Every finding on record at Autumn Care of Marshville

Based on observation, record review, and interviews with Resident #101, the resident's Power of Attorney (POA), and staff, the facility failed to follow professional standards of practice for medication administration for 1 of 1 resident reviewed (Resident #101) when Nurse #3 crushed and administered Atorvastatin 40 mg (milligrams), a medication used to lower cholesterol and reduce the risk of cardiovascular events such as heart attack and stroke.The findings included:Resident #101 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, epilepsy, slurred speech, and dysphagia.Review of physician orders dated 02/07/2026 revealed Atorvastatin 40 mg was ordered to be administered orally once daily. The order specified the medication was to be administered whole and was not to be crushed.Review of the manufacturer's Prescribing Information for Atorvastatin dated February 2023, revealed the tablets are to be swallowed whole and should not be crushed, chewed, or broken.Review of the Medication Administration Record (MAR) revealed on 02/09/2026 at 9:00 PM Nurse #3 administered Atorvastatin 40 mg to Resident #101. The MAR did not specify the form in which the medication was administered however, The MAR included instructions indicating the Atorvastatin 40 mg was not to be crushed. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact.An interview conducted with Resident #101's Power of Attorney (POA) on 02/10/2026 at 10:00 AM revealed she stayed overnight on 02/09/2026 and observed Nurse #3 crush and administer Resident #101's nighttime medications, including Atorvastatin 40 mg. The POA stated she informed Nurse #3 that the physician's order specified the medication was to be administered whole and not crushed and reported she had a copy of the order available at that time. The POA stated Nurse #3 responded that the medications had already been crushed and informed her that if Resident #101 refused to take the medication in crushed form, she would not receive her medication until the next scheduled dose.An interview conducted with Resident #101 on 02/10/2026 at 10:15 AM revealed Nurse #3 administered her nighttime medication, including Atorvastatin 40 milligrams (mg), in crushed form on 02/09/2026. Resident #101 stated Nurse #3 informed her the medication would not harm her and told her that if she refused to take it, she would not receive it again until the next scheduled dose. Resident #101 stated she took the medication as instructed.An interview conducted with Nurse #3 on 02/10/2026 at 6:17 PM revealed she crushed and administered Resident #101's nighttime medications, including Atorvastatin 40 mg, on 02/09/2026. Nurse #3 stated it was her first shift at the facility as an agency nurse and her first time caring for Resident #101. Nurse #3 stated she believed the medications needed to be crushed due to the Resident #101's history of stroke and information reportedly received from the previous shift nurse. Nurse #3 acknowledged she did not verify the physician's order prior to crushing the medication and did not contact the provider or pharmacy to clarify the order.An interview conducted with the Director of Nursing (DON) on 02/12/2026 at 12:48 PM revealed Nurse #3 was working as an agency nurse on 02/09/2026. The DON stated nursing staff are expected to review physician orders prior to medication administration and administer medications as prescribed. The DON stated she was notified of the incident on 02/10/2026 by Resident #101's POA. The DON reported she initiated an internal investigation upon learning of the incident. The DON stated Nurse #3 acknowledged crushing the medication without verifying the physician's order. The DON indicated Nurse #3 was removed from the schedule pending investigation.An interview conducted with the Administrator on 02/12/2026 at 1:57 PM revealed he was made aware of the medication administration incident involving Resident #101 by the DON. The Administrator stated nursing staff are expected to follow physician orders and facility policy regarding medication administration.

Based on record review, Physician and staff interviews, the facility failed to have effective systems in place for shift change narcotic reconciliation and failed to keep discontinued narcotic medications under two locks for return to the pharmacy. This failure resulted in 30 missing oxycodone/acetaminophen 10/325 milligrams (mg) and 50 missing oxycodone 5 mg for a total of 80 missing tablets. This occurred for 2 of 2 residents reviewed for misappropriation of medications (Resident #98 and Resident #103).The findings included:Review of the medical record for Resident #98 revealed a physician order dated [DATE] for oxycodone/acetaminophen (a narcotic pain medication) 10/325 mg one (1) tablet by mouth twice per day as needed for moderate pain.Review of the medication administration record revealed on [DATE] Resident #98 received oxycodone/acetaminophen 10/325 mg at 9:21 AM for pain he rated 9 (1-10 scale with 1 being no or minimal pain and 10 being intense pain). This was administered by Medication Aide (MA) #1 and it was documented as effective for his pain.Review of the schedule for [DATE] revealed MA #1 was scheduled to work on the day shift (7:00 AM to 3:00 PM) and Nurse #1 was scheduled to work afternoon and night shift (3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM).Review of the schedule for [DATE] revealed MA #1 was scheduled to work the day shift. A facility initial allegation report completed by the former Administrator dated [DATE] reported that oxycodone/acetaminophen 10/325 mg belonging to Resident #98 was not located in the medication cart. The report indicated that the pharmacy was notified, the police were notified, and an investigation of Change of Custody and delivery was initiated.The facility investigation report completed by the former Assistant Director of Nursing dated [DATE] described the investigation that was initiated on [DATE] that included suspension of MA #1 and Nurse #1. Alert and oriented residents were interviewed regarding administration of their pain medications and pain assessments were conducted on moderately cognitively impaired residents. No issues were identified during the assessments. The facility conducted a 30-day look back audit on all narcotics received and the facility identified one other resident (Resident #103) with missing narcotics. The facility reviewed 7 employee files and licenses, and conducted urine drug screening on 7 staff, including MA #1 and Nurse #1 and all urine drug screens were negative for narcotic medications. The facility notified Adult Protective Services on [DATE] as well as the local police and Drug Enforcement Administration. The facility concluded that they were unable to substantiate the misappropriation of the medications. A statement given by MA #1 dated [DATE] documented, (MA#1) worked 100, 300, and 600 units on [DATE]. The narcotics count was 36 for the AM and the PM shifts (number of cards of narcotics matched the number of narcotic sheets). My relief for the afternoon on [DATE] was (Nurse #1). On [DATE] (MA #1) received the cart from (Nurse #1). She assured me the count was still 36 like the previous day and we counted the cart. I gave return meds to (Unit Manager (UM) #1) .I continued my med pass on 300 unit. (Resident #98) asked for pain meds while being transported to therapy. I assured him I would bring it to him. As I looked in narcotics book and cart, I didn't see a blister pack for him (of oxycodone/acetaminophen 5/325 mg tablets). I know that I didn't give the last pill the previous day, so I was unsure of why he didn't have any more (narcotic medication). I notified (UM #1) .A clarifying statement given by MA #1 dated [DATE] documented Tuesday morning ([DATE]) Nurse #1 and I were counting narcotics on 600 hall . and the count was accurate. We went to the 100/300 hall medication cart to count narcotics, we started counting, she said, 'we still have 36 items in the cart' and I did not count to confirm.An interview was conducted with MA #1 on [DATE] at 2:21 PM. MA #1 reported she had worked several shifts before and after Nurse #1 prior to [DATE] and the morning of [DATE], she and Nurse #1 had counted the narcotics in the medication cart for the 600 hall, but when MA #1 went to count the 300 hall cart and Nurse #1 told her, Oh, we don't need to do that, it's the same as it was yesterday afternoon. MA #1 reported she knew she should not skip the narcotic count, but she believed Nurse #1 and signed the narcotic count sheet without counting the narcotics in the 300-hall cart. MA #1 reported later that morning, Resident #98 requested oxycodone/acetaminophen pain medication and when she opened the locked narcotic drawer, she discovered Resident #98 did not have pain medications in the drawer. MA #1 reported she had administered one tablet to Resident #98 on [DATE] and knew he had a full card of medications in the locked narcotic drawer. MA #1 explained she immediately alerted Unit Manager (UM) #1. MA #1 explained that on [DATE] during the narcotic count at 3:00 PM, she recalled seeing a full card with 30 tablets of oxycodone/acetaminophen for Resident #98 in the narcotic drawer. MA #1 reported she was suspended from work during the investigation and submitted urine for drug screening.An email statement written by Nurse #1 dated [DATE] documented that Nurse #1 worked from 2:45 PM on [DATE] until 7:15 AM on [DATE]. The statement indicated that Nurse #1 had given report at the end of her shift to MA #1 and the two of them counted narcotics on the first cart (the hall was not specified) and all narcotics were accounted for, and Nurse #1 gave MA #1 the keys for that cart. The note documented that MA #1 and Nurse #1 proceeded to count the second cart (the hall was not specified). The note documented that all narcotic counts were correct and there were no concerns or issues.A statement dated [DATE] from Nurse #1 was reviewed. The statement reported Nurse #1 was scheduled to work [DATE] on the 100, 300, and 600 halls from 3:00 PM to 11:00 PM and the 100, 300, 600 and 200-210 halls from 11:00 PM to 7:00 AM on [DATE]. The statement read that when MA #1 arrived on [DATE] they counted the narcotics on the 600-hall cart. The statement did not include information regarding the 300-hall cart. Multiple efforts were made to contact Nurse #1 for interviews and those attempts were unsuccessful.UM #1 was interviewed on [DATE] at 10:16 AM. UM #1 explained that she was working on [DATE] and MA #1 approached her to report that Resident #98 was missing narcotic pain medications. UM #1 reported she asked MA #1 if she had counted the narcotics at shift change and MA #1 reported she and Nurse #1 had not counted the narcotics on the 300-hall cart. UM #1 described searching all narcotic drawers in each of the medication carts and she was unable to locate the missing oxycodone/acetaminophen for Resident #98. UM #1 reported she called Nurse #1 to inquire about the missing medications and Nurse #1 was evasive with her answers and told her she would be in to work at 3:00 PM [DATE].The former Director of Nursing (DON) was interviewed by phone on [DATE] at 12:56 PM. The former DON reported she was not working on [DATE] but was notified of the missing oxycodone/acetaminophen by UM #1. The former DON explained that MA #1 and Nurse #1 had not counted the narcotics at shift change on [DATE], but the facility was not able to determine who took the oxycodone/acetaminophen. The former DON reported all nurses and medication aides were trained to complete narcotic counts at the change of any shift, including MA #1 and Nurse #1.The Director of Nursing was interviewed on [DATE] at 3:12 PM and she reported she had started her position after the incidents, but she expected all narcotics to be counted at the end of one shift and the beginning of the next shift by the oncoming and leaving nursing staff and if the narcotic counts had discrepancies, the nursing staff should report those issues immediately.The Physician was interviewed on [DATE] at 1:37 PM. The physician reported he was notified of the medications for Resident #98 and Resident #103 were missing and he was part of the Quality Assurance Performance Improvement (QAPI) meeting on [DATE]. The Physician reported that Resident #98 had replacement medications provided by the facility and Resident #98 was not harmed.Review of the medical record for Resident #103 revealed a physician order dated [DATE] for oxycodone 5 mg with instructions to administer one (1) tablet by gastric tube every 4 hours as needed for pain.An interview was conducted with MA #1 on [DATE] at 2:21 PM. MA #1 reported when she received report on [DATE] from Nurse #1, she was told there were medications that needed to be returned to the pharmacy that belonged to Resident #103. MA #1 reported the medications were in a bag and sitting unlocked in the medication room, and she took the medications to UM #1 to be returned to the pharmacy. MA #1 reported she was aware that Resident #103 had died a few days before and knew that the medications would need to go back to the pharmacy, but she did not have authorization to do that, so she took the medications to UM #1. MA #1 explained she did not look at the medications or know what medications were in the bag.A statement by Nurse #1 dated [DATE] documented that (unspecified time and date) that Resident #103's medications were separated in the locked narcotic drawer and Nurse #1 took the medications out of the locked narcotic drawer and put in a clear pharmacy return back and put the bag into the medication room. The statement documented that Nurse #1 told MA #1 there were narcotics that needed to be returned (to pharmacy). Multiple attempts were made to contact Nurse #1 for interviews and those attempts were unsuccessful.The facility investigation report dated [DATE] described the investigation that was initiated on [DATE] that included suspension of MA #1 and Nurse #1. Alert and oriented residents were interviewed regarding administration of their pain medications and pain assessments were conducted on moderately cognitively impaired residents. No issues were identified during the assessments. The facility conducted a 30-day look back audit on all narcotics received and the facility identified one other resident (Resident #103) with missing narcotics. The facility reviewed 7 employee files and licenses, and conducted urine drug screening on 7 staff, including MA #1 and Nurse #1 and all urine drug screens were negative for narcotic medications. The facility notified Adult Protective Services on [DATE] as well as the local police and Drug Enforcement Administration. The facility concluded that they were unable to substantiate the misappropriation of the medications. UM #1 was interviewed on [DATE] at 10:16 AM. UM #1 explained that she was working on [DATE] and MA #1 approached her with medications for Resident #103 that needed to be returned to the pharmacy. UM #1 explained she was in the middle of investigating the missing narcotic medications for Resident #98 and she placed the medications for Resident #103 into an unlocked cabinet in the nurses' station. UM #1 explained that she should have locked the medications in a locked cabinet in the medication room, but she was preoccupied with the investigation for Resident #98's missing narcotic medications. UM #1 reported that later that day, she and Nurse #2 were preparing to return the medications to the pharmacy and that was when they discovered that the oxycodone prescribed for Resident #103 was missing. UM #1 explained that two nurses were required to count medications before returning them to the pharmacy and that's when they discovered the missing oxycodone prescribed to Resident #103 was not in the bag. Nurse #2 was interviewed on [DATE] at 10:50 AM. Nurse #2 reported that to return narcotic medications to the pharmacy, two nurses must count the medications and scan the medication for return. Nurse #2 explained that medications should not have been removed from the cart by one nurse and should not have been left unlocked. The former Director of Nursing (DON) was interviewed by phone on [DATE] at 12:56 PM. The former DON stated UM #1 was aware that the narcotic medications needed to be locked up. The former DON did not know why Nurse #1 removed the medications from the locked medication cart.During the interview with the DON on [DATE] at 3:12 PM, the Regional Director of Clinical Services reported that discontinued narcotics were kept under two locks until the pharmacy returns for them and there are two nurses to sign them out.The Administrator was interviewed on [DATE] at 3:16 PM. The Administrator explained he started his position after the incident happened and he expected all narcotic hand-offs were completed per policy. The facility submitted the following corrective action plan: Nurse #1 and Med Aide #1 failed to properly complete the shift change controlled substance inventory log. Staff relied on verbal confirmation rather than physically verifying and documenting the count together. Additionally, a nurse manager failed to secure medications intended for return to pharmacy by leaving them in an unlocked cabinet behind nurses' station. Address how the corrective action will be accomplished for those residents found to have been affected by the deficient practice.On [DATE], Med Aide #1 identified missing oxycodone/acetaminophen 10/325mg tabs for Resident #98 based on availability from previous day. A thorough search was conducted in the facility to locate the medication without success.On [DATE] Medication Aide (MA) #1 received 300 med cart from Nurse #1, they did not complete a proper narcotic count. During med pass Resident #98 requested pain med from MA #1. When MA #1 looked inside med cart she did not see the medication. The MA #1 remembered that the previous day the medication was there. The medication aide immediately notified the Unit Manager, who confirmed with the pharmacy that 60 tablets had been delivered on [DATE]. A search of the medication cart did not locate the missing medication. Resident #98 was found to be missing #50 oxycodone/acetaminophen 10/325mg tablets. The Nurse Manager informed the Administrator and Director of Nursing. The Administrator subsequently notified the Regional [NAME] President of Operations, Regional Director of Clinical Services, Marshville Police, the pharmacy representative, medical director, responsible party, and the resident. All nurses who had worked the medication cart, including the DON, submitted to urine drug screening. MA #1 and Nurse #1 (assigned during the timeframe the medication went missing) were suspended pending investigation. The Staff Development Coordinator conducted a full narcotic count on all medication carts. Additionally, the SDC initiated education for licensed nurses and medication aides on Chain of Custody for Controlled Substances and Abuse to include misappropriation. Director of Nursing and Nurse Managers completed pain audits on all residents receiving narcotics. Interviews completed on alert and oriented residents with a BIMS of 12 or above. No issues identified. A new script was obtained for Resident #98's pain medication by NP #1 and pharmacy sent pain medication which was billed to the facility on [DATE]. Resident #98 did not have any negative outcomes due to missing pain medication.The morning of [DATE] Nurse #1 informed MA #1 about medications on the counter in the medication room that needed to be returned. MA #1 took the medications from the medication room to the main nurse's station to give to the Unit Manager. The Unit Manager placed the medications in an unlocked cabinet behind the nurses' station where she was working to return later. Later in the day, Unit Manager and Nurse #2 scanned and returned all medications to pharmacy. During the investigation for missing narcotics, it was discovered that Resident #103 was missing 30 tablets of oxycodone 5mg. Resident #103 expired [DATE]. Address how the facility will identify other residents having the potential to be affected by the same deficient practice.All residents receiving controlled pain medication have the potential of being affected.Director of Nursing/Designee completed pain audits on all residents receiving narcotics. Interviews completed on all alert and oriented residents with a Brief Interview for Mental Status of 12 or above. No negative findings noted. These audits were completed on [DATE]. Residents with a BIMS of 12 or above were asked the following questions: 1) Do you receive medication for pain? 2) If yes, are you having any problems receiving your pain medication? 3) Do you have any unrelieved pain that we need to address at this time? Confused residents received the Pain Assessment in Advanced Dementia (PAINAD) Scale.Upon discovery on [DATE] the facility, in accordance with our Quality Assurance Performance Improvement program, leadership implemented the following corrective action measures:[DATE] Facility staff notified unit manager of the discrepancies on the narcotic count sheet. Unit manager notified Director of Nursing and Nursing Home AdministratorXXX[DATE] Administrator and Staff Development Coordinator interviewed Med Aide #1 and Nurse #1 and urine drug tests completed. MA #1 and Nurse #1 denied taking the medications. MA #1 and Nurse #1's urine drug tests were negative for oxycodoneXXX[DATE] Administrator notified Med Aide #1 and Nurse #1 of being suspended pending investigationXXX[DATE] Director of Nursing and Nursing Home Administrator notified Regional [NAME] President of Operations, Regional Director of Clinical Services, Marshville police department, pharmacy representative, medical director, nurse practitioner, Resident #98, and Responsible PartyXXX[DATE] Staff Development Coordinator completed full narcotic counts on all medication carts. No other missing narcotics were identifiedXXX[DATE] Staff Development Coordinator initiated education on the Chain of Custody Controlled Substances Process and abuse to include misappropriation with licensed nurses and medication aidesXXX[DATE] Director of Nursing/Designee completed a complete pain assessment audit on all residentsXXX[DATE] Director of Nursing and Staff Development Coordinator completed a 30-day lookback audit of all narcotics received and identified Resident #103 (deceased on [DATE]) had #30 oxycodone 5mg tabs that were received on [DATE] from pharmacy cannot be accounted for. No other discrepancies identifiedXXX[DATE] Ad hoc Quality Assurance Performance Improvement meeting was completed.Audits completed on all narcotic sheets on [DATE]/600/800 med carts to determine if there was any diversion. One area was identified for Resident #98 and Resident #103. Director of Nursing/designee completed audits with all licensed nurses/medication aides of the count process during shift change from [DATE]-[DATE]. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.The Director of Nursing/Designee re-educated all licensed nurses/medication aides including agency nurses on Chain of Custody Controlled Substances, securing medications, and misappropriation on [DATE]. The education included that both outgoing and incoming staff are required to physically visualize each controlled substance and reconcile the count against the log before signing. Reinforced that verbal confirmation alone is not acceptable practice. All newly hired licensed nurses and agency staff will be educated on said process during orientation. Nurse #1 and MA#1 that failed to complete the narcotic count received disciplinary action. The nurse manager who failed to secure medications received disciplinary action as well. The Director of Nursing placed a lock on cabinet in medication room to store medications that need to be returned to pharmacy. Director of Nursing/Designee is conducting unannounced spot checks during shift change. Indicate how the facility plans to monitor its performance and make sure that solutions are sustained.The Director of Nursing/Designee will audit five random narcotic counts with licensed nurses/medication aides weekly, to ensure accuracy and proper reconciliation of narcotics.The Director of Nursing/Designee will audit medication carts, medication rooms, and nurses' station weekly to ensure narcotics are secured properly. This audit will be completed weekly for 8 weeks.The Director of Nursing/Designee will audit five random residents to ensure that they have no issues with care and services weekly for 8 weeks.The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.The facility completed and accepted the plan of correction at an ad hoc QAPI meeting on [DATE].Root cause analysis: The facility completed a thorough investigation to determine the root cause of the missing medications. All investigative steps were taken in accordance with internal protocols and applicable regulatory standards. Nevertheless, the missing narcotics were not recovered, and no evidence was found to clarify the nature of the loss. The facility investigation did reveal that nurses/medication aides were not completing the Shift Change Controlled Substances Inventory Log properly during shift change/narcotic counts. Some staff were relying on verbal confirmation and taking each other's word that the count was correct. Additionally, the investigation revealed a nurse manager left medications in unlocked cabinet. Nurse Manager failed to follow facility policy which requires all narcotics to be secured under a double-lock system at all times. Include dates when the corrective action will be completed. Date of Compliance: [DATE]The plan of correction was validated on [DATE]. Initial audits of the narcotic drawers were reviewed, resident interviews and pain assessments were reviewed, and education provided to staff was reviewed. Nursing staff were interviewed, and they were able to correctly describe the process for narcotic medication counts and when to perform those counts. A change of shift narcotic count was observed and no issues were identified. Narcotic drawers and sheets were reviewed and no issues were identified. The facility's date of compliance of [DATE] was validated.

Based on observation, record review, and interviews with Resident #101's Power of Attorney (POA), Facility Physician, Pharmacist, Nurse Practitioner #1 (NP), and staff, the facility failed to ensure Resident #101 was free from a significant medication error when Nurse #3 crushed and administered Brivaracetam (anticonvulsant medication used to control partial -onset seizures) 100 milligram (mg) extended-release, Eslicarbazepine 800 mg (anticonvulsant used to treat seizure disorders), Lamotrigine 200 mg (anticonvulsant medication used to control various types of seizures), and Xcopri 150 mg (anticonvulsant used to treat partial-onset seizures), despite physician orders indicating the medications were to be administered whole and not crushed. This deficient practice occurred 1 of 1 resident reviewed for significant medication errors (Resident #101).The findings included:Resident #101 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, epilepsy, slurred speech, and dysphagia.Resident #101's quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact and revealed no physical or verbal behavioral symptoms and no rejection of care.Review of the Medication Administration Record (MAR) revealed on 02/09/2026 at 9:00 PM Nurse #3 initialed the MAR indicating she had administered Brivaracetam 100 mg, Eslicarbazepine 800 mg, Lamotrigine 200 mg, and Xcopri 150 mg to Resident #101. The MAR did not specify whether the medications were to be administered whole or crushed.Review of physician orders revealed Brivaracetam 100mg was ordered on 02/09/2026 to be administered orally twice daily, with special instructions stating DO NOT CRUSH; Eslicarbazepine 800 mg was ordered on 02/07/2026 to be administered orally once daily and not crushed; Lamotrigine 200 mg was ordered on 02/07/2026 to be administered orally five times daily and not crushed; and Xcopri 150 mg was ordered on 02/08/2026 to be administered orally twice daily and not crushed.Review of the manufacturer's Prescribing Information revealed that Brivaracetam Prescribing Information dated January 2021 states that tablets should be swallowed whole and should not be chewed or crushed. The Lamotrigine (extended-release) Prescribing Information dated July 2023 states that tablets should be swallowed whole and must not be chewed, crushed, or divided. The Eslicarbazepine Prescribing Information dated March 2024 states that tablets may be administered whole. The Xcopri Prescribing Information dated April 2023 states that tablets may be taken whole. Failure to administer these anti-seizure medications as recommended by the manufacturer and as ordered by the physician may alter drug effectiveness and can increase the risk for breakthrough seizures, increased adverse reactions, or other complications.An interview conducted with Resident #101's Power of Attorney (POA) on 02/10/2026 at 10:00 AM revealed she stayed the night on 02/09/2026 and was present when Nurse #3 crushed and administered Resident #101's nighttime medications. The medications included Brivaracetam, Eslicarbazepine, Lamotrigine and Xcopri. Resident #101's Power of Attorney stated she informed Nurse #3 that the medications should not be crushed according to the physician's orders, which she had a copy of. Resident #101's Power of Attorney stated Nurse #3 informed her that she had already crushed the medications and that if Resident #101 did not take the crushed medications, she would not receive them again until the next night. Resident #101's Power of Attorney stated that within 40 minutes of taking the medication, side effects occurred. She stated Resident #101 felt extremely nauseated, experienced slurred speech beyond baseline, sweating, feeling extremely hot, and weakness. Resident #101's Power of Attorney stated she informed Nurse #3 of the symptoms. Nurse #3 stated she would check on Resident #101; however, the Power of Attorney stated Nurse #3 only checked on Resident #101 once during the night to obtain vital signs.Interview with Resident #101 on 02/10/2026 at 10:15AM revealed Nurse #3 told her to take the crushed medication on 02/09/2026 because it would not hurt her. Resident #101 stated she took the medication because it was important for her seizures, and Nurse #3 stated she would not receive the medication again until the next night if she refused to take it. Resident #101 stated she felt nauseated, experienced slurred speech, sweating, feeling hot, and weakness. Resident #101 stated she could not recall exactly how long the symptoms lasted but reported they began an hour after taking the medication. Resident #101 stated she was unable to participate in physical therapy on 02/10/2026 because her symptom of weakness was present. Review of Resident #101's vital signs taken by Nurse #3 revealed on 02/10/2026 at 12:51 AM, Resident #101's temperature was 98 degrees Fahrenheit, pulse 80 beats per minute, respirations 18 per minute, blood pressure 118/69 mmHg, and oxygen saturation 98%. On 02/10/2026 at 9:41 AM, Resident #101's temperature was 98 degrees Fahrenheit, pulse 72 beats per minute, respirations 18 per minute, blood pressure 126/60 mmHg, oxygen saturation 95%.An interview conducted with Nurse Aide (NA) #2 on 02/10/2026 at 11:35 AM revealed she cared for Resident #101 on 02/09/2026. NA #2 stated Resident #101 informed her that she was scared when Nurse #3 crushed her medications instead of administering them whole. NA #2 stated that around 9:00 PM, Resident #101 was sweating more than usual. NA #2 reported assisting Resident #101 by washing her up, changing her into a gown, and removing her blanket. The NA #2 indicated that Resident #101 did not express complaints of nausea or weakness at that time. NA #2 further stated she did not obtain Resident #101's vital signs.An interview conducted with Nurse #3 on 02/10/2026 at 6:17 PM revealed 02/09/2026 from 11:00 PM to 7:00 AM on 2/10/2026 was her first day working for the facility and first time working with Resident #101, as she was an agency nurse. Nurse #3 stated she crushed Resident #101's medications on 02/09/2026 because the facility had not specified otherwise and the nurse from the morning shift of 02/09/2026 stated Resident #101's medications needed to be crushed. Nurse #3 stated she assumed Resident #101's night medications should have been crushed because the resident had a history of stroke. Nurse #3 stated stroke patients often receive crushed medication, and she thought Resident #101 needed her medications crushed. Nurse #3 stated Resident #101's family did not express concerns about the crushed medications until after they were administered. Nurse #3 stated she got vital signs on Resident #101 at 4:00 AM on 02/10/2026, and the resident appeared to be fine.An interview conducted with the Pharmacist on 02/10/2026 at 6:01 PM revealed that crushing Brivaracetam, Eslicarbazepine, Lamotrigine, and Xcopri could decrease the effectiveness of the active ingredients needed to control seizures and other diagnoses. The Pharmacist stated that the symptoms may have resulted from the medications being administered in crushed form and administered all at once. The Pharmacist further stated she did not believe the crushed medications would be a significant concern, as Resident #101 would have already had the medications in her system from previous doses.An interview conducted with the Nurse Practitioner #1 (NP) on 02/10/2026 at 6:52 PM revealed she assessed Resident #101 on 02/10/2026 at 5:00 PM and reported that Resident #101 was stable with no observed side effects or complications. The NP#1 reported that nursing staff did not contact her at the time of the medication error. NP #1 stated she was made aware of the medication error by the Director of Nursing on 02/10/2026. NP #1 indicated that if a medication error occurs, the dose may be wasted and re-administered as appropriate. NP #1stated the Brivaracetam was designed to be extended-release over time. NP #1 stated administering the Eslicarbazepine, Lamotrigine, and Xcopri crushed and all at once, rather than allowing it to release gradually, could contribute to potential side effects. The NP #1stated the side effects the resident experienced were a direct result of the medications being crushed.An interview conducted with the facility's Physician on 02/12/2026 at 11:00 AM revealed he was unaware of the medication error involving Resident #101. The facility's Physician stated that Eslicarbazepine, Lamotrigine, and Xcopri could be crushed if necessary. The Facility's Physician stated Brivaracetam should not be crushed because it is an extended-release medication that absorbs into the bloodstream more quickly when crushed. The Facility's Physician stated the symptoms occurred as a side effect of the medications being crushed and administered all at once.An interview conducted with the Director of Nursing (DON) on 02/12/2026 at 12:48 PM revealed Nurse #3 was hired as an agency nurse. The DON stated Nurse #3 obtained vital signs at midnight for Resident #101, and no abnormal vital signs were found. The DON further stated she was made aware of the medication error on 02/10/2026 by Resident #101's POA.An interview conducted with the Administrator on 02/12/2026 at 1:57 PM revealed he was made aware of the medication error involving Resident #101 by the DON.

