Every finding on record at Carver Living Center

Based on observations, record review and interviews with staff and the Medical Director, the facility failed to implement their infection control policies and procedures when Nurse #14 administered medications to Resident #112 through a gastrostomy tube (tube that enters through the abdominal wall into the stomach) and did not wear a gown and gloves and when Nurse #14 failed to wear gloves when handling Resident #75's glucometer after a finger stick with a blood sample on the test strip. The deficient practice occurred for 1 of 4 staff observed for infection control practices (Nurse #14). Findings included:1. The facility Enhanced Barrier Precautions policy dated August 2022 documented in part 3. Examples of high-contact resident care activities requiring the use of gown and gloves for enhanced barrier precautions include g. device care or use (central line, urinary catheter, feeding tube. On 5/11/26 at 10:00 am an observation and interview was completed of Nurse #14 when she checked placement and administered crushed medication into Resident #112's gastrostomy tube (feeding tube) without use of Personal Protective Equipment (PPE). There was signage on the resident's door for enhanced barrier precautions which instructed staff to wear a gown and gloves when accessing the gastrostomy tube and suprapubic catheter. There was PPE available just outside the resident's door. Nurse #14 stated, they are all like that the resident's doors have signage. Nurse #14 commented she was new to long-term care and this facility and she did not think it was necessary to have so many residents with enhanced barrier precautions.On 5/13/26 at 9:20 am the Director of Nursing was interviewed. The DON stated Nurse #14 had discussed with the DON the use of enhanced barrier precautions with PPE for gastrostomy tube access and medication administration for Resident #112. The DON stated Nurse #14 reported to the DON that she had not worn gloves when handling the glucometer with a test strip which had a blood sample and discarded the strip with a tissue. Nurse #14 had not mentioned the use of PPE for gastrostomy tube access. The DON indicated that enhanced barrier precaution signage was present on Resident #112's room door and PPE was available and required to be used to care for and access the gastrostomy tube. The DON stated that Nurse #14 was new to long term care and had received infection control education upon hire. On 5/13/2026 at 12:50 pm an interview was completed with the Medical Director. The Medical Director was informed that Nurse #14 failed to use PPE for enhanced barrier precautions. The Medical Director indicated gloves and enhanced barrier precautions were very important to prevent infection and were required. On 5/14/26 at 12:30 pm an interview was completed with the Infection Preventionist. The Infection Preventionist was informed of Nurse #14's failure to use PPE when accessing Resident #14's gastrostomy tube. The Infection Preventionist stated she would follow up with Nurse #14 and commented that she completed observations for staff's use of PPE regularly. The Infection Preventionist commented that all staff received infection control education, including use of PPE, upon hire and annually. 2. The facility Obtaining a Fingerstick Glucose Level policy dated October 2011 documented in part Equipment and Supplies: 7. Personal protective equipment (e.g. gowns, gloves, mask, etc. as needed). Steps in the Procedure: 5. Wear clean gloves. 11. Place a drop of blood on the strip. 12. Wipe the fingertip with a cotton ball to seal the puncture site. 13. If bleeding persists, apply a bandage. 15. Point the spring-loaded device down and away from the face and body and carefully remove the lancet. Dispose of the lancet in the sharps disposable container. 17. Discard disposable supplies in the designated containers. 18. Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice. 19. Remove gloves and discard into designated container. 20. Wash hands. On 5/11/26 at 12:30 pm Nurse #14 was observed to exit Resident #75's room holding Resident #75's glucometer with the test strip in place which had a blood sample with her right ungloved hand. Nurse #14 was not wearing any gloves, and she handled the glucometer after the finger stick with a test strip in place. Nurse #14 was observed to remove the test strip from the glucometer using an ungloved hand and tissue and placed the strip into the garbage. Nurse #14 walked to the medication cart with the glucometer in her hand and placed it on a piece of paper. Nurse #14 was interviewed at the medication cart and stated she was new to long term care, about 8 days. Nurse #14 stated all residents had their own glucometer with a plastic case to store on the medication cart. Nurse #14 confirmed she had not worn gloves to handle the glucometer with the test strip that had the blood sample and discarded the test strip using a tissue. Nurse #14 indicated she thought using a tissue was an appropriate barrier. On 5/13/26 at 9:20 am the Director of Nursing was interviewed. The DON stated Nurse #14 had discussed with the DON the use of gloves for handling the glucometer with a test strip that had a blood sample and discard of the strip for Resident #75 on 5/12/26. The DON stated Nurse #14 reported to the DON that she had not worn gloves when handling the glucometer with a test strip which had a blood sample and discarded the strip with a tissue. The DON stated that Nurse #14 was new to long term care and had received infection control education and use of PPE upon hire. On 5/14/26 at 12:30 pm an interview was completed with the Infection Preventionist. The Infection Preventionist was informed of Nurse #14's handling of a glucometer with a test strip which had a blood sample without gloves and discarding the strip with a tissue. The Infection Preventionist stated she would follow up with Nurse #14. The Infection Preventionist commented that all staff received infection control education, including obtaining a blood sample for the test strip and management of the resident's glucometer, upon hire and annually. On 5/13/2026 at 12:50 pm an interview was completed with the Medical Director. The Medical Director was informed that Nurse #14 failed to wear gloves to handle the glucometer with test strip with a blood sample. The Medical Director indicated gloves were very important to prevent infection and were required.

Based on observation, record review, and staff interviews, the facility failed to accommodate food preferences for 1 of 10 residents reviewed for food preferences (Resident #109).Findings included: Resident #109 was admitted on [DATE] with diagnosis that included hypertension.Record review of Physician orders dated 3/10/2026 revealed Resident #109 was prescribed a regular diet with thin liquids.Record review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #109 was cognitively intact. An observation of Resident #109's breakfast tray delivered to the room on 5/11/2026 at 9:30 AM identified bacon on the tray. Resident #109's dietary tray ticket revealed dislikes of pork, peppers, cheese, salt, and gravy. Observation of Resident #109's lunch tray delivered to the room on 5/13/2026 at 12:45 PM identified rice with gravy. Resident #109's dietary tray ticket revealed dislikes of pork, peppers, cheese, salt, and gravy. During an interview on 5/12/2026 at 9:14 AM, Resident #109 stated she received pork at meals several times in the past, although her tray ticket clearly identified her dislikes of pork, peppers, cheese, and gravy. Resident #109 stated she would eat what she could on tray and leave the disliked items on her tray. Resident #109 stated nurse aides would sometimes offer an alternate item when they picked up her tray, but not always. Resident #109 stated she had told several nurses and nurse aides that she does not eat pork or greasy food, but she still receives those items.On 5/13/2026 at 12:45 PM the Dining Room Supervisor and Dining Room Server were accompanied to Resident #109's room to observe the lunch tray that was served. The Dining Room Supervisor and Dining Room Server confirmed Resident #109's dislikes were listed on the tray ticket, and Resident #109's lunch tray contained rice with gravy. The Dining Room Supervisor obtained rice without gravy from the steam table for Resident #141 and stated the Dining Room Assistant should have read the tray cards to the Dining Room Server prior to plating the Resident's food.During an interview on 5/13/2026 at 12:50 PM, the Dining Room Assistant stated the Dining Room Assistants were supposed to read the residents' dislikes aloud to the Dining Room Server prior to plating each tray from the dining room steam table. The Dining Room Assistant stated Resident #141 dietary tray card identified the dislike of pork, peppers, cheese and gray. The Dining Room Assistant verified she had not read aloud the dislikes on Resident #141 tray card to the Dining Room Server on 5/13/2026.During an interview on 5/14/2026 at 10:00 AM, the Director of Nursing stated the Dietary Staff should verify the meal trays do not include a resident's dislike, and nurse aides delivering trays should verify tray cards and correct trays if dislikes were observed before the tray was delivered to the residents.

Based on observation, record review, and staff interviews, the facility failed to provide a dignified dining experience by ensuring all residents seated at the same table were served their meals at the same time for 1 of 2 sampled residents (Resident #141).Findings included:Resident # 141 admitted on [DATE] with diagnosis that included Alzheimer's disease, peripheral vascular disease, chronic kidney disease, and blindness in the right eye.Record review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #141 was cognitively intact, required set-up or clean-up assistance with eating, and ambulated independently with a walker.Record review of Resident #141's care plan initiated 3/25/2026 revealed he required set-up or clean-up assistance with meals and received a therapeutic diet of no added salt for hypertension.Record review of the meal consumption report revealed Resident #141 consumed 75-100% of meals.Continuous observation of the 400 Hall dining room on 5/11/2026 from 12:45 PM through 1:15 PM showed Resident #141 sitting at a table with one other resident. The Dining Room Attendant served the tablemate first and then proceeded to serve other residents. Resident #141 sat and watched the others receive and eat their meals. The dining attendant served all other residents in the dining room before going out of the dining room at 1:05 PM and returned with Resident #141's tray at 1:10 PM, after the tablemate had finished his meal. During an interview on 5/11/2026 at 1:30 PM, Resident #141 stated he was mad that he was the last one served and that he had to watch everyone else eat and his tablemate finish lunch before he received his meal.During an interview on 5/12/2026 at 1:10 PM, the Dining Room Attendant stated they normally served each table at the same time; however, they had run out of the alternate meal and had to obtain one from another dining room for Resident #141.During an interview on 5/13/2026 at 12:45 PM, the Dining Room Supervisor stated that all residents seated at the same table should be served at the same time.During an interview on 5/14/2026 at 10:00 AM, the Director Nursing stated all residents at the same table should have been served at the same time.During an interview on 5/14/2026 at 11:00 AM, the Administrator stated the Residents at the same table should have been served at the same time.

Based on observations, record reviews, and staff interviews, the facility failed to post an updated daily nurse staffing sheet for residents and visitors on 1 of 4 days during the survey period (5/11/26).Findings included:On 5/11/26 (Monday) at 9:35 AM, during the initial tour, the daily nurse staffing sheet posted near the facility's main entrance was dated 5/8/26 (Friday). The sheet had not been updated to reflect the current date, census, or staffing information.On 5/13/26 at 11:10 AM, during an interview, the Scheduler indicated that she prepared the daily nurse staffing sheets on Fridays and placed them in a folder at the nurses' station for weekend staff to update and post. She noted that she was not on duty on 5/9/26 or 5/10/26 (weekend) and had not realized on the morning of 5/11/26 that the posted sheet still reflected the date of 5/8/26.On 5/13/26 at 11:40 AM, during a phone interview, Nurse #8, indicated that she worked as weekend supervisor the night shift on 5/10/26 and was responsible for updating and posting the staffing sheet. She reported that she updated the sheet on the morning of 5/11/26 but became busy with resident care and did not post it near the main entrance.On 5/13/26 at 12:10 PM, during an interview, the Director of Nursing (DON) indicated that the Scheduler was responsible for completing the daily nurse staffing sheet and posting it on weekdays, while the weekend nurse supervisor was responsible for posting it on weekends. The DON acknowledged that the sheet was not updated on 5/11/26 because the weekend nurse supervisor became busy that morning.

Based on record reviews, observations, and interviews with staff and the Medical Director, the facility staff failed to utilize a resident's assigned blood glucose meter (glucometer) and instead used a loose, unassigned, and unlabeled glucometer located in the medication cart to check Resident #8's blood glucose (sugar) level. In addition, the staff member did not disinfect the glucometer before or after obtaining Resident #8's blood glucose level and would have had no way to know if another staff member had previously disinfected the loose, unassigned, and unlabeled glucometer. This occurred while there were 11 residents identified with a known bloodborne pathogen in the facility with 4 of the 11 residents requiring blood glucose levels. Loose, unlabeled glucometers can be contaminated with blood and must be disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA)-registered disinfectant in accordance with the manufacturer of the glucometer has the high likelihood to expose residents to the spread of bloodborne infections. Care must also be taken by personnel handling and storing glucometers to protect the glucometers against cross-contamination via contact with other meters or equipment. The deficient practice occurred for 1 of 3 residents observed to have his blood glucose (sugar) level checked (Resident #8). Immediate jeopardy began on 5/15/25 when Nurse #1 was observed to perform blood glucose testing for Resident #8 using a loose, unlabeled, unassigned glucometer without disinfecting the glucometer. Immediate jeopardy was removed on 5/16/25 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) for the facility to complete agency and employee staff training with monitoring to ensure appropriate interventions are put into place. Findings included: The facility's policy and procedure titled Obtaining a Fingerstick Glucose Level that did not contain a date read under the title Steps in the Procedure always ensure the blood glucose meter intended for reuse is clean and disinfected between resident use following the manufacturers instructions and the current infection control standards of practice. The manufacturer instructions for cleaning and disinfecting the (Brand Name) glucometer used at the facility were summarized in a Technical Brief (Revised 9/24). The Technical Brief read in part, To minimize the risk of transmitting bloodborne pathogens, the cleaning and disinfecting procedures should be performed as recommended in the instructions below. The (Brand Name) meter may only be used for testing multiple patients when standard precautions and the manufacturer's disinfecting procedures are followed. The meter should be cleaned and disinfected after use on each patient. The cleaning procedure is needed to clean dirt, blood and other bodily fluids off the exterior of the meter before performing the disinfecting procedure. The disinfecting procedure is needed to prevent the transmission of bloodborne pathogens .Clean and disinfect the meter following step-by-step instructions in the Quality Assurance (QA) / Quality Control (QC) Reference Manual. Cleaning and Disinfecting Procedures specified in the glucometer's QA/QC Reference Manual (Revised 10/24) included, in part: --Cleaning: Step 1 (of 7): Wear appropriate protective gear such as disposable gloves. Step 3 (of 7): Wipe the surface of the meter to clean blood and other body fluids . Step 4 (of 7): If blood is visible on the meter, it should be cleaned prior to each disinfection step. --Disinfecting: Step 5 (of 7): Pull out 1 new towelette and wipe the entire surface of the meter horizontally and vertically to remove bloodborne pathogens. Carefully wipe around the test strip port by inverting the meter so that the test strip port is facing down. Step 6 (of 7): Treated surface must remain wet for recommended contact time. Please refer to wipe manufacturer's instructions. The manufacturer's Technical Brief for the glucometer listed the disinfectant wipes used at the facility as one of the EPA-registered wipes recommended to clean and disinfect the (Brand Name) glucometer. The instructions on the label of the disinfectant wipes read in part: To clean and disinfect and deodorize hard, nonporous surfaces: Wipe surface to be disinfected. Use enough wipes to treat surface to remain visibly wet to the contact time listed. Let Dry. Special instructions for cleaning and decontamination against human immunodeficiency virus (HIV), hepatitis B and hepatitis C indicated, Allow surfaces to remain wet for one minute, let air dry. For all other organisms, see directions for contact time. The Director of Nursing provided education for Nurse #1. The education was dated 2/4/25 with a return competency completed on 2/5/25. The education titled glucometer testing included how to store, disinfect before and after each use, and using the resident's designated glucometer. A continuous observation from 5:10am to 5:25am occurred on 5/15/25 in the 100 Hall hallway. The observation revealed Nurse #1 walking away from her medication cart (lower 100-hall medication cart) with a glucometer in her hand. Nurse #1 entered Resident #8's room, stood on the left side of the bed, lifted the cover exposing Resident #8's left hand, the nurse wiped one finger on Resident #8's hand with an alcohol pad, used a lancet device to prick Resident #8's finger, and then held the glucometer (with the test strip already in the machine) to the resident's finger obtaining his blood sugar. Nurse #1 was observed to walk out of the resident's room, place the used lancet into the secure needle container, throw her gloves into the trash receptacle, and place the glucometer on top of the medication cart. The glucometer was observed to not have any label. At 5:15am, Nurse #1 was observed to place the glucometer in the top drawer of the medication cart without disinfecting it. Nurse #1 was observed for another 10 minutes with no other residents receiving blood sugar checks. Nurse #1 an agency nurse who worked the 7:00pm to 7:00am shift was interviewed on 5/15/25 at 5:25am. Nurse #1 discussed every resident having their own glucometers that were kept in the top drawer of the medication cart in a plastic container. Nurse #1 opened the top drawer of her medication cart and there was an individual plastic container labeled with each resident's name. There was also a loose unlabeled glucometer in one of the compartments on the left side of the drawer. Nurse #1 confirmed she had just obtained a blood sugar from Resident #8 with the loose unlabeled glucometer that was on the left side of the drawer. Nurse #1 showed the surveyor that Resident #8 had his own glucometer. She stated she had obtained the loose unlabeled glucometer from the bottom drawer of the medication cart. Nurse #1 explained she did not know why she had not used Resident #8's dedicated glucometer I don't know, I just saw this one and used it. She discussed not knowing if the glucometer was disinfected before she used it and stated she had not disinfected it herself prior to obtaining Resident #8's blood sugar. Nurse #1 also confirmed she had placed the glucometer back into the top drawer of the medication cart in the left compartment without disinfecting it. The nurse explained she did not disinfect it because she was going to take it to the nursing station to throw it away. She explained she was going to throw it away because Resident #8 already had his own. Nurse #1 stated she had received education on the proper care/disinfecting glucometers before and after use but said I'm agency. I don't work here all the time. She confirmed there was no visual cues on the medication cart to help her remember how/when to disinfect the glucometers and stated, I have never seen anything on the cart. Upon request, the facility provided a Diagnosis Report for its current residents (dated 5/15/25 at 9:42am). The Diagnosis Report indicated 11 residents were identified as having at least one bloodborne pathogen, which included hepatitis C and HIV. Upon review of the 11 residents, it was discovered that 4 of the residents required blood sugar monitoring with one (1) of the 4 residing on hall-100. The Quality Assurance Nurse/Infection Preventionist was interviewed on 5/15/25 at 8:33am. The Nurse explained that she was responsible for having staff sign an acknowledgement form on the computer that staff would adhere to all the facility's rules, expectations, and procedures. She stated the Unit Managers were responsible for any specific training for the nurses/staff. The Quality Assurance Nurse/Infection Preventionist confirmed Nurse #1 had signed the acknowledgement form. Observation of the lower 100-hall medication cart with Nurse #6 occurred on 5/15/25 at 9:43am. A loose unlabeled glucometer was observed in the bottom drawer of the medication cart in a small white basket. The observation also revealed there were EPA wipes present in the bottom drawer, but there was no visual cue cards present on the medication cart for disinfecting the glucometers. Nurse #6 was interviewed on 5/15/25 at 9:44am. Nurse #6 explained he worked the 7:00am to 7:00pm shift. The nurse confirmed there was a non-labeled loose glucometer in the bottom drawer of his medication cart. He explained the glucometer was for emergencies only and used only on non-diabetics. Nurse #6 discussed not knowing if the glucometer had been disinfected but stated, it should be cleaned before using. He was unable to answer how long it took to clean the glucometer. He stated he had never had to use the loose unlabeled glucometer. Nurse #6 stated he had received education on storing/disinfecting glucometers and stated he thought it was in February 2025. Nurse #6 confirmed there was no visual cues on the medication cart to help him remember how/when to disinfect a glucometer and said he did not remember ever seeing a visual cue on the medication cart. A telephone interview occurred with the Medical Director on 5/15/25 at 10:21am. The Medical Director discussed being aware of staff not disinfecting glucometers a few months ago but nothing recently. She stated the concern of not disinfecting glucometers before and after use was the spread of diseases. The Medical Director explained she expected staff to follow infection control practices when using glucometers. The Director of Nursing (DON) was interviewed on 5/15/25 at 11:31am. The DON explained during the facility's last annual survey in February 2025 there had been an issue with staff not disinfecting shared glucometers before and after use between residents. She stated when that occurred the facility began monitoring/auditing glucometer use to ensure staff were disinfecting as required, placed visual cue cards on the medication carts to help staff remember the steps in disinfecting the glucometers, and provided education to all the staff including agency staff. The DON also stated the facility purchased plastic cases and assigned each resident their own glucometer. The DON discussed the facility was continuing to do monitoring and audits of the medication carts for visual cue cards and ensuring each resident had their own glucometer. She stated this was being done by the Unit Managers and/or the Quality Assurance Nurse. She explained that no medication cart should have a loose unlabeled glucometer and was unaware there had been one on the lower 100-hall medication cart. The DON also stated she was not aware the visual cue cards were no longer present on the medication carts. She stated all staff including agency staff had been educated on glucometer use back in March 2025 and could not speak to why Nurse #1 had used a loose glucometer and not disinfected it. The DON stated Nurse #1 should have used Resident #8's designated glucometer and thrown away the loose unlabeled glucometer. The DON explained the loose unlabeled glucometer could be thrown away because if a staff member needed a new one, there were new ones located in the medication room. During an interview with the Administrator on 5/15/25 at 2:00pm, the Administrator explained during the facility's last annual survey in February 2025 there had been an issue with staff not disinfecting shared glucometers before and after use between residents. He explained right after the February survey, the facility purchased plastic containers and more glucometers so each resident could have their own designated glucometer, the facility began monitoring/auditing, and education was provided. The Administrator discussed the on-going monitoring and audits related to glucometer use. He also discussed the education that was completed and included agency staff. The Administrator stated this was an unforeseeable action and could not comment on what he thought caused Nurse #1 to not disinfect a glucometer. The facility's Administrator was informed of the immediate jeopardy (IJ) on 5/15/25 at 2:30pm. The facility provided the following plan for IJ removal: 1. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: On May 15, 2025, it was observed that a facility staff member (an agency nurse) used an unlabeled glucometer (blood glucose meter) on Resident #8 without disinfecting the glucometer before or after use. The Director of Nursing (DON) promptly called and left a voicemail with the Responsible Party (RP) for Resident #8 regarding this incident. Upon interview, the nurse stated she did not use that particular unlabeled glucometer for any other residents. The glucometer used was not a shared facility glucometer designated for multiple residents; rather, it was an unlabeled glucometer discovered in the medication cart. The nurse acknowledged her awareness that Resident #8 had an individually assigned, labeled, and properly stored glucometer present in the medication cart. She indicated she used the unlabeled glucometer because she was nervous about being observed by the surveyor. This agency nurse had received training on February 5, 2025, as part of a previous Directed Plan of Correction (DPOC). She stated she failed to disinfect the glucometer involved in the May 15, 2025, incident due to being nervous while under observation by the surveyor. The nurse's failure to use the individually assigned glucometer for Resident #8 and her failure to disinfect the unassigned glucometer before and after use are significant deviations from established infection control procedures. The facility's system mandates individually assigned glucometers for each resident requiring blood glucose monitoring. These glucometers are labeled with the resident's name, and each resident's glucometer is stored in an individual plastic container on the medication cart. The system failed in this instance because the unlabeled glucometer should not have been present in the medication cart, making it available for potential use, and the trained staff member failed to adhere to established procedures regarding use of resident-specific glucometer and proper disinfection. A review of resident records who were receiving blood glucose monitoring through the use of glucometers was conducted by the Minimum Data Set (MDS) Nurse on the morning of May 15, 2025. The review identified there were at least four residents currently residing in the facility, and having their blood glucose monitored with a glucometer, who had been diagnosed with one or more bloodborne pathogens. Failure to clean and disinfect shared or improperly maintained medical equipment, such as glucometers, according to manufacturer's instructions and with a disinfectant registered with the national environmental protection agency (EPA), created a significant risk of cross-contamination and exposure to bloodborne pathogens. Shared or improperly cleaned blood glucose meters can become contaminated with blood and bodily fluids. This practice potentially exposes any resident undergoing blood glucose monitoring with a shared, improperly disinfected device to the spread of bloodborne pathogens. Resident #8, and any other resident who the facility might have determined (though none were identified) to have had their blood glucose tested using an unassigned and improperly disinfected glucometer, are considered likely to suffer a serious adverse outcome (e.g., transmission of bloodborne pathogens) as a result of this noncompliance. An immediate audit was initiated on May 15, 2025, by the Director of Nursing (DON) to identify all residents requiring blood glucose monitoring and to ensure each had an individually assigned and properly labeled glucometer. This audit confirmed all residents requiring blood glucose monitoring had an individually assigned and properly labeled glucometer, and no other issues were identified. Immediate Actions Taken for Affected and At-Risk Residents (Completed: May 15, 2025): A series of immediate actions were completed on May 15, 2025, for affected and at-risk residents. Firstly, the medical provider for Resident #8 was notified of the potential exposure on May 15, 2025, by the DON. Secondly, the one unlabeled glucometer identified was immediately removed from the medication cart and discarded on May 15, 2025, by the DON, ensuring no further use was possible. Thirdly, an immediate inventory check was completed on May 15, 2025, by the DON and nursing leadership (Assistant Director of Nursing (ADON), Quality Assurance (QA) Nurse, Unit Managers), which confirmed that sufficient individually assigned, and resident-labeled, glucometers, and appropriate EPA-registered disinfectant wipes were available for all residents requiring blood glucose monitoring. Reporting (Completed: May 15, 2025): This infection control breach and the potential for exposure to bloodborne pathogens were reported to the local health department on May 15, 2025, by the Director of Nursing (DON). The health department recommendations included testing for Human Immunodeficiency Virus (HIV), Hepatitis B, and Hepatitis C for any potentially exposed residents. Action Taken on Health Department Recommendations (Completed: May 15, 2025): In response to health department recommendations, several actions were completed on May 15, 2025. Orders for baseline testing for HIV, Hepatitis B, and Hepatitis C were obtained from the medical provider for Resident #8. Subsequently, specimens for these ordered tests for Resident #8 were ordered on May 15, 2025, and collected on May 16, 2025, as per facility policy and state regulations. Any follow-up on results and further medical intervention for Resident #8 will be managed by their attending physician and documented in their medical record. The facility acknowledges this is a repeat Immediate Jeopardy (IJ) citation. A previous Directed Plan of Correction (DPOC) had been implemented. This DPOC included comprehensive training for all nursing staff, including the involved agency nurse on February 5, 2025, covering infection control practices for glucometer use. This training emphasized principles from established guidelines (e.g., statewide infection control and epidemiology guidelines (SPICE)), such as the use of single-use, auto-disabling disposable lancets; proper hand hygiene; individual assignment of glucometers; and correct disinfection of devices using EPA-registered wipes with appropriate contact time (noting alcohol pads are for skin preparation only and unsuitable for device disinfection). A thorough root cause analysis was conducted by the Administrator, Director of Nursing (DON), Regional Director of Operations, and Regional Nurse Consultant following the May 15, 2025, incident. The recurrence of the deficient practice was determined to be due to a combination of factors. Firstly, a System Failure in Glucometer Control occurred, as an unauthorized, unlabeled glucometer was present on a medication cart, indicating a weakness in previous inventory control processes. Secondly, Individual Staff Performance under Stress was a factor, wherein the individual agency staff member, despite prior training and knowledge of correct procedure (and the availability of the resident's assigned glucometer), failed to adhere to established and previously trained procedures when under the perceived pressure of surveyor observation. Thirdly, there was a lapse in Environmental Reinforcement, as visual aids related to glucometer procedures were not replaced by pharmacy staff after a medication cart upgrade, potentially weakening environmental reinforcement of correct procedures (though the nurse involved did not state this as a factor for her specific actions). The employment of the agency nurse involved in the incident was terminated by the Director of Nursing (DON) on May 15, 2025. No other staff members have been identified as committing the same deficient practice. 2. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: The following systemic changes were implemented to immediately alter the deficient practice, prevent recurrence, and ensure ongoing compliance, thereby removing the immediate jeopardy. All actions listed below were completed by the end of day on May 15, 2025, unless otherwise specified. System for Glucometer Control, Assignment, and Policy To strengthen the system for glucometer control, assignment, and policy, several actions were completed by May 15, 2025. Firstly, the facility's Glucometer Procedure: Use, Cleaning, and Infection Control was reviewed and updated. This procedure now reflects all current corrective actions, emphasizing the critical importance of using only individually assigned, labeled glucometers and adherence to new surveillance. Following this, all licensed nursing personnel acknowledged receipt and understanding of this updated policy and its implications for daily practice. This was presented by the DON and nursing leadership (ADON, QA Nurse, Unit Managers). Secondly, an initial system-wide glucometer audit was performed. A comprehensive audit was conducted by the DON and nursing leadership (ADON, QA Nurse, Unit Managers), ensuring every resident requiring blood glucose monitoring had an individually assigned, correctly labeled glucometer, stored in its designated clean, individual, hard container within the medication cart. As noted, this audit found no deficiencies. All unauthorized/unlabeled glucometers (the single one identified) were removed from circulation and discarded by the DON and nursing leadership. Thirdly, a strict protocol for the introduction of new or replacement glucometers became effective May 15, 2025. The Director of Nursing (DON), or Nursing Leadership (ADON, QA Nurse, Unit Manager) in the DON's absence, is responsible for obtaining new glucometers for the facility. The Administrator notified and trained the DON on this new process on May 15, 2025. All new glucometers will be delivered directly to DON's office. The glucometers will then be labeled for a specific resident and distributed by the DON or Nursing Leadership (ADON, QA Nurse, Unit Manager) in her absence, before being placed into service on any medication cart. New glucometers not yet in use (unassigned) will be stored exclusively in the DON's office. No unassigned or unlabeled stock glucometers will be permitted to be stored on medication carts or in general nursing units outside of the DON office's control. For new admissions requiring a glucometer after hours or on weekends, the assigned nurse will notify the Unit Manager or other member of the nursing leadership team (ADON, QA Nurse), who will obtain the glucometer from the DON's office. In an emergency after hours, if a current resident suddenly requires a glucometer, the DON's office has an access code (communicated to nursing leadership: ADON, QA Nurse, Unit Managers, and Administrator); the nurse would notify the nursing manager on duty, who will obtain the glucometer from the DON office. Unused glucometers for discharged residents will be removed from the medication cart by the Unit Manager within 24 hours during routine audits and discarded. On May 15, 2025, the Administrator in-serviced the Central Supply Clerk regarding the new protocol, specifically that all glucometers were to be delivered to the DON office upon receipt at the facility. The DON and the nursing leadership team (ADON, QA Nurse, Unit Managers) were also included in this in-service and communication regarding the new glucometer control protocol. System for Maintaining Visual Aids and Equipment Management Effective May 15, 2025, laminated visual reminders outlining critical steps from the Glucometer Procedure: Use, Cleaning, and Infection Control policy, including disinfection steps, were reviewed and confirmed to be accurately placed on all medication carts and in medication rooms by the DON and nursing leadership. Furthermore, the facility's equipment management protocol has been updated. Following any medication cart modification, replacement, or significant repair that may impact visual aids, the Director of Nursing (DON) or Nursing Leadership (ADON, QA Nurse, Unit Manager) in her absence, is responsible for ensuring all necessary signage and visual aids, including the 'Glucometer Procedure: Use, Cleaning, and Infection Control' reminder cards, are promptly verified as present and correctly reinstalled before the medication cart is returned to service. The Administrator trained the Director of Nursing on this updated process. This ensures direct oversight by nursing leadership for this critical component. Education and Competency Validation All actions regarding education and competency validation were completed on May 15, 2025. Medication aides do not perform blood sugar checks and therefore are not included in this specific glucometer competency training. Immediate In-service Training was conducted for all licensed nursing staff (including agency nurses) on May 15, 2025. This training was conducted by the Director of Nursing (DON) and Administrative Nurses (DON, ADON, Unit Managers). The training covered the facility's comprehensive Glucometer Procedure: Use, Cleaning, and Infection Control policy, which includes the new protocol detailed in this plan of correction, covering several key areas. Emphasis was placed on the critical importance of adhering to infection control principles. The facility's policy on blood glucose monitoring was reviewed, stressing the use of individually assigned glucometers for each resident, stored in an individually labeled, hard storage container, and the strict prohibition of using unlabeled or shared glucometers. The process for gathering equipment and supplies was detailed, ensuring gloves, glucometer, alcohol pads, gauze pads, single-use, auto-disabling, disposable lancet, blood glucose testing strips, approved disinfecting wipes, and paper towels/tissues are available. Hand hygiene procedures were reinforced: performing hand hygiene before entering the resident's room, before handling supplies, after removing gloves, and after cleaning is complete. The resident-interaction portion of the training on May 15, 2025, conducted by the Director of Nursing (DON) and Administrative Nurses (ADON, Unit Managers) for all licensed nursing staff (including agency nurses), covered protocols for explaining the blood glucose monitoring procedure to the residents and ensuring their privacy was maintained throughout the process. The procedure for obtaining the capillary blood sample according to facility policy and manufacturer guidelines, including donning gloves, was reviewed. The critical steps for cleaning and disinfection of the glucometer were explicitly detailed: retrieving two approved disinfecting wipes (noting alcohol pads are for skin preparation only and not suitable for device disinfection, per SPICE guidelines and manufacturer instructions for EPA-registered disinfectant wipes); using the first wipe to clean the glucometer, removing any visible blood, dirt, or contaminants; using the second wipe to disinfect, ensuring the surface remains wet for at least 3 minutes (or per the disinfectant's contact time instructions); and allowing the glucometer to air dry completely. Regarding storage and labeling, the training reiterated the prohibition of using unlabeled or extra glucometers found in medication carts. As part of the comprehensive Glucometer Procedure: Use, Cleaning, and Infection Control in-service training on May 15, 2025, conducted by the Director of Nursing (DON) and Administrative Nurses (ADON, Unit Managers) for all licensed nursing staff (including agency nurses), staff were explicitly educated on this prohibition. The training included the updated procedure to follow if a resident does not have a labeled glucometer: nursing staff are to immediately notify nursing leadership (DON, ADON, QA Nurse, Unit Manager) to retrieve a new, properly labeled glucometer and approved storage container from DON's office before any use. Instructions were provided for placing glucometers on a clean, dry paper towel or tissue if set on a bedside table or medication cart, and proper storage and handling of all associated supplies were reviewed. Finally, the risks associated with noncompliance, including the potential for transmission of bloodborne pathogens, were thoroughly discussed. All staff were required to sign an acknowledgement form confirming receipt and understanding of this training. Competency Validation was completed for all licensed nursing staff (including agency nurses) through direct observational competency validation for blood glucose monitoring on May 15, 2025. This validation, conducted by the DON or other qualified nursing leadership (ADON, Unit Managers), ensured adherence to all steps outlined in the Glucometer Procedure: Use, Cleaning, and Infection Control training. This included correct identification and use of the resident's individually assigned glucometer and labeled hard storage container; correct procedure for cleaning and disinfecting the glucometer (two-wipe method, 3-minute contact time, air dry); proper hand hygiene at all required steps; and correct disposal of used lancets, test strips, and wipes. Ongoing Training requirements were established on May 15, 2025. This comprehensive education and competency validation will be incorporated into the orientation program for all new nursing hires and agency staff prior to them performing any resident care assignments independently. Annual competency refreshers will also be conducted. This training will be conducted by the DON or Nursing Leadership (ADON, QA Nurse, Unit Manager) in her absence, or the Staff Development Coordinator. A Tracking System was implemented. As of May 15, 2025, the DON, ADON, and scheduler were assigned responsibility for maintaining records of all completed training, signed acknowledgement forms, and competency validations. They are responsible for ensuring all nursing staff have completed the required training and demonstrated competency before they are assigned to resident care duties involving blood glucose monitoring. Ongoing Supervisory Support and Procedural Adherence Commencing May 15, 2025, and on an ongoing basis, the facility is committed to a comprehensive plan of direct supervisory support and surveillance of licensed nurses, including agency nurses, to ensure continued adherence to the correct blood glucose monitoring procedures. This will involve active engagement with all nursing staff performing this procedure, across all shifts (day, evening, night, and weekends). These supportive surveillance activities will be conducted by Nursing Leadership (DON, ADON, Unit Managers, Regional Nurse Consultant), ensuring a visible leadership presence and resource availability. This initiative focuses on creating supervisory moments through on-the-spot observation and evaluation of staff performance during act [TRUNCATED]

Based on observation and staff interviews, the facility failed to secure residents' medications in a locked medication cart for 2 of 5 (upper and lower carts on hall 100) medication carts reviewed. Findings included: a. A continuous observation of the upper 100-hall medication cart occurred on 5/15/25 at 5:15am. The medication cart was in the hallway unattended and was observed to have a resident's insulin pen sitting on top of the cart, the cart was unlocked, and the bottom drawer of the medication cart was open. The medication cart was observed for 3 minutes and during that time 2 Nursing Assistants walked past the cart. Nurse #5 was interviewed on 5/15/25 at 5:18am. Nurse #5 confirmed she was the nurse responsible for the upper 100-hall medication cart. The nurse immediately stated she knew what was wrong and said, I should have put the medication away, closed the drawer and locked my cart. Nurse #5 explained she did not think about completing the tasks before leaving the cart to provide medication to a resident. b. A continuous observation of the lower 100-hall medication cart occurred on 5/15/25 at 5:20am. The observation revealed the cart was unlocked. The medication cart was observed for 3 minutes and during that time 2 Nursing Assistants had walked past the cart. Nurse #1 was interviewed on 5/15/25 at 5:23am. Nurse #1 confirmed she was the nurse responsible for the lower 100-hall medication cart. The nurse explained she was an agency nurse but was aware she should have locked her medication cart prior to walking away. Nurse #1 stated, I just didn't think about it. The Director of Nursing (DON) was interviewed on 5/15/25 at 6:38am. The DON explained that the Quality Assurance Nurse was responsible for the education but stated she was not sure what education was provided. She further explained that each shift had a shift supervisor who was responsible for ensuring staff were following facility rules. The DON stated she did not know why Nurse #5 and Nurse #1 left their medication carts unlocked. During an interview with the Quality Assurance Nurse on 5/15/25 at 8:33am, the Quality Assurance Nurse explained that the Unit Managers were responsible for educating staff on their specific job assignments. The Quality Assurance Nurse stated she did not know what education was provided to the employee by the Unit Managers. The Administrator was interviewed on 5/15/25 at 1:43pm. The Administrator discussed staff needing to take responsibility for their actions and in keeping the residents safe. He stated he could not say why Nurse #5 and Nurse #1 had left their medication carts unlocked.

Based on record review, and staff and family interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident's active diagnosis of peripheral vascular disease (PVD) for 1 of 8 residents whose Minimum Data Set was reviewed (Resident #1). The findings included: Resident #1 was admitted on [DATE] with a diagnosis of diabetes mellitus, dementia, contractures of the right knee, left wrist, left hip, and left knee, protein malnutrition, and hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) affecting the left side of the body. Review of a Podiatry Consult note dated 1/30/2025 revealed Resident #1 was given a new diagnosis of PVD. An interview was conducted with the Podiatrist on 5/20/2025 at 10:45AM. The Podiatrist stated that Resident #1 presented physically with signs and symptoms of PVD based on a clinical assessment. The Podiatrist further stated during the visit on 1/30/2025 Resident #1 had no pedal pulses in both feet, capillary fill time (the time it takes for blood to flow to a specific area after pressure is released) was +3 seconds (normal time is less than 2 seconds) bilaterally, staining of the skin, thickening of nails, and all signs and symptoms of PVD. The quarterly Minimum Date Set (MDS) assessment dated [DATE] indicated Resident #1 was severely cognitively impaired. The MDS did not indicate Resident #1 was diagnosed with PVD. An interview was conducted with the Social Service Coordinator on 5/20/2025 at 10:06AM. The interview indicated that the Social Service Coordinator received the written consultations and if there was an order from the consultation, the order was given to the Unit Manager. The Social Service Coordinator discussed that once she received the consultation, she would give the consultation to medical records who would then upload the consultation into the electronic health care system. The Social Service Director was not able to confirm if any new diagnosis for Resident #1 from his podiatry visit was added to the MDS as an active diagnosis but stated the MDS nurses have access to the consultations. A telephone interview with MDS Nurse #2 and MDS Nurse #1 on 5/20/2025 at 11:26AM revealed they were both unaware of the diagnosis of PVD for Resident #1. The MDS Nurses reviewed the quarterly MDS dated [DATE] and the diagnosis of PVD was not marked for Resident #1. During the interview with MDS Nurse #2 and MDS Nurse #1, they stated that for a diagnosis to be coded on the MDS it must be active in the last 60 days and there needed to be treatment for the diagnosis. MDS Nurse #2 stated that she spoke with her Regional MDS consultant and who felt that not coding the 4/11/2025 quarterly MDS with a diagnosis of PVD was accurate. MDS Nurse #2 and MDS Nurse #1 explained they reviewed the residents' medical records, including consultations for any new information.

Based on record review, staff, and resident interviews, the facility failed to implement their grievance policy and procedures when Resident #2 reported his catheters and wheelchair charger were missing for 1 of 3 residents reviewed for grievances (Resident #2). Findings included: The facility's policy titled Grievances/Complaints, Filing which was not dated read in part Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff. The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the residents and/or representatives. Upon receipt of a grievance and/or complaint, the Grievance Officer will review and investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint Resident #2 was admitted to the facility on [DATE] with diagnoses of heart failure and paraplegia (paralysis that can affect all or part of the trunk and legs). The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #2 was cognitively intact and was documented as having an electric wheelchair. Resident #2 was interviewed on 5/14/25 at 10:18am. The resident discussed he had a box of self-Cath catheters in his room and stated while he was sleeping someone came in and took them. Resident #2 also discussed someone taking his electric wheelchair charger. The resident explained that this happened about 2 weeks ago and that he informed the Director of Nursing (DON) and the Administrator immediately. Resident #2 voiced being upset because he had not heard of any resolution and he still did not have his self-Cath catheters or his electric wheelchair charger. During an interview with Unit Manager #1 on 5/15/25 at 1:00pm, the Unit Manager discussed Resident #2 had informed her about 2 weeks ago that his self-Cath catheters were missing along with his charger for his electric wheelchair. She explained that she immediately told the Social Worker and the Administrator but had not filled out a grievance form. The Unit Manager stated she had attempted to find the items herself but was unable to locate them. The Social Worker (SW) was interviewed on 5/15/25 at 1:21pm. The SW confirmed Resident #2 was on her case load. She stated about 2 weeks ago she was informed by Unit Manager #1 that Resident #2 self-Cath catheters were missing but was also told that nursing was ordering him new ones, so she did not fill out grievance or follow up. The SW discussed not learning about the charger for Resident #2 electric wheelchair until today. She stated she could not recall Unit Manager #1 telling her 2 weeks ago and that she learned about the charger from the resident today. The SW stated she did fill out a grievance today for the catheters and the charger. She explained that anyone can file a grievance. During an interview with the Administrator on 5/15/25 at 1:35pm, the Administrator stated he had not heard about Resident #2 missing items 2 weeks ago. He explained Resident #2 had told him about his missing self-Cath catheter and his charger for his wheelchair on 5/9/25. The Administrator stated he did not think every concern needed to have a grievance filed but confirmed that concerns/grievances needed to be resolved within 5 days. He stated he ordered Resident #2's self-Cath catheter's today, and that staff are continuing to look for the charger. He stated the resolution for the charger was not yet determined. The Administrator stated he would have expected a grievance to be filed once the items had not been found and stated that 2 weeks was too long to go without a resolution.

