Every finding on record at Alamance Health Care Center

Based on observation, and interviews with residents, staff, and Pest Control Technician the facility failed to ensure that 1) staff contained food soiled clothing in a laundry basket located in a room where multiple roaches were observed harboring 2) the facility staff and the pest control technician worked together in order that residents were out of their rooms if needed for pest control measures to take place as planned 3) staff worked with a pest control company to identify and initiate a way to treat roaches potentially harboring in the inner walls and within electrical equipment on a unit identified to have multiple rooms with German roaches. This was for one (Mauve 2) of three facility units.The findings included:1a. Resident # 18 was admitted to the facility on [DATE] and resided on Mauve 2 within the facility.Review of Resident # 18's 6/12/26 quarterly Minimum Data Set assessment revealed Resident # 18 was cognitively intact.Record review revealed Resident # 17 was admitted to the facility on [DATE] and resided on Mauve 2 within the same room as Resident # 18. Resident # 17's 8/12/26 annual Minimum Data Set assessment coded Resident # 17 as cognitively impaired and as needing partial to moderate assistance to turn in bed.During an interview with Nurse Aide (NA) # 1 on 8/19/26 at 12:08 PM, NA # 1 reported the following information. Every day during which she worked on Mauve 2 she saw live roaches. They climbed on the ceilings and the floors. Resident # 17's and Resident # 18's room was one of the rooms in which she saw roaches. NA # 1 was accompanied to Resident # 17's and Resident # 18's room. Upon entering there was a roach between the two residents' beds which moved when walking closer to it. There was a strong odor within the room. There was an overflowing basket of laundry on Resident # 18's side of the room. NA # 1 reported that Resident # 18 tended to drool and the resident kept a washcloth or bib on her clothing. On the top of the pile of laundry, it was visible that there was a washcloth soiled with food and some soiling of clothes with food remnants. NA # 1 reported she typically tried to bag and send the clothing down to laundry when she worked with the resident. NA # 1 was observed to move Resident # 18's trashcan beside the resident's bed and three roaches ran out from behind it. NA # 1 reported the roaches tended to stay in the corner near Resident # 18's trashcan and by Resident # 18's bedside nightstand.On 8/19/26 at 12:35 PM the Administrator was accompanied to Resident # 17's and Resident # 18's room and observed the overflowing basket of soiled laundry and validated she smelled an odor in the room. The Administrator reported she was aware there were roaches in the facility, and the soiled laundry should have been bagged. The Administrator further reported they were working to try to obtain another pest control management company to take over services in the facility because they felt the current pest control company was not helping solve the problem.On 8/19/26 at 12:40 PM Housekeeper # 1 was observed entering Resident # 17's and Resident # 18's to clean. Housekeeper # 1 reported the following information. Every day she cleaned the room and saw roaches. She thought they were in the oxygen concentrator used by Resident # 17 because every day when she cleaned and moved the concentrator, roaches ran out on the floor from behind it. Housekeeper # 1 was observed to move the oxygen concentrator on Resident # 17's side of the room, and three roaches were observed to run out from under it.On 8/20/26 at 8:50 AM Resident # 18 was interviewed and was observed to communicate by motioning with her hands. When asked if she saw roaches in the room, Resident # 18 responded with a thumbs up, indicating yes. When asked if the roaches had been in her bed, Resident # 18 responded with a thumbs down. Resident # 18 was interviewed regarding where she saw the roaches and motioned towards her trashcan and the wall beside her bed.NA # 2 was interviewed on 8/20/26 at 11:40 AM and reported the following information. He cared for Resident # 17 and Resident # 18 at times. He had witnessed a roach in Resident # 17's bed on one occurrence when he pulled back the covers to care for her. The roach was not on her at the time but in the bed. He estimated that this had occurred within the last 2 to 3 months. NA # 2 reported he saw roaches everywhere on Mauve 2. He reported the facility was trying to deep-clean the rooms to take care of the problem.Nurse # 4 was interviewed on 8/20/26 at 9:00 AM and reported she had seen roaches on Mauve 2 for a while. The facility had been cleaning, and she had talked to the Nurse Aides about not letting soiled laundry pile up.During interviews with Unit Manager # 1 on 8/20/26 at 9:20 AM and again on 8/20/26 at 11:15 AM, Unit Manager # 1 reported they were aware there were roaches on Mauve 2, but the facility's pest control company was spraying, and they were trying to rectify the problem. Unit Manager # 1 was interviewed regarding Housekeeper # 1's belief that the roaches were in Resident # 17's oxygen concentrator and reported the following information. A week prior she (Unit Manager # 1) removed Resident # 17's oxygen concentrator and gave her a new one because there seemed to be a possible problem. The old oxygen concentrator had been placed outside, and she did not know how roaches could be within the new oxygen concentrator. Unit Manager # 1 was accompanied to Resident # 17's room and the oxygen concentrator was moved. When it was moved, four roaches ran out from around it.1 b. Record review revealed Resident # 20 was admitted to the facility on [DATE]. Resident # 20's 7/30/26 MDS assessment coded the resident as cognitively intact. Resident # 20 was interviewed on 8/19/26 at 11:05 AM and reported the following information. He had just moved to his current room on 8/17/26 because he had resided on Mauve 2 and the facility had to bomb his room due to the roaches. The roaches had been on the floor and the walls while he resided on Mauve 2. 1c. Record review revealed Resident #1 was admitted to the facility on [DATE] and resided on Mauve 2 within the facility. Resident # 1's admission Minimum Data Set assessment, dated 7/31/26, coded Resident #1 as cognitively intact.On 8/19/26 at 12:08 PM Nurse Aide (NA # 1) was interviewed and reported that Resident #1 was alert and able to report problems with pests. According to NA # 1, Resident #1 reported he had seen roaches in his room that morning. NA # 1 further reported she saw live roaches in multiple residents' rooms on Mauve 2 daily when she worked.Resident #1 was interviewed on 8/19/26 at 12:25 PM and reported he daily saw roaches in his room, and he had seen five or six live roaches in his room that morning. Resident #1 was interviewed regarding whether he had reported the issue and responded that the staff could see the roaches themselves.Resident #1 was interviewed again on 8/20/26 at 9:09 AM and reported he had again seen roaches on the floor in his room last night.1d. Resident #14 was admitted to the facility on [DATE].A quarterly Minimum Data Set assessment, dated 6/19/26, indicated Resident #14 was cognitively intact.On 8/20/26 at 9:40 AM Nurse Aide (NA) # 3 was interviewed and reported she often worked on Resident #14's hall and had seen roaches in the residents' rooms specifically on the floors and walls.On 8/20/26 at 9:55 AM Nurse # 5 was interviewed and reported she had seen roaches in residents' rooms. Resident #14 was interviewed on 8/20/26 at 6:45 PM and reported since moving to his current room after the July 4th holiday, he had seen roaches on the floor and walls during the day and night. Resident #14 added he had reported his concerns to nursing staff. The facility's pest control technician was interviewed on 8/20/26 at 2:41 PM and reported the following information about his treatment plan, issues he had encountered, and how roaches reproduced. The facility had German roaches. It had been problematic for about two to three months. One German female roach can reproduce every seven days until the female roach dies and thereby yield multiple roaches in her lifetime. Thus, a roach population can grow quickly in any dwelling. Roaches could also emit a smell which can be similar to a urine odor when there were numerous ones. One issue he had encountered while trying to resolve the facility's roach problem was that residents were not always out of their rooms when he arrived to spray. The type of spray he used required residents to be out of the rooms. Therefore, there were some instances where rooms could not be treated on the dates on which he planned. He had talked to the Administrator and the Maintenance Director about that issue. Another issue was the roaches were within the walls because he had seen them behind the outlets in the rooms. The facility's inner walls had insulation, and therefore if he attempted to put a pest control product in the inner walls, the insulation would prevent the product from going where it needed to go and being effective. Additionally, food attracted roaches. Open food or food particles needed to be contained. One grain of rice could feed multiple roaches. According to the pest control technician, there was a lot of food being stored in the rooms. The technician did not specify if the food was open or sealed when he had observed the food. The Pest Control technician further reported roaches were attracted to electrical items such as televisions, radios, and other electrical equipment and they possibly could be in the equipment. At the current time, his course of action was to continue to try to spray.Review of the facility's Pest Control Records revealed a service record dated 8/18/26. Under recommendations and observations from your service professional, there were four sentences. These were: Medium roach activity in Room (Resident # 20's room). Lite roach activity in room (another resident's room). Follow up scheduled with next service. Thank you for your business. There was no plan on how to identify if roaches were in the electrical equipment, eradicate them from the inner walls, or any other documented recommendations to help resolve the pest issue. The Maintenance Director was interviewed on 8/20/26 at 5:20 PM and reported the following information. There were only a few times the staff had forgotten to get residents up so that the pest control technician could spray, but there were other times the pest control technician had not shown up as planned. The residents needed to be out of their rooms for 1.5 to 2 hours for the rooms to be sprayed, and when the technician did not show up as planned the residents were frustrated. He had worked at the facility for 30 years and he did not recall roaches being a problem until the previous year. He was aware they were spreading and they were trying to contain the issue and do their best. He routinely serviced the air and heating units and had not identified the roaches in the units. He also had not personally seen them behind the outlets. He was not sure how to open and identify an oxygen concentrator unit to determine if the roaches were in any of the oxygen concentrators. They were also trying to declutter rooms as residents would allow them. The facility was also planning to change pest control companies to another contracted provider. The new pest control company had reported they had better ways to treat the rooms and residents could stay in the rooms. He (the Maintenance Director) was hopeful that the new pest control company could better help advise the facility and eradicate the roaches. The Maintenance Director was interviewed whether there were special procedures used when moving residents off Mauve 2 to another room, and reported they tried to shake their belongings and wash items before moving.During a follow up interview with the Administrator on 8/20/26 at 3:51 PM, the Administrator reported the following. She was aware of only two incidents in which the pest control technician could not spray because the residents were not out of the rooms. This was because the residents did not want to get up. They were currently in the process of changing pest control companies and were waiting on the corporate office to finalize the contract with the new pest control company. She felt the new pest control company could provide more options such as baiting the roaches. In the interim if a resident did have to move off Mauve 2 then they cleaned and shook their items to make sure that they did not move the roaches with the resident.

Based on record review, and interviews with staff and Responsible Party, the facility failed to implement their abuse policy in the areas of immediately reporting to the Administrator and reporting to the State Agency, and the Department of Social Services (DSS) as required for allegations of resident to resident sexual abuse. On 7/28/26 staff did not immediately report to the Administrator an allegation of inappropriate touching between a cognitively intact male resident (Resident # 3) and a severely cognitively impaired female resident (Resident # 4). Later the same day, a second allegation of inappropriate touching occurred between the same residents. The first incident was not reported to the State Agency or DSS and the second incident was not reported until the following day. This was for 1 (Resident # 4) of 3 residents reviewed for abuse.The findings included:Review of the facility's policy entitled Abuse/ Neglect/Misappropriation/Crime, dated as effective 2/5/23, revealed the following information. Sexual abuse included sexual coercion, sexual harassment and inappropriate touching. The Administrator was to be immediately notified of any alleged violation of abuse and would immediately (and no later than 2 hours) report the alleged abuse to the State Agency. The appropriate law enforcement authorities were also to be notified as deemed appropriate for incidents of abuse, neglect, exploitation, or mistreatment.Resident # 4 was admitted to the facility on [DATE].Resident # 4's admission Minimum Data Set (MDS) assessment, dated 7/22/26, coded the resident as severely cognitively impaired.Resident # 3's was admitted to the facility on [DATE] and his quarterly Minimum Data Set assessment dated [DATE] indicated he was cognitively intact.Assistant Maintenance Employee # 1 was interviewed on 8/20/26 at 12:30 PM and reported the following information about the date of 7/28/26. He had walked into the dining room on 7/28/26 during the daytime and saw Resident # 3 and Resident # 4 seated as close as they could possibly get together in their wheelchairs. Resident # 4's hand was on Resident # 3's thigh and Resident # 3 moved Resident # 4's hand up his thigh to the groin area. He (Assistant Maintenance Employee # 1) did not know if Resident # 3 had placed Resident # 4's hand on Resident 3's thigh or if Resident # 4 had done that herself. The former Social Worker (SW # 1) entered at that time, saw what was happening, and stopped Resident # 4 just as Resident # 4's hand got near to Resident # 4's private area. Social Worker # 1 told Resident # 4 she was going to speak to her family. He did not report the incident because SW # 1 saw what happened, was aware, and therefore he did not see the need to further report it. The following day he was asked by administrative staff about the incident. Maintenance Employee # 1 did not specify which administrative staff. SW # 1 had also been present when he was questioned about the incident, and SW # 1 did not tell the truth when questioned. SW # 1 indicated she had not witnessed anything to have happened.On 8/20/26 at 2:13 PM an attempt was made to interview SW # 1 by phone and she could not be reached for interview.On 7/28/26 at 9:03 PM Nurse # 2, who had been assigned to care for Resident # 3 beginning at 7:00 PM on 7/28/26, entered the following information in a nursing note for Resident # 3. She (Nurse # 2) had been informed by Nurse # 1, who was caring for Resident # 4, of an incident with Resident # 4 and Resident # 3. Resident # 4's roommate (Resident # 21) was alleging Resident # 3 had touched Resident # 4 between Resident # 4's legs. Both she and Nurse # 1 went to Resident # 4's room and Resident # 4 was asked what happened. Resident # 4 reported, He touched my cat. Resident # 4 was asked to point to where her cat was located, and Resident # 4 touched her vaginal area. Resident # 3 was notified he could not be on Resident # 4's unit for any reason, and the Director of Nursing was notified by telephone of the incident.Resident # 21's 7/22/26 admission MDS assessment coded Resident 21 as cognitively intact. An attempt was made to interview Resident # 21 by phone on 8/19/26 at 3:50 PM and she could not be reached for interview.On 7/28/26 at 11:34 PM Nurse # 1, who had been assigned to care for Resident # 4 beginning at 7:00 PM on 7/28/26, entered the following information in a nursing note for Resident # 4. She (Nurse # 1) had called Resident # 4's RP (Responsible Party) to report an incident to her. (The nursing note did not specify details of the incident). The RP informed her (Nurse # 1) that there had been an incident that occurred prior to Nurse # 1's shift when Resident # 3 had followed Resident # 4 and made Resident # 4 touch his private parts. (The note indicated the incident had occurred prior to Nurse # 1's shift but not indicate the exact time and date.) The RP reported to Nurse # 1 that she wanted to press charges. She (Nurse # 1) notified the Director of Nursing (DON) of the request and the DON reported she would reach out to the RP. The DON noted that the RP would report the incident to the police.Nurse # 1 was interviewed on 8/19/26 at 10:47 PM and reported the following information about the evening of 7/28/26. Resident # 4's roommate, (Resident # 21), had been in the doorway of the room and whispered to her (Nurse # 1) man indicating there was man in the room. Resident # 4's roommate had reported that she had heard the man saying just touch it over and over to Resident # 4. The curtain was pulled and therefore she (Nurse # 1) had not personally seen any touching and Resident # 21 did not validate any witnessed touching either. While she (Nurse # 1) was talking to Resident # 4's roommate, Resident # 3 came from around the Resident # 4's curtain and she (Nurse # 1) asked him what he was doing. Resident # 3 used profanity and told her not to worry about it and left the room. She called the Director of Nursing to inform her that Resident # 3 had been in Resident # 4's room and told her that she thought the incident was reportable. The DON had told her to keep the residents separated and to call the police if Resident # 3 came back to her room. The DON indicated that would avoid the paperwork. She (Nurse # 1) went back to the room and asked Resident # 4 specifically if Resident # 3 had touched her and the resident responded, yes. She had asked Resident # 4 where Resident # 3 touched her, and Resident # 4 responded her Kitty Cat and patted her vagina. The Resident had a brief on and did not indicate Resident # 4 touched her under the brief but rather on top. Nurse #1 again called the DON and told her the resident was saying she had been touched in the vaginal area. The DON indicated she would be in discussion with the Administrator. She (Nurse # 1) initially was unable to get in touch with the RP, but when she was able to do so later that evening, the RP wanted to press charges. The RP indicated to her (Nurse # 1) that there had been an earlier incident that same day in which Resident # 3 coerced Resident # 4 to touch his male genitalia and of which a different family member had been made aware by a different staff member. After talking to the RP, she (Nurse # 1) called the DON again and let her know the RP wanted to press charges. She did not report the incident that had occurred earlier in the day to the DON. She explained that it was her understanding that the DON already knew about it. Nurse # 1 said they had told the DON. Nurse # 1 did not specify who they were. She (Nurse # 1) did not call the police that night. The RP called the police. The RP and the police both came to the facility that night. Resident # 4's RP was interviewed on 8/19/26 at 1:22 PM and confirmed she had been the one to call the police on the evening of 7/28/26. The RP reported earlier in the day, a different family member had been visiting Resident # 4 and been informed by Social Worker # 2 that there had been a male resident (Resident # 4) coercing her to touch his genital. After talking to Nurse # 1, she had wanted to press charges and spoke to the DON who had indicated the facility was part of a big company and to avoid paperwork it would be better if she reported the incident to the police.Interview with SW # 2 on 8/20/26 at 10:40 AM revealed she had not notified Resident # 4's family member of any earlier incident on 7/28/26 and had not been aware of any incident to report on that date. SW # 2 reported that SW # 1 may have talked to Resident # 4's family, but she did not know what the conversation entailed.Review of the facility's initial report to the State Agency revealed the report was submitted on 7/29/26 by the facility Administrator regarding an allegation concerning Resident # 3 and Resident # 4. The initial report noted the facility first became aware of an incident between Resident # 3 and Resident # 4 on 7/28/26 at 8:51 PM. The allegation details included that it had been reported that Resident # 3 was in the room behind the curtain of Resident # 4 speaking sexually to each other. Resident # 3 left the room and nursing staff asked Resident # 4 what happened. Resident # 4 reported Resident # 3 'touched her cat' indicating sexual contact. The initial allegation details submitted to the state agency made no mention of the incident observed on 7/28/26 by Maintenance Employee # 1 during which Resident # 3 was observed moving Resident # 4's hand up his thigh towards his groin.The facility's five-day investigation report, submitted to the State Agency on 8/3/26, included the same allegation details with no mention of an earlier incident on 7/28/26 during which Resident # 3 moved Resident # 4's hand up his thigh towards his groin. The report also included the County Department of Social Services was notified on 7/29/26 (the day after the alleged incident). The DON was interviewed on 8/19/26 at 4:30 PM and reported the following information. Resident # 4's roommate could not see what had transpired behind the curtain on the evening of the alleged incident. She (the DON) had never been told of any incident of Resident # 3 moving Resident # 4's hand up his thigh on 7/28/26 in the dining room on the date of 7/28/26. That was not told to her until the following day when the Corporate Regional Clinical Coordinator started investigating and taking statements. At that point, it was brought to her attention that there had been an earlier incident between the two residents on 7/28/26. Initially she (the DON), had just been told by Nurse # 1 on the evening of 7/28/26 that Resident # 3 was in Resident # 4's room saying inappropriate things. She had talked to the Administrator by phone and they felt as if they needed more information before making a decision that the incident was reportable to the State Agency and that the police needed to be called. The following morning, the facility decided to report to the State Agency that Resident # 4 was alleging she was touched by Resident # 3 on the evening of 7/28/26 in her private area. They also called the police on 7/29/26 and reported this same information. The decision was made to report to both these entities when the corporate office became aware of the incident. The DON did not specify who had notified the corporate office.The Administrator was interviewed on 8/20/26 at 1:30 PM and reported the following information. She had been called on the evening of 7/28/26 around 11:00 PM and informed by the DON that Resident # 3 had been behind Resident # 4's curtain for a long time. Resident # 4 had reported Resident # 3 had touched her cat outside her brief. She assumed Resident # 4 was talking about her vaginal area but had not clarified. She felt as if they needed more information before deciding to call the police and report the incident to the State Agency. She instructed that staff were to put one-on-one supervision with Resident # 3, make sure Resident # 4 was safe, and call Resident # 4's family. When making the decision not to report the evening incident of 7/28/26, she had not been made aware by Social Worker # 1 or Assistant Maintenance Employee # 1 of the earlier incident witnessed in the dining room by the Assistant Maintenance Employee. The corporate Regional Clinical Care Coordinator helped with the investigation on 7/29/26 and the incident in the dining room came up at that time while the Regional Clinical Care Coordinator was interviewing staff.Interview with the Regional Clinical Coordinator on 8/20/26 at 3:48 PM revealed the following information. She had been called around 6:45 AM on 7/29/26 about Resident # 4 alleging she was touched in her private area on the evening of 7/28/26. While obtaining statements, the incident came up regarding Resident # 3 moving Resident # 4's hand up his thigh on 7/28/26. SW # 1 had reported during the investigation that she did not see the incident of Resident # 3 moving Resident # 4's hand towards his groin. Maintenance Employee # 1 reported he did and he should have reported the incident.The facility submitted a corrective action plan that was not acceptable to the State Agency.

Based on observation, record review, and interviews with resident, staff, Respiratory Therapist, Hospice staff, and Nurse Practitioner the facility failed to 1) provide nebulizer treatments as ordered for a resident experiencing an upper respiratory infection (Resident #15) and 2) ensure a nurse was aware that sterile technique was needed while changing a resident's inner tracheostomy cannula (An inner cannula is a removal insert for a tracheostomy (A tracheostomy is a surgical opening into an individual's trachea(windpipe))) (Resident #8). The deficient practices were found for 2 of 3 residents reviewed for respiratory care.The findings included: 1. Resident #15 was admitted on [DATE] with diagnoses that included unspecified dementia and anxiety. The resident was admitted to Hospice services on 9/29/25. The quarterly Minimum Data Set (MDS), completed on 7/15/26, indicated intact cognition with no behaviors noted during the review period. Resident #15 was coded as receiving Hospice services. The MDS did not indicate any respiratory treatments, including breathing treatments, oxygen, or respiratory therapy.The quarterly care plan completed on 7/29/26 included Hospice services, noting that Resident #15 was not expected to improve due to cerebrovascular disease and would require comfort focused care. The care plan did not include any respiratory related problems or interventions.Resident #15's physician's orders revealed an order on 8/4/26, for Ipratropium and Albuterol nebulization solution (a medication used to open the airways in the lungs), one vial inhaled orally every four hours as needed for 30 days. A review of the August Medication Administration Record (MAR) revealed the nebulizer treatment was added to the MAR on 8/5/26, to be administered for five days. The MAR indicated the nurses signed out the medication as administered at 10:00 p.m. on 8/6/26; four administrations daily on 8/7/26, 8/8/26, and 8/9/26; and three administrations on 8/10/26. An interview with Nurse #5 on 8/20/26 at 12:14 pm indicated he did not recall if the resident had a nebulizer machine or not, but if he signed out the Albuterol nebulizer treatment on 8/5/26 on 7:00pm to 7:00am, then Resident #15 was given one. An interview with Nurse #6 on 8/20/26 at 12:24 pm indicated she did not recall if Resident #15 had a nebulizer machine or not. When told that it was signed by her on 8/6/26 7:00am-7:00 pm, that it was given, she said maybe we borrowed one, she was not sure. No other details were given by Nurse #6.Resident #15 was interviewed on 08/19/26 at 1:30 p.m. She stated that a Hospice Nurse ordered a breathing treatment for her on 08/04/26, but she did not receive the treatment for almost a week. She reported that her daughter eventually came to the facility and complained to the Administrator because the resident was still not receiving the ordered treatment. Resident #15 stated that at the time she had a bad cough and could hear herself wheezing, and that her symptoms were worsening. She reported that she had been taking cough syrup, which eased the coughing somewhat during the day, but not at night. She stated that the Nurse Practitioner assessed her on 8/5/26 and determined she needed an antibiotic because she continued to cough and wheeze, and her sinuses were congested. Resident #15 indicated that she had asked several times why she was not receiving her breathing treatment. She reported being told that the facility did not have a breathing machine available, and that she would have to wait until another resident finished using theirs so it could be cleaned for her. She stated that she informed her daughter, the Hospice Nurse, and the Nurse Practitioner, hoping the issue would be resolved. Resident #15 stated that she was not certain but believed she received her first breathing treatment approximately five days after it was ordered. An order was written on 8/10/26 for Augmentin 500 milligram (mg) (an antibiotic for bacterial infection) for respiratory symptoms and cough.During a phone interview on 8/19/26 at 2:17 p.m., Resident #15's family reported that the Hospice Nurse had written the nebulizer order on 8/4/26. Resident #15 told the family she had not received any nebulizer treatments. The family stated they left a message for the Director of Nursing (DON) on 8/6/26 but did not receive a return call. When the family visited on 8/8/26, Resident #15 confirmed she still had not received nebulizer treatments. The family contacted the Hospice Nurse, who stated she would notify the NP. The family reported she was informed by the Nurse (she didn't remember which one) that Resident #15 had not received nebulizer treatments because no nebulizer machine was available. A Medication Technician informed the family that the facility only had one nebulizer machine, and staff had to wait for another resident to finish treatment so the machine could be cleaned. The family reported that they contacted the Administrator, who escorted them to the DON's office, where the Regional Nurse was also. The DON stated she was new to the position and did not know why nebulizer machines were unavailable. The Regional Nurse asked if Central Supply had been contacted; the DON stated she did not know. The Regional Nurse obtained a nebulizer machine on 8/8/26 but was not sure where she got the machine from. The family stated Resident #15's symptoms were worsening, including increased coughing, weakness, and wheezing, despite receiving cough syrup. The NP was notified and subsequently ordered an antibiotic Augmentin 500 mg on 8/10/26 to treat the upper respiratory symptoms. A phone interview with the Hospice Nurse on 8/19/26 at 11:49 am., reported that on 8/4/26, an order had been written for an Ipratropium and Albuterol nebulization solution, one vial inhaled orally every four hours as needed for 30 days. On 8/10/26, the facility physician-initiated Augmentin 500/125 mg every 12 hours for seven days due to respiratory symptoms and cough. The Hospice Nurse reported that Resident #15 had not started nebulizer treatment because no nebulizer machine was available, as told to her by Resident #15. The nebulizer treatment began on 8/9/26 when equipment became available. During the Hospice Nurse visit on 8/11/26, the nurse confirmed a delay in initiating breathing treatments. Resident #15 had received cough medication prior to beginning nebulizer treatments and reported partial relief; however, symptoms continued, including cough and wheezing. During the Hospice visit on 8/14/26, the nurse documented significant improvement following initiation of both the antibiotic and nebulizer treatments.An interview with the Pharmacy Manager on 8/19/26 at 12:53 p.m. confirmed the nebulizer medication order had been received on 8/4/26 at 12:00 p.m., filled, and sent out at 8:21 p.m. on the same day. Nurse# 4 signed for the delivery. The Pharmacy Manager stated that the pharmacy did not supply nebulizer machines; these were obtained through a respiratory equipment vendor.An interview with the Nurse Practitioner (NP) on 8/19/26 at 1:20 p.m. reported that she evaluated Resident #15 on 8/5/26 after Hospice notified her of itching, coughing, and wheezing. She was also told by the Hospice Nurse and the family that Resident #15 was not receiving nebulizer treatments. The NP changed the order from as needed to scheduled dosing because she initially thought that Resident #15 wasn't getting her medication because it was not scheduled, and not that she did not have an available nebulizer machine for administration. The NP indicated that Resident #15 was clinically stable on 8/5/26 without chest pain or shortness of breath. The NP stated that the facility was waiting for another resident to complete treatment so the nebulizer machine could be cleaned before Resident #15 could use it. She reported that Resident #15's symptoms had persisted for two weeks, including sinusitis and wheezing, and that no laboratory testing was completed due to the resident's Hospice status. Resident #15 did not exhibit shortness of breath or confusion. The NP stated earlier nebulizer access would not have significantly changed the clinical outcome.An interview with the Director of Nursing (DON) on 8/19/26 at 1:40pm indicated that she was not aware that Resident #15 was not getting her nebulizer treatments due to not having a nebulizer machine until after the fact. She then indicated that she was new and was still learning how the departments worked and was not exactly clear on how Central Supply received orders when Nebulizer machines were needed. The DON then said that when it was realized the residents that had respiratory issues were waiting on nebulizer machines, central supply ordered the machines immediately. She then stated the nurse that takes the order entered it into the system and orders like diet or equipment were given to the appropriate department. An interview on 8/20/26 at 3:00 pm with the Central Supply Manager indicated she had been notified on 8/4/26 that a resident required a nebulizer machine, but none were available. The Central Supply Manager placed an order on 8/6/26 for 3 nebulizer machines. She stated the machines were delivered on the afternoon of 8/8/26. The Central Supply Manager stated she typically kept one or two spare machines, but both were already in use. She further indicated that when the equipment is no longer being used it is brought to them and wiped down with a sanitizer wipe (nebulizers, oxygen compressors, vital machines, etc.). She did not recall if she had told the nursing department that the supplies had been delivered. Review of the 8/6/26 supply company invoice confirmed delivery of three nebulizer machines on the afternoon of 8/8/26. An interview with the Administrator on 8/20/26 at 5:20 pm indicated that she was made aware of the nebulizer treatment administration not being given by the family who came to her office to let her know. She further indicated that she escorted the family to the DON for answers. She further indicated that the DON was unaware of what had happened or how to get the nebulizer machine. She further indicated that the DON was told by the Clinical Manager that Central Supply was responsible for ordering the nebulizer machines. The Administrator further indicated that the DON went to the Central Supply Manager to see if there were any machines available. There were not any available nebulizer machines. 2) Record review revealed Resident # 8 was admitted to the facility on [DATE]. One of Resident # 8's diagnoses included tracheostomy placement with a speaking valve secondary to laryngeal cancer. Resident # 8's 5/16/26 quarterly Minimum Data Set assessment coded Resident # 8 as moderately cognitively impaired and as having a tracheostomy. Resident # 8's care plan, revised on 6/21/26, revealed Resident #8 was to receive tracheostomy care per order. The care plan also included the information that Resident # 8 had behaviors which included refusing tracheostomy care and removing his inner cannula and laying it on the table. Review of current physician orders revealed an order, which originated on 5/7/26, for Resident # 8 to have tracheostomy care every shift and as needed. Additionally current orders, which originated on 4/30/26, indicated the tracheostomy ties were to be changed three times per week. (Tracheostomy ties/securing collar wrap around an individual's neck and are used to keep the flange (neck plate) in place.) Review of Resident # 8's Treatment Administration Record from 8/14/26 through 8/19/26 revealed tracheostomy care was documented to be done as ordered. Review of nursing notes from 8/12/26 to 8/20/26 did not reveal problems or signs of infection related to Resident # 8's tracheostomy. On 8/19/26 at 11:55 AM Resident # 8 was interviewed and reported he had not had tracheostomy care in four days. At the time, there was no excessive drainage observed around the tracheostomy, and it appeared clean. On 8/19/26 at 11:58 AM Nurse # 3 was interviewed regarding Resident # 8 reporting no tracheostomy care in four days. Nurse # 3 reported she had not worked in several days, but she typically dated the collar ties and she would check and see if there was a date on Resident # 8's collar ties. Nurse # 3 entered Resident # 8's room with the surveyor and informed Resident # 8 she would check his collar ties to see if there was a date. Nurse # 3 put on clean gloves and tried to view the back of the tracheostomy collar ties but could not see the date clearly. Therefore, Nurse # 3 decided to go ahead and change the inner cannula and replace the tracheostomy collar ties. With the gloves she already had on, she obtained new tracheostomy collar ties and a new inner cannula from Resident # 8's bedside supplies and opened them. With the same gloves, she removed Resident # 8's disposable inner cannula. With the same gloves, she then inserted the new inner cannula and replaced the collar ties. She viewed the old tracheostomy collar ties and reported the date was not clear to establish when the collar ties had last been placed. Nurse # 3 was interviewed regarding changing the disposable inner cannula without using sterile technique and keeping her dominant hand sterile while inserting the new inner cannula. Nurse # 3 reported that Resident # 8 was not a new tracheostomy and therefore they would not have to use a sterile technique to replace the inner cannula. She showed the surveyor there was a sterile tracheostomy kit in Resident # 8's room but indicated that since Resident # 8 was an older, established tracheostomy resident then it was her understanding that a clean technique could be used and sterile technique with the inner cannula was not indicated. The facility's contracted Respiratory Therapist (RT) was interviewed on 8/20/26 at 12:49 PM regarding Nurse # 3's understanding that a sterile technique was not indicated in replacing an inner cannula for an older, established, tracheostomy resident. According to the RT, Resident # 8 should have his inner cannula inserted using a sterile technique. The RT reported that she visited every two weeks and when she had provided Resident # 8's tracheostomy care, she used sterile technique. The RT further reported that approximately a month ago, her (the RT's) supervisor had provided education training to facility staff regarding tracheostomy care. The DON (Director of Nursing) was interviewed on 8/20/26 at 6:40 PM, provided a copy of the facility's procedures for tracheostomy care, referenced the procedures, and reported the following information. Nurses should be using sterile technique when providing tracheostomy care and replacing an inner cannula. She did not know why Nurse # 3 had the understanding that an older, established tracheostomy did not still require a sterile technique. There was training recently regarding tracheostomy care. An attempt was made to reach Nurse # 3 again on 6/20/26 at 6:50 PM to validate with her why she had the understanding that inserting an inner cannula did not require a sterile technique and she could not be reached. Resident # 8's Nurse Practitioner (NP # 1) was interviewed on 8/20/26 at 4:23 PM and reported the following information. She was not aware of specific policies that the facility used for tracheostomy care. Resident # 8 did take out his own inner cannula and put it back in at times. He would also put a suction catheter in his tracheostomy and had personal practices related to his tracheostomy that could contribute to infection. Therefore, Resident # 8 had a high risk for infection regardless of any failure of the nursing staff to use a sterile technique when replacing his inner cannula.

Based on record review, observation, resident interviews, significant other interview, and staff interviews, the facility failed to ensure the provision and availability of linens to meet the hygiene and comfort needs for 9 of 9 residents representing three of four halls and interviewed regarding linen availability (Residents #4, #12, #10, #13, #14, #15, #16's significant other, #17, and #18).Findings included:a. Record review revealed Resident #4 had a Medicare 5-day Minimum Data Set assessment dated [DATE] which coded her as cognitively intact.An interview was conducted with Resident #4 on 6/22/2026 at 8:09 AM who resided in Mauve one hall. Resident #4 stated that both nurse aides and nurses told her they did not have washcloths or towels. She reported that staff attempted to bathe her daily, but due to the lack of linens, they used one end of a towel to bathe her and the other end to dry her because there were not enough towels available.b. Record review revealed Resident #12 had a significant change Minimum Data Set assessment dated [DATE] which coded her as cognitively intact.Resident #12, who resided in Mauve one hall, was interviewed on 6/22/2026 at 8:50 AM. Resident #12 stated she was unable to receive a bed bath when the facility did not have sufficient linen and reported that the facility frequently did not have enough linen available.c. Record review revealed Resident #10 had a quarterly Minimum Data Set assessment dated [DATE] which coded her as cognitively intact.Resident #10, who resided in Mauve one hall, was interviewed on 6/22/2026 at 8:38 AM. Resident #10 stated there were no towels or washcloths available that morning and that residents would not receive washups or showers until later in the day. Resident #10 also reported that there was nobody in the laundry room to run the laundry machines that morning.d. Record review revealed Resident #13 had a quarterly Minimum Data Set assessment dated [DATE] which coded him as cognitively intact.Resident #13, who resided in Mauve one hall, was interviewed on 6/22/2026 at 9:13 AM. Resident #13 stated there frequently were no washcloths or towels available in the mornings. Resident #13 stated he wiped himself down with wipes that morning due to the lack of clean washcloths and towels.e. Record review revealed Resident #14 had a Medicare 5-day Minimum Data Set assessment dated [DATE] which coded her as cognitively intact.On 6/22/2026 at 9:44 AM, an observation and interview were conducted with Resident #14, who resided in Mauve one hall. Resident #14 stated she had to use bibs to wash up in the bathroom when no towels or washcloths were available. She stated she did not use soiled bibs, but at times they were the only item available. Resident #14 held up a clothing protector (bib) and stated that was what she planned to use to clean herself that day. She stated the lack of towels and washcloths bothered her but not enough for her to report it to staff.f. Record review revealed Resident #15 had a quarterly Minimum Data Set assessment which coded her as cognitively intact.Resident #15, who resided in Mauve two hall, was interviewed on 6/22/2026 at 10:02 AM. Resident #15 stated her biggest complaint was that in the morning the facility may or may not have any linen. She stated she held on to towels when she had them in case, she needed one later. Resident #15 stated that her nurse aides often searched other halls to locate a pad or sheet for her when none were available in her own hall.g. Record review revealed Resident #16 had a quarterly Minimum Data Set assessment dated [DATE] which coded her as having moderately impaired cognition.On 6/22/2026 at 10:33 AM, an interview was conducted with the significant other of Resident #16, who was also her emergency contact. Resident #16 resided in Mauve one hall. He stated he visited frequently and washed Resident #16's laundry himself because linens in the facility had just disappeared. He reported bringing in packages of washcloths for Resident #16's personal use due to the lack of facility-provided washcloths.h. Record review revealed Resident #17 had a quarterly Minimum Data Set assessment dated [DATE] which coded her as cognitively intact.Resident #17, who resided in Teal Hall, was interviewed on 6/22/2026 at 11:19 AM. Resident #17 stated she was lying on two pillowcases on top of a pad because the laundry did not have any clean sheets that morning. Resident #17 was observed to have a sheet on her mattress, an incontinence pad, and two pillowcases on top of the pad at the time of the interview. She stated that at 10:00 AM, when Hospice attempted to bathe her, there were no clean sheets available. She also stated that at times there were no clean gowns available depending on the time of day.i. Record review revealed Resident #18 had an annual Minimum Data Set assessment dated [DATE] which coded him as cognitively intact.Resident #18, who resided in Teal Hall, was interviewed on 6/22/2026 at 11:52 AM. Resident #18 stated he had been waiting all morning for a washcloth and towel so he could bathe himself. He stated that sometimes there were no sheets, but that morning there were no washcloths or towels. Immediately following the interview, at 11:55 AM, the linen cart outside Resident #18's room was observed, and it contained no washcloths or towels and one folded sheet.Nurse Aide (NA) #4 was interviewed on 6/22/2026 at 9:23 AM. NA #4, who worked the 7:00 AM to 7:00 PM shift in the Mauve one hall, stated there were no linens, washcloths, or towels available. She stated she went to the laundry room and found no staff present and no linens. NA #4 stated she would have to use wipes until laundry was completed and that baths and showers would not be provided until later in the shift. NA #5 was interviewed on 6/22/2026 at 9:32 AM. NA #5, who worked the 7:00 AM to 7:00 PM shift in the Mauve one hall, stated there were currently no clean washcloths or towels available. She stated she had to prioritize which residents received linens based on therapy schedules or appointments. She stated additional linens might be available between 2:00 PM and 3:00 PM and that she had voiced concerns about linen shortages in the past, but nothing had changed. NA #6 was interviewed on 6/22/2026 at 9:56 AM. NA #6 stated she had worked the 7:00 PM to 7:00 AM shift and was working a 16 hour shift that day in the Mauve two hall. She stated she was able to give four bed baths that morning but that there were currently no towels or washcloths available, and she was waiting for laundry to be completed before continuing. An observation and interview were conducted with the Environmental Services Director on 6/23/2026 beginning at 2:40 PM. The Director stated that as of 6/1/2026, the environmental services department was no longer contracted, and staff were employed by the facility. She reported three laundry shifts: 6:00 AM to 2:00 PM, 2:00 PM to 10:00 PM, and 10:00 PM to 6:00 AM. She stated that on 6/22/2026, a laundry aide called out, and she could not arrive until 8:23 AM to cover the shift. She stated laundry did not reach the hallways until around 9:20 AM and that even one missed hour affects the entire laundry production cycle. Observations were made at the time of the interview of the laundry department shelves and the locked backup laundry storage room. The Director stated only she and the Maintenance Director had a key to the backup room. She acknowledged she had removed the last of the facility's supply of washcloths on 6/22/2026 and on the morning of 6/23/2026. She stated she was only able to order more washcloths at the end of the month and was still learning required quantities and budgeting. The Director reported she was unaware of any resident concerns with not having enough washcloths, towels, or linens. The Administrator was interviewed on 6/24/2026 at 8:18 AM. The Administrator stated it was her expectation that linens be kept at par levels according to the building census. She reported that the Environmental Services Director did not need to wait until the end of the month to order washcloths if supplies were needed.

Based on record review and staff interviews, the facility failed to ensure staff implemented the facility's abuse reporting and protection policy and procedures by failing to immediately report to the Administrator leading to a lack of protection after an allegation of staff to resident physical abuse involving Nurse #1 and Resident #3. This failure affected one of three residents that were reviewed for implementation of abuse policies and procedures (Resident #3).Findings included:Review of the facility's policy titled Abuse/Neglect/Misappropriation/Crime, effective 10/17/2024, under Patient Protection, stated: All employees are responsible for immediately (no later than two hours after the allegation is made if the incident involves abuse or bodily injury) reporting to the Administrator, or in their absence, the Director of Nursing, or their immediate supervisor, any and all suspected or witnessed incidents of patient abuse, neglect, theft, exploitation, and/or mistreatment of a patient as well as any reasonable suspicion of a crime against a patient. Review of the same policy and procedures under Reporting Requirements/Investigations, stated documentation in the investigation must include that immediate action was taken to protect the patient from further injury.Resident #3 was admitted on [DATE] with cumulative diagnoses including Parkinson's disease with dyskinesia, hemiplegia, hemiparesis, anxiety disorder, schizophrenia, intellectual disabilities, and major depressive disorder.Review of a facility reported intake dated 5/26/2026 revealed that Nurse Aide (NA) #1 reported Nurse #1 had physically abused Resident #3 in the hallway. NA #1 acknowledged she learned of the allegation approximately one week prior, but the facility had not been informed at the time of the alleged incident. The facility reported intake noted that protection of Resident #3 began with the suspension of Nurse #1 on 5/26/2026 after the abuse allegation was reported to the Administrator. An interview with NA #1 on 6/23/2026 at 5:00 PM revealed her scheduled hours were 7:00 PM to 7:00 AM. NA #1 stated Nurse #1 was known to intimidate Resident #3 due to the resident's behavior of walking the halls late at night seeking food. NA #1 stated she did not previously report concerns regarding Nurse #1 because she believed staff would not believe her and had been told Nurse #1 was an asset for consistently working nights and picking up extra shifts. NA #1 reported that on 5/25/2026 she was written up and sent home by Nurse #1 for eating in the day room. Later that evening, NA #2 sent her four photographs depicting Nurse #1's right hand on the back of Resident #3's neck and going down the hallway, to use as evidence against Nurse #1. NA #1 recognized the actions in the photographs as abuse but stated she did not know when the photographs had been taken. On the morning of 5/26/2026 at approximately 10:30 AM, NA #1 met with the Administrator and Director of Nursing and provided the photographs sent to her by NA #2. NA #1 reported she was suspended and ultimately terminated after coming forward.Attempts to contact NA #2 by telephone and text were unsuccessful.An interview with NA #3 on 6/22/2026 at 2:53 PM revealed her usual hours were also 7:00 PM to 7:00 AM. NA #3 reported witnessing several occasions where Nurse #1 pulled Resident #3 down the hallway to his room. NA #3 specifically described an incident in February 2026 at approximately 12:30 PM where she observed Nurse #1 dragging Resident #3 by the neck down the hallway. NA #3 did not report the incident because she believed Nurse #1 was a respected employee and feared retaliation or suspension. NA #3 reported she was terminated from the facility on 5/29/2026 after revealing her knowledge of the alleged abuse.An interview was conducted with Nurse #2 on 6/22/2026 at 4:19 PM. Nurse #2 reported she had started working the 7:00 PM to 7:00 AM shift beginning in March or April 2026. She further reported she worked consistently from the same nursing station as Nurse #1 on the same shift in May 2026 until 5/26/2026 when she was notified Nurse #1 was suspended. Nurse #2 confirmed Nurse #1 was assigned to the hallway Resident #3 resided during May 2026. An interview with the Assistant Director of Nursing (ADON) on 6/23/2026 at 3:09 PM confirmed the facility was not made aware of the abuse allegation involving Nurse #1 and Resident #3 until 5/26/2026 when NA #1 was interviewed. The ADON stated that NA #2 told her in an interview the photographs had been taken in February 2026 and that he had submitted them to the corporate compliance phone line. The ADON stated that the corporate phone line could not receive photographs via a text message, so the compliance phone line did not receive the photographs from NA #2 in February 2026. NA #2 also confirmed he shared the photographs with NA #1. An interview with the Administrator on 6/24/2026 at 4:24 PM revealed the Administrator expected the abuse policies and procedures to be followed and all abuse allegations to be reported to her or the Director of Nursing immediately.

Based on record review, family interview, nurse practitioner interviews, and staff interviews, the facility failed to ensure accurate documentation of a medical diagnosis for one of three residents reviewed for the accuracy of medical record documentation (Resident #4).The findings included:Resident #4 was admitted to the facility on [DATE] with cumulative diagnoses including coronary artery disease, myocardial injury, hypertension, Type 2 diabetes mellitus, congestive heart failure, and chronic kidney disease.Record Review of the electronic medical record revealed the principal admitting diagnosis listed for Resident #4 was Parkinson's disease, entered on 5/6/2026 by Minimum Data Set (MDS) Nurse #1. This diagnosis represented an acute neurological condition not supported by the resident's documented medical history.Record review of follow-up notes dated 5/13/2026, 5/14/2026, and 5/17/2026 written by NP #1 revealed that the diagnosis of Parkinson's disease first appeared in NP #1's documentation on 5/14/2026 for Resident #4. Subsequent documentation in progress notes after 5/14/2026 by NP #1 listed Parkinson's disease as a diagnosis for Resident #4.A telephone interview was conducted with a family member of Resident #4 on 6/22/2026 at 1:34 PM. The family member reported that Resident #4 was scheduled for discharge to another skilled nursing facility on 6/12/2026. Upon arrival, the receiving facility refused admission because the transfer documents listed a diagnosis of Parkinson's disease. The family member stated she informed the receiving facility that Resident #4 did not have Parkinson's disease; however, due to the incorrect documentation, the resident was denied admission and returned to the originating facility.An interview was conducted with MDS Nurse #1 on 6/23/2026 at 11:01 AM. MDS Nurse #1 stated she utilized a web-based software platform designed to identify potentially relevant clinical information for MDS assessments. She reported receiving an alert that new documentation, such as orders, hospital records, or progress notes, might affect reimbursement for the MDS look-back period for Resident #4. MDS Nurse #1 stated that after reviewing the electronic medical record, she added Parkinson's disease as a diagnosis on 5/6/2026 and documented that her source was a follow up note dated 4/21/2026 written by Nurse Practitioner (NP) #2.A telephone interview was conducted with NP #2 on 6/24/2026 at 11:53 AM. NP #2 confirmed that Resident #4 was not admitted from the hospital with a diagnosis of Parkinson's disease. NP #2 acknowledged that she mistakenly entered Parkinson's disease in her 4/21/2026 follow-up note. NP #2 stated she was unsure how the error occurred and speculated it may have resulted from an Artificial Intelligence (AI) dictation suggestion based on the resident's symptoms, but she confirmed it was an incorrect entry requiring correction.An interview was conducted with NP #1 on 6/23/2026 at 11:01 AM. After reviewing her notes, NP #1 acknowledged that Parkinson's disease was included in her documentation without explanation or verification. NP #1 stated that she does not independently add diagnoses such as Parkinson's disease, as a neurology evaluation would be required. NP #1 reported that an AI program was used to review resident documentation for completeness and that it was possible the program generated an erroneous diagnosis by analyzing hospital records, symptoms, and medications. NP #1 stated that documentation from her prior notes, including diagnoses, was pulled forward automatically into subsequent notes. She reported having identified previous AI related documentation errors in other resident charts. NP #1 acknowledged that she signed, dated, and time stamped her notes for accuracy and was responsible for reviewing the entire note to ensure accuracy when AI generated suggestions were included.An interview with the Administrator was conducted on 6/24/2026 at 8:18 AM. The Administrator stated it was her expectation that all resident documentation be accurate.

Based on observation, record review, and staff interviews, the facility failed to implement their infection control policy for Enhanced Barrier Precautions (EPB) when nurse aides failed to wear a gown while providing incontinence care for Resident #59 who was on EPB. The deficient practice was observed for 3 of 9 staff observed for infection control practices (Nurse Aide #1, Nurse Aide #2, and Nurse Aide #3).The findings included:A review of the facility's policy titled Enhanced Barrier Precautions, revised on 3/26/2024. The policy stated Employees providing high-contact patient care activities will follow EBP for patients who meet the criteria. This included indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy, etc.)An observation of Resident #59's room on 4/27/2026 at 10:27 AM revealed there was yellow signage outside the room indicating Personal Protective Equipment (PPE) were to be used. The signage advised staff to clean hands before and after entering Resident #59's room, wear gloves and gowns for high contact activities such as changing briefs. The PPE was hanging on the back of the door and included gowns and gloves.An observation and interview were conducted with Nurse Aide (NA) #1 and NA #2 on 4/28/2026 at 4:26 PM. NA #1 and NA #2 were in Resident #59's room completing incontinence care for Resident #59 wearing only gloves. Both NA #1 and NA #2 stated Resident #59 was on EBP because of his feeding tube. NA #1 stated she knew she should also have a gown on while providing personal care to Resident #59 but stated she forgot. NA #1 stated they use gloves with all personal care and she just did not remember to put a gown on for Resident #59. NA #2 stated she normally did not work with Resident #59 and did not remember to put the gown on. During this observation the PPE was observed to be hanging on the back of Resident #59's room door. An interview with Nurse #4 was completed on 4/29/2026 at 11:05 AM. She stated Resident #59 was on EBP due to his feeding tube and staff were aware of the precautions due to the EPB sign outside the room and the PPE on the door. An observation on 4/29/2026 at 11:15AM revealed NA #3 completing incontinence care for Resident #59 wearing only gloves. The EPB signage and PPE were observed at the time of the observation. An interview completed at the time of the observation revealed NA #3 was aware Resident #59 was on EBP. NA #3 stated she was in a hurry and forgot to put a gown on with the gloves. The Director of Nursing (DON) was interviewed 4/30/2026 at 12:29 PM. The DON stated she expected staff to follow the parameters that were listed on the EBP signage that was posted at the doors of residents who required EBP. She stated they were expected to put on the proper PPE that was provided for everyone's safety. The DON indicated she expected staff to intervene if they observed other staff not following the precautions. She was unable to explain why the nurse aides were not using the PPE. An interview with the Administrator was conducted on 4/30/2026 at 3:40 PM. She stated she expected staff to follow the guidelines for EBP. The Administrator indicated the staff were aware of the EBP signage at the residents' room doors and the PPE that was provided. She further stated she expected staff to follow through with the EBP requirements when providing activities of daily living and personal care. The interview further revealed staff were provided with training for EBP and she was unable to explain why staff were providing care without the appropriate PPE.

Based on record review and interviews with family, facility staff, and Support Representative from the money transfer application company, the facility failed to protect the resident's right to be free from misappropriation of Resident #186's cell phone and an unauthorized transfer of funds from the resident's money transfer application (a financial platform that allows users to send, receive, and manage money directly from their smartphone) on his cell phone. This deficient practice affected 1 of 1 resident reviewed for misappropriation of property (Resident #186). The findings included:Resident #186 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) dated [DATE] indicated Resident #186 had moderate cognitive impairment and was dependent on staff for assistance with all activities of daily living. An initial allegation report dated 9/22/25 completed by the Staff Development Coordinator (who worked as the Assistant Director of Nursing at the time of the report) indicated on 9/20/25 Resident #186 reported his cell phone was missing. A search of Resident 186's room and surrounding facility areas was conducted, but the phone was not located. On 9/22/25, the resident also reported money was missing from his money transfer application account. Staff interviewed the resident to obtain details regarding when the phone was last seen and the timeframe of the missing funds. The resident's family/responsibly party was informed, and law enforcement and Adult Protective Services were contacted. A police report dated 9/22/25 revealed the facility staff reported a missing cell phone and equipment. The police report listed in the property description as: telephone/telephone equipment with the value of $600.00.An attempt to contact the local police department was made 4/30/26 at 9:00 AM and the detective handling the case was unavailable for interview.Review of disputed charges reported to Resident #186's money transfer application company revealed on 9/24/25 a claim was filed to dispute a transaction totaling $492.00.A telephone interview was conducted on 4/30/26 at 9:30 AM with Support Representative for Resident #186's money transfer application company. The Support Representative stated on 9/19/25 a transaction was made from Resident #186's account to a mobile payment service that did not belong to the resident in the amount of $492.00. She reported that they were unable to inform the Surveyor of the identity of the account holder for the mobile payment service due to legal reasons. She indicated a dispute was filed and initially Resident #186's account had been reimbursed $492.00 and an investigation was conducted. She explained that during the investigation, it was identified that the $492.00 transaction was withdrawn from Resident #186's money transfer application account and when sent to the mobile payment service it was declined/not accepted by the mobile payment service's account holder. She further explained that the $492.00 that was withdrawn was returned back to Resident #186's money transfer application account. A statement written on 9/24/25 by Nurse Aide #12 indicated on 9/20/25 she was called into Resident #186's room (statement did not indicate who called her into the room) and asked to look and see if Resident #186's phone could be found. Nurse Aide #12 searched the room and could not find the phone. She indicated she obtained Resident #186's family's phone number so they could be notified (the statement did not indicate the date of the notification). The family reported they had been trying to reach Resident #186 and last talked with the resident on 9/19/25 but was unable to reach him. Attempts were made to contact Nurse Aide #12 on 4/30/26 at 7:45 AM and 1:30 PM and she was unavailable for interview.A telephone interview was conducted on 4/30/26 at 7:45 AM with Nurse Aide #11 who stated she had assisted the resident with purchases from an on-demand delivery platform (utilized for purchases from local merchants such as restaurants) through his money transfer application account on his phone. She indicated on the evening of 9/19/25 she assisted Resident #186 with a purchase from the on-demand delivery platform and that was the last time she saw the resident with that cell phone. An interview was conducted on 4/29/26 at 8:09 AM with Nurse #7 who stated she believed it was on 9/21/25 that she received a call from Resident #186's family who reported the resident's cell phone and some money was missing from Resident #186's money transfer application. She explained that Resident #186 was dependent on staff for all activities of daily living and using his cell phone. Nurse #7 revealed the resident used a voice communication application on his cell phone with the assistance of staff and he utilized his cell phone to access his personal contacts, bank accounts, and his money transfer application. She stated that Resident #186's family also had access to the resident's money transfer application account, and they would transfer funds to the account or order him food/snacks through the resident's on-demand delivery platform account. She stated a search for the cell phone throughout the facility was conducted and the cell phone was not found and she reported the incident to the Director of Nursing (DON) and Administrator (unable to recall specific date of the report). Nurse #7 indicated she helped the family reach out to the money transfer application company to track the transactions. She stated a transaction was identified transferring funds from the resident's money transfer application to a mobile payment service account that did not belong to the resident. A telephone interview was conducted on 4/29/26 at 11:16 AM with Resident #186's Family Member #1 who stated the resident was totally dependent on assistance with all activities of daily living and the use of his cell phone. Family Member #1 stated Resident #186 used a voice communication application on his cell phone to access his personal contacts and bank accounts. She added that Resident #186 had a money transfer application account on his cell phone that he needed staff assistance to access and his bank account was connected to this application. Family Member #1 explained that the resident's money transfer application was also connected to an on-demand delivery platform. She reported that the resident's family would transfer funds into his money transfer application. She stated that his cell phone was not password protected and was easily able to be accessed by anyone. Family Member #1 explained that on Friday 9/19/25 and Saturday morning 9/20/25 the family had been trying to reach Resident #186 and was not able to do so. She stated later in the day on 9/20/25 she received a call from the facility staff (unable to recall who) to let her know Resident #186's cell phone was missing. Family Member #1 stated the facility informed her they had searched the entire facility and were unable to locate the cell phone. She indicated that the incident was reported to the police. She stated the facility initially provided a temporary flip phone; however, Resident #186 did not have the ability to operate the phone as it did not have the same functions as his previous cell phone which was a smartphone. The facility then provided a check in the amount of $315.00 for a new phone. She indicated that on 9/22/25 the resident identified that funds were transferred out of his money transfer application without his authorization. She stated Nurse #7 and the local police department assisted with getting access to the money transfer application account to find out information on the transaction. It was identified that $492.00 was transferred out of Resident #186's money transfer application to a mobile payment service account. She explained that the mobile payment service company would not release the name of the account holder. She further stated the family disputed the $492.00 transaction with the money transfer application company on 9/24/25. Family Member #1 stated during the money transfer application investigation the $492.00 was initially refunded to Resident #186's account by the company, but on and later date (unable to recall the exact date) the refund was reversed (it was identified the $492.00 had been returned to the resident's account when the account holder for the mobile payment service declined/rejected the transfer). She indicated the local police still had the case opened. Family Member #1 stated Resident #186 had since passed away.The investigation report dated 9/26/25 (the summary did not note who completed it) related to the allegation of misappropriation of property for Resident #186 reiterated the information in the initial allegation report. The summary further indicated that interviews with staff and residents yielded no evidence. The facility replaced the resident's cell phone, and the money transfer application company confirmed reimbursement of the missing funds. The police investigation remained ongoing. A telephone interview was conducted on 4/29/25 at 10:45 AM with the Former Director of Nursing (DON) who indicated he recalled the allegations of Resident #186's missing cell phone and the unauthorized money transfer application transaction. He confirmed the cell phone was not recovered. During interviews and the investigation, it was discovered that multiple facility staff had used Resident #168's cell phone to make purchases for the resident with his permission via Resident #186's money transfer application account. He stated that following the incident staff were re-educated on the abuse, neglect and the misappropriation policy that included that staff were strictly prohibited from using residents' funds, cash, money transfer applications or any other digital payment platforms for transactions. He stated there were no other systemic measures implemented at that time to secure resident personal property/prevent further misappropriation. A telephone interview was conducted on 4/29/26 at 2:31 PM with the Former Administrator who indicated he recalled the allegations of Resident #186's missing cell phone and the unauthorized money transfer application transaction. He stated the initial investigation was started by Nurse #7 and when the original phone could not be found, a temporary flip phone was provided to the resident until a new phone could be purchased. The facility reimbursed Family Member #1 with $315 for a replacement phone. He indicated during the investigation Nurse #7 had communicated with the local police department and the money transfer application company to determine what transactions were made around the timeframe the cell phone was noticed to be missing. The money transfer application company and local police department indicated that they would also do an investigation. The Former Administrator indicated the facility's investigation revealed staff had been assisting Resident #186 with purchases for food and snacks on his cell phone utilizing his money transfer application and an on-demand delivery platform due to the resident's limited physical mobility. The Administrator stated an immediate in-service was done by Nurse #7 on the abuse, neglect and misappropriation of property policy at the time of incident. He stated there was no further action taken or implemented to ensure the situation did not occur in the future for other residents. An interview was conducted on 4/30/26 at 4:20 PM with the Regional Nurse Consultant who indicated she was not part of the investigation process related to the misappropriation of property allegation for Resident #186. She revealed she reviewed the facility's investigation and their plan of correction (POC) and verified the POC was not complete. She indicated she had zero tolerance of misappropriation of resident's property.

