Every finding on record at Highfield Nursing and Rehabilitation

Based on observations and resident and staff interviews, the facility failed to maintain intact tiles and grout on a shower room floor and prevent black colored buildup on the shower floor, walls, and ceiling in 1 of 2 shower rooms reviewed for safe, clean, and homelike environment (100/200 shower room).Review of the quarterly MDS dated [DATE] for Resident #29 coded her as cognitively intact.On 3/23/26 at 2:39PM an interview was conducted with Resident #29 that revealed she received showers in the 100/200 shower room [ROOM NUMBER] times per week. Resident #29 went on to state that while receiving showers, she had observed what she described as black colored mold and filth on the walls and the ceiling. She described observations of what she believed was mold, and she felt it had been there since she was admitted (on 7/28/25) but was confident she had observed the mold to be in the shower for at least the past 3 months. Resident #29 indicated she had not reported this or complained about it to anyone in the facility.An observation was made on 3/23/26 at 3:47PM of the 100/200 shower room. The observation revealed an area of 1 inch by 1-inch ceramic floor tiles, under the shower head broken and loose from the grout and mortar of the shower floor. The shower walls contained 6 inch by 6 inch ceramic tiles. These tiles were noted to be broken along the base of the wall under the shower head. There were several areas of black colored buildup noted on various areas on the tile walls, (on both tile and grout), and on the tile floor (on both tile and grout). There was a large, mostly tan in color, about 3 feet in diameter, discolored ring noted to be on the ceiling which also had spotted black colored discoloration throughout the ring.An interview was conducted on 3/23/26 at 3:50PM with Nurse Aide (NA) #3 who revealed that she was aware of the black colored buildup on the 100/200 shower room floors and walls but she did not report to anyone and did not provide reason why she didn't report it.Review of maintenance log for the period of 6/1/25 through 3/24/26 revealed there were no reports of loose and broken tiles or buildup, of any color, on floor or walls for the 100/200 shower room.During an interview and observation of the 100/200 shower room with the Maintenance Director on 3/24/26 at 8:44AM, he stated he had observed the loose tiles since he had started working at the facility which had been at least 2 months. He described how he had heard of the loose and broken tiles in the shower room by word of mouth but could not recall who told him specifically or on what date he was told. He approximated the size of the loose tiles to be 6 to 7 inches wide by 2 feet long. The observation revealed old mortar to be visible under the loose and broken tiles. He described the ring on the ceiling to be a 2 feet by 2 feet area and was likely caused from something that leaked in the ceiling. The Maintenance Director indicated he was going to fix the tiles that were loose and broken in the shower. He stated the black and pink areas on the shower tiles were either mold or mildew and he was not responsible for the mold, as that would have been the responsibility of the housekeeping department. The Maintenance Director indicated the ring on the ceiling would also have been the responsibility of the housekeeping department because it was mold or mildew. He explained he was alerted of work that needed to be addressed either by word of mouth or by a request entered into the maintenance log.During an interview on 3/24/26 at 9:10AM with the Housekeeping Assistant Supervisor, she stated she thought the black and pink colored buildup on the shower tiles and grout on the shower floor and walls in the 100/200 shower room were shower grime, then she looked closer at it and then stated it looked like mold and shower grime. She stated the 100/200 shower room had been cleaned every day by the 100/200 hall housekeeper (Housekeeper #1) and was last cleaned on 3/23/26. She inspected the buildup and explained it did not look clean, and she believed the housekeeper responsible for that shower room needed to do a better job and use a cleaner such as bleach to get the buildup off. She further stated she would notify Housekeeper #1 to clean the shower room again. She observed the area on the ceiling and stated the black areas looked like mold, but that housekeeping could not address that area because it was too high and that the maintenance staff would have needed to address the area on the ceiling.During an interview and observation on 3/26/26 at 9:44AM with the Housekeeper #1, she revealed she was the housekeeper for the 100/200 halls, and she had not been cleaning the 100/200 shower room for about 6 months. She explained she was physically unable to clean the shower. She stated that the 100/200 shower room had been tasked to the other housekeepers and the Housekeeping Assistant Supervisor. The Housekeeper stated when she observed the 100/200 shower room shower yesterday (3/25/26) there was mold all over the tile and she explained she took care of it with bleach. She indicated she had been employed by the facility for 2 years in July and the discolored spot on the ceiling had been there the entire time. She further stated she had told the maintenance workers before about the ceiling and the loose and broken tiles, but the maintenance workers who were employed before did not do what they were supposed to do. The Housekeeper could not remember if she told the current maintenance worker about the discolored ceiling or loose and broken tiles in the shower.An interview on 3/24/26 at 9:20AM with the Housekeeping Supervisor revealed he had not been aware of the spot on the ceiling in the 100/200 shower room. He stated nobody had notified him of that area before and he stated he did not look up when he went in there at different times. The Housekeeping Supervisor explained that he thought a pipe had leaked up in the ceiling to cause that ring of discoloration and that someone would need to get up above the ceiling to be able to find out what was leaking. He stated he could not say for sure what the pink, black, and black spotted buildup on the shower walls and floor (tiles and grout) or the black spotted buildup on the ceiling was. On 3/24/26 at 2:40PM an interview with the Housekeeping Supervisor revealed he had deep cleaned the floors in the 100/200 shower room every week and cleaned the ceiling vents near the discolored ceiling area but had not noticed the discolored ring on the ceiling.During an interview with the Administrator on 3/26/26 at 10:11AM the Administrator stated the housekeepers and maintenance workers should keep the shower room clean and in good repair.

Based on observation, record review, and staff interviews, the facility failed to adhere to the required personal protective equipment (PPE) for Resident #29 who had a peg tube (a feeding tube inserted directly into the stomach through the abdominal wall) when nursing staff members were observed providing a bath to the resident without wearing a gown and gloves for 2 of 5 staff members observed for infection control practices (Nurse Aide #1 and NA #2). A facility policy provided by the Director of Nursing (DON) titled 'Enhanced Barrier Precautions' (EBP) revised 11/13/25 indicated the facility would implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. It also stated EBP referred to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employed targeted gown and gloves during high contact resident care activities. The policy included dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting with peg tubes and wound care as high contact activities. During an observation on 3/23/26 at 2:15PM, an EBP sign was noted outside Resident #29's door. The sign indicated everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and a gown for the following high-contact resident care activities: Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting, and device care or use of peg tube.During an observation on 03/23/26 at 3:40 PM Nurse Aide (NA) #1 and NA #2 were both in Resident #29's room providing her with a bed bath. Neither NA had on gowns and only NA #2 had on gloves. They both said they were aware of the EBP sign on the door. NA #2 stated she usually only wore a gown when she worked with the resident's external urine collection device. NA #2 indicated bathing was a task that required EPB and they were supposed to wear gowns. NA #1 agreed that they should have had on gowns and gloves for bathing the resident and she asked NA #2 if there were any gowns out in the hallway. NA #2 proceeded to go to the hall and collect 2 gowns, 2 masks, and 2 pairs of gloves for them and they both donned the PPE.An interview was conducted on 3/26/26 at 9:21AM with the Director of Nursing (DON), who indicated she was the Infection Preventionist. She stated NA#1 and NA #2 should have put on the required PPE per the EBP sign on the door which should have included at least gloves and a gown prior to bathing Resident #29. The DON said that both NAs received training on EBP during their initial 3-day orientation to the facility and that all staff also received EBP training during their annual competency training as well. DON stated that the training for EBPs was normally provided by the staff development coordinator, but at this time the facility did not have anyone in that position so she (the DON) would be providing any training needed until that position could be filled.During an interview on 3/26/26 at 10:11AM with the facility Administrator, he indicated that NA #1 and NA #2 should have followed what the EBP sign indicated and put on gloves and a gown before providing the bath to Resident #29.

