility and agency staff, including dietary, maintenance and housekeeping. Education included the Elopement Policy and providing effective supervision for cognitively impaired residents with wandering and exit seeking behaviors to prevent unsupervised exits from the facility. Education also included examples of effective techniques for resident redirection, effective monitoring of residents, supervision to ensure resident safety, response system in the event of a resident elopement, response system of a facility fire watch (15-minute door checks) and timely response to door alarms. Facility and agency staff will not be permitted to work until receiving education. On 2/1/22, the Director of Nursing and MDS Coordinator completed an audit of residents at risk of exiting the facility unsupervised who are cognitively impaired and exhibit exit seeking and wandering behaviors to ensure appropriate supervision and safety. For residents identified at risk for elopement, an updated Wandering Risk Assessment was completed by the licensed nurse and care plans updated to ensure appropriate interventions implemented based on resident risk. The Director of Nursing updated the Elopement Risk Binder to contain resident profiles, photographs, current Wandering Risk Assessment and care plan and placed binders at the nurse station and front lobby. Effective 2/1/22, all residents will be assessed for elopement risk by a Licensed Nurse upon admission, quarterly and with changes in resident condition. Residents identified at risk with exit seeking and wandering behaviors will have a care plan in place to ensure safety and profile, photo, Wandering Risk Assessment, and care plan will be placed in the Elopement Binder at the nurse station and front lobby. Residents with wanderguards will be monitored every shift for placement and every day for function by the licensed nurse. Effective 2/1/22, residents with exit seeking and wandering behaviors who have an increased need for monitoring including a change in room location from the secured unit to the unsecured unit will be reassessed by the licensed nurse and care plan revised as appropriate to ensure increased interventions are implemented to ensure resident safety. This may include, but is not limited to, the addition of a wanderguard, 15-minute checks or 1:1 observation as determined appropriate to ensure resident safety and supervision. Effective 2/1/22, the facility will ensure proper functioning and monitoring of the wanderguard system and facility doors and alarm system. The Maintenance Director, Maintenance Assistant or Administrator will perform and document door and alarm safety checks at least weekly. Effective 2/1/22, the facility will conduct elopement drills on all shifts monthly to ensure continued staff understanding of the facility process in the event of an elopement. Effective 2/1/22, newly hired Maintenance Directors, Assistance Maintenance Director and Administrators will receive education by the Administrator, Director of Nursing or Regional Director of Nursing on the wanderguard system, door security system and process for system malfunctions. Education to include wanderguard system and doors and alarm safety checks weekly and 24/7 continuous door monitoring shall be implemented and documented in the event of malfunction until system is fixed. Effective 2/1/22, the facility implemented a revised Safety Watch System to ensure continuous staff supervision for residents requiring 1:1 observation. The Administrator will ensure the 1:1 staff coverage is posted on the Safety Watch Schedule and assigned staff will utilize the Safety Watch Log to document coverage by signing and dating in and out times. During staff breaks and during change of shift, an alternate staff member will provide supervision and document on-coming and off-going coverage by signature and date on the Safety Check Log. In the event of call-outs or late arrivals, the current staff will notify the Administrator or Director of Nursing immediately and will remain with resident to ensure continuous supervision until alternate staff coverage is obtained. Staff who are assigned 1:1 resident observations will utilize interventions per resident plan of care to distract, redirect and intervene as appropriate. Any concerns with following the plan of care will be reported to the Physician and Administrator and/or Director of Nursing immediately and additional interventions implemented as necessary. Beginning 2/1/22, the Regional Director of Operations and Regional Director of Clinical Services will provide education to facility and agency staff on the Safety Watch System and the expectation of providing continuous 1:1 supervision as assigned and the process to follow to ensure resident safety without any disruptions in continuous coverage. Education will include the process of utilizing the Safety Watch Log to document coverage by signing and dating in and out times. During staff breaks and during change of shift, an alternate staff member will provide supervision and document on-coming and off-going coverage by signature and date on the Safety Check Log. In the event of call-outs or late arrivals, the current staff will notify the Administrator or Director of Nursing immediately and will remain with resident to ensure continuous supervision until alternate staff coverage is obtained. Staff who are assigned 1:1 resident observations will receive education on utilizing interventions per resident plan of care to distract, redirect and intervene as appropriate and reporting any concerns with following the plan of care and Safety Watch System to the Administrator and/or Director of Nursing immediately. Staff not educated by 2/1/22 will receive education prior to working on the floor. Effective 2/1/22, staff assigned to provide 1:1 resident supervision will not leave resident unattended at any time. During staff breaks and during change of shift, an alternate staff member will provide supervision and document on-coming and off-going coverage by signature and date on the Safety Check Log. In the event of call-outs or late arrivals, the current staff will notify the Administrator or Director of Nursing immediately and will remain with resident to ensure continuous supervision until alternate staff coverage is obtained. Effective 2/1/22, the Maintenance Director will audit the wanderguard system and door and alarm system weekly for proper function. This will be documented in the TELS system (electronic system used for maintenance tracking) Effective 2/1/2022, the facility Administrator or Director of Nursing will conduct weekly questionnaires with five (5) facility or agency staff to ensure proper understanding of providing effective supervision for cognitively impaired residents with wandering and exit seeking behaviors to prevent unsupervised exits from the facility. Effective 2/1/22, the Administrator, Director of Nursing or Manager on Duty will and will review the Safety Watch Log to ensure continuous supervision is being provided and documented for residents assigned 1:1 observation. Monitoring will be conducted daily. Effective 2/1/2022, the Administrator or Regional Director of Operations and Director of Nursing will be ultimately responsible to ensure implementation of this immediate jeopardy removal for this alleged noncompliance. The facility alleges the removal of Immediate Jeopardy on 2/2/22. The credible allegation of immediate Jeopardy removal was validated by onsite verification on 2/2/22 as evidenced by interviews with direct care, ancillary, and administrative staff, interviews with residents, record review and observations. Review of the 100% census verification and resident roll call was completed on 1/11/22 and Elopement drill on 1/12/22. Interviews conducted with nursing, housekeeping, dietary, therapy, medical record and other ancillary staff revealed they had attended training on the door alarm system, elopement education policy and procedures which included monitoring and managing residents with unsafe wandering and risk for elopement. The training included ways to modify behaviors and minimize risk associated hazards to prevent accidents and elopements. The education included tips for elopement prevention and that elopement risk we [TRUNCATED]

Based on record review, observation, and physician and staff interviews, the facility failed to have sufficient staffing to prevent and protect Residents #53 and #39 from being physically abused by Resident #29 for 1 of 1 resident reviewed for resident-to-resident physical abuse (Resident #29) and to provide supervision to prevent residents with severe cognitive impairment (Resident #21 and Resident #29) from exiting the facility unsupervised for 2 of 2 residents reviewed for wandering. Immediate Jeopardy began on 11/08/21 when the facility failed to have sufficient staff to protect residents from physical abuse resulting in Resident #29 placing Resident #53 in a headlock and throwing the resident to the floor. Immediate Jeopardy was removed on 2/2/22 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity of E (no actual harm with a potential for minimum harm that is not Immediate Jeopardy) to ensure the monitoring of the systems put into place and to complete facility employee and agency in-services, orientation and training. The findings included: This is cross-referred to: F600: Based on record review and physician and staff interviews, the facility neglected to protect the residents' right to be free from abuse when Resident #29 physically abused Residents #39 and #53. Resident #53 sustained injuries that required emergency room evaluation. This was for 1 of 1 resident (Resident #29) reviewed for resident-to-resident abuse. F689: Based on record review, staff interview and observation, the facility failed to provide supervision to prevent residents with severe cognitive impairment who displayed exit seeking behaviors from exiting the facility unsupervised for 2 of 2 residents (Resident #21, Resident #29) reviewed for wandering behavior. The facility also failed to implement 1 to 1 supervision for Resident #29. On 1/27/22 at 10:10 AM an interview was conducted with Nursing Assistant (NA) #18 who stated she worked on the SCU (Secured Care Unit). NA #18 stated 14 residents were too much for one nurse and one NA to monitor. She indicated that there were multiple resident on the SCU who wandered. She explained if the nurse was passing medications and she was in a room providing care to a resident there was no one to monitor or supervise the residents who were wandering in the hall. On 1/27/22 at 11:42 AM an interview was conducted with the Staffing Scheduler who stated she scheduled one nurse or Medication Aide (Med Aide) and one NA on the SCU, and she would schedule 2 NAs if the census reached 13-14 residents, if she had the staff. The Scheduler further stated if there was not enough staff, then everyone helps out. The Staff Scheduler stated she used a computer program to do the staffing and the acuity of the unit was not taken into consideration when making out the schedule. The Scheduler stated none of the staff on the SCU have spoken with her about the staffing on the unit. The Interim Director of Nursing (DON) stated in an interview on 1/27/22 at 11:23 AM the staff on the SCU had told her there was not enough staff on the unit. The DON further stated they did not have the additional staff and if the agency staff did not pick up a shift they could not put more staff on the unit. The Administrator was notified of Immediate Jeopardy at F725 on 1/31/22 at 7:21 PM. The facility provided a credible allegation of Immediate Jeopardy removal on 2/1/22. The allegation of Immediate Jeopardy Removal indicated: Credible Allegation of Immediate Jeopardy Removal: The facility failed to have sufficient staffing to 1) Prevent and protect Residents #53 and #39 from being physically abused by Resident #29 and 2) to provide supervision to prevent two residents with severe cognitive impairment (Resident #21 and #29) from exiting the facility unsupervised. Because all residents are at risk when the facility fails to provide sufficient staffing to 1) prevent and protect residents from being physically abused by Resident #29 or other residents and 2) to provide supervision: to prevent residents with severe cognitive impairment (Resident #21 and #29) from exiting the facility unsupervised the following plan has been formulated to address this issue: On 2/1/2022, an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held by the Administrator, Director of Nursing, Regional Director of Clinical Services and Regional Director of Operations to discuss root cause analysis of the facilities failure to provide sufficient staffing levels to ensure supervision to keep residents free from physical abuse by other residents and to prevent unsupervised exits from the facility. The facility determined that administration and leadership failed to consider the number, acuity and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/1/22, the Regional Director of Operations provided education to the Administrator and Director of Nursing on daily discussions of sufficient staff scheduling to ensure residents with behaviors towards others and residents exhibiting exit seeking or wandering behaviors are factored in when determining appropriate staffing levels to protect all residents from harm. Education included considering resident acuity and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Effective 2/1/22, the Administrator and Director of Nursing will discuss residents with behaviors towards others and residents exhibiting exit seeking or wandering behaviors daily to determine appropriate staffing levels to protect all residents from harm. The daily schedule will be adjusted to consider resident acuity and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Effective 2/1/22, the facility implemented a revised Safety Watch System to ensure continuous staff supervision for residents requiring 1:1 observation. The Administrator will ensure the 1:1 staff coverage is posted on the Safety Watch Schedule and assigned staff will utilize the Safety Watch Log to document coverage by signing and dating in and out times. During staff breaks and during change of shift, an alternate staff member will provide supervision and document on-coming and off-going coverage by signature and date on the Safety Check Log. In the event of call-outs or late arrivals, the current staff will notify the Administrator or Director of Nursing immediately and will remain with resident to ensure continuous supervision until alternate staff coverage is obtained. Staff who are assigned 1:1 resident observations will utilize interventions per resident plan of care to distract, redirect and intervene as appropriate. Any concerns with following the plan of care will be reported to the Physician and Administrator and/or Director of Nursing immediately and additional interventions implemented as necessary. Effective 2/1/22, the Regional Director of Operations and Regional Director of Clinical Services will provide education to facility and agency staff on the Safety Watch System and the expectation of providing continuous 1:1 supervision as assigned and the process to follow to ensure resident safety without any disruptions in continuous coverage. Education will include the process of utilizing the Safety Watch Log to document coverage by signing and dating in and out times. During staff breaks and during change of shift, an alternate staff member will provide supervision and document on-coming and off-going coverage by signature and date on the Safety Check Log. In the event of call-outs or late arrivals, the current staff will notify the Administrator or Director of Nursing immediately and will remain with resident to ensure continuous supervision until alternate staff coverage is obtained. Staff who are assigned 1:1 resident observations will receive education on utilizing interventions per resident plan of care to distract, redirect and intervene as appropriate and reporting any concerns with following the plan of care and Safety Watch System to the Administrator and/or Director of Nursing immediately. Effective 2/1/22, staff assigned to provide 1:1 resident supervision will not leave resident unattended at any time. During staff breaks and during change of shift, an alternate staff member will provide supervision and document on-coming and off-going coverage by signature and date on the Safety Check Log. In the event of call-outs or late arrivals, the current staff will notify the Administrator or Director of Nursing immediately and will remain with resident to ensure continuous supervision until alternate staff coverage is obtained. Effective 2/1/2022, the Administrator and Director of Nursing will make observational rounds to ensure adequate staffing levels are being provided based on acuity to prevent and protect residents from harm. Monitoring will be conducted at least weekly on 1) residents who exhibit exit seeking and wandering behaviors and 2) residents who have behaviors of aggression towards. Effective 2/1/22, the Administrator, Director of Nursing or Manager on Duty will and will review the Safety Watch Log to ensure continuous supervision is being provided and documented for residents assigned 1:1 observation. Monitoring will be conducted daily Effective 2/1/2022, the Administrator or Regional Director of Operations and Director of Nursing will be ultimately responsible to ensure implementation of this immediate jeopardy removal for this alleged noncompliance. Alleged Date of IJ Removal: 2/2/22. On 2/2/22 the Immediate Jeopardy removal plan was validated by onsite verification. Interviews were conducted with the DON and the Staffing Scheduler who stated they had been in-serviced to hold daily discussions to ensure sufficient staff were scheduled to ensure residents with behaviors towards others was factored in when determining appropriate staffing levels to provide adequate supervision to keep residents safe from physical abuse from other residents. The DON stated she had attended a QAPI meeting on 2/1/22 with the Regional Interim Administrator and discussed staff scheduling, neglect, abuse, reporting of abuse, behaviors. Immediate Jeopardy was removed on 2/2/22.