Based on observation and staff interviews, the facility failed to protect residents' healthcare information by leaving confidential medication information unattended, visible, and accessible to others on the computer screen for 2 of 5 (upper and lower medication carts on the 100-hall) medication carts observed. Findings included: A continuous observation of the upper 100-hall medication cart occurred on 5/15/25 at 5:15am. The medication cart was in the hallway unattended, and it was observed to have the computer screen showing resident information such as resident name, resident diagnosis, medications, date of birth, and room number. The medication cart was observed for 3 minutes and during that time 2 Nursing Assistants walked past the cart. Nurse #5 was interviewed on 5/15/25 at 5:18am. Nurse #5 confirmed she was the nurse responsible for the upper 100-hall medication cart. The nurse immediately stated she knew what was wrong and said, I should have put the privacy screen up on the computer. Nurse #5 explained she did not think about completing the task before leaving the cart to provide medication to a resident. A continuous observation of the lower 100-hall medication cart occurred on 5/15/25 at 5:20am. The observation revealed the computer screen showed resident information such as resident name, resident diagnosis, medications, date of birth, and room number. The medication cart was observed for 3 minutes and during that time 2 Nursing Assistants had walked past the cart. Nurse #1 was interviewed on 5/15/25 at 5:23am. Nurse #1 confirmed she was the nurse responsible for the lower 100-hall medication cart. The nurse explained she was an agency nurse but was aware she should have placed the computer screen on the privacy screen prior to walking away. Nurse #1 stated, I just didn't think about it. The Director of Nursing (DON) was interviewed on 5/15/25 at 6:38am. The DON explained that the Quality Assurance Nurse was responsible for the education but stated she was not sure what education was provided. She further explained that each shift had a shift supervisor who was responsible for ensuring staff were following facility rules. The DON stated she did not know why Nurse #5 and Nurse #1 left their computer screens open to resident information. During an interview with the Quality Assurance Nurse on 5/15/25 at 8:33am, the Quality Assurance Nurse explained that the Unit Managers were responsible for education staff on their specific job assignments. The Administrator was interviewed on 5/15/25 at 1:43pm. The Administrator discussed staff needing to take responsibility for their actions and in keeping the residents safe. He stated he could not say why Nurse #5 and Nurse #1 had left their computer screens showing resident information.

Based on record review, and staff and Responsible Party (RP) interviews, the facility failed to notify the Responsible Party (RP) of Resident #1's change in condition after a new diagnosis of peripheral vascular disease (PVD) with the lack of pedal pulses in both feet and failed to notify the Medical Director, who was the resident's attending physician, of a new diagnosis of PVD, and failed to notify the Medical Director of the identification of a new wound and transfer to the hospital for 1 of 8 residents (Resident #1). The findings included: 1a. Resident #1 was admitted on [DATE] with a diagnosis of diabetes mellitus, dementia, contractures of the right knee, left wrist, left hip, and left knee, malnutrition, and hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) affecting the left side of the body. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #1 was severely cognitively impaired. Review of a Podiatry Consult note dated 1/30/2025 revealed Resident #1 was given a new diagnosis of PVD. The consultation note also discussed lack of pedal pulses in both feet. A review of Resident #1's medical revealed no documentation that Resident #1's RP was informed of Resident #1's new diagnosis of PVD or that the resident had absent pedal pulses. An interview was conducted with the Podiatrist on 5/20/2025 at 10:45AM. The Podiatrist stated that Resident #1 presented physically with signs and symptoms of PVD based on a clinical assessment. The Podiatrist further stated during the visit on 1/30/2025 Resident #1 had no pedal pulses in both feet, capillary fill time (the time it takes for blood to flow to a specific area after pressure is released) was +3 seconds (normal time is less than 2 seconds) bilaterally, staining of the skin, thickening of nails, and all signs and symptoms of PVD. The Podiatrist had not informed Resident #1's RP of the new diagnosis of PVD because she expected the facility staff to inform the RP. Review of medical record revealed an order on 4/30/2025 at 1:00PM to transfer Resident #1 to the emergency room for wound on right smallest toe one time. A review of Resident #1's hospital records dated 4/30/2025 revealed Resident #1 received a diagnosis of high fever, severe sepsis likely to infection of right fifth toe possible osteomyelitis. An interview conducted with Resident #1's RP over the telephone on 5/14/2025 at 11:09AM. The RP stated that on 4/30/25 the facility called her and informed her that Resident #1 needed to go to the hospital because of a fever and a wound. The RP requested more information from the facility and stated she did not receive any more information. The RP stated that she attended a care conference with the facility over the telephone on 4/8/2025 and there was no mention of any wounds or diagnosis of PVD with Resident #1. The RP stated she was not informed of Resident #1 having a lack of pedal pulses. The RP indicated she came to the facility after Resident #1 was admitted to the hospital and spoke with the Director of Nursing (DON) to inquire about Resident #1's wound development. An additional interview was conducted with Resident #1's RP over the telephone on 5/19/2025 at 3:24PM. The RP was unaware of the diagnosis of PVD and stated she was never informed of any vascular disease or any new diagnosis. The RP stated that the only time she was informed Resident #1 had any skin issues was the day Resident #1 was sent to the emergency roiagnom on [DATE]. An interview occurred with the Social Service Coordinator on 5/20/2025 at 10:06AM. The Social Service Coordinator stated there was a care conference on 4/8/2025 via telephone with the RP to discuss Resident #1's individual care plan. The Social Service Coordinator discussed not being aware of Resident #1's new diagnosis of PVD or that Resident #1 had a lack of pedal pulses. She stated she discussed with the RP Resident #1's care plan which she stated did not include any goals or interventions related to Resident #1's diagnosis of PVD or lack of pedal pulses. The Social Service Coordinator stated when a consultation was completed, the provider would give her any new orders that she would then deliver to the Unit Manager/nurse. She explained if the provider of the consultation did not have any orders, the provider would upload their consultation directly into the facility's electronic computer system. The Social Service Coordinator did not view the Podiatry note from 1/30/2025 for Resident #1. An interview was conducted with the Director of Nursing (DON) on 5/15/2025 at 6:27AM. The DON stated that she had a conversation with the RP at the facility regarding Resident #1's wound after he was admitted into the hospital. The DON did not state to the RP that Resident #1 had a diagnosis of PVD. The DON discussed the RP should have been made aware of the new diagnosis by the Medical Director. The DON indicated consultations were available on their computer system to be reviewed by any staff member. She stated once the consultation documentation was available in the computer system, the Medical Director should have been informed and was not. The DON was not able to speak to who would or should review consultations and inform the Medical Director of any changes in a resident's diagnosis/change of condition. b. Review of the medical record revealed no documentation the Medical Director was notified of Resident #1's new diagnosis of PVD or the lack of pedal pulses after his Podiatry consultation on 1/30/25. An interview conducted with the Medical Director on 5/14/2025 at 1:23PM. The Medical Director stated she was not aware of the new wound on Resident #1's right foot or being transferred to the hospital on 4/30/25 until 5/14/2025. The Medical Director discussed not being informed of Resident #1's new diagnosis of PVD or the lack of pedal pulses. She also stated she was not aware Resident #1 had been seen by a Podiatrist in January 2025. The Medical Director stated she had not looked at the consultations that were in the facility's computer system. An interview was conducted with the Director of the Nursing (DON) on 5/15/2025 at 6:27AM. The DON did not know if notification was made to the Medical Director of Resident #1's change in condition and new diagnosis of PVD and lack of pedal pulses from the 1/30/2025 Podiatry Consult. The DON indicated she did not notify the Medical Director of Resident #1's transfer to the hospital on 4/30/2025 until 5/14/2025.

Based on record review, and staff and Medical Director interviews, the facility failed to ensure that during provider visits the provider reviewed the total plan of care for 1 of 8 residents (Resident #1) newly diagnosed peripheral vascular disease (PVD). Resident #1 was examined by the Medical Director and the Medical Director failed to recognize Resident #1 did not have active pedal pulses in both feet. An interview with the Medical Director revealed that there was no examination of the feet during her visit on 3/25/2025. Resident #1 needed an assessment of his feet based on the new diagnosis of PVD to recognize the need for further treatment, review the plan of care, and consultations. This deficient practice occurred for 1 of 3 residents reviewed for Physician visits (Resident #1). The findings included: Resident #1 was admitted on [DATE] with a diagnosis of diabetes mellitus, dementia, contractures of the right knee, left wrist, left hip, and left knee, malnutrition, hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) affecting the left side of the body and PVD. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 was severely cognitively impaired and unable to make decisions for himself. Record review of the Podiatrist consult note from 1/30/2025 were obtained for review. The Podiatrist notes stated Resident #1 was newly diagnosed with, indicated peripheral vascular disease. Patient was not a referral to a vascular surgeon as they do not meet any one of the following guidelines for referral: 1. Critical limb ischemia, 2. Claudication that affects quality of life, 3. Symptoms are unresponsive to conservative management. They do however, meet the qualifications for routine or at risk footcare. Further record review of the Podiatrist clinical note indicated that Resident #1 had Pedal pulses absent in both feet, Capillary refill +3 seconds, and pigmentary changes on both feet. An interview was conducted on 5/19/2025 at 4:02PM with Nurse #3. Nurse #3 indicated that when a consultation was received from a provider the licensed nursing staff would give information to the medical director if needed. Nurse #3 further revealed that they would contact the Medical Director by phone, place information in the provider's book, and/or copy of the order left for the provider. Nurse #3 was asked if the Medical Director was notified of the new diagnosis of PVD for Resident #1 and she could not recall. Resident #1 was last evaluated by the Medical Director on 3/25/2025. Review of the progress notes revealed general information about medications and diagnosis but there was no follow up plan or discussion of Resident #1's recent diagnosis of PVD. An interview was conducted with the Medical Director on 5/14/2025 at 1:23PM. The Medical Director confirmed she last saw Resident #1 on 3/25/2025. The Medical Director stated she reviewed Resident #1's medications and progress notes. She discussed examining Resident #1 at that time but had not looked at his feet or felt for pedal pulses (pulses that are on the top of the foot). The Medical Director stated she was unaware the Podiatrist had seen Resident #1 in January 2025, so she had not reviewed the consultation. She discussed not being aware, from the Podiatrist consultation, that Resident #1 did not have any pedal pulses in his feet or that the Podiatrist had diagnosed Resident #1 with a new diagnosis of PVD. She further discussed not being made aware by the facility staff that Resident #1 had the Podiatrist consultation or the findings.

Based on record reviews, and interviews with staff, Physician Assistant, and responsible party (RP), the facility failed to protect 2 cognitively impaired residents' right to be free from sexual abuse. On 4/4/25 at approximately10:00 PM, a Medication Aide observed a female resident (Resident #1) in a male resident's (Resident #2) room sitting upright on Resident #2's bed. Resident #2 was standing in front of Resident #1 with his pants down and his penis inside of her mouth. When the Medication Aide asked what was going on, Resident #2 backed away from Resident #1 removing his penis from her (Resident #1) mouth. The residents did not have the capacity to consent to sexual relations. Resident #1's RP stated due to Resident #1's advanced dementia she was not aware of her behaviors and had no insight into what happened. A reasonable person expects to be protected from abuse in their home environment and would have experienced trauma with feelings such as fear, humiliation, anger, anxiety, and depressed mood as a result of the intimate sexual relations enacted without the capacity to consent. This deficient practice affected 2 of 3 residents (Resident #1 and Resident #2) reviewed for abuse. The findings included: Resident #1 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 #1 had unclear speech, had difficulty making herself-understood and was severely cognitively impaired. Resident #1 had no behavioral symptoms and she wandered 1 to 3 days during the 7-day MDS look back period. Resident #1 required 1-person assistance from staff for activities of daily living and supervision or touching assistance with ambulation. Resident #1's revised care plan dated 1/7/25 included a focus area for impaired cognitive function and impaired thought process related to dementia/Alzheimer's disease. Resident #1's care plan did not identify any sexually inappropriate behaviors. Resident #2 was initially admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses that included dementia, mood disturbance, anxiety and depression. Resident #2's revised care plan dated 2/17/25 included a focus area for behaviors of disrobing in common areas, wandering in other resident rooms, and inappropriate behaviors toward others. Resident #2 had potential sexual behaviors exhibited by attempting to invite other residents into his room. Resident #2 had a behavior problem as evidence by wandering and threatening behavior towards other residents. He had the potential to become aggressive when his space was invaded without warning. Resident #2 was historically territorial over his room and personal space. The goal included Resident #2 would not demonstrate inappropriate sexual behaviors. The approaches included notifying physicians of behavior; staff to monitor behaviors, offer redirection and provide structured activities; and staff to provide one to one (1:1) monitoring for inappropriate behaviors. The quarterly MDS assessment dated [DATE] revealed Resident #2 was severely cognitively impaired and had no behavioral symptoms or wandering during the 7-day MDS look back period. Resident #2 was independent with dressing, transfers, and ambulation. A physician order for Resident #2 dated 3/31/25 revealed Depakote (a mood stabilizer that can be used to decrease sexual urges) 125 milligrams one tablet daily and estradiol (synthetic form of estrogen) transdermal patch 0.1 milligrams to be applied on the right shoulder weekly for sexual behavior. The incident report completed by Nurse #1 on 4/4/25 at 9:45 PM revealed Resident #1 was found in Resident #2's room performing oral sex on Resident #2. Both residents were separated immediately. Skin assessments were done for both residents and there were no injuries noted. The physician, responsible parties for both residents and Director of Nursing were notified of the incident. The initial allegation report dated 4/4/25 completed by the Administrator indicated Resident #1 and Resident #2 resided on the memory care unit. Resident #1 was noted in Resident #2's room with Resident #2's penis exposed. Both residents were placed on 1:1 observation. 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. The Medication Aide's statement dated 4/4/25 revealed the Medication Aide was looking for another resident to administer medications when he walked into Resident #2's room and saw Resident #1 sitting on the bed. Resident #2 was standing in front of Resident #1 with his pants down and his penis in Resident #1's mouth. He asked what they were doing and Resident #2 backed up and pulled his pants up. Resident #1 was removed from the room and he (the Medication Aide) got the nurse. A telephone interview was conducted on 4/10/25 at 9:45 AM with the Medication Aide who stated Resident #2's room was at the end of a hall and he did not have a roommate. On 4/4/25 around 10:00 PM he walked to Resident#2's room and the door to the room was open. Resident #1 was observed to have her mouth around the penis of Resident #2. The Medication Aide stated Resident #2 was standing on the floor at the head of the bed with his pants down and Resident #1 was seated on the edge of the bed with her right knee down on the floor. She was actively performing oral sex on Resident #2. The Medication Aide stated when he asked what was going on Resident #2 backed away and pulled up his pants. Both residents were separated immediately. There were no visible signs that Resident #2 forced Resident #1 to perform oral sex. The Medication Aide stated Resident #2's penis was flaccid after he removed his penis from Resident #1's mouth and Resident #1 was removed from the room with the assistance of Nurse Aide #1. He stated he asked Resident #1 what happened, and she was unable to state what happened. Resident #1 left the room with Nurse Aide #1 in no apparent distress. The nurse was immediately notified of the incident. He further stated within 15 minutes sitters were sent to each of the residents' rooms for 1:1 monitoring. The Medication Aide stated Resident #2 had been moved to another unit about two years ago before coming back to the memory care unit on 3/7/25 due to a history of inappropriate sexual behaviors and comments. Resident #2 previously made the statement can an old man get some before he dies. An interview was conducted on 4/9/25 at 3:29 PM with Nurse Aide #1 who assisted Resident #1 back to her room following the incident on 4/4/25. The Nurse Aide stated when she entered the room, both residents had already been separated and Resident #2 was already dressed. Resident #1 was unable to state what happened when asked and she willingly left the room. Nurse Aide #1 stated Resident #1 did not show any visible distress, voiced no complaints, and expressed no discomfort. Nurse Aide #1 stated she sat with Resident #1 until Nurse #1 did a full assessment. The assigned sitter arrived after completion of the assessment. A telephone interview was conducted on 4/9/25 at 2:26 PM with Nurse #1 who stated on 4/4/25 the Medication Aide reported that Resident #2 was in his room standing in front of Resident #1 with his pants down. Resident #1 was sitting on the bed. Resident #1 was observed in Resident #2's room actively performing oral sex on Resident #2. She indicated she last saw Resident #2 in the dayroom a little after 9:00 PM and could not recall the location of Resident #1. She further stated she went to Resident #2's room and both residents had already been separated and Resident #1 had been taken to her room by Nurse Aide #1. She stated she did a head-to-to-toe assessment of Resident #2 who had no complaints or injuries. Nurse #1 stated she asked Resident #2 what happened and Resident #2 put his head down. Nurse #1 reported she did Resident #1's head-to-toe assessment and no injuries were noted. Following the assessments, she notified Nurse #2 who immediately came to the unit and provided 1:1 sitters to monitor both residents. Attempts were made to contact Nurse #2 on 4/10/25 at 1:43 PM and 4/11/25 at 9:00 AM. She was unable to be reached for interview. Resident #2's RP was contacted on 4/9/25 at 2:37 PM and 4/10/25 at 1:15 PM and was unavailable for interview. A telephone interview was conducted on 4/10/25 at 1:08 PM with Resident #1's RP who stated he received a call from the Director of Nursing who informed him of the 4/4/25 incident. He stated due to Resident #1's advanced dementia she was not aware of her behavior and had no insight into what happened. A full body assessment dated [DATE] at 10:35 PM completed by the Director of Nursing revealed Resident #1 was assessed due to resident-to-resident sexual abuse. No negative findings were observed. A full body assessment dated [DATE] at 10:38 PM completed by the Director of Nursing revealed Resident #2 was assessed due to resident-to-resident sexual abuse. No negative findings. An interview was conducted on 4/9/25 at 3:30 PM, with the Director of Nursing (DON) who stated she received a call on 4/4/25 around 10:00 PM about the incident. She notified the Administrator who came into the facility with her to initiate a full investigation. She reported when they arrived at the facility, both residents had been separated and placed on 1:1 monitoring with sitters. The DON stated Nurse #1 completed skin assessments and contacted the physician assistant who gave instructions to contact the families and inform them of the incident and offer each of them the option to have the resident transferred to the hospital for evaluation to rule out a sexually transmitted disease. The DON further stated she also did a complete head-to-toe assessment of both residents and did not have any negative findings mentally or physically. Following the completion of the physical assessments, she contacted the RPs for both residents and informed them of the incident and offered them a transfer to the hospital for further evaluation and both families declined transfer. Neither family reported any concern with the information provided or the investigation process. The DON stated Resident #1 did not have any known sexual behaviors prior to the incident. The DON asked Resident #1 what happened, and she was unable to state what happened due to her severe cognitive impairment and dementia. Resident #1 did not have the capacity to consent to any sexual activity. Resident #2 was also diagnosed with dementia and had limited insight into what happened or the significance of the inappropriate behavior. The DON reported Resident #2 had a documented history of inappropriate sexual behaviors of touching others without consent and making sexual comments. She reported the behaviors were addressed on the care plan with 1:1 supervision, redirection to activities of interest, psychiatric evaluations, transfer to another unit and medication adjustment. The family requested Resident #2 be returned to the memory care unit for safety reasons due to a recent fall. She further stated she was aware all residents must be protected from any form of abuse and the interdisciplinary team would review the current behavior plans for all residents. Resident #2's current medications at the time of the incident included the estradiol transdermal patch and Depakote to address the inappropriate sexual behaviors. The Depakote was increased after the 4/4/25 incident. An interview was conducted on 4/10/24 at 9:45 AM with the Social Worker who stated Resident #2 had a history of inappropriate sexual advances toward others. The Social Worker reported Resident #2 would attempt to inappropriately touch others or make sexual comments or advances. Resident #2's RP was aware of the inappropriate sexual behaviors and the use of medication to address the behaviors. Resident #2 had been on the memory care unit in the past but had been transferred to another unit for inappropriate sexual advances and comments about a year and half ago. He had 1:1 supervision on the unit. Resident #2 recently returned from the hospital and the family requested the resident return to the memory care unit for safety reasons due to recent falls. The Social Worker stated there had been no previous incident of Resident #1 exhibiting any sexual behaviors toward others. An interview was conducted on 4/10/25 at 10:00AM with the Physician Assistant who stated he received a call on 4/4/25 about inappropriate sexual activity between Resident #1 and Resident #2. He stated he gave the nurse instructions to offer the residents family the option for hospital transfer for evaluation for sexually transmitted diseases. He was informed both residents had been separated and placed on 1:1 monitoring. He further stated he had a discussion with the Director of Nursing who informed him both resident's family declined the hospital evaluation, therefore he ordered a psychiatric evaluation. Review of the skin assessments done by nursing and the Director of Nursing revealed there was no evidence of any sexual penetration other than the visible observation made by the medication aide. The Physician Assistant indicated Resident #1 and Resident #2 did not have the capacity to consent due to their diagnosis of dementia. Resident #1 did not exhibit any inappropriate sexual behavior prior to the 4/4/25 incident. Resident #2 had been on estradiol transdermal patch weekly and Depakote 125 milligram daily to address inappropriate sexual behaviors for more than a year along with intermittent 1:1 supervision on different units. An interview was conducted on 4/10/25 at 5:30 PM with the Administrator who stated when he received the call on 4/4/25 about the incident between Resident #1 and Resident #2, he came to the facility along with the Director of Nursing to investigate the incident. He reported the nursing team handled the residents' care and assessments and he completed the documents and reporting process to the local authorities and state agencies in accordance to facility policies and procedures and federal regulations. The Administrator acknowledged that all residents must be protected from any form of abuse. He stated the interdisciplinary team would evaluate the current behavior plans for all residents. The Administrator was notified of the Immediate Jeopardy on 4/10/25 at 4:36 PM. The facility provided the following Corrective Action Plan: 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. The facility identified an incident where residents' rights to be free from sexual abuse were not adequately protected. On 04/04/2025 at 10:00 PM, a Medication Aide observed an incident between Resident #1, a female resident with severe cognitive impairment related to dementia/Alzheimer's Disease (last seen between 8:45 PM and 9:00 PM by a CNA), and Resident #2, a male resident with severe cognitive impairment (last seen by a nurse at 9:03 PM). Resident #2 had a care plan for behaviors including wandering and disrobing due to personal preference to sleep without clothing and brief. The incident occurred in Resident #2's room where the Medication Aide observed Resident #1 sitting upright on the bed with Resident #2 standing in front of her. Resident #2's penis was in Resident #1's mouth; the penis was observed to be flaccid. When the Medication Aide asked what was going on, Resident #2 backed away, removing his penis from Resident #1's mouth. Neither resident possessed the cognitive capacity to consent to sexual activity. Upon discovering the incident on 04/04/2025 at 10:00 PM, the Medication Aide immediately separated the residents and notified the Charge Nurse. The Charge Nurse promptly conducted initial physical assessments of both residents, with no immediate concerns identified. No evidence of ejaculation was noted in Resident #1's mouth. Both residents were immediately placed on 1:1 supervision by nursing staff following the incident to ensure their safety and prevent recurrence. As of 04/11/2025, both Resident #1 and Resident #2 are still residents at the facility and currently remain on 1:1 supervision. On 04/04/2025 at 11:00 PM, Residents #1 and #2 were assessed by the Director of Nursing (DON), including complete skin assessments, with no injuries noted. The DON notified the primary care physician for both residents at 10:30 PM on 04/04/2025. The physician did not provide any new orders at that time. At 11:30 PM on 04/04/2025, the DON completed further assessments for Residents #1 and #2, including behavior assessments and updated sexual behavior assessments, covering areas such as trauma, psychosocial status, behavior monitoring, sexual history/activity, and change in condition evaluation. Also at 11:30 PM on 04/04/2025, the Director of Nursing notified the responsible parties for Residents #1 and #2 of the incident, with detailed documentation of these conversations obtained and filed. The DON notified the psychiatric services provider on 04/05/2025 at 1:44 AM. A medication review was conducted for both residents by the Psychiatric Provider on 04/05/2025 at 1:44 AM, resulting in new orders for Resident #2 that were implemented immediately upon receipt. For Resident #2, the psychiatric provider increased the dosage of his prescribed mood stabilizer (Divalproex Sodium) to address the inappropriate sexual behaviors. Resident #1 did not require medication changes as her assessment did not indicate a need for pharmacological intervention. The Director of Nursing updated care plans for both residents on 04/04/2025 at 11:45 PM to reflect current status, behavioral interventions, and increased monitoring requirements. For Resident #1, care plan updates included: 1) documentation of the incident, 2) implementation of 1:1 supervision, 3) specific approaches for redirection during periods of increased confusion, 4) activity participation guidelines to promote appropriate social interaction, and the addition of a trauma-informed care approach. For Resident #2, care plan updates included: 1) documentation of the incident, 2) implementation of 1:1 supervision, 3) behavior monitoring with specific triggers and warning signs identified, 4) incorporation of the psychiatric provider's medication recommendations including monitoring parameters for the increased mood stabilizer dosage, 5) specific interventions for staff to redirect inappropriate sexual behaviors, 6) activity programming to channel energy appropriately. Both care plans include detailed guidance for all shifts and disciplines on prevention strategies, early intervention techniques, and response protocols. The Administrator notified the local police department at 11:30 PM on 04/04/2025 of the incident/potential abuse, and a formal police report was taken. Adult Protective Services was also notified on 04/04/2025 at 11:35 PM. A long-term plan for Residents #1 and #2 has been developed. Initially, both residents will remain on 1:1 supervision for 10 days. Both Resident #1 and Resident #2 are still residents at the facility and currently remain on 1:1 supervision (as of 04/11/2025). Following this period, the interdisciplinary team will conduct a comprehensive reassessment to determine appropriate ongoing monitoring levels based on individual needs. This may include continued 1:1 supervision, 15-minute checks, or 30-minute checks as determined necessary. Resident #2 will receive ongoing behavioral health services with weekly assessments for the first month. Room placement and activity participation will be carefully monitored to ensure appropriate separation while maintaining quality of life for both residents. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents are at risk for this deficient practice, particularly those with cognitive impairments. On 04/05/2025, the Director of Nursing individually interviewed all residents with a Brief Interview for Mental Status (BIMS) score of 10 or greater to determine if they had experienced any inappropriate/unwanted sexual contact and if they felt safe in the facility. These interviews were conducted using a standardized interview protocol. Results of these interviews revealed no additional concerns or reports of inappropriate or unwanted sexual contact, and all interviewed residents reported feeling safe in the facility. On 04/05/2025, licensed nurses, specifically the Unit Managers on each unit, assessed all residents on the secured memory care unit for behaviors using the Behavior Assessment tool (Point of Care User-Defined Assessment). All residents on the secured memory care unit have severe cognitive impairment. This assessment revealed no resident who had additional concerns for sexual behaviors or resident abuse. Documentation was completed in each resident's electronic health record. On 04/05/2025, the Director of Nursing completed comprehensive skin assessments on all residents with a BIMS score of 9 or less to determine if there were any signs or symptoms of abuse, with no additional concerns noted. These assessments included full-body skin checks with documentation of findings in each resident's record. On 04/05/2025, licensed nursing staff, including Unit Managers and Charge Nurses, updated sexual history/behavior assessment User-Defined Assessment for all residents to ensure complete and current documentation of potential risk factors or concerns. This comprehensive assessment identified residents' normal sexual behaviors, history of inappropriate sexual behaviors, and risk factors that may contribute to sexual behaviors. On 04/05/2025, the Director of Nursing created a comprehensive list of all residents with behaviors, including those with histories of being sexually inappropriate or care planned for being sexually inappropriate, to ensure appropriate monitoring. This identification process included review of admission assessments, behavior tracking records, care plans, progress notes, and consultation with direct care staff who regularly interact with residents. No additional residents were found to have these behaviors. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 04/05/2025, the Administrator, Director of Nursing, and Quality Assurance (QA) Nurse educated all facility staff on the abuse prohibition and reporting policy, with emphasis on the requirement to document and report any behaviors affecting other residents at the time of occurrence. This education was conducted in person during all shifts through mandatory in-service meetings. The education covered: 1) identification of all forms of abuse including sexual abuse, 2) immediate intervention protocols to ensure resident safety, 3) proper reporting procedures including timeframes and notification chain, 4) documentation requirements, 5) resident rights, and 6) staff responsibilities for prevention and reporting. Following the education session, each staff member's understanding was verified through discussion and response to scenario-based questions. Staff acknowledged their understanding of the material and responsibilities by signing an attestation form, which is maintained in their personnel file. All education is documented in individual personnel files with employee signatures acknowledging understanding. Staff who were not present will not be permitted to work until they receive this education. The Director of Nursing maintains a tracking log to ensure 100% staff completion. On 04/05/2025, the facility established a comprehensive behavioral monitoring program for residents identified with behaviors such as physical/verbal aggression, wandering, disruptive vocalizations, inappropriate sexual advances, etc., to be placed on 15-minute checks, 30-minute checks by designated nursing staff, or 1:1 supervision for 72 hours or until determination can be made for continuation of monitoring. On 04/05/2025, all staff members (including agency personnel) received comprehensive education about the behavioral monitoring program. This education was provided by the Director of Nursing and Unit Managers. Any staff member not educated by 04/05/2025 will be educated prior to their next scheduled shift. The Administrator is responsible for ensuring this education is completed and documented in personnel files. Education includes dementia-specific training components. On 04/05/2025, the facility implemented clear staff responsibilities when a behavior is identified, with emphasis on prevention and immediate intervention when abuse is observed or reported. These responsibilities are detailed as follows: Nurses are responsible for immediately assessing residents involved in reported behavioral incidents for both physical and psychological impacts. They must document comprehensive assessment findings in progress notes including physical and mental status. Nurses implement interventions according to facility protocols and individualized care plans, which include specific approaches for each resident based on their unique needs and triggers. They notify the Unit Manager, Director of Nursing, and Administrator of significant behavioral incidents immediately upon discovery. Nurses contact the appropriate provider for consultation regarding new or modified orders when residents exhibit behavioral changes. They follow the provider's orders and document implementation and resident response. Following incidents, nurses monitor residents closely for changes in condition, complete incident reports for all behavioral events per facility policy, conduct thorough shift-to-shift handoff regarding residents with behavioral concerns, ensure appropriate supervision levels are maintained based on resident needs, and report changes in resident condition to primary physician and psychiatric services. Nurses report directly to their Unit Managers for guidance and support when managing resident behaviors. Nurse Aides immediately report any observed behaviors to the charge nurse/unit manager verbally and document observed behaviors in the Point of Care system at time of occurrence. They implement immediate interventions as directed by care plan (redirection, one-to-one supervision, etc.), monitor residents for escalation or changes in behavior and report changes promptly, and follow specific behavioral care plan approaches for each individual resident. Nurse Aides also follow directives from nurses and/or management regarding interventions for behaviors and use techniques learned in dementia-specific training to de-escalate situations before they progress. Unit Managers assess residents when behavior is reported, conducting comprehensive evaluations that include physical, cognitive, and psychosocial components. They document assessment findings in progress notes, notify the Director of Nursing/Administrator of behavior incidents, contact primary physician and responsible party as appropriate, update care plans to reflect new or increased behaviors, communicate behavior and interventions to all staff during shift report, conduct follow-up assessments to monitor effectiveness of interventions, ensure all documentation is complete and accurate, and coordinate interdisciplinary team response to behavior incidents. Social Workers conduct psychosocial assessment following behavior incidents, facilitate communication with families regarding behaviors and interventions, coordinate referrals to mental health services when indicated, assist with development of behavior management strategies, provide staff education on behavior management techniques specific to individual residents, participate in care plan meetings to address behavioral concerns, document all interventions and resident response in the medical record, follow up with residents to assess ongoing psychosocial needs, and provide resources and support to residents and families. On 04/05/2025, the Director of Nursing implemented daily reviews of progress notes, electronic Medication Administration Record, and Plan of Care for behavior documentation. These reviews occur 7 days a week; the DON or designee reviews the previous day's documentation during the morning clinical meeting held Monday-Friday at 9:30 AM, and the weekend Charge Nurse performs these reviews on Saturdays, Sundays, and holidays. This process identifies any new or increased behaviors and ensures appropriate follow-up. The appropriate follow-up includes immediate notification to providers, family, updating care plans, and implementing appropriate interventions. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Beginning 04/05/2025, the Administrator and Director of Nursing will interview at least 5 staff members per week for 4 weeks to identify any new or increased resident behaviors (including sexual behaviors) using an incident-specific monitoring tool and ensure appropriate reporting. This will be followed by interviewing 3 staff members per week for an additional 8 weeks (total monitoring period of 12 weeks). If the Administrator or Director of Nursing is unavailable, this responsibility will be delegated to the Social Worker to ensure continuity. Beginning 04/05/2025, the Director of Nursing will conduct daily reviews of all behavior documentation, including progress notes, electronic Medication Administration Record, and Point of Care during morning clinical meetings, seven days a week including weekends and holidays. On days when the Director of Nursing is not available, the Assistant Director of Nursing or designated Unit Manager will conduct these reviews to ensure continuous monitoring. Beginning 04/05/2025, the Administrator determined all findings shall be formally reported to the Quality Assurance Performance Improvement committee with detailed documentation. Audits will continue at the discretion of the Quality Assurance Performance Improvement committee based on findings, with potential for increased frequency or extended duration if any concerns are identified. The monitoring process will include verification that all staff have received the required education, documentation review, and continued assessment of all residents with specific attention to those residents identified as being at higher risk. All corrective actions were implemented by 04/05/2025. The facility's alleged date of compliance is 04/06/2025. Allegation of immediate jeopardy removal and compliance date: 4/6/25. The corrective action plan was validated onsite on 4/9/25 and 4/10/25. It was verified through staff interviews that Residents #1 and #2 were immediately separated and assessed for injury. There were no negative findings for either resident. Resident #1 and Resident #2 were placed on 1:1 supervision and documentation of supervision was verified. Observations of the 1:1 for both residents were conducted on 4/9/25 and 4/10/25. Review of skin assessments and body audit forms verified they were completed on all residents on the memory care unit as well as residents on the other 4 units on 4/5/25. In addition to skin assessments, resident interviews were conducted for individuals with a BIMS score of 10 or greater to determine if they had experienced any type of inappropriate/unwanted sexual contact. All residents were assessed with the use of the behavior assessment tool, sexual activity assessment, and post-traumatic stress disorder assessment. Care plans for Resident #1 and Resident #2 and other residents with identified behavioral concerns were reviewed and revised if needed. Staff interviews verified employees were educated with post-education knowledge checks completed as indicated in the corrective action plan that included sexual abuse, dementia, reporting/ documentation of abuse, 1:1 supervision, increased unit rounds for wandering residents and review of the updated care plans for residents with behaviors. The facility implemented monitorin [TRUNCATED]

