Every finding on record at Blumenthal Health and Rehabilitation Center

Based on record review and resident, staff, and Nurse Practitioner interviews, the facility failed to ensure physician orders for daily weights were implemented as prescribed for 3 of 3 residents reviewed with orders for daily weights (Residents #9, #11, and #12).Findings included:1. Record review revealed Resident #12 was originally admitted to the facility on [DATE], with diagnoses of Type 2 diabetes mellitus and congestive heart failure. A discharge Minimum Data Set assessment dated [DATE], documented Resident #12 as cognitively intact. Resident #12 was readmitted to the facility on [DATE]. Record review revealed Resident #12 had a physician's order initiated on 3/28/2026, directing staff to obtain a daily weight at 7:00 AM and to report to the physician if the resident experienced more than a two-pound weight increase for monitoring congestive heart failure. Resident #12 had an additional physician's order initiated 3/28/2026 for 20 milligrams of furosemide (diuretic) to be administered as two tablets by mouth one time a day for fluid retention. A care plan focus area initiated on 3/30/2026, identified Resident #12 as being at risk for nutritional decline related to congestive heart failure and diabetes mellitus, with an intervention directing staff to obtain weights as ordered. During an interview conducted on 5/6/2026 at 12:05 PM, Resident #12 stated he had a history of congestive heart failure since 2020 and denied current shortness of breath. Resident #12 reported it had been approximately one month since his weight had last been taken at the facility and that he had only been weighed monthly since admission. Review of the March, April, and May 2026 electronic Medication Administration Records revealed no documentation that daily weights were obtained for Resident #12. Additional record review showed that Resident #12 had a recorded weight of 191.6 pounds on 3/28/2026. The next documented weight was 217.9 pounds on 4/2/2026. There was no further documentation of any weights obtained after 4/2/2026 for Resident #12. An interview with the previous interim Director of Nursing on 5/6/2026 at 3:33 PM, revealed that when the physician's order for daily weights for Resident #12 was entered into the electronic record, a required selection box was not activated, resulting in the order not populating onto the electronic Medication Administration Record (MAR). The interim Director of Nursing confirmed the nurse who entered the verbal order into the electronic medical record should have selected the box to have the order populate into the electronic MAR. The interim Director of Nursing stated that if the order had appeared on the MAR, nursing staff would have known to complete the daily weights on Resident #12. During an interview on 5/6/2026, at 12:26 PM, Nurse Practitioner (NP) #1 stated it was clinically indicated for Resident #12 to have daily weights obtained due to congestive heart failure. NP #1 acknowledged it was a problem that the daily weights were not completed and that the physician's order was not followed, as the absence of weight data made it impossible to determine whether the resident experienced fluid-related weight gain. 2. Resident #11 was originally admitted to the facility on [DATE] with a diagnosis of congestive heart failure. A care plan focus area revised on 12/11/2025, identified Resident #11 as having an increased nutritional and hydration risk related to congestive heart failure and diuretic use, which could promote significant weight fluctuations. The care plan included an intervention directing staff to monitor weights as ordered. An annual Minimum Data Set assessment dated [DATE], coded Resident #11 as cognitively intact and able to independently stand from a seated position and transfer to and from a chair or the side of the bed. Resident #11 had a physician's order dated 4/14/2026 for 20 milligrams of torsemide (diuretic) to be administered as one tablet by mouth every 24 hours as needed for a weight gain of 3 to 5 pounds for congestive heart failure. Resident #11 had an additional physician's order dated 4/14/2026 for 60 milligrams of torsemide to be administered as three 20 milligrams tablets by mouth two times a day for fluid retention. Resident #11 had a physician's order dated 4/16/2026 that directed staff to obtain a daily weight at 6:00 AM and to notify the physician of a three-pound weight gain in a 24-hour period as an indicator of fluid retention. During an interview on 5/6/2026 at 8:25 AM, Resident #11 reported that the facility's floor weight scale had been broken for approximately a month. Resident #11 stated she had an active physician's order for daily weights due to congestive heart failure and fluid retention. Resident #11 denied shortness of breath but reported feeling as though she was retaining fluid. Resident #11 stated she had been offered the option of being weighed using a mechanical lift but declined because the lift caused shoulder pain due to an injury she sustained. Resident #11 reported she was able to stand on a floor scale but had been told her weight could not be obtained until the scale was repaired. Review of the April 2026 Medication Administration Record (MAR) for Resident #11 revealed multiple dates on which daily weights were not obtained, including April 16, 17, 18, 19, 20, 23, 24, 25, 26, 27, 28, and 30, with entries marked as blank, not applicable, or coded as 9 - other/see progress notes. Corresponding medication administration progress notes documented repeated statements that the scale was broken or unavailable, including entries on April 18 ( unable to weigh. Scale is waiting to be fixed), April 19 ( weigh scale waiting to be fixed), April 24 ( resident refused to be weighed by mechanical lift), April 25 ( unable to assess weight due to inoperable scale), April 26 ( scale unavailable), April 27 ( unable to obtain scale unavailable), and April 30 ( unable to obtain weight scale inoperable). No explanatory comment was documented for April 28.Review of the May 2026 MAR for Resident #11 showed additional missed weights on May 1, 2, 3, 4, and 6, with medication administration progress notes stating on May 1 that the scale [was] broken and on May 6 that the scale [was] broken [and the resident] did not want a lift weight due to shoulder pain.During an interview on 5/6/2026, at 11:19 AM, Unit Supervisor #2 reported the floor scale had been broken for several weeks, though she was unsure of the exact duration. She stated the mechanical lift scale was operational, but Resident #11 declined its use. Unit Supervisor #2 confirmed that the Medical Director and Nurse Practitioner (NP) #1 were aware that the scale was non-operational and that daily weights for Resident #11 were not being recorded. She also confirmed the physician's order for daily weights had not been placed on hold despite the inability to obtain weights.During an interview on 5/6/2026 at 3:33 PM, the previous interim Director of Nursing (DON) stated she had been informed during a risk-management meeting the prior week that the scale had been broken for approximately one month. She stated the physician's order for daily weights should have been placed on hold for residents unwilling to be weighed on the mechanical lift scale while the floor scale was being repaired. In an interview on 5/6/2026, at 12:26 PM, Nurse Practitioner (NP) #1 confirmed he had been made aware that daily weights were not being completed for residents with physician orders requiring them due to the floor scale being non-operational. He stated it was a significant problem that daily weights were not obtained for Resident #11, as they were clinically indicated for monitoring congestive heart failure. Although the resident was not experiencing shortness of breath, NP #1 stated the failure to follow physician orders created a potentially unknown problem regarding whether the resident was experiencing fluid related weight gain. 3. Resident #9 was admitted to the facility on [DATE] with a diagnosis of congestive heart failure. A care plan focus area initiated on 7/5/2024 identified Resident #9 as being at risk for complications secondary to diuretic use related to congestive heart failure, with an intervention directing staff to monitor for weight loss and weight gain. Resident #9 had a physician order initiated 11/27/2025, which directed staff to obtain a daily weight on every day shift. A quarterly Minimum Data Set assessment dated [DATE], coded Resident #9 as cognitively intact and able to independently stand from a seated position and transfer to and from a chair or the side of the bed.During an interview on 5/6/2026, at 12:15 AM, Resident #9 stated he had congestive heart failure and shortness of breath and therefore had a physician's order for daily weights. The resident reported the scale had been broken and believed he had been weighed four or five days prior, though he was unsure of the exact date.Review of Resident #9's April 2026 Medication Administration Record (MAR) revealed multiple dates on which daily weights were not obtained, including April 18, 19, 21, 22, 23, 25, 28, and 30, with entries coded as 9 - other/see progress notes. The medication administration progress notes documented repeated statements that the scale was broken or not working, including entries on April 21 ( scales for repair all parties), April 22 ( scale not working), April 23 ( scale broken), April 28 ( scale not working), and April 30 ( scale broke). No explanatory comment was documented for April 25.Review of Resident #9's May 2026 MAR revealed additional missed weights on May 1 and May 3, with administration progress notes stating on both dates that the scale [was] not working.During an interview on 5/6/2026 at 11:19 AM, Unit Supervisor #2 reported the floor scale had been broken for several weeks, though she did not know the exact duration. Unit Supervisor #2 reported that the mechanical lift scale was operational, and Resident #9 was willing to be weighed on that scale sometimes. Unit Supervisor #2 stated that, in addition, there was a resident who had a personal scale in her room that was used to weigh other residents, and this might be how weights in the electronic record were obtained for Resident #9, after the floor scale became non-operational. Unit Supervisor #2 stated that the Medical Director and Nurse Practitioner (NP) #1 were aware that the floor scale was non-operational and that daily weights for Resident #9 had not been consistently completed. Unit Supervisor #2 confirmed that the order for daily weights for Resident #9 was not put on hold when the weight scale was identified as broken. During an interview on 5/6/2026, at 3:33 PM, the previous interim Director of Nursing (DON) stated she had been informed during a risk management meeting the prior week that the scale had been broken for approximately one month. The interim DON stated the physician's order for daily weights should have been placed on hold while the scale was being repaired, or that the mechanical lift scale should have been offered as an alternative.In an interview on 5/6/2026, at 12:26 PM, Nurse Practitioner (NP) #1 confirmed he had been made aware that daily weights were not being completed for residents with physician orders requiring them. He stated it was a significant problem that daily weights were not obtained for Resident #9, as they were clinically indicated for monitoring congestive heart failure. Although the resident was not experiencing shortness of breath, NP #1 stated that the failure to follow physician orders created an issue in determining whether the resident was experiencing fluid related weight gain.

Based on record review, and interviews with staff, Interim Director of Nursing, Former Director of Nursing, Assistant Director of Nursing, Medical Director, Nurse Practitioner, Regional Director of Clinical Services, Director of Pharmacy Operations, Pharmacist, and Infectious Disease Physician, the facility failed to provide services to ensure the acquiring, dispensing, and administration of a medication for 3 of 7 sampled residents whose medications were reviewed (Resident #3, Resident #13, Resident #24). The facility failed to ensure uninterrupted access to prescribed antiretroviral medication for Resident #24. The facility failed to have a medication used to treat diabetes available for administration to Resident #3. The facility failed to have a nasal spray available on the correct medication cart for Resident #13.Findings included: 1. Documentation on a hospital Discharge summary dated [DATE] revealed Resident #24 had a prescription for Biktarvy filled by a local retail pharmacy before discharge and was to closely follow up with the infectious disease clinic. Biktarvy is an antiretroviral medication used to treat human immunodeficiency virus (HIV). The same discharge summary also documented Resident #24 had a follow-up appointment scheduled for the infectious disease clinic on 11/12/2025. Resident #24 was admitted to the facility on [DATE] with multiple diagnoses, including a mental health disorder and human immunodeficiency virus infection (HIV). Resident #24 had a physician's order initiated on 10/10/2025 for 50-200-25 milligrams of Biktarvy (Bictegravir-Emtricitabine-Tenofovir) oral tablets to be administered as one tablet by mouth one time a day for HIV. On 11/26/2025 at 11:57 AM, the Transportation Coordinator reported during an interview that she had been unable to contact Resident #24's Guardian prior to the scheduled infectious disease clinic appointment on 11/12/2025. The Transportation Coordinator further explained that she cancelled the appointment on 11/12/2025 and rescheduled it for 11/24/2025. Documentation on the November Medication Administration Record (MAR) for Resident #24 revealed that Biktarvy was not administered on 11/13/2025 by Nurse #8, with a chart code that referenced the progress notes. Documentation in a Medication Administration note dated 11/13/2025 at 1:23 PM written by Nurse #8 indicated the ordered dose of Biktarvy was not administered to Resident #24 and the Medical Doctor and Responsible Party were aware. Documentation on the November MAR for Resident #24 revealed that Biktarvy was not administered on 11/14/2025 by Nurse #8, with a chart code that referenced the progress notes. Documentation in a Medication Administration note dated 11/14/2025 at 10:49 AM, written by Nurse #8, explained that Resident #24 did not have the medication Biktarvy stocked on the medication cart. The Medical Doctor, Unit Manager, and Assistant Director of Nursing (ADON) were aware of the situation. Nurse #8 communicated information regarding the last prescriber, awaited further instruction, and documented that both the Responsible Party and emergency contact had been notified. Nurse #8 was interviewed on 11/26/2025 at 12:40 PM. During the interview, Nurse #8 reported that Resident #24's supply of Biktarvy was depleted on 11/13/2025. Nurse #8 stated she contacted the facility's pharmacy; however, the pharmacy was unable to provide a refill. The pharmacy informed Nurse #8 that Resident #24 would require a new prescription from the original prescribing physician. Nurse #8 reported she provided the Medical Director with the prescriber's name and contact information obtained from the empty Biktarvy medication container. Nurse #8 stated she assumed the Medical Director would contact the prescriber to obtain a new prescription for Resident #24. Nurse #8 further stated she notified the Director of Nursing (DON), ADON, the Administrator, and the Transportation Coordinator that Resident #24 needed to secure another prescription from the Infectious Disease clinic, where the original prescription for Biktarvy was obtained. Documentation on the November MAR for Resident #24 revealed that Biktarvy was not administered on 11/16/2025 by Nurse #3, as indicated by a chart code that referenced the progress notes. Documentation in a Medication Administration note dated 11/16/2025 at 9:28 AM, written by Nurse #3, indicated the ordered dose of Biktarvy was not administered to Resident #24, and the Medical Doctor and Responsible Party were aware. Nurse #3 did not respond to a request for an interview. Documentation on the November MAR for Resident #24 revealed that Biktarvy was not administered on 11/17/2025, 11/18/2025, and 11/19/2025 by Nurse #8, as indicated by a chart code that referenced the progress notes. Documentation in a Medication Administration note dated 11/17/2025 at 10:09 AM written by Nurse #8 indicated Resident #24 was awaiting an appointment with the infectious disease clinic for a refill of Biktarvy. Documentation in the Medication Administration notes dated 11/18/2025 at 8:14 AM and 11/19/2025 at 11:03 AM written by Nurse #8 indicated Resident #24 did not have Biktarvy on the medication cart. The Medical Director, who was also the physician for Resident #24, was interviewed on 11/25/2025 at 7:11 PM. The Medical Director stated he was not involved with resolving the issue of Resident #24 running out of Biktarvy. Documentation in a communication progress note dated 11/18/2025 at 9:36 AM written by the Assistant Director of Nursing (ADON) revealed the following information. It was discussed with Resident #24's Guardian that his HIV medication needed to be obtained from the facility pharmacy and NP #1 was made aware Resident #24 was missing doses of Biktarvy. On 11/25/2025 at 6:24 PM, the ADON was interviewed and reported that Biktarvy had initially been obtained for Resident #24 through the hospital retail pharmacy. The ADON explained that the facility was unable to secure subsequent refills through the same pharmacy because the infectious disease clinic required Resident #24 to be seen to issue a new prescription. The ADON confirmed Resident #24 did not have Biktarvy available from 11/13/2025 until 11/22/2025. On 11/26/2025 at 12:13 PM, NP #1 was interviewed and stated that he was not actively working to obtain Biktarvy for Resident #24 and was unaware of the lapse in administration until the ADON approached him. The ADON informed NP #1 that insurance would not cover the medication through the facility pharmacy. NP #1 emphasized that Biktarvy was essential, had no therapeutic alternatives, and should not be withheld. NP #1 believed a referral was made to the infectious disease clinic, later cancelled, and rescheduled, attributing the delays to transportation issues. NP #1 indicated the matter was ultimately resolved. On 12/1/2025 at 1:35 PM, the facility Pharmacist was interviewed and reported that Resident #24's initial prescription for Biktarvy had been filled at the hospital retail pharmacy upon admission on [DATE]. A refill request was denied by the infectious disease clinic provider because the resident had not been seen recently. The Pharmacist explained that it was uncommon for facility residents to obtain medications from outside pharmacies, as tracking was unreliable. The facility pharmacy could not dispense Biktarvy because insurance coverage was denied. The Pharmacist submitted three high-cost item forms to the (former) Director of Nursing requesting facility payment for the medication, but no response was received. On 11/25/2025 at 6:48 PM, the Director of Pharmacy Operations was interviewed and reported that the facility pharmacy could not fill Biktarvy because insurance had not approved coverage. The Director explained that Biktarvy was classified as a high-cost item requiring procurement from a specialty pharmacy, with an out-of-pocket cost exceeding $5,000 for a 30-day supply. There were no alternative medications available, and partial dispensing was not possible. On 11/18/2025, insurance approved coverage, and the facility received the medication on 11/19/2025 at 9:35 PM. Documentation on a packing slip for delivery of Biktarvy for Resident #24 confirmed it was delivered to the facility on [DATE] at 9:35 PM and signed for by Nurse #1. Nurse #1 was interviewed 12/1/2025 at 11:28 AM. Nurse #1 stated that she did not recall signing for the medication delivery from the pharmacy on 11/19/2025 at 9:35 PM. Nurse #1 said that usually she delivers the medications from the pharmacy to the medications carts for which the medication belongs so they can be put away by the nurse or the medication aide on that cart. Documentation on the November MAR revealed Medication Aide #1 administered an ordered dose of Biktarvy to Resident #24 on 11/20/2025. Medication Aide #1 was interviewed on 11/25/2025 at 6:02 PM. Medication Aide #1 stated that she documented the medication Biktarvy was administered to Resident #24 by mistake on 11/20/2025. Medication Aide #1 stated that everybody knew that the medication Biktarvy was not available on the medication cart that week. Documentation on the November MAR for Resident #24 revealed an ordered dose of Biktarvy was not administered on 11/21/2025 by Nurse #8. Documentation on the November MAR for Resident #24 revealed an ordered dose of Biktarvy was reinitiated and administered on 11/22/2025 by Nurse #8. On 11/26/2025 at 12:40 PM, Nurse #8 was interviewed and confirmed that she removed the seal from the Biktarvy bottle and administered the first ordered dose to Resident #24 on 11/22/2025. Nurse #8 reported that the Biktarvy bottle had not been present on the medication cart for several days prior to 11/22/2025 and stated that the bottle could not have been overlooked once placed on the cart. The Regional Director of Clinical Services was interviewed on 11/26/2025 at 1:03 PM and described the facility's process for receiving medications from the pharmacy. The pharmacy driver delivers medications to the charge nurse, who signs for the delivery and distributes the medications to the nurse or medication aide responsible for the appropriate cart. The Regional Director stated that Resident #24's Biktarvy should have been delivered to the correct cart on the evening of 11/19/2025. On 12/1/2025 at 11:18 AM the facility's Pharmacist was interviewed and stated that the expectation was for nurses to ensure medications delivered at night were placed on the correct cart to prevent missed doses. The Pharmacist confirmed that Resident #24's scheduled dose of Biktarvy should have been administered at 9:00 AM on 11/20/2025. The Former DON was interviewed on 11/25/2025 at 5:11 PM and stated that Resident #24 did not receive Biktarvy for approximately one week. The Former DON acknowledged that Biktarvy was costly but necessary and reported that NP #1 had indicated Resident #24 required the medication. The Former DON stated he discussed payment for Biktarvy with the Administrator, who allegedly informed the Former DON that the facility would not pay for the medication. The Administrator was interviewed on 12/1/2025 at 12:15 PM and reported awareness that Resident #24 had obtained Biktarvy from an outside source upon admission. The Administrator stated she was not notified when residents ran out of medications, as nursing staff managed that process. The Administrator denied ever refusing to pay for Biktarvy and denied telling the Former DON that the facility would not pay. On 12/1/2025 at 11:54 AM and again on 12/5/2025 at 12:32 PM the interim DON was interviewed. The DON stated that Resident #24 was expected to receive medications as prescribed. She explained that when Resident #24 was running low on Biktarvy, nurses submitted an electronic refill request to the pharmacy. The pharmacy then sent a high-cost item form to the Former DON, as Biktarvy could not have been dispensed without facility payment approval. The DON reported that the first high-cost item request for Resident #24's Biktarvy was submitted on 10/31/2025 and should have been addressed at that time. An infectious disease clinic physician was interviewed on 12/8/2025 at 1:03 PM and the following information was provided. The infectious disease clinic physician was not the prescribing physician for the Biktarvy while Resident #24 was in the hospital. The Infectious disease clinic physician had seen Resident #24 in the past, but the inpatient infectious disease team saw him in the hospital. A prescription for Biktarvy was sent to the hospital retail pharmacy by the hospitalist with a denial for a refill. The physician reported that there was no record of the long-term care facility contacting the infectious disease clinic for a refill or new prescription. The physician explained that typically the facility provider would write orders for Biktarvy, which would then be filled by the facility pharmacy. 2. Record review revealed Resident # 3 was admitted to the facility on [DATE] with a diagnosis of diabetes. Review of physician orders revealed Resident # 3 was ordered to receive Ozempic 1milligram subcutaneously weekly on Wednesdays for Diabetes. According to the order the Ozempic was supplied in a Subcutaneous Pen-Injector which had 4 mg (milligrams)/3 ml (milliliters). This order originated on 3/25/25 and remained as a current order. Review of Resident # 3's November MAR (Medication Administration record) revealed the resident was scheduled to receive the Ozempic on 11/5/25, 11/12/25, and 11/19/25. The doses of 11/12/25 and 11/19/25 were checked as administered and were the only documented doses in November as of the record review date on 11/25/25. The dose of 11/5/25 was not checked as administered by Nurse # 9 who signed a 9 rather than a check mark, which indicated the medication was not administered. Nurse # 9 was interviewed on 11/5/25 at 1:40 PM and reported the following information. Resident # 9's Ozempic was not available for administration on 11/5/25 when it was due. She had called the pharmacy that day, but it did not come in for administration while she was there. She had passed along the information in report. Interview with Resident # 3 on 11/25/25 at 1:50 PM revealed during one of the weeks in November the facility did not have the Ozempic to give him. He had missed one week's dose in November 2025. He did not recall the specific week. On 11/25/25 at 2:05 PM Nurse # 9 was accompanied as she looked in storage for Resident # 3's Ozempic medication to determine if it was currently available for the next dose the resident was scheduled to receive, which was due on 11/26/25 (Wednesday). After searching for the Ozempic, Nurse #9 reported she could not find Resident # 3's Ozempic supply for the next day's scheduled dose and she would call the pharmacy. During a follow up interview with Nurse #9 on 11/25/25 at 2:50 PM, Nurse # 9 reported she had called the pharmacy to request the Ozempic in order to ensure that it would be available for administration the next day and was told the pharmacy would send it but could not send it till the next day. According to Nurse # 9 the pharmacy had asked that the facility follow up with them the next day also to make sure it was sent. On 11/25/25 at 3:50 PM and again on 11/25/25 at 7:00 PM the Pharmacy's Director of Operations was interviewed via phone. Regarding the Ozempic dose not being available on 11/5/25, the Pharmacy Director reported the following information. Prior to 11/5/25 the facility had last requested a refill on 9/11/25 and it was sent. Prior to 9/11/25 the facility had been ordering Resident # 3's Ozempic consistently and may have had enough till 11/5/25. Prior to 11/5/25 the pharmacy had not received an electronic request for a refill since 9/11/25. Resident # 3's Ozempic was sent out on 11/5/25 on the late delivery which was at 10:29 PM on 11/5/25. That supply was for 28 days because one pen had 4 milligrams in each pen and the resident was ordered only to receive one milligram per week. Therefore, the facility should still have Resident # 3's Ozempic dose available for the next scheduled dose for the following day (11/26/25). Regarding why Nurse # 9 was told that the pharmacy could not fill the Ozempic on 11/25/25 for the missing 11/26/25 dose, the Pharmacy Director reported it was rejected in the pharmacy's system because it was too early to fill given the facility should have a dose available. On 11/26/26 the pharmacy would be able to refill it and would send it on 11/26/25. Further review of Resident # 3's record revealed on 11/25/26 at 6:09 PM orders were obtained from Nurse Practitioner # 1 to hold Resident's Ozempic. There was a notation by the order which noted, awaiting pharmacy, RP (responsible party notified and NP notified. There was no time limit to hold the Ozempic. On the MAR a notation was placed by the Ozempic order to hold from 11/25/25 at 6:09 PM to 11/26/25 at 6:08 PM. On 11/26/25 there was no documentation that Resident # 3 received his Ozempic or any day following that as of a review of the MAR on 12/1/25. On 12/1/25 at 11:55 AM Nurse # 10 was interviewed via phone and reported the following information. She had cared for Resident # 3 on 11/26/26 (Wednesday) and she did not give Resident # 3 his Ozempic because it was not there. She called the pharmacy, and they said they had already sent it. She did not routinely work at the facility. She did not know who she had told but she was sure she passed along the problem to someone. During a follow up interview on 12/1/25 at 12:57 PM with the Pharmacy's Director of Operations the Pharmacy's Director reported the following. The pharmacy had sent Resident # 3's Ozempic on 11/26/25 at 8:20 AM and the pharmacy's records showed it was received by Nurse # 10 on 11/26/26 at 9:17 AM. Therefore, from their records, the medication should have been available to be given. The Corporate Clinical Consultant, who was working as the interim Director of Nursing, was interviewed via phone on 12/1/25 at 1:24 PM and again at 1:58 PM and reported the following information. The facility records showed that the Ozempic was delivered to them on 11/26/25 at 9:17 AM. She had located the medication that day and looked to see if a dose was administered from it. She was unable to tell from looking at the pen and needles which were supplied with the multidose pen. There was one missing needle but no documentation that it had been administered in the record since it had been received. She had talked to the resident that day and Resident # 3 reported he had not received his 11/26/25 dose of Ozempic. Nurse Practitioner # 1 was interviewed on 12/1/25 at 9:15 AM and reported the following information. He would not consider missing Ozempic a significant medication error. During the interview, NP # 1 reviewed the resident's blood sugars and reported that they appeared stable. In reviewing the record, he recalled that the facility had asked for a hold for the Ozempic. He also saw on 12/1/25 that it was never given. That to him was concerning. NP # 1 further reported Ozempic is a medication that is ramped up to avoid any gastrointestinal side effects. With missed doses there is sometimes a risk for gastrointestinal side effects, but he (NP# 1) was not aware of any harm or side effects to Resident # 3. 3. Record review revealed Resident # 13 was admitted to the facility on [DATE]. The resident had a diagnosis of allergic rhinitis. Review of current physician orders revealed an order, which was initiated on 9/27/24, for Fluticasone propionate nasal spray 50 micrograms/ACT (actuation) one spray in both nostrils two times per day. Review of Resident # 13's November MAR (Medication Administration Record) revealed the following information. 11/20/25 for the 9 PM dose-Nurse # 7 documented a check mark indicating the Fluticasone was given. 11/21/25 for the 9 AM dose-Nurse # 2 documented a check mark indicating the Fluticasone was given. 11/21/25 for the 9 PM dose-Nurse # 7 documented a check mark indicating the Fluticasone was given. 11/22/25 for the 9 AM dose-Nurse # 6 documented a check mark indicating the Fluticasone was given. 11/22/25 for the 9 PM dose-Nurse # 11 documented a check mark indicating the Fluticasone was given. 11/23/25 for the 9 AM dose-Nurse # 2 documented a check mark indicating the Fluticasone was given. 11/23/25 for the 9 PM dose-Nurse # 11 documented a check mark indicating the Fluticasone was given. 11/24/25 for the 9 AM dose-MA # 2 documented a check mark indicating the Fluticasone was given. During an interview with Resident # 13 on 11/24 25 at 10:16 AM the resident reported her nose would run especially in the morning and the facility did not have her prescribed Flonase (Fluticasone). She had complained of this for several weeks and was not given a reason. During a follow up interview on 11/25/25 at 3:15 PM Resident # 13 was interviewed regarding with whom she had discussed the problem of the missing Flonase (Fluticasone). Resident # 13 reported she had discussed it with Nurse 7, Medication Aide # 2, and Nurse # 3. Medication Aide (MA) # 2 was interviewed on 11/24/25 at 3:05 PM about Resident # 13 reporting not receiving the Fluticasone. MA # 2 reported he had not given the Fluticasone because he could not find it. He was observed to look through his medication cart and show the surveyor that it was not available on the cart. MA # 2 further reported the following information. He had called the pharmacy about the missing medication. He had not meant to sign that he had given it on the MAR. That had been an unintentional mistake. Interview with Nurse # 3 on 11/25/25 at 9:30 AM revealed she covered (fulfilled the responsibilities which a medication aide was not certified to do) on 11/24/25 for MA # 2. Resident # 13's Fluticasone had not been available from the pharmacy although it had been ordered from the pharmacy. Nurse # 7 was interviewed on 11/25/25 at 7:50 PM via phone and reported the following information. She had not administered the Fluticasone on 11/20/25 and 11/21/25 when she worked and the check mark indicating it was given was an inadvertent error. She had ordered the Fluticasone from the pharmacy and faxed them several times about the missing medication, but it had not been delivered. Nurse # 2 was interviewed on 11/25/25 at 9:40 AM and reported she did not recall any issues with Resident # 13 having a runny nose and her Fluticasone not being available. According to Nurse # 2 it had been a busy morning on 11/23/25 and she had gotten pulled to another floor, but she thought she would have taken care of it if it had been brought to her attention. Nurse # 6 was interviewed on 11/24/25 at 7:35 PM via phone and reported the following information. She had been a supervisor on 11/22/25 and was trying to help an agency nurse catch up on medications. She may have inadvertently clicked that the Fluticasone was administered on 11/22/25 while doing so but she had not given the Fluticasone and did not know about it missing from the pharmacy delivery. An attempt was made to interview Nurse # 11 on 11/24/25 at 7:47 PM and the nurse could not be reached for interview. The facility's Pharmacy Director of Operations was interviewed on 11/25/25 at 3:50 PM and reported the following information. The pharmacy records showed the facility staff had requested the Fluticasone on 11/14/25 and 11/20/25 for Resident # 13. They had already sent a 30-day supply of the Fluticasone on 11/1/25 and therefore it was too early to fill it. The facility should have had the medication available when they ordered it on 11/14/25 and 11/20/25. When the facility requests a medication too early then in the pharmacy system it will show as pending since the pharmacy cannot fill it. On 11/24/25 the time between refills was sufficient so that they did send it on 11/24/25. Therefore, their records showed they had sent it on 11/2/25 and 11/24/25. Unit Manager # 1 was interviewed on 11/25/25 at 1:30 PM and reported the following information. She had located a Fluticasone nasal spray for Resident # 13 in another unit's storage supply the previous day (11/24/25). It had not been stored on the unit where Resident # 13 resided. When nurses received medications from the pharmacy, they were told to take the medication to the proper nurse if it is not a medication for one of their residents. The Regional Director of Clinical Services, who was filling in for the interim Director of Nursing (DON), on 11/25/25 was interviewed on 11/25/25 at 12:40 PM and reported the following information. Resident # 13 was a credible resident in the things she reported. Their records showed that they had ordered the Fluticasone on 11/14/25 and it was sent on 11/20/25.

Based on record review, and interviews with staff, Nurse Practitioner, Medical Director, Pharmacist, Interim Director of Nursing, Assistant Director of Nursing, Pharmacy Operations manager and Infectious Disease Clinic Physician, the facility failed to prevent a significant medication error for 1 of 5 residents whose medications were reviewed (Resident #24). The facility failed to administer prescribed antiretroviral medication to Resident #24 when the initial supply was exhausted and for two subsequent scheduled administration times following delivery from the pharmacy. Findings included:Record review of a hospital Discharge summary dated [DATE] revealed Resident #24 had not received prescribed antiretroviral medications, resulting in an uncontrolled viral load and a CD4 count of less than 200. An uncontrolled viral load with a CD4 count below 200 indicates active damage to the immune system, placing the resident at high risk for opportunistic infections and progression to Acquired Immune Deficiency Syndrome (AIDS), requiring urgent medical intervention. Resident #24 had a prescription for Biktarvy filled by the hospital retail pharmacy prior to discharge and was scheduled for close follow-up with the infectious disease clinic. Biktarvy is an antiretroviral medication used in the treatment of human immunodeficiency virus (HIV).Resident #24 was admitted to the facility on [DATE] with cumulative diagnoses which included a mental health disorder and human immunodeficiency virus infection (HIV).Resident #24 had a physician's order initiated on 10/10/2025 for 50-200-25 milligrams of Biktarvy (Bictegravir-Emtricitabine-Tenofovir) oral tablets to be administered as one tablet by mouth one time a day for HIV.Review of the November Medication Administration Record (MAR) revealed Biktarvy was not administered to Resident #24 on 11/13/2025 by Nurse #8, with documentation directing to see the progress notes.A Medication Administration note dated 11/13/2025 at 1:23 PM, written by Nurse #8, indicated the ordered dose of Biktarvy was not administered to Resident #24 and that the Medical Doctor and Responsible Party were aware.Review of the November MAR further revealed Biktarvy was not administered to Resident #24 on 11/14/2025 by Nurse #8, with documentation again directing to see the progress notes. A Medication Administration note dated 11/14/2025 at 10:49 AM, written by Nurse #8, indicated Biktarvy was not available on the medication cart. The Medical Doctor, Unit Manager (#1), and Assistant Director of Nursing (ADON) were aware. Nurse #8 documented communication with the prescriber, awaited further instruction, and notified the Responsible Party and emergency contact.During interview on 11/26/2025 at 12:40 PM, Nurse #8 stated Resident #24 ran out of Biktarvy on 11/13/2025. Nurse #8 reported contacting the facility pharmacy, which was unable to refill the medication, and notifying the Medical Director, Unit Manager (#1), and ADON. During interview on 11/25/2025 at 7:11 PM, the Medical Director, who was also Resident #24's physician, stated he was not involved in resolving the lapse in medication supply. The Medical Director stated interruption of antiretroviral therapy could result in mutation of the HIV virus and emphasized that only the infectious disease clinic could interpret blood tests to determine the consequences of the lapse in administration.Unit Manager #1 was interviewed on 11/25/2025 at 6:07 PM and revealed she was aware Resident #24 was admitted from the hospital with a bottle of Biktarvy but was unsure of the quantity of pills contained in the bottle. Unit Manager #1 further stated she was aware that once Resident #24 exhausted his supply, the hospital retail pharmacy was unable to refill the prescription, and the ADON subsequently addressed the issue of obtaining the medication.Review of the November MAR revealed documentation by Nurse #2 of an administered dose of Biktarvy to Resident #24 on 11/15/2025; however, during interview on 11/25/2025 at 6:13 PM, Nurse #2 stated she did not administer the medication and acknowledged she likely documented the dose for the sake of completion without actual administration.Documentation on the November MAR for Resident #24 revealed Biktarvy was not administered to Resident #24 on 11/16/2025 by Nurse #3, with a chart code to see the progress notes.Documentation in a Medication Administration note dated 11/16/2025 at 9:28 AM written by Nurse #3 indicated the ordered dose of Biktarvy was not administered to Resident #24 and the Medical Doctor and Responsible Party were aware.Nurse #3 did not respond to a request for an interview.Further review of the November MAR revealed Biktarvy was not administered on 11/17/2025, 11/18/2025, and 11/19/2025 by Nurse #8, with progress notes indicating the medication was unavailable on the cart and that Resident #24 was awaiting an infectious disease clinic appointment for a refill.A communication note dated 11/18/2025 written by the ADON revealed the Guardian and NP #1 were informed that Resident #24 was missing doses of Biktarvy.During interview on 11/25/2025 at 6:24 PM, the ADON confirmed the facility was unable to obtain Biktarvy through the hospital retail pharmacy or the facility pharmacy, and that Resident #24 did not have the medication available from 11/13/2025 through 11/22/2025.NP #1 was interviewed on 11/26/2025 at 12:13 PM and revealed he was not actively working to obtain Biktarvy and was unaware of the missed doses until informed by the ADON. NP #1 stated the medication was necessary and should not have been withheld under any circumstances. NP #1 reported he was aware Biktarvy was a high-cost medication that insurance was initially not paying for.On 12/1/2025 at 1:35 PM, the facility Pharmacist was interviewed and reported that Resident #24's initial prescription for Biktarvy had been filled at the hospital retail pharmacy upon admission on [DATE]. A refill request was denied by the infectious disease clinic provider because the resident had not been seen recently. The facility pharmacy could not dispense Biktarvy because insurance coverage was denied. The Pharmacist submitted three high-cost item forms to the (former) Director of Nursing requesting facility payment for the medication, but no response was received. The Pharmacist stated that Resident #24 should not have missed doses and that any clinical consequences of missed doses would need to be determined by the infectious disease clinic.The Director of Pharmacy Operations confirmed on 11/25/2025 that the facility pharmacy could not fill the prescription until insurance payment approval was obtained on 11/18/2025, with delivery documented on 11/19/2025 at 9:35 PM.Documentation on a packing slip for delivery of Biktarvy for Resident #24 confirmed it was delivered to the facility on [DATE] at 9:35 PM and signed for by Nurse #1.Nurse #1 was interviewed 12/1/2025 at 11:28 AM. Nurse #1 stated that she did not recall signing for the medication delivery from the pharmacy on 11/19/2025 at 9:35 PM.Documentation on the November MAR revealed Medication Aide #1 administered an ordered dose of Biktarvy to Resident #24 on 11/20/2025.Medication Aide #1 was interviewed on 11/25/2025 at 6:02 PM. Medication Aide #1 stated that she documented the medication Biktarvy was administered to Resident #24 by mistake on 11/20/2025. Medication Aide #1 stated everybody knew that the medication Biktarvy was not available on the medication cart that week.Documentation on the November MAR for Resident #24 revealed an ordered dose of Biktarvy was not administered on 11/21/2025 by Nurse #8.Documentation on the November MAR for Resident #24 revealed an ordered dose of Biktarvy was reinitiated and administered on 11/22/2025 by Nurse #8. Nurse #8 was interviewed on 11/26/2025 at 12:40 PM. Nurse #8 confirmed she removed the seal from the Biktarvy bottle and gave an ordered dose on 11/22/2025 to Resident #24. Nurse #8 stated the bottle of Biktarvy was not on the medication cart for several days prior to 11/22/2025, and that the bottle could not be overlooked on the medication cart.On 11/26/2025 at 12:13 PM NP #1 was interviewed and explained that Resident #24 had a viral disorder requiring Biktarvy, an antiretroviral medication that suppresses viral replication. NP #1 stated that interruption of Biktarvy allows the virus to replicate and suppress the immune system, increasing susceptibility to infection. NP #1 reported that the administration of Biktarvy was never placed on hold and should have been administered by 11/20/2025, or by 11/21/2025, at the latest. NP #1 stated that administration of Resident #24's Biktarvy on 11/22/2025 after arriving at the facility on the evening of 11/19/2025 represented an unacceptable delay and indicated a breakdown in the process.The facility's Pharmacist was interviewed on 12/1/2025 at 11:18 AM. The Pharmacist stated that the expectation was that when the facility received a delivery from the pharmacy at night, the nurse would make sure the medications make it to the correct medication cart so that residents do not miss any doses at the scheduled administration times. The Pharmacist confirmed the scheduled dose of Biktarvy should have been administered to Resident #24 at 9:00 AM on 11/20/2025. The Pharmacist confirmed that only the physician from the infectious disease clinic would be able to relay the significance of Resident #24 missing doses of Biktarvy.On 12/1/2025 at 11:54 AM and again on 12/5/2025 at 12:32 PM the interim DON was interviewed. The DON stated that Resident #24 was expected to receive medications as prescribed. The DON reported the pharmacy request for Resident #24's Biktarvy to be paid for by the facility was submitted on 10/31/2025 to the former DON, and it should have been addressed at that time.An infectious disease clinic physician was interviewed on 12/8/2025 at 1:03 PM and the following information was provided. Biktarvy requires laboratory testing and since Resident #24 had uncontrolled HIV in 10/2025, he was due for a follow-up for viral load testing four weeks after starting Biktarvy. Without recent laboratory testing, the physician could not determine whether Resident #24 experienced harm from the interruption in therapy. The physician stated that potential negative outcomes included increased risk of death, opportunistic infections, and drug resistance. The physician reported that a safe number of days to miss Biktarvy was unknown leaving a potential for harm.

Based on record review, and staff, Guardian, Nurse Practitioner, Infectious Disease Physician interviews, the facility failed to ensure Resident #24 attended a scheduled infectious disease clinic appointment as ordered, for 1 of 5 residents reviewed for professional standards of care (Resident #24). Findings included:Record review of a hospital Discharge summary dated [DATE] revealed Resident #24 was prescribed Biktarvy, an antiretroviral medication used to treat human immunodeficiency virus (HIV), filled by the hospital retail pharmacy prior to discharge, with instructions to closely follow up at the infectious disease clinic. The discharge summary further documented a follow-up appointment scheduled for 11/12/2025. Resident #24 was admitted to the facility on [DATE] with cumulative diagnoses including a mental health disorder and HIV infection. Physician's orders for Resident #24, dated 10/10/2025, directed administration of Biktarvy 50-200-25 milligrams, one tablet orally daily. Review of the care plan for Resident #24 initiated 10/14/2025 identified chronic disease management as a focus area with interventions to administer medications as ordered and monitor for complications related to HIV. The admission Minimum Data Set, dated [DATE] documented Resident #24 had moderate cognitive impairment.Interview with the Guardian for Resident #24 on 11/26/2025 at 11:03 AM revealed she was not notified of the 11/12/2025 infectious disease clinic appointment. The Guardian stated she did not receive a phone call or message regarding the appointment and reported that, prior to hospitalization from 10/4/2025 to 10/9/2025, a mental health service employee typically accompanied Resident #24 to appointments. The Guardian was uncertain when the 11/12/2025 appointment was cancelled.Interview with the facility Transportation Coordinator on 11/26/2025 at 11:57 AM revealed Resident #24's 11/12/2025 appointment required accompaniment per administrative policy. The Guardian was called several times the week prior, but no response was received, and no message could be left. The Transportation Coordinator cancelled the appointment one to two days prior and rescheduled it for 11/24/2025. During a follow-up interview on 12/1/2025 at 8:02 AM, the Transportation Coordinator acknowledged awareness of the importance of the 11/12/2025 appointment and stated she notified the Administrator, Unit Manager #1, and Nurse Practitioner #1 of the rescheduling.Interview with the Social Worker on 11/26/2025 at 1:19 PM revealed the Transportation Coordinator was responsible for arranging Resident #24's appointments. The Social Worker confirmed the Guardian was sometimes difficult to contact.Review of the November Medication Administration Record and notes written by Nurse #8 on 11/13/2025 at 1:23 PM revealed Biktarvy was not administered. Interview with Nurse #8 on 11/26/2025 at 12:40 PM confirmed the medication was unavailable on the medication cart beginning 11/13/2025. Nurse #8 reported contacting the physician, who indicated Resident #24 needed to be seen at the infectious disease clinic before the pharmacy would dispense additional medication.Review of a communication progress note dated 11/18/2025 at 9:36 AM by the Assistant Director of Nursing (ADON) documented the Guardian was updated regarding Resident #24's HIV medication. The note revealed the pharmacy would not dispense Biktarvy until Resident #24 was seen at the clinic, and an appointment was scheduled for the following week. Interview with the ADON on 11/25/2025 at 6:24 PM confirmed Resident #24 had run out of Biktarvy and required a clinic visit for refill authorization. The ADON stated the facility pharmacy ultimately obtained Biktarvy after insurance was willing to pay for it prior to the rescheduled clinic appointment.Review of a progress note dated 11/18/2025 at 10:19 PM by Nurse Practitioner #1 documented Resident #24 was not receiving Biktarvy due to lack of insurance coverage and refusal by the infectious disease provider to refill without a recent clinic visit.Interview with NP #1 on 11/26/2025 at 12:13 PM revealed the ADON informed him of the lapse in medication. NP #1 confirmed the infectious disease physician declined to refill until Resident #24 was seen. NP #1 acknowledged awareness of multiple cancellations and rescheduling of the clinic appointment. NP #1 stated the facility pharmacy ultimately obtained Biktarvy, and Resident #24 resumed therapy on 11/22/2025.Interview with the Guardian on 11/26/2025 at 11:03 AM revealed she was notified on 11/17/2025 that the 11/12/2025 appointment was cancelled and rescheduled for 11/24/2025. She was also informed Resident #24 was not receiving Biktarvy pending clinic evaluation. The Guardian arranged for a mental health service representative to accompany Resident #24 to the 11/24/2025 appointment.Interview with the Transportation Coordinator on 11/26/2025 at 11:57 AM revealed she believed the appointment was scheduled for 11/24/2025 and contacted the Guardian accordingly. The Guardian arranged accompaniment. However, the actual appointment was on 11/17/2025, which Resident #24 missed. The Transportation Coordinator acknowledged recording the wrong date. Resident #24 was subsequently placed on a waiting list, with the next appointment scheduled for 2/2/2026.Interview with the infectious disease Physician on 12/8/2025 at 1:03 PM confirmed the 11/12/2025 appointment was cancelled and rescheduled for 11/17/2025. Resident #24 did not attend the 11/17/2025 clinic appointment but did attend an orthopedic appointment later that day. The Physician stated Resident #24 was rescheduled for February 2026 and reported her nursing staff was having difficulty contacting the facility Transportation Coordinator to arrange a sooner date. The Physician further stated Resident #24 had uncontrolled HIV in October 2025 and required follow-up viral load testing after initiation of Biktarvy.Interview with the Administrator on 12/1/2025 at 12:15 PM revealed she did not recall being informed by the Transportation Coordinator that the 11/12/2025 appointment was cancelled. The Administrator stated her expectation was that Resident #24 would attend scheduled appointments and that the Transportation Coordinator would accurately record appointment dates.

