Every finding on record at Copperfield Health & Rehabilitation

Based on observation, record review, and interviews with resident, staff, Psychiatric Nurse Practitioner, and Medical Director, the facility failed to ensure residents were free from abuse when Resident #6, who had a known history of aggressive behaviors toward others, physically abused 2 of 5 residents (Resident #10 and Resident #117) reviewed for abuse. On 11/24/25 Resident #6 hit Resident #10, a resident with severe cognitive impairment, in the face resulting in a bruised, swollen, and busted open and bleeding lip. On 1/10/26 Resident #6 spat on and punched Resident #10 in the face resulting in swelling to the right eyebrow and swelling, bruising, and a gash on her upper lip. Resident #10 did not have the cognitive capacity to express an adverse psychosocial outcome. A reasonable person would have experienced feelings such as fear, anxiety, isolation, and withdrawal. On 2/13/26 Resident #6 struck Resident #117 multiple times in the head and upper body. Resident #117 had no physical injuries but reported that he felt victimized, did not feel safe, and had to sleep with one eye open.Findings included:Resident #6 was admitted to the facility on [DATE] with diagnoses that included anxiety, violent behavior, bipolar disorder, paranoid schizophrenia, dementia with mood disturbance, and insomnia.Physician orders for Resident #6 dated 1/26/24 included: haloperidol (antipsychotic medication) 10 milligrams (mg) tablet twice daily for schizophrenia, buspirone HCl (antianxiety medication) 5 mg three times a day for agitation related to anxiety, and trazodone (antidepressant medication) 50 mg once daily at bedtime for insomnia.The significant change Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #6 was cognitively intact and had no behavioral issues within the review period. He was able to ambulate with a walker 150 feet once standing. Resident #6 was on antipsychotic, antianxiety, and antidepressant medications. Resident #6's care plan dated 10/30/25 revealed a care area with interventions initiated on 7/22/25 related to a history of verbal aggression towards his peers, poor impulse control, and threatening statements towards his peers. The goal for Resident #6 was to be less distressed by his own behaviors. The interventions included one to one (1:1) activity as needed; monitor behavior episodes and attempt to determine the underlying cause, consider location, time of day, persons involved and situations; staff to explain all procedures to Resident #6 before starting and allow him time to adjust to changes; and psychiatric and behavioral services as needed with medication reviews.a. Resident #10 was readmitted to the facility on [DATE] with diagnoses that included Alzheimer's dementia, wandering, and cognitive communication deficit.The quarterly MDS assessment dated [DATE] for Resident #10 revealed she rarely/never understood others, was rarely/never understood, had short-term and long-term memory problems, and cognitive skills for daily decision-making was coded as severely-impaired-never/rarely made decisions. Resident #10 had no behavioral issues and no wandering. She was coded as fully dependent on staff for all activities of daily living with the exception of eating and she used a manual wheelchair. She was not on any blood thinning medication. Resident #10's Care Plan dated 9/10/25 revealed a care area with interventions initiated on 7/6/25 related to the risk for elopement. She was noted to seek out exits and bump into doorways and furniture. The interventions included checking placement of her wanderguard each shift; staff to guide her away from doors; offer pleasant distractions; observe for purposeful or aimless wandering; and intervene with distractions for the resident.An Initial Report dated 11/24/25 at 6:40 PM completed by the Administrator for an allegation of resident to resident abuse stated Resident #6 hit Resident #10 in the face at 6:00 PM when she self propelled her wheelchair into his room. The report stated the incident was not witnessed by staff. Resident #124 (Resident #6's roommate) reported seeing Resident #10 with a bloody lip. Resident #10's lip cut was treated, and she resumed her usual routine with no noted behavior changes.A Nurse 's note completed by Unit Manager #1 dated 11/24/25 at 7:20 PM stated Resident #6 hit another resident who wandered into his room. After hitting the other resident, he climbed into his bed. The on-call provider was notified and advised that Resident #6 be monitored. Resident #6 was placed on 1:1 supervision for close monitoring.An interview with Unit Manager #1 was conducted on 2/18/26 at 8:45 AM. She reported that on 11/24/25 she responded to a call for assistance from a nursing assistant (unable to recall which nursing assistant) and when she arrived at Resident #6's door she saw Resident #10 in her wheelchair outside of the room. She observed Resident #10 with a bruised, swollen lip and a cut that had stopped bleeding. The nursing assistant reported that Resident #6's roommate, Resident #124, stated he saw Resident #6 strike Resident #10. Unit Manager #1 reported that Resident #124 was alert and oriented and able to communicate what he witnessed. She indicated that Resident #124 had passed away and was not available for an interview. She reported that Resident #10 was calm and had a confused look on her face. She stated she had nursing staff move Resident #10 to her room, placed Resident #6 on 1:1 supervision, and brought Resident #6 to the Nurse s Station to sit with staff. Unit Manager #1 indicated a stop sign was placed on Resident #6's doorway as a visual cue for Resident #10. Unit Manager #1 reported she was aware of Resident #6's past aggressive behaviors towards other residents and staff.The nurse's note completed by Nurse #9 dated 11/24/25 at 7:37 PM stated Resident #10 was struck in the mouth by another resident (Resident #6) for entering his room and caused injury. The Police were called and the supervisor and Administrator were notified. The on-call provider service was notified and made aware with instructions to notify the provider of any changes and keep separation between the two residents. Resident #10 was given medication for pain.A telephone interview with Nurse #9 was conducted on 2/27/26 at 7:30 AM. Nurse #9 reported that on 11/24/25 she responded to Resident #6's room when she heard his roommate hollering Stop, don't you hit her like that. When she arrived at Resident #6's room she saw Resident #10 sitting in her wheelchair outside the room with Resident #6 standing inside his doorway. Nurse #9 reported she escorted Resident #6 to the nurse's station and observed her top lip was busted open and bleeding. She washed the blood off of Resident #10's lips and cleansed the cut to her top lip and applied ointment. Nurse #9 reported she applied a cold compress because Resident #10 kept touching her lip and it would start to bleed again. She reported that Resident #10 stayed with her at the nurse's station for an extended period of time and remained calm. She reported the police arrived and completed their interviews. Nurse #9 stated she assisted during the exam of Resident #10 for the on-call provider's video visit. Nurse #9 reported she interviewed Resident #6 and he told her that he hit Resident #10 because he did not want her in his room. Nurse #9 indicated she was aware Resident #6 had a past history of aggressive behaviors. The provider's note for Resident #6 completed by Physician #2 dated 11/24/25 at 9:16 PM stated Resident #6 was evaluated via telehealth with the DON present and assisting with the exam. Resident #6 reportedly hit another resident, returned to bed, and had no further contact. Resident #6 was negative for acute symptoms and was to remain in the facility and be monitored for mood and behaviors. The provider's note for Resident #10 completed by Advanced Practice Nurse #3 dated 11/24/25 at 8:19 PM stated Resident #10 had swelling and bruising of the upper lip and a small cut to the upper right side of her lip. She was calm and made no complaints of pain. The provider's note stated the injuries were consistent with being struck in the mouth with a closed fist. The resident's vital signs were normal. No new orders were issued, and she was to remain at the facility under observation. The facility's investigation report dated 11/27/25 completed by the Administrator stated Resident #10 required no further treatment. Resident #6 denied hitting Resident #10 and stated he only told her to get out. Corrective actions included placing Resident #6 on 1:1 observation for 24 hours, then reducing to checks every four hours for 48 hours and a STOP sign was placed on the doorway of Resident #6's room.A Psychiatric Nurse Practitioner's note for Resident #6 completed by Psychiatric Nurse Practitioner #2 dated 11/27/25 at 8:00 AM stated Resident #6 denied hitting Resident #10 and smiled during the interaction. The Psychiatric Nurse Practitioner educated him that physical aggression was not permitted. No changes to the plan of care were recommended.An Initial Report dated 1/8/26 at 9:00 PM completed by the Administrator for an allegation of resident-to-resident abuse stated Resident #6 spat on, cursed at, and punched Resident #10 when she wandered into his room. The incident was witnessed by Resident #6's roommate, Resident #124. Resident #10's lip cut was treated with topical ointment and she resumed usual activities. Resident #6 was moved to another hall, encouraged to engage in activities, and placed on 1:1 supervision immediately. The report stated Resident #6 told staff he didn't mean to hurt her and just wanted her out of his room.A telehealth note completed by On-Call Provider #3 dated 1/9/26 at 12:35 AM stated Resident #10 had swelling and bleeding of the lip and jaw. Vital signs were normal. Resident #10 was alert but confused. The plan was to order a jaw x ray and have staff notify a clinician if there were any changes in condition.A medical provider's note for Resident #10 completed by Nurse Practitioner #1 dated 1/9/26 at 10:30 AM stated Resident #10 was seen for follow up related to injuries from the assault, noting she was assaulted by the same resident (Resident #6) two months prior. Medication changes included scheduling acetaminophen for pain, as she was unable to communicate pain reliably. Cold compresses were ordered, and additional safety measures were recommended, including consideration for placement in a locked Alzheimer's Unit.A nurse's note dated 1/9/26 at 6:47 AM completed by the Director of Nursing indicated Resident #10 showed no signs of distress. Swelling, bruising, and a gash were present on her upper lip, and swelling was noted to the right eyebrow.An interview with the Director of Nursing (DON) was conducted on 2/16/26 at 10:45 AM. The DON reported she previously served as the Evening/Nights Supervisor and recently assumed the DON role. She stated she was present and working on the unit during the incident on 1/8/26. The DON reported that on 1/8/26, she responded to Resident #6's room when Resident #124 (Resident #6's roommate) put his call light on to report that Resident #6 had hit Resident #10 in the face. The DON assessed Resident #10 and noted she had facial injuries with a swollen lip. She reported that she ensured the residents were safe, separated, and notified the on call provider. The DON reported she moved Resident #10 to a room on the opposite side of the facility during the night shift on 1/8/26 to reduce the risk of Resident #10 re entering Resident #6's room. She stated the on call provider was notified of Resident #6's behaviors, and Resident #6 was sent to the emergency room for evaluation on 1/9/26. She reported Resident #6's roommate, Resident #124, witnessed the incident. Emergency Department documentation for Resident #6 dated 1/9/2026 stated the resident was seen for evaluation of agitation and aggressive behavior. He was awake and alert but uncooperative and spat at staff. He received 10 mg olanzapine (antipsychotic medication). Labs, an electrocardiogram, and vital signs were normal.A provider's note for Resident #6 completed by Nurse Practitioner (NP) #1 dated 1/12/26 at 9:30 AM stated Resident #6 was medically cleared in the local emergency department, evaluated by psychiatry, had his haloperidol increased and returned to the facility on 1/11/26. Resident #6 continued to be combative following hospital return. He would not cooperate with the exam, was agitated, and was noted to be a danger to other residents, staff, and possibly himself. He remained on 1:1 supervision.A Psychiatric Nurse Practitioner's note for Resident #6 completed by Psychiatric NP #2 dated 1/13/26 at 12:22 AM indicated Resident #6 was sent to the emergency room for evaluation and remained hospitalized from [DATE] through 1/11/26. During his hospitalization, his medications were adjusted, and he was discharged . Resident #6 stated, If she comes here again, I will do it again, and I don't care. He remained on 1:1. Resident #10 had been moved to another unit. Psychiatric NP #2 initiated divalproex sodium (anticonvulsant used as a mood stabilizer) 250 mg twice daily to help stabilize his mood swings and recommended 1 to 1 supervision for one more day; hourly safety checks for three days; safety checks each shift for two weeks; maintaining relocation of the other resident; early de escalation techniques; and minimizing overstimulation.An x-ray report for Resident #10 indicated it was completed by a mobile radiology service on 1/13/26 at 7:33 AM. The report findings signed by the radiologist on 1/13/26 at 7:54 AM revealed no fractures. A Computed Tomography (CT) scan was recommended if clinically indicated. No further imaging was ordered. b. Resident #117 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease. A provider's admission history and physical note completed by NP #1 on 2/13/26 at 7:40 AM stated Resident #117 was in no distress and was seen while resting in bed. Resident #117 had intact skin and no bruising or lesions were observed. Resident #117 had normal cognition, orientation, insight and judgement, and memory.The Initial Report completed by the Administrator dated 2/13/26 for an allegation of resident-to-resident abuse stated Resident #6 was the aggressor and struck Resident #117. Resident #117 was moved to another room, had no injuries, and went to sleep without issue. Resident #6 was placed on 1:1.An interview and observation were conducted with Resident #117 on 2/18/26 at 4:30 PM. He was observed with no visible injuries to his face, neck, or arms. Resident #117 reported he arrived at the facility on 2/12/26 shortly before lunch. He stated that when he was wheeled into his new room, his roommate, Resident #6, was present lying in bed with his eyes closed. He indicated Resident #6 briefly opened his eyes, waved slightly, and said hello. He stated this was their only interaction prior to going to sleep. Resident #117 reported that around midnight he activated his call light to request that staff lower the room temperature. While waiting, he stated that Resident #6 approached the foot of his bed and began yelling, cursing, and spitting at him. He reported that Resident #6 then moved to the side of the bed and struck him multiple times on the head and upper body. He stated he did not recall whether Resident #6's hand was open or closed when striking him. Resident #117 reported that a female staff member entered the room, instructed Resident #6 to stop, and escorted him into the hallway. He reported he had just arrived at the facility so he did not know any of the staff by voice and could not see clearly to provide a description of which staff came in the doorway and told Resident #6 to stop. Staff then moved Resident #117, in his bed, to another room. When asked whether he felt safe at the facility, Resident #117 responded, No! I do not feel safe here, and I feel like I have to sleep with one eye open. I have no peace here. He stated that, although difficult for him to say, as a man this age, I feel victimized. He reported that because it was sudden and unprovoked, he believed Resident #6 would repeat the behavior if they encountered one another without staff present. During this portion of the interview, Resident #6's voice trembled, he appeared visibly distressed, and his facial expression was downturned.During the telephone interview with Nurse #10 on 2/20/2026 at 11:06 AM she reported that on 2/13/26 staff came down the hall and stated that Resident #117 put his call light on and when it was responded to the indicated that Resident #6 had hit and spit on him. She did not recall which of the staff members it was. She reported that she had staff immediately remove Resident #6 from the doorway of the room and placed on 1:1 supervision. She indicated that she completed an assessment of Resident #117 and he remained calm and laid in bed during her assessment. She found no injuries and the resident did not report pain. She reported that she had staff move Resident #117 while in his bed to another unit across the facility. Nurse #10 notified the DON and Administrator and reported to the police what Resident #6 told her. She reported Resident #6 claimed he struck Resident #117 because he believed he was going to be kicked. She was unaware of prior incidents involving Resident #6 due to previously being on extended leave. Nurse #10 reported Resident #6 remained on 1:1 observation as of her last scheduled workday, 2/17/26.On 2/16/26 at 1:12 PM Resident #6 was observed lying in bed with staff at bedside providing 1:1 observation. Resident #6 acknowledged the surveyor but would not engage or respond when asked for an interview and turned over in bed and closed his eyes.A provider's note for Resident #6 completed by Nurse Practitioner #1 dated 2/13/26 at 8:15 AM stated Resident #6 was sitting in a wheelchair during exam with a staff member monitoring him. He reported his roommate tried to kick him when he adjusted the thermostat, so he (Resident #6) spit on and punched him. No visible injuries were noted.A provider's note for Resident #117 completed by Nurse Practitioner #1 dated 2/13/26 at 8:30 AM stated Resident #117 reported he was spat on and struck three times in the right cheek. No injuries or marks were observed. No new orders.An interview with the Psychiatric Nurse Practitioner (NP) was conducted on 2/18/26 at 3:48 PM. The Psychiatric NP reported Resident #6 had diagnoses of bipolar disorder and schizophrenia and his mood swings were related to bipolar disorder. She reported Resident #6 was aware and cognizant of his actions during the incidents (11/24/25, 1/8/26, and 2/13/26) and would likely respond the same way again if someone entered his environment and he was not redirected by staff. The Psychiatric NP reported she adjusted Resident #6's mood stabilizer on 2/13/26 in response to his continued aggressive behaviors. She stated that his earlier behaviors had appeared to be reactions to Resident #10, but she now believed the aggression was triggered by anyone altering or stressing his environment. The Psychiatric NP reported Resident #6 refused to discuss the 2/13/26 incident with her or other staff.An interview with the Medical Director was conducted on 2/19/26 at 10:10 AM. The Medical Director reported he was aware of the incidents on 11/24/25, 1/8/26, and 2/13/26 involving Resident #6 and other residents. He reported he was not aware of any severe injuries to Resident #10 or Resident #117 but stated his collaborating NP would notify him of any serious injury and he would conduct an on site evaluation. He stated Resident #6 was followed by psychiatry and that he and the Psychiatric NP collaborated on care management. He reported Resident #6 was cognitively intact and had the ability to refrain from violent behavior but had developed a pattern of striking out when he did not get his way. He stated he did not believe Resident #6 felt threatened during the incidents but did not want other residents to enter his room. The Medical Director stated that close observation and monitoring were the most effective interventions to protect other residents. He stated redirection and reducing the risk of wanderers entering Resident #6's environment were preferred strategies over increasing medications to avoid overmedicating Resident #6. He explained that the facility attempted to avoid over-medication to prevent cumulative side effects. He reported he had no concerns about Resident #6's safety in the facility and that the NP would continue to see Resident #6 as needed. The Medical Director reported that the facility attempted to keep all residents safe from abuse.An interview with the Administrator was conducted on 2/17/26 at 2:30 PM. She reported she was not present for the incidents on 11/24/25, 1/8/26, or 2/13/26. She stated she was aware of Resident #6's aggressive behaviors before and since the incidents on 11/24/25, 1/8/26, and 2/13/26. She reported that the facility implemented 1:1 observation and later close supervision for several weeks following the 11/24/25 incident. She stated that after the 1/8/26 incident, 1:1 observation was put in place and remained in place for a few days after her returned from the hospital. She reported Resident #6 was placed on 1:1 observation after the 2/13/26 incident and remained on 1:1 at present. She reported Resident #6 would be more appropriate for an assisted living setting or small group home with fewer environmental stressors and that they had been referring the resident to other facilities but none of the referrals had been accepted.A follow up interview with the Administrator was conducted on 2/19/26 at 2:30 PM. The Administrator reported that Resident #6 would remain on 1:1 observation and close supervision as long as he posed a safety risk to other residents, himself, or staff. She reported the facility worked to keep all residents at the facility safe and free from abuse.

Based on observations, record reviews, and staff interviews, the facility failed to follow the planned menu for residents prescribed a mechanically altered diet during 2 of 2 lunch meal observations. This deficient practice affected 1 of 5 residents observed on mechanically altered diets (Resident #78) and 23 other residents who were prescribed a mechanically altered diet. Findings included: Resident #78 was admitted to the facility on [DATE] with diagnoses including protein calorie malnutrition, lipoprotein deficiency (inherited metabolic disorder where a defective gene prevents the body from producing the enzyme needed to break down dietary fat), and dysphagia (difficulty swallowing). The significant change Minimum Data Set (MDS) dated [DATE] indicated Resident #78 was severely cognitively impaired. The MDS was coded for Resident #78 receiving a mechanically altered diet. Review of the physician order dated 1/7/2026 indicated Resident #78 required a mechanically altered diet with thin liquids for diagnosis of dysphagia. The diet spread sheet for therapeutic diets for the lunch meal on 2/16/2026 revealed mechanically altered diets were to receive seasoned sauteed zucchini (soft, cooked and fork mashable) as their vegetable and apple sauce for dessert for their lunch meal. The Diet Type Report revealed there were 24 residents on mechanically altered diets.Resident #78 was observed in the main dining room on 2/16/2026 at 11:57 AM. Resident #78's tray ticket indicated she was on a regular, mechanically altered diet with thin liquids. Her lunch meal consisted of herb roasted pork chopped, pasta alfredo, broccoli with mixed vegetables, and tropical fruit. There was no evidence of seasoned zucchini or apple sauce on Resident #78's meal tray. Resident #78 was observed in the main dining room on 2/17/2026 at 12:00 PM. The diet spread sheet for the lunch meal indicated mechanically altered diets and Resident #78 should receive turkey cutlet ground with gravy, mashed potatoes, cut green beans (soft, cooked and fork mashable) and cherry cobbler for dessert. Resident #78's meal tray was observed with turkey cutlet with gravy chopped, red whole sliced potatoes, broccoli, and a cookie for dessert. During an interview with the Dietary Manager on 2/18/2026 at 2:34 PM, she indicated she was aware of Resident #78's mechanically altered diet. She stated Resident #78 had received the wrong vegetables and wrong dessert. The Dietary Manager confirmed that all residents who were prescribed a mechanically altered diet, 24 total residents, received the wrong vegetables and wrong dessert on 2/16/2026 and 2/17/2026. The Dietary Manager stated the expectation was to serve what is on the menu. The Dietary Manager added that when items were not in supply, they must adjust the menu. During an interview on 2/17/2026 at 12:25 PM, the Regional Dietary Manager indicated the facility had run out of food and this was why there were changes made in the menu. The Regional Dietary Manager confirmed 24 total residents prescribed mechanically altered diets did not receive the correct vegetable or dessert for their lunch meal. During an interview with the Administrator on 2/18/2026 at 2:49 PM she stated her expectation was the facility dietary staff follow the menu as planned. She further revealed that if there are changes to the menu the facility dietary staff should log those changes and notify the residents.

Based on observations and staff interviews, the facility failed to label and date leftover food stored for use, discard food past its use-by-date and discard food showing signs of spoilage in 1 of 1 walk-in cooler and 1 of 1 walk-in freezer. These practices had the potential to affect food served to residents. The findings included:a. During an initial observation of the facility's kitchen with the Regional Dietary Manager and the Dietary Manager on 2/16/2026 at 9:52 AM, the walk-in freezer was noted to have the following concerns: - An opened unsealed package of chicken tenderloins with signs of frost bite spots and discolored grayish brown patches; - An opened, unlabeled, and unsealed package of chicken breasts with signs of frost bite spots and discolored grayish brown patches; - One opened, unlabeled, unsealed box of chocolate chip cookies with signs of frost bite spots and discolored grayish brown patches and; - One opened, unlabeled, unsealed package of biscuit dough with ice crystal formation. b. During an initial observation of the facility's kitchen with the Regional Dietary Manager and the Dietary Manager on 2/16/2026 at 10:00 AM the walk-in refrigerator was noted to have the following concerns: - An opened and unlabeled 5-pound (lb.) bag of parmesan fancy shredded cheese; -An opened, unlabeled, and unsealed box of herb thyme with signs of spoilage (brownish/ blackish in color) and; -An open, 1-quart size of pimento cheese spread with use by date of 2/2/2026. An interview was conducted with the Dietary Manager on 2/18/2026 at 2:34 PM. The Dietary Manager stated that labels and dates on open food items should be checked weekly. The Dietary Manager further stated the items in the walk-in freezer should not have been opened and needed to be discarded. The Dietary Manager stated items in the walk-in cooler and in the walk-in refrigerator should have an open date, be closed and sealed in both areas. She further indicated whenever a staff member used an item they were to label when opened and the item should be closed. An interview with the Administrator on 2/18/2026 at 2:49 PM revealed all food and beverage items should be dated when they were opened, food with signs of spoilage should be discarded, and food items should be used or discarded according to use-by policies. She further stated the dietary department was responsible for food storage and safety daily.

Based on observation, record review, and interviews with resident, staff, and Nurse Practitioner (NP), the facility failed to administer oxygen as ordered by the physician for 1 of 3 residents reviewed for respiratory care (Resident #59). The findings included:Resident #59 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, chronic obstructive pulmonary disease (COPD), and chronic respiratory failure.Review of physician orders dated 10/02/2025 revealed an order for oxygen at 3 liters per minute via nasal cannula continuously for shortness of breath.The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #59 was cognitively intact, received oxygen therapy and utilized a non-invasive mechanical ventilator.Observations of Resident #59's oxygen via nasal cannula connected to the bedside oxygen flowmeter revealed the oxygen was set at 2 liters per minute on 02/16/2026 at 11:00 AM, 02/17/2026 at 10:00 AM, and 02/18/2026 at 10:00 AM.An interview with Resident #59 was conducted on 02/16/2026 at 10:30 AM. Resident #59 stated her oxygen was supposed to be set at 3 liters per minute. She reported she was unsure how long she had not received 3 liters Resident #59 stated that when she was placed in her wheelchair, nursing staff sometimes set the oxygen at 2 liters instead of the prescribed 3 liters. Resident #59 stated staff informed her of the oxygen setting and the amount remaining in the tank, as the equipment is positioned behind her wheelchairReview of Resident #59's electronic Medication Administration Record (eMAR) revealed that Nurse #6 documented that the resident received oxygen at 3 liters per minute in accordance with the physician's order on 2/16/2026, 2/17/2026 and 2/18/2026 for first shift and Nurse #7 documented that the resident received oxygen at 3 liters per minute in accordance with the physician's order on 2/17/2026 and 2/18/2026 for the night shift. Review of the nurse assignment sheets reflected Nurse #6 was assigned to Resident #59 on first shift and Nurse #7 was assigned on third shift on 02/16/2026, 02/17/2026, and 02/18/2026.An interview conducted with Nurse #6 on 02/18/2026 at 11:15 AM revealed she was assigned to and responsible for the care of Resident #59 on 02/16/2026, 02/17/2026, and 02/18/2026 during first shift. Nurse #6 verified that Resident #59's oxygen was observed set at 2 liters per minute via nasal cannula connected to the bedside oxygen flowmeter at the time of observation. Nurse #6 confirmed the physician order indicated oxygen was to be administered at 3 liters per minute continuously. Nurse #6 stated Resident #59 told her a few months ago to set the oxygen at 2 liters, reporting that the resident was familiar with that setting from home use. Nurse #6 stated Resident #59 had been receiving 2 liters previously and she was unaware of the updated order requiring 3 liters per minute. Nurse #6 stated Resident #59 had not complained of pain or shortness of breath. Nurse #6 further stated the electronic Medication Administration Record (eMAR) allows staff to document oxygen administration by selecting yes if oxygen was administered or no if it was not administered in accordance with physician orders. Nurse #6 indicated oxygen had been documented as yes (administered), as she believed the resident was receiving 3 liters per minute as ordered.On 02/18/2026 at 11:45 AM, Nurse #6 stated Resident #59's bedside oxygen equipment was not functioning properly. Nurse #6 reported the oxygen regulator was turned to the highest setting however, it was only delivering 2 liters per minute instead of the physician orders of 3 liters per minute. Nurse #6 stated she replaced the oxygen tank with a new tank, which functioned properly. Nurse #6 further stated she documented her concerns regarding the resident not receiving the prescribed amount of oxygen in the facility's medical provider communication binder to notify the Nurse Practitioner (NP) of the non-emergent issue.An interview with Nurse #7 was conducted on 02/19/2026 at 12:33 PM and revealed she was assigned to and responsible for the care of Resident #59 on third shift of 02/17/2026 and 02/18/2026. Nurse #7 stated she documented oxygen as administered because she believed Resident #59 was receiving 3 liters per minute as ordered.An interview with Unit Manager #1 was conducted on 02/19/2026 at 12:55 AM. Unit Manager #1 stated if oxygen was set at the wrong liter flow, it was to be fixed immediately, and nursing staff should follow up by routinely checking the oxygen settings and verify the correct liter flow during rounds. Unit Manager #1 stated she also checked oxygen settings when completing her rounds and had not previously noticed an incorrect liter setting for Resident #59. An interview with the Nurse Practitioner (NP) was conducted on 02/19/2026 at 1:35 PM. The NP stated she reviewed the patient communication binder on 02/19/2026 located at the nurses' station for non-emergent concerns. The NP reported she observed documentation in the communication binder regarding Resident #59's oxygen being set at the incorrect liter flow. The NP stated she reviewed Resident #59's oxygen saturation levels, which appeared stable and above 92%. The NP further stated she asked Resident #59 whether she had adjusted the oxygen setting herself, and the resident stated she had not. The NP stated that because Resident #59 has Chronic Obstructive Pulmonary Disease (COPD), the oxygen must be maintained at the prescribed liter flow to support breathing.An interview with the Director of Nursing (DON) was conducted on 02/18/2026 at 2:00 PM. The DON stated she had not been made aware that Resident #59's oxygen was set at an incorrect liter flow. She stated nursing staff should notify the on-call physician or Nurse Practitioner if oxygen was found to be administered at an incorrect setting.An interview with the Administrator was conducted on 02/18/2026 at 2:15 PM. The Administrator stated she was unaware that Resident #59's oxygen was not being administered at the prescribed liter flow. The Administrator stated it was the expectation that all staff follow physician orders.

Based on observation, record review, and responsible party, Lieutenant of Criminal Investigations and staff interviews the facility failed to protect a resident's privacy for 1 of 3 residents (Resident #2). Nurse aide (NA) # 1 and NA # 2 provided personal care to Resident # 2 while live streaming on a cell phone. The staff allowed a prison inmate who was watching the live stream to view the resident while the resident was naked from the waist up and while care was provided; the staff allowed this live streaming while other inmates were observed in the open area behind him. As Resident #2 was severely cognitively impaired, the reasonable person concept was applied. A reasonable person would have been traumatized and have feelings of worthlessness, powerlessness and dehumanization through people that were not caregivers viewing them naked and while care was provided without consent. Immediate jeopardy began on 10/4/24 when Resident #2's privacy was violated. Immediate jeopardy was removed on 12/5/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at the scope and severity of D (no actual harm with potential for more than minimal harm that is immediate jeopardy) to ensure education is completed and monitoring systems put into place and are effective. The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses which included anxiety, Alzheimer's, dementia, and mood disturbance. Review of Resident #2s quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was severely cognitively impaired. Review of video footage provided by the Sheriff Department revealed the following events took place on 10/04/24 at 10:30 PM. The video revealed NA #1 and NA #2 located in a facility in the resident's room on live stream video through a cell phone with a prison inmate. The inmate was observed talking into a telephone receiver in an open area with several other inmates behind him. The inmate was looking at the live stream. The video was reviewed on 12/4/24 at 4:45 PM. The following was found and documented by the time mm:ss (minutes colon seconds) where mm represents minutes and ss represents seconds. -:01 Video starts with NA #1 walking down the facility hallway towards Resident #2's room. No residents were shown at this time. -:33 NA #1 entered Resident #2's room. -:45 NA #1 laid the cell phone down. The video showed several inmates walking around the inmate while he was speaking to NA #1 and Resident #2 was visible sitting in the wheelchair with NA #1 and NA #2 present in the resident's room. NA #2 was observed undressing Resident #2 and taking off her shirt. It was observed that multiple inmates and a guard walked by the inmate during this time. -:53 NA #2 was observed jerking the resident's shirt out of Resident #2's hands aggressively. Residents #2's bare shoulders were observed to be showing. -2:09 NA #1 pointed the live stream video at Resident #2 and Resident #2 was visible in the wheelchair with her shirt removed and NA # 1 was trying to remove her bra from her right arm; both breasts were showing. The inmate stated, come on man, come on man. The inmate stated, I got to go, bye. NA #1 states no we're talking. The inmate replies, that s . just p . me off. NA #2 comes in the live video frame and was laughing. During this time multiple inmates were behind the inmate in an open public area. -3:02 NA #1 was holding the cell phone and pointed it to NA #2 smiling and laughing into the camera. NA #2 acknowledged again she is on a live video stream call with the inmate. -3:07 NA #2 was viewed fastening Resident #2's gown behind her back and the inmate states, y'all are crazy., y'all crazy as hell. Y'all two together is trouble. -3: The inmate stated, you just put anything on camera you need to stop that s NA #1 replied I don't give a damn. -4:29 NA #1 was observed standing on the right side of the bed and NA #2 was on the left between the resident's beds with Resident #2 sitting in the mechanical lift sling suspended. NA #1 had the phone live streaming Resident #2 and laughing. The privacy curtain was not pulled between the two beds. The roommate was not visualized at this time. -4:42 NA #1 turned the cell phone camera, and Resident #2 was suspended in the mechanical lift. Inmates were passing by behind the inmate that was watching. -5:01 Resident #2 was being transferred to her bed in the mechanical lift and there was another resident in the room in the opposite bed. The privacy curtain was not pulled while Resident #2 was being transferred. -6:01 NA #1 laid the cell phone down still showing care and rolled Resident #2 aggressively on to her left side by jerking up by the lift pad. Resident #2's face was away from the camera with her full brief exposed. The inmate stated, damn, don't roll her out of bed. NA #1 looked back at the video and laughed. NA #2 was still present in the room on the other side of the bed assisting with Resident #2. Two inmates were observed in the back in the open area. -6:08 NA #1 stated, patient confidentiality and moved the phone to the side of the bed pointing towards the end wall not viewing the resident but still live streaming while giving care to the resident. -7:17 NA #1 stated to resident, open your legs girl. NA # 1 stated more that was not discernable. -8:45 NA #1 and NA #2 exited the resident's room and walked down the facility hall and continued to talk to the inmate on the cell phone. -9:46 Video ends. A phone interview conducted with the Lieutenant of Criminal Investigations on 12/2/24 at 11:30 AM revealed he had obtained video footage of an inmate and NA #1 having a video call where NA #1 had shown the inmate view of an elderly resident in a wheelchair. The Lieutenant stated he had reported the concerns to Adult Protective Services (APS) and was concerned NA #1 had exploited Resident #2. A follow up phone interview with Lieutenant of Criminal Investigations on 12/05/24 at 9:20 AM explained the video occurred on 10/4/24 and the video call app used was Home WAV which is a video call that is recorded of both parties. The Lieutenant indicated when a video call occured the inmate had a phone receiver to hear the conversation but had a computer size screen mounted on the wall to see who they are face calling. The Lieutenanr stated other inmates were unable to hear the conversation but could visually see the video because the screen is in a non-private area with other inmates present. An interview conducted with NA #1 on 12/02/24 at 2:35 PM revealed she had worked in the facility for two years. NA #1 further revealed she had completed an in-service on resident privacy and video and telephone calls were prohibited in care areas. NA #1 stated she had never taken any pictures or videos of any resident in the facility. A phone interview conducted with Nurse Aide (NA) #2 on 12/4/24 at 6:00 PM revealed she had been employed by the facility for approximately two years. NA #2 further revealed she had been educated on residents' privacy. NA #2 stated she had never observed any staff or had taken a video or picture of a resident. NA #2 indicated if she was to observe a staff member record a resident that she would report it to the Administrator. NA #2 denied any staff videoing Resident #2 while giving care. An interview conducted with the Director of Nursing (DON) and Administrator on 12/02/24 at 2:45 PM revealed they both had been recently employed at the facility. The interview revealed no staff had reported concerns about staff having their phones out in care areas and taking pictures or video footage of a resident. Both indicated nursing staff had been in-service at hire, annually, and anytime on resident privacy and person phones were not allowed to be out in resident rooms. The video was shared with facility staff on 12/4/24 at 5:45 PM. Those present were the Director of Nursing (DON), [NAME] President of Clinical Operations, and [NAME] President of Risk and QAPI (quality assurance and performance improvement). The facility staff cried. After the video was reviewed, Resident #2, NA #1, and NA #2 were identified by the DON. It was further revealed nursing staff were not allowed to have personal cell phones in care areas and it was not permitted to record any audio or image of a resident. The DON stated NA #1 failed to protect the privacy of Resident # 2 and NA #2 failed to report the exploitation and privacy of Resident #2. An interview conducted with Resident #2's Responsible Party (RP) on 12/5/24 at 3:15 PM revealed the facility had notified the family of the video on 12/04/24. The RP further revealed she was upset this had happened to Resident #2 but was glad it was being investigated and hoped justice would be served to NA #1 and NA #2. An interview conducted with the Administrator on 12/9/24 at 4:00 PM revealed she had been employed by the facility for a short period of time but assisted with the initial investigation. The Administrator further revealed NA #1 and NA #2 had denied being in any video or on a telephone call with a resident present. The Administrator further revealed she expected nursing staff to not break confidentiality and protect residents' privacy. The Director of Nursing (DON), [NAME] President of Clinical Operations, and [NAME] President of Risk and QAPI were notified of immediate jeopardy on 12/5/24 at 12:35 PM. The Administrator was not present. The facility provided the following immediate jeopardy removal plan. The facility failed to maintain privacy for Resident # 2 while personal care was provided. NA # 1 used her personal cell phone while in the residents' room to facetime with a male inmate which allowed Resident # 2 to be observed sitting in a wheelchair, naked, with no shirt or bra on, with her breasts exposed without her consent. The observation was provided in real time through the use of a wall mounted screen in a common area of an incarceration center while other people in the prison were also observed walking past the screen. On 12/2/24 at 1:35pm, the DON suspended NA #1 pending outcome of abuse investigation and notified the Medical Director (MD) of allegation. Because the resident was unknown at this time and the presence of a witness was unknown, the facility was unable to make notifications to Resident #2's resident representative or initiate immediate suspension of NA #2. On 12/2/24 at 2:15pm, the Social Worker (SW) notified the local police department and adult protective services (APS). A police report number was obtained. On 12/2/24 at 3:30pm, the Administrator submitted the initial allegation report to North Carolina Department of Health Human Services (NCDHHS). On 12/2/24 at 4:00pm, the Administrator completed an observational round of facility residents and staff to ensure that resident's right to privacy is maintained. Observations include 1) care being provided only be authorized staff, 2) use of privacy curtains, closed doors during personal care and covering/draping to prevent exposure of body parts, 3) no cellular or other video devices used by staff in resident care areas and 4) any other violation of resident right to personal privacy not only of a residents' own physical body, but of his or her personal space. No additional concerns identified. On 12/2/24 and on 12/4/2024, the DON, VPCO, VPRQA, Administrator and Medical Director held an Ad Hoc meeting to discuss incident to determine root cause analysis of the facility's failure to maintain privacy for a resident while personal care was being provided. Root cause analysis determined that the facility failed to implement an effective system to ensure strict enforcement and monitoring measures to prohibit cellular phones and video recording devices in resident care areas. On 12/4/24 at 3:30pm, additional information was provided to the facility to include identification of resident (Resident #2) and addition of a witness (NA #2). In response to this new information, the DON immediately suspended NA #2, notified Resident #2 resident representative(s) and the MD and the VPRQA notified local law enforcement and APS with updated information to initial 12/2/24 reports. The VPCO assessed Resident #2 for physical injury, pain and signs or symptoms of psychosocial distress and no concerns were observed and resident was pleasantly confused at baseline. On 12/4/2024 the VPCQA, VPCO and DON attempted to obtain information regarding the location of the prison. Upon receipt of this information, the facility plans to inquire on the security of the recording and ensure that Resident #2 is protected from any additional violation of privacy by others who are unauthorized to have such information. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring, and when the action will be complete. Effective 12/2/24, all current facility staff were in-serviced on the Resident Rights Policy, CMS guidance 483.10(h) and the Cell Phone Policy by the Staff Development Coordinator (SDC) and licensed nurse manager. Training included examples of violation of residents' privacy to include, but not limited to 1) privacy of not only a residents' own physical body, but of his or her personal space, including accommodations and personal care, 2) only authorized staff directly involved in providing care and services for the resident may be present when care is provided, unless the resident consents to other individuals being present during the delivery of care, 3) during the delivery of personal care and services, staff must remove residents from public view, pull privacy curtains or close doors, and provide clothing or draping to prevent exposure of body parts, 4) photographs or recordings of a resident and/or his or her body or private space without the resident's, or designated representative's written consent, is a violation of the resident's right to privacy and confidentiality, 5) staff taking unauthorized photographs of a resident's room or furnishings (which may or may not include the resident), or a resident eating in the dining room, or a resident participating in an activity in the common area, 6) taking unauthorized photographs or recordings of residents in any state of dress or undress using any type of equipment (for example, cameras, smart phones, and other electronic devices), 7) keeping or distributing them through multimedia messages or on social media networks is a violation of a resident's right to privacy and confidentiality, 8) potential effects on residents whose privacy is not maintained to include, humiliation, dignity, respect and feelings of dehumanization, 9) strict prohibition and NO TOLERANCE to use cellular phones or any type of audio or video device in resident care areas, resident rooms, common areas such as hallways, dining rooms, courtyards, etc.,10) cell phones are allowed to be kept in staff possession in the facility on a silenced or vibrate mode to allow for emergency alerts but may only be used in breakrooms or other non-resident areas and 11) staff are responsible to intervene if witnessing any violation of the Cell Phone Policy and/or the Resident Rights Policy and immediately remove risk from resident and notify Administrator and 12) violation of the Cell Phone Policy or Resident Rights Policy will result in disciplinary action up to and including termination of employment and/or notification to licensing boards and law enforcement where applicable to ensure resident privacy is maintained. Effective 12/2/2024, questionnaires were also completed following in-servicing with current facility staff to validate competency of education received and to identify if additional incidences of resident privacy had been violated. No additional concerns reported. The SDC will be responsible for ensuring all staff are trained by tracking and reviewing the daily schedule and ensuring training is provided. Newly hired staff and staff not receiving education by 12/2/2024 will receive education prior to first worked shift by the SDC, DON or licensed nurse supervisor. Effective 12/2/2024, the Administrator, DON or designee will complete observational rounds of facility residents and staff to ensure that resident's right to privacy is maintained. Observations to include 1) care being provided only by authorized staff, 2) use of privacy curtains, closed doors during personal care and covering/draping to prevent exposure of body parts, 3) no cellular or other video devices used by staff in resident care areas and 4) any other violation of resident right to personal privacy not only of a residents' own physical body, but of his or her personal space. On 12/2/24, licensed nurses were educated and notified by the VPCO of their responsibility to complete observational rounds each shift for his/her unit as above. Effective 12/2/2024, the Administrator is ultimately responsible for the implementation and completion of this removal plan. Alleged Date of IJ Removal: 12/05/2024 On 12/10/2024, the facility's credible allegation for immediate jeopardy was validated. Resident #2 was observed in the dining room pleasant and smiling with other residents in the table. During the tour of the facility residents were observed to have their doors closed for care and curtains were seen pulled to cover for privacy. There were no signs of staff cell phone use in the hallways and in resident care areas. The in-services by the facility included information on abuse, privacy, resident rights, and cellphone use, including notification of administration for any resident's behavior changes, and increased rounding observations of residents and staff. Staff interviews confirmed education was received for abuse, privacy, resident rights, and cellphone use. The facility provided psych evaluation follow up for Resident #2 regarding the incident. The facility provided evidence of daily Quality Assurance auditing of all residents divided on cognitively intact residents for interview and cognitively impaired residents for body audits, the auditing for the observational rounds every shift, staff abuse questionnaires, and new on-hire screening process and employee handbook review were executed. The facility showed evidence of communication with the sheriff's office that the video was encrypted and secured with only authorized person could access and view the footage. The IJ removal date if 12/05/24 was validated.

