Every finding on record at Autumn Care of Myrtle Grove

Based on record review and staff interviews, the facility failed to protect a cognitively impaired resident (Resident #1) with agitated behaviors from being physically restrained by an employee during care when Nurse #1 was witnessed by two other employees (Nurse Aide #1 and Nurse Aide #2) to hold Resident #1's arms down to restrict her hand and arm movements. Resident #1 screamed while being restrained by Nurse #1 and sustained bruising and pain in her bilateral hands and wrists that was relieved with as needed medications for pain following this incident. Resident #1 also had scratches to the right forearm and wrist. This occurred for 1 of 1 resident reviewed for physical restraints. Findings included:Resident #1 was admitted on [DATE] with diagnosis which included severe vascular dementia with psychotic disturbance, cognitive communication deficit, anxiety, delusional disorder and depression, and chronic pain with peripheral neuropathy. A review of Resident #1's physician orders revealed orders dated 10/9/25 for acetaminophen 325 milligrams (mg) give 2 tablets every 6 hours as needed for pain and tramadol 50 mg every 6 hours as needed for pain and 50 mg every 6 hours as needed for pain. Resident #1's physician orders did not include anticoagulant medication. A review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had a short- and long-term memory impairment with severely impaired decision making and exhibited physical behavioral symptoms directed towards others (e.g. hitting, kicking, pushing, scratching, grabbing) 1 to 3 days during the 7-day assessment look back period. Resident #1 demonstrated verbal behaviors (threatening, screaming, cursing) 1 to 3 days and other behaviors not directed at others (hitting, scratching self, verbal vocal symptoms including screaming and disruptive sounds) 1 to 3 days in the 7- day look back period. Resident #1 rejected care 4-6 days in the 7-day look back period. Resident #1 had moderate difficulty hearing, had unclear speech, sometimes made herself understood and sometimes was able to understand others. Resident #1 had moderately impaired vision. Resident #1 received opioid and as needed pain medication during the look back period. A pain assessment interview was completed with the staff. Resident #1 complained of or exhibited signs of pain 1-2 days during the assessment look back period.Resident #1's care plan indicated a problem of behavioral symptoms with resistance to care at times. The care plan problem was last updated on 10/27/25 and the interventions indicated to allow the resident to make choices about her treatment regimen, encourage the resident to participate in activities of daily living, reapproach if the resident refuses care and give a clear explanation of care activities. Review of a facility investigation report revealed that on 11/14/25 at 4:10 PM Nurse Aide (NA) #1 and Nurse Aide (NA) #2 alleged that Nurse #1 physically restrained and cursed at Resident #1and held her physically restraining her against her will during incontinence care on 11/13/25. The NAs stated that they witnessed verbal and physical abuse by Nurse #1 while they were providing care to Resident #1 on the night of 11/13/25 at approximately 10:00 PM. An interview was conducted with Nurse Aide (NA) #1 on 12/2/25 at 1:09 PM. NA #1 indicated that Resident #1 frequently screamed, hit, bit, spit and scratched staff during care. NA #1 stated that she attempted to talk to Resident #1 in a calm tone and explain all tasks and procedures, but it was still difficult at times to provide the needed care. NA #1 stated on the evening of 11/13/25, she was not assigned to Resident #1, but at approximately 10:00 PM NA #2 who was the assigned Nurse Aide asked her to assist with providing incontinence care. NA #1 stated that Resident #1 always required 2-person assistance with incontinence care due to her combative behaviors. NA #1 stated that while she and NA #2 were providing incontinence care to Resident #1, Nurse #1 entered the room to administer medication. NA #1 stated she did not know why, but Nurse #1 stayed in the room after she administered the medication. Nurse #1 went to the side of the bed where NA #2 was assisting with positioning Resident #1 on her side while NA #1 was cleaning the resident's buttock and perineal area. Nurse #1 was at the upper part of Resident #1's body and grabbed Resident #1's arms and held them against her body. Resident #1 was trying to get the nurse to stop and was screaming. Nurse #1 continued to hold Resident #1's wrists. Resident #1 spit and cursed at Nurse #1 and the nurse spit back at the resident and cursed at her. Nurse #1 then put a pillow up to Resident #1's face. NA #1 stated that she was behind the resident on the other side of the bed, so she was unable to tell if the pillow was touching the resident's face. NA #1 stated that during this incident, NA #2 told Nurse #1 several times that she needed to leave the resident alone and walk away. Nurse #1 eventually left the room, and NA #1 stated that she and NA #2 finished the incontinence care and were able to calm Resident #1 down. NA #1 stated that she had never witnessed a staff member treat a resident this way before, and it was very upsetting to her. NA #1 stated that she had received training on abuse, and she knew that what Nurse #1 did was not right. NA #1 stated that she knew that restraining a resident, holding them down and providing care against their will, cursing and spitting at a resident were all forms of abuse but due to being in shock at the time, she did not report it until the following day when she returned to work. An interview was conducted with Nurse #1 on 12/2/25 at 1:38 PM. Nurse #1 stated that she began employment at the facility in October 2025. Nurse #1 stated that she had never worked in a nursing facility before and was unaware of the policies and procedures. Nurse #1 indicated that she did not think that holding a resident's arms was abuse, as this was a technique used in the emergency department with patients with combative behavior. Nurse #1 stated that on 11/13/25 she was assigned to Resident #1 from 7:00 PM to 7:00 AM and the resident was scheduled for a weekly skin assessment. Nurse #1 indicated that she administered Resident #1's scheduled medications that evening and then a few minutes later went back into the room while the NAs were providing incontinence care so she could complete the scheduled weekly skin assessment. Nurse #1 indicated that she observed Resident #1 on her side with NA #2 assisting to position her and NA #1 provided the incontinence care. Resident #1 was agitated and was attempting to bite and scratch the NAs. Nurse #1 stated she observed Resident #1's skin including the buttock and perineal area and then went to the other side of the bed positioning herself by the resident's face and upper body. Nurse #1 stated that Resident #1 scratched her on the face, so she held the resident by her wrists and held her arms against her body. Nurse #1 indicated that she crossed the resident's arms across her body and held them there, using a technique that she had used in the emergency department to control a combative patient. Resident #1 was cursing at her so Nurse #1 stated she cursed back at her, and she revealed that she did not think that this was abuse. Nurse #1 stated that the NAs completed the incontinence care and rolled the resident onto her back. Nurse #1 indicated that she observed a pillow on the nightstand and she threw it on the resident because she did not want to get close enough to the resident to place it under her head. The pillow landed on the resident's chest. Nurse #1 stated that she did not hold the pillow over Resident #1's face. Nurse #1 stated that she was informed the following day that she was suspended due to the incident with Resident #1.An interview was conducted with NA #2 on 12/3/25 at 3:15 PM. NA #2 stated that she and NA #1 went into Resident #1's room to provide incontinence care on 11/13/25 at approximately 10:00 PM. Nurse #1 was in the room and had just administered medication to Resident #1. The nurse remained in the room as NA #2 and NA #1 rolled Resident #1 over and provided incontinence care. Resident #1 became more agitated seeing that Nurse #1 was still in the room. Resident #1 started spitting and Nurse #1 spit back at the resident. Resident #1 was cursing and Nurse #1 cursed back at the resident. Nurse #1 held the resident's arms tightly across her chest to prevent the resident from hitting or moving. Nurse #1 was making Resident #1 more agitated. Nurse #1 put a pillow over Resident #1's face but was not holding it down. Nurse #1 laid the pillow over the resident's face. NA #2 stated she and NA #1 removed the pillow from the resident's face. NA #2 indicated that several times, she told Nurse #1 to leave the room and let them provide Resident #1's care but the nurse did not listen and did not leave. NA #2 stated that she and NA #1 were finishing Resident #1's care and Nurse #1 eventually left the room. NA #2 indicated that she was in shock that Nurse #1 engaged in this abusive behavior toward a resident. NA #2 stated that Resident #1 did not complain of pain at the time of the incident, and she did not recall if resident had pain the following day when she was assigned to her. NA #2 recalled that Resident #1 had bruising to her hands and wrists following the incident. NA #2 stated that she did not recall any changes in Resident #1's behavior on 11/14/25. Review of a skin observation completed by the Assistant Director of Nursing (ADON) dated 11/14/25 at 4:37 PM revealed that Resident #1 had bruising and a scratch on her right forearm and wrist. A nursing progress note written by the ADON dated 11/14/25 at 4:39 PM indicated that Resident #1 had new bruising and a small scratch to the right forearm and wrist. Full range of motion to the bilateral upper extremities was noted. The note indicated that Resident #1 was not complaining of any pain at this time where the bruise was. The provider was notified. An interview was conducted with the Assistant Director of Nursing (ADON) on 12/3/25 at 12:20 PM. The ADON stated that she was responsible for staff education and orientation of new staff members. The ADON stated that she discussed abuse and the forms of abuse with all newly hired staff and that Nurse #1 received this training as part of her orientation. The ADON indicated that she interviewed Nurse #1 after the incident and Nurse #1 stated that she held Resident #1's arms but that the nurse did not think her action was abuse or a form of restraint. A review of a facility event report dated 11/14/25 at 5:12 PM revealed that Resident #1 was involved in an alleged episode of verbal and physical abuse. Resident #1 sustained discoloration to the right forearm and wrist. The report indicated that at approximately 10:00 PM on 11/13/25 Nurse #1 spit on Resident #1, cursed at her, placed a pillow over the resident's face and held the resident's arms during care. An interview was conducted with NA #3 on 12/2/25 at 2:05 PM. NA #3 stated that Resident #1 was combative with care spitting, kicking and biting. NA #3 stated that she tried to redirect the resident, explain all tasks and procedures, remain calm, and talk to the resident during care. NA #3 indicated that these interventions usually worked but if Resident #1 remained agitated, she would ensure the resident's safety and reapproach after a few minutes. NA #3 stated that she was assigned to Resident #1 on 11/14/25 from 3:00 PM to 11:00 PM but she worked on the 7:00 AM to 3:00 PM shift that day also and assisted with Resident #1's care that morning. NA #3 stated that on the morning of 11/14/25, Resident #1 kept saying that her thumb and hand were broken and hurt. NA #3 stated that Resident #1 seemed scared and upset during the day on 11/14/25 but was unable to state how the resident's behavior was different. A review of Resident #1's physician orders indicated an order dated 11/14/25 for lorazepam 0.25 mg twice per day as needed for severe anxiety or agitation due to a diagnosis of vascular dementia with psychotic disturbance. Review of Resident #1's MAR revealed that the pain monitoring on the day shift and night shift from 11/14/25 through 11/16/25 was documented as 0 out of 10 pain level. Review of Resident #1's electronic Medication Administration Record (MAR) revealed that as needed lorazepam was administered on 11/16/25 at 12:08 AM and 10:09 AM due to behavioral issues and was documented as effective. Review of Resident #1's MAR revealed that tramadol 50 mg as needed was administered on 11/17/25 at 11:08 AM for a pain level of 6 due to hand pain. The MAR indicated that the medication was effective. A nursing progress note dated 11/17/25 at 1:44 PM written by Unit Manager #1 revealed that Resident #1 complained of bilateral hand pain and reported the left-hand pain was worse than the right. The note indicated that Resident #1 had no swelling to the right hand and was able to move her fingers as she normally did. Resident #1 was unwilling to allow the Unit Manager to assess her left hand due to pain. The provider was notified and an order was received for x rays of resident's bilateral hands. Review of Resident #1's physician order revealed an order dated 11/17/25 to obtain x-rays of the right and left wrists.A nursing progress note dated 11/17/25 at 2:20 PM written by Unit Manager #1 revealed that Resident #1 had mild bruising to her bilateral forearms. The note indicated that Resident #1 had a history of pain to the left hand. Resident #1 complained of bilateral hand pain earlier in the day but no complaint of pain at this time. No mental anguish or changes in behavior were noted. Review of a Physician progress note dated 11/17/25 indicated that Resident #1 complained of bilateral hand pain with pain greater in the left hand than the right. Two Nurse Aides reported that they observed a nurse grab Resident #1 roughly by her hands. Resident #1 reported that someone grabbed her and hurt her. Resident #1 did not report any other trauma. An order was written for lorazepam as needed for anxiety due to trauma following the incident. Resident #1 was observed using her right hand but not using the left hand and did not want anyone to touch it. The assessment and plan indicated that Resident #1 had left greater than right hand pain and bruising after being grabbed by a nurse. X rays were ordered. The progress note indicated that staff were to provide supportive care and administer lorazepam as needed for anxiety due to the trauma. No evidence of injury to other areas of the body was observed. Review of an x ray report dated 11/17/25 indicated that x rays of the bilateral wrists were completed on 11/17/25. The results indicated no gross abnormality however it was a limited study and a fracture was not excluded due to a non-diagnostic lateral view. A recommendation was made to repeat the x rays and obtain a multiple view study. A review of a weekly skin observation dated 11/18/25 indicated that Resident #1 had bruising to her right forearm. A Nurse Practitioner (NP) note dated 11/18/25 indicated that Resident #1 was evaluated for a scheduled follow up regarding x rays that were obtained of the bilateral hands after the resident complained of hand pain to the nursing staff. Resident #1 was noted with bruising of the bilateral hands and wrists. The note further indicated that the NP was notified about an incident in which a staff member grabbed the resident's hands and held them down firmly. X-rays were negative for a fracture. Review of a psychiatric follow-up note dated 11/18/25 indicated that Resident #1 was followed for depression and anxiety. Staff reported that Resident #1 was abused by a staff member. Staff reported that the nurse grabbed Resident #1's hands and arms restraining the resident so she couldn't move. The note indicated that Resident #1 stated she was scared about the lady coming back and endorsed she was abused. A recommendation was made to continue with the low dosage of lorazepam, that was added to Resident #1's medications on 11/14/25 as needed for anxiety. A review of Resident #1's MAR revealed that pain monitoring on the day shift and night shift from 11/18/25 through 11/23/25 was documented as a 0 out of 10 pain level. Review of Resident #1's physician orders revealed an order dated 11/24/25 to obtain complete multiple views of the right and left wrists. An x-ray report dated 11/24/25 indicated that complete multi view x rays of the bilateral wrists were completed on 11/24/25 with no fracture or dislocation noted with mild osteoarthritis and no acute abnormality of the wrists. A review of Resident #1's MAR revealed that pain monitoring on the day shift on 11/24/25 was documented at a 5 out of 10 pain level. A physician note dated 11/24/25 at 8:28 PM indicated that x ray results were reviewed. Resident #1 continued with bruising and pain to the left hand after she was grabbed by a nurse. A review of Resident #1's MAR revealed that the resident received tramadol 50 mg for a pain level of 4 on 11/27/25 at 9:42 PM and the medication was effective. On 12/2/25 at 12:30 PM Resident #1 was observed in her bed with the head of the bed elevated feeding herself lunch using her right hand. Resident #1 was calm and able to answer simple questions. Resident #1 was observed with bruising to the left hand around the thumb, on top of the hand and the wrist. Resident #1 stated that girl was squeezing my hand and my thumb is broken. It hurts.An interview with the Regional Nursing Consultant on 12/2/25 at 4:04 PM revealed that she, the Administrator and Director of Nursing developed the plan of correction and determined that the root cause was poor decision making by Nurse #1. The Regional Nursing Consultant stated that a specific plan of correction for restraints was not written but restraints were discussed in the staff education that was provided and staff were informed that residents had the right to be free from restraints. The Regional Nursing Consultant confirmed that Nurse #1 holding Resident #1's arms during care was a form of physical restraint and was not allowed.An interview was conducted with the Director of Nursing (DON) on 12/3/25 at 1:40 PM. The DON stated that it was not appropriate for Nurse #1 to physically restrain Resident #1 during care. The DON stated that Nurse #1 should have used better judgment in the situation and that physically restraining a resident during care was not allowed. The DON indicated that Nurse #1 was reported to the Board of Nursing due to this incident. An interview was conducted with the Nurse Practitioner (NP) on 12/3/25 at 2:10 PM. The NP indicated that she evaluated Resident #1 a few days after the incident occurred and noted that the resident had bruises on both hands and wrists and complained of pain in both hands with pain greater in the left than the right. The NP stated that she ordered x rays to rule out an injury to her hands or wrists. The NP stated that the x rays were negative. The NP indicated that she did not observe any changes in Resident #1's behavior following the incident. An interview with the Administrator on 12/3/25 at 4:30 PM revealed that she was out of the facility on 11/13/25 and 11/14/25 but was informed by the DON of the alleged abuse incident. The Administrator stated that after the investigation was completed, the allegation of abuse was substantiated. The Administrator indicated that physically restraining a resident during care was not appropriate and Nurse #1 was terminated and reported to the Board of Nursing due to her actions.

Based on record review and staff interviews, the facility failed to follow its abuse policies and procedures in the area of immediately reporting an allegation of staff to resident abuse to the Administrator and in the area of protection. This occurred for 1 of 1 resident who was investigated for a staff to resident allegation of abuse (Resident #1). Findings included:Review of the facility resident abuse policy titled North Carolina Abuse Policy last reviewed on 7/2/2025 revealed in part; staff must report all allegations, suspicions and incidents of abuse and neglect to the Administrator/Abuse Coordinator immediately, but no later than 2 hours. The Administrator/Abuse Coordinator will immediately begin an investigation and notify the applicable local and state agencies. The investigation must be completed within five (5) working days of the alleged occurrence. The policy indicated that if a staff member was accused or suspected of abuse, the staff member will immediately be removed from the facility and removed from the schedule pending the outcome of the investigation. Resident #1 was admitted on [DATE] with diagnosis which included severe vascular dementia with psychotic disturbance, cognitive communication deficit, anxiety, delusional disorder and depression, chronic pain with peripheral neuropathy. An interview was conducted with Nurse Aide (NA) #1 on 12/2/25 at 1:09 PM. NA #1 stated on the evening of 11/13/25, she was not assigned to Resident #1, but at approximately 10:00 PM NA #2 who was the assigned Nurse Aide, asked her to assist with providing incontinent care. NA #1 stated that Resident #1 required 2-person assistance with incontinence care due to her combative behaviors. NA #1 stated that while she and NA #2 were providing incontinence care to Resident #1, Nurse #1 entered the room to administer medication. NA #1 stated she did not know why, but after administering the medication, Nurse #1 stayed in the room while she and NA #2 were completing incontinence care. Nurse #1 went to the side of the bed where NA #2 was holding Resident #1 on her side while NA #1 was cleaning the resident's buttock and peri area. Nurse #1 was at the upper part of Resident #1's body and grabbed Resident #1's arms and held them against her body. Resident #1 was trying to get the nurse to stop and was screaming. Nurse #1 continued to hold Resident #1's wrists. Resident #1 spit and cursed at Nurse #1 and the nurse spit back at the resident and cursed at her. Nurse #1 then put a pillow up to Resident #1's face. NA #1 stated that she was behind the resident on the other side of the bed and was unable to tell if the pillow was touching the resident's face. NA #1 stated that during this incident NA #2 told Nurse #1 several times that she needed to leave the resident alone and walk away. Nurse #1 eventually left the room, and NA #1 stated that she and NA #2 finished the incontinence care and were able to calm Resident #1 down. NA #1 stated she tried to collect herself and complete the rest of her work for the shift and left at the end of her shift. NA #1 stated that she did not report the incident until the next day on 11/14/25 when she returned for her 3:00 PM to 11:00 PM shift. NA #1 stated that she received training on abuse, and she knew that what Nurse #1 did was not right. NA #1 stated that she knew that restraining a resident, holding them down and providing care against their will, cursing and spitting at a resident were all forms of abuse and acknowledged awareness of the facility's abuse reporting policy. NA #1 stated that she was so upset by the incident that she needed time to process what happened, so she did not report it until the following day when she returned to work. An interview was conducted with NA #2 on 12/3/25 at 3:15 PM. NA #2 stated that she and NA #1 went into Resident #1's room to provide incontinence care on 11/13/25 at approximately 10:00 PM. Nurse #1 was in the room and had just administered medication to Resident #1. The nurse remained in the room as NA #2 and NA #1 rolled Resident #1 over and provided incontinence care. Resident #1 became more agitated seeing that Nurse #1 was still in the room. Resident #1 started spitting and Nurse #1 spit back at the resident. Resident #1 was cursing and Nurse #1 cursed back at the resident. Nurse #1 held the resident's arms tightly across her chest to prevent the resident from hitting or moving. NA #2 stated that Nurse #1 was making Resident #1 more agitated. Nurse #1 laid the pillow over the resident's face. NA #2 stated she and NA #1 removed the pillow from the resident's face. NA #2 indicated that several times, she told Nurse #1 to leave the room and let them provide Resident #1's care but the nurse did not listen and did not leave. NA #2 stated that she and NA #1 were finishing Resident #1's care and Nurse #1 eventually left the room. NA #2 stated that she was in shock that the nurse engaged in this behavior and treated the resident like that. Following the incident, NA #2 stated that she needed time to process what happened, so she did not report it to administration until the next day, 11/14/25 when she returned to work for her 3:00 PM to 11:00 PM shift. NA #2 stated that she was aware of the abuse policy and that all staff were required to report abuse or suspected abuse immediately. A review of a facility event report dated 11/14/25 at 5:12 PM revealed that Resident #1 was involved in an alleged episode of verbal and physical abuse. Resident #1 sustained discoloration to the right forearm and wrist. The report indicated on 11/13/25 at approximately 10:00 PM Nurse #1 spit on Resident #1, cursed at her, placed a pillow over the resident's face and held her arms. A facility summary report of the incident stated that on 11/14/25 at approximately 4:10 PM, Nurse Aide (NA) #1 and NA #2 alleged that Nurse #1 physically restrained Resident #1 by holding her against her will during care and cursed at the resident on 11/13/25. Resident #1 was assessed on 11/14/25 by the Assistant Director of Nursing (ADON) and found to have discoloration and a small scratch to her right wrist. The provider, responsible party, [NAME] Police Department and Adult Protective Services were notified of the allegation on 11/14/25. Nurse #1 was suspended pending facility investigation on 11/14/25. The report indicated that an interview was conducted on 11/14/25 with NA #1 which revealed that NA#2 requested that she assist her with providing incontinence care to Resident #1. When Nurse #1 entered the room to administer Resident #1's medication, NA #1 and NA #2 were providing incontinence care. Upon seeing Nurse #1 enter the room, Resident #1 started screaming. Resident #1 was turned on her side. Nurse #1 approached Resident #1 and held the resident's arms against her body. Resident #1 spit in Nurse #1's face and scratched her. Resident #1 cursed at Nurse #1 and the nurse cursed back at the resident. Resident #1 started spitting at Nurse #1 and the nurse spit back at Resident #1. Nurse #1 placed a pillow in front of Resident #1's face. NA #2 was telling Nurse #1 to walk away, and Nurse #1 did not initially but finally walked out of the room. An interview was conducted with the Assistant Director of Nursing (ADON) on 12/3/25 at 12:20 PM. The ADON stated that she and the Director of Nursing (DON) were informed on 11/14/25 by NA #1 and NA #2 of the staff to resident abuse allegation that occurred on 11/13/25 by Nurse #1 to Resident #1. The ADON stated she immediately notified the Administrator. An interview was conducted with the DON on 12/3/25 at 1:40 PM. The DON stated that it was not appropriate for Nurse #1 to physically restrain Resident #1 during care or to curse or spit at her. The DON stated that Nurse #1 should have used better judgment in the situation and that this incident constituted abuse. The DON stated that NA #1 and NA #2 should have reported the incident immediately and that Nurse #1 should have been removed from the assignment for the remainder of the 7:00 PM to 7:00 AM shift on 11/13/25 to protect Resident #1 and the other residents. The DON stated an investigation should have been immediately initiated after the alleged incident occurred. The DON indicated that when the incident of abuse was reported by NA #1 and NA #2 on 11/14/25, Nurse #1 was informed that she was suspended pending the investigation, was not to report for her scheduled shift on 11/14/25 from 7:00 PM to 7:00 AM or any other shifts. The DON stated that the investigation concluded that abuse occurred, Nurse #1 was terminated and a complaint was filed with the Board of Nursing regarding Nurse #1's actions. An interview was conducted with the Administrator on 12/3/25 at 3:25 p.m. The Administrator explained that she was out of the facility on 11/14/25 when she received a phone call from the ADON who informed her of the abuse allegation. The Administrator further explained that NA #1 and NA #2 did not report the allegation of staff to resident abuse within the required 2-hour timeframe and that disciplinary action forms were completed on 11/14/25 for the employees regarding their failure to report staff to resident abuse immediately. The Administrator indicated that due to NA #1 and NA #2 not immediately reporting the incident, Nurse #1 finished out her 7:00 PM to 7:00 AM shift on 11/13/25 which included being assigned to Resident #1. The Administrator stated that Nurse #1 was scheduled to work from 7:00 PM to 7:00 AM on 11/14/25 but was suspended prior to the start of that shift and did not return to work due to the conclusion of the investigation which substantiated the allegation of abuse.

Based on record review and staff interviews, the facility failed to protect a resident's right to be free from neglect when Resident #1, a resident with severely impaired cognition and known behavioral symptoms, requested as needed pain medication from Nurse #1 and the nurse disregarded the resident's pain and withheld the medication in response to the resident spitting at her when she (the nurse) entered the resident's room. This occurred for 1 of 3 residents reviewed for abuse and neglect.Findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses which included severe vascular dementia with psychotic disturbance, cognitive communication deficit, anxiety, delusional disorder and depression, chronic pain with peripheral neuropathy. Review of Resident #1's physician orders revealed orders dated 10/9/25 for acetaminophen 325 milligrams (mg) administer 2 tablets every 6 hours as needed and tramadol 50 mg administer one tablet every 6 hours as needed for pain. Review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had a short-term and long-term memory impairment, severely impaired decision making, and exhibited physical behavioral symptoms directed towards others, verbal behavioral symptoms, and other behavioral symptoms not directed towards others on 1 to 3 days during the 7-day assessment look back period. Resident #1 rejected care on 4-6 days during the 7- day look back period. Resident #1 had moderate difficulty hearing and sometimes made herself understood and sometimes was able to understand others. Resident #1 had moderately impaired vision. Resident #1 received opioid and as needed pain medication during the look back period. A pain assessment interview was completed with the staff. Resident #1 complained of or exhibited signs of pain 1-2 days during the assessment look back period.Resident #1's care plan, last updated on 10/27/25, included a problem of behavioral symptoms with resistance to care at times. The interventions indicated to allow the resident to make choices about her treatment regimen, encourage the resident to participate in activities of daily living, reapproach if the resident refuses care and give a clear explanation of care activities. A care plan dated 10/27/25 indicated Resident #1 had pain due to immobility and interventions included to administer pain medication as ordered, assess for pain and attempt to utilize non-pharmacological interventions to relieve pain. A review of Resident #1's November 2025 electronic Medication Administration Record (eMAR) revealed that Nurse #1 documented on 11/13/25 for the 7:00 PM to 7:00 AM night shift entry that the resident exhibited behavior of scratching, biting and spitting. Nurse #1 documented that the non-pharmacological intervention of reassurance was utilized in response to the behavior. Further review of Resident #1's November 2025 eMAR indicated that Nurse #1 documented that the resident had a pain level of 6 out of 10 with 0 indicating no pain and 10 indicating the worst pain ever on 11/13/25 for the 7:00 PM to 7:00 AM night shift. The eMAR contained no documentation of administration of the ordered as needed tramadol 50 milligrams (mg) one tablet every 6 hours as needed for pain. The Controlled Medication Utilization Record for Resident #1 for as needed tramadol 50 mg revealed an entry on 11/13/25 at 10:00 PM for one dose signed by Nurse #1 with an entry that indicated that the dose was wasted. The entry was checked by Nurse #3 as wasted.A phone interview was conducted with Nurse #1 on 12/2/25 at 1:38 PM. Nurse #1 stated that Resident #1 was cognitively impaired but was able to report a pain level and request pain medication. Nurse #1 stated that Resident #1 requested pain medication on the evening of 11/13/25 and when she went in the room to administer the ordered medication, the resident spit at her as she came into the room, so she (the nurse) immediately left the room without making any effort to calm the resident with known behaviors. Nurse #1 stated that she wasted the medication, did not administer it and did not attempt to administer the medication later. Nurse #1 indicated that she was aware that Resident #1 demonstrated combative and agitated behaviors and that she (the nurse) was not tolerating it and did not attempt to give Resident #1 pain medication later in the shift. Nurse #1 stated that she thought Resident #1 eventually went to sleep but she did not evaluate her pain again later in the shift and did not reattempt to administer the medication. Nurse #1 stated that she did not think her action was abuse or neglect, she just did not tolerate the behavior that Resident #1 exhibited. Attempts via phone to interview Nurse #3 on 12/2/25 and 12/3/25 were unsuccessful.Attempts via phone to interview NA #4, the NA assigned to Resident #1 on 11/13/25 from 11:00 PM to 7:00 AM, were unsuccessful. Review of Resident #1's electronic MAR revealed a pain rating of 0 out of 10 on 11/14/25 on the day shift from 7:00 AM to 7:00 PM. An interview with the Director of Nursing (DON) on 12/3/25 at 1:40 PM revealed that it was not appropriate for Nurse #1 to not administer the ordered as needed pain medication to a resident that expressed pain and requested medication. The DON stated that Nurse #1 should have used better judgment when she withheld the as needed medication from Resident #1 and that she should have attempted to administer the medication again later. The DON agreed that this incident was neglect. An interview was conducted with the Nurse Practitioner (NP) on 12/3/25 at 2:10 PM. The NP indicated that pain should be addressed by the staff and the as needed medication for pain should be administered. The NP stated that it was not appropriate for the nurse to withhold medication from a resident that expressed pain and requested pain medication. The NP further indicated that pain could contribute to agitated behaviors in a cognitively impaired resident.

Based on observations, record review, and staff interviews, the facility failed to follow the infection control policy and procedures when 1.) Medication Aide #1 entered a resident's room (Resident #73) who was on Contact Precautions due to a wound infection without donning personal protective equipment (PPE) to include gloves and a gown. 2.) Nurse Aide #1 did not don PPE for Enhanced Barrier Precautions (EPB) to include a gown when providing high-contact resident care activities for Resident #26 who had a surgical wound dressing and a lower leg dressing. This occurred for 2 of 4 staff members reviewed for infection control practices. Findings Included. 1.The facility’s Infection Control Policy revised 5/19/25 revealed Contact Precautions were intended to prevent the transmission of infectious agents which were spread by direct or indirect contact with the resident or resident’s environment. Contact Precautions were indicated in the presence of excessive wound drainage, urine or fecal incontinence or other discharges that could not be contained and suggest an increased potential for environmental contamination and risk of transmission. Personal Protective equipment included to wear gloves and a gown. During observations on 8/20/25 at 10:30 AM Medication Aide #1 was observed entering Resident #73’s room who was on contact precautions without wearing gloves or a gown. A sign was posted on the outside of the resident's doorway that read to don gloves and a gown prior to entering the room and remove before exiting. A PPE supply cart was outside of the room by the doorway and stocked with gloves and gowns. Medication Aide #1 was observed at Resident #73’s bedside using a stethoscope and blood pressure cuff to obtain Resident#73’s blood pressure. Medication Aide #1 left the room after obtaining the blood pressure. During an interview on 8/20/25 at 10:35 AM Medication Aide #1 stated she was not aware that Resident #73 was on contact precautions due to not being assigned to her care since contact precautions were implemented. She stated she went in the room to check Resident #73’s blood pressure before administering her medications and she did not notice the sign by the doorway. Medication Aide #1 stated she had received infection control training including providing care to residents on contact precautions and knew if contact precautions were in place that she was supposed to wear a gown and gloves. She indicated that not wearing the required PPE prior to entering the room was done in error. During an interview on 8/20/25 at 11:30 AM the Infection Preventionist Nurse stated Resident #73 was on contact precautions due to a wound infection and remained on antibiotics. A gown and gloves were required prior to entering Resident #73’s room. She indicated staff had received infection control training to include contact precautions. During an interview on 8/20/25 at 4:30 PM the Director of Nursing (DON) stated Resident #73 remained on contact precautions due to a wound infection with wound drainage. Medication Aide #1 should have followed their policy for contact precautions and put on a gown and gloves before going into Resident #73’s room. She stated staff had been trained on the infection control policy. 2. Review of facility’s Enhance Barrier Precautions (EBP) Policy dated 05/19/25 revealed in part: “EBP are intended to prevent transmission of multi-drug-resistant organisms (MDROs) via contaminated hands and clothing of healthcare workers to high-risk residents during high contact. High-risk residents: those with chronic wounds and indwelling devices (such as central lines, urinary catheters, and tracheotomy) and for all those colonized or infected with MDRO currently targeted by Centers for Disease Control (CDC). High contact care activities: activities that may result in transfer of MDRO to hands and clothing of healthcare personnel, even when blood and body fluid exposure is not anticipated. These include dressing, bathing/showering, transferring, providing hygiene, changing linen, changing briefs, assisting with toileting, device care or use, and wound care. Residents placed on EBP should remain on EBP for the duration of their stay or until resolution of the wound.” Review of Resident #26’s August/2025 Medication Administration Record (MAR) revealed to cleanse right chest surgical incision with normal saline, apply petroleum ointment to wound bed and cover with dry dressing daily, and apply foam dressing to left shin wound every 3 days, with order dates for both orders of 07/24/25. During an observation on 08/18/25 at 2:00 PM an EBP sign was posted on Resident #26's room door that read in part: Enhanced Barrier precautions, and providers and staff must wear gloves and a gown for the following high-contact resident care activities: dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use of a central line, urinary catheters, feeding tubes, and wound care: any skin opening requiring a dressing. A follow-up observation was conducted on 08/18/25 at 2:01 PM, after knocking and opening Resident #26’s door, revealed Nurse Aide (NA) #1 in Resident #26's room removing bed linen, helping the resident with activities of daily living, emptying resident’s urinal, and was assisting resident from bed to wheelchair without a gown on. Resident #26 was lying in bed dressed, with sheets and blanket pulled off resident. NA #1 had on gloves when providing care activities for Resident #26 but was not wearing a gown. A bin with PPE (personal protective equipment) supplies was by the door, including one time use disposable gowns. An interview was conducted on 08/18/25 at 2:06 PM with NA #1. She stated she did not put on a gown when providing care for Resident #26. She stated she was trained on EPB and knew Resident #26 was on EPB (due to having wound dressings) and did not need to wear a gown because she was not doing wound care, just ADL care and transferring the resident. After reading the EPB sign on resident’s door, NA #1 said she should have donned a gown during Resident #26’s ADL care and transfer but had not read the whole EBP sign. An interview was conducted on 08/20/25 at 2:45 PM with the Director of Nursing (DON). She revealed on 08/18/25 at 2:01 PM the NA #1 should have donned a disposable gown during Resident #26’s ADL care, linen change, and transfer, while being on Enhanced Barrier Precautions. An interview was conducted on 08/21/25 at 3:00 PM with the Administrator. She stated staff should wear the appropriate personal protective equipment PPE when providing direct care to residents on enhanced barrier precautions. She also stated that all the staff knew to abide by the different types of precautions posted on the residents' door and to follow the assigned personal protective equipment (PPE).

Based on observations, record review, and staff interviews, the facility failed to discard four expired insulin pens according to the manufacturer's guidelines and record an opened date on an insulin pen on 1 of 4 medication carts (700 hall medication cart) that were reviewed for medication storage. Findings Included. Review of the manufacturer's guidelines for Insulin Lispro (Humalog) pens and Insulin Glargine (Lantus) pens instructed to discard 28 days after opening. An observation of the 700-hall medication cart on 8/20/25 at 11:00 AM revealed the following:Insulin Lispro (Humalog) pen with an opened date of 6/12/25 and expiration date of 7/10/25. Insulin Lispro (Humalog) pen with an opened date of 7/7/25 and expiration date of 8/5/25. Insulin Lispro (Humalog) pen with an opened date of 6/18/25 and expiration date of 7/16/25. Insulin Glargine (Lantus) pen with an opened date of 7/1/25 and expiration date of 7/29/25. Insulin Glargine (Lantus) pen with no opened date and 60 of 300 units had been administered. During an interview on 08/18/25 at 11:01 AM Medication Aide #1 stated she was assigned to the 700-hall medication cart today. She stated she was not allowed to administer insulin and only nurses administered insulin therefore she did not check the cart for expired insulin. During an interview on 08/18/25 at 11:30 AM Unit Manager #1 stated the nurses were required to check the carts for expired medications. Unit Manager #1 indicated the nurses were required to check insulin pens for expiration dates before administering and record the date on the pen when opened. She stated she thought all of the medication carts had been checked today but unfortunately the insulin on the 700-hall cart was missed. During an interview on 08/19/25 at 4:00 PM the Director of Nursing (DON) stated all nurses were responsible for checking medication carts at least weekly for expired medications and insulin pens should be checked daily and prior to use. She stated the expired insulin on the 700-hall cart should have been discarded and an open date labeled on the Lantus pen.

Based on record review, and staff interviews, the facility failed to maintain an environment that was free from accident hazards when a mechanical lift that was not in use was left in the hallway (600 hall) by a staff member (Nurse Aide #3) which resulted in a cognitively impaired resident with poor safety awareness and a history of falls with injury to trip over the lift while ambulating in the hallway causing a fall with minor injury of blood on her left nostril. This occurred for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #11). Findings included: Resident #11 was admitted to the facility on [DATE] with diagnoses including Alzheimer's with dementia and agitation, and a history of falls. A care plan revised 3/14/25 revealed Resident #11 was at risk for falls due to a history of falls with injury, other risk factors included weakness, use of psychotropic medications, impaired memory, confusion and incontinence. The goal of care was to minimize the risk of falls and minimize injuries. Interventions included in part; provide staff education regarding fall hazards and implement preventative fall interventions. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #11 was severely cognitively impaired and independent with ambulation. She had two or more falls with injury. A post fall report dated 6/25/25 at 2:30 PM revealed Resident #11 had a fall in the hallway while ambulating. The current interventions that were not in place was the mechanical lift was in the hallway. The root cause was that a staff member left the lift in the hallway. Resident #11 tripped on the lift due to poor vision, inattention, and poor safety awareness. The immediate intervention was one-to-one education with the staff member (Nurse Aide #3). Education included the importance of always taking the mechanical lift back to the clean utility room when not in use.Attempts were made to contact Nurse Aide #3 on 8/21/25 at 1:30 PM with no response. A progress note dated 6/25/25 at 2:30 PM written by Nurse #1 revealed Resident #11 was found sitting on the floor on her buttocks having tripped on the mechanical lift while ambulating. A small trickle of blood was coming from her left nostril but subsided after being cleaned. There were no other injuries noted. Her vital signs were stable, and neurological checks were within normal limits. Resident #11 was able to move all extremities without difficulty or discomfort. She was wearing shoes at the time and was able to stand from the floor with two-person assistance as she was unsafe using the mechanical lift as evidenced by being unable to follow simple directions and grabs at the moving components of the lift. Resident #11 had been quickly ambulating throughout the facility with a slight lean to the left. She was taken to her room to rest throughout the day, but she gets out of the bed and continues to ambulate within minutes. During an interview on 8/21/25 at 10:15 AM Nurse #1 stated she routinely provided care to Resident #11 who had severe dementia with agitation and ambulated independently in the hallway and needed constant redirection. Nurse #1 stated Resident #11 had a fall in June 2025 when she tripped on the mechanical lift that was in the hallway outside of her room. She stated Resident #11 had some blood coming from her nose from the fall but had no other injuries, and her vital signs and neurological checks remained stable. Nurse #1 indicated Resident #11 continued to ambulate unassisted and due to severe dementia and poor safety awareness she would not be able to call for staff assistance before ambulating in and out of her room. Nurse #1 stated the mechanical lifts were to be kept in the utility room when not in use. An interdisciplinary note dated 7/2/25 at 12:15 PM revealed Resident #11 had a fall on 6/25/25. Resident #11 tripped over the mechanical lift that was in the hallway. Intervention was one to one staff education in regard to maintaining egress (a continuous unobstructed pathway) of the hallway. Resident #11 remained at baseline and continued to wander ad lib through the facility. Resident #11 has occasional periods of agitation and continues with poor safety awareness and impulsivity. During an interview on 08/19/25 at 2:47 PM Unit Manager #1 stated the mechanical lifts were to be kept in the utility room when not in use and not left in the hallway. She stated Resident #11 had a fall in June 2025 due to tripping on the mechanical lift that was left unattended in the hallway by a staff member (Nurse Aide #3). She provided one-to-one education to Nurse Aide #3 regarding properly storing the lifts and not leaving the lift in the hallway when not in use due to it being a fall hazard. During an interview on 8/21/25 at 2:00 PM the Director of Nursing (DON) indicated Resident #11 had severe dementia, a history of falls, and ambulated independently on the 600-hall. The DON stated the mechanical lifts were to be stored when not being used and not left in the hallway to prevent accidents. She indicated staff had received training on fall hazards including where to properly store the mechanical lifts.