Based on record review and interviews with the Power of Attorney (POA), the Nurse Practitioner, three dental offices, the dental Chief Compliance Officer, Chief Medical Officer, and facility staff, the facility failed to ensure necessary assistance was provided to obtain routine and emergency dental services for 1 of 1 resident reviewed (Resident #95).The findings included:Resident #95 was admitted to the facility on [DATE] with diagnoses of unspecified dementia, anoxic brain damage, unspecified intellectual disability, and hypertensive heart disease without heart failure. Resident #95 discharged from the facility on 10/13/2025.Resident #95 was care planned on 08/19/2025 with no identified dental health problems.The quarterly Minimum Data Set (MDS) dated [DATE] coded Resident #95 as cognitively intact, receiving a therapeutic diet, with no significant weight loss. The MDS further indicated no mouth or facial pain and no discomfort with chewing. Resident #95 required partial/moderate assistance with ADL, including bathing and toileting, setup or clean-up assistance for oral hygiene, did not ambulate, and required substantial assistance for transfers.Review of the electronic health record (EHR) from 11/20/2024 through 07/09/2025 showed no evidence of a dental examination for Resident #95. A Unit Manager #1 progress note dated 7/10/2025 indicated Resident #95 returned from Dental Office #1 for an initial dental exam with no new orders and was not seen due to inability to ambulate. A Unit Manager #1 progress note dated 7/29/2025 indicated Resident #95 returned from Dental Office #3 with a diagnosis of gum disease and required extractions of tooth #10, #11, #12, #13, #15, #28, #29, and #30. A progress note dated 8/27/2025 indicated prior authorization was completed for Dental Office #3.A Social Work progress note dated 10/07/2025 indicated Dental Office #3 could not treat Resident #95 unless he was able to transfer independently from his wheelchair to the dental chair.A Social Work progress note dated 10/07/2025 indicated Resident #95 was scheduled for an in-house dental appointment on 10/17/2025 for an initial dental examination. An interview with the POA on 02/10/2026 at 7:08 PM revealed ongoing concerns regarding Resident #95's dental needs beginning in April 2025. The POA stated Resident #95 had not been seen by a dentist at the facility despite repeated requests. He reported notifying the Social Worker on more than one occasion that Resident #95 required a dental evaluation due to complaints of pain and difficulty chewing. The POA stated he observed Resident #95 during visits appearing uncomfortable while eating and he reported Resident #95 verbally complained of mouth pain when chewing food. The POA stated he communicated these concerns to facility staff, including the Social Worker, but was informed that Unit Manager #1 was attempting to locate a dentist. The POA stated he independently scheduled the first dental appointment at Dental Office #1 on 07/10/2025. He reported Dental Office #1 communicated directly with the facility and he was unaware of any referral to Dental Office #2. The POA indicated that he removed Resident #95 from the facility due to the length of time it took the facility to follow up on the resident's dental needs.Unit Manager # 1 was interviewed on 02/11/2026 at 2:33 PM and stated that she recalled family concerns regarding Resident #95's teeth. She stated Resident #95 required assistance transferring to a dental chair and the facility did not have the appropriate resources to assist with transfers at the dental office. Unit Manager #1 indicated that nursing staff and the Social Worker attempted to locate dental offices that could accommodate Resident #95's transfer needs. She stated the appointment scheduler was responsible for communication with Dental Office #1. Unit Manager #1 stated she was unaware of any referral appointments at Dental Office #2. Unit Manager #1 stated the facility communicated with outside physician and dental offices by placing appointment paperwork, referrals, and written instructions in a communication binder that traveled with Resident #95.On 02/11/2026 at 3:31PM the Social Worker stated she first learned about Resident #95's dental concerns from the POA in July 2025. During that conversation, the POA did not mention that Resident #95 was in pain or discomfort. The Social Worker stated she could not recall the specific dental concerns but frequently spoke with the POA regarding scheduling dental appointments. The Social Worker stated she was responsible for planning in-house dental appointments and nursing staff were responsible for outside appointments. The Social Worker stated the facility used an in-house dental provider that came to the facility once every three months for dental hygiene and basic extractions and was present in October 2025. The Social Worker could not recall or provide documentation indicating whether Resident #95 had ever been seen by the in-house dental provider since admission. The Social Worker stated she was notified by Unit Manager #1 that Resident #95 was sent back from Dental Office #3 because he could not transfer to the dental chair. Social Worker stated she was in communication with Resident #95's POA in August 2025, and the POA informed her he would schedule the dental appointments because it was taking too long for the facility to. The Social Worker stated it was taking too long for the facility to meet Resident #95's dental needs. She stated she informed the POA that it would take time to locate a dental office that would accept Resident #95's managed insurance. She also stated the Nurse Practitioner #2 (NP) needed to complete authorization for Resident #95 before dental services could be provided. The Social Worker stated she believed dental services had been provided for Resident #95 from August 2025 through September 2025 because she did not receive any follow-up communication from nursing staff or the NP #2. The Social Worker stated Resident #95's POA called in October 2025 regarding dental services that had not been provided. At that time, she offered the in-house dental appointment scheduled for 10/17/2025, and the POA agreed. Social Worker stated the POA informed her of his intent to discharge Resident #95 from the facility on 10/13/2025 due to delays in obtaining necessary dental services. The Social Worker further stated there was no established process in place to follow up on outside dental appointments, and she was unaware of any scheduled appointment with Dental Office #2.An interview with the NP #2 on 02/11/2026 at 3:30 PM revealed she was not aware of an appointment with Dental Office #2 for Resident #95. The NP #2 stated the delay in treatment was related to finding a facility that could accommodate his physical needs and that most dental offices may not accept Resident #95's managed insurance. The NP #2 stated she completed authorization in August 2025 for Resident #95 and that caused additional delays for dental services while waiting for approval.An interview with NA #3 on 02/11/2026 at 4:00 PM revealed she was responsible for transporting Resident #95 to dental appointments. NA #3 stated she did not take Resident #95 to Dental Office #1 on 7/10/2025 because she was on leave. NA #3 stated she transported Resident #95 to Dental Office #3 on 8/27/2025 and no orders were indicated in Resident #95's communication binder. NA #3 stated she did not stay during Resident #95's dental appointment because the POA wanted to attend instead. NA #3 stated Resident #95 required a mechanical lift for transfers and was non-ambulatory. She reported learning from the POA that Dental Office #3 declined treatment because Resident #95 could not transfer from his wheelchair to the dental chair. NA #3 stated she did not have equipment available to facilitate a safe transfer for the dental visit.An interview with the Dentist at Dental Office #1 on 02/12/2026 at 11:40 AM revealed Resident #95 was seen on 7/10/2025 for dental consultation. The Dentist stated Resident #95 had periodontal disease and needed five extractions due to tooth decay and seven extractions due to cavities. The Dentist stated Resident #95's teeth appeared not to have been properly cared for, which contributed to nerve damage. The Dentist stated that due to the condition of Resident #95's teeth, he would have experienced pain. The Dentist stated he referred Resident #95 to an oral and maxillofacial specialist (Dental Office #2) for extractions and that the referral was placed in Resident #95's communication binder with instructions for the facility to call Dental Office #2 to schedule the appointment. The Dentist stated Dental Office #1 verbally communicated with the transporter regarding the referral.An interview with the Dentist at Dental Office #2 on 02/12/2026 at 12:00 PM revealed there was no record of treatment for Resident #95 and no documentation of contact from the facility.An interview with the Chief Compliance Officer at Dental Office #3 on 02/12/2026 at 12:56 PM revealed Resident #95 was seen on 7/29/2025 and received only a cleaning and X-ray. Dental Office #3 revealed no treatment orders were communicated to the facility because the visit was an initial appointment scheduled by Resident #95's POA.An interview with the Director of Nursing (DON) on 02/12/2026 at 1:42 PM revealed she was not employed at the facility during the time of Resident #95's dental concerns. The DON stated she learned from the Social Worker that when NA #3 was out on leave, a nursing staff member was responsible for transportation for outside appointments. The DON stated that the nursing staff member had not been identified. The DON revealed that the referral for Dental Office #2 may have been lost in communication.An interview with the Administrator on 02/12/2026 at 2:17 PM revealed he was not made aware of Resident #95's dental concerns because he was hired after Resident #95 discharged from the facility. The Administrator stated he expects nursing staff and social work to follow up on dental needs for residents in the facility.

Based on record review, observations, and staff interviews, the facility failed to provide care in a safe manner when a resident fell out of bed during incontinence care for 1 of 3 residents reviewed for accidents (Resident #2). Resident #2 was prescribed a daily low-dose aspirin for stroke prevention. Nursing Assistant (NA) #1 rolled Resident #2 away from her during incontinence care, and Resident #2 fell out of bed sustaining a laceration to her forehead, which necessitated 8 sutures to close. The findings included: Resident #2 was admitted to the facility 2/21/2019 with diagnoses including epilepsy, stroke, and hypertension.Review of the medical record revealed a physician order dated 12/3/24 for aspirin 81 milligrams administered daily. The quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #2 to be severely cognitively impaired. The MDS documented limited range of motion on one side of her upper body and for both legs. The MDS documented Resident #2 required substantial assistance with bed mobility and was dependent on staff for transfers. A nursing note dated 8/1/25 at 6:40 AM written by Nurse #1 documented NA #1 called Nurse #1 to Resident #2's room, and she found Resident #2 on the floor beside the bed face down in a puddle of blood. Nurse #2 documented she performed an assessment on Resident #2 prior to assisting her back into bed with a mechanical lift. Nurse #1 documented Resident #2 had a laceration to the right forehead, approximately 4 inches long, as well as an abrasion to the left knee. The physician and resident representative were notified, and orders were received to send Resident #2 to the hospital. A phone interview was conducted with NA #1 on 8/20/25 at 8:58 AM. NA #1 described Resident #2 had no movement on the right side of her body and her right arm and leg were contracted due to a stroke and Resident #2 had no control of that side of her body. NA #1 explained she was providing incontinence care to Resident #2 on 8/1/25 at about 6:30 AM. NA #1 described that she was standing on the side of the bed near the door with Resident #2 turned towards her. NA #1 explained she walked around the bed to the other side near the window, and she rolled Resident #2 away from her (towards the door). NA #1 explained she was attempting to change the fitted sheet under Resident #2 and when she pushed the fitted sheet under Resident #2, the resident rolled off the bed and fell on the floor. NA #1 explained she went to get Nurse #1 to come assist. NA #1 reported she was aware that she should not have pushed Resident #2 away from her during care, because there was a risk she could roll off the bed. When asked why she left Resident #2 alone to get the nurse, NA #1 reported that there was no one else on the hall and she needed to get the nurse as quickly as possible because Resident #2 was bleeding. Nurse #1 was interviewed by phone on 8/20/25 at 9:38 AM. Nurse #1 reported she was in the medication room counting narcotics at the change of shift on 8/1/25 at about 6:30 AM, when NA #1 came to her and said, Can you come help me? Nurse #1 reported she followed NA #1 to Resident #2's room and found Resident #2 face down on the floor in a puddle of blood. Nurse #1 reported she assessed Resident #2 and cleaned the laceration to her forehead. Nurse #1 reported she asked NA #1 what happened, and NA #1 told her she rolled Resident #2 away from her and Resident #2 rolled off the bed. Nurse #1 reported she contacted the physician and received orders to send Resident #2 to the hospital emergency room for evaluation, because the laceration was more than the facility could treat. Hospital records dated 8/1/25 for Resident #2 were reviewed. Resident #2 arrived at the emergency room with a laceration to her right forehead, as well as an abrasion to her left knee. A computed tomography (CT) scan of the neck did not show fracture. A CT scan of the head did not show any abnormalities. The 6-centimeter laceration to the right forehead was closed with 8 sutures. Resident #2 was admitted to the hospital for elevated lab results and tachycardia (a fast heart rate). Resident #2 returned to the facility on 8/4/25 with orders to remove the sutures to the right forehead laceration on 8/11/25. The Director of Nursing (DON) was interviewed on 8/20/25 at 3:47 PM. The DON reported NA #1 was changing Resident #2 and she rolled over the side of the bed. The DON reported she was not aware NA #1 pushed Resident #2 away from her during care, causing her to roll off the bed. The DON reported she expected residents to be turned correctly in bed during care to prevent them from falling out of bed. The facility submitted the following corrective action plan. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice:On 8/1/2025, NA #4 was providing incontinence care to Resident #2. The fitted sheet on Resident #2's bed needed changed and NA #4 rolled Resident #2 away from her in order to tuck the fitted sheet onto the mattress. Resident #2 rolled from the bed and NA #4 was unable to stop Resident #2. NA #4 stated that she knew she would have turned Resident#2 towards her, but she did not. Resident #2 was noted to have a laceration to the right forehead requiring first aid outside of the facility. On 8/1/2025, NA # 4 received education on bed mobility and positioning as well as requesting assistance when turning a resident in bed as needed. On 8/1/2025 Resident #2's regular bed was changed to a wider bed with a perimeter defined mattress cover to define the edges of the bed and allow more surface area for turning and positioning per the Assistant Director of Nursing and maintenance staff to allow more room for turning when in bed. Address how the facility will identify other residents having the potential to be affected by the same deficient practice:On 8/1/2025 the Assistant Director of Nursing reviewed the falls for the last 30 days to ensure there were no other falls related to staff transferring or positioning with care. No other falls were identified. On 8/1/2025 the Director of Nursing or designee reviewed like residents in the facility for the need for a wider bed. No other residents were identified. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur:On 8/1/2025 the Director of Nursing or designee educated all nurses and nursing assistants on turning and positioning residents when in bed/providing care to include moving the resident from the middle of the bed before rolling towards themselves. The education also included notifying the supervisor if the resident requires a larger bed. Any staff member that was unable to be educated on 8/1/2025 was educated by the Director of Nursing or designee prior to working their next scheduled shift. Newly hired staff/agency staff will be educated by the Staff Development Coordinator during orientation. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained:To monitor the effectiveness of the plan beginning 8/1/25 the Director of Nursing or designee will observe 6 random staff per week (Monday - Sunday on random shifts) x 8 weeks while providing bed mobility and resident care to ensure staff are properly positioning residents in the bed starting 8/1/2025. The Director of Nursing or designee will audit 6 like residents per week (Monday - Sunday on random shifts) x 8 weeks to ensure that staff are providing safe bed mobility during care starting 8/1/2025. This plan of correction was reviewed in our Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting which was held with the Interdisciplinary Team on 8/1/2025. The audit will be reviewed by the QAPI committee every month for two months to ensure the plan is effective. The plan of correction will be revised as needed. Alleged Compliance date: 8/4/2025The plan of correction was reviewed and validated on 8/21/25, which included reviewing the education provided to nurses and nursing assistants, reviewing the initial audits of falls, reviewing the weekly audits, interviewing nurses and nursing assistants, and observation of Resident #2's wider bed with perimeter defined mattress cover. In addition, bed mobility for a resident was observed with 2 staff members. The corrective action plan date of compliance of 8/4/25 was validated.

Based on record review and staff and physician interviews, the facility failed to complete and document ongoing comprehensive assessments for a resident after an unwitnessed fall and to have effective systems in place for communicating changes in condition. Resident #1 was severely cognitively impaired and had an unwitnessed fall from bed on 1/5/2025. Resident #1 was assessed by a nurse immediately after the fall, with no pain or injury noted at that time. This was the only documented nursing assessment. During the 7:00 AM to 3:00 PM shift on 11/6/2025, a nurse aide observed Resident #1 wince when she was turned on her left side during care, and this was not reported to a nurse. On 1/6/2025, between 2:20 PM and 3:00 PM, the Physical Therapist (PT) and Occupational Therapist (OT) went to work with Resident #1, and she did not want to get out of bed and complained of pain in her lower right extremity after sustaining a fall over the weekend. OT #1 pulled back the covers and noted Resident #1's right lower extremity was externally rotated and flexed. OT #1 indicated this observation was reported to a nursing staff member who reported it to the Assistant Director of Nursing. No physical assessment was completed. On 1/6/2025, at approximately 6:00 PM, a family member reported to the nurse that Resident #1 was hurting badly and that Resident #1 would not allow the nurse to touch her leg. The physician was contacted and ordered an x-ray. The family member declined this and asked for Resident #1 to be sent to the hospital. Resident #1 was diagnosed with a closed right hip fracture, which required TFN surgery (trochanteric fixation nail, an orthopedic nail to stabilize the hip joint), and a right closed clavicle fracture that was non-operable. The failure occurred for 1 of 3 residents reviewed for professional standards (Resident #1). The findings included: Resident #1 was readmitted to the facility on [DATE] and discharged on [DATE] with diagnoses of atrial fibrillation, severe dementia, and emphysema with chronic obstructive pulmonary disease. The physician's order dated 11/20/2024 stated to administer Acetaminophen Extra Strength 500-milligram tablets by mouth. Give 2 tablets at 8:00 AM, 12:00 PM, and 8:00 PM for pain. Review of the care plan dated 12/4/2024 revealed Resident #1 was at risk for falls due to muscle weakness. Interventions were to anticipate her needs. Review of the quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident #1's cognition was severely impaired. She required partial assistance to transfer from the chair to the bed and supervision to walk ten feet. She was incontinent with both bowel and bladder. She had the ability to understand and speak clearly and was understood by others. She received speech therapy, occupational therapy, and physical therapy during the review period. Review of the Event Fall Report dated 1/5/2025 completed by Nurse #1 revealed that Resident #1 had an unwitnessed fall on the floor with no injury in her room. She had no pain after the fall. Range of motion was without pain. No rotation, deformity, or shortening of extremity was observed. Right and left upper extremities had a strong grasp, and right and left lower extremities had strong movement. Resident #1's monitoring was continued; there were no complaints of pain or discomfort. Record review of the post-fall huddle dated 1/5/2025 indicated the fall was at 10:11 AM per Nurse #1 and the last time toileting was at 9:00 AM, and she was clean and dry at the time of the fall. Blood pressure was 122/60 with a pulse of 99 lying down, 124/63 with a pulse of 87 sitting up, and 124/64 with a pulse of 88 standing. The physician and responsible party were contacted. During a telephone interview on 1/23/25 at 8:07 PM, Nurse #1 stated she was standing in the hall administering medications and at about 10:00 AM, NA #1 reported that Resident #1 was on the floor lying on her back. Nurse #1 asked Resident #1what she was doing, and she said she wanted to go to bed. She indicated she was not in pain, and each extremity was moved without discomfort. Nurse #1 assisted Resident #1 to bed with the gait belt. The physician and the responsible party were notified by telephone. Resident #1 was monitored for pain, and each time she denied experiencing any pain. Her responsible party came and sat with her. A telephone interview with Nursing Assistant (NA) 1 on 1/24/2025 at 10:08 AM revealed that on 1/5/2025 at 9:30 AM, she went into the room to remove Resident #1's breakfast tray. She was sitting in her wheelchair with her blanket on her lap watching television. NA #1 stated she continued her rounds, and when she returned at about 10:00 AM, Resident #1 was lying on the floor on top of her blanket. NA #1 asked Resident #1 how she got to the floor, and she said she wanted to lie down. She stated Nurse #1 was notified of the fall. Resident #1's blood pressure and pulse were taken, and all values were at Resident #1's baseline. Nurse #1 came into the room and asked Resident #1 if she was in pain, and she denied pain. Nurse #1 assessed the upper and lower extremities for movement, and then together they used the gait belt and contact assistance to help Resident #1 off the floor. Resident #1 was assisted to bed. NA #1 indicated she checked on Resident #1 often. She continued to deny any pain or injury. During a telephone interview on 1/24/2025 at 8:15 AM, Nurse #2 revealed she had worked on 1/5/2025 during the 3:00 PM - 11:00 PM shift with Resident #1. She revealed she made her rounds, and Resident #1 had no complaints of pain. Resident #1's family was visiting and stayed with her into the evening. There were no complaints of pain during this shift. A telephone interview on 1/24/2025 at 8:14 AM revealed that Nurse #3 indicated she worked on 1/5/2025 from 11:00 PM to 7:00 AM. Nurse #3 stated she did not remember Resident #1 and continued that she worked in various buildings. She stated that if she had a resident who had pain, she would assess and medicate as ordered. For some people, acetaminophen worked; if they were still in pain, she would call the doctor and report the excessive pain. She documented medications on the medication administration record, and if there was an event, she documented it in the notes. A telephone interview on 1/24/2025 at 10:18 AM with NA #3 stated she worked on 1/5/2025 from 11:00 PM to 7:00 AM. She did not remember Resident #1 experiencing pain. She reported that she had provided incontinence care between 5:00 AM and 6:00 AM and Resident #1 did not report any pain at that time. She did not notice anything different during the incontinence care. During an interview on 1/23/2025 at 2:18 PM, NA #4 indicated she cared for Resident #1 on 1/6/2025 during the 7:00 AM through 3:00 PM shift. Resident #1 was cleaned up for breakfast and she was fine. While she was lying flat, she had pulled herself up in bed and her brief was checked. She was not hungry for breakfast, and normally, she sat in the wheelchair at 9:00 AM. Resident #1 said, No. She was left in bed. A therapist came in and said to leave her in bed. NA #4 told the Medication Aid that Resident #1 wasn't getting up as usual. Resident #1 had a better appetite at lunch. She didn't say she was in pain during the shift. Resident #1 sat in her bed with her eyes closed and never asked for pain medication. An interview on 1/23/2025 at 2:32 PM with NA #6 indicated on 1/6/2025 assisted NA #4 with a brief change with Resident #1. During care, he noticed her leg was propped up on a pillow, and he did not notice anything unusual. He indicated he rolled her to her left side. Resident #1 didn't yell in pain at all; he noted she did wince. He stated he didn't see anything to report. An interview on 1/24/2025 at 12:00 PM, Speech Therapist #1 stated she saw Resident #1 for swallowing and cognition. On the morning of 1/6/2025, she was at her baseline. Resident #1 was severely impaired and verbalized her wants, needs, and pain. Record review of the Physical Therapist (PT) 1 note dated 1/6/2025 at 3:40 PM revealed in part, Patient's skin intact before and after treatment. Patient stated she did not want to get out of bed today and complained of pain in her lower right extremity after sustaining a fall over the weekend. The Occupational Therapist #1 notified nursing of the patient's complaint of pain in her right lower extremity and the right lower extremity being externally rotated and flexed. Record review of the Occupational Therapist (OT) 1 note dated 1/6/2025 at 4:35 PM revealed that she checked Resident #1's bilateral lower extremities for edema/swelling and noted that the right lower extremity was externally rotated at the hip and the right hip/knee was flexed. She attempted to straighten the right lower extremity, and the patient yelled out in pain with movement of the right lower extremity. She notified the medication technician, and the medication technician notified the Assistant Director of Nursing (ADON), and the ADON stated she documented in the book for the Nurse Practitioner to see Resident #1. During the interview on 1/23/2025 at 1:08 PM, Physical Therapist #1 (PT) revealed that on 1/6/2025, between 1:30 PM and 2:00 PM, Resident #1 declined to get out of bed for therapy. Electric Stimulation (E-Stim) therapy (a type of electronic therapy used to stimulate the muscles with a mild electrical current for pain control and muscle strengthening) was applied to both thighs. She did not observe an injury to the right hip. She returned between 2:20 PM and 3:00 PM, accompanied by Occupational Therapist #1 (OT). Resident #1 stated she didn't feel good. OT #1 pulled the covers back and observed her right leg on a pillow with the knee bent and the hip externally rotating out from the body. The OT stated she went to touch the leg, but Resident #1 didn't want her leg touched. During an interview on 1/23/2025 at 1:30 PM, Occupational Therapist #1 (OT) stated that on the morning of 1/6/2025 at 10:30 AM, Resident #1 said she wanted to stay in bed. OT #1 applied the E-Stim to both of her upper arms and asked her why she didn't feel well. OT #1 checked her blood pressure, temperature, and pulse. When she returned to remove the E-Stim between 2:30 PM and 3:00 PM, OT #1 thought Resident #1's stomach looked distended, and she pulled the covers back. The right leg was on a pillow, and it was externally rotated with the knee bent. She touched the foot, and Resident #1 grimaced. She then went to the nursing desk and asked Medication Aide (MA) #1 to look at Resident #1's right leg and explained the deformity of the right leg. OT #1 stated she stayed in Resident #1's room and watched MA #1 speak to the Assistant Director of Nursing (ADON). OT #1 revealed she reported to the Rehabilitation Therapy Director what was observed and reported to MA #1. She mentioned she reported to the MA because she was the nursing staff on the hall. During a telephone interview on 1/24/2025 at 10:45 AM, MA #1 stated that on 1/6/2025, Resident #1 wanted to stay in bed; this was not unusual. In the afternoon, a therapist came and stated that Resident #1 was in pain. MA #1 reported that Resident #1 was in pain to the ADON, and she medicated her with acetaminophen. During an interview on 1/24/2025 at 12:25 PM, the Rehabilitation Therapy Director indicated that OT #1 reported the right externally rotated hip and the pain of Resident #1 to MA #1 on the medication cart, and that she had observed her report to the ADON. No other action was taken by the therapy department. During a telephone interview on 1/24/2025 at 2:46 PM, the ADON revealed she was the nurse overseeing the hall for MA #1. MA #1 reported to her on 1/6/2025 at 3:00 PM that Resident #1 had pain and was medicated with acetaminophen. She revealed that chronic pain was not unusual for Resident #1. She entered the information in the physician's book for the following day. The ADON revealed during the morning report (1/6/2025) for Resident #1 that there was no report of pain during the night and no report that there was any bruise or change of condition that required an assessment. The ADON further stated had MA #1 reported there was a change in pain level or change in condition, then she would have assessed the change in condition. The ADON verbalized that MA #1 did not report OT #1 had observed the change of condition. A follow-up telephone interview was conducted on 1/24/2025 at 3:16 PM with MA #1, who indicated that OT #1 stated Resident #1's leg was painful. MA #1 explained that OT #1 verbalized she was not getting her up to do therapy. MA #1 stated she reported to ADON that Resident #1 wasn't getting up today and that she had given her acetaminophen for pain. MA #1 stated she did not know there was anything wrong. MA #1 indicated she was not a nurse and did not do physical assessments. During a telephone interview on 1/24/2025 at 8:15 AM Nurse #2 indicated she returned to work on 1/6/2025 for the 3:00 PM - 11:00 PM shift, and there was no reported severe pain from the previous shift. Nurse #2 stated that at about 6:00 PM, two family members came to visit Resident #1. One family member said that Resident #1 was hurting badly. She stated she went to assess, and Resident #1 said, Don't touch my leg. She left the room to call the physician and got the x-ray order. She stated she went back to tell the family, and the family said to send her to the hospital. She stated she notified the physician and sent her to the hospital. Resident #1 did yell as Emergency Medical Services were putting her on the stretcher. Nurse #1 stated that each time Resident #1 was asked if she had pain, she denied or ignored the question. A review of the Emergency Medical Services (EMS) report revealed paramedics arrived at the facility at 8:56 PM, and Resident #1 was assessed by EMS at 9:08 PM. Resident #1 was transported non-emergently to the emergency room and arrived at 9:23 PM. Documentation revealed Resident #1 was lying in her bed with cognition alert and oriented, with a Glasgow Coma Scale (GCS, a tool used to assess traumatic brain injury) intact. Resident #1 had a fall the previous day, and the complaint was right hip, right thigh, and right shoulder pain. The report stated, While enroute, a baseline set of vitals were obtained with nothing remarkable of note. The patient was carefully monitored and assessed throughout transport. All subsequent vitals were concurrent with baseline. Vital signs and cognition were baseline. No pain medications were administered. Record review of the hospital emergency report dated 1/6/2025 revealed Resident #1 had a right closed clavicle fracture, non-operable, and a closed right hip fracture. Orthopedic surgery was consulted. On 1/7/2025, Resident #1 underwent TFN surgery (trochanteric fixation nail, an orthopedic nail to stabilize the hip joint) to the right hip. During an interview on 1/24/2025 at 4:50 PM, the Director of Nursing stated that in the electronic medical record software for event reporting, there was a box that needed to be triggered to schedule the post-monitoring after a fall, and that did not happen. The therapist did not communicate directly with the nurse the urgency of the situation, which resulted in a delay in treatment. A telephone interview on 1/24/25 at 1:29 PM with the Medical Director indicated that it was possible for a person to have a fracture and not experience pain. He was notified of the fall on 1/5/2025, and there was no injury or severe pain. He stated that if the resident had neurological changes or uncontrolled pain, he expected the resident would be sent out immediately. The facility provided the following action plan with a completion date of 1/9/2025. 1. Corrective action for residents(s) affected by the alleged deficient practice: Upon discovery of the occurrence facility implemented the following quality assurance measures: On 1/6/2025 Resident #1 was assessed for pain with new orders received to obtain x-rays and ultimately sent to the ED per family request. 1/7/2025 Right intertrochanteric femur fracture open reduction internal fixation with long intramedullary nail was completed. . 2. Corrective action for residents (s) with the potential to be affected by the alleged deficient practice: To identify other residents with this same issue: on 1/7/2025 the Assistant Director of Nursing reviewed current residents who have the potential to transfer without assistance to ensure proper interventions are in place. All alert and oriented residents were interviewed regarding the presence of pain and needs being met with no negative findings. Non-interviewable residents were assessed for signs and symptoms of pain with no negative findings. 1/7/2025 Staff Development Coordinator completed a 30 day look back of current resident's pain scale to ensure any pain had been treated and treatment was effective. Non alert residents were observed by a licensed nurse for signs and symptoms of pain. No other residents were identified. 3. Measures/Systemic changes to prevent recurrence of deficient practice. To prevent this from recurring: on 1/7/2025 all staff were interviewed to identify if there were any concerns of residents reporting pain that had not been assessed by a licensed nurse as well as if there were any concerns of abuse to include neglect with no negative findings. On 1/8/2025 the Director of Nursing or designee educated all staff on reporting acute changes in condition of residents to include use of the STOP & WATCH tool. On 1/8/2025 all licensed nurses were educated on initiating post fall monitoring in the electronic health record, pain assessments, acute changes, head to toe assessments and physician notification of changes. 4. Monitoring procedure was started on 1/8/2025 to ensure that the plan of correction is effective, and that specific deficiency cited remains corrected and sustained: To monitor and maintain ongoing compliance: Beginning 1/8/2025 the Director of Nursing or designee will review the record of all residents that have had a fall to ensure a proper assessment has been completed and pain is being monitored/treated Monday through Friday for 8 weeks. The Director of Nursing or designee will also complete a follow up head-to-toe assessment of any resident that has had a fall upon being notified. The date of correction was 1/9/2025. All above responsibilities were discussed during Ad hoc QAPI completed on 1/8/2025. The corrective action plan was validated on 1/24/2025 by reviewing the education provided to the staff and reviewing the audits of assessment sheet. Staff were interviewed and they confirmed that they received an education on use of the Stop and Watch tool, correctly initiating the post fall monitoring in the electronic health record, pain assessments, acute changes, head to toe assessments and physician notification of changes. The facility's corrective action plan was validated as completed 1/9/2025. Monitoring every resident fall for pain and follow up on any acute pain will be audited daily Monday through Friday for 8 weeks. On Mondays, a review of the weekend will be completed as well to ensure no acute pain was unidentified or followed up on. The Quality Improvement Committee will review the results of the audits for further recommendation weekly for 8 weeks. Should the committee feel that further auditing is necessary, it will be determined at that time. The corrective action plan was validated on 1/24/2025 by reviewing the education provided to the staff and reviewing the audits of assessment sheet. Staff were interviewed and they confirmed that they received an education on use of the Stop and Watch tool, correctly initiating the post fall monitoring in the electronic health record, pain assessments, acute changes, head to toe assessments and physician notification of changes. The facility's corrective action plan was validated as completed 1/9/2025.