Based on record review, observations, Resident interviews as well as staff and Nurse Practitioner interviews, the facility failed to provide pain management during a painful dressing change procedure. Resident #136 had a chronic unstageable pressure ulcer on his left heel requiring regular dressing changes. During an ordered dressing change, Resident #136 was observed to exhibit signs of pain which included facial grimacing, increased breathing rate, shifting of position and verbal expressions of the dressing change procedure being painful and was not provided pain management. The deficient practice occurred in 1 of 4 residents reviewed for pressure ulcers (Resident #136).Findings included:Review of records revealed a hospital Discharge summary dated [DATE] which indicated that Resident #136 fell at home and fractured his left femoral neck (the part of the thigh bone that connects to the hip socket) and his right fifth metatarsal (a bone in the foot) and needed emergent surgery to repair the thigh bone fracture. Surgical intervention for the foot fracture was not indicated. Resident #136 had other medical diagnoses of paroxysmal atrial fibrillation, coronary artery disease, congestive heart failure, abdominal aortic aneurysm, hypertension, dementia and an unstageable pressure ulcer on his left heel. Resident #136 was admitted to the facility on [DATE] for rehabilitation services following his fall. A 7/24/25 admission Minimum Data Set (MDS) assessment revealed that Resident #136 had moderate cognitive impairment. A revised care plan dated 8/21/25 revealed focus areas for atrial fibrillation, congestive heart failure, hypertension, diuretics complications monitoring, fractures, pressure ulcers, falls, impaired skin integrity and pain riskReview of records revealed physician orders which included:An 8/12/25 order for hydrocodone-acetaminophen 5-325mg, one (1) tablet by mouth every 6 hours as needed for pain.An order dated 8/13/25 indicated that the left heel wound was to be cleansed with topical cleansing solution 0.125% and pat dried. Fluffed gauze, moistened with cleansing solution, was to be placed to the wound and covered with dry dressing, then wrapped with gauze and compression wrap bandage every day shift and as needed. In an observation and interview with Resident #136 on 9/8/25 at 12:39 PM, the Resident was awake and alert. He responded appropriately to questions and was pleasant and conversant. Resident #136 was sitting up in his wheelchair with both feet resting on the floor. He was wearing a non-skid sock on his right foot, and his left foot was covered with a wrap dressing which was intact. No odors were discerned from his left foot dressing. Resident #136 said he gets dressing changes for his foot every day and even a couple times a day if it gets dirty.On 9/10/25 at 10:36 AM, an interview with Resident #136's nurse, Nurse #3, was conducted. Nurse #3 said she did not know the Resident yet as she was new and had not finished her rounding or given medications yet. Nurse #3 said she was not yet familiar with the Resident's dressing change orders.On 9/10/25 at 10:40 AM, a second interview with Resident #136 was conducted. Resident #136 said his left foot was not healing, that he fell at home and ever since then, the wound on his heel wouldn't get better. Resident #136 said that his left foot hurts really bad any time they move it or do my dressing changes. They do my dressing changes a couple of times per day but I don't have a lot of pain otherwiseAt 10:46 AM on 9/10/25, an interview with Nurse #3 and Unit Manager #2 and an observation of Resident #136's dressing change were conducted. Unit Manager #2 said she did not know Resident #136 or his wound care orders because she was only filling in for the day but his dressing had not been changed yet for the day. Resident #136 was observed awake, sitting up in his wheelchair, his legs were uncrossed with both of his feet resting on the floor. Resident #136 was calm and conversant prior to the dressing change. Immediately prior to the dressing change, the Surveyor asked Nurse #3 and Unit Manager #2 if the Resident may need pain medication prior to the start of his dressing change. Nurse #3 and Unit Manager #2 said the Resident usually did not have a lot of pain during his dressing changes and so he was not pre-medicated for pain prior to the initiation of the dressing change. There was no witnessed pain assessment for Resident #136 immediately prior to the dressing change. Unit Manager #2 stepped outside of the room to a treatment cart and returned wearing gloves and carrying dressing change supplies. Unit Manager #2 sat down on the floor in front of Resident #136 and laid a clean gauze pad on the bare room floor to her left side and set the dressing change supplies on the gauze pad. Nurse #3 stood at the left side of the Resident's wheelchair and elevated Resident #136's left leg and held it in the elevated position. Unit Manager #2, from a seated floor position, then proceeded to remove the existing outer wrap from Resident 136's left leg and foot. Resident #136 grimaced his face and said, oh goodness, that hurts. The Resident then closed his eyes tightly and grimaced his face again and proceeded to take several deep breaths in quick succession. Unit Manager #2 continued to remove the outer wrap and then proceeded to remove the old gauze wrap and the fluffed gauze that was on the Resident's left heel. Neither Nurse #3 nor Unit Manager #2 spoke to Resident #136 or attempted to assess the Resident's pain. When Unit Manager #2 removed the gauze from the Resident's heel, he said Oh, Oh, that really hurts and grimaced his face again, took several deep breaths in quick succession and attempted to shift his position in the wheelchair. When the Resident was observed grimacing, breathing deeply and quickly, and attempting to shift his position, the Surveyor asked Nurse #3 if she would consider giving the Resident a dose of his pain medication at that point and Nurse #3 replied yeah, I would probably give him some pain medication at this point but did not stop the dressing change to do so. Resident #136 again began taking deep breaths in quick succession. Nurse #3 continued to hold Resident 136's left leg in an elevated position and Unit Manager #2 continued to moisten the gauze with the clear solution and clean the Resident's exposed heel wound with the moistened gauze. Resident #136 groaned and said, oh my goodness that really hurts and grimaced his face while breathing deeply and quickly. At that point, the Surveyor intervened and asked Nurse #3 to retrieve pain medication for the Resident before continuing. Unit Manager #2 said yes, he needs some pain medication. Nurse #3 then lowered the Resident's left leg back down to the bare floor and said she would get Resident #136 some pain medication and left the room. Unit Manager #2 placed another piece of moistened gauze to the heel wound and then began re-wrapping the Resident's foot with the gauze wrap. Unit Manager #2 finished wrapping the Resident's left foot with the gauze wrap prior to Nurse #3 returning with the pain medication. Upon Nurse #3's return, Nurse #3 asked Resident #136 to rate his pain and he said his pain was an 8 during the dressing change, where on a 0-10 pain scale 0 was no pain at all, and 10 was severe pain. Nurse #3 then administered the ordered pain medication. Unit Manager #2 said she had never done wound care before, was not familiar with the orders and had been pulled to assist with wound rounds and dressing changes for the shift because the normal wound nurse was out on a family emergency. In a follow up interview with Nurse #3 on 9/10/25 at 1:30 PM, Nurse #1 stated that she was so focused on the wound and the dressing change, that she did not immediately think to stop the dressing change procedure and get the Resident some pain medication. Nurse #3 said in hindsight, it would have better to have stopped, I'm sorry. In an interview with the Director of Nursing (DON) on 9/10/25 at 11:20 AM, the DON confirmed that the expectation was that a dressing change would be performed according to physician orders and that a resident should be made as comfortable as possible during a dressing change. The DON stated not assessing for pain or give pain medication when a resident was in pain during a dressing change was not the expected practice. In an interview with the Administrator on 9/10/25 at 1:30 PM, the Administrator said that she would expect that a resident should not be in pain during a dressing change, that any resident who was in pain during a dressing change should be treated for pain. On 9/10/25 at 1:50 PM, an interview with the Nurse Practitioner was conducted. The Nurse Practitioner said that all residents should be treated for pain if they were in pain during dressing changes. An interview with the wound care Nurse Practitioner was conducted on 9/10/25 at 2:20 PM. The wound care Nurse Practitioner said that Resident #136 had a lot of pain during some of his dressing changes, particularly during any attempts to debride, or remove dead tissue from the wound. The Nurse Practitioner said that he would be given pain medication but at times she would just have to stop the debridement.

Based on observations and staff interviews, the facility failed to: prevent cross-contamination of dishware during the operation of the dishwashing machine; ensure dietary staff's personal belongings were not stored in the food preparation area; maintain food service equipment clean and free from debris; and store dishware clean and dry. These deficient practices had the potential to affect residents residing in the facility.1. During the initial tour of the kitchen on 9/8/25 at 11:20 a.m., Dietary Staff #1 was observed wearing plastic gloves as she scraped the excess food debris and placed the dirty dishware on a dish rack in preparation for cleaning in the dishwashing machine. The Dietary Staff #1 crossed to the opposite side of the machine and removed a rack of clean glassware without removing the soiled gloves and washing her hands. She placed the rack of glassware onto a preparation table for use during the lunch tray line service. Dietary Staff #1 revealed she had been working at the facility for three days and had not received any training on cross-contamination. She was not aware she was to remove her gloves and wash her hands after handling soiled dishware. On 9/8/25 at 11:30 a.m., the Dietary Manager stated Dietary Staff #1, a new employee, had only been working in the kitchen for three days. The Dietary Manager had not completed Dietary Staff #1's training because he had been busy trying to ensure residents received their meals on time. 2. On 9/8/25 at 11:40 a.m. a large, pink travel mug was observed on the bottom shelf of a food preparation table in the kitchen. Dietary [NAME] #1 stated the mug belonged to one of the dietary staff. On 9/8/25 at 11:45 a.m., a dietary staff was observed entering the kitchen and placing a large travel mug on the bottom shelf of a preparation table after sipping from the straw inserted in the mug. During the meal tray service in the kitchen on 9/8/25 at 12:00 p.m., a small 3-shelf cart was observed next to the trayline service with plate covers stacked on the top shelf, large blue travel mug on the second shelf, one large pink travel mug, one large can of kidney beans, and one bushel of plastic flowers were on the bottom shelf of the cart. 3. During the tour of the kitchen on 9/8/25 at 11:42 a.m., there was a thick, black grease build-up covering the stove top and dried dark stains on the front and sides of the stove. The interior of the double convection ovens also contained thick, dark grease buildup. The interior of the double-sided plate warmer had dried brown/yellow stains. There were clean plates observed in the warmer. On 9/12/25 at 2:31 p.m., the Dietary Manager stated Sundays were scheduled as the deep cleaning day in the kitchen, including equipment. He revealed he last cleaned the ovens on 8/30/25. 4. During an observation of the meal service trayline in the kitchen on 9/10/25 at 12:08 p.m., there were seven wet and dirty (dried food particles) divided plates stacked on the meal service trayline. During an interview on 9/12/25 at 2:31 p.m. the Dietary Manager stated the Registered Dietitian conducted audits of the kitchen every Monday on sanitation, safety, dating and labelling of foods.

Based on record review, observations, resident, staff and physician interviews, the facility failed to maintain accurate medical records for a peripherally inserted central catheter (PICC) line dressing change (Resident #112), intravenous antibiotic medication (Residents #101), and for assessing and documenting blood sugars and the administration of insulin (Resident #82). This was for 3 of 3 resident reviewed for resident records (Resident #112, #101, and #82). Findings included: Resident #112 was admitted to the facility on [DATE] with a peripherally inserted central catheter line. An admission Minimum Data Set (MDS) assessment on 8/27/25 noted Resident #112 was cognitively intact. Review of physician orders revealed an 8/28/25 order for a peripherally inserted central catheter line dressing change on admission, then every 7 days on day shift and as needed. On 9/8/2025 at 12:02 PM an observation and interview with Resident #112 was conducted. Resident #112 was observed with a right upper arm peripherally inserted central catheter line, with an antibiotic infusing as ordered. The dressing was clean, dry, intact and was hand-labeled in black ink 8/25. The Resident said the special IV was for her antibiotics and she did not remember when the dressing was last changed. On 9/10/2025 at 09:48 AM Resident #112 was observed in her room, awake, lying in bed watching tv. Her right upper arm peripherally inserted central catheter line was clean, dry and intact with the same dressing hand-labeled in black ink 8/25. A review of Resident #112's Medication Administration Record (MAR) for September 2025 revealed a last documented dressing change as having occurred on 9/3/25 and was documented by Nurse #4. On 9/11/25 at 10:20 AM, Nurse #4 confirmed that she saw the previous dressing was dated 8/25. Nurse #4 confirmed that her initials were present on Resident #112's MAR as having changed the line dressing on 9/3/25 but stated she had made an error, and she had not changed the peripherally inserted central catheter line dressing on 9/3/25. In a joint interview with the Administrator and the Director of Nursing (DON) on 9/10/25 at 11:45 AM, both the Administrator and the DON said documentation should be accurate. On 9/10/25 at 12:00 PM an interview with the Nurse Practitioner was conducted. The Nurse Practitioner stated the documentation should be accurate and complete. A telephone interview with the Medical Director was conducted on 9/11/25 at 12:19 PM. The Medical Director said that all documentation should be accurate and complete. 2. Resident #101 was admitted on [DATE]. An active physician's order dated 08/02/25 and renewed on 08/07/25 revealed Resident #101 had an order to receive meropenem (an antibiotic used to treat severe bacterial infections) intravenous (IV) solution reconstituted 1 gram intravenously every 8 hours. The August 2025 Medication Administration Record (MAR) for Resident #101 was reviewed and revealed 2 occurrences indicating the meropenem antibiotic was not administered for the following dates: 08/17/25 at 4:00 PM and 08/22/25 at 12:00 AM. An interview was conducted on 09/13/25 at 2:00 PM with Nurse #1. She verified she worked on 08/17/25. She stated she did administer Resident #101's IV medication on 08/17/25 at 4:00 PM. She explained she forgot to sign the MAR. A phone interview was conducted on 09/11/25 at 10:52 AM with the Wound Nurse. She verified she worked on 08/22/25 at 12:00 AM. She stated she knew she administered the IV antibiotic for Resident #101 but that she could not remember why she didn't sign the MAR. She indicated it was an oversight. The Physician's Assistant was interviewed on 9/12/25 at 12:50 PM he stated he was aware the MAR was not signed as being administered. He explained medications should have been accurately documented. The Director of Nursing was interviewed on 9/12/25 at 2:42 PM and stated nurses were supposed to document on the MAR after administering IV antibiotics. The DON verified he was aware of the missed signatures on the MAR. 3. Resident #82 was admitted on [DATE] with diagnoses that included type II diabetes and cognitive communication deficit. An active physician's order dated 5/28/25 and renewed on 8/5/25 revealed Resident #82 had an order to receive 8 units of Novolin R (insulin regular human); inject 8 units subcutaneously two times a day related to type II diabetes with hyperglycemia. Hold if not eating meal; hold for blood glucose less than 150. The August 2025 Medication Administration Record (MAR) for Resident #82 was reviewed and revealed 5 occurrences indicating Resident #82's blood sugar was not assessed, and the Novolin R insulin was not administered for the following dates: 8/2/25 at 11:30 AM, 8/28/25 at 4:00 PM, and 8/30/25 at 4:00 PM. On 9/12/25 at 12:00 PM Nurse #1 was interviewed and verified she had worked the dates of 8/2/25, 8/28/25, and 8/30/25. She stated she did not recall having missed checking Resident #82's blood sugars or giving him insulin on the missing dates, and she was uncertain why her initials were not recorded on the MAR. The Physician's Assistant was interviewed on 9/12/25 at 12:50 PM and stated medications should have been administered and accurately documented as ordered. The Director of Nursing was interviewed on 9/12/25 at 2:42 PM and stated nurses were supposed to document on the MAR after checking a resident's blood sugar and administering insulin.

Based on record review, resident, and staff interviews, the facility failed to document if the Covid-19 immunization was administered or if education was provided in the medical record regarding the benefits and potential side effects of the COVID-19 vaccines. This occurred for 3 of 5 residents reviewed for COVID-19 immunizations (Resident #15, Resident #53, and Resident #132). In addition, the facility was unable to provide evidence of Covid-19 immunization status or if education had been provided for 2 of 5 staff members (Staff #13 and Staff #14).The findings included:a. Resident #13 was admitted to the facility on [DATE]. A review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #13 was severely cognitively impaired, and the Covid-19 immunization was not offered. A review of Resident #13's electronic medical record indicated the resident's family, who was unnamed, had refused the Covid-19 immunization on behalf of Resident #13. Further review revealed there was no information in the medical record that indicated Resident #13, or her family, was provided with education regarding the benefits and potential side effects of the Covid-19 immunization. A vaccine consent form provided by the facility had a checkmark beside decline the Covid-19 immunization section. However, the consent form dated 7/1/25 only had the word verbal written on the signature line for the resident or representative to sign. There was no name of the family member who may have declined where the word verbal was written, and the Infection Preventionist's (IP's) name was listed as the facility's representative. Attempts to contact Resident #13's family members were unsuccessful. b. Resident #53 was admitted to the facility on [DATE]. Resident #53 was listed as her own responsible party in the electronic medical record. A Review of the comprehensive Minimum Data Set assessment dated [DATE] revealed Resident #53 was moderately cognitively impaired, and the Covid-19 immunization was offered and declined. A review of Resident #53's electronic medical record indicated the Covid-19 immunization was declined. A vaccine consent form provided by the facility had a checkmark beside the section to decline the Covid-19 immunization was listed. However, there was no signature or date on the form. On the resident signature line, the word verbal was written, and the IP's name was listed as the facility representative. On 9/11/25 at 10:13 AM Resident #53 was interviewed and stated she was not offered the Covid-19 immunization since being at the facility. She stated she would not have refused the vaccine due to having a history of asthma. c. Resident #132 was admitted to the facility on [DATE]. A review of the comprehensive Minimum Data Set assessment dated [DATE] revealed Resident #132 was cognitively intact, and the Covid-19 immunization was offered and declined. A review of Resident #132's electronic medical record revealed there was no information in the medical record that the resident or their legal representative had declined the Covid-19 immunization, or if the resident had been provided education regarding the benefits and potential side effects of the Covid-19 immunization. The facility was unable to provide documentation that the resident or their legal representative gave consent or declined the immunization. Attempts made to interview Resident #132 were unsuccessful. d. The facility was unable to provide evidence of Covid-19 immunization status or if education had been provided for Staff member #13 or Staff member #14 when requested for review. The Administrator stated the facility did not have information on file for either staff member when she presented immunization history for the staff members requested for review on 9/12/25 at 10:00 AM. The Infection Preventionist was interviewed on 9/12/25 at 12:50 PM and explained she offered residents the Covid-19 immunization upon admission to the facility as well as on an individual basis. She stated after speaking with the resident she would check their immunization preference then write the word verbal on the consent form. The IP indicated not all residents were able to sign their names, but if the resident wished to sign their vaccine consent form, then they could sign beside where she had written the the word verbal. The IP stated she was unsure why Resident #132 did not have information in his electronic medical record about his immunization or education status. She further indicated Covid-19 immunizations were not offered to the staff by the facility, but she did keep a record of the staff members' immunization status. The IP indicated she mailed a copy of the vaccine consent form to the address on file for Resident #13's representative. She stated she thought the records for Staff member #13 and Staff member #14 might be missing because of all the changes that had taken place at the facility, including the change in ownership of the facility. An interview was conducted with the Director of Nursing (DON) 9/12/25 at 2:45 PM. The DON explained he had only been at the facility for three weeks, but all residents should be offered Covid-19 immunization, and the consent forms should be signed by the residents or their representatives. The DON stated a record of the education provided to the residents or their representatives should be maintained in the electronic medical record. The DON further stated the Infection Preventionist should have kept a record of all staff members Covid-19 immunization records.

Based on observations, record review, and resident, family, ombudsman, and staff interviews, the facility failed to provide incontinence care (Resident #162), failed to assist with a meal (Resident #107and Resident #162), and failed to provide nail care and assistance with facial hair (Resident #85) to residents who were dependent on staff for assistance. This was for 3 of 13 residents reviewed for activities of daily living (ADL) (Residents #85, #107, #162). 1. a. Resident #162 was admitted to the facility on [DATE] and had cumulative diagnoses that included dementia, contracture of right and left hands, dysphagia, and aphasia. Resident #162's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated she was non-verbal. The Staff Assessment of Cognition completed by staff indicated Resident #162 had short- and long-term memory problems and her Cognitive Skills for Daily Decision Making was severely impaired. Resident #162 had functional limitation in range of motion to one side of her upper extremity and to both sides of lower extremities. She was dependent on staff for all ADL and was always incontinent with bowel and bladder. Resident #162 also had a stage 4 pressure ulcer to her sacrum. Resident #162's active care plan included the focus area of an Activity of Daily Living (ADL) self-care deficit. The interventions included she required 2-person assistance with transfers and bed mobility. Resident #162 also had an active care plan with a focus area of bowel and bladder incontinence which included the intervention Resident #162 required 2-person assistance with toileting, check and change briefs frequently and as needed, and provide toileting hygiene with brief changes. Another focus area included Resident #162 had a stage 4 pressure ulcer to her sacrum. The interventions included to assess Resident #162 for risk of skin breakdown, assist the resident to turn and reposition often, and to keep her skin as clean and dry as possible. An interview with the Ombudsman was conducted on 09/04/25 at 3:44 PM. The Ombudsman stated she came to the facility on [DATE] for a visit and when she walked by Resident #162's room on 06/12/25 around 3:00 PM she observed a lunch tray sitting on the bedside table beside Resident #162's bed untouched. The Ombudsman stated she told the nurse who then told the Director of Nursing (DON). The Ombudsman explained that the DON informed her that they were short staffed and that was why Resident #162's meal tray was untouched at her bedside. She continued to explain that as of 3:00 PM on 06/12/24, Resident #162 had not been offered or assisted with lunch. Nurse #9 provided direct care to Resident #162 on 06/12/25 from 7:00 AM until 7:00 PM. She was not available for interview during the survey period. A phone interview was conducted on 09/11/25 at 1:44 PM with the previous DON. She stated it was brought to her attention by the Ombudsman on 06/12/25 at approximately 3:30 PM that Resident #162's lunch tray was still in her room on the bedside table and that it had not been touched, and it did not appear that staff had attempted to assist Resident #162 with her lunch. The DON stated they had several call outs on 06/12/25 and the NA who was assigned Resident #162 did not ask for assistance by other staff members and forgot to go back and assist Resident #162 with her lunch. Corrective action was rendered. The DON indicated that administrative staff were assisting in answering call lights and providing care. An interview was conducted on 09/12/25 at 2:27 PM with NA #8. She verified she was the direct care NA for Resident #162 on 06/12/25. She explained that the Ombudsman did locate Resident #162's lunch tray in her room and that it had not been touched since the trays were passed out. She stated it was around 2:00 PM, not 3:30 PM, and she could not recall what time the trays were passed out. She then stated she did not forget to assist Resident #162 with her lunch; she was just the last person she had to feed that day and she was doing the best she could do because they were short staffed. NA #8 could not recall how many residents she had to care for on 06/12/25. She further explained that she did not ask for assistance with feeding or changing Resident #162 because everyone was busy. She indicated when they were short staffed it was difficult to get her tasks done, she would be running late, but the tasks would get done. An interview was conducted on 09/12/25 at 4:12 PM with the DON. He stated the NAs were to make sure the residents were changed and fed in a timely manner. The DON further explained that staffing had been a problem, and they were using a lot of agency staff. b. Review of the grievance log revealed a concern dated 08/20/25 at 5:25 PM written by the Wound Nurse who observed Resident #162 saturated from head to toe in urine and still had night clothes on. The roommate stated Resident 162 had not been cleansed or repositioned all day. The Wound Nurse added Resident 162's linens were soiled, she needed to be changed, and the resident had a stage 4 pressure ulcer. A phone interview was conducted on 09/11/25 at 10:52 AM with the Wound Nurse. She stated when she went in Resident #162's room to do her wound care Resident#162's brief and bedding were soaked with urine. A phone interview was conducted on 09/11/25 at 11:00 AM with NA #9. She verified she was the direct care NA for Resident #162 on 08/20/25. She explained Resident #162 required 2 people for bed mobility and there were no staff members seen in the hall to assist her with performing Resident #162's incontinence care on 08/20/25. Incontinence care was provided however there was normally a delay with completing it. NA #9 confirmed she did one round on Resident #162 after breakfast at approximately 9:45 AM at which time she provided incontinence care, however she did not do another round on her because she did not have any help to safely provide care until approximately 5:30 when the Wound Nurse notified the DON. An interview was conducted on 09/11/25 at 11:16 AM with Unit Manager #1. She stated she recalled the situation when Resident #162 was observed saturated with urine by the Wound Nurse on 08/20/25. She explained the Wound Nurse notified her Resident #162's brief and sheets were soaked with urine. Unit Manager #1 stated she did speak to the NA who told her she had not provided incontinence care to Resident #162 yet because she was behind with her tasks. The Unit Manager also indicated the NAs provided the care; however, it was delayed. An interview was conducted on 09/11/25 at 4:07 PM with the DON. He stated he did recall the Wound Nurse reporting Resident #162's brief, sheets, and blankets being saturated with urine. 2) Resident #107 was admitted to the facility on [DATE] from a hospital. The resident's cumulative diagnoses included acute respiratory failure with hypoxia (an inadequate supply of oxygen to the tissues) and non-Alzheimer's dementia. The resident's weight history included an initial weight of 128.3 pounds (#) obtained on 2/13/24. The resident's physician's orders included a diet order dated 1/30/25 for a regular diet with dysphagia pureed textures and nectar thick liquids. The resident's weight obtained on 5/2/25 was 115.6#. Resident #107's care plan included the following areas of focus, in part:--Long term care: the resident requires assistance with Activities of Daily Living (ADL) related to advanced age, chronic health conditions and is a Hospice patient (Date Initiated: 2/5/25). The planned interventions included: provide assistance with feeding for meals (Date Initiated 5/13/25). The resident's most recent Minimum Data Set (MDS) assessment was an annual assessment dated [DATE]. The assessment indicated Resident #107 had severely impaired cognitive status. She had no behaviors nor rejection of care. The resident was reported as being dependent on staff for all her ADL (including eating). The resident's weight history did not include June or July weights. However, a weight obtained on 8/18/25 indicated Resident #107 weighed 111.0#. The resident's Care Area Assessments (CAAs) included “Nutritional Status.” A CAA worksheet dated 9/3/25 noted the following, in part: “…requires assist when eating…Wts [Weights] are not normally monitored per hospice protocol…” Upon the family's request, an interview was conducted with Resident #107's family member on 9/9/25 at 2:30 PM. During the interview, the family member expressed concerns about the resident's weight loss of approximately 17# over the last 18 months or so. She acknowledged the resident was on Hospice but stated Resident #107 “was not actively dying.” The family member reported Resident #107 was totally dependent on staff for all her needs and she felt strongly that the resident was not always being fed her meals. Meal rounds conducted on 9/10/25 for breakfast and lunch revealed Resident #107 was provided with staff assistance for her meals. Based on the observations, she had a fair to good intake. On 9/11/25 at 8:13 AM, Resident #107 was observed from the hallway as Nurse Aide (NA) #5 sat next to her bed and attempted to feed her the breakfast meal. The NA was overheard as he called the hall nurse into the room to tell her the resident was not wanting to eat. The nurse was observed as she went into the room and encouraged the resident to try to eat and drink. An interview was conducted on 9/11/25 at 12:55 PM with NA #5. Upon inquiry, the NA reported that once Resident #107 got started eating her breakfast earlier that morning, she ended up having a fair to good intake. An observation made on 9/11/25 at 12:56 PM revealed Resident 107's lunch tray was not present in her room. The resident's lunch tray was located among the meal trays that had already been served and returned to a meal cart. The observation of Resident #107's lunch tray revealed the meal had not been touched. On 9/11/25 at 1:13 PM, no residents on the hall (other than Resident #107) remained to be assisted with his/her meal. NA #5 was then asked about the resident's lunch meal tray. The NA stated he thought someone else had fed the resident. When told where Resident #107's meal tray was located, NA #5 went to the meal cart, observed her meal tray, and confirmed no one tried to feed Resident #107. The NA was observed as he removed the lunch tray from the cart and proceeded into Resident 107's room to assist her with the meal. On 9/11/25 at 2:00 PM, NA #5 requested an interview. The NA appeared excited as he pulled out his phone, stating he wanted to share a picture of Resident #107's lunch plate. The picture showed the resident consumed nearly 100% of the food provided. When the NA was asked what would have happened if the lunch tray on the meal cart had not been brought to his attention, he stated, “She wouldn't have gotten fed her lunch at all.” A follow-up interview was conducted on 9/12/25 at 11:00 AM with NA #5. Upon inquiry, NA #5 reported he fed the resident her dinner last evening (9/11/25) and she ate very well. He showed a picture of her meal plate, revealing she consumed almost 100% of the meal. During this interview, NA #5 was asked as to how staff were assigned to help the residents who required assistance with their meal. The NA stated, There's no communication. He reported that because this resident's lunch tray had been moved from one cart to another cart on 9/11/25, he mistakenly assumed someone had fed her. An interview was conducted on 9/12/25 at 11:20 AM with the facility's Director of Nursing (DON) related to the concern of the resident's 9/11/25 lunch meal tray not being served to her without surveyor intervention. The DON stated his expectation was that every resident who needed assistance with feeding would be fed. An interview was conducted on 9/12/25 at 1:10 PM with the facility's Administrator. During the interview, the observation made of staff failing to assist Resident #107 with her lunch meal on 9/11/25 was discussed. The Administrator stated that all residents requiring assistance with meals should be assisted. She reported the facility's process needed to be reviewed to ensure NAs knew who they were assigned to assist with each meal. 3. Resident #85 was readmitted to the facility 2/28/24 with diagnoses including stroke and hemiplegia (paralysis on one side of the body from a stroke). The most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #85 to be cognitively intact. The MDS documented Resident #85 had limited range of motion on one side of his body, upper and lower limbs. Resident #85 was documented to require set-up assistance for personal hygiene (including shaving), and he was dependent on staff for bathing. A review of the care plan for Resident #85 with a revision date of 3/3/25 addressed his need for assistance with activities of daily living (ADLs) but did not include specific interventions for the provision of bathing and personal hygiene. Resident #85 was observed on 9/8/25 at 11:02 AM. His facial hair was thick, covering his cheeks, chin, neck, and was greater than ¼ inch in length. The free edge of the fingernail for all 10 of Resident #85's fingernails extended greater than ¼ inch past the tips of his fingers and there was dark material noted under the free edge of the nails on the right hand. Resident #85 was interviewed at the time of the observation, and he reported he was able to shave his face with an electric razor if he was set up for the task by a nursing assistant (NA). Resident #85 reported he had asked the NAs (unknown) to set up his electric razor to shave himself, but no NA staff had set him up with the electric razor to shave. Resident #85 clarified he needed the razor brought to him, and he needed to be sitting up with a mirror to shave. When asked about his long fingernails, Resident #85 reported that because of his stroke, he was unable to clip his fingernails and needed someone to do that for him. Resident #85 reported he had asked several (unknown) NAs to have his nails trimmed, but no one had done that for him. Resident #85 reported he felt frustrated because he could not maintain his normal level of grooming. Resident #85 was observed on 9/10/25 at 11:18 AM. His facial hair and fingernails were unchanged from the observation from 9/8/25 at 11:02 AM. Resident #85 was interviewed at the time of the observation, and he reported a NA had brought him one washcloth “a while ago” and told him to wash his face and body it with it. He showed one dry washcloth and that he didn't have water, soap, or a towel to wash. NA #10 was interviewed when she returned to Resident #85's room on 9/10/25 at 11:24 AM. NA #10 reported she had been assigned to Resident #85 “a few times” and she had left Resident #85 with one washcloth to protect his privacy while he was using the urinal. NA #10 reported she had planned to return to Resident #85's room to assist him with a bath. When asked about his facial hair and his fingernails, NA #10 agreed that both were long and needed trimming. When asked if she had offered to provide shaving and nail care to Resident #85, NA #10 reported that she had never offered him shaving or nail trimming. Resident #85 was observed again on 9/10/25 at 3:39 PM. Resident #85's facial hair had been shaved, but his fingernails remained in the same condition as the observations on 8/8/25 and 9/9/25. Regarding the status of Resident #85's nails, which remained untrimmed and the debris from under the free edge of the nail uncleaned, Resident #85 reported in an interview, “She (NA #10) left and said she would try to do it later.” NA #10 was interviewed again on 9/10/25 at 3:45 PM and she reported she would cut Resident #85's fingernails “later, after dinner.” Nurse #6 was interviewed 9/10/25 at 3:53 PM at Resident #85's bedside and she agreed that Resident #85's nails were too long and should have been trimmed. Unit Manager (UM) #1 was interviewed on 9/11/25 at 3:24 PM and she reported she had not noticed Resident #85's facial hair or long nails. UM #1 explained that she did daily rounds to check on residents, but she was not checking to ensure that care and ADLs, including facial shaving and nail care, were being completed. UM #1 reported she was mostly concerned with residents being clean, dry, and fed. The Director of Nursing (DON) was interviewed by phone on 9/12/25 at 4:58 PM. The DON reported he was not aware Resident #85 had facial hair was greater than ¼ inch in length, and the free edge of his fingernails were greater than ¼ inch past the tips of his fingers or there was dark material noted under the nails. The DON explained that agency staff were providing care, and the facility had been working with the agency staff to improve the quality of care. The DON reported he expected ADL care to be provided to residents, including shaving and nail care.

Based on record reviews, observations and resident and staff resident interviews, the facility failed to provide supervision for a resident who was assessed as requiring both supervision and use of a smoking apron to promote safety while smoking. This deficient practice occurred for 1 of 16 residents reviewed for accidents (Resident #7)The findings included:Resident #7 was admitted to the facility on [DATE] from a hospital. The resident's cumulative diagnoses included a history of a stroke with hemiplegia/hemiparesis (complete paralysis to partial weakness), and unspecified psychosis not due to a substance or known physiological condition.The resident's most recent Minimum Data Set (MDS) assessment was a quarterly assessment dated [DATE]. The assessment indicated Resident #7 had intact cognition. The MDS indicated Resident #7 had a functional impairment of range of motion on one side of his upper and lower extremities. The resident was reported as being independent with eating but required substantial to maximum assistance for bed mobility, sit to stand, and chair to bed to chair transfers. Resident #7 was totally dependent on staff for toileting, bathing, dressing, and personal hygiene.Resident #7's care plan included the following area of focus, in part:--The resident prefers to smoke cigarettes (Date Initiated: 8/27/25). The planned interventions included: may smoke independently (Date Initiated: 8/27/25); supervise with smoking (Date Initiated: 9/2/25); and smoking apron (Date Initiated: 9/2/25).The resident's electronic medical record (EMR) included one Smoking-Safety Screen dated 9/2/25 and conducted by the facility's Director of Nursing (DON). This smoking assessment reported Resident #7 had a problem with dexterity and required the use of a smoking apron/blanket for safety. The assessment score was a 10, and noted a score of 5 or greater was indicative of requiring supervision with smoking. Under the topic of Care Plan, each box was checked on the Smoking - Safety Screen form to include all Care Plan Interventions listed. These interventions included: educate on facility smoking policy, may smoke independently, Occupational Therapy referral as needed, smoking apron, smoking assessment as needed, and supervise with smoking.An interview was conducted on 9/10/25 at 9:32 AM with Resident #7. During the interview, the resident confirmed he was a smoker and reported that late yesterday a facility staff member (not identified) told him he needed to be supervised when he went out to smoke. When asked if specific times were now designated when he can go out to smoke, he said, No. The resident was asked if he wore a smoking apron when he smoked in the courtyard. He stated, No and added that there weren't any smoking aprons available in the courtyard until this morning. Observations and interviews were conducted on 9/10/25 at 10:15 AM of the courtyard utilized as the facility's smoking area. Five (5) residents were in the smoking courtyard with one Nurse Aide (NA) #4 supervising. An interview was conducted on 9/10/25 with NA #4 on 9/10/25 at 10:17 AM. During the interview, the NA stated someone was always supposed to be out in the smoking area to supervise the smokers. When asked about the smoking aprons, the NA reported the facility just began using smoking aprons the day before (on 9/9/25). At that time, the NA was asked how she knew which residents were safe smokers, which required supervision, and which residents should wear a smoking apron to promote safety. NA #4 pointed to a list of Supervised Smokers located on a nearby table. Resident #7's name was observed to be on this list of Supervised Smokers. The NA reported she understood that all smokers requiring supervision needed to wear a smoking apron. An interview was conducted on 9/10/25 at 11:30 AM with the Administrator in the presence of the [NAME] President (VP) of Operations. During the interview, the Administrator was asked about the recent changes related to smoking that were implemented at the facility on 9/9/25. The Administrator and VP explained that during a recent mock survey, inconsistencies in the implementation of the facility's smoking practices were identified. Since the mock survey, smoking assessments have been conducted on all residents and the smokers were identified as either independent smokers or those that required supervision. Smoking aprons were ordered and received last week. Use of the smoking aprons began yesterday (9/9/25). The Administrator and VP reported the facility's smoking policy was discussed during each resident's smoking assessment and these changes were again reviewed with the residents on 9/9/25. The contradiction documented on Resident #7's smoking assessment (and care plan) which indicated the resident could smoke independently yet was required to smoke with supervision was addressed. The Administrator responded by stating that the smoking assessment (and care plan) should have indicated a smoker was either an independent or a supervised smoker. Upon inquiry, the VP of Operations reported the facility did not have a plan of correction (POC) in place related to smoking because the facility was still in the process of implementing a plan.An observation of the smoking courtyard was conducted 9/11/25 at 8:54 AM. Resident #7 was observed to be talking with another male resident in the courtyard designated for smoking. No staff members were in the courtyard for supervision at the time of the observation. Resident #7 was observed to be smoking a cigarette. The resident was neither supervised nor was he wearing a smoking apron. A follow up interview was conducted on 9/11/25 at 12:42 PM with the Administrator. During the interview, the Administrator was informed of the observation made of a smoker (who was designated as requiring supervision) smoking in the courtyard without staff supervision. The Administrator responded by stating that there needed to be supervision.An interview was conducted on 9/11/25 at 1:23 PM with the facility's DON. During the interview, the DON confirmed he completed all the residents' smoking assessments recently conducted. The DON reported he was made aware of the error he made on Resident #7's smoking assessment and needed to correct this resident's assessment to indicate he required supervision with smoking and was not an independent smoker. A follow up interview was conducted on 9/11/25 at 4:10 PM with the DON, who was joined by the Activities Director. When asked if nursing was responsible to schedule staff for smoking supervision in the courtyard, the DON reported the Activities Director would be taking over the scheduling of staff for smoking supervision at this point. Upon further inquiry, the DON and Activities Director stated the NA assigned to supervise smoking on 9/11/25 worked on the hall when no one was requiring supervision with smoking. The DON and Activities Director surmised that Resident #7 may have sneaked out there without telling the assigned NA that he was going out to smoke. They stated Resident #7 should have let the NA know he was going out to smoke so she could have gone with him.

Based on record review, observations, Resident Representative, and staff interviews, the facility failed to implement a fall mat for fall precautions for 1 of 4 residents reviewed for accidents (Resident #126).The findings included: Resident #126 was readmitted to the facility on [DATE] with diagnoses including dementia and hypertension. The annual Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #126 to be severely cognitively impaired. The MDS documented Resident #126 was dependent on staff for bed mobility. The MDS documented no falls since the previous quarterly MDS completed on 4/2/25. Care plans for Resident #126 last revised on 7/9/25 addressed Resident #126's potential for falling. Interventions included placing a fall mat on the floor on the left side of the bed. Resident #126 was observed on 9/8/25 at 12:03 PM. There was no fall mat on the floor on the left side of the bed. Resident #126 was positioned in the center of the bed, and the bed was in the low position. During the observation, Resident #126's Representative reported that Resident #126 could roll in bed. Another observation of Resident #126 was conducted on 9/10/25 at 11:31 AM. Resident #126 was positioned in the middle of the bed, turned on her left side, and the bed was in the low position. There was no fall mat on the floor on the left side of the bed. The fall mat was in the bathroom, rolled up against the wall. Unit Manager #1 was interviewed 9/10/25 at 11:58 AM. Unit Manager #1 reported she was not aware the fall mat for Resident #126 was rolled up in the bathroom, and it should be on floor as the care plan directed. Unit Manager #1 reported she did not know why the fall mat would have been in the bathroom and maybe a staff member had removed it during care and forgotten to put it back. Nursing Assistant (NA) #12 was interviewed 9/10/25 at 12:08 PM. NA #12 reported Resident #126 was able to roll in bed sometimes. NA #12 reported she had provided care to Resident #126 several times over the past month and was familiar with her care. NA #12 explained Resident #126 bed needed to be low and she required frequent checks, but NA #12 was not aware the fall mat should be on the floor. An interview was conducted by phone with NA #4 on 9/12/25 at 2:09 PM and she reported she provided care to Resident #126 almost every day and she was aware to keep Resident #126's bed low for fall precautions. NA #4 reported she had not seen the fall mat on the floor beside Resident #126's bed. NA #4 reported in the past several months Resident #126 had attempted to get out of bed.The Director of Nursing (DON) was interviewed by phone on 9/12/25 at 4:58 PM. The DON reported he was not aware the fall mat was rolled up in the bathroom and not on Resident #126's floor on the left side of her bed. The DON reported the fall mat should remain on the floor to prevent injuries if Resident #126 were to fall out of bed.

Based on observations, record reviews, and staff, resident, and Physician Assistant interviews, the facility failed to assess a resident for the ability to self-administer medications for 1 of 1 resident reviewed for self-administering medications (Resident #82).The findings included:Resident #82 was admitted on [DATE] with diagnoses that included progressive supranuclear ophthalmalgia (a disease that makes a person unable to move their eyes at will in all directions, especially looking upward), type II diabetes, and cognitive communication deficit.Resident #82 had an active physician's order for Refresh Tears Solution; instill 1 drop in both eyes every 1 hour as needed for dry eye, ordered 5/29/25, and Systane Solution 0.4-0.3%; instill 1 drop in both eyes three times a day for eye lubricant, ordered 6/9/25.Resident #82's significant change Minimum Data Set (MDS) assessment dated [DATE] assessed him to be cognitively intact with supervision or touching assistance with personal hygiene. A review of Resident #82's care plan dated 5/25/25 did not include a plan for self-administration of medication. The review of Resident #82's medical record did not reveal an assessment for self-administration of medication. During an observation of Resident #82's room and interview on 9/8/25 at 11:37 AM, a partially used bottle of Systane eye drops as well as an unopened bottle of Refresh eye drops were found on the resident's nightstand. The resident stated he had been administering his own eye drops every 3 hours whenever he needed them. Resident #82 said the nurses were aware he was giving his own eye drops as needed.A subsequent observation on 9/9/25 at 2:00 PM revealed a partially used bottle of Systane eye drops, a partially used bottle of Refresh eye drops, and an unopened bottle of Refresh eye drops continued to remain on Resident #82's nightstand.On 9/9/25 at 2:08 PM Nurse #1 was interviewed and stated she was aware Resident #82 had eye drops at the bedside because the resident's spouse kept bringing bottles of eye drops to the facility for his use. Nurse #1 stated she had told the spouse the facility was able to supply the resident's eye drops, but she did not instruct the spouse not to bring them in. Nurse #1 indicated she was not aware if the resident had an order to self-administer medications, and she had not reported the eye drops being left at the bedside to management because she was not aware they needed to be reported. Unit Manager #2 was interviewed on 9/9/25 at 2:14 PM who stated residents were not supposed to have medications kept at their bedside. She indicated Resident #82 had not been assessed for self-administration of medications, and the nurses should have kept all medications, including eye drops, locked in the medication cart.On 9/10/25 at 12:19 PM the Director of Nursing (DON) was interviewed who stated eye drops were not supposed to be left on the resident's nightstand unless the resident had a care plan to self-administer. He verified Resident #82 did not have an order to self-administer medications.The Physician's Assistant (PA) was interviewed on 9/11/25 at 12:50 PM who stated he had not written an order for Resident #82 to self-administer his medications or have eye drops at the bedside. The PA stated due to the resident's multiple diagnoses, he was not sure if the resident knew how to administer eye drops correctly.