Based on observations, record review, staff and resident interviews, the facility failed to 1.) develop a person-centered comprehensive care plan as indicated by the Minimum Data Set (MDS) care area assessment to include a plan of care for a resident (Resident #9) admitted with a feeding tube. 2.) implement the use of bilateral fall mats as care planned to prevent injury in the event of a fall from bed (Resident #5) for 2 of 21 residents reviewed for care plan development and implementation. Findings Included: 1.) Resident #9 was admitted to the facility on [DATE] with diagnoses including gastrostomy (feeding) tube. The Minimum Data Set (MDS) admission assessment and care areas assessment dated [DATE] revealed Resident #9 was cognitively impaired and received tube feedings. The care area assessment indicated to initiate a care plan for Resident #9’s feeding tube. Review of Resident #9’s medical record from 9/18/24 through 8/21/25 revealed no care plan was developed to care for Resident #9’s feeding tube. During an observation on 8/18/25 at 1:00 PM Resident #9 was observed with a feeding tube in place. During an interview on 8/21/25 at 1:00 PM the MDS Nurse stated she was not aware Resident #9 did not have a care plan in place for care of the feeding tube. She stated she began working as the MDS Nurse a few months ago and the previous MDS Nurse would have been the person responsible for initiating a care plan for the feeding tube after the MDS admission assessment was completed. During an interview on 8/21/25 at 2:00 PM the Director of Nursing (DON) stated the previous MDS nurse was no longer employed with the facility. She indicated care plans should be developed and implemented according to the required guidelines. 2. Resident #5 was admitted to the facility 07/01/25. Review of Resident #5’s physician order dated 07/30/25 listed: Bilateral fall mats - left and right side of bed, while resident is in bed. Review of Resident #5’s admission Minimum Data Set assessment dated [DATE] revealed Resident #5 was severely cognitively impaired, required total assistance for bed mobility and transfers, extensive assistance for locomotion, personal hygiene, and dressing. A nursing note dated 07/23/25 at 3:53 PM for Resident #5 revealed resident experienced a witnessed fall in their room at 1:30 PM with no complaints of pain or discomfort reported at the time of the fall. The resident slid out of bed to a sitting/upright position and no visible injuries, bleeding, swelling, or deformities noted. The resident returned to bed via mechanical lift with two nursing staff assisted. Fall prevention measures were reinforced, and resident’s Responsible Party (RP) and provider were notified of the incident. An Interdisciplinary Team (IDT) Meeting note dated 07/30/25 at 1:29 PM for Resident #5 revealed the resident was admitted on [DATE] after stroke. Fall on 07/23/25. Resident lowered himself from bed to floor. Fall mat was added to left side of his bed, as previously a fall mat was added to the right side of the bed, with bed kept in low position to reduce injury. Resident #5’s revised care plan dated 07/30/25 revealed he had self-care and mobility deficits and was at risk for falls related to recent falls, weakness, right-side hemiplegia, and poor safety awareness. An updated care plan intervention included: Bilateral fall mats (right and left side of bed) while resident was in bed. A nursing note dated 08/02/25 at 6:05 AM for Resident #5 revealed the resident slid out of bed onto his buttocks on the fall mat on the left side of his bed. No injuries noted. Resident at his baseline for responsiveness and was sitting up smiling and giving us a thumbs up that he was okay. Resident representative (RP) and Nurse Practitioner (NP) notified. A nursing note dated 08/14/25 at 4:37 PM for Resident #5 revealed the resident was relocated to a room on the 700-hall, per family and Resident #5 request, with housekeeping staff placing all personal belongings in his 700-hall room. An observation was conducted on 08/20/25 at 11:10 AM for Resident #5 revealed resident resting in bed, fully dressed, with one fall mat located on the floor next to the left side of his bed, and no fall mat on the right side of his bed. The resident motioned with his hands that he did not know where his second fall mat was, and that he only had one mat in his current room but had bilateral fall mats in his previous room. An interview and observation were conducted on 08/20/25 at 11:15 AM with the Director of Nursing (DON). She observed Resident #5’s room on the 700-hall and stated the resident should have had bilateral fall mats, one placed on each side of his bed as stated in resident’s care plan and it did not. She stated the resident was recently transferred to a new room from the 400-hall within last few days and that facility staff must have left resident’s second fall mat in his old room on. The DON stated per resident’s care plan she would immediately ask housekeeping to make sure Resident #5 had another fall mat placed on the right side of his bed to help prevent him from a possible injury from another fall due to his history of falls. An interview was conducted on 08/20/25 at 11:20 AM with the Administrator. She stated the resident should have had bilateral fall mats, one placed on each side of his bed as stated in resident’s care plan and it did not.

Based on record review and interviews with the Responsible Party, Nurse Practitioner, Medical Director and staff, the facility failed to have a system in place to train agency nurses and verify their competency to provide care for a resident with a jejunostomy tube (j-tube [a feeding tube placed in the small intestine]). On 1/25/25 when Resident #1's j-tube became dislodged, Nurse #1 did not identify the need for hospital treatment to replace the dislodged j-tube and she replaced it by inserting a urinary catheter tube into the j-tube site. Nurse #1 stated she assumed Resident #1's j-tube was a gastrostomy tube (tube placed in the stomach for nutritional support). Replacing a j-tube requires radiographic (x-ray) guidance or surgical placement and Nurse #1 performing this action at the facility created a high likelihood of Resident #1 suffering serious harm from the risks of placing the j-tube in the wrong place, perforation of the small intestine, sepsis (life-threatening infection), and bleeding due to anticoagulant (blood thinner) use. This deficient practice was identified for 1 of 3 nurses reviewed for competency. Immediate jeopardy began on 1/25/25 when Nurse #1 failed to demonstrate competency to care for a resident with a j-tube when she replaced Resident #1's dislodged j-tube with an indwelling urinary catheter tube. Immediate jeopardy was removed on 4/25/25 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. The findings included: This Tag is cross referenced to: F693: Based on record review, Nurse Practitioner (NP), Medical Director, staff, and Responsible Party (RP) interviews, the facility failed to ensure a resident (Resident #1) was provided with the necessary treatment to replace his dislodged jejunostomy tube (a surgically placed feeding tube that delivers nutrition and medications directly into the small intestine). On 1/25/25, Nurse #1 did not identify the need for hospital treatment to replace the dislodged jejunostomy tube (j-tube) and she inserted an indwelling urinary catheter tube to replace the j-tube without a physician's order. The replacement tube became dislodged from the j-tube site on 1/25/25, and Nurse #1 sent the resident to the hospital for reinsertion. Resident #1 went to the Operating Room (OR) on the evening of 1/27/25 and the j-tube was successfully placed. This noncompliance created a high likelihood of Resident #1 suffering serious harm from the risks of placing the j-tube in the wrong place, perforation of the small intestine, sepsis (life-threatening infection), and bleeding due to anticoagulant (blood thinner) use. This deficient practice was identified for 1 of 3 residents reviewed for feeding tubes. Review of Nurse #1's employee record verified she was hired by the facility on 1/10/25 as an agency licensed practical nurse (LPN). There was no evidence of competency and training regarding j-tubes in her file. Review of the facility training for agency nurses did not identify specific training and competency for j-tubes. An interview was completed with Nurse #1 on 1/23/25 at 10:00 AM. Nurse #1 stated she was an experienced nurse, and she had completed training regarding gastrostomy tubes and jejunostomy tubes at other facilities she had worked at. She further stated she did not recall completing training specifically regarding j-tubes when she was in orientation at this facility. An interview was completed with the Director of Nursing (DON) on 4/23/25 at 4:10 PM. The DON stated the agency was responsible for verifying a nurse's training and competencies prior to employment by the facility. She indicated the facility's orientation for agency nurses did not include specific competency and training for j-tubes at the time of Nurse #1's employment. The Administrator was notified of immediate jeopardy on 4/23/25 at 4:00 PM. The Administrator provided the following credible allegation of Immediate Jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: The facility failed to ensure Nurse #1 was trained and competent to provide the necessary care and treatment for residents with jejunostomy tubes (j-tubes). Nurse #1 did not identify the need for hospital treatment to replace Resident #1's dislodged j-tube and she inserted an indwelling urinary catheter tube to replace the tube. Surgical Residents were able to place an indwelling urinary catheter tube into the tract in the emergency room (ER). Interventional Radiology (IR) attempted placement on January 27, 2025 but were not able to place. Resident #1 went to the Operating Room (OR) on the evening of January 27, 2025 and the j-tube was successfully placed. Resident #1 returned to the facility on [DATE]. During the remainder of Resident #1's time at facility, the j-tube did not dislodge again. Resident #1 was discharged from the facility on March 28, 2025. On April 23, 2025, the Director of Nursing (DON) reviewed all residents that resided in the facility from [DATE] until April 23, 2025 and no additional residents were identified with a j-tube in the facility at this time. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: The Director of Nursing (DON), Assistant Director of Nursing (ADON), and Unit Managers will provide education to Licensed Nurses on Gastrostomy Tube Reinsertion Policy, to include what to do if a j-tube becomes dislodged to include physician notification, not to attempt reinsertion of the j-tube and risks and sending the resident to the hospital for surgical reinsertion. A quiz was created to validate staff understanding of the material that was taught. Any nurse that cannot answer the quiz questions appropriately will be retrained by the DON or ADON on the material. Training will be completed by April 24, 2025. The Director of Nursing will track and verify that employees with scheduled time off, on leave of absence (FMLA), vacation, agency staff or PRN staff will be re-educated prior to returning to duty. New hires and Agency Nurses will be educated by the DON or ADON during the orientation process using the Gastrostomy Tube Reinsertion Policy. The quiz will be given at the end of their training to validate understanding on what to do if a j-tube becomes dislodged to include physician notification, not to attempt reinsertion of the j-tube and risks and sending the resident to the hospital for surgical reinsertion. Alleged immediate jeopardy removal date: April 25, 2025. The immediate jeopardy removal plan was validated on 4/24/25. The audit of 100% of residents with feeding tubes verified there were no other residents with j-tubes identified. The educations sign in sheets were reviewed for in-services conducted with the nurses on 4/23/25 and 4/24/25 regarding the facility's Gastrostomy Tube Reinsertion Policy which included education regarding what to do if a j-tube becomes dislodged including physician notification, not attempting reinsertion of the j-tube, risks involved in reinsertion, and sending the resident to the hospital for surgical reinsertion. Staff interviews confirmed education and a quiz on gastrostomy tubes, j-tubes, and what to do if a jejunostomy becomes dislodged. The validation quizzes were reviewed with no concerns. The DON stated on 4/24/25 at 12:22 PM that all the nurses, including new hires and agency nurses, would have to pass the validation quiz for competency regarding feeding tubes. The facility's immediate jeopardy removal date of 4/25/25 was validated.

Based on record review, Nurse Practitioner (NP), Medical Director, staff, and Responsible Party (RP) interviews, the facility failed to ensure a resident (Resident #1) was provided with the necessary treatment to replace his dislodged jejunostomy tube (a surgically placed feeding tube that delivers nutrition and medications directly into the small intestine). On 1/25/25, Nurse #1 did not identify the need for hospital treatment to replace the dislodged jejunostomy tube (j-tube) and she inserted an indwelling urinary catheter tube to replace the j-tube without a physician's order. The replacement tube became dislodged from the j-tube site on 1/25/25, and Nurse #1 sent the resident to the hospital for reinsertion. Resident #1 went to the Operating Room (OR) on the evening of 1/27/25 and the j-tube was successfully placed. This noncompliance created a high likelihood of Resident #1 suffering serious harm from the risks of placing the j-tube in the wrong place, perforation of the small intestine, sepsis (life-threatening infection), and bleeding due to anticoagulant (blood thinner) use. This deficient practice was identified for 1 of 3 residents reviewed for feeding tubes. Immediate jeopardy began on 1/25/25 when Nurse #1 replaced Resident #1's dislodged jejunostomy tube. Immediate jeopardy was removed on 4/25/25 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. The findings included: The hospital discharge summary for Resident #1 dated 1/14/25 indicated he was admitted to the hospital on 1/2/25 with diagnoses of cerebral infarction due to occlusion of left middle cerebral artery (stroke), global aphasia (unable to speak), oropharyngeal dysphagia (difficulty swallowing), and right hemiparesis (muscle weakness on one side of the body). A j-tube was placed surgically into the small intestine on 1/10/25 as the main source for meeting his nutritional needs. He was discharged to the facility on [DATE] for rehabilitation services. Resident #1 was admitted to the facility on [DATE] with diagnoses including cerebral infarction due to occlusion or stenosis or left middle cerebral artery, dysphagia, and aphasia. The physician's orders for Resident #1 revealed orders dated 1/14/25: 1) j-tube 16 French (size), 2) tube feeding at a continuous rate of 70 milliliters (ml) an hour for 22 hours to allow for activities of daily living, and 3) apixaban tablet (an anticoagulant) 5 milligrams (mg) twice a day per feeding tube. There was not a physician's order to change the j-tube. The Care Plan for Resident #1 dated 1/14/25 revealed a plan of care for risk for nutritional decline, dehydration, weight fluctuations related to recent stroke resulting in dysphagia and aphasia, and 100% reliance on tube feeding for nutrition/hydration with a goal that he would be free of signs and symptoms of dehydration, fluid overload, and electrolyte imbalances through the next review. The interventions included: monitoring for signs and symptoms of dehydration, checking for residual prior to administering tube feeding; administering tube feeding as ordered by the physician. Another plan of care for impaired skin integrity related to Resident #1 was admitted with abdominal surgical wounds from j-tube placement in the distal (far) right upper quadrant (divides the abdomen in four quarters with the umbilicus [navel or bellybutton] in the middle), the right upper quadrant, umbilicus and left upper quadrant with a goal that the wounds would heal without complications (infection, hemorrhage, dehiscence [wound opens up]). The interventions included observing and reporting signs of infection (pain, redness, swelling, tenderness), and providing treatments as ordered. A nurse progress note dated 1/15/25 at 10:21 AM by the Wound Nurse revealed Resident #1 was seen that day for new admission wound assessments and j-tube care. Four surgical incisions were noted to abdomen status post j-tube placement and the areas were scabbed with surgical glue in place, and open to air. No signs or symptoms of infection were noted. A small, scabbed area was observed near the j-tube site with surgical glue in place. The jejunostomy site was cleansed and new split gauze in place. The Physician's History and Physical dated 1/16/25 for Resident #1 indicated that he was admitted to the facility with right-sided weakness related to left medial cerebral artery occlusion. The note indicated Resident #1 was status post-surgical placement of a j-tube on 1/10/25 to meet his nutritional needs due to dysphagia. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was severely cognitively impaired. He was coded as having no speech and receiving greater than 51% of his nutrition and over 500 ml of water from enteral (tube) feeding daily. He was coded as dependent on staff assistance with toileting, transferring, and bed mobility and he was always incontinent of bowel and bladder. The assessment listed that he was receiving speech therapy, occupational therapy, and physical therapy. He was coded for receiving an anticoagulant. A partially filled out SBAR (Situation, Background, Appearance, and Review and Notify is a structured communication tool used to transmit clear concise information) communication form in the chart dated 1/25/25 and signed by Nurse #1 listed the Situation was: The change in condition, symptoms, or signs observed and evaluated were Resident #1 pulling out his j-tube 2 times and the condition was listed as occurring before due to resident consistently playing and tugging on the tube. There was no other information listed except that the RP was notified at 12:51 PM and the on-call provider was notified at 1:12 PM. The box to call for 911 for transfer to the hospital was checked. An incomplete Hospital Transfer Form for Resident #1 listed the following information: His name, date of admission, date of birth, and primary diagnosis. It further listed the RP was notified of the situation and of the transfer to the hospital. The reason for the transfer was listed as pulled out j-tube. The risk alert boxes for anticoagulation, aspiration, high fall risk, needs medications crushed, and pain level were checked. The form was not signed by facility staff and no other information was noted. A telephone interview was conducted with Nurse #1 on 4/23/25 at 10:00 AM. Nurse #1 indicated that on 1/25/25 she was assigned to care for Resident #1. She stated she was an agency nurse with [AGE] years of experience. Nurse #1 further stated she had worked for the facility in January for approximately 3 weeks, but she was no longer employed there. She stated that on 1/25/25 at approximately 12:15 PM she went into administer Resident #1 his medications per feeding tube, and the tube was not in his abdomen. Nurse #1 stated that the tube feeding was scheduled for only 22 hours a day to allow for activities of daily living (ADL) care and therapy and she had not had a chance to reconnect the tube feeding that morning. She indicated that there was no bleeding at that time. She reported that she went and asked Nurse Aide (NA) #1 if she knew what happened to Resident #1's feeding tube. Nurse #1 stated that NA #1 reported she had seen something that looked like a tube on the bathroom floor 2-3 hours ago, but she had not reported it to the nurse. She further stated that NA #1 informed her that therapy was working with Resident #1 in the bathroom early that morning around 9:15 AM. Nurse #1 indicated that after speaking with NA #1 she had gone back to Resident #1's room and found the feeding tube on the bathroom floor. Nurse #1 stated she had consulted the Wound Nurse, who was the Manager on duty, and that she had instructed her to replace it with an enteral feeding tube of the same size or a tube for an indwelling urinary catheter. Nurse #1 indicated she had replaced the j-tube with a 16 French indwelling urinary catheter tube. She stated she was unaware that it was a j-tube and had assumed it was a gastrostomy tube (in the stomach). Nurse #1 indicated that if she had known Resident #1 had a j-tube and not a gastrostomy tube she would have sent him to the hospital the first time it dislodged. She stated that she had never heard of anyone reinserting a j-tube in a nursing facility. She further indicated she never had a chance to administer any medications or tube feeding through the tube after replacing it the first time because Resident #1 pulled it out approximately 30 minutes later. She indicated the RP for Resident #1 was the one that found him the second time the tube was dislodged and that the tube was laying on the floor beside his wheelchair and there was blood on his abdomen, legs, and the floor. Nurse #1 stated she notified the Director of Nursing (DON) the second time the tube was dislodged and she instructed her to notify the provider and transfer him to the hospital. She indicated that the residents she was assigned to care for that day were high acuity (residents requiring closer monitoring and treatments with i.e. tracheostomy tubes, feeding tubes, wounds) and she had not completed the documentation related to the incident. Nurse #1 indicated that after transferring Resident #1 to the hospital she had asked the Certified Occupational Therapy Assistant (COTA) if he had noticed if the feeding tube was dislodged during the transfer in the bathroom and he stated he was unaware that it had dislodged. She further indicated that 1/25/25 was the last day she worked for the facility. A telephone interview was completed with NA #1 on 4/23/25 at 12:23 PM. NA #1 stated that on 1/25/25 she had noticed something that looked like a tube lying on Resident #1's bathroom floor after she observed the COTA working with Resident #1 at approximately 9:15 AM. She stated she was busy and was in a hurry and had not stopped to examine the object on the floor. She further stated she had not notified the nurse that something was lying on the floor. A telephone interview was completed with the Wound Nurse on 4/23/25 at 12:28 PM. The Wound Nurse stated she was the Manager on Duty on 1/25/25. She further stated she remembered Nurse #1 telling her that a feeding tube was dislodged. The Wound Nurse indicated she could not recall if Nurse #1 told her it was a j-tube. She further indicated that she did tell Nurse #1 that she could replace a gastrostomy tube and that if the facility didn't have the correct size tube, she could use the same size indwelling urinary catheter tube instead. The Wound Nurse stated that she told Nurse #1 to call the provider for an order. A telephone interview was completed with the COTA who was assigned to Resident #1 on 1/25/25. The COTA stated that on 1/25/25 he was working with Resident #1 in the bathroom with toilet transfers. He stated that he was aware Resident #1 had a feeding tube, so he had placed the gait belt up higher around the chest instead of around the abdomen to prevent dislodging the feeding tube. The COTA indicated that nothing out of the ordinary occurred during the transfer and he did not know how the tube became dislodged. He further indicated there had not been any indications from Resident #1 that the tube was dislodged such as grimacing, pointing, or any sign of pain. The COTA stated he never saw a tube on the bathroom floor, but if he had seen a tube, he would have notified the nurse. A telephone interview was completed with the RP on 4/24/25 at 10:54 AM. The RP stated that on 1/25/25 at approximately 12:45 PM she walked into Resident #1's room and found him sitting in his wheelchair and the feeding tube was lying on the floor beside the wheelchair. She further stated that Resident #1 had his finger in the hole trying to stop the bleeding. The RP indicated that blood was on his abdomen, his legs, and the floor. She indicated she called for the nurse to come help Resident #1. She further indicated Nurse #1 placed a bandage over the wound and called 911 to have him transferred to the hospital. A nurse's progress note written by the DON on 1/25/25 at 2:00 PM indicated that she received a call from floor nurse that Resident #1's j-tube fell out. Nurse #1 was advised to call the Provider on call and send to the hospital or placement of j-tube. An interview with the DON was completed 4/23/25 at 4:10 PM. The DON stated she had documented the note related to Resident #1 on 1/25/25 from her home computer. She further stated that when Nurse #1 notified her that Resident #1's j-tube was dislodged she had instructed her to call the provider to get an order to send him to the hospital. The DON indicated that Nurse #1 had mentioned something about reinserting the tube and she had informed her that resident's with dislodged j-tubes were sent to the hospital to have it replaced. She further indicated that Nurse #1 was suspended that day and never returned to the facility. The DON stated she had called Nurse #1 multiple times to try to get her to come by the facility and complete the paperwork and documentation about the incident involving Resident #1 on 1/25/25. The DON indicated that j-tubes were inserted at the hospital using radiographic (x-ray) guidance or surgically placed. The DON stated the facility policy and procedures allowed nurses to change gastrostomy tubes in a facility with a physician's order, but not j-tubes. She stated she expected all the nurses to follow the facility's policies and procedures. The hospital record included an Emergency Department (ED) Encounter note by the ED Physician dated 1/25/25 that revealed Resident #1 presented to the hospital with a dislodged j-tube. The note indicated the j-tube was approximately two weeks old and it was dislodged and replaced with temporary urinary catheter, and it became dislodged again. Surgical Residents were able to place a urinary catheter tube into the tract in the emergency room (ER). Interventional Radiology (IR) attempted placement on 1/27/25 but were not able to place. Resident #1 went to the Operating Room (OR) on the evening of 1/27/25 and the j-tube was successfully placed. There were no complications related to the surgery and Resident #1 returned to the facility on [DATE]. An interview was conducted with the Nurse Practitioner (NP) on 4/23/25 at 10:43 AM. The NP stated that it was not appropriate for a nurse to change the j-tube. She further stated there was risk perforation (poking a hole through the wall of the intestine) and an increased chance of causing a serious infection by pushing bacteria into the abdomen. The NP indicated Resident #1 was on an anticoagulant that put him at higher risk of bleeding. She further indicated a physician's order would be needed to change any tube. The NP stated it was out the nurse's scope of practice to replace a tube without a physician's order. An interview with the Medical Director was completed on 4/23/25 at 11:47 AM. The Medical Director stated that it was totally inappropriate for a nurse to replace a j-tube in the facility. She further stated that since the tube was surgically inserted on 1/10/25 the site was probably not mature (a jejunostomy site needs to mature to form a stable track between the skin and the jejunum [small intestine] to prevent leakage of intestinal contents and this takes approximately 4 weeks) and there would be higher risk for bowel perforation, the tissue would be more friable (tissue that is easily irritated, which makes it more prone to inflammation, bleeding, and tearing) and cause more bleeding, and the fact that he was on an anticoagulant would definitely increase the risk of bleeding. There was definitely a high likelihood of harm due to risk or sepsis, bleeding, and perforation. An interview was completed with the Administrator on 4/24/25 at 9:35 AM. The Administrator stated he expected the nursing staff to follow the facility's policies and procedures regarding feeding tubes. The Administrator was notified of immediate jeopardy on 4/23/25 at 4:00 PM. The Administrator provided the following credible allegation of Immediate Jeopardy removal: Identify those residents who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: On January 25, 2025, the facility failed to ensure Resident #1 was provided with the necessary treatment to replace his dislodged jejunostomy tube (a tube surgically placed feeding tube that delivers nutrition and medications directly into the small intestine). Nurse #1 did not identify the need for hospital treatment to replace the dislodged j-tube and she inserted an indwelling urinary catheter tube to replace the j-tube. The tube then became dislodged a second time on January 25, 2025, and Nurse #1 sent the resident to hospital for reinsertion. Surgical Residents were able to place an indwelling urinary catheter tube into the tract in the emergency room (ER). Interventional Radiology (IR) attempted placement on January 27, 2025, but were not able to place. Resident #1 went to the Operating Room (OR) on the evening of January 27, 2025, and the j-tube was successfully placed. Resident #1 returned to the facility on [DATE]. During the remainder of Resident #1's time at facility, the j-tube did not dislodge again. Resident #1 was discharged from the facility on March 28, 2025. On April 23, 2025, the Director of Nursing (DON) reviewed all residents that resided in the facility from [DATE], until April 23, 2025, and no additional residents were identified with a j-tube in the facility at this time. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: The Director of Nursing (DON), Assistant Director of Nursing (ADON), and Unit Managers will provide education to Licensed Nurses on Enteral Feeding Tube(s) Policy, to include what to do if a j-tube becomes dislodged to include physician notification, not to attempt reinsertion of the j-tube, and sending the resident to the hospital for surgical reinsertion. Training will be completed by April 24, 2025. The Director of Nursing will track and verify that employees with scheduled time off, on leave of absence (FMLA), vacation, agency staff or PRN staff will be re-educated prior to returning to duty by the DON or ADON. New hires and Agency Nurses will be educated by the Director of Nursing or Assistant Director of Nursing during the orientation process. Effective April 24, 2025, the DON or ADON will review all new admissions in the Clinical Morning Meeting on Monday through Friday, as well as any pending weekend admissions, to determine if any admissions have a j-tube present and ensure all Licensed Nursing staff are made aware of the presence of a j-tube and the process for physician notification and treatment if a j-tube becomes dislodged. Licensed nurses will be made aware of residents that are admitted with a j-tube via the Admission Notification Form that is provided by the Admission Director for all pending admissions. Admission Notification Form will be delivered to the admitting nurse with the hospital discharge summary by the Admission Director prior to resident arrival. Alleged immediate jeopardy removal date: April 25, 2025 The immediate jeopardy removal plan was validated on 4/24/25. The audit of 100% of residents with feeding tubes verified there were no other residents with j-tubes identified. The education sign in sheets were reviewed for the in-services conducted with the nurses on 4/23/25 and 4/24/25 regarding enteral feeding tubes policy and what to do if a j-tube becomes dislodged. Staff interviews confirmed education on gastrostomy tubes, j-tubes, and what to do if a jejunostomy becomes dislodged. The DON stated on 4/24/25 at 12:22 PM stated that effective 4/24/25 the DON or ADON will review all new admissions in the Clinical Morning Meeting on Monday through Friday, as well as pending weekend admissions, to determine if any admissions have a j-tube present and ensure all licensed nursing staff are made aware of the presence of a j-tube and the process of physician notification and treatment if a j-tube becomes dislodged. The facility's immediate jeopardy removal date of 4/25/25 was validated.

Based on record review and interviews with staff, the Medical Director, and the Nurse Practitioner (NP), the facility failed to immediately notify the physician on 1/25/25 of a resident's (Resident #1) dislodged jejunostomy tube (j-tube [a tube surgically inserted into the small intestine to deliver nutrition and medications]). Nurse #1 did not communicate with the physician and she inserted an indwelling urinary catheter tube to replace the j-tube without a physician's order. The replacement tube became dislodged from the j-tube site on 1/25/25 and Nurse #1 sent the resident to the hospital for reinsertion. Resident #1 went to the Operating Room (OR) on the evening of 1/27/25 and the j-tube was surgically placed. This delayed physician notification had a high likelihood of resulting in serious harm for Resident #1 from the risks of placing the j-tube in the wrong place, perforation of the small intestine, sepsis (life-threatening infection), and bleeding due to anticoagulant (blood thinner) use. This deficient practice affected 1 of 2 residents reviewed for notification. Immediate jeopardy began on 1/25/25 when Nurse #1 failed to notify the physician regarding Resident #1's dislodged jejunostomy tube. Immediate jeopardy was removed on 4/25/25 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. The findings included: The hospital discharge summary for Resident #1 dated 1/14/25 indicated he was admitted to the hospital on 1/2/25 and a j-tube was placed surgically into the small intestine on 1/10/25 as the main source for meeting his nutritional needs. He was discharged to the facility on [DATE] for rehabilitation services. Resident #1 was admitted to the facility on [DATE] with diagnoses including cerebral infarction due to occlusion or stenosis of left middle cerebral artery (stroke), dysphagia (difficulty swallowing), and aphasia (absence of speech). The physician's orders for Resident #1 revealed orders dated 1/14/25: 1) j-tube 16 French (size), 2) tube feeding at a continuous rate of 70 milliliters (ml) an hour for 22 hours to allow for activities of daily living, and 3) apixaban tablet (an anticoagulant) 5 milligrams (mg) twice a day per feeding tube. There was not a physician's order to change the j-tube. The Physician's History and Physical dated 1/16/25 for Resident #1 indicated that he was admitted to the facility with right-sided weakness related to left medial cerebral artery occlusion. The note indicated Resident #1 was status post-surgical placement of a j-tube on 1/10/25 to meet his nutritional needs due to dysphagia. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was severely cognitively impaired. He was coded as having no speech and receiving greater than 51% of his nutrition and over 500 ml of water from enteral (tube) feeding daily. He was coded for receiving an anticoagulant. A partially filled out SBAR (Situation, Background, Appearance, and Review and Notify is a structured communication tool used to transmit clear concise information) communication form in the chart dated 1/25/25 and signed by Nurse #1 listed the Situation was: The change in condition, symptoms, or signs observed and evaluated were Resident #1 pulling out his j-tube 2 times and the condition was listed as occurring before due to resident consistently playing and tugging on the tube. There was no other information listed except that the Responsible Party (RP) was notified at 12:51 PM and the on-call provider was notified at 1:12 PM. The box to call for 911 for transfer to the hospital was checked. An incomplete Hospital Transfer Form for Resident #1 listed the following information: His name, date of admission, date of birth, and primary diagnosis. It further listed the RP was notified of the situation and of the transfer to the hospital. The reason for the transfer was listed as pulled out j-tube. The risk alert boxes for anticoagulation, aspiration, high fall risk, needs medications crushed, and pain level were checked. The form was not signed by facility staff and no other information was noted. A telephone interview was conducted with Nurse #1 on 4/23/25 at 10:00 AM. Nurse #1, an agency nurse, stated she worked for the facility in January for approximately 3 weeks, but she was no longer employed there. She stated that on 1/25/25 she was assigned to care for Resident #1 and at approximately 12:15 PM she went into administer Resident #1 his medications per feeding tube and the tube was not in his abdomen. Nurse #1 stated that the tube feeding was scheduled for only 22 hours a day to allow for activities of daily living (ADL) care and therapy and she had not had a chance to reconnect the tube feeding that morning. She indicated that there was no bleeding at that time. She reported that she went and asked Nurse Aide (NA) #1 if she knew what happened to Resident #1's feeding tube. Nurse #1 stated that NA #1 reported she had seen something that looked like a tube on the bathroom floor 2-3 hours ago, but she had not reported it to the nurse. She further stated that NA #1 informed her that therapy was working with Resident #1 in the bathroom early that morning around 9:15 AM. Nurse #1 indicated that after speaking with NA #1 she had gone back to Resident #1's room and found the feeding tube on the bathroom floor. She indicated she had been a nurse for [AGE] years and she was experienced in reinserting gastrostomy tubes (in the stomach). She explained that she was unaware Resident #1 had a j-tube and she had assumed it was a gastrostomy tube. Nurse #1 stated that instead of calling the physician she had consulted the Wound Nurse, who was the Manager on duty that weekend. She stated the Wound Nurse had instructed her to replace it with an enteral feeding tube of the same size or a tube for an indwelling urinary catheter. Nurse #1 indicated she had replaced the j-tube with a 16 French indwelling urinary catheter tube. Nurse #1 indicated that if she had known Resident #1 had a j-tube and not a gastrostomy tube she would have sent him to the hospital the first time it dislodged. She stated that she had never heard of anyone reinserting a j-tube in a nursing facility. Nurse #1 stated she notified the Director of Nursing (DON) the second time the tube was dislodged, and she instructed her to notify the provider and transfer him to the hospital. Nurse #1 indicated that after transferring Resident #1 to the hospital she had asked the Certified Occupational Therapy Assistant (COTA) if he had noticed if the feeding tube was dislodged during the transfer in the bathroom and he stated he was unaware that it had dislodged. She further indicated that 1/25/25 was the last day she worked for the facility. A telephone interview was completed with NA #1 on 4/23/25 at 12:23 PM. NA #1 stated that on 1/25/25 she had noticed something that looked like a tube lying on Resident #1's bathroom floor after she observed the COTA working with Resident #1 at approximately 9:15 AM. She stated she was busy and was in a hurry and had not stopped to examine the object on the floor. She further stated she had not notified the nurse that something was lying on the floor. A telephone interview was completed with the Wound Nurse on 4/23/25 at 12:28 PM. The Wound Nurse stated she was the Manager on Duty on 1/25/25. She further stated she remembered Nurse #1 telling her that a feeding tube was dislodged. The Wound Nurse indicated she could not recall if Nurse #1 told her it was a j-tube. She further indicated that she did tell Nurse #1 that she could replace a gastrostomy tube and that if the facility didn't have the correct size tube, she could use the same size indwelling urinary catheter tube instead. The Wound Nurse stated that she instructed Nurse #1 to call the provider for an order. A telephone interview was completed with the COTA who was assigned to Resident #1 on 1/25/25. The COTA stated that on 1/25/25 he was working with Resident #1 in the bathroom with toilet transfers. The COTA indicated that nothing out of the ordinary occurred during the transfer, and he did not know how the tube became dislodged. He further indicated there had not been any indications from Resident #1 that the tube was dislodged such as grimacing, pointing, or any sign of pain. The COTA stated he never saw a tube on the bathroom floor, but if he had seen a tube, he would have notified the nurse. A nurse's progress note written by the DON on 1/25/25 at 2:00 PM indicated that she received a call from floor nurse that Resident #1's j-tube fell out. Nurse #1 was advised to call the Provider on call and send to the hospital or placement of j-tube. An interview with the DON was completed 4/23/25 at 4:10 PM. The DON stated she had documented the note related to Resident #1 on 1/25/25 from her home computer. She further stated that when Nurse #1 notified her that Resident #1's j-tube was dislodged she had instructed her to call the provider to get an order to send him to the hospital. The DON indicated that Nurse #1 had mentioned something about reinserting the tube and she had informed her that resident's with dislodged j-tubes were sent to the hospital to have it replaced. She stated that Nurse #1 should have notified the physician when the j-tube was initially dislodged. The DON indicated that Nurse #1 was suspended that day and never returned to the facility. The DON stated j-tubes were inserted at the hospital using radiographic (x-ray) guidance or surgically placed. The hospital record included an Emergency Department (ED) Encounter note by the ED Physician dated 1/25/25 that revealed Resident #1 presented to the hospital with a dislodged j-tube. The note indicated the j-tube was approximately two weeks old and it was dislodged and replaced with temporary urinary catheter, and it became dislodged again. Surgical Residents were able to place a urinary catheter tube into the tract in the emergency room (ER). Interventional Radiology (IR) attempted placement on 1/27/25 but were not able to place. Resident #1 went to the Operating Room (OR) on the evening of 1/27/25 and the j-tube was successfully placed. There were no complications related to the surgery and Resident #1 returned to the facility on [DATE]. An interview was conducted with the Nurse Practitioner (NP) on 4/23/25 at 10:43 AM. The NP stated that it was not appropriate for a nurse to change the j-tube. She further stated there was risk perforation (poking a hole through the wall of the intestine) and an increased chance of causing a serious infection by pushing bacteria into the abdomen. The NP indicated Resident #1 was on an anticoagulant that put him at higher risk of bleeding. She further indicated a physician's order would be needed to change any tube. The NP stated it was out the nurse's scope of practice to replace a tube without a physician's order. She indicated Nurse #1 should have notified the on-call provider before reinserting a replacement tube. An interview with the Medical Director was completed on 4/23/25 at 11:47 AM. The Medical Director stated that it was totally inappropriate for a nurse to replace a j-tube in the facility. She further stated that since the tube was surgically inserted on 1/10/25 the site was probably not mature (a jejunostomy site needs to mature to form a stable track between the skin and the jejunum [small intestine] to prevent leakage of intestinal contents and this takes approximately 4 weeks) and there would be higher risk for bowel perforation, the tissue would be more friable (tissue that is easily irritated, which makes it more prone to inflammation, bleeding, and tearing) and cause more bleeding, and the fact that he was on an anticoagulant would definitely increase the risk of bleeding. The Medical Director indicated there was definitely a high likelihood of harm due to risk or sepsis, bleeding, and perforation for a nurse to change a j-tube in a nursing facility. She stated that Nurse #1 should not have attempted to reinsert the j-tube without notifying the provider. The Medical Director indicated that j-tubes were placed at the hospital using x-ray or computed tomography (CT) scan guidance. An interview was completed with the Administrator on 4/24/25 at 9:35 AM. The Administrator stated he expected the nursing staff to follow the facility's policies and procedures regarding feeding tubes and notifying the physician. The Administrator was notified of immediate jeopardy on 4/23/25 at 4:00 PM. The Administrator provided the following credible allegation of Immediate Jeopardy removal: Identify those residents who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: On January 25, 2025, the facility failed to immediately notify the physician of Resident #1's dislodgement of a jejunostomy tube (a tube surgically inserted into the small intestine to deliver nutrition and medications). Nurse Aide #1 identified a tube on the floor of Resident #1's bathroom at approximately 9:00 AM. She did not communicate this information to Nurse #1. At approximately 12:15 PM Nurse #1 identified Resident #1's dislodged j-tube. Nurse #1 replaced Resident #1's dislodged j-tube and she inserted an indwelling urinary catheter tube to replace the tube and did not notify the physician. The j-tube then became dislodged a second time on January 25, 2025 at approximately 12:45 PM, and Nurse #1 notified the physician at 1:15 PM and sent the resident to hospital for reinsertion. Surgical Residents were able to place a foley into the tract in the emergency room (ER). Interventional Radiology (IR) attempted placement on January 27, 2025 but were not able to place. Resident #1 went to the Operating Room (OR) on the evening of January 27, 2025 and j-tube was successfully placed. Resident #1 returned to the facility on [DATE]. During the remainder of Resident #1's time at facility, the j-tube did not dislodge again. Resident #1 was discharged from the facility on March 28, 2025. The Director of Nursing (DON) conducted a 30 day look back to review other residents identified with a change in condition to verify Physician and/or Provider was notified in a timely manner. This review was completed by the DON on April 23, 2025 and consisted of a thorough review of change of condition assessments identified in our electronic medical record through observations titled Interact SBAR (an SBAR stands for Situation, Background Assessment, Recommendation), Interact Nursing Home to Hospital Transfer Form, and Events. An email was sent to the Medical Director with a list of all residents that experienced a significant change of condition during that time period. A significant change of condition is identified as a decline or improvement in the resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical intervention(s); and/or one that 2. Impacts more than one area of the resident's health status; and/or one that 3. Requires interdisciplinary review and/or revision to the care plan. No additional concerns were identified. The Medical Director replied to the email sent by the Director of Nursing that she had reviewed the list without further concerns on April 24, 2025. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: The DON, Assistant Director of Nursing (ADON), and Unit Managers re-educated Licensed Nurses and Nurse Aides (NA) on Resident Change in Condition Policy with emphasis on changes that require immediate physician notification and documentation by April 24, 2025. Changes requiring prompt notification include a decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions(s), impacts more than one area of the resident's health status, and/or requires interdisciplinary review or revision to the care plan. The Nurse Aides were educated to notify the charge nurses if any devices, such as enteral feeding tubes, were displaced or not in resident at time of care. The Director of Nursing will track and verify that employees with scheduled time off, on leave of absence (FMLA), vacation, agency staff or PRN staff will be re-educated prior to returning to duty. New Licensed Nurses, Agency Nurses, and Nurse Aides will be educated by the DON or ADON during the orientation process. Effective April 24, 2025, the Director of Nursing will review the Facility Activity Report for any Interact SBAR, Interact Nursing Home to Hospital Transfer Forms, or any Events in the morning Clinical Morning Meeting, which will be held seven days a week, to verify prompt and/or immediate notification is communicated to the Physician and/or Provider. If notification to the physician has not occurred, the DON will notify the physician at that time. Alleged immediate jeopardy removal date: April 25, 2025. The immediate jeopardy removal plan was validated on 4/24/25. The DON provided a list of residents who were reviewed by the Medical Director for notification of a significant change in condition on 4/24/25. An interview with the NP on 4/24/24 at 12:15 PM confirmed that the facility had sent the list of residents to the Medical Director and the providers had reviewed the list and no other concerns were identified. The education sign in sheets were reviewed for the in-services conducted with the nursing staff on 4/23/25 and 4/24/25 regarding Resident Change in Condition Policy and Changes requiring prompt notification of the nurse or provider. Staff interviews with nurses confirmed education regarding significant changes in condition and when to notify the provider was provided. Interviews completed with the Nurse Aides confirmed education on notifying the charge nurses if any devices, such as enteral feeding tubes, were displaced. The DON stated on 4/24/25 at 12:22 PM that effective 4/24/25 she would be reviewing the Facility Activity Report for any Interact SBAR, Nursing Home to Hospital Transfer Forms, and any Events identified in the morning Clinical Meeting to verify the provider was notified. She stated the meetings would be held in person Monday through Friday and conducted remotely on a virtual computer meeting on Saturday and Sunday. The facility's immediate jeopardy removal date of 4/25/25 was validated.

