Every finding on record at Charlotte Health & Rehabilitation Center

Based on observations, record review, and resident, staff and Nurse Practitioner interviews, the facility failed to provide a safe transfer for a dependent resident that required the use of a mechanical lift. After the fall, Resident #56 was complaining of unbearable left hip pain and was transferred to the emergency department (ED) by emergency medical services (EMS) for further evaluation. A computed tomography (CT) scan obtained in the ED revealed Resident #56 had a nondisplaced greater trochanteric fracture of the left femur (the hard boney protrusion on the upper outer side of the thigh bone). An orthopedic evaluation completed in the ED determined non-operative management of the fracture was appropriate due to Resident #56's non-weightbearing status prior to the injury. Resident #56 was discharged back to the facility with orders for oxycodone/acetaminophen 5-325 milligrams (mg) one tablet administered every 12 hours for pain. This deficient practice was identified for 1 of 5 residents reviewed for accidents (Resident #56).The findings included: 1. Resident #56 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke) with left hemiplegia (paralysis) and hemiparesis (weakness). The quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #56 was cognitively intact, had impairment to the upper and lower extremities on one side and was dependent on staff for transfers. The care plan dated 1/06/26 indicated Resident #56 required assistance with activities of daily living related to chronic health issues, utilized a manual wheelchair for mobility, and required 2-person assistance with the use of a mechanical lift for all transfers. A review of the medical record revealed Resident #56 was not taking anticoagulant medication. The incident report dated 1/12/26 at 8:00 PM completed by Nurse #1 indicated Resident #56 was sitting in the wheelchair transferring with the assistance of the Nurse Aide and he fell to the floor hitting his head. Resident #56 was complaining of left hip pain and assessed for injury. Resident #56 was observed to have an abrasion to his lower left leg, but no other injury was noted, and his vital signs were within normal limits. Resident #56 was transferred from the floor into bed with staff assistance and pain medication was administered but ineffective. The on-call provider was notified and Resident #56 was transferred to the ED for further evaluation. A phone interview with Nurse #1 on 1/21/26 at 3:12 PM indicated she was assigned to Resident #56 on 1/12/26 from 7:00 PM to 7:00 AM. Nurse #1 revealed at approximately 8:00 PM she was down the hall administering medications and heard Resident #56 yelling for help and responded to his room. She indicated NA #1 was in Resident #56's room and Resident #56 was sitting on the floor in front of the wheelchair. She revealed NA #1 reported to her that Resident #56 slid out of the wheelchair onto the floor. Nurse #1 indicated the lift pad was still in the wheelchair and soaked with urine. She stated Resident #56 was complaining of left hip pain and had an abrasion to his left lower leg. Nurse #1 revealed she assessed Resident #56 and he had no other visible injuries. Nurse #1 revealed she was unsure if it was safe to use the mechanical lift to transfer Resident #56 from the floor to the bed, so she, NA #1 and two other staff members, she did not recall their names, lifted Resident #56 off the floor and into bed. Nurse #1 indicated Resident #56 was administered pain medication but reported the hip pain was unbearable. She stated she notified the on-call provider and orders were received to transfer Resident #56 to the ED for further evaluation. Nurse #1 revealed Resident #56 did not report to her the fall occurred during a transfer with the mechanical lift and that he was unable to recall any details related to the fall. A statement written by NA #1 dated 1/13/26 revealed Resident #56 was sitting in his wheelchair with a lift pad underneath him and his pants and the lift pad were soaked in urine. NA #1 was repositioning the lift pad under Resident #56 when he slid out of the wheelchair with the lift pad and onto the floor. A phone interview was conducted with NA #1 on 1/15/2026 at 5:02 PM. She stated she was assigned to Resident #56 on 1/12/26 from 7:00 AM to 3:00 PM and again from 3:00 PM to 11:00 PM due to a call out. NA #1 indicated at approximately 8:00 PM Resident #56 requested assistance with incontinent care and was ready to get into bed. She stated Resident #56 was sitting in his wheelchair with a lift pad underneath him and his pants and the lift pad were soaked in urine. She stated the lift pad needed to be repositioned because it was pulled up under his bottom. NA #1 revealed she was standing beside the wheelchair repositioning the lift pad when Resident #56 and the lift pad slid out of the wheelchair down to the floor. NA #1 indicated Resident #56 started yelling and Nurse #1 responded to his room. She indicated Resident #56 was complaining of terrible pain to his left hip. NA #1 stated she assisted Nurse #1 along with two other staff members, she did not recall their names, to lift Resident #56 off the floor and into bed. NA #1 stated Resident #56 was transferred to the ED for further evaluation and was diagnosed with a left hip fracture. She indicated when she was transferring a resident with the mechanical lift, she positioned the lift pad under the resident and hooked it to the lift before she got a second person to assist with the transfer. NA #1 revealed she was unsure why Resident #56 was reporting the lift sling broke while she was transferring him with the mechanical lift. She stated the lift pad was not hooked to the mechanical lift yet and the lift was sitting in the doorway to his room and the lift pad was not hooked to the lift. NA #1 indicated she did not recall if the lift pad that Resident #56 was sitting on at the time of the incident was labeled with his name and she was not aware Resident #56 had his own lift pad. The EMS prehospital care report dated 1/12/26 revealed EMS responded to the facility for a resident that sustained an injury during a witnessed fall from the mechanical lift. Facility staff reported to EMS that one staff member was using the mechanical lift to transfer Resident #56 from the wheelchair to the bed when a strap on the lift pad broke and he fell approximately two feet to the floor and was complaining of left hip pain. Resident #56 was alert and awake and confirmed he had fallen from the mechanical lift. Resident #56 reported hitting his head on the mechanical lift and hitting his left leg on the side of the bed before landing on the floor. Resident #56 was observed to have abrasions to the left knee and shin and was complaining of left hip pain. Resident #56's vital signs were within normal limits, and he was transferred by ambulance to the ED for further evaluation, The ED records dated 1/12/26 revealed Resident #56 presented to the ED for evaluation due to left hip pain after a fall. Resident #56 was being transferred with a mechanical lift at the nursing facility when one of the straps on the lift pad broke and he fell approximately two feet to the floor landing on his left side. A computed tomography (CT) scan obtained in the ED revealed Resident #56 had a left nondisplaced fracture of the greater trochanteric femur (the hard boney bump on the top outer side of the thigh bone) and noted osteopenia (weakening of the bones). The orthopedic evaluation noted due to Resident #56's non-weightbearing status prior to the injury, the fracture would be managed non-operatively and he was safe for discharge. Resident #56 was discharged back to the facility with orders for oxycodone/acetaminophen 5-325 mg one tablet administered twice a day and to schedule a follow-up appointment at the trauma clinic in 2-3 weeks. A review of Resident #56's physician orders and medication administration record (MAR) revealed the following: 3/12/25 oxycodone-acetaminophen 5-325 mg one tablet administered every 12 hours as needed for pain. The MAR indicated it was administered on 1/12/26 at 8:05 PM. 1/13/26 oxycodone-acetaminophen 5-325 mg one tablet administered every 24 hours as needed for pain. The MAR indicated it was administered on 1/13/26 at 4:52 PM. 1/13/26 oxycodone-acetaminophen 5-325 mg one tablet administered two times a day (9:00 AM and 9:00 PM) for pain. The MAR indicated it was administered on 1/13/25 at 9:00 PM, 1/14/26 at 9:00 AM and 9:00 PM, 1/15/26 at 9:00 AM and 9:00 PM, and 1/16/26 at 9:00 AM. An interview was conducted with Resident #56 on 1/15/26 at 2:25 PM. Resident #56 stated on 1/12/26 after dinner, he called for assistance with incontinence care and NA #1 responded to his room. He revealed NA #1 was lifting him out of the wheelchair with the mechanical lift when he heard fabric ripping and the left front strap on the lift pad broke. Resident #56 stated he fell approximately 2 feet to the floor, hitting his head on the lift mast and his left leg on the side of the bed before landing on the floor on his left side. He indicated he was having severe left hip and tailbone pain. Resident #56 revealed a lot of staff members responded to his room and they picked him up off the floor and put him into bed. He stated the nurse administered pain medication, but it was not helping and he went by ambulance to the ED for further evaluation. Resident #56 revealed x-rays and a CT scan were obtained in the ED and he was diagnosed with a left hip fracture. Resident #56 indicated he was experiencing pain at times but was receiving scheduled pain medication twice a day and overall, his pain was managed. Resident #56 stated the lift pad that broke was labeled with his name in black marker and he had not seen it since the incident. An interview conducted with NA #6 on 1/16/26 at 10:30 AM revealed she assisted with Resident #56's shower today. NA #6 indicated Resident #56 had his own lift pad and it was labeled with his name, but she was unable to find it in his room or in the laundry room. NA #6 revealed the laundry aides told her they had not seen Resident #56's lift pad in the laundry room this week. An interview was conducted with Laundry Aide #1 on 1/16/26 at 12:15 PM. She revealed clean lift pads were stored in the laundry room and available to nursing staff as needed. She stated the lift pads were shared for all the residents, however Resident #56 had his own lift pad and it was labeled with his name in black marker. Laundry Aide #1 revealed she had not seen Resident #56's lift pad in the laundry room this week. A phone interview was conducted with the Nurse Practitioner on 1/21/26 at 1:00 PM. She stated Resident #56 was transferred to the ED on 1/12/26 due to a fall from the wheelchair and was diagnosed with a left hip fracture. The NP indicated she was not aware of any reports from staff or Resident #56 that the fall occurred during a transfer with the mechanical lift. She stated Resident #56 was at his baseline and his pain was managed well. A phone interview conducted with the Director of Nursing (DON) on 1/22/26 at 3:15 PM revealed she was on vacation when the incident occurred with Resident #56. The DON revealed the Administrator informed her of the incident when she returned to work on 1/19/25. The DON indicated NA #1 should not have attempted to reposition the lift sling under Resident #56 without the assistance of a second person to ensure the resident was safe. The DON stated she was not aware that Resident #56 or any staff reported that Resident #56's fall was due to a strap on the lift pad breaking while he was being transferred with the mechanical lift. A phone interview was conducted with the Administrator on 1/22/26 at 1:58 PM. She stated Nurse #1 notified her on 1/12/26 that Resident #56 fell from the wheelchair to the floor and was transferred to the ED for further evaluation. The Administrator revealed she investigated the incident and interviewed NA #1 and determined NA #1 was attempting to reposition Resident #56's lift pad, it was soaked in urine and Resident #56 slid out of the wheelchair with the lift pad down to the floor. The Administrator stated she was not aware of any reports from staff or Resident #56 that he fell from the mechanical lift due to a strap on the lift pad breaking and based on her investigation Resident #56 slid out of the wheelchair landing on the floor. The Administrator stated she could not speak to whether NA #1 should have requested the assistance of a second staff member when repositioning Resident #56's lift pad.

Based on observations, record review, and staff and Pest Control Technician interviews, the facility failed to maintain a pest free environment in 1 of 1 kitchen and 1 of 2 nourishment rooms observed for maintaining an effective pest control program.The findings included: A review of the facility's electronic maintenance request system since 2/6/25 was conducted. There were no work orders for broken or missing tiles or pest control treatment requests documented for the kitchen area or nourishment rooms.A review of the monthly pest control service report dated 3/7/25 and signed by the Maintenance Director read in part: kitchen area floor drains in need of cleaning. The floor drains in both kitchen and in the preparation area needed to be cleaned and replaced. Please clean around drain frequently to help prevent pest breeding sites. A review of the monthly pest control service report dated 4/8/25 and signed by the Maintenance Director read, in part: kitchen area floor tiles and baseboards were loose or missing. Floor tiles near dishwasher needed to be repaired to eliminate potential pest harborage and breeding site. Floor drains in kitchen needed cleaning. Please clean around drain frequently to help prevent pest breeding sites.A review of the monthly pest control service report dated 5/12/25 read, in part: kitchen area interior-excess water noted. This area needed to be dried, cleaned, and regrouted. Floor drains in need of cleaning. Please clean in and around drains frequently to help prevent pest breeding sites.A review of the monthly pest control service report dated 6/2/25 read, in part: kitchen area-floor tiles and baseboards were loose/missing. Floor tiles needed resealing and replacement. Please repair to eliminate potential pest control harborage and breeding sites. Floor drains needed cleaning. Kitchen had drainage issue, please fix. Please clean in and around drains frequently to help prevent pest breeding sites.A review of an additional pest control service report dated 7/1/25 and signed off by the Maintenance Director read, in part: kitchen in need of a complete overhaul once again documented today. When returning for regular service we will see if the kitchen is getting repaired on 7/2/25 as reported. Floor tiles or baseboard in kitchen loose or missing. Kitchen can never be pest free as long as the major issues exist. Please repair to eliminate potential pest harborage and breeding site.A review of the monthly pest control service report dated 7/7/25 and signed off by the Maintenance Director read, in part: kitchen area- floor tiles or baseboards were loose or missing. Although work has begun, the floor isn't to be completely repaired in kitchen. Please repair to eliminate potential harborage and breeding site. A review of the monthly pest control service report dated 8/5/25 read, in part: Maintenance Director not on site at time of service-checked kitchen and treated kitchen, found excess water beneath dishwasher.A review of the monthly pest control service report dated 9/10/25 read, in part: treated in kitchen to help prevent cockroaches, they were present due to standing water in kitchen. Excess water noted in kitchen. Pool of water in kitchen has been a constant for a year or more and needs to be repaired otherwise cockroaches will continue to have a breeding site. Keep areas dry and please repair. Floor drains in need of cleaning. Please clean floor drains as they could be a breeding site for small flies. Please clean in and around drains frequently to help prevent pest breeding sites.A review of the monthly pest control service report dated 11/13/25 and signed off by the Maintenance Director read, in part: customer reports seeing pests in kitchen due to quality of cleanliness in kitchen. Once again documented today sanitation in kitchen has not changed in over a year until kitchen is clean. They will continue to have issues.a. An observation of the main kitchen on 1/12/26 at 10:00 AM revealed three small, black flies flying near the handwashing sink next to the cooking area and standing water in missing tile areas to the left of the floor drain under the steamer. The presence of the Dietary Manager was requested, but no kitchen staff were available for the initial tourA second observation during a tour with the Dietary Manager, Administrator, Dietician, and Regional Operations Director for Food Services of the main kitchen on 1/12/26 at 1:15 PM revealed a large trash can with food debris positioned next to the handwashing sink near the food service area. When a staff member threw food trash into the trash can, a large amount (estimated 20-30) small, back flies flew out of the trash can into the air near the food preparation area and handwashing sink. The surveyor alerted the touring group to the small, black flies near the food service area. The Administrator stated the facility would address the concerns.b. An observation of the 100 Hall Nourishment Room on 1/15/26 at 11:30 AM revealed three small, black flies flying around the room. The observation included standing water under the ice cooler near the door and approximately three floor tiles that had come loose from the floor under the ice cooler. Further observation of the 100- Hall Nourishment Room revealed approximately two to three floor tiles under the ice chest that had detached from the floor. There was standing water observed on the tiles and under the loose tiles to the left of and under the ice chest. An interview with the Pest Control Technician on 1/15/26 at 10:45 AM revealed the company he worked for was contracted to provide services at the facility monthly and when there were callbacks for pest sightings in between those visits. He stated the kitchen had multiple areas where the floor tiles were broken or missing and needed to be fixed which he had reported to the Maintenance Director each time he serviced the building as noted in his comments on the monthly reports. The Pest Control Technician stated he had documented the broken and missing floor tiles in the kitchen for a year and a half in his visit reports. He stated the broken tile areas and the missing grout between the tiles were causing water to pool, and therefore attracting pests such as roaches, maggots, and small black flies. The Pest Control Technician stated the broken floor tiles under the steamer appliance and under the oven were a few of the many areas with pooling water. He stated the facility's pest control coverage did not include fly treatment; however, he performed the additional fly treatment on 1/12/26 and earlier in the morning on 1/15/26 at the request of management. The Pest Control Technician stated he had encouraged the Maintenance Director over the past few months to add fly treatment to their standard pest control agreement, but the facility did not agree to it until 1/12/26. He stated his company had infrared pest traps, but the facility had not contracted with them for these products. An interview with the Senior Director of Operations for Food Service on 1/15/26 at 11:08 AM revealed a small fly treatment was completed by the pest control company on 1/13/26 and 1/15/26. She stated she hoped there was a plan for the broken tiles on the floor in the kitchen because of the standing water in those areas. The Senior Director of Operations for Food Service stated she was unaware of a plan to repair the floor tiles, but she stated a request to the facility's regional maintenance office had been made on 1/12/26.A tour and observation of the kitchen and the 100-hall nourishment room occurred on 1/16/26 at 2:05 PM with the Dietary Manager, Maintenance Director, Regional Nurse Consultant, and Administrator in attendance. Small black flies were still visible in the kitchen and in the 100-hall nourishment room. Standing water was visible under the floor tiles under the ice chest in the 100-hall nourishment room and in the broken and missing tile areas in the kitchen under the steamer appliance. The Maintenance Director, who had been employed at the facility for a couple of years, stated the Pest Control Technician gave him a chemical to treat the drains in the kitchen for small flies on 1/12/26. He stated he was not aware of the broken and missing floor tiles in the kitchen. The Maintenance Director stated he was not aware of the loose floor tiles in the 100-hall nourishment room and stated the standing water was from ice dropped onto the floor from the ice chest. He stated the kitchen staff had not logged a maintenance request into their electronic work order system. The Maintenance Director also stated he had not received any verbal requests for floor tile repair in either the kitchen or the 100-hall nourishment rooms.An interview with the Dietary Manager on 1/16/26 at 2:47 PM revealed she had been in her position since September 2025 and since then she has worked to get the kitchen back on track as there had been no accountability for kitchen staff or processes. She stated she was not aware of the online maintenance request system used by the facility until very recently and had not logged any entries for the kitchen to include general maintenance concerns or pest concerns. The Dietary Manager stated she had sent many text messages to the Maintenance Director about the broken floor tiles and small flies in the kitchen since arriving at the facility and he was aware of the concerns. She stated the Pest Control Technician had started a treatment for small flies in the kitchen on 1/12/26.An interview on 1/16/26 at 4:18 PM with the Administrator revealed she had the expectation that the Maintenance and Kitchen staff would follow their policies to eliminate pests. She stated she expected all staff to put in maintenance requests for anything broken in the facility, such as floor tiles.

Based on observations, record review, and staff interviews, the facility failed to label and date leftover food items stored for use, keep a food preparation area clean and orderly, store a scoop without the potential for cross-contamination, discard dented canned goods stored for use and maintain a pipe of a steamer appliance and floor tiles in good repair. These practices occurred in 2 of 3 reach-in coolers, 1 of 1 dry goods storage area, and 1 of 1 food preparation areas.The findings included:1. An initial tour of the main kitchen occurred 1/12/26 at 10:00 AM. The presence of the Dietary Manager (DM) was requested, but no kitchen staff were available for the initial tour. The following concerns were identified:a. Visible dirt and grime build up present on a knife holder on the wall next to the handwash sink. Seven knives were in the holder.b. Visible black buildup and food particles were present on the cooking range. A large white stain was observed on the left side of the gas stove approximately two feet in width. The white stain continued onto the floor next to the gas stove.c. Visible black buildup was on the oven door seals and window areas.d. Broken and missing floor tiles were observed under the right side of the oven and on the left side of the floor drain under the steamer appliance. The areas of missing tiles were approximately 4-6 inches (in.) wide and filled with standing water.e. A foam drinking cup was utilized as a scoop and was left in the cornmeal bin touching the cornmeal in the food preparation area.f. Items in the reach-in coolers that were open and not labeled with a use by date included:-Three 13-ounce (oz.) cans of whipped cream dated 12/24 -A resealable bag of provolone cheese slices dated 1/5 g. Item in the reach in cooler that was open, dated and past the use by date included: -One half full plastic preparation container of olives dated 12/22 with use by date of 12/25 h. Items in the dry storage area that were open, resealed and not labeled with a use by date included:-One 5-pound (lb.) bag of dry yellow cake mix dated 12/15 - One bag of crisped rice cereal dated 12/15 i. Items in the dry storage area that were open, resealed and not labeled with an open or use by date included:-One 5lb. container of cocoa powder -One 1lb. bag of strawberry gelatin An additional observation and kitchen tour occurred on 1/12/26 at 1:15 AM with the Dietary Manager Administrator, Dietician, and Senior Director of Operations for Food Service. All areas of concern from the initial kitchen tour were observed and addressed.A third kitchen tour with the Dietary Manager occurred on 1/15/26 at 11:02 AM. Two, 6lb. 9oz cans of sliced beets were observed with dents measuring approximately 2 inches in length along the rims. The cans were located on the rotation rack for use.An interview with the Dietary Manager on 1/16/26 at 2:47 PM revealed she had been in the Dietary Manager role for around four months. She stated she had been working with kitchen staff on the correct processes and procedures in the kitchen for labeling and storing food. The Dietary Manager stated the kitchen staff were not completing the labeling procedure with use by dates, which for perishable foods was anywhere from three to seven days past the open date. She stated the main cook in the kitchen typically oversaw the cleaning tasks in the kitchen, but she had been out on medical leave. The DM stated other staff members had been filling in on the cleaning duties and cleaning had fallen behind schedule.An interview with the Administrator on 1/16/26 at 4:18 PM revealed she had the expectation that the kitchen staff and managers would follow policies and procedures.2. An observation made on 1/12/26 at 10:15 AM revealed a large puddle of water under the food steamer next to the gas stove adjacent to the food preparation area. Water was observed dripping out a plastic pipe on the back of the appliance. The pipe was not located over the floor drain, and a large puddle of water was observed on the kitchen floor. A second observation was made during a kitchen tour with the Dietary Manager, Administrator, Dietician, and Regional Operations Director for Food Services on 1/12/26 at 1:15 PM. Water was observed pouring out of a plastic pipe on the back of the steamer appliance as the steamer was in use. The pipe was not located over the floor drain, and a large puddle of water was observed on the kitchen floor. An interview with Dietary Manager on 1/12/26 at 1:16 PM revealed she had verbally reported the leaking appliance to the Maintenance Department multiple times.A review of the facility's electronic maintenance request system, which kept track of work orders, since 2/6/25 was conducted and there were no requests for the kitchen area.An interview with the Maintenance Director on 1/16/26 at 2:25 PM revealed he was not aware of the leaking pipe from the steamer. He stated the facility used an online maintenance tracking system and no one had entered any work orders. The Maintenance Director indicated no one from the kitchen staff informed him of the steamer leaking water onto the floor.An interview with the Administrator on 1/16/26 at 4:18 PM revealed she was not aware of the leaking pipe under the steamer appliance, and she had the expectation that the kitchen staff and managers would alert the Maintenance staff of any repair concerns.

Based on record review and interviews with staff, the Operations Manager for the transportation provider, and Medical Director, Nurse Aide (NA) #8 failed to report Resident #114's pain to Nurse #11 prior to transferring the resident to another Skilled Nursing Facility (SNF) and as a result no assessment was completed. The deficient practice occurred for 1 of 3 residents reviewed for quality of care (Resident #14). The findings included: Resident #114 was admitted to the facility on [DATE] with diagnoses including chronic pain, bed confinement, morbid obesity, muscle weakness, abnormalities of gait and mobility. A review of the facility's fall and injury reports from 6/17/2025 through 7/31/2025 revealed no falls documented for Resident #114. A review of the admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #114 was cognitively intact. Resident #114 was coded for bilateral lower extremity range of motion impairment, and a manual wheelchair and walker for mobility. Resident #114 reported no pain in the past 5 days and no falls prior to MDS assessment. A physician order dated 6/25/2025 specified Tramadol 50 milligrams (mg) every 12 hours and hold for sedation.On 1/15/2025 at 3:43 PM an interview with the Physical Therapist was completed. The Physical Therapist stated Resident #114 could not complete the initial Physical Therapy assessment on admission due to pain and fatigue and he could not start working with Resident #114 until 7/18/2025. The Physical Therapist reported only working on bed mobility and stretching with Resident #114 because she could not tolerate getting out of bed due to pain. The Physical Therapist stated Resident #114 began to complain of increased pain in her left hip on 7/23/2025 and he notified the Medical Director. The Physical Therapist reported that the Medical Director asked him to continue to monitor. The Physical Therapist stated he had to discontinue therapy services because Resident #114 had reached her potential and was unable to progress.A review of Resident #114's pain assessments documented on the Treatment Administration Record for the month of July 2025 revealed pain was assessed twice a day- on day shift and night shift. Resident #114's last report of pain was on 7/28/2025 on dayshift rated a 7 out of 10 with 10 being the highest level of pain. The pain level charted for the day of discharge on [DATE] was zero (0) and was documented by Nurse #11. A review of the Medication Administration Record (MAR) for the month of July 2025 revealed Resident #114 last received Tramadol 50 mg on 7/30/25 at 9:58 AM. There was no documentation of pain medication given on 7/31/2025. A phone interview was completed on 1/15/2026 at 10:48 AM with Nurse Aide (NA) #8. NA #8 reported she was assigned to Resident #114 on 7/31/2025 and transferred her to a wheelchair to be transported to another SNF. NA #8 stated she and NA #3 transferred Resident #114 from her bed to a manual wheelchair using a mechanical lift. NA #8 reported while raising Resident #114 in the mechanical lift, Resident #114 yelled out that her left leg was hurting. NA #8 stated she and NA #3 worked quickly to lower Resident #114 in the manual wheelchair to ease her pain. NA #8 reported that Resident #114 stopped complaining of pain once she was in the wheelchair. NA #8 stated she did not inform the nurse or anyone of Resident #114's complaint of pain. NA #8 stated Resident #114 always complained of pain with positioning but never yelled or screamed. NA #8 reported she did not think of getting the nurse, she wanted to expedite the transfer to limit the amount of time Resident #114 was in pain. NA #8 reported that once Resident #114 was in the manual wheelchair, the Transportation Driver pushed Resident #114 out of the room to the transportation van. NA #8 reported that she and NA #3 did not escort Resident #114 and the Transportation Driver to the van. An interview with NA #3 on 1/15/2026 at 10:57 AM revealed that she had just started working with the facility and did not recall assisting NA #8 with transferring Resident #114. A review of progress note dated 7/31/2025 at 4:45 PM written by Nurse #11 revealed that Resident #114 was discharged to another SNF with all belongings via transport company. Report was given to SNF that there were no concerns/issues noted at time of discharge. A call was placed to Nurse #11 on 1/15/2026 at 10:47 AM, who was assigned to Resident #114 on 7/31/2025. The number was no longer in service, and Nurse #11 no longer worked for the facility. A review of the incident report dated 8/5/2025 revealed that Resident #114 was discharged from the facility to another Skilled Nursing Facility (SNF) on 7/31/25 and upon arrival to the next SNF Resident #114 complained of pain. The facility became aware on 8/1/2025 that an x-ray revealed a left closed displaced femoral neck fracture (the upper thigh bone broke at the connection with the hip) of the left hip and sent to the hospital. The facility initiated an investigation on 8/1/2025 with chart review, interviews and skin observations. A review of the hospital records revealed that Resident #114 was sent to the emergency room on 8/1/2025 at approximately 3:40 AM with a complaint of left hip pain. The impression of the x-ray of the left hip on 8/1/2025 revealed there was an acute impacted fracture (a type of bone break where the ends of the fractured bone are driven into each other, causing compression without complete separation) through the femoral neck. Mild to moderate degenerative disease was noted.An interview with the Operations Manager for the Transportation Driver was completed on 1/15/2026 at 3:21 PM. The Operations Manager stated the transportation driver that transported Resident #114 to the new SNF was not available and could assist with information regarding Resident #114's transport on 7/31/2025. The Operations Manager stated he recalled the incident because the facility had contacted the transportation company to review the video of the Transportation Driver transferring Resident #114 into the van. The Operations Manager stated the company retains video for 72 hours and completed a report for the facility. The Operations Manager stated the Transportation Driver rolled Resident #114 on a hydraulic lift and locked the wheelchair in place inside the van. The Operations Manager reported Resident #114 was never removed from the wheelchair by the Transportation Driver and there were no observations of Resident #114 experiencing a fall or impact during the video while with the Transportation Driver. The Operations Manager stated the Transportation Driver reported Resident #114 did not complain of pain to the driver.An interview with the Director of Nursing (DON) was completed on 1/20/2026 at 11:00 AM. The DON stated that NA #8 should have paused Resident #114's transfer to the wheelchair when she complained of pain and informed Nurse #11. The DON reported that if NA #8 had informed Nurse #11 of Resident #114's pain, Nurse #11 could have assessed Resident #114 to provide pain medication, contact the provider, and inform the transferring facility of the pain. An interview with the Medical Director on 1/16/2026 at 3:49 PM was completed. The Medical Director stated Resident #114 had chronic pain and it was not uncommon for someone with chronic pain to experience pain after working with physical therapy. The Medical Director stated he did not provide new orders for Resident #114 because Resident #114 had chronic pain and the staff had not reported a fall, impact or significant change in Resident #114.An additional interview with the Medical Director was completed on 1/23/2026 at 10:43 AM. The Medical Director reported based on his impression of the results for the x-ray completed by the hospital on 8/1/2025 Resident #114 could have obtained the left hip fracture prior to admission to this facility or anytime during the transfer to the new SNF and while at the new SNF. A review of the Past Noncompliance (PNC) document revealed the plan was not acceptable for PNC and did not meet the requirements for PNC.

Based on record reviews, observations and staff interviews, the facility failed to follow their infection control policies and procedures for Enhanced Barrier Precautions (EBP) when Nurse #4 did not wear Personal Protective Equipment (PPE) while providing gastric tube care for Resident #89. In addition, Nurse Aide (NA) #5 failed to wear PPE while providing tracheostomy (trach) care for Resident #5. This deficiency occurred for 2 of 10 staff members observed for infection control practices (Nurse #4 and NA #5).The findings included:A review of the facility's policy titled Enhanced Barrier Precautions, revised on 3/26/2024, indicated: Enhanced Barrier Precautions (EBP) referred to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) by using gowns and gloves during high-contact resident care activities. High-contact activities included dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, device care or use (central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, Peripherally Inserted Central Catheter (PICC) lines, midline catheters, and wound care if deemed chronic by a medical provider or if MDRO was present. a. An observation of feeding tube care for Resident #89 provided by Nurse #4 was made on 1/14/2026 at 11:00 AM. Resident #89's room had an enhanced barrier precautions sign posted outside the door with personal protective equipment (PPE) stored in a white plastic bin outside the door. Nurse #4 entered the room without wearing a gown. She washed her hands and put gloves on. She then stopped the feeding pump and used a syringe to flush the feeding tube. At 11:20 AM Nurse #4 reconnected Resident #89's feeding tube to the feeding pump. She then discarded any unused supplies and her gloves and proceeded to wash her hands with soap and water at the sink.An interview with Nurse #4 on 1/14/2026 at 11:23 AM revealed she was aware that Resident #89 was on enhanced barrier precautions. Nurse #4 stated that she only needed to wear a gown for residents that were on contact precautions.b. An observation of NA #5 providing trach care for Resident #5 was completed on 1/15/2026 at 1:28 PM. Resident #5's room had an enhanced barrier precautions sign posted outside the door stated staff should wear gown and gloves for personal protective equipment (PPE). PPE was stored in a white plastic bin outside the door. NA #5 was observed cleaning around Resident #5's trach with gloves and gauze. NA #5 did not wear a gown.An interview with NA #5 at 1:30 PM on 1/15/2026 was completed when NA #5 was exiting Resident #5's room. NA #5 stated she knew she should have had a gown on while providing trach care but did not plan to be in the room long.An interview with the Infection Preventionist was completed on 1/16/26 at 10:47 AM. The Infection Preventionist stated she completed rounds daily to ensure that all residents had the appropriate infection precaution signs posted and staff had available PPE. The Infection Preventionist reported that all staff were trained during orientation on proper use of PPE and proper PPE use was reviewed in monthly staff meetings on all shifts by the Infection preventionist and shift supervisors. The Infection Preventionist stated that the staff should wear the appropriate PPE according to the infection precaution signs posted for each resident.An interview with the Director of Nursing (DON) was completed on 1/20/2026 at 11:00 AM. The DON stated she expected all staff members to use the appropriate PPE according to the infection precaution sign posted for each resident.