Based on record review, observation, and interviews with physician and staff, the facility Administration failed to provide oversight and leadership to 1) ensure the facility was free from abuse and to prevent and protect Resident #53 and #39 from being physically abused by Resident #29, 2) provide supervision to prevent residents with severe cognitive impairment from exiting the facility unsupervised (Residents #21 and #29); and 3) provide sufficient staffing to meet the needs of the residents. Immediate Jeopardy began on 11/08/21 when the facility leadership failed to implement interventions to maintain a safe and abuse free environment for the residents resulting in Resident #29 placing Resident #53 in a headlock and pulling her to the floor. Immediate Jeopardy was removed on 2/2/22 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity of E (no actual harm with a potential for minimum harm that is not Immediate Jeopardy) to ensure the monitoring of the systems put into place and to complete facility employee and agency in-services, orientation and training. The findings included: This tag is cross referenced to: F600: Based on record review and physician and staff interviews, the facility neglected to protect the residents' right to be free from abuse when Resident #29 physically abused Residents #39 and #53. Resident #53 sustained injuries that required emergency room evaluation. This was for 1 of 1 resident (Resident #29) reviewed for resident-to-resident abuse. F689: Based on record review, staff interview and observation, the facility failed to provide supervision to prevent residents with severe cognitive impairment who displayed exit seeking behaviors from exiting the facility unsupervised for 2 of 2 residents (Resident #21, Resident #29) reviewed for wandering behavior. The facility also failed to implement 1 to 1 supervision for Resident #29. F725: Based on record review, observation, and physician and staff interviews, the facility failed to have sufficient staffing to prevent and protect Residents #53 and #39 from being physically abused by Resident #29 for 1 of 1 resident reviewed for resident-to-resident physical abuse (Resident #29) and to provide supervision to prevent residents with severe cognitive impairment (Resident #21 and Resident #29) from exiting the facility unsupervised for 2 of 2 residents reviewed for wandering. The Administrator was notified of the Immediate Jeopardy at F835 on 1/31/22 at 7:21 PM. The facility provided a credible allegation of Immediate Jeopardy removal on 2/1/22. The allegation of Immediate Jeopardy removal indicated: Credible Allegation of Immediate Jeopardy Removal: The facility Administration failed to provide effective oversight and leadership to 1) ensure the facility was free from abuse and to prevent and protect Residents #53 and #39 from being physically abused by Resident #29, 2) provide supervision to prevent residents with severe cognitive impairment from exiting the facility unsupervised (Resident #21 and #29) and 3) provide sufficient staffing to meet the needs of the residents. On 2/1/2022, an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held by the Administrator, Director of Nursing, Regional Director of Clinical Services and Regional Director of Operations to discuss root cause analysis of the facilities failure to provide effective oversight and leadership to provide sufficient staffing to keep residents free from physical abuse by other residents and to prevent unsupervised exits from the facility. Root cause determined that the Administrator and Director of Nursing did not have clear understanding of acuity-based staffing. Additionally, administration failed to implement systems to ensure staffing schedules were adjusted to include coverage during staff breaks, late arrivals with shift changes, to factor in the additional staff required to provide adequate supervision to keep residents safe from physical abuse by other residents and unsupervised exits from the facility. On 2/1/22, an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held by the Administrator, Regional Director of Operations, Director of Nursing and Regional Director of Nursing on 2/1/22 to re-assess effective oversight and leadership to ensure 1)residents are protected from abuse, 2) that supervision is provided and interventions are implemented to prevent unsupervised exits from the facility and 3) sufficient staffing levels are provided based on resident acuity to ensure resident safety. On 2/1/22, the Regional Director of Operations provided education to the Administrator on effective administrative strategies and processes to ensure residents are protected from abuse, that supervision is provided and interventions are implemented to prevent unsupervised exits from the facility and that sufficient staffing levels are provided based on resident acuity to ensure resident safety. Education included review of company Abuse, Neglect and Exploitation Policy, Elopement and Wandering Residents Policy, a system to ensure staffing schedules are adjusted to include coverage during staff breaks, late arrivals with shift changes and the process for providing acuity-based staffing utilizing the ABS (acuity-based system) to provide adequate supervision to keep residents safe from physical abuse by other residents and unsupervised exits from the facility. Education of the ABS system included calculating staffing needs by adding the number of days at each RUG (Resident Utilization Grouper) level and case mix index divided by average daily census to determine number of staff needed. Newly hired Administrators will receive education upon hire during orientation. Effective 2/1/2022, the facility Administrator, Regional Director of Operations, Director of Nursing or Regional Director of Nursing will perform facility tours (including off shifts and weekends) daily to observe for any residents with behaviors which would need additional interventions. Additionally, the Administrator and Director of Nursing will monitor staffing levels every shift (including coverage during breaks and lunches) on the memory care unit based on resident acuity to ensure adequate staff to provide supervision to residents to prevent physical abuse. Effective 2/1/22, the Regional Director of Operations and/or the Regional Director of Clinical Services will be contacted by the Administrator and/or Director of Nursing when a resident-to-resident incident or unsupervised resident exit occurs to receive additional support and guidance and to ensure effective interventions to protect residents from harm. Effective 2/1/2022, the Regional Director of Operations and Regional Director of Clinical Services will meet at least bi-weekly with the Administrator and Director of Clinical Services in person or telephonically to discuss administrative oversight and leadership effectiveness in ensuring compliance with regulation F600, F689, and F725. Results of ongoing monitoring completed by the facility for F600, F689, F725 and F835 will be reviewed for completeness and effectiveness and additional support and interventions will be provided if necessary to maintain compliance. Effective 2/1/2022, the Administrator and Director of Nursing will be ultimately responsible to ensure implementation of this immediate jeopardy removal for this alleged noncompliance. Alleged Date of Immediate Jeopardy Removal: 2/2/22. On 2/2/22 the Credible Allegation was validated by onsite verification. Interviews were conducted with the DON and the staffing scheduler who stated they had been in-serviced to hold daily discussions to ensure sufficient staff were scheduled to ensure residents with behaviors towards others was factored in when determining appropriate staffing levels to provide adequate supervision to keep residents safe from physical abuse from other residents. The DON stated she had attended a QAPI meeting on 2/1/22 with the Regional Interim Administrator and discussed staff scheduling, resident elopement, neglect, abuse, reporting of abuse, behaviors and the use of the Safety Watch Log. Resident #29 was observed to be monitored 1:1 by facility staff and the Safety Watch Log was reviewed and the documentation revealed no gaps in monitoring from 1/28/22 (when the monitoring tool was implemented) until 2/2/22. The Immediate Jeopardy was removed on 2/2/22.