Based on record review and staff and resident interviews, the facility failed act upon concerns that were reported by the resident council and communicate the efforts to address concerns that were reported during Resident Council Meetings for 6 of 6 months (November 2024, December 2024, January 2025, February 2025, March 2025 and April 2025) reviewed. Findings included: a. The Resident Council meeting minutes dated November 27, 2024, recorded by the Activity Director indicated a concern expressed at the previous month's meeting regarding the meal tickets not matching what was served. The minutes indicated a concern form was filed. The November meeting minutes did not indicate that a response was provided to the council regarding the concern form and any follow-up that the facility completed. The meeting minutes were signed by the Administrator on 11/27/24. b. The Resident Council meeting minutes dated December 13, 2024, recorded by the Activity Director indicated a concern was expressed at the previous month's meeting regarding the taste of the food. The minutes indicated the council was informed that staff were spoken to regarding the taste of the food. The December meeting minutes did not indicate any follow-up that the facility completed. c. The Resident Council meeting minutes dated January 14, 2025, recorded by the Activity Director indicated a concern was expressed at the previous month's meeting regarding the meal tickets not matching what was served and not having enough staff assisting during mealtimes. The January minutes did not indicate that a response was provided to the council regarding the concern form that was filed or any follow-up that the facility completed. The meeting minutes were signed by the Administrator on January 14, 2025. d. The Resident Council meeting minutes dated February 11, 2025, recorded by the Activity Director indicated a concern was expressed at the previous month's meeting regarding the meal tickets not matching what was served and the always available menu items were not available. The February minutes did not indicate that a response was provided to the council regarding the concern form that was filed, or any follow-up that the facility completed. The meeting minutes indicated that the Ombudsman attended the meeting. The meeting minutes were signed by the Administrator on 2/11/25. The list of attendees at the meeting indicated that the Administrator did not attend the meeting. e. The Resident Council meeting minutes dated March 18, 2025, recorded by the Activity Director indicated a concern was expressed at the previous month's meeting regarding the anytime available menu items were not available. The March minutes did not indicate that a response was provided to the council regarding the concern form that was filed, or any follow-up that the facility completed. The meeting minutes indicated that the Ombudsman attended the meeting. The meeting minutes were signed by the Administrator on March 18, 2025. The list of attendees at the meeting indicated that the Administrator did not attend the meeting. f. The Resident Council meeting minutes dated April 14, 2025, indicated a concern was expressed at the previous month's meeting regarding the meal tickets not matching what was served and the always available menu items were not available. The April meeting minutes did not indicate that a response was provided to the council regarding the concern form that was filed the month prior, or any follow-up the facility completed. An interview was conducted with the Resident Council President on 4/23/25 at 4:00 PM. The Resident Council President stated that the Resident Council met monthly, and the Activity Director recorded the concerns that were expressed. The Resident Council President indicated that nothing was done about the concerns that were expressed in the meetings. The Resident Council President stated he attended all the Resident Council meetings and was frustrated with the lack of follow up because he felt that management did not address the concerns of the council. He stated the council was not provided with a resolution to the concerns that were expressed each month. He stated the Regional [NAME] President attended the Resident Council meeting held on April 14, 2025, but she was unable to explain why the concerns were not addressed. An interview was conducted with the Regional [NAME] President on 4/24/25 at 9:00 AM. The Regional [NAME] President stated that she was asked by the residents to attend the Resident Council meeting on April 14, 2025. The Regional [NAME] President stated it was at that meeting she was made aware that concerns expressed in the meetings were not addressed for the past several months. The Regional [NAME] President stated following the meeting, she investigated the residents' concerns and learned that the facility had no process in place to address the concerns expressed in the Resident Council Meetings. The Regional [NAME] President indicated that concern forms were not being addressed following the Resident Council Meetings and there was no follow up to ensure that the concerns were addressed. The Regional [NAME] President stated there was not a system in place to address concerns or grievance voiced at the meetings and this was not acceptable. An interview was conducted with the Activity Director on 4/24/25 at 12:10 PM. The Activity Director indicated she conducted the monthly Resident Council Meetings and took the minutes at the meeting. The Activity Director stated that at each meeting, the old concerns from the previous meeting were discussed as well as new concerns. The Activity Director stated she completed a concern form with each concern expressed by the Resident Council members, and she gave these forms as well as the minutes from the current meeting to the Administrator to follow up on. The Activity Director stated for the past several months the concerns from the previous meetings were not being addressed and the residents were frustrated by this. The Activity Director stated that she requested that the Ombudsman attend the Resident Council meetings to assist with addressing the residents' concerns. The Activity Director indicated that the Ombudsman attended the Resident Council meetings recently and was aware that the concerns were not being addressed. The Activity Director stated she had not seen the concern forms after she completed them. An interview was conducted with the Social Services Director on 4/24/25 at 2:05 PM. The Social Services Director stated she had not seen any forms from the Resident Council Meetings, was not involved in any follow-up and she had not attended a Resident Council meeting. An interview was conducted with the Administrator on 4/24/25 at 3:20 PM. The Administrator stated the Social Services Director was responsible for addressing the concerns of the Resident Council Meetings. The Administrator stated the previous Social Services Director left the facility a few months ago and she had stopped addressing the concern forms prior to her leaving. The Administrator indicated that he did not attend the Resident Council meetings, and he was not involved with addressing the concerns that were expressed at the meetings. The Administrator acknowledged he should have implemented measures to address the concerns expressed by the Resident Council members and he should have addressed the concern forms that were given to him. The Administrator had no documentation that showed that the grievances reported during the monthly Resident Council meetings for the past 6 months were addressed. The Administrator acknowledged he signed the monthly meeting minutes but was unable to explain if he was aware of the repeated concerns expressed as the meetings.

Based on observations, record review, and staff interviews the facility failed to implement the infection control policy and procedures for Enhanced Barrier Precautions (EBP) when providing direct care activities to residents. Nurse #2 and Nurse #3 provided tracheostomy (an opening surgically created in the neck to insert a tube into the trachea (windpipe) allowing for air to enter the lungs directly) care which included tracheal suctioning (a procedure to remove excess secretions from the airway). Nurse #2 also administered a tube feeding through a gastrostomy tube (a feeding tube placed directly into the stomach). The nurses donned gloves and a mask but no gown during the procedures. This occurred for 2 of 2 staff members (Nurse #2, and Nurse #3) who were observed for infection control practices. Findings included: The facility's Infection Control Policy revised 03/15/25 revealed Enhanced Barrier Precautions (EBP) were intended to prevent transmission of multi-drug-resistant organisms (MDRO's) via contaminated hands and clothing to high-risk residents. Enhanced Barrier Precautions were indicated for high contact care activities for residents with chronic wounds or indwelling devices such as tracheostomies and gastrostomy tubes. 1.) A blue Enhanced Barrier Precautions (EBP) sign was noted outside Resident #2's door. The sign read in part, Perform hand hygiene with alcohol based handrub (ABHR) or wash with soap and water before entering and leaving room .Wear gown and gloves for the following High Contact Resident Care Activities which include: Dressing, bathing/showering, Transferring, changing linens, changing briefs or assisting with toileting, and Device care or use; central lines, urinary catheter, feeding tubes, tracheostomy, Wound care: any skin opening requiring a dressing. An observation of Nurse #2 performing tracheostomy (a surgically created hole through the neck into the trachea (windpipe) to allow air to fill the lungs) suctioning and providing bolus feeding through a gastrostomy tube (a feeding tube place directly into the stomach) for Resident #2 was conducted on 4/22/25 at 2:07 PM. Nurse #2 performed hand hygiene with ABHR prior to applying gloves and was observed suctioning Resident #2's tracheostomy without wearing a protective gown. Nurse #2 removed her soiled gloves and used ABHR sanitizer prior to donning clean gloves. Nurse #2 was observed providing bolus tube feeding through Resident #2's gastrostomy tube without a protective gown. An interview with Nurse #2 was completed on 4/22/25 at 2:25 PM. Nurse #2 stated she was unaware she was supposed to be wearing a protective gown while performing procedures involving tracheostomy and tube feeding care. An interview was completed with the Assistant Director of Nursing (ADON) /Infection Control Preventionist (ICP) on 4/22/25 at 2:31 PM. The ADON/ICP stated she had only worked at the facility for a about 6 months. She stated she was the Staff Development Coordinator (SDC) prior to receiving her SPICE training just a couple of weeks ago. The ADON/ICP further stated that the nursing staff were educated multiple times in the last 6 months involving Enhanced Barrier Precautions. She indicated the nursing staff were to follow the enhanced barrier precaution signs posted outside of the residents' rooms. The ADON/ICP stated Nurse #2 should have been wearing a protective gown while performing tracheostomy suctioning and providing bolus tube feeding for Resident #2. An interview with the Director of Nursing (DON) occurred on 4/24/25 at 9:20 AM. The DON stated Nurse #2 was supposed to follow the Enhanced Barrier Precautions while performing tracheostomy suctioning and bolus tube feeding. She further stated Nurse #2 should have been wearing a gown while performing hands on care for a resident with a tracheostomy and a feeding tube. The DON indicated she expected the nursing staff to follow the facility's infection control policies and procedures while performing care for the residents. She stated the facility needed to continue conducting audits and providing education to the nursing staff. 40044 2.) During an observation on 4/22/25 at 5:00 PM Nurse #3 was observed providing tracheostomy care including performing tracheal suctioning to Resident # 5. Nurse #3 was wearing gloves, and a mask but no gown while providing direct care. A sign was located outside of the residents room indicating Resident #5 was on Enhanced Barrier Precautions and to don gloves, gown, and a mask prior to performing direct care activities. A supply cart with gowns and gloves was located outside of Resident #5's room. During an interview on 4/22/25 at 5:00 PM Nurse #3 stated she should have put on a gown along with the gloves and mask before providing Resident 5#'s tracheostomy care. She stated she had received education on Enhanced Barrier Precautions and using personal protective equipment. She stated it was done in error. During an interview with the Infection Control Preventionist Nurse on 4/23/25 at 11:00 AM she stated Resident #5 was on Enhanced Barrier Precautions due to having a tracheostomy. She indicated a sign was located outside of Resident #5's room along with a supply cart. She stated the nurses had received education on Enhanced Barrier Precautions and donning personal protective equipment (PPE) and were aware of the policy. She stated further education would be provided. During an interview on 4/24/25 at 2:00 PM the Director of Nursing (DON) stated staff had been trained on Enhanced Barrier Precautions and were aware that personal protective equipment including gloves, gown, and masks were required when providing direct care such a tracheostomy care. She stated Nurse #3 should have donned a gown along with gloves and a mask prior to providing care. She stated education would be provided.

Based on record review, staff and the Medical Director's interviews the facility failed to hold a fast-acting insulin (insulin that begins working within 15 minutes after administration) as ordered by the physician for a blood sugar level less than 150. Resident #4 was administered 2 units of sliding scale insulin with a blood sugar of 103. This occurred for 1 of 1 resident (Resident #4) reviewed for unnecessary medications. Findings included. Resident #4 was admitted to the facility on [DATE] with diagnoses including diabetes. A physician's order for Resident #4 dated 1/6/25 and discontinued on 1/31/25 revealed Humulin R Regular insulin U-100 insulin 100units per milliliter. Administer per sliding scale as follows: No sliding scale coverage for blood sugar less than 150. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #4 was nonverbal and unable to assess cognition. He received insulin. Review of the Medication Administration Record (MAR) dated January 2025 for Resident #4 revealed Humulin R sliding scale insulin was signed off by Nurse #1 as 0 (zero) units administered at 11:00 AM on 1/25/25. The blood sugar reading was 103. During a phone interview on 4/23/25 at 9:10 AM Nurse #1 stated she administered insulin to Resident #4 in error on 1/25/25. She stated on 1/25/25 she checked Resident #4's blood sugar and recalled his blood sugar was in the low 90's or 100's, and she told his family who were in his room at the time that he would not need the sliding scale insulin. She stated she went back to the medication cart and three nurse aides approached her with problems which distracted her. She then drew up 2 units of insulin and administered it to Resident #4. Once she administered the insulin the family stated they thought he didn't need insulin, and she realized then that he wasn't supposed to get the 2 units that she had just administered. She stated she checked Resident #4's blood sugar following the medication error and his blood sugar remained stable. She stated she reported the medication error to the Director of Nursing (DON) that day. Nurse #1 stated if she documented 0 units administered then it was signed in error because she did give 2 units of insulin at 11:00 AM on 1/25/25. She stated she worked until 7:00 PM on that date and Resident #4 never had any signs or symptoms of low blood sugar. She stated the insulin was administered in error. During a phone interview on 4/23/25 at 11:55 AM the Medical Director stated administering 2 units of sliding scale insulin would not cause Resident #4 any harm and there were no reports made to her of concerns with his insulin or his blood sugar. She indicated if Resident #4 had experienced any negative outcome from receiving insulin when it was not needed she would have wanted to be notified but there had been no reported concerns. She stated the physician orders for administering sliding scale insulin should have been followed. During an interview on 4/23/25 at 2:00 PM the Director of Nursing (DON) stated she was made aware of the medication error by Nurse #1 on 1/25/25. She stated Nurse #1 was no longer employed with the facility and she had been unable to contact Nurse #1 since that time. She stated Nurse #1 should not have administered Resident #4 sliding scale insulin with a blood sugar reading less than 150. She stated Resident #4 did not experience any negative outcome from receiving the insulin in error. She indicated since that time she had provided education to staff regarding medication administration and further education would be provided.

Based on record review and staff interview, the facility failed to maintain complete and accurate medical records for 2 of 11 residents whose medical records were reviewed (Resident #1 and Resident #4). Findings included. 1.) Resident #1 was admitted to the facility on [DATE]. The physician's orders for Resident #1 revealed orders dated 1/14/25 for: - a jejunostomy tube (a surgically placed feeding tube that delivers nutrition and medications directly into the small intestine) 16 French (size) - tube feeding at a continuous rate of 70 milliliters (ml) an hour for 22 hours to allow for activities of daily living - amlodipine (used to treat high blood pressure) 5 milligrams (mg) tablet per feeding tube, once a day for hypertension (high blood pressure) - cetirizine 10 mg tablet once a day per feeding tube for seasonal allergies - apixaban 5 mg tablet twice a day per feeding tube for anticoagulant (blood thinner) - loratadine 10 mg tablet once a day for allergies The January 2025 Medication Administration Record (MAR) for Resident #1 listed Eliquis, Loratadine, Amlodipine, and Cetirizine as administered via j-tube by Nurse #1 on 1/25/25 during the 7:00 AM to 11:00 AM medication pass. A partially filled out SBAR (Situation, Background, Appearance, Review and Notify is a structured communication tool used to transmit clear concise information) 4 page form in the chart dated 1/25/25 and signed by Nurse #1 listed the Situation was: The change in condition, symptoms, or signs observed and evaluated were Resident #1 pulling out his jejunostomy tube (j-tube) twice and the condition was listed as occurring before due to resident consistently playing and tugging on the tube. In the section under Background: the box was checked that the resident was in the facility for long-term care. The areas that were not completed were the primary diagnosis, other pertinent history, Medication Alerts for changes, anticoagulants, hypoglycemics, allergies, and vital signs including pulse oximetry (measures the oxygen saturation in the blood cells). The Resident Evaluation was not completed regarding his mental and functional status, behavioral evaluation, respiratory evaluation, cardiovascular evaluation, abdominal/gastrointestinal (GI) evaluation, Genitourinary/Urine evaluation, skin evaluation, pain evaluation, neurological evaluation, and care plan information. There was a box at the top of the evaluations to check if the area was not clinically applicable to the change in the condition being reported. The Section regarding Appearance was not filled out. In the section to Review and Notify the box to call for 911 for transfer to the hospital was checked. Resident #1's name was listed on the form, the Responsible Party (RP) was notified at 12:51 PM, the on-call provider was notified at 1:12 PM and the form was signed and dated by Nurse #1 on 1/25/25 at 12:51 PM. An interview with Nurse #1 was completed on 4/23/25 at 10:00 AM. Nurse #1 stated she was the nurse assigned to care for Resident #1 on 1/25/25 when his j-tube became dislodged. She further stated the residents she was assigned to care for that day were high acuity (residents requiring closer monitoring and treatments with i.e. tracheostomy tubes, feeding tubes, wounds) and she had not completed the documentation related to the incident. Nurse #1 indicated that the Director of Nursing (DON) called her multiple times to return to the facility to complete the paperwork, but she never went back to the facility. Nurse #1 also stated she did not administer Eliquis, Loratadine, Amlodipine, and Cetirizine to Resident #1 on 1/25/25 during the 7:00 AM to 11:00 AM medication pass. She stated that she must have checked the medications off on the MAR as administered when she pulled them from the medication cart, but she did not administer the medications. An interview with the DON was completed on 4/23/25 at 4:00 PM. The DON stated she tried to call Nurse #1 multiple times to get her to come back to the facility to complete the paperwork regarding Resident #1's transfer to the hospital, but she never came back. She indicated she expected the nursing staff documentation to be complete and accurate. 40044 2.) Resident #4 was admitted to the facility on [DATE] with diagnoses including diabetes. A physician's order for Resident #4 dated 1/6/25 and discontinued on 1/31/25 revealed Humulin R Regular insulin U-100 insulin 100units per milliliter. Administer per sliding scale as follows: No sliding scale coverage for blood sugar less than 150. Review of the Medication Administration Record (MAR) dated January 2025 for Resident #4 revealed Humulin R sliding scale insulin was signed off by Nurse #1 as 0 (zero) units administered at 11:00 AM on 1/25/25. The blood sugar reading was 103. During a phone interview on 4/23/25 at 9:10 AM Nurse #1 stated she administered insulin to Resident #4 in error on 1/25/25. She stated on 1/25/25 she checked Resident #4's blood sugar and recalled his blood sugar was in the low 90's or 100's. She stated she went back to the medication cart and three nurse aides approached her with problems which distracted her. She then drew up 2 units of insulin and administered it to Resident #4. Once she administered the insulin the family stated they thought he didn't need insulin, and she realized then that he wasn't supposed to get the 2 units that she had just administered. Nurse #1 stated if she documented 0 (zero) units administered then it was signed in error because she did give 2 units of insulin at 11:00 AM on 1/25/25. She stated she should have documented that 2 units of insulin was administered to Resident #4. During an interview on 4/23/25 at 2:00 PM the Director of Nursing (DON) stated she was made aware of the medication error by Nurse #1 on 1/25/25. She stated Nurse #1 should not have administered Resident #4 sliding scale insulin with a blood sugar reading less than 150 and she was not aware that she documented in error on the MAR. She stated Nurse #1 should have documented on the MAR that she administered 2 units of insulin to Resident #4. She indicated education would be provided regarding accurately documenting in the medical record.

Based on record review and staff interview, the facility failed to communicate all required information to the hospital for 1 of 1 resident (Resident #1) reviewed for hospital transfers. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction due to occlusion or stenosis of left middle cerebral artery (stroke), dysphagia (difficulty swallowing), and aphasia (absence of speech). The physician's orders for Resident #1 dated 1/14/25 included a jejunostomy tube (a surgically placed feeding tube that delivers nutrition and medications directly into the small intestine) 16 French (size). The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was severely cognitively impaired and had no speech. A nurse's progress note written by the Director of Nursing on 1/25/25 at 2:00 PM indicated that she received a call from the floor nurse that Resident #1's jejunostomy tube (j-tube) fell out. Nurse #1 was advised to call the Provider on call and send to the hospital or placement of j-tube. An incomplete 2-page Hospital Transfer Form for Resident #1 listed the following information on page 1: His name, date of admission, date of birth , and primary diagnosis. It further listed the Responsible Party was notified of the situation and of the transfer to the hospital. The reason for the transfer was listed as pulled out j-tube. The form indicated that Resident #1 was alert, disoriented, could not follow/simple commands, he required a proxy for decision making capacity, he was incontinent of bowel and bladder, and the date of his last bowel movement was noted. Page 1 of the form was missing the code status, relevant diagnoses, and functional status. On page 2 of the form the risk alert boxes for anticoagulation, aspiration, high fall risk, needs medications crushed, and pain level were checked. His diet was listed as enteral feeding. The sections for respiratory, medications, devices, isolation precautions, and vital signs were not completed. The form was not signed and dated. An interview with Nurse #1 was completed on 4/23/25 at 10:00 AM. Nurse #1 stated she was the nurse assigned to care for Resident #1 on 1/25/25 when his j-tube became dislodged. She further stated the residents she was assigned to care for that day were high acuity (residents requiring closer monitoring and treatments with i.e. tracheostomy tubes, feeding tubes, wounds) and she had not completed the documentation related to the incident. Nurse #1 indicated that the Director of Nursing (DON) called her multiple times to return to the facility to complete the paperwork, but she never went back to the facility. An interview with the DON was completed on 4/23/25 at 4:00 PM. The DON stated she tried to call Nurse #1 multiple times to get her to come back to the facility to complete the paperwork regarding Resident #1's transfer to the hospital, but she never came back. She indicated she expected the nursing staff documentation to be complete and accurate.

Based on record review, staff, the Nurse Practitioner and Physician interviews, the facility failed to obtain an ordered urinalysis and culture and sensitivity (a urine test obtained to identify the presence of bacteria. A urine culture identifies the presence and type of bacteria causing an infection. Sensitivity tests determine which antibiotics are effective against the bacteria) for a resident experiencing symptoms of burning, urgency and decreased urinary output for 1 of 1 resident (Resident #3) reviewed for laboratory services. Findings included. Resident #3 was admitted to the facility on [DATE] with diagnosis including chronic kidney disease. A physician progress note dated 4/15/25 revealed Resident #3 was assessed due to suspected urinary tract infection due to dysuria (painful urination), urinary frequency and urgency. The plan of care was to test a urine culture to evaluate for urinary tract infection. A physician's order dated 4/15/25 at 11:07 AM was entered by Nurse #4 for Resident #3 to obtain a urinalysis and culture and sensitivity for evaluation of urinary tract infection due to complaints of dysuria, frequent urination, and urgency. A physician's order dated 4/15/25 at 11:12 AM for Resident #3 revealed Cephalexin (antibiotic) 500 milligrams (mg) three times a day due to possible urinary tract infection and dysuria. A nursing progress note dated 4/15/25 at 6:32 PM written by Nurse #4 indicated a urinalysis and culture and sensitivity test was pending to rule out a urinary tract infection. Resident #3 complained of burning, urgency and a small amount of urine output. An antibiotic was started according to the physician's order. The Minimum Data Set (MDS) admission assessment dated [DATE] indicated Resident #3 had moderately impaired cognition and was frequently incontinent of bowel and bladder. A Nurse Practitioner note dated 4/22/25 indicated Resident # 3 remained on antibiotics for suspected urinary tract infection with complaints of intermittent discomfort with urination. The Nurse Practitioner indicated that Resident #3 had a suspected urinary tract infection due to dysuria, urinary frequency, and urgency. Review of Resident #3's electronic medical record from 4/15/25 through 4/24/25 revealed no results from the urinalysis and culture and sensitivity report. During an interview on 4/24/25 at 12:15 PM the Nurse Practitioner stated a urinalysis with culture and sensitivity was ordered for Resident #3 on 4/15/25 by Physician #2. She stated they did not get the lab results back and then discovered on 4/23/25 that the urine sample was still in the refrigerator in the facility and was never picked up by lab services. She stated the nurse who obtained the urine sample (Nurse #4) told her she did obtain the urine sample from Resident #3 via urinary catheterization on 4/15/24. She stated the urinalysis should have been obtained and sent to the lab when the order was written. She stated Resident #3 continued with mild symptoms, but he did not want to be catheterized again at this time. The plan now was to reevaluate Resident #3 on Monday 4/28/25 and a urinalysis would be obtained at that time if needed. During an interview on 4/24/25 at 12:30 PM Nurse #4 stated she received the order for the urinalysis on 4/15/25 and collected the urine sample from Resident #3 that day. She stated she entered the information into the electronic medical record and into the lab services website. She indicated that she did not recall if she recorded it in the lab book for pick up. During an interview on 4/24/25 at 1:00 PM the Unit Manger stated Resident #3's urine sample was obtained on 4/15/25 by Nurse #4 and the order was entered into the electronic medical record and into the lab services database to collect the urine. She stated the process included that once the order was entered into the residents medical record by the nurse, the nurse then had to enter the order into the lab services website and print a requisition form (informs the lab of what tests to perform) and then record it in the lab book which was kept at the nurses station. When the lab company comes to the facility they review the lab book to determine what needed to be collected. She stated the breakdown was that the order was not entered into the lab book therefore the lab did not pick up the urine sample. She indicated she usually checked the lab book to ensure the labs were recorded. She stated it was done in error. During an interview on 4/24/25 at 2:00 PM the Director of Nursing stated she was not aware of the urine sample obtained for urinalysis not being picked up from the lab for Resident #3. She stated a process was in place for obtaining labs and the process was not followed. She stated once the lab order was entered into the resident's medical record it also had to be written in the lab book and that was not done. She stated education would be provided. During an interview on 4/24/25 at 3:00 PM Physician #2 stated she was made aware of the urinalysis not being collected today. She indicated there had been no significant outcome from not obtaining the urinalysis with culture and sensitivity. She stated Resident #3 remained on antibiotics for urinary tract infection and she expected lab orders to be entered correctly, and results made available and that was not done.