Based on record review, and staff and Ombudsman interviews, the facility failed to send a copy of the Notice of Transfer/Discharge to the Ombudsman for 3 of 3 residents reviewed for discharge process (Resident #117, Resident #182 and Resident # 179). The findings included: 1. Resident # 117 was admitted to the facility on [DATE]. Nursing documentation dated 11/1/25 noted Resident #117 had been sent to the hospital. Resident #117's discharge assessment-return anticipated Minimum Data Set assessment noted he was discharged to the hospital on [DATE]. Review of Resident #117's medical record revealed there was no documentation that the Regional Ombudsman had received a copy of the Notice of Transfer/Discharge. A telephone interview was conducted with the former Discharge Planner on 4/30/26 at 2:40 PM. She revealed she was the discharge planner in November of 2025 and was not aware that a copy of the Notice of Transfer/Discharge was required to be sent to the Regional Ombudsman. A telephone interview was conducted with the Regional Ombudsman on 4/29/26 at 3:13 PM and she indicated she did not receive a copy of Resident #117's Notice of Transfer/Discharge. An interview was conducted with the Administrator on 4/30/26 at 4:25 PM and indicated she was new to the facility, and she expected the facility to send the Ombudsman the Notices of Transfer/Discharge as stated in the regulations. 2. Resident # 182 was admitted to the facility on [DATE]. Review of the SNF/NF (skilled nursing facility/nursing facility) Hospital Transfer Form dated 7/14/25 indicated Resident #182 was transferred to the hospital on 7/14/25. Review of the Admission/Discharge To/From Report (a cumulative list of residents that have either transferred or discharged from the facility during the reporting period) for the period of 7/1/25 through 4/30/26 revealed Resident #182 was discharged on 7/14/25 to an acute care hospital. A telephone interview was conducted with the Ombudsman on 4/30/26 at 1:40 PM. The Ombudsman confirmed she did not receive a copy of the Notice of Transfer/Discharge for Resident #182's discharge to an acute hospital on 7/14/25. A telephone interview was conducted with the former Discharge Planner on 4/30/26 at 2:35 pm and she indicated she was responsible for sending the Notice of Transfer/Discharge to the Ombudsman; however, she reported she did not start sending any notices until August 2025. The Discharge Planner indicated she had just started in July 2025 and was not aware the facility was required to provide the Ombudsman with a copy of the Notice of Transfer/Discharge. An interview was conducted with the Administrator on 4/30/26 at 4:25 PM and indicated she was new to the facility, and she expected the facility to send the Ombudsman the Notices of Transfer/Discharge as stated in the regulations. 3. Resident #179 was admitted on [DATE]. Resident #179's admission Minimum Data Set (MDS) assessment dated [DATE] noted he had severe cognitive impairment, received skilled therapy services, and his diagnoses included muscle wasting and hypertension. Nursing documentation dated 2/14/26 noted Resident #179 had been discharged to home in the care of his Responsible Party (RP). Resident #179's discharge return not anticipated MDS noted he was discharged to home/community on 2/14/26. Review of Resident #179's medical record revealed there was no documentation the Ombudsman was notified of the transfer/discharge. An interview with the Social Worker (SW) was conducted on 4/28/26 at 4:12 PM. The SW stated Resident #179 would not have received a transfer/discharge notice because his RP had initiated the discharge. The SW explained she had been recently hired and the previous SW would have sent the February discharge information to the Ombudsman. A telephone interview with the Regional Ombudsman was conducted on 4/29/26 at 3:13 PM. After reviewing the facility's information, she indicated the facility had not sent in discharge notifications. A phone interview with the Administrator was conducted on 5/1/26 at 3:38 PM. The Administrator explained the SW verified that the February discharge information had not been sent to the regional Ombudsman as it should have been.

Based on observation, record review, and staff, Wound Nurse Practitioner (NP), and Medical Director interviews, the facility failed to keep the resident's pressure ulcer wound vacuum device off the floor. The resident had sacral pressure ulcer and osteomyelitis (infection of the bone) of the sacral bone. The deficient practice affected 1 of 6 residents reviewed for pressure ulcer (Resident #14). The findings included:The National Institute for Health (NIH) defines a wound vacuum device as a method using negative pressure wound therapy with proper wound preparation, debridement, dressing placement, and airtight sealing. A porous foam dressing is placed into the wound to which continuous or intermittent suction is applied by tubing and connected to a suction device. An air-tight transparent film dressing is applied over the wound. The device may be placed using sterile technique when clinically indicated. (February 21, 2026).The NIH clinical guidelines for the wound vacuum usage were that you would emphasize keeping the pump and drainage system in a controlled, clean environment, often on a treatment table or in a designated care area, to maintain sterility and ensure proper function (February 21, 2026). Resident #14 was admitted to the facility on [DATE] with diagnoses including sacral pressure ulcer and osteomyelitis of the sacral bone. Resident #14's admission Minimum Data Set, dated [DATE] documented his cognition was intact. The resident was dependent for all his activities of daily living. The active diagnoses were quadriplegia, pressure ulcer, osteomyelitis of the vertebral/sacral/sacrococcygeal regions, and injury of the spinal cord unspecified level of the cervical spine. The resident had a stage 4 pressure ulcer that was present on admission. The care plan for Resident #14 dated 3/5/26 included areas to address the pressure ulcer and osteomyelitis requiring antibiotic administration.Resident #14 had an order for sacral pressure ulcer wound care to cleanse the wound with saline, apply wound vacuum at 125 millimeters of pressure continuous therapy and apply silver alginate to surrounding areas underneath the transparent film dated 4/13/26.Resident #14's had an order for Vancomycin (antibiotic) intravenous solution 1250 milligrams in 250 milliliters of fluids administered each morning related to osteomyelitis of the vertebral, sacral, and coccygeal region dated 4/27/26.NP #3's note dated 3/8/26 documented Resident #14 had a complex medical history including quadriplegia, chronic respiratory failure with tracheostomy, Stage 4 sacral pressure ulcer with known osteomyelitis, recent Clostridioides difficile infection of his stool, and diabetes on insulin. Resident #14 was seen today for follow-up to review lab results and provide recommendations per guidelines.On 04/28/26 at 9:35 AM an observation and interview with Resident #14 was completed. A wound vacuum was in place with tubing that went to the resident's sacrum. The vacuum device was covered in a case that had a strap with a tube attached with collection container to the resident's wound dressing. The wound vacuum device was on the floor. On 4/28/26 at 9:40 am the assigned Nurse #7 was interviewed after she entered Resident #14's room and observed the wound vacuum was on the floor. Nurse #7 commented she thought the wound vacuum may need to be lower for gravity but did not know why the device was on the floor, had not placed the device on the floor and had not noticed this morning during medication administration and tracheal suction. Nurse #7 stated she was unfamiliar with the resident and was usually assigned to another hall. On 4/28/26 at 11:05 am Nursing Assistant (NA) # 4 was interviewed. NA #4 stated she was assigned to Resident #14 on day shift 7:00 am to 7:00 pm (4/28/26). She noted the wound vacuum was on the floor and thought that was unusual but did not elevate the vacuum off the floor or report this to the nurse. NA #4 stated it was usually on a chair but not today.On 4/30/26 at 11:15 AM an interview was completed with NA #7. NA #7 stated Resident #14's wound vacuum was usually sitting on the floor. On 4/30/26 at 12:53 PM an interview was completed with NA #8. NA #8 stated she observed Resident #14's wound vacuum on the floor recently. On 4/30/26 at 4:19 PM an interview was completed with NA # 6. NA #6 stated she observed Resident #14's wound vacuum on the floor on different occasions. NA #6 commented she was not sure where it should be. On 04/28/26 at 9:52 am the Director of Nursing (DON) was interviewed. The DON was informed that Resident #14's wound vacuum was observed to be on the floor this morning. The DON frowned when she was informed the wound vacuum was on the floor and stated she would need to get back to me when the Wound Nurse was available. The DON commented that the wound vacuum device on the floor had the tubing directly connected into the resident's sacral pressure ulcer dressing which was a concern. On 4/28/26 at 1:15 pm the Wound Nurse was interviewed. The Wound Nurse thought the wound vacuum was sitting on a chair and not on the floor daily. The Wound Nurse stated the wound vacuum should be off the floor because it was attached to the resident's wound and was part of his sterile dressing and the collection container was part of the device. The floor was not a controlled environment and the device needed to be in a clean area. The Wound Nurse indicated the dressing was placed using sterile technique. On 4/28/26 at 1:32 pm an interview was completed with the Medical Director. The Medical Director reviewed Resident #14's record and commented that the resident had a sacral pressure ulcer with osteomyelitis and the wound vacuum should not be placed on the floor because it was connected to and part of his wound dressing. The Medical Director further stated no wound care items/dressings used for a wound that had high risk of infection should be placed on the floor. On 4/29/26 at 9:00 am an interview was conducted with the Wound Nurse and Wound NP. The Wound NP stated that Resident #14's wound vacuum should not be on the floor in case of contamination because it was attached to the resident's sacral pressure ulcer dressing. The Wound NP further commented that the pressure ulcer was not infected, but the resident had osteomyelitis of his sacral bone because of the pressure ulcer and was being actively treated.On 4/29/26 at 4:10 pm an observation was completed of Resident #14's sacral pressure ulcer wound care with replacement of the wound vacuum dressing and tubing by the Wound Nurse. The Wound Nurse removed the sacral dressing and then donned sterile gloves. The wound was cleaned with sterile saline. The wound vacuum kit was in an enclosed sterile package which included a foam dressing which was cut to fit inside the wound opening and placed, the vacuum tubing was placed into the foam and covered with a transparent film dressing using sterile technique. The wound vacuum was placed on the bed's headboard, off the floor. The Wound Nurse entered the settings in the vacuum device. The Infection Preventionist (IP) was interviewed on 4/30/26 at 11:50 AM. The IP stated the wound vacuum should not be on the floor exposed to potential contamination. The IP indicated the wound vacuum was attached to Resident #14's sterile dressing and he currently had osteomyelitis as a complication of the pressure ulcer.

Based on observations, record review, and staff and Medical Director interviews, the facility failed to have an effective system in place for communicating a therapy order for a resting left hand splint to nursing staff for 1 of 1 resident reviewed for a contracture and limited range of motion (Resident #36).Findings included:Resident #36 was admitted to the facility on [DATE]. Diagnoses included contracture of the left hand, muscle weakness and cerebral infarction (stroke).Review of an Occupational Therapy note entered by Occupational Therapist (OT) #1 and dated 12/11/25 revealed Resident #36 was referred to occupational therapy for functional decline and reassessment of compliance with splinting. The musculoskeletal assessment revealed the range of motion (ROM) and strength of both the left and right upper extremities were impaired, functional limitations were present due to contractures, the location of the contractures were the left hand and elbow, and the current orthotic device was a resting hand splint. The long-term goal was for Resident #36 to safely wear a resting hand splint on left hand for up to 5 hours with no report of pain, swelling or redness in order to reduce progression of contracture and increase ease of hygiene.The discharge summary note written by OT #1 dated 1/23/26 revealed Resident #36 progress and response to treatment had demonstrated improved tolerance of left resting hand splint to 6 hours with no complaints of pain, redness, or skin irritation. The discharge summary further revealed OT #1 recommended Resident #36 to have 24-hour care and lifeline for safety and left resting hand splint.Review of Resident #36's physician orders from 1/23/26 through 4/28/26 revealed there were no orders in place to apply a resting left hand splint.Review of the Medication Administration Record (MAR) from 1/23/26 through 4/28/26 revealed there were no orders for nursing staff to sign off that a resting left hand splint for Resident #36 was applied.The Minimum Data Set quarterly assessment dated [DATE] revealed Resident #36 was moderately cognitively impaired and demonstrated no behaviors. Resident #36 was dependent on staff for all activities of daily living assistance. The assessment indicated Resident #36 had limited range of motion in both the upper and lower extremities and had not received occupational therapy.A review of Resident #36's active care plan revealed there was no care plan for the use of left hand splint.An observation of Resident #36 on 4/28/26 at 9:20 AM and at 12:33 PM revealed there was no resting left hand splint applied. There was no splint in view in his room at any of these times. Resident #36's left hand was noted to be contracted.An interview was conducted with OT #1 on 4/29/26 at 9:42 AM. Upon review of Resident #36's Occupational Therapy discharge summary, OT #1 confirmed that she did recommend Resident #36 to continue to wear a left resident hand splint for 6 hours a day and she did not communicate the order. The OT initially stated that it was the rehabilitation staff's responsibility to enter the orders, and then she said she needed to check with her manager.An interview was conducted with Nurse # 5 on 4/29/26 at 9:47 AM and she indicated she was regularly assigned to Resident #36 and does not recall every seeing him with a splint in use and had no active physician order for the use of a splint.An observation of Resident #36 on 4/29/26 at 10:22 AM revealed there was no resting left hand splint applied. There was no splint in view in his room at that time. An interview conducted with Nurse Aide (NA) #6 on 4/29/26 at 12:00 PM revealed she had been regularly assigned to Resident #36 since December of 2025 and had not seen or applied a splint to his left hand.An interview was conducted with the Rehabilitation Manager on 4/29/26 at 2:50 PM. The Rehabilitation Manager indicated that OT #1 was responsible for entering Resident #36's OT recommendations into the orders.An interview was conducted with the Medical Director on 4/28/26 at 1:40 PM. The Medical Director stated he would have expected the therapist to follow through with her recommendation and communicate clear orders and instructions so the order could be implemented.An interview with the Director of Nursing (DON) on 4/30/26 at 2:57 PM indicated that she would have expected rehabilitation staff to enter all therapy recommendations into the orders so the recommendations could be implemented.

Based on observation, record review, and staff and Medical Director interviews, the facility failed to keep a dependent resident positioned in the center of his bed so when the air mattress rotated for offload it did not cause the resident to fall out of his bed. The resident sustained a laceration above his right eye and was sent to the Emergency Department (ED). The deficient practice affected 1 of 9 residents reviewed for accidents (Resident #14).The findings included:Resident #14 was admitted to the facility on [DATE] with a diagnosis of quadriplegia.Resident #14's admission Minimum Data Set, dated [DATE] documented his cognition was intact. The resident was dependent for all his activities of daily living. The active diagnoses were quadriplegia and injury of the spinal cord unspecified level of the cervical spine. The resident had a stage 4 pressure ulcer that was present on admission. The care plan for Resident #14 dated 3/5/26 included areas that addressed his high risk for a fall and he was dependent for all his activities of daily living. The interventions were to place items within reach and to remind the resident to use the call light. Resident #14's fall progress note description dated 4/15/26 at 11:00 pm and documented by Nurse #3 revealed Nursing Assistant (NA) #6 arrived at the desk and reported Resident #14 was on the floor. The NA heard the resident yelling for help. Upon entering, the resident was noted to the lying on the floor in between the beds on the left side of his body. The right side of his shoulder, back and hip were lying on top of the leg piece of the bedside table. The urinary catheter was intact and had become separated from the bag. Blood was noted to be rolling down the left side of the resident's face. The resident was placed back in his bed by 3 staff members. The blood was noted to be coming down from the left side of the resident's eye. His face was cleaned and a laceration was noted at the top lateral left eye and left lateral cheek. Both areas were cleaned with saline and covered with xeroform (non-stick dressing) and a dry sterile dressing. A full body assessment was completed, and no further impairments were noted. A hematoma was noted to form to the top left side of the forehead at the hairline. Emergency Medical Services were called (EMS). Neurological checks of the resident were initiated. The bed was in low position, and the call pad was within reach. The resident had been and was being repositioned often. On 4/30/26 at 4:14 PM an interview was completed with NA #6. NA #6 stated she was assigned to Resident #14 on 7/15/26 day shift from 7:00 am to 7:00 pm. NA #6 stated toward the end of the shift, she heard the resident call out and found him on the floor next to his bed. NA #6 indicated she reported this to Nurse #3 immediately. The resident was assessed by the nurse. NA #6 stated she believed the resident went out to the ED. NA #6 had adjusted the resident in the bed before the fall. The resident requested to sit up in bed and would slide over and requested staff to straighten him. That was the last time NA #6 saw the resident in bed. NA #6 was not sure how long from the last time she saw the resident until he called out for help. NA #6 further stated she straightened the resident several times that shift. NA #6 stated she was not sure how the resident fell out of bed but the resident's sitting up straight in bed. may have contributed to his sliding to one side. Nurse #3 was unable to be contacted for an interview. On 4/15/2026 at 7:37 pm a change in condition for Resident #14 nurses' note was documented by Nurse #3. Nurse #3 documented the resident fell and his vital signs were Blood Pressure: 109/71 (range 110-139/60-80); Pulse: 70 (range 60 to 100); Respiratory Rate: 20 (range 12-20); Temperature: 97.9 (range 97 - 99); Pulse Oximetry: oxygen level 94.0 % (range 90 to 100%). There were no changes in mental status observed. It was documented that Resident #14 was found lying on his left side on the floor facing the window with his face against the floor and blood was on the floor under his head. The primary care provider was contacted and gave the order to send the resident to the ED for further evaluation of the laceration to his left upper eye and cheek. Resident #14's ED record dated 4/15/26 documented he fell out of bed. The resident had x-rays and a CAT (diagnostic imaging procedure) scan which revealed he had no fracture. The resident had a one (1) centimeter laceration to the left eyelid/brow area. The laceration was cleaned and closed with tissue adhesive. There was no mention of an injury to Resident #1's cheek. The resident was sent back to the facility the same day with no new orders. On 4/28/26 at 10:20 AM an observation and interview were completed with Resident #14. Resident #14 stated about 3 days ago he fell out of bed. The resident commented he was a quad (quadriplegic) due to a recent motor vehicle accident. The resident was on a rotating air mattress for pressure relief. He stated the staff left him on the edge of the bed and not in the middle of the bed and he fell out when the rotating mattress rotated him out of the bed. The manufacturer sheet for the rotating mattress was noted to be slick to the touch and not cotton linen. The bed was observed and was operating by his weight setting. The resident was able to state the bed was rotating left and right to move his weight to offload his wound. Resident #14 was in the center of the bed at the time of the observation. On 4/28/26 at 3:16 pm an interview was completed with NA #4. NA #4 stated she had been assigned to Resident #14 frequently and knew him well. NA #4 indicated the resident could not move independently and would not be able to roll over. NA #4 thought the resident was sitting up and coughed hard and slid to the side and then out of bed. NA #4 stated she had seen the resident cough and start leaning to his right before and had to be straightened to the center of his bed. NA #4 commented that she has had to straighten the resident in bed frequently. NA #4 indicated she was informed about Resident #14's fall out of bed and the staff were educated to keep the bed low, resident in the middle of the bed, and the head of the bed lower to keep him from sliding out of bed. On 4/28/26 at 3:33 pm an interview was conducted with NA #5. NA #5 stated she worked nights and was assigned to Resident #14. NA #5 indicated she was assigned to the resident the night before he fell. NA #5 stated Resident #14 liked to sit up in his bed and would lean to the right. She further stated she was placing a pillow on his right side at the bedrail. NA #5 stated she reported the leaning to the nurse and in shift report. The next night the resident fell out of bed. After the fall, staff was instructed to keep the resident's bed in the low position. On 4/28/26 at 1:32 pm an interview was completed with the Medical Director. The Medical Director reviewed Resident #14's record and stated the resident had quadriplegia and cannot move. The Medical Director indicated this fall was a never event and should not have happened. The staff needed to place the resident appropriately in the center of his bed so when the mattress rotates for offload it does not cause a resident to fall out. The Medical Director stated staff cannot place a resident on the edge of the bed. On 4/29/28 at 9:52 am an interview was completed with the Director of Nursing (DON). The DON stated she was aware resident #14 had fallen out of bed and that he was dependent. She was not sure how he fell out and staff was to keep his bed low. There was an investigation after the unwitnessed fall, and the cause of the fall was not determined. On 4/30/26 at 3:40 pm, an interview was completed with the Administrator. The Administrator stated she was aware that Resident #14 had fallen out of bed and he was dependent. The Administrator had no further comments.

Based on record review, and resident, staff, and Quality Assurance Pharmacist interviews, the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, and administering of medication to meet the resident's needs for 1 of 1 resident reviewed for medication administration (Resident #89). The findings included:Resident #89 was admitted to the facility on [DATE] with a diagnosis of atrophic vaginitis.Review of Resident #89's order summary revealed an order for Estrace Cream 0.1miligram(mg)/gram(gm) (a medication that restores hormone levels in vaginal tissue, insert 1gm vaginally one time of day for Atrophic vaginitis for 365 days written on 3/10/25 with an end date of 3/11/26. Estrace Cream 0.1mg/gm, insert 1 gm vaginally one time a day for atrophic vaginitis was reordered on 4/13/26.Review of Resident #89's Medication Administration Records (MAR) from May 2025 through April 2026 indicated 9 (refer to progress note) for the dates listed below: 5/26/25 and 5/27/258/4/25, 8/5/25, 8/8/25 and 8/17/259/11/2511/19/25, 11/20/25, and 11/21/251/14/26 and 1/15/262/2/26 and 2/3/26Review of a progress note dated 5/26/25 written by Nurse #6 indicated the Estrace cream was ordered due to no medication applicator.Review of a progress note dated 5/27/25 written by Nurse #6 indicated she was waiting on Estrace cream that was ordered on May 26th.Review of a progress note dated 8/4/25 written by Nurse #6 indicated Estrace cream was ordered from pharmacy.Review of a progress note dated 8/5/25 written by Nurse #6 indicated she followed up with the pharmacy regarding the Estrace cream. The progress note further indicated the medication would be delivered that day on night shift. Review of a progress note dated 8/8/25 written by Nurse #6 indicated Estrace cream was ordered from the pharmacy.Review of a progress note dated 8/17/25 written by Nurse #8 indicated Estrace cream was unavailable and ordered from the pharmacy.Review of a progress note dated 9/11/25 written by Nurse #6 indicated Estrace cream was ordered from the pharmacy because there was no medication applicator.Review of a progress note dated 11/19/25 written by Nurse #6 indicated the Estrace cream was on hold because there was no medication applicator.Review of a progress note dated 11/20/25 written by Nurse #6 indicated she followed up with pharmacy regarding the Estrace cream. The progress note further indicated that the medication would be delivered with the overnight delivery.Review of a progress note dated 1/14/26 written by Nurse #6 indicated the Estrace cream was on hold because there was no medication applicator.Review of a progress note dated 1/15/26 written by Nurse #6 indicated Estrace cream was ordered because there was no medication applicator.Review of a progress note dated 2/2/26 written by Nurse #6 indicated the Estrace cream was on hold.Review of a progress noted dated 2/3/26 written by Nurse #6 indicated the Estrace cream was on hold.Multiple attempts were made with no success to contact Nurse #6 and Nurse #8, the nurses responsible for Resident #89's care when the MAR indicated 9.An interview was conducted on 4/27/26 at 12:28pm with Resident #89 (Minimum Data Set, dated [DATE] indicated resident was cognitively intact). Resident #89 verified that she was not receiving her Estrace cream as ordered. She stated at times she still does not receive her Estrace cream but was unable to provide specific dates.An interview was conducted on 5/4/26 at 4:28 pm with Quality Assurance Pharmacist with the facilities pharmacy. The Quality Assurance Pharmacist indicated they delivered 42.5 grams of Estrace cream, a 42-day supply, to the facility. The Quality Assurance Pharmacist provided the dates and times when Resident #89's Estrace cream was delivered to the facility. The dates and times are listed below:4/29/25 at 5:10 am5/29/25 at 4:56 pm6/25/25 at 4:40 am7/13/25 at 9:12 pm8/8/25 at 5:23 am8/29/25 at 5:01 pm9/20/25 at 5:05 pm10/12/25 at 9:14 pm11/21/25 at 4:24 am1/14/26 at 4:27 pm2/10/26 at 4:09 pm4/14/26 at 3:12 [NAME] interview was conducted on 4/30/26 at 12:00 pm and 5/4/26 at 2:15 pm with the Director of Nursing (DON). The DON indicated the Estrace cream only came with one applicator in the box. When asked if the facility was ordering the applicators separate from the cream, the DON was unable to answer. The DON indicated nurses should order the medication when they see that the supply is getting low. If the medication was not available in the facility, nurses were expected to make the provider aware that the medication was not available and follow the providers' recommendation.An interview was conducted with the Administrator on 5/1/26 at 11:11 am. The Administrator indicated she would expect staff to be aware of the medications and supplies that were needed and order them.

Based on observations, resident and staff interviews and record review, the facility failed to maintain an effective pest control program for 7 of 94 resident rooms (Rooms #11, # 12, #57, #50, #89, #88 and #74). The deficient practice occurred on 4 of 4 halls (Mauve 1, Mauve 2, Teal 1 and Teal 2 halls). The findings included: Review of the monlthy and special visit pest control service reports from 8/12/24 through 3/26/25 revealed there were no recommended changes to the service provided for each visit: On 8/12/24, Gentrol IGR concentrate was used to treat medium roach activity in resident rooms, baseboards and crown moldings in the crack and crevices. On 8/17/24 Alpine WSG.2% was used to treat medium roach activity in wall voids of resident rooms. On 9/3/24 Alpine WSG.2% was used to treat light roach activity in the baseboard and crown molding in resident rooms. On 9/28/24 Alpine WSG.2% was used to treat light ant and fly activity in the cracks and crevices of baseboards, break room, common areas, dining room, dishwasher area, drink stations, foyer/lobby, gym, kitchen/kitchen island, refrigerator area, rest rooms, sink area, storage/utilities and stove area. Glue board Patrol was used in the cracks and crevices in the interior and exterior foundations to address roaches, silver fish, ants, crickets, millipedes and house flies. On 10/31/24 Alpine WSG.2% was used to treat light roach and fly activity in rooms #50, # 52, #88, #89, #90 and #91 in the baseboard, bathrooms and crown molding. On 11/30/24 Alpine WSG.2% was used as regular service in resident rooms, baseboards, bathrooms, dining rooms and common areas. There were no pest issues reported. On 12/6/24 Alpine WSG.2% was used as regular service in resident rooms, baseboards, bathrooms, dining rooms and common areas. Additional treatment in rooms #27, #28, #29, #30, #88, #89, #90 and #91). There were no pest issues reported. On 12/28/24, Alpine WSG.2% and glue boards were used for interior and exterior perimeter controls in resident rooms, common areas, bathrooms, baseboards, crown moldings, laundry and storage/utility rooms. There was no visit in January 2025. On 2/15/25 Alpine WSG.2% was used to treat light fly activity, No other pest issues. On 3/17/25 Monitor Board Alpine WSG.2% was used to treat light roach activity in the kitchen and in rooms #50 and #89, bathrooms, common areas and base boards. On 3/26/25 Alpine WSG.2% was used in rooms #17 and #50, No roach activity reported. 1a. An observation was conducted on 4/28/25 at 9:30 AM in room [ROOM NUMBER] revealed dead bugs in the bathroom in the corners along the edges of the wall where the base board was coming apart from the wall. b. An observation was conducted on 4/28/25 at 9:45 AM in room [ROOM NUMBER] revealed dead bugs underneath the air conditioner unit in the room, around the sides of the closet, behind the nightstand, and in the corners of the bathroom near the sink. c. An observation was conducted on 4/28/25 at 10:20 AM in room [ROOM NUMBER] revealed dead bugs and active bugs were coming from behind the nightstand, underneath the closet and base boards behind the bed. d. An observation was conducted on 4/28/25 at 10:21 AM in room [ROOM NUMBER] revealed roaches coming out from behind nightstand, under the bed and the in bathroom. e. An observation was conducted on 4/28/25 at 1:51 PM in Room # 89 revealed dead roaches/bugs surrounding the base of the closet area, behind the nightstand and behind the bed area. f. An observation was conducted on 4/28/25 at 1:53 PM in room [ROOM NUMBER] revealed dead roaches/bugs around the closet and under the air conditioner unit. g. An observation was conducted on 4/28/25 at 2:40 PM in Room revealed #74 dead and active bugs surrounding the clutter room of boxes and bags of personal items and food. An interview was conducted on 4/30/25 at 3:00 PM, with Nurse Aide #7 who stated the facility management team were aware of the roaches/bug problem since 2024 and things had gotten worse to a point where staff brought in their own sprays to help control the bugs when they were providing care for the residents. She reported maintenance had called in the bug company many times, but nothing had been successful. She stated the residents clutter in the room and not properly stored food/drinks and personal items continue to feed the bugs and residents should not have to wake up and find bugs crawling all over them. The issues have been reported and documented by many staff but there have been no changes, families and residents complain to the aides, but we have no control over how things get resolved. The rooms were allowed to be junky and other residents complained that their personal space has been invaded by the other residents' poor habits. An interview was conducted on 4/28/25 at 12:10 PM with Housekeeper (HK) #1 who stated she had seen bugs on the floor, under closets, bathrooms and around the base board behind beds. She further stated she would kill them and report to the housekeeping supervisor and maintenance. She further stated she was instructed not to move resident personal belongings unless they had resident's permission to clean areas outside of the routine cleaning checklist. She stated there were times when there were only two housekeepers, and she was unable to complete all the assigned tasks. An interview was conducted on 4/28/29 at 12:28 PM, with HK #2 who stated that when she observed any bugs, ants/ rodents or needed repairs in resident rooms, she would report her observation to the Housekeeping and Maintenance Director. HK#2 stated when she had seen them, she would just kill them or sweep them up and put in trash. An observation and interview were conducted on 4/28/25 at 1:30 PM with the Housekeeping Director who observed the identified rooms with either the dead or active bugs present. She reported the roaches and bugs have been reported to maintenance and the pest control company had visited the facility numerous times, however residents with excessive amounts of food/drinks stored and clutter continued to be an on-going problem for recurrent bugs. Effective cleaning and reduction of the bugs have been a challenge due to the poor storage of personal items and food/drinks in resident rooms. The Maintenance Director was aware of the visible bugs and contacted the pest control company monthly and for the specific rooms with chronic concerns. An observation and interview were conducted on 4/29/25 at 1:55 PM to 3:00 PM with the Maintenance Director of the identified rooms with dead or active bugs present. The Maintenance Director stated that anytime there was a report of any visible bugs within the facility, he would contact the pest control company for special sprays and monthly spray of the interior and exterior of the facility. He further stated several rooms had been identified to receive special attention due to resident hoarding and clutter. He further stated the previous Administrator had offered residents alternative storage options for personal items and asked them not to store large quantities of food/drinks in the rooms. Families had been asked not to bring in items that may contribute to the recurrence of bugs/roaches due to storage issues. He further stated with the additional visits to specific rooms the visibility of roaches/bugs had decreased. He acknowledged additional efforts would need to be explored. An interview was conducted on 4/30/25 at 4:00 PM, with the Director of Nursing (DON), who stated he was aware there were several environmental concerns that needed to be addressed. He confirmed the condition of resident rooms were not cleaned and maintained by maintenance and housekeeping. The DON stated that immediate action would occur to correct the problem. An interview was conducted on 5/1/25 at 8:51 AM with the Administrator who stated the facility had been working with residents and families about the storage of personal items and foods to reduce the visibility of any pests. He reported the monthly pest control visits and special visits for the identified rooms had been in place. He further stated he was aware of the pest control issue and was currently working on an effective solution to address the situation.

Based on observations, staff interviews and record review, the facility failed to clean sticky floors with debris, repair base boards and clean and maintain air conditioning units in resident rooms for 13 of 94 (Rooms #11, # 12, 14, 18, 20, 25, 46, 50, 52, 56, 70, 74 and 90) observed for cleanliness. The deficient practice occurred on 4 of 4 halls (Mauve 1, Mauve 2, Teal 1 and Teal 2 halls). The findings included: 1a. An observation was conducted on 4/28/25 at 9:30 AM, in room [ROOM NUMBER] the floor underneath the nightstand was very sticky, with brown substance, old food/paper products on the floor. The air conditioning unit inside and outside had large volumes of thick dust and debris buildup. b. An observation was conducted on 4/28/25 at 9:45 AM, in room [ROOM NUMBER] the floor was stained and dirty, sticky, with old paper products and food under the nightstand and beside the closet. The air conditioning unit inside and outside had large volumes of thick dust and debris buildup. c. An observation was conducted on 4/28/25 at 9:50 AM, in Room # 14, a hole was in the baseboard of room near bed B, the baseboard was detached from the wall with broken and exposed sheet rock. The floor was dirty sticky, leftover cups, paper products and old food were underneath the nightstands. The air conditioning unit inside and outside had large volumes of thick dust and debris buildup. d. An observation was conducted on 4/28/25 at 10:00 AM, room [ROOM NUMBER] the floor was sticky when walked across, underneath the bed and nightstand, there was a hole in the wall and baseboard coming apart from the wall. The air conditioning unit inside and outside had large volumes of thick dust and debris buildup. e. An observation was conducted on 4/28/25 at 10:12AM, in room [ROOM NUMBER], the floor was dirty, sticky and paper products were behind and underneath the nightstand. The air conditioning unit inside and outside had large volumes of thick dust and debris buildup. The baseboard came apart from the wall behind the bed. f. An observation was conducted on 4/28/25 at 10:14 AM, in room [ROOM NUMBER] the floor was dirty, sticky, with paper products behind nightstand and the air conditioning unit inside and outside had large volumes of thick dust and debris buildup. g. An observation was conducted on 4/28/25 at 10:15 AM, in room [ROOM NUMBER] the floor was stained with brown matter and the baseboard behind the bed coming apart from the wall. h. An observation was conducted on 4/28/25 at 10:16 AM, in room [ROOM NUMBER], the floor was dirty, sticky and stained with brown matter around baseboards, under the nightstand and closet area. The baseboard came apart from the wall. i. An observation was conducted on 4/28/25 at 10:18 AM, in room [ROOM NUMBER] underneath the nightstand and bed had leftover food and paper products. The floor was very dirty and sticky when it was walking across. The air conditioning unit inside and outside had large volumes of thick dust and debris buildup. j. An observation was conducted on 4/28/25 at 10:20 AM, in room [ROOM NUMBER] the baseboard behind the bed came apart from the wall and leftover paper products and food debris were underneath the nightstand and closet area. The air conditioning unit inside and outside had large volumes of thick dust and debris buildup. k. An observation was conducted on 4/28/25 at 10:21 AM, in room [ROOM NUMBER] underneath the nightstand and around the closet area leftover food and paper products were on the floor. The floor was sticky, heavily stained with brown matter and dried liquids. The air conditioning unit inside and outside had large volumes of thick dust and debris. l. An observation was conducted on 4/28/25 at 1:59 PM, in room [ROOM NUMBER] the air conditioning unit had broken slates with sharp edges. m. An observation was conducted on 4/28/25 at 2:00 PM, in room [ROOM NUMBER] the air conditioning unit had food and paper products on the inside and dried food liquids on the outside. o. An observation was conducted on 4/28/25 at 2:40 PM, in room [ROOM NUMBER], the room had a strong urine odor, the floors were very sticky with dried yellow and brown stains. The air conditioning unit had food and paper products on the inside and dried liquids on the outside. A facility tour was conducted with the Housekeeping Director (HKD) on 4/28/25 at 1:35 PM, who observed the identified rooms and confirmed additional cleaning needed to be done. The HKD stated each housekeeper was provided with a daily assignment sheet with the responsibility to thoroughly clean resident rooms, bathrooms, sweep mop, empty trash and air conditioning units, in addition to assigned rooms to be deep cleaned weekly. The Housekeeping Director acknowledged some rooms had not been cleaned in accordance with the cleaning checklist. An observation and interview were conducted on 4/29/25 at 1:55 PM to 3:00 PM with the Maintenance Director of the identified rooms with observations of air flow of the air conditioning unit and cleanliness of the units and the baseboards that came apart from the walls. The Maintenance Director acknowledged the air conditioning units were dirty inside and outside; blowing dust and dirt into the air of resident rooms. He further stated he was responsible for the repairs of the baseboards throughout the facility. He stated housekeeping and maintenance would develop a plan to improve the environment. An interview was on 4/30/25 at 4:00 PM, with the Director of Nursing (DON), who stated he was aware there were several environmental concerns that needed to be addressed. He confirmed the condition of resident rooms were not cleaned and maintained by maintenance and housekeeping. The DON stated that immediate action would occur to correct the problem.

Based on record review, resident, and staff interviews, the facility failed to schedule an an opthamologist consultation for cataract extraction surgery when ordered by the Medical Director for 1 of 2 residents (Resident #81) reviewed for vision. Findings included: Resident #81 was admitted to the facility on [DATE]. The significant change Minimum Data Set (MDS) dated [DATE] noted Resident #81 was cognitively intact, had impaired vision, and used glasses. Resident #81's comprehensive care plan dated 10/02/24 noted he had impaired vision and for staff to refer him to ophthalmology as needed. Review of an optometrist consultation note dated 11/15/24 and scanned into the electronic medical record (EMR) documented Resident #81 had a diagnosis of combined forms of age-related cataract in both eyes. The optometrist noted his right eye cataract was causing blurred vision which increased his likelihood of falling. The optometrist noted the facility needed to choose a local ophthalmologist for cataract extraction removal surgery. The former Medical Director, Doctor #2, initialed the top right corner of the consultation. Resident #81's physician orders documented an order dated 3/25/25 for the resident to receive an ophthalmologist consultation for cataract extraction. Review of Resident #81's clinical record did not reveal a documented appointment with a local ophthalmologist or address the need for an outside appointment after the 11/15/24 optometrist consultation until 3/25/25. An ophthalmologist consultant report dated 4/15/25 indicated Resident #81 had visible cataracts and needed to be referred to a larger clinical practice for surgery. In an interview on 4/28/25 at 10:25 AM, Resident #81 stated he had recently been to the eye doctor about his cataracts, but he had to keep asking different staff members to look into it. He said he could not see well out of his right eye. He said he recently went to the eye doctor and will be having his cataracts removed. He was not aware the eye doctor recommended an outside appointment in November, just that there was an order in March. During an interview on 5/01/25 at 8:43 AM with Unit Manager #1, she said she was not aware Resident #81 was originally referred to an ophthalmologist in November 2024. She said when a resident saw the facility eye doctor, the former Social Worker (SW) would provide the nurses with a copy of the report if there were any recommendations. She said the former SW did not notify her to make an appointment for Resident #81, but the resident went to see an ophthalmologist recently after requesting an appointment. In an interview on 5/01/25 at 4:08 PM, the Unit Secretary said she was the staff member responsible for scheduling appointments for the residents and had been in that role for approximately a year. She said she was not made aware of the optometrist's recommendation for Resident #81 to see an ophthalmologist when the resident had the consultation in November 2024. She said when there was a request for an appointment from an outside provider, the SW or nurse would let her know to schedule the appointments and obtain transportation. In an interview on 5/01/25 at 4:11 PM, the Director of Nursing said the Unit Secretary made appointments when there was a referral from a consulting physician. He said he was not at the facility when Resident #81 had the consultation in November 2024, so he was not sure how it was missed. He was not aware of the consultation recommendation until the surveyor asked for additional information about the recommendation. In an interview on 5/01/25 at 4:16 PM, the new SW said she had only been working in the facility for approximately one month and she was not aware of Resident #81's ophthalmologist referral. She said the system to manage the recommendations from the outside consultants was still being developed at the time of the survey. Attempts to interview the former SW were unsuccessful. In an interview on 5/01/25 at 4:56 PM, the Administrator said he was not aware Resident #81 had a referral for an ophthalmologist in November 2024. He said the former SW would give the information to the Unit Secretary and he was not sure how it was missed.

Based on record review, observations and staff interviews the facility failed to maintain clean nourishment refrigerators, failed to record the nourishment refrigerator and freezer temperatures from 4/24/25 to 4/28/25, and failed to label and date residents' food stored in the nourishment refrigerators for 2 of 3 nourishment refrigerators (on Teal and Mauve 1 hallway). These practices had the potential to affect food being served to residents. Findings included: 1 a. During an observation of the nourishment refrigerator on Mauve 1 hallway on 4/28/25 at 9:15 AM, revealed the April temperature logs for the refrigerator and freezer were not documented from 4/24/25 to 4/28/25. There was water on the shelves inside the refrigerator and yellowish red stains on the shelves. The refrigerator contained an unlabeled and undated 11-ounce (oz.) protein shake bottle. The nourishment freezer had an unlabeled and undated 20 oz bag with seafood mix-raw shrimps, squid, mussel, scallops printed on it. During an interview on 4/28/25 at 9:20 AM, the Dietary Manager stated the raw shellfish bag belonged to a resident, who ordered food from the grocery store. She was unsure why the resident ordered raw shellfish from the grocery store. The Dietary Manager indicated that residents' foods were labeled by the nursing staff with the name of the resident and the date the food was placed, prior to placing them in the nourishment refrigerator. The Dietary Manager stated that refrigerator temperatures were recorded by the dietary staff. The Dietary Manager further stated the housekeeping staff were responsible for cleaning the nourishment refrigerator weekly. During an interview on 5/1/25 at 9:45 AM, Nurse #2 stated she was the acting Unit Manager for Mauve 1 hallway. She stated Dietary department was responsible for maintaining and updating the temperature log for the nourishment refrigerators, and the housekeeping department was responsible for cleaning the refrigerator. Nurse #2 further stated all nursing staff were responsible for labeling the resident's food with their name, date and room number prior to placing the food in the nourishment refrigerator. 1b. During an observation of the nourishment refrigerator on Teal hallway on 4/28/25 at 9:25 AM, the refrigerator temperature log on the door was last documented on 4/24/25. The shelves inside the refrigerator had light yellowish stain on them. There was an unlabeled and undated fast-food milkshake container (16 oz) which was open. During an interview on 4/28/25 at 9:30 AM, the Dietary Manager stated all residents' food should be labeled with their name and date by the nursing staff, prior to being placed in the refrigerator. During a follow-up interview with the Dietary Manager on 5/1/25/ at 10:30 AM, she indicated she had gone on vacation for few days (4/24/25 to 4/27/25) and had not communicated the assignment to check the temperatures of the nourishment refrigerator to the dietary staff. She indicated most of the dietary snacks were shelf stable and not usually placed in the nourishment refrigerator. These were placed in the cabinets in the nourishment rooms. She stated that this was the reason why she was unable to check if the refrigerators were dirty. The housekeeping staff would clean the nourishment rooms and other appliances like the microwave and the refrigerator in the nourishment room. During an interview on 5/1/25 at 10:35 AM the Housekeeping Manager indicated the housekeeping staff only cleaned the cabinets, countertop, microwave and outside of the refrigerator in the nourishment refrigerator. The Housekeeping Manager stated the housekeeping staff did not clean the inside of the refrigerator. During an interview on 5/1/25 at 10:45 AM, the Administrator stated Dietary, Nursing and Housekeeping staff were responsible for keeping the refrigerators clean. Nursing staff should check the food placed in the refrigerator and no raw food should be placed in the nourishment refrigerator. The Administrator stated all residents' foods should be labeled with resident's names and date.

Based on observation, record review, and interviews with the resident and staff, the facility failed to treat one of six residents (Resident #4) reviewed for respect in a dignified manner when Nurse Aide (NA) #3 pulled Resident #4's geriatric wheelchair (a padded chair with a wheeled base) backwards down the hall. Resident #4 said she felt like she was being treated as if she was a crazy person and she thought that the NA did not like her because she pulled the wheelchair in that manner. The findings were: Resident #4 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke). Resident #4's Minimum Data Set (MDS) dated [DATE] noted she was cognitively intact, had no behaviors, had limited range of motion on one side of her upper and lower extremities, and was dependent on staff for locomotion in her wheelchair. In an observation on 4/29/25 at 10:01 AM, Resident #4 was observed in her geriatric wheelchair and NA #3 was pulling her wheelchair backwards down the hall from the nurses' station to the dining room, approximately 50 yards. NA #3 wheeled Resident #4 into the dining room. In an interview on 4/29/25 at 10:05 AM, Resident #4 said she did not want to go to the dining room and did not like being pulled backwards in her wheelchair. She said it made her feel like she was a crazy person needing help and she thought that NA #3 did not like her because she pulled her like that. She explained that NA #3 was the only NA that pulled her around that way which was why she felt the NA did not like her. In an interview on 4/29/25 at 3:49 PM, NA #3 said she pulled Resident #4's geriatric wheelchair backwards because the wheels were misaligned, making it difficult to push the chair properly. She said she had not told anyone that the wheels were misaligned, but if the wheels worked better, she would have pushed the chair forward like she had been trained. The facility maintenance work orders for 2025 did not include a request to repair Resident #4's geriatric wheelchair. In an interview on 5/01/25 at 4:56 PM, the Nurse Consultant and the Administrator said they were not aware the wheels were not aligned on the chair and that Resident #4 should not have been pulled down the hall and that the NAs knew to push the chair instead of pulling the chair. The Nurse Consultant said pulling a wheelchair backwards was treating the resident in an undignified manner.

Based on observations, staff interviews and record review, the facility failed to ensure resident's fingernails were trimmed for 1 of 4 residents dependent on staff for Activity of Daily Living (ADL) care (Resident # 124). Findings included: Resident #124 was admitted to the facility on [DATE] with diagnoses that included adult failure to thrive and parkinsonism (group of brain conditions that causes slowed movements, rigidity and tremors). The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #124 was assessed as severely cognitively impaired with no behaviors or rejection of care. Resident #124 was assessed as requiring substantial / maximum assistance for personal hygiene and supervision/touching assistance with eating. The care plan dated 3/28/25 revealed Resident #124 was care planned for requiring assistance with ADL care due to cognition, weakness and Parkison disease. The goal indicated Resident #124 will maintain or improve their ADL functionality. Interventions included providing assistance with ADL care. During an observation on 4/28/25 at 11:22 AM, Resident #124 was observed lying in bed. Observation of resident's right hand revealed all five fingernails were approximately three fourthsof an inch to one-inch-long. There was some black debris under the nails. When the resident was asked if she liked her fingernails trimmed, Resident # 124 did not respond to surveyor's question. On 4/28/25 at 1:19 PM, Resident #124 was observed during lunch. Resident was eating her lunch in her room and was able to feed self. The lunch tray consisted of sub sandwich, potato salad and brownie. The resident was observed eating the brownie with her hands. The resident was using both of her hands to eat. The resident's thumb fingernail was observed with black color debris and food particles under it. During an interview on 4/28/25 at 1:25 PM, Nurse Aide (NA) #1 indicated he was assigned to the resident. NA #1 further indicated Resident #124 required extensive / total assistance with for ADL care. The resident was able to eat independently and consumed meals using her hands. The NA stated resident fingernails and toenails were trimmed after a shower or a bed bath. NA #1 further stated he had noticed the resident's fingernails were long but had notified the assigned nurse. NA #1 indicated the nurses were responsible for trimming/cutting resident's fingernails On 4/28/25 at 1:30 PM, Nurse #1 upon observation of Resident #124's fingernails stated the resident's nails should have been trimmed when the resident was offered a bed bath or when offered a shower. She explained that nurses trimmed fingernails or toenails if the resident was diagnosed with diabetes. Nurse #1 indicated the resident was not diagnosed with diabetes. Nurse #1 indicated she was assigned to the resident and had not noticed the resident's fingernails to be long. During an interview on 5/1/24 at 4:10 PM, the Director of Nursing (DON) indicated the resident's fingernails and toenails should be checked and trimmed as needed, when the resident was offered a shower or a bed bath. He indicated unless the resident was diagnosed with diabetes, the NA could trim resident's fingernails or toenails. If the resident was diagnoses with diabetes, then the assigned nurse was responsible for trimming their fingernails and toenails. The DON stated the resident's fingernails should have been trimmed and cleaned by staff as needed.

Based on observations, record review, and resident and staff interviews, the facility failed to protect a resident's right to be free from abuse when Resident #3 struck Resident #4 with a 15 ounce can of peaches. This affected 1 of 3 residents reviewed for abuse. The findings included: Resident #4 most recent admission to the facility was on 08/29/24 with diagnoses that included hemiplegia following cerebral infarction, contracture, essential hypertension, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #4 was cognitively intact with no behaviors. Resident #3 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, essential hypertension, anxiety disorder, and depression. Review of the quarterly MDS dated [DATE] revealed Resident #3 was cognitively intact and had verbal behavioral symptoms directed towards others that included threatening others, screaming at others, cursing at others, and rejection of care. Resident #3's Care Plan updated on 11/04/24 included Resident had behaviors related to history of cocaine use and alcohol abuse; angers easily, yelling, verbally aggressive towards staff, throwing personal items, physical aggression. fabricates stories and has manipulative behaviors, residents play music loud at times, resident antagonizes other residents. Review of a Facility Reported Incident (FRI) dated 11/03/24 revealed that Resident #3 threw a can of peaches at Resident #4 because he thought he ate his food off his tray. Residents were immediately separated and Resident #3 was placed one on one. Resident #4 was placed in a different room. Resident #4 was sent to the emergency room for further evaluation; however, he refused to go. This allegation type was classified as resident abuse. A review was completed of the 5-working day investigation report dated 11/07/24. The review revealed Resident #3 was provoked due to Resident #4 allegedly ate Resident #3's tray and Resident #3 threw a can of peaches at Resident #4 out of frustration. Resident #3 is blind and was unable to see where he was throwing the object. Resident #3 threw the can of peaches, and it struck Resident #4 on the right side of the head above his right eye, and he sustained a laceration. Residents were separated and educated on how to voice concerns and issues. Residents remained in vastly different geographic areas of the center. Both remained in good health and had no animosity. Resident #4 sustained a laceration to the right outer eye that was cleansed with normal saline and taped closed. Emergency Medical Technicians (EMTs) were called and Resident #4 refused to go to the hospital. EMTs glued resident's laceration closed and covered it with tape. The provider was made aware. Police were notified. The Psychiatry provider was notified. Resident #4 was moved to another room. An observation and an interview were conducted with Resident #4 on 11/20/24 at 1:15 pm and he indicated he was asleep and Resident #3 threw a can and hit him in the face. Resident #4 stated, he thought I ate his dinner, his food, woke up to him throwing a can to my head. He indicated he had a cut above his right eye and declined to go to the hospital. A healed scar was observed above Resident #4's right eye. An interview was conducted with Resident #3 on 11/20/24 at 1:21 pm and he indicated he was asleep in bed when a staff member (resident could not remember who it was) came in to get his tray, but he had not eaten his food. He stated, I asked the man did he eat my food, he was coming towards me, I'm blind, only see shadows, heard his bed moving and he was cussing at me, I grabbed a can of peaches and threw them his way, didn't know I hit him, was mad he ate my food, I left out the room and told the nurse, they took him out of the room. On 11/20/24 at 1:30 pm an interview was conducted with NA#1, and she indicated she was assigned to Resident #3 and #4 on 11/03/24. She indicated she did not pick Resident #3's tray up and did not recall who did. She stated she did not witness the altercation however she saw Resident #3 rolling himself up the hall and heard Resident #4 say he was going to bust him upside the head. NA #1 indicated Resident 3 said Resident #4 ate his food off his tray. An interview was conducted on 11/20/24 at 1:46 pm with Nurse #1 and she indicated she was assigned to Resident #3 and Resident #4 on 11/3/24. She indicated she heard Resident #3 fussing about his food, and he was in the hallway. She indicated Resident #4 was going up the hall and was bleeding from the right side of his head above the eye. She indicated Resident #4 had an open area about 1/2 centimeters above his right eye and she cleaned it up and put steri-strips on it. Nurse #1 indicated Resident #4 told her he got hit in the head because Resident #3 said he ate his food. During a telephone interview on 11/20/24 at 1:59 pm with the Unit Manager she indicated she took over when Nurse #2 left after providing treatment to Resident #4's eye. She stated, I was not present at the time of the altercation but followed up with everything, called the police, EMS, Resident #4 did not want to go to the hospital so they had him sign a form stating he refused, moved Resident to the front of the building, Resident #3 stayed in his room and had a sitter the remainder of the shift that sat with him all night. An interview was conducted with the Administrator on 11/20/24 at 2:28 pm and he indicated Resident #3 had a history of being incarcerated and after he interviewed him concluded due to Resident being blind, he did not have any intention of abusing his roommate and the allegation was unsubstantiated. The Administrator indicated Resident #3 had been triggered when his roommate ate his food and was why Resident #3 became frustrated and threw the can. The Administrator stated, He isn't capable of seeing that the can was going to hit his roommate. The facility implemented the following Corrective Action Plan with a completion date of 11/08/24. -Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice; Resident # 3 became frustrated when his roommate, Resident #4, ate his food. Resident #3 is blind and grabbed a can of peaches and threw it out of frustration. The can of peaches hit roommate Resident # 4. After the incident, the residents were immediately separated by the unit nurse and the alleged aggressor was immediately placed on 1 on 1 care by the nursing supervisor, until evaluated by psychiatric services. Psychiatric services reviewed the aggressor on 11/04/2024 and determined that there was no need to continue the one-on-one supervision. Resident #3 was placed on 1:1 immediately after separating from Resident #4. Resident #4 was evaluated for injury by the floor nurse. The Medical Provider was notified by the nurse. Both Resident representatives were notified of the altercation by the floor nurse. Adult Protective Services and Local Police department were contacted by the Administrator. Resident #4 had an injury, and it was recommended that he go to the emergency room . However, residents refused and Emergency Medical Services (EMS) glued the laceration together. Psychiatry provider evaluated and made recommendations to remove Resident #3 from one-to-one care. Depakote 125mg by mouth daily was initiated for Resident #3. Trauma screens were completed by the social worker/discharge planner to evaluate the effect of the incident on the residents. Trauma screens were completed on Resident #3 and #4. This was done on 11/04/2024. Education on free from abuse was initiated by the Staff Development Coordinator and Assistant Director of Nursing on 11/03/2024 for all current staff. The Administrator and Director of Nursing were notified of the occurrence at the time of the occurrence by the nursing supervisor. -Address how the facilty will identify other residents having the potential to be affected by the same deficient practice; Current residents at risk for resident-to-resident altercations were identified by the interdisciplinary team during the ADHOC meeting on 11/04/2024. No residents were identified during the interview process. On 11/04/2024 alert and oriented residents were interviewed by the Administrator and designees of the Director of Nursing regarding abuse and were educated to alert staff immediately of any concerns. Residents were also educated and notified by the Administrator and designee during the interview, that there will be no tolerance for abuse. -Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur; Progress notes are reviewed by the Unit Managers or designee for the previous 24 hours daily, potential residents that have behavior notes documented are discussed with the interdisciplinary team during morning clinical meeting daily Monday through Friday. Current residents with a BIMS score of 13-15 will be interviewed weekly regarding safety concerns at the center during angel rounds. Current residents with a BIMS of 13-15 will be assigned by the Administrator to department managers. The results of the interviews are provided to the Administrator during the morning meeting. The interview questions are to evaluate safety concerns the current residents have in the center. These interviews will help determine if there is a particular resident that is starting to make other residents feel uncomfortable. These identified residents from the resident interview process will be referred to psychiatric provider to determine if behaviors are escalating or if it is temporary as a result of an underlying medical condition. Appropriate interventions such as one on one during the acute episode, or medication adjustment, and/or notification of the primary provider to initiate medical evaluation. Staff will be made aware by huddle given by the Unit Managers, when the resident is identified. Identifying potential escalations in resident behaviors will assist in preventing resident altercations, thus preventing abuse. -Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; All occurrences of resident-to-resident behavior will be reviewed by the Administrator weekly x 12 weeks. The results will be reported to the monthly Quality Committee for review and discussion to ensure substantial compliance. Once the QA Committee determines the problem no longer exists, then review will be completed on a random basis. ADHOC with interdisciplinary team met on 11/04/202. The facility's alleged compliance date was 11/08/24. The Corrective Action Plan was validated onsite on 11/20/24 and concluded the facility had implemented an acceptable corrective action plan on 11/08/24. A review was conducted of the education dated 11/03/24 provided to staff. Interviews with current nursing staff revealed they received education on and training on free from abuse and resident to resident physical altercations. A review of the audits dated 11/04/2024 was conducted of alert and oriented residents interviewed by the Administrator and designees of the Director of Nursing regarding abuse reporting. There were no altercations revealed from the audits conducted for the week of 11/11/24-11/15/24. Interviews were conducted with alert and oriented residents and no concerns were identified. The compliance date of 11/08/24 was validated.