Based on observation, record review, and interviews with staff, Psychiatric Nurse Practitioner, Responsible Party (RP), and the Police Detective, the facility failed to protect the right of two cognitively impaired residents (Residents # 1 and # 7) to be free from abuse. On the evening of 2/6/25 Resident # 2 returned from an outing and was observed by staff to show signs of being inebriated. That evening he was also observed at the bedside of Resident # 1, who was cognitively impaired and who did not have the ability to invite him into her room. After his removal from Resident # 1's room by staff, Resident # 2 was observed in Resident # 1's room a second time with the curtain pulled so that he and Resident # 1 were out of view. During this second incident, Nurse Aide # 1 and Nurse # 1 entered the room and walked around the curtain and witnessed Resident # 2 with his hand under Resident # 1's right leg lifting it up while Resident # 1's brief was open on the right side exposing part of her private area. Resident # 2 was seated in his wheelchair at Resident # 1's bedside at the time with his hand between Resident # 1's thighs to the point that only above his wrist was visible. Resident # 1 was in her bed clenching her brief which was unfastened on the right side and with part of her private area exposed. Resident # 1 was saying No, no, no. Resident # 1's RP reported during interview that if Resident # 1 could have spoken about what had occurred to her, it would have made her sad and cry, and furthermore Resident # 1 would have called out to God asking why it had happened to her in her old age after she had lived through hard times. In addition, Resident # 6, who had a history of aggressive and volatile behaviors, was observed by staff standing over her cognitively impaired roommate (Resident # 7) and pulling her hair. At the time, Resident # 7 was observed screaming and crying. A reasonable person would expect to be safe from abuse in their home and could experience trauma, fear and anxiety. This was for two (Residents # 1 and # 7) of two sampled residents reviewed for abuse. Example #2 was cited at a lower scope and severity of G. The findings included: Resident # 2 was admitted to the facility on [DATE]. The resident's diagnoses included muscle weakness and right leg below knee amputation. Resident # 2's annual MDS (Minimum Data Set) assessment, dated 1/28/25, coded the resident as cognitively intact. The resident was also coded as totally independent with bathing, dressing, and transfers. The resident was assessed to be able to walk 150 feet with supervision. The resident's age was less than [AGE] years of age. On 2/6/25 at 1:12 PM a nurse documented in a progress note that Resident # 2 signed out with a friend for a leave of absence at 1:10 PM. He left the facility in stable condition. On 2/6/25 at 7:29 PM the DON (Director of nursing) entered the following information in a progress note. At 6:15 PM Resident # 2 had been noted to be in a female resident's room and her brief was undone. Resident # 2 was removed from the room and placed on one on supervision. Appropriate staff, family, police, and physician were notified. Investigation with the police and detectives resulted in Resident # 2 being arrested. A review of the facility's investigative file revealed Resident # 1 was the resident whose brief was undone when Resident # 2 was found in the room. A review of Resident # 1's record revealed the following information. Resident # 1 had been admitted to the facility on [DATE] and was elderly. Resident # 1's diagnoses in part included a history of stroke, hemiplegia, hemiparesis, anxiety, and heart disease. Resident # 1's 1/21/25 quarterly MDS assessment coded the resident as severely cognitively impaired and as being totally dependent on staff for her dressing and hygiene needs. She was also assessed to need substantial to maximum assistance to turn in bed and was dependent on staff for transfers. Resident # 1's care plan, updated on 1/31/25, included the information that the resident was dependent on staff for intellectual; physical, and emotional needs secondary to her hemiparesis, hemiplegia, and a language barrier. Review of physician orders revealed a hospice consultation was ordered for Resident # 1 on 2/3/25. Further review of Resident # 1's record revealed the DON made a nursing entry on 2/6/25 at 8:42 PM that was entered as a late entry. The DON documented the following information within the entry. At 6:15 PM a male resident was noted going in Resident # 1's room and upon nursing staff entering the room Resident # 1's brief was found open on the right side and the male resident was observed touching the resident. All appropriate parties were notified. The police were notified for investigation. The family members were notified, and Resident # 1 was sent to the hospital for evaluation. Review of 2/6/25 hospital ED (emergency department) notes revealed the following notations by the ED physician. Resident # 1 was assessed for possible sexual assault and found to have no overt signs of trauma. The resident had advanced dementia and had no recall of the event. The physician talked to the family who declined sexual disease testing and declined to send off testing and to pursue sexual assault nursing examination. Resident # 1's family member reported the resident was starting hospice and she just wanted to focus on her being kept comfortable. Review of the facility's investigative file revealed typed statements the DON had obtained from Nurse Aide (NA) # 1 and Nurse # 1 during the facility's investigation. NA # 1's statement read as typed, [Resident # 2] had returned from being out with friends/family, he appeared to have been drinking, as we were passing dinner trays noticed he went into [Resident # 1's] room. Myself and the nurse removed him from the room and redirected him to his room across the hall. As we were continuing to pass trays, we saw him enter her room again and we went down the hall to get him again. As we entered the room, we noticed that she was uncovered, and his right hand was under her leg with her brief undone. The nurse yelled at him to stop, and we immediately removed him from the room back to his room, reported it to supervisor. NA # 1 was interviewed on 2/24/25 at 4:55 PM and reported the following information about the incident. She had not often cared for Resident # 2 before 2/6/25. Resident # 2 had returned to the facility around 6:00 PM or 6:30 PM on 2/6/25 after being out to celebrate his birthday. When he returned, she could smell fumes on him and he appeared to be drunk. While the staff were passing out trays he sat in the hall and was not going to eat. She went to check on Resident # 1 after Resident # 1 had already been served her tray. When she went to Resident # 1's room to check on her, she found Resident # 2 in Resident # 1's room. He was seated in his wheelchair. Resident # 1 was in her bed. Resident # 2 was messing with her tray and at the same time he was pulling down her gown. At the time she (NA # 1) first saw Resident # 2 pulling Resident # 1's gown down, the gown was above Resident # 1's waist. Resident # 1's brief was on and intact. At the time, the privacy curtain was open. Resident # 1's covers were down, but that was not unusual because she did not always like the covers on her. She (NA #1) told Nurse # 1, who told Resident # 2 to leave the room. Nurse # 1 also told the supervisor about the situation. Resident # 2 did leave the room and went into the hallway. She (NA # 1) continued to take up trays, but she kept an eye on Resident # 2. As she was taking up dinner trays, she noticed that Resident # 2 had disappeared. She went and got Nurse # 1 and informed her. They went back to Resident # 1's room. At that time the door was open and the curtain was closed where you could not see Resident # 1 in her bed. They entered and rounded the curtain together. She (NA # 1) saw Resident # 2 in his wheelchair and Resident # 1 was in her bed. Resident # 2 had his hand under Resident # 1's right leg lifting it up. Resident # 1's brief was open on the right side to the point that part of her private area was exposed. Nurse # 1 yelled for Resident # 2 to get out of the room. He stopped lifting Resident # 1's leg and left the room. Nurse # 1 sent Resident # 2 to his room and notified the supervisor again, who called the DON. At the time when Resident # 2 was found in Resident # 1's room the second time, she was moaning in a way that she usually moaned. She (NA # 1) stood guard over Resident # 1 to protect her after the second incident, and another person was stationed to stand guard over Resident # 2's room where he was. Prior to the incident, no one had mentioned to her, and she was not aware of any incidents in which Resident # 2 allegedly was touching any other resident inappropriately. During an interview with the Administrator on 2/28/25 at 10:11 AM, the Administrator reported that no staff member had reported during their immediate interviews following the incident that Resident # 2 was touching Resident # 1 in anyway during the first incident on 2/6/25 when Resident # 2 was found in Resident # 1's room. The surveyor agreed to interview NA # 1 again for clarification. A second interview with NA # 1 on 2/28/25 at 11:11 AM was conducted with the Administrator per a three- way telephone call. NA # 1 reported the following information. In recalling the events weeks after the initial event had occurred, she may have been recalling the touching of the gown incorrectly when she first spoke to the surveyor. The touching of the gown was possibly during the second incident. She could recall for certainty that in the first incident she was surprised to see Resident # 2 in Resident # 1's room and he had been eating something off the resident's tray at the time. He had been removed from the room. NA # 1 further reported Resident # 1 could move and slide down in bed and that at times her gown would ride up from her movement in the bed. Review of the statement from Nurse # 1 as typed by the DON read as follows: [Resident # 2] appeared to be drunk when returned from LOA (leave of absence) with family as he went down the hall, he went into [Resident # 1's] room and myself and a CNA (certified nursing assistant) removed him to his room and told him that we would help her. We went on about passing trays and about 10 minutes later saw him go into the room again. We immediately went down the hall and into the room, I yelled for him to get out. He was sitting in his wheelchair beside the bed, her brief was undone, and his right hand was under her leg and unable to see where it was at. We immediately removed him and placed him in his room with someone watching him 1:1 per supervisor. Nurse # 1 was interviewed on 2/25/25 at 11:27 AM and reported the following information. She usually worked throughout the facility and did not care for Resident # 1 and Resident # 2 all the time. On the date of the incident, she had been at the desk when Resident # 2 had returned from an outing. He walked in with a walker and had a prosthesis on at the time. By looking at his eyes and his walk, it appeared he was inebriated when he returned. He went to his room. Later dinner trays came out on the hall. At that time, she recalled Resident # 2 being in his wheelchair without his prosthesis. While dinner trays were on the hall, NA # 1 got her to go to Resident # 1's room because Resident # 2 was in the room. When she entered the room, Resident # 1 was looking at the television. Resident # 2 was seated in his wheelchair in her room. Resident # 1's bedside table was between Resident # 2 and Resident # 1 at the time. Resident # 2 was eating dessert in Resident # 1's room and said he was talking to her. She informed Resident # 2 that the resident did not speak his language, he was not to help feed her, and he needed to leave the room. Resident # 2 did leave. She (Nurse # 1) informed Nurse # 3 (the supervisor for that evening) and she (Nurse # 1) then continued to help with tasks on the hall. Approximately ten minutes later she and NA # 1 met in the hall and went back to check on Resident # 1. At the time, the privacy curtain was pulled where you could not see Resident # 1 from the doorway. They could hear Resident # 1 saying very softly and not loud enough to hear down the hallway, No, no, no. They rounded the curtain. Resident # 1 was in her bed clenching her brief which was unfastened on the right side. Part of her private area was exposed. Resident # 2 was in his wheelchair and closer to her bed than previously. His hand was between her thighs to the point that only above his wrist was visible, and therefore she could not see exactly where his hand was touching. She told him to get out of the room right then and put him in his room. She ran to tell Nurse # 3. One on one was placed with both residents. Prior to the incident, she had only been working in that section of the facility about every two weeks and therefore was not often assigned to care for Resident # 2. She knew Resident # 2 had fresh tendencies and he would say he had multiple girlfriends, but she had never witnessed him touching another resident inappropriately. She did not recall anything in report about any special monitoring Resident #2 needed around other residents. There was no statement from Nurse # 3 (the nursing supervisor) in the investigation file. Nurse # 3 was interviewed on 2/24/25 at 4:02 PM and reported the following information. She had not witnessed either incident. She did know that Resident # 2 had returned that evening and appeared to be inebriated. That evening NA # 1 had told Nurse # 1 about an incident in which Resident # 2 was in Resident # 1's room with his hand under her covers. Nurse # 1 had relayed this to her (Nurse # 3). Resident # 2 and Resident # 1 had immediately been separated and Nurse # 1 had reported it to her (Nurse # 3). She (Nurse # 3) immediately went to a private area to call the DON about the incident. At that time, the DON had already left work and was planning to return to the facility. Immediately after she got off the phone and was returning to the unit, she saw Nurse # 1 and NA # 1 power walking-running to her. They reported there was a second incident in which Resident # 2 was found in Resident # 1's room and this time it was her understanding that Resident # 2 had been in Resident # 1's bed. She (Nurse # 3) was told that Resident # 2 had been on top of Resident # 1 and Resident # 2 was violating her while Resident # 1 was saying, no, no, no. Resident # 2 had been removed by them and put back in his room before Nurse # 1 and NA # 1 came to her. Nurse # 3 stated it had seemed like a minute since the first report and all she had done was go call the DON before the second incident with Resident #1 and Resident #2 was reported to her. She immediately called the DON back again after the second incident, and the DON was on her way. The Administrator called and talked to her (Nurse #3) and told her to call the police which was done. She checked Resident # 1's blankets to make sure she was not bleeding but she did not tamper with her brief until emergency services and the police could arrive. Staff did stay one on one with Resident # 2 and Resident # 1. The DON, who was the person to record Nurse # 1 and NA # 1's statements, was interviewed on 2/24/25 at 12:00 PM, 1:30 PM, and again on 5:10 PM and reported the following information. Resident # 1 had appeared to be drinking when he returned to the facility on [DATE]. NA # 1 and Nurse # 1 were his assigned caregivers. Nurse # 3 was the supervisor that evening. Nurse # 3 was not the witness to the actual events. Resident # 2 had never been in bed with Resident # 1, and as in the recorded statements, Resident # 2 was found seated in his wheelchair beside Resident #1. He had his hand underneath her leg. The staff could not tell exactly where Resident # 2 had been touching Resident # 1 with his hand. Resident # 1 had been sent out to the hospital and found to have no trauma or penetration. NA # 3 was interviewed on 2/25/25 at 11:40 AM and reported the following information. She routinely cared for Resident # 1 and Resident # 2. Resident # 2 was usually in his room or the dining room when she was assigned to him. She had not seen him in other residents' rooms. In taking care of Resident # 1, Resident # 1 did not use her call bell to call for assistance. Resident # 1 had communication problems. The Administrator was interviewed on 2/26/25 at 3:30 PM and again on 2/28/25 at 10:11 AM and reported the following information. On 2/6/25 Resident # 2 returned from his outing and appeared inebriated. Staff did find him in Resident # 1's room one time prior to the actual incident and he should not have been in her room. Resident # 2 was not touching Resident # 1 or her clothing in any way during the first incident. He was removed from Resident #1's room. A short time later when the curtain was observed pulled, two staff members entered at the same time. As they rounded the corner of the pulled curtain, one of the staff members had a phone and obtained a photograph of Resident # 2 touching Resident # 1. The photograph was not taken to disrespect or slow the removal of Resident # 2 from Resident # 1. It was taken quickly to