Based on record review and staff, resident, family, Nurse Practitioner and Physician interviews, the facility failed to provide thorough and ongoing pain assessments that included identifying the source of the pain and to evaluate a resident's pain regimen when the prescribed medication was not effectively managing the resident's pain. The resident was discharged from the hospital on 3/3/25 after being admitted for pain control following a total knee replacement. The initial pain assessment on admission to the facility indicated a pain rating of 5 (on a 0 to 10 scale with 10 being the worst pain imaginable). The resident experienced a fall on 3/3/25 in the evening. The following day (3/4/25), Resident #2 experienced increased pain with a pain level ranging from 6 to 10 through 3/10/25. On 3/10/25 the resident was evaluated at the hospital and was identified with a comminuted right intertrochanteric femur fracture (most common type of hip fracture which the long bone of the thigh breaks into multiple pieces caused by a fall and is characterized by severe pain in the hip, inability to bear weight on the affected leg, and shortening and external rotation of the leg). The resident underwent intermedullary nailing of the right femur (a procedure in which a metal rod is inserted into the long thigh bone to stabilize the fracture) with no complications as a result of the surgery. The deficient practice was observed for 1 of 1 resident reviewed for pain management (Resident #2). Findings included: A review of Resident #2's hospital discharge summary dated 3/3/25 indicated the resident was diagnosed with weakness. The history of the present illness indicated Resident #2 had a total knee replacement one week prior to hospitalization and was unable to make progress at home. The resident was admitted for pain control on 2/28/25. The hospital course indicated the resident was stable upon discharge and the resident's pain was improved. Resident #2 made slow progress with physical therapy at the hospital and was discharged to the skilled nursing facility to continue with therapy. Resident #2 was admitted on [DATE] with diagnoses which included: aftercare following knee replacement surgery, muscle weakness, unsteadiness on feet and a history of dementia. Resident #2's electronic health record indicated a physician order dated 3/3/25 for hydrocodone-acetaminophen 5-325 milligram 2 tablets every 6 hours as needed (PRN) for moderate to severe pain not to exceed 8 tablets in 24 hours. A physician order dated 3/3/25 indicated Resident #2 was also ordered tramadol 50 milligrams every 6 hours PRN for moderate to severe pain not to exceed 200 milligrams in 24 hours. A nursing progress note dated 3/3/25 at 5:40 PM written by Nurse #1 indicated that Resident #2 was admitted for aftercare following a right total knee replacement. Resident #2 was alert and oriented to person, place and event with some confusion. Resident #2 transferred with stand and pivot assistance with one person assistance with orders for weight bearing as tolerated. Resident #2 was noted as continent of bowel and bladder and had been using a urinal and bedpan prior to admission. Resident #2 wore glasses and had a hearing aid which he left at home. A pain assessment dated [DATE] at 6:11 PM by Nurse #1 indicated a pain interview was conducted and indicated that Resident #2 had pain in the past 5 days, the pain affected his sleep, participation with therapy and day to day activities. Resident #2 rated his pain intensity as a 5 (out of 10). A nursing progress note completed by Nurse #4 dated 3/3/25 at 11:54 PM indicated Resident #2 had a fall in the room. The resident was alert and oriented. The right knee, which was recently replaced, had a dressing in place and showed old bruises and slight swelling. Resident #2 reported no new injuries or increased pain. The note indicated every 4 hour neurological checks were initiated and the on-call provider was contacted. A focused head to toe observation dated 3/3/25 at 11:45 PM completed by Nurse #4 indicated an observation was made of Resident #2 as a follow up to a fall. The observation indicated that Resident #2 was alert to person, place, time and situation with strong bilateral hand grasps. Foot press strength, a test in which the resident is asked to push against resistance as part of a neurological evaluation, was not assessed due to right knee surgery. The observation noted impaired range of motion of Resident #2's right knee and leg with the lower extremities equal in length. A fall event report dated 3/3/25 at 11:58 PM completed by Nurse #4 indicated Resident #2 had an unwitnessed fall with no injuries. Resident #2 was found in his room on the floor. The report indicated Resident #2 did not complain of or exhibit pain related to the fall. The report indicated the nurse was unable to complete range of motion of his right lower extremity and a rotation deformity or shortening of Resident #2's right lower extremity was observed (an abnormal finding often associated with a femur fracture). This was different than the 11:45 PM observation completed by Nurse #4 which indicated Resident #2's lower extremities were equal in length. An interview was conducted with Nurse #4 on 3/25/25 at 3:00 PM. Nurse #4 stated she worked night shift the night that Resident #2 had an unwitnessed fall (3/3/25) in which he slipped out of bed when he was using the urinal. Nurse #4 indicated she assessed the resident, and he did not have any injury, so he was transferred back to the bed using a mechanical lift. Nurse #4 indicated that throughout the night, Resident #2 complained of spasms in his back and he could not get comfortable. Nurse #4 stated she did not recall if she administered pain medication that night, but she thought that she and the staff repositioned the resident frequently to try to get him comfortable. Resident #2's electronic Medication Administration Record (eMAR) for 3/4/25 at 9:23 AM revealed resident received PRN hydrocodone-acetaminophen for a pain level of 9. The eMAR indicated the medication was effective. The pain level recorded after the medication was administered was a 9. Resident #2's occupational therapy evaluation and plan of treatment by the Occupational Therapist (OT) dated 3/4/25 indicated based on behavior exhibited, the resident demonstrated a pain level of 10 out of 10. The evaluation indicated nursing was aware of Resident #2's pain and was providing medication as prescribed. Resident #2 participated in the evaluation as able. Resident #2's physical therapy evaluation and plan of care dated 3/4/25 indicated the resident verbalized a pain level of 10 out of 10 with constant and sharp pain to the right knee and shin which limited mobility, standing and ambulation. Resident #2 reported a 10 out of 10 pain level at rest and with movement and was unable to bear weight on the right lower extremity during transfers. An interview was conducted with the Physical Therapist (PT) on 3/26/25 at 10:26 AM. PT stated that he was aware that Resident #2 had a fall on 3/3/25 after admission. PT stated Resident #2 had a lot of pain and difficulty with weight shifting. PT stated Resident #2 had cognitive impairment and it was difficult to discern if resident's pain was out of proportion or as intense as it seemed or if it was more behavioral. PT indicated Resident #2 not bearing weight was not necessarily an indication of a problem. PT stated Resident #2's therapy had to be modified due to his pain level and his inability to bear weight. PT stated from what he was told, Resident #2 did not progress at home with home health therapy so he assumed the resident probably would not do well here. PT indicated Resident #2's right leg was externally rotated, but he assumed this could have been caused by staying in bed a lot. PT stated he did not report Resident #2's increased pain level or inability to bear weight to the nursing staff or the medical provider since he assumed it was related to his dementia. An interview was conducted with the Physical Therapy Assistant on 3/26/25 at 10:40 AM. PTA stated that she worked with Resident #2 for therapy during his stay and his right leg was very painful. PTA indicated Resident #2 could not tolerate standing due to pain and was not able to bear weight on the right leg. PTA stated Resident #2 was difficult to work with, but she assumed this was because he was not motivated. PTA stated she did not report Resident's pain level or inability to bear weight to the therapist or the nursing staff. A physician progress note dated 3/4/25 at 7:58 PM by Physician #1 documented Resident #2 indicated he had 8 out of 10 right leg pain. Resident #2 was to continue with pain management with the pain medications that were prescribed from the hospital. An interview was conducted with Nursing Assistant (NA) #1 on 3/25/25 at 2:30 PM. NA #1 stated she was assigned to Resident #2 on 3/3/25 from 3:00 PM to 7:00 PM, on 3/4/25 from 7:00 AM to 7:00 PM and 3/8/25 from 7:00 AM to 7:00 PM. NA #1 stated Resident #2 was pleasant and cooperative when he was admitted on [DATE] and did not complain of pain. NA #1 stated when she came in on 3/4/25 she was told by the previous NA that the resident had a fall. Later that day when she was providing care for him, Resident #2 yelled out in pain when she turned or rolled him in bed. NA #1 stated Resident #2 complained of pain in the right leg and described the pain as a pulling or a burning pain. NA #1 stated it took 2 people to provide care for Resident #2 due to the pain he had in his right leg. NA #1 indicated Resident #2 was only able to tolerate sitting up in a wheelchair for a short time due to the pain. NA #1 stated she observed swelling in Resident #2's right thigh about a day or 2 after he was admitted , and she reported this to the floor nurse who she thought was Nurse #4. NA #1 stated Resident #2 would get aggravated during care due to the pain in his groin area and upper leg. Resident #2 stayed in bed when he was not receiving therapy due to the pain and the inability to sit comfortably in a wheelchair. NA #1 indicated she would try to position the resident in bed with pillows for comfort. A Nurse Practitioner progress note dated 3/5/25 at 6:50 AM indicated in part that she evaluated Resident #2 due to the resident screaming and giving the Nursing Assistant and Nurse difficulty with care. Resident #2 was agitated and incontinent. The note indicated Resident #2 was to continue with the prescribed pain medication and stated that the resident's mild dementia was affecting his ability to comply with therapy and was impacting his recovery. An interview was conducted with the Nurse Practitioner (NP) on 3/26/25 at 10:00 AM. The NP stated she went into Resident #2's room early on the morning of 3/5/25 when she heard him hollering and screaming during care. The NP stated Resident #2 was calm after the incontinence care was provided. The NP stated she was not aware that Resident #2 was having pain at an intensity of 10 out of 10 and that he was not able to bear weight on his right leg. The NP stated if she had been made aware of Resident #2's pain intensity of 10 and inability to bear weight she would have evaluated the resident further as these are signs of a serious condition such as a fracture. Resident #2's eMAR indicated PRN hydrocodone-acetaminophen was administered on 3/5/25 at 8:02 AM for a pain level of 6. The eMAR indicated the medication was effective. The pain level after the medication was administered was a 6. Resident #2's eMAR indicated PRN hydrocodone-acetaminophen was administered on 3/5/25 at 2:13 PM for a pain level of 6. The eMAR indicated the medication was effective. The pain level after the medication was administered was a 6. A care plan for falls was created on 3/5/25 and revealed Resident #2 was at risk for falls related to pain. The interventions dated 3/5/25 included to administer medications as ordered, assist with mobility as needed, and ensure the resident was wearing non-skid footwear when out of bed. A skilled nursing note dated 3/5/25 at 7:49 PM by Nurse #1 indicated Resident #2 was pleasant, cooperative, anxious, and combative or resistive to care with no changes in condition in the past 24 hours. The note gave no indication of Resident #2's pain level, participation with therapy or assessment of his right leg. An interview was conducted with NA #6 on 3/26/25 at 8:40 AM. NA #6 indicated that she worked from 3:00 PM to 11:00 PM and was assigned to Resident #2 on 3/5/25. NA #6 stated that when she attempted to provide incontinence care, Resident #2 began screaming. NA #6 stated she did not know what was wrong but could tell Resident #2 was in a lot of pain. NA #6 stated she asked another NA to assist her and they were able to provide incontinence care to Resident #2 by providing increased time and support with moving him. NA #6 indicated she informed the assigned nurse that Resident #2 was having severe pain during care. NA #6 stated she did not know if the nurse evaluated the resident. An interview was conducted with Nurse #2 on 3/26/25 at 8:15 AM. Nurse #2 stated she was an agency nurse that worked as needed at the facility. Nurse #2 was assigned to Resident #2 on 3/5/25 from 7:00 PM to 7:00 AM. Nurse #2 stated she did not recall anything about Resident #2. Nurse #2 stated she did not have much interaction with the residents other than administering medication and she did not recall if a NA reported that Resident #2 had pain. A skilled nursing note dated 3/6/25 at 2:36 PM by Nurse #4 indicated Resident #2 was alert, oriented to person, place, time and situation and had no changes in condition in the past 24 hours. The note gave no indication of Resident #2's pain level, participation with therapy or assessment of his right leg. An interview was conducted with Nurse #4 on 3/25/25 at 3:00 PM. Nurse #4 stated she was assigned to Resident #2 a couple of days after his 3/3/25 fall and he was unable to participate with therapy. Nurse #4 indicated she did not recall the NAs reporting any swelling in Resident #2's thigh or pain in his groin or hip area. Nurse #4 stated when she observed that Resident #2 had pain, she administered as needed pain medication, and it seemed to be effective for a short time but he required it frequently to try to manage his pain. Nurse #4 stated she did not report Resident #2's pain or inability to participate in therapy to the physician but she probably should have. An interview was conducted with NA #2 on 3/25/25 at 2:50 PM. NA #2 was assigned to Resident #2 on the 7:00 AM to 3:00 PM shift on 3/5/25 and 3/6/25. NA #2 indicated she did not recall much about Resident #2's care but she did recall he had a lot of pain in his leg. NA #2 stated she did not report Resident #2's pain to the floor nurse as she thought they already knew since he had been having pain for several days. Resident #2's eMAR indicated PRN hydrocodone-acetaminophen was administered on 3/6/25 at 9:03 PM for a pain level of 6. The eMAR indicated the medication was effective. The pain level after the medication was administered was a 6. An interview was conducted with NA #5 on 3/26/25 at 8:50 AM. NA #5 indicated she worked on the 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM shifts. NA #5 stated she and NA #4 worked together on the rehabilitation unit where Resident #2 resided. NA #5 indicated that she provided care to Resident #2 on 3/3/25, 3/4/25 and 3/6/25 from 11:00 PM to 7:00 AM. NA #5 stated she recalled when Resident #2 fell on [DATE] and indicated that he was very agitated after the fall. NA #5 stated that Resident #2 required 2 person assistance with turning and reposition and incontinence care. NA #5 stated resident screamed and hollered during incontinence care and would become combative. NA #5 stated it seemed like Resident #2 was having a lot of pain so she and the other NA would try to be gentle and provide increased time with care. NA #5 stated it was difficult to get Resident #2 comfortable, but she did not report this to the nurse as she thought the nurses already knew. A Minimum Data Set (MDS) pain assessment completed by the MDS Nurse on 3/7/25 at 8:16 AM indicated Resident #2 had pain in the last 5 days almost constantly and the pain affected his sleep, therapy and day to day activities frequently. Resident #2 rated his pain intensity as 10. Resident #2's electronic health record revealed no nursing progress note by the MDS Nurse regarding resident's pain level of 10 or notification of the medical provider. Resident #2's eMAR indicated PRN hydrocodone-acetaminophen was administered on 3/7/25 by Nurse #3 at 2:13 PM for a pain level of 7. The eMAR indicated the medication was effective. The pain level after the medication was administered was a 2. An interview was conducted with Nurse #3 on 3/25/25 at 1:14 PM. Nurse #3 was new to the facility and was assigned to Resident #2 on 3/7/25 from 7:00 AM to 7:00 PM. Nurse #3 stated on 3/7/25 Resident #2 did not want to get up out of bed or participate in therapy. Nurse #3 stated this was her first day assigned to Resident #2 and did not know what his baseline was. Nurse #3 stated nothing was reported to her by the previous shift regarding resident's condition or increased pain. During the shift on 3/7/25, Nurse #3 indicated eventually, Resident #2 was assisted up out of bed to the wheelchair and went to therapy. During the shift on 3/7/25, Nurse #3 stated she administered Resident #2's pain medication but did not complete a full assessment of the resident as she was busy with passing medications and other duties. Nurse #3 indicated she was new to the facility and was still learning. Nurse #3 stated she did not recall anything about Resident #2's pain on 3/7/25 regarding the area, the pain level or factors that affected the pain. An interview was conducted with NA #3 on 3/25/25 at 5:15 PM. NA #3 indicated that she worked from 7:00 AM to 3:00 PM and was assigned to Resident #2 on 3/7/25. NA #3 indicated Resident #2 had a lot of pain in his hip and leg. Resident #2 did not want to move his leg and seemed scared to move it. NA #3 stated she informed the floor nurse of Resident #2's pain and stated the nurse knew that his leg was hurting. Resident #2's eMAR indicated PRN hydrocodone-acetaminophen was administered on 3/7/25 by Nurse #3 at 5:03 PM for a pain level of 10. The eMAR indicated the medication was effective. The pain level after the medication was administered was a 0. Resident #2's electronic health record revealed no nursing progress note dated 3/7/25 by Nurse #3 regarding resident's pain level of 10 or notification of the medical provider. An interview was conducted with Nurse #6 on 3/25/25 at 4:51 PM. Nurse #6 was an agency nurse assigned to Resident #2 on 3/6/25 and 3/7/25 from 7:00 PM to 7:00 AM. Nurse #6 stated she did not know much about Resident #2 as she only was assigned to him a couple of times. Nurse #6 stated Resident #2 was confused and was combative at times with personal care. Nurse #2 stated that she assumed that was Resident #2's baseline as that was what she was told by other staff, but she could not recall which staff members told her this. Nurse #6 stated she thought that his behavior might be due to pain so she thought she administered his PRN pain medication, and this seemed to help him. Nurse #6 stated she did not attempt to identify the source of the pain. Nurse #6 stated that since the pain medication seemed to help, she did not assess Resident #2 any further. Review of the eMAR revealed that PRN hydrocodone-acetaminophen was not recorded as administered by Nurse #6 on 3/6/25 or 3/7/25 from 7:00 PM to 7:00 AM. A skilled nursing note dated 3/8/25 at 6:19 PM by Nurse #1 indicated Resident #2 was oriented to person, was pleasant, anxious and combative or resistive to care and had no change in condition in the past 24 hours. The note gave no indication of Resident #2's pain level, participation with therapy or assessment of his right leg. Resident #2's eMAR indicated PRN tramadol was administered on 3/8/25 by Nurse #1 at 6:23 PM. No pain level was recorded prior to or following administration of the medication. The eMAR indicated the medication was effective. Resident #2's 5-day Minimum Data Set (MDS) dated [DATE] indicated the resident had moderate cognitive impairment and demonstrated rejection of care 1 to 3 days. Resident #2 had functional limitation in range of motion with impairment on 1 side of the lower extremity and required moderate assistance with bed mobility and transfers. Resident #2 had frequent incontinence of bowel and bladder, had a diagnosis of muscle weakness and unsteadiness. Resident #2 had almost constant pain that interfered with sleep, therapy and day-to-day activities. Resident #2 rated his pain a 10. Resident #2's eMAR indicated PRN tramadol was administered on 3/9/25 by Nurse #1 at 9:12 AM with no pain level recorded prior to or following administration of the medication. The eMAR indicated the medication was slightly effective. A skilled nursing dated 3/9/25 by Nurse #1 indicated Resident #2 was oriented to person, was pleasant, anxious, combative or resistive to care and had no change in condition in the past 24 hours. The note gave no indication of Resident #2's pain level, participation with therapy or assessment of his right leg. An interview was conducted with Nurse #1 on 3/26/25 at 3:30 PM. Nurse #1 stated she had a hard time recalling specific information about Resident #2, as the rehabilitation hall was her primary assignment and there was a high rate of turnover of residents. Nurse #1 recalled that Resident #2 had pain with movement. Resident #2 had difficulty expressing where the pain was, but Nurse #1 stated he would say repeatedly Oh my leg with any movement or activity. It was hard for him to describe where the pain was. She reported that with transfers, bed mobility, incontinence care Resident #2 demonstrated non-verbal signs of intense pain. Nurse #1 stated she did not recall that therapy reported that Resident #2 had 10 out of 10 pain, was unable to stand or bear weight. Nurse #1 stated she did not inform the provider that Resident #2 had intense pain with movement as he had some dementia and she assumed the provider knew. An interview was conducted with NA #4 on 3/25/25 at 5:00 PM. NA #4 indicated that she worked from 7:00 PM to 7:00 AM and was assigned to Resident #2 on 3/3/25, 3/7/25, 3/8/25 and 3/9/25. NA stated when Resident #2 fell on [DATE] he had pain and required 2-person assistance to get him up and provide his care. Prior to the fall, NA #4 stated Resident #2 seemed fine and did not have pain. NA #4 indicated she observed that his right thigh area had swelling on the nights she was assigned to Resident #2 after the fall and he complained of hip pain. NA #4 stated she checked on Resident #2 often, tried to talk to him to calm him down and reassure him. NA #4 stated that she thought Resident #2 was restless due to pain. NA #4 stated she reported his pain to the floor nurse each time she worked but she did not know if the nurse administered pain medication or assessed the resident. An interview was conducted with Nurse #5 on 3/25/25 at 2:00 PM. Nurse #5 was an agency nurse assigned to Resident #2 on 3/4/25, 3/8/25 and 3/9/25 from 7:00 PM to 7:00 AM. Nurse #5 stated she did not know that Resident #2 had a fall on 3/3/25 and that information regarding falls was normally communicated verbally during shift report. Nurse #5 stated she found out after Resident #2 was transferred to the hospital that he had fallen. Nurse #5 stated Resident #2 had a lot of pain and it required 2 people to provide care for him. Nurse #5 stated she assumed that his complaints of pain were more of a behavior or were related to his dementia and did not require medication or further evaluation. Nurse #5 indicated she only administered pain medication to Resident #2 once because she assumed his complaint of pain was a behavior and he was just being difficult. Nurse #5 stated Resident #2 yelled at her one of the nights when she went into the room, so she did not attempt to complete an assessment. Nurse #5 indicated that if she had assessed Resident #2 and observed swelling in his upper thigh or hip area she would have notified the provider. Nurse #5 stated she probably should have assessed Resident #2 and evaluated his pain. Resident #2's eMAR indicated PRN hydrocodone-acetaminophen was administered on 3/10/25 by Nurse #3 at 6:42 AM for a pain level of 8. The eMAR indicated the medication was effective with a pain level of 3 after the medication was administered. A physician progress note dated 3/10/25 at 1:31 PM written by Physician #2 indicated the physician was asked to see Resident #2 as he was not participating in therapy, and he had a fall following admission to the facility. Per Resident #2's family member the resident was not himself, was not acting right and she (the family member) was concerned. Resident #2 was seen and examined with the resident complaining that his right groin was in a lot of pain down into this thigh. Resident #2 stated it hurt whenever anyone touched the area. An interview was conducted with Physician #2 on 3/26/25 at 2:42 PM. Physician #2 indicated that he was asked to see Resident #2 on 3/10/25 due to the resident not participating in therapy and increased pain. Physician #2 indicated Resident #2 stated he had pain in his groin. Physician #2 stated he and two of the therapists assisted Resident #2 into bed. Physician #2 stated Resident #2 seemed worse from what staff reported since his fall. Physician #2 stated he was concerned that Resident #2 may have a fracture, and this needed to be addressed right away so he ordered for the resident to be sent to the hospital. Physician #2 stated that the resident's increased pain level and inability to bear weight should have been reported to the physician or NP to evaluate. Physician #2 indicated it was possible that the fracture may not have had any outward signs, but increased pain was a sign. Physician #2 indicated that Resident #2 had mild dementia with some impaired cognition, but his pain level should have been addressed. A nursing progress note dated 3/10/25 at 1:43 PM written by Nurse #3 indicated Resident #2 was sent to the emergency room for evaluation. Resident's family member stated that Resident #2 complained of pain in his right hip area since he had an unwitnessed fall on 3/3/25. Resident #2's family member stated he had decreased mentation and the family member requested a urinalysis and Computed Tomography (CT) scan be completed. The physician assessed the resident and decided to send Resident #2 to the emergency room due to pain in the hip/groin area. An interview was conducted with Nurse #3 on 3/25/25 at 1:14 PM. Nurse #3 stated she worked with Resident #2 during the 7:00 AM to 7:00 PM shift on 3/10/25. Nurse #3 stated that Resident #2's family member indicated that she wanted the resident evaluated so she informed the physician of the family member's request. Nurse #3 stated on 3/10/25, Resident #2 was in acute pain, could not get up out of bed and was unable to sit up. Nurse #3 stated Resident #2 was only able to tolerate lying flat in bed due to significant hip and groin pain. Nurse #3 stated Resident #2's pain was excruciating. Nurse #3 stated when the family member came in and expressed concerns, she informed the physician of Resident #2's severe groin and hip pain. The physician gave the order to transfer Resident #2 to the hospital for evaluation. Nurse #3 stated she looked at Resident #2's legs and did not observe a rotation of resident's leg or a leg length difference. The emergency department encounter note dated 3/10/25 indicated Resident #2 presented with groin pain since an unwitnessed fall at the facility on 3/3/25. The note indicated Resident #2 had right groin tenderness, right leg pain and deformity with external rotation of the right lower extremity. Resident #2's right leg was shorter than the left and was mildly edematous, a condition characterized by swelling due to abnormal accumulation of fluid in the body's tissues. A two view x-ray of the right femur result indicated a comminuted right intertrochanteric femur fracture. Resident #2 was admitted to the hospital on 3/10/25, underwent intermedullary nailing of the right femur (a procedure in which a metal rod is inserted into the long thigh bone to stabilize the fracture) and was discharged to a skilled nursing facility on 3/20/25. There was no indication of complications as a result of the surgery. During a phone interview on 3/25/25 at 9:45 AM with Resident #2's family member she reported Resident #2 experienced pain at the facility that was not addressed. She indicated the pain medication provided to the resident was not effective to manage the pain. She revealed that Resident #2's decreased participation with therapy and inability to bear weight on the affected leg due to pain should have been evaluated sooner. An interview was conducted with Unit Manager #2 on 3/26/25 at 3:00 PM. Unit Manager #2 stated she was not aware of Resident #2 having increased pain, not participating in therapy or inability to bear weight. Unit Manager #2 stated she did not assess the resident at any time or consult with the provider regarding the resident's pain. An interview was conducted with the MDS Coordinator on 3/26/25 at 4:15 PM. The MDS Coordinator stated the MDS Pain Assessment was to be attempted with each resident, even if the resident had a diagnosis of dementia. The MDS Coordinator stated the resident was interviewed or a picture scale was used to identify the resident's pain. The MDS Coordinator recalled that the staff struggled to manage Resident #2's pain. When a resident reported a high level of pain, frequent pain or pain that interfered with therapy or daily activities, the MDS Nurse should review the resident's medical record and inform the Unit Manager and medical provider of the results of the interview. The MDS Coordinator indicated that the MDS Nurse was new to the position, but she should have informed the Unit Manager or the medical provider of the results of Resident #2's pain assessment. An interview was conducted with Physician #1 on 3/26/25 at 2:00 PM. Physician #1 indicated that she was not aware of Resident #2 sustaining a fall on 3/3/25. Physician #1 stated she would have expected the floor nurse to notify her of the fall. She indicated the on-call provider was notified of the fall but typically the floor nurse also informed her (Physician #1) of changes such as recent falls when she was making her rounds. Physician #1 stated if she had been informed that Resident #2 had a fall on 3/3/25 she would have evaluated the resident regarding the fall and possible injury. Physician #1 stated Resident #2 complained of pain and she attributed this to his recent right total knee replacement. During Resident #2's stay, neither the nursing staff nor the therapists reported increased pain level or inability to stand or bear weight. Physician #1 stated if the nursing staff or therapists had reported that Resident #2 had a pain level of 10 out of 10, inability to stand or bear weight, she would have ordered x rays and evaluated the resident further. Physician #1 stated that she expected that the nursing staff or therapists would have reported the changes and there seemed to be a lack of communication. Physician #1 stated she was not aware that Resident #2 was diagnosed with an intertrochanteric femur fracture when he was sent to the hospital for evaluation on 3/10/25. An interview was conducted with the Director of Nursing on 3/25/25 at 3:40 PM. The DON stated that Resident # 2 had pain during his stay in the facility and the staff assumed it was his knee and did not evaluate to determine where the pain was. The DON indicated she was aware that Resident #2 was not participating well with therapy, but the staff assumed it was just the resident a [TRUNCATED]

Based on record review and staff, Nurse Practitioner and Physician interviews, the facility failed to comprehensively assess a resident and failed to identify or recognize the significance of external rotation and shortening of the leg, severe pain, and inability to bear weight after a fall. The resident had external rotation (an outward rotation of the thigh and knee away from the body), was unable to bear weight and experienced pain from 3/4/25 (the day after a fall) through 3/10/25 at which time he was sent to the emergency room and identified with a comminuted right intertrochanteric femur fracture (most common type of hip fracture which the long bone of the thigh breaks into multiple pieces caused by a fall and is characterized by severe pain in the hip, inability to bear weight on the affected leg, and shortening and external rotation of the leg). The resident underwent intermedullary nailing of the right femur (a procedure in which a metal rod is inserted into the long thigh bone to stabilize the fracture) with no complications as a result of the surgery. This failure to comprehensively assess a resident was observed for 1 of 4 residents reviewed for accidents (Resident #2). Findings included: A review of Resident #2's hospital discharge summary dated 3/3/25 indicated the resident was diagnosed with weakness. The history of the present illness indicated Resident #2 had a total knee replacement one week prior to hospitalization and was unable to make progress at home. The resident was admitted for pain control on 2/28/25 and the hospital course indicated the resident was stable upon discharge with the resident's pain improved. Resident #2 made slow progress with physical therapy at the hospital and was discharged to the skilled nursing facility to continue with therapy. Resident #2 was admitted on [DATE] with diagnoses which included: aftercare following knee replacement surgery, muscle weakness and unsteadiness on feet. A diagnosis of dementia was discussed in Resident #2's hospital discharge summary but was not listed as a discharge diagnosis and was not included in the facility diagnosis list. A nursing progress note dated 3/3/25 at 5:40 PM written by Nurse #1 indicated that Resident #2 was admitted for aftercare following a right total knee replacement. Resident #2 was alert and oriented to person, place and event with some confusion. Resident #2 transferred with stand and pivot assistance with one person assistance with orders for weight bearing as tolerated. The progress note indicated Resident #2 was noted as continent of bowel and bladder and had been using a urinal and bedpan prior to admission. Resident #2 wore glasses and had a hearing aid which he left at home. A nursing progress note completed by Nurse #4 dated 3/3/25 at 11:54 PM indicated Resident #2 had a fall in the room. The note indicated Resident #2 reported that he was supplied with a urinal for toileting, but he spilled it before slipping out of bed. The resident was alert and oriented. The right knee, which was recently replaced, had a dressing in place and showed old bruises and slight swelling. Resident #2 reported no new injuries or increased pain. There were no signs of head trauma. Vital signs remained within normal limits. A mechanical lift was used to safely assist the resident back to bed. Close monitoring was to continue for any changes in condition. The note indicated every 4 hour neurological checks were initiated and the on-call provider was contacted. A focused head to toe observation dated 3/3/25 at 11:45 PM completed by Nurse #4 indicated an observation was made of Resident #2 as a follow up to a fall. The observation indicated that Resident #2 was alert to person, place, time and situation with strong bilateral hand grasps. Foot press strength, a test in which the resident is asked to push against resistance as part of a neurological evaluation, was not assessed due to right knee surgery. The observation noted impaired range of motion of Resident #2's right knee and leg with the lower extremities equal in length. A fall event report dated 3/3/25 at 11:58 PM completed by Nurse #4 indicated Resident #2 had an unwitnessed fall with no injuries. Resident #2 was found in his room on the floor. The report indicated Resident #2 did not complain of or exhibit pain related to the fall. The report indicated the nurse was unable to complete range of motion of his right lower extremity and a rotation deformity or shortening of Resident #2's right lower extremity was observed (an abnormal finding often associated with a femur fracture). This was different than the 11:45 PM observation completed by Nurse #4 which indicated Resident #2's lower extremities were equal in length. An interview was conducted with Nurse #4 on 3/25/25 at 3:00 PM. Nurse #4 stated she worked night shift the night that Resident #2 had an unwitnessed fall (3/3/25) in which he slipped out of bed when he was using the urinal. Nurse #4 indicated she assessed the resident, and he did not have any injury, so he was transferred back to the bed using a mechanical lift. Resident #2 stated he did not hit his head. Nurse #4 indicated that throughout the night, Resident #2 complained of spasms in his back, and he was unable to get comfortable. Nurse #4 stated she did not recall if she administered pain medication that night, but she stated that she and the staff repositioned the resident frequently to try to make him comfortable. Nurse #4 could not explain why she documented at 11:45 PM on 3/3/25 that Resident #2's lower extremities were equal in length and then at 11:58 PM on the event report she indicated a rotation deformity or shortening of the right lower extremity. Nurse #4 stated she knew that rotation and shortening of the leg was abnormal, but she was unable to explain why she did not report the observation to the on-call provider nor did she report that he complained of spasms in his back although she acknowledged that she should have. An interview was conducted with Nursing Assistant (NA) #1 on 3/25/25 at 2:30 PM. NA #1 stated she was assigned to Resident #2 on 3/3/25 from 3:00 PM to 7:00 PM, on 3/4/25 from 7:00 AM to 7:00 PM and 3/8/25 from 7:00 AM to 7:00 PM. NA #1 stated Resident #2 was pleasant and cooperative when he was admitted on [DATE] and did not complain of pain. NA #1 stated when she came in on 3/4/25 she was told by the previous NA that the resident had a fall. Later that day when she was providing care for him, Resident #2 yelled out in pain when she turned or rolled him in bed. NA #1 stated Resident #2 complained of pain in the right leg and described the pain as pulling or a burning pain. NA #1 stated it took 2 people to provide care for Resident #2 due to the pain he had in his right leg. NA #1 indicated Resident #2 was only able to tolerate sitting up in a wheelchair for a short time due to the pain. NA #1 stated she observed swelling in Resident #2's right thigh about a day or 2 after he was admitted , and she reported this to the floor nurse who she thought was Nurse #4. NA #1 stated Resident #2 would get aggravated during care due to the pain in his groin area and upper leg. Resident #2 stayed in bed when he was not receiving therapy due to the pain and the inability to sit comfortably in a wheelchair. NA #1 indicated she would try to position the resident in bed with pillows for comfort. An interview was conducted with NA #4 on 3/25/25 at 5:00 PM. NA #4 indicated that she worked from 7:00 PM to 7:00 AM and was assigned to Resident #2 on 3/3/25, 3/7/25, 3/8/25 and 3/9/25. NA #4 stated when Resident #2 fell on [DATE] he had pain and required 2-person assistance to get him up and provide his care. Prior to fall, NA #4 stated Resident #2 seemed fine and did not have pain. NA #4 indicated she observed that his right thigh area had swelling on the nights she was assigned to Resident #2 after the fall, and he complained of hip pain. NA #4 stated she checked on Resident #2 often, tried to talk to him to calm him down and reassure him. NA #4 stated that she thought Resident #2 was restless due to pain. NA #4 stated she reported his pain to the floor nurse each time she worked but she did not know if the nurse administered pain medication or assessed the resident. Resident #2's physical therapy evaluation and plan of care dated 3/4/25 indicated the resident verbalized a pain level of 10 out of 10 with constant and sharp pain to the right knee and shin which limited mobility, standing and ambulation. Resident #2 reported a 10 out of 10 pain level at rest and with movement and was unable to bear weight on the right lower extremity during transfers, which was a change from his admission on 3/3/25 when he transferred with stand and pivot assistance of 1 person. An interview was conducted with the Physical Therapist (PT) on 3/26/25 at 10:26 AM. PT stated that he was aware that Resident #2 had a fall on 3/3/25 after admission. PT stated Resident #2 had a lot of pain and difficulty with weight shifting. PT stated Resident #2 had cognitive impairment and it was difficult to discern if the resident's pain was out of proportion to the activity or as intense as it seemed or if it was more behavioral. PT indicated he did not recognize that Resident #2 not bearing weight when he was evaluated and during his therapy sessions as an indication of a problem. PT stated Resident #2's therapy had to be modified due to his pain level and his inability to bear weight. PT stated from what he was told, Resident #2 did not progress at home with home health therapy so he assumed the resident probably would not do well with the therapy in the facility. PT indicated Resident #2's right leg was externally rotated (a condition in which the leg is outwardly rotated with the thigh and knee pointed away from the body) which he acknowledged is a sign of a fracture, but he assumed this was caused by the resident staying in bed a lot and not participating in therapy at home. PT stated he did not report Resident #2's increased pain level, inability to bear weight or the external rotation of his right leg to the nursing staff or the medical provider. PT stated he assumed the pain he noted that Resident #2 demonstrated was related to his dementia and was not an abnormal finding. PT stated that some residents with dementia demonstrate intense pain but it is more of an exaggerated response than actual pain and he assumed that was the case with Resident #2. An interview was conducted with the Physical Therapy Assistant (PTA) on 3/26/25 at 10:40 AM. PTA stated that she worked with Resident #2 for therapy during his stay and she recalled that his right leg was very painful. PTA indicated Resident #2 could not tolerate standing due to pain and was not able to bear weight on the right leg. PTA stated Resident #2 was difficult to work with, but she assumed this was because he was not motivated. PTA stated she did not report Resident's pain level or inability to bear weight to the therapist or the nursing staff as she assumed this was normal for the resident. PTA indicated she had not noticed Resident #2's leg to be externally rotated or shortened. Review of Resident #2's electronic health record revealed that on 3/4/25 there was no nursing progress note regarding an assessment of Resident #2 post fall, his pain level, participation with the therapy evaluations or ability to bear weight on the right lower extremity. A physician progress note dated 3/4/25 at 7:58 PM by Physician #1 documented Resident #2 indicated he had 8 out of 10 right leg pain. The progress note did not reference Resident #2's fall that occurred on 3/3/25 nor was an assessment made due to the fall. The progress note indicated for Resident #2 was to continue pain management with the pain medications that were prescribed from the hospital. An interview was conducted with Nurse #5 on 3/25/25 at 2:00 PM. Nurse #5 was an agency nurse assigned to Resident #2 on 3/4/25, 3/8/25 and 3/9/25 from 7:00 PM to 7:00 AM. Nurse #5 stated she did not know that Resident #2 had a fall on 3/3/25 and that information regarding falls was normally communicated verbally during shift report. Nurse #5 stated she found out after Resident #2 was transferred to the hospital that he had fallen. Nurse #5 stated Resident #2 had a lot of pain and required 2 people to provide care for him. Nurse #5 stated she assumed that his complaints of pain were more of a behavior or were related to his dementia and did not require medication or further evaluation. Nurse #5 indicated she only administered pain medication to Resident #2 once because she assumed his complaint of pain was a behavior and he was just being difficult. Nurse #5 stated Resident #2 yelled at her one of the nights when she entered his room, so she did not attempt to complete an assessment. Nurse #5 indicated that if she had assessed Resident #2 and observed swelling in his upper thigh or hip area she would have notified the provider. Nurse #5 stated she probably should have assessed Resident #2 and evaluated his pain. A Nurse Practitioner progress note dated 3/5/25 at 6:50 AM indicated in part that she evaluated Resident #2 due to the resident screaming and giving the Nursing Assistant and Nurse difficulty with care. The progress note indicated Resident #2 was agitated and incontinent. The note indicated Resident #2 was to continue with the prescribed pain medication and stated that the resident's mild dementia was affecting his ability to comply with therapy and was impacting his recovery. The progress note did not reference Resident #2's fall that occurred on 3/3/25 nor was an assessment made due to the fall. The progress note did not reference a pain level or an assessment of Resident #2's right lower extremity. An interview was conducted with the Nurse Practitioner (NP) on 3/26/25 at 10:00 AM. The NP stated she went into Resident #2's room early on the morning of 3/5/25 when she heard him hollering and screaming during care. The NP stated Resident #2 was calm after the incontinence care was provided so she assumed he was exhibiting behaviors related to his dementia. The NP stated she was not aware that Resident #2 was having pain at an intensity of 10 out of 10, that he was unable to bear weight on his right leg and that his leg was externally rotated with shortening. The NP stated she did not complete a full physical exam of the resident. The NP stated if she had been made aware of Resident #2's pain intensity of 10 and inability to bear weight she would have evaluated the resident further as these are signs of a serious condition such as a fracture. A care plan for falls was created on 3/5/25 and revealed Resident #2 was at risk for falls related to pain. The interventions dated 3/5/25 included to administer medications as ordered, assist with mobility as needed, and ensure the resident was wearing non-skid footwear when out of bed. A skilled nursing note dated 3/5/25 at 7:49 PM by Nurse #1 indicated Resident #2 was pleasant, cooperative, anxious, and combative or resistive to care with no changes in condition in the past 24 hours. The note gave no indication of Resident #2's pain level, participation with therapy or assessment of his right leg. Resident #2 was not previously documented as combative or resistive to care. An interview was conducted with NA # 6 on 3/26/25 at 8:40 AM. NA #6 indicated that she worked from 3:00 PM to 11:00 PM and was assigned to Resident #2 on 3/5/25. NA #6 stated that when she attempted to provide incontinence care, Resident #2 began screaming. NA #6 stated she did not know what was wrong but could tell Resident #2 was in a lot of pain. NA #6 stated she asked another NA to assist her and they were able to provide incontinence care to Resident #2 by providing increased time and support with moving him. NA #6 indicated she informed the assigned nurse, Nurse #2, that Resident #2 was having severe pain during care. NA #6 stated she did not know if the nurse evaluated the resident. NA #6 did not notice anything different about Resident #2's leg. An interview was conducted with Nurse #2 on 3/26/25 at 8:15 AM. Nurse #2 stated she was an agency nurse that worked as needed at the facility. Nurse #2 was assigned to Resident #2 on 3/5/25 from 7:00 PM to 7:00 AM. Nurse #2 stated she did not recall anything about Resident #2. Nurse #2 stated she did not have much interaction with the residents other than administering medication and she did not recall if the NA reported that Resident #2 had pain. Review of Resident #2's electronic health record revealed that on 3/5/25 there was no nursing progress note regarding an assessment of Resident #2 post fall, his pain level, or that NA #6 reported the resident was screaming or demonstrating increased pain during incontinence care. A skilled nursing note dated 3/6/25 at 2:36 PM by Nurse #4 indicated Resident #2 was alert, oriented to person, place, time and situation and had no changes in condition in the past 24 hours. The note gave no indication of Resident #2's pain level, participation with therapy or assessment of his right leg. An interview was conducted with NA #2 on 3/25/25 at 2:50 PM. NA #2 was assigned to Resident #2 on the 7:00 AM to 3:00 PM shift on 3/5/25 and 3/6/25. NA #2 indicated she did not recall much about Resident #2's care but she did recall he had a lot of pain in his leg. NA #2 stated she did not report Resident #2's pain to the floor nurse as she thought they already knew since he had been having pain for several days. An interview was conducted with NA #5 on 3/26/25 at 8:50 AM. NA #5 indicated she worked on the 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM shifts. NA #5 stated she and NA #4 worked together on the rehabilitation unit where Resident #2 resided. NA #5 indicated that she provided care to Resident #2 on 3/3/25, 3/4/25 and 3/6/25 from 11:00 PM to 7:00 AM. NA #5 stated she recalled when Resident #2 fell on [DATE] and indicated that he was very agitated after the fall. NA #5 stated that Resident #2 required 2 person assistance with turning and reposition and incontinence care. NA #5 stated resident screamed and hollered during incontinence care and would become combative. NA #5 stated Resident #2's right leg had swelling in the thigh area, and he was having a lot of pain. NA #5 stated she and the other NA would try to be gentle and provide increased time with care. NA #5 stated it was difficult to get Resident #2 comfortable, but she did not report this to the nurse as she thought the nurses already knew. NA #5 could not recall if Resident #2's leg was externally rotated. Review of Resident #2's electronic health record revealed that on 3/6/25 from 11:00 PM to 7:00 AM there was no nursing progress note regarding an assessment of Resident #2, his pain level or that he was screaming and agitated during incontinence care. A Minimum Data Set (MDS) pain assessment completed by the MDS Nurse on 3/7/25 at 8:16 AM indicated Resident #2 had pain in the last 5 days almost constantly and the pain affected his sleep, therapy and day to day activities frequently. Resident #2 rated his pain intensity as 10. Resident #2's electronic health record revealed no nursing progress note by the MDS Nurse regarding resident's pain level of 10, notification of the medical provider or further assessment of the resident. An interview was conducted with Nurse #3 on 3/25/25 at 1:14 PM. Nurse #3 was new to the facility and was assigned to Resident #2 on 3/7/25 from 7:00 AM to 7:00 PM. Nurse #3 stated on 3/7/25 Resident #2 did not want to get up out of bed or participate in therapy. Nurse #3 stated it was her first day assigned to Resident #2 and she did not know what his baseline was. Nurse #3 stated nothing was reported to her by the previous shift regarding resident's condition or increased pain. Nurse #3 acknowledged that she did not attempt to determine why Resident #2 did not want to get up or participate in therapy. During the shift on 3/7/25, Nurse #3 indicated eventually, Resident #2 was assisted up out of bed to the wheelchair and went to therapy. During the shift on 3/7/25, Nurse #3 stated she administered Resident #2's pain medication but did not complete a full assessment of the resident as she was busy with passing medications, her other duties, being new to the facility and still learning. Nurse #3 stated she did not recall anything about Resident #2's pain on 3/7/25, his right lower extremity, the pain level or factors that affected the pain. An interview was conducted with Nurse #6 on 3/25/25 at 4:51 PM. Nurse #6 was an agency nurse assigned to Resident #2 on 3/6/25 and 3/7/25 from 7:00 PM to 7:00 AM. Nurse #6 stated she did not know much about Resident #2 as she only was assigned to him a couple of times. Nurse #6 stated Resident #2 was confused and was combative with personal care. Nurse #2 stated that she assumed that was Resident #2's baseline as that was what she was told by other staff, but she could not recall which staff members told her this. Nurse #6 stated she thought that his behavior might be due to pain, so she thought she administered his PRN pain medication, and this seemed to help him. Nurse #6 stated she did not attempt to identify the source of the pain or complete an assessment of Resident #2 as she thought the pain medication seemed to help. An interview was conducted with NA #3 on 3/25/25 at 5:15 PM. NA #3 indicated that she worked from 7:00 AM to 3:00 PM and was assigned to Resident #2 on 3/7/25. NA #3 indicated Resident #2 had a lot of pain in his hip and leg. Resident #2 did not want to move his leg and seemed scared to move it. NA #3 stated she informed the floor nurse of Resident #2's pain and stated the nurse knew that his leg was hurting. Resident #2's electronic health record revealed no nursing progress note dated 3/7/25 by Nurse #3 regarding resident's pain level of 10, notification of the medical provider or assessment of the resident. A skilled nursing note dated 3/8/25 at 6:19 PM by Nurse #1 indicated Resident #2 was oriented to person, was pleasant, anxious and combative or resistive to care and had no change in condition in the past 24 hours. The note gave no indication of Resident #2's pain level, participation with therapy or assessment of his right leg. Resident #2's 5-day Minimum Data Set (MDS) dated [DATE] indicated the resident had moderate cognitive impairment and demonstrated rejection of care 1 to 3 days. Resident #2 had functional limitation in range of motion with impairment on 1 side of the lower extremity and required moderate assistance with bed mobility and transfers. Resident #2 had frequent incontinence of bowel and bladder, had a diagnosis of muscle weakness and unsteadiness. Resident #2 had almost constant pain that interfered with sleep, therapy and day-to-day activities. Resident #2 rated his pain a 10. A skilled nursing progress note dated 3/9/25 by Nurse #1 indicated Resident #2 was oriented to person, was pleasant, anxious, combative or resistive to care and had no change in condition in the past 24 hours. The note gave no indication of Resident #2's pain level, participation with therapy or assessment of his right leg. An interview was conducted with Nurse #1 on 3/26/25 at 3:30 PM. Nurse #1 stated she had a hard time recalling specific information about Resident #2, as the rehabilitation hall was her primary assignment and there was a high rate of turnover of residents. Nurse #1 recalled that Resident #2 had pain with movement, but she did not assess his leg. Resident #2 had difficulty expressing where the pain was, but Nurse #1 stated he would say repeatedly Oh my leg with any movement or activity. It was hard for him to describe where the pain was. She reported that with transfers, bed mobility, and incontinence care Resident #2 demonstrated non-verbal signs of intense pain which included grimacing or wincing. Nurse #1 stated she did not recall that therapy reported that Resident #2 had 10 out of 10 pain, was unable to stand or bear weight. Nurse #1 stated she did not inform the provider that Resident #2 had intense pain with movement as he had some dementia, and she assumed the provider knew. A physician progress note dated 3/10/25 at 1:31 PM written by Physician #2 indicated the physician was asked to see Resident #2 as he was not participating in therapy, and he had a fall following admission to the facility. Per Resident #2's family member the resident was not himself, was not acting right and she (the family member) was concerned. Resident #2 was seen and examined with the resident complaining that his right groin was in a lot of pain down into this thigh. Resident #2 stated it hurt whenever anyone touched the area. An interview was conducted with Physician #2 on 3/26/25 at 2:42 PM. Physician #2 indicated that he was asked to see Resident #2 on 3/10/25 due to the resident not participating in therapy and increased pain. Physician #2 indicated Resident #2 stated he had pain in his groin. Physician #2 stated he and 2 of the therapists assisted Resident #2 into bed. Physician #2 stated Resident #2 seemed worse from what staff reported since his fall. Physician #2 stated he was concerned that Resident #2 may have a fracture, and this needed to be addressed right away so he ordered for the resident to be sent to the hospital. Physician #2 stated that the resident's increased pain level and inability to bear weight should have been reported to the physician or NP to evaluate. Physician #2 indicated it was possible that the fracture may not have had any outward signs, but increased pain and inability to bear weight was a sign that should have been reported for further evaluation. Physician #2 indicated that Resident #2 had mild dementia with some cognitive impairment. Physician #2 stated that a resident with dementia may demonstrate increased behaviors including agitation or combativeness because of pain. Physician #2 stated he did not recall if Resident #2's leg was shorter or externally rotated. A nursing progress note dated 3/10/25 at 1:43 PM written by Nurse #3 indicated Resident #2 was sent to the emergency room for evaluation. Resident #2's family member stated that the resident complained of pain in his right hip area since he had an unwitnessed fall on 3/3/25. Resident #2's family member stated he had decreased mentation and the family member requested a urinalysis and Computed Tomography (CT) scan be completed. The physician assessed the resident and decided to send Resident #2 to the emergency room due to pain in the hip/groin area. An interview was conducted with Nurse #3 on 3/25/25 at 1:14 PM. Nurse #3 stated she worked with Resident #2 during the 7:00 AM to 7:00 PM shift on 3/10/25. Nurse #3 stated that Resident #2's family member indicated that she wanted the resident evaluated so she informed the physician of the family member's request. Nurse #3 stated on 3/10/25, Resident #2 was in acute pain, could not get up out of bed and was unable to sit up. Nurse #3 stated Resident #2 was only able to tolerate lying flat in bed due to significant pain in the right hip and groin. Nurse #3 stated Resident #2's pain was excruciating. The physician gave the order to transfer Resident #2 to the hospital for evaluation. The emergency department encounter note dated 3/10/25 indicated Resident #2 presented with groin pain since an unwitnessed fall at the facility on 3/3/25. The note indicated Resident #2 had right groin tenderness., right leg pain and deformity with external rotation of the right lower extremity. Resident #2's right leg was shorter than the left and was mildly edematous, a condition characterized by abnormal accumulation of fluid and can be caused by an injury. Two view x ray of the right femur result indicated a comminuted right intertrochanteric femur fracture. Resident #2 was admitted to the hospital on 3/10/25, underwent intermedullary nailing of the right femur (a procedure in which a metal rod is inserted into the long thigh bone to stabilize the fracture) and was discharged to a skilled nursing facility on 3/20/25. There was no indication of complications as a result of the surgery. An interview was conducted with Physician #1 on 3/26/25 at 2:00 PM. Physician #1 indicated that she was not aware of Resident #2 sustaining a fall on 3/3/25 or having external rotation or shortening of his leg. Physician #1 stated if she had been informed that Resident #2 had a fall on 3/3/25 she would have evaluated the resident regarding the fall and possible injury. Physician #1 stated Resident #2 complained of pain, and she attributed this to his recent right total knee replacement. During Resident #2's stay, neither the nursing staff nor the therapists reported increased pain level or inability to stand or bear weight. Physician #1 stated if the nursing staff or therapists had reported that Resident #2 had a pain level of 10 out of 10, inability to stand or bear weight, she would have ordered x rays and evaluated the resident further. Physician #1 stated that she expected that the nursing staff or therapists would have reported the changes and there seemed to be a lack of communication. Physician #1 stated she was not aware that Resident #2 was diagnosed with an intertrochanteric femur fracture when he was sent to the hospital for evaluation on 3/10/25. An interview was conducted with Unit Manager #2 on 3/26/25 at 3:00 PM. Unit Manager #2 stated she was not aware of Resident #2 having increased pain, not participating in therapy or inability to bear weight. Unit Manager #2 stated she did not assess the resident at any time or consult with the provider regarding the resident's pain or external rotation or shortening of his leg. Unit Manager #2 stated that the floor nurses were expected to report changes in the residents to her and she reported changes to the NP or Physician. An interview was conducted with the Director of Nursing on 3/25/25 at 3:40 PM. The DON stated that Resident # 2 had pain during his stay in the facility and the staff assumed it was his knee and did not evaluate to determine where the pain was. The DON indicated she was aware that Resident #2 was not participating well with therapy, but the staff assumed it was just the resident and his behavior and did not attribute it to the pain or a change in condition such as an injury or fracture. The DON's expectation was that the nursing staff monitored the residents for pain, assessed the residents and reported increased pain and changes to the physician for evaluation. An interview was conducted with the Administrator on 3/26/25 at 1:45 PM. The Administrator stated Resident #2 was a complicated case and the facility may have missed something. The Administrator indicated that communication could have been better between the nursing staff, therapy staff and the provider. The Administrator stated that Resident #2 should have had a complete assessment and changes including external rotation and shortening of the leg, increased pain and changes in weight bearing should have been reported to the NP or physician for evaluation.