Based on record review, staff interview, Pharmacist interview, Nurse Practitioners' interview, and Physician interview the facility failed to coordinate care for a resident with a seizure disorder. The resident's valproic acid medication dosage was decreased by a Psychiatric Nurse Practitioner who believed it only to be used for mood stabilization and who was unaware the medication was being using for seizure control. There was no communication with the medical provider before the change. The resident seized, was hospitalized , and intubated following the dosage decrease. Prior to transport to the hospital, Resident # 10's seizure was documented to not respond to intramuscular Ativan medication and lasted approximately 28 minutes before emergency medical services arrived for care and transport. This was for one (Resident # 10) of three sampled residents reviewed for seizure medications. Immediate Jeopardy began on 6/15/23 when Resident #10's valproic acid dosage was decreased by a Psychiatric Nurse Practitioner without consulting with the health care providers. Immediate Jeopardy was removed on 7/3/23 when the facility provided an acceptable credible allegation for immediate jeopardy removal. The facility will remain out of compliance at a scope and severity level of D (not actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to assure monitoring systems put in place are effective. The findings included: Record review revealed Resident # 10 was initially admitted to the facility on [DATE]. The resident's diagnoses included in part traumatic brain injury and complex partial epilepsy (seizure disorder,) depression, and anxiety. Resident #10's quarterly Minimum Data Set assessment, dated 3/16/23, coded the resident as severely cognitively impaired. He was also assessed to need total assistance with his activities of daily living, have no behaviors during the assessment period, and to have a seizure disorder. Record review revealed Resident # 10 received both lacosamide and valproic acid for seizures. The last order for lacosamide was dated 5/12/23 and directed that the resident receive 10 ml (milliliters) 10 mg (milligrams)/ml two times per day. This remained as an active order up until his date of discharge. Orders and lab results related to Resident # 10's valproic acid medication were as follows: From 5/2/23 until 5/10/23, Resident # 10 was ordered to receive 11 ml (250 mg/5ml) valproic acid three times per day. (This would equate to 550 mg three times per day) On 5/10/23 a valproic acid level was done and registered 108. (A therapeutic medication level is when the blood level of the medication is in a range to be helpful but not dangerous. The facility's lab report noted therapeutic range for valproic acid to be 50 to 100 for seizures.) On 5/10/23 at 2:38 PM Nurse # 2 noted in a nursing note that she had received a critical lab value regarding a valproic acid level of 108 and called it into Medical Nurse Practitioner (NP) # 1. On 5/10/23 an order was given to decrease the valproic acid dosage to 10 ml (250 mg/ 5 ml) three times per day.( This would equate to 500 mg three times per day.) This order stayed in effect until 6/15/23. The order specifically noted the valproic acid was for seizures. On 5/11/23 the Physician ordered Resident # 10's valproic acid level be rechecked on the date of 5/15/23. The order was electronically signed by the Physician on 5/12/23. This order remained as an active order up until the resident's discharge date of [DATE] with no revision of the order. There was no valproic acid level drawn on 5/15/23 or a notation in the record why it was not done. On 6/15/23 Resident # 10 was seen by the Psychiatric Nurse Practitioner (NP) related to behaviors. The psychiatric NP noted that Resident # 10's valproic acid was prescribed for mood stabilization, and she was going to start a gradual dose reduction because his level had been high. On 6/15/23 Nurse # 5 entered an order into the computer for the Psychiatric NP for a lower dosage of the valproic acid. The order was for 5 ml (250 mg/ 5ml) three times per day. (This would equate to 250 mg three times per day.) The order was specifically written that the valproic acid was being used for behaviors. It did not mention that it was used for seizure control. On 6/15/23 Nurse # 5 noted in a nursing note that she had informed Resident # 10's responsible party that the valproic acid dosage had been dropped from 10 ml to 5 ml. Nurse # 5 noted this was done following a visit from the psychiatric NP and the valproic acid was given for behaviors. There was no notation that the medical physician or medical Nurse Practitioner were consulted. On 6/19/23 at 12:48 PM Nurse # 4 noted in a nursing note that Resident # 10 had a grand mal seizure (a seizure where there is loss of consciousness and violent muscle contractions), facility staff and the Medical NP responded, the resident was given IM (intramuscular) Ativan without any positive results. Nurse # 4 further noted the seizure became more intense and EMS (Emergency Medical Services) was called to transfer the resident to the hospital. On 6/19/23 Medical Nurse Practitioner # 2 entered a note in Resident # 10's record noting the resident's seizure had worsened although he had been given the Ativan. She noted he had seized for about 28 minutes when EMS arrived. According to hospital records Resident # 10 was evaluated in the emergency department on 6/19/23 and was intubated. The resident's valproic acid level was determined to be subtherapeutic at 39 and he was loaded (given an initial large dose of medication to obtain a quick response) with intravenous valproic acid. The Emergency Department physician also noted Resident # 10 had arrived in the Emergency Department in a postictal state (a period of recovery after a seizure) and within two hours started to have leftward eye deviation that was concerning for possible seizure activity. According to hospital records, the Emergency Department physician determined Resident #10 required a higher level of care. A larger hospital was contacted, and a transfer acceptance was obtained that same day (6/19/23) to their Intensive Care Unit for LTM EEG (long term electroencephalographic monitoring, which is the capability of recording electrical brain activity over long periods of time). Resident # 10 remained hospitalized as of 6/26/23. Following Resident # 10's discharge from the facility, the facility received from their lab the first valproic acid level that had been drawn since the order for the 5/15/23 level. The lab report showed the valproic acid level had been drawn on 6/17/23. The lab report noted it was received on 6/21/23 and reported to the facility on [DATE]. The valproic acid level registered 21, which indicated the resident's level was subtherapeutic prior to his 6/19/23 seizure. The facility's pharmacy consultant was interviewed on 6/26/23 at 12:22 PM and reported the following. A therapeutic valproic acid level for seizure control would be 50 to 100. The lab had flagged the value of 108 on 5/10/23 because it was higher than the upper therapeutic range. Toxic levels (levels when serious adverse effects are brought about due to excessive medication in a person's system) would be considered 175 or greater. She had last reviewed Resident # 10's record on 5/26/23 and noted that his dosage had been changed following the lab value on 5/10/23. Resident # 10 had a history of his levels going up and down. It would have been her recommendation that no changes be made in the dosage until a repeat level be done given his history, but the dosage had been already changed before she did her review. The valproic acid dosage which had been ordered on 6/15/23 by the Psychiatric NP was historically a very low dose for Resident # 10, but she had not reviewed him again following 5/26/23 to have reported this. According to the facility pharmacy consultant the facility had been doing monthly valproic acid levels and she thought that was appropriate, and therefore she did not have any recommendation on 5/26/23. Medical Nurse Practitioner # 1 was interviewed on 6/26/23 at 4:10 PM and reported the following. She was the on- call provider when a facility nurse called her on 5/10/23 with the valproic acid level of 108 on 5/10/23. She had asked about any seizure activity the resident had, and the nurse had told her that he had none. She had decreased his dosage by 1 ml during the three times per day it was given. She had instructed the nurse to have the level repeated in a month. It would have been the nurse's responsibility to have put the order in. No one had told her that his level had been going up and down. If this had been shared with her, then she would have instructed the facility nurse to consult with the regular provider the next day and let them decide. Medical NP # 2, who generally covered the facility's residents, was interviewed on 6/23/23 at 11:38 AM and reported the following. She was not aware of any changes to the order that had been given to draw the valproic acid level on 5/15/23. She was also not aware Resident # 10's valproic acid level had been decreased on the date of 6/15/23. She found this out on 6/19/23 after he had the seizure. The facility's Psychiatric NP was interviewed on 6/23/23 at 1:25 PM and reported the following. She did not think the valproic acid was being used for seizure control. She thought it was only used for mood stabilization and behaviors. She was seeing him on 6/15/23 because of his increased behaviors. He had recently bitten a staff member. When she saw Resident # 10 on 6/15/23 she saw that his last valproic acid level had been critically high and she ordered that the dosage be decreased. She had talked to the facility nurses about this but not with the medical physician or the medical NP. Nurse # 5 was interviewed on 6/23/23 at 12:30 PM and reported the following. She had entered in the order on 6/15/23 for the decrease in the valproic acid level after the Psychiatric Nurse Practitioner wrote the order but did not talk to the medical physician or the medical Nurse Practitioner. She thought the Psychiatric NP had talked to the Medical NP about the dose change. During an interview with the DON on 6/23/23 at 1:40 PM, the DON reported the valproic acid was being used for seizure control and was also helping with some of the resident's behaviors. The facility's Medical Director was interviewed on 6/23/23 at 5:15 PM and reported the following. He felt the Nurse Practitioners could have collaborated better about the medication changes for Resident # 10. Resident # 10 had a history of having seizures regardless of seizure medications. He could not say that the lower dose of valproic acid and subtherapeutic level did not contribute to his seizure on 6/19/23. The Administrator was interviewed on 6/23/23 at 6:00 PM with the Director of Nursing. According to the Administrator and the Director of Nursing, the facility had identified that Resident # 10's seizure medication dosage had been changed by the Psychiatric Nurse Practitioner without checking with the medical provider and they had initiated but not completed a plan of correction. The Administrator was informed of Immediate jeopardy on 6/26/23 at 7:19 PM. The Administrator presented the following Immediate Jeopardy removal plan. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Resident #10 was on Valproic Acid, as indicated for seizures. On 6/15/23 a consulting Psychiatric Nurse Practitioner (NP) decreased the dosage from Valproic Acid Oral Solution 250 MG/5ML, Give 10 ml three times a day to Valproic Acid Oral Solution 250 MG/5ML, Give 5 ml three times a day, related to a medication review regarding behaviors. However, as noted previously in the resident's medical record, its diagnosis and indication for use was for seizures. The Psychiatric NP was not aware the medication was used for seizure control because she did not conduct a thorough review of the medical record. The medical physician and/or facility medical staff (Nurse practitioner) were not consulted, and orders were not reviewed with the attending physician and/or his NP before the change in dosage. The resident seized and was hospitalized and intubated on 6/19/23 and remains there as of this date. The center staff did not follow professional standards in assuring that Nursing Policy 2303, entitled Report of Consultation, related to physician consults was followed. Previously, this internal contracted provider (in this case the Psychiatric NP) was functioning independently with no medical reviews conducted by the attending physician or medical NP, to approve, deny or change recommended orders prior to implementation. The psychiatric NP was being supervised by her contract provider, a Psychiatrist. All other residents receiving Valproic Acid and being followed by the Psychiatric NP were audited on 6/23/23 by the regional director of clinical services, to determine if there were other such discrepancies noted, such as change of indication for use or diagnosis. Any discrepancy found was reported to the attending physician and/or medical NP for immediate follow-up. The regional director of clinical services and/or DON will review all residents by 6/30/23 at the direction of the medical director/attending physician (the same individual) to assure the appropriate levels for anti-seizure medications are being monitored via lab including the mediations Valproic Acid (Depakote), Carbamazepine (Tegretol), Phenytoin (Dilantin), Levetiracetam (Keppra), to assure there are no medications not being monitored appropriately, no delayed lab results, and no failures of the provider or center to monitor other residents on these anti-seizure medications. As of 6/28/23, the Chief Nursing Officer, the Medical Director/attending physician, the consulting pharmacy group, and the DON met to determine, agree upon and implement the following process for all current residents that receive Valproic Acid (Depakote), Carbamazepine (Tegretol), Phenytoin (Dilantin), Levetiracetam (Keppra) and other seizure medications will have labs to monitor these drug levels All of those receiving these medications will be subject to the following: o Lab monitoring once every three months for two months. o Lab monitoring once every six months thereafter. o Baseline lab will occur for new admissions, then at the notated schedule above The consultant pharmacist will be involved at admission and monthly thereafter to identify anti-seizure medications and to determine if they are being monitored appropriately via the recommended labs at the recommended intervals noted above. The Chief Nursing Officer communicated with the pharmacy consultant about this expectation on 6/28/23. After the meeting of the Chief Nursing Officer, Medical Director/attending physician, consulting pharmacy group, and DON, the nurse administrative team will be educated by the DON or regional director of clinical services on this process by 6/30/23, to ensure all expected labs have been ordered on admission and ongoing. This will be tracked via the lab tracking policy outlined below, and monitored for implementation ongoing via the process outlined below in the daily clinical meeting. The Chief Nursing Officer communicated with the pharmacy consultant about this expectation on 6/28/23. 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 completed. The Psychiatric NP was educated on 6/27/23 by the Medical Director on his expectations for comprehensive medical record review, specifically review for indications of use and diagnosis for anti-seizure medications and/or for gradual dose reductions for psychotropic medications which can also be used for seizures (ie. Valproic Acid) before making recommendations for changes. Any concerns on the medical impact, related and unrelated to mood and behavior, should be discussed and coordinated with the provider (attending physician and/or medical NP) before changes are recommended. Additionally, any medication such as Valproic Acid, which can also be indicated for mood stabilization should be reviewed closer to determine actual indication for usage, and to monitor lab values prior to recommending a decrease in dosage. The Medical Director is the attending physician for all residents at the facility. Moving forward and related to this event, he will educate any current advanced care practitioners (current NPs medical and other consulting NPs), any future attending physicians, advanced care practitioners and internal consulting entities on comprehensive medical review and interdisciplinary provider discussion when consulting providers desire to make changes, and/or when the Medical NP is making changes to an anti-seizure medication. The expectation is that levels will be drawn and a comprehensive review done before dosages are being changed for all providers involved. The center DON knows who all current providers are; she will be made aware by the Administrator and/or Medical Director when new providers and consultant providers begin practicing at the facility. She has ensured all current providers have been educated by the Medical Director as of 6/29/23, and will ensure the new providers are communicated to the Medical Director for the need to education, tracked to completion, and maintain documentation of it onsite moving forward. The consultant pharmacist will be involved at admission and monthly thereafter to identify anti-seizure mediations and to determine if they are being monitored appropriately via the recommended labs. Education began for nursing staff to include licensed nurses and nursing assistants on 6/27/23 by the Director of Nursing (DON), regional director of clinical services, or a member of nursing administration. Education included Nursing policy 2303, Report of Consultation. Education included: The physician may order a consultation with another physician or healthcare provider Nurse (DON, supervisor, unit manager, charge nurse or designee) should review the report of consultation or physician progress notes as applicable. These reports are provided to center nursing staff by the contracted provider at the time of the consultation. The nurse will report findings to attending physician, Physician Assistant (PA) or Nurse Practitioner (NP). This will be reported verbally onsite or via phone call if the provider is not available onsite, at the time of the review, as indicated for order implementation, changes to current orders or rejection of orders if not approved by the provider. Implement orders as indicated and/or approved by the attending physician, PA or NP after review after review verbally. If the order was rejected, the nurse will communicate to the consulting entity and follow-up as needed with the provider. Any nursing staff member that did not receive education on 6/27/23 will receive education by the beginning of their next shift by the DON or designee. The Staff Development Coordinator will be responsible for tracking staff that still require education. Any staff that has not received education will not be allowed to work until education is received. All new hire licensed staff will be educated by the Staff Development Coordinator, DON or a member of nursing administration on this policy. This education will be added to the orientation process. Staff Development was notified of this responsibility on 6/27/23. All consultation visits and associated orders will be tracked by the DON or regional director of clinical services to ensure that the policy/process was followed as outlined above. All reports of consultation from the previous day and all new orders related to consultations will be brought to and tracked in the daily clinical meeting (M-F) and the weekend supervisor will review reports of consultation on Saturday/Sunday to ensure the process has been followed. This process will begin on 6/29/23. Date of immediate jeopardy removal is 7/3/23. Person responsible for implementation the plan is the Administrator. The facility's credible allegation of Immediate Jeopardy removal was validated on 7/5/23 and 7/6/23. The validation was evidenced by record reviews and interviews to verify all residents receiving anti-seizure medications (including valproic acid, carbamazepine, phenytoin, and levetiracetam) had lab work completed to ensure their blood levels of the medications were monitored appropriately. An interview with the facility's consultant pharmacist confirmed she would recommend newly admitted residents receiving such medications would have a baseline drug level obtained and the level monitored appropriately. Multiple interviews were conducted with licensed nurses to ensure the necessary in-service education was provided prior to working their shift. The nurses consistently reported they received in-service education, which included the process for reporting consultation findings to the facility's medical team (Medical NPs or MD) and verifying any new orders with one of these providers prior to initiating the orders. An interview conducted with the Psychiatric NP confirmed she was counseled on the need to complete a comprehensive medical review prior to recommending a change in medication. Interviews with the facility's medical team (Medical NPs and MD) indicated they would be responsible for reviewing and verifying all orders recommended by a consulting provider prior to the implementation of these orders. On 7/6/23 it was confirmed that Immediate Jeopardy was removed on 7/3/23.

Based on record review and staff, Pharmacist, Nurse Practitioner, and Physician interviews the facility failed to provide effective monitoring of medication blood levels and manage dose changes for a seizure medication (valproic acid). On 5/10/23 Resident #10's valproic acid level was 108 (therapeutic level is 50-100 mcg/mL). The laboratory results were reported to the on-call provider who ordered a decrease in the daily dosage of Resident #10's valproic acid. No orders were entered into the resident's record that day for any repeat valproic acid level to be drawn. On 5/12/23 Resident #10's Physician electronically signed an order to repeat the valproic acid level on 5/15/23. This order was not received by the laboratory and remained active up until the resident's hospitalization on [DATE]. On 6/15/23 Resident #10 was seen by the Psychiatric Nurse Practitioner (NP) related to behaviors. The Psychiatric NP noted incorrectly that Resident # 10's valproic acid was prescribed for mood stabilization and ordered a further reduction of the valproic acid daily dosage. No monitoring of the resident's valproic acid level was ordered at the time of the visit. The lab successfully drew a valproic acid level on 6/17/23, and the result revealed the level was subtherapeutic. The subtherapeutic level was not reported to the facility until 6/22/23, and there was no documentation in the record the facility tried to obtain the result prior to 6/22/23. On 6/19/23 Resident # 10 had a grand mal seizure (a seizure where there is loss of consciousness and violent muscle contractions), which was documented not to respond to intramuscular Ativan medication and lasted approximately 28 minutes before emergency medical services arrived for care and transport. Resident #10 was transported to the local hospital emergency department and intubated (a tube was inserted into the trachea for ventilation). Upon Emergency Department evaluation, Resident # 10's valproic acid level was 39, which was subtherapeutic. The Emergency Department physician determined Resident #10 required LTM EEG (long term electroencephalographic monitoring, which is the capability of recording electrical brain activity over long periods of time) and Resident #10 was transferred to the Intensive Care Unit at a larger hospital that same day. This was for 1 of 3 sampled residents reviewed for seizure medications (Resident #10). Immediate Jeopardy began on 5/15/23 when the facility did not obtain the physician ordered valproic acid level for Resident #10. The immediate jeopardy was removed on 7/03/23 when the facility provided and implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of D to ensure monitoring of systems put into place are effective and to complete staff training. The findings included: Record review revealed Resident # 10 was initially admitted to the facility on [DATE]. The resident's diagnoses included in part traumatic brain injury and complex partial epilepsy (neurological disorder that causes seizures), depression, and anxiety. Resident #10's quarterly Minimum Data Set assessment, dated 3/16/23, coded the resident as severely cognitively impaired. He was also assessed to need total assistance with his activities of daily living, have no behaviors during the assessment period, and to have a seizure disorder. Record review revealed Resident # 10 received both lacosamide and valproic acid for seizures. The last order for lacosamide was dated 5/12/23 and directed that the resident receive 10 ml (milliliters) 10 mg (milligrams)/ml two times per day. This remained as an active order up until his date of discharge. From 5/2/23 until 5/10/23, Resident # 10 was ordered to receive 11 ml (250 mg/5ml) valproic acid three times per day. (This would equate to 550 mg three times per day). On 5/10/23 a valproic acid level was done and registered 108 mcg/mL. (A therapeutic medication level is when the blood level of the medication is in a range to be helpful but not dangerous. The facility's lab report noted therapeutic range for valproic acid to be 50 to 100 mcg/ml. A subtherapeutic level for valproic acid would be medication blood levels below 50 mcg/ml. A toxic level would indicate levels when serious adverse effects are brought about due to excessive medication in a person's system). On 5/10/23 at 2:38 PM Nurse # 2 noted in a nursing note that she had received a critical lab value regarding a valproic acid level of 108 and called it into Medical Nurse Practitioner (NP) # 1. On 5/10/23 a phone order was given by Medical NP # 1 to decrease the valproic acid dosage to 10 ml (250 mg/ 5 ml) three times per day. (This would equate to 500 mg three times per day.) This order stayed in effect until 6/15/23. The order specifically noted the valproic acid was for seizures. On 5/11/23 the Physician ordered Resident # 10's valproic acid level be rechecked on the date of 5/15/23. The order was electronically signed by the physician on 5/12/23. This order remained as an active order up until the resident's discharge date of [DATE] with no revision of the order. There was no valproic acid level drawn on 5/15/23 or a notation in the record why it was not done. On 5/27/23 the facility Pharmacy Consultant completed a Medication Regimen Review and noted she had no recommendations related to Resident # 10's medications. On 6/15/23 Resident # 10 was seen by the Psychiatric Nurse Practitioner (NP) related to behaviors. The Psychiatric NP noted that Resident # 10's valproic acid was prescribed for mood stabilization, and she was going to start a gradual dose reduction because his level had been high. On 6/15/23 Nurse # 5 entered the order from the Psychiatric NP into the computer for a lower dosage of the valproic acid. The order was for 5 ml (250 mg/ 5ml) three times per day. (This would equate to 250 mg three times per day.) The order was specifically written that the valproic acid was being used for behaviors. It did not mention that it was used for seizure control. On 6/15/23 Nurse # 5 noted in the record that she had informed Resident # 10's responsible party that the valproic acid dosage had been dropped from 10 ml to 5 ml in addition of increasing another medication for behaviors the resident had. Nurse # 5 noted this was done following a visit from the Psychiatric NP and the valproic acid was given for behaviors. There was no notation that the Medical Physician or Medical Nurse Practitioner were consulted. Nurse # 5 was interviewed on 6/23/23 at 12:30 PM and reported the following. She had entered the order written by the Psychiatric NP on 6/15/23 for the decrease in the valproic acid but did not talk to the Medical Physician or the Medical Nurse Practitioner. She thought the Psychiatric NP had talked to the Medical NP about the dose change. On 6/16/23 at 9:42 AM Nurse # 6 noted in a nursing noted the following. The phlebotomist said she was unable to draw the resident's lab due to the resident moving his arm. The phlebotomist recommended that the resident be given a medication to help him not move so the blood draw could be completed. Nurse # 6 further noted the Medical NP was made aware. According to a lab report, a valproic acid level was drawn on 6/17/23. On 6/19/23 at 12:48 PM Nurse # 4 noted in a nursing note that Resident # 10 had a grand mal seizure, facility staff and the Medical NP # 2 responded, the resident was given IM (intramuscular) Ativan without any positive results. Nurse # 4 further noted the seizure became more intense and EMS was called to transfer the resident to the hospital. On 6/19/23 Medical Nurse Practitioner # 2 entered a note in Resident # 10's record noting the resident's seizure had worsened although he had been given the Ativan. She noted he had seized for about 28 minutes when EMS arrived. According to hospital records Resident # 10 was evaluated in the emergency department on 6/19/23 and was intubated. The resident's valproic acid level was determined to be subtherapeutic at 39 and he was loaded (given an initial large dose of medication to obtain a quick response) with intravenous valproic acid. The Emergency Department physician also noted Resident # 10 had arrived in the Emergency Department in a postictal state (a period of recovery after a seizure) and within two hours started to have leftward eye deviation that was concerning for possible seizure activity. According to hospital records, the Emergency Department physician determined Resident #10 required a higher level of care. A larger hospital was contacted, and a transfer acceptance was obtained that same day (6/19/23) to their Intensive Care Unit for LTM EEG (long term electroencephalographic monitoring, which is the capability of recording electrical brain activity over long periods of time). Resident # 10 remained hospitalized as of 6/26/23. Following Resident # 10's discharge from the facility, the facility received from their lab the first valproic acid level that had been drawn since the order for the 5/15/23 level. The lab report showed the valproic acid level had been drawn on 6/17/23. The lab report noted it was received on 6/21/23 and reported to the facility on [DATE]. The valproic acid level registered 21, which indicated the resident's level was subtherapeutic prior to his 6/19/23 seizure. The facility's Pharmacy Consultant was interviewed on 6/26/23 at 12:22 PM and reported the following. A therapeutic valproic acid level for seizure control would be 50 to 100. The lab had flagged the value of 108 on 5/10/23 because it was higher than the upper therapeutic range. Toxic levels would be considered 175 or greater. She had last reviewed Resident # 10's record on 5/26/23 and noted that his dosage had been changed following the lab value on 5/10/23. Resident # 10 had a history of his levels going up and down. It would have been her recommendation that no changes be made in the dosage until a repeat level be done given his history, but the dosage had already been changed before she did her review. According to the facility Pharmacy Consultant the facility had been doing monthly valproic acid levels and she thought that was appropriate, and therefore she did not have any recommendation on 5/26/23. She further reported the decreased daily dosage of valproic acid which had been ordered on 6/15/23 by the Psychiatric NP was historically a very low dose for Resident # 10, but she had not reviewed him again following 5/26/23 to have reported this. Medical Nurse Practitioner # 1 was interviewed on 6/26/23 at 4:10 PM and reported the following. She was the on- call provider when a facility nurse called her on 5/10/23 with the valproic acid level of 108 on 5/10/23. She had asked about any seizure activity the resident had, and the nurse had told her that he had none. She had decreased his dosage by 1 ml three times per day and she had instructed the nurse to have the level repeated in a month. It would have been the nurse's responsibility to have put the order in. No one had told her that his level had been going up and down. If this had been shared with her, then she would have instructed the facility nurse to consult with the regular provider the next day and let them decide. The facility's Psychiatric NP was interviewed on 6/23/23 at 1:25 PM and reported the following. She did not think Resident #10 was prescribed the valproic acid for seizure control. She thought it was only used for mood stabilization and behaviors. When she saw Resident # 10 on 6/15/23 she saw that his last valproic acid level had been critically high, and she ordered that the dosage be decreased. She had talked to the facility nurses about this but not with the Physician or the Medical NP. The Medical NP #2, who generally covered the facility's residents, was interviewed on 6/23/23 at 11:38 AM and reported the following. She was not aware of any changes to the order that had been given to draw Resident #10's valproic acid level on 5/15/23. She was also not aware Resident # 10's valproic acid dosage had been decreased on 6/15/23. On 6/19/23 after Resident # 10 had a seizure, she found the valproic acid dosage had been decreased. The Director of Nursing (DON) was interviewed on 6/23/23 at 11:00 AM and reported the following. She thought the ordered lab for valproic acid for 5/15/23 was an error in the electronic medical record system, and the order was supposed to have been drawn on 6/15/23. The DON reported it was her understanding that the lab had not obtained enough blood for the valproic acid on 6/15/23 but they had attempted to get it that day. They tried again on 6/16/23 and the resident was moving too much. The lab was obtained on 6/17/23. During a follow up interview with the DON on 6/23/23 at 1:40 PM, the DON reported the valproic acid was being used for seizure control and was also helping with some of the resident's behaviors. The facility's lab manager was interviewed on 6/23/23 at 3:35 PM and reported the following. On 6/15/23 there had been no order for a valproic acid level. The lab was trying to draw another unrelated lab which had had been ordered for Resident # 10. On 6/16/23 they had the first order from the facility to have a valproic acid level done. The lab tried to draw it on 6/16/23 along with the special-order lab, which they had been unsuccessful in obtaining the previous day. On 6/16/23 the resident moved too much, and they could not get the valproic acid lab or the specialty lab. On 6/17/23 they returned and drew both labs, the valproic acid lab and the specialty lab. They ran the valproic acid lab themselves that day (6/17/23) because it was a routine lab for them. They sent out the specialty lab to their cooperative lab they worked with. The results for the specialty lab usually took a few days to complete and both results (the valproic acid level and the specialty lab) were released to the facility on [DATE]. The Chief Executive Officer for the facility's lab was interviewed on 6/23/23 at 4:12 PM and reported the following. They retained a scanned copy of requisitions from facilities. The first requisition for Resident # 10's valproic acid level, since the 5/10/23 level had been done was 6/16/23. It was drawn on 6/17/23 and the result was finalized on 6/17/23 at 2:15 PM that same day. They had sent the specialty lab that had been drawn along with the valproic acid level to their cooperating lab to run. Lab results automatically populate electronically when all results are completed from the lab into the facility's electronic medical record computer system. It had been several years since they had contracted to do lab services for the facility, and there had been management changes since procedures had been set up and discussed with staff. At the initiation of services, he generally went over with the facility how lab results would be delivered to them. It had been set up with the facility that labs would automatically populate to their electronic medical record. There was a way the facility staff could log directly into the lab's system and see a result, but the facility had not chosen to have access when things were set up with them. The resident's Physician, who also serves as the facility's Medical Director, was interviewed on 6/23/23 at 5:15 PM and reported the following. He felt the Nurse Practitioners could have collaborated better about the medication changes for Resident # 10. Resident # 10 had a history of having seizures regardless of seizure medications. The Physician reported that although Resident # 10 had a history of seizures while on medications, he could not say that the lower dose of valproic acid and subtherapeutic level did not contribute to his seizure on 6/19/23. The Administrator was interviewed on 6/23/23 at 6:00 PM with the Director of Nursing. According to the Administrator and the Director of Nursing, the facility had identified that Resident # 10's seizure medication dosage had been changed by the Psychiatric Nurse Practitioner without checking with the medical provider and they had initiated but not completed a plan of correction. The facility Administrator was informed of Immediate Jeopardy on 6/26/23 at 7:19 PM. The Administrator submitted the following Immediate Jeopardy removal plan. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Resident #10 was ordered to receive two medications for seizure management, Lacosamide Oral Solution 10 MG/ML Give 10 ml by mouth two times a day and Valproic Acid Oral Solution 250 MG/5ML, Give 11 ml three times a day. On 5/10/23 a routine lab was drawn to measure the valproic acid level, an elevated level was determined high at 108, normal range 50-100 by the lab, and the high result was called from the lab to the center charge nurse. The charge reported it to the Medical NP who was not in the center, but on-call via phone at the time, who changed the dosage from 11mls three times a day to 10ml's three times day, diagnosis epilepsy. Upon further investigation, the medical NP who answered the call related to the critical lab stated she decreased the medication, but did not give follow-up lab orders. When asked why, she stated she would have left it to the provider onsite to determine the next lab date. On 6/15/23, the dosage was again decreased from Valproic Acid Oral Solution 250 MG/5ML, Give 10 ml three times a day to Valproic Acid Oral Solution 250 MG/5ML, Give 5 ml three times a day by the psychiatric NP, as part of a consult related to behaviors. The psychiatric NP failed to recognize the Valproic Acid was indicated for epilepsy, and failed to determine the current valproic acid level prior to decreasing the dosage given his history of epilepsy. An interview with the pharmacist revealed she would never have recommended an additional dosage change without a repeat level because Resident #10's levels tended to go up and down. However, this change was made without any level being checked. Upon investigation, the psychiatric NP stated she likely verbally ordered a Valproic Acid level on 6/15/23 for the next lab day, to monitor his levels, because that is her normal practice. This order was not entered into the electronic health record, but was entered in writing onto the lab requisition log. The facility lab called the center on 6/16/23 shortly after midnight to state an unrelated requisitioned lab for 6/15/23 needed to be repeated. The night shift nurse added the requisitioned lab for Valproic Acid (ordered on 6/15/23 for next lab day) to the carbon copy of the unrelated lab that was scheduled to be repeated on 6/16/23. The lab called the facility on 6/16/23, to let them know they would be unable to draw the lab, due to the behaviors of the resident and suggested that he needed Ativan prior to his labwork. This was discussed with the IDT, and it was determined that an alternative non-medicinal patient-center approach could be used to attempt the draw the lab the next lab day, on 6/17/23. The lab was successfully drawn on 6/17/23 and was sub-therapeutic at that time, but the facility did not receive the results until 6/22. The facility failed to follow procedures of critical importance, related to lab tracking, monitoring of serious medication for seizures at the time of dose changes, and timely follow up on lab results. The Valproic Acid was not monitored. The resident had a seizure, was hospitalized , and intubated in the interim on 6/19/23 and remains at the hospital at this time. The regional director of clinical services and/or DON will review all residents by 6/30/23 at the direction of the medical director/attending physician (the same individual) to assure the appropriate levels for anti-seizure medications are being monitored via lab including the mediations Valproic Acid (Depakote), Carbamazepine (Tegretol), Phenytoin (Dilantin), Levetiracetam (Keppra), to assure there are no medications not being monitored appropriately, no delayed lab results, and no failures of the provider or center to monitor other residents on these anti-seizure medications. As of 6/28/23, the Chief Nursing Officer, the Medical Director/attending physician, the consulting pharmacy group, and the DON met to determine, agree upon and implement the following process for all current residents that receive Valproic Acid (Depakote), Carbamazepine (Tegretol), Phenytoin (Dilantin), Levetiracetam (Keppra) and other seizure medications will have labs to monitor these drug levels All of those receiving these medications will be subject to the following: o Lab monitoring once every three months for two months. o Lab monitoring once every six months thereafter. o Baseline lab will occur for new admissions, then at the notated schedule above The consultant pharmacist will be involved at admission and monthly thereafter to identify anti-seizure medications and to determine if they are being monitored appropriately via the recommended labs at the recommended intervals noted above. The Chief Nursing Officer communicated with the pharmacy consultant about this expectation on 6/28/23. After the meeting of the Chief Nursing Officer, Medical Director/attending physician, consulting pharmacy group, and DON, the nurse administrative team will be educated by the DON or regional director of clinical services on this process by 6/30/23, to ensure all expected labs have been ordered on admission and ongoing. This will be tracked via the lab tracking policy outlined below, and monitored for implementation ongoing via the process outlined below in the daily clinical meeting. The Chief Nursing Officer communicated with the pharmacy consultant about this expectation on 6/28/23. 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 completed. The Psychiatric NP will be educated by the Medical Director on his expectations for comprehensive medical record review, specifically review for indications of use and diagnosis for anti-seizure medications and/or for gradual dose reductions for psychotropic medications which can also be used for seizures (ie. Valproic Acid) before making recommendations for changes. Any concerns on the medical impact, related and unrelated to mood and behavior, should be discussed and coordinated with the provider (attending physician and/or medical NP) before changes are recommended. Additionally, any medication such as Valproic Acid, which can also be indicated for mood stabilization should be reviewed closer to determine actual indication for usage, and to monitor lab values prior to recommending a decrease in dosage. This will be done by 6/28/23. The Medical Director is the attending physician for all residents at the facility. Moving forward and related to this event, he will educate any current advanced care practitioners (current NPs medical and other consulting NPs), any future attending physicians, advanced care practitioners and internal consulting entities on comprehensive medical review and interdisciplinary provider discussion when consulting providers desire to make changes, and/or when the Medical NP is making changes to an anti-seizure medication. The expectation is that levels will be drawn and a comprehensive review done before dosages are being changed for all providers involved. The center DON knows who all current providers are; she will be made aware by the Administrator and/or Medical Director when new providers and consultant providers begin practicing at the facility. She has ensured all current providers have been educated by the Medical Director as of 6/29/23, nd will ensure the new providers are communicated to the Medical Director for the need to education, tracked to completion, and maintain documentation of it onsite moving forward. Education began for nursing staff to include licensed nurses and nursing assistants on 6/27/23 by the Director of Nursing (DON) or designee. In the case of this deficient practice, the lab tracking process, from order/requisition to a timely final result was not in place and was in violation of our Laboratory Tracking Policy 1702. Education included the policy and protocols listed: -A licensed nurse will monitor and track all physician or physician extender ordered laboratory tests and will ensure that lab tests are drawn as ordered and communicate results to the physician in a timely manner. 1. The Center will obtain lab services to meet the needs of its patients. Education occurred to nurses, specifically related to the need for blood levels drawn for residents on seizure medications, such as Dilantin, Valproic Acid and Keppra. 2. Lab services will be provided only when ordered by the physician or physician extender and the physician or extender will be notified of lab results in a timely manner. 3. When an order for a lab test is received, for the current month, a licensed nurse receiving the order will complete a lab requisition form from the lab vendor. The information will include: a. patient name and room number. b. Test ordered. c. Date lab test is to be drawn. d. Medicare/Medicaid numbers. e. Other insurance information. f. Name of the physician ordering the test. g. Date of birth. h. Diagnosis related to the test ordered. i. Any special instructions. 4. A licensed nurse receiving the order will document the information on the appropriate current month's lab tracking log located in the lab notebook. Routine labs will be recorded on the lab tracking log. The DON, Unit Manager or Nursing Administration monitors the lab tracking log, to assure from order, to requisition, to result, to communication to the provider is timely. The expectation is that all routine/normal labs should be back in 24 hours. Labs results not back in 24 hours should be reviewed and monitored for timeliness in the case that they are not expected to take more than 24 hours. 5. If the routine lab test order is not due in the current month, the licensed nurse will document the appropriate information onto the Lab Tracking Log indicating the type of lab test ordered and date to be completed. The 11-7 shift licensed nurse or supervisor will check the Lab Tracking Form and the Culture & Sensitivity Lab Tracking Form nightly for lab work to be drawn in the morning. The appropriate requisition will be pulled from the lab book (or completed if necessary) and placed in the Center designated location for the lab technician. 6. Upon completion of the lab draw, a licensed nurse will document the date the specimen was drawn on the appropriate Lab Tracking Log. If the lab is unable to be drawn, the information will be communicated to the attending physician, NP or PA for new orders, approval to move the lab or any follow-up as needed depending on the need of the resident. 7. Upon receipt of lab results, a licensed nurse will document the date the results were received on the appropriate Lab Tracking form. All routine lab results, such as Valproic acid, Dilantin and Keppra level should be back in 24 hours. All lab values that are not back in 24 hours where the expectation was 24 hours, should be investigated for timeliness, follow-up to the lab and report to physician for any further actions or orders needed. 8. Critical results will be called to the physician or extender and documented as indicated. The lab reports critical findings via phone to the charge nurse, and the charge nurse will report this verbally in person or via phone to the provider as soon as possible for follow-up, but not later than 9. Once the physician or extender has been notified of lab results, the nurse will document the date of notification and the method of notification in the appropriate space(s) on the appropriate Lab Tracking Log and place his/her initials in the nurse initial column on the form. 10. A licensed nurse will document any necessary information for follow up on the 24-hour shift report Any nursing staff member that did not receive education on 6/27/23 will receive education by the beginning of the next shift by the DON or designee. The Staff Development Coordinator will be responsible for tracking staff that still require education. Any staff that has not received education will not be allowed to work until education is received. All new hire licensed staff will be educated by the Staff Development Coordinator or designee on this policy. This education will be added to the orientation process. Staff Development was notified of this responsibility on 6/27/23. All lab orders will be tracked by the DON or designee to ensure that they are requisitioned, tracked for timely results, reviewed by the attending physician, NP or PA daily and follow-up as indicated. Each day (M-F) the lab tracking log along with the previous day's new lab orders will be brought to the clinical meeting by nursing administration from each unit to review for this process by the DON, and on Saturday/Sunday, the weekend supervisor will complete the same process for each unit. Date of immediate jeopardy removal is 7/3/23. Person responsible for implementation the plan is the Administrator The facility's credible allegation of Immediate Jeopardy removal was validated on 7/5/23 and 7/6/23. The validation was evidenced by record reviews and interviews to verify all residents receiving anti-seizure medications (including valproic acid, carbamazepine, phenytoin, and levetiracetam) had lab work completed to ensure their blood levels of the medications were monitored appropriately. An interview with the facility's consultant pharmacist confirmed she would recommend newly admitted residents receiving such medications would have a baseline drug level obtained and the level monitored appropriately thereafter. Multiple interviews were conducted with licensed nurses to ensure the necessary in-service education was provided prior to working their shift. The nurses consistently reported they received in-service education, which included the facility's procedures for tracking, monitoring, providing follow up, and communicating the results for all lab orders utilizing a lab tracking log (located in a lab notebook at the Nursing Station). An interview conducted with the Psychiatric NP confirmed she was counseled on the need to complete a comprehensive medical review prior to recommending a change in medication. Interviews with the facility's medical team (Medical NPs and MD) indicated they would be responsible for reviewing and verifying all orders recommended by a consulting provider prior to the implementation of these orders. The facility's Immediate Jeopardy removal date of 7/3/23 was validated.

Based on record review, review of video surveillance footage and Emergency Medical Service (EMS) report and staff, paramedic and hospital staff interviews, the facility staff neglected to provide necessary services after a resident experienced an oxygen explosion and sustained second- and third-degree flame burns to both sides of his face, both ears, left chest, left upper arm, left forearm, and back of left hand. Resident #1 was unconscious and slumped over in his wheelchair when he was wheeled out of the facility. Facility staff moved by and stood adjacent to the resident and failed to position the resident to facilitate an open airway or render any assistance. When EMS arrived, Resident #1 remained slumped over in a wheelchair, unresponsive, and without a pulse or respirations. Resident #1 went into cardiac arrest twice before arriving at the hospital, required intubation, and became comatose due to his injuries. Resident #1 expired on [DATE]. This is evidenced for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). Immediate jeopardy began on [DATE] when the facility staff neglected to provide necessary services to Resident #1 after he sustained third degree burns to both sides of his face, both of his ears and second degrees burns on his left chest, upper left arm, left forearm, and back of left hand. He was wheeled out of the facility unconscious and slumped over in his wheelchair and facility staff moved by and stood adjacent to the resident with attempting to open his airway or render any assistance. Immediate jeopardy was removed on [DATE] when the facility provided an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of D (No actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure completion of education and monitoring systems put into place are effective. Findings included: Cross Refer to F684: Based on record review, review of video surveillance footage and Emergency Medical Service (EMS) report and staff, paramedic and hospital Attending Physicians/Nurse/Physician Assistant/receptionist interviews, the facility failed to identify the seriousness of 3rd degree facial burns when staff did not provide continuous monitoring of Resident #1's vital signs or assess the resident to determine the need for nursing or medical interventions until Emergency Medical Services arrived. Resident #1 sustained second and third degree burns to his face, both ears, left side of chest, left upper arm, left forearm, and back of left hand. Additionally, the low outdoor temperature on [DATE] was recorded as 29-degrees Fahrenheit, and Resident #1 was only wearing thin pajama pants and a short sleeve shirt while outside. Resident #1 was described by EMS records as being slouched/slumped over in his wheelchair when they arrived, and he was pulseless and not breathing. EMS personnel immediately began cardiopulmonary resuscitation (CPR) inside the ambulance. Resident #1 went into cardiac arrest, required intubation, and became comatose due to his injuries. This deficient practice occurred for 1 of 3 residents reviewed for supervision to prevent accidents. The Administrator was notified of immediate jeopardy on [DATE], at 10:50 AM. The facility provided the following credible allegation for immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and The facility failed to provide care and services to Resident #1 after he had sustained significant facial injuries, as well as 2nd and 3rd degree burns. Resident #1 was unresponsive and was wheeled outside slumped over in his wheelchair. No attempts were made to maintain an open airway or assess the resident for nursing or medical needs. On [DATE], shortly before 3AM, Resident #1 was noted in doorway of his room as the Night Shift Supervisor was coming down the hall. She could see that smoke was coming from the room. She began to call his name and as she approached him, she could see his hair was singed. As she got closer, she called his name, and he did not answer as his head was down. She pushed his head up and back and noted his face was melted off referring to his burned face. She immediately closed his door given the smoke detector was sounding and there was visible smoke, rescued him from danger to the nurses station, immediately pulled the fire alarm and called 911 for Emergency Medical Services (EMS) and Fire Rescue at 2:56am. While on the phone with 911, the Night Shift Supervisor assessed respirations and pulse and provided the information to dispatch as instructed. The 911 dispatcher asked her to get him to the front of the building to await pickup. The Night Shift Supervisor instructed the certified nurse aide (CNA) to take him to the front of the building to await EMS at the request of the 911 dispatch. In the meantime, the Night Shift Supervisor was asked to stay on the phone with the dispatcher. However, the nurse did not provide instruction to the certified nurse aide as to what to do for this resident; she didn't assess what the resident needed and failed to render emergency care to maintain Resident # 1's airway. During the wait for EMS to arrive, the CNA states she and other staff watched him, took his pulse, and she and other staff continued to speak to him and touch him to reassure him knowing he was unresponsive. His body was severely slumped over in the chair at his torso. The CNA notes on interview that she and other staff handed him off to EMS upon their arrival at 3:02am. They dismissed themselves when EMS took over. In review of this incident, the nurse and staff assigned to him after he left the unit failed to monitor and assess Resident #1 who had been through a traumatic event suffering multiple burns, did not assess him fully to know what nursing and medical needs he had, did not position the resident to promote breathing, did not cover the resident in 30 degree weather outside, and did not provide basic necessary services until EMS arrived. The nurse further sent him to the lobby with an unlicensed staff member who was unable to monitor him which was required per policy. All residents are at risk for neglect. 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 completed. Education began for nursing staff to include licensed nurses and nursing assistants on [DATE], by the DON or designee. Education included Nursing policy 1110-Emergecy First Aide, and other information noted below. Education included: Provision of emergency first aide as indicated by the situation to anyone in the center experiencing an accident or incident. A licensed nurse will assess injured persons, obtain vitals, monitor patient for changes. Obtain vital signs, pulse ox etc. as condition warrants. In the case of burn, protect airway, such as positioning, rescue breathing, CPR, emergency oxygen Providing emergency first aide for other accidents/incidents as needed-CPR, Rescue breathing, control bleeding, emergency oxygen, cleansing wounds/applying dressing, immobilizing fractures. Notification to physician/Next of Kin as soon as possible. Contacting EMS Assuring that licensed staff attend resident until EMS arrives, continue to monitor, assess and intervene as needed Completion of documentation related to the incident Education began for all staff on abuse and neglect began on [DATE] by staff development coordinator. Education included information regarding types of abuse and neglect as referenced in administrative policy 704. Any nursing staff member that did not receive education on [DATE] will receive education by the beginning of the next shift by the DON or designee. The Staff Development Coordinator will be responsible for tracking staff that still require education. Any staff that has not received education will not be allowed to work until education is received. All new hire licensed staff will be educated by the Staff Development Coordinator on this policy. This education will be added to the orientation process. Staff Development was notified of this responsibility on [DATE]. The DON or designee will verify the understanding of the education through oral discussion and feedback with all staff and notate this on a tracking tool. The SDC will also do this in orientation. Nursing staff will complete a post- test based on the education provided. Staff Development Coordinator is responsible for the post test and monitoring the post test results. The post test is initiated on [DATE]. Date of immediate jeopardy removal is [DATE] Person responsible for implementation the plan is the Administrator On [DATE], the facility's credible allegation for immediate jeopardy removal was validated by record review of the in-services and sign in sheet which discussed the Nursing Policy - 1110 Emergency First Aid, first aid, and abuse/neglect; multiple staff interviews which indicated education was provided by the Director of Nursing which discussed accidents/incidents (including in case of burns), assessments, notification of physician, cardiopulmonary resuscitation (CPR), emergency oxygen, and effective communication; and an interview with the Administrator which indicated the Director of Nursing and Staff Development Coordinator provided mandatory education for all nursing staff. The immediate jeopardy removal date of [DATE] was confirmed.

Based on record review, review of video surveillance footage and Emergency Medical Service (EMS) report and staff, paramedic and hospital staff interviews, the facility failed to identify the seriousness of 3rd degree facial burns when staff did not provide continuous monitoring of Resident #1's vital signs or assess the resident to determine the need for nursing or medical interventions until EMS arrived. Resident #1 sustained second- and third-degree flame burns to both sides of his face, both ears, left chest, left upper arm, left forearm, and back of left hand. Additionally, the low outdoor temperature on [DATE] was recorded as 29-degrees Fahrenheit, and Resident #1 was only wearing thin pajama pants and a short sleeve shirt while outside. Resident #1 was described by EMS records as being slouched/slumped over in his wheelchair when they arrived, and he was pulseless and not breathing. EMS personnel immediately began cardiopulmonary resuscitation (CPR) once inside the ambulance. Resident #1 went into cardiac arrest twice, required intubation, and became comatose due to his injuries. Resident #1 expired on [DATE]. This deficient practice occurred for 1 of 3 residents reviewed for supervision to prevent accidents. Immediate jeopardy began on [DATE] when the facility failed to provide continuous monitoring by staff or assess the resident to determine the need for nursing or medical interventions until Emergency Medical Services arrived. Immediate jeopardy was removed on [DATE] when the facility provided an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of D (No actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure completion of education and monitoring systems put into place are effective. The findings included: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses which included Chronic Obstructive Pulmonary Disease, respiratory failure, peripheral vascular disease, heart failure, and tobacco use. A physician's order dated [DATE] indicated Resident #1 was to receive oxygen at 4 liters per minute via nasal cannula every day and night shift. The admission nursing assessment dated [DATE] revealed Resident #1 was cognitively intact and required supervision with chair/bed-to-transfers. Resident #1 was designated to be a Full Code. There was no documentation of vital signs recorded in Resident #1's electronic medical chart for [DATE]. The nursing note written by the Night Shift Supervisor in the electronic medical record of Resident #1 dated [DATE] at 3:15 AM stated, Resident found unresponsive and breathing in front of room door in W/C [wheelchair] with burns to face and hair. Transferred to nurses' station and called 911. Instructed by 911 to bring resident to front of building by EMS and transferred care to EMS. An interview was conducted with the Night Shift Supervisor on [DATE] at 10:30 AM. Night Shift Supervisor stated at about 3:00 AM on [DATE] she was sitting at the nurses' station when she heard an annoying beeping sound, which she later discovered it was the room's smoke detector going off. She got up to investigate the noise. As she walked down the hall, she saw and smelled gray smoke coming from Resident #1's room. She yelled I know you're not smoking! to Resident #1. When she reached Resident #1, she saw him in the doorway of his room, sitting upright, with his head down. She lifted his head and noticed Resident #1's face and hair severely burned, he was breathing, and unresponsive. She described his facial burns as it was like his face melted off. She immediately brought Resident #1 into the hallway via his wheelchair and closed the door. She pushed him to the nurses' station, pulled the fire alarm, and called 911. She stated she was instructed by 911 to escort Resident #1 to the front of the building and to stay on the phone. She instructed Nursing Assistant #1 (NA) to push Resident #1 to the front of the building. She stated she had checked Resident #1 for a pulse and respirations but could not remember the rate. She stated his pulse was strong, and his breathing was normal. She stated she did not indicate to other staff to stay with Resident #1 because she was worried about evacuating the other residents. A review of the video surveillance footage on [DATE] revealed Resident #1 was being assisted outside by three staff members. Resident #1 was in a wheelchair, slouched, with his chest to his knees, and arms dangling off the sides of the wheelchair, limp, with no movement. Once outside, two of the staff members stepped away. One staff member remained behind Resident #1. One staff member who stepped to the side, returned to Resident #1. She crouched down, looked at Resident #1's face, stood up, and intermittently touched him. Four additional staff members exited the building and walked past Resident #1. Resident #1 remained sitting in the wheelchair, slouched, with his chest to his knees, and arms dangling off the sides of the wheelchair, limp, with no movement until EMS arrived. He did not have a blanket or jacket to provide protection from the 29-degree Fahrenheit temperature. According to www.accuweather.com, the low temperature was 29-degrees Fahrenheit on [DATE] in [NAME]. An interview with NA #1 on [DATE] at 3:36 PM revealed she was not assigned to work with Resident #1 on [DATE]. She responded to the fire alarm sound and when she arrived at the nurses' station, she was instructed by the Night Shift Supervisor to bring Resident #1 to the outside front of the building. She indicated she saw Resident #1's injuries and described them as his skin was peeled off his face and his hair was burned on the side. She indicated she was not given other instructions from the Night Shift Supervisor regarding providing aid to Resident #1. She further stated she could not remember if she provided Resident #1 with a covering to protect him from the 29-degree Fahrenheit temperature. Nurse #1 was interviewed on [DATE] at 2:58 PM. She indicated she was assigned to work with Resident #1 on [DATE] and knew Resident #1 was dependent on oxygen. She indicated she was not on the floor when the incident occurred. She went to the front of the building because she was notified by other staff members Resident #1 had burned himself while smoking a cigarette. When she had arrived at the front of the building, EMS had already arrived. She indicated when she saw Resident #1, his head was down, and he was unresponsive. She did not assess Resident #1 because EMS had already arrived. Later in the interview, she stated the first time she checked Resident #1 for a pulse and respirations was when he was outside front of the building. She took his pulse and respirations manually and noted his breathing was shallow and his pulse was strong and within normal range. She stated she could not remember the pulse or respiration rates. She indicated she was not provided any instructions regarding providing aid to Resident #1 and did not indicate why she had not stayed with Resident #1. NA #3 was interviewed on [DATE] at 10:25 AM. She indicated she was assigned to work with Resident #1 on [DATE], was familiar with his care needs, and knew he was oxygen dependent. She stated she had checked 10 to 15 minutes prior to the incident. She indicated she was outside of the building and was not on the floor when the incident occurred. The first time she saw Resident #1 after the incident was when he was outside on the stretcher with EMS. Documentation of the Emergency Medical Services (EMS) report dated [DATE] revealed at 3:01 AM, EMS arrived on scene. Resident #1 was sitting in a wheelchair outside of the front door of the facility. Resident #1 was noted to be slouched/slumped over in the wheelchair. Staff was immediately asked if the resident was breathing and if the resident had a pulse. The nursing staff responded, he's unconscious. EMS personnel, again, asked if the resident was breathing and if he had a pulse, to which the nursing staff did not check the patient. EMS noted all nursing staff had no hands on the resident, the resident was not being assessed, nor was treatment administered by nursing staff prior to EMS arrival. EMS personnel quickly assessed the resident. The resident was found to not be breathing or have a pulse. EMS personnel asked the nursing staff about Resident #1's information and paperwork, and the staff responded with we don't know anything about the patient, and there is a fire, so we can not [sic] get you that information. It was noted that nursing staff continued to enter and exit the front doors of the facility. An interview was conducted with the responding Paramedic on [DATE] at 12:29 PM. The Paramedic stated when he arrived, he saw Resident #1 slumped over in a wheelchair outside in front of the facility. Resident #1 did not look like he was breathing. There were staff members around Resident #1; however, no staff member hand their hands on Resident #1. He stated staff members were either on their phones or walking around. He further indicated staff members could not report if Resident #1 was breathing or had a pulse. He also stated facility staff was not able to provide him Resident #1's name, date of birth, or medical conditions. When he assessed Resident #1 it was determined Resident #1 did not have a pulse or respirations. Resident #1 was assessed to the stretcher via 2-person manual lift and cardiopulmonary resuscitation (CPR) was started in the ambulance. The emergency room hospital records indicated presented to the hospital with partial-thickness burns covering Resident #1's face and neck as well as clavicle and shoulder, approximately 10% of body surface area, and soot in the nostrils. The emergency room physician noted EMS reported Resident #1 was sitting in wheelchair with oxygen on via nasal cannula when he subsequently lit a cigarette that exploded in his face causing severe burns to the face, neck, shoulders, and clavicle. Resident #1 was noted to be unresponsive, without a pulse so CPR was initiated by EMS. CPR was performed for 30 minutes then his pulse and blood pressure returned. Resident #1 went into cardiac arrest again for several minutes and was intubated after his pulse and blood pressure returned for the second time. Due to his significant burns, the hospital initiated transfer to a local burn unit. A review of the Burn Attending Intensive Care Unit (ICU) hospital note dated [DATE] revealed Resident #1 was critically ill and sustained second- and third-degree flame burns to both sides of his face, both ears, left chest, left upper arm, left forearm, and back of left hand to 5.5% of his body. It was noted that he also went into cardiac arrest twice as well has having acute respiratory failure secondary to pulmonary edema (excess fluid in the lungs) and aspiration. An interview with the ICU Nurse #1 was conducted on [DATE] at 3:02 PM. She indicated Resident #1 was comatose, intubated, unable to speak, and had an anoxic brain injury (a brain injury caused by a complete lack of oxygen to the brain). Resident #1's code status was switched from Full Code to Do Not Resuscitate (DNR). The ICU Physician Assistant was interviewed on [DATE] at 12:32 PM. She indicated it was reported to her that Resident #1 was smoking at the facility and caught fire. He was found to be unresponsive and remained unresponsive since admission to the ICU burn unit. She stated his injuries were consistent with smoking while on oxygen. The ICU Attending Physician was interviewed on [DATE] at 9:39 AM via phone revealed at the time of the call, Resident #1 had an anoxic brain injury (brain injury which occurs due to lack of oxygen to the brain) and had a poor prognosis. He was intubated, in critical condition, and unresponsive. She indicated she did not expect a full recovery and a palliative care consult would be placed due to Resident #1's poor prognosis. An interview with ICU Nurse #2 was conducted on [DATE] at 3:51 PM. She indicated Resident #1 remained in critical condition. Resident #1 was placed on comfort care with no aggressive treatment. He was not expected to recover, and death was imminent. On [DATE] at 12:34 PM the ICU Receptionist was interviewed. She indicated Resident #1 died on [DATE] at 5:15 PM. The Director of Nursing (DON) was interviewed on [DATE] at 1:57 PM. She stated she received a call from a staff member around 3:00 AM on [DATE] notifying her of Resident #1 sustaining injuries from lighting a cigarette while on oxygen. She indicated she did not see Resident #1 when she arrived at the facility as he had already been taken by ambulance; therefore, she was unable to assess Resident #1. She indicated she felt the staff responded appropriately to the emergency. The Administrator was notified of immediate jeopardy on [DATE], at 7:35 PM. The facility provided the following credible allegation for immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and On [DATE], shortly before 3AM, Resident #1 was noted in doorway of his room as the Night Shift Supervisor was coming down the hall. She could see that smoke was coming from the room. She began to call his name and as she approached him, she could see his hair was singed. As she got closer, she called his name, and he did not answer as his head was down. She pushed his head up and back and noted his face was melted off referring to his burned face. She immediately closed his door given the smoke detector was sounding and there was visible smoke, rescued him from danger to the nurses station, immediately pulled the fire alarm and called 911 for Emergency Medical Services (EMS) and Fire Rescue at 2:56am. While on the phone with 911, the Night Shift Supervisor assessed respirations and pulse and provided the information to dispatch as instructed. The 911 dispatcher asked her to get him to the front of the building to await pickup. The Night Shift Supervisor instructed the certified nurse aide (CNA) to take him to the front of the building to await EMS at the request of the 911 dispatch. In the meantime, the Night Shift Supervisor was asked to stay on the phone with the dispatcher. However, the nurse did not provide instruction to the certified nurse aide as to what to do for this resident; she didn't assess what the resident needed and failed to render emergency care to maintain Resident # 1's airway. During the wait for EMS to arrive, the CNA states she and other staff watched him, took his pulse, and she and other staff continued to speak to him and touch him to reassure him knowing he was unresponsive. His body was severely slumped over in the chair at his torso. The CNA notes on interview that she and other staff handed him off to EMS upon their arrival at 3:02am. They dismissed themselves when EMS took over. In review of this incident, the nurse and staff assigned to him after he left the unit failed to monitor and assess Resident #1 who had been through a traumatic event suffering multiple burns, did not assess him fully to know what nursing and medical needs he had, did not position the resident to promote breathing, did not cover the resident in 30 degree weather outside, and did not provide basic necessary services until EMS arrived. The nurse further sent him to the lobby with an unlicensed staff member who was unable to monitor him which was required per policy. 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 completed. Education began for nursing staff to include licensed nurses and nursing assistants on [DATE], by the DON or designee. Education included Nursing policy 1110-Emergency First Aide, and other information noted below. Education included: o Provision of emergency first aide as indicated by the situation to anyone in the center experiencing an accident or incident. o A licensed nurse will assess injured persons, obtain vitals, monitor patient for changes. Obtain vital signs, pulse ox etc. as condition warrants. o In the case of burn, protect airway, such as positioning, rescue breathing, CPR, emergency oxygen o Providing emergency first aide for other accidents/incidents as needed-CPR, Rescue breathing, control bleeding, emergency oxygen, cleansing wounds/applying dressing, immobilizing fractures. o Notification to physician/Next of Kin as soon as possible. o Contacting EMS o Assuring that licensed staff attend resident until EMS arrives, continue to monitor, assess and intervene as needed o Completion of documentation related to the incident Any nursing staff member that did not receive education on [DATE] will receive education by the beginning of the next shift by the DON or designee. The Staff Development Coordinator will be responsible for tracking staff that still require education. Any staff that has not received education will not be allowed to work until education is received. All new hire licensed staff will be educated by the Staff Development Coordinator on this policy. This education will be added to the orientation process. Staff Development was notified of this responsibility on [DATE]. The DON or designee will verify the understanding of the education through oral discussion and feedback with all staff and notate this on a tracking tool. The SDC will also do this in orientation. Nursing staff will complete a post- test based on the education provided. Staff Development Coordinator is responsible for the post test and monitoring the post test results. The post test is initiated on [DATE]. Date of immediate jeopardy removal is [DATE] Person responsible for implementation the plan is the Administrator On [DATE], the facility's credible allegation for immediate jeopardy removal was validated by record review of in-services; multiple interviews with facility staff revealed they received education on the facility's Nursing Policy - 1110 Emergency First Aid and education on situation of accidents including the case of burns, assessment, notification, and effective communication; and interview with the Administrator affirming the education was provided by the Director of Nursing and Staff Development Coordinator. Immediate jeopardy was removed on [DATE].