Based on record review and staff interviews, the facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) form 10555 prior to discharge from Medicare Part A skilled services for 2 of 3 residents reviewed for beneficiary protection notification review (Resident #28 and Resident #83).The findings included:1. Resident #28 was admitted to the facility and to Medicare Part A skilled services on 5/22/25.Resident #28's Medicare Part A skilled services ended on 7/2/25. She remained in the facility.Record review revealed there was no documentation Resident #28, or her Responsible Party (RP) were issued a SNF-ABN. During a phone interview with the previous facility Social Worker on 9/11/25 at 12:56 PM she stated it was her job to issue the SNF-ABN. She stated when a resident's Medicare Part A skilled services were about to end, she provided the SNF-ABN to either the resident if they were their own Responsible Party or to the family if they were still going to remain in the facility. The Social Worker did not provide a reason as to why the SNF-ABN for Resident #28 was overlooked.An interview was conducted with the Administrator on 9/12/25 at 10:35 AM who indicated it was the Social Worker's responsibility to issue all SNF-ABN's if the resident remained in the facility after the Medicare Part A skilled services ended and that Resident #28 should have received the SNF-ABN as required by Federal guidelines. 2. Resident #83 was admitted to the facility and to Medicare Part A skilled services on 6/6/25.Resident #83's Medicare Part A skilled services ended on 7/2/25. He remained in the facility.Record review revealed there was no documentation Resident #83, or his Responsible Party were issued a SNF-ABN. During a phone interview with the previous facility Social Worker on 9/11/25 at 12:56 PM she stated it was her job to issue the SNF-ABN. She stated when a resident's Medicare Part A skilled services were about to end, she provided the SNF-ABN to either the resident if they were their own Responsible Party or to the family if they were still going to remain in the facility. The Social Worker did not provide a reason as to why the SNF-ABN for Resident #83 was overlooked.An interview was conducted with the Administrator on 9/12/25 at 10:35 AM who indicated it was the Social Worker's responsibility to issue all SNF-ABN's if the resident remained in the facility after the Medicare Part A skilled services ended and that Resident #83 should have received the SNF-ABN as required by Federal guidelines.

Based on record review, and resident representative and staff interviews, the facility failed to maintain documentation of resolved grievances for 2 of 3 residents (Resident #121 and Resident #170) and evidence of the results of all grievances for 6 of 11 months reviewed (February 2025 to July 2025). Findings included: Review of the facility policy last reviewed on 3/8/24 titled Grievance Policy read in part: The facility must ensure that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent finding or conclusions regarding the resident's concerns, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken by the facility, and the date the written decision was issued.Review of the current facility grievance log for November 2024 through present showed there were no grievances logged between 2/1/25 through 7/31/25.During a phone interview with the previous Social Worker (SW) on 9/11/25 at 12:56 PM who stated her last date of work at the facility was 8/15/25. The SW reported that she was taking paper grievances until the facility began using a new computer system sometime during the Spring of 2025. The SW stated she would pass out the grievances to the different department heads as needed if she couldn't resolve the issue on her own and then kept a copy of all of the grievances in her office in a binder. The SW she did not know who was in charge of the grievances after the computer program was initiated and stated she only handled the paper ones that were given directly to her by residents and/or family members. The SW added she thought it was each department head's responsibility to follow-up on their specific grievances.The facility did not have a staff member in the role of Social Worker during the survey.During an interview on 9/9/25 at 1:11 PM with Resident #121's Responsible Party (RP), she stated she was very concerned about the length of time it took for staff to provide incontinent care for Resident #121 who was not cognitively intact. Resident #121's RP reported she did notify the facility Social Worker of her concerns regarding incontinent care on 7/12/25 after a Medicaid representative advised her to file a grievance with the facility. Resident #121's RP reported the facility never responded to her or resolved her concerns with a written response.During an interview on 9/10/25 at 4:25 PM with Resident #170's Responsible Part (RP), she stated she filed a paper grievance with an unnamed nurse aide on 7/31/25 regarding a delay with incontinent care on behalf of Resident #170 who was not cognitively intact. Resident #170's RP reported she did not receive any communication from the facility regarding the issue. During an interview with Administrator #1, the current administrator, on 9/11/25 at 2:20 PM she stated the grievances from February 2025 through July 2025 were not available and could not be reviewed because she did not have the grievances as the facility had been unable to locate the grievances in the Social Worker office. The Administrator stated any paper grievances she had received from residents or resident family members were handed off to the Social Worker who would enter them into the computer system. The Administrator stated she had been made aware the previous facility Social Worker had not been maintaining any paper grievances for several months during an internal mock survey by the company last month. The Administrator reported she was currently handling grievances since 8/1/25 until they can hire a new Social Worker. The Administrator presented a draft plan of correction to show they were working on a plan to correct that issue. The draft plan of the plan of the correction was found to be incomplete due to a lack of information regarding who was going to be responsible for grievances in the future and there was no information as to how grievances would be monitored to ensure compliance.

Based on record reviews, and interviews with staff, family, Nurse Practitioner, Medical Director, and responsible party (RP), the facility failed to protect the residents' right to be from resident- to- resident sexual abuse when a cognitively intact male resident (Resident #5) touched a female resident's (Resident #160's) breasts without her consent and made sexually explicit statements to her that included talking about the size of his penis. In addition, Resident #178 who was a moderately impaired male resident touched a female (Resident #163) between her legs near her vaginal area without her consent. This was for 2 of 4 residents reviewed for resident-to-resident abuse (Resident #160 and Resident #163). The findings included: Resident #160 was admitted to the facility on [DATE]. with diagnoses that included depression and anxiety. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #160's cognition was intact, she had no behaviors and was independent with using her wheelchair. Resident #160's care plan dated 8/4/2025 indicated the resident had problem areas that included the risk for complications related to cognitive impairment secondary to memory impairment; and the resident had signs and symptoms of depression and was at risk for adverse reactions. Resident #160 had no care plan related to behaviors. Resident #5 was admitted to the facility on [DATE] with diagnoses that included stroke, hemiplegia (paralysis or complete loss of movement on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction affecting right dominant side, and depression. Resident #5's care plan dated 6/25/25 indicated the resident had a problem area that included the resident having behaviors. The care plan provided no specifics as to the type of behaviors the resident had. The interventions included to administer medication as ordered, assign staff members that were familiar or preferred by the resident when possible, and referral to psychiatric services as needed. A quarterly MDS assessment dated [DATE] indicated that Resident #5's cognition was intact, he had no behaviors and was independent with using his wheelchair. An initial report dated 8/18/25 at 3:36 PM completed by the Administrator indicated there was an allegation of resident-to-resident sexual abuse between Resident #160 and Resident #5 on 8/17/25. The initial report recorded the facility became aware of the incident on 8/18/25 at 3:00PM. Details of the allegation stated that Resident #5 sexually assaulted Resident #160. Resident #160 stated that Resident #5 brushed her breast area and was asking her if she wanted to have sex and was talking to her about his privates. Resident #160 stated this happened while she was outside in the courtyard on Sunday (8/17/25) morning. Resident #160 stated that Resident #5 approached her in his electric wheelchair. Resident #5 was put on 1 on 1 supervision until an assessment could be completed by the physician. The facility notified the local law enforcement of the allegation on 8/18/25 at 3:00 PM. Written statements completed by the Administrator dated 8/18/25 indicated the following: - Resident #160 was upset when she shared the allegations with the Administrator. Resident #160 reported to Nurse Practitioner (NP) #2 that she was having difficulty sleeping due to the trauma but also reported that she had been having trouble sleeping since her admission to the facility. - Resident #5 stated that he and Resident #160 were very close friends and Resident #160 had enjoyed time with him and his family during their visits. Resident #5 stated that he and Resident #160 talked in the courtyard and on 8/17/25 Resident #160 asked him for cigarettes and Resident #5 refused to share. Resident #5 stated that she was upset but they continued to talk. Resident #5 stated that he told Resident #160 a story about an ex-girlfriend and private times that they shared together. The Administrator asked Resident #5 if he thought it was appropriate to discuss sex or private parts when talking with females and Resident #5 stated “we are just friends, but I guess not.” Resident #5 stated that he didn't mean anything by what he was talking about and that he thought they were just friends. Resident #5 stated that he probably touched Resident #160's arm and maybe around the area of her breasts. Resident #5 stated that it was nothing. The police report dated 8/18/25 at 2:59 PM indicated the following: Resident #160 reported that Resident #5 sexually assaulted her. She indicated that she arrived at the rehabilitation center 4 months prior and met Resident #5. Resident #160 stated that the two were friendly and would interact when she went outside to smoke. Resident #160 stated that her relationship with Resident #5 was never romantic and that they only interacted in common areas. She stated that “about a week and a half ago his behaviors changed.” Resident #160 reported that Resident #5 began making sexual comments and following her around the facility. She indicated that Resident #5's comments consisted of referring to his penis as “Robo” and discussing “Robo” with her. Resident #160 reported that Resident #5 grabbed her right breast on two different occasions. She stated that one time it happened in the courtyard and another time near one of the nurse's stations. Resident #160 stated that both times she pushed his hand away and firmly stated “no.” On 9/11/25 at 8:05 AM call was placed to the local police department, message was left for the investigating officer, but no return call was received. The facility's investigation report dated 8/22/25 completed by the Administrator indicated the following: The resident-to-resident abuse was not a willful intent to inflict harm. Both Resident #160 and Resident #5 were instructed not to visit each other and Resident #5 continued to have 1 on 1 staff supervision until he was cleared through the behavioral health provider's visit scheduled for 8/25/25. The facility unsubstantiated the allegation of abuse. On 09/09/2025 at 8:45 AM an interview occurred with Resident #160. Resident #160 stated that an incident had occurred between she and Resident #5 two to three weeks ago. Resident #160 was unable to give an exact date. Resident #160 stated that she spent a lot of time outside in the smoking area daily. Resident #160 stated that sometimes Resident #5 came to her in the smoking area and said inappropriate things to her when no one else was around. Resident #160 revealed a video from her phone of Resident #5 on 8/15/25 at 5:00pm. In the video, Resident #5 was sitting in his wheelchair and only parts of his legs and feet could be seen. Resident #5 was heard saying I have a big dick, and the girls call it Robo like a big ship.” Resident #160 was not heard in the video responding but she stated that she told Resident #5 that she did not want to hear those types of things about him. Resident #160 reported that she told Resident #5 that she just wanted him to leave her alone. Resident #160 stated that she did not report this initial occurrence because she figured that Resident #5 would just leave her alone after she told him to. She indicated that at no time had she ever expressed any interest in Resident #5 speaking to her this way. Resident #160 reported that this occurrence was a different occurrence from the one that she reported to the Administrator on 8/18/25. She explained that the incident she reported to the Administrator occurred on the morning of 8/17/25 in the courtyard when Resident #5 grabbed her breasts inappropriately. Resident #160 reported that it occurred quickly, and it happened over top of her t-shirt that she was wearing. Resident #160 reported that she did not consent to this sexual act. Resident #160 reported that she told Resident #5 to leave her alone and he did. Resident #160 reported that she did not report the incident on that day but did report it the following afternoon because her friend encouraged her to do so. Resident #160 reported that her friend assisted her in pressing charges against Resident #5 through the police department. Resident #160 reported that at no time had she ever expressed any interest in Resident #5 inappropriately touching her. Resident #160 reported that there were other residents outside during the time of the incidents, but she was unable to recall who they were. Resident #160 reported that no one else saw what happened. Resident #160 reported that Resident #5 would not come around her if others were around her already. Resident #160 did not report that this incident was preventing her from doing anything in her normal daily routine. She indicated that she had continued to go outside and smoke whenever she wanted. She stated that she had seen Resident #5 since the incident but only from a distance. Resident #160 reported that initially staff were supervising Resident #5 when he was outside smoking but that had stopped. On 9/10/25 at 11:20 AM an interview occurred with Resident #5. Resident #5 revealed that the incident between him and Resident #160 did occur on 8/17/25 where he touched her breasts and said sexual things to her in the smoking courtyard area. Resident #5 reported that he touched Resident #160's arm and maybe around her breasts. Resident #5 reported that it all happened in seconds, and Resident #160 was wearing a t-shirt that she wears a lot. Resident #5 reported that he was telling Resident #160 a story about his ex-girlfriend and private times that they shared together. Resident #5 reported that he did this because he thought they had a relationship going. Resident #5 reported that in the past (unable to provide a date) he and Resident #160 had even talked about getting an apartment together once they got out of the facility. Resident #5 stated that when he grabbed Resident #160's breasts she did get upset with him, told him to stop, and reported him the next day for doing it. Resident #5 stated that the Administrator had him come into her office the same day that Resident #160 reported him. Resident #5 stated that since that happened, he had been maintaining his distance from Resident #160 and has not touched anyone else. Resident #5 stated that generally he is a follow the rules kind of guy. On 9/10/25 at 11:30 AM an interview with Nurse Practitioner (NP) #1 revealed that he had been working with both Resident #5 and Resident #160 on addressing the concerns from the reported allegations. NP #1 stated that he had been given the impression through conversations by both residents that they had been in a long-standing relationship up until recently. NP #1 stated that the allegations of sexual misconduct including touching and inappropriate comments were reported to him and both parties did agree that it happened but with different versions of the incident. NP #1 stated he asked Resident #5 if he touched Resident #160 and he stated that he probably touched her arm and maybe her breasts. NP #1 stated that Resident #160 reported that Resident #5 grabbed her breast area and was talking to her about his private parts. NP #1 indicated that after the incident was reported he referred both residents to be evaluated by psychiatry. A psychiatry progress note was completed on 8/19/25 by NP #2 (Psychiatric Nurse Practitioner) for Resident #160. Resident #160 was seen on this date per request due to allegations of sexual misconduct. Resident #160 reported that another resident had sexually assaulted her a few days prior. Resident #160 reported to NP #2, I'm okay, I already told that other guy what happened, Resident #5 grabbed my breast yesterday, I've told him several times to leave me alone and he will not. He talks dirty and says sexual things to me constantly and I try to ignore him but then he keeps telling me how big his dxxx is, I don't care anything about his dxxx and I want him to leave me alone. They moved me to another hallway, and he still comes to hunt for me. Yesterday when he grabbed my boob, I called the police and reported him. Resident #160 reported to NP #2 that her appetite was good and she was sleeping good. Resident #160 denied any suicidal thoughts or depressive symptoms reporting to NP #2 I just want him to leave me alone. Staff reported no new behavioral issues to NP #2. NP #2 referred Resident #160 to psychotherapy for follow up as she did not want any medication changes. Plan was to continue with Effexor and Remeron for her mood. Staff were to continue supportive care as needed. Staff were to continue to encourage self-care and socialization. Resident #160 was encouraged to notify staff if Resident #5 made any contact with her. A psychiatry progress note was completed on 8/25/25 by NP #2 for Resident #160. Resident #160 was seen on this date to follow up regarding depression and anxiety. Resident #160 reported to NP #2, I'm doing fine, just wish everyone would stop bothering me, I'm not even thinking about Resident #5, so everyone just needs to hush about the situation. Resident #160 reported that Resident #5 had not bothered her since her last visit with NP #2. Resident #160 reported to NP #2 that her appetite was good, and she was sleeping well. Resident #160 denied any suicidal thoughts or depressive symptoms during this visit. Staff reported no new behavioral issues to NP#2. Plan was to continue with Effexor and Remeron for her mood. Staff were to continue supportive care as needed. Staff were to continue to encourage self-care and socialization. Resident #160 was encouraged to notify staff if Resident #5 made any contact with her. A psychiatry initial consult was completed on 8/26/25 by NP #2 for Resident #5. Resident #5 was seen on this date for initial psychiatric evaluation and to establish care under psychiatry services. NP #2 also seeing Resident #5 regarding recent allegations made by another resident that he grabbed her breast. Resident #5 reported that he had been eating and sleeping just fine. Resident #5 stated to NP #2 he thought she was there because of Resident #160. Resident #5 indicated he thought we were friends, and they had been talking to each other for a long time. Resident #5 stated, I did grab her boob a while ago. The resident told NP #2 he would not bother Resident #160 again because she's not going to get me in trouble. He also stated to NP #2, I don't want to be in trouble here in the facility, but it wasn't all me, but I will absolutely stay away from her, I would never touch anyone without their permission, never been in any kind of trouble before. Resident #5 reported to NP #2 that he did not want any medications changes regarding his depression. Plan was to continue Sertraline as ordered and refer to psychotherapy. NP #2 also discouraged Resident #5 from any type of interaction with Resident #160. On 9/11/2025 at 11:40 AM a phone interview occurred with NP #2. NP #2 reported that she had worked with both Resident #160 and Resident #5. NP #2 reported that it was hard to get much information from Resident #160 because she did not like to talk much. NP #2 reported that Resident #160 basically stated on 8/19/25 that she did not want Resident #5 touching her or saying sexual things to her. NP #2 reported that Resident #160 shared on 8/19/25 that her appetite was good and she was sleeping well and denied any suicidal thoughts or depressive symptoms. NP #2 stated that Resident #5 reported on 8/26/25 that he and Resident #160 were in an ongoing relationship and he admitted to touching Resident #160 stating, “I did grab her boob a while ago” because he felt that they were in a relationship and she would be fine with him touching her. NP #2 stated that during her visit with Resident #5 on 8/26/25 she told him moving forward that he needed to stay away from Resident #160 and he agreed to do so. NP #2 stated that after speaking with Resident #5 she felt like he understood the importance of staying away from Resident #160 and that he did not need ongoing 1 on 1 supervision. NP #2 stated that she referred both Resident #160 and Resident #5 to therapy. On 09/11/2025 at 3:53 PM an interview was conducted with Nurse Aide (NA) #7. She reported that she worked with both Resident #160 and Resident #5 and heard about the allegation related to both residents. She indicated she had no first-hand knowledge of the allegation, but she spoke about Resident #5's history. She stated that Resident #5 had no history of inappropriate sexual behaviors. On 09/11/2025 at 1:51 PM interview occurred with the Director of Nursing (DON). The DON reported that he and the Administrator met with Resident #5 on 8/18/25 about sexual abuse concerns and explained to him the importance of not going near Resident #160 and not saying anything to her. The DON stated that Resident #5 was placed on 1 on 1 supervision on 8/18/25 until he was cleared by both medical providers, Medical Director (MD) and NP #1, on 8/25/25. The DON stated that MD and NP #1 agreed with Resident #5 returning to the communal resident areas within the facility without 1 on 1 supervision. On 09/11/2025 at 2:19 PM an interview occurred with Administrator and revealed that Resident #160 and her family member came into her office the afternoon of 8/18/25 and reported that Resident #5 sexually assaulted Resident #160 on 8/17/25. The Administrator reported that Resident #160 stated that Resident #5 brushed her breast area and was talking to her about his privates. Resident #160 stated that this occurred while she was in the outside courtyard on the morning of 8/17/25. The Administrator reported that she called the local police department so that a report could be made. The Administrator reported that the police came and met with Resident #160 and her family member privately without staff present and took the report. The Administrator reported that she and the DON met with Resident #5 on 8/18/25 regarding the allegations of sexual assault. The Administrator reported that they explained to Resident #5 the importance of him not going near Resident #160 again. The Administrator reported that he (Resident #5) expressed understanding and stated that he would not go near her again. The Administrator reported that Resident #5 was placed on 1 on 1 supervision on 8/18/25 until he was cleared by medical providers, MD and NP #1. On 09/12/2025 at 8:44 AM a phone interview occurred with the Medical Director (MD). He indicated that he was not present at the facility when the initial reported incident allegations of sexual assault occurred, but NP #1 updated him regarding the allegations. The MD reported that he saw both Resident #160 and Resident #5 for follow-up later that week. The MD reported that he had no concerns regarding Resident #5 being taken off 1 on 1 supervision and returning to the communal resident areas within the facility without supervision effective 8/25/25. The MD indicated he did not feel that Resident #5 was a danger to others. The facility was unable to provide evidence of a corrective action plan regarding the facility's failure to protect a resident's right to be free from resident-to-resident abuse. 2. Resident #178 was initially admitted to the facility on [DATE] with diagnoses that included communication deficit, adult failure to thrive and depression. The quarterly MDS assessment dated [DATE] revealed Resident #178 was moderately cognitively impaired and had no behavioral symptoms or wandering during the 7-day MDS look back period. Resident #178 was independent with dressing, transfers, and ambulation. Resident #178's revised care plan dated 2/17/25 did not have a care plan for behaviors or for inappropriate verbal statements to staff. Resident #178 was discharged on 4/17/25 and unavailable for interview. The telephone number listed in the record was no longer available. Resident #163 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, communication deficit and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #163 had unclear speech, had difficulty making herself-understood and was severely cognitively impaired. Resident #163 had no behavioral symptoms during the 7-day MDS look back period. Resident #163 required 1-person assistance from staff for activities of daily living and used a wheelchair for mobility. Resident #163's revised care plan dated 4/1/25 included a focus area for impaired cognitive function and impaired thought process related to dementia/Alzheimer's disease. Resident #163's care plan did not identify any inappropriate behaviors. An interview was conducted on 9/9/25 at 9:30 AM with Resident #163 who was unable to be interviewed due to advanced dementia. The incident report completed by the former Director of Nursing on 3/7/25 at 1:35 PM revealed Resident #178 was found in the dining /activity room with Resident #163 with his hand located on Resident #163's genital area. Both residents were separated immediately. Skin assessments were done for both residents and there were no injuries noted. The nurse practitioner, physician, responsible parties for both residents and local law enforcement were notified of the incident. A full body assessment dated [DATE] was completed by the Director of Nursing revealed Resident #163 was assessed due to resident-to-resident sexual abuse. No injuries observed at time of incident. A full body assessment dated [DATE] was completed by the Director of Nursing revealed Resident #178 was assessed due to resident -to-resident sexual abuse. No injuries observed at time of incident. The initial allegation report dated 3/7/25 completed by the former Administrator indicated Resident #178 and Resident #163 were seated at a table in the dining room. Resident #178 was seen rubbing his hand near the vaginal area, on top of clothing of Resident #163, witnessed by Nurse Aide #13. Both residents were separated immediately, and Resident #178 was placed on 1:1 pending psych evaluation. The physician, state agency, local law enforcement and responsible person(s) for both residents were notified. No injury or harm or change of condition noted for either resident and they were each at baseline mental and physical status. Nurse Aide #13's written statement could not be located by the current Administrator. A telephone interview was conducted on 9/9/25 at 1:47 PM with the Nurse Aide #13 who stated Resident #178 and Resident #163 were in the dining room at the same table on 3/7/25 and Nurse Aide #13 recalled on 3/7/25 around 1:00 PM she walked through the dining/activity door and saw the two clothed residents sitting at the table. Resident #178 had one hand on the back of the wheelchair and one hand in between the legs of Resident #163 near the private area. Resident #163 was non-verbal and unaware of what was happening and did not have a direct reaction to what was being done to her. Resident #163 did not show any emotion or discomfort. Nurse Aide #13 stated she immediately separated the two residents and there were no visible signs that any force by Resident #178 was applied to Resident #163 private area. Nurse Aide #13 further stated she was not certain whether Resident #178 knew exactly what he was doing, and he did not express why he was doing what he was doing. Resident #178 walked back to his room, and she immediately reported the observation to Nurse #10. Resident #178 was placed on 1:1 supervision and Nurse #10 took over from that point. She indicated she documented a written statement of events and spoke with the Administrator and the police about the incident. Nurse Aide #13 did recall if Resident #178 had previous inappropriate behaviors. A telephone interview was conducted on 9/11/25 at 11:00 AM with Nurse #10 who stated on 3/7/25 Nurse Aide #13 reported to her she had observed Resident #178 inappropriately touching Resident #163 in the dining area. Nurse Aide #13 stated both residents were fully clothed, and Resident #178 had his hand on Resident #163's private area. Nurse #10 stated she could not recall if the nurse aide stated there was any force being applied by Resident #178 to Resident #163 private area. She stated the nurse aide reported she removed the two residents and the male resident returned to his room. She indicated the incident was immediately reported to the Director of Nursing and Nurse Practitioner at 1:21 PM. She indicated both residents were checked for any injuries or skin /mental changes. She further stated Resident #178 was immediately assigned a staff member and placed on 1:1 supervision on 3/7/25 until he could be seen by psychiatric services for evaluation. Resident #163 was non-verbal and unable to recall any part of the incident. Resident #163 did not show any visible distress, voice any complaints, or express discomfort. Nurse #10 stated she obtained a statement from Resident #178 who stated nothing happened and he was upset that he was accused of touching the female resident. Nurse #10 stated she spoke with Resident #163's RP and informed him that Resident #163 was inappropriately touched by a male resident. She further stated the RP was informed the investigation process included Resident #163 was assessed from head-to-toe with no visible injuries and Resident #178 placed on 1:1 supervision. Nurse #10 reported the RP for Resident #163 did not express that he was extremely upset and stated he was glad Resident #163 was safe, and the other person was removed immediately. Nurse #10 stated she also contacted Resident #178's RP and informed them of the incident and that Resident #178 would be referred to psychiatric services and placed on 1:1 pending the evaluation. The RP stated she was unaware of previous or a history of inappropriate sexual behaviors from Resident #178 and agreed with the monitoring and referral. Nurse #10 did not indicate Resident #178 had displayed any prior inappropriate physical or verbal behaviors. A psychiatric note dated 3/7/25 revealed a telehealth visit occurred for Resident #178 about an incident involving inappropriate touching of another patient at the facility. The facility requested the visit which was done by telehealth with assistance from facility staff. Resident #178 reported that he was trying to shoo a fly off another patient's leg and denied any inappropriate touching. He states, I got more sense than that. The patient was able to ambulate freely and is not in a wheelchair. He is currently on trazodone but denies any issues with sleep and is unsure why he is taking the medication. The psychiatric assessment revealed Resident #178 was not currently a danger to self/others. The incident involving Resident #178 and another patient was discussed, where he reportedly shooed a fly off the other patient's leg. There was no indication of inappropriate touching or any malicious intent. Resident #178 was alert and oriented, as evidenced by his correct identification of the date and his clear responses during the conversation. Plan: A reminder about appropriate behavior and personal boundaries will be given to Resident #178. A 1:1 supervision will be implemented for the rest of the day, followed by 30-minute checks four times, and then hourly checks until an in-person psychiatric evaluation can be conducted. This plan was designed to ensure the safety and well-being of all patients in the community. No new orders, labs, or referrals at this time. A telephone interview was conducted on 9/11/25 at 11:22 AM with the Psychiatric Nurse Practitioner who stated she received a referral from the facility for an evaluation for Resident #178 due to a report of inappropriate touching of a female resident. The Psychiatric Nurse Practitioner stated she had seen Resident #178 on 3/11/25. She reported Resident #178 had history of inappropriate verbal statements to staff and no reports against any residents. She indicated Resident #178 was assessed with a basic interview of mental status (BIMS) of 12 which indicated Resident #178 had moderate cognitive impairment. She further stated Resident #178 continued to report he did not touch the female inappropriate and was moving a fly away from the individual. She stated she did not feel the resident had any malicious intent to harm or inappropriately touch anyone. She noted there had been no evidence or report of Resident #178 inappropriately touching any other residents reported by facility staff prior to incident. She stated there were no medication adjustments recommended based on this incident, however psychotherapy was the recommended intervention of choice to work with Resident #178 on cognitive behaviors on how to handle verbal emotions, motivation interactions/therapy. She reported Resident #178 had multiple psychotherapy visits until 4/17/25. She reported based on her evaluation the therapy was effective at the time, and the resident did not present as threat to other residents. The Investigation Report completed on 3/14/25 and submitted to the state by the former Administrator revealed Resident #178 was observed on 3/7/25 at 1:30 PM by a nurse aide rubbing his hand near the vaginal area on top of clothing of Resident #163. The incident occurred in the dining room and was witnessed by the nurse aide. Both residents were immediately separated, and Resident #178 was placed on 1:1 supervision pending psychiatric evaluation. Both residents received skin assessments with no negative findings by nursing. Both residents and staff were interviewed. Resident #163 was unable to be interviewed due to advanced dementia and Resident #178 stated he was shooing a fly away from Resident #163. The NP, Physician, police and responsible person for both residents were notified of the incident. Resident #178 was referred to psychiatric services for an evaluation on 3/7/25. Resident #178 was evaluated via telehealth on 3/7/25 and in-person on 3/11/25, there were no medication changes for Resident #178. Resident #178 continued with every hour checks until cleared by psychiatric services and a nurse aide was assigned to the dining area during meals. A telephone interview was conducted on 9/9/25 at 10:08 AM with Resident #163's RP who stated he received a call from the Director of Nursing who informed him of the 3/7/25 incident. He stated that due to Resident #163's advanced dementia she was not aware of and had no insight into what happened. Resident #178's RP was contacted on 9/11/25 at 10:09 AM and was unavailable for interview. The Greensboro police department was contacted on 9/8/25 at 12:16 PM and the officer that responded to call was unavailable for interview. Review of the social service note dated 3/7/25 revealed Resident #178 as well as the former Social Worker spoke with the physician from mental health via a telehealth visit due to the incident where Resident #178 was

Based on staff interviews and record reviews, the facility failed to complete annual Minimum Data Set (MDS) assessments within the required 14-day timeframe after the Assessment Reference Date (ARD, the last day of the assessment look-back period) for 2 of 54 residents whose MDS assessments were reviewed (Resident #107 and Resident #126).The findings included: 1. Resident #107 was admitted to the facility on [DATE]. The resident's annual comprehensive Minimum Data Set (MDS) assessment had an Assessment Reference Date (ARD) of 7/30/25. This assessment was signed as completed by the facility's Registered Nurse (RN) MDS Coordinator on 9/3/25. An interview was conducted on 9/10/25 at 3:23 PM with the MDS Coordinator, who was later joined by MDS Nurse #2. During the interview, Resident #107's annual MDS with an ARD of 7/30/25 was reviewed. Upon inquiry, the MDS Coordinator confirmed Resident #107's annual MDS was completed on 9/3/25 and acknowledged this assessment was completed late. An interview was completed on 9/10/25 at 11:30 AM with the facility's Administrator in the presence of the company's [NAME] President (VP) of Operations. During this interview, concerns were discussed related to the resident's MDS having been identified as completed more than 14 days after the assessment's ARD. The Administrator stated that the facility was aware of the issue and had hired two new MDS nurses (the MDS Coordinator and MDS Nurse #2) since May 2025. She was aware the new MDS nurses were behind on completing MDS assessments when they started. 2. Resident #126 was readmitted to the facility 8/13/25. The annual comprehensive Minimum Data Set (MDS) assessment had an Assessment Reference Date (ARD) of 6/26/25. The annual MDS was signed as completed by the Registered Nurse MDS coordinator on 8/15/25. The Care Area Assessment (CAA) was dated 6/26/25 and completed 8/15/25. An interview was conducted on 9/10/25 at 3:23 PM with the MDS Coordinator, who was later joined by MDS Nurse #2. During the interview, the nurses reported they were two months behind on completing MDS assessments when they started their positions at the facility and were still working towards catching up on the assessments. An interview was completed on 9/10/25 at 11:30 AM with the facility's Administrator in the presence of the company's [NAME] President (VP) of Operations. During this interview, concerns were discussed related to several residents' MDS assessments having been identified as completed more than 14 days after the ARD or greater than 120 days after the last MDS assessment was completed. The Administrator reported that the facility was aware of the issue and had hired two new MDS nurses (the MDS Coordinator and MDS Nurse #2) since May 2025. She was aware the new MDS nurses were behind on completing MDS assessments when they started. Upon inquiry, the VP of Operations reported the facility did not have a Plan of Correction (POC) fully implemented regarding the MDS assessments.

Based on staff interviews and record reviews, the facility failed to complete significant change in status Minimum Data Set (MDS) assessments within the required 14-day timeframe after the Assessment Reference Date (ARD, the last day of the assessment look-back period) for 2 of 54 residents whose MDS assessments were reviewed (Resident #14 and Resident #158).The findings included: 1. Resident #14 was admitted to the facility on [DATE]. The resident's significant change in status Minimum Data Set (MDS) assessment had an Assessment Reference Date (ARD) of 6/26/25. This assessment was signed as completed on 8/18/25. An interview was conducted on 9/10/25 at 3:23 PM with the MDS Coordinator, who was later joined by MDS Nurse #2. During the interview, Resident #14's significant change in status MDS with an ARD of 6/26/25 was reviewed. Upon inquiry, the MDS Coordinator confirmed Resident #14's significant change in status MDS was completed on 8/18/25 and acknowledged this assessment was completed late. An interview was completed on 9/10/25 at 11:30 AM with the facility's Administrator in the presence of the company's [NAME] President (VP) of Operations. During this interview, concerns were discussed related to the resident's MDS having been identified as completed more than 14 days after the assessment's ARD. The Administrator stated that the facility was aware of the issue and had hired two new MDS nurses (the MDS Coordinator and MDS Nurse #2) since May 2025. She was aware the new MDS nurses were behind on completing MDS assessments when they started. 2. Resident #158 was admitted to the facility 10/18/24 with diagnoses including dementia and chronic lung disease. Resident #158 was admitted to hospice on 7/31/25. Review of the significant change in status Minimum Data Set (MDS) assessment had an Assessment Reference Date (ARD) of 8/7/25. The assessment was signed as completed by the facility's Registered Nurse MDS Coordinator on 9/8/25. An interview was conducted on 9/10/25 at 3:23 PM with the MDS Coordinator, who was later joined by MDS Nurse #2. During the interview, the nurses reported they were two months behind on completing MDS assessments when they started their positions at the facility and were still working towards catching up on the assessments. An interview was completed on 9/10/25 at 11:30 AM with the facility's Administrator in the presence of the company's [NAME] President (VP) of Operations. During this interview, concerns were discussed related to several residents' MDS assessments having been identified as completed more than 14 days after the ARD. The Administrator reported that the facility was aware of the issue and had hired two new MDS nurses (the MDS Coordinator and MDS Nurse #2) since May 2025. She was aware the new MDS nurses were behind on completing MDS assessments when they started. Upon inquiry, the VP of Operations reported the facility did not have a Plan of Correction (POC) fully implemented regarding the MDS assessments.

Based on staff interviews and record reviews, the facility failed to accurately code Minimum Data Set (MDS) assessments in the areas of: 1) Activities of Daily Living (Resident #107); 2) Use of an antibiotic medication (Resident #8), and 3) Brief Interview for Mental Status (BIMS) and Pain assessment interview (Resident #48). This occurred for 3 of 54 residents whose MDS assessments were reviewed.The findings included: 1. Resident #107 was admitted to the facility on [DATE]. The resident's cumulative diagnoses included acute respiratory failure with hypoxia (an inadequate supply of oxygen to the tissues) and non-Alzheimer's dementia. The resident's care plan included the following areas of focus, in part:--Long term care: the resident requires assistance with Activities of Daily Living (ADL) related to advanced age, chronic health conditions and is a Hospice patient (Date Initiated: 2/5/25); --The resident is incontinent of bladder and bowels: inability to control bowel and bladder (Date Initiated: 2/5/25). Resident #107's most recent Minimum Data Set (MDS) assessment was an annual assessment dated [DATE]. The assessment reported the resident had severely impaired cognitive status and was dependent on staff for all her ADLs. The MDS also reported Resident #107 was occasionally incontinent of bladder and frequently incontinent of bowel. An interview was conducted on 9/11/25 at 8:22 AM with MDS Nurse #2. During the interview, MDS Nurse #2 was asked to review Resident's #107's MDS section related to “Bladder and Bowel.” Upon inquiry as to whether the MDS was correct when it indicated the resident as only occasionally incontinent of bladder and frequently incontinent of bowel, the nurse stated it was not. The nurse confirmed the resident was bedbound and the MDS assessment should have indicated the resident was always incontinent of bladder and bowel. An interview was conducted on 9/12/25 at 1:10 PM with the facility's Administrator to discuss the MDS concerns identified. During the interview, the Administrator reported she would expect the MDS assessments to be completed accurately. 2. Resident #8 was admitted to the facility on [DATE]. The resident's cumulative diagnoses included chronic kidney disease and respiratory failure with hypoxia. The resident's most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The MDS section on “Medications” indicated Resident #8 received an antibiotic medication during the 7-day look back period. Resident #8's electronic medical record (EMR) included May 2025 and June 2025 Medication Administration Records (MAR). A review of the MARs revealed no antibiotic medication was administered to the resident during the 7-day look back period for the 6/4/25 quarterly MDS assessment. An interview was conducted on 9/10/25 at 3:23 PM with the MDS Coordinator, who was later joined by MDS Nurse #2. During the interview, the MDS Coordinator reviewed Resident #8's EMR and 6/4/25 MDS. Upon review, she confirmed the resident did not receive an antibiotic during the 7-day look back period. An interview was conducted on 9/12/25 at 1:10 PM with the facility's Administrator to discuss the MDS concerns identified. During the interview, the Administrator reported she would expect the MDS assessments to be completed accurately. 3. Resident #48 was admitted to the facility on [DATE] with diagnoses that included gout, diabetes mellitus with diabetic polyneuropathy, contracture of left hand muscle, and hemiplegia and hemiparesis affecting left non dominant side. Resident #48's annual Minimum Data Set (MDS) assessment dated [DATE] was not completed in the areas of cognitive patterns and health conditions. The area under cognitive patterns read “Brief Interview for Mental Status (BIMS)” and “staff assessment for mental status” with the proceeding questions answered with “not assessed, no information”. The area under health conditions read “pain assessment interview” with the proceeding questions answered with “not assessed, no information”. An interview was conducted on 09/12/25 at 3:53 PM with the MDS Nurse #2. She stated she had worked at the facility for approximately one month and that she was trying to get the assessments caught up because the facility went for a period without an MDS person. She verified Resident #48's annual assessment dated [DATE] was not completed in the areas of cognition and pain assessments. She explained that the person who completed the assessment was a traveling MDS person. An interview was conducted on 09/12/25 at 4:12 PM with the Director of Nursing (DON). The DON stated the MDS assessments should be coded accurately to reflect Resident 48's condition.

Based on record review, resident representative, and staff interviews, the facility failed to revise a care plan for 2 of 54 residents reviewed for care plans (Resident #158 and #28). The findings included: 1. Resident #158 was admitted to the facility 10/18/24 with diagnoses including diabetes and chronic lung disease. The significant change Minimum Data Set (MDS) assessment dated [DATE] documented Resident #158 was cognitively intact and had a condition or chronic disease that resulted in a life expectancy less than 6 months. The MDS documented Resident #158 received Hospice services. A. Review of Resident #158's medical record revealed a physician order dated 8/11/25 that changed Resident #158 full code status (full resuscitative efforts to be made in the event of cardiac arrest) to Do Not Resuscitate status (no resuscitative efforts to be provided in the event of cardiac arrest). This order was evident on Resident #158's face sheet in the electronic medical record.Review of the care plan revealed Resident #158's full code status, with interventions to honor Resident #158's code status and review the code status with the resident. There was no care plan that addressed Resident #158's do not resuscitate status. B. A physician order dated 7/29/25 ordered for a Hospice referral. Review of Resident #158's medical record revealed she had been admitted to Hospice 7/31/25. Review of Resident #158's care plan revealed no care plan in place addressing Hospice services. An interview was conducted with the MDS Nurse #1 on 9/10/25 at 3:23 PM. The MDS Nurse #1 reported once the MDS was completed, they would review the care plan and orders with the Interdisciplinary team (IDT) to make revisions. The MDS Nurse #1 reported that the care plans were updated daily during the clinical care meetings, and the care plan revisions were considered a team effort.The Director of Nursing (DON) was interviewed by phone on 9/12/25 at 4:58 PM. The DON reported he was not aware the care plan for Resident #158 had not been updated to reflect her updated code status or her hospice admission. The DON explained that a daily clinical meeting was held with the IDT, which included all departments, including MDS, and the care plans were reviewed and updated as needed. The DON reported he expected the care plans to accurately reflect the needs of each resident.

Based on observation, record review, and resident and staff interviews, the facility failed to provide a record of an activity assessment and provide an ongoing resident centered activities program that included activities to meet the interests of a resident who did not participate in activities outside of his room for 1 of 1 resident reviewed for activities (Resident #3). Resident #3 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction (stroke) affecting his right dominant side. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #3 was cognitively intact; and his activity preferences included books, music, animals, and being outside. Review of the care plan dated 6/20/25 revealed Resident #3 preferred to participate in self-directed activities such as reading books, watching television programs in his room. The interventions included review with the resident his self-directed preferences, as needed. During an observation and interview on 9/8/25 at 1:43 p.m., Resident #3 was awake reclining in bed in his private room. The lights and television were in the off position. When asked, the resident stated he did not attend out of room activities by choice. He revealed he enjoyed reading but after his stroke it was difficult to hold and turn the pages of a book with one hand (the resident demonstrated his inability to move his right arm and leg but was able to open and close his right hand). The resident revealed the activity he missed most was coloring pictures with pencils and all of his finished pictures were in an album at his home. He indicated he was unaware if the facility had art supplies available to him because no one had talked to him about his activity interests and if the facility was able to provide supplies to assist with his activity preferences. On 9/12/25 at 11:58 a.m., an interview was conducted with the Activity Director (AD). She stated she worked at the facility for three weeks and had 2 part-time assistants and 1 full-time assistant. The AD revealed on 9/6/25 she initiated a one-on-one visit program with residents who refused to attend out of room activities and Resident #3 was visited on Sunday 9/7/25 for fifteen minutes. The AD revealed she was unable to locate a completed Activity Assessment of Resident #3's activity preferences and one should have been completed at the time of the resident's admission. She indicated she was unaware the resident was interested in coloring and reading but would immediately begin working with the resident and the rehabilitation department in finding ways to accommodate the resident's activity interests due to his hemiplegia and hemiparesis.