Based on observations, record review, Nurse Practitioner (NP), staff, and resident interviews, the facility failed to provide supervision to Resident #7, a severely cognitively impaired resident, who asked the Weekend Receptionist to sit on the porch. Resident #7 exited from the building without nursing staff's knowledge when the Weekend Receptionist unlocked the front door and let the resident out of the facility unsupervised at approximately 12:00 PM on 9/21/2024. The resident was outside unsupervised, until Nurse #5 who was inside the building observed Resident #7 self-propelling on the road in the facility's parking lot near the curb on the right side of the building around 1:15 to 1:20 PM. The distance was approximately 332 feet from the porch of the facility. Nurse #5 instructed Nurse Aide (NA) #3 to bring Resident #7 back into the facility. The resident had taken her sweater off and stated she was warm. According to the Weather Channel website, the temperature on 9/21/2024 was approximately 82 degrees in [NAME] at noon. NA #3 stated Resident #7 was trying to get her wheelchair up on the curb, and Resident #7 stated she was going to church. This noncompliance created a high likelihood for serious harm. If Resident #7 had self-propelled toward the left instead of the right, she would have been on a busy four lane highway with a speed limit of 45 miles per hour. The highway had a shoulder and no sidewalks. This deficient practice was identified for 1 of 4 residents reviewed for supervision to prevent accidents. The findings included: Resident #7 was admitted to the facility on [DATE] with diagnoses including non-traumatic brain dysfunction, unspecified dementia, history of falling, and unsteadiness on feet. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #7 was severely cognitively impaired. She was not coded for wandering, and required supervision with transfers, and activities of daily living. She was coded as ambulatory with walker and not a wheelchair. The Care Plan for Resident #7 updated 8/3/2024 revealed a plan of care for impaired cognitive function and impaired thought processes related to dementia with a goal for being able to communicate basic needs on a daily basis for next 90 days. Interventions included to break tasks into one step at a time and do not rush or show annoyance or impatience and to cue, reorient, and supervise as needed dated. The care plan included a risk for falls characterized by history of falls, and multiple risk factors related to falls such as weakness, need for activities of daily living (ADL) assistance, and cognitive impairment and incontinence plan of care dated 7/4/2024 with the goal to minimize risks for falls and minimize injuries related to falls through next 90 days. Interventions included to maintain call bell within reach, maintain resident's needed items within reach, and physical therapy (PT), occupational therapy (OT), and Speech and Language therapist SLP to screen and treat as necessary. An interview with the Weekend Receptionist was conducted on 10/30/2024 at 3:30 PM. The Weekend Receptionist stated she had only been working at the facility for a few weeks when the incident with Resident #7 occurred. She stated that on Sunday 9/21/2024 at approximately 12:00 PM she had noticed Resident #7 sitting in her wheelchair close to the front door. The Weekend Receptionist further stated that Resident #7 was appropriately dressed and wearing shoes, and she was holding a notebook. She stated that she asked Resident #7 if she could help her, and Resident #7 stated that she wanted to go out and sit on the front porch and read her notebook. The Weekend Receptionist stated that Resident #7 was not wearing a wander guard, and she assumed she could go outside by herself. She further stated that she did not check with the nurse prior to letting Resident #7 out of the facility. The Weekend Receptionist further stated that she was called away from the desk to deliver a meal to a resident, and when she returned Resident #7 was not on the front porch. She stated that it was over an hour before the nursing staff had come to her and asked her if she knew how Resident #7 exited the facility. The Weekend Receptionist indicated that she took full responsibility for her actions and that she should have asked someone prior to letting Resident #7 outside by herself. A telephone interview was completed with NA #3 on 10/31/2024 at 10:53 AM. NA #3 stated she was working on the 200 Hall and it was after lunch on 9/21/2024 when the incident occurred. She further stated that Nurse #5 told her Resident #7 was outside and for her to go get her and bring her inside the facility. NA #3 indicated she went outside and found Resident #7 trying to get her wheelchair up on the sidewalk so she could reach the doors. She stated Resident #7 told her she was going to church and that she had taken off her sweater because she was warm. NA #3 further stated that it was warm and sunny that day and it was not raining. She indicated that Resident #7 was assessed by Nurse #5 and was given a drink of water. An interview with Nurse Aide (NA) #4 was completed on 10/30/2024 at 2:45 PM. NA #4 stated that Resident #7 was not displaying any exit seeking behaviors prior to her elopement. She further stated Resident #7 enjoyed staying in her room most of the time looking at her pictures and books. NA #4 indicated that the staff tried to keep an eye on her most of the time and redirect her when she was wandering. She further indicated when Resident #7 wandered before the elopement she usually went as far as the nurse's station or the dining room. NA #4 stated Resident #7 loved potato chips and was easily redirected with a bag of chips. NA #4 further stated Resident #7 was not wearing a wander guard prior to her elopement. A follow-up interview with NA #4 was completed on 10/31/2024 at 10:05 AM. NA #4 stated she was assigned to care for Resident #7 on the day she eloped. She further stated she had been giving a shower to another resident that took her about two hours to complete and when she came out, she was told by Nurse #5 that Resident #7 was found outside. She stated that she was unsure of the time that she went into the shower, but it was sometime before lunch and lunch had been served when they came out. An interview was conducted with NA #5 on 10/31/2024 at 10:13 AM. NA #5 stated she was the other nurse aide assigned to the 200 Hall on 9/21/2024 when Resident #7 eloped. She further stated she was on her break when Resident #7 was found outside the facility. NA #5 indicated that she last saw Resident #7 that day around lunch time and that it was around 1:15 PM when she was found. A nurse's progress note written by Nurse #5 on 9/21/2024 at 3:45 PM, read in part, that Resident #7 was observed in her wheelchair propelling herself in the parking lot. Resident was taken back to her room and offered something to drink. The staff was educated on her elopement and a wander guard was placed on resident's left wrist at the time with the expiration date 7/28/2027. The Responsible Party (RP) and NP were notified of the elopement. A facility Event Report dated 9/21/2024 at 3:14 PM written by Nurse #5 revealed Resident #7 was found unsupervised in the facility parking lot. According to the report, Resident #7 was not experiencing any new traumas, or stressors, recent changes in medications, or abnormal lab values in the last 30 days, and was not exhibiting any exiting behaviors. The intervention listed was the door alarm band (wander guard) was applied. The on-call provider was notified at 1:20 PM and the RP was notified at 3:46 PM. An interview with Nurse #5 occurred on 10/29/2024 at 2:20 PM. Nurse #5 pointed down the hallway and stated that she could see the emergency exit doors down the 100 and 200 Halls from the nurse's station. She further stated that approximately a month ago on 9/21/2024, she was standing at the nurse's station and looked out the door down at the end of the 100 hall and saw Resident #7 propelling herself in her wheelchair in the facility parking lot. Nurse #5 indicated Resident #7 was found safe and uninjured. She stated that Resident #7 was exhibiting wandering behaviors prior to the elopement but was not exit seeking. Nurse #5 further stated that prior to the elopement Resident #7 was usually wandering up and down the hall to the nurse's station. A progress note written by Unit Manager #2 recorded as a late entry on 9/21/2024, read in part, that Resident #7 was placed in a safe area when she was brought in, and a skin check was performed, and her needs were met. Resident #7 was not experiencing any distress or pain, and remained at baseline cognition, and knew her name and her family. Resident #7 was unable to voice the name of the facility, but she was aware of her room location and personal belongings that were in the room. Resident #7 was able to move all extremities without difficulty and was verbally responsive to questions. A follow-up telephone interview was conducted with Nurse #5 on 10/31/2024 at 8:21 AM. Nurse #5 stated that when she had spotted Resident #7 outside of the facility on 9/21/2024 she sent NA #3 to go outside and bring her back in the facility. She further stated that Resident #7 had self-propelled from her room at the end of the 200 Hall all the way outside to the parking lot. Nurse #5 indicated Resident #7 was smiling and self-propelling near the curb not in the middle of the parking lot. Nurse #5 indicated Resident #7 was wearing pants, shirt a sweater, and shoes. She stated Resident #7 did not say anything about being outside, and they gave her a drink of water. Nurse #5 further indicated that she had assessed Resident #7 for injuries and there were no injuries. She stated that Resident #7 had never exhibited exit seeking behaviors before and that she mostly stayed in her room. Nurse #5 further stated that she put the wander guard bracelet on Resident #7, completed the incident report, and filled out the assessment and observation form. An interview with Nurse Practitioner (NP) was completed on 10/30/2024 at 09:01 AM. NP #1 stated she was familiar with Resident #7 and her recent elopement. She stated that Resident #7 was severely cognitively impaired and unaware of safety hazards. NP further stated that as far as she knew Resident #7 was not experiencing any exit seeking behaviors prior to the elopement on 9/21/2024. She further stated Resident #7 was able to ambulate short distances prior to using the wheelchair to self-propel. A measurement from the facility front porch to the curb in the parking lot outside the 100 hall doors was completed on 10/31/2024 at 8:45 AM with the Maintenance Director using the therapy measuring roller. The distance from the front porch to the curb outside the 100 Hall door was 332 feet and the distance from the front porch to the entrance stop sign at the highway was 185 feet. The parking lot was divided into a left and right parking lot and there were no sidewalks on the sides of the building, only in the front. There were no accessible places to get on the sidewalk except at the main entrance, and Resident #7 had to self-propel through the parking lot that is narrow on the right side which is where she was found. According to the visitors log there were 32 visitors to the facility on [DATE] that would have parked in the parking lot. A measurement of the 200 hallway was completed with Occupational Therapist (OT) #1 on 10/31/2024 at 9:00 AM. The measurement was 70 feet from Resident #7's door to the nurse's station. OT #1 timed Resident #7 self-propelling in her wheelchair to the nurse's station and she was able to reach the desk in one minute. The OT indicated that Resident #7 was able to self-propel her wheelchair at a normal walking pace. According to the Weather Channel website it was 82 degrees and sunny in [NAME], NC on 9/21/2024 at 12:00 PM. An interview was conducted with the Administrator on 10/31/2024 at 12:45 PM. The Administrator stated that a severely cognitively impaired resident was found outside the facility on 9/21/2024. He further stated that it was just a human mistake, and the Weekend Receptionist was unaware of the resident's cognitive status and made the mistake of letting her go outside by herself. The Administrator indicated the Weekend Receptionist should have asked the nursing staff prior to letting Resident #7 out the front door. The Administrator was notified of immediate jeopardy on 10/31/2024 at 12:54 PM. The facility provided 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 September 21, 2024 Nurse #5 assigned to Resident #7 notified the Unit Manager that Resident #7 needed a wander guard band because resident #7 was in the side parking lot of the building. It was determined Resident #7 had been assisted out of front door by the Weekend Receptionist and had self-propelled to the side parking lot. Resident #7 was assisted back into the facility on [DATE] by Nursing Assistant #3 and assessed for injuries by Nurse #5. Resident #7 was in no distress and had no injuries from the unauthorized departure. The wander guard was placed on Resident #7 by Nurse #5 on September 21, 2024. The responsible party and provider were notified on September 21, 2024 by Nurse #1. Resident #7's elopement assessment prior to the unauthorized departure was reviewed by the Director of Nursing and it was determined that the resident was not at risk for elopement at the time of the assessment. On September 22, 2024 the Director of Nursing reviewed the progress notes between the date of the last elopement assessment that was completed on June 30, 2024 and the date of the unauthorized departure to ensure there was no documentation of wandering behaviors. There was no documentation of wandering or exit seeking behavior in the Electronic Medical Record. The root cause of the incident was discussed by the Interdisciplinary team on September 23, 2024 and it was determined that Resident #7 displayed new onset of exit seeking behaviors not reported to nurse #5 by the receptionist, therefore Resident #7 did not have a wander guard in place. Also the receptionist failed to consult with Nurse #5 on the condition of Resident #7 prior to assisting Resident #7 out of the front door. The Receptionist was re-educated by the DON on 9/23/2024 to consult with the nurse before letting residents onto the porch and checking the wander guard book located at the reception desk. The Interdisciplinary team consisted of the Director of Nursing, Unit Manager #1, Unit Manager #2, Minimum Data Set Nurse, Administrator, Social Worker, Wound Care Nurse and Infection Control Nurse. Address how the facility will identify other residents having the potential to be affected by the same deficient practice On September 23 and September 24, 2024 the Director of Nursing, Unit Manager #1, Unit Manager #2 and the Infection Control nurse completed a new Brief Interview for Mental Status assessment and an Elopement assessment on all residents in the facility that had not been assessed since August 23, 2024. On September 23, 2024 the Director of Nursing reviewed all progress notes since August 21, 2024 to ensure all residents with documented wandering behavior had a wander guard and care plan in place. No additional new residents were identified with wandering behaviors. The wander guard books were updated on September 24, 2024, by the Director of Nursing, following the completion of the Elopement assessments. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur Staff education was started by the Director of Nursing on September 24, 2024 on the Elopement Policy and Procedure and Immediately reporting exit seeking behaviors to the nurse and administration. When in doubt ask a nurse. The When in doubt ask a nurse education included consulting with the nurse assigned to a resident prior to letting a resident out of the facility. Education also included consulting the wander guard books which were placed at all three nurse stations and the reception desk. The wander guard books include photo ID of all residents that are at risk for unauthorized departures. Anyone that the Director of Nursing could not educate face to face was educated via phone. Anyone that the Director of Nursing could not educate will be educated prior to their next scheduled shift. All newly hired staff will be educated by the Director of Nursing on the Elopement Policy and Procedure and Immediately reporting exit seeking behaviors to the nurse and administration When in doubt ask a nurse before the end of their employee orientation. The Director of Nursing also validated there was a sign on the main entrance informing visitors and staff to talk with a nurse prior to assisting residents out of the facility. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained The facility decided to take the elopement incident and the plan of correction to the Quality Assurance Performance Improvement team on September 23, 2024. The Quality Assurance Performance Improvement Committee consisted of the Director of Nursing, Unit Managers, Social Worker, Administrator, Minimum Data Set Nurse, Wound Care Nurse and the Therapy Director. To ensure ongoing compliance the Director of Nursing will review all progress notes 5 times a week for 8 weeks to ensure all residents with wandering behaviors have a wander guard in place and that there are no other instances of other unsafe residents being outside of the facility without supervision. In addition, the Director of Nursing will interview 3 employees weekly for 8 weeks to ensure all staff understand the elopement drill process. Elopement books will be reviewed weekly during resident review to ensure the books are up-to-date and all residents at risk for elopement are listed in the books. The audits will be reviewed by the Quality Assurance Performance Improvement Committee for 3 months. The facility alleged IJ removal date of 9/25/24 and the completion date for the corrective action plan was 9/25/2024. As part of the validation process on 10/31/2024, the corrective action plan was reviewed and included a sample of staff which included nurse aides, receptionists, nurses, and housekeeping staff regarding the in-services and training related to elopements. The wander guard books were reviewed and all residents with wandering behaviors were identified and were wearing wander guards. The staff verified the education and training. The receptionists verified the training and provided the updated wander guard book located at the front entrance and the wander books were verified on the nursing units by the nursing staff. The monitoring tools and continued monitoring were reviewed to ensure compliance. An observation and interview with Resident #7 occurred on 10/30/2024 at 2:20 PM. Resident #7 was observed sitting up in her wheelchair self-propelling in her room and a wander guard was attached to the frame of the wheelchair. Resident #7 stated that she used to walk with her walker, but she felt safer in the wheelchair, because she did not want to fall. The immediate jeopardy was removed on 9/25/2024 and the compliance date of 9/25/2024 was validated.

Based on observations, record review, and interviews with staff, residents, Nurse Practitioner, and family member the facility failed to protect a vulnerable male resident's (Resident #1) right to be free from sexual abuse by a cognitively impaired male resident (Resident #2). On 10/17/24 Resident #2 was observed by Resident #1's family member to have his hand inside Resident #1's brief as Resident #1 laid in bed. Resident #1 was incapable of giving consent for sexual contact and was unable to protect himself. Following the incident, Resident #1's antidepressant was increased due to an increase in agitation and restlessness. A reasonable person expects to be protected from abuse in their home and would have experienced psychosocial harm with feelings such as intimidation, severe anxiety, agitation, humiliation, withdrawal, and fear. This deficient practice was reviewed for 1 of 3 residents for abuse. Findings included: Resident #1 was admitted to the facility on [DATE] with a diagnosis of dementia and depression. Review of Resident #1's Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive impairment. Resident #1 had no behaviors, had disorganized thinking and inattention. Resident #1 was dependent on staff for bed mobility and transfers, had no limitations of range of motion and received an antidepressant. Resident #2 was admitted on [DATE] with diagnosis which included dementia and conduct disorder. Review of Resident #2's physician orders revealed an order dated 4/30/24 for paroxetine 20 milligrams (mg) at bedtime for depression. During an interview with Nurse Practitioner #2 on 10/31/24 at 2:05 PM she indicated Resident #2 was prescribed an antidepressant for depression, but it also was used to manage sexually inappropriate behavior and poor impulse control. A review of Resident #2's Care Plan included a focus of behavioral symptoms initiated on 1/17/20 with the last routine update on 7/5/24. The care plan indicated Resident #2 had behavioral symptoms including disrobing in public, inappropriate touching of other residents and a history of public displays of inappropriate touching. The Care Plan goal indicated Resident #2 would have no evidence of inappropriate sexual behavior by the next review date. Interventions included intervene as necessary to protect the rights and safety of others, divert resident's attention, and remove from the situation and take to an alternate location as needed. Review of Resident #2's electronic health record revealed a physician progress note dated 9/24/24 at 3:45 PM. The progress note indicated Resident #2 had diagnosis of dementia and inappropriate sexual behaviors. The plan indicated Resident #2 was to continue with the antidepressant paroxetine and was to be followed by psychiatric services. Review of Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate difficulty with hearing, short- and long-term memory impairment and exhibited wandering daily and other behavioral symptoms daily (such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, and verbal and vocal symptoms like screaming or disruptive sounds). Resident #2 had no limitations of range of motion, required limited assistance with wheelchair mobility and received an antidepressant. Review of Resident #1's electronic health record revealed a nursing progress note dated 10/17/24 at 2:45 PM written by Nurse #1. The progress note indicated Resident #1's family member came to the nurses' station and reported that another resident in a wheelchair was in Resident #1's room. Emotional support was provided to Resident #1 and his family member. A head-to-to-toe assessment of Resident #1was completed. An initial allegation report dated 10/17/24 revealed the following allegation details: Resident #1's family member entered the room to find a male resident in the room next to Resident #1's bed. The family member observed Resident #2's hand in Resident #1's brief. The family member voiced that Resident #2's hand was under the covers near Resident #1's genitals. Resident #1 was disoriented at baseline and unable to recall the situation. Review of a signed witness statement dated 10/17/24 by Resident #1's family member revealed Resident #1 was laying on his back taking a nap. The statement indicated when Resident #1's family member entered the room, there was a man (Resident #2) in a wheelchair next to the bed at an angle facing towards Resident #1. The other resident (Resident #2) had his hand under the covers. The family member pulled back the covers and Resident #2's hand was in Resident #1's diaper. The family member screamed at Resident #2 to get out at least twice. Resident #2 did not move. The statement indicated Resident #1's family member ran out into the hall yelling for help and yelled at Resident #2 to never come back into that room again. An interview was conducted with Resident #1's family member on 10/29/24 at 4:00 PM. The family member stated she visited Resident #1 daily. Resident #1's family member indicated on 10/17/24, Resident #1 was sliding down in the wheelchair, so staff stated he needed to be lay down for a nap. Resident #1's family member stated she agreed to the staff laying him down for a short nap and she left. Resident #1's family member stated when she returned shortly after and went down to Resident #1's room the door was open when she approached, and she observed a man (Resident #2) in the room with his wheelchair angled towards Resident #1's bed. Resident #1's family member went over to the bed where she observed Resident #2's hand under Resident #1's blanket. The family member pulled the blanket back and observed Resident #1 with no pants on, only a shirt and a brief on with Resident #2's hand inside Resident #1's brief making skin to skin contact. The family member stated she could not tell if Resident #1 was awake or asleep and noted that he had a baseball cap covering his face. Resident #1's brief was gaping open at the side and Resident #2's hand was inside the brief from the side. The family member did not observe Resident #1's genitals or if there was any hand motion by Resident #2, but stated it was inappropriate for Resident #2's hand to be inside the brief. When she observed this, Resident #1's family member stated she ran out of the room yelling for staff. Staff came, removed Resident #2 from the room and assessed Resident #1. The family member stated following the incident, Resident #1 was moved to a room on another hall. The family member further stated following the incident, Resident #1 seemed agitated, anxious and restless exhibiting fidgety behaviors and not wanting to participate in usual daily routine. The family member explained she came to the facility daily and Resident #1's normal routine included her taking him outside in his wheelchair, to the dining room and to activities and after this incident, he was more fidgety and not interested. The family member stated after a brief period, Resident #1 returned to his usual routine. The family member indicated Resident #1 was quiet and not able to articulate what he was feeling. The family member stated the Nurse Practitioner evaluated the resident after the incident and increased Resident #1's antidepressant. An interview was conducted with Nurse #1 on 10/30/24 at 2:05 PM. Nurse #1 indicated she was assigned to Resident #1 on 10/17/24 from 7:00 AM to 7:00 PM. Nurse #1 stated she was at the nurses' station when she heard yelling from down the hall Resident #1 resided on by Resident #1's room. Nurse #1 stated a staff member, she could not recall who, was quickly pushing Resident #2 in his wheelchair up the hallway from the direction of Resident #1's room. Nurse #1 stated Resident #1's family member was visibly upset and stated Resident #2 was in her family member's room and had touched Resident #1 inappropriately. Nurse #1 stated Resident #1 was having difficulty sitting up in the wheelchair that day, so after lunch the nursing assistant laid him down in bed for a nap. Resident #1's family member left while he was taking a nap and when she returned, she observed Resident #2 in the room in his wheelchair beside Resident #1's bed. Nurse #1 stated Resident #1's family member stated she observed Resident #2's hand in Resident #1's brief. Nurse #1 stated she was familiar with Resident #2 and was aware that he made inappropriate sexual comments to the staff frequently, was combative and refused or resisted care. Nurse #1 stated Resident #1 was moved to another room later that day, so she did not observe changes in his behavior following the incident. A review of Resident #1's nursing progress notes revealed a note dated 10/17/24 at 2:49 PM written by Unit Manager #1. The note indicated Unit Manager #1 was called to Resident #1's room and indicated the family member was upset. The family member stated she left so that Resident #1 could take a nap and when she came back another resident was sitting in a wheelchair next to the bed. The family member noticed that the other resident's hand was under Resident #1's covers. Unit Manager #1 assessed Resident #1. Resident #1 was unable to recall anything that occurred due to his baseline confusion. A head-to-toe assessment of Resident #1 was completed with no concerns noted. The note stated Unit Manager #1 immediately notified the Administrator and Director of Nursing of the incident. Review of a signed witness statement dated 10/17/24 by Unit Manager #1 revealed she was called to Resident #1's room by the nursing staff. Upon entering the room, the Unit Manager saw Resident #1's family member standing next to Resident #1's bed. Unit Manager #1 stated Resident #1's family member observed Resident #2's hand in the resident's brief. Resident #1 was assessed after the incident. Resident #1 did not recall what occurred. No distress was noted. An interview was conducted with Unit Manager #1 on 10/30/24 at 3:15 PM. Unit Manager #1 stated she was in a room on another hall when Nurse #1 came and alerted her of a situation with Resident #1 and Resident #2. Unit Manager #1 stated she went down to the hall Resident #1 resided on and saw the family member of Resident #1 in the hallway outside of Resident #1's room. Resident #1's family member stated when she approached the room, she observed Resident #2 in his wheelchair next to Resident #1's bed. Unit Manager #1 further stated Resident #1's family member stated she observed Resident #2's hand inside Resident #1's brief. Unit Manager #1 stated she and the Director of Nursing (DON) assessed Resident #1. Unit Manager #1 stated Resident #1's brief was loosely fastened. Resident #1 was moved to a room on the other side of the facility after the incident. Resident #2 was assisted to his room by NA #2 and placed in bed immediately after the incident. Unit Manager #1 stated Resident #2 was unable to get out of bed without assistance. When Resident #2 was up in his wheelchair, a staff member, either the Nursing Assistant (NA) assigned to him or an ancillary staff member, was assigned for 1:1 supervision. Review of a focused head-to-toe evaluation dated 10/17/24 at 4:16 PM by Unit Manager #1 revealed Resident #1 was assessed due to resident-to-resident sexual abuse. No negative findings were observed. Review of a signed witness statement dated 10/17/24 by Nursing Assistant (NA) #1 revealed she was assigned to Resident #2 on 10/17/24 on 7:00 AM to 3:00 PM shift. The witness statement indicated NA #1 got Resident #2 up at 11:00 AM to eat lunch. When she returned from her break at 1:30 PM Resident #2 was in his wheelchair down the hallway where Resident #1 resided. A telephone interview conducted on 10/29/24 at 3:15 PM with NA #1 revealed she had been in the position for 2 years and was assigned to Resident #2 on 10/17/24 from 7:00 AM to 3:00 PM. NA #1 stated Resident #2 was rude and used sexual language, but she had not observed him touching other residents. NA #1 stated Resident #2 was able to propel his wheelchair independently, wandered in the hallways but did not typically enter other resident rooms, was confused and had no limitations using his hands. NA #1 stated that when she went on her lunch break, Resident #2 was propelling himself in his wheelchair on the hall that Resident #1 resided on. NA #1 stated when she returned from her break, she observed Resident #2 on the hall Resident #1 resided on in his wheelchair. NA #1 indicated she went to assist another staff member on another hall and when she returned to her assigned area, she observed Resident #1's family member crying. NA #1 indicated she assisted Resident #2 to his room and assisted him to bed following the incident. NA #1 stated Resident #2 required assistance to get into and out of bed. A telephone interview was conducted with NA #2 on 10/30/24 at 12:32 PM. NA #2 stated she was assigned to Resident #1 on 10/17/24 from 7:00 AM to 3:00 PM. NA #2 indicated she laid Resident #1 down for a nap with his brief and a shirt on. NA #2 stated she did not have the correct size brief available when she changed Resident #1, so she applied a larger sized brief. NA #2 stated she went to take her lunch break and when she returned, she was informed there was an incident with Resident #2 inappropriately touching Resident #1. NA #2 stated shortly after the incident, Resident #1 was moved to a room on the other side of the facility. Review of a Nurse Practitioner (NP) progress note written on 10/17/24 at 4:50 PM by NP #1 revealed Resident #1 was seen and examined with no abnormal physical findings. A recommendation was made to increase resident's ordered antidepressant medication. A physician's order for Resident #1 dated 10/17/24 indicated his sertraline (antidepressant) was increased from 25 milligram (mg) to 50 mg at bedtime daily. An interview was conducted with Nurse Practitioner (NP) #1 on 10/30/24 at 9:00 AM. NP #1 stated Resident #1 was cognitively impaired, confused and disoriented. NP #1 stated she was not in the facility at the time of the incident but was made aware of the incident with Resident #2 found in Resident #1's room touching him. The NP indicated she was informed by Unit Manager #1 Resident #2's hand was inside Resident #1's brief. NP #1 stated Resident #1 was unable to comprehend or give consent to Resident #2 touching him. NP #1 indicated she assessed Resident #1 following the incident and there were no abnormal physical findings with no redness to his hips, thighs or groin and no evidence of trauma. NP #1 stated Resident #1 had no recall of what happened. NP #1 indicated Resident #1's antidepressant was increased due to increased agitation and restlessness. A review of Resident #2's electronic health record revealed a note written by Nurse Practitioner #2 dated 10/17/24 at 5:38 PM. The note indicated Resident #2 was assessed due to inappropriate touching of another resident. The progress note indicated Resident #2 had a diagnosis of severe vascular dementia with psychotic disturbance and inappropriate sexual behavior. The Nurse Practitioner recommended an increase of the medication paroxetine, an antidepressant, due to sexual behavior and would consult with the psychiatric provider. An interview was conducted with Nurse Practitioner #2 on 10/31/24 at 2:05 PM. Nurse Practitioner #2 stated she saw Resident #2 on 10/17/24 after she was informed by the NA of the incident that occurred. Nurse Practitioner #2 stated Resident #2 did not recall the incident. Nurse Practitioner #2 indicated Resident #2 had dementia. Nurse Practitioner #2 stated staff reported that Resident #2 used very foul and derogatory language and made comments that were sexual in nature at times. Nurse Practitioner #2 indicated at one time when she examined Resident #2 he demonstrated sexually suggestive behavior during a physical exam. The NP stated she was surprised by the incident but not surprised at the same time as behaviors in dementia can be unpredictable. An interview was conducted with Medical Records on 10/29/24 at 3:30 PM. Medical Records stated she was in the dining room on 10/17/24 when the incident between Resident #1 and Resident #2 occurred. Medical Records stated Resident #2 exhibited behaviors of wandering in his wheelchair, used foul language and sexual language. Medical Records stated Resident #2 propelled his wheelchair independently and had full use of his hands. An interview was conducted with the Social Worker (SW) on 10/30/24 at 11:30 AM. The SW stated she had been in the position since March 2024, and she was not aware of Resident #2 touching any other residents in a sexually inappropriate manner prior to the incident on 10/17/24. The SW stated she was made aware of the incident that afternoon and talked to Resident #1's family member, Resident #1 and Resident #2. The SW stated she did not observe Resident #1 to have any changes and he did not recall the incident. The SW indicated Resident #2 did not recall the incident later that afternoon when she interviewed him. The SW stated Resident #2 had short- and long-term memory impairment and exhibited wandering behaviors propelling himself independently in the facility. An interview was conducted with Nurse #2 on 10/30/24 at 2:15 PM. Nurse #2 stated she was not working on 10/17/24 but was frequently assigned to Resident #2. Nurse #2 stated Resident #2 exhibited behaviors of wandering, propelling himself in his wheelchair throughout the facility, using vulgar language and making sexually inappropriate comments to the staff. Resident #2 was observed and interviewed on 10/30/24 at 4:30 PM in bed. Resident #2 was confused and continuously attempted to grab the writer's hands. Resident #2 was unable to recall the incident with Resident #1. An observation and interview of Resident #2 was conducted on 10/31/24 at 9:50 AM. Resident #2 was observed in bed, alert and pleasant. Resident #2 stated he wanted to get up out of bed today and that he enjoyed getting up in the wheelchair and seeing other people. An observation of Resident #2 was conducted on 10/31/24 at 11:10 AM. Resident #2 was sitting up in a wheelchair in the dining room with NA # 6 sitting beside him. Resident #2 stated he was happy to be out of bed with a beautiful woman beside him, referring to NA # 6. An interview was conducted with the Administrator on 10/30/24 at 1:40 PM. The Administrator stated he was informed by Unit Manager #1 of the incident between Resident #2 and Resident #1 immediately after it occurred. Prior to this incident, he was not aware of Resident #2 entering other resident rooms or exhibiting sexual behaviors of this nature. The Administrator stated the family member reported the incident between Residents #1 and #2 with no other witnesses present. The Administrator stated after interviewing the family member several times, the staff felt there were discrepancies regarding her testimony stating at first, Resident #1 was asleep when she entered the room and then stating she couldn't tell if he was asleep or awake. The Administrator was unable to provide any other discrepancies identified. The Administrator stated although he was unable to gather sufficient witness testimony that the incident occurred, measures were initiated to protect Resident #1 and other residents from abuse. The Administrator was notified of immediate jeopardy on 10/30/24 at 1:45 PM. The facility provided the following corrective action plan: 1. The facility failed to protect Resident #1's right to be protected from sexual abuse perpetrated by Resident #2 on October 17, 2024. Resident #2 was redirected by his assigned certified nursing assistant once the nurse was made aware of the interaction. Resident #1 was assessed by the Director of Nursing with no signs of injury or emotional distress on October 17, 2024. Resident #1 was then moved to another room on the opposite side of the building on October 17, 2024. The Director of Nursing started continuous monitoring with Resident #2 on October 17, 2024 while he was out of bed since Resident #2 cannot transfer independently. The continuous monitoring is one to one and is being performed by clinical and non-clinical staff members. This monitoring is ongoing. The Nursing Home Administrator notified the local police department, the Department of Health and Human Services and Adult Protective Services of the incident on October 17, 2024. Resident #1 was referred to psychiatric services and is pending Veteran Affair approval. Resident #2 was referred to psychiatric services and was seen in the facility on October 23, 2024. A root cause analysis was completed on October 17, and it was determined that Resident #2 had poor impulse control and needed increased supervision while out of bed. 2. On October 17, 2024, the Director of Nursing, Unit Manager #1 and Unit Manager #2 interviewed all alert and oriented residents to ensure that no additional incidents had occurred in the facility. There were no additional incidents reported. On October 17, 2024, the Director of Nursing, Unit Manager #1 and Unit Manager #2 assessed all cognitively impaired residents to ensure there were no signs of abuse. There were no negative findings on the physical assessments. On October 17, 2024, the Interdisciplinary Team, consisting of the Director of Nursing, Unit Manager #1, Unit Manager #2, Nursing Home Administrator and the Minimum Data Set nurse reviewed resident care plans to identify any additional residents with similar behaviors. One additional resident was identified with like behaviors but had no documented behaviors since May 1, 2024. The additional resident was also placed on hourly visual observations that are conducted by the assigned nurse and certified nursing assistant. 3. The Director of Nursing educated all staff on October 18, 2024, on the North Carolina Abuse Policy and Procedure as well as Management of Sexual Behaviors Policy. The education reinforced documentation of behaviors, implementing immediate intervention to ensure the safety of other residents from inappropriate or unwanted sexual behaviors or conduct. The education also reviewed the development of individualized care plans and notification to the Director of Nursing and the Provider. All staff that were not educated face to face on October 18, 2024, were educated via phone. Any staff member that the Director of Nursing was unable to reach will be required to sign the education prior to working their next scheduled shift. All newly hired staff will be educated by the Director of Nursing, upon hire, prior to working in resident care areas. 4. The facility decided to monitor and take the plan of correction to the Quality Assurance Committee which consisted of the Director of Nursing, Nursing Home Administrator, Unit Managers, Wound Care Nurse, Minimum Data Set Nurse and the Social Worker, on October 17, 2024. To monitor and maintain ongoing compliance, the Director of Nursing or designee will conduct 5 resident interviews weekly for 4 weeks, then 3 resident interviews weekly for 4 weeks, then 1 resident interview weekly for 4 weeks to ensure there are no allegations of inappropriate sexual touching. In addition, the Director of Nursing or designee will conduct 5 skin assessments on cognitively impaired residents weekly for 4 weeks, then 3 skin assessments on cognitively impaired residents weekly for 4 weeks, then 1 skin assessment on cognitively impaired residents weekly for 4 weeks to ensure there are no signs of inappropriate sexual touching. Audits will be reviewed by the Quality Assurance Performance Improvement Committee, which consist of the Director of Nursing, Nursing Home Administrator, Unit Managers, Wound Care Nurse, Minimum Data Set Nurse and the Social Worker monthly for 3 months. Allegation of immediate jeopardy removal and compliance date: 10/19/24. The corrective action plan was validated onsite on 10/31/24 when it was verified through staff interviews that Residents #1 and #2 were immediately separated and assessed for injury. Observations and interviews during the survey validated that Resident #1 was moved to another room on the opposite side of the facility and Resident #2 was in a room by himself. An observation of Resident #2 was conducted on 10/31/24 at 11:10 AM. Resident #2 was sitting up in a wheelchair in the dining room with NA # 6 sitting beside him. Interviews with Unit Manager #1, nurses and NAs revealed that Resident #2 received 1:1 supervision when out of bed. Audit tools were reviewed and validated that all cognitively intact residents were interviewed to ensure that no other incidents of sexual abuse had occurred. No other incidents were reported. Audit tools were reviewed and validated that all cognitively impaired residents were assessed for signs of sexual abuse with no negative findings. A sample of staff that included nurses, medication aides and nursing assistants were interviewed regarding in-service training. All staff stated they received in-service training as indicated in the corrective action plan to include abuse and sexual abuse training. The audit forms that were utilized for monitoring that the systems put in place were effective were reviewed and validated. Skin assessments and resident interviews were conducted as designated in the corrective action plan. The facility's corrective action plan's compliance date of 10/19/24 was validated.