Based on observation, record review, and family, Lieutenant of Criminal Investigations and staff interviews, the facility failed to protect a resident's right to be free from abuse for 1 of 3 residents (Resident #2). Nurse aide (NA) # 1 and NA # 2 provided personal care to Resident # 2 while live streaming on a cell phone, the resident was naked from the waist up, the staff and the prison inmate watching the live stream spoke with profanity and vulgarity without any regard for the resident; the staff did not explain care as it was provided to the resident; the staff were physically aggressive during care; the staff allowed an inmate who was watching the live stream to view the resident and speak to the resident; the staff allowed this live streaming while other inmates were observed in the open area behind him. As Resident #2 was severely cognitively impaired, the reasonable person concept was applied. A reasonable person would have been traumatized by being abused by caregivers in their home environment making them feel worthless, angry, dehumanized and powerless. Immediate jeopardy began on 10/4/24 when Resident #2 was abused. Immediate jeopardy was removed on 12/5/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at the scope and severity of D (no actual harm with potential for more than minimal harm that is immediate jeopardy) to ensure education is completed and monitoring systems put into place and are effective. The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses which included anxiety, Alzheimer's disease, dementia, and mood disturbance. Review of Resident #2's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance with two-person for bed mobility and transfers. The MDS further revealed Resident #2 had adequate hearing and vision and was able to understand others. The MDS indicated no behaviors of rejection and care. Review of Resident #2's care plan dated 04/07/23 revealed the resident had an activities of daily living (ADL) self-care performance deficient due to Alzheimer's disease, impaired cognition, and muscle weakness. The goal was for Resident #2 to maintain its current level of function through the review date. Resident #2's care plan revised on 08/19/24 revealed the resident was resistive to care and refused to see the dentist and other medical directors at time due to dementia. The goal was for the resident to cooperate with care through the next review date. Interventions included for Resident #2 to make decisions about treatment regime and to give clear explanation of all care activities prior to an as they occur during each contact. Review of video footage provided by the Sheriff Department revealed the following events took place on 10/04/24 at 10:30 PM. The video revealed NA #1 and NA #2 located in a facility in the resident's room on live stream video through a cell phone with a prison inmate. The inmate was observed talking into a telephone receiver in an open area with several other inmates behind him. The inmate was looking at the live stream. The video was reviewed on 12/4/24 at 4:45 PM. The following was found and documented by the time mm:ss (minutes colon seconds) where mm represents minutes and ss represents seconds. -:01 Video starts with NA #1 walking down the facility hallway towards Resident #2's room. No residents were shown at this time. -:33 NA #1 entered Resident #2's room. -:45 NA #1 laid the cell phone down and shook her rear in the camera as the inmate states, that damn ass is fat. Look at that ass. That mother f . is fat. The video showed several inmates walking around the inmate while he was speaking to NA #1 and Resident #2 was visible sitting in the wheelchair with NA #1 and NA #2 present in the resident's room. NA #2 was observed undressing Resident #2 and taking off her shirt. It was observed that multiple inmates and a guard walked by the inmate during this time. Staff were not observed to be explaining their actions related to care to the resident. -:53 NA #2 was observed jerking the resident's shirt out of Resident #2's hands aggressively. Residents #2's bare shoulders were observed to be showing. NA #2 was not observed to explain care to the resident. -1:28 NA #1 picked up the cell phone and spoke to the inmate walking throughout the resident's room. -2:07 NA #2 was observed waving and smiling at the inmate through the cell phone acknowledging the inmate. -2:09 NA #1 pointed the live stream video at Resident #2 and Resident #2 was visible in the wheelchair with her shirt removed and NA # 1 was trying to remove her bra from her right arm; both breasts were showing. The inmate stated, come on man, come on man. NA #1 pointed the live stream video at NA #2, and she is observed smiling and laughing. The inmate stated, I got to go, bye. NA #1 states no we're talking. The inmate replies that s . just p . me off. NA #2 comes in the live video frame and was laughing. During this time multiple inmates were behind the inmate in the open public area. -3:02 NA #1 was holding the cell phone and pointed it to NA #2 smiling and laughing into the camera. NA #2 acknowledged again she is on a live video stream call with the inmate. -3:07 NA #2 was viewed fastening Resident #2's gown behind her back and the inmate stated, y'all are crazy., y'all crazy as hell. Y'all two together is trouble. Staff did not explain the care being provided to the resident. -3:32 NA #1 stated, this mother f . about to hit this resident in the head and proceeded to state it's not going to hurt her; she isn't going to bruise because she is black. The inmate stated, you just put anything on camera you need to stop that s NA #1 replied I don't give a damn. -4:05 NA #1 stated, Resident #2 (Name of resident) say hey to him, and put the camera in the resident's face while sitting in the lift sling starting to be lifted. Resident #2 was moving her mouth and breathing heavy. NA #1 and NA #2 did not explain to the resident they were putting her into a mechanical lift. NA #1 stated, she is trying to focus on going into the lift. She is scared as hell. The inmate stated, are yall about put her in the bed? NA #1 replied hell yeah she will be falling like a mother f . I know I am not lifting her up. While the inmate was speaking to NA #1 another inmate was observed behind him in the open area. -4:29 NA #1 was observed standing on the right side of the bed and NA #2 was on the left between the resident's beds with Resident #2 sitting in the mechanical lift sling suspended. NA #1 had the phone live streaming Resident #2 and laughing. The privacy curtain was not pulled between the two beds. A roommate was not visualized at that time. -4:42 NA #1 had the phone pointed towards her and stated, who the f . shoes she got on (NA #2's nickname.) NA #1 and NA #1 started to laugh, and NA #1 stated, this is not this ladies' shoes. NA #1 turned the cell phone camera, and Resident #2 was suspended in the mechanical lift with neither aide beside her. Inmates were passing by behind the inmate that was watching. -5:01 Resident #2 was being transferred to her bed in the mechanical lift and there was another resident in the room in the opposite bed. The privacy curtain was not pulled while Resident #2 was being transferred. -5:09 Resident #2 was still in the mechanical lift sling and NA #1 put the camera in the resident's face and stated, say hey. Resident's face was scrunched up. The inmate stated, why you looking so mean? speaking about the resident's facial expression. NA #1 stated, she is mad, but she doesn't even understand what we are saying. -5:18 NA #1 laid the phone down while she was still being shown on live video stream and the inmate stated, put that camera down a little more let me see that mother f (inaudible words). NA #1 grabbed the phone and lowered it showing off her rear. The inmate stated, that mother f NA #1 and NA #2 began to laugh. -6:01 NA #1 laid the cell phone down still showing care and rolled Resident #2 aggressively on to her left side by jerking up by the lift pad. The care was not explained to the resident. Resident #2's face was away from the camera with her full brief exposed. The inmate stated, damn, don't roll her out of bed. NA #1 looked back at the video and laughed. NA #2 was still present in the room on the other side of the bed assisting with Resident #2. Two inmates were observed in the back in the open area. -6:08 NA #1 stated, patient confidentiality and moved the phone to the side of the bed pointing towards the end wall not viewing the resident but still live streaming while giving care to the resident. -6:16 Resident #2 stated, oh, oh, while NA #1 assisted the resident and NA # 1 stated, you aren't about to fight me. -6:20 Resident #2 grabbed NA #1's left pant leg and NA #1 stepped back and then stepped forward, and the resident swatted at NA #1. NA #1 looked at the camera and laughed while continuing care. The inmate stated, what happened why did you move the phone? NA #1 stated, because she is trying to fight me. F . she is trying to fight us. I am not going to get my ass whooped by an old lady. -7:17 NA #1 stated to resident open your legs girl. NA # 1 stated more that was not discernable. -7:30 NA #1 stated good night (residents name) . After you fought like a mother f . Then stated God d NA #2 stated go to sleep (residents name). -7:40 NA #2 was observed taking off two sets of gloves and the inmate asked, why you put on two gloves? NA #1 stated this mother f be sh . like hell. NA #2 stated and pissin'. NA #1 agreed and stated, pissin' like hell. -7:54 NA #1 picked up phone and turned towards Resident #2 and showed the resident in bed with covers up to her neck and stated, good night boo. Resident #2 had facial grimacing. -7:58 NA #2 stated the way she pissed is like she can hold her piss all day. NA #1 replied and stated, yeah, she can hold her piss all day. Like a waterfall. NA #2 replied yep. -8:15 NA #1 stated, I'm fixing to clock out. NA #1 had the cell phone pointed towards her with NA #2 following her. NA #2 stated it's not even 11 o'clock where the f . are you going? NA #1 replied, I'm ready to go I'm tired as a mother f .,. The NAs walked towards the resident's door to leave. -8:45 NA #1 and NA #2 exited the resident's room and walked down the facility hall and continued to talk to the inmate on the cell phone. -9:46 Video ends. A phone interview conducted with the Lieutenant of Criminal Investigations on 12/2/24 at 11:30 AM revealed he had obtained video footage of an inmate and NA #1 having a video call where NA #1 had shown the inmate view of an elderly resident in a wheelchair and completed a phone call where NA #1 discussed abusing residents and not leaving bruises on them. The Lieutenant stated he had reported the concerns to Adult Protective Services (APS) and was concerned NA #1 had exploited Resident #2. A follow up phone interview with Lieutenant of Criminal Investigations on 12/05/24 at 9:20 AM explained the video occurred on 10/4/24 and the video call app used was Home WAV which is a video call that is recorded of both parties. The Lieutenant indicated when a video call occured the inmate had a phone receiver to hear the conversation but had a computer size screen mounted on the wall to see who they are face calling. The Lieutenanr stated other inmates were unable to hear the conversation but could visually see the video because the screen is in a non-private area with other inmates present. An interview conducted with NA #1 on 12/02/24 at 2:35 PM revealed she had worked in the facility for two years. NA #1 further revealed she had completed an in-service on abuse and neglect and was educated to report abuse or neglect to the administrator. NA #1stated she had never taken any pictures or videos of any resident in the facility. A phone interview conducted with Nurse Aide (NA) #2 on 12/4/24 at 6:00 PM revealed she had been employed by the facility for approximately two years. NA #2 further revealed she had been educated on abuse upon hire, yearly, and randomly. NA #2 stated she had never observed any staff or had taken a video or picture of a resident. NA #2 indicated if she was to observe a staff member record a resident that she would report it to the Administrator. NA #2 denied any staff videoing Resident #2 while giving care. An interview conducted with the Director of Nursing (DON) and Administrator on 12/02/24 at 2:45 PM revealed they both had been recently employed at the facility. The interview revealed no staff had reported concerns about staff having their phones out in care areas and taking pictures or video footage of a resident. Both indicated nursing staff had been in-service at hire, annually, and anytime on resident privacy and person phones were not allowed to be out in resident rooms. The video was shared with facility staff on 12/4/24 at 5:45 PM. Those present were the Director of Nursing (DON), [NAME] President of Clinical Operations, and [NAME] President of Risk and QAPI (quality assurance and performance improvement). Facility staff were crying. After the video was reviewed, Resident #2, NA #1, and NA #2 were identified by the DON. It was further revealed NA #1 and NA #2 had been in-serviced on abuse and neglect and reporting upon hire, annually, and during any abuse investigations. It was indicated Resident #2 was not alert and oriented and could be combative and resistive to care. The DON revealed she expected staff to walk away and get help if the resident becomes frustrated or combative. It was further revealed nursing staff were not allowed to have personal cell phones in care areas and it was not permitted to record any audio or image of a resident. The DON stated NA #1 failed to protect the privacy of Resident # 2 and NA #2 failed to report the exploitation and privacy of Resident #2. An interview conducted with Resident #2's Responsible Party (RP) on 12/5/24 at 3:15 PM revealed the facility had notified the family of the video on 12/04/24. The RP further revealed she was upset this had happened to Resident #2 but was glad it was being investigated and hoped justice would be served to NA #1 and NA #2. An interview conducted with the Administrator on 12/9/24 at 4:00 PM revealed she had been employed by the facility for a short period of time but assisted with the initial investigation. The Administrator further revealed NA #1 and NA #2 had denied being in any video or on a telephone call with a resident present. The Administrator further revealed she expected nursing staff to prevent abuse and neglect and report. The Director of Nursing (DON), [NAME] President of Clinical Operations, and [NAME] President of Risk and QAPI were notified of immediate jeopardy on 12/5/24 at 12:35 PM. The Administrator was not present. The facility provided the following immediate jeopardy removal plan. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. The facility failed to protect a resident's right to be free from mental and sexual abuse (Resident #2). On 10/4/24 Resident #2 was shown in compromised positions during an audiovisual phone call from Nursing Assistant (NA) #1 with a male individual who was witnessing the audiovisual through the use of a wall mounted screen in a common area of an incarceration center while other people in the prison were observed walking past the screen. During the audiovisual surveillance, NA #1 was observed to show Resident #2 to the male through her phone camera, the resident sitting in a wheelchair, naked, with no shirt or bra on, with her breasts exposed. There were two NAs witnessed in the video, NA #1 and NA #2. The NA's did not explain to the resident before each step of care was provided; NA # 1 shoved the resident to turn on her side aggressively; NA # 1 and the inmate talked inappropriately, using vulgar language including f**k and sh*t, about the resident and to the resident while NA # 1 and the inmate carried on their own private, foul mouthed (including discussion of NA #1's buttocks), conversation in the presence of the resident. On 12/2/2024 at 1:30pm, the Director of Nursing (DON), [NAME] President of Clinical Operations (VPCO) and [NAME] President of Risk and Quality Assurance (VPRQA) were notified by a surveyor during a recertification and complaint survey that a complaint was received from the community alleging an inappropriate photo or video of an unknown elderly female, partially unclothed and a female identified as NA #1was witnessed. On 12/2/24 at 1:35pm, the DON suspended NA #1 pending outcome of abuse investigation and notified the Medical Director (MD) of allegation. Because the resident was unknown at this time and the presence of a witness was unknown, the facility was unable to make notifications to Resident #2's resident representative or initiate immediate suspension of NA #2. On 12/2/24 at 2:15pm, the Social Worker (SW) notified the local police department and adult protective services (APS). A police report number was obtained. On 12/2/24 at 3:30pm, the Administrator submitted the initial allegation report to North Carolina Department of Health Human Services (NCDHHS). On 12/2/24 at 4:00pm, the Administrator completed an observational round of facility residents and staff to ensure that resident rights to privacy and freedom from abuse is maintained. Observations included 1) care being provided only by authorized staff, 2) use of privacy curtains, closed doors during personal care and covering/draping to prevent exposure of body parts, 3) no cellular or other video devices used by staff in resident care areas and 4) any other violation of resident right to personal privacy not only of a residents' own physical body, but of his or her personal space and 5) observations t ensure residents have no physical signs or behaviors indicative of potential abuse. No additional concerns identified. On 12/2/2024 and on 12/4/2024, the DON, VPCO, VPRQA, Administrator and Medical Director held an Ad Hoc meeting to discuss incident to determine root cause analysis of the facility's failure protect a resident's right to be free from abuse. Root cause analysis determined that the facility failed to implement an effective system to ensure strict enforcement and monitoring measures to prohibit cellular phones and video recording devices in resident care areas. Effective 12/2/2024, licensed nurses completed resident abuse questionnaires with cognitively intact residents and body audits with cognitively impaired residents to identify any additional concerns of resident abuse. No additional concerns reported or observed. On 12/4/24 at 4:00pm, the DON, VPCO and VPRQA were notified of additional information and observed video surveillance provided by the survey team identifying Resident #2 as a resident of the facility and of mental and sexual abuse by NA #1 in the presence of NA #2. The DON immediately suspended NA #2 pending investigation. The VPRQA notified police and provided additional information and left a message with APS. The DON notified Resident #2's resident representative (RP) and MD was provided updated information received. On 12/4/2024 at 6:00pm, the VPCO assessed Resident #2 for physical injury, pain and signs or symptoms of psychosocial distress and no concerns were observed and was pleasantly confused at baseline. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring, and when the action will be complete. Effective 12/2/2024, all current facility staff were in-serviced on the Abuse, Neglect and Exploitation Policy, Resident Rights Policy and Cell Phone Policy by the Staff Development Coordinator (SDC) and licensed nurse manager. Abuse training topics included preventing, reporting and identifying what constitutes abuse and NO TOLERANCE for failure to comply and ensure resident protection. Identification examples included; physical, mental, sexual, verbal, neglect, exploitation and signs of mental or emotional abuse such as, sudden unexplained changes in behavior, changes in eating habits, withdrawal from care, fear of certain persons or expressions of guilt or shame and staff obligation of reporting abuse immediately to the Administrator and prevention of abuse by the immediate intervention of removing the harm or potential for harm from the resident by removing the perpetrator or threat. Education of proper resident care includes examples such as ensuring residents are not harmed physically or handled roughly during care but are provided with care that is gentle, kind, dignified and that residents are free from offensive comments, profanities or other form of verbal abuse. To protect resident's right to privacy, the facility is adopting a NO TOLERANCE Cell Phone Policy focusing on the strict prohibition of cellular phones and any type of electronic recording device use in resident care areas, especially while providing personal care. Training included examples of violation of residents' privacy to include, but not limited to 1) privacy of not only a residents' own physical body, but of his or her personal space, including accommodations and personal care, 2) only authorized staff directly involved in providing care and services for the resident may be present when care is provided, unless the resident consents to other individuals being present during the delivery of care, 3) during the delivery of personal care and services, staff must remove residents from public view, pull privacy curtains or close doors, and provide clothing or draping to prevent exposure of body parts, 4) photographs or recordings of a resident and/or his or her body or private space without the resident's, or designated representative's written consent, is a violation of the resident's right to privacy and confidentiality, 5) staff taking unauthorized photographs of a resident's room or furnishings (which may or may not include the resident), or a resident eating in the dining room, or a resident participating in an activity in the common area, 6) taking unauthorized photographs or recordings of residents in any state of dress or undress using any type of equipment (for example, cameras, smart phones, and other electronic devices), 7) keeping or distributing them through multimedia messages or on social media networks is a violation of a resident's right to privacy and confidentiality, 8) potential effects on residents whose privacy is not maintained to include, humiliation, dignity, respect and feelings of dehumanization, 9) strict prohibition and NO TOLERANCE to use cellular phones or any type of audio or video device in resident care areas, resident rooms, common areas such as hallways, dining rooms, courtyards, etc., 10) cell phones are allowed to be kept in staff possession in the facility on a silenced or vibrate mode to allow for emergency alerts but may only be used in breakrooms or other non-resident areas and 11) staff are responsible to intervene if witnessing any violation of the Cell Phone Policy and/or the Resident Rights Policy and immediately remove risk from resident and notify Administrator and 12) violation of the Cell Phone Policy or Resident Rights Policy will result in disciplinary action up to and including termination of employment and/or notification to licensing boards and law enforcement where applicable to ensure resident privacy is maintained and resident's remain free from abuse. Effective 12/2/2024, abuse questionnaires were also completed with current facility staff to validate competency of education received and to identify any additional allegations or incidence of resident abuse. No additional concerns reported. The SDC will be responsible for ensuring all staff are trained by tracking and reviewing the daily schedule and ensuring training is provided. Newly hired staff and staff not receiving education by 12/2/2024 will receive education prior to first worked shift by the SDC, DON or licensed nurse supervisor. Effective 12/2/2024, the Administrator, DON or designee will complete ongoing daily observational rounds of facility residents and staff to ensure that residents are free from abuse and resident rights to privacy is maintained, including strict prohibition of staff cellular phone use or any type of audio or video device use in resident care areas. Observations to include 1) care being provided only be authorized staff, 2) use of privacy curtains, closed doors during personal care and covering/draping to prevent exposure of body parts, 3) no cellular or other video devices used by staff in resident care areas, 4) any other violation of resident right to personal privacy not only of a residents' own physical body, but of his or her personal space, 5) observations of any form of physical, sexual or emotional abuse which include but are not limited to; a. ensuring residents are not harmed physically or handled roughly during care but are provided with care that is gentle, kind, dignified; b. residents are free from offensive comments, profanities or other form of verbal abuse and c. observations to ensure residents are not exhibiting signs of mental anguish such as tearfulness, withdrawal, fear, guarding, aggressiveness and other unusual changes in resident behaviors. On 2/2/24, licensed nurses were educated and notified by the VPCO of their responsibility to complete observational rounds each shift for his/her unit and observe resident and staff interactions as above. Effective 12/4/24, the facilities new hire screening process has been updated to include additional measures to better determine the candidate's probability of providing excellent resident care to further ensure residents are free from abuse. Updates include improved interview process, a minimum of two professional references, screening of social media content for inappropriate content and improved screening of background checks. Human Resources (HR) and/or the Administrator, DON or SDC are responsible for the interview process, screening reference checks and screening social media platforms. With the guidance of our legal counsel, a template including a set of questions will be used during the interview process which include the categories of background, interpersonal skills and qualifications and a template for reference checks will be used. Screening of social media platforms will be used via internet search to provide information related to a candidate's personal character. The Human Resource (HR) Director will process and review criminal background checks and forward to the Administrator or DON for approval if a criminal record is identified. The Administrator or DON will consider all screening results to make a final determination. However, the facility will NOT extend employment to any candidate with convictions or pending convictions involving elder abuse, neglect or exploitation. Effective 12/2/2024, the Administrator is ultimately responsible for the implementation and completion of this removal plan. Alleged Date of IJ Removal: 12/5/2024 On 12/10/2024, the facility's credible allegation for immediate jeopardy was validated. Resident #2 was observed in the dining room pleasant and smiling with other residents in the table. During the tour of the facility residents were observed to have their doors closed for care and curtains were seen pulled to cover for privacy. There were no signs of staff cell phone use in the hallways and in resident care areas. The in-services by the facility included information on abuse, privacy, resident rights, and cellphone use, including notification of administration for any resident's behavior changes, and increased rounding observations of residents and staff. Staff interviews confirmed education was received for abuse, privacy, resident rights, and cellphone use. The facility provided evidence of daily Quality Assurance auditing of all residents divided on cognitively intact residents for interview and cognitively impaired residents for body audits, the auditing for the observational rounds every shift, staff abuse questionnaires, and new on-hire screening process and employee handbook review were executed. The immediate jeopardy removal date of 12/5/24 was validated.

Based on observation, record review, and responsible party, Lieutenant of Criminal Investigations and staff interviews, the facility failed to develop and implement abuse policies in the area of identification, protection and reporting for 1 of 3 residents (Resident #2). While Resident # 2 was being abused, neither of the two nurse aides (NA #1 and NA #2) in the room identified the abuse, intervened to stop the abuse, and neither of the two nurse aides reported the abuse immediately to licensed staff or administrative staff. Immediate jeopardy began on 10/4/24 when Resident #2 was abused without staff identification, intervention or reporting. Immediate jeopardy was removed on 12/5/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at the scope and severity of D (no actual harm with potential for more than minimal harm that is immediate jeopardy) to ensure education is completed and monitoring systems put into place and are effective. The findings included: A review of the facility policy and procedure titled Abuse, Neglect, and Exploitation, with a revised date of 10/22/24, read in part it is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property. As read in section 1: Policy Explanation and Compliance Guidelines, reads 1a.) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. This tag is cross referred to F600 Based on observation, record review, and family, Lieutenant of Criminal Investigations and staff interviews, the facility failed to protect a resident's right to be free from abuse for 1 of 3 residents (Resident #2). Nurse aide (NA) # 1 and NA # 2 provided personal care to Resident # 2 while live streaming on a cell phone, the resident was naked from the waist up, the staff and the prison inmate watching the live stream spoke with profanity and vulgarity without any regard for the resident; the staff did not explain care as it was provided to the resident; the staff were physically aggressive during care; the staff allowed an inmate who was watching the live stream to view the resident and speak to the resident; the staff allowed this live streaming while other inmates were observed in the open area behind him. As Resident #2 was severely cognitively impaired, the reasonable person concept was applied. A reasonable person would have been traumatized by being abused by caregivers in their home environment making them feel worthless, angry, dehumanized and powerless. Immediate jeopardy began on 10/4/24 when Resident #2 was abused. Immediate jeopardy was removed on 12/5/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at the scope and severity of D (no actual harm with potential for more than minimal harm that is immediate jeopardy) to ensure education is completed and monitoring systems put into place and are effective. The Director of Nursing (DON), [NAME] President of Clinical Operations (VPCO), and [NAME] President of Risk and QAPI (VPRQA) were notified of immediate jeopardy on 12/5/24 at 1:45 PM. The Administrator was not present. The facility provided the following credible allegation of immediate jeopardy removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: The facility failed to follow their abuse policy in the areas of identification, prevention, and reporting when NA #2 witnessed NA #1 conduct an audiovisual phone call where NA #1 showed Resident #2 in compromised positions during a recorded call NA #1 was having with a male individual who was witnessing Resident #2 through the use of a wall mounted screen in a common area of an incarceration center. During the audiovisual conversation NA #1 was observed to show Resident #2 to the male individual through her phone camera, the resident sitting in a wheelchair, naked, with no shirt or bra on, with her breasts exposed. NA #2 failed to intervene to stop the audiovisual device and protect the resident from ongoing mental abuse, and did not immediately get licensed staff or administrative staff to intervene and stop it, nor did she notify administration, or a supervisor. On 12/4/24 at 4:00pm, the DON, VPCO and VPRQA were first made aware of the presence of NA #2 during the incident on 10/4/2024. The DON immediately suspended NA #2 pending investigation. The VPRQA notified police and provided additional information and left a message with APS. The DON notified Resident #2's resident representative (RR) and MD was provided updated information received. On 12/4/2024 at 6:00pm, the VPCO assessed Resident #2 for physical injury, pain and signs or symptoms of psychosocial distress and no concerns were observed and was pleasantly confused at baseline. On 12/4/2024 the VPCQA, VPCO and DON attempted to obtain information regarding the location of the prison. Upon receipt of this information, the facility plans to inquire on the security of the recording and ensure that Resident #2 is protected from any additional violation of privacy by others who are unauthorized to have such information. On 12/4/2024, the DON, VPCO, VPRQA, Administrator and Medical Director held an Ad Hoc meeting to discuss incident to determine root cause analysis of the facility's failure to protect a resident's right to be free from abuse when NA #2 did not identify, prevent or report the incident on 10/4/2024. Root cause analysis determined that the facility failed to 1) implement an effective system to ensure staff knowledge of the Abuse, Neglect and Exploitation Policy to include detailed examples of how to identify, prevent and report abuse and validation of staff understanding and 2) the facility failed to enforce a strict NO TOLERATION for cell phone use and video recording device use in resident care areas per the Cell Phone Policy. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring, and when the action will be complete. Effective 12/2/2024, all current facility staff were in-serviced on the Abuse, Neglect and Exploitation Policy, Resident Rights Policy and Cell Phone Policy by the Staff Development Coordinator (SDC) and licensed nurse manager. Abuse training topics included preventing, reporting and identifying what constitutes abuse and NO TOLERANCE for failure to comply and ensure resident protection. Identification examples included; physical, mental, sexual, verbal, neglect, exploitation and signs of mental or emotional abuse such as, sudden unexplained changes in behavior, changes in eating habits, withdrawal from care, fear of certain persons or expressions of guilt or shame and staff obligation of reporting abuse immediately to the Administrator and prevention of abuse by the immediate intervention of removing the harm or potential for harm from the resident by removing the perpetrator or threat. Education of proper resident care includes examples such as ensuring residents are not harmed physically or handled roughly during care but are provided with care that is gentle, kind, dignified and that residents are free from offensive comments, profanities or other form of verbal abuse. To protect resident's right to privacy, the facility is adopting a NO TOLERANCE Cell Phone Policy focusing on the strict prohibition of cellular phones and any type of electronic recording device use in resident care areas, especially while providing personal care. Training included examples of violation of residents' privacy to include, but not limited to 1) privacy of not only a residents' own physical body, but of his or her personal space, including accommodations and personal care, 2) only authorized staff directly involved in providing care and services for the resident may be present when care is provided, unless the resident consents to other individuals being present during the delivery of care, 3) during the delivery of personal care and services, staff must remove residents from public view, pull privacy curtains or close doors, and provide clothing or draping to prevent exposure of body parts, 4) photographs or recordings of a resident and/or his or her body or private space without the resident's, or designated representative's written consent, is a violation of the resident's right to privacy and confidentiality, 5) staff taking unauthorized photographs of a resident's room or furnishings (which may or may not include the resident), or a resident eating in the dining room, or a resident participating in an activity in the common area, 6) taking unauthorized photographs or recordings of residents in any state of dress or undress using any type of equipment (for example, cameras, smart phones, and other electronic devices), 7) keeping or distributing them through multimedia messages or on social media networks is a violation of a resident's right to privacy and confidentiality, 8) potential effects on residents whose privacy is not maintained to include, humiliation, dignity, respect and feelings of dehumanization, 9) strict prohibition and NO TOLERANCE to use cellular phones or any type of audio or video device in resident care areas, resident rooms, common areas such as hallways, dining rooms, courtyards, etc., 10) cell phones are allowed to be kept in staff possession in the facility on a silenced or vibrate mode to allow for emergency alerts but may only be used in breakrooms or other non-resident areas and 11) staff are responsible to intervene if witnessing any violation of the Cell Phone Policy and/or the Resident Rights Policy and immediately remove risk from resident and notify Administrator and 12) violation of the Cell Phone Policy or Resident Rights Policy will result in disciplinary action up to and including termination of employment and/or notification to licensing boards and law enforcement where applicable to ensure resident privacy is maintained and resident's remain free from abuse. Effective 12/2/24, abuse questionnaires were also completed with current facility staff to validate competency of education received and to identify any additional allegations or incidence of resident abuse. No additional concerns reported. The SDC will be responsible for ensuring all staff are trained by tracking and reviewing the daily schedule and ensuring training is provided. Newly hired staff and staff not receiving education by 12/2/24 will receive education prior to first worked shift by the SDC, DON or licensed nurse supervisor. Effective 12/2/24, abuse questionnaires were also completed with current facility staff to validate competency of education received and to identify any additional allegations or incidence of resident abuse. No additional concerns reported. The SDC will be responsible for ensuring all staff are trained by tracking and reviewing the daily schedule and ensuring training is provided. Newly hired staff and staff not receiving education by 12/2/24 will receive education prior to first worked shift by the SDC, DON or licensed nurse supervisor. Effective 12/2/2024, the Administrator, DON or designee will complete ongoing daily observational rounds of facility residents and staff to ensure that residents are free from abuse and resident rights to privacy is maintained, including strict prohibition of staff cellular phone use or any type of audio or video device use in resident care areas. Observations to include 1) care being provided only be authorized staff, 2) use of privacy curtains, closed doors during personal care and covering/draping to prevent exposure of body parts, 3) no cellular or other video devices used by staff in resident care areas, 4) any other violation of resident right to personal privacy not only of a residents' own physical body, but of his or her personal space, 5) observations of any form of physical, sexual or emotional abuse which include but are not limited to; a. ensuring residents are not harmed physically or handled roughly during care but are provided with care that is gentle, kind, dignified; b. residents are free from offensive comments, profanities or other form of verbal abuse and c. observations to ensure residents are not exhibiting signs of mental anguish such as tearfulness, withdrawal, fear, guarding, aggressiveness and other unusual changes in resident behaviors. On 2/2/24, licensed nurses were educated and notified by the VPCO of their responsibility to complete observational rounds each shift for his/her unit and observe resident and staff interactions as above. Effective 12/4/24, the facilities new hire screening process has been updated to include additional measures to better determine the candidate's probability of providing excellent resident care to further ensure residents are free from abuse. Updates include improved interview process, a minimum of two professional references, screening of social media content for inappropriate content and improved screening of background checks. Human Resources (HR) and/or the Administrator, DON or SDC are responsible for the interview process, screening reference checks and screening social media platforms. With the guidance of our legal counsel, a template including a set of questions will be used during the interview process which include the categories of background, interpersonal skills and qualifications and a template for reference checks will be used. Screening of social media platforms will be used via internet search to provide information related to a candidate's personal character. The Human Resource (HR) Director will process and review criminal background checks and forward to the Administrator or DON for approval if a criminal record is identified. The Administrator or DON will consider all screening results to make a final determination. However, the facility will NOT extend employment to any candidate with convictions or pending convictions involving elder abuse, neglect or exploitation. Effective 12/2/2024, the Administrator is ultimately responsible for the implementation and completion of this removal plan. Alleged Date of IJ Removal: 12/5/2024 On 12/10/2024, the facility's credible allegation for immediate jeopardy was validated. Resident #2 was observed in the dining room pleasant and smiling with other residents in the table. During the tour of the facility residents were observed to have their doors closed for care and curtains were seen pulled to cover for privacy. There were no signs of staff cell phone use in the hallways and in resident care areas. The in-services by the facility included information on abuse, privacy, resident rights, and cellphone use, including notification of administration for any resident's behavior changes, and increased rounding observations of residents and staff. Staff interviews confirmed education was received for abuse, privacy, resident rights, and cellphone use. The facility provided evidence of an Ad Hoc meeting discussion of the root cause analysis of the facility failure to implement effective systems of their abuse policy. The facility provided evidence of daily Quality Assurance auditing of all residents divided on cognitively intact residents for interview and cognitively impaired residents for body audits, the auditing for the observational rounds every shift, staff abuse questionnaires, and new on-hire screening process and employee handbook reviewed. The facility's IJ removal date of 12/05/24 was validated.

Based on record review, and interviews with staff, the facility failed to protect the resident's right to be free from misappropriation of controlled medications for 1 of 3 residents reviewed for misappropriation of a resident's property (Resident #6). The resident received her pain medication as scheduled. Findings included: The facility's Abuse, Neglect, and Exploitation Policy, last updated on 10/22/24, was reviewed and it included misappropriation in part was the protection of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. Resident #6 was admitted to the facility on [DATE] with a diagnosis of chronic pain. Resident #6 had an order for oxycodone 10 milligrams (mg) every 6 hours for chronic pain dated 2/13/24. A pharmacy packing slip dated 3/25/24 documented dispense date of 3/25/24 of 4 cards of oxycodone 10 mg and each card had 10 tablets for a total of 40 tablets. A review of the medication monitoring/control record received by Nurse #4 documented between 3/25/24 through 3/27/24 there were 10 oxycodone 10 mg administered every 6 hours as ordered, signed with correct descending amount. The remaining amount was 0 for card number one. There were three remaining oxycodone 10 mg cards with 10 tablets each with a medication monitoring/control record. The daily nursing schedule dated 3/27/24 had Nurse #2 scheduled on B-Hall assigned to Resident #6 on day shift, and she was responsible for this hall's medication cart. The shift change narcotic count verification for total number of narcotic sheets for all residents on Hall B medication cart ending date 3/26/24 was documented by Nurse #3 total number 32 sheets. Four sheets were added for a total of 36. A 6 was written with a 4 for the column sheets added and the total column was written as 38. The 8 appeared to be written on with another number that was not legible. The comments column documented Resident #6 had 4 oxycodone cards on 3/26/24. All rows were filled on this sheet. A new shift change narcotic count verification sheet was started dated 3/27/24 3 pm shift oncoming nurse signature Nurse #2 and off going nurse was blank. Number 36 was in the narcotic sheets column. A new row on the narcotic count verification sheet was started dated 3/27/24 11 pm shift oncoming nurse and off going nurse columns were both signed with a signature of Nurse #3's name. There was no number in the narcotic sheets column. The handwriting of the signatures on this sheet appeared to be the same for both names, all 3 signatures. The Director of Nursing (DON) provided a folder with Resident #6's narcotic misappropriation investigation dated 3/27/24 documentation: On 3/27/24 the 2nd shift nurse reported that Resident #6 was missing 1 of 4 cards of oxycodone 10 mg that were delivered on 3/25/24. The DON completed a review of the shift verification count sheet and noted that the sheet count number had been altered. Further investigation revealed 1 medication monitoring control record and 1 card of 10 oxycodone 10 mg tablets were missing. The pharmacy and police were notified. All other facility medication carts of narcotic counts were audited, and no other concerns were noted. Nurse #2 was suspended pending investigation. The pharmacy confirmed that 4 cards of oxycodone 10 mg were delivered on 3/25/24. The pharmacy packing slip indicated that 4 cards of oxycodone 10 milligrams with 10 tablets on each card were delivered. Nurse #2 was contacted by phone and refused to provide a statement related to oxycodone. Nurse #2 was reported to the North Carolina Board of Nursing on 4/3/24. Education was initiated with licensed nurses regarding the narcotic count and correcting errors in the medication record properly. Corrective actions: The pharmacy was contacted by the DON on 3/28/24 and a replacement refill card of oxycodone 10 mg 10 tablets was obtained at the expense of the facility. The police were contacted, and they informed the facility they were unable to reach Nurse #1 by phone or the address on file by the agency. Nurse #2 will not be allowed to work in the facility. On 4/8/24 a urine specimen was obtained from Nurse #3. The test was negative for all drugs including opiate. Nurse #2 was left messages on 3/27/24 and 3/28/24 twice. A return call was received from her on 3/29/24 at 10:40 am. She stated that she wanted her pay approved. Nurse #2 was asked to come to the facility and provide a statement. A statement was not provided. All residents that had narcotic orders were reviewed for accuracy of administration and count. All medication control records were reviewed and medication audited, and no other misappropriation of medication was identified. Audits were completed for weeks 4/3/24 through 5/1/24 weekly for 4 weeks or longer if concerns were identified. Goal: Residents' controlled drugs will be properly handled and the facility will have correct records/documentation on the narcotic count sheets. The audits were completed, and counts were correct. An in-service roster of nurses signed for education about the policy controlled substance administration and accountability revision November 2017 had 32 staff signatures. Additional information to correct mistakes appropriately was included. On 12/5/24 at 2:54 pm an interview was conducted with Nurse #2. She stated on 3/25/27 four oxycodone cards with 10 tabs each were received for Resident #6 and Nurse #3 and #4 observed, documented, and counted that this was added to the shift change narcotic count verification sheet and there was a medication monitoring control record for each oxycodone card. Both nurses signed for the received oxycodone. The new cards were added to the shift change narcotic count verification sheet, and we used the last row of that sheet with a date of 3/26/24. A new shift change narcotic count verification sheet was started and signed by Nurse #3 and #4. Nurse #2 was on day shift 3/27/24 responsible for the narcotics and counted with Nurse #3 at shift change 3:00 pm. The Medication monitoring control record that was being used was accurate. There were the correct number of shift change narcotic count verification sheets numbered. Nurse #3 stated she went to administer an oxycodone at the beginning of her evening shift and checked the paperwork. She noticed that the new shift change narcotic count verification sheet was not the sheet she and Nurse #4 had started and signed on 3/26/24. The signatures were not theirs and both appeared to be signed by the same person. A check of the previous shift change narcotic count verification sheet ending date 3/26/24 that Nurse #3 and #4 had completed to the last row of the sheet had the number of narcotic sheets added and total number of narcotic sheets on the cart were changed. The numbers were written over and were not the correct numbers, the numbers written by Nurse #3 the evening before 3/26/24. Nurse #3 noticed that one of the oxycodone cards was missing. There should have been 3 cards remaining and now there were only 2. Nurse #2 had left immediately after report at shift change and narcotic count and was unable to be reached by telephone. On 12/5/24 at 2:40 pm an interview was conducted with the [NAME] President of Quality. She stated the Administrator was not present and the DON employed March 2024 was no longer working at this facility. She also stated she would look for additional nursing education roster sheets, QAPI (Quality Assurance/Performance Improvement) minutes, and Drug Enforcement Administration notification. On 12/5/24 at 4:20 pm the [NAME] President of Quality provided a QAPI minute meeting dated 3/27/24 with the topic drug diversion and the team roster. Nurse # 4 was interviewed on 12/10/24 at 12:25 pm. Nurse #4 stated 4 cards of oxycodone 10 mg were received for Resident #6 on 3/25/24. Nurse #3 and Nurse #4 counted, documented, and signed for the receipt of the Oxycodone 3/25/24 at 7:00 am. One card of the Oxycodone 10 mg was used and counted down to 0 on 3/27/24. The count was correct when Nurse #4 left after night shift 3/27/24 7:00 am and counted with Nurse #2. Nurse #4 started a new shift change narcotic count sheet with Nurse #3 and signed and dated 3/26/24. Nurse #4 counted with Nurse #2 at the beginning of her day shift 3/27/24 at 7:00 am and the narcotic count was correct. The sheet Nurse #4 started was present and there were 3 full cards of oxycodone 10 mg remaining. On 3/27/24 at 3:00 pm the shift change narcotic count sheet that Nurse #3 and Nurse #4 started was missing. Another sheet was started by an agency nurse (Nurse #2). Nurse #4's name was not on this new sheet. Nurse #3 and Nurse #2's name were on the new sheet and the handwriting looked the same. On 12/10/14 the [NAME] President of Quality provided the remaining nurse education roster and a statement that the Drug Enforcement Administration was notified under the facility's previous name and identification number and the document was not obtainable. The facility provided the following corrective action plan with a completion date of 4/7/24: F602 1. Corrective action for resident(s) affected by the alleged deficient practice: Resident #6 was affected by misappropriation of her schedule oxycodone pain medication. The resident received her medication as scheduled. The medication was replaced by the facility. 2. Corrective action for residents with the potential to be affected by the alleged deficient practice: All residents with a narcotic order for pain had potential to be affected. The Director of Nursing completed an audit of all medication carts with narcotics to verify that all narcotics and narcotic sheets were accounted for with no other concerns identified. The audit was completed on 3/27/24. 3. Measures/Systemic changes to prevent recurrence of alleged deficient practice: On 3/27/24 through 4/7/24 training on the following topics for all licensed nurses and medication aids regarding misappropriation of personal property that focused on shift-to-shift count, verifying medications on hand, misappropriation, and documentation. The Director of Nursing and/or designee would continue to maintain and monitor controlled medication records to ensure consistency and accountability. Education was completed by 4/7/24 for all nursing staff, including agency staff. Monitoring of the medication carts began on 3/27/24 with the initial audit after the misappropriation. The monitoring continued weekly for 4 weeks. The QA members were notified on 3/27/24. 4. Monitoring procedure to ensure that the plan of correction is effective, and that specific deficiency cited remains corrected and/or in compliance with regulatory requirements. The Director of Nursing audited all medication carts weekly for 4 weeks. There were no adverse findings. The misappropriation was reported to the QAPI (Quality Assurance/Performance Improvement) Committee) on 3/27/24. Compliance Date: 4/8/24 Validation of the corrective action plan was completed on 12/11/24. Review of documentation/staff roster of education that was completed with 33 nurses and medication aides who had responsibility to administer narcotic medication and had access to controlled substances covered drug loss or theft, administration, and shift-to-shift drug count was completed. The education took place between 3/27/24 through 4/7/24. On 12/5/24 interviews were conducted individually with Nurse #1 and #3 and on 12/10/24 with Nurse #4. The Nurses stated they participated in education for narcotic misappropriation, storage, reporting, count, and documentation. The compliance date of 4/8/24 was validated.

Based on observations, record review, and interviews with Resident #65 and staff, the facility failed to provide nail care and hand hygiene for a dependent resident (Resident #65). This deficient practice affected 1 of 4 sampled dependent residents. Findings included: Resident #65 was admitted to the facility on [DATE] with the diagnosis of limited range of motion. Resident #65's Minimum Data Set, dated dated dated [DATE] documented her cognition was intact. The resident required assistance from one staff member for bathing and personal grooming. The care plan for Resident #65 dated 9/13/24 included the resident required assistance with all activities of daily living. The intervention was nail care to be provided with showers or bathing. On 12/2/24 at 11:40 am an observation and interview was completed of Resident #65. The Resident was sitting in her bed in a hospital gown. The Resident's nails were noted to be uneven, long, and had black matter underneath the nails, especially the right hand. The resident stated she usually had a bed bath and had no offer from the Nursing Assistant (NA) to provide nail care. The resident stated she would like nail care, and she had not refused care. The resident also stated she had asked an NA to cut her nails, but the NA had not returned to provide care a couple of days earlier. On 12/5/24 at 1:50 pm an observation and interview was completed with Resident #65. The Resident's nails remained long, uneven but had less black matter. The right hand had two nails that remained with black matter underneath. The Resident stated she was taken to the dining room by the Activity Director yesterday for an activity. The Resident was informed she was going to receive a manicure including nail polish. The Resident stated she had not gotten her nails done and was taken back to her room and had not known why. The resident stated she had a bed bath yesterday and the NA assigned had not provided nail care and she did not know why. The Resident had not asked for nail care. The Resident stated she required assistance with all bathing and nail care. She could not cut her own nails and had no access to wash her hands/nails without staff assistance. An interview was conducted with NA #4 on 12/5/24 at 1:55 pm. NA #4 stated he was assigned on day shift to Resident #65 on 12/4/24 and 12/5/24. NA #4 stated he provided a bed bath on 12/4/24 but had not provided nail care. NA #4 had not provided nail care because his assignment was heavy. NA #4 stated he ran out of time. NA #4 had not offered or provided nail care today (12/5/24) but would provide care now. NA #4 stated he was aware and had observed the resident place her hand inside her brief to scratch and had not provided hand hygiene before meals. The resident had itchy skin all over her body. NA #4 further stated he had not informed the nurse about the scratching. On 12/5/24 at 1:45 pm an interview was conducted with NA #3. NA #3 stated she was assigned to Resident #65 on 12/5/24, day shift. The NA stated she provided morning care for the resident and her bath was yesterday. The NA stated on rounds this morning the resident was observed to have her hands in her brief scratching what appeared to be her private area. The resident told the NA that she was scratching her leg. The NA stated she had not offered to clean the resident's hands after the scratching and before lunch. The NA had not known why the resident's nails were long, uneven, and dirty underneath. The NA stated she would provide nail care following the interview. On 12/5/24 at 1:55 pm an interview was conducted with the Activity Assistant. She stated there was an activity yesterday for manicures. She stated the activity ran out of time and the dining room was needed for lunch. Resident #65 was not able to have her manicure due to a lack of time. The Activity Director was also an NA and would clean/cut a resident's nails if needed. The Activity Assistant stated she was going to have another manicure activity on Saturday but could not cut the resident's nails, she was not an NA. She further stated Resident #65 would be added to the list for manicure this Saturday (12/7/24). On 12/4/24 at 3:39 pm an interview was conducted with Nurse #1. She stated the NAs were responsible to provide the residents with nail care during the shower or bed bath unless refused and the nurse would need to be notified. She stated the NAs had not notified her Resident #65 had refused care, including nail care. Nurse #1 was not aware that the resident's nails required care and would let the NA scheduled know. An interview was conducted with Nurse #1 on 12/5/24 at 2:05 pm. She was not aware that the resident's nails were not cared for yesterday with the bath (12/4/24). The resident sometimes preferred a bath over a shower but had not refused care. She was not aware that the resident was observed by NA #3 and NA #4 putting her hand into her brief and scratching. She could not remember which NA provided the bed bath yesterday. On 12/5/24 at 3:45 pm an interview was conducted with the Director of Nursing (DON). The DON was not aware Resident #65 had not received nail care and was scratching her skin, including inside her undergarment. The DON would want staff to provide hand hygiene before meals if a resident was scratching inside an undergarment.

Based on record review and staff interviews, the facility failed to complete a quarterly smoking assessments for 2 of 3 residents reviewed for smoking (Resident #31 and Resident #72). The findings included: 1a. Resident #31 was admitted to the facility on [DATE] with diagnoses which included hypertension, muscle weakness, dementia, and blindness in one eye. Review of Resident #31's annual MDS dated [DATE] revealed the resident was coded for smoking. Review of Resident #31's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was severely cognitively impaired and was totally dependent on staff for most activities of daily living (ADL). Resident #31 was coded for moderate visual impairment. The MDS indicated Resident #31's mobility device was a wheelchair use. Review of Resident #31's care plan revised on 12/4/24 revealed the resident was a smoker and was supervised because he was once non-compliant with smoking policy and witnessed smoking in his room. The goal was for Resident #31s smoking related injuries to be minimized with intervention through next review. Interventions included smoking assessment to be completed per facility policy. Review of Resident #31's smoking assessments revealed the only smoking assessment completed since the last recertification dated 07/08/23 was on 09/17/24. The smoking assessment dated [DATE] concluded Resident #3 was a supervised smoker because he was unable to demonstrate and understand the smoking policy, times, and place to smoke. 1b. Resident #72 was originally admitted to the facility on [DATE] with diagnoses which included hypertension and unsteadiness of feet. Review of Resident #72's annual MDS dated [DATE] revealed the resident was not coded for smoking. Review of Resident #72's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident's cognition was moderately impaired and required supervision for most ADL. The MDS further revealed Resident #72 had adequate vision. Resident #72 was coded for wheelchair and walking cane use. Resident #72's had a smoking assessment completed on 12/02/23 and the next smoking assessment was not conducted until 06/02/24 which assessed Resident #72 as an independent smoker. Review of Resident #72's care plan revised on 07/24/24 revealed the resident was an independent smoker. The goal was for Resident #72 to not suffer injury from unsafe smoking practices. The interview conducted with Nurse #6 on 12/05/24 at 12:55 PM revealed Resident #31 was a supervised smoker and Resident #72 was an unsupervised smoker. Nurse #6 further revealed nurses assigned to residents were expected to complete smoking assessment quarterly. The Nurse indicated the computer system notified staff when a residents' assessment needs to be completed. Nurse #6 revealed she does not know why they were not completed on time but should have been. Interview conducted with Unit Manager (UM) #1 on 12/05/24 at 1:20 PM revealed smoking assessments were expected to be completed quarterly. UM #1 indicated nurses were notified by the computer what assessments were pending and needed to be completed during their shift, and they were expected to do so. UM #1 indicated she was not aware Resident #31 and Resident #72's smoking assessments had not been completed quarterly. Interview conducted with the Director of Nursing on 12/05/24 at 3:10 PM revealed she had not been employed with the facility for long but expected quarterly smoking assessments to be completed. The DON further revealed she was not aware Resident #31 and Resident #72 went several months without a smoking assessment being conducted.

Based on manufacturer's recommendations, observations, and staff interviews, the facility failed to date three opened bottles of artificial tears stored for use in 1 of 2 medication carts reviewed for medication storage (the B-hall medication cart). Findings included: A review of the manufacturer's recommendations for artificial tears stated after the bottle was opened it should have been discarded after 28 days. On 12/3/2024 at 11:00 am an observation of the B-hall medication cart with Nurse #5 revealed 3 bottles of artificial tears were found without an open date. Nurse #5 stated the bottles were in the boxes and the date was on the box on the previous evening. Nurse #5 stated either the bottle or the box should be dated when the bottle is opened. On 12/9/2024 at 11:06 am the Director of Nursing was interviewed by phone, and she sated the bottles of artificial tears that were opened in the B-hall medication cart should have been dated when they were opened. The Administrator was present during the interview and stated either the box or the bottle of the artificial tears should have been dated when the bottle was opened.

Based on record review and staff interviews, the facility failed to notify Resident #27's Representative and Resident #28 in writing, of transfers to the hospital for 2 of 3 residents reviewed for hospitalization (Resident #27 and Resident #28). The findings included: 1. Resident #27 was admitted to the facility on [DATE]. Resident #27 was readmitted to the facility on [DATE], 8/4/24, and 11/9/24. The most recent quarterly Minimum Data Set assessment dated [DATE] assessed Resident #27 to be severely cognitively impaired. a. Review of Resident #27's medical record revealed a progress note dated 2/28/24 that documented Resident #27's transfer to the hospital for difficulty swallowing. A progress note dated 3/7/24 documented Resident #27's return from the hospital with a diagnosis of elevated sodium level. Review of the medical record revealed no transfer notification. b. A progress note dated 8/3/24 documented Resident #27's transfer to the hospital after a fall and complaints of head pain. A progress note dated 8/4/24 documented Resident #27's readmission to the facility after hospitalization for fall. Review of the medical record revealed no transfer notification. c. A progress note dated 11/6/24 documented Resident #27 was experiencing nausea and vomiting, and he was sent to the hospital for evaluation. A progress note dated 11/9/24 documented Resident #27's return from the hospital. The hospital discharge note dated 11/9/24 documented Resident #27 was admitted to the hospital for intractable nausea and vomiting. Review of the medical record revealed no transfer notification. The Social Worker (SW) was interviewed on 12/5/24 at 3:25 PM. The SW reported the previous administrator had told her she needed to provide a written notice of transfer for residents sent to the hospital, but she had not started to provide the written notice of transfer to residents or their representative. The SW reported she had not provided a written notice of transfer for any resident. The Administrator was interviewed by phone on 12/9/24 at 11:10 AM. The Administrator reported she was not aware the SW was not providing a written notice of transfer for residents, or their representatives and she expected all residents or their representatives to receive a written notice of transfer. 2. Resident #28 was admitted to the facility 8/27/24. The most recent quarterly Minimum Data Set assessment dated [DATE] documented Resident #28 was cognitively intact. A progress note dated 12/3/24 documented Resident #28 was sent to the hospital for cellulitis (infection of the soft tissue) of the leg, elevated white blood cells, and elevated kidney function. Resident #28 remained hospitalized during the survey. Review of the medical record revealed no transfer notification to Resident #28. The Social Worker (SW) was interviewed on 12/5/24 at 3:25 PM. The SW reported the previous administrator had told her she needed to provide a written notice of transfer for residents sent to the hospital, but she had not started to provide the written notice of transfer to residents or their representative. The SW reported she had not provided a written notice of transfer for any resident. The Administrator was interviewed by phone on 12/9/24 at 11:10 AM. The Administrator reported she was not aware the SW was not providing a written notice of transfer for residents, or their representatives and she expected all residents or their representatives to receive a written notice of transfer.