Based on observations, record review, and staff interviews, the facility failed to disinfect a dedicated resident glucometer according to the manufacturer's germicidal disinfectant instructions for 1 of 1 observations of glucometer disinfection (Nurse #1). The findings included: The facility policy Glucometer/Point of Care blood testing and disinfection procedure dated 10/15/2015 with a revision date of 12/27/2023 read in part: wipe meter using friction with recommended type of germicidal disinfectant wipe; maintain visible wetness of meter for required kill time according to the germicidal disinfectant instructions . The label for the germicidal disposable bleach wipe instructed: Unfold wipe and thoroughly wet surface. Allow surface to remain visibly wet for 4 minutes. Let air dry. A continuous observation of Nurse #1 was conducted 11/19/24 at 11:34 AM. Nurse #1 removed Resident #73's glucometer from an unsealed zip top plastic bag with Resident #73's name on it from the medication cart drawer and proceeded to his room to check his blood glucose level. Nurse #1 placed the glucometer directly on Resident #73's over the bed table and proceeded to check his blood glucose level, disposing of the trash after and returning to the medication cart where she placed the contaminated glucometer directly on the top of the medication cart. Nurse #1 applied gloves and dispensed 1 germicidal disposable bleach wipe, and she wiped the exterior of the glucometer for approximately 10 seconds before carrying the glucometer to the nursing station desk and taking a tissue from a box and drying the glucometer with the tissue. Nurse #1 was interviewed on 11/19/24 at 11:44 AM regarding the amount of time the glucometer was required to stay wet with the germicidal disinfectant wipe and Nurse #1 responded she did not know and would need to check the package directions. Nurse #1 was shown the manufacturer instructions for the germicidal disinfectant wipe that instructed the surface was to remain visibly wet for 4 minutes and be allowed to air dry. Nurse #1 stated she did not know how she would keep the surface of the glucometer wet for 4 minutes and she thought that it might be an infection control issue to allow something to sit for 4 minutes. Nurse #1 reported she thought that wiping the glucometer off with the bleach wipe was enough to disinfect it. The Director of Nursing (DON) was notified of the observation on 11/19/24 at 11:52 AM. The DON was interviewed on 11/20/24 at 9:21 AM and she reported Nurse #1 had received training and had competency reviews of her skills and she should have known the procedure for disinfecting the glucometer. The DON reported she did not know why Nurse #1 did not use the correct procedure to disinfect the glucometer and she expected all staff to correctly use the disinfecting wipes. The Staff Development Coordinator (SDC) nurse was interviewed on 11/20/24 at 1:09 PM. The SDC nurse reported she reviewed Nurse #1's competency check list and in December 2023 she had updated training on the disinfecting procedure for glucometers and she should have known how to properly disinfect the glucometer. The SDC nurse explained Nurse #1 had expressed feeling nervous about the glucometer observation. The Administrator was interviewed on 11/20/24 at 2:48 PM. The Administrator reported she expected the staff to follow manufacturer guidelines for the products used by the facility.

Based on record review and staff interviews the facility failed to post accurate totals of licensed nurses for 4 of 4 days (11/1/2024, 11/2/2024, 11/3/2024, and 11/4/2024) reviewed for posted nurse staffing. Findings included: Review of the Daily Posted Nurse Staffing with the Staffing Coordinator on 11/20/2024 at 12:40 pm to 12:49 pm revealed discrepancies in the number of Licensed Nurses for the following dates: On 11/1/2024 the Daily Posted Nurse Staffing form indicated the facility staffed 3 Licensed Practical Nurses (LPNs), but the nursing schedule indicated there was 1 LPN and 2 Certified Medication Aides (CMA). On 11/2/2024 the Daily Posted Nurse Staffing form indicated the facility staffed 3 LPNs, but the nursing schedule indicated there were 2 LPNs and 1 CMA. On 11/3/2024 the Daily Posted Nurse Staffing form indicated the facility staffed 3 LPNs, but the nursing schedule indicated there was 1 LPN and 2 CMAs. On11/4/2024 the Daily Posted Nurse Staffing form indicated the facility staffed 1 Registered Nurse (RN) and 2 LPNs, but the nursing schedule indicated there was 1 RN, 1 LPN, and 1 CMA. During an interview with the Staffing Coordinator on 11/20/2024 at 12:59 pm she stated she was responsible for updating the Daily Posted Nurse Staffing forms. She stated she counted the CMAs as LPNs on the Daily Posted Nurse Staffing forms. She stated she had been the Staffing Coordinator for the past 4 months and she had counted the CMAs as LPNs since she had been employed. She stated she was told to count the CMAs as LPNs when she was trained for the position and did not realize they should be counted separately. On 11/20/2024 at 11:08 am an interview was conducted with the Administrator, and she stated she was not aware the Posted Nurse Staffing was not posted correctly by the Staffing Coordinator. She stated the CMAs should not have been recorded as LPNs on the Posted Nurse Staffing.

Based on observation, record review, staff, and Nurse Practitioner (NP) interviews the facility failed to ensure that Cardiopulmonary Resuscitation (CPR) was administered immediately and failed to operationalize an effective system so staff could respond to an emergency situation as needed. On [DATE] Nurse #1 was notified that Resident #1 was unresponsive, not breathing and had no pulse. Nurse #1 verified Resident #1 was not breathing. Nurse #1 did not verify Resident #1's code status and resumed her nursing duties on another hall. Nurse #1 was later informed that Resident #1 was a full code, Nurse #1 then started CPR without initiating a code blue protocol. Nurse #1 stopped CPR when she became tired. Resident #1 was pronounced deceased by emergency medical services (EMS) on [DATE]. This was for 1 of 3 residents reviewed for CPR (Resident #1). The findings included: Review of the facility's CPR policy revised [DATE] indicated the following: Activate the emergency response team: The resident should not be left alone. If you are alone with the victim, call out for help. If someone is nearby, instruct them to dial 911 immediately. In the event help is not available, call 911 and retrieve emergency cart prior to starting CPR, return as soon as possible. Use an AED as soon as possible if one is available. If no AED is available, continue the cycle of compressions: Breaths for about two minutes then recheck pulse and continue if none noted. Continue CPR efforts until pulse is restored, EMS arrives, an onsite physician or nurse practitioner instructs otherwise, or until the team can no longer continue due to exhaustion. Resident #1 was readmitted to the facility on [DATE]. His diagnosis included type 2 diabetes mellitus (DM), anxiety, chronic congestive heart failure (CHF), and dysphagia (difficulty swallowing). A physician order dated [DATE] indicated Resident #1 was a full code. Chart review did not reveal a Medical Orders for Scope of Treatment (MOST) form (a legal document that allows patients to outline their treatment preferences and end-of-life care. No MOST form indicates that a resident wishes the full scope of treatment for saving their life) for Resident #1. Resident #1's care plan, last reviewed/revised on [DATE], revealed a focus that read: Category: Advanced Directives/Code Status Resident #1 has chosen full code status A nursing progress note written [DATE] at 5:33 AM by Nurse #1 revealed Resident #1expired at 5:00 AM. A nursing progress note recorded as a late entry on [DATE] for [DATE] by Nurse #1 read: This nurse did resident rounding at 4:28 AM on the 800 hall before starting medication pass on the 200 hall. Walked in Resident #1 ' s room and heard rales (abnormal rattling sound in the lungs) during inspiration. This nurse checked vitals BP:,d+[DATE], P:48, R:12, O2: 89% room air, T:96.1 (auxiliary) resident previously refused to have CPAP place on for the night. NA started her resident rounding at the bottom of the 800 hall. NA observed that Resident #1 wasn't breathing. This nurse walked down to Resident #1's room and also observed that patient wasn't breathing. Code status was validated, and CPR initiated. EMS pronounce death 6:15 AM. Postmortem care done. A phone interview was conducted with Nurse #1 on [DATE] at 11:30 AM. Nurse #1 verified she was the nurse for Resident #1 on [DATE] from 4:00 PM through [DATE] at 7:00 AM. She explained at 5:00 AM Nursing Assistant (NA) #1 was exiting Resident #1's room and stated he was not breathing. She stated she told NA #1 she knew it was coming because his vital signs were sitting low at 4:28 AM. Nurse #1 verified she did not check his code status at 5:00 AM. She also stated, I don't know why I didn't check his code status, I thought he was a Do Not Resuscitate (DNR). She explained she was informed at 5:55 AM by NA #2 that Resident #1 was a full code. NA # 2 proceeded to the nurses' station to call 911 and Nurse #1 started CPR, however she stopped CPR a short time later to retrieve the crash cart. When Nurse #1 returned to Resident #1, she put the back board under him and resumed CPR at approximately 6:00 AM. She stated Resident #1's body was warm to the touch. NA #2 returned to Resident #1's room and Nurse #1 told her she did not have anything on the crash cart to do CPR such as an AED, oxygen, tubing, or a suction machine. Nurse #1verified she did not ask for assistance from other staff members, nor did she activate the code blue protocol. She explained she stopped performing CPR at 6:06 AM because she was tired. Law enforcement arrived at 6:08 AM and then emergency medical services (EMS) arrived at 6:10 AM. Resident #1 was pronounced deceased at 6:15 AM by EMS. She further stated when she wrote the nursing note on [DATE] for the events that occurred on [DATE] she did not add the times that she verified Resident #1 did not have a pulse or what time she started CPR. Nurse #1 indicated she did not know why she thought Resident #1 was a DNR, she just assumed he was. A phone interview was conducted with Nursing Assistant (NA) #1 on [DATE] at 3:01 PM. NA #1 explained that at 5:00 AM on [DATE] she went in to change Resident #1, he was warm to the touch, however he was unresponsive, not breathing and had no pulse. NA #1 immediately notified Nurse #1. NA #1 stated Nurse #1 said she figured it was coming due to his vital signs being low earlier. NA #1 observed Nurse #1 check for Resident #1's pulse and the rise and fall of his chest which were absent. Nurse #1 verified Resident #1 was not breathing. NA #1 stated that Nurse #1 did not start cardiopulmonary resuscitation (CPR) and she went to another hall to pass medications. NA #1 explained she provided postmortem care to Resident #1. NA #1 further stated at approximately 5:55 AM she informed Nurse #2 that Resident #1 had passed away. A phone interview was conducted with Nurse #2 on [DATE] at 2:54 PM. Nurse #2 stated she was coming up the 100 hall when she was approached at 5:55 AM by Nursing Assistant (NA) #1 and was told that Resident #1 had passed away. Nurse #2 explained that after she had spoken to NA #1, she was at the nurses' station on the ,d+[DATE] hundred hall and she informed NA #2 that Resident #1 had passed away. Nurse #2 stated NA #2 jumped up and said, oh my god he's a full code, as she went towards the main nursing station to check the code status binder. Between 6:02 AM and 6:06 AM she went to the 800 hall to see if Nurse #1 needed help and Nurse #1 stated no, she did not need help and emergency medical services (EMS) were on the way. Nurse #2 went back to the ,d+[DATE] hall to check on her residents then went back to the 800 hall. Nurse #2 explained she went back to the ,d+[DATE] hall for two or three minutes then went to Resident #1's room at approximately 6:08 AM, law enforcement and first responders were in the room. At that time EMS was at the side door of the building. Nurse #2 recalled Nurse #1 was talking to law enforcement, and she went to make copies of Resident #1's paperwork. She further stated Nurse #1 did not call the code overhead when she was made aware of his code status. Nurse #2 confirmed she did not observe Nurse #1 perform CPR at any time. An interview was conducted with Nursing Assistant (NA) #2 on [DATE] at 11:44 AM. NA #2 verified she worked on [DATE] from 11:00 PM through [DATE] at 7:00 AM on the ,d+[DATE] halls. NA #2 stated she was sitting at the nursing station when Nurse #2 told her Resident #1 had passed away. She explained that she jumped up and said, oh my god, he's a full code, as she went up the hall towards the main nursing station. She looked in the Do Not Resituate (DNR) binder and removed Resident #1's sheet that indicated he was a full code. NA #2 then stated she took that sheet to Nurse #1 which was halfway down the 800 hall to show her Resident #1 was a full code. She explained that Nurse #1 stated several times, you've got to be kidding me. NA #2 told Nurse #1 to grab the crash cart, and she would call 911. NA # 2 proceeded to the nurse station to call 911. After the call was completed, she went to Resident #1's room where Nurse #1 was going through the drawers of the crash cart saying she didn't have anything to do CPR with such as an automated external defibrillator (AED), oxygen, tubing, or a suction machine. NA #2 stated the ambu-bag was located on the side of the crash cart unopened, it appeared that the backboard was under Resident #1's back and she reminded Nurse #1 the oxygen tank was located beside the crash cart. She looked up and saw law enforcement and the first responders coming up the hall. She indicated she then went back to her assignment. She was unaware Nurse #1 initiated CPR prior to grabbing the crash cart. NA #2 explained that she also did medical records at the facility and that was how she was aware of Resident #1's code status. Emergency medical services (EMS) report revealed the following: the call was received/dispatched at 6:01 AM, on scene at 6:09 AM, and at patient at 6:11 AM. Primary Impression was obvious death, at scene, emergency medical services (EMS) crew directed to Resident #1's room by facility staff. The fire department (FD) and police department (PD) were already at bedside. Per report from FD, staff reported Resident #1 was last known well at 5:15 AM this morning. FD and law enforcement on scene reported that cardiopulmonary resuscitation (CPR) was not in progress by facility staff at their arrival. No facility staff were present at bedside. EMS crew requested a firefighter to obtain patient information and code status from facility staff. Resident #1 found to be full code on facility paperwork. The primary impression was obvious death. Resident #1 found supine in facility bed. Resident #1 found to be apneic (cessation of respiration) and without pulse. A 4-lead electrocardiogram (ECG) (a test that measures the heart's electrical activity) performed and noted asystole (when your heart's electrical system fails, causing your heart to stop pumping) in all pre-cordial leads. Mottling (blotchy patches of discoloration on the skin) noted in extremities and posterior of patient's trunk. Eyes non-reactive to light. Per protocol, due to extended downtime without CPR and asystole upon presentation, CPR efforts not initiated, and time of death noted at 6:15 AM. A phone interview was conducted with the Nurse Practitioner (NP) on [DATE] at 4:00 PM. He stated he would expect the nurse to verify code status immediately if a resident was observed with no pulse. The NP stated he could not speculate and say that if CPR was immediately initiated that Resident #1's outcome would have been different. An interview with the Director of Nursing (DON) was conducted on [DATE] at 11:18 AM. She stated Nurse #1 should have checked Resident #1's code status when she observed increased congestion, change in his oxygen levels, and immediately after verifying, he was without a pulse. She also stated everything was on the crash cart that the facility keeps on it and the oxygen is located right beside the crash cart. The facility does not utilize an AED. The Administrator was notified of immediate jeopardy on [DATE] at 1:15 PM. The facility provided the following corrective action plan with a completion date of [DATE]. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: On [DATE] at 0500, NA #1 notified Nurse #1 that Resident #1 was unresponsive. Nurse #1 failed to verify Resident #1's code status and failed to initiate Cardiopulmonary Resuscitation timely. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: On [DATE], a record review of the last 30 days of deaths was audited by the Director of Nursing. There were no deaths or change in condition identified that required Cardiopulmonary Resuscitation. On [DATE], crash carts were audited by the wound nurse to ensure that all appropriate equipment is on the cart and in working condition. On [DATE], the wound nurse completed a full facility review of all code status orders and care plans to ensure there were no concerns, no discrepancies noted. On [DATE], the Staff Development Coordinator reviewed employee files for licensed staff to ensure they have up to date CPR certification to include licensed staff present at the time of the event. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: On [DATE] the Staff Development Coordinator or designee educated all staff on the facility Cardiopulmonary Resuscitation Policy. The same education will be provided by the Staff Development Coordinator or designee to agency staff upon first shift worked and all new hires during orientation effective [DATE] per directive of the Director of Nursing. On [DATE], mock codes were conducted across all shifts by the Staff Development Coordinator with nursing department staff. Nursing department staff includes Registered Nurses, Licensed Practical Nurses and Certified Nurse Aides. Routine crash cart audits will be completed daily by a member of the Interdisciplinary Team effective [DATE] per the Administrator. The Interdisciplinary Team includes Medical Records Coordinator, Director of Social Services, Life Enrichment Director, Director of Environmental Services, Food Service Director, Administrator, Business Office Coordinator, and Central Supply Manager. These members of the Interdisciplinary Team have been educated on crash cart equipment compliance per the Administrator and Director of Nursing. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: On [DATE] it was established by the Interdisciplinary Team that beginning the week of [DATE] through [DATE], the following steps will be completed and documented weekly for 8 weeks. Mock code audits will be conducted one random shift per week by the Director of Nursing or designee across all shifts to ensure timely and appropriate response. Any identified concerns will be addressed immediately. Crash carts will be audited daily by the Assistant Director of Nursing or designee to ensure that appropriate equipment is present. The Quality Improvement Committee will review the results of the audits for further recommendation weekly for 8 weeks. Should the committee feel that further auditing is necessary, it will be determined at that time. Above responsibilities were discussed during Ad-hoc QAPI completed on [DATE]. Alleged Compliance date: [DATE] Date of immediate jeopardy removal is [DATE] On [DATE] the credible allegation of Immediate Jeopardy removal was validated by onsite verification and included: The facility provided documentation to support their corrective action plan. The initial facility audits dated [DATE] were reviewed and revealed no issues were noted. Education across all staff departments regarding CPR was reviewed and sign in sheets were provided. Staff interviews across all departments were completed and those staff were able to verbalize that they had received education and knew the procedures to take. QAPI meetings were discussed with the Administrator and meeting notes were reviewed. An observation of the crash cart at the main nursing station on [DATE] at 12:35 PM revealed the cart to be stocked with an ambu bag and backboard along with numerous others supplies that would be required for an emergency. The facility's date of [DATE] for the corrective action plan was validated on [DATE].

Based on record review, and staff and Medical Director (MD) interviews, the facility failed to notify the physician for a resident who had a significant change in condition. On [DATE] Resident #1 was observed with audible congestion, difficulty swallowing, and was trying to cough up phlegm. The MD or Nurse Practitioner (NP) were not notified. On [DATE] Resident #1 had his mouth open with clear phlegm noted in his mouth and he was coughing. Resident #1's vital signs included a blood pressure (BP) of ,d+[DATE] (normal ,d+[DATE]), pulse of 48 (normal range ,d+[DATE]), oxygen at 89% (normal range between 95% and 100%) on room air, and respirations of 12 (normal range ,d+[DATE]). He had audible congestion, and his skin was extremely hot to touch. The MD or Nurse Practitioner (NP) were not notified. At 5:00 AM Resident #1 was found not breathing and was pronounced deceased at 6:15 AM. This was for 1 of 3 residents reviewed for notification of change of condition. The findings included: Resident #1 was readmitted to the facility on [DATE]. His diagnosis included type 2 diabetes mellitus (DM), anxiety, chronic congestive heart failure (CHF), and dysphagia (difficulty swallowing). Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated his cognition was intact. There was no rejection of care or behaviors coded. A Nurse Practitioner (NP) progress note dated [DATE] revealed Resident #1 was lying in bed with eyes closed, easily arousable and answering questions when asked. He denied shortness of breath and there was no cough observed. The note also revealed that during physical exam of Resident #1's chest/pulmonary and general/constitutional systems that no physical findings pertinent to this encounter. An interview with Med Aide (MA) #1 was conducted on [DATE] at 10:40 AM. She verified she was the direct care MA for Resident #1 on [DATE] and she did not observe any concerns with him on first shift (7A-3P). She further stated he was talkative and did not voice any concerns. An interview with Nurse #3 was conducted on [DATE] at 10:05 AM. Nurse #3 stated she cared for Resident #1 on [DATE] from 3:00 PM to 4:00 PM. Nurse #3 explained she was the wound care nurse however they had a call out and she was covering the assignment until Nurse #1 arrived. Nurse #3 also stated when she received report from first shift, they informed her that Resident #1 refused his medications at noon. Nurse #3 verified she did go and speak with Resident #1 at approximately 3:25 PM, and he was fine. Nurse #3 did not observe Resident #1 with increased cough or congestion. Nurse #3 also stated she was still working assisting with meal trays and Resident #1 refused dinner on [DATE], however that was not a new behavior, as he refused meals and medications at times. A phone interview was conducted with Nursing Assistant (NA) #1 on [DATE] at 3:01 PM. She verified she worked from [DATE] at 11:00 PM through [DATE] at 7:00 AM and she was the direct care NA for Resident #1. NA #1 stated she notified Nurse #1 at 2:00 AM that Resident #1's roommate had requested her to come look at Resident #1 because he did not sound good. NA #1 stated she observed Resident #1 coughing, and she could hear congestion. NA #1 also notified Nurse #1 at 3:30 AM that Resident #1 had his mouth open, and you could see phlegm in his mouth, and he was coughing. She stated Nurse #1 went to his room but did not tell her anything. NA #1 indicated she had not worked with the resident that often and she was not sure of his baseline. NA #1 explained at 5:00 AM she went in to change him and he was not breathing and had no pulse. She immediately notified Nurse #1. A nursing progress note recorded as a late entry on [DATE] for [DATE] by Nurse #1 revealed at 4:28 AM she entered Resident #1's room and heard rales (fine crackles, are abnormal breath sounds that occur when a person inhales and sound like small clicking, bubbling, or rattling) during inspiration. She checked his vital signs which included a blood pressure (BP) of ,d+[DATE], pulse of 48, oxygen at 89% room air, and temperature of 96.1 (axillary). Resident #1 had previously refused to have continuous positive airway pressure (CPAP) on for the night. Nursing Assistant (NA) observed that Resident #1 wasn't breathing. This nurse walked down to Resident #1's room and also observed that he wasn't breathing. Code status was validated, and CPR initiated. EMS pronounce death 6:15 AM. A phone interview was conducted with Nurse #1 on [DATE] at 11:30 AM. Nurse #1 verified she was the nurse for Resident #1 on [DATE] from 4:00 PM through [DATE] at 7:00 AM. Nurse #1 indicated she checked on Resident #1 at 4:15 PM and observed Resident #1 resting with his eyes closed, even rise and fall of chest, and no distress noted. Nurse #1 asked Resident #1 if he wanted his afternoon medication and Resident #1 shook his head no. Nurse #1 told Resident #1, she would be back later. Nurse #1 indicated she did not normally crush Resident #1's medications however she did crush his 8:00 PM medications due to him exhibiting congestion, trying to cough up clear phlegm, and difficulty swallowing. Nurse #1 verified these symptoms were not normal for Resident #1. Resident #1 did not voice any concerns at that time and Nurse #1 she did not check Resident #1's vital signs. Nurse #1 indicated she left Resident #1's room to administer other resident's medications. Nurse #1 explained she checked on Resident #1 at 10:50 PM and she could still hear audible congestion, but no difficulty breathing was observed. He was resting with eyes closed. Nurse #1 checked on Resident #1 at 2:00 AM and he was resting with eyes closed and exhibiting audible congestion. Nurse #1 stated she checked on Resident #1 again at 3:30 AM, Resident #1 had his eyes closed and did not appear to be in distress. Resident #1 had his mouth open, clear phlegm was noted in his mouth, and he was coughing which was not normal for Resident #1. She stated she did not notify the physician or Nurse Practitioner (NP) of the coughing, audible congestion, and phlegm. Nurse #1could not give a reason for not notifying the physician or NP. Nurse #1 explained she returned to check on Resident #1 at 4:28 AM and she could still hear the audible congestion, but no difficulty breathing or coughing was observed. Nurse #1 checked his vital signs which included: blood pressure (BP) ,d+[DATE], pulse 48, oxygen level 89% on room air, respirations 12, and his skin was clammy and tepid. Nurse #1 removed his blanket and put a sheet on him to help cool him off because his skin was extremely hot to the touch. Resident #1 did not speak to Nurse #1 during this assessment. Nurse #1 stated she did not know why she did not notify the physician or Nurse Practitioner (NP) at that time, she said, I just didn't. She further explained when she returned to the hall at 5:00 AM NA #1 exited Resident #1's room and stated he was not breathing. Emergency medical services (EMS) report revealed the following: the call was received/dispatched at 6:01 AM, on scene at 6:09 AM, and at patient at 6:11 AM. Primary Impression was obvious death, at scene, emergency medical services (EMS) crew directed to Resident #1's room by facility staff. The fire department (FD) and police department (PD) were already at bedside. Per report from FD, staff reported Resident #1 was last known well (LKW) at 5:15 AM this morning. FD and law enforcement (LE) on scene reported that cardiopulmonary resuscitation (CPR) was not in progress by facility staff at their arrival. No facility staff were present at bedside. EMS crew requested a firefighter to obtain patient information and code status from facility staff. Resident #1 found to be full code on facility paperwork. The primary impression was obvious death. Resident #1 found supine in facility bed. Resident #1 found to be apneic (cessation of respiration) and without pulse. A 4-lead electrocardiogram (ECG) (a test that measures the heart's electrical activity) performed and noted asystole (when your heart's electrical system fails, causing your heart to stop pumping) in all pre-cordial leads. Mottling (blotchy patches of discoloration on the skin) noted in extremities and posterior of patient's trunk. Eyes non-reactive to light. Per protocol, due to extended downtime without CPR and asystole upon presentation, CPR efforts not initiated, and time of death noted at 6:15 AM. A phone interview was conducted with the Medical Director (MD) on [DATE] at 3:08 PM. He stated he would have expected the staff to call him or the Nurse Practitioner (NP) when the difficulty swallowing, audible congestion, and cough were first observed. The MD had not received a call about Resident #1 having a change in condition that included swallowing difficulties, cough, congestion, or low vital signs. He also stated that it was standard practice to call the MD when a change occurs. He stated he thought the nurse deviated out of the standard practice when she did not call a NP or MD. He indicated if Resident #1's vital signs were low, and he was having difficulty breathing he would have needed to be sent to the hospital for evaluation. An interview with the Director of Nursing (DON) was conducted on [DATE] at 11:18 AM. She stated Nurse #1 should have applied oxygen due to Resident #1's oxygen levels dropping, and she expected Nurse #1 to notify the physician for a change in condition of a resident as soon as it was observed. The Administrator was notified of immediate jeopardy on [DATE] at 1:15 PM. The facility provided the following corrective action plan with a completion date of [DATE]. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: On [DATE], Nurse #1 obtained vital signs for Resident #1 at 0428. Vital signs documented: axillary temperature 96.1, pulse 48, respirations 12, blood pressure ,d+[DATE], oxygen saturation 89% on room air. Nurse #1 identified congestion, difficulty swallowing, and the presence of phlegm on the 3p-11p shift with no follow up or ongoing monitoring. Nurse #1 failed to notify physician of Resident #1's change in condition during her shift. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: On [DATE] all current interviewable residents were interviewed by the Director of Social Services to ensure that they felt any change in conditions were acted upon timely by the staff including physician notification and to ensure there were no concerns with delay or withholding of care and treatment. On [DATE] a 30 day look back of progress notes was reviewed by the Assistant Director of Nursing for current non-interviewable residents to ensure that there were no concerns related to change in condition or delay or withholding of care and treatment, including physician notification. On [DATE] all staff were interviewed by the Director of Nursing or designee to determine if there were any concerns related to delay or withholding of care related to a resident change in condition including physician notification. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: On [DATE] the Staff Development Coordinator or designee educated all staff on care services related to identification of change in condition, providing timely treatment as ordered not withholding care, reporting any concerns and notification to physician. The same education will be provided by the Staff Development Coordinator or designee to agency staff upon first shift worked and all new hires during orientation effective [DATE] per directive of the Director of Nursing. Change in condition identification, notification of physician, validation of timely treatment and follow up will be reviewed in clinical morning meeting by the Interdisciplinary Team Monday through Friday. Any negative findings will be acted upon immediately. The Interdisciplinary Team includes the Administrator, Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Wound Nurse, Clinical Coordinator, Director of Social Services, Director of Rehabilitation, Life Enrichment Director, Dietary Manager, MDS Coordinator per the directive of the Director of Nursing on [DATE]. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: On [DATE] it was established by the Interdisciplinary Team that beginning the week of [DATE] through [DATE], the following steps will be completed and documented weekly for 8 weeks. Five interviewable residents will be interviewed weekly by the Director of Social Services or designee to ensure that resident concerns are addressed timely, that there are no unresolved concerns, that facility is respecting Resident Rights, that the facility is identifying resident changes in condition, if a resident has had a medical concern the facility has addressed it timely and notified the physician, and have no concerns that have the potential to be considered abuse/neglect. Five non-interviewable residents will have their medical record reviewed weekly by a clinical manager to identify any concerns related to change in condition, any delay or withholding of care or treatment, or any concerns with Resident Rights, code statuses not being honored will also be reviewed. Any concerns will be immediately addressed to include physician notification if indicated. Five staff members will be interviewed weekly the Administrator or designee to determine if there are any concerns related to delay in identification in resident Change in Condition, delay or withholding of treatment or concerns regarding physician notification. Facility Activity Report will be reviewed Monday through Friday in Clinical Morning Meeting to ensure timely identification of Change in Condition, notification of physician, prompt treatment if indicated, appropriate response for a resident that is a full code, timely identification of potential neglect. The Quality Improvement Committee will review the results of the audits for further recommendation weekly for 8 weeks. Should the committee feel that further auditing is necessary, it will be determined at that time. Above responsibilities were discussed during Ad-hoc QAPI completed on [DATE]. Alleged Compliance date: [DATE] Date if immediate jeopardy removal is [DATE] On [DATE] the credible allegation of Immediate Jeopardy removal was validated by onsite verification and included: The facility provided documentation to support their corrective action plan. The initial facility audits dated [DATE] were reviewed and revealed no issues were noted. Education to licensed nursing, nurse aides and medication aide staff regarding a change in condition was reviewed and sign in sheets were provided. Staff interviews across all departments were able to verbalize that they had received education on change in condition, examples of change in condition, and who to notify of a change in resident condition. QAPI meetings were discussed with the Administrator and meeting notes were reviewed. The facility's date of [DATE] for the corrective action plan was validated on [DATE].