Based on observation, record review, and staff, Nurse Practitioner and Physician interviews the facility failed to follow a physician order to hold a tube feeding (nutrition administered through a tube directly into the stomach) following an episode of vomiting for 1 of 1 resident (Resident #98) reviewed for tube feeding. The tube feeding that was ordered to be held was administered to Resident #98 on 1/24/24 through 1/25/24. The Nurse Practitioner observed the resident lying flat in bed, with the tube feeding running, vomit on his body, and respiratory distress symptoms that included elevated respirations, shortness of breath and decreased oxygen level. Resident #98 was hospitalized from 1/25/24 through 2/14/24 with a diagnosis of septic shock (widespread infection) secondary to aspiration pneumonitis (lung infection due to material from the stomach entering the lungs) and acute hypoxic respiratory failure (inadequate oxygen in the blood). Findings included: Resident #98 was admitted on [DATE] with diagnosis which included stroke, dysphagia (difficulty swallowing), feeding tube status, and diabetes. Review of Resident #98's electronic health record revealed the following physician orders dated 12/27/23: Pureed diet with nectar consistency liquids. Tube feeding formula Fiber Source 240 milliliters (ml) via feeding tube every 4 hours. Elevate the head of bed 30-45 degrees during feeding and for 30 minutes after, if tolerated. Review of Resident #98's care plan revealed a focus area dated 12/28/23 that resident required tube feeding for nutrition. The goal indicated Resident #98 would maintain adequate nutrition and hydration via tube feeding. Interventions included administer feeding and hydration via feeding tube as ordered, report to the provider abnormal breath sounds, nausea or vomiting and maintain the head of the bed elevated. Review of Resident #98's admission Minimum Data Set (MDS) assessment dated [DATE] indicated resident was severely cognitively impaired, had a feeding tube and received 51% or more total calories via tube feeding during the entire 7 day look back period and his average fluid intake was 501 cubic centimeters (cc's) or more via tube feeding. Review of a 1/4/24 Speech Therapy evaluation indicated Resident #98 had severe dysphagia and increased risk of aspiration. Resident #98 also had impaired cognition with impaired expressive language and communication skills. Review of Resident #98's electronic health record revealed the following physician orders dated 1/5/24: if resident did not consume 50 percent of meals, then administer a bolus, an intermittent method of delivering tube feeding, of tube feeding formula Fiber Source 240 ml daily three times per day. Discontinue Fiber Source 240 ml via feeding tube every 4 hours. Review of a weight note by the Registered Dietitian (RD) dated 1/17/24 revealed Resident #98 was reviewed for significant weight loss. The note indicated Resident #98 received a regular pureed diet with nectar thick liquids and Fiber Source 240 ml after meals if less than 50 percent consumed. RD recommended nocturnal tube feeding at 60 ml per hour for 10 hours daily with water flushes of 150 ml before and after tube feeding due to continued poor intake and weight loss. Review of Resident #98's electronic health record revealed a physician order dated 1/17/24 for tube feeding formula Fiber Source at 60 milliliters (ml) per hour for 10 hours nightly from 8:00 PM to 6:00 AM. Flush the feeding tube with 150 ml of water at tube feeding initiation nightly and when the feeding is taken down in the morning. A nursing progress note written by Nurse Manager #1 dated 1/24/24 at 2:42 PM indicated Resident #98 had a poor appetite. Resident #98 had an order for mechanically altered diet with thickened liquids and received tube feedings nightly and as needed following meals if intake was less than 50 percent. Resident #98 had a change in condition. Nurse Manager #1 stated in the progress note that following the lunch meal she administered the ordered bolus tube feeding due to poor intake less than 50 percent at the meal. Following administration of the bolus tube feeding, Resident #98 vomited. The provider and family were notified. Review of Resident #98's electronic health record revealed a physician order dated 1/24/24 at 5:50 PM entered by Unit Manager #1 from Nurse Practitioner (NP)#3. The order stated hold tube feeding due to emesis (vomiting) and tube feeding intolerance. The order did not specify the bolus or continuous feeding or both. A nursing progress note written by Unit Manager #1 dated 1/24/24 at 5:58 PM indicated Resident #98 experienced a second episode of vomiting and NP #3 was notified. A new physician order was received to hold the ordered tube feeding. An in-person interview was conducted with Unit Manager #1 on 7/10/24 at 3:10 PM. Unit Manager #1 stated she was assigned to Resident #98 on 1/24/24 from 7:00 AM to 3:00 PM. Unit Manager #1 stated on 1/24/24 Resident #98 had episodes of emesis and she reported this to NP #3. Unit Manager #1 stated NP #3 gave an order to hold Resident #98's tube feeding on 1/24/24. Unit Manager #1 stated she did not put the order in the computer correctly and explained that she did not put a notation on the electronic Medication Administration Record (MAR) that the tube feeding was to be held. Unit Manager #1 stated because she did not enter the order onto the MAR correctly, the nurse would not have known to hold the feeding. Unit Manager #1 stated Resident #98 was sent out on 1/25/24 with vomiting and respiratory distress before she arrived for work that day. Unit Manager #1 stated after Resident #98 was sent to the hospital, she was reeducated regarding entering orders and placing orders on hold as well as reprimanded for the error she made. Unit Manager #1 stated in services were conducted with all nurses regarding carrying out physician orders and how to place an order on hold. A progress note written by NP #3 on 1/24/24 at 6:08 PM revealed the NP was notified of the emesis episode. NP #3 indicated Resident #98 was seen sitting up in a wheelchair and appeared very fatigued and slumped over in the wheelchair. NP #3 helped the nursing assistant to safely transfer the resident back to bed. Resident #98 was boosted up in the bed and shook his head side to side indicating no when asked if he would like his head of bed elevated. Order was written to hold tube feedings. Review of Resident #98's electronic Medication Administration Record (MAR) revealed the order to hold the tube feeding due to emesis did not appear on the MAR and the tube feeding orders remained in place, active and were not designated as on hold. The MAR indicated the tube feeding was electronically signed by Nurse #15 as administered at 8:00 PM on 1/24/24. The MAR indicated the tube feeding was electronically signed by Nurse #15 as completed at 6:00 AM on 1/25/24. Review of a nursing progress note dated 1/25/24 at 8:35 AM written by Nurse #14 revealed upon start of shift, Resident #98 was observed with large amount of emesis of tube feeding from his nose and mouth. Resident #98 was coughing and struggling to expel emesis. Immediately the resident was placed in an upright sitting position in bed. Vital signs were obtained and were temperature 98.9, blood pressure 114/73, pulse 146 (above normal), oxygen saturation 85 percent (below normal of 95-100 percent) on room air. Resident was lethargic. NP #3 was notified of resident's condition. Oxygen was applied at 5 liters and a stat nebulizer treatment was administered. NP #3 arrived at the facility, assessed the resident and an order was received to send resident to the emergency room for evaluation. An interview via phone was conducted with Nurse #14 on 7/10/24 at 3:30 PM. Nurse #14 stated she worked at the facility through an agency for the past year. Nurse #14 stated she was assigned to Resident #98 on 1/25/24 for 7:00 AM to 7:00 PM shift. Nurse #14 stated she was a few minutes late for her shift that morning and the nurse from the prior shift (Nurse #15) had already left the facility. Nurse #14 stated she started making rounds on the residents right away. Nurse #14 stated she observed Resident #98 in bed with the tube feeding infusing. Resident #98 was coughing, struggling to breathe and had emesis pooled on him on the right side of the neck and right side of his body. Nurse #14 stated she sat the resident up higher in the bed, stopped the tube feeding, called NP #3 and received new orders. Nurse #14 stated NP #3 immediately responded and assessed Resident #98. Nurse #14 stated NP #3 instructed her to apply oxygen, give a nebulizer treatment and call 911. Nurse #14 stated NP #3 stated she could tell the Resident #98 aspirated. Nurse #14 stated the tube feeding was supposed to be held for Resident #98, but it was not. Review of Resident #98's electronic health record revealed a progress note was written by NP #3 dated 1/25/24 at 8:45 AM. The note stated NP #3 received a call at 7:22 AM notifying of a change in Resident #98's condition. The note indicated Resident #98 was found with more emesis, a congested wet cough and oxygen saturations of 80% on room air (normal oxygen saturation is 95-100%). An order was given to initiate oxygen stat (immediately) at 5 liters via nasal cannula and administer a stat nebulizer treatment. The note stated NP #3 had emergently driven to the facility and entered the facility at 7:47 AM. Upon arrival, Resident #98 was observed with the nebulizer treatment in progress and was lethargic with an oxygen saturation of 90%. A verbal order was given to send Resident #98 to the emergency room and the NP remained with the resident at bedside until medics arrived at 8:15 AM. Assessment and plan indicated a diagnosis of aspiration with subsequent change in condition and oxygen desaturation with emergency room evaluation. An interview was conducted via phone with NP #3 on 7/10/24 at 11:45 AM. NP #3 stated she no longer worked for the Medical Director. NP #3 indicated she frequently educated and reminded the nurses to keep Resident #98's head of the bed elevated 30-45 degrees to prevent aspiration. NP #3 stated Resident #98 was at increased risk for aspiration. NP #3 stated she arrived the morning of 1/25/24 early in the morning. NP #3 stated she entered Resident #98's room and observed him lying flat in bed with the tube feeding running and emesis on his body. NP #3 stated on 1/24/24 in the evening she entered the order in the computer system to hold the tube feeding and she informed Nurse #15 that the order was entered. NP # 3 stated the order was not carried out to hold the tube feeding and Resident #98 received the feeding all night. NP # 3 stated it was contraindicated to administer the tube feeding to a resident that was vomiting. Resident #98 was transferred to the hospital on 1/25/24. Review of Resident #98's emergency department encounter report dated 1/25/24 indicated resident presented with aspiration and bibasilar atelectasis (the lower parts of both lungs collapsed). Resident presented with tube feedings pouring out of his nose per EMS. Resident #98 was hypoxic (having low oxygen saturation) and hypotensive (having low blood pressure) on presentation to the emergency room and was also breathing at 50 breaths per minute. Resident #98's vital signs were blood pressure 86/61 (below normal), heart rate 118, temperature 100.7, respirations 46 (above normal). Resident #98 was treated with intravenous antibiotics and intravenous fluids. Review of the hospital discharge summary dated 2/14/24 indicated Resident #98 was hospitalized from 1/25/24 through 2/14/24 with discharge diagnosis of septic shock secondary to aspiration pneumonitis and acute hypoxic respiratory failure. Resident #98 was discharged to another skilled nursing facility. An interview via phone was conducted with Nurse #15 on 7/10/24 at 12:20 PM. Nurse #15 indicated she was an agency nurse that was assigned to Resident #98 on 1/24/24 on the 7:00 PM to 7:00 AM shift. Nurse #15 indicated she could not remember any specific information about Resident #98 and the NP order to hold the tube feeding on 1/24/24. Nurse #15 indicated she recalled being asked about an order for tube feeding for a resident but did not remember if it was part of an investigation regarding Resident #98. Nurse #15 indicated if the order was entered into the computer system correctly, it would have been designated on the electronic Medication Administration Record (MAR) as on hold. Nurse #15 indicated she utilized the electronic MAR to administer the tube feeding and medications. Nurse #15 stated the tube feeding order showed up on Resident #98's electronic MAR at 8:00 PM so she administered it. Nurse #15 did not recall if was reported to her by Unit Manager #1 or NP #3 to hold the tube feeding that night. Nurse #15 stated she did not recall if she turned off the tube feeding at 6:00 AM and did not recall Resident #98's condition when she left at the end of the shift. An interview via phone was conducted with the Assistant Director of Nursing (ADON) on 7/11/24 at 10:30 AM. ADON stated she was working as the Assistant Director of Nursing in January 2024 but was no longer employed at the facility. ADON stated she recalled she had just come in to work the morning Resident #98 went to the hospital. ADON stated the nurse assigned to Resident #98 on 1/25/24 for the 7:00 AM to 7:00 PM shift was assessing Resident #98, and she went down to assist. ADON stated she observed Resident #98 had vomited tube feeding and she discovered later the tube feeding was supposed to have been on hold, but it was not held that previous night as ordered. ADON stated following this incident, she completed an incident report, an investigation and completed education/reeducation with all the nurses regarding placing orders on hold and ensuring all residents receiving tube feeding have the head of the bed elevated. An interview via phone was conducted with the Physician on 7/11/24 at 10:45 AM. The Physician stated Resident #98 may have had aspiration pneumonitis. The Physician stated vomiting could likely have caused respiratory distress symptoms. The Physician stated the order should have been carried out to hold the tube feeding per the NP order. The Physician stated when a resident is vomiting, tube feeding should be held. An in-person interview was conducted with the Regional Nurse Consultant on 7/11/24 at 1:30 PM. The Regional Nurse Consultant indicated the error was identified and the corrective action plan was initiated. The Regional Nurse Consultant stated the administrative nurses were educated regarding placing orders on hold and audits were completed 5 times per week for 6 weeks. The Regional Nurse Consultant stated the audits consisted of daily review of all new orders and the results were reviewed by the Quality Assurance committee. The Regional Nurse Consultant further stated all nursing staff were educated on elevating the head of the bed for all residents receiving tube feeding. An in-person interview was conducted with the Director of Nursing (DON) on 7/11/24 at 4:00 PM. The DON stated she had just started at the time of the incident with Resident #98. The DON stated it was her expectation that orders would be followed as written and residents receiving tube feeding would have the head of the bed elevated. The DON stated the order to hold the tube feeding should have been entered onto the electronic Medication Administration Record and carried out. The DON further indicated she expected that if a resident was vomiting the tube feeding should have been held. The Administrator was notified of immediate jeopardy on 7/11/24 at 5:15 PM. The facility provided the following corrective action plan with a completion date of 2/16/24: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: On January 24, 2024, at 5:58 pm the Nurse Practitioner was notified that Resident #98 had episode of liquid vomitus, tan in color with no odor. The Nurse Practitioner ordered a diagnostic imaging for the Kidneys, Ureters and Bladder, a complete blood count, basic metabolic panel, Zofran 4 mg every 6 hours as needed for nausea and to hold tube feedings. The complete blood count and the basic metabolic panel were collected on January 24, 2024 at 9:00 pm. On January 25, 2024, at 7:22 am the Nurse Practitioner was notified for more emesis and congestion and oxygen saturation of 80% on room air. Telephone order was given by the Nurse Practitioner to start Resident #98 on 5 liters (L) of oxygen and to administer a breathing treatment. The Nurse Practitioner arrived at the facility on January 25, 2024 at 7:47 am and assessed Resident #98. The resident was lying flat with the tube feeding running when the NP arrived to assess the resident. Resident #98 appeared lethargic, heart rate was 118 and oxygen saturation 96% on 5L of oxygen. A verbal order was given to send the resident to the hospital. Resident left the facility with emergency medical transport at 8:15 am. Resident #98 did not return to our facility after the hospital transfer. The Assistant Director of Nursing reviewed the electronic medical record on January 25, 2024 and determined that the tube feeding order was never placed on hold and Resident #98 received enteral tube feeding from January 24, 2024 at 8:00 pm until January 25, 2024 at 6:00 AM. Root cause was discussed by the Interdisciplinary team, which included the Director of Nursing, Assistant Director of Nursing, Unit Manager #1, Unit Manager #2, the Wound Care Nurse and the Administrator on February 1, 2024 and it was determined that an additional order to hold the tube feeding was entered into the Electronic Medical Record but the actual tube feeding order was not placed on hold. This enabled the tube feeding order to remain active on the Medication Administration Record. The facility was unable to determine why the resident was lying flat during the tube feeding administration but the risk of aspiration for tube feeding residents was discussed. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: On February 1, 2024, the Assistant Director of Nursing reviewed the electronic medical records for all other residents that had received enteral feeding since January 25, 2024 to ensure the tube feeding orders were correct and there were no missed hold orders and that each resident had an order to maintain the head of the bed at 30-40 degrees during feeding and for 30 minutes after, if tolerated. There were two additional residents receiving enteral feeding during the time frame but there were no hold orders identified and both residents had orders to maintain a 30-40-degree angle. The Assistant Director of Nursing assessed both like residents on February 1, 2024, and determined that lung sounds were clear for one resident, but the second resident had wheezing. The resident with wheezing was being treated for influenza and had breathing treatments ordered. A progress note was documented in each electronic medical record by the Assistant Director of Nursing on February 1, 2024. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: The Assistant Director of Nursing provided education to the nurses on appropriately placing an order on hold instead of entering an additional hold order on February 5, 2024. The nurse who failed to enter the order correctly received one on one education on appropriately placing an order on hold instead of entering an additional hold order by the Assistant Director of Nursing on February 5, 2024. Unit Managers, the Wound Care Nurse and the Minimum Data Nurse were educated during the Interdisciplinary Team meeting by the Assistant Director of Nursing on February 1, 2024. The Assistant Director of Nursing contacted all nurses and certified nursing assistants on February 15, 2024, and provided education on ensuring residents with enteral tube feeding are kept at a 30-40-degree angle when in bed. 100% education was completed on February 15, 2024, via telephone. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: The Director of Nursing or designee will review all new orders 5 times per week for 6 weeks to ensure any orders to hold tube feedings, medications or treatments were applied to the actual tube feeding, medication or treatment order instead of only entering an additional hold order. Weekend orders will be reviewed on Monday during the Clinical Morning Meeting. The facility determined the need to take the plan of correction to the Quality Assurance Performance Improvement Committee on February 1, 2024. A meeting was held on February 16, 2024 with the Medical Director and the Quality Assurance Performance Improvement committee to review the plan of correction and the monitoring plan. The facility conducts concierge rounds 5 times a week for all residents. Residents with enteral feeding are assigned the Minimum Data Set nurse. The concierge document includes resident bed positioning and are discussed in the administrative meeting 5 times a week. There were no reports of residents lying flat in the bed while receiving enteral feeding. Alleged Immediate Jeopardy Removal and Compliance date: 2/16/24 The Corrective Action Plan was validated on 7/11/24. Interviews with the nursing staff, DON and Administrator revealed the facility had provided education and training regarding placing orders on hold and ensuring that residents receiving enteral feeding had the head of the bed elevated at a 30-40-degree angle when in bed. Review of the monitoring tools for audits that began on 2/5/24 revealed the tools were completed as outlined in the corrective action plan. No concerns with placing orders on hold in the electronic MAR were identified. Positioning of residents in bed were observed with no concerns identified regarding residents lying flat in bed while receiving enteral feeding. The facility's immediate jeopardy removal date and compliance date was verified as 2/16/24.

Based on record review, Nurse Practitioner, and staff interviews, the facility failed to review the hospital discharge medication summary for a newly admitted resident (Resident #1) resulting in the failure to transcribe and administer an anticoagulant (blood thinner) medication listed on the discharge medication summary. [MEDICATION(S)] (anticoagulant) was not administered from 05/27/22 through 06/14/22 (18 days). Resident #1 developed swelling to the left arm, was sent to the hospital, and was diagnosed with a blood clot. The facility also failed to transcribe and administer a blood pressure/heart rate (BP/HR) medication that was on the discharge medication summary (Resident #1) and to administer a medication used to treat hypertension (high blood pressure) and [CONDITION(S)] (irregular heart rate) as ordered (Resident #6). This deficient practice occurred for 2 of 3 residents reviewed for significant medication errors. Immediate jeopardy began on 05/27/22 when the facility failed to transcribe and administer [MEDICATION(S)] (anticoagulant medication) for Resident #1. The immediate jeopardy was removed on 07/07/22 when the facility provided and implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of level E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. The facility was also cited at scope and severity level E for examples #1b and #2. The findings included: 1a. The Medicaid Long Term Care FL2 form (a form which includes the physicians ' recommended level of care as well as medical diagnoses, care needs and medications) did not include orders for [MEDICATION(S)]. The FL2 form was signed by the Physician from the discharging hospital on 05/23/22. There were no handwritten provider ' s initials or signatures from the facility noted on the FL2 form. A review of the discharge medication summary, also received from the discharging hospital, dated 05/27/22 revealed, in part, the following order: [MEDICATION(S)] 5 milligrams (mg) one tablet 2 times daily. There were no handwritten provider ' s initials or signatures from the facility noted on the discharge summary. Resident #1 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #1. The Minimum Data Set (MDS) 5-day assessment dated [DATE] revealed Resident #1 was cognitively intact and was assessed as having recent surgery. The MDS indicated Resident #1 did not receive any anticoagulants during this assessment. Review of Nurse Practitioner #3 ' s progress note on 06/02/22 assessment and plan revealed, in part, intertrochanteric fracture of right femur, anticoagulation with [MEDICATION(S)] ([MEDICATION(S)]). A nursing note written by Nurse #1 on 06/14/22 at 8:38 AM regarding Resident #1 revealed extreme swelling to left upper extremity. Denies pain/discomfort. No redness or warmth noted. Resident states, ' I just woke up and my arm was like this. ' Physician notified and was in to assess resident. New order for STAT [immediate] Ultrasound [U/S] and STAT dose of [MEDICATION(S)] and [MEDICATION(S)] [blood thinners]. Medications given and U/S called in. Inquired about estimated time of arrival and was informed the U/S would be done today but could not give writer an exact time. Updated Nurse Practitioner [NP] on the fact that radiology was uncertain of time at this point, but it will be done today. Family and resident requested to be sent to the emergency room [ER] and did not want to wait for U/S. Resident sent to theER on [DATE]. A review of the ER record dated 06/14/22 revealed Resident #1 was sent back to the facility on [DATE] with an order to start [MEDICATION(S)] (blood thinning medication) 15 mg twice per day for 21 days. The ER record provided instructions regarding diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing note written on 06/15/22 revealed resident returned to facility at 12:25 AM via Emergency Medical Services from the hospital. Resident was diagnosed with positive left upper extremity [LUE] [CONDITION(S)] [blood clot]. LUE continued to be swollen, and resident denied pain. New order for [MEDICATION(S)] noted. Review of the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with Nurse #1 on 07/27/22 at 11:10 AM. Nurse #1 stated she transcribed the orders on 5/27/22 for Resident #1 from the Medicaid Long Term Care FL2 form, and she should have transcribed the orders from the hospital discharge summary. Nurse #1 confirmed the FL2 form did not include [MEDICATION(S)]. Nurse #1 stated she did not review the orders on the FL2 form with the Physician or Nurse Practitioner because there was a signature on FL2 form, and she assumed they were already reviewed and realized later the physician who signed the FL2 form was the physician from the discharging hospital. Nurse #1 stated she did not see the other hospital discharge summary (dated 5/27/22) when she was admitting Resident #1 and added there was a lot of stuff in the packet. Nurse #1 stated she thought it was unusual Resident #1 came from the hospital with a FL2 form, but she did not question it. Nurse #1 stated the protocol was to review the discharge summary forms ' listed medications with the NP or the Physician before the orders were put into the EMR, which she should have done, and she should have looked further for discharge summary orders instead of using the FL2 form. Nurse #1 stated once the orders were reviewed with the NP or the Physician, they would date, and hand write their initials or signature on the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with the Administrator on 07/27/22 at 3:25 PM. He stated he became aware of Resident #1 not receiving the ordered [MEDICATION(S)] from Resident #1 ' s spouse on 06/14/22 after the resident was sent to the hospital. He stated on 06/14/22 the facility investigated why the [MEDICATION(S)] was not ordered. He stated the facility found a discharge summary from the hospital and realized the nurse did not use this summary to transcribe the medications but instead had used the FL2 form. The Administrator stated it was noticed at this time the [MEDICATION(S)] was on the hospital discharge summary to be ordered. The Administrator added, the investigation into the [MEDICATION(S)] error was completed on 07/06/22. The Administrator confirmed that the hospital discharge summary that was found was not signed or initialed by the facility provider to indicate they had reviewed the orders. An interview was conducted with Nurse Practitioner (NP) #3 via phone on 07/27/22 at 2:35 PM. NP #3 stated Resident #1 came from a hospital with a discharge summary. NP #3 stated she did not know what an FL2 form was and did not recall seeing this form. NP #3 stated when a resident was admitted to the facility from the hospital the admissions coordinator would give her the discharge summary, the history and physical, lab work, etc. in one packet. The NP stated once she received the packet she would go through the orders and revise the orders if needed or discontinue orders if she felt the resident was not going to require the medication and put a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . NP #3 said she would sign the orders and give a copy to the nurse taking care of the resident. NP #3 stated when she had learned of Resident #1 having a [CONDITION(S)] (DVT) and he had not received his ordered [MEDICATION(S)] she tried looking back on her orders which would have been scanned in his medical record, but she could not find them. The NP was sure she had reviewed the orders and signed the discharge summary, and she knew Resident #1 was on [MEDICATION(S)] because she had that information in her history and physical. NP #3 stated the DVT likely occurred because Resident #1 did not get his blood thinning medication for 18 days. NP #3 stated her expectation of the nursing staff was to confirm discharge summary orders with a Physician, or Nurse Practitioner by checking to see if the orders were signed by the Physician or NP prior to putting the orders in the electronic medical record. An interview was conducted with the Regional Director of Clinical Services (RDCS) on 07/27/22 at 4:10 PM. The RDCS stated the protocol was the Physician or Nurse Practitioner reviewed the orders, signed the orders, and then passed the orders to the nurse on duty who was responsible for that resident. The RDSC stated the nurse would then enter the orders in the electronic medical record. The Physician was not available for interview during the survey. The Administrator and Regional Director of Clinical Services were notified of the immediate jeopardy on 07/27/22 at 6:15 PM. · Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; Resident #1 was without medications related to the error in transcription that resulted in significant medication errors. He suffered hospitalization related to a venous clot. This occurred on 5/27/22 when the admitting nurse did not consult the physician, nurse practitioner (NP) or physician assistant (PA) to review the orders for the admitting resident. The medications on the document that was used by this nurse was not the Discharge Summary document. The significant medication that was not transcribed was [MEDICATION(S)]-a blood thinning medication. The physician extender did include [MEDICATION(S)] in her list of medications that were being given during the first visit on 5/27/22 with the resident. She was unaware that the transcription of the Discharge Summary medications was incomplete. Resident #1 developed a change of condition on 6/14/22 with new swelling to left upper extremity and was sent to the hospital. This was the date that the [MEDICATION(S)] was identified as having been missed in the initial admission process. He was diagnosed with a blood clot in his left arm that would have been prevented if the [MEDICATION(S)] had been given according to the Discharge Summary. Residents who are admitting to the facility are at risk for this deficient practice. On 6/16/2022, the Regional Director of Clinical Services completed a 30-day medical record review on all residents admitted or readmitted using the Discharge Summary and compared it to the transcribed orders. All identified issues have been 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. Current nursing staff were educated by the end of the day on 7/06/22 concerning the admission order entry process and the follow up validations involved in the completion of the admission process. This education was provided by the Director of Nursing or licensed nurse designee. The nurses educated included full time, part time, and agency staff who are currently employed by the facility. The process will be that the MD, NP, or PA will be given the orders for review if in the facility or orders will be reviewed by phone with a nurse. This review will be documented on the Discharge Summary. The nurse assigned to transcribe the orders from the Discharge Summary will be the person who will review the documents with the MD, NP, or PA. The reviewed and signed Discharge summary will be given to the nurse admitting the resident into the facility. The orders will be transcribed into the Electronic Medical record. A second review will be completed by a second nurse who is working in the facility at the time of the admission. This review will be documented on the same Discharge Summary that was approved by the physician or extender to ensure the initial transcription was complete and correct. This education will be completed on 7/06/22 and the process of transcription will be in place with the next resident who is admitted /readmitted to the facility. The facility alleges the removal of immediate jeopardy on 7/07/22. On 7/29/22 the Credible Allegation was validated by onsite verification. Record review indicated the 6/16/22 medical record review was completed by the RDCS. Review of inservice sign in sheets verified education was provided on the admission order entry process and the follow up validations involved in the completion of the admission process. Nursing staff interviews confirmed they received education and were aware of the admission order entry process. The facility ' s removal date of 7/07/22 was validated. 1b. The Medicaid Long Term Care FL2 form (a form which includes the physicians ' recommended level of care as well as medical diagnoses, care needs and medications) did not include orders for [MEDICATION(S)]. The FL2 form was signed by the Physician from the discharging hospital on 05/23/22. There were no handwritten provider ' s initials or signatures from the facility noted on the FL2 form. A review of the discharge medication summary, also received from the discharging hospital, dated 05/27/22 revealed, in part, the following order: [MEDICATION(S)] 25 mg, give 1/2 tablet twice daily. There were no handwritten provider ' s initials or signatures from the facility noted on the discharge summary. Resident #1 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #1. The Minimum Data Set (MDS) 5-day assessment dated [DATE] revealed Resident #1 was cognitively intact and was assessed as having recent surgery. Review of a nursing note written on 06/28/22 revealed Resident #1 was discharged home on 06/28/22. The physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Records (MARs) from 05/27/22 through 06/28/22 revealed [MEDICATION(S)] was not administered to Resident #1 at any time during his stay at the facility. An interview was conducted with Nurse #1 on 07/27/22 at 11:10 AM. Nurse #1 stated she transcribed the orders on 5/27/22 for Resident #1 from the Medicaid Long Term Care FL2 form, and she should have transcribed the orders from the hospital discharge summary. Nurse #1 confirmed the FL2 form did not include [MEDICATION(S)]. Nurse #1 stated she did not review the orders on the FL2 form with the Physician or Nurse Practitioner because there was a signature on FL2 form, and she assumed they were already reviewed and realized later the physician who signed the FL2 form was the physician from the discharging hospital. Nurse #1 stated she did not see the other hospital discharge summary (dated 5/27/22) when she was admitting Resident #1 and added there was a lot of stuff in the packet. Nurse #1 stated she thought it was unusual Resident #1 came from the hospital with a FL2 form, but she did not question it. Nurse #1 stated the protocol was to review the discharge summary forms ' listed medications with the NP or the Physician before the orders were put into the EMR, which she should have done, and she should have looked further for discharge summary orders instead of using the FL2 form. Nurse #1 stated once the orders were reviewed with the NP or the Physician, they would date, and hand write their initials or signature on the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with the Administrator on 07/27/22 at 3:25 PM. He stated the facility found a discharge summary from the hospital and realized the nurse did not use this summary to transcribe the medications but instead had used the FL2 form. The Administrator explained that on 6/14/22 the facility identified a medication error for this resident related to an anticoagulant medication, but they had not realized until 7/27/22 when identified by the surveyor that the [MEDICATION(S)] had also not been transcribed and administered. The Administrator confirmed that the hospital discharge summary that was found was not signed or initialed by the facility provider to indicate they had reviewed the orders. An interview was conducted with Nurse Practitioner (NP) #3 via phone on 07/27/22 at 2:35 PM. NP #3 stated Resident #1 came from a hospital with a discharge summary. NP #3 stated she did not know what an FL2 form was and did not recall seeing this form. NP #3 stated when a resident was admitted to the facility from the hospital the admissions coordinator would give her the discharge summary, the history and physical, lab work, etc. in one packet. The NP stated once she received the packet she would go through the orders and revise the orders if needed or discontinue orders if she felt the resident was not going to require the medication and put a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . NP #3 said she would sign the orders and give a copy to the nurse taking care of the resident. The NP stated she was sure she had reviewed the orders and signed the discharge summary, but she added she was not aware of the [MEDICATION(S)] being ordered. NP #1 stated Resident #1 ' s blood pressure and heart rate remained stable during his stay despite not getting the ordered [MEDICATION(S)], but added it was a necessary medication and should have been ordered. NP #3 stated her expectation of the nursing staff was to confirm discharge summary orders with a Physician, or Nurse Practitioner by checking to see if the orders were signed by the Physician or NP prior to putting the orders in the electronic medical record. An interview was conducted with the Regional Director of Clinical Services (RDCS) on 07/27/22 at 4:10 PM. The RDCS reported the facility completed a plan of correction on 7/6/22 for a separate medication (anticoagulant medication) that was not transcribed from the discharge summary for Resident #1, but they had not identified the ordered [MEDICATION(S)] on the discharge summary form was also not transcribed to the electronic medical record for Resident #1. The RDCS stated she would have expected the facility to capture that in their investigation. The RDCS stated the protocol was the Physician or Nurse Practitioner reviewed the orders, signed the orders, and then passed the orders to the nurse on duty who was responsible for that resident. The RDSC stated the nurse would then enter the orders in the electronic medical record. The Physician was not available for interview during the survey. 2. Resident #6 was admitted to the facility on [DATE] and discharged on [DATE]. Resident #6's medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the hospital Discharge Medication Profile Report dated 5/13/22 for Resident #6 indicated she was to continue taking [MEDICATION(S)] 40 milligrams twice per day, hold for systolic blood pressure if less than 110 or heart rate less than 60. An allergy was listed to [MEDICATION(S)], a medication used to treat hypertension. Review of the facility physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's medical record revealed a progress note dated 5/14/22 at 1:16 PM which indicated the drug [MEDICATION(S)] was not available. Review of Resident #6's medical record revealed the hospital Emergency Department Encounter dated 5/15/22 indicated resident presented with complaint of fluttering in her chest and her heart racing. Resident #6 was noted to have elevated heart rate and [CONDITION(S)] (widespread, life-threatening infection) protocol was initiated. Resident #6 was diagnosed with [CONDITION(S)] due to pneumonia. An interview on 7/26/22 at 5:33 PM with Nurse #3 revealed she did not recall why she did not administer [MEDICATION(S)] as ordered on 5/13/22 at 9PM and on 5/14/22 at 9PM when she was assigned to Resident #6. Nurse #3 could not recall if she checked the emergency medication kit (E kit) for the medication. She indicated that the facility had an E kit in May which contained some common medications that could be used for residents until the medications were received from the pharmacy. Nurse #3 indicated that the pharmacy made deliveries between midnight and 3:00 AM. If the medications were not received on that delivery the nurse was to call the pharmacy to determine why they were not received. Nurse #3 stated she did not do this and did not pass the information on to Nurse #9 who worked on 5/14/22 7 AM-7 PM shift assigned to Resident #6. Nurse # 3 further stated when a medication was not available or not administered the physician was to be notified to obtain further orders. Nurse #3 stated she did not notify the physician that Resident #6 did not receive medication [MEDICATION(S)] as ordered on 5/13/22 and 5/14/22 at 9 PM. An interview was conducted on 7/27/22 at 11:25 AM with Nurse #2 who was assigned to Resident #6 on 5/15/22 7AM-7 PM shift. Nurse #2 revealed the medication [MEDICATION(S)] for Resident #6 was not available in the facility. Nurse #2 stated that when she arrived on duty on 5/15/22 at 7:00 AM Resident #6 complained of fluttering in her chest and that her heart was racing. Nurse #2 assessed Resident #6 and noted that her blood pressure and pulse rates were elevated. Nurse #2 stated she notified the physician of Resident #6's condition and that [MEDICATION(S)] was not available. The physician instructed Nurse #2 to obtain the medication [MEDICATION(S)] as soon as possible and disregard the allergy to [MEDICATION(S)]. Nurse #2 did not know how long it would take to arrive, so she received an order to send Resident #6 to the hospital. Resident #6 was sent to the hospital via emergency medical services where she was admitted with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with Nurse #1 on 7/27/22 at 11:40 AM indicated that when a new resident was admitted the orders were transcribed into the computer. Nurse #1 indicated that a telephone call should be made to the pharmacy to inform them that the medications were needed that day. Nurse #1 indicated that the E kit was to be checked to see which medications were available. Nurse #1 also indicated that there was a local pharmacy that could provide medications quickly if needed. She revealed that the physician was to be notified of any medications that were not available or not given. An interview was conducted with the Pharmacy Manager on 7/27/22 at 3:48 PM. The Pharmacy Manager stated that the pharmacy's protocol was to inform the facility via phone call or fax of an allergy or discrepancy in an order which required clarification from the physician. The Pharmacy Manager revealed that on 5/13/22 at 3:48 PM the pharmacy noted Resident #6's allergy to [MEDICATION(S)] and sent a fax regarding potential sensitivity to [MEDICATION(S)]. On 5/13/22 at 3:52 PM and again at 6:17 PM the pharmacy called the facility to request clarification of the order for [MEDICATION(S)] due to [MEDICATION(S)] allergy. The facility did not answer the phone calls from the pharmacy. [MEDICATION(S)] was placed on hold by the pharmacy due to unsuccessful attempts via fax and two phone calls to clarify with the facility the sensitivity. Multiple unsuccessful attempts were made to interview Nurse # 9, the nurse that was assigned to Resident #6 on 5/13/22 and 5/14/22 for 7 AM-7 PM shift. Nurse #9 no longer worked at the facility. Phone and text messages were left which Nurse #9 did not return. Multiple attempts were made to interview the Nursing Supervisor, who worked on 5/13/22 and 5/14/22 from 7 AM-7PM. The Nursing Supervisor no longer worked at the facility Phone and text messages were left which the Nursing Supervisor did not return. An interview with Nurse Practitioner (NP) #2 on 7/28/22 at 12:15 PM indicated that it was unlikely that Resident #6 would be sensitive to [MEDICATION(S)] if allergic to [MEDICATION(S)] and was surprised that the pharmacy would not deliver the medication. NP #2 further indicated that Resident #6 had received [MEDICATION(S)] while in the hospital without adverse effect. NP #2 revealed that the expectation was that the nurse would notify the provider when a medication was not available or not given so that a substitution could be made, or further orders given. NP #2 stated that not receiving [MEDICATION(S)] could cause a worsening of [CONDITION(S)], however an elevated heart rate could also be indicative of a [CONDITION(S)] reaction. An interview on 7/28/22 at 4:25 PM with the Regional Director of Clinical Services revealed that her expectation was that there would be communication between the pharmacy and the facility. The Regional Director of Clinical Services further stated that she expected that the nursing staff are to be notified of all calls from the pharmacy. She also indicated that her expectation was that all medications ordered by the physician would be readily available and if not, the physician would be notified as soon as possible.

Based on record review and staff and Nurse Practioner interviews, the facility failed to 1) notify the resident's provider until 11/13/21 when a resident presented with signs and symptoms of a change of condition that started on 11/12/21 to include signs and symptoms of pain, decreased oral intake, not ambulating, or getting out of bed, refusing care, and requiring two staff assistance with transfers after an unwitnessed fall on 11/11/21 for 1 of 2 residents (Resident #11) reviewed for notification. The delay in notification to the provider resulted in delayed identification and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] #66) for 1 of 2 residents reviewed for notification. Immediate Jeopardy began on 11/12/21 when Resident #11 presented with signs and symptoms of pain, decreased oral intake, inability to ambulate or transfer out of bed, refusing care, and requiring assistance of two staff to transfer and the physician was not notified. Immediate Jeopardy was removed on 12/15/21 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy Removal. The facility will remain out of compliance at a lower scope and severity level D isolated with potential for more than minimal harm to correct the deficient practice and to ensure that the education and monitoring systems put in place to remove the Immediate Jeopardy are effective. Example #2 was cited at a scope and severity level D. Findings included: 1. Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the incident report documented as completed by Nurse Supervisor (NS) #2 on 11/11/21 at 3:00 AM revealed Nursing Aide (NA) [#1] and Patient Care Assistant (PCA) [#1] informed nurse [#1] at 3:10 AM resident was observed on the floor in her room with her head under the sink in a fetal position with walker over lower legs and wheelchair facing her. The NA discovered resident on the floor at 3:00 AM and got help from the PCA. Due to uncomfortable position, the NA and PCA lifted Resident #11 back to wheelchair and then informed nurse. An interview was conducted with Nurse Aide (NA) #1 via phone on 12/10/21 at 5:30 AM who provided care for Resident #11 the night of 11/11/21 after her fall. NA #1 stated when she came back to work on Friday 11/12/21 from 7:00 AM -3:00 PM and brought Resident #11 her breakfast tray, the resident was sitting in her wheelchair, slumped over. NA #1 stated she told Nurse #2 and Nurse #2 told NA #1 to get her into bed. NA #1 stated when she and NA #2 were moving Resident #11, they tried to get the resident to stand up with her walker because that was how the resident usually transferred and the resident refused to get up and became combative. NA #1 stated she and NA #2 tried to move the resident from the chair to the bed and she was crying out like she was in pain. NA #1 stated she and NA #2 tried to transfer the resident with a gait belt and Resident #11 started complaining No! Stop! NA #1 stated she and NA #2 got the sit to stand mechanical lift to transfer the resident. NA #2 stated the Resident #11 did not tolerate the transfer and showed signs of pain, but she and NA #2 were able to get the resident to bed. NA #1 stated Resident #11 was showing signs that she was in pain such as moaning and crying. NA #1 stated she went to Nurse #2 and told her the resident was having pain when she and NA #2 transferred her and Nurse #2 stated it was probably because she had been sitting in the wheelchair for so long and to let her know when NA #1 went back to the room. NA #1 stated she went back in the resident ' s room around 10:00 AM by herself to check and change the resident and Resident #11 was refusing care. NA #1 stated Resident #11 said, Stop, quit! when NA #1 attempted to roll her. NA #1 stated she reported this to Nurse #2 and Nurse #2 said I'm busy right now, I ' m trying to finish my med pass. NA #1 stated when she went to bring the resident her lunch tray, the Physical Therapist (PT #1) had asked if NA #1 noticed a change in Resident #11 and NA #1 said yes, Resident #11 was not eating and refusing to let NA #1 change her and she was crying out. NA #1 stated while she was talking with PT #1, Nurse #2 was right there at the medication cart. NA #1 stated when she went to change Resident #11 to do her care at around 2:30 PM, she was wincing and moaning and said to Stop and was pushing NA #1's hands away. An interview was conducted with NA #2 on 12/10/21 at 10:00 AM who worked 7:00 AM to 3:00 PM on 11/12/21. NA #2 reported when she came in on 11/12/21 she did rounds with NA #1. NA #2 stated the resident was noted to be slumped over in her wheelchair. NA #2 stated she and NA #1 went to put Resident #11 in the bed and when she and NA #1 stood the resident up from the wheelchair and tried transfer her, she made a noise of discomfort and was acting out of the ordinary. NA #2 stated Resident #11 was very wet and very soiled and she grimaced and moaned when she and NA #1 moved her. NA #2 stated Resident #11 wasn't responding to NA #1 and NA #2 and wasn't eating anything. NA #2 stated she believed both she and NA #1 reported to Nurse #2 that Resident #11 was not her normal self because she was not eating and had pain. NA #2 reported the resident slept for a majority of the day which was out of the norm. An interview with the PT #1 on 12/10/21 at 10:30 AM revealed PT #1 had gone to see Resident #11 on 11/12/21 due to the resident having a fall which was reported to her through risk management (a meeting with nursing and department heads to discuss falls). PT #1 stated Resident #11 was noted to have had a significant change because she was not out of bed or ambulating. PT #1 stated when she went into the resident's room to see her, she was lying in bed and PT #1 tried to touch her to wake her, but the resident did not respond. PT #1 stated NA #1 and Nurse #2 were outside of Resident #11's door and she reported to Nurse #2 that she needed to be checked out due to change of status because she was not moving or walking and she was usually up and ambulating and NA #1 told PT #1 that it took 2 aides to transfer Resident #11 back to bed that morning. An interview with Nurse #2 on 12/10/21 at 10:15 AM revealed Nurse #2 stated on 11/12/21 she went to the resident's room after PT #1 had told her Resident #11 did not seem right and the resident was in her bed. Nurse #2 stated the resident was lethargic but she thought it was because she had been told by NA #1 that Resident #11 had been sitting up in her wheelchair. Nurse #2 stated no one told her she had fallen and if she had known she would have done a thorough assessment. Nurse #2 stated she did not assess her and added that the resident did not verbalize much but did not show signs and symptoms of pain and no one had ever told her Resident #11 was in pain. Nurse #2 stated the resident never ate that day and never got out of bed, which was not her norm, but she thought the resident was just tired from sitting up in the wheelchair. During the interview with NA #1 via phone on 12/10/21 at 5:30 AM, NA #1 stated when she came back to work on 11/13/21 from 7:00 AM to 3:00 PM and went to bring Resident #11 her breakfast tray about 7:30 AM or so, Resident #11 was lying in bed on her right side and she would not eat breakfast. NA #1 stated she told Nurse #3 the resident was in pain because was refusing to let her change her and reposition her to set her up to eat. NA #1 stated Resident #11 was moaning and wincing and showing signs like she was in pain when she was trying to move her. NA #1 stated she reported this to Nurse #3 and asked Nurse #3 to please look at her. NA #1 stated Nurse #3 assessed Resident #11 and Nurse #3 stated the resident was having pain and needed an x-ray on her left leg. An interview with Nurse #3 via phone on 12/11/21 at 11:02 AM revealed when she came on duty the morning of 11/13/21, Nurse #6 told her in report Resident #11 had a fall with an abrasion to her shoulder but that she seemed okay. Nurse #3 stated NA #1 came to her about 7:45 AM and asked her to please assess Resident #11. Nurse #3 stated NA #1 was concerned that the previous nurse (Nurse #2) had not followed up and checked on the resident. Nurse #3 stated NA #1 stated Why was no one following up as to why she is still in bed and not eating? Nurse #3 stated she went in to assess Resident #11 and because she could not verbally express if she had pain, she started to do passive range of motion and when she moved the resident's left leg, she cried out with a loud sound and was reaching down toward her left leg and moaning. Nurse #3 stated she gave Resident #11 some pain medicine and notified the physician and obtained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with Nurse Practioner (NP) #1 via phone on 12/16/21 at 12:15 PM. NP #1 stated he was not made aware Resident #11 was not eating or getting out bed and would have expected the nursing staff to notify him of this change of condition. Review of the hospital record dated 11/13/21 at 7:01 PM revealed Resident #11 presented to the Emergency Department (ED) with new left hip fracture. Resident had a fall two days ago and staff noted her to not be using her left leg. An x-ray was obtained {on 11/13/21} and read moderately displaced sub capital left hip fracture with no dislocation. Resident is hemodynamically stable and without a fever and she is lying on her right side and states she does not need any medication for pain at this time. Per Emergency Medical Services (EMS) she had pain with any movement. Hospital records revealed another x-ray was taken at 8:50 PM and the impression read left sub capital neck displaced fracture. The emergency department course and medical decision making revealed the x-ray was positive for left sub capital neck displaced fracture, on call orthopedic surgeon notified and will plan for surgery on {11/15/21} and to admit the resident. The hospital discharge summary dated 11/17/21 revealed Resident #11 was status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Administrator was notified of the Immediate Jeopardy on 12/30/21 at 8:25 AM. The facility provided the following credible allegation of Immediate Jeopardy removal: 1. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: a. The facility failed to notify the residents provider until 11/13/21 when the resident presented with signs and symptoms of a change in condition that started on 11/12/21 which included signs and symptoms of pain, decreased oral intake, not ambulating or getting out of bed, refusing care, and requiring 2 staff to assist with transfers after an unwitnessed fall on 11/11/21. On 11/13/21 the provider was notified of the resident's change in condition and orders were obtained and followed. The resident was medicated for pain per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was sent to the hospital for further evaluation per Physician orders. b. All residents have the potential to be affected. On 12/30/21 medical records were reviewed for all residents that sustained a fall since 11/11/2021 by the Regional Director of Clinical Services to ensure that the provider was made aware of any resident with any significant change. There were no negative findings. 2. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. a. The Regional Director of Clinical Services reeducated all licensed nurses on the Resident Change in Condition Policy to include that the Medical Provider must be notified of any change in the resident's condition and request further orders. If the provider does not respond in a timely manner, the Medical Director will be contacted for guidance, consultation, and orders. This education will also be provided to any agency staff working in the facility. The Regional Director of Clinical Services educated all certified nursing assistants, personal care aides and therapists on stop and watch, (a form the facility utilizes which assists the staff to identify when there is a change in the resident ' s condition) when they identify any changes in the resident condition to inform the licensed nurse so further assessment and treatment can be initiated. Any staff that were unable to be educated will be removed from the schedule and will be required to have the education prior to working in the facility. Person responsible for the removal plan: LNHA The facility alleges the removal date of the Immediate Jeopardy was 12/15/21. The Immediate Jeopardy removal date was 12/15/21. The Removal Plan of the Immediate Jeopardy was validated on 01/04/22. The facility provided in service sheets showing staff received the in service on Resident Change in Condition Policy and the Stop and Watch form. The facility provided audits of all resident with falls since 11/11/21 that showed a physician was notified. The Administrator stated all staff have been in serviced including three agency staff used by the facility. A sample of staff including nurses, nurse aides, and the Therapy Director were interviewed regarding in services they received related to the deficient practice. All staff interviewed stated they had been in serviced regarding the Resident Change in Condition Policy. Staff confirmed they received the education on the Resident Change of Condition Policy and the Stop and Watch form and the nurses were knowledgeable of both and the nursing aides were knowledgeable on the Stop and Watch Form. All facility policy and procedures that were provided to address the deficient practice were reviewed. The Immediate Jeopardy was removed on 12/15/21. 2. Resident #66 was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] A progress note dated 12/03/21 by Nurse Practitioner #1 revealed in part; Resident #66 was seen today, stated she felt okay, denied pain, no acute distress noted. Continue [MEDICATION(S)]. Was notified by nursing on 11/23/21 that the resident had not been receiving [MEDICATION(S)] since the resident's initial admission on 11/10/21. [MEDICATION(S)] was able to be obtained and was restarted on 11/24/21. A phone interview was conducted on 12/13/21 at 2:45 PM with Nurse Practitioner #1. He indicated per his progress note dated 12/03/21, he was notified by nursing on 11/23/21 that Resident #66 had not received [MEDICATION(S)] since her admission on 11/10/21. He stated [MEDICATION(S)] was prescribed for walking issues, and the medication did not stop the progression of [CONDITION(S)]. He stated he was not certain as to why she did not receive [MEDICATION(S)] for that length of time and indicated staff should have notified one of the providers sooner that there was an issue with obtaining the medication. An interview was conducted on 12/09/21 at 02:40 PM with Nursing Supervisor #1. She stated Nurse #10 had notified her that the medication ([MEDICATION(S)]) wasn't there, and pharmacy needed approval for it. She instructed Nurse #10 to call (the Senior Care Program that Resident #66 was affiliated with) to see if they could supply the medication and then call pharmacy. She stated the (Senior Care Program) informed the facility that they did not supply resident medications and the medication would need to come from the facility's pharmacy. Nursing Supervisor #1 reported another nurse checked on the medication again after the issue had not been resolved but she could not recall which nurse it was and could not recall an exact date. She indicated she thought the issue had been resolved after that time by the Director of Nursing (DON) or one of the nurses because she was not made aware of any issue after that. She stated if a medication was missing the nurse would call the pharmacy regarding the medication and if the medication could not be obtained the physician should have been notified. An interview was conducted on 12/10/21 at 10:32 AM with Nurse #10. She stated [MEDICATION(S)] needed to have prior approval from the Administrator due to the cost before the pharmacy could fill the medication order. She indicated she spoke with Nursing Supervisor #1 regarding trying to get the [MEDICATION(S)] but could not recall an exact date. She indicated she wasn't certain when the provider was notified. An interview was conducted on 12/10/21 at 02:14 PM with the Director of Nursing. He stated the pharmacy called and made the facility aware that preauthorization was needed to fill the order for [MEDICATION(S)] 10 milligrams, but he could not recall a date or the time frame when he was made aware of the medication issue. He indicated the resident went from 11/10/21 through 11/23/21 without receiving [MEDICATION(S)] so any correspondence with pharmacy occurred during that time. He stated he wasn't sure why the authorization form was not followed through with. He stated he had only worked at the facility for six months and indicated he was not certain of whose responsibility it was to fill out the authorization forms. He stated the provider should have been made aware of Resident #66 not receiving [MEDICATION(S)] sooner and staff should not have waited until the 13th day of not receiving the medication so that the issue could have been addressed. A phone interview was conducted on 12/13/21 at 4:30 PM with the Corporate Nurse Consultant. He stated the DON should have followed through with completing the medication authorization form and sending the form back to the pharmacy so that the order could have been filled. He indicated Resident #66 should not have gone 13 days without receiving [MEDICATION(S)], and the provider should have been notified sooner of the delay in getting the medication. A phone interview was conducted on 12/13/21 at 4:45 PM with the facility Physician. He stated he was not made aware that Resident #66 didn't have the [MEDICATION(S)] until (the Senior Care Program) reached out to him and he could not recall exactly when that was. He indicated it was around the time the issue was resolved. He stated Resident #66 didn't receive [MEDICATION(S)] until the 12th or 13th day after her admission but stated he was not aware of why the medication was delayed. He indicated he should have been notified sooner so the issue could have been addressed.