Based on record review, fire department report review, Emergency Medical Services report review, and staff, facility's contracted transportation driver, facility's contracted transportation company's owner, fire department Captain, hospital staff, and Paramedic interviews, the contracted facility transportation company failed to notify the facility Resident #1 was observed to be smoking with an oxygen tank on his wheelchair, was in possession of cigarettes, a lighter, and repeatedly asked the driver to stop for cigarettes and coffee while en route to a physician's appointment. On [DATE] Resident #1 lit a cigarette in his room with oxygen in use and sustained second- and third-degree flame burns to both sides of his face, both ears, left chest, left upper arm, left forearm, and back of left hand. EMS personnel immediately began cardiopulmonary resuscitation (CPR) once inside the ambulance. He went into cardiac arrest twice, was intubated, and became comatose. Resident #1 expired on [DATE]. This is evidenced for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). In addition, the facility continued to assess a resident as safe to smoke without supervision after he was non-compliant with the facility's smoking policy for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #2). Immediate jeopardy began on [DATE] when the contracted facility transportation company failed to notify the facility Resident #1 was smoking with an oxygen tank on the back of his wheelchair, was in possession of cigarettes, a lighter, and was repeatedly asking the driver to stop for coffee and cigarettes while en route to a physician's appointment. Immediate jeopardy was removed on [DATE] when the facility provided an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of D (No actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure completion of education and monitoring systems put into place are effective. Example #2 for Resident #2 was cited at a scope and severity of D. The findings included: 1. The hospital discharge summary dated [DATE] revealed Resident #1 is to place one 21 milligram (mg) Nicotine patch on the skin daily (reason unspecified) as well as to utilize oxygen at 4 liters continuously was also ordered (reason unspecified). Resident #1 was admitted to the facility on [DATE] with multiple diagnoses which included Chronic Obstructive Pulmonary Disease, respiratory failure, peripheral vascular disease, heart failure, and tobacco use. Resident #1 was admitted to and remained in a private room. A physician's order dated [DATE] revealed Resident #1 to utilize oxygen at 4 liters per minute via nasal cannula every day and night shift. A physician's order dated [DATE] staff is to pipe oxygen into Resident #1's BiPAP machine (a device that helps with breathing which pushes air into the lungs) every night shift and as needed for low oxygen saturation levels and shortness of breath. A physician's order dated [DATE] stated apply one 24-hour 21 milligrams Nicotine patch transdermal (on the skin) one time a day for nicotine cessation for 6 weeks and remove per schedule. A physician's order dated [DATE] stated apply one 24- hour 14 milligrams Nicotine patch transdermal (on the skin) one time a day for smoking cessation for 2 weeks and remove per schedule. A physician's order dated [DATE] stated apply one 24-hour 7 milligrams Nicotine patch transdermal (on the skin) one time a day for smoking cessation for 2 weeks and remove per schedule. The admission nursing assessment dated [DATE] revealed Resident #1 was cognitively intact and required supervision with chair/bed-to-transfers. The Smoking Safety Screen dated [DATE] completed by the Unit Manager revealed Resident #1 did not smoke. A nursing note written by the Unit Manager on [DATE] at 4:10 PM stated Resident stated that he has not had a cigarette in 2 months and did not have the urge to smoke. Writer made resident aware that he will be on nicotine patches. Resident #1's care plan dated [DATE] indicated Resident #1 is at risk for respiratory complications due to Chronic Obstructive Pulmonary Disease, respiratory failure, supplementary oxygen requirement and Bilevel Positive Airway Pressure machine (a machine used to help push air into lungs and opens airway). The goal was for Resident #1 to be free from respiratory complications through the review period. Interventions included: administer medications as ordered; administer nebulizer treatments as ordered; administer oxygen as ordered; BiPAP as ordered; observe for signs and symptoms of respiratory complications; and vitals as needed. The Unit Manager was interviewed on [DATE] at 12:30 PM. She indicated she completed Resident #1's admission on [DATE] and was familiar with him. Resident #1 was admitted directly from the hospital. Resident #1 was cognitively intact during her assessment. She completed the Smoking Safety Screen and indicated Resident #1 does not smoke. She stated Resident #1 indicated he did not want to smoke and had no desire to smoke while at the facility. She reviewed the facility's smoking policy and Resident #1 voiced understanding. While completing his admission, she did not notice any smoking materials in Resident #1's possessions. She did not recall Resident #1 ever having friends or family visit him while at the facility. She indicated she was aware of the facility's smoking policy that all smoking materials are to be kept at the nurses' station until ready to be used and smoking materials should not be kept in resident's rooms. An interview with the facility's contracted transportation driver on [DATE] at 4:43 PM revealed he picked Resident #1 up in the morning on [DATE] to transport him to a physician's appointment. Resident #1 frequently asked for the driver to stop at a store to purchase coffee and cigarettes while he was transporting Resident #1 to his physician's appointment. He told Resident #1 he could not stop and proceeded to drive to the physician's office. He stated when picking up Resident #1 after his physician's appointment, Resident #1 was outside of the physician's office, on an elevator lift, and smoking a cigarette with an oxygen tank on the back of his wheelchair. He told Resident #1 he could not smoke while on oxygen or while in the transportation van. He requested Resident #1 to put the cigarette out. Resident #1 agreed to stop smoking and threw the cigarette off the side of the elevator lift (The lift is a platform that is used to raise clients in wheelchairs to the level of the parking lot). On the way back to the facility, Resident #1 only asked to stop for a cup of coffee. He reminded Resident #1 that he could not make any additional stops. He stated he reported his observations to the owner of the facility's contracted transportation company. During a follow up interview on [DATE] at 1:21 PM the facility's contracted transportation driver reiterated Resident #1 was on the outside elevator lift when he arrived. Resident #1 had a lit cigarette in his hand. The cigarette was about half-way gone. He told Resident #1 that he could not smoke in the van or while on oxygen. Resident #1 agreed and put the cigarette out by throwing it over the side of the elevator lift. An additional interview with facility's contracted transportation driver was conducted on [DATE] at 9:24 AM. He, again, stated when he arrived to pick Resident #1 from his physician's appointment Resident #1 was smoking a lit cigarette with an oxygen tank on the back of his wheelchair. Resident #1 had a package of cigarettes and a lighter in his hands. He told Resident #1 that he could not smoke with oxygen on or smoke in the transportation van. He stated Resident #1 voiced understanding and put the cigarette out. On [DATE] at 11:34 AM with the owner of the facility's contracted transportation company revealed the driver did not notify him of his observations of Resident #1 smoking or asking for cigarettes until after the nursing home facility started their investigation on [DATE]. He stated if the driver had notified him of the observations, he would have notified the facility. An interview with the Scheduler at the physician's office was conducted on [DATE] at 2:15 PM. She stated Resident #1 sat in the lobby until transportation came. She assisted Resident #1 on the outside elevator then the transportation driver helped him onto the transportation van. She stated she could not recall Resident #1 having a cigarette or lighter visible when she assisted Resident #1 outside. The nursing note written by the Night Shift Supervisor in the electronic medical record of Resident #1 dated [DATE] at 3:15 AM stated, Resident found unresponsive and breathing in front of room door in W/C [wheelchair] with burns to face and hair. Transferred to nurses' station and called 911. Instructed by 911 to bring resident to front of building by EMS and transferred care to EMS. An interview was conducted with the Night Shift Supervisor on [DATE] at 10:30 AM. Night Shift Supervisor stated at about 3:00 AM on [DATE] she was sitting at the nurses' station when she heard an annoying beeping sound, which she later discovered was from the room's smoke detector. She got up to investigate the noise. As she walked down the hall, she saw and smelled gray smoke coming from Resident #1's room. She yelled I know you're not smoking! to Resident #1. When she reached Resident #1, she saw him in the doorway of his room, sitting upright, with his head down. She lifted his head and noticed Resident #1's face and hair severely burned, he was breathing, and unresponsive. She described his facial burns as it was like his face melted off. She immediately brought Resident #1 into the hallway via his wheelchair and closed the door. She pushed him to the nurses' station, pulled the fire alarm, and called 911. She stated she was instructed to escort Resident #1 to the front of the building and to stay on the phone. She indicated she did not know Resident #1 smoked. She stated she never saw smoking materials in his room and Resident #1 never asked about smoking. Additional interview with the Night Shift Supervisor was conducted on [DATE] at 10:44 AM. Resident #1 was not on fire and there was not a fire actively burning. She stated Resident #1 was wearing clothes when the incident had started, and a gray burned shirt was found on the floor. When she approached Resident #1, she could smell burned flesh and hair. His long hair and long beard were burned unevenly including all the way up to one of his ears. She could not remember which ear was burned. An interview with NA #1 on [DATE] at 3:36 PM revealed she was not assigned to work with Resident #1 on [DATE]. She further indicated she was not familiar with Resident #1 and had never worked with him. She was responding to the fire alarm when she was instructed by the Night Shift Supervisor to take Resident #1 to the front. Documentation of the Emergency Medical Services (EMS) report dated [DATE] revealed at 3:01 AM, EMS arrived on scene. Resident #1 was sitting in a wheelchair outside of the front door of the facility. Resident #1 was noted to be slouched/slumped over in the wheelchair. Staff was immediately asked if the resident was breathing and if the resident had a pulse. The nursing staff responded, he's unconscious. EMS personnel, again, asked if the resident was breathing and if he had a pulse, to which the nursing staff did not check the patient. It was noted that all nursing staff had no hands on the resident, the resident was not being assessed, nor was treatment administered by nursing staff prior to EMS arrival. EMS personnel quickly assessed the resident. The resident was found to not be breathing or have a pulse. EMS personnel asked the nursing staff about Resident #1's information and paperwork, and the staff responded with we don't know anything about the patient, and there is a fire, so we can not [sic] get you that information. It was noted that nursing staff continued to enter and exit the front doors of the facility. An interview was conducted with the responding paramedic on [DATE] at 12:29 PM. The Paramedic stated when he arrived, he saw Resident #1 slumped over in a wheelchair outside front of the facility building. Resident #1 did not look like he was breathing. There were staff members around Resident #1; however, no staff member hand their hands on Resident #1. He stated staff members were either on their phones or walking around. He further indicated staff members could not report if Resident #1 was breathing or had a pulse. He also stated facility staff was not able to provide him Resident #1's name, date of birth, or medical conditions. When he assessed Resident #1 it was determined Resident #1 did not have a pulse or respirations. Resident #1 was assessed to the stretcher via 2-person manual lift and cardiopulmonary resuscitation (CPR) was started in the ambulance. He further indicated Resident #1's eyes were swollen and not opened as well has had third degree burns on face and charring on his nose. Documentation of the Fire Department report dated [DATE] revealed at 3:03 AM the fire department arrived on scene. The location of the incident was Resident #1's room. Upon arrival to the room, they found the door was shut and inside of the room was light to moderate smoke and found no fire. After gathering information from the facility staff and investigating, it was determined the incident occurred due to Resident #1 was attempting to smoke a cigarette while on oxygen. The factor which contributed to ignition was misuse of material. An interview was conducted with the responding Fire Department Captain on [DATE] at 10:42 AM. He stated EMS was on scene upon his arrival and was attending to Resident #1. When he investigated the fire, the room was filled with residual smoke as well as powder from a fire extinguisher. He noticed a gray shirt on the floor with burns. He further indicated there was melted oxygen tubing located on the floor as well. He stated it was determined Resident #1 had a history of smoking and was attempting to smoke while on oxygen. The emergency room hospital records dated [DATE] indicated Resident #1 presented to the hospital with partial-thickness burns covering Resident #1's face and neck as well as clavicle and shoulder, approximately 10% of body surface area, and soot in the nostrils. The emergency room physician noted EMS reported Resident #1 was sitting in wheelchair with oxygen on via nasal cannula when he subsequently lit a cigarette that exploded in his face causing severe burns to the face, neck, shoulders, and clavicle. Resident #1 was noted to be unresponsive, without a pulse so CPR was initiated by EMS. CPR was performed for 30 minutes then his pulse and blood pressure returned. Resident #1 went into cardiac arrest again for several minutes and was intubated after his pulse and blood pressure returned for the second time. Due to his significant burns, the hospital initiated a transfer to a local burn unit. A review of the Burn Attending Intensive Care Unit (ICU) hospital note dated [DATE] revealed Resident #1 was critically ill and sustained second- and third-degree flame burns to both sides of his face, both ears, left chest, left upper arm, left forearm, and back of left hand to 5.5% of his body. It was noted that he also went into cardiac arrest twice as well has having acute respiratory failure secondary to pulmonary edema (excess fluid in the lungs) and aspiration. An interview with ICU Nurse #1 was conducted on [DATE] at 3:02 PM. She indicated Resident #1 was comatose, intubated, unable to speak, and had an anoxic brain injury (a brain injury caused by a complete lack of oxygen to the brain). Resident #1's code status was switched from Full Code to Do Not Resuscitate (DNR). The ICU Physician Assistant was interviewed on [DATE] at 12:32 PM. She indicated it was reported to her that Resident #1 was smoking at the facility and caught fire. He was found to be unresponsive and remained unresponsive since admission to the ICU burn unit. She stated his injuries were consistent with smoking while on oxygen. The ICU Attending Physician was interviewed on [DATE] at 9:39 AM via phone revealed at the time of the call, Resident #1 had an anoxic brain injury (brain injury which occurs due to lack of oxygen to the brain) and had a poor prognosis. He was intubated, in critical condition, and unresponsive. She indicated she did not expect a full recovery and a palliative care consult would be placed due to Resident #1's poor prognosis. An interview with ICU Nurse #2 was conducted on [DATE] at 3:51 PM. She indicated Resident #1 remained in critical condition. Resident #1 was placed on comfort care with no aggressive treatment. He was not expected to recover, and death was imminent. On [DATE] at 12:34 PM the ICU Receptionist was interviewed. She indicated Resident #1 died on [DATE] at 5:15 PM. An observation of Resident #1's room on [DATE] at 9:30 AM revealed 5 permanent dark brown burn marks on the linoleum tile floor on the left side of the bed, which was located near the window. One burn mark was approximately 5 (inches) x 2; one was approximately 4 x 3, one was approximately 4 x 2, and two were approximately 1 x 1. The areas felt rough to the touch. NA #2 was interviewed on [DATE] at 10:25 AM. She indicated she was assigned to work with Resident #1 on [DATE], was familiar with his care needs, and knew he was oxygen dependent. She stated she did not know Resident #1 smoked. He never asked for cigarettes, lighters, matches, or to go outside to smoke. She stated she had checked 10 to 15 minutes prior to the incident and did not notice anything abnormal. An interview with NA #3 on [DATE] at 11:40 AM revealed she had only worked with Resident #1 one time. While working with Resident #1, she never saw cigarettes or lighters in his room or in his possession. She further stated Resident #1 never asked her about smoking. An interview with Housekeeper #1 on [DATE] at 1:11 PM revealed she frequently cleaned Resident #1's room. She stated she did not know Resident #1 smoked. She never saw smoking materials in his room, and he never asked her about smoking while she cleaned his room. The Social Worker was interviewed on [DATE] at 2:15 PM. He stated he was familiar with Resident #1. He introduced himself to Resident #1 a week before the incident. He asked Resident #1 if he was a smoker, and Resident #1 denied being a smoker. He stated Resident #1 knew about the smoking policy. He further provided education to Resident #1 regarding oxygen safety which included safe mobility in the room while wearing oxygen and smoking while on oxygen. This education is provided to all residents who utilize oxygen. The Director of Nursing (DON) was interviewed on [DATE] at 1:57 PM. She stated she received a call from a staff member around 3:00 AM on [DATE] notifying her of Resident #1 sustaining injuries from lighting a cigarette while on oxygen. She indicated she did not see Resident #1 when she arrived at the facility as he had already been taken by ambulance; therefore, she was unable to assess Resident #1. She indicated she felt the staff responded appropriately to the emergency. When she investigated the room, she noticed a gray burned shirt on the floor as well as 5 burned marks on linoleum tile flooring. Additionally, she saw approximately 6 to 10 feet of melted oxygen tubing. There was a lighter located under the window's Packaged Terminal Air Conditioner (PTAC) unit and a package of cigarettes hidden in an animal cracker package with one cigarette missing. She threw the gray shirt away as well as the oxygen tubing. She did not indicate why she had thrown these items away. She stated the Smoking Safety Screens were completed at admission, quarterly, and whenever a residents changed their mind about smoking. She indicated the charge nurse or the unit manager completes the Smoking Safety Screen. The Unit Manager completed Resident #1's Smoking Safety Screen. She did not know where Resident #1 obtained smoking materials. The Administrator was notified of immediate jeopardy on [DATE], at 5:43 PM. The facility provided the following credible allegation for immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and Resident # 1 was taken to an appointment by a transportation company on [DATE]th. The transportation driver failed to communicate with the facility that Resident # 1 was observed by the transportation driver smoking with an oxygen tank present on his wheelchair and was observed in possession of smoking materials. The transportation driver failed to notify the facility that Resident #1 had requested numerous times during the transportation to stop and purchase smoking materials. As a result, on [DATE], shortly before 3AM, resident #1 was noted in doorway of his room as the Night Shift Supervisor was coming down the hall. She could see that smoke was coming from the room. She began to call his name and as she approached him, she could see his hair was singed. As she got closer, she called his name, and he did not answer as his head was down. She pushed his head up and back and noted his face was melted off referring to his burned face. All residents that are transported to appointments by a transport company and residents that are not compliant with smoking policy 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 completed. Education began on [DATE], for all staff in all departments by Staff Development Coordinator Education included: The smoking policy, including but not limited to: o Those patients currently assessed as deemed independent vs supervised for safety for smoking and supervised smoking times as indicated on the updated smoking list which was revised on [DATE] and is available at all nursing stations. The Director of Nursing was responsible for updating the list of supervised smokers on [DATE] and will update smoking list as necessary. o Monitoring patient behavior and activity in room related to having combustible materials on self and reporting it to the charge nurse and/or supervisor for follow-up. o Monitoring changes in the condition of patients that previously were non-smoking in the center, but who may express a desire to smoke, and reporting this to the charge nurse and/or supervisor for follow-up. o Immediately notifying administrator and/or Director of Nursing at the time of occurrence for any resident caught smoking out of the designated times and area. Consequences of smoking with oxygen on can result in serious injury. o Nurse management (director of nursing, assistant director of nursing, unit managers and/or staff development coordinator) will remove any employee that did not receive the education from the schedule until education is completed. The staff development coordinator is responsible for tracking that staff have received the required training prior to working their next shift. All future employees will be educated by staff development coordinator on the above in-services during new hire orientation. Current staff have received this education. The Staff Development Coordinator is tracking this information to ensure no staff works that have not received the education. o Education began on [DATE] for all nurses, discharge planners and IDT on completion of the smoking assessment and discussion of the smoking acknowledgement with all new admissions by the DON, SDC or designee, including discussions with patients who state they are not a current smoker but have a history of smoking, and education to patients desiring to smoke but who wear oxygen. This education will be done by the SDC, DON or designee. All disciplines were educated on their responsibility on [DATE]. All new admissions will be discussed during morning clinical meeting with the disciplines and updates on progress of assigned task. Anyone working after [DATE] who has not received the education will not be allowed to work. This education will also be done in orientation beginning of [DATE], for all new hire nurses and new hire members of the IDT. Staff Development Coordinator will track and ensure education is provided. Staff Development Coordinator was notified of this responsibility on [DATE]. o All smoking assessments and care plans for current smokers were reviewed and updated by the Interdisciplinary Team (IDT) to assure appropriateness of supervised vs. unsupervised smoking status. This was completed by the Director of Nursing or designee on [DATE]. o All new admissions for the last 30 days will be reviewed for evidence of a smoking assessment and their completion, as well as the care plan for anyone desiring to smoke by [DATE] by the DON or designee. o On [DATE] all residents' POC Kardex were updated to reflect smoking designation as supervised smoker, unsupervised smoker, or history of smoking. The resident Point of Care Kardex is seen on the Certified Nursing Assistance kiosk where daily resident review and documentation is done by the certified nursing assistants each shift. Education began on [DATE], for all staff in all departments by Staff Development Coordinator Education included: All current patients that smoke received re-education of the smoking policy, smoking acknowledgements for all current smokers and all new admits were re-reviewed and completed on [DATE] by the discharge planning director or designee. The smoking policy states smoking materials will not be kept in the patient room. For all current smokers and all new admissions, the discharge planner or designee will educate responsible parties/emergency contacts on proper providing and delivery of smoking materials to the charge nurse for safe keeping. The discharge planner performs this task by going over the smoking policy and having the resident or resident representative sign the smoking acknowledgement. Any new admission that arrives with smoking materials will have their smoking materials taken and properly stored in secure area by the discharge planners. Discharge planners contacted all emergency contacts/responsible parties and provided verbal education on smoking policy specifically delivery of smoking materials and storage. This will be completed on [DATE]. To ensure that smoking materials are returned for all smokers, residents are assisted from smoking patio by staff and smoking materials are placed in the designated locked and secured location. A smoking attendant is assigned to monitor the smoking area 8a-8p and will be noted on the daily nursing staffing sheets to communicate what staff member is assigned. The facility scheduler will be responsible for assuring that the assignment sheet notates what staff is assigned each shift as smoking attendant. The smoking attendant will collect smoking material when they return inside from the smoking area. The smoking attendant will distribute the smoking material when the resident goes to smoke. Between the hours of 8p-8a, if a resident, who is deemed a safe smoker would like to smoke a smoking attendant will be assigned individually as needed to distribute the resident their smoking materials and at the end of the smoking session retrieve smoking materials to be returned to proper storage location. All current safe/unsupervised smokers will be educated on this process by the Director of Nursing or designee beginning on [DATE] and this education will be tracked by the Staff Development Coordinator. The smoking attendant will supervise all unsupervised smokers and distribute and collect their smoking materials. Education began to all staff on the new smoking process by the Director of Nursing or designee on [DATE] on the responsibilities of the smoking attendant, location of assignment sheet, and appropriate storage of smoking materials. Any staff that have not received this education will not be allowed to work until they have received the required education. On [DATE] all smoking residents' rooms and persons were searched with consent by Director of Nursing and Unit manager and all smoking materials were confiscated and placed behind locked doors. Unit manager provided education to smokers on risks of having smoking materials in room and on person. Unsupervised smokers verbalized understanding of this policy. The Staff Development Coordinator will provide the education in writing to the third-party vendor on [DATE] who will then communicate the written education to the two transportation companies utilized by the facility and all drivers assigned to drive for the facility. Education will be provided by our third-party entity who provides administrative oversite for all transportation vendors for Alamance Nursing and Rehabilitation. Any driver not educated will not be allowed to transport residents from the center until education has been received. The third-party entity will communicate with the center that the transportation companies have been educated. This education will be tracked by the Staff Development Coordinator. Drivers that did not complete the education on [DATE], will not be allowed to transport for the center until education is received. The Staff Development Coordinator or designee will educate all service ambassadors and the in-house transportation coordinator on the written education received by the transportation companies and responsibilities for verifying and providing education on [DATE]. The service ambassadors and in-house transportation scheduler, located at the front desk will verify with any driver that reports to pick up a resident has received the required education by asking the driver when they enter the facility. Transportation drivers are required come into the facility to check out the resident for the transport. When a new transportation driver is hired by the company verification of education will be forwarded from the third-party entity to the facility for tracking of required education. The service ambassadors and facility appointment scheduler will be educated on [DATE] on the same items as the transportation company drivers by the Staff Development Coordinator. Education to the transportation drivers; service ambassadors, facility appointment scheduler will include. Safety concerns would include but not be limited to unbuckling, attempts to stand, attempts to smoke, known smoking or vaping. o Type of concerns to report-behaviors, unusual requests for stops, noncompliance with safety directions during transport. This will be part of the ongoing orientation process for the transportation vendors to use in their orientation process. o Returning the resident to facility and drop off procedure to include reporting concerns to Service Ambassador. The service ambassador is located at the front desk at the front door. The service ambassador is located at the front desk from the hours 8am- 8pm. If the transportation driver returns when the service ambassador is not available, the charge nurse for the patient will be notified by the transportation driver. Education provided to the Service Ambassadors and Charge Nurses by the Staff Development Coordinator is listed below o Any concerns noted by Service Ambassador will be immediately given to the charge nurse, unit manager or supervisor for follow up. The service ambassador is the front desk attendant. Education will be provided to current service ambassadors by Staff Development Coordinator on [DATE]. Any service ambassador will not be able to work until they have received education by the staff development coordinator. o [NAME] [TRUNCATED]

Based on resident interview, staff interviews, Ombudsman interview, Department of Social Services interview and record review, the facility failed to permit a resident to return to the facility following a facility-initiated transfer to the hospital for 1 of 2 residents transferred to the hospital. Resident #7 was medically stable for return on 10/26/22 when the facility refused to readmit the resident. This resulted in Resident #7 being upset and scared he would be put out on the street and become homeless. The resident remained in hospital until 11/18/22 when alternate facility placement was found. The findings included: Resident #7 was admitted to the facility on [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) dated [DATE], indicated Resident #7's cognition was intact, and he required extensive assistance with activities of daily living. The care plan updated 8/17/22 identified the problem area as Resident #7's preference for discharge was to remain in Long Term Care (LTC) at facility. The goal included Resident would accept LTC services and interventions. The interventions included encourage resident to participate in out of room activities of choice for socialization, encourage resident, guardian/caregivers to participate in care plan meetings. Provide resident with referrals for dental, vision, podiatry, hearing, and psychological services as needed. Financial ledger documentation for Resident #7 revealed the following: - On 9/30/22 the Business Office Manager (BOM) attempted to take payment for Resident #7's facility bill but it was denied. The ledger indicated the BOM called the resident and advised Resident #7 that the bank card (used for payment of the bill) was not working. He confessed his daughter had the card and had been using his retirement income. The BOM advised Resident #7 that the new card information needed to be sent. - On 10/4/22 the BOM spoke with Resident #7's daughter about changing the bank card information without updating the card information on file with facility. - On 10/6/22 the BOM spoke with the resident and discharge planning person about his bill and the non-payment as well as changing the card information and not notifying the facility. The BOM informed the resident that the financial discharge is being issued and the Ombudsman has been notified. Review of the Notice of Transfer/Discharge form dated 10/6/22 with date of transfer/discharge on 11/7/22, for failure, after reasonable and appropriate notice, to pay for (or have paid under Medicare or Medicaid) a stay at this facility. The Administrator signed the form on 10/6/22 that documented the discharge location was to the home of the daughter. Review of the Hearing Request form dated 10/6/22 documented the scheduled discharge date of [DATE], was unsigned by resident. Review of nursing hospital transfer note summary dated 10/19/2022 at 4:10 AM indicated Resident #7 had a significant change in condition, Emergency Medical Service (EMS) were called, and the resident was transferred to the hospital. A telephone interview was conducted on 11/21/22 at 1:17 PM with the Ombudsman who stated that she received a call from the resident on 10/18/22 while still a resident in the facility. The resident told the Ombudsman he received a 30-day discharge notice on 10/6/22. Resident #7 was told by the facility he would be discharged and could not return to the facility based on the 30-day notice and financial obligation and wanted to know what would happen. She met with the resident on 10/18/22 and verbal consent was obtained from the resident to start the discharge appeal process. The resident was transferred to the hospital on 10/19/22. An interview was conducted on 11/21/22 at 11:15 AM with the Business Office Manager who stated Resident #7 was transferred to hospital on 10/19/22 due to a medical condition. The Business office Manager further stated Resident #7 was admitted to the facility as private pay. The Business Office Manager spoke with Resident #7 and his daughter regarding the Medicaid benefits. The Medicaid screening process was completed on 8/23/21 and the information was sent to the Department of Social Services. Resident #7's financial income sources included social security and a pension plan. Resident #7 was given a 30-day discharged notice on 10/6/22 due to an outstanding financial obligation. The Business Office Manager stated the Administrator informed her on 10/26/22 Resident #7 was declined return to the facility due to outstanding financial obligation. The Business Office Manager stated on 10/26/22 she received a call from the resident from the hospital and she informed him he would not be readmitted to the facility. She advised the resident that his belongings could be picked up by his daughter. A telephone interview was conducted on 11/21/22 at 1:17 PM with the Ombudsman who stated during discussion with Resident #7 on 10/18/22 about the location of discharge to his daughter's home was a concern for Resident #7 due to her inability to care for his needs properly once discharged home. The Ombudsman did not specify when the discussions were held with the family member. Resident #7 revealed discharging the resident to the community would have resulted in Resident #7 being homeless. The Ombudsman added Resident #7 stated he wanted to return to the facility and was aware of the financial obligation. Resident #7 was upset and afraid of what might happen due to the facility's refusal to accept him for readmission when discharged from the hospital. The Ombudsman indicated discussions had been held with Resident #7 regarding the facility's obligation for his return to the facility and Resident #7 remained upset and was unsure what to do due to the financial situation with the facility and his family member. A telephone interview was conducted on 11/21/22 at 2:30 PM with the Department of Social Service Worker (DSS) who stated the resident was currently located in another facility. DSS received a call from the resident who stated he received his 30-day notice for discharge with the last covered day of 10/28/22. The resident stated he wanted to return to the facility. The DSS Worker also stated the hospital called the facility on 10/26/22 for the resident to return and the facility refused to accept the resident back due to non-payment. DSS added the resident and family indicated the resident was unable to return home even though the notice indicated he would return home to family. DSS further stated additional discussion had been held with the facility regarding the resident's financial status regarding social security benefits that were being sent to the facility, Medicaid application and additional personal funds. It was discovered there was some financial mismanagement done by the family which resulted in the non-payment. DSS submitted a request of financial records from the facility on 11/4/22. DSS stated the facility should have taken resident back for continued care and their knowledge that the resident did not have an appropriate place for discharge at the time he became ready for return. The hospital did keep resident until alternate placement could be found based on the refusal of return by the facility. A telephone interview was conducted on 11/21/22 at 4:00 PM with Resident #7 who stated he received a 30-day notice for discharge from the facility the 1st week of October due to non-payment per the facility Administrator. The resident further stated he wanted to stay at the facility but because the facility told him and the hospital, he could not return he had to stay at the hospital. Since he left the faciity on [DATE], he had been sent to another skilled nursing facility on 11/18/22 and back to the hospital on the same date (11/18/22). Resident #7 stated I really wanted to return to the facility, but I was really scared I would be put out on the street and become homeless because my daughter could not take care of him, and he could not care for himself or walk. Resident #7 added that being sent to various places in the past few weeks had made him upset and sad. He added that he had been trying to get his family to return his bank card, get Medicaid, and return to the facility. He stated that since the facility did not accept him back, I will probably be sent all over North Carolina where I have no friends or family. The Ombudsman and hospital tried to help me, but no-one called me from the facility. An interview was conducted on 11/21/22 at 4:30 PM with the Administrator who stated the facility management team issued the 30-day notice for non-payment on 10/6/22 and declined to accept the resident back to the facility for non-payment. The Administrator indicated on 10/26/22 the hospital contacted the facility for the resident to return and the facility refused the resident's return. Review of the notice of discharge revealed the resident was scheduled for discharge on 11/7/22 and placement would be to the home of a family member. The Administrator confirmed the resident went to the hospital prior to the actual scheduled discharge date . He indicated awareness that placement to home was not appropriate due to the family member's inability to provide proper care for the resident. The Administrator stated he thought the hospital staff would handle placement for the resident, but he did not have any direct documentation of the discussion with the hospital staff that they would handle placement. The Administrator further stated several attempts had been made to obtain Medicaid for the resident by previous and current business office managers. He did state the resident had become non-compliant with completing the Medicaid process. The Administrator further stated the resident would be accepted for return when he was ready for discharge from the current hospital. During a follow-up telephone conversation on 11/22/22 at 8:38 AM with Resident #7 he stated the Administrator and the facility Patient Advocate staff called Resident #7 on 11/21/22 and offered the resident to return to the facility when he was ready for discharge from hospital. Resident #7 stated during the conversation, he spoke with Administrator and admission staff about continuing to work on his Medicaid and obtaining a bank card from family member. I really wanted to come back the 1st time I was so scared I was going to be put out on the street if I did not go with my daughter. Everyone knew my daughter could not take care of me. I have been sent everywhere and I am not sure the facility would take me back. An interview was conducted on 11/22/22 at 9:04 AM with the facility Patient Advocate who stated she was informed by the Administrator on 10/26/22 the resident would not be accepted back to the facility due to the outstanding financial obligation. The Patient Advocate further stated she had spoken with the hospital discharge planner on 10/26/22 and informed them Resident #7 would not be accepted back to the facility due to the outstanding financial obligation and if the resident could pay the bill he could return. The discharge planner was informed Resident #7 did not have Medicaid. The Patient Advocate further stated she had spoken with Resident #7 who stated he did want to return and had retrieved his bank card from family and wanted to continue the Medicaid process. During a follow-up telephone interview on 11/22/22 at 10:21 AM with the Ombudsman she stated the facility was aware Resident #7 was not appropriate for discharge to home and the family member could not provide the care the resident needed. The resident had requested the appeal for discharge on 10/18/22. The Ombudsman was uncertain if the Medicaid application was completed.

Based on record review, staff interviews, and physician interviews, the facility failed to notify the physician or nurse practitioner (NP) when antiseizure medication remained unavailable for Resident #140, pain medication was unavailable for Resident #42, and when the nurse was unable to obtain intravenous (IV) access for Resident #111 to provide hydration as ordered for 3 of 4 residents reviewed for notifications (Resident #140, Resident #42, and Resident #111). Immediate jeopardy began on 7/14/22 when the physician was not notified the antiseizure medication continued to be unavailable and was not being administered. The facility failed to notify the physician of antiseizure medication not being administered as ordered for Resident #140. Immediate jeopardy was removed on 9/17/22 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of E no actual harm with potential for more than minimal harm that is not immediate jeopardy to ensure monitoring systems and staff education put in place are effective. The facility was also cited at a scope and severity of E for example #2 (Resident #42) and example #3 (Resident #111). The findings included: 1. Resident #140 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #140 was initially ordered [MEDICATION(S)] (antiseizure medication) on 10/12/20. The order dated 5/27/22 revealed [MEDICATION(S)] 200 milligrams (MG) give 1 tablet by mouth two times a day for seizures, controlled substance. A nurse progress note dated 6/24/22 at 2:06 PM indicated there was a follow up with the neurologist's office for a replacement medication for [MEDICATION(S)]. It was noted the office would send new orders to the facility. A nurse medication administration note written by Nurse #10 dated 6/27/22 at 1:36 PM revealed Resident #140's [MEDICATION(S)] was unavailable, and the physician was aware. During an interview with Nurse #10 on 9/13/22 at 10:52 AM, she stated she did not notify the physician that Resident #140's antiseizure medication was unavailable. Nurse #10 stated Nurse #6 had notified the physician and the family representative. She stated resident #140 went without his [MEDICATION(S)] for awhile in June and July. Nurse #10 did not know exactly how long the resident was without the medication. A nurse medication administration note written by Nurse #23 dated 7/18/22 at 9:44 AM revealed Resident #140's [MEDICATION(S)] was unavailable, and the physician was aware. Review of controlled substance records revealed nurses administered [MEDICATION(S)] to Resident #140 until 6/26/22 when the medication became unavailable. The resident did not receive prescribed [MEDICATION(S)] from 6/26/22 - 7/9/22 or from 7/14/22 - 7/21/22. During an interview with Nurse #6 on 9/14/22 at 10:35 AM, she stated Resident #140 did not receive his [MEDICATION(S)] after the pharmacy could not refill it. Nurse #6 notified the NP who requested that staff contact the neurologist. Nurse #6 stated she did not know which nurse contacted the neurologist. An interview was conducted with NP #1 on 9/14/22 at 10:45 AM. NP #1 stated she was notified in June 2022 that Resident #140's [MEDICATION(S)] was not available. NP #1 informed the staff Resident #140 could not go without [MEDICATION(S)] and could end up in the hospital. Administrator #2 assured NP #1 the medication would be obtained, and the facility could cover the cost if needed. NP #1 understood the medication would be provided and was unaware the [MEDICATION(S)] continued to not be administered in June and July. An interview was conducted with Physician #1 on 9/15/22 at 10:19 AM. Physician #1 stated he was not aware Resident #140 did not receive [MEDICATION(S)] as ordered. During an interview with NP #2 on 9/16/22 at 9:41 AM, she stated in June 2022 Nurse #6 informed her Resident #140's [MEDICATION(S)] was not available. NP #2 believed Nurse #6 spoke with the neurologist. A follow up interview was conducted with NP #2 on 9/16/22 at 12:07 PM. NP #2 clarified she was made aware Resident #140 did not have his [MEDICATION(S)] in June 2022. She was not aware of the 3-day supply that was obtained 7/10/22 - 7/13/22 and was not aware the resident was again without the medication on 7/14/22 - 7/21/22 after the 3-day supply ran out. An interview was conducted with the Neurologist on 9/16/22 at 12:37 PM. She stated the office was notified that insurance would not cover [MEDICATION(S)] for Resident #140. On 6/24/22, a facility nurse called and requested an alternate medication. A prescription for the generic form of [MEDICATION(S)] was sent to the facility. She was not aware of how long Resident #140 was without [MEDICATION(S)]. In July 2022, the resident's family member spoke with the office nurse and reported Resident #140 had not been receiving [MEDICATION(S)] at the facility. The Administrator and Nurse Consultant were verbally notified of Immediate Jeopardy for F580 on 9/15/22 at 2:09 PM. The facility provided a credible allegation of Immediate Jeopardy removal with a correction date of 9/17/22: Removal Plan F580 1. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance [MEDICATION(S)] was not administered as ordered on 6/26/22 - 7/10/22 and from 7/14/22 - 7/21/22. The medication was ultimately made available via generic medication order/ insurance authorization and after 7/21/22, the patient has received the medication. The MD and NP indicated [MEDICATION(S)] was a medication Resident #140 should not go without and he could have a [CONDITION(S)], end up in the hospital, and/or sustain serious harm as a result of a [CONDITION(S)]. There was no harm or adverse effect on Resident #140. Resident was receiving other ordered [CONDITION(S)] medications during the missed administrations of the [MEDICATION(S)]. 2. 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; The assistant director of nursing (ADON) reviewed MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . No other anti-[CONDITION(S)] medications were unavailable. Education will be provided by 9/16/22, by the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, or designee to all full time, part time, as needed, and contracted nursing staff (if applicable) on proper notification to providers, including Physician and NP, when a medication is unavailable. The expectation would be to receive clarification for a medication hold order, and/or alternative orders. Staff not working on 9/16/22 will receive education prior to the start of their shift after 9/16/22. Alleged date of IJ removal is September 17th 2022. Person responsible for implementation is the administrator The credible allegation was validated on 9/16/22 when staff interviews revealed that they had received recent education on processes when medications were unavailable, pharmacy notifications, when to have an authorization form completed, and notifying the physician and nurse practitioner when medications were unavailable. Facility documentation revealed staff were educated on issues related to medication availability and notifications. Date of IJ removal 9/17/22 2. Resident #42 was readmitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #42's care plan, created on 1/16/22 with a target date of 9/19/22, revealed a focus area for pain. An intervention was listed for providing medication as ordered. Resident #42 was ordered an over-the-counter pain patch ([MEDICATION(S)] pain relief patch) on 5/25/22. It was to be applied to the left shoulder daily. Resident #42's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact. The MDS indicated the resident did not receive pain medication. Nurse progress notes written by Nurse #12 dated 8/20/22 and 8/21/22 revealed Resident #42's [MEDICATION(S)] pain patch was unavailable. The pain assessment was not completed on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The pain level was documented as 0 on the MAR for nightshift on 8/20/22 and 8/21/22. Attempts to interview Nurse #12 who did not administer Resident #42's [MEDICATION(S)] pain patch on 8/20/22 and 8/21/22 were unsuccessful. During an interview with Nurse #6 on 9/14/22 at 10:35 AM, she stated she was aware the [MEDICATION(S)] patches were not administered on 8/20/22 and 8/21/22. Nurse #6 asked Nurse #12 to get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with Administrator #1 on 9/14/22 at 1:00 PM. She stated she was unaware Resident #42 did not receive pain patches on 8/20/22 and 8/21/22. An interview was conducted with Nurse Practitioner (NP) #2 on 9/14/22 at 2:16 PM. NP #2 stated she was not notified that Resident #42 did not receive her pain patches. During an interview with Physician #1 on 9/15/22 at 10:19 AM, he stated he was not notified Resident #42 did not receive her pain patches on 8/20/22 and 8/21/22. During an interview with the Assistant Director of Nursing (ADON) on 9/15/22 at 2:41 PM, she confirmed Nurse #12 documented that the [MEDICATION(S)] patches were unavailable. There was no documentation that the physician was notified. 3. Resident #111 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set readmission assessment dated [DATE] revealed Resident #111 was cognitively intact and required extensive assistance with activities of daily living. She was independent with eating. Review of provider orders dated 7/26/22 revealed an order to infuse normal saline at 100 milliliters over 24 hours intravenously. The progress note dated 7/27/22 at 10:21 am revealed IV access was not successful and IV fluids were not administered. The nurse indicated she contacted the provider and received an order to send Resident #111 to the emergency room for acute kidney failure. The progress note dated 7/27/22 at 11:20 am revealed Nurse Practitioner #1 reviewed laboratory results and assessed Resident #111 for acute kidney injury. Nurse Practitioner #1 indicated the order given on 7/26/22 to infuse IV fluid was not implemented by the night shift nurse on 7/26/22 and she failed to notify the on-call provider to get further recommendations for hydration. Nurse Practitioner #1 further indicated Resident #111 was sent to the hospital on 7/27/22 for large volume repletion for acute kidney injury. On 9/12/22 at 9:46 am during an interview was conducted with Resident #111 she indicated she had access to adequate fluids. On 9/16/22 at 1:54 pm during an interview with the interim Director of Nursing she revealed she expected the provider to be contacted when the nurse was unable to gain IV access to infuse fluids to Resident #111 as ordered. She indicated notification to the provider should not be delayed. On 9/16/22 at 2:07 pm a telephone interview was conducted with the current provider, Nurse Practitioner #3. She indicated based on the clinical presentation and progress note the previous provider had written that the nurse should have contacted the provider to make them aware that she could not gain IV access to infuse fluids to obtain further instructions. Nurse Practitioner #3 further indicated if the provider had been notified promptly, alternate measures to infuse fluids and diagnostic tests could have been implemented to treat dehydration in the facility. On 9/16/22 at 4:20 pm a telephone interview was conducted with the former provider, Nurse Practitioner #1, who was employed when the IV fluids were ordered on 7/26/22. She indicated the nurse on duty on 7/27/22 should have notified her immediately when she could not gain IV access for Resident #111 to get further instructions. Nurse Practitioner #1 explained she did not believe that this caused Resident #111 to be hospitalized that day but the nurse failing to notify was an issue due to her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . At that time the decision was made to send Resident #111 to the emergency room for further evaluation and treatment. An interview with the Medical Director was unsuccessful. On 9/16/22 at 11:30 am during an interview with Administrator #1 she revealed she expected nurses to notify the provider when there were difficulties following physician orders.

Based on observations, record review and interviews of staff, contracted Respiratory Therapist, and Medical Director, the facility failed to train nursing staff and verify competency to provide for and to meet the respiratory care needs for 1 of 1 resident reviewed for [CONDITION(S)] care. Resident #46 required 5 trips to the Emergency Department (ED) over a two and a half week period of time to clear her airway and treat [CONDITION(S)] as a result of staff not maintaining a clear airway from tracheal secretions. Immediate jeopardy began on 8/26/22 when the failure to train and verify competence of nursing staff resulted in the necessary [CONDITION(S)] care not being provided and Resident #46 had to be sent to the ED for tracheal tube obstruction, large amounts of secretions, and loss of her [CONDITION(S)] tube. Immediate jeopardy was removed on 9/17/22 when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of an E which is no actual harm with potential for more than minimal harm that is not immediate jeopardy to complete staff education and ensure monitoring systems put in place are effective. Findings included: Resident #46 was admitted to the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #46's admission Minimum Data Set (MDS) dated [DATE] documented the resident had an intact cognition and no refusal of care. Treatments included [CONDITION(S)] care and suctioning. Resident #46's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] - [CONDITION(S)] care every shift and as needed. Clean or change the inner cannula as applicable. Specify inner cannula size 6. - Suction excess secretions as needed On 9/13/22 at 3:15 pm an interview was conducted with the Medical Director (MD). The MD clarified his order for [CONDITION(S)] care each shift meant every twelve hours (nursing had 12 hours shifts) and included suctioning the resident at least once a shift, but this was not how the order was written on 7/12/22. On 9/13/22 at 3:15 pm an interview was conducted with Unit Supervisor #1. She stated she was not aware the physician expected nursing staff to suction Resident #46 each shift with the [CONDITION(S)] care. She stated she was aware there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that nursing staff were responsible for all respiratory care including the equipment, there was no Respiratory Therapist. a. On 8/26/22, a nurse's note was documented by Nurse #6. Resident #46 had a change of condition due to an obstructed [CONDITION(S)] tube. The resident's oxygen level was 95% out of 100%, pulse was 80, and respirations were 19. The Nurse Practitioner (NP) was called and gave orders to send the resident to the ED. The Emergency Department (ED) record dated 8/26/22 documented Resident #46 was seen for tracheal tube obstruction. The facility informed the ED that they were unable to suction the resident. No inner cannula was in place from the facility, and one was placed in the ED. The Respiratory Therapist (RT) was unable to pass a suction catheter because of secretions and mucous accumulation and hardening causing a partial obstruction. The ear nose and throat (ENT) physician changed the [CONDITION(S)] tube. The resident was observed for two- and one-half hours and returned to the facility. On 9/14/22 at 11:40 an interview was conducted with Nurse #6. She stated, I was assigned to Resident #46 on 8/26/22. I was not able to pass the suction catheter and suction the resident. She said she typically suctioned when she completed [CONDITION(S)] care. Nurse #6 stated she did not listen to the resident's lungs. She reported that she participated in a [CONDITION(S)] in-service when Resident #46 was first admitted . Nurse #6 stated this was her first [CONDITION(S)] care resident. b. On 8/30/22 a nurse's note was documented and indicated Resident #46 coughed, and her [CONDITION(S)] tube came out (it was not noted if the inner cannula was in place). All efforts to replace the [CONDITION(S)] by staff were not successful. Emergency Medical Services (EMS) were contacted, and the resident was taken to the emergency room . The ED note dated 8/30/22 documented Resident #46 was seen and diagnosed with [CONDITION(S)] tube change and aspiration pneumonia of the left lung. The resident required suctioning by the RT and the cough improved. Antibiotics were ordered. The resident was suctioned, [CONDITION(S)] tube was changed, and she returned to the facility. The resident maintained her oxygen level with use of oxygen while in the ED. On 9/16/22 at 12:30 pm an interview was conducted with the facility contracted Respiratory Therapist (RT) hired on 9/16/22. She stated that nursing should not replace a [CONDITION(S)] tube because they were not trained to properly perform this. She stated that EMS should be called. She stated that the resident should be suctioned as needed to clear the rhonchi and cough. Cough can contribute to loss of the [CONDITION(S)] tube. She stated repeated loss of a [CONDITION(S)] tube was not usual. c. The ED note dated 9/4/22 documented Resident #46 was seen for dried secretions and [CONDITION(S)] change due to secretion accumulation. The inner cannula was not present when the resident arrived at the ED and the Ear Nose and Throat (ENT) Physician recommended the resident have a disposable inner cannula in place at all times to prevent crust and secretion accumulation. The resident was suctioned of a large amount of secretions. The resident reported to the ED Staff the [CONDITION(S)] was dislodged due to coughing secretions and she was feeling short of breath. The resident had increased work of breathing and oxygen was provided at the ED until the tube was changed. There was no corresponding nurse's note for the 9/4/22 ED evaluation. d. On 9/9/22 Nurse #1 documented a nurse's note. Resident #46 came out into the hall with her [CONDITION(S)] in her hand. She had coughed the [CONDITION(S)] out and staff was unable to replace. The resident was sent to the ED. No oxygen level was documented in this nurse's note. Resident #46's ED documentation dated 9/9/22 indicated ENT had inserted a size 4 (smaller) [CONDITION(S)] cannula in place of the size 6 [CONDITION(S)] cannula that was dislodged due to coughing and lodged secretions. The resident received oxygen to increase her oxygen level from 90% to 98%. The ED physician was unable to place a size 6. The facility reported to ED staff they were unable to suction the resident at the facility due to thick, dry secretions. The hospital documented discharge instructions to change the inner cannula every 12 hours and to suction the [CONDITION(S)] every 4 hours to prevent clogging. An order was provided to follow up with ENT to be evaluated to have a surgical procedure to enlarge the [CONDITION(S)] again. Nurse #1 was not available for interview. e. Resident #46's nurse's note dated 9/12/22 documented that the resident complained about not being able to breathe. The resident was suctioned a few times. Oxygen reading was 88% out of 100% and heart rate was 133. The Nurse Practitioner was called and provided an order to send the resident out to the ED. Resident #46's ED note dated 9/12/22 documented the resident was unable to breathe due to secretions. The resident had secretions that the facility, reportedly, was not able to suction and clear without significant relief. EMS documented resident was hypoxic (low in oxygen) in the high 80s oxygen reading (out of 100). The resident had increased work of breathing. with oxygen saturation of 90% on room air. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Coarse rhonchi were cleared after suctioning. The oxygen saturation was 96% on room air after suctioning. The chest x-ray had no acute findings. The resident was stable for discharge back to the facility. On 9/14/22 at 5:50 am an observation was done of Resident #46. She was sleeping in her bed with the head of the bed elevated approximately 30 degrees. The resident's [CONDITION(S)] dressing was clean and dry. Her mist collar (provides humidification to the [CONDITION(S)]) was in place but was dry and not misting. On 9/14/22 at 5:40 am an interview with Nurse #3. She stated she worked here 2 months and was agency staff. She indicated she had worked with Resident #46 and provided [CONDITION(S)] care that included suctioning but had not been provided education for [CONDITION(S)] care and/or suctioning by the facility. She stated she had a concern that the mist collar was not moist this shift, it appeared dry. There was no mist observed. On 9/14/22 at 8:10 am an observation was conducted of Resident #46 with assigned Nurse #4. The resident was ambulating in her room and not wearing the mist collar. The collar was sitting on the humidification device, and it was not misting. The resident coughed and rhonchi were audible, and she was holding her [CONDITION(S)] in place. Interview with Resident #4, she stated the mist collar was dry. Nurse #4 was concurrently interviewed and stated she was not aware the mist collar was not working. Nurse #4 stated she did not know how to correct the mist/humidification device. On 9/16/22 at 12:30 pm an interview was conducted with the facility contracted Respiratory Therapist hired on 9/16/22. She stated that the [CONDITION(S)] collar mist device was not properly set up and was not misting as intended for an unknown period. Secretions can become dry and occlude when humidification was not provided. Occlusion can cause [CONDITION(S)] and an inability to pass the suction catheter. On 9/13/22 at 10:00 am an interview was conducted with Nurse #2. Nurse #2 stated she had not received in-service for [CONDITION(S)] care and was assigned to a resident with a [CONDITION(S)]. On 9/13/22 at 3:30 pm an interview was conducted with the Medical Director (MD). The MD stated that he was not aware Resident #46 was seen in the Emergency Department (ED) 5 times in the last 3 weeks due to a mucous-plugged or loss of her [CONDITION(S)] tube. The staff had called the Nurse Practitioner and she had addressed the concerns by sending the resident to the ED. A stable [CONDITION(S)] would not need to be sent to the ED for this frequency. The MD stated Resident #46's [CONDITION(S)] was no longer stable. The Medical Director revealed when Resident #46 was admitted to the facility with a [CONDITION(S)] he had concerns that nursing would not be capable to manage the resident's [CONDITION(S)]. There was currently 70% agency nursing staff that he was not sure could manage or was trained in [CONDITION(S)] care. The Medical Director stated he informed the facility they could not take another [CONDITION(S)] resident. The Medical Director stated he had a discussion with corporate staff and administration that there were concerns with nurse staffing and care provided. The Administrator was notified of immediate jeopardy on 9/16/22. The facility provided a credible allegation of immediate jeopardy removal. 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 document the resident's tracheal suctioning frequency, how the resident tolerated suctioning, and what was retrieved. The facility failed to provide adequate training to staff, including agency staff and hires including: [CONDITION(S)] care, including suctioning, respiratory assessment, and steps to take when a resident requires additional suctioning or is hypoxic. 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; Resident #46 was assessed by the Director of Nursing (DON) on 9/15/22 and was noted as stable with [CONDITION(S)] care and suctioning. New orders were implemented between 9/13- 9/14/22 to include suctioning every four hours, and [CONDITION(S)] care every 12 hours and as needed. The DON verified the new orders were being implemented on the specific frequency, the new orders were validated to be present on the TAR for the ordered frequency, and the DON verified the respiratory equipment was functioning as intended. The care plan was updated on 9/16/22 to include every aspect of [CONDITION(S)] care, suctioning, and respiratory assessment. A contracted respiratory therapist evaluated resident #46 on 9/16/22 and orders were updated as needed, to include suctioning documentation related to amount, consistency, color and odor. No other current patients are receiving [CONDITION(S)] care at the center. In the event there is a concern during ordered [CONDITION(S)] care, the staff member cannot effectively suction a resident's [CONDITION(S)] care, and/or the [CONDITION(S)] tube become dislodged, the physician will be notified for follow-up, and this will be documented in the medical record for shift reporting, and for nursing administration during the 24-hour review. Current nursing leadership to include DON, Assistant Director of Nursing (ADON) Staff Development Coordinator (SDC) and all nurse leadership received education on 9/16/22 by a contracted registered respiratory therapist (RTT), respiratory care practitioner (RCP), contracted on 9/16/22, according to professional standards of [CONDITION(S)] care. Training with return demonstration included: [CONDITION(S)] care, tracheal suctioning, how to manage a dislodged tracheal tube, and documentation of care provided. In turn, nurse leadership (DON, ADON SDC) provided full time, part time, as needed, and contracted nursing staff (agency) the same education with return demonstration on 9/16/22. Any staff assigned to a [CONDITION(S)] patient will receive this education prior to the beginning of their shift, if not available on 9/16/22. This education with return demonstration will be added to all future orientations and as needed when [CONDITION(S)] patients are admitted . The individual responsible for this education is a registered respiratory therapist (RTT), respiratory care practitioner (RCP). The contracted RTT, RCP will be here weekly to monitor the [CONDITION(S)] patient, with monthly visits to review [CONDITION(S)]/[CONDITION(S)] patients. She will also be available as needed to address any issues related to respiratory care needs. Alleged date of immediate jeopardy removal is 9/17/22. Person responsible for implementation is the Administrator. The credible allegation of immediate jeopardy removal was verified on 9/19/22 by onsite validation. On 9/19/22 at 1:15 pm an observation was done of nursing education and return demonstration for respiratory care/[CONDITION(S)] suctioning of Nurse #14 and Unit Supervisor #1 according to the credible allegation requirements. The nursing in-service signed roster was reviewed. The skills check list had all required components for [CONDITION(S)] care and suctioning. The list was reviewed by the contracted Respiratory Therapist. A Respiratory Therapist (RT) was contracted on 9/16/22 to oversee all respiratory care, education, and equipment. The RT completed education and return demonstration of all nursing management on 9/16/22. The facility's immediate jeopardy removal date was determined to be 9/17/21 based on the validation.