Based on record review and interviews with the resident's Responsible Party (RP), Medical Director and staff, the facility failed to notify the physician at the onset of pain and when the x-ray could not be completed stat (immediately) after Resident #1 had an unwitnessed fall on 11/17/24 (Sunday). The x-ray was not performed until 11/18/24 and the results indicated an acute nondisplaced (the bone does not break completely and there will be a crack on the bone) transverse (horizontal and perpendicular to the bone) left femur (thigh bone) fracture. The physician was not made aware of the fracture until 11/22/24 and was not notified the orthopedic consult ordered on 11/19/24 was scheduled for 11/26/24. The facility also failed to notify the physician when the resident's pain was not manageable on night shift (11/20/24 and 11/21/24). Failure to notify the physician delayed orthopedic medical management, care and treatment and put the resident at high risk for complications such as deep vein thrombosis, pneumonia, bed sores, and increased risk for mortality. Resident #1 was seen by the orthopedist on 11/22/24 and was sent directly to the hospital and a left femur intramuscular nail surgery was performed on 11/23/24. Resident #1 had an aspiration event (foods, stomach contents, or fluids are breathed into the lungs) while hospitalized which resulted in acute hypoxic respiratory failure (low levels of oxygen in your blood) and IV antibiotics were initiated on 11/24/24. The resident was prescribed additional oral antibiotics for three days after discharge back to the facility on [DATE]. This deficient practice affected 1 of 5 residents reviewed for notification of change (Resident #1). Immediate jeopardy began on 11/17/24 when the facility failed to notify the Medical Director that the STAT x-ray of Resident #1's left hip could not be completed as ordered on 11/17/24. The immediate jeopardy was removed on 1/5/25 when the facility implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a scope and severity of D (no actual harm with potential for more than minimal harm that is immediate jeopardy) to ensure education is completed and monitoring systems put into place and are effective. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, muscle weakness, difficulty in walking, bradycardia (a condition where the heart beats too slowly) (initiated 11/12/24), traumatic brain injury (TBI) in 1999, history of a stroke, chronic obstructive pulmonary disease/asthma, and dysarthria (slurred speech). An Unwitnessed Fall Report dated 11/17/24 at 11:05 AM and completed by Nurse #1 revealed she was notified by Nurse Aide (NA) #1 that Resident #1 was on the floor next to her bed sitting on her bottom. The on-call provider and responsible party (RP) were notified. She was assessed, and no injuries were noted. Vital signs were within normal limits. Resident #1 reported no pain or discomfort. She was then assisted back to her bed. Nurse #1 was interviewed on 12/19/24 at 11:14 AM. She revealed that on 11/17/24 around 11:00 AM, NA #1 told her that Resident #1 had fallen in her room. Nurse #1 went to the room and saw Resident #1 on her bottom next to her bed. Although Resident #1 was nonverbal, she could shake/nod her head to yes and no questions. Nurse #1 asked if she was ok, and she said yes. She then assessed Resident #1, including her extremities (limbs, hands, and feet), and asked if she hit her head. Resident #1 said no. She was then put back into bed with Nurse #1's assistance. Nurse #1 took vital signs and notified her supervisor at the time (name unknown). Nurse #1 was instructed to complete all documentation related to the fall and then called Resident #1's RP. The RP came later (45 minutes or so) and said Resident #1 complained of pain. Nurse #1 assessed her again, and Resident #1 said she was in pain. She assessed her left leg while she was laying on her right side. When she pressed on it, Resident #1 winced with pain, and there was a bruise. She contacted the On-Call Provider again and told her that the newly onset pain had not been discovered until just then. She was instructed to order an x-ray STAT. Nurse #1 stated she gave Resident #1 some Tylenol and then she left for the night at 7:00 PM. A 72 Hour Post Fall Documentation note dated 11/17/24 at 11:21 AM and completed by Nurse #1 revealed that Resident #1 reported pain in her left hip. The RP was interviewed on 12/18/24 at 1:56 PM. She revealed that when she arrived at the facility on 11/17/24, about 45 minutes after the fall, Resident #1 complained of pain. The RP indicated she reported the pain to Nurse #1. An On-Call NP note dated 11/17/24 at 2:32 PM revealed that Resident #1 had a fall at 11:00 AM. No injuries were reported, and Resident #1 denied pain. Now, Resident #1 reported left hip pain with tenderness to palpation. A STAT x-ray of the left hip was ordered, as well as Tylenol 500 milligrams (mg) every 6 hours as needed for pain. Neurological checks should be performed every 4 hours. Physician orders for Resident #1 revealed that a one-time STAT x-ray of the left hip was ordered on 11/17/24 at 3:05 PM. A telephone interview was conducted with Nurse #1 on 12/19/24 at 6:05 PM. She revealed that radiology told her they would get to the facility on [DATE] as soon as they could. Nurse #1 indicated she did not notify the On-Call NP that the x-rays were not yet performed when she finished her shift at 7:00 PM on 11/17/24. Nurse #1 could not provide a reason as to why she did not notify the On-Call NP of the STAT x-ray delay. A Medical Progress note dated 11/18/24 at 10:00 AM and completed by the NP revealed that Resident #1 had a fall on 11/17/24. She denied hitting her head, injury, or pain following the fall. Resident #1 appeared at her baseline mental status. A Health Status note dated 11/18/24 at 10:18 AM and completed by Nurse #2 revealed that radiology services were in the facility to perform the STAT x-rays ordered on 11/17/24. Review of the x-ray results dated 11/18/24 revealed an acute nondisplaced transverse left femur fracture. The x-rays were taken at 9:23 AM and reported to the facility at 12:54 PM. Review of a health status dated 11/18/24 at 2:59 PM and completed by Nurse #2 revealed that the results were back from the STAT x-rays. The RP and NP were notified. During an interview with the Medical Director on 12/20/24 at 12:57 PM, he revealed that the expectation of a STAT x-ray was for it to be performed on the same day it was ordered. If a STAT x-ray was delayed until the next day, he should have been notified. The Director of Nursing (DON) was interviewed on 12/30/24 at 11:49 AM. She revealed that if a STAT x-ray was not performed within 2-4 hours after it was ordered or before a shift was completed, then Nurse #1 should have contacted the on-call provider for further instructions on whether to wait or receive other orders. An interview was conducted with the Administrator on 12/31/24 at 12:00 PM. He revealed that if a STAT order was not completed the same day, Nurse #1 should have notified the on-call provider to receive further instruction on how to move forward. Review of a medical progress note dated 11/19/24 and completed by the NP revealed that Resident #1 had an acute nondisplaced transverse intertrochanteric femur fracture. Resident #1's RP was waiting for the NP to contact her for consultation, which took place the same day. The RP requested an orthopedic evaluation. The NP discussed complications about potential surgery with the RP and told her that orthopedics would consider Resident #1's overall health, specifics about the fracture, and new asymptomatic bradycardia. Review of physician orders for Resident #1 revealed that on 11/19/24 an orthopedic surgery consultation for a left hip/leg fracture was ordered. The Transportation Scheduler was interviewed on 1/7/25 at 4:20 PM. She revealed that she had received a consultation order from the NP on 11/19/24 to schedule an orthopedic appointment for Resident #1. The Transportation Scheduler stated she did not receive an order as soon as possible (ASAP) for the appointment from the NP, but she called that day (11/19/24) to schedule. The appointment was originally scheduled for 11/26/24. The Transportation Scheduler indicated she was notified on 11/22/24 to get Resident #1 an immediate orthopedics appointment for that day, but she could not recall who the request came from. Review of Resident #1's medical record revealed that there was no documentation for an orthopedics consultation scheduled for 11/26/24. During a telephone interview with NA #3, who worked with Resident #1 during the overnight shift from 7:00 PM on 11/20/24 until 7:00 AM on 11/21/24, she stated that Resident #1 had fallen 3 days prior, and this was the first time she had worked with Resident #1. NA #3 recalled when she arrived for her shift, she was notified by the off coming NA #5 that Resident #1's left hip was hurt and to be cautious during care. NA #3 remembered that Resident #1 said ow during an incontinence care episode when she touched her left hip. NA #3 did not notify anyone of the pain because she was notified about the left hip at the beginning of her shift. NA #3 further stated she made sure not to change or move Resident #1 during the shift unless necessary. A telephone interview was conducted with NA #2 on 12/19/24 at 10:53 AM. NA #2 confirmed she worked with Resident #1 during the overnight shift from 7:00 PM on 11/21/24 until 7:00 AM on 11/22/24. NA #2 revealed that it appeared Resident #1 was in a lot of pain during her shift because she would refuse care, was not willing to get out of bed, and was not willing to roll side to side. Resident #1 was nonverbal, but when NA #2 tried to turn her in the bed, Resident #1 would grab her arm as if she was telling NA #2 to stop. The DON was interviewed on 12/30/24 at 11:49 AM. She revealed that if Resident #1 was in any discomfort after the fall on 11/17/24, NA #2 and NA #3 should have notified the nurse on duty or the provider. The NAs could have performed a Stop N Watch, which meant they were not allowed to assess Resident #1's pain, but they could have completed charting in her medical record that would alert the DON, unit managers, and the providers. The Administrator was interviewed on 12/31/24 at 12:00 PM. He revealed that NA #2 and NA #3 should have completed a Stop N Watch task as well as notified the charge nurse that they thought Resident #1 had some discomfort during their shifts. A telephone interview was conducted with the Medical Director on 12/19/24 at 10:19 AM. He revealed that he did not review Resident #1's x-ray results reported on 11/18/24 until 11/22/24, and he did not receive an update from the NP that entire week. He was unaware that an orthopedic appointment had been scheduled for the following week and not sooner. When he saw Resident #1 on 11/22/24, Resident #1 was in pain, and the Medical Director told staff that she needed to be sent out immediately. The Medical Director indicated he was told that Resident #1 had an orthopedic appointment the following week, but he told them she needed to go that day (11/22/24). The Medical Director stated that Resident #1 should have gone to the hospital as soon as the x-ray results came in on 11/18/24, and the surgeon would have made the decision if she was a surgical candidate or not. During a follow-up telephone interview with the Medical Director on 12/20/24 at 11:13 AM, he revealed that the nurses always put the printout of the x-ray results in his mailbox or the provider communication book to review. The Medical Director stated that he relied on the paperwork in his mailbox or provider communication book for further evaluation or orders. He further stated that he did not see Resident #1's x-ray results in the provider's communication book until 11/22/24. Review of an Orthopedic Visit note dated 11/22/24 revealed that Resident #1 was in no acute distress, and the left leg was warm and perfused. Resident #1 pointed to the left groin area as a source of pain. Due to the results of the x-rays taken during the visit (intertrochanteric fracture of the left femur), Resident #1 was sent to the hospital from the appointment. Review of a Hospital Discharge Summary dated 11/26/24 revealed that Resident #1 had a closed intertrochanteric fracture of the left femur. She was seen in the orthopedic office on 11/22/24 for further evaluation, and an x-ray was obtained which showed an intertrochanteric fracture of the left femur. She was sent to the emergency department (ED) for further evaluation, and a left femur intramuscular nail surgery was performed on 11/23/24. The discharge summary indicated Resident #1 had an aspiration event while hospitalized which resulted in acute hypoxic respiratory failure and IV antibiotics were initiated on 11/24/24. The resident was prescribed additional oral antibiotics for three days after discharge back to the facility. The Administrator was notified of immediate jeopardy on 1/3/25 at 8:48 AM. The facility provided the following Acceptable Allegation of Immediate Jeopardy removal. An incident report was completed on 11/17/2024 at 11:05 am by the charge nurse, based on information obtained from certified nursing aide. Resident #1 was observed on the floor next to her bed sitting on her bottom. The resident was assessed by the charge nurse and no injuries were discovered during the initial assessment. The resident was assisted back to bed by the charge nurse and the certified nursing aide without incident. The nurse called the resident's Responsible Party (RP) and the Nurse Practitioner (NP) and no new orders were given. On 11/17/24 at 11:21 AM another progress note was entered in the electronic record which stated that the resident reported pain in her left hip and elbow when the RP arrived at the facility. The facility failed to immediately notify the medical provider of the new onset of pain. The on-call medical provider was not called until 2:14 PM and at that time the medical provider gave new orders for a stat x-ray and Tylenol 500mg every 6 hours as needed for pain. The medical provider was not notified the stat x-ray could not be obtained on 11/17/2024. On 11/18/2024 the x-ray of the left hip was obtained at 9:23 am. The x-ray resulted on 11/18/2024 12:54 pm and the impressions were an acute transverse, nondisplaced intertrochanteric femur fracture. The residents' responsible party and NP were informed of the results on 11/18/2024 at 2:59 pm. On 11/19/2024 the NP assessed the resident after reviewing the x-ray and new orders were given for the resident to be seen by an orthopedic doctor. The NP elected not to send the resident out immediately after conferring with the daughter who stated it was acceptable at the time. An orthopedic appointment was obtained for 11/26/2024. The NP ordered Tramadol 25 milligrams twice a day and to be given every 12 hours as needed for breakthrough pain. The facility failed to notify the Medical Director (MD) that the orthopedic consult could not be scheduled ASAP. The facility failed to notify the MD when the resident's pain was not manageable on night shift for the following dates, 11/20/2024 and 11/21/2024, when Resident #1 grabbed the aide and said stop. The MD was not aware of the fracture until he saw Resident #1 on 11/22/2024 at which time he ordered the resident to be sent to the emergency department if she could not be seen by the orthopedist that day. Resident #1 was seen by the orthopedist on 11/22/2024 and was sent directly to the hospital and a left femur intramuscular nail surgery was performed on 11/23/2024. On 12/27/2024 the Director of Nursing and Nurse Managers reviewed residents who have fallen during the last 30 days to confirm that the Medical Director had been notified. Any opportunities identified during this audit will be corrected by the Nurse Managers by 1/3/2025. On 12/27/2024 the Director of Nursing and Nurse Managers reviewed 30 days of diagnostic and laboratory testing to ensure they were obtained as ordered and the Medical Director had been notified. The audit included reading 30 days of progress notes to identify any residents that may have been in pain and were not addressed. Any opportunities identified during this audit will be corrected by the nurse managers by 1/3/2025. On 12/20/2024 the Director of Nursing/Staff Development Coordinator began in person education for all nursing staff on the facility policy and procedures for physician notification to include notification of physician for any complaints of unrelieved pain by residents to be reported to the physician immediately. Education also included notification to the physician of any delays in physician orders including stat orders and delay in any physician ordered appointments, consultations, and X-rays this is to include the weekends and after hours. Licensed nurses were also educated on utilization of the MD communication book to report diagnostic reports and other non-emergent resident issues. All nurse aides were also educated on the process of notification to licensed nurse of any identified resident issues such as pain or other resident concerns and use the electronic medical record, which is to document the pain and/or concerns of the resident in their electronic medical record. The licensed nurses will review the information and report to the medical provider. The licensed nurses will document in the residents' electronic medical record the notification to the medical provider and the plan of care. The Nurse Managers will review the residents electronic medical record daily and the documentation to ensure the medical provider was notified. Education will be provided for all new nursing staff and agency staff prior to the beginning of their first shift. Education will be completed by 1/4/2025 by the Director of Nursing/Staff Development Coordinator. This education will become a part of the new hire orientation process for newly hired nursing staff. The Staff Development Coordinator will track the education for all staff who did not receive the education to ensure they receive the education prior to their first assigned shift. The Staff Development Coordinator was notified of her responsibilities on 12/20/2024. Nurse Aides can report directly to the nurse or use the computer system which serves as an alert system within the resident's electronic record which nurse aides can send alerts to the nurse electronically. Once a computer system alert is triggered the nurse can see it instantly on the clinical dashboard for continued assessment to be done. The Director of Nursing educated Licensed Nurses regarding the requirements for notification of the Physician following a fracture and/or a significant change of condition. The Licensed Nurse will call the Medical Director with any results of fractures and/or a significant change of condition. The Licensed Nurse will place this information in the Medical Directors' communication book after making verbal notification to the medical providers for additional follow-up by the Medical Director and in-house NP. The Director of Nursing will ensure no staff will work without receiving this education. Any new hires, including agency staff, will receive education prior to the start of their shift via telephone or in person. The Director of Nursing or designee will complete in person review with any staff that receive education by telephone to assure their understanding of the education received. The Staff Development Coordinator will be responsible for tracking which employees have received their education. The Staff Development Coordinator was made aware of this responsibility on 12/20/24. On 1/3/2024 the Director of Nursing and Administrator completed an Ad-Hoc QAPI to ensure that all components of the credible allegation were completed and followed. The QAPI included the Administrator, Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Regional Director of Clinical Services, Admissions Director, Unit Managers, Maintenance Director and Discharge Planner. Effective 1/3/2025 the Administrator will be responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged date of IJ removal: 1/5/2025 An onsite validation was conducted on 01/09/25. A review of in-service records revealed that all nursing staff were educated on the facility's policy and procedures for physician notification to include any complaints of unrelieved pain by residents to be reported to the physician immediately. Education also included notification to the physician of any delays in physician orders including STAT orders and delay in any physician ordered appointments, consultations, and X-rays, this is to include the weekends and after hours. Licensed nurses were also educated on utilization of the physician communication book to report diagnostic reports and other non-emergent resident issues. All nurse aides were also educated on the process of notification to the licensed nurse of any resident experiencing issues such as pain or other resident concerns and use of the electronic medical record, which is to document the pain and/or concerns of the resident in their electronic medical record. Interviews conducted with nurses and nurse aides during the onsite validation were completed and the staff were able to verbalize knowledge of the policy and procedures for notification. The physician communication book was reviewed for verification of physician notification. The immediate jeopardy removal date of 01/05/25 was validated.

Based on record review, and facility staff, Nurse Practitioner (NP), Medical Director, and Responsible Party (RP), and Orthopedic Surgeon interviews, the facility failed to protect a resident's right to be free of neglect as evidenced by the following: they failed to notify the physician at the onset of pain and when an x-ray could not be completed STAT (immediately) after Resident #1 had an unwitnessed fall on 11/17/24 and reported pain in her left hip. The x-ray was completed on 11/18/24 and revealed an acute nondisplaced (the bone does not break completely and there will be a crack on the bone) transverse (horizontal and perpendicular to the bone) left femur (thigh bone) fracture. The NP failed to communicate and collaborate with the Medical Director when the x-ray results were received on 11/18/24 and the facility failed to recognize the seriousness of the injury and identify the need for urgent orthopedic evaluation and surgical intervention. On 11/19/24 the NP ordered scheduled opioid medication for increased pain and ordered an orthopedic consultation at the request of Resident #1's RP. The resident remained in the facility awaiting an orthopedic consultation scheduled for 11/26/24. The facility failed to notify the physician when the resident's pain was not manageable on night shift (11/20/24 and 11/21/24). The Medical Director (MD) was not aware of the fracture or the orthopedic consult scheduled for 11/26/24 until he saw Resident #1 on 11/22/24 at which time he ordered the resident to be sent to the emergency department if she could not be seen by the orthopedist that day. The resident was seen by the orthopedist on 11/22/24 and was sent directly to the hospital and a left femur intramuscular nail surgery was performed on 11/23/24. While hospitalized , Resident #1 had an aspiration event (foods, stomach contents, or fluids are breathed into the lungs) which resulted in acute hypoxic respiratory failure (low levels of oxygen in your blood) and Intravenous (IV) antibiotics were initiated on 11/24/24. The resident was prescribed additional oral antibiotics for three days after discharge back to the facility on [DATE]. The Orthopedic Surgeon indicated an injury like Resident #1's required an immediate transfer to the hospital for evaluation by an orthopedic specialist and that the risks of complications increased with the delay of care such as deep vein thrombosis (blood clots in veins deep in the body), pneumonia, and bed sores. This deficient practice affected 1 of 1 sampled residents reviewed for neglect (Resident #1). Immediate jeopardy began on 11/18/24 when the facility neglected to provide the necessary care and services for Resident #1 when x-ray results verified the resident sustained a transverse left femur fracture. The immediate jeopardy was removed on 1/5/25 when the facility implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a scope and severity of D (no actual harm with potential for more than minimal harm that is immediate jeopardy) to ensure education is completed and monitoring systems put into place and are effective. The findings included: This tag is cross referenced to: F580: Based on record review and interviews with the Medical Director and staff, the facility failed to notify the physician at the onset of pain and when the x-ray could not be completed stat (immediately) after Resident #1 had an unwitnessed fall on 11/17/24 (Sunday). The x-ray was not performed 11/18/24 and the results indicated an acute nondisplaced (the bone does not break completely and there will be a crack on the bone) transverse (horizontal and perpendicular to the bone) left femur (thigh bone) fracture. The physician was not made aware of the fracture until 11/22/24 and was not notified the orthopedic consult ordered on 11/19/24 was scheduled for 11/26/24. The facility also failed to notify the physician when the resident's pain was not manageable on night shift (11/20/24 and 11/21/24). Failure to notify the physician delayed orthopedic medical management, care and treatment and put the resident at high risk for complications such as deep vein thrombosis, pneumonia, bed sores, and increased risk for mortality. Resident #1 had an aspiration event (foods, stomach contents, or fluids are breathed into the lungs) while hospitalized which resulted in acute hypoxic respiratory failure (low levels of oxygen in your blood) and IV antibiotics were initiated on 11/24/24. The resident was prescribed additional oral antibiotics for three days after discharge back to the facility on [DATE]. This deficient practice affected 1 of 5 residents reviewed for notification of change (Resident #1). F684: Based on record review and interviews from the Medical Director, the Nurse Practitioner (NP), Orthopedic Surgeon, Responsible Party (RP) and staff the facility failed to recognize the seriousness of the injury Resident #1 sustained from a fall and identify the need for urgent orthopedic evaluation. Resident #1 reported pain in her left hip on 11/17/24 following a fall. A STAT (with no delay) x-ray was ordered on Sunday 11/17/24, was not completed until 11/18/24, and revealed a nondisplaced (the bone does not break completely and there will be a crack on the bone) transverse (horizontal and perpendicular to the bone) left femur (thigh bone) fracture. On 11/19/24 the NP ordered scheduled opioid medication for increased pain and ordered an orthopedic consultation at the request of Resident #1's RP. The resident remained in the facility awaiting an orthopedics consultation scheduled for 11/26/24. The Medical Director was not aware of the fracture until he saw Resident #1 on 11/22/24 at which time he ordered the resident to be sent to the emergency department if she could not be seen by the orthopedist that day. Resident #1 was seen by the orthopedist on 11/22/24 and was sent directly to the hospital and a left femur intramuscular nail surgery was performed on 11/23/24. While hospitalized , Resident #1 had an aspiration event (foods, stomach contents, or fluids are breathed into the lungs) which resulted in acute hypoxic respiratory failure (low levels of oxygen in your blood) and Intravenous (IV) antibiotics were initiated on 11/24/24. The resident was prescribed additional oral antibiotics for three days after discharge back to the facility on [DATE]. The Orthopedic Surgeon indicated an injury like Resident #1's required an immediate transfer to the hospital for evaluation by an orthopedic specialist and that the risks of complications increased with the delay of care such as deep vein thrombosis (blood clots in veins deep in the body), pneumonia, and bed sores. This deficient practice affected 1 of 5 residents reviewed for falls (Resident #1). F714: Based on record review, and staff, Medical Director (MD) and Nurse Practitioner (NP) interviews, the NP failed to communicate and collaborate with the MD when Resident #1 was diagnosed on [DATE] with an acute nondisplaced (the bone does not break completely and there will be a crack on the bone) transverse (horizontal and perpendicular to the bone) left femur (thigh bone) fracture following an unwitnessed fall on 11/17/24. The NP did not consult with the MD before making the decision the resident was probably not a surgical candidate and attempting to treat the resident in-house. Due to the lack of communication and coordination the Medical Director (MD) was not aware of the fracture until he saw Resident #1 on 11/22/24 at which time he ordered the resident to be sent to the emergency department if she could not be seen by the orthopedist that day. Resident #1 was seen by the orthopedist on 11/22/24 and was sent directly to the hospital and a left femur intramuscular nail surgery was performed on 11/23/24. The lack of communication and collaboration between the NP and MD delayed orthopedic medical management, care and treatment and put the resident at high risk for complications such as deep vein thrombosis, pneumonia, and bed sores. Resident #1 had an aspiration event (foods, stomach contents, or fluids are breathed into the lungs) while hospitalized which resulted in acute hypoxic respiratory failure (low levels of oxygen in your blood) and IV antibiotics were initiated on 11/24/24. The resident was prescribed additional oral antibiotics for three days after discharge back to the facility on [DATE]. This failure affected 1 of 3 reviewed for accidents (Resident #1). The Administrator was notified of immediate jeopardy on 1/3/25 at 8:48 AM. The facility provided the following Acceptable 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: An incident report was completed on 11/17/2024 at 11:05 am by the charge nurse, based on information obtained from certified nursing aide. Resident #1 was observed on the floor next to her bed sitting on her bottom. The resident was assessed by the charge nurse and no injuries were discovered during the initial assessment. The resident was assisted back to bed by the charge nurse and the certified nursing aide without incident. The charge nurse called the resident's Responsible Party (RP) and the Nurse Practitioner (NP) and no new orders were given. On 11/17/24 at 11:21 AM another progress note was entered in the electronic record which stated that the resident reported pain in her left hip and elbow when the RP arrived to the facility. The facility failed to immediately notify the medical provider of the new onset of pain. The medical provider was not called until 2:14 PM and at that time the medical provider gave new orders for a stat x-ray and Tylenol 500mg every 6 hours as needed for pain. The Tylenol order was not entered until 3:05pm on 11/17/2024. The stat x-ray was not obtained on 11/17/2024. The nursing staff failed to notify the medical provider that the stat x-ray could not be obtained on 11/17/2024. On 11/18/2024 the x-ray of the left hip was obtained at 9:23 am. The x-ray resulted on 11/18/2024 12:54 pm and the impressions were an acute transverse, nondisplaced intertrochanteric femur fracture. The resident's RP and NP were informed of the results on 11/18/2024 at 2:59 pm. On 11/19/2024 the NP assessed the resident after reviewing the x-ray and new orders were given for the resident to be seen by an orthopedic doctor. The NP elected not to send the resident out immediately after conferring with the daughter who stated it was acceptable at the time. An orthopedic appointment was obtained for 11/26/2024. The NP ordered Tramadol 25 milligrams twice a day and to be given every 12 hours as needed for breakthrough pain. The Medical Director (MD) was not aware of the fracture until he saw Resident #1 on 11/22/24 at which time he ordered the resident to be sent to the emergency department if she could not be seen by the orthopedist that day. Resident #1 was seen by the orthopedist on 11/22/2024 and was sent directly to the hospital and a left femur intramuscular nail surgery was performed on 11/23/2024. The facility failed to notify the physician of an acute change in condition requiring emergent orthopedic medical treatment (x-ray results positive for fracture). The facility failed to notify the physician that an x-x-ray ordered stat was not going to be done stat. The facility failed to notify the physician that the orthopedic consult could not be scheduled ASAP. The facility failed to notify the physician when the resident's pain was not manageable on night shift on 11/20/2024 and 11/21/2024 when resident grabbed the aide and said stop. The facility failed to identify the seriousness of Resident #1's left intertrochanteric femur fracture after a fall on 11/17/2024 and identify the urgent need for orthopedic evaluation and surgical intervention. A STAT x-ray was ordered but not completed until 11/18/2024 and confirmed the fracture. The Nurse Practitioner ordered scheduled and as needed opioid pain medication and an orthopedic consultation on 11/19/2204 but failed to collaborate with the MD he was attempting to treat the fracture in- house. The facilities neglect led to delayed treatment of Resident #1's left intertrochanteric femur fracture on 11/18/2024 causing Resident #1 to be sent to the hospital 11/22/2024. Resident #1 had surgery on 11/23/2024 to repair the left femur fracture. To assist in identifying other residents who may have been affected by this deficient practice on 12/20/24 the Nurse Practitioner and Medical Director reviewed the previous 45 days of labs and radiology reports to ensure that all abnormalities have been addressed. On 12/27/2024 the Nurse Managers reviewed residents who have fallen during the last 30 days to assess residents to include active and passive range of motion and pain assessment. This review also included examination of all recent incident reports to identify any patterns or recurring issues related to falls or delayed medical interventions. The Director of Nursing and Regional Director of Clinical Services completed a review of all pain scales on 1/4/25 to assist in identifying any resident with unrelieved pain. Any opportunities identified during this audit will be corrected by the Nurse Managers by 1/4/25. On 12/27/2024 the Nurse Managers reviewed residents who have fallen during the last 30 days to validate the Medical Director had been notified. Any opportunities identified during this audit will be corrected by the Nurse Managers by 1/4/2025. 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: On 12/20/24 the Director of Nursing/Staff Development Coordinator began in-person education for all facility staff in all departments including agency and contract staff. Education included review of policy regarding abuse/neglect. - Recognizing signs of abuse and neglect - Examples of neglect, including not providing necessary care and services. - Reporting of abuse and neglect - Facility policy and procedures for physician notification to include notification of physician to any complaints of unrelieved pain by residents to be reported to the physician immediately. - Notification to physician of any delays in physician orders including stat orders and delay in any physician ordered appointments and x-rays. - Education to certified nurse aides on reporting identified pain and other abnormal events identified during delivery of care. Any nursing staff member that did not receive education on 12/20/2024 will receive education by the beginning of the next shift by the DON or designee. The Staff Development Coordinator will be responsible for tracking staff that still require education. Any staff that has not received education will not be allowed to work until education is received. All newly hired licensed staff will be educated by the Staff Development Coordinator on this policy. This education will be added to the orientation process. Staff Development was notified of this responsibility on 12/20/2024. The DON or designee will verify the understanding of education through oral discussion and feedback with all staff and notate this on a tracking tool. The SDC will also do this in orientation. In person education was completed on 12/27/2024 by the Director of Nursing to current medical providers including on-call providers, Nurse Practitioners and Medical Director. Education consisted of communication between all providers should be clear, concise and collaborative. Communication should include a discussion of treatment plans and seeking advice when necessary. Providers should participate in decision making in a timely manner. On 1/3/2025 the Medical Director and the Physician Extenders agreed to meet with the Director of Nursing weekly to discuss abnormal labs, radiology or test results as a team. On 1/3/2025 the Regional Director of Clinical Services informed the Staff Development Coordinator and/or the Director of Nursing to complete monthly training on abuse and neglect for 3 months and then quarterly ongoing. Education will ensure abuse and neglect is explained to all staff per federal guidelines, Neglect as defined at 483.12, the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Effective 1/4/2025 the Administrator will be responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of Immediate Jeopardy removal: 1/5/2025 An onsite validation was conducted on 01/09/25. A review of in-service records revealed that all facility staff were educated on the facility's policy and procedures for abuse and neglect. This in-service training included: Recognizing signs of abuse and neglect, examples of neglect, including not providing necessary care and services, reporting of abuse and neglect, facility policy and procedures for physician notification to include notification of physician to any complaints of unrelieved pain by residents to be reported to the physician immediately, notification to physician of any delays in physician orders including STAT orders and delay in any physician ordered appointments and x-rays and education to nurse aides on reporting identified pain and other abnormal events identified during delivery of care. Interviews conducted with staff verified they had received training on abuse and neglect. The immediate jeopardy removal date of 01/05/25 was validated.

Based on record review and interviews with the Medical Director, the Nurse Practitioner (NP), Orthopedic Surgeon, Responsible Party (RP) and staff, the facility failed to recognize the seriousness of the injury Resident #1 sustained from a fall and identify the need for urgent orthopedic evaluation. Resident #1 reported pain in her left hip on 11/17/24 following a fall. A STAT (immediately) x-ray was ordered on Sunday 11/17/24, was not completed until 11/18/24, and revealed a nondisplaced (the bone does not break completely and there will be a crack on the bone) transverse (horizontal and perpendicular to the bone) left femur (thigh bone) fracture. On 11/19/24 the NP ordered scheduled opioid medication for increased pain and ordered an orthopedic consultation at the request of Resident #1's RP. The resident remained in the facility awaiting an orthopedics consultation scheduled for 11/26/24. The Medical Director was not aware of the fracture until he saw Resident #1 on 11/22/24 at which time he ordered the resident to be sent to the emergency department if she could not be seen by the orthopedist that day. Resident #1 was seen by the orthopedist on 11/22/24 and was sent directly to the hospital and a left femur intramuscular nail surgery was performed on 11/23/24. While hospitalized , Resident #1 had an aspiration event (foods, stomach contents, or fluids are breathed into the lungs) which resulted in acute hypoxic respiratory failure (low levels of oxygen in your blood) and Intravenous (IV) antibiotics were initiated on 11/24/24. The resident was prescribed additional oral antibiotics for three days after discharge back to the facility on [DATE]. The Orthopedic Surgeon indicated an injury like Resident #1's required an immediate transfer to the hospital for evaluation by an orthopedic specialist and that the risks of complications increased with the delay of care such as deep vein thrombosis (blood clots in veins deep in the body), pneumonia, and bed sores. This deficient practice affected 1 of 5 residents reviewed for falls (Resident #1). Immediate jeopardy began on 11/18/24 when the facility failed to recognize the seriousness of the injury and identify the need for urgent orthopedic evaluation when x-ray results verified the resident sustained a transverse left femur fracture. The immediate jeopardy was removed on 1/9/25 when the facility implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a scope and severity of D (no actual harm with potential for more than minimal harm that is immediate jeopardy) to ensure education is completed and monitoring systems put into place and are effective. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, muscle weakness, difficulty in walking, bradycardia (initiated 11/12/24), traumatic brain injury (TBI) in 1999, history of a stroke, chronic obstructive pulmonary disease/asthma, and dysarthria (slurred speech). Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #1 had adequate vision/hearing, usually understood/understands, and was severely cognitively impaired. She did not have any falls since the previous assessment, and there was no pain presence or pain medication regimen in place at the time of the review period. Resident #1 was 62 inches tall and weighed 89 pounds. Review of physician orders for Resident #1 revealed that a pain assessment using 0-10 (0 = no pain, 10 = excruciating pain) scale or non-verbal scoring tool every shift was ordered on 11/9/24. Review of an unwitnessed fall report dated 11/17/24 at 11:05 AM and completed by Nurse #1 revealed she was notified by Nurse Aide (NA)#1 that Resident #1 was on the floor next to her bed sitting on her bottom. Resident #1 denied hitting her head. The On-Call Provider and RP were notified. She was assessed, and no injuries were noted. Vital signs were within normal limits. Resident #1 reported no pain or discomfort. She was then assisted back to her bed. Review of a 72-hour post fall documentation note dated 11/17/24 at 11:21 AM and completed by Nurse #1 revealed that Resident #1 reported pain in her left hip when the RP arrived at the facility. An On-Call NP note dated 11/17/24 at 2:32 PM revealed that Resident #1 had a fall at 11:00 AM. No injuries were reported, and Resident #1 denied pain. Now, Resident #1 reported left hip pain with tenderness to palpation (a method of feeling with the fingers or hands during a physical examination). Nurse #1 reports right facial swelling and concern for facial droop. A neurological check was performed by the NP via video and there were no acute deficits noted. A STAT x-ray of the left hip was ordered, as well as Tylenol 500 milligrams (mg) every 6 hours as needed (PRN) for pain. Neurological checks should be performed every 4 hours. Review of physician orders for Resident #1 revealed that a one-time STAT x-ray of the left hip was ordered on 11/17/24 at 3:04 PM. On the same day, Tylenol 500mg tablet given every 6 hours as needed for pain was also ordered. Nurse #1 was interviewed on 12/19/24 at 11:14 AM. She revealed that on 11/17/24 around 11:00 AM, NA #1 told her that Resident #1 had fallen in her room. Nurse #1 went to the room and saw Resident #1 on her bottom next to her bed. Although Resident #1 was nonverbal, she could shake/nod her head to yes and no questions. Nurse #1 asked if she was ok, and she said yes. She then assessed Resident #1, including her extremities (limbs, hands, and feet), and asked if she hit her head. Resident #1 said no. She was then put back into bed with Nurse #1's assistance. Nurse #1 took vital signs and notified her supervisor at the time (name unknown). Nurse #1 was instructed to complete all documentation related to the fall and then called Resident #1's RP. The RP came later (45 minutes or so) and said Resident #1 complained of pain. Nurse #1 assessed her again, and Resident #1 said she was in pain. She assessed her left leg while she was laying on her right side. When she pressed on it, Resident #1 winced with pain, and there was a bruise. She contacted the On-Call NP again and told her that there was new onset pain. The On-Call NP ordered an x-ray STAT. Nurse #1 stated she gave Resident #1 some Tylenol and then she left for the night at 7:00 PM. A follow-up telephone interview was conducted with Nurse #1 on 12/19/24 at 6:05 PM. She revealed that radiology told her they would get to the facility on [DATE] as soon as they could. Nurse #1 did not notify the On-Call Provider that the x-rays were not yet performed when she finished her shift at 7:00 PM on 11/17/24. Nurse #1 could not provide a reason as to why she did not notify the On-Call Provider of the STAT x-ray delay. During a telephone interview with the Medical Director on 12/20/24 at 12:57 PM, he revealed that the expectation of a STAT x-ray was for it to be performed on the same day it was ordered. The Director of Nursing (DON) was interviewed on 12/30/24 at 11:49 AM. She revealed that if a STAT x-ray was not performed within 2-4 hours after it was ordered or before a shift was completed, then Nurse #1 should have contacted the On-Call Provider for further instructions on whether to wait or receive other orders. The RP was interviewed via telephone on 12/18/24 at 1:56 PM. She revealed that Nurse #1 called her on 11/17/24 when Resident #1 fell and said she was fine. She visited 45 minutes later, and when asked if anything hurt, Resident #1 would say her left hip. The RP was told by Nurse #1 that an x-ray was ordered. She waited until 8:00 PM, but no one came. During a telephone interview with Nurse #3 on 12/19/24 at 11:41 AM, he revealed that when he arrived for the night shift on 11/17/24, he was instructed by the day shift nurses to pay more attention to Resident #1 due to her trying to get up without assistance. Resident #1 needed assistance with transfers and was very unsteady on her feet. Review of a medical progress note dated 11/18/24 at 10:00 AM and completed by the NP revealed that Resident #1 had a fall on 11/17/24. She denied hitting her head, injury, or pain following the fall. Resident #1 appeared at her baseline mental status and had tenderness to the left hip with palpation. Review of a health status note dated 11/18/24 at 10:18 AM and completed by Nurse #2 revealed that radiology services were in the facility for Resident #1 to perform the STAT x-rays ordered on 11/17/24. Review of a health status note dated 11/18/24 at 11:40 AM and completed by Nurse #2 revealed that Resident #1 continued to have pain/discomfort in her left hip. Review of the x-ray results dated 11/18/24 revealed an acute transverse left femur fracture. The x-rays were taken at 9:23 AM and reported at 12:54 PM. Review of a 72-hour post fall documentation note dated 11/18/24 at 2:18 PM and completed by Nurse #2 revealed that Resident #1 had a nondisplaced fracture to the left femur and reported a pain level of 4 in the left hip. Review of the November 2024 medication administration record (MAR) revealed that Nurse #2 administered 500mg of as needed Tylenol to Resident #1 on 11/18/24 at 2:54 PM due to a pain level of 7. Nurse #2 was interviewed on 12/19/24 at 12:09 PM. Nurse #2 revealed that she had worked with Resident #1 from 7:00 AM - 7:00 PM on 11/18/24. Resident #1 was not alert and oriented and was nonverbal but able to shake her head yes or no when asked a question. She stated Resident #1 had bruising on her left hip, and an x-ray was ordered. On 11/18/24, it was found that Resident #1 had a left hip/leg fracture. Nurse #2 would ask Resident #1 how she was feeling during medication pass on 11/18/24 and if she was hurting, and she would nod yes if in pain. When working with her and turning her in bed, Nurse #2 noticed that Resident #1 would grimace some. It seemed she had pain from between a 4 to 7 out of 10 on the pain scale on 11/18/24. During a telephone interview with Nurse #3 on 12/19/24 at 11:41 AM, he stated he did not recall if he received any special instructions or was notified of the fracture when he arrived for the night shift on 11/18/24. Resident #1 was nonverbal but would shake her head yes or no for responses. During the week of 11/18/24, he indicated that he could not recall if Resident #1 had any significant signs or symptoms of pain/discomfort. Review of a medical progress note dated 11/19/24 and completed by the NP revealed that Resident #1 had an acute nondisplaced transverse intertrochanteric femur fracture. Resident #1's RP was waiting for the NP to contact her for consultation, which took place the same day. The RP requested an orthopedic evaluation. The NP discussed complications about potential surgery with the RP and told her that orthopedics would consider Resident #1's overall health, specifics about the fracture, and new asymptomatic bradycardia. An interview was conducted with the Unit Manager on 12/19/24 at 12:22 PM. She revealed that she spoke to the RP on 11/19/24, and she wanted Resident #1 to be sent out to the hospital. The Unit Manager instructed her to speak to the NP, who then told her that Resident #1 was not a surgical candidate due to her low body mass. The Unit Manager indicated there was a non-verbal scoring tool with pain assessments on the MAR, and all nurses should have performed pain assessments during each shift. Review of physician orders for Resident #1 revealed that on 11/19/24, an orthopedic surgery consultation for a left hip/leg fracture was ordered. An order note dated 11/19/24 at 10:16 AM by Nurse #2 revealed that new orders were received for an orthopedic consultation of Resident #1's left femur fracture after a fall. Review of a health status note dated 11/19/24 at 11:43 AM by Nurse #2 revealed that Resident #1 continued to have pain/discomfort in her left hip. A consultation for orthopedics was ordered. Review of a 72-hour post fall documentation note dated 11/19/24 at 2:29 PM and completed by Nurse #2 revealed that the note read in part: Current status of the resident's injuries or reports of pain from the fall: Acute transverse, nondisplaced intertrochanteric fracture femur is noted. No other acute fracture or dislocation. Interventions are currently in place to prevent additional falls: keep wheelchair beside bed, call bell within reach, bed in lowest/locked position, and Nurse Aides rounding every 2 hours. Resident's response to new interventions remains in the bed, Tylenol given for pain. Nurse #2 was interviewed on 12/19/24 at 12:09 PM. Nurse #2 revealed that she had worked with Resident #1 from 7:00 AM - 7:00 PM on 11/19/24. The nurse stated she asked Resident #1 how she was feeling during medication pass on 11/19/24 and if she was hurting, and she would nod yes if in pain. On 11/19/24, an order for Tramadol was added. Review of a health status note dated 11/19/24 at 2:40 PM and completed by the Unit Manager revealed that Resident #1's RP was at her bedside with some concerns of increased pain due to the left hip/leg fracture. The RP stated that her family told her that Resident #1 needed to go to the hospital for 24-hour care. It was explained to the RP that Resident #1's pain could be managed at the facility; however, if she felt the pain was getting worse, the family could make the decision to send her out to the hospital. The Unit Manager spoke with the NP, who ordered scheduled Tramadol (treats moderate to moderately severe pain). The RP was made aware. On 11/19/24, a physicians order for Tramadol (opioid) 25mg twice daily due to the resident having increased pain. During an interview via telephone on 12/18/24 at 1:56 PM the RP indicated they visited on 11/18/24 and found out about the left hip/leg fracture x-ray results. She requested to speak to the NP, but she was not contacted until 11/19/24. He (the NP) told her that Resident #1 had a broken hip and would not send her out because she was not a surgical candidate due to her small body frame and the fracture could possibly heal on its own. On 11/19/24, the RP stated she told the Unit Manager that Resident #1 was still in pain, and the RP wanted her to be sent out to the hospital. The RP stated she could not rate Resident #1's pain level due to her dementia but when she (the resident) reached for something she would say her left hip was hurting. When the RP asked if they could send Resident #1 to the hospital, the Unit Manager told her that the hospital would send her right back. The Unit Manager then ordered stronger pain medication. The RP stated her main concern was that Resident #1 was not sent to the hospital immediately after the fall. During a telephone interview with the RP on 12/18/24 at 10:28 AM, she revealed on 11/19/24 when she spoke to the NP over the phone, he told her that he would not send Resident #1 to the hospital due to her small body frame, and it would be difficult for the surgeons to work on her. The RP recalled the facility scheduled an orthopedic appointment originally for 11/26/24. During a follow-up telephone interview with the RP on 12/20/24 at 9:56 AM, she revealed that when she spoke to the NP over the phone on 11/19/24, he never spoke to her about the risks of not sending Resident #1 out to the hospital. Review of a medical progress note dated 11/20/24 and completed by the Medical Director revealed that Resident #1 denied pain and neurological checks remain normal. The note indicated staff were to provide closer supervision and that fall protocols were in place. Laboratory results and radiology were reviewed. The Night Nurse Supervisor was interviewed via telephone on 12/21/24 at 7:48 AM. She revealed that she did not assess Resident #1 for pain at all on 11/18/24, 11/19/24, or 11/20/24 She stated that she took the information in the 72-hour post fall documentation notes from the previous shift and copied the details into the notes she wrote just so that some kind of documentation was completed during her shift. The Night Nurse Supervisor indicated that as a supervisor, she would review the documentation that needed to be completed by the nurses during her shift. If documentation was not completed, then she would have done it herself. Resident #1 was nonverbal, so she could not verbally provide a pain scale rating. During a telephone interview with NA #3, who worked with Resident #1 during the night shift from 7:00 PM on 11/20/24 until 7:00 AM on 11/21/24, she revealed that Resident #1 had fallen 3 days prior, and this was the first time she had worked with Resident #1. When she arrived for her shift, she was notified by the off coming NA that Resident #1's left hip was hurt and to be cautious during care. NA #3 remembered that Resident #1 said ow during an incontinence care episode when she touched her left hip. She did not notify anyone of the pain because she was notified about the left hip at the beginning of her shift. She made sure not to change or move Resident #1 during the shift unless necessary. Review of a medical progress note dated 11/21/24 and completed by the Medical Director revealed that Resident #1 denied all pain and appeared comfortable. There was no injury since her last fall and fall protocols were already in place. Laboratory results and radiology reviewed. A telephone interview was conducted with NA #2 on 12/19/24 at 10:53 AM. She worked with Resident #1 during the overnight shift from 7:00 PM on 11/21/24 until 7:00 AM on 11/22/24. NA #2 revealed that it appeared Resident #1 was in a lot of pain during her shift because she would refuse care, was not willing to get out of bed, and was not willing to roll side to side. Resident #1 was nonverbal, but when NA #2 tried to turn her in the bed, Resident #1 would grab her arm as if she was telling NA #2 to stop. Review of the MAR for November 2024 revealed that pain assessments were completed with a check mark from 11/19/24 - 11/22/24 without a numerical value or location for pain or a non-verbal pain scoring tool result in the medical record. Review of a medical progress note date 11/22/24 and completed by the Medical Director revealed that at the time of Resident #1's last fall on 11/17/24, she denied injury and denied pain. Since her last clinical examination on 11/21/24, Resident #1 complained of pain to the nurses. A recent x-ray of the left hip indicated a left intertrochanteric femur fracture. The Medical Director documented an immediate referral to orthopedics was made for today (11/22/24). A telephone interview was conducted with the Medical Director on 12/19/24 at 10:19 AM. He revealed that he did not review Resident #1's x-ray results from 11/18/24 until 11/22/24, and he did not receive an update from the NP that entire week. When he saw Resident #1 on 11/22/24, Resident #1 was in pain, and the Medical Director told staff that she needed to be sent out immediately. The Medical Director indicated he was told that Resident #1 had an orthopedic appointment the following week, but he told them she needed to go that day (11/22/24). The Medical Director stated that Resident #1 should have gone to the hospital as soon as the x-ray results came in on 11/18/24, and the surgeon would have made the decision if she was a surgical candidate or not. An interview was conducted with the Unit Manager on 12/19/24 at 12:22 PM. She revealed that she thought Resident #1 was not in pain the week after the fall because there was one day (date unknown) that she got out of bed into her wheelchair. However, for most of that week after the 11/17/24 fall, Resident #1 remained in bed, even though she was usually up daily. Every time she (the Unit Manager) asked if Resident #1 was in pain, she shook her head no. The RP told nursing staff that Resident #1 was in pain, but when staff asked her themselves, she would shake her head no. On 11/22/24, after the Medical Director saw the x-ray results and evaluated Resident #1, he wanted her to be sent out to an orthopedic appointment that same day. The RP was interviewed via telephone on 12/18/24 at 10:28 AM and 1:56 PM. She indicated Resident #1 remained in bed the entire week until 11/22/24, the day she went to the hospital. The Scheduler called the RP on 11/22/24 and told her that the orthopedics appointment was rescheduled for that same day. No reason was provided. The orthopedics office saw the fracture, and Resident #1 was then sent to the emergency department (ED). The NP was interviewed on 12/18/24 at 1:00 PM. The NP stated radiology took an x-ray of Resident #1's left hip on 11/18/24 and the results indicated a left femur fracture. He revealed that he was concerned whether Resident #1 would be suitable for surgery due to asymptomatic bradycardia. The NP indicated on 11/19/24 he requested Resident #1 be sent to the first available appointment at an orthopedics office to determine if she was a surgical candidate. The RP told the NP that she wanted Resident #1 to go to surgery, which was why an orthopedic consultation was scheduled for the following week (11/26/24). The NP indicated that he did not send Resident #1 to the emergency department (ED) because he was unsure if she was a surgical candidate or whether she would be better conservatively managed so that the fracture could heal on its own. Resident #1 was having a little bit of pain, which was managed with pain medication. The pain became unmanageable on 11/22/24, and she was seen by the orthopedics office on 11/22/24, who then sent her to the emergency department (ED) for surgery. Review of an Orthopedic Visit note dated 11/22/24 revealed that Resident #1 was in no acute distress, and the left leg was warm and perfused (adequate blood flow). Resident #1 pointed to the left groin area as a source of pain. Due to the results of the x-rays taken during the visit (intertrochanteric fracture of the left femur), Resident #1 was sent to the hospital from the appointment. Review of a Hospital Discharge Summary dated 11/26/24 revealed that Resident #1 had a closed intertrochanteric fracture of the left femur. She was seen in the orthopedic office on 11/22/24 for further evaluation, and an x-ray was obtained which showed an intertrochanteric fracture of the left femur. She was sent to the ED for further evaluation, and a left femur intramuscular nail surgery was performed on 11/23/24. The discharge summary indicated Resident #1 had an aspiration event while hospitalized which resulted in acute hypoxic respiratory failure and IV antibiotics were initiated on 11/24/24. The resident was prescribed additional oral antibiotics for three days after discharge back to the facility. The Orthopedic Surgeon, who performed the left hip surgery for Resident #1 on 11/23/24 in the hospital, was interviewed on 1/2/25 at 5:22 PM. He revealed that the healing and the treatment of Resident #1's left hip/leg fracture would not change with the delay of surgery. However, the risk of complications would go up if there was a delay. Such complications could be deep vein thrombosis (blood clots in veins deep in the body), pneumonia, and bed sores. The Orthopedic Surgeon stated that if Resident #1 was lying completely still, then the left hip pain could be well tolerated. However, if she was transferred to a chair or back to bed or rolling in bed, that could be significantly painful for her. In general, the standard of care was that if someone broke a long bone (such as the femur), they would need to be evaluated by an orthopedic specialist, who would then make the final decision for surgery within 24-48 hours after the injury. An injury like this would need an immediate transfer to the hospital. If she came to the clinic to be seen, she would have been sent directly to the ED, and they would not let her go home and wait for surgery. If this type of fracture was not treated within 24-48 hours, there are good outcome studies that were done showing a 30% perioperative mortality rate. That mortality rate would decrease if the injury was treated with surgery within 48 hours. The DON was interviewed on 12/30/24 at 11:58 AM. She revealed that nurses should have used a non-verbal pain tool or a pain scale when assessing Resident #1 for pain. She believed that the nurses chose N/A in the MAR when performing the pain assessments because Resident #1 denied pain. If a STAT x-ray was not done within 2-4 hours or before a shift was completed, then the nurse should have contacted the on-call provider for further instructions whether to wait or complete other orders. Resident #1 was noted during that week without pain or discomfort. The providers made their decision, and if any pain or discomfort was observed, the providers and managers would have agreed on further steps. The DON stated Resident #1 was not neglected, and the NP made his judgement call to keep her at the facility. During an interview with the Administrator on 12/30/24 at 12:31 PM, he revealed that he could not speak on this issue due to not having a clinical background. The Administrator was notified of immediate jeopardy on 1/3/25 at 8:48 AM. The facility provided the following Acceptable 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: An incident report was completed on 11/17/2024 at 11:05 am by the charge nurse, based on information obtained from certified nursing aide. Resident #1 was observed on the floor next to her bed sitting on her bottom. The resident was assessed by the charge nurse and no injuries were discovered during the initial assessment. The resident was assisted back to bed by the charge nurse and the certified nursing aide without incident. The charge nurse called the resident's Responsible Party (RP) and the Nurse Practitioner (NP) and no new orders were given. On 11/17/24 at 11:21 AM another progress note was entered in the electronic record which stated that the resident reported pain in her left hip and elbow when the RP arrived to the facility. The facility failed to immediately notify the medical provider of the new onset of pain. The medical provider was not called until 2:14 PM and at that time the medical provider gave new orders for a stat x-ray and Tylenol 500mg every 6 hours as needed for pain. The Tylenol order was not entered until 3:05pm on 11/17/2024. On 11/18/2024 the x-ray of the left hip was obtained at 9:23 am. The x-ray resulted on 11/18/2024 12:54 pm and the impressions were an acute transverse, nondisplaced intertrochanteric femur fracture. The residents' RP and NP were informed of the results on 11/18/2024 at 2:59 pm. On 11/19/2024 the NP assessed the resident after reviewing the x-ray and new orders were given for the resident to be seen by an orthopedic doctor. The NP elected not to send the resident out immediately after conferring with the RP who stated it was acceptable at the time. An orthopedic appointment was obtained for 11/26/2024. The NP ordered Tramadol 25 milligrams twice a day and to be given every 12 hours as needed for breakthrough pain. The NP made a determination to treat the injury in-house because he considered the resident to not be a good surgical candidate. The Medical Director was not aware of the fracture until he saw Resident #1 on 11/22/24 at which time he ordered the resident to be sent to the emergency department if she could not be seen by the orthopedist that day. Resident #1 was seen by the orthopedist on 11/22/24 and was sent directly to the hospital and a left femur intramuscular nail surgery was performed on 11/23/24. The facility failed to identify the seriousness of Resident #1's left intertrochanteric femur fracture after the fall on 11/17/24, identify the urgent need for orthopedic evaluation and surgical intervention, obtain the x-ray stat as ordered by the medical provider. In addition, the facility also failed to explain to the RP the risk of not sending the resident out for treatment versus managing the fracture in-house without a physician and/or orthopedic consultation. The delay in orthopedic medical management care and treatment put the resident at risk for complications such as DVT, PNA and bed sores. On 12/27/24 the Director of Nursing, Unit Managers and Regional Director of Clinical Services, reviewed the last 30 days of diagnostic results and progress notes for all residents to identify any instances of delay in carrying out orders, changes in condition, abnormal results, refusals or other clinical conditions that had not been properly identified and acted upon. If there were instances identified, the Unit Manager completed proper assessment and follow-up with resident, medical providers and responsible party as needed. 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 Staff Development Coordinator, Regional Director of Clinical Services, and Unit Managers conducted in-person education for Licensed Nurses, including agency nurses, on recognizing when to seek medical treatment for residents with fracture and changes in condition and notification to the Physician/Medical Director following an incident or change of condition and when receiving ordered diagnostic test results. Requirements for notification included reporting of abnormal labs and x-ray results, if an order is not to be carried out as ordered by the physician or nurse practitioner, refusal of treatment plan by the resident or responsible party. Education also included knowing the risk and benefits of not sending a resident out for treatment when needed and how to effectively communicate this information to the RP or resident if they are responsible for making their own healthcare decisions. Risks include worsening condition, delayed treatment plan, increased pain or discomfort and complications associated with the disease process. The Director of Nursing will ensure that no staff member works without receiving this education. The Staff Development Coordinator is responsible for tracking that all staff received the required education. Any new hires, including agency staff, will receive education prior to the start of their shift. Education will be completed by 1/8/2025 by the Staff Development Coordinator. The Staff Development Coordinator, Regional Director of Clinical Services, and Unit Managers initiated in-person training for all Licensed Nurses, including agency nurses, to ensure they understand the requirements for orders received for diagnostic tests. The requirements included: If the diagnostic test is ordered stat and the mobile diagnostic company is unable to perform the study stat or in an acceptable time at the direction of the medical provider the resident is to be sent to the hospital. The Director of Nursing will ensure no staff will work without receiving this education. Any new hires, including agency staff, will receive education prior to the start of their shift. Education will be completed by 1/4/2025. The Staff Development Coordinator will be responsible for tracking all staff to make sure they have received the required education. The Staff Development Coordinator was informed of her responsibility on 12/27/24. This education will also become a part of the new hire orientation process for all newly hired licensed nurses. On 12/27/24, the Staff Development Coordinator, Regional Director of Clinical Services, and Unit Managers conducted in-person education for all Licensed Nurses, including agency nurses, on the procedure for handling abnormal x-ray results. The training emphasized that abnormal results must be reported to the Medical Director for further orders. Education will be completed by 1/4/2025. Any staff who did not receive the in-person training will be educated before their next scheduled shift. The Staff Development Coordinator is responsible for tracking that all staff receive the required education. This training will also be included in the new hire orientation for all newly hired licensed staf [TRUNCATED]