Based on observations, record review and staff, Resident Representative and Medical Director interviews, the facility failed to follow hospital discharge orders for a resident to perform urinary self-catheterization (Resident #95) and failed to keep a urinary catheter drainage bag from touching the floor to reduce the risk of infection (Resident #9) for 2 of 3 residents reviewed for urinary catheters. The findings included: 1. The hospital Discharge summary dated [DATE] indicated Resident #95 had a urinary obstruction which required self-catheterization. Resident #95 was discharged from the hospital to the facility on [DATE] and the hospital discharge orders indicated Resident #95 was to continue self-catheterization. There were no further details regarding self-catheterization in the discharge summary. Resident #95 was admitted to the facility on [DATE] with diagnoses including benign prostatic hyperplasia (enlarged prostate) with urinary obstruction. A nurse's note dated 11/05/25 written by Nurse #6 indicated Resident #95 was admitted to the facility from the hospital and required self-catheterization due to urinary obstruction. During a phone interview with Nurse #6 on 1/15/26 at 11:13 AM she stated she was assigned to Resident #95 on 11/05/25. Nurse #6 indicated when a resident was admitted to the facility the admission nurse or a nurse manager was responsible for reviewing the hospital discharge summary and entering the orders in the electronic medical record (EMR). She stated Resident #95 was admitted to the facility from the hospital and received report from the hospital nurse before he arrived and was informed he was performing self-catheterization due to a urinary blockage. Nurse #6 revealed she immediately notified the Director of Nursing (DON) that Resident #95 was self-catheterizing and needed physician orders and catheter supplies and the DON responded that she would handle it. Nurse #6 stated she only worked at the facility as needed and was unsure what occurred after she notified the DON or if Resident #95 was provided with catheter supplies. A review of the physician orders revealed no orders for Resident #95 to perform self-catheterization. A physician's note dated 11/06/25 written by the Medical Director indicated Resident #95 had a diagnosis of benign prostatic hyperplasia (BPH) with urinary obstruction which required self-catheterization. Resident #95 received education on proper catheter hygiene to prevent infection and would continue to perform self-catheterization as needed. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #95 was moderately cognitively impaired, occasionally incontinent of urine and independent with toileting hygiene. The MDS was not coded for intermittent catheterization. The care plan dated 11/08/25 indicated Resident #95 required assistance with activities of daily living due to chronic health conditions and recent hospitalization but was usually continent of bladder and independent with toileting. A nurse's note dated 11/14/25 written by Nurse #7 revealed Resident #95 became increasingly belligerent and repeatedly requested to self-catheterize due to pain with urination. Resident #95 reported he was self-catheterizing prior to admission and insisted it needed to be done. Nurse #7 observed Resident #95 urinating into the toilet and provided education that self-catheterization was not required because he was able to urinate. Nurse #7 notified the Medical Director that Resident #95 was complaining of pain when urinating and orders were given to obtain a urinalysis. A phone interview conducted with Nurse #7 on 1/15/26 at 11:19 AM indicated she was assigned to Resident #95 on 11/14/25 from 7:00 AM to 7:00 PM. She stated Resident #95 was complaining of pain and insisting that he needed to self-catheterize. Nurse #7 indicated she observed Resident #95 urinating in the toilet without difficulty and explained to him self-catheterization was not indicated. She stated she notified the Medical Director and was given an order to obtain a urinalysis. Nurse #7 revealed she was not aware that Resident #95 required self-catheterization and there were no physician orders or supplies in his room indicating to her otherwise. A review of Resident #95's medical record revealed laboratory results for a urinalysis obtained on 11/14/25 were received on 11/16/25 and the results were negative. Resident #95 was discharged from the facility to an unknown location on 11/28/25. A phone interview conducted with the Resident Representative (RR) on 1/15/26 at 11:19 AM revealed Resident #95 had been self-catheterizing for approximately two years due to a urinary blockage that required surgery. She stated Resident #95 had a history of homelessness and was discharged to the facility after being hospitalized for a urinary tract infection due to reusing catheters. The RR revealed Resident #95 reported to her about a week after he was admitted to the facility that they were not providing catheter supplies. The RR indicated she went to Resident #95's urologist's office and was able to obtain approximately 15 catheters which she brought to Resident #95. She stated Resident #95 was discharged from the facility on 11/28/25 and no catheter supplies were provided when he was discharged . During an interview conducted with the Medical Director on 1/15/26 at 2:30 PM he indicated Resident #95 had a diagnosis of BPH with urinary obstruction and was performing self-catheterization upon admission to the facility. The Medical Director stated he was unable to recall if he signed orders in the electronic medical record (EMR) for Resident #95 related to self-catheterization but was not aware of any concerns related to nursing staff not knowing Resident #95 was self-catheterizing or that catheter supplies were not being provided. The Medical Director revealed he did not recall the date or the name of the nurse, but he was notified that Resident #95 was complaining of painful urination and he ordered a urinalysis however he did not recall the nurse questioning whether Resident #95 was supposed to be self-catheterizing. A phone interview with the DON on 1/20/26 at 3:20 PM revealed when a resident was admitted to the facility from the hospital the admission nurse reviewed the hospital discharge summary and entered the medication and treatment orders in the electronic medical record (EMR) for the Medical Director to approve and sign. The DON stated when a resident was admitted with orders to perform self-catheterization, orders were entered in the EMR for the Medical Director to review and sign, the resident was assessed to ensure they were able to self-catheterize safely using proper technique, and the resident was provided with catheter supplies. The DON revealed when Resident #95 was admitted to the facility on [DATE] the admission nurse position was vacant, and the nurse assigned to the resident when they were admitted was responsible for reviewing the hospital orders and entering them in the EMR. The DON indicated she was unsure why the orders for Resident #95 to self-catheterize were overlooked, and she did not recall Nurse #6 informing her that he was self-catheterizing and needed supplies. 2. Resident #9 was admitted to the facility on [DATE] with a diagnosis of unspecified neuromuscular dysfunction of the bladder and urinary tract infection. A review of Resident #9's care plan dated 06/26/24 revealed a focused area of urinary catheter. The stated goals were Resident #9 would remain free from complications related to an indwelling catheter. Interventions included providing catheter care every shift, empty drainage bag as needed, monitor for signs of urinary tract infection, and enhanced barrier precautions. Resident #9 had a physician's order dated 03/31/25 for an indwelling urinary catheter 16 French 10 milliliter balloon for neuromuscular dysfunction of the bladder. A significant change Minimum Data Set (MDS) assessment completed 12/23/25 revealed Resident #9 was severely cognitively impaired and had an indwelling urinary catheter. An observation of Resident #9 occurred on 01/12/26 at 11:38 AM. Resident #9 was resting in bed and had an indwelling urinary catheter connected to a bedside drainage bag. The bedside drainage bag was observed positioned below the bladder level, attached to bed frame, and the bottom of the bedside drainage bag was observed touching the floor. An observation of Resident #9 occurred on 01/13/26 at 9:53 AM. Resident #9's was resting in bed and had an indwelling urinary catheter connected to a bedside drainage bag. The bedside drainage bag was observed positioned below the bladder level, attached to bed frame, and the bottom of the bedside drainage bag was observed touching the floor. An interview with Nurse Aide (NA) #1 occurred on 01/13/26 at 2:16 PM. NA #1 stated she was assigned to Resident #9 first shift (7:00 AM to 7:00 PM) on 01/12/26 and 01/13/26. NA #1 indicated Resident #9 was provided with catheter care during her shift, but she did not notice Resident #9's urinary catheter bag was in contact with the floor during her rounds. NA #1 stated she was aware the urinary catheters are not supposed to be in contact with the floor to prevent infection. An interview with Nurse #1 on 01/16/26 at 10:18 AM. Nurse #1 stated she was the assigned nurse for Resident #9 on 01/12/26 and 01/13/26 from 7:00 AM to 7:00 PM. Nurse #1 reported that Resident #9's catheter was leaking so it was changed on 01/13/26. Nurse #1 verbalized she did not observe Resident #9's catheter bag touching the floor during her shift to prevent infection. An observation of Resident #9 occurred on 01/14/26 at 2:13 PM. Resident #9's was resting in bed and had an indwelling urinary catheter connected to a bedside drainage bag. The bedside drainage bag was observed positioned below the bladder level, attached to bed frame, and the bottom of the bedside drainage bag was observed touching the floor. An interview with NA #2 occurred on 01/14/26 at 2:37 PM. NA #2 stated she was assigned to Resident #9 on 01/14/26 from 7:00 AM to 7:00 PM. NA #2 indicated Resident #9 was provided with catheter care during her shift, but she did not notice Resident #9's urinary catheter bag was in contact with the floor during her rounds. NA #2 stated she was aware the urinary catheters were not supposed to be in contact with the floor to prevent infection. An interview with Nurse #2 was conducted on 01/14/26 at 3:18 PM. Nurse #2 stated she was the assigned nurse for Resident #9 on 01/14/26 from 7:00 AM to 7:00 PM. Nurse #2 verbalized she did not observe Resident #9's catheter bag touching the floor during her shift. An interview was conducted with the Infection Preventionist/Staff Development Coordinator (IP/SDC) on 01/16/26 at 12:14 PM. The IP/SDC stated urinary catheter drainage bags, and the drainage valve should be kept off the floor because of germs to prevent contamination of the bag which could cause a urinary tract infection. The IP/SDC shared that urinary catheter bags should be hung on the side of the bed below the level of the bladder when a resident was in bed and the drainage valve should be secured. She stated that staff were provided with this training during the new hire process and during the facility's annual competency training. The Director of Nursing (DON) was unavailable for interview due to scheduled time off. An interview was conducted with the Corporate Nurse Consultant on 01/16/26 at 2:52 PM. The Corporate Nurse Consultant stated that urinary catheter drainage bags should not be on the floor for infection control reasons. She stated the urinary drainage bag should be hung on the bed frame and positioned below the level of the bladder but should not be touching the floor.

Based on observations, staff interviews, and record reviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of wounds (Resident #40), and medications. This deficient practice was identified for 2 of 19 sampled residents (Resident #75).The findings included:1. Resident #40 was admitted to the facility on [DATE] with diagnoses including pressure ulcer of the sacral region, stage 4 (full-thickness tissue loss with exposed bone, tendon or muscle).A care plan was initiated 01/18/24 and revised 07/21/25 with a focused area of chronic wound stage 4 to sacrum. The stated goal was sacrum wound would show signs of healing through the review period. Interventions included alternating air mattress, regular assessment of skin, staff to turn and reposition resident regularly, and enhanced barrier precautions for wound care.A review of the Wound Care Provider note dated 12/29/25 revealed Resident #40 had been evaluated and noted Resident #40 had a Stage 4 Pressure Ulcer.Resident #40's physician order dated 01/04/26 was reviewed and revealed a treatment order for a Stage 4 pressure ulcer.A review of Resident #40's January 2026 Treatment Administration Record (TAR) revealed treatment for a stage 4 coccyx (the base of the spinal column) pressure ulcer had been completed daily.A quarterly Minimum Data Set (MDS) dated [DATE] was reviewed and did not indicate Resident #40 had a diagnosis of a pressure ulcer. Resident #40 was not coded for an unhealed pressure ulcer, was not coded for a stage 4 pressure ulcer, or that pressure ulcer care was provided.An interview with the Wound Nurse was conducted on 01/14/26 at 2:26 PM. The Wound Nurse stated that Resident #40 had a stage 4 wound to his coccyx which had been present on admission. He received wound care daily, had not developed any new wounds since admission and was seen by the wound care provider weekly.An interview with the MDS Coordinator was conducted on 01/16/26 at 11:58 AM. She confirmed she had completed Resident #40's 01/05/26 MDS. She indicated Resident #40 had a diagnosis of a Stage 4 pressure ulcer to his sacrum which was being treated daily. The MDS Coordinator explained that the MDS was completed incorrectly and the pressure ulcer was overlooked and should have been coded.An interview with the Corporate MDS Coordinator was conducted on 01/16/26 at 2:52 PM. The Corporate MDS Coordinator stated that all MDS assessments should be coded correctly for relevant diagnoses and health issues.An interview with the Corporate Nurse Liaison was conducted on 01/16/26 at 2:55 PM. The Corporate Nurse Liaison stated that all MDS assessments should be coded correctly for relevant diagnoses.2. Resident #75 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus with hyperglycemia (high blood sugar).A review of Resident #75's physician admission orders dated 12/15/25 revealed an order for Insulin glargine solution (long-acting insulin and hypoglycemic medication used to manage blood glucose levels) 100 units per milliliter. Inject 50 units subcutaneously (under the skin) daily in the evening for diabetes.A review of Resident #75's December 2025 Medication Administration Record (MAR) revealed Resident #75 received insulin injections daily as ordered. A care plan was initiated 12/21/25 with a focused area for diabetes mellitus. The stated goal was Resident #75 would have no complications related to diabetes mellitus through the review period. Interventions included administering medication as ordered, monitoring symptoms of hyperglycemia (high blood sugar) or hypoglycemia (low blood sugar), therapeutic diet as ordered, and labs as ordered.Resident #75's admission Minimum Data Set (MDS) dated [DATE] was reviewed and did not indicate insulin injections or hypoglycemic medications had been received. An interview with the MDS Coordinator was conducted on 01/16/26 at 11:58 AM. The MDS Coordinator confirmed she completed the 12/21/25 MDS for Resident #75. The MDS Coordinator stated Resident #75 received insulin daily and the MDS assessment should have included both insulin injections and the use of hypoglycemic medication. She stated the insulin injections and hypoglycemic medication had been overlooked and the MDS had been coded incorrectly.An interview with the Corporate MDS Coordinator was conducted on 01/16/26 at 2:52 PM. The Corporate MDS Coordinator stated that all MDS assessments should be coded correctly for relevant medications.An interview with the Corporate Nurse Liaison was conducted on 01/16/26 at 2:55 PM. The Corporate Nurse Liaison stated that all MDS assessments should be coded correctly for relevant medications.

Based on record review and staff, Adult Protective Services (APS) Intake Social Worker, Medical Director and Resident Representative interviews, the facility failed to implement an effective discharge planning process for Resident #95 in order to sufficiently prepare the resident for a safe and orderly discharge that ensured his needs were met, home health services were coordinated, a safe discharge location was identified, and necessary medical supplies were provided. This deficient practice was identified for 1 of 3 residents reviewed for discharge (Resident #95).The findings included:The hospital Discharge summary dated [DATE] indicated Resident #95 was admitted to the hospital and treated for a urinary tract infection related to a diagnosis of benign prostatic hyperplasia (enlarged prostate) with urinary obstruction requiring self-catheterization and a history of reusing catheters. Resident #95 was also assisted with finding nursing home placement due to recent eviction from his home. Resident #95 was discharged to the facility on [DATE] with instructions to continue self-catheterization until a surgery that was scheduled for urinary obstruction (blockage that inhibits the flow of urine).Resident #95 was admitted to the facility on [DATE] with diagnoses including benign prostatic hyperplasia with urinary obstruction, homelessness, substance abuse, and cognitive communication deficit. A discharge planning note dated 11/07/25 completed by the Social Worker (SW) indicated Resident #95 was moderately cognitively impaired, unable to make his own decisions and his Resident Representative (RR) would be his decision maker. Resident #95 was recently evicted from his home and was homeless at the time of admission to the facility. During a discussion with the RR today concerning discharge plans it was determined Resident #95 returning to the community was not feasible. The RR requested assistance with completing a Medicaid application and finding long term placement for Resident #95 in a facility closer to where she lived.The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #95 was moderately cognitively impaired, exhibited no behaviors or rejections of care, walked independently, was occasionally incontinent of bladder and required partial to moderate assistance with bathing, and supervision with toileting. He was not coded for a urinary catheter device. The MDS further indicated Resident #95 and a legally authorized representative were participating in discharge planning with active discharge planning noted to already be occurring for the resident to return to the community. The following MDS question was noted to be skipped: Do you want to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community? The care plan dated 11/08/25 indicated Resident #95 had problem areas including impaired communication with the potential for poor health literacy and signs and symptoms of acute delirium. The interventions included providing a safe and supportive environment, assisting with reading/comprehending written communications from the physician and pharmacy as needed. The care plan also noted Resident #95's stay at the facility was expected to be short term, discharge planning was ongoing, and updates would be made to the discharge plan as needed. A review of the medical record revealed a Centers for Medicare and Medicaid Services (CMS)-10123 Notice of Medicare Non-Coverage (NOMNC) letter was issued to Resident #95 on 11/26/25 explaining Medicare Part A coverage for skilled services were ending on 11/28/25. The form was signed by the SW and Resident #95. A discharge planning note dated 11/27/25 written by the SW revealed Resident #95 was discharging from the facility to a homeless shelter on 11/28/25. Therapy recommended home health services for safety awareness; however services could not be arranged due to the discharge location. The clinical team deemed the discharge was against medical advice (AMA), AMA paperwork was completed and signed, and a report was made to APS.A Release of Responsibility Unauthorized Discharge form dated 11/28/25 signed by the SW indicated Resident #95 was discharged from the facility AMA and noted on the section for the patient signature was refused to sign. The discharge instructions dated 11/28/25 completed by the SW and Nurse #5 indicated Resident #95 was discharged to a homeless shelter. Therapy recommended home health services for medication and household management; however services were not arranged because the address of the discharge location was unknown. The clinical team deemed the discharge was AMA, AMA paperwork was completed and a report was made to APS. The discharge instructions noted that Resident #95 had no devices/treatments and no education or medical supplies were provided. Resident #95 was provided medications and list of medication orders at the time of discharge. An interview conducted with the Physical Therapist on 1/14/26 at 1:30 PM revealed Resident #95 was admitted to the facility 11/05/25 and was receiving physical therapy for strengthening and to improve balance. The Physical Therapist indicated that on 11/26/25 Resident #95 was functioning independently and appropriate for discharge from the facility however his safety awareness was poor, so he recommended home health services to continue working on safety awareness. A phone interview conducted with the APS Intake Social Worker on 1/14/26 at 11:16 AM revealed there was not a report made by the facility or any record of Resident #95 in the APS system. A phone interview with Resident #95's RR on 1/15/26 at 11:19 AM indicated she operated a non-profit organization and was a patient advocate for individuals that were homeless. The RR revealed she had been working with Resident #95 for approximately 10 years to ensure he had housing, medical care, medications and medical supplies. The RR stated approximately one week before Resident #95 was admitted to the facility he was evicted from his home. She indicated a few days after Resident #95 was admitted to the facility she met with the SW to discuss Resident #95's discharge plans. She indicated the SW was aware Resident #95 was homeless and they agreed discharging Resident #95 back to the community was not feasible. The RR revealed she requested assistance with a Medicaid application and finding a facility closer to her for long term placement. The RR revealed she had no further follow up from the SW regarding the status of Resident #95's Medicaid application or transferring him to a closer facility. The RR indicated on 11/26/25 she received a phone call from the SW notifying her that Resident #95 was being discharged from the facility due to therapy services ending. She revealed the SW did not inform her that the decision could be appealed but did explain if Resident #95 remained in the facility after 11/28/25 he (Resident #95) would be responsible for payment. The RR indicated she made it very clear to the SW on 11/26/25 that Resident #95 did not have housing and all the local shelters were full. She revealed the SW offered no recommendations or assistance with placement and stated Resident #95 was able to remain in the facility but would have to pay five hundred dollars a day starting on 11/29/25. The RR indicated when she arrived at the facility on 11/28/25 at 8:00 AM, a nurse, she did not recall her name, handed her a bag with Resident #95's medications, a list of the medication orders and instructions to schedule a follow up visit with the primary care physician. The RR revealed the nurse did not provide any catheter supplies or further instructions related to Resident #95's care. The RR indicated she was unaware that Resident #95 was asked to sign an AMA form and that Resident #95 did not leave the facility AMA, but rather because the facility initiated discharge due to therapy services ending. The RR stated when they (she and Resident #95) left the facility, she was able to find a friend for Resident #95 to stay with until his surgery on 12/23/25. The RR indicated she went to the urology office to inquire about catheter supplies which they were able to provide and she brought those supplies to Resident #95. She revealed Resident #95 was able manage his personal care independently, but she visited him daily to ensure he had food, catheter supplies and was taking his medications. She revealed Resident #95 had surgery for the urinary blockage on 12/23/25 and was released from the hospital the same day but the local homeless shelters were still full, and she was unable to find him housing. The RR stated since the surgery Resident #95 no longer had to self-catheterize but was living on the streets and remained on the waiting list for shelter placement. An interview was conducted with the SW on 1/14/26 at 5:36 PM. She stated when Resident #95 was admitted to the facility a Brief Interview for Mental Status (BIMS) was completed and indicated Resident #95 was moderately cognitively impaired, so she discussed discharge plans with his RR on 11/07/25. She indicated Resident #95 was homeless and the RR requested assistance with a Medicaid application and wanted to find a facility for long-term placement closer to where she lived. The SW stated she notified the Business Office Manager on 11/07/25 that Resident #95's RR requested assistance with completing a Medicaid application but wanted to wait until the application was approved before sending out referrals to other facilities regarding long term placement. The SW indicated she did not follow up with the Business Office Manager to confirm the Medicaid application was submitted or to check on the status of the application. The SW revealed she attended a clinical team meeting every morning along with therapy staff, the DON and the Administrator. She stated during the clinical team meeting on 11/26/25 she was notified by therapy that Resident #95's services were ending. The SW stated there was a follow up BIMS assessment completed for Resident #95 which indicated he was cognitively intact, but she was unsure who conducted the assessment or the date it was completed. The SW revealed she issued and reviewed the CMS-10123 NOMNC letter with Resident #95 on 11/26/25 and explained the appeal process. The SW revealed Resident #95 acknowledged understanding and stated he would not remain at the facility and would go to a homeless shelter. The SW indicated Resident #95 immediately called his RR while she was still in the room. She stated Resident #95 explained to the RR he was being discharged from the facility due to therapy services ending and she would need to pick him up from the facility on 11/28/25 and take him to a homeless shelter and the RR agreed. The SW indicated Resident #95 named two possible homeless shelters he would be going to but she did not call either of the shelters to see if they had any openings. The SW stated she was not aware Resident #95 was performing urinary self-catheterization, so catheter supplies were not provided. She further stated that the nurse was responsible for reviewing the discharge instructions and medications, so she was unsure if that occurred. The SW indicated because Resident #95 was unsure which homeless shelter he would be going to, she was unable to provide an address to arrange home health services. The SW revealed she informed the clinical team that home health services could not be arranged for Resident #95, and the clinical team determined the discharge was AMA. The SW revealed the AMA form was completed but Resident #95 refused to sign the form. She indicated it was the facility's policy to file an APS report whenever a resident was discharged AMA. The SW stated she informed the former SW Assistant to file a report for Resident #95 with APS and could not say why the report was not filed. The SW indicated she did not follow up with Resident #95 or the RR after the resident was discharged and was unsure of his status after leaving the facility.An interview conducted with the Business Office Manager on 1/16/26 at 12:30 PM revealed she did not recall being notified of a request from Resident #95's RR for assistance with a Medicaid application nor was there any documentation in her records that a Medicaid application was initiated for Resident #95.Several attempts made to contact the former SW Assistant were unsuccessful.A phone interview was conducted with Nurse #5 on 1/28/26 at 10:23 AM. Nurse #5 revealed she did not recall if she was assigned to Resident #95 on 11/28/25. She revealed she did not remember Resident #95 or what assistance he required with care. Nurse #5 also did not recall if she reviewed the discharge instructions with Resident #95 or his RR before they left the facility or if she gave them any medications or medical supplies. An interview was conducted with the Medical Director on 1/15/26 at 2:30 PM. He stated on 11/28/25 he was informed by the DON that Resident #95 was discharged from the facility AMA but was unaware of any further details related to the discharge. The Medical Director indicated Resident #95's cognition varied and he was not consistently able to make decisions and manage his care independently. The Medical Director revealed Resident #95 was homeless and required self-catheterization due to a urinary blockage and there were concerns related to him reusing catheters. The Medical Director indicated discharging Resident #95 from the facility without housing and catheter supplies was not a safe discharge. During an interview with the Administrator on 1/16/26 at 4:09 PM she stated the SW was notified by therapy when a resident's Medicare Part A benefit was ending and then issued the CMS-10123 NOMNC letter to the resident and/or RR. She indicated the SW was also responsible for arranging any services and ordering the needed medical equipment for the resident prior to discharge. The Administrator revealed she was aware Resident #95 was discharged from the facility AMA but did not recall who notified her or when. The Administrator indicated she was not aware of any other details related to Resident #95's discharge, why it was determined to be AMA or if Resident #95 was agreeable to leaving the facility AMA. She stated discharging a resident with no arranged housing and without needed medical supplies was not a safe discharge.

Based on record review and staff interviews, the facility failed to submit the results of an investigation of an allegation of alleged employee to resident abuse that included the date/time of the alleged incident, the patients full name/room number, details of the allegation, names of the accused and any witnesses, name of facility staff who investigated the allegation, results of the investigation, and any corrective action that was taken by the facility to the Division of Health Service Regulation (DHSR) within 5 working days of the allegation for 1 of 3 sampled residents reviewed for abuse (Resident #113).The findings included:A review of the facility's policy titled Abuse/Neglect/Misappropriation/Crime, Patient Protection effective date 10/17/2023 read, in part a zero tolerance for mistreatment, abuse, neglect, misappropriation of property, or any crime against a patient of the facility. The policy also indicated all suspected or witnessed incidents of abuse, neglect, theft, and/or exploitation or any reasonable suspicion of a crime against a patient brought to the attention of the center's administration will result in internal investigation, appropriate and timely reporting to the State Survey Agency. A review of the facility's policy entitled Abuse/Neglect/Misappropriation/ Crime, Reporting Requirement/Investigations effective date 2/5/2023 read, in part the Administrator must thoroughly investigate and file a complete written report of the investigation to the State Agency within 5 working days of the incident. The written follow-up investigative reporting documented must contain sufficient details to demonstrate a thorough investigation was conducted. The report must include but is not limited to the date of occurrence, name of the resident staff, or individuals involved, location of and the description of the injury to the resident, location and description of the occurrence, immediate action taken to protect the resident from further injury, mechanisms in place to prevent recurrence of the incident, and documentation of reports to Adult Protective Services, law enforcement, or the Department of Health Professions, as appropriate.A review of the initial allegation report submitted by the facility to the Division of Health Service Regulation (DHSR) revealed an allegation of employee to resident abuse. The allegation details noted, in part that Resident #113 stated he was beat up by a staff member the previous evening (6/5/25). The report continued Resident #113 was severely cognitively impaired and disoriented and he was unaware of who the staff member was. The initial allegation report description included a head-to-toe skin assessment was completed on Resident #113 with no signs of injury, and a facility investigation was initiated. The initial allegation report noted there were no details of physical or mental injury or harm. The report indicated the facility was made aware of the incident on 6/6/25 at 11:30 AM, the initial report was submitted to DHSR via fax transmission on 6/6/25 at 12:20 PM and law enforcement was notified on 6/6/25 at 12:00 PM. The initial allegation report was completed and signed by the Director of Nursing (DON).A review of Resident #113's Electronic Medical Record (EMR) revealed a Medical Director's note on 6/6/25 stating Resident #113 was seen for a follow up visit and stated he was beaten up yesterday. The note further revealed Resident #113 endorsed being agitated and difficult to deal with. The Medical Director's note continued upon further questioning, nursing staff reported that Resident #113 liked to roll out of bed and scream for help and Resident #113 had baseline intermittent confusion and agitation toward staff. A review of a copy of an email correspondence from Health Care Personnel Investigations copied to DHSR Complaint Intake Unit was conducted. The email was addressed to the Administrator and DON on 6/17/25 revealed a five-day investigation report associated with the 24-hour report submitted on 6/6/25 had not been received by DHSR. The email indicated the facility should fax the 5-day investigation report as soon as possible. An interview with the Administrator on 1/16/26 at 10:30 AM revealed she did not know which staff member reported the initial allegation and she was unable to find the email sent from DHSR on 6/17/25 regarding the 5-day report not being received by DHSR. She stated she did not have any records of fax transmittals for the 5-day report to DHSR and stated the report was not sent to DHSR. A review of the facility's 5-day investigation folder revealed a summary written by the Administrator on 6/10/25. The summary stated Resident #113 reported he had been beat up by a staff member and a head-to-toe assessment was completed with no signs of abuse. The summary revealed Resident #113 was unable to specify when the alleged incident occurred when asked shortly after it was reported. The summary noted body audits were completed on the hallway for residents with a BIMS (Brief Interview for Mental Status) score of 12 or below with no issues noted. Interviews were completed on the hallway for residents with a BIMS score or higher with no issues noted. The summary concluded that the facility was unable to substantiate abuse as Resident #113 had cognitive impairment and there was no evidence of abuse. The investigation folder did not reveal the staff member who reported the alleged abuse and did not include any witness statements.An interview with the DON on 1/26/26 at 11:02 AM revealed she did not recall the alleged incident involving Resident #113. She stated she sent the initial allegation report to DHSR, and the 5-day investigation was completed although she was not sure if it had been submitted to DHSR. The DON stated sending the 5-day investigation report to DHSR may have been missed and she did not recall receiving an email from the State Agency on 6/17/25 to remind the facility to submit the 5-day investigation report. The DON stated the Administrator typically sent all the reports to DHSR and she would cover if the Administrator was out of the office. She stated gathering as many witness statements as possible for the full investigation was a good idea moving forward to have for any abuse investigation. The DON could not recall which staff member alerted management to Resident #113's allegation.A second interview with the Administrator on 1/16/26 at 4:23 PM revealed she had the expectation that all reports be submitted to DHSR within proper timeframes and the investigation should have been more thorough.

Based on record reviews, and resident and staff interviews, the facility failed to treat a resident in a respectful and dignified manner when 1 of 2 staff (Nurse Aide (NA) #1) failed to provide incontinent rounding resulting in urine saturated pants, mechanical lift pad and wheelchair seat for 1 of 3 reviewed for dignity and respect (Resident #56). Resident #1 indicated it made him feel bad to have to sit in urine-soaked pants. Findings included:Resident #56 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia (complete paralysis on one side of the body) and hemiparesis (neurological condition characterized by weakness on one side of the body) following cerebral infarction affecting the left non-dominant side and acute kidney failure.The resident's Care Plan dated 02/11/25 identified incontinence care as a focus area. The resident was assessed as incontinent of bowel and bladder with severe physical impairment. Interventions included assistance from two staff members for toileting, hygiene, and incontinence care, with the goal of keeping the resident as clean and dry as possible.The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact. The assessment further indicated the resident was dependent on two staff members for toileting, personal hygiene, and lower body dressing and was assessed as always incontinent of urine and bowel. Resident #56 was assessed with clear speech, understood by staff and had the ability to understand others.An interview conducted on 01/16/26 at 11:58 PM with Resident #56 revealed on 01/12/26 Nurse Aide (NA) #1 assisted him into his wheelchair at approximately 2:00 PM and did not return to check on him until approximately 8:00 PM. The resident stated his brief and pants were soaked with urine during that time and even through the supper meal when he felt he was wet. He stated staff were supposed to check on him every two hours but did not and did not come into the room until approximately 8:00 PM. When asked how the incident made him feel, the resident stated it made him feel bad having to sit in wet pants. He stated he did not tell staff that he had urinated because he didn't want to bother them.An interview conducted on 01/16/26 at 12:15 PM with NA #1 revealed she was assigned to Resident #56 on 01/12/26 from 7:00 AM to 11:00 PM. She stated she transferred the resident to his wheelchair between 2:00 PM and 3:00 PM and did not check his incontinence status again until 8:00 PM when the resident activated his call light. NA #1 stated the residents' brief, pants, wheelchair seat, and lift pad were saturated with urine. She stated she did not perform routine incontinence checks because she believed the resident was alert and could request assistance as needed. The interview further revealed NA #1 cared for Resident #56 on a regular basis and was familiar with him. An interview conducted on 01/16/26 at 12:36 PM with NA #2 revealed NA #1 was assigned to Resident #56 on 01/12/25 and responsible for completing two-hour incontinence rounding. NA #2 stated the resident was not consistently able to notify staff when he needed to be changed and required routine monitoring. NA #2 stated she left at 3:00 PM and did not observe the resident to be wet at that time. She stated she felt like he was unable to consistently notify staff because he would be observed incontinent without alerting staff that he had went to the restroom. She stated he was dependent upon staff to provide incontinence rounding. An interview conducted on 01/21/26 at 3:12 PM with Nurse #1 revealed at approximately 8:00 PM on 01/12/26 she responded to Resident #56 yelling for help and found him on the floor. Nurse #1 stated the resident's pants, wheelchair seat, and lift pad were saturated to the extent that a mechanical lift could not be safely used. Four staff members were required to assist the resident back into bed. Nurse #1 stated her shift had started at 7:00 PM, but she had not checked on Resident #56 or gone into his room prior to the incident. She stated she was unsure if or when the Nurse Aide had completed incontinence checks on the prior shift.An interview conducted on 01/20/26 at 11:00 AM with the Director of Nursing revealed the resident should have received incontinence care during the period between 2:00 PM and 8:00 PM and should not have been left saturated with urine. The DON stated residents should be provided with incontinence care every two hours in the facility and no resident should feel upset due to sitting in incontinence.During an interview conducted on 01/16/26 at 1:19 PM, the Administrator stated it was the facility's expectation that residents be rounded on every two hours and changed as needed to maintain dignity and comfort.

Based on observations, record review, resident and staff interviews, the facility failed to maintain a clean floor and failed to maintain baseboards in good repair in a resident's room and bathroom (Resident #27). Additionally, the facility failed to maintain a window screen in a resident's room (Resident #109). The deficient practice affected 2 of 19 rooms on 2 of 4 halls observed for environmental concerns.Findings included: 1. An interview was conducted with Resident #27 on 1/12/2026 at 12:53 PM and she stated her room and bathroom had not been swept or mopped for some time. Resident #27 could not recall when the room had last been thoroughly cleaned. Resident #27 pointed out that there was debris on the floor at the head of her bed which resulted when the bed hit the wall when adjusting the head of the bed position. Resident #27 stated she told housekeeping but could not remember exactly when or to whom she had reported the issue about the debris. An observation of Resident #27's room and bathroom on 1/12/2026 at 1:00 PM revealed approximately a half cup of white plaster-like debris that ranged in size from dime size pieces to a white powdery substance on the floor at the head of Resident #27's bed. There were two white plaster like patches on the wall approximately six inches by six inches at the head of the bed which appeared to have been previous areas of repair. An observation in Resident 27's bathroom revealed one section of baseboard approximately four inches along the left wall and another section of baseboard approximately three inches long under the sink had pulled away from the wall by approximately one inch. There was also one section of baseboard approximately three inches long observed under the left side of the Packaged Terminal Air Conditioner (PTAC) unit which had pulled away from the wall by approximately one inch. Housekeeper #1 was observed on the hall on 1/12/2026 at 1:30 PM but was not observed cleaning Resident #27's room. Subsequent observations in Resident #27's room on 1/13/2026 at 8:45 AM, 1/14/2026 at 2:00 PM, 1/15/2026 at 4:45 PM and 1/16/2026 at 2:30 PM revealed the debris remained untouched under Resident #27's bed and the baseboards remained in disrepair. A telephone interview on 1/20/2026 at 10:31 AM with Housekeeper #1 revealed she had worked at the facility for 3 1/2 years. Housekeeper #1 stated she swept/mopped the residents' rooms/bathrooms twice a day and as needed. Housekeeper #1 disclosed that Resident #27's room was part of her routine assignment on the hall and she cleaned the room each morning and then rechecked the room before the end of her shift for any additional housekeeping needs. Housekeeper #1 indicated she had never noticed the debris under the head of the bed in Resident #27's room and Resident #27 had never told her about it. Housekeeper #1 stated the beds were heavy and she was unable to move them by herself. Housekeeper #1 reported she had been notified on 1/16/2026 in the afternoon that there was debris under the head of Resident #27's bed and she had cleaned up the debris immediately. A review of the Work Order Log from December 15, 2025 to January 15, 2026 revealed no work orders which reported the bed in Resident #27's room hitting the wall when the head of the bed position was changed or the sections of baseboard pulling away from the wall. During a facility tour with the Administrator, Maintenance Director and the Dietary Services/Housekeeping Director on 1/16/2026 at 2:30 PM, Resident #27's room was visited and the debris was observed on the floor under the head of the bed. The Maintenance Director also observed the baseboard in Resident #27's bathroom and under the PTAC unit pulling away from the wall. An interview with the Maintenance Director on 1/16/2026 at 2:33 PM revealed the floors were [AGE] years old and that the facility was aware new flooring/baseboards were needed. The Maintenance Director stated the facility had started to replace flooring in the facility but was unsure when Resident #27's room was scheduled to have flooring/baseboards replaced. The Maintenance Director explained that the debris at the head of Resident #27's bed was plaster from the patched areas being knocked off when the bed hit the wall when the head position of the bed was changed. The Maintenance Director stated staff could place work orders in the computer through The Equipment Lifecycle System (TELS) but many times just told him in person about issues noted. During an interview with the Dietary Services/Housekeeping Director on 1/16/2026 at 2:37 PM, she stated the residents' rooms/bathrooms should be swept/mopped at least daily. The debris in Resident #27's room should have been noticed and cleaned up by housekeeping. A virtual interview was conducted with the Director of Nursing (DON) on 1/20/2026 at 11:00 AM and she expressed that the residents' rooms and bathrooms should be cleaned at least once a day. The DON stated the debris under Resident #27's bed should have been noticed and immediately cleaned up by housekeeping. An interview with the Administrator on 1/16/2026 at 3:30 PM revealed the residents' rooms and bathrooms should be kept clean and in good repair which included the flooring and baseboards. The Administrator stated the debris in Resident #27's room should have been observed and cleaned up immediately. 2. An observation conducted in Resident #109's room on 1/12/26 at 12:05 PM revealed a window screen with a large, vertical tear approximately 12 inches long on the right side of the left window panel. The window was not latched. An additional observation of Resident #109's room was conducted on 1/14/26 at 10:58 AM. The window screen had a large, vertical tear approximately 12 inches long on the right side of the left window panel. The window was closed and latched. A third observation was conducted in Resident #109's room during a facility tour on 1/16/26 at 2:05 PM with the Dietary Manager, Maintenance Director, Regional Nursing Consultant, and Administrator in attendance. The window screen had a large, vertical tear approximately 12 inches long on the right side of the left window panel. The window was closed and latched. The Maintenance Director stated he did weekly random room checks to keep up with any maintenance concerns and expected all staff to make a maintenance request for any repairs. The Maintenance Director had not checked this room and was not aware of the tear in the screen. He stated he did not recall any maintenance requests to fix the screen. A review of the maintenance work order log was completed and no concerns regarding the window screen in room [ROOM NUMBER] were noted. An interview with the Director of Nursing (DON) on 1/20/26 at 11:06 AM revealed she had the expectation that all nursing staff would make a maintenance request for repairs in resident spaces to include screens in disrepair and any general maintenance concerns. An interview with the Administrator on 1/16/26 at 4:18 PM revealed she expected all staff to alert maintenance staff to any issue and to fill out work orders for the concern.