Based on record review, staff interviews, Nurse Practioner and Physician interviews, the facility neglected the resident by not conducting a full body assessment and a neurological assessment to include range of motion of all extremities prior to moving the resident after a fall on 11/11/21. The facility also neglected to perform continued neurological assessments including range of motion and vital signs to assess for any change of condition; and failed to identify a change of condition when the resident presented with signs and symptoms of pain, decreased oral intake, inability to ambulate or transfer out of bed, refusing care, and requiring assistance of two staff to transfer on 11/12/21 for 1 of 5 residents (Resident #11) reviewed for accidents. The failures resulted in delayed identification and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Immediate Jeopardy began on 11/11/21 at 3:10 AM when Resident #11 had an unwitnessed fall and was transferred to her wheelchair without being assessed by a nurse. The facility neglected the resident by not conducting a full body assessment and a neurological assessment to include range of motion of all extremities prior to moving the resident after the fall. The facility neglected to perform continued neurological assessments including range of motion and vital signs to assess for any change of condition and failed to identify a change of condition when the resident presented with signs and symptoms of pain, decreased oral intake, inability to ambulate or transfer out of bed, refusing care, and requiring assistance of two staff to transfer. The failures resulted in delayed identification and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Immediate Jeopardy was removed on 12/15/21 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy Removal. The facility will remain out of compliance at a lower scope and severity level D isolated with potential for more than minimal harm to correct the deficient practice and to ensure that the education and monitoring systems put in place to remove the Immediate Jeopardy are effective. Findings included: Resident #11 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set quarterly assessment dated [DATE] revealed Resident #11 was severely cognitively impaired and did not demonstrate any refusal of care or behaviors. Resident #11 required limited assistance with one staff physical assistance with bed mobility, transfers, walking in the room and corridor, locomotion on and off the unit, dressing, toileting, and personal hygiene. Resident #11 had one fall with no injury, required a walker or wheel chair for mobility device and was not steady but able to stabilize self without human assistance. A plan of care dated 09/17/21 revealed Resident #11 was at risk for falls related to dementia. Interventions included to keep bed in lowest position and apply non skid socks while in bed. A review of an incident report documented as completed by Nurse Supervisor (NS) #2 on 11/11/21 at 3:10 AM revealed Nursing Aide (NA) [#1] and Patient Care Assistant (PCA) [#1] informed Nurse [#1] at 3:10 AM resident was observed on the floor in her room with her head under the sink in a fetal position with walker lying over her lower legs and her wheelchair facing her. The NA discovered resident on the floor at 3:10 AM and got help from the PCA. Due to uncomfortable position, the NA and PCA lifted Resident #11 back to wheelchair and then informed nurse. Review of the neurological check (an assessment to check neurological function) assessments beginning on 11/11/21 at 3:10 AM revealed hand grasps were equal, vital signs (VS) were recorded as blood pressure (BP) 114/72, respiration rate (RR) 18 breaths per minute (bpm), heartrate (pulse) was recorded as 72 beats per minutes (bpm) at 3:10 AM. The neuro checks were documented every 15 minutes X 4 for 1 hour, every 30 minutes for 2 hours, every 1-hour X 2 by Nurse #1 and each assessment indicated the hand grasps were equal, no range of motion was assessed, and each VS recording for these assessments were recorded as BP 114/72, RR 18, Pulse 72 with the time recorded for each assessment as 3:10 AM and the date stamp of 11/11/21. There were no continued neurological check assessments documented for 11/11/21. Review of the hospital record dated 11/13/21 at 7:01 PM revealed Resident #11 presented to the Emergency Department (ED) with new left hip fracture. Resident had a fall two days ago and staff noted her to not be using her left leg. An x-ray was obtained {on 11/13/21} and read moderately displaced sub capital left hip fracture with no dislocation. Resident is hemodynamically stable and without a fever and she is lying on her right side and states she does not need any medication for pain at this time. Per Emergency Medical Services (EMS) she had pain with any movement. Hospital records revealed another x-ray was taken at 8:50 PM and the impression read left sub capital neck displaced fracture. The ED course and medical decision making revealed the x-ray positive for left sub capital neck displaced fracture, on call orthopedic surgeon notified and will plan for surgery on {11/15/21} and to admit the resident. The hospital discharge summary dated 11/17/21 revealed Resident #11 was status post [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with NA #1 via phone on 12/10/21 at 5:30 AM who worked the nightshift on 11/11/21 revealed at about 3:00 AM she and PCA #1 noted Resident #11 laying on her left side with her head under the sink. Resident #11's walker was straddled on top of the resident and her wheelchair was facing the resident at the end of bed and Resident #11 was asleep on the floor, she was dressed and had socks and shoes on her feet. NA #1 stated she went to get Nurse #1 to come and check on her, and when she told Nurse #1, Nurse #1 replied I ' m coming, I'm coming. NA #1 stated PCA #2 was in the next room assisting another resident and she went through the adjoining bathroom to ask PCA #2 to come and help NA #1 and PCA #1. NA #1 stated she sat with Resident #11 for no less than 20 minutes waiting because she knew the nurse needed to assess her. NA #1 stated after about 20 minutes, she decided to go ahead and transfer Resident #11 to get her off the cold floor because Nurse #1 was taking too long. NA #1 stated she, PCA #1 and PCA #2 got the mechanical lift and transferred the resident to the wheel chair. NA #1 stated Resident #11 had no complaints of pain at the time of the transfer. NA #1 stated about an hour and half later (about 5:00 AM) Nurse #1 went in to see the resident and NA #1 went with her. NA #1 stated Nurse #1 asked NA #1 if she saw any signs of injury during the transfer and NA #1 stated she noted a bruise on her elbow and shoulder. NA #1 stated Nurse #1 observed that as well and asked NA #1 if the resident had any complaints of pain during the transfer and NA #1 reported she did not. NA #1 stated Nurse #1 checked Resident #11's head and there were no bumps and Nurse #1 said the resident was fine and left the room. NA #1 stated at 6:00 AM she and PCA #2 went to the resident ' s room to do the last round and transfer Resident #11 to bed, but she was combative and would not let them transfer her. NA #1 stated she told Nurse #1 that the resident refused to let them transfer her to bed. NA #1 stated Resident #11 was in her wheel chair when she last saw her at 7:00 AM on 11/11/21. An interview with PCA #1 via phone on 12/10/21 at 11:15 AM revealed on the night of 11/11/21, he and NA #1 were in the room because the resident had a fall. PCA #1 stated NA #1 told PCA #2 they needed help and PCA #2 went to get Nurse #1 to notify her of the fall. PCA #1 stated Resident #11 was lying on her left side with her head under the sink. PCA #1 stated he and PCA #2 and NA #1 lifted the resident without a mechanical lift after about 20 minutes of waiting for Nurse #1 because they wanted to get the resident off the floor. PCA #1 stated she tolerated the transfer fine and had no signs or symptoms of pain or complaints of pain. He stated they transferred her to the wheelchair because it was closer than the bed. PCA #1 stated he left the 300 hall and went back to his hall and in the morning when he checked on Resident #11 before he left about 7:00 AM and Resident #11 was sleeping. An interview with PCA #2 via phone on 12/11/21 at 9:41 AM revealed she had last checked Resident #11 at 12:00 AM on 11/11/21 and she was in her reclining chair and did not need to be changed at that time. PCA #2 stated around 3:00 AM she was in the room next door to Resident #11 when NA #1 opened the adjoining bathroom door and told her she needed help with Resident #11 because she had fallen. PCA #2 stated NA #1 and PCA #1 were with Resident #11 and she was lying on the floor on her left side with her head under the sink. PCA #2 stated, at this time, she went to the 200 hall to get Nurse #1 and Nurse #1 stated she was coming but it had taken her a long while to come down to the room. PCA #2 was unable to say how long it took. PCA #2 stated she went back to the room and they (NA #1, PCA #1, and PCA #2) waited a while for Nurse #1 but she had not come after about 20 minutes, so they decided to move her to the wheelchair. PCA #2 stated PCA #1 held the wheelchair and her and NA #1 lifted the resident off the floor under her arms and transferred her to the wheelchair. PCA #2 stated she did not use the mechanical lift. PCA #2 was not aware she was supposed to use a mechanical lift. PCA #2 stated they kept asking Resident #11 if she was okay and she would say yes or if she had any pain and the resident said, no. PCA #2 stated she did not recall going back in the resident ' s room after they transferred her. PCA #2 stated she left the facility at 6:30 AM. An interview with Nurse #1 on 12/09/21 at 8:30 AM who worked 7:00 PM to 7:00 AM on 11/11/21 stated she was told by NA #1 that the resident had fallen and NA #1 and PCA #1 had already transferred the resident to the wheelchair before she could assess Resident #11. Nurse #1 stated NA #1 and PCA #1 moved her because they said she looked uncomfortable. Nurse #1 stated NA #1 and PCA #1 should not have moved Resident #11 until she assessed her. Nurse #1 stated whenever a resident had an unwitnessed fall, the staff needed to determine if the resident hit their head and if the resident could not say, nursing would start doing neurological (neuro) checks. Nurse #1 explained that the neuro checks included checking the resident's level of consciousness to see if the resident could respond verbally to the nurse, check the residents' pupils to see if they react to light as they should, check the residents' hand grasps on both sides to see if the strength was equal and check the resident's range of motion to see if they have any pain upon movement. Nurse #1 stated an initial set of vital signs needed to be obtained as well. She stated the assessments should be done every 15 minutes for one hour, every 30 minutes for 2 hours, every hour for 4 hours, every 4 hours for 16 hours, and every 8 hours for 48 hours. Nurse #1 stated staff were not supposed to move a resident after a fall until the resident was assessed by a nurse. Nurse #1 added if a resident was unable to stand by themselves and were dependent on staff to reposition them, a mechanical lift with 2 staff members should be used to transfer the resident to the bed or a wheelchair. Nurse #1 stated she did not know how long it took before she assessed the resident because she was busy on another hall, but when she got to the room she saw Resident #11 sitting in the wheelchair and the resident said her shoulder hurt. Nurse #1 stated she noted she had a small abrasion on Resident #11's shoulder which she cleansed with normal saline, applied an antibiotic ointment and covered with a dressing. Nurse #1 stated the resident also had a red area on her left inner elbow. Nurse #1 stated she did not check the range of motion (ROM) to the upper and lower extremities because the resident could not follow commands to raise her arms or extend her legs. Nurse #1 stated she did not do neuro checks because Resident #11 could not follow the command to squeeze her hands to check for equal strength on each side or the command to push down on her legs to check for equal strength on each side. Nurse #1 stated the resident had no signs or symptoms of pain and she left her in the wheelchair. Nurse #1 stated she should have checked passive range of motion (conducting the range of motion without the residents ' assistance) to see if Resident #11 could move her extremities without pain and she should have obtained new vital signs with every neurological check assessment. An interview was conducted with Nurse Supervisor (NS) #1 via phone on 12/13/21 at 8:33 AM who worked 7:00 AM - 7:00 PM on 11/11/21. NS #1 stated she received in report from Nurse #1 Resident #11 had a fall around 3:00 AM but that Resident #11 was okay. NS #1 stated when she went in to see Resident #11 that morning to give her medications, she assessed Resident #11 while she was sitting in her wheelchair by conducting passive range of motion to her upper and lower extremities and she had no signs or symptoms of pain. NS #1 stated the resident appeared to be at baseline and was answering NS #1's questions appropriately. NS #1 stated since the Nurse Practioner (NP) #1 was in the building on 11/11/21 she had let him know the resident had a fall and he had gone in to assess Resident #11. NS #1 stated neither PCA #3 nor NA #8 came to her and reported Resident #11 was in pain or not eating. NS #1 stated Nurse #1 did not inform her that Resident #11 was transferred after her fall before Nurse #1 could assess her. NS #1 stated she had no knowledge that had occurred. NS #1 stated the resident would ambulate and she did not see her ambulate on 11/11/21. NS #1 stated she had done the neurological assessments; she just did not record the results in the computer system. NS #1 stated she should have documented her findings to include current vital signs, hand grasps, pupil assessment and range of motion in the computer system to ensure the nursing staff were aware of all the assessments conducted to monitor for any change in condition. There was no documentation for the continued neuro check assessments from NS #1 which would have been for every 1-hour X 2 (9:00 AM and 10:00 AM) and every 4 hours X 2 (2:00 PM and 6:00 PM) during her shift on 11/11/21. A progress note written by Nurse Practioner #1 on 11/11/21 at 12:12 PM revealed resident was in her wheelchair, sitting up eating lunch. She was noted to have a fall over night. Nursing states she was laying on the floor on her left shoulder. Small abrasion noted to left posterior shoulder, open to air. Resident denied any pain and had full range of motion. Resident stated she was doing ok. An interview with Nurse Practioner (NP) #1 via phone on 12/13/21 at 11:50 AM reported when he was made aware by NS #1 Resident #11 had a fall, he assessed the resident on 11/11/21. NP #1 reported when he entered the resident's room she was sitting in her wheelchair eating lunch. NP #1 stated he was told by staff the resident had an abrasion to her left shoulder but no complaints of pain or any other obvious injury. NP #1 stated the resident had no acute distress and he had moved her arms and palpated her lower back, hips, and knees to see if there was any pain. The NP #1 stated he did not do any range of motion with the lower extremities and added, typically, the nurses would assess range of motion if a resident had a fall. NP #1 stated he would have expected the nurses to do a full assessment to include vital signs, neuro assessments, and range of motion to see if the resident had any pain or decreased range of motion in any extremities. He stated he would expect the nursing staff to complete a comprehensive assessment to determine how and when to move a resident after a fall, but that a nurse should do a complete assessment before a resident was transferred. An interview was conducted with NA #8 on 12/10/21 at 11:30 AM who worked the 7:00 AM - 3:00 PM shift on 11/11/21. NA #8 stated she could not remember taking care of Resident #11 on 11/11/21 and could not recall getting a report from NA #1 regarding Resident #11 having a fall. An interview with PCA #3 via phone on 12/13/21 at 10:35 AM who worked the 7:00 AM - 3:00 PM shift on 11/11/21 revealed she could not recall getting in report from NA #1 that Resident #11 had a fall. PCA #3 stated she had no knowledge of the resident having a fall and could not recall caring for Resident #11 on 11/11/21. PCA #3 stated what she remembered about Resident #11 was that she would be up and walking the halls with her walker and sometimes she would sit in her room in her recliner. PCA #3 stated it was rare for the resident to sit in her wheelchair or to be in her bed. An interview with NA #7 via phone on 12/11/21 at 10:47 AM who worked the 3:00 PM - 11:00 PM shift on 11/11/21 revealed she could not recall anything about the evening of 11/11/21 related to Resident #11. An interview with NA #9 via phone on 12/11/21 at 11:15 AM who worked from 7:00 PM - 7:00 AM shift on 11/11/21 going into 11/12/21 revealed she could not recall anything about the evening or the early morning hours of 11/11/21 or 11/12/21 related to Resident #11. An interview with NA #5 via phone on 12/14/21 at 8:41 AM who worked the 3:00 PM - 11:00 PM shift on 11/11/21 revealed she could not recall anything about the evening of 11/11/21 related to Resident #11. An interview with NA #14 via phone on 12/13/21 at 12:11 PM who worked on 11/11/21 from 11:00 PM - 7:00 AM reported she had worked the 100/200 hall that night and did not provide any care to Resident #11. NA #14 stated she was not aware Resident #11 had a fall. NA #14 stated the resident was usually up and ambulating and was confused and would need redirection when she wandered. She stated the resident very rarely slept in her bed and would usually sleep in her recliner. An interview with Medication Aide #1 (MA) via phone on 12/13/21 at 12:11 PM who worked 7:00 PM - 7:00 AM on 11/11/21 going into 11/12/21 revealed she could not recall the night of 11/11/21 and could not recall being told by NS #1 Resident #11 had a fall. MA #1 stated if the resident did have a fall and neuro checks were needed, the nurse would get the neuro checks and she would obtain the vital signs. MA #1 could not recall obtaining any vital signs for Resident #11 during this shift. MA #1 stated she believed Nurse #9 from the Rehab Hall would have been the nurse overseeing her as the MA and she would have done the neuro assessments. An interview was conducted with Nurse #9 via phone on 12/14/21 at 2:10 PM. Nurse #9 who worked the Rehab Hall the night of 11/11/21 going into 11/12/21 reported she was not overseeing the Medication Aide on the night of 11/11/21. Nurse #9 stated she was not informed that neurological assessments needed to be done for Resident #11 and therefore did not complete any neuro assessments for this resident. There were no neuro check assessments documented during the shift 7:00 PM - 7:00 AM on 11/11/21 going into 11/12/21 which would have included every 4 hours X 2 more times (10:00 PM and 2:00 AM) for Resident #11. During the interview with NA #1 via phone on 12/10/21 at 5:30 AM she stated she came back to work on Friday 11/12/21 from 7:00 AM -3:00 PM and when she arrived she brought Resident #11 her breakfast tray and Resident #11 was sitting in the wheelchair, slumped over. She stated she told Nurse #2 (day shift nurse) and Nurse #2 told NA #1 to get her into bed. NA #1 stated when she and NA #2 were moving Resident #11, they tried to get her to stand up with her walker because that was how the resident usually transferred and the resident refused to get up and became combative. NA #1 stated she and NA #2 tried to move the resident from the chair to the bed and she was crying out like she was in pain. NA #1 stated they tried to transfer her with a gait belt and Resident #11 started complaining No! Stop! NA #1 stated they got the sit to stand mechanical lift which she did not tolerate but she and NA #2 were able to get the resident to bed. NA #1 stated Resident #11 was showing signs that she was in pain like moaning and crying. NA #1 stated she and NA #2 got her to the bed and laid her down and then the resident rolled on to her right side. NA #1 stated she went to Nurse #2 and told her the resident was having pain when she and NA #2 transferred her and Nurse #2 stated it was probably because she had been sitting in the wheelchair and to let her know when NA #1 went back to the room. NA #1 stated she went back in the resident ' s room around 10:00 AM by herself to check and change Resident #11 and the resident was refusing care. NA #1 stated Resident #11 said, stop, quit when NA #1 attempted to roll her. NA #1 stated she reported this to Nurse #2 and Nurse #2 said I ' m busy right now, I ' m trying to finish my med pass. NA #1 stated when she went to bring the resident her lunch tray, the Physical Therapist (PT #1) was in Resident #11 ' s room and had asked if NA #1 noticed a change in Resident #11 and NA #1 said yes, and that Resident #11 was not eating and refusing to let NA #1 change her and she was crying out. NA #1 stated while she was talking with PT #1, Nurse #2 was with them while she was at the medication cart. NA #1 stated when she went to change Resident #11 to do her care at around 2:30 PM, she was wincing and moaning and said to stop and was pushing NA #1's hands away. NA #1 stated she told Nurse #2 again, but NA #1 did not observe Nurse #2 go into her room to assess the resident at that time. An interview was conducted with NA #2 on 12/10/21 at 10:00 AM who worked 7:00 AM - 3:00 PM on 11/12/21. NA #2 reported when she came in on 11/12/21 she did rounds with NA #1. NA #2 stated the resident was noted to be slumped over in her wheelchair. NA #2 stated she and NA #1 went to put Resident #11 in the bed and when she and NA #1 stood the resident up from the wheelchair and tried to transfer her, Resident #11 made a noise of discomfort and was acting out of the ordinary because she grimaced and moaned when she and NA #1 moved her. NA #2 could not recall using the sit to stand mechanical lift to transfer her. NA #2 stated Resident #11 was very wet and very soiled and NA #2 stated both she and NA #1 reported to Nurse #2 that Resident #11 was not her normal self because she had not eaten and was showing signs and symptoms of pain. NA #2 reported the resident slept for a majority of the day which was out of the norm. NA #2 stated she did not follow up with the Nurse #2 to see if she had gone to see the resident and when she left at 3:00 PM and Resident #11 was still sleeping in bed. An interview with PT #1 on 12/10/21 at 10:30 AM revealed she had gone to see Resident #11 on 11/12/21 due to the resident having a fall which was reported to her through risk management (a meeting with nursing and department heads to discuss falls). PT #1 stated Resident #11 had a significant change because she was not out of bed or ambulating. PT #1 stated when she went into the resident's room to see her, she was lying in bed and PT #1 tried to touch her to wake her, but the resident did not respond. PT #1 stated NA #1 and Nurse #2 were outside of Resident #11's door and she reported to Nurse #2 that she needed to be checked out due to change of status because she was not moving or walking and she was usually up and ambulating and NA #1 told PT #1 that it took 2 aides to transfer Resident #11 back to bed that morning. An Interview with Nurse #2 on 12/10/21 at 10:15 AM revealed on 11/12/21 when she arrived, she was never made aware by Medication Aide #1 Resident #11 had a fall. Nurse #2 stated she went to the resident's room after PT #1 had told her Resident #11 did not seem right and the resident was in her bed. Nurse #2 stated the resident was lethargic but she thought it was because Resident #11 had been sitting up in her wheelchair for a while. Nurse #2 stated no one told her she had fallen and if she had known she would have done a thorough assessment. Nurse #2 stated she did not assess her and added that the resident did not verbalize much and did not show signs and symptoms of pain and no one had ever told her Resident #11 was in pain. Nurse #2 stated the resident never ate that day and never got out of bed, which was not her norm, but again she thought the resident was just tired from sitting up in her wheelchair. A follow up interview was conducted with Nurse #2 via phone on 12/15/21 at 12:56 PM. Nurse #2 revealed neuro checks were initiated whenever a resident had an unwitnessed fall and they would continue for 3 days (72 hours). Nurse #2 confirmed she documented the neuro checks in the computer system but did not make the connection as to why she was doing neuro checks when she was documenting them. Nurse #2 stated she did do the neuro checks but added she did not always check the range of motion or obtain current vital signs when she was doing her neuro checks and the previous vital signs that were recorded auto populated in the computer system. Nurse #2 stated part of doing neuro check assessment was to obtain current vital signs with each assessment and it was important to check them to make sure there was no significant change in condition in the resident, and to check range of motion. Nurse #2 stated she should have questioned why she was having to document and perform the neuro checks. Review of the neuro check assessments by Nurse #2 beginning on 11/12/21 at 9:00 AM hourly until 12:00 PM revealed hand grasps were equal and moved extremities equally, vital signs (VS) were recorded by Nurse #2 as blood pressure (BP) 114/72, respiration rate (RR) 18 breaths per minute (bpm), heartrate (pulse) was recorded as 72 beats per minutes (bpm) at 3:10 AM with a time stamp of 11/11/21. On 11/12/21 the neuro checks would have been due to be completed at 10:00 AM and 6:00 PM by Nurse #2. Interview with Nurse #6 on 12/11/21 at 6:37 AM who worked 7:00 PM - 7:00 AM on 11/12/21 revealed he received report from Nurse #2 Resident #11 had a fall with no injury. Nurse #6 stated he was told Resident #11 was transferred from the floor without being assessed by Nurse #1. Nurse #6 stated Nurse #2 did not mention anything about the resident having pain, not eating, or staying in bed all day. Nurse #6 stated during the night on 11/12/21, Resident #11 had no signs or symptoms of pain. Nurse #6 stated he had administered eye drops to her, and at this point Resident #11 was in bed and responding to him while applying the eye drops and following the command to open her eyes. Nurse #6 stated at one point during the night NA #3 came to him to assist with giving Resident #11 a boost in the bed and while they repositioned her, she had no signs or symptoms of pain. Nurse #6 stated NA #3 had not reported the resident was having any pain during the shift. Nurse #6 stated the resident stayed in bed all shift. Nurse #6 added, the resident would sometimes sleep in bed all night especially if she had been up all day, but most times the resident was in bed maybe 5 - 10% of the time. Nurse #6 stated if he were assessing a cognitively impaired resident after a fall he would perform passive range of motion as part of his assessment to determine if the resident had any pain or rotation of the extremities. Nurse #6 stated he did not perform passive range of motion on Resident #11 because he was told she was fine after her fall. Nurse #6 stated he did not recall recording neuro check assessments in the computer system for Resident #11. Review of the continued neuro check assessments for Resident #11 on 11/12/21 revealed Nurse #6 recorded the vital signs (VS) as blood pressure (BP) 114/72, respiration rate (RR) 18 breaths per minute (bpm), heartrate (pulse) was recorded as 72 beats per minutes (bpm) at 3:10 AM with a time stamp of 11/11/21, and indicated the resident was able to verbalize needs and obeyed commands, moved all extremities equally and hand grasps were equal. During the interview with NA #1 via phone on 12/10/21 at 5:30 AM, NA #1 stated when she came back to work on 11/13/21 from 7:00 AM to 3:00 PM and went to bring Resident #11 her breakfast tray about 7:30 AM or so, Resident #11 was lying in bed on her right side and refused to be set up to eat breakfast. NA #1 stated Resident #11 was moaning and wincing and showing signs like she was in pain when she was trying to move her. NA #1 stated she told Nurse #3 the resident seemed like she was in pain and was refusing to let her change her and reposition her to set her up to eat. NA #1 stated she asked Nurse #3 to please look at her. NA #1 stated Nurse #3 assessed Resident #11 and after Nurse #3 assessed her, Nurse #3 said the resident was having pain and needed an x-ray on her left leg. An interview was conducted with Nurse #3 via phone on 12/11/21 at 11:02 AM. Nurse #3 revealed when she came on duty the morning of 11/13/21, Nurse #6 told her in report Resident #11 had a fall with an abrasion to her shoulder but that she seemed okay. Nurse #3 stated NA #1 came to her about 7:45 AM and asked her to please assess Resident #11. Nurse #3 stated NA #1 was concerned that the previous nurse (Nurse #2) had not followed up and checked on the resident. Nurse #3 stated NA #1 stated Why was no one following up as to why she was still in bed and not eating? Nurse #3 stated she went in to assess Resident #11 and because she could not verbally express if she had pain, she started to do passive range of motion and when she moved the resident ' s left leg, she cried out with a loud sound and was reaching down toward her left leg and moaning. Nurse #3 stated she gave Resident #11 some pain medicine and notified the physician and obtained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/13/21 the incident report (related to Resident #11 ' s fall on 11/11/21 at 3:00 AM) was updated by NS #2 and stated, resident complained of pain on 11/13/21 and NA {#1} called Nurse {#3} to room around 8AM and said, Can you please check on her? Nurse assessed for signs of pain and upon range of motion to left leg resident winced and cried out. MD notified, x-ray ordered for left hip and femur. X-ray arrived around 12 noon and the report came back around 5:30 PM that resident had an acute left hip fracture. An interview was conducted with the Rehabilitation Manager on 12/10/21 at 5:45 PM. The Rehab Manager stated it would take a lot more force than a transfer with 3 staff to worsen the fracture to the resident's leg. The Rehab Manager added that sometimes nursing staff may not be able to tell if there was any injury upon assessment and the injury could be more evident later. An interview was conducted with Director of Nursing (DON) on 12/10/21 at 6:08 PM. The DON stated he had no knowledge the nurse aide and patient care assistants moved Resident #11 before being assessed by the nurse. The DON reported whenever a resident had a fall, the nurse was to complete a head-to-toe assessment with vital signs for a witnessed or unwitnessed fall. The DON stated if the fall was unwitnessed, and the resident was not cognitively aware to report if they had hit their head or not, the nurses would be expected to initiate neurological checks which would include current vital signs with each assessment, assessing hand grasps, range of motion of all extremities, mental status and an assessment of the pupil [TRUNCATED]