Based on record review, and staff, Medical Director and Nurse Practitioner (NP) interviews, the NP failed to communicate and collaborate with the Medical Director when Resident #1 was diagnosed on [DATE] with an acute nondisplaced (the bone does not break completely and there will be a crack on the bone) transverse (horizontal and perpendicular to the bone) left femur (leg) fracture following an unwitnessed fall on 11/17/24. The NP did not consult with the Medical Director before making the decision the resident was probably not a surgical candidate and attempting to treat the resident in-house. Due to the lack of communication and coordination the Medical Director was not aware of the fracture until he saw Resident #1 on 11/22/24 at which time he ordered the resident to be sent to the emergency department if she could not be seen by the orthopedist that day. Resident #1 was seen by the orthopedist on 11/22/24 and was sent directly to the hospital and a left femur intramuscular nail surgery was performed on 11/23/24. The lack of communication and collaboration between the NP and Medical Director delayed orthopedic medical management, care and treatment and put the resident at high risk for complications such as deep vein thrombosis, pneumonia, and bed sores. Resident #1 had an aspiration event (foods, stomach contents, or fluids are breathed into the lungs) while hospitalized which resulted in acute hypoxic respiratory failure (low levels of oxygen in your blood) and IV antibiotics were initiated on 11/24/24. The resident was prescribed additional oral antibiotics for three days after discharge back to the facility on [DATE]. This failure affected 1 of 3 reviewed for accidents (Resident #1). Immediate jeopardy began on 11/18/24 when the NP failed to collaborate and communicate with the Medical Director regarding medical management when x-ray results confirmed Resident #1 had an acute nondisplaced intertrochanteric femur fracture. Immediate jeopardy was removed on 1/5/25 when the facility implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a scope and severity of D (no actual harm with potential for more than minimal harm that is immediate jeopardy) to ensure education is completed and monitoring systems put into place and are effective. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, muscle weakness, difficulty in walking, bradycardia (a condition where the heart beats too slowly) (initiated 11/12/24), traumatic brain injury (TBI) in 1999, history of a stroke, chronic obstructive pulmonary disease/asthma, and dysarthria (slurred speech). Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #1 was severely cognitively impaired, had adequate hearing/vision, could speak clearly, and usually understood/understands. Review of an Unwitnessed Fall Report dated 11/17/24 at 11:05 AM and completed by Nurse #1 revealed she was notified by Nurse Aide (NA) #1 that Resident #1 was on the floor next to her bed sitting on her bottom. She was assessed, and no injuries were noted. Vital signs (VS) were within normal limits (WNL). Resident #1 reported no pain or discomfort and was then assisted back to her bed. Review of a 72 Hour Post Fall Documentation note dated 11/17/24 at 11:21 AM and completed by Nurse #1 revealed that Resident #1 reported pain in her left hip when the responsible party (RP) arrived at the facility. Review of On-Call Provider progress note dated 11/17/24 at 4:15 PM and completed by the on-call provider revealed that Resident #1 had a fall at 11:00 AM on 11/17/24. No injuries were reported, and Resident #1 denied pain. The RP visited the facility and now Resident #1 reported left hip pain with tenderness to palpation. A neurological check was performed via video and there were no acute deficits noted. A STAT (immediately) x-ray of the left hip was ordered, as well as Tylenol 500 milligrams (mg) every 6 hours as needed for pain. Neurological checks should be performed every 4 hours. Review of physician orders for Resident #1 revealed that a one-time STAT x-ray of the left hip was ordered on 11/17/24 at 3:04 PM. Review of a medical progress note dated 11/18/24 at 10:00 AM and completed by the NP revealed that Resident #1 had a fall on 11/17/24. She denied hitting her head, injury, or pain following the fall. Resident #1 appeared at her baseline mental status and had tenderness to the left hip with palpation. Review of a health status note dated 11/18/24 at 10:18 AM and completed by Nurse #2 revealed that radiology services were in the facility to perform the STAT x-ray ordered for Resident #1 on 11/17/24. Review of a health status note dated 11/18/24 at 11:40 AM and completed by Nurse #2 revealed that Resident #1 continued to have pain/discomfort in her left hip. Review of a health status note dated 11/18/24 at 3:00 PM and completed by Nurse #2 revealed Resident #1's x-ray results of the left hip were an acute nondisplaced intertrochanteric (where the hip and thigh meet) femur fracture. Review of Resident #1's radiology results report in the electronic medical record revealed an entry on the x-ray results that noted the Medical Director reviewed the report on 11/18/24 at 6:29 PM. During a telephone interview with the Medical Director on 12/20/24 at 11:13 AM, he revealed that the nurses always put the printout of x-ray results in his mailbox or provider book to review. The Medical Director stated on 11/18/24 he had cleared all the lab and x-ray results from the computer without looking at the x-ray report for Resident #1. He did not review the x-ray results of any resident if he did not place the original order. He stated that he relied on the paperwork in his mailbox or provider book for further evaluation/orders. Review of a medical progress note dated 11/19/24 and completed by the NP revealed that Resident #1 had an acute nondisplaced transverse intertrochanteric femur fracture. Resident #1's RP was waiting for the NP to contact her for consultation, which took place the same day. The RP requested an orthopedic evaluation. The NP discussed complications about potential surgery with the RP and told her that orthopedics would consider Resident #1's overall health, specifics about the fracture, and new asymptomatic bradycardia. Review of a health note dated 11/19/24 at 2:40 PM and completed by the Unit Manager revealed that Resident #1's RP was at her bedside with some concerns of increased pain due to the left hip/leg fracture. The RP stated that her family told her that Resident #1 needed to go to the hospital for 24-hour care. It was explained to the RP that Resident #1's pain could be managed at the facility; however, if she felt the pain was getting worse, the family could make the decision to send her out to the hospital. The Unit Manager spoke with the NP, who ordered scheduled Tramadol. The RP was made aware. Review of physician orders for Resident #1 revealed that on 11/19/24, an orthopedic surgery consultation for a left hip/leg fracture was ordered. Review of a medical progress note dated 11/20/24 and completed by the Medical Director revealed that Resident #1 denied pain and neurological checks remain normal. Staff to provide closer supervision and fall protocols were in place. Laboratory results and radiology reviewed. Review of a medical progress note dated 11/21/24 and completed by the Medical Director revealed that Resident #1 denied all pain and appeared comfortable. There was no injury since her last fall and fall protocols were already in place. Laboratory results and radiology reviewed. Review of a medical progress note date 11/22/24 and completed by the Medical Director revealed that at the time of Resident #1's last fall on 11/17/24, she denied injury and denied pain. Since her last clinical examination on 11/21/24, Resident #1 complained of pain to the nurses. A recent x-ray of the left hip indicated a left intertrochanteric femur fracture. The Medical Director documented an immediate referral to orthopedics that had been made for today. A telephone interview was conducted with the Medical Director on 12/19/24 at 10:19 AM. He revealed that he did not review Resident #1's x-ray results from 11/18/24 until 11/22/24, and he did not receive an update from the NP that entire week. When he saw Resident #1 on 11/22/24, Resident #1 was in pain, and the Medical Director told staff that she needed to be sent out immediately. The Medical Director indicated he was told that Resident #1 had an orthopedic appointment the following week, but he told them she needed to go that day (11/22/24). The Medical Director stated that Resident #1 should have gone to the hospital as soon as the x-ray results came in on 11/18/24, and the surgeon would have made the decision if she was a surgical candidate or not. A telephone interview was conducted with the Unit Manager on 1/3/25 at 8:33 AM, and she revealed that the NP did consult with her and the Director of Nursing (DON) on 11/18/24 about the decision to keep Resident #1 in the facility and order an orthopedic consultation. The NP was interviewed on 12/18/24 at 1:00 PM. The NP stated radiology took an x-ray of Resident #1's left hip on 11/18/24 and the results indicated a left femur fracture. He revealed that he was concerned whether Resident #1 would be suitable for surgery due to asymptomatic bradycardia (asymptomatic). The NP indicated on 11/19/24 he requested Resident #1 be sent to the first available appointment at an orthopedics office to determine if she was a surgical candidate. The RP told the NP that she wanted Resident #1 to go to surgery, which was why an orthopedic consultation was scheduled for the following week (11/26/24). The NP indicated that he did not send Resident #1 to the ER because he was unsure if she was a surgical candidate or whether she would be better conservatively managed so that the fracture could heal on its own. Resident #1 was having a little bit of pain, which was managed with pain medication. The pain became unmanageable on 11/22/24, and she was seen by the orthopedics office on 11/22/24, who then sent her to the ER for surgery. During a follow-up telephone interview with the NP on 12/20/24 at 8:09 AM, he revealed that he did not recall why the MD was not consulted prior to 11/22/24. The NP stated he made the decision to keep Resident #1 in the facility from consultations with the unit supervisor and the DON. During a follow-up telephone interview with the NP on 1/2/25 at 3:34 PM, he revealed that he was not trained to communicate with the Medical Director on specific topics. The NP and the Medical Director communicate on things that require additional assessments or moderate to severe issues (for example: a suspected arterial blockage in the lower extremities). The NP stated the only time he would communicate to the Medical Director about x-rays, or a fracture, was if he had a question about the treatment. During a follow-up telephone interview with the Medical Director on 12/20/24 at 8:27 AM, he revealed the NP consulted with him quite often, but he should have consulted with the Medical Director about the fracture when he found out on 11/18/24. The Medical Director stated that the NP had lots of experience and was qualified to look at x-rays and make decisions. However, in this case, the NP made the wrong decision. He should have sent Resident #1 out when the x-ray results were received. The Medical Director indicated that he had seen Resident #1 on 11/20/24, and she denied pain. He was unaware of the fracture on that date, and he was unaware that an x-ray was ordered by the On-Call Provider. He became aware of the fracture on 11/22/24 from the provider communication book. When he saw Resident #1 on 11/22/24, and she said she was in pain, he went to look at the communication report and found out about the fracture on that day. The fracture report was not in the communication book the days prior. During an additional telephone interview with the Medical Director on 1/2/25 at 3:09 PM, he revealed that the NP could have made the decision on his own to wait for surgery for Resident #1 because he had a lot of experience and was an independent practitioner. The NP made those types of decisions daily and well. The Medical Director stated that if the NP was comfortable managing those type of situations (fractures), then he did not need to consult with the Medical Director. The Medical Director indicated that he expected the NP to communicate with him when he was unsure/unclear about something or had a question, which the NP did regularly. The Medical Director indicated he and the NP spoke daily. Review of an Orthopedic Visit note dated 11/22/24 revealed that Resident #1 was in no acute distress, and the left leg was warm and perfused. Resident #1 pointed to the left groin area as a source of pain. Due to the results of the x-rays taken during the visit (intertrochanteric fracture of the left femur), Resident #1 was sent to the hospital from the appointment. Review of a Hospital Discharge Summary dated 11/26/24 revealed that Resident #1 had a closed intertrochanteric fracture of the left femur. She was seen in the orthopedic office on 11/22/24 for further evaluation, and an x-ray was obtained which showed an intertrochanteric fracture of the left femur. She was sent to the ER for further evaluation, and a left femur intramuscular nail surgery was performed on 11/23/24. The discharge summary indicated Resident #1 had an aspiration event while hospitalized which resulted in acute hypoxic respiratory failure and IV antibiotics were initiated on 11/24/24. The resident was prescribed additional oral antibiotics for three days after discharge back to the facility. During an interview with the DON on 12/30/24 at 12:03 PM, she revealed that she was unaware of the medical providers' communication protocol. During a follow-up telephone interview with the DON on 1/6/25 at 8:54 AM, the DON recalled the NP giving the order for the orthopedic consultation and an explanation why Resident #1 may not have been a surgical candidate but did not ask for her opinion. An interview was conducted with the Administrator on 12/30/24 at 12:34 PM, and he revealed that he could not speak on the medical provider collaboration issue due to not having a clinical background. The Administrator was notified of immediate jeopardy on 1/3/25 at 8:48 AM. The facility provided the following Acceptable Allegation of Immediate Jeopardy removal. An incident report was completed on 11/17/2024 at 11:05 am by the charge nurse, based on information obtained from certified nursing aide. Resident #1 was observed on the floor next to her bed sitting on her bottom. The resident was assessed by the charge nurse and no injuries were discovered during the initial assessment. On 11/17/24 at 11:21 AM another progress note was entered in the electronic record which stated that the resident reported pain in her left hip and elbow when the responsible party (RP) arrived to the facility. The on-call medical provider was called at 2:14 PM and at that time the medical provider gave orders for a stat x-ray. On 11/18/2024 the x-ray of the left hip was obtained at 9:23 am. The x-ray resulted on 11/18/2024 at 12:54 pm and the impressions were an acute transverse, nondisplaced intertrochanteric femur fracture. The resident's responsible party (RP) and Nurse Practitioner (NP) were informed of the results on 11/18/2024 at 2:59 pm. The NP made a determination to treat the injury in-house, but did not consult with the Medical Director regarding this treatment plan before making the decision to treat in house because he considered the resident to not be a good surgical candidate. The Medical Director (MD) saw the resident on 11/20/24 and 11/21/24 but was unaware of the fracture because of the lack of communication and coordination from the facility and the NP. On 12/20/2024, the MD reviewed the NP's notes for the previous 30 days, including the on-call providers, to ensure the plan of care was appropriate for the residents. Any opportunities identified during this audit were corrected by the MD on 12/20/2024. On 12/20/2024, the Regional Director of Clinical Services, Nurse Practitioner, Medical Director, and the Director of Nursing reviewed Resident #1's plan of care and collaborated on what the best course of treatment should have been for the resident. On 1/4/25 the Regional [NAME] President educated the Medical Director, NPs, and covering providers on collaborating/consulting following a fracture and/or a significant change of condition. The Medical Director, Nurse Practitioners and covering providers will collaborate 3 times a week via phone, in-person, or virtual to discuss the plan of care for the residents that have obtained a fracture or a significant change in condition. The Regional [NAME] President educated The Director of Nursing and the Administrator to participate in the meeting. On 1/4/2025, the Medical Director reviewed the guidelines for how the Nurse Practitioners and other covering providers to communicate with the Medical Director. The Medical Director and Regional [NAME] President discussed this agreement with the NPs and other providers on 1/4/25. The Regional Director of Clinical Services educated the Nurse Management Team and the Director of Nursing regarding the nurse practitioners' notes, including on call to ensure communication and collaboration is completed. The Director of Nursing, unit managers, staff development nurse and Assistant Director of Nursing will review and print the nurse practitioner notes, including the on-call providers daily and place them in the Medical Director's communication book. When the Medical Director is not in the facility, he will receive an electronic HIPAA compliant copy of the medical progress notes generated each day. Any new hires, including agency staff, will receive education prior to the start of their shift via telephone or in person. This education was completed on 1/4/2025 by the Regional Director of Clinical Services. Effective 1/4/2025 the Administrator will be responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of Immediate Jeopardy Removal: 1/5/2025 An onsite validation was conducted on 01/09/25. The in-service conducted by Regional [NAME] President with the Medical Director, Nurse Practitioners, and covering providers on collaborating/consulting following a fracture and/or a significant change of condition was reviewed. The Medical Director, Nurse Practitioners and covering providers will collaborate 3 times a week via phone, in-person, or virtual to discuss the plan of care for the residents that have obtained a fracture or a significant change in condition. Interviews completed with the Medical Director and Nurse Practitioner verified knowledge of the new process for collaborating and consulting following a significant change in condition. The immediate jeopardy removal date of 01/05/25 was validated.

Based on record review, and Medical Director, Nurse Practitioner, Responsible Party and staff interviews, the facility failed to effectively intervene for complaints of pain, failed to provide thorough and ongoing pain assessments, and failed to effectively manage a resident's pain. This was for 1 of 1 resident reviewed for pain (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, muscle weakness, difficulty in walking, bradycardia (a condition where the heart beats too slowly) (initiated 11/12/24), traumatic brain injury (TBI) in 1999, history of a stroke, chronic obstructive pulmonary disease/asthma, and dysarthria (slurred speech). Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #1 was severely cognitively impaired. She did not have any falls since the previous assessment, and there was no pain presence or pain medication regimen in place at the time of the review period. Review of physician orders for Resident #1 revealed that a pain assessment using 0-10 (0 = no pain, 10 = excruciating pain) scale or non-verbal scoring tool every shift was ordered on 11/9/24. Review of an unwitnessed fall report dated 11/17/24 at 11:05 AM and completed by Nurse #1 revealed she was notified by Nurse Aide (NA)#1 that Resident #1 was on the floor next to her bed sitting on her bottom. Resident #1 denied hitting her head. The on-call provider and responsible party (RP) were notified. Resident #1 was noted to have regular white socks on both of her feet. She was assessed, and no injuries were noted. Vital signs (VS) were within normal limits (WNL). Resident #1 reported no pain or discomfort. She was then assisted back to her bed. Review of a 72-hour post fall documentation note dated 11/17/24 at 11:21 AM and completed by Nurse #1 revealed that Resident #1 reported pain in her left hip when the RP arrived at the facility. Review of an On-Call Provider note dated 11/17/24 at 4:15 PM and completed by the On-Call Provider revealed that Resident #1 had a fall at 11:00 AM. No injuries were reported, and Resident #1 denied pain. The RP visited the facility and now Resident #1 reported left hip pain with tenderness to palpation. A neurological check was performed via video and there were no acute deficits noted. A STAT (with no delay) x-ray of the left hip was ordered, as well as Tylenol 500 milligrams (mg) every 6 hours as needed for pain. Neurological checks should be performed every 4 hours. Review of physician orders for Resident #1 revealed that a one-time STAT x-ray of the left hip was ordered on 11/17/24 at 3:04 PM. On the same day, Tylenol 500mg tablet given every 6 hours as needed for pain was also ordered at 3:15 PM. Review of Resident #1's vital signs from 11/17/24 - 11/22/24 revealed that she had a pain value of 0 on 11/17/24 at 11:08 AM and 4:14 PM. On 11/18/24, Resident #1 had pain values of 7 at 2:54 PM and 4 at 3:26 PM. Only numerical values were entered. Where the pain was located was not included. Nurse #1 was interviewed on 12/19/24 at 11:14 AM. She revealed that she completed all documentation related to Resident #1's fall and called the responsible party (RP). She was nonverbal. She checked on her multiple times after the fall, and she did not voice any pain/concerns. The RP came later that day and said Resident #1 complained of pain. She assessed her again, and Resident #1 said she was in pain. She assessed her left leg while she was laying on her right side. When she pressed on it, she winced with pain and there was a bruise. She contacted the doctor again and told her that the pain had not been discovered until just then. She was instructed to order an x-ray ASAP. She told the RP that Resident #1 could go to the emergency room (ER) because the x-ray time was uncertain. The RP said no to the ER, and she would be ok waiting (not too long). She gave her some Tylenol and then she left for the night at 7:00 PM but the Tylenol was not documented as given. Review of the November 2024 medication administration record (MAR) revealed that Nurse #2 administered 500mg of as needed Tylenol to Resident #1 on 11/18/24 at 2:54 PM due to a pain level of 7. Review of a health note dated 11/19/24 at 2:40 PM and completed by the Unit Manager revealed that Resident #1's RP was at her bedside with some concerns of increased pain due to the left hip/leg fracture. The RP stated that her family told her that Resident #1 needed to go to the hospital for 24-hour care. It was explained to the RP that Resident #1's pain could be managed at the facility; however, if she felt the pain was getting worse, the family could make the decision to send her out to the hospital. The Unit Manager spoke with the Nurse Practitioner (NP), who ordered scheduled Tramadol (treats moderate to moderately severe pain). The RP was made aware. The NP was interviewed on 12/18/24 at 1:00 PM, and he revealed that Resident #1 was having a little bit of pain on 11/19/24 but was managed with pain medication. Review of physician orders for Resident #1 revealed that on 11/19/24, 25mg of Tramadol was ordered twice daily and as needed every 12 hours. Review of the MAR for November 2024 revealed that pain assessments were completed with a check mark from 11/19/24 through 11/22/24 without a numerical value or location for pain or a non-verbal pain scoring tool result in the medical record. Review of a 72-hour post fall documentation note dated 11/19/24 at 2:29 PM and completed by Nurse #2 revealed that Resident #1 remained in bed and Tylenol was given for pain. However, this pain medication administration was not documented. An interview was not conducted with Nurse #2 related to this documentation. Review of a 72-hour post fall documentation note dated 11/19/24 at 10:29 PM and completed by the Night Nurse Supervisor revealed that it read the same information from Nurse #2's 72-hour post fall documentation note at 2:29 PM. Review of a 72-hour post fall documentation note dated 11/20/24 at 10:45 PM and completed by the Night Nurse Supervisor revealed that Resident #1 had a nondisplaced fracture to the left femur and reported a pain level of 4 in the left hip. The Night Nurse Supervisor was interviewed on 12/21/24 at 7:48 AM. She revealed that Resident #1 was not assessed for pain by the Night Nurse Supervisor on 11/18/24, 11/19/24, or 11/20/24. She stated that she took the information in the 72-hour Post Fall Documentation notes from the previous shift and copied the details into the notes she wrote just so that some kind of documentation was completed during her shift. The Night Nurse Supervisor indicated that as a supervisor, she would review the documentation that needed to be completed by the nurses during her shift. If documentation was not completed, then she would have done it herself. Resident #1 was nonverbal, so she could not quantify her pain a 4. She stated that Resident #1 was not in pain on 11/18/24 - 11/20/24 during the overnight shifts because a NA (name unknown) got her up out of bed and into the wheelchair without knowing she had a broken hip/leg. However, Resident #1 did not display any nonverbal expressions of pain. Nurse #3, who worked with Resident #1 during the overnight shifts from 11/17/24 through 11/21/24, was interviewed on 12/19/24 at 11:57 AM. He revealed that during the week of 11/18/24, he could not recall a change in Resident #1's status or if she had displayed any signs/symptoms of pain or discomfort. During an interview with NA #3, who worked with Resident #1 during the overnight shift from 7:00 PM on 11/20/24 until 7:00 AM on 11/21/24, she revealed that Resident #1 had fallen 3 days prior, and this was the first time she had worked with Resident #1. When she arrived for her shift, she was notified by the off going NA that Resident #1's left hip was hurt and to be cautious during care. NA #3 remembered that Resident #1 said ow during an incontinence care episode when she touched her left hip. She did not notify anyone of the pain because she was notified about the left hip at the beginning of her shift. She made sure not to change or move Resident #1 during the shift unless necessary. An interview was conducted with NA #2 on 12/19/24 at 10:53 AM. She worked with Resident #1 during the overnight shift from 7:00 PM on 11/21/24 until 7:00 AM on 11/22/24. NA #2 revealed that it appeared Resident #1 was in a lot of pain during her shift because she would refuse care, was not willing to get out of bed, and was not willing to roll side to side. Resident #1 was nonverbal, but when NA #2 tried to turn her in the bed, Resident #1 would grab her arm as if she was telling NA #2 to stop. Review of a 72-hour post fall documentation note dated 11/22/24 at 2:24 AM and completed by Nurse #3 revealed that Resident #1 had a nondisplaced fracture to the left femur and reported a pain level of 4. Nurse #3 was interviewed on 12/23/24 at 9:58 AM. He stated that he could not recall the 72-hour post fall documentation note dated 11/22/24, and no NA notified him that Resident #1 was in pain from 11/18/24 - 11/22/24. The RP was interviewed on 12/18/24 at 10:28 AM. She revealed that Resident #1 continued to have pain after the fall on 11/17/24. An x-ray was performed on 11/18/24, which resulted in a left leg/hip fracture. During a follow-up interview with the RP on 12/18/24 at 1:56 PM, she revealed that on 11/19/24, Resident #1 was still in pain. She asked the Unit Supervisor to order stronger pain medication. Resident #1 remained in bed the entire week until 11/22/24 when she went to the hospital. The RP stated she could not rate Resident #1's pain level due to her dementia, but when she reached for something, she would say her hip was hurting. An interview was conducted with the Unit Manager on 12/19/24 at 12:22 PM. She revealed that she thought Resident #1 was not in pain the week after the fall because there was one day (date unknown) that she got out of bed into her wheelchair. However, for most of that week after the 11/17/24 fall, Resident #1 remained in bed, even though she was usually up daily. Every time she (the Unit Manager) asked if Resident #1 was in pain, she shook her head no. The RP told nursing staff that Resident #1 was in pain, but when staff asked her themselves, she would shake her head no. On 11/22/24, after the Medical Director saw the x-ray results and evaluated Resident #1, he wanted her to be sent out to an orthopedic appointment that same day. Review of a medical progress note date 11/22/24 and completed by the Medical Director revealed that at the time of Resident #1's last fall on 11/17/24, she denied injury and denied pain. Since her last clinical examination on 11/21/24, Resident #1 complained of pain to the nurses. A recent x-ray of the left hip indicated a left intertrochanteric femur fracture. The MD documented an immediate referral to orthopedics was made for today. During an interview with the Medical Director on 12/20/24 at 8:27 AM, he revealed that he saw Resident #1 on 11/20/24 and she denied pain. When the MD saw Resident #1 on 11/22/24, and she said she was in pain, he went to look at the provider communication book and found out about the fracture on that day. Review of an Orthopedic Visit note dated 11/22/24 revealed that Resident #1 was in no acute distress, and the left leg was warm and perfused. Resident #1 pointed to the left groin area as a source of pain. Due to the results of the x-rays taken during the visit (intertrochanteric fracture of the left femur), Resident #1 was sent to the hospital from the appointment. Review of the emergency department note dated 11/22/24 revealed that Resident #1 was seen for left hip pain after a fall 5 days prior. She was treated for pain with Tylenol and Tramadol at the facility. Resident #1 has had left hip pain for a while now but not if resting. The DON was interviewed on 12/20/24 at 12:25 PM. She stated that she was unable to retrieve the results of the twice daily pain assessments from 11/19/24 - 11/22/24 based on the MAR details. If the nonverbal pain assessment tool was entered and the pain was 0, it would show up in vital signs of Resident #1's medical record. The DON stated she was unsure why the pain assessment results were not included in vital signs from 11/19/24 through 11/22/24. If the pain assessment was checked off in the MAR but not displayed in vital signs, then the pain assessment results were not necessarily a 0. During a follow-up interview with the DON on 12/20/24 at 12:47 PM, she revealed that the nurses who completed the pain assessments from 11/19/24 through 11/22/24 must have chosen not applicable as a response because the results did not show up in the medical record. During a follow-up interview with the DON on 12/30/24 at 12:00 PM, she revealed that all nurses should have continued with the complete pain assessments after 11/18/24. During an interview with the Administrator on 12/30/24 at 12:32 PM, he revealed that he could not speak on the issue of missing pain assessment from 11/19/24 through 11/22/24 and delayed pain medication due to not having a clinical background.