Based on record review, and staff, resident and family member interviews, the facility failed to develop and implement effective discharge planning that ensured a resident would have the necessary durable medical equipment when she was discharged home to include a hospital bed, gel bed overlay with mattress, half side rails, a trapeze bar, and oxygen supplies for 1 of 4 residents reviewed for discharge (Resident #1). Resident #1 stated she was not provided with equipment for oxygen therapy and would get short of breath, and it would wake her up. Resident #1 reported she would cough, and it made her throw up at night. In addition, Resident #1 indicated that the hospital bed was not delivered, and she was sleeping in a recliner due to the shortness of breath which resulted in edema in her ankles and worsening of gastroesophageal reflux disease (GERD) symptoms. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses including GERD, sleep apnea, and rhabdomyolysis (a serious condition caused by a direct or indirect muscle injury and could lead to serious complications such as kidney failure). A review of physician order dated 1/22/25 revealed Resident #1 received oxygen therapy at two liters per minute via nasal cannula, every day and night shift. An admission Minimum Data Set (MDS) on 1/29/25 revealed Resident #1 was cognitively intact. Resident #1 was not coded for oxygen use. The MDS was coded for Resident #1 to discharge back to the community. A review of Resident #1's Treatment Administration Record (TAR) revealed she received oxygen at two liters per minute via nasal cannula, every day and night shift from 1/22/25 to 2/5/25. A review of a physician order/note dated 2/5/25 and signed by the previous Medical Director revealed Resident #1 needed the use of durable medical equipment (DME) in her home. The equipment included a semi-electric hospital bed, a gel overlay for the mattress and a trapeze bar. The order described Resident #1 as having severe back pain and needed frequent changes in body position to alleviate the pain caused by arthritis. Resident #1 was described in the note as having a compromised circulatory status, therefore requiring pressure reducing support surface to treat and prevent skin breakdown. Resident #1 also needed a trapeze bar to get in and out of bed. The order did not include oxygen supplies. A review of an itemized physician's order form dated 2/5/25 and signed by the previous Medical Director included a semi-electric hospital bed, wheelchair, gel overlay, a mattress, half bed rails, and a trapeze bar. The order did not include oxygen supplies. A review of a nursing progress note written by Nurse #1 dated 2/6/25 revealed Resident #1 was given patient discharge instructions. Nurse #1 reviewed medications with Resident #1 who voiced understanding. She was discharged with medications and prescriptions. A review of the discharge summary dated 2/6/25 and signed by Nurse #1 revealed Resident #1 was discharged home with home health services and needs for a hospital bed and walker. The discharge summary did not include the need for any oxygen supplies and did not indicate Resident #1's use of oxygen at the facility. The discharge summary did not have contact information for the durable medical equipment provider and listed a bed and walker as the equipment needed by Resident #1. A telephone interview with Nurse #1 on 3/19/25 at 2:39 PM revealed she discharged Resident #1 home on 2/6/25. She stated the SW would order any durable medical equipment for any residents discharging home. She stated she printed a discharge summary for Resident #1 and went through her medications with her. Nurse #1 stated if oxygen was listed on the summary, she would have discussed it with Resident #1. She stated nursing would typically fill out the device section of the assessment. Nurse #1 explained if oxygen was not checked off on the discharge summary list for Resident #1, it would not have been ordered for the discharge. A telephone interview with a DME Company Representative on 3/19/25 at 12:47 PM revealed Resident #1 had not received her equipment in her home after her discharge. She stated Resident #1's family had called the equipment company many times inquiring why the bed and other equipment had not been delivered. A second telephone interview with a DME Company Representative on 3/20/25 at 9:08 AM revealed she spoke to Resident #1's family member for the first time on 3/10/25 but the family member had placed many calls to the call center requesting information about Resident #1's equipment. She stated the facility originally did not fax over the needed information to complete the DME order to include the medical need for the supplies requested. The DME Company Representative explained the DME requested was for the bed and the bed accessories. She did not know Resident #1 needed oxygen therapy, but added they would be able to get her the supplies she needed if the facility would send over an order and medical need for the oxygen. The DME Company Representative stated no DME, or supplies had been delivered to Resident #1 yet as they were waiting on the documents requested from the facility. A telephone interview was conducted with Resident #1's family member on 3/19/25 at 1:50 PM. She stated Resident #1 had not yet received the hospital bed or any equipment that came with the bed. The Family Member indicated Resident #1 did receive a walker and a bedside commode when she was discharged from the facility. She understood from the DME company that the correct information needed for the DME including oxygen supplies was not given by the facility during the discharge process. The Family Member stated she called the call center at the durable medical equipment company many times. She stated the DME Company Representative was helping her to get the documentation needed for the equipment from the facility. A second telephone interview with Resident #1's family member on 3/19/25 at 2:12 PM. She stated Resident #1 had continuous oxygen in the hospital prior to her admission at the facility. She revealed the facility did not provide Resident #1 a portable oxygen tank after discharge, and she wore oxygen every day during her stay at the facility. A telephone interview with Resident #1 on 3/20/25 at 10:03 AM revealed she did not have her hospital bed, the gel overlay, the trapeze bar, or oxygen as of 3/20/25. She stated when she was in the facility, she had oxygen because when she was sleeping, her oxygen level would go down. Resident #1 stated she was not sent home with any oxygen equipment from the facility, and when she slept, she would get short of breath, and it would wake her up. Resident #1 reported she would cough, and it made her throw up at night. Resident #1 explained she had been sleeping in a recliner because of her shortness of breath and her GERD. She stated that because she has been in her recliner to sleep, her ankles were swollen, and they were not before when she was sleeping in an adjustable bed at the facility. Resident #1 stated her GERD has worsened because of not being able to sleep in an adjustable bed. Resident #1 indicated she had not been hospitalized since her discharge from the facility. An interview with the Social Worker (SW) on 3/19/25 at 2:19 PM revealed Resident #1 discharged home on 2/6/25 with orders for home health services and equipment that included a hospital bed and accessories to include a trapeze bar, mattress and overlay and side rails. She stated Resident #1's discharge plan included a bed with other accessories and a walker. The SW indicated she created the DME order on 2/5/25 and sent over the paperwork in the ordering portal to start the ordering process with the DME company. The SW recalled on 3/10/25, Resident #1's family member called and stated they had not received the bed. The SW stated the DME company needed documentation that explained the necessity of the bed to fulfill the order. She stated she sent the information to the durable medical equipment company on 3/17/25 and she received a message from the contact at the durable medical equipment company on 3/19/25 that the documentation was approved. The SW explained she was not aware Resident #1 had an order for oxygen in the facility or needed oxygen therapy after discharge. The SW revealed she did not review residents' orders before discharge and nursing would have been responsible for alerting her to Resident #1's need for oxygen. She stated discharges were discussed during the morning meeting at the facility. The SW further stated she did not follow up with Resident #1 after her discharge from the facility. She explained she made the official request for DME supplies based on the reports given to her from other departments during the morning meeting. An interview with the Unit Manager on 3/20/25 at 9:51 AM revealed he could not recall specifics about Resident #1's care but stated typically discharges were discussed in the morning meeting. He stated supplies needed for a resident's discharge would be discussed and the SW would order anything needed for the discharge. The Unit Manager indicated nursing would typically inform the SW if oxygen was needed. A telephone interview with the previous Medical Director on 3/20/25 at 11:55 AM revealed he had written the discharge orders for Resident #1 but explained he did not specially recall Resident #1 as he was temporally filling in as Medical Director for the facility. He stated if a resident used oxygen in a facility and still had the need for oxygen, then oxygen therapy should have been part of the discharge plan. The previous Medical Director explained that if he signed a physician's order for DME for a resident before discharge, then the equipment was necessary. An interview with the Administrator on 3/20/25 at 11:04 AM occurred. She stated Resident #1 did not receive her bed and DME due to the need for additional information to document Resident #1's need for the equipment to fulfill the order. The Administrator indicated the facility reviewed discharges during the clinical part of their morning meeting but did not recall Resident #1's discharge discussion. She stated during this meeting all DME was reviewed for each resident discharging. The Administrator stated Resident #1's needs for oxygen should have been reviewed before she was discharged from the facility. She explained the SW should have followed up with Resident #1 before she left the faciity on her needs. The Administrator explained the facility had implemented a plan in response to the discharge concerns with Resident #1 to improve coordination with DME and home health services for residents discharging home from the facility. The facility presented a plan of correction that was not accepted by the State Survey Agency. The facility failed to provide evidence of the audits being completed at the time the plan was completed. The interview with the SW on 3/19/25 revealed that she was not calling all discharges as stated she would in the plan but only called the residents who left against medical advice or had a lot of concerns and indicated that she was just recently been given this directive from her Regional Consultant. Furthermore, the ongoing monitoring failed to include the names of the residents that were audited upon discharge and what equipment was needed and verified to have been delivered to the discharged resident.

Based on record reviews, and Psychiatric Mental Health Nurse Practitioner, Resident Representative (RR) and staff interviews, the facility failed to protect a resident's right to be free from resident-to-resident abuse. In January 2025, Resident # 2 was observed touching Resident # 1's breasts. On Saturday, 2/1/25 Resident #1 was positioned in a reclining wheelchair in the dayroom when Resident #2 was observed sitting next to Resident #1 with his right arm on her reclining wheelchair in the day room. Nurse Aide (NA) #1 intervened asking Resident #2 to give Resident #1 space and observed the blanket used to cover Resident #1 had been removed, Resident #1's pants and brief were pulled down, the brief was torn on the right-side exposing Resident #1's private area. Resident #1 was severely cognitively impaired and her ability to speak was rare according to the most recent Minimum Data Set (MDS). Resident #1's Representative stated Resident #1 would feel completely violated. A reasonable person would expect to be free from abuse in their own home and could experience trauma, fear and anxiety. This affected 1 of 3 residents reviewed for abuse (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease and degeneration of nervous system. Resident #1 was under Hospice care. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #1 was severely cognitively impaired and her ability to speak was coded as rare or never understood and her ability to understand speech was coded as rare or never understood. Resident #1 was dependent on staff for all Activities of Daily Living (ADL). A review of Resident #1's care plan revised on 2/26/24 indicated she was at risk for complications related to communication impairment due to impaired cognition and was rarely or never understood. Interventions included anticipating needs and observing for nonverbal cues which may indicate care needs. Resident #2 was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left side, cognitive communication deficit, and hypertension. The admission MDS dated [DATE] indicated Resident #2 was cognitively intact and used a wheelchair for mobility. A review of Resident #2's care plan revised 12/2/24 indicated he required assistance with Activities of Daily Living (ADL) and the interventions included two-person assistance for bed mobility, mechanical lift for all transfers. Resident #2's care plan did not indicate any problem areas pertaining to behaviors. An interview with Housekeeper #1 on 2/19/25 at 2:55 PM revealed she saw Resident #2 touching Resident #1's chest area in the day room. She stated that she could not remember the exact date but stated it was the beginning to middle of January 2025. She stated she immediately let the nursing staff, which included NA #3, at the nurse's desk know and the residents were separated. She stated she never saw Resident #2 touching Resident #1 after this incident but stated Resident #2 stared at Resident #1 quite often. Housekeeper #1 stated she watched out for Resident #1 after this incident. A second telephone interview with Housekeeper #1 occurred on 2/20/25 at 3:52 PM. She stated when she witnessed Resident #2 touching Resident #1 in early to mid-January, he touched her on the outside of her shirt with his left hand rubbing across her chest and breasts. She explained Resident #1 was sitting next to a table in the day room and Resident # 2 was sitting next to her. A telephone interview with NA #3 on 2/20/25 at 2:14 PM revealed she was standing at the nurse's desk when Housekeeper #1 alerted them to Resident #2 touching Resident #1's breasts. NA #3 responded and went down to the dayroom. She could not recall the date but stated it occurred the beginning or middle of January 2025. NA #3 did not indicate if she reported this incident or not. She stated she kept an eye on Resident #2 and would often tell him to leave Resident #1 alone when they were in common areas. A review of a Psychiatric Mental Health Nurse Practitioner's note on 1/16/25 revealed Resident #2 exhibited increased sexual behaviors towards female peers and he had touched a female peer's breasts. A telephone interview with the Psychiatric Mental Health Nurse Practitioner on 2/18/25 at 3:36 PM revealed she visited Resident #2 on 1/16/25 for sexual misconduct as he had touched a female resident's breasts and exposed himself to female staff at the facility. The Psychiatric Mental Health Nurse Practitioner suggested supervision and an increase in medication to address Resident #2's depression. A telephone interview with the Psychiatric Nurse Practitioner occurred on 2/18/25 at 4:54 PM. She stated on her visit to Resident #2 on 1/16/25, a nurse verbally told her about Resident #2's sexually inappropriate behaviors directed at another female resident. She could not recall who told her and she was not aware of the name of the female resident. A review of the initial allegation report submitted by the facility to the Division of Health Service Regulation (DHSR) revealed an allegation type of resident abuse on 2/1/25. The allegation details noted Nurse Aide (NA) #1 observed Resident #2 sitting next to Resident #1 in the day room with his hand in her lap. NA #1 removed Resident #2 immediately. Resident #2 was placed on one-to-one supervision. Resident #1 was sent to the hospital for further evaluation. A written statement from NA #1 written on 2/1/25 from the facility's investigation submitted to DHSR on 2/5/25 was reviewed. The statement read, in part, that NA #1 walked past the day room on 2/1/25 and saw Resident #2 sitting close to Resident #1 with his hand resting on the right side of her reclining wheelchair. NA #1 stated she asked Resident #2 to back up and when she walked closer to Resident #1, she noted her pants were pulled down some and her incontinence brief tabs on the right side were undone and she was exposed. A telephone interview with NA #1 on 2/18/25 at 2:21 PM revealed she was walking down the hallway when she noticed Resident #2 sitting next to Resident #1 with his right arm on the left side of her reclining wheelchair. She stopped and asked Resident #2 to back up and give Resident #1 some space. Resident #2 backed away and she noticed Resident #1's pants were pulled down and her incontinence brief tab closure was undone on the right side. NA #1 noted that Resident #1 was completely asleep and was unable to move any aspects of her clothes or blanket. NA #1 stated she immediately reported the incident to Nurse #1 and Resident #1 was sent to the hospital for evaluation. A written statement from NA #2 written on 2/1/25 from the facility's investigation submitted to DHSR on 2/5/25 was reviewed. The statement read, in part, that NA #2 had assisted Resident #1 to transfer to her reclining wheelchair earlier on 2/1/25 and was asleep in the chair in the day room. She was called into the day room and Resident #2 exited the room stating that he did nothing. NA #2 stated when she walked towards Resident #1, her pants appeared disheveled, and her brief was open on the right side and her private area was exposed. She also noted the sheet Resident #1 was covered with, was pulled away from her lap. NA #2 stated Resident #1's clothing and sheet covering her were not left that way 20 minutes prior when Resident #1 was transferred to her reclining wheelchair. A telephone interview with NA #2 on 2/18/25 at 1:49 PM revealed she fed Resident #1 lunch in the day room and she transferred her to a reclining wheelchair after lunch so she could rest in the day room. NA #2 indicated she covered Resident #1, who was fully dressed, with a blanket. NA #2 stated NA #1 called her to the day room approximately 20 minutes later and found Resident #2 leaving promptly saying he didn't do anything. NA #2 stated Resident #1's incontinence brief was pulled down, torn on the side and her pubic hair was visible. NA #2 stated she did not see Resident #2 touch Resident #1 when she arrived to the day room. A telephone interview with Nurse #1 occurred on 2/20/25 at 12:51 PM. She stated she was at the nurse's station on 2/1/25 when she was alerted by NA #1 of the incident. She noted she did not see Resident #2 do anything, but stated Resident #1's pants were pulled down and incontinence brief was open, and Resident #2 exited the day room. She stated Resident #1 was sent to the hospital immediately for evaluation and Resident #2 went back to his room. She stated Resident #2 was placed with a one-on-one sitter on 2/1/25 after the incident. Nurse #1 stated she was not aware of any previous inappropriate sexual behaviors toward female residents or staff exhibited by Resident #2. A review of the staffing schedules was conducted and revealed Resident #2 was placed under one-to-one supervision from staff from 2/1/25 after the incident until his transfer to the hospital on 2/3/25. A review of a progress note written by the Psychiatric Mental Health Nurse Practitioner, dated 2/3/25 read, in part that Resident #2 was no longer appropriate to live at the facility after recent inappropriate sexual behavior with Resident #1. She further wrote that Resident #2 was a threat to female peers and to facility staff due to recent and past inappropriate behaviors. The Psychiatric Mental Health Nurse Practitioner indicated Resident #2 would be more appropriate in an all-male facility wherein other patient's safety would not be a factor. A telephone interview with the Psychiatric Mental Health Nurse Practitioner occurred on 2/18/25 at 3:36 PM. She stated she wrote a progress note on 2/3/25 that Resident #2 was not appropriate for the facility due to the incident involving Resident #2 exhibiting inappropriate sexual behaviors towards Resident #1 on 2/1/25. She suggested Resident #2 be discharged to the hospital for psychological evaluation. A nursing progress note dated 2/3/25 written by the Director of Nursing (DON) revealed Resident #2 was sent to the hospital for evaluation and management per Psychiatric Mental Health Nurse Practitioner's recommendation on 2/3/25. The DON was not available to interview during the survey. A telephone interview with Resident #1's Representative occurred on 2/20/25 at 2:51 PM. She stated Resident #1 was very modest and would often try to cover herself when care was being provided. Resident #1's Representative stated if Resident #1 was able to speak for herself, she would feel completely violated if she knew about the incident where Resident #2 allegedly touched her. She further indicated Resident #1 was very protective of her private areas. An interview with the Administrator on 2/18/25 at 4:57 PM revealed she was not aware of any inappropriate sexual behaviors directed to female residents by Resident #2 before the incident on 2/1/25. She stated she was not aware of the Psychiatric Mental Health Nurse Practitioner's note dated 1/16/25 until after the incident on 2/1/25 when she was compiling her investigation to submit to the state agency. The Administrator also added that she could not determine who reported Resident #2's inappropriate sexual behaviors to the Psychiatric Mental Health Nurse Practitioner on 1/16/25.

Based on record review, and Hospital Case Manager, Resident Representative, and staff interviews, the facility failed to allow a resident to return to the facility after being sent to the hospital for evaluation using the resident's inappropriate sexual behaviors prior to discharge as a basis for their decision for 1 of 3 residents reviewed for transfer and discharge (Resident #2). The findings included: Resident #2 was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left side and hypertension. The admission Minimum Data Set, dated dated dated [DATE] indicated Resident #2 was cognitively intact. Resident #2 was discharged to the hospital on 2/3/25 and did not return to the facility. A review of Resident #2 electronic medical record (EMR) revealed he had a Resident Representative listed as a contact. A review of a progress note written by the Psychiatric Mental Health Nurse Practitioner, dated 2/3/25 read, in part that Resident #2 was no longer appropriate to live at the facility after recent inappropriate sexual behavior with Resident #1. She further wrote that Resident #2 was a threat to female peers and to facility staff due to recent and past inappropriate behaviors. The Psychiatric Mental Health Nurse Practitioner indicated Resident #2 would be more appropriate in an all-male facility wherein other patient's safety would not be a factor. A telephone interview with the Psychiatric Mental Health Nurse Practitioner occurred on 2/18/25 at 3:36 PM. She stated she wrote a progress note on 2/3/25 that Resident #2 was not appropriate for the facility due to the incident involving Resident #2 exhibiting inappropriate sexual behaviors towards Resident #1 on 2/1/25. She suggested Resident #2 be discharged to the hospital for psychological evaluation. A nursing progress note dated 2/3/25 written by the Director of Nursing revealed Resident #2 was sent to the hospital for evaluation and management per Psychiatric Mental Health Nurse Practitioner's recommendation on 2/3/25. A telephone interview occurred with Resident #2's Resident Representative on 2/20/25 at 11:27 AM. He stated he was told by the facility he would have a 30-day notice for his discharge, but stated Resident #2 was still in the hospital and the facility would not let him return. He stated many other facilities have come to the hospital to evaluate Resident #2, but there have been no offers for placement. A telephone interview with the Hospital Case Manager on 2/20/25 at 2:30 PM revealed hospital case management called the facility on 2/3/25 immediately after Resident #2 was sent to the hospital emergency room . She stated the facility Social Worker (SW) dropped off a notice of transfer/discharge to Resident #2. The facility was called about the readmission of Resident #2 on 2/3/25 at 6:38 PM and the facility refused to readmit Resident #2. An interview with the facility SW on 2/20/25 at 5:33 PM revealed she delivered the notice of transfer/discharge to Resident #2 on 2/3/25 at the hospital. A telephone interview with the facility Admission Liaison on 2/20/25 at 4:24 PM revealed the hospital case manager reached out for the facility to readmit Resident #2. She stated the facility would not readmit him per the Psychiatric Nurse Practitioner stating he was not appropriate for the facility due to his behaviors, The Director of Nursing was not available during the survey to interview. A telephone interview with the Administrator on 2/20/25 at 3:58 PM revealed she did not speak to the hospital case managers regarding Resident #2. She stated the Admission Liaison spoke to the hospital and they pushed to have Resident #2 readmitted . She stated Resident #2 was sent out due to his inappropriate sexual behaviors and the Psychiatric Mental Health Nurse Practitioners stated he was not appropriate for their facility. The Administrator understood from the case managers that they would look for placement in another facility for him. The Administrator was notified by the survey team by telephone on 2/20/25 at 5:41 PM there was an expectation Resident #2 would be readmitted to the facility with appropriate supervision. The Administrator notified the survey team by email on 2/20/25 at 5:57 PM that the facility would readmit Resident #2 to the facility when a male bed was available.

Based on record review, and staff, Adult Care Home Admission Director, and Ombudsman interviews, the facility failed to provide a complete written notice of transfer/discharge including a statement of the resident's appeal rights for 1 of 3 residents (Resident #2) reviewed for discharge. The findings included: Resident #2 was admitted to the facility on [DATE]. The admission Minimum Data Set, dated dated dated [DATE] indicated Resident #2 was cognitively intact. A nursing progress note dated 2/3/25 revealed Resident #2 was discharged to the hospital on 2/3/25. Resident #2 did not return to the facility. A review of Resident #2's medical record revealed a notice of transfer/discharge form was completed by the Administrator on 2/3/25 with the discharge location of a local adult care home, not the hospital. The form was issued without the second page entitled Nursing Home Hearing Request form which included instructions for Resident #2 to request an administrative hearing to appeal the discharge. A review of an email from the Ombudsman to the Social Worker (SW) dated 2/5/25 revealed the second page of the notice of transfer/discharge entitled Nursing Home Hearing Request Form was attached and sent to the SW. The Ombudsman indicated both forms would need to be issued together to Resident #2 and she stated the facility would need to reissue the notice of Transfer/Discharge. A telephone interview was conducted with the Ombudsman on 2/21/25 at 2:10 PM. She stated she received an email from the Social Worker on 2/4/25 with the notice of transfer/discharge for Resident #2 and the second page was missing. The Ombudsman explained to SW that the second page was the Hearing Request form and contained the instructions to request an administrative hearing to appeal the discharge. She informed the SW that both pages were required and without the second page Resident #2 would not be able to appeal the notice. The Ombudsman stated she asked the SW to reissue the notice of transfer/discharge to Resident #2. An interview with the SW occurred on 2/20/25 at 5:33 PM. She stated the notice of transfer/discharge was written before Resident #2 was sent to the hospital. The SW explained she delivered the notice to Resident #2 and the staff at the hospital on 2/3/25. She stated the notice of transfer/discharge did not include the second page. The SW was not aware she needed to include the second page until she received the email from the Ombudsman. She stated the Ombudsman was supposed to send the second page to her. The SW explained the notice was not reissued to Resident #2. The SW stated someone at the facility started a conversation with the adult care home listed on the notice as the discharge location, but she did not know who it was. A telephone interview with the Admission Director at the adult care home listed on the notice of transfer/discharge on 2/20/25 at 4:54 PM revealed Resident #2's name was not in their system as a possible resident. They had not received any referrals with his name. A telephone interview was conducted with the Administrator on 2/20/25 at 3:58 PM. The Administrator stated Resident #2 was sent to the hospital due his inappropriate behaviors and putting female residents at risk. She stated the Psychiatric Mental Health Nurse Practitioner stated Resident #2 was not appropriate for the facility. A second telephone interview with the Administrator on 2/20/25 at 5:42 PM revealed she was aware of the notice of transfer/discharge given to Resident #2 by the SW who typically handled these notices. She stated the adult care home listed on the notice of transfer/discharge given to Resident #2 did not currently have a bed open for him. She was not aware Resident #2 did not receive the second page of the notice of transfer/discharge.