Based on record review and staff, Nurse Practitioner (NP) and Medical Director (MD) interviews the facility failed to provide complete, thorough, and ongoing assessments, and failed to intervene when Nurse #1 failed to recognize the seriousness of a resident's (Resident #1) change in condition. Resident #1, who was a full code, was experiencing a change in condition on [DATE] with symptoms of difficulty swallowing, audible congestion (able to hear without the use of stethoscope), and trying to cough up phlegm. Nurse #1 did not obtain vital signs or put interventions into place to relieve the congestion. On [DATE] Resident #1 had his mouth open, clear phlegm was noted in his mouth, audible congestion continued, and he was coughing. Resident #1's vital signs, which included a blood pressure (BP) of ,d+[DATE] (normal ,d+[DATE]), pulse of 48 (normal range ,d+[DATE]), oxygen saturation at 89% (normal range between 95% and 100%) on room air, respirations 12 (normal range ,d+[DATE]), and temperature 96.7 (axillary/arm pit). Nurse #1 did not obtain another set of vital signs, and at 5:00 AM when Resident #1 was discovered with no pulse. Nurse #1, who did not verify Resident #1's full code status, did not initiate lifesaving resuscitative efforts and returned to administering medications. At 5:55 AM when Nurse #1 became aware of Resident #1's full code status, she initiated Cardiopulmonary Resuscitation (CPR). Emergency medical services (EMS) were called at 6:00 AM, arrived at 6:10 AM, and Resident #1 was pronounced deceased at 6:15 AM. This was for 1 of 3 residents reviewed for change of condition (Resident #1). The findings included: Resident #1 was readmitted to the facility on [DATE]. His diagnosis included type 2 diabetes mellitus (DM), anxiety, chronic congestive heart failure (CHF), and dysphagia (difficulty swallowing). A physician order dated [DATE] indicated Resident #1 was a full code. A physician order dated [DATE] to apply Bi-pap (Bilateral Positive Airway Pressure-a noninvasive breathing machine that helps people breathe by delivering pressurized air into their airways) every HS (hour of sleep) and remove in the morning. Note if resident does not wear. Chart review did not reveal a Medical Orders for Scope of Treatment (MOST) form for Resident #1. Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated his cognition was intact without behaviors. There was no rejection of care or behaviors coded. Resident #1's care plan, last reviewed/revised on [DATE], revealed a focus that read he had the potential for altered respiratory status/difficulty breathing related to a history of respiratory failure. The interventions included for staff to assess/document/report abnormal breathing patterns to physician, elevate head of bed to facilitate breathing per resident comfort level, as needed, and provide oxygen as ordered. Another focus read Resident #1 was at risk for complications related to vascular congestion and was on diuretic therapy which placed him at risk for adverse effects due to medication use. The interventions included for staff to administer medication as ordered and monitor for possible side effects such as dizziness, postural hypotension, fatigue, and an increased risk for falls. Notify physician as needed. A focus that read: Category: Advanced Directives/Code Status Resident #1 had chosen full code status. The interventions included for staff to notify physician of any changes, as needed, and if resident /responsible party chooses to change code status, necessary protocol will be completed: new order, update documentation/care plan, face sheet/identifying tool. Note by the Nurse Practitioner (NP) dated [DATE] revealed Resident #1 was lying in bed with eyes closed, easily arousable and answering questions when asked. He denied shortness of breath and there was no cough observed. The note also revealed that during physical exam of Resident #1's chest/pulmonary and general/constitutional systems that no physical findings pertinent to this encounter. An interview with Medication Aide (MA) #1 was conducted on [DATE] at 10:40 AM. MA #1 verified she was the direct care MA for Resident #1 on [DATE] and MA #1 did not observe any concerns with him on first shift (7A-3P). She further stated he was talkative and did not voice any concerns. Review of medication administration record (MAR) for medications received on [DATE] and [DATE]. [DATE]-refused all 5:00 PM medications. All 8:00 PM medications were signed as being administered. No medications were documented as having been administered on [DATE]. Treatment administration record (TAR) for refusing Bi-PAP on [DATE], [DATE], [DATE] and [DATE]. An interview with Nurse #3 was conducted on [DATE] at 10:05 AM. Nurse #3 stated she cared for Resident #1 on [DATE] from 3:00 PM to 4:00 PM. Nurse #3 explained she was the wound care nurse however the facility had a call out and she was covering the assignment until Nurse #1 arrived. Nurse #3 also stated when she received report from first shift. Nurse #3 verified she did go and speak with Resident #1 at approximately 3:25 PM, and he was fine. Nurse #3 did not observe Resident #1 with increased cough or congestion. Nurse #3 also stated she was still working assisting with meals and Resident #1 refused dinner, however that was not a new behavior, he refused meals and medications at times. A nursing progress note recorded as a late entry on [DATE] for [DATE] by Nurse #1 read: This nurse did patient rounding at 4:28 AM on 800 hall before starting medication pass on 200 hall. Walked in Resident #1's room and heard rales (abnormal breath sounds that occur when a person inhales and sound like small clicking, bubbling, or rattling) during inspiration. This nurse checked vitals BP:,d+[DATE], P:48, R:12, O2: 89% room air, T:96.1 (axillary) patient previously refused to have CPAP place on for the night. CNA (Certified Nursing Assistant) started her pt. (patient) rounding at the bottom of the eight hundred hall. CNA observed that pt. (Resident #1) wasn't breathing. This nurse walked down to the resident's room and also observed that patient wasn ' t breathing. Code status was validated, and CPR initiated. EMS pronounce death at 6:15 AM. Postmortem care done. A phone interview was conducted with Nurse #1 on [DATE] at 11:30 AM. Nurse #1 verified she was the nurse for Resident #1 on [DATE] from 4:00 PM through [DATE] at 7:00 AM. Nurse #1 indicated she checked on Resident #1 at 4:15 PM and observed Resident #1 resting with his eyes closed, even rise and fall of chest, and no distress noted. Nurse #1 asked Resident #1 if he wanted his afternoon medication and Resident #1 shook his head no. Nurse #1 indicated she normally did not crush Resident #1's medications, however she did crush his 8:00 PM medications due to him exhibiting congestion, trying to cough up clear phlegm, and difficulty swallowing. Nurse #1 stated the symptoms she observed when administering Resident #1 his 8:00 PM medications were abnormal for Resident #1. She said Resident #1 did not voice any concerns at that time and she did not check Resident #1's vital signs. Nurse #1 indicated she left Resident #1's room to administer other residents their medications. Nurse #1 explained she checked on Resident #1 at 10:50 PM and she could still hear audible congestion, but no difficulty breathing was observed such as gasping. He was resting with his eyes closed. Nurse #1 checked on Resident #1 at 2:00 AM and he was resting with his eyes closed and continued to exhibit audible congestion. Nurse #1 stated she checked on Resident #1 again at 3:30 AM, Resident #1 had his eyes closed and did not appear to be in distress. Nurse #1 described Resident #1 as having had his mouth open, clear phlegm was noted in his mouth, and he was coughing which was not normal for Resident #1. She stated she did not notify the physician or Nurse Practitioner (NP) of the coughing, audible congestion, and phlegm. Nurse #1could not give a reason for not notifying the physician or NP. Nurse #1 explained she returned to check on Resident #1 at 4:28 AM and she could still hear the audible congestion, but no difficulty breathing or coughing was observed such as gasping. Nurse #1 checked his vital signs which included: blood pressure (BP) ,d+[DATE], pulse 48, oxygen level 89% on room air, respirations 12, and his skin was clammy and tepid. Nurse #1 removed his blanket and put a sheet on him to help cool him off because his skin was extremely hot to the touch. Resident #1 did not speak to Nurse #1 during this assessment, and she believed he was asleep. Nurse #1 stated she did not know why she did not notify the physician or Nurse Practitioner (NP) at that time about Resident #1's coughing, audible congestion, and low vital signs, she said, I just didn't. She further explained when she returned to the 800 hall from passing medications on the 200 hall at 5:00 AM NA #1 exited Resident #1's room and stated he was not breathing. Nurse #1 checked for Resident #1's pulse and the rise and fall of his chest which were absent. Nurse #1 verified Resident #1 was not breathing. A phone interview was conducted with Nursing Assistant (NA) #1 on [DATE] at 3:01 PM. She verified she worked from [DATE] at 11:00 PM through [DATE] at 7:00 AM and she was the direct care NA for Resident #1. NA #1 stated she notified Nurse #1 at 2:00 AM that Resident #1's roommate had requested her to come look at Resident #1 because he did not sound good. NA #1 stated she observed Resident #1 coughing, and she could hear congestion. NA #1 notified Nurse #1 again at 3:30 AM about Resident #1 having had his mouth open, phlegm was visible in his mouth, he was coughing, and she went and told the nurse immediately. She stated Nurse #1 went to his room but did not tell her anything. NA #1 indicated she had not worked with the resident that often and she was not sure of his baseline. NA #1 explained at 5:00 AM she went in to change him and he was not breathing and had no pulse. She immediately notified Nurse #1. Resident #1's roommate was not able to be interviewed. A phone interview was conducted with Nurse #2 on [DATE] at 2:54 PM. Nurse #2 stated she was coming up the 100 hall when she was approached at 5:55 AM by Nursing Assistant (NA) #1 and was told that Resident #1 had passed away. Nurse #2 explained that after she had spoken to NA #1, she was at the nurses' station on ,d+[DATE] hall with NA #2, and she informed NA #2 that Resident #1 had passed away. Nurse #2 stated NA #2 jumped up and said, Oh my god he's a full code, as NA #2 went towards the main nursing station. Nurse #2 then stated NA #2 checked the code status binder that was located at the 800 nurses' station and verified Resident #1 was a full code. Between 6:02 AM and 6:06 AM she went to the 800 hall to see if Nurse #1 needed help and Nurse #1 stated no, she did not need help and emergency medical services (EMS) were on the way. Nurse #2 went back to the ,d+[DATE] hall to check on her residents then went back to the 800 hall. Nurse #2 then explained the crash cart was on the hall in front of Resident #1's room and law enforcement, first responders, and fire department were in the room assessing Resident #1, Resident #1 was not receiving CPR. At that time EMS was at the side door of the building. Nurse #2 recalled Nurse #1 was talking to law enforcement, and she went to make copies of Resident #1's paperwork. She further stated Nurse #1 did not call the code overhead when she was made aware of Resident #1's code status. An interview was conducted with Nursing Assistant (NA) #2 on [DATE] at 11:44 AM. She verified she worked on [DATE] from 11:00 PM through [DATE] at 7:00 AM on the ,d+[DATE] hall, not the hall where Resident #1 resided. NA #2 stated she was sitting at the nursing station when Nurse #2 told NA #2 Resident #1 had passed away. NA #2 explained she jumped up and said, oh my god, he's a full code, as NA #2 went up the hall towards the main nursing station. NA #2 said she looked in the Do Not Resituate (DNR) binder and removed Resident #1's sheet that indicated he was a full code. NA #2 then stated she took that sheet to Nurse #1 who was halfway down the 800 hall to show her Resident #1 was a full code. NA #2 explained that Nurse #1 stated several times, you've got to be kidding me. NA #2 told Nurse #1 to grab the crash cart, and NA #2 went to call 911. NA # 2 proceeded to the nurses' station to call 911. NA #2 explained she is responsible for medical records at the facility, and she was an NA, that was how she was aware of Resident #1's code status. NA # 2 stated she had not been assigned to Resident #1 at all from [DATE] to [DATE]. Emergency medical services (EMS) report revealed the following: the call was received/dispatched at 6:01 AM, on scene at 6:09 AM, and at patient at 6:11 AM. Primary Impression was obvious death, at scene, emergency medical services (EMS) crew directed to Resident #1's room by facility staff. The fire department (FD) and police department (PD) were already at bedside. Per report from FD, staff reported Resident #1 was last known well (LKW) at 5:15 AM this morning. FD and law enforcement (LE) on scene reported that cardiopulmonary resuscitation (CPR) was not in progress by facility staff at their arrival. No facility staff were present at bedside. EMS crew requested a firefighter to obtain patient information and code status from facility staff. Resident #1 found to be full code on facility paperwork. The primary impression was obvious death. Resident #1 found supine in facility bed. Resident #1 found to be apneic (cessation of respiration) and without pulse. A 4-lead electrocardiogram (ECG) (a test that measures the heart's electrical activity) performed and noted asystole (when your heart's electrical system fails, causing your heart to stop pumping) in all pre-cordial leads. Mottling (blotchy patches of discoloration on the skin) noted in extremities and posterior of patient's trunk. Eyes non-reactive to light. Per protocol, due to extended downtime without CPR and asystole upon presentation, CPR efforts not initiated, and time of death noted at 6:15 AM. A phone interview was conducted with the Medical Director (MD) on [DATE] at 3:08 PM. He stated he would have expected the staff to obtain vital signs and to call him or the NP when the difficulty swallowing, audible congestion, and cough were first observed. The MD had not received a call about Resident #1 having a change in condition that included swallowing difficulties, cough, congestion, or low vital signs. He also stated that it was standard practice to call the MD when a change occurs. He stated he thought the nurse deviated out of the standard practice when she did not call a NP or MD. He indicated if his vital signs were low, and he was having difficulty breathing he would have needed to be sent to the hospital for evaluation. A phone interview was conducted with the Nurse Practitioner (NP) on [DATE] at 4:00 PM. He stated he saw Resident #1 on [DATE] and he seemed to be in his normal state, alert and oriented to per, place, and time. He also stated he observed the resident as having no cough or shortness of breath. He indicated staff should have obtained vital signs and monitored Resident #1 and he would have expected the staff to call him or the Medical Director (MD) when the difficulty swallowing, audible congestion, and cough were first observed. An interview with the Director of Nursing (DON) was conducted on [DATE] at 11:18 AM. She stated Nurse #1 should have applied oxygen due to Resident #1's oxygen levels dropping, she should have notified the physician, and she should have been obtaining vital signs throughout the shift. She also expected Nurse #1 to notify the physician for a change in condition of a resident as soon as it was observed. On [DATE] at 1:15 PM the Administrator and DON were made aware of the Immediate Jeopardy. The facility implemented the following corrective action plan with a completion date of [DATE]. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: On [DATE], Resident #1 was noted with abnormal vital signs at 4:28 AM per Nurse #1. Nurse #1 identified congestion, difficulty swallowing, and the presence of phlegm on the ,d+[DATE]p shift with no follow up or ongoing monitoring. Nurse #1 failed to further assess Resident #1's change in condition or implement interventions to improve Resident #1's condition. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: On [DATE] all current interviewable residents were interviewed by the Director of Social Services to ensure that they felt any change in conditions were acted upon timely by the staff including physician notification and to ensure there were no concerns with delay or withholding of care and treatment. On [DATE] a 30 day look back of progress notes was reviewed by the Assistant Director of Nursing for current non-interviewable residents to ensure that there were no concerns related to change in condition or delay or withholding of care and treatment, including physician notification. On [DATE] all staff were interviewed by the Director of Nursing or designee to determine if there were any concerns related to delay or withholding of care related to a resident change in condition including physician notification. On [DATE] a record review of the last 30 days of deaths was audited by the Director of Nursing. There was no change in condition identified that required Cardiopulmonary Resuscitation. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: On [DATE] the Staff Development Coordinator or designee educated all staff on care services related to identification of change in condition, providing timely treatment as ordered not withholding care, reporting any concerns and notification to physician. The same education will be provided by the Staff Development Coordinator or designee to agency staff upon first shift worked and all new hires during orientation effective [DATE] per directive of the Director of Nursing. Change in condition identification, notification of physician, validation of timely treatment and follow up will be reviewed in clinical morning meeting Monday through Friday. Any negative findings will be acted upon immediately. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: On [DATE] it was established by the Interdisciplinary Team that beginning the week of [DATE] through [DATE], the following steps will be completed and documented weekly for 8 weeks. Five interviewable residents will be interviewed weekly by the Director of Social Services or designee to ensure that resident concerns are addressed timely, that there are no unresolved concerns, that facility is respecting Resident Rights, that the facility is identifying resident changes in condition, if a resident has had a medical concern the facility has addressed it timely and notified the physician, and have no concerns that have the potential to be considered abuse/neglect. Five non-interviewable residents will have their medical record reviewed weekly by a clinical manager to identify any concerns related to change in condition, any delay or withholding of care or treatment, or any concerns with Resident Rights, code statuses not being honored will also be reviewed. Five staff members will be interviewed weekly the Administrator or designee to determine if there are any concerns related to delay in identification in resident Change in Condition, delay or withholding of treatment or concerns regarding physician notification. Facility Activity Report will be reviewed Monday through Friday in Clinical Morning Meeting to ensure timely identification of Change in Condition, notification of physician, prompt treatment if indicated, appropriate response for a resident that is a full code, timely identification of potential neglect. The Quality Improvement Committee will review the results of the audits for further recommendation weekly for 8 weeks. Should the committee feel that further auditing is necessary, it will be determined at that time. Above responsibilities were discussed during Ad-hoc QAPI completed on [DATE]. Alleged Compliance date: [DATE] Date of immediate jeopardy removal is [DATE] On [DATE] the credible allegation of Immediate Jeopardy removal was validated by onsite verification and included: The facility provided documentation to support their corrective action plan. The initial facility audits dated [DATE] were reviewed and revealed no issues were noted. Education to licensed nursing, nurse aides and medication aide staff regarding a change in condition was reviewed and sign in sheets were provided. Staff interviews across all departments were able to verbalize they had received education on change in condition, examples of change in condition, and who to notify in the event of a change in condition of a resident. Quality Assurance and Performance Improvement (QAPI) meetings were discussed with the Administrator and meeting notes were reviewed. The facility's compliance date of [DATE] for the corrective action plan was validated on [DATE].