Based on observations, record review, and staff and Nurse Practitioner (NP) interviews, the facility failed to implement a broad-based approach COVID-19 testing for staff and residents on 10/13/24 when residents tested positive for COVID-19 on two resident halls. The facility had been in outbreak status since 10/08/24 when a staff member tested positive and only residents/staff with symptoms, roommates of residents that tested positive and staff that requested or were symptomatic tested for COVID-19. Broad-based COVID-19 testing per the Centers for Disease Control and Prevention (CDC) guidance was not implemented until 10/23/24. Before broad-based testing was implemented on 10/23/24, a total of 4 staff members and 22 residents had tested positive for COVID-19. Results of the broad-based testing from 10/23/24 through 10/25/24 yielded one (1) staff member and 6 additional residents positive for COVID-19. In addition, 11of 14 staff members failed to wear surgical masks covering both their mouth and nose for source control to help prevent transmission while working in the facility during the COVID-19 outbreak and one staff member (Nurse Aide #6) entered a resident room under transmission-based precautions for COVID-19 without wearing eye protection. The facility's infection control policy and procedures for outbreak testing did not conform with CDC guidance. had not initiated the administration of any 2024-2025 COVID-19 vaccinations for residents. The resident census at the time of the survey was 129. The facility had their first 2024-2025 COVID-19 vaccination clinic on 10/16/24 through10/18/24. These cumulative practices and system failures occurred during a COVID-19 outbreak and had the high likelihood for continued transmission of COVID-19 to residents and staff and a serious adverse outcome. Immediate Jeopardy began on 10/13/24 when COVID positive residents were identified on the 200-hall and 400-hall and broad-based testing of staff and residents was not initiated. Immediate jeopardy was removed on 10/25/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a scope and severity of E (no actual harm with potential for more than minimal harm that is immediate jeopardy) to ensure education is completed and monitoring systems are in place and are effective. The findings included: A. The facility policy titled Policies and Procedures [Infection Prevention and Control], Section Emerging Infectious Disease(s), Policy Name COVID-19 Effective date 03/11/24 revealed the center followed the Centers for Disease Control and Prevention (CDC) and standards of practice for prevention of COVID-19 to protect employees and patients. Section 4 revealed Infection Prevention and Control measures may include, but were not limited to: i. Employee and patient testing according to current standards Per the CDC guidelines dated 6/24/24, The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based approach is preferred if all potential contacts cannot be event identified or managed with contact tracing or if contact tracing fails to halt transmission. If additional cases are identified, strong consideration should be given to shifting to broad based approach if not already being performed and implementing quarantine for residents in affected areas of the facility. As part of the broad-based approach testing should continue on affected units or facility wide every 3-7days until there are no new cases for 14 days. If antigen testing is used more frequent testing (every three days) should be considered. A review of the facility document titled COVID-19 Contact Tracing Investigation revealed the following: - The COVID outbreak started on 10/08/24 when the facility Social Worker tested positive for COVID. - The Receptionist tested positive on 10/10/09/24. - On 10/13/24 four residents on the 200-hall (Resident #98, Resident #126, Resident #442, and Resident #443) and 1 resident on the 400-hall (Resident #5) tested positive for COVID. - On 10/14/24 two residents on the 400-hall (Resident #90 and Resident#92) and 1 resident on the 700 hall (Resident #67) tested positive for COVID. - On 10/15/24 one resident on the 200-hall (Resident #68) and one resident on the 700-hall (Resident #3) tested positive for COVID. - On 10/17/24 one resident on the 200-hall (Resident #29), one resident on the 300-hall (Resident #55), one resident on the 400-hall (Resident #111), and two residents on the 700-hall (Resident #107 and Resident #116). - On 10/18/24 one resident on the 300-hall (Resident #39) and two residents on the 700-hall (Resident #4 and Resident #119) tested positive. - On 10/21/24 one resident on the 300-hall (Resident #13) tested positive. - On Tuesday, 10/22/24, two more residents and one staff member tested positive. - On Wednesday, 10/23/24, one additional resident and one staff member tested positive. On 10/23/24 at 11:09 AM an interview was conducted with the Infection Preventionist (IP)/Assistant Director of Nursing /Staff Development Coordinator, and she stated residents were tested when they were symptomatic or the roommate of a COVID positive resident. She further stated staff were tested when they requested or if they were symptomatic. The IP stated the facility Social Worker tested positive for COVID on 10/8/24 and on 10/09/24 the Receptionist tested positive for COVID. She stated on 10/13/24 five residents on the 200 hall and one resident on the 400-hall tested positive. On 10/14/24 there were 2 more residents on the 400-hall who tested positive for COVID and 1 resident on the 700-hall. On 10/15/24 another resident on the 700-hall and 1 resident on the 200-hall tested positive. On 10/17/24 a total of 5 more residents tested positive - 1 on the 200-hall, 1 on the 300- hall, 1 on the 400-hall and 2 on the 700-hall. On 10/18/24 another resident on the 300-hall and 2 residents on the 700-hall tested positive. She stated on Monday, 10-21-24, there were19 COVID+ residents and zero COVID+ staff. On Tuesday, 10/22/24 two more residents and 1 staff tested COVID+. On Wednesday, 10/23/24, 1 additional resident and 1 staff tested positive. The IP stated residents were tested on ly when they were symptomatic or if they were roommates of a resident who tested positive. She stated a COVID outbreak was when 6 or more residents and/or staff were positive. The Infection Preventionist stated she had spoken with her corporate clinical nurse consultant who had informed her that she did not have to report the COVID outbreak to the Health Department as they had in the past because the facility reported to National Healthcare Safety Network (NHSN). She said she reported this outbreak to the health department on 10/18/24 when the number of COVID+ residents reached 18. The IP stated she felt the spread of COVID throughout the building was largely due to noncompliant residents and the agency staff working at different facilities and getting exposed from numerous sources. The IP stated she felt they did all the protocols they should have initiated. The IP stated COVID+ residents were quarantined for 10 days and then they're off of quarantine and they do not re-test those residents after the 10-day quarantine. The interview further revealed the facility had a COVID-19 vaccine clinic In an interview with Nurse Aide (NA) #6 on 10/22/24 at 12:43 PM she stated she had not been tested for COVID by the facility. On 10/23/24 at 11:09AM the IP stated the facility had a COVID vaccine clinic from 10/16/24 through 10/18/24 and had one scheduled for that week (the week of 10/21/24) but cancelled it due to the survey. An interview was conducted with the Director of Nursing (DON) on 10/23/24 at 2:06 PM and she stated she expected all nurses (staff and agency) to follow the standards of nursing and to follow the infection prevention/infection control practices. The DON deferred questions regarding testing and education to the IP. A follow up interview with the DON was conducted on 10/25/24 5:00 PM revealed all residents in the facility and all staff members entering the facility were tested for COVID beginning on 10/23/24. The facility identified 6 more COVID+ residents on Wednesday, 10/23/24 and one staff member on Friday, 10/25/24. No positive cases were identified on Thursday 10/24/24. B. The facility policy titled Infection Prevention and Control Committee, updated 08/02/2024, revealed the Infection Prevention and Control Committee was responsible for implementing established program plans and standards of practice that promoted, monitored, and maintained an environment that reduced the risk of transmission and acquisition of center-acquired infections. The facility policy titled Policies and Procedures [Infection Prevention and Control], Section Emerging Infectious Disease(s), Policy Name COVID-19 Effective date 03/11/24 revealed the center followed the Centers for Disease Control and Prevention (CDC) and standards of practice for prevention of COVID-19 to protect employees and patients. Section 4 revealed Infection Prevention and Control measures may include, but were not limited to: a. Source control (well-fitting face mask/face covering): - For those with suspected or confirmed respiratory infection - For those who have had close contact with someone with COVID-19 for 10 days after contact - For those who reside or work in an area of the facility experiencing COVID-19 outbreak with uncontrolled transmission, or - When otherwise recommended by public health authorities - Even if not otherwise required by the facility, individuals should always be allowed to wear source control based on personal preference. c. Respiratory Hygiene/cough etiquette d. Visual alerts posted to inform current infection control practices f. Appropriate staff use of PPE, when indicated On 10/21/24 at 7:45 AM an interview and observation was conducted upon entry with Receptionist #1, and she informed the survey team masks were in use due to COVID-19 infection in the facility. Receptionist #1 was wearing mask during the interview. A box of yellow surgical masks and a box of black N-95 masks were available on the reception desk. There was no signage at the entrance to alert staff and visitors of a COVID outbreak, visual alerts for infection control practices or instructions about when to use personal protective equipment and hand hygiene. On 10/22/24 at 12:26 PM in an interview with Receptionist #2 she stated the front door was kept locked, so all visitors had to ring the bell to enter. She was wearing a mask covering her nose and mouth during the interview. She further stated visitors were directed to sign-in at the digital kiosk. Receptionist #2 stated that while she did not talk about the COVID status in the facility, she did talk to visitors about protecting themselves and also helping to protect the residents. She stated and offered the visitors a mask, either a surgical, KN95 or N95. Receptionist #2 stated it was not mandatory for visitors to wear masks while in facility. Receptionist #2 added she was unsure of what the mask policy was for staff working in the facility. On 10/21/24 at 3:08 PM an observation revealed Nurse Aide (NA) #2 walking down the 700-hall without wearing a mask. An interview was conducted with the Director of Nursing (DON) on 10/21/24 at 3:19 PM after she was observed removing her mask to speak to a resident in the Unit 2 common area. The DON stated she removed her mask to talk to the resident because he was hard of hearing. She further stated the purpose of the masks was to stop the spread of COVID. An observation on 10/22/24 at 10:38 AM revealed a housekeeper enter and exit 2 rooms on the 600-hall with a mask worn under his chin not covering his mouth and nose. An observation on 10/22/24 at 10:41 AM revealed Nurse #5 was reviewing medication administration records while seated in the Unit 2 common area. Nurse #5 was wearing a surgical mask tucked under her chin and the other nurse had on an N95 mask as well as a face shield. On 10/22/24 at 1:42 PM an observation and interview were conducted with Nurse #6 while she prepared to pass medications on the 600-hall. There were no COVID positive residents on the 600-hall. She was observed wearing a surgical mask below her nose. Nurse #6 stated when working on a COVID hall staff wore masks and the facility preferred for staff to wear N95 masks during the COVID outbreak. An interview was conducted with NA#3 on 10/22/24 at 1:45 PM as she entered the 600-hall from the therapy department hall. She was not wearing a face mask. NA #3 stated she was assigned to obtain weights on residents throughout the facility who were due weights. NA #3 added she was not assigned to weigh any residents with COVID. She said since the COVID outbreak masks were to be worn by staff and staff could wear the mask of their preference. On 10/22/24 at 1:52 PM an observation and interview were conducted with NA #4 on the 600 Hall. Her mask was under her nose. NA #4 stated she did not think the facility had an outbreak. NA #4 further stated an outbreak was when 50 or more residents were positive for COVID. She added the type of mask staff wore was an individual preference. On 10/23/24 at 10:04 AM Nurse #8 was observed as she prepared to administer medications on the 200-hall (a hall where there were COVID positive residents). Her surgical mask did not cover her mouth or nose. On 10/23/24 at 10:43 AM Nurse #8 was observed as she stood at a medication cart across from a room with droplet precaution signage on the 200-hall. Nurse #8 was wearing her surgical mask below her chin, not covering her mouth or nose. On 10/23/24 at 10:49 AM the Medical Director was observed walking down the 200-hall to the 400- hall then to 600-hall with his surgical mask under his nose. On 10/23/24 at 5:20 PM the IP brought staff folders to the conference room with no mask on. On 10/22/24 at 1:59 PM an observation and interview were conducted with Nurse #7 while she was walking through the Unit 2 common area. Nurse #7 was wearing a surgical mask, which covered her nose and mouth, and she stated the facility was considered in a COVID outbreak. She further stated masks were required, either surgical or N95. Nurse #7 added masks should be worn for the duration of the shift and should cover both the nose and mouth to keep from breathing in or out droplets. The facility policy titled Policies and Procedures [Infection Prevention and Control], Section Precautionary Measures Policy Name Transmission Based Precautions- General Practice Effective date 12/01/21 revealed the facility initiates transmission-based precautions to protect other patients, employees and visitors from the spread of a confirmed or suspected infection or contagious disease. The TBPs will be based on the type of pathogens, knowledge of the natural history of certain diseases and studies of epidemiology. The TBP measures will be the least restrictive possible for the patient under the circumstances. Measures included: 19. If protective attire is determined necessary, when donning the protective attire follow these steps: a. Wash hands or perform hand hygiene with alcohol-based hand rub b. Put on gown c. Apply mask over mouth and nose, (1) Pinch the metal band above the nose to make the mask fit to the contour of the face. (2) The mask must be replaced if it becomes moist or after 20 minutes (3) Do not touch the mask once it is positioned until it is removed (4) Remove the mask when leaving the room and discard immediately, (5) Do not reuse the mask. d. Put on goggles or face shield if required. Place over eyes and adjust to fit. e. Put on gloves. An observation on 10/22/24 at 12:43 PM was conducted of NA #6 as she passed lunch trays to residents on the 200-hall. Prior to entering a COVID+ resident's room (room [ROOM NUMBER]), she sanitized her hands and then donned PPE which consisted of an N95 mask, gown and gloves. She did not wear eye protection as she entered the room. When NA #6 exited the room, she was asked why she had not donned eye protection. NA #6 pointed towards the top of her head and patted a pair of goggles. NA #6 explained that she had been busy, moving fast to get the lunch trays passed out and had forgotten to put them on. NA #6 stated she was an agency NA, and it was her first time working in the facility. When asked if she had been made aware of the COVID outbreak in the facility, she confirmed the DON told her that morning. An interview was conducted on 10/23/24 at 11:09 AM with the Infection Preventionist (IP) and she stated she educated staff in all departments related to COVID protocol. The IP stated masks were mandatory during COVID outbreaks. She stated education for donning and doffing personal protection equipment (PPE) was provided during orientation, during yearly competencies, and in-services as needed. When informed of observations of staff not wearing their masks over both their nose and mouth, she stated she tried to make rounds periodically throughout the day to check to make sure staff were using PPE correctly. She stated when she saw staff not wearing their masks correctly, she reminded them to cover both their nose and mouth with the mask. She stated all staff were fit-tested for N95 masks and had been instructed on the proper application of masks and PPE. An interview was conducted with the Director of Nursing (DON) on 10/23/24 at 2:06 PM and she stated she expected all nurses (staff and agency) to follow the standards of nursing and to follow the infection prevention/infection control practices. The DON deferred questions regarding testing and education to the IP. In an interview with the Nurse Practitioner (NP) on 10/23/24 at 3:53 PM she stated staff not wearing masks properly can increase the transmission of COVID from staff to staff and from staff to resident. She stated none of her residents who tested COVID+ had been hospitalized . On 10/22/24 at 2:14 PM an interview was conducted with the Administrator, and he stated it was his expectation that any staff member caring for a COVID+ resident wear an N95 mask. C. The facility policy titled Infection Prevention and Control Committee, updated 08/02/2024, revealed the Infection Prevention and Control Committee was responsible for implementing established program plans and standards of practice that promoted, monitored, and maintained an environment that reduced the risk of transmission and acquisition of center-acquired infections. The facility policy titled Policies and Procedures [Infection Prevention and Control], Section Emerging Infectious Disease(s), Policy Name COVID-19 Effective date 03/11/24 revealed the center followed the Centers for Disease Control and Prevention (CDC) and standards of practice for prevention of COVID-19 to protect employees and patients. Section 4 revealed Infection Prevention and Control measures may include, but were not limited to: i. Employee and patient testing according to current standards A review of the CDC's policy for COVID testing dated June 2024 revealed the following guidance for nursing homes: - The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. - Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. - Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. - Due to challenges in interpreting the result, testing is generally not recommended for asymptomatic people who have recovered from SARS-CoV-2 infection in the prior 30 days. Testing should be considered for those who have recovered in the prior 31-90 days; however, an antigen test instead of a nucleic acid amplification test (NAAT) is recommended. This is because some people may remain NAAT positive but not be infectious during this period. - Empiric use of Transmission-Based Precautions for residents and work restriction for HCP are not generally necessary unless residents meet the criteria described in Section 2 or HCP meet criteria in the Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, respectively. However, source control should be worn by all individuals being tested . -In the event of ongoing transmission within a facility that is not controlled with initial interventions, strong consideration should be given to use of Empiric use of Transmission-Based Precautions for residents and work restriction of HCP with higher-risk exposures. In addition, there might be other circumstances for which the jurisdiction's public authority recommends these and additional precautions. - If no additional cases are identified during contact tracing or the broad-based testing, no further testing is indicated. Empiric use of Transmission-Based Precautions for residents and work restriction for HCP who met criteria can be discontinued as described in Section 2 and the Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, respectively. - If additional cases are identified, strong consideration should be given to shifting to the broad-based approach if not already being performed and implementing quarantine for residents in affected areas of the facility. As part of the broad-based approach, testing should continue on affected unit(s) or facility-wide every 3-7 days until there are no new cases for 14 days. - If antigen testing is used, more frequent testing (every 3 days), should be considered. An interview was conducted with the IP on 10/23/24 at 11:09 AM and she stated there was a lot of back and forth about the infection control policy with the new facility ownership. She stated all staff receive PPE and infection control training during orientation, yearly during competency training and in-services as needed. The Administrator was notified of immediate jeopardy on 10/23/24 at 5:47 PM. The facility provided the following credible allegation of IJ removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of noncompliance. On 10/23/2024, during the annual certification survey for [NAME] Health and Rehabilitation, it was noted that the facility had multiple residents affected by COVID. These residents were noted to be located on more than one hallway throughout the facility. During the survey it was noted that multiple staff did not employ appropriate source control throughout the facility. The facility did not initiate broad-based testing on all staff and residents with the increase in COVID cases throughout the facility. It is also noted that the facilities policy did not meet the CDC's guidance related to testing. On 10/23/24, the Director of Nursing and Infection Preventionist completed broad-based testing on all staff and residents within the facility. The facility will complete testing on all residents and staff twice per week until there is a 14-day interval of no new positive cases. The Infection Preventionist was notified on 10/24/24 and will be responsible for continuing testing until resolution of the outbreak. Specify action the entity will take to alter the process or system to prevent a serious adverse outcome from occurring or recurring, and when the action will be completed. On 10/23/2024 the Regional Nurse Consultant educated the Director of Nursing, Staff Development Coordinator/Infection Preventionist, and the Unit Managers regarding Special Droplet Contact Precautions when a resident tested positive for COVID-19. All staff, including medical director and Nurse Practitioner, will perform hand hygiene using soap and water and/or alcohol-based hand rub before entering and before exiting the room. All staff, including medical director and nurse practitioner will wear a gown when entering the room, remove before exiting the room. All staff, including medical director and nurse practitioners, will wear an N95 when entering the room and remove before exiting the room. All staff, including the medical director and nurse practitioner will wear eye protection such as a face shield or goggles when entering the room and remove them before exiting the room. All staff, including the medical director and nurse practitioner will wear gloves when entering the room and remove them before leaving the room. Education completed 10/23/2024. On 10/23/2024 the Director of Nursing, Staff Development Coordinator, and the Unit Managers initiated education with current staff and providers, including the medical director and nurse practitioners, regarding source control to include wearing face mask throughout the building during outbreak status regardless of if they are in a covid positive room or not. On 10/23/2024 the Director of Nursing, Staff Development Coordinator, and the Unit Managers initiated education with current staff and providers, including the medical director and nurse practitioners, regarding Special Droplet Contact Precautions when a resident test positive for COVID-19. All staff, including the medical director and nurse practitioners, will perform hand hygiene using soap and water and/or alcohol-based hand rub before entering and before exiting the room. All staff, including the medical director and nurse practitioner, will wear a gown when entering the room, remove before exiting the room. All staff including the medical director and nurse practitioner will wear an N95 when entering the room and remove before exiting the room. All staff, including the medical director and nurse practitioners will wear eye protection such as a face shield or goggles when entering the room and remove them before exiting the room. All staff, including the medical director and nurse practitioners, will wear gloves when entering the room and remove them before leaving the room. The Director of Nursing and the Administrator will ensure no staff will work without receiving this education. Any new hires, including agency staff, will receive education prior to the start of their shift in person. This education will be by 10/24/24. On 10/23/2024 the Regional Nurse Consultant educated the Director of Nursing, Staff Development Coordinator, and the Unit Managers regarding how to properly [NAME] Personal Protective Equipment. The gown will fully cover the torso from neck to knees, arms to end of wrists, and wrap around the back. Then fasten behind neck and waist. Once the gown is fastened, the mask or respirator will be secure with ties or elastic bands at middle of head and neck and ensure the flexible band to nose bridge fits properly. The fit of the mask should be snug to the face and below chin. All staff, including the medical director and nurse practitioners will then Fit-check respirator by gently exhaling while blocking any paths for air to escape. If air is escaping, reposition the respirator and check again until you feel no air escaping. All staff, including the medical director and nurse practitioners will then place goggles or face shield over their face or eyes and adjust to fit. Then the staff will don the glove and extend to cover wrist of isolation gown. Education completed 10/23/2024. On 10/23/2024 the Regional Nurse Consultant educated the Director of Nursing, Staff Development Coordinator, and the Unit Managers regarding how to properly Doff Personal Protective Equipment. All staff, including the medical director and nurse practitioners will use a gloved hand, grasp the palm area of the other gloved hand and peel off the first glove, hold removed glove in gloved hand, slide fingers of ungloved hand under remaining glove at wrist and peel off second glove over first glove. All staff, including the medical director and nurse practitioners will then discard gloves in a waste container. All staff, including the medical director and nurse practitioners will then remove goggles or face shield from the back by lifting head band or earpieces. Otherwise, discard in a waste container. All staff, including the medical director and nurse practitioners will unfasten the gown ties and take the gown off by taking care that sleeves don't contact your body when reaching for ties. The gown will then need to be pulled away from neck and shoulders, touching inside of gown only. All staff, including the medical director and nurse practitioners, will then remove the mask or respirator by grasping the bottom ties or elastics, then the ones at the top, and remove without touching the front and discarding in a waste container. All staff, including the medical director and nurse practitioners, will then wash their hands or use an alcohol-based hand sanitizer immediately after removing all personal protective equipment. Education completed 10/23/2024. On 10/23/2024 the Director of Nursing, Staff Development Coordinator, and the Unit Managers initiated education regarding how to properly [NAME] Personal Protective Equipment with current staff. The gown will fully cover the torso from neck to knees, arms to end of wrists, and wrap around the back. Then fasten behind neck and waist. Once the gown is fastened, the mask or respirator will be secure with ties or elastic bands at middle of head and neck and ensure the flexible band to nose bridge fits properly. The fit of the mask should be snug to the face and below chin. All staff, including the medical director and nurse practitioners will then Fit-check respirator by gently exhale while blocking any paths for air to escape. If air is escaping, reposition the respirator and check again until you feel no air escaping. All staff, including the medical director and nurse practitioners will then place goggles or face shield over their face or eyes and adjust to fit. All staff, including the medical director and nurse practitioners will don the glove and extend to cover wrist of isolation gown. The Director of Nursing and the Administrator will ensure no staff will work without receiving this education. Any new hires, including agency staff, will receive education prior to the start of their shift in person. Education will be completed by the Staff Development Coordinator or Director of Nursing. On 10/23/2024 the Director of Nursing, Staff Development Coordinator, and the Unit Managers initiated education regarding how to properly Doff Personal Protective Equipment with current staff. All staff, including the medical director and nurse practitioners will use a gloved hand, grasp the palm area of the other gloved hand and peel off the first glove, hold removed glove in gloved hand, slide fingers of ungloved hand under remaining glove at wrist and peel off second glove over first glove. All staff, including the medical director and nurse practitioners will then discard gloves in a waste container. The staff will then remove goggles or face shield from the back by lifting head band or earpieces. Otherwise, discard in a waste container. All staff, including the medical director and nurse practitioners will unfasten the gown ties and take the gown off by taking care that sleeves don't contact your body when reaching for ties. The gown will then need to be pulled away from neck and shoulders, touching inside of gown only. All staff, including the medical director and nurse practitioners will then remove the mask or respirator by grasping the bottom ties or elastics, then the ones at the top, and remove without touching the front and discarding in a waste container. All staff, in [TRUNCATED]

Based on observations, record review, staff interviews, and Physician interviews the facility failed to keep a resident free from an injury of unknown origin when a resident reported pain in the right upper arm and an Xray revealed a [NAME] distal humerus shaft fracture (a spiral fracture) of the right arm. The facility had been unable to determine how the injury occurred. This was for 1 of 3 residents reviewed for injuries of unknown origin (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, osteopenia, chronic pain and anemia. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had severe cognitive impairment and required extensive assistance of one staff member for bed mobility, dressing, toileting and personal hygiene. She required total assistance of one staff member with transferring and bathing. She was incontinent of bowel and bladder. The assessment documented she had not experienced a fall since admission and had no pain during the lookback period. A review of the care plan dated 4/5/2023 identified Resident #1 had required assistance of staff with activities of daily living and was at risk of falls. Interventions included to monitor for changes in condition that may warrant increased supervision or assistance and assist as needed. The care plan also identified the Resident had chronic pain with interventions that included to assist as needed and administer pain medications as ordered or indicated. A review of the Physician orders included: 1. Tramadol HCL (an opioid analgesic used to relieve moderate to moderately severe pain) 50 mg tab, take 1tablet by mouth 2 times a day. Ordered on 1/02/2023. 2. Morphine Sulfate (an opioid analgesic agonist used to treat severe pain) 100 milligrams (mg)/per 5 milliliters (ml) concentration, take 0.25 ml by mouth every 2 hours as needed for pain. Ordered on 2/10/2023. An interview was conducted with Nursing Assistant (NA) #3 on 6/14/2023 at 4:27 p.m. and she revealed she was assigned to Resident #1 on 5/27/2023 on first shift. She stated on the final round for the day, she and another NA entered the room and provided incontinent care to the Resident. When asked if the Resident had any pain during her shift, she stated the Resident had complaints of her legs hurting and did not complain during the care provided. An interview was conducted with NA #1 on 6/14/2023 at 10:34 a.m. and he revealed he was assigned to the care of Resident #1 on 5/27/2023 from 3:00 p.m. to 11:00 p.m. He stated Resident #1 would sometimes yell out about her legs. Her normal behavior was to yell out about leg pain and when a staff member entered the room, to not be sure what she wanted or to deny the pain. On the night of 5/27/2023 during his last round, he heard the Resident yell out that she was hurting, and it sounded different than her normal behavior or yelling. He entered the room around 10:45 p.m. and noticed her lying in bed stating her arm hurt. He said when he looked at her arm it looked, loose, and went to find a nurse. He stated when he went to report to the nurse, he asked NA #2 to come with him to look at the Resident because the nurse was in a room with another resident. He added he did not know what had happened and the resident was not twisted in her bed linens, she had no bed rails, and nothing appeared different than normal except for her arm hurting. When asked if anything had happened earlier in the shift, he stated the Resident had not required incontinent care during the shift and he had not been in the room to provide incontinent care. He added had been running behind because he had arrived late, and he was not sure who had covered for him prior to taking over the shift but the Resident had been dry and had not required care. A review of the punch detail report revealed NA #1 had been scheduled to arrive at 3:00 p.m. and had arrived at 3:53 p.m. The report revealed first shift staff had remained until second shift staff arrived. An interview was conducted with NA #2 on 6/14/2023 at 3:27 p.m. and she revealed on 5/27/2023 around 10:45 p.m. NA #1 came to the hall where she was assigned looking for Nurse #1. The nurse was occupied and not available for a few minutes. She asked if she could be of assistance and NA #1 explained what his concern was with Resident #1. She and NA #1 went to look at the Resident. Upon entering the room, the Resident was lying in the bed and stated her arm hurt. NA #2 stated the right arm looked like it was out of socket or something and she thought the nurse needed to come to assess. When asked if there were bed rails, she said the facility does not use bed rails and she did not know what had happened. A telephone interview was conducted with Nurse #1 on 6/13/2023 at 4:08 p.m. and she revealed that on the night of 5/27/2023 around 10:50 p.m. NA #1 reported to her that something was wrong with Resident #1's right arm. Upon assessment the arm was swollen without bruising, and the Resident reported pain. She called the on-call physician and an Xray was ordered. She stated the Resident was receiving hospice services and updated the Hospice provider and the responsible party (RP). She provided pain medication as ordered and followed up for effectiveness later in the shift. She added the pain medication was effective to reduce the pain. She was unsure how the injury occurred to the Resident. She revealed if the Resident had a fall, she could not get back up on her own and would have required a mechanical lift with multiple staff to get out of the floor. The assigned staff were not aware of a fall. She added there were no bed rails and NA #1 reported the Resident had been clean and dry during the shift and had not required incontinence care. Nurse #1 stated she was assigned to the rehabilitation hall and was covering for the medication aide on the hall. She added the medication aide on the hall had provided the scheduled pain medication, Tramadol, during the medication pass and had not reported new pain to the nurse and denied knowledge of the new pain when asked, prior to notification of the physician. A review of the May Medication Administration Record (MAR) revealed Tramadol HCL was documented as administered at 8:00 p.m. on 5/27/2023 by the medication aide. A review of the pain assessment record on the MAR on 5/27/2023 at 2:00 p.m. a pain of 2 on a scale of 0 to 10 with 0 being no pain and 10 being the worst pain ever. The documented pain assessment record on the MAR prior to 5/27/2023 for the month of May did not include an assessment with a pain over the level of 2. A review of the Morphine administration documentation prior to 5/27/2022 for the month of May revealed it was administered one time on 5/1/2023 at 9:54 a.m. A review of the electronic medical records progress notes: 5/27/2023 at 11:47 p.m. Nurse #1 documented NA#1 notified nurse that Resident #1's arm was hurting. When the nurse checked the arm, it was noted to be swelling in the right elbow and upper arm. The resident says it hurts really bad. Nurse tried to move arm gently and the Resident reported that it hurt. Swelling noted in right shoulder, elbow, and upper arm. A call was placed, and he ordered an x ray, a call placed to RP, Xray called in, and PRN morphine given for pain. 5/28/2023 at 7:34 a.m. Nurse #1 documented Resident had been medicated with morphine for pain. Resident persist in saying that her arm hurt. NA has been shown how to turn and position resident to avoid strain to arm. Resident reassured that she will have an Xray and be kept comfortable. Resident is alert with some confusion and did not verbalize why her arm was hurting. No noted injuries or falls. Unknown origin. Nurse #2 on 5/28/2023 at 3:11 p.m. documented the Resident had a decrease in range of motion in her right arm due to pain. She was unable to rate the pain. The Nurse observed moaning, facial grimacing, yelling, and guarding. Morphine 0.25 milliliters as needed for pain was given and noted to be effective. The results of the x ray showed a fracture of the right upper extremity. The Physician was notified and ordered the Resident to be transferred to the hospital for evaluation and treatment. The RP was notified and consented to the transfer for treatment. A review of the radiology records for 5/28/2023 revealed Resident #1 had an acute spiral fracture of the right distal humerus with lateral displacement, moderate osteoarthritis, moderate osteopenia, and an acute mildly displaced fracture of the radial head. A review of the Hospital records for the date of 5/28/2023 documented Resident #1 arrived on 5/28/2023 at 3:20 p.m. She had a diagnosis of dementia and was not able to provide a review of systems or a history of the injury. The admission assessment documented swelling and tenderness were present in the right upper arm, and pain with movement. The radiological examination revealed an acute spiral fracture involving the distal right humerus with mild posterior and lateral displacement and a chronic right radial head and neck fracture with osteopenia. The recommendations included a posterior slab long-arm splint with extra padding at a 90-degree angle. The Resident was discharged back to the facility on [DATE]. A review of the progress note written by Nurse #2 on 5/28/2023 at 10:02 p.m. documented Resident #1 returned from the hospital with a long splint on her right arm covered with a wrap. She was not in acute pain. Resident was alert but confused and picking at the wrap. Resident was recommended to have a follow up appointment with an orthopedic surgeon and receive pain management. A review of the MAR for 5/29/2023 - 5/31/2023 revealed the following doses of Morphine Sulfate 0.25 ml were administered: 5/29/2023 at 7:38 a.m., 9:46 a.m., 12:15 a.m., 2:22 p.m., 4:25 p.m. 5/30/2023 at 2:58 a.m. 5/31/2023 at 12:35 a.m. A review of the Care plan revealed the focus area for pain was updated on 5/29/2023 to read: Resident #1 had a right humorous fracture and an old fracture to the right elbow. The goal read she will remain free from pain with pain intervention through the next review. The interventions included to assist as needed, ensure the sling to the right arm remains in place, keep the call light within arm's reach, and administer pain medication as ordered or indicated. Two attempts were made to interview the roommate of Resident #1 without success. An interview was conducted with the Director of Nursing (DON) on 6/14/2023 at 10:53 a.m. and she revealed on the morning of 5/28/2023 she was informed Resident #1 had been complaining of pain and an x ray was ordered. When she was informed the Resident had incurred an injury, she interviewed the Resident just prior to her leaving for the hospital. She stated the Resident was not an accurate or reliable historian and not cognitively intact. Upon entering the room with Nurse #2, the Resident provided a description of the event, and stated a tall male staff member hurt me, and did not include many details. Until an investigation could be conducted NA #1 was suspended, per the facility protocol. The Resident was sent to the Hospital and the x ray results revealed the Resident had osteopenia with an old fracture to the arm with an acute fracture to the humerus. She interviewed all staff that provided care during the previous 24 hours. No one was able to recall an incident and stated the Resident had only her normal complaints of leg pain during the previous shifts. When the Resident returned, the Administrator and herself scheduled a care plan meeting with the RP and interviewed the Resident with the RP present. She stated the Resident was not able to provide any details and did not give descriptions. She added it was the decision of the team that they could not determine how this injury occurred. The Administrator was present during this interview. An interview was conducted with the Administrator on 6/14/2023 at 11:00 a.m. and he stated his investigation included the details of the DON's investigation. When the Resident returned to the facility, an interview was conducted with the RP present, and the Resident was unable to recall the details of the event. He stated the interviews with staff did not reveal an incident that led to an injury. Interviews were conducted with alert and oriented residents, and no one had concerns with abuse. Skin checks had been conducted and revealed no concerns. The conclusion of the investigation was this was not a situation of abuse, and the cause of the injury was not known. A review of the Orthopedic Surgeon progress notes for the date of service, 6/7/2023 documented Resident #1 was diagnosed with a right distal humeral shaft fracture. She was a total care patient who cannot feed herself due to significant comorbidities. There was some type of trauma that occurred. He recommended nonoperative treatment given her osteopenic bone and comorbidities.

Based on observations, record review, staff interviews, and Physician interviews the facility failed to keep a resident free from an injury of unknown origin when a resident reported pain in the right upper arm and an Xray revealed a [NAME] distal humerus shaft fracture (a spiral fracture) of the right arm. The facility had been unable to determine how the injury occurred. This was for 1 of 3 residents reviewed for injuries of unknown origin (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, osteopenia, chronic pain and anemia. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had severe cognitive impairment and required extensive assistance of one staff member for bed mobility, dressing, toileting and personal hygiene. She required total assistance of one staff member with transferring and bathing. She was incontinent of bowel and bladder. The assessment documented she had not experienced a fall since admission and had no pain during the lookback period. A review of the care plan dated 4/5/2023 identified Resident #1 had required assistance of staff with activities of daily living and was at risk of falls. Interventions included to monitor for changes in condition that may warrant increased supervision or assistance and assist as needed. The care plan also identified the Resident had chronic pain with interventions that included to assist as needed and administer pain medications as ordered or indicated. A review of the Physician orders included: 1. Tramadol HCL (an opioid analgesic used to relieve moderate to moderately severe pain) 50 mg tab, take 1tablet by mouth 2 times a day. Ordered on 1/02/2023. 2. Morphine Sulfate (an opioid analgesic agonist used to treat severe pain) 100 milligrams (mg)/per 5 milliliters (ml) concentration, take 0.25 ml by mouth every 2 hours as needed for pain. Ordered on 2/10/2023. An interview was conducted with Nursing Assistant (NA) #3 on 6/14/2023 at 4:27 p.m. and she revealed she was assigned to Resident #1 on 5/27/2023 on first shift. She stated on the final round for the day, she and another NA entered the room and provided incontinent care to the Resident. When asked if the Resident had any pain during her shift, she stated the Resident had complaints of her legs hurting and did not complain during the care provided. An interview was conducted with NA #1 on 6/14/2023 at 10:34 a.m. and he revealed he was assigned to the care of Resident #1 on 5/27/2023 from 3:00 p.m. to 11:00 p.m. He stated Resident #1 would sometimes yell out about her legs. Her normal behavior was to yell out about leg pain and when a staff member entered the room, to not be sure what she wanted or to deny the pain. On the night of 5/27/2023 during his last round, he heard the Resident yell out that she was hurting, and it sounded different than her normal behavior or yelling. He entered the room around 10:45 p.m. and noticed her lying in bed stating her arm hurt. He said when he looked at her arm it looked, loose, and went to find a nurse. He stated when he went to report to the nurse, he asked NA #2 to come with him to look at the Resident because the nurse was in a room with another resident. He added he did not know what had happened and the resident was not twisted in her bed linens, she had no bed rails, and nothing appeared different than normal except for her arm hurting. When asked if anything had happened earlier in the shift, he stated the Resident had not required incontinent care during the shift and he had not been in the room to provide incontinent care. He added had been running behind because he had arrived late, and he was not sure who had covered for him prior to taking over the shift but the Resident had been dry and had not required care. A review of the punch detail report revealed NA #1 had been scheduled to arrive at 3:00 p.m. and had arrived at 3:53 p.m. The report revealed first shift staff had remained until second shift staff arrived. An interview was conducted with NA #2 on 6/14/2023 at 3:27 p.m. and she revealed on 5/27/2023 around 10:45 p.m. NA #1 came to the hall where she was assigned looking for Nurse #1. The nurse was occupied and not available for a few minutes. She asked if she could be of assistance and NA #1 explained what his concern was with Resident #1. She and NA #1 went to look at the Resident. Upon entering the room, the Resident was lying in the bed and stated her arm hurt. NA #2 stated the right arm looked like it was out of socket or something and she thought the nurse needed to come to assess. When asked if there were bed rails, she said the facility does not use bed rails and she did not know what had happened. A telephone interview was conducted with Nurse #1 on 6/13/2023 at 4:08 p.m. and she revealed that on the night of 5/27/2023 around 10:50 p.m. NA #1 reported to her that something was wrong with Resident #1's right arm. Upon assessment the arm was swollen without bruising, and the Resident reported pain. She called the on-call physician and an Xray was ordered. She stated the Resident was receiving hospice services and updated the Hospice provider and the responsible party (RP). She provided pain medication as ordered and followed up for effectiveness later in the shift. She added the pain medication was effective to reduce the pain. She was unsure how the injury occurred to the Resident. She revealed if the Resident had a fall, she could not get back up on her own and would have required a mechanical lift with multiple staff to get out of the floor. The assigned staff were not aware of a fall. She added there were no bed rails and NA #1 reported the Resident had been clean and dry during the shift and had not required incontinence care. Nurse #1 stated she was assigned to the rehabilitation hall and was covering for the medication aide on the hall. She added the medication aide on the hall had provided the scheduled pain medication, Tramadol, during the medication pass and had not reported new pain to the nurse and denied knowledge of the new pain when asked, prior to notification of the physician. A review of the May Medication Administration Record (MAR) revealed Tramadol HCL was documented as administered at 8:00 p.m. on 5/27/2023 by the medication aide. A review of the pain assessment record on the MAR on 5/27/2023 at 2:00 p.m. a pain of 2 on a scale of 0 to 10 with 0 being no pain and 10 being the worst pain ever. The documented pain assessment record on the MAR prior to 5/27/2023 for the month of May did not include an assessment with a pain over the level of 2. A review of the Morphine administration documentation prior to 5/27/2022 for the month of May revealed it was administered one time on 5/1/2023 at 9:54 a.m. A review of the electronic medical records progress notes: 5/27/2023 at 11:47 p.m. Nurse #1 documented NA#1 notified nurse that Resident #1's arm was hurting. When the nurse checked the arm, it was noted to be swelling in the right elbow and upper arm. The resident says it hurts really bad. Nurse tried to move arm gently and the Resident reported that it hurt. Swelling noted in right shoulder, elbow, and upper arm. A call was placed, and he ordered an x ray, a call placed to RP, Xray called in, and PRN morphine given for pain. 5/28/2023 at 7:34 a.m. Nurse #1 documented Resident had been medicated with morphine for pain. Resident persist in saying that her arm hurt. NA has been shown how to turn and position resident to avoid strain to arm. Resident reassured that she will have an Xray and be kept comfortable. Resident is alert with some confusion and did not verbalize why her arm was hurting. No noted injuries or falls. Unknown origin. Nurse #2 on 5/28/2023 at 3:11 p.m. documented the Resident had a decrease in range of motion in her right arm due to pain. She was unable to rate the pain. The Nurse observed moaning, facial grimacing, yelling, and guarding. Morphine 0.25 milliliters as needed for pain was given and noted to be effective. The results of the x ray showed a fracture of the right upper extremity. The Physician was notified and ordered the Resident to be transferred to the hospital for evaluation and treatment. The RP was notified and consented to the transfer for treatment. A review of the radiology records for 5/28/2023 revealed Resident #1 had an acute spiral fracture of the right distal humerus with lateral displacement, moderate osteoarthritis, moderate osteopenia, and an acute mildly displaced fracture of the radial head. A review of the Hospital records for the date of 5/28/2023 documented Resident #1 arrived on 5/28/2023 at 3:20 p.m. She had a diagnosis of dementia and was not able to provide a review of systems or a history of the injury. The admission assessment documented swelling and tenderness were present in the right upper arm, and pain with movement. The radiological examination revealed an acute spiral fracture involving the distal right humerus with mild posterior and lateral displacement and a chronic right radial head and neck fracture with osteopenia. The recommendations included a posterior slab long-arm splint with extra padding at a 90-degree angle. The Resident was discharged back to the facility on [DATE]. A review of the progress note written by Nurse #2 on 5/28/2023 at 10:02 p.m. documented Resident #1 returned from the hospital with a long splint on her right arm covered with a wrap. She was not in acute pain. Resident was alert but confused and picking at the wrap. Resident was recommended to have a follow up appointment with an orthopedic surgeon and receive pain management. A review of the MAR for 5/29/2023 - 5/31/2023 revealed the following doses of Morphine Sulfate 0.25 ml were administered: 5/29/2023 at 7:38 a.m., 9:46 a.m., 12:15 a.m., 2:22 p.m., 4:25 p.m. 5/30/2023 at 2:58 a.m. 5/31/2023 at 12:35 a.m. A review of the Care plan revealed the focus area for pain was updated on 5/29/2023 to read: Resident #1 had a right humorous fracture and an old fracture to the right elbow. The goal read she will remain free from pain with pain intervention through the next review. The interventions included to assist as needed, ensure the sling to the right arm remains in place, keep the call light within arm's reach, and administer pain medication as ordered or indicated. Two attempts were made to interview the roommate of Resident #1 without success. An interview was conducted with the Director of Nursing (DON) on 6/14/2023 at 10:53 a.m. and she revealed on the morning of 5/28/2023 she was informed Resident #1 had been complaining of pain and an x ray was ordered. When she was informed the Resident had incurred an injury, she interviewed the Resident just prior to her leaving for the hospital. She stated the Resident was not an accurate or reliable historian and not cognitively intact. Upon entering the room with Nurse #2, the Resident provided a description of the event, and stated a tall male staff member hurt me, and did not include many details. Until an investigation could be conducted NA #1 was suspended, per the facility protocol. The Resident was sent to the Hospital and the x ray results revealed the Resident had osteopenia with an old fracture to the arm with an acute fracture to the humerus. She interviewed all staff that provided care during the previous 24 hours. No one was able to recall an incident and stated the Resident had only her normal complaints of leg pain during the previous shifts. When the Resident returned, the Administrator and herself scheduled a care plan meeting with the RP and interviewed the Resident with the RP present. She stated the Resident was not able to provide any details and did not give descriptions. She added it was the decision of the team that they could not determine how this injury occurred. The Administrator was present during this interview. An interview was conducted with the Administrator on 6/14/2023 at 11:00 a.m. and he stated his investigation included the details of the DON's investigation. When the Resident returned to the facility, an interview was conducted with the RP present, and the Resident was unable to recall the details of the event. He stated the interviews with staff did not reveal an incident that led to an injury. Interviews were conducted with alert and oriented residents, and no one had concerns with abuse. Skin checks had been conducted and revealed no concerns. The conclusion of the investigation was this was not a situation of abuse, and the cause of the injury was not known. A review of the Orthopedic Surgeon progress notes for the date of service, 6/7/2023 documented Resident #1 was diagnosed with a right distal humeral shaft fracture. She was a total care patient who cannot feed herself due to significant comorbidities. There was some type of trauma that occurred. He recommended nonoperative treatment given her osteopenic bone and comorbidities.

Based on record review, family interview, physician interview, staff interview and observation the facility failed to provide tube feeding at a rate consistent with the rate on the discharge summary and clarify the admission tube feeding orders which resulted in unplanned, severe weight loss for 1 of 1 resident (Resident #72) reviewed for nutrition. Findings included: Resident #72 was re-admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The discharge summary paperwork from the hospital dated 1-2-19 revealed Resident #72 was to continue [MEDICATION NAME] 1.5 (brand of nutrients given through a feeding tube) at 55ML (milliliters) per hour continuous for 24 hours. This rate provided 1980 kilocalories. The hospital discharge medication list dated 1-2-19 revealed Resident #72 was to receive [MEDICATION NAME] 1.5 place 1,000ML into feeding tube continuous. There was no rate of administration for the tube feeding on the medication list. A review of the facility admission notes dated 1-2-19 revealed the admitting nurse set the rate for Resident #72's tube feedings at 42ML per hour continuous for 24 hours. There was no further documentation noted that the admitting nurse clarified the rate for Resident #72's feeding. The physician's orders [REDACTED].#72's tube feedings. The Director of Nursing was interviewed on 3-13-19 at 3:30pm. The Director of Nursing stated the admitting nurse calculated the per hour rate by using the 1,000 ML order from the hospital discharge medication list and dividing it by 24 hours. He also stated we don't look at the summary. We typically only look at the medication orders. The Director of Nursing also stated the admitting nurse would use the hospital discharge orders and not re-write the order for the facility physician unless she was clarifying an order. A review of Resident #72's weights upon discharge from the hospital and re-admission to the facility on [DATE] revealed a weight of 174 pounds. The nurse's notes were reviewed from 1-2-19 to 1-9-19 and revealed Resident#72 continued to receive [MEDICATION NAME] 1.5 at 42ML per hour continuous for 24 hours. This tube feeding prescription provided 1512 kilocalories per day. An interview with dietitian #3 occurred on 3-14-19 at 10:00am. The dietitian stated she did not see Resident #72 when he was admitted on [DATE] and did not assess the resident's nutritional needs. She also stated Resident #72 was not seen by dietary until dietitian #1 saw him on 1-9-19. The 14-day Minimum Data Set ((MDS) dated [DATE] revealed Resident #72 was severely cognitively impaired and needed extensive assistance with 2 people for bed mobility and transfers, extensive assistance with one person for dressing and total assistance with 2 people for toileting and personal hygiene. The MDS also revealed the resident was 6 feet 6 inches tall and weighed 189 pounds. He was coded for a feeding tube and not on a physician-prescribed weight loss regimen. The care plan for Resident #72 dated 1-9-19 revealed a goal stating he would have adequate intake with no weight loss. The interventions for that goal were dietician to evaluate and feeding tube. A review of dietitian #1's note dated 1-9-19 revealed documentation of Resident #72 receiving [MEDICATION NAME] 1.5 at 42ML per hour continuous over 24 hours and other discharge documentation from the hospital stating Resident #72 was to receive [MEDICATION NAME] 1.5 at 55ML per hour continuous over 24 hours. The documentation also revealed the dietician #1 recommended Resident #72 receive [MEDICATION NAME] 1.5 at 70ML per hour for 20 hours due to a weight loss greater than 25% in 30 days. This tube feeding recommendation provided 2100 kilocalories per day. During an interview with dietitian #1 on 3-14-19 at 10:33am, the dietitian stated the procedure when a resident was admitted to the facility on tube feedings the dietitian #3 or the Director of Nurses would call her within 24 hours with the resident's weight, height, pertinent information about the resident and the current order. The dietitian #1 stated she had received a call about Resident #72 and was informed of the resident's height, weight and the order for his tube feedings. The dietitian stated she calculated Resident #72's tube feeding to be 42ML per hour giving him 1500 calories a day and that was an adequate number of calories to sustain his weight and appropriate since the resident was new to tube feedings. She also denied the need to see the resident earlier because I rely on staff to let me know if the rate is insufficient, if the resident is losing weight or if something is wrong with the feeding. Dietitian #1 stated Resident #72 could have been losing weight due to his recent illness but that is why I increased the rate, to see if it would help with his weight loss. The physician's orders [REDACTED]. The facility's Physician Assistant (PA) was interviewed on 3-13-19 at 2:45pm. The PA stated she did not remember the amount of tube feeding Resident #72 was receiving when he was admitted to the facility on [DATE] but did state If the resident was not receiving enough feeding he would certainly lose weight. Resident #72's weight for 1-17-19 was reviewed and revealed a weight of 167 pounds. The weights for Resident #72 were reviewed for 2-8-19 and 2-9-19 and revealed a weight of 159 pounds. Resident #72's weight for 2-15-19 was reviewed and revealed a weight of 152 pounds. A review of Resident #72's physician orders [REDACTED].#2. A review of dietitian #2's documentation dated 2-15-19 revealed Resident #72 was still underweight and had a weight loss greater than 4.11 % in 39 days. Dietitian #2 recommended for Resident #72's tube feedings to be increased to [MEDICATION NAME] 1.5 at 80ML per hour continuous for 24 hours which would increase Resident #72's kilocalorie intake to 2880. A review of the physician's orders [REDACTED]. The weights for Resident #72 was reviewed for 2-25-19 and revealed a weight of 167 pounds. During a family interview on 3-11-19 at 1:29pm, the family member stated she could see Resident #72 becoming weaker as he could no longer help to turn himself and the resident was losing weight. She also stated she mentioned her concerns to the facility physician but nothing was changed for about a month. The family member also stated the resident would say he was hungry every day until about a month ago when the doctor increased the amount of his tube feedings. During an interview with dietitian #2 on 3-12-19 at 2:50pm, she stated she did not rely on a resident's weight to determine the nutritive value the resident may need but reviewed trends in the resident's health and weight and then determined what type of diet or amount of tube feeding was needed. She also stated she recommended to increase the tube feeding to [MEDICATION NAME] 1.5 at 80ML per hour continuous for 24 hours because she recognized Resident #72's weights showed a steady decline. Resident #72 was observed through out the survey from 3-11-19 to 3-14-19. The resident's tube feeding was noted to be [MEDICATION NAME] 1.5 running at 80ML per hour continuous. Resident #72 was noted to be in the bed during the survey, unable to reposition himself but was able to sporadically inform staff of his needs. The Administrator and Director of Nursing was interviewed on 3-14-19 at 5:19pm. The Director of Nursing stated he did not have any expectations because the facility carried out the physicians orders and followed the RD recommendations.