provide evidence so that the police could arrest Resident # 2 and remove Resident # 2 from the facility. As one staff member took the photograph, the other staff member was pulling the resident away. Resident # 2 had never been on top of Resident # 1. At the time, as shown in the photographic evidence, he was in a wheelchair beside her. He did not have his prosthesis on and it would have been impossible for him to have been in Resident #1's bed. The Administrator was also interviewed regarding the difference in some of the statements given by the staff to the surveyor. The Administrator reported the following information regarding this. Statements had been obtained that night directly following the incident at a time when things were fresh in his staff members' mind. The two witnesses were Nurse # 1 and NA # 1, and their recall at the time was that the resident [Resident #2] had not been touching the resident [Resident #1] or the resident's clothing in anyway during the first incident. Nurse # 3 had not witnessed either incident and Nurse # 3 had been very shaken up about things and there had been a lot of discussion about what had occurred. The Administrator felt like the details had become conflated over time and was not sure why Nurse # 3's interview about what occurred was different than what Nurse #1 and Nurse Aide #1 reported at the time of the incidents. On 2/26/25 the Administrator provided a copy of the photograph that had been provided to the police on 2/6/25. Review of the photograph revealed the following observation. Due to the angle of the photograph, it did not depict any of Resident # 1's private area or Resident # 1's brief. The photograph was taken from the perspective of someone at the foot of the bed. Resident # 2 was seated in his wheelchair with his wheelchair parallel and right next to Resident # 1's bed. His wheelchair was positioned so that he was seated facing Resident #1. Resident # 1 was in bed with the head of the bed slightly elevated and the majority of her right thigh was exposed. The majority of Resident # 2's right forearm was under Resident # 1's right thigh pointed in the direction of her private area. The exact placement of Resident #2's hand was not visible in the photograph. The police detective, who was investigating the assault, was interviewed on 2/27/25 at 3:51 PM and reported the following information. The call came into the police at 6:53 PM and they arrived at 7:17 PM. The police detective confirmed Resident # 2 was in his room and under surveillance by facility staff when police arrived. Staff reported that Resident # 2 did not normally associate with Resident # 1 and on that evening Resident # 2 had reported to staff that Resident # 1 was wanting her dinner tray removed. On the evening of 2/6/25 Resident #2 was removed from the facility and jailed. Resident # 1's RP (Responsible Party) was interviewed on 2/24/25 at 12:38 PM and again on 2/28/25 at 9:20 AM and reported the following information. Resident # 1 had recently been placed on hospice before the incident of 2/6/25. She (the RP) had received a voice mail on 2/6/25 around 8:00 PM from the DON and returned it around 8:15 PM. The DON informed her that Resident # 1 had been assaulted by another resident. The DON further told her Resident # 1 was fine, and as a precaution the facility was sending Resident # 1 to the hospital to be checked. She had been told that staff had entered Resident # 1's room and the resident, who had assaulted Resident # 1, had been in a wheelchair at the time. Family members had been very involved in Resident # 1's care and would visit regularly. Family had noted a male resident sitting in the hallway near doorways and looking into rooms when they visited. She and the family were not aware of any incidents prior to 2/6/25 where anyone had entered Resident # 1's room and touched her inappropriately before 2/6/25. The RP reported Resident # 1 had lived through the hard times during the depression years and through war times. Due to the resident's medical status, she could not speak up for herself regarding what had happened. If the resident could have spoken up for herself and understood what had happened to her, the RP reported Resident # 1 would have been sad, cried, and prayed a lot. The RP further reported Resident # 1 would have asked God, At my old age why did this happen? Why God, why me? The Administrator was informed of immediate jeopardy on 2/27/25 at 11:00 AM and presented the following corrective action plan. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. At approximately 6:15 PM on 02/06/2025, Resident #2 was found to have his hand under the gown and between the legs of Resident #1 in Resident #1 room which was the B bed (closer to window) with privacy curtain pulled. Resident #1 brief was unfastened and hospital gown she was wearing was around her waist but witness statements do not state that Resident #1 was exposed and was covered by hospital gown. Resident #2 was immediately removed from Resident #1 room and placed on 1:1 supervision. Police were contacted and arrived on scene to conduct investigation. Resident #2 was placed under arrest for 2nd degree felony sexual offense and misdemeanor sexual battery. Resident #2 was formally discharged from the facility due to action and arrest with notification to family to collect his personal belongings. As of 02/27/2025, Resident #2 continues incarceration with $10,000.00 jail bond per detective assigned to this case. This was the first incident with Resident #2 being noted to have any touching of Resident #1 or having any contact with Resident #1's clothing per immediate interview with on-site clinical team of Certified Nursing Assistant (CNA) and Licensed Practical Nurse (LPN) who were assigned to both Resident #1 and Resident #2. Based on those immediate interviews, we were not aware of any inappropriate touching and Resident #2 was immediately placed on 1:1 observation when touching was identified. Resident #1 was monitored for psycho-social needs with no concerns identified during bathing and/or incontinent care. Resident #1 did not present with any recall of the adverse event and did not present with any facial grimacing or signs of fear or distress at any time after the event occurred. Resident #1 was relocated to a private room on 02/12/2025 which was when a private room became available. The Medical Director was notified. Both resident's Responsible Parties were notified. A physical exam to include a skin assessment was conducted by assigned staff LPN for Resident #1 following the adverse event on 02/06/2025. No signs of bruising or trauma were indicated. As an additional precaution, the facility sent Resident #1 to the hospital emergency department for an additional exam. The resident's daughter declined extensive testing as she wished Resident #1 to return to the facility and wanted to keep Resident #1 comfortable. Resident #1 returned at approximately 3:45 AM on 02/07/2025 and no signs of trauma or penetration were identified. Adult Protective Services (APS) was contacted and determined that a formal investigation was not warranted as Resident #2 was no longer a potential threat to Resident #1. Allegation of abuse was submitted to North Carolina Division of Healthcare Service Regulation (NCDHSR) at 7:38 PM on 02/06/2025. Address how corrective action will be accomplished for those residents having the potential to be affected by the same deficient practice. On 02/06/2025, nursing managers completed skin assessments on residents with a brief interview of mental status (BIMS) of 8 or below and abuse questionnaires for residents with a BIMS of 9 or greater. Abuse and neglect education was provided to staff on 02/06/2025 by the Director of Nursing. A Resident Council meeting was held on 02/07/2025 to ensure residents understood sexual abuse and to report any allegation of sexual abuse. Signage was discussed during the meeting and then posted in all common areas on 02/07/2025 as a reminder to Residents and Staff and vendors IF YOU SEE SOMETHING, SAY SOMETHING. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur On 02/06/2025, the Facility Administrator and Director of Nursing re-educated current staff (including contracted services) on Abuse/Neglect policy and procedures with emphasis on signs and symptoms of sexual abuse and ways to prevent sexual abuse. This also included timely reporting for Administrator and/or Director of Nursing to provide formal notification to NCDHSR within the required 2-hour window. Education included examples of what to look for including inappropriate touching or unwanted advances. This included covering unwanted intimate touching of any kind especially of breast or perineal area, all types of sexual assault, forced observation of masturbation and/or pornography, taking sexually explicit photographs and/or audio/video recordings of a resident and maintaining or distributing them. Residents should be monitored for bruises or grip marks, dismissive attitude about any injuries, uncommunicative or unresponsive, unreasonably fearful or suspicious, lack of interest in social contact, unexplained changes in behavior Education forms were signed by trained staff for the verbal education that was provided. Existing staff who were not present on the evening of 02/06/2025 or on 02/07/2025 were required to undergo abuse and neglect training prior to their return to work. This subset of staff were directed to contact unit managers prior to return to work and a list of all employees was cross-referenced and checked off as education was completed. All new hire staff are required to undergo abuse and neglect training during new-hire orientation. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained Facility Administrator and Director of Nursing determined on 02/06/2025 to monitor facility performance in an ongoing pursuit of quality control. The Social Worker will interview five residents with a brief interview of mental status (BIMS) of eight or greater per week for twelve weeks to inquire if they have felt abused or have witnessed or suspected abuse or neglect. Skin audits will be conducted by Director of Nursing or designee for 5 randomly selected residents with a BIMS of 8 or below. Immediate action to be taken for any positive findings. Results of these audits/interviews will be brought before the Quality Assurance Performance Improvement (QAPI) Committee monthly with the QAPI Committee responsible for ongoing compliance. Facility Administrator and Director of Nursing conducted an Ad hoc QAPI on 02/07/2025 with the Interdisciplinary Team (IDT) which includes Executive Director, Director of Nursing, Medical Director, Social Services Director, Activities Director, Dining/Nutrition Supervisor, Minimum Data Set (MDS) Team of RN and LPN, Rehabilitation Director, Housekeeping/Laundry Supervisor, Maintenance Supervisor, LPN Unit Manager, Business Office Director and Human Resources Director to review the event and conduct a root cause analysis for group discussion. Resident #2 was known to be very social and outgoing and friendly with all residents and staff. The root cause was determined to be that although staff did not have any reasonable expectation that this event had the likelihood to occur, it is possible for anyone at any time to make a poor decision with little to no consideration of consequence. In the monthly Quality Assurance and Performance Improvement (QAPI) Meeting, the Interdisciplinary Team (IDT) will review all resident to resident abuse allegations to ensure appropriate interventions are in place and the individualized resident-specific Plan of Care is updated for 8 weeks. The Administrator will report the results of the monitoring to the QAPI committee to review audits and make recommendations to assure compliance is maintained on an ongoing basis. The QAPI Committee will determine the need for further intervention and auditing beyond three months to ensure compliance is sustained on an ongoing basis. Compliance Date - 02/08/2025 Alleged date of IJ removal date: 02/08/2025 2. Resident # 6 was admitted to the facility on [DATE] with diagnoses of dementia, restlessness, agitation, hypertension, depressive disorder, anxiety, insomnia, muscle weakness, and cognitively communication problems. A review of Resident # 6's care plan, updated on 11/21/24 and which was in place until her final discharge on 12/23/24, revealed the following information. Resident # 6 independently bathed, toileted, and transferred herself. She was continent. She had exit seeking behaviors. She displayed inappropriate behaviors which included agitation, screaming, inappropriate language, and resistance to care. She had the potential to be verbally and physically aggressive. Resident # 6's care plan directed staff to monitor, document, and report when a resident posed a danger to others. The care plan also indicated a psychiatric consult would be done as indicated. According to the care plan, Resident # 6 had been on psychoactive medications since 3/20/24. Review of progress notes revealed a notation by the Social Worker on 11/25/24 at 2:17 PM noting that Resident # 6 had returned to the facility on [DATE] after being at the hospital for aggressive and combative behaviors. The Social Worker noted she was continuing to look for appropriate long- term placement in a secured memory care unit. On 11/25/24 the Psychiatric NP noted she visited the resident, and the resident was calm at the time. The Psychiatric NP noted there had been an issue with noncompliance with the resident taking her medication. The psychiatric NP also noted that because of the resident's history of aggression and the potential for future volatility plans were underway to transfer her to a psychiatric facility for a higher level of care. On 11/27/24 at 1:15 PM Nurse # 2 documented the following information in a nursing entry. Resident # 6 was being sent to the ED (emergency department) for combative behavior. Both the NP (Nurse Practitioner) and management had been advised with orders to send the resident out. The family was also notified. There were no specific details in the nursing note about what had occurred. Review of EMS (Emergency Medical Services) records, dated 11/27/24, revealed the following information by the paramedic. Facility staff stated the pt. (patient) refused to take any of her medications since being discharged from [name of hospital] for the same behavior several days ago. They stated she was striking her roommate and facility staff as well as throwing 'tea and coffee' at them. Pt would not answer questions or speak with EMS, except [TRUNCATED]

Based on observation, and interviews with resident and staff, the facility failed to provide housekeeping services to ensure a clean bathroom for a bathroom which was jointly shared by multiple residents. This was for one (Resident # 5) of four sampled residents who were interviewed regarding services at the facility. The findings included: Resident # 5 was admitted to the facility on [DATE]. A review of Resident # 5's quarterly Minimum Data Set assessment, dated 12/2/24, revealed Resident # 5 was cognitively intact and continent. During interviews held with Resident # 5 on 2/24/25 at 10:12 AM and again on 2/25/25 at 8:35 AM, Resident # 5 expressed concerns related to his bathroom being cleaned so that he could use it. Resident # 5 reported the following information. He resided in a room which shared a bathroom with two other residents who had an adjoining door to the bathroom from their room. One of the other residents, who used the bathroom, needed adaptive devices (a riser) over the toilet and this resident also had some confusion. When this resident would use the bathroom, the resident at times would leave fecal matter on the floor, on the toilet, and other places in the bathroom. He had trouble getting staff to clean the bathroom so that he could use it and feel that it was clean. He had talked to staff about the problem. About two weeks ago, the resident from the adjoining room had used the bathroom and there was a lot of feces on the toilet. He had asked NA (Nurse Aide) # 10 to clean the toilet so that he could use it. No one ever came to clean the toilet, and so he cleaned the toilet himself although it was not his feces. During the interview on 2/25/25 at 8:35 AM with Resident # 5, observations were made with Resident # 5 of the condition of his bathroom. The following observations were made. There was brownish black matter on the back of the toilet lid and on the back of the toilet. On a shelf above the toilet, Resident # 5 had stored a personal item he used. Beside his personal item, there was a toilet seat that had been removed from the toilet and had brownish black matter on it. There was a part of the toilet riser's adaptive equipment (a funnel piece) which had brownish black matter on it sitting on the shelf. There was trash behind the toilet. There was brownish black matter on the wall beside the sink and the mirror. The mirror had a large amount of white matter on it. During the observation of the bathroom with Resident # 5 on 2/25/25 at 8:35 AM, the resident reported housekeeping had not come in yet that morning. He also reported that the adaptive equipment for the toilet riser, which was on the shelf, was