Based on record review, and interviews with staff, Medical Director and Pharmacist, the facility failed to prevent a significant medication error when Resident #1 received a dose of Ativan (a benzodiazepine, used as a sedative medication) as a one-time dose. Resident #1 had an allergy to Ativan documented on the Allergy List in the electronic medical record (EMR) on [DATE]. The medication order was entered into the electronic health record by Nurse #3. She stated the electronic medical record flagged the order due to the allergy, but she bypassed the alert and entered the order in the EMR, which was then pulled from the automated system for medication management. Nurse #2, a nurse who was orienting under the supervision of the Unit Manager, administered the medication on [DATE] at 7:44 AM. On [DATE] at 8:13 AM Resident #1 became unresponsive with seriously abnormal vital signs. Resident #1 was pronounced deceased by Emergency Medical Services (EMS) staff at 8:30 AM. This deficient practice occurred for 1 of 3 sampled residents reviewed for medication errors. The findings included: An undated After-Hours Standing Physician Orders revealed for aggression or agitated behavior the nurse may administer Ativan 0.5 milligram (mg) by mouth. The nurse could repeat the action in 20 minutes if the resident did not respond to the medication. The order read to notify the primary care physician in the AM for further orders. Resident #1 was readmitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD) and respiratory failure. An allergy list in the electronic medical record updated on [DATE] included the medication Ativan. Resident #1's allergy reaction was documented as unspecified. A review of Resident #1's quarterly Minimum Data Set assessment dated [DATE] revealed she was cognitively intact. A review of the facility's medication error report dated [DATE] at 11:20 AM by the Director of Nursing (DON) revealed Resident #1 was ordered and administered Ativan 0.5 mg for a one-time dose with a documented allergy to the medication by Nurse #2. The result of the incident was documented as Resident #1 experienced an unresponsive event. The medication error was reported to the Medical Director. A medication administration note in the electronic medical record dated [DATE] at 7:43 AM revealed Nurse #3 entered an order for Ativan oral tablet 0.5 mg. Give 0.5 mg by mouth one time only related to Chronic Obstructive Pulmonary Disease with Acute Exacerbation until [DATE] at 9:00 AM. The medication order triggered an alert for a system identified drug allergy. Resident #1's Medication Administration Record (MAR) for [DATE] revealed an order for Ativan oral tablet 0.5 mg by mouth on time only related to COPD with acute exacerbation. The medication was administered on [DATE] at 7:44 AM and signed off by Nurse #1. On [DATE] at 3:56 PM an interview was conducted with Nurse #1, who was no longer employed by the facility. During the interview she stated she wanted to use her initial statement to the facility as a response to questions asked. A statement written and signed by Nurse #1 on [DATE] obtained by the facility revealed she was assigned Resident #1 during the 7:00 PM to 7:00 AM shift on [DATE] - [DATE]. The statement revealed Resident #1 kept getting out of the bed and laying on the floor during the shift. Nurse #3 asked her if the resident had any Ativan available and Nurse #1 stated she wasn't sure. Nurse #3 then told her the facility had standing orders for Ativan, and it could be pulled from the automated system for medication management. Nurse #1 was unable to access the automated system for medication management and had to wait until the next shift to be able to obtain the Ativan. When the next shift arrived at 7:00 AM Nurse #1 gave a report to Nurse #2. NA #1 came to the office after Nurse #3's medication pass and stated something was wrong with Resident #1. Nurse #3 asked if she would go to the resident's room for support, so Nurse #1 did. Upon arrival to the resident's room Resident #1 was face up, lying in bed with a slow response to communicate. She asked for vital signs and for someone to call EMS after feeling a weak pulse on the resident. Nurse #1 continued to do a sternal rub on the resident until EMS arrived. After EMS arrived, she was told Resident #1 had expired. Nurse #1 was later told Resident #1 had received by mouth Ativan and that she had an allergy to the medication. Nurse #1 noted in her statement she did not administer the medication but had signed off on the resident's MAR because she was the nurse responsible for the resident and had initiated the process of Resident #1's need for the medication. On [DATE] at 12:53 PM an interview was conducted with Nurse #3. Nurse #3 worked on [DATE] - [DATE]. during the 7:00 PM to 7:00 AM shift with Nurse #1 but was not responsible for Resident #1. Nurse #3 stated Nurse #1 asked her what to do regarding the resident because she was very anxious and kept getting in/ out of bed. Nurse #1 seemed overwhelmed with the situation so Nurse #3 went to the resident's room with her to see what she could do. Nurse #3 stated Resident #1 was screaming out, crawling out of the bed and very anxious. At approximately 3:00 AM on [DATE], Nurse #1 again came to her and stated she did not know what to do with Resident #1. Nurse #3 then told her the facility had standing orders for Ativan, she stated she told her it was okay to give the resident Ativan because the resident was all over the place by screaming, pulling on her oxygen tubing and crawling out of bed. The interview revealed Nurse #3 had access to the automated system for medication management, but Nurse #1 did not. The two nurses waited until the day shift arrived and asked Unit Manager #1 to be a second witness to pull the Ativan out of the automated system for medication management. Nurse #3 and Unit Manager #1 then pulled Ativan 0.5 mg for Resident #1 and Unit Manager #1 took the medication and gave it to Nurse #2 to administer. The interview revealed there were no alerts that popped up in the automated system for medication management. However, when Nurse #3 put the Ativan order in the electronic charting system an allergy alert did pop up and she bypassed the alert in the system. At that time Nurse #3 did not know if they had administered the medication or not and left the facility after entering the medication order. She then received a call after leaving the facility from the DON that Resident #1 had an allergy to the medication, and Nurse #3 had put the standing order into the Medication Administration Record (MAR). Nurse #3 stated she knew she should not have bypassed the allergy alerts in the system but was not thinking clearly about the situation and just clicked the button. She stated she felt that Resident #1 had a diagnosis of COPD and was just excited like most residents with the diagnosis and the Ativan would help calm her. Nurse #3 stated she did not review the resident's allergy list. On [DATE] at 10:19 AM an interview was conducted with Unit Manager #1. During the interview she stated she had come in on [DATE] as the manager on call to orient Nurse #2 during the 7:00 AM to 7:00 PM shift. The interview revealed she arrived at the facility around 7:12 AM and was touching base with Nurse #2 when Nurse #3 asked her to be a second witness to remove Ativan 0.5mg from the automated system for medication management for Resident #1 due to agitation. She was told Resident #1 had been very restless, agitated and had been throwing herself out of bed during the night and Nurse #1 did not have access to the automated system for medication management to pull the medication. Unit Manager #1 went with Nurse #3 and removed the medication from the as the second witness. After, she took the medication and gave it to Nurse #2 whom she was orienting and instructed her to administer the medication to Resident #1. On [DATE] at 12:07 PM an interview was conducted with Nurse Aide (NA) #1. During the interview she stated she came on shift around 6:30 AM on [DATE] to find Resident #1 lying on her fall mat on the floor. She went to Nurse #1 who told her not to get the resident off the floor because she had been back and forth from the bed to the floor all night. NA #1 was in the room with the resident when Nurse #2 entered the room and administered the resident's medication around 7:44 AM. NA #1 said Resident #1 acted like she did not want to take the medication, but she had her back to the resident untangling oxygen tubing. Nurse #2 then left the room as NA #1 continued to untangle the resident's oxygen tubing cord. NA #1 then heard the resident call out her name. When she turned around Resident #1 was lying flat on her back with her eyes fixed up at the ceiling and mouth open. Resident #1 would not respond to her, so she yelled out for Nurse #2 who was in the hallway outside of the resident's room. NA #1 stayed with the resident until Nurse #1 and Nurse #2 entered the room. Nurse #1 was doing a sternal rub on the resident to try and get her to respond, however she did not. EMS was called and took over the resident's care once they arrived. On [DATE] at 12:30 PM an interview was conducted with Nurse #2. During the interview she stated she worked the 7:00 AM to 7:00 PM shift on [DATE]. The interview revealed when she came in at 7:00 AM Nurse #1 was giving her report and stated Resident #1 had been anxious during the night and they had tried to give the resident Ativan but did not have access to the automated system for medication management. Nurse #2 was getting a report from Nurse #1 when Unit Manager #1 arrived at the nurses station. Nurse #3 and Unit Manager #1 then went to pull the Ativan for Resident #1 while Nurse #2 finished getting report and began to start her medication pass. Unit Manager #1 then brought her a cup with a 0.5mg Ativan in it for Resident #1 and stated to her to administer the medication. Nurse #2 stated she did not ask any questions or look at the resident's allergies prior to administering the Ativan 0.5 mg along with the resident of Resident #1's morning medication around 7:44 AM. When she went into the resident's room, she was sitting up on the floor on her fall mat. Nurse #2 and NA #1 assisted the resident to get up to the side of the bed to take her medication. Nurse #2 administered the medication and stated the resident drank water provided and Nurse #2 left the room. She was then alerted by NA #1 approximately five to ten minutes later that something was wrong with Resident #1. Nurse #2 and Nurse #1 went into the resident's room to find her lying on the bed with her eyes open and fixed, mouth open and a faint pulse. EMS were called and vital signs were obtained. Nurse #2 stated Resident #1 was pronounced deceased by EMS at 8:30 AM. A nursing note written by Nurse #1 dated [DATE] at 8:10 AM as a late entry revealed she was made aware by Nurse #2 that Resident #1 was in possible distress after being discovered by NA #1 after the morning medication pass. Upon entering the room, the resident was slow to respond. Nurse #1 requested vital signs to be obtained and to call EMS. Resident #1's blood pressure was ,d+[DATE] (normal blood pressure reading ,d+[DATE]), pulse 111 (normal pulse range ,d+[DATE]), respiratory rate 4 (normal respiratory rate ,d+[DATE]) and oxygen saturation level 54% (normal oxygen saturation level greater than 92%), she was noted to be receiving an undocumented amount of supplemental oxygen via nasal cannula. Nurse #1 continued to call the resident's name without a response. Resident #1's oxygen saturation was checked for a second time with a reading of 30%. EMS then arrived on scene and were able to take over the resident's care. EMS records dated [DATE] revealed they were notified at 8:13 AM, dispatched to the facility at 8:18 AM, arrived on scene at 8:29 AM and to the resident at 8:30 AM with a chief complaint of cardiac/ respiratory arrest. Upon EMS arrival Resident #1 was found lying in bed. The resident was apneic (without breathing) and pulseless. Resident #1 had no heart tones with a valid do not resuscitate order (DNR). She was pronounced deceased at 8:30 AM. Allergies listed on the EMS report for Resident #1 included Ativan. On [DATE] at 2:24 PM an interview was conducted with the former Director of Nursing (DON). The DON stated Unit Manager #1 called her on [DATE] to notify her Resident #1 had expired. After looking through documentation she saw Resident #1 had a documented allergy to the medication Ativan she was administered at 7:44 AM. The DON stated it was around 11:00 AM when she was notified, and she immediately suspended the nurses involved. She notified the Medical Director at 1:00 PM. The interview revealed the facility had standing orders to use Ativan if a resident was having agitation which was to administer 0.5mg of Ativan as a one-time dose. The nurses were new to the facility and the nurse who administered the medication (Nurse #2) was still in orientation and did not ask any questions prior to giving it to the resident because she was told to do so by Unit Manager #1 who was her preceptor. The DON stated all nurses involved should have followed the facility protocol for administration of medication which included review of the resident's allergies. She stated Nurse #3 should have never bypassed the allergy alerts in the EMR system. On [DATE] at 11:28 AM an interview was conducted with the Administrator and Regional Nurse Consultant. The interview revealed on [DATE] around 7:30 AM Nurse #2 administered Ativan 0.5 mg to Resident #1 due to behaviors of restlessness and agitation. At 7:30 AM Nurse #3 and Unit Manager #1 pulled Ativan 0.5 mg out of the automated system for medication management based on standing orders the facility had. The facility had a standing order to give Ativan 0.5 mg as needed for agitation. Nurse #2 administered Ativan to Resident #1 at 7:44 AM and Resident #1 was then found unresponsive with a low oxygen saturation level. EMS was called to the facility, and the resident was pronounced as deceased . At 11:30 AM the Former Director of Nursing (DON) was reviewing the documentation and noted the resident had a allergy to the medication and notified the Regional Nurse Consultant who then called the Administrator. The interview revealed they immediately suspended the nurses involved and completed an investigation into the incident. Nurse #1 was responsible for the resident during the 7:00 PM to 7:00 AM shift and had needed guidance from Nurse #3 who told her about the standing order for Ativan 0.5mg however they did not have access to the automated system for medication management to pull the medication. They waited until the next shift arrived at 7:00 AM on [DATE] and had Unit Manager #1 be the second witness to pull the medication with Nurse #3. Nurse #2 was working the day shift on [DATE] and was asked to administer the medication to Resident #1 in which she did and did not ask any questions. None of the 4 nurses involved in the incident verified Resident #1 had no allergies to the medication. Nurse #3 bypassed the alerts in the electronic medical record when entering the medication order into the resident's MAR. The Administrator stated the nurses were responsible for verifying that the resident did not have an allergy to the medication and they did not. On [DATE] at 1:38 PM an interview was conducted with the Medical Director (MD). The MD stated the DON notified him of an incident that happened on [DATE] when a nurse administered Ativan to a resident with a documented allergy to the medication. He stated it happened because the facility had standing orders for the medication for agitation as needed. The nurse involved did not check the resident's allergies and just gave the medication. The interview revealed he was contacted around 1:00 PM on [DATE] and the medication error occurred earlier in the morning. The MD stated he knew the resident had expired but it did not sound like she had an anaphylactic reaction to the medication, however, would not know unless an autopsy was performed, and to his knowledge it had not been done. Resident #1 was not noted to have any rash or hives by the nursing staff. The MD stated there was no justification for the staff members to administer Ativan to the resident with a documented allergy. On [DATE] at 2:18 PM an interview was conducted with the Pharmacist. During the interview he stated a true medication allergy would result in anaphylaxis (severe, life-threatening allergic reaction that can occur within minutes of exposure to an allergen) and a rash. After reviewing Resident #1's medication orders he stated there were no active physician orders for Ativan 0.5mg from the pharmacy for the resident but he did see an allergy listed for Ativan. The interview revealed if the facility initiated a standing order for the medication, it would not have come from the pharmacy, but they would have pulled it from the automated system for medication management located at the facility. The staff would not have been alerted to the resident's allergy in the sytem when pulling the medication. He stated he completed a system report that showed on [DATE] the medication Ativan 0.5mg was removed from the machine under Resident #1's name. The Pharmacist stated the allergy error would have shown when the nurses were putting the order into the electronic medical record and the nurses would have had to click off on the allergy alert to get the error screen to remove and move forward in the system. The interview revealed the nurse would have to bypass the alert. The pharmacist stated no resident should receive medication with a documented allergy. That is why alerts were put in place for staff to recognize prior to administration of the medication. The Administrator was notified of the immediate jeopardy on [DATE] at 12:31 PM. The facility provided the following corrective action plan. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice; The facility failed to prevent a significant medication error when Resident #1 received a dose of Ativan 0.5 milligram (mg) as a one-time dose. Resident #1 had a documented allergy to Ativan on [DATE]. The medication order was entered into the electronic health record by Nurse #3 who said that the Electronic Health record electronic order entry flagged the order due to the allergy but she bypassed the alert and entered the order which was then pulled from the automated system for medication management. Nurse #2 Administered the medication on [DATE] at 7:44 AM. At 8:13 AM Resident #1 was noted in her room unresponsive with a blood pressure of ,d+[DATE], pulse rate of 111, respiratory rate of 4 and oxygen saturation level of 54%. Resident #1 was pronounced deceased by Emergency Medical Services (EMS) staff at 8:30 AM. On the evening of [DATE], Resident #1 showed signs of restlessness and agitation according to the licensed nurses' statements. Licensed nurses made multiple attempts to make Resident #1 comfortable. Licensed nurses repositioned residents many times, changed the room temperature, and offered fluids and snacks. Resident #1 tried to crawl onto the floor and roll around in the bed. Staff provided Resident #1 with one on one supervision periodically throughout the night, due to Resident #1 trying to crawl out of the bed related to agitation and restlessness. The morning of [DATE], at approximately 7:00 am, the day shift nursing staff came on duty. At about 7:15 am, the standing order for Ativan 0.5 mg tablet was pulled from the automated system for medication management. The medication was provided to Nurse #2 to give to Resident #1. Ativan 0.5 mg was given by mouth to Resident #1 at approximately 7:35 am. The medication order was placed into the electronic health record system at 7:43 am by Nurse #3. The electronic medication administration record (EMAR) was signed off as medication given at 7: 44 am by Nurse #3. This information was obtained through interviews with the above-mentioned nurses. On [DATE], after the occurrence, all licensed nurses were given access to the automated system for medication management by the Director of Nursing. At 8:13 am Resident # 1 was in her room and unresponsive with Vital Signs as follows: BP ,d+[DATE], Pulse 111, Resp 4, Oxygen sat level 54. EMS was called for transport. Resident #1 was Do Not Resuscitate. EMS arrived on scene and resident #1 was pronounced deceased at approximately 8:30am. Upon review of the chart by the Director of Nursing on [DATE], it was noted that Resident #1 had an allergy to Ativan. The severity of the allergy was unknown. The Medical Director was notified that Resident #1 expired and Ativan was given with a documented allergy on [DATE]. Nurse #3 and Nurse #1 were terminated [DATE] by the facility Administrator. Address how the facility will identify other residents having the potential to be affected by the same deficient practice; Current residents are at risk of this occurring. An audit of current resident's allergy listing and current medication list was completed by the Director of Nursing and designee to ensure that medications were not ordered or given with the listed allergies. This was completed by the Director of nursing on [DATE]. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur; On [DATE], Director of Nursing was notified at 11:13 am by Nurse #1 that Resident #1 had an allergy to Ativan. The Director of Nursing started an investigation. Education started [DATE] by the Director of Nursing for all licensed nurses and medication aides on alerts in the electronic health record order entry in the MAR. Education was also conducted for pulling medications from the automated system for medication management to ensure there is order in place and allergies are checked prior to withdrawing medication. All flagged notifications will be reviewed when flagged as an alert when entering the order in the electronic health record by the nurse, and the nurse will notify the physician for direction. Any licensed nurse not receiving this education will not be able to work until receiving the education. New licensed nurses will receive education during the orientation process. Director of Nursing ensured all licensed nurses and medication aides were educated prior to working their next scheduled shift as of [DATE]. Medication observations on current licensed nurses and medication aides will be completed by the Director of Nursing or designee to ensure residents are not receiving medication with listed allergies on their EMAR by [DATE]. Allergies are listed on the EMAR and show up when the EMAR is pulled up or displayed in the electronic health record. Medication pass observations will be completed by the Director of Nursing or Designee on 5 licensed nurses weekly x 12 weeks to ensure residents do not receive medications with listed allergies on the EMAR. Audits begin as of [DATE]. Allergies are listed on the EMAR and show up when the EMAR is pulled up or displayed in the electronic health record. Education was provided to all licensed nurses that before activating a standing order, allergies must be reviewed to ensure the resident does not have a listed allergy for the medication by the Director of Nursing on [DATE]. All new orders are reviewed during the morning clinical meeting by the nursing clinical team to ensure no new medications are ordered that residents have an allergy too. This will be completed in 5x weeks x 12 weeks. As of [DATE], Regional Clinical Nurse or designee will review medication allergy alerts in the electronic health record by reviewing the progress notes for allergy alerts weekly to ensure no allergy alerts were bypassed. These audits will be completed weekly x 12 weeks. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; As of [DATE] the results of the monitoring will be reviewed by the Administrator or Director of Nursing in the weekly Risk meeting and during the monthly Quality Assurance Performance Improvement (QAPI) meeting with the Interdisciplinary Team (IDT) as of [DATE]. Changes will be made to the plan as necessary to maintain compliance with resident safety. The IDT team will consist of the Administrator, Director of Nursing, Medical Director, Social Worker, Activities Director and Minimum Data Set (MDS) nurse. This meeting lasted for 1 hour. IJ removal date: [DATE]. On [DATE], the corrective action plan was validated by onsite verification through facility staff interviews and record review. The interviews revealed all nursing staff had received education on alerts in the electronic health record order entry in the MAR. Education was also conducted for pulling medications from the automated system for medication management to ensure there was an order in place and allergies were checked prior to withdrawing medication. All flagged notifications will be reviewed when flagged as an alert when entering the order in the electronic health record by the nurse, and the nurse will notify the physician for direction. Education was provided to all licensed nurses that before activating a standing order, allergies must be reviewed to ensure the resident does not have a listed allergy for the medication. The facility's in-service log, audits and training material were reviewed. The immediate jeopardy removal date of [DATE] and the compliance date of [DATE] for the corrective action plan were validated.

Based on record review, and interviews with staff, Medical Director and Pharmacist, the facility failed to provide effective training and orientation for new hires including preceptorship, skills validations and specific training related to pharmacy services and resident allergies in the electronic medical record (EMR) system alerts. On [DATE] Unit Manager #1, who had not received a complete orientation, was scheduled to precept Nurse #2. Under Unit Manager #1's direction Nurse #2 administered Ativan to Resident #1 who had a documented allergy to Ativan. At 8:13 AM Resident #1 was noted in her room unresponsive and vital signs were blood pressure ,d+[DATE] (normal blood pressure reading ,d+[DATE]), pulse 111(normal pulse range ,d+[DATE]), respiratory rate 4 (normal respiratory rate ,d+[DATE]) and oxygen saturation level 54% (normal oxygen saturation level greater than 92%). Resident #1 was pronounced deceased by Emergency Medical Services (EMS) staff at 8:30 AM. The incomplete orientation and training for Unit Manager #1 put all residents at risk for a serious adverse outcome. For example b. the facility failed to provide complete orientation and training for Nurse #1 before she worked independently. This is cited at D (no actual harm with potential for more than minimal harm that is immediate jeopardy). The deficient practice occurred for 2 of 4 nurses reviewed for competencies. The findings included: This tag is cross-referred to: F760: Based on record review, and interviews with staff, Medical Director and Pharmacist, the facility failed to prevent a significant medication error when Resident #1 received a dose of Ativan (a benzodiazepine, used as a sedative medication) as a one-time dose. Resident #1 had an allergy to Ativan documented on the Allergy List in the electronic medical record (EMR) on [DATE]. The medication order was entered into the electronic health record by Nurse #3. She stated the electronic medical record flagged the order due to the allergy, but she bypassed the alert and entered the order in the EMR, which was then pulled from an automated system for medication management. Nurse #2, a nurse who was orienting under the supervision of the Unit Manager, administered the medication on [DATE] at 7:44 AM. On [DATE] at 8:13 AM Resident #1 became unresponsive with seriously abnormal vital signs. Resident #1 was pronounced deceased by Emergency Medical Services (EMS) staff at 8:30 AM. This deficient practice occurred for 1 of 3 sampled residents reviewed for medication errors. a. Review of Unit Manager #1's employee file revealed she had been hired on [DATE]. An undated, incomplete skills validation record titled, Unit Manager revealed Unit Manager #1 had not received training on facility equipment, supervising Nurse Aides (NA), clinical processes, pharmacy services, EMR documentation, or clinical skills competencies. She also had not completed nursing competencies under the heading, Unit Manager Responsibilities. On [DATE] at 10:19 AM an interview was conducted with Unit Manager #1. Unit Manger #1 stated she was hired on [DATE] and received three days of class orientation with the facility Scheduler. The training included introducing her to the company, discussing the schedule, discussing the facility policy regarding attendance and paid time off. On the second day she met with the Staff Development Coordinator (SDC) going over infection control, contact isolation, enhanced barrier precautions and watching informative videos. Unit Manager #1 was given a skills validation packet and told she would be placed with a preceptor and the preceptor would assist her in completing the nursing competencies. Unit Manager #1 stated nothing else happened after that, she was never placed with a preceptor or received any more training after the in-class training. She stated she asked the Former Director of Nursing about receiving education or training and she would say okay, but never followed back up with Unit Manager #1. When Nurse #1 and Nurse #2 were hired the facility did not have a SDC and their orientation wasn't even half of what she had received. Nurse #3 would state to her that she hadn't received any on-the-floor training. Unit Manager #1 stated on [DATE] she was scheduled to precept Nurse #2. However, she had not even received orientation herself but was told by the Scheduler that Nurse #2 just needed support because she really did not need orientation. Unit Manager#1 stated she had her skills validation sheet however it wasn't completed other than the three days of classroom orientation. Unit Manager #1 stated no one from the facility had gone over verifying residents allergies prior to administration of medication or system alerts related to resident allergies. She stated she knew she should have verified the residents' allergies but thought Nurse #1 had already done so. She was not the primary nurse and was just signing as a witness. The interview revealed no one from the facility had gone over medication rights or change of condition with her until after the incident on [DATE]. On [DATE] at 10:56 AM an interview was conducted with the Scheduler. The interview revealed she assisted during the orientation process and provided each newly hired Nurse Aide or Nurse with a skills check off sheet. She stated the newly hired staff received an orientation lasting three days and then were placed with a preceptor on the units that would sign off the newly hired staff member was competent in the area on the checklist. The interview revealed once the checklist was completed it would be returned to herself or the Staff Development Coordinator who placed it into the employee's file. The Scheduler stated the facility had a period of time with no SDC in the building from [DATE] until [DATE] and the Former Director of Nursing had been responsible for gathering the completed checklist and oversight of newly hired staff. The Scheduler stated she had not seen a completed skills checklist from Nurse #1 and Unit Manager #1. She stated Nurse #2 was still in orientation and Nurse #3 had a completed skills checklist. On [DATE] at 9:24 AM an interview was conducted with the Staff Development Coordinator (SDC). She stated she had left the facility at the end of October and not returned until [DATE]. The SDC stated the Former DON was responsible for all nursing orientation during that time. Orientation in the facility consists of ,d+[DATE] days in person class time for the Nurses and Nurse Aides (NA). After the class orientation nurses were typically placed with a preceptor for at least a week or two after the in-class orientation. The interview revealed Nurses received access to the automated medication dispensing system during the class orientation. The SDC stated she was unaware if Nurse #1, and Unit Manager #1 had completed their skills validation record or received a precepted orientation because she had only been back into the building for one day. The SDC verified that part of the orientation training included reviewing residents allergies prior to administration of medication. An interview conducted on [DATE] at 2:24 PM with the Former Director of Nursing (DON) revealed Unit Manager #1 called her on [DATE] to notify her Resident #1 had expired. After looking through documentation she saw Resident #1 had a documented allergy to the medication Ativan she was administered at 7:44 AM. The DON stated it was around 11:00 AM when she was notified, and she immediately suspended the nurses involved. She notified the Medical Director at 1:00 PM. The interview revealed the facility had standing orders to use Ativan if a resident was having agitation which was to administer 0.5mg of Ativan as a one-time dose. The nurses were new to the facility and the nurse who administered the medication (Nurse #2) was still in orientation and did not ask any questions prior to giving it to the resident because she was told to do so by Unit Manager #1 who was her preceptor. The DON stated all nurses involved should have followed the facility protocol for administration of medication which included review of the resident's allergies. She stated Nurse #3 should have never bypassed the allergy alerts in the EMR system. The Former DON stated verifying resident's allergies and acknowledging system alerts were covered during orientation to the facility by the Staff Development Coordinator (SDC) or nursing preceptor assigned to newly hired employees. On [DATE] at 11:23 AM an interview was conducted with the Administrator. During the interview she stated immediately following the incident on [DATE] through [DATE] the facility put a plan of correction in place regarding orientation. The facility realized the biggest mistake was during the orientation process and their Corporate Clinical Educator put together a structured orientation process of what the facility should be doing for newly hired staff. Education was completed for every staff member that was still in the orientation process. The Administrator stated the staff members had not received the clinical preceptorship to meet her expectations, and each staff member had voiced they felt they were not properly trained by the facility. The Administrator was notified of the immediate jeopardy on [DATE] at 4:15 PM. b. Review of Nurse #1's employee file revealed she had been hired on [DATE]. An undated, incomplete skills validation record titled, Charge Nurse revealed Nurse #1 did not receive training on Pharmacy Services, Electronic Medical Record (EMR) clinical documentation for allergies or clinical skills competencies. An interview conducted on [DATE] at 3:56 PM with Nurse #1 revealed she was hired by the facility on [DATE] and received an in-person class training for 2 days. She stated following the class training she was assigned with a nurse that was as needed (PRN) in the facility and was only with her for a duration of two days before being placed on her own because the staff member wasn't working in the facility. Nurse #1 stated she had come from a hospital setting where she had received 8 weeks' training, and she felt like the long-term care training was not adequate. The interview revealed the training was incomplete because she had not received an actual precepted orientation and no one from the facility had provided training on resident allergies or EMR system alerts. The facility submitted the following corrective action plan: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice; While interviewing 4 nurses involved in the incident occurring on [DATE], It was mentioned that they did not feel as if they received proper orientation from the facility. The facilities failure to have a proper orientation and training program in place, led to an undesirable resident outcome. Address how the facility will identify other residents having the potential to be affected by the same deficient practice; On [DATE] the Administrator identified that current clinical staff hired on or after [DATE] were not properly orientated, onboarded, and thoroughly trained to completely fulfill their role. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur; As of [DATE] it was decided by the Administrator to have identified employees return for a corrected orientation, onboarding, and training process beginning on [DATE]. Licensed Nurses completed Medication Pass Observations with the Director of Nursing starting on [DATE] after medication error on [DATE]. Nurses who did not complete this Medication Pass Observation before their next scheduled shift, were not allowed to work until it was completed. Skills Validations were started on [DATE] for Licensed Nurses by the Director of Nursing or designee after incident on [DATE]. All Licensed Nurses hired on [DATE] or after participated in the training program on [DATE]. Those who did not attend were not allowed to return until they went through the training program. Nurses involved in the incident were suspended on [DATE] pending investigation. Nurse #1, and Nurse #3 were terminated and reported to the Board of Nursing as of [DATE]. Nurse # 2 turned in a resignation letter on [DATE]. The Unit Manger was initially terminated and appealed the termination. She was brought back on ,d+[DATE] and placed back into the training program. She resigned effective immediately on ,d+[DATE]. This training program was held by the Administrator, Director of Nursing and Human Resources Director. Training included prior to accepting responsibility for an assignment without preceptor supervision, the Director of Nursing or designee must validate successful completion of the Skills Validation Record, Medication Pass Observation, and Treatment Observation. Skills Validation Record, Medication Pass Observation, and Treatment Observation was completed by designated preceptor or supervisor. The Director of Clinical Education and Regional Director of Clinical Services provided detailed training on company expectations in the area of appropriate orientation, onboarding, and thorough training on Wednesday, [DATE] to the Administrator, Director of Nursing, and Human Resources Director. Once a Staff Development Coordinator is hired, they will be educated by the administrator on the expected orientation process. The Administrator, Director of Nursing or designee, and Human Resources Director will ensure that company expectations for appropriate orientation, onboarding, and thorough training for newly hired clinicians are implemented beginning [DATE]. The Director of Nursing will complete this training until an SDC is hired. Company expectations are as follows: 5 days of classroom orientation adhering to the company-specific orientation agenda, followed by no less than 2 weeks of on-the-floor 1:1 onboarding and training with a center-designated clinical preceptor. Prior to accepting responsibility for an assignment without preceptor supervision, the Director of Nursing or designee must validate successful completion of the Skills Validation Record, Medication Pass Observation, and Treatment Observation. Skills Validation Record, Medication Pass Observation, and Treatment Observation will be completed by designated preceptor or supervisor. Effective [DATE], the Administrator will be ultimately responsible for ensuring implementation of this corrective action plan. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; As of [DATE], HR will interview new hire employees weekly x 12 weeks to ensure that they are receiving proper orientation and feel comfortable with the training that is being provided. As of [DATE] Medication pass observations will be completed by the Director of Nursing or Designee on 5 licensed nurses weekly x 12 weeks to ensure residents do not receive medications with listed allergies on the EMAR. Allergies are listed on the EMAR and show up when the EMAR is pulled up or displayed in the electronic health record. As of [DATE] The results of the monitoring will be discussed by the Administrator during the monthly QAPI meeting with the Interdisciplinary Team. Changes will be made to the plan as necessary to maintain compliance with resident safety. IJ removal date: [DATE] On [DATE], the corrective action plan was validated by onsite verification through facility staff interviews. The interviews revealed the facility staff were provided with company expectations of the following: 5 days of classroom orientation adhering to the company-specific orientation agenda, followed by no less than 2 weeks of on-the-floor 1:1 onboarding and training with a center-designated clinical preceptor. Prior to accepting responsibility for an assignment without preceptor supervision. The facility's in-service log, monitoring results and training material was reviewed. The IJ removal date of [DATE] and the compliance date of [DATE] for the corrective action plan were validated.