Based on record review and staff interviews the facility failed to protect the residents right to be free of misappropriation of narcotic pain medication for 1 of 1 resident (Resident #1) reviewed for misappropriation of resident property. Findings included: A review of the facility's Abuse, Neglect and Exploitation policy dated 11/1/2020 indicated the facility would prohibit and prevent misappropriation of resident property. Resident #1 was admitted for a short stay for rehabilitation to the facility on [DATE] after a hospitalization for encephalopathy and weakness. A review of Resident #1's Physician's Orders revealed he did not have an order for hydromorphone. An admission Minimum Data Set assessment dated [DATE] indicated Resident #1 was cognitively intact and required extensive assistance with bed mobility and transfers, and he did not require pain medication. Attempted to call Resident #1 during the survey and there was no answer at the number the facility had for him, and the phone did not receive messages. Nurse #13 was interviewed by phone on 9/13/2023 at 3:32 pm and she stated she had gone into Resident #1's room shortly after he admitted to the facility on [DATE] and found a medication bottle with 58 hydromorphone, a narcotic pain medication, sitting on his bedside table and had explained to him it would need to be locked in the medication cart and he agreed. Nurse #13 stated she put the bottle in the medication cart and counted the medications with another nurse and put a medication count form in the narcotic book to ensure the medication was counted each shift. Nurse #13 stated she notified the Director of Nursing (DON) the medication was in the locked narcotic drawer on the medication cart. Nurse #13 stated she worked on 8/1/2023 on the 7:00 am to 3:00 pm shift and counted the hydromorphone with Nurse #14 when she arrived for the 3:00 pm to 11:00 pm shift on 8/1/2023. Nurse #13 stated when she arrived for her shift on 8/2/2023 on the 7:00 am to 3:00 pm shift the bottle of hydromorphone was missing from the medication cart. Nurse #13 stated there were fifty-eight pills in the medication bottle when she left the faciity on [DATE] at 3:00 pm. On 9/13/2023 at 3:46 pm Nurse #14 stated she worked the 3:00 pm to 11:00 pm shift on 8/1/2023 and an agency nurse, Nurse #15, was the nurse that came in on the 11:00 pm to 7:00 am shift, and he had counted the narcotic medications with her when she was leaving at 11:00 pm and there were 58 hydromorphone tablets in Resident #1's medication bottle. Nurse #4 was interviewed on 9/13/2023 at 4:11 pm and she stated she was the supervisor on the 3:00 pm to 11:00 pm shift on 8/1/2023. Nurse #4 stated Nurse #15 became erratic and was cussing and taking his clothes off in the courtyard of the facility during the 3:00 pm to 11:00 pm shift on 8/1/2023 and she stated she questioned him about his behavior he said he was sleep deprived and she sent him home. Attempted to contact Nurse #15 during the survey and there was no answer on his phone and the phone did not accept messages. On 8/2/2023 at 12:15 pm Nurse #13's Nurse's Progress Note stated Resident #1 was discharged home with his family without pain or discomfort. The note further stated Resident #1 was informed his personal medication was missing and he was not happy. The Director of Nursing was interviewed on 9/13/2023 at 4:35 pm and she stated Resident #1 brought in a bottle of medication that was a narcotic pain medication, hydromorphone, when he was admitted to the facility. She stated the day he was discharged the hydromorphone were no longer in the medication cart but they were the evening before he was discharged . The DON stated the facility does not drug test nurses unless there is a reasonable suspicion of them being under the influence. The DON stated Nurse #15 was sent home due to erratic behavior and when the narcotic medication was discovered missing, he would not come back to the facility for a drug test. The DON stated the facility had reported the missing narcotic medication to the police department and the Drug Enforcement Agency (DEA). The Director of Nursing stated she did notify the staffing agency of the incident and told them she did not want Nurse #15 to return to the facility. The Administrator stated on 9/14/2023 at 3:36 pm he was not the administrator when the drug Resident #1's home medications were misplaced 8/1/2023.

Based on record reviews, resident, family, nurse practitioner (NP), physician (MD), and staff interviews, the facility failed to notify the MD of a resident who experienced pain following a fall for 1 of 3 residents investigated for notification of changes (Resident #94). Resident #94 sustained a fall on 6/2/2023 and reported the fall and right hip pain to Physical Therapist (PT) #1 on 6/3/2023. PT #1 reported the fall and the hip pain to a nurse. Resident #94 reported the fall and right hip pain when she was assessed by NP#2 on 6/5/2023. NP#2 ordered an x-ray of the right hip, which revealed a fractured femur (the long bone in the leg). Resident #94 was sent to the hospital on 6/6/2023 at 12:30 AM and had a partial hip replacement surgery on 6/7/2023. Immediately Jeopardy began on 6/3/2023 when Resident #94 reported the fall and right hip pain to PT #1 and the MD was not notified. Immediate Jeopardy was removed on 7/26/2023when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a scope and severity level of D (not actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put in place are effective. The findings included: Resident #94 was admitted to the facility on [DATE] with diagnoses to include dementia and frequent falls. The admission nursing assessment recorded by Nurse #6 dated 6/2/2023 documented that Resident #94 was alert and oriented to person and situation. An interview was conducted with Resident #94 on 7/20/2023 at 3:30 PM. Resident #94 reported the evening of 6/2/2023 she used her call light to get assistance to use the bathroom, but no staff came to help her, so she got up to go to the bathroom on her own. Resident #94 reported she fell on the floor outside of the bathroom and hit her right hip. Resident #94 explained that she started yelling for help immediately, and her roommate (Resident #50) yelled for help, too. Resident #94 said that 2 nurse aides (NAs) came to her room, picked her up and put her back in bed. Resident #94 recalled her leg hurt terribly and she told the NAs her leg was hurting. Resident #94 explained the therapist (PT #1) came in the next day to see her and she told PT #1 she did not think she could stand up because she fell the night before. PT #1 told Resident #94 she would talk to the nurse. Resident #94 reported her right leg hurt so bad all the time and every time staff moved her in bed, she told them that it hurt. Resident #94 said the NP #2 came in to see her on Monday morning 6/5/2023 and she told the NP that she had fallen and was having right hip pain. A follow-up interview was conducted with Resident #94 on 7/21/2023 at 1:58 PM. Resident #94 recounted the fall on 6/2/2023 and added that she thought she fell after dinner but could not specifically recall the time. Resident #94 recounted that she screamed and screamed (for help) and 2 ladies (NAs) came and got me into bed, I screamed in pain the entire time. Resident #94 reported she had called her family member on 6/2/2023 to report the fall. The family member of Resident #94 was interviewed by phone on 7/20/2023 at 4:19 PM. The family member reported that Resident #94 called him at 7:10 PM on 6/2/2023 to tell him that she had fallen, and she was having pain in her hip. The family member explained that Resident #94 told him 2 staff members had picked her up off the floor, and he didn't think he needed to call the facility to report the fall. The family member reported he came to visit Resident #94 on 6/3/2023 and talked to Nurse #1 and reported that Resident #94 had fallen and was having pain. The family member explained that he visited again on Sunday, 6/4/2023 and asked the nurse on duty about getting Resident #94 a walker, and he also mentioned the fall and pain to Nurse #8. When asked about the nurse's response, the family member said the nurse did not say anything about the reported fall. The family member reported he had called the admission's staff member and left her a voice mail reporting the fall on Monday, 6/5/2023. A physical therapy evaluation conducted by PT #1 and dated 6/3/2023 documented that Resident #94 reported right hip pain from a fall 6/2/2023. PT #1 documented that Resident #94 required moderate assistance to stand with right-sided leaning noted. The note documented the physical therapist notified the nurse (unnamed) and was told nursing would order an x-ray. PT #1 was interviewed by phone on 7/21/2023 at 2:49 PM. PT#1 reported she evaluated Resident #94 on 6/3/2023 and she attempted to stand Resident #94 at the bedside, but Resident #94 was unable to stand. The PT explained that Resident #94 and her roommate, Resident #50, told her that Resident #94 fell the night before. Resident #94 reported right hip pain to her with touch. Resident #94 was unable to stand during the evaluation without moderate assistance and was leaning to the right. PT #1 indicated she went to the nursing station and looked for a nurse and reported the fall and the pain that Resident #94 was experiencing. PT #1 reported an unknown nurse and told her she would get an order for an x-ray for Resident #94. PT#1 was not certain the time of day she evaluated Resident #94. PT #1 was unable to provide the name of the nurse or the time she reported to the nurse. Nurse #1, an agency nurse, was assigned to Resident #94 on 6/3/2023 on the day shift (7:00 AM to 3:00 PM). Multiple attempts to contact Nurse #1 for an interview were unsuccessful including phone calls with voice messages and text messages. NA #1 was interviewed on 7/20/2023 at 11:57 AM. NA #1 reported she was assigned to Resident #94 on 6/3 and 6/4/2023 for the day shift. NA #1 reported Resident #94 had pain during the weekend when they moved her in bed. NA #1 reported she had reported the pain to Nurse #1 on 6/3/2023. NA #1 reported Resident #94 did not get out of bed on day shift for 6/3/2023 or 6/4/2023 and she required incontinence care in bed because of the right hip pain. An interview was conducted with NA #2 on 7/20/2023 at 2:28 PM. NA #2 reported she was assigned to Resident #94 on 6/3/2023 for the afternoon shift. The NA explained that Resident #94 complained of pain in her hip, but she did not report to any nurse because she had observed PT #1 reporting the pain a nurse. NA #2 explained she did not remember the nurse that received the report from PT #1, but she had seen the two of them talking. Resident #94 was unable to get out of bed during the afternoon shift on 6/3/2023 because of the pain she experienced with moving. NA #2 reported she did not notice bruising on Resident #94's right hip. There was no evidence in the medical record that Nurse #1 or any other staff notified the physician of Resident #94's fall and subsequent pain or that an x-ray was ordered on 6/3/2023. An interview was conducted with NA #4 by phone on 7/25/2023 at 11:10 AM. NA #4 reported she provided Resident #94 with incontinence care on 6/5/2023 during the afternoon shift and Resident #94 was in intense pain all shift. NA #4 reported she attempted to provide incontinence care by herself, and this caused Resident #94 to scream and scream in pain. NA #4 explained that she had to get another NA to assist her with care. NA #4 reported she told Nurse #2 that Resident #94 was in pain. Nurse #2 was interviewed on 7/19/2023 at 4:05 PM and she reported that she was assigned to Resident #94 during the afternoon shift on 6/2, 6/3, 6/4, and 6/5/2023 had not expressed she was in pain at all to her when Nurse #2 conducted the pain assessments on those dates. A follow up interview with Nurse #2 on 7/25/2023 at 1:44 PM revealed no one reported Resident #94 was experiencing pain on 6/3/2023, 6/4/2023, or 6/5/2023 during her afternoon shift. Nurse #2 reported that no one reported Resident #94 had a fall or was experiencing hip pain. Nurse #2 indicated that when she performed the pain assessment for Resident #94 on 6/2/2023, 6/3/2023, 6/4/2023, and 6/5/2023, the resident denied pain. Nurse #2 reported she did not notice swelling or bruising of Resident #94's right leg during any of her shifts. Nurse #2 reported she was aware of the fall when she arrived for work on 6/5/2023 for the afternoon shift. Nurse #2 reported she waited for the x-ray results to call to the physician but was told the results were not sent until after the end of her shift. Nurse #2 denied conducting any assessments on Resident #94, except for the daily shift pain assessment. Nurse #8 was interviewed by phone on 7/20/2023 at 1:53 PM and she reported she remembered Resident #94's family member requesting a walker during her shift (3:00 PM to 11:00 PM) on 6/4/2023 but denied the family member reporting Resident #94 was experiencing pain. There was no evidence in the medical record that Nurse #2, Nurse #8, or any other staff notified the physician of Resident #94's fall and subsequent pain or that an x-ray was ordered on 6/4/2023. NP#1 was interviewed on 7/20/2023 at 12:14 PM. NP #1 reported that a review of the on-call logs revealed no calls came from the facility to report a fall or pain for Resident #94 on 6/2, 6/3, or 6/4/2023. NA #3 was interviewed on 7/21/2023 at 4:49 PM. NA #3 explained she was working on day shift on 6/2/2023 when Resident #94 was admitted to the facility, and she had assisted her to the bathroom. NA #3 indicated Resident #94 was able to transfer to the wheelchair and to the toilet by standing and pivoting to sit and the resident had no issues with the transfers or any episodes of incontinence on 6/2/2023. NA #3 reported she returned to work on 6/5/2023 and was assigned to Resident #94 on the day shift, and when she attempted to provide care, Resident #94 yelled in pain my leg, my leg! NA #3 reported on Monday 6/5/2023 for the day shift Resident #94 was in bed with an incontinence brief on and required incontinence care. NA #3 reported she went to get the nurse, and when they returned to Resident #94's room, NP #2 was at the bedside. NA #3 explained Resident #94 was unable to move in bed without yelling out in pain. NA #3 reported she went to get Nurse #6 and when she returned to Resident #94's room, NP #2 was at the bedside. NA #3 described that Resident #94 experienced pain all day on 6/5/2023 and she had to get another NA to assist her with incontinence care for Resident #94 because of her pain level. NA #3 reported Resident #94 said her pain was in her right hip and it was very sharp and severe with any kind of movement and turning for incontinence care was unbearable painful. NA #3 reported on 6/2/2023 Resident #94 was able to get up to the bathroom, but she stayed in bed all day 6/5/2023 and received incontinence care in the bed. A progress note written by NP #2 dated 6/5/2023 documented Resident #94 reported to her that on 6/2/2023 she attempted to go to the bathroom and had a fall with pain in her right hip since (the fall). The NP documented Resident #94 had increased pain/discomfort with touch, no bruising was noted, and the hip appeared to be swollen. The NP documented Resident #94 had pain to the right hip/thigh that Resident #94 rated as 4 and described as aching. The note documented Resident #94 had as needed (acetaminophen) at this time, and staff were to continue to monitor Resident #94 until an x-ray result were received. NP #2 was interviewed on 7/21/2023 at 2:45 PM. NP #2 reported she was performing the admission assessment on Resident #94 on 6/5/2023 when Resident #94 reported the hip pain and fall. NP #2 explained she ordered an x-ray of Resident #94's hip and when the x-ray was read and it was determined Resident #94 had a fracture, she was sent to the hospital for evaluation. NP #2 reported she had not received notification of the fall or reports of pain prior to 6/5/2023. NP #2 reported she would have ordered an x-ray on 6/3/2023 of Resident #94's hip if she had been notified of the fall with pain. A hip x-ray dated 6/5/2023 and read at 9:39 PM read a right subcapital fracture with moderate displacement (acute right hip fracture). A nursing note dated 6/6/2023 at 12:31 AM documented the results of the hip x-ray were received by the facility at 11:45 PM on 6/5/2023. The on-call NP was paged, and the nurse received an order to send Resident #94 to the hospital for evaluation for the right hip fracture. The note documented that Resident #94 left the facility by ambulance at 12:30 AM. The emergency department (ED) provider note dated 6/6/2023 at 1:28 AM documented Resident #94 presented with right hip pain that was found to be fractured on an x-ray obtained outpatient earlier that day. Resident #94 reported she fell three days ago and has had right hip pain ever since. The note documented the x-ray obtained by the facility showed a right hip fracture. On exam the ED physician noted tenderness to the right hip without deformity. Repeat x-rays obtained confirmed a closed subcapital right femoral neck fracture. There was no pain rating, or documentation of medications administered for pain. Orthopedic surgery was consulted and at 3:05 AM recommended for Resident #94 to be admitted and make her NPO (nothing by mouth) status. An orthopedic trauma consult note dated 6/6/2023 at 10:40 AM documented: Patient (Resident #94) reported on Friday 6/2/2023 she was attempting to get up to the bathroom and fell , landing on her right hip. She reported immediate pain in the right hip and being unable to get up after the fall. The history and physical noted: Right lower extremity: skin intact without (redness). Leg length short in comparison to contralateral leg (left leg) and hip held in external rotation (leg was rotated to the right). Endorses (agreed) hip pain with heel strike (touching heel to the floor during mobility). Details in the assessment and plan included the right femoral neck fracture was discussed with Resident #94 and the recommendation was to proceed with the hip hemiarthroplasty, to which she agreed. This plan was also discussed with a family member who agreed and stated Resident #94 was competent to sign her own consents. An orthopedic trauma operative (surgical) report dated 6/7/2023 documented Resident #94 had a right partial hip replacement performed on that date for a right hip fracture. An interview was conducted with the MD on 7/21/2023 at 11:54 AM. The MD reported that his medical group has an on-call triage line where a NP was available 24 hours a day to answer medical questions and provide orders. The MD reported that the facility had not contacted the on-call triage for anything related to Resident #94 on 6/2, 6/3, or 6/4/2023. The MD reported that delaying treatment for a fractured large bone could have resulted in many complications for Resident #94. The Director of Nursing (DON) was interviewed on 7/21/2023 at 3:21 PM. The DON explained that she had thought Resident #94 had not reported the fall to anyone until 6/5/2023 when NP #2 assessed her. The DON reported she was not aware of the physical therapy assessment conducted on 6/3/2023 and that PT #1 reported to Nurse #1 that Resident #94 had a fall and was experiencing pain. The DON explained staff should have immediately contacted the on-call NP and reported the fall and pain. The DON reported she was not certain why this had not happened on 6/3/2023. The Administrator was notified of Immediate Jeopardy on 7/21/2023 at 6:42 PM. o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance The facility failed to notify the physician and/or the resident representative after Resident #94 reported to the Physical Therapist on 6/3/23 that she had fallen in her room on 6/2/23. On 6/3/23, the physical therapy evaluation revealed that Resident #94 reported to the physical therapist that she had fallen on 6/2/23 in her room and had not reported the incident to the facility staff. The physical therapist also reported that the resident complained of right hip pain, and this was reported to the Nurse #1 on the hall who reported that she would follow up and obtain an order for an x-ray. On 7/21/23, the Director of Nursing spoke to Nurse #1, and she denied any knowledge of Resident #94 reporting that she had fallen or that the physical therapist or any other staff member reporting to her that Resident #94 had fallen. In addition, Nurse #1 was asked if Resident #94 requested pain medication or had signs or symptoms of pain and Nurse #1 reported no. On, 7/20/23, the Therapy Director spoke to the physical therapist that was working on 6/3/23 and she reported that Resident #94 had reported to her that she had fallen on 6/2/23 while attempting to go to the bathroom. The physical therapist reported that the roommate also reported that the resident had fallen on the previous day (6/2/23). On 6/5/23, after the Nurse Practitioner reported that Resident #94 reported a fall on 6/2/23, the Director of Nursing completed a follow up interview and Resident #94 reported that she had fallen while attempting to go to the bathroom and had gotten herself up off the floor and had not reported this to the staff. On 6/5/23, Unit Manager #1 and the Admissions Director spoke to Resident #94's family member who reported that on 6/2/23, Resident #94 had reported to him that she had fallen on the way to the bathroom and that she was having a lot of pain. The family member reported that he reported that Resident #94 was having pain to the charge nurse. On 6/5/23, during the Nurse Practitioner initial assessment, Resident #94 reported that she had fallen on 6/2/23 in her room while attempting to go to the bathroom and was having right hip pain. On 7/17/23, the facility investigation by the Director of Nursing revealed that the Nurse Practitioner was informed of Resident #94's fall on 6/2/23 during her initial assessment on 6/5/23 by the resident. In addition, further review of the medical record revealed that there was no fall nursing assessment documentation or physician/physician extender notification documentation by the licensed nurse of the 6/2/23 fall until 6/5/2023. The Director of Nursing completed the interviews on 7/21/23. The interviews revealed that the licensed nurses and the certified nursing assistants that worked on 6/2/23, 6/3/23, and 6/4/23 reported that Resident #94 did not report to them that she had fallen on 6/2/23. The licensed nurses, certified nursing assistants, and certified medication aide interviews by the Director of Nursing of staff that who worked on 6/2/23, 6/3/23, and 6/4/23 per the nursing assignment sheets revealed that Resident #94 did not report the fall to the assigned licensed nurse, certified nursing assistant or certified medication aide. On 7/17/23, Nurse #3 (Weekend Supervisor) interview with the Director of Nursing revealed that Resident #94 did not express pain concerns and she did not observe signs or symptoms of excruciating pain on 6/3/23 and 6/4/23. Nurse # 3 also reported that Resident #94 as well as the other nursing staff to include the physical therapist who worked on 6/3/23 and 6/4/23, did not report that Resident #94 has fallen on 6/2/23. Nurse #3 reported that Resident #94's family member did not report to her that the resident was having pain and that the resident had fallen on 6/2/23. All current residents are also at risk as a result of this deficient practice. Starting 7/21/23, the Director of Nursing/the Unit Managers and designee will complete an audit of the medical records to include review of progress notes, outside provider notes, incident reports, medication administration records, physician orders, and nursing shift reports of all the current residents for the last 60 days to ensure the physician/ physician extenders and resident representatives have been notified of any resident falls or changes in condition and identified concerns have been address by 7/25/23. Starting 7/21/23 the Director of Nursing / designee will complete interviews of the alert current residents to ensure resident concerns to include incident and accidents, pain management, medication/ treatments and other resident care concerns have been identified and reported to the physician/ physician extenders in the last 60 days by 7/25/23. Starting 7/21/23, the Director of Nursing/ designee will complete interviews of the facility staff to include licensed nurses, certified nursing assistants, certified medication aides, dietary, housekeeping/laundry, agency, new hire and prn staff to ensure all resident changes in condition or any reported concerns in the last 60 days have been reported to the DON, Unit Manager and/or the Nursing supervisor by 7/25/23. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete Starting 7/21/23, the Staff Development Coordinator/ designee will complete education by 7/25/23 of the facility staff to include licensed nurses, certified nursing assistants, certified medication aides, dietary, therapy department, housekeeping/laundry, agency, new hire and prn staff related to ensuring resident changes in condition to include incident and accidents, pain management changes, medication/treatment concern, resident care concerns and any resident/families reported concerns have been reported to the licensed nurse and to the physician and/or DON, Unit Managers and nursing supervisor. Starting 7/21/23, the Staff Development Coordinator/ designee will complete education with the licensed nurses to include agency, new hire, and prn licensed nurses related to immediate notification and documentation of resident changes in condition to include incident and accidents, pain management changes, medication/treatment concern, resident care concerns and any resident/ families reported concerns to the physician/ physician extenders and resident representatives and document in the medical record by 7/25/23. After hours the licensed nurse will notify the on-call provider and document in the medical record. Starting 7/21/23, the Staff Development Coordinator was made aware by the Director of Nursing that she will be responsible for verifying that the education has been completed by the required staff members by using the facility personal roster and the nursing, dietary, therapy and housekeeping/laundry staffing schedules to include new hires, agency and prn staff and ongoing education by 7/25/23. No staff will be allowed to work until they have received this education. The SDC/ designee which includes the DON, Unit Managers, and Nursing supervisors will be responsible for providing all of the education. On 7/25/23, The Director of Nursing educated the therapy manager to ensure that all therapists to include occupational therapist, physical therapist, speech therapist, weekend therapist, new hire, and prn therapist report resident observed and reported falls to the therapy manager and the Director of Nursing immediately. Starting 7/25/23, the therapy manager will educate the therapists to include occupational therapist, physical therapist, speech therapist, weekend therapist, new hire, and prn therapist related to ensuring resident observed and reported falls are immediately reported to the therapy manager and the Director of Nursing. Therapy staff to include prn and new hire staff will not be allowed to until they receive this education. Effective 7/21/2023 the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: 7/26/2023 On 7/27/2023, the facility's credible allegation for immediate jeopardy removal was validated by the following: The facility's documentation to support the Credible Allegation for F580 was reviewed. The facility's Director of Nursing (DON) evaluated the named resident after she was notified the resident complained of pain due to a fall on 6/5/2023 and a pain assessment was completed. The Nurse Practitioner assessed the named resident on 6/5/2023 and sent her to the hospital for evaluation due to right hip pain due to a fall the previous Friday, 6/2/2023. The facility completed chart reviews for all residents and interviews were conducted with all cognitively intact residents and family members of residents that were not able to be interviewed. An in-service education which included the facility's policy for staff to notify the supervisor, provider, and responsible party of any falls. The education also included the nurse who was responsible for the resident would complete a post fall review with all resident falls. The facility provided the education all staff (nursing, housekeeping, therapy, dietary, and all agency staff) receive when they are oriented to the facility. Staff were interviewed to ensure their understanding of the education. The facility completed the assessment of the named resident, review and monitoring of all resident's charts and interviews with residents and family members of residents, and education of all staff by 7/25/2023. The facility's date of the immediate jeopardy removal plan of 7/26/2023 was validated on 7/27/2023.

Based on record reviews, and resident, family member, Physical Therapist (PT) #1, Nurse Practitioner #2, Director of Rehab Services, Physician (MD), and staff interviews, the facility neglected to protect a resident from the right to be free from deprivation of goods and services related to pain management and initiating medical care and treatment after a fall on 6/2/2023 for 1 of 4 residents investigated for abuse/neglect (Resident #94). Nurse Practitioner (NP) #2 completed Resident #94's admission assessment on 6/5/2023 and Resident #94 reported the fall on 6/2/2023 and pain in her right hip since the fall. An x-ray of the right hip revealed a right femoral neck fracture (type of hip fracture of the thigh bone). Resident #94 was sent to the hospital on 6/6/2023 and had a partial hip replacement surgery on 6/7/2023. Immediately Jeopardy began on 6/3/2023 when Resident #94 reported right hip pain after a fall and was not assessed by nursing staff to determine what medical care and services were needed. Immediate Jeopardy was removed on 7/26/2023 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a scope and severity level of D (not actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put in place are effective. The findings included: Resident #94 was admitted to the facility on [DATE] with diagnoses to include dementia and frequent falls. The admission nursing assessment recorded by Nurse #6 dated 6/2/2023 at 2:03 PM documented that Resident #94 was alert and oriented to person and situation. Resident #94 was always continent of bowels and bladder and required a wheelchair for mobility. Resident #94 was oriented to her room and demonstrated correct use of the call light. A review of the admission medication orders dated 6/2/2023 did not include orders for pain medication. An interview was conducted with Resident #94 on 7/20/2023 at 3:30 PM. Resident #94 reported the evening of 6/2/2023 she used her call light to get assistance to use the bathroom, but no staff came to help her, so she got up to go to the bathroom on her own. Resident #94 reported she fell on the floor outside of the bathroom and hit her right hip. Resident #94 explained that she started yelling for help immediately, and her roommate (Resident #50) yelled for help, too. Resident #94 said that 2 nurse aides (NAs) came to her room, picked her up and put her back in bed. Resident #94 recalled her leg hurt terribly and she told the NAs her leg was hurting. Resident #94 was unable to identify the NAs who put her back in bed. Resident #94 explained the therapist (PT #1) came in the next day to see her and she told PT #1 she did not think she could stand up because she fell the night before. PT #1 told Resident #94 she would talk to the nurse. Resident #94 reported her right leg hurt so bad all the time and every time staff moved her in bed, she told them that it hurt. Resident #94 denied that a nurse assessed her after the fall and reported she had not received pain medication. Resident #94 said the NP #2 came in to see her on Monday morning 6/5/2023 and she told the NP that she had fallen and was having right hip pain. A follow-up interview was conducted with Resident #94 on 7/21/2023 at 1:58 PM. Resident #94 recounted the fall on 6/2/2023 and added that she thought she fell after dinner but could not specifically recall the time. Resident #94 explained that she couldn't recall if the lights were on in the bathroom. Resident #94 reported she was wearing slippers on her feet, and she fell against the wall opposite to the bathroom door and hit her right hip. Resident #94 recounted that she screamed and screamed (for help) and 2 ladies (NAs) came and got me into bed, I screamed in pain the entire time. Resident #94 reported I screamed every time I was touched or moved after the fall. I never got pain medication. Resident #94 reported she had called her family member on 6/2/2023 to report the fall. Resident #94 said her pain was 10 out of 10 all the time, they did not do anything for it. Resident #94 explained she had an x-ray that showed her right hip was fractured and she was sent to the hospital. Resident #94 reported she cried about the right leg pain every time someone came into her room and that it was horrible pain. The family member of Resident #94 was interviewed by phone on 7/20/2023 at 4:19 PM. The family member reported that Resident #94 called him at 7:10 PM on 6/2/2023 to tell him that she had fallen, and she was having pain in her hip. The family member explained that Resident #94 told him 2 staff members had picked her up off the floor, and he didn't think he needed to call the facility to report the fall. The family member reported he came to visit Resident #94 on 6/3/2023 and talked to Nurse #1 and reported that Resident #94 had fallen and was having pain. The family member reported that the nurse got acetaminophen (an over-the-counter pain reliever) and administered the medication to Resident #94. The family member explained that he visited again on Sunday, 6/4/2023 and asked the nurse on duty about getting Resident #94 a walker, and he also mentioned the fall and pain to Nurse #8. When asked about the nurse's response, the family member said the nurse did not say anything about the reported fall. The family member reported he had called the admission's staff member and left her a voice mail reporting the fall on Monday, 6/5/2023. The family member explained that an x-ray wasn't ordered until Monday 6/5/2023 after NP #2 examined Resident #94. A pain assessment was ordered on 6/2/2023 to be conducted 3 times per day. A review of the medication orders for Resident #94 revealed no scheduled or as needed pain medications were prescribed for her 6/2/2023, 6/3/2023, 6/4/2023, or 6/5/2023. The medication administration record for June 2023 was reviewed. No administration of acetaminophen was documented for Resident #94 on 6/2/2023, 6/3/2023, 6/4/2023, or 6/5/2023. No nursing assessments related to pain after a fall were conducted on 6/2/2023. NA #3 was interviewed on 7/21/2023 at 4:49 PM. NA #3 explained she was working on day shift (7:00 AM to 3:00 PM) on 6/2/2023 when Resident #94 was admitted to the facility, and she had assisted her to the bathroom. NA #3 indicated Resident #94 was able to transfer to the wheelchair and to the toilet by standing and pivoting to sit and the resident had no issues with the transfers or any episodes of incontinence on 6/2/2023. The pain assessment for the afternoon shift on 6/2/2023, 6/3/2023, 6/4/2023, and 6/5/2023 was recorded by Nurse #2 and she documented a pain level of 0. (0-10 with 10 being the most intense pain). An interview was conducted on 7/21/2023 at 12:04 PM with NA #7 and she reported she provided care to Resident #94 on 6/2/2023 for the afternoon shift. NA #7 reported Resident #94 experienced urinary incontinence, but she did not report pain and she did not report a fall during her shift. When asked if she had assisted Resident #94 off the floor after a fall, NA #7 reported that no, she had not picked Resident #94 up off the floor after a fall. Nurse #2 was interviewed on 7/19/2023 at 4:05 PM and she reported that she was assigned to Resident #94 during the afternoon shift on 6/2, 6/3, 6/4, and 6/5/2023 had not expressed she was in pain at all to her when Nurse #2 conducted the pain assessments on those dates. A follow up interview with Nurse #2 on 7/25/2023 at 1:44 PM revealed no one reported Resident #94 was experiencing pain on 6/3/2023, 6/4/2023, or 6/5/2023 during her afternoon shift. Nurse #2 reported that no one reported Resident #94 had a fall or was experiencing hip pain. Nurse #2 indicated that when she performed the pain assessment for Resident #94 on 6/2/2023, 6/3/2023, 6/4/2023, and 6/5/2023, the resident denied pain. Nurse #2 reported she did not notice swelling or bruising of Resident #94's right leg during any of her shifts. Nurse #2 reported she was aware of the fall when she arrived for work on 6/5/2023 for the afternoon shift. Nurse #2 reported she waited for the x-ray results to call to the physician but was told the results were not sent until after the end of her shift. Nurse #2 denied conducting any assessments on Resident #94, except for the daily shift pain assessment. Night shift (11:00 PM to 7:00 AM) 6/2/2023 pain assessment was recorded as 0 by Nurse #9. An interview was conducted with Nurse #9 by phone on 7/21/2023 at 11:33 AM. Nurse #9 explained that she did not frequently work Resident #94's hallway (C), but she was assigned to that hallway on 6/2/2023. Nurse #9 indicated Resident #94 did not report pain when she performed the pain assessment or at any other time during the shift, and Nurse #9 stated, No, if a resident reported pain, I would have written a note or addressed it in the pain assessment. There was no evidence in the medical record that any nurse notified the physician of Resident #94's fall and subsequent pain, completed an assessment of Resident #94 or that an x-ray was ordered on 6/2/2023. Day shift on 6/3/2023 pain assessment recorded by Nurse #1 documented a pain level of 0'. Nurse #1, an agency nurse, was assigned to Resident #94 on 6/3/2023 on the day shift (7:00 AM to 3:00 PM). Multiple attempts to contact Nurse #1 for an interview were unsuccessful including phone calls with voice messages and text messages. NA #1 was interviewed on 7/20/2023 at 11:57 AM. NA #1 reported she was assigned to Resident #94 on 6/3/2023 and 6/4/2023 for the day shift. NA #1 reported Resident #94 had pain during the weekend when they moved her in bed. NA #1 reported she had reported the pain to Nurse #1 on 6/3/2023. NA #1 reported Resident #94 did not get out of bed on day shift for 6/3/2023 or 6/4/2023 and she required incontinence care in bed because of the right hip pain. NA #6 was interviewed on 7/19/2023 at 1:05 PM. NA #6 reported that he was not assigned to Resident #94, but had provided care to her roommate, Resident #50 for day shift on 6/3/2023. NA #6 reported that he found out Resident #94 fell on [DATE]. NA #6 was interviewed again on 7/20/2023 at 12:01 PM and he reported he worked day and evening shift on 6/2/2023, 6/3/2023 and 6/4/2023 and he had not picked up Resident #94 from the floor on 6/2/2023 and if Resident #94 had reported pain, he would have reported the pain. The weekend supervisor Nurse #3 was interviewed by phone on 7/20/2023 at 1:39 PM. Nurse #3 reported she worked 6/3/2023 and 6/4/2023 from 7:00 AM until 11:00 PM and no staff reported that Resident #94 was experiencing pain. A physical therapy evaluation performed by PT #1 and dated 6/3/2023 documented that Resident #94 reported right hip pain from a fall 6/2/2023. The note documented the physical therapist notified the nurse (unnamed) Resident #94 was having pain in her right hip. PT #1 was interviewed by phone on 7/21/2023 at 2:49 PM. PT#1 reported she evaluated Resident #94 on 6/3/2023 and she attempted to stand Resident #94 at the bedside, but Resident #94 was unable to stand. The PT explained that Resident #94 and her roommate, Resident #50, told her that Resident #94 fell the night before. Resident #94 reported right hip pain to her with touch. Resident #94 was unable to stand during the evaluation without moderate assistance and was leaning to the right. PT #1 indicated she went to the nursing station and looked for a nurse and reported the fall and the pain that Resident #94 was experiencing. PT #1 reported an unknown nurse and told her she would get an order for an x-ray for Resident #94. PT#1 was not certain the time of day she evaluated Resident #94. PT #1 was unable to provide the name of the nurse or the time she reported to the nurse. The Director of Rehabilitation was interviewed on 7/25/2023 at 8:59 AM by phone. The Director of Rehabilitation reported that PT #1 clocked in to work on 6/3/2023 at 3:46 PM. An occupational therapy evaluation dated 6/3/2023 was reviewed. The evaluation note documented that Resident #94 had pain that interfered or limited functional activity (no location) and that nursing would address pain management. The note documented that Resident #94 reported she had a fall on 6/2/2023 and she had pain in her right leg. The Occupational Therapist (OT) #1 was interviewed on 7/25/2023 at 9:19 AM by phone. OT #1 reported she also assessed Resident #94 on 6/3/2023 and Resident #94 reported she had fallen on 6/2/2023. OT #1 explained that she did not report to the nurse because Resident #94 had told her that the NA staff had helped her get up off the floor. OT #1 indicated that Resident #94 did not have pain during the evaluation, but she had not gotten Resident #94 out of bed. An interview was conducted with NA #2 on 7/20/2023 at 2:28 PM. NA #2 reported she was assigned to Resident #94 on 6/3/2023 for the afternoon shift. The NA explained that Resident #94 complained of pain in her hip, but she did not report to any nurse because she had observed PT #1 reporting the pain a nurse. NA #2 explained she did not remember the nurse that received the report from PT #1, but she had seen the two of them talking. Resident #94 was unable to get out of bed during the afternoon shift on 6/3/2023 because of the pain she experienced with moving. NA #2 reported she did not notice bruising on Resident #94's right hip. There was no evidence in the medical record that any nurse notified the physician of Resident #94's fall and subsequent pain, completed an assessment of Resident #94, or that an x-ray was ordered on 6/3/2023. The pain assessment for day shift on 6/4/2023 was recorded by Nurse #8 as 0. Nurse #8 was interviewed by phone on 7/20/2023 at 1:53 PM and she reported she was assigned to Resident #94 during the day shift on 6/4/2023 and reported Resident #94 had not expressed she was in pain at all to her when Nurse #8 conducted the pain assessment on 6/4/2023. Nurse #8 reported she remembered Resident #94's family member requesting a walker during the day shift on 6/4/2023. Nurse #8 reported she recalled that Resident #94 was very pleasant and not in any pain. Nurse #8 reported that no staff reported a fall to her. The pain assessment for night shift on 6/3/2023 and 6/4/2023 were recorded by Nurse #7 as 0. Nurse #7 was interviewed by phone on 7/21/2023 at 3:15 PM. Nurse #7 reported that Resident #94 had not complained of pain when Nurse #7 conducted the pain assessment during 6/3/2023 or 6/4/2023 on the night shifts. Nurse #7 explained that Resident #94 had an order to administer acetaminophen at 6:00 AM daily and she did administer the medication to her. Nurse #7 reported the resident had not complained of pain, and she had received scheduled acetaminophen at 6:00 AM on 6/3 and 6/4/2023. NA #5 was interviewed on 7/21/2023 at 11:33 AM. NA #5 reported she was assigned to Resident #94 on 6/4/2023 for the night shift. NA #5 was unable to recall if Resident #94 required incontinence care during her shift and reported that Resident #94 did not complain of pain to her during the night shift. There was no evidence in the medical record that any staff notified the physician of Resident #94's fall and subsequent pain, completed an assessment or that an x-ray was ordered on 6/4/2023. The pain assessment day shift on 6/5/2023 recorded by Nurse #6 documented a pain level of 0. Nurse #6 was interviewed on 7/21/2023 at 12:10 PM. Nurse #6 reported she was the nurse who admitted Resident #94 on 6/2/2023 and she was also assigned to her during the day shift on 6/5/2023. Nurse #6 reported Resident #94 did not report pain to her when Nurse #6 conducted the pain assessment on 6/5/2023, and if she had reported pain, there were facility standing orders she could have activated for administering acetaminophen to Resident #94. Nurse #6 explained that because Resident #94 did not report pain to her, she did not activate the standing orders. During an interview conducted on 7/21/2023 at 4:49 PM, NA #3 reported she returned to work on 6/5/2023 and was assigned to Resident #94 on the day shift, and when she attempted to provide care, Resident #94 yelled in pain my leg, my leg! NA #3 reported on Monday 6/5/2023 for the day shift Resident #94 was in bed with an incontinence brief on and required incontinence care. NA #3 explained she went to get Nurse #6, and when they returned to Resident #94's room, NP #2 was at the bedside. NA #3 described that Resident #94 was unable to move in bed without yelling out in pain. NA #3 explained that Resident #94 experienced pain all day on 6/5/2023 and she had to get another NA to assist her with incontinence care for Resident #94 because of her pain level. NA #3 reported Resident #94 said her pain was in her right hip and it was very sharp and severe with any kind of movement and turning for incontinence care was unbearably painful. NA #3 reported on 6/2/2023 Resident #94 was able to get up to the bathroom, but she stayed in bed all day 6/5/2023 and received incontinence care in the bed. A progress note written by NP #2 dated 6/5/2023 documented Resident #94 reported to her that on 6/2/2023 she attempted to go to the bathroom and had a fall with pain in her right hip since (the fall). The NP documented Resident #94 had increased pain/discomfort with touch, no bruising was noted, and the hip appeared to be swollen. The NP documented Resident #94 had pain to the right hip/thigh that Resident #94 rated as 4 and described as aching. The note documented Resident #94 had as needed (acetaminophen) at this time, and staff were to continue to monitor Resident #94 until an x-ray result were received. NP #2 was interviewed on 7/21/2023 at 2:45 PM. NP #2 reported she was performing the admission assessment on Resident #94 on 6/5/2023 when Resident #94 reported the hip pain and fall. NP #2 explained she ordered an x-ray of Resident #94's hip and when the x-ray was read and it was determined Resident #94 had a fracture, she was sent to the hospital for evaluation. An interview was conducted with NA #4 by phone on 7/25/2023 at 11:10 AM. NA #4 reported she provided Resident #94 with incontinence care on 6/5/2023 during the afternoon shift and Resident #94 was in intense pain all shift. NA #4 reported she attempted to provide incontinence care by herself, and this caused Resident #94 to scream and scream in pain. NA #4 explained that she had to get another NA to assist her with care. NA #4 reported she told Nurse #2 that Resident #94 was in pain. A hip x-ray dated 6/5/2023 and read at 9:39 PM read a right subcapital fracture with moderate displacement (acute right hip fracture). A nursing note dated 6/6/2023 at 12:31 AM documented the results of the hip x-ray were received by the facility at 11:45 PM on 6/5/2023. The on-call NP was paged, and the nurse received an order to send Resident #94 to the hospital for evaluation for the right hip fracture. The note documented that Resident #94 left the facility by ambulance at 12:30 AM. There was no evidence in the medical record that pain medication was ordered on 6/5/2023. The emergency department (ED) provider note dated 6/6/2023 at 1:28 AM documented Resident #94 presented with right hip pain that was found to be fractured on an x-ray obtained outpatient earlier that day. Resident #94 reported she fell three days ago and has had right hip pain ever since. The note documented the x-ray obtained by the facility showed a right hip fracture. On exam the ED physician noted tenderness to the right hip without deformity. Repeat x-rays obtained confirmed a closed subcapital right femoral neck fracture. There was no pain rating, or documentation of medications administered for pain. Orthopedic surgery was consulted and at 3:05 AM recommended for Resident #94 to be admitted and make her NPO (nothing by mouth) status. An orthopedic trauma consult note dated 6/6/2023 at 10:40 AM documented: Patient (Resident #94) reported on Friday 6/2/2023 she was attempting to get up to the bathroom and fell , landing on her right hip. She reported immediate pain in the right hip and being unable to get up after the fall. The history and physical noted: Right lower extremity: skin intact without (redness). Leg length short in comparison to contralateral leg (left leg) and hip held in external rotation (leg was rotated to the right). Endorses (agreed) hip pain with heel strike (touching heel to the floor during mobility). Details in the assessment and plan included the right femoral neck fracture was discussed with Resident #94 and the recommendation was to proceed with the hip hemiarthroplasty, to which she agreed. This plan was also discussed with a family member who agreed and stated Resident #94 was competent to sign her own consents. An orthopedic trauma operative (surgical) report dated 6/7/2023 documented Resident #94 had a right partial hip replacement performed on that date for a right hip fracture. An interview was conducted with the MD on 7/21/2023 at 11:54 AM. The MD reported that his medical group has an on-call triage line where a NP is available 24 hours a day to answer medical questions and provide orders. The MD reported that the facility had not contacted the on-call triage for anything related to Resident #94 6/2/2023, 6/3/2023, 6/4/2023 or 6/5/2023. The MD reported that delaying treatment for a fractured large bone could have resulted in many complications for Resident #94 and would have been very painful for Resident #94, and he was not aware she did not have an order for pain medication. The Director of Nursing (DON) was interviewed on 7/21/2023 at 3:21 PM. The DON explained that she had thought Resident #94 had not reported the fall to anyone until 6/5/2023 when NP #2 assessed her. The DON reported she was not aware of the physical therapy assessment conducted on 6/3/2023 and that PT #1 reported to an unknown nurse that Resident #94 had a fall and was experiencing pain. The DON stated she interviewed Resident #94 on 6/5/2023 after the NP evaluation and Resident #94 reported she had fallen and gotten herself up off the floor and did not report the fall to staff. The DON explained staff should have immediately contacted the on-call NP and reported the fall and pain and assessed Resident #94. The DON reported she was not certain why this had not happened on 6/3/2023. The Administrator was notified of Immediate Jeopardy on 7/21/2023 at 6:42 PM. o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance The facility failed to ensure that Resident #94 was free from neglect. The facility failed to notify the physician of resident changes in condition related to an unwitnessed fall on 6/2/23 until 6/5/23 which resulted in a delay of provision of necessary medical care, treatment, and services for a right hip fracture. The facility failed to address resident pain from 6/2/23 to 6/5/23 that would be associated with a hip fracture. The facility staff failed to follow up on resident reported pain resulting in resident unaddressed pain from 6/3/23 to 6/5/23. Review of Resident #94's Medication Administration revealed no documentation of pain medication being provided to the resident from 6/2/23 through 6/6/23. The facility failed to complete all the facility admission assessments on 6/2/23 for a new admission to ensure preventative measures are in place. There was no evidence from record review and staff interviews that nursing staff completed an assessment of the resident after the fall on 6/2/23 until she was seen by the Nurse Practitioner on 6/5/23. Resident #94's roommate stated she reported Resident #94's fall on 6/2/23 to Nurse #2 on 6/2/23. Nurse #2 denied knowledge of the fall on 6/2/23. On 6/3/23, the physical therapy evaluation revealed that Resident #94 reported to the physical therapist that she had fallen on 6/2/23 in her room and had not reported the incident to the facility staff. The physical therapist also reported that the resident complained of right hip pain, and this was reported to the Nurse #1 on the hall who reported that she would follow up and obtain an order for an x-ray. Review of the medical record revealed that Nurse #1 did not complete any documentation related to the fall and did not complete a nursing assessment of Resident #94. On 6/5/23, during the Nurse Practitioner initial assessment, resident #94 reported that she had fallen on 6/2/23 in her room while attempting to go to the bathroom and was having right hip pain. The Nurse Practitioner assessed the resident and noted pain/discomfort to the right hip area, but no bruising was noted. The Nurse Practitioner also noted swelling to the right hip and reported that it appeared that the hip was dislocated. New orders for stat x-ray was given to the nursing staff and to send the resident to the emergency room if x ray results reveal a fracture. On 6/5/23, Resident #94 reported to the Director of Nursing that she had fallen while attempting to go to the bathroom and had gotten herself up off the floor and had not reported this to the staff on 6/2/23. On 6/5/23, the right hip x-ray was obtained. On 6/5/23 at 11:45pm, the licensed nurse received the x ray results which revealed an acute right hip fracture. On 6/6/23 at about 12:30am resident #94 was transported to the emergency room by Emergency Transportation per stretcher for further evaluation. On 6/6/23, Resident #94 was admitted to the hospital and a right hemiarthroplasty was performed on 6/7/23. On 7/20/23, the 3-11 nursing supervisor and the Staff Development Coordinator interviewed Resident #94 and she reported that two black females came into her room and picked her up and put her back in bed after the fall on 6/2/23. Resident #94 reported that she could not remember who they were. All the current residents are at risk as a result of this deficient practice. Starting 7/21/23, Social Services will interview the alert and interviewable residents to ensure that any concerns related to resident abuse/neglect have been identified and addressed by 7/25/23. Starting 7/21/23 a skin assessment will be completed by the Unit Managers on all the current residents to identify any bruising, redness, or swelling that has not been reported or that might require further investigation by 7/25/23. On 7/24/23, the Activities Director will meet with the Resident Council President to request a short Resident Council Meeting to review resident rights and reporting Abuse/Neglect. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. Starting 7/21/23, the Staff Development Coordinator/ Unit Manager/ Director of Nursing/ Nursing supervisor will educate facility staff to include licensed nurses, certified nursing assistants (CNA), certified medication aide (CMA), dietary, housekeeping/ laundry, therapy staff, maintenance, administrative staff, agency and prn staff on the abuse policy and procedures to include examples of Abuse/neglect, abuse prevention, reporting and identifying Abuse and Neglect. The staff will also be made aware that all reports of Abuse and Neglect to include resident care concerns, fall concerns, unaddressed pain, and resident bruising should be reported to the Administrator immediately 7 days a week regardless of the time of the event. The Administrator contact information will be posted at each nursing station, at the time clock and at the receptionist desk. The Staff Development Coordinator and the Director of Nursing will be responsible for ensuring all staff to include licensed nurses, housekeeping/ laundry, dietary, administrative, CNA, and CMA receive the Abuse and Neglect education through validation by the facility employee roster and nursing, housekeeping/laundry, therapy, and dietary schedules. Staff including new hires and prn staff will not be allowed to work without completing this education. The education will be ongoing after 7/25/23 to include new hires and prn staff. Effective 7/21/23, the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: 7/26/2023 On 7/27/2023, the facility's credible allegation for immediate jeopardy removal was validated by the following: The facility provided documentation to support their credible allegation for Abuse, Neglect and Exploitation. The named resident was assessed by the Nurse Practitioner on 6/5/2023 and sent to the hospital for evaluation of pain from a fall sustained on 6/2/2023. The facility also provided documentation of their investigation of the residents fall. The facility interviewed all alert and oriented residents regarding any issues regarding abuse and neglect and completed skin assessments for each resident by 7/25/2023. The facility also had a resident council meeting to review all residents' rights regarding abuse and neglect. The facility provided documentation of audits of resident interviews and skin assessments to ensure continued monitoring for abuse and neglect. All staff (dietary, housekeeping, maintenance, therapy, and nursing) received an in-service education regarding abuse, neglect, and exploitation by 7/25/2023. A sample of staff across these disciplines revealed understanding of the in-service provided for abuse and neglect. The facility further provided the in-service education provided to all facility staff, new orientees, and agency staff before they are allowed to work in the facility. The facility completed the initial skin assessments and interviews, monitoring of all residents, and education for abuse and neglect by 7/25/2023. The facility's date of the immediate jeopardy removal plan of 7/26/2023 was validated on 7/27/2023.