Based on record reviews, observations, and interviews with staff and Medical Director, the facility staff failed to disinfect a shared blood glucose meter (glucometer) between residents for 1 of 3 residents (Resident #107) observed to have her blood glucose (sugar) level checked. This occurred while there were 18 residents identified with a known bloodborne pathogen in the facility. Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA)-registered disinfectant in accordance with the manufacturer of the glucometer potentially exposes residents to the spread of bloodborne infections. Care must also be taken by personnel handling and storing glucometers to protect the glucometers against cross-contamination via contact with other meters or equipment. Also, the facility failed to disinfect individually assigned glucometers stored outside of the residents' rooms in accordance with the instructions provided by the manufacturer of the disinfectant wipes for 2 of 3 residents (Residents #66 and #93) observed to have their blood glucose levels checked. Immediate jeopardy began on 2/4/25 when Nurse #1 was observed to perform blood glucose testing for Resident #107 using a glucometer dedicated to Resident #134 without disinfecting the shared glucometer between residents. Immediate jeopardy was removed on 2/6/25 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) for finding #2 and for the facility to complete agency and employee staff training with monitoring to ensure appropriate interventions are put into place. The findings included: The manufacturer instructions for cleaning and disinfecting the (Brand Name) glucometer used at the facility were summarized in a Technical Brief (Revised 9/24). The Technical Brief read in part, To minimize the risk of transmitting bloodborne pathogens, the cleaning and disinfecting procedures should be performed as recommended in the instructions below. The (Brand Name) meter may only be used for testing multiple patients when standard precautions and the manufacturer's disinfecting procedures are followed. The meter should be cleaned and disinfected after use on each patient. The cleaning procedure is needed to clean dirt, blood and other bodily fluids off the exterior of the meter before performing the disinfecting procedure. The disinfecting procedure is needed to prevent the transmission of bloodborne pathogens .Clean and disinfect the meter following step-by-step instructions in the Quality Assurance (QA) / Quality Control (QC) Reference Manual. Cleaning and Disinfecting Procedures specified in the glucometer's QA/QC Reference Manual (Revised 10/24) included, in part: --Cleaning: Step 1 (of 7): Wear appropriate protective gear such as disposable gloves. Step 3 (of 7): Wipe surface of the meter to clean blood and other body fluids . Step 4 (of 7): If blood is visible on the meter, it should be cleaned prior to each disinfection step. --Disinfecting: Step 5 (of 7): Pull out 1 new towelette and wipe the entire surface of the meter horizontally and vertically to remove bloodborne pathogens. Carefully wipe around the test strip port by inverting the meter so that the test strip port is facing down. Step 6 (of 7): Treated surface must remain wet for recommended contact time. Please refer to wipe manufacturer's instructions. The manufacturer's Technical Brief for the glucometer listed the disinfectant wipes used at the facility as one of the EPA-registered wipes recommended to clean and disinfect the (Brand Name) glucometer. The instructions on the label of the disinfectant wipes read in part: To clean and disinfect and deodorize hard, nonporous surfaces: Wipe surface to be disinfected. Use enough wipes to treated surface to remain visibly wet to the contact time listed. Let Dry. Special instructions for cleaning and decontamination against human immunodeficiency virus (HIV), hepatitis B and hepatitis C indicated, Allow surfaces to remain wet for one minute, let air dry. For all other organisms, see directions for contact time. Mycobacterium bovis (an organism that can cause tuberculosis) was killed in 2 minutes. The instructions indicated enough wipes should be used for the treated surface to remain visibly wet for 3 minutes to kill Clostridium difficile spores. 1. A medication administration observation was initiated on 2/4/25 at 5:39 AM with Nurse #1. Nurse #1 identified himself as an agency (temporary staff) nurse. Upon approaching the medication (med) cart, a glucometer was observed to be placed directly on top of the med cart. Nurse #1 reported he needed to do a blood glucose check for Resident #107. Nurse #1 was observed as he collected supplies (a test strip, lancet and alcohol wipe), donned gloves, picked up the glucometer stored on top of the medication cart, and entered Resident #107's room to conduct the blood glucose check. Nurse #1 inserted a strip into the glucometer and used a lancet to puncture the resident's finger. As he held the glucometer (with the strip inserted) at an angle and applied a drop of blood to the strip, the glucometer was observed to have lettering on the side of the meter. After the blood glucose check was completed, Nurse #1 returned to the med cart and placed the glucometer back on top of the medication cart. The side of the glucometer was observed to be labeled with the name of Resident #134. Nurse #1 removed his gloves, opened a drawer of the med cart, and placed this glucometer in the drawer directly in contact with other glucometers which were each stored inside an individual, resealable bag. As the nurse did so, an individually assigned and labeled glucometer for Resident #107's (in a clear, plastic resealable bag) was observed to be stored in the same drawer. At that time, Resident #107's glucometer was pointed out to the nurse. When asked why Resident #107's assigned glucometer was not used for her blood glucose check, Nurse #1 stated, [I] grabbed the wrong one by mistake. The interview with Nurse #1 continued on 2/4/25 at 5:46 AM. During the interview, the nurse was informed that the glucometer (labeled for Resident #134) used to check Resident #107's blood glucose was not observed to be disinfected either before or after it was used for her. When asked if this was correct, the nurse stated, Correct. When asked if it would be correct to say he did not disinfect this glucometer at any point in time, he responded, yes. The nurse was then asked when glucometers should be disinfected. Nurse #1 stated, I don't know the routine here. The nurse further explained, I don't know the protocol [at the facility]. Nurse #1 reported he thought that most places where he worked would have the glucometers cleaned only once at the start of the first nursing shift. Upon further inquiry, the nurse confirmed he didn't disinfect any glucometers on his current night shift while working from 7:00 PM - 7:00 AM. He reported Resident #107 was the only resident whose blood glucose was checked during his shift. On 2/4/25 at 6:17 AM, a follow-up observation and interview were conducted with Nurse #1. When asked if there were disinfectant wipes stored on the medication cart, Nurse #1 was observed as he pulled each drawer of the med cart open to look. There were no disinfectant wipes stored on the med cart. Nurse #1 stated there should be sanitation wipes in a container on the med cart. However, he added that if these wipes were not available on his med cart, he could always use alcohol wipes kept in individual packets on the med cart. The nurse held up two packets of alcohol wipes (taken from the medication cart drawer) to show what he could alternatively use for cleaning/disinfection of the glucometers (alcohol is not an EPA-registered disinfectant approved for glucometer disinfection). When asked to confirm whether he had conducted any other blood glucose checks during his shift, he stated, That was the only blood glucose I had to do. An interview was conducted on 2/4/25 at 6:28 AM with the facility's Director of Nursing (DON) as she was standing nearby in the hallway assigned to Nurse #1. When the DON was informed there were no disinfectant wipes on Nurse #1's medication cart, she provided a container of the facility's EPA-registered disinfectant wipes to enable a review of the manufacturer labeling. The DON reported she would expect these wipes to be used for glucometer disinfection with a wet contact time of three (3) minutes, as the product labeling indicated. On 2/4/25 at 1:30 PM, the facility's DON provided a copy of the facility's (Brand Name) glucometer instructions printed on page 47 of its User Instruction Manual. At that time, an interview conducted with the DON revealed the facility did not have a policy/procedure specifically related to glucometer disinfection. The DON reported the facility used the glucometer instructions which read: Cleaning and Disinfecting Guidelines: Healthcare professionals should wear gloves when cleaning the [Brand Name] meter. Wash hands after taking off gloves. Contact with blood presents a potential infection risk. We suggest cleaning and disinfecting the meter between patient use. --Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe. --To use a wipe, remove from container and follow product label instructions to disinfect the meter. Take extreme care not to get liquid in the test strip and key code ports of the meter. --Many wipes act as both a cleaner and disinfectant, though if blood is visibly present on the meter, two wipes must be used; use one wipe to clean and a second wipe to disinfect. An interview was conducted on 2/7/25 at 8:08 AM with the facility's Infection Preventionist. During the interview, the Infection Preventionist was asked what her thoughts were with regards to the concerns identified with the glucometer's disinfection observed on 2/4/25. She stated, It's unfortunate. A telephone interview was conducted with the facility's Medical Director on 2/6/25 at 2:27 PM to discuss the concerns related to glucometer disinfection identified during observations conducted at the facility. When asked, the Medical Director reported she had been informed of these concerns. She stated, This is the first time I have heard of this happening. The Medical Director reported she thought glucometer disinfection required better learning or training for all staff throughout. Upon request, the facility provided a Diagnosis Report for its current residents (dated 2/4/25 at 3:39 PM). The Diagnosis Report indicated 18 residents were identified as having at least one bloodborne pathogen, which included hepatitis B, hepatitis C, and HIV. The facility's Administrator and DON were informed of the immediate jeopardy (IJ) on 2/4/25 at 3:00 PM. The facility provided the following plan for IJ removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance On 02/04/2025, an agency nurse used a glucometer (blood glucose meter) dedicated to Resident #134 for Resident #107 without disinfecting the shared glucometer between residents. This occurred for 1 of 3 residents who were observed to have their blood glucose checked (Resident #107). At the time of the incident, Resident #107 had an assigned glucometer that was properly labeled with a label maker and stored in the medication cart, but the agency nurse incorrectly used another resident's glucometer instead. All residents requiring blood glucose checks are at risk of being affected by this practice. An audit conducted by the Director of Nursing and nursing unit coordinators on 02/04/2025 identified all facility residents requiring blood glucose checks. All residents were confirmed to have an individual glucometer assigned. Each glucometer is labeled with the resident's name using a label maker and stored in individual re-sealable plastic bags in the medication cart. The following immediate actions were taken for affected residents: - At approximately 7:00 AM on 02/04/2025, upon discovery of the incident, the Director of Nursing and the Unit Coordinator cleaned and disinfected the glucometer per manufacturer guidelines and professional standards - On 02/04/2025, Resident #107 was assigned a new individual glucometer by the Unit Coordinator, labeled with the resident's name using a label maker and stored in an individual re-sealable plastic bag in the medication cart - Resident #107's medical provider was notified of this occurrence by the Director of Nursing with no additional instructions provided 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 following systemic changes have been implemented as of 02/04/2025: 1. Staff Education and Competency Validation: - The agency nurse involved was contacted by telephone by the Director of Nursing to provide education regarding proper glucometer disinfection protocols. The Director left a voicemail, and the nurse will not be allowed to accept a resident care assignment at facility prior to education and blood glucose competency being validated in person - All licensed nurses were educated by the Director of Nursing and nursing unit coordinators regarding: - The importance of using appropriate EPA-registered disinfectant wipes - Following manufacturer's instructions for cleaning and disinfection - Requirements for stocking medication carts with EPA-registered disinfectant wipes - Blood glucose monitoring is performed only by licensed nurses at the facility - All licensed nurses' competency to check blood glucose, including proper disinfection, was validated through direct observation by nurse management. This validation included observation of: - Proper glucometer disinfection technique - Correct storage of glucometers in labeled individual re-sealable plastic bags - Complete blood glucose monitoring procedure - Newly hired, contract, agency, as-needed staff, and staff returning from leave will be educated and have their competency validated through direct observation prior to accepting any resident assignment - The Director of Nursing is responsible for tracking education completion and competency validation 2. Process Changes: - Visual reminders have been placed on all medication carts outlining the complete glucometer procedure: 1. Obtain needed equipment and supplies: - Gloves - Glucometer - Alcohol pads - Single-use lancet - Blood glucose testing strips - Disinfecting wipes 2. Perform hand hygiene 3. Explain procedure to resident 4. Provide privacy 5. [NAME] gloves 6. Obtain blood glucose sampling 7. Remove and discard gloves, perform hand hygiene 8. Retrieve (2) disinfectant wipes 9. Clean with first wipe to remove soil/blood 10. Disinfect with second wipe, maintaining 3-minute wet contact time 11. Allow to air dry 12. Discard wipes 13. Perform hand hygiene This infection control breach was reported to the local health department on 2/5/2025, and they provided no further recommendations. Immediate Jeopardy Removal Date: 2/6/2025 The facility's credible allegation of immediate jeopardy removal was validated on 2/7/25. The validation was evidenced by nurse observations and/or interviews conducted on each hallway with regards to the required infection control practices for the disinfection of glucometers. All nurses who were interviewed reported they had received the required in-service training prior to beginning their shift. The education provided stressed the importance of using individually assigned glucometers for each resident requiring blood glucose monitoring and storing these glucometers in individual, re-sealable plastic bags. The in-service training also included a review of the manufacturer's instructions for the facility's glucometer and disinfectant wipes related to glucometer disinfection, as well as completing a return demonstration of the proper procedures for effective glucometer disinfection. Nurses observed to conduct blood glucose checks and subsequent glucometer disinfection completed the task without difficulty. The nursing practices observed included the proper handling and storage of glucometers to protect the meters from potential cross-contamination via contact with other meters or surfaces. There were no concerns identified during either the interviews or observations. The credible allegation was validated, and the immediate jeopardy was removed on 2/6/25. 2. An observation of blood glucose checks and medication administration was initiated on 2/4/25 at 12:04 PM with Nurse #2. Nurse #2 identified herself as an agency (temporary staff) nurse. As the nurse prepared to conduct a blood glucose check for Resident #66, she removed his individually assigned (and labeled) glucometer from the medication (med) cart drawer. The glucometer labeled for Resident #66 was observed to have been stored in the med cart drawer directly in contact with six (6) other glucometers which were stored in individual, resealable bags. The glucometer for Resident #66 was not stored in an individual, resealable bag. Nurse #2 was observed as she placed the glucometer directly on top of the med cart and collected supplies for the blood glucose check (a test strip, lancet and alcohol wipe) and placed these supplies in a clean plastic cup. The nurse removed a container containing (Brand Name) disinfectant wipes from the bottom drawer of the medication cart and placed it on top of the cart. She did not use any of the disinfectant wipes at that time. Nurse #2 was observed as she picked up the cup (containing the supplies) and glucometer and entered Resident #66's room to conduct a blood glucose check. Upon entering the resident's room, Nurse #2 placed the cup and glucometer on Resident #66's dresser while she used hand sanitizer and donned gloves. The nurse checked Resident #66's blood glucose. On 2/4/25 as 12:12 PM, Nurse #2 returned to the med cart. At that time, she disposed of the used supplies, placed the glucometer directly on the pullout tray of the med cart, and removed her gloves. The nurse performed hand hygiene with hand sanitizer and donned clean gloves. Nurse #2 then picked up the glucometer and used one disinfectant wipe to wipe the meter for 15 seconds. Afterwards, she placed the glucometer back on top of the pullout tray of the med cart, then into the drawer of the medication cart with the other glucometers. She did not place Resident #66's meter in an individual, resealable bag. The observation of Nurse #2 continued on 2/4/25 at 12:15 PM as the nurse prepared to check Resident #93's blood glucose. The nurse was observed as she pulled Resident #93's individually assigned (and labeled) glucometer from the medication (med) cart drawer. His glucometer was observed to be stored in an individual, resealable bag while in the drawer. Nurse #2 placed the glucometer (in the bag) on top of the med cart and began to collect the supplies needed for Resident #93's blood glucose check. The nurse reported this resident also needed to receive 3 units of Novolin R (regular) insulin. However, she was unable to find an insulin syringe on the med cart. On 2/4/25 at 12:18 PM, the nurse picked up the glucometer (still in the bag) and supplies and left the med cart to retrieve an insulin syringe. She returned to the med cart on 2/4/25 as 12:23 PM. Upon her return, Nurse #2 placed the glucometer (stored in the bag) and supplies on the top of the med cart. After all of the supplies were collected, Nurse #2 performed hand hygiene and donned a gown and gloves prior to entering the resident's room. Resident #93's room was currently on Enhanced Barrier Precautions (EBP). EBP is an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. On 2/4/25 at 12:27 PM, Nurse #2 entered Resident #93's room, removed his glucometer from its bag and placed the meter on a bedside tray table. After checking the resident's blood glucose level, the glucometer was again placed on the tray table while the nurse administered the resident's insulin. On 2/4/25 at 12:32 PM, Nurse #2 picked up the glucometer and used supplies and returned to the medication cart. She discarded the used supplies and placed the meter directly on the pullout tray of the med cart. The nurse removed her gloves, performed hand hygiene, and donned clean gloves. She then picked up the glucometer and used one disinfectant wipe to wipe the surface of the glucometer for 20 seconds. The meter was placed directly on top of the med cart as Nurse #2 removed her gloves, put the glucometer back into its individual resealable bag, and returned it to the med cart drawer. An interview was conducted on 2/4/25 at 12:35 PM with Nurse #2. During the interview, the nurse was asked what the required wet contact time was for the disinfectant wipe to be effective in disinfecting the glucometer. Nurse #2 responded by stating she did not know. When asked, the nurse acknowledged Resident #93's glucometer was not visibly wet when it was put away. Additionally, concern related to the potential for the cross-contamination of both Resident #66's and Resident #93's glucometers was discussed. During an interview conducted on 2/4/25 at 6:28 AM, the facility's Director of Nursing (DON) reported she would expect the facility's EPA-registered wipes to be used for glucometer disinfection with a wet contact time of three (3) minutes, as the product labeling indicated. On 2/4/25 at 1:30 PM, the facility's DON provided a copy of the facility's (Brand Name) glucometer instructions printed on page 47 of its User Instruction Manual. At that time, an interview conducted with the DON revealed the facility did not have a policy/procedure specifically related to glucometer disinfection. The DON reported the facility used the glucometer instructions which read: Cleaning and Disinfecting Guidelines: Healthcare professionals should wear gloves when cleaning the [Brand Name] meter. Wash hands after taking off gloves. Contact with blood presents a potential infection risk. We suggest cleaning and disinfecting the meter between patient use. --Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe. --To use a wipe, remove from container and follow product label instructions to disinfect the meter. Take extreme care not to get liquid in the test strip and key code ports of the meter. --Many wipes act as both a cleaner and disinfectant, though if blood is visibly present on the meter, two wipes must be used; use one wipe to clean and a second wipe to disinfect. Upon request, the facility provided a Diagnosis Report for its current residents (dated 2/4/25 at 3:39 PM). The Diagnosis Report indicated 18 residents were identified as having at least one bloodborne pathogen, which included hepatitis B, hepatitis C, and human immunodeficiency virus (HIV). A follow-up interview was conducted on 2/5/25 at 8:40 AM with the facility's DON. During this interview, the DON reported it was assumed that agency nurses had received training to ensure their overall competency to care for residents prior to being hired and assigned to work in their facility. An interview was conducted on 2/7/25 at 8:08 AM with the facility's Infection Preventionist (IP). During the interview, the IP was asked what her thoughts were with regards to the concerns identified with the glucometers' disinfection observed on 2/4/25. She stated, It's unfortunate. She added that the facility initiated education and training then and there immediately after the concerns were brought to the facility's attention on 2/4/25. A telephone interview was conducted with the facility's Medical Director on 2/6/25 at 2:27 PM to discuss the concerns related to glucometer disinfection identified during observations conducted at the facility. When asked, the Medical Director reported she had been informed of these concerns. She stated, This is the first time I have heard of this happening. The Medical Director reported she thought glucometer disinfection required better learning or training for all staff throughout.

Based on record reviews, observations, and interviews with staff and Medical Director, the facility failed to provide an agency nurse (Nurse #1) with orientation and training to meet residents' care needs, including education and verification of the nurse's competency on glucometer (blood glucose meter) disinfection. Nurse #1 used a shared glucometer without disinfecting the meter between residents for 1 of 3 residents (Resident #107) who was observed to have her blood glucose checked. This occurred while there were 18 residents identified with a known bloodborne pathogen in the facility. There was a high likelihood that a resident without an existing blood borne pathogen could be exposed to a bloodborne pathogen as a result of staff not using the resident's dedicated glucometer, not knowing how to effectively clean and disinfect a glucometer, and staff not handling and storing the glucometer in a method to protect against cross-contamination via contact with other meters or equipment. Also, Nurse #2 (an agency nurse) failed to demonstrate competency with the disinfection of individually assigned glucometers stored outside of the residents' rooms in accordance with the instructions provided by the manufacturer of the disinfectant wipes for 2 of 3 residents (Residents #66 and #93) observed to have their blood glucose levels checked. This occurred for 2 of 2 nurses reviewed for training and competency (Nurse #1 and Nurse #2). Immediate jeopardy began on 2/4/25 when Nurse #1 failed to demonstrate competency as he used a glucometer dedicated to Resident #134 to check Resident #107's blood glucose without disinfecting the shared glucometer between residents. Immediate jeopardy was removed on 2/6/25 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) for finding #2 and for the facility to complete agency and employee staff training with monitoring to ensure appropriate interventions are put into place. The findings included: This tag is cross referred to: F880 Based on record reviews, observations, and interviews with staff and Medical Director, the facility staff failed to disinfect a shared blood glucose meter (glucometer) between residents for 1 of 3 residents (Resident #107) observed to have her blood glucose (sugar) level checked. This occurred while there were 18 residents identified with a known bloodborne pathogen in the facility. Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA)-registered disinfectant in accordance with the manufacturer of the glucometer potentially exposes residents to the spread of bloodborne infections. Care must also be taken by personnel handling and storing glucometers to protect the glucometers against cross-contamination via contact with other meters or equipment. Also, the facility failed to disinfect individually assigned glucometers stored outside of the residents' rooms in accordance with the instructions provided by the manufacturer of the disinfectant wipes for 2 of 3 residents (Residents #66 and #93) observed to have their blood glucose levels checked. 1. An interview was conducted on 2/4/25 at 6:17 AM with Nurse #1. When Nurse #1 was asked how long he had worked at the facility, he stated this was his first week. Upon further inquiry, the nurse reported he received a short orientation from facility for agency nurses. On 2/4/25, the facility provided a copy of the orientation packet given to agency nurses when they first began working at the facility. A review of the Information Packet for Registry Nurses revealed it contained information on the following topics: Welcome to [Name of Facility]; Important Guidelines (including dress code, personal devices, medication protocol, supplies, and identification); Admission Assessment (indicating the admission documentation required); Nurse Responsibilities in Admission; Daily Responsibilities; and Documentation Expectations. The orientation packet did not include any information about either the disinfection or storage of glucometers. During an interview conducted with the facility's Director of Nursing (DON) on 2/5/25 at 8:40 AM, the DON stated the only orientation material the facility provided for agency nurses was the Information Packet for Registry Nurses. She acknowledged the facility did not provide education on glucometer disinfection to agency nurses prior to the nurse working at the facility. The DON stated it was assumed that agency nurses had received training to ensure their overall competency to care for residents prior to being hired and assigned to work in their facility. A follow-up interview was conducted on 2/7/25 at 8:19 AM with the DON to inquire about the training / orientation provided to newly hired staff nurses. When asked, the DON reported that staff nurses went through an orientation program led by the facility's Staffing Coordinator and Human Resources Manager. She also noted new staff nurses were assigned a mentor to supplement their orientation. A telephone interview was conducted with the facility's Medical Director on 2/6/25 at 2:27 PM to discuss the concerns related to glucometer disinfection identified during observations conducted at the facility. When asked, the Medical Director reported she had been informed of these concerns. She reported this sounded like a training issue and stated, This is the first time I have heard of this happening. The Medical Director reported she thought glucometer disinfection required better learning or training for all staff throughout. The facility's Administrator and DON were informed of the immediate jeopardy (IJ) on 2/5/25 at 2:00 PM. The facility provided the following plan for IJ removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance On 02/04/2025, an agency nurse (Nurse #1) provided care without receiving proper orientation and competency validation regarding glucometer disinfection procedures. The nurse used a glucometer dedicated to Resident #134 for Resident #107 without proper disinfection between residents. When interviewed, the nurse stated they were unaware of facility policies and procedures for glucometer disinfection and did not know which products were approved for disinfection. All residents requiring blood glucose checks were identified as being at risk. An audit conducted by the Director of Nursing and nursing unit coordinators on 02/04/2025 identified all facility residents requiring blood glucose checks and confirmed the presence of residents with blood borne pathogens, creating risk for cross-contamination. The following immediate actions were taken: - At approximately 7:00 AM on 02/04/2025, upon discovery of the incident, Nurse #1 was immediately removed from resident care duties - The Director of Nursing contacted Nurse #1 by telephone regarding the requirement to complete comprehensive glucometer competency validation before accepting any future assignments at the facility 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 following systemic changes have been implemented as of 02/05/2025: 1. Comprehensive Glucometer Training and Competency Program: All licensed nurses (including facility staff and agency staff) must complete the following training and demonstrate competency before performing blood glucose monitoring: a. Required Equipment and Supplies: - Gloves - Glucometer - Alcohol pads - Single-use lancet - Blood glucose testing strips - Disinfecting wipes - Paper towels or tissues b. Complete Glucometer Procedure and Cleaning Steps: - Obtain needed equipment and supplies - Perform hand hygiene - Explain the procedure to the resident - Provide privacy - [NAME] gloves - Obtain capillary blood glucose sampling - Remove and discard gloves, perform hand hygiene prior to exiting the room - Retrieve (2) disinfectant wipes from container - Using the first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer - After cleaning, disinfect with second wipe, maintaining 3-minute wet contact time. Allow the glucometer to air dry - Discard disinfectant wipes in waste receptacle - Perform hand hygiene - Ensure glucometer is stored in individual plastic bag for each resident to prevent cross contamination - Place clean dry paper towel or tissue under glucometer before placing on resident table or on top of medication cart to prevent contamination 2. Competency Validation Process: Direct observation by nurse management of: - Complete blood glucose monitoring procedure as outlined above - Proper hand hygiene and glove use at specified steps - Correct glucometer cleaning and disinfection technique - Appropriate wet contact time monitoring - Proper barrier use and storage procedures - Return demonstration required for all steps - Documentation of competency verification in employee file - No blood glucose monitoring permitted until competency validated 3. Ongoing Monitoring: - The Director of Nursing maintains documentation of all completed competency validations - The staffing coordinator verifies completion of glucometer competency before scheduling Immediate Jeopardy Removal Date: 2/6/2025 The facility's credible allegation of immediate jeopardy removal was validated on 2/7/25. The validation was evidenced by nurse observations and/or interviews conducted on each hallway with regards to the required infection control practices for the disinfection of glucometers. All nurses who were interviewed reported they had received the required in-service training prior to beginning their shift. The education provided stressed the importance of using individually assigned glucometers for each resident requiring blood glucose monitoring and storing these glucometers in individual, re-sealable plastic bags. The in-service training also included a review of the manufacturer's instructions for the facility's glucometer and disinfectant wipes related to glucometer disinfection, as well as completing a return demonstration of the proper procedures for effective glucometer disinfection. Nurses observed to conduct blood glucose checks and subsequent glucometer disinfection completed the task without difficulty. The nursing practices observed included the proper handling and storage of glucometers to protect the meters from potential cross-contamination via contact with other meters or surfaces. There were no concerns identified during either the interviews or observations. The credible allegation was validated, and the immediate jeopardy was removed on 2/6/25. 2. An interview was conducted on 2/4/25 at 12:14 PM with Nurse #2. During the interview, the nurse estimated that she had worked at the facility four times in the last three months. On 2/4/25 at 12:35 PM, a follow-up interview was conducted with the nurse. At that time, Nurse #2 was asked if she received orientation upon starting to work at the facility. She stated, No, I did not. When asked, Nurse #2 reported she did not know how long a glucometer should remain wet (wet contact time) after using a disinfectant wipe to ensure the meter was adequately disinfected. On 2/4/25, the facility provided a copy of the orientation packet given to agency nurses when they first began working at the facility. A review of the Information Packet for Registry Nurses revealed it contained the following topics: Welcome to [Name of Facility]; Important Guidelines (including dress code, personal devices, medication protocol, supplies, and identification); Admission Assessment (indicating the admission documentation required); Nurse Responsibilities in Admission; Daily Responsibilities; and Documentation Expectations. During an interview conducted with the facility's Director of Nursing (DON) on 2/5/25 at 8:40 AM, the DON stated the only orientation material the facility provided for agency nurses was the Information Packet for Registry Nurses. She acknowledged the facility did not provide education on glucometer disinfection to agency nurses prior to the nurse working at the facility. The DON stated it was assumed that agency nurses had received training to ensure their overall competency to care for residents prior to being hired and assigned to work in their facility. A follow-up interview was conducted on 2/7/25 at 8:19 AM with the DON to inquire about the training / orientation provided to newly hired staff nurses. When asked, the DON reported that staff nurses went through an orientation program led by the facility's Staffing Coordinator and Human Resources Manager. She also noted new staff nurses were assigned a mentor to supplement their orientation. A telephone interview was conducted with the facility's Medical Director on 2/6/25 at 2:27 PM to discuss the concerns related to glucometer disinfection identified during observations conducted at the facility. When asked, the Medical Director reported she had been informed of these concerns. She reported this sounded like a training issue and stated, This is the first time I have heard of this happening. The Medical Director reported she thought glucometer disinfection required better learning or training for all staff throughout.

Based on observations and staff interviews, the facility failed to: 1) Discard expired medications on 2 of 5 medication (med) carts observed (Front 200 Hall Med Cart and Back 200 Hall Med Cart) and in 1 of 2 medication storerooms (400 Hall Medication Storeroom); and 2) Date medications as to when they were opened to allow for the determination of its shortened expiration date for meds stored on 2 of 5 med carts (Front 200 Hall Med Cart and Front 400 Hall Med Cart) and in 1 of 2 medication storerooms (400 Hall Medication Storeroom). The findings included: 1. An observation was conducted on 2/3/25 at 1:24 PM of the Front 200 Hall Medication (Med) Cart in the presence of Nurse #4. The observation revealed the following medications were stored on the med cart: a. One bubble-pack card containing 29 tablets of 0.125 milligrams (mg) hyoscyamine (a medication that may be used to treat muscle spasms in the bowel or bladder) was stored past its expiration date. The pharmacy labeling on the bubble-pack card indicated this medication was dispensed for Resident #46 on 5/23/23 and had an expiration date of 5/23/24. b. One stock bottle of 100 mg docusate (a stool softener) was stored past its expiration date. The stock bottle originally contained 200 softgels (with approximately 180 remaining in the bottle) and was observed to have a manufacturer expiration date of September 2024. c. According to the manufacturer, containers of latanoprost eye drops (a medication used to treat glaucoma) may be stored at room temperature up to 77 degrees Fahrenheit (o F) for 6 weeks. One opened bottle of 0.005% latanoprost eye drops dispensed from the pharmacy for Resident #160 on 12/2/24 was stored on the medication cart. The bottle was not dated as to when it had been opened to allow for the determination of its shortened expiration date. An interview was conducted on 2/3/25 at 1:38 PM with Nurse #4. After examining the labeling on the medications, Nurse #4 agreed the hyoscyamine and docusate medications were expired. She also expressed concern related to not knowing when the latanoprost eye drops dispensed for Resident #160 had been opened. Nurse #4 reported the resident's medications had been recently moved to this med cart, so she would check the resident's previous medication cart to see if there was another bottle of latanoprost dispensed for her on that cart. 2. An observation was conducted on 2/3/25 at 1:39 PM of the Back 200 Hall Medication (Med) Cart in the presence of Nurse #5. The observation revealed the following medications were stored on the med cart: a. One bubble-pack card containing 3 tablets of 40 milligrams (mg) rosuvastatin (a medication used to treat high levels of lipids and cholesterol in the blood) was stored past its expiration date. The pharmacy labeling on the bubble-pack card indicated this medication was dispensed for Resident #108. The labeling did not contain a legible dispensed date. However, the medication had an expiration date of 11/19/24. b. Twenty (20) syringes containing 0.5 mg lorazepam (an antianxiety medication and a controlled substance medication) was stored in the locked drawer of the medication cart. The medication was labeled by the pharmacy as dispensed for Resident #150 on 12/2/24 with an expiration date of 12/19/24. An interview was conducted with Nurse #5 at the time of the med storage observation on 2/3/25 at 1:39 PM. During the interview, the nurse confirmed the rosuvastatin and lorazepam identified on the med cart were expired. Nurse #5 reported she would remove both medications from the med cart and bring them to the Director of Nursing (DON). 3. According to the manufacturer, in-use prefilled pens of Lantus insulin should be stored at room temperature and used within 28 days. An observation was conducted on 2/4/25 at 6:22 AM of the Front 400 Hall Medication (Med) Cart in the presence of Nurse #1. The observation revealed an in-use Lantus insulin pen dispensed for Resident #175 was not labeled as to when it was opened to allow for the determination of its shortened expiration date. Additionally, the label on the insulin pen did not indicate when it was dispensed from the pharmacy. At the time of the observation conducted on 2/4/25 at 6:22 AM, Nurse #1 was shown the insulin pen and asked when it had been opened. Nurse #1 stated he did not know and confirmed there was no date written on the pen to indicate when it was opened. 4. An observation was conducted on 2/4/25 at 6:30 AM of the 400 Hall Medication Storeroom in the presence of Nurse #1 and the facility's Director of Nursing (DON). The observation revealed the following medications were stored in the medication storeroom: a. The manufacturer's storage instructions for a multi-dose vial of Tuberculin PPD (Purified Protein Derivative) injectable solution (used for skin testing in the diagnosis of tuberculosis) indicated that once opened, the product should be discarded after 30 days. One (1) opened multi-dose vial of Tuberculin PPD injectable solution was stored in the med room refrigerator. Neither the vial nor the manufacturer box it was stored in were labeled as to when the vial had been opened to allow for the determination of its shortened expiration date. b. Three (3) unopened stock bottles of 100 micrograms Vitamin B-12 were stored in the medication storeroom. Each bottle contained 100 tablets and was labeled to have a manufacturer expiration date of January 2025. An interview was conducted with the Director of Nursing (DON) at the time of the med storage observation conducted on 2/4/25 at 6:30 AM. At that time, the DON reported that the Tuberculin PPD injectable solution needed to be discarded, and the stock bottles of Vitamin B-12 also needed to be removed from the medication storeroom due to being past their expiration date. A follow-up interview was conducted with the DON on 2/7/25 at 8:21 AM. During the interview, the medication storage observations were discussed. The DON reported she had been made aware of the concerns related to expired medications and the failure to date medications as to when they were opened.

Based on record review, and resident, staff and Nurse Practitioner interviews, the facility failed to protect the rights of residents from resident to resident abuse for 4 of 5 residents reviewed for abuse. (1) On 8/2/2024, two residents, Resident #52 and Resident #104, who had a previous history of a resident-to-resident altercation on 6/9/2024, were involved in a resident to resident altercation in the smoking area. Nursing staff responded to a loud noise from the smoking area and observed Resident #52, who had a history of aggressive behavior, lying on the concrete floor of the smoking area. Resident #104 was observed sitting in his wheelchair. Resident #52 and Resident #104 were observed swinging their arms and hitting each other. The nursing staff immediately separated Resident #52 and #104. (2) On 10/20/2024, Resident #47 struck Resident #17 in the face when Resident #17 did not move for Resident #47 when Resident #47 entered the smoking area. Findings included: 1. Resident #52 was admitted to the facility on [DATE] with diagnoses including traumatic brain injury and a stroke. Resident #52's care plan included a focus revised on 3/27/2024 for verbal and physical aggressive behaviors towards the staff and other residents. Altercations with another resident was recorded on 6/9/2024 and 8/2/2024. The goal for Resident #52's behaviors was to have fewer episodes of verbal aggression and demonstrate effective coping skills. Interventions included increased monitoring that included every 15 minute checks to one-to-one staffing and psychiatric evaluations for behaviors. Resident #52's smoking assessment dated [DATE] indicated Resident #52 was an unsupervised smoker (the ability for a resident to go to the designated smoking area without the supervision of a staff member) The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #52 was cognitively intact and physical behaviors had been directed toward others for 1-3 days. The MDS also indicated Resident #52 could independently operate his wheelchair. Resident #104 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus and end stage renal disease. Resident #104's smoking assessment dated [DATE] indicated Resident #104 was a unsupervised smoker. Resident #104's care plan dated 6/10/2024 recorded Resident #104 exhibited behaviors evidence by a resident to resident altercation in which Resident #104 struck another resident. Interventions included immediate separation from the other resident, one-to-one monitoring, caregivers providing opportunity for positive interactions and attention by stopping by and talking with Resident #104 and explaining and reinforcing why Resident #104's behavior was inappropriate and unacceptable. The care plan was revised on 7/2/2024 to include every 15 minute checks and on 8/3/2024 for one-to-one monitoring. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #104 was cognitively intact and independently operated his wheelchair. Resident #104 was not coded for any behaviors during the 7-day look back period of the MDS assessments. An incident report for Resident #52 dated 8/2/2024 at 7:30 pm completed by the Director of Nursing (DON) reported Resident #52 was involved in a resident -to- resident altercation with Resident #104 that initially started as a verbal confrontation. When Resident #104 rolled past Resident #52, a physical altercation occurred and Resident #52 was pushed to the floor. Resident #52 and Resident #104 were immediately separated and Resident #52 was assessed by a nurse. Resident #52 refused to make a statement. Immediate action included immediate separation of Resident #104 and Resident #52 and placing Resident #52 on increased monitoring (every 15 minute checks), an assessment of Resident #52, a psychosocial and behavioral assessment and a skin assessment that reported an abrasion to Resident #52's back right shoulder and bruise to face, and back right shoulder. The Physician and Resident #52's Representative was notified. The incident report recorded no witness were found to the resident-to- resident altercation. Nursing documentation recorded the following: - 8/2/2024 at 10:47 pm by Nurse #26: Resident #52's representative was at bedside and Resident #52 was medicated for complaints of right neck pain, right inner thigh pain after the resident- to- resident altercation with Resident #104. Nursing documentation further recorded Resident #52 refused to go to the hospital for further evaluation. - 8/3/2024 at 10:20 am by the DON: Resident #52 sustained a fall to the floor as a result of physical contact with Resident #104. Resident #52 was assessed for injuries that included bruise and abrasion to the back of the right shoulder, right upper back and bruise to face and cheek. Resident #52 was placed on increasing monitoring (15 minute checks) at time of incident and Resident #52 representative notified. - 8/3/2024 at 12:46 pm by the DON: Resident #52 placed on one-to-one supervision due to incident with another unidentified resident and Resident #52 was agitated about having one-to-one supervision. - 8/3/2024 at 1:28 pm by Nurse #27: Psychiatry telehealth evaluation completed and Resident #52 was ordered haloperidol (an antipsychotic medication used to treat agitation and acute psychosis to improve thinking, mood and behavior) 1 milligram (mg) twice a day for agitation. Physician orders dated 8/3/2024 included an one-time order for haloperidol 1 mg for explosive personality disorder and an order for haloperidol twice a day for explosive personality disorder. There was an order to discontinue haloperidol on 8/5/2024. Physician progress notes dated 8/5/2024 recorded Resident #52 continued to have occasional aggressive behaviors and altercations with other residents. Resident #52 was on one-to-one supervision due to a resident-to- resident altercation where Resident #52 and Resident #104 were hitting each other. Resident #52 sustained bruise to right shoulder, back and left cheek and denied any discomfort. The physician recorded Resident #52's representative voiced concerns with Resident #52 sleepiness after psychiatry physician started Resident #52 on Haloperidol 1 milligram twice a day and was sent to the hospital per Resident #52's representative request for evaluation of ongoing progressive behaviors and fall after the one-to-one altercation on 8/2/2024. Follow up physician progress notes dated 8/6/2024 post the hospital visit recorded radiology tests were negative for injury. Resident #52 complained of back pain and was started on Oxycodone 5 milligrams for pain for 5 days. Psychiatric physician notes dated 8/14/2024 recorded anxiety as possible cause for Resident #52's impulsive behavior and agitation. There was no changes in Resident #52's medications and monitoring Resident #52's behaviors, using different smoking areas and avoiding triggers that caused altercations with others was the plan. The psychiatric physician note further stated one-to-one supervision was at the discretion of the facility. An incident report for Resident #104 dated 8/2/2024 at 7:00 pm completed by Nurse #23 recorded Resident #104 stated Resident #52 came up to him and started yelling at him and hitting him on his shoulder and legs. Resident #104 stated he hit Resident #52 back to defend himself. He stated an nurse aide came and assisted with separating the two residents. Immediate actions included one-to-one supervision until completion of the investigation, notification of physician, an assessment of Resident #104, skin assessment, psychological assessment and behavioral assessment for Resident #104. Resident #104 was observed with no injuries. The incident report indicated Resident #104 was his own representative. Physician progress notes dated 8/6/2024 recorded Resident #104 was on one-to-one supervision and received no injury from the resident-to-resident altercation on 8/2/2024. There was no physician order for a psychiatry evaluation in Resident #104's electronic medical record. In a written statement from Resident #104 dated 8/3/2024, Nurse #23 recorded Resident #104 stated Resident #52 went charging at him and Resident #104 went on Resident #52, hitting Resident #52 really hard and knocking Resident #52 out of his wheelchair. Resident #104 stated Resident #52 hit him in the face, beat Resident #104 on his leg and called Resident #104 bitches. The Initial allegation report dated 8/3/2024 and signed by the former Director of Nursing was submitted to the state agency. The initial allegation report recorded Resident #52 an Resident #104 were noted with a verbal altercation that escalated to Resident #52 and Resident #104 physically struck each other when Resident #104 rolled past Resident #52 in a wheelchair. Resident #52 and Resident #104 were immediately separated and placed on one-to-one supervision to ensure the safety of others and an investigation was initiated. The initial allegation report recorded follow-up assessments on Resident #52 reported minor injuries that required no treatment and reported Resident #104 with no injuries. An psychosocial assessment completed on both Resident #52 and Resident #104 reveal no mental anguish. The initial allegation report recorded the local police department was notified on 8/3/2024 at 10:15 am. A review of witness statements from residents dated 8/2/2024 and 8/3/2024 reported Resident #52 and Resident #104 were in the smoking area when Resident #52 and Resident #104 started arguing and hitting each other. Resident #52 stood up from his wheelchair and fell to the ground. Nursing staff came and split Resident #52 and Residennt #104 up. A review of witness statements from nursing staff dated 8/3/2024 when interviewed by Nurse #23 stated the resident-to-resident altercation had started prior to the nursing staff arriving on the scene, and Resident #52, who was lying on the ground and Resident #104, who was in his wheelchair, were swinging their arms hitting each other. The 5-day investigation report dated 8/9/2024 and signed by the former Director of Nursing was submitted to the state agency for resident abuse and reported per witness statements obtained Resident #52 came to the smoking area where Resident #104 was at and verbally began to argue with Resident #104. Resident #52 struck Resident #104 and after being struck, Resident #104 struck Resident #52 back and Resident #52 stood up from his wheelchair. Resident #52 and Resident #104 were separated, placed on one-to-one supervision and assessed by the nursing staff. Resident interviews were completed with interviewable residents and skin assessments completed on non-interviewable residents with no new findings. Staff interviews completed to identify any other potential for resident -to- resident altercation or increased agitation with no new findings. Resien #52 and Resident #104 remained on one-to-one supervision. The 5-day investigation report also recorded the Department of Social Service was notified on 8/5/2024 with no on-site visit conducted. On 2/3/2025 at 2:56 pm in an interview with Resident #52, he answered yes to having been in a resident-to-resident altercation and denied any injury from the altercation. He declined to talk about the resident-to-resident altercation. On 2/4/2025 at 6:38 am in an interview with Resident #104, he explained on 8/2/2025 when he was in the smoking area, Resident #52 put his hands like a fist to his chest when he went to go around Resident #52. He stated he struck Resident #52 back in the face and they continued to hit each other until staff arrived and separated Resident #52 and Resident #104. He said he was placed on one-to-one supervision for a while and stated there had been no further resident-to-resident altercations with Resident #104 or any other residents. On 2/4/2025 at 10:32 am in a follow up interview with Resident #52, when asked specifically about the resident-to-resident altercation in August 2024 with Resident #104, Resident #52 declined to discuss the altercation. He stated he felt safe in the facility and was not afraid of Resident #104 or any other residents. He stated he was placed on 1:1 supervision that was recently discontinued. On 2/5/2025 at 2:57 pm in an interview with Nurse Aide (NA) #11, she remembered Resident #52's and Resident #104's resident-to-resident altercation on 8/2/2024 occurring in the smoking area. She stated she was assisting another resident to the smoking area and observed Resident #52 on the ground and another staff member was moving Resident #104's wheelchair back away from Resident #52 to separate the residents. She stated Resident #104 went to the smoking area to smoke daily, and Resident #52 seldom went to the smoking area since the weather turned cold outside. NA #11 was unaware of any further resident-to-resident altercations between Resident #52 and Resident #104 since 8/2/2024. On 2/5/2024 at 3:10 pm in an interview with NA #10, she stated she was assigned one-to-one supervision to Resident #52 after the resident-to-resident altercation with Resident #104. She stated Resident #52 informed her that Resident #52 and Resident #104 were arguing, cursing and Resident #104 tried to run over him with Resident's wheelchair. She stated she was not present during the resident-to-resident altercation. On 2/5/2024 at 3:20 pm in an interview with the Transportation Coordinator, she stated on 8/2/2024 while walking in the hallway, she heard loud cursing from outside in the smoking area. She responded to the area and observed Resident #104 in his wheelchair on top of Resident #52 who was on the concrete ground. She stated she called for help and other nursing staff responded to help separate Resident #52 and Resident #104. She said she was not aware of any other resident-to-resident altercations since August 2024 between Resident #52 and Resident #104, and she had noticed Resident #52 and Resident #104 stayed away from each other in the facility. She explained the nursing staff also tried to ensure Resident #52 and Resident #104 were not in the same area at the same time to prevention any other resident-to-resident altercation. On 2/6/2025 at 7:08 am in an interview with Nurse #25 she stated Resident #52 and Resident #104 had a history of verbal and physical altercations and recalled Resident #52 and Resident #104 on one-to-one supervision after a resident-to-resident alteration. She explained Resident #52 would argue with other residents if he did not like them and was sexually inappropriate with nursing staff. She said the nursing staff tried to keep Resident #52 away from other residents to keep a peacefu environment. She stated Resident #52 usually stayed in his room and went to the smoking area during the night. Nurse #25 was unable to recall any further resident-to-resident incidents involving Resident #52 since August 2024 and stated the Director of Nursing determined when one-to-one supervision was discontinued for residents. Nurse #25 stated Resident #104 usually didn't argue with other residents unless he was provoked, and Resident #104 spent a lot of time outside the facility. She explained Resident #52 and Resident #104 were to smoke in separate smoking areas or at different times to prevention further resident-to-resident- altercation. On 2/7/2025 at 7:53 am in an interview with Smoking Aide #3, she stated after the resident-to-resident altercation between Resident #52 and Resident #104 in August 204, the Administrator had informed the smoking aides (smoking aide: a person who supervised the resident smoking area) that Resident #52 and Resident #104 were not to be together in the smoking area. She explained Resident #104 came out to smoke all the time with no verbal or physical aggressive behaviors observed toward other residents or staff. She explained Resident #52 had a sitter for a long time period and would go to the employee smoking area to smoke until it became too cold to come outside to smoke. Attempts to interview Nurse #23, who no longer worked at the facility, were unsuccessful. On 2/7/2025 at 10:18 am in a phone interview with Nurse Practitioner #2, she explained she was no longer working with the facility and did not have access to residents' medical records. She recalled Resident #52 and Resident #104 having two resident-to-resident altercations (6/24/2024 and 8/2/2024). She explained Resident #104 was displaying a new behavior and no medications were ordered to manage his behavior and could not recall if a psychiatry evaluation was ordered. She stated Resident #52 had a history of aggressive behaviors toward others and was followed by psychiatry for depression. She stated Haloperidol was ordered in an attempt to manage Resident #52's aggressive behaviors after the resident-to-resident altercation on 8/2/2024 and was discontinued at the request of Resident #52's Representative due to a concern causing Resident #52 to be drowsy. She explained Resident #52 and Resident #104 were placed on one-to-one supervision, and the Director of Nursing determined when one-to-one supervision was discontinued based on when no aggressive behaviors were observed. On 2/7/2025 at 6:53 pm in a phone interview with the former Director of Nursing (DON), she recalled Resident #52 and Resident #104 engaging in a couple of resident-to-resident verbal and physical altercations while working at the facility. She recalled completing the initial and investigation report for the state agency and stated Resident #52 would not provide the facility with a statement. She stated the goal of the facility was to keep Resident #52 and Resident #104 safe. She explained Resident #52 and Resident #104 were placed on one-to-one supervision, and their behaviors were monitored until behaviors stabilized. She stated staff ensured Resident #52 and Resident #104 were smoking in different smoking areas even with one-to-one supervision. She explained Resident #52 had a psychiatric evaluation with a medication change ordered, and she was unable to recall if Resident #104 was ordered a psychiatric evaluation. She stated the facility initiated and completed a plan of correction after the resident-to-resident altercation and was unable to recall any further resident-to resident altercations between Resident #52 and Resident #104 after 8/2/2024. On 2/7/2024 at 5:24 pm in an interview with the Director of Nursing, who started in October 2024, she stated Resident #52 had been choosing not to leave his room and when he went to smoke, there was one-to-one supervision with Resident #52 in the smoking area. She explained Resident #104 had not been on one-to-one supervision since she started in October 2024. She stated the nursing staff continued to monitor Resident #52 and Resident #104 for behaviors and were to report any behaviors exhibited by the residents to Administration immediately. She stated there had been no further resident-to-resident altercations with Resident #52 and Resident #104 or with other residents reported since October 2024, On 2/7/2024 at 4:53 pm in an interview with the current Administrator, he stated he started at the facility three weeks ago. He stated Resident #52's one-to-one supervision had been reviewed with the Director of Nursing, and it was determined on 1/31/2025 due to Resident #52 not exhibiting any inappropriate behaviors to discontinue the one-to-one supervision. He stated Resident #52 was on every 15 minute checks as long as there were no inappropriate behaviors observed toward others. On 2/7/2024 at 5:10 pm in an interview with the current Administrator, he explained Resident #52's one-to-one supervision for the resident-to-resident altercation was changed to every 15 minute checks on 8/5/2024 and was on one-to-one supervision until 1/31/2025 for inappropriate sexual behaviors toward the staff and not argumentative behaviors with other residents and staff. He stated Resident #104's one-to-one supervision was discontinued on 9/23/2024. 20906 2. Resident #47 was admitted to the facility on [DATE] with diagnoses of hypertension, diabetes, cerebral vascular accident, and left-hand contracture/hemiparesis. A focus area on the care plan dated 9/14/24 revealed Resident #47 had a behavior problem as evidenced by episodes of verbal/physical aggression towards other residents within the facility. The goal included Resident #47 would have no evidence of behavior problems. The interventions included on 10/20/24 one-to-one supervision, administer medications as ordered. Monitor/document for side effects and effectiveness. Assist him to smoke in separate supervised smoking areas. Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention and remove from the situation and take him to an alternate location as needed. Monitor behavior episodes and attempt to determine underlying causes. Consider location, time of day, person(s) involved, and situations. Document behavior and potential causes. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #47 was severely cognitively impaired with cognitive communication deficit and behaviors. Resident #17 was admitted to the facility on [DATE] with the diagnoses of metabolic encephalopathy, dementia, cerebral vascular accident, epilepsy, chronic obstructive pulmonary disease, schizophrenia, and lung cancer and cognitive communication deficit. The quarterly Minimum Data Set (MDS) dated [DATE], indicated Resident #17 was severely cognitively impaired and no behaviors. The initial allegation report dated 10/20/24 the facility became aware of the resident-to-resident altercation on 10/20/24 at 10:20AM while the two residents were outside on the patio. The alleged victim was Resident #17 and Resident #47 was the perpetrator. Resident #47 was observed by staff hitting Resident #17 in the face. Nurse Aide #6 and the Housekeeping Supervisor were present in the area. The Nurse Aide #6 immediately was able to remove Resident #17 from Resident #47's personal space. Nurse #19 notified the nurse practitioner and responsible parties for both residents. Nurse #19 assessed both residents and Resident #17 had a small swollen red around below the left eye. Resident #47 was placed on 1:1 supervision and x-rays were ordered for Resident #17. A review of the 5-day investigation report dated 10/24/24 revealed the x-ray results for Resident #17 was negative and both residents were evaluated by psychiatric services and Resident #47 was placed on 1:1 supervision and medications were adjusted. Both residents were provided with separate smoking areas. Skin assessments were done on other residents with no new findings. Other residents were interviewed about abuse and safety awareness and there were no new findings. Staff interviews and training on abuse and behavior management were completed. An interview was conducted on 2/3/25 at 11:30 AM with Resident #47 who stated he does not recall having an altercation with anyone. An interview was conducted on 2/5/24 at 2:24 PM, with the Housekeeping Supervisor who stated she was passing by the common area for the smokers when she heard Resident #47 telling Resident #17 to move out of the way. Resident #47 did not like others to be in his personal space. Resident #17 moved very slowly and as he was trying to move out of the way as the wheelchairs bumped into one another and Resident #47 hit him in the face. Resident #17 did not retaliate back to Resident #47. She further stated Nurse Aide #6 who was in the area immediately separated the two residents and the nurse supervisor was notified of the incident. An interview was conducted on 2/6/25 at 4:55 PM, with Nurse Aide #6 who stated she was assisting another resident with the door near the smoking area when she observed Resident #47 hitting and punching Resident #17 in the face. She stated she immediately separated the two residents; she stated the only time the two residents interacted with one another was during smoke breaks. She further stated this was the first time she had ever seen Resident #47 hit anyone. She reported the incident to the nurse supervisor. An interview was conducted on 2/7/25 at 12:35 PM, with Nurse #19 who stated he was informed of the altercation between Resident #47 and Resident #17. Resident #47 was upset with Resident #17 because he would not move out of his personal space and punched Resident #17 in the face. Nurse #19 stated the staff that was present separated the two residents immediately. Resident #47 was immediately placed on 1:1 supervision. He further stated a physical assessment was done for both residents. Resident #17's left eye was red and swollen. Nurse #19 stated he contacted the nurse practitioner and notified family of the incident. The nurse practitioner ordered x-rays to rule out any other injuries. He further stated there had been no other incidents between the two residents when the smoking environment was changed. An interview was conducted on 2/6/25 at 4:00 PM, with the Director of Nursing who stated she was informed of the altercation between Resident #17 and Resident #47. She stated the two residents were headed to the smoking area when Resident #47 asked Resident #17 to move out of the way. Resident #17 did not move away fast enough when Resident #47 hit Resident #17 in the face. The staff present immediately separated the two residents. Nurse #19 assessed both residents for injuries and notified the nurse practitioner and the responsible parties for both residents. Resident #17's left eye was swollen. Resident #47 was immediately placed on 1:1 supervision and referred for a psychological evaluation. Psych service evaluated Resident #47 on 10/23/24 and a medication adjustment was done. Resident #47 remained at 1:1 until the medication adjustment was effective. Resident #17 was sent out for x-rays to rule out any further injuries. The results from the x-ray were negative for any other injuries. Resident #17 was also seen by psych services and there were no changes or recommendations. She stated the care plans were updated for both residents to address behaviors. The Director of Nursing stated an evaluation was done of the smoking area by management and it was determined the previous location was too small for the number of residents who smoke; therefore, the location was changed to allow all residents space to smoke in comfort. Both residents were assessed for any behavioral issues/concerns, skin assessments were done for both residents for 72 hours. There were no further incidents or changes in physical or mental well-being for either resident. The Director of Nursing stated both residents were interviewed, and Resident #17 was able to state what happened but did not express any concerns of fear of Resident #47 or any other residents. Resident #47 stated nothing happened. She reported the social service staff conducted interviews with individual residents and during resident council about abuse and safety awareness and there were no concerns from the residents. The Director of Nursing stated both residents continue to smoke at leisure and have not had any further incidents since the changes were implemented in the smoking area. All current and newly hired staff were educated on abuse/dementia training. An interview was conducted on 2/6/25 at 5:00 PM with the current Administrator who stated the previous Administrator completed the compliance action plan and there had been no new behavior since the incident. He stated the change of environment for both residents have been beneficial in limiting the interactions with one another. He further stated the previous Administrator completed the investigation and implemented the corrective actions to monitor the smoking area and added assigned staff during scheduled smoking times. All staff have been educated on resident-to-resident behaviors, abuse, neglect in [DATE] as well as current. The Director of Nursing and Unit managers have been monitoring all resident behaviors and completing behavior assessment and making necessary referrals to psych services for evaluation when appropriated. A telephone interview was conducted on 2/7/25 at 10:15 AM, with the Nurse Practitioner #1 who stated she assessed Resident #17 following the altercation with Resident #47. Resident #17 complained of some pain in his face, and she ordered an x-ray to make sure there were no other injuries. She reported Resident #17 was already on scheduled pain medications and after a few days the swelling went down, and Resident #17 did not report any other concerns in relation to the incident. The facility implemented a corrective action plan: 8/2/2024 for the Resident #52 and Resident #104 altercation and 10/20/24 for Resident #17 and Resident #47 altercation. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 8/2/2024 at 7:30 pm, Resident #52 and Resident #104 were observed in a physical altercation and were separated by facility staff and taken to a separate area to interview. On 8/2/2024, initial head to toe assessments were completed by facility nurse with no apparent injuries for Resident #52 and Resident #104. A follow-up skin assessment by facility nurse revealed minor injuries to Resident #52 that required no treatment. On 8/2/2024, Resident #104 was placed on one-to-one supervision. On 8/2/2024, Resident #52's representative was notified of the resident-to resident altercation. Resident #104 was his own responsible party. On 8/2/2024, the physician was notified by facility nurse with no new orders for Resident #52 and Resident #104. On 8/2/2024, the facility nurse interviewed known resident witnesses. On 8/3/2024, Resident #52 and Resident #104 were re-interviewed by Director of Nursing. On 8/3/2024, Resident witnesses were reinterviewed by Director of Nursing. On 8/3/2024, Resident #52's physician was contacted by the Director of Nursing and new orders were received. On 8/3/2024, Resident #52 completed a telehealth visit with the mental health physician with new orders obtained. On 10/20/24, Resident #17 and Resident #47 were immediately separated by facility staff. Resident#47 was placed with 1:1 supervision. Resident #47 was assessed by the facility nurse on 10/20/24 with no negative findings or change of condition. Resident #17 was assessed by the facility nurse with pain and edema noted to left eye orbit and no other change of condition. On 10/20/24 the provider was notified by the licensed nurse of the assessment of findings for Resident#17. An order for x-ray was obtained. Resident #47's provider was notified and there were no new orders. On 10/20/24 Resident #17 was assessed for psychosocial harm by the licensed nurse with no ill effects. Resident #17 and Resident #47's responsible parties were notified of the incident by the licensed nurse. On 10/21/24 Resident #47's care plan was updated to include intervention for 1:1 supervision and Resident #14's x-rays returned with no findings related to this occurrence. Psych evaluation completed 10/23/24 for Resident #17 and Resident #47. Root cause analysis was conducted on 10/20/2024: Resident to resident altercation occurred between Resident #14 and Resident #47 in the smoking area. Resident #47 experienced frustration and tension due to overcrowding in the designated smoking space. The designated smoking area was too small to comfortably accommodate the number of residents who smoke. The facility's original space plan didn't adequately account for the number of residents who smoke and their need for personal space while smoking. The facility evaluated the current smoking area was too small which attributed to these behaviors, so the smoking area was moved to a larger area. Address how the facility will identify other residents at risk and determine if there were any identified problems for those residents: All residents were at risk. Resident interviews were completed with residents with a brief interview for mental [TRUNCATED]