for the resident who shared the bathroom. He (Resident # 5) was concerned it was kept on the shelf with his personal item. Resident # 5 also reported that the toilet seat was broken and so he had taken it off many weeks ago and used the riser when he needed to use the toilet. He had placed the broken toilet seat on the shelf but no one had cleaned it or removed it. Resident # 5's bathroom was observed again on 2/25/25 at 4:15 PM with the DON (Director of Nursing). The bathroom conditions observed on 2/25/25 at 8:35 AM were still observed on 2/25/25 at 4:15 PM. According to Resident # 5, housekeeping had come in at midday to clean his room, but they had not cleaned his bathroom. The DON reported that the housekeeping staff were contracted workers, and she would report it to the supervisor of housekeeping about the condition of the bathroom. On 2/25/25 at 4:45 PM Nurse # 6 was interviewed and reported the following information. There was a resident who shared Resident # 5's bathroom from an adjoining room. This resident at times would drop his pants on the way to the bathroom and would miss the toilet. He (Nurse # 6) was also aware of an incident in which Resident # 5 had reported he (Resident # 5) had cleaned up the other resident's feces after asking Nurse Aide # 10 to help and no one helped him. He (Nurse # 6) had talked to NA # 10 after the incident and NA # 10 had not realized it was her job to clean obvious signs of feces and then alert housekeeping to disinfect surfaces. Nurse # 6 recalled this incident occurred about a month ago. NA # 10 was interviewed on 2/26/26 at 1:55 PM and reported the following information about the incident in which she was asked to help clean the bathroom. She recalled Resident # 5 asking her for help to get his toilet bowl cleaned when she was walking down the hallway to help another resident. She told him she would tell housekeeping, which she did. She did not know what housekeeping did after she told them. Resident # 5 was not her assigned resident that day and she went to care for another resident. The Housekeeping Director was interviewed on 2/26/25 at 10:00 AM and reported the following information. He had not been aware of the condition of Resident # 5's bathroom the previous day (2/25/25) until the DON had called him after the 4:15 PM observation made by her and the surveyor. The bathroom should have been cleaned and not left in the condition it was throughout the day. If there were broken, dirty items such as a toilet seat sitting up on a shelf used to store personal items, then there should be some type of communication between maintenance and his staff to rectify that issue. On 2/26/25 at 11:20 AM the housekeeper (Housekeeper #1), who had been assigned to Resident # 5's hall on 2/25/25, was interviewed with the Housekeeping Director and reported the following information. Housekeeper # 1 was aware that one of the residents who used Resident # 5's bathroom at times had explosive diarrhea. He had cleaned the bathroom on 2/25/25 around 7:30 AM or 8:00 AM and did not have time to go back during the day to clean again. He had not cleaned the walls when he initially cleaned the bathroom, and he did not clean any adaptive equipment that was on the shelf that had brownish black matter when he had cleaned. The Housekeeping Director further reported during this interview on 2/26/25 at 11:20 AM that his housekeeping staff were responsible for cleaning small drips of fecal matter. If there were large amounts of stool or emesis then nursing staff were to clean, and then his staff would disinfect. No one had mentioned a problem to him that Resident # 5's bathroom needed more frequent checks and cleaning. After 5:00 PM, there was one of his staff members who worked in laundry. They could also provide housekeeping services to the nursing staff if needed after his routine housekeepers left for the day.

Based on observation, record review and interviews with resident and staff, the facility failed to ensure a system was in place to avoid placing an item on a resident's tray which she preferred not to have. This was for one (Resident # 4) of three sampled residents reviewed for food choices. The findings included: Resident # 1 was admitted to the facility on [DATE]. Review of Resident # 4's admission Minimum Data Set assessment, dated 1/26/25, revealed the resident was cognitively intact. Review of physician orders revealed Resident # 1 was ordered a regular diet. The Dietary Manager was interviewed on 2/26/25 at 8:55 AM and provided a copy of the way Resident # 4's tray card printed from their system. Observation of the resident's printed dietary card revealed near the top of the card, there was a notation which read, No Potatoes. The Dietary Manager reported the following information. Resident # 4 had a dislike to potatoes. As noted on her printed tray card, it showed as a disklike and she should not be served potatoes. He was aware of one time when she had gotten the potatoes and thought it had not happened again. Resident # 4 was interviewed on 2/26/25 at 12:50 PM and reported the following information. The texture and smell of potatoes make her nauseated and she had received them multiple times since she had been admitted to the facility. The Nurse Aides were aware of the problem, and it had been reported to the dietary department, but the potatoes were still served to her even after the problem had been reported to the dietary department. Nurse Aide (NA) #8 was interviewed on 2/26/25 at 2:20 PM and reported the following information. Resident # 4 had received potatoes on her tray even though staff in the kitchen had been told. She knew that NA # 9 had directly spoken to the kitchen staff about the problem. She had also witnessed other residents receive items on their tray that per their tray card they were not supposed to be served. This had happened in recent weeks. NA # 9 was interviewed on 2/26/25 at 2:40 PM and reported while she had worked with Resident # 4, she (NA # 9) knew Resident # 4 had received potatoes on her tray three times and she had spoken to the kitchen staff about the problem because the resident did not like them and was not supposed to be served them. The Administrator was interviewed on 2/26/25 at 5:50 PM and reported there should be a person on the dietary tray line checking the tray cards and the trays to make sure that foods which residents disliked were not served to them.

Based on observation, record review, and staff interviews, the facility failed to ensure a resident received a beverage on her tray per her preference. This was for one (Resident # 8) of three residents reviewed for dietary preferences. The findings included: Record review revealed Resident # 8 was admitted to the facility on [DATE] after sustaining a hip fracture. Review of Resident # 8's 2/21/25 admission Minimum Data Set assessment, dated 2/21/25, revealed the resident was cognitively intact. Review of physician orders revealed the resident was ordered a regular diet. Lunch observations were made on 2/25/25 starting at 12:00 PM. During this lunch time observation Resident # 8 was observed in her room. She had completed eating her lunch meal and stated the food was good, but the dietary department had not served any drinks on her tray. It was observed there were no cups on the meal tray. She further reported that she had some water in a Styrofoam cup at her bedside which she had before the lunch meal tray was served, and therefore she had drunk the water with her meal since the dietary department had not sent anything else to drink. She would have preferred to have had tea with the meal. Directly following this observation and interview, Nurse # 5 was asked to view Resident # 8's tray and validated that no beverage had been served with the resident's 2/25/25 lunch meal. The dietary menus were reviewed with the Dietary Manager on 2/26/25 at 8:55 AM. A review of the menu with the Dietary Manager revealed tea of choice should have been served with lunch trays on 2/25/25. According to the Dietary Manager food items and beverages are printed on a tray card which includes residents' preferences. Nurse Aide (NA) #8 was interviewed on 2/26/25 at 2:20 PM and NA # 9 was interviewed on 2/26/25 at 2:40 PM. Both Nurse Aides, who worked on Resident # 8's hall, reported there had been problems in recent weeks they had observed with meal tray items not matching meal tray cards. The Administrator was interviewed on 2/26/25 at 5:50 PM and reported there should be a person on the dietary tray line checking the tray cards and the trays to make sure that items were correct on the trays before they were served to residents.