Based on record reviews, resident, family, nurse practitioner, physician, and staff interviews, the facility failed to effectively manage pain for a resident after she experienced a fall and reported pain for 1 of 5 residents investigated for pain management (Resident #94). Resident #94 experienced pain that caused her to yell and scream. The pain affected her ability to go to the bathroom and she became incontinent. Immediately Jeopardy began on 6/3/2023 when Resident #94 reported hip pain to Physical Therapist (PT) #1 and nursing did not effectively manage her pain. Immediate Jeopardy was removed on 7/26/2023 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a scope and severity level of D (not actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put in place are effective. The findings included: Resident #94 was admitted to the facility on [DATE] with diagnoses to include dementia and frequent falls. The admission nursing assessment recorded by Nurse #6 dated 6/2/2023 documented that Resident #94 was alert and oriented to person and situation. Resident #94 was always continent of bowels and bladder and required a wheelchair for mobility. Resident #94 was oriented to her room and demonstrated correct use of the call light. An interview was conducted with Resident #94 on 7/20/2023 at 3:30 PM. Resident #94 reported the evening of 6/2/2023 she used her call light to get assistance to use the bathroom, but no staff came to help her, so she got up to go to the bathroom on her own. Resident #94 reported she fell on the floor outside of the bathroom and hit her right hip. Resident #94 explained that she started yelling for help immediately, and her roommate (Resident #50) yelled for help, too. Resident #94 said that 2 nurse aides (NAs) came to her room, picked her up and put her back in bed. Resident #94 recalled her leg hurt terribly and she told the NAs her leg was hurting. Resident #94 was unable to identify the NAs who put her back in bed. Resident #94 explained the therapist (PT #1) came in the next day to see her and she told PT #1 she did not think she could stand up because she fell the night before. PT #1 told Resident #94 she would talk to the nurse. Resident #94 reported her right leg hurt so bad all the time and every time staff moved her in bed, she told them that it hurt. Resident #94 denied that a nurse assessed her after the fall and reported she had not received pain medication. Resident #94 said the NP #2 came in to see her on Monday morning 6/5/2023 and she told the NP that she had fallen and was having right hip pain. A follow-up interview was conducted with Resident #94 on 7/21/2023 at 1:58 PM. Resident #94 recounted the fall on 6/2/2023 and added that she thought she fell after dinner but could not specifically recall the time. Resident #94 explained that she couldn't recall if the lights were on in the bathroom. Resident #94 reported she was wearing slippers on her feet, and she fell against the wall opposite to the bathroom door and hit her right hip. Resident #94 recounted that she screamed and screamed (for help) and 2 ladies (NAs) came and got me into bed, I screamed in pain the entire time. Resident #94 reported I screamed every time I was touched or moved after the fall. I never got pain medication. Resident #94 reported she had called her family member on 6/2/2023 to report the fall. Resident #94 said her pain was 10 out of 10 all the time, they did not do anything for it. Resident #94 explained she had an x-ray that showed her right hip was fractured and she was sent to the hospital. Resident #94 reported she cried about the right leg pain every time someone came into her room and that it was horrible pain. The family member of Resident #94 was interviewed by phone on 7/20/2023 at 4:19 PM. The family member reported that Resident #94 called him at 7:10 PM on 6/2/2023 to tell him that she had fallen, and she was having pain in her hip. The family member explained that Resident #94 told him 2 staff members had picked her up off the floor, and he didn't think he needed to call the facility to report the fall. The family member reported he came to visit Resident #94 on 6/3/2023 and talked to Nurse #1 and reported that Resident #94 had fallen and was having pain. The family member reported that the nurse got acetaminophen (an over-the-counter pain reliever) and administered the medication to Resident #94. The family member explained that he visited again on Sunday, 6/4/2023 and asked the nurse on duty about getting Resident #94 a walker, and he also mentioned the fall and pain to Nurse #8. When asked about the nurse's response, the family member said the nurse did not say anything about the reported fall. The family member reported he had called the admission's staff member and left her a voice mail reporting the fall on Monday, 6/5/2023. The family member explained that an x-ray wasn't ordered until Monday 6/5/2023 after NP #2 examined Resident #94. A pain assessment was ordered on 6/2/2023 to be conducted 3 times per day. A review of the medication orders for Resident #94 revealed no scheduled or as needed pain medications were prescribed for her 6/2/2023, 6/3/2023, 6/4/2023, or 6/5/2023. Standing orders for the facility, which included acetaminophen, were not transcribed to Resident #94's medical record. The medication administration record for June 2023 was reviewed. No administration of acetaminophen was documented for Resident #94 on 6/2, 6/3, 6/4, or 6/5/2023. No nursing assessments related to pain after a fall were conducted on 6/2/2023. NA #3 was interviewed on 7/21/2023 at 4:49 PM. NA #3 explained she was working on day shift (7:00 AM to 3:00 PM) on 6/2/2023 when Resident #94 was admitted to the facility, and she had assisted her to the bathroom. NA #3 indicated Resident #94 was able to transfer to the wheelchair and to the toilet by standing and pivoting to sit and the resident had no issues with the transfers or any episodes of incontinence on 6/2/2023. An interview was conducted on 7/21/2023 at 12:04 PM with NA #7 and she reported she provided care to Resident #94 on 6/2/2023 for the afternoon shift. NA #7 reported Resident #94 experienced urinary incontinence, but she did not report pain and she did not report a fall during her shift. The pain assessment for the afternoon shift on 6/2/2023, 6/3/2023, 6/4/2023, and 6/5/2023 was recorded by Nurse #2 and she documented a pain level of 0. (0-10 with 10 being the most intense pain). Nurse #2 was interviewed on 7/19/2023 at 4:05 PM and she reported that she was assigned to Resident #94 during the afternoon shift on 6/2/2023, 6/3/2023, 6/4/2023, and 6/5/2023 had not expressed she was in pain at all to her when Nurse #2 conducted the pain assessments on those dates. A follow up interview with Nurse #2 on 7/25/2023 at 1:44 PM revealed no one reported Resident #94 was experiencing pain on 6/3/2023, 6/4/2023, or 6/5/2023 during her afternoon shift. Nurse #2 reported that no one reported Resident #94 had a fall or was experiencing hip pain. Nurse #2 indicated that when she performed the pain assessment for Resident #94 on 6/2/2023, 6/3/2023, 6/4/2023, and 6/5/2023, the resident denied pain. Nurse #2 reported she did not notice swelling or bruising of Resident #94's right leg during any of her shifts. Nurse #2 reported she was aware of the fall when she arrived for work on 6/5/2023 for the afternoon shift. Nurse #2 reported she waited for the x-ray results to call to the physician but was told the results were not sent until after the end of her shift. Nurse #2 denied conducting any assessments on Resident #94, except for the daily shift pain assessment. Night shift (11:00 PM to 7:00 AM) 6/2/2023 pain assessment was recorded as 0 by Nurse #9. An interview was conducted with Nurse #9 by phone on 7/21/2023 at 11:33 AM. Nurse #9 explained that she did not frequently work Resident #94's hallway (C), but she was assigned to that hallway on 6/2/2023. Nurse #9 indicated Resident #94 did not report pain when she performed the pain assessment or at any other time during the shift, and Nurse #9 stated, No, if a resident reported pain, I would have written a note or addressed it in the pain assessment. There was no evidence in the medical record that any nurse notified the physician of Resident #94's fall and subsequent pain, completed an assessment of Resident #94 or that an x-ray was ordered on 6/2/2023. Day shift (7:00 AM to 3:00 PM) on 6/3/2023 pain assessment recorded by Nurse #1 documented a pain level of 0'. Nurse #1, an agency nurse, was assigned to Resident #94 on 6/3/2023 on the day shift (7:00 AM to 3:00 PM). Multiple attempts to contact Nurse #1 for an interview were unsuccessful including phone calls with voice messages and text messages. NA #1 was interviewed on 7/20/2023 at 11:57 AM. NA #1 reported she was assigned to Resident #94 on 6/3/2023 and 6/4/2023 for the day shift. NA #1 reported Resident #94 had pain during the weekend when they moved her in bed. NA #1 reported she had reported the pain to Nurse #1 on 6/3/2023. NA #1 reported Resident #94 did not get out of bed on day shift for 6/3/2023 or 6/4/2023 and she required incontinence care in bed because of the right hip pain. NA #6 was interviewed on 7/20/2023 at 12:01 PM and he reported he worked day and evening shift on 6/2/2023, 6/3/2023 and 6/4/2023 and if Resident #94 had reported pain, he would have reported the pain. The weekend supervisor Nurse #3 was interviewed by phone on 7/20/2023 at 1:39 PM. Nurse #3 reported she worked 6/3/2023 and 6/4/2023 from 7:00 AM until 11:00 PM and no staff reported that Resident #94 was experiencing pain. A physical therapy evaluation performed by PT #1 and dated 6/3/2023 documented that Resident #94 reported right hip pain from a fall 6/2/2023. The note documented the physical therapist notified the nurse (unnamed) Resident #94 was having pain in her right hip. PT #1 was interviewed by phone on 7/21/2023 at 2:49 PM. PT#1 reported she evaluated Resident #94 on 6/3/2023 and she attempted to stand Resident #94 at the bedside, but Resident #94 was unable to stand. The PT explained that Resident #94 and her roommate, Resident #50, told her that Resident #94 fell the night before. Resident #94 reported right hip pain to her with touch. Resident #94 was unable to stand during the evaluation without moderate assistance and was leaning to the right. PT #1 indicated she went to the nursing station and looked for a nurse and reported the fall and the pain that Resident #94 was experiencing. PT #1 reported an unknown nurse and told her she would get an order for an x-ray for Resident #94. PT#1 was not certain the time of day she evaluated Resident #94. PT #1 was unable to provide the name of the nurse or the time she reported to the nurse. The Director of Rehabilitation was interviewed on 7/25/2023 at 8:59 AM by phone. The Director of Rehabilitation reported that PT #1 clocked in to work on 6/3/2023 at 3:46 PM. An occupational therapy evaluation dated 6/3/2023 was reviewed. The evaluation note documented that Resident #94 had pain that interfered or limited functional activity (no location) and that nursing would address pain management. The note documented that Resident #94 reported she had a fall on 6/2/2023 and she had pain in her right leg. The Occupational Therapist (OT) #1 was interviewed on 7/25/2023 at 9:19 AM by phone. OT #1 reported she also assessed Resident #94 on 6/3/2023 and Resident #94 reported she had fallen on 6/2/2023. OT #1 explained that she did not report to the nurse because Resident #94 had told her that the NA staff had helped her get up off the floor. OT #1 indicated that Resident #94 did not have pain during the assessment, but she had not gotten Resident #94 out of bed. An interview was conducted with NA #2 on 7/20/2023 at 2:28 PM. NA #2 reported she was assigned to Resident #94 on 6/3/2023 for the afternoon shift. The NA explained that Resident #94 complained of pain in her hip, but she did not report to any nurse because she had observed PT #1 reporting the pain a nurse. NA #2 explained she did not remember the nurse that received the report from PT #1, but she had seen the two of them talking. Resident #94 was unable to get out of bed during the afternoon shift on 6/3/2023 because of the pain she experienced with moving. NA #2 reported she did not notice bruising on Resident #94's right hip. There was no evidence in the medical record that any nurse notified the physician of Resident #94's fall and subsequent pain, completed an assessment of Resident #94, or that an x-ray was ordered on 6/3/2023. The pain assessment for day shift on 6/4/2023 was recorded by Nurse #8 as 0. Nurse #8 was interviewed by phone on 7/20/2023 at 1:53 PM and she reported she was assigned to Resident #94 during the day shift on 6/4/2023 and reported Resident #94 had not expressed she was in pain at all to her when Nurse #8 conducted the pain assessment on 6/4/2023. Nurse #8 reported she remembered Resident #94's family member requesting a walker during the day shift on 6/4/2023. Nurse #8 reported she recalled that Resident #94 was very pleasant and not in any pain. Nurse #8 reported that no staff reported a fall to her. The pain assessment for night shift on 6/3/2023 and 6/4/2023 were recorded by Nurse #7 as 0. Nurse #7 was interviewed by phone on 7/21/2023 at 3:15 PM. Nurse #7 reported that Resident #94 had not complained of pain when Nurse #7 conducted the pain assessment during 6/3/2023 or 6/4/2023 on the night shifts. Nurse #7 explained that Resident #94 had an order to administer acetaminophen at 6:00 AM daily and she did administer the medication to her. Nurse #7 reported the resident had not complained of pain, and she had received scheduled acetaminophen at 6:00 AM on 6/3 and 6/4/2023. NA #5 was interviewed on 7/21/2023 at 11:33 AM. NA #5 reported she was assigned to Resident #94 on 6/4/2023 for the night shift. NA #5 was unable to recall if Resident #94 required incontinence care during her shift and reported that Resident #94 did not complain of pain to her during the night shift. There was no evidence in the medical record that any staff notified the physician of Resident #94's fall and subsequent pain, completed an assessment or that an x-ray was ordered on 6/4/2023. The pain assessment day shift on 6/5/2023 recorded by Nurse #6 documented a pain level of 0. Nurse #6 was interviewed on 7/21/2023 at 12:10 PM. Nurse #6 reported she was the nurse who admitted Resident #94 on 6/2/2023 and she was also assigned to her on 6/5/2023. Nurse #6 reported Resident #94 did not report pain to her when Nurse #6 conducted the pain assessment., and if she had reported pain, there were facility standing orders she could have activated for administering acetaminophen to Resident #94. Nurse #6 explained that because Resident #94 did not report pain to her, she did not activate the standing orders. During an interview conducted on 7/21/2023 at 4:49 PM, NA #3 reported she returned to work on 6/5/2023 and was assigned to Resident #94 on the day shift, and when she attempted to provide care, Resident #94 yelled in pain my leg, my leg! NA #3 reported on Monday 6/5/2023 for the day shift Resident #94 was in bed with an incontinence brief on and required incontinence care. NA #3 explained she went to get Nurse #6, and when they returned to Resident #94's room, NP #2 was at the bedside. NA #3 described that Resident #94 was unable to move in bed without yelling out in pain. NA #3 explained that Resident #94 experienced pain all day on 6/5/2023 and she had to get another NA to assist her with incontinence care for Resident #94 because of her pain level. NA #3 reported Resident #94 said her pain was in her right hip and it was very sharp and severe with any kind of movement and turning for incontinence care was unbearably painful. NA #3 reported on 6/2/2023 Resident #94 was able to get up to the bathroom, but she stayed in bed all day 6/5/2023 and received incontinence care in the bed. A progress note written by NP #2 dated 6/5/2023 documented Resident #94 reported to her that on 6/2/2023 she attempted to go to the bathroom and had a fall with pain in her right hip since (the fall). The NP documented Resident #94 had increased pain/discomfort with touch, no bruising was noted, and the hip appeared to be swollen. The NP documented Resident #94 had pain to the right hip/thigh that Resident #94 rated as 4 and described as aching. The note documented Resident #94 had as needed (acetaminophen) at this time, and staff were to continue to monitor Resident #94 until an x-ray result were received. NP #2 was interviewed on 7/21/2023 at 2:45 PM. NP #2 reported she was performing the admission assessment on Resident #94 on 6/5/2023 when Resident #94 reported the hip pain and fall. NP #2 explained she ordered an x-ray of Resident #94's hip and when the x-ray was read and it was determined Resident #94 had a fracture, she was sent to the hospital for evaluation. An interview was conducted with NA #4 on 7/25/2023 at 11:10 AM. NA #4 reported she provided her with incontinence care on 6/5/2023 during the afternoon shift and Resident #94 was in intense pain all shift. NA #4 reported she attempted to provide incontinence care by herself, and this caused Resident #94 to scream and scream in pain. NA #4 explained that she had to get another NA to assist her with care. NA #4 reported she told Nurse #2 that Resident #94 was in pain. A hip x-ray dated 6/5/2023 and read at 9:39 PM read a right subcapital fracture with moderate displacement (acute right hip fracture). A nursing note dated 6/6/2023 at 12:31 AM documented the results of the hip x-ray were received by the facility at 11:45 PM on 6/5/2023. The on-call NP was paged, and the nurse received an order to send Resident #94 to the hospital for evaluation for the right hip fracture. The note documented that Resident #94 left the facility by ambulance at 12:30 AM. There was no evidence in the medical record that pain medication was ordered on 6/5/2023. The emergency department (ED) provider note dated 6/6/2023 at 1:28 AM documented Resident #94 presented with right hip pain that was found to be fractured on an x-ray obtained outpatient earlier that day. Resident #94 reported she fell three days ago and has had right hip pain ever since. The note documented the x-ray obtained by the facility showed a right hip fracture. On exam the ED physician noted tenderness to the right hip without deformity. Repeat x-rays obtained confirmed a closed subcapital right femoral neck fracture. There was no pain rating, or documentation of medications administered for pain. Orthopedic surgery was consulted and at 3:05 AM recommended for Resident #94 to be admitted and make her NPO (nothing by mouth) status. It was unknown if Resident #94 received pain medication during transport to the hospital for evaluation on 6/6/2023. An orthopedic trauma consult note dated 6/6/2023 at 10:40 AM documented: Patient (Resident #94) reported on Friday 6/2/2023 she was attempting to get up to the bathroom and fell , landing on her right hip. She reported immediate pain in the right hip and being unable to get up after the fall. The history and physical noted: Right lower extremity: skin intact without (redness). Leg length short in comparison to contralateral leg (left leg) and hip held in external rotation (leg was rotated to the right). Endorses (agreed) hip pain with heel strike (touching heel to the floor during mobility). Details in the assessment and plan included the right femoral neck fracture was discussed with Resident #94 and the recommendation was to proceed with the hip hemiarthroplasty, to which she agreed. This plan was also discussed with a family member who agreed and stated Resident #94 was competent to sign her own consents. An interview was conducted with the MD on 7/21/2023 at 11:54 AM. The MD reported that his medical group has an on-call triage line where a NP is available 24 hours a day to answer medical questions and provide orders. The MD reported that the facility had not contacted the on-call triage for anything related to Resident #94 6 /2/2023, 6/3/2023, 6/4/2023, or 6/5/2023. The MD reported that delaying treatment for a fractured large bone would have been very painful for Resident #94, and he was not aware she did not have an order for pain medication. The Director of Nursing (DON) was interviewed on 7/21/2023 at 3:21 PM. The DON explained that she had thought Resident #94 had not reported the fall to anyone until 6/5/2023 when NP #2 assessed her. The DON reported she was not aware of the physical therapy assessment conducted on 6/3/2023 and that PT #1 reported to an unknown nurse that Resident #94 had a fall and was experiencing pain. The DON stated she interviewed Resident #94 on 6/5/2023 after the NP evaluation and Resident #94 reported she had fallen and gotten herself up off the floor and did not report the fall to staff. The DON explained staff should have immediately contacted the on-call NP and reported the fall and pain and assessed Resident #94. The DON reported she was not certain why this had not happened on 6/3/2023. The Administrator was notified of Immediate Jeopardy on 7/21/2023 at 6:42 PM. o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance The facility failed to notify the physician and/or the resident representative after Resident #94 reported to the Physical Therapist on 6/3/23 that she had fallen in her room on 6/2/23. On 6/3/23, the physical therapy evaluation revealed that Resident #94 reported to the physical therapist that she had fallen on 6/2/23 in her room and had not reported the incident to the facility staff. The physical therapist also reported that the resident complained of right hip pain, and this was reported to the Nurse #1 on the hall who reported that she would follow up and obtain an order for an x-ray. On 7/21/23, the Director of Nursing spoke to Nurse #1, and she denied any knowledge of Resident #94 reporting that she had fallen or that the physical therapist or any other staff member reporting to her that Resident #94 had fallen. In addition, Nurse #1 was asked if Resident #94 requested pain medication or had signs or symptoms of pain and Nurse #1 reported no. On, 7/20/23, the Therapy Director spoke to the physical therapist that was working on 6/3/23 and she reported that Resident #94 had reported to her that she had fallen on 6/2/23 while attempting to go to the bathroom. The physical therapist reported that the roommate also reported that the resident had fallen on the previous day (6/2/23). On 6/5/23, after the Nurse Practitioner reported that Resident #94 reported a fall on 6/2/23, the Director of Nursing completed a follow up interview and Resident #94 reported that she had fallen while attempting to go to the bathroom and had gotten herself up off the floor and had not reported this to the staff. On 6/5/23, Unit Manager #1 and the Admissions Director spoke to Resident #94's family member who reported that on 6/2/23, Resident #94 had reported to him that she had fallen on the way to the bathroom and that she was having a lot of pain. The family member reported that he reported that Resident #94 was having pain to the charge nurse. On 6/5/23, during the Nurse Practitioner initial assessment, Resident #94 reported that she had fallen on 6/2/23 in her room while attempting to go to the bathroom and was having right hip pain. On 7/17/23, the facility investigation by the Director of Nursing revealed that the Nurse Practitioner was informed of Resident #94's fall on 6/2/23 during her initial assessment on 6/5/23 by the resident. In addition, further review of the medical record revealed that there was no fall nursing assessment documentation or physician/physician extender notification documentation by the licensed nurse of the 6/2/23 fall until 6/5/2023. The Director of Nursing completed the interviews on 7/21/23. The interviews revealed that the licensed nurses and the certified nursing assistants that worked on 6/2/23, 6/3/23, and 6/4/23 reported that Resident #94 did not report to them that she had fallen on 6/2/23. The licensed nurses, certified nursing assistants, and certified medication aide interviews by the Director of Nursing of staff that who worked on 6/2/23, 6/3/23, and 6/4/23 per the nursing assignment sheets revealed that Resident #94 did not report the fall to the assigned licensed nurse, certified nursing assistant or certified medication aide. On 7/17/23, Nurse #3 (Weekend Supervisor) interview with the Director of Nursing revealed that Resident #94 did not express pain concerns and she did not observe signs or symptoms of excruciating pain on 6/3/23 and 6/4/23. Nurse # 3 also reported that Resident #94 as well as the other nursing staff to include the physical therapist who worked on 6/3/23 and 6/4/23, did not report that Resident #94 has fallen on 6/2/23. Nurse #3 reported that Resident #94's family member did not report to her that the resident was having pain and that the resident had fallen on 6/2/23. All current residents are also at risk as a result of this deficient practice. Starting 7/21/23, the Director of Nursing/the Unit Managers and designee will complete an audit of the medical records to include review of progress notes, outside provider notes, incident reports, medication administration records, physician orders, and nursing shift reports of all the current residents for the last 60 days to ensure the physician/ physician extenders and resident representatives have been notified of any resident falls or changes in condition and identified concerns have been address by 7/25/23. Starting 7/21/23 the Director of Nursing / designee will complete interviews of the alert current residents to ensure resident concerns to include incident and accidents, pain management, medication/ treatments and other resident care concerns have been identified and reported to the physician/ physician extenders in the last 60 days by 7/25/23. Starting 7/21/23, the Director of Nursing/ designee will complete interviews of the facility staff to include licensed nurses, certified nursing assistants, certified medication aides, dietary, housekeeping/laundry, agency, new hire and prn staff to ensure all resident changes in condition or any reported concerns in the last 60 days have been reported to the DON, Unit Manager and/or the Nursing supervisor by 7/25/23. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete Starting 7/21/23, the Staff Development Coordinator/ designee will complete education by 7/25/23 of the facility staff to include licensed nurses, certified nursing assistants, certified medication aides, dietary, therapy department, housekeeping/laundry, agency, new hire and prn staff related to ensuring resident changes in condition to include incident and accidents, pain management changes, medication/treatment concern, resident care concerns and any resident/families reported concerns have been reported to the licensed nurse and to the physician and/or DON, Unit Managers and nursing supervisor. Starting 7/21/23, the Staff Development Coordinator/ designee will complete education with the licensed nurses to include agency, new hire, and prn licensed nurses related to immediate notification and documentation of resident changes in condition to include incident and accidents, pain management changes, medication/treatment concern, resident care concerns and any resident/ families reported concerns to the physician/ physician extenders and resident representatives and document in the medical record by 7/25/23. After hours the licensed nurse will notify the on-call provider and document in the medical record. Starting 7/21/23, the Staff Development Coordinator was made aware by the Director of Nursing that she will be responsible for verifying that the education has been completed by the required staff members by using the facility personal roster and the nursing, dietary, therapy and housekeeping/laundry staffing schedules to include new hires, agency and prn staff and ongoing education by 7/25/23. No staff will be allowed to work until they have received this education. The SDC/ designee which includes the DON, Unit Managers, and Nursing supervisors will be responsible for providing all of the education. On 7/25/23, The Director of Nursing educated the therapy manager to ensure that all therapists to include occupational therapist, physical therapist, speech therapist, weekend therapist, new hire, and prn therapist report resident observed and reported falls to the therapy manager and the Director of Nursing immediately. Starting 7/25/23, the therapy manager will educate the therapists to include occupational therapist, physical therapist, speech therapist, weekend therapist, new hire, and prn therapist related to ensuring resident observed and reported falls are immediately reported to the therapy manager and the Director of Nursing. Therapy staff to include prn and new hire staff will not be allowed to until they receive this education. Effective 7/21/2023 the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: 7/26/2023 On 7/227/2023, the facility's credible allegation for immediate jeopardy removal was validated by the following: The facility provided documentation to support the Credible Allegation for F697. The facility's Nurse Practitioner assessed the named resident and sent her to the hospital for evaluation of a right subcapital fracture. The facility further provided documentation of pain assessment for all residents in the facility. The facility further provided auditing of pain assessments, pain documentation, pain medication management, and pain care plan updates for all residents in the facility. An in-service education was completed with the nursing and therapy staff regarding resident pain identification, signs of pain, management of pain medication, documentation of pain, and update of the care plan. The facility further provided the education that will be provided to all new hires and agency staff regarding pain management before being allowed to work in the facility. Facility nursing staff were interviewed regarding their understanding of the education provided. The assessment of the named resident and all other residents; the auditing of pain assessments, documentation, medication management, and care plan update; and the education of staff were completed by 7/25/2023. The facility's date of the immediate jeopardy removal plan of 7/26/2023 was validated on 7/27/2023.

Based on observations, and interviews with staff, the facility failed to maintain the exterior facility grounds clean, free of broken equipment and trash and repair broken floor tiles in the kitchen. This failure occurred for one to nine months. The findings included: 1. On 7/19/23 at 1:42 PM, an observation of the exterior facility grounds revealed two commercial dumpsters. One dumpster was open without a lid, filled with cardboard and no room for additional storage. The second commercial dumpster's lid was closed with room for additional storage. The following broken items were observed stored on the ground or propped against the facility: Multiple boards of sheet rock, propped against the facility. One broken shower chair stored on the ground. Four cement stairs stored on the ground. Five wooden pallets, broken, stored on the ground. One black leather chair, broken and stored on the ground. One used surgical face mask, stored on the ground. Four particle board headboards and footboards, broken, propped against the facility shed. One used glove, laying on the ground. Two recliner chairs, broken, stored on the ground next to the open commercial dumpster. Three empty cardboard boxes, stored on the ground. An interview with the Maintenance Director occurred on 7/19/23 at 1:45 PM. The Maintenance Director stated he started this role in November 2022, and he had been waiting several months for the broken items stored outside to be picked up by the waste removal company. He stated that the cement stairs had been stored outside since the previous year. He stated the stairs were used to access a mobile kitchen the facility used in the summer of 2022. He stated he placed the broken black leather chair from the facility's van outside about a month ago. He stated that all the other broken items were placed outside a few weeks ago. He stated that he was in the process of moving the broken items to the dumpster, but he was waiting on the commercial dumpsters to be emptied. He stated that typically the commercial dumpsters were emptied once every two weeks, but that he had been waiting several weeks now for the waste removal company to empty them. The Maintenance Director stated he was aware these items were left on the ground and that it was his responsibility to maintain the grounds of the facility clean. The Administrator stated in an interview on 7/20/23 at 3:07 PM that he was aware that broken equipment and other items were stored on the ground outside the facility and that these items should be placed in the commercial dumpster. He stated that the facility was currently undergoing renovations and so they secured a second commercial dumpster to store trash, but that emptying the commercial dumpster was not on a schedule. He stated that the waste removal company emptied the commercial dumpsters at will, and that the facility was currently waiting for the dumpsters to be emptied so that the broken items could be placed in the dumpster for removal. 2. An observation of the kitchen on 7/17/23 at 11:28 AM revealed multiple broken and missing floor tiles in the dish pit area with water pooling on the floor. A second observation of the same occurred on 7/19/23 at 1:10 PM. During an interview on 7/19/23 at 1:10 PM the Dietary Manager (DM) stated the floor tiles in the dish pit area had been broken/missing for a while, since piping was replaced in the kitchen last year. The DM stated that as a result, water pooled on the floor where the tiles were broken/missing and staff mopped this area daily, but water still pooled there. The Maintenance Director stated in an interview on 7/19/23 at 1:45 PM that he was aware of the broken/missing floor tiles in the kitchen. He stated the floor tiles were in disrepair since piping underneath the kitchen floor was repaired in the summer of 2022, when the facility had a mobile kitchen. He stated repairs to the piping took a while and he just needed to identify a time when we could get in the kitchen and repair the broken tiles and replace the missing tiles when there was no activity going on in the kitchen. The Administrator stated in an interview on 7/20/23 at 3:07 PM that the piping underneath the kitchen floor was repaired in the summer of 2022 and as a result a few floor tiles still needed repair. He stated that he expected these repairs to be made.

Based on observations, staff interviews, and record review, the facility failed to maintain one of one freezer free of accumulated ice and remove pooled water on the kitchen floor. This failure occurred for approximately four months and had the potential to affect food served to residents. The findings included: 1. An observation of the walk-in freezer occurred on 7/17/23 at 11:45 AM. A metal storage rack approximately 11 inches in height was observed with milk crates stored on top. The milk crates were approximately 11 inches in height. Multiple cases of carrot coins, crinkle cut French fries and garlic bread were stored on top of the milk crates. Ice was observed on top of these cases of food items and the ice extended to the floor, approximately 22 inches and pooled on the floor around the base of the metal storage rack. The ice was also observed inside the cases of food items and on the food. The freezer compressor was observed with ice accumulation and water dripping. The Dietary Manager (DM) stated in an interview on 7/17/23 at 11:45 AM that compressor had been leaking for the past two weeks, the Maintenance Director was aware and ordered a part for repair, but that the part had not arrived yet. The DM stated that she and the Maintenance Director were trying to remove the ice buildup in the interim, but that due to amount of water leaking from the compressor, the ice accumulation was hard to keep removed. An interview with the Maintenance Director occurred on 7/17/23 at 12:12 PM. He stated that in February 2023 he called for a repair service to repair the freezer because the compressor was leaking. He stated part of the repairs were completed, but that a part that was needed to complete the repairs had been ordered, but had not arrived. He stated the repair service came to the facility a few weeks ago to complete the repairs, and identified a part that was needed and ordered the part. The Maintenance Director stated that the compressor was leaking and that he tried to remove the ice accumulation as often as possible. He said he saw the ice accumulation on Friday, 7/14/23 and spoke to the DM about coming up with a plan to remove the ice build-up, but that he had not had a chance to address it yet. He stated that he would start checking for ice accumulation more frequently and develop a plan for removing the ice accumulation until the part came in for repair. The Maintenance Director provided a copy of the invoice from the repair service provider. The date of the invoice was 2/5/23 and recorded the reason for the call was to repair the walk-in freezer and add refrigerant to the walk-in cooler. The lock to the compressor of the walk-in freezer was recorded as rusted and leaking and broke off during the repair. It was replaced. The drain line heater to the compressor was also in need of repair allowing the drain to freeze up. This repair was still incomplete. The Administrator was interviewed on 7/20/23 at 3:10 PM and stated he was aware that the facility was waiting on a part to repair the compressor in the freezer. He stated that the ice should be removed in the interim while the facility waited on the part for repair. 2. An observation of the kitchen on 7/17/23 at 11:28 AM revealed puddles of brown colored water pooled on the floor in the dish pit area where missing/broken floor tiles were observed. A second observation of the same occurred on 7/19/23 at 1:10 PM. Review of vendor service reports dated 3/27/23 and 6/19/23 recorded kitchen sanitation recommendations to remove excess water noted in the dish pit area, and to keep the area clean/dry. During an interview on 7/19/23 at 1:10 PM the Dietary Manager (DM) stated the floor tiles in the dish pit area had been broken/missing for a while, since piping was replaced in the kitchen last year. The DM stated that as a result, water pooled on the floor where the tiles were broken/missing and staff mopped this area daily, but water still pooled there. The Administrator stated in an interview on 7/20/23 at 3:07 PM that the piping underneath the kitchen floor was repaired in the summer of 2022 and as a result a few floor tiles still needed repair. He stated that he expected the dish pit area to be kept clean and the floor dry.

Based on record review and staff interviews the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions the committee put into place following the 8/31/2021 infection control and complaint investigation survey, 2/14/2022 recertification and complaint investigation, 7/29/2022 complaint investigation survey. The facility had deficiencies previously cited in the areas of notification of change (F580), baseline care plans (F655) and kitchen sanitation (F812). F580 was cited on 8/31/2021 during a complaint investigation and infection control survey, on 2/14/2022 during a recertification and complaint investigation survey, and on 7/29/2022 during a complaint investigation survey; F655 was cited on 2/14/2022 during recertification and complaint investigation survey and F812 was cited on 2/14/2022 during a recertification and complaint investigation and on 7/29/2022 during a complaint investigation. These deficiencies were cited again during the facility's current recertification and complaint investigation survey of 7/28/2023. The continued failure of the facility during four federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA Program. The findings included: This tag is cross referenced to: F580-Based on record reviews, resident, family, nurse practitioner (NP), physician (MD), and staff interviews, the facility failed to notify the MD of a resident who experienced pain following a fall for 1 of 3 residents investigated for notification of changes. The resident sustained a fall on 6/2/2023 and reported the fall and right hip pain to Physical Therapist (PT) #1 on 6/3/2023. PT #1 reported the fall and the hip pain to a nurse. The resident reported the fall and right hip pain when she was assessed by NP#2 on 6/5/2023. NP#2 ordered an x-ray of the right hip, which revealed a fractured femur (the long bone in the leg). She was sent to the hospital on 6/6/2023 at 12:30 AM and had a partial hip replacement surgery on 6/7/2023. During the focused infection control and complaint investigation survey conducted on 7/29/22 the facility was cited for failing to notify a Resident's Physician when two doses of an anticonvulsant (anti-seizure) medication were not available to administer on 03/18/22. The resident had two episodes of seizure activity and required two hospitalization s to control the seizure activity on 03/19/22-03/21/22 and 03/24/22-03/28/22 for 1 of 3 residents reviewed for medication management. During the recertification and complaint investigation survey conducted on 2/14/22 the facility was cited for failing to notify a Resident's Physician when two different blood pressure medications were not available for administration on 07/21/21 and 07/22/21; and when the blood pressure reading was out of normal range for 1 of 3 residents reviewed for medication management. During the focused infection control and complaint investigation survey conducted on 8/31/22 the facility was cited for failing to notify the provider of skin assessment changes for 1 of 3 residents reviewed for pressure ulcers. F655- Based on record reviews and staff interviews, the facility failed to develop a baseline care plan within 48 hours of admission that addressed the needs of a resident with a history of frequent falls for 1 of 29 residents reviewed for baseline care plans. During the recertification and complaint investigation survey conducted on 2/14/22 the facility was cited for failing to develop a baseline care plan within 48 hours of admission to address the immediate needs of a resident for enteral feedings or identify the correct smoking status for 1 of 2 residents reviewed for baseline care plans. F812-Based on observations, staff interviews, and review of facility records, the facility failed to maintain one of one freezer free of accumulated ice and remove pooled water on the kitchen floor. This failure occurred for approximately four months and had the potential to affect food served to residents. During the recertification and complaint investigation survey conducted on 2/14/22 the facility was cited for failing to 1) thaw a potentially hazardous food with an effective food safety system, and 2) store cold/frozen foods sealed and with a label and date of opening. The facility thawed frozen diced ham, that was not submerged, under running water with a temperature of 93.4 degrees Fahrenheit (F). The facility stored hot dogs, sliced ham, sliced turkey, French fries, pancakes, sliced cheese and chicken tenders without a label and date of opening and open to air. This failure occurred in 2 of 3 cold storage units and had the potential to affect food served to residents. During the focused infection control and complaint investigation survey conducted on 7/29/22 the facility was cited for failing to perform hand hygiene for 1 of 3 dietary staff (Dietary Aide #1), monitor refrigerator temperatures for 1 of 1 reach-in refrigerators, store potentially hazardous cold foods at least 41 degrees Fahrenheit (milk, pimento cheese sandwiches and a bologna sandwich), and store pans (muffin pans, sheet pans) and a cutting board clean. This deficient practice had the potential to affect food served to residents. During an interview with the Administrator on 7/27/2023 at 1:43 pm he stated the Quality Assurance Performance Improvement (QAPI) committee meets monthly and the Medical Director and Pharmacist are present for the meeting every 3 months. The Administrator stated the other members of the QAPI team are at the monthly meeting, which includes the Director of Nursing, Infection Preventionist, Maintenance Director, Housekeeping Director, Therapy Manager, and Dietary Manager. The Administrator stated the facility uses their quality measures, grievances, resident weights, wounds, and trends for infections as areas to improve. The Administrator stated he was not sure of why the facility had repeated concerns in the current survey since he had just started in the facility on 12/1/2022. He stated the facility would continue to work on the issues brought up during the survey and strive to improve.

Based on observations, staff interviews, and record review, the facility failed to maintain an effective pest control program as evidenced by observations of current pest activity in 3 of 3 resident rooms, on two of two units, and the conference room. The facility failed to utilize insect light traps and implement pest service recommendations for four months to prevent reoccurring pest activity. The findings included: 1 a. Observations of live pest activity occurred on the following: - On 7/17/23 at 12:33 PM, flies were observed flying around the covered lunch meal tray that was stored on the over bed table in room [ROOM NUMBER] on the A/B unit. - On 7/17/23 at 12:55 PM, multiple small flying insects were observed flying around the nightstand in room [ROOM NUMBER] on the C/D unit. - On 7/17/23 at 12:59 PM, flies were observed in room [ROOM NUMBER] on the C/D unit. - On 7/19/23 at 11:21 AM, multiple flies were observed on the C/D unit flying around the open food cart. - On 7/19/23 at 11:44 AM a spider was observed crawling on the floor in the conference room. - On 7/19/23 from 12:35 PM to 12:49 PM, flies were observed on the C/D unit around an open food cart. 1 b. On 7/19/23 at 1:10 PM, two wall mounted insect light traps were observed unplugged in the kitchen. The Dietary Manager (DM) was interviewed during the observation and stated that she had not noticed these wall mounted insect light traps before and that she did not know what they were for. The DM stated she had not noticed that the insect light traps were unplugged. During an interview on 7/19/23 at 1:12 PM, dietary staff #1 stated that she unplugged the insect light trap in the cook's prep area to use the electrical outlet and forgot to plug it back in. The Maintenance Director stated in an interview on 7/19/23 at 1:45 PM, that he noticed that the two insect light traps in the kitchen were unplugged, but that he was not sure who unplugged them or why. He stated they should be plugged in to deter pest activity. 1 c. An observation of the kitchen on 7/17/23 at 11:28 AM revealed puddles of brown colored water pooled on the floor in the dish pit area where missing/broken floor tiles were observed. A second observation of the same occurred on 7/19/23 at 1:10 PM. Pest control service reports dated 3/27/23 and 6/19/23, both recommended to remove excess water noted in the dish pit area, and to keep the area clean/dry to reduce pest activity. During an interview on 7/19/23 at 1:10 PM the DM stated she was aware of the pest service reports and recommendations. The DM stated that the floor tiles in the dish pit area had been broken/missing for a while, since piping was replaced in the kitchen floor last year. The DM stated that as a result, water pooled on the floor where the tiles were broken/missing and staff mopped this area daily, but water still pooled there. 1 d. On 7/19/23 at 1:42 PM, an observation of the exterior facility grounds revealed multiple broken items stored on the ground or propped against the facility: Multiple boards of sheet rock, propped against the facility. One broken shower chair stored on the ground. Four cement stairs stored on the ground. Five wooden pallets, broken, stored on the ground. One black leather chair, broken and stored on the ground. One used surgical face mask, stored on the ground. Four particle board headboards and footboards, broken, propped against the facility shed. One used glove, laying on the ground. Two recliner chairs, broken, stored on the ground next to the open commercial dumpster. Three empty cardboard boxes, stored on the ground. A pest control service report dated 4/19/23, recommended the removal of medical equipment left outside, against the building to reduce the number of pests entering the facility. An interview with the Maintenance Director occurred on 7/19/23 at 1:45 PM. The Maintenance Director stated he started this role in November 2022, and he had been waiting several months for the broken items stored outside to be picked up by the waste removal company. He stated that the cement stairs had been stored outside since the previous year and were used to access a mobile kitchen the facility used in the summer of 2022. He stated he placed the broken black leather chair from the facility's van outside about a month ago. He stated that all the other broken items were placed outside a few weeks ago. He stated that he was in the process of moving the broken items to the dumpster, but he was waiting on the commercial dumpsters to be emptied. He stated that typically the commercial dumpsters were emptied once every two weeks, but that he had been waiting several weeks now for the waste removal company to empty them. The Maintenance Director stated he was aware these items were left on the ground and that it was his responsibility to maintain the grounds of the facility clean. The Administrator stated in an interview on 7/20/23 at 3:07 PM that the insect light traps should be plugged in for use. He stated that the piping underneath the kitchen floor was repaired in the summer of 2022 and as a result a few floor tiles still needed repair. He stated that he expected the dish pit area to be kept clean and the floor dry. He stated that he was aware that broken equipment and other items were stored on the ground outside the facility and that these items should be placed in the commercial dumpster. He stated that the facility was currently undergoing renovations and so they secured a second commercial dumpster to store trash, but that emptying the commercial dumpster was not on a schedule. He stated that the waste removal company emptied the commercial dumpsters at will, and that the facility was currently waiting for the dumpsters to be emptied so that the broken items could be placed in the dumpster for removal.