Based on observations, resident interviews, staff interviews and record review, the facility failed to apply a left hand splint for 1 of 1 resident (Resident #47) reviewed for contractures. The findings included: Resident #47 was admitted to the facility on [DATE] with diagnoses of hypertension, diabetes, cerebral vascular accident, and left-hand contracture/hemiparesis. Review of quarterly Minimum Data Set(MDS) assessment dated [DATE] indicated Resident #47 was severely cognitively impaired. The MDS coded Resident #47 with left hand contracture. Review of the physician order dated 9/27/23 revealed please assist in the application of the left palmar guard to left hand. Resident #47 may wear the palmar guard all day except during the care and meals. Resident #47 may remove guard at his discretion. Check for signs and symptoms of skin breakdown and discoloration prior to and after administration. Every shift the palmar guard may be laundered or hand washed. Review of the occupational therapy discharge summary on 9/8/23 revealed Resident#47 was to wear left hand splint 6 hours without adverse reaction. This included no pain and no skin irritation. Resident #47 has demonstrated tolerance to left hand splint for approximately 8 hours. The discharge goal dated 9/7/23 revealed Resident #47 required assistance to apply splint. Resident #47 was able to take off splint independently due to discomfort and during meals/care. Review of the Medication Administration Records (MAR) December 1, 2024 through February 1, 2025 revealed Nurse #20 documented the repetitive statement that read: please assist in application of left palmar guard to left hand. Pt may wear the palmar guard all day except during care and meals. Pt may remove guard at his discretion. Check for signs and symptoms of skin breakdown and discoloration prior to and after administration. Every shift the palmar guard may be laundered in laundry or hand washed. The palmar guard was not in use today. There was no documentation in the record when the palmar was applied, refused or removed. Several attempts were made to contact Nurse #20 who was not available for interview. An observation was conducted on 2/3/25 at 11:00 AM, Resident #47 was observed rolling around the facility without the left hand palmar guard in place. There was a beige foam palmar guard available in the top drawer of the dresser. An observation of Resident #47 on 2/4/25 at 8:45 AM revealed the left hand had no palmar guard/splint in place. An observation was conducted on 2/4/25 at 11:03 AM in conjunction with an interview with Resident #47 who was sitting at bedside with his left hand clenched. The left hand palmar guard/splint was in the top drawer of the dresser with Resident #47's name on it. Resident #47 stated he needed assistance to apply the splint because he was unable to put the splint on himself. He stated that staff had not put the splint on in a long time. An observation was conducted on 2/4/25 at 2:30 PM, Resident #47 was in the smoke area and the left-hand palm splint was not in place. An observation was conducted on 2/5/24 at 8:20 AM, Resident #47 was lying in bed without the left hand palmar guard/splint. The splint was in the top dresser drawer. An observation was conducted on 2/5/24 at 10:00 AM, Resident #47 was rolling around the halls in the facility without the left hand palmar guard/splint. An observation was conducted on 2/5/25 at 1:30 PM, Resident #47 was at the nursing station and the left hand palmar guard/splint was not in place. An interview was conducted on 2/6/25 at 10:20 AM in conjunction with a record review with the Unit Manager #1 who reviewed the chart and confirmed there was a copy paste of the physician orders but no documentation of when the splint was applied, refused or removed. The Unit Manager #1 confirmed the Medication Administration Record documentation was only done by Nurse #20 and she was unable to determine when the splint was applied or removed throughout the day. The Unit Manager#1 stated she was unaware of the location of Resident #47's left hand palmar guard/splint and only observed Resident #47 wearing a glove. An observation was conducted on 2/6/25 at 10:25AM, Resident #47 was rolling around the facility in his wheelchair and the left hand palmar guard/splint was not in place. An interview was conducted on 2/6/25 at 10:33 AM with Nurse Aide #7 who stated she had not ever seen the resident with a splint on. She looked through the top drawer of the dresser and found a beige foam splint in the drawer. Nurse Aide #7 stated she had not seen that splint on Resident #47, nor had she applied the splint. She further stated she was unaware of who was responsible for documenting the application or how long Resident #47 should wear the splint. An interview was conducted on 2/6/25 at 10:36 AM, with the Smoke Aide #2 who stated that rehabilitation therapy staff was responsible for applying the hand splint. She stated she was not aware if the resident was consistently wearing the splint. An interview was conducted on 2/6/25 at 10:45 AM, with Nurse #21 who stated she was aware the resident should wear the splint all day, but she was unaware of the location of the splint. Nurse #21 further stated Resident #47 was non-compliant and she was unaware if therapy was notified that the resident was not wearing the splint. An interview was conducted on 2/6/25 at 10:56 AM, in conjunction with a record review with the Rehabilitation Director who stated the left-hand palm splint order had been in place since 9/8/23. The nursing staff and/or nurse aide were responsible for applying the splint daily per physician orders. Nursing should document when the splint was applied, refusal and removal. He stated he was unaware Resident #47 was not wearing the splint. The Rehabilitation Director reviewed the record and confirmed the Medication Administration Record(MAR), and nursing notes did not document when the splint was applied, refused or removed. The record confirmed repetitive statement of the physician order, and the care plan was not updated to reflect the splint application. He further stated the resident would need to be re-evaluated. An interview was conducted on 2/6/25 at 12:07 PM, in conjunction with a record review with the Director of Nursing who reviewed the record and confirmed there was no documentation of when Resident #47's splint was applied, refused or removed. She further stated nursing and/or nurse aide was responsible for the application of the splint in accordance with the physician orders. The nurses were responsible for documenting on the MAR when the splint was applied, refused or removed. An interview was conducted on 2/7/25 at 12:00 PM with the Administrator who stated he expected the nursing staff to follow the physician orders and therapy instructions for the application of the splint, document appropriately on the Medication Administration Record (MAR) and the Minimum Data Set (MDS) Coordinators to update the resident's care plan.

Based on observation, staff interviews and record review, the facility staff failed to provide care according to professional standards by borrowing medication from one resident (Resident #14) to give to another (Resident #8) for 1 of 5 residents observed during the medication administration observation. The findings included: Resident #8 was admitted to the facility on [DATE] with cumulative diagnoses which included hemiplegia (severe or complete paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (an ischemic stroke where blood flow to the brain has been interrupted) affecting the left dominant side, and atrial fibrillation (a type of irregular heart rhythm). Resident #14 was admitted to the facility on [DATE] with cumulative diagnoses which included a history of pulmonary embolism. On 2/5/25 at 9:08 AM, a continuous observation was conducted as Nurse #3 began to prepare thirteen (13) medications (meds) for administration to Resident #8. After the nurse had pulled 9 of the 13 medications, Nurse #3 began to look through other residents' meds stored on the medication cart. On 2/5/25 at 9:24 AM, Nurse #3 stated she had to find one as she was observed to take one tablet of 5 milligrams (mg) apixaban (an oral anticoagulant) dispensed from the pharmacy for Resident #14 to give to Resident #8. Afterwards, Nurse #3 completed pulling the medications for Resident #8 and was observed as she administered them to the resident. Resident #8's current physician's orders revealed her medication orders included 5 mg apixaban to be given as 1 tablet by mouth every 12 hours related to hemiplegia and hemiparesis following cerebral infarction affecting left dominant side and atrial fibrillation (Start Date 2/8/21). Resident #14's current physician's orders revealed her medication orders also included 5 mg apixaban to be given as 1 tablet by mouth every 12 hours for anticoagulation (Start Date 5/30/24). An interview was conducted on 2/5/25 at 12:14 PM with Nurse #3. During the interview, Nurse #3 was asked about the borrowing of apixaban from Resident #14 to give to Resident #8. The nurse stated that if a resident was out of a medication, nursing staff was supposed to order it from the pharmacy. However, she also reported that as an agency nurse (temporary staff member), she felt it was her responsibility to give all the medications to a resident and then reorder more if the supply of that medication was low (or out). When asked, Nurse #3 reported she had been coming to work at this facility approximately once a week for two months. The nurse reported she typically floated to work as a hall nurse on various halls. An interview was conducted on 2/5/25 at 3:43 PM with the facility's Director of Nursing (DON). During the interview, the borrowing of apixaban from one resident to give to another resident was discussed. The DON responded by stating, We can't do that. The DON reported that if an agency (or staff) nurse did not know what to do if a resident ran out of his/her prescribed medication, the nurse could ask for assistance from a Unit Manager, the Quality Assurance (QA) Nurse, or the DON herself. The DON reported she was fairly certain apixaban was readily available in the facility's automated emergency medication box. When asked if she thought the borrowing of medications was consistent with the provision of care in accordance with professional standards, the DON agreed it was not. A follow-up interview was conducted on 2/7/25 at 11:45 AM with the DON. At that time, the DON reported Resident #8's apixaban could have been obtained from the facility's emergency medication box (as 2 - 2.5 mg tablets of apixaban). She provided an Active Inventory list of medications currently available in the emergency medication box. These medications included 14 tablets of 2.5 mg apixaban.

Based on record review and staff interviews, the facility failed to develop a baseline care plan within 48 hours of admission for 1 of 9 residents reviewed for new admission (Resident #382). Findings included: Resident #382 was admitted on [DATE]. His diagnoses included influenza due to influenza virus with other respiratory manifestations, unsteadiness of feet, and muscle weakness. Review of Resident #382's baseline care plan initiated on 1/29/25 only included information on medication allergies and code status. An interview was conducted on 2/06/25 at 5:04 PM with Minimum Data Set (MDS) Coordinator #1. She stated upon admission that the initial care plans were completed by the admitting nurse. After reviewing Resident #382's baseline care plan, she noted it had been opened on 1/29/25, the date after admission, but not completed and only included his allergies and code status. She explained the baseline care plan should have been completed by the admitting nurse. An interview with the Director of Nursing (DON) was conducted on 2/07/25 at 9:20 AM. The DON stated the baseline care plans should have been completed with the admission assessment.

Based on record review, staff interviews and Resident Council Interview, the facility failed to resolve grievances that were reported during Resident Council meetings for 3 of 3 consecutive months (November 2024, December 2024 and January 2025). Findings included: The Resident Council minutes were reviewed for the past 12 months and it was observed the most recent 3 months (November 2024, December 2024 and January 2025) did not include resolutions to the concerns expressed. - November 13, 2024, Resident Council Meeting minutes noted concerns about receiving their medications late on night shift. - December 27, 2024, Resident Council Meeting minutes noted concerns night shift was not answering call lights. - January 24, 2025, Resident Council Meeting minutes noted concerns regarding nurse and nurse aide care on night shift. During the Resident Council Interview on 2/05/25 at 2:30 PM, residents present stated they had ongoing concerns regarding the night shift staff and did not think their concerns had been resolved related to receiving medications, call lights and nurse and nurse aide care. An interview with the Activities Director was conducted on 2/07/25 at 12:01 PM. She stated when there was a concern, she would write it up on a grievance notice and would give it to the responsible party for follow up. She explained she thought she had written up grievances but would have to check. An interview with the Administrator was conducted on 2/07/25 at 3:55 PM. The Administrator stated he had attended the January Resident Council Meeting and had asked if anything was unresolved, and they said they had no concerns. After checking for grievances from the Resident Council from November, December and January, none were discovered. He stated he would expect all grievances to be documented and addressed.

Based on record review and resident, staff, and Nurse Practitioner interviews, the facility failed to protect 1 of 3 residents (Resident #3) right to be free from physical abuse when Resident #4 assaulted Resident #3 which resulted in chest pain, left thumb pain, swelling and an x-ray being ordered to the chest and thumb. Resident #3 was administered Acetaminophen as needed (PRN) for pain. This assault made Resident #3 feel scared. Findings included: Resident #3 was admitted to the facility on [DATE] with diagnosis that included vascular dementia, bipolar disorder, major depressive disorder, and anxiety disorder. Resident #3's annual Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact, had no behaviors coded, required extensive assistance with bed mobility and transfers. Resident #4 was admitted to the facility on [DATE] with diagnosis that included cognitive communication deficit, muscle weakness, restlessness and agitation, dementia, major depressive disorder and received 7 days of antidepressant medication. A review of Resident #4's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired, had no coded behaviors and was independent with bed mobility and supervision with transfers. Review of the Initial Allegation Facility Reported Incident (FRI), submitted to the N.C Department of Health and Human Services (DHHS) on 8/27/2023 at 3:22am by the facility administrator revealed facility was aware of resident-to-resident abuse at 2:07am on 8/27/2023. The initial FRI report indicated that Resident #4 was upset that Resident #3 had his TV and bedside light on at 1:45am. The report also indicated that Resident #4 threw his bedside table, glass of water at Resident #3 and then got up and punched Resident #3 in the chest twice. Resident #4 was moved to a private room and placed on every (Q)15-minute checks. The facility then submitted to the NC DHHS an investigation report on 8/31/2023, that revealed Resident #3 upon interview with facility social worker (SW) stated he did not feel safe with Resident #4 remaining on the unit after the resident-to-resident abuse. The investigation report further revealed statements by nursing staff. Written statement from Nursing Assistant (NA) #1 dated 08/28/2023, used by the facility during their initial investigation, revealed NA #1 stated Resident #4 was complaining, wanting Resident #3 to turn off TV so he could rest. NA #1 continued to state that Resident #4 couldn't get his way, and assaulted Resident #3. NA #1 also stated when she got to the room, the table appeared thrown against Resident #3, both him and his property were wet, he was shaking, appeared red and crying. On 9/27/2023 at 10:44am a telephone interview was conducted with NA #1 in reference to the resident-to-resident abuse between Resident #3 and Resident #4. NA #1 stated while doing night shift room rounds, Resident #4 had told her, Resident #3 did not want to turn off his TV. NA #1 told Resident #4 that she would notify the Nurse on duty (unknown). NA #1 notified Nurse on duty (unknown). NA#1 went on to state, 15 minutes later while doing room rounds, she went back to his room and upon entering the room Resident #3 was shaking, upset and afraid, had a red mark line across his clavicle, his left hand was balled up, his thumb looked like it was jumped and had water all over his overbed table, face, gown, and bed. NA #1 called out for assistance and other nursing staff (including Nurse #1, NA #2) came into his room. Resident #3 stated to NA #1 that Resident #4 had stood up from his wheelchair, pushed his table against his chest, threw water all over him and hit his face twice. Written Statement on 08/27/2023 by Nurse #1 used during facility initial investigation revealed Nurse #1, upon arriving to room, noted tray from Resident #4 was on top of Resident #3, water was also covering Resident #3, his gown, phone, and he was visibly trembling. Written statement from NA #2 dated 08/28/2023, used by the facility during their initial investigation, revealed NA #2 went to room after NA #1 called for assistance. NA #2 indicated that the bedside table was turned over onto Resident #3 and his hand was hurt. A review of Resident #3's nurse note dated 8/27/2023 at 5:02am written by Nurse #1 revealed Resident #3 and his roommate Resident #4 got into an altercation regarding the TV being on. Resident #4 liked the TV off at night and Resident #3 liked the TV on. The note further stated the altercation between Resident #3 and Resident #4 was unwitnessed. Nursing Assistant (NA) #1 heard the commotion and called out for help. Nurse #1 went to residents' room and found Resident #3 visible shaking. Resident #4 was getting back into his bed and told staff that he wanted Resident #3 to turn the TV off. Resident #3 stated Resident #4 threw the bedside table to his chest as well as punched him. The nurses note continued with, Resident #3 at the time, complained of minimal pain and Acetaminophen was administered. Resident #4 was moved to a different room and the on-call provider has been notified. The nurse practitioner (NP)#1 ordered x-ray for Resident #3's left thumb and chest. On 09/28/2023 at 10:34 am, a telephone interview was conducted with Nurse #1 in reference to the resident-to-resident incident between Resident #3 and Resident #4. Nurse #1 indicated that she responded to a call for assistance from NA #1 in room (Resident #3 and Resident #4 room). Nurse #1 indicated that the tray table was leaning over Resident #3, who could not move. Nurse #1 indicated Resident #4 was moved to a different room in the same unit and was checked on frequently. Nurse #1 indicated prior to the resident-to-resident incident between Resident #3 and Resident #4, she was not notified of any disagreements or concerns from either resident by NA#1. A review of Resident #3 nurse practitioner note dated 8/27/2023 by NP #1 revealed nursing staff had reported Resident #3 was involved in altercation with his roommate (Resident #4). Resident #3 sustained an injury to his left thumb and had a bruise across chest from the bedside table. Resident #3 denied chest pain but reported pain to his thumb and Acetaminophen as needed (PRN) was given. The note further indicated that NP #1 ordered an x-ray of Resident #3's left thumb for swelling and chest due to bruising. Ice was applied to Resident #3's chest and thumb for pain and swelling. Nurses note dated 8/28/2023 at 10:14am written by Assistant Director of Nursing (ADON), indicated effective date 8/27/2023 at 1:45am, revealed Nurse #1 responded to a call for assistance from NA#1 that Resident #4 was upset that Resident #3 had his TV and light on. The note further indicated that, there was a bedside table toppled over and observed wet with water. The note also indicated that new orders were obtained for x-ray of the chest and hand for Resident #3 and Resident #4 had labs and Urine Analysis (UA) Culture and Sensitivity ordered. X-ray results for Resident #3 chest and hand revealed no evidence of fracture or acute abnormalities to left thumb or any abnormal findings to chest. A review of Resident #3's SW #1 note, dated 8/28/2023 at 10:34am, revealed Resident #3 recalled altercation with Resident #4. The note further indicated SW #1 identified Resident #4 as the aggressor. An in-person interview was conducted on 9/27/2023 at 3:27pm with SW #1 in reference to the resident-to-resident abuse that happened between Resident #3 and Resident #4. SW #1 indicated that Resident #3 recalled an altercation with Resident #4. SW #1 indicated Resident #3 stated he didn't feel safe and did not want to close his eyes, because he felt that Resident #4 would return to the room. SW #1 indicated that Resident #4 did not recall the resident-to-resident abuse. SW#1 also indicated that resident #1 had a psychiatry evaluation on 9/11/2023, and no new changes were made for his plan of care. SW #1 stated Resident #4 did not have any prior concerns or behaviors towards Resident #3 prior to the resident-to-resident abuse that occurred on 8/27/2023. Nurse Practitioner progress note dated 8/28/2023, written by NP #2 revealed Resident #3 was being seen for a follow up of resident-to-resident abuse and x-ray. NP#2 indicated Resident #3 was observed sitting up in his bed, awake and alert. Resident #3 informed NP#2 that on the day of the resident-to-resident abuse, he was sitting up in bed watching TV and his roommate (Resident #4) came out of the bathroom and came over to him, knocked his bedside table over onto his chest, threw water on him, and hit him twice in the face. Resident #3 further stated to NP#2, that he pressed his call bell for assistance and nursing staff came and removed his roommate (Resident #4) from the room. The NP #2 note also indicated Resident #3 stated that he did not want to close his eyes to go to sleep, because he felt nervous and did not feel safe. A telephone interview was done on 9/28/2023 at 12:02pm with NP #2 in reference to Resident #3 and Resident #4. NP#2 indicated that after the resident-to-resident abuse, Resident #3 informed her that he was nervous and did not feel safe after the incident. NP #2 indicated that Resident #4 did not remember anything about the resident-to-resident abuse. Interview with Resident #3 was completed on 09/26/2023 at 3:16pm. Resident #3 indicated that he recalled the incident that happened to him and his prior roommate Resident #4. Resident #3 indicated that Resident #4 wanted him to turn off his TV, and when he did not do that, Resident #4 got up from his wheelchair, beat him twice on the face, pushed the table at him and threw water all over him. Resident #3 continued to state that Resident #4 was moved to a different room. Resident # 3 further stated that he was afraid and could not even sleep at night after the incident. An attempt to interview Resident #4 on 09/26/2023 at 3:09pm revealed he could not recall anything about resident-to-resident abuse, between him and Resident #3. On 9/27/2023 at 10:23am, an interview was conducted with the Administrator. The Administrator indicated that he was notified of the incident between Resident #3 and Resident #4 by ADON on 08/27/2023 at 2:15am. The administrator stated he was in the facility at 3:45am. Administrator further stated that Resident #4 was moved to a different room in the same unit as Resident #3, before his arrival to facility and was asleep when he checked on him. Administrator stated that Resident #3 was still awake when he went to see him. The administrator also stated that Resident #3 was scared, complained of chest discomfort and his finger not doing well.

Based on observations, record review, resident, Nurse practitioner (NP)and staff interview, the facility's quality assurance (QA) program failed to implement, monitor, and revise as needed the action plan developed for the recertification surveys dated 8/12/2021 and 9/29/2022 and complaint surveys dated 3/2/2023 and 5/4/2023 in order to achieve and sustain compliance. These were repeat deficiencies cited during a complaint survey on 9/28/2023. The repeat deficiencies were in the areas of Minimum Data Set (MDS) Accuracy of (F641) and Resident-to-resident abuse (F600). The continued inadequate root cause analysis and lack of sustained compliance during five federal surveys of record shows pattern of the facility's inability to sustain an effective QA program. The findings included: This tag is cross-referenced to: F 600: Based on record review, resident interview, staff interview and Nurse Practitioner interview, the facility failed to protect 1 of 3 resident's (Resident #3) right to be free from physical abuse when Resident #4 assaulted Resident #3 which resulted in chest pain, left thumb pain, swelling and an x-ray being ordered to the chest and thumb. Resident #3 was administered Acetaminophen as needed (PRN) for pain. This made Resident #3 feel scared. These residents were reviewed for resident-to-resident abuse (Residents #3 and #4). During the previous complaint survey 5/4/2023. The facility failed to protect a resident's right to be free from physical abuse when a resident assaulted another for 1 of 3 residents reviewed for resident-to resident abuse. During complaint survey 3/2/2023. The facility failed to protect residents' right to be free from mistreatment for 2 of 4 residents investigated for staff to resident abuse. F 641: Based on record review and staff interview, the facility failed to accurately code Minimum Data Set (MDS) assessment in the area of Preadmission Screening and Resident Review (PASRR) for 1 of 3 sampled residents (Resident #3). During the previous annual recertification survey on 9/29/2022, the facility failed to accurately code the MDS for 1 of 1 resident reviewed for smoking. During the annual recertification survey on 8/12/2021, the facility failed to accurately code the MDS for 5 of 35 residents reviewed for antipsychotics, PASRR and pressure ulcer. An interview was conducted with the Administrator on 9/28/2023 at 1:13pm. During the interview the Administrator stated he was unable to provide an answer as to why the facility had not been able to achieve compliance with the repeated deficiencies. He stated all the citations would be reviewed, and a plan of correction would be put in place. The administrator continued that the Quality Assistant Assurance committee met regularly, identified areas of concern, conducted the root cause analysis, created the plan of correction, and discussed the outcome. The interdisciplinary team would continue monitoring until the deficient area of concern was resolved.

Based on observation, record review and staff interview and Nurse Practitioner (NP) interviews, the facility failed to allow 1 of 4 residents the choice to take a shower (Resident #1). Resident #1 was very sad and stated she felt less than a person not being able to get a shower. The findings included: Resident #1 was admitted to the facility on [DATE] with a diagnosis that included major depressive disorder and spinal stenosis. Review of physician order dated 3/20/20 revealed Resident #1 was to have a shower on Monday, Wednesday, and Friday. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #1 was cognitively intact and was dependent on 2 staff for bathing. The MDS assessment also noted it was very important to her to choose between a bed bath, tub bath or shower. Review of Resident #1's care plan dated 7/23/23 revealed she required staff assistance with activities of daily living secondary to impaired mobility and muscle weakness, associated with diagnosis of Multiple Sclerosis. The interventions included she would be provided a sponge bath when a full bath or shower could not be tolerated, receive extensive assistance of one staff person for mobility, and required a mechanical Lift. The shower documentation log revealed the following documented showers for Resident #1 recorded by Nurse Aide (NA) #5. - 8/31/23 - 9/14/23 - 9/19/23. An interview was attempted on 9/27/23 at 3:17 pm but not successful with NA #5. Resident # 1 was interviewed on 9/26/23 at 11:15 am. Resident #1 indicated that she was upset because she had not had a shower for over a year. She further indicated she had made a complaint that she had not been getting a shower on 8/17/23. Resident further stated she was unable to bend her hips, knees, and feet in order to sit in a shower chair, she also had contractures of both hands. The resident continued by indicating she was very sad and felt less of a person because she was not able to get a shower. Resident #1 further indicated she wanted to get a shower like she did when she was at home. The Assistant Director of Nursing (ADON) #2 was interviewed on 9/26/23 at 2:40 pm. She revealed she was not aware the facility had not provided Resident #1 with a shower or for others residents who would benefit from the use of a shower bed. Observation and interview with the Maintenance Director on 9/27/23 at 8:45 am revealed whirlpool room [ROOM NUMBER] and whirlpool room [ROOM NUMBER] had no shower head. The Maintenance Director indicated the whirlpool rooms were being used as storage and a shower head needed to be installed to provide residents with a shower that could not be showered in individual resident bathrooms. The interview further revealed individual showers in resident rooms would accommodate residents who used adaptive equipment such as shower chair. NA #4 was interviewed on 9/27/23 at 9:20 am revealed that she had not given Resident #1 a shower just a bed bath. Interview with the NP on 9/28/23 at 11:56 am revealed Resident #1 had ordered showers on Monday, Wednesday, and Friday. She further indicated she had not been notified that Resident #1 was not getting the ordered showers, but if the patient was getting clean, she would not expect them to call her for that. She lastly indicated she was not aware a shower bed was not available for any resident to get a shower. An interview with the Administrator on 9/28/23 at 4:00 pm indicated that he was not aware there was not a facility in the facility where residents could take a shower other than the residents' individual bedrooms. He further stated he did not know that not being able to take showers made Resident #1 feel sad and less of a person.

Based on record review, resident interview and staff interview the facility failed to follow the abuse policies in the area of protection after an allegation of abuse for 1 of 3 resident (Resident #3), by not implementing Q 15-minute checks on Resident #4 following a resident-to-resident abuse. The findings included: Resident #3 was admitted to the facility on [DATE] with diagnosis that included vascular dementia, bipolar disorder, major depressive disorder, and anxiety disorder. Resident #3's Annual Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact, had no behaviors coded, required extensive assistance with bed mobility and transfers. Resident #4 was admitted to the facility on [DATE] with diagnosis that included cognitive communication deficit, muscle weakness, restlessness and agitation, dementia, major depressive disorder and received 7 days of antidepressant medication. A review of Resident #4's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired, had no coded behaviors and was independent with bed mobility and supervision with transfers. Review of the Initial Allegation Facility Reported Incident (FRI), submitted to the N.C Department of Health and Human Services (DHHS) on 8/27/2023 at 3:22am by the facility administrator revealed facility was aware of resident-to-resident abuse at 2:07am on 8/27/2023. The initial FRI report indicated that Resident #4 was upset that Resident #3 had his TV and bedside light on at 1:45am. The report also indicated that Resident #4 threw his bedside table, glass of water at Resident #3 and then got up and punched Resident #3 in the chest twice. Resident #4 was moved to a private room and placed on every (Q)15-minute checks. The facility then submitted to the NC DHHS an investigation report on 8/31/2023, that revealed Resident #3 upon interview with facility social worker (SW) stated he did not feel safe with Resident #4 remaining on the unit after the resident-to-resident abuse. On 09/28/2023 at 10:34 am, a telephone interview was conducted with Nurse #1 in reference to the resident-to-resident incident between Resident #3 and Resident #4. Nurse #1 indicated that she responded to a call for assistance from NA #1 in room (Resident #3 and Resident #4 room). Nurse #1 indicated that the tray table was leaning over Resident #3, who could not move. Nurse #1 indicated Resident #4 was moved to a different room in the same unit and was checked on frequently. A review of Resident #3's SW #1 note, dated 8/28/2023 at 10:34am, revealed Resident #3 recalled altercation with Resident #4. The note further indicated SW #1 identified Resident #4 as the aggressor. Resident #3 stated he didn't feel safe and did not want to close his eyes, because he felt that Resident #4 would return to the room. An in-person interview was conducted on 9/27/2023 at 3:27pm with SW #1 in reference to the resident-to-resident abuse that happened between Resident #3 and Resident #4. SW #1 indicated that Resident #3 did share with her that Resident #4 did in fact come back to his room, after he was moved to a different room after the resident-to-resident abuse. SW #1 indicated that Resident #4 was moved from the room in the same unit as Resident #3, to a different room in another unit to ensure that Resident #4 would not come back to the room where Resident #3 resided. SW #1 indicated she interviewed Resident #4 on 8/28/2023 and he did not recall the resident-to-resident abuse that occurred on 8/27/2023 between him and Resident #3. SW#1 also indicated that Resident #4 had a psychiatry evaluation on 9/11/2023, and no new changes were made for his plan of care. SW #1 stated Resident #4 did not have any prior concerns or behaviors towards Resident #3 prior to the resident-to-resident abuse that occurred on 9/27/2023. Nurse Practitioner progress note dated 8/28/2023, written by NP #2 revealed Resident #3 was being seen for a follow up of resident-to-resident abuse and x-ray. NP#2 indicated Resident #3 was observed sitting up in his bed, awake and alert. Resident #3 informed NP#2 that on the day of the resident-to-resident abuse, he was sitting up in bed watching TV and his roommate (Resident #4) came out of the bathroom and came over to him, knocked his bedside table over onto his chest, threw water on him, and hit him twice in the face. Resident #3 further stated to NP#2, that he pressed his call bell for assistance and nursing staff came and removed his roommate (Resident #4) from the room. Resident #3 went on to state to NP#2 that Resident #4 came back twice after he was removed but did not approach him and staff quickly removed him from the room. The NP #2 note also indicated Resident #3 stated that he did not want to close his eyes to go to sleep, because he felt nervous and did not feel safe. A telephone interview was done on 9/28/2023 at 12:02pm with NP #2 in reference to Resident #3 and Resident #4. NP #2 indicated that Resident #4 was moved to a different room on the same unit and did not remember anything about the resident-to-resident abuse. NP#2 indicated that after the resident-to-resident abuse, Resident #3 informed her, that he was nervous and did not feel safe. NP #2 indicated Resident #3 informed her that Resident #4 had come back at least once to his room and staff had to assist Resident #4 back to his new room. NP#2 indicated she reassured Resident #3 of his safety. Review of the facility's Q 15-minute form, that was used to document checks on Resident #4, revealed Q 15-minute checks for Resident #4 were initiated on 08/27/2023 at 7:00am to 08/29/2023 at 10:45am, and then from 08/29/2023 at 7:30pm to 8/30/2023 7:30am. Q 15-minute checks from 8/27/2023 2:30am to 8/27/2023 6:45am and 8/29/2023 11am to 08/29/2023 at 7:15pm were not documented. The facility did not provide any other Q 15-minute check forms. Interview with Resident #3 was completed on 09/26/2023 at 3:16pm. Resident #3 indicated that he recalled the incident that happened to him and his prior roommate Resident #4. Resident #3 indicated that Resident #4 wanted him to turn off his TV, and when he did not do that, Resident #4 got up from his wheelchair, beat him twice on the face, pushed the table at him and threw water all over him. Resident #3 continued to state that Resident #4 was moved to a different room but Resident #4, after the incident, would come back to the room where he resided. Resident # 3 further stated that he was afraid and could not even sleep at night because Resident #4 kept coming back to his room for more than a week before Resident #4 stopped. An attempt to interview Resident #4 on 09/26/2023 at 3:09pm revealed he could not recall anything about resident-to-resident abuse, between him and Resident #3. Interview with NA #3 was conducted on 9/27/2023 at 2:10pm in reference to the resident-to-resident abuse that happened between Resident #3 and Resident #4. NA #3 indicated that Resident #4 was moved to a different room on the same unit as Resident #3, after the incident, and she had to complete Q 15-minute checks on Resident #4 but did not recall documenting this on any form. NA #3 indicated that Resident #4 did leave his room and NA #3 would redirect Resident #4 because he would come out and go towards the hallway of the room where Resident #3 resided. Interview with Nurse #2 was conducted on 9/27/2023 at 11:07am revealed that she was aware of the resident-to-resident abuse that happened between Resident #3 and Resident #4. Nurse #2 indicated that Resident #4 was moved to a different room on the same unit as Resident #3, after the incident. Nurse #2 indicated that she performed Q15-minute checks on Resident #4 while in his new room and documented using the Q15-minute check form. Nurse #2 also indicated that Resident #4 left his new room and went down the hallway of the room where Resident #3 resided but never got into the room. On 9/27/2023 at 10:23am, an interview was conducted with the Administrator. The Administrator indicated that he was notified of the incident between Resident #3 and Resident #4 by ADON on 08/27/2023 at 2:15am in which he informed ADON to initiate Q15-Minute checks on Resident #4 immediately. The administrator stated he was in the facility at 3:45am. Administrator further stated that Resident #4 was moved to a different room on the same unit as Resident #3, before his arrival to facility and was asleep when he checked on him. Administrator stated that Resident #3 was still awake when he went to see him. The Administrator also stated that Resident #3 was scared, complained of chest discomfort and his finger not doing well. The administrator indicated that after Resident #4 was moved to a different room on the same unit as Resident #3, Resident #4 did, at least once, go back to the room where resident #3 resided. The Administrator continued to state, that was the reason why Resident #4 was moved from the room on the same unit as Resident #3 on 8/30/2023, to another new room, in a different unit. The Q 15-minute checks from 8/27/2023 2:30am to 8/27/2023 6:45am and 8/29/2023 11am to 08/29/2023 at 7:15pm were not documented. Administrator indicated that he did not have the documentation for the Q 15minute checks from 8/27/2023 2:30am to 8/27/2023 6:45am and 8/29/2023 11am to 08/29/2023 at 7:15pm. The Administrator indicated that the Q 15-minutes checks were stopped on Monday 8/28/2023 because Resident #4 was moved to a different room after the resident-to-resident abuse.