Based on record review, staff and resident interviews, Pharmacy Supervisor, Nurse Practitioner, and Physician interviews the facility failed to 1) complete and return a medication authorization form to the pharmacy regarding a medication order for [MEDICATION(S)] (prescribed for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 2) the facility administered a muscle relaxing medication with a narcotic pain medication and did not wait the ordered one hour in between medication administration of the relaxing medication after giving a narcotic medication 30 out of 30 days during the month of November and 7 out of 7 days reviewed during the month of December, administered a scheduled morning muscle relaxing medication late and administered the medication along with the afternoon muscle relaxing medication 3 out of 30 days during the month of November, and; administered a sleep aide medication late 4 out of 30 days during the month of November and 2 out of 7 days reviewed in the month of December for 1 of 5 residents reviewed for unnecessary medications. (Resident # 42); and 3) the facility failed to follow manufacturer's instructions to not crush an extended release medication ([MEDICATION(S)]) for 2 of 5 residents (Resident #66 and #63) reviewed for medication administration. Findings included. Example #1 Resident #66 was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Give one tablet by mouth two times a day for [CONDITION(S)]. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #66 had adequate vision and hearing with clear speech. She had mildly impaired cognition, and exhibited no behaviors and no rejection of care. She required extensive two-person assistance with bed mobility, transfers, and activities of daily living. A care plan dated 11/18/21 revealed Resident #66 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal of care included in part; to administer medications as ordered, and monitor and document side effects and effectiveness. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] A progress note dated 12/03/21 by Nurse Practitioner #1 revealed in part; Resident #66 was seen today, stated she felt okay, denied pain, with no acute distress noted. Continue [MEDICATION(S)]. Was notified by nursing on 11/23/21 that the resident had not been receiving [MEDICATION(S)] since the resident's initial admission on 11/10/21. [MEDICATION(S)] was able to be obtained and was restarted on 11/24/21. A phone interview was conducted on 12/13/21 at 2:45 PM with Nurse Practitioner #1. He stated he could not say how much it affected Resident #66 by not receiving [MEDICATION(S)]. He stated the medication was prescribed for walking issues, and the medication did not stop the progression of [CONDITION(S)]. He stated he was not fully aware if Resident #66 had a decline in function, and stated he was not certain as to why she did not receive the [MEDICATION(S)] for that length of time. He stated he last evaluated Resident #66 on 12/06/21 and she seemed okay. An interview was conducted on 12/09/21 at 02:40 PM with Nursing Supervisor #1. She stated Nurse #10 had notified her that the medication ([MEDICATION(S)]) wasn't there, and pharmacy needed approval for it. She instructed Nurse #10 to call (the Senior Care Program that Resident #66 was affiliated with) to see if they could supply the medication and then call pharmacy. She stated the (Senior Care Program) informed the facility that they did not supply resident medications and the medication would need to come from the facility's pharmacy. Nursing Supervisor #1 reported another nurse checked on the medication again after the issue had not been resolved but the nursing supervisor could not recall which nurse it was and could not recall an exact date. She indicated she thought the issue had been resolved after that time by the Director of Nursing (DON) or one of the nurses because she was not made aware of any issue after that. She stated she thought the DON handled authorization forms and indicated if a medication was missing the nurse would call the pharmacy regarding the medication and if the medication could not be obtained the physician should have been notified. The admission nurse for Resident #66 on 11/10/21 was unavailable for interview. An interview was conducted on 12/10/21 at 10:32 AM with Nurse #10. She stated Resident #66 was admitted to the facility due to diverticulitis and issues with mobility. She stated the resident was alert and oriented to person, place, and time, was wheelchair bound, and could communicate her needs. She stated the medication [MEDICATION(S)] had to have prior approval from the Administrator, and Pharmacy told her they sent the authorization form to the facility. She stated the medication authorization forms were sent to the DON or the ADON (Assistant Director of Nursing) for approval. Nurse #10 stated she called the (Senior Care Program) and asked them about supplying the medication and they said the facility needed to provide the medication. She stated she didn't recall Resident #66 having a decline in function during her time at the facility. An interview was conducted on 12/10/21 at 11:17 AM with Nurse Aide #18. She stated Resident #66 was oriented to person, place, and time and could voice her needs. She stated at one point Resident #66 declined, but then she seemed better, then declined again with transfers. She stated the resident went from requiring two-person assistance with the mechanical lift for transfers on admission and progressed to only needing two-person assistance to stand and pivot with transfers, then started needing the mechanical lift again. She stated therapy staff informed her that Resident #66 was back to needing the mechanical lift for transfers, but she could not recall the date. An interview was conducted on 12/10/21 at 11:25 AM with Nurse Aide #19. She stated on admission Resident #66 needed the mechanical lift with two-person assistance, then improved to needing one person assistance to stand and pivot for transferring, then suddenly declined to needing two-person assistance with transfers. She stated she could see a decline in Resident #66 while she was at the facility. She stated initially Resident #66 could stand with assistance long enough for the nurse aide to get some of her clothing on, then the nurse aide was off a few days and when she came back to work, she noticed Resident #66 had declined in function. She stated her orientation declined too, and her appetite decreased but the resident continued to be able to feed herself. An interview was conducted on 12/09/21 at 12:00 PM with the Pharmacy Supervisor. She stated the pharmacy tried to fill the medication [MEDICATION(S)] for Resident #66 a couple of times but [MEDICATION(S)] was not covered by the insurance they had on file. The pharmacy sent out a non-covered medication authorization form to the facility on [DATE], 11/18/21, and again on 11/23/21. She stated someone from the facility must have called about the medication on 11/18/21 and the non-covered form was faxed again but the form was not filled out by the facility with the needed insurance information. She stated someone from the facility called the pharmacy on 11/23/21 and the form was faxed again and was received back to the pharmacy on that day and the medication was sent to the facility the same day on 11/23/21. She stated sometimes the facility would have the pharmacy send a small supply while waiting on authorization forms therefore a small supply of [MEDICATION(S)] could have been sent for Resident #66. She stated [MEDICATION(S)] was indicated for patients with [CONDITION(S)] to improve walking and muscle strengthening. She stated without the medication Resident #66 could have had a decline in ADL (activities of daily living) function or quality of life but stated the medication didn't stop the disease from progressing. She indicated abruptly stopping the medication wouldn't cause an acute relapse. A follow up phone interview was conducted on 12/13/21 at 11:30 AM with the Pharmacy Supervisor. She stated the medication went from 11/10/21 until 11/23/21 before pharmacy received the approval to dispense. She stated the facility could have had the medication within 24 hours after the pharmacy received the initial order if they had received the non-covered medication authorization. An interview was conducted on 12/10/21 at 02:14 PM with the Director of Nursing. He stated the pharmacy called and made the facility aware that preauthorization was needed to fill the medication order, but he could not recall a date or the time frame when he was made aware of the medication issue. He indicated the resident went from 11/10/21 through 11/23/21 without receiving the [MEDICATION(S)] so any correspondence with pharmacy occurred during that time. He stated he wasn't sure why the authorization form was not followed through with, and stated no staff brought the non-covered medication authorization forms to him. He stated he had only worked at the facility for six months and indicated he was not certain of whose responsibility it was to fill out the authorization forms. He indicated he wasn't sure which fax the pharmacy used for correspondence with the facility but stated on 11/23/21 the pharmacy was given another fax number to use, and the authorization form was completed and returned to pharmacy and Resident #66 was administered [MEDICATION(S)] beginning 11/24/21. An interview was conducted on 12/10/21 at 3:22 PM with the Rehab Director. She stated Resident #66 received therapy services from 11/10/21 - 12/06/21. She stated Resident #66 required moderate assistance with transfers which meant 74% assistance was needed by staff with transfers. She stated initially Resident #66 was progressing, then she began a slow steady decline. She stated by 12/06/21 the resident required 75% with two-person assistance with transfers and was only able to walk 8 feet and required walking with the parallel bars with 75% assistance which was a decline. She stated Resident #66 was asked by therapy staff that day if she felt bad and stated the resident was not complaining of pain. She stated Resident #66 still tried to do as much as she could. She stated her last therapy session was on 12/06/21 and a stop/watch form was completed by therapy, which was a communication tool used to alert nursing that a concern was identified. A phone interview was conducted on 12/13/21 at 4:30 PM with the Corporate Nurse Consultant. He stated Resident #66 initially required the use of the parallel bars for walking then progressed to a rollator, then went back to needing the parallel bars but stated she never stopped ambulating. He stated she continued to be able to participate in therapy at some level. He stated the DON should have followed through with completing the medication authorization form and sending the form back to the pharmacy so that the order could have been filled. He indicated Resident #66 should not have gone 12 days without receiving the [MEDICATION(S)]. A phone interview was conducted on 12/13/21 at 4:45 PM with the facility Physician. He stated he was not made aware that Resident #66 didn't have the medication [MEDICATION(S)] until (the Senior Care Program) reached out to him and he could not recall when exactly that was. He stated Resident #66 didn't receive the medication until the 12th or 13th day after her admission but stated he was not aware of why the medication was delayed. He stated she should have received the medication after her admission, she didn't, and it did cause a decline in function. A phone interview was conducted on 12/16/21 at 12:07 PM with the Occupational Therapist from the (Senior Care Program). He stated their Nurse Practitioner was informed that Resident #66 had not received [MEDICATION(S)] for two weeks. He stated he was very familiar with Resident #66 and had provided rehab care to the resident for a long time. He stated prior to her hospitalization she was living home alone and was independent with ADL's (activities of daily living) and was admitted to the nursing facility for short term rehab with the expectation of going back to her apartment. He reported that when she was seen at (the Senior Care Program) during her time at the nursing facility he realized she was not making progress with therapy which was concerning to him. Example #2 Resident #42 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set quarterly assessment dated [DATE] revealed Resident #42 was moderately cognitively aware and received 7 days of hypnotics and opioid medication. Resident #42's care plan dated 10/30/21 revealed the resident had pain affecting his left shoulder with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included, in part, to administer pharmacological interventions as indicated per physician and monitor the effectiveness. Review of the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The narcotic pain medication was scheduled to be given at 12:00 AM, 8:00 AM and 4:00 PM. The Medication Administration Audit Report (MAAR) for the month of November and the first week of December (December 1 - 7) was reviewed. The report listed the name of the medication that was ordered by the physician, the time the medication was to be administered, the time the nurse removed the medication from the medication cart, the actual time the medication was administered, and the name of the nurse who administered the medication. The MAAR for the month of November revealed the muscle relaxing medication was administered the same time as the narcotic pain medication 30 out of 30 days reviewed without waiting the prescribed hour in between medications by Nursing Supervisor (NS) #1, Nurse #2 and Nurse #3. The MAAR for the first week in December revealed the muscle relaxing medication was given the same time as the narcotic pain medication 7 out of 7 days reviewed without waiting the prescribed hour in between medications by Nurse #2, and Nurse #3. An observation of Resident #42 was conducted on 12/07/21 at 12:50 PM. Resident #42 was alert and oriented and was lying in bed and had no signs or symptoms of sedation. An interview with Resident #42 was conducted on 12/07/21 at 12:50 PM. Resident #42 reported he was having pain in his shoulder and his foot and stated the nurse had medicated him for his pain a few hours ago. The resident stated he was not sleepy and he did not feel sedated. Resident #42 was conversing and eating his lunch. a. An interview was conducted with Nursing Supervisor (NS) #1 on 12/08/21 at 11:10 AM. NS #1 explained the columns on the Medication Administration Audit Reports and stated the 1st column was the name of the medication to be given, the 2nd column on the report was the time the medication was ordered to be given, the 3rd column was when the nurse clicked on the medication to be given in the computer system and took the medication out of the medication cart, and the 4th column was the time stamped after the administration of the medication to the resident. NS #1 confirmed that she had given the muscle relaxing medication and the narcotic pain medication to Resident #42 at the same time and added, I must have missed the part of the order that said do not give within one hour of [MEDICATION(S)]. NS #1 stated the medications should not have been entered in the computer system to be given at the same time since the order stated to wait one hour after giving the pain medication. An interview was conducted with Nurse #2 on 12/09/21 at 10:15 AM. Nurse #2 confirmed she had been administering the muscle relaxing medication and the narcotic pain medication together during the month of November and December and stated she should have followed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #2 stated although they were written to give at the same time, nurses have a one-hour window before and after a medication was due and she should have waited the hour and administered the muscle relaxing medication at 9:00 AM. An interview was conducted with Nurse #3 on 12/11/21 at 11:02 AM via phone. Nurse #3 stated she should have looked at the order more closely and did not realize the muscle relaxing medication needed to be administered an hour after the narcotic pain medication. b. A review of the MAR for November 2021 revealed the muscle relaxing medication was scheduled to be given at 8:00 AM and 1:00 PM. The Medication Administration Audit Report (MAAR) for November revealed on 11/06/21 the muscle relaxing medication was ordered to be given at 8:00 AM and was administered late at 12:02 PM along with 1:00 PM dose by Nurse #2. On 11/12/21 the muscle relaxing medication was ordered to be given at 8:00 AM and was administered late along with the 1:00 PM dose at 1:21 PM by Nurse #2. On 11/14/21 the muscle relaxing medication was ordered to be given at 8:00 AM and was administered late along with the 1:00 PM dose at 12:18 PM by Nurse #3. An interview with Nurse #2 on 12/09/21 at 10:15 AM stated when the muscle relaxing medication due at 8:00 AM was given 4-5 hours late on 11/6 and 11/12 (given at 12:02 PM and 1:21 PM), she should not have administered the 1:00 PM dose of the muscle relaxer to Resident #42 with it. Nurse #2 stated she should have called the physician to let him know the medications were being administered late and see what orders he would give. An interview was conducted with Nurse #3 on 12/11/21 at 11:02 AM via phone. Nurse #3 confirmed she should not have administered the 1:00 PM dose of the muscle relaxer with the muscle relaxer that was due to be given at 8:00 AM on 11/14/21. Nurse #3 stated she double dosed the resident by giving both the 8:00 AM and 1:00 PM medication together. c. Review of the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of manufacturer ' s instructions for the administration of [MEDICATION(S)] include, in part, take medication before bed, and do not take the medication when your schedule does not permit you to get a full nights ' sleep (7-8 hours). Side effects include feeling drowsy and experiencing memory problems because the effects of the medication have not worn off. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Audit Report (MAAR) for the month of November and the first week of December (December 1 - 7) was reviewed. The report listed the name of the medication that was ordered by the physician, the time the medication was to be administered, the time the nurse removed the medication from the medication cart, the actual time the medication was administered, and the name of the nurse who administered the medication. The MAAR for the month of November revealed on 11/01/21 the sleep aide medication was ordered to be given at 11:00 PM and was administered at 2:57 AM on 11/02/21 by Nurse #1. On 11/02/21 the sleep aide medication was ordered to be given at 11:00 PM and was given at 4:11 AM on 11/03/21 by Nurse #1. On 11/13/21 the sleep aide medications was ordered to be given at 11:00 PM and was administered at 2:04 AM on 11/13/21 by Nurse #6. On 11/27/21 the sleep aide medication was ordered to be given at 11:00 PM and was administered at 4:06 AM on 11/28/21 by Nurse #6. The MAAR for the first week in December revealed on 12/02/21 the sleep aide medication was ordered to be given at 11:00 PM and was administered at 3:11 AM on 12/03/21 by Nurse #6. On 12/05/21 the sleep aide medication was ordered to be given at 11:00 PM and was administered at 4:00 AM on 12/06/21 by Nurse #1. An observation of Resident #42 on 12/06/21 at 10:50 AM revealed an alert and oriented resident lying in bed. Resident #42 was awake and participated in conversation. An interview with Resident #42 on 12/06/21 at 10:50 AM revealed the resident was sharing his likes and dislikes regarding his breakfast choices and stated that he was having pain to his shoulder and the nurse had medicated him. An interview with Nurse #1 on 12/09/21 at 8:30 AM was conducted. Nurse #1 reviewed the MAAR report and explained what each column meant. She stated the 1st column was the name of the medication to be given, the 2nd column on the report was the time the medication was ordered to be given, the 3rd column was when the nurse took the medication out of the medication cart, and the 4th column was when the nurse returned from the resident's room after administering the medication. Nurse #1 confirmed the medications were given late on each of the dates in November and December, and added, she thought there may have been some problems with the computer system shutting off in the middle of a medication pass so she would have had to sign them off as administered later on. An interview was conducted with Nurse #6 on 12/11/21 at 6:37 AM via phone. Nurse #6 stated if the time stamp stated that he gave the medication at 2:04 on 11/13/21 and 4:06 AM on 11/28/21 and at 3:11 AM on 12/02/21 then that was the time he administered the medication. Nurse #6 confirmed that each of those days the medication was late and he should have notified the physician before administering the medication. Nurse #6 could not recall any of the days or could not say why the medications were late. Nurse #6 stated he has never had the computer shut off in the middle of a medication pass. An interview was conducted with the Nurse Practioner (NP) on 12/13/21 at 11:51 AM. The NP stated he would have expected the nurses to follow the orders as written by the provider and would expect the nurses to notify him before administering medications that were late. The NP stated giving the ordered 8:00 AM dose with the 1:00 PM dose was double dosing and he would expect nurses not to administer the 8:00 AM late medication, but to call him for new orders. The NP stated he would have also expected the nurses to follow the physicians order with the sleep aide and administer it at 11:00 PM as ordered and not 3 or more hours later. The NP stated giving a sleep aide that late into the morning could cause the resident somnolence during the day. Example #3 Resident #63 was admitted to the facility 12/31/15 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Pharmacy Consultation Report for 10/15/21 indicated Resident #63 had an order to crush mediations and received medications that were not recommended to be crushed per manufacturer's guidance. The medications that were not be crushed included [MEDICATION(S)] (an extended-release pain medication) and [MEDICATION(S)] (an extended-release heart medication). Review of the annual Minimum Data Set assessment dated [DATE] indicated Resident #63 was cognitively intact. The care plan for Resident #63 dated 11/10/21 revealed he had a plan of care to remain free from complications related to altered cardiac status through next review. Interventions included, in part, to administer medications as directed by the physician and to monitor for chest pain. Review of Resident #63's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] *Crush medications * [MEDICATION(S)] tablet extended-release 24-hour 60 mg one tablet by mouth daily (heart medication) * [MEDICATION(S)] tablet extended release 15 mg ([MEDICATION(S)] [MEDICATION(S)] ER-pain medication) tablet by mouth twice a day. An interview and observation was conducted on 12/09/21 at 11:10 AM with Nurse #5. She stated the only medication she did not crush for Resident #63 was the [MEDICATION(S)] because it was extended release. Nurse #5 further stated she was unaware [MEDICATION(S)] was also extended release. She removed the [MEDICATION(S)] medication package from the medication cart and on the right side at the top of the blister pack was written DO NOT CRUSH. Nurse #5 stated Resident #63 could swallow his medications whole but he didn't like how they tasted. She stated the resident preferred the medications crushed with applesauce. A telephone interview was conducted on 12/09/21 at 12:00 PM with the Pharmacy Supervisor. She stated that [MEDICATION(S)] should definitely not be crushed because it was an extended-release medication. She further stated that crushing [MEDICATION(S)] would cause all the nitrates to be released in a short period of time and this could cause the heart rate to not be controlled correctly and the blood pressure could drop. An interview was conducted on 12/09/21 at 1:48 PM with the Nurse Practitioner (NP) #1. He stated [MEDICATION(S)] was an extended release heart medication and should not be crushed. He further stated that crushing [MEDICATION(S)] was concerning because it could slow the heart rate and cause [CONDITION(S)] (low blood pressure). NP#1 indicated that crushing [MEDICATION(S)] had the potential to cause serious harm to the resident. Interview with the Director of Nursing (DON) was conducted on 12/09/21 at 12:55 PM. He stated crushing [MEDICATION(S)] could cause serious adverse reactions. He further stated the nurses should look at the medication package prior to administering a medication. He indicated he expected the nurses not to crush medications that should not be crushed.

Based on record review and staff interviews the facility failed to provide effective oversight to ensure a system was in place to 1) complete and return non covered medication authorization forms to the pharmacy to prevent a delay in receiving medications (Resident #66). 2) act upon pharmacy recommendations contained in the monthly Consultant Pharmacist's Medication Regimen Reviews for 5 of 5 residents (Residents #35, #20, #61, #19, #63) whose medications were reviewed. The findings included: 1)This tag is cross-referenced to: F760 H: Based on record review, staff interviews, Pharmacy Supervisor, Nurse Practitioner, and Physician interviews the facility failed to complete and return a medication authorization form to the pharmacy regarding a medication order for [MEDICATION(S)] (prescribed for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] #66) reviewed for medication administration. An interview was conducted on 12/10/21 at 02:14 PM with the Director of Nursing (DON). He stated he wasn't sure why the authorization form was not followed through with, and stated no staff brought the non-covered medication authorization forms to him. He stated he had only worked at the facility for six months and indicated he was not certain of whose responsibility it was to fill out the authorization forms. He indicated he wasn't sure which fax the pharmacy used for correspondence with the facility but stated on 11/23/21 the pharmacy was given another fax number to use, and the authorization form was completed and returned to the pharmacy. A phone interview was conducted on 12/13/21 at 4:30 PM with the Corporate Nurse Consultant. He stated the DON should have followed through with completing the medication authorization form and sending the form back to the pharmacy so that the order could have been filled. 2)This tag is cross-referenced to: F756 E: Based on record review, staff, Consultant Pharmacist, and Physician interviews the facility failed to act upon the recommendations contained in the monthly Consultant Pharmacist's Medication Regimen Review (MRR) for 5 of 5 residents (Resident #35, #20, #61, #19, #63) whose medications were reviewed. An interview was conducted on 12/07/21 at 2:00 PM with the Administrator along with the Corporate Nurse Consultant. They each stated the monthly pharmacy MRR reports had not been acted on and not scanned into the medical records since the Director of Nursing (DON) started working in the facility in July 2021. The Corporate Nurse Consultant stated the DON was trained upon hire on the process regarding the MRR reports, which was to notify the providers of the MRR recommendations provided by the Consultant Pharmacist immediately once the reports were received in the facility so they could be addressed. The Administrator stated he had spoken to the DON regarding acting on MRR recommendations, but he did not provide a specific date as to when that was. An interview was conducted on 12/09/21 at 1:00 PM with the DON. He stated he was not aware that he was supposed to do anything with the monthly pharmacy MRR reports. He stated he started working at the facility in July 2021 and thought the unit manager was supposed to follow up with the pharmacy recommendations and forward them to the providers. He stated he wasn't aware until now that it was his responsibility. He reported no one had spoken to him regarding his responsibility to act on MRR reports.

Based on observation, record review, and resident and staff interviews the facility failed to provide a resident (Resident #63) with soft drinks from his personal supply when requested resulting in him crying and stating staff had made him feel like a child. This was for 1 of 36 residents reviewed for choices. Findings included: Resident #63 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual Minimum Data Set (MDS) indicated Resident #63's cognition was intact. The Care Plan for Resident #63 revealed a plan of care for Risk for Dehydration with information that included: Resident states he does not like water; requests not to have a water pitcher and requests soda only to drink. A nursing note dated 11/30/21 at 1:36 PM by Nurse #5 indicated Resident #63 was upset because he didn't have any soft drinks. It further revealed the Activities Assistant (AA) was notified Resident #63 was requesting more soda. A nursing note by Nurse #5 dated 12/4/21 at 10:38 AM reported Resident #63 couldn't stand water and wouldn't drink water. An observation and interview was conducted on 12/7/21 at 12:26 PM with Resident #63. He was observed to be talkative, dressed, and up in wheelchair. The Activities Assistant (AA) knocked on the door and entered the room. AA stated she had just given him a 12-pack of soft drinks on Sunday and it was only Tuesday. She further stated she was not going to give him his other 12-pack of soft drinks because he was drinking them too fast. Nurse #4 entered the room and told Resident #63 he needed to drink more water. She further stated he shouldn't be drinking so many soft drinks. Resident #63 stated he didn't like water and was not going to drink water. He revealed he had paid for the soft drinks and wanted them. Resident #63's face had turned red and he began to raise his voice. After AA and Nurse #4 left Resident #63's room he began to cry and stated they had made him feel like a child. AA was interviewed on 12/7/21 at 3:49 PM. AA stated she was the person in charge of shopping for personal items for the residents in the facility. She reported she bought Resident #63 two 12-packs of soft drinks per week with his money. AA acknowledged she could buy three 12-packs of soft drinks per week but didn't think he should drink that many. She stated she thought she had treated Resident #63 with dignity and respect. She further stated she had been unaware Resident #63 had cried after she left the room. An interview was conducted on 12/7/21 at 4:09 PM with Nurse #4. She admitted she had entered Resident #63's room to join the conversation AA was having with him about the soft drinks. She reported she was only trying to help Resident #63. She stated she had asked him to take a drink of water and then follow it with a drink of soda. She further stated she was just trying to get Resident #63 to drink more water. She indicated she was aware Resident #63 didn't like water and was not going to drink water. She stated she was unaware Resident #63 had cried when she had left the room. An interview was conducted with Activities Director (AD) on 12/8/21 at 10:51 AM. She reported that she had informed AA that the residents had the right to make their own choices. She stated she had told AA to give Resident #63 his soft drinks. She further stated that the Activities department would bring Resident #63 his soft drinks when he requested them. The Director of Nursing (DON) was interviewed on 12/9/21 at 12:55 PM. The DON stated the residents had a right make their own choices. He further stated it was Resident #63's right to drink what he wanted. He indicated the staff should have treated Resident #63 with dignity and respected his choices. An interview was conducted with the Regional Consultant Nurse on 12/8/21 at 02:54 PM. He stated the facility staff had been reeducated on Residents Rights and the right to make their own choices on 12/8/21. The Administrator was interviewed on 12/9/21 at 9:00 AM. He stated he had heard about what happened to Resident #63. He stated the staff had already been reeducated on Resident Rights and the right to make their own choices on 12/8/21. He further stated that the staff involved had been informed that they needed to respect the residents' rights to make their own choices.

Based on facility staff, Nurse Practitioner, Home Health staff, and surgeon interviews and facility, surgeon, and hospital record reviews, the facility failed to use two staff members as required to safely transfer a resident resulting in an assisted fall. The resident incurred an injury to the incision site of a recent amputation that required further surgical intervention. This occurred for one of three sample residents reviewed for accidents (Resident #189). Immediate Jeopardy began on 5/1/18 when Nursing Assistant (NA) #1 attempted to transfer Resident #189 from her wheelchair to the bed using a slide board and assist of one. The resident sustained [REDACTED]. Resident #189 was evaluated by her surgeon three days after the fall. Due to extensive tissue damage, the surgeon determined the probability of salvaging her BKA was low at that time. The resident underwent [REDACTED]. Immediate Jeopardy was removed as of 5/23/18 when the facility implemented an acceptable allegation of Immediate Jeopardy removal. The facility remains out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) for the facility to continue staff education and ensure monitoring systems put into place are effective. The findings included: Resident #189 was admitted to the facility on [DATE] from a hospital with a cumulative [DIAGNOSES REDACTED]. A review of Resident #189 ' s Physical Therapy (PT) Evaluation and Plan of Treatment dated 4/5/18 was completed. The resident was evaluated as requiring maximum assistance of two persons for transfers out of bed using a slide board. Resident #189 ' s admission Minimum Data Set ((MDS) dated [DATE] indicated the resident had intact cognitive skills for daily decision making. Section G of the MDS assessment revealed the resident required extensive assistance of two + (plus) persons for bed mobility, transfers, locomotion on/off the unit, and toileting. The MDS also addressed Resident #189 ' s balance during transitions. It indicated she was not steady and only able to stabilize with staff assistance for surface-to-surface transfers (transfer between bed and chair or wheelchair). A review of the resident ' s Care Area Assessment (CAA) Worksheets for ADL/Functional/Rehabilitation Potential and Falls (dated 4/12/18) included an analysis of findings. These findings read, in part: .She is extensive assist of two with most adls (ADLs), set up for eating. She is presently on therapy services . Resident #189 ' s Care Plan (last revised 4/18/18) included the following areas of focus, in part: --Resident is at risk for falls. The planned interventions did not specifically address transfers of the resident from one surface to another. --Resident has self-care deficit. The interventions did not specifically address transfers of the resident from one surface to another. A review of Resident #189 ' s undated Kardex (a printed summary of individual patient needs) included a section on ADL Self Performance and Support. This section indicated the resident required extensive assistance with two + persons physical assist. It also reported the resident was not steady during transitions/walking when moving from seated to standing; moving on and off the toilet; and for surface-to-surface transfers. A review of Resident #189 ' s medical record from her surgeon ' s office indicated the resident was seen for a follow-up visit with the surgeon on 4/17/18. The surgeon ' s progress note reported the patient had some open wounds on the medial (inside portion of the knee) and lateral side (outside portion) of the right BKA that had Xeroform in place. Xeroform is a fine mesh gauze used as an occlusive wound dressing that prevents air from reaching the wound. The surgeon ' s note also reported the incision ' s staples were in place and approximated (meaning the wound edges were close together, closed, and in relative alignment) with no drainage noted. A review of the facility ' s medical record for Resident #189 included a Nursing Note dated 5/1/18 at 9:02 AM. The Nursing note was written as a weekly wound care note by the facility ' s Wound Care Nurse. The nurse reported the resident ' s right BKA surgical site continued to have staples in place and noted the lateral sides of the incision were starting to heal. Review of an Incident/Accident report written by Nurse #1 and dated 5/1/18 at 6:33 PM revealed Resident #189 had a witnessed fall. A description of the fall reported the resident ' s nursing assistant (NA #1) informed the nurse that Resident #189 slid off of the sliding board during a transfer. When the nurse entered the room, the resident was in a sitting position parallel to the bed with her legs extended. The resident was reported to be, moaning in pain and holding amputated site. The nurse assessed the resident and assisted the NA with transferring her onto the bed with a total mechanical lift. The nurse reported reassessing the surgical site further and found the staples were intact with no bleeding or open areas (bruising was not specifically addressed in the report). The nurse redressed the surgical site and gave Resident #189 her prescribed pain medication. Further review of the resident ' s medical record included a Nursing Note written by Nurse #1 and dated 5/1/18 at 6:33 PM. The Nursing Note further described the incident by reporting an NA lowered the resident to the floor when the resident failed to transfer from w/c (wheelchair) to bed correctly. The resident was described as tearful and moaning. The resident ' s perceived level of pain was a 10 (based on a scale ranging from 0 to 10, with 10 being the highest level of pain). A Nursing Note written by Nurse #1 (dated 5/2/18 at 10:33 AM) indicated a Head to Toe Evaluation was completed as follow up to Resident #189 ' s fall. The resident was reported to have a surgical incision that was intact and well approximated. The dressings were dry and intact. No injury or pain was reported from the fall and the staples were reported as intact. The Nursing Note indicated the resident required two + persons physical assist with transfers. The resident was described as alert and oriented x 3. Bruising was not specifically addressed in the Nursing Note. The Nursing Note did not indicate the resident ' s dressing was removed or that the incision assessed on 5/2/18. Resident #189 was discharged from the facility as planned on the morning of 5/2/18. A review of the facility ' s Grievance and Complaint Log revealed a concern was reported on 5/3/18 by Resident #189 ' s family in regards to her 5/1/18 fall. The concern reported the resident ' s amputation site was discolored black. Follow-up was conducted by the facility and noted no bruising was reported after the incident. Safe handling re-education was completed with the employee (NA #1) prior to her returning to work. The family member was notified of the concern resolution on 5/7/18, but documentation on the report indicated the family member was not satisfied with the facility ' s resolution. Further review of Resident #189 ' s medical record from the surgeon ' s office was conducted. These records indicated the resident was seen for another follow-up visit with the surgeon on 5/4/18. The surgeon ' s progress note included an impression which read: Hx (history) of right BKA. She had been well but recently fell on the wound with significant compromise. The patient ' s plan read as follows: I am concerned about the ability to salvage the BKA. Plan on surgical debridement (the removal of damaged tissue from a wound) and possible conversion to AKA (above knee amputation). Resident #189 was admitted to the hospital on [DATE]. A review of the resident ' s hospital records revealed she underwent surgery on 5/9/18 for an above knee amputation. An interview was conducted on 5/21/18 at 4:10 PM with the Physical Therapist (PT) #1 who completed Resident #189 ' s initial PT evaluation and discharge summary. PT #1 reported she was the primary PT who worked with this resident and her family to prepare for her upcoming discharge home. When asked how the resident was supposed to be transferred while she resided in the facility, the PT stated she had verbally communicated with the nursing staff the resident should be transferred with the assistance of two staff members. Upon inquiry, the PT stated she did not recall recommending the transfers be done with only one staff member. The PT stated, It should have been two. An interview was conducted on 5/22/18 at 12:23 PM with the Physical Therapy Assistant (PTA) who had frequently worked with Resident #189. The PTA was accompanied by PT #1. During the interview, the PTA was asked how the resident was transferred during her stay at the facility. The PTA stated, We used a sliding board with her .when I went in it was usually myself and OT. Sometimes she didn ' t require both of us, but I liked to have them in there. When asked if the assistance provided by therapy staff in transferring a resident was sometimes different from how nursing staff was instructed to safely transfer that same resident, PT #1 stated, Yes. An interview was conducted on 5/23/18 at 2:20 PM with the facility ' s Wound Care Nurse. During the interview, the Wound Care Nurse reported wound care was provided once daily for Resident #189 ' s BKA surgical incision. She reported that from the time the resident was admitted to the facility and up until the last day she saw the incision on 5/1/18 (prior to her fall), the wound was healing. She reported there was no swelling or bruising noted. The wound care nurse reported she did not see the incision site after Resident #189 ' s fall because the resident was discharged on [DATE] before she got to her hall to do the treatments that day. Interviews were conducted on 5/21/18 at 3:03 PM and 6/6/18 at 2:30 PM with NA #1. NA #1 was the nursing assistant who attempted to transfer Resident #189 on 5/1/18 at the time the resident fell . The NA reported on the evening of 5/1/18, Resident #189 had eaten her evening meal on a tray while she was sitting in her wheelchair. The resident asked the NA to put her to bed. The NA stated she would, but she needed to finish passing the hall meal trays first. When the NA came back to transfer Resident #189 from the wheelchair to the bed, she reported the resident was already upset. The NA was not sure why she was upset because the resident did not say. In describing the transfer, the NA stated she had a sliding board under the resident and was trying to assist her with the transfer from the wheelchair to her bed. NA #1 reported, She did not hold onto the board to help scoot her. The NA stated the resident was supposed to have her hand flat on the sliding board, but she didn ' t do that. The NA showed the resident where to put her hand but she didn ' t. NA #1 stated Resident #189 became hysterical and fell forward. The NA stated she had a hold of the resident ' s gait belt but could not hold her because of the weight. The NA reported she had to think fast so she released the break on the wheelchair and moved it over. The resident was still on the sliding board so the NA pulled the sliding board from the wheelchair and used it to slide the resident onto the floor. She stated the resident landed on her bottom (no longer on the board) and was sitting up with her back to the bed and her legs perpendicular to the bed when she landed on the floor. NA#1 reported, She basically was eased to the floor. The NA stated she hollered for the hall nurse (Nurse #1). After the nurse came, they got her into the bed and checked her vital signs. The nurse removed the dressing from her stump while the NA was in the room. The NA stated she saw there was no bleeding. During the interview, the NA was asked if there was any impact on the resident ' s stump during the fall. The NA replied, It didn ' t hit. When asked what Resident #189 said after the fall, the NA reported the resident asked Nurse #1 to check her stump. NA #1 stated she thought the resident said her stump hurt, but also reported it was not unusual for her to say her stump hurt. During the interview conducted on 5/21/18 at 3:03 PM with NA #1, the NA was asked how many people were required to transfer the resident safely. She responded by stating, At the end, just one. NA #1 was asked how she would have been notified if it was be safe to transfer a resident with one person assistance versus two person assist. The NA stated that most of the time, therapy staff would come and show the NAs how to transfer a resident or tell them if a resident ' s transfer status had changed. NA #1 stated, I think one day I just happened to be there when she (an unidentified therapy staff member) was assisting the resident to the bed with only the assistance of one. During the follow-up interview conducted on 6/6/18 at 2:30 PM, the NA reiterated that she had been in the room when she observed a therapy person (unidentified) transfer the resident by herself, so thought she could do so as well. The NA reported that at no time was she told Resident #189 could be transferred with the assistance of only one person (versus two). A telephone interview was conducted on 5/21/18 at 5:45 PM with Nurse #1. Nurse #1 was identified as the hall nurse who was working at the time Resident #189 had a fall on 5/1/18. Upon inquiry, the nurse recalled the incident but stated she could not provide details about the incident because she was not in the room at the time of the fall. During a follow-up interview conducted on 6/6/18 at 11:03 AM, Nurse #1 stated the resident ' s nursing assistant (NA #1) came and got her after the fall. She reported when NA #1 came and got her, the NA told her in the hallway on the way to the room that she had lowered the resident to the floor. I don ' t know what happened or why she wasn ' t transferred successfully. When the nurse got to the room, the resident was sitting on her bottom with her legs extended and parallel to the bed. When asked what the resident said, the nurse reported, Not much of anything. She said she was hurting and she was upset. I assessed her stump bandage on the floor and it was clean. There were no other bumps or cuts on body. The nurse reported she had the NA get the lift and the two of them put her on the bed. Once on the bed, the nurse took the bandage off of the resident ' s stump. Nurse #1 reported that she, looked at it real good, staples were in place and there were no open areas or bleeding. I cannot say if it was hit or not because I wasn ' t there. The nurse reported Resident #189 said, My leg hurt. The nurse stated she redressed the incision and gave the resident a pain pill. When asked how the resident landed on the floor, the nurse reported she did not know. She stated the resident told her she slid off of the board. When asked if the resident reported striking her stump, the nurse stated she did not recall. However, Nurse #1 reported the resident was holding her stump and other leg saying, It hurts. When asked if the nurse considered this an assisted fall, she reported the NA had told her, She didn ' t fall, I lowered her. During the interview conducted on 6/6/18 11:03 AM with Nurse #1, Resident #189 ' s Incident Report dated 5/1/18 and completed by Nurse #1 was discussed. The Incident Report described this incident as a witnessed fall. When asked why the incident was not described as an assisted fall, the nurse reported the only options to describe the fall on this electronic report were either as witnessed or unwitnessed. Nurse #1 was then asked what she meant in her Nursing Note dated 5/1/18 at 6:33 PM when she wrote, resident failed to transfer from w/c (wheelchair) to bed correctly. The nurse stated, It would have been better if there was two (persons for the transfer). Another follow-up interview was conducted on 5/23/18 at 2:25 PM with Nurse #1. When asked, the nurse confirmed she worked with Resident #189 on the morning of 5/2/18 when she was discharged . Nurse #1 stated she did not do a dressing change for the resident that morning, so she did not look at the incision site prior to her discharge. An interview was conducted on 5/22/18 at 9:53 AM with the facility ' s Nurse Practitioner (NP). Upon inquiry, the NP confirmed she saw Resident #189 the morning of 5/2/18 prior to her discharge. The NP stated the resident told her she had a fall the night before. When asked if she removed the resident ' s wound dressing to look at the incision that morning, the NP stated, No. An interview was conducted on 6/7/18 at 9:38 AM with the Home Care Nurse who worked with Resident #189 upon her discharge from the facility. Upon review of the resident ' s records, the nurse confirmed she went to see Resident #189 for an initial home care visit on 5/3/18. The nurse reported when she arrived at the home, the resident was up in her wheelchair with her stump elevated on the leg rest. The nurse reported a family member was observed as he appropriately transferred the resident to a hospital bed so she could be assessed. The nurse recalled Resident #189 was in a lot of discomfort. After the dressing was removed from the resident ' s stump, the nurse noted the distal aspect of the stump had bruising with eschar (dead tissue that falls off or sheds from healthy skin) along the incision line and lateral aspect. She reported the resident and her family were very concerned because the stump looked quite different from the last time they had seen it. At that time, Resident #189 told the nurse she had fallen directly on her stump the night before she was discharged home from the facility. The nurse reported she contacted both the surgeon ' s office and the resident ' s primary care physician about the changes seen in her stump. The Home Care Nurse reported another nurse visited the resident on 5/5/18. On 5/8/18, she herself went back out to see Resident #189. When asked how her stump looked on 5/8/18, the nurse reported, It looked darker with eschar more apparent. She reported the resident was scheduled for debridement on 5/9/18 with the possibility of undergoing an above knee amputation. A telephone interview was conducted on 5/25/18 at 10:20 AM with Resident #189 ' s surgeon. During the interview, the surgeon was asked how the BKA incision looked on 4/17/18 when the resident was seen for a follow-up visit. The surgeon stated, It looked wonderful .I was surprised and had a lot of concerns about it, but it actually looked very good. He reported the wound edges were clean and healthy at the 4/17/18 follow-up visit. When asked how the incision site had changed when the resident was seen on 5/4/18, the surgeon reported she had a disruption of skin and subcutaneous tissue and necrosis on the lateral aspect of the BKA. He stated there was obvious extensive tissue damage noted at that time and he told the resident the probability of salvaging the BKA was low. The surgeon reported he needed to operate and make the decision from there. The operation took place on 5/9/18 and Resident #189 underwent an AKA. The surgeon was asked for his medical opinion on whether the changes seen in the resident ' s incision site on 5/4/18 were directly caused by an injury or another possible complication unrelated to the reported fall. He responded, I suspect more of a traumatic injury .there was significant ecchymosis and bruising along the stump site. He reported if this would have been solely a vascular issue, he thought concerns would likely have been seen earlier on. The surgeon was also asked if the incision site observed on 5/4/18 was consistent with an injury which would have been incurred 2-3 days prior to the follow-up visit. The surgeon stated, Yes, but it seems more extensive then I would have expected, but there is the combination of the injury with her existing vascular issues. An interview was conducted with the facility ' s Director of Nursing (DON) on 5/22/18 at 12:11 PM. During the interview, the DON was asked how staff were informed as to the number of persons required to safely transfer a resident. The DON reported this information was typically found on the resident ' s care plan and in the electronic Kardex. During an interview conducted on 5/23/18 at 8:30 AM with the DON, the DON confirmed Nurse #1 ' s immediate assessment after Resident #189 ' s fall on 5/1/18 was the last time the resident ' s surgical incision was assessed prior to her discharge on 5/2/18. A follow-up interview was conducted on 5/23/18 at 2:55 PM with the DON. At that time, the DON was asked what her expectation was in regards to Resident #189 ' s transfer and fall on 5/1/18. The DON stated, I would expect that she (the NA) would transfer with two people. Another follow-up interview was conducted on 6/6/18 at 3:35 PM with the DON. During this interview, the DON reported she looked at falls each day and when she saw a pattern emerge, she did conduct in-service education in mid-May which included resident transfers. However, the missing piece not included in the education was where information could be found on the assistive devices needed and the number of persons required for the safe transfer of a resident. The facility ' s Administrator was notified of Immediate Jeopardy on 6/6/18 at 5:10 PM. On 6/7/18 at 11:00 AM, the facility provided the following credible allegation of Immediate Jeopardy removal. The process that lead to the deficiency This deficiency occurred because a nursing assistant transferred the resident by herself using a slide board instead of having 2 people present when using a slide board for transfers on 5/1/2018 around 6:30pm. This resulted in an assisted fall/ lower to the floor for this resident. Resident was identified on the MDS as requiring 2 people to assist with transfers. The resident affected was discharged to home as pre planned on 5/2/18 around 9:30am. The plan for correcting the specific deficiency The Director of Nursing corrected this issue with immediate education related to proper use of a sliding board, including a return demonstration of how to use. (This included using 2 people when using a slide board). This education was provided to the staff member on 5/2/18, before she was allowed to return to work. Additional education to this employee was provided that included the use of a Hoyer lift, stand to sit lift, stand to pivot, and using 2 staff members to transfer if required and Review of Resident Safe handling Video. Audits and education were completed by the facility to ensure resident care guides reflected accurate resident transfer status. Nursing staff educated to use care guide for transfer status on 5/22/18 by the Staff Development Nurse. Additional education to the nursing staff was provided on 5/16/2018 by the Director of Nursing: The education was titled, Lift Program, and included education on the proper use of a sliding board, use of a hoyer lift, stand to sit lift, stand to pivot, and using 2 staff members to transfer if required and Review of Resident Safe handling Video. The procedure for implementing the acceptable plan of correction for the specific deficiency cited: The nursing department completed an audit for all residents on 5/22/2018 using the Resident mobility/transfer profile to determine and ensure that the transfer status of each resident was correctly assessed and properly identified on the resident care guide. A 100% audit of Resident Care Guides for accurate transfer status was completed by the Director of Nursing on 5-22-18. (The resident care guide is an internal document that provides information about the resident such as transfer status for the caregivers to use). The nursing staff were educated by the Director of Staff development on the resident care guide which included resident transfer status on 5/23/18. The nursing staff were educated on this because prior education provided on 5-16-18 didn ' t cover where to locate resident transfer status. New employees will receive education upon hire on: Resident Care Guide, which includes Resident Care Guide content such as resident transfer status and delivering care. New employees will be educated on the Lift Program including education on the proper use of a sliding board, use of a hoyer lift, stand to sit lift, stand to pivot, and using 2 staff members to transfer if required and Review of Resident Safe handling Video. The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements; The facility will interview 3 nursing staff weekly x4, then monthly x2 to ensure staff are aware of how to locate resident transfer status and delivering care such as transfers using the Resident Care Guide. Immediate education will be provided as needed. The facility will observe 3 transfers (requiring 2 person assist, i.e. slide board) weekly x4, then monthly x2 to ensure residents are being transferred per the resident care guide. Immediate education will be provided as needed. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations. The facility held an Ad hoc QAPI meeting on 5/22/18 to address the deficient practice and put a plan of correction in place. Title of person responsible for implementing the acceptable Plan of Correction Implementation of the plan will be overseen by the Administrator of the facility with assistance from the Director of Nursing. Completion Date: 5/23/18 The credible allegation was verified on 6/7/18 at 4:50 PM as evidenced by licensed and non-licensed staff interviews on where to locate information regarding the assistive devices needed and the number of persons required for the safe transfer of a resident. Review of on-going in-service records revealed licensed and unlicensed staff were in-serviced prior to working on the floor. Based on the staff interviews and a review of the facility ' s in-service records, the facility ' s credible allegation of compliance was verified as having been implemented as of 5/23/18 (the date of the initial survey exit).