Based on observation, record review, resident, staff, physician, and wound clinic nurse interviews, the facility failed to assess and identify skin changes for 1 of 4 residents who was at risk for pressure ulcer development. (Resident #40). Findings included: Record review of hospital discharge record dated 11/17/21 revealed Resident #40 had a surgical debridement (removal of dead tissue) of necrotic sacral pressure ulcer. Resident #40 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #40 ' s facility admission assessment dated [DATE], completed by Nurse #8, revealed skin was normal with no skin integrity issues documented. Record review of Weekly Pressure Wound Observation Tool dated 11/18/21 completed by Wound Nurse revealed Resident #40 had a stage 4 sacral pressure ulcer with measurements of 12 x 0.8 x 1.6 centimeters (cm). The wound bed had 50% granulation (new tissue) and 20% slough (yellow, stringy) tissue with moderate drainage and no odor. Record review of in-house wound provider report dated 11/18/21 revealed Resident #40 ' s sacral pressure wound measurements were 12 x 0.8 x 1.6 cm. The wound had granulation tissue and slough tissue, with moderate drainage, and no odor present. Treatment recommendation clean with Dakin ' s, moist to dry Dakin ' s dressing, cover with dry clean dressing, change twice daily and with every incontinence episode. The treatment plan was discussed with the facility staff which included facility pressure ulcer prevention protocol and turn and reposition. Record review of Resident #40 ' s Minimum Data Set (MDS) Admission assessment dated [DATE] revealed she was cognitively intact and was total dependence on staff for bed mobility, transfers, bathing, and personal hygiene. Resident #40 had a stage 4 pressure ulcer to sacrum. She was at risk for pressure ulcer development and was not on a turn/repositioning program. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Registered Dietitian (RD) progress note dated 11/22/21 Resident #40 ' s Admission RD Assessment revealed she was at increased risk for weight loss related to pressure ulcer and variable PO (by mouth) intake. RD recommendations for multivitamin daily, vitamin C twice daily, [MEDICATION(S)] daily, Prostat (liquid protein) twice a day for wound healing and house supplement twice daily for weight management and nutritional support. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #40 ' s care plan dated 11/23/21 revealed a care plan for a stage 4 pressure ulcer to sacrum. Interventions in place which included monitoring effectiveness of treatment, monitoring of any skin changes, and weekly treatment documentation to include measurement of each area of skin breakdown with width, length, depth, type of tissue and exudate (drainage). Resident #40 care plan for nutritional problem or potential nutritional problem related to pressure wound. Interventions in place which included RD evaluation and supplements as ordered. Record review of the Weekly Skin Review dated 11/24/21 revealed Resident #40 had an open, pre-existing area to sacrum. No other skin integrity issues documented. Record review of the Weekly Pressure Wound Observation Tool dated 11/25/21 completed by Wound Nurse revealed Resident #40 had a stage 4 sacral pressure ulcer with measurements of 12 x 11 x 1 cm. The wound bed had 50% granulation tissue, 50% slough tissue with moderate drainage and no odor. Record review of in-house wound provider report dated 11/25/21 revealed Resident #40 had a bedside debridement (cleaning of wound) with post procedure wound measurements of 12 x 11 cm. The treatment plan was discussed with the facility staff which included facility pressure ulcer prevention protocol and turn and reposition. Record review of RD progress note dated 11/26/21 revealed Resident #40 had significant weight loss. Resident #40 had nutritional supplement in place twice daily and new recommendation for house supplement and fortified foods at all meals. Record review of Wound Clinic Treatment Report dated 11/30/21 revealed Resident #40 ' s sacral pressure ulcer measurements were 13 x 8.5 x 3.0 cm with undermining (extends under the skin) of 4 cm from 5 o ' clock to 7 o ' clock. The wound bed observed with moderate pink granulation tissue, minimal necrotic tissue, and no odor. The treatment plan included silver cell dressing to cover with dry dressing and tape changed daily rinse with saline. Offloading will make sure resident in a low-air-loss mattress and on a turn schedule. Follow-up in two weeks. Record review of the Weekly Skin Review dated 11/30/21 revealed Resident #40 had an open, pre-existing area to sacrum. No other skin integrity issues documented. Record review of RD progress note dated 12/13/21 revealed Resident #40 continued with significant weight loss with interventions in place. New recommendations for Glucerna supplement twice daily and ice cream with lunch and supper. Record review of Wound Clinic Treatment Report dated 12/14/21 revealed Resident #40 ' s sacral pressure ulcer had improved with measurements of 10 x 6 x 3.0 cm with unchanged undermining. The wound bed observed with moderate pink granulation tissue, minimal necrotic tissue, and no odor. The treatment plan included silver cell dressing cover with dry dressing and tape to be changed daily rinse with saline. Follow-up in 1 week. Record review of the Weekly Skin Review dated 12/20/21 revealed Resident #40 had an open, pre-existing area to sacrum with treatment in place. No other skin integrity issues documented. Record review of the Weekly Skin Review dated 12/28/21 revealed Resident #40 had an open, pre-existing area to sacrum with treatment in place. No other skin integrity issues documented. Record review of Resident #40 ' s electronic medical record revealed the Weekly Skin Review was not completed the weeks of 12/6/21, 12/13/21, 1/3/22, 1/10/22, 1/17/22, and 1/24/22. Record review of Resident #40 ' s Weekly Pressure Wound Observation Tool was not completed for the months of December or January. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 1/25/22 at 2:32 pm Resident #40 revealed she had pressure ulcers to her heels but was not sure if they were getting better or worse. During an observation of wound care on 1/27/22 at 10:32 am Resident #40 sacral pressure ulcer observed to have a strong odor and slough covering wound bed. No rinsing or cleansing of wound prior to new dressing placed. Resident #40 observed with a round, approximately half dollar size wound with black base on side of right foot that did not receive treatment. During an interview on 1/27/22 at 10:35 am the Wound Nurse stated she thought the foot wound was a vascular wound, and she did not treat the foot wound. She stated she was pretty sure Resident #40 had the wound on her foot upon admission but was unable to state why no documentation was available about the wound. The Wound Nurse stated Resident #40 was seen initially by in-house wound provider but was changed to the wound clinic for wound management but was not sure about treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Wound Nurse stated Resident #40 would benefit from an air mattress, but she stated she did not receive a recommendation from wound clinic or a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the Weekly Pressure Ulcer Observation Tool was required to be completed every week. The Wound Nurse reported she worked on a medication cart at times and did not complete the Weekly Pressure Ulcer Observation Tool as required. During an interview on 1/27/22 at 11:54 am the Director of Nursing (DON) stated she expected Resident #40 to have an air mattress because of the stage 4 sacral pressure ulcer. She stated a recommendation for an air mattress could come from the Wound Nurse, Physician, or wound clinic but she was not aware of a recommendation for air mattress. During a telephone interview on 1/27/22 at 5:30 pm Physician #1 revealed he was not certain if he had seen the wound on Resident #40 ' s foot. He stated that he would have ordered a treatment if he was aware. Physician #1 stated the nurse was able to make a recommendation for an air mattress for Resident #40 and he would have approved the order. Physician #1 was not notified of recommendation from wound clinic for a low-air-loss mattress. Record review of RD progress note dated 1/28/22 revealed Resident #40 continued with significant weight loss with multiple interventions in place. RD recommendations for discontinue house supplement and increase Glucerna to three times a day between meals, Prostat twice daily, assist with eating, and update food preferences. During an interview on 1/28/22 at 11:20 am the RD revealed Resident #40 was followed since admission related to risk for inadequate nutrition and presence of pressure ulcer. She stated multiple interventions were implemented including ice cream, fortified foods, supplements, and updating food preferences but Resident #40 continued to have weight loss. The RD stated Resident #40 continued to be seen by RD related to weight loss and nutritional support for wound healing. During an interview on 1/31/22 at 9:50 am Nurse Aide (NA) #10 revealed that Resident #40 had a wound on her backside. She stated she would tell the nurse if new skin issues were seen. She stated she turns and repositions every two hours. NA #10 stated that Resident #40 had pillows under her legs, but she had not noticed wounds on Resident #40 ' s feet. During an interview on 1/31/22 at 9:58 am NA #16 revealed Resident #40 had a wound on her backside and one on her foot. She was not able to recall when she first noticed the wound on the foot but stated she told the nurse that was working. During an interview on 1/31/22 at 10:08 am Nurse #10 revealed Resident #40 had a sacral pressure ulcer but did not recall any other wounds. She stated that she does not recall being told by NA about a new wound on her foot at any time and she did not observe any foot wounds for Resident #40. Nurse #10 stated the Weekly Skin Review was to be completed by the cart nurse, but it was not scheduled on a specific day. She stated the assessment would generate in the electronic medical record for the nurse to know it was assigned so she was not able to state why the Weekly Skin Review was not completed for Resident #40. During an interview on 1/31/22 at 11:07 am Nurse #8 revealed she observed a sacral pressure ulcer for Resident #40 upon admission but was unable to state why she did not document on the admission assessment. Nurse #8 stated she was not aware of foot wounds for Resident #40. Nurse #8 reported the Weekly Skin Review was required to be completed for all types of wounds and it was done weekly. She was unable to state why the Weekly Skin Review was not completed for Resident #40. During an interview on 1/31/22 at 12:49 pm the Wound Nurse revealed she was not aware Resident #40 had not been seen by the wound clinic since December and she was not able to state if the physician was aware. She stated Resident #40 was COVID positive in the beginning of January and the wound clinic would not take COVID positive at the office. The Wound Nurse stated that she did not measure the sacral pressure ulcer for Resident #40 because the physician did not ask her to. She was unable to state why she did not obtain wound measurements of sacral pressure ulcer or new observed wounds to the foot to notify the physician of the status of Resident #40 ' s wounds. The Wound Nurse did not recall if she received information from the wound clinic regarding treatment recommendations, low-air-loss mattress, and turning and repositioning for Resident #40. She reported nursing was expected to put a copy of the wound clinic consult report under her door, but it was not being done. She stated the administration was aware of the problem. The Wound Nurse stated she did not try to contact the wound clinic to obtain a copy of the report when Resident #40 returned from the appointments. During an interview on 1/31/22 at 4:11 pm the Regional Director of Operations revealed the expectation was for all wounds to be discussed in clinical meeting and weekly during the risk meeting. She is not certain when the facility had the risk meeting, but wounds would have been discussed including interventions and progress of wounds. The Regional Director of Operations stated the low-air-loss mattress was placed for Resident #40 on 1/28/22. Record review of Physician #1 ' s progress note dated 1/31/22 revealed Resident #40 was seen via telehealth for follow-up to sacral pressure wound. Physician #1 ' s assessment revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Weekly Pressure Wound Observation Tool dated 1/31/22 completed by Wound Nurse revealed the following wound information and measurements: Wound #1: Sacral pressure wound, worsening. Measurements 12.4 x 11.8 x 1 cm, slough and necrotic (dead) tissue. Wound #2: New wound to right heel, deep tissue injury, blister. Measurements 2.4 x 2.1 x 0 cm. Wound #3: New wound to left lateral foot, unstageable with necrotic tissue. Measurements 3.5 x 3.6 x 0 cm. Wound #4: New wound to right hip, stage 2. Measurement 2.5 x 2.5 x 0 cm. Wound #5: New wound to right medial foot, unstageable with necrotic tissue. Measurements 2.8 x 3.0 x 0 cm. During an interview on 2/1/22 at 6:45 am Nurse #11 revealed Resident #40 had a pressure ulcer to her sacrum but was not aware of other wounds. She stated she did not normally complete the Weekly Skin Assessment for Resident #40 because she worked the overnight shift, and it was normally completed on day shift. During an interview on 2/1/22 at 9:38 am the DON revealed the Wound Nurse was responsible to complete the Weekly Pressure Wound Observation. She stated the Wound Nurse rounds with the in-house wound provider and was responsible to complete the assessment for all residents with pressure ulcers including any resident being seen by wound clinic. The DON stated the Wound Nurse was to review the wound clinic recommendations and order changes and was responsible to communicate with the physician and floor nurse. The DON reported the floor nurse assigned to Resident #40 was to complete the Weekly Skin Review as scheduled. During an interview on 2/1/22 at 10:06 am Physician #1 revealed he would review wound clinic reports that were given to him and determine if new orders were needed. Physician #1 stated the Wound Nurse would review when he was not in facility and contact him when new orders needed. He does not recall receiving information from the wound clinic reports from 11/30/21 or 12/14/21 with the recommendations for Resident #40 treatment and to have a low-air-loss mattress but if he was told this recommendation he would approve the order for the mattress. Physician #1 reported the Wound Nurse completed a video telehealth visit on 1/31/22 and he observed the wounds and provided new orders for treatment and wound clinic consult for Resident #40. During an interview on 2/2/22 at 1:06 pm the Regional Clinical Nurse revealed the skin assessment was to be completed upon admission for all residents and documented in the admission assessment. She was unable to state why the Weekly Skin Review and the Weekly Pressure Wound Observation Tool was not completed as required. She stated the Wound Nurse was responsible to complete both assessments for Resident #40. The Regional Clinical Nurse state the Wound Nurse was responsible to manage all wounds in the facility and she was responsible to review consult information for Resident #40 from the wound clinic. During an interview on 2/3/22 at 1:20 pm the Wound Clinic Nurse revealed that Resident #40 was seen in the clinic for management of a sacral pressure wound. He did not see any documentation or recall Resident #40 having wounds on her feet. He stated the facility received a call before the resident left the clinic with appointment information including measurements, treatment, interventions, and follow-up appointment. He stated the facility sent a carbon consult sheet that was also completed and sent back with Resident #40 with the same information. The Wound Clinic Nurse stated the facility was able to contact them if any questions regarding the appointment or if they did not receive the recommendations and information would be sent to the facility.