Based on record review, resident, staff, physician, and Emergency Medical Services (EMS) staff interviews, the facility failed to assess and seek medical attention for a resident who reported shortness of breath for 1 of 1 resident reviewed for respiratory care (Resident #3). Resident #3 was transferred to the local emergency room and was treated for shortness of breath and significant anemia. The findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), shortness of breath, and anxiety. Review of physician's order dated 2/1/18 read: Oxygen at 5 liters (L) via nasal canula continuously every shift for COPD. Review of physician's order dated 3/7/18 read: Obtain vital signs every shift on Wednesday for monitoring. Review of physician's order dated 3/1/19 read: routine resident checks to help maintain resident safety and well-being at least every 2 hours, document exceptions in nurses notes every shift. Review of physician's order dated 12/1/22 read: Albuterol Sulfate Nebulization Solution (2.5MG/3ML) 0.083% 1 vial inhale orally every 3 hours as needed for shortness of breath. Review of Resident #3's Care Plan dated 5/22/22 revealed a focus area of Emphysema/COPD and the goal was for Resident #3 to display optimal breathing patterns daily through next review. Interventions included monitoring for signs and symptoms of acute respiratory insufficiency and administering aerosol or bronchodilators as ordered. An additional focus area dated 3/7/23 included a behavior problem as evidenced by overly anxious of medication administration and the goal was to have fewer behavioral episodes weekly by next review. Interventions included administer medications as ordered and to anticipate and meet the resident's needs. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively intact. The MDS further revealed that Resident #3 was able to make herself understood via clear speech, able understand others and received oxygen therapy during the assessment period. Review of Resident #3's Medication Administration Record (MAR) for April 2023 revealed the following: On 4/8/23 Albuterol was administered at 1:33 AM, 1:00 PM and at 5:18 PM. There were no additional breathing treatments documented on 4/8/23 by facility staff. A routine check was initialed on the MAR for Resident #3 by Nurse #3 on 4/8/23 at 2:34 PM and no additional checks were documented for the remainder of the day. Review of electronic record revealed vital signs documentation on 4/8/23 oxygen saturation level of 99.0% via nasal canula oxygen at 10:54 AM. There were no further vital signs documented on 4/8/23. A review of the rotation schedule for Residents #3's room revealed a total unit census of 64. Nurse #4 and Nursing Assistant #5 were assigned to Resident #3 on 4/8/23 7PM-7AM shift. Nurse #6 was assigned to the residents on the front end of the hall and Nurse #5 was assigned to the back end of the hall but was noted as a call out. There were no medication aide staff members noted on this schedule. A review of the facility staff punch detail noted Medication Aide #1 to have worked on 4/8/23 from 7:57 AM to 8:40 PM. Nurse #4 worked on 4/8/23 from 7:55PM to 7:31AM and Nurse #3 worked on 4/8/23 from 7:00AM to 8:30PM. Nurse #3 was interviewed on 6/14/23 at 11:55 AM. He revealed that he did not recall working on 4/8/23 but indicated that he was assigned to Resident #3 on a regular basis, and she was known to use her call light and to verbally notify staff if she has difficulty breathing. Review of Nurse #4 progress note dated 4/8/23 read in part; Resident #3 called EMS due to shortness of breath. EMS responded at 9:30 PM, resident was resistive to hospitalization initially but was sent to the hospital for evaluation and treatment at 10:55 PM. Nurse #4 was interviewed via phone on 6/14/23 at 2:08 PM. Nurse #4 recalled working on the evening of 4/8/23 but did not recall the specifics of receiving report from Nurse #3. She revealed Resident #3 was sent out to the hospital during her shift and she was unaware that she was assigned to the resident until EMS entered the building and approached her about Resident #3's health concerns. Once EMS made her aware of the situation, she walked down to the room to talk to Resident #3 and assist EMS with the transfer to the hospital. Resident #3 received treatment from EMS for her shortness of breath and then sent to the hospital. An interview was conducted with Nursing Assistant # 5 on 6/14/23 9:58 AM. She revealed that that she didn't recall the evening of 4/8/23 or the events leading up to Resident #3 being sent out to the hospital but was assigned to Resident #3. A telephone interview was conducted on 6/15/23 at 10:54 AM with Nurse # 5 who revealed she was not aware of this incident as she had to call out the evening of 4/8/23 and did not come into the facility on [DATE]. An attempt was made to interview Nurse #6 (agency) who was assigned to Resident #3's hall on 4/8/23 but on another section, but facility was not able to produce a contact number for the interview. A telephone interview was conducted with Medication Aide #1 on 6/15/23 at 2:43 PM and she revealed that she was not assigned to Resident #3 and did not administer medications to her on the evening of 4/8/23. She does not recall any staff member making her aware of Resident #3's concern of shortness of breath. An interview was conducted with Resident #3 on 6/13/23 at 1:41 PM. She revealed that she contacted EMS via 911 call on 4/8/23 due to having a lot of trouble breathing most of that evening and had requested her next dose of available medication for shortness of breath to the evening shift (7 PM-7 AM) nursing assistant but she told her it was too early for her medication. Resident #3 further revealed that she recalled telling her nursing assistant several times to let the nurse know again that she was still having trouble breathing and wanted her breathing treatment but was told that it was not time yet for her medicine. She waited about an hour and when the nurse still had not come to her room, she felt she had to call 911 to get help. EMS staff came in and gave her several treatments and they did help in part and felt that she did not need to go to the hospital. The EMS staff member and the doctor (via telephone) talked to her about their concerns and recommendation to go to hospital. She further revealed that when she went to the hospital, she was told that she was anemic and had to get a blood transfusion and was started on prednisone. Review of EMS incident report dated 4/9/23 revealed in part: Resident #3 contacted EMS by telephone on 4/8/23 at 9:33 PM and reported that she could not breath and had not had her medicine. EMS arrived at the facility at 9:43 PM and received a brief report by a staff member who indicated Resident # 3 had been asking for her medications due to shortness of breath, but it was not time yet for her to receive medication. At 9:44 PM, EMS staff found Resident #3 in a sitting position in her bed, alert and oriented to person, place, time, and situation. EMS staff checked oxygen saturation level at 9:44 PM and was at 97 % however Resident #3 was observed to be tachypneic (abnormal rapid breathing), pale, and having heavy chest wall movement. Resident #3 received the following medications that were administered by EMS staff between 9:46 PM through 10:37 PM. Oxygen at 8 lpm (liters per minute) via nasal cannula Albuterol 5mg (milligram) via nebulizer (used to treat respiratory conditions) Ipratropium 0.5 mg via nebulizer (used to treat respiratory conditions) 20 gauge Antecubital (arm in front of the elbow) Right Saline lock via IV. Albuterol 2.5 mg via nebulizer (used to treat respiratory conditions) Ipratropium 0.5mg via nebulizer (used to treat respiratory conditions) Methylprednisolone 125 mg intramuscular (used to treat for inflammation) Albuterol 5mg via nebulizer (used to treat for respiratory conditions) Ipratropium .5mg via nebulizer (used to treat for respiratory conditions) Consult with EMS physician and patient regarding high-risk refusal and counselling with patient regarding need for hospitalization . On 6/15/23 at 2:56 PM a telephone interview was conducted with the lead EMS crew member who treated Resident #3 on the night of 4/8/23. She revealed that she and two other EMS crew members arrived at the facility on 4/8/23 at approximately 9:40 PM. She observed Resident #3 sitting in bed with oxygen at 5 L via nasal cannula, and breathed very quickly and used her whole upper body to breath. She checked her oxygen saturation level, and it was at 97% but she was visibly breathing hard and could not get a full breath. Resident #3 was described as feeling clammy and sweaty to touch. The EMS crew member gave Resident #3 multiple breathing treatments, and her oxygen saturation level would go up but then fall back down and could not keep her stable without intervention. The lead EMS Staff member spoke with a facility staff member who was at the medication cart and asked why Resident #3 had not yet been assessed by a nurse or received medication to address her complaints of shortness of breath. The staff member responded that they were short of staff tonight due to a nurse call out and nobody has gotten down there yet and that she had not received medication because it was not time yet. She asked when the staff member thought someone would be able to get to Resident #3's room and was told that she did not know how long it would be until a nurse could get down to her room. The EMS staff member returned to Resident #3 to continue to treat her shortness of breath and to discuss hospital transfer. Resident #3 indicated at first that she did not want to go to the hospital but then after consulting with an EMS physician via telephone she decided to proceed with the hospital transfer, and they exited the facility around 10:55 PM that night. Review of the emergency department provider note from the local hospital dated 4/9/23 read in part; date of service 4/8/23 at 11:33 PM, diagnoses: anemia, acute dyspnea (breathing discomfort), shortness of breath and COPD exacerbation (worsening of respiratory symptoms associated with COPD). The provider notes further read in part: Resident #3's labs, were unremarkable with exception of significant anemia (not enough red blood cells or hemoglobin to carry oxygen throughout the body). A point-of-care basic metabolic panel (BMP) was performed to confirm. The BMP showed a hemoglobin level of 5.1 grams per deciliter (gm/dl) (a hemoglobin's normal range for a female is 12.3gm/dl and 15.3gm/dl) which resulted in Resident #3 requiring a blood transfusion of 2 units of packed red blood cells. She discharged back to the facility on [DATE] with a prescription for prednisone for the next 4 days. A telephone interview was conducted with Unit Manager/Nurse on call #1 on 06/15/23 at 10:54 AM who stated that she was on call the evening of 4/8/23 and was not notified by the facility of any staff call outs on 4/8/23 or any issues regarding Resident #3. If she were made aware of a call out it was her job to find a replacement or reorganize the assignment to ensure all residents have adequate staff available to them. An interview was conducted with the Director of Nursing (DON) on 6/15/23 at 3:40 PM and she revealed that if a resident was experiencing shortness of breath they should be assessed and provided medications as ordered by the physician. The Physician was interviewed at the facility on 6/14/23 at 1:20 PM. He explained that he was Resident #3' s physician and that it was his expectation that nursing staff assess any resident who has expressed or showed signs of shortness of breath and medicate according to the current orders.

Based on observations, record review and interviews with resident, family, staff, and Emergency Medical Services paramedic, Police Detective, Nurse Practitioner, psychiatry provider, and Medical Director, the facility failed to protect a resident's right to be free from physical abuse when a resident (Resident #1) assaulted another resident (Resident #2) for 1 of 3 residents reviewed for resident-to-resident abuse. On [DATE], Resident #1 approached his roommate (Resident #2) with a knife (described as a butter knife on a meal tray) to cut Resident #2's head. Resident #2 initially pushed Resident #1 away; however, Resident #1 returned to Resident #2's bedside multiple times and continued to cut his head with the knife. Resident #2 was a bedbound resident who was cognitively intact and, on an anticoagulant (apixaban). Resident #2 was unable to loudly shout out for help due to a history of a tracheostomy. While passing out lunch trays, a Nurse Aide (NA #1) observed Resident #1 standing beside Resident #2 and carving on his forehead. The attack ended and Emergency Medical Services (EMS) was called to transport Resident #2 to the hospital. Resident #2 sustained profuse bleeding with a 19-centimeter (cm) laceration on his forehead that exposed his skull, a 2-cm cut on the bridge of his nose, and multiple defensive wounds on his hands. He was taken to the hospital for treatment and required two units of fresh frozen plasm (used to help blood clot during active bleeding when a person is on a blood thinner), two units of packed red blood cells (used to replace blood when a person has had a large amount of bleeding with blood loss), sutures for the laceration, and pain management. Immediate Jeopardy began on [DATE] when Resident #1 assaulted Resident #2 with a knife. Immediate jeopardy was removed as of [DATE] when the facility implemented an acceptable allegation of Immediate Jeopardy removal. The facility remains out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) for the facility to continue staff education and ensure monitoring systems put into place are effective. The findings included: A review of Resident #1's hospital record dated [DATE] revealed the resident was initially found sleeping on the floor in a gas station. When he was told to leave, he got up, wandered around and failed to respond to anyone. The police were contacted, then EMS was called. EMS transported Resident #1 to the hospital Emergency Department (ED). Resident #1 was unable to provide much of his medical history and provided incorrect information of his place of residence. It was determined he had lived in at least 3 different group homes since [DATE]. Resident #1's Physical Examination in the ED Provider Notes was dated [DATE] at 12:37 AM. It reported the resident was initially cataleptic [a condition that disrupts a person's awareness of the world and their ability to move and communicate], waxy flexibility [a relatively rare symptom typically seen in catatonia where a person's limbs respond like a warm candlestick being moved and positioned], staring, mute. Then spontaneously converted to normal pleasant interactive behavior. The trigger for the resident's catatonia was unclear. A hospital ED Provider Note dated [DATE] at 8:40 AM read, Reached out to case management .case has been escalated to difficult placement. Another notation in the hospital record (dated [DATE] at 3:33 PM) reported the resident, Had an episode of leaving ED room and being found outside, now stable and back in room safely. Has had previous similar presentations in past. Resident #1 was discharged from the hospital and admitted to the locked Memory Care Unit (MCU) of the facility on [DATE]. His cumulative diagnoses included dementia with other behavioral disturbance and schizophrenia. The resident's admission orders included the following psychotropic medications: 20 mg citalopram (an antidepressant) to be given as one tablet by mouth one time a day; 1 mg lorazepam (an antianxiety medication) to be given as one tablet by mouth every 8 hours as needed for anxiety/agitation for 14 days; 80 mg lurasidone (an antipsychotic medication) to be given as one tablet by mouth one time a day for schizophrenia; and 10 mg asenapine (an antipsychotic medication) to be given as one sublingual tablet placed under the tongue each night at bedtime. Additional admission orders included the following: -- Monitor behaviors of anxiety/agitation. --Routine resident checks to help maintain resident safety and well-being at least every 2 hours, document exceptions in nurses notes every shift (documented by a check mark on the resident's monthly MAR with a Start Date of [DATE]). Resident #1's individualized care plan included the following areas of focus, in part: --[Resident's name] is not an elopement risk/wanderer r/t [related to] Dementia, Psychotic Disturbance and Mood Disorder. Date Initiated: [DATE]; Revision on [DATE]. --[Resident's name] has potential to have behaviors r/t Dementia, Mental / Emotional illness. Date Initiated: [DATE]; Revision on: [DATE]. --[Resident's name] uses psychotropic medications r/t Behavior management (Dx [Diagnosis] of schizophrenia). Date Initiated: [DATE]; Revision on: [DATE]. The resident's admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 had severely impaired cognition. He was reported as having no behaviors nor rejection of care during the 7-day look back period. The resident required supervision for walking in the corridor, locomotion on the unit and for eating; limited assistance for walking in his room and personal hygiene; and extensive assistance from staff for bed mobility, transfers, dressing and toileting. Resident #1 was seen for a Psychiatry Initial Consult by a Psychiatric Mental Health Nurse Practitioner (PMHNP) on [DATE]. The consultation progress note included an Assessment and Plan as follows: 1. Dementia: Provide supportive care. He takes citalopram for depression associated with dementia. Continue med. 2. Schizophrenia: Continue lurasidone as prescribed. Please report any change in behavior or mood. No changes at this time. 3. Insomnia: Continue melatonin (a nutritional supplement). Supportive care. Orders: Orders for this visit: None A review of Resident #1's April Medication Administration Record (MAR) revealed the resident was documented as having anxiety/agitation one time in April (on [DATE] during the 7:00 PM to 7:00 AM shift). He was administered one dose of lorazepam on [DATE] with the medication reported as having been effective. No other documentation of anxiety/agitation, side effects of the psychotropic medications, nor exceptions related to the routine resident checks were identified. An Interdisciplinary Team (IDT) Progress Note dated [DATE] at 5:52 PM was authored by the facility's Social Worker (SW). This note documented Resident #1 was moved from his room in the locked MCU to a room on the 200 Hall outside of the Unit as he no longer met the criteria to be in the MCU. The notation read, Appropriate staff will continue to monitor roommate compatibility. Accompanied by the facility's Administrator, Resident #1's new room was observed on [DATE] at 11:45 AM. Resident #1 was assigned to Bed A (the bed closest to the door) while his new roommate (Resident #2) remained in Bed B (the bed next to the window). The room was observed to be located just before the entrance to the MCU and at the farthest end of the hallway from the Nursing Station. On [DATE] at 9:27 AM, the facility's Maintenance Director reported the distance from Resident #1 and Resident #2's door to the Nursing Station was 126 feet. Resident #2 was initially admitted to the facility on [DATE] with re-entry to the facility on [DATE] after a hospital stay. His cumulative diagnoses included glaucoma, atrial fibrillation (a type of irregular heartbeat), chronic obstructive pulmonary disease, muscle wasting / atrophy, and chronic pain syndrome. The resident's most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. Resident #2 was assessed to have intact cognition. He was reported as having no behaviors nor rejection of care during the 7-day look back period. The resident was independent with eating, required supervision with dressing, extensive assistance for bed mobility and toileting, and he was totally dependent on staff for personal hygiene. Transfers, walking, and locomotion did not occur during the 7-day look back period. Resident #2's Care Plan included the following areas of focus, in part: --The resident has an Activities of Daily Living (ADL) self-care performance deficit and mobility deficit related to chronic health conditions. He needs staff assistance to complete daily ADL tasks (Date Initiated: [DATE]; Revision on: [DATE]). --The resident is on anticoagulant therapy related to atrial fibrillation (Date Initiated: [DATE]; Revision on: [DATE]). --The resident is at risk for pain .he has chronic pain and consults a pain clinic for treatment (Date Initiated: [DATE]; Revision on: [DATE]). A review of the resident's electronic medical record (EMR) indicated he was seen for a 60-day follow up visit on [DATE] from his Medical Doctor (MD) who also served as the facility's Medical Director. A progress note from this visit reported Resident #2 had no complaints of pain at that time. He described the resident's general appearance as comfortable, alert, no anxiety noted, no acute distress. Resident #2's EMR also included a physician's progress note for a palliative care follow-up visit dated [DATE]. The resident was being seen for help with advance care planning, symptom management, and ongoing psychosocial support. This note reported the resident had a history of prolonged respiratory failure resulting in a tracheostomy (which had since been removed). Resident #2's chronic pain was noted as stable and a report made to indicate he was now off of opioid therapy altogether and only taking gabapentin (a medication frequently used to treat nerve pain) and acetaminophen. A review of Resident #2's current medication orders as of [DATE] included the following, in part: --650 mg acetaminophen scheduled for administration by mouth every 6 hours for pain (Start Date [DATE]). --100 mg gabapentin to be given as two capsules by mouth at bedtime for neuropathy pain (Start Date [DATE]); --2.5 milligrams (mg) apixaban to be given as one tablet by mouth every 12 hours for clot prevention (Start date [DATE]). Resident #2's EMR included a Nursing Note dated [DATE] at 1:35 PM and authored by the facility's Weekend Supervisor (Nurse #1). This Nursing Note read: I was alerted by the CNA [Certified Nurse Aide] to come to the resident's room. Upon entering the resident's room, resident [Resident #2] was noted with a large gash across his forehead, an injury to his right eye and injuries to the left side of his face. Copious amount of blood noted on the resident and the resident's bedding. Staff present was trying to control the bleeding. I immediately called 911. I walked into the hall so 911 could hear me. Resident's roommate [Resident #1] was noted in the tv room, down the hall, in the presence of staff. I explained to 911 the situation at hand and they stated ems was on the way. After speaking to 911, I went back into the room to assist staff in the care of the injured resident until EMS and police arrived. EMS took over the situation, controlled the bleeding and dressed the resident wounds. Resident was then transported to [name of hospital]. Resident's RP [name of Responsible Party] was made aware of the situation. An interview was conducted on [DATE] at 2:40 PM with Nurse Aide #2 (NA #2). NA #2 reported she was assigned to care for both Resident #1 and Resident #2 on the first shift of [DATE] from 7:00 AM to 7:00 PM. The NA reported this was the first time she had cared for Resident #1, but she was familiar with Resident #2. Upon inquiry, the NA reported everything seemed to be fine with these two roommates at the beginning of her shift. NA #2 stated she last went into their room before lunch around 12:00 to 12:15 PM as she was doing her rounds. At that time, Resident #2 was asleep lying on his back with his left leg hanging off the bed. She asked the resident if she could help him put his leg back up on the bed, but he declined saying he always laid like that. As she walked out of the room, NA #2 recalled seeing Resident #1 laying on his bed with his hands placed behind his head. Resident #1 gave her a half-smile as she left the room to go assist another resident next door since the lunch meal trays had not yet come out to the hall. Approximately 10 minutes later, NA #2 reported, I heard the screaming. The NA stated she initially thought this screaming was coming from the memory care unit but later thought it may have been Resident #2 calling for help. As she opened the door of the room she was in, she saw NA #1 going into Resident #1 and Resident #2's room. The NA heard NA #1 scream and run out of the room hollering, He's trying to kill him, He's trying to kill him! NA #2 reported she went right behind NA #1 to get help and to find the Weekend Supervisor (Nurse #1). A telephone interview was conducted with NA #1 on [DATE] at 12:37 PM. During the interview, the NA reported on [DATE] around 1:30 PM, she and several other NAs were passing out lunch trays for the residents on the hall. She pulled the lunch tray for Resident #2 from the meal cart. As she was walking into the room, she could see Resident #2's leg had blood on it. She reported, I put the tray down and pulled the curtain back and saw [Resident #1] carving into [Resident #2's] skull. I yelled at [Resident #1], 'What are you doing?' and he moved away. When she asked Resident #1 what he was doing, the NA reported Resident #2 only said, Help! She stated Resident #1 stepped back from Resident #2 and started to walk in the direction of his own bed and the room's door. NA #1 continued by stating, At that point, I ran out of the room. When I came back another [NA] had [Resident #1] in a wheelchair. The NA explained she had run out of the room to get help. Meanwhile, Nurse #1 and 3 other NAs ran into the room to provide assistance. Upon inquiry, NA #1 reported after everyone was in the room, Resident #2 said he had been calling for help for a while. However, the NA stated she had not heard him from out in the hallway because his voice was quite soft. When asked what kind of knife had been used to cut Resident #2's forehead, she reported it was a butter knife, like off of the [meal] trays. An interview was conducted on [DATE] at 11:40 AM with NA #3. NA #3 recalled seeing Resident #1 self-propelling his wheelchair as he came out of the MCU around 12:10 to 12:15 PM. She was passing meal trays on the 100 Hall at that time. A while later, she was helping to pass meal trays on the 200 Hall when she saw her coworker coming out of Resident #1 and Resident #2's room saying something was done to the resident. NA #3 stated, I went in [to the room] within seconds. When asked what she saw, the NA reported, A lot of blood. [Resident #1] was going back to the bed .he was heading to his bed. He was about at the curtain dividing the two beds with his back to [Resident #2]. NA #3 reported she knew her Unit Manager (Nurse #2) was in the MCU, so she went to the door of the unit (next to the residents' room) and screamed for Nurse #2 to come, then returned directly back to help care for Resident #2. NA #3 reported Nurse #2 and a couple of others came to help. Resident #1 was removed from the room by a co-worker while Nurse #2 instructed the NAs to put pressure on Resident #2's wounds. NA #3 stated she stayed with Resident #2 until EMS came. When asked, the NA reported Resident #2 was just crying out in pain. She did not recall hearing the resident say much else. An interview was conducted on [DATE] at 11:14 AM with NA #4. NA #4 reported she had been sitting in the MCU hall monitoring when she heard a co-worker yell for help outside the Unit. She went into Resident #1 and Resident #2's room, looked to see how Resident #2 was, then put Resident #1 into a wheelchair and took him to the smoking area. The NA reported when she asked Resident #1 what had happened, he said he didn't know. She stated, He just acted like he hadn't done anything. She reported she was familiar with Resident #1 from working in the MCU when he resided there. NA #4 reported she was not aware of Resident #1 having any issues with his roommate or other residents while he was in the Unit. An interview was conducted on [DATE] at 2:15 PM with Nurse #2. Nurse #2 reported she worked as the Unit Manager over the 100 and 200 Halls, which included the MCU. The nurse recalled there were no behaviors or roommate issues for Resident #1 when he was initially admitted to the facility on the Unit. Nurse #2 stated that although she was not assigned to work on [DATE], she just came into the facility to check in and make sure everything was going smoothly. While she was there, she relieved the Hall monitor on the MCU so she could go to lunch. In a written statement provided by Nurse #2, the nurse reported being on the Unit around 1:20 PM on [DATE] when Resident #1 came into the Unit; she redirected him outside the Unit and back to his room (the first door to the right after exiting the MCU). During the interview, Nurse #2 stated that after just a few minutes she heard her name being screamed outside of the MCU. She jumped up, ran out of the Unit to see what was going on, then entered the residents' room. At that time, she saw Resident #1 lying on his bed relaxing with his legs crossed and hands placed behind his head. As she approached Resident #2, she saw the brown comforter on his bed had blood on it. She stated, There was a lot of blood. He had a white blanket on his head but after seeing all the blood, she called for someone to get towels and sheets to help stop the bleeding. She reported, Everyone was running and getting me stuff. The nurse stated she didn't realize how bad Resident #2's injuries were until they moved the blanket off his head, and she could see the forehead laceration was to the bone. She reported staff put wet towels on his wounds to try and stop the bleeding. Resident #2 was moving his hands and saying he couldn't see. Nurse #2 told him who she was and kept trying to reassure him she was there to help. She recalled Resident #2 was alert, he knew who she was, and he let her hold his hands. Meanwhile one of the NAs (NA #4) put Resident #1 into a wheelchair and took him out of the room. Three NAs (identified as NA #3, NA #5, and NA #6) assisted the nurse in getting linens and applying pressure to the wounds. Nurse #2 reported she stayed with Resident #2 until EMS arrived on the scene. After EMS came for Resident #2, the nurse reported she went out to the resident smoking area where staff had brought Resident #1. She recalled when she asked Resident #1 what happened he stated, I don't know. Afterwards, she accompanied a police officer back to the residents' room. She reported at that time she observed blood behind Resident #2's headboard, on pillows, his blanket, and comforter. She also observed a knife was on Resident #1's rolling bedside table. An interview was conducted on [DATE] at 2:56 PM with Nurse #3. Nurse #3 reported she was working on [DATE], the date of the incident involving Resident #1 and Resident #2. She recalled working in the front conference room on another task when she received a phone call from Nurse #2 requesting 911 be called and that she come to Resident #1 and Resident #2's room for assistance. She reported being unable to get through to 911 (although another staff member did). When she reached Resident #1 and Resident #2's room, she noted there was a lot going on as she tried to assist in providing first aid to Resident #2. Resident #2 was trying to touch his head and staff were encouraging him not to do so as they provided reassurance to the resident that they were there to help him. She reported the resident was low spoken .he was mumbling. Shortly after Nurse #3 got to the room, EMS arrived. An interview was conducted on [DATE] at 11:20 AM with Nurse #4. Nurse #4 identified herself as Resident #1 and Resident #2's usual hall nurse on first shift. The nurse reported she was working on the hall the day of the incident involving these two residents ([DATE]) and recalled she had last seen them around 11:30 AM on that day without any concerns noted. During the interview, the nurse reported on [DATE] she was in another room on the hall feeding a resident when she heard someone call out for 911 to be called because Resident #2 was stabbed. Nurse #4 reported she was able to get through to 911 on the second attempt. Nurse #4 then went to the room. She stated, All I could see was a towel on his head I stepped out of the room. She noted other staff members were in the room helping the resident. After stepping out of the room, she reported seeing Resident #1 on the patio. The nurse went to the nursing station to get Resident #2's paperwork together and ready for EMS to transfer him to the hospital. When asked if she was aware of any disagreements between the two residents since they became roommates, she stated she was not. The nurse added that she was certain Resident #2 would have told her if there was a problem with his roommate because they were close. But she stated, He never said a word to me. An interview was conducted on [DATE] at 3:09 PM with Nurse #1. Nurse #1 identified himself as the Weekend Supervisor assigned to work on [DATE] at the time of the incident. The nurse reported he was sitting outside in the smoking area when NA #1 banged on the glass yelling, He's trying to kill him. Nurse #1 went to Resident #1 and Resident #2's room and reported he saw blood all over the bed. Resident #2 had a huge wound on his forehead and a bloodied area on the right side of his face around his right ear and eye. However, the nurse reported it was hard to know the extent of the injuries due to all of the blood. He stated, It was shocking what I saw. Staff were already providing first aid while he stepped out of the room to focus on calling 911. He reported there was blood everywhere and he wanted to get help as quickly as possible. After he got through to 911, he went back into the room to assist with what was happening but there were already several staff members in there to help the resident. Nurse #1 stated that meanwhile, Resident #1 was being contained in the TV room. An interview was conducted on [DATE] at 1:00 PM with NA #8. NA #8 reported he was in another resident's room when he heard someone yelling his name. He went into Resident #1 and Resident #2's room. At that time, he observed Resident #1 in his bed. When he went to Resident #2's side of the room, he saw the resident was injured. He retrieved some towels for him while another staff member took Resident #1 outside. He saw Resident #1 run back inside (from the smoking area) so he re-directed him to the TV room, and he stayed with the resident. When asked if the resident said anything to him, he stated, No. However, when the police came to talk to him, they told him if he didn't stay still, he would be put in handcuffs. Resident #1 didn't want that. When the police asked him if he was hurt, he said only his mind was. A Police Report dated [DATE] at 1:35 PM included the following narrative, in part: .Upon arriving, I spoke with the nurse, [name of NA #1], who stated that she walked into Resident #1 and Resident #2's room and saw the suspect, [Resident #1] sitting on top of [Resident #2] in his bed carving into his head with a butter knife. She said that she yelled what are you doing but [Resident #1] did not say anything back. The nurse took [Resident #1] out of the room while the medic unit came into the room. [Resident #1] and [Resident #2] have been roommates in the living center for a week. [Resident #1] was transferred from [name of hospital] Psychiatric Ward a month ago. [Resident #1] has Schizophrenia and dementia. When I asked [Resident #1] what happened he stated that he does not remember. I asked him if they were in an argument, and he said no. [Resident #1] looks to be spaced out. And continued to try and walk away. [EMS] arrived on scene and transferred [Resident #2] to [name of hospital] with semi life threatening injuries. [Resident #2] has a large gash on his forehead from one temple to the other. He has severe face and head injuries and his ear was cut off . [Resident #1] was transported to [name of hospital] for emergency commitment. A telephone interview was conducted on [DATE] at 1:21 PM with the Police Detective who was the lead investigator on the case involving Resident #1 and Resident #2 on [DATE]. The Detective reported when he arrived at the facility on [DATE], the attacker was already in the police car. Resident #1 had told the patrol officer he was [NAME]. The Detective requested Resident #1 be brought to the hospital where he spent one day being evaluated before being arrested. During the telephone interview conducted on [DATE] at 1:21 PM, the Detective stated he has talked with the victim 3 times since the incident occurred. Resident #2 reported to the Detective that he and his roommate had on-going conversations regarding Resident #2's television. Resident #2 told the Detective Resident #1 tried several times to cut him, perhaps as many as ,d+[DATE] times. Resident #1 tried to cut him, then left (not sure where he went), and then returned to cut him again. Resident #2 reported this occurred over a period of up to 20 minutes (reported on the 2nd interview), but this estimation of time was changed on the 3rd interview to the assault lasting 5-minutes. Resident #2 said he was yelling for help and thought his yelling would have been heard outside of the room. However, the Detective reported the resident was soft-spoken and may not have been heard. Upon inquiry, the Detective reported he has looked into the statement written in the initial police report which indicated Resident #1's ear had been severed. He stated he was not finding anything from the hospital to support that statement and it was likely that due to the massive amount of bleeding, the actual injuries could not be accurately determined. The Detective reported as of [DATE], Resident #1 was incarcerated at the County Jail. There were four felony charges against him: --Assault inflicting serious bodily injury; --Assault with a deadly weapon inflicting serious bodily injury; --Felony assault on an individual with a disability; --Maming without malice. A follow-up telephone interview was conducted on [DATE] at 8:50 AM with the Police Detective. At that time, the Detective was asked about the possibility of interviewing Resident #1 about the incident. The Detective returned the call on [DATE] at 8:58 AM after talking with his supervisor. The Detective reported the resident may have been transferred out of the County Jail, so he was not sure of his location at that time. Regardless, he stated it was a bad idea to try to interview Resident #1. A review of the EMS Report revealed a 911 call was received from the facility on [DATE] at 1:36 PM. EMS arrived at the scene at 1:39 PM. The EMS Report indicated the resident had a deep laceration across his forehead ear to ear with active bleeding and defensive abrasions on both hands. The resident's level of distress was reported to have been moderate. The EMS report read, in part: EMS immediately placed hemostatic dressing [a dressing with an adhesive-like action that seals the wound and controls the bleeding] on the pts [patient's] wounds and wrapped the wound to control bleeding. EMS then transitioned the pt onto the stretcher and rapidly transported pt to [name of hospital]/Trauma alert was made to [hospital]. A telephone interview was conducted on [DATE] at 12:05 PM with the Emergency Medical Technician-Paramedic (EMT-P) who was the first responder to the facility on [DATE]. The EMT-P recalled when she arrived at the scene, ,d+[DATE] staff members were in the room with Resident #2 as he was lying on the bed. He was actively bleeding from a very deep laceration extending from ear to ear and from what she could recall, she thought one ear may have been severed because there was so much blood. Bloody wet towels were wrapped around the resident's head; no other residents were in the room. A knife was observed to be sitting on a rolling table in the room. She reported the EMTs' main focus during the call was to stop the bleeding. The resident was on a blood thinner and had already lost a lot of blood. She described the resident as very alert but noted that while he could tell the EMT-P his name, he seemed disoriented. The EMT-P reported she thought the incident had gone on for several minutes, based on the amount of damage done to Resident #2 before someone noticed and called 911. The hospital ED Provider Notes dated [DATE] at 2:20 PM reported Resident #2 presented to the ED as an assault victim with a stab wound to his head. The note read, Per EMS, pt was reportedly stabbed across forehead using butter knife. The resident's physical examination documented he had a complex, irregular border, deep laceration extending across his forehead. Upon examination, he complained of right eye pain with extra-ocular eye movements intact (testing that examines the function of the eye muscles). The resident was reported to have bilateral eyelid bruising and mild swelling. Another laceration was noted over his nose and there were scattered lacerations (defensive wounds) over both of his hands. No trauma was reported to the resident's ears. Resident #2 was noted to be hypotensive (have low blood pressure) and treated with two units of fresh frozen plasm (used to help blood clot during active bleeding when a person is on a blood thinner) and two units of packed red blood cells (used to replace blood when a person has had a large amount of bleeding with blood loss). Resident #2's records reported the hospital's Ear, Nose and Throat (ENT) service was consulted for the large scalp laceration down to bone. An ENT consultation note dated [DATE] at 6:32 PM reported Resident #2 was status post right eye corneal transplant with baseline left eye blindness. The resident was moaning in pain when seen by ENT and stated the pain was along his forehead but particularly in the right eye. Resident #2 reported his vision in the right eye was not at baseline and he was very sensitive to moving his right eye laterally (to the side). The ENT service closed the 19-centimeter forehead laceration (described as down to bone) with sutures and two Penrose drains sutured on either side of the head. A Penrose drain is a soft, flexible latex drain that allows blood and other fluids to move out of an area to prevent fluid from collecting and causing an infection. The 2-centimeter laceration over the resident's right nasal bridge and extending toward the medial canthus (the corner of the eye where the upper and lower lids meet) was also closed. Resident #2's hospital records revealed he received multiple medications in the ED, including 50 micrograms (mcg) fentanyl injection (an opioid pain medication) given intravenously on [DATE] at 2:18 PM and 0.5 milligrams (mg) hydromorphone (an opioid pain medication) administered intravenously on [DATE] at 4:39 PM. Additional pain medications administered to the resident during his hospital stay included the following: --On [DATE] at 10:25 PM, one dose of 4 mg of morphine (an opioid pain medication) was administered intravenously; --On [DATE], one dose of 25 mcg of fentanyl was administered intravenously; --One dose of 10 mg oxycodone (an opioid pain medication) was administered as one tablet by mouth on ,d+[DATE] [TRUNCATED]

Based on record review, observations, interviews with residents and staff, the facility failed to protect a resident's right to be free from mistreatment for 2 of 4 residents investigated for staff to resident abuse (Resident #3 and Resident #5). Resident #5 felt angry when an employee made a threatening gesture and treated her roughly during incontinence care, failing to stop pulling on her when resident requested. Resident #3 experienced pain and anxiety when an employee handled her roughly during incontinence care and failed to stop providing care when she requested. The findings included: 1. Resident #5 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, diabetes, and hypoventilation syndrome (neurological disorder characterized by inadequate breathing). Resident #5's annual Minimum Data Set (MDS) dated [DATE] indicated the resident was cognitively intact, had adequate hearing and vision, required extensive assistance with activities of daily living. She required extensive assistance with bed mobility and toileting. The resident was coded as occasional incontinent of urine and frequently incontinent of bowel. Resident #5 received a diuretic 7 out of 7 days during the assessment period. Resident #5's comprehensive care plan was last updated 2/10/2023. The resident had a focus for self-care deficit related to diagnoses. Interventions included extensive assistance by two staff members for toileting and personal hygiene. An interview was conducted with Resident #5 on 2/28/2023 at 1:30PM. She stated Nurse Assistant (NA) #1 was working the hall Friday night shift on 2/10/2023. Resident #5 stated around 4:00 AM on 2/11/2023 she called out for incontinence care. She stated NA #1 entered her room and asked, what do you want?. The resident informed the NA she needed to be cleaned. NA#1 stated she would have to wait until she could find another NA to assist. Resident #5 stated NA #1 entered her room along with NA#2. During incontinence care, NA #1 pulled roughly on the resident's left leg. When Resident #5 yelled out in pain and asked the NA to stop pulling on her left leg, the NA ignored her and did not stop. Resident #5 stated after the two NAs completed incontinence care, as NA#2 had her back turned exiting the room, she requested to be repositioned. NA #1 made a threatening gesture by taking her finger and running it horizontally across the base of her own throat. Resident #5 stated the gesture and the rough treatment made her angry and anxious. She called out for her nurse, Nurse #1, and reported it immediately to the nurse. On 2/28/2023 at 2:32PM a phone interview was conducted with NA#2. She stated she was in the room with NA #1 when she performed care for Resident #5 on the early morning hours of 2/11/2023. She stated she was not assigned to the hall but NA#1 told her Resident #5 required two persons to turn, so she agreed to help NA #1. She stated she felt NA #1 was verbally rude to Resident #5 and she did observe NA #1 pull on the resident's leg causing her to yell out in pain. She stated NA#1 did not release the resident's leg but continued to provide care, ignoring the resident's request to stop. NA#2 stated NA#1 handled Resident #5 rougher than she handles residents. A phone interview was conducted with NA#1 on 2/28/2023 at 2:35PM. She stated she was contracted through a nursing agency and had never worked a night shift at the facility. She was not familiar with any of the residents. She did not know why any of the residents would have reported she was rough with them. She stated there was one resident who was bariatric and required a lot of effort to turn. She had asked another NA to assist her with that resident. She did not recall making any of the residents angry and denied making any gestures to any residents. On 3/1/2023 at 10:00 AM a phone interview was conducted with Nurse #1. She stated Resident #5 reported NA#1 was rude, treated her roughly, and made a threatening gesture by taking her finger and running horizontally across the base of her own throat around 4:00 AM on 2/11/2023. Nurse #1 stated she assured the resident that she was safe and no one was going to hurt her. 2.Resdient #3 was admitted to the facility on [DATE] with diagnoses that included chronic renal disease, and bilateral lower leg venous hypertension with stasis ulcers. The resident's annual Minimum Data Set (MDS) dated [DATE] indicated the resident was mildly cognitively impaired, required extensive assistance with activities of daily living, and was dependent upon staff for assistance with toileting and personal hygiene. The resident was coded as always incontinent of urine and frequently incontinent of bowel. An interview was conducted with Resident #3 on 2/28/2023 at 10:30AM. She stated she did not recall the date or time of the incident or the name of the Nurse Assistant (NA) who handled her roughly. She reported she pressed her call bell and the NA came into her room, snatched the curtain back and asked, what do you want? Resident #3 stated she was wet and needed to be cleaned. She stated the NA snapped the curtain back and stated, you will have to wait. Resident #3 stated when the NA returned, she was rough with her and grabbed her leg to turn her. She told the NA she was hurting her and the NA ignored her. Resident #3 stated she told the NA to stop or she was going to call 911 and the NA told her, go ahead, I don't care. Resident #3 stated she did not report the incident to anyone until her daughter visited. She did not recall the date or time she told her daughter. Resident #3 stated the NA did not return to her room that night and she had not seen the NA since that incident. Resident #3 stated the incident made her feel anxious. When asked why she did not report the incident to staff, she stated she was scared she might anger the NA who hurt her. The staffing assignment sheet for 2/10/2023 indicated NA #1 was assigned to Resident #3 on 2/10/2023 from 7:00PM until 7:00AM on 2/11/2023. On 2/28/2023 at 1:16PM a phone interview was conducted with Resident #3's Responsible Party (RP). She stated she visited Resident #3 on 2/11/2023 around 5:30PM and it was during that visit Resident #3 made her aware a staff member had treated her roughly and been rude to her around 9:00PM the night before. The RP stated she went to the nurse station and requested the name of the NA assigned to Resident #3 the night before. She was told NA #1 was assigned to Resident #3. The RP stated she went back and asked her mother what the NA looked like. Resident #3 was able to describe the color of her clothing and the fact she had long false eyelashes. The staff confirmed NA #1 fit the description and that she was a agency nurse. The RP stated she then called the nursing agency and spoke with an individual regarding the behavior of their NA. She stated she did not report the incident to the facility Administrator. During an interview with the Administrator on 3/1/2023 at 9:40AM, she stated she was not made aware of the incident until 2/12/2023. She stated she received a call from the Director of the staffing agency who employed NA#1 and NA#2. The Director informed her a family member of Resident #3 called her an alleged mistreatment by NA#1. The facility provided the following corrective action plan with a completion date of 2/13/2023 Problem identified: Resident # 5 alleged Nursing Assistant (NA)#1 made a threatening gesture toward her and handled her roughly during incontinent care. Immediate Action: The Administrator completed education on 2/12/2023, for the unit managers, wound nurse, and supervisors regarding the Abuse Policy and Procedure, definitions of abuse, and residents' rights to be free from mistreatment. The Assistant Director of Nursing (ADON) and unit managers provided education to the facility staff on 2/12/2023, regarding the Abuse Policy and Procedure to include the definition of abuse and implementing an intervention to keep resident safe. Education included staff will stop providing care at resident's request. Staff not present for the education, will be educated prior to return to work. Newly hired staff and agency staff will be educated during new hire orientation. Identification of other Residents: The ADON and the Administrator reviewed incident reports and grievance reports for the last 30 days to identify concerns of abuse or mistreatment. There were no other allegations identified. The licensed nurses completed interviews 2/12/2023 for residents with BIMS score of 10 or higher, asking if they felt safe in the facility and were there any concerns of abuse. There were not concerns identified. The license nurses completed skin assessments on 2/12/2023 for residents with BIMS score of less than 10 to identify bruises/injuries that had not been reported and/or treated. There were no concerns identified. Systemic Changes: The ADON and unit managers provided education to the facility staff on 2/12/2023 regarding the abuse policy and procedure to include definition of abuse, residents' rights to be free of mistreatment, and implementing an intervention immediately to keep resident(s) safe. Education included staff will stop providing care at resident's request. Staff not present will be educated prior to return to work. Newly hired staff will be educated during new hire orientation. Quality Assurance: The Administrator and/or Social Worker (SW) will interview 10 alert and oriented residents weekly for 4 weeks then 20 per month for 2 months to identify any concerns of abuse. The DON and/or the ADON will review incident reports and grievance reports 5x week for 4 weeks then 3x week for 2 months to identify concerns of abuse. The Administrator and/or the DON will review the audits monthly to identify patterns/trends and will adjust the plan as necessary to maintain compliance. The Administrator and/or the DON will review the plan during the monthly QAPI meeting and the audits will continue at the discretion of the QAPI committee. Completion dated 2/13/2023 The past noncompliance was validated on 3/1/2023 when staff interviews and interviews with agency staff, revealed that they had received recent education on the Abuse policy and procedures and resident rights to be free from mistreatment. The education included the staff need to stop providing care if a resident request they stop. Facility documentation revealed staff were trained on the following topics: Abuse policy and procedures, resident's rights education, and interviewing for abuse or mistreatment. Attestations were signed by trained staff for the verbal education that was provided. Staff indicated they were trained prior to working in the facility for their next shifts. Newly hired staff and agency staff received an in-service packet prior to working and this was verified by the facility trainers and added to the orientation checklist. The facility deficiency was corrected on 2/13/2023.