Based on record review, staff interviews, family interview, pharmacist interview, and physician interviews, the facility failed to provide prescribed antiseizure medication for 1 of 10 residents (Resident #140) reviewed for medication errors. Resident #140 did not receive prescribed [MEDICATION(S)] (antiseizure medication) from 6/26/22 - 7/10/22 and from 7/14/22 - 7/21/22. This resulted in the resident not receiving 45 doses of antiseizure medication. Immediate jeopardy began on 6/26/22 when the facility failed to obtain Resident #140's antiseizure medication. Immediate jeopardy was removed on 9/17/22 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of E no actual harm with potential for more than minimal harm that is not immediate jeopardy to ensure monitoring systems and staff education put in place are effective. The findings included: Resident #140 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #140's care plan, created 11/3/21 and revised on 1/20/22, revealed a focus area for seizures. Interventions included provided medications as ordered. The annual minimum data set (MDS) dated [DATE] revealed Resident #140 was moderately cognitively impaired. Resident #140 had an order dated 5/25/22 to give [MEDICATION(S)] (antiseizure medication) delayed release 500 milligrams (MG). He received two tablets by mouth every 12 hours for seizures. Resident #140 was initially ordered [MEDICATION(S)] on 10/12/20. The order dated 5/27/22 revealed [MEDICATION(S)] 200 MG give one tablet by mouth two times a day for seizures, controlled substance. A progress note by Nurse Practitioner (NP) #2 dated 6/7/22 indicated Resident #140 was seen for an assessment. It was noted Resident #140 had seizures and was managed on [MEDICATION(S)] and [MEDICATION(S)] (antiseizure medications). No [CONDITION(S)] activity was documented or reported by the resident. A nurse progress note written by Director of Nursing (DON) #2 dated 6/24/22 at 2:06 PM indicated there was a follow up with the neurologist's office for a replacement medication for [MEDICATION(S)]. The neurologist office sent a new prescription on 6/24 after speaking with the facility nurse. The pharmacy received the prescription (unreadable) on 6/25/22. Review of controlled substance records revealed nurses administered [MEDICATION(S)] to Resident #140 until 6/26/22 when the medication became unavailable. The resident did not receive prescribed [MEDICATION(S)] from 6/26/22 - 7/9/22 or from 7/14/22 - 7/21/22. Resident #140 received [MEDICATION(S)] from 7/10/22 - 7/13/22 when a 3-day emergency supply had been authorized and dispensed to the facility by the pharmacy. An interview was conducted with Resident #140's family member on 9/12/22 at 11:40 AM. The family member stated they received a notification from the pharmacy stating [MEDICATION(S)] would no longer be on the formulary (a formulary was a list of medications that were available and provided by the pharmacy). The family member gave the information to Nurse #6 and did not hear back from the facility. At some point, the Neurologist faxed over a generic prescription to the facility, but the family member learned it was not covered by insurance either. The family member completed paperwork and was told Resident #140 did not qualify for the medication assistance program. The family member did not know how long the resident was without [MEDICATION(S)] but had documentation that showed the [MEDICATION(S)] was filled for a 3-day supply in July and again on 7/22/22. An interview was conducted with Nurse #10 on 9/13/22 at 10:52 AM. She stated resident #140 went without his [MEDICATION(S)] for awhile. Nurse #10 did not know exactly how long the resident was without the medication. She indicated, in June 2022, Nurse #6 informed her there was a pharmacy and insurance issue with Resident #140's [MEDICATION(S)]. During an interview with Nurse #6 on 9/14/22 at 10:35 AM, she stated Resident #140 did not receive his [MEDICATION(S)] in June 2022 after the pharmacy could not refill it due to issues with insurance coverage. The NP was notified by Nurse #6 and requested staff contact the neurologist. Nurse #6 indicated she did not contact the neurologist and an unknown nurse had called the neurology office. Nurse #6 explained Resident #140 did not receive [MEDICATION(S)] during June 2022 and July 2022. No medications were prescribed in the place of [MEDICATION(S)]. Resident #140 had received [MEDICATION(S)] since 10/2020. An interview was conducted with NP #1 on 9/14/22 at 10:45 AM. NP #1 stated she was notified in June 2022 that Resident #140's [MEDICATION(S)] was not available. NP #1 discussed the issue in a meeting with Administrator #2, the DON at the time, and the unit managers. NP #1 informed the staff Resident #140 could not go without [MEDICATION(S)] and could end up in the hospital. Administrator #2 assured NP #1 the medication would be obtained, and the facility could cover the cost if needed. NP #1 understood the medication would be provided and was unaware the [MEDICATION(S)] continued to not be administered. During an interview with Pharmacist #1 on 9/14/22 at 11:03 AM, she stated there were no insurance coverage issues or prior authorization requests for Resident #140's [MEDICATION(S)]. The dispensing history was as follows: On 6/25/22, the pharmacy received a fax from the facility that was unreadable. The pharmacist at the time spoke with a nurse aide (name unknown) at the facility. The nurse aide told the pharmacist they would have the nurse fax over the prescription. No refax was obtained. On 7/9/22 a verbal authorization was received for an emergency 3-day supply of [MEDICATION(S)] for Resident #140, and it was dispensed. On 7/22/22, a new prescription was received for [MEDICATION(S)], and it was dispensed. An interview was conducted with former Administrator #2 on 9/14/22 at 11:17 AM. She did not recall Resident #140, the medication, or being notified the resident's [MEDICATION(S)] was not available. During an interview with the Regional Director of Clinical Services #1 on 9/14/22 at 1:00 PM, she stated nurses should call the physician for further orders when a medication was not available in the medication backup system. An interview was conducted with Physician #1 on 9/15/22 at 10:19 AM. Physician #1 stated he was not aware Resident #140 did not receive [MEDICATION(S)]. He indicated not receiving a medication such as [MEDICATION(S)] was a very serious problem, and the resident could have had seizures that he wouldn't have otherwise. Resident #140 was on [MEDICATION(S)] and [MEDICATION(S)] was ordered to stop recurrent seizures that were not maintained on [MEDICATION(S)] alone. Physician #1 stated residents should receive medications as ordered and without delay. He considered missing [MEDICATION(S)] a significant medication error and indicated abruptly stopping the medication could result in withdrawals. During an interview with NP #2 on 9/16/22 at 9:41 AM, she stated in June 2022 Nurse #6 informed her Resident #140's [MEDICATION(S)] was not available. NP #2 explained she was told there was an issue with insurance and the medication would not be covered. The NP further indicated Resident #140 needed the [MEDICATION(S)] but was on [MEDICATION(S)] while the [MEDICATION(S)] was not available. NP #2 believed Nurse #6 spoke with the neurologist, but the neurologist did not order a substitute medication. NP #2 explained Resident #140 did not have any reported seizures or withdrawal symptoms while he was without [MEDICATION(S)]. During an interview with DON #1 on 9/16/22 at 10:45 AM, she indicated she was not working at the facility at the time the [MEDICATION(S)] was not provided to Resident #140. The DON stated [MEDICATION(S)] was not available in the medication backup system during June and July. There was not a way for [MEDICATION(S)] to be obtained for Resident #140 until it was dispensed by the pharmacy. A follow up interview was conducted with NP #2 on 9/16/22 at 12:07 PM. NP #2 clarified she was made aware Resident #140 did not have his [MEDICATION(S)] in June 2022. She was not aware of the 3-day supply that was obtained in July 2022 and was not aware the resident was again without the medication after the 3-day supply ran out. NP #2 stated it took a week initially in June to contact the neurologist office regarding Resident #140's [MEDICATION(S)]. NP #2 was not aware the resident began receiving [MEDICATION(S)] in July 2022 as prescribed until she followed up with the nurse. An interview was conducted with the Neurologist on 9/16/22 at 12:37 PM. She stated Nurse #6 notified the office that insurance would not cover [MEDICATION(S)] for Resident #140. On 6/24/22, the nurse requested an alternate medication. A prescription for the generic form of [MEDICATION(S)] was sent to the facility. The office nurse provided the facility with information regarding a patient medication assistance program. The Neurologist indicated the resident had been on [MEDICATION(S)] since being admitted to the facility 10/2020. [MEDICATION(S)] had been added to Resident #140's [MEDICATION(S)] because he continued to have seizures while just being on [MEDICATION(S)]. The neurologist explained it was not ideal for Resident #140 to only be on [MEDICATION(S)]. She explained antiseizure medications should not be stopped abruptly or substituted with a different medication as seizures could occur. She was not aware of how long Resident #140 was without [MEDICATION(S)]. In July 2022, the resident's family member spoke with the office nurse and reported Resident #140 had not been receiving [MEDICATION(S)] at the facility. The Administrator and Nurse Consultant were verbally notified of Immediate Jeopardy for F760 on 9/15/22 at 2:09 PM. The facility provided a credible allegation of Immediate Jeopardy removal with a removal date of 9/17/22: Removal Plan F760 1. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance [MEDICATION(S)] was not administered as ordered on 6/26/22 - 7/10/22 and from 7/14/22 - 7/21/22. The medication was ultimately made available via generic medication order/ insurance authorization and after 7/21/22, the patient has received the medication. The MD and one NP indicated [MEDICATION(S)] was a medication Resident #140 should not go without and he could have a [CONDITION(S)], end up in the hospital, and/or sustain serious harm as a result of a [CONDITION(S)]. There was no harm or adverse effect on Resident #140. Resident was receiving other ordered [CONDITION(S)] medications during the missed administrations of the [MEDICATION(S)]. 2. 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; The Assistant Director of Nursing (ADON) reviewed MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . No other anti-[CONDITION(S)] medications were unavailable. Education will be provided by 9/16/22 by the Director of Nursing, Staff Development Coordinator, or designee to all full time, part time, as needed, and contracted nursing staff (if applicable) on proper notification to providers, including Physician and NP, when a medication is unavailable. Staff not working on 9/16/22 will receive education prior to the start of their shift after 9/16/22. The protocol would include, but not limited to the following: 1. receive clarification for a medication hold order, and/or 2. request alternative orders while original order is being processed or provided by pharmacy or while insurance authorization is being obtained. 3. Follow-up with the pharmacy to understand the cause of medication unavailability with immediate resolution. 4. Follow-up to internal provider (MD or NP) if specialist office is not available immediately for follow-up orders. Alleged date of IJ removal is September 17th 2022. Person responsible for implementation is the administrator. The credible allegation was validated on 9/16/22 when staff interviews revealed that they had received recent education on processes when medications were unavailable, pharmacy notifications, addressing issues with insurance, when to have an authorization form completed, contacting the physician and nurse practitioner when medications were unavailable, and obtaining orders for medication substitutes when applicable. Facility documentation revealed staff were educated on issues related to medication availability. Review of the audit performed by the facility revealed all residents had their antiseizure medication available on the medication carts and the order listing report was used to verify this information. Date of IJ removal 9/17/22

Based on observation, record review and interview of the staff, physician, Respiratory Therapist, and resident, the facility failed to provide necessary respiratory care and services that met the need for Resident #46 to maintain a clear airway from tracheal secretions and frequent coughing which resulted in five trips in a two- and one-half week period of time to the Emergency Department (ED) to clear her airway and treat [CONDITION(S)]. The facility failed to seek medical attention for Resident #505 when he complained of shortness of breath earlier in the night which resulted in low oxygen of 50% (out of 100%) by early morning. Emergency medical services were required, and a non-rebreather oxygen mask (high level oxygen flow) was needed and treatment at the Emergency Department. Resident #505 was also sent to an outside cardiology appointment without oxygen and was in respiratory distress for 2 of 2 residents reviewed for respiratory care. Immediate jeopardy began on [DATE] for Resident #46 when staff had not provided the necessary respiratory care and services and the resident had to be sent to the ED for tracheal tube obstruction, large amounts of secretions, and loss of her [CONDITION(S)] tube. Immediate jeopardy began on [DATE] for Resident #505 when staff failed to seek medical attending when he complained of shortness of breath which began early in the night, was not addressed, and became acute by morning. Immediate jeopardy was removed on [DATE] when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of an E which is no actual harm with potential for more than minimal harm that is not immediate jeopardy to ensure continued staff education and monitoring. Findings included: 1. A review of Resident #46 ' s record documented she was admitted to the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was admitted to the facility for [CONDITION(S)] tube management. She was able to ambulate on room air with the [CONDITION(S)] tube in place during the day and required oxygen at night. Resident #46 ' s care plan dated [DATE] documented a focus for [CONDITION(S)] care and the interventions were an oxygen setting at 2 liters per minute and suction as necessary. Resident #46 ' s admission Minimum Data Set (MDS) dated [DATE] documented the resident had an intact cognition and no refusal of care. Resident #46 had multiple active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Treatments included oxygen therapy and [CONDITION(S)] care and suctioning. Resident #46 ' s physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Dated [DATE] humified oxygen 2 liters to the [CONDITION(S)]. Dated [DATE] monitor the oxygen saturation every day and night shift. Dated [DATE] suction excess secretions as needed. Dated [DATE] [CONDITION(S)] care every shift and as needed. Clean or change the inner cannula as applicable. Specify inner cannula size 6. Review of Resident #46 ' s Treatment Administration Record (TAR) documented the following for [CONDITION(S)] care: There were no nursing initials for year 2022 dates ,d+[DATE], ,d+[DATE]-14, ,d+[DATE]-31 day shift. There were no nursing initials for year 2022 dates ,d+[DATE]-5, ,d+[DATE] and 10, ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE]-23-, ,d+[DATE], and ,d+[DATE] night shift. There were no nursing initials for year 2022 dates ,d+[DATE], ,d+[DATE] - ,d+[DATE] dayshift. There were no nursing initials for year 2022 dates ,d+[DATE] night shift. On [DATE] at 3:15 pm an interview was conducted with the Medical Director (MD) The MD clarified his order for [CONDITION(S)] care each shift meant every twelve hours (nursing had 12 hours shifts) and included suctioning the resident at least once a shift, but this is not how the order was written on [DATE]. It also was not described that way in the policy. There was also an order [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE] at 3:15 pm an interview was conducted with Unit Supervisor #1. She stated she was not aware the physician expected nursing staff to suction Resident #46 each shift with the [CONDITION(S)] care. She stated she was aware there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that nursing staff were responsible for all respiratory care including the equipment, there was no Respiratory Therapist. Review of Resident #46 ' s TAR documented the following for suction [CONDITION(S)] as needed. No nursing initials for the month of August and [DATE] - 13, 2022. On [DATE] at 9:15 an interview was conducted with Unit Supervisor #1. She reviewed the treatment record for Resident #46 and was not aware there was no nursing initials for [CONDITION(S)] care documented and would identify the nursing staff for interview. On [DATE], a nurse ' s note was documented by Nurse #6. Resident #46 had a change of condition due to an obstructed [CONDITION(S)] tube. The resident ' s oxygen level was 95% out of 100%, pulse was 80, and respirations were 19. The Nurse Practitioner (NP) was called and gave orders to send the resident to the ED. The TAR for [DATE] was not initialed for as needed suctioning. On [DATE] at 11:40 an interview was conducted with Nurse #6. She stated, I was assigned to Resident #46 on [DATE]. I was not able to pass the suction catheter and suction the resident. She said she typically suctioned when she completed [CONDITION(S)] care. She stated, I do not document the suctioning. I initial the [CONDITION(S)] care order on the Treatment Administration Record. Nurse #6 stated that she participated in a [CONDITION(S)] in-service when Resident #46 was first admitted . Nurse #6 stated she did not listen to the resident ' s lungs. Nurse #6 stated this was her first [CONDITION(S)] care resident. The Emergency Department (ED) record dated [DATE] documented Resident #46 was seen for tracheal tube obstruction. The facility informed the ED that they were unable to suction the resident. No inner cannula was in place from the facility, and one was placed in the ED. The Respiratory Therapist (RT) was unable to pass a suction catheter because of secretions and mucous accumulation and hardening causing a partial obstruction. The ear nose and throat (ENT) physician changed the [CONDITION(S)] tube. The resident was observed for two- and one-half hours and returned to the facility. On [DATE] at 12:30 pm an interview was conducted with the facility contracted Respiratory Therapist (RT) hired on [DATE]. She stated that the [CONDITION(S)] collar mist device (provides humidification to the [CONDITION(S)]) was not properly set up and was not misting as intended for an unknown period. Secretions can become dry and occlude when humidification was not provided. Occlusion can cause [CONDITION(S)] and an inability to pass the suction catheter. On [DATE] a nurses ' note was documented Resident #46 coughed, and her [CONDITION(S)] tube came out (it was not noted if the inner cannula was in place). All efforts to replace the [CONDITION(S)] by staff were not successful. Emergency Medical Services (EMS) were contacted, and the resident was taken to the emergency room . On [DATE] at 12:30 pm an interview was conducted with the facility contracted Respiratory Therapist (RT) hired on [DATE]. She stated that nursing should not replace a [CONDITION(S)] tube because they were not trained to properly perform this. She stated that EMS should be called. She stated that the resident should be suctioned as needed to clear the rhonchi and cough. Cough can contribute to loss of the [CONDITION(S)] tube. She stated repeated loss of a [CONDITION(S)] tube was not usual. Resident #46 ' s Treatment Administration Record had no documentation that she had [CONDITION(S)] care on [DATE] through [DATE] day shift and ,d+[DATE] night shift. There was no documentation that she had [CONDITION(S)] suctioning as needed for all of [DATE]. The ED note dated [DATE] documented Resident #46 was seen and diagnosed with [CONDITION(S)] tube change and aspiration pneumonia of the left lung. The resident required suctioning by the RT and the cough improved. Antibiotics were ordered. The resident was suctioned, [CONDITION(S)] tube was changed, and she returned to the facility. The resident maintained her oxygen level with use of oxygen while in the ED. Resident #46 had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #46 had no nurses ' note documented for the ED visit of [DATE]. The ED note dated [DATE] documented Resident #46 was seen for dried secretions and [CONDITION(S)] change due to secretion accumulation. The inner cannula was not present when the resident arrived at the ED and the Ear Nose and Throat (ENT) Physician recommended the resident have a disposable inner cannula in place at all times to prevent crust and secretion accumulation. The resident was suctioned of a large amount of secretions. The resident reported to the ED Staff the [CONDITION(S)] was dislodged due to coughing secretions and she was feeling short of breath. The resident had increased work of breathing and oxygen was provided at the ED until the tube was changed. On [DATE] Nurse #1 documented a nurses ' note. Resident #46 came out into the hall with her [CONDITION(S)] in her hand. She had coughed the [CONDITION(S)] out and staff was unable to replace. The resident was sent to the ED. No oxygen level was documented in this nurses ' note. Nurse #1 was not available for interview. Resident #46 ' s ED documentation dated [DATE] indicated ENT had inserted a size 4 (smaller) [CONDITION(S)] cannula in place of the size 6 [CONDITION(S)] cannula that was dislodged due to coughing and lodged secretions. The resident received oxygen to increase her oxygen level from 90% to 98%. The ED physician was unable to place a size 6. The facility reported to ED staff they were unable to suction the resident at the facility due to thick, dry secretions. The hospital documented discharge instructions to change the inner cannula every 12 hours and to suction the [CONDITION(S)] every 4 hours to prevent clogging. An order was provided to follow up with ENT to be evaluated to have a surgical procedure to enlarge the [CONDITION(S)] again. Review of Resident #46 ' s record did not reveal a new order for suction every 4 hours and to keep the inner cannula in place after the [DATE] ED visit. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #46 ' s record revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 12:30 pm an interview was conducted with Unit Supervisor #1. She stated that the facility was not aware that Resident #46 had an ED discharge order dated [DATE] to suction every 4 hours. The facility had received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #46 ' s nurses ' note dated [DATE] documented that the resident complained about not being able to breathe. The resident was suctioned a few times. There was no documentation of what was obtained. Oxygen reading was 88% out of 100% and heart rate was 133. The Nurse Practitioner was called and provided an order to send the resident out to the ED. Resident #46 ' s ED note dated [DATE] documented the resident was unable to breathe due to secretions. The resident had secretions that the facility, reportedly, was not able to suction and clear without significant relief. EMS documented resident was hypoxic (low in oxygen) in the high 80s oxygen reading (out of 100). The resident had increased work of breathing. with oxygen saturation of 90% on room air. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Coarse rhonchi were cleared after suctioning. The oxygen saturation was 96% on room air after suctioning. The chest x-ray had no acute findings. The resident was stable for discharge back to the facility. On [DATE] at 10:00 am an interview was conducted with Nurse #2. Nurse #2 stated she completed [CONDITION(S)] care and asked the resident if she wanted to be suctioned and she said, No. On [DATE] at 11:50 am an interview was conducted with Resident #46. The resident nodded no to whether she was suctioned with her [CONDITION(S)] care this morning and nodded no that she had not refused. On [DATE] at 11:55 an interview was conducted with Nurse #2. She stated she was assigned to the resident on [DATE]. She reviewed the resident ' s electronic chart to confirm the resident had [CONDITION(S)] care each 12-hour shift and was suctioned as needed (the new order for every 4 hours had not been entered yet). She stated she only suctioned the resident when the resident requested to be suctioned. She stated she does not document the suctioning other than placing her initials on the Treatment Administration Record for [CONDITION(S)] care. If there were no initials on the TAR, then suctioning was not completed or needed. She does not document what was obtained, if the inner cannula was cleaned or changed, and how the resident tolerated the procedure. She stated she was not aware that the resident's oxygen concentrator was set to 5 liters this morning at 9:00 am when the resident was sleeping. She stated she provided [CONDITION(S)] care earlier in the morning. She stated the night shift nurses set the concentrator setting when the resident goes to bed. The resident usually had not used oxygen when she was up, only while sleeping. She stated she was not familiar with the resident's oxygen order for her humidified [CONDITION(S)] collar. She stated she was not aware the hospital had sent the discharge instructions to suction the resident every 4 hours and to change the inner cannula every 12 hours. On [DATE] at 3:20 pm an observation was done of Resident #46 in the therapy room. The resident had an audible rhonchi (gurgling of mucous) when breathing. The resident was interviewed. The resident nodded, yes, that she would have a suctioning and needed to be suctioned. The resident nodded no that she had not refused suction today. On [DATE] at 3:30 pm an interview was conducted with the Medical Director (MD). The MD stated that he was not aware Resident #46 was seen in the Emergency Department (ED) 4 times in the last 3 weeks due to a mucous-plugged or loss of her [CONDITION(S)] tube. The staff had called the Nurse Practitioner and she had addressed the concerns by sending the resident to the ED. A stable [CONDITION(S)] would not need to be sent to the ED for this frequency. The MD stated Resident #46's [CONDITION(S)] was no longer stable. The MD was not aware the hospital sent discharge instructions for Resident #46 for nursing to change the [CONDITION(S)] inner cannula every 12 hours and to suction every 4 hours after the third trip to the ED. The MD stated he had a discussion with corporate staff and administration that there were concerns with nurse staffing and care provided. Resident #46 ' s physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] [DATE] [CONDITION(S)] care every 12 hours and as needed. Change inner cannula as applicable (size at the time of care). Specify inner cannula size 4. [DATE] suction resident every 4 hours at 12 am, 4 am, 8 am, 12 pm, 4 pm, and 8 pm. [DATE] oxygen 2 liters per minute via [CONDITION(S)] collar when sleeping. On [DATE] at 3:50 pm an interview was conducted with Resident #46. Nursing staff was ready to suction the resident and she asked about the suctioning and was informed that the physician had a concern about the secretions and would like for the resident to be suctioned at least once a shift (12 hours). The resident agreed to be suctioned. (The timeframe was before the facility followed up on the new order suction every 4 hours which was missed on [DATE].) On [DATE] at 5:50 am an observation was done of Resident #46. She was sleeping in her bed with the head of the bed elevated approximately 30 degrees. The resident's [CONDITION(S)] dressing was clean and dry. Her mist collar was in place but was dry and not misting. The oxygen concentrator was set to 2 liters as ordered this observation. On [DATE] at 8:10 am an observation was done of Resident #46 with assigned Nurse #4. The resident was ambulating in her room and not wearing the mist collar. The collar was sitting on the humidification device, and it was not misting. The resident coughed and rhonchi were audible, and she was holding her [CONDITION(S)] in place. Interview with Resident #4, she stated the mist collar was dry. Nurse #4 was interviewed concurrently and stated she was not aware the mist collar was not working, and the resident had new orders to suction every 4 hours. On [DATE] at 9:15 am an interview was conducted with Unit Supervisor #1. Unit Supervisor #1 stated she was not informed or aware that Resident #46's humidification for the [CONDITION(S)] collar was not working. Unit Supervisor #1 stated nursing was responsible to check the respiratory equipment and inform her or management when there were issues. Unit Supervisor #1 stated she would call the vendor to check the resident's humidifier equipment. On [DATE] at 2:30 an interview was conducted with US #1. She stated that Resident #46 ' s misting device was turned off. The equipment was operating as intended when turned on. On [DATE] at 12:30 pm an interview was conducted with the facility contracted Respiratory Therapist (RT). The RT stated she checked the mist/humification on [DATE] for Resident #46 and it was not set up correctly and operating as intended. On [DATE] at 9:15 am an interview was conducted with the Corporate Nurse Consultant and Interim Administrator. The Corporate Nurse Consultant stated the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Corporate Nurse Consultant stated the [CONDITION(S)] care policy did not include [CONDITION(S)] suction as part of the care. Corporate Nurse Consultant stated there was an order to suction as needed. The Corporate Nurse Consultant and Administrator stated they were not aware there were no nurse initials signed for the months of [DATE] and [DATE] through 13 on the resident's TAR for [CONDITION(S)] suctioning. The Corporate Nurse Consultant and Administrator stated they were not aware there were no nurse initials signed on the TAR for [CONDITION(S)] care for several occasions both shifts during the month of [DATE] and [DATE] through 13, 2022 on occasions for both shifts. The Corporate Nurse Consultant and Administrator stated they were not aware of the hospital discharge summary order for the resident's inner [CONDITION(S)] cannula to be changed every shift and to suction the resident every 4 hours dated [DATE]. This was missed. The Corporate Nurse Consultant and Administrator stated they were not aware the Medical Director felt the hospital discharge instruction to increase suctioning to every 4 hours and a needed procedures to make the [CONDITION(S)] larger made the resident's [CONDITION(S)] unstable. A review of Resident #46 ' s ENT office visit dated [DATE] documented the resident was seen for a return visit (last visit date unknown). The resident had difficulty speaking due to [CONDITION(S)]. She had a copious amount of oral and pharynx (voice box) secretions. Her [CONDITION(S)] was well seated. There were no signs of infection. The [CONDITION(S)] was stable. There were two problems: (1) paralysis of the vocal cords and (2) a very high risk for aspiration. On [DATE] at 5:40 am an interview with Nurse #3. She stated she worked here 2 months and was agency staff. She provided Resident #46 [CONDITION(S)] care each shift when she worked which included suctioning. She reused the catheter which was stored in its original packaging on her shift and then discarded it. The facility had not provided education for [CONDITION(S)] care and/or suctioning. She stated the order just changed this shift to provide suctioning every 4 hours. She stated the resident needed frequent [CONDITION(S)] tube change, not just the inner cannula because she had a large amount of secretions that got stuck to the cannula. She stated she had a concern that the mist collar was not moist this shift, it appeared dry. There was no mist observed. She stated this concern was not reported to management. She stated she was not aware the resident had gone to the hospital on 4 occasions for a mucous plugged [CONDITION(S)] tube and/or tube dislodgement and was not aware that the resident's tracheotomy (opening) had gotten small and would require a surgical procedure to widen the opening. She stated there were replacement [CONDITION(S)] inner cannulas in the resident's bedside nightstand. B. Resident #46 ' s physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 9:58 am an observation was done of Resident #46. The resident was in her bed sleeping with the [CONDITION(S)] collar in place. The collar had a tube approximately 24 to 30 inches that was attached to a sterile water misting device for humidification. The [CONDITION(S)] had a velcro tie around the neck holding the [CONDITION(S)] in place. The oxygen concentrator at the bedside was set to 5 liters attached to the [CONDITION(S)] collar tubing. The [CONDITION(S)] site was clean and dry. Suction equipment was present. The resident ' s respirations were even and unlabored. On [DATE] at 10:00 am an interview was conducted with Nurse #2. Nurse #2 stated Resident #46 was known to ambulate with room air and the [CONDITION(S)] site can get dry. Nurse #2 stated she was not aware the oxygen concentrator was set to 5 liters and was unsure of the liter flow order. Nurse #2 stated she had not observed the oxygen liter flow this morning and would adjust the flow. C. On [DATE] at 3:55 pm an observation was done of Nurse #3 providing tracheal suction for Resident #46 with the Director of Nursing (DON). Nurse #3 put on sterile gloves and asked the resident to remove the cap to her inner cannula. The resident was not able to remove the cap and Nurse #3 removed the cap. The nurse used her sterile gloves to touch items on the bedside table. The nurse used the same gloves to touch the suction catheter. Nurse #3 suctioned the resident and passed the catheter approximately 2 to 3 inches with a catheter sterile fluid flush 4 times and obtained thick white secretions. Suctioning did not cause cough. Audible rhonchi were heard, and the resident coughed after the procedure. The resident nodded yes that she felt better. The resident appeared to tolerate the procedure without breathing harder or distress. There was no oxygen saturation check and/or respiratory assessment of the resident. After the procedure an interview was conducted with Nurse #2. Nurse #2 stated she was not aware she did not follow a sterile procedure by keeping her sterile glove sterile to handle the suction catheter. 2. Resident #505 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #505 ' s Minimum Data Set, dated dated dated [DATE] documented the resident ' s cognition was intact. Resident #505 had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A. Resident #505 ' s nurses' note dated [DATE] at 5:45 am documented the resident was noted to have oxygen saturation of 50% while on continuous positive airway pressure ([CONDITION(S)]). The resident was immediately placed on oxygen by nasal cannula at 8 liters to bring up his oxygen saturation while Emergency Medical Services (EMS) were dispatched and in route. The resident ' s oxygen saturation rose to 84% with no improvement. The note was written by Nurse #7. Resident #505 was not available for interview. The resident expired at the hospital months later. On [DATE] at 10:20 am an interview was conducted with Nurse #7. Nurse #7 stated she was assigned to Resident #505 night shift on [DATE] (morning of [DATE]). The resident complained he had been short of breath during the night, but his oxygen saturation was within normal limits during the night. The resident was placed on his [CONDITION(S)] to sleep. I cannot remember if the [CONDITION(S)] had an order to attach oxygen or if I attached oxygen. She stated another nurse informed her the resident was found in his room very short of breath. The resident was in distress but able to talk. I called for Emergency Medical Services and the resident was sent to the hospital. Nurse #7 stated the resident remained short of breath with oxygen by nasal cannula. Resident #505 ' s emergency department (ED) record dated [DATE] documented the resident informed the physician that he ran out of oxygen while in his room for about 45 minutes. The resident called for staff, but they did not respond. The resident was dependent on continuous oxygen. The resident was provided oxygen by a non-rebreather mask and recovered quickly and was weaned to nasal cannula. The resident returned to the facility the same day. B. A review of Resident #505 ' s facility record revealed he was sent to a cardiology appointment on [DATE]. A review of Resident #505 ' s cardiology office record dated [DATE] documented the resident arrived from the facility without oxygen in his tank and was in respiratory distress with an oxygen saturation of 80%. The resident was provided oxygen by nasal cannula and recovered. On [DATE] at 12:15 pm an interview was conducted with the nurse at Resident #505 ' s cardiology physician office. She stated the resident was brought from the facility to the office for an appointment on [DATE]. The oxygen tank that came from the facility was empty. The resident was in respiratory distress, cyanotic, and agitated. His oxygen level was 80%. She stated the resident reported this was not the first time he was without oxygen. The resident was provided 4 liters of oxygen by nasal cannula and recovered within 20 minutes. The resident cannot be without oxygen, he was dependent. On [DATE] at 10:40 am an interview was conducted with the Transportation Coordinator. The coordinator stated she remembered Resident #505 and that the van driver who was responsible to take the resident to his appointment left without an oxygen tank. A tank was sent to the cardiology office for the resident to return. On [DATE] at 2:40 pm an interview was conducted with the Interim Administrator and Corporate Nurse Consultant. The Interim Administrator stated she was not aware that Resident #505, oxygen dependent, was sent to an outside cardiology appointment without oxygen on one occasion and that the resident had respiratory distress. The Administrator was notified of immediate jeopardy on [DATE]. The facility provided a credible allegation of immediate jeopardy removal. Credible Allegation of Compliance F695 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 provide ordered respiratory care that met the need for Resident #46 to maintain a clear airway from tracheal secretions which resulted in [CONDITION(S)] and multiple trips to the emergency department to clear her airway. Per interview with resident, center staff did not respond to resident #505 ' s call for help early morning [DATE] due to shortness of breath for a reported 45 minutes which resulted in [CONDITION(S)] of 50% oxygen level. Resident stated he was not receiving oxygen; it had run out. Emergency medical services were required, and a non-rebreather oxygen mask (high level oxygen flow) was needed. For same resident, on [DATE] the facility did not provide a full oxygen tank for Resident #505 ' s cardiology appointment. When the resident arrived at the office, he was in respiratory distress and the oxygen tank was found to be empty. Upon notification to the center, the center took a replacement oxygen tank to the MD office. 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; Resident #46 was assessed by the Director of Nursing (DON) on [DATE] and was noted as stable with [CONDITION(S)] care and suctioning. New orders were implemented between ,d+[DATE]- [DATE] to include suctioning every four hours, and [CONDITION(S)] care every 12 hours and as needed. The DON verified the new orders were being implemented on the specific frequency, the new orders were validated to be present on the TAR for the ordered frequency, and the DON verified the respiratory equipment was functioning as intended. The care plan was updated on [DATE] to include every aspect of [CONDITION(S)] care, suctioning, and respiratory assessment. A contracted Respiratory Therapist evaluated resident #46 on [DATE] and orders were updated as needed, to include suctioning documentation related to amount, consistency, color and odor, and documented through/in the supplemental documentation attached to the treatment administration record. No current patients are receiving [CONDITION(S)] care at the center. In the event there is a concern during ordered [CONDITION(S)] care, the staff member cannot effectively suction a resident ' s [CONDITION(S)] care, and/or the [CONDITION(S)] tube become dislodged, the physician will be notified for follow-up, and this will be documented in the medical record for shift reporting, and for nursing administration during the 24-hour review. In the event of an [CONDITION(S)] tube becoming dislodged, nurse will use the beside ambu bag and/or replacement [CONDITION(S)] located at beside to aide in respirations. Resident # 505 discharged on [DATE]. Currently, there are five residents that are on either [CONDITION(S)] or [CONDITION(S)] therapies. Additionally, 26 patients are on oxygen therapy. Personalized care plans for residents with [CONDITION(S)], [CONDITION(S)] and oxygen therapies were developed for all residents with oxygen to include every aspect such as supplemental oxygen, transportation with oxygen, application of oxygen to a [CONDITION(S)]/[CONDITION(S)]. There were no new orders or recommendations by the Registered Respiratory Therapist, Respiratory Care Practitioner. (RTT, RCP) Current nursing leadership to include DON, Assistant Director of Nursing (ADON) Staff Development Coordinator (SDC) and all nurse leadership received education on [DATE] by the center respiratory therapist regarding [CONDITION(S)] care to include: [CONDITION(S)] care, frequency of suctioning, respiratory assessment and documentation of such care, to include return demonstration, as well as caring for patients with cpaps, bipaps, and oxygen while in center and preparing for external appointments. In turn, nurse leadership (DON, ADON SDC) provided full time, part time, as needed, and contracted nursing staff (agency) the same education with return demonstration on [DATE]. Any staff assigned to a [CONDITION(S)] patient or patient with oxygen therapies will receive this education prior to the beginning of their shift, if not available on [DATE]. This training will be added to the orientation program. The individual responsible for this education is a registered respiratory therapist (RTT), respiratory care practitioner (RCP). As a contracted RTT RCP, she will be here weekly to monitor the [CONDITION(S)] patient, with monthly visits to review [CONDITION(S)]/[CONDITION(S)] patients. She will also be available as needed to address any issues related to other respiratory care needs. Alleged date of IJ removal is [DATE]. Person responsible for implementation is the administrator

Based on record review, staff interviews, physician, nurse practitioner, respiratory therapist and Administrator interview the facility Administration failed to provide effective leadership and oversight of processes and policies and procedures to ensure an effective systems was in place. This impacted several residents including: Resident #46 where the facility failed to maintain a clear airway resulting in 5 trips to the Emergency Department. Resident #505 complained of respiratory distress at night with no medical attention provided. This resulted in requiring emergency medical services. Resident #505 was also sent to an outside appointment without oxygen resulting in respiratory distress. The facility failed to assure nursing staff were competent to provide necessary care to meet respiratory need for the residents including [CONDITION(S)]. Resident #140 did not receive the prescribed [MEDICATION(S)] (antiseizure medication). The physician or nurse practitioner (NP) were not notified when antiseizure medication remained unavailable for Resident #140. This failure resulted in 3 of 3 residents to have Immediate Jeopardy level deficiencies for respiratory, competent staff, medication errors, and notification. The facility's failure resulted in Resident # 46 having 5 hospital admissions in 2 and a half weeks, Resident #505 being sent to the hospital for hypoxemia, and Resident #140 missing 45 doses of an anti-[CONDITION(S)] medication which placed the resident at a high risk for [CONDITION(S)]. The facility administration failed to provide and maintain documentation of annual updates and review of the facility ' s Emergency Preparedness Plan. This failure had the potential to affect all staff and residents. Immediate jeopardy began on 6/26/22 when the facility when the residents didn't have effective systems in place to provide necessary care and services for the residents. Immediate jeopardy was removed on 9/17/22 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of E no actual harm with potential for more than minimal harm that is not immediate jeopardy to ensure monitoring systems and staff education put in place are effective. Findings include This is cross referenced to: F695 Based on observation, record review and interview of the staff, physician, Respiratory Therapist, and resident, the facility failed to provide necessary respiratory care and services that met the need for Resident #46 to maintain a clear airway from tracheal secretions and frequent coughing which resulted in five trips in a two- and one-half week period of time to the Emergency Department (ED) to clear her airway and treat [CONDITION(S)]. The facility failed to seek medical attention for Resident #505 when he complained of shortness of breath earlier in the night which resulted in low oxygen of 50% (out of 100%) by early morning. Emergency medical services were required, and a non-rebreather oxygen mask (high level oxygen flow) was needed and treatment at the Emergency Department. Resident #505 was also sent to an outside cardiology appointment without oxygen and was in respiratory distress for 2 of 2 residents reviewed for respiratory care. F726 Based on observations, record review and interviews of staff, contracted Respiratory Therapist, and Medical Director, the facility failed to train nursing staff and verify competency to provide for and to meet the respiratory care needs for 1 of 1 resident reviewed for [CONDITION(S)] care. Resident #46 required 5 trips to the Emergency Department (ED) over a two and a half week period of time to clear her airway and treat [CONDITION(S)] as a result of staff not maintaining a clear airway from tracheal secretions. F760 Based on record review, staff interviews, family interview, pharmacist interview, and physician interviews, the facility failed to provide prescribed antiseizure medication for 1 of 10 residents (Resident #140) reviewed for medication errors. Resident #140 did not receive prescribed [MEDICATION(S)] (antiseizure medication) from 6/26/22 - 7/10/22 and from 7/14/22 - 7/21/22. This resulted in the resident not receiving 45 doses of antiseizure medication. F580 Based on record review, staff interviews, and physician interviews, the facility failed to notify the physician or nurse practitioner (NP) when antiseizure medication remained unavailable for Resident #140, pain medication was unavailable for Resident #42, and when the nurse was unable to obtain intravenous (IV) access for Resident #111 to provide hydration as ordered for 3 of 4 residents reviewed for notifications (Resident #140, Resident #42, and Resident #111). E004Based on record review and staff interviews, the facility failed to provide and maintain documentation of annual updates and review of the facility ' s Emergency Preparedness Plan. This failure had the potential to affect all staff and residents. During an interview 9/16/22 at 1:45 PM, the Administrator indicated she was an interim administrator and was hired in August. She indicated she had recently conducted the quality assurance (QA) meeting on 9/15/22. The identified concerns were discussed in the QA meeting. During an interview on 9/16/22 at 1:48 PM, Regional Director of Clinical Services she stated she was hired in August of 2022. She tried to be on-site once a week and while on site, she would attend morning and clinical meetings. A 24 or 72 hour look back review was completed for any concerns reported in the meetings. The Regional Director of Clinical Services further stated a weekly report from the Director of Nursing (DON) was reviewed and follow up meeting done for repeated concerns. The DON was educated on repeated concerns, and monitoring tools were put in place. The DON and Administrator could contact the Regional Director of Clinical Services at any time. Regional Director of Clinical Services stated since her hire, she was not involved in QA meeting and moving forward would be involved with QA meetings. The Regional Director of Clinical Services further stated the facility now has a respiratory therapy on board to provide good care for residents with respiratory care needs. On 9/15/2021 at 5:15 PM, the administrator was informed of the immediate jeopardy. The allegation of immediate jeopardy removal indicated: Credible Allegation of Immediate Jeopardy removal: F835 - Administration Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance The facility Administration failed to provide effective oversight and leadership to ensure respiratory care needs were met, staff were trained and competent to provide necessary care and services to meet respiratory needs of residents, provide anti-[CONDITION(S)] medications, provide physician notification of medications not administered for residents #46, #505 and #140. 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; The individual responsible for this education is a registered respiratory therapist (RTT), respiratory care practitioner (RCP). The contracted RTT, RCP began on 9/16/22, and will be here weekly to monitor the [CONDITION(S)] patient, with monthly visits to review [CONDITION(S)]/[CONDITION(S)] patients ongoingly. She will also be available as needed to address any issues related to respiratory care needs. The center's pharmacy provider has resources available, such as the Customer Service Representative, Regional Director of Customer Success, and VP of Customer Success available to center administration 24/7, related to medication availability concerns. The systems identified during this survey related to provision of services for [CONDITION(S)] care, oxygen therapies, and medication procurement were evaluated as part of this plan of correction by center administration, corporate leadership and the governing body on 9/16/22. Alleged date of IJ removal is 9/17/22. Person responsible for implementation is the administrator. on 9/19/22 at 4:55 PM an interview was conducted with the Administrator and Corporate Nurse Consultant. The Administrator stated a contracted Respiratory Therapist was hired on 9/16/22. The Administrator further stated the Respiratory Therapist would return to the facility each week to monitor [CONDITION(S)] residents and residents with [CONDITION(S)] and [CONDITION(S)] monthly and as needed ongoing. The Administrator stated she was aware the current medication pharmacy provider was sending medication late and the medication was not available. The Administrator stated the center's pharmacy provider would provide resources needed to address when medication were unavailable. Medication substitutions would be to address issues related to mediation unavailability and the physician would be notified immediately for medication replacement. The Administrator indicated training to all agencies staff had been added to the QAPI plan. All identified concerns in each area were evaluated on 9/16/22. The Administrator indicated a new Medical Director was also hired and would assist to address care issues related to medication unavailability.

Based on record review, staff, Nurse Practitioner, and Medical Director interviews, the facility failed to develop and implement effective interventions when the resident manipulated and taped his condom catheter; when the resident refused ADL (activities of daily living) care; when the resident refused full body skin assessments for 1 of 8 residents, (Resident #7). On 3/13/22 Resident #7 arrived at the Emergency Department (ED) with significant swelling of his scrotum and groin and his condom catheter was extensively taped with medical tape. The skin assessment in ED described multiple excoriated [CONDITION(S)] to his foreskin with active bleeding, multiple skin discolorations, two sacral pressure ulcers and abrasions over the body. One Resident #7's toenails lifted up from the nail bed when his compression hose were removed. Findings included: Resident #7 was admitted to the facility on [DATE]. His quarterly Minimum Data Set (MDS) assessment, dated 12/4/21, revealed his intact cognition. Resident #7's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment indicated the resident required extensive assistance with ADL, was always incontinence of bowel and bladder, and used a condom (external) catheter. He exhibited rejection of care 1 to 3 days during the 7-day look back. Record review of Resident #7's plan of care, dated 3/6/22, revealed he exhibited adverse behavioral symptoms as resistive to care. The interventions were to administer medications as ordered, monitor, and document for side effects and effectiveness. The resident had an ADL self-care performance deficit. The resident often refused repositioning in bed, bed baths and incontinence care, skin observations and assessments. There were no effective interventions related to refusing assistance with ADL. Record review of Resident #7's plan of care, dated 3/6/22, revealed he had a condom catheter, manipulated his condom catheter, and wrapped it with tape regardless of education. The interventions were to change the condom catheter per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no interventions, related to wrapping the condom with tape and possible negative outcomes. Record review of Resident #7's plan of care, dated 3/6/22, revealed he often refused skin observations and assessments. There were no effective interventions to address the resident refusing skin assessments. Record review of Resident #7's plan of care, dated 3/6/22, revealed he often refused the compression hose application and removal per schedule. The plan of care did not show interventions to address the resident's refusal and noncompliance. On 3/29/22 at 11:50 AM, during an interview, Nurse #12, MDS Nurse, indicated that she was responsible for care planning and conducting resident assessments. Nurse #12 mentioned that she worked a long time on the floor with Resident #7 and was very familiar with his refusal behavior. The plan of care reflected the resident ' s current interventions for refusal behavior to provide medications per order and monitoring. Nurse #12 confirmed that the interventions, included in the plan of care, were discussed with Director of Nursing (DON), the Unit Manager. Nurse #12 mentioned that the effectiveness of interventions was limited. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] to complete weekly skin assessment and document it; Record review of multiple nurses' notes for 2022 revealed that Resident #7 often refused ADL assistance, including incontinence care, bed baths, and skin assessments. The resident often did not allow the staff to apply the condom catheter, assess his genitalia for a skin break down or provide catheter care. The resident constantly manipulated his condom catheter and wrapped it with white, adhesive tape that was not provided by the facility. The resident was educated about the possible negative outcome of his manipulation with tape but continued the same behavior. The resident did not allow the staff to remove the compression hose from his lower legs at noon, according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #7 would agree but would not allow the staff to remove the ted hose. The resident often refused full body skin assessment, skin check of his back area, and lower legs skin for compression hose application. The staff attempted to offer the skin assessment later with the same result. On 3/28/22 at 1:45 PM, during an interview, Nurse #6, Unit Manager, indicated that Resident #7 was alert/oriented, and could make his own decisions. He was known for refusal and manipulative behavior. Based on his psychiatric diagnoses, the resident received psychiatric visits and treatment. The Interdisciplinary Team discussed his situation and agreed with current interventions that were partially effective for the resident. On 3/29/22 at 7:10 AM, during an interview, Nurse #5 indicated that Resident #7 refused routine ADL care, skin assessments and compression hose applications. The resident did not allow the staff to provide overall condom catheter care and manipulated with white tape around his condom catheter very often. 3/29/22 at 9:00 AM, during the phone interview, Nurse #8 indicated that she was assigned for Resident #7 on third shift. He refused his condom catheter care and incontinence care. The resident became agitated with repeated offers. On 3/9/22, the resident requested to have more white tape to apply on his condom catheter. The resident was confused. Nurse #8 reoriented him and reminded him that he placed the tape around the condom himself and he refused to remove the tape from his condom catheter. Nurse #8 did not know how the resident received the white tape. On 3/30/22 at 8:30 AM, during an interview, Nurse Aide (NA) #6 indicated that on first shift of 3/8/22, Resident #7 refused to change his adult brief, refused the bed bath or repositioning in bed. The resident stated, he received it yesterday. On 3/30/22 at 8:40 AM, during the phone interview, NA #2 indicated that she worked with Resident #7 on night shift of 3/12/22. The resident refused care, became agitated, and did not allow the staff to touch him in bed. She could observe resident's upper body, not covered with blanket, and the resident refused full body skin observation. On 3/30/22 at 8:40 AM, during the phone interview, NA #7 indicated that he worked with Resident #7 on 3/7/22, 3/9/22, 3/11/22 and 3/12/22 during first shift. NA #7 stated the resident often refused incontinence care, often applied the white tape around the condom and did not want to remove it. NA #7 did not know how the resident received the tape and observed the roll of white tape in resident's room. On 3/30/22 at 9:30 AM, during an interview, NA #8 indicated that she worked with Resident #7 on first shift of 3/10/22. Nurse Aide #8 attempted several times to offer the incontinence care and the resident refused it. At the end of shift, the resident accepted incontinence care, and the nurse aide observed the condom catheter had come off. The penis, scrotum and perineal area were dark color, with dry skin and no skin issues. There was some redness noted on the glans penis without discharge. The resident stated it did not bother him at all. NA #8 stated this was reported to the floor nurse. Hospital records review revealed that on 3/13/22, Resident #7 arrived at the Emergency Department (ED) with significant swelling of his scrotum and groin and his condom catheter was extensively taped with medical tape. The skin assessment in ED described multiple excoriated [CONDITION(S)] to his foreskin with active bleeding, multiple skin discolorations, two sacral pressure ulcers and abrasions over the body. The staff in ED found an identification band embedded in his back skin and during removal of compression hose a toenail partially lifted from the nail bed. On 3/28/22 at 2:15 PM, during an interview, the Director of Nursing (DON) indicated that Resident #7 was alert, oriented, and his own responsible party. His plan of care reflected his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated regardless of education and psychiatric treatment, the resident continued his resistance to care and refusal behavior. On 3/28/22 at 3:40 PM, during the phone interview, Psychiatric Nurse Practitioner (NP #1) indicated that Resident #7, according to his mental status assessment, was cognitively intact and made his own decisions. He had psychiatric diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . NP #1 adjusted the resident's [CONDITION(S)] medication regimen with limited and temporary effects on his behavior.

Based on record review and staff, Nurse Practitioner, and Medical Director interviews, the facility failed to complete full body skin assessments, including resident's genitalia, back and lower legs for 1 of 8 sampled residents (Resident #7). On 3/13/22, Resident #7 was sent to the emergency department (ED) for evaluation and the ED records indicated the Resident had significant swelling of his scrotum and groin, multiple excoriations to his foreskin with active bleeding, two sacral pressure ulcers and multiple skin discolorations over the body. In addition, an identification band (ID) band was imbedded in his back and a toenail partially lifted when they removed his compression hose. Findings included: Resident #7 was admitted to the facility on [DATE]. His discharge Minimum Data Set (MDS) assessment, dated 3/13/22, revealed intact cognition. Resident #7's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident received extensive assistance with ADL, was always incontinent for bowel and bladder, and used a condom (external) catheter. He exhibited rejection of care 1 to 3 days during the 7-day look back, and received [CONDITION(S)] medications and psychotherapy. Review of Resident #7's plan of care, dated 3/6/22, revealed that due to his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The interventions were to administer medications as ordered, monitor, and document for side effects and effectiveness. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] to complete a weekly skin assessment every Friday's day shift and document it; to apply condom catheter, provide catheter care, validate anchor for the catheter and privacy bag every shift, change it as needed; to apply the compression hose in the morning and remove it at noon. Record review of the skin assessments for Resident #7 revealed his last documented full skin assessment, dated 3/4/22. Nurse #5, who conducted the assessment, documented the resident's skin was intact. On 3/28/22 at 11:50 AM, during an interview, Nurse #12 indicated that on first shift of 3/11/22, she was assigned to Resident #7 and he refused the skin assessment. The nurse came back with the same offer twice during her shift with the same result. Nurse #12 did not notify the physician she did not complete the skin assessment due to the resident's refusal. On 3/29/22 at 7:10 AM, during an interview, Nurse #5 indicated that Resident #7 refused skin assessments very often. Before his discharge to the hospital on 3/13/22, the last time Nurse #5 completed his full body assessment was on 3/4/22, and did not find skin issues. Review of the care tracker for March 2022 revealed that on 3/2/22, 3/3/22, 3/8/22, and 3/11/22, nurse aides observed Resident #7 ' s skin without new skin conditions. Review of the nurses' notes, dated 3/13/22 at 4:32 AM, revealed that Resident #7 complained of the abdominal pain. Upon assessment, the resident ' s penis and scrotum were purple and swollen, and purple urine was observed in the catheter drainage bag. Nurse #7 reported this to the physician on call. She received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . After conversation with EMS team and floor staff, the resident agreed to go to the hospital. Nurse #7 was not available for interview. Hospital records review revealed that on 3/13/22, Resident #7 arrived at the Emergency Department (ED) with significant swelling of his scrotum and groin, and his condom catheter was extensively taped with medical tape. The skin assessment in ED described multiple excoriated [CONDITION(S)] to his foreskin with active bleeding, multiple skin discolorations, two sacral pressure ulcers and abrasions over the body. The staff in ED found an ID (identification) band embedded in his back skin and during removal of compression hose a toenail partially lifted from the nail bed. On 3/28/22 at 2:15 PM, during an interview, Director of Nursing ( DON) expected weekly skin assessments to be done weekly as ordered by the physician. She was aware of skin assessments not being completed per schedule or in full due to Resident #7's resistance to care behavior. The DON could not provide Resident #7's skin assessment documentation after 3/4/22 through when he was discharged on [DATE]. The DON confirmed that the facility did not utilize the armbands. She did not know how the resident could get the armband embedded in his back as hospital nurses described. On 3/28/22 at 3:40 PM, during the phone interview, Psychiatric Nurse Practitioner (NP #1), indicated that Resident #7 was cognitively intact and made his own decisions. NP #1 was aware that he refused care, including skin assessments. The NP #1 stated she had adjusted the resident's [CONDITION(S)] medication regimen with limited and temporary effects on his behavior. On 3/29/22 at 12:00 PM, during an interview, the Corporate Nurse Consultant indicated that Resident #7's skin assessment and documentation should have been completed weekly and as needed. On 3/29/22 at 12:00 PM, during a phone interview, the Medical Director stated he was aware of Resident #7's behavior issues. The Medical Director further stated that the staff could not forcefully push alert/oriented, cognitively intact residents to do or not to do tasks until it became dangerous for himself or others. The interview further revealed staff continued to educate the resident about possible negative outcomes of his non-compliance and provide psychiatric evaluation and treatment with monitoring.

Based on the record review, staff, Nurse Practitioner, and Medical Director interviews, the facility failed to manage the care for a condom catheter; the facility had knowledge the resident was applying a condom catheter independently without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/13/22 Resident #7 arrived at the Emergency Department (ED) with significant swelling of his scrotum and groin and his condom catheter was extensively taped with medical tape. The condom catheter was removed immediately on arrival due to concerns for compromised circulation to the penis and scrotal area. Blood was observed coming from his penis when the catheter was removed. The skin assessment in ED described multiple excoriated [CONDITION(S)] to his foreskin with active bleeding. Resident #7 was admitted due to suspected septic shock. Findings included: Record review revealed the facility's policy, Urinary Catheter Care and Catheterization, dated 11/1/19, indicated for licensed nurses the procedure of application of the condom catheter in accordance with the standard of practice. The nurse should assess the penis for skin discoloration, swelling and signs of impaired circulation several times each shift, and document in the progress notes the date/time of procedure, size of the catheter, skin and penis condition during the external catheter application, any unusual findings, and urine appearance and amount. Resident #7 was admitted to the facility on [DATE]. His quarterly Minimum Data Set (MDS) assessment, dated 12/4/21, revealed his intact cognition. Resident #7's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated the resident required extensive assistance with activities of daily living (ADL), was always incontinent for bowel and bladder, and used a condom (external) catheter. He exhibited rejection of care 1 to 3 days during the 7-day look back, and received [CONDITION(S)] medications and psychotherapy. Record review of Resident #7's plan of care, dated 3/6/22, revealed that he had a condom catheter, manipulated his condom catheter, and wrapped it with tape regardless of education that this is not appropriate and can lead to injury. The interventions were to change the condom catheter per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The same plan of care indicated that the resident exhibited adverse behavioral symptoms as resistive to care. The interventions were to administer medications as ordered, monitor, and document for side effects and effectiveness. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Records review revealed the written statement of the Director of Nursing (DON), dated 2/15/22, indicate that DON educated Resident #7 regarding the risks and consequences of continuous refusal of care and inappropriate actions witnessed with regard to taped condom catheter and serious danger of this action up to including death. Resident #7 replied If I die, I die. Records review of the nurses' notes, dated 2/16/22, revealed that Resident #7 asked this to put his condom catheter back on because it came off. Nurse #12 applied the condom catheter and the resident requested to put tape around his penis. The Nurse #12 refused to do it, explained the hazard in using tape and that it could cause serious skin issues, and was encourage not to use it. Resident #7 stated he would use it anyway. On 3/28/22 at 1:25 PM, during an interview, Social Worker (SW) was aware that Resident #7 often did not allow the staff to apply condom catheter. SW remembered in February 2022, the resident asked her for tape, which he would apply to the condom. SW replied that the facility employed experienced staff for condom catheter application, according to the standard of care. SW mentioned that using the tape could lead him to bad and scary consequences. Resident #7 verbalized that SW probably right, but he does not like anyone but him touching his catheter. The SW notified the floor nurse (could not recall the name). On 3/29/22 at 9:00 AM, during the phone interview, Nurse #8 indicated that Resident #7 refused condom catheter application and care very often and preferred to complete this task himself. On 3/9/22, he was observed with white tape around the condom. When the nurse asked to remove it, the resident became agitated, confused, and requested to have more white tape. The nurse reoriented him to the place and reminded him that he had placed the tape around the condom himself. The resident fell back to sleep and did not allow Nurse #8 to remove the tape from his condom catheter. Nurse #8 did not know where the resident received the white tape. There was no [CONDITION(S)] or discoloration of resident's genitalia noted. On 3/9/22, Nurse #8 did not notify the nurse practitioner or physician because it was well known and the resident's routine behavior. Review of the nurses' notes, dated 3/13/22 at 4:32 AM, revealed that Resident #7 complained of the abdominal pain. Upon assessment, the resident had purple, swollen private area, and purple urine in the catheter drainage bag and presented symptoms of upper abdominal pain. Nurse #7 reported it to the physician on call. She received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . After additional conversation with the EMS team and floor staff, the resident agreed to go to the hospital. The Nurse #7, who was assigned for Resident #7 on 3/13/22, was not available for interview. On 3/28/22 at 1:45 PM, during an interview, Nurse #6, Unit Manager, indicated the nurses reported that Resident #7 refused assistance with condom catheter application and skin assessment of his private area, and constantly manipulated with white tape around the condom. The staff educated the resident about possible poor outcomes, but he continued the same behavior. Nurse #6 reported it to the Director of Nursing (DON) and Nurse Practitioners several times. On 3/13/22, Nurse #7 reported that the resident complained of abdominal pain. Upon assessment, his genitalia were enlarged, swollen, and purple. Nurse #7 communicated this to the physician on call and obtained an order to send the resident to the hospital. Record review of the EMS report, dated 3/13/22, revealed the team observed Resident #7 to have a condom catheter that was taped extensively to his penis with medical tape. His scrotum was also noted to be enlarged and tight. The urine in the drainage bag was purple. Hospital records review revealed that on 3/13/22, Resident #7 arrived at the Emergency Department (ED) with significant swelling of his scrotum and groin and his condom catheter was extensively taped with medical tape. There was purple colored urine in the drainage bag. The skin assessment in ED described multiple excoriated [CONDITION(S)] to his foreskin with active bleeding. It was also noted the condom catheter was removed immediately on arrival due to concerns for compromised circulation to the penis and scrotal area. Blood was observed coming from his penis when the catheter was removed. Resident #7 was admitted due to suspected septic shock. Records review revealed the written statement of the Administrator, dated 3/28/22, indicated that Nurse #7, assigned for the Resident #7 on 3/13/22, reported she assessed the resident: his private area was red/purple and swollen with purple urine in the drainage bag. Nurse #7 called Emergency Medical Service (EMS). The resident refused to go to the hospital, but after additional conversation, EMS team took the resident to the Emergency Department (ED). On 3/28/22 at 3:40 PM, during the phone interview, Psychiatric Nurse Practitioner (NP #1) indicated that Resident #7 was cognitively intact and made his own decisions. NP #1 was aware that he refused care, including condom catheter care. NP #1 indicated the resident's [CONDITION(S)] medication regimen was adjusted with limited and temporary effects on his behavior. On 3/29/22 at 7:10 AM, during an interview, Nurse #5 indicated that Resident #7 did not allow the staff to provide overall condom catheter care and manipulated with white tape around his condom catheter very often. On 3/29/22 at 11:50 AM, during an interview, Nurse #12, indicated that Resident #7 did not comply with condom catheter application and care. He constantly manipulated his condom catheter, did not allow the staff to provide catheter care, used white tape around the condom, and rejected the genitalia skin check. The Nurses #12 did not document in the nurses notes each time she observed the tape around resident's condom catheter. She did not notify the NP or Medical Director every time the resident applied the tape on his condom catheter. On 3/30/22 at 8:40 AM, during the phone interview, Nurse Aide #7 indicated that Resident #7 often applied the white tape around the condom and did not want to remove it. Nurse Aide #7 did not know how the resident received the tape and observed the roll of tape in the resident's room. Nurse Aide #7 did not touch the tape on the condom catheter because nurses provided the condom catheter application, adjustment, and removal procedures. The resident was well known for tape application around his condom catheter, so Nurse Aide #7 did not notify the nurses when he observed tape on the condom catheter. On 3/30/22 at 9:30 AM, during an interview, Nurse Aide #8 indicated that she often observed Resident #7 with tape around his condom catheter. He did not allow the staff to remove it. Nurse Aide #8 did not know where and how the resident received the tape, he used for his condom catheter. Nurse Aide #8 stated at times she reported it to the floor nurses, who would come to talk to the resident. On 3/30/22 at 2:55 PM, during an interview, the DON stated she was aware that Resident #7 was not in compliance with condom catheter application and care. The staff reported he applied tape around the condom and refused to remove it. The staff did not provide the tape to the resident. The DON stated most likely, he ordered it online and had it delivered to the facility. The Resident's behavior, risks, and consequences of continuous refusal of care, inappropriate actions witnessed with regard to taped condom catheter, with possible serious danger of this action, was discussed with NP #1 and Medical Director. On 2/2/22 and 2/24/22, during the visits, NP #1 adjusted the [CONDITION(S)] medication regimen without significant changes in the resident behavior. When Nurse #7 assessed the resident with swollen genitalia and purple urine in the drainage bag, she sent the resident to the ED per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 3/29/22 at 12:00 PM, during the phone interview, Medical Director was aware of Resident #7's behavior issues, including not following the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medical Director mentioned he did not visit the Resident #7 but discussed his situation with NP#1. In the case like that, the Medical Director would contact the resident's family, but the staff reported the Resident #7 was estranged from his family and had no support. Therefore, the NP#1 adjusted the [CONDITION(S)] treatment, and the staff continued to educate the resident about possible negative outcomes of his non-compliance and provided monitoring.