Based on record review, and staff, family member, Physician Assistant, and Medical Director interviews the facility failed to notify the physician of a significant change in condition when staff were unable to obtain a urine sample on 3 instances ([DATE] at approximately 5:00 AM and 9:00 PM and [DATE] at approximately 5:30 AM) for a resident identified with complaints of burning urination and decreased fluid intake. Resident #294 was first identified with decreased nutritional and fluid intake on [DATE] requiring staff to push fluids (deliberately drink beyond what thirst dictates to avoid dehydration) through [DATE]. On [DATE] the resident complained of burning urination (dysuria) and was ordered a urinalysis (used to detect abnormalities such as blood, protein, glucose, and indirect indicators of bacterial infection) and urine culture and sensitivity (used to diagnose a urinary tract infection and determine the best treatment). Resident #294 exhibited signs and symptoms of dehydration on [DATE] at approximately 9:00 PM and [DATE] at approximately 5:30 AM as evidenced by the inability to collect urine via an in and out catheter (inserting a thin, hollow tube into the bladder) when the resident had no recent episodes of urination. The first notification to a medical provider was made to the Physician Assistant when she arrived at the facility on [DATE] at approximately ,d+[DATE]:30 AM. During this time, nursing staff continued to administer the resident's Lasix (diuretic) 20 milligrams once daily at 9:00 AM despite signs and symptoms of dehydration and did not contact the physician regarding the diuretic administration. On [DATE] Resident #294's family member requested the resident be sent to the hospital. Emergency Medical Services (EMS) were contacted at 3:42 PM and Resident #294 was transferred to the emergency room where he was identified with altered mental status, tachypnea (rapid and shallow breathing), poor perfusion (occurs when there is inadequate blood circulation to organs and tissues and can be an early sign of circulatory or heart problems and can lead to life-threatening conditions), hypothermia (a medical emergency that occurs when the body's temperature drops below 95 F), severe lactic acidosis (occurs when the body produces too much lactic acid and the liver can't metabolize it fast enough), and new vasopressor requirements (vasopressors are a medication that are used to treat people with low blood pressure) most consistent with septic shock (a life-threatening condition that happens when your blood pressure drops to a dangerously low level after an infection) with end organ dysfunction. Resident #294 died at 8:26 PM on [DATE]. This deficient practice occurred for 1 of 3 residents (Resident #294) reviewed for notification of significant changes. Immediate jeopardy began on [DATE] when staff failed to notify the physician of a significant change in condition when Resident #294 exhibited signs and symptoms of dehydration and staff were unable to obtain a urine specimen via an in and out catheter when the resident had no recent episodes of urination. Immediate jeopardy was removed on [DATE] when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a scope and severity of D (no actual harm with potential for more than minimal harm that is immediate jeopardy) to ensure education is completed and monitoring systems put into place and are effective. The findings included: Resident #294 was admitted to the facility on [DATE]. His diagnoses included dementia, type 2 diabetes, adult failure to thrive, generalized muscle weakness, chronic kidney disease, and congestive heart failure. A physician order dated [DATE] indicated give Lasix oral tablet 20 milligram by mouth one time a day for edema (swelling from fluid retention). Lasix is a diuretic used to treat fluid retention that can result from congestive heart failure, kidney disease or other medical conditions. (Lasix increases the flow of urine and can lead to dehydration.) Resident #294's admission Minimum Data Set (MDS) assessment dated [DATE] coded Resident #294 as cognitively intact. He required supervision or touching assistance with toileting. He required setup or clean up assistance with eating. He was coded as frequently incontinent of bowel and bladder and was also coded as taking a diuretic. Resident #294's overall discharge goal was to return to the community. He was not coded for hospice care. A facility 24-hour condition report completed by Nurse #5 dated [DATE] indicated Resident #294 had poor oral intake on day shift. The facility's 24-hour condition report is a form that nurses document the status of all the residents during or at the end of their shift to communicate any pertinent information to the next shift and nursing management. (Breakfast and lunch meals are served during the day shift which starts at 7:00 AM and ends at 3:00 PM.) During an interview with Nurse #5 on [DATE] at 2:45 PM, she stated that she had cared for Resident #294 on [DATE] from 7:00 AM to 7:00 PM. Nurse #5 indicated that normally Resident # 294 consumed more than 25% of his tray food and drinks but on [DATE] he had eaten and drank less than 25% during breakfast, lunch and dinner and she documented it in the 24 hour report and informed the oncoming night shift nurse (Nurse # 4). A facility 24-hour condition report completed by Nurse #4 dated [DATE] indicated Resident #294 was complaining of burning with urination on night shift ([DATE] 11:00 PM to [DATE] 7:00 AM shift). During an interview on [DATE] at 3:53 PM with Nurse #4, she stated that she was assigned to care for Resident #294 on [DATE] at 7:00 PM to [DATE] at 7:00 AM. Nurse #4 stated that during shift change Nurse #5 had informed her and documented in the 24-hour condition report that Resident #294 had a decreased oral intake with food and drinks. Nurse #4 verbalized that Resident #294 complained of burning with urination during her shift and she left a note for the Provider in the physician book, noted it in the 24-hour condition report and informed the oncoming day shift nurse (Nurse #1). Nurse #4 stated that Resident #294 was stable and the only concern during her shift was complaints of burning with urination which she noted in the physician's book and she pushed fluids while Resident #294 was awake because she thought it was a sign of urinary tract infection. Resident #294's medication administration record indicated Lasix 20 mg was administered on [DATE] at 9:00 AM by Nurse #1. A Physician telephone order dated [DATE] at 11:59 AM ordered by Physician Assistant (PA) #2 indicated urinalysis (UA), urine culture and sensitivity (C & S) for a diagnosis of dysuria. A facility 24-hour condition report dated [DATE] on day shift (7:00 AM to 3:00 PM) completed by Nurse #1 and evening shift (3:00 PM to 11:00 PM) completed by Nurse #6 indicated the need for a UA/C&S for Resident #294 in the morning ([DATE]). During an interview on [DATE] at 10:20 AM with Nurse #1, she indicated that she had cared for Resident #294 on [DATE]. Nurse #1 stated that when she came to work on [DATE] at around 7:00 AM she was informed by the off going night shift nurse (Nurse #4) that Resident #294 had complained of pain with urination during the night shift ([DATE] at 7:00 PM to [DATE] at 7:00 AM). Nurse #1 verbalized that a UA/C&S to rule out a urinary tract infection was ordered during her shift ([DATE] 7:00 AM- 7:00 PM) but she did not attempt to obtain a urine sample since it would not have been picked up until around 6:00 AM the following morning. Nurse #1stated that Resident #294 was less talkative than usual on [DATE]. An interview was conducted on [DATE] at 1:40 PM with Nurse #6. He