Based on observations, record review, staff and physician interviews, the facility failed to administer 21 doses of a medication prescribed to treat [CONDITION(S)] per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: Resident #43 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #43 was severely cognitively impaired. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The January 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - 1/5/22 at 5:00 PM - 1/6/22 at 9:00 PM - 1/7/22 at 12:00 PM, 5:00 PM, and 9:00 PM - 1/8/22 at 9:00 AM, 12:00 PM, 5:00 PM, and 9:00 PM - 1/9/22 at 12:00 PM, 5:00 PM, and 9:00 PM - 1/10/22 at 9:00 AM, 12:00 PM, 5:00 PM, and 9:00 PM - 1/11/22 at 12:00 PM, 5:00 PM, and 9:00 PM - 1/12/22 at 9:00 AM and 12:00 PM Electronic MAR (eMAR) notes from 1/5/22 through 1/12/22 were reviewed for Resident #43 and revealed awaiting pharmacy was documented by Nurse #7 for the [MEDICATION(S)] medication administration on 1/6/22, 1/7/22, 1/8/22, 1/9/22, 1/10/22, and 1/11/22. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations of Resident #43 on 1/25/22 at 11:46 AM, and 01/27/22 at 09:47 AM revealed her right eye was enlarged, red and swollen on the lower lid. During a phone interview on 1/28/22 at 9:27 AM with Nurse #7, she revealed she called the pharmacy about the missing [MEDICATION(S)] medication, and they said it was signed for and delivered to the facility. She stated she let the interim Director of Nursing (DON) know that they did not have the [MEDICATION(S)] medication available to give to Resident #43. During a phone interview on 1/27/22 at 12:03 PM, Nurse #8 revealed Resident #43 was prescribed, but never received, [MEDICATION(S)] eye drops while she resided on the COVID unit. When she inquired with the pharmacy about the missing medication, they said it was received by a night shift nurse at the facility and an additional refill could not be sent over. Nurse #8 stated Nurse #7 notified the physician about this issue. Nurse #8 indicated on 1/6/22 at 9:00 AM, 1/7/22 at 9:00 AM, 1/9/22 at 9:00 AM, and 1/11/22 at 9:00 AM, the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #43. However, nurse #8 indicated this was a typing mistake, and she never administered this medication for Resident #43. An observation of Resident #43 on 02/01/22 at 11:19 AM revealed her right eye was enlarged, red and swollen on the lower lid. A nursing progress note dated 2/1/22 at 12:38 PM was reviewed and revealed Nurse #12 documented Resident #43 had redness and inflammation to right lower eyelid. Her left eye appeared to be swollen, and the physician was contacted. A verbal phone order was given to start [MEDICATION(S)] ointment to right and left eye 3 times daily for the next 5 days. During an interview with Nurse #12 on 2/1/22 at 11:23 AM, she observed Resident #43's right eye as pink and the lower lid inflamed on 2/1/22. She stated she saw it earlier that day and was going to inquire with the unit manager and nurse aide, since she last time she saw Resident #43 was 3 weeks prior. After discussing with staff, she indicated she was going to notify the physician. Nurse #12 stated there were not any current interventions in place for the infected eye. The Pharmacist in-charge (PIC) was interviewed on 1/27/22 at 1:44 PM. She revealed pharmacy filled the January 2021 [MEDICATION(S)] prescription for Resident #43, and it was received by Nurse #11 on 1/6/22. The PIC indicated there were no notes/documentation on the prescription that the facility needed a new refill. If the facility called the pharmacy to let them know they could not find the medication, pharmacy would have told the facility it was already filled and sent over an authorization form to be signed for a refill. During a phone interview with Nurse #11 on 1/30/22 at 7:15 PM, she revealed she could not recall any pharmacy delivery details for Resident #43 on 1/6/22. During a phone interview with the Medical Director (MD) on 1/31/22 at 11:04 AM, he revealed he did not recall there was an issue that Resident #43 did not receive eye antibiotic medication. If he was notified, he would have tried to reauthorize another prescription. On 2/01/22 at 11:08 AM, the MD stated if the eye infection did not get better on its own, then that should have been addressed. He further stated the facility had not communicated with him about Resident #43's eye infection not resolving. The interim DON and Regional Director of Clinical Services (RDCS) were interviewed on 2/2/22 at 12:17 PM. They revealed the pharmacy said the [MEDICATION(S)] was delivered and this was confirmed. Resident #43 tested positive for COVID and was moved to the quarantined unit, but the medication did not follow her properly. The interim DON stated she was not aware of the missing [MEDICATION(S)] medication for Resident #43 until last week when the pharmacist was in the building. When the pharmacist brought it to her attention, Resident #43 should have been evaluated to determine if treatment/follow-up would have been necessary. On 2/2/22 at 4:40 PM the Regional Director of Operations (RDO) revealed Resident #43 should have received the medication as prescribed. She stated this medication was necessary for her eye infection to be resolved.

Based on record review, observation, staff interviews and physician interview, the facility failed to operationalize effective systems so staff could respond to emergency situations as needed for 3 of 3 residents (Resident # 6, # 1, # 9). Resident # 6 and # 1 expired in the facility. Resident # 9 was in acute distress. Immediate Jeopardy began on [DATE] when Resident #6 was found without a pulse and cold and Nurse #3 was unable to find the resident's code status and was unable to obtain help from other nursing staff to locate the code status or assist in CPR prior to the arrival of Emergency Medical Services (EMS). Immediate Jeopardy began on [DATE] when Resident #1 was found unresponsive and Nurse #2 and Nurse #4 were unable to find the resident's code status. On [DATE] there were 24 residents on the Covid-19 unit. Also, on [DATE], Nurse #4 was unable to find an ambu bag on the emergency cart when Resident #9 was experiencing agonal breathing and may have required CPR prior to the arrival of EMS. The immediate jeopardy was removed on [DATE] when the facility provided and implemented an acceptable credible allegation for Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of an D (No actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place are effective. Findings included: The facility policy for Cardiopulmonary Resuscitation (CPR) stated, The facility will provide basic life support, including CPR -Cardiopulmonary Resuscitation, when a resident requires emergency respiratory support care, prior to the arrival of emergency medical services, and consistent with the resident Advance Directives, and physician orders. The facility policy in part required a staff member to verify the DNR (Do Not Resuscitate) or code status of the individual prior to starting CPR. The facility policy listed an ambu bag as a needed supply on the crash cart. In the procedure for CPR, the policy indicated both chest compressions and breaths via a resuscitator or an ambu bag were required. The standard of practice for death and resuscitation dated as revised ,[DATE] was used as policy for the facility. The standard of practice stated in part that it was the responsibility of the Director of Nursing to identify, develop, and update policies, standards, and procedures related to nursing care. The same standard of practice stated emergency policies should address witnessed and unwitnessed cardiopulmonary arrests, presence or absence of DNR orders, anticipated/expected deaths, assessment guidelines, and documentation requirements. 1. Resident #6 was admitted to the facility from another facility on [DATE] with a primary [DIAGNOSES REDACTED].#6 had additional cumulative [DIAGNOSES REDACTED]. Resident #6 had a 5- day Medicare Minimum Data Set assessment dated [DATE] which revealed he was cognitively impaired and required extensive to total assistance with activities of daily living. Resident #6 was coded as receiving oxygen while he was at the facility. The code status of Resident #6 was located under the Miscellaneous tab in the electronic medical record on the 12th page of the admission documentation. Resident #6 was a full code. An interview with Nurse #3 revealed on [DATE] she worked a double shift in the Covid-19 unit from 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM ending on [DATE]. Nurse #3 confirmed she was a travel nurse employed by an agency. Nurse #3 stated Resident #6 was found in his bed cold and without a pulse just prior to the end of her shift on [DATE] at approximately 6:00 AM. Nurse #3 stated she looked in the electronic record system in the physician orders [REDACTED]. Nurse #3 stated she knew she needed to find the code status. Nurse #3 stated she needed to get the resident help immediately if he was to be resuscitated. Nurse #3 stated she felt she was put in a difficult position because if the resident was a full code then she needed to start CPR and if he was a DNR (Do Not Resuscitate), she was not supposed to start CPR. Nurse #3 stated she could not find the code status and she was unable to initiate CPR by herself on a Covid-19 resident, so she called Code Blue over the intercom. Code Blue indicates a medical emergency. Nurse #3 explained that one nurse was needed to do compressions while another nurse was needed to use the ambu bag over the mouth because mouth to mouth resuscitation could not be done on a Covid-19 positive resident. Nurse #3 stated that the phone numbers for the Administrator and the Director of Nursing were not posted anywhere. Nurse #3 stated she requested the phone numbers of the facility Administrator and the Director of Nursing from the other unit nurse on the phone. Nurse #3 stated that the other unit nurse told her she did not have their phone numbers. Nurse #3 stated she called the facility scheduler to ask for the phone number of the facility Administrator, so she get assistance finding the code status of Resident #6. Nurse #3 stated that Emergency Medical Services (EMS) arrived at approximately 6:15 PM, and they were unable to revive the resident. Nurse #3 stated ultimately EMS called somebody to get the code status of the resident. Nurse #3 stated she was never able to find Resident #6's code status. Nurse #3 stated that she was never told where to find the resident's code status at the facility, but she thought the code status should have been in the physician orders [REDACTED]. Nurse #3 confirmed she did not perform CPR on Resident #6 prior to the arrival of EMS. Nurse #3 stated that the next day, [DATE], she went to the Director of Nursing to express her concern of her inability to find the code status of Resident #6. The facility scheduler was interviewed on [DATE] at 3:10 PM. The facility scheduler stated that she received a phone call from Nurse #3 on [DATE] requesting the phone number of the Administrator. The facility scheduler stated she called the Administrator to tell her that someone had passed, and the nurse was unable to find the code status. Documentation in the nursing notes on [DATE] at 6:57 AM, written by Nurse #3 stated, Resident was found not breathing. Writer contacted staff for assistance. (Administrator) notified. (Medical Doctor) notified. Son (name) notified. Son stated he will contact the building (with) regards to where the body will be sent. Documentation in an emergency medical services report for Resident #6 on [DATE] revealed, HCEMS (Hertford County Emergency Medical Services) dispatched to priority one call for a [MEDICAL CONDITION] at Creekside .Dispatch advised crew to enter through the Covid hall door On scene, crew entered facility and was directed to PT (patient). NH (nursing home) advised multiple times that the PT was a DNR. NH staff was instructed to get the PT's DNR (Do Not Resuscitate) paperwork for EMS to visualize . PT paperwork was obtained from PT nurse. She advised the PT had only been at the facility for 2 days and that they did not have all the PT's paperwork. PT history other than Covid-19 was unknown . An interview was conducted with the Director of Nursing (DON) on [DATE] at 3:59 PM. The DON stated that the first thing he expected the nursing staff to do when a resident was unresponsive was to check the code status of the resident. The DON indicated the code status was in a book at the nurses' station and in the electronic medical record. An interview was conducted with the DON and the Administrator on [DATE] at 12:31 PM. The DON stated upon arrival to begin to work at the facility the agency nursing staff were shown to their work station, given an assignment, and provided with access to the electronic medical record. The DON stated the electronic medical record system the facility uses was known through the industry and the nurses were expected to have the knowledge of how to use it. The DON stated he did at one point realize not all the residents had a code status in the electronic medical record. The DON stated he went through and made sure all residents had a code status located on the gray bar on the electronic medical record visible on every screen on a resident's chart. The DON stated it would be an ongoing process for him to go through and check to make sure the code status was in the electronic medical record of each resident. Both the Administrator and the DON agreed CPR could be performed by one nurse on a resident until EMS arrived; nurses working on other halls do not need to go to the Covid-19 unit to help. An interview was conducted with the facility Medical Director on [DATE] at 5:15 PM. The Medical Director stated that there was an expectation that the nursing staff be able to quickly find the code status of a resident. The Medical Director stated that if a resident started to code, the nurse should first check the code status while someone calls 911. The Medical Director stated that one nurse on the Covid-19 unit could not do CPR alone and help needed to be called from the other halls in the facility. 