Based on record review and interviews with resident, staff, and the Administrator, the facility failed to report an allegation of abuse to the administrator immediately per facility's policy and protocol and failed to immediately assess other residents who were under the care of Nurse assistant (NA) #1, and protect all residents from verbal abuse and mistreatment by allowing NA #1 to continue working after an allegation of abuse was reported to facility staff. The deficient practice occurred for 1 of 3 residents (Resident #5) sampled for abuse, however the deficient practice had the potential to impact other residents. The findings included: The facility provided a paper form titled, Abuse and Neglect Protocol. The policy was dated 6/13/2021. The policy read in part, employees, facility consultants and /or attending Physicians must immediately report any suspected abuse or incidents of abuse to the Director of Nursing Services (DON). In the absence of the DON, such reports may be made to the Nurse Supervisor on duty. The policy also included the following, If such incidents occur or are discovered after hours, the Administrator and Director of Nursing Services must be called at home or must be paged and informed of such incident. Employees of the facility who have been accused of resident abuse shall be suspended from duty until the results of the investigation has been reviewed by the Director of Nursing/Designee or Administrator. Resident #5 was admitted to the facility on [DATE]. Resident #5's annual Minimum Data Set (MDS) dated [DATE]. indicated the resident was cognitively intact, had adequate hearing and vision, required extensive assistance with activities of daily living. She required extensive assistance with bed mobility and toileting. Resident #5 received a diuretic (causes increased urine output) 7 out of 7 days during the assessment period. An interview was conducted with Resident #5 on 2/28/2023 at 1:30PM. She stated NA #1 was assigned to her hall Friday, night shift, on 2/10/2023. Resident #5 stated around 4:00 AM on 2/11/2023 she called out for incontinence care. She stated NA #1 entered her room and asked, what do you want?. The resident informed the NA she needed to be cleaned. NA#1 stated she would have to wait until she could find another NA to assist. Resident #5 stated NA #1 entered her room along with NA#2. During incontinence care, NA #1 pulled roughly on the resident's left leg. When Resident #5 yelled out in pain and asked the NA to stop pulling on her left leg, the NA ignored her and did not stop. Resident #5 stated after the two NAs completed incontinence care, as NA#2 had her back turned exiting the room, she requested to be repositioned. NA #1 made a threatening gesture by taking her finger and running it horizontally across the base of her own throat. The NA then exited the room without repositioning her as she had requested. Resident #5 stated the gesture and the rough treatment made her angry and anxious. She called out for her nurse, Nurse #1, and reported it immediately to the nurse. On 2/28/2023 at 2:32PM a phone interview was conducted with NA#2. She stated she was in the room with NA #1 when she performed care for Resident #5 on the early morning hours of 2/11/2023. She stated she felt NA #1 was verbally rude to Resident #5 and she did observed NA #1 pull on the resident's leg causing her to yell out in pain. She stated NA#1 did not release the resident's leg but continued to provide care, ignoring the resident's request to stop. NA#2 stated NA#1 handled Resident #5 rougher than she handles residents. NA #2 stated she did not witness NA #1 make any gestures toward Resident #5. NA#2 stated she did not report the incident to the nurse or the nurse supervisor. On 3/1/2023 at 10:00 AM a phone interview was conducted with Nurse #1. She stated Resident #5 reported NA#1 was rude, treated her roughly, and made a threatening gesture by taking her finger and running horizontally across the base of her own throat around 4:00 AM on 2/11/2023. Nurse #1 stated she assured the resident that she was safe, and no one was going to hurt her. Nurse #1 stated she did not recall there being a nursing supervisor in the facility that night, so she reported the incident to the weekend supervisor when she arrived at the facility for here regularly scheduled shift around 8:00 AM. She further stated she was not aware the incident should have been reported immediately. A phone interview was conducted with the weekend nurse supervisor, Nurse #2, on 3/1/2023 at 10:15 AM. She stated Nurse #1 made her aware of the incident between Resident #5 and NA#1 around 8:00AM on 3/1/2023. She was not in the facility when the incident occurred at 4:00AM. Nurse #2 stated she followed the facility's policy and reported the incident to the Nurse on call. She stated the nurse on call, Nurse #3, was in the facility when she reported to her what had occurred. They had a brief conversation about the incident, decided it was not abuse. She stated she did not make the Administrator aware of the incident. On 3/1/2023 at 10:30AM an interview was conducted with Nurse #3, the on-call nurse. She recalled Nurse #2 informed her of an incident that occurred on the morning of 2/11/2023 between Resident #5 and NA #1 around 8:30AM, shortly after she arrived at the facility. She was told Resident #5 alleged NA #1 took her finger and ran it horizontally across the base of her throat as a gesture. She did not recall being told about the NA being rough. Nurse #3 stated she and Nurse #2 talked about the incident and determined it was not abuse. She did not inform the Administrator about the incident. An interview was conducted with the Administrator on 3/1/2023 at 9:40AM, she stated she was not made aware of the incident until 2/12/2023. She did not recall what time of day she was made aware. She stated she received a call from the Director of the staffing agency who employed NA#1 and NA#2. The Director informed her a family member of another resident (Resident #3) called her an alleged mistreatment by NA#1. The Administrator stated she immediately went to the facility and began an investigation. Both NA#1 and NA#2 were terminated. After resident interviews and assessments of affected residents, the facility substantiated the allegations, and all employees were educated on what constitutes abuse, timely reporting of allegations, and to stop providing care when a resident requests to stop. The facility provided the following corrective action plan with a completion date of 2/13/2023 Problem identified: Resident # 5 alleged Nursing Assistant (NA)#1 made a threatening gesture toward her and handled her roughly during incontinent care. Resident #5 reported the mistreatment to Nurse #1 at 4:00AM on 2/11/2023. Nurse #1 reported the incident to the weekend Nursing Supervisor on 2/11/2023 at 8:00AM. The incident was reported to the Administrator on 2/12/2023, late afternoon. Immediate Action: The Administrator completed the Facility Reported Incident (24 hr report) on 2/12/2023 when the facility was made aware of an allegation of abuse regarding Resident #5 and Resident #3. The Administrator completed education on 2/12/2023 , for the unit managers, wound nurse, and supervisors regarding the Abuse Policy and Procedure and reporting of the allegation of abuse to the Director of Nursing, Administrator, and State Agency. The Assistant Director of Nursing (ADON) and unit managers provided education to the facility staff on 2/12/2023, regarding the Abuse Policy and Procedure to include reporting all allegations of abuse promptly to the Director of Nursing and/or Administrator and implement and intervention immediately to keep resident(s) safe. Staff not present for the education will be educated prior to return to work. Newly hired staff and agency staff will be educated during new hire orientation. Identification of other Residents: The ADON and the Administrator reviewed incident reports and grievance reports for the last 30 days to identify concerns of abuse and validate the allegation was reported as required. There were no other allegations identified. The licensed nurses completed interviews 2/12/2023 for residents with BIMS score of 10 or higher, asking if they felt safe in the facility and were there any concerns of abuse that had not been reported. There were not concerns identified. The license nurses completed skin assessments on 2/12/2023 for residents with BIMS score of less than 10 to identify bruises/injuries that had not been reported. There were no concerns identified. Systemic Changes: The ADON and unit managers provided education to the facility staff on 2/12/2023 regarding the abuse policy and procedure to include reporting all allegations of abuse promptly and the need to implement an intervention immediately to keep residents safe. Staff not present will be educated prior to return to work. Newly hired staff will be educated during new hire orientation. Quality Assurance: The Administrator and/or Social Worker (SW) will interview 10 alert and oriented residents weekly for 4 weeks then 20 per month for 2 months to identify concerns of abuse and will validate that the allegation was investigated and reported to the DON/Administrator and State Agency. The DON and/or the ADON will review incident reports and grievance reports 5x week for 4 weeks then 3x week for 2 months to identify concerns of abuse and will validate that the incident or concern was investigated and reported to the DON/Administrator and State agency. The Administrator and/or the DON will review the audits monthly to identify patterns/trends and will adjust the plan as necessary to maintain compliance. The Administrator and/or the DON will review the plan during the monthly QAPI meeting and the audits will continue at the discretion of the QAPI committee. Completion dated 2/13/2023. The past noncompliance was validated on 3/1/2023 when staff interviews and interviews with agency staff, revealed that they had received recent education on the Abuse policy and procedures and immediately reporting any allegations of abuse. The education included documentation and reporting to the DON or Administrator immediately when they become aware of reported abuse, suspected abuse, and/or injury and take immediate action to ensure the safety of resident(s). Facility documentation revealed staff were trained on the following topics: Abuse policy and procedures, definition of abuse, and nurse notification to management. Attestations were signed by trained staff for the verbal education that was provided. Staff indicated they were trained prior to working in the facility for their next shifts. Newly hired staff and agency staff received an in-service packet prior to working and this was verified by the facility trainers and added to the orientation checklist. The facility deficiency was corrected on 2/13/2023.

Based on record review, staff interviews, physician assistant interview, nurse practitioner interview, and physician interviews, the facility failed to administer insulin and perform glucose monitoring for one (Resident #1) of three residents reviewed for significant medication errors. The facility failed to transcribe orders for insulin and blood glucose monitoring resulting in a hospital admission for Resident #1 for diabetic ketoacidosis (Diabetic ketoacidosis is a severe and life-threatening complication of diabetes.) Finding include: Resident #1 had [DIAGNOSES REDACTED]. Resident #1 was admitted to the facility on [DATE] from the hospital status [REDACTED]. Documentation on a hospital discharge summary, printed by the facility on 9/22/20, listed current discharge medications for Resident #1 for the treatment of [REDACTED]. Another order was for [MEDICATION NAME] 500 milligram (mg) tablet to be administered as two tablets (1,000 mg) by mouth two times daily with meals. [MEDICATION NAME] is an oral diabetes medicine that helps control blood sugar levels. An additional order requested glucose monitoring before meals and at bedtime. Documentation on the baseline care plan completed on 9/22/20 revealed Resident #1 had Diabetes and was prescribed insulin. Documentation on the physician orders [REDACTED].#1 listed the physician order [REDACTED]. Documentation on an admission physician's progress note dated 9/22/20 revealed Resident #1 was noted to have a [DIAGNOSES REDACTED]. Documentation in the plan portion of the physician's progress note stated that for the [DIAGNOSES REDACTED]. Documentation on an Admission Medicare 5-Day Minimum Data Set assessment completed on 9/26/20 coded Resident #1 as cognitively intact and receiving no insulin injections and no insulin during the assessment period. Documentation on the Medication Administration Record [REDACTED]. Documentation on the MAR indicated [REDACTED]. Documentation on the MAR indicated [REDACTED]. (A normal blood glucose level is in the range of 80-100 mg/dl.) Review of the nursing progress notes did not reveal any signs or symptoms of [DIAGNOSES REDACTED] or [MEDICAL CONDITION] for Resident #1 during his stay in the facility. Documentation in a nursing progress note dated 10/5/20 stated, Resident was sent out to MD (medical doctor) appointment. From appointment resident was transferred to the ER (emergency room ) (due to) suspected [MEDICAL CONDITION]. [MEDICAL CONDITION] is an irregular heart beat that often causes the heart to beat too quickly. Documentation in a hospital record revealed Resident #1 was taken to the emergency roiagnom on [DATE] and found to be in diabetic ketoacidosis. Resident #1 was admitted to the intensive care unit with the principle problem of diabetic ketoacidosis without coma associated with Type 2 diabetes mellitus. Documentation of initial laboratory values taken on 10/5/20 at 12:58 PM stated Resident #1 had a blood glucose level of 821 mg/dl. Resident #1 stayed in the hospital until 10/24/20 until his blood glucose levels returned to normal levels with aggressive treatment. Documentation of laboratory values taken on 10/24/20 at 11:44 AM stated Resident #1 had a blood glucose level of 88 mg/dl. An interview was conducted with Nurse #2 on 11/5/20 at 10:47 AM. Nurse #2 explained the process for entering the physician orders [REDACTED].#1. Nurse #2 stated that the discharge summary from the hospital was printed, given to the facility physician or Nurse Practitioner (NP) for review/approval, and then entered by a nurse into the electronic health record. Nurse #2 indicated that the orders were then supposed to be checked by another nurse for accuracy in the electronic health record prior to the resident's arrival at the facility. An interview was conducted with NP #1 on 11/5/20 at 11:20 AM. NP #1 revealed that she was the one who reviewed and approved the medications on the hospital discharge summary for Resident #1 as evidenced by her initials and the date 9/22/20. NP #1 stated that the orders for the insulin and the glucose monitoring should have been put into the electronic health record after her approval of the orders was given. An interview was conducted with Nurse #1, the unit manager, on 11/5/20 at 12:00 PM. Nurse #1 revealed that she was the one who put the physician orders [REDACTED].#1 prior to admission. Nurse #1 stated she did not put the orders for the insulin and glucose monitoring into the electronic health record on 9/22/20 after NP #1 approved the medications on the hospital discharge summary. Nurse #1 stated she remembered entering the medications in to the computer in between passing medications on two medication carts and doing her charting on the residents on the halls. Nurse #1 stated usually she would check off the medications as she put them in and go down the list in order but on that day, she was interrupted multiple times by requests from the therapy department, a resident who wanted pain medication, processing two residents who were discharging that day in addition to multiple admissions. Nurse #1 acknowledged that usually one of the unit managers would go behind her and check the orders usually a day or so after orders were entered in the electronic health record. Nurse #1 indicated she had been working 7:00 AM to 7:00 PM, 12-hour shifts, in the capacity as a medication nurse and the unit manager for 7 days in a row prior to the day of the admission of Resident #1. An interview was conducted on 11/5/20 at 2:28 PM with the physician (MD #1) for Resident #1 who wrote the admission progress note on 9/22/20. MD #1 stated that he reviewed the hospital discharge summary and wrote his progress note for Resident #1 based on the orders and information he obtained from that discharge summary. MD #1 stated he found it surprising that Resident #1 was admitted to the hospital with [REDACTED]. An interview was conducted with the Director of Nursing (DON) on 11/5/20 at 6:49 PM. The DON stated that Nurse #1 was called into her office to discuss why the order for insulin and blood glucose monitoring was not put into the electronic health record of Resident #1. The DON stated that Nurse #1 had been working a lot of hours prior to the admission of Resident #1. The DON revealed it was the facility policy to use the unit managers and supervisors as floor nurses when a nurse was not available to work the shift. An interview was conducted on 11/6/20 at 9:57 AM with the physician's assistant (PA #1) who saw Resident #1 in the post operation clinic on 10/5/20. PA #1 stated that when she entered the room to see Resident #1, she saw that he was short of breath, altered, incoherent, and in acute distress. PA #1 stated that laboratory values were taken at the clinic but Resident #1 was sent to the emergency room prior to obtaining the results. PA #1 stated the results revealed Resident #1 was in diabetic ketoacidosis and had a blood glucose level of 804 mg/dl taken at the clinic. PA #1 stated that not giving Resident #1 insulin for 14 days and not doing any glucose monitoring was an extremely serious error. An interview was conducted on 11/6/20 at 1:29 PM with the [MEDICATION NAME] surgeon for Resident #1 (MD #2). MD #2 stated that it was extremely important to have strict blood glucose control after open heart surgery due to the increased risk of infection. MD #2 revealed that while in the hospital the blood glucose levels for Resident #1 were kept under tight control due to the risk of infection. MD #2 stated that omitting the insulin and blood glucose monitoring at the facility could have been fatal for the resident. An interview was conducted with the facility Administrator on 11/5/20 at 1:40 PM. The Administrator stated that on the evening of 10/5/20 the power of attorney (POA) for Resident #1 came to the facility to pick up the resident's belongings. The Administrator stated that she was notified by the Business Office Manager that the POA had stated Resident #1 was not returning to the facility and was hospitalized due to elevated blood glucose levels. The Administrator stated the next morning on 10/6/20, she and the DON compared the discharge summary from the hospital to the facility orders. After the error in the electronic health record was found, the Administrator stated she began an investigation and immediately started an action plan. Documentation on the Action Plan stated, A self-imposed action plan by the facility had been completed and implemented on 10/6/2020 with ongoing monitoring to ensure compliance. The action plan was completed on 10/8/20 and the facility alleged compliance as of 10/8/20. Resident #1 was transferred to the hospital on [DATE] from the doctor's office where he had an appointment. Doctor's office informed facility that he was transferred for possible [MEDICAL CONDITION]. Identification of other residents: The Director of Nursing and Unit Managers completed an audit on 10/7/20, for residents that were admitted or readmitted from 9/8/20 through 10/7/20, to validate that orders were transcribed as ordered upon admission. No other residents were identified with transcription errors. Measures for Systematic change: The Director of Nursing completed education on 10/7/20 for the Unit Mangers, regarding facility protocol for reconciliation of medications upon admission. The Director of Nursing and/or Unit Managers completed education on 10/8/20 for current licensed nurses regarding facility protocol for reconciliation of medications upon admission. Newly hired licensed nurses will be educated during new hire orientation. The process includes upon admission, the licensed nurses will review the discharge summary and will notify the physician or NP to verify orders. The licensed nurse will transcribe the order into the electronic medical record. The unit manager and/or the nursing supervisor will review the orders within 24 hours of admission to validate the physician orders [REDACTED]. When new residents are admitted with a [DIAGNOSES REDACTED]. How corrective action will be monitored: The DON and/or the unit managers will audit admission orders [REDACTED]. The DON will review the audits monthly to identify patterns/trends and will adjust the plan as necessary to maintain compliance. The DON will review the plan during the monthly Quality Assurance and Performance Improvement Committee (QUAPI) meeting, and the audits will continue at the discretion of the QUAPI committee. The plan was reviewed in an ad hoc QUAPI meeting held on 10/9/20 and the monthly QUAPI meeting held on 10/21/20. The facility action plan was verified on 11/6/20 at 2:00 PM. Interviews were conducted with the licensed nursing staff to confirm their knowledge of the protocol for transcription procedures upon admission of a resident as well as their knowledge of the required orders for blood sugar checks for residents admitted with the [DIAGNOSES REDACTED]. The facility documentation was reviewed of the initial audit of transcribed records of new admissions from 9/8/20 to 10/9/20, ongoing audits of transcribed records of new admissions, in-service training, and written policy and procedures for reconciliation of medications on admission. Interviews were conducted with members of the QUAPI committee about the action plan.

Based on record review, emergency medical services (EMS) report, and staff and physician interviews, the facility failed to immediately notify the resident's physician of respiratory distress and continuous [MEDICAL CONDITION], for 1 of 3 sampled residents reviewed for notification of change (Resident 186). The Immediate Jeopardy (IJ) began on [DATE] at 5:30 AM for Resident #186 when the resident was found with continuous [MEDICAL CONDITION] and respiratory distress. The Administrator was notified on [DATE] at 10:45 AM and the IJ was removed on [DATE] at 6:45 PM when the facility demonstrated it had implemented a credible allegation. The facility was left out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy (D) so that the facility can complete all staff in-services and monitoring systems could be implemented and included in the Quality Assurance Program. Findings included: Resident #186 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's physician order [REDACTED]. [MEDICATION NAME] is an anticonvulsant, [MEDICATION NAME] is an anticonvulsant and Klonopin is a medication with anticonvulsant properties. A [DATE] quarterly minimum data set (MDS) indicated the resident was severely cognitively impaired. The care plan of [DATE] indicated [MEDICAL CONDITION] as a problem. The goal was resident will have airway open. Approaches included administer medications as ordered, observe for side effects and effectiveness, neurological assessment as needed, notify MD as needed, maintain airway, and report [MEDICAL CONDITION]. On [DATE] at 5:45 PM, an interview was conducted with Nurse Aide (NA #1) who took care of the resident on [DATE] (third shift 11PM to 7AM). She stated the resident was fine during the night. "I went into the room on rounds about 5:30 AM and she was breathing hard." NA #1 indicated when she discovered the resident, she was having trouble breathing and jerking movements. NA #1 stated she went to get Nurse #1. In an interview with Nurse #1 on [DATE] at 11:51 AM, she stated she knew Resident #186 and had taken care of her prior to [DATE]. She stated when she entered the room around 5:30 AM she observed the resident in respiratory distress and having [MEDICAL CONDITION]. The resident was in a supine (flat on her back) position. The nurse stated she took the resident's vital signs and her pulse oxygen saturation was low at 87 percent. She moved the resident to a 45 degree angle, and applied oxygen at 2 liters per minute. Nurse #1 stated "I gave her a breathing treatment with a Nebulizer." Nurse #1 stated the resident was unresponsive and actively having a continuous [MEDICAL CONDITION]. She stated the resident normally had some movements in her extremities but this was non-stop movements. Nurse #1 stated it sounded like she had a blockage in her throat. She stated there were no secretions coming from her mouth. She stated she did not attempt to suction the resident. Nurse #1 stated when a repeat oxygen saturation was done the oxygen was up to 89 or 90 percent and she increased the oxygen flow to 4 liters per minute. Nurse #1 stated she did not call the resident's physician to report the [MEDICAL CONDITION] or see if oxygen should be increased at that time. Nurse #1 stated she called Emergency Medical Service (EMS) and stated probably sometime after 6:00 AM. Nurse #1 stated she did not call the physician at that time. She stated she called the physician and responsible party after the resident had left the facility with EMS at 8:14 AM. In nursing notes for [DATE] at 8:14 AM Nurse #1 documented, "Blood pressure ,[DATE] at 5:30 AM, pulse (rate) 64, temperature 98.2, respiratory rate 25 (breaths per minute), O2 (oxygen saturation) 87% on room air at 5:30 AM. Comments: Resident was wheezing, obvious gurgling, very lethargic/sleepy; difficult to arouse, has [MEDICAL CONDITION]. Nebulizer treatment given, O2 (oxygen) started at 4L/minute (Liters per minute). [MEDICAL CONDITION] was non-stop and resident status did not improve. The Night Nurse in the front hall also helped in assessing the resident. EMS was called and resident was transported to (local hospital) via stretcher at 7:30 AM. Dr. (attending physician) notified; resident's daughter notified of resident's transfer". Review of Resident #186's [DATE], Emergency Medical Service (EMS) report Dispatch for the County services "was called at 6:53 AM on [DATE] reporting a resident with [MEDICAL CONDITION], ambulance in route at 6:54 AM, the ambulance traveled one mile and arrived at the facility on 6:59 AM, emergency crew at bedside 7:05 AM. Chief Complaint, [MEDICAL CONDITION]/Convulsion, Actively. [MEDICAL CONDITION] duration greater than 5 minutes, [MEDICAL CONDITION] type- Grand Mal (for) 1 hour." (Taber's Medical Dictionary, 19th edition, describes Grand Mal as [MEDICAL CONDITION], loss of consciousness with violent movements of the extremities). The report continued, "lung sounds Left Wheeze/Rhonchi, and lung sounds right wheezes/ Rhonchi." (Rhonchi are described by Taber's as "A wheezing, snoring, or squeaking sound heard during auscultation (listening to chest with stethoscope) of a person with partial airway obstruction. Mucus or other secretion in the airway, [MEDICATION NAME] that occlude respiratory passages.") In an interview with Nurse #2 on [DATE] at 12:21 PM, she stated that on [DATE] between 6:00 AM to 7:00 AM Nurse #1 came out in the hall to request help with Resident #186. She stated it must have been between 6 and 7 AM; she did not recall the exact time. Nurse #2 stated she went into Resident #186's room with Nurse #1 and observed the resident lying on the bed; she was shaking and having difficulty breathing. The resident had a blood pressure cuff on her right arm, and was getting oxygen via nasal cannula and was unresponsive. Nurse #2 stated "We woke her up using a sternal rub. She opened her eyes but never spoke. Her eyes were hazy and she was coughing." Nurse #2 stated she repeated the sternal rub. She stated the resident's body continued to shake during sternal rubs. Nurse #2 stated that she told Nurse #1 that they needed to call EMS. Nurse #2 stated Nurse #1 left the room to call EMS and prepare the discharge paperwork and she stayed in the room with the resident. She stated "I opened the closet and picked out an outfit for the resident. Then I washed her up and dressed her. I had to lay her down to get her shirt and pants on." Nurse #2 stated the resident was seizing and unresponsive while being bathed and dressed. Nurse #2 stated she was aware the resident was having continued [MEDICAL CONDITION] throughout the bath and dressing, however she continued on with the tasks because she wanted the resident to look nice to go to the hospital. Summary statement from EMS read: "Dispatched by 911 to a [MEDICAL CONDITION]. Arrived to find a [AGE] year old female actively seizing. Patient assessed as charted. Patient found in care of staff at local skilled facility with active [MEDICAL CONDITION] activity noted. Staff stated patient with hx (history) of same secondary to [MEDICAL CONDITION] and [MEDICAL CONDITIONS]. Patient began seizing at approx (approximately) 5:30 this morning. IV (intravenous) access established x 1 attempt as charted and IV Versed administered per protocol." (Versed is a benzodiazepine used for [DIAGNOSES REDACTED], a continuous [MEDICAL CONDITION] activity without a pause.) "[MEDICAL CONDITION] activity reduced however some residual focal activity remained. Patient continued on O2 at 10 liters per minute. During transport, second dose of IV Versed administered due to continued [MEDICAL CONDITION] activity. [MEDICAL CONDITION] activity never fully ceased during EMS care and/or transport." Review of Resident #186's hospital records on [DATE] in part read, "The patient presented in [DIAGNOSES REDACTED]. She required intubation for airway protection and admission to the ICU (intensive care unit). She was placed on a Versed gtt (drip), her [MEDICATION NAME] was increased and she was [MEDICATION NAME] (another anticonvulsant) loaded. Her EEG (electroencephalogram, to view brain waves) indicated an underlying [MEDICAL CONDITION] disorder. She was felt to be having breakthrough [MEDICAL CONDITION] due to infection (aspiration pneumonia)". Patient was also suffering from septic shock due to possible aspiration pneumonia. Interview with the Director of Nursing (DON) on [DATE] at 2:13 PM, revealed that her expectation was if nursing staff observed a resident seizing that the resident should be raised to an upright position to protect airway, rolled toward the left side, and the nurse should call EMS if the [MEDICAL CONDITION] lasted more than 15 minutes. The DON stated Resident #186 was experiencing a medical emergency on [DATE] and laying the resident flat on her back for bathing and dressing the resident was inappropriate. The DON revealed the event was discussed on [DATE] at the morning meeting. She stated she saw the two hour time frame on the nurses' notes but was not concerned because sometimes it takes EMS time to stabilize a resident. She stated she thought the 'gurgling' was due to [MEDICAL CONDITION] activity. In an interview with the Medical Director on [DATE] at 12:52 PM, he acknowledged he was called by the nurse on [DATE] after the resident left for the hospital. He stated he would have expected to have been called by staff if the resident, with a history of [MEDICAL CONDITION], had a [MEDICAL CONDITION] that lasted more than ,[DATE] minutes and EMS should be initiated immediately. The Administrator was notified of the Immediate Jeopardy on [DATE] at 10:45 AM. The facility provided the following credible allegation of compliance: RESIDENT IDENTIFIED 1. Resident #186 no longer resides at this facility. IDENTIFYING OTHER RESIDENTS AT RISK 1. A 100% audit was completed on [DATE] and again on [DATE] by the nurse management team (director of nursing, assistant director of nursing, 2 unit managers, wound nurse) a. The audit consisted of reviewing 100% of the nursing notes in the past 24 hours to ensure all residents experiencing any change of condition have had an appropriate nursing assessment and interventions, as indicated; physician notification for further guidance, as indicated and activation of EMS immediately, if indicated. 1. 2 residents were started on an antibiotic with appropriate physician notification 2. 2 resident had a fall with appropriate physician notification 3. 1 hospice resident expired with appropriate physician notification 4. No other concerns were identified 2. On [DATE] and [DATE], a facility nurse manager has been assigned to each unit observing all facility residents which reside on those units for any concerns and or change in condition. 1. No concerns were identified in regards to MD notification. 3. The MD and/or his nurse practitioner are in the facility Monday - Friday and while in the facility staff will notify them there. When they are not in the facility then they will be contacted through the on-call service. MD notification is documented under the nursing charting in the medical record. 4. The MD is notified immediately in non-life threatening emergencies for further guidance and after EMS is activated in life threatening emergencies. PROCESSES IMPLEMENTED TO PREVENT FURTHER OCCURRENCES 1. In-servicing for the nurses was started on [DATE] by the Clinical Resource Nurse and DON. At this point 40 nurses out of 52 have been in-serviced. No nurse will be able to work the floor until they are in-serviced. The in-service addressed the following: a. 24 Hour Report b. Alert Charting Process c. Infection Reports d. Change of Condition Guidelines- which included physician notification e. Documentation Guidelines- which included physician notification f. Appropriate assessment, interventions, follow up to interventions g. Emergency Procedures- [MEDICAL CONDITION] Management h. Care of a Resident in Emergency Situations- which included but not limited to- initial assessment (objective and subjective symptoms), head injuries, lacerations, suspected fractures, burns, choking, shortness of breath, chest pain, [MEDICAL CONDITIONS], dizziness, diabetic coma/ketoacidosis, insulin shock/insulin reaction, acute psychotic behaviors, ingestion of toxins and physician notification. i. Emergency Procedures- which included physician notification 2. Two nurses were identified in this deficiency. a. One nurse was in-serviced on [DATE]. b. The other nurse has been suspended at this time pending an abuse allegation of neglect- she was suspended on [DATE]. 3. The Nurse Managers were in-serviced by the Clinical Resource Nurse on [DATE] on the following: a. 24 Hour Report- and how to use them b. Alert Charting Process c. Infection Reports d. Change of Condition Guidelines- which included physician notification e. Documentation Guidelines- which included physician notification f. Appropriate assessment, interventions, follow up to interventions g. Emergency Procedures- [MEDICAL CONDITION] Management h. Care of a Resident in Emergency Situations- which included but not limited to- initial assessment (objective and subjective symptoms), head injuries, lacerations, suspected fractures, burns, choking, shortness of breath, chest pain, [MEDICAL CONDITIONS], dizziness, diabetic coma/ketoacidosis, insulin shock/insulin reaction, acute psychotic behaviors, ingestion of toxins and physician notification. i. Emergency Procedures- which included physician notification 4. The nurse managers will continue with the AM Clinical Meeting Monday - Friday a. On Saturday and Sunday a nurse manager will be in the facility each day. b. Physical rounds will be completed on each unit, every AM, prior to AM Clinical Meeting. A nurse manager will be speaking to the floor nurses regarding any resident change of conditions and physician notification for further guidance. In addition, the nurse manager will round on any residents which have had an identified change of condition. c. A nurse manager will review the 24 hour report, alert charting log and nursing notes to ensure all change of conditions have been communicated to the MD, that guidance has been provided and documented in the medical record under the nurse charting tab. MONITORING 1. During the AM Clinical Meeting all areas listed in #2 will be completed by the Nurse Management Team. a. The Nurse Management Team consists of the DON, ADON, 2 Unit Managers and 2 MDS Coordinators. b. The AM Clinical Meeting is held Monday-Friday at 8:15 AM. c. On Saturday and Sunday a nurse manager will be in the facility each day to complete the areas listed in #2. 2. During the AM Clinical Meeting any discrepancies identified will be documented, investigated and corrected immediately by the Nurse Management Team. 3. From any discrepancies identified further education or disciplinary action will occur with the staff member responsible. 4. The Clinical Resource Nurse will review the daily audits (labs, nursing notes, BM list, telephone orders) completed by the Nurse Management Team, weekly times 4 weeks, to ensure there is appropriate MD notification and guidance has been provided for any change of condition. 5. If trends or discrepancies are noted this QA process will be revised by the QA committee. 6. As discrepancies and trends are identified through these QA audits further education and training will be provided. 7. The facility will continue to involve the Medical Director in the facility processes in order to seek guidance and support. 8. A member of the Home Office staff will be on-site weekly for at least the next 30 days to offer guidance, support, training and monitoring of this plan. 9. On [DATE], Apex hired a new Clinical Resource Nurse, who will continue to provide guidance, support, training and monitoring to the DON and Nurse Management Team. The facility alleges the immediacy of these discrepancies have been abated on [DATE]. On [DATE] at 6:45 PM, the credible allegation was validated. Staff interviews with licensed nurses revealed the facility had implemented corrective measures which included in-services of licensed nurses regarding proper facility procedure and protocol for residents experiencing [MEDICAL CONDITION], respiratory distress, changes in levels of consciousness (LOC), emergency situations, physician notification, activation of emergency medical services and appropriate resident care during a [MEDICAL CONDITION], respiratory distress, change in LOC or any emergency situation.

Based on record review, staff and physician interviews, the facility failed to provide emergency treatment for [REDACTED].#186). The Immediate Jeopardy (IJ) began on 8/18/14 at 5:30 am for Resident #186 when the resident was found by the staff in continuous [MEDICAL CONDITION] and respiratory distress. The immediate jeopardy was removed on 9/11/14 at 6:45 pm when the facility provided and implemented an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity of (D) (no actual harm with the potential for more than minimal harm) that is not immediate jeopardy to ensure monitoring systems put in place are effective and included in the facility's Quality Assurance Program. Findings included: A review of the facility's procedure policy dated 2006 titled "[MEDICAL CONDITION], Nursing Management of: Basic responsibility - Licensed Nurse" in part read "If a resident is in bed, remove pillow from under resident's head and gently hyperextend head to maintain airway patency. Position on side, if possible, to facilitate drainage of mucus and decrease possibility of aspiration of secretions." Resident #186 was admitted into the facility on [DATE]. [DIAGNOSES REDACTED].The Minimum Data Set completed on 7/10/14 indicated the resident's cognitive pattern was severely impaired. Extensive assistance was required with bed mobility and transfers. [MEDICAL CONDITION] was indicated. The care plan dated 2/14/14 indicated [MEDICAL CONDITION] as a problem. A stated goal read: resident will have airway open. Approaches read: administer meds as ordered, observe for side effects and effectiveness, neuro (neurological) assessment as needed, notify physician as needed, maintain airway, and report [MEDICAL CONDITION]. A review of the nurses' notes dated 8/14 and 8/17/14 revealed no [MEDICAL CONDITION] or respiratory or lung concerns. A review of the physician orders [REDACTED]. Scheduled [MEDICAL CONDITION] medications included: ? [MEDICATION NAME] 1 milligram (mg) every eight hours at 6:00 am, 2:00 pm and 10:00 pm. ? Lacosamide 200 mg every 12 hours at 6:00 am and 6:00 pm. ? [MEDICATION NAME] 1000 mg twice daily at 8:00 am and 8:00 pm. On 9/10/14 at 11:51 AM, in an interview, Nurse #1 acknowledged she was resident #186's primary nurse from 7 pm - 7 am. She stated when she entered the room around 5:30 am she observed the resident in respiratory distress, having [MEDICAL CONDITION] and in a supine (flat on her back) position. The nurse stated she assessed the resident's vital signs and her pulse oxygen saturation was low at 87 percent (%). She indicated she positioned the resident to a 45 degree upright angle, applied oxygen at 2 liters per minute and gave her a breathing treatment with a Nebulizer. Nurse #1 stated the resident was unresponsive and actively having a [MEDICAL CONDITION]. She stated the resident normally has some movements in her extremities but this was non-stop and sounded like she (Resident #186) had a blockage in her throat. Nurse #1 stated there were no secretions observed coming from the resident's mouth, nor did she have to suction. Nurse #1 stated repeated oxygen saturation revealed the oxygen increased to 89 or 90 % and she further increased the oxygen flow to 4 liters per minute. Nurse #1 indicated she initiated EMS - she stated she probably initiated EMS after 6:00 am. She stated she did not notify the physician concerning the resident's current status. Nurse #1 stated she called the physician after the resident left the facility by ambulance to the local hospital with EMS. Nurse #1 did not elaborate why she did not immediately call 911. A review of the nurse's noted dated 8/18/14 revealed at 5:30 am, Resident #186 was assessed by Nurse #1 with an oxygen saturation of 87% (normal 95-100%) on room air, blood pressure 92/58, respiratory rate of 25 breaths per minute, wheezing, obvious gurgling, very lethargic/sleepy; difficult to arouse and [MEDICAL CONDITION]. A nebulizer treatment (a common treatment for [REDACTED]. Nurse #1 further noted the night nurse (Nurse #2) in the front hall helped her in assessing the resident. Emergency Medical Services was documented as called and the resident was transported to the local hospital via stretcher at 7:30 am. The physician and responsible party were indicated as notified of the resident's transfer to the hospital by Nurse #1. On 9/10/14 at 12:21 pm, in an interview, Nurse #2 stated Nurse #1 came out in the hall and requested her help. She stated it must have been between 6:00 am and 7:00 am because she was making rounds and did not recall the exact time. Nurse #2 indicated she went into Resident #186's room with Nurse #1 and observed the resident lying on the bed; the resident was shaking and having difficulty breathing and coughing a lot. She stated the resident had a blood pressure cuff on her right arm, receiving oxygen by nasal cannula and unresponsive. Nurse #2 indicated they (she and Nurse #1) woke the resident up using a sternal rub (briskly rubbing knuckles over sternum) performed 2 or 3 times and her body continued to shake throughout the sternal rubs. She elaborated the resident opened her eyes but never spoke, eyes were hazy and she was coughing. Nurse #2 said she informed Nurse #1 they needed to activate (call) EMS. Nurse #2 indicated Nurse #1 then left the room and she (Nurse #2) opened the closet, picked out an outfit for the resident, lowered the resident to a flat position on her back, bathed the resident in the flat position on her back and then dressed the resident while in the same position, until she completed the bath and put the resident's shirt and pants on. She further indicated the resident continued with [MEDICAL CONDITION] and coughing throughout being bathed and dressed by her. Nurse #2 concluded she was aware the resident was having continued [MEDICAL CONDITION] and coughing while she bathed and dressed the resident, however she continued with the tasks because the resident had oxygen on and she wanted the resident to look nice to go to the hospital. A review of the EMS dispatch report for the county emergency services in part read "Was called at 6:53 am on 8/18/14 reporting a resident with [MEDICAL CONDITION], ambulance in route at 6:54 am, the ambulance traveled one mile and arrived at the facility at 6:59 am, emergency crew at bedside 7:05 am. Chief complaint: [MEDICAL CONDITION]/convulsion - actively. [MEDICAL CONDITION] duration greater than 5 minutes, [MEDICAL CONDITION] type - Grand Mal (for) 1 hour." The EMS report further read "Vital signs on scene on 8/18/14 at 7:09 am temperature 97.4, pulse 84, respirations 20, lung sounds left wheeze/rhonchi (abnormal lung sounds), lung sounds right wheezes/ rhonchi. Rhonchi is described by Taber's as "A wheezing, snoring, or squeaking sound heard during auscultation (listening to chest with stethoscope) of a person with partial airway obstruction. Mucus or other secretion in the airway, [MEDICATION NAME] that occlude respiratory passages." A review of the summary statement from the EMS report read "Dispatched by 911 to a [MEDICAL CONDITION]. Arrived to find Resident #186 actively seizing. Patient assessed as charted. Patient found in care of staff at local skilled facility with active [MEDICAL CONDITION] activity noted. Staff state patient with hx (history) of same secondary to [MEDICAL CONDITION] and [MEDICAL CONDITIONS]. Patient began seizing at approx (approximately) 5:30 this morning. IV (intravenous) access established x 1 attempt (by EMS) as charted and IV Versed administered per protocol. Versed is a Benzodiazepine used for [DIAGNOSES REDACTED], a continuous [MEDICAL CONDITION] activity without a pause. [MEDICAL CONDITION] activity reduced however some residual focal activity remained. Patient continued on oxygen at 10 liters per minute. During transport, second dose of IV Versed administered due to continued [MEDICAL CONDITION] activity. [MEDICAL CONDITION] activity never full ceased during EMS care and/or transport." A review of the hospital record dated 8/18/14 in part read, "The patient presented in [DIAGNOSES REDACTED]. She required intubation (insertion of a tube into the trachea or windpipe to keep open or restore patency if obstructed) for airway protection and aspiration pneumonia and was admitted into to the ICU (intensive care unit). She was placed on a Versed gtt (drip), her [MEDICATION NAME] ([MEDICAL CONDITION] prevention medication) was increased and she was [MEDICATION NAME] (anticonvulsant medication) loaded. Her EEG (electroencephalogram, to view brain waves) indicated an underlying [MEDICAL CONDITION] disorder. She was felt to be having breakthrough [MEDICAL CONDITION] due to infection and thought to have septic shock due to aspiration pneumonia, which required volume resuscitation with intravenous fluids." Resident #186 was discharged from the hospital on [DATE] to another skilled nursing facility. On 9/10/14 at 2:13 pm, in an interview, the Director of Nursing stated if a resident was observed having a [MEDICAL CONDITION] she expected the nursing staff to position the resident in an upright position to protect the airway with the resident rolled toward the left side and call EMS immediately if the [MEDICAL CONDITION] lasted more than 15 minutes. The DON stated Resident #186 was experiencing a medical emergency and laying the resident flat on her back and bathing her was inappropriate considering the resident's physical condition. On 9/10/14 at 12:52 pm, in an interview, the physician (medical director) stated if a resident was having a [MEDICAL CONDITION] that lasted longer than 10-15 minutes, he expected the resident to be transported to the hospital immediately by EMS and to be notified immediately afterwards. The physician indicated if a resident was having an active [MEDICAL CONDITION] he did not expect the resident to be positioned in a flat supine (positioned on back) position because the resident would be at risk for respiratory aspiration. He concluded he recalled being made aware by the facility the resident was transported to the hospital; however he did not know the exact time he was called. The Administrator and the Director of Nursing were notified of the immediate jeopardy on 9/11/14 at 10:45 am. The immediate jeopardy was removed on 9/11/14 at 6:45 pm when the facility provided an acceptable credible allegation that in part read: "Credible Allegation of Compliance: RESIDENT AT RISK 1. Resident #186 no longer resides at this facility. IDENTIFYING OTHER RESIDENTS AT RISK 1. A 100% audit was completed on 9/10/14 and again on 9/11/14 by the nurse management team (director of nursing, assistant director of nursing, 2 unit managers, wound nurse) 2. The audit consisted of reviewing all nursing notes in the past 24 hours to ensure there were no identified concerns of neglect with residents experiencing a change of condition. a. 0 out of a 181 residents had no identified concerns regarding neglect. b. No other concerns were identified. 3. On 9/10/14 and 9/11/14, a facility nurse manager has been assigned to each unit observing all facility residents which reside on those for signs and symptoms of neglect related to ADL (Activities of Daily Living) cares. a. No concerns were identified in regards to neglect related to activities of daily living (ADL) cares. 4. On 9/11/14 the administrator completed 100% facility rounds to ensure there were no areas of concerns with neglect related to ADL cares. a. No concerns were identified in regards to neglect related to ADL cares. PROCESSES IMPLEMENTED TO PREVENT FURTHER OCCURRENCE 1. In-servicing for the nurses was started on 9/10/14 by the Clinical Resource Nurse and DON. At this point 40 nurses out of 52 have been in-serviced. No nurse will be able to work the floor until they are in-serviced. The in-service addressed the following: a. 24 Hour Report b. Alert Charting Process c. Change of Condition Guidelines d. Documentation Guidelines e. Appropriate assessment, interventions, follow up to interventions f. Emergency Procedures- [MEDICAL CONDITION] Management g. Care of a Resident in Emergency Situations- which included but not limited to- initial assessment (objective and subjective symptoms), head injuries, lacerations, suspected fractures, burns, choking, shortness of breath, chest pain, [MEDICAL CONDITIONS], dizziness, diabetic coma/ketoacidosis, insulin shock/insulin reaction, acute psychotic behaviors, ingestion of toxins and physician notification. h. Emergency Procedures 2. Two nurses were identified in this deficiency. a. One nurse was in-serviced on 9/11/14.- (see bullet points a-h above) b. The other nurse has been suspended at this time pending an abuse allegation of neglect- she was suspended on 9/11/14. i. The allegation of neglect was reported to the appropriate state agencies on 9/11/14. ii. The resident is protected as they no longer reside in the facility. iii. The facility administrator will follow the abuse protocol and complete the investigation as outlined in the policy and procedures and per federal regulations. 3. The Nurse Managers were in-serviced by the Clinical Resource Nurse on 9/10/14 on the following: a. 24 Hour Report- and how to use them b. Alert Charting Process c. Infection Reports d. Change of Condition Guidelines- which included physician notification e. Documentation Guidelines- which included physician notification f. Appropriate assessment, interventions, follow up to interventions g. Emergency Procedures- [MEDICAL CONDITION] Management h. Care of a Resident in Emergency Situations- which included but not limited to- initial assessment (objective and subjective symptoms), head injuries, lacerations, suspected fractures, burns, choking, shortness of breath, chest pain, [MEDICAL CONDITIONS], dizziness, diabetic coma/ketoacidosis, insulin shock/insulin reaction, acute psychotic behaviors, ingestion of toxins and physician notification. i. Emergency Procedures- which included physician notification 4. The nurse managers will continue with the AM Clinical Meeting Monday - Friday a. On Saturday and Sunday a nurse manager will be in the facility each day. b. Physical rounds will be completed on each unit, every AM, prior to AM Clinical Meeting. A nurse manager will be speaking to the floor nurses regarding any resident change of conditions and physician notification for further guidance. In addition, the nurse manager will round on any residents which have had an identified change of condition to ensure there are no concerns with ADL cares. c. A nurse manager will review the 24 hour report, alert charting log and nursing notes to ensure all change of conditions have been communicated to the MD, that guidance has been provided and documented in the medical record under the nurse charting tab. The facility alleges the immediacy of these discrepancies have been abated on 9/11/14." On 9/11/14 at 6:45 pm, the credible allegation was validated. Staff interviews with licensed nurses revealed the facility had implemented corrective measures which included in-services of licensed nurses regarding proper facility procedure and protocol for residents' experiencing [MEDICAL CONDITION], respiratory distress, changes in levels of consciousness (LOC), emergency situations, physician notification, activation of emergency medical services and appropriate resident care during a [MEDICAL CONDITION], respiratory distress, change in LOC or any emergency situation.