Based on record review, staff interviews, Physician Assistant (PA) interviews, Physician interviews, Administrator interview, Interim Director of Nursing (DON) interview, and previous Director of Nursing interview the facility neglected to provide necessary care and services by failing to administer the correct medication; failing to provide effective and ongoing nursing and medical assessments and medical interventions for a resident with an acute/significant change in condition; and failing to implement effective medical intervention for a resident with signs of dehydration for one (Resident #1) of one resident reviewed for neglect. Resident #1 received 29 incorrect medications for a period of 8 days. Resident #1 was noted to have a change in condition beginning on [DATE] with a hypotensive episode. Resident #1 continued to decline, suffering from lethargy, dehydration, hypotensive episodes, and inability to swallow until the facility recognized the error in transcription of medication on [DATE]. Resident #1 was sent to the hospital on [DATE] and expired in the hospital on [DATE]. The cause of death of Resident #1 was determined to be septic shock. Immediate Jeopardy began on [DATE] when Resident #1 entered the facility and the facility failed to have effective systems in place to order and administer correct medications, and to effectively address a decline and change in condition. The immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation for Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of an E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place are effective. Example C. is a scope and severity level of a D (Isolated -No actual harm with potential for more than minimal harm that is not immediate jeopardy.) Findings included: A. Cross Refer to F757: Based on record review, staff interview, Administrator interview, physician assistant interview, and physician interview the facility failed to administer the correct medications and administered medications without supporting diagnoses for one (Resident #1) of three residents reviewed for unnecessary drugs. The facility failed to recognize the incorrect medications were entered into the electronic medical record system upon admission for Resident #1 resulting in the resident receiving 29 incorrect medications for a period of 8 days. These medications included in part antipsychotics, seizure medication, pain medication, insomnia medication, hypertension medication, diabetic medication, glaucoma medication, and smoking cessation. Resident #1 was admitted to the hospital on [DATE] and expired on [DATE]. B. Resident #1 was admitted from the hospital emergency room to the facility on [DATE]. A North Carolina FL-2 form for Resident #1, dated as completed on [DATE] at 1:45 PM was sent to the facility from the hospital. A FL-2 is a North Carolina form that describes a patient's medical condition and the amount of care they need when placed in a facility. Resident #1 had diagnoses listed on the FL-2 form dated [DATE] from the emergency room of Parkinson's disease, chronic obstructive pulmonary disease, esophageal reflux, personal history of transit ischemic attack without residual deficits (2016), Hypertension, prostate cancer (2018), esophageal reflux, cerebral vascular disease, and hyperlipidemia. The FL-2 form also revealed the emergency room admission complaint of Resident #1 was weakness and failure to thrive. The FL-2 form dated [DATE] included documentation attested to by the physician stating Resident #1 was oriented to self, place, time, and situation as well as continent of bowel and bladder. He was also described on the documentation as requiring limited assistance with bathing, feeding, and dressing. A physical therapy evaluation included in the FL-2 dated [DATE] revealed Resident #1 required maximum assistance with getting into the sitting position from laying flat but required minimum assistance from sitting to standing. The hospital physical therapy evaluation noted Resident #1 was able to walk 85 feet with a rolling walker. Documentation in the facility electronic record listed the Resident's diagnoses as being cerebral infarction, Parkinson's disease, adult failure to thrive, muscle weakness, chronic obstructive pulmonary disease, gastro-esophageal reflux disease, hyperlipidemia, and Hypertension. The Rehabilitation Manager was interviewed on [DATE] at 2:18 PM and revealed Resident #1 received both occupational and physical therapy assessments on [DATE] revealing the resident was a typical rehabilitation patient and had good potential for therapy improvement. The Rehabilitation Manager stated Resident #1 scored as being severely dependent on the assessment tools they used but he was able on [DATE] to walk 50 feet with a rolling walker. The Rehabilitation Manager added on [DATE] Resident #1 was able to walk 175 feet with the rolling walker. On [DATE] at 4:21 PM Resident #1 was noted in the nursing notes to have had a change in condition. Nurse #12 documented in the nursing note the blood pressure of Resident #1 had dropped, oxygen saturation levels went to 88%, and PA #1 was contacted. Resident #1 was placed on 2 Liters of oxygen and blood pressure medication was ordered to be put on hold. The Director of Nursing was contacted, vital signs were rechecked, and stabilized within the hour. Nurse #12 was interviewed on [DATE] at 1:58 PM and confirmed she was assigned to care for Resident #1 on [DATE] for the 7:00 AM to 7:00 PM shift. Nurse #12 stated Resident #1 was sluggish the whole day, but his blood pressure improved after the blood pressure medications were put on hold. Nurse #12 stated she was concerned about Resident #1 because he was on seizure medication as well as the multiple blood pressure medications and she felt he needed to be monitored closely. On [DATE] at 7:33 AM Resident #1 was noted in the nursing notes to have had a change in condition where he was noted to be lethargic. The nursing note revealed the Director of Nursing was made aware of the change in condition for Resident #1. Nurse #17, who wrote the nursing note for Resident #1 on [DATE] at 7:33 AM, was interviewed on [DATE] at 7:15 AM and she stated she did not recall the resident or his condition on [DATE]. On [DATE] at 11:17 AM PA #1 wrote a progress note where documentation stated under history of present illness, Per nursing complaint of patient slightly more lethargic than baseline, hypotensive, and decreased O2 (oxygen) sats (saturation levels). On exam the patient was arousable, will hold BP (blood pressure) medication and start O2, monitor for improvement or worsening condition. I have ordered labs (laboratory tests) and CXR (chest x-ray) to check for any infectious process or metabolic disturbance causing the symptoms. No medication abnormalities were noted. Documentation in the progress notes entitled Orders-Administration note on [DATE] at 3:09 PM, 3:11 PM, and 3:12 PM revealed Resident #1 was unable to swallow. Documentation in the nursing notes for Resident #1entitled Change in Condition dated [DATE] at 3:27 PM revealed, Resident appears [asleep] with respirations even and nonlabored. [Vital Signs] stable. [PA #1] assessed resident this shift and gave new orders to obtain [Urgent] labs & Chest x-ray [due to] health decline. [Emergency Contact #1] was on site and made aware of change of condition & new orders. Currently awaiting results. A basic metabolic panel results for Resident #1 came back on [DATE] at 6:29 PM with the abnormalities of a high BUN (Blood Urea Nitrogen) of 37.8 mg (milligrams)/dl (deciliters) (normal values are 6XXX,d+[DATE].0 mg/dl) and BUN/Creatinine ratio of 44.0 (normal values are 6XXX,d+[DATE].0). PA #1 signed the laboratory results as reviewed on [DATE] at 8:23 AM. The chest x-ray results for Resident #1were ordered on [DATE] at 2:00 PM were reported on [DATE] at 8:10 PM. The chest x-ray impression was bilateral basilar atelectasis and left effusion. Bilateral basilar atelectasis is defined as both sides of the lowermost lobes of the lungs are collapsed entirely or partially. Left effusion is defined as a build-up of fluid in the area between the layers of tissue that line the lungs and the chest wall. The chest x-ray results were signed as reviewed by PA #1 on [DATE] at 8:17 AM. Documentation in the nursing notes for Resident #1 entitled Change in Condition dated [DATE] at 12:12 AM revealed the physician for Resident #1 (MD #1) was notified of the chest x-ray results with no new orders given. Documentation in the progress notes entitled Orders-Administration note on [DATE] at 9:48 AM revealed Resident #1 was unable to take medication due to difficulty breathing. On [DATE] at 11:16 AM a nursing note written by Nurse #21 stated, Resident (#1) is currently resting in bed. Resident is not alert and oriented. Vitals are within normal range at (Blood pressure) ,d+[DATE], [Pulse] 82, O2 99 %, [Temperature] 97.4, [Respirations] 22 Resident is abdominal breathing with mouth open. Resident on 3.5 Liters of oxygen. [Capillary Blood Glucose] 174 no insulin needed. Resident consumed 0 percent of breakfast. Medication on hold due to resident not being alert. ADON (Assistant Director of Nursing) and doctor is aware of resident's condition. Will continue to monitor resident's vitals. Nurse #21, wrote the progress note on [DATE] at 11:16 AM, was interviewed on [DATE] at 1:43 PM. Nurse #21 stated she had concern for Resident #1 on [DATE]. Nurse #21 described Resident #1 on [DATE] as not being able to swallow and he did not have a feeding tube to obtain nutrition or hydration. Nurse #21 explained this was her first time caring for Resident #1 and his baseline was unknown to her. Nurse #21 stated she notified the physician and her Director of Nursing. Nurse #21 indicated her nursing judgement told her Resident #1 needed to go to the hospital. Nurse #21 explained she noted he was his own responsible party, but she saw he was not arousable indicating he had a major change in condition from his arrival at the facility. Nurse #21 stated her concern grew when she spoke with the family of Resident #1 to update them on the resident's condition. Nurse #21 stated the DON and the ADON went to assess Resident #1 but did not want him sent to the hospital. Nurse #21 stated PA #1 also did not want him sent to the hospital but for her to continue to monitor his condition. An interview with the ADON was conducted on [DATE] at 4:00 PM. The ADON stated she did an assessment on [DATE] to determine if Resident #1 had another stroke but after an assessment he did not seem critical enough to send to the hospital. The ADON explained her assessment was focused on assessing if he had any deficits to indicate he had another stroke such as inability to speak or weakness in his extremities. The ADON explained she thought the resident was at his baseline. An admission minimum data set (MDS) assessment dated [DATE] coded Resident #1 was having moderately impaired cognition and feeling tired 7 to 11 days of the assessment period. He was coded as requiring extensive assistance with bed mobility and toilet use. He was independent with feeding himself after set-up. He did not transfer, ambulate, or perform locomotion during the assessment period. He was coded as always incontinent of bowel and bladder. He was coded as receiving 5 days of antipsychotics, 3 days of antibiotics, oxygen therapy in the facility, and intravenous medications during the assessment period. There were no nursing notes or documentation in the medical record on the condition of Resident #1 on Saturday, [DATE] or Sunday, [DATE]. On [DATE] at 9:41 AM the progress notes entitled Orders- Administration note for Resident #1 stated, Unable to swallow. An interview was conducted on [DATE] with Nurse #22, who wrote the [DATE] administration note at 9:41 AM. Nurse #22 stated she contacted PA #1 because she had great concern for Resident #1, and she wanted to know what was going on. Nurse #22 described Resident #1 as really passed out and not responding at all. Nurse #22 said she was told by PA #1 he was aware of the condition of the resident, he had ordered laboratory tests, and she was told to continue to monitor the resident. On [DATE] an initial physician visit progress note was written by the Physician for Resident #1 (MD #1). The impression portion of the note stated, New recent problem. Has improvement with changes in medication. Continue to [rule out] other etiologies with urine and blood work testing. Review of the physician orders revealed on [DATE] the Physician (MD #1) for Resident #1 gave a verbal order for one liter of sodium chloride solution 0.9% to be administered intravenously at a rate of 75 cc (cubic centimeters)/hour until [DATE] for dehydration. On [DATE] at 11:30 AM nursing notes revealed peripheral intravenous fluids were started for Resident #1. On [DATE] at 1:14 PM nursing progress notes revealed Resident #1 had a blood pressure of ,d+[DATE] and the ADON advised for oxygen levels to be increased. The documentation in the note also revealed PA #2 was called and additional laboratory tests were ordered to include a complete blood count, basic metabolic panel, and a chest x-ray. An interview was conducted on [DATE] at 12:30 PM with Nurse #9, who wrote the [DATE] 1:14 PM nursing note. Nurse #9 stated when she came into to work on [DATE] she was told in report Resident #1 had overdosed on blood pressure medication and was no longer able to stand or feed himself. Nurse #9 stated she really thought Resident #1 needed to be sent to the hospital because of the low blood pressure and a rectal temperature of 99.9 degrees. Nurse #9 confirmed she also worked on the 7:00 AM to 7:00 PM shift caring for Resident #1 on [DATE]. Nurse #9 stated she continued to have concern for Resident #1 because he was very confused and out of it. Nurse #9 stated her nursing judgement told her he needed to be sent out to the hospital. Nurse #9 stated she relayed her concerns to the DON and the PA but neither felt it was necessary to send Resident #1 to the hospital. Nurse #9 stated she knew that if she sent Resident #1 to the hospital, she would be disciplined like some of the other nurses had been who sent residents to the hospital. An interview was conducted with PA #2 on [DATE] at 11:15 AM. PA #2 revealed Resident #1 appeared to have altered mental status and drowsy but was not lethargic. PA #2 stated she was not as familiar with this resident and thought blood tests and a repeat chest x-ray were ordered. PA #2 did not recall a request being made to send the resident to the hospital. On [DATE] at 3:23 PM an order note documented an order for saline to be administered intravenously was clarified by PA #2 to provide one liter of saline for this shift only (7:00 AM to 7:00 PM) and then discontinued. Laboratory results reported on [DATE] at 4:46 PM flagged at low hemoglobin 13.8 g (grams)/dl (normal range of 14XXX,d+[DATE].0 g/dl), high glucose 118 (normal range of ,d+[DATE] mg/dl), low calcium 8.5 (normal range of 8XXX,d+[DATE].2), a high BUN of 65.5 (normal range of 6XXX,d+[DATE].0 mg/dl), a BUN/Creatine ratio of 54.6, and a sodium of 147 (normal range is ,d+[DATE] mmol (millimole)/L (liter). A physical therapy progress note dated [DATE] for Resident #1 stated, Did well the first two days (in facility) but has struggled to perform interventions without considerable assistance. The chest x-ray results ordered on [DATE] for Resident #1 were dated as reported on [DATE] at 1:15 PM. The results stated in part under the impression, There are mild patchy bibasilar densities compatible with pneumonia or less likely atelectasis. An interview was conducted on [DATE] at 6:48 PM with Nurse #19, who cared for Resident #1 on the 7:00 PM to 7:00 AM shift on [DATE]. Nurse #19 recalled Resident #1 was very sedated when she started her shift on [DATE]. Nurse #19 stated she was told just to monitor him. Nurse #19 further stated the only thing she remembered was Resident #1 slept her entire shift. An interview was conducted on [DATE] at 2:45 PM with Nurse #10. Nurse #10 revealed she was not assigned to care for Resident #1 on the 7:00 PM to 7:00 AM shift on [DATE]. Nurse #10 explained she took over two medications carts because the agency nurse for one of the medication carts could not get log in information to access the electronic records despite numerous attempts to get help from the information technology team. An interview was conducted on [DATE] at 6:51 PM with Nurse #24, who was assigned to care for Resident #1 on the 7:00 PM to 7:00 AM shift on [DATE]. Nurse #24 confirmed she received report from Nurse #9 on [DATE] and did not recall any concerns regarding Resident #1 being given to her. Nurse #9 stated her major concern was she did not have access to the electronic medical records despite numerous attempts to obtain information technology assistance. Nurse #24 stated she was not familiar with any of the residents and stated none of the residents were unresponsive with most of them sleeping on the shift. An interview was conducted on [DATE] at 1:51 PM with Nurse #4, who cared for Resident #1 on the 7:00 AM to 7:00 PM shift on [DATE]. Nurse #4 revealed [DATE] was the first time she had ever cared for Resident #1. Nurse #4 did not recall if he was receiving intravenous fluids on her shift or not. Nurse #4 did not recall being told to monitor Resident #1, but she recalled being told by the nurse aide he slept all day. An interview was conducted on [DATE] at 6:43 AM with Nurse #8, who cared for Resident #1 on the 7:00 PM to 7:00 AM shift on [DATE]. Nurse #8 stated Resident #1 had low oxygen level on his shift, and he heard in report from the previous nurse the resident had pneumonia, but he was to only monitor him and not send him out. Nurse #8 stated he gave Resident #1 continuous oxygen and he improved by the end of his shift. Nurse #8 stated he had to leave his shift early at 6:30 PM and he gave a nursing report to Nurse #10, who was on another hall on his shift. An interview was conducted on [DATE] at 1:29 PM with Nurse #3, who was assigned to care for Resident #1 beginning on [DATE]. Nurse #3 recalled when Resident #1 was first admitted to the facility he was up with physical and occupational therapy walking and talking. Nurse #3 explained that by the time he was moved to another hallway he was just not the same. Nurse #3 stated she heard from occupational therapy Resident #1 could no longer walk, eat on his own, or sit on the edge of the bed. Nurse #3 also stated she heard from occupational therapy Resident #1 received three blood pressure pills he was not supposed to get. Nurse #3 stated she did not work on [DATE] through [DATE] and when she came back Resident #1 had really changed. Nurse #3 stated she received no information regarding Resident #1 in report on the morning of [DATE]. Nurse #3 stated Resident #1 was unresponsive and didn't look right so she called PA #1 who told her he would see the resident as soon as he arrived at the facility. Nurse #1 stated when PA #1 arrived he told her to hold all his medications. Nurse #3 stated she started her nursing duties which involved first getting blood sugars, blood pressures, vital signs and then passing out morning medications. Nurse #3 stated she also had skin assessments she needed to do after the medication pass. In addition, she explained she was on the behavior unit, so she needed to watch out for wandering residents. Nurse #3 also explained she started giving out the medications to the residents who were known to her and then the new residents, Resident #1 was going to be last because his medications were on hold. Nurse #3 stated she did not recall what time she sent Resident #1 to the hospital. There were no documented vitals in the medical record for Resident #1 on [DATE] prior to 2:33 PM. Documentation in the nursing notes written by Nurse #3 on [DATE] at 2:33 PM stated, Resident unresponsive to voice and painful stimuli. PA (#1) and ADON notified of declining status and vitals (Temperature) 99.3, (Pulse) 65, (Blood pressure) ,d+[DATE], (O2) 89 % on 4 [Liters] of O2. No urine output in foley. PA [#1] ordered resident to be sent to [Emergency Department] for further evaluation, [Emergency contact #1] resident emergency contact also notified of the changes. The emergency room report dated [DATE] stated in the narrative in part, [Resident #1] laying supine in his bed unresponsive but breathing. Nurse in room advised he has been unresponsive since at least 7 AM when she began shift this morning. Nurse also stated that he is normally alert and talking. Noted [patient's] skin was hot to touch, and radial pulses were absent. The hospital discharge summary dated [DATE] at 4:28 AM revealed Resident #1 expired due to septic shock. Review of the death certificate dated [DATE] revealed the immediate cause of death for Resident #1 was septic shock with contributing diagnoses of pneumonia, sacral decubitus ulcer, and possible meningitis. An interview was conducted on [DATE] at 4:00 PM with the ADON. The ADON stated on [DATE] she arrived at the facility around 2:00 PM because she was going to be supervising the night shift that day. The ADON stated shortly after she arrived PA #1 arrived to assess Resident #1, who the facility staff had been working all weekend to stabilize. The ADON stated she saw Resident #1 on [DATE] and he was okay. The ADON revealed when she did her assessment at 2:00 PM on [DATE] Resident #1 was not responding to painful stimuli. An interview was conducted with PA #1 on [DATE] at 8:15 AM. PA #1 revealed on [DATE] he was on his way to the facility when he received a phone call notifying him of the chest x-ray results for Resident #1. PA #1 indicated he told the nurse he would assess Resident #1 as soon as he arrived at the facility and gave a verbal order for an antibiotic for the resident. PA #1 recalled he told the nurse to send the resident out as soon as he saw him in the facility that morning. PA #1 stated Resident #1 was debilitated upon admission and did not think the medication errors necessarily contributed to his decline. A subsequent interview was conducted on [DATE] at 2:07 PM with PA #1. PA #1 corrected his version of the events of [DATE] during which Resident #1 was sent to the hospital. PA #1 confirmed he saw Resident #1 on the morning of [DATE] and he appeared lethargic, so he ordered more laboratory tests and continued monitoring. PA #1 stated Resident #1 had no signs of infection and his vital signs were good. PA #1 stated he had left for another facility when he received a phone call around 1:00 PM informing him Resident #1 was unresponsive and needed to be sent to the hospital. An interview was conducted on [DATE] at 10:08 AM with the Physician (MD #1) for Resident #1. MD #1 explained if the facility nurses had a resident concern and wanted someone evaluated to be sent to the emergency room it was facility policy to reach out to the Director of Nursing or a Physician. MD #1 explained, previously the nurses were sending residents to the hospital without letting anybody in administration know. MD #1 stated there was a chain of command and the nurses can certainly send a resident to the hospital if needed but someone on the administrative level needed to know. MD #1 stated it was critical the nurses in the facility reach out if he or she has a concern for a resident. C. Cross refer to F692: Based on record review, staff interview, Physician Assistant interview, and Medical Doctor interview the facility failed to take immediate measures to prevent dehydration for one (Resident #1) of one resident reviewed for dehydration. On [DATE] at 12:30 PM, the administrator was informed of the immediate jeopardy. The allegation of immediate jeopardy removal indicated: Credible Allegation of Immediate Jeopardy removal: F600 - Abuse and Neglect Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance Synopsis: Resident was admitted [DATE]. Upon admission, a charge nurse entered inaccurate admission orders and did not confirm the orders. The resident did not receive ordered medications for two days until they were confirmed by the nurse on ,d+[DATE]. On ,d+[DATE], resident exhibited a change in status and PA placed blood pressure medication on hold and resident on oxygen. On ,d+[DATE], resident was noted to be lethargic and the PA ordered a chest x-ray and lab tests. On ,d+[DATE], abnormal lab results returned with elevated BUN and creatinine levels. On ,d+[DATE], the resident was observed to be not alert, had abdominal breathing, and not eating or taking meds. Resident was assessed by DON and ADON and no new orders were received at that time in response to resident's change in condition. No additional assessment or documentation was present on ,d+[DATE] or ,d+[DATE]. Then, on ,d+[DATE], PA examined the patient and indicated mild dehydration and ordered to increase PO fluids. On ,d+[DATE], it was discovered in the IDT meeting that medication diagnosis codes were missing. Upon review of the patient's discharge summary, it was discovered that his current meds did not match the discharge summary. The resident did not receive the medications that he should have received until ,d+[DATE]. An attempt to discover the source of these orders was unsuccessful at the time. PA and medical director were notified. Medications were reconciled and corrected. Later (,d+[DATE]), the ADON, while auditing new admissions since ,d+[DATE], discovered the discharge summary for a different patient that matched what had originally been entered for the resident. If the charge nurse disagrees with the decision from physician extenders, DON and/or attending physician for need for higher level of care, notify administrator who will notify medical director to make the call. Administrator notified nursing leadership of this on ,d+[DATE]. SDC or designee will notify all nurses working currently and the remainder before their next shift. On ,d+[DATE], DON spoke with every charge nurse and instructed each charge nurse to observe and assess each patient for any signs of acute change of condition. A census sheet was used to ensure each current resident was observed. DON reviewed this list once it was complete to ensure residents had been observed. Based on this, two acute changes were identified. One resident had refused dialysis. Nurse assessed patient for signs of fluid overload, educated patient on importance of receiving dialysis, and MD and RP were notified. Care plan was updated to include refusal of dialysis. The second patient was noted to have decreased intake. NP was informed and gave verbal order to increase oral intake of fluids, and RP was notified. Specify the action the entity will take to alter the process or system failure to prevent a serious outcome from occurring or recurring, and when the action will be complete Facility Action: Current licensed nursing (nurses and CNAs) and rehab staff were educated by the staff development coordinator or designee regarding identification, reporting, and documentation of acute/significant changes in condition to be completed by [DATE]. The staff development coordinator or designee will educate licensed nurses to notify Administrator if they disagree with the decisions from PA/NP, attending physician, and/or DON starting [DATE] to be completed for additional nurses before their next scheduled shift. Any agency staff will be educated before their next scheduled shift. The staff development coordinator will communicate the scheduler to identify when agency staff are scheduled and educate them before their shift. All staff will receive abuse/neglect education via our SDC using the Relias learning system during their next scheduled shift. Any who have not received this by ,d+[DATE] will be taken off the schedule until they do. Our SDC is notifying staff and presenting the Relias presentation to them. Nurse aides will notify charge nurses verbally for any observed change in resident status. Charge nurses will observe/assess patient. If any acute significant change is observed, charge nurse will notify physician. Recommendations will be implemented, and nursing leadership will be notified. If the charge nurse disagrees with the decision from physician extenders (PAs, NPs), DON, and/or attending physician for need for higher level of care, the Administrator will be notified who will then notify the Medical Director to make the call. Patient will be observed, and a progress note will be written every shift until the situation is resolved. Shift reports (24 hour/72 hour) will be reviewed by nursing leadership daily 5 X weekly to identify and follow up acute/significant changes in condition. PA will assess patients who have had a change of condition and provide a list of these patients to nursing leadership. Nursing leadership will verify that orders were implemented and report any questions or concerns to the PA. The DON will meet with the Medical Director and PA weekly on the status of Residents with acute significant changes in condition. Medical director will meet with physician assistants to discuss any concerns coming from the weekly meeting with the DON. Nursing leadership will review Residents experiencing changes in condition during daily (5 X weekly) morning IDT meetings. Medical director has been in contact with administrator, nurse consultant, DON, and ADON during this process and is committed to these weekly meetings moving forward. Medical director will meet with physician assistants weekly to discuss patients. This will include patients with acute changes, new patients, patients who are recently had major changes in treatment plans, and any other topics that need to be addressed. During weekly meeting between medical director and director of nursing, any questions or concerns about treatment decisions will be discussed. The Director of Nursing or designee will ensure implementation of the plan. Planned removal of IJ: [DATE] Attending physician provided coaching to PA on ,d+[DATE] regarding appropriate management and management of significant changes and med reconciliation. After meds were corrected, patient's lethargy improved. MD saw patient on ,d+[DATE] after meds had been corrected. The credible allegation was verified on [DATE] as evidenced by interviews with staff both nursing assistants and nurses. Nursing staff, nursing assistants reported receiving education on regarding preventing abuse and neglect and recognizing a change in condition and medical provider notification of change. Per review of documentation all residents with change in condition were reviewed in daily IDT meetings and the DON meet weekly with the MD since alleged compliance date of [DATE]. The facility's credible allegation of immediate jeopardy removal was verified as having been implemented on [DATE].

Based on record review, staff interview, and Physician interview the facility failed to perform skin assessments to monitor or identify skin concerns for 2 (Residents #1 and #2) of 3 residents reviewed for pressure ulcer/wound care. Resident # 1 was assessed by the hospital to have a severe unstageable spine decubitus ulcer. Immediate Jeopardy began on 8/30/21 when Resident # 1 was found to have a severe unstageable spine decubitus ulcer at the hospital. The resident was admitted to the facility on [DATE] and there was no evidence of a thorough skin assessment at that time or during the duration of his stay. The immediate jeopardy was removed on 10/25/21 when the facility implemented an acceptable credible allegation for Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of an E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place are effective and for example # 2. Findings included: 1. Resident #1 was admitted from the hospital emergency room to the facility on [DATE]. A North Carolina FL2 form for Resident #1, dated as completed on 8/13/2021 at 1:45 PM was sent to the facility from the hospital. A FL-2 is a North Carolina form that describes a patient's medical condition and the amount of care they need when placed in a facility. Resident #1 had diagnoses listed on the FL-2 form dated 8/13/2021 from the emergency room of Parkinson's disease, chronic obstructive pulmonary disease, esophageal reflux, personal history of transit ischemic attack without residual deficits (2016), Hypertension, prostate cancer (2018), esophageal reflux, cerebral vascular disease, and hyperlipidemia. The FL-2 form also revealed the emergency room admission complaint of Resident #1 was weakness and failure to thrive. Documentation in an admission progress note dated 8/14/2021 at 7:10 AM as a late entry revealed Resident #1 had a laceration to his swollen red ear and his buttocks were red but blanchable. Blanchable indicates there was a temporary obstruction of blood flow to that area. An interview was conducted on 9/7/2021 at 6:30 PM with Nurse #23, who wrote the admission progress note on 8/14/2021 for Resident #1. Nurse #23 explained she had two residents who were declining rapidly with one of those residents being about to expire as well as a resident who needed blood work on her shift 7:00 PM to 7:00 AM beginning on 8/13/2021. Nurse #23 stated she did not recall what time or what day Resident #1 was admitted to the facility. Nurse #23 stated she knew she had to additionally put into the electronic medical record admission assessments for Resident #1. Nurse #23 stated she was not able to complete the admission assessments for Resident #1 and she passed this information on to the next nursing shift. There were no additional skin assessments for Resident #1 until 8/19/2021. The 8/19/2021 skin assessment for Resident #1 indicated his skin was intact without impairment. An interview was conducted on 9/4/2021 at 4:46 PM with Nurse #14 who completed a skin assessment for Resident #1 on 8/19/2021. Nurse #14 stated she worked from 11:00 PM to 7:00 AM on 8/19/2021. Nurse #14 stated she recalled Resident #1 but denied she did any kind of skin assessment on Resident #1. Nurse #14 declared another nurse must have gone into the medical record under her name and documented she did the skin assessment on Resident #1. Resident #1 had an admission minimum data set assessment dated [DATE] which coded him as having moderately impaired cognition with no behaviors or rejection of care. He was coded as always incontinent of bladder and bowel but with no pressure sores. He was coded as at risk for pressure sores and on a pressure reducing device for his bed. Documentation on the care plan for Resident #1, dated as initiated on 8/14/2021, was a focus area for potential for skin impairment. One of the interventions was to perform a weekly skin assessment. There was no other documentation in the medical record of skin assessments for Resident #1 after 8/19/2021. An interview was conducted on 9/4/2021 at 1:30 PM with Nurse #9. Nurse #9 confirmed she was assigned to care for Resident #1 on 8/27/2021 from 7:00 AM to 7:00 PM as well as 8/28/2021 from 7:00 AM to 7:00 PM. Nurse #9 stated she provided incontinent care to Resident #1 around 4:00 PM or 5:00 PM on 8/27/2021. Nurse #9 stated there were no skin concerns for Resident #1 at that time and confirmed she saw no bruising or skin tears. An interview was conducted on 9/3/2021 at 4:48 PM with Nurse Aide (NA #1), who confirmed she cared for Resident #1 on 8/28/2021 and 8/29/2021 for the 7:00 AM to 7:00 PM shift. NA #1 stated she was very busy on 8/28/2021 and only checked on Resident #1 one time during her shift. NA #1 stated on 8/29/2021 she provided incontinent care to Resident #1 two times during her shift. NA #1 did not recall Resident #1 having any skin issues on either day for which she would have to alert the nurse on the hall. An interview was conducted on 9/7/2021 at 6:55 AM with NA #4, who confirmed he cared for Resident #1 on 8/28/2021 for the 7:00 PM to 7:00 AM shift. NA #4 stated he was working short that night with two nurse aides when there were usually three nurse aides. NA #4 stated that evening was the first time he had ever seen Resident #1 and he checked on him every two hours. Na #4 did not recall Resident #1 having any skin concerns or issues. An interview was conducted on 9/4/2021 at 8:00 PM with NA #3, who confirmed he cared for Resident #1 on 8/29/2021 for the 7:00 PM to 7:00 AM shift. NA #3 stated he checked on Resident #1 three or four times, but he really did not need to provide incontinent care because Resident #1 had a foley catheter. NA #3 stated Resident #1 had no skin issues or any bruising. Documentation in the nursing notes dated 8/30/2021 at 7:44 AM stated, Called [Physician Assistant (PA) #1] in regard to [chest x-ray] results. No new orders were obtained at this time. Will f/u today when arrives to facility. Resident afebrile. [Productive] cough noted. Will follow up. Documentation in the nursing notes dated 8/30/2021 at 2:33 PM revealed emergency medical services were called to take Resident #1 to the hospital. Resident #1 was described as unresponsive to voice and painful stimuli receiving 4 liters of oxygen. An interview was conducted on 9/3/2021 at 1:29 PM with Nurse #3, who was assigned to care for Resident #1 on 8/30/2021 from 7:00 AM to 7:00 PM. Nurse #3 stated she was not told of any concerns in nursing report from the previous shift on 8/30/2021. Nurse #3 revealed the Director of Nursing told her of the skin assessments she needed to do when she arrived for her shift, and Resident #1 was one of them. Nurse #3 stated when she arrived, she notified the PA #1 of the chest x-ray results and she knew PA #1 would check on him. Nurse #3 indicated she would have to look in the medical record to confirm what time Resident #1 was sent to the emergency room . Nurse #3 stated when she sent Resident #1 to the hospital, she did a quick skin assessment and did not see anything, not even redness. Nurse #3 confirmed Resident #1 was unresponsive and on 4 liters of oxygen, but she did roll him to look at his skin prior to the arrival of the emergency medical services. Nurse #3 stated she did not document her assessment of his skin prior to his transport to the hospital. The first documentation in the emergency room nursing notes from the hospital for Resident #1 was on 8/30/2021 at 3:13 PM. Review of the emergency room nursing notes dated 8/30/2021 at 7:15 PM revealed, [Patient is laying in bed. [Patient] had cardiac, [blood pressure] and pulse [oximetry] monitor on and temperature foley. [Patient] responds to pain. Previous [Registered Nurse] stated skin breakdown to the back. [Registered Nurse] unable to turn [patient] at this tme, [Registered Nurse] does not have help to turn [patient]. [Patient] is on 6 [Liters per Minute] [Nasal Cannula] of oxygen. Review of emergency room department provider notes revealed Resident #1 was assessed by the first medical doctor in the emergency roiagnom on [DATE] at 3:12 PM. The first medical doctor to assess Resident #1 requested a wound care consult for a sacral decubitus ulcer present on admission. The clinical notes of the hospital record revealed the wound care consultant requested photos of the wound be place on the electronic medical record along with the concerns for review. The death summary portion of the hospital record dated 9/1/2021 at 1:35 AM revealed the preliminary cause of death for Resident #1 was septic shock. In the brief hospital course, the medical record stated, It was also noted [patient] had a severe unstageable spine decubitus ulcer. The death certificate for Resident #1, dated as signed by the adult-gerontology nurse practitioner on 9/1/2021, listed the immediate cause of death as septic shock with contributing causes of pneumonia, sacral decubitus ulcer, and possible meningitis. An interview was conducted with the previous Director of Nursing (DON) on 9/4/2021 at 1:45 PM. The previous DON stated it was facility policy for an admission skin assessment to be completed upon arrival of a new resident and then a weekly skin assessment after that. The previous DON revealed the facility had an agency wound care nurse who was doing treatments and assessments, but the facility terminated her services in the middle of July 2021 putting this responsibility on the hall nurses. An interview was conducted on 9/7/2021 at 10:08 AM with the physician for Resident #1 (MD #1). The MD #1 stated he had looked at the hospital records for Resident #1 when he was sent to the hospital on 8/30/2021. He acknowledged he saw the emergency room physician documentation of a sacral wound and he surmised the emergency room physician did not know what he was looking at. The MD #1 stated he looked at the photo of the sacral area of Resident #1 from the hospital and declared it to be a Kennedy ulcer. The MD #1 further explained the Kennedy ulcer could have appeared in the twenty-four hours Resident #1 sat in the emergency room . The MD #1 stated the wound was clearly a Kennedy ulcer which were notoriously quick in presentation. The MD #1 further explained a Kennedy ulcer was created when blood flow was being diverted and was a part of the disease process at the end of life for some patients. An interview was conducted on 9/13/2021 at 12:56 PM with the wound care consultant who was contacted when Resident #1 was in the emergency room . The hospital wound care consultant confirmed she was asked to provide a wound consult for Resident #1, but she did not see Resident #1 in the emergency room because she was told he was decompensating or failing in health. The wound care consultant revealed she requested photographs of the wound so she could perform a telehealth consult. The wound care consultant stated a Kennedy ulcer usually appears within 24 to 48 hours of a patient's death. The wound care consultant stated if the wound on Resident #1 was a Kennedy terminal ulcer, it would have appeared or started twenty-four to forty-eight hours prior to arrival in the emergency room . The wound care consultant stated, Without documentation as to what his (Resident #1's) skin looked like prior to going to the hospital and without knowing what the sacral area looked like at the nursing home, it can not be determined if this was a deep tissue injury or a Kennedy ulcer. The nursing home administrator was notified of Immediate Jeopardy on 12/10/21 at 8:44 am. The facility provided an acceptable credible allegation of immediate jeopardy removal plan on 12/10/21. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance Resident # 1 admitted on [DATE]. Resident was admitted to the hospital on 8/30/2021 and it was documented in emergency department notes that resident # 1 had a unstageable spinal decubitus ulcer. The facility failed to follow processes related to identification of skin impairments. This deficient practice affects all residents. 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; Current licensed nursing staff were educated by the SDC or designee to complete skin assessments on admission, weekly thereafter and with any new skin impairments. If a new skin impairment is identified, the licensed nurse will notify MD, obtain treatment orders, and update the care plan with other nursing interventions. Education with licensed nurses was completed 10/25/2021. This is tracked by nursing leadership and administrator. Director of Nursing or designee provided education to all licensed nurses, CNAs, and rehab staff on identifying changes of condition, including skin conditions outside of weekly skin assessment and report to the charge nurse for follow up. This was completed 10/25/2021. Alleged date of IJ removal is 10/25/21. Person responsible for implementation is the administrator. On 12/13/21 the facility's credible allegation was validated through record review, staff, and resident interviews. The facility provided education documentation for all staff including the therapy department on identifying and reporting a change in condition especially in skin integrity. In addition, the facility provided signed education sheets on the new system for completing skin assessments. The education provided detailed how all new admissions, re-admissions would have initial, weekly, and as needed skin assessments completed by the nurse. Interviews conducted with the nursing staff validated skin assessments were assigned to each resident and flagged on the Medication Administration Record for the nurse to complete. The nurses interviewed were able to describe with accuracy the new system implemented by the facility. The Director of Nursing (DON) was interviewed and described the ways the new system to ensure skin assessments were completed. She reported all skin assessments were assigned in the electronic medical record on the Medication Administration Record (MAR) to be completed by the nurse on the resident's scheduled shower day. She explained she was responsible for reviewing the assessments daily to ensure all skin assessments had been thoroughly completed. The DON explained that she verified the sheets were completed in detail and not just checked as done. A resident identified by the facility as alert and oriented was interviewed and reported his skin was assessed by the nurse each week during his showers. The credible allegation for the immediate jeopardy with a removal date of 10/25/21 was validated on 12/13/21. 2. Resident #2 was readmitted to the facility on [DATE] with diagnoses of peripheral vascular disease, chronic kidney disease Stage 4, Hypertension, and surgical amputation. The admission minimum data set assessment dated [DATE] revealed Resident #2 was severely cognitively impaired with a stage two pressure wound upon admission and a surgical wound. The care plan, dated 6/30/2021, had a focus area for Resident #2 for a pressure ulcer on her left buttock and potential for pressure ulcer development relative to immobility. One of the interventions was to administer treatments as ordered and monitor for effectiveness. An additional focus area on the care plan for Resident #2 initiated on 6/28/2021 was for the potential for further skin impairment relative to admission with a pressure ulcer and surgical site. One of the interventions was for weekly skin assessments. Review of the electronic medical record revealed a communication with family note dated 9/1/2021 at 7:05 PM for which the responsible party for Resident #2 was informed of a pressure area on the left anterior foot. Review of the electronic medical record for Resident #2 revealed a skin/wound note dated 9/1/2021 at 7:10 PM stating, left anterior foot, pressure area, ppp (peripheral pulse palpable) 2+ Peripheral pulse palpable refers to her pulse being able to be felt in her legs and feet. Documentation in the medical record dated 9/1/2021 for Resident #2 revealed an order for one Xeroform Petrolatum Gauze to be applied to the left anterior heel topically every day shift related to muscle weakness. The 9/1/2021 physician's order for the left anterior heel was discontinued and corrected on 9/3/2021 for the same treatment to be applied twice daily on every day and night shift. Review of the electronic medical record did not reveal a corresponding skin assessment for the left anterior foot for Resident #2. The most recent skin assessment for Resident #2 was dated 8/19/2021 with documentation of a wound and treatment plan for the right knee. The medical record of Resident #2 did not contain skin assessments for the weeks 7/25/2021 to 7/31/2021, 8/9/2021 to 8/14/2021, 8/22/2021 to 8/28/2021, 8/9/2021 to 9/4/2021, and 9/5/2021 to 9/11/2021. An interview was conducted with the Interim Director of Nursing on 9/13/2021 at 4:30 PM. The Interim Director of Nursing confirmed there should be skin assessments completed weekly for Resident #2 as specified in the care plan. The Interim Director of Nursing also confirmed a skin assessment should have been completed on 9/1/2021 to document the pressure area on the left anterior foot of Resident #2.

Based on record review, staff interview, Administrator interview, physician assistant interview, and physician interview the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 3 residents (Resident # 1). Resident #1 was sent to the hospital on [DATE] and expired in the hospital on [DATE]. The cause of death of Resident #1 was determined to be septic shock. Based on record review and resident, staff, and Physician Assistant (PA) interviews the facility failed to obtain pain medication from the pharmacy which delayed medication administration for 1 of 2 residents (Resident #14) reviewed for pain. Immediate Jeopardy began on [DATE] when Resident # 1 entered the facility and the facility did not have effective procedures in place to ensure it accurately acquired and administered the correct medications to meet the needs of its residents, and then errors were not identified on the pharmacist review. The immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation for Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of an E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place are effective and for example 2. Findings included: 1. Cross refer to f757 Based on record review, staff interview, Administrator interview, physician assistant interview, and physician interview the facility failed to administer the correct medications and administered medications without supporting diagnoses for one (Resident #1) of three residents reviewed for unnecessary drugs. The facility failed to recognize the incorrect medications were entered into the electronic medical record system upon admission for Resident #1 resulting in the resident receiving 29 incorrect medications for a period of 8 days. These medications included in part antipsychotics, seizure medication, pain medication, insomnia medication, hypertension medication, diabetic medication, glaucoma medication, and smoking cessation. Resident #1 was admitted to the hospital on [DATE] and expired on [DATE]. 2. Cross refer to f756 Based on record review, staff interview, consultant pharmacist interview, and pharmacy manager interview, the facility consultant pharmacist failed to complete a comprehensive review of a new admission's medications for 1 (Resident #1) of 3 residents reviewed for pharmacy reviews upon admission. Resident #1 received medications ordered for another resident for a period of 8 days. Resident #1 was noted to have a change in condition beginning on [DATE] with a hypotensive episode. Resident #1 continued to decline, suffering from lethargy, dehydration, hypotensive episodes, and inability to swallow until the facility recognized the error in transcription of medication on [DATE]. Resident #1 was sent to the hospital on [DATE] and expired in the hospital on [DATE]. The cause of death of Resident #1 was determined to be septic shock. The administrator was notified of Immediate Jeopardy on [DATE] at 8:44 am. On [DATE] the facility provided an accetable credible allegation of immediate jeopardy removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance Resident # 1 admitted on [DATE]. Upon admission, a charge nurse entered admission orders for resident #1, using a set of discharge orders for a different resident. Per nursing policy, upon receiving admission orders, the nurse will record the order to include the right patient, right name of medication, right dosage, right route, right time and include the diagnosis/reason for use. Because the charge nurse did not verify the patient's name, the wrong orders were entered. The pharmacy received electronic information via the EMR that the patient had arrived at the center, on ,d+[DATE]. The pharmacy did not notify the center that admission orders had not been received, via electronic transmission. Therefore, the resident did not receive medications between ,d+[DATE]-,d+[DATE]. On ,d+[DATE], a nurse confirmed resident's medication orders without verifying discharge orders, and resident began receiving inaccurate medications. Per the medication management policy, upon receiving admission orders, the nurse will record the order to include the right patient, right name of medication, right dosage, right route, right time and include the diagnosis/reason for use. Again, because the charge nurse did not verify the patient's name, the wrong orders were entered. Per pharmacy policy, the facility consultant pharmacist as a part of the contracted pharmacy, will review medication regimen review (MRR) and document the review and findings in a readily retrieval-able format at least monthly, but more frequently under certain conditions, such as upon admission, incorporating federally mandated standards of care in addition to other applicable professional standards. In addition, per policy, the consultant pharmacy will provide the MRR's to the medical director, director of nursing and attending physician within three day once completed, unless there is a significant irregularity, requiring immediate or urgent action. In this case, the policy requires the pharmacist will notify the DON and assigned nurse at the time the irregularity is identified for follow-up and intervention by the nurse, DON and/or physician. In addition, the consultant pharmacy, under contract with the pharmacy, should assure through review that medications are administered at the frequency and times indicated on the prescriber orders. The pharmacy consultant performed the required admission medication regime review on [DATE], but a discharge summary had not been scanned into the EMR, to compare hospital discharge orders to those entered and given the EMR. The facility failed to ensure the complete medical record was available for the pharmacist to complete the MRR and The consultant pharmacist failed to notify the IDT that this information was missing, in order to conduct a complete regimen review, and also failed to notate the patient had a gap in medications between the dates of ,d+[DATE]-[DATE]. Therefore, the consultant pharmacist failed to assure that federally mandated standards of care and professional standards of care were upheld. Orders inaccurately entered for Resident #1 were identified on [DATE] to be orders for a different patient. Orders for this resident were notated as corrected entered, dispensed and administered according to the physician orders. 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; The center identified the error in medications for resident #1 on [DATE] and corrected the errors. Education was provided to all licensed nurses on [DATE] by the DON, SDC or designee on the center's nursing policy related to admission physician orders. Specifically, education stated that upon receiving admission orders, the nurse will record the order to include the right patient, right name of medication, right dosage, right route, right time and include the diagnosis/reason for use. This is to occur with both entering and confirming orders. This provides a check and balance to ensure order entry is correct. Education was provided to the admissions team on [DATE] in order to ensure the discharge summaries are electronically loaded into the EMR, so that the required admission MRR can be completed timely by the consultant pharmacist. The pharmacy consultant was educated on [DATE] to ensure all required MRRs are done within 48 hours of admission, to ensure any serious irregularities are reported immediately by phone to the DON and assigned nurse for immediate intervention, and to report missing information (such as a discharge summary) to the DON, so that it can be received and an MRR can be done according to professional standards. The consultant pharmacist beginning [DATE] conducted MRRs, including dc summaries, for all residents admitted [DATE] and after, according to education provided above. Any discrepancies were noted to the physician for follow-up. The pharmacy contract was terminated and new one started as of [DATE]. For all new admissions, new patient admission alerts are created by the admission team, including the pharmacy, via email. If the pharmacy does not receive admission orders, the pharmacy phones the center to inquire of the patient's arrival, estimated time of arrival and/or cancellation/delay of the admission. This is to ensure medications are dispensed timely for new patient admissions. The assistant director of nursing (ADON) reviewed medication orders for current residents admitted after [DATE] and compared to the hospital discharge summary to ensure accuracy. Any discrepancies were addressed by the physician. This continues to occur as part of our POC# 757 to ensure admission orders are entered correctly, and medications dispensed timely by the pharmacy, and administered by the licensed nurse. Alleged date of IJ removal is [DATE]th 2021 Person responsible for implementation is the administrator. On [DATE] the facility's credible allegation was validated onsite through observations, record review and staff interviews. The facility provided the new pharmacy contract effective [DATE]. In addition, the facility provided an in-service verification sheet signed by the new consultant pharmacist on [DATE]. The education included detailed explanation of the new receipt system for obtaining medications along with the monthly medication review process. The facility also provided in-service education signed by all nurses including agency nurses. The education sheet described the new system for verifying the right resident, right name of medication, right dosage, right route, right time and including the corresponding diagnosis for each medication ordered. Interviews were conducted with nurses who validated the education and were knowledgeable of the new system for entering discharge summaries with medication orders into the electronic medical record. Interviews with the licensed nurses also revealed the delivery system of medications was reconciled to ensure the availability of all ordered medications. The Director of Nursing (DON) was interviewed and described the new system to ensure the correct medications were ordered for the correct resident and obtained from the pharmacy. The credible allegation for immediate jeopardy with a removal date of [DATE] was validated on [DATE]. 38077 3. Resident #14 was readmitted to the facility on [DATE] with diagnosis that included chronic respiratory failure, presence of left artificial shoulder joint, lower back pain, acute kidney failure, chronic pain syndrome and heart failure. Review of Resident #14's quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed the resident was cognitively intact. The resident was coded as having pain with a pain scale of 10 and was on scheduled and as needed (PRN) pain medications. Resident received opioids for 7 of the 7 days during the look back period. Review of the nursing note, dated [DATE], revealed the facility received orders for Resident #14 for pain medications. Note also indicated methadone 10 mg (milligram) by mouth every 8 hours was ordered. Review of the medication order summary report for [DATE] revealed on [DATE] Methadone HCl Tablet 10 MG (milligrams) 1 tablet by mouth every 8 hours was ordered for lower back pain. Review of the Medication Administration record (MAR) for Resident #14 for [DATE] revealed, Methadone HCl 10 MG was not administered from [DATE] to [DATE]. A total of 13 doses were not administered. During an interview on [DATE] at 3:00 PM, Nurse #35 stated she was assigned to the Resident #14 on [DATE] (7AM to 7 PM). Nurse indicated she received verbal orders from the pain clinic related to the new medication. Nurse #35 further indicated when she contacted the pharmacy for medication, they had notified her that they had not received the orders. Nurse stated she contacted the pain clinic on [DATE] to verify if the medications were faxed to the pharmacy. The pain clinic had faxed the medication to the wrong pharmacy. Nurse# 35 further stated the pain clinic was given the correct fax number so that the medications could be faxed to the pharmacy. Nurse # 35 indicated later that evening she did call the pharmacy to find out if they received the script. The pharmacist had informed her that they would have received it if it was faxed to them. During an interview on [DATE] at 9:25 AM, Nurse# 36 indicated she was assigned to the Resident #14 on [DATE] (7AM - 7 PM). She stated she noticed that the medication methadone had not yet arrived from the pharmacy. Nurse #36 stated she notified the Assistant Director of Nursing (ADON) and was informed that the ADON was looking into the issue. Nurse confirmed she did not call the pharmacy for the medication. During a telephone interview on [DATE] at 9:12 AM. Nurse #37 stated she was assigned to the resident on [DATE] and [DATE] (7 AM to 7 PM). She indicated on [DATE] she was given a report that there was a discrepancy in the script sent in by the pain clinic. Nurse # 37 further indicated, she was told that the medication was ordered by pain clinic physician and the pain clinic was closed over the weekend. Nurse #37 stated she did explain to the resident that the pharmacy needed the script from the physician so that pharmacy could dispense the medication. Nurse #37 stated she did not contact the pharmacy regarding the medication. Nurse # 37 stated on [DATE], she did contact the pharmacy. The pharmacy indicated that they were waiting for the script to be signed by the physician. Nurse further stated she did not contact the facility physician as the script was sent by the pain clinic and not the facility physician. During an interview on [DATE] at 1:45 PM, Nurse #21 indicated she was assigned to the Resident #14 on [DATE] (7AM to 7 PM) and had noticed that the medication was not available to be administered to the resident. She stated she called the pharmacy and was informed that a script needs to be signed by the provider. Nurse #21 indicated she faxed a new signed script to the pharmacy that afternoon after it was signed by the PA. During an interview on [DATE] at 10:15 AM, Physician assistant (PA) #1, stated he does not recollect the name of the nurse, but on [DATE] a nurse assigned to the resident had asked him to sign a script for the medication to be sent to the pharmacy. This medication was ordered by the pain clinic. PA #1 stated he did sign the script. During a telephone interview on [DATE] at 11:44 AM, the Assistant Director of Nursing (ADON) indicated Resident #14 had an appointment with pain clinic center on [DATE]. ADON stated on [DATE] at around 4 PM Resident #14 notified her that he did not receive his medication. The ADON stated she had called the pain center to verify the orders and get clarification as to which pharmacy number the order was faxed. ADON further indicated when she called the clinic on [DATE] (Friday), the clinic was closed. ADON stated on [DATE] (Monday), she called the clinic, and the orders were refaxed to the pharmacy. During a telephone interview on [DATE] at 3:10 PM, PA #4, indicated Resident #14 was seen in the pain clinic on [DATE]. PA #4 stated the clinic faxed the script to the pharmacy on [DATE]. On [DATE] the pain clinic received a call from the facility informing them that the script was faxed to a wrong pharmacy and another fax number was provided. The script was re faxed to the pharmacy. During a telephone interview on [DATE] at 11:23 AM, the pharmacy staff stated the pharmacy received the script for methadone on [DATE] and the medication was immediately dispatched to the facility. During a telephone interview on [DATE] at 1:30 PM, the administrator stated the facility had changed pharmacy on [DATE] and this would not have caused the resident not receiving his medication. He stated the residents should receive all medications as prescribed by the physician. He further stated that when medication was unavailable the physician need to be notified for new orders.

Based on record review, staff interview, Administrator interview, physician assistant interview, and physician interview the facility failed to administer the correct medications and administered medications without supporting diagnoses for one (Resident #1) of three residents reviewed for unnecessary drugs. The facility failed to recognize the incorrect medications were entered into the electronic medical record system upon admission for Resident #1 resulting in the resident receiving 29 incorrect medications for a period of 8 days. These medications included in part antipsychotics, seizure medication, pain medication, insomnia medication, hypertension medication, diabetic medication, glaucoma medication, and smoking cessation. Resident #1 was admitted to the hospital on [DATE] and expired on [DATE]. Immediate Jeopardy began on [DATE] when Resident #1 entered the facility and the facility failed to have an effective system in place to order and administer the correct medications. Resident #1 was noted to have a change in condition beginning on [DATE] with a hypotensive episode. Resident #1 continued to decline, suffering from lethargy, dehydration, hypotensive episodes, and inability to swallow until the facility recognized the error in transcription of medication on [DATE]. Resident #1 was sent to the hospital on [DATE] and expired in the hospital on [DATE]. The cause of death of Resident #1 was determined to be septic shock. The immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation for Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of an E (no actual harm with the 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 from the hospital emergency room to the facility on [DATE]. A North Carolina FL-2 form for Resident #1, dated as completed on [DATE] at 1:45 PM was sent to the facility from the hospital. A FL-2 is a North Carolina form that describes a patient's medical condition and the amount of care they need when placed in a facility. Resident #1 had diagnoses listed on the FL-2 form dated [DATE] from the emergency room of Parkinson's disease, chronic obstructive pulmonary disease, esophageal reflux, personal history of transit ischemic attack without residual deficits (2016), Hypertension, prostate cancer (2018), esophageal reflux, cerebral vascular disease, and hyperlipidemia. The FL-2 form also revealed the emergency room admission complaint of Resident #1 was weakness and failure to thrive. The FL-2 form dated [DATE] included documentation attested to by the physician stating Resident #1 was oriented to self, place, time, and situation as well as continent of bowel and bladder. He was also described on the documentation as requiring limited assistance with bathing, feeding, and dressing. A physical therapy evaluation included in the FL-2 dated [DATE] revealed Resident #1 required maximum assistance with getting into the sitting position from laying flat but required minimum assistance from sitting to standing. The hospital physical therapy evaluation noted Resident #1 was able to walk 85 feet with a rolling walker. The same [DATE] FL-2 form also listed the current hospital medication orders for Resident #1 as the following: 81 milligrams (mg) Aspirin (a blood thinner) to be given as one tablet by mouth a day; 10 mg Atorvastatin (treatment of heart disease) to be given as one tablet by mouth a day; 0XXX,d+[DATE].5% Brimonidine-Timolol (eye drops) to be given as one drop in each eye every 12 hours; ,d+[DATE] mg Carbidopa-levodopa (used to treat Parkinson's) to be given as one and half tablets by mouth three times a day; 500 mg Cephalexin (antibiotic) to be given as one capsule by mouth two times a day for 5 days; 1000 units Cholecalciferol (Vitamin D) to be taken as one capsule by mouth once a day; 500 mg Ciprofloxacin (antibiotic) to be taken as one tablet by mouth two times a day for 5 days; 2% Dorzolamide ophthalmic solution (eye drops) to be taken as one drop in both eyes two times a day; 20 mg Doxycycline (used to treat gum disease) to be taken as one tablet by mouth two times a day; 40 mg Famotidine to be taken as one tablet by mouth once a day; 0.005% Latanoprost ophthalmic solution (eye drops) to be taken as one drop in both eyes at bedtime; Multivitamins- Mineral to be taken as one capsule by mouth two times a day; 75 mg Sertraline (used to treat depression) to be taken as one and a half tablets (75 mg total) by mouth one time a day; and 0.4 mg Tamsulosin (used to treat frequent urination) to be taken as one capsule by mouth once a day; 50 mg Trazadone to be taken as one capsule by mouth at bedtime as needed for sleep; 80 mg Valsartan (blood pressure medication)to be taken as one tablet by mouth one time daily; and 1000 microgram (mcg) Vitamin B-12 to be taken by mouth once daily. Documentation in the facility electronic record listed the Resident's diagnoses as being cerebral infarction (principle diagnosis), Parkinson's disease, adult failure to thrive, muscle weakness, chronic obstructive pulmonary disease, gastro-esophageal reflux disease, hyperlipidemia, and Hypertension. An admission nursing progress note dated [DATE] at 7:10 AM as a late entry stated, Received resident to Room [#] via stretcher with medical transport, alert and oriented x 2, skin [warm/dry] to touch denies [complaint of] pain, [abdomen] soft none distended, [Range of Motion] x4, laceration to left ear swollen and red, buttocks red but blanchable. Continent of bladder not bowel. Resident is full code, no [signs/symptoms] of distress noted. Resident in bed resting. An interview with Nurse #23, who wrote the admission progress note on [DATE] for Resident #1, was conducted on [DATE] at 6:30 PM. Nurse #23 revealed Resident #1 was admitted to the facility in the late evening on [DATE] or early morning hours of [DATE]. Nurse #23 also revealed she was very busy on the 7:00 PM to 7:00 AM shift on [DATE] with several residents in distress as well as trying to figure out how to put the new orders into the record for Resident #1. Nurse #23 stated she called to the other nursing unit for assistance. An interview was conducted with Nurse #11 on [DATE] at 2:52 PM. Nurse #11 stated she was working on her nursing unit on [DATE] on the 7:00 PM to 7:00 AM shift when she was approached by a nursing assistant and was asked to go to another unit to assist because another nurse was having a hard time. Nurse #11 revealed she went to the other nursing unit and found a travel nurse (Nurse #23) who did not know how to put orders into the electronic medical system. Nurse #11 indicated it was going to be faster for her to put the orders in rather than show the travel nurse how to put the orders in. Nurse #11 stated she took the hospital emergency room discharge orders for Resident #1 that were on the nursing unit desk and returned to her own nursing unit to put them into the electronic medical record. Nurse #11 stated she called the on-call service at approximately 3:00 AM to have the orders verified. The on-call service connected her to the phone for Physician's Assistant (PA) #1. Nurse #11 stated the phone did not answer and the voice mail box was full. Nurse #11 stated she attempted to call the on-call PA #1 four times. Nurse #11 stated it took her four hours to put the orders into the electronic medical record for Resident #1 due to multiple interruptions every 15 to 20 minutes. Nurse #11 confirmed she had gone down the list to make sure she had put the orders in correctly. According to the Medication Administration Record (MAR) for Resident #1, he did not receive any ordered medications on [DATE] or [DATE]. Documentation on the MAR for Resident #1 revealed he began to receive medications which had been ordered for him by Nurse #11 beginning on [DATE]. Review of the physician orders and the MAR for Resident #1 in the electronic record revealed the following medication orders and their administration: On [DATE] the physician ordered 10 mg of Amlodipine Besylate to be given as one tablet by mouth one time a day for Hypertension and angina. Review of the MAR revealed Resident #1 received two doses under this medication order, one dose on [DATE] and one dose on [DATE]. The order was discontinued on [DATE]. On [DATE] the physician ordered 10 mg Amlodipine Besylate to be given as one tablet by mouth one time a day for Hypertension and angina to be put on hold if the blood pressure diastolic was less than 100. Review of the MAR revealed Resident #1 received one dose on [DATE]. This order was discontinued on [DATE]. On [DATE] the physician ordered 10 mg Amlodipine Besylate Tablet 10 mg to be given as 1 tablet by mouth one time a day for Hypertension and angina to be put on hold if the blood pressure systolic was less than 100. This medication was not discontinued while the resident was in the facility. Review of the MAR revealed Resident #1 received four doses under this medication order: one dose on [DATE], one dose on [DATE], one dose on [DATE], and one dose on [DATE]. On [DATE] the physician ordered 40 mg Atorvastatin Calcium to be given as one tablet by mouth at bedtime for his cholesterol level. This physician's order was for 30 mg more of Atorvastatin Calcium than was ordered on the FL-2 from the hospital for Resident #1. This order was discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received six doses under this medication order: one dose on [DATE], one dose on [DATE], one dose on [DATE], one dose on [DATE], one dose on [DATE], and one dose on [DATE]. On [DATE] the physician ordered 1000 mg of Divalproex Sodium delayed release to be given as two tablets of 500 mg each by mouth one time a day for seizures. This order was discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received five doses under this medication order: one dose on [DATE], one dose on [DATE], one dose on ,d+[DATE]//2021, one dose on [DATE], and one dose on [DATE]. On [DATE] the physician ordered 1500 mg of Divalproex Sodium Delayed Release to be given as three tablets of 500 mg each by mouth at bedtime for seizures. This order was discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received five doses under this medication order: one dose on [DATE], one dose on [DATE], one dose on [DATE], one dose on [DATE], and one dose on [DATE]. On [DATE] the physician ordered 30 mg Duloxetine HCL (hydrochloride) Delayed Release Particles to be given as one capsule by mouth one time a day as an antidepressant. This medication order was discontinued on [DATE]. Review of the MAR revealed Resident #1 received three doses under this medication order: one dose on [DATE], one dose on [DATE], and one dose on [DATE]. On [DATE] the physician ordered 325 mg Ferrous Sulfate to be given as one tablet one time a day for supplementation. This medication was discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received five doses under this medication order: one dose on [DATE], one dose on [DATE], one dose on [DATE], one dose on [DATE], and one dose no [DATE]. On [DATE] the physician ordered 10 mg Fluphenazine HCL to be given as one tablet by mouth at bedtime as an antipsychotic. This order was discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received five doses under this medication order: one dose on [DATE], one dose on [DATE], one dose on [DATE], one dose on [DATE], and one dose on [DATE]. On [DATE] the physician ordered two Lidocaine Patches to be applied to the skin of the affective areas topically one time a day every 12 hours then removed for treatment of pain. No strength for the Lidocaine was listed on the physician's order. This order was discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received three doses under this order: two patches on [DATE], two patches on [DATE], and two patches on [DATE]. On [DATE] the physician ordered 6 mg Melatonin to be given as two tablets of 3 mg each by mouth at bedtime for insomnia. This order was discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received five doses under this medication order: one dose on [DATE], one dose on [DATE], one dose on [DATE], one dose on [DATE], a one dose on [DATE]. On [DATE] the physician ordered 7 mg/24 hours NicoDerm CQ Patch to be applied at 8:00 AM as one patch trans dermally one time a day at for smoking and removal of the patch at 7:59 AM. This order was discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received one patch under this order on [DATE]. On [DATE] the physician ordered 15 mg Olanzapine Tablet to be given as one tablet by mouth at bedtime for a psychotic disorder. This medication order was put on hold on [DATE] and discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received two doses under this medication order: one dose on [DATE] and one dose on [DATE]. On [DATE] the physician ordered a duplicate order for 15 mg Olanzapine Tablet to be given as one tablet by mouth at bedtime for restlessness. This medication order was put on hold on [DATE] and discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received two doses under this medication order: one dose on [DATE] and one dose on [DATE]. On [DATE] the physician ordered a third duplicate order for 15 mg Olanzapine Tablet to be given as one tablet by mouth at bedtime for restlessness. This medication order was put on hold on [DATE] and discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received three doses under this medication order: one dose on [DATE], one dose on [DATE], and one dose on [DATE]. On [DATE] the physician ordered 5 mg Olanzapine to be given as one tablet by mouth two times as day for insomnia. This medication order was put on hold on [DATE] and discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received eleven doses under this medication order: two doses on [DATE], two doses on [DATE], two doses on [DATE], one dose on [DATE], one dose on [DATE], two doses on [DATE], and one dose on [DATE]. On [DATE] the physician ordered 2.5 mg Olanzapine Tablet to be given as one tablet by mouth three times a day for restlessness as needed. This medication order was put on hold on [DATE] and discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received six doses under this medication order: one dose on [DATE], one dose on [DATE], three doses on [DATE], and one dose on [DATE] On [DATE] the physician ordered 17 grams Polyethylene Glycol to be given as one packet by mouth one time a day for constipation. This order was discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received three doses under this medication order: one dose on [DATE], one dose on [DATE], and one dose on [DATE]. On [DATE] the physician ordered 1 mg Prazosin HCL to be given as one capsule by mouth at bedtime for Hypertension. This medication order was discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received four doses under this medication order: one dose on [DATE], one dose on [DATE], one dose on [DATE], and one dose on [DATE]. On [DATE] the physician ordered 40 mg Protonix Tablet Delayed Release to be given as one tablet by mouth one time a day as an acid reducer. This medication order was discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received three doses under this medication order: one dose on [DATE], one dose on [DATE], and one dose on [DATE]. On [DATE] the physician ordered a duplicate order for 40 mg Protonix Tablet Delayed Release to be given as one tablet by mouth one time a day as an acid reducer. This medication order was discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received three doses under this medication order: one dose on [DATE], one dose on [DATE], and one dose on [DATE]. On [DATE] the physician ordered 8.6 mg Senna to be given as one tablet by mouth at bedtime for constipation. This medication order was discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received five doses under this medication order: one dose on [DATE], one dose on [DATE], one dose on [DATE], one dose on [DATE], and one dose on [DATE]. On [DATE] the physician ordered 0.5mg/ml (milliliter) Budesonide Suspension to be administered by inhaling orally two times a day for shortness of breath. This order was discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received nine doses under this medication order: one dose on [DATE], one dose on [DATE], one dose on [DATE], two doses on [DATE], one dose on [DATE], two doses on [DATE], and one dose on [DATE]. On [DATE] the physician ordered 0.5 mg Carboxymethylcellulose Sodium Liquid to be administered as eye drops, two drops in each eye two times a day for treatment of glaucoma. Instill 0.5 mg in both eyes two times a day for glaucoma. This order was discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received six administrations under this medication order: one administration on [DATE], one administration on [DATE], two administrations on [DATE], one administration on [DATE], and one administration on [DATE]. On [DATE] the physician ordered 6.25 mg Carvedilol to be given as one tablet two times a day by mouth for Hypertension. This medication order was discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received nine doses under this medication order: one dose on [DATE], one dose on [DATE], one dose on [DATE], one dose on [DATE], two doses on [DATE], one dose on [DATE], one dose on [DATE], and one dose on [DATE]. On [DATE] the physician ordered 200 mg Celebrex dispensed as written to be given as one capsule by mouth two times a day for pain. This medication order was discontinued on [DATE]. The MAR for Resident #1 revealed he received five doses under this medication order: one dose on [DATE], one dose on [DATE], one dose on [DATE], and one dose on [DATE]. On [DATE] the physician ordered 500 mg Acetaminophen to be given as one tablet by mouth every 8 hours for pain. This medication order was discontinued on [DATE]. The MAR for Resident #1 revealed he received nineteen doses under this medication order: one dose on [DATE], three doses on [DATE], three doses on [DATE], one dose on [DATE], one dose on [DATE], three doses on ,d+[DATE]//2021, three doses on [DATE], two doses on [DATE], and two doses on [DATE]. On [DATE] the physician ordered 100 units/ml (milliliters) Insulin Aspart Solution Pen-Injector to be injected with a pen injector as per sliding scale: If ,d+[DATE] = 4 units, ,d+[DATE] 6 units, ,d+[DATE] 8 units, ,d+[DATE] 10 units; ,d+[DATE] 10 units, 400 to HI 10 units repeat in 2 hours and cover greater than 300 subcutaneously three times a day for insulin give 5 units three times a day repeat finger stick blood sugar in 2 hours and cover as per sliding scale. This medication order was discontinued on [DATE]. The MAR for Resident #1 revealed he had been administered 4 units of insulin [DATE] at 2:00 PM for a blood sugar of 215. On [DATE] the physician ordered 2 grams of Voltran Gel 1 % to be applied to his skin topically three times a day for pain. This medication order was discontinued on [DATE]. Review of the MAR revealed Resident #1 received five doses under this medication order: one dose on [DATE], one dose on [DATE], one dose on [DATE], and one dose on [DATE]. On [DATE] the physician ordered ,d+[DATE] microgram/actuation Combivent Aerosol to be administered with an inhaler as 2 puffs inhaled orally four times a day every four hours for shortness of breath as needed. This medication order was discontinued on [DATE]. Review of the MAR revealed Resident #1 received fifteen doses under this medication order: one dose on [DATE], one dose on [DATE], four doses on [DATE], two doses on [DATE], three doses on [DATE] three doses on [DATE], and one dose on [DATE]. On [DATE] the physician ordered 0.65 mcg (microgram) Sodium Chloride Solution to be administered as one spray in both nostrils four times a day for congestion. This medication order was discontinued on [DATE]. Review of the MAR revealed Resident #1 received twenty two doses of under this medication order: four doses on [DATE], three doses on [DATE], three doses on [DATE], four doses on [DATE], three doses on [DATE], four doses on [DATE], and one dose on [DATE]. On [DATE] at 3:02 PM Physician Assistant (PA #1) wrote an admission progress note. Documentation in the history of present illness indicated Resident #1 was up in the chair ready to eat breakfast and was at the facility for physical and occupational therapy. The documentation further stated on his exam he was slow to speech but had no other acute issues. No medication abnormalities were noted. The care plan for Resident #1, dated [DATE], had a focus area for the resident's use of psychotropic medications (antipsychotics) relative to behavior management. The one intervention was to monitor for side effects and effectiveness. An admission minimum data set (MDS) assessment dated [DATE] coded Resident #1 was having moderately impaired cognition and feeling tired 7 to 11 days of the assessment period. He was coded as requiring extensive assistance with bed mobility and toilet use. He was independent with feeding himself after set-up. He did not transfer, ambulate, or perform locomotion during the assessment period. He was coded as always incontinent of bowel and bladder. He was coded as receiving 5 days of antipsychotics, 3 days of antibiotics, oxygen therapy in the facility, and intravenous medications during the assessment period. On [DATE] PA #1 wrote a progress note stating under history of present illness, Per nursing complaint of patient still more lethargic than baseline. On exam the patient was arousable, will hold medications and monitor for improvement or worsening of condition. I have reviewed labs, he appears mildly dehydrated and will have nursing encourage increased PO fluids. No acute infectious process on chest x-ray. PA #1 did not note any medication irregularities. On [DATE] at 12:19 PM a nursing progress note written by the ADON stated, Reviewed medication list reconciled with [PA #1]. New orders obtained and updated. An interview was conducted on [DATE] at 9:27 AM with the ADON regarding the [DATE] 12:19 PM progress note she wrote. The ADON revealed the physician orders for Resident #1 were mis-transcribed and the physician orders were reviewed and realigned with new physician orders. On [DATE] an initial physician visit progress note was written by the Physician for Resident #1 (MD #1). The impression portion of the note stated, New recent problem. Has improvement with changes in medication. Continue to [rule out] other etiologies with urine and blood work testing. On [DATE] at 11:09 AM nursing notes indicated medications were held for Resident #1. An interview was conducted with PA #1 on [DATE] at 8:15 AM. PA #1 stated he did not recall if he was on call on [DATE], the day Resident #1 was admitted . PA #1 remembered signing off electronically on the medications for Resident #1 on [DATE]. PA #1 stated he was notified by the previous DON the medications given to Resident #1 were ordered for another resident. PA #1 stated, As soon as the DON alerted me, I reviewed his medications and put him on the correct medications. PA #1 did not recall which day the DON notified him of the medication errors, stating it was sometime after [DATE]. The emergency room report dated [DATE] stated in the narrative in part, Nurse stated as we were leaving the room that this was caused by a medication error that put him in this state but she had no other information, unknown where she obtained that information. The hospital discharge summary dated [DATE] at 4:28 AM revealed Resident #1 expired due to septic shock. Review of the death certificate dated [DATE] revealed the immediate cause of death for Resident #1 was septic shock with contributing diagnoses of pneumonia, sacral decubitus ulcer, and possible meningitis. An interview was conducted with the previous Director of Nursing (previous DON) on [DATE] at 1:45 PM. The Director of Nursing stated she was out on medical leave beginning on [DATE] and when she returned on [DATE] she went through to check the paperwork for the new admissions who had come in her absence. She discovered the medications for Resident #1 were transcribed incorrectly and she had no idea where the list of medications ordered for Resident #1 came from. The previous DON revealed she immediately notified her Administrator who told her he would contact the legal department of the corporation. The previous DON stated she notified PA #1 and the Medical Director of the medication errors and the seriousness of the situation on [DATE]. She stated PA #1 told her he would never have approved Resident #1 to be on four orders for Zyprexa. The previous DON stated PA #1 came into the facility on ,d+[DATE]//2021 and went through the medication list for Resident #1 with the ADON to make sure Resident #1 was on the correct medications. She stated the medical director was very alarmed when notified of the medication errors. The previous DON stated the medication errors put him at risk for acute renal injury. The previous DON stated she called Nurse #11 into her office to explain what happened. The previous DON stated she suspended Nurse #11 for two weeks. The previous DON revealed she, herself, quit effectively immediately on the morning of [DATE]. An interview was conducted on [DATE] at 11:38 AM with the facility Administrator. The Administrator stated a root cause analysis was conducted by the facility on [DATE] when the medication errors were discovered. The Administrator stated the previous Director of Nursing and the MDS Nurse (Current Interim DON) discovered the incorrect medications were transcribed into the electronic medical record. The Administrator stated the MDS Nurse recognized Resident #1 was on antipsychotics without a diagnosis for their use, and she then went to the previous DON to question why he was receiving antipsychotics. The facility Administrator stated they did not know where Nurse #11 got the medication orders from for Resident #1, but the medication orders for Resident #1 were corrected. In addition, the Administrator revealed Nurse #11 was counseled so the error would not happen again. The Administrator stated all recent new admissions were audited and no other medication errors were found. An interview was conducted with the resident's physician (MD #1) on [DATE] at 10:08 AM. MD #1 confirmed he was told by the previous DON the wrong medication list was put into the electronic medical record for Resident #1 but he was told the issue was resolved when PA #1 put the correct medications into the medical record. MD #1 was unsure how it happened. MD #1 stated it is the facility policy to have the admitting nurse put the medications from the hospital discharge summary into the electronic medical record to be ordered from the pharmacy when a resident arrives from the hospital. MD #1 explained the orders do not need to be checked or verified by a physician prior to the medications being ordered from the pharmacy. MD #1 stated a physician will reconcile the medications upon an admission assessment. MD #1 explained the physician was only looking to see if the medications logically make sense. MD #1 stated it was the job of the nurse to put the medications into the electronic medical record correctly. On [DATE] at 12:30 PM, the administrator was informed of the immediate jeopardy. The allegation of immediate jeopardy removal indicated: Credible Allegation of Immediate Jeopardy removal: F757 - Unnecessary Drugs Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance Synopsis: Resident was admitted [DATE]. Upon admission, a charge nurse entered inaccurate admission orders and did not confirm the orders. On ,d+[DATE], charge nurse confirmed resident's medication orders and resident began receiving medications. On ,d+[DATE], resident exhibited a change in status and PA placed blood pressure medication on hold and resident on oxygen. On ,d+[DATE], resident was noted to be lethargic and the PA ordered a chest x-ray and lab tests. On ,d+[DATE], the resident was observed to be not alert, had abdominal breathing, and not eating or taking meds. Resident was assessed by DON and ADON and no new orders were received at that time. On ,d+[DATE], PA examined the patient and indicated mild dehydration and ordered to increase PO fluids. On ,d+[DATE], it was discovered in the IDT meeting that medication diagnosis codes were missing. Upon review of the patient's discharge summary, it was discovered that his current meds did not match the discharge summary. An attempt to discover the source of these orders was unsuccessful at the time. PA and medical director were notified. Medications were reconciled and corrected. Later (,d+[DATE]), the ADON, while auditing new admissions since ,d+[DATE], discovered the discharge summary for a different patient that matched what had originally been entered for the resident. The assistant director of nursing (ADON) reviewed medication orders for current residents admitted after [DATE] and compared to the hospital discharge summary to ensure accuracy. Specify the action the entity will take to alter the process or system failure to prevent a serious outcome from occurring or recurring, and when the action will be complete Facility action: Current licensed nursing staff were educated by the SDC or designee regarding procedures for admitting a Resident to include accurate order entry and confirming orders. Education started last week, however, the SDC was made aware ,d+[DATE] of the need to complete further education. Licensed nursing staff on ,d+[DATE] were educated, and all remaining licensed nursing staff will receive education before their next shift. This will be tracked by nursing leadership and administrator. Charge nurse on duty will enter medication orders electronically based on hospital discharge summary and confirm orders. Residents' physician will review and approve new admission orders. The hospital discharge summary will be scanned electronically into miscellaneous file in Resident record. This will be done by admissions or medical records. They were notified ,d+[DATE]. Nursing leadership will complete an admission audit to ensure accuracy of orders within 24 hours. Physician/PA are required to review new admissions with 48 hours of admission. This was confirmed with medical director ,d+[DATE]. PA and MD will be notified of new admissions by email, phone, and/or in person. DON or designee will inform the Medical Director of new admissions weekly to include any concerns with medication or medical status. New patients will also be discussed in weekly meeting between medical director and physician assistants. During weekly meeting between medical director and director of nursing, any questions or concerns about treatment decisions or medication orders will be discussed. The Director of Nursing or designee will ensure implementation of the plan. Planned removal of IJ: [DATE] The credible allegation was verified on [DATE]. Interview with th [TRUNCATED]