Based on observations, record review, and resident, staff, Nurse Practitioner (NP), and Medical Director (MD) interviews, the facility failed to identify the seriousness of a significant change in condition, complete ongoing thorough assessments and identify the urgent need for medical attention for a resident with a history of chronic obstructive pulmonary disease who reported she could not breathe. On [DATE] during the 3:00 PM to 11:00 PM shift, Resident #1 was restless, agitated, crawling onto the floor and verbally expressed to staff she could not breathe. During the night shift (11:00 PM to 7:00 AM) the difficulty breathing, anxiety and agitation continued and Resident #1 asked staff repeatedly to help her. On [DATE] at 8:13 AM Resident #1 was noted in her room unresponsive with a blood pressure of ,d+[DATE] (normal blood pressure reading ,d+[DATE]), pulse 111(normal pulse range ,d+[DATE]), respiratory rate 4 (normal respiratory rate ,d+[DATE]) and oxygen saturation level 54% (normal oxygen saturation level greater than 92%). Resident #1 was pronounced deceased by Emergency Medical Services (EMS) staff at 8:30 AM. This deficient practice occurred for 1 of 3 sampled residents reviewed for quality of care (Resident #1). The findings included: Resident #1 was readmitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD) and respiratory failure. Resident #1 was [AGE] years old. An allergy list in the electronic medical record (EMR) updated on [DATE] included the medication Ativan. Resident #1's allergy reaction was documented as unspecified. A physician order dated [DATE] revealed Resident #1 required continuous supplemental oxygen via 2 liters/minute to maintain oxygen saturation levels greater than 92 %. A physician order dated [DATE] revealed Resident #1 was prescribed formoterol fumarate inhalation nebulization solution (breathing treatment) to inhale orally via nebulizer two times a day related to COPD with acute exacerbation. A review of Resident #1's quarterly Minimum Data Set assessment dated [DATE] revealed she was cognitively intact. The resident had no behaviors during the assessment period. Resident #1 received antianxiety medication during the assessment period and continuous oxygen therapy. On [DATE] at 11:27 AM a telephone interview was conducted with Nurse Aide (NA) #2. NA #2 stated she had cared for Resident #1 on [DATE] during the 3:00 PM to 7:00 PM shift. Resident #1 was very anxious when she came on shift at 3:00 PM and did not eat her supper meal. NA #2 recalled Resident #1 had flipped over her bedside table and had thrown her supper meal onto the floor. The interview revealed Resident #1 would not stay in the bed and NA #2 had to keep repositioning the resident so she was sitting up because Resident #1 said to her, I can't breathe. NA #2 stated, I sat her up to calm her down, I would give her the call light and she would immediately hit the light again asking me to come back saying she couldn't breathe. NA #2 recalled she told Nurse #2 and Nurse #1 about the resident's condition; however they just told her the resident was anxious. Resident #1 continued to use her call light throughout the shift and if she did not call out, she would yell out the door stating, I can't breathe, I can't breathe. NA #2 had not cared for Resident #1 prior to that day and was not familiar with the resident to know if that was typically how Resident #1 acted. Resident #1 was wearing supplemental oxygen during the shift. NA #2 stated Resident #1 continued to be anxious and have behaviors throughout her shift and reported the behaviors to the oncoming NA (NA#5). A nursing note dated [DATE] at 6:39 PM documented by Nurse #2 revealed Resident #1's vital signs taken on [DATE] with readings of blood pressure ,d+[DATE], temperature 97.6, pulse 67, respiratory rate 14 and O2 96%. Resident #1 was receiving oxygen therapy at 2 liters per minute. No signs or symptoms of distress were noted. On [DATE] at 12:30 PM a telephone interview was conducted with Nurse #2. During the interview she stated she had taken care of Resident #1 on [DATE] during the 7:00 AM to 7:00 PM shift. Nurse #2 stated Resident #1 seemed fine during her shift and did not seem anxious or short of breath. She did not recall NA #2 coming to her and stating the resident had not eaten her supper meal or thrown over the bedside table. Nurse #2 did not recall hearing Resident #1 yell out that she could not breathe during the shift. Nurse #2 stated she had administered Resident #1's medication around 5:00 PM and she was able to swallow her medication and did not seem to be in any distress. She gave report to Nurse #1 that Resident #1 was using her call light repeatedly, but the nurses said that was normal for the resident. Nurse #2 indicated she left the facility at 7:00 PM. Nurse #2 stated she was new to the facility and was not very familiar with Resident #1. Review of Resident #1's medical record revealed no vital signs were documented for Resident #1 on [DATE] during the 7:00 AM to 7:00 PM shift. On [DATE] at 1:20 PM a telephone interview was conducted with NA #5. NA #5 stated she was responsible for Resident #1 on [DATE] during the 7:00 PM to 11:00 PM shift. NA #5 indicated she received report from NA #2 who had stated Resident #1 was very anxious and having difficulty breathing. NA #5 stated she had a hard time assisting Resident #1 with incontinence care because she needed to sit up and seemed very anxious. NA #5 notified Nurse #1 of the resident's behavior around 10:00 PM however she stated Nurse #1 was already aware of how the resident was acting because she had been in and out of the room during the shift. NA #5 revealed she gave report to NA #6 at 11:00 PM and she (NA #5) was assigned to another hall. During the night (could not recall what time) she saw Resident #1's call light on so she went back into the room to assist NA #6 with changing the resident's brief. Once she raised the bed up, Resident #1 would not stop moving and trying to get off the bed. She stated she cleaned the resident as best as she could, but Resident #1 would not lay down long enough, so she had a difficult time placing the new brief back onto the resident. NA #5 stated she had taken care of Resident #1 before, and she had never been that way. Resident #1 was wearing supplemental oxygen during the shift. NA #5 indicated she once again let Nurse #1 know Resident #1 seemed very anxious, wanting to sit up and could not be still. Nurse #1 stated to her she was aware of the resident's condition. NA #5 then went back to her assigned hall. On [DATE] at 9:05 AM a telephone interview was conducted with NA #6 who was responsible for Resident #1 on [DATE] during the 11:00 PM to 7:00 AM shift. She stated at 11:00 PM she received a report NA #5 that the resident was very anxious. Resident #1 was up and down all night and would not stay in bed. NA #6 recalled she sat in the room with Resident #1 during the shift because if she didn't then Resident #1 would end up lying on the floor. Resident #1 was talking but seemed confused. NA #6 stated Resident #1 was having difficulty breathing, was wheezing and did not want to lay down. She assisted the resident to sit up in the bed and sit on the side of the bed during the night. Resident #1 kept saying, Help me so she went and got Nurse #1 to go to the room to look at the resident (could not recall what time). Nurse #1 went into the room and looked at Resident #1 and said she was going to notify a physician and send her to the hospital. However, shortly after Nurse #1 changed her mind and said there was nothing the hospital could do for the resident because they were aware of her condition. Resident #1 was constantly moving from the bed to the floor on her fall mat during the shift, sitting up on the fall mat. Resident #1 was wearing supplemental oxygen during the shift. Nurse #1 did not ask her to obtain vital signs, so she did not get them. She stated she had taken care of Resident #1 before and had never seen her in the state she was in, and it seemed like she was in distress. At 6:30 AM she gave a report to NA #1 and stated the resident had a change of condition and did not get any sleep during the night. She told NA #1 to keep a close eye on Resident #1 because she did not seem like herself. Review of Resident #1's Medication Administration Record dated [DATE] revealed an order for nebulization solution (breathing treatment) to inhale orally via nebulizer at bedtime related to Chronic Obstructive Pulmonary Disease with Acute Exacerbation. On [DATE] the medication was scheduled for 9:00 PM. Nurse #1 documented a (2) for the [DATE] 9:00 PM dose. Review of the legend located at the bottom of the MAR dated [DATE] revealed documentation of a (2) meant the medication was refused. A statement written and signed by Nurse #1 on [DATE] obtained by the facility revealed she was assigned Resident #1 during the 7:00 PM to 7:00 AM shift on [DATE] through [DATE]. The statement revealed Resident #1 kept getting out of the bed and laying on the floor during the shift. Nurse #3 asked her if the resident had any Ativan available and Nurse #1 stated she wasn't sure. Nurse #3 then told her the facility had standing orders for Ativan, and it could be pulled from the automated medication dispensing system. Nurse #1 was unable to access the automated medication dispensing system. and had to wait until the next shift to be able to obtain the Ativan. When the next shift arrived at 7:00 AM Nurse #1 gave report to Nurse #2. NA #1 came to the office after Nurse #3's medication pass and stated something was wrong with Resident #1. Nurse #3 asked if she would go to the resident's room for support, so Nurse #1 did. Upon arrival to the resident's room Resident #1 was face up, lying in bed with a slow response to communicate. She asked for vital signs and for someone to call EMS after feeling a weak pulse on the resident. Nurse #1 continued to do a sternal rub on the resident until EMS arrived. After EMS arrived, she was told Resident #1 had expired. Nurse #1 was later told Resident #1 had received by mouth Ativan and that she had an allergy to the medication. Nurse #1 noted in her statement she did not administer the medication but had signed off on the resident's MAR because she was the nurse responsible for the resident and had initiated the process of Resident #1's need for the medication. Nurse #1 was assigned to Resident #1 on [DATE] at 7:00 PM through [DATE] at 7:00 AM. A nursing note written by Nurse #1 as a late entry dated [DATE] at 8:30 PM revealed Resident #1 was very restless during the shift and had continued to attempt to place herself onto the floor and pull cords from the wall and wrap them around various body parts. At 10:15 PM Resident #1 was assisted to the chair and stated she wanted to get back into bed. The note read, vital signs completed WNL (within normal limits). When she was assisted back into bed, she then stated she wanted to get back on the floor. The note revealed at 10:30 PM staff were sitting in the room with Resident #1 for a duration of 30 minutes to try and calm her down. At 12:00 AM on [DATE], Resident #1 was noted to rest for brief periods of time and then become very restless again. Resident #1 was documented to continue being restless and staff assisted the resident back and forth from the bed to the chair and to the floor per her request at 2:00 AM. At 7:45 AM ([DATE]) Resident #1 continued to be restless and a standing order for Ativan was given. At 8:10 AM Resident #1 had respiratory distress and Emergency Medical Services (EMS) was called. A nursing note written by Nurse #1 as a late entry dated [DATE] at 7:48 AM revealed Nurse #1 was made aware by the NA that Resident #1 had attempted to get out of bed several times and had pulled down multiple items in her room. The resident stated she felt warm and thirsty. Resident #1's temperature decreased, and she was provided with water. Resident #1 continued to thrust herself forward to get out of bed. She was redirected and remained in bed. The incident occurred on [DATE] at 9:00 PM. A nursing note written by Nurse #1 as a late entry for [DATE] dated [DATE] at 8:10 AM revealed Nurse #1 was made aware by Nurse #2 that Resident #1 was in possible distress after being discovered by NA #1 after medication administration. Upon entering the room, the resident was face up and slow to respond. Nurse #1 requested vital signs and to call emergency medical services. Resident #1's vital signs were blood pressure ,d+[DATE] (normal blood pressure reading ,d+[DATE]), pulse 111(normal pulse range ,d+[DATE]), respiratory rate 4 (normal respiratory rate ,d+[DATE]) and oxygen saturation level 54% (normal oxygen saturation level greater than 92%), Nurse #1 continued to call Resident #1's name with no response, the nurse requested oxygen saturation levels again with an oxygen saturation reading of 30% with supplemental oxygen (amount unspecified). EMS arrived on scene and were able to take over the resident's care. On [DATE] at 3:56 PM a telephone interview was conducted with Nurse #1. She confirmed she was responsible for Resident #1 on [DATE] through [DATE] for the 7:00 PM to 7:00 AM shift. Nurse #1 stated when she received a report from Nurse #2 at 7:00 PM on [DATE] the nurse had stated the resident was up and down from the bed to the floor, very anxious and moving around a lot. Nurse #1 recalled the anxious behavior continued throughout the night for her entire shift. Nurse #1 said she was not familiar with the resident. Nurse #1 stated she didn't know the process for notification to the physician because she was new to the facility. She stated she assumed since a Nurse Practitioner (NP) was in the building daily that the NP knew what was going on with Resident #1 and would be back in the facility the next day to see the resident. Nurse #1 stated because she assumed the Nurse Practitioner was aware of Resident #1's condition and wasn't concerned, then the condition was probably the resident's baseline. Nurse #1, who was no longer employed by the facility, stated she wanted to use her initial statement to the facility as a response to any more questions asked. On [DATE] at 12:07 PM an interview was conducted with Nurse Aide (NA) #1. During the interview she stated she came on shift around 6:30 AM on [DATE] to find Resident #1 lying on her fall mat in the floor with supplemental oxygen on via nasal cannula. Resident #1 looked at NA #1 and stated, I can't take this no more. She went to Nurse #1 who told her not to get the resident off the floor because she had been back and forth from the bed to the floor all night. NA #1 told Nurse #1 she did not feel comfortable leaving the resident lying on her fall mat on the floor but since she was wanting to be on the fall mat she proceeded to clean Resident #1 up and change her brief while she was lying on the fall mat. NA #1 then assisted Resident #1 up to the side of her bed and began fixing her oxygen tubing cord which was tangled. NA #1 was in the room with the resident when Nurse #2 entered the room and administered the resident's medication. NA #1 then heard the resident call out her name. When she turned around Resident #1 was lying flat on her back with her eyes fixed up at the ceiling and with her mouth open. Resident #1 would not respond to her, so she yelled out for Nurse #2 who was in the hallway outside of the resident's room. NA #1 stayed with the resident until Nurse #1 and Nurse #2 entered the room. Nurse #1 was doing a sternal rub on the resident to try and get her to respond, however she did not. EMS was called and took over the resident's care once they arrived. She stated she had taken care of Resident #1 the day prior on [DATE] during the 7:00 AM to 3:00 PM shift and she was in no distress and was not anxious during the shift. An undated After-Hours Standing Physician Orders revealed for aggression or agitated behavior the nurse may administer Ativan 0.5 milligram (mg) by mouth. The nurse could repeat the action in 20 minutes if the resident did not respond to the medication. The orders read to notify the primary care physician in the AM for further orders. A medication administration note in the electronic medical record dated [DATE] at 7:43 AM revealed Nurse #3 entered an order for Ativan oral tablet 0.5 mg. Give 0.5 mg by mouth one time only related to COPD with acute exacerbation. The medication order triggered an alert for a system identified drug allergy. Resident #1's Medication Administration Record (MAR) for [DATE] revealed an order for Ativan oral tablet 0.5 mg by mouth on time only related to COPD with acute exacerbation. The medication was administered on [DATE] at 7:44 AM and signed off by Nurse #1. A nursing note written by Nurse #2 dated [DATE] at 12:14 PM as a late entry revealed she had received report from Nurse #1 who stated Resident #1 was restless all evening and attempted to get out of bed multiple times throughout the night. Nurse Aide #1 alerted Nurse #2 the resident was unresponsive. Upon assessment Resident #1 was noted to be hypoxic (low levels of oxygen) with an oxygen saturation of 60% (normal level greater than 92%) on 4 liters of supplemental oxygen via nasal cannula. Emergency Medical Services (EMS) was notified, Resident #1 was noted to have a do no resuscitate (DNR) order in place. EMS took over in administering life saving measures without success. Resident #1 was pronounced deceased by EMS at 8:30 AM. On [DATE] at 12:30 PM a telephone interview was conducted with Nurse #2. Nurse #2 stated she returned to the facility on [DATE] at 7:00 AM and Nurse #1 gave her report and stated Resident #1 had been anxious during the night and they had tried to give the resident Ativan but did not have access to the automated medication dispensing system. Nurse #2 recalled she was getting a report from Nurse #1 when Unit Manager #1 arrived at the nurse's station. Nurse #3 and Unit Manager #1 then went to pull the Ativan for Resident #1 while she (Nurse #2) finished getting report and began to start her medication pass. Unit Manager #1 brought her a cup with a 0.5mg Ativan in it for Resident #1 and stated to her to administer the medication. Nurse #2 stated she did not ask any questions or look at the resident's allergies prior to administering the Ativan 0.5 mg along with Resident #1's morning medication. When she went into the resident's room, Resident #1 was sitting up on the floor on her fall mat. Nurse #2 and NA #1 assisted the resident to get up to the side of the bed to take her medication. Nurse #2 administered the medication and stated the resident drank water provided and Nurse #2 left the room. She was then alerted by NA#1 approximately ,d+[DATE] minutes later that something was wrong with Resident #1. Nurse #2 and Nurse #1 went into the resident's room to find her lying on the bed with her eyes open and fixed, mouth open and a faint pulse. EMS were called and vital signs were obtained. Nurse #2 stated Resident #1 was pronounced deceased by EMS at 8:30 AM. On [DATE] at 12:53 PM a telephone interview was conducted with Nurse #3. Nurse #3 worked on [DATE] through [DATE] during the 7:00 PM to 7:00 AM shift with Nurse #1 but was not responsible for Resident #1. Nurse #3 stated Nurse #1 asked her what to do regarding the resident because she was very anxious and kept getting in/ out of bed. Nurse #1 seemed overwhelmed with the situation so Nurse #3 went to the resident's room with her to see what she could do. Nurse #3 stated Resident #1 was screaming out, crawling out of bed and very anxious. At approximately 3:00 AM on [DATE], Nurse #1 again came to her and stated she did not know what to do with Resident #1. Nurse #3 then told her the facility had standing orders for Ativan, she stated she told her it was okay to give the resident Ativan because the resident was all over the place by screaming, pulling on her oxygen tubing and crawling out of bed. The interview revealed Nurse #3 had access to the automated medication dispensing system. but Nurse #1 did not. The two nurses waited until the day shift arrived and asked Unit Manager #1 to be a second witness to pull the Ativan out of the automated medication dispensing system. machine. Nurse #3 and Unit Manager #1 then pulled Ativan 0.5 mg from the automated medication dispensing system for Resident #1 and Unit Manager #1 took the medication and gave it to Nurse #2 to administer. The interview revealed there were no alerts that popped up in the automated medication dispensing system. machine. However, when Nurse #3 put the Ativan order in the electronic charting system an allergy alert did pop up and she bypassed the alert in the system. At that time Nurse #3 did not know if they had administered the medication or not and left the facility after entering the medication order. Nurse #3 recalled she received a call after leaving the facility from the DON that Resident #1 had an allergy to the medication, and Nurse #3 had put the standing order into the Medication Administration Record (MAR). Nurse #3 stated she knew she should not have bypassed the allergy alerts in the system but was not thinking clearly about the situation and just clicked the button. She stated she felt that Resident #1 had a diagnosis of COPD and was just excited like most residents with the diagnosis and the Ativan would help calm her. Nurse #3 stated she did not review the resident's allergy list. The interview revealed looking back on the situation, the nurses should have contacted the on-call Nurse Practitioner regarding Resident #1's change in behavior. On [DATE] at 10:19 AM an interview was conducted with Unit Manager #1. During the interview she stated she had come in on [DATE] as the manager on call to orient Nurse #2 during the 7:00 AM to 7:00 PM shift. The interview revealed she arrived at the facility around 7:12 AM and noticed Resident #1 lying on her fall mat on the floor. She asked Nurse #1 if she was aware the resident was on the fall mat and Nurse #1 stated it was the safest place the resident could be. The interview revealed she was touching base with Nurse #2 when Nurse #3 asked her to be a second witness to remove Ativan 0.5mg from the automated medication dispensing system. for Resident #1 due to agitation. She was told Resident #1 had been very restless, agitated and had been throwing herself out of bed during the night and Nurse #1 did not have access to the automated medication dispensing system. to pull the medication. Unit Manager #1 indicated she went with Nurse #3 and removed the medication from the automated medication dispensing system. as the second witness. She took the medication and gave it to Nurse #2 and instructed her to administer the medication to Resident #1. She was then notified by a nurse aide (name she could not recall) that Resident #1 was coding. Resident #1 was a DNR, so she went to the room to find Nurse #1, Nurse #2 and NA #1 in the room with the resident. EMS had already been contacted and were enroute to the facility. The interview further revealed Unit Manager #1 was new to the facility and was not familiar with Resident #1. Unit Manager #1 stated if Resident #1 had a change of condition and experienced difficulty breathing the nurses on duty should have notified the on-call Nurse Practitioner of the resident's condition. EMS records dated [DATE] revealed they were notified at 8:13 AM, dispatched to the facility at 8:18 AM, arrived on scene at 8:29 AM and to the resident at 8:30 AM with a chief complaint of cardiac/ respiratory arrest. Upon EMS arrival Resident #1 was found lying in bed. The resident was apneic (without breathing) and pulseless. Resident #1 had no heart tones with a valid do not resuscitate order (DNR). She was pronounced deceased at 8:30 AM. On [DATE] at 2:24 PM a telephone interview was conducted with the former Director of Nursing (DON). The DON stated Unit Manager #1 called her on [DATE] to notify her Resident #1 had expired. The DON indicated nurses were new to the facility and did not notify the on-call provider that Resident #1 had experienced a change of condition, and the nurses should have completed an assessment on the resident. The interview revealed she instructed Nurse #1 to go back into the system and document nursing notes for the night of [DATE] through [DATE] because the nurse had not originally documented the resident's change of condition. The DON stated all nurses involved should have followed the facility protocol if a resident had experienced a change of condition and notified the physician. The DON revealed looking through documentation she saw Resident #1 had a documented allergy to the medication Ativan she was administered at 7:44 AM on [DATE]. The DON stated it was around 11:00 AM on [DATE] when she was notified of Resident #1 being administered a medication she had a documented allergy to and she immediately suspended the nurses involved. She notified the Medical Director on [DATE] at 1:00 PM Resident #1 had received the medication Ativan with a documented allergy. The interview revealed the facility had standing orders to use Ativan if a resident was having agitation which was to administer 0.5mg of Ativan as a one-time dose. The nurses were new to the facility and the nurse who administered the medication (Nurse #2) was still in orientation and did not ask any questions prior to giving it to the resident because she was told to do so by Unit Manager #1, who was her preceptor. The DON stated all nurses involved should have followed the facility protocol for administration of medication which included review of the resident's allergies. She stated Nurse #3 should have never bypassed the allergy alerts in the EMR system. All nurses were suspended pending the investigation. On [DATE] at 11:28 AM an interview was conducted with the Administrator and Regional Nurse Consultant. The interview revealed on [DATE] around 7:30 AM, Nurse #2 administered Ativan 0.5 mg to Resident #1 due to behaviors of restlessness and agitation based off of standing physician orders the facility had in place. The Regional Nurse Consultant stated Nurse #2 administered Ativan to Resident #1 at 7:44 AM and Resident #1 was then found unresponsive with a low oxygen saturation level. EMS was called to the facility, and the resident was pronounced as deceased . At 11:30 AM the Former Director of Nursing (DON) was reviewing the documentation, and they immediately suspended the nurses involved and completed an investigation into the incident. Nurse #1 was responsible for the resident during the 7:00 PM to 7:00 AM shift on [DATE] through [DATE] and needed guidance from Nurse #3 who told her about the standing order for Ativan 0.5mg. The Administrator stated none of the four nurses involved in the incident notified a provider or documented assessments when Resident #1 had experienced difficulty breathing, restlessness or increased anxiety and should have identified Resident #1 had experienced a change of condition during the night. Resident #1 was noted to have a documented allergy to the medication Ativan administered at 7:44 AM. None of the four nurses involved in the incident verified Resident #1 had no allergies to the medication. Nurse #3 bypassed the alerts in the electronic medical record when entering the medication order into the resident's MAR. The Administrator stated the nurses were responsible for verifying that the resident did not have an allergy to the medication, and they did not. The Regional Nurse Consultant stated nurses should be documenting the resident assessments and vital signs throughout the shift especially if there were changes to the resident's condition. On [DATE] at 1:34 PM a telephone interview was conducted with the on-call Nurse Practitioner. During the interview she stated she was not contacted on [DATE] or [DATE] regarding Resident #1. She stated that it was unusual because the facility typically would let her know if anything acute happened but if a resident was having trouble breathing, she would have immediately sent the resident to the hospital for an evaluation. On [DATE] at 1:38 PM a telephone interview was conducted with the Medical Director (MD). The MD stated the DON notified him of an incident that happened on [DATE] when a nurse administered Ativan to a resident with a documented allergy to the medication. The interview revealed the first time he was contacted was on [DATE] at 1:00 PM and told a medication error had occurred. He wasn't notified Resident #1 had experienced a change of condition starting at approximately 3:00 PM on [DATE]. The MD stated the on-call Nurse Practitioner would have been notified if it happened after 5:00 PM. The MD stated the facility should have sent Resident #1 to the hospital for an evaluation because from review of the nursing progress notes she had a respiratory episode and could have had increased carbon dioxide (A waste product produced during metabolism. It is transported through the bloodstream to the lungs, where it is exhaled as a gas.) in the blood. He stated the result of increased CO2 levels would be psychotic behavior such as getting up and down out of bed along with confusion. The MD stated if they had contacted the Nurse Practitioner, she would have sent the resident to the hospital for an evaluation because the resident was likely having an acute exacerbation of COPD as she had experienced in the past and needed to be on a BiPap (non-invasive ventilation therapy). The Administrator was notified of the immediate jeopardy on [DATE] at 6:30 PM. The facility provided the following corrective action plan with a compliance dated of [DATE]. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice; The facility failed to provide comprehensive assessments, failed to identify a significant change in condition that required medical attention, failed to obtain vital signs and ongoing oxygen saturations during the evening and night on [DATE] through [DATE]. On [DATE] during the 3:00 PM to 11:00 PM shift, Resident #1 showed signs of restlessness, agitation, crawling onto the floor and verbally expressed to staff that she was experiencing difficulty breathing which continued from 11:00 PM to 7:00 AM. At 8:13 AM Resident was noted in her room unresponsive with a blood pressure of ,d+[DATE], pulse rate of 111, respiratory rate of 4 and oxygen saturation level of 54%. Resident #1 was pronounced deceased by Emergency Medical Services (EMS) staff at 8:30 AM. On the evening of [DATE], Resident #1 showed signs of restlessness and agitation according to the licensed nurses' statements. Licensed nurses made multiple attempts to make resident #1 comfortable. Nurse #2 continued to assist Resident #1 throughout the night moving her from bed to chair to help the resident to become more comfortable. Nurse #2 obtained Resident #1's oxygen saturations at 98% at approximately 2:00 AM. Resident #1 needed one on one supervision periodically during the night by nursing staff for safety. Nurse #2 failed to properly assess the resident. Address how the facility will identify other residents having the potential to be affected by the same deficient practice; Current residents are at risk of this occurring. As of [DATE] an audit was completed by the Director of Nursing and designee to review nursing notes, 24-hour reports, and vital sign logs in the electronic healthcare record to ensure any noted changes in residents' condition were noted and the physician notified from [DATE] forward. The audit also included a review to ensure that residents' vital signs were taken and noted in the electronic record. This was completed by the Director of nursing and designees on [DATE] Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur; Education started by the Director of Nursing on [DATE] for the change in condition and included providing comprehensive assessments that require medical attention, obtaining vital signs, signs o [TRUNCATED]

Based on record review, and facility staff, Nurse Practitioner (NP), and Medical Director (MD) interviews, the facility failed to protect Resident #1's right to be free of neglect when the facility failed to: 1) immediately consult with the on-call Nurse Practitioner on [DATE] when a resident had a significant change in condition during the 3:00 PM to 11:00 PM shift that included signs of restlessness, agitation, crawling onto the floor and verbally expressing to staff that she had difficulty breathing; 2) complete ongoing thorough assessments for the change in condition that continued through the 11:00 PM to 7:00 AM shift; 3) prevent a significant medication error when staff deliberately disregarded an electronic medical record (EMR) system alert when Ativan (a benzodiazepine, used as a sedative medication) was entered into the EMR and administered to a resident who had a documented allergy to the medication; 4) notify the physician that Ativan was administered to a resident with a documented allergy; and 5) recognize the seriousness of a significant change in condition and identify the urgent need for medical attention. On [DATE] at 8:13 AM EMS were contacted when Resident #1 was found in her room unresponsive. Upon EMS arrival, Resident #1 was apneic (without breathing) and pulseless and Resident #1 was pronounced deceased at 8:30 AM. This deficient practice affected 1 of 3 sampled residents reviewed for neglect (Resident #1). The findings included: This tag is cross referenced to: F580: Based on record review and interviews with staff, Nurse Practitioner and Medical Director, the facility failed to immediately consult with the on-call Nurse Practitioner on [DATE] when Resident #1 had a significant change in condition. Resident #1 showed signs of restlessness, agitation, crawling onto the floor and verbally expressed to staff that she had experienced difficulty breathing. The facility also failed to notify the provider that Resident #1 had received a medication for anxiety for which she had a documented allergy on [DATE] at 7:44 AM. On [DATE] at 8:13 AM Resident #1 was found in her room unresponsive with seriously abnormal vital signs. Resident #1 was pronounced deceased by Emergency Medical Services (EMS) staff at 8:30 AM on [DATE]. The deficient practice affected 1 of 3 residents reviewed for physician notification (Resident #1). F684: Based on observations, record review, and resident, staff, Nurse Practitioner (NP), and Medical Director (MD) interviews, the facility failed to identify the seriousness of a significant change in condition, complete ongoing thorough assessment and identify the urgent need for medical attention for a resident with a history of chronic obstructive pulmonary disease who reported she could not breathe. On [DATE] during the 3:00 PM to 11:00 PM shift, Resident #1 was restless, agitated, crawling onto the floor and verbally expressed to staff she could not breathe. During the night shift (11:00 PM to 7:00 AM) the difficulty breathing, anxiety and agitation continued and Resident #1 asked staff repeatedly to help her. On [DATE] at 8:13 AM Resident was noted in her room unresponsive with a blood pressure of ,d+[DATE], pulse rate of 111, respiratory rate of 4 and oxygen saturation level of 54%. Resident #1 was pronounced deceased by Emergency Medical Services (EMS) staff at 8:30 AM. This deficient practice occurred for 1 of 3 sampled residents reviewed for quality of care (Resident #1). F760: Based on record review, and interviews with staff, Medical Director and Pharmacist, the facility failed to prevent a significant medication error when Resident #1 received a dose of Ativan (a benzodiazepine, used as a sedative medication) as a one-time dose. Resident #1 had an allergy to Ativan documented on the Allergy List in the electronic medical record (EMR) on [DATE]. The medication order was entered into the electronic health record by Nurse #3. She stated the electronic medical record flagged the order due to the allergy, but she bypassed the alert and entered the order in the EMR, which was then pulled from an automated system for medication management. Nurse #2, a nurse who was orienting under the supervision of the Unit Manager, administered the medication on [DATE] at 7:44 AM. On [DATE] at 8:13 AM Resident #1 became unresponsive with seriously abnormal vital signs. Resident #1 was pronounced deceased by Emergency Medical Services (EMS) staff at 8:30 AM. This deficient practice occurred for 1 of 3 sampled residents reviewed for medication errors. The Administrator was notified of the immediate jeopardy on [DATE] at 6:30 PM. The facility provided the following corrective action plan with a compliance date of [DATE]. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice; The facility neglected to act upon the system alert for Resident #1's allergy to Ativan when ordering a one-time dose on [DATE]. Nurse #3 entered the order for Ativan and when the system flagged the order due to a documented allergy for Resident #1, Nurse #3 by passed the alert, continued to enter the order which was then pulled from the Omnicell and given to Resident #1 on [DATE] at approximately 7:35 AM. At approximately 8:15 AM Resident #1 was found in her room unresponsive with vital signs: b/p: ,d+[DATE], Pulse: 111, Respirations: 4, Oxygen saturation level of 54%. Emergency Medical Services (EMS) was called and pronounced Resident #1 deceased at 8:30 AM. The facility failed to provide comprehensive assessments, failed to identify a significant change in condition that required medical attention, failed to obtain vital signs and ongoing oxygen saturations during the evening and night on [DATE] through [DATE]. On [DATE] during the 3:00 PM to 11:00 PM shift, Resident #1 showed signs of restlessness, agitation, crawling onto the floor and verbally expressed to staff that she was experiencing difficulty breathing which continued from 11:00 PM to 7:00 AM. The facility failed to notify the on call medical provider that a resident had experienced a change of condition on [DATE]. On [DATE], the Director of Nursing was notified at 11:13 am by Nurse #1 that Resident #1 had an allergy to Ativan. Nurses involved in the incident were suspended on [DATE] pending investigation. Nurse #1, and Nurse #3 were terminated and reported to the Board of Nursing as of [DATE]. Nurse # 2 turned in a resignation letter on [DATE]. The Unit Manger was initially terminated and appealed the termination. She was brought back on ,d+[DATE] and placed back into the training program. She resigned effective immediately on ,d+[DATE]. Medical Director was notified of Residents #1 change in condition and medication allergy at around 1:00 pm on [DATE] by the Director of Nursing. The Nurse Practitioner was notified around 8:30 AM of a change in condition and an allergy to Ativan. Address how the facility will identify other residents having the potential to be affected by the same deficient practice; Current residents are at risk of this occurring. An audit of medication allergy alerts, change in condition and physician notification in the electronic medical records was completed by the Director of Nursing and designee on [DATE] to ensure that medications were not ordered with the listed allergies. An audit on [DATE] completed by the Director of Nursing and designee to review nursing notes, 24 hour reports, vital sign logs in the electronic healthcare record to ensure any noted changes in residents' condition were noted and physician notified. The audit also included that residents' vital signs were taken and noted in the electronic record. Audits included all current residents who could be affected by this deficient practice of neglect were reviewed to ensure any change in condition and physician notification as well as bypassing the allergy alert which would result in neglect were reviewed by the director of nursing. No negative findings noted following the audit on [DATE]. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur; Education started by the Director of Nursing on [DATE] for the process for medication order entry in regard to alerts related to allergies and acknowledgement of alerts. Education also included physician notification of known allergies. Education started by the Director of Nursing on [DATE] for the change in condition and included providing comprehensive assessments that require medical attention, obtaining vital signs, signs of restlessness, agitation, oxygen saturations, and any breathing issues and notification of physician of change in condition. Education also included the documentation of comprehensive assessment into the electronic medical record. Education also addressed failure to follow above processes results in neglect which is a form of abuse. . Director of nursing educated all certified nursing assistants on reporting any noted change in condition to the nurse verbally for assessment as of [DATE]. Any licensed nurse and medication aides not receiving this education will not be able to work until receiving the education. Director of Nursing ensured all licensed nurses and medication aides were educated prior to working their next scheduled shift as of [DATE]. New licensed nurses will receive education during the orientation process by the Director of Nursing until a Staff Development Coordinator is hired. Medication Observations on current licensed nurses and medication aides will be completed by the Director of Nursing or designee by [DATE] to ensure no medications are given related to a resident allergy. Med pass observations will be completed by Director of Nursing or Designee on 5 licensed nurses and/or medication aides weekly x 12 weeks. New medication alerts will be reviewed by the director of nursing and the clinical team during morning clinical meetings. This occurs 5 times weekly and is ongoing as of [DATE]. Any allergy alerts will be addressed at the time. All nursing notes and 24-hour reports will be reviewed by the nursing clinical team during morning clinical meetings for any noted changes in condition to ensure vital signs and oxygen saturation were done for change in condition. This occurs 5 times weekly and is ongoing as of [DATE]. Director of Nursing or designee will review nursing notes over the weekend to ensure any change in condition is addressed. Nursing note reviews will be completed by the Director of Nursing or Designee on 5 residents weekly x 12 weeks. As of [DATE] the Director of nursing or designee will interview 5 nurse aides weekly for 12 weeks to ensure they are reporting any change in condition to their charge nurse verbally. Until a Staff Development Coordinator is hired, the Director of Nursing will complete monthly training on abuse and neglect for 3 months and then quarterly ongoing. Education will ensure abuse and neglect is explained to all staff per federal guidelines, Neglect as defined at 483.12, the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; As of [DATE] the results of the monitoring will be reviewed by the Administrator or Director of Nursing in the weekly Risk meeting and during the monthly Quality Assurance Performance Improvement (QAPI) meeting with the Interdisciplinary Team (IDT) as of [DATE] for 3 months. Changes will be made to the plan as necessary to maintain compliance with resident safety. The IDT team will consist of the Administrator, Director of Nursing, Medical Director, Social Worker, Activities Director and Minimum Data Set (MDS) nurse. Alleged date of IJ removal: [DATE] On [DATE], the corrective action plan was validated by onsite verification through facility staff interviews. The interviews revealed all nursing staff had received education on the process for medication order entry in regard to alerts related to allergies and acknowledgement of alerts. Education also included physician notification of known allergies. The education also included change in condition and included providing comprehensive assessments that require medical attention, obtaining vital signs, signs of restlessness, agitation, oxygen saturations, and any breathing issues. Education also included the documentation of comprehensive assessment into the electronic medical record. Education also addressed failure to follow above processes results in neglect which is a form of abuse. Nurse Aides were interviewed regarding notification to the nursing staff if they see a resident with a change of condition. The facility's in-service log, monitoring results and training material was reviewed. The immediate jeopardy removal date of [DATE] and the compliance date of [DATE] for the corrective action plan were validated.