2. Resident #1 was admitted to the facility from another facility on [DATE] with cumulative [DIAGNOSES REDACTED]. The location of the code status of Resident #1 was in the care plan dated [DATE]. Resident #1 had a focus area for the advance directive of full code. Documentation in a nursing progress note for Resident #1 dated [DATE], written by Nurse #2, stated, Patient was alert and responsive during the beginning of the shift. Patient ate about 25% of dinner. After dinner while CNA's were picking up trays at approximately 6:45 PM patient was found unresponsive. Compressions were immediately started; ambulance crew were called. When ambulance arrived, they took over with compressions. Pulse could not be reestablished. Patient was then pronounced expired by emergency crew. Proper staff were notified (DON, Social Worker). Nurse #2, a travel nurse employed by an agency, was interviewed on [DATE] at 1:14 PM, [DATE] at 2:03 PM and on [DATE] at 10:06 AM. Nurse #2 revealed she arrived to work in the Covid-19 unit on [DATE] at approximately 3:30 PM. Nurse #2 said [DATE] was her first time in the facility and she was not given any directions or orientation to the unit upon arrival. Nurse #2 stated that she received report about the residents from Nurse #1, but she was not told of any concerns with any of the residents during report. Nurse #1 stated she was never told all the residents were fine and she never told Resident #1 was having any kind of respiratory distress or any concerns at all. Nurse #2 stated she was not given any other information upon arrival to the facility. Nurse #2 stated she had 12 residents on her assignment and Nurse #4 had 12 residents on her assignment. Nurse #2 stated she did go into the electronic medical record to look at the vital signs of her 12 residents on her assignment and to familiarize herself with each of their care needs. Nurse #2 stated that after dinner one of the nurse aides (NA #2) came to her and told her Resident #1 wasn't looking right at approximately 6:45 PM. Nurse #2 stated she immediately went into the room of Resident #1 and asked him if he was okay without a response. Nurse #2 stated she found him to be cold to the touch and without a pulse. Nurse #2 stated she along with Nurse #4 moved Resident #1 to the floor using a sheet. Nurse #2 stated she started chest compressions while Nurse #4 went to look for the code status, called 911 and went to get an ambu bag to provide air to Resident #1 because mouth to mouth resuscitation could not be done on a Covid-19 resident. Nurse #2 indicated that when Nurse #4 was unable to find the code status of Resident #1, she went looking for the code status of the resident after EMS arrived to assist with CPR. Nurse #2 stated she was unable for an hour and a half to get in contact with the Director of Nursing to receive assistance in locating the code status of Resident #1. Nurse #4, a travel nurse employed by an agency, was interviewed on [DATE] at 1:49 PM. Nurse #4 stated at the start of the shift on [DATE] Nurse #2 did not have access to the electronic medical records, but that issue was resolved shortly after starting her shift. Nurse #4 stated that she remembered Nurse #2 stating to her there was no way to check the code status of the residents. Nurse #4 stated Nurse #2 was complaining there was no book or folder with the code status of the resident's in it, no list of physician phone numbers, and no list of phone numbers for the Administrator or Director of Nursing on the Covid-19 unit. Nurse #4 stated that all the needed information should have been given to them at the start of the shift and it was not. Nurse #4 indicated she was not given any orientation to the Covid-19 unit at the start of her shift. Nurse #4 stated after the paramedics took over CPR on Resident #1, she ran to the front of the building to get the attention of Nurse #3 on the other unit. Nurse #3 answered the door and told Nurse #4 she would assist her in trying to contact someone to get the code status of Resident #1. Nurse #4 stated one of the nurse aides suggested she call the facility the resident arrived from to obtain the code status. Nurse #4 stated she was not aware of the other facility or who to call. An interview with the Director of Nursing (DON) on [DATE] at 3:59 PM. The DON stated that the first thing he expected the nursing staff to do when a resident was unresponsive was to check the code status of the resident. The DON indicated the code status was in a book at the nurses' station and in the electronic medical record. The DON confirmed Resident #1 was a full code and the Nurses were correct in starting CPR prior to the arrival of EMS. An interview was conducted with the DON on [DATE] at 12:31 PM. The DON stated that the agency staff were shown to their work station upon arrival, given an assignment, and provided with access to the electronic medical record. The DON stated the electronic medical record system the facility uses was known through the industry and the nurses were expected to have the knowledge of how to use it. The DON stated he did at one point realize not all the residents had a code status in the electronic medical record. The DON stated he went through and made sure all residents had a code status located on the gray bar on the electronic medical record visible on every screen on a resident's chart. The DON stated it would be an ongoing process for him to go through and check to make sure the code status was in the electronic medical record of each resident. The DON confirmed Resident #1 was a full code and CPR needed to be initiated when the resident was found unresponsive on [DATE]. An interview was conducted with the facility Medical Director on [DATE] at 5:15 PM. The Medical Director stated that there was an expectation that the nursing staff be able to quickly find the code status of a resident. The Medical Director stated that if a resident started to code, the nurse should first check the code status while someone calls 911. 3. The most recent annual Minimum Data Set assessment, completed on [DATE] at a previous facility, coded Resident #9 as alert and oriented. Resident #9 required limited to extensive assistance with activities of daily living except for eating. Resident #9 was admitted to the facility from another facility on [DATE] with [DIAGNOSES REDACTED]. Documentation in a nursing progress note dated [DATE] at 3:10 PM revealed Resident #9 was experiencing agonal breathing (gasping when a person is struggling to breathe), had a peripheral capillary oxygen saturation rate of 84 % with room air. Resident #9 was seen for a virtual visit from a physician and an order was given to send her to the emergency room . Documentation in a nursing progress note dated [DATE] at 3:45 PM revealed Resident #9 was sent to the emergency room alert and responsive but remained hypoxic (inadequate oxygen level) and [MEDICAL CONDITION] (rapid heartbeat). Resident #9 was placed on a nonrebreather by EMS. Documentation in an emergency medical services report for Resident #9 on [DATE] revealed EMS was called to the Covid-19 unit at 3:18 PM. Upon arrival the EMS staff noted Resident #9 had cold extremities and oxygen saturation levels could not be obtained. After registering a pulse, the resident was put on a nonrebreather. EMS noted the resident was transferred to a stretcher and put in the ambulance for transport to the hospital. Nurse #4, a travel nurse employed by an agency, was interviewed on [DATE] at 1:49 PM. Nurse #4 stated Resident #9 was slumped over and having trouble breathing on [DATE] when she was working on the Covid-19 unit of the facility on the 3:00 PM to 11:00 PM shift. Nurse #4 stated an ambu bag was not on the emergency cart. Nurse #4 stated the emergency cart had not been restocked on the Covid-19 unit in preparation for her shift. Nurse #4 stated she called EMS for Resident #9, told the 911 operator the Covid-19 unit did not have the supplies for CPR, and the ambulance needed to come quickly in case the resident was to code. Nurse #4 stated she did not know how she was going to do CPR on a resident in the Covid-19 unit if she had needed the supplies to do so and did not have them. Nurse #4 stated that most of the Residents on the Covid-19 unit had the advance directive of full code. Observations and an interview with Nurse #8, a travel nurse employed by an agency, were made on the Covid-19 unit on [DATE] beginning at 8:37 AM. The crash cart on the unit was observed to not contain an ambu bag. Nurse #8 stated she was instructed to only do chest compressions on Covid-19 residents and that an ambu bag was not needed. Nurse #8 indicated it was the facility policy that it was the responsibility of the evening shift to restock the emergency cart with needed items. The Director of Nursing (DON) and the Administrator were interviewed on [DATE] at 12:31 PM. The DON stated an ambu bag should be used in place of mouth to mouth resuscitation in addition to chest compressions on the Covid-19 unit when CPR was needed. The Administrator stated that the facility policies and procedures for CPR needed to be followed. An interview was conducted with the facility Medical Director on [DATE] at 5:15 PM. The Medical Director stated CPR was not to be done any differently on the Covid-19 unit, but an ambu bag was to be used along with chest compressions. The facility Administrator was notified of the immediate jeopardy on [DATE] at 11:20 AM. The facility provided an Immediate Jeopardy removal credible allegation on [DATE] at 4:24 PM. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. The facility failed to assure the facility staff were aware of how to locate the code status for Resident #6 and Resident #1. The facility failed to provide the needed supplies for CPR on the Covid-19 unit for Resident #9. The facility failed to provide orientation for agency nurses on how to perform CPR when alone on the Covid-19 unit for Resident #6. All residents have the potential to be affected by this deficient practice. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On [DATE] All nursing staff to include agency were in-serviced regarding the initiation of nursing and medical treatment with acute changes to include how and when to perform CPR but not limited to change in vital signs, level of conscientious, etc. by either the Administrator or Director of Nursing. This will ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is change requiring notification. Discussion topics included accuracy of vital signs; acute changes from baseline; carefully listening to the patient and asking for assistance if indicated; how to get in touch with another nurse or administrative staff outside of business hours. For example, if assistance is needed for the main building in the event of an emergency you may ask for help and notify administration for coverage. Each nursing station is equipped with a step process, a system which provides guidelines for what to do in the event of CPR performed or not initiated per resident's advanced directive which are guidelines on how to handle incidents and provides contact information and contact information for the Administrator, Director of Nursing and Accordius Corporate contacts. The Director of nursing will ensure staff and any agency or travel nurses who were unable to attend received the training via phone and will sign and receive materials prior to working. In-services provided by the Director of Nursing or the Administrator were completed for all staff including agency and travel nurses occurred in small groups to ensure social distancing or via phone for those not in attendance. The licensed nurses were educated by the Director of nursing or the administrator to ask for assistance with any assignments and on to for assistance with acute changes in residents as needed. They may contact a charge nurse, Director of Nursing or Administrator their contact numbers and extensions can be found at the nurses' stations. The education was completed on [DATE] by the DON. Each nursing station is equipped with the step process. The Director of nursing will ensure staff including agency and travel nurses who were unable to attend received the training via phone and will sign and receive materials prior to working. In-services provided by the Director of Nursing or the Administrator were completed for all staff including agency and travel nurses occurred in small groups to ensure social distancing or via phone for those not in attendance. On [DATE] an audit was completed by the Social Services Director for code status validation in the medical record. The audit was completed to ensure every resident has a code status located on PCC (Point Click Care system for documentation) in the upper left side that is readily available to licensed nursing staff. This audit included the blue book located at each nursing station. This book includes the face sheet and code status for each resident in the event of a power outage. An in-service was provided by the Administrator and Director of Nurses to all licensed nurses to include agency on how to access code status. The Director of nursing will ensure staff who were unable to attend including agency and travel nurses received the training via phone and will sign and receive materials prior to working. In- services provided by the Director of Nursing or the Administrator were completed for all staff including agency and travel nurses occurred in small groups to ensure social distancing or via phone for those not in attendance. The Director of Nursing will be responsible for making sure the code status is in place at all times and the information is readily at hand for licensed nurses On [DATE] the Director or Nurses audited all crash carts in the building to ensure all carts are equipped with the necessary equipment to complete CPR (Cardiopulmonary Resuscitation). Crash Carts are sealed with a tag with a number. Only when the tag is broken an audit is required to ensure all equipment is available for immediate use. Replacement supplies are available for immediate use and stored in the supply room. The Director of Nursing assigned the task of checking the crash cart to the night nurse. An audit is performed by the charge nurse on duty when the tag is broken, and supplies are replenished as necessary. Date of Immediate Jeopardy removal [DATE] The credible allegation was verified on [DATE] at 4:12 PM as evidenced by observations, staff interviews, and record review. Interviews were conducted with the nursing staff to conform in-services were done on how and when to conduct CPR, how and when to request assistance with CPR, and how to locate the code status of a resident. Observations were made of the emergency carts for each unit to visualize the carts were sealed with a tag and the supply audits were complete. Observations were made at each nursing unit to confirm emergency phone numbers and the step process was posted as well as for the availability of the blue book with the code status of each resident. Resident records were reviewed of the new admissions to assure code status was in the electronic medical record. Documentation of the code status audit, emergency cart audit, and in-service education on the STEP process and CPR was reviewed. The STEP process is a system which provides guidelines for what to do in the event of CPR performed or not initiated per resident's advanced directive which are guidelines on how to handle incidents and provides contact information and contact information for the Administrator, Director of Nursing and Accordius Corporate contacts. The facility's immediate jeopardy removal date of [DATE] was validated.