Based on record review, and physician, Nurse Practitioner (NP), and staff interviews, the facility failed to protect a resident's right to be free from neglect when staff failed to provide necessary care and services for 1 of 3 residents reviewed for neglect. Resident #1 had a significant change in condition on [DATE] and the nurse did not recognize the seriousness, notify the physician or provide thorough and ongoing assessments. In addition, Resident #1 was found not breathing and without a pulse on [DATE] and Cardiopulmonary Resuscitation (CPR) was not immediately administered. Resident #1 was pronounced deceased by emergency medical services (EMS) on [DATE]. This was for 1 of 3 residents reviewed for neglect (Resident #1). The findings included: This citation is cross referred to: 1. F580 Based on record review, and staff and Medical Director (MD) interviews, the facility failed to notify the physician for a resident who had a significant change in condition. On [DATE] Resident #1 was observed with audible congestion, difficulty swallowing, and was trying to cough up phlegm. The MD or Nurse Practitioner (NP) were not notified. On [DATE] Resident #1 had his mouth open with clear phlegm noted in his mouth and he was coughing. Resident #1 ' s vital signs included a blood pressure (BP) of ,d+[DATE] (normal ,d+[DATE]), pulse of 48 (normal range ,d+[DATE]), oxygen at 89% (normal range between 95% and 100%) on room air, and respirations of 12 (normal range ,d+[DATE]). He had audible congestion, and his skin was extremely hot to touch. The MD or Nurse Practitioner (NP) were not notified. At 5:00 AM Resident #1 was found not breathing and was pronounced deceased at 6:15 AM. This was for 1 of 3 residents reviewed for notification of change of condition. 2. F678 Based on observation, record review, and staff, and Nurse Practitioner (NP) interviews the facility failed to ensure that Cardiopulmonary Resuscitation (CPR) was administered immediately and failed to operationalize an effective system so staff could respond to an emergency situation as needed. On [DATE] Nurse #1 was notified that Resident #1 was unresponsive, not breathing and had no pulse. Nurse #1 verified Resident #1 was not breathing. Nurse #1 did not verify Resident # s code status and resumed her nursing duties on another hall. Nurse #1 was later informed that Resident #1 was a full code, Nurse #1 then started CPR without initiating a code blue protocol. Nurse #1 stopped CPR when she became tired. Resident #1 was pronounced deceased by emergency medical services (EMS) on [DATE]. This was for 1 of 3 residents reviewed for CPR (Resident #1). 3. F684 Based on record review, staff interviews, Nurse Practitioner (NP) and Medical Director (MD) interviews, the facility failed to provide complete, thorough, and ongoing assessments, and failed to intervene when Nurse #1 failed to recognize the seriousness of a resident ' s (Resident #1) change in condition. Resident #1, who was a full code, was experiencing a change in condition on [DATE] with symptoms of difficulty swallowing, audible congestion (able to hear without the use of stethoscope), and trying to cough up phlegm. Nurse #1 did not obtain vital signs or put interventions into place to relieve the congestion. On [DATE] Resident #1 had his mouth open, clear phlegm was noted in his mouth, audible congestion continued, and he was coughing. Resident #1's vital signs, which included a blood pressure (BP) of ,d+[DATE] (normal ,d+[DATE]), pulse of 48 (normal range ,d+[DATE]), oxygen saturation at 89% (normal range between 95% and 100%) on room air, respirations 12 (normal range ,d+[DATE]), and temperature 96.7 (axillary/arm pit). Nurse #1 did not obtain another set of vital signs, and at 5:00 AM when Resident #1 was discovered with no pulse. Nurse #1, who did not verify Resident #1's full code status, did not initiate lifesaving resuscitative efforts and returned to administering medications. At 5:55 AM when Nurse #1 became aware of Resident #1's full code status, she initiated Cardiopulmonary Resuscitation (CPR). Emergency medical services (EMS) were called at 6:00 AM, arrived at 6:10 AM, and Resident #1 was pronounced deceased at 6:15 AM. This was for 1 of 3 residents reviewed for change of condition. An interview with the Director of Nursing (DON) was conducted on [DATE] at 11:18 AM. The DON stated she did not feel the failure to monitor, assess, call the physician when a change of condition was observed, not checking Resident #1's code status and not initiating CPR was neglect but a lack of nursing competency of Nurse #1. She indicated Nurse #1 should have notified the physician, should have been obtaining vital signs and monitoring Resident #1 throughout the shift. The DON further also expected Nurse #1 to notify the physician of a change in condition of a resident as soon as it was observed and to verify a resident's code status immediately if found without a pulse. The Administrator was notified of immediate jeopardy on [DATE] at 1:15 PM. The facility provided the following corrective action plan with a completion date of [DATE]. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: On [DATE] Nurse #1 failed to notify physician of change in condition of Resident #1. Nurse #1 failed to monitor Resident #1 ' s change in condition. Nurse #1 failed to verify Resident #1's code status and failed to initiate CPR for Resident #1 with Advanced Directive of Full Code. Nurse #1 neglected to honor Resident #1's rights. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: On [DATE] Director of Social Services interviewed all alert and oriented residents to ensure they felt their rights were honored; change in conditions were acted upon timely by the staff and to ensure there were no concerns with delay or withholding of care and treatment. On [DATE] Medical records were reviewed by the Assistant Director of Nursing for current non-verbal residents to identify any concerns related to change in condition or delay or withholding of care. On [DATE] All staff were interviewed by Director of Nursing or designee to determine if there were any concerns related to delay or withholding of care or identification of resident change in condition and treatment, violation of resident rights, or concerns with any code status not being provided as ordered. On [DATE] A record review of the last 30 days of deaths was audited by the Director of Nursing. There were no deaths or change in condition identified that required Cardiopulmonary Resuscitation. On [DATE] crash carts were audited to ensure that all appropriate equipment is on the cart and in working condition. On [DATE] the wound nurse completed a full facility review of all code status orders and care plans to ensure there were no concerns, no discrepancies noted. On [DATE] the Staff Development Coordinator reviewed employee files for licensed staff to ensure they have up to date CPR certification to include licensed staff present at the time of the event. On [DATE] Nurse #1's agency was notified of event to review her employee file for any previous issues or disciplinary action. The Director of Compliance & Client Services of Convergence Medical Staffing validated no previous issues or disciplinary action documented. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: On [DATE] the Staff Development Coordinator or designee educated all staff on care services related to identification of change in condition, providing timely treatment as ordered not withholding care, facility CPR policy, honoring resident rights, reporting any concerns immediately, Abuse policy and procedures with a special focus on neglect. The same education will be provided by the Staff Development Coordinator or designee to agency staff upon first shift worked and all new hires during orientation effective [DATE] per directive of the Director of Nursing. On [DATE], mock codes were conducted across all shifts by the Staff Development Coordinator with nursing department staff. Nursing department staff includes Registered Nurses, Licensed Practical Nurses and Certified Nurse Aides. On [DATE] Change in condition identification, notification of physician, validation of timely treatment, follow up, appropriate code response, concerns of resident right violations and any potential abuse will be reviewed in clinical morning meeting Monday through Friday. Any negative findings will be acted upon immediately. On [DATE] Routine resident council will be held by the facility leadership routinely but no less than monthly. Resident Rights will be reviewed. Any concerns will be addressed by the appropriate department manager. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: On [DATE] it was established by the Interdisciplinary Team that beginning the week of [DATE] through [DATE], the following steps will be completed and documented weekly for 8 weeks. Director of Life Enrichment or designee will conduct and follow up on a weekly Resident Council meeting to ensure that resident concerns are addressed timely, that there are no unresolved concerns, that facility is respecting Resident Rights, that the facility is identifying resident changes in condition and if a resident has had a medical concern, has the facility addressed it timely. Five interviewable residents will be interviewed weekly by the Director of Social Services or designee to ensure that resident concerns are addressed timely, that there are no unresolved concerns, that facility is respecting Resident Rights, that the facility is identifying resident changes in condition, if a resident has had a medical concern the facility has addressed it timely, and have no concerns that have the potential to be considered abuse/neglect. Five non-interviewable residents will have their medical record reviewed weekly by a clinical manager to identify any concerns related to change in condition, any delay or withholding of care or treatment, or any concerns with Resident Rights, code statuses not being honored will also be reviewed. Five staff members will be interviewed weekly the Administrator or designee to determine if there are any concerns related to delay in identification in resident Change in Condition, delay or withholding of treatment, violation of Resident Rights, or concerns with code status not being provided as ordered. All resident deaths or code activity will be reviewed by the clinical team to ensure the resident ' s code status was carried out by staff without delay. Mock codes will be conducted one random shift per week by the Director of Nursing or designee across all shifts to ensure timely and appropriate response. Any identified concerns will be addressed immediately. Crash carts will be audited daily by the Assistant Director of Nursing or designee to ensure that appropriate equipment is present. Facility Activity Report will be reviewed Monday through Friday in Clinical Morning Meeting to ensure timely identification of Change in Condition, notification of physician, prompt treatment if indicated, appropriate response for a resident that is a full code, timely identification of potential neglect. The Quality Improvement Committee will review the results of the audits for further recommendation weekly for 8 weeks. Should the committee feel that further auditing is necessary, it will be determined at that time. Above responsibilities were discussed during Ad-hoc QAPI completed on [DATE]. Alleged Compliance date: [DATE] Date of immediate jeopardy removal is [DATE] On [DATE] the credible allegation of Immediate Jeopardy removal was validated by onsite verification and included: The facility provided documentation to support their corrective action plan. The initial facility audits dated [DATE] were reviewed and revealed no issues were noted. Education to licensed nursing, nurse aides and medication aide staff regarding a change in condition was reviewed and sign in sheets were provided. Staff interviews across all departments were able to verbalize they had received education on change in condition, examples of change in condition, and who to notify in the event of a change in condition of a resident. Quality Assurance and Performance Improvement (QAPI) meetings were discussed with the Administrator and meeting notes were reviewed. The facility's compliance date of [DATE] for the corrective action plan was validated on [DATE].

Based on record review and staff interviews the facility failed to accurately code the behavior section and failed to code the medication section on the Minimum Data Set (MDS) assessment for 2 of 5 residents reviewed for MDS accuracy. (Resident #34, and #39). Findings included: 1. Resident #34 was admitted to the facility on [DATE] with a diagnosis of dementia, psychotic disturbance, mood disturbance and anxiety. A nursing progress note dated 6/4/23 read in part; Resident had been yelling mom for approximately one hour, several attempts to redirect without positive results. Resident #34's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 had not exhibited any behaviors during the assessment period. An interview was conducted on 6/22/23 at 12:07 PM with the facility's MDS Nurse. The MDS Nurse stated that she was responsible for coding resident behaviors on the MDS. The MDS Nurse stated that any behavior that is on the care plan would not need to be documented on the MDS if it is a continued behavior and not a change. The MDS Nurse stated only new behaviors would be coded on the MDS. The MDS Nurse stated that she would become aware of new resident behaviors during the facilities weekly meetings that she would attend, and she would also get a report about a new behavior being documented in the progress note. An interview was conducted with the facility's Director of Nursing (DON) on 6/22/23 at 12:55 PM who stated that if behaviors were present, then behaviors should have been coded on the MDS. 32394 2-a. Resident #39 was admitted to the facility on [DATE] with re-entry from a hospital on 1/23/21. Her cumulative diagnoses included anxiety disorder, manic depression, bipolar disorder, psychotic disorder, and a neurocognitive disorder with Lewy bodies. Lewy body dementia is a disease associated with abnormal deposits of a specific protein in the brain. The deposits, called Lewy bodies, affect chemicals in the brain which can lead to problems with thinking, movement, behavior, and mood. A review of Resident #39's physician orders included the following medications, in part: --550 milligrams (mg) rifaximin (an antibiotic) to be given as one tablet by mouth two times a day related to cirrhosis of the liver (Start date 10/23/20). --50 mg tramadol (an opioid pain medication) to be given as 1/2 tablet by mouth every 12 hours as needed for pain (Start date 10/13/21). --200 mg quetiapine (an antipsychotic medication) to be given as one tablet by mouth every morning and at bedtime related to schizoaffective disorder, bipolar type (Start date 2/7/22; Discontinued 6/19/23). Documentation on Resident #39's June 2023 Medication Administration Record (MAR) revealed the resident received rifaximin on 7 out of 7 days, tramadol on 5 out of 7 days, and quetiapine on 7 out of 7 days from 6/9/23 through 6/15/23. A review of Resident #39's quarterly Minimum Data Set (MDS) assessment dated [DATE] was conducted. The Medications section of the MDS assessment indicated Resident #39 received an antipsychotic, antianxiety, antidepressant, anticoagulant, and diuretic medication on 7 out of 7 days. However, the MDS did not indicate the resident also received an antibiotic (rifaximin) and opioid medication (tramadol) during the 7-day look-back period. While the Medications section of the MDS indicated Resident #39 received an antipsychotic medication on 7 out of 7 days during the look back period, the Antipsychotic Medication Review of this section inaccurately reported the resident did not receive an antipsychotic medication since her last assessment. An interview was conducted on 6/22/23 at 11:33 AM with the facility's MDS Nurse. During the interview, the MDS Nurse was asked to review the Medications section of Resident #39's quarterly MDS assessment dated [DATE]. The nurse confirmed this section did not report Resident #39 received either an antibiotic or an opioid medication during the 7-day look-back period. When asked, the MDS Nurse stated she was not aware rifaximin was an antibiotic or that tramadol was classified as an opioid medication. The nurse confirmed a medication classified as an antibiotic or as an opioid needed to be reported as such in the Medications section of the MDS. Upon further review of the 6/15/23 MDS assessment, inquiry was made as to the inaccuracy of the Antipsychotic Medication Review of this section. When asked, the MDS nurse reported she had the correct information on her reference sheet but made an error completing the Antipsychotic Medication Review. The MDS Nurse stated the Antipsychotic Medication Review should have reported an antipsychotic was received on a routine basis only, no gradual dose reduction (GDR) was attempted, and the date her physician documented a GDR as clinically contraindicated. An interview was conducted with the facility's Director of Nursing (DON) on 6/22/23 at 11:50 AM. During the interview, concerns regarding the accuracy of the Medications section of Resident #39's MDS assessments were discussed. The DON stated, I would agree they (the errors on the MDS) need to be corrected. 2-b. Resident #39 was admitted to the facility on [DATE] with re-entry from a hospital on 1/23/21. Her cumulative diagnoses included anxiety disorder, manic depression, bipolar disorder, psychotic disorder, and a neurocognitive disorder with Lewy bodies. Lewy body dementia is a disease associated with abnormal deposits of a specific protein in the brain. The deposits, called Lewy bodies, affect chemicals in the brain which can lead to problems with thinking, movement, behavior, and mood. A review of Resident #39's physician orders included the following medications, in part: --550 milligrams (mg) rifaximin (an antibiotic) to be given as one tablet by mouth two times a day related to cirrhosis of the liver (Start date 10/23/20). --50 mg tramadol (an opioid pain medication) to be given as 1/2 tablet by mouth every 12 hours as needed for pain (Start date 10/13/21). Documentation on Resident #39's March 2023 Medication Administration Record (MAR) revealed the resident received rifaximin on 7 out of 7 days and tramadol on 3 out of 7 days from 3/9/23 through 3/15/23. A review of Resident #39's quarterly Minimum Data Set (MDS) assessment dated [DATE] was conducted. The Medications section of the MDS assessment indicated Resident #39 received an antipsychotic, antianxiety, antidepressant, anticoagulant, and diuretic medication on 7 out of 7 days. However, the MDS did not indicate the resident also received an antibiotic (rifaximin) and opioid medication (tramadol) during the 7-day look-back period. An interview was conducted on 6/22/23 at 11:33 AM with the facility's MDS Nurse. During the interview, the MDS Nurse was asked to review the Medications section of Resident #39's quarterly MDS assessment dated [DATE]. The nurse confirmed this section did not report Resident #39 received either an antibiotic or an opioid medication during the 7-day look-back period. When asked, the MDS Nurse stated she was not aware rifaximin was an antibiotic or that tramadol was classified as an opioid medication. The nurse confirmed a medication classified as an antibiotic or as an opioid needed to be reported as such in the Medications section of the MDS. An interview was conducted with the facility's Director of Nursing (DON) on 6/22/23 at 11:50 AM. During the interview, concerns regarding the accuracy of the Medications section of Resident #39's MDS assessments were discussed. The DON stated, I would agree they (the errors on the MDS) need to be corrected.

Based on record review, observation and staff interviews the facility failed to provide feeding assistance (Resident #54) for 1 of 5 residents who were dependent on staff for their activities of daily living needs (ADL) needs. Findings included: 1. Resident #54 was admitted to the facility on [DATE] with a diagnosis which included vascular dementia, cerebral infarction due to embolism, hemiplegia, weakness, and dysphagia. Review of Resident #54's annual Minimum Data Set, dated dated dated [DATE] revealed that she was severely cognitively impaired and required extensive assistance with eating. The Care Area Assessment worksheet dated 4/18/23 read in part; Resident #54 received a regular, mechanical soft with thin liquids diet daily requiring assistance with meals. A review of Resident #54's care plan dated 4/18/23 included a focus are for self-care deficits with an intervention which required extensive one person feeding assistance. Review of Resident #54's Kardex form (a desktop file system that gives a brief overview of each patient and is updated every shift), revealed a care area for Eating/Nutrition that indicated extensive one person feeding assistance for eating. On 6/21/23 at 8:26 AM Resident #54 was observed sitting upright in bed and was eating toast independently. At 8:35 AM an interview and second observation were conducted with Resident #54 who was eating oatmeal with her fingers. Her silverware was wrapped in a napkin secured by an adhesive wrap. Nurse Aide (NA) #3 entered Resident #54's room to assist the other resident in the room and was asked if Resident #54 received assistance with eating. NA #3 stated, no she is fine, unless something had changed. Resident #54 did not receive assistance with her breakfast meal. An interview was completed with NA#3 on 6/21/23 at 8:43 AM who stated that she had worked at the facility for almost a year and had worked with Resident #54 a couple of times. NA #4 stated that she had never assisted Resident #54 with feeding assistance. NA #3 was asked how she would know if a resident needed assistance with eating and she stated Resident #54 eats by herself, but she would know if a resident needed assistance by being told by another NA or Nurse. NA #3 was asked if there were any other methods to know if a resident needed assistance and she stated that she would walk the hall and look at the residents. NA #3 was how she sets up a meal tray and she stated that she would set the tray down and open the juice and put a straw in the juice. NA #3 was informed that Resident #54 did not have her silverware opened and she stated that she had forgotten to open her silverware but eventually Resident #54 would eat with her hands. NA #3 was asked if she would check a resident Kardex (a desktop file system that gives a brief overview of each patient and is updated every shift) and NA #3 stated she would do that only for transferring needs but not for specific care. An interview with NA #1 was conducted on 6/21/23 at 5:23 PM who stated that Resident #54 required one on one assistance with feeding. NA #1 stated that Resident #54 will hold her food in her mouth and needs reminders to swallow her food. A joint interview was conducted with the Administrator and the Director of Nursing on 6/22/23 at 12:55 PM. The Administrator stated that it was her expectation if a resident is care planned as needing assistance with meals, they should be getting assistance.

Based on observations, record review and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following a recertification dated 11/4/21 for one deficiency in the area of Activities of Daily Living (ADL) for dependent residents. The continued failure of the facility during two surveys of record in the same area showed a pattern of the facility's inability to sustain an effective Quality Assurance program. Findings included: This tag is crossed referenced to: F677 - Based on record review, observation and staff interviews the facility failed to provide feeding assistance (Resident #54) for 1 of 5 residents who were dependent on staff for their activities of daily living needs (ADL) needs. During the recertification survey of 11/4/21 the facility failed to provide personal care for 2 of 3 residents related to incontinence care and nail care. An interview was conducted with the Administrator on 6/22/2023 at 12:55 PM. The Administrator stated although ADL care had been cited on the last annual survey on 11/4/21 it was for a different ADL concern. The Administrator stated that when we have a citation, we will write a Plan of Correction (POC) for that concern and work through it and conduct our auditing until the Quality Improvement (QI)committee determines it is no longer necessary.

Based on record review and interview of the staff, Physician Assistant (PA), Nurse Practitioner (NP), Wound Nurse Practitioner #1, and Physician, the facility failed to notify the medical staff of the Resident #1's sacral pressure ulcer deterioration to the point the wound was 11.5 centimeters (cm) long by 16 cm wide and failed to notify the medical staff when Resident #1 sustained a full-thickness skin tear injury which extended down into the subcutaneous tissue (tissue below the skin) and measured 7 centimeters (cm) long by 3 cm wide on 12/31/22 for 1 of 2 residents reviewed for pressure ulcer(s) and skin tear(s). Immediate jeopardy began on 12/31/22 for Resident #1 when staff failed to notify medical staff of Resident #1's lower right leg injury at the time of hospitalization on [DATE] directly after being discharged from the facility. The wound was bleeding and required pressure to control, was open with an approximate/unknown depth, and was unable to approximate (close skin edges). Immediate jeopardy continued on 1/9/23 when staff failed to notify medical staff of Resident #1's sacral pressure ulcer deterioration when the wound increased in size and was discovered to have a foul odor. Immediate jeopardy was removed on 3/4/23 when the facility implemented a credible allegation of 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 ensure monitoring systems put in place are effective. Findings included: a. On 2/28/23 at 9:50 am an interview was conducted with the Wound Nurse. The Wound Nurse stated she was aware of Resident #1's deterioration in sacral pressure ulcer wound on 1/9/23 and 1/13/23 and had not informed the medical staff (Wound NP, facility NP, PA, or Physician). She further stated she was not informed by Nurse #1 of any wound deterioration over the weekend of 1/7/23 -1/8/23. On 2/28/23 at 10:26 am an interview was conducted with the Director of Nursing (DON). The DON stated she was asked by the Wound Nurse to look at Resident #1's sacral wound on 1/13/22, not medical staff. The DON stated, if there was a concern with a wound you would ask the staff to reach out to the medical staff. The DON stated she had not contacted medical staff regarding the resident's sacral wound decline and initiated a nurse judgement of treatment change. On 2/28/23 at 12:20 pm an interview was conducted with the Discharge Nurse. The Discharge Nurse was aware of the reported deterioration to Resident #1's sacral pressure ulcer on 1/14/23 and she had not reported to medical staff. On 2/28/23 at 2:45 pm an interview was conducted with Nurse # 1. Nurse #1 stated she worked every weekend and provided sacral pressure ulcer wound care to Resident #1 on 1/7/23 and 1/8/23 and noted the sacral wound had changed compared to the prior weekend. The wound was horrible with black tissue and odor and this change was not reported to medical staff. She stated the change was not reported because she thought Wound NP #1 was going to see the resident during the week. If the Wound NP was not following, she would call the medical staff member covering the weekend. On 2/28/23 at 11:03 am an interview was conducted with the facility NP. The NP stated she started her position at the facility on 1/6/23. She stated she first saw Resident #1 on 1/10/23 for a medical visit and had not evaluated the resident's wounds. On 3/1/23 at 10:30 am an interview was conducted with the Physician Assistant (PA). The PA stated she saw Resident #1 on 1/6/23 and assessed the resident but was not informed by nursing or aware that there was a second skin tear to the right leg and the right leg was not evaluated. On 3/1/23 at 11:20 am an interview was conducted with Nurse #2. Nurse #2 stated she assisted the Medication Aide with sacral pressure ulcer wound care and observed that the wound had opened, drainage changed to white purulent, and had foul odor on 1/14/23 and had not reported this to medical staff. The resident was discharged to home as planned. Nurse #2 had not stated why this change was not reported. b. A nursing note written by Nurse #1 dated 12/31/2022 at 7:37 pm documented: This nurse across the hall in another room when the NA (nurse aide) came to this nurse and stated resident got a skin tear when they (were) transferring resident into her wheelchair. This nurse into room and assess a large skin tear noted to the (right lower leg). Skin and subcutaneous tissue noted to be pushed to the right side of the wound and unable to be approximated. On 3/1/23 at 3:02 pm an interview was conducted with Nurse #1. Nurse #1 stated she was assigned to Resident #1 when staff transferred her without the mechanical lift and the resident hit her right lower leg on the wheelchair footrest, on 12/31/22 and sustained an injury. Nurse #1 stated she completed an incident report and called the weekend medical staff on-call voice mail and left a message on the skin tear line (where to leave a message regarding skin tear). Nurse #1 stated she had not informed medical staff nor considered sending the resident to the Emergency Department at the time of accident because the bleeding had stopped after pressure was applied, and she did not think the wound was that bad. Nurse #1 had not entered a physician order or notice in the physician follow-up book for the treatment she initiated to the injury. On 2/28/23 at 11:03 am an interview was conducted with the facility Nurse Practitioner (NP). The NP stated she started her position at the facility on 1/6/23. She stated she first saw Resident #1 on 1/10/23 for a medical visit and had not evaluated the resident's wounds. She stated there was a communication breakdown and missing documentation regarding the wounds. The NP stated when the Wound NP was not available, she wanted to be informed by the Wound Nurse or Wound NP any changes to the resident's wound to follow up. She stated the 1/4/23 wound NP #2 by telehealth note was not in the medical record for her to review. She stated the right lower leg injury should have been evaluated by medicine before discharge on 1/14/23 since it significant. On 2/28/23 at 2:00 pm an interview was conducted with Wound NP #1. She stated she was not available on 12/31/22 when Resident #1 suffered the injury to her leg. Wound NP #1 stated she reviewed the resident's record and Wound NP #2 who was covering by telehealth visit had not assessed the right lower leg skin tear (no documentation). On 3/1/23 at 10:30 am an interview was conducted with the Physician Assistant (PA). The PA stated she saw Resident #1 on 1/6/23 and assessed the resident but was not informed or aware that there was a skin tear injury to the right leg and the right leg was not evaluated. Nor was she made aware of the severity of the injury. On 3/1/23 at 12:40 pm and interview was conducted with the Physician. The Physician stated she was not informed of Resident #1's right lower leg injury until 1/4/23 when an order was requested. The physician further explained she was not informed of its severity and because of the severity she would have expected to be notified or the resident sent out to the Emergency Department when the injury happened. The Administrator was advised of immediate jeopardy on 3/1/23 at 6:21 pm. The facility provided a credible allegation of immediate jeopardy removal. Credible Allegation of Compliance on 3/4/23. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of noncompliance The facility failed to notify the medical staff Resident #1 sacral wound deterioration and change on 1/9/2023, 1/13/2023 and 1/14/2023 and failed to notify the physician of the severity of the right lower leg injury on 12/31/2022 which resulted in no medical attention being provided. Resident was hospitalized with an infected sacral wound pressure ulcer stage 4 which resulted in sepsis. In addition, Resident #1 sustained a 7 cm by 2cm by 0.1 cm skin tear to the lower right leg. This wound deteriorated to expose bone and subcutaneous tissue and had the high likelihood to become infected. All residents have the potential to be affected. On 3/2/2023 the facility completed a 100% skin sweep for all current residents. No issues were identified. On 3/2/2023 the Director of Nursing/Designee reviewed previously completed wound reports for the last 30 days for any wound declines or changes. There were no wound declines or changes. On 3/2/2023 the Director of Nursing/Designee reviewed the previous 30 days of eInteract (electronic assessment tool in the Electronic Health Record) Change in Condition assessments for any missed physician notifications. There were no missed notifications identified. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 3/2/2023 the Director of Nursing provided 1:1 education with the facility Designated Wound Nurse on notification to Medical Provider (Medical Doctor (MD)/Nurse Practitioner (NP)/Wound Nurse Practitioner (NP)) for changes in condition including deterioration of wounds, notification of injuries at the time of injury, and wound protocol to ensure that proper protocol is followed and in place. The facility wound protocol includes a description along with a picture of different types of altered skin integrity and acceptable treatment options to implement for each. On 3/2/2023 all Licensed Nursing Staff, including agency staff were educated by the Nursing Administration Team on notification to Medical Provider (MD/NP/Wound NP) for changes in condition including deterioration of wounds, facility wound protocol and location of wound protocol (available on each medication cart and at the main nurses station), immediate notification of injuries that cannot be treated per facility wound protocol, description of the problem and immediate need of the situation, per physician triage line as indicated which is available 24 hours a day, 7 days per week. Education of all Licensed Nursing Staff including current agency Licensed Nurses was completed on 3/3/2023. All newly hired Licensed Nursing Staff, including agency staff will be educated by the Director of Nursing/Designee during the facility orientation process on Notification to Medical Provider (MD/NP) for changes in condition including changes in wounds, notification of injuries and the wound protocol. The Regional Director of Clinical Services notified the Director of Nursing on 3/2/2023 on the implementation for new hires. An Ad Hoc QAPI was completed with the Interdisciplinary Team (IDT) which includes the Administrator, Director of Nursing, Assistant Director of Nursing, Nurse Managers, Director of Rehab, Director of Life Enrichment, Director of Social Services, Environmental Services Director, Admissions Director, Business Office Manager, Minimum Data Set (MDS) Nurse, Wound Nurse, Clinical Coordinator, and the Medical Director on 3/2/2023. The IDT was updated regarding Immediate Jeopardy (IJ) citations the facility received on 3/1/2023 along with regulation, policy, and necessary education that is needed in order to be in compliance. The Director of Nursing/Designee will audit Weekly Wound reports for deterioration and MD/NP notification beginning 3/3/2023. The Director of Nursing/Designee will audit all incident reports to ensure appropriate treatment, MD/NP notification beginning 3/6/2023. Alleged date of IJ removal is 3/4/23. The credible allegation of immediate jeopardy removal was validated on 3/7/23. On 3/7/23 observation and nursing interviews of all shifts were done of nursing education for resident change notification, use of the wound care protocol, and injury notification, for proper assessment/evaluation of wound status and care care, wound changes (including deterioration) and, and medical staff involvement (notification). New nursing hires and contract staff would receive the education before assignment. Current and ongoing wound care planned audits were reviewed. A Quality Assurance meeting was held by the Administrator and Corporate and plans for improvement were outlined. The facility's immediate jeopardy removal date of 03/04/23 was validated.