Based on observations, record review and staff interviews the facility failed to prevent 2 of 3 residents from leaving the facility unattended. Resident #4 who was cognitively impaired left the facility and walked across two 4-lane roads with moderate to heavy traffic before being found approximately 1.2 miles from the facility. Resident #5 who had experienced a change in mental status left the facility dressed in a t-shirt, shorts and no shoes in 37 degree F weather walked approximately 520 feet from the facility and remained out of the facility for approximately 54 minutes. Findings Included: 1. Resident #4 was admitted to the facility on [DATE] and his [DIAGNOSES REDACTED]. An elopement / wandering risk review dated 5/17/17 for Resident #4 completed by Nurse #4 identified risk factors that included impaired cognition, [DIAGNOSES REDACTED]. The sections for history of elopement, conclusion and interventions were left blank. Review of a nursing note dated 5/17/17 at 9:40 pm for Resident #4 stated the resident was observed by staff attempting to walk out of the front door. The staff was able to easily guide the resident back into the facility. Will continue to monitor. Review of a nursing note dated 5/18/17 at 9:52 am for Resident #4 stated the resident was alert with confusion noted. Difficult to keep resident in his room and he was up and down most of the shift. He showed confusion as to where he was. He was looking for his family and wanted to leave the building. Resident was given [MEDICATION NAME] (an antipsychotic) 5 milligrams (mg) which was somewhat effective. Resident was informed it was after 1:00 am in the morning and slept for a short period of time. Within a few hours he was noted walking the hallways again. No acute distress. Staff will monitor resident to maintain safety. A care plan dated 5/18/17 identified that Resident #4 wandered about the facility. Interventions included to observe whereabouts frequently, redirect resident as needed, anticipate needs for hunger, thirst, toileting and other needs, label resident ' s belongings and have familiar objects in his room when available. Review of a general note dated 5/30/17 at 11:55 am stated a care plan meeting had been held with Resident #4 ' s responsible party and his family members. Resident now familiar with the facility routine and not attempting to leave the building as often. Staff must continue to monitor due to past history of wandering. An admission, comprehensive minimum data set ((MDS) dated [DATE] identified Resident #4 had no behaviors of wandering and had impaired cognition. Review of a nursing note dated 7/1/17 at 8:01 am for Resident #4 stated resident was awake most of the night wandering around in his room. Resident was pleasantly confused and easily redirected. Safety maintained and continued with every 1 hour checks. Review of a nursing note for Resident #4 dated 7/2/17 at 1:40 am revealed resident exited the facility on 7/1/17. The resident was last seen sitting in the common area of unit 1. At 5:45 pm staff started to search for the resident within the building including rooms and common areas. At 6:00 pm a code orange (facility code for a missing resident) was called. At that time all staff began to search for the resident. His family was called at 6:10 pm and arrived at the facility at 6:40 pm. The Director of Nursing (DON) was notified at 6:11 pm. All staff continued to search for the resident. At 6:49 pm the resident ' s family member informed the staff she received a call that Resident #4 had been found by the police and had been taken to the hospital for evaluation. The DON was notified immediately. The resident returned to the facility at 8:00 pm and a head to toe assessment was completed and within normal limits. Resident showed no signs or symptoms of distress. Resident went to bed soon after returning to the facility. Call bell in reach and 15 minute checks were initiated. Elopement assessment completed and will continue to monitor. Resident #4 was discharged to another facility on 8/14/17. The local police department was contacted on 12/19/17 at 2:00 pm. The department representative indicated there was no written report for the incident that occurred on 7/1/17 for Resident #4. An interview on 12/19/17 at 3:24 pm with the facility Administrator revealed the staffing schedule for July 1, 2017 to identify the nursing assistants (NAs) assigned to Resident #4 was not available. The Administrator stated she had started at the facility in September and was unable to locate the staffing schedule for that time frame. An interview on 12/19/17 at 3:51 pm with Nurse #2 revealed she was familiar with Resident #4 and had been his nurse the evening he was admitted to the facility and the evening he left the facility unattended. She stated Resident #4 was able to walk independently and was very confused. Nurse #2 explained the first night Resident #4 was at the facility she had observed him walk to the front door and attempt to go outside; she was able to persuade him to come back inside. She added she notified her supervisor, the DON who no longer worked at the facility. She was not aware of any additional interventions for his wandering at that time except for staff to keep a close eye on him. Nurse #2 stated the facility did not use wander guards. She added Resident #4 continued to wander throughout the facility, but he would primarily stay between the 2 nursing units and the common areas. He really didn ' t go toward the back of the building and she wasn ' t aware of him going to the front door again until the incident on 7/1/17. Nurse #2 explained she had last seen the resident about 4:45 pm and he was in the common area for unit 1. Around 5:00 pm she didn ' t see Resident #4 and started looking for him. She notified the DON that he was missing and called code orange for elopement; that is when all the facility staff started searching the facility for him. Nurse #2 added staff went outside, looked around the grounds of the facility and drove through the neighborhood looking for him. She stated she had called Resident #4 ' s family member who arrived at the facility around 6:30 pm. Resident #4 ' s family member received a call from another family member that the resident had been picked up by the police who took him to the hospital. Resident #4 ' s family member brought him back to the facility around 8:00 pm and they implemented 15 minute checks. Nurse #4 stated the front door to the facility was locked at 8:00 pm. She believed Resident #4 followed another resident ' s family out of the front door. She added that Resident #4 walked fairly quickly and she suspected that is why he got as far away from the facility as he did. She believed all together it was 30 to 40 minutes from the time they started looking for the resident until his family heard he was in the emergency room . An interview on 12/19/17 at 4:47 pm with Nurse Unit Manager #2 revealed she was familiar with Resident #4 and was the nurse manager for the unit he resided on. She stated he was confused and would wander from unit 1 to unit 2, sit in the common areas and talk about trying to get to work. She added she was not aware of him attempting to go to any exit doors. Unit Manager #2 stated the first night Resident #4 was admitted he did go to the front door and attempt to go outside, but the staff was with him the whole time and he was easily redirected to come back inside. She added that was when he was identified as an elopement risk and added to the elopement profile book. Unit Manager #2 then explained she wasn ' t sure when the elopement profile books were implemented and she couldn ' t be sure if that was before or after Resident #4 eloped on 7/1/17. She added the facility did not have a wander guard system and at the time of his elopement the exit doors were not alarmed but had key pad codes. She stated she could not recall what nursing assistants (NAs) routinely worked with the resident. An observation was made on 12/20/17 from 8:00 am until 8:30 am of the potential route Resident #4 walked on 7/1/17. The facility was located at the end of an unmarked, paved two- lane street. To the right of the facility there was a small residential neighborhood. To the left of the facility one side of the street was wood covered and the other side of the street was an open field with one large commercial building. It was approximately 1.1 miles from the facility to the mid-point of the street where Resident #4 was found. This street was an unmarked paved two-lane road in a residential area. To reach this location from the facility there were two 4-lane roads with moderate to heavy traffic that would need to be crossed. There was a paved side walk on one of the 4-lane roads. There was a stop light at the intersection of the two 4-lane roads. The 2 4-lane roads had a combination of businesses, churches and residential properties. The majority of the grounds were paved parking lots and flat grass covered grounds. An interview on 12/20/17 at 8:50 am with Nurse #4 revealed she was the nurse that admitted Resident #4 to the facility and had completed his admission elopement / wandering risk assessment. Nurse #4 stated she only answered the questions she knew the answers to and at the time she had completed the assessment the resident hadn ' t demonstrated any behaviors of wandering. She added the assessment wasn ' t fully completed because it took some time to determine the answers to some of the questions and the assessment should have been updated after Resident #4 attempted to leave the building the first night he was there. Nurse #4 explained she was frequently the day (7:00 am to 3:00 pm) nurse for the resident during his stay at the facility and he did wander up and down the hallways on her shift. She added Resident #4 didn ' t really show any pattern to his wandering and would also sleep on and off during the day. There were times that he was placed on 15 minute checks to monitor his whereabouts but that was not continuous. A phone interview on 12/20/17 at 9:44 am with the DON of the facility during the time of Resident #4 ' s stay at the facility revealed she was aware of his elopement from the facility on 7/1/17. She stated the first evening Resident #4 was at the facility he did attempt to go out of the front door, but the staff was with him the entire time. She believed he was put on 15 minute checks after that incident. The DON added that his admission wandering / elopement risk assessment should have been updated at that time, but she could not remember if it was or not. The DON stated Resident #4 did continue to wander throughout the facility and the staff were aware to keep a close eye on him. She added the facility did not have a wander guard system at that time. She explained there was a receptionist on duty at the front door until 8:00 pm and then the front door was locked and you needed a code to enter and exit the door. The DON stated the evening Resident #4 left the building she believed it was about 5:00 pm and he followed a group of visitors out the front door. She was not aware if any staff member actually saw him leave the facility. She explained the resident ' s nurse realized shortly after that he was missing and started looking for him. A code orange was called and all facility staff searched inside the building, the facility grounds and drove through the neighborhood looking for the resident. She added the nurse called her and she returned to the facility. The DON stated Resident #4 ' s family had been called and they came to the facility. She was with the family member when they received a call from another family member that the police had found Resident #4 sitting on a curb and they had taken him to the emergency room for evaluation. Resident #4 ' s family went to the emergency room who determined the resident was fine and the family brought him back to the facility. The DON stated it was approximately 20 minutes from the time the staff realized Resident #4 was missing until the police found him and notified his family. She added she had spoken with the police officer who told her he found the resident at 5:49 pm and the location that he was found. The location was approximately 3000 yards from the facility. She stated the police officer told her the resident appeared fine and was able to provide the officer with his name and told the officer he was just out for a walk. The previous DON added the police officer did not write a report regarding the incident. She was unable to provide the officer ' s name. An observation of the facility exit doors was made on 12/20/17 at 10:30 am. The facility had a total of nine exit doors. During the observation eight of the nine exit doors were locked and had key pads used for entrance / exit from the doors. The front door located in the facility lobby was unlocked. There was a receptionist located in the front lobby who had an unobstructed view of the front door. A review of the weather for 7/1/17 identified the average temperature was 80 degrees F and there was 0.04 inches of precipitation on that day. An interview with the facility Administrator on 12/20/17 at 11:12 am revealed the front door was locked from 5:00 pm until 8:30 am and required a key code to be unlocked. She stated the facility was in the process of installing a wander guard system to the exit doors and anticipated this being completed within a few weeks. The Administrator explained there was a 24 hour a day receptionist located at the front door until the wander guard system was operational. She added all of the other facility exit doors were locked at all times. Staff members were provided with the code for the employee entrance door located in the back of the facility. The key codes for the other exit doors were only know by a few administrative staff members. 2. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was discharged to the hospital on [DATE] and re-admitted to the facility on [DATE] with an additional [DIAGNOSES REDACTED]. Review of the admission elopement / wandering risk review dated 11/25/17 for Resident #5 identified she was not at risk for elopement. A review of the admission Minimum Data Set ((MDS) dated [DATE] for Resident #5 revealed she required limited assistance with ambulation, was alert and oriented and had not exhibited any behaviors during the look back period. Review of a nursing note for Resident #5 on 12/5/17 at 2:11 pm stated the resident had been noted to have bizarre behaviors and hallucinations. Due to such a significant change in behavior psychiatric services were sent a referral to assess and treat this resident as soon as possible. Review of a nursing note for Resident #5 on 12/5/17 at 11:47 pm revealed the resident had increased confusion, hallucinations and attempted to vacate the facility. [MEDICATION NAME] (used to treat anxiety) 1mg was administered and the resident was assisted into bed. The height of the bed was lowered. At 6:00 pm resident was noted lying on the floor beside her bed, no signs of injury. The resident was unable to tell the staff how the incident occurred and was able to walk with assistance back to bed. She remained restless in bed with tremor of her upper extremities. One to one care was initiated. Her physician and family were notified. The physician gave an order to send the resident out to the emergency room and she was transported to the hospital at 7:30 pm. Review of the hospital history and physical dated 12/5/17 for Resident #5 revealed she presented with agitation and altered behavior. The resident had been okay since being at the nursing home until today when per nursing she was restless in the morning, hallucinating, confused with nonsensical speech and attempted to pack her bags and leave the facility. She was treated with [MEDICATION NAME], slept for 1 hour, and was then found lying on the floor. The resident continued to hallucinate so she was sent to the emergency room . The patient was oriented to self and place, but otherwise had disorganized thinking and unable to answer questions. She appeared to be responding to internal stimuli, talking to herself and laughing. She became aggressive and had to be sedated with [MEDICATION NAME] (an antipsychotic that can treat hallucinations), the police were called to the room and she was admitted . Review of the hospital discharge summary dated 12/7/17 for Resident #5 revealed a discharge [DIAGNOSES REDACTED]. Psychiatry was consulted and started on [MEDICATION NAME] (an antipsychotic) and patient was much better. Discharge instructions included to avoid too many sedating medications. Patient has [MEDICATION NAME] and [MEDICATION NAME] for pain control, please use with caution. New medication was [MEDICATION NAME] at bedtime. Review of the re-admission facility elopement / wandering risk review dated 12/7/17 for Resident #5 identified resident was not at risk for elopement. Review of a nursing note for Resident #5 dated 12/8/17 at 12:02 am stated resident appeared to be very confused. She had not unpacked her bags since arriving back to the facility at 5:00 pm. She continued to sit in the same position on her bed, unzipped her luggage and would take a few things out. She would then place those items back in her luggage. Several staff members have tried to help her get situated in her room but she has refused any help. Review of a nursing note for Resident #5 dated 12/8/17 at 12:08 am was identified as a late entry. Resident arrived at 5:00 pm to the facility via ambulance. Resident is alert, but confused. Review of a nursing note for Resident #5 dated 12/9/17 at 3:30 am was identified as a late entry for 12/8/17. The note stated at approximately 5:38 am a nursing assistant (NA) informed me that the resident went toward the front of the building. I told the NA to come with me to the front. When I got to the front door I noticed the resident ' s wheelchair was at the front door and the resident was not in it. I contacted the unit manager to inform her of the current situation. I went outside and looked in both directions to see if the resident was in site. I did not observe her. I ran back inside and instructed the receptionist to call code orange for a missing resident. At approximately 5:41 am the Director of Nursing (DON) was called and as the phone connected I observed Resident #5 at the edge of the woods swinging and screaming. I explained to the DON the situation and was instructed to call 911. The resident kept walking up the street and began stating she wanted to call her family. At approximately 5:48 the officers arrived to assist with the resident. The resident was accompanied back to the facility and placed on 1 to 1 supervision. The resident would not allow staff to complete a head to toe assessment. Review of a telephone order dated 12/8/17 for Resident #5 stated to send out to the emergency department for evaluation. She was discharged from the facility on 12/8/17. An interview on 12/19/17 at 4:07 pm with Nurse #2 revealed she was the nurse for Resident #5 the morning she left the facility. She stated this was the first time she had worked with the resident as she had been readmitted to the facility on her unit. Nurse #2 explained the resident was confused and agitated when she came on shift at 11:00 pm. The resident was sitting on her bed with her personal items around her and she kept zipping and unzipping her suitcase. The resident was upset about her medications and kept telling the nurse that she was not giving her the correct amount of her Parkinson ' s medicine. The nurse added Resident #5 wanted to call her family and she tried to call him twice using the facility phone at the nursing desk but did not reach him. The resident also dialed 911 from the facility phone, but didn ' t speak to anyone. Nurse #2 stated later in the shift a NA told her the resident had left her room going up towards the front. The resident was walking pushing her wheelchair. She explained it was around 5:00 am at that point and she headed up to the front lobby. She stated the receptionist was at the front desk and told the nurse she had unlocked the front door so the funeral home staff could leave and Resident #5 had run out the front door. Nurse #2 stated she went out the front door and saw an empty wheelchair but did not see the resident. She then notified the unit manager who told her to notify the DON, call a code orange for elopement and call 911. Nurse #2 explained as she and a NA were calling out and looking for the resident she heard some rustling and yelling in the woods located at the front right side of the property. She observed it was Resident #5 who was yelling the nurse wouldn ' t give her the right medicine and she needed to call her family. She added the resident had a stick and was shaking it at the staff at they approached her. The resident came out of the wooded area to the street in front of the facility. Nurse #2 stated the police arrived within about 4 minutes and tried to take the resident to the emergency room , but the resident refused to go. The resident would not come back in the facility, but she eventually allowed one of the officers to wheel her back into the facility. The resident ' s family arrived at the facility approximately 30 minutes to an hour later and he took the resident home against medical advice (AMA.) Nurse #2 stated it was cold out and the resident had gone out wearing a t-shirt, shorts and had no shoes on. An interview on 12/19/17 at 4:55 pm with nurse unit manager #2 stated she was familiar with the resident. She explained during the course of her stay the resident became confused and was hospitalized . The resident had been readmitted to the facility the day prior to the incident. Unit Manager #2 stated she received a phone call from Nurse #2 that the resident was becoming more confused and somewhat combative with staff and I told the nurse to keep an eye on the resident and she was on her way back up to the facility and to notify the physician if needed. She added on the way to the facility she received another call from Nurse #2 at approximately 5:20 to 5:30 am from Nurse #2 who told her Resident #5 had left the building. She instructed her to call the DON and Administrator to notify them of the incident. Unit Manager #2 continued that when she pulled onto the street she observed the resident sitting on the curb with Nurse #2, a NA and the police officers. She stated the resident was calmed down by then and the officers tried to get the resident into their car but the resident wouldn ' t and eventually the resident agreed to let the officers push her back to the facility in her wheelchair. Unit Manager #2 stated when they got back into the facility lobby she helped the resident call her family who told them he was on his way and that she needed to let the staff take her back to her room. She explained they took the resident back to her room and placed her on one to one observation. When her family arrived at the facility he signed the resident out AMA. Unit Manager #2 stated it was cold out that morning and the resident had on a t-shirt, she believed bedroom slippers and wasn ' t sure what type of pants. A phone interview was conducted on 12/19/17 at 5:50 pm with NA #2 who stated he was the NA for Resident #5 the morning she left the facility. He stated the resident had just returned from the hospital and this was the first time he had worked with her. NA #2 explained he came on shift at 11:00 pm and the resident was sitting on her bed with all kinds of personal items spread all over her bed and she just kept going through them. He added the resident was talking very loud and fast and seemed kind of incoherent. He stated he checked on her throughout the shift and tried to get her to lay down but she wouldn ' t and never slept during the night. NA #2 explained around 4:30 to 5:00 am he saw Resident #5 leave her room and she was walking very quickly; she had on a t-shirt, Capri pants and no shoes. He stated he didn ' t go after her right then because he thought she was just up based on her behavior during the night. NA #2 added another NA had notified Nurse #2 that she saw the resident running up the hallway to the front lobby. The Nurse and NA went up to the front to check on her and found the resident ' s wheelchair outside on the front porch but didn ' t see the resident. He stated he went outside to help look for the resident and she was up in the woods and they eventually convinced her to come out but she would only come out on the street. She had a stick and was waving it at them and yelling that the nurse had given her the wrong medicines and she needed to talk to her family. NA #2 described her location at being about halfway between the facility and the commercial business up the street. He stated the police came and they eventually were able to get her to come back in the building. NA#2 added the resident ' s family came to the facility and he never saw the resident again. A phone interview was conducted on 12/20/17 at 9:06 am with NA #3 who stated she was working on third shift (11:00 pm to 7:00 am) the evening Resident #5 left the facility. She explained she saw the resident running toward the front of the building pushing her wheelchair. She added she didn ' t know the resident but it startled her because of the time of the night and you typically don ' t see residents moving that fast. NA #3 stated she reported it to the med aide who was her supervisor that evening and she told her to let the resident ' s nurse know. She added when she notified Nurse #2 she took her with her to the front lobby door and the resident was gone. She stated it was very cold outside and she went and grabbed a jacket and took the wheelchair off of the front porch and started pushing it up the street to look for the resident. NA #3 stated the first time she saw the resident she was half way between the facility and a commercial business on the street. She added the resident was only dressed in shorts, a t-shirt with no socks or shoes. The resident was yelling and had a stick she was shaking at the staff. She explained the resident would not come back in the building with them but the police arrived and they eventually convinced the resident to sit in her wheelchair and she allowed them to push her back to the building. An observation was made on 12/20/17 from 9:15 am to 9:25 am of the route Resident #5 took the morning of 12/8/17. Upon exiting the front door of the facility there was a covered cement porch that led to a paved parking lot. Approximately 130 feet to front right of the front porch was a wooded area. This included a curb and slightly elevated grassy area to walk into the woods. The street the facility was located on was an unmarked, paved two-lane street. It was approximately 520 feet from the facility to the commercial building that the resident was located per the 911 report. A review of the weather for 12/8/17 revealed the average temperature was 37 degrees F and the precipitation was 0.75 inches on that date. On 12/20/17 phone messages were left at 2:00 pm, 3:50 pm, 4:30 pm and 5:23 pm for the receptionist that was working the morning Resident #5 left the facility. The receptionist no longer worked at the facility and did not return any of the calls. An interview was conducted on 12/20/17 at 5:50 pm with the Administrator and DON. The Administrator stated the receptionist that was working on 12/8/17 had initially told her Resident #5 had run out the front door in front of the funeral home attendants and she could see the resident the entire time. The Administrator explained during the investigation of the incident she determined that could not have been true because interviews with Nurse #2 and NA #3 stated the funeral home attendants left after Resident #5 left the building. She stated during a follow-up interview with the receptionist she admitted that her first story wasn ' t what happened. The receptionist told the Administrator she had unlocked the front door to get ahead so the funeral home attendants could get out and Resident #5 went out the front door pushing her wheelchair prior to the funeral home attendants getting to the door. The receptionist saw the resident go out the front door but did not go out to check on her. The Administrator stated the receptionist was terminated for not following the protocol she was trained on when a resident attempted to leave the building and for lying. The DON stated during the investigation of the incident the following time line of events was determined: 12/8/17 at 5:36 am - Resident #5 went out the front door 12/8/17 at 5:38 am - Nurse #2 and NA #3 arrived at the front lobby 12/8/17 at 5:40 am - Receptionist called code orange 12/8/17 at 5:41 am - Nurse #2 spotted Resident #5 in the woods 12/8/17 at 5:44 am - Receptionist called 911 12/8/17 at 5:48 am - Police arrived 12/8/17 at 6:30 am - Police convinced resident to come back in the building A review of the 911 communication event information identified a call to 911 on 12/8/17 at 5:43 am requesting transport for a patient. Officer dispatched at 5:46 am and arrived at 5:52 am. Additional officer dispatched at 5:48 am and arrived at 5:57 am. The notes revealed at 5:47 am the subject was holding a stick, not waving it, could hear the subject yelling at the staff in the background, subject was in front of the commercial building on street of the facility. At 5:48 am no one injured at this time. At 5:52 am first officer arrived and patient was sitting on the sidewalk and seemed to be calming down a little. At 5:50 am patient refused to go back in the building. At 6:21 am resident returned to the building. An interview with the Administrator on 12/20/17 at 6:20 pm revealed the facility had put a plan of correction in place following both incidents. The facility provided a plan of correction for the incident that happened on 7/1/17. The facility corrected the deficient practice on 7/3/17. The corrective action was as follows: 1. Processes that lead to the alleged deficiency cited: Resident #4 exited the facility on 7/1/2017 between 5:00PM - 5:30PM by following another person; resident was observed by Greensboro Police Department (GPD) officer on(NAME)road at 5:49PM, about 3000 feet from the facility. Greensboro Policy officer, contacted Greensboro EMS. Resident #4 was transported to the hospital via Greensboro Emergency Medical Services (EMS) at 5:49PM. Per GPD officer resident was able to state his name, but was unable to say where he resides. GPD officer shared those information with the facility Director of Nursing by phone on 7/3/3017, officer added that, while at hospital emergency department, staff at the hospital was able to locate resident #4's demographic information using his name that he provided. The information ware located in the hospital electronic records, as resident had previously being in that Hospital. Hospital staff contacted a family member listed on resident's hospital record who confirmed resident #4's identity after arriving at the emergency room . Resident #4 assessed at the emergency room (ER) and was transported back to the facility by his family via a personal vehicle. The resident was unharmed as evidenced by completed clinical assessment completed upon return to the facility completed by the Registered Nurse that indicated no injuries. Resident was not admitted for observation or consulted in the ER. No ER report on file. Resident #4 exited the facility following another person through the facility main entrance door. This is concluded based on resident's cognitive and physical in-ability to open the front door alone (BIMS score 6). Front door was locked by the receptionist approximately 15 minutes before the last time resident was observed in the facility and was still locked at the time resident was reported being observed at(NAME)Drive. Resident # (TRUNCATED)

Based on record review and interviews with staff, the medical director and the director of clinical pharmacy services, the facility failed to administer the correct dose of [MEDICATION NAME] (a narcotic pain medication) per physician order. Resident #1 received 100 mg of [MEDICATION NAME] instead of 5 mg which was 20 times more [MEDICATION NAME] than what was prescribed by the physician and a significant medication error. This was evident in 1 (Resident #1) of 3 residents receiving narcotic medications. Immediate jeopardy began on [DATE] when Resident #1 received 20 times the prescribed dose of [MEDICATION NAME]. The immediate jeopardy was removed on [DATE] when the facility provided an acceptable credible allegation of removal. The facility will remain out of compliance at a scope and severity of no actual harm with the potential of no more than minimal harm that is not immediate jeopardy (D). The facility was in the process of full corrective action at that time. Findings included: Resident #1 was admitted to the facility on [DATE]. The resident [DIAGNOSES REDACTED]. Review of the resident's annual Minimum Data Set (MDS) of [DATE] revealed the Brief Interview for Mental Status score was 7 which indicated the resident was severely cognitively impaired. The MDS indicated the resident received a scheduled pain medication regimen in the last 5 days during the look behind period. Pain did not trigger on the MDS. A Care plan was initiated on [DATE] to address the resident's risk for alteration in comfort related to [MEDICAL CONDITION]. The goal was the resident will verbalize or show non-verbal (no grimacing, no moaning etc.) relief of pain 45 minutes to an hour after administering of medications through the next review. The interventions included to administer tender loving care (i.e. change in position, back rub etc.) as needed, encourage resident to report any pain (noting location, duration, intensity and severity), give medication as ordered, observe for effectiveness of pain medications for the control of pain, handle gently and try to eliminate any environmental stimuli, encourage to express fears and concerns, observe for non-verbal signs of pain (i.e. grimacing, guarding, moaning, restlessness, diaphoresis), notify Medical Doctor as needed, and conduct pain assessment routinely. Review of the resident's Departmental Notes revealed on [DATE], the resident started hospice services. Review of the Physician's Telephone Orders revealed a physician order [REDACTED]. Give 5 mg Q (every) 8 hrs (hours) SL (sublingual) routinely for pain/SOB (shortness of breath). Give 5 mg SL Q 2hrs prn (as needed) SOB/pain. Review of Resident #1's Controlled Drug Receipt/Record/Disposition Form revealed documentation that 30 ml of [MEDICATION NAME] 100mg/5ml solution were received at the facility on [DATE]. The order written on the Controlled Drug Receipt/Record/Disposition Form was to give the resident 0.25 ml (5 mg) every 8 hours as needed. Review of Resident #1's eMAR (electronic medication administration record) -Medication Record for the month of October, 2017 revealed a typed Description of the order on the left side of the page that read as [MEDICATION NAME] 20mg/ml oral syringe, Give 5 mg every 8 hours sublingual for pain. On the same row of the order, on the right side of the page, and under the column of [DATE], there were a check mark and the initials of the medication aide indicating the resident was administered [MEDICATION NAME] at 6:00 AM and, again, 2 PM on [DATE]. Review of the Controlled Drug Receipt/Record/Disposition Form revealed documentation that 0.25 ml (5 mg) of [MEDICATION NAME] were given to the resident and 29.75 ml of [MEDICATION NAME] were left in the bottle at 6 AM on [DATE]. Another 0.25 ml of [MEDICATION NAME] were documented as given to the resident and 29.50 ml of [MEDICATION NAME] were left in the bottle at 2 PM on [DATE]. Review of the Physician's Telephone Order revealed a physician order [REDACTED]. Give 5 mg PO/SL Q 4 h (hour) scheduled and Q 2 hr (hour) prn (for) pain/SOB. Review of Resident #1's eMAR-Medication Record for the month of October, 2017 revealed a typed order on the left side of the page read as [MEDICATION NAME] 20mg/ml-oral syringe, Give 5 mg sublingual every 2 hours as needed for shortness of breath/pain. On the same row as the order, on the right side of the page, and under the column of [DATE], there were a check mark and the initials of Nurse #1 indicating Nurse #1 administered [MEDICATION NAME] at 8:14 PM on [DATE]. Review of the Controlled Drug Receipt/Record/Disposition Form revealed documentation that 5 ml of [MEDICATION NAME] were given to the resident and 24.50 ml of [MEDICATION NAME] were left in the bottle at 8 PM on [DATE]. The resident received 100 mg (5 ml) of [MEDICATION NAME] instead of 5 mg (0.25 ml) at 8 PM on [DATE]. This resident received 20 times more [MEDICATION NAME] than prescribed by the physician. Review of Resident #1's eMAR-Medication Record for the month of October, 2017 revealed a typed order on the left side of the page that read as [MEDICATION NAME] 20mg/ml oral syringe, Give every 4 hours sublingual for pain. There was no dosage specified on this order. On the same row of the order, on the right side of the page, and under the column of [DATE], there were a check mark and the initials of Nurse #2 indicating Nurse #2 administered [MEDICATION NAME] at 1:00 AM and 5:00 AM on [DATE]. Review of the Controlled Drug Receipt/Record/Disposition Form revealed documentation that 0.25 ml of [MEDICATION NAME] were given to the resident and 24.25 ml of [MEDICATION NAME] were left in the bottle at 1 AM on [DATE]. There was also documentation that 0.25 ml of [MEDICATION NAME] were given to the resident and 24.00 ml of [MEDICATION NAME] were left in the bottle at 5 AM on [DATE]. Review of the resident's Departmental Notes dated [DATE] revealed the Resident died at 9:10 AM. An interview with Nurse #1 was conducted on [DATE] at 5:30 PM. She worked with the resident on [DATE] at the ,[DATE] shift. The nurse gave the resident a [MEDICATION NAME] dose around 8 PM on [DATE]. At around 10:45 PM, the resident was sleeping and her breathing was slow. The nurse listened to her heart and checked her pulse and repositioned her. The nurse gave report at ,[DATE]:15 PM. Nurse #1 told the incoming nurse (Nurse #4) about the resident's slow breathing and the nurse said that was normal for the resident when she got [MEDICATION NAME]. Nurse #1 left the facility for the day. The next day, Nurse #1 came to the facility at 3 PM and was told that the resident passed away. The administrator told Nurse #1 that she gave Resident #1 5 ml (100 mg) of [MEDICATION NAME] instead of 0.25 ml (5 mg). When asked what contributed to the error, Nurse # 1 said she read the physician order [REDACTED].#1 said the administrator educated her about medication error and gave her print out on how to avoid medication error on [DATE]. An interview was conducted with Nurse #2 on [DATE] at 6:15 PM. Nurse #2 provided care to Resident #1 on the 11 PM - 7 AM shift that started on [DATE]. She said she gave the resident her scheduled dose of [MEDICATION NAME] of 5 mg around 1 AM on [DATE]. Then she went to the Controlled Drug Receipt Record to record the [MEDICATION NAME] administration to the resident and noticed documentation that the resident received 5 ml (100 mg) instead of 0.25 ml (5 mg) at 8 PM. Nurse #2 said the amount of [MEDICATION NAME] in the bottle matched the documented amount of [MEDICATION NAME] left on the Controlled Drug Receipt Record. Nurse #2 thought there was no way the resident received the 5 ml of [MEDICATION NAME] since the resident was still moaning when Nurse #2 went to look at the resident. Nurse #2 said she gave the resident the scheduled doses of 5 mg of [MEDICATION NAME] at 1 AM and again at 5 AM. Nurse #2 said she left the facility at 7:15 AM. Nurse #2 was interviewed again via telephone on [DATE] at 6:35 AM. The nurse said she did not call the doctor because the resident was still moaning, so she doubted that the resident got 5 ml of [MEDICATION NAME]. On [DATE] at 2:58 PM, an interview was conducted with Nurse #3. Nurse #3 said she never worked with Resident #1. Nurse #3 said on [DATE] around 11:05 PM to 11:10 PM, she did a drug count with Nurse #1 and the count on the Controlled Drug Receipt Record matched the amount in the medication bottle for Resident #1. Nurse #3 said she did not look at the Controlled Drug Receipt Records during the drug count because she was not supposed to. Nurse #3 said that around 1 AM, Nurse #2 came to her and told her that documentation on the Controlled Drug Receipt Form indicated Resident #1 got 5 ml instead of 5 mg of [MEDICATION NAME] at 8 PM. Nurse #3 stated to Nurse #2, surely to God, she did not give her 5 ml. Nurse #3 said she did not give Nurse #2 any direction on what she should do. Nurse #2 said she would let Unit Coordinator #1 know in the morning. Nurse #3 said if this happened to her and she gave a resident an incorrect dose, Nurse #3 would let her supervisor know immediately. If there was no supervisor in the facility she would call the doctor. An interview was conducted with the Unit Coordinator #1 on [DATE] at 9:29 AM. She usually worked the 7 AM -3 PM shift. She said Nurse #2 came to her about 8 or 8:30 AM on [DATE] and said she (Nurse #2) did not know if Resident #1 [MEDICATION NAME] dose was given correctly. Unit Coordinator #1 looked at the Controlled Drug Receipt Record and the [MEDICATION NAME] bottle. The amount in the [MEDICATION NAME] bottle matched what was documented as left on the Controlled Drug Receipt Record, then she told the administrator. Unit Coordinator #1 did look at the resident and the resident was moving some and she was not moaning. Unit Coordinator #1 stated, when she would realize a resident got more than the prescribed dose of [MEDICATION NAME], then she would assess the resident and notify the doctor immediately and get an order for [REDACTED].>An interview was conducted with the physician on [DATE] at 10:32 AM via telephone. He said he was familiar with Resident #1 situation. He said that adverse effect of a [MEDICATION NAME] overdose would appear during the first 60 minutes to two hours after administration of the overdose. His expectation was the physician would be notified immediately when a medication error occurred. He expected the nursing staff to monitor vital signs, may be every 15 minutes, monitor breathing, and check clinical status. However, since the first nurse (Nurse #1) did not become aware of the error before the end of her shift at 11 PM, he stated we missed the window of opportunity for monitoring and preventing harm (if it was to happen) since the harm would have appeared during the first two hours after the overdose. If he was notified when Nurse #2 discovered the error around 1 AM, the physician would not have given the resident [MEDICATION NAME] right away, unless she was having breathing problems. At that time, the nurse would check the resident's level of consciousness and sedation. The physician stated that he did not see any problem with the nurse (Nurse #2) giving the resident the scheduled [MEDICATION NAME] doses at 1 AM and 5 AM, even after Nurse #2 became aware that the resident received 20 times more [MEDICATION NAME] than prescribed. The physician thought the resident did not absorb the [MEDICATION NAME] that was why she did not have the typical overdose symptoms. The physician did not think the [MEDICATION NAME] overdose hastened the resident's death. On [DATE] at 5:28 PM, an interview was conducted with the director of clinical pharmacy services. The director stated the [MEDICATION NAME] order is delivered to the facility with a Controlled Drug Receipt Record form that would have the resident's name, physician name, the name of the drug, a concentration, administration route, a dose (with the number of ml that needed to be administered so nurses would not have to do the math) and frequency of administration. When a nurse needed to administer [MEDICATION NAME], the order would come up on the computer and the nurse should compare the [MEDICATION NAME] dose on the computer with the dose on the Controlled Drug Receipt Record to make sure it matched. Nurses would measure the [MEDICATION NAME] with a 1 ml syringe and administer it and document on the Controlled Drug Receipt Record how much was given and how much was left in the [MEDICATION NAME] bottle. The director stated the nurse (Nurse #1) would have to fill up the 1 ml syringe with [MEDICATION NAME] 5 times to administer 5 ml to Resident #1. On [DATE] at 6:44 PM, an interview was conducted with the corporate nurse consultant. He said Nurse #2 did not assess the resident when she found out that the resident received an incorrect dose of [MEDICATION NAME] on [DATE]. The only source of information of the resident's condition after she reveived the incorrect dose of [MEDICATION NAME] was from interviews with Nurse #2 by the facility and the state agency. There was no documentation in the medical record by Nurse #2 that the resident was moaning during the 11 PM-7 AM shift on [DATE]. The administrator was interviewed on [DATE] at 10:30 AM. The administrator stated that Nurse #1 told her she had to use five 1-ml syringe full of [MEDICATION NAME] to administer 5 ml of [MEDICATION NAME] to Resident #1. The administrator was notified of immediate jeopardy on [DATE] at 1 PM. The facility provided the following acceptable allegation of removal of the immediate jeopardy on [DATE] at 1:26 PM: On [DATE], Nurse #1 administered 5ml of [MEDICATION NAME] 100mg instead of 0.25mL (5mg) as ordered by physician to Resident #1. No adverse effects were noted in relation to this medication error. Resident #1 had a terminal diagnosis, and elected to receive Hospice services, with the life expectancy of six months or less. On [DATE] at approximately 4:30pm, Nurse #2 who administered two doses of [MEDICATION NAME] during the night on [DATE] (1am and 5am) to Resident #1 was interviewed by the Administrator. She revealed that during her shift on [DATE], Resident #1 showed signs and symptoms of pain and she administered 0.25mL of [MEDICATION NAME] per physician order. She stated, she noticed 5ml was documented on the Controlled Drug Receipt form for Resident #1 at 1am when she was signing for the [MEDICATION NAME] she administered. She did not think 5ml was administered because Resident #1 was still moaning with pain and showed no symptoms of medication overdose. She interpreted the entry as documentation error. She also indicated Resident # 1 did not show any signs or change in condition to warrant contacting the physician. Unit Coordinator #1 attempted to contact Nurse #2 with no response on [DATE] at 9:30AM. Director of Health Services attempted to contact Nurse #2 on [DATE] at 5:52PM, and no response. Nurse #2 will not be allowed to work until re-educated on physician notification requirements. On [DATE], Resident #1 was moaning with pain at 1am and 5am. Nurse #2 administered [MEDICATION NAME] 0.25mL per Physician order. Nurse #2 recognized the previous shift documented [MEDICATION NAME] 5mL instead of 0.25mL. Nurse #2 did not have the ability to contact Nurse #1 to verify whether [MEDICATION NAME] 5mL documented on the Controlled Drug receipt form was administered to Resident #1 or not. Per Nurse #2, no signs or symptoms of distress noted during the night for Resident #1. Although Resident #1 died on [DATE], it is our assertion that the resident's death was a result of their terminal illness and not from the medication error approximately thirteen hours prior. Our assertion is based on the following facts; [MEDICATION NAME] Pharmacokinetics indicate: 30% of orally administered medication is typically absorbed Has a half-life of ,[DATE] hours Peak time of 60 minutes Duration of ,[DATE] hours The attending Physician was notified about this medication error on [DATE] at 3:30PM, this was done within 24 hours. At 11pm on [DATE] controlled drugs receipt for Resident #1 indicated the remaining quantity of [MEDICATION NAME] was 24.5mL. This amount matched the amount of [MEDICATION NAME] sulfate remaining in Resident #1's dispensed medication bottle. On [DATE] at approximately 9:00 am, during a controlled drug reconciliation for Resident #1, a discrepancy was noted on the Controlled Drug Receipt form by the facility Administrator. The control sheet indicated resident received 5ml of [MEDICATION NAME] sulfate instead of 0.25ml of [MEDICATION NAME] as ordered by the Physician. On [DATE] at approximately 3:00pm, Nurse #1, who administered the stated medication to Resident #1 was interviewed by the Administrator. She revealed that during the medication administration on the previous day, she noted medication order change for Resident #1. She verified the written order in resident's record and read it as 5ml instead of 5mg. The Administrator explained and demonstrated to Nurse #1 what was supposed to be administered compared to what she signed for on the Controlled Drug Receipt form. Nurse #1 acknowledged that an incorrect amount of [MEDICATION NAME] had been administered. Based on the interview conducted by the Administrator and the record review of all controlled medications administered by Nurse #1, it was concluded that this error resulted from an honest oversight. Nurse #1 misread the order, and misinterpreted [MEDICATION NAME] 5mg as [MEDICATION NAME] 5mL. Nurse #1 was re-educated and counseled by the Director of Health Services and the Administrator on ,[DATE]. Medication administration competency and [MEDICATION NAME] dosage calculation education was provided to Nurse #1 by the Director of Health Services on [DATE]. 100% audit of all active residents controlled medications was completed on [DATE] by Director of Health Services to identify any other resident with an order for [REDACTED]. No other written Controlled medication order were noted with any discrepancy. Effective [DATE], and moving forward, all liquid medication orders will be written with the specificity of the amount of liquid to be administered based on concentration; for example an order for [REDACTED]. All Licensed nurses and Medication aides were notified of this new process on [DATE] and [DATE] by an education conducted by the Director of Health Services (DHS), Quality Assurance Nurse and/or Staff Development Coordinator (SDC). Effective [DATE] any liquid medication ordered and written by the physician will be transcribed in resident Electronic Administration records to reflect the amount of liquid to be administered by licensed nurses on duty. Effective [DATE], Director of Health Services, Quality Assurance Nurse, Unit Coordinator and/or Staff Development Coordinator will review all new medication and treatment orders from prior day (M-F), by comparing new written telephone orders to orders transcribed in electronic health record to ensure accuracy. This process will be incorporated in the facility daily Clinical rounds. Any medication not transcribed correctly will be corrected promptly and findings reported to the Director of Health Services. Findings from this process will be maintained in the Daily Clinical round binder located in the Director of Health Services office. Effective [DATE], the center clinical interdisciplinary team, which includes Director of Health Services, Quality Assurance Nurse, Unit Coordinator and/or Staff Development Coordinator, initiated a process for reviewing all new admission/re-admissions Monday through Friday to ensure all ordered medication were transcribed appropriately and administered per physician orders. Any negative finding will be addressed promptly. Effective [DATE], the center's week end RN supervisor and/or designated licensed nurse will review all new admission/re-admissions by comparing new written telephone orders to orders transcribed in electronic health record to ensure accuracy every Saturday and Sunday to ensure all new ordered medication were transcribed appropriately and administered per physician orders. Any negative finding will be addressed promptly, and reported to the Director of Health Services. Director of Health Services (DHS), Quality Assurance Nurse and/or Staff Development Coordinator (SDC) will complete 100% education for all licensed nurses and medication aides, to include full time, part time and as needed staff, regarding medication administration per physician orders [REDACTED]. The emphasis of this education was on the liquid medication specifically [MEDICATION NAME] sulfate. This education will be completed by [DATE]. Any licensed nurse and/or Medication aide not educated by [DATE] will not be allowed to work until educated. This education will also be added on new hires orientation process for all new Licensed nurses and Medication aides effective [DATE], and will be provided annually. Effective [DATE], Director of Health Services, Quality Assurance Nurse, Unit Coordinator and/or Staff Development Coordinator will monitor compliance or medication order administration per physician orders, specifically, all [MEDICATION NAME]. Controlled Drug Receipts will be reviewed in clinical meeting, 5 times per week (Monday - Friday) for 2 weeks, then 3 time weekly for 2 more weeks, then weekly for 4 weeks then monthly x 3 months or until the pattern of compliance is maintained. Findings from this meeting will be documented on a daily clinical report form and filed in clinical meeting binder in Director of Nursing office after proper follow ups are done. Executive Director will review the completion of daily clinical report, and daily clinical checklist forms daily (M-F) for 2weeks, weekly x 2 more weeks, then monthly x 3 months or until the pattern of compliance is maintained. Effective [DATE], Director of Nursing will report findings of this monitoring process to the facility Quality Assurance and Performance Improvement Committee for any additional monitoring or modification of this plan monthly for 3 months, or until the pattern of compliance is maintained. The QAPI committee can modify this plan to ensure the facility removal of the alleged immediate jeopardy. Effective [DATE], the center Executive Director and the Director of Health services will be ultimately responsible to ensure implementation of credible allegation to remove this alleged immediate jeopardy. Validation of the credible allegation was done on [DATE] at 11:47 AM. The facility provided documentation that the administrator initiated an investigation as soon as she became aware of the medication error. The administrator interviewed Nurse #1 to determine how the error occurred and provided the nurse education on how to avoid future medication error. Interview with Nurse #1 validated that she did receive education and counselling from the administrator. A written statement was reviewed indicating that the administrator interviewed Nurse #2 on [DATE] at 4:30 pm. The statement indicated that the resident was showing signs and symptoms of pain and was not showing signs of distress. That was why Nurse #2 did not think that the 5 ml of [MEDICATION NAME] on the Controlled Drug Receipts was accurate. The facility has filled out a medication discrepancy report. The facility provided evidence of audits of medication orders and inservices provided to staff about medication error and physician notification. Staff were interviewed to validate that they received education on medication error and notifying the physician. Resident on [MEDICATION NAME] were reviewed for medication error.