Based on record review, staff interview, physician interviews, and emergency medical services interview, the facility failed to recheck the oxygen saturation levels, assess the resident, continuously monitor the resident, and initiate nursing and medical treatment for [REDACTED].#1) of 3 residents reviewed for respiratory care. Resident #1 coded and expired in the facility on [DATE]. Immediate Jeopardy began on [DATE] when Nurse #1 failed to initiate an assessment after being notified by NA #1 of Resident #1 having trouble breathing with a pulse oximetry reading of 66%. Documentation on an ambulance service incident report dated [DATE] revealed Resident #1 died at the facility at 7:42 PM after 3 rounds of cardiopulmonary resuscitation (CPR). The immediate jeopardy was removed on [DATE] when the facility provided and implemented an acceptable credible allegation for Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of an D (No actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place are effective. Findings included: Resident #1 was admitted to the facility from another facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Documentation on a quarterly Minimum Data Set assessment dated [DATE], prior to transfer to the facility, coded the resident as alert and oriented and independent with his activities of daily living. Resident #1 was not coded as requiring oxygen therapy on the [DATE] MDS assessment. Documentation on the care plan, dated as initiated on [DATE], revealed a focus area for Covid-19 suspected/active diagnosis. One of the interventions on the care plan under the Covid-19 focus area was to monitor for any changes in condition. Documentation on the same care plan had a focus area for the advance directive of full code with a BIMS (Brief Interview for Mental Status) score indicating Resident #1 had moderately impaired cognition. Resident #1 did not have a care plan focus area for oxygen therapy. Resident #1 had a current physician's orders [REDACTED]. Resident #1 had an additional physician's orders [REDACTED]. Documentation on the Medication Administration Record (MAR) revealed the oxygen saturation levels of Resident #1 were 99% at 8:00 AM and 12:00 PM on [DATE]. There were no abnormal vital signs documented on the MAR on [DATE]. Documentation on an assignment sheet completed by NA #1 stated that the vital signs of Resident #1 were normal except for a pulse of 121 beats per minute and oxygen saturation level of 66%. The time the vitals were taken was not documented on the assignment sheet. Documentation of the most recent vital signs taken in the electronic medical record were on [DATE] at 7:23 PM and did not include O2 saturation. An interview was conducted with PTA #1 on [DATE] at 9:54 AM. PTA #1 revealed she entered the room of Resident #1 on [DATE] and he was lying flat on the bed with an O2 cannula on. PTA stated Resident #1 was short of breath. PTA stated she raised the head of the bed of Resident #1 and called for NA #1 who was across the hall in another resident's room taking vital signs. PTA #1 stated NA#1 came immediately with a pulse oximeter. PTA #1 stated NA #1 took the vital signs of Resident #1 and she noted that the resident's oxygen saturation level was at 66%. PTA #1 stated NA #1 left the room immediately to tell the nurse. PTA #1 did not know the exact time she went into the room of Resident #1, but she knew it was after 3:00 PM. Documentation in a physical therapy note written by PTA #1 dated [DATE] stated, (Patient) supine upon arrival with 2 (Liters) O2. Short shallow breaths. When asked how he was feeling, (patient) muttered, fine. (Patient) was unable to follow any directions. Asked (nursing assistant) for a pulse oximeter. Vital signs checked. (Blood Pressure) = ,[DATE], (Heart Rate) ,[DATE], O2 ,[DATE]%. Nurse made aware. (Patient) positioned for comfort. The PTA note was electronically signed at 11:52 PM on [DATE]. An interview was conducted with NA #1 on [DATE] at 2:20 PM. NA #1 revealed she went into the room of Resident #1 on [DATE] at 3:30 PM to take his vital signs. NA #1 noted the O2 saturation level of Resident #1 was at 66 %. NA #1 stated that a physical therapist (PTA #1) was in the room with Resident #1 and noted Resident #1 was having trouble breathing. NA #1 stated she immediately went to the nursing staff (Nurse #1 and Nurse # 4) while they were giving report and told them Resident #1 had an O2 saturation level of 66%. NA #1 stated that none of the nurses got up to check on Resident #1. NA #1 stated she continued to monitor Resident #1 and fed him the evening meal. NA #1 stated that she went on break after the service of the evening meal. NA #2 was interviewed on [DATE] at 2:49 PM. NA #2 stated she heard NA #1 tell two nurses about low O2 saturation rate for one of the residents. NA #2 stated the nurses sat there and did not get up. NA #2 stated after NA #1 went on break she was passing the room of Resident #1 and noticed his O2 cannula had fallen out of his nose. NA #2 stated she went into the room and he did not look right, so she immediately alerted his nurse (Nurse #2). An interview was conducted with Nurse #1 on [DATE] at 12:41 PM. Nurse #1 revealed that she was the nurse on the Covid-19 unit on [DATE] scheduled to work from 7:00 AM to 7:00 PM. Nurse #1 stated that she took the vital signs of Resident #1 twice on her shift and they were normal. Nurse #1 stated that respiratory assessments were completed by the nursing staff and the vital signs were taken by the nurse aides two times a shift. Nurse #1 stated that at 3:00 PM on [DATE] two more agency nurses (Nurse # 2 and Nurse # 4) came to work on the Covid-19 unit. Nurse #1 stated that she stayed in the Covid-19 unit until 4:00 PM because three nurses were not needed. Nurse #1 stated toward the end of her shift in the middle of counting narcotics at the medication cart and giving report with another nurse (Nurse #4), the second shift aide (NA #1) came up and told them the O2 saturation levels were low on Resident #1. Nurse #1 stated that they were in the middle of counting narcotics and needed to complete the task. Nurse #1 said the other nurse (Nurse #4) told the second shift nurse aide (NA #1) she would go and check on the resident after the counting of medications was complete. Nurse #1 stated she did not go down to check the breathing status of Resident #1 because the other nurse (Nurse #4) stated she was going to check on him after the completion of counting the medications. Nurse #2 was interviewed on [DATE] at 1:14 PM, [DATE] at 2:03 PM, and on [DATE] at 10:06 AM. Nurse #2 revealed she arrived to work in the Covid-19 unit on [DATE] at approximately 3:30 PM. Nurse #2 said [DATE] was her first time in the facility. Nurse #2 stated that the Covid-19 unit already had two other nurses when she arrived (Nurse #1 and Nurse #4). Nurse #2 stated that the scheduler was called to determine if the three nurses (Nurse #1, Nurse #2 and Nurse #4) were needed. Nurse #2 stated that she received report about the residents from Nurse #1, but she was not told of any concerns with any of the residents during report. Nurse #1 stated she was never told all the residents were fine and she never told Resident #1 was having any kind of respiratory distress or any concerns at all. Nurse #2 stated she was not given any other information upon arrival to the facility. Nurse #2 stated she had 12 residents on her assignment and Nurse #4 had 12 residents on her assignment. Nurse #2 stated she did go into the electronic medical record to look at the vital signs of her 12 residents on her assignment and to familiarize herself with each of their care needs. Nurse #2 stated that after dinner one of the nurse aides (NA #2) came to her and told her Resident #1 wasn't looking right at approximately 6:45 PM. Nurse #2 stated she immediately went into the room of Resident #1 and asked him if he was okay without a response. Nurse #2 stated she found him to be cold to the touch and without a pulse. Nurse #2 stated she along with Nurse #4 moved Resident #1 to the floor using a sheet. Nurse #2 stated she started chest compressions while Nurse #4 went to look for the code status, called 911 and went to get an ambu bag to provide air to Resident #1 because mouth to mouth resuscitation could not be done on a Covid-19 resident. Nurse #2 stated that emergency medical services (EMS) arrived at approximately 7:30 PM. Nurse #2 stated that she did not see Resident #1 prior to him coding nor did she have knowledge of the O2 saturation level of 66% taken by NA #1. Nurse #2 stated that if she had received nursing report of any of the residents having a concern, she would have addressed it. Nurse #4 was interviewed on [DATE] at 1:49 PM. Nurse #4 revealed she was an agency nurse and she arrived on the Covid-19 unit at 3:00 PM. Nurse #4 stated that Nurse #1 was sitting at a desk on the Covid-19 unit when Nurse #4 overheard NA #1 tell Nurse #1 that one of the one of the residents had low oxygen saturation levels and expressed her concern. Nurse #4 stated she had not yet received report and she did not know the name of the resident. Nurse #4 stated she expected Nurse #1 to go and check on the resident prior to leaving the facility because it was her responsibility. Nurse #4 stated Nurse #1 did not get up to check on the Resident with NA #1. Nurse #4 stated Nurse #1 went home after giving report because the Covid-19 unit did not need three nurses. Nurse #4 stated the 24 residents on the Covid-19 unit were divided between herself and Nurse #2. Nurse #4 stated that Resident #1 was not assigned to her. Nurse #4 confirmed that after dinner she was called into the room of Resident #1 by Nurse #2 upon the discovery Resident #1 was unresponsive. Nurse #4 stated that both she and Nurse #2 assisted Resident #1 to the floor. Nurse #4 stated she ran to check the code status of Resident #1, but she could not find it in the electronic medical record. Nurse #4 stated she went to get the emergency cart and found an ambu bag. Nurse #4 stated that both she and Nurse #2 continued with CPR until the paramedics arrived. Nurse #4 stated she did not realize until after the coding event that the resident with low oxygen saturation levels reported by NA #1 was the same resident who coded. Documentation on the meal service delivery schedule revealed the dinner meal service to the Covid-19 unit was served at 5:15 PM. Documentation on percentage of meal consumption records for Resident #1 dated [DATE] revealed he refused breakfast and lunch and ate 0 to 25 % of the dinner meal. NA #1 was interviewed again on [DATE] at 10:50 AM. NA #1 stated she left for her break on [DATE] at 6:45 PM and returned from break at approximately 7:20 PM. Documentation on an EMS incident report for Resident #1 dated [DATE] revealed, Station 19 was dispatched to a call for CPR in progress. Units 1910, 1911, and 1900 responded. Upon arrival on scene pt (patient) was found laying supine on the floor. Staff stated the last time seen normal was around the time (6:00 PM) and pt was found at the time 6:45 PM. Pt was cold to the touch. Nursing home staff had already initiated CPR before EMS arrival. (Automated External Defibrillator) pads were attached to the pt by EMS. Pt was asystole. (Asystole is a dire form of [MEDICAL CONDITION] in which the heart stops beating and there is no electrical activity in the heart.) Time of death was called in the field at the time of (7:42 PM.) Pt physician was contacted to sign Death Certificate. Pt was turned back over to nursing home staff. Proper signatures were obtained. EMS cleared. EMS was called at 7:19 PM and EMS arrived at 7:35 PM. An interview was conducted on [DATE] at 4:45 PM with the lead emergency medical technician (EMT) who responded to the 911 call from the facility on [DATE] for Resident #1. The lead EMT stated she arrived at the facility and took over CPR from a first responder who arrived on site prior to the arrival of the EMT. The lead EMT stated three rounds of CPR were performed on Resident #1 and the resident remained in asystole. An interview with the Director of Nursing (DON) conducted on [DATE] at 3:59 PM. The DON revealed on [DATE], NA #1 came to him in the evening and told him of her concern for the lack of response when she told the nursing staff about the low oxygen saturation levels for Resident #1 on [DATE]. The DON stated that at that point he had not yet investigated the concern of NA #1. An additional interview was conducted with the DON and the Administrator on [DATE] at 12:31 PM. The DON stated that he did not have the expectation that the nurses round on their residents at the start of the shift. The DON stated that he would have expected Nurse #4 to go and assess Resident #1 based on what information NA #1 shared with the nursing staff. The DON stated that the agency staff were shown to their work station upon arrival, given an assignment, and provided with access to the electronic medical record. The DON stated that the electronic medical record system the facility uses was known through the industry and the nurses are expected to have the knowledge of how to use it. An interview was conducted with the physician (MD #1) of Resident #1 on [DATE] at 12:22 PM. MD #1 stated that he did not think the pulse oximetry device was used correctly on Resident #1 to obtain the measurement of 66 %. MD #1 stated that the pulse oximetry needed to be taken again correctly. MD #1 stated that Resident #1 had multiple comorbidities. MD #1 stated that if Resident #1 was in distress then an assessment should have been done while looking at the resident. MD #1 stated that he would have expected the nurse to call him if the second pulse oximetry reading correctly done gave the same low reading. MD #1 stated he doubted Resident #1 was in distress but if he was then he would have instructed the nurses to increase the oxygen he was receiving to see if that would help. MD #1 stated there were so many levels to an emergency but, if the resident was short of breath, then it could have been a medical emergency. An interview was conducted with the facility medical director (MD #2) on [DATE] at 5:15 PM. MD #2 stated that the nurses should respond immediately to a report of oxygen saturation level of 66% for a resident with Covid-19 having trouble breathing. MD #2 stated the nurse should first recheck the oxygen saturation level for the resident and make sure the resident was not in distress. MD #2 stated that if the resident was in distress then the nurse should send the resident to the hospital immediately. MD #2 stated that if the pulse oximetry reading was a false reading or due to poor circulation then emergency measures are not needed. MD #2 stated that if the oxygen saturation level for a Covid-19 resident was below 90 % the nurse should send the resident to the emergency room immediately. MD #2 stated that as the medical director for the facility, the staff could call him at any time to seek his medical advice. MD #2 stated that a physician should be informed if the resident was having respiratory distress. MD #2 stated that a confirmed pulse oximetry reading of 66 % was a medical emergency. Documentation on the death certificate of Resident #1 revealed the immediate cause of death was [MEDICAL CONDITION] with the underlying causes being Hypertension, Covid-19, and Diabetes Mellitus. The facility Administrator was notified of the immediate jeopardy on [DATE] at 1:30 PM. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. The facility failed to recheck the oxygen saturation levels, assess resident #1, continuously monitor resident #1, and initiate nursing and medical treatment for [REDACTED]. All residents have the potential to be affected by this deficient practice. On [DATE] a record review of any vital signs available was completed by the MDS nurse on all residents in the building for the previous 72 hours. Vital signs were within baseline. No areas of concerns were identified. Root cause analysis conducted revealed the alleged non-compliance resulted from failure to respond to an acute change in condition which was communicated as having an oxygen saturation of 66%. A 24-hour initial allegation of neglect was faxed to NC Department of Health Human Services, Division of Health Service Regulation on [DATE] at 8:00PM. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete On [DATE] all residents (census 102) received a respiratory assessment to ensure there are no acute change in condition by the Director of Nursing, Unit Manager and Charge Nurse. There were no acute changes in conditions identified. On [DATE] All nursing staff to include agency were in-serviced regarding the initiation of nursing and medical treatment with acute changes to include but not limited to change in vital signs, level of conscientious, etc. by either the Administrator or Director of Nursing. This will ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is change requiring notification. Discussion topics included accuracy of vital signs; acute changes from baseline; carefully listening to the patient and asking for assistance if indicated; how to get in touch with another nurse or administrative staff outside of business hours. Each nursing station is equipped with a step process, a system which provides guidelines for what to do in the event of but not limited to falls with significant injury, equipment malfunction, elopement etc. which are guidelines on how to handle incidents and provides contact information and contact information for the Administrator, Director of Nursing and Accordius Corporate contacts. Staff who were unable to attend received the training via phone and will sign and receive materials prior to working. In-services for all staff including agency occurred in small groups to ensure social distancing or via phone for those not in attendance. Reference materials were included. The licensed nurses were educated to ask for assistance with assignment of acute changes as necessary. They may contact a charge nurse, Director of Nursing or Administrator The education was completed on [DATE] by the DON. Each nursing station is equipped with the step process. Contact information can be found at the nursing stations within the Step Process instructions. Staff who were unable to attend received the training via phone and will sign and receive materials prior to working. In-services occurred in small groups to ensure social distancing or via phone for those not in attendance. The Administrator, DON, and nurse management team-initiated re-education to all staff regarding abuse, neglect and exploitation on [DATE]. An example was given that the failure to respond timely to a change in condition could be considered neglect. Staff who were unable to attend received the training via phone and will sign and receive materials prior to working. In-services occurred in small groups to ensure social distancing or via phone for those not in attendance. Completed on [DATE]/2020. On [DATE] an audit was completed for code status was completed. The audit was completed to ensure every resident has a code status located on PCC (Point Click Care system for documentation) in the upper left side that is readily available to licensed nursing staff. An in-service was provided by the Administrator and Director of Nurses to all licensed nurses to include agency on how to access code status. Staff who were unable to attend received the training via phone and will sign and receive materials prior to working. In-services occurred in small groups to ensure social distancing or via phone for those not in attendance. Acute changes include but not limited to changes in vital signs, low oxygen saturation rates and breathing problems new or worsening skin issues, changes in weight, etc. will be monitored during the daily clinical review by the nursing leadership. Nurses #1, #2, #4 no longer work at this facility. Nurses #1, #2 and #4 will not respond to nursing leadership at this facility. On [DATE] an in-service was provided to all licensed nurses and Certified Nursing Assistants by the Director of Nursing regarding who is responsible to obtain an oxygen saturation. CNAs will not be obtaining oxygen saturation. Licensed staff will obtain oxygen saturation levels. Staff who were unable to attend received the training via phone and will sign and receive materials prior to working. In-services occurred in small groups to ensure social distancing or via phone for those not in attendance. A written agenda was provided to staff for reference. Date of immediate jeopardy removal [DATE] The credible allegation was verified on [DATE] at 11:00 AM as evidenced by observations, staff interviews, and record review. Interviews were conducted with the nursing staff to confirm in-services on the initiation of nursing and medical treatment with acute changes to include the step process were completed. Interviews were conducted with the licensed staff to confirm in-services on asking for assistance with assignment of acute changes were completed. Interviews were conducted with both front line and administrative staff to confirm all staff had been re-educated on the facility abuse, neglect, and exploitation policy. Observations and interviews were made of the availability of the step process and administrative contact information at the nursing stations. Documentation of audits of vitals, code status audits, a 24-hour report of neglect for Resident #1, daily clinical risk meeting forms, and in-service education was reviewed. The facility removed immediate jeopardy on [DATE].

Based on record reviews, observations and resident and staff interviews, the facility failed to ensure the lift platform of the facility's transport van was in the elevated position before unloading a resident from the van for 1 of 3 residents reviewed for accidents (Resident #1). When unloading Resident #1, who was seated in a wheel chair, from the facility's transport van, the staff failed to raise the van's lift platform to floor level which resulted in Resident #1 falling from the transportation van. Resident #1 was transported to the hospital for evaluation and treatment and sustained a subarachnoid hemorrhage and posterior scalp abrasion. The findings include: The manufacturer's instructions for unloading a passenger from the facility's transportation van was reviewed. The manufacturer's instructions read in part, To unfold platform stand clear until the platform stops (reaches floor level-unfolds fully) release switch. To unload passenger, Note: Outer barrier must be fully unfolded (ramp position) until the entire wheelchair (or standee) has crossed the outer barrier. Load passenger onto platform and lock wheelchair brakes. Note: Outer barrier must be up. Press down switch until the entire platform reaches ground level and the outer barrier unfolds fully (ramp position). Release switch. Unlock wheelchair brakes and unload passenger from platform. Resident #1 was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the most recent Admission Minimum Data Set ((MDS) dated [DATE], Resident #1's cognition was intact. The resident needed extensive assistance with transfers and required physical assistance of one person. Resident #1 was totally dependent with locomotion (use of wheelchair) both inside and outside the facility. Resident #1's care plan dated 5/29/18 identified her as being at risk for falls related to gait/balance problem and incontinence. The goal was for Resident #1 to be free from falls and not sustain serious injury through the next review date. The interventions included assist with all transfers and locomotion. Follow facility protocol for fall. Patient evaluation and treatment as ordered or as needed. On 6/6/18, other goals were for Resident #1 to be free of minor injury through the next review date. Review of a Nurse's note dated 6/25/18 at 5:48 PM, read in part, Resident had a witnessed fall this shift. This writer observed a hematoma to the middle back area of her head. She also had some bruising to the top of her back from shoulder to shoulder. Resident denies any pain. Resident has some confusion but not loss of consciousness. Resident's family members made aware. Doctor notified. Emergency medical services was contacted and the resident is off of the facility grounds at this time. They have resident as DNR (do not resuscitate) and all significant paperwork for transport to the hospital. Review of a note written by the Administrator on 6/25/18 at 8:10 PM revealed she contacted Resident #1's family member regarding the resident's fall and informed the family member that an investigation was in progress and the family member would be informed of the investigation outcome. Review of a nurse's note dated 6/25/18 at 9:00 PM revealed a report was received from the hospital emergency room staff stating Resident #1 was being sent to the medical center due to a head injury. Review of another Administrator's note dated 6/25/18 at 9:39 PM revealed she spoke with Resident #1's family member to provide an update on how Resident #1 was doing and provided an update on the investigation surrounding the fall. The Administrator explained there was no mechanical or operational failure with the wheelchair or van lift gate and the fall was the result of human error. Review of Resident #1's hospital discharge summary dated 6/26/18, which was written by a trauma nurse practitioner in the hospital, revealed in part, Active hospital problems: Diagnosis: [REDACTED]. Patient was coming back from [MEDICAL TREATMENT] being transported in a wheelchair out of the side and landed on her back on the loading ramp. She did strike her occipital skull but does not remember if she had level of consciousness. She was otherwise neurologically intact and did not complain of nausea, emesis, or headache. She was taken to hospital where a Computed Tomography Scan (CT scan) of her head identified subarachnoid hemorrhage and she was noted to have a small abrasion to her posterior cranium. During an interview on 7/10/18 at 12:50 PM Resident #1 said she did not remember what happened. She stated when she came to she was on the ground and she saw people around her. She revealed there was a problem with the back of her head and she said she felt it the other day and it was bleeding a little bit. Resident #1 revealed other than that she was fine. During an interview on 7/10/18 at 2:52 PM, Nursing Assistant (NA)#1 stated the Assistant Director of Nursing (ADON) wanted her to pick up residents with the facility van from the [MEDICAL TREATMENT] center on 6/25/18. She revealed she transported two residents from the [MEDICAL TREATMENT] center, Resident #1 and a male resident, to the facility. NA#1 reported that the male resident was in the back of the van with a soda and turned his soda over on the floor of the van. She said Resident #1's wheelchair got stuck on the wheelchair anchor on the floor of the van. NA#1 stated she was standing in front of Resident #1's wheelchair trying to get it unstuck. She stated she had to push Resident #1's wheelchair back and she slipped. NA #1 explained as she slipped she had the lift control in her hand and she must have fallen forward and when she did she accidentally pushed the lift control button. NA #1 stated she fell into the wheelchair and she held the wheelchair with her right hand as much as she could to prevent it from falling. She said the wheelchair was turned sideways up in the air. NA#1 stated she did not know how far the lift had gone down. She said there was no one there to help her and she did the best that she could. NA #1 stated the lift did not go all the way down and it did not hit the pavement. She said she held onto the wheelchair as much as she could and got the wheelchair upright before she got out of the van. NA#1 said she had to go outside the van to get the lift down on the ground safely. She stated she made sure Resident #1 was secure and would not fall anymore before she went inside the facility to get help. NA#1 emphasized no part of Resident #1's body touched the ground. NA #1 had been trained to transport residents in the facility van but had not transported residents for seven or eight months. NA#1 reported she was trained to transport residents in wheelchairs. During an interview on 7/10/18 at 4:20 PM, Staff Nurse #1, who assessed Resident #1, after her fall on 6/25/18 revealed she was called outside from the building. She stated Resident #1 was lying on her back and her wheelchair was still under her. She revealed she took the resident's her vital signs and called 911 to get emergency medical services. Staff Nurse #1 said she made sure Resident #1's head was stable. She revealed Resident #1 was conscious the entire time. She stated the lift on the van was down and the wheelchair had come out from