Based on record review and staff interviews, the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor these interventions that the facility put in place in [DATE]. This was for two federal deficiencies which were originally cited in July of 2014 on a Recertification survey and recited on a current Recertification revisit, complaint survey of [DATE]. The deficiencies were recited in the areas of Care & Services and Physician notification. The continued failures of the facility during a Recertification revisit, complaint survey of records show the facility's inability to sustain an effective Quality Assurance program. The Immediate Jeopardy (IJ) began on [DATE] at 5:30 am for Resident #186 when the resident was found by the staff in continuous [MEDICAL CONDITION] and respiratory distress. The immediate jeopardy was removed on [DATE] at 6:45 pm when the facility provided and implemented an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity of (D) (no actual harm with the potential for more than minimal harm) that is not immediate jeopardy to ensure monitoring systems put in place are effective and included in the facility's Quality Assurance Program. Findings included: This tag is cross referenced to: 1a. F 309: Care and Services - During the Recertification survey of [DATE] the facility was cited: Based on record review, staff, physician and nurse practitioner interviews, the facility failed to manage the care of a resident by failure to obtain or recheck a stool sample as ordered by the physician for persistent diarrhea, that resulted in a 17 day delay in medical treatment because the physician was not notified. As a result of continued loose stools, the resident experienced low blood pressures and a fluid volume deficit (loss of bodily fluids), which lead to a low potassium level. The facility also failed to administer potassium as ordered by the physician for a critical potassium level of 2.3 (3.5 - 5.3 reference range) for 1 of 2 residents records reviewed for [MEDICAL CONDITION] (Resident #263). The facility on [DATE] during a Recertification revisit, complaint survey was recited for F 309 for failure to provide emergency treatment for [REDACTED].#186) - see F 309 per the CMS-2567 for investigation details. F 309 was originally cited during the [DATE] recertification survey as indicated above in 1a. b. F 157: Physician Notification of Changes - During the Recertification survey of [DATE] the facility was cited: Based on record review, staff, physician and nurse practitioner interviews, the facility failed to notify or consult with the physician or nurse practitioner that a resident had persistent loose stools which resulted in a 17 day delay in medical treatment for 1 of 2 residents reviewed for [MEDICAL CONDITION] and failed to notify the physician of missed doses of potassium for 1 of 1 resident with a critical potassium level of 2.3 (Resident #263). The facility on [DATE] during a Recertification revisit, complaint survey was recited F 157 for failure to immediately notify the resident's physician of respiratory distress and continuous [MEDICAL CONDITION] for 1 of 3 sampled residents reviewed for notification of change (Resident #186) - see F 157 per the CMS-2567 for investigation details. F 157 was originally cited during the [DATE] recertification survey as indicated in b. On [DATE] at 2:13 PM, an interview with the Director of Nursing (DON) in the presence of the Administrator revealed she was part of the quality assurance (QA) committee. The DON stated she was aware of the events that had taken place with Resident #186 and acknowledged she had read the nurse's note in its entirety dated [DATE], prior to the entry of the Recertification revisit/complaint survey. The DON stated after reading the nurse's note written by Nurse #1, she wondered why there was a time lapse from the point in which the resident was identified with oxygen saturation at 87 percent and the time the resident was sent to the hospital. She stated she had not identified any deficient concerns from the nurses notes nor had she conducted any interviews with the nursing staff (Nurse #1, Nurse #2), or that the staff needed to be re-trained. The DON elaborated there was no discussion in the last QA meeting held on [DATE], regarding needed care areas of improvement, surrounding the nurse's note dated [DATE]. She further stated the event (Resident #186) was discussed on [DATE] at the morning team meeting but she did not call Nurse #1 or Nurse #2 in to talk to them regarding any problematic care concerns. The DON stated at the time, she did not see a quality assurance problem since the resident was discharged from the facility. The DON indicated "I saw the two hour time frame on the nurses' note but was not concerned because sometimes it takes EMS time to stabilize a resident. I thought the "gurgling" was due to [MEDICAL CONDITION] activity." The DON indicated during the QA committee meeting held on [DATE], there was no identified problems related to Resident #186, that needed to be systemically corrected related to continued [MEDICAL CONDITION], respiratory distress or proper response and care in an emergency situation. The DON concluded the purpose of the QA is to identify problematic areas through chart review, nurses' notes, and clinical meetings and develop a QA plan for identified problems, with corrective measures and monitoring. On [DATE] at 10:52 am, in an interview, the Administrator stated she expected such a questionable concern (speaking of the nurse's note dated [DATE] written by Nurse #1) to have been brought to the Quality Assurance (QA) meeting for a team discussion and a plan initiated and implemented to ensure safe care of the residents and to prevent any reoccurrences. The administrator concluded after reviewing the nurse's note herself dated [DATE], she expected the concern to have been QA'd and a plan developed immediately, to educate the nursing staff and systems put in place for monitoring. The Administrator and the Director of Nursing were notified of the immediate jeopardy on [DATE] at 10:45 am. The immediate jeopardy was removed on [DATE] at 6:45 pm, when the facility provided an acceptable credible allegation that in part read: "Credible Allegation of Compliance: RESIDENT AT RISK 1. Resident #186 no longer resides at this facility. IDENTIFYING OTHER RESIDENTS AT RISK 1. A 100% audit was completed on [DATE] and again on [DATE] by the nurse management team (director of nursing, assistant director of nursing, 2 unit managers, wound nurse) 1. The audit consisted of reviewing 100% of the nursing notes in the past 24 hours to ensure all residents experiencing any change of condition have had an appropriate nursing assessment and interventions, as indicated; physician notification for further guidance, as indicated and activation of EMS immediately, if indicated. 1. 2 residents were started on an antibiotic with appropriate physician notification 2. 2 resident had a fall with appropriate physician notification 3. 1 hospice resident expired with appropriate physician notification 4. No other concerns were identified 2. On [DATE] and [DATE], a facility nurse manager has been assigned to each unit observing all facility residents which reside on those units for any concerns and or change in condition. 1. No concerns were identified in regards to MD notification. 3. The MD and/or his nurse practitioner are in the facility Monday - Friday and while in the facility staff will notify them there. When they are not in the facility then they will be contacted through the on-call service. MD notification is documented under the nursing charting in the medical record. 4. The MD is notified immediately in non-life threatening emergencies for further guidance and after EMS is activated in life threatening emergencies. 5. An abbreviated QA&A meeting will be conducted on [DATE] to address the identified concerns physician notification, change of condition ([MEDICAL CONDITION], shortness of breath, change in level of consciousness to include unresponsiveness) from the follow-up survey (Revisit). PROCESSES IMPLEMENTED TO PREVENT FURTHER OCCURRANCES 1. To enhance current compliant operations and under the direction of the administrator the Facility Department Heads will receive in-service training regarding the QA&A process on [DATE]. 2. The DON will submit all audits on physician notification and change of condition monthly to the QA&A to be reviewed and revised as needed. 3. The administrator will submit all audits on abuse allegations monthly to the QA&A to be reviewed and revised as indicated. 4. A QAPI Action Plan will be implemented whenever an issue is identified during AM Clinical Meeting and/or Department Head Meeting. 5. The QA&A will review findings submitted by the different sub-committee to monitor continued compliance and opportunities for improvement. 6. The administrator and/or Apex Clinical Resource Nurse will monitor the QA&A process weekly to ensure identified issues are monitored and revised to correct quality deficiencies. The facility alleges the immediacy of these discrepancies have been abated on [DATE]." On [DATE] at 6:45 pm, the credible allegation was validated. Staff interviews with licensed nurses and administrative staff revealed the facility had implemented corrective measures which included in-services of licensed nurses and administrative personnel regarding proper facility procedure and protocol for residents' experiencing [MEDICAL CONDITION], respiratory distress, changes in levels of consciousness (LOC), emergency situations, physician notification, activation of emergency medical services and appropriate resident care during a [MEDICAL CONDITION], respiratory distress, change in LOC or any emergency situation.

Based on record review, emergency medical services (EMS) report, and staff and physician interviews, the facility failed to provide emergency treatment for [REDACTED].#186). The Immediate Jeopardy (IJ) began on [DATE] at 5:30 AM for Resident #186 when resident was found by staff in continuous [MEDICAL CONDITION] and respiratory distress. The Administrator was notified of the Immediate Jeopardy on [DATE] at 10:45 AM. The Immediate Jeopardy was removed on [DATE] at 6:45 PM when the facility demonstrated it had implemented a credible allegation. The facility was left out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy (D) so that the facility can complete all staff in-services and monitoring systems could be implemented and included in the Quality Assurance Program. Findings included: Resident #186 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. A review of resident's physician order [REDACTED]. [MEDICATION NAME] is an anticonvulsant, [MEDICATION NAME] is an anticonvulsant and Klonopin is medication with anticonvulsant properties. A review of the quarterly Minimum Data Set ((MDS) dated [DATE] indicated the resident was severely cognitively impaired. Care plan dated [DATE] indicated [MEDICAL CONDITION] as problem. Goal: resident will have airway open. Approaches: administer meds as ordered, observe for side effects and effectiveness, neuro (neurological) assessment as needed, notify MD as needed, maintain airway, and report [MEDICAL CONDITION]. On [DATE] at 5:45 PM, an interview was conducted with Nurse Aide (NA #1) who took care of the resident on [DATE] (third shift 11PM to 7AM). She stated the resident was fine during the night. "I went into the room on rounds about 5:30 AM and she was breathing hard." NA#1 indicated when she discovered the resident, she was having trouble breathing and jerking movements. NA #1 stated she went to get Nurse #1. In an interview with Nurse #1 on [DATE] at 11:51 AM, she stated she knew Resident #186 and had taken care of her prior to [DATE]. She stated when she entered the room around 5:30 AM she observed the resident in respiratory distress and having [MEDICAL CONDITION]. The resident was in a supine (flat on her back) position. The nurse stated she took the resident's vital signs and her pulse oxygen saturation was low at 87 percent. She moved the resident to a 45 degree angle, and applied oxygen at 2 liters per minute. Nurse #1 stated "I gave her a breathing treatment with a Nebulizer." Nurse #1 stated the resident was unresponsive and actively having a continuous [MEDICAL CONDITION]. She stated the resident normally had some movements in her extremities but this was non-stop movements. Nurse #1 stated it sounded like she had a blockage in her throat. She stated there were no secretions coming from her mouth. She stated she did not attempt to suction the resident. Nurse #1 stated when a repeat oxygen saturation was done, the oxygen was up to 89 or 90 percent and she increased the oxygen flow to 4 liters per minute. Nurse #1 stated she did not call the resident's physician to report the [MEDICAL CONDITION] or see if oxygen should be increased at that time. Nurse #1 stated she called Emergency Medical Service (EMS) and stated probably sometime after 6 AM. Nurse #1 stated she did not call the physician at that time. She stated she called the physician and responsible party after the resident had left the facility with EMS at 8:14 AM. In nursing notes for [DATE] at 8:14 AM Nurse #1 documented, "Blood pressure ,[DATE] at 5:30 AM, pulse (rate) 64, temperature 98.2, respiratory rate 25 (breaths per minute), O2 (oxygen saturation) 87% on room air at 5:30 AM. Comments: Resident was wheezing, obvious gurgling, very lethargic/sleepy; difficult to arouse, has [MEDICAL CONDITION]. Nebulizer treatment given, O2 (oxygen) started at 4L/minute (Liters per minute). [MEDICAL CONDITION] was non-stop and resident status did not improve. The Night Nurse in the front hall also helped in assessing the resident. EMS was called and resident was transported to (local hospital) via stretcher at 7:30 AM. Dr. (attending physician) notified; resident's daughter notified of resident's transfer". In an interview with Nurse #2 on [DATE] at 12:21 PM, she stated that on [DATE] between 6:00 AM to 7:00 AM Nurse #1 came out in the hall to request help with Resident #186. She stated it must have been between 6 and 7 AM; she did not recall the exact time. Nurse #2 stated she went into Resident #186's room with Nurse #1 and observed the resident lying on the bed; she was shaking and having difficulty breathing. The resident had a blood pressure cuff on her right arm, and was getting oxygen via nasal cannula and was unresponsive. Nurse #2 stated "We woke her up using a sternal rub. She opened her eyes but never spoke. Her eyes were hazy and she was coughing." Nurse #2 stated she repeated the sternal rub. She stated the resident's body continued to shake during sternal rubs. Nurse #2 stated that she told Nurse #1 that they needed to call EMS. Nurse #2 stated Nurse #1 left the room to call EMS and prepare the discharge paperwork and she stayed in the room with the resident. She stated "I opened the closet and picked out an outfit for the resident. Then I washed her up and dressed her. I had to lay her down to get her shirt and pants on." Nurse #2 stated the resident was seizing and unresponsive while being bathed and dressed. Nurse #2 stated she was aware the resident was having continued [MEDICAL CONDITION] throughout the bath and dressing, however she continued on with the tasks because she wanted the resident to look nice to go to the hospital. Review of Resident #186's [DATE] Emergency Medical Service (EMS) report revealed Dispatch for the County services " was called at 6:53 AM on [DATE] reporting a resident with [MEDICAL CONDITION], ambulance in route at 6:54 AM, the ambulance traveled one mile and arrived at the facility on 6:59 AM, emergency crew at bedside 7:05 AM. Chief Complaint, [MEDICAL CONDITION]/Convulsion, Actively. [MEDICAL CONDITION] duration greater than 5 minutes, [MEDICAL CONDITION] type- Grand Mal (for) 1 hour." (Taber's Medical Dictionary, 19th edition, describes Grand Mal as [MEDICAL CONDITION], loss of consciousness with violent movements of the extremities). The report continued, "lung sounds Left Wheeze/Rhonchi, and lung sounds right wheezes/ Rhonchi." (Rhonchi are described by Taber's as "A wheezing, snoring, or squeaking sound heard during auscultation (listening to chest with stethoscope) of a person with partial airway obstruction. Mucus or other secretion in the airway, [MEDICATION NAME] that occlude respiratory passages.") Summary statement from EMS read: "Dispatched by 911 to a [MEDICAL CONDITION]. Arrived to find a [AGE] year old female actively seizing. Patient assessed as charted. Patient found in care of staff at local skilled facility with active [MEDICAL CONDITION] activity noted. Staff stated patient with hx (history) of same secondary to [MEDICAL CONDITION] and [MEDICAL CONDITIONS]. Patient began seizing at approx (approximately) 5:30 this morning. IV (intravenous) access established x 1 attempt as charted and IV Versed administered per protocol. "(Versed is a benzodiazepine used for [DIAGNOSES REDACTED], a continuous [MEDICAL CONDITION] activity without a pause.)" [MEDICAL CONDITION] activity reduced however some residual focal activity remained. Patient continued on O2 at 10 liters per minute. During transport, second dose of IV Versed administered due to continued [MEDICAL CONDITION] activity. [MEDICAL CONDITION] activity never fully ceased during EMS care and/or transport." Review of Resident #186's hospital records on [DATE] in part read, "The patient presented in [DIAGNOSES REDACTED]. She required intubation for airway protection and admission to the ICU (intensive care unit). She was placed on a Versed gtt (drip), her [MEDICATION NAME] was increased and she was [MEDICATION NAME] (another anticonvulsant) loaded. Her EEG (electroencephalogram, to view brain waves) indicated an underlying [MEDICAL CONDITION] disorder. She was felt to be having breakthrough [MEDICAL CONDITION] due to infection (aspiration pneumonia)" . Patient was also suffering from septic shock due to possible aspiration pneumonia. Interview with the Director of Nursing (DON) on [DATE] at 2:13 PM, revealed that her expectation was if nursing staff observed a resident seizing that the resident should be raised to an upright position to protect airway, rolled toward the left side, and the nurse should call EMS if the [MEDICAL CONDITION] lasted more than 15 minutes. The DON stated Resident #186 was experiencing a medical emergency on [DATE] and laying the resident flat on her back for bathing and dressing the resident was inappropriate. The DON revealed the event was discussed on [DATE] at the morning meeting. She stated she saw the two hour time frame on the nurses' notes but was not concerned because sometimes it takes EMS time to stabilize a resident. She stated she thought the 'gurgling' was due to [MEDICAL CONDITION] activity. In an interview with the Medical Director on [DATE] at 12:52 PM, he acknowledged he was called by the nurse on [DATE] after the resident left for the hospital. He stated he would have expected to have been called by staff if the resident, with a history of [MEDICAL CONDITION], had a [MEDICAL CONDITION] that lasted more than ,[DATE] minutes and EMS should be initiated immediately. The Administrator was notified of the Immediate Jeopardy on [DATE] at 10:45 AM. The facility provided the following credible allegation of compliance: RESIDENT IDENTIFIED 1. Resident #186 no longer resides at this facility. IDENTIFYING OTHER RESIDENTS AT RISK 1. A 100% audit was completed on [DATE] and again on [DATE] by the nurse management team (director of nursing, assistant director of nursing, 2 unit managers, wound nurse) a. The audit consisted of reviewing 100% of the nursing notes in the past 24 hours to ensure all residents experiencing any change of condition have had an appropriate nursing assessment and interventions, as indicated; physician notification for further guidance, as indicated and activation of EMS immediately, if indicated. 1. 2 residents were started on an antibiotic with appropriate assessment, intervention and physician notification 2. 2 resident had a fall with appropriate assessment, intervention and physician notification 3. 1 hospice resident expired with appropriate assessments, intervention and physician notification 4. No other concerns were identified regarding shortness of breath, [MEDICAL CONDITION] and change in level of consciousness. 2. On [DATE] and [DATE], a facility nurse manager has been assigned to each unit observing all facility residents which reside on those units for any concerns and or change in condition. 1. No concerns were identified in regards to MD notification or failure to identify a resident's change of condition related to shortness of breath, [MEDICAL CONDITION] and change in level of consciousness. 3. The MD and/or his nurse practitioner are in the facility Monday - Friday and while in the facility staff will notify them there. When they are not in the facility then they will be contacted through the on-call service. MD notification is documented under the nursing charting in the medical record. a. If the MD or NP is on-site they will immediately be called to the resident's room if a change of condition related to shortness of breath, [MEDICAL CONDITION] and change in level of consciousness is noted. 4. The MD is notified immediately in non-life threatening emergencies for further guidance and after EMS is activated in life threatening emergencies. PROCESSES IMPLEMENTED TO PREVENT FURTHER OCCURRENCES 1. In-servicing for the nurses was started on [DATE] by the Clinical Resource Nurse and DON. At this point 40 nurses out of 52 have been in-serviced. No nurse will be able to work the floor until they are in-serviced. The in-service addressed the following: a. 24 Hour Report b. Alert Charting Process c. Change of Condition Guidelines- which included physician notification d. Documentation Guidelines- which included physician notification e. Appropriate assessment, interventions, follow up to interventions f. Emergency Procedures- [MEDICAL CONDITION] Management g. Care of a Resident in Emergency Situations- which included but not limited to- initial assessment (objective and subjective symptoms), head injuries, lacerations, suspected fractures, burns, choking, shortness of breath, chest pain, [MEDICAL CONDITIONS], dizziness, diabetic coma/ketoacidosis, insulin shock/insulin reaction, acute psychotic behaviors, ingestion of toxins and physician notification. h. Emergency Procedures- which included physician notification 2. Two nurses were identified in this deficiency. a. One nurse was in-serviced on [DATE].- (see bullet points a-h above) b. The other nurse has been suspended at this time pending an abuse allegation of neglect- she was suspended on [DATE]. 3. The Nurse Managers were in-serviced by the Clinical Resource Nurse on [DATE] on the following: a. 24 Hour Report- and how to use them b. Alert Charting Process c. Infection Reports d. Change of Condition Guidelines- which included physician notification e. Documentation Guidelines- which included physician notification f. Appropriate assessment, interventions, follow up to interventions g. Emergency Procedures- [MEDICAL CONDITION] Management h. Care of a Resident in Emergency Situations- which included but not limited to- initial assessment (objective and subjective symptoms), head injuries, lacerations, suspected fractures, burns, choking, shortness of breath, chest pain, [MEDICAL CONDITIONS], dizziness, diabetic coma/ketoacidosis, insulin shock/insulin reaction, acute psychotic behaviors, ingestion of toxins and physician notification. i. Emergency Procedures- which included physician notification 4. The nurse managers will continue with the AM Clinical Meeting Monday - Friday a. On Saturday and Sunday a nurse manager will be in the facility each day. b. Physical rounds will be completed on each unit, every AM, prior to AM Clinical Meeting. A nurse manager will be speaking to the floor nurses regarding any resident change of conditions and physician notification for further guidance. In addition, the nurse manager will round on any residents which have had an identified change of condition. c. A nurse manager will review the 24 hour report, alert charting log and nursing notes to ensure all change of conditions have been communicated to the MD, that guidance has been provided and documented in the medical record under the nurse charting tab. MONITORING 1. During the AM Clinical Meeting all areas listed in #2 will be completed by the Nurse Management Team. a. The Nurse Management Team consists of the DON, ADON, 2 Unit Managers and 2 MDS Coordinators. b. The AM Clinical Meeting is held Monday-Friday at 8:15 AM. c. On Saturday and Sunday a nurse manager will be in the facility each day to complete the areas listed in #2. 2. During the AM Clinical Meeting any discrepancies identified will be documented, investigated and corrected immediately by the Nurse Management Team. 3. From any discrepancies identified further education or disciplinary action will occur with the staff member responsible. 4. The Clinical Resource Nurse will review the daily audits (labs, nursing notes, BM list, telephone orders) completed by the Nurse Management Team, weekly times 4 weeks, to ensure there is appropriate MD notification and guidance has been provided for any change of condition. 5. If trends or discrepancies are noted this QA process will be revised by the QA committee. 6. As discrepancies and trends are identified through these QA audits further education and training will be provided. 7. The facility will continue to involve the Medical Director in the facility processes in order to seek guidance and support. 8. A member of the Home Office staff will be on-site weekly for at least the next 30 days to offer guidance, support, training and monitoring of this plan. 9. On [DATE], Apex hired a new Clinical Resource Nurse, who will continue to provide guidance, support, training and monitoring to the DON and Nurse Management Team. The facility alleges the immediacy of these discrepancies have been abated on [DATE]. On [DATE] at 6:45 PM, the credible allegation was validated. Staff interviews with licensed nurses revealed the facility had implemented corrective measures which included in-services of licensed nurses regarding proper facility procedure and protocol for residents experiencing [MEDICAL CONDITION], respiratory distress, changes in levels of consciousness (LOC), emergency situations, physician notification, activation of emergency medical services and appropriate resident care during a [MEDICAL CONDITION], respiratory distress, change in LOC or any emergency situation.

Based on record review, staff, physician and pharmacist consultant interviews, the facility failed to administer potassium as ordered by the physician for a resident with a critical potassium level of 2.3 (3.5 -5.3 reference range) for 1 of 1 residents' records reviewed (Resident #263). The immediate jeopardy began on 7/8/14 when potassium 20 milliequivalent (meq) was not administered to Resident #263 who had a critical potassium level. The immediate jeopardy was removed on 7/17/14 at 8:47 pm when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity of D (no actual harm with the potential for more than minimal harm) that is not immediate jeopardy to ensure monitoring systems put in place are effective. Findings included: Resident #263 was admitted into the facility on [DATE]. [DIAGNOSES REDACTED]. The admission Minimum Data Set completed on 5/9/14 indicated Resident #263 had short and long term memory problems. Decision making was listed as moderately impaired. Lexi-Comp's Geriatric Dosage Handbook, 17th edition in part reads "potassium is the major cation (causes a positive charge) of intracellular (located or occur within the cell) fluid and is essential for conduction of nerve impulses in heart, brain and skeletal muscle; contraction of cardiac, skeletal and smooth muscles; maintenance of normal renal (kidney) function, acid-base balance, carbohydrate metabolism, and gastric (stomach) secretion." A review of the April 2014 admission monthly physician orders [REDACTED]. Medications that related to heart/blood pressure included: ? Aspirin 325 milligram (mg) by mouth daily ? [MEDICATION NAME] 5 mg by mouth daily A review of the lab report received by the nursing facility from the lab provider on 5/13/14 revealed a potassium level of 3.6. A review of the Medication Administration Record [REDACTED]. The order was indicated as discontinued on 7/6/14. [MEDICATION NAME] is a medication used to treat conditions such as high blood pressure and [MEDICAL CONDITION]. An action of [MEDICATION NAME] is that it functions to decrease certain chemicals that tighten the blood vessels, thus allowing the blood to flow more smoothly. A review of a critical lab result, reported to the nursing facility by the lab provider on 7/8/14 at 6:16 am to Nurse #7 in part read "Critical potassium 2.3." Physician #1 was indicated as notified with a new order received on 7/8/14 at 6:18 am by Nurse #7. A review of a physician telephone order dated 7/8/14 received by Nurse #7 in part read "potassium 20 meq every day." The MAR indicated [REDACTED]. A review of the MAR indicated [REDACTED]. A review of the MAR indicated [REDACTED]. A review of the physician order [REDACTED]." The MAR indicated [REDACTED]. A review of the lab report received by the nursing facility from the lab provider on 7/11/14 in part read "potassium 2.2 critical level." The MAR indicated [REDACTED]. A review of the lab report received by the nursing facility on 7/14/14 at 2:56 pm from the lab provider reported to Nurse #6 in part read "potassium 2.2 critical level." A review of the physician order [REDACTED]." The MAR indicated [REDACTED]. A review of the lab report received by the nursing facility from the lab provider on 7/16/14 in part read "potassium 2.4." The MAR indicated [REDACTED]. In an interview on 7/10/14 at 5:07 pm, the DON stated she expected all orders to have been obtained as ordered by the physician and the clinical record to reflect such, if the stool sample was unable to be obtained. In an interview on 7/16/14 at 12:54 pm, Nurse #7 acknowledged on 7/8/14 from 7pm-7am she received a critical potassium lab result via telephone from the lab provider; however she was not the primary nurse and thought she conveyed the critical lab (potassium) to Nurse #3. Nurse #7 stated she did not administer potassium 20 meq to the resident on 7/8/14. In an interview on 7/16/14 at 1:28 pm, Nurse #3 who was the primary nurse on 7/8/14 from 7am-7pm indicated she did not administer potassium 20 meq during her shift because she was not made aware there was an order to administer potassium on 7/8/14. In an interview on 7/16/14 at 1:53 pm, the medical director stated he became aware of the critical potassium level on 7/8/14 "early morning" and ordered for potassium 20 meq to be administered due to the critical lab. He stated he expected the medication to have been administered to the resident on 7/8/14 as ordered, considering the facility staff was aware of the resident critical lab result. He indicated he expected the potassium to have been administered on 7/8/14, because the resident's potassium level was at a critical level and the resident could have had cardiac problems such as an abnormal heart rhythm, while awaiting the potassium to be administered on 7/9/14. He stated on 7/14/14 the resident required more aggressive treatment in which potassium 40 mg was ordered to be given "now" and then to 40 mg twice daily (total of 80 mg daily) because the potassium level continued to drop. As the medical director, he concluded factors which contributed to the low potassium were "fluid loss as a result of continued loose stools/diarrhea." In an interview on 7/16/14 at 4:02 pm, the DON stated per her review of the physician orders, the MAR indicated [REDACTED]. She indicated the MAR indicated [REDACTED]. The DON added potassium 20 meq was also ordered to be administered on 7/10, 7/11, 7/12, 7/13/14 twice daily and the MAR indicated [REDACTED]. She stated the order to increase potassium was not transcribed into the electronic computer system properly, so the order was not carried out. The DON concluded her expectation was for the unit manager to have checked the carbon copies of the orders to ensure the physician orders [REDACTED]. In an interview on 7/17/14 at 12:32 pm, the administrator indicated the facility process for ensuring physician orders [REDACTED]. She added the unit managers were responsible for following up on new orders daily, to ensure all new orders had been properly transcribed and medications administered as ordered. In an interview on 7/17/14 at 3:09 pm, the facility's consultant pharmacist stated she expected all orders for potassium to have been administered as ordered by the physician due to the resident's critical potassium level. In an interview on 7/17/14 at 6:55 pm, Nurse #7 who worked 7pm-7am when presented the critical lab result dated 7/8/14 acknowledged she 1) was notified by the lab provider on 7/8/14 at 6:16 am as indicated on the lab report, 2) called the medical director as indicated on the lab report on 7/8/14 at 6:18 am, and received an order from the medical director on 7/8/14 at 6:18 am, to "administer potassium 20 meq every day." She stated that she was suppose to transcribe the order into the electronic computer system for the potassium 20 meq to be administered on 7/8/14, however she mistakenly scheduled it to be administered on 7/9/14. Nurse #7 indicated she did not administer the potassium to Resident #263 on 7/8/14 as ordered. Nurse #7 concluded Nurse #3 who worked on 7/8/14 from 7am-7pm took over the care of Resident #263 after her. Nurse #7 indicated she was not sure if she made her (Nurse #3) aware of the critical potassium level/order received. The administrator was notified of the immediate jeopardy on 7/17/14 at 10:10 am. The facility provided the following credible allegation on July 17, 2014 at 8:25 pm for F 333 as follows: "RESIDENT IDENTIFIED At the time this IJ was announced R 263- ? Had a [MEDICAL CONDITION] re-culture on 7/9/10 During the survey ? MD was aware of the loose stools 7/9/10 during the survey ? The Potassium errors have been resolved as 7/14/14 with correct orders. The MD was notified of errors on 7/16/14 and had given no changes in the current treatment plan. ? The MD is aware of R 263 condition and is monitoring closely. IDENTIFYING OTHER RESIDENTS AT RISK 1. A 100% Bowel Movement audit was completed from 7/10-7/16/14 to identify any residents that are exhibiting persistent diarrhea/loose stools. The facility printed out the CNA bowel movement charting from the Electronic charting. This audit was completed at 9:03 pm on 7/16/14. This task was completed by the Nurse Managers. ? From this audit R1, R2 and R3 were identified as having a long history of loose stools. The facility notified the MD of these loose stools on 7/16/14 and orders for [MEDICAL CONDITION] cultures were obtained as a safety measure. 2. A 100% lab audit was completed for the last 30 days to ensure all labs were obtained and any orders that were received were transcribed and administered as ordered. The Managers printed out all lab orders from the Electronic Charting system to validate this. This was completed by the nurse managers on 7/16/14 at 9:10 pm. ? From this audit no further medication errors in relationship to lab results were observed. The facility did note that 13 labs were not drawn per orders in the last 30 days. The MD was notified of these errors and new orders were obtained. 3. A 100% in house resident audit was completed to ascertain if all changes of Condition ' s were identified by nursing and the MD was aware. This audit was completed from 7/14/14-7/16/14 by the Nurse Managers. This was completed on 7/16/14 @ 10:37 PM. ? From this audit there were 19 changes of condition that the facility could not find MD notification. The MD was notified of all changes on 7/16/14 by the nurse managers. Upon notification the MD had no new orders or interventions for these residents. 4. A 100% MD order audit was completed from 7/10/14-7/16/14 to ensure that all new orders were entered into the Electronic Charting System as ordered. This process was started on 7/16/14 by the nurse managers. This process will continue and will be completed on 7/16/14 by the nurse managers. This audit was completed on 7/17/14 @ 3:35 pm ? From this audit 4 med errors were noted. These error for R4- the [MEDICATION NAME] was ordered to be held on 7/16/14 and was administered (MD notified and no new received), R5 had multi 2 tabs ordered and 1 tab was transcribed (MD changed to 2 tabs), R6 Facility failed to give [MEDICATION NAME] weekly as ordered for 2 weeks (MD stated to start [MEDICATION NAME] weekly), R7 treatment order of Dry gauze and TAO was ordered 3 times a week and it was transcribed as daily ( MD stated to change to 3 times weekly). None of these residents suffered any Ill effects related to these errors. PROCESSES IMPLEMENTED TO PREVENT FURTHER OCCURRENCES 1. In-servicing for the nursing staff and nursing assistants was started on 7/16/14 by the Nurse Managers. At this point 84 nursing staff and nursing assistants out of 138 are in-serviced. No member of the nursing staff or nursing assistants will be able to work the floor until they are in serviced. ? The facility's Change of Condition Policy and the requirements of MD notification which includes; residents that are experiencing persistent loose stools and have critical potassium levels and other critical/abnormal labs. ? The facility's Medication transcription policy which would include the proper transcription of potassium. a. STARTED ON 7/16/14 AND ONGOING AT THIS TIME. 2. The Nurse Managers were in-serviced by the Regional Vice President on 7/17/14 on the following: ? The Facility's New Morning Nurses QA Meeting which will include: o Review of the 24 hour condition report to ensure that all residents that have exhibited persistent loose stools have been communicated to the MD and that all new orders have been carried out. o Review of the 24 hour Bowel Record to ensure that any resident that is having continuous diarrhea or 3 loose stools in a 24 hour period has MD notification for proper interventions. o Review of all new orders to ensure that the order was properly transcribed into the Electronic Charting System and that the resident received the treatment promptly. The Nurse responsible for receiving the lab/[MEDICAL CONDITION] culture order will enter into it into the ECS lab tracking. The Nurse Managers will ensure this is completed during their morning QA review. o Review of the lab tracking sheet to ensure that all [MEDICAL CONDITION] cultures were obtained as ordered. The Nurse responsible for receiving the lab order will enter into it into the ECS lab tracking. o The 2nd shift Supervisor will ensure that all labs/ [MEDICAL CONDITION] cultures obtained are received, distributed to the appropriate responsible nurse, the MD is notified and new orders are transcribed and implemented. o The Morning Nurses QA will review all these completed labs/[MEDICAL CONDITION] cultures the following morning to ensure the 2nd shift Supervisor completed the assigned task. o The Lab Company and all Critical Labs will be called to the DON/designee. The DON/designee will ensure that the MD is notified and ensure that any new orders are carried out. o Properly managing the facility staff to ensure proper resident care is provided. The Completion date is 7/17/14." On 7/17/2014 at 8:26 pm, the credible allegation was validated. Staff interviews with licensed nurses and nursing assistants revealed the facility had implemented the following as it related to actions one should take if the staff 1) received a physician order [REDACTED].