Based on record reviews, family member, home health liaison, and staff interviews, the facility failed to safely discharge 1 of 3 residents to home (Resident #1). The facility failed to submit a signed order for home health services to the home health agency until 3 days after discharge from the facility. Resident #1 had an unstageable pressure wound of the sacrum with purulent malodorous drainage and a large skin tear of the lower right leg that the family described as very deep, and she was able to see white meat that looked like a bone. Additionally, Resident #1 had an unstageable pressure wound of the left heel and a skin tear of the left lower leg. Resident #1 was sent home with incorrect wound care supplies and incorrect wound care orders. Resident #1 was taken to the emergency room by family members immediately after the facility discharged Resident #1. The family members recognized Resident #1 had serious wounds that needed medical treatment and could not be cared for at home. Immediate Jeopardy began on 1/14/2023 when Resident #1 was discharged home with an unstageable pressure wound of the sacrum with purulent malodorous drainage, an unstageable pressure wound of the left heel, a skin tear of the lower left leg, and a large skin tear of the lower right leg and without an order for home health services, with incorrect wound care supplies and instructions for wound care. Immediate Jeopardy was removed on 3/4/2023 when the facility implemented a credible allegation of 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 ensure monitoring systems put in place are effective. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses to include acute on chronic respiratory failure, (an acute illness affecting a patient with chronic respiratory insufficiency), COVID-19 virus infection, anemia (requiring blood transfusions), kidney disease with acute kidney injury, pain in right knee, 2 Stage 2 pressure ulcers (ulcer extends into the deeper layers of the skin and can look like a shallow crater or blister) of the sacrum, deep tissue injuries (a pressure injury that begins in the muscle closest to the bone and appears as dark, non-blanchable skin) of the right and left heel, congestive heart failure and debility. A hospital admission note dated 1/14/2023 documented Resident #1 had an ejection fraction (measurement of the percentage of blood leaving the heart with each heartbeat) of 45% (normal 50-70%). A care plan dated 12/14/2022 addressed Resident #1's plan to discharge to the community after rehabilitation services. The goal for the care plan was to provide Resident #1 with a safe transition back to the community with interventions to involve home health agencies and appropriate community support services (none specified in the care plan). The admission Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #1 to be moderately cognitively impaired. The MDS documented Resident #1 required extensive assistance with bed mobility, dressing, hygiene, and bathing, and total assistance to transfer and to toilet. The MDS assessment indicated Resident #1 was to be discharged to the community after rehabilitation services. A physician order dated 12/15/2022 was reviewed. The order was to float heels (elevate off the bed). An order dated 12/27/2022 directed for both heels to have betadine (a topical antiseptic) applied daily. A wound assessment dated [DATE] documented an unstageable pressure wound on the left heel that measured 7 centimeters (cm) by 6.5 cm, and the depth of the wound was unable to be determined. The note documented that the wound had no drainage and no odor and was improving. A physician order dated 1/9/2023 directed for left lower leg wound care to be completed daily with normal saline to clean the wound, calcium alginate (an absorbent dressing that promotes wound healing) to the wound bed, cover with an absorbent pad and apply gauze to secure. A wound assessment dated [DATE] documented the skin tear to the left lower leg to measure 7.1 cm by 1.9 cm and 0.1 cm. the wound was described as a trauma that was acquired in-house with a scant (very small) amount of serosanguineous (pink) drainage, a red wound bed, and no odor to the drainage was noted. The wound care documented wound care including applying calcium alginate to the wound, covering the wound with an absorbent pad, and securing the dressing with gauze. A wound assessment dated [DATE] documented the skin tear on the lower right leg that measured 7.2 cm by 3.5 cm by 0.1 cm. The wound was documented to have a moderate amount of serosanguineous drainage with a pink wound bed. Wound care orders dated 1/12/2023 for the right lower leg read to clean with normal saline, apply collagen powder (used to promote wound healing), cover with absorbent dressing, and wrap with gauze to secure once daily. A wound assessment dated [DATE] documented Resident #1 had an unstageable pressure ulcer of the sacrum that measured 11.5 cm by 16 cm. The depth of the wound was unable to be determined due to the presence of slough (dead, moist, stringy tissue). The note documented a moderate amount of serosanguineous drainage with a faint odor and noted the wound was deteriorating. Wound care orders for the sacrum dated 1/12/2023 read to apply an antiseptic solution (sodium hypochlorite and boric acid diluted in water) to clean the wound, then apply an antiseptic soaked gauze to the wound bed, cover with calcium alginate, cover with absorbent dressing, and secure with tape. This dressing change was to be completed daily. An email dated 1/11/2023 from the Social Worker (SW) to a home health agency liaison read, in part: Attached is the face sheet for (Resident #1). She is scheduled to be discharged on Saturday, 1/14/2023. She will need home health for nursing (medication management) .as soon as I have the signed orders, I will send them to you. An interview was conducted with the SW on 2/28/2023 at 1:41 PM. The SW explained that Resident #1 and her family planned on her returning home after rehabilitation services and a home health agency had been chosen by the family members. The SW reported that she had reached out to home health on 1/11/2023 to alert them to the referral. The SW reported the family was concerned about the discharge home because of Resident #1's high care needs (including transfers, toileting, and bed mobility, as well as wound care) but was relieved to know that home health would be out to assist with Resident #1's care. The family told the SW they had a male family member who was able to lift Resident #1 for transfers. The Director of Nursing (DON) was interviewed on 3/1/2023 at 9:45 AM. The DON reported she was asked by the Wound Nurse to assess Resident #1's sacral wound on 1/13/2023 because the wound was deteriorating. The DON reported that she did not measure the sacral wound and did not remember the status of the wound bed. The DON explained that based on her experience with wounds and her judgement, she decided to change the wound care from medihoney to an antiseptic wound care because she noticed an odor. The DON spoke to the nurse practitioner, who did not observe Resident #1's sacral wound but wrote orders for the antiseptic solution to be used. The DON reported she was not certain if the Wound Nurse had notified the Wound Nurse Practitioner that the sacral wound had deteriorated. The DON reported the facility discharged residents with wounds that home health managed, she felt Resident #1's sacral and right lower leg wound could be managed at home. A physician discharge order dated 1/13/2023 was reviewed. The order documented Resident #1 was to be discharged on [DATE] and required a home health evaluation for nursing and therapy services. The facility discharge summary dated 1/13/2023 listed the equipment ordered for Resident #1, which included a wheelchair, walker, bedside commode, shower chair, and oxygen. A physician order dated 1/13/2023 ordered for Resident #1 to be discharged on [DATE] with home health to evaluate for nursing and therapy services. The follow-up appointment with Resident #1's primary physician was noted, as well as medical equipment for Resident #1's home. No wound care orders or mention of wounds were included in the physician order. A certified medication assistant (CMA) #1 was interviewed on 3/1/2023 at 11:12 AM. CMA #1 reported she had assisted Nurse #2 with Resident #1's discharge from the facility on 1/14/2023. The CMA reported the family members were present during wound care for Resident #1 and observed the pressure ulcer care and asked her for wound care supplies. CMA #1 listed the supplies she had given to Resident #1's family members: absorbent pads, wound cleanser, medihoney and gauze. CMA #1 reported Resident #1's pressure ulcer on the sacrum was large, foul-smelling, and had a pus-like, red-brown drainage. CMA #1 reported she had not sent the wound care supplies for the lower right leg wound care. Nurse #2 was interviewed on 3/1/2023 at 11:20 AM. Nurse #2 reported she was the weekend supervisor and had discharged Resident #1 from the facility on 1/14/2023. Nurse #2 explained she and CMA #1 performed wound care on Resident #1 before she was discharged , and she had explained wound care to the family members. Nurse #2 reported the family members did not indicate they were going to take Resident #1 to the hospital, nor did they seem to be concerned with the pressure ulcer on the sacrum. Nurse #2 reported she did not think the wound appeared to be infected. Nurse #2 concluded by reporting she had received a call later in her shift from the hospital requesting medication administration records for Resident #1. The discharge instructions signed by the family dated 1/14/2023 noted follow-up appointments with Resident #1's primary care physician on 1/20/2023, the name and phone number of the home health agency, scheduled infusion appointments (for treatment of anemia) on 1/17/2023, 1/24/2023, 1/31/2023, and 2/7/2023. The discharge instructions included a note that a list of medications had been provided to the family and written prescriptions were sent to the pharmacy. The discharge instructions did not include a list of wound care supplies or ordered wound care for the sacrum or right lower leg wound. Discharge instructions dated 1/14/2023 without a signature of the family member for Resident #1 were reviewed. These instructions included wound care to the sacrum (medihoney [an antibacterial wound treatment that removes dead tissue and keeps the wound moist], and dry dressing daily) as well as wound care for the wounds on her right calf (betadine, calcium alginate [anti-microbial absorbent dressing], absorbent pad, wrap with gauze). This summary was faxed to the home health agency on 1/17/2023. The family member of Resident #1 was interviewed on 3/12023 at 12:09 PM. The family member reported she was with Resident #1 during the discharge process on 1/14/2023. The family member reported Nurse #2 and the CMA performed wound care and gave them instructions before discharge on 1/14/2023. The family member reported she and her sister saw Resident #1's pressure ulcer on her bottom and decided they were going to take Resident #1 directly to the hospital for evaluation because the pressure ulcer was very deep, smelled bad, had a lot of drainage, and it needed to be evaluated by a physician. The family member described the wound on the right lower leg to be very deep, and she was able to see white meat that looked like a bone. The family member concluded by stating she and her sister did not take Resident #1 home but drove directly from the facility to the hospital emergency room . The emergency room (ER) notes dated 1/14/2023 documented Resident #1 had been brought to the ER for evaluation, after discharge from the facility. The notes documented the family reported they were concerned that Resident #1 had an infected pressure ulcer of her sacrum. The diagnoses for Resident #1 included infected decubitus (pressure) ulcer, unstageable (full thickness tissue loss but is covered by extensive necrotic (dead) tissue). The admission note documented 3 different antibiotics were started and surgical consult was needed for pressure ulcer debridement (surgical removal of dead tissue). The right lower leg wound was documented as a chronic wound without further description. Blood cultures completed at the hospital on 1/14/2023 tested positive for 3 different bacteria. A wound culture of the sacral wound was obtained on 1/14/2023 and showed positive growth of 2 different bacteria. An email dated 1/17/2023 at 3:24 PM from the home health liaison to the SW was reviewed. The email read, in part: Just checking on the orders for (Resident #1). A reply from the SW to the home health liaison dated 1/17/2023 at 3:30 PM read, in part, I just sent you the order for (Resident #1). The Home Health Administrator was interviewed by phone on 3/1/2023 at 10:23 AM. The Home Health Administrator reported that the home health agency had not received orders for Resident #1 until 1/17/2023 and home health services would not have been initiated until after the home health agency received those orders. A follow-up interview was conducted with the SW on 3/1/2023 at 1:42 PM. The SW was not certain why she had not sent the orders to the home health agency until 1/17/2023. The SW returned at 2:23 PM with a log of discharge residents for January 2023. The log indicated Resident #1's family had been contacted by phone call on 1/16/2023 by the SW. The SW explained the family told her that Resident #1 was hospitalized . The SW reported the orders were signed by the physician on 1/13/2023, but she had left for the day and did not get the signed orders sent to the home health agency. The SW reported she had not worked on 1/14/2023.The SW reported that because Resident #1 was in the hospital, the orders for home health slipped her mind and she did not send the orders until she received the email from the home health liaison on 1/17/2023. The SW reported this was not a safe discharge home for Resident #1 without the home health referral. The facility Administrator was notified of Immediate Jeopardy on 3/1/2023 at 5:51 PM. *Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a results of the noncompliance: The facility failed to prepare for a safe discharge as evidenced by the signed order for home care services was not submitted to the home care agency until 3 days after discharge from the facility. Resident #1 would have been at home without skilled home care nursing services for an unstageable pressure ulcer of the sacrum with purulent odorous drainage from 1/14/2023 until 1/17/2023 when the facility sent the signed physician order to the home care agency. The family member recognized this was a serious wound that needed medical treatment and could not be cared for at home. All residents discharging home have the potential to be affected. On 3/2/2023 the Social Services Director/Designee reviewed all residents that discharged home or to Assisted Living Facilities for the last 30 days to ensure the order for home care services were sent to the agency prior to discharge. Any issues were immediately corrected. *Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 3/2/2023 the [NAME] President of Social Services for [NAME] Healthcare Group provided education to the facility Social Service Director on Discharge Planning Policy to include timely notification to outside agencies. Social Services Director will confirm with outside agencies that discharge information has been received and confirm start date of services. Newly hired Social Service employees will receive education as part of the orientation process. An Ad Hoc QAPI was completed with the Interdisciplinary Team (IDT) which includes the Administrator, Director of Nursing (DON), Assistant Director of Nursing, Nurse Managers, Director of Rehab, Director of Life Enrichment, Director of Social Services, Environmental Services Director, Admissions Director, Business Office Manager, Minimum Data Set (MDS) Nurse, Wound Nurse, Clinical Coordinator, and the Medical Director on 3/2/2023. The IDT was updated regarding Immediate Jeopardy (IJ) citations the facility received on 3/1/2023 along with regulation, policy, and necessary education that is needed in order to be in compliance. Beginning on 3/3/2023 a review of all planned discharges will be reviewed during morning clinical meeting, which is attended by the Administrator, DON, ADON and all department heads, to ensure proper notification, communication, and documentation has been/will be made with any and all outside agencies as indicated to ensure a safe discharge. Notification of outside agencies will occur as soon as discharge date is determined. Alleged date of IJ removal 3/4/23. On 3/7/2023, the facility's credible allegation for immediate jeopardy removal was validated by the following: Review of the education provided to the SW related to timely notification of outside agencies, and confirmation of the information with the outside agency. Interview with SW and nursing staff to review education provided and procedure for discharging residents to home with outside agencies. Review of the discharges from 3/4/2023: 2 discharges noted with correct process in place. Review of audits completed by the facility. The facility's date of the immediate jeopardy removal plan of 3/4/2023 was validated on 3/7/2023.

Based on record review and interviews with staff, Wound Nurse Practitioner (NP) #1, Physician Assistant, Facility Nurse Practitioner, Physician, and Family Member, the facility failed to provide treatment and services, consistent with the facility's wound protocol, to promote healing and identify infection of the pressure areas Resident #1 had on admission. Resident #1's Stage 2 pressure ulcers deteriorated, increased in size and developed odor, drainage, and eschar (dead tissue) during her one month stay. Staff did not consult with medical staff when there was drainage and deterioration of the wound. On the day of discharge, the Family Member took Resident #1 directly to the hospital where she was diagnosed with a stage 4, open and infected decubitus ulcer of the sacrum. The infection was not identified at the facility. This deficient practice affected 1 of 2 residents reviewed for pressure sores (Resident #1). Immediate jeopardy began on 1/9/23 for Resident #1 when staff failed to address the resident's continued sacral pressure ulcer deterioration. Immediate jeopardy was removed on 3/4/23 when the facility implemented a credible allegation of 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 ensure monitoring systems put in place are effective. Findings included: The facility standing order revised 3/2021 documented Wound Care Protocol, 1. Document wound assessments to include measurements and description of the wound. 2. Only wound nurse to stage wounds. 3. Place in problem book for follow up with PEC (on-call physician). The unstageable pressure ulcer wounds that are completely covered with nonviable necrotic (dead) tissue cannot be staged. Ulcers should be carefully evaluated for the presence of undermining, sinus tracts or tunning. A physician or wound care specialist should evaluate wounds that show signs and symptoms of infection. Debridement of ulcers with unstable devitalized tissue is necessary. Notify the medical doctor or wound consultant for debridement options (i.e., enzymatics, referral for sharp debridement). Debridement is the removal of non-viable material, foreign bodies, and poorly healing tissue. Resident #1 was admitted from the hospital to the facility on [DATE] acute on chronic respiratory failure, (an acute illness affecting a patient with chronic respiratory insufficiency), COVID-19 virus infection, anemia (requiring blood transfusions), kidney disease with acute kidney injury, pain in right knee, 2 Stage 2 pressure ulcers (ulcer extends into the deeper layers of the skin and can look like a shallow crater or blister) of the sacrum, deep tissue injuries (a pressure injury that begins in the muscle closest to the bone and appears as dark, non-blanchable skin) of the right and left heel, congestive heart failure and debility. A hospital admission note dated 1/14/2023 documented Resident #1 had an ejection fraction (measurement of the percentage of blood leaving the heart with each heartbeat) of 45% recorded on 11/22 (normal 50-70%). An admission nurses' note dated 12/14/22 documented pressure ulcer assessment as follows: The right buttock had a stage two ulcer 3.0 centimeters (cm) x 3.9 cm x 0.1 cm. The wound bed was red. The left buttock had a stage two ulcer 4.9 cm x 3.5 cm x 0.1 cm. The wound bed was red. The right gluteal fold had a stage two ulcer 0.4 cm x 0.6 cm x 0.1 cm (newly identified on admission). Resident #1's physician order dated 12/14/22 was to cleanse the buttocks with normal saline and cover with foam dressing. Resident #1's admission Minimum Data Set, dated dated dated [DATE] documented a moderately impaired cognition. The resident was dependent with all activities of daily living. The resident had 4 stage 2 pressure ulcers. The resident was always incontinent of urine and stool. The resident required 1 staff member assistance for bed mobility. A pressure ulcer risk assessment scale completed on admission documented high risk for pressure ulcer development. Resident #1's admission care plan dated 12/20/22 had a focus for actual and potential skin breakdown. The interventions were to provide treatment as ordered, assess, and document the status, monitor, document and report changes to the physician, turn and reposition as indicated, and use pressure relieving devices. The Wound Nurse note dated 12/20/22 indicated the pressure ulcer assessment to the buttocks was as follows: The right buttock had a stage two ulcer 3.0 x 3.9 x 0.1 cm. The wound bed was red with no odor and drainage was a small amount of sanguineous (watery red). The wound was unchanged and pain level was none. The right inferior buttock had a stage two ulcer 1.0 x 0.8 x 0.1. The wound and dressing order were unchanged and there was no pain. The left buttock had a stage two ulcer 4.9 x 3.5 x 0.1. There was scant sanguineous drainage. Wound bed was pink with no odor. The right gluteal fold had a stage 2 ulcer 0.4 x 0.6 x 0.1. The wound was unchanged. A white blood cell count result was 6.6 on 12/21/23 (range 6 - 10). Resident #1 had a multidisciplinary note written by the Wound Nurse dated 12/22/22 documented the stage 2 pressure ulcers to the buttocks, a protein drink was added to promote healing, and staff were to turn and position. The Wound NP was supposed to follow up on 12/27/22. The Wound Nurse note dated 12/27/22 documented that all the buttock areas were measured together and described as a sacral pressure ulcer stage 2. The wound bed was pink and yellow with no odor. The wound was assessed by the Wound NP #1. The measurement was 4.8 x 5.6 x 0.3 with no drainage. The Wound NP #1 ordered honey-based wound gel and dry dressing daily. On 12/27/22 Wound NP #1 documented her initial assessment of Resident #1's sacral pressure ulcer wound. The chief complaint was necrotic tissue in the wound and services were requested. The wound was present on admission and unstageable. Tissue depth was subcutaneous with mild serous drainage. The measurement was 4.8 x 5.6 x 0.3. The wound was documented as unavoidable. On 2/28/23 at 2:00 pm an interview was conducted with Wound NP #1. She stated she saw Resident #1 for her first visit on 12/27/22 for sacral pressure ulcer. The ulcer was stable and the same size as when admitted . She stated she went on leave after the 12/27/22 visit and was not available for resident care until 1/17/23. Arrangements were made for telehealth wound care on 1/4/23. A multidisciplinary meeting on 12/29/22 documented by the Wound Nurse the resident had an air mattress in place. The Wound Nurse note dated 1/4/23 documented the Wound NP #2 telehealth visit evaluated the resident's sacral pressure ulcer wound. The Wound Nurse measured the sacral wound during the evaluation. Measurements were, 11.5 x 15 and depth was undetermined. It had a small amount of sanguineous drainage. The wound bed had pink and yellow tissue with a necrotic appearance and slough (dead skin tissue) with no odor. The wound had gotten significantly larger, deteriorated with necrotic tissue and was close to the sacral bone. New orders were received to apply hydrogel to the wound, imaging to assess the sacral bone for involvement, and labs. Autolytic debridement (medication added to stimulate the body to naturally eliminate dead tissue) was being utilized and Wound NP #1 will continue to follow. On 2/28/23 at 9:50 am an interview was conducted with the Wound Nurse. The Wound Nurse stated on 1/4/23 there was a noted change in Resident #1's sacral pressure ulcer wound. A wound NP telehealth visit was done with Wound NP #2 by video. The wound had new necrosis (dead tissue in the wound bed). The order was changed to use hydrogel with silver to the wound bed. Wound NP #2 ordered labs and a sacral x-ray. Wound NP #2's note dated 1/4/23 for documented the sacral wound length 11.5 cm by width 15 cm and depth was 0.5 cm down to the subcutaneous (tissue below the skin) layer. The wound bed had 80% yellow/black tissue with mild serous drainage. The wound was unstageable and deteriorating. The deterioration was significant with an increase in wound volume and percentage of necrotic tissue. Labs were ordered to rule out osteomyelitis. A new order to cleanse with normal saline, apply skin prep around the wound, place hydrogel with silver to the wound bed, and dry protective dressing each day was written. On 3/1/22 at 2:00 pm an attempt was made to interview Wound NP #2 and she was not available. A Physician Assistant (PA) note, dated 1/6/23, documented that Resident #1's sacral pressure ulcer wound was assessed and had small drainage with no odor and pink with yellow wound bed. The wound order was changed to honey-based wound gel with dressing each day. No measurement was documented. On 3/1/23 at 10:30 am an interview was conducted with the PA. The PA stated she saw Resident #1 on 1/6/23 and assessed the resident's sacral pressure ulcer. The PA stated the sacral wound had minimal drainage with no odor and the wound was unstageable with pink tissue and yellow slough. She stated the sacral wound order was changed to honey-based wound gel with calcium alginate instead of the hydrogel ordered two days earlier. She was not aware that Wound NP #2 documented the sacral wound was deteriorating and to the bone and had ordered an x-ray to assess for osteomyelitis and a complete blood count to assess for infection. The PA stated she had not read Wound NP #2's note prior to changing the dressing order. The PA stated 1/6/23 was her last day at the facility. On 2/28/23 at 2:45 pm an interview was conducted with Nurse #1. Nurse #1 stated she provided wound care to Resident #1 on the weekends. Nurse #1 stated on the weekend of 1/7/23 and 1/8/23 she noted the sacral wound had deteriorated from the prior weekend. There was black necrosis and red around the black part with drainage and odor. Nurse #1 stated she had to use a larger dressing to cover the wound that had gotten larger. Nurse #1 stated she was aware there was a telehealth visit by Wound NP #2 who was following the resident and thought the Wound NP #2 was following. Nurse #1 had not contacted medical staff about her concerns and had not documented her findings. The Wound Nurse note dated 1/9/23 documented the Wound Nurse assessed and measured Resident #1's sacral pressure ulcer wound as follows: the length 11.5 cm by width 16 cm and depth was 0.5 cm. There was a moderate amount of serosanguineous drainage, and the wound bed appeared yellow with slough and faint odor. The wound was deteriorating, and the resident had a pain level score of 3 (0 to 10 scale with 0 being no pain). The family was notified. No medical staff communication was documented. Lab results were collected on 1/9/23 for a complete blood count. The 1/9/23 result revealed an elevated white blood cell count of 13.2 (range 6 - 10). An elevated white blood cell count can be an indicator of infection. The radiograph taken on 1/6/23 of the sacrum showed a result dated 1/6/23 that reported no osteomyelitis (bone infection). On 2/28/23 at 11:25 am an interview was conducted with the Facility Nurse Practitioner. She stated she started her position on 1/6/23 and took the place of the Physician Assistant. She saw Resident #1 on 1/10/23 for a medical visit and had not evaluated the resident's wounds. She stated the Wound NPs were seeing the resident and she did not evaluate the wounds, unless there was a need. She stated there was a mildly elevated white blood cell count lab, but that there was no concern for wound infection and the x-ray did not show osteomyelitis of the sacrum. She stated staff had not informed her Wound NP #1 was not available to consult from 12/31/22 to 1/17/23. A review of the resident's record did not document a nursing assessment of the sacral pressure ulcer wound condition or measurements for 1/13/23. A new order for antiseptic solution cleanse and wet to dry dressing with the solution each day was written by the Director of Nursing and signed by the Physician without observation of the wound. On 2/28/23 at 9:50 am an interview was conducted with the Wound Nurse. The Wound Nurse stated she was not aware that the resident's white blood cell count was elevated. She said the physician was responsible for labs. She added the Nurse Supervisor would provide lab reports to whoever need the labs. She said if wounds changed and developed odor, then you would change the course of treatment. She stated she asked the DON to look at the sacral wound because the wound had deteriorated further. She stated, usually, an antiseptic solution was initiated when there was a concern for infection. The Director of Nursing (DON) and she decided on 1/13/23 there was an odor to the resident's sacral wound and started using antiseptic solution to clean and pack. There was no physician order. On 2/28/23 at 10:26 an interview was conducted with the Director of Nursing (DON). The DON stated she was asked by the Wound Nurse to look at Resident #1's sacral wound on 1/13/22 for a second opinion for treatment change. On 1/13/22 the Wound Nurse asked me to evaluate Resident #1's sacral wound and the DON said she was not familiar with the status of the wound. She stated that she could not recall if using an antiseptic for a deteriorating pressure ulcer was part of the standing order. The record had no further documentation of the sacral wound's status. On 2/28/23 at 11:25 am, the Facility Nurse Practitioner (NP) stated staff had not informed her that the resident's wound had deteriorated and had odor and increased drainage until 1/13/23. The DON informed her that the nurses changed the wound treatment to antiseptic cleanse and packed it with gauze wet to dry and she wanted to be informed of the wound deterioration. The Facility Nurse Practitioner evaluated the resident for discharge on 1/13/23 and had not evaluated her wounds. The DON gave report of the wounds' condition but not of the amount of deterioration. She observed a photo of the sacral wound taken on 1/14/23 from the resident's hospital record. She stated there was a breakdown in communication and missing documentation when Wound NP #1 was not available and wanted to be informed by the nurse of the changes to the resident's wound. On 2/28/23 at 12:20 pm an interview was conducted with the Discharge Nurse. She stated the Wound Nurse completed the dressing changes and she was informed that the sacral wound was getting worse. She stated there was an odor coming from the resident's wound during the 1/4/23 dressing change reported by the nurse assigned (was not reported to medical staff). She stated the odor and drainage was a concern by the nursing staff. The family would visit and complain that there was an odor and drainage coming from the sacral wound. She stated when she saw the sacral wound during the week of 1/9/23, it was pink, getting larger with yellow slough. The resident was noted to have declined the last week of her admission. On 3/1/23 at 9:45 am an interview was conducted with the DON. She stated that on 1/13/23 she accompanied the Wound Nurse as requested and observed Resident #1's sacral pressure ulcer wound because of wound changes. The DON stated the Wound Nurse was new to her role and the DON was asked to look at the wound. The DON stated she had not measured the wound or evaluated the depth nor remembered if the pressure ulcer had black eschar. The DON stated she made the decision to change the wound care order from honey-based gel treatment with calcium alginate to antiseptic solution cleanse and wet to dry with the solution. The DON stated she gave her assessment of what she saw to the Facility NP later. The Facility NP had not assessed the resident's wound. The DON stated she was not aware that Wound NP #1 instructed the Wound Nurse to contact the Wound NP consultant's office if there were changes to the wound so that an assessment could be done by telehealth. The DON stated she was not aware that the Wound Nurse had not contacted medical staff that the resident's sacral wound had continued to deteriorate, and the plan was to notify the Wound NP consultant's office if there were changes. The DON stated that the physician signed off on orders electronically from her computer and had not assessed the resident's sacral wound. The DON stated she had not documented her observation on 1/13/23 of the resident's sacral wound. On 3/1/23 at 11:12 am an interview was conducted with the Medication Aide (MA). The MA stated she was assigned to Resident #1 on the day of discharge 1/14/23. She changed the dressing to the resident's sacral pressure ulcer wound and found that it had a bad odor and was open. The wound had a reddish, brown purulent drainage. Nurse #2 was present for the wound care. She had not reported her findings to medical staff. On 3/1/23 at 11:20 am an interview was conducted with Nurse #2. Nurse #2 stated she was present when the MA changed Resident #1's sacral wound dressing and provided assistance. She was not concerned about the wound and provided the supplies for wound care to take home. Nurse #2 stated that the sacral wound had opened, had black tissue, and had white drainage. On 3/1/23 at 12:50 pm an interview was conducted with the Physician. The physician stated she was not aware of Resident #1's sacral pressure ulcer wound deterioration. The physician stated she would have wanted the nursing staff to report changes and continued deterioration of a wound to the medical staff. The medical staff was required to evaluate all wounds at least 5 days before discharge. The physician stated she was not aware Resident #1 had no medical staff assessment within this timeframe. The physician stated she was not sure the pressure ulcer was avoidable, but the lack of medical staff attention was avoidable. She further stated the resident outcome was hard to predict because of the many other diagnoses. On 2/27/23 at 1:40 pm an interview was conducted with Resident #1's family member. She stated the resident had a sacral wound that had a strong odor and pain. I reported my concerns to the nurse several times and the wound was not treated by a physician. On the day of discharge (1/14/23) the resident's smell and pain to the sacrum was so bad we went straight to the hospital. The family member commented that before hospitalization for COVID the resident had never had a pressure ulcer. Resident #1's hospital record documented the resident was brought to the hospital by the family on 1/14/23 instead of being taken home as discharge planned by the facility. The resident was seen for complaint about wound to the buttock. The family felt the wound was not addressed (at the facility). The family reported foul smell coming from the buttock wound. The hospital physician assessment documented the resident had two lower extremity wounds that were prior and a new wound from trauma in wheelchair. The buttock wound was a large, open stage 4 pressure ulcer that was malodorous, had a large amount of purulent (containing pus) drainage, and had pitting edema surrounding. The diagnosis was unstageable infected decubitus ulcer of the sacrum. The Administrator was notified of immediate jeopardy on 3/1/23 at 6:22 PM. 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 noncompliance The facility failed to seek medical attention for Resident #1's sacral pressure ulcer that had deteriorated and had become larger and developed sour odor, increased pain, increased drainage, black eschar tissue, and purulent drainage to determine the appropriate wound changes (1/9/2023, 1/13/2023 and 1/14/2023). Nursing had not followed their wound protocol and discontinued a physician order for sacral wound care and initiated antiseptic solution treatment without medical evaluation/observation (last completed 1/6/2023) of deteriorating wound on 1/13/2023. The resident was hospitalized with an infected sacral wound pressure ulcer stage 4 (as staged by the hospital) which resulted in sepsis. A review of the residents' hospital record admitted d 1/14/2023 documented blood cultures and wound culture to be positive of the same organism for infection and sepsis. All residents have the potential to be affected. On 3/2/2023 the facility completed a 100% skin sweep for all current residents. No issues were identified. On 3/2/2023 the Director of Nursing/Designee reviewed previously completed wound reports for the last 30 days for any wound declines or changes. No issues were identified. On 3/2/2023 all wound physician orders for the last 30 days were reviewed by Director of Nursing/Designee for appropriateness of treatment orders. No issues were identified. On 3/2/2023 Braden Scale Skin Risk assessment were reviewed by the Director of Nursing/Designee and updated if indicated. On 3/2/2023 Care Plans for identified skin risk were reviewed and updated as indicated by the Director of Nursing/Designee. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 3/2/2023 the Director of Nursing provided 1:1 education with the facility Designated Wound Nurse on notification to Medical Provider (Medical Director (MD)/Nurse Practitioner (NP)/Wound Nurse Practitioner (NP)) for changes in condition including wounds/skin tears/pressure injuries (PIs), obtaining orders timely, following facility wound protocol, ensuring the medical provider (MD/NP/Wound NP) is notified timely of new or deteriorating wounds, evaluates and that an appropriate treatment order is in place as indicated. The facility wound protocol includes a description along with a picture of different types of altered skin integrity and acceptable treatment options to implement for each. On 3/2/2023 all Licensed Nursing Staff, including Licensed Nursing agency staff were educated by the Nursing Administration Team on notification to Medical Provider (MD/NP/Wound NP) for changes in skin condition including deterioration of wounds regardless of day or time, wound protocol location (in binder on medication carts and at main nurses station) and entering orders into the electronic health record (EHR). All education completed on 3/3/2023. All Certified Nurse Aides (C.N.A.s) including agency C.N.A.s were educated to report any identified skin integrity concerns (redness, open areas, saturated dressings, odors from wounds) to Licensed Nursing Staff immediately. All education completed on 3/3/2023. All newly hired Licensed Nursing Staff and Certified Nurse Aides, including Licensed Nursing and Certified Nurse Aide agency staff will be educated by the Director of Nursing/Designee during the facility orientation process on Notification to Medical Provider (MD/NP/Wound NP) for changes in condition including deterioration of wounds and wound protocol. The Regional Director of Clinical Services notified the Director of Nursing on 3/2/2023 on the implementation for new hires. The Director of Nursing/Designee will audit Weekly Wound reports for deterioration beginning on 3/3/2023. The Director of Nursing/Designee will audit all new treatment orders to ensure wound protocol is followed and assessment by medical provider (MD/NP/Wound NP) beginning on 3/3/2023. Residents with current wounds including pressure injuries (PI) will continue to be reviewed by the Interdisciplinary Team during weekly Resident Review Meeting. An Ad Hoc QAPI was completed with the Interdisciplinary Team (IDT) which includes the Administrator, Director of Nursing, Assistant Director of Nursing, Nurse Managers, Director of Rehab, Director of Life Enrichment, Director of Social Services, Environmental Services Director, Admissions Director, Business Office Manager, Minimum Data Set (MDS) Nurse, Wound Nurse, Clinical Coordinator, and the Medical Director on 3/2/2023. The IDT was updated regarding Immediate Jeopardy (IJ) citations the facility received on 3/1/2023 along with regulation, policy, and necessary education that is needed in order to be in compliance. Alleged date of IJ removal 3/4/23. The credible allegation of immediate jeopardy was validated on 3/7/23. On 3/7/23 observation and nursing interviews of all shifts were done of nursing education and the in-service signed roster was reviewed regarding proper assessment/evaluation of wound care and changes, timely entering of orders, use of the wound care standing order, and medical staff involvement notification. New nursing hires and contract staff would receive the education before assignment. Current and ongoing wound care planned audits were reviewed. A Quality Assurance meeting was held by the Administrator and Corporate and plans for improvement were outlined. The facility's immediate jeopardy removal date of 03/04/23 was validated.