Based on record review and interviews with staff, Nurse Practitioner and Medical Director, the facility failed to immediately consult with the on-call Nurse Practitioner on [DATE] when Resident #1 had a significant change in condition. Resident #1 showed signs of restlessness, agitation, crawling onto the floor and verbally expressed to staff that she had experienced difficulty breathing. The facility also failed to notify the provider that Resident #1 had received a medication for anxiety for which she had a documented allergy on [DATE] at 7:44 AM. On [DATE] at 8:13 AM Resident #1 was found in her room unresponsive with seriously abnormal vital signs. Resident #1 was pronounced deceased by Emergency Medical Services (EMS) staff at 8:30 AM on [DATE]. The deficient practice affected 1 of 3 residents reviewed for physician notification (Resident #1). The findings included: Resident #1 was readmitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD) and respiratory failure. A review of Resident #1's quarterly Minimum Data Set assessment dated [DATE] revealed she was cognitively intact. The resident had no behaviors during the assessment period. On [DATE] at 11:27 AM an interview was conducted with Nurse Aide (NA) #2. NA #2 stated she had cared for Resident #1 on [DATE] during the 3:00 PM to 7:00 PM shift. Resident #1 was very anxious when she came on shift at 3:00 PM and did not eat her supper meal. NA #2 recalled Resident #1 had flipped over her bedside table and had thrown her supper meal onto the floor. The interview revealed Resident #1 would not stay in the bed and NA #2 had to keep repositioning the resident so she was sitting up because Resident #1 said to her, I can't breathe. NA #2 stated, I sat her up to calm her down, I would give her the call light and she would immediately hit the light again asking me to come back saying she couldn't breathe. The interview revealed she told Nurse #2 and Nurse #1 about the resident's condition; however they just told her the resident was anxious. Resident #1 continued to use her call light throughout the shift and if she did not call out, she would yell out the door stating, I can't breathe, I can't breathe. NA #2 had not cared for Resident #1 prior to that day and was not familiar with the resident to know if that was typically how Resident #1 acted. On [DATE] at 12:30 PM an interview was conducted with Nurse #2. During the interview she stated she had taken care of Resident #1 on [DATE] during the 7:00 AM to 7:00 PM shift. Nurse #2 stated Resident #1 seemed fine during her shift and did not seem anxious or short of breath. She did not recall NA #2 coming to her and stating the resident had not eaten her supper meal or thrown over the bedside table. Nurse #2 did not recall hearing Resident #1 yell out that she could not breathe during the shift. She gave report to Nurse #1 and left the facility at 7:00 PM. On [DATE] at 1:20 PM an interview was conducted with NA #5. NA #5 was responsible for Resident #1 on [DATE] during the 7:00 PM to 11:00 PM shift. She stated she had a hard time assisting Resident #1 with incontinence care because she needed to sit up and seemed very anxious. NA #5 notified Nurse #1 of the resident's behavior however she stated Nurse #1 was already aware of how the resident was acting. At 11:00 PM she gave report to NA #6 and was assigned another hall. During the night she saw Resident #1's call light on so she went back into the room (but could not recall the time) to assist in changing the resident's brief. Once she lifted the bed up, Resident #1 would not stop moving and trying to get off of the bed. She stated she cleaned the resident as best as she could but Resident #1 would not lay down long enough, so she had a difficult time placing the new brief back onto the resident. NA #5 stated she had taken care of Resident #1 before, and she had never been that way. NA #5 indicated she once again let Nurse #1 know Resident #1 seemed very anxious, wanting to sit up and could not be still. Nurse #1 stated to her she was aware of the resident's condition. NA #5 then went back to her assigned hall. On [DATE] at 9:05 AM an interview was conducted with NA #6. NA #6 was responsible for Resident #1 on [DATE] during the 11:00 PM to 7:00 AM shift. She stated at 11:00 PM she received a report that the resident was very anxious. Resident #1 was up and down all night and would not stay in bed. During the shift she would sit in the room with her because if she didn't then Resident #1 would end up lying on the floor. Resident #1 was talking but seemed confused. NA #6 stated Resident #1 was having difficulty breathing, was wheezing and did not want to lay down. She would assist the resident to sit up in the bed and sit on the side of the bed during the night. Resident #1 kept saying, Help me so she went and got Nurse #1 to go to the room to look at the resident. NA #6 stated at one point Nurse #1 said she was going to notify a physician and send her to the hospital. However, shortly after she changed her mind and said there was nothing the hospital could do for the resident because they were aware of her condition. Resident #1 was constantly moving from the bed to the floor on her fall mat during the shift, sitting up on the fall mat. Nurse #1 did not ask her to obtain vital signs. She stated she had taken care of Resident #1 before and had never seen her in the state she was in. NA #6 stated Resident #1 seemed like she was in distress. At 6:30 AM she gave a report to NA #1 and stated the resident had a change of condition and did not get any sleep during the night. She told NA #1 to keep a close eye on Resident #1 because she did not seem like herself. Nurse #1 was assigned to Resident #1 on [DATE] - [DATE] during the 7:00 PM to 7:00 AM shift. A nursing note written by Nurse #1 as a late entry dated [DATE] at 8:30 PM revealed Resident #1 was very restless during the shift and had continued to attempt to place herself onto the floor and pull cords from the wall and wrap them around various body parts. At 10:15 PM Resident #1 was assisted to the chair and stated she wanted to get back into bed. When she was assisted back into bed, she then stated she wanted to get back on the floor. The note revealed at 10:30 PM staff were sitting in the room with Resident #1 for a duration of 30 minutes to try and calm her down. At 12:00 AM on [DATE], Resident #1 was noted to rest for brief periods of time and then become very restless again. Resident #1 was documented to continue being restless and staff assisted the resident back and forth from the bed to the chair and to the floor per her request at 2:00 AM. At 7:45 AM Resident #1 continued to be restless and a standing order for Ativan was given. At 8:10 AM Resident #1 had respiratory distress and Emergency Medical Services (EMS) was called. A nursing note written by Nurse #1 as a late entry dated [DATE] at 7:48 AM revealed Nurse #1 was made aware by the NA that Resident #1 had attempted to get out of the bed several times and had pulled down multiple items in her room. The resident stated she felt warm and thirsty. Resident #1's temperature decreased, and she was provided with water. Resident #1 continued to thrust herself forward to get out of bed. She was redirected and remained in bed. The incident occurred on [DATE] at 9:00 PM. On [DATE] at 3:56 PM an interview was conducted with Nurse #1. Nurse #1 stated when she received a report from Nurse #2 at 7:00 PM the nurse had stated the resident was up and down from the bed to the floor, very anxious and moving around a lot. The anxious behavior continued throughout the night. Nurse #1 said she was not familiar with the resident. Nurse #1 stated she didn't know the process for notification to the physician because she was new to the facility. She stated she assumed since a Nurse Practitioner (NP) was in the building daily that the NP knew what was going on with Resident #1 and would be back in the facility the next day to see the resident. Nurse #1 stated because she assumed the Nurse Practitioner was aware of Resident #1's condition and wasn't concerned, then the condition was probably the resident's baseline. She stated, I would rather talk to the physician in the morning than at 3:00 AM in the middle of the night. It seems like something day shift would tell them. A nursing note written by Nurse #1 as a late entry dated [DATE] at 8:10 AM revealed Nurse #1 was made aware by Nurse #2 that Resident #1 was in possible distress after being discovered by NA #1 after medication administration. Upon entering the room, the resident was faced up and slow to respond. Nurse #1 requested vital signs and to call emergency medical services. Resident #1's vital signs were blood pressure ,d+[DATE] (normal blood pressure reading ,d+[DATE]), pulse 111(normal pulse range ,d+[DATE]), respiratory rate 4 (normal respiratory rate ,d+[DATE]) and oxygen saturation level 54% (normal oxygen saturation level greater than 92%), Nurse #1 continued to call Resident #1's name with no response, the nurse requested oxygen saturation levels again with an oxygen saturation reading of 30% with supplemental oxygen (amount unspecified). EMS arrived on scene and were able to take over the resident's care. On [DATE] at 12:53 PM an interview was conducted with Nurse #3. Nurse #3 worked on [DATE] -[DATE] during the 7:00 PM to 7:00 AM shift with Nurse #1 but was not responsible for Resident #1. Nurse #3 stated Nurse #1 asked her what to do regarding the resident because she was very anxious and kept getting in and out of bed. Nurse #1 seemed overwhelmed with the situation so Nurse #3 went to the resident's room with her to see what she could do. Nurse #3 stated Resident #1 was screaming out, crawling out of the bed and very anxious. At approximately 3:00 AM Nurse #1 again came to her and stated she did not know what to do with Resident #1. Nurse #3 did not instruct Nurse #1 to notify the on-call physician because she felt that Resident #1 had a diagnosis of COPD and was just excited like most residents with the diagnosis and the Ativan would help calm her. A nursing note written by Nurse #2 dated [DATE] at 12:14 PM as a late entry revealed she had received report from Nurse #1 who stated Resident #1 was restless all evening and attempted to get out of bed multiple times throughout the night. Nurse Aide #1 alerted Nurse #2 the resident was unresponsive. Upon assessment Resident #1 was noted to be hypoxic (low levels of oxygen) with an oxygen saturation of 60% (normal level greater than 92%) on 4 liters of supplemental oxygen via nasal cannula. Emergency Medical Services (EMS) was notified, Resident #1 was noted to have a do no resuscitate (DNR) order in place. EMS took over in administering life saving measures without success. Resident #1 was pronounced deceased by EMS at 8:30 AM. On [DATE] at 12:30 PM an interview was conducted with Nurse #2. Upon return to the facility on [DATE], she came in at 7:00 AM. Nurse #1 was giving her report and stated Resident #1 had been anxious during the night and they had tried to give the resident Ativan but did not have access to the An automated system for medication management, an automated system for medication management. Nurse #2 was getting a report from Nurse #1 when Unit Manager #1 arrived at the nurses station. Nurse #3 and Unit Manager #1 then went to pull the Ativan from the An automated system for medication management machine for Resident #1 while Nurse #2 finished getting report and began to start her medication pass. Unit Manager #1 then brought her a cup with a 0.5mg Ativan in it for Resident #1 and stated to her to administer the medication. Nurse #2 stated she did not ask any questions or look at the resident's allergies prior to administering the Ativan 0.5 mg along with the resident of Resident #1's morning medication around 7:44 AM. When she went into the resident's room, she was sitting up on the floor on her fall mat. Nurse #2 and NA #1 assisted the resident to get up to the side of the bed to take her medication. Nurse #2 administered the medication and stated the resident drank water provided and Nurse #2 left the room. She was then alerted by NA#1 approximately ,d+[DATE] minutes later that something was wrong with Resident #1. Nurse #2 and Nurse #1 went into the resident's room to find her lying on the bed with her eyes open and fixed, mouth open and a faint pulse. EMS were called and vital signs were obtained. Nurse #2 stated Resident #1 was pronounced deceased by EMS at 8:30 AM. On [DATE] at 12:07 PM an interview was conducted with Nurse Aide (NA) #1. During the interview she stated she came on shift around 6:30 AM on [DATE] to find Resident #1 lying on her fall mat in the floor. Resident #1 looked at NA #1 and stated, I can't take this no more. She went to Nurse #1 who told her not to get the resident off the floor because she had been back and forth from the bed to the floor all night. NA #1 told Nurse #1 she did not feel comfortable leaving the resident lying on her fall mat in the floor but since she was wanting to be on the fall mat she proceeded to clean Resident #1 up and change her brief while she was lying on the fall mat. NA #1 then assisted Resident #1 up to the side of her bed and began fixing her oxygen tubing cord which was tangled. NA #1 was in the room with the resident when Nurse #2 entered the room and administered the resident's medication around 7:44 AM. NA #1 said Resident #1 acted like she did not want to take the medication, but she had her back to the resident untangling oxygen tubing. Nurse #2 then left the room as NA #1 continued to untangle the resident's oxygen tubing cord. NA #1 then heard the resident call out her name. When she turned around Resident #1 was lying flat on her back with her eyes fixed up at the ceiling and mouth open. Resident #1 would not respond to her, so she yelled out for Nurse #2 who was in the hallway outside of the resident's room. NA #1 stayed with the resident until Nurse #1 and Nurse #2 entered the room. Nurse #1 was doing a sternal rub on the resident to try and get her to respond however she did not. EMS was called and took over the resident's care once they arrived. She stated she had taken care of Resident #1 the day prior on [DATE] during the 7:00 AM to 3:00 PM shift and she was in no distress and was not anxious during the shift. On [DATE] at 10:19 AM an interview was conducted with Unit Manager #1. During the interview she stated she had come in on [DATE] as the manager on call to orient Nurse #2 during the 7:00 AM to 7:00 PM shift. The interview revealed she arrived to the facility around 7:12 AM and noticed Resident #1 lying on her fall mat on the floor. She asked Nurse #1 if she was aware the resident was on the fall mat and Nurse #1 stated it was the safest place the resident could be. She was told Resident #1 had been very restless, agitated and had been throwing herself out of bed during the night. She was then notified by a Nurse Aide (name she could not recall) that Resident #1 was coding. Resident #1 was a DNR, so she went to the room to find Nurse #1, Nurse #2 and NA #1 in the room with the resident. EMS had already been contacted and were enroute to the facility. She left the room to print the resident's paperwork and gave EMS the resident's DNR paperwork upon their arrival to the facility. EMS records dated [DATE] revealed they were notified at 8:13 AM, dispatched to the facility at 8:18 AM, arrived on scene at 8:29 AM and to the resident at 8:30 AM with a chief complaint of cardiac/ respiratory arrest. Upon EMS arrival Resident #1 was found lying in bed. The resident was apneic (without breathing) and pulseless. Resident #1 had no heart tones with a valid do not resuscitate order (DNR). She was pronounced deceased at 8:30 AM. On [DATE] at 2:24 PM an interview was conducted with the former Director of Nursing (DON). The DON stated Unit Manager #1 called her on [DATE] to notify her Resident #1 had expired. The nurses were new to the facility and did not notify the on-call provider that Resident #1 had experienced a change of condition. The DON stated all nurses involved should have followed the facility protocol if a resident had experienced a change of condition and notified the physician. On [DATE] at 11:28 AM an interview was conducted with the Administrator and Regional Nurse Consultant. The interview revealed on [DATE] around 7:30 AM, Nurse #2 administered Ativan 0.5 mg to Resident #1 due to behaviors of restlessness and agitation. Nurse #2 administered Ativan to Resident #1 at 7:44 AM and Resident #1 was then found unresponsive with a low oxygen saturation level. EMS was called to the facility, and the resident was pronounced as deceased . At 11:30 AM the Former Director of Nursing (DON) was reviewing the documentation, and they immediately suspended the nurses involved and completed an investigation into the incident. Nurse #1 was responsible for the resident during the 7:00 PM to 7:00 AM shift and had needed guidance from Nurse #3 who told her about the standing order for Ativan 0.5mg. None of the 4 nurses involved in the incident notified a provider that Resident #1 had experienced difficulty breathing, restlessness or increased anxiety. On [DATE] at 1:34 PM an interview was conducted with the on-call Nurse Practitioner. During the interview she stated she was not contacted on [DATE] or [DATE] regarding Resident #1. She stated that was unusual because the facility typically would let her know if anything acute happened but if a resident was having trouble breathing, she would have immediately sent the resident to the hospital for an evaluation. On [DATE] at 1:38 PM an interview was conducted with the Medical Director (MD). The MD stated the DON notified him of an incident that happened on [DATE] when a nurse administered Ativan to a resident with a documented allergy to the medication. The interview revealed the first time he was contacted was on [DATE] at 1:00 PM and told a medication error had occurred. He wasn't notified Resident #1 had experienced a change of condition starting at approximately 3:00 PM on [DATE]. The MD stated the on-call Nurse Practitioner would have been notified if it happened after 5:00 PM. The MD stated the facility should have sent Resident #1 to the hospital for an evaluation because from review of the nursing progress notes she had a respiratory episode and could have had increased carbon dioxide (A waste product produced during metabolism. It is transported through the bloodstream to the lungs, where it is exhaled as a gas.) in the blood. He stated the result of increased CO2 levels would be psychotic behavior such as getting up and down out of bed along with confusion. The MD stated if they had contacted the Nurse Practitioner, she would have sent the resident to the hospital for an evaluation because the resident was likely having an acute exacerbation of COPD as she had experienced in the past and needed to be on a BiPap (non-invasive ventilation therapy). The Administrator was notified of the immediate jeopardy on [DATE] at 6:30 PM. The facility provided the following corrective action plan with a completion date of [DATE]. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice; The facility failed to notify the on-call medical provider that Resident #1 had experienced a change of condition. Based on staff interviews on [DATE] during the 3:00 PM to 7:00 AM shift, Resident #1 showed signs of restlessness, agitation, crawling onto the floor and verbally expressed to staff that she was experiencing difficulty breathing. At 8:13 AM Resident was noted in her room unresponsive with a blood pressure of ,d+[DATE], pulse rate of 111, respiratory rate of 4 and oxygen saturation level of 54%. The staff applied a non-rebreather mask then called Emergency Medical Services (EMS). Resident #1 was pronounced deceased by EMS staff at 8:30 AM. Address how the facility will identify other residents having the potential to be affected by the same deficient practice; Current residents are at risk of this occurring. An audit was completed by the Director of Nursing and designee to review the last 7 days of nursing notes to ensure any noted changes in residents' condition were noted and the physician had been notified. This was completed by the Director of nursing on [DATE]. The audit included a review of nursing notes and 24-hour shift to shift reports. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur; Education started by the Director of Nursing on [DATE] for the change in condition and physician notification related to change in condition to include providing comprehensive assessments, that required medical attention, obtain vital signs, signs of restlessness, agitation, oxygen saturations, and any breathing issues. Any licensed nurse and medication aides not receiving this education will not be able to work until receiving the education. New licensed nurses and medication aides will receive education during the orientation process. Director of Nursing ensured all licensed nurses and medication aides were educated prior to working their next scheduled shift as of [DATE]. Director of nursing reeducated all certified nursing assistants on verbally reporting any noted change in condition such as altered mental status, abnormal behaviors, abnormal vital signs, etc. to the nurse for assessment as of [DATE]. All nursing note reviews, and 24-hour reports reviews were completed by the Director of Nursing or designee by [DATE] to ensure noted changes in condition were addressed, vitals taken and physician notified. Nursing note reviews will be completed by the Director of Nursing or Designee on 5 residents weekly x 12 weeks. New changes in conditions will be reviewed by the nursing clinical team during morning clinical meetings for any noted change in condition and physician notification. This occurs 5 times weekly and is ongoing as of [DATE]. New changes in condition from the weekend will be reviewed by the nursing clinical team during the Monday clinical meeting. The nursing team was notified of this responsibility on [DATE] by the facility administrator. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; As of [DATE] the results of the monitoring will be reviewed by the Administrator or Director of Nursing in the weekly Risk meeting and during the monthly Quality Assurance Performance Improvement (QAPI) meeting with the Interdisciplinary Team (IDT) as of [DATE] for 3 months. Changes will be made to the plan as necessary to maintain compliance with resident safety. The IDT team will consist of the Administrator, Director of Nursing, Medical Director, Social Worker, Activities Director and Minimum Data Set (MDS) nurse. Alleged date of compliance and the immediate jeopardy removal date is [DATE]. On [DATE], the corrective action plan was validated by onsite verification through facility staff interviews. The interviews revealed all nursing staff had received education on the change in condition and physician notification related to change in condition to include providing comprehensive assessments, that required medical attention, obtain vital signs, signs of restlessness, agitation, oxygen saturations, and any breathing issues. Nurse Aides were interviewed regarding notification to the nursing staff if they see a resident with a change of condition. The facility's in-service log, monitoring results and training material was reviewed. The immediate jeopardy was removed on [DATE]. The completion date of [DATE] for the corrective action plan was validated.

Based on record review, staff interviews, Guardian interview, Family Nurse Practitioner (FNP) and Medical Director (MD) interview, the facility failed to provide supervision for a cognitively impaired resident who exited the facility and left the facility's property while unsupervised for 1 of 3 sampled residents (Resident #1) reviewed for provision of supervision to prevent accidents. Resident #1 exited the facility and left the facility's property unsupervised and was returned by an unknown driver who gave him a ride back to the facility where he was assessed to have no injuries. Immediate jeopardy began on 08/17/18 when Resident #1 exited the facility and left the facility property unsupervised for over 45 minutes without the knowledge of facility staff. The Immediate jeopardy was removed on 08/30/18 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place are effective. The findings included: Resident #1 was admitted to the facility on [DATE] after a hospitalization . Record review of hospital records indicated Resident #1 was living at home by himself prior to his hospitalization . The discharge assessment indicated a [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 had moderately impaired cognitive skills and required assistance with bed mobility, transfers, hygiene and toileting. The MDS also revealed Resident #1 used a walker or a wheelchair for mobility and had no instances of wandering. The Care Area Assessment (CAA) for cognitive loss revealed Resident #1 had decreased safety awareness related to [DIAGNOSES REDACTED]. Review of a wandering risk assessment dated [DATE] and completed by nurse #1 indicated the following: admission within past month - ambulates with 1 assist - medication changes. Review of a care plan for Resident #1 dated for 03/21/18 indicated Resident #1 was at risk for falls related to deconditioning, weakness, impaired balance, impaired safety aware with Alzheimer's and dementia, history of chronic infarcts, unsteady gait. Review of a wandering risk assessment dated [DATE] completed by nurse #1 indicated the following: forgetful/short attention span - combative/severely agitated - independent with mobility. Review of nursing progress notes after 05/27/18 through 08/16/18 gave no indication of any follow up with this decline for Resident #1 from the previous wandering risk assessment dated [DATE]. There were no interventions to address Resident #1's forgetfulness and mobility independence, which potentially placed the resident at a higher risk to wander/elope. The quarterly MDS dated [DATE] revealed Resident #1 had severely impaired cognition (a decline from the previous assessment) and required only supervision with bed mobility, transfers and hygiene, and limited assistance with toileting. The MDS also revealed Resident #1 used a walker or wheelchair for mobility and had no instances of wandering. Record review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. During an interview with the day Receptionist on 08/28/18 at 4:40 PM, she stated on 08/17/18 she was sitting at the front desk when a woman came into the facility around 11:20 AM and told her that Resident #1 was in her car. The Receptionist stated she went out to see him then came back inside and got 2 NAs from the dining room to come outside and verify it was Resident #1. The Receptionist further stated she had never seen Resident #1 come up to the front or go outside to sit down before and that's why she got the 2 NAs to make sure that it was him since she was unfamiliar with him. The Receptionist added she had never seen Resident #1 exit the facility and she always had another staff member at the front desk for her meal and bathroom breaks. Record review of a progress note by Nurse #1 on 08/17/18 revealed the following: Resident had head to toe assessment with no areas noted when he returned to facility from getting some fresh air. Further review of Resident #1's medical record revealed no documentation in the record that reflected that on 08/17/18 the resident exited the facility while unsupervised, left the facility property for over 45 minutes without staff ' s knowledge and was returned to the facility by an unknown driver. During an interview with Nursing Aide #1 (NA #1) on 08/28/18 at 8:14 AM, NA #1 stated that she regularly worked with Resident #1 and he always stayed in his room, did not go outside, refused activities, often refused showers but would wash up in the bathroom. NA #1 also stated Resident #1 always said he was leaving. NA #1 further stated he kept his belongings in bags tied to his wheelchair and didn ' t like them touched. During an interview with the FNP on 08/28/18 at 10:58 AM, the FNP stated that she was aware Resident #1 had gotten outside the facility unsupervised. The FNP also stated this was very out of character him and she was very shocked this had happened because he rarely came out of his room. She also stated she had seen him yesterday and observed that he had several bags tied to his walker. When she asked him about the bags, he reportedly told her he was trying to keep bugs out of his belongings and if he kept them up high on his walker the bugs could not get to them. The FNP stated she saw no bugs in his room. During an interview with the Maintenance Director on 08/28/18 at 1:03 PM, he stated the only doors open are the facility's main entrance doors from 9:00 AM to 5:00 PM daily. There is a front desk receptionist present during this time 7 days a week. The Maintenance Director proceeded to explain all other doors in the facility could not be entered or exited without an employee badge. The Maintenance Director also stated that electronic alert devices worn by some of the residents cause the front door to lock if they approach it and will alarm if they go through the front door. The Maintenance Director acknowledged that Resident #1 did not have an electronic alert device when he left the facility unattended, but if he would have had the alert device he would have not been able to exit the facility without the alarm alerting staff. During an interview with Nursing Aide #2 (NA #2) on 08/28/18 at 2:56 PM, NA #2 stated she had worked with Resident #1 the morning he left the facility unsupervised. NA #2 also stated she had last seen Resident #1 between 9:45 AM and 10:00 AM in his room and he was acting no differently than usual. She stated Resident #1 was usually quiet, stayed in his room, didn ' t want to take showers or give up his clothes to be washed and sometimes would refuse food. NA #2 also stated Resident #1 had told her he did not like being in the facility because it was like jail, but never spoke of actually leaving the facility. NA #2 further stated she worked with Resident #1 the day before he exited the facility unsupervised and he was not acting any different than he usually did. NA #2 stated he had always kept his belonging tied in bags on his wheelchair, so this was not new for him. During an interview with Resident #1's Guardian on 08/28/18 at 3:04 PM, the Guardian stated she had received a phone call from the Administrator on 08/17/18 indicating Resident #1 was exit seeking and the discharge planner would try to find him more suitable placement. The Guardian was not aware Resident #1 had gotten out of the facility and stated she would have expected the facility to share this information with her. During an interview with Nurse #1 on 08/29/18 at 9:24 AM, Nurse #1 stated after she received a phone call at 11:20 AM on 08/17/18 that Resident #1 was outside the front of the facility, she proceeded to go outside and witnessed Resident #1 sitting in a vehicle. Nurse #1 stated she talked with Resident #1 and he stated he was not in any pain, but he stated he was thirsty. Nurse #1 also stated Resident #1 was able to get out of the car on his own. Nurse #1 further stated she completed a head to toe assessment, took vital signs, and determined there were no injuries to Resident #1. Nurse #1 verified she had not been aware prior to her phone call that Resident #1 had been outside the facility unsupervised. During an interview with Nurse #2 on 08/29/18 at 11:27 AM, Nurse #2 stated she had worked with Resident #1 the morning he exited the facility. Nurse #2 also stated this was the first and only time she worked with Resident #1. Nurse #2 stated she remembered giving him his medication and that he was sitting up on the side of his bed with his legs crossed and seemed very pleasant. Nurse #2 further stated she was not aware he was out of the facility and did not see him again after she gave him his medication until he was returned to the facility. During an interview with the Director of Nursing (DON) on 08/29/18 at 11:55AM, the DON stated that after Resident #1 was returned to the facility on [DATE], that the Administrator, Unit Manager and she met with him to discuss what happened. The DON added that Resident #1 had stated he had just went outside for a walk and to get some fresh air. The DON also stated they put an electronic alert device on his wrist upon his return, but he was able to remove it, so he was started on 15-minute checks and has remained on them until they are able to find appropriate placement for him on a secured unit. During an interview with the Administrator on 08/29/18 at 4:20 PM the Administrator stated that Resident #1 had been returned to the facility by an unknown driver who transported Resident #1 from Brookshire Boulevard which was 2.5 miles from the facility. The Administrator also stated that he called and left a message for Resident #1's Guardian indicating that he was exit seeking and an effort was being made by the discharge planner to find him placement in a more appropriate setting. The Administrator also stated he called the MD to inform him of the incident. During an interview with the Medical Director (MD) on 08/30/18 at 8:45 AM, the MD stated the incident with Resident #1 exiting the facility totally out of character for this guy and he had not had exit seeking behaviors prior to this incident. The MD further stated he was surprised to hear this had happened and verified the Administrator had notified him about the incident on the day of the occurrence. Notification of Immediate Jeopardy was given to the Administrator on 08/29/18 at 2:03 PM. The credible allegation for immediate jeopardy removal was verified on 08/30/18 at 1:05 PM. Plan of Correction and Credible Allegation of Immediate Jeopardy Removal The statements included are not an admission and do not constitute agreement with the alleged deficiencies herein. This plan of correction is submitted in compliance with applicable law and regulation. To demonstrate continuing compliance with applicable law, the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the center ' s allegation of compliance. All alleged deficiencies have been or will be completed by the dates indicated. The plan of correcting the specific deficiency. The plan should address the processes that lead to the deficiency cited; ·Deficient practice is evident by, on 8/17/18, between the times of approximately 10:26AM and 11:20AM, upon which he was returned, Resident #1 left from the facility unattended from the front lobby door. He was transported from an unknown location on Brookshire Blvd., approximately 2.5 miles away, to the facility by an unknown person who noticed his yellow identification bracelet. The resident did not have a wander guard on as he was never deemed to have exit seeking behaviors. Receptionist was unaware of what the resident looked like, had never been to the front lobby, and had not been assessed to need a wander guard. Facility failed to determine he was at risk, related to his [DIAGNOSES REDACTED]. Facility could have prevented this by determining the resident could have been at risk based on [DIAGNOSES REDACTED]. All doors are locked 24 hours per day with the exception of the front door and back door. The front door is unlocked from 9:00AM to 5:00PM. Facility Action ·At 12:45 on 8/17/18 voicemail was left with responsible party to update her on resident exit seeking behaviors. ·The Resident had a wander guard applied on him on 08/17/2018 at 12:50 PM. Wander guard was tested prior to placement and worked per manufacturers guidelines. The resident refuses to wear the wander guard and therefore 15-minute checks have been in place since 8/17/18. ·On 08/17/2018 Resident #1's Wandering and Elopement Risk Assessment was re-evaluated. It was determined that Resident #1 is at risk due to him leaving the building unattended, ambulating independently, and has a [DIAGNOSES REDACTED]. ·A Skin Assessment was also complete on 08/17/2018 at 11:45AM. No skin changes noted. ·08/17/2018 initially at 11:20AM resident was supervised one to one. Since 12:00 p.m., on 8/17/2018, every 15-minute visual checks continue on Resident #1 until safe placement can be found for him. The Director of Nursing initiated this and informed nursing staff. ·Education with receptionist and front office staff complete on 8/17/18 to ensure 100% watch on front door. Education was documented and included that in absence of the receptionist a front office staff member will watch the front door for visitors and residents entering and exiting. Education was complete by the Administrator. Resident #1 photograph was placed at the reception desk on 8/17/18 so all receptionists and front office staff would know what Resident #1 looked like. Any questions of the identity of a resident that the receptionist or front office staff have, can be validated by reviewing the resident picture in the electronic medical record. ·On 08/17/2018 the Director of Nursing conducted a resident wandering assessment on all current residents with a dementia diagnosis. ·Under direction of DON, all current residents with a wander guard in place was assessed for placement. All were in place on 8/17/2018. In-servicing began on 08/17/2018 for missing resident/search and reporting that included in the event a resident is reported missing, Code Orange is to be immediately activated. The Administrator and Director of Nursing are to be immediately notified. All available resources are to be utilized to search and find the resident as quickly as possible. Immediately upon notification of a missing resident, Code Orange will be activated throughout the Health and Rehabilitation Center. All established search and recover plans will be initiated in full force to locate and secure the resident as quickly as possible. All staff members will be pre-assigned and trained on their duties and responsibilities during a critical event. ·On 08/17/18 the door was tested and the wander guard that is on Resident #1 was tested . Both worked according to manufacturer's guidelines. Maintenance Director or designee will test door alarms daily for one month. The procedure for implementing the acceptable plan of correction for the specific deficiency cited; ·08/17/2018 every 15-minute visual checks were conducted on Resident #1. ·The DON rounded facility ensuring all residents with wander guards were accounted for on 8/17/18. ·On 08/17/2018 all residents in house on this date with a [DIAGNOSES REDACTED]. ·On 8/17/2018 and ongoing, facility receptionist remained posted in the front lobby to monitor for any attempts by any resident to exit the facility. The hours of this were 9AM-8PM. From 8PM to 9AM the doors remain locked and any person has to be badged out by a staff member. ·All residents with a [DIAGNOSES REDACTED]. Discussion with Responsible Party, Medical Doctor/NP, and Interdisciplinary team will occur to accurately assess safety of the resident. This was complete on 8/17/2018. ·Discussion with Responsible Party, Medical Doctor/NP, and Interdisciplinary team will occur to accurately assess safety of the resident, that have been deemed at risk, based off [DIAGNOSES REDACTED]. All doors lock between the hours of 5:00PM and 9:00AM. To open doors, a person must be badged out by a staff member. Badging members out of the building has been in process since (MONTH) (YEAR). ·Education to all staff started on 8/17/18 by department managers on the following policies to ensure understanding. New hires will be educated during general orientation. 1)Nursing Policy and Procedure Code Orange, the reasons of Resident #1 leaving the facility without us knowing, and the importance of Code Orange, which covers the immediate notification of a missing resident, Code Orange will be activated throughout the Center. All established search and recover plans will be initiated in full force to locate and secure the resident as quickly as possible. All staff will be pre-assigned and trained on their duties and responsibilities during this critical event. This was started on 08/17/2018 and complete on 8/29/18. No other employees will be allowed to work unless training is complete. Training included the above mentioned and education on increased awareness for change in behavior such as packing belongings, statements of wanting to leave, and exit seeking to all nursing staff, dietary staff, environmental service staff, therapy staff and administrative staff. 2)Nursing Policy and Procedure, Search and Reporting, in the event a resident is reported missing, all available resources will be utilized to search for and find the resident as quickly as possible. Anyone that suspects or realizes that a resident is missing must notify a licensed nurse and/or the Nursing Supervisor immediately. A Nursing Supervisor on duty must immediately initiate a search of the Center and grounds, and at the same time report to the Administrator, the Director of Nursing and Nurse Consultant that the resident is missing. This was started on 08/17/2018 and complete on 8/29/18. No other employees will be allowed to work unless training is complete 3)Nurses and receptionist's will be in-serviced, by the Administrator or their designee, on resident check in/out procedures. Education was provided on 8/17/18 and 8/30/18. Facility will utilize a single check in/out book for all residents that enter and leave the facility. All visitors will receive a visitor pass. Visitor passes must be worn during visit and returned to the front desk upon exiting the building. Any person to be a visitor in the building will be required to have a pass. Those that do not have passes will be residents. Receptionist to nurse verification will be required for any resident that signs out that is leaving unattended. Between the hours of 8:00PM and 9:00AM a clinical staff member will then make the determination as to let a resident out unattended or not. 4)No employee is allowed to work unless they have completed the required in-servicing ·All new admissions with a [DIAGNOSES REDACTED]. Discussion with Responsible Party, Medical Doctor/NP, and Interdisciplinary team will occur to accurately assess safety of the resident. The Director of Nursing, Unit Manager, and Admission Nurse will be educated to assess at risk status using the above criteria. Education complete on 8/30/18 by Regional Nurse Consultant. The monitoring procedure to ensure that the plan of correction is effective, and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements; ·All new admissions will be audited by the Director of Nursing or Regional Nurse Consultant for accurate identification for assessment and risk based on residents with a [DIAGNOSES REDACTED]. Audits will be weekly for one months, bi-weekly for 2 weeks, and monthly for one month. Determination included discussion with Responsible Party, Medical Doctor/NP, and Interdisciplinary team. Audits will be reviewed in quarterly quality assurance process improvement meeting X ' s 2 quarters. ·Administrator or their designee will audit lobby twice daily between the hours of 9:00AM to 5:00PM daily for two weeks, two times daily one time a week for 2 weeks, and monthly for two months. Administrator will audit for coverage presence, the sign in/out book is complete, and that the receptionist or front office staff is validating that the resident is safe to go out unattended. The title of the person responsible for implementing the acceptable plan of correction. ·Administrator approved that the above is accurate and complete as of 8/30/18 The credible allegation for immediate jeopardy removal was verified on 08/30/18 at 1:05 PM as evidenced by the following: verification of re-education for licensed nurses, nursing assistants and other facility staff of Code Orange (covers the immediate notification of a missing resident), Nursing Policy and Procedure regarding search and reporting of a missing resident, in-servicing for licensed nurses and the receptionist for check-in and check-out procedures for residents and visitors, daily testing of the door locking mechanism by the Maintenance Director or designee and re-evaluation by the DON of all residents with dementia/Alzheimer ' s [DIAGNOSES REDACTED].