under resident half way. Staff Nurse #1 stated Resident #1 was lying on her back and her knees were bent. She said Resident #1 was lying in her wheelchair on the lift facing the back of the van. She said the ramp was between the resident and the pavement. Staff Nurse #1 explained Resident #1's head was on the lift ramp and her feet were dangling under the seat of the wheelchair. Staff Nurse #1 stated Resident #1 denied pain the entire time. She reported that Resident #1 had some bleeding from the back of her head. She stated she waited until emergency medical services (ems) arrived and she did not move Resident #1. Staff Nurse #1 revealed Resident #1 was conscious and was able to tell staff her name and where she was. During an interview on 7/10/18 at 4:41 PM, the Administrator stated on 6/25/18 NA #1 came in the building hollering brake failure, brake failure! She stated she ran outside and observed Resident #1 was lying on top of the lift gate from waist up and from waist down she was leaning up against the bumper of the van. The Administrator said she got onto the van to see if she could figure out what happened. She stated the Assistant Director of Nursing and Activity Assistant also came out to assist. She stated the brake on the van was operating properly. The Administrator revealed she looked at the floor of the van to see if there was anything out of the ordinary and after checking out the van she went back inside the building to talk to NA#1. She stated NA#1 said the brakes on the wheelchair failed. The Administrator stated about that time, the maintenance man showed up and they checked out the wheelchair and the van. The Administrator revealed both the lift and the wheelchair brakes were operating properly. She stated she told NA#1 the brakes on the wheelchair were working fine. She stated NA#1 said it happened so fast that she did not know what happened. She stated she told NA#1 to tell her step by step what happened. The Administrator stated NA#1 said she took the male resident inside the building and she went back outside to get Resident #1. NA#1 said she got back on the van by going around the van to the passenger side and got back in the van. NA#1 stated after she got back on the van, she unstrapped the belts from the security device on the floor of the van as well as undoing the shoulder harness and seat belt on Resident #1. She said NA#1 stated Resident #1's wheelchair started rolling backwards and she tried to hold onto the wheelchair as best she could, but she could not stop Resident #1 from falling out of the back of the van. The Administrator said asked NA#1 to write a statement the next day, which was different from what NA#1 reported the previous day. The Administrator stated as part of her investigation, she re-enacted the scene. She explained, in order for the lift to lower you had to have your finger on the control button continuously. She stated NA#1 said when she could not stop the wheelchair from rolling backwards, she held onto the wheelchair as hard as she could and she lowered the wheelchair as soft as she could so Resident #1 would not land so hard. The Administrator further revealed the resident was sent went to the hospital and she suspended NA#1. She stated after she got all the statements after the investigation and reviewed them, she stated everything pointed to the lift was never put back in position to lower Resident #1 to the ground in her wheelchair. She stated when NA#1 brought the male resident in the building, she never put the lift gate back up. She stated the lift gate was working fine and nothing was wrong with the equipment. The Administrator stated the lift gate was down on the ground instead of in the up position, therefore the Resident #1's wheelchair rolled back off the van and NA#1 tried to catch it to prevent it from falling. The Administrator said she wrote a plan of correction. She stated maintenance does the training and oversees it. She stated the plan of correction was discussed in the small QAPI meeting and they will review the plan again with the big QAPI meeting to see what changes were needed and whether the plan was effective or not. She stated there was nothing created regarding monitoring. She stated the most effective thing was to have a second person to assist when residents returned from [MEDICAL TREATMENT] appointments. The Administrator explained after the maintenance man checked the equipment and got with staff, she stated van drivers always rode the lift gate back up after taking one wheelchair off the van. She stated if a person went around the passenger side, then it was too late. The Administrator stated she revised the check list form to make sure everything was operating properly. The Administrator revealed the van drivers got a second training to make sure safety precautions were followed and for new drivers to have more in-depth training. The Administrator reported that NA#1 had been driving handicapped vans for over ten years. She stated the incident was human error and to minimize opportunities for the situation happening again she said two sets of eyes would be required before any other resident's wheelchairs were detached or unsecured. The Administrator stated after she finished getting all the statements during the investigation she determined that the incident was operator error. She stated the staff person neglected to put the lift gate back up and that is what resulted in the fall. She stated NA #1 was terminated. The Administrator stated she went back through risk records and it was the first incident they have had on a van. She stated the incident was a result of staff error. During an interview on 7/10/18 at 5:37 PM, the Maintenance Director revealed he was not there when the incident happened, he was off. He stated he was called to come in after hours. He said he assessed the lift and wheelchair, they were inspected properly and the brakes on the wheelchair worked fine. The Maintenance Director said he wrote a statement and gave it to the Administrator. He said he did training for van drivers. He explained after the incident he did observations and there had been extra precautions since the incident. The Maintenance Director said the lift was working totally fine on 6/25/18. He said it was operator error from what he saw. He said he got in the van and there were no spills. He said new drivers do an inspection report and turn it in before they leave. He stated he observed van drivers several times to make sure they were safe. He stated he completed observation sheets when he conducted his observations. The Maintenance Director could not provide documentation of the last time NA#1 was last observed or evaluated for transport van and transporting a resident in a wheelchair for the facility. During an observation on 7/11/18 at 10:25 AM Resident #1 was being assisted on van to go to a [MEDICAL TREATMENT] appointment. Resident #1 was placed on the wheelchair. One NA used remote control outside the van to lift Resident #1's wheelchair on to the van and the other NA was inside the van in front of the wheelchair, secured the wheelchair front and back to the floor anchors and placed a shoulder harness and seat belt securely on the resident. 1. During an observation on 7/11/18 at 12:20 PM Resident #1 returned from her [MEDICAL TREATMENT] appointment on the van. The van driver unhooked the belts from the floor that were attached to Resident #1's wheelchair and shoulder harness and seat belt on Resident #1. After releasing the seat belt and harness, another NA went to the back of Resident #1's wheelchair and pulled the wheelchair onto the lift gate which was already in the up position. Resident #1 remained on lift and held onto the bars on lift gate as the NA pushed the control button to lower the lift gate to the ground. Once the wheelchair and the lift was on the ground, the NA rolled the wheelchair from the lift, which was on the ground and took resident back in the building. During an interview on 7/12/18 at 1:52 PM, Resident #1's doctor said he was aware of Resident #1's fall from the facility's transport van on 6/25/18. He said it was an accident. He said he saw her yesterday (7/11/18) and she was fine. The doctor said as a result of the fall Resident #1 had a subarachnoid hemorrhage which was bleeding in the lining of the brain, not the brain itself. He stated he had not noticed any significant changes. The doctor revealed Resident #1 already had a blood disorder and she was on blood thinners, which she had a risk for bleeding, not necessarily because of the injury, but because of the blood disorder. On 7/12/18 the facility provided an acceptable plan of correction with a correction date of 6/27/18. The plan of correction included: The plan for correcting the specific deficiency: The deficient practice of failing to prevent an accident occurred when a C.N.A. (trained and experienced in the transporting of residents) failed to follow the proper policy and procedure for safely transporting residents, including the proper management of the transport vehicle lift-gate. On (MONTH) 25th while un-boarding a resident returning back from [MEDICAL TREATMENT], the C.N.A./transport aide failed to put the transport bus lift gate in the up position prior to disengaging the wheelchair from the transport vehicle security straps. She was unable to control the wheelchair from rolling and with the gate in the down position, there was no barrier to stop the fall. This failure to follow both facility safety transport policy and the manufacturers' safety recommendations, resulted in the residents fall from the back of the transport vehicle. An analysis of the incident was initiated immediately and included a thorough inspection of the scene, re-enactment of the C.N.A.s account of what transpired (she attributed the fall to brake failure on the resident's wheelchair) and gathering statements from all staff members who responded to the incident). When investigating as to why the lift-gate was in the down position, we discovered that after the C.N.A. had already un-boarded one resident and returned him safely into the facility, she re-boarded the transport vehicle through the passenger entrance, versus riding the lift-gate back up to its' secured position. The resident's wheelchair and the transport vehicle were locked-out/tagged out until checked by the Maintenance Director who arrived at the facility approximately 6:30 p.m. Equipment failure was ruled out as a contributing factor to the fall. The C.N.A. was immediately removed from all duties and responsibility and was sent home as soon as we were able to have a family member come pick her up at the facility (due to her emotional state it would not have been safe for either herself or other drivers to allow her to drive) At the conclusion of the completed investigation she was subsequently terminated on (MONTH) 27th for findings of failure to follow protocol, safety procedures and failure to prevent an accident. On (MONTH) 26th we implemented having a second person to assist in the process of un-boarding residents returning from appointments or activity functions. On (MONTH) 27th in a meeting between the Administrator and Maintenance Director, the process for the training of any new personnel responsible for resident transport was restructured to include a more detailed and extensive real-life training experience and observation of safe driving skills. Employees must be signed-off by the Maintenance Director prior to being assigned the responsibility of driving or riding as a transport assistant. 1. Implementing the plan of correction was completed through the following corrective actions: On the evening of (MONTH) 25th the Administrator developed a revised resident transport skills safety assessment and presented it to members of the QA Committee the morning of (MONTH) 26th. It was adopted as our new process and the new resident transport safety assessments were initiated that afternoon. The Maintenance Director utilized the transport safety checklist for all authorized drivers and transportation assistants to be reassessed for skill competency in transportation. On (MONTH) 26th transport and activities staff were re-educated regarding the importance of returning the lift-gate back to its upright position after un-boarding a resident. Education consisted of verbal instruction, securing the wheelchair and participation in real-life on the road, safe transport skills driving training. In addition to boarding and un-boarding procedures, all participants were required to be observed driving and securing/unsecuring wheelchairs, all safety components i.e location and use of the fire extinguisher, first aid kit, safety cones, etc. 2. Monitoring the plan of correction for compliance with safety standards and the policy and procedures for preventing accidents include the following: Random un-boarding observation audits were initiated by the Maintenance Director and conducted by the Maintenance Director or his Assistant beginning on (MONTH) 26th to ensure two (2) staff members were engaged in the un-boarding process. These observation audits were implemented by the Maintenance Director to verify the staff were following process expectations and training protocols. An observation tool was created to formally document the safety observation audits. Audit tools will be reviewed bi-weekly by the Administrator and during QAPI meetings for three months or until sustained compliance is achieved 3. The Administrator and Maintenance Director were accountable for initiating all corrective actions immediately following the incident on (MONTH) 25th and completing the process on (MONTH) 27th. The facility alleges full compliance with this plan of correction effective 6/27/18. As part of the validation process on 7/12/18, the plan of correction was received including the re-education of van drivers and observations and interventions put into place to ensure two staff members were engaged in the process of unboarding of residents. Interviews with transport drivers revealed they were retrained to ensure two staff assisted in the process of unboarding residents. Residents who were transported in the van were interviewed to make sure they felt safe. A review of the monitoring tool revealed that the facility completed the audits and re-training of van drivers. The plan was verified for compliance effective 6/27/18.