Based on observation, record review and resident, staff, physician and neurologist interview the facility failed to notify a Resident's Physician when two doses of an anticonvulsant (anti-[CONDITION(S)]) medication were not available to administer on 03/18/22. The resident had two episodes of [CONDITION(S)] activity and required two hospitalization s to control the [CONDITION(S)] activity on 03/19/22-03/21/22 and 03/24/22-03/28/22 for 1 of 3 residents reviewed for medication management (Resident #1). Immediate Jeopardy began on 03/18/22 when the facility failed to administer two doses of an anti-convulsant medication and notify the Physician that the medication was not available. Resident #1 had two episodes of [CONDITION(S)] activity and required hospitalization on [DATE] and 03/24/22. Immediate Jeopardy was removed on 07/29/22 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level D (no actual harm with potential for more that minimal harm that is not immediate jeopardy) to correct the deficient practice and ensure monitoring systems put in place to remove the immediate jeopardy are effective. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the March Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MAR for the [MEDICATION(S)] administration for 03/18/22 indicated Nurse #2 failed to give the 8:00 AM dose and Nurse #1 failed to administer the 8:00 PM dose to Resident #1. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #2 documented 'waiting on pharmacy delivery.' A phone interview was conducted on 07/27/22 at 4:24 PM with Nurse #2 regarding the 03/18/22 8:00 AM [MEDICATION(S)] dose not being administered and physician notification. She did not recall Resident #1 or the missing medication details. Nurse #2 said if she did not have the medication to administer, she would have called the pharmacy to ensure they had the order. Nurse #2 added if the pharmacy was sending the medication, she would not have called the doctor. She said she did not recall notifying any Provider. She noted she would only call the doctor if the medication was not on its way or if it needed a new prescription. Record review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #1, Nurse #1 had documented at 10:41 PM on 03/18/22. It noted: 9-other, in route from pharmacy, resident vitals all within normal limits. A phone interview was conducted on 07/28/22 at 12:08 PM with Nurse #1 that had not administered the [MEDICATION(S)] medication on 03/18/22 at 8:00 PM for Resident #1 regarding physician notification. She stated, the medication was not available, I had checked with pharmacy. She said she was talking generally as she did not recall the event. Nurse #1 noted the process for notifying would have been to call the on-call physician, and usually she would let the physician know the expected time of arrival. She believed the medicine was an issue. She was 'informed that her medical record note was- 'medication in route from pharmacy.' Nurse #1 stated she would have known to call the physician and she did not know why this documentation was not there, but no one told me to call the physician from the facility and she can't explain why she did not document it. Record review indicated on 03/19/22 the resident had a [CONDITION(S)] [MEDICATION(S)] 35 minutes. Emergency Medical Services (EMS) were called and administered two doses intravenously (IV) of the sedative [MEDICATION(S)] enroute to the hospital. Resident #1 was hospitalized until 03/21/22. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review noted on 03/24/22, Resident #1 had another [CONDITION(S)] for 20 minutes. EMS was called and he received IV [MEDICATION(S)] by EMS and was transported to the hospital. The Neurologist was interviewed via phone on 7/27/22 at 12:46 PM regarding Resident #1. He stated the medication [MEDICATION(S)] were being used for his [CONDITION(S)](tremors) and the seizures. He stated the nurses needed to be educated on the importance of giving medications as ordered and obtaining the medications. The Physician stated the nurse should have called when the medication was not available. The Neurologist noted if he would have been called, he would have called a local pharmacy if the facility's Pharmacy could not provide it. The Neurologist stated when he did not receive the medications it caused the resident harm and he had breakthrough seizures because of it. A follow up phone interview with the Neurologist was conducted on 07/27/22 at 4:51 PM regarding Resident #1's [MEDICATION(S)] doses that were not administered on 03/18/22. He stated when the resident missed the 2 doses of medication, it resulted in seizures due to non-therapeutic blood levels and the second hospitalization was also due to the 2 missing doses. He stated it took a while to get the optimum blood level back and it can take several days to occur. He noted education should be done on the importance of ensuring they had the medication and to call the physician when they don't have the medication, even one dose was crucial. He noted that when Resident #1 did not receive the medication, it led him to have breakthrough seizures and the rehospitalization was also due to him missing the medication, which was also a breakthrough [CONDITION(S)]. He stated it can take many days to get the therapeutic/optimum blood level back to regulate the brain and control the seizures when the [CONDITION(S)] medications were stopped. He added it was not unusual for it to take 5 days or more for this to occur. The Medical Director was interviewed via phone on 7/27/22 at 1:37 PM regarding the [MEDICATION(S)] doses not being administered to Resident #1 for 24 hours. He was informed the resident had [CONDITION(S)] activity and resident required hospitalization on [DATE] and 03/24/22 following the missed doses. He stated he would have expected the on call physician would be notified when the medication was not available. The Medical Director stated he did not believe it was significant harm that occurred. An interview was done with the Unit Manager (UM) on 07/26/22 at 11:27 AM regarding medication administration. She stated the nurses should have notified the Physician if medications were not given to Resident #1. The Director of Nursing was interviewed on 07/27/22 at 2:30 PM regarding the anti-[CONDITION(S)] medication not administered to Resident #1. The DON stated that the Physician should have been notified when the medication was not available, and the nurses had been educated as it was cited recently. The Director of Nursing provided an orientation/education packet on 07/27/22 that was being given to agency nurses currently. Review of the paperwork titled: 'New hire education checklist, for complaint survey 8/18/21-8/31/21' and 'F580-notification of changes' was done. It noted: -report to the medical provider/on call medical provider medications that are unavailable to be administered as ordered. -Notification to provider and response/received orders must be documented in the resident's medical record. A phone interview was conducted with the Administrator on 07/28/22 at 9:09 AM regarding Resident #1 not receiving his [MEDICATION(S)] medication. He stated that medication should be available, given as ordered and the physician should be notified if the medication was not available. The Administrator was informed of Immediate Jeopardy (IJ) on 07/28/22 at 10:07 AM. The Facility provided the following Credible Allegation of IJ removal. - Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance Resident#1 did not receive physician ordered anti-[CONDITION(S)] medications on 3/18/22 due to the medication not being available from the pharmacy. The Medical Director was not notified the medication was unavailable to be administered as ordered. Resident #1 had [CONDITION(S)] activity on 3/19/22 and was found in bed having seizures. The resident was assessed and 911 transported the resident to emergency room . As paramedics were transferring resident from bed to stretcher, he had another [CONDITION(S)]. Resident #1 was admitted to the hospital and readmitted to the facility on [DATE]. He returned to the hospital on 3/24/22 for [CONDITION(S)] activity and did not return to the facility. Nurse Managers will complete an audit on 7/28/22 of the Medication Administration Records of current residents with physician ordered anti-[CONDITION(S)] medications and identify those who did not receive anti-[CONDITION(S)] medications as ordered during the last 7 days. A Medication error report will be completed by the Nurse Managers for any missing documentation and the Physician notified immediately. - Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete Nurse Managers will re-educate licensed nurses, including agency staff, regarding the facility's policy for notifying the Physician to include notification related to physician ordered anti-[CONDITION(S)] medications that are unavailable for administration. The Director of Nursing will ensure no staff will work without receiving this education. Any new hires, including agency staff will receive education prior to the start of their shift. Education will be completed by 7/28/22 by the Nurse Managers. The Regional Director of Clinical Services educated the Director of Nursing, Nurse Managers and the Administrator regarding the clinical morning meeting process to include a review of the Medication Administration Report for residents with physician ordered anti-[CONDITION(S)] medications to identify those who did not receive anti-[CONDITION(S)] medications as ordered and validate documentation of notification to the physician related to ordered anti-[CONDITION(S)] medications unavailable for administration. This education was completed on 07/28/22. Effective 07/28/2022 the Administrator will be responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance Alleged Date of IJ Removal: 07/29/2022 The credible allegation of Immediate Jeopardy was validated on 07/29/22 as evidenced by onsite validation through record review, observations and staff interviews. Staff were interviewed to validate in-service education completion and education rosters were reviewed. The Immediate Jeopardy was removed on 07/29/22.

Based on observations, record review and resident, staff, physician and neurologist interviews, the facility failed to administer two doses of an anticonvulsant (anti-[CONDITION(S)]) medication, the resident had two episodes of [CONDITION(S)] activity and required two hospitalization s to control the seizures (03/19/22-03/21/22 and 03/24/22-03/28/22) for 1 of 3 resident reviewed for significant medications (Resident #1). Immediate Jeopardy began on 03/18/22 when the facility failed to administer two doses of an anti-convulsant medication. Resident #1 had two episodes of [CONDITION(S)] activity and required hospitalization on [DATE] and 03/24/22. Immediate Jeopardy was removed on 07/29/22 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to correct the deficient practice and ensure monitoring systems put in place to remove the immediate jeopardy are effective. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the March Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/27/22, the Director of Nursing obtained the Pharmacy delivery slips that indicated the Medication [MEDICATION(S)] was ordered from pharmacy on 03/17/22 and delivered late on 3/18/22 for Resident #1. A nurse had dated and signed for the medication, but no time was noted in the date field on the form. Record review of the MAR for the [MEDICATION(S)] medication on 03/28/22 indicated Nurse #2 failed to give the medication at 8:00 AM and Nurse #1 did not administer the 8:00 PM dose to Resident #1. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #2 documented 'waiting on pharmacy delivery.' A phone interview was conducted on 07/27/22 at 4:24 PM with Nurse #2 regarding the 03/18/22 8:00 AM [MEDICATION(S)] dose not being administered. She did not recall the resident or the missing medication details for Resident #1. Record review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #1, Nurse #1 had documented at 10:41 PM on 03/18/22. It noted: 9-other, in route from pharmacy, resident vitals all within normal limits. A phone interview was conducted on 07/28/22 at 12:08 PM with Nurse #1 that had not administered the [MEDICATION(S)] medication on 03/18/22 at 8:00 PM for Resident #1. She stated, the medication was not available, I had checked with pharmacy. Record review indicated on 03/19/22 the resident had a [CONDITION(S)] [MEDICATION(S)] 35 minutes. Emergency Medical Services (EMS) were called and administered two doses intravenously (IV) of the sedative [MEDICATION(S)] enroute to the hospital. Resident #1 was hospitalized until 03/21/22. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review noted on 03/24/22, Resident #1 had another [CONDITION(S)] for 20 minutes. EMS was called and he received IV [MEDICATION(S)] by EMS and was transported to the hospital. The Minimum Data Set (MDS) Assessment completed on 03/24/22 indicated Resident #1 was cognitively intact. Review of the hospital records indicated Resident #1 was discharged from the hospital to another facility on 03/28/22. The Director of Nursing was interviewed on 07/27/22 at 2:30 PM regarding the anti-[CONDITION(S)] medication for Resident #1. She stated if the medication was not there, the nurse should have checked the automated drug dispensing machine, called the pharmacy to see if the medication was on the way and notified the physician if the medication was not available. The Neurologist was interviewed via phone on 07/27/22 at 12:46 PM regarding Resident #1. He stated the medication [MEDICATION(S)] were being used for his [CONDITION(S)] (muscle twitching) and the seizures. He stated the nurses needed to be educated on the importance of giving medications as ordered and getting the medications. The Physician stated the nurse should have called when the medication was not available. The Neurologist stated when he did not receive the medications it caused the resident harm and he had breakthrough seizures because of it. A follow up phone interview with the Neurologist was conducted on 07/27/22 at 4:51 PM regarding Resident #1's [MEDICATION(S)] doses, that were not administered on 03/18/22. He stated when the resident missed the 2 doses of medication, it resulted in seizures due to non-therapeutic blood levels and the second hospitalization was also due to the 2 missing doses. He noted that when Resident #1 did not receive the medication, it led him to have breakthrough seizures and the rehospitalization was also due to him missing the medication, which was also a breakthrough [CONDITION(S)]. He stated it can take many days to get the therapeutic/optimum blood level back to regulate the brain and control the seizures when the [CONDITION(S)] medications were stopped. He added it was not unusual for it to take 5 days or more for this to occur. The Medical Director was interviewed via phone on 07/27/22 at 1:37 PM regarding the [MEDICATION(S)] doses not being administered to Resident #1 for 24 hours on 03/18/22. He was informed the resident had [CONDITION(S)] activity on 03/19/22 and 03/24/22 and resident required hospitalization both times, following the missed doses. He stated he would have expected the on call physician would be notified when the medication was not available. The Medical Director stated he did not believe it was significant harm that occurred. A follow-up call was received from the Medical Director on 07/28/22 at 12:47 PM. He stated he had reviewed the records for Resident #1 and the neurologist information and the [MEDICATION(S)] was being used for tremors not the seizures. He said he thought the second anticonvulsant Resident #1 was on, was being used for seizures. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A phone interview was conducted with the Administrator on 07/28/22 at 9:09 AM regarding Resident #1 not receiving his [MEDICATION(S)] medication. He stated that medication should be available and given as ordered by the physician and the medication should have been ordered in time to have the doses available. The Administrator was informed of Immediate Jeopardy (IJ) on 07/28/22 at 10:07 AM. The Facility provided the following Credible Allegation of IJ removal 7/29/22. - Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Resident#1 did not receive physician ordered anti-[CONDITION(S)] medications on 3/18/22 due to the medication not being available from the pharmacy. Resident #1 had [CONDITION(S)] activity on 3/19/22 and was found in bed having seizures. The resident was assessed and 911 transported the resident to emergency room . As paramedics were transferring resident from bed to stretcher, he had another [CONDITION(S)]. Resident #1 was admitted to the hospital and readmitted to the facility on [DATE]. He returned to the hospital on 3/24/22 for [CONDITION(S)] activity and did not return to the facility. Nurse Managers will complete an audit on 7/28/22 of the Medication Administration Records of current residents with physician ordered anti-[CONDITION(S)] medications and identify those who did not receive anti-[CONDITION(S)] medications as ordered during the last 7 days. A Medication error report will be completed by the Nurse Managers for any missing documentation and the Physician notified immediately. -Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete, Nurse Managers will re-educate licensed nurses, including agency staff regarding the process for reordering physician ordered medications and obtaining an ordered medication that is unavailable for administration. This process includes contacting the pharmacy to obtain the medication and notification of the physician when unavailable. The Director of Nursing will ensure no staff will work without receiving this education. Any new hires, including agency staff will receive education prior to the start of their shift. Education will be completed by 7/28/22 by the Nurse Managers. The Regional Director of Clinical Services educated the Director of Nursing, Nurse Managers and the Administrator regarding the clinical morning meeting process to include a review of the Medication Administration Report for residents with physician ordered anti-[CONDITION(S)] medications to identify those who did not receive anti-[CONDITION(S)] medications as ordered and validate documentation of notification to the physician related to ordered anti-[CONDITION(S)] medications unavailable for administration. The Nurse Managers will complete an audit of the medication carts daily to validate [CONDITION(S)] medications are available for administration and needs identified will be corrected. This education was completed on 7/28/22. Effective 07/28/2022 the Administrator will be responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: 07/29/2022 Date of IJ removal 07/29/22 The credible allegation of Immediate Jeopardy was validated on 07/29/22 as evidenced by onsite validation through record review, observations and staff interviews. Staff were interviewed to validate in-service education completion and education rosters were reviewed. The Immediate Jeopardy was removed on 07/29/22.

Based on observation, record review, and resident and staff interview, the facility failed to safely execute the use of a shower gurney with side rails that included pins to hold the side rails in place which resulted in Resident #74 falling from the shower gurney when the side rail did not remain in place. Resident #74 was diagnosed with three post-traumatic fractures of the right and left legs that required surgical repair. Accident hazards were reviewed for 1 of 2 residents reviewed (Resident #74). Findings included: Resident #74 was admitted to the facility on [DATE] with the diagnoses of pain and [CONDITION(S)]. Resident #74's quarterly Minimum Data Set, dated dated dated [DATE] documented she had no memory problems. The resident required extensive assistance of 2 staff for transfer and was dependent for bathing. The resident's weight was 248 pounds. Resident #74's care plan dated 9/24/21 documented she was at risk for falls and fall related injuries due to an impaired balance and was dependent on staff for transfers. Interventions included to anticipate and meet the resident's needs and side rails as ordered. The resident required assistance with self-care needs related to disease process and generalized weakness. Interventions included offer shower twice a week and as needed, one staff to assist with bathing, dressing and grooming, and side rails to remain on bed to assist with self-positioning while in bed per resident request. A nurses' note dated 11/10/21 documented Nurse #1 was notified by staff (NA #4) at 7:41 am that Resident #74 had fallen in the shower room and that the resident was on the floor. Upon arrival to the shower room, resident was seen laying on the floor on her back in the shower. At this time, the shower stretcher was noted in the hallway. I was informed by nursing staff that Emergency Medical Service (EMS) had already been called to transport the resident to the emergency room for evaluation and treatment as indicated. When asked what happened, Resident #74 stated that she fell from the shower bed. The resident noted to be yelling out in pain and reported pain 10/10 scale at this time in her bilateral lower legs from the waist down and that the left was greater than the right. The resident was asked if there was any specific area that hurt specifically, and she stated her whole lower half but the left ankle specifically. The resident was asked if she could wiggle her toes, and the resident was able to wiggle her toes on both feet without increased pain. Nurse was unable to further assess the resident ' s range of motion due to level of pain. Nurse #1 requested staff at the nursing station call for EMS and remained with the resident. Nurse #1 went at this time to retrieve the resident ' s as needed pain medication per her request. EMS arrived and further assessed the resident. EMS stated to hold off and that they would administer pain medication once they were in the ambulance to manage her pain. The resident remained on the floor until assessed further by EMS, at which time the resident was mechanically lifted to the stretcher. The resident left the facility by ambulance with EMS at approximately 8 am to be transported to the emergency room . On 1/26/22 at 3:00 pm an interview was conducted with Nurse #1. Nurse #1 stated she was called to the shower room by Nursing Assistant (NA) #4 when Resident #74 fell off the shower gurney. The resident was found on the floor next to the gurney in pain. EMS was called. Nurse #1 interviewed NA #4 (agency) who stated she was showering the resident on the gurney when the resident slid off. The rail had a pin which did not hold the resident on the gurney. Nurse #1 stated that she would place towels on the gurney to prevent slipping and use the rail. Nurse #1 state that NA #4 had given her two different accounts of what happened. The rail broke and the rail was not used. Nurse #1 stated she interviewed the resident who informed the nurse that NA #4 was rushing, and the gurney was not up against the wall for stability with NA #4 on the other side to prevent falling. Nurse #1 stated that the information NA #4 gave her sounded like the side rails were not used. The resident informed Nurse #1 this was how it was normally done (shower on a gurney). Nurse #1 stated that this was the second day for NA #4, and she was terminated. Nurse #1 stated that there was nursing in-service for use of the new gurney function, showering, transfer, and safety immediately after the incident on 11/13/21. According to the hospital discharge summary she moved to another facility after treatment at the hospital. On 2/7/22 at 1:34 pm a telephone interview was conducted with Resident #74. Resident #74 stated that NA #4 gave her a shower on the gurney. She preferred the gurney because of back pain. She stated that both side rails were up on the gurney. Resident #74 stated she used the side rail on the NA ' s side and it was secure, but when she grabbed the side rail on the other side, it gave way as if it was not secured. She stated she did not think it had broken. Resident #74 stated she had never had a problem receiving her shower before. This incident was isolated to this one, new NA #4. The side rails were always secure with other staff and there was never a problem. Resident #74 stated that NA #4 was rushing. Resident #74 stated that the fracture to her left leg had plate and screws to hold the bone together which caused her pain and was presently unable to bear weight on her left leg. On 1/26/22 at 11:15 am an interview was attempted with NA #4 and her phone number was no longer in service. Resident #74's hospital discharge summary dated 11/25/21 documented the resident was brought to the hospital from the nursing home after a fall. The Emergency Department Physician documented on 11/10/21 the resident informed him they dropped me from the shower bed. The resident sustained three post traumatic fractures of the left and right legs. The resident informed the physician that the handle she was holding gave way and did not believe it was a mechanical failure. The plan was for orthopedic surgery. Preoperative diagnoses were right one third femur shaft fracture, left peri-prosthetic femur fracture, left distal metaphyseal tibia fracture, and [CONDITION(S)]. The procedure performed was closed management of left peri-prosthetic of distal fracture, closed management of left distal one third tibial fracture, and operative fixation of periprosthetic femur fracture with nail plate construct. Pain level was 8 out of 10. The resident was discharged to another nursing home with no weight bearing on both legs to receive physical and occupational therapy. On 01/26/22 at 11:36 am an interview was conducted with the Maintenance Director. The Maintenance Directed stated he remembered Resident #74 and when she fell . The shower gurney side rail was down and the pins that held the rail up could not be found and were not used. Without the pins, the rail would not remain up to support a resident. The gurney siderails were not safe to use without the pins. The staff were aware that the side rails required pins. The pins were observed on weekly rounds before the resident's fall. The Maintenance Director stated that there were two types of shower gurneys. One type that required a pin to hold the rail and another type where the rail was secured within the gurney. The Maintenance Director stated he observed the gurney that required the pin, and it was used with the side rail down and the resident fell out of the gurney onto the shower room floor. The pins to hold the side rail were not in place and this was the first time he had observed missing pins. The shower gurney that required pins to hold the side rail up was replaced with gurneys that do not require pins but had side rails enforcement that were part of the gurney. The quality assurance evaluation that the gurney was not properly used was documented, and audits were completed ongoing of the shower equipment each week by Maintenance. Concurrent observation of documented shower equipment checks for working order logs were provided. On 1/27/22 at 2:30 pm an interview was conducted with the Director of Nursing (DON). She described actions the facility took to correct the problem. She stated that the accidental fall on 11/10/21 with Resident #74 was caused by the improper use of the gurney. The improper use was failure to use pins to secure the side rail. NA #4 was agency staff, new on her second day of employment, and was no longer allowed to work for the organization. All agency nursing staff were required to read and sign an attestation for proper facility equipment usage and if there was a lack of understanding the nurse was required to obtain assistance. A root cause analysis was completed (improper use of gurney) and presented to the quality assurance team. The gurney was discarded, and a new type of gurney was purchased that do not require pins to hold the side rail. The side rail secured as part of the gurney frame. There were no additional pieces. All nursing staff were in-serviced on the proper usage of the new shower gurney with return demonstration, fall prevention and shower safety, and transfer. Documented attendance roster sheets were provided. The facility provided the following corrective action plan with a completion date of 11/19/21. ·Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice; The accidental fall on 11/10/21 with Resident #74 was caused by the improper use of the shower gurney. There was failure to use required metal pins to secure the side rail. Resident #74 was sent to the emergency room and subsequently did not return to the facility. A root cause analysis was completed by the Director of Nursing on 11/10/21, and cause was identified as improper use of the gurney side rail. High-risk fall investigation was completed. The outcome investigation was submitted to quality assurance on 11/11/21. Quality assurance directed the Maintenance Director to audit the proper working function of the shower gurneys 11/11/21. The Maintenance Director found that the pins were missing for the gurney used for Resident #74 and the other type of gurneys were working as manufacturer expected. ·Address how the facility will identify other residents having the potential to be affected by the same deficient practice; The gurney that required a pin to secure the side rail was discarded on 11/11/21. There were [MEDICATION(S)] chloride (PVC) gurneys in the facility on 11/11/21. This type of gurney that did not require a pin to secure the side rail. It was used for education and return demonstration and additional PVC type gurneys were purchased/ordered immediately (11/11/21) and obtained within a week. All nursing staff, including agency staff, were in-serviced on 11/10/21 through 11/17/21 for the proper usage of the PVC type shower gurney with return demonstration, fall prevention and shower safety, and transfer by the Director of Nursing. The deficient practice was isolated to one gurney that required a pin and an agency nursing assistant that was not familiar with the one gurney that required a pin to secure the side rail. That nursing assistant no longer worked at the facility. Observation of nursing staff use of the shower gurney to provide resident showers began on 11/15/21 was documented three times a week. No concerns of correct usage were identified. ·Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; All nursing staff, including agency, were required to provide return demonstration to the Director of Nursing of the PVC type shower gurney use and participate in in-service for showering residents, transfer, falls, and safety from 11/10/21 through 11/17/21. Audits were documented of shower gurney use with the resident by the Director of Nursing (DON) which began on 11/15/21 for three times a week. All agency staff are required to read and sign an attestation that they have experience with the facility equipment or ask for assistance. Weekly audits of shower equipment function/operation were documented and are ongoing to the present by the Maintenance Director which started 11/11/21. Audits are presented to quality assurance by the Maintenance Director to assure shower gurneys were in proper working order. The results of the monitoring/audits were presented by the DON in an ad hoc meeting to the Quality Assurance members on 11/11/21 to address the Resident #74's fall and again at each of the regularly scheduled meetings each month to evaluate the plan was sustained. The QAPI team reviewed the audits, and no changes were made to the plan. There were no further fall incidents with use of the shower gurney. The results of this monitor were ongoing and presented to the QAPI team by the DON. ·Include dates when corrective action will be completed. All actions were competed by 11/17/21 including education and return demonstration was completed. Additional gurneys were obtained by 11/19/21. Observation of nursing staff use of the shower gurney with the resident present began on 11/15/21 three times a week and was ongoing. Validation of the correction action plan was on 1/27/22. On 1/26/22 at 11:55 am an observation was done of the shower gurneys. The shower gurney that required pins to hold the side rails was not present in the facility. The current gurneys had side rails that were secured within the gurney. Pins or other unconnected pieces were not required to secure the side rails. Side rails were tested and were operating as intended. On 1/27/22 at 3:00 pm an interview was conducted with Nurse #1. She stated that all nursing staff, including agency were required to participate in in-service for shower gurney use, safety, falls, and return demonstration. We also participated in shower and transfer safety in-service and were required to sign a roster. On 1/27/22 at 3:30 pm random interviews of 3 NAs revealed that they were aware of the resident fall from the shower gurney, that the gurney with required pins was discarded, additional PVC gurneys were obtained, and participated in in-service. The facility corrected accident/hazards by 11/19/21 after completion of in-service, return demonstration of shower gurney use, and receipt of new PVC gurney. Based on the validation of the corrective action plan F 689 was corrected 11/20/21.

Based on record reviews and staff and family interviews, the facility failed to perform the dressing change the day of discharge, provide discharge instructions for the care of a newly acquired right heel pressure ulcer; in addition, the facility failed to provide the information needed for the family to set up the wound clinic appointment at discharge for 1 of 1 resident reviewed for discharge (Resident #328). Resident #328 was admitted to the hospital the day after discharge with a blood infection, severe heel pain and a wound infection. Findings included: Resident #328 was admitted to the facility on [DATE] from the hospital. Resident #328's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse progress note dated 07/25/21 at 2:32 PM stated Resident #328 complained of pain in her right foot. The nurse removed her sock, and the resident was noted to have a new 2.5 centimeter(cm) x 3.0 cm open blister to her right heel. The area was cleansed, a petroleum based non-stick gauze was placed and a dressing was applied. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the NP discharge note dated 07/27/21 noted the patient was to go home with health home. The NP indicated Resident #328 had the pressure ulcer (PU) on her right heel and the heel and foot were wrapped. The NP recommended the resident was to follow up with outpatient wound care and to follow up with her Primary Care Provider. Resident #328 was discharged on [DATE] before the wound consult was done. Review of the nurse progress note from 07/28/21 indicated the pressure ulcer dressing was not done prior to discharge home. The nurse progress noted dated 07/28/21 at 4:02 PM indicated the heel PU dressing was not done by Nurse #9 due to Resident #328 being discharged home. The instructions provided to Resident #328 and a family member at discharge did not include any information for pressure ulcer care. The Home Health Certification form dated 7/27/21 completed by the NP noted recommend outpatient wound care and follow up with Primary Care Provider. No wound care physician was listed, no contact information or appointment. A phone interview was conducted with Nurse #9 on 01/31/22 at 9:02 AM who had cared for Resident #328 on 7/28/21. She had vague recollection of a resident with casts on her arms but was unable to answer other questions. Record review indicated a Social Services note from 07/28/21 at 2:10 PM that Resident #328 was discharged home with a family member. A phone interview was conducted on 02/14/22 at 12:32 PM with Resident #328's family member. She stated the nurse did not do her mother's heel dressing before her discharge on 07/28/21. She also noted the facility never instructed her on how to take care of the wound. The family member stated the resident had been vomiting for two days and was vomiting the day of discharge. She stated the physician was not notified of vomiting the day of discharge. The family member said, if they would have just told me what to do with her foot and sent supplies, she could have done it. The family member stated she was told to follow up with wound care, but she had no clue what to do to get a wound care physician's appointment. She stated she had called one place and was told they required more information. She said setting up the wound care referral was left completely up to her-no names or contact numbers were given. The family member stated she ended up taking her back to the hospital the next day with terrible pain from the pressure ulcer and she was still vomiting, as she had been for 3 days. The family member noted the wound was terribly infected and she had a blood infection from the pressure ulcer. She said the discharge nurse had not notified the physician of the vomiting that day. She said the hospital set up the wound care referral, placed a wound vacuum assisted closure device on the heel and coordinated home health when she was discharged home on 08/16/21 after her readmission. Review of hospital records following discharge from the Skilled Nursing Facility dated 07/29/21-08/16/21 indicated Resident #328 was diagnosed with a right foot infection and bacteremia (infection of the blood) related to the pressure ulcer. Her creatinine level (kidney function) was elevated at 1.20 (normal 0.51-0.95) and she was given 1 liter of intravenous fluids. The pressure ulcer on hospital admission was described as very red and inflamed with overlying black eschar (dead tissue). The heel wound measured 3.0 centimeters (cm) x 3.0 cm. The resident underwent [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record reviews and staff and nurse practitioner interviews, the facility failed to assess and implement interventions for pressure ulcer prevention and notify the provider of heel redness which resulted in a newly identified pressure ulcer to the right heel for 1 of 2 residents reviewed for pressure ulcers. In addition, the facility failed to assess the wound and complete daily pressure ulcer dressing changes for 2 of 4 consecutive dates (Resident #328). Subsequently, the resident was readmitted to the hospital the day after discharge with a wound infection. Findings included: Resident #328 was admitted to the facility on [DATE] from the hospital. Resident #328's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the hospital physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . She had a normal ejection fraction (heart pumping ability) of 60-65%. Her total protein level was 6.8 on 07/09/21 with a normal range of 6.3-8.3 grams/deciliter. The admission assessment completed on 07/21/21 at 14:27 PM noted Resident #328 was total dependence for bed mobility, transfer, dressing and personal hygiene. The skin assessment revealed she had bruising to knees, shins and mild swelling of her right ankles and casts on both forearms. Her pain was listed as mild with a rating of 4 on a 0-10 scale. The resident's pain was in her hands, left ankle, left leg and left rib cage area. The skin was normal color and turgor, and the temperature was warm. The admission assessment indicated Resident #328's skin was intact without redness on both heels. A phone interview was done on 01/31/22 at 04:10 PM with Nurse #7 that completed the skin assessment on 07/21/21 on Resident #328. She recalled the resident and stated she could not turn well due to discomfort. She said skin assessments were done on admission and on shower days. She noted on shower days, the Nurse Assistant (NA) signed the skin assessment and then the nurse reviewed it and signed it. She noted the mattress on the bed was supposed to prevent skin breakdown. She was asked if preventive measures should have been used to prevent skin breakdown and placed on the care plan. Nurse #7 stated that was a nursing and therapy judgement and could also be communicated nurse to nurse in report. She added that using a pillow and floating heels off the bed could be checked off in the medical record as an intervention, and then it would display on the Treatment Administration Record (TAR), and the nurse would have to check it off on the TAR. The Baseline Care plan completed on 07/21/21 indicated Resident #328 required the physical assistance of 1 person with toileting and bed mobility, and that transfers and walking did not occur. The care plan for Resident #328 initiated on 07/22/21 listed the care areas as: 1) Activities of Daily Living (ADL) self-care decline with the interventions of bed mobility-the resident is able to (SPECIFY- area not specified) and skin inspection-the resident requires skin inspection (SPECIFY frequency- area not specified) and to observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse. 2) An additional care area noted the resident had (SPECIFY-area not specified) pressure ulcer (SPECIFY LOCATION- area not specified) or potential for pressure ulcer (PU) development r/t immobility which was initiated on 07/22/21. Interventions were to follow facilities policies/protocol for the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] A nurse progress note dated 07/22/21 indicated Resident #328 was non-weight bearing for upper extremities bilaterally. Review of the Facility Skin Assessment policy revised 10/28/20 revealed a full body skin assessment was to be completed on admission, daily for three days, then weekly thereafter. The facility policy revised 10/28/20 for Pressure Injury Prevention and Management indicated repositioning would be done of all residents at risk every 2 hours and staff were to ensure heels were floated off the bed. The Nurse Practitioner (NP) Day 1 progress note dated 7/22/21 revealed Resident #328 was dependent on a wheelchair for mobility. The resident also had some bruising on her right leg, pedal pulses were present on both feet, and she had no peripheral [CONDITION(S)]. The July TAR were reviewed for Resident #328. It indicated a skin assessment should be done weekly on Thursday and was signed on 7/22/22 by Nurse #5. A phone interview was done on 01/31/22 at 10:41 AM with Nurse #10 who cared for Resident #328 on 07/23/21. She noted the resident was up in the chair and did not recall any heel pain. She stated she assisted her with toileting, and she did not recall elevating her heels or doing anything special for the heels. She noted the resident was unable to pivot her lower extremities or bear much weight. She stated skin assessments were done on admission and she was not aware of the ongoing skin assessments requirements. A phone interview was done with Nurse #11 who cared for Resident #328 on 7/21/21, 7/23/21 and 7/24/21. She stated skin assessments were done on admission and weekly. She was asked about pressure ulcer prevention and said it depended on the resident's needs, their mobility and any areas of concerns. She noted the nurse puts the treatments in place and then the treatment nurse did the weekly assessment. A nurse progress note dated 07/25/21 at 2:32 PM stated Resident #328 complained of pain in her right foot. The nurse removed her sock, and the resident was noted to have a 2.5 centimeter(cm) x 3.0 cm open blister to her right heel. The area was cleansed, a petroleum based non-stick gauze was placed and a dressing was applied. A skin issue report was reviewed from 07/25/21 at 11:35 AM for Resident #328 that was completed by the Unit Manager/Interim DON at the time. It indicated the resident complained of pain in her right foot, the gripper sock was removed and revealed a 5 cm x 3.0 cm open blister to the right heel. The resident stated she had sharp pain that started at her heel and went up the sole of the foot. It stated the medical director was notified on 07/25/21 at 1:45 PM. An interview was conducted on 01/27/22 at 4:03 PM with the Unit Manager/Interim Director of Nursing (DON) in the role in July 2021. She had discovered the pressure ulcer on 07/25/21 and stated she did not recall the resident. She reviewed Resident #328's information and said she recalled the family taking her home earlier than anticipated but nothing else. The unit manager stated with a new pressure ulcer they completed a wound pressure ulcer assessment in the electronic medical record (EMR), but she was unable to locate one. She had no recall of the PU when she reviewed the EMR during the interview. NA #6 that cared for Resident #328 on 07/22/21-7/25/21 and 07/27/21was interviewed via phone on 01/28/22 at 1:04 PM. She recalled the resident well and stated, she was totally dependent, and the NA would do most of her bath. She said she would get a second person to transfer her, and the resident would stand up and pivot with 2 people assisting her. She noted the resident would sit up a lot for comfort and not stay in the bed much during the day. She recalled the resident complaining of her right heel hurting and a blister. She could not recall if it was an open blister or not. She said the resident did not complain initially but after a few days there, she complained of her heel. The NA stated she complained about her heel when it was only a little red spot and not open. The NA recalled one time when she complained of her heel, and said the resident was bawling and the NA took her sock off and rubbed cream on it. The NA said she would elevate her heel when she was in her wheelchair by placing it up on a pillow and pulling the foot pedal up to elevate it. She recalled the resident having her own different colored gripper socks and thought her socks were usually changed daily. A revision to Resident #328's care plan was done on 07/26/21 noted area to right heel, continue treatment until healed. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #328's July 2021 TAR noted a treatment with the start date of 07/26/21 to cleanse right heel with wound cleanser, pat dry, apply xeroform gauze and cover with a protective dressing daily every day shift. It was documented as 9 on 07/26/21(MAS), completed on 07/27/21 and 9 on 07/28/21 by Nurse #9. Per the TAR legend 9 indicated Other/See Nurse Notes. The nurse progress noted dated 07/26/21 at 2:58 PM revealed the heel pressure ulcer (PU) dressing was not done by Nurse #8 due to family request as Resident #328 was resting following pain medication and her lack of sleeping. Nurse #8 had medicated the resident with a pain pill at 1:47 PM. The 5 day Minimum Data Set (MDS) assessment completed on 07/28/21 indicated Resident #328 was cognitively intact. The MDS indicated the resident was at risk for pressure ulcer/injury. No pressure ulcers, wounds or skin problems were identified. Per the MDS Skin and Ulcer/Injury Treatment section there was no treatments applied for pressure reducing device for bed, turning/repositioning program or nutrition. A follow up phone interview was done on 01/31/22 at 2:55 PM with the Unit Manager/Interim DON in the role in July 2021. She was asked about skin assessments and stated they were done on admission, the first 3 days and then weekly. She was asked if this was on the MAR/TAR as a task and stated the facility staff nurses knew to do it by routine. When asked how this was communicated to the agency nurses, she stated she did not know that it was, and it was not on the MAR/TAR. The Manager/Interim DON said nothing was set in place for prevention automatically with residents that don't have a concern on admission. She said the resident was able to use her feet, so nothing was put in place for prevention. MDS Nurse #1 was interviewed on 01/28/22 at 11:57 AM about Resident #328's care plan. She reviewed the medical record for the 7/21/21 admission assessment and saw bruising was noted and she had no pressure ulcer. She was asked about the care plan initiated on 7/22/21, with a care area for pressure ulcer and potential for pressure ulcer and stated when everyone was admitted , they initiated a potential risk for pressure ulcer. MDS nurse #1 noted on 7/26 that MDS Nurse #2 had added to continue dressings until healed and put interventions for the pressure ulcer in. An interview was done via phone with Nurse #4 that cared for Resident #328 on 07/21/21, 07/24/21 and 07/25/21. She was asked about skin assessments and pressure ulcer prevention. She stated head to toe skin assessments were done on admission and then weekly. She said a resident's heels should be propped up no matter what, and interventions should be placed in the treatment orders to float the heels, skin prep to heels if they were red or boggy and both displayed on the TAR. She was informed these were not on the TAR and she said she did not recall the resident. An interview was done with Nurse #12 via phone on 01/31/22 at 11:22 AM. She stated skin assessments were done on new admissions and then she believed the treatment nurse followed up the next day and she was not sure after that. Nurse #12 noted pressure ulcer prevention depended on the resident regarding they needed a special mattress or heels floated but it was not a routine. Record Review indicated a NP note from 07/26/21 for the 3 day post admission follow up. It noted her history of fracture of multiple ribs (left side 2-10), MVA, ankle joint pain and bilateral hand fractures. The NP documented Resident #328 had normal skin temperature, no peripheral [CONDITION(S)], had decreased mobility and her functional status was listed as confined to bed. It was noted the resident had a pressure ulcer on her right heel, the right heel and foot were wrapped and an order was place for the wound physician. The NP noted the resident stated the pressure ulcer was very painful. Record review of a Dietician's note from 07/27/21 at 12:29 PM indicated Resident #328 was recommended to add fortified foods and stated there was no current lab work on file. A phone interview was done on 01/31/22 at 3:26 PM with the wound nurse that was in the role since December 2021. She stated the admission nurse completed the initial skin assessment and then it was done weekly. She was not aware about the daily for 3 days skin assessment after admission or if there should be implementation of interventions for pressure ulcer prevention on admission. She stated she had not been trained as a wound nurse. She said if there were deep tissue injuries on the heels, they should put interventions in place. However, if there were no issues on the admission assessment then no interventions would be done unless the resident had a problem. She said if the resident was able to push themselves up in the bed, they were usually able to get out of bed also and no prevention was done. Record review of the NP discharge note dated 07/27/21 noted the patient was to go home with health home. The NP indicated Resident #328 had the pressure ulcer on her right heel and the heel and foot were wrapped. It was documented the patient stated it was very painful. The discharge summary indicated she was confined to bed, had decreased mobility, no peripheral [CONDITION(S)] and the NP recommended the resident was to follow up with outpatient wound care and to follow up with her Primary Care Provider. Review of the nurse progress note from 07/28/21 at 4:02 PM indicated the heel PU dressing was not done by Nurse #9 due to Resident #328 being discharged home. A phone interview was conducted with Nurse #9 on 01/31/22 at 9:02 AM. She cared for Resident #328 on 7/24/21, 7/25/21, 7/27/21 and 7/28/21. She stated skin assessments were done on admission, the first 3 days and then weekly. She said she did not know who was documenting the first three days after admission, but it was not on the TAR. She had vague recollection of a resident with casts on her arms but was unable to answer other questions. Record review indicated a Social Services note from 07/28/21 at 2:10 PM that Resident #328 was discharged home with daughter. The resident was to have home health nursing at home. Resident #328 was discharged on [DATE] before the wound consult was done. Resident #328 was readmitted to the hospital the following day on 07/29/21 with severe right heel pain. Her white blood cell count was 16.4. Blood cultures completed on 07/29/21 were positive for bacteria and revealed Proteus Mirabilis. Review of hospital records from 07/29/21-08/16/21 indicated Resident #328 had bacteremia (infection of the blood) related to the pressure ulcer. The pressure ulcer on hospital admission was described as very red and swollen and measured 3.0 centimeter (cm) x 3.0 cm with overlying black eschar (dead tissue). The resident underwent [MEDICAL RECORD OR PHYSICIAN ORDER] . A phone interview with Nurse Practitioner (NP) #1 on 02/01/22 at 12:09 PM regarding Resident #328's pressure ulcer was done. She stated the pressure ulcer was avoidable, and she didn't recall how the staff were helping her with the bed mobility, but she should not get a pressure ulcer. She said she would have expected more skin assessments between her admission and the day of the pressure ulcer discovery. In addition, that if they noticed redness, they should have floated her heels for prevention. A phone interview was conducted with the Director of Nursing (DON) on 02/01/22 at 2:10 PM regarding pressure ulcers. She noted that following the previous concerns with pressure ulcers, they had done extensive education in September 2021 and ongoing audits and monitoring for the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . She was asked about the skin protocol for skin observation daily for 3 days of any new areas and said this was documented with ADL care and any changes are noted in the record. The DON was asked how skin assessments and preventative treatments were communicated to staff, and stated it was on task record for nurses and NA's and staff were trained to report any skin changes during their care. The DON was asked how this information was communicated to agency personnel and stated in the electronic medical record they see the interventions as PRN (as needed) tasks for both the nurses and nurse assistants (NA). She was asked about prevention for pressure ulcers and stated they evaluate the pressure ulcer risk with a skin assessment scale on admission, and weekly for 4 weeks. She noted if the resident was at a medium or high risk, then they were discussed at the Interdisciplinary Team (IDT) daily clinical meeting which met Monday through Friday and discussed at the weekly risk IDT meeting. She stated if interventions were identified they were listed on the care plan. She noted normally the MDS nurse did the care plan updates but she had updated care plans as well and usually they were updated during the IDT meetings. The facility provided the following corrective action plan with a completion date of 09/30/21. Inservices were done for pressure ulcer prevention, skin assessment, treatment and services to heal pressure ulcers and staff and agency attendance roster sheets were provided. The education was completed on 09/29/21. 09/17/21, licensed nurses completed skin assessments for 62 recurrent in-house residents. Residents identified with skin concerns were reviewed for associated treatment orders and documentation of treatments on the TAR. The physician was notified by the licensed nurse of newly identified skin concerns and treatment orders obtained and care plan updated to reflect associated care and interventions to prevent and/or heal pressure wounds. -Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: 09/17/21-09/27/21, the DON, MDS Coordinator and or Nurse supervisor provided education to licensed nurses including agency nurses on facility guidelines for pressure ulcer prevention and management. Education includes completing resident skin assessments, notification of changes in skin condition, obtaining treatment orders, updating and revising care plans and documenting completion of treatments as ordered to prevent and heal pressure wounds. 09/17/21-09/27/21 The DON, MDS Coordinator and Nurse Supervisor provided education to nurse aides including agency aids on facility guidelines for completing skin observations and reporting resident skin changes to supervising licensed nurse. Education includes use of Body Scan Tools and Point Click Care (PCC) Clinical Alerts to communicate skin concerns observed during ADL care. Newly hired licensed nurses and nurse aides will receive education during orientation. Going forward new agency staff will be educated prior to working their next scheduled shift. The licensed nurse will complete resident skin reviews upon admission, weekly and with changes in skin condition to identify skin concerns. The nurse aide will complete skin observations during bathing and routine ADL care to identify skin concerns and communicate such findings to the licensed nurse. The licensed nurse will notify the physician and/or nurse practitioner of new skin concerns and implement treatments as ordered. Treatments will be completed and documented on the TAR by the licensed nurse as ordered. Care plans to prevent and/or heal pressure wounds will be initiated upon new findings and reviewed and revised by the IDT with changes in skin condition and associated treatments. Pressure and non-pressure will be assessed by the licensed nurse upon finding, weekly and with changes in condition and documented in PCC on the Pressure/Non-Pressure Ulcer UDA tool. The Director of Nursing and Wound Nurse will monitor the TAR daily for completion of treatments as ordered and will monitor residents with skin concerns for compliance with pressure ulcer management and prevention during daily clinical meetings for new skin concerns and weekly during risk meetings. The DON, MDS Coordinator and or Nurse Supervisor will complete an audit of resident assessments, notification to practitioner, associated treatment orders, TAR and care plan. Monitoring will be completed for 5 random residents at a frequency of 5 times weekly for 4 weeks, then weekly for 8 weeks and as necessary thereafter. The Administrator will report findings of the monitoring to the Interdisciplinary Team (IDT) during Quality Assessment Process Improvement (QAPI) meetings monthly for 3 months and will make changes to the plan as necessary to maintain compliance with treatment to prevent and heal pressure wounds. -Include dates when corrective action will be completed. Education would be completed by 09/29/21 of current staff and agency staff. Ongoing education was done for new staff and new agency staff. Review was completed of audits for prevention and treatment to heal pressure ulcers which were completed 09/27/21-12/29/21. Review was done of the QAPI meeting minutes when pressure ulcer audits for prevention and treatment to heal pressure ulcer were reviewed. -All actions were completed by: Validation of the correction action plan was on 10/27/21 during an onsite follow-up to a pressure sore citation. Based on the validation of the corrective action plan F 686 was corrected on 09/30/21.