Based on record review, staff, physician and nurse practitioner interviews, the facility failed to manage the care of a resident by failure to obtain or re-check a stool sample as ordered by the physician for persistent diarrhea, that resulted in a 17 day delay in medical treatment because the physician was not notified. As a result of continued loose stools, the resident experienced low blood pressures and a fluid volume deficit (loss of bodily fluids), which lead to a low potassium level. The facility also failed to administer potassium as ordered by the physician for a critical potassium level of 2.3 (3.5 - 5.3 reference range) for 1 of 2 residents' records reviewed for [MEDICAL CONDITIONS] (Resident #263). The immediate jeopardy began on 6/23/14 when a stool specimen was not obtained as ordered by the physician to recheck stool for [MEDICAL CONDITION] due to persistent diarrhea. The immediate jeopardy was removed on 7/17/14 at 8:47 pm when the facility provided an implemented an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity of D (no actual harm with the potential for more than minimal harm) that is not immediate jeopardy to ensure monitoring systems put in place are effective. Findings included: Resident #263 was admitted into the facility on [DATE]. [DIAGNOSES REDACTED]. The admission Minimum Data Set completed on 5/9/14 indicated Resident #263 had short and long term memory problems. Decision making was listed as moderately impaired. Lexi-Comp's Geriatric Dosage Handbook, 17th edition in part reads "potassium is the major cation (causes a positive charge) of intracellular (located or occur within the cell) fluid and is essential for conduction of nerve impulses in heart, brain and skeletal muscle; contraction of cardiac, skeletal and smooth muscles; maintenance of normal renal (kidney) function, acid-base balance, carbohydrate metabolism, and gastric (stomach) secretion." A review of the April 2014 admission monthly physician orders [REDACTED]. Medications that related to heart/blood pressure included: ? Aspirin 325 milligram (mg) by mouth daily ? [MEDICATION NAME] 5 mg by mouth daily A review of the lab report received by the nursing facility from the lab provider on 5/13/14 revealed a potassium level of 3.6. A review of the lab report received by the nursing facility on 6/12/14 from the lab provider in part read "[MEDICAL CONDITION] toxin result positive." It was further indicated that the report was "Read back and verified with the director of nursing at 8:55 am." A review of the physician order [REDACTED]." The Medication Administration Record [REDACTED]. [MEDICATION NAME] is an antibiotic that is used to treat a bacterial infection. A review of the nurses' notes revealed the following blood pressures: ? 6/21/14 (128/70) at 10:53 pm ? 6/21/14 (126/68) at 10:54 pm A review of the physician order [REDACTED]." A review of the nurses' notes on 6/23, 6/24, 6/25, 6/26/14, did not reflect an attempt to collect a stool specimen, facility care interventions to manage loose stools/diarrhea or the physician or nurse practitioner was consulted for guidance. A review of the bowel elimination pattern record revealed the following: ? 6/26/14 "three large loose stools" A review of the nurses' notes on 6/27, 6/28, 6/29/14 did not reflect an attempt to collect a stool specimen, facility care interventions to manage loose stools/diarrhea or the physician or nurse practitioner was consulted for guidance. A review of the bowel elimination pattern record revealed the following: ? 6/29/14 "two medium loose stools" ? 6/30/14 "two large loose stools" A review of the nurse's notes on 6/30, 7/1, 7/2, 7/3/14 did not reflect an attempt to collect a stool specimen, facility care intervention to manage loose stools/diarrhea or the physician or nurse practitioner was consulted for guidance. A review of the nurse's note revealed the following blood pressure: ? 7/3/14 (108/64) at 2:47 am A review of the MAR indicated [REDACTED]. The order was indicated as discontinued on 7/6/14. [MEDICATION NAME] is a medication used to treat conditions such as high blood pressure and [MEDICAL CONDITION]. An action of [MEDICATION NAME] is that it functions to decrease certain chemicals that tighten the blood vessels, thus allowing the blood to flow more smoothly. A review of the bowel elimination pattern record revealed the following: ? 7/5/14 "one medium loose stool" ? 7/6/14 "two medium loose stools, one large loose stool" A review of the nurse's notes on 7/4, 7/5, 7/6 7/7/14 did not reflect an attempt to collect a stool specimen, facility care intervention to manage loose stools/diarrhea or the physician or nurse practitioner was consulted for guidance. A review of the bowel elimination pattern record revealed the following: ? 7/7/14 "one large loose stool" A review of the nurse's note revealed the following blood pressure: ? 7/7/14 (109/65) at 4:42 am A review of the nurses' note revealed the following blood pressure: ? 7/7/14 (111/57) at 5:51 pm A review of the bowel elimination pattern record revealed the following: ? 7/8/14 "one small loose stool" A review of a critical lab result, reported to the nursing facility by the lab provider on 7/8/14 at 6:16 am to Nurse #7 in part read "Critical potassium 2.3." Physician #1 was indicated as notified with a new order received on 7/8/14 at 6:18 am by Nurse #7. A review of a physician telephone order dated 7/8/14 received by Nurse #7 in part read "potassium 20 milliequivalent (meq) every day." The MAR indicated [REDACTED]. A review of the nurse's note revealed the following blood pressure: ? 7/8/14 (98/58) at 7:02 pm A review of the nurses' notes on 7/8, and 7/9/14 did not reflect an attempt to collect a stool specimen, facility care interventions to manage loose stools/diarrhea or the physician or nurse practitioner was consulted for guidance. A review of the nurse's note revealed the following blood pressure: ? 7/9/14 (98/58) at 6:10 am A review of the MAR indicated [REDACTED]. A review of the nurses' notes revealed the following blood pressures: ? 7/9/14 (95/54) at 5:12 pm ? 7/9/14 (100/54) at 8:46 pm A review of the nurse's notes dated 7/9/14 at 8:46 pm revealed a stool sample was obtained for [MEDICAL CONDITION]. A review of the bowel elimination pattern record revealed the following: ? 7/10/14 "two large loose stools, two medium loose stools" A review of the lab report received by the nursing facility on 7/10/14 from the lab provider at in part read "[MEDICAL CONDITION] toxin result positive. Critical results called to, read back and verified with unit manager #1 at 8:20 am." Due to the critical lab reported to UM #1 on 7/10/14 at 8:20 am by the lab provider related to positive [MEDICAL CONDITION], the physician ordered [MEDICATION NAME] 125 mg by mouth four times a day for [MEDICAL CONDITION] for 14 days ([MEDICATION NAME] is an antibiotic used to treat bacterial infections), and potassium chloride 20 meq twice daily for low potassium. A review of the physician order [REDACTED]." The MAR indicated [REDACTED]. A review of the lab report received by the nursing facility from the lab provider on 7/11/14 in part read "potassium 2.2 critical level." The MAR indicated [REDACTED]. A review of the lab report received by the nursing facility on 7/14/14 at 2:56 pm from the lab provider reported to Nurse #6 in part read "potassium 2.2 critical level." A review of the physician order [REDACTED]." The MAR indicated [REDACTED]. A review of the lab report received by the nursing facility from the lab provider on 7/16/14 in part read "potassium 2.4." The MAR indicated [REDACTED]. In an interview on 7/9/14 at 11:42 am, Nurse #2 and unit manager (UM) #1 were asked about the results of the stool sample ordered to be rechecked by the physician on 6/23/14. Nurse #2 stated per review of Resident #263's chart and the electronic record she did not see another stool sample had been attempted or collected to date. UM #1 indicated a stool sample recheck should have been completed as ordered by the physician, however she could not find where the stool specimen had been completed or obtain. In an interview on 7/9/14 at 12:40 pm, the medical director stated he expected the stool sample ordered on [DATE] to have been obtained as ordered to reevaluate the resident for continued [MEDICAL CONDITION], due to persistent diarrhea, so medical treatment could have been initiated. In an interview on 7/9/14 at 4:21 pm, Nurse #3 and Nurse #4 both acknowledged they reviewed residents' bowel elimination pattern on a daily basis as part of their daily routine. Both nurses acknowledged they were aware Resident #263 had completed previous antibiotics (ABT) for [MEDICAL CONDITION] and the resident continued to have loose stools after completion of the ABT ([MEDICATION NAME]) on 6/21/14. They both indicated they did not contact the physician via telephone regarding the continued loose stools, nor had they obtained a second stool sample. Both nurses stated they had no permanent hall assignment and worked throughout the facility. In an interview on 7/10/14 at 2:05 pm, Nurse #4 acknowledged she signed the physician order [REDACTED]." Nurse #4 indicated she was aware a stool sample was needed but she did not obtain a stool sample on her shift because there was no bowel movement. She further stated she did not follow back up regarding the order because she assumed the stool specimen had been obtained. In an interview on 7/10/14 at 5:07 pm, the DON stated she expected all orders to have been obtained as ordered by the physician and the clinical record to reflect such, if the stool sample was unable to be obtained. In an interview on 7/16/14 at 10:52 am, Nurse #6 acknowledged she worked with Resident #263 on 6/26/14 from 7am-7pm. She stated she recalled the resident having loose stools, moderate amount and observed loose stools in the resident's brief. She stated NA (nursing assistant) #10 made her aware the resident was having loose stools. She concluded she did not contact the physician regarding the loose stools because the resident was already on contact isolation and "did not appear to have running stool to me." In an interview on 7/16/14 at 11:26 am, NA #8 stated on 7/8/14 Resident #263 had a loose small stool described as "watery, greenish color, with mucous and slimy." She stated she reported her findings to Nurse #3 before she documented as part of her normal routine. In an interview on 7/16/14 at 12:15 pm, NA #10 who worked on 6/26/14 and 6/30/14 stated she observed Resident #263 's stools "loose, brownish, and smelled bad." She stated she notified Nurse #6 on 6/26/14 and Nurse #4 on 6/30/14 of her findings. In an interview on 7/16/14 at 12:54 pm, Nurse #7 acknowledged on 7/8/14 from 7pm-7am she received a critical potassium lab result via telephone; however she was not the primary nurse and thought she conveyed the critical lab (potassium) to Nurse #3. Nurse #7 stated on occasions she had worked with Resident #263 and recalled her stools having a strong foul odor but could not recall any specific dates. She concluded she did not contact the physician related to the foul odor, nor did she administer potassium 20 meq to the resident. In an interview on 7/16/14 at 1:28 pm, Nurse #3 who was the primary nurse on 7/8/14 from 7am-7pm indicated she checked residents' bowel elimination pattern daily that was put in the computer system by the NAs. She added she was aware Resident #263 was having continued loose stools. She stated she recalled informing (no date specified) the nurse practitioner (NP) because she (Nurse #3) felt the resident needed an intervention to help with the loose stools. Nurse #3 concluded she did not administer potassium 20 meq during her shift because she was not made aware there was an order to administer potassium on 7/8/14. In an interview on 7/16/14 at 1:53 pm, the medical director stated he became aware of the critical potassium level on 7/8/14 "early morning" and ordered for potassium 20 meq to be administered due to the critical lab. He stated he expected the medication to have been administered to the resident on 7/8/14 as ordered, considering the facility staff was aware of the resident critical lab result. He indicated he expected the potassium to have been administered on 7/8/14, because the resident's potassium level was at a critical level and the resident could have had cardiac problems such as an abnormal heart rhythm, while awaiting the potassium to be administered on 7/9/14. He stated on 7/14/14 the resident required more aggressive treatment in which potassium 40 mg was ordered to be given "now" and then to 40 mg twice daily (total of 80 mg daily) because the potassium level continued to drop. As the medical director, he stated factors which contributed to the low potassium were "fluid loss as a result of continued loose stools/diarrhea." The medical director concluded he was not made aware by the facility staff the resident was having persistent diarrhea, however he was aware the resident had a history of [REDACTED]. In an interview on 7/16/14 at 2:23 pm, the DON stated any abnormal stool presentation such as persistent diarrhea, color change or foul odor; she expected the clinical record to reflect such and the physician or NP to be notified. In an interview on 7/16/14 3:40 pm, the nurse practitioner stated she recalled being informed once (6/23/14) the resident was having continued diarrhea, however did not specifically know who contacted her. The NP stated she entered an order for [REDACTED].#1 of the order and the unit manager responded she would follow up. She stated if she was made aware by the facility related to Resident #263 continued to have loose stools/diarrhea, following the order on 6/23/14, she would have ordered an antibiotic, as an intervention to help with the persistent loose stools/diarrhea. In an interview on 7/16/14 at 4:02 pm, the DON stated per her review of the physician orders, the MAR indicated [REDACTED]. She indicated the MAR indicated [REDACTED]. The DON added potassium 20 meq was also ordered to be administered on 7/10, 7/11, 7/12, 7/13/14 twice daily and the MAR indicated [REDACTED]. She stated the order to increase potassium was not transcribed into the electronic computer system properly, so the order was not carried out. The DON concluded her expectation was for the unit manager to have checked the carbon copies of the orders to ensure the physician orders [REDACTED]. In an interview on 7/16/14 at 6:17 pm, the medical director stated [MEDICATION NAME] 5 mg by mouth daily was discontinued on 7/6/14 due to the resident's low blood pressures. He stated "persistent loose stools/diarrhea was causing the blood pressure to drop." In an interview on 7/17/14 at 12:32 pm, the administrator stated when a physician gives an order, the receiving nurse is responsible for ensuring the order is read back for clarity and transcribed into the electronic computer system correctly. She added the unit managers were responsible for following up on new orders daily, to ensure all new orders had been properly transcribed and medication administered as ordered. In an interview on 7/17/14 at 6:55 pm, Nurse #7 who worked from 7pm-7am when presented the critical lab result dated 7/8/14 acknowledged she 1) was notified by the lab provider on 7/8/14 at 6:16 am as indicated on the lab report, 2) called the medical director as indicated on the lab report on 7/8/14 at 6:18 am, and received an order from the medical director on 7/8/14 at 6:18 am, to "administer potassium 20 meq every day." She stated she was suppose to transcribe the order into the electronic computer system for the potassium 20 meq to be administered on 7/8/14, however she mistakenly scheduled it to be administered on 7/9/14. She concluded she did not administer the potassium to Resident #263 on 7/8/14 as ordered. Nurse #7 concluded Nurse #3 who worked on 7/8/14 from 7am-7pm took over the care of Resident #263 after her. Nurse #7 indicated she was not sure if she made her (Nurse #3) aware of the critical potassium level/order received. The administrator was notified of the Immediate Jeopardy on 7/16/14 at 6:56 pm. The immediate jeopardy was removed on 7/17/14 at 8:47 pm when the facility provided an acceptable credible allegation on July 17, 2014 at 8:25 pm for F 309 as follows: "RESIDENT IDENTIFIED At the time this IJ was announced R 263- ? Had a [MEDICAL CONDITION] re-culture on 7/9/10 During the survey ? MD was aware of the loose stools 7/9/10 during the survey ? The Potassium errors have been resolved as 7/14/14 with correct orders. The MD was notified of errors on 7/16/14 and had gave no changes in the current treatment plan. ? The MD is aware of R 263 condition and is monitoring closely. IDENTIFYING OTHER RESIDENTS AT RISK 1. A 100% Bowel Movement audit was completed from 7/10-7/16/14 to identify any residents that are exhibiting persistent diarrhea/loose stools. The facility printed out the CNA bowel movement charting from the Electronic charting. This audit was completed at 9:03 pm on 7/16/14. This task was completed by the Nurse Managers. ? From this audit R1, R2 and R3 were identified as having a long history of loose stools. The facility notified the MD of these loose stools on 7/16/14 and orders for [MEDICAL CONDITION] cultures were obtained as a safety measure. 2. A 100% lab audit was completed for the last 30 days to ensure all labs were obtained and any orders that were received were transcribed and administered as ordered. The Managers printed out all lab orders from the Electronic Charting system to validate this. This was completed by the nurse managers on 7/16/14 at 9:10 pm. ? From this audit no further medication errors in relationship to lab results were observed. The facility did note that 13 labs were not drawn per orders in the last 30 days. The MD was notified of these errors and new orders were obtained. 3. A 100% in house resident audit was completed to ascertain if all changes of Condition ' s were identified by nursing and the MD was aware. This audit was completed from 7/14/14-7/16/14 by the Nurse Managers. This was completed on 7/16/14 @ 10:37 PM. ? From this audit there were 19 changes of condition that the facility could not find MD notification. The MD was notified of all changes on 7/16/14 by the nurse managers. Upon notification the MD had no new orders or interventions for these residents. 4. A 100% MD order audit was completed from 7/10/14-7/16/14 to ensure that all new orders were entered into the Electronic Charting System as ordered. This process was started on 7/16/14 by the nurse managers. This process will continue and will be completed on 7/16/14 by the nurse managers. This audit was completed on 7/17/14 @ 3:35 pm ? From this audit 4 med errors were noted. These error for R4- the [MEDICATION NAME] was ordered to be held on 7/16/14 and was administered (MD notified and no new received), R5 had multi 2 tabs ordered and 1 tab was transcribed (MD changed to 2 tabs), R6 Facility failed to give [MEDICATION NAME] weekly as ordered for 2 weeks (MD stated to start [MEDICATION NAME] weekly), R7 treatment order of Dry gauze and TAO was ordered 3 times a week and it was transcribed as daily ( MD stated to change to 3 times weekly). None of these residents suffered any Ill effects related to these errors. PROCESSES IMPLEMENTED TO PREVENT FURTHER OCCURRENCES 1. In-servicing for the nursing staff and nursing assistants was started on 7/16/14 by the Nurse Managers. At this point 84 nursing staff and nursing assistants out of 138 are in-serviced. No member of the nursing staff or nursing assistants will be able to work the floor until they are in serviced. ? The facility's Change of Condition Policy and the requirements of MD notification which includes; residents that are experiencing persistent loose stools and have critical potassium levels and other critical/abnormal labs. ? The facility's Medication transcription policy which would include the proper transcription of potassium. a. STARTED ON 7/16/14 AND ONGOING AT THIS TIME. 2. The Nurse Managers were in-serviced by the Regional Vice President on 7/17/14 on the following: ? The Facility's New Morning Nurses QA Meeting which will include: o Review of the 24 hour condition report to ensure that all residents that have exhibited persistent loose stools have been communicated to the MD and that all new orders have been carried out. o Review of the 24 hour Bowel Record to ensure that any resident that is having continuous diarrhea or 3 loose stools in a 24 hour period has MD notification for proper interventions. o Review of all new orders to ensure that the order was properly transcribed into the Electronic Charting System and that the resident received the treatment promptly. The Nurse responsible for receiving the lab/[MEDICAL CONDITION] culture order will enter into it into the ECS lab tracking. The Nurse Managers will ensure this is completed during their morning QA review. o Review of the lab tracking sheet to ensure that all [MEDICAL CONDITION] cultures were obtained as ordered. The Nurse responsible for receiving the lab order will enter into it into the ECS lab tracking. o The 2nd shift Supervisor will ensure that all labs/ [MEDICAL CONDITION] cultures obtained are received, distributed to the appropriate responsible nurse, the MD is notified and new orders are transcribed and implemented. o The Morning Nurses QA will review all these completed labs/[MEDICAL CONDITION] cultures the following morning to ensure the 2nd shift Supervisor completed the assigned task. o The Lab Company and all Critical Labs will be called to the DON/designee. The DON/designee will ensure that the MD is notified and ensure that any new orders are carried out. o Properly managing the facility staff to ensure proper resident care is provided. The Completion date is 7/17/14." On 7/17/2014 at 8:26 pm, the credible allegation was validated. Staff interviews with licensed nurses and nursing assistants revealed the facility had implemented the following as it related to: 1) actions one should take if a resident is observed or reported with persistent, continued loose stools or diarrhea, 2) changes in stools pattern, 3) physician orders [REDACTED].

Based on record review, emergency medical services (EMS) report, and staff and physician interviews, the facility failed to immediately notify the resident's physician of respiratory distress and continuous [MEDICAL CONDITION], for 1 of 3 sampled residents reviewed for notification of change (Resident 186). The Immediate Jeopardy (IJ) began on [DATE] at 5:30 AM for Resident #186 when the resident was found with continuous [MEDICAL CONDITION] and respiratory distress. The Administrator was notified on [DATE] at 10:45 AM and the IJ was removed on [DATE] at 6:45 PM when the facility demonstrated it had implemented a credible allegation. The facility was left out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy (D) so that the facility can complete all staff in-services and monitoring systems could be implemented and included in the Quality Assurance Program. Findings included: Resident #186 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's physician order [REDACTED]. [MEDICATION NAME] is an anticonvulsant, [MEDICATION NAME] is an anticonvulsant and Klonopin is a medication with anticonvulsant properties. A [DATE] quarterly minimum data set (MDS) indicated the resident was severely cognitively impaired. The care plan of [DATE] indicated [MEDICAL CONDITION] as a problem. The goal was resident will have airway open. Approaches included administer medications as ordered, observe for side effects and effectiveness, neurological assessment as needed, notify MD as needed, maintain airway, and report [MEDICAL CONDITION]. On [DATE] at 5:45 PM, an interview was conducted with Nurse Aide (NA #1) who took care of the resident on [DATE] (third shift 11PM to 7AM). She stated the resident was fine during the night. "I went into the room on rounds about 5:30 AM and she was breathing hard." NA #1 indicated when she discovered the resident, she was having trouble breathing and jerking movements. NA #1 stated she went to get Nurse #1. In an interview with Nurse #1 on [DATE] at 11:51 AM, she stated she knew Resident #186 and had taken care of her prior to [DATE]. She stated when she entered the room around 5:30 AM she observed the resident in respiratory distress and having [MEDICAL CONDITION]. The resident was in a supine (flat on her back) position. The nurse stated she took the resident's vital signs and her pulse oxygen saturation was low at 87 percent. She moved the resident to a 45 degree angle, and applied oxygen at 2 liters per minute. Nurse #1 stated "I gave her a breathing treatment with a Nebulizer." Nurse #1 stated the resident was unresponsive and actively having a continuous [MEDICAL CONDITION]. She stated the resident normally had some movements in her extremities but this was non-stop movements. Nurse #1 stated it sounded like she had a blockage in her throat. She stated there were no secretions coming from her mouth. She stated she did not attempt to suction the resident. Nurse #1 stated when a repeat oxygen saturation was done the oxygen was up to 89 or 90 percent and she increased the oxygen flow to 4 liters per minute. Nurse #1 stated she did not call the resident's physician to report the [MEDICAL CONDITION] or see if oxygen should be increased at that time. Nurse #1 stated she called Emergency Medical Service (EMS) and stated probably sometime after 6:00 AM. Nurse #1 stated she did not call the physician at that time. She stated she called the physician and responsible party after the resident had left the facility with EMS at 8:14 AM. In nursing notes for [DATE] at 8:14 AM Nurse #1 documented, "Blood pressure ,[DATE] at 5:30 AM, pulse (rate) 64, temperature 98.2, respiratory rate 25 (breaths per minute), O2 (oxygen saturation) 87% on room air at 5:30 AM. Comments: Resident was wheezing, obvious gurgling, very lethargic/sleepy; difficult to arouse, has [MEDICAL CONDITION]. Nebulizer treatment given, O2 (oxygen) started at 4L/minute (Liters per minute). [MEDICAL CONDITION] was non-stop and resident status did not improve. The Night Nurse in the front hall also helped in assessing the resident. EMS was called and resident was transported to (local hospital) via stretcher at 7:30 AM. Dr. (attending physician) notified; resident's daughter notified of resident's transfer". Review of Resident #186's [DATE], Emergency Medical Service (EMS) report Dispatch for the County services "was called at 6:53 AM on [DATE] reporting a resident with [MEDICAL CONDITION], ambulance in route at 6:54 AM, the ambulance traveled one mile and arrived at the facility on 6:59 AM, emergency crew at bedside 7:05 AM. Chief Complaint, [MEDICAL CONDITION]/Convulsion, Actively. [MEDICAL CONDITION] duration greater than 5 minutes, [MEDICAL CONDITION] type- Grand Mal (for) 1 hour." (Taber's Medical Dictionary, 19th edition, describes Grand Mal as [MEDICAL CONDITION], loss of consciousness with violent movements of the extremities). The report continued, "lung sounds Left Wheeze/Rhonchi, and lung sounds right wheezes/ Rhonchi." (Rhonchi are described by Taber's as "A wheezing, snoring, or squeaking sound heard during auscultation (listening to chest with stethoscope) of a person with partial airway obstruction. Mucus or other secretion in the airway, [MEDICATION NAME] that occlude respiratory passages.") In an interview with Nurse #2 on [DATE] at 12:21 PM, she stated that on [DATE] between 6:00 AM to 7:00 AM Nurse #1 came out in the hall to request help with Resident #186. She stated it must have been between 6 and 7 AM; she did not recall the exact time. Nurse #2 stated she went into Resident #186's room with Nurse #1 and observed the resident lying on the bed; she was shaking and having difficulty breathing. The resident had a blood pressure cuff on her right arm, and was getting oxygen via nasal cannula and was unresponsive. Nurse #2 stated "We woke her up using a sternal rub. She opened her eyes but never spoke. Her eyes were hazy and she was coughing." Nurse #2 stated she repeated the sternal rub. She stated the resident's body continued to shake during sternal rubs. Nurse #2 stated that she told Nurse #1 that they needed to call EMS. Nurse #2 stated Nurse #1 left the room to call EMS and prepare the discharge paperwork and she stayed in the room with the resident. She stated "I opened the closet and picked out an outfit for the resident. Then I washed her up and dressed her. I had to lay her down to get her shirt and pants on." Nurse #2 stated the resident was seizing and unresponsive while being bathed and dressed. Nurse #2 stated she was aware the resident was having continued [MEDICAL CONDITION] throughout the bath and dressing, however she continued on with the tasks because she wanted the resident to look nice to go to the hospital. Summary statement from EMS read: "Dispatched by 911 to a [MEDICAL CONDITION]. Arrived to find a [AGE] year old female actively seizing. Patient assessed as charted. Patient found in care of staff at local skilled facility with active [MEDICAL CONDITION] activity noted. Staff stated patient with hx (history) of same secondary to [MEDICAL CONDITION] and [MEDICAL CONDITIONS]. Patient began seizing at approx (approximately) 5:30 this morning. IV (intravenous) access established x 1 attempt as charted and IV Versed administered per protocol." (Versed is a benzodiazepine used for [DIAGNOSES REDACTED], a continuous [MEDICAL CONDITION] activity without a pause.) "[MEDICAL CONDITION] activity reduced however some residual focal activity remained. Patient continued on O2 at 10 liters per minute. During transport, second dose of IV Versed administered due to continued [MEDICAL CONDITION] activity. [MEDICAL CONDITION] activity never fully ceased during EMS care and/or transport." Review of Resident #186's hospital records on [DATE] in part read, "The patient presented in [DIAGNOSES REDACTED]. She required intubation for airway protection and admission to the ICU (intensive care unit). She was placed on a Versed gtt (drip), her [MEDICATION NAME] was increased and she was [MEDICATION NAME] (another anticonvulsant) loaded. Her EEG (electroencephalogram, to view brain waves) indicated an underlying [MEDICAL CONDITION] disorder. She was felt to be having breakthrough [MEDICAL CONDITION] due to infection (aspiration pneumonia)". Patient was also suffering from septic shock due to possible aspiration pneumonia. Interview with the Director of Nursing (DON) on [DATE] at 2:13 PM, revealed that her expectation was if nursing staff observed a resident seizing that the resident should be raised to an upright position to protect airway, rolled toward the left side, and the nurse should call EMS if the [MEDICAL CONDITION] lasted more than 15 minutes. The DON stated Resident #186 was experiencing a medical emergency on [DATE] and laying the resident flat on her back for bathing and dressing the resident was inappropriate. The DON revealed the event was discussed on [DATE] at the morning meeting. She stated she saw the two hour time frame on the nurses' notes but was not concerned because sometimes it takes EMS time to stabilize a resident. She stated she thought the 'gurgling' was due to [MEDICAL CONDITION] activity. In an interview with the Medical Director on [DATE] at 12:52 PM, he acknowledged he was called by the nurse on [DATE] after the resident left for the hospital. He stated he would have expected to have been called by staff if the resident, with a history of [MEDICAL CONDITION], had a [MEDICAL CONDITION] that lasted more than ,[DATE] minutes and EMS should be initiated immediately. The Administrator was notified of the Immediate Jeopardy on [DATE] at 10:45 AM. The facility provided the following credible allegation of compliance: RESIDENT IDENTIFIED 1. Resident #186 no longer resides at this facility. IDENTIFYING OTHER RESIDENTS AT RISK 1. A 100% audit was completed on [DATE] and again on [DATE] by the nurse management team (director of nursing, assistant director of nursing, 2 unit managers, wound nurse) a. The audit consisted of reviewing 100% of the nursing notes in the past 24 hours to ensure all residents experiencing any change of condition have had an appropriate nursing assessment and interventions, as indicated; physician notification for further guidance, as indicated and activation of EMS immediately, if indicated. 1. 2 residents were started on an antibiotic with appropriate physician notification 2. 2 resident had a fall with appropriate physician notification 3. 1 hospice resident expired with appropriate physician notification 4. No other concerns were identified 2. On [DATE] and [DATE], a facility nurse manager has been assigned to each unit observing all facility residents which reside on those units for any concerns and or change in condition. 1. No concerns were identified in regards to MD notification. 3. The MD and/or his nurse practitioner are in the facility Monday - Friday and while in the facility staff will notify them there. When they are not in the facility then they will be contacted through the on-call service. MD notification is documented under the nursing charting in the medical record. 4. The MD is notified immediately in non-life threatening emergencies for further guidance and after EMS is activated in life threatening emergencies. PROCESSES IMPLEMENTED TO PREVENT FURTHER OCCURRENCES 1. In-servicing for the nurses was started on [DATE] by the Clinical Resource Nurse and DON. At this point 40 nurses out of 52 have been in-serviced. No nurse will be able to work the floor until they are in-serviced. The in-service addressed the following: a. 24 Hour Report b. Alert Charting Process c. Infection Reports d. Change of Condition Guidelines- which included physician notification e. Documentation Guidelines- which included physician notification f. Appropriate assessment, interventions, follow up to interventions g. Emergency Procedures- [MEDICAL CONDITION] Management h. Care of a Resident in Emergency Situations- which included but not limited to- initial assessment (objective and subjective symptoms), head injuries, lacerations, suspected fractures, burns, choking, shortness of breath, chest pain, [MEDICAL CONDITIONS], dizziness, diabetic coma/ketoacidosis, insulin shock/insulin reaction, acute psychotic behaviors, ingestion of toxins and physician notification. i. Emergency Procedures- which included physician notification 2. Two nurses were identified in this deficiency. a. One nurse was in-serviced on [DATE]. b. The other nurse has been suspended at this time pending an abuse allegation of neglect- she was suspended on [DATE]. 3. The Nurse Managers were in-serviced by the Clinical Resource Nurse on [DATE] on the following: a. 24 Hour Report- and how to use them b. Alert Charting Process c. Infection Reports d. Change of Condition Guidelines- which included physician notification e. Documentation Guidelines- which included physician notification f. Appropriate assessment, interventions, follow up to interventions g. Emergency Procedures- [MEDICAL CONDITION] Management h. Care of a Resident in Emergency Situations- which included but not limited to- initial assessment (objective and subjective symptoms), head injuries, lacerations, suspected fractures, burns, choking, shortness of breath, chest pain, [MEDICAL CONDITIONS], dizziness, diabetic coma/ketoacidosis, insulin shock/insulin reaction, acute psychotic behaviors, ingestion of toxins and physician notification. i. Emergency Procedures- which included physician notification 4. The nurse managers will continue with the AM Clinical Meeting Monday - Friday a. On Saturday and Sunday a nurse manager will be in the facility each day. b. Physical rounds will be completed on each unit, every AM, prior to AM Clinical Meeting. A nurse manager will be speaking to the floor nurses regarding any resident change of conditions and physician notification for further guidance. In addition, the nurse manager will round on any residents which have had an identified change of condition. c. A nurse manager will review the 24 hour report, alert charting log and nursing notes to ensure all change of conditions have been communicated to the MD, that guidance has been provided and documented in the medical record under the nurse charting tab. MONITORING 1. During the AM Clinical Meeting all areas listed in #2 will be completed by the Nurse Management Team. a. The Nurse Management Team consists of the DON, ADON, 2 Unit Managers and 2 MDS Coordinators. b. The AM Clinical Meeting is held Monday-Friday at 8:15 AM. c. On Saturday and Sunday a nurse manager will be in the facility each day to complete the areas listed in #2. 2. During the AM Clinical Meeting any discrepancies identified will be documented, investigated and corrected immediately by the Nurse Management Team. 3. From any discrepancies identified further education or disciplinary action will occur with the staff member responsible. 4. The Clinical Resource Nurse will review the daily audits (labs, nursing notes, BM list, telephone orders) completed by the Nurse Management Team, weekly times 4 weeks, to ensure there is appropriate MD notification and guidance has been provided for any change of condition. 5. If trends or discrepancies are noted this QA process will be revised by the QA committee. 6. As discrepancies and trends are identified through these QA audits further education and training will be provided. 7. The facility will continue to involve the Medical Director in the facility processes in order to seek guidance and support. 8. A member of the Home Office staff will be on-site weekly for at least the next 30 days to offer guidance, support, training and monitoring of this plan. 9. On [DATE], Apex hired a new Clinical Resource Nurse, who will continue to provide guidance, support, training and monitoring to the DON and Nurse Management Team. The facility alleges the immediacy of these discrepancies have been abated on [DATE]. On [DATE] at 6:45 PM, the credible allegation was validated. Staff interviews with licensed nurses revealed the facility had implemented corrective measures which included in-services of licensed nurses regarding proper facility procedure and protocol for residents experiencing [MEDICAL CONDITION], respiratory distress, changes in levels of consciousness (LOC), emergency situations, physician notification, activation of emergency medical services and appropriate resident care during a [MEDICAL CONDITION], respiratory distress, change in LOC or any emergency situation.

Based on record review, staff, physician and nurse practitioner interviews, the facility failed to notify or consult with the physician or nurse practitioner that a resident had persistent loose stools which resulted in a 17 day delay in medical treatment for 1 of 2 residents reviewed for [MEDICAL CONDITIONS] and failed to notify the physician of missed doses of potassium for 1 of 1 resident with a critical potassium level of 2.3 (3.5 - 5.3 reference range) (Resident #263). The immediate jeopardy began on 6/26/14 when Resident #263 had three large loose stools within twenty four hours and neither the physician nor the nurse practitioner was contacted for guidance. The immediate jeopardy was removed on 7/17/14 at 8:47 pm when the facility provided and implemented an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity of D (no actual harm with the potential for more than minimal harm) that is not immediate jeopardy to ensure monitoring systems put in place are effective. Findings included: Lexi-Comp's Geriatric Dosage Handbook, 17th edition in part reads "potassium is the major cation (causes a positive charge) of intracellular (located or occur within the cell) fluid and is essential for conduction of nerve impulses in heart, brain and skeletal muscle; contraction of cardiac, skeletal and smooth muscles; maintenance of normal renal (kidney) function, acid-base balance, carbohydrate metabolism, and gastric (stomach) secretion." Resident #263 was admitted into the facility on [DATE]. [DIAGNOSES REDACTED]. The admission Minimum Data Set completed on 5/9/14 indicated Resident #263 had short and long term memory problems. Decision making was listed as moderately impaired. A review of the lab report received by the nursing facility on 6/12/14 from the lab provider in part read "[MEDICAL CONDITION] toxin result positive. It was further indicated that the report was "Read back and verified with the director of nursing at 8:55 am." A review of the physician order [REDACTED]." The Medication Administration Record [REDACTED]. [MEDICATION NAME] is an antibiotic that is used to treat a bacterial infection. A review of the physician order [REDACTED]." A review of the bowel elimination pattern record revealed the following: ? 6/26/14 "three large loose stools" ? 6/29/14 "two medium loose stools" ? 6/30/14 "two large loose stools" ? 7/5/14 "one medium loose stool" ? 7/6/14 "two medium loose stools, one large loose stool" ? 7/7/14 "one large loose stool" ? 7/8/14 "one small loose stool" A review of a critical lab result, reported to the nursing facility by the lab provider on 7/8/14 at 6:16 am to Nurse #7 in part read "Critical potassium 2.3." Physician #1 was indicated as notified with a new order received on 7/8/14 at 6:18 am by Nurse #7. A review of a physician telephone order dated 7/8/14 received by Nurse #7 in part read "potassium 20 meq every day." The Medication Administration Record [REDACTED]. A review of the nurse's notes dated 7/9/14 at 8:46 pm revealed a stool sample was obtained for [MEDICAL CONDITION]. A review of the MAR indicated [REDACTED]. A review of the nurses' notes from 6/23/14 to 07/09/14 did not reflect any facility care interventions to manage loose stools/diarrhea or the physician or nurse practitioner was consulted for guidance. A review of the bowel elimination pattern record revealed the following: ? 7/10/14 "two large loose stools, two medium loose stools" A review of the lab report received by the nursing facility on 7/10/14 from the lab provider at in part read "[MEDICAL CONDITION] toxin result positive. Critical results called to, read back and verified with unit manager #1 at 8:20 am." Due to the critical lab reported to the nursing facility on 7/10/14 by the lab provider related to positive [MEDICAL CONDITION], the physician ordered [MEDICATION NAME] 125 mg by mouth four times a day for [MEDICAL CONDITION] for 14 days. [MEDICATION NAME] is an antibiotic used to treat bacterial infections. A review of the MAR indicated [REDACTED]. A review of the physician order [REDACTED]." The MAR indicated [REDACTED]. A review of the lab report received by the nursing facility from the lab provider on 7/11/14 in part read "potassium 2.2 critical level." The MAR indicated [REDACTED]. A review of the lab report received by the nursing facility on 7/14/14 at 2:56 pm from the lab provider reported to Nurse #6 in part read "potassium 2.2 critical level." A review of the physician order [REDACTED]." The MAR indicated [REDACTED]. A review of the lab report received by the nursing facility from the lab provider on 7/16/14 in part read "potassium 2.4." The MAR indicated [REDACTED]. In an interview on 7/9/14 at 11:42 am, Nurse #2 stated per review of Resident #263's chart and the electronic record she did not see in the medical records, that another stool sample had been attempted or collected to date; ordered to be rechecked by the physician on 6/23/14. UM #1 acknowledged she was responsible for overseeing the nursing unit as the "unit manager." UM #1 indicated a stool sample recheck should have been completed as ordered by the physician, however she could not find where the stool specimen had been completed or obtain either. In an interview on 7/9/14 at 12:40 pm, the medical director stated he expected the stool sample ordered on [DATE] to have been obtained as ordered to reevaluate the resident for continued [MEDICAL CONDITION], due to persistent diarrhea, so medical treatment could have been initiated. In an interview on 7/9/14 at 4:21 pm, Nurse #3 and Nurse #4 both acknowledged they reviewed residents' bowel elimination pattern on a daily basis as part of their daily routine. Both nurses indicated they were aware that Resident #263 had completed previous antibiotics (ABT) for [MEDICAL CONDITION] and the resident continued to have loose stools after completion of the ABT ([MEDICATION NAME]) on 6/21/14. They both indicated they did not contact the physician via telephone regarding the continued loose stools, nor had they obtained a second stool sample. Nurse #3 and #4 stated they had no permanent hall assignment and worked throughout the facility In an interview on 7/10/14 at 2:05 pm, Nurse #4 acknowledged she signed the physician order [REDACTED]." Nurse #4 indicated she was aware that a stool sample was needed but she did not obtain a stool sample on her shift because there was no bowel movement. She further stated she did not follow up regarding the order because she assumed the stool specimen had been obtained. In an interview on 7/10/14 at 5:07 pm, UM #1 in the presence of the director of nursing (DON) stated her role was to oversee the nursing unit/nurses to ensure physicians orders were carried out as ordered, UM #1 acknowledged she was aware Resident #263 had completed a course of antibiotics to treat [MEDICAL CONDITION] (completed on 6/21/14) due to continued diarrhea/loose stools. She stated it was an oversight the stool sample ordered to be obtained on 6/23/14 was not obtained until 7/9/14. The DON added she expected all orders to have been obtained as ordered by the physician and the clinical record to reflect such, if the stool sample was unable to be obtained. In an interview on 7/16/14 at 10:52 am, Nurse #6 acknowledged she worked with Resident #263 on 6/26/14 from 7am-7pm. She stated she recalled the resident having loose stools, moderate amount and she observed loose stools in the resident's brief. She stated NA (nursing assistant) #10 made her aware the resident was having loose stools. She concluded she did not contact the physician regarding the loose stools because the resident was already on contact isolation and "did not appear to have running stool to me." In an interview on 7/16/14 at 11:26 am, NA #8 stated on 7/8/14 Resident #263 had a loose small stool that was "watery, greenish color, with mucous and slimy." She stated she reported her findings to Nurse #3 before she documented as part of her normal routine. In an interview on 7/16/14 at 12:15 pm, NA #10 who worked on 6/26/14 and 6/30/14 stated she observed Resident #263's stools "loose, brownish, and smelled bad." She stated she notified Nurse #6 on 6/26/14 and Nurse #4 on 6/30/14 of her findings. In an interview on 7/16/14 at 12:54 pm, Nurse #7 acknowledged on 7/8/14 she worked from 7pm-7am. She stated on occasions she had worked with Resident #263 and recalled the resident's stools having a strong foul odor but could not recall any specific dates. She concluded she did not contact the physician related to the foul odor. In an interview on 7/16/14 at 1:28 pm, Nurse #3 who worked on 7/8/14 from 7am-7pm indicated she checked residents' bowel elimination pattern daily that was put in the computer system by the NAs. She added she was aware that Resident #263 was having continued loose stools. She stated she recalled informing (no date specified) the nurse practitioner (NP) because she (Nurse #3) felt the resident needed an intervention to help with the loose stools. Nurse #3 concluded she did not administer potassium 20 meq during her shift because she was not made aware there was an order to administer potassium on 7/8/14. In an interview on 7/16/14 at 1:53 pm, the medical director indicated he was not made aware by the facility staff the resident was having persistent diarrhea; however he was aware the resident had a history of [REDACTED]. He stated on 7/8/14, he ordered for the resident to be given potassium 20 meq every day due to a critical potassium level, however the medication was not administered. He stated he expected the medication to have been administered to the resident on 7/8/14 as ordered, considering the facility staff was aware of the resident critical lab result. He indicated he expected the potassium to have been administered on 7/8/14, because the resident's potassium level was at a critical level and the resident could have had cardiac problems such as an abnormal heart rhythm, while awaiting the potassium to be administered on 7/9/14. On 7/14/14, he indicated the resident required more aggressive treatment in which potassium 40 mg was ordered to be given "now" and then to 40 mg twice daily (total of 80 mg daily) because the potassium level continued to drop. As the medical director, he stated factors which contributed to the low potassium were "Fluid loss as a result of continued loose stools/diarrhea." In an interview on 7/16/14 at 2:23 pm, the DON stated any abnormal stool presentation such as persistent diarrhea, color change or foul odor; she would expect the clinical record to reflect such and the physician or NP to be notified. In an interview on 7/16/14 3:40 pm, the nurse practitioner stated she recalled being informed once (6/23/14) Resident #263 was having continued diarrhea, however did not specifically know who contacted her. The NP stated she ordered for the resident's stool to be re-checked "stool sample" for [MEDICAL CONDITION]. She added she also informed unit manager #1 of the order and the unit manager responded she would follow up. She stated if she was made aware by the facility Resident #263 had continued to have loose stools/diarrhea, following the order on 6/23/14, she would have ordered an antibiotic, as an intervention to help with the persistent loose stools/diarrhea. In an interview on 7/16/14 at 4:02 pm, the DON indicated her expectation was for the unit manager to have checked the carbon copies of the orders to ensure the physician orders [REDACTED]. She further stated per her review of the physician orders, the MAR indicated [REDACTED]. She indicated the MAR indicated [REDACTED]. The DON added potassium 20 meq was also ordered to be administered on 7/10, 7/11, 7/12, 7/13/14 twice daily and the MAR indicated [REDACTED]. She stated the order to increase potassium was not transcribed into the electronic computer system properly, so the order was not carried out. The DON concluded her expectation was for the unit manager to have checked the carbon copies of the orders to ensure the physician orders [REDACTED]. In an interview on 7/17/14 at 12:32 pm, the administrator stated the facility process for ensuring physician orders [REDACTED]. She added the unit managers were responsible for following up on new orders daily, to ensure all new orders had been properly transcribed and medications administered as ordered. In an interview on 7/17/14 at 6:55 pm, Nurse #7 who worked 7pm-7am when presented the critical lab result dated 7/8/14 acknowledged she 1) was notified by the lab provider on 7/8/14 at 6:16 am as indicated on the lab report, 2) called the medical director as indicated on the lab report on 7/8/14 at 6:18 am, and received an order from the medical director on 7/8/14 at 6:18 am, to "administer potassium 20 meq every day." She stated that she was suppose to transcribe the order into the electronic computer system for the potassium 20 meq to be administered on 7/8/14, however she mistakenly scheduled it to be administered on 7/9/14. Nurse #7 indicated she did not administer the potassium to Resident #263 on 7/8/14 as ordered nor did she notify the physician. Nurse #7 concluded Nurse #3 who worked on 7/8/14 from 7am-7pm took over the care of Resident #263 after her. Nurse #7 indicated she was not sure if she made her (Nurse #3) aware of the critical potassium level/order received. The administrator was notified of the immediate jeopardy on 7/16/14 at 6:56 pm. The facility provided the following credible allegation on July 17, 2014 at 8:25 pm for F 157 as follows: "RESIDENT IDENTIFIED At the time this IJ was announced R 263- ? Had a [MEDICAL CONDITION] re-culture on 7/9/10 During the survey ? MD was aware of the loose stools 7/9/10 during the survey ? The Potassium errors have been resolved as 7/14/14 with correct orders. The MD was notified of errors on 7/16/14 and had gave no changes in the current treatment plan. ? The MD is aware of R 263 condition and is monitoring closely. IDENTIFYING OTHER RESIDENTS AT RISK 1. A 100% Bowel Movement audit was completed from 7/10-7/16/14 to identify any residents that are exhibiting persistent diarrhea/loose stools. The facility printed out the CNA bowel movement charting from the Electronic charting. This audit was completed at 9:03 pm on 7/16/14. This task was completed by the Nurse Managers. ? From this audit R1, R2 and R3 were identified as having a long history of loose stools. The facility notified the MD of these loose stools on 7/16/14 and orders for [MEDICAL CONDITION] cultures were obtained as a safety measure. 2. A 100% lab audit was completed for the last 30 days to ensure all labs were obtained and any orders that were received were transcribed and administered as ordered. The Managers printed out all lab orders from the Electronic Charting system to validate this. This was completed by the nurse managers on 7/16/14 at 9:10 pm. ? From this audit no further medication errors in relationship to lab results were observed. The facility did note that 13 labs were not drawn per orders in the last 30 days. The MD was notified of these errors and new orders were obtained. 3. A 100% in house resident audit was completed to ascertain if all changes of Condition's were identified by nursing and the MD was aware. This audit was completed from 7/14/14-7/16/14 by the Nurse Managers. This was completed on 7/16/14 @ 10:37 PM. ? From this audit there were 19 changes of condition that the facility could not find MD notification. The MD was notified of all changes on 7/16/14 by the nurse managers. Upon notification the MD had no new orders or interventions for these residents. 4. A 100% MD order audit was completed from 7/10/14-7/16/14 to ensure that all new orders were entered into the Electronic Charting System as ordered. This process was started on 7/16/14 by the nurse managers. This process will continue and will be completed on 7/16/14 by the nurse managers. This audit was completed on 7/17/14 @ 3:35 pm ? From this audit 4 med errors were noted. These error for R4- the [MEDICATION NAME] was ordered to be held on 7/16/14 and was administered (MD notified and no new received), R5 had multi 2 tabs ordered and 1 tab was transcribed (MD changed to 2 tabs), R6 Facility failed to give [MEDICATION NAME] weekly as ordered for 2 weeks (MD stated to start [MEDICATION NAME] weekly), R7 treatment order of Dry gauze and TAO was ordered 3 times a week and it was transcribed as daily ( MD stated to change to 3 times weekly). None of these residents suffered any Ill effects related to these errors. PROCESSES IMPLEMENTED TO PREVENT FURTHER OCCURRENCES 1. In-servicing for the nursing staff and nursing assistants was started on 7/16/14 by the Nurse Managers. At this point 84 nursing staff and nursing assistants out of 138 have been in-serviced. No member of the nursing staff or nursing assistants will be able to work the floor until they are in serviced. ? The facility's Change of Condition Policy and the requirements of MD notification which includes; residents that are experiencing persistent loose stools and have critical potassium levels and other critical/abnormal labs. ? The facility's Medication transcription policy which would include the proper transcription of potassium. a. STARTED ON 7/16/14 AND ONGOING AT THIS TIME. 2. The Nurse Managers were in-serviced by the Regional Vice President on 7/17/14 on the following: ? The Facility's New Morning Nurses QA Meeting which will include: o Review of the 24 hour condition report to ensure that all residents that have exhibited persistent loose stools have been communicated to the MD and that all new orders have been carried out. o Review of the 24 hour Bowel Record to ensure that any resident that is having continuous diarrhea or 3 loose stools in a 24 hour period has MD notification for proper interventions. o Review of all new orders to ensure that the order was properly transcribed into the Electronic Charting System and that the resident received the treatment promptly. The Nurse responsible for receiving the lab/[MEDICAL CONDITION] culture order will enter into it into the ECS lab tracking. The Nurse Managers will ensure this is completed during their morning QA review. o Review of the lab tracking sheet to ensure that all [MEDICAL CONDITION] cultures were obtained as ordered. The Nurse responsible for receiving the lab order will enter into it into the ECS lab tracking. o The 2nd shift Supervisor will ensure that all labs/ [MEDICAL CONDITION] cultures obtained are received, distributed to the appropriate responsible nurse, the MD is notified and new orders are transcribed and implemented. o The Morning Nurses QA will review all these completed labs/[MEDICAL CONDITION] cultures the following morning to ensure the 2nd shift Supervisor completed the assigned task. o The Lab Company and all Critical Labs will be called to the DON/designee. The DON/designee will ensure that the MD is notified and ensure that any new orders are carried out. o Properly managing the facility staff to ensure proper resident care is provided. The Completion date is 7/17/14." On 7/17/2014 at 8:26 pm, the credible allegation was validated. Staff interviews with licensed nurses and nursing assistants revealed the facility had implemented the following actions one should take related to 1) physician notification of persistent, continued loose stools or diarrhea, critical potassium level, 2) changes in stools pattern, 3) physician order [REDACTED].