Based on record review, staff interview, consultant pharmacist interview, pharmacy manager interview, Administrator interview, Physician Assistant interviews, Physician interview the facility Administration failed to provide effective leadership and oversight of processes and policies and procedures to ensure an effective system was in place to implement medication orders for new admissions for one (Resident #1) of three new admissions; failed to have an effective system in place for new admission medication reconciliation for one (Resident #1) of three new admissions; failed to have an effective system in place for comprehensive pharmacy reviews for one (Resident #1) of three residents with pharmacy reviews. The facility Administration also failed to perform a root cause analysis for the medication errors and implement systematic changes to prevent additional medication errors from occurring until immediate jeopardy was identified for one (Resident #1) of three new admissions. The facility Administration failed to have an effective, comprehensive approach to responding to acute/significant changes in condition to ensure necessary care and services were provided for 1 (Resident #1) of 1 resident reviewed for neglect. Resident #1 received 29 incorrect medications for a period of 8 days. Resident #1 was noted to have a change in condition beginning on [DATE] with a hypotensive episode. Resident #1 continued to decline, suffering from lethargy, dehydration, hypotensive episodes, and inability to swallow until the facility recognized the error in transcription of medication on [DATE]. Resident #1 was sent to the hospital on [DATE] and expired in the hospital on [DATE]. The cause of death of Resident #1 was determined to be septic shock. Immediate Jeopardy began on [DATE] when Resident #1 entered the facility and the facility failed to have effective systems in place to order and administer correct medications; failed to have an effective system in place for new admission medication reconciliation; failed to have a system in place for comprehensive pharmacy reviews; and failed to have a system to effectively address a decline and change in condition. The immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation for Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of an E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place are effective. Example C. for F600 is a scope and severity level of a D (Isolated -No actual harm with potential for more than minimal harm that is not immediate jeopardy.) Findings included: A. Cross refer to F600: Based on record review, staff interviews, Physician Assistant (PA) interviews, Physician interviews, Administrator interview, Interim Director of Nursing (DON) interview, and previous Director of Nursing interview the facility neglected to provide necessary care and services by failing to administer the correct medication; failing to provide effective and ongoing nursing and medical assessments and medical interventions for a resident with an acute/significant change in condition; and failing to implement effective medical intervention for a resident with signs of dehydration for one (Resident #1) of one resident reviewed for neglect. Resident #1 received 29 incorrect medications for a period of 8 days. Resident #1 was noted to have a change in condition beginning on [DATE] with a hypotensive episode. Resident #1 continued to decline, suffering from lethargy, dehydration, hypotensive episodes, and inability to swallow until the facility recognized the error in transcription of medication on [DATE]. Resident #1 was sent to the hospital on [DATE] and expired in the hospital on [DATE]. The cause of death of Resident #1 was determined to be septic shock. B. Cross refer to F756: Based on record review, staff interview, consultant pharmacist interview, and pharmacy manager interview, the facility consultant pharmacist failed to complete a comprehensive review of a new admission's medications for 1 (Resident #1) of 3 residents reviewed for pharmacy reviews upon admission. Resident #1 received medications ordered for another resident for a period of 8 days. Resident #1 was noted to have a change in condition beginning on [DATE] with a hypotensive episode. Resident #1 continued to decline, suffering from lethargy, dehydration, hypotensive episodes, and inability to swallow until the facility recognized the error in transcription of medication on [DATE]. Resident #1 was sent to the hospital on [DATE] and expired in the hospital on [DATE]. The cause of death of Resident #1 was determined to be septic shock. C. Cross refer to F757: Based on record review, staff interview, Administrator interview, physician assistant interview, and physician interview the facility failed to administer the correct medications and administered medications without supporting diagnoses for one (Resident #1) of three residents reviewed for unnecessary drugs. The facility failed to recognize the incorrect medications were entered into the electronic medical record system upon admission for Resident #1 resulting in the resident receiving 29 incorrect medications for a period of 8 days. These medications included in part antipsychotics, seizure medication, pain medication, insomnia medication, hypertension medication, diabetic medication, glaucoma medication, and smoking cessation. Resident #1 was admitted to the hospital on [DATE] and expired on [DATE]. On [DATE] at 12:30 PM, the administrator was informed of the immediate jeopardy. The allegation of immediate jeopardy removal indicated: Credible Allegation of Immediate Jeopardy removal: F835 - Administration Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance Synopsis: Patient received incorrect medications because medications from the wrong discharge summary were entered. A root cause analysis was initiated at the time the mistake was noticed by nursing leadership and the administrator. The nurse who entered the orders was counseled and disciplined and education was provided. We gathered info from this nurse, but she was unable to say where she had gotten these orders. As part of the ongoing chart reviews, the ADON found where these orders originated. They were from the discharge summary of another patient who had not yet admitted but was to admit soon after this patient. The nurse who entered the orders was assisting another nurse, took the paperwork from her, and failed to verify that it was for the correct patient. A 24-hour admission audit was not completed for the patient, allowing him to continue to receive these medications. We failed to have a comprehensive system in place for pharmacy reviews due to the pharmacist not having access to the discharge summary. Additionally, a change of condition was not responded to appropriately. MD educated PA on ,d+[DATE] about appropriate response to change of condition and med reconciliation. The facility determined the root cause of the medication error. A charge nurse inadvertently entered medications from another Resident's discharge summary when she failed to verify that the orders were for the correct patient. Nursing leadership will complete 24-hour admission audits to ensure accuracy of orders. Current policy and procedures will be implemented to provide care to new admissions, provide accurate medications, to identify and treat changes in condition, to provide necessary care and services, and QAPI to address situations and errors with root cause analysis. Corporate nurse consultant has been assisting and will be visiting weekly beginning ,d+[DATE] to assist with plan of correction and observation and oversight of processes. Medical director has been involved in this plan of correction and will be formally meeting with the DON and Administrator weekly to discuss status of plan of correction and any clinical concerns. Specify the action the entity will take to alter the process or system failure to prevent a serious outcome from occurring or recurring, and when the action will be complete Facility Action: The Interdisciplinary team will meet daily 5 X weekly to discuss issues and plans for the day for each department to include status changes with Residents. Residents exhibiting acute changes in condition will be discussed and any identified needs will be directed to the responsible discipline for action. This was reemphasized on ,d+[DATE]. New admissions will be audited within 24 hours by nursing leadership to ensure accuracy of medication orders comparing to hospital discharge summary. Any discrepancies will be corrected at the time of identification. Shift reports (24 hour/72 hour) will be reviewed daily 5 X weekly by nursing leadership and reviewed with the IDT in daily meeting to identify and discuss changes in condition. The DON or designee will complete facility room rounds daily 5 X weekly to ensure necessary care and services are being provided to Residents. Any issues will be corrected at the time of identification. Medical director will meet with physician assistants weekly to discuss patients. This will include patients with acute changes, new patients, patients who are recently had major changes in treatment plans, and any other topics that need to be addressed. During weekly meeting between medical director and director of nursing, any questions or concerns about treatment decisions will be discussed. The Administrator or designee will ensure implementation of the plan. Corporate nurse and VP of operations will conduct weekly visits to provide oversight to administration and to assure systems and processes are in place and effectively being implemented to provide necessary care and services to residents in the facility. Attending physician provided coaching to PA on ,d+[DATE] regarding appropriate management and management of significant changes and med reconciliation. After meds were corrected, patient's lethargy improved. MD saw patient on ,d+[DATE] after meds had been corrected. Planned removal of IJ: [DATE] The credible allegation was verified on [DATE]. Significant change education was provided to all staff on [DATE]. Interview with licensed nursing staff revealed that they look for changes in behavior, eating habits, input/output, or any unusual event to determine change in condition. Evidence of new admission audits were reviewed [DATE]. The facility's credible allegation of immediate jeopardy removal was verified as having been implemented on [DATE].

Based on record review, staff interview, consultant pharmacist interview, and pharmacy manager interview, the facility consultant pharmacist failed to complete a comprehensive review of a new admission's medications for 1 (Resident #1) of 3 residents reviewed for pharmacy reviews upon admission. Resident #1 received medications ordered for another resident for a period of 8 days. Resident #1 was noted to have a change in condition beginning on [DATE] with a hypotensive episode. Resident #1 continued to decline, suffering from lethargy, dehydration, hypotensive episodes, and inability to swallow until the facility recognized the error in transcription of medication on [DATE]. Resident #1 was sent to the hospital on [DATE] and expired in the hospital on [DATE]. The cause of death of Resident #1 was determined to be septic shock. Immediate Jeopardy began on [DATE] when Resident #1 had an initial pharmacy review completed and the facility failed to have a system in place for the facility pharmacist to perform a comprehensive review of the medications ordered for a resident upon admission. The immediate jeopardy was removed on [DATE] when the facility 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 the 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 from the hospital emergency room to the facility on [DATE]. A North Carolina FL2 form for Resident #1, dated as completed on [DATE] at 1:45 PM was sent to the facility from the hospital. A FL-2 is a North Carolina form that describes a patient's medical condition and the amount of care they need when placed in a facility. Resident #1 had diagnoses listed on the FL-2 form from the emergency room of Parkinson's disease, chronic obstructive pulmonary disease, esophageal reflux, personal history of transit ischemic attack without residual deficits (2016), Hypertension, esophageal reflux, cerebral vascular disease, and hyperlipidemia. The FL-2 form also revealed the emergency room admission complaint of Resident #1 was weakness and failure to thrive. The FL-2 form also listed the current hospital medication orders for Resident #1 as the following: 81 mg Aspirin (a blood thinner) to be given as one tablet by mouth a day; 10 mg Atorvastatin (treatment of heart disease) to be given as one tablet by mouth a day; 0XXX,d+[DATE].5% Brimonidine-Timolol (eye drops) to be given as one drop in each eye every 12 hours; ,d+[DATE] mg Carbidopa-levodopa (used to treat Parkinson's) to be given as one and half tablets by mouth three times a day; 500 mg Cephalexin (antibiotic) to be given as one capsule by mouth two times a day for 5 days; 1000 units Cholecalciferol (Vitamin D) to be taken as one capsule by mouth once a day; 500 mg Ciprofloxacin (antibiotic) to be taken as one tablet by mouth two times a day for 5 days; 2% Dorzolamide ophthalmic solution (eye drops) to be taken as one drop in both eyes two times a day; 20 mg Doxycycline (used to treat gum disease) to be taken as one tablet by mouth two times a day; 40 mg Famotidine to be taken as one tablet by mouth once a day; 0.005% Latanoprost ophthalmic solution (eye drops) to be taken as one drop in both eyes at bedtime; Multivitamins- Mineral to be taken as one capsule by mouth two times a day; 75 mg Sertraline (used to treat depression) to be taken as one and a half tablets (75 mg total) by mouth one time a day; and 0.4 mg Tamsulosin (used to treat frequent urination) to be taken as one capsule by mouth once a day; 50 mg Trazadone to be taken as one capsule by mouth at bedtime as needed for sleep; 80 mg Valsartan (blood pressure medication)to be taken as one tablet by mouth one time daily; and 1000 microgram (microgram) Vitamin B-12 to be taken by mouth once daily. Documentation in the facility electronic record listed the Resident's diagnoses as being cerebral infarction (principle diagnosis), Parkinson's disease, adult failure to thrive, muscle weakness, chronic obstructive pulmonary disease, gastro-esophageal reflux disease, hyperlipidemia, and Hypertension. An interview was conducted with Nurse #11 on [DATE] at 2:52 PM. Nurse #11 stated she was working on her nursing unit on [DATE] on the 7:00 PM to 7:00 AM shift when she was approached by a nursing assistant and was asked to go to another unit to assist because another nurse was having a hard time. Nurse #11 revealed she went to the other nursing unit and found an agency nurse (Nurse #23) who did not know how to put orders into the electronic medical system. Nurse #11 indicated it was going to be faster for her to put the orders in rather than show the agency nurse how to put the orders in. Nurse #11 stated she took the hospital emergency room discharge orders for Resident #1 that were on the nursing unit desk and returned to her own nursing unit to put them into the electronic medical record. Nurse #11 stated she called the on-call service at approximately 3:00 AM to have the orders verified. The on-call service connected her to the phone for Physician's Assistant (PA) #1. Nurse #11 stated the phone did not answer and the voice mail box was full. Nurse #1 stated she attempted to call the on-call PA #1 four times. Nurse #11 stated it took her four hours to put the orders into the electronic medical record for Resident #1 due to multiple interruptions every 15 to 20 minutes. Nurse #11 confirmed she had gone down the list to make sure she had put the orders in correctly. According to the medication administration record (MAR) for Resident #1, he did not receive any medications on [DATE] or [DATE]. Documentation on the MAR for Resident #1 revealed he began to receive medications which had been ordered for him by Nurse #11 beginning on [DATE]. Review of the physician orders and the Medication Administration Record (MAR) for Resident #1 in the electronic record revealed the following medication orders and their administration: On [DATE] the physician ordered 10 mg of Amlodipine Besylate to be given as one tablet by mouth one time a day for Hypertension and angina. On [DATE] the physician ordered 10 mg Amlodipine Besylate to be given as one tablet by mouth one time a day for Hypertension and angina to be put on hold if the blood pressure diastolic was less than 100. On [DATE] the physician ordered 10 mg Amlodipine Besylate Tablet 10 mg to be given as 1 tablet by mouth one time a day for Hypertension and angina to be put on hold if the blood pressure systolic was less than 100. On [DATE] the physician ordered 40 mg Atorvastatin Calcium to be given as one tablet by mouth at bedtime for his cholesterol level. This physician's order was for 30 mg more of Atorvastatin Calcium than was ordered on the FL-2 from the hospital for Resident #1. On [DATE] the physician ordered 1000 mg of Divalproex Sodium delayed release to be given as two tablets of 500 mg each by mouth one time a day for seizures. On [DATE] the physician ordered 1500 mg of Divalproex Sodium Delayed Release to be given as three tablets of 500 mg each by mouth at bedtime for seizures. On [DATE] the physician ordered 30 mg Duloxetine HCL (hydrochloride) Delayed Release Particles to be given as one capsule by mouth one time a day as an antidepressant. On [DATE] the physician ordered 325 mg Ferrous Sulfate to be given as one tablet one time a day for supplementation. On [DATE] the physician ordered 10 mg Fluphenazine HCL to be given as one tablet by mouth at bedtime as an antipsychotic. On [DATE] the physician ordered two Lidocaine Patches to be applied to the skin of the affective areas topically one time a day every 12 hours then removed for treatment of pain. No strength for the Lidocaine was listed on the physician's order. On [DATE] the physician ordered 6 mg Melatonin to be given as two tablets of 3 mg each by mouth at bedtime for insomnia. On [DATE] the physician ordered 7 mg/24 hours NicoDerm CQ Patch to be applied at 8:00 AM as one patch trans dermally one time a day at for smoking and removal of the patch at 7:59 AM. On [DATE] the physician ordered 15 mg Olanzapine Tablet to be given as one tablet by mouth at bedtime for a psychotic disorder. On [DATE] the physician ordered a duplicate order for 15 mg Olanzapine Tablet to be given as one tablet by mouth at bedtime for restlessness. On [DATE] the physician ordered a third duplicate order for 15 mg Olanzapine Tablet to be given as one tablet by mouth at bedtime for restlessness. On [DATE] the physician ordered 5 mg Olanzapine to be given as one tablet by mouth two times as day for insomnia. On [DATE] the physician ordered 2.5 mg Olanzapine Tablet to be given as one tablet by mouth three times a day for restlessness as needed. On [DATE] the physician ordered 17 grams Polyethylene Glycol to be given as one packet by mouth one time a day for constipation. On [DATE] the physician ordered 1 mg Prazosin HCL to be given as one capsule by mouth at bedtime for Hypertension. On [DATE] the physician ordered 40 mg Protonix Tablet Delayed Release to be given as one tablet by mouth one time a day as an acid reducer. On [DATE] the physician ordered a duplicate order for 40 mg Protonix Tablet Delayed Release to be given as one tablet by mouth one time a day as an acid reducer. On [DATE] the physician ordered 8.6 mg Senna to be given as one tablet by mouth at bedtime for constipation. On [DATE] the physician ordered 0.5mg/ml (milliliter) Budesonide Suspension to be administered by inhaling orally two times a day for shortness of breath. On [DATE] the physician ordered 0.5 mg Carboxymethylcellulose Sodium Liquid to be administered as eye drops, two drops in each eye two times a day for treatment of glaucoma. Instill 0.5 mg in both eyes two times a day for glaucoma. On [DATE] the physician ordered 6.25 mg Carvedilol to be given as one tablet two times a day by mouth for Hypertension. On [DATE] the physician ordered 200 mg Celebrex dispensed as written to be given as one capsule by mouth two times a day for pain. On [DATE] the physician ordered 500 mg Acetaminophen to be given as one tablet by mouth every 8 hours for pain. On [DATE] the physician ordered 100 units/ml (milliliters) Insulin Aspart Solution Pen-Injector to be injected with a pen injector as per sliding scale: If ,d+[DATE] = 4 units, ,d+[DATE] 6 units, ,d+[DATE] 8 units, ,d+[DATE] 10 units; ,d+[DATE] 10 units, 400 to HI 10 units repeat in 2 hours and cover greater than 300 subcutaneously three times a day for insulin give 5 units three times a day repeat finger stick blood sugar in 2 hours and cover as per sliding scale. On [DATE] the physician ordered 2 grams of Voltran Gel 1 % to be applied to his skin topically three times a day for pain. On [DATE] the physician ordered ,d+[DATE] microgram/ actuation Combivent Aerosol to be administered with an inhaler as 2 puffs inhaled orally four times a day every four hours for shortness of breath as needed. On [DATE] the physician ordered 0.65 mcg Sodium Chloride Solution to be administered as one spray in both nostrils four times a day for congestion. Documentation in the medical record for Resident #1 under assessments revealed a consultant pharmacist admission medication regimen review was completed on [DATE]. The review stated, See report for any noted irregularities and/or recommendations. The facility pharmacist was interviewed on [DATE] at 11:50 AM. The facility pharmacist explained when he did the Admission medication review on Resident #1 on [DATE], he did so remotely and did not have access to the discharge information from the hospital in the electronic medical record. The pharmacist confirmed he did not look at the diagnoses to compare to the medications on the admission medication review. He also explained that most of the medications for Resident #1 had not been transmitted to the pharmacy on [DATE] so he was not able to see them as medication orders. The facility pharmacist further explained he filled out a form in the electronic medical record to say he had noted irregularities for Resident #1, but the actual consultation reports were sent to the Director of Nursing. The pharmacist reported on the consultation report the concern the resident was on two antipsychotics and needed an AIMS test (abnormal involuntary movement scale). An AIMS test is used to detect abnormal movements in patients receiving antipsychotics. The consultant pharmacist stated the two antipsychotics administered to Resident #1 could have led to over sedation and falls. The pharmacist stated he sent his review to the previous DON on [DATE] with the usual expectation it would be acted upon by his next review in 30 days. The pharmacist stated he would not know if his review in this case was acted upon because the facility had a new pharmacy and pharmacist effective [DATE].The pharmacist stated his concerns after reviewing the medication list for Resident from [DATE] to [DATE] was for over sedation and falls as well as for low blood pressure episodes due to a new regimen for Hypertension. An interview was conducted on [DATE] at 9:45 AM with a pharmacy manager for the pharmacy the facility had a contract in [DATE]. The Pharmacy manager stated most of the medication orders for Resident #1 were dated as being put into the electronic medical record on [DATE] but were not transmitted or signed off by the physician until Monday, [DATE] or later. The Pharmacy manager stated there was no way for the pharmacy to know the physician orders were for the wrong resident and the pharmacy relies on the physician and the consultant pharmacist to catch medication order errors. On [DATE] at 12:30 PM, the administrator was informed of the immediate jeopardy. The allegation of immediate jeopardy removal indicated: Credible Allegation of Immediate Jeopardy removal: F756 - Drug Regimen Review Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance Synopsis: Pharmacy consultant performed admission medication review for the patient on [DATE], but a discharge summary had not been scanned into the EMR system. This missing info allowed the resident to continue to receive incorrect medications for eight days without appropriate diagnoses. Fourteen residents admitted on or after ,d+[DATE] had pharmacy consults with irregularities or recommendations that had not been addressed. Current consultant pharmacist was notified on [DATE] and completed a medication review on these Residents. The consultation report was sent to the facility and the ADON will complete on [DATE]. Specify the action the entity will take to alter the process or system failure to prevent a serious outcome from occurring or recurring, and when the action will be complete Facility Action: Consultant pharmacist will review each new admission within ,d+[DATE] hours. This will happen remotely with EMR access. Pharmacist will have access to PointClickCare (PCC), EMAR, and hospital discharge summary in the miscellaneous section of a patient's electronic record. Each review will be electronically documented for facility access. The consultant pharmacist will report any time sensitive recommendations or irregularities to the Director of Nursing via phone. Upon receipt of recommendations, the Director of Nursing will forward to the physician for review and action. The Director of Nursing will provide the Medical Director completed pharmacy recommendations weekly. During a call with the consultant pharmacist on ,d+[DATE], pharmacist informed us she will be visiting the facility to conduct monthly medication review on [DATE]. During the call, DON and administrator instructed consultant pharmacist of location of discharge summary in miscellaneous file in PCC on EMR. Medications will be confirmed at time of admission so that they are accessible for consultant pharmacist to review. Not having confirmed the medications in this instance led to them not being available for the pharmacist to review. Medical director will meet with physician assistants weekly and also meet with director of nursing weekly. During weekly meeting between medical director and director of nursing, any questions or concerns about actual or proposed pharmaceutical changes will be discussed. The Director of Nursing or designee will ensure implementation of the plan. Planned removal of IJ: [DATE] The credible allegation was verified on [DATE]. Review of medical records of new admission revealed a pharmacy review. All medications for new admissions were reviewed by the Pharmacist between ,d+[DATE] hours of facility admission. Facility staff alleged compliance as of [DATE]. The facility's credible allegation of immediate jeopardy removal was verified as having been implemented on [DATE].

Based on record review, staff interviews, Physician Assistant (PA) interviews, Physician interviews, Administrator interview, Interim Director of Nursing (DON) interview, and previous Director of Nursing interview the facility neglected to provide necessary care and services by failing to administer the correct medication; failing to provide effective and ongoing nursing and medical assessments and medical interventions for a resident with an acute/significant change in condition; and failing to implement effective medical intervention for a resident with signs of dehydration for one (Resident #1) of one resident reviewed for neglect. Resident #1 received 29 incorrect medications for a period of 8 days. Resident #1 was noted to have a change in condition beginning on [DATE] with a hypotensive episode. Resident #1 continued to decline, suffering from lethargy, dehydration, hypotensive episodes, and inability to swallow until the facility recognized the error in transcription of medication on [DATE]. Resident #1 was sent to the hospital on [DATE] and expired in the hospital on [DATE]. The cause of death of Resident #1 was determined to be septic shock. Immediate Jeopardy began on [DATE] when Resident #1 entered the facility and the facility failed to have effective systems in place to order and administer correct medications, and to effectively address a decline and change in condition. The immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation for Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of an E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place are effective. Example C. is a scope and severity level of a D (Isolated -No actual harm with potential for more than minimal harm that is not immediate jeopardy.) Findings included: A. Cross Refer to F757: Based on record review, staff interview, Administrator interview, physician assistant interview, and physician interview the facility failed to administer the correct medications and administered medications without supporting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to recognize the incorrect medications were entered into the electronic medical record system upon admission for Resident #1 resulting in the resident receiving 29 incorrect medications for a period of 8 days. These medications included in part antipsychotics, [CONDITION(S)] medication, pain medication, [CONDITION(S)] medication, hypertension medication, diabetic medication, [CONDITION(S)] medication, and smoking cessation. Resident #1 was admitted to the hospital on [DATE] and expired on [DATE]. B. Resident #1 was admitted from the hospital emergency room to the facility on [DATE]. A North Carolina FL-2 form for Resident #1, dated as completed on [DATE] at 1:45 PM was sent to the facility from the hospital. A FL-2 is a North Carolina form that describes a patient's medical condition and the amount of care they need when placed in a facility. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The FL-2 form also revealed the emergency room admission complaint of Resident #1 was weakness and failure to thrive. The FL-2 form dated [DATE] included documentation attested to by the physician stating Resident #1 was oriented to self, place, time, and situation as well as continent of bowel and bladder. He was also described on the documentation as requiring limited assistance with bathing, feeding, and dressing. A physical therapy evaluation included in the FL-2 dated [DATE] revealed Resident #1 required maximum assistance with getting into the sitting position from laying flat but required minimum assistance from sitting to standing. The hospital physical therapy evaluation noted Resident #1 was able to walk 85 feet with a rolling walker. Documentation in the facility electronic record listed the Resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Rehabilitation Manager was interviewed on [DATE] at 2:18 PM and revealed Resident #1 received both occupational and physical therapy assessments on [DATE] revealing the resident was a typical rehabilitation patient and had good potential for therapy improvement. The Rehabilitation Manager stated Resident #1 scored as being severely dependent on the assessment tools they used but he was able on [DATE] to walk 50 feet with a rolling walker. The Rehabilitation Manager added on [DATE] Resident #1 was able to walk 175 feet with the rolling walker. On [DATE] at 4:21 PM Resident #1 was noted in the nursing notes to have had a change in condition. Nurse #12 documented in the nursing note the blood pressure of Resident #1 had dropped, oxygen saturation levels went to 88%, and PA #1 was contacted. Resident #1 was placed on 2 Liters of oxygen and blood pressure medication was ordered to be put on hold. The Director of Nursing was contacted, vital signs were rechecked, and stabilized within the hour. Nurse #12 was interviewed on [DATE] at 1:58 PM and confirmed she was assigned to care for Resident #1 on [DATE] for the 7:00 AM to 7:00 PM shift. Nurse #12 stated Resident #1 was sluggish the whole day, but his blood pressure improved after the blood pressure medications were put on hold. Nurse #12 stated she was concerned about Resident #1 because he was on [CONDITION(S)] medication as well as the multiple blood pressure medications and she felt he needed to be monitored closely. On [DATE] at 7:33 AM Resident #1 was noted in the nursing notes to have had a change in condition where he was noted to be lethargic. The nursing note revealed the Director of Nursing was made aware of the change in condition for Resident #1. Nurse #17, who wrote the nursing note for Resident #1 on [DATE] at 7:33 AM, was interviewed on [DATE] at 7:15 AM and she stated she did not recall the resident or his condition on [DATE]. On [DATE] at 11:17 AM PA #1 wrote a progress note where documentation stated under history of present illness, Per nursing complaint of patient slightly more lethargic than baseline, hypotensive, and decreased O2 (oxygen) sats (saturation levels). On exam the patient was arousable, will hold BP (blood pressure) medication and start O2, monitor for improvement or worsening condition. I have ordered labs (laboratory tests) and CXR (chest x-ray) to check for any infectious process or metabolic disturbance causing the symptoms. No medication abnormalities were noted. Documentation in the progress notes entitled Orders-Administration note on [DATE] at 3:09 PM, 3:11 PM, and 3:12 PM revealed Resident #1 was unable to swallow. Documentation in the nursing notes for Resident #1entitled Change in Condition dated [DATE] at 3:27 PM revealed, Resident appears [asleep] with respirations even and nonlabored. [Vital Signs] stable. [PA #1] assessed resident this shift and gave new orders to obtain [Urgent] labs & Chest x-ray [due to] health decline. [Emergency Contact #1] was on site and made aware of change of condition & new orders. Currently awaiting results. A basic metabolic panel results for Resident #1 came back on [DATE] at 6:29 PM with the abnormalities of a high BUN (Blood Urea [MEDICATION(S)]) of 37.8 mg (milligrams)/dl (deciliters) (normal values are 6.,d+[DATE].0 mg/dl) and BUN/Creatinine ratio of 44.0 (normal values are 6.,d+[DATE].0). PA #1 signed the laboratory results as reviewed on [DATE] at 8:23 AM. The chest x-ray results for Resident #1were ordered on [DATE] at 2:00 PM were reported on [DATE] at 8:10 PM. The chest x-ray impression was bilateral basilar atelectasis and left effusion. Bilateral basilar atelectasis is defined as both sides of the lowermost lobes of the lungs are collapsed entirely or partially. Left effusion is defined as a build-up of fluid in the area between the layers of tissue that line the lungs and the chest wall. The chest x-ray results were signed as reviewed by PA #1 on [DATE] at 8:17 AM. Documentation in the nursing notes for Resident #1 entitled Change in Condition dated [DATE] at 12:12 AM revealed the physician for Resident #1 (MD #1) was notified of the chest x-ray results with no new orders given. Documentation in the progress notes entitled Orders-Administration note on [DATE] at 9:48 AM revealed Resident #1 was unable to take medication due to difficulty breathing. On [DATE] at 11:16 AM a nursing note written by Nurse #21 stated, Resident (#1) is currently resting in bed. Resident is not alert and oriented. Vitals are within normal range at (Blood pressure) ,d+[DATE], [Pulse] 82, O2 99 %, [Temperature] 97.4, [Respirations] 22 Resident is abdominal breathing with mouth open. Resident on 3.5 Liters of oxygen. [Capillary Blood Glucose] 174 no insulin needed. Resident consumed 0 percent of breakfast. Medication on hold due to resident not being alert. ADON (Assistant Director of Nursing) and doctor is aware of resident's condition. Will continue to monitor resident's vitals. Nurse #21, wrote the progress note on [DATE] at 11:16 AM, was interviewed on [DATE] at 1:43 PM. Nurse #21 stated she had concern for Resident #1 on [DATE]. Nurse #21 described Resident #1 on [DATE] as not being able to swallow and he did not have a feeding tube to obtain nutrition or hydration. Nurse #21 explained this was her first time caring for Resident #1 and his baseline was unknown to her. Nurse #21 stated she notified the physician and her Director of Nursing. Nurse #21 indicated her nursing judgement told her Resident #1 needed to go to the hospital. Nurse #21 explained she noted he was his own responsible party, but she saw he was not arousable indicating he had a major change in condition from his arrival at the facility. Nurse #21 stated her concern grew when she spoke with the family of Resident #1 to update them on the resident's condition. Nurse #21 stated the DON and the ADON went to assess Resident #1 but did not want him sent to the hospital. Nurse #21 stated PA #1 also did not want him sent to the hospital but for her to continue to monitor his condition. An interview with the ADON was conducted on [DATE] at 4:00 PM. The ADON stated she did an assessment on [DATE] to determine if Resident #1 had another stroke but after an assessment he did not seem critical enough to send to the hospital. The ADON explained her assessment was focused on assessing if he had any deficits to indicate he had another stroke such as inability to speak or weakness in his extremities. The ADON explained she thought the resident was at his baseline. An admission minimum data set (MDS) assessment dated [DATE] coded Resident #1 was having moderately impaired cognition and feeling tired 7 to 11 days of the assessment period. He was coded as requiring extensive assistance with bed mobility and toilet use. He was independent with feeding himself after set-up. He did not transfer, ambulate, or perform locomotion during the assessment period. He was coded as always incontinent of bowel and bladder. He was coded as receiving 5 days of antipsychotics, 3 days of antibiotics, oxygen therapy in the facility, and intravenous medications during the assessment period. There were no nursing notes or documentation in the medical record on the condition of Resident #1 on Saturday, [DATE] or Sunday, [DATE]. On [DATE] at 9:41 AM the progress notes entitled Orders- Administration note for Resident #1 stated, Unable to swallow. An interview was conducted on [DATE] with Nurse #22, who wrote the [DATE] administration note at 9:41 AM. Nurse #22 stated she contacted PA #1 because she had great concern for Resident #1, and she wanted to know what was going on. Nurse #22 described Resident #1 as really passed out and not responding at all. Nurse #22 said she was told by PA #1 he was aware of the condition of the resident, he had ordered laboratory tests, and she was told to continue to monitor the resident. On [DATE] an initial physician visit progress note was written by the Physician for Resident #1 (MD #1). The impression portion of the note stated, New recent problem. Has improvement with changes in medication. Continue to [rule out] other etiologies with urine and blood work testing. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #1) for Resident #1 gave a verbal order for one liter of [MEDICATION(S)] solution 0.9% to be administered intravenously at a rate of 75 cc (cubic centimeters)/hour until [DATE] for dehydration. On [DATE] at 11:30 AM nursing notes revealed peripheral intravenous fluids were started for Resident #1. On [DATE] at 1:14 PM nursing progress notes revealed Resident #1 had a blood pressure of ,d+[DATE] and the ADON advised for oxygen levels to be increased. The documentation in the note also revealed PA #2 was called and additional laboratory tests were ordered to include a complete blood count, basic metabolic panel, and a chest x-ray. An interview was conducted on [DATE] at 12:30 PM with Nurse #9, who wrote the [DATE] 1:14 PM nursing note. Nurse #9 stated when she came into to work on [DATE] she was told in report Resident #1 had overdosed on blood pressure medication and was no longer able to stand or feed himself. Nurse #9 stated she really thought Resident #1 needed to be sent to the hospital because of the low blood pressure and a rectal temperature of 99.9 degrees. Nurse #9 confirmed she also worked on the 7:00 AM to 7:00 PM shift caring for Resident #1 on [DATE]. Nurse #9 stated she continued to have concern for Resident #1 because he was very confused and out of it. Nurse #9 stated her nursing judgement told her he needed to be sent out to the hospital. Nurse #9 stated she relayed her concerns to the DON and the PA but neither felt it was necessary to send Resident #1 to the hospital. Nurse #9 stated she knew that if she sent Resident #1 to the hospital, she would be disciplined like some of the other nurses had been who sent residents to the hospital. An interview was conducted with PA #2 on [DATE] at 11:15 AM. PA #2 revealed Resident #1 appeared to have altered mental status and drowsy but was not lethargic. PA #2 stated she was not as familiar with this resident and thought blood tests and a repeat chest x-ray were ordered. PA #2 did not recall a request being made to send the resident to the hospital. On [DATE] at 3:23 PM an order note documented an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Laboratory results reported on [DATE] at 4:46 PM flagged at low hemoglobin 13.8 g (grams)/dl (normal range of 14.,d+[DATE].0 g/dl), high glucose 118 (normal range of ,d+[DATE] mg/dl), low calcium 8.5 (normal range of 8.,d+[DATE].2), a high BUN of 65.5 (normal range of 6.,d+[DATE].0 mg/dl), a BUN/[MEDICATION(S)] ratio of 54.6, and a sodium of 147 (normal range is ,d+[DATE] mmol (millimole)/L (liter). A physical therapy progress note dated [DATE] for Resident #1 stated, Did well the first two days (in facility) but has struggled to perform interventions without considerable assistance. The chest x-ray results ordered on [DATE] for Resident #1 were dated as reported on [DATE] at 1:15 PM. The results stated in part under the impression, There are mild patchy bibasilar densities compatible with pneumonia or less likely atelectasis. An interview was conducted on [DATE] at 6:48 PM with Nurse #19, who cared for Resident #1 on the 7:00 PM to 7:00 AM shift on [DATE]. Nurse #19 recalled Resident #1 was very sedated when she started her shift on [DATE]. Nurse #19 stated she was told just to monitor him. Nurse #19 further stated the only thing she remembered was Resident #1 slept her entire shift. An interview was conducted on [DATE] at 2:45 PM with Nurse #10. Nurse #10 revealed she was not assigned to care for Resident #1 on the 7:00 PM to 7:00 AM shift on [DATE]. Nurse #10 explained she took over two medications carts because the agency nurse for one of the medication carts could not get log in information to access the electronic records despite numerous attempts to get help from the information technology team. An interview was conducted on [DATE] at 6:51 PM with Nurse #24, who was assigned to care for Resident #1 on the 7:00 PM to 7:00 AM shift on [DATE]. Nurse #24 confirmed she received report from Nurse #9 on [DATE] and did not recall any concerns regarding Resident #1 being given to her. Nurse #9 stated her major concern was she did not have access to the electronic medical records despite numerous attempts to obtain information technology assistance. Nurse #24 stated she was not familiar with any of the residents and stated none of the residents were unresponsive with most of them sleeping on the shift. An interview was conducted on [DATE] at 1:51 PM with Nurse #4, who cared for Resident #1 on the 7:00 AM to 7:00 PM shift on [DATE]. Nurse #4 revealed [DATE] was the first time she had ever cared for Resident #1. Nurse #4 did not recall if he was receiving intravenous fluids on her shift or not. Nurse #4 did not recall being told to monitor Resident #1, but she recalled being told by the nurse aide he slept all day. An interview was conducted on [DATE] at 6:43 AM with Nurse #8, who cared for Resident #1 on the 7:00 PM to 7:00 AM shift on [DATE]. Nurse #8 stated Resident #1 had low oxygen level on his shift, and he heard in report from the previous nurse the resident had pneumonia, but he was to only monitor him and not send him out. Nurse #8 stated he gave Resident #1 continuous oxygen and he improved by the end of his shift. Nurse #8 stated he had to leave his shift early at 6:30 PM and he gave a nursing report to Nurse #10, who was on another hall on his shift. An interview was conducted on [DATE] at 1:29 PM with Nurse #3, who was assigned to care for Resident #1 beginning on [DATE]. Nurse #3 recalled when Resident #1 was first admitted to the facility he was up with physical and occupational therapy walking and talking. Nurse #3 explained that by the time he was moved to another hallway he was just not the same. Nurse #3 stated she heard from occupational therapy Resident #1 could no longer walk, eat on his own, or sit on the edge of the bed. Nurse #3 also stated she heard from occupational therapy Resident #1 received three blood pressure pills he was not supposed to get. Nurse #3 stated she did not work on [DATE] through [DATE] and when she came back Resident #1 had really changed. Nurse #3 stated she received no information regarding Resident #1 in report on the morning of [DATE]. Nurse #3 stated Resident #1 was unresponsive and didn't look right so she called PA #1 who told her he would see the resident as soon as he arrived at the facility. Nurse #1 stated when PA #1 arrived he told her to hold all his medications. Nurse #3 stated she started her nursing duties which involved first getting blood sugars, blood pressures, vital signs and then passing out morning medications. Nurse #3 stated she also had skin assessments she needed to do after the medication pass. In addition, she explained she was on the behavior unit, so she needed to watch out for wandering residents. Nurse #3 also explained she started giving out the medications to the residents who were known to her and then the new residents, Resident #1 was going to be last because his medications were on hold. Nurse #3 stated she did not recall what time she sent Resident #1 to the hospital. There were no documented vitals in the medical record for Resident #1 on [DATE] prior to 2:33 PM. Documentation in the nursing notes written by Nurse #3 on [DATE] at 2:33 PM stated, Resident unresponsive to voice and painful stimuli. PA (#1) and ADON notified of declining status and vitals (Temperature) 99.3, (Pulse) 65, (Blood pressure) ,d+[DATE], (O2) 89 % on 4 [Liters] of O2. No urine output in foley. PA [#1] ordered resident to be sent to [Emergency Department] for further evaluation, [Emergency contact #1] resident emergency contact also notified of the changes. The emergency room report dated [DATE] stated in the narrative in part, [Resident #1] laying supine in his bed unresponsive but breathing. Nurse in room advised he has been unresponsive since at least 7 AM when she began shift this morning. Nurse also stated that he is normally alert and talking. Noted [patient's] skin was hot to touch, and radial pulses were absent. The hospital discharge summary dated [DATE] at 4:28 AM revealed Resident #1 expired due to septic shock. Review of the death certificate dated [DATE] revealed the immediate cause of death for Resident #1 was septic shock with contributing diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted on [DATE] at 4:00 PM with the ADON. The ADON stated on [DATE] she arrived at the facility around 2:00 PM because she was going to be supervising the night shift that day. The ADON stated shortly after she arrived PA #1 arrived to assess Resident #1, who the facility staff had been working all weekend to stabilize. The ADON stated she saw Resident #1 on [DATE] and he was okay. The ADON revealed when she did her assessment at 2:00 PM on [DATE] Resident #1 was not responding to painful stimuli. An interview was conducted with PA #1 on [DATE] at 8:15 AM. PA #1 revealed on [DATE] he was on his way to the facility when he received a phone call notifying him of the chest x-ray results for Resident #1. PA #1 indicated he told the nurse he would assess Resident #1 as soon as he arrived at the facility and gave a verbal order for an antibiotic for the resident. PA #1 recalled he told the nurse to send the resident out as soon as he saw him in the facility that morning. PA #1 stated Resident #1 was debilitated upon admission and did not think the medication errors necessarily contributed to his decline. A subsequent interview was conducted on [DATE] at 2:07 PM with PA #1. PA #1 corrected his version of the events of [DATE] during which Resident #1 was sent to the hospital. PA #1 confirmed he saw Resident #1 on the morning of [DATE] and he appeared lethargic, so he ordered more laboratory tests and continued monitoring. PA #1 stated Resident #1 had no signs of infection and his vital signs were good. PA #1 stated he had left for another facility when he received a phone call around 1:00 PM informing him Resident #1 was unresponsive and needed to be sent to the hospital. An interview was conducted on [DATE] at 10:08 AM with the Physician (MD #1) for Resident #1. MD #1 explained if the facility nurses had a resident concern and wanted someone evaluated to be sent to the emergency room it was facility policy to reach out to the Director of Nursing or a Physician. MD #1 explained, previously the nurses were sending residents to the hospital without letting anybody in administration know. MD #1 stated there was a chain of command and the nurses can certainly send a resident to the hospital if needed but someone on the administrative level needed to know. MD #1 stated it was critical the nurses in the facility reach out if he or she has a concern for a resident. C. Cross refer to F692: Based on record review, staff interview, Physician Assistant interview, and Medical Doctor interview the facility failed to take immediate measures to prevent dehydration for one (Resident #1) of one resident reviewed for dehydration. On [DATE] at 12:30 PM, the administrator was informed of the immediate jeopardy. The allegation of immediate jeopardy removal indicated: Credible Allegation of Immediate Jeopardy removal: F600 - Abuse and Neglect Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance Synopsis: Resident was admitted [DATE]. Upon admission, a charge nurse entered inaccurate admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On ,d+[DATE], resident exhibited a change in status and PA placed blood pressure medication on hold and resident on oxygen. On ,d+[DATE], resident was noted to be lethargic and the PA ordered a chest x-ray and lab tests. On ,d+[DATE], abnormal lab results returned with elevated BUN and creatinine levels. On ,d+[DATE], the resident was observed to be not alert, had abdominal breathing, and not eating or taking meds. Resident was assessed by DON and ADON and no new orders were received at that time in response to resident's change in condition. No additional assessment or documentation was present on ,d+[DATE] or ,d+[DATE]. Then, on ,d+[DATE], PA examined the patient and indicated mild dehydration and ordered to increase PO fluids. On ,d+[DATE], it was discovered in the IDT meeting that medication diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident did not receive the medications that he should have received until ,d+[DATE]. An attempt to discover the source of these orders was unsuccessful at the time. PA and medical director were notified. Medications were reconciled and corrected. Later (,d+[DATE]), the ADON, while auditing new admissions since ,d+[DATE], discovered the discharge summary for a different patient that matched what had originally been entered for the resident. If the charge nurse disagrees with the decision from physician extenders, DON and/or attending physician for need for higher level of care, notify administrator who will notify medical director to make the call. Administrator notified nursing leadership of this on ,d+[DATE]. SDC or designee will notify all nurses working currently and the remainder before their next shift. On ,d+[DATE], DON spoke with every charge nurse and instructed each charge nurse to observe and assess each patient for any signs of acute change of condition. A census sheet was used to ensure each current resident was observed. DON reviewed this list once it was complete to ensure residents had been observed. Based on this, two acute changes were identified. One resident had refused [CONDITION(S)]. Nurse assessed patient for signs of fluid overload, educated patient on importance of receiving [CONDITION(S)], and MD and RP were notified. Care plan was updated to include refusal of [CONDITION(S)]. The second patient was noted to have decreased intake. NP was informed and gave verbal order to increase oral intake of fluids, and RP was notified. Specify the action the entity will take to alter the process or system failure to prevent a serious outcome from occurring or recurring, and when the action will be complete Facility Action: Current licensed nursing (nurses and CNAs) and rehab staff were educated by the staff development coordinator or designee regarding identification, reporting, and documentation of acute/significant changes in condition to be completed by [DATE]. The staff development coordinator or designee will educate licensed nurses to notify Administrator if they disagree with the decisions from PA/NP, attending physician, and/or DON starting [DATE] to be completed for additional nurses before their next scheduled shift. Any agency staff will be educated before their next scheduled shift. The staff development coordinator will communicate the scheduler to identify when agency staff are scheduled and educate them before their shift. All staff will receive abuse/neglect education via our SDC using the Relias learning system during their next scheduled shift. Any who have not received this by ,d+[DATE] will be taken off the schedule until they do. Our SDC is notifying staff and presenting the Relias presentation to them. Nurse aides will notify charge nurses verbally for any observed change in resident status. Charge nurses will observe/assess patient. If any acute significant change is observed, charge nurse will notify physician. Recommendations will be implemented, and nursing leadership will be notified. If the charge nurse disagrees with the decision from physician extenders (PAs, NPs), DON, and/or attending physician for need for higher level of care, the Administrator will be notified who will then notify the Medical Director to make the call. Patient will be observed, and a progress note will be written every shift until the situation is resolved. Shift reports (24 hour/72 hour) will be reviewed by nursing leadership daily 5 X weekly to identify and follow up acute/significant changes in condition. PA will assess patients who have had a change of condition and provide a list of these patients to nursing leadership. Nursing leadership will verify that orders were implemented and report any questions or concerns to the PA. The DON will meet with the Medical Director and PA weekly on the status of Residents with acute significant changes in condition. Medical director will meet with physician assistants to discuss any concerns coming from the weekly meeting with the DON. Nursing leadership will review Residents experiencing changes in condition during daily (5 X weekly) morning IDT meetings. Medical director has been in contact with administrator, nurse consultant, DON, and ADON during this process and is committed to these weekly meetings moving forward. Medical director will meet with physician assistants weekly to discuss patients. This will include patients with acute changes, new patients, patients who are recently had major changes in treatment plans, and any other topics that need to be addressed. During weekly meeting between medical director and director of nursing, any questions or concerns about treatment decisions will be discussed. The Director of Nursing or designee will ensure implementation of the plan. Planned removal of IJ: [DATE] Attending physician provided coaching to PA on ,d+[DATE] regarding appropriate management and management of significant changes and med reconciliation. After meds were corrected, patient's lethargy improved. MD saw patient on ,d+[DATE] after meds had been corrected. The credible allegation was verified on [DATE] as evidenced by interviews with staff both nursing assistants and nurses. Nursing staff, nursing assistants reported receiving education on regarding preventing abuse and neglect and recognizing a change in condition and medical provider notification of change. Per review of documentation all residents with change in condition were reviewed in daily IDT meetings and the DON meet weekly with the MD since alleged compliance date of [DATE]. The facility's credible allegation of immediate jeopardy removal was verified as having been implemented on [DATE].