Based on observations, record reviews and staff, nurse practitioner and physician interviews, the facility failed to assess and implement interventions to Resident #1's newly identified reddened sacral area that worsened to an unstageable wound within seven days (Resident #1) and provide evidence that wound care was completed as ordered for 2 of 2 sampled residents reviewed for pressure ulcers (Residents #1, Resident #2). This resulted in Resident #1 developing an unstageable pressure ulcer that was not treated as ordered. Findings included: 1. Resident #1 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She also had Sjogrens syndrome-an [CONDITION(S)] disease with lung involvement. The care plan for Resident #1, which was initiated on 06/24/21, contained a focus area for the potential for impaired skin integrity related to generalized weakness and decreased mobility. Interventions included to administer medications and treatments as ordered and follow prevention/treatment protocols for skin breakdown. Bloodwork completed on 06/21/21 indicated Resident #1's [MEDICATION(S)] (protein) level was 2.5. Normal levels are 3.7-4.8. The total protein level was 4.9 with a normal range of 6.3-8.3. The Admission Minimum Data Set (MDS) completed on 07/01/21 indicated Resident #1 was moderately cognitively impaired. She required extensive assistance with bed mobility, dressing, toileting and transfers. No pressure ulcers were noted, and she was assessed to be at risk for pressure ulcers and no turning program was documented. A House Supplement was ordered 07/06/21 three times a day 240 milliliters between meals to assist with Resident #1's low protein level and poor nutritional intake. Resident #1's estimated protein daily requirements per the Dietician note was 62 grams. The weekly skin check from 07/14/21 documented the skin was intact, with no redness or breakdown. Record review of the weekly skin check from 07/22/21 completed by Nurse # 1 indicated redness was noted to her bottom. Nurse #1 documented the weekly skin check on 07/22/21 and was interviewed via phone on 08/27/21 at 4:38 PM. She stated she noticed redness and had applied barrier cream and always told her supervisor of skin changes. She said she had told her evening shift supervisor and the Infection Preventionist (IP)/Wound education supervisor on 7/22/21 whom told her what treatment to do. She noted they applied the barrier cream every day and would communicate that to the Nurse Aides (NAs) as well. She said the NAs knew to do the barrier cream as part of the skin protocol. The evening Supervisor #3 was interviewed via phone on 8/28/21 at 12:05 AM regarding Resident #1's pressure ulcer. She said on 7/22/21 the redness was seen on the weekly skin check and she didn't recall anyone telling her about the redness. This nurse stated she knew about the redness, but she did not recall if she had found out about it on 07/22/21. She stated all the staff knew to do the barrier cream and that was readily available in stock and in every resident's room. Resident #1 was preparing to go home, then developed the red area that was treated with barrier cream, and it progressed quickly to thick eschar on 07/29/21 and then the wound opened up. She noted some of the redness had cleared up around the perineal area but not the sacrum. She said the redness was blanchable initially and the breakdown seemed to occur very sudden. She noted Resident #1 was a very picky eater, liked fast food and would usually drink her supplements. She said the supplement ordered in July had been increased on 08/10/21. They had encouraged her to turn and to eat. An interview was done 08/28/21 at 11:33 AM with the IP/Wound Educator Supervisor regarding Resident #1's wound 07/22/21 assessment. She stated she did not recall being told about the redness from Nurse #1 and she was usually not there on evening shift. The Nurse Practitioner (NP) note dated 07/29/21 revealed Resident #1's planned discharge was cancelled due to lower back and buttock pain and an inability to move in bed. The NP turned the resident to her side and noted a large unstageable pressure wound covering her lower back and buttock area. Orders were written for a wound care consult and to keep the resident off her back. Daily dressing orders were given until the resident was assessed by the wound physician. The wound was to be cleaned with wound care cleanser using 4x4 gauze, patted dry, apply [MEDICATION(S)] paste and cover with foam dressing. The weekly skin check completed on the evening shift on 07/29/21 completed by Nurse #1 documented an area was noted to Resident #1's bottom and treatment was in place. Nurse #1 documented the weekly skin check on the evening shift 07/29/21 and was interviewed via phone on 08/27/21 at 4:38 PM. She had also completed the 07/22/21 assessment. She stated with the 07/29/21 skin assessment, the decline had progressed so fast, and the skin was hard and black. She said she did not tell anyone as she thought they already were aware, as she was told they were waiting on the wound doctor. On the 07/29/21 assessment she did not document the size and treatment as she believed wound care had been ordered already and they were waiting on the Wound Doctor to debride it. The Care plan was updated on 07/30/21 under the focus area for Risk for Pressure Ulcer with the notes of a wound to the sacrum, and to continue treatment until healed. The Wound Physician note from 07/30/21 documented the wound was unstageable with 100% thick adherent black necrotic tissue and had a duration of greater than 3 days. The wound was 9 centimeters (cm) long x 10.4cm wide and the depth could not be measured. Orders for a pressure reduction air mattress, daily dressing changes, to off-load wound and reposition per facility protocol were given. The estimated time to heal was 168 days. The NP note from 07/30/21 indicated Resident #1's white blood count was 17.7 (normal 3.6-11.7) and the resident had a newly diagnosed large sacral ulcer, and she had been less interactive. The weekly skin check assessment from 08/06/21 noted an unstageable facility acquired pressure ulcer and it was worsening. This was documented by Supervisor #1 that conducted weekly wound rounds with the physician. The assessment noted necrotic tissue was at 60% with 40% granulation tissue present and the wound drainage was purulent. The wound measured 14.4 cm in length, 10.5 cm wide and 3 cm deep. It indicated the wound was debrided by the Wound Physician on 08/06/21 and antibacterial dressings were ordered daily. An air mattress was in place at that time. Review of the Treatment Administration Record (TAR) from 08/01/21-08/23/21 indicated the daily dressing with an antibacterial solution was not documented as being completed on the weekend of 08/07/21 or 08/08/21. Nurse #3, the assigned nurse for Resident #1 on day shift 08/07/21 was interviewed on 08/19/21 at 3:46 PM regarding Resident #1's wound dressing. She was asked if the wound care was completed and said she probably completed the dressing and had not signed it off. When asked what type of dressing she did, the description was not the ordered treatment and she could not recall the wound appearance. She then added she did not usually work that unit and she was busy administering medications, and someone came in to do treatments that day, but the dressing never got done. When asked about Resident #1's wound she said it was improving. The nurse said it had been an issue with staffing to get treatments done since COVID hit and there had been consistent problems, and weekends were worse. The assignment sheet was reviewed, and this nurse was assigned to Resident #1 several shifts. A phone interview was conducted on 08/24/21 at 12:14 PM with Agency Nurse #2 that was assigned to Resident #1 on 08/08/21 on dayshift. She did not recall completing the wound care on Resident #1. She said there was no treatment nurse, and she was assigned treatments and medications for her residents. Review of the Wound Physician note on 08/13/21 indicated the sacral wound was measured at 12 cm long x 12.5 cm wide x 3.3 cm deep. Wound progress was documented as improved. The evening Supervisor #3 was interviewed via phone on 8/28/21 at 12:05 AM regarding Resident #1's pressure ulcer. She said the supplement ordered in July had been increased on 08/10/21. They had encouraged her to turn and to eat. The Supervisor indicated the Wound Physician saw her and debrided the wound 08/06/21 and by 08/13/21 it had decreased in size. A nursing note from 08/17/21 at 04:03 PM indicated Resident #1 screamed in pain when range of motion was completed following a fall, due to the stage 4 sacral ulcer. Resident #1 was observed on 08/18/21 at 09:30 AM. She was positioned on her left side, resting in bed with eyes closed and was on continuous oxygen via nasal cannula. An observation was done of Resident #1 on 08/18/21 at 12:12 PM. She remained positioned on her left side as she had been that morning. An interview with Resident #1 was attempted on 08/18/21 at 12:12 PM. She opened her eyes to voice and answered some questions but was not understandable. She was grimacing and had no response when asked if she had pain. An observation was done of Resident #1 on 08/18/21 at 3:09 PM, and she was still positioned on her left side. An interview was done on 08/18/21 at 09:10 AM with the Nursing Supervisor/Wound Care Nurse. She stated a nurse was assigned today to do treatments. An interview was done with Agency Nurse #1 on 08/18/21 at 09:30 AM regarding Resident #1's dressing. She said she was not able to do treatments on 8/18/21 as planned because of staffing and she was 3 hours late starting on the medication cart. The nurse stated she was assigned to do treatments and when a nurse did not show she was assigned to give medications and she had just been told of the change. An interview was done with Agency Nurse #1 on 08/18/21 at 12:30 regarding Resident #1's dressing. The nurse said she would see if another nurse would do Resident #1's dressing as she had many more medications to do. An observation was done of Resident #1's wound care on 08/18/21 at 03:10 PM. The resident was turned more on her side and hollered out in pain frequently during the dressing change. The resident had been medicated about 1:30 PM Agency Nurse #1 stated. The wound was cleaned, and an antibacterial solution soaked gauze dressing was applied. The wound was pink and very large across both buttocks and the sacral area. An air mattress was on the bed. An interview was done on 08/18/21 at 3:33 PM with Agency Nurse #1. She was asked if Resident #1 had been turned today and stated, I am not 100% sure. An interview was completed on 08/19/21 at 11:03 AM with Nurse Aide (NA) #1 who worked with Resident #1 on 08/18/21. She noted she had worked with Resident #1 since admission, and she used to be more alert and walked with help. She said she would get someone to help turn her due to the resident's pain. The NA said she cared for Resident #1 on 08/18/21 and had turned her to the right about 07:30 AM and to the left toward door at 11:00 AM. She said she was not positioned on her back and would be turned every 2 hours. A follow-up phone interview was done on 08/28/21 at 3:19 PM with NA #1 about Resident #1. She said initially after her 2 weeks of quarantine and moving the B hall, her appetite was good. The NA stated then she got sick with her knee swelling, and in less than a week she had the pressure ulcer. She said she had started to complain of knee pain when she was laying in the bed and did not want to move. Her sacral area had one little dark spot and another one was a little bigger, and she reported it to her charge nurse which she believed was an agency nurse. She was told to put barrier cream on it, and at the end of her shift she also told the Director of Nursing. She thought it was three days later a dressing was on it. She had tried to reposition her every 2 hours in the bed, 2-3 times a day. She noted Resident #1 used to get up and sit in her wheelchair for 2-3 hours, but once her knee swelled, she would not get out of bed. A follow-up call with the Director of Nursing was done on 08/28/21 at 3:49 PM. She was asked if NA #1 had reported the black area on Resident #1 when it was first noticed to her. She said she thought she had first found out about the blackened area by the Nurse Practitioner and was not told by an NA. A phone interview was done on 08/27/21 at 4:20 PM with NA #4. She noted Resident #1, who was African American, that her skin was darker on her bottom and she had informed her nurse and the charge nurse, who stated she was going to do a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she never saw changes in her skin other than the darkness and she was in pain, and then the second time it was black, and the skin was changing color around it. The NA noted they always had a barrier cream for the redness, turned her every two hours and put a pillow between her legs. She said Resident #1 would not eat at all and refused her meals. An interview was done at 08/19/21 at 11:30 AM with Agency Nurse #1 about Resident #1. She was not in her room and the nurse stated that they sent her to the hospital mid-morning due to a low grade fever and vomiting. Review of the hospital records from Resident #1's 08/20/21-08/26/21 admission indicated the sacral wound did not show sign of acute infection. The wound was pink without purulent drainage and a wound vac was placed. She was treated with an antibiotic specific to a urinary tract infection ([CONDITION(S)]). She was to follow up with the wound care clinic at discharge. An interview with the MDS coordinator was done on 08/18/21 at 08:45 AM regarding wound care. She stated they had not had a wound nurse in several months. Nurse #1 was interviewed on 08/19/21 at 3:30 PM regarding wound care and missed documentation of wound care. She was assigned to Resident #1 on 08/07/21 and 08/08/21. She worked evenings and said if wound care was not done on days, the day nurse had not always relayed the treatments that still needed to be done. She said she would have completed treatments if she had known they weren't done. She said previously, there was a treatment nurse at times on days that could do the wound care but not now due to staffing. A phone interview was done with Nurse #4 at 5:45 PM on 08/23/21 regarding wound care. She noted she had Resident #1 initially on admission for several shifts, but she had no skin issues at that time. She said they had been working with 2 nurses each shift for a while, and the Infection Prevention nurse and the 2 MDS nurses took turns helping with wounds. She said on Saturday there may be a treatment nurse but on Sundays the treatments were left up to the two nurses with 60+ residents. She said weekly skin checks were assigned to someone else but not the nurse on the floor. She stated if she was told of new redness, she would have paged the doctor or the NP for orders. The nurse said they had a skin care protocol they could initiate with application of skin prep on the heels or coccyx or to use barrier cream. The protocol did not need an order. She added with new redness, she would tell the NAs in report and put a pillow under the hip if the resident did not want to turn on their side completely. She stated with the pandemic, staffing was short. The Registered Dietician was interviewed on 08/27/21 at 1:33 PM and stated she reviewed all new admissions and followed them monthly for wound care needs. Resident #1 was seen on 07/06/21 and she ordered supplements as her meal consumption was documented anywhere from 0-75% and her family was bringing in some food. She stated most meals were 50% or less. The dietician stated she followed up for Resident #1's wound care nutritional needs on 08/10/21 and her intake was 0-25 %. She had increased her supplement at that time to 240 ml three times a day. Her estimated protein needs for wound healing had increased to 92 grams. Bloodwork completed on 08/19/21 for Resident #1 indicated her protein level was 2.6. Normal level was 3.7-4.8. The total protein was 6.4 with a normal range of 6.3-8.3. A phone interview was done with the Nurse Practitioner (NP) on 08/23/21 at 3:12 PM. She stated she was doing a discharge visit for Resident #1 on 07/27/21, but her discharge was cancelled due to a new pressure ulcer and her pain. She said neither the redness identified on 07/22/21 or the pressure ulcer was ever reported to her. If the redness had been reported she would have had them off load the pressure and if more than that was needed, she would have ordered a wound care consult. She said her dressings should be done daily as ordered. She said there had been chronic issues with the orders for dressings. She said there was no follow up from nursing once she asked about it. She said after discussing with the nurses responsible for care and no improvement she went to the Administrator over a month ago. She noted an improvement since that time. A phone interview was done with the Wound Doctor on 08/23/21 at 1:09 PM regarding Resident #1. He stated with the new onset of redness on 07/22/21, when they had noted it, they should have called the physician and some interventions would have been initiated. He said her wound required [MEDICATION(S)] multiple times and with the current treatment, the wound was looking better. The Physician said the last assessment noted 80% good tissue and 20% necrotic tissue. He said he expected the orders for dressing changes to be followed. A follow up phone interview was conducted with the Wound Doctor on 08/27/21 at 11:09 AM. He was asked if the pressure ulcer could have been avoided and he stated this was hard to say, as she had several other issues that would contribute to skin breakdown. He said there was not a clear yes or no. He noted her age, being immunocompromised and in a poor nutritional state contributed to her muscle mass decreasing. The Wound Doctor stated she had lost subcutaneous fat with not eating well, which led to not much between her skin and bone, and that would send off a cascade of events. She had decreased mobility and with several negative factors going against her, she was at a much higher risk. He said he was called in after the breakdown so he could not comment on the redness or the timeframe to skin breakdown. The physician added Resident #1 may have been at the tipping point, and being in long term care, showed she was declining in status, was closer to end of life, had failing faculties cognitively and her protein level was off with the poor nutrition. An interview was done on 08/19/21 at 12:19 PM with the Supervisor responsible for Infection Prevention/Staff Development/Scheduling regarding wound care. She said she had rounded with the wound doctor on Fridays since she started the end of February, and there was no wound nurse since that time. She said the nurses did the treatments and depending on the staffing, they would schedule a treatment nurse. If they were short staffed, either she or the MDS nurse would help with treatments. She said they were trying to improve the wounds at the facility. She stated 99% of the time she did the treatments on Friday with wound rounds, or if the resident was soiled the assigned nurse would complete it. The nurse noted every resident had a weekly skin assessment done, and residents with skin risks were discussed at the weekly risk meetings. They also discussed wounds, infections, new admissions and indwelling catheters. She said if it was determined a resident was high risk at the risk meeting, they would discuss it with the Nurse Practitioner or Physician. She said all mattresses were the pressure reducing mattress, and if a resident developed a wound, they would add the air mattress. A follow-up interview was done with Supervisor #1 regarding Resident #1's wound on 08/28/21 at 11:33 AM. She noted the resident initially had been up in the wheelchair frequently, and then was not eating at one point. When asked about the wound she stated the NAs doing incontinence care and bathing should have reported the skin changes. She said she was still in therapy preparing to go home but the wound progressed in about 2 days. She stated the wound had improved significantly. The wound went from eschar and black the first week, then the second week the Wound Doctor debrided it, and third week the area was very clean, and it had decreased in size. She also noted that during her recent hospital stay 08/19/21-08/26/21, they had been following with the hospital team and were told the hospitalists had said the wound was very clean and healing. The Director of Nursing (DON) was interviewed via phone on 08/23/21 at 3:47 PM. She said they had noticed several times that wound care was not documented, and the Infection Prevention (IP) nurse had conducted a treatment documentation audit recently. The DON did not recall when it was done. She said the IP nurse was usually rounding and doing treatments with the wound Doctor 1 day a week and the MDS nurses were doing treatments three days a week. The other days, the assigned nurse was to complete wound care and treatments. She said she had no extra staff to assign a treatment nurse to do wound care and treatments. She said the nurses were aware of the days the treatments would be done by other staff. She said the agencies couldn't provide needed staff and they don't have facility staff to fill the slots. She said the nurses were administering medications and were expected to do treatments, if they couldn't get to it, they need to do the treatments on 2nd shift. Weekly skin checks were being done by the nurse on the hall and if new redness was noted they should tell the supervisor and they contacted the Physician. The DON stated the new onset of skin redness for Resident #1 was not reported to her and should have been. An interview was conducted with the Corporate Director of Quality Assurance (QA) on 08/19/21 at 4:52 pm regarding wound care. She stated she had reviewed the documentation and noted the omissions. She said she had seen missing documentation frequently when facilities had agency nurses and this facility had a lot. She stated that the facility should have notified the Physician for preventive treatment when the redness was identified on Resident #1's bottom and staff should document the administration of treatments as ordered by the doctor. An interview was held with the Administrator, Corporate Director of QA and Corporate Director on 08/19/21 at 5:20 PM. The administrator stated if new redness was noted she would expect the Physician would be notified and a plan would be put in place. The Administrator said treatments that were ordered should be followed, the Physician directions were to be done and staff were to document their actions and findings. 2. Resident #2 was admitted to the facility on [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan for Resident #2 initiated on 08/10/20 included a focus area for pressure ulcer development. Wounds to the right sacrum and right gluteus were noted and the care plan was last updated on 07/13/21. Review of the Wound Care Physician note from 09/17/20 indicated Resident #2 had a sacral ulcer for at least 6 days duration. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply vacuum-assisted closure device at 125 millimeters of mercury (mm Hg) with black foam, bridge to right hip, and transparent semipermeable cover dressing. Change 3 times weekly and PRN. It was updated on 04/13/21 to change twice weekly and the order was discontinued on 06/12/21. Review of the Treatment Administration Record (TAR) from 05/01/21-05/31/21 indicated the wound Vacuum Assisted Closure (vac) dressing ordered to be changed 2x weekly was not documented as being completed on 05/11/21 or 05/25/21. The wound vac suction cannister was ordered to be changed weekly and was not documented as being completed on 05/24/21. The wound vac monitoring was not documented as being completed each shift on 05/01/21, 05/02/21, 05/08/21, 05/10/21, 05/11/21, 05/15/21, 05/22/21-05/24/21 or 05/29/21-05/30/21. Several attempts were made to contact the assigned staff and agency nurses that cared for the resident without success. Review of the Treatment Administration Record (TAR) from 06/01/21-06/30/21 indicated the wound vac monitoring ordered each shift was not documented as being completed on 06/01, 06/04/21, 06/05/21, 06/06/21, 06/08/21 or 06/12/21. The physician wound notes from 06/18/21 noted the right sacral ulcer was 3.3 long x 5.7cm wide x 1.7 cm deep with 20% necrotic tissue and 80% granulation tissue. Review of the NP note from 06/18/21 stated that the Stage 4 pressure ulcer was healing per the wound doctor and was improved. The resident was sent to the Emergency Department to rule out fistula with purulent urethral drainage. The hospital records were reviewed for 06/18-21-06/23/21 and indicated she was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a radiology report from 06/18/21 revealed a fistula was ruled out, and possible sacral [CONDITION(S)]. The resident was placed on antibiotics to treat the [CONDITION(S)], bladder infection and possible [CONDITION(S)], which were continued for 28 days upon her return to the facility. At discharge, the resident was to follow up at the hospital's wound care clinic. The Annual Minimum Data Set completed on 06/30/21 indicated the resident had moderately impaired cognition. The skin assessment indicated she was at risk for pressure ulcers, had a pressure reducing device on the bed and she had a Stage 4 wound on the right sacrum. She required extensive assistance with bed mobility and dressing and was total dependence for bathing and transfers. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the initial wound clinic note from 07/12/21 indicated Resident #2 had a right gluteal ulcer and sacral ulcer that began approximately in January 2021. The sacral wound was stage 4, 1.7 centimeters (cm) long x 3.5cm wide x 2.5 deep with a small amount of necrotic tissue. The gluteal wound was stage 3, 0.4cm long x 1.1cm wide x 0.1cm deep with a large amount of necrotic tissue. Review of the Wound clinic note from 07/26/21 indicated the gluteal wound had healed since the previous visit 2 weeks ago and the sacral ulcer had improved. Review of the Treatment Administration Record (TAR) from 08/01/21-08/24/21 indicated the right gluteus daily wound care was not documented as being completed on 08/05/21-08/08/21 or 08/10/21-08/11/21. The sacral/coccyx wound care ordered daily was not completed on 08/05/21-08/08/21 or 08/10/21-08/11/21. The Wound clinic note from 08/23/21 documented that the gluteal wound remained healed, and the sacral ulcer had improved since the previous visit. A phone interview was done with Nurse #4 at 05:45 PM on 08/23/21 regarding wound care. She was assigned to Resident #2 for 6 dates when the wound care was not documented. She said they had been working with 2 nurses each shift for a while, and the Infection Prevention nurse and the 2 MDS nurses took turns helping with wounds. She said on Saturday there may be a treatment nurse but on Sundays the treatments were left up to the two nurses with 60+ residents. She did not recall if the treatments had been completed. She stated with the pandemic, staffing was short and that was bad for Pressure Ulcer (PU) care. A phone interview was conducted on 8/24/21 at 12:14 PM with Agency Nurse #2 and stated she did not recall completing the wound care on Resident #2 on 08/08/21. Multiple attempts were made to call facility and agency nurses that cared for Resident #2 and failed to document completion of wound care without return calls. A phone interview was done on 08/27/21 at 04:20 PM with NA #4 regarding Resident #2. She stated she would turn with help, and her appetite wasn't good but the past few weeks she has been doing better. She said her wound was getting better and on occasion she would get up out of bed. An interview was done with the IP nurse/supervisor on 08/19/21 at 12:19 PM. She said she had been doing the wound rounds with the physician on Friday. She did Friday treatments unless the resident was soiled, then the care nurse completed it. There was no wound nurse at the facility since she started in February 2021. The nurses did the treatments usually depending on the staffing, and would try and schedule a treatment nurse, however if they were short the 2 MDS nurses helped. She said they were trying to improve the wounds. Every resident had a weekly skin assessment done, and skin risks were discussed at the weekly risk meetings. They also discussed wounds, infections, new admissions and indwelling catheters. If residents were determined to be high risk, they discussed it with the NP or physician. All mattresses were pressure reduction mattress, and if residents developed a wound, they added the air mattress. The supervisor said Resident #2's wound had decreased in size. A follow-up interview was done with the IP nurse/supervisor regarding Resident #2. She stated the resident had a Stage 4 pressure ulcer in February and was in and out of the hospital frequently post COVID. During one of the hospital stays, they ordered a wound vac and were changing it twice a week at the facility. She noted the resident had frequent bouts of diarrhea with the [CONDITION(S)] and they would have to change the wound vac to gauze dressings. She stated the wound continued to heal with the wound vac and they eventually changed her to antibacterial soaked gauze. The last time she saw the wound in June it was very small and clean and 100% better compared to what it was. She said she was wound certified and had completed education with staff since she started in February 2021 on wound care and wound vacs. A phone interview was conducted with the dietician on 08/27/21 at 1:33 PM regarding Resident #2. She stated she saw her monthly for her wound care needs. She noted in March, she saw her for a readmission review and at that time being post COVID, she had increased her supplements. In July, she added a dissolvable protein supplement and a frozen nutritional treat. On 08/10/21, she saw her and noted she had followed her for weight loss previously and the wounds. Resident #2 had a 16% loss in 6 months and an 11% in 3 months, and the dietician stated she was more stable now. A phone interview was done with the Nurse Practitioner (NP) on 08/23/21 at 3:12 PM. She was asked about Resident #2 and stated the resident was going to the wound care clinic now. She said there had been chronic issues with the orders for her dressings and the wound VAC not being on. She said gauze dressings would be on sporadically instead of the wound VAC. She said there was no follow up once she asked about it. She said after discussing with the nurses responsible for her care and seeing no improvement, she went to the Administrator over a month ago. She stated she noted an improvement since that time with wound care. A phone interview was done with the Wound Doctor on 08/23/21 at 1:09 PM regarding Resident #2. He stated he followed her for several months and in July the family wanted her care switched to the wound clinic. He said when the wound

Based on observations, record reviews and staff and Nurse Practitioner interviews the facility failed to provide sufficient nursing staff to identify new wounds and provide evidence of treatments provided as ordered for pressure ulcers for 2 of 2 sampled residents reviewed for pressure ulcers (Residents #1, Resident #2). Findings included: This tag is cross referenced to F686 treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] F686 Based on observations, record reviews and staff, nurse practitioner and physician interviews, the facility failed to assess and identify a new sacral wound (Resident #1) and complete and document wound care as ordered for 2 of 2 sampled residents reviewed for pressure ulcers (Residents #1, Resident #2). An interview with the MDS coordinator was done on 08/18/21 at 08:45 AM regarding wound care. She stated they had not had a wound nurse in several months. An interview was done with Agency Nurse #1 on 08/18/21 at 09:30 AM regarding Resident #1's dressing. She said she was not able to do treatments today as planned because of staffing and she was 3 hours late starting on the med cart. The nurse stated she was assigned to do treatments and when a nurse did not show she was assigned to give medications and she had just been informed of the change. A phone interview was done with Nurse #4 at 5:45 PM on 08/23/21 regarding wound care. She said they had been working with 2 nurses each shift for a while, and the Infection Prevention nurse and the 2 MDS nurses took turns helping with wounds. She said on Saturday there may be a treatment nurse but on Sundays the treatments were left up to the two nurses with 60+ residents. She stated with the pandemic, staffing was short and that was bad for Pressure Ulcer (PU) care. An interview was done on 08/19/21 at 12:19 PM with the Supervisor responsible for Infection Prevention/Staff Development/Scheduling regarding wound care. If they were short staffed, either she or the MDS nurse would help with treatments. She said they were trying to improve the wounds at the facility. The Director of Nursing (DON) was interviewed via phone on 08/23/21 at 3:47 PM. She said they had noticed several times that wound care was not documented, and the IP nurse had conducted a treatment documentation audit recently. She said she had no extra staff to assign a treatment nurse to do wound care and treatments. She said the agencies couldn't provide needed staff and they don't have facility staff to fill the slots. She noted she and other facility staff were often filling in for medication administration and nursing needs. An interview was held with the Administrator, Corporate Director of QA and Corporate Director on 08/19/21 at 5:20 PM. The administrator stated staffing had been a concern for several months with the pandemic.

Based on observations, record reviews and interviews with facility staff the facility failed to follow their policy and procedures for staff reporting for COVID-19 symptoms and not working with symptoms consistent with COVID-19 (Nurse #1, Nurse #2, Nurse Aide (NA) #1, Nurse Aide #13), the facility failed to implement their policies and Centers for Disease Control (CDC) guidelines for Personal Protective Equipment (PPE) for residents on Transmission Based Precautions (NA #8), have respirator masks and face shields available to staff at the onset of the COVID 19 outbreak, contracted transportation drivers were not screened by the facility prior to transporting residents (Residents #4,5,6) and a COVID 19 positive staff member with a cough worked on the COVID unit in the staff breakroom (Administrative Staff #1). The facility had a total of 72 of the 74 residents on the 12/07/20 census to be diagnosed with COVID 19 between 11/25/20-12/27/20. As of 12/21/20 there had been 9 resident deaths. From 11/24/20 through 12/28/20 31 of the 66 staff members tested positive for COVID-19. Immediate Jeopardy began on 11/30/20 when NA #1 came to work and did not report symptoms consistent with possible COVID 19. Immediate Jeopardy was removed on 12/23/20 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level F (no actual harm with the potential for more than minimal harm). Findings included: A review of the Facility Infection Prevention and Control Policies and Procedures: COVID 19 dated 10/30/2020 stated in part . gowns and gloves are changed between residents on Transmission Based Precautions prior to entry into the room. N95 masks are required while caring for residents that are known to be COVID +, confirmed or suspected residents of COVID 19 will always have their doors closed, the center assessed for COVID-19 trends and patterns based on resident room location and staff assignments with the facility of current residents and staff who are asymptomatic. Any resident who has had direct close contact with a COVID positive resident will be placed on a 14-day quarantine, with no roommate and the door closed. The Health Department will be notified of residents who are positive, and recommendations/guidance requested/documented. Staff to the extent possible should be assigned to only work on COVID positive units or quarantined rooms or the well units. Testing should be done based on the extent of the county positivity rate, for signs and symptoms of COVID 19 in staff or residents, performed if triggered by an outbreak of any new case in the facility, testing every 3-7 days until no new cases for 14 days since the most recent positive result. Documentation in a book to include the date and time of the identification of the signs and symptoms, when testing was conducted and when results were obtained, actions taken, county positivity rate, refusals or unable to test, results of residents must be in the medical record, and results of employee, sitters and vendors must be in a binder. An employee roster and vendor sign in to indicate who was required to be tested . 1. A review of the Facility Infection Prevention and Control Policies and Procedures: COVID 19 dated 11/2020 stated in part . staff assessment will include presence of fever, cough, symptoms of respiratory illness or any change in condition, screening must be completed outside the entrance. Staff and any personnel entering the center are educated that they should not report to the facility if they have a temperature and/or lower respiratory symptoms and they should report these symptoms immediately to their supervisor, Symptomatic employees were to apply a facemask and sent home immediately and instructed to contact their healthcare provider. A review of the Facility's Staff Health Attestation Form dated 6/10/20 that all team members, employed or contracted, were required to sign stated they would self-monitor and self-report to avoid exposures to communicable diseases such as COVID 19. This included reports of fever, cough, sore throat, new shortness of breath. The Centers for Disease Control and Prevention (CDC) guidelines dated 5/13/20 included in part: signs and symptoms of COVID-19 of chills, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, congestion or runny nose, nausea or vomiting, diarrhea. A review of the Staff screening logs utilized since March 2020 asked for the temperature and Do you have any symptoms of sore throat, fever, cough, shortness of breath, sore throat, malaise and GI symptoms, The screening log for the beginning of the shift, also asked Have you have had any type of sickness or generally not feeling well in the last 72 hours. Screening questions required to be completed at the end of the shift included the temperature and At any time during your shift did you feel sick or have any respiratory symptoms, if you did please see _______ (left empty or not visible on the employee logs). The screening log did not list chills, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, congestion or runny nose, nausea, GI symptoms was listed but did not specify nausea, vomiting, diarrhea. An observation of the staff and vendor screening process was completed on 12/07/20 at 12:05 PM. The receptionist facilitated the process in the front lobby and ensured temperatures were checked, appropriate PPE was worn, and the screening questions were answered on the COVID-19 Employee or Vendor Sign In/Out Log. The screening log was completed, and temperatures were checked upon entry and exit. 1a. The COVID-19 Employee Sign In/Out Log for screening initiated in March was reviewed for Nurse Aide (NA) #1. At the beginning of her shifts on 11/30/20, 12/2/20 and 12/3/20 NA #1 did not have elevated temperatures and answered No to the questions Do you have any symptoms of sore throat, fever, cough, shortness of breath, malaise or GI symptoms and Have you had any type of sickness or generally not feeling well in the last 72 hours? NA #1 answered No to the question At any time during your shift did you feel sick or have any respiratory symptoms at the end of all three shifts. NA #1 was tested for COVID 19 on 12/03/20 with routine testing and on 12/04/20 she was confirmed positive. A review of the NA assignment sheets indicated NA #1 was assigned to a non-COVID hall on 11/30/20 and 12/02/20 and a COVID hall on 12/3/20. Several of the residents she cared for on the non-COVID halls later tested positive for COVID-19. Residents #15-tested positive on 12/02/20, Residents #21, #25 and #26 were positive on 12/07/20, Resident #27 on 12/06/20 at the hospital, and Residents #28 and #29 on 12/15/20. A phone interview was done on 12/10/20 at 1:38 PM with NA #1. She noted that she started getting sick and that she had a cold on Monday 11/30/20 and was COVID tested on Wednesday. She had body aches, a cough and a stuffy nose since Monday 11/30/20. She worked on Monday 11/30/20 and Wednesday 12/2/20 on the Non-COVID B and C halls and Thursday 12/3/20 on the COVID halls. She stated she did not have a temperature but had a cough. She did not remember how she answered the questions when she was asked about the screening before work and said she did not think it was COVID symptoms just a cold. NA #1 explained she had not reported her symptoms to anyone at the facility as she did not think they were COVID related. 1b. The COVID-19 Employee Sign In/Out Log for screening initiated in March was reviewed and Nurse #2 had signed the form on 12/7/20 and answered No to the questions, Do you have any symptoms of sore throat, fever, cough, shortness of breath, malaise or GI symptoms and Have you had any type of sickness or generally not feeling well in the last 72 hours. Review of the Employee Sign In/Out Log at the end of her shift on 12/7/20 revealed Nurse #2 was afebrile and had marked Yes for At any time during your shift did you feel sick? On the screening log for 12/10/20 Nurse #2 answered No to all the screening questions at the beginning and end of her shift. Nurse #2 was tested for COVID 19 on 12/8/20 with routine testing and on 12/11/20 she was confirmed positive. Review of the Staff Assignment sheet from 12/07/20 from 11:00 PM-7:00 AM revealed NA #13 and Nurse #2 both worked on 12/07/20 on Non-COVID B and C halls. Residents #6 was located on the B hall, cared for by Nurse #2 and NA #13 and tested positive at the hospital on 12/08/20. Nurse #2 was interviewed via phone on 12/12/20 at 9:31 AM. She was tested for COVID on 12/8/20 with routine testing, the positive result was reported to the facility on [DATE]. She stated she had been sick all week. She had worked Monday night 12/7/20 and started feeling bad and when she left that morning, she was vomiting in the parking lot. On Tuesday night 12/08/20 she called in sick, however she worked Thursday night 12/10/20 from 11:00 PM-7:00 AM. She stated the DON knew she had been vomiting on Tuesday and the DON text her on Thursday 12/10/20 during the day and asked how she was and if she felt better, and if she was able to come to work. Nurse #2 said she responded back to her that she felt a little better and she would try and come to work. When she was asked about the screening log, she stated she had put yes on Tuesday morning when she left that she felt bad during her shift. When she returned on Thursday, she denied any symptoms on the screening log because she said she felt a little better at that time. She stated she knew she was not herself and was sick and thought it was the flu or a virus and not COVID, so she went to work. 1c. Review of the Employee In/Out Sign in log for 12/07/20, 12/08/20 and 12/09/20 revealed NA #13 had signed the form, recorded a normal temperature and answered No when she answered the questions which asked, Do you have any symptoms of sore throat, fever, cough, shortness of breath, malaise or GI symptoms and Have you had any type of sickness or generally not feeling well in the last 72 hours? and Did you feel sick or have respiratory symptoms during your shift? NA# 13 was tested for COVID 19 on 12/8/20 with routine testing and on 12/11/20 she was confirmed positive. She was assigned to work on the B and C halls-the non-COVID units. Residents #6 and #22 was located on the B hall, cared for by Nurse #2 and NA #13. Resident #6 tested positive at the hospital on 12/08/20. A phone interview with NA #13 was done on 12/14/20 at 9:23 AM. She stated she worked third shift on 12/7/20, 12/08/20 and 12/9/20 not feeling well and was called on 12/11/20 with the results of her 12/08/20 test. She said she worked last week on Monday 12/7/20 and she was sick and went to the DON on Tuesday 12/8/20 and told she had felt like crap for 2-3 days with nausea, diarrhea and a bad headache. She stated she continued to feel bad on 12/09/20. She said she thought it was due to a new medication but did not think she had COVID. She said the DON did not tell her not to work but looking back she should not have worked. She stated she had put yes on the screening questions for having symptoms. 1d. The COVID-19 Employee Sign In/Out Log for screening initiated in March was reviewed and Nurse #1 had signed the form, recorded a normal temperature and answered the questions which asked, Do you have any symptoms of sore throat, fever, cough, shortness of breath, malaise or GI symptoms and Have you had any type of sickness or generally not feeling well in the last 72 hours? Nurse #1's documentation revealed she had answered No to the screening questions at the beginning and end of her shifts on 11/25/20, 11/26/20, 11/27/20, 11/30/20, 12/1/20, 12/2/20, 12/3/20, 12/4/20 and 12/5/20. She was tested twice weekly since the outbreak 11/25/20 and weekly before that, with negative results. She was tested on [DATE] and was confirmed positive for COVID-19 on 12/11/20. Nurse #1 was interviewed by phone on 12/10/20 at 12:31 PM and stated she had been coughing for several weeks, did not have a temperature and had not tested positive. She thought it was related to the weather change. She stated her COVID tests had been negative. She was coughing during the interview. Nurse #1 indicated she was the nursing supervisor and conducted in-services for staff and worked with residents throughout the building. She stated she did the respiratory assessments frequently on residents. She was tested on [DATE] and resulted positive for COVID-19 on 12/11/20. An interview was conducted with the Director of Nursing (DON) on 12/07/20 at 11:55 AM. She stated the census was 74, and they had 29 COVID cases in the building. She stated Resident #1 was the first case of COVID 19 at the facility on 11/25/20 and he had been transferred to a COVID facility. She stated Nurse Aide (NA) #2 was tested outside the facility for cold symptoms on 11/23/20 and was the first positive staff case. All residents were tested on [DATE] and revealed an additional 16 residents had tested positive. Twice weekly resident testing was started and revealed positive COVID 19 results for 15 residents on 11/30/20, 4 residents on 12/02/20, and 16 residents on 12/07/20. Results through 12/28/20 revealed 74 residents had tested positive. A phone interview was done with the Director of Nursing (DON) on 12/09/20 at 12:02 PM regarding possible causes for the outbreak. She stated the only connection with staff and the positive residents, was that they were on the same two halls, B and C. She said the outbreak was scattered at first with staff from 1st and 2nd shifts as well. When asked if any staff had become ill at work and sent home, she stated no. A phone interview was done with the Regional Nurse Consultant on 12/31/20 at 12:40 PM. She stated if staff were sick on site and showing signs and symptoms, they should report the symptoms to someone in charge and be sent home. She noted they could be tested as well. 2. A review of the Facility Infection Prevention and Control Policies and Procedures: COVID 19 dated 10/30/2020 stated in part . for outbreaks, N95 are required while caring for residents on a COVID + unit or that are known to be COVID +, KN95 can be utilized when caring for all other residents. PPE is stored in a locked/secured area and accessible to team members. The Centers for Disease Control and Prevention (CDC) guidelines for nursing homes dated 4/30/20 recommended that the COVID-19 personal protective equipment (PPE) for positive residents should include the use of an N-95 or higher respirator (or a facemask if a respirator was not available), and eye protection that covered the front and side of the face, and a gown and gloves. An observation was done on 12/08/20 at 12:35 PM of NA #8 passing meal trays on the non-COVID unit. She went into Resident #21 and Resident #22's room with Enhanced Droplet Precautions wearing a KN95 mask, a face shield and hand hygiene was performed. She did not wear a gown or gloves per the sign posted on the door. There were two tables outside the rooms with glove boxes, no gowns were visible on the hall. The doors were also left open throughout the shift, 1 of the 2 room doors was propped open with a trash can. Review of medical records revealed Residents #21 and #22 had recently had roommates that tested positive for COVID-19 and they were being monitored. Resident #21 was confirmed positive for COVID-19 on 12/9/20. NA #8 was interviewed on 12/08/20 at 12:40 PM about the Enhanced Droplet Precaution and she stated Resident #21 and #22 had roommates that had tested positive. When she was questioned about the PPE that should be worn in the rooms per the isolation sign, that stated specifically for gowns and gloves to be worn, she stated the PPE was supposed to be on the tables outside the rooms and she was going to get some more gowns after the trays were delivered. She acknowledged she should have worn gloves. A phone interview was conducted with NA #5 on 12/09/20 at 9:34 PM. She said she was concerned about the facility's PPE and isolation techniques. She stated when the initial positive results came back for 15 residents from the 11/25/20 testing that morning, they continued to work with the COVID-19 positive residents with only a surgical mask until they moved them about 3:00 PM that day to the COVID unit. She noted they were not given KN95 masks or face shields until the next day for the non-COVID unit and yet they had worked with the positive residents all shift. NA #3 was interviewed via phone on 12/09/20 at 9:17 PM. She said that she tested COVID-19 positive on 12/2/20. Her concern was when the initial tests came back to the facility from the 11/25/20 testing and there were 17 positive residents, the staff worked with these positive residents on the non-COVID unit for most of their shift until they were moved and they did not have face shields to wear. She stated they only had surgical masks and no face shields, and the residents were coughing. A phone interview was done on 12/09/20 at 8:30 PM with NA #15. She worked as a restorative aide and worked all over the building. She had developed symptoms after being notified on 12/03/20 that her 12/02/20 test was positive and had since lost her sense of taste and had headaches. She noted on the day of the outbreak, administration waited all day long to move the residents and staff did not have a N95 mask to wear. A phone interview was done on 12/10/20 at 12:31 PM with the Nursing Supervisor on evenings. She stated after the outbreak they were given KN95 masks for the non-COVID side and then N95 masks for the COVID unit. She stated these items had been at the facility and there were plenty locked in the conference room. An interview was done on 12/11/20 at 9:54 AM with the Infection Control Nurse about the outbreak and the positive resident test results. She stated that she was not aware when the N95/KN95 masks, face shields or Enhanced Droplet Precautions had been implemented as she was not at the facility that day. An interview was done with the DON on 12/08/20 at 1:02 PM and she stated they had enough PPE and noted that masks and gowns were put out daily, and especially on Friday's she made sure there was a good supply for the weekend. She stated staff could have called the DON or the Administrator as they lived a short distance away from the facility, but they never did. She said the reason PPE was locked up was a whole box of PPE had walked away. She said they put masks in the medication cart and gowns were in the medication rooms. A phone interview was conducted with the Director of Nursing (DON) at 9:33 AM on 12/11/20. She said the results were back from 11/25/20 testing on the morning of 11/26/20 and the residents were moved to the COVID unit at the beginning of the 2nd shift around 3:00 PM. Enhanced Droplet Precautions were initiated in the COVID unit and on the non-COVID unit and quarantine areas for roommates of the positive residents. She stated they have had plenty of supplies and had N95 masks and face shields and KN95 on site for months. She stated they were now using the N95 on the COVID unit and the non-COVID units were using KN95. She stated the day after the initial COVID outbreak face shields were implemented and prior to that they were wearing surgical masks. She acknowledged the staff's concerns that KN95 and N95 masks were not put out for use on the first day in the morning. There were no explanation why N-95 masks were not implemented on the non-COVID halls on 11/26/20 when 16 COVID positive cases had been identified and residents weren't moved until later in the afternoon. She noted the KN95 and N95 masks should have been utilized earlier with the outbreak. A phone interview with the Administrator was done on 12/11/20 at 4:12 PM about staff concerns that PPE and masks were locked up. She said she found it hard to believe that staff did not have access to PPE as they had some masks locked in their medication carts. She stated that anyone that asked for a face mask or shield was given one. She said they had concerns about PPE walking away as that had occurred. A phone interview was done with the Regional Nurse Consultant on 12/31/20 at 12:40 PM. She stated the facility had plenty of PPE prior to the outbreak and currently. She noted the conference room was full of masks and gowns and they should be available. 3. A review of the Facility Infection Prevention and Control Policies and Procedures: COVID 19 dated 11/2020 stated in part .all visitors and vendors must adhere to the screening protocol. Screening must be completed outside the entrance. Any personnel entering the center are educated that they should not report to the facility if they have a temperature and or lower respiratory symptoms and that they should report these symptoms immediately to their supervisor. The Vendor/Visitor log utilized since March asked for the temperature and Do you have any symptoms of sore throat, fever, cough, shortness of breath, malaise and GI symptoms. At exit, it asked for the temperature and Have you have had any type of sickness or generally not feeling well in the last 72 hours. For the vendor/visitor sign out, the log required the temperature and an answer to At any time during your visit did you feel sick or have any respiratory symptoms, If you did please see ______ (left empty or not visible on the vendor/visitor logs). A review of the vendor log utilized from 12/07/20-12/08/20 revealed there was no documentation of van drivers being screened for symptoms of COVID-19. A phone interview with the Coordinator for Transportation Company #1 was done on 12/8/20 at 11:50 AM. This company had been utilized since 11/17/20. The Coordinator for her drivers and stated there was no screening process for her drivers, and she guessed if they were symptomatic the staff would have told her, and they would be removed from service. She said right now none of her staff were transporting COVID positive residents, if they were COVID positive they outsourced to Transportation company #2. A phone interview was done on 12/08/20 at 12:00 PM with the Manager for Transportation Company #2 that transported the facility's COVID positive residents, Resident #5 to [CONDITION(S)] three times a week and Resident #6 to [CONDITION(S)] therapy 5 times a week. He stated his drivers wore a N95 mask, gloves and a gown and sprayed the van and wiped it down after each transport. The Manager was asked about screening of his staff and he stated the nursing homes they go to screen the drivers. An interview was conducted with the DON on 12/07/20 at 11:55 AM. She stated that Resident #6 was being transported for [CONDITION(S)] Monday-Friday from the COVID unit. It was stated the facility had 2 [CONDITION(S)] residents that went to [CONDITION(S)] (Resident #4, #5), Resident #5 had tested positive for COVID and was in the hospital and both residents had been going to treatment 3 times a week An interview with the Director of Nursing (DON) was done on 12/07/20 at 4:55 PM. She stated that transportation drivers were not screened for COVID 19 symptoms because the drivers did not come in the building. A phone interview was done on 12/11/20 at 9:33 AM with the DON regarding Transportation drivers not being screened. She stated the screening policy for COVID 19 had not changed. A phone interview was done with the Administrator on 12/11/20 at 4:12 PM regarding the screening of the vendors. She stated that the process was the vendors would be screened and temperatures checked when they come in the door and when leaving. She referenced the podiatrist, dentist, beautician, etc. were screened. She said vendors that transported their residents should go to their home facility and were screened. She stated the facility was not doing the screening, and from what they were told they were screened daily at the company. 4. The Centers for Disease Control and Prevention (CDC) guidelines for Return to Work Criteria for Health Care Personnel (HCP) with [CONDITION(S)]-CoV-2 Infection dated 08/10/20 stated in part: The Symptom-base strategy for determining when HCP can return to work for HCP with mild to moderate illness who are not severely immunocompromised: may return to work after at least 10 days have passed since symptoms first appeared and at least 24 hours have passed since the last fever . and symptoms such as cough or shortness of breath have improved. Mild illness was defined as Individuals who have any of the various signs and symptoms of COVID 19 (e.g., fever, cough, sore throat, malaise, headache, muscle pain) without shortness of breath, dyspnea, or abnormal chest imaging. CDC guidance last updated on 11/20/20 titled Preparing for COVID in the Nursing Home stated in part that all healthcare personnel should be screened at the beginning of their shift for fever and symptoms of COVID-19. Symptoms included: Fever- either measured temperature >100.0oF or subjective fever, chills, cough, shortness of breath or difficulty breathing, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting or diarrhea. An interview with the DON was conducted on 12/07/20 at 5:29 PM at and she stated Administrative Staff #1 was asymptomatic and COVID positive and working on the COVID unit. An observation was conducted of the COVID-19 unit on 12/08/20 at 3:17 PM. Administrative Staff #1 that had tested positive 12/04/20 had continued to work in the breakroom on the COVID unit, with her office set up in the staff breakroom. She was wearing a N95 mask, face shield and a gown. She later put gloves on to assist with the breakroom trash removal. This area also housed the staff bathroom, a donning and doffing location and staff dining, all in the same room. A phone interview with the local Health Department (HD) Nurse #1 was done at 12:15 on 12/09/20 regarding the facility COVID-19 outbreak and communication between the facility. She stated the local HD had not approved Administrative Staff #1 that had tested positive to work. She stated Administrative Staff #1 was not given the clearance to work as having had tested COVID-19 positive on 12/04/20 and attempts to contact her had been unsuccessful. The Health Department noted they had attempted to call her Monday (12/07/20) with multiple calls and was told she was not in the building. She had left a voice mail on 12/07/20 and had emailed her on 12/08/20 to contact them. She noted positive staff should not be working unless staffing was a crisis and the Health Department had documentation that needed to be completed before that would occur. A conference call initiated by the HD Epidemiologist was done on 12/08/20 at 2:10 PM. The meeting included the HD's COVID Resource Nurse and HD Manager. The Epidemiologist shared the concern that Administrative Staff #1 was told not to work for 10 days at the facility. The HD COVID Manager stated there was specific documentation that needed to be completed if this occurred. The Epidemiologist stated when she spoke with Administrative Staff #1 on 12/7/20 she had told her she should not be working with a positive COVID-19 status. An interview with NA #3 was conducted on 12/11/20 at 8:56 AM who worked on the COVID unit. She stated she had observed Administrative Staff #1 and the last two days her coughing was really bad, and the workers were telling her to go home. NA #13 was interviewed on 12/14/20 at 9:23 AM and stated Administrative Staff #1 had been coughing for over two weeks and could be heard coughing in the halls and in her office prior to testing positive. An interview was conducted with Nurse #4 on 12/18/20 at 12:52 PM who confirmed she had been working the COVID unit since the facility became COVID 19 positive. She asked why Administrative Staff #1 was working with a cough and was also going in and out of resident rooms and did not social distance. An interview was held on 12/21/20 at 3:30 PM with Administrative Staff #1 about the Health Department call from the Epidemiologist and she stated she did not recall speaking with her. She stated she been speaking with the HD Nurse #1 and clarifying the information she needed and understood that asymptomatic positive staff needed to be discussed with the HD prior to working. The Administrator was notified of the Immediate Jeopardy on 12/14/20 at 9:53 AM. The facility provided the following credible allegation for Immediate Jeopardy Removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance All residents have the potential to be negatively impacted by a systemic failure of infection control standards during an outbreak of Covid 19. Non-compliance was demonstrated: Resident number 4, 5, and 6 had the potential to be affected by this through the failure to properly and consistently screen drivers for the transportation contractor, placing residents who are transported at risk of contracting the virus. When a staff person failed to wear the appropriate Personal Protective Equipment (PPE) when entering the rooms of resident's 21 and 22, who were in quarantine for observation for possible infection related to former positive roommates, By staff who failed to disclose that they were having signs and symptoms of Covid 19 though they were repeatedly asked through screening, placing each resident with whom they had contact at risk of infection. All Residents have the potential to be affected for failure to exercise infection control procedures, which included the ongoing education of staff about signs and symptoms and their clear understanding. The Staff Development Coordinator and the Director of Education provided education on signs and symptoms of COVID and in serviced on 12-15-20 either in written, handout or verbal format. Staff will not be allowed to work without completing the in-service. The signs and symptoms of Covid 19 Virus, The consistent and vigilant screening for such signs and symptoms of every staff person or contractor who may have contact with residents and other staff. Their absolute commitment to report such symptoms and immediately be removed from the workplace for the protection of other staff and residents. Clear communication between the staff, management and the Health Department and ongoing adherence to infection control standards of care. Correct utilization of PPE prior to entering the unit where Covid 19 residents were being cared for while known positive health care workers were providing care. Utilizing the correct testing frequency as per the guidance of the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare and Medicaid Services (CMS). Specify the Action the Facility will take to alter the process or system failure to Prevent a Serious Outcome from occurring or reoccurring and when the Action will be complete. The Staff Development Coordinator and the Director of Education has reviewed the CDC guidelines around screening of staff and contractors and has added to the list symptoms on the screening log to include chills, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea. The top of the form now includes: Completing and signing the Staff Screening Tool indicates your understanding of the signs and symptoms, the requirement to report any of these or other symptoms and complete and truthful reporting. All staff from each department, including those who serve in a contract capacity, will be inserviced on this form change on 12/15/2020 by the Director of Nursing, and members of the Regional Clinical team either in written, handout or verbal format. Staff will not be allowed to work without completing this inservice. All staff has previous [TRUNCATED]