Based on record reviews, family member, physician, Nurse Practitioner, and staff interviews, the facility failed to ensure 1 of 3 residents were transferred safely (Resident #1). Resident #1 was transferred to the wheelchair by one NA without the use of a mechanical lift which resulted in a 7 centimeter (cm) long by 2 cm wide by 0.1 cm deep skin tear of her right lower leg that the family described as very deep, and the family member was able to see white meat that looked like a bone. This wound required pressure to control the bleeding and the edges of the wound were not able to be approximated (skin was unable to be pulled over the open wound to provide protection to the healing wound). Immediate Jeopardy began on 12/31/2022 when Resident #1 was transferred unsafely by one NA without the use of a mechanical lift, resulting in a 7 cm by 2 cm by 0.1 cm skin tear of the lower right leg that required pressure to stop the bleeding and could not be approximated. Immediate Jeopardy was removed on 3/4/2023 when the facility implemented a credible allegation of 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 ensure monitoring systems put in place are effective. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses to include acute on chronic respiratory failure, (an acute illness affecting a patient with chronic respiratory insufficiency), COVID-19 virus infection, anemia (requiring blood transfusions), kidney disease with acute kidney injury, pain in right knee, 2 Stage 2 pressure ulcers (ulcer extends into the deeper layers of the skin and can look like a shallow crater or blister) of the sacrum, deep tissue injuries (a pressure injury that begins in the muscle closest to the bone and appears as dark, non-blanchable skin) of the right and left heel, congestive heart failure and debility. A hospital admission note dated 1/14/2023 documented Resident #1 had an ejection fraction (measurement of the percentage of blood leaving the heart with each heartbeat) of 45% (normal 50-70%). The admission Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #1 to be moderately cognitively impaired. The MDS assessed Resident #1 to require total assistance of 2 people to transfer. The MDS documented Resident #1 had limited range of motion of both lower legs and she required a wheelchair for mobility. Resident #1 was unable to perform surface to surface transfers without staff assistance. A care plan dated 12/14/2022 identified Resident #1 was at risk of falling, with an intervention to transfer total lift with 2+ assistance. A review of the physician orders revealed Resident #1 was not prescribed blood thinners. The Kardex (a brief summary of resident care needs available for review within the electronic documentation system) for Resident #1 was reviewed, and it was noted that transfer instructions included the extensive assistance of 2 people with the use of a mechanical lift. A physical therapy evaluation note written by physical therapist (PT) #1 dated 12/14/2022 assessed Resident #1 to require maximum assistance of 2 people to transfer. The evaluation noted that Resident #1 was unable to assist with transfers. PT #1 was interviewed on 3/6/2023 at 2:21 PM. PT #1 reported she was the primary therapist for Resident #1 during her stay at the facility. PT #1 reported Resident #1 able to stand and bear weight for brief periods of time but required 2-person extensive assistance to transfer safely. PT #1 explained NA staff used the mechanical lift to transfer Resident #1. PT #1 clarified transferring a resident with 2-person extensive assistance without a mechanical lift involved one person standing behind the resident and using the gait belt to lift, with another person in front of the resident to stabilize them and guide the resident to the chair. PT #1 reported Resident #1 had limited range of motion of both of her knees and required one person to move her legs to transfer from the bed to the chair. PT #1 concluded that a transfer with one person would not be a safe transfer. The Director of Rehabilitation was interviewed on 3/6/2023 at 2:09 PM. The Director of Rehabilitation reported she had provided treatment to Resident #1 once prior to 12/31/2022. The Director of Rehabilitation reported Resident #1 was very weak and she declined getting out of bed for therapy treatment. An interview was conducted with the Certified Occupational Therapist Assistant (COTA) on 2/28/2023 at 12:54 PM The COTA reported that Resident #1 was very weak, and she required 2-person assistance to transfer with a mechanical lift. The COTA reported that Resident #1 was able to bear weight on her legs to stand, but she was unable to pivot to transfer from the bed to the wheelchair, and she was unable to lift her legs to take steps to transfer without extensive assistance of 2 people. The COTA reported that one person transferring Resident #1 by lifting her under her arms was very unsafe and could result in serious injury. An incident report dated written by Nurse #1 on 12/31/2022 documented Resident #1 sustained a skin tear to her lower right leg after transfer to the wheelchair. The note documented Resident #1's family members were at the facility and notified of the incident, and the on-call physician services were notified by a voice mail that Resident #1 had a skin tear. A nursing note written by Nurse #1 dated 12/31/2022 at 7:37 PM documented: This nurse across the hall in another room when the NA came to this nurse and stated resident got a skin tear when they (were) transferring resident into her wheelchair. This nurse into room and assess a large skin tear noted to the (right lower leg). Skin and subcutaneous tissue noted to be pushed to the right side of the wound and unable to be approximated. Area cleaned with wound cleanser, (non-stick, antibacterial dressing) applied to wound bed and (absorbent) pad placed on top and wrapped in (gauze). Resident states this area is sore. (Family member) in the facility at this time and was notified of skin tear by this nurse. (On-call physician) was notified via (voicemail) of skin tear. The nurse documented Resident #1 reported pain at a level 5 (1-10 scale, 10 being the most intense pain) of the lower right leg at the skin tear site. Nurse #1 was interviewed on 2/28/2023 at 2:37 PM. Nurse #1 reported she was assigned to Resident #1 on 12/31/2022 and was notified by the nursing assistant (NA) that Resident #1 had sustained a skin tear to her right lower leg during a transfer. Nurse #1 reported she arrived at Resident #1's room and found 3 NAs at the bedside, 2 fulltime employees and 1 orienting staff member. Nurse #1 reported NA #1 was holding a towel on Resident #1's leg to stop the bleeding from a heck of a large skin tear on her lower right leg. Nurse #1 reported she was told by NA #1 that Resident #1 hit her leg on the wheelchair when she was being transferred. Nurse #1 went on to explain that NA#1 and NA #4 were in the room, as well as NA #5 who was orienting. Nurse #1 reported Resident #1 was transferred to the wheelchair by the NA #5 and they had not used a mechanical lift. Nurse #1 reported she did not think the skin tear was serious and did not require evaluation at the hospital. A follow-up interview was conducted with Nurse #1 on 3/1/2023 at 3:02 PM. Nurse #1 reported she had called the Director of Nursing (DON) right after the incident to report it and had been instructed by the DON to talk to NA #1, NA #4, and NA #5 to instruct them on proper transfer techniques. Nurse #1 reported that when she arrived to assess the wound and apply a dressing, the skin that had been torn was dry and curled away from the wound. Nurse #1 reported she was unable to pull the skin back over the wound because it was so dry. Nurse #1 estimated that it took her about 1 minute to get to the resident's room after being notified of the injury. An interview was conducted on 2/28/2023 at 4:24 PM with NA #1, and she reported she had worked on 12/31/2022. NA #1 explained she was working on the 100 hall, and the 300 hall NA (NA #4) had asked her to come to Resident #1's room. NA #1 reported she was orienting NA #5 and the two of them went to Resident #1's room on the 300 hall. NA #1 described Resident #1 was in bed with her upper body supported on 3 pillows and NA #4 told her the bed control was not working to elevate the head and she wanted to move Resident #1 to a bed that worked. Resident #1's family member was at the bedside during this time. NA #1 left the room to get the lift to transfer Resident #1 to the other bed. NA #1 shared that when she returned to Resident #1's room, and Resident #1's family member had sat Resident #1 up on the side of the bed. According to NA #1's report, Resident #1 was unable to support herself sitting on the side of the bed and was crying out, I can't take it. NA#1 described how NA #5 said, I used to be an EMT (emergency medical technician), I know how to do this (transfer Resident #1), and proceeded to lift Resident #1 from the bed over to the wheelchair, bumping Resident #1's leg on the wheelchair footrest and causing a skin tear. NA #1 reported she got a towel to hold on the open area of the skin tear to top the bleeding and NA #4 went to get the nurse. NA #1 reported that Nurse #1 arrived in just a few seconds. NA #4 was interviewed on 3/1/2023 at 4:27 PM and she reported she was working 12/31/2022 and assigned to Resident #1 on that date. NA #4 explained NA #1 was training NA #5. NA #4 said that Resident #1's bed would not work to elevate the head of the bed, and they were planning to transfer her to another bed using the mechanical lift. NA #4 verbalized she was not in the room, when NA #5 transferred Resident #1 and she did not see Resident #1 moved from the bed to the wheelchair but remembered that Resident #1 had sustained a large skin tear on her lower right leg and NA #1 was holding a towel on the leg to stop the bleeding. NA #5 was interviewed on 3/7/2023 at 4:18 PM. NA #5 reported her first time working on the floor of the facility was 12/31/2022 and she was assigned to train with NA #1. NA #5 explained that they were called to Resident #1's room because the bed did not work, and they were going to transfer her to a new bed. NA #5 reported she was standing behind the wheelchair and NA #1 and NA #4 lifted Resident #1 from the side of the bed to the wheelchair, and during the transfer, Resident #1's leg scraped against the footrest of the wheelchair. NA #5 reported she had alerted NA #1 and NA #4 that the footrest was [NAME] out and to push it back, but the other NAs did not correct the position of the footrest. NA #5 reported the wound was bleeding and she took a bedsheet and held pressure on the wound until the nurse arrived almost 20 minutes later. NA #5 reported that after the incident, they were instructed to correctly transfer residents by Nurse #1. NA #5 concluded by stating she didn't return to work at the facility after that night. The family member was interviewed on 3/1/2023 at 12:09 PM. The family member recalled she and other family members were in the facility on 12/31/2023 and the nursing staff had asked the family to step out of the room so they could transfer Resident #1 to a different bed and apply the air mattress to the bed. The family member reported that when she and the other family members returned to the room, they were told that Resident #1 had sustained a skin tear from the wheelchair. The family member explained that they asked for the wound dressing on the right lower leg to be removed and when they saw the skin tear, they told the nurse that the wound needed to be evaluated at the hospital. The family member described the wound on the right lower leg to be very deep, and she was able to see white meat that looked like a bone. The family member reported the skin was pushed back away from the wound and the nurse said she had not been unable to pull it back over the open wound and Resident #1 reported pain at the wound site. The family member said that Nurse #1 told them the physician had been notified of the skin tear and didn't feel that the wound needed to be assessed at the hospital. A wound assessment dated [DATE] documented a skin tear of the right lower leg that measured 7.6 centimeters (cm) by 3.5 cm by 0.1 cm and had a pink wound bed and a moderate amount of serosanguinous (pink) drainage. The note documented the wound was cleaned with normal saline, and an antimicrobial non-stick dressing was applied to the open wound, it was covered with an absorbent pad, and wrapped with gauze. The nursing note that correlated with wound assessment dated [DATE] documented Resident #1 was reporting 3 pain to her right lower leg. Wound care orders dated 1/4/2023 for the right lower leg read to clean with normal saline, apply antimicrobial non-stick dressing, cover with absorbent dressing, and wrap with gauze to secure once daily. The Wound Nurse was interviewed on 3/1/2023 at 11:48 AM. The Wound Nurse reported she was also the staff development coordinator and she had provided orientation to the NA #5 before the NA went out onto the floor for hands-on training. The Wound Nurse reported that during orientation, new staff are shown videos with proper transfer techniques, and they are shown where to find the information related resident care for each resident in the kardex. The Wound Nurse explained she was unable to do further training with the NA #5 because she had quit without notice the next day and did not return to the facility. The Wound Nurse reported she had assessed the right lower leg wound on 1/2/2023. The Wound Nurse reported that she had not considered sending Resident #1 out for further treatment of the wound to the right lower leg. The facility nurse practitioner (NP) was interviewed on 2/28/23 at 11:03 AM. The NP stated that the skin tear to the lower right leg should have been followed by medical staff. She stated that the trauma wound was a full-thickness skin tear to the right lower leg. The Physician (MD) was interviewed on 3/1/23 at 12:40 pm. The MD reported she was not informed of Resident #1's right lower leg skin tear with its severity. The MD reported the resident should have been sent to the Emergency Department on 12/31/22 or at least followed by the medical staff in the facility due to the size of the skin tear. The Administrator was notified of Immediate Jeopardy on 3/1/2023 at 5:51 PM. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of noncompliance. The facility failed to ensure Resident #1 was transferred safely from her bed to the wheelchair by the use of the total lift. Resident #1 was transferred to the wheelchair by one NA which resulted in a 7 centimeter (cm) long by 2 cm wide by 0.1 cm deep skin tear of her right lower leg. This wound deteriorated to expose bone and subcutaneous tissue and had the high likelihood to become infected. In addition, there was the high likelihood of a serious adverse outcome when the resident was not transferred using the total lift. All residents not transferred as determined by their assessment or plan of care could be affected. On 3/2/2023 each Electronic Health Record (EHR) was reviewed by the Director of Nursing/Designee to ensure the Kardex and Care plans reflected the correct transfer status. On 3/2/2023 the Director of Nursing reviewed all incident reports for the last 30 days to ensure resident were transferred as specified in their plan of care. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 3/2/2023 all Licensed Nursing Staff and Certified Nurse Aides, to include agency Licensed Nursing staff and Certified Nurse Aides were educated with return demonstration by the Nursing Administration Team and/or Rehab staff on transferring according to the resident's individualized plan of care according to the facility Mechanical Lift Policy and accessing transfer status from the Kardex or Care Plan. The Director of Nursing/Designee will supply a list of all nursing department individuals that have not completed return demonstration of transfers on 3/3/2023 to the Nursing Administration Team (RN Weekend Supervisor notified of this responsibility on 3/3/2023) to ensure no Nursing Staff work before the return demonstration has been validated. All verbal education was completed on 3/3/2023. All newly hired Licensed Nursing Staff and Certified Nurse Aides, including agency nursing staff will be educated with return demonstration during the facility orientation process on total lift transfers according to the facility Mechanical Lift Policy and accessing transfer status from Kardex or Care Plan. The Regional Director of Clinical Services notified the Director of Nursing on 3/2/2023 on the implementation for new hires. An Ad Hoc QAPI was completed with the Interdisciplinary Team (IDT) which includes the Administrator, Director of Nursing, Assistant Director of Nursing, Nurse Managers, Director of Rehab, Director of Life Enrichment, Director of Social Services, Environmental Services Director, Admissions Director, Business Office Manager, Minimum Data Set (MDS) Nurse, Wound Nurse, Clinical Coordinator, and the Medical Director on 3/2/2023. The IDT was updated regarding Immediate Jeopardy (IJ) citations the facility received on 3/1/2023 along with regulation, policy, and necessary education that is needed in order to be in compliance. Alleged IJ removal date 3/4/23. On 3/7/2023, the facility's credible allegation for immediate jeopardy removal was validated by the following: Review of the education provided to the nursing staff and NA staff related to safe transfer techniques. Interview with nursing staff to review education provided and procedure for transfers, with transfer competencies for each staff member included. Observation of transfer of a resident with mechanical lift. Review of audits completed by the facility. The facility's date of the immediate jeopardy removal plan of 3/4/2023 was validated on 3/7/2023.

Based on record review and staff, family member, Physician Assistant (PA), Nurse Practitioner (NP), and Physician interviews, the facility failed to identify the seriousness and complete and document a thorough assessment of an injury to Resident #1's right lower leg sustained during a transfer on 12/31/22. The injury was described as a deep skin tear which measured 7 centimeters (cm) in length, width of 2.5 cm and approximately 0.5 cm deep and required direct pressure with a towel for several minutes to stop the bleeding. The edges of the wound were not able to be approximated (skin was unable to be pulled over the open wound to provide protection to the healing wound). This was reported to the on-call physician via voicemail as a skin tear with no other details provided. There was no treatment order until 1/4/23. The family member described the injury as very deep and was able to see white meat that looked like a bone. This deficient practice occurred for 1 of 2 residents reviewed for quality of care (Resident #1). Immediate jeopardy began on 12/31/22 when the facility failed to identify the seriousness of an injury to Resident #1's right lower leg and the need for medical attention. Immediate jeopardy was removed on 3/4/23 when the facility implemented a credible allegation of 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 ensure monitoring systems put in place are effective. Findings included: Resident #1 was admitted from the hospital to the facility on [DATE] acute on chronic respiratory failure, (an acute illness affecting a patient with chronic respiratory insufficiency), COVID-19 virus infection, anemia (requiring blood transfusions), kidney disease with acute kidney injury, pain in right knee, 2 Stage 2 pressure ulcers (ulcer extends into the deeper layers of the skin and can look like a shallow crater or blister) of the sacrum, deep tissue injuries (a pressure injury that begins in the muscle closest to the bone and appears as dark, non-blanchable skin) of the right and left heel, congestive heart failure and debility. A hospital admission note dated 1/14/2023 documented Resident #1 had an ejection fraction (measurement of the percentage of blood leaving the heart with each heartbeat) of 45% recorded on 11/22 (normal 50-70%). Resident #1's admission Minimum Data Set, dated dated dated [DATE] documented moderately impaired cognition. The resident was dependent with all activities of daily living. The resident required two-person assist for transfer. Resident #1's admission care plan had a focus for actual and potential skin breakdown and assistance with activities of daily living. The transfer intervention was for mechanical lift. An interview was conducted on 2/28/2023 at 4:24 PM with NA #1, and she reported she had worked on 12/31/2022. NA #1 explained she was working on the 100 hall, and the 300 hall NA (NA #4) had asked her to come to Resident #1's room. NA #1 reported she was orienting NA #5 and the two of them went to Resident #1's room on the 300 hall. NA #1 described Resident #1 was in bed with her upper body supported on 3 pillows and NA #4 told her the bed control was not working to elevate the head and she wanted to move Resident #1 to a bed that worked. Resident #1's family member was at the bedside during this time. NA #1 left the room to get the lift to transfer Resident #1 to the other bed. NA #1 shared that when she returned to Resident #1's room, and Resident #1's family member had sat Resident #1 up on the side of the bed. According to NA #1's report, Resident #1 was unable to support herself sitting on the side of the bed and was crying out, I can't take it. NA#1 described how NA #5 said, I used to be an EMT (emergency medical technician), I know how to do this (transfer Resident #1), and proceeded to lift Resident #1 from the bed over to the wheelchair, bumping Resident #1's leg on the wheelchair footrest and causing a skin tear. NA #1 reported she got a towel to hold on the open area of the skin tear to top the bleeding and NA #4 went to get the nurse. NA #1 reported that Nurse #1 arrived in just a few seconds. NA #5 was interviewed on 3/7/2023 at 4:18 PM. NA #5 reported her first time working on the floor of the facility was 12/31/2022 and she was assigned to train with NA #1. NA #5 reported she was standing behind the wheelchair and NA #1 and NA #4 lifted Resident #1 from the side of the bed to the wheelchair, and during the transfer, Resident #1's leg scraped against the footrest of the wheelchair. NA #5 reported she had alerted NA #1 and NA #4 that the footrest was [NAME] out and to push it back, but the other NAs did not correct the position of the footrest. NA #5 reported the wound was bleeding and she took a bedsheet and held pressure on the wound until the nurse arrived almost 20 minutes later. NA #4 was interviewed on 3/1/2023 at 4:27 PM and she reported she was working 12/31/2022 and assigned to Resident #1 on that date. NA #4 verbalized she was not in the room, when NA #5 transferred Resident #1 and she did not see Resident #1 moved from the bed to the wheelchair but remembered that Resident #1 had sustained a large skin tear on her lower right leg and NA #1 was holding a towel on the leg to stop the bleeding. A nursing note written by Nurse #1 dated 12/31/2022 at 7:37 PM documented: This nurse across the hall in another room when the NA came to this nurse and stated resident got a skin tear when they (were) transferring resident into her wheelchair. This nurse into room and assess a large skin tear noted to the (right lower leg). Skin and subcutaneous tissue noted to be pushed to the right side of the wound and unable to be approximated. Area cleaned with wound cleanser, (non-stick, antibacterial dressing) applied to wound bed and (absorbent) pad placed on top and wrapped in (gauze). Resident states this area is sore. (Family member) in the facility at this time and was notified of skin tear by this nurse. (On-call physician) was notified via (voicemail) of skin tear. The nurse documented Resident #1 reported pain at a level 5 (1-10 scale, 10 being the most intense pain) of the lower right leg at the skin tear site. Nurse #1 was interviewed on 2/28/2023 at 2:37 PM. Nurse #1 reported she was assigned to Resident #1 on 12/31/2022 and was notified by the nursing assistant (NA) that Resident #1 had sustained a skin tear to her right lower leg during a transfer. Nurse #1 reported she arrived at Resident #1's room and found 3 NAs at the bedside, 2 fulltime employees and 1 orienting staff member. Nurse #1 reported NA #1 was holding a towel on Resident #1's leg to stop the bleeding from a heck of a large skin tear on her lower right leg. Nurse #1 reported she was told by NA #1 that Resident #1 hit her leg on the wheelchair when she was being transferred. Nurse #1 reported she did not think the skin tear was serious and did not require evaluation at the hospital. On 3/1/23 at 3:02 pm an interview was conducted with Nurse #1. Nurse #1 stated she was assigned to Resident #1 on 12/31/22 when staff transferred her without the mechanical lift and the resident hit her right lower leg on the wheelchair footrest. NA #1 informed her the resident had cut her leg. When she arrived NA #1 was holding a towel and providing pressure on the resident's right lower leg injury due to the bleeding. There was blood on the floor and the resident's leg, and it took a couple of minutes of pressure to stop the bleeding. Nurse #1 stated she completed an incident report and documented that subcutaneous tissue could be observed. Nurse #1 indicated the injury was 7 centimeters (cm) long by 2.5 cm wide and depth approximately 0.5 cm. Nurse #1 further stated, I placed a non-stick dressing into the wound and covered with a large, absorbent cotton pad dry dressing and wrapped as nursing judgement. Nurse #1 stated there was not a wound protocol for placement of the dressing and I made the decision to place a non-stick dressing to prevent adherence to the wound. The leg wound was approximately 2.5 centimeters open (wide), and I was unable to approximate the edges (place them together), and I had not considered sending the resident to the Emergency Department because the bleeding had stopped. I called the physician on-call and left a message on the skin tear notification voicemail line (on-call physician phone line). Nurse #1 stated she had not initiated an order for the wound care to the resident's leg and she had not placed the injury in the physician notification book. Nurse #1 stated she completed the resident's right lower leg wound care on 1/1/23 and the following weekend 1/7/23 and 1/8/23. The wound looked the same size (had not measured), was without signs and symptoms of infection, and the drainage was a small amount of serosanguineous. Nurse #1 stated she had not documented the resident's wound observation; she initialed the treatment administration record on 1/7/23 and 1/8/23. On 1/2/23 there was a multi-disciplinary team meeting documented by the Wound Nurse. It was documented Resident #1 was noted with a skin tear to her right lower leg after being transferred from bed to the wheelchair. The area was noted to be treated per standing orders (there was no standing order for use of non-adherent dressing to an injury). Resident #1's Treatment Administration Record (TAR) revealed no orders for wound care to the residents right lower leg until 1/4/23 when an order was entered to cleanse with normal saline, place a non-stick dressing to the wound bed, and cover with dry dressing each day initiated by the Wound Nurse and signed by the Physician electronically (documented in the order). Documentation of a telehealth visit by Wound Nurse Practitioner (NP) #2 completed on 1/4/23 did not include an assessment of Resident #1's right lower leg skin tear. The Wound Nurse note dated 1/4/23 documented Wound NP #2's telehealth visit to evaluate Resident #1's sacral pressure ulcer wound and both heels. There was no evaluation of the resident's skin tear of the right lower leg documented. On 3/1/23 at 2:00 pm an interview was attempted with Wound NP #2, and she was unavailable. On 2/28/23 at 9:30 am an interview was conducted with the Wound Nurse. The Wound Nurse stated she assessed Resident #1's right lower leg skin tear on 1/4/23 and informed the physician the resident had a skin tear injury to her right lower leg but had not documented a measurement or condition. A new order was received from the physician to place hydrogel (wound healing ointment) to the wound bed and cover with a large dry dressing (change from the non-stick dressing initiated by Nurse #1). The Wound Nurse stated she had not informed nor asked Wound NP #2 to evaluate the resident's right lower leg skin tear during the 1/4/23 telehealth visit. The Wound Nurse dressed the resident's right lower leg injury each day and measured and documented the condition of the injury on 1/9/23 and reported findings to the physician. An order dated 1/4/23 was initiated by the Wound Nurse to apply hydrogel in the wound bed on the right lower leg and cover with dry dressing every day as prescribed by the Physician and was signed electronically by the Physician (after the telehealth visit). A review of Resident #1's record revealed the PA saw Resident #1 on 1/6/23 and assessed her sacral wound, both heels, and left leg. The right lower leg was not assessed. On 3/1/23 at 10:30 am an interview was conducted with the PA. The PA stated she saw Resident #1 on 1/6/23 and assessed the resident sacral pressure ulcer, both heels, and left leg skin tear. The PA stated she was not informed by nursing nor aware that there was a second skin tear to the right leg and the right leg was not evaluated. The PA stated 1/6/23 was her last day at the facility. A wound assessment dated [DATE] documented a skin tear of the right lower leg that measured 7.6 centimeters (cm) by 3.5 cm by 0.1 cm and had a pink wound bed and a moderate amount of serosanguinous (pink) drainage. The note documented the wound was cleaned with normal saline, and an antimicrobial non-stick dressing was applied to the open wound, it was covered with an absorbent pad, and wrapped with gauze. The nursing note that correlated with wound assessment dated [DATE] documented Resident #1 was reporting 3 pain to her right lower leg. The Wound Nurse's note dated 1/9/23 documentated the resident's right lower leg skin tear by the Wound Nurse. The entry documented Resident #1's skin tear to the right lower leg measured 7 cm length by 3.5 cm wide by 0.1 cm deep. There was moderate serosanguineous drainage, wound bed was pink, there was pain level 3, and the wound was improving. The physician was notified of the wound status and a new order was obtained electronically. The Wound Nurse was interviewed on 3/1/23 at 9:20 am. The Wound Nurse stated she informed the physician by phone of the resident's right leg skin tear status on 1/9/23 and was provided a new treatment order but did not remember why. She had not asked the physician or any other medical staff member to assess the resident's skin tear. Nursing assessed the wounds during daily dressing changes on the weekends and the Wound Nurse assessed the wound during daily dressing changes Monday through Friday and measured and documented the wound status once a week. Resident #1's new order documented by the Wound Nurse for the right lower leg skin tear dated 1/9/23 was to place calcium alginate in the wound and cover with a dry dressing and wrap with rolled gauze. The order was initiated by the Wound Nurse as prescribed by the Physician and signed electronically. Wound care orders dated 1/12/2023 for the right lower leg read to clean with normal saline, apply collagen powder (used to promote wound healing), cover with absorbent dressing, and wrap with gauze to secure once daily was initiated by the Wound Nurse and signed by the physician. There was no further documentation about Resident #1's right lower leg wound after 1/9/23. On 2/27/23 at 1:40 pm an interview was conducted with the family member. She stated the family visited on Monday (1/2/23) and that the resident had a large wound to the right lower leg. The dressing was soiled and falling off. The nurse was informed, and the Wound Nurse changed the dressing. The family member stated they asked nursing about the dressing to the right leg, and it was changed. The resident complained of pain in the right leg wound. The family member was interviewed on 3/1/2023 at 12:09 PM. The family member recalled she and other family members were in the facility on 12/31/2023 and the nursing staff had asked the family to step out of the room so they could transfer Resident #1 to a different bed and apply the air mattress to the bed. The family member reported that when she and the other family members returned to the room, they were told that Resident #1 had sustained a skin tear from the wheelchair. The family member explained that they asked for the wound dressing on the right lower leg to be removed and when they saw the skin tear, they told the nurse that the wound needed to be evaluated at the hospital. The family member described the wound on the right lower leg to be very deep, and she was able to see white meat that looked like a bone. The family member reported the skin was pushed back away from the wound and the nurse said she had not been unable to pull it back over the open wound and Resident #1 reported pain at the wound site. The family member said that Nurse #1 told them the physician had been notified of the skin tear and didn't feel that the wound needed to be assessed at the hospital. On 2/28/23 at 10:26 an interview was conducted with the Director of Nursing (DON). The DON stated, if there was a concern with a wound you would ask the staff to reach out to the medical staff. I would use nursing judgement for standing orders only. Resident #1's skin tear to the right lower leg was not assigned to Wound NP #1 to follow, nursing was taking care of the skin tear by initiating the wound treatment and obtained an order from the Physician. The DON stated she was not sure if the wound treatment initiated by Nurse #1 for Resident #1's skin tear was part of the standing orders. The DON had no comment about the lack of the Wound Nurses' documentation of the right lower leg skin tear. She stated that all wounds were to be assessed and measured each week by the Wound Nurse and the Wound NP if following. The Wound Nurse completed all resident wound care Monday through Friday and assigned nursing staff were to complete wound care on the weekends. The DON stated that the resident's skin tear was treated each day and the physician provided an order and the Wound Nurse was responsible to report any decline in the wound. The DON stated she had not assessed the resident's right lower leg injury herself and was aware that the Wound Nurse was following and had provided updates to the Physician. On 2/28/23 at 11:03 am an interview was conducted with the NP for the facility. The NP stated she started her position here on 1/6/23 and took the place of the PA. She stated she first saw Resident #1 on 1/10/23 for a medical visit and had not evaluated the resident's wounds on 1/10/23. She was of the understanding the Wound NP was following all the residents' wounds and was to be notified of concerns and changes. She stated that the skin tear to the lower right leg should have been followed by medical staff and wanted to be informed by the Wound Nurse or Wound NP of the changes to the resident's wound. All the resident's wounds should have been evaluated by medicine before discharge on 1/14/23 since it was significant and there was a change. On 3/1/23 at 12:40 pm an interview was conducted with the Physician. The Physician stated she was not informed of the severity of Resident #1's right lower leg skin tear. The Wound Nurse communicated her assessments she provided the wound care order. The physician stated the resident should have been sent to the Emergency Department on 12/31/22 or at least followed by the medical staff in the facility from when the injury occurred on 12/31/22. The Physician was not aware that the NP or PA had not assessed/observed the right lower leg wound. Resident #1's hospital record dated 1/14/23 documented the right lower leg wound was a chronic wound without further description. The Administrator was notified of IJ on 3/1/23 at 6:21 pm. 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 noncompliance. The facility failed to ensure that Resident #1 accidental injury on 12/31/22 to her right calf which resulted in a 7 cm by 2cm by 0.1 cm skin tear to the lower right leg was evaluated by a medical provider (MD/NP/Wound NP). There was no physician order for treatment for 4 days. Notification of the accidental injury to Resident #1 lower right leg was reported on the physician triage line voicemail per protocol as a skin tear. The resident's hospital record dated 1/14/2023 documented that the resident's injury to her right lower leg was trauma with tissue injury depth to the bone. All residents have the potential to be affected. On 3/2/2023 the Wound Nurse, Assistant Director of Nursing, and Clinical Coordinator completed head to toe skin assessments on all residents in the facility to include assessment of current wounds. Appropriate treatment orders are in place. No issues were identified. On 3/2/2023 the Director of Nursing/Designee reviewed all incident reports for the last 30 days to ensure thorough assessment of injury, Medical Provider (MD/NP/Wound NP) notification, treatment orders were obtained timely as indicated, and care plans were up to date. No issues were identified. On 3/2/2023 eInteract (electronic assessment tool in the Electronic Health Record) Change in Condition assessment for the last 30 days were reviewed by the Director of Nursing to ensure MD/NP notification and orders were obtained timely as indicated. No issues were noted. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 3/2/2023 the Director of Nursing provided 1:1 education with the facility Designated Wound Nurse on notification to Medical Provider (Medical Director (MD)/Nurse Practitioner (NP)/Wound Nurse Practitioner (NP)) for changes in condition including notification of injuries, obtaining orders timely, wound protocol, ensuring the medical provider (MD/NP/Wound NP) evaluates and an appropriate treatment order is in place as indicated. The Wound Nurse was educated to follow up with Medical Providers to ensure evaluation of wounds has been completed when they are in the facility. The Wound Nurse will continue to complete weekly wound assessments and assigned Licensed Nurses complete treatments and dressing changes per physician orders. The facility wound protocol includes a description along with a picture of different types of altered skin integrity and acceptable treatment options to implement for each. The NP will be educated by the respective physician group manager regarding proper assessment and evaluation of all residents to include assessment of wounds/skin integrity concerns by 3/3/2023 in order to prevent deterioration of wounds and to ensure appropriate orders are in place to prevent worsening of wounds/skin conditions and follow up with facility Wound Nurse/Designee to ensure no evaluation needs have been missed. Education for all Licensed Nurses and agency Licensed Nurses was completed on 3/3/2023 regarding following facility wound protocol, notifying Medical Providers of any abnormal assessment findings during routine dressing changes immediately to ensure timely evaluation is completed and any changes to treatments be implemented immediately as indicated, and notification of Medical Providers if a new skin condition cannot be treated with facility wound protocol. Education will be provided to any newly hired Licensed Nurses and agency Licensed Nurses prior to providing direct care. Education was completed on 3/3/2023 with all Licensed Nursing Staff, including Licensed agency nursing staff of wound protocol and location of wound protocol (in binder on medication carts and at main nurses station), documentation of any skin integrity concerns, notification of medical provider (MD/NP/Wound NP) regardless of day or time, notification of new skin concerns for the Wound Nurse to ensure proper follow up and assessment is completed. An Ad Hoc QAPI was completed with the Interdisciplinary Team (IDT) which includes the Administrator, Director of Nursing, Assistant Director of Nursing, Nurse Managers, Director of Rehab, Director of Life Enrichment, Director of Social Services, Environmental Services Director, Admissions Director, Business Office Manager, Minimum Data Set (MDS) Nurse, Wound Nurse, Clinical Coordinator, and the Medical Director on 3/2/2023. The IDT was updated regarding Immediate Jeopardy (IJ) citations the facility received on 3/1/2023 along with regulation, policy, and necessary education that is needed in order to be in compliance. Alleged date of IJ removal 3/4/23. The credible allegation of immediate jeopardy removal was validated on 3/7/23. On 3/7/23 observation and nursing interviews of all shifts were done of nursing education and the in-service signed roster was reviewed regarding proper assessment/evaluation of wound care, notification of changes, use of the wound care protocol, and medical staff involvement. A documented resident audit was completed of all residents for injuries. New nursing hires and contract staff would receive the education before assignment. A Quality Assurance meeting was held by the Administrator and Corporate and plans for improvement were outlined. The facility's immediate jeopardy removal date of 03/04/23 was validated.