Based on record review, staff interview, Administrator interview, physician assistant interview, and physician interview the facility failed to administer the correct medications and administered medications without supporting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to recognize the incorrect medications were entered into the electronic medical record system upon admission for Resident #1 resulting in the resident receiving 29 incorrect medications for a period of 8 days. These medications included in part antipsychotics, [CONDITION(S)] medication, pain medication, [CONDITION(S)] medication, hypertension medication, diabetic medication, [CONDITION(S)] medication, and smoking cessation. Resident #1 was admitted to the hospital on [DATE] and expired on [DATE]. Immediate Jeopardy began on [DATE] when Resident #1 entered the facility and the facility failed to have an effective system in place to order and administer the correct medications. Resident #1 was noted to have a change in condition beginning on [DATE] with a hypotensive episode. Resident #1 continued to decline, suffering from lethargy, dehydration, hypotensive episodes, and inability to swallow until the facility recognized the error in transcription of medication on [DATE]. Resident #1 was sent to the hospital on [DATE] and expired in the hospital on [DATE]. The cause of death of Resident #1 was determined to be septic shock. The immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation for Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of an E (no actual harm with the 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 from the hospital emergency room to the facility on [DATE]. A North Carolina FL-2 form for Resident #1, dated as completed on [DATE] at 1:45 PM was sent to the facility from the hospital. A FL-2 is a North Carolina form that describes a patient's medical condition and the amount of care they need when placed in a facility. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The FL-2 form also revealed the emergency room admission complaint of Resident #1 was weakness and failure to thrive. The FL-2 form dated [DATE] included documentation attested to by the physician stating Resident #1 was oriented to self, place, time, and situation as well as continent of bowel and bladder. He was also described on the documentation as requiring limited assistance with bathing, feeding, and dressing. A physical therapy evaluation included in the FL-2 dated [DATE] revealed Resident #1 required maximum assistance with getting into the sitting position from laying flat but required minimum assistance from sitting to standing. The hospital physical therapy evaluation noted Resident #1 was able to walk 85 feet with a rolling walker. The same [DATE] FL-2 form also listed the current hospital MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] .,d+[DATE].5% [MEDICATION(S)]-[MEDICATION(S)] (eye drops) to be given as one drop in each eye every 12 hours; ,d+[DATE] mg [MEDICATION(S)]-[MEDICATION(S)] (used to treat [CONDITION(S)]) to be given as one and half tablets by mouth three times a day; 500 mg [MEDICATION(S)] (antibiotic) to be given as one capsule by mouth two times a day for 5 days; 1000 units [MEDICATION(S)] (Vitamin D) to be taken as one capsule by mouth once a day; 500 mg [MEDICATION(S)] (antibiotic) to be taken as one tablet by mouth two times a day for 5 days; 2% Dorzolamide ophthalmic solution (eye drops) to be taken as one drop in both eyes two times a day; 20 mg [MEDICATION(S)] (used to treat gum disease) to be taken as one tablet by mouth two times a day; 40 mg [MEDICATION(S)] to be taken as one tablet by mouth once a day; 0.005% [MEDICATION(S)] ophthalmic solution (eye drops) to be taken as one drop in both eyes at bedtime; Multivitamins- Mineral to be taken as one capsule by mouth two times a day; 75 mg [MEDICATION(S)] (used to treat depression) to be taken as one and a half tablets (75 mg total) by mouth one time a day; and 0.4 mg Tamsulosin (used to treat frequent urination) to be taken as one capsule by mouth once a day; 50 mg Trazadone to be taken as one capsule by mouth at bedtime as needed for sleep; 80 mg [MEDICATION(S)] (blood pressure medication)to be taken as one tablet by mouth one time daily; and 1000 microgram (mcg) Vitamin B-12 to be taken by mouth once daily. Documentation in the facility electronic record listed the Resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission nursing progress note dated [DATE] at 7:10 AM as a late entry stated, Received resident to Room [#] via stretcher with medical transport, alert and oriented x 2, skin [warm/dry] to touch denies [complaint of] pain, [abdomen] soft none distended, [Range of Motion] x4, laceration to left ear swollen and red, buttocks red but blanchable. Continent of bladder not bowel. Resident is full code, no [signs/symptoms] of distress noted. Resident in bed resting. An interview with Nurse #23, who wrote the admission progress note on [DATE] for Resident #1, was conducted on [DATE] at 6:30 PM. Nurse #23 revealed Resident #1 was admitted to the facility in the late evening on [DATE] or early morning hours of [DATE]. Nurse #23 also revealed she was very busy on the 7:00 PM to 7:00 AM shift on [DATE] with several residents in distress as well as trying to figure out how to put the new orders into the record for Resident #1. Nurse #23 stated she called to the other nursing unit for assistance. An interview was conducted with Nurse #11 on [DATE] at 2:52 PM. Nurse #11 stated she was working on her nursing unit on [DATE] on the 7:00 PM to 7:00 AM shift when she was approached by a nursing assistant and was asked to go to another unit to assist because another nurse was having a hard time. Nurse #11 revealed she went to the other nursing unit and found a travel nurse (Nurse #23) who did not know how to put orders into the electronic medical system. Nurse #11 indicated it was going to be faster for her to put the orders in rather than show the travel nurse how to put the orders in. Nurse #11 stated she took the hospital emergency room discharge orders for Resident #1 that were on the nursing unit desk and returned to her own nursing unit to put them into the electronic medical record. Nurse #11 stated she called the on-call service at approximately 3:00 AM to have the orders verified. The on-call service connected her to the phone for Physician's Assistant (PA) #1. Nurse #11 stated the phone did not answer and the voice mail box was full. Nurse #11 stated she attempted to call the on-call PA #1 four times. Nurse #11 stated it took her four hours to put the orders into the electronic medical record for Resident #1 due to multiple interruptions every 15 to 20 minutes. Nurse #11 confirmed she had gone down the list to make sure she had put the orders in correctly. According to the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Documentation on the MAR for Resident #1 revealed he began to receive medications which had been ordered for him by Nurse #11 beginning on [DATE]. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE] the physician ordered 10 mg of [MEDICATION(S)] to be given as one tablet by mouth one time a day for Hypertension and [CONDITION(S)]. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was discontinued on [DATE]. On [DATE] the physician ordered 10 mg [MEDICATION(S)] to be given as one tablet by mouth one time a day for Hypertension and [CONDITION(S)] to be put on hold if the blood pressure diastolic was less than 100. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was discontinued on [DATE]. On [DATE] the physician ordered 10 mg [MEDICATION(S)] Tablet 10 mg to be given as 1 tablet by mouth one time a day for Hypertension and [CONDITION(S)] to be put on hold if the blood pressure systolic was less than 100. This medication was not discontinued while the resident was in the facility. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] the physician ordered 40 mg [MEDICATION(S)] Calcium to be given as one tablet by mouth at bedtime for his cholesterol level. This physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #1. This order was discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received six doses under this medication order: one dose on [DATE], one dose on [DATE], one dose on [DATE], one dose on [DATE], one dose on [DATE], and one dose on [DATE]. On [DATE] the physician ordered 1000 mg of [MEDICATION(S)] delayed release to be given as two tablets of 500 mg each by mouth one time a day for seizures. This order was discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received five doses under this medication order: one dose on [DATE], one dose on [DATE], one dose on ,d+[DATE]//2021, one dose on [DATE], and one dose on [DATE]. On [DATE] the physician ordered 1500 mg of [MEDICATION(S)] Delayed Release to be given as three tablets of 500 mg each by mouth at bedtime for seizures. This order was discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received five doses under this medication order: one dose on [DATE], one dose on [DATE], one dose on [DATE], one dose on [DATE], and one dose on [DATE]. On [DATE] the physician ordered 30 mg [MEDICATION(S)] HCL ([MEDICATION(S)]) Delayed Release Particles to be given as one capsule by mouth one time a day as an antidepressant. This medication order was discontinued on [DATE]. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] the physician ordered 325 mg [MEDICATION(S)] Sulfate to be given as one tablet one time a day for supplementation. This medication was discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received five doses under this medication order: one dose on [DATE], one dose on [DATE], one dose on [DATE], one dose on [DATE], and one dose no [DATE]. On [DATE] the physician ordered 10 mg [MEDICATION(S)] HCL to be given as one tablet by mouth at bedtime as an antipsychotic. This order was discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received five doses under this medication order: one dose on [DATE], one dose on [DATE], one dose on [DATE], one dose on [DATE], and one dose on [DATE]. On [DATE] the physician ordered two [MEDICATION(S)] Patches to be applied to the skin of the affective areas topically one time a day every 12 hours then removed for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR for Resident #1 revealed he received three doses under this order: two patches on [DATE], two patches on [DATE], and two patches on [DATE]. On [DATE] the physician ordered 6 mg [MEDICATION(S)] to be given as two tablets of 3 mg each by mouth at bedtime for [CONDITION(S)]. This order was discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received five doses under this medication order: one dose on [DATE], one dose on [DATE], one dose on [DATE], one dose on [DATE], a one dose on [DATE]. On [DATE] the physician ordered 7 mg/24 hours [MEDICATION(S)] CQ Patch to be applied at 8:00 AM as one patch trans dermally one time a day at for smoking and removal of the patch at 7:59 AM. This order was discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received one patch under this order on [DATE]. On [DATE] the physician ordered 15 mg [MEDICATION(S)] Tablet to be given as one tablet by mouth at bedtime for a [CONDITION(S)]. This medication order was put on hold on [DATE] and discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received two doses under this medication order: one dose on [DATE] and one dose on [DATE]. On [DATE] the physician ordered a duplicate order for 15 mg [MEDICATION(S)] Tablet to be given as one tablet by mouth at bedtime for restlessness. This medication order was put on hold on [DATE] and discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received two doses under this medication order: one dose on [DATE] and one dose on [DATE]. On [DATE] the physician ordered a third duplicate order for 15 mg [MEDICATION(S)] Tablet to be given as one tablet by mouth at bedtime for restlessness. This medication order was put on hold on [DATE] and discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received three doses under this medication order: one dose on [DATE], one dose on [DATE], and one dose on [DATE]. On [DATE] the physician ordered 5 mg [MEDICATION(S)] to be given as one tablet by mouth two times as day for [CONDITION(S)]. This medication order was put on hold on [DATE] and discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received eleven doses under this medication order: two doses on [DATE], two doses on [DATE], two doses on [DATE], one dose on [DATE], one dose on [DATE], two doses on [DATE], and one dose on [DATE]. On [DATE] the physician ordered 2.5 mg [MEDICATION(S)] Tablet to be given as one tablet by mouth three times a day for restlessness as needed. This medication order was put on hold on [DATE] and discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received six doses under this medication order: one dose on [DATE], one dose on [DATE], three doses on [DATE], and one dose on [DATE] On [DATE] the physician ordered 17 grams Polyethylene [MEDICATION(S)] to be given as one packet by mouth one time a day for constipation. This order was discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received three doses under this medication order: one dose on [DATE], one dose on [DATE], and one dose on [DATE]. On [DATE] the physician ordered 1 mg [MEDICATION(S)] HCL to be given as one capsule by mouth at bedtime for Hypertension. This medication order was discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received four doses under this medication order: one dose on [DATE], one dose on [DATE], one dose on [DATE], and one dose on [DATE]. On [DATE] the physician ordered 40 mg [MEDICATION(S)] Tablet Delayed Release to be given as one tablet by mouth one time a day as an [MEDICATION(S)]. This medication order was discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received three doses under this medication order: one dose on [DATE], one dose on [DATE], and one dose on [DATE]. On [DATE] the physician ordered a duplicate order for 40 mg [MEDICATION(S)] Tablet Delayed Release to be given as one tablet by mouth one time a day as an [MEDICATION(S)]. This medication order was discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received three doses under this medication order: one dose on [DATE], one dose on [DATE], and one dose on [DATE]. On [DATE] the physician ordered 8.6 mg Senna to be given as one tablet by mouth at bedtime for constipation. This medication order was discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received five doses under this medication order: one dose on [DATE], one dose on [DATE], one dose on [DATE], one dose on [DATE], and one dose on [DATE]. On [DATE] the physician ordered 0.5mg/ml (milliliter) [MEDICATION(S)] Suspension to be administered by inhaling orally two times a day for shortness of breath. This order was discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received nine doses under this medication order: one dose on [DATE], one dose on [DATE], one dose on [DATE], two doses on [DATE], one dose on [DATE], two doses on [DATE], and one dose on [DATE]. On [DATE] the physician ordered 0.5 mg [MEDICATION(S)] Sodium Liquid to be administered as eye drops, two drops in each eye two times a day for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Instill 0.5 mg in both eyes two times a day for [CONDITION(S)]. This order was discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received six administrations under this medication order: one administration on [DATE], one administration on [DATE], two administrations on [DATE], one administration on [DATE], and one administration on [DATE]. On [DATE] the physician ordered 6.25 mg [MEDICATION(S)] to be given as one tablet two times a day by mouth for Hypertension. This medication order was discontinued on [DATE]. Review of the MAR for Resident #1 revealed he received nine doses under this medication order: one dose on [DATE], one dose on [DATE], one dose on [DATE], one dose on [DATE], two doses on [DATE], one dose on [DATE], one dose on [DATE], and one dose on [DATE]. On [DATE] the physician ordered 200 mg [MEDICATION(S)] dispensed as written to be given as one capsule by mouth two times a day for pain. This medication order was discontinued on [DATE]. The MAR for Resident #1 revealed he received five doses under this medication order: one dose on [DATE], one dose on [DATE], one dose on [DATE], and one dose on [DATE]. On [DATE] the physician ordered 500 mg Acetaminophen to be given as one tablet by mouth every 8 hours for pain. This medication order was discontinued on [DATE]. The MAR for Resident #1 revealed he received nineteen doses under this medication order: one dose on [DATE], three doses on [DATE], three doses on [DATE], one dose on [DATE], one dose on [DATE], three doses on ,d+[DATE]//2021, three doses on [DATE], two doses on [DATE], and two doses on [DATE]. On [DATE] the physician ordered 100 units/ml (milliliters) [MEDICATION(S)] Solution Pen-Injector to be injected with a pen injector as per sliding scale: If ,d+[DATE] = 4 units, ,d+[DATE] 6 units, ,d+[DATE] 8 units, ,d+[DATE] 10 units; ,d+[DATE] 10 units, 400 to HI 10 units repeat in 2 hours and cover greater than 300 subcutaneously three times a day for insulin give 5 units three times a day repeat finger stick blood sugar in 2 hours and cover as per sliding scale. This medication order was discontinued on [DATE]. The MAR for Resident #1 revealed he had been administered 4 units of insulin [DATE] at 2:00 PM for a blood sugar of 215. On [DATE] the physician ordered 2 grams of Voltran Gel 1 % to be applied to his skin topically three times a day for pain. This medication order was discontinued on [DATE]. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] the physician ordered ,d+[DATE] microgram/actuation [MEDICATION(S)] Aerosol to be administered with an inhaler as 2 puffs inhaled orally four times a day every four hours for shortness of breath as needed. This medication order was discontinued on [DATE]. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] the physician ordered 0.65 mcg (microgram) Sodium Chloride Solution to be administered as one spray in both nostrils four times a day for congestion. This medication order was discontinued on [DATE]. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 3:02 PM Physician Assistant (PA #1) wrote an admission progress note. Documentation in the history of present illness indicated Resident #1 was up in the chair ready to eat breakfast and was at the facility for physical and occupational therapy. The documentation further stated on his exam he was slow to speech but had no other acute issues. No medication abnormalities were noted. The care plan for Resident #1, dated [DATE], had a focus area for the resident's use of [CONDITION(S)] medications (antipsychotics) relative to behavior management. The one intervention was to monitor for side effects and effectiveness. An admission minimum data set (MDS) assessment dated [DATE] coded Resident #1 was having moderately impaired cognition and feeling tired 7 to 11 days of the assessment period. He was coded as requiring extensive assistance with bed mobility and toilet use. He was independent with feeding himself after set-up. He did not transfer, ambulate, or perform locomotion during the assessment period. He was coded as always incontinent of bowel and bladder. He was coded as receiving 5 days of antipsychotics, 3 days of antibiotics, oxygen therapy in the facility, and intravenous medications during the assessment period. On [DATE] PA #1 wrote a progress note stating under history of present illness, Per nursing complaint of patient still more lethargic than baseline. On exam the patient was arousable, will hold medications and monitor for improvement or worsening of condition. I have reviewed labs, he appears mildly dehydrated and will have nursing encourage increased PO fluids. No acute infectious process on chest x-ray. PA #1 did not note any medication irregularities. On [DATE] at 12:19 PM a nursing progress note written by the ADON stated, Reviewed medication list reconciled with [PA #1]. New orders obtained and updated. An interview was conducted on [DATE] at 9:27 AM with the ADON regarding the [DATE] 12:19 PM progress note she wrote. The ADON revealed the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] an initial physician visit progress note was written by the Physician for Resident #1 (MD #1). The impression portion of the note stated, New recent problem. Has improvement with changes in medication. Continue to [rule out] other etiologies with urine and blood work testing. On [DATE] at 11:09 AM nursing notes indicated medications were held for Resident #1. An interview was conducted with PA #1 on [DATE] at 8:15 AM. PA #1 stated he did not recall if he was on call on [DATE], the day Resident #1 was admitted . PA #1 remembered signing off electronically on the medications for Resident #1 on [DATE]. PA #1 stated he was notified by the previous DON the medications given to Resident #1 were ordered for another resident. PA #1 stated, As soon as the DON alerted me, I reviewed his medications and put him on the correct medications. PA #1 did not recall which day the DON notified him of the medication errors, stating it was sometime after [DATE]. The emergency room report dated [DATE] stated in the narrative in part, Nurse stated as we were leaving the room that this was caused by a medication error that put him in this state but she had no other information, unknown where she obtained that information. The hospital discharge summary dated [DATE] at 4:28 AM revealed Resident #1 expired due to septic shock. Review of the death certificate dated [DATE] revealed the immediate cause of death for Resident #1 was septic shock with contributing diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with the previous Director of Nursing (previous DON) on [DATE] at 1:45 PM. The Director of Nursing stated she was out on medical leave beginning on [DATE] and when she returned on [DATE] she went through to check the paperwork for the new admissions who had come in her absence. She discovered the medications for Resident #1 were transcribed incorrectly and she had no idea where the list of medications ordered for Resident #1 came from. The previous DON revealed she immediately notified her Administrator who told her he would contact the legal department of the corporation. The previous DON stated she notified PA #1 and the Medical Director of the medication errors and the seriousness of the situation on [DATE]. She stated PA #1 told her he would never have approved Resident #1 to be on four orders for [MEDICATION(S)]. The previous DON stated PA #1 came into the facility on ,d+[DATE]//2021 and went through the medication list for Resident #1 with the ADON to make sure Resident #1 was on the correct medications. She stated the medical director was very alarmed when notified of the medication errors. The previous DON stated the medication errors put him at risk for acute renal injury. The previous DON stated she called Nurse #11 into her office to explain what happened. The previous DON stated she suspended Nurse #11 for two weeks. The previous DON revealed she, herself, quit effectively immediately on the morning of [DATE]. An interview was conducted on [DATE] at 11:38 AM with the facility Administrator. The Administrator stated a root cause analysis was conducted by the facility on [DATE] when the medication errors were discovered. The Administrator stated the previous Director of Nursing and the MDS Nurse (Current Interim DON) discovered the incorrect medications were transcribed into the electronic medical record. The Administrator stated the MDS Nurse recognized Resident #1 was on antipsychotics without a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility Administrator stated they did not know where Nurse #11 got the medication orders from for Resident #1, but the MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . The Administrator stated all recent new admissions were audited and no other medication errors were found. An interview was conducted with the resident's physician (MD #1) on [DATE] at 10:08 AM. MD #1 confirmed he was told by the previous DON the wrong medication list was put into the electronic medical record for Resident #1 but he was told the issue was resolved when PA #1 put the correct medications into the medical record. MD #1 was unsure how it happened. MD #1 stated it is the facility policy to have the admitting nurse put the medications from the hospital discharge summary into the electronic medical record to be ordered from the pharmacy when a resident arrives from the hospital. MD #1 explained the orders do not need to be checked or verified by a physician prior to the medications being ordered from the pharmacy. MD #1 stated a physician will reconcile the medications upon an admission assessment. MD #1 explained the physician was only looking to see if the medications logically make sense. MD #1 stated it was the job of the nurse to put the medications into the electronic medical record correctly. On [DATE] at 12:30 PM, the administrator was informed of the immediate jeopardy. The allegation of immediate jeopardy removal indicated: Credible Allegation of Immediate Jeopardy removal: F757 - Unnecessary Drugs Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance Synopsis: Resident was admitted [DATE]. Upon admission, a charge nurse entered inaccurate admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On ,d+[DATE], resident exhibited a change in status and PA placed blood pressure medication on hold and resident on oxygen. On ,d+[DATE], resident was noted to be lethargic and the PA ordered a chest x-ray and lab tests. On ,d+[DATE], the resident was observed to be not alert, had abdominal breathing, and not eating or taking meds. Resident was assessed by DON and ADON and no new orders were received at that time. On ,d+[DATE], PA examined the patient and indicated mild dehydration and ordered to increase PO fluids. On ,d+[DATE], it was discovered in the IDT meeting that medication diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An attempt to discover the source of these orders was unsuccessful at the time. PA and medical director were notified. Medications were reconciled and corrected. Later (,d+[DATE]), the ADON, while auditing new admissions since ,d+[DATE], discovered the discharge summary for a different patient that matched what had originally been entered for the resident. The assistant director of nursing (ADON) reviewed MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . Specify the action the entity will take to alter the process or system failure to prevent a serious outcome from occurring or recurring, and when the action will be complete Facility action: Current licensed nursing staff were educated by the SDC or designee regarding procedures for admitting a Resident to include accurate order entry and confirming orders. Education started last week, however, the SDC was made aware ,d+[DATE] of the need to complete further education. Licensed nursing staff on ,d+[DATE] were educated, and all remaining licensed nursing staff will receive education before their next shift. This will be tracked by nursing leadership and administrator. Charge nurse on duty will enter medication orders electronically based on hospital discharge summary and confirm orders. Residents' physician will review and approve new admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This will be done by admissions or medical records. They were notified ,d+[DATE]. Nursing leadership will complete an admission audit to ensure accuracy of orders within 24 hours. Physician/PA are required to review new admissions with 48 hours of admission. This was confirmed with medical director ,d+[DATE]. PA and MD will be notified of new admissions by email, phone, and/or in person. DON or designee will inform the Medical Director of new admissions weekly to include any concerns with medication or medical status. New patients will also be discussed in weekly meeting between medical director and physician assistants. During weekly meeting between medical director and director of nursing, any questions or concerns about treatment decisions or medication orders will be discussed. The Director of Nursing or designee will ensure implementation of the plan. Planned removal of IJ: [DATE] The credible allegation was verified on [DATE]. Interview with th [TRUNCATED]

Based on record review, staff interview, consultant pharmacist interview, pharmacy manager interview, Administrator interview, Physician Assistant interviews, Physician interview the facility Administration failed to provide effective leadership and oversight of processes and policies and procedures to ensure an effective system was in place to implement MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] #1) of three residents with pharmacy reviews. The facility Administration also failed to perform a root cause analysis for the medication errors and implement systematic changes to prevent additional medication errors from occurring until immediate jeopardy was identified for one (Resident #1) of three new admissions. The facility Administration failed to have an effective, comprehensive approach to responding to acute/significant changes in condition to ensure necessary care and services were provided for 1 (Resident #1) of 1 resident reviewed for neglect. Resident #1 received 29 incorrect medications for a period of 8 days. Resident #1 was noted to have a change in condition beginning on [DATE] with a hypotensive episode. Resident #1 continued to decline, suffering from lethargy, dehydration, hypotensive episodes, and inability to swallow until the facility recognized the error in transcription of medication on [DATE]. Resident #1 was sent to the hospital on [DATE] and expired in the hospital on [DATE]. The cause of death of Resident #1 was determined to be septic shock. Immediate Jeopardy began on [DATE] when Resident #1 entered the facility and the facility failed to have effective systems in place to order and administer correct medications; failed to have an effective system in place for new admission medication reconciliation; failed to have a system in place for comprehensive pharmacy reviews; and failed to have a system to effectively address a decline and change in condition. The immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation for Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of an E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place are effective. Example C. for F600 is a scope and severity level of a D (Isolated -No actual harm with potential for more than minimal harm that is not immediate jeopardy.) Findings included: A. Cross refer to F600: Based on record review, staff interviews, Physician Assistant (PA) interviews, Physician interviews, Administrator interview, Interim Director of Nursing (DON) interview, and previous Director of Nursing interview the facility neglected to provide necessary care and services by failing to administer the correct medication; failing to provide effective and ongoing nursing and medical assessments and medical interventions for a resident with an acute/significant change in condition; and failing to implement effective medical intervention for a resident with signs of dehydration for one (Resident #1) of one resident reviewed for neglect. Resident #1 received 29 incorrect medications for a period of 8 days. Resident #1 was noted to have a change in condition beginning on [DATE] with a hypotensive episode. Resident #1 continued to decline, suffering from lethargy, dehydration, hypotensive episodes, and inability to swallow until the facility recognized the error in transcription of medication on [DATE]. Resident #1 was sent to the hospital on [DATE] and expired in the hospital on [DATE]. The cause of death of Resident #1 was determined to be septic shock. B. Cross refer to F756: Based on record review, staff interview, consultant pharmacist interview, and pharmacy manager interview, the facility consultant pharmacist failed to complete a comprehensive review of a new admission's medications for 1 (Resident #1) of 3 residents reviewed for pharmacy reviews upon admission. Resident #1 received medications ordered for another resident for a period of 8 days. Resident #1 was noted to have a change in condition beginning on [DATE] with a hypotensive episode. Resident #1 continued to decline, suffering from lethargy, dehydration, hypotensive episodes, and inability to swallow until the facility recognized the error in transcription of medication on [DATE]. Resident #1 was sent to the hospital on [DATE] and expired in the hospital on [DATE]. The cause of death of Resident #1 was determined to be septic shock. C. Cross refer to F757: Based on record review, staff interview, Administrator interview, physician assistant interview, and physician interview the facility failed to administer the correct medications and administered medications without supporting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to recognize the incorrect medications were entered into the electronic medical record system upon admission for Resident #1 resulting in the resident receiving 29 incorrect medications for a period of 8 days. These medications included in part antipsychotics, [CONDITION(S)] medication, pain medication, [CONDITION(S)] medication, hypertension medication, diabetic medication, [CONDITION(S)] medication, and smoking cessation. Resident #1 was admitted to the hospital on [DATE] and expired on [DATE]. On [DATE] at 12:30 PM, the administrator was informed of the immediate jeopardy. The allegation of immediate jeopardy removal indicated: Credible Allegation of Immediate Jeopardy removal: F835 - Administration Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance Synopsis: Patient received incorrect medications because medications from the wrong discharge summary were entered. A root cause analysis was initiated at the time the mistake was noticed by nursing leadership and the administrator. The nurse who entered the orders was counseled and disciplined and education was provided. We gathered info from this nurse, but she was unable to say where she had gotten these orders. As part of the ongoing chart reviews, the ADON found where these orders originated. They were from the discharge summary of another patient who had not yet admitted but was to admit soon after this patient. The nurse who entered the orders was assisting another nurse, took the paperwork from her, and failed to verify that it was for the correct patient. A 24-hour admission audit was not completed for the patient, allowing him to continue to receive these medications. We failed to have a comprehensive system in place for pharmacy reviews due to the pharmacist not having access to the discharge summary. Additionally, a change of condition was not responded to appropriately. MD educated PA on ,d+[DATE] about appropriate response to change of condition and med reconciliation. The facility determined the root cause of the medication error. A charge nurse inadvertently entered medications from another Resident's discharge summary when she failed to verify that the orders were for the correct patient. Nursing leadership will complete 24-hour admission audits to ensure accuracy of orders. Current policy and procedures will be implemented to provide care to new admissions, provide accurate medications, to identify and treat changes in condition, to provide necessary care and services, and QAPI to address situations and errors with root cause analysis. Corporate nurse consultant has been assisting and will be visiting weekly beginning ,d+[DATE] to assist with plan of correction and observation and oversight of processes. Medical director has been involved in this plan of correction and will be formally meeting with the DON and Administrator weekly to discuss status of plan of correction and any clinical concerns. Specify the action the entity will take to alter the process or system failure to prevent a serious outcome from occurring or recurring, and when the action will be complete Facility Action: The Interdisciplinary team will meet daily 5 X weekly to discuss issues and plans for the day for each department to include status changes with Residents. Residents exhibiting acute changes in condition will be discussed and any identified needs will be directed to the responsible discipline for action. This was reemphasized on ,d+[DATE]. New admissions will be audited within 24 hours by nursing leadership to ensure accuracy of medication orders comparing to hospital discharge summary. Any discrepancies will be corrected at the time of identification. Shift reports (24 hour/72 hour) will be reviewed daily 5 X weekly by nursing leadership and reviewed with the IDT in daily meeting to identify and discuss changes in condition. The DON or designee will complete facility room rounds daily 5 X weekly to ensure necessary care and services are being provided to Residents. Any issues will be corrected at the time of identification. Medical director will meet with physician assistants weekly to discuss patients. This will include patients with acute changes, new patients, patients who are recently had major changes in treatment plans, and any other topics that need to be addressed. During weekly meeting between medical director and director of nursing, any questions or concerns about treatment decisions will be discussed. The Administrator or designee will ensure implementation of the plan. Corporate nurse and VP of operations will conduct weekly visits to provide oversight to administration and to assure systems and processes are in place and effectively being implemented to provide necessary care and services to residents in the facility. Attending physician provided coaching to PA on ,d+[DATE] regarding appropriate management and management of significant changes and med reconciliation. After meds were corrected, patient's lethargy improved. MD saw patient on ,d+[DATE] after meds had been corrected. Planned removal of IJ: [DATE] The credible allegation was verified on [DATE]. Significant change education was provided to all staff on [DATE]. Interview with licensed nursing staff revealed that they look for changes in behavior, eating habits, input/output, or any unusual event to determine change in condition. Evidence of new admission audits were reviewed [DATE]. The facility's credible allegation of immediate jeopardy removal was verified as having been implemented on [DATE].

Based on record review, staff interview, consultant pharmacist interview, and pharmacy manager interview, the facility consultant pharmacist failed to complete a comprehensive review of a new admission's medications for 1 (Resident #1) of 3 residents reviewed for pharmacy reviews upon admission. Resident #1 received medications ordered for another resident for a period of 8 days. Resident #1 was noted to have a change in condition beginning on [DATE] with a hypotensive episode. Resident #1 continued to decline, suffering from lethargy, dehydration, hypotensive episodes, and inability to swallow until the facility recognized the error in transcription of medication on [DATE]. Resident #1 was sent to the hospital on [DATE] and expired in the hospital on [DATE]. The cause of death of Resident #1 was determined to be septic shock. Immediate Jeopardy began on [DATE] when Resident #1 had an initial pharmacy review completed and the facility failed to have a system in place for the facility pharmacist to perform a comprehensive review of the medications ordered for a resident upon admission. The immediate jeopardy was removed on [DATE] when the facility 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 the 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 from the hospital emergency room to the facility on [DATE]. A North Carolina FL2 form for Resident #1, dated as completed on [DATE] at 1:45 PM was sent to the facility from the hospital. A FL-2 is a North Carolina form that describes a patient's medical condition and the amount of care they need when placed in a facility. Resident #1 had diagnoses listed on the FL-2 form from the emergency room of [CONDITION(S)], chronic obstructive pulmonary disease, [CONDITION(S)] reflux, personal history of transit ischemic attack without residual deficits (2016), Hypertension, [CONDITION(S)] reflux, cerebral vascular disease, and [CONDITION(S)]. The FL-2 form also revealed the emergency room admission complaint of Resident #1 was weakness and failure to thrive. The FL-2 form also listed the current hospital medication orders for Resident #1 as the following: 81 mg Aspirin (a blood thinner) to be given as one tablet by mouth a day; 10 mg [MEDICATION(S)] (treatment of heart disease) to be given as one tablet by mouth a day; 0.,d+[DATE].5% [MEDICATION(S)]-[MEDICATION(S)] (eye drops) to be given as one drop in each eye every 12 hours; ,d+[DATE] mg [MEDICATION(S)]-[MEDICATION(S)] (used to treat [CONDITION(S)]) to be given as one and half tablets by mouth three times a day; 500 mg [MEDICATION(S)] (antibiotic) to be given as one capsule by mouth two times a day for 5 days; 1000 units [MEDICATION(S)] (Vitamin D) to be taken as one capsule by mouth once a day; 500 mg [MEDICATION(S)] (antibiotic) to be taken as one tablet by mouth two times a day for 5 days; 2% Dorzolamide ophthalmic solution (eye drops) to be taken as one drop in both eyes two times a day; 20 mg [MEDICATION(S)] (used to treat gum disease) to be taken as one tablet by mouth two times a day; 40 mg [MEDICATION(S)] to be taken as one tablet by mouth once a day; 0.005% [MEDICATION(S)] ophthalmic solution (eye drops) to be taken as one drop in both eyes at bedtime; Multivitamins- Mineral to be taken as one capsule by mouth two times a day; 75 mg [MEDICATION(S)] (used to treat depression) to be taken as one and a half tablets (75 mg total) by mouth one time a day; and 0.4 mg Tamsulosin (used to treat frequent urination) to be taken as one capsule by mouth once a day; 50 mg Trazadone to be taken as one capsule by mouth at bedtime as needed for sleep; 80 mg [MEDICATION(S)] (blood pressure medication)to be taken as one tablet by mouth one time daily; and 1000 microgram (microgram) Vitamin B-12 to be taken by mouth once daily. Documentation in the facility electronic record listed the Resident's diagnoses as being cerebral infarction (principle diagnosis), [CONDITION(S)], adult failure to thrive, muscle weakness, chronic obstructive pulmonary disease, gastro-[CONDITION(S)] reflux disease, [CONDITION(S)], and Hypertension. An interview was conducted with Nurse #11 on [DATE] at 2:52 PM. Nurse #11 stated she was working on her nursing unit on [DATE] on the 7:00 PM to 7:00 AM shift when she was approached by a nursing assistant and was asked to go to another unit to assist because another nurse was having a hard time. Nurse #11 revealed she went to the other nursing unit and found an agency nurse (Nurse #23) who did not know how to put orders into the electronic medical system. Nurse #11 indicated it was going to be faster for her to put the orders in rather than show the agency nurse how to put the orders in. Nurse #11 stated she took the hospital emergency room discharge orders for Resident #1 that were on the nursing unit desk and returned to her own nursing unit to put them into the electronic medical record. Nurse #11 stated she called the on-call service at approximately 3:00 AM to have the orders verified. The on-call service connected her to the phone for Physician's Assistant (PA) #1. Nurse #11 stated the phone did not answer and the voice mail box was full. Nurse #1 stated she attempted to call the on-call PA #1 four times. Nurse #11 stated it took her four hours to put the orders into the electronic medical record for Resident #1 due to multiple interruptions every 15 to 20 minutes. Nurse #11 confirmed she had gone down the list to make sure she had put the orders in correctly. According to the medication administration record (MAR) for Resident #1, he did not receive any medications on [DATE] or [DATE]. Documentation on the MAR for Resident #1 revealed he began to receive medications which had been ordered for him by Nurse #11 beginning on [DATE]. Review of the physician orders and the Medication Administration Record (MAR) for Resident #1 in the electronic record revealed the following medication orders and their administration: On [DATE] the physician ordered 10 mg of [MEDICATION(S)] to be given as one tablet by mouth one time a day for Hypertension and [CONDITION(S)]. On [DATE] the physician ordered 10 mg [MEDICATION(S)] to be given as one tablet by mouth one time a day for Hypertension and [CONDITION(S)] to be put on hold if the blood pressure diastolic was less than 100. On [DATE] the physician ordered 10 mg [MEDICATION(S)] Tablet 10 mg to be given as 1 tablet by mouth one time a day for Hypertension and [CONDITION(S)] to be put on hold if the blood pressure systolic was less than 100. On [DATE] the physician ordered 40 mg [MEDICATION(S)] Calcium to be given as one tablet by mouth at bedtime for his cholesterol level. This physician's order was for 30 mg more of [MEDICATION(S)] Calcium than was ordered on the FL-2 from the hospital for Resident #1. On [DATE] the physician ordered 1000 mg of [MEDICATION(S)] delayed release to be given as two tablets of 500 mg each by mouth one time a day for seizures. On [DATE] the physician ordered 1500 mg of [MEDICATION(S)] Delayed Release to be given as three tablets of 500 mg each by mouth at bedtime for seizures. On [DATE] the physician ordered 30 mg [MEDICATION(S)] HCL ([MEDICATION(S)]) Delayed Release Particles to be given as one capsule by mouth one time a day as an antidepressant. On [DATE] the physician ordered 325 mg [MEDICATION(S)] Sulfate to be given as one tablet one time a day for supplementation. On [DATE] the physician ordered 10 mg [MEDICATION(S)] HCL to be given as one tablet by mouth at bedtime as an antipsychotic. On [DATE] the physician ordered two [MEDICATION(S)] Patches to be applied to the skin of the affective areas topically one time a day every 12 hours then removed for treatment of pain. No strength for the [MEDICATION(S)] was listed on the physician's order. On [DATE] the physician ordered 6 mg [MEDICATION(S)] to be given as two tablets of 3 mg each by mouth at bedtime for [CONDITION(S)]. On [DATE] the physician ordered 7 mg/24 hours [MEDICATION(S)] CQ Patch to be applied at 8:00 AM as one patch trans dermally one time a day at for smoking and removal of the patch at 7:59 AM. On [DATE] the physician ordered 15 mg [MEDICATION(S)] Tablet to be given as one tablet by mouth at bedtime for a [CONDITION(S)]. On [DATE] the physician ordered a duplicate order for 15 mg [MEDICATION(S)] Tablet to be given as one tablet by mouth at bedtime for restlessness. On [DATE] the physician ordered a third duplicate order for 15 mg [MEDICATION(S)] Tablet to be given as one tablet by mouth at bedtime for restlessness. On [DATE] the physician ordered 5 mg [MEDICATION(S)] to be given as one tablet by mouth two times as day for [CONDITION(S)]. On [DATE] the physician ordered 2.5 mg [MEDICATION(S)] Tablet to be given as one tablet by mouth three times a day for restlessness as needed. On [DATE] the physician ordered 17 grams Polyethylene [MEDICATION(S)] to be given as one packet by mouth one time a day for constipation. On [DATE] the physician ordered 1 mg [MEDICATION(S)] HCL to be given as one capsule by mouth at bedtime for Hypertension. On [DATE] the physician ordered 40 mg [MEDICATION(S)] Tablet Delayed Release to be given as one tablet by mouth one time a day as an [MEDICATION(S)]. On [DATE] the physician ordered a duplicate order for 40 mg [MEDICATION(S)] Tablet Delayed Release to be given as one tablet by mouth one time a day as an [MEDICATION(S)]. On [DATE] the physician ordered 8.6 mg Senna to be given as one tablet by mouth at bedtime for constipation. On [DATE] the physician ordered 0.5mg/ml (milliliter) [MEDICATION(S)] Suspension to be administered by inhaling orally two times a day for shortness of breath. On [DATE] the physician ordered 0.5 mg [MEDICATION(S)] Sodium Liquid to be administered as eye drops, two drops in each eye two times a day for treatment of [CONDITION(S)]. Instill 0.5 mg in both eyes two times a day for [CONDITION(S)]. On [DATE] the physician ordered 6.25 mg [MEDICATION(S)] to be given as one tablet two times a day by mouth for Hypertension. On [DATE] the physician ordered 200 mg [MEDICATION(S)] dispensed as written to be given as one capsule by mouth two times a day for pain. On [DATE] the physician ordered 500 mg Acetaminophen to be given as one tablet by mouth every 8 hours for pain. On [DATE] the physician ordered 100 units/ml (milliliters) [MEDICATION(S)] Solution Pen-Injector to be injected with a pen injector as per sliding scale: If ,d+[DATE] = 4 units, ,d+[DATE] 6 units, ,d+[DATE] 8 units, ,d+[DATE] 10 units; ,d+[DATE] 10 units, 400 to HI 10 units repeat in 2 hours and cover greater than 300 subcutaneously three times a day for insulin give 5 units three times a day repeat finger stick blood sugar in 2 hours and cover as per sliding scale. On [DATE] the physician ordered 2 grams of Voltran Gel 1 % to be applied to his skin topically three times a day for pain. On [DATE] the physician ordered ,d+[DATE] microgram/ actuation [MEDICATION(S)] Aerosol to be administered with an inhaler as 2 puffs inhaled orally four times a day every four hours for shortness of breath as needed. On [DATE] the physician ordered 0.65 mcg Sodium Chloride Solution to be administered as one spray in both nostrils four times a day for congestion. Documentation in the medical record for Resident #1 under assessments revealed a consultant pharmacist admission medication regimen review was completed on [DATE]. The review stated, See report for any noted irregularities and/or recommendations. The facility pharmacist was interviewed on [DATE] at 11:50 AM. The facility pharmacist explained when he did the Admission medication review on Resident #1 on [DATE], he did so remotely and did not have access to the discharge information from the hospital in the electronic medical record. The pharmacist confirmed he did not look at the diagnoses to compare to the medications on the admission medication review. He also explained that most of the medications for Resident #1 had not been transmitted to the pharmacy on [DATE] so he was not able to see them as medication orders. The facility pharmacist further explained he filled out a form in the electronic medical record to say he had noted irregularities for Resident #1, but the actual consultation reports were sent to the Director of Nursing. The pharmacist reported on the consultation report the concern the resident was on two antipsychotics and needed an AIMS test (abnormal involuntary movement scale). An AIMS test is used to detect abnormal movements in patients receiving antipsychotics. The consultant pharmacist stated the two antipsychotics administered to Resident #1 could have led to over sedation and falls. The pharmacist stated he sent his review to the previous DON on [DATE] with the usual expectation it would be acted upon by his next review in 30 days. The pharmacist stated he would not know if his review in this case was acted upon because the facility had a new pharmacy and pharmacist effective [DATE].The pharmacist stated his concerns after reviewing the medication list for Resident from [DATE] to [DATE] was for over sedation and falls as well as for low blood pressure episodes due to a new regimen for Hypertension. An interview was conducted on [DATE] at 9:45 AM with a pharmacy manager for the pharmacy the facility had a contract in [DATE]. The Pharmacy manager stated most of the medication orders for Resident #1 were dated as being put into the electronic medical record on [DATE] but were not transmitted or signed off by the physician until Monday, [DATE] or later. The Pharmacy manager stated there was no way for the pharmacy to know the physician orders were for the wrong resident and the pharmacy relies on the physician and the consultant pharmacist to catch medication order errors. On [DATE] at 12:30 PM, the administrator was informed of the immediate jeopardy. The allegation of immediate jeopardy removal indicated: Credible Allegation of Immediate Jeopardy removal: F756 - Drug Regimen Review Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance Synopsis: Pharmacy consultant performed admission medication review for the patient on [DATE], but a discharge summary had not been scanned into the EMR system. This missing info allowed the resident to continue to receive incorrect medications for eight days without appropriate diagnoses. Fourteen residents admitted on or after ,d+[DATE] had pharmacy consults with irregularities or recommendations that had not been addressed. Current consultant pharmacist was notified on [DATE] and completed a medication review on these Residents. The consultation report was sent to the facility and the ADON will complete on [DATE]. Specify the action the entity will take to alter the process or system failure to prevent a serious outcome from occurring or recurring, and when the action will be complete Facility Action: Consultant pharmacist will review each new admission within ,d+[DATE] hours. This will happen remotely with EMR access. Pharmacist will have access to PointClickCare (PCC), EMAR, and hospital discharge summary in the miscellaneous section of a patient's electronic record. Each review will be electronically documented for facility access. The consultant pharmacist will report any time sensitive recommendations or irregularities to the Director of Nursing via phone. Upon receipt of recommendations, the Director of Nursing will forward to the physician for review and action. The Director of Nursing will provide the Medical Director completed pharmacy recommendations weekly. During a call with the consultant pharmacist on ,d+[DATE], pharmacist informed us she will be visiting the facility to conduct monthly medication review on [DATE]. During the call, DON and administrator instructed consultant pharmacist of location of discharge summary in miscellaneous file in PCC on EMR. Medications will be confirmed at time of admission so that they are accessible for consultant pharmacist to review. Not having confirmed the medications in this instance led to them not being available for the pharmacist to review. Medical director will meet with physician assistants weekly and also meet with director of nursing weekly. During weekly meeting between medical director and director of nursing, any questions or concerns about actual or proposed pharmaceutical changes will be discussed. The Director of Nursing or designee will ensure implementation of the plan. Planned removal of IJ: [DATE] The credible allegation was verified on [DATE]. Review of medical records of new admission revealed a pharmacy review. All medications for new admissions were reviewed by the Pharmacist between ,d+[DATE] hours of facility admission. Facility staff alleged compliance as of [DATE]. The facility's credible allegation of immediate jeopardy removal was verified as having been implemented on [DATE].

Based on record review, staff interview, and Physician interview the facility failed to perform skin assessments to monitor or identify skin concerns for 2 (Residents #1 and #2) of 3 residents reviewed for pressure ulcer/wound care. Resident # 1 was assessed by the hospital to have a severe unstageable spine decubitus ulcer. Immediate Jeopardy began on 8/30/21 when Resident # 1 was found to have a severe unstageable spine decubitus ulcer at the hospital. The resident was admitted to the facility on [DATE] and there was no evidence of a thorough skin assessment at that time or during the duration of his stay. The immediate jeopardy was removed on when the facility implemented an acceptable credible allegation for Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of an E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place are effective and for example # 2. Findings included: 1. Resident #1 was admitted from the hospital emergency room to the facility on [DATE]. A North Carolina FL2 form for Resident #1, dated as completed on 8/13/2021 at 1:45 PM was sent to the facility from the hospital. A FL-2 is a North Carolina form that describes a patient's medical condition and the amount of care they need when placed in a facility. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The FL-2 form also revealed the emergency room admission complaint of Resident #1 was weakness and failure to thrive. Documentation in an admission progress note dated 8/14/2021 at 7:10 AM as a late entry revealed Resident #1 had a laceration to his swollen red ear and his buttocks were red but blanchable. Blanchable indicates there was a temporary obstruction of blood flow to that area. An interview was conducted on 9/7/2021 at 6:30 PM with Nurse #23, who wrote the admission progress note on 8/14/2021 for Resident #1. Nurse #23 explained she had two residents who were declining rapidly with one of those residents being about to expire as well as a resident who needed blood work on her shift 7:00 PM to 7:00 AM beginning on 8/13/2021. Nurse #23 stated she did not recall what time or what day Resident #1 was admitted to the facility. Nurse #23 stated she knew she had to additionally put into the electronic medical record admission assessments for Resident #1. Nurse #23 stated she was not able to complete the admission assessments for Resident #1 and she passed this information on to the next nursing shift. There were no additional skin assessments for Resident #1 until 8/19/2021. The 8/19/2021 skin assessment for Resident #1 indicated his skin was intact without impairment. An interview was conducted on 9/4/2021 at 4:46 PM with Nurse #14 who completed a skin assessment for Resident #1 on 8/19/2021. Nurse #14 stated she worked from 11:00 PM to 7:00 AM on 8/19/2021. Nurse #14 stated she recalled Resident #1 but denied she did any kind of skin assessment on Resident #1. Nurse #14 declared another nurse must have gone into the medical record under her name and documented she did the skin assessment on Resident #1. Resident #1 had an admission minimum data set assessment dated [DATE] which coded him as having moderately impaired cognition with no behaviors or rejection of care. He was coded as always incontinent of bladder and bowel but with no pressure sores. He was coded as at risk for pressure sores and on a pressure reducing device for his bed. Documentation on the care plan for Resident #1, dated as initiated on 8/14/2021, was a focus area for potential for skin impairment. One of the interventions was to perform a weekly skin assessment. There was no other documentation in the medical record of skin assessments for Resident #1 after 8/19/2021. An interview was conducted on 9/4/2021 at 1:30 PM with Nurse #9. Nurse #9 confirmed she was assigned to care for Resident #1 on 8/27/2021 from 7:00 AM to 7:00 PM as well as 8/28/2021 from 7:00 AM to 7:00 PM. Nurse #9 stated she provided incontinent care to Resident #1 around 4:00 PM or 5:00 PM on 8/27/2021. Nurse #9 stated there were no skin concerns for Resident #1 at that time and confirmed she saw no bruising or skin tears. An interview was conducted on 9/3/2021 at 4:48 PM with Nurse Aide (NA #1), who confirmed she cared for Resident #1 on 8/28/2021 and 8/29/2021 for the 7:00 AM to 7:00 PM shift. NA #1 stated she was very busy on 8/28/2021 and only checked on Resident #1 one time during her shift. NA #1 stated on 8/29/2021 she provided incontinent care to Resident #1 two times during her shift. NA #1 did not recall Resident #1 having any skin issues on either day for which she would have to alert the nurse on the hall. An interview was conducted on 9/7/2021 at 6:55 AM with NA #4, who confirmed he cared for Resident #1 on 8/28/2021 for the 7:00 PM to 7:00 AM shift. NA #4 stated he was working short that night with two nurse aides when there were usually three nurse aides. NA #4 stated that evening was the first time he had ever seen Resident #1 and he checked on him every two hours. Na #4 did not recall Resident #1 having any skin concerns or issues. An interview was conducted on 9/4/2021 at 8:00 PM with NA #3, who confirmed he cared for Resident #1 on 8/29/2021 for the 7:00 PM to 7:00 AM shift. NA #3 stated he checked on Resident #1 three or four times, but he really did not need to provide incontinent care because Resident #1 had a foley catheter. NA #3 stated Resident #1 had no skin issues or any bruising. Documentation in the nursing notes dated 8/30/2021 at 7:44 AM stated, Called [Physician Assistant (PA) #1] in regard to [chest x-ray] results. No new orders were obtained at this time. Will f/u today when arrives to facility. Resident afebrile. [Productive] cough noted. Will follow up. Documentation in the nursing notes dated 8/30/2021 at 2:33 PM revealed emergency medical services were called to take Resident #1 to the hospital. Resident #1 was described as unresponsive to voice and painful stimuli receiving 4 liters of oxygen. An interview was conducted on 9/3/2021 at 1:29 PM with Nurse #3, who was assigned to care for Resident #1 on 8/30/2021 from 7:00 AM to 7:00 PM. Nurse #3 stated she was not told of any concerns in nursing report from the previous shift on 8/30/2021. Nurse #3 revealed the Director of Nursing told her of the skin assessments she needed to do when she arrived for her shift, and Resident #1 was one of them. Nurse #3 stated when she arrived, she notified the PA #1 of the chest x-ray results and she knew PA #1 would check on him. Nurse #3 indicated she would have to look in the medical record to confirm what time Resident #1 was sent to the emergency room . Nurse #3 stated when she sent Resident #1 to the hospital, she did a quick skin assessment and did not see anything, not even redness. Nurse #3 confirmed Resident #1 was unresponsive and on 4 liters of oxygen, but she did roll him to look at his skin prior to the arrival of the emergency medical services. Nurse #3 stated she did not document her assessment of his skin prior to his transport to the hospital. The first documentation in the emergency room nursing notes from the hospital for Resident #1 was on 8/30/2021 at 3:13 PM. Review of the emergency room nursing notes dated 8/30/2021 at 7:15 PM revealed, [Patient is laying in bed. [Patient] had cardiac, [blood pressure] and pulse [oximetry] monitor on and temperature foley. [Patient] responds to pain. Previous [Registered Nurse] stated skin breakdown to the back. [Registered Nurse] unable to turn [patient] at this tme, [Registered Nurse] does not have help to turn [patient]. [Patient] is on 6 [Liters per Minute] [Nasal Cannula] of oxygen. Review of emergency room department provider notes revealed Resident #1 was assessed by the first medical doctor in the emergency roiagnom on [DATE] at 3:12 PM. The first medical doctor to assess Resident #1 requested a wound care consult for a sacral decubitus ulcer present on admission. The clinical notes of the hospital record revealed the wound care consultant requested photos of the wound be place on the electronic medical record along with the concerns for review. The death summary portion of the hospital record dated 9/1/2021 at 1:35 AM revealed the preliminary cause of death for Resident #1 was septic shock. In the brief hospital course, the medical record stated, It was also noted [patient] had a severe unstageable spine decubitus ulcer. The death certificate for Resident #1, dated as signed by the adult-gerontology nurse practitioner on 9/1/2021, listed the immediate cause of death as septic shock with contributing causes of pneumonia, sacral decubitus ulcer, and possible meningitis. An interview was conducted with the previous Director of Nursing (DON) on 9/4/2021 at 1:45 PM. The previous DON stated it was facility policy for an admission skin assessment to be completed upon arrival of a new resident and then a weekly skin assessment after that. The previous DON revealed the facility had an agency wound care nurse who was doing treatments and assessments, but the facility terminated her services in the middle of July 2021 putting this responsibility on the hall nurses. An interview was conducted on 9/7/2021 at 10:08 AM with the physician for Resident #1 (MD #1). The MD #1 stated he had looked at the hospital records for Resident #1 when he was sent to the hospital on 8/30/2021. He acknowledged he saw the emergency room physician documentation of a sacral wound and he surmised the emergency room physician did not know what he was looking at. The MD #1 stated he looked at the photo of the sacral area of Resident #1 from the hospital and declared it to be a Kennedy ulcer. The MD #1 further explained the Kennedy ulcer could have appeared in the twenty-four hours Resident #1 sat in the emergency room . The MD #1 stated the wound was clearly a Kennedy ulcer which were notoriously quick in presentation. The MD #1 further explained a Kennedy ulcer was created when blood flow was being diverted and was a part of the disease process at the end of life for some patients. An interview was conducted on 9/13/2021 at 12:56 PM with the wound care consultant who was contacted when Resident #1 was in the emergency room . The hospital wound care consultant confirmed she was asked to provide a wound consult for Resident #1, but she did not see Resident #1 in the emergency room because she was told he was decompensating or failing in health. The wound care consultant revealed she requested photographs of the wound so she could perform a telehealth consult. The wound care consultant stated a Kennedy ulcer usually appears within 24 to 48 hours of a patient's death. The wound care consultant stated if the wound on Resident #1 was a Kennedy terminal ulcer, it would have appeared or started twenty-four to forty-eight hours prior to arrival in the emergency room . The wound care consultant stated, Without documentation as to what his (Resident #1's) skin looked like prior to going to the hospital and without knowing what the sacral area looked like at the nursing home, it can not be determined if this was a deep tissue injury or a Kennedy ulcer. The nursing home administrator was notified of Immediate Jeopardy on 12/10/21 at 8:44 am. The facility provided an acceptable credible allegation of immediate jeopardy removal plan on 12/10/21. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance Resident # 1 admitted on [DATE]. Resident was admitted to the hospital on 8/30/2021 and it was documented in emergency department notes that resident # 1 had a unstageable spinal decubitus ulcer. The facility failed to follow processes related to identification of skin impairments. This deficient practice affects all residents. 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; Current licensed nursing staff were educated by the SDC or designee to complete skin assessments on admission, weekly thereafter and with any new skin impairments. If a new skin impairment is identified, the licensed nurse will notify MD, obtain treatment orders, and update the care plan with other nursing interventions. Education with licensed nurses was completed 10/25/2021. This is tracked by nursing leadership and administrator. Director of Nursing or designee provided education to all licensed nurses, CNAs, and rehab staff on identifying changes of condition, including skin conditions outside of weekly skin assessment and report to the charge nurse for follow up. This was completed 10/25/2021. Alleged date of IJ removal is October 25th 2021 Person responsible for implementation is the administrator 2. Resident #2 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission minimum data set assessment dated [DATE] revealed Resident #2 was severely cognitively impaired with a stage two pressure wound upon admission and a surgical wound. The care plan, dated 6/30/2021, had a focus area for Resident #2 for a pressure ulcer on her left buttock and potential for pressure ulcer development relative to immobility. One of the interventions was to administer treatments as ordered and monitor for effectiveness. An additional focus area on the care plan for Resident #2 initiated on 6/28/2021 was for the potential for further skin impairment relative to admission with a pressure ulcer and surgical site. One of the interventions was for weekly skin assessments. Review of the electronic medical record revealed a communication with family note dated 9/1/2021 at 7:05 PM for which the responsible party for Resident #2 was informed of a pressure area on the left anterior foot. Review of the electronic medical record for Resident #2 revealed a skin/wound note dated 9/1/2021 at 7:10 PM stating, left anterior foot, pressure area, ppp (peripheral pulse palpable) 2+ Peripheral pulse palpable refers to her pulse being able to be felt in her legs and feet. Documentation in the medical record dated 9/1/2021 for Resident #2 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/1/2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the electronic medical record did not reveal a corresponding skin assessment for the left anterior foot for Resident #2. The most recent skin assessment for Resident #2 was dated 8/19/2021 with documentation of a wound and treatment plan for the right knee. The medical record of Resident #2 did not contain skin assessments for the weeks 7/25/2021 to 7/31/2021, 8/9/2021 to 8/14/2021, 8/22/2021 to 8/28/2021, 8/9/2021 to 9/4/2021, and 9/5/2021 to 9/11/2021. An interview was conducted with the Interim Director of Nursing on 9/13/2021 at 4:30 PM. The Interim Director of Nursing confirmed there should be skin assessments completed weekly for Resident #2 as specified in the care plan. The Interim Director of Nursing also confirmed a skin assessment should have been completed on 9/1/2021 to document the pressure area on the left anterior foot of Resident #2.

Based on resident interview, staff interviews, and record reviews the facility failed to used two staff member transferring residents using lifts which resulted in 1 of 3 sample residents (Resident # 2), who experienced falls, sustaining a laceration on the back of her head and a closed right clavicle fracture. Findings included: Resident # 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A 7/24/2014 care plan identified Resident #2 being at risk for falls due to history of falls and the use of psychotropic medication. This care plan also specified " Requires extensive to total assistance with all ADL ' s (activities of daily living) and requires mechanical lift for transfer (sit to stand with transfer). " Transfer requires two person assistance during all transfer. The resident ' s Minimum Data Set ((MDS) dated [DATE] documented Resident #2 had moderately impaired cognition, and Resident # 2 functional status revealed she was extensive assistance with one to two person physical assist with all transfers. An incident report on 7/12/2014 at 9:00 PM specified Resident #2 fell from sit to stand lift while a Nurse Aide was outside of the room getting towel to clean up urine on the floor. Resident # 2 was found on the floor at the foot of the bed with 1.5cm x 0.5 cm laceration on the back of her head. Review of Resident #2 medical record revealed a progress note written by Nurse # 1 on 7/13/2014 at 1:01AM which specified the resident fell from a sit to stand lift during bedtime preparation. The nursing assistant found the resident on the floor and contacted the nurse to assess the resident. The Resident was found at the foot of the bed on her back in a puddle of urine with blood coming from her head. The resident was assessed with [REDACTED]. The site was cleaned with normal saline and a steristrip was applied to the laceration. The Nurse Practitioner was notified and neurochecks were ordered. The resident complained of pain in the right shoulder, back of the head and jaw and stated the jaw was from the impact of the fall. One injury was identified at the time of the assessment. That was the laceration to the back of the head. The resident also complained of nausea and dry heaved for 3-4 minutes with no emesis. The staff was to continue to monitor the resident. A Physician ' s Progress Note dated 7/13/2014 revealed a clinical impression of scalp contusion, closed right clavicle fracture and minor head injury post fall. A radiology report dated 7/13/2014 of a computed tomography (CT) head scan for Resident # 2 revealed a large posterior scalp hematoma. A radiology report dated 7/13/2014 of a right shoulder radiograph for Resident #2 revealed a nonplaced fracture at the distal end of the clavicle. An interview on 8/11/2014 at 9:30AM with Resident #2 revealed on 7/12/2014 NA #1 put her in a sit to stand lift and left her unsupervised in the room to go get a pillow chase for her bed. Resident #2 indicated during the time she was left unsupervised in the lift, all she remember was hitting the floor hard and hitting the back of her head. Resident #2 stated she was in pain all over and her head hurt badly. Resident #2 indicated that she was sent out to the hospital hours later because her pain got worst in her shoulder. An interview on 8/11/2014 at 11:58AM with the Director of Nurses (DON) revealed that the facility policy has always been that two staff were needed to complete a lift transfer of any kind. The DON indicated that her expectation was for all Nurses and Nursing Assistants to have two persons to assist with lift transfer. The DON also indicated that the facility has completed a full investigation of Resident #2 falls. An interview was conducted with Nurse #1 on 8/12/2014 at 12:15PM. Nurse #1 stated she was the Nurse on duty the evening of 7/12/2014 when Resident #2 fell from lift. Nurse #1 indicated that NA #1 found the resident on the floor on 7/12/2014 and came to her and stated that Resident #2 had fallen off the lift. NA #1 told her that she just stepped out of the room to get a towel and when she came back the resident was on the floor. Nurse #1 indicated that she and NA went into the resident ' s room. The resident was on the floor at the foot of her bed in a large puddle of urine and a growing puddle of blood near her head. Nurse #1 stated that she told NA #1 that " you know you are not supposed to leave anyone of the residents on a lift by themselves no matter how long. " A second attempt was make to call NA #1 on 8/12/2014 at 12:45PM no answer message left again. The facility indicated that on 8/11/2014 the NA called in sick and on 8/12/2014 the NA was off of work. A review of the written statement from the facility ' s investigation of the resident ' s fall revealed that the NA on 7/12/2014, NA #1 put Resident #2 on the sit to stand lift and when she elevated the lift Resident #2 started to urine on the floor. NA #1 went to get something to put under her and when she returned to the room Resident #2 was on the floor.