Based on record review and staff, Nurse Practitioner, Primary Physician, Medical Director, Infectious Disease Nurse and Infectious Disease Physician and laboratory staff interviews the facility failed to stop the administration of an intravenous antibiotic for 9 days after a critically high laboratory result was available for the facility to review and failed to obtain an ordered laboratory test for the antibiotic for 1 of 4 residents reviewed for unnecessary medications (Resident #145). Resident #145 was transferred to the hospital for evaluation and treatment. At the hospital the resident had a critically elevated [MEDICATION NAME] Level of 87.3 micrograms per milliliters, a critically elevated Creatinine level of 7.07 milligrams per deciliter, was diagnosed with [REDACTED]. At the time of the survey, Resident #145 remained in the hospital with required ventilator support. Immediate Jeopardy began on 2/10/2020, when the facility failed to implement measures to address Resident #145's critical [MEDICATION NAME] Level and continued to administer the resident's [MEDICATION NAME] until [DATE]20. The Immediate Jeopardy was removed on 2/28/2020 when the facility provided and implemented a credible allegation of immediate jeopardy removal. The facility remained 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 were put into place are effective. Findings included: Resident #145 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's order dated 2/6/2020 stated, [MEDICATION NAME] Injection solution reconstituted 1 gram intravenously two times a day for [MEDICAL CONDITION] [CONDITION] until 3/2/2020 by the Primary Physician. A Care Plan for Resident #145 dated 2/6/2020 specified, he had a [DIAGNOSES REDACTED]. The Care Plan also stated Resident #145's laboratory and diagnostic work should be obtained and monitored as ordered. Resident #145's February 2020 Medication Administration Record [REDACTED]. A Progress Note dated [DATE]20, written by the Nurse Practitioner, stated Resident #145 was seen for new admission to the facility. The progress note also stated Resident #145 was receiving [MEDICATION NAME] intravenously until 3/2/2020 and was being followed by the Infectious Disease Clinic. The progress note also specified the resident's laboratory results and dosing of the [MEDICATION NAME] would be done by the pharmacy. A physician's order dated 2/10/2020 specified [MEDICATION NAME] Trough (a blood test to check the [MEDICATION NAME] level in Resident #145's blood) was to be administered 30 minutes prior to [MEDICATION NAME] administration every Monday and the results were be faxed to the Infectious Disease Physician at the Infectious Disease Center within 24 hours of drawing specimen. A [MEDICATION NAME] Trough collected on 2/10/2020 and marked reported by the laboratory on 2/10/2020 revealed Resident #145's [MEDICATION NAME] level was critical at 41.52 micrograms/milliliter (mcg/ml) with a normal reference range of 10.00 to 20.00 mcg/ml. Resident #145's medical record revealed on 2/10/2020 there was no indication the Infectious Disease Physician at the Infectious Disease Center or the resident's physician was notified of the resident's critically high [MEDICATION NAME] level of 41.52 mcg/ml. Additionally, there was no physician's order written on 2/10/2020 to stop the administration of the resident's [MEDICATION NAME] twice a day based on the resident's critically high [MEDICATION NAME] level. Review of the Pharmacist's Medication Review dated 2/12/2020 for Resident #145 revealed the laboratory results were reviewed and no irregularities were found. The pharmacy review did not mention the resident's 2/10/2020 critical [MEDICATION NAME] level of 41.52 mcg/ml. A Progress Note dated 2/12/2020, written by the Nurse Practitioner (NP), specified Resident #145 was receiving [MEDICATION NAME] intravenously and the Infectious Disease Clinic and Pharmacy were monitoring the dose. The NP progress note did not mention the resident's 2/10/2020 critical [MEDICATION NAME] level of 41.52 mcg/ml. An Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #145 was cognitive intact. The Admission MDS Assessment further revealed Resident #145 was on antibiotics and had [DIAGNOSES REDACTED]. A Progress Note dated 2/14/2020, written by the Nurse Practitioner, specified Resident #145 was receiving [MEDICATION NAME]. The progress note also specified Infectious Disease was monitoring the resident's antibiotic therapy. The NP progress note did not mention the resident's 2/10/2020 critical [MEDICATION NAME] level of 41.52 mcg/ml. On [DATE]20 (a Monday) a [MEDICATION NAME] Trough was not drawn for Resident #145 on this Monday as ordered on [DATE]. A Progress Note dated [DATE]20, written by the Nurse Practitioner, stated Resident #145 was seen for a 10-day post admission follow-up. The progress note further specified Resident #145 was tolerating intravenous [MEDICATION NAME] and the [MEDICATION NAME] dose was managed by the infectious disease clinic and pharmacy. The NP progress note did not mention the resident's 2/10/2020 critical [MEDICATION NAME] level of 41.52 mcg/ml. On [DATE] a physician's order was written by the Nurse Practitioner to hold the resident's [MEDICATION NAME]. A Nurse's Note dated 2/20/2020 at 12:45 pm written by Nurse #3, stated Resident #145 was sent to the emergency room for abnormal laboratory findings after Director of Nursing spoke with the Infectious Disease Clinic. The hospital History and Physical dated 2/20/2020, stated the resident was discharged from the hospital to the facility on [DATE] with a Creatinine of 1.47milligrams/deciliter but returned to the hospital on [DATE] with a Creatinine of 7.07 milligrams/deciliter (a normal reference range for Creatinine Level is 0.[AGE] to 1.30 milligrams/deciliter). The History and Physical also stated Nephrology was consulted and Resident #145's acute [MEDICAL CONDITION] was possibly related to [MEDICATION NAME] therapy, diarrhea, and [MEDICAL CONDITION]. Resident #145's [MEDICATION NAME] Trough level was 87.3 mcg/ml on 2/20/2020 when he returned to the hospital (a normal reference range for a [MEDICATION NAME] Trough level is 10.00 to 20.00 mcg/ml). An interview was conducted on 2/25/2020 at 3:42 pm with the Director of Nursing (DON). The DON stated the resident's 2/10/2020 [MEDICATION NAME] Trough Level that was elevated was not reported to the Infectious Disease Center until 2/12/2020 when she left a voice message for the Infectious Disease Nurse. The DON stated her voice message specified the resident's [MEDICATION NAME] Trough level was critically high at 41.52 mcg/ml. The DON also specified on 2/20/20 Resident #145 was transferred to the hospital due to a high [MEDICATION NAME] Trough Level and poor kidney function. An interview was conducted with the Infectious Disease (ID) Nurse on 2/27/2020 at 8:58 am. The ID nurse stated she received a voice mail message from the facility's DON on 2/12/2020 which stated Resident #145's [MEDICATION NAME] Trough Level was 41.52 mcg/ml. The ID Nurse stated she immediately called the facility on 2/12/2020, but no one answered the facility's phone. She stated she also called the facility several times on [DATE]20, but could not reach anyone. She further stated on 2/18/2020 she called the facility and spoke to Nurse #6 and asked to speak to the nurse who was caring for Resident #145. The Infectious Disease Nurse stated Nurse #6 told her she could not reach anyone on that side of the facility and would ask the Director of Nursing to call her back. The Infectious Disease Nurse stated she called the facility again on Wednesday ([DATE]20) and spoke to the Director of Nursing. She said the DON informed her when the facility did not hear back from the Infectious Disease Clinic on 2/12/2020, after she left the voice message about the resident's critically high [MEDICATION NAME] level, the facility did not stop the administration of the resident's [MEDICATION NAME] medication until [DATE]20. The Infectious Disease Nurse further stated after the DON informed her that the resident's [MEDICATION NAME] medication was not discontinued on 2/12/2020 she told the Director of Nursing that Resident #145 should be sent immediately to the emergency room due to [MEDICAL CONDITION]. An interview with the Infectious Disease Physician on 2/27/2020 at 9:19 am revealed with a [MEDICATION NAME] Trough level of over 20 mcg/ml the resident's [MEDICATION NAME] should have been stopped. The Physician stated continuing to administer the resident's [MEDICATION NAME] at the same dose would have caused Resident #145's [MEDICAL CONDITION]. An interview with the Nurse Practitioner on 2/27/2020 at 9:50 am revealed he stated the Infectious Disease Clinic was following Resident #145's [MEDICATION NAME] and he was not aware of the [MEDICATION NAME] trough being elevated on 2/10/2020 until his visit on [DATE]20. The NP stated on [DATE]20 he gave an order to stop the [MEDICATION NAME] and to notify the infectious Disease Clinic of the elevated levels, but he did not remember which nurse he spoke to regarding the order. The Nurse Practitioner stated he did not know why an order was not written to stop the resident's [MEDICATION NAME] until [DATE]20. An interview with the resident's Primary Physician on 2/27/2020 at 10:22 am revealed he saw Resident #145 on 2/10/2020, but was not aware of the resident's elevated [MEDICATION NAME] Trough Level. He stated if staff had notified him of the resident's critically high [MEDICATION NAME] he would have stopped the [MEDICATION NAME]. An interview was conducted with The Laboratory Supervisor on 2/27/2020 at 1:45 pm. The lab supervisor stated Resident #145's 2/10/2020 [MEDICATION NAME] Trough level was processed on 2/10/2020 at 5:15 pm and were released on the laboratory website at 6:19 pm on 2/10/2020. The Laboratory Supervisor stated the facility had access to the results at that time. The Laboratory Supervisor stated once a critical laboratory level is noted they immediately call the Nurse at the facility. She stated the Laboratory called the facility numerous times but could not get through because no one was answering the facility's phone. The Laboratory Supervisor also stated on 2/10/20 the Laboratory faxed Resident #145's lab results to the facility as well. A second interview with the Director of Nursing was conducted on 2/27/2020 at 2:00 pm. The DON revealed she did not know why Resident #145's [MEDICATION NAME] Trough was not drawn on [DATE]20. The Director of Nursing stated the normal procedure regarding laboratory tests is the orders are entered into the computer by the Physician and Nurse Practitioner and the evening shift supervisor prints the order listing report and fills out a laboratory request sheet for each laboratory test ordered. The laboratory request sheets are placed in the lab book for the phlebotomist. The phlebotomist draws the laboratory specimens each morning. The Director of Nursing stated the laboratory results are printed to the fax machine in the medication room. She stated if the fax machine is not working the supervisor or unit manager prints the results from the laboratory site on the computer. The Director of Nursing stated she was responsible for printing the laboratory results if the fax machine was not working, since she was also the Unit Manager for the unit. The Director of Nursing stated the facility's telephones were not working properly from 2/10/2020 to [DATE]20 and Resident #145's 2/10/2020 lab results did not print to the fax machine. She stated she did not retrieve the results of the resident's 2/10/2020 [MEDICATION NAME] Trough drawn until 2/12/2020, but confirmed the resident's lab results were accessible on the laboratory's website. The Director of Nursing stated she gave the results of Resident #145's [MEDICATION NAME] Trough drawn on 2/10/2020 to the Nurse Practitioner on 2/12/2020 when she printed the results from the laboratory website on the computer and the NP did not say to hold the resident's [MEDICATION NAME] at that time. An interview with the facility's Consultant Pharmacist on 2/28/2020 at 10:48 am revealed she reviewed Resident #145's medications on 2/12/2020, but was not informed the resident had a critical [MEDICATION NAME] Trough of 41.52 mcg/ml on 2/10/2020. The Pharmacist stated she was aware Resident #145 was on [MEDICATION NAME], but the pharmacy was not involved in dosing Resident #145's [MEDICATION NAME] since the Infectious Disease Clinic was following him. An interview with the facility's Medical Director on 2/28/2020 at 11:32 am revealed he was not notified of the Resident #145's 2/10/2020 critical [MEDICATION NAME] Trough drawn of 41.52 mcg/ml. The Medical Director stated he would have stopped the [MEDICATION NAME] immediately if he had been notified of the resident's critical level and continuing to administer the [MEDICATION NAME] could have led to the resident's [MEDICAL CONDITION]. The Medical Director also stated the Infectious Disease Clinic was managing the dosing of Resident #145's [MEDICATION NAME] and they were notified by voicemail of the laboratory result. An interview was conducted on 2/28/2020 at 11:57 am with a representative of the phone company the facility utilizes. The representative stated the facility called on 2/10/2020 to report they were not receiving calls into the facility and could not call out of the facility. The Representative stated the phones were repaired on [DATE]20. An interview with the Administrator was conducted on 2/28/2020 at 2:42 pm. The Administrator stated the nursing staff should have reported the resident's critical [MEDICATION NAME] laboratory result to the Medical Director on 2/12/2020 when they did not hear back from the Infectious Disease Clinic. A palliative care consult from the hospital dated 2/27/2020 specified Resident #145 had a ventricular fibrillation arrest on 2/26/2020 and currently required ventilator support. The consult further revealed Resident #145 was being evaluated for palliative care and family members were made aware of his condition. The Administrator was notified of immediate jeopardy on 2/27/2020 at 4:11 pm. On 2/28/2020 the facility provided the following Credible Allegation of Immediate Jeopardy Removal: F[AGE]7 Credible Allegation of Immediate Jeopardy removal Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance Resident #145 continued to receive [MEDICATION NAME] intravenously after the facility drew a trough level on 2/10/20 with elevated levels reported to the facility on the laboratory portal on 2/10/20 according to the laboratory and noted by the Director of Nursing (DON) on 2/11/20 through the laboratory portal. The facility began having scattered problems with phone transmission on 2/10/20 but with a server reset, it appeared that faxes were being received and phones were working. On the evening of 2/11/20 the DON realized that no laboratory results had been received by fax on that day, 2/11/20, and DON opened the lab portal on the computer to pull all results for the day and identified the critical lab alert. In checking, the laboratory reported that multiple attempts were made to reach the facility on 2/10/20 and were unsuccessful. Neither realized that fax reports were also not reaching the facility. The DON pulled the critical alert from the laboratory portal, late in the day on 2/11/20 and due to the time of day, the DON did not call the Infectious Diseases office who had ordered the [MEDICATION NAME] trough until the morning or 2/12/20. When the DON attempted to reach the Infectious Disease practice on 2/12/20 to report the result, the DON was unable to reach a person and left a message on the Nurse Line providing the name of resident #145, the resident's date of birth, the critical lab value and informed them that the phones and faxes were not working consistently in the facility at that moment and asked that they contact the Director of Nursing, (DON) on the DON's cell phone to give orders. When the DON had not received a response from Infectious Disease physician by 2/13, DON again contacted the Infectious Disease office and left a second message on the Nurse Line. The Infectious Disease office nurse claims to have attempted to call the facility on 2/12 and 2/13 repeatedly but was unable to reach the facility by phone. The Infectious Disease nurse did not attempt to reach the DON on the DON's cell phone as directed on the two messages left. According to the DON the Nurse Practitioner (NP) was made aware of the critical lab on 2/12/20 while in the facility and instructed the Nurse to notify Infectious Diseases. The NP has denied knowing about the critical lab. The [MEDICATION NAME] trough was again scheduled for [DATE] but as the 2/10/20 result remained unresolved, the Nurse did not add the [MEDICATION NAME] trough to the laboratory requisition or draw it thirty minutes prior to the next dose as would be required for a trough. According to the record, the DON notified the Nurse Practitioner on 2/18/20 about the critical value of 2/10/20 and the order was placed to discontinue the [MEDICATION NAME] until the Infectious Disease practitioner could be reached. Infectious Diseases and the DON finally made contact on 2/20/20 to discuss the critical lab result of 2/10/20 resulting in an order to send send Resident #145 to the hospital by the Infectious Disease office. The DON failed to make contact with the Nurse Practitioner or the Medical Director for instructions when the DON was unable to contact the Infectious Disease doctor's office and continued to administer the [MEDICATION NAME] resulting in a toxic level of [MEDICATION NAME] in the Resident #145. Resident #145 was hosptalized on [DATE] with elevated [MEDICATION NAME] levels and remains hospitalized as of 2/27/20. Any resident who is administered medications where doses and administration depend on blood levels would have the potential to be affected by a failure to properly monitor those levels. To assure no other residents were affected by the same circumstances of telephone and fax issues and the decisions made around managing critical labs, on 2/26/20 and 2/27/20 the Staff Development Coordinator, DON and Regional Director of Clinical Services reconciled the last thirty (30) days of lab listings from Point Click Care, compared these to the laboratory requisitions used to draw laboratory specimens and examined the results received. No other laboratory orders had been missed and no other critical labs had not been reported. There are no other residents being administered antibiotics that require laboratory monitoring by intravenous methods at this time. Specify the Action the Facility will take to alter the process or system failure to Prevent a Serious Outcome from occurring or reoccurring and when the Action will be complete. The facility had experienced telephone and fax transmission inconsistencies and had contacted the telephone service provider and the Information Technology firm on 2/10/20 to forward calls to the facility cell phone number which was held by the Receptionist to answer all incoming calls and faxes were forwarded to the email address of the Business Office Manager in effort to resolve the issue. The initial recommendation by Information Technology to reset the server appeared to correct the problem which gave the facility a sense of confidence that the communication issues were resolved. On 2/11/20 the DON realized that the problem was occurring again, the telephone service provider and the IT firm were again notified. The problem was fully resolved on [DATE] and telephone and fax service has been consistent since that time. The Administrator's and the Director of Nursing's cell phone numbers as well as the facility cell phone number have been provided to the laboratory, pharmacy, Xray and Medical Director in order to provide a back up number for emergency contact in the event of if these providers are unable to reach the facility effective 2/28/20. As the DON was responsible for failing to notify the Medical Director when the DON was unable to reach the prescribing physician immediately (within two hours of receiving the Critical value), the DON was re-educated by the Regional Director of Clinical Services on both 2/26 and 2/27 with an emphasis on the urgency of reporting Critical lab values and changes in condition to the physician and the Medical Director if unable to reach the physician. The DON received a verbal counseling session that required a signature acknowledging the failure counseled on by the Regional Director of Clinical Services on 2/27/20. On 2/26/20 the Administrator, DON and SDC began in-servicing all nurses on the importance of 1) informing the physician about any significant changes in condition. 2) the process for assuring order listings for lab draws are correctly entered in the lab draw book for the following morning, 3) the process for assuring that blood is drawn as ordered, 4) the process for confirming that results are received. In-services of nurses include a clarified process by which the nurse will immediately contact the prescribing physician to report any abnormal lab values for medication monitoring. A message left must be returned within two hours or the nurse will call the facility's Medical Director to advise of the abnormal value and get instructions for managing the elevated level. The nurse is instructed not to continue to administer the medication associated with the elevated blood level until the nurse has received clear instructions from the physician. In-servicing also stressed that nurses must inform the medical director about any significant changes in condition if unable to reach the attending or consulting physician who may have initially ordered medication or treatment and prior to administering any such medication or treatment. CNAs were in-serviced on the importance of reporting any changes in condition to the Nurse in charge immediately both in writing/verbally through the Stop and Watch ticket as well as placing a Nurse Alert on the Point of Care wall kiosk system in which CNAs document care. Staff who was not assigned to work on 2/26 or 2/27 was contacted by telephone and informed of the requirement. Each will also be in-serviced in person prior to working on the floor. The Administrator and the Director of Nursing completed the in-service of all employed nurses and CNAs on 2/27/20. In addition, the instruction has been added to the Nurse and CNA Orientation programs to assure that future nursing staff fully understands both the importance and the process for reporting changes in condition, abnormal labs or other diagnostic findings immediately to the physician or NP. The facility does not contract with any outside staffing agencies or use agency or contract staff. If, in the future this occurs, the nursing supervisor for that shift will be responsible for providing written instruction to that agency staff person. To assure that the complication of the phones and faxes inconsistency does not reoccur, the Administrator contacted the Information Technology service who worked with the telephone provider to resolve the issues. Telephone and fax services are working dependably as of [DATE]. The back up cellular service has been established as above as an extra measure in assuring that someone from the facility who is in a position of responsibility can be reached at all times. Immediate Jeopardy is removed as of 2/28/20. Validation of the facility's Credible Allegation of Immediate Jeopardy Removal: A review on 2/28/2020 of the plan to ensure those affected by the deficient practice revealed the facility had investigated the incident. The facility reconciled the last thirty days of resident with laboratory test and compared them to the laboratory requisitions used to draw laboratory specimens to ensure no other residents were affected. The facility found that no other critical laboratory results had not been reported. The Administrator's, Director of Nursing's, and the facility cell phone numbers were provided to the laboratory, pharmacy, x-ray, and Medical Director in order to provide a backup number for emergency contact in the event of these providers not being able to reach the facility effective 2/28/2020. The Director of Nursing was re-educated on the urgency of reporting critical laboratory values to the physician and Medical Director within 2 hours of receiving a critical laboratory value. The facility developed an audit tool to monitor the reporting of critical laboratory values. The nursing staff were in-serviced on the importance of the process for assuring order listings for laboratory draws are correctly entered in the lab draw book; the process for assuring blood is drawn as ordered; and the process for confirming the results are received. The in-servicing also included ensuring the physician is contacted regarding any abnormal laboratory results immediately. Nursing staff from all three shifts were interviewed regarding the in-services and verbalized understanding. The facility will provide the same in-service education to any new nursing employees.

Based on record review, observations, staff interviews, physician interview, guardian interview, nurse practitioner interview and resident interviews the facility failed to supervise a cognitively impaired resident who was assessed to need supervision when smoking from obtaining lighters and starting a fire in his room for 1 of 2 residents (Resident #1) reviewed for smoking supervision. Resident #1 obtained 3 lighters that were found in his room and subsequently set objects on his over bed table on fire while he was laying in the bed. The fire resulted in Resident #1 having to be removed from his room and staff had to extinguish the fire. No residents were harmed as a result of the fire. Immediate jeopardy began on 8-3-19 when Resident #1 used a lighter to set objects on his over bed table on fire while he was laying in the bed. Resident #1 was removed from his room and relocated to another room. Immediate jeopardy was removed on 10-2-19 when the facility provided an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no harm with the potential for more than minimal harm that is not immediate jeopardy) to complete staff education and ensure monitoring systems put into place are effective. Findings included: The facility's smoking policy and procedure, which was not dated, revealed in part; Curis Health Systems provides a safe environment for residents and staff who smoke and for residents and staff who do not smoke. The facility's designate areas for residents to smoke, residents who desire to smoke and their responsible party receive a copy of the smoking policy on admission or upon request to smoke, the interdisciplinary team evaluates residents desiring to smoke for their ability to smoke independently or dependently upon admission, quarterly, with a significant change or as deemed necessary, smoking paraphernalia is not permitted to be stored in resident rooms, the facility will care plan residents who smoke. Resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A smoking assessment was completed in (MONTH) 2019 which determined Resident #1 was an unsafe smoker and required supervision while smoking. This was determined by Resident #1 answering no to the following questions; ability to safely light and smoke a cigarette, safe technique for extinguishing matches or lighter and disposing of ash, ability to physically hold the cigarette while smoking, understands that smoking materials are for use only in designated smoking areas, does not have loss of sensation to touch or pain, understands smoking is not permitted while using portable oxygen and may not smoke in close proximity to oxygen, can the resident move quickly in the event of an emergency, can the resident call for emergency assistance, can the resident get in and out of the designated smoking area unassisted. The smoking assessment revealed the resident could only smoke at designated times and area with staff and could not carry his own smoking materials. There were no further smoking assessments completed since (MONTH) 2019. Resident #1's care plan dated 5-22-19 revealed a goal that he would maintain a safe environment free from injury related to smoking. The interventions included; a smoking assessment would be done as needed to determine safety, smoking supplies would be kept in a locked box at the nurses' station and distributed by nursing staff, would smoke in designated areas only under supervision. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was moderately cognitively impaired and was not coded for any mood or behavior issues. Resident #1 was coded for needing extensive assistance with one person for bed mobility, toileting, personal hygiene and dressing. The coding for Resident #1's upper and lower extremity range of motion revealed no impairment in that area. The MDS did not have Resident #1 coded as a tobacco user. A nursing progress note by nurse #1 dated 8-3-19 revealed the facility's fire alarm had sounded at 8:25pm and staff was able to locate the area. When staff arrived at the area, they saw smoke in the hall and located the source of the smoke was coming from Resident #1's room. The staff noted Resident #1's over the bed table was on fire and the resident was holding a lighter. The progress note revealed staff was able to put the fire out, remove the lighter from the resident and relocate him to another room. The fire department arrived and assessed the situation with no further findings. The social workers documentation was reviewed dated 8-9-19 and revealed Resident #1 had informed the social worker that he received the lighter from a male visitor earlier in the day of 8-3-19. During an interview with Resident #1 on 10-2-19 at 11:50am, the resident stated he remembered there was a fire but did not remember how it started. Resident #1 stated he had a lighter that I bought but the resident could not remember where or when he bought the lighter. He also stated he did go out to smoke but that staff has to watch me and stated he was aware he was not allowed to have a lighter or cigarettes in his room. The nursing assistant (NA) #1 who worked the morning of 8-3-19, during 7:00am to 3:00pm shift was interviewed on 10-3-19 at 10:10am. NA #1 stated on 8-3-19 she saw visitors in Resident #1's room but she did not know who they were. She also stated the visitors did not inform her that they were leaving anything for Resident #1 in his room and she denied the visitors took Resident #1 out to smoke during their visit no he was in the bed my whole shift. NA #1 stated the visitors were leaving as she was leaving at 3:00pm on 8-3-19. NA #1 also stated Resident #1 hardly ever asked to go out to smoke He enjoys staying in the bed and refuses to get up when we ask him. Nurse #1, who worked the evening of 8-3-19, was interviewed on 10-2-19 at 3:23pm. Nurse #1 stated she did not see any visitors for Resident #1 but was told by the previous shift that the resident had a male visitor earlier in the day. The nurse stated she had seen Resident #1 prior to the fire laying in his bed watching TV and denied that the resident was upset or anxious. She stated she had arrived at the resident's room after the nursing assistant had extinguished the fire but that she assessed Resident #1 after the fire, and he was not injured. Nurse #1 stated the resident had told her I just cut the lighter on and that he had received the lighter from a friend. Nurse #1 stated she assessed Resident #1's room and found 2 other lighters and 1.5 packs of cigarettes which she stated she removed from Resident #1's night stand and locked up in the lock box at the nurses' station. She also stated Resident #1 had to be escorted out to the smoking area where he would be given one cigarette at a time and that staff would light the cigarette for him so Resident #1 would not have had a lighter in his possession. The nurse stated Resident #1 had not gone out to smoke prior to the fire and was not aware when Resident #1 had been out to smoke. The nurse shift supervisor was interviewed on 10-2-19 at 12:54pm. The shift supervisor stated she was not present when the fire occurred but spoke with Resident #1 Monday morning (8-5-19). She stated Resident #1 informed her a friend had visited and brought him the lighter and cigarettes. She also stated staff had not been able to identify the male visitor. The supervisor stated the over bed table had not caught fire but rather objects (Styrofoam cups and paper) on the table were on fire. She also stated Resident #1 did not go out alone to smoke, but that staff escorted him out, gave him a cigarette and then would light the cigarette not allowing Resident #1 to hold the lighter at any time. Resident #1's state guardian was interviewed on 10-2-19 at 1:30pm. The guardian stated Resident #1 did not have a history of fire setting or property damage and that she had not been able to identify the male visitor who brought the lighter and cigarettes to the resident. She also stated Resident #1 had many family members who lived in the area and could have come to visit. The guardian stated she was aware Resident #1 could not keep lighters and cigarettes in his room but did not know if family members were aware that Resident #1 could not keep lighters and cigarettes in his room. During an interview with the nurse practitioner on 10-2-19 at 2:00pm, the nurse practitioner stated, Resident #1 setting his table on fire was out of the blue and that the resident had told him he was trying to light a cigarette not start a fire. He also denied seeing any behaviors that may have indicated Resident #1 setting a fire. The Administrator was interviewed on 10-3-19 at 9:00am. The Administrator stated he had arrived at the facility shortly after the incident on the evening of 8-3-19 and interviewed staff and assessed the other residents as well as the damage. The Administrator stated he was informed by nurse #1 that the resident had a total of 3 lighters and 1.5 packs of cigarettes which were found in the resident's night stand and that the resident told staff a male visitor who had visited earlier in the day provided the smoking materials to Resident #1. He denied any injury to Resident #1 and stated the resident did not have a roommate at the time of the fire. He also stated the resident was relocated to another room but Resident #1 requested to move back to his original room after 3 days. The Administrator also stated he met with the department heads and reviewed the smoking policy and the events that occurred and concluded that no systemic changes were needed at that time. He stated on 8-15-19 he met with the quality improvement team and the physician and a plan of correction was derived to search and monitor Resident #1's room each shift for a month for any smoking materials. He stated there was not any training done with staff or the resident at that time or any further steps to ensure visitors did not leave lighters and cigarettes with the residents. During an interview with the facility's physician on 10-3-19 at 2:57pm, the physician stated he met with the quality improvement team on 8-15-19 and the plan of correction for Resident #1 and the fire were for staff to search the resident's room every shift for a month for any smoking materials. He also stated the fire was totally unexpected and denied any previous incidences. The Administrator was notified of immediate jeopardy on 10-2-19 at 5:50pm. On 10-3-19 at 3:45pm the facility provided the following credible allegation of immediate jeopardy removal. On 8/3/2019, at 8:25pm, the fire alarm sounded. CNAs immediately responded by moving into their assigned halls, checking rooms and closing doors. When checking room [ROOM NUMBER], CNAs noted active flame and smoke at the overbed table. As the fire was small and contained, one CNA moved the table away from the resident, and the other C NA moved the resident's bed away from the fire. The fire extinguished without difficulty. The fire department arrived within five (5) minutes and found the fire had been extinguished. The fire department checked all rooms and common areas to assure there was no other sign of fire or smoke and determined the fire to be located only with the table and confirmed it was fully extinguished. The fire department then assisted staff in relocating the resident to another room, prior to leaving the facility. On 8/3/19 at 8:37pm the Administrator was notified of the fire and arrived at the facility by 9:30pm. As instructed by the administrator prior to his arrival, the staff began to check all residents to assure they were safe. They collected statements from all staff. The Administrator also instructed the staff to thoroughly search the resident's room and take possession of any materials found and begin a room to room search of each resident room, with the resident's permission, to remove any other smoking materials that were potentially in the possession of the residents. The Administrator checked the visitor log and noted a family member had visited earlier in the day on 8/3/19. The Administrator attempted to reach the family member to verify the smoking materials had been provided earlier that day by the visitor but was unable to find a contact number to confirm the source of the lighter. The Administrator was familiar with resident #1s smoking patterns based on QAPI corrective action that was underway for a citation (F641) during annual survey where the facility had failed to accurately code a resident as a smoker on his MDS. Resident #1 was considered a dependent smoker due to his [MEDICAL CONDITION] associated with multiple [MEDICAL CONDITION]; his physical limitations caused him to need supervision. With a BIMs of 11, he was considered cognitively able to manage his smoking. Resident #1 was aware and had agreed to the smoking rules as evidenced by his signed smoker's contract in (YEAR) in which the requirement of turning in smoking materials was stated. He was being seen by psychiatry for his depression which was partially associated with his [MEDICAL CONDITION] and deteriorating condition. The psychiatric nurse practitioner states that there was no reason to suspect resident #1 would engage in such a behavior. It was not part of his history or hinted to by any prior behavior or verbiage. Nothing in this resident's history suggested the need for additional monitoring to prevent him setting fire to his bedside table. The leadership team met on 8/5/19 to discuss the event. They reviewed the individual circumstance of resident #1 and carefully considered the potential for any other residents to take similar actions. As the behavior was entirely individual and the motivation so unclear, it was determined by the team that this was an isolated incident that was not a result of a policy issue. The staff participated in the room searches with the instruction to inform the residents that it was necessary to search the room with their permission to find any smoking materials that might be in their possession for safety reasons. No additional smoking materials were found. Staff was aware that if they found anything, they would inform the resident that it is a violation of smoking policy to be in possession of their smoking materials and that they would be secured in their individual lock boxes. On 8/5/19, staff was reeducated about the smoking policy with an emphasis on importance of collecting and securing all smoking materials, without regard for smoking status (independent or dependent). They did decide and schedule a fire drill to assure all staff clearly understand action to be taken in such an event even though the staff who was there was commended for their quick, appropriate response. The team felt that further education on this was appropriate. The team discussed the smoking policy to determine if revisions were warranted, if changes to procedure were needed, if the systems that were set up for smoking safety were enough to prevent such an incident in the future. The decision on the part of the team was that, considering the isolated and unanticipated nature of this event, the process was sufficiently comprehensive and to continue as per current actions. A fire drill was completed on 8/5/19 during afternoon shift involving all departments. The facility-initiated room searches for resident #1 on 8/5/19 that were conducted 3X daily for 4 weeks to assure the resident had not obtained any new smoking materials from outside sources. During a QAPI meeting on 8/15, the Medical Director and the entire team discussed the event and what had been implemented in response and determined the event could not have been anticipated and that response to this point had been effective in assuring no further incidents. Summary In response to the allegation of immediate jeopardy: Corrective Action for Resident included in citation: Resident #1 was immediately placed in a safe situation away from the fire and smoke. Resident #1's room was thoroughly searched, and contraband removed and secured. Resident was questioned by the Administrator to determine his motivation in setting the fire and was unable to provide any additional information. The psychiatric provider was notified with no new orders at that time. The psych provider consulted by phone and agreed to see the resident on the next possible visit. An appointment was scheduled for 8/16/19 for a psychiatric review. The Social Worker saw the resident on 8/9/19 to complete a repeat BIMs with a score of 11. The social worker noted that the resident did not pose a threat to himself or others based on discussion with the resident during which he said he did not intend to set a fire. The care plan was updated with his need for increased supervision. Identification of other resident with the potential to be affected: To identify any other residents who were at similar risk, each resident room was reviewed with the resident's permission with any smoking materials secured on 8/3/19. Resident had recently been reviewed for smoking status and those continued to be monitored. Systems and Process Changes in Response The policy was clarified and notes clearly that all smoking materials must be secured. All smokers will have quarterly Safe Smoking Assessment and those residents who are determined to be safe for independent smoking are permitted to smoke at will but must secure all smoking materials with the nurse who places them in a locked container with the resident's name. Residents who are found to be dependent on others for safety are required to be monitored at all times and may not be in possession of their own materials. The policy which states these restrictions is provided in the admission packet for all admissions. In response to the allegation of immediate jeopardy, on 10/2/19 the smoking policy was reviewed with all staff to assure complete knowledge of the policy and its restrictions on possession of smoking materials. Any staff not in-serviced on 10/2/19 will be in-serviced prior to working again. This was however, an extra measure taken in direct response to the IJ to reinforce the information already provided. The facility has additionally posted a reminder for all visitors that they may not provide smoking materials to any resident without going through the nurse 10/2/19. Independent residents have been re-educated on the importance of all smoking materials being secured. For those residents who are not safe smokers, smoking materials are secured at all times unless the smoker is supervised during smoking. Each resident's smoking materials are kept under lock at all times and provided to the resident during smoking consistent with the process which has been in place since early in 2019. Monitoring to assure Sustained Compliance As an additional measure, a spreadsheet has been created and will be maintained by the smoking attendant that indicates what smoking materials each dependent smoker possesses. Use will be tracked by reducing the number of available cigarettes allowing the staff to maintain an accurate count of what should be available. This tool will be audited daily by the nursing supervisor X 30 days then weekly for 90 days to assure sustained compliance. All audits will be reviewed by the QAPI committee. At the end of the 120-day monitoring period beginning on 10/2/19, the committee will determine the need to continue the monitoring process. Allegation of Immediate Jeopardy removal: The facility alleges Immediate Jeopardy removal as of 10/2/19 when the team met to review the event and followed a four-point planning structure to determine the best course of action for the individual, evaluate the potential for involvement of other residents, the systems and processes that failed to prevent the event and the monitoring process to assure compliance was sustained. No further events have occurred that suggest a lack of effectiveness of these actions taken on 10/2/2019. The facility's credible allegation of immediate jeopardy removal, with an immediate jeopardy removal date of 10-2-19 was verified on 10-3-19 at 4:00pm as evidenced by licensed and non-licensed staff interviewed regarding in-service training on the smoking policy and securing all smoking materials in a locked location. Review of on-going in-service records revealed staff that were not present for the training would receive the in-service training prior to working their next shift. Observations of supervised and non-supervised smokers occurred through out the survey revealing the non-supervised smokers locked their smoking materials in their locked box and the supervised smokers' materials were locked in the medication cart by facility staff.