Based on observations, staff, nurse practitioner and Law Enforcement interviews and record review, the facility failed to follow policy and procedures for Abuse Prohibition for protecting a resident after an assault for 1 of 3 sampled residents (Resident #2). After the assault, the facility allowed the unknown male to remain in the room with the resident, waited to contact police and allowed the unknown male to flee the facility. The unknown male was arrested on 09/05/17 and confessed to two 2nd degree sex offenses. Immediate Jeopardy began on 08/31/17 when Nurse #2 had to use force to open Resident # 2's barricaded door and observed an unknown male in Resident #2's room, the sheets were off the bed and the resident's brief had been removed. The Nurse allowed the unknown male to stay in the room, the nursing staff waited before calling police and allowed the unknown male to flee the facility before the police arrived. The Immediate Jeopardy is present and ongoing. The findings included: A policy titled Abuse/Neglect/Misappropriation/Crime dated 11/04/16 read in part, There is a zero tolerance for mistreatment, abuse, neglect, misappropriation of property, or any crime against a patient of the Health and Rehabilitation Center. Procedures include: - Any staff member observing or suspecting abuse, neglect, misappropriation of property, mistreatment or a reasonable suspicion of a crime will remove the patient from any observed danger or farm and immediately report the incident to the immediate supervisor. - The Administrator will immediately file an initial report to the State Agency. o Serious bodily injury must be reported no later than two hours after forming the suspicion. - The Administrator and/or Director of Nursing will immediately initiate a thorough internal investigation of the alleged/suspected occurrence. The investigative protocol will include but not limited to, collecting evidence, interviewing alleged victims and witnesses and involving other appropriate individuals, agents or authorities to assist in the process and determinations. - The Administrator will immediately (within 2 or 24 hours of knowledge of the allegation) notify the Adult Protective Services Agency, the local Ombudsman and the appropriate law enforcement authorities. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] specified the resident had short and long term memory impairment with severely impaired cognitive skills for daily decision making. The MDS also specified the resident was not comatose, but had no speech and the rare ability to make herself understood. The resident required two person physical assistance with activities of daily living. A nurse's entry made by Nurse #1 dated 08/31/17 at 11:38 PM specified 911 was called and police arrived at the facility in relation to an unknown male observed in Resident #2's room. Review of Resident #2's medical record revealed a medical transportation report dated 08/31/17. The report specified the medical transport was dispatched at 11:38 PM and arrived to Resident #2 at 11:52 PM. The report specified the chief complaint was assault and that they arrived on scene to find an [AGE] year old semi-flower in bed. The report also revealed family reported the resident may have been sexually assaulted by an unknown male that barricaded himself in the room and had removed the resident's brief. The unknown male had been allowed to leave the facility. Staff reported to the medical transport unit that the resident had not been changed or cleaned since the assault. Further review of the medical record revealed a document titled Sexual Assault Nurse Examination dated 09/01/17 at 1:42 AM performed in the Emergency Department. The exam revealed that Resident #2 had no physical injuries from the assault. The exam report revealed the resident had a 4 millimeter excoriation on her labia. Evidence was collected and provided to Law Enforcement. A nurse's entry made by Nurse #3 dated 09/01/17 at 5:15 AM revealed Resident #2 was returning to the facility from the Emergency Department after having had a sexual assault exam. The nurse documented, Report was received from the hospital that according to the assessment and testing it appeared the unidentified male was interrupted before he could do anything to the resident. The facility provided a 24-Hour Initial Report dated 09/01/17 that specified an allegation of Resident Abuse with reasonable suspicion of crime had occurred on 08/31/17 for Resident #2. The facility documented there was a Reasonable Suspicion of a Crime but there was no Serious Bodily Injury. The facility notified the Police Department. The police report titled Criminal Investigations Case Synopsis created on 09/01/17 and updated on 09/05/17 specified the unknown male became a person of interest on 09/01/17 for possible sexual assault when he was found in Resident #2's room. The Resident's gown was opened and brief pulled down. The report revealed the unknown male had been allowed to flee. The unknown male was located and interviewed on 09/05/17. The unknown male was arrested and charged with two 2nd degree sex offenses against Resident #2 on 09/05/17. On 09/07/17 at 9:50 AM Resident #2 was observed in bed and her eyes were closed. On 09/07/17 at 10:35 AM Nurse #1 was interviewed and reported the facility had one entrance for visitors that automatically locked at 9:30 PM. She stated that after 9:30 PM visitors were dependent on a staff member to let them in and out of the facility. Nurse #1 described that on 08/31/17 she was working 3 PM to 11 PM and was preparing to start her 9 PM medication pass on the 200 A Hall. The Nurse explained that at 9:15 or 9:20 PM she was at the top of the 200 A Hall standing at her medication cart when she noticed an unknown male walk past her to the end of the 200 A Hall, opened a door, looked in the room, shut the door and walked back up the hall. She stated she felt this was odd because she didn't know who the male was and why he would have been visiting that Resident. The Nurse added that when the unknown male walked back up the hall she said, Hi and the unknown male waved and stated, Good night. During the same interview the Nurse continued with her story that she remained in the same location at the top of the 200 A Hall and assumed the unknown male exited the building. Nurse #1 explained that she proceeded with her medication pass and approximately 5 minutes later she heard a boom and Nurse #2 yelling for the House Coordinator to, Call 911! He's trying to rape her (Resident #2). Nurse #1 described that she stopped her medication pass, grabbed an umbrella and went to Nurse #2 on the 200 B Hall. Nurse #1 asked what was going on and Nurse #2 reported that she found Resident #2's door closed and when she opened it she saw an unknown male in the room and he had taken the Resident's bed sheets off and removed her brief. Nurse #1 stated that it was the same unknown male she saw 5 minutes earlier that she assumed had left the building. The unknown male told the nurses he was visiting his aunt and needed to provide incontinence care because the nursing staff were not doing their jobs of providing care to Resident #2. Continuing the interview, Nurse #1 stated she asked the unknown male his identity and he provided his name. She stated she wanted to try to diffuse the situation because she could tell the unknown male was angry with Nurse #2, so she asked the unknown male to have a seat in Resident #2's room while she called the family to verify his identify. Nurse #1 stated she realized when she walked away from the room, the unknown male had shut the door to the room. Nurse #1 opened the door and explained to the unknown male that he would need to sit in the room with the door open. Nurse #2 stood outside the room continuing her medication pass to watch the unknown male while Nurse #1 used the telephone. Nurse #1 reported that the unknown male attempted to shut the door 4 times until she finally told him he had to get out of the room. Nurse #1 stated the unknown male was shutting the door because he was fixing Resident #2 back. Nurse #1 explained the unknown male had reattached the resident's brief and put the covers back on her body. Nurse #1 described that she went to the nurses' station area and observed the House Coordinator on the telephone and assumed she was on the phone with 911 as Nurse #2 had called for her to do. The Nurse stated her goal became to keep Resident #2 safe and contact the family. The nurse stated she saw the House Coordinator and asked her if she had called 911 and she hadn't. The Nurse stated she was so confused and upset that 911 had not been called but she knew she had to protect Resident #2. Nurse #1 decided to contact the family because she knew the unknown male was locked inside the facility since it was after 9:30 PM. The nurse used her cell phone to track call times and revealed she spoke with Resident #2's daughter at 9:52 PM to ask if she had a family member with the name provided and the daughter said, Yes. Nurse #1 provided a description of the unknown male and the descriptions did not match but the family stated she was on her way to the facility. Nurse #1 placed a second call to the daughter at 10:18 PM asking her where she was and she was pulling into the parking lot. During the phone call the daughter sat in her vehicle and was able to see the unknown male through the window and front door of the facility. The daughter told Nurse #1 the unknown male was not family and to call the police. Nurse #1 ended the call with the daughter and called 911 at 10:20 PM. At the same time, Nurse #1 explained nurse aide #1 unlocked the front door for the unknown male and he left. Nurse #1 added the police arrive to the facility less than 5 minutes after she called. In the same interview with Nurse #1 she reported that she had received training on abuse and knew to report immediately any suspected allegation and to protect the resident. On 09/07/17 at 11:15 AM Nurse #2 was interviewed and described on 08/31/17 around 9:45 PM she observed the door to Resident #2's room closed. The nurse stated this was concerning because the resident required close monitoring because she was a fall risk and had a [MEDICAL CONDITION] and unable to call for help. The Nurse described that she attempted to open the door but it was barricaded and she called inside the room and there was no answer. The Nurse stated she forced the door open and witnessed an unknown male in Resident #2's room and the unknown male had removed the resident's brief leaving her exposed. The Nurse stated at first she thought the unknown male had killed her (Resident #2) and feared he was going to rape her (Resident #2). Nurse #2 reported she left the room and yelled for the House Coordinator to call 911. Nurse #2 stated the House Coordinator replied that she was on the phone. Nurse #2 explained that it was 15- 20 minutes before the police were called because she was trying to keep the Resident #2 safe. Nurse #2 stated that when the police arrived a staff member had allowed the unknown male to leave the facility. Nurse #2 described that the unknown male had lowered Resident #2's bed to the floor, removed the sheets and placed them in the floor, removed the pillows from the bed and, extended the resident's legs out straight and had them separated and the unknown male had taken his shoes off. On 09/07/17 at 12:03 PM the House Coordinator was interviewed on the telephone and explained that the night of 08/31/17 she was on the telephone with another resident's family for a non-emergency situation when she heard Nurse #2 ask her to call 911. The House Coordinator stated she did not know what was going on for the Nurse #2 to yell for help and to call 911 but that she remained on the phone and did not call 911. The House Coordinator offered no explanation why she did not respond to Nurse #2's yell to call 911. The House Coordinator explained that when she finished with the phone call she went to Nurse #2 to find out what was going on. The House Coordinator was unaware of how long she was on the phone. She explained that she spoke with the unknown male and asked him to sign the guest registry located at the front entrance. She added she walked him to the front and watched as he signed the guest registry. The House Coordinator stated that when the police arrived to the facility, the unknown male had left the facility. The House Coordinator explained that in an attempt to keep the unknown male from leaving she told Nurse #4 (the 100 Hall nurse) not to let anyone out of the facility. The House Coordinator stated that she assumed Nurse #4 relayed the message to all staff on the 100 Hall. Nurse #4 no longer works in the facility and was unable to be reached for an interview. On 09/07/17 at 11:56 AM nurse aide (NA) #1 was interviewed and explained that on 08/31/17 around 10:30 PM she met an unknown male in the hall who asked her to let him out and she did. The aide reported the unknown male looked scary and was upset because he stated he had been trying to get out of the building for an hour. NA #1 stated she asked him who he was and he told the aide he was visiting his aunt but did not provide a name. On 09/07/17 at 1:34 PM Law Enforcement Officer #1 was interviewed on the telephone and explained he was the reporting officer for the case against Resident #2. The Law Enforcement Officer reviewed police reports and stated police were contacted by the facility on 08/31/17 at 10:20 PM and were dispatched immediately. The Law Enforcement Officer explained that when the police arrived to the facility, the unknown male had been allowed to leave the facility. He added that witnesses in the parking lot were able to give a description of the unknown male and make and model of the vehicle he was driving. The Law Enforcement Officer added that once the resident was transported to the Emergency Department for a sexual assault examination, police were re-dispatched to the facility at 11:41 PM. The Law Enforcement Officer stated the unknown male had confessed to crimes against Resident #2. He also explained that samples taken from Resident #2 had been sent to the crime lab and could take weeks to get results. He stated the results could show fingerprints and saliva from the unknown male on Resident #2 that would not be evident in the sexual assault exam. He added the unknown male was currently in custody for the crime committed on 08/31/17. The Officer reported the unknown male stated he walked in the front entrance to the facility and entered Resident #2's room with intention to steal items of value, sifted along her body looking for items to steal and penetrated her vagina with his fingers more than once. On 09/07/17 at 2:27 PM the Administrator was interviewed and explained he was notified of the incident on 09/01/17 by the Corporate Consultant because he was on vacation. He stated that in his absence the Director of Nursing, Corporate Consultant and Director of Operations oversaw facility operations. The Administrator added that he returned to work on 09/05/17 and started the investigation into the incident. The Administrator reported the police should have been called sooner on 08/31/17 and would expect staff to call the police immediately if there was suspicion of a crime. On 09/07/17 at 3:55 PM the interim Director of Nursing (DON) was interviewed and reported she was contacted by Nurse #2 on 08/31/17 at 9:59 PM informing her an unknown male was found in Resident #2's room and had removed her brief. The DON stated she directed Nurse #2 to call the police. The DON explained that it did not matter that the unknown male was alleging to be family based on what Nurse #2 had witnessed in the room. The DON was unaware when the police were called. But the DON was aware the unknown male had been able to leave the locked facility prior to the police arriving at the facility on 08/31/17 the first time they were dispatched to the facility. The DON added an abuse investigation was initiated that night when she contacted the Corporate Consultant. The DON stated she expected staff to call police immediately of suspicion of a crime and that she would want staff to question the identity of anyone in the facility after 9:30 PM they did not recognize. The facility's medical director was out of the country and unable to be reached for an interview. On 09/08/17 at 2:10 PM the Nurse Practitioner (NP) was interviewed and explained that she would expect staff to call police immediately if they suspected assault on a resident and send the resident to the Emergency Department immediately for evaluation. The NP also stated that it would be helpful if the facility had a communication system such as a code system to alert all staff of a dangerous situation to prevent a staff member from letting a perpetrator from leaving the building. On 09/08/17 at 11:15 AM the Administrator was notified of Immediate Jeopardy.

Based on staff interviews, Law Enforcement Officer Interview, nurse practitioner interview and record review the facility failed to notify Health Care Personnel Investigations of a crime against a resident within the required 2 hour timeframe, failed to notify Adult Protective Services of the incident and failed to notify law enforcement immediately of suspicion of a crime for 1 of 1 sampled resident (Resident #2). An unknown male was arrested and charged on 09/05/17 with two second degree sex offenses against Resident #2. Immediate Jeopardy began on 08/31/17 when Nurse #2 had to use force to open Resident #2's barricaded door and observed an unknown male in Resident #2's room, the sheets were off the bed and the resident's brief had been removed; and the facility did not notify local law enforcement immediately. The Immediate Jeopardy is present and ongoing. The findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] specified the resident had short and long term memory impairment with severely impaired cognitive skills for daily decision making. The MDS also specified the resident was not comatose, but had no speech and the rare ability to make herself understood. The resident required two person physical assistance with activities of daily living. The facility provided a 24-Hour Initial Report dated 09/01/17 that specified an allegation of Resident Abuse with reasonable suspicion of crime had occurred on 08/31/17 for Resident #2. The facility documented there was a Reasonable Suspicion of a Crime but there was no Serious Bodily Injury. The facility notified the Police Department. A facsimile receipt documented Health Care Personnel Investigations was notified of the allegation on 09/01/17 at 4:39 PM. The facility did not provide documentation that Adult Protective Services (APS) was notified of the incident. The police report titled Criminal Investigations Case Synopsis created on 09/01/17 and updated on 09/05/17 specified the unknown male became a person of interest on 09/01/17 for possible sexual assault when he was found in Resident #2's room. The Resident's gown was opened and brief pulled down. The report revealed the unknown male had been allowed to flee. The unknown male was located and interviewed on 09/05/17. The unknown male was arrested and charged with two 2nd degree sex offenses against Resident #2 on 09/05/17. On 09/07/17 at 11:15 AM Nurse #2 was interviewed and described on 08/31/17 around 9:45 PM she observed the door to Resident #2's room closed. The nurse stated this was concerning because the resident required close monitoring because she was a fall risk and had a [MEDICAL CONDITION] and unable to call for help. The Nurse described that she attempted to open the door but it was blocked and she called inside the room and there was no answer. The Nurse stated she forced the door open and witnessed an unknown male in Resident #2's room and the unknown male had removed the resident's brief leaving her exposed. The Nurse stated at first she thought the unknown male had killed her (Resident #2) and feared he was going to rape her (Resident #2). Nurse #2 reported she left the room and yelled for the House Coordinator to call 911. Nurse #2 stated the House Coordinator replied that she was on the phone. Nurse #2 explained that it was 15- 20 minutes before the police were called because she was trying to keep the Resident #2 safe. Nurse #2 stated that when the police arrived a staff member had allowed the unknown male to leave the facility. On 09/07/17 at 12:03 PM the House Coordinator was interviewed on the telephone and explained that the night of 08/31/17 she was on the telephone with another resident's family for a non-emergency situation when she heard Nurse #2 ask her to call 911. The House Coordinator stated she did not know what was going on for Nurse #2 to yell for help and to call 911 but that she remained on the phone and did not call 911. The House Coordinator offered no explanation why she did not respond to Nurse #2's yell to call 911. The House Coordinator explained that when she finished with the phone call she went to Nurse #2 to find out what was going on. The House Coordinator was unaware of how long she was on the phone. The House Coordinator stated that when the police arrived to the facility, the unknown male had left the facility. On 09/07/17 at 1:34 PM Law Enforcement Officer #1 was interviewed on the telephone and explained he was the reporting officer for the case against Resident #2. The Law Enforcement Officer reviewed police reports and stated police were contacted by the facility on 08/31/17 at 10:20 PM and were dispatched immediately. The Law Enforcement Officer explained that when the police arrived to the facility, the unknown male had been allowed to leave the facility. He added that witnesses in the parking lot were able to give a description of the unknown male and make and model of the vehicle he was driving. The Law Enforcement Officer added that once the resident was transported to the Emergency Department for a sexual assault examination, police were re-dispatched to the facility on [DATE] at 11:41 PM. On 09/07/17 at 2:27 PM the Administrator was interviewed and explained he was notified of the incident on 09/01/17 by the Corporate Consultant because he was on vacation. He stated that in his absence the Director of Nursing, Corporate Consultant and Director of Operations oversaw facility operations. The Administrator added that he returned to work on 09/05/17 and started the investigation into the incident and intended to have the 5 day report completed and submitted to the State Agency on 09/08/17. The Administrator did not state if other agencies had been notified of the allegation. The Administrator stated the police should have been called sooner and would expect police to be called immediately if there was suspicion of a crime. On 09/07/17 at 3:55 PM the interim Director of Nursing (DON) was interviewed and reported she was contacted by Nurse #2 on 08/31/17 at 9:59 PM informing her an unknown male was found in Resident #2's room and had removed her brief. The DON stated she directed Nurse #2 to call the police. The DON explained that it did not matter that the unknown male was alleging to be family based on what Nurse #2 had witnessed in the room. The DON was unaware when the police were called. But the DON was aware the unknown male had been able to leave the locked facility prior to the police arriving at the facility on 08/31/17 the first time they were dispatched to the facility. The DON added an abuse investigation was initiated that night when she contacted the Corporate Consultant. The DON stated she expected staff to call police immediately of suspicion of a crime and that she would want staff to question the identity of anyone in the facility after 9:30 PM they did not recognize. On 09/08/17 at 11:10 AM the Corporate Consultant was interviewed and reported that she was contacted by the Director of Nursing (DON) about the assault allegation on 08/31/17. The Consultant explained that the facility proceeded with an abuse investigation. The Consultant reported the Health Care Personnel Investigations was not notified of the crime within the 2 hour timeframe because there was no serious bodily injury sustained to Resident #2. The Consultant stated she did not consider an allegation of sexual assault to be serious bodily injury because the resident did not have signs of injury to her body such as vaginal trauma or bleeding. The Consultant referenced Resident #2's Sexual Assault Nurse Examination dated 09/01/17 that specified the Resident had no physical injuries from the assault. The facility's medical director was out of the country and unable to be reached for an interview. On 09/08/17 at 2:10 PM the Nurse Practitioner (NP) was interviewed and explained that she would expect staff to call police immediately if they suspected assault on a resident and send the resident to the Emergency Department immediately for evaluation. The NP also stated that it would be helpful if the facility had a communication system such as a code system to alert all staff of a dangerous situation to prevent a staff member from letting a perpetrator from leaving the building. On 09/08/17 at 11:15 AM the Administrator was notified of Immediate Jeopardy.

Based on observations, staff, nurse practitioner and Law Enforcement interviews and record review, the facility failed to protect a resident from being assaulted by an unknown male for 1 of 3 sampled residents (Resident #2). The unknown male was arrested and charged on 09/05/17 with two 2nd degree sex offenses against Resident #2. Immediate Jeopardy began on 08/31/17 when Nurse #2 had to use force to open Resident # 2's barricaded door and observed an unknown male in Resident #2's room, the sheets were off the bed and the resident's brief had been removed. The Immediate Jeopardy is present and ongoing. The findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident was currently being treated with antibiotics for a urinary tract infection and an over the counter medication for a yeast infection. The admission Minimum Data Set ((MDS) dated [DATE] specified the resident had short and long term memory impairment with severely impaired cognitive skills for daily decision making. The MDS also specified the resident was not comatose, unable to speak and had the rare ability to make herself understood. The resident required two person physical assistance with activities of daily living. A nurse's entry made by Nurse #1 dated 08/31/17 at 11:38 PM specified 911 was called and police arrived at the facility in relation to an unknown male observed in Resident #2's room. Review of Resident #2's medical record revealed a medical transportation report dated 08/31/17. The report specified the medical transport unit was dispatched at 11:38 PM and arrived to Resident #2 at 11:52 PM. The report specified the chief complaint was assault and they arrived on scene to find an [AGE] year old female semi-flower in bed. The report also revealed family of Resident #2 reported the resident may have been sexually assaulted by an unknown male that barricaded himself in the room and had removed the resident's brief. The unknown male had been allowed to leave the facility. Staff reported to the medical transport unit that the resident had not been changed or cleaned since the assault. Further review of Resident #2's medical record revealed a document titled Sexual Assault Nurse Examination dated 09/01/17 at 1:42 AM performed in the Emergency Department. The exam revealed that Resident #2 had no physical injuries from the assault. The exam report revealed the resident had a 4 millimeter excoriation on her labia. Evidence was collected and provided to Law Enforcement. A nurse's entry made by Nurse #3 dated 09/01/17 at 5:15 AM revealed Resident #2 was returning to the facility from the Emergency Department after having had a sexual assault exam. The nurse documented, Report was received from the hospital that according to assessment and testing it appeared the unidentified male was interrupted before he could do anything to the resident. The police report titled Criminal Investigations Case Synopsis created on 09/01/17 and updated on 09/05/17 specified the unknown male became a person of interest on 09/01/17 for possible sexual assault when he was found in Resident #2's room. The Resident's gown was opened and brief pulled down. The report revealed the unknown male had been allowed to flee. The unknown male was located and interviewed on 09/05/17. The unknown male was arrested and charged with two 2nd degree sex offenses against Resident #2 on 09/05/17. On 09/07/17 at 9:50 AM Resident #2 was observed in bed and her eyes were closed. On 09/07/17 at 10:35 AM Nurse #1 was interviewed and reported the facility had one entrance for visitors that automatically locked at 9:30 PM. She stated that after 9:30 PM when the door was locked, visitors were dependent on a staff member to let them in and out of the facility. The Nurse described that on 08/31/17 she was working 3 PM to 11 PM and was preparing to start her 9 PM medication pass on the 200 A Hall. The Nurse explained that at 9:15 or 9:20 PM she was at the top of the 200 A Hall standing at her medication cart when she noticed an unknown male walk past her to the end of the 200 A Hall, opened a door to a resident's room, looked in the resident's room, shut the door and walked back up the hall. She stated she felt this was odd because she didn't know who the male was and why he would have been visiting the resident who lived in the room that he opened the door and looked into. The Nurse added that when the unknown male walked back up the hall, she said, Hi and the unknown male waved and stated, Good night. The Nurse reported that she remained in the same location at the top of the 200 A Hall and assumed the unknown male exited the building. Nurse #1 explained that she proceeded with her medication pass and approximately 5 minutes later she heard a boom and Nurse #2 yelling for the House Coordinator to, Call 911! He's trying to rape her (Resident #2's name). Nurse #1 described that she stopped her medication pass, grabbed an umbrella and went to Nurse #2 on the 200 B Hall. Nurse #1 stated that she asked what was going on and Nurse #2 reported that she found Resident #2's door closed and when she opened it she saw an unknown male in the room and he had taken the Resident's bed sheets off and removed her brief. Nurse #1 stated she entered Resident #2's room and observed the same unknown male she saw 5 minutes earlier that she assumed had left the building. The unknown male told the nurses he was visiting his aunt and needed to provide incontinence care because the nursing staff were not doing their jobs of providing care to Resident #2. Nurse #1 stated she asked the unknown male his identity and he provided his name. She stated she wanted to try to diffuse the situation because she could tell the unknown male was angry with Nurse #2, so she asked the unknown male to have a seat in Resident #2's room while she called the family to verify his identify. Nurse #1 stated she realized when she walked away from the room, the unknown male had shut the door to the room. Nurse #1 stated she opened the door and explained to the unknown male that he would need to sit in the room with the door open. Nurse #1 explained that Nurse #2 stood outside the resident's room continuing her medication pass to watch the unknown male while Nurse #1 used the telephone. Nurse #1 reported that the unknown male attempted to shut the door 4 times until she finally told him he had to get out of the room. Nurse #1 stated she didn't realize at the time but when he was shutting the door, the unknown male was fixing Resident #2 back. Nurse #1 explained the unknown male had reattached the resident's brief and put the covers back on her body. Nurse #1 described that she went to the nurses' station area to call Resident #2's family and observed the House Coordinator on the telephone and assumed she was on the phone with 911 as Nurse #2 had called for her to do. The Nurse stated her goal became to keep Resident #2 safe and contact the family. The nurse stated she asked the House Coordinator if she had called 911 and she informed her that she hadn't. The Nurse stated she was so confused and upset that 911 had not been called but she knew she had to protect Resident #2. Nurse #1 stated she decided to contact the family because she knew the unknown male was locked inside the facility since it was after 9:30 PM. The nurse used her cell phone to track call times and revealed she spoke with Resident #2's daughter at 9:52 PM to ask if she had a family member with the name provided by the unknown male and the daughter said, Yes. Nurse #1 provided a description of the unknown male and the descriptions did not match but the family stated she was on her way to the facility. Nurse #1 placed a second call to the daughter at 10:18 PM asking her where she was and she was pulling into the parking lot. During the phone call the daughter sat in her vehicle and was able to see the unknown male through the window and front door of the facility. The daughter told Nurse #1 the unknown male was not family and to call the police. Nurse #1 ended the call with the daughter and called 911 at 10:20 PM. At the same time, Nurse #1 explained nurse aide #1 unlocked the facility's front door for the unknown male and he left the facility. Nurse #1 added the police arrived to the facility less than 5 minutes after she called. In the same interview with Nurse #1 she was asked if she had ever seen the unknown male prior to the incident. Nurse #1 explained that she had seen the unknown male 2 previous times and was not aware of who he was visiting or his reason for being in the facility. She stated that the instances occurred over a two week period and described that both times the unknown male was with someone else that she was unable to identify. The Nurse reported that one instance she saw the unknown male during the 7 am to 3 pm shift and the other time was on the 3 pm to 11 pm shift. She could not recall what he was doing and she did not ask him his identity. On 09/07/17 at 11:15 AM Nurse #2 was interviewed and described on 08/31/17 around 9:45 PM she observed the door to Resident #2's room closed. The nurse stated this was concerning because the resident required close monitoring because she was a fall risk and had a [MEDICAL CONDITION] and unable to call for help. The Nurse described that she attempted to open the door but it was barricaded and she called inside the room and there was no answer. The Nurse stated she forced the door open and witnessed an unknown male in Resident #2's room and the unknown male had removed the resident's brief leaving her exposed. The Nurse stated at first she thought the unknown male had killed her (Resident #2) and feared he was going to rape her (Resident #2). Nurse #2 described that the unknown male had lowered Resident #2's bed to the floor, removed the sheets and placed them in the floor, removed the pillows from the bed and, extended the resident's legs out straight and had them separated and the unknown male had taken his shoes off. On 09/07/17 at 12:03 PM the House Coordinator was interviewed on the telephone and explained that the night of 08/31/17 she was on the telephone with another resident's family for a non-emergency situation when she heard Nurse #2 ask her to call 911. The House Coordinator stated she did not know what was going on for the Nurse #2 to yell for help and to call 911 but that she remained on the phone and did not call 911 as Nurse #2 requested. The House Coordinator offered no explanation why she did not respond to Nurse #2's yell to call 911. The House Coordinator explained that when she finished with the phone call she went to Nurse #2 to find out what was going on. The House Coordinator was unaware of how long she was on the phone. She explained that she spoke with the unknown male and asked him to sign the guest registry located at the front entrance. She added she walked him to the front and watched as he signed the guest registry. The House Coordinator stated that when the police arrived to the facility, the unknown male had left the facility. The House Coordinator explained that in an attempt to keep the unknown male from leaving she told Nurse #4 (the 100 Hall nurse) not to let anyone out of the facility. The House Coordinator stated that assumed Nurse #4 relayed the message to all staff on the 100 Hall. Nurse #4 no longer works in the facility and was unable to be reached for an interview. On 09/07/17 at 1:34 PM Law Enforcement Officer #1 was interviewed The Law Enforcement Officer stated the unknown male had confessed to sexual crimes against Resident #2. The Law Enforcement Officer added that he was aware the hospital concluded Resident #2 had no visible injury from the assault and that sexual assault exam showed a 4 millimeter excoriated area on Resident #2's vagina. He explained that samples obtained from Resident #2 had been sent to the crime lab and could take weeks to get results. He stated the results could show fingerprints and saliva from the unknown male on Resident #2 that would not be evident in the sexual assault exam. He added the unknown male was currently in custody for the crime committed on 08/31/17. The Officer reported the unknown male stated he walked in the front entrance to the facility and entered Resident #2's room with intention to steal items of value, sifted along her body looking for items to steal and penetrated her vagina with his fingers more than once. An attempt was made to contact the hospital nurse that performed the sexual assault exam for Resident #2. On 09/07/17 at 2:16 PM floor technician #1 was interviewed and stated he had seen the unknown male in the facility several times and did not feel his behavior was suspicious. The floor technician explained that he did not know the reason for unknown male's visits. The floor technician added that on each witnessed account he noticed the unknown male brought a fast food bag with him but did not have the bag when he left. The floor technician stated he assumed the unknown male was bringing food to someone. The floor technician stated there was a lot of people in and out of the facility and unless they were wandering around or going in and out of rooms he would not question them or ask them what they were doing. On 09/07/17 at 2:27 PM the Administrator was interviewed and explained he would expect his staff to question the identity of a visitor that was acting suspicious. The Administrator stated he did not believe the unknown male opening a closed door to a resident's room, looking inside the room, then leaving was suspicious behavior. The Administrator reported the police should have been called sooner and would expect police to be called immediately if there was suspicion of a crime. On 09/07/17 at 3:55 PM the interim Director of Nursing (DON) was interviewed and reported she was contacted by Nurse #2 on 08/31/17 at 9:59 PM informing her an unknown male was found in Resident #2's room and had removed her brief. The DON stated she directed Nurse #2 to call the police. The DON explained that it did not matter that the unknown male was alleging to be family based on what Nurse #2 had witnessed in the room. The DON was unaware when the police were called. But the DON was aware the unknown male had been able to leave the locked facility prior to the police arriving at the facility on 08/31/17 the first time they were dispatched to the facility. The DON added an abuse investigation was initiated that night when she contacted the Corporate Consultant. The DON stated she expected staff to call police immediately of suspicion of a crime and that she would want staff to question the identity of anyone in the facility after 9:30 PM they did not recognize. The facility's medical director was out of the country and unable to be reached for an interview. On 09/08/17 at 11:15 AM the Administrator was notified of Immediate Jeopardy.

Based on observations, staff, nurse practitioner and Law Enforcement interviews and record review, the administration failed to impose expectations related to immediately intervening when sexual abuse was suspected; failed to impose expectations related to immediately removing a perpetrator from resident care areas; failed to impose expectations related to immediately calling law enforcement when a crime was suspected; failed to empower the staff to respond to suspected sexual abuse and not sending the resident out for professional evaluation, failure to have systems in place whereby staff in the building are notified of an immediate threat to residents safety and failed to empower staff to know how to respond to an emergency situation immediately that would be in the best interest of all the residents for 1 of 3 sampled residents (Resident #2). Immediate Jeopardy began on 08/31/17 when Nurse #2 had to use force to open Resident # 2's barricaded door and observed an unknown male in Resident #2's room, the sheets were off the bed and the resident's brief had been removed. And the staff did not immediately respond in a protective manner. The Immediate Jeopardy is present and ongoing. The findings included: 1. Cross refer to F 223: Based on observations, staff, nurse practitioner and Law Enforcement interviews and record review, the facility failed to protect a resident from being assaulted by an unknown male for 1 of 3 sampled residents (Resident #2). The unknown male was arrested and charged on 09/05/17 with two 2nd degree sex offenses against Resident #2. 2. Cross refer to F 225: Based on staff interviews, Law Enforcement Officer Interview, nurse practitioner interview and record review the facility failed to notify Health Care Personnel Investigations of a crime against a resident within the required 2 hour timeframe, failed to notify Adult Protective Services of the incident and failed to notify law enforcement immediately of suspicion of a crime for 1 of 1 sampled resident (Resident #2). An unknown male was arrested and charged on 09/05/17 with two second degree sex offenses against Resident #2. 3. Cross refer to F 226: Based on observations, staff, nurse practitioner and Law Enforcement interviews and record review, the facility failed to follow policy and procedures for Abuse Prohibition for protecting a resident after an assault for 1 of 3 sampled residents (Resident #2). After the assault, the facility allowed the unknown male to remain in the room with the resident, waited to contact police and allowed the unknown male to flee the facility. The unknown male was arrested on 09/05/17 and charged with two 2nd degree sex offenses. On 09/07/17 at 3:00 PM the Administrator was interviewed and stated he felt that facility had no way of knowing a crime like this could occur to a resident and felt the facility had necessary resources and procedures in place for handling emergency situations.