Based on record review, staff interviews, and observation, the facility failed to prevent the elopement of 1 (Resident #1) of 3 cognitively impaired sampled residents assessed to have exit seeking behavior. Findings included: A review of the 14 day Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was severely cognitively impaired. Behaviors exhibited included verbal abuse towards others, rejection of care, wandering, hallucinations, and delusions. Resident #1 required limited assistance with activities of daily living (ADLs), had no limb impairment, and was able to ambulate without assistance. Active [DIAGNOSES REDACTED]. A review of the care plans for Resident #1 dated 12/22/15 revealed care planning in place for a focus titled Elopement Risk Needs-needs re-directing/distracting. Needs (brand name) bracelet related to (r/t) wandering. The goals listed included Resident will have no elopements through next review. Interventions listed included (brand name) bracelet placement and functioning every (Q) shift to left ankle Q shift. Start 12/25/15. A review of a nursing note dated 12/25/15 and timed 5:45 AM revealed, Nurse stated she observed resident (Resident #1) at back door to therapy room. Seems as if resident was coming in, not sure. Resident was just standing at door. Unknown if she was coming in or just standing. Resident brought back to room. Resident due to wandering an ankle alarm applied to her right ankle and checked for working. NA assisted resident near door. Did not lock. A review of a nursing note dated 12/25/15 and timed 8:39 AM revealed, Resident (Resident #1) noted with increased anxiety and keeps wandering around facility at this time. Resident states ' It just hurts my feelings. I ' m a doctor and nobody will believe me. I ' m just going to go. ' Resident keeps wandering down hallways toward exit doors and attempts to leave facility. Resident currently has (brand name) bracelet in place. A review of a nursing note dated 12/25/15 and timed 1:16 PM revealed Resident #1 attempted to leave the facility. A review of a nursing note dated 12/25/15 and timed 10:17 PM revealed Resident #1 opened 400 hall exit door and was shaking front lobby doors and punching in various numbers attempting to unlock the door. A review of a nursing note dated 12/26/15 and timed 7:52 AM revealed Resident #1 states she is going home, pulls the fire alarm and alarms sounding. Resident (Resident #1) succeeded in getting directly outside of doors. A review of a nursing note dated 12/27/15 and timed 3:06 AM revealed the resident (Resident #1) was heading to front lobby to go out. Stated she has to go home to her husband. A review of a nursing note dated 1/4/16 and timed 2:06 AM revealed Resident #1 attempted several times in leaving the facility. The note also revealed the (name brand) bracelet was in place on her left leg and worked properly. A review of a nursing note dated 1/4/16 and timed 11:47 AM revealed Resident #1 was transported to the emergency department by emergency medical services (EMS). A review of a nursing note dated1/5/16 and timed 12:40 AM revealed Resident #1 was returned to the facility and sent to the emergency department for further evaluation. A review of a nursing note dated 1/5/16 and timed 2:16 PM revealed, Clarification 1/5/16 at 12:40 AM- Resident (Resident #1) returned to facility accompanied by police. Patient out of facility approximately 15 minutes. The (name brand) bracelet was not present when resident returned. A review of the investigation report by the local police department revealed a police officer was dispatched to a private residence at 12:08 AM on the morning of 1/5/16. The report read, in part, On January 5, 2016 at approximately 0008hrs (12:08 AM) I was dispatched to (home address) in reference to someone knocking on the callers door and yelling. I arrived on scene and noticed a white elderly female on the door step at the caller home. While I was getting out of my car, she asked me if I lived there and told me she was cold. I asked her where she lived and she told me she stayed at Autumn Care. I asked her why she was not at Autumn Care and she told me that the nurses had given her some medicine and were being mean to her. I told her to come and get in my car and warm up and I would take her back to Autumn Care. I gave (Resident #1) a ride back and while talking to her, she grabbed my arm. Her hands were ice cold, possible to the point of frost bite. I advised the nurse when we got to Autumn Care and they advised that they were going to have her transported to the hospital for an evaluation. It is unclear how (Resident #1) was able to walk out of the facility unnoticed. An attempt was made to interview the police officer without success. A review of the outside temperature for the hours between 11:00 PM on 1/4/16 and 1:00 AM on 1/5/16 was completed on 2/4/16 at 3:40 PM. The temperature was reported to be 20 degrees Fahrenheit. On 2/4/16 at 3:30 PM an observation was made of the distance from the facility door to the house where Resident #1 was discovered. The distance was 0.3 miles. The terrain was uneven and grassy with a paved driveway to the left of the grassy area. On the far left side of the driveway was a ravine. The house and grassy area was separated by trees and underbrush. The front yard of the house abutted a 2 lane road with a speed limit of 35 miles per hour (mph). An interview was attempted with the homeowner without success. A review of the hospital record for Resident #1 on 1/5/16 revealed Resident #1 was admitted to the emergency department on 1/5/16 at 1:06 AM with an admitting [DIAGNOSES REDACTED]. The record also revealed The patient (Resident #1) apparently wandered outside for 20-30 minutes. Her rectal temperature is 97.0 degrees Fahrenheit (the average normal rectal temperature is 99.1 degrees Fahrenheit to 99.6 degrees Fahrenheit). She is mildly cool to touch. She will have passive warming put in place (blankets and increased warmth in the room), reassessed, and discharged back to the nursing home when normothermic (a temperature within normal range). Resident #1 was discharged from the emergency department at 4:06 AM on 1/5/16 and returned to the facility. An interview was conducted on 2/3/16 at 3:30 PM with NA #1. She stated if a resident exhibited exit seeking behaviors the staff watch them and try to redirect them, especially if they are near an exit door. She also stated the doors alarm if a resident with a (name brand) bracelet exits the facility, but the doors locked if a resident had on a (brand name) bracelet and walked within 10 feet of an exit door. She stated Resident #1 was sitting in the front lobby of the facility at 11:00 PM on 1/4/16. An interview was conducted on 2/3/16 at 3:50 PM with Nurse #1. She stated the staff needed a physician order [REDACTED]. . She also stated all exit doors in the facility were connected to the bracelet system and if a resident was wearing a (name brand) bracelet and approached an exit door, the door would lock, but there were no audible alarms. She further stated if a resident exited the facility without a (name brand) bracelet on the staff had no way of knowing they had exited. An interview was conducted with NA #2 on 2/3/16 at 4:00 PM and revealed exit seeking behaviors included trying to go to the door, and trying to get out. If the resident was completely confused the nurse was informed. Confused residents who had exit seeking behaviors wore (name brand) bracelets and would set off an alarm on the door if a resident got too close. She described the alarm as loud and stated the door would lock too if a resident was too close. An interview with the Direct of Nursing (DON) on 2/3/16 at 4:35 PM revealed Resident #1 was, paranoid, delusional, aggrssive and exhibited exit seeking behaviors. She would say she wanted go home, she needed to get our of here, she said her husband wouldn't let her leave. I did not actually see her at the doors. When the staff saw her trying to exit they would redirect her with snacks, coloring, making cards, and spending a lot of time with the staff at the nurses station. She had a (brand name) bracelet on from the day of admission. If she was sent out to the emergency department we'd remove it. The (name brand) bracelet locks every door they come close to. Every one of our doors has a (name brand) bracelet safety on them. Every door should alarm and lock, even the main lobby door. The resident (Resident #1) exited the front door. She was not injured. The staff received a phone call from one of the houses in the neighborhood (directly in front of the facility). She was returned by the Marshville Police Department. The home owner called the police. The resident had on just a nightgown when she eloped. She didn ' t have on shoes or socks. An interview was conducted with Nurse #2 on 2/3/16 at 5:15 PM and revealed she worked 7AM-3PM on 1/4/16 and was the care nurse for Resident #1. She stated she removed the (name brand) bracelet at the request of EMS when they took Resident #1 to the hospital. Resident #1 returned to the facility at 3:30pm and Nurse #2 stated she had ' reported off ' to the 3PM-11PM nurse and had not replaced the (brand name) bracelet. An interview was conducted with Nurse #3 on 2/3/16 at 5:20 PM and revealed she was the 3PM-11PM care nurse for Resident #1 on 1/4/16. She stated she did not take report from EMS when Resident #1 returned (about 3:30-4:00) but knew she was back because she saw her in the hallways. she did not replace the (name brand) bracelet because, I was very busy. I was orienting a new nurse and this shift is a very busy shift. She further stated she was charting after her shift when Resident #1 was returned by the police. She said the resident was cold, but had not appeared to be injured. She stated when the local neighbor called the facility to say there was a lady in her yard hollering they suspected it was Resident #1 because, She had attempted to exit the facility the night before she actually did elope. Nurse #3 stated she was charting after her shift on 1/4/16 and saw Resident #1 attempting to leave through the front door. She followed her and was able to redirect her to her room. When Resident #1 eloped, this nurse stated it was through the front door. She was not sure how the resident got the code to unlock the doors because they are locked from 8 PM until morning a code was needed to enter or exit. An interview was conducted on 2/4/16 at 11:30 AM with NA #4 and revealed Resident #1 went to the doors a lot , and always stated she needed to be somewhere. She also stated the doors locked if a resident with a (name brand) bracelet walked to close to an exit door. An interview with Nurse #4 on 2/4/16 at 11:35 AM revealed Resident #1 always stated she wanted to leave,or was going to leave. Nurse #4 also stated she did notrecall Resident #1 going to the doors often during the day time. She also stated Resident #1 wore a (name brand) bracelet and was re-directed when she started 'threatening' to leave. The nurses had access to (name brand) bracelets and did not need an physician (MD) order to place one on a resident. An interview with the Quality Assurance Nurse on 2/4/16 at 11:40 AM revealed no MD order was needed to place a (name brand) bracelet. Anyone could physically place one on a resident, but it was up to licensed staff to assess the need for one. If a resident was being taken to the hospital by EMS the (name brand) bracelet was usually removed. When the resident was returned to the facility it was the responsibility of the nurse completing the return assessment to re-place the (name brand) bracelet on the resident. She stated that did not happen the night Resident #1 eloped. An interview with the director of maintenance was conducted on 2/4/16 at 12:15 PM. He stated, Door locks are checked weekly by the maintenance department. Restorative aides check them daily. That includes every exit door we have. Every exit door is connected to the (name brand) bracelet system. The front door locks from the inside and out at 8 PM, but there is a keypad to enter a code and override the lock. It unlocks at 6 AM. The staff called me the night the resident (Resident #1) eloped and told me she had gotten out. I came down and I checked the door. I couldn't find anything wrong with it. The door was locked when I got here. I called the company that installed the system and I had a tech come up to double check every exit door. He couldn't find anything wrong either. There is an override switch beside every keypad in the facility per state requirement. It is a clear plastic cover with a red light switch underneath it. If the cover were to be opened, a loud, a very loud squeel is heard. The squeel remains on as long as that box is opened. If a resident with a (name brand) bracelet on walks across the threshold of an exit door an alarm will sound, even if the lock has been overridden. As long as the doors remain closed, no audible alarm is heard, the doors just lock. Since the resident (Resident #1) didn't have a (name brand) bracelet, no audible alarm would have sounded. I remember her (Resident #1). She was confused at times and would talk in a paranoid way about the government monitoring her and such. An interview was conducted on 2/4/16 at 12:40 PM with Nurse #5. She stated she last saw Resident #1 on 1/4/16 between 11:45 PM and 11:50 PM in the common area and had asked for something to drink. An interview was conducted with Nurse #6 on 2/4/16 at 12:45 PM. She stated she worked 3 PM-11 PM on 1/4/16. She said the resident (Resident #1) exited out the front door, and that it was not locked the way it usually was when she arrived for work on 1/4/16 at 10:45 PM. She stated the staff discovered it would not lock automatically the way it was supposed to, but the staff did not know why. She stated they called the maintenance director at home and after 'awhile' here told them he had fixed it. She also stated when the resident (Resident #1) returned with the police she had not appeared injured, but she was sent to the emergency department just in case. Nurse #6 stated Resident #1 was wearing a thin nightgown. That was it. She also stated it was really cold that night, but she doesn't know what the temperature was, just that it was one of our colder nights. She stated Resident #1 was found across the street from the main entrance of the facility in a neighborhood yard. She does not recall seeing a (name brand) bracelet on the resident and was told Resident #1 had gotten out once before around Christmas, but She was just walking around the yard. An interview with NA #5 was conducted on 2/4/16 at 1:10 PM. She stated she was an NA on the 11PM-7 AM shift and also stated if a resident was discovered to be missing a code yellow is called overhead, but no Code Yellow was called that night. An interview was conducted on 2/4/16 at 1:22 PM with Nurse #7. She stated she had known the resident (Resident #1) had eloped after she was returned. She also stated the resident had eloped out the front door and, We had a problem with the front door locking that night. I know it was mentioned someone was working on the front doors because they wouldn ' t lock. Resident #1 was often seen near the exit doors and that ' s why she had on a (brand name) bracelet. She also stated multiple times she had to, or was going to leave because she had to go to work for the government. An interview was conducted with Nurse #8 on 2/4/16 at 2:00 PM. She staed she was the 11 PM-7 AM care nurse for Resident #1 on 1/4/16-1/5/16. She stated, When we got here that night, she (Resident #1) had come down the 600 Hall and into the nursing station to put chairs together. She stated she was going to sleep there that night. About 11:30 PM she (Resident #1) said she was going to get ready for bed. When I was doing my rounds and checking my patients I got a phone call from a lady saying one of our residents was at her house. This was about 12:20 AM. When she (Resident #1) got back she didn ' t have her (name brand) bracelet on. I don ' t know what happened to it. When she (Resident #1) came back she had on some night clothes. A silk jacket and a silk nightgown. She had no shoes or socks on. She was always talking about going home, and we all the time kept up with her because she was always trying to get out. She ' d go to the front door to try to get out. With the (name brand) bracelet on we knew the doors would automatically lock. You know, she successfully got out another time, but we got her back in. And the night she eloped the front doors weren ' t locking properly. Every time I come to work I have to punch a code in to unlock the door. The night she eloped I didn ' t have to enter a code because the doors weren ' t locked. I arrive to work between 10:45 PM and 10:50 PM. An observation was made on 2/4/16 at 3:00 PM of the front doors to the facility. A resident with a (name brand) bracelet on was wheeled towards the exit door and the door was observed to automatically lock when the resident was within 10 feet of the door. On 2/4/16 at 3:00 PM through 2/5/16 at 10:00 AM validation of the corrective action plan, submitted by the facility administrator, was reviewed. · A (brand name) bracelet was placed on Resident #1 when she returned to the facility on [DATE]. · All residents with a (name brand) bracelet in place were checked on 1/5/16 by licensed nurses to ensure the (name brand) bracelet was in place and functioning properly. · The maintenance director came to the facility upon notification of the elopement and checked center doors for proper functioning on 1/5/16. Doors were found to be in compliance. · The following day, 1/6/16, the vendor who services the doors was brought in and while the doors were found to be functioning properly they adjusted the programming mechanism of the door to ensure that it locks from 8pm to 6am. From 1-5-2016 to present, facility has not had any issues with (name brand) bracelet function and placement, security of doors, and no residents have displayed exit seeking behavior. · A review of the maintenance logs for 1/5/16 through 1/16/16 revealed weekly tests by the maintenance department of all fire and exit doors for proper operation. No concerns were identified. · In-servicing began with all staff on 1-5-16 and continued until all staff received in-service training prior to their next scheduled shift 1-7-16.The nurse who did not place the (name brand) bracelet back on identified resident after return from hospital, was reeducated 1-5-2016 on ensuring that a (name brand) bracelet is placed back on the resident when they return from an external location. This nurse as well as other licensed staff were also reeducated (1-5-16 through 1-7-16) on how to identify residents at risk for elopement, what behaviors that may constitute an elopement risk, how to determine if a resident needs a (name brand) bracelet placed and where to find a (name brand) bracelet, how to apply it, how to document it in the electronic medical record system so that placement and proper functioning every shift can be validated. However, it needs to be noted that employees ' were not permitted to work until they received this education. Licensed staff were educated on completing elopement risk assessments upon admission, checking function and placement every shift, how to utilize a secure care tester, where this device is located, the process for removing an ineffective (name brand) bracelet to include placement of a new one, how to manage exit seeking behavior and measures to take if a resident is unable to be located. Staff in other departments were reeducated (1-5-16 through 1-7-16; please note that staff was not allowed to work their next scheduled shift until re-education had been completed) on (name brand) bracelets, identifying behavior that may be considered as an elopement risk, what to do if a resident appears to be attempting to remove their (name brand) bracelet, and what to do if they identify a resident attempting to elope to include immediate supervisor notification. · Center doors auditing began 1/5/16 and continue to be audited daily to ensure proper functioning by nursing staff. · Maintenance has been conducting weekly audits of the doors since 1/5/16. Moving forward until deemed no longer necessary by the quality improvement committee doors will be audited daily to ensure proper functioning by maintenance and/or nursing. · Beginning 1/5/16, and occurring weekly, the quality improvement committee will review daily audits. This will continue for three months. If after three months of daily auditing, no issues were noted the door audits will then move to being done weekly which is normal center practice. At the time of this incident, 1/5/16, the center instituted weekly audits of residents with (name brand) bracelets conducted by administrator and/or nursing administration. No issues were noted. Center will continue to conduct weekly audits until deemed no longer necessary by the quality improvement committee. Administrator or designee will continue to audit the residents requiring a (name brand) bracelet for an additional four weeks. If after these additional four weeks the center is found to be in compliance then center will allow the process of checking function and placement every shift by the nurses to continue. · An interview was conducted on 2/5/16 at 9:05 AM with NA #7 and she was able to describe the elopement training and protocol. · An interview was conducted with Nurse #9 on 2/5/16 at 9:15 AM and she was able to describe the elopement training and protocol. · An interview was conducted with the DON on 2/5/16 at 9:20 AM and she was able to describe the elopement training and protocol. · An interview was conducted with facility administrator on 1/5/16 at 9:37 AM. She staed, I expect in-services to be held annually, and as issues come up in the facility. I expect competencies to be done at hire and annually. If a resident elopes, we will conduct a search if the entire facility first, then we search the grounds, notify the police, family, and physician. When the resident returns they receive a complete body assessment, we notify the family and physician, and the resident is sent to the hospital if needed. My expectation going forward, if there is another elopement, is that we act immediately using the procedures in our manual. We will make sure the doors are checked, and we need to put interventions in place like a (name brand) bracelet, care planning 1 on 1 observation, sitters, anything we can to prevent cognitively impaired residents from eloping. We need to get the family involved too by encouring frequent visits, maybe a home visit, anything to keep a cognitively impaired resident from attempting to leave. We also need the nurses to tell us immediately if any exit seeking behaviors are noticed so we can put preventive measures in place. We have educated staff on re-placing the (name Brand) bracelet when a resident returns from going out of the facility, and we will continue to educate them. We are also looking at not removing the (name brand) bracelet at all when a cognitively impaired resident goes to the hospital. There really isn ' t a need to remove them.