Based on record review, observations and staff interviews the facility failed to prevent 1 of 3 cognitively impaired resident from exiting the facility unsupervised, resulting in a hospital visit due to exposure to outdoor weather (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with the current [DIAGNOSES REDACTED]. The resident had a care plan in place initiated on [DATE] for elopement risk/wanderer related to impaired safety awareness. The goal, updated on [DATE], included that staff would be alerted when resident attempted to leave the facility unsupervised through the review date . Relevant interventions included distract resident from wandering by offering pleasant diversion activities, structured activities, food, conversation, television and books ([DATE]), monitor location ([DATE]), provide structural activities ([DATE]), and a Wanderguard device, which staff are to check function and placement as ordered ([DATE]). The resident Minimum (MDS) data set [DATE] revealed the resident was severely cognitively impaired. Wandering behavior was not exhibited and the Resident ' s behavior had improved from the prior assessment. The resident was independent with all Activities of Daily Living (ADL ' s) and used a wheelchair. A note by social work dated [DATE] stated the resident had an elopement risk evaluation completed and was at risk for leaving the facility. Based on the data collection, the following was documented: Resident propelled self with some assistance. The resident ' s emotional status was, voices a desire to leave. Resident #1 had a history of [REDACTED]. Her behavioral history was noted to be difficult to redirect. The note also stated the resident wore a Wanderguard device and her name was entered into the elopement book. Resident #1 physician's order [REDACTED]. The elopement book was reviewed and revealed that Resident #1 was identified/assessed as an elopement risk and had a wheelchair and glasses. The book included her name, identification and picture in it. The elopement book was located at the nurse ' s station and identified residents who were at risk for leaving the facility. A social work note dated [DATE] stated Resident #1 had exit seeking behavior that afternoon. This staff along with other staff attempted to redirect the resident and she became verbally abusive and yelled at staff. The resident never exited the front doors. The resident eventually backed up from the front door and went back to her room. The resident was sitting in her door way at that time and had calmed down and spoke to staff as this staff member walked by. The note indicated the social worker would continue to update and monitor as needed. The incident report dated [DATE] stated the resident exited the facility without supervision between 4:45 AM and 5:15 AM. She was in her wheelchair and in a wooded area adjacent to the Apartment complex behind the facility. She was not dressed for the weather. She was noted by someone outside the facility, who called the police. The police called Emergency Medical Services (EMS) to transport the resident to the hospital as they were unsure how long she had been outside. The police arrived at the facility at approximately 5:50 AM to inform that she had been located and transported. The resident told the administrator that she exited through the back door and that she was never going to do that again as she was cold. No injuries were observed. The report also stated the resident has in the past exhibited exit seeking behaviors and made comments at times about going home. However, made no attempts to remove wander guard bracelet. She normally wheeled herself around the facility when she was awake. The immediate action taken stated the resident was reassessed upon return to the facility with no injuries noted. She did have a new bruise to her hand from blood drawn while in the hospital. The Wanderguard device was in place to wrist and functioning properly. The resident ' s cognition waxed and waned during the day. At times, she was more confused. She was able to discuss what happened shortly after event but unable to in an hour. The report stated the Nurse Practitioner and resident ' s family were notified. The police communications record dated [DATE] at 5:36 AM stated a female was found in the woods and had been there a while and needed to have her temperature checked. EMS was dispatched. Caller was going to help her out but was unsure where she belonged. She was an elderly female stuck in the woods in a wheelchair. The Emergency Department Documentation dated [DATE] at 6:17 AM revealed the Resident ' s chief complaint was hypothermia. The note stated the resident was found in the middle of the wooded area by EMS. The patient was in a wheelchair and in her nightgown. They could not get a temperature in the field. She required evaluation regarding hypothermia. The patient claimed she was on her way home from church. She denied any pain, shortness of breath, nausea or vomiting. The resident had laboratory work completed, a chest X-RAY and an electrocardiogram. The resident was discharged from the hospital on [DATE] at 7:37 AM. A nursing note dated [DATE] at 8:10 AM stated the resident was brought back to the facility by her family. The resident ' s family stated She is okay, I have to get back to work. The resident stated It is all her fault and pointed to her family member. I am glad to be back home . The Wanderguard device was intact to her right arm and working. The staff member was with the resident. Skin evaluation was to be completed. The resident had a care plan in place last updated on [DATE] for elopement risk/wandering. The care plans stated on [DATE], the resident exited the facility without supervision. Interventions included: the resident was to have close supervision until further notice, distract the resident from wandering, monitor location, provide structured activities, seek alternative placement, and staff to check function and placement of the resident ' s Wanderguard device. Nurse #1 (the nurse who worked day shift on [DATE]) was interviewed on [DATE] at 1:16 PM. She stated staff rounded every 2 hours to check on residents. Residents with Wanderguards were checked on more often and there was a book to keep check on who had Wanderguards. She stated residents at risk for elopement were redirected. She stated the doors would alarm if a resident got close to the door with a Wanderguard system on it. Around 10:00 AM on [DATE], Resident #1 ' s family brought the resident back to the facility. The resident was assessed and was fine. She had never left the facility before this time. When first shift came on, staff were posted at each door. The maintenance man was interviewed on [DATE] at 2:15 PM. He stated they had a Wanderguard system on the front door and the D hall door. He explained all the exit doors were locked at all times except for the front door. Before he left every night, he checked the doors to make sure the doors were locked and checked the doors in the morning too. He stated he checked the doors the night before resident #1 left and knew she had left the facility but did not know the details of her leaving. Nurse #2 (who worked third shift on [DATE]) was interviewed on [DATE] at 5:01 PM. She stated she made rounds about every 2 hours and that some residents sat out in the hallways so she could watch the residents that were at risk for elopement. At the beginning of the shift, she made sure residents were wearing their Wanderguard bracelets and document it on the MAR (medication administration record.) Nurse #2 stated the NA asked around 5:15 AM if she had seen Resident #1. Nurse #2 did not know which door the resident went out of. Nurse #2 stated she never heard any doors or alarms going off when Resident #1 left the facility. She was not sure who found the resident but the police stated that she had been found. The resident had on her Wanderguard when she came back to the facility. She stated she checked the C hall door (near the maintenance office) and the door beside the central supply and they were unlocked. Those were the only 2 doors that were not locked. Nurse #2 explained that after the incident, a nursing assistant was placed between the doors on the hall so the doors could be watched. She stated that prior to this incident, the resident had packed a bag at times and stated that she was going home but that usually occurred on day shift and the resident had not said anything like that in a while. Nurse #2 stated the resident would usually sleep at night except on occasion. A weekly nurse ' s skin observation dated [DATE] revealed a skin observation was completed on resident #1. There was bruising to the back of the resident ' s left hand from blood work drawn at the emergency room . The resident had a small red area to the mid-right forearm and the resident stated she had been scratching her arm. Door observations were conducted with the maintenance man on [DATE] at 4:35 PM and included the following: The A/B and C/D doors were locked and did not have a Wanderguard system attached to it. The front door and D door had a Wanderguard system attached it, which was tested and working on [DATE] An interview with the administrator was conducted on [DATE] at 10:10 AM. She stated the two doors in the back C/D door and A/B doors were unlocked on [DATE] and she spoke with the resident after she came back from the hospital on [DATE]. The resident told her that she exited from the C/D door and that the resident was upset with her family. She stated the doors were locked the night before on [DATE] so she was surprised they were unlocked in the morning of [DATE]. The administrator stated that after the incident, she placed a staff member at each door and told staff to stay put until the director of nursing got to the facility and in-serviced staff on [DATE]. She stated this resident had come to visit her office often, which was located close to the front exit door, but that she wasn ' t trying to exit but just visit her. Nursing assistant # 4 was interviewed on [DATE] at 2:46 PM. She stated she was working third shift on [DATE]. She stated she kept a close eye on residents with a Wanderguard and would let the nurse know if residents were going towards the door. She stated the night of [DATE], she did not hear an alarm go off or see anyone leave through the doors. An interview with the Nursing assistant #3 (who worked third shift from 11:00 PM on [DATE] through 7:00 AM on [DATE]) was conducted on [DATE] at 8:26 AM. Nursing Assistant #3 if a resident was at risk for elopement she redirected them. She stated Resident #1 had packed her clothes in her wheelchair at times or sat at her room ' s doorway. She stated she was not assigned to this resident but was working on the same hall on the night of [DATE]. She stated she did not see anything unusual at 1:00 AM. Nursing assistant #3 stated that after the incident, one of the staff members alerted her after the police had come. This was at approximately 6:00 AM when the police came on [DATE]. She stated she did not hear any alarms that night. The nurses were supposed to check the doors. The police took resident #1 to the hospital. She stated she had to meet with director of nursing about the elopement and was asked questions. She stated the nurses were instructed to watch the doors. An interview with the Director of Nursing (DON) was conducted on [DATE] at 9:10 AM. The DON stated all the doors were being checked twice a day after the incident. She stated that not all doors had Wanderguard alarm systems on them and that the other doors were being checked twice a day indefinitely. The DON stated most of the staff have been in-serviced on elopement and missing resident policy. No one had worked that had not been in-serviced first. The DON explained Resident #1 had a staff member with her at all times after the incident until she was discharged . She stated that it should be on the assignment sheets that resident had a staff member with her at all times to monitor her. The unit manager assessed the resident and gave her a shower when she returned from the hospital on [DATE]. The plan was to have the resident go someplace more secure but the family did not want that. The Administrator and DON were interviewed on [DATE] at 11:55 AM. The DON stated that some person (unsure of who) found the resident and called the police. The police called the EMS and the police called the facility to report. The DON and the administrator explained the nursing assistant that worked that night (no interview for her above) and Nurse # 2 had seen Resident #1 at 3:15 AM on [DATE]. The nursing assistant noticed the resident was not there when they passed ice around 5:00 AM, which was not unusual for the resident because she was frequently out of her room. According to the past weather report on [DATE] for Concord, NC, the temperature outside was 38.2 degrees Fahrenheit at 4:01 AM and 38.5 degrees Fahrenheit at 5:01 AM. According to the police communication record the resident was found on Country Club road, which was approximately 0.5 miles away from the facility. The resident was discharged to the hospital on [DATE] then expired for an unrelated illness. The facility presented the following plan of correction on [DATE] Resident elopement: dated Identified [DATE] Area Identified: The resident exited the facility on [DATE] at approximately 500 AM hours. No alarms sounded to alert staff of her exit from the facility. The resident was noted without any recent attempts and no voiced desire to leave the facility. The resident was oriented most of the time. The resident returned to the facility from the emergency room at 8:10 AM. Action taken: Notified administrator/ Director of Nursing (DON) - the responsible party was the charge nurse with target dated [DATE] and completed. Per witness statement, the nurse working stated she notified DON/Administration on [DATE]. Notify family and physician- responsible party was the charge nurse/DON with target dated [DATE] and completed. -family and Nurse Practitioner notified according to incident report Notify Regional Vice President (RVPO) - The responsible party was the administer (NHA) with target date on [DATE] and completed. Other facility resident present verified- responsibly party was the charge nurse with target date of [DATE] and completed. A census sheet dated [DATE] stated on [DATE] at 6:15 AM a head in bed resident check revealed all residents except room 178 were in their rooms/accounted for. (94) Do Wanderguard checks/orders for placement and function. Ensure order present and to check placement every shift and function every day- responsible party was DON and target date was [DATE] and stated it stated check complete and all present. - Wanderguard audit completed [DATE] on residents at risk for wandering for function, location, care plan, Medication Administration and expiration date of Wanderguard and location. - Per nursing note on [DATE], the resident came back to the facility with her Wanderguard on and functioning. Initiate short term close observation for the resident to ensure safety until determined no longer needed- responsible party was the DON with a target date of [DATE]. The plan also stated one to one observation was initiated upon return from the emergency room . - Staffing schedules from [DATE] till resident ' s discharged revealed 1 staff member was assigned to the resident. Update the elopement risk assessment- responsible party was the DON and completed - An elopement risk assessment was completed and updated on [DATE]. Update the care plan- responsible party was the MDS and completed - Resident #1 Care plan was updated on [DATE] Check preventative maintenance logs to ensure appropriate monitoring- responsible party was the Administrator with target dated of [DATE]. - Weekly door checks were being completed and ongoing. Completed on [DATE], [DATE], and [DATE]. (none completed from [DATE]- [DATE]) - Wanderguard door checks completed [DATE] through [DATE]. Nurse Practitioner (NP) to assess for potential acute medical condition- responsible party was the NP with target dated [DATE]. The Plan of correction stated no issues identified in emergency room /nurse practitioner. - NP note dated [DATE] revealed the resident was seen for elopement. Hospital discharge summery reviewed. Conduct investigation as needed- responsible party DON/administrator with target dated [DATE] and initiated. - Staff (Nursing assistants, nurses, maintenance, DON and unit manager etc) were interviewed on [DATE] that were working third shift on [DATE]. Discuss alternatives placement with family (ie: locked unit) - responsible party was the social worker (SW) with a target dated of [DATE] and stated the DON discussed briefly with son on [DATE]. SW will continue to issue identified. -Fax confirmations reviewed for attempting to transfer resident #1 to a locked unit. Fax dates were dated [DATE]. Door checked for function- responsible party was Maintenance with target date of [DATE] that stated issue identified. Staff assigned to visually monitor doors until repaired. Repairs completed and doors functioning properly. - Staff had signed a paper starting they were assigned to watch the doors on [DATE] from 9:00 AM to 2:00 PM. The paper stated per the fire marshal there will be door checks on the hour every hour on fire watch. According to documentation, the front door was watched from 9:00 AM to 2:00 PM. C/D door was watched 9:00 AM to 1:00 PM and 1 unlabeled sheet revealed a door was checked at 10:00 AM and 11:00 am and 1 other unlabeled sheet revealed a door was checked from 12:00 PM to 2:00 PM on [DATE]. Potential residents Identify residents with the potential to be affected through review of elopement risk assessments, review of incident/accidents. Actions: Update risk assessment for residents currently with Wanderguard in facility, review elopement risk assessments for other resident and update as needed- responsible party was the DON target date was [DATE] and completed. - Elopement risk data collection dated [DATE] through [DATE] identified all resident who were at risk for elopement. An elopement scoring report was also completed and dated [DATE] for all resident ' s. Review and update care plans as needed- responsible party was the DON and Minimum Data Set nurse; target date [DATE] and completed. - Other resident ' s reviewed for wandering in the extended survey had updated care plans in place for wandering behaviors. Maintain an ongoing list of resident who have a Wanderguards are in the Wanderguard book. The responsible party was the DON with target date [DATE] and completed and on- going. - The Wanderguard book was reviewed on [DATE] for resident ' s that were at risk for wandering. The book was located at the nurse ' s station. For each resident with a Wanderguard bracelet, ensure physicians order for Wanderguard placement for checks every shift and for function checked every day to be on the Medication Administration Record (MAR)/Treatment Administration Record and are signed off as completed. Check expiration date of Wanderguard- responsible party was the DON and target date was [DATE] and completed. - All resident that were at risk for wandering and had orders for a Wanderguard device were reviewed on [DATE]. - Wanderguard audit completed [DATE] (on residents at risk for wandering) for function, location, care plan, MAR and expiration date of Wanderguard device. Updated elopement risk assessment develop/update care plan for other resident- Responsible party was the DON, unit manager, Minimum Data Set nurse with target date [DATE] and completed. - Wanderguard audit completed [DATE] on resident at risk for wandering for function, location, care plan, MAR and expiration date of Wanderguard. Check each exit/door monitoring unit for function and range to ensure in good working order/other preventative maintenance as directed by policy/manufacturer ' s directions. Follow preventive maintenance schedule- responsible party was maintenance/DON with target date of [DATE] and stated this was ongoing. The plan stated the problem with the door identified and corrected on [DATE], the door company called to check/repair door on [DATE]. - Per interview with the door company, the doors were fixed and on observation the doors were locked. - Policy and procedure for elopement was reviewed. Discuss in morning meeting Monday through Friday - responsible party was the DON/Administrator with target date was ongoing. - Quality Assurance and Performance improvement (QAPI) meeting dated[DATE], [DATE], [DATE] and [DATE] and [DATE] revealed elopement was reviewed during meeting. Measure/Systemic Changes Action: In-services staff regarding door alarms- responsible party was maintenance with target date [DATE]. 13 staff members were in-serviced on [DATE] at 7:00 PM on use of the panic button if there is a fire alarm. In-service staff in facility regarding elopement risk, care plans, doors, code silver . Responsible party was the DON/remote patient monitor with target date of [DATE] started and on-going until complete. - In-services were started on [DATE] and went through [DATE]. There were 17 staff members that were either scheduled to be in services after [DATE] or were not on the working schedule that had not been in-serviced. The in service sheet for elopement stated 74% of staff education was completed. Elopement risk assessment to be completed on admission, Quality, annual, and with a significant change and if there was an incident utilizing the same schedule. The responsible party was the MDS nurse /unit manager/charge nurse and was on-going. - Wanderguard Audit sheet stated that all resident that were at risk for wandering were audited for elopement risk assessment due with quarterly on [DATE]. Administration staff to monitor for compliance of Wanderguard doors function and placement through random audits/reviews of MAR/TAR ' s- Responsible party was the DON and was on-going. - Wanderguard audit completed [DATE] (on resident at risk for wandering) for function, Location, care plan, MAR and expiration date of Wanderguard and location. Daily door checks at least once per day with plans for two times/day to be done by maintenance, floor tech/administration- responsible party was maintenance door/floor tech and was on going. - Wanderguard door checks were being completed at least once a day when reviewed from [DATE] through [DATE]. - Weekly door checks were being completed and ongoing. Weekly door checks were completed on [DATE], [DATE] and [DATE]. (None were completed from [DATE]- [DATE]) - Door checks completed [DATE] through [DATE] weekly. Monitoring/QAPI Review of 24 hour report and incidents/accidents in morning at stand up meeting- responsible party was the interdisciplinary team and target date was ongoing. - QAPI meetings dated [DATE], [DATE], [DATE], [DATE] and [DATE] revealed elopement was reviewed. Review of maintenance and door related issues- responsible party was the DON/unit manager/change nurse and target dated was ongoing and stated changed to order for date. - QAPI meeting dated [DATE], [DATE] and [DATE], [DATE], [DATE] revealed elopement was reviewed. Check expiration dates of wander guard routinely (quarterly minimum) - responsible party was the DON/UM/charge nurse with target dated on going. - QAPI meeting dated [DATE], [DATE] and [DATE] and [DATE] and [DATE] revealed elopement was reviewed. - Wanderguard audit revealed the resident at risk for elopement with a Wanderguard on had the expiration checked on [DATE] and the date documented on the audit sheet. Review of incidents/accidents monthly analyzing for trends/patterns and reporting to QA&A committee. Plan to be adjusted based on outcome/patterns identified- responsible party was the DON/IDT/QA and target date was ongoing. - QAPI meeting dated [DATE], [DATE] and [DATE] and [DATE] and [DATE] revealed elopement was reviewed. On [DATE] at 10:05 AM, the credible allegation of compliance was validated. The survey team confirmed the doors were working properly and that other residents who were identified as an elopement risk were being monitored; the facility implemented auditing tools to validate the function, location, and orders of residents who had Wanderguard devices; staff was re-educated on the policy and procedure for elopement, care plans, doors and code silver , which was still on going as of [DATE]; a system was in place for checking the function of the doors and of the Wanderguard system.

Based on record reviews, resident and staff interviews, the facility failed to provide assistance from two staff during a mechanical lift in the shower. The resident fell from the mechanical sit to stand lift and sustained a fractured femur for 1 of 3 residents sampled for supervision to prevent accidents (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent quarterly minimum data set ((MDS) dated [DATE] revealed that Resident #1 was cognitively intact and had no behaviors. The MDS further revealed that Resident #1 required total assistance of 2 staff members with transfers and had functional limitations on one upper and lower extremity. The MDS also stated that Resident #1 had no falls during the look back period. Review of a facility policy titled No lift Policy revised 08/04/09 read in part All transfers requiring the mechanical lift will be performed with 2 co-workers during the mechanical lift process. Review of a care plan initiated 03/01/11 read, in part, Resident #1 was at risk for falls secondary to [DIAGNOSES REDACTED]. The goal of the care plan was Resident #1 would not have a fall with injury through the next review date. The intervention of the care plan included: Educate staff on 2 person assistance during the use of the mechanical lift (initiated 05/05/15). Review of a Physical Therapy (PT) Evaluation and Plan of Care dated 02/19/16 indicated that Resident #1 required the use of a sit to stand lift and the short term goal was Resident #1 would transfer with the sit to stand lift with modified assistance of 2 staff members. Review of a facility document titled Kardex with no date noted read, in part, that Resident #1 required the mechanical stand up lift with assistance of 2 staff members. Review of a nurse's note dated 06/23/16 at 4:23 PM read resident was lowered to the floor in the shower room during care. Resident #1 complained of left knee pain. X-ray to left knee was ordered stat, no injury noted. Assisted back to chair then to bed by staff. Will continue to monitor. The note was signed by Nurse #1. The facility was unable to provide an incident report or investigation of the fall. Review of a physician order [REDACTED]. Review of a Radiology Report dated 06/23/16 read in part: No fracture or dislocation is seen. Conclusion: Mild OA of the left knee. Review of a physician order [REDACTED]. Review of Radiology Report of left hip dated 06/30/16 read Conclusion: Acute, displaced left femoral neck fracture as noted. Interview with Nursing Assistant (NA) #2 on 07/14/16 at 9:18 AM revealed that she was walking a patient right past the shower room 06/23/16 and she heard Resident #1 hollering for help so she went to the shower room. NA #2 stated when she opened the door she saw Resident #1 hanging from the sit to stand lift with her bottom pooched out and NA #1 was the only other staff member in there at that time. Before NA #2 could get to Resident #1 she was on the floor. NA #2 stated it looked like the chair slid out from under her. NA #2 stated that when Resident #1 landed on the floor her feet were still in the base of the sit to stand lift. NA #2 further stated that Resident #1 kept saying my leg hurts, another staff member had went and got the nurse and then they transferred Resident #1 off the floor and put her in her wheelchair. NA #2 stated that after Resident #1 was back in her wheelchair I left the shower room and did not assist in getting Resident #1 back to her bed. Interview with Resident #1 on 07/14/16 at 9:56 AM revealed that on 06/23/16 between 11:00 AM and 12:00 PM NA #1 and #2 got her out of bed with the sit to stand lift, and then NA #1 proceed to push me to the shower room. Resident #1 stated that NA #1 proceed to hook up the sit to stand lift by herself and while being lowered to the shower chair heard NA #1 say the chair is tipping forward and Resident #1 stated the next thing I knew I was on the floor and I started hollering help. Resident #1 stated that NA #2 heard her hollering help and came in to the shower room and I was laying on the floor with my feet still in the base of the stand-up lift. Resident #1 stated that when Nurse #1 came into the shower room she asked me if I was hurting and I stated while rubbing my left knee yes my knee is hurting bad, I told them that my knee did not bend because of my [DIAGNOSES REDACTED] and it was bent so I knew something was wrong. Resident #1 stated 3 NAs rolled me from side to side to get me on the total lift pad and lifted me off the floor and put me back in my wheelchair and took me to my room and laid me on my bed. Resident #1 stated she was informed that the X-ray of her knee was negative for a fracture. Resident #1 stated that a week later her MD came to see her and ordered additional X-rays and that is when they discovered the fractured femur. Resident #1 stated that the whole thing could have been avoided if NA #1 would have had someone in the shower room to help her. Interview with the MD on 07/14/16 at 10:36 AM revealed that initially the staff reported to him on 06/23/16 that Resident #1 was lowered to the floor and was complaining of left knee pain so he ordered an X-ray of that area and those were negative. The MD stated that he did not hear anything from the staff until he returned a week later for his regularly scheduled visit to the facility and the staff then reported that Resident #1 was still complaining of pain so he went and examined Resident #1. The MD noted that her pain was a little higher than the knee so he ordered an X-ray of her hip and that is when the fracture was detected After noting the fractured femur they made her non weight bearing and scheduled an appointment with an orthopedic doctor the next day. The goal was to keep Resident #1 on bed rest to allow the fracture to approximate and heal. Interview with Nurse #1 on 07/14/16 at 12:14 PM revealed that on 06/23/16 she was passing her morning medications and one of the NAs called her to the shower room and what she was told was that Resident #1 was lowered to the floor. The NAs explained that while lowering Resident #1 to the shower chair it had moved and Resident #1 was lowered to floor. Nurse #1 stated that she did move Resident #1's left leg and Resident #1 complained of pain in the left ankle. Resident #1 reported to her that while the staff was trying to lower her they had twisted her leg and she was hurting from her knee to her ankle. Nurse #1 stated that Resident #1 had no other injury and no obvious deformity but was complaining of pain. Nurse #1 stated that they used the total lift to get Resident #1 off the floor and into her wheelchair and took her back to her room and put her back to bed. Nurse #1 stated that luckily the doctor was in the building and I was able to obtain an order for [REDACTED]. Interview with NA #2 on 07/14/16 at 12:28 PM revealed that on 06/23/16 she had transferred Resident #1 by herself to the shower chair and Resident #1 had leaned forward and the chair started to tilt forward. NA #1 stated that I jumped in front of her and yelled for help and NA #2 came into the shower room and they grabbed Resident #1 but were unable to get her back into the chair so they lowered her to the floor. NA #1 stated that Resident #1 was hollering get my foot and one of the NAs grabbed her feet off the sit to stand lift. NA #1 stated that 3 NAs assisted in rolling Resident #1 from side to side to get her on the total lift pad and they lifted her off the floor and back to her wheelchair and took her back to her room and put her back in the bed. NA #1 stated that Nurse #1 had come in and assessed Resident #1 before they lifted her off the floor. NA #1 also stated that she was aware that all mechanical lifts required 2 staff members but stated Resident #1 gets upset if she has to wait for help, so on this day I just went ahead and lifted her by myself. Interview with the Director of Nursing (DON) on 07/15/16 at 12:18 PM revealed that she would have expected NA #1 to have another staff member with her while lifting Resident #1 on 06/23/16 because we can't take chances with these residents. After the incident we did some re-education with the staff on the importance of following the facility policy and for safety reason all lifts requiring the mechanical lift require 2 staff member to be present. Interview with the Administrator on 07/15/16 at 1:14 PM revealed that she would expect the staff to follow the facility policy that all lifts requiring the use of a mechanical lift must have 2 staff members present, at that same time honoring the request of the resident.

Based on observation, staff interviews and record review, the facility failed to prevent one (1) of seven (7) cognitively impaired residents (Resident #4) who exhibited wandering behaviors from eloping from the facility. On December 9, 2013, December 22, 2013 and December 25, 2013, Resident #4 exited the building unsupervised by staff. Immediate Jeopardy began on 12/09/13 and was identified on 12/31/13 at 5:33PM. Immediate Jeopardy was removed on 1/2/14 at 6:30 PM when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems put in place and 100% of employee training. Findings included: The manufacturer's instruction on wanderguards was reviewed. The instruction indicated under warning "Do not place the signaling device on or next to metal such as wheelchair frames, jewelry, watches, etc (etcetera) or allow it to come in contact with a door or associated hardware, such as crash bar, push bar, etc. Metal could interfere with the signal sent to the door module." Resident #4 was originally admitted to the facility 7/1/09 with last readmitted d 10/5/13. Cumulative [DIAGNOSES REDACTED]. Ammonia is a toxic substance normally made harmless by the liver. In liver disease, ammonia builds up in the body and elevated ammonia levels can cause, in part, poor judgment, disorientation, confusion and changes in thinking). An elopement risk assessment dated [DATE] indicated Resident #4 propelled herself and had some assistance with propelling. Resident #4 was content with placement; no attempt at elopement. No behaviors noted. Safety measures being implemented--wander bracelet/ roam alert. Score 6.0 (score of 10 or greater puts resident at risk). A Quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #4 had short term and long term memory impairment and modified independence with cognitive skills. She required limited assistance with transfers. No ambulation occurred during the assessment period. Resident #4 was independent with locomotion on and off the unit. There was no limitation in range of motion for the upper/ lower extremities. Mobility device used was checked as wheelchair. A care plan last reviewed in November 2013 revealed Resident #4 was at risk for elopement from facility related to confusion as evidenced by episode of elopement from facility. Interventions included: approach in a quiet, calm manner using a soft voice. Ensure a wanderguard (security alarm bracelet) was in place at all times and working properly. Notify physician, responsible party, Administrator and DON (Director of Nursing) of any elopement attempts; observe whereabouts at all times in the facility. Provide assistance with ambulation. A nursing note dated 11/10/13 at 3:10 PM stated Resident #4 attempted to leave through the front door. Supervisor aware of need for wanderguard bracelet. A nursing note dated 11/10/13 at 6:12 PM stated wanderguard applied to left wrist at 4:30 PM. No further attempts to go out of a door thus far this PM. A nursing note dated 11/13/13 at 10:56 AM stated Resident #4 at around 7:30 PM was seen between the two front doors at the front of the building. She had gotten out of the first door. Her wanderguard bracelet was intact and on her left wrist. She was brought back inside by the supervisor on 3-11 shift. A care plan dated 11/14/13 was reviewed. One of the care problems indicated Resident #4 was an elopement risk/ wanderer AEB (as evidenced by) history of attempts to leave facility unattended. Interventions included: Distract Resident #4 from wandering by offering pleasant diversions, structured activities, food, conversation, television and book. Wander device to remain on resident. A care plan dated November 2013 was reviewed. One of the care plan problems indicated Resident #4 at times had delirium or an acute confusional episode related to an association with increased ammonia levels. Interventions included: monitor and report to physician new onset signs/ symptoms of delirium-changes in behavior, altered mental status, wide variation in cognitive function throughout the day, disorientation, communication decline, lethargy, restlessness and agitation. A nursing note dated 12/1/13 at 5:49AM stated Resident #4 was alert and responsive with periods of confusion noted. A nursing note dated 12/2/13 at 2:49AM stated Resident #4 was alert and verbal with confusion. A nursing note dated 12/9/13 stated Resident #4, at around 9:30 PM was noted by another resident (Resident #1) leaving the facility. Resident #4 was found outside on the side of the building. Resident #4 did not have on a wanderguard bracelet. An incident report dated 12/9/13 at 9:30 PM was reviewed and revealed the location of occurrence was outdoors. Resident #4 was observed leaving the building by another resident (Resident #1). Nursing assistants went to get her and she was outside in the parking lot. She was in her wheelchair. Follow-up investigation noted that Resident #4 removed her wanderguard bracelet before she tried to elope. The wanderguard bracelet was replaced on Resident #4. Hourly rounds on Resident #4 were put into place. The report did not document how many days they planned to do the hourly rounds. A witness statement regarding the elopement on 12/9/13 by NA #1 stated she was at the A hall nursing station around 9:30PM when Resident #1 came up to her and stated that Resident #4 was seen outside of the building. NA#1 stated she and NA #2 ran out the front door and to the parking lot of the right side of the building and found Resident #4 almost to the sidewalk. They returned Resident #4 inside the building and immediately reported the incident to the supervisor. A witness statement regarding the elopement on 12/9/13 by NA #2 stated she was at A hall nursing station doing flow books around 9:30PM. Resident #1 came up in his wheelchair saying resident #4 had gone out the front door in the front lobby. She and NA #1 went down to the lobby and outside. Resident #4 was in her wheelchair on the left side of the building near the curb of the parking lot. Resident #1 who saw Resident #4 exit the building was no longer in the facility and unable to be interviewed. A review of laboratory results revealed an ammonia level on 12/10/13 was 136 (normal is 11-35). On 12/30/13 at 4:56 PM, Nurse #1 stated it was a resident who actually saw Resident #4 go out of the building. Nurse #1 stated Resident #4 had been without a wanderguard bracelet for awhile and did not have a wanderguard bracelet in place on 12/9/13. Nurse #1 stated she did not have a wanderguard bracelet available to put on Resident #4 and Resident #4 was put on every fifteen (15) minute checks ( documentation stating where Resident #4 was located and what she was doing every fifteen minutes) after she came back in the building. She stated Resident #4 stayed pretty much in her room the remainder of the evening shift. On 12/30/13 at 5:18 PM, Nurse #2 stated she was the evening supervisor on 12/9/13. She said the nursing assistants came to her and told her that Resident #4 had been spotted outside and they had brought her back in. She stated they notified the Administrator, Director of Nursing, physician and resident ' s RP (responsible party) at the time of the incident and locked the front door. Nurse #2 said the front door was typically locked around 8:00 PM by the A hall nurse when the receptionist left for the evening. Once the front doors were locked, an alarm would sound if someone went out of the door. Nurse #2 stated Resident #4 did not have a wanderguard bracelet on until sometime last week. She stated Resident #4 had a wanderguard bracelet on at one point but she did not know when it had been removed. Nurse #2 said she did not know anything until Resident #4 went out the door. On 12/31/13 at 9:31 AM, NA#1 stated Resident #4 was found in the front parking lot on the left side of the building close to the building. NA #1 said she did not know how long resident #4 was outside. She stated she did not think Resident #4 had a wanderguard bracelet on. NA #1 did not remember if any alarms went off during the time Resident #4 went out of the building. On 12/31/13 at 10:54 AM, NA #3 stated she was assigned to care for Resident #4 on the evening of 12/9/13. She said that was the first time she had provided care for Resident #4 and she was not made aware that Resident #4 was a wanderer until after she had already gone out of the building. On 12/31/13 at 11:22 AM, NA #2 stated Resident #1 came up to her and NA #1 and told then that Resident #4 got out the front door through the lobby. She stated Resident #4 was on the far right side of the building in the parking lot facing the rehabilitation building. Resident #4 told them she was trying to go to the store. NA #2 stated the time was around 10:00 PM. She said when they went out the front door in the lobby, no alarms went off when they exited the building and they did not have to unlock the front door when they went out to get Resident #4. On 12/31/13 at 11:30AM, an observation of the parking lot where resident was found on 12/9/13 was completed with NA #2. She pointed to the end of the building that would have been the right side of the building when going out the door and stated Resident #4 was in the parking lot area at the end of the building 12/9/13. It was observed that one of the main entrances was directly across from the end of the building and that entrance leads to a very busy 4 lane street with an additional lane in the center for turning. On 12/31/13 at 4:27 PM, Nurse #2 stated, from her understanding, Resident #4 was down at the end of the building near the sidewalk on 12/9/13. She said the nurse and nursing assistant responsible for Resident #4 said they had just seen her five (5) to ten (10) minutes prior to Resident #4 exiting the building. Nurse #2 said it was cold that evening and she thought Resident #4 had on a lightweight jacket and her regular clothes. Nurse #2 said Resident #4 did not have a wanderguard bracelet on and nursing staff did not have access to any of the wanderguard bracelets. She said the wanderguard bracelets were kept in the DON ' s (Director of Nursing) office and she was not aware that there were any kept on the med carts. Nurse #2 stated she worked on 12/10/13 and Resident #4 did not have a wanderguard bracelet on 12/10/13 and did not have one placed until the end of last week when Nurse #2 put one on Resident #4 ' s wheelchair. She said she did not think hourly rounds were actually initiated at all even after the 12/9/13 incident. On 12/16/13, laboratory results revealed Resident #4 ' s ammonia level was recorded at 69. A nursing note dated 12/19/13 at 11:32 PM stated Resident #4 still had no wander guard bracelet in place. A nursing note dated 12/22/13 at 01:36 AM stated Neomycin continued due to elevated ammonia without signs/ symptoms of adverse reaction. Confusion continued. A nursing note dated 12/22/13 at 4:36 PM stated a nursing assistant found Resident #4 outside in the back parking lot. Resident #4 said she was going to the store. No injuries were noted. Resident #4 was brought back into the building safely. A nursing note dated 12/22/13 at 8:30 PM stated a wanderguard bracelet was placed on Resident #4 ' s wrist. The nursing note did not document if the wanderguard was replaced at that time. An incident report dated 12/22/13 at 4:30 PM stated a nursing assistant noticed Resident #4 outdoors near the back parking lot. No injuries were noted. Mental status before occurrence was noted as alert/ disoriented and same after occurrence. Action taken: Keep closer eye on resident. Suggest wanderguard bracelet be applied again. A witness statement dated 12/22/13 by NA #3 said she was getting something out of her car. When she got out of her car, she saw Resident #4. When she asked her where she was going, Resident #4 said she was going to the store. NA#3 told her she could not go to the store and she would take Resident #4 out of the rain. Resident #4 said no and NA #3 knocked on the D hall door and the nurse helped NA #3 get Resident #4 inside the building. A nursing note dated 12/23/13 at 01:49 AM stated Resident #4 continued to be confused. Unable to locate wanderguard bracelet on patient (Resident #4). Patient was unable to recall when/ where/ if she removed it. There was no notation that a wanderguard bracelet was reapplied at that time. A review of laboratory results revealed Resident #4 ' s ammonia level on 12/23/13 was 58. On 12/31/13 at 4:50 PM, Nurse #3 stated the elopement on 12/22/13 occurred around 4:00 PM. She stated Resident #4 did not have a wanderguard bracelet on when she was found outside. Nurse #3 said she thought Resident #4 used to have one on but her legs were swelling so they took it off. She was not sure when the wanderguard bracelet had been removed. She stated she had never seen Resident remove any wanderguard bracelets. Nurse #3 said she put a wanderguard bracelet on Resident #4 ' s left wrist when she came back in the building. Nurse #3 said she did not think they figured out which door Resident #4 went out but she was in the back parking lot (employee parking lot). She thought it was cloudy that day and might have been lightly raining. Resident #4 was wearing her jacket. She said no alarms went off to alert them that Resident #4 had gone out of the building. A nursing note dated 12/25/13 at 11:38 AM stated Resident #4 went out the door unattended. She was returned to the facility and placed on every fifteen minute checks. An incident report dated 12/25/13 stated Resident #4 exited the facility unattended. No apparent injury was noted. Resident #4 was placed on every fifteen minute checks. A witness statement dated 12/25/13 by Nurse # 4 stated Resident #4 was noted outside and was returned by the receptionist. A nursing note dated 12/26/13 at 1:43 PM stated a wanderguard bracelet was attached to Resident #4 and was placed on the back of her wheelchair out of her view to prevent her from removing the bracelet. On 12/31/13 at 3:42PM, receptionist #2 stated she was working on 12/25/13 when Resident #4 went out of the building. She stated Resident #4 came up to the receptionist desk around 9:00 AM. She was between the receptionist desk and the Administrator ' s office. Receptionist #4 said the wanderguard alarm usually goes off when they are in that area but the alarm did not go off at that time. Resident #4 went toward the front door of the lobby. She was dressed in a patient gown and lightweight jacket. It was very cold that day. Receptionist #2 stated she got up and turned Resident #4 around and told her she needed to go back to her room. She watched Resident #4 go down D hall like she was going back to her room. Receptionist #2 said around 10:00 AM, she was at her desk typing, looked up and saw Resident #4 going past the front door in the parking lot at the front of the building. She stated she went out, talked to Resident #4 and brought her back in the building. She said she thought Resident #4 must have gone out the side door on d hall (employee door). No alarms had gone off when Resident #4 exited the building or when she brought her back in the front door. Receptionist #2 said she did not see her leave the building but Resident #4 could not have been outside the building more than ten to fifteen minutes. Receptionist #2 stated Resident #4 could manipulate her wheelchair all by herself and moved very fast in her wheelchair. On 12/31/13 at 5:27 PM, Nurse #4 stated Resident #4 was more agitated than usual on 12/25/13. She said the receptionist came and told her that Resident #4 had gone out the employee side door. Nurse #4 stated she could not find the wanderguard bracelet on Resident #4 when they brought her back into the building. Nurse #4 said she place Resident #4 on every fifteen minute checks until they put a wanderguard bracelet on her the next morning. When asked if Resident #4 usually wore a wanderguard bracelet, Nurse #4 stated she had been wearing one " for a good while " and had it on her ankle but her ankle swelled so nursing staff had put it on her wrist. She said nursing staff checked every shift to make sure it was there. Nursing documented placement and function on the Medication Administration Record (MAR). Nurse #4 said she had not checked for the wanderguard bracelet that morning. She said she had not seen Resident #4 take the bracelet off but she knew Resident #4 had taken it off in the past. A review of the November 2013 MAR revealed no record of monitoring for placement and function of wanderguard bracelet. A review of the December MAR revealed monitoring for placement every shift and function every night shift was initiated on 12/26/13. Documentation was noted that the wanderguard bracelet was functioning and in place on Resident #4 ' s wheelchair all shifts on 12/26/13 through 12/30/13. Physician orders [REDACTED]. On 12/30/13 at 5:50 PM, receptionist #1 stated there was a receptionist in the front lobby seven days a week and worked until 7:00PM. She said she notified the nurse on A hall when she was leaving for the day so the nurse could lock the front door and set the front door alarm with a key. On 12/30/13 at 5:55 PM, Administrative staff #1 stated there was always an alarm that went off for the wanderguard bracelets. He stated Resident #4 would cut off the wanderguard bracelet and one day last week, they were talking about where they could place the wanderguard bracelet so she would not cut it off. On 12/30/13 at 6:00 PM, the maintenance supervisor stated the front doors did not have an automatic lock on them. Nursing staff locked the door. An alarm would go off when the door was locked and alarm was activated. An observation of how the alarm worked was conducted. The nurse from A hall came to the front door and locked the door on the left side. She raised the handle on the right side and also activated the alarm by using a key in the keypad on the right side of the door. She demonstrated that the outside doors would open and there was a doorbell on the wall just inside those doors for people to ring for assistance. When she opened the inner door, a very loud alarm sounded and she said that was what sounded if someone was trying to exit the building from the inside. She said she usually locked the doors between 7:30 and 8:00 PM. On 12/31/13 at 8:20 AM, Nurse #5 stated Resident #4 could propel herself in the wheelchair and go all over the facility. Nurse #5 said Resident #4 used a wanderguard bracelet and it had been placed on her wrist and on her ankle in the past. He said Resident #4 would remove her bracelet from her wrist and staff were aware and knew she could do that. On 12/31/13 at 8:57AM, Nurse #6 stated both of the elopement care plans were in place and active. She said Resident #4 becomes more confused when her ammonia levels are elevated. Nurse #6 said Resident #4 has had a wanderguard bracelet since June 2011. She stated recently, Resident #4 decided she did not want it on at all. Staff had placed the wanderguard bracelet on her wheelchair because she needed her wheelchair to get around. Nurse #6 said she had checked for the wanderguard bracelet on 12/26/13 and it was on the back of her wheelchair at that time. On 12/31/13 at 9:20 AM, Administrative staff #2 stated, per the elopement policy, all people on risk for elopement had wanderguard bracelets on them. If a resident attempted to elope, nursing staff would notify her and the Administrator immediately. The nurse would document the elopement and, if the resident was injured, Administrative staff #2 would come to the facility. She said the family and physician were also notified of the elopement. Administrative staff #2 stated that documentation for monitoring for function and placement of the wanderguard bracelet was located on the MAR. She said functioning of the wanderguard bracelet is done by using a monitor and the light on the monitor turns green which shows the wanderguard bracelet is functioning properly. The facility only had one monitor to check for functioning of the bracelet. She stated there should have been documentation on the chart for placement and function of the wanderguard bracelet. On 12/31/13 at 9:20 AM, Administrative staff #2 said Resident #4 had recently broken five (5) of the wanderguard bracelets. She said nursing staff had applied the wanderguard bracelet to Resident #4 ' s wrist and Resident #4 had broken five of them. Nursing staff had told her over a month ago that Resident #4 was pulling the wanderguard bracelets off. They had changed the site of the wanderguard bracelet to Resident #4 ' s non-dominant wrist in November but that did not work. In December, they had placed the wanderguard bracelet on the ankle but Resident #4 ' s ankle became swollen so they placed it back on the wrist area. Administrative staff #2 stated she told the nursing staff to make sure that Resident #4 did not wander out of the building. She stated the last one was broken on December 20 something and was not sure of exact date. She said the last wanderguard bracelet was applied to the back of the wheelchair arm. On 12/31/13 at 11:47 AM, Administrative staff #3 stated Resident #4 had worn a wanderguard bracelet for a long time. Nursing staff on the floor were supposed to check for function and placement of the wanderguard bracelet every shift and record on the MAR that the wanderguard had been checked. She said there were new wanderguard bracelets available on each medication cart so they could be replaced if they were not functioning properly. The monitor ( a wireless portable device for testing wanderguard ID signaling device bracelets and for testing working operation for wanderguard ID door monitors and door alarms) to check the wanderguard for functioning was kept on the A hall at the nursing station or in the med cart. Administrative staff #3 said the monitor was not working and they had ordered a new one that day. She said she had not been aware the monitor was not working until 12/31/13. She also stated there were no wanderguard bracelets available in the building-none on the medication carts. On 12/31/13 at 12:00 noon, Resident #4 ' s wheelchair was taken to the front lobby door and the wanderguard alarm sounded appropriately. The alarm also sounded appropriately when the wheelchair was taken to the D hall side door (employee door). Resident #4 was not in the building at the time and had been admitted to the hospital on [DATE] due to an elevated ammonia level and lethargy. On 12/31/13 at 12:15 PM, the person who ordered supplies stated she had not been aware that there were no extra wanderguard bracelets in the building and that the wanderguard monitor was not working until 12/31/13 and had ordered both today as well as some extra wanderguard bracelet straps. An invoice dated 12/31/13 at 8:46AM was noted for a universal door/ trigger tester for the wanderguard bracelets and another invoice dated 12/31/13 at 7:49 AM was noted for four (4) signaling devices and ten (10) wristbands. On 12/31/13 at 4:00 PM, Administrative staff #2 stated the wanderguard bracelet was replaced on 12/9/13-wanderguard was good, just needed straps. She indicated nursing staff said the bracelet was found on the floor. She stated she expected nursing staff to document in the nursing notes when they replaced the wanderguard bracelet along with the location of the wanderguard. She said nursing staff has wanderguards in the med carts for replacement if needed but Resident #4 had broken five of the wanderguards and facility has had to order more. She also stated that resident had been on hourly monitoring since October 2013. The paper was posted on her door and every staff member was supposed to document on the paper every hour. Administrative staff #2 said they tried every fifteen checks around September and was changed to hourly checks in October. When asked regarding care planning and changes if needed, she said the care planning team (MDS coordinators) was present in the morning meetings. Resident #4 had been discussed in morning meeting in December and that was where they decided to put the wanderguard on the wheelchair. On 12/31/13 at 4:15 PM, Administrative staff #6 stated Resident #4 ' s care plan stated to have the wanderguard on at all times and if she was taking them off, nursing staff needed to put another one on. If she was exhibiting the behavior of taking them off, the social worker would be the one to care plan that behavior and that must have been why the social worker added to the care plan 11/14/13. She said she learned that resident was taking off the bracelets in December (week of Christmas) and the bracelet was moved to the back of her wheelchair. On 1/2/14 at 9:30 AM, Administrative staff #1 stated the side door (employee door) was not locked during the day and the alarm was turned off when going on and out; however, if a resident had a wanderguard alarm on, the alarm will sound when they go near the door. An observation of the alarm system was conducted using a resident who had a wanderguard bracelet on her wrist and a loud alarm sounded when the door was approached by the resident who had a wanderguard bracelet on. The alarm sounded until a staff member reset the alarm. On 1/2/14 at 3:00 PM, Administrative staff #2 stated she had the following twenty four hour (24) reports with the following information noted: 12/9/13 Resident #4 was started on hourly rounds. On 12/23/13, Resident #4 removed wanderguard and needs new one; eloped Saturday (12/22/13). On 12/25/13, Resident #4 went out of the building-every fifteen minute checks. Administrative staff #2 said she had looked but was unable to find hourly round sheets for 12/9/13, 12/22/13 and 12/25/13. The Administrator was notified of the Immediate Jeopardy on 12/31/13 at 5:33PM. The facility presented a credible allegation of compliance on 1/2/14 at 6:30 PM. which included: Address how the corrective action will be accomplished for those residents found to have been affected by the deficient practice: It is the practice of this facility to provide nursing services relevant to maintaining a safe environment for all residents. It is the practice of this facility to assess all residents to determine what safety interventions are necessary to prevent elopement. Those residents who have been identified as an elopement risk by the facility interdisciplinary team inclusive of the physician, nursing staff, and social worker will have appropriate interventions care planned and implemented with the goal of maintaining safety and minimizing the risk for elopement. Corrective action has been achieved for Resident #4 due to being in hospital. Resident # 4 was discharged to hospital on December 30th 2013. Upon return of resident #4, the facility will assess resident for elopement risk and follow facility policy and procedure. How corrective action will be accomplished for those residents having potential to be affected by the same deficient practice: All other facility residents with impaired cognition that do not understand the safety implications for elopement behavior have the potential to be affected by the same alleged deficient practice. All facility residents were assessed for Wandering and Elopement behaviors on December 31, 2013 by members of nursing administration inclusive of the Director of Nursing, Assistant Director of Nursing, and Licensed Practical and Registered Nurses. The assessment tool is inclusive of evaluation of cognition, physical functioning, history of wandering, and diagnoses. Any and all residents identified as an Elopement/Wandering risk has had a care plan created or reviewed to determine appropriate interventions necessary to meet the intended goal of providing safety through minimizing the risk of elopement. Address what measures will be put in place or systemic changes made to ensure that the deficient practice will not occur: In-service education was provided to all facility personnel on the current policy for Wandering and Elopement beginning on December 31, 2013 and completing on January 1, 2014. In-service education completed by the facility educator and was inclusive of: Inclusive list of all residents identified as being at risk for Wandering and Elopement will be maintained at each nurse ' s station. Members of Administrative Nursing including the Director of Nursing, Assistant Director of Nursing, Resident Care Management Director, and other members of the IDT will review the cumulative list weekly to determine if those identified residents are still exhibiting behaviors indicative of a risk for wandering and elopement. All staff who sees any resident having exit seeking behaviors will report the behaviors to residents nurse. Staff will also try and redirect resident. Nurse will evaluate resident for elopement risk and follow facility policy and procedure for elopement risk. Residents deemed at risk will have wanderguard bracelet placed for safety and monitoring. Facility will keep extra bracelet on med carts at all times. In the absence of bracelet, facility will provide one on one monitoring until available. Extra bracelets were ordered on [DATE]. Date of Completion: January 2, 2014 Immediate Jeopardy was removed on 1/2/14 at 6:30 PM. Observations of residents with wanderguard bracelets revealed bracelets were appropriately placed on the residents and/or on wheelchairs. Interviews with direct care staff and licensed staff confirmed they had received in-servicing on responding to the alarm system, monitoring of the wanderguard alarm bracelets, checking the bracelets for functioning and appropriate documentation and what to do if the bracelets did not function properly and/or were not in place on residents who wore the wanderguard bracelets. The location of the book containing the names of residents who wore the wanderguard bracelet was in place at A/B hall and C/D hall nursing stations. Documentation was provided by the facility that a new monitoring device and a supply of extra wanderguard bracelets had been ordered. Checks of the wanderguard door alarms were conducted and the alarms functioned properly.

Based on review of records from the facility, hospital and emergency medical services and interviews with staff, physician and emergency medical technician, the facility failed to ensure residents were free of an excessive dosage of [MEDICATION NAME] (a narcotic [MEDICATION NAME]) for one of three residents (Resident #3) receiving [MEDICATION NAME]es. The findings included: Resident #3 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Physician orders [REDACTED]. For diabetes management, orders included [MEDICATION NAME] N (an intermediate-acting insulin) 24 units with breakfast and 12 units with supper, and Humalog (a rapid acting insulin) 12 units daily with breakfast and sliding scale before meals and at bedtime. (Blood samples, obtained by fingerstick, must be checked for glucose levels so that the appropriate dose of insulin can be administered in accordance with the sliding scale.) On [DATE] the [MEDICATION NAME] was changed to 50 mg every 3 hours as needed for severe pain. The History and Physical (H&P) dated [DATE] indicated the resident had chronic pain and was under consideration for surgery for [REDACTED]. Physician orders [REDACTED]. On [DATE] physician orders [REDACTED]. The physician was interviewed on [DATE] at 3:20 PM. He indicated that the resident demanded that the fingersticks get stopped, so he discontinued the sliding scale insulin and did not order periodic fingersticks. The physician stated he expected staff to check a blood glucose only if the resident was showing signs of [DIAGNOSES REDACTED] or [MEDICAL CONDITION]. The admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #3 was cognitively intact and had frequent pain. The Care Plan for pain, dated [DATE], revealed a problem of back pain, requiring pain meds daily. Interventions included administering medications as ordered and notifying the physician if ineffective. physician progress notes [REDACTED]. On [DATE] the [MEDICATION NAME] was changed to 50 mg every 3 hours for back pain, hold if drowsy. On [DATE] Resident #3 presented to the pain clinic. The visit note indicated that surgery was the only option that would provide relief. Physician orders [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]#2. There was no documentation that the previous patch was removed. During an interview on [DATE] at 12:43 PM, Nurse #2 stated she had only taken care of Resident #3 one time and did not recall details. She said she would have administered the [MEDICATION NAME] on [DATE] because it had come up on the electronic MAR indicated [REDACTED]. She did not recall if she actually removed a [MEDICATION NAME] from Resident #3. Nurse #2 also indicated she could not recall if removal of the old patch was something she would document. Nurse's notes, written by Nurse #3, dated [DATE] at 2:21 PM read, "Resident at 11 AM requested a bacon sandwich which was not available and refused alternative that was offered. At 11:30 AM resident requested her scheduled pain med which was given. At 11:45 AM resident requested for iced (sic), Resident was observed by staff at 12:30 PM unresponsive, writer and other staff (responded) immediately, on assessment resident BS (blood sugar) 27, [MEDICATION NAME] (an injectable medication used to raise low blood sugar) 1 mg injection given, medic called and resident sent to the ED (Emergency Department)." Emergency Medical Services (EMS) record dated [DATE] indicated arrival time at the resident's bedside was 1:38 PM. The notes read in part, "Patient was found unresponsive lying in bed. Breathing normally. EMS was advised that staff had been administering insulin without first checking blood glucose. Patient had also been receiving narcotic pain medication every 3 hours and had 2 [MEDICATION NAME]es on her chest and back. Patient's blood glucose was checked at 27. An IV (intravenous access) was established and 25 grams of D50 (a 50% solution of [MEDICATION NAME] and water to raise blood sugar) was administered. Blood glucose was rechecked at 327 however, patient was still unresponsive. Patients pupils were checked and were pinpoint. 1 mg of [MEDICATION NAME] (a drug to counteract narcotics) was administered with improvement. Patient was still not completely alert and was very lethargic. Responsive to verbal and painful stimuli." Emergency Department records indicated Resident #3 was alert on arrival and pupils were equal and reactive to light. The resident scored 11 - 12 on the Glasgow Coma Scale (the range is 3 - 15, with 3 indicating deep coma and 15 is fully awake). The hospital discharge summary dated [DATE] revealed the resident was admitted due to altered mental status and significant back pain. While hospitalized , the resident had an aspiration event, subsequent [MEDICAL CONDITION] and expired on [DATE]. During an interview on [DATE] at 12:47 PM, Nurse #3 recalled sending Resident #3 to the ED. The nurse said the resident was demanding pain medication that morning, and settled for her scheduled dose of [MEDICATION NAME] at 11:00 AM. The nurse recalled that the resident had requested a sandwich, but when the Nursing Assistant (NA) brought it in the resident refused it because it was not the kind of sandwich she ordered. Nurse #3 did not recall what was meant by "iced" in the note she wrote. The nurse said a little while after giving the [MEDICATION NAME], someone reported to her that the resident was unresponsive. She checked the BS and it was in the 20's. She gave [MEDICATION NAME] and called Emergency Medical Services (EMS). The nurse stated when the Emergency Medical Technicians (EMTs) arrived they administered glucose and her blood sugar came up to the 300's but the resident was not responding. The nurse recalled the EMT saying the resident's pupils were pinpoint and an antidote was given. Nurse #3 indicated that the resident did respond. The nurse remembered seeing a [MEDICATION NAME] on the resident's left shoulder and also saw a [MEDICATION NAME] patch on her. The NA assigned to Resident #3 on the ,[DATE] shift on [DATE] and [DATE] was unavailable for interview during the survey. During an interview on [DATE] at 3:53 PM, the EMT primary caregiver for Resident #3 recalled that the resident did not respond much after the glucose was administered but she did respond more after [MEDICATION NAME] was administered. The EMT indicated he did not notice that the resident had a 2nd [MEDICATION NAME] on her until she was in the ambulance. The EMT said he removed both [MEDICATION NAME]es plus a third patch that had no identification ([MEDICATION NAME] is a plain white patch). During an interview on [DATE] at 2:45 PM, the Director of Nursing (DON) explained that the original entry on the MAR for the [MEDICATION NAME] was discontinued because the resident had requested a change in the administration time. She said the nursing supervisor intended to update the order with the new administration time but the computer system discontinued the old order and entered a new order on the MAR. The computer automatically prompted the first dose to be given on the same day that the change was made. The DON said she had just become aware of this problem and will work with the corporate office for resolution.