Based on observations, staff interview and record review, the facility failed to prevent a cognitively impaired resident from exiting the facility without staff supervision (Resident #1) for 1 of 3 sampled residents identified as elopement risks. The facility also failed to remove a wheel chair scale from a common area which resulted in a fall with injury (subdural hematoma which required surgery) for 1 of 3 sampled residents at risk for falls (Resident #1). Immediate jeopardy began on 06/01/17 when Resident #1 left the facility unattended and without the facility's knowledge. Immediate jeopardy also occurred on 06/05/17 when Resident #1 fell off a wheel chair scale which resulted in a subdural hematoma requiring surgery. Immediate jeopardy was removed on 06/16/17 when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of (D) (No actual harm with potential for more than minimal harm that is not immediate jeopardy.) for monitoring of the revised systems put in place related to supervision to prevent elopements and falls. The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a) Review of Resident #1's annual Minimum Data Set ((MDS) dated [DATE] revealed an assessment of severely impaired cognition with rejection of care and wandering behaviors. The MDS indicated Resident #1 was independent in locomotion after set up. Review of Resident #1's Care Area Assessment (CAA) for behaviors dated 08/28/16 revealed Resident #1 had no exit seeking behavior but wore a wander guard. Review of Resident #1's quarterly MDS dated [DATE] revealed an assessment of severely impaired cognition with rejection of care. The MDS indicated Resident #1 required the physical assistance of one person with locomotion and had no falls. Review of Resident #1's quarterly MDS dated [DATE] revealed an assessment of severely impaired cognition with wandering behavior. The MDS indicated Resident #1 required supervision with independent locomotion and had no falls Review of Resident #1's wandering risk assessment dated [DATE] revealed documentation of Resident #1's disorientation to person, place and time with a [DIAGNOSES REDACTED]. The wandering risk assessment form used by the facility did not contain a section for level of elopement risk. Review of Resident #1's quarterly MDS dated [DATE] revealed an assessment of severely impaired cognition with rejection of care. The MDS indicated Resident #1 required set up help and was independent in locomotion with no falls. Review of Resident #1's care plan reviewed 04/18/17 revealed identification of elopement risk due to confusion, wandering behavior and independence in wheel chair with the goal of will not leave facility unattended. Interventions included application and regular function check of a wander guard on the right wrist, diversional activities and monitoring of Resident #1's location. Review of Resident #1's May 2017 electronic Treatment Administration Record (eTAR) revealed documentation of wander guard placement checks every shift. The eTAR also contained documentation weekly function checks on the evening shift every Wednesday. Nurse #1 documented Resident #1's wander guard functioned on 05/03/17, 05/10/17, 05/17/17, 05/24/17 and on 05/31/17. Review of a nursing note dated 06/01/17 revealed Resident #1 left the facility without staff knowledge. Nurse #1 documented a visitor was at the front door with Resident #1. Nurse #1 assessed Resident #1 and notified the physician, the Director of Nursing and Resident #1's family member. Nurse #1 checked Resident #1's wander guard which functioned and replaced it with a new wander guard on the left forearm. Review of a nurse practitioner's (NP) note dated 06/02/17 revealed documentation of a physical assessment. The NP documented a bruise on Resident #1's left thumb and no injuries. The NP documented Resident #1 self-propelled in a wheel chair with no changes in motor function or alertness. Telephone interview with Resident #1's family member on 06/13/17 at 11:45 AM revealed the family member visited Resident #1 on 06/01/17. The family member explained she left Resident #1 in the room and left the facility at approximately 5:30 PM to obtain clothing for Resident #1. The family member reported she informed Nurse #1 of her departure and expected return to the facility. The family member explained she received a call from the facility approximately 30 minutes later when she was driving back to the facility. Resident #1's family member reported she stayed that evening (06/01/17) with Resident #1 to make certain he was alright. Resident #1's family member met the next day (06/02/17) with the Director of Nursing and Administrator and agreed to the plan of daily wander guard function checks for Resident #1. Telephone interview with Nurse Aide (NA) #3 on 06/13/17 at 12:42 PM revealed Resident #1 wandered independently in a wheel chair. NA #3 reported she worked on 06/01/17 and did not hear an alarm sound. Observation on 06/13/17 at 2:30 PM revealed a high pitched, shrill alarm sounded which could be heard at the end of the nursing unit. Interview with NA #4 on 06/13/17 at 2:31 PM revealed the shrill alarm signaled the front door opened with a wander guard resident nearby. NA #4 explained Resident #1 wandered independently in a wheel chair throughout the facility. Interview with Nurse #1 on 06/13/17 at 3:02 PM revealed Resident #1 used a wheel chair independently with a wander guard on the wrist. Nurse #1 reported she checked Resident #1's wander guard for placement each shift. Nurse #1 explained she checked Resident #1's wander guard for alarm and door lock function at the front door every Wednesday. Nurse #1 reported Resident #1's wander guard alarmed on 06/01/17 at approximately 5:00 PM when the pharmacy delivered medications. Nurse #1 explained Resident #1 was in lobby with her at the time of medication delivery and the wander guard alarmed when the front door opened. Nurse #1 reported she was not aware that Resident #1's family member left the facility. Nurse #1 explained Resident #1's family member visited frequently and always informed her when leaving. Nurse #1 reported Resident #1 would be distracted with conversation when the family member left to prevent Resident #1 from becoming upset. Continued interview with Nurse #1 revealed she was in the front lobby's restroom at approximately 6:00 PM when the front door alarm sounded. Nurse #1 reported a visitor, who was not known to her, was with Resident #1 at the front door. Resident #1's wander guard alarmed when the visitor opened the door. Nurse #1 explained she checked Resident #1's wander guard for function and it worked. Nurse #1 explained she did not have the opportunity to interview the unknown visitor because she immediately assessed Resident #1 for injury. Nurse #1 reported the unknown visitor stated Resident #1 was on the road. Nurse #1 did not know if the visitor meant the front entrance driveway into the facility's campus, the front circular driveways or the street address road. The visitor left during the assessment. Nurse #1 reported she notified Resident #1's physician, family member and the Director of Nursing. Nurse #1 replaced Resident #1's wander guard with a new one and implemented visual checks every 15 minutes. Interview with Nurse Aide (NA) #1 on 06/13/17 at 3:25 PM revealed she saw Resident #1 seated in a wheel chair on the nursing unit approximately 15 minutes before the alarm sounded which would be approximately at 5:45 PM on 06/01/17. NA #1 explained Resident #1 used the wheel chair independently and wandered throughout the facility. NA #1 reported she checked Resident #1 on a regular basis throughout the shift since Resident #1's admission to the facility. Interview with NA #5 on 06/13/17 at 4:36 PM revealed Resident #1 wandered independently in a wheel chair on 06/01/17. NA #5 reported she did not hear an alarm sound until Resident #1 returned and Nurse #1 responded. NA #5 reported she did not know Resident #1's family member left the faciity on [DATE]. Interview with NA # 6 on 06/13/17 at 4:45 PM revealed Resident #1 wandered independently in a wheel chair on 06/01/17. NA #6 reported she did not hear an alarm sound until Resident #1 returned and Nurse #1 responded. Interview with the maintenance director on 06/13/17 at 4:57 PM revealed the facility's wander guard system functioned, he checked it daily 5 days a week, and the wander guard battery lasted 3 years. The maintenance director explained the front door automatically locked when a resident with a wander guard approached within 9 feet. If someone opened the door during the hours of 6:30 AM and 9:30 PM when the front door was unlocked, then an alarm would sound if a wander guard resident was within 9 feet. The maintenance director reported he repaired a mag lock on 05/17/17 with the vendor on site that same day to ensure the locks and system operated. There was no problem. The maintenance director explained he checked the system after Resident #1's elopement and found no problems. The maintenance director explained he contacted the wander guard company by telephone and email to make certain he checked the system thoroughly. Interview with the Director of Nursing (DON) on 06/14/17 at 8:52 AM revealed only licensed nurses and the front office staff could silence the alarm. The DON reported Nurse #1 notified her of Resident #1's elopement on 06/01/17. The DON reported she directed Nurse #1 to replace Resident #1's wander guard as a precaution and implement frequent checks. The DON explained all residents with wander guards were checked for function and no problem identified. The DON reported she interviewed all evening staff on duty on 06/01/17 and no staff member heard an alarm sound until Resident #1 was at the front door with the unknown visitor. The DON explained the alarm could only be turned off physically with a badge. Observation on 06/14/17 at 3:30 PM revealed the facility's campus consisted of a driveway from the main road into a parking lot. The main road was a two-lane street with a speed limit of 35 miles per hour in a residential area. Three private single homes faced and used the facility's driveway for egress. The parking lot extended to the front of the facility which consisted of 2 circular driveways under a portico. A sidewalk bordered the circular driveway and parking lots. The distance from the front door to the driveway into the parking lot was approximately 100 yards and the distance from the front door to the street was approximately 133 yards. The immediate jeopardy was identified on 06/15/17. The facility administrator was notified of the immediate jeopardy on 06/15/17 at 10:50 AM. The facility provided an acceptable credible allegation of compliance which included: How the corrective action will be accomplished for those residents found to have been affected by the deficient practice: · On 6/1/17 Resident # 1, who had a wander guard initiated on 6/7/15 - was observed before dinner at the facility's front door and it locked preventing him from leaving. Resident #1 was re-directed to dining room by nursing assistant. After dinner, a family member of Resident #1 visited the resident. Approximately 15 minutes after she had left the facility's front door alarmed. At approximately 6:00 PM a visitor was with Resident #1 at the facility's outside front entrance and stated the resident had fallen near the road. Initial nurse assessment revealed no injury. Resident said he was following his daughter when asked why he left the building. The resident's wander guard was checked for function near the front door by his charge nurse. When the door was closed and wander guard was two feet away from door it locked. A new wander guard was placed on Resident #1's left forearm. On 06/01/17 Resident #1's family member and the on call MD were informed of the resident's unsupervised exit from the facility and his statement. Family member returned to the facility and stayed with him until approximately 10:30 PM. Charge nurse initiated frequent checks ranging from 15 minutes to an hour. They were initiated at approximately 6:30 PM and concluded approximately 10:00 AM the following day. · On 6/2/17 Resident #1 Wandering and Elopement Risk Assessment was re-evaluated to ensure appropriate interventions were in place by the Director of Nursing (DON). DON and administrator also met with the resident's concerned party/family member and discussed the care plan. New intervention was added to the Kardex for nursing assistants to validate the function of the resident's wander guard daily. Function checks were located on the Medication Administration Record (MAR) for nursing to validate weekly. Nurse practitioner assessment completed on 6/2/17 revealed a bruise to the left thumb. On 06/05/17 Resident #1 experienced a fall in the facility and was transferred to a hospital and remains in the hospital as of 06/16/17. How corrective action will be accomplished for those residents having potential to be affected by the same deficient practice: · As a routine practice, visual rounds and cross shift communication will be done by nursing every shift to observe and ensure all residents are accounted for. Orders are placed on the MAR for documentation of location of wander guard on resident's body every shift and function of wander guard weekly. The resident's nurse will be responsible for checking and documenting the location of the resident's wander guard on their body every shift and the function of the wander guard weekly. Care plans are updated to include location of wander guard and serial number of device. This will be reviewed in Risk Management Meeting on a weekly basis and through quarterly Quality Assurance (QA) meeting as needed. · All facility staff were in-serviced beginning on 6/13/17 for Policy #1902 - Missing resident - and code orange including elopement procedures, patient rounding, and responding to alarms. Education was provided by DON, unit managers, and unit coordinator. New hires will be educated during general orientation. All staff will be in-serviced before returning to work. · Beginning on 6/13/17, as per policy, the Maintenance director or designee will continue to test door alarms daily and results of checks will be documented in our maintenance software program. The alarm monitoring company will be contacted if any issues are identified. · On 6/13/17, all 7 residents in-house on this date with wander guards had their Wandering and Elopement Risk Assessments and care plans re-evaluated and revised as needed by the DON and Regional Nurse Consultant. All wander guards were checked by DON for function and all were working appropriately. Administrator, DON, Regional Nurse Consultant, and Maintenance Director were unable to re-create the scenario of door not alarming with a wander guard in place. · On 6/13/17, the maintenance director contacted an Alarm Monitoring Company who performed in house testing of all facility doors and alarms on 6/15/17 and they were also unable to re-create this scenario of door not alarming with a wander guard in place. The system is working as designed. b) Review of Resident #1's quarterly Minimum Data Set ((MDS) dated [DATE] revealed an assessment of severely impaired cognition with rejection of care. The MDS indicated Resident #1 required set up help and was independent in locomotion and had no falls. Review of Resident #1's care plan revised 03/29/17 revealed a risk for falls related to gait/balance problems and unawareness of safety needs. Interventions included to keep the environment free of trip hazards. Review of a nurse note dated 06/05/17 at 5:00 PM revealed Nurse #1 documented Resident #1 fell backward in a wheel chair onto the floor. Nurse #1 documented Resident #1's back of the head swelled and Resident #1 remained alert and confused. Resident #1's blood pressure measured 148/81 millimeters of mercury, heart rate measured 80 with a respiratory rate of 20. Resident #1's oxygen saturation rate measured 96% on room air. Resident #1's pupils were equal and reactive to light. Nurse #1 notified the physician and transferred Resident #1 to the hospital. Review of Resident #1's fall assessment dated [DATE] revealed Nurse #1 documented the intervention to prevent recurrence was to not leave the wheel chair scale unattended. Review of Resident #1's emergency room admitted d 06/05/17 revealed a [DIAGNOSES REDACTED]. Review of a neurosurgical operative note dated 06/06/17 revealed Resident #1 underwent a left craniotomy for evacuation of the subdural hematoma. Telephone interview with Nurse Aide (NA) #3, who cared for Resident #1 on the day shift, on 06/13/17 at 12:42 PM revealed Resident #1 used a wheel chair independently and wandered in the facility on 06/05/17. Interview with Nurse #1 on 06/13/17 at 3:02 PM revealed she witnessed Resident #1's fall. Nurse #1 explained she was at the medication cart approximately 6 to 7 feet away when Resident #1 rolled up the ramp to the wheel chair scale. Nurse #1 reported Resident #1 fell backwards when the wheel chair reached the top of the ramp incline. Nurse #1 explained she could not reach Resident #1 in time to prevent the fall. Nurse #1 explained the wheel chair scale was placed in front of the nursing desk with both ramps lowered. Nurse #1 reported the wheel chair was usually stored in the alcove but was placed in front of the nursing desk when the nurse aides weighed residents. Nurse #1 reported she transferred Resident #1 to the hospital. Interview with Nurse Aide (NA) #1 on 06/13/17 at 3:25 PM revealed Resident #1 used his wheel chair independently and wandered in the facility. NA #1 reported she assisted Resident #1 into the wheel chair on 06/05/17 when she came on duty at 3:00 PM. NA #1 explained NA #2 was weighing all residents in the facility at the time of Resident #1's fall. NA #1 reported the wheel chair scale was placed in front of the nursing station with the ramps down. Interview with NA #2 on 06/13/17 at 3:30 PM revealed he volunteered to obtain resident weights on 06/05/17 with permission from the unit coordinator. NA #2 explained he moved the wheel chair scale in front of the nursing station and lowered the ramps on each side at approximately 3:30 to 4:00 PM. NA #2 reported he transported residents to the scale from the resident rooms and the other nursing unit. NA #2 reported he stopped transporting residents to the wheel chair scale for approximately 10 minutes to assist transporting residents to the dining room for the dinner meal. NA #2 reported he did not return the wheel chair scale to the alcove or place the ramps in the up position. Observation of the metal wheel chair scale with the maintenance director on 06/14/17 at 9:01 AM revealed the wheel chair scale measured 54 inches by 29 inches with the two ramps in the down position. The incline of each ramp was approximately 35 degrees. Telephone interview with the unit coordinator on 06/14/17 at 9:06 AM revealed NA #2 placed the wheel chair scale in front of the nursing station on 06/05/17. The unit coordinator explained the wheel chair scale was always placed in front of the nursing station while in use. The unit coordinator reported the scale was unattended for the time it took to transport residents to the scale which would be less than 2 minutes. The unit coordinator was aware NA #2 left wheel chair scale unattended to assist with transportation to the dining room. Interview with the Director of Nursing (DON) on 06/14/17 at 9:31 AM revealed after Resident #1's fall from the wheel chair scale, she directed staff not to leave the wheel chair scale unattended with the ramps down. The DON explained the wheel chair scales were stored in an alcove when not in use. The immediate jeopardy was identified on 06/15/17. The facility administrator was notified of the immediate jeopardy at 10:50 AM. The facility provided an acceptable credible allegation of compliance which included: How the corrective action will be accomplished for those residents found to have been affected by the deficient practice: · On 6/5/17 at approximately 6:00 PM Resident # 1 was observed by a staff nurse. One of the facility's wheelchair scales was near the nursing station with its ramp lowered. Resident #1 was observed to roll himself onto the scale's ramp in his wheelchair and leaned backwards once he arrived at the top of incline and fell backwards hitting his head on the floor. Resident was evaluated by Director of Nursing (DON) and orders were obtained to send to the emergency room (ER) for evaluation. Resident #1 has not returned to facility since his fall of 6/5/17 and remains in the hospital. How corrective action will be accomplished for those residents having potential to be affected by the same deficient practice: · Facility identified ambulatory and self-propelled wheelchair residents as potentially being affected by deficient practice. Root cause analysis of Resident #1's fall on 06/05/17 was performed by DON and revealed that on 6/05/17 a nursing assistant was using one of the facility's wheel chair scales to obtain resident weights at the nursing station and stepped away to take the resident to the dining room. The nursing assistant left the scale's ramp in the down position, which allowed Resident #1 to wheel his wheel chair across the scale's ramp surface and fall backwards. · Staffing in-service began on 6/13/17 for new storage procedures for wheelchair scale for all staff. In-service is conducted by DON, unit manager, and unit coordinator. Staff were directed the wheel chair scale's ramp is to be closed when it is not in use. All staff have been in-serviced to include proper storage of all equipment when not in use and to identify any environmental safety concerns. New staff hires will be educated during general orientation. All staff will be in-serviced before being allowed to return to work. · Nursing assistant that was using the scale on 6/5/17 has been given one-on-one education on proper storage of wheelchair ramps when not in use. The immediate jeopardy was removed on 06/16/17 at 11:30 AM following observations of staff supervision of residents identified as at risk of elopement and the function of the wander guard system. Observations revealed resident areas were free from environmental hazards. Staff interviews revealed receipt of training related to elopement and fall prevention. Documentation was reviewed regarding staff training related to resident supervision, fall prevention and freedom from environmental hazards.

Based on record review, hospital records and facility staff interviews, the facility failed to monitor [MEDICATION NAME] blood levels for 2 of 7 sampled residents receiving anticonvulsant therapy. (Resident #1 and #3). Immediate Jeopardy began 09/04/12 when the facility failed to obtain a [MEDICATION NAME] level on Resident #1 and the resident subsequently had a [MEDICAL CONDITION] which resulted hospitalization for [DIAGNOSES REDACTED] and acute [MEDICAL CONDITION]. Resident #1 was admitted to the intensive care unit of the hospital on a ventilator. In addition, the facility failed to obtain a [MEDICATION NAME] level on Resident #3 on 09/07/12 and the resident subsequently was admitted to the hospital with [REDACTED]. The facility remains out of compliance at a lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems are in place and the completion of employee training. The findings are: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#1 had a [MEDICATION NAME] level on 08/27/12 of 12.1 microgram per milliliter (ug/ml) and on 08/28/12 of 10.3 ug/ml. Further review of hospital records revealed the resident was ordered three (3) capsules of [MEDICATION NAME] (an anti-[MEDICAL CONDITION] medication) 100 milligrams (mg) (totaling 300 mg) each night at bedtime. Review of physician orders [REDACTED]. Further review of physician orders [REDACTED]. Review of Resident #1's care plan 08/30/12 revealed no plan of care for [MEDICAL CONDITION] disorder or monitoring of drug levels for [MEDICATION NAME] related to her [MEDICAL CONDITION] disorder. Further review of Resident #1's medical record revealed no result of the [MEDICATION NAME] level that was to be drawn on 09/04/12. Lab results indicated the two other labs that were to be drawn on 09/04/12, the CBC and BMP, had been drawn and the results were in the resident's medical record. Review of the Lab Tracking form with lab orders due to be drawn on 09/04/12 listed the CBC and the BMP to be drawn for Resident #1 and were initialed as being done. The [MEDICATION NAME] level was not listed on this form. Review of the Lab Requisition form dated 09/04/12 listed both the CBC and the BMP that were drawn on Resident #1. The [MEDICATION NAME] level was not listed on this form. Review of Medication Administration Records (MAR) indicated the [MEDICATION NAME] was signed as having been administered from 08/29/12 through 10/03/12. Review of nurses notes dated 10/04/12 at 10:13 PM read, "Resident sent out due to having multiple [MEDICAL CONDITION] 2-3 minutes non-stop." Review of hospital records dated 10/04/12 revealed the resident was admitted to the hospital with [REDACTED]. The hospital records stated Resident #1 had a tonic clonic [MEDICAL CONDITION] that lasted for greater than 30 minutes. Resident #1's [MEDICATION NAME] level, when she was admitted to the hospital, was less than 2.5 microgram per milliliter (ug/ml) (a therapeutic [MEDICATION NAME] level is 10 -20 ug/ml). The resident was intubated in the emergency department and was admitted to the intensive care unit of the hospital. Resident #1 continued to be on a ventilator until 10/05/12 when she was extubated and was able to breathe on her own. Resident #1 was discharged from the hospital on [DATE] to another long term care facility. An interview was conducted on 11/19/12 at 1:45 PM with the Director of Nursing (DON). The DON confirmed the [MEDICATION NAME] level that was to be drawn 09/04/12 on Resident #1 was not drawn. She stated it was a transcription error. She further explained the BMP and the CBC were completed but the [MEDICATION NAME] level was missed. She stated the nurse who received the order for the labs was responsible for entering the ordered labs on the Lab Requisition and the Lab Tracking forms. She stated the third shift nurse who had completed the chart check should also have made sure all three labs had been entered on the Lab Requisition form and the Lab Tracking form. During a later interview on 11/19/12 at 5:47 PM with the DON, she stated a chart check was completed and initialed and dated on 08/30/12 on Resident #1's physician order [REDACTED]. A telephone interview was conducted on 11/21/12 at 4:21 PM with Nurse #2, the third shift nurse who had initialed and dated the physician order [REDACTED]. She stated she would have checked the lab book to make sure the labs had been listed. She further stated that because this lab order was written toward the end of the month and due the following month, neither the Lab Requisition form nor the Lab Tracking forms would have been in the lab book yet. She stated it was the unit supervisor's job to take the labs that had been written in the lab book and transcribe them to the Lab Requisition form and the Lab Tracking forms. She stated that when she initialed and dated the physician's orders [REDACTED]. 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#3 as cognitively intact. A plan of care dated 09/13/12 recorded Resident #3 at risk for injury related to [MEDICAL CONDITION] activity with an intervention to perform lab tests as ordered by the physician. A review of Resident # 3's laboratory report revealed a [MEDICATION NAME] lab result dated 06/28/12 with a [MEDICATION NAME] level of 9.6 micrograms per milliliter (ug/ml) and indicated the therapeutic [MEDICATION NAME] level range as 10.0-20.0 ug/ml. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A neurology consultation note dated 08/27/12 indicated a recommendation for Resident #3's [MEDICATION NAME] to be restarted at 200 milligrams (mg) twice daily and a [MEDICATION NAME] level to be drawn in 2 weeks. A review of Resident #3's physician orders [REDACTED]. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further review of Resident #3's medical record revealed no documentation of a [MEDICATION NAME] blood level lab drawn on 09/07/12. A nurse's progress note dated 09/27/12 at 10:10 PM indicated Resident #3 requested to be sent out to hospital due to "feeling dizzy and drunk in the head". The physician was notified and an order was received to send the resident to the emergency department (ED) for evaluation. At 10:00 PM a call from the ED stated the resident had toxic [MEDICATION NAME] levels and would return to the facility later in the evening. A review of the ED summary dated 09/27/12 indicated Resident #3's condition included mild [MEDICATION NAME] toxicity with instructions to hold [MEDICATION NAME] tomorrow and contact the physician to adjust the [MEDICATION NAME] dose. Per the hospital records, the [MEDICATION NAME] level was 28 ug/ml. A physician's progress note dated 09/28/12 recorded an assessment and plan to hold the [MEDICATION NAME] and to check the [MEDICATION NAME] level on Monday. A laboratory report dated 10/01/12 recorded Resident #3's [MEDICATION NAME] level was 18.8 ug/ml. Interview with the Director of Nursing (DON) on 11/19/12 at 1:46 PM revealed [MEDICATION NAME] levels were usually ordered by the physician and not scheduled unless the resident was remaining in the facility long term. The DON stated the nurse who received the order for a lab was responsible for entering the lab on a lab requisition sheet as well as a facility lab tracking form. She further explained the 3rd shift nurse was responsible to complete a 24 hour chart check, verify the lab ordered was placed on a lab requisition sheet for the next lab draw, and initial the order to indicate all steps had been completed. A follow-up interview with the DON on 11/19/12 at 5:46 PM confirmed the 09/07/12 [MEDICATION NAME] level was not drawn for Resident #3. The DON stated she could not identify the nurse who had initialed the order indicating a chart check and lab form had been completed. The DON stated she would have expected the nurse who initialed the order to have verified the lab was placed on the lab requisition and lab tracking sheet to ensure the [MEDICATION NAME] level would have been drawn on 09/07/12 as per physician order. An interview with the Nurse Practitioner (NP) 12/05/12 at 9:50 AM revealed Resident #3 was prone to have [MEDICAL CONDITION] and therefore she relied on the labs to monitor and evaluate Resident #3's need for changes in his [MEDICATION NAME] dose. Credible Allegation of Compliance for F-329 Resident #3, affected by the deficient practice, was sent to the hospital on [DATE] and was evaluated in the emergency room for dizziness. The resident readmitted to Charlotte Health Care Center on 9/27/2012. Resident #3's labs are currently being monitored by nursing as ordered by the physician. Resident #1, affected by the deficient practice, was sent to the hospital on [DATE] with [MEDICAL CONDITION] and subsequently did not return to the facility. An audit was completed by the Unit Manager (UM) and a Licensed Practical Nurse (LPN) on 11/19/2012 for residents who are on [MEDICATION NAME] therapy to ensure that labs were completed as ordered. The total number of residents on [MEDICATION NAME] was four (4). The audit identified zero (0) residents requiring additional labs to obtain [MEDICATION NAME] levels. Licensed Practical Nurse, Unit Manager and Staff Development Coordinator conducted a 100% audit of all current lab orders on 12/5/2012. All lab discrepancies identified were obtained and corrected on nine (9) residents. The following process for the ordering, monitoring, and reviewing of labs will be systemically implemented at the facility. The following process was revised and implemented on 11/28/2012 by the Director of Nursing. 1. A licensed nurse receiving a lab order will document the order on the current month ' s lab tracking form. The licensed nurse will then complete a lab requisition from the lab vendor. 2. If a routine lab test is not due during the current month the licensed nurse will document the appropriate information onto the Lab Tracking Log and complete a lab requisition, indicating the type of lab test ordered and the date to be completed. 3. The 11-7 shift licensed nurse or supervisor will check the lab tracking form nightly for lab work to be drawn the following morning. The appropriate requisition will be pulled from the lab book (or completed if necessary) and placed in the facility ' s designated location for the lab technician. 4. Upon completion of the lab draw a licensed nurse will document the date the specimen was drawn on the appropriate lab tracking form. 5. A licensed nurse will then notify the physician as soon as possible of any abnormal lab results. 6. Once the physician has been notified of the lab results, the nurse will document the date of notification and the method of notification on the Lab Tracking Log. 7. A licensed nurse will document any necessary information for follow up on the 24-hour Report. 8. Daily, during shift change, the licensed nursing staff for both shifts will sign, indicating completion and review of steps 1-8 above. 9. At the end of each month, the unit manager or director of nursing will file the completed lab tracking and requisition forms and prepare the lab book for the new month; this process will include placing any recurring labs from the master lab log on the appropriate date's lab tracking form in the new month. 10) As an additional audit process, the licensed nurse on 11 p.m. to 7 a.m. shift will complete a 24-hour chart check on all in-house resident charts for new orders to ensure that orders are transcribed correctly. This process will be monitored by the Unit Manager. a. Licensed nurse will follow steps 1-8 above. b. Labs identified will be obtained and any discrepancies will be corrected as necessary. Upon completion of the chart check the nurse will complete the 24 hour chart check form. This process will be monitored by the Unit Manager by completing an additional 24 hour chart check on any resident receiving [MEDICATION NAME] for a period of: 1. Daily (Monday - Friday) for four weeks, 2. Three times per week for four weeks, 3. Then weekly for four weeks, 4. Then quarterly x2. 5. Completed audits to be given to be given to the Director of Nursing. An in-service, which started on 11/28/2012, is being conducted by the Director of Nursing (DON) for all licensed nurses who are currently working in the facility and will be completed for all nurses by 12/06/2012. The in-service includes lab policy and including the revised procedures as stated above. Any licensed nurse that is on Family Medical Leave Act (FMLA), Leave Of Absence (LOA), or vacation will be in-serviced before their next scheduled shift via phone or in person by the DON or UM. To monitor the laboratory system, the Unit Manager or House Supervisor will review all new orders for residents on [MEDICATION NAME] each weekday. Monitoring will also include auditing the charts of residents receiving [MEDICATION NAME], lab book, lab tracking forms. Such monitoring will occur: a) Daily (Monday - Friday) for four weeks, b) Three times per week for four weeks, c) Then weekly for four weeks, d) Then quarterly x2. e) Results from the Unit Manager audits will be given to the Director of Nursing for tracking and trending of concerns weekly for a period of 12 weeks and quarterly x2. Any deficient practice or concern will be addressed, at the time of the occurrence, including progressive disciplinary action if needed. The DON will report any patterns or trends to the quality assurance committee. The quality assurance committee will determine if further education or systemic changes are needed and continuation of audits as deemed necessary for further compliance. The Immediate Jeopardy was lifted on 12/06/12 at 5:00 PM. The facility provided evidence of in-service training for all nursing staff. Interviews and observations of nursing staff implementing shift to shift report of all laboratory orders was completed. Nursing staff were observed using computer print out of all physician orders, specifically laboratory orders written that day, and comparing them to the labs listed on the Lab Requisition and Lab Tracking forms. Interview of nursing staff for all shifts was completed confirming they were trained on the procedure of obtaining and confirming that laboratory orders were carried out. Furthermore, interviews with third shift staff responsible for checking physician orders [REDACTED].

Based on record review, staff interviews and consultant pharmacist interview, the consultant pharmacist failed to report the missing laboratory monitoring of Dilantin blood levels for 2 of 7 sampled residents receiving anticonvulsant therapy. (Resident #1 and #3). Immediate Jeopardy began on 09/24/12 when the facility's pharmacist failed to identify and report missing Dilantin levels. Failure to identify and report the missing Dilantin blood levels resulted in Resident #1's hospitalization for [DIAGNOSES REDACTED] and acute respiratory failure. Resident #1 was admitted to the intensive care unit of the hospital on a ventilator. In addition, failure to identify and report the missing Dilantin levels resulted in Resident #3 being admitted to the hospital with [REDACTED]. The facility remains out of compliance at a lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems are put into place. The findings are: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#1 had a Dilantin level on 08/27/12 of 12.1 microgram per milliliter (ug/ml) and on 08/28/12 of 10.3 ug/ml. Further review of hospital records revealed the resident was ordered three (3) capsules of Dilantin 100 milligrams (mg) (totaling 300 mg) each night at bedtime. Review of Physician orders [REDACTED]. Review of physician orders [REDACTED]. Further review of Resident #1's medical record revealed no result of the Dilantin level that was to be drawn on 09/04/12. Lab results indicated the two other labs that were to be drawn on 09/04/12, the CBC and BMP had been drawn and the results were in the resident's medical record. A review of Pharmacy notes dated 09/25/12 revealed the Pharmacist did not mention Dilantin, the need for monitoring a Dilantin level, or the missing results of the physician ordered Dilantin blood level. Review of nurses notes dated 10/04/12 at 10:13 PM read, "Resident sent out due to having multiple seizures 2-3 minutes non-stop." Review of hospital records dated 10/04/12 revealed Resident #1 was admitted to the hospital with [REDACTED]. Resident #1 was noted to have a tonic clonic seizure for greater than 30 minutes. Resident #1's Dilantin level when she was admitted to the hospital was less than 2.5 microgram per milliliter (ug/ml)(a therapeutic Dilantin level is 10-20 ug/ml). The resident was intubated on 10/04/12 and placed on a ventilator. The resident was admitted to the intensive care unit of the hospital. An interview on 11/19/12 at 1:45 PM was conducted with the Director of Nursing (DON). She confirmed the Dilantin level was not drawn for Resident #1 on 09/04/12. A telephone interview was conducted on 11/19/12 at 4:50 PM with the facility's pharmacist. He stated he usually looked at the physician orders [REDACTED]. He further stated if a lab was not in the chart he did not look for it. He stated he would look for clinical presentation indicating there was a need for a Dilantin level. A later interview was conducted on 11/19/12 at 5:15 PM with the DON. The DON stated typically the pharmacist gave her a recommendation for a lab to be done if he did not see one in the medical record. She stated the pharmacist did not give her a recommendation indicating Resident #1 needed a Dilantin level. 2. Resident #3 was admitted to the facility on [DATE]. The Resident's [DIAGNOSES REDACTED].#3 as cognitively intact. A plan of care dated 09/13/12 recorded Resident #3 at risk for injury related to seizure activity with an intervention to perform lab test as ordered by the physician. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A neurology consult dated 08/27/12 recommended restarting Dilantin at 200 mg (milligrams)twice daily and to recheck Dilantin blood levels in 2 weeks. A physician order [REDACTED]. Further review of the Medication Administration Records (MARs) for August 2012 revealed that this dose change was appropriately made and Resident #3 received 400 mg Dilantin every day from August 27th 2012 until September 27th 2012. Review of Resident # 3's laboratory reports revealed no labs were drawn on 09/07/12. Review of the monthly pharmacy progress notes revealed that Resident #3's chart was reviewed by the consultant pharmacist on 09/24/12. There was no mention about the missing Dilantin level in the review and no recommendations were forwarded to the physician or Director of Nursing by the consultant pharmacist. Further review of the medical record revealed a nurse's progress note dated 09/27/12 at 10:10 PM indicated Resident #3 requested to be sent out to hospital due to "feeling dizzy and drunk in the head." The physician was notified and an order was received to send the resident to the emergency department (ED) for evaluation. At 10:00 PM a call from the ED stated the resident had toxic Dilantin levels and would return to the facility later in the evening. A review of the ED summary dated 09/27/12 indicated Resident #3's condition included mild Dilantin toxicity with instruction to hold Dilantin tomorrow and contact the physician to adjust Dilantin dose due to a Dilantin level of 28 ug/ml (therapeutic range 10 -20 ug/ml). A telephone interview was conducted on 11/19/12 at 4:50 PM with the facility's pharmacist. He stated he usually looked at the physician orders [REDACTED]. He further stated if a lab was not in the chart he did not look for it. He stated he would look for clinical presentation indicating there was a need for a Dilantin level. An interview with the DON on 11/19/12 at 5:46 PM confirmed that the facility had missed the 09/07/12 lab draw for Resident #3 after a dose change in Dilantin. The DON also explained she would have expected the consultant pharmacist to have caught the error on his monthly visit and made her aware of the missed lab. Credible Allegation of Compliance F428 Resident #3, affected by the deficient practice, was sent to the hospital on [DATE] and was evaluated in the emergency room for dizziness. The resident readmitted to Charlotte Health Care Center on 9/27/2012. Resident #3 ' s labs are currently being monitored. Resident #1, affected by the deficient practice, was sent to the hospital on [DATE] for seizures and subsequently did not return to the facility. Administrator met with Pharmacy Consultant on 12/05/2012 at 8 p.m. The Administrator educated Pharmacy Consultant on: 1) Expectation of Consultant Pharmacist to review lab orders and medications that have recommendations for laboratory monitoring during his monthly facility reviews. 2) Pharmacist is to recommend laboratory monitoring to the physician as outlined in the suggested laboratory monitoring parameters for selected medications in the Omnicare Pharmacy Reference. 3) Expectation of Consultant Pharmacist that, if an order is on the chart for a laboratory test to be conducted, he is to verify the lab results are in the medical record and that this is to be completed with each monthly review. If the results are not available on the medical record, then he is to identify the concern each month with his consultant review report. An audit was completed by the Unit Manager (UM) and a Licensed Practical Nurse (LPN) on 11/19/2012 for residents who are on Dilantin therapy to ensure that labs were completed as ordered. The total number of residents on Dilantin was four (4). The audit identified zero (0) residents requiring additional labs to obtain Dilantin levels. Licensed Practical Nurse, Unit Manager and Staff Development Coordinator conducted a 100% audit of all current lab orders on 12/5/2012. All lab discrepancies identified and corrected. An audit was completed on 100% of all in-house resident charts by the Pharmacy Consultant on 12/05/2012 through 12/06/2012 to ensure residents receiving Dilantin had the required labs as physician ordered. The audit identified zero (0) residents on Dilantin requiring additional labs. The Pharmacy Consultant will continue to audit patients receiving Dilantin. This audit will include ensuring that required or ordered labs are present. If the results are not available on the medical record, then he is to identify the concern each month with his consultant review report. The Director of Nursing, or in their absence the Unit Manager or Registered Nurse Supervisor, will review recommendations with the Pharmacy Consultant during his monthly facility visit and compare those recommendations to the list of patients on Dilantin and ordered labs to ensure recommendations are addressed and any discrepancies are corrected as needed. Monthly, the Director of Nursing will review the completed Pharmacy recommendations. The Consultant Pharmacist or Director of Nursing will report findings of Pharmacy recommendations and any missing Dilantin recommendations to the Quality Assurance and Assessment Committee quarterly x3 for continued compliance and revision of monitoring as needed and directed by the committee. Immediate Jeopardy was lifted on 12/06/12 at 5:00 PM. The facility's Unit Manager and DON completed a 100% audit of all medical records. The pharmacist was in-serviced on his responsibility to complete a review of all facility residents' medical records monthly and indicate in his monthly reports any need for further laboratory testing. The Pharmacist specifically reviewed all residents on Dilantin and their physician orders [REDACTED].