Based on record review and interviews with staff, the medical director and the director of clinical pharmacy services, the facility staff failed to notify the physician immediately after discovering that a resident received 20 times the amount of [MEDICATION NAME] (a narcotic pain medication) prescribed by the physician. The resident did receive two additional scheduled doses of [MEDICATION NAME] after the excessive dose. This was evident in 1 (Resident #1) of 3 sampled residents receiving narcotic medications. Immediate jeopardy began on [DATE] when Resident #1's physician was not notified of the excessive dose immediately after discovery. Resident #1 received 20 times the prescribed dose of [MEDICATION NAME]. The immediate jeopardy was removed on [DATE] when the facility provided an acceptable credible allegation of removal. The facility will remain out of compliance at a scope and severity of no actual harm with the potential of no more than minimal harm that is not immediate jeopardy (D). The facility was in the process of full corrective action at that time. Findings included: Resident #1 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the resident's annual Minimum Data Set (MDS) of [DATE] revealed the Brief Interview for Mental Status score was 7 which indicated the resident was severely cognitively impaired. The MDS indicated the resident received a scheduled pain medication regimen in the last 5 days during the look behind period. Pain did not trigger on the MDS. A Care plan was initiated on [DATE] to address the resident's risk for alteration in comfort related to [MEDICAL CONDITION]. The goal was the resident will verbalize or show non-verbal (no grimacing, no moaning etc.) relief of pain 45 minutes to an hour after administering of medications through the next review. The interventions included to administer tender loving care (i.e. change in position, back rub etc.) as needed, encourage resident to report any pain (noting location, duration, intensity and severity), give medication as ordered, observe for effectiveness of pain medications for the control of pain, handle gently and try to eliminate any environmental stimuli, encourage to express fears and concerns, observe for non-verbal signs of pain (i.e. grimacing, guarding, moaning, restlessness, diaphoresis), notify Medical Doctor as needed, and conduct pain assessment routinely. Review of the resident's Departmental Notes revealed that on [DATE], the resident started hospice services. Review of the Physician's Telephone Order revealed a physician order [REDACTED]. Give 5 mg PO (by mouth)/SL (sublingual) Q (every) 4 h (hour) scheduled and Q 2 hr (hour) prn (as needed) (for) pain/SOB (shortness of breath). Review of Resident #1's eMAR (electronic medication administration record) -Medication Record for the month of October, 2017 revealed a typed order on the left side of the page, [MEDICATION NAME] 20mg/ml-oral syringe, Give 5 mg sublingual every 2 hours as needed for shortness of breath/pain. On the same row as the order, on the right side of the page, and under the column of [DATE], there was a check mark and the initials of Nurse #1 indicating Nurse #1 administered [MEDICATION NAME] at 8:14 PM on [DATE]. Review of the Controlled Drug Receipt/Record/Disposition Form revealed documentation that 5 ml of [MEDICATION NAME] were given to the resident and 24.50 ml of [MEDICATION NAME] were left in the bottle at 8 PM on [DATE]. The resident received 100 mg (5 ml) of [MEDICATION NAME] instead of 5 mg (0.25 ml) at 8 PM on [DATE]. This resident received 20 times more [MEDICATION NAME] than prescribed by the physician. Review of Resident #1's eMAR-Medication Record for the month of October, 2017 revealed a typed order on the left side of the page that read as [MEDICATION NAME] 20mg/ml oral syringe, Give every 4 hours sublingual for pain. There was no dosage specified on this order. On the same row of the order, on the right side of the page, and under the column of [DATE], there were check marks indicating Nurse #2 administered [MEDICATION NAME] at 1:00 AM and 5:00 AM on [DATE]. Review of the Controlled Drug Receipt/Record/Disposition Form revealed documentation that 0.25 ml of [MEDICATION NAME] were given to the resident and 24.25 ml of [MEDICATION NAME] were left in the bottle at 1:00 AM on [DATE]. There was also documentation that 0.25 ml of [MEDICATION NAME] were given to the resident and 24.00 ml of [MEDICATION NAME] were left in the bottle at 5:00 AM on [DATE]. Review of the resident's Departmental Notes dated [DATE] revealed the Resident died at 9:10 AM. An interview with Nurse #1 was conducted on [DATE] at 5:30 PM. She worked with the resident on [DATE] on the ,[DATE] shift. The nurse gave the resident a [MEDICATION NAME] dose around 8:00 PM on [DATE]. At around 10:45 PM, the resident was sleeping and her breathing was slow. The nurse listened to her heart and checked her pulse and repositioned her. The nurse gave report at 11:00 -11:15 PM. Nurse #1 told the incoming nurse (Nurse #4) about the resident's slow breathing and the nurse said that was normal for the resident when she got [MEDICATION NAME]. Nurse #1 left the facility for the day. The next day, Nurse #1 came to the facility at 3:00 PM and was told that the resident passed away. The administrator told Nurse #1 that she gave Resident #1 5 ml of [MEDICATION NAME] instead of 5 mg. When asked what contributed to the error, Nurse # 1 said she read the physician order [REDACTED]. An interview was conducted with Nurse #2 on [DATE] at 6:15 PM. Nurse #2 provided care to Resident #1 on the 11 PM - 7 AM shift that started on [DATE]. The nurse said she administered 0.25 ml of [MEDICATION NAME] at 1:00 AM as prescribed by the physician. Then, she went to the Controlled Drug Receipt Record to record the administration of the [MEDICATION NAME] to the resident and noticed documentation that the resident received 5 ml instead of 5 mg at 8:00 PM. Nurse #2 said the amount of [MEDICATION NAME] in the bottle matched the documented amount of [MEDICATION NAME] left on the Controlled Drug Receipt Record. Nurse #2 thought there was no way the resident received the 5 ml of [MEDICATION NAME] since the resident was still moaning when Nurse #2 went to look at the resident. Nurse #2 said she gave the resident the scheduled doses of 5 mg of [MEDICATION NAME] at 1:00 AM and again at 5:00 AM. Nurse #2 said she left the facility at 7:15 AM. Nurse #2 was interviewed again via telephone on [DATE] at 6:35 AM. The nurse said she did not call the doctor because the resident was still moaning, so she doubted that the resident got 5 ml of [MEDICATION NAME]. Nurse #2 said she did not assess the resident. On [DATE] at 2:58 PM, an interview was conducted with Nurse #3. Nurse #3 said she never worked with Resident #1. Nurse #3 said on [DATE] around 11:05 PM to 11:10 PM, she did a drug count with Nurse #1 and the count on the Controlled Drug Receipt Record matched the amount in the medication bottle for Resident #1. Nurse #3 said she did not look at the Controlled Drug Receipt Records during the drug count because she was not supposed to. Nurse #3 said that around 1:00 AM, Nurse #2 came to her and told her that documentation on the Controlled Drug Receipt Form indicated Resident #1 got 5 ml instead of 5 mg of [MEDICATION NAME] at 8 PM. Nurse #3 said she did not give Nurse #2 any direction on what she should do. Nurse #2 said she would let Unit Coordinator #1 know in the morning. Nurse #3 said if this happened to her and she gave a resident an incorrect dose, Nurse #3 would let her supervisor know immediately. If there was no supervisor in the facility she would call the doctor. An interview was conducted with the Unit Coordinator #1 on [DATE] at 9:29 AM. She usually worked the 7 AM -3 PM shift. She said Nurse #2 came to her about 8:00 or 8:30 AM on [DATE] and said she (Nurse #2) did not know if Resident #1 [MEDICATION NAME] dose was given correctly. Unit Coordinator #1 looked at the Controlled Drug Receipt Record and the [MEDICATION NAME] bottle. The amount in the [MEDICATION NAME] bottle matched what was documented as left on the Controlled Drug Receipt Record, then she told the administrator. Unit Coordinator #1 observed the resident and the resident was moving some and she was not moaning. The Unit Coordinator #1 stated, when she realized a resident got more than the prescribed dose of [MEDICATION NAME], then she would assess the resident and notify the doctor immediately and get an order for [REDACTED]. An interview was conducted with the physician on [DATE] at 10:32 AM via telephone. He said he was familiar with Resident #1 situation. He was notified of the medication error on the morning of [DATE] after the facility's administrator became aware of the error. He said that adverse effect of a [MEDICATION NAME] overdose would appear during the first 60 minutes to two hours after administration of the overdose. His expectation was the physician would be notified immediately when a medication error occurred. He expected the nursing staff to monitor vital signs, may be every 15 minutes, monitor breathing, and check clinical status. However, since the first nurse (Nurse #1) did not become aware of the error before the end of her shift at 11:00 PM, he stated we missed the window of opportunity for monitoring and preventing harm (if it was to happen) since the harm would have appeared during the first two hours after the overdose. If he was notified when Nurse #2 discovered the error around 1:00 AM, the physician would not have given the resident [MEDICATION NAME] right away, unless she was having breathing problems. At that time, the nurse would check the resident's level of consciousness and sedation. The physician stated that he did not see any problem with the nurse (Nurse #2) giving the resident the scheduled [MEDICATION NAME] doses at 1:00 AM and 5:00 AM, even after Nurse #2 became aware that the resident received 20 times more [MEDICATION NAME] than prescribed. The physician thought the resident did not absorb the [MEDICATION NAME] and that was why she did not have the typical overdose symptoms. The physician did not think the [MEDICATION NAME] overdose hastened the resident's death. The administrator was interviewed on [DATE] at 10:30 AM. The administrator stated that Nurse #1 told her she had to use five 1-ml syringe full of [MEDICATION NAME] to administer 5 ml of [MEDICATION NAME] to Resident #1. The administrator was notified of immediate jeopardy on [DATE] at 1 PM. The facility provided the following acceptable allegation of removal of the immediate jeopardy on [DATE] at 1:26 PM: On [DATE] at approximately 4:30pm, Nurse #2 who administered two doses of [MEDICATION NAME] during the night on [DATE] (1am and 5am) to Resident #1 was interviewed by the Administrator. She revealed that during her shift on [DATE], Resident #1 showed signs and symptoms of pain and she administered 0.25mL of [MEDICATION NAME] per physician order. She stated, she noticed 5ml was documented on the Controlled Drug Receipt form for Resident #1 at 1am when she was signing for the [MEDICATION NAME] she administered. She did not think 5ml was administered because Resident #1 was still moaning with pain and showed no symptoms of medication overdose. She interpreted the entry as documentation error. She also indicated Resident #1 did not show any signs of change in condition to warrant contacting the physician. Nurse #2 will not be allowed to work until re-educated on physician notification requirements. Unit Coordinator #1 attempted to contact Nurse #2 with no response on [DATE] at 9:30AM. Director of Health Services attempted to contact Nurse #2 on [DATE] at 5:52PM, and no response. Nurse #2 will not be allowed to work until re-educated on physician notification requirements. On [DATE], Nurse #1 administered 5ml of [MEDICATION NAME] (100mg) instead of 0.25mL (5mg) as ordered by physician to Resident #1. No adverse effects were noted in relation to this medication error. Resident #1 had a terminal diagnosis, and elected to receive Hospice services, with the life expectancy of six months or less. On [DATE], Resident #1 was moaning with pain at 1am and 5am; Nurse #2 administered [MEDICATION NAME] 0.25mL per Physician order [REDACTED]. Nurse #2 recognized the previous shift documented [MEDICATION NAME] 5ml instead of 0.25mL. Per Nurse #2, no signs or symptoms of distress were noted during the night. Although Resident #1 died on [DATE] it is our assertion that the resident's death was a result of their terminal illness and not from the medication error approximately thirteen hours prior. Our assertion is based on the following facts; [MEDICATION NAME] Pharmacokinetics indicate: 30% of orally administered medication is typically absorbed Has a half-life of ,[DATE] hours Peak time of 60 minutes Duration of ,[DATE] hours The attending Physician was notified about this medication error on [DATE] at 3:30PM, this was done within 24 hours. At 11pm on [DATE] controlled drugs receipt for Resident #1 indicated the remaining quantity of [MEDICATION NAME] was 24.5mL. This amount matched the amount of [MEDICATION NAME] sulfate remaining in Resident #1 dispensed medication bottle. On [DATE] at approximately 9:00 am, during a controlled drug reconciliation for Resident #1, a discrepancy was noted on the Controlled Drug Receipt form by the facility Administrator. The Controlled Drug Receipt form indicated resident received 5ml of [MEDICATION NAME] sulfate instead of 0.25ml of [MEDICATION NAME] as ordered by the Physician. On [DATE] at approximately 3:00pm, Nurse #1, who administered the stated medication to Resident #1 was interviewed by the Administrator. She revealed that during the medication administration on the previous day, she noted medication order change for Resident #1. She verified the written order in the resident's record and read it as 5ml instead of 5mg. On [DATE] at approximately 4:30pm, Nurse #2 who administered two doses of [MEDICATION NAME] during the night on [DATE] (1am and 5am) to Resident #1 was interviewed by the Administrator. She revealed that during her shift on [DATE], Resident #1 showed signs and symptoms of pain and she administered 0.25mL of [MEDICATION NAME] per physician order. She stated, she noticed 5ml was documented on the Controlled Drug Receipt form for Resident #1 at 1am when she was signing for the [MEDICATION NAME] she administered. She did not think 5ml was administered because Resident #1 was still moaning with pain and showed no symptoms of medication overdose. She interpreted the entry as documentation error. She also indicated Resident #1 did not show any signs of change in condition to warrant contacting the physician. Nurse #2 will not be allowed to work until re-educated on physician notification requirements. 100% audit of all active resident controlled medication was completed on [DATE] by Director of Health Services to identify any other resident with an order for [REDACTED]. There were no other discrepancies in any other written Controlled medication orders. 100% audit of all current residents' clinical documentation within the last 7 days were completed by the Director of Nursing, Quality assurance nurse, Nurse Supervisor, MDS nurse #1 and/or MDS nurse #2 and to determine any identified need for notification of changes was completed in a timely manner. The audit revealed no other incident of missing/delayed notification of changes to both physician and responsible party. This audit was completed on [DATE]. Findings of this audit are documented on clinical records audit tool located in the facility compliance binder. On [DATE], 100% audit was completed by the Director of Nursing, Quality assurance nurse, Nurse Supervisor, MDS nurse #1 and/or MDS nurse #2 of all incidents reports completed within the last 30 days to ensure notifications were done in a timely manner. The audit revealed no other incident of missing/delayed notification of changes to both physician and responsible party. This audit was completed on [DATE]. Findings of this audit were documented on incident reports audit tool located in the facility compliance binder. Effective [DATE], and moving forward, all liquid medication orders will be written with the specificity of the amount of liquid to be administered based on concentration; for example an order for [REDACTED]. Effective [DATE], the center nursing administrative team, which includes DON, ADON, and/or SDC, initiated a process for reviewing clinical documentation for the last 24 hours, 24 hour report sheets, incident reports for the last 24 hours and Physician orders [REDACTED]. This systemic process will take place daily (Monday through Friday). Any identified issues will be addressed promptly and appropriate actions will be implemented by the DON, ADON, SDC and/or Registered Nurse supervisor. This process will be incorporated in a daily clinical rounds. Any negative findings will be documented on the daily checklist form and maintained in the daily clinical meeting binder. Effective [DATE], week end Registered Nurse supervisor and/or designated Nurse will review clinical documentation for the last 24 hours, 24 hour report sheets, incident reports for the last 24 hours and Physician orders [REDACTED]. This systemic process will take place every Saturday and Sunday. Any identified issues will be addressed promptly and appropriate actions will be implemented by the DON, ADON, SDC and/or Registered Nurse supervisor. This process will be incorporated in daily clinical rounds. Any negative findings will be documented on the daily checklist form and maintained in the daily clinical meeting binder. Director of Nursing (DON), Assistant Director of Nursing (ADON) and/or Staff Development Coordinator (SDC) will complete 100% education for all Nurses and Medication aides, to include full time, part time and as needed staff. The emphasis of this education was on the importance of notifying Physician and the responsible party in a timely manner for any incident/accidents, resident's change of condition, change of treatment/intervention, an injury of unknown source and/or Medication error if any. This education will be completed by [DATE]. Any Nurse or Medication Aide not educated by [DATE] will not be allowed to work until educated. This education will also be added on new hires orientation process for all new Nurses and Medication Aides effective [DATE]. Effective [DATE], Director of Nursing, Assistant Director of Nursing, and/or Staff Development Coordinator, will monitor compliance with notification of changes to Physician and/or responsible party by conducting clinical meeting daily (M-F), review the daily clinical meeting checklist to ensure completion and proper follow through to include notification to Physician and responsible party, will review any admission/discharges occurred from the last clinical meeting and/or any incidents or accidents occurred from the prior clinical meeting to include any medication error happened from the previous clinical meeting. Any issues identified during this monitoring process will be addressed promptly. Findings from this meeting will be documented on a daily clinical report form and filed in a clinical meeting binder in the Director of Health Services office. Director of Nursing will review the completion of daily clinical report, and daily clinical checklist forms daily Monday to Friday for two weeks, weekly for two more weeks, then monthly for three months or until a pattern of compliance is maintained. Effective [DATE], Director of Nursing will report findings of this monitoring process to the facility Quality Assurance and Performance Improvement Committee for any additional monitoring or modification of this plan monthly for three months, or until a pattern of compliance is maintained. The QAPI committee can modify this plan to ensure the facility remains in substantial compliance. Effective [DATE], the center Executive Director and the Director of Health services will be ultimately responsible to ensure implementation of credible allegation to remove this alleged immediate jeopardy. Validation of the credible allegation was done on [DATE] at 11:47 AM. The facility provided documentation that the physician was notified of the medication error shortly after the facility became aware of the error. Review of the clinical record audit tools revealed all records were audited for physician notification on [DATE]. Review of audit for incident and skin was also checked. the inservice was conducted on [DATE] regarding physician notification. Interview with Nurse #1 validated that she did receive education and counselling from the administrator. A written statement was reviewed indicating that the administrator interviewed Nurse #2 on [DATE] at 4:30 pm. The statement indicated that the resident was showing signs and symptoms of pain and was not showing signs of distress. That was why Nurse #2 did not think that the 5 ml of [MEDICATION NAME] on the Controlled Drug Receipts was accurate. The facility has filled out a medication discrepancy report. The facility provided evidence of audits of medication orders and inservices provided to staff about medication error and physician notification. Staff were interviewed to validate that they received education on medication error and notifying the physician. Residents who received [MEDICATION NAME] were reviewed for medication errors.

Based on record review and interviews with staff, the medical director and the director of clinical pharmacy services, the facility failed to administer the correct dose of [MEDICATION NAME] (a narcotic pain medication) resulting in Resident #1 receiving 20 times more [MEDICATION NAME] than what was prescribed by the physician. The facility staff failed to immediately assess the resident for adverse effects after facility staff discovered documentation that the resident received 20 times more [MEDICATION NAME] than prescribed. The resident did receive two additional scheduled doses of [MEDICATION NAME] after the excessive dose. This was evident in 1 (Resident #1) of 3 sampled residents receiving narcotic medications. Immediate jeopardy began on [DATE] when Resident #1 received 20 times the prescribed dose of [MEDICATION NAME], was not assessed for adverse effects after facility staff discovered documentation that the resident received 20 times more [MEDICATION NAME] than prescribed. The immediate jeopardy was removed on [DATE] when the facility provided an acceptable credible allegation of removal. The facility will remain out of compliance at a scope and severity of no actual harm with the potential of no more than minimal harm that is not immediate jeopardy (D). The facility was in the process of full corrective action at that time. Findings included: Resident #1 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the resident's annual Minimum Data Set (MDS) of [DATE] revealed the Brief Interview for Mental Status score was 7 which indicated the resident was severely cognitively impaired. The MDS indicated the resident received a scheduled pain medication regimen in the last 5 days during the look behind period. Pain did not trigger on the MDS. A Care plan was initiated on [DATE] to address the resident's risk for alteration in comfort related to [MEDICAL CONDITION]. The goal was the resident will verbalize or show non-verbal (no grimacing, no moaning etc.) relief of pain 45 minutes to an hour after administering of medications through the next review. The interventions included to administer tender loving care (i.e. change in position, back rub etc.) as needed, encourage resident to report any pain (noting location, duration, intensity and severity), give medication as ordered, observe for effectiveness of pain medications for the control of pain, handle gently and try to eliminate any environmental stimuli, encourage to express fears and concerns, observe for non-verbal signs of pain (i.e. grimacing, guarding, moaning, restlessness, diaphoresis), notify Medical Doctor as needed, and conduct pain assessment routinely. Review of the resident's Departmental Notes revealed the following about the resident's condition: On [DATE], the resident started hospice services. On [DATE] and [DATE], the resident refused some of her medications. On [DATE], the Resident was lying in bed sleeping most of the day. She mumbled, refused all morning medications by spitting it back out after taking them. Review of the Physician's Telephone Orders revealed a physician order [REDACTED]. Give 5 mg Q (every) 8 hrs (hours) SL (sublingual) routinely for pain/SOB (shortness of breath). Give 5 mg SL Q 2hrs prn (as needed) SOB/pain. Review of Resident #1's Controlled Drug Receipt/Record/Disposition Form revealed documentation that 30 ml of [MEDICATION NAME] 100mg/5ml solution were received at the facility on [DATE]. The order written on the Controlled Drug Receipt/Record/Disposition Form was to give the resident 0.25 ml (5 mg) every 8 hours as needed. Review of Resident #1's eMAR (electronic medication administration record)-Medication Record for the month of October, 2017 revealed a typed Description of the order on the left side of the page that read as [MEDICATION NAME] 20mg/ml oral syringe, Give 5 mg every 8 hours sublingual for pain. On the same row of the order, on the right side of the page, and under the column of [DATE], there were a check mark and the initials of the medication aide indicating the resident was administered [MEDICATION NAME] at 6:00 AM and, again, 2 PM on [DATE]. Review of the Controlled Drug Receipt/Record/Disposition Form revealed documentation that 0.25 ml (5 mg) of [MEDICATION NAME] were given to the resident and 29.75 ml of [MEDICATION NAME] were left in the bottle at 6 AM on [DATE]. Another 0.25 ml of [MEDICATION NAME] were documented as given to the resident and 29.50 ml of [MEDICATION NAME] were left in the bottle at 2 PM on [DATE]. Review of the resident's Departmental Notes written by Nurse #4 on [DATE] at 4:15 PM revealed documentation that the Resident was lying in bed moaning, and was given [MEDICATION NAME] as ordered 0.25 (ml). The resident refused breakfast and lunch. The resident declined water, when offered, by biting on the straw. The staff will continue to monitor the resident and provide comfort, and keep call bell in place. Review of the Physician's Telephone Order revealed a physician order [REDACTED]. Give 5 mg PO/SL Q 4 h (hour) scheduled and Q 2 hr (hour) prn (for) pain/SOB. Review of Resident #1's eMAR-Medication Record for the month of October, 2017 revealed a typed order on the left side of the page read as [MEDICATION NAME] 20mg/ml-oral syringe, Give 5 mg sublingual every 2 hours as needed for shortness of breath/pain. On the same row as the order, on the right side of the page, and under the column of [DATE], there were a check mark and the initials of Nurse #1 indicating Nurse #1 administered [MEDICATION NAME] at 8:14 PM on [DATE]. Review of the Controlled Drug Receipt/Record/Disposition Form revealed documentation that 5 ml of [MEDICATION NAME] were given to the resident and 24.50 ml of [MEDICATION NAME] were left in the bottle at 8:00 PM on [DATE]. The resident received 100 mg (5 ml) of [MEDICATION NAME] instead of 5 mg (0.25 ml) at 8:00 PM on [DATE]. This resident received 20 times more [MEDICATION NAME] than prescribed by the physician. Review of Resident #1's eMAR-Medication Record for the month of October, 2017 revealed a typed order on the left side of the page that read as [MEDICATION NAME] 20mg/ml oral syringe, Give every 4 hours sublingual for pain. There was no dosage specified on this order. On the same row of the order, on the right side of the page, and under the column of [DATE], there were a check mark and the initials of Nurse #2 indicating Nurse #2 administered [MEDICATION NAME] at 1:00 AM and 5:00 AM on [DATE]. Review of the Controlled Drug Receipt/Record/Disposition Form revealed documentation that 0.25 ml of [MEDICATION NAME] were given to the resident and 24.25 ml of [MEDICATION NAME] were left in the bottle at 1 AM on [DATE]. There was also documentation that 0.25 ml of [MEDICATION NAME] were given to the resident and 24.00 ml of [MEDICATION NAME] were left in the bottle at 5 AM on [DATE]. Review of the resident's Departmental Notes dated [DATE] revealed the Resident died at 9:10 AM. An interview with Nurse #1 was conducted on [DATE] at 5:30 PM. She worked with the resident on [DATE] at the ,[DATE] shift. The resident would not eat or drink and would yell help and mumble. The resident was not verbal but this nurse would assess the resident's pain by looking for grimacing and moaning. The resident would sleep when her pain was relieved. The nurse gave the resident a [MEDICATION NAME] dose around 8:00 PM on [DATE]. At around 10:45 PM, the resident was sleeping and her breathing was slow. The nurse listened to her heart and checked her pulse and repositioned her. The nurse gave report at ,[DATE]:15 PM. Nurse #1 told the incoming nurse (Nurse #4) about the resident's slow breathing and the nurse said that was normal for the resident when she got [MEDICATION NAME]. Nurse #1 left the facility for the day. The next day, Nurse #1 came to the facility at 3 PM and was told that the resident passed away. The administrator told Nurse #1 that she gave Resident #1 5 ml (100 mg) of [MEDICATION NAME] instead of 5 mg. When asked what contributed to the error, Nurse # 1 said she read the physician order [REDACTED].#1 said the administrator educated her about medication error and gave her print out on how to avoid medication error on [DATE]. An interview was conducted with Nurse #2 on [DATE] at 6:15 PM. Nurse #2 provided care to Resident #1 on the 11 PM - 7 AM shift that started on [DATE]. The resident had pain in her legs because they were contracted and she yelled constantly. Nurse #2 acknowledged that the physician order [REDACTED]. Nurse #2 said she looked at the hand written physician order [REDACTED]. The nurse said she administered 0.25 ml of [MEDICATION NAME] at 1 AM as prescribed by the physician. Then, she went to the Controlled Drug Receipt Record to record the administration of the [MEDICATION NAME] to the resident and noticed documentation that the resident received 5 ml (100 mg) instead of 5 mg at 8:00 PM. Nurse #2 said the amount of [MEDICATION NAME] in the bottle matched the documented amount of [MEDICATION NAME] left on the Controlled Drug Receipt Record. Nurse #2 thought there was no way the resident received the 5 ml of [MEDICATION NAME] since the resident was still moaning when Nurse #2 went to look at the resident. Nurse #2 said she gave the resident the scheduled doses of 5 mg of [MEDICATION NAME] at 1 AM and again at 5 AM. Nurse #2 said she left the facility at 7:15 AM. Nurse #2 was interviewed again via telephone on [DATE] at 6:35 AM. The nurse said she did not call the doctor because the resident was still moaning, so she doubted that the resident got 5 ml of [MEDICATION NAME]. Nurse #2 said she did not assess the resident. On [DATE] at 2:58 PM, an interview was conducted with Nurse #3. Nurse #3 said she never worked with Resident #1. Nurse #3 said on [DATE] around 11:05 PM to 11:10 PM, she did a drug count with Nurse #1 and the count on the Controlled Drug Receipt Record matched the amount in the medication bottle for Resident #1. Nurse #3 said she did not look at the Controlled Drug Receipt Records during the drug count because she was not supposed to. Nurse #3 said that around 1 AM, Nurse #2 came to her and told her that documentation on the Controlled Drug Receipt Form indicated Resident #1 got 5 ml instead of 5 mg of [MEDICATION NAME] at 8:00 PM. Nurse #3 stated to Nurse #2, surely to God, she did not give her 5 ml. Nurse #3 said she did not give Nurse #2 any direction on what she should do. Nurse #2 said she would let Unit Coordinator #1 know in the morning. Nurse #3 said if this happened to her and she gave a resident an incorrect dose, Nurse #3 said she would let her supervisor know immediately. If there was no supervisor in the facility she would call the doctor. An interview was conducted with Unit Coordinator #1 on [DATE] at 9:29 AM. She usually worked the 7 AM -3 PM shift. She said Nurse #2 came to her about 8:00 or 8:30 AM on [DATE] and said she (Nurse #2) did not know if Resident #1 [MEDICATION NAME] dose was given correctly. Unit Coordinator #1 looked at the Controlled Drug Receipt Record and the [MEDICATION NAME] bottle. The amount in the [MEDICATION NAME] bottle matched what was documented as left on the Controlled Drug Receipt Record, then she told the administrator. Unit Coordinator #1 observed the resident and the resident was moving some and she was not moaning. The Unit Coordinator #1 stated, when she would realize a resident got more than the prescribed dose of [MEDICATION NAME], then she would assess the resident and notify the doctor immediately and get an order for [REDACTED]. An interview was conducted with the physician on [DATE] at 10:32 AM via telephone. He said he was familiar with Resident #1 situation. He was notified of the medication error on the morning of [DATE] after the facility's administrator became aware of the error. He said that adverse effect of a [MEDICATION NAME] overdose would appear during the first 60 minutes to two hours after administration of the overdose. His expectation was the physician would be notified immediately when a medication error occurred. He expected the nursing staff to monitor vital signs, may be every 15 minutes, monitor breathing, and check clinical status. However, since the first nurse (Nurse #1) did not become aware of the error before the end of her shift at 11 PM, he stated we missed the window of opportunity for monitoring and preventing harm (if it was to happen) since the harm would have appeared during the first two hours after the overdose. If he was notified when Nurse #2 discovered the error around 1 AM, the physician said he would not have given the resident [MEDICATION NAME] right away, unless the resident was having breathing problems. At that time, the nurse would check the resident's level of consciousness and sedation. The physician stated that he did not see any problem with the nurse (Nurse #2) giving the resident the scheduled [MEDICATION NAME] doses at 1 AM and 5 AM, even after Nurse #2 became aware that the resident received 20 times more [MEDICATION NAME] than prescribed. The physician thought the resident did not absorb the [MEDICATION NAME] and that was why she did not have the typical overdose symptoms. The physician did not think the [MEDICATION NAME] overdose hastened the resident's death. On [DATE] at 5:28 PM, an interview was conducted with the director of clinical pharmacy services. She explained that physician orders [REDACTED]. The facility's nurses were responsible for entering the physician order [REDACTED]. If the order on the eMAR was not complete, then the nurse should go back to the original order to verify and they can correct it on the eMAR without pharmacy intervention. The [MEDICATION NAME] order is delivered to the facility with a Controlled Drug Receipt Record form that would have the resident's name, physician name, the name of the drug, a concentration, administration route, a dose (with the number of ml that needed to be administered so nurses would not have to do the math) and frequency of administration. When a nurse needed to administer [MEDICATION NAME], the order would come up on the computer and the nurse should compare the [MEDICATION NAME] dose on the computer with the dose on the Controlled Drug Receipt Record to make sure it matched. Nurses would measure the [MEDICATION NAME] with a 1 ml syringe and administer it and document on the Controlled Drug Receipt Record how much was given and how much was left in the [MEDICATION NAME] bottle. During the narcotic count at the end of the shift, the oncoming nurse would be looking only at the amount of [MEDICATION NAME] in the bottle and the outgoing nurse would be looking at the Controlled Drug Receipt Record and then they match them up. The oncoming nurse would not look at the Controlled Drug Receipt Record until they administer [MEDICATION NAME] or at the drug count at the end of their shift. The director stated the nurse (Nurse #1) would have to fill up the 1 ml syringe with [MEDICATION NAME] 5 times to administer 5 ml to Resident #1. On [DATE] at 6:44 PM, an interview was conducted with the corporate nurse consultant. He said Nurse #2 did not assess the resident when she found out that the resident received an incorrect dose of [MEDICATION NAME] on [DATE]. The only source of information of the resident's condition after she received the incorrect dose of [MEDICATION NAME] was from interviews with Nurse #2 by the facility and the state agency. There was no documentation in the medical record by Nurse #2 that the resident was moaning during the 11 PM-7 AM shift on [DATE]. The administrator was interviewed on [DATE] at 10:30 AM. The administrator stated that Nurse #1 told her she had to use five 1-ml syringe full of [MEDICATION NAME] to administer 5 ml of [MEDICATION NAME] to Resident #1. The administrator was notified of immediate jeopardy on [DATE] at 1 PM. The facility provided the following acceptable allegation of removal of the immediate jeopardy on [DATE] at 1:26 PM: On [DATE], Nurse #1 administered 5ml of [MEDICATION NAME] 100mg instead of 0.25mL (5mg) as ordered by physician to Resident #1. No adverse effects were noted in relation to this medication error. Resident #1 had a terminal diagnosis, and elected to receive Hospice services, with the life expectancy of six months or less. On [DATE] at approximately 4:30pm, Nurse #2 who administered two doses of [MEDICATION NAME] during the night on [DATE] (1am and 5am) to Resident #1 was interviewed by the Administrator. She revealed that during her shift on [DATE], Resident #1 showed signs and symptoms of pain and she administered 0.25mL of [MEDICATION NAME] per physician order. She stated, she noticed 5ml was documented on the Controlled Drug Receipt form for Resident #1 at 1am when she was signing for the [MEDICATION NAME] she administered. She did not think 5ml was administered because Resident #1 was still moaning with pain and showed no symptoms of medication overdose. She interpreted the entry as documentation error. She also indicated Resident # 1 did not show any signs or change in condition to warrant contacting the physician. Unit Coordinator #1 attempted to contact Nurse #2 with no response on [DATE] at 9:30AM. Director of Health Services attempted to contact Nurse #2 on [DATE] at 5:52PM, and no response. Nurse #2 will not be allowed to work until re-educated on physician notification requirements. On [DATE], Resident #1 was moaning with pain at 1am and 5am. Nurse #2 administered [MEDICATION NAME] 0.25mL per Physician order. Nurse #2 recognized the previous shift documented [MEDICATION NAME] 5mL instead of 0.25mL. Nurse #2 did not have the ability to contact Nurse #1 to verify whether [MEDICATION NAME] 5mL documented on the Controlled Drug receipt form was administered to Resident #1 or not. Per Nurse #2, no signs or symptoms of distress noted during the night for Resident #1. Although Resident #1 died on [DATE], it is our assertion that the resident's death was a result of their terminal illness and not from the medication error approximately thirteen hours prior. Our assertion is based on the following facts; [MEDICATION NAME] Pharmacokinetics indicate: 30% of orally administered medication is typically absorbed Has a half-life of ,[DATE] hours Peak time of 60 minutes Duration of ,[DATE] hours The attending Physician was notified about this medication error on [DATE] at 3:30PM, this was done within 24 hours. At 11pm on [DATE] controlled drugs receipt for Resident #1 indicated the remaining quantity of [MEDICATION NAME] was 24.5mL. This amount matched the amount of [MEDICATION NAME] sulfate remaining in Resident #1's dispensed medication bottle. On [DATE] at approximately 9:00 am, during a controlled drug reconciliation for Resident #1, a discrepancy was noted on the Controlled Drug Receipt form by the facility Administrator. The control sheet indicated resident received 5ml of [MEDICATION NAME] sulfate instead of 0.25ml of [MEDICATION NAME] as ordered by the Physician. On [DATE] at approximately 3:00pm, Nurse #1, who administered the stated medication to Resident #1 was interviewed by the Administrator. She revealed that during the medication administration on the previous day, she noted medication order change for Resident #1. She verified the written order in resident's record and read it as 5ml instead of 5mg. The Administrator explained and demonstrated to Nurse #1 what was supposed to be administered compared to what she signed for on the Controlled Drug Receipt form. Nurse #1 acknowledged that an incorrect amount of [MEDICATION NAME] had been administered. Based on the interview conducted by the Administrator and the record review of all controlled medications administered by Nurse #1, it was concluded that this error resulted from an honest oversight. Nurse #1 misread the order, and misinterpreted [MEDICATION NAME] 5mg as [MEDICATION NAME] 5mL. Nurse #1 was re-educated and counseled by the Director of Health Services and the Administrator on ,[DATE]. Medication administration competency and [MEDICATION NAME] dosage calculation education was provided to Nurse #1 by the Director of Health Services on [DATE]. 100% audit of all active residents controlled medications was completed on [DATE] by Director of Health Services to identify any other resident with an order for [REDACTED]. No other written Controlled medication order were noted with any discrepancy. Effective [DATE], and moving forward, all liquid medication orders will be written with the specificity of the amount of liquid to be administered based on concentration; for example an order for [REDACTED]. All Licensed nurses and Medication aides were notified of this new process on [DATE] and [DATE] by an education conducted by the Director of Health Services (DHS), Quality Assurance Nurse and/or Staff Development Coordinator (SDC). Effective [DATE] any liquid medication ordered and written by the physician will be transcribed in resident Electronic Administration records to reflect the amount of liquid to be administered by licensed nurses on duty. Effective [DATE], Director of Health Services, Quality Assurance Nurse, Unit Coordinator and/or Staff Development Coordinator will review all new medication and treatment orders from prior day (M-F), by comparing new written telephone orders to orders transcribed in electronic health record to ensure accuracy. This process will be incorporated in the facility daily Clinical rounds. Any medication not transcribed correctly will be corrected promptly and findings reported to the Director of Health Services. Findings from this process will be maintained in the Daily Clinical round binder located in the Director of Health Services office. Effective [DATE], the center clinical interdisciplinary team, which includes Director of Health Services, Quality Assurance Nurse, Unit Coordinator and/or Staff Development Coordinator, initiated a process for reviewing all new admission/re-admissions Monday through Friday to ensure all ordered medication were transcribed appropriately and administered per physician orders. Any negative finding will be addressed promptly. Effective [DATE], the center's week end RN supervisor and/or designated licensed nurse will review all new admission/re-admissions by comparing new written telephone orders to orders transcribed in electronic health record to ensure accuracy every Saturday and Sunday to ensure all new ordered medication were transcribed appropriately and administered per physician orders. Any negative finding will be addressed promptly, and reported to the Director of Health Services. Director of Health Services (DHS), Quality Assurance Nurse and/or Staff Development Coordinator (SDC) will complete 100% education for all licensed nurses and medication aides, to include full time, part time and as needed staff, regarding medication administration per physician orders [REDACTED]. The emphasis of this education was on the liquid medication specifically [MEDICATION NAME] sulfate. This education will be completed by [DATE]. Any licensed nurse and/or Medication aide not educated by [DATE] will not be allowed to work until educated. This education will also be added on new hires orientation process for all new Licensed nurses and Medication aides effective [DATE], and will be provided annually. Effective [DATE], Director of Health Services, Quality Assurance Nurse, Unit Coordinator and/or Staff Development Coordinator will monitor compliance or medication order administration per physician orders, specifically, all [MEDICATION NAME]. Controlled Drug Receipts will be reviewed in clinical meeting, 5 times per week (Monday - Friday) for 2 weeks, then 3 time weekly for 2 more weeks, then weekly for 4 weeks then monthly x 3 months or until the pattern of compliance is maintained. Findings from this meeting will be documented on a daily clinical report form and filed in clinical meeting binder in Director of Nursing office after proper follow ups are done. Executive Director will review the completion of daily clinical report, and daily clinical checklist forms daily (M-F) for 2weeks, weekly x 2 more weeks, then monthly x 3 months or until the pattern of compliance is maintained. Effective [DATE], Director of Nursing will report findings of this monitoring process to the facility Quality Assurance and Performance Improvement Committee for any additional monitoring or modification of this plan monthly for 3 months, or until the pattern of compliance is maintained. The QAPI committee can modify this plan to ensure the facility removal of the alleged immediate jeopardy. Effective [DATE], the center Executive Director and the Director of Health services will be ultimately responsible to ensure implementation of credible allegation to remove this alleged immediate jeopardy. Validation of the credible allegation was done on [DATE] at 11:47 AM. The facility provided documentation that the administrator initiated an investigation as soon as she became aware of the medication error. The administrator interviewed Nurse #1 to determine how the error occurred and provided the nurse education on how to avoid future medication error. Interview with Nurse #1 validated that she did receive education and counselling from the administrator. A written statement was reviewed indicating that the administrator interviewed Nurse #2 on [DATE] at 4:30 pm. The statement indicated that the resident was showing signs and symptoms of pain and was not showing signs of distress. That was why Nurse #2 did not think that the 5 ml of [MEDICATION NAME] on the Controlled Drug Receipts was accurate. The facility has filled out a medication discrepancy report. The facility provided evidence of audits of medication orders and inservices provided to staff about medication error and physician notification. Staff were interviewed to validate that they received education on medication error and notifying the physician. Resident who received [MEDICATION NAME] were reviewed for medication error.