stated that he had filled in for four hours and cared for Resident #294 on [DATE] from 7:00 PM to 11:00 PM and he was aware that Resident #294 required a urine sample but he did not obtain it because it wouldn't have been picked up until the morning around 6:00 AM. He notified the third shift nurse (Nurse #2) to collect the urine specimen when she took over at 11:00 PM. Nurse #6 explained that the laboratory specimens were picked up by laboratory staff in the morning at approximately 6:00 AM. A facility 24-hour condition report dated [DATE] on night shift ([DATE] 11:00 PM to [DATE] 7:00 AM) completed by Nurse #2 and day shift ([DATE] 7:00 AM to 3:00 PM) completed by Nurse #1 indicated the need for a UA and C&S for Resident #294. During an interview on [DATE] at 3:38 PM with Nurse #2, she stated that she had cared for Resident #294 on night shift ([DATE] at 11:00 PM to [DATE] at 7:00 AM). Nurse #2 stated that when she took over the assignment that night, she was notified by the off going nurse (Nurse #6) that a urine sample was needed for Resident #294. She indicated that when she came on shift Resident # 294 was asleep and she did not recall waking him up to give him any fluids. Nurse #2 indicated that Resident #294 slept throughout her shift, and she attempted to obtain the urine specimen via an in and out catheter at around 5:00 AM on [DATE] but was unsuccessful and she notified the oncoming day shift nurse (Nurse #1). Nurse #2 indicated Resident #294's incontinence brief was wet during the in and out catheter attempt. Nurse #2 also indicated that she was not Resident #294's regular nurse and she was not familiar with his baseline. She verified that she did not notify the physician that she was unable to obtain the ordered urine specimen. An interview was conducted on [DATE] at 2:12 PM with NA #2 who had cared for Resident #294 on [DATE] and [DATE] on night shift. NA #2 stated that Resident #294 took only a few sips of water during her shifts and when she changed his incontinence brief there was very little urine. NA #2 stated that Nurse #3 was aware of Resident's condition from the beginning of her shift when she had told NA #2 to offer and encourage the Resident to drink water when she went to check on him. Resident #294's medication administration record indicated Lasix 20 mg was administered on [DATE] at 9:00 AM by Nurse #1. During an interview with Nurse #1 on [DATE] at 10:20 AM she stated that when she came back to work on [DATE] at around 7:00 AM she was informed by the off going night shift Nurse (Nurse #2) that a urine sample was still needed for Resident #294 since she had not been able to obtain the urine during the night shift. Nurse #1 stated that she did not attempt to obtain the urine sample on [DATE] day shift. She indicated that Resident #294 was more like he was the previous day when she had noted he was not at his baseline. He was less talkative than usual and not eating/drinking as usual and she continued to push fluids. Nurse #1 stated that Resident #294 normally ate and drank most of what was on his tray, and he also drank most of the water she gave him during medication administration, but on [DATE] he took only sips with the medication. She further stated that Resident #294 consumed 0 out of 120 milliliters of his med pass (nutritional supplementation) on [DATE] at approximately 9:00 AM and 5:00 PM whereas previously he consumed 100 % of the supplementation. Nurse #1 verified that she did not notify the physician of Resident #294's change of condition from baseline. A facility 24-hour condition report completed by Nurse #3 dated [DATE] on night shift ([DATE] 7:00 PM to [DATE] 7:00 AM) indicated the nurse attempted twice to collect urine unsuccessfully. A late entry nursing progress note written by Nurse #3 dated [DATE] at 6:13 AM indicated report was given to the nurse that a UA/C&S was needed. The nurse attempted to push fluids, however, resident would only take small sips. The first attempt to obtain the UA/C&S was around 9:00 PM on [DATE] and she was unable to collect as not enough urine came out. The writer continued to push fluids throughout the shift, again, only getting small sips. The first attempt to collect the urine was reported to the supervisor. The second attempt to obtain the UA/C&S was at 5:33 AM on [DATE] and was again unsuccessful. Oncoming nurse (Nurse #1) and the Unit Manager were made aware of the attempts and that the resident was still in need of a specimen or the medical doctor may need to be called to get further orders. Nursing progress note written by Nurse #3 dated [DATE] at 6:31 AM indicated writer attempted to collect urine twice, however, was unsuccessful and Nurse #3 would report off to oncoming nurse (Nurse #1). An interview was conducted on [DATE] at 1:54 PM with the Nurse #3 who was assigned to care for Resident #294 on [DATE] at 7:00 PM through [DATE] at 7:00 AM. Nurse #3 stated she had received report from the off going day shift nurse (Nurse #1) that a urine specimen was needed for Resident #294 and she attempted to obtain the specimen at around 9:00 PM on [DATE] and at approximately 5:30 AM on [DATE] via an in and out catheter both times but was unsuccessful. She stated that there was barely any urine and it was too thick to be processed. She stated that Resident #294's incontinence brief was dry during both attempts, and she was pushing fluids but Resident #294 was only taking small sips and could not get in much. Nurse #3 reported to the oncoming day shift nurse (Nurse #1) that she had been unsuccessful in obtaining the urine specimen via an in and out catheter. Nurse #3 stated that Resident #294's vital signs were completed on day shift and were stable. She stated that she could not recall if she had obtained any vital signs during her shift and if she did, she would have documented them if they were outside parameters. Nurse #3 stated that Resident #294 did not seem different than other nights she had cared for him, he was verbal and did not seem to be in any acute distress otherwise she would have informed the physician to send him out. She verified she did not notify the physician. During an interview on [DATE] at 3:05 PM with Nursing Assistant (NA) #1 she stated that she had cared for Resident #294 on [DATE] through [DATE] during the 7:00 AM to 3:00 PM shift. NA #1 stated that during those 3 days she noticed that Resident #294 was eating and drinking less than usual, and he had become incontinent whereas previously he was using the urinal. She also stated that previously he could feed himself, but she had to feed him and offer drinks on [DATE] and [DATE] but he did not eat or drink as he usually did. NA #1 also stated that when she changed Resident #294's briefs there was minimal urine. NA #1 further stated that when she was giving Resident #294 a shower on [DATE] he was not as responsive as usual, he was quiet and not shouting like he would normally do during showers. She verbalized that Nurse #1 was aware of Resident #294's condition and had told NA #1 to encourage Resident #294 to drink his fluids and also to give him a shower because he kept pulling off his clothes. Resident #294's medication administration record indicated Lasix 20 mg was administered on [DATE] at 9:00 AM by Nurse #1. A Physician order dated [DATE] at 10:15 AM ordered by PA #1 indicated obtain peripheral intravenous (PIV) access (small catheter inserted into a superficial vein [a vein located close to the surface of the skin]). If unable to obtain, obtain a midline (a long flexible tube that is inserted into a vein in the upper arm to deliver fluids or medication into the blood stream). A Physician order dated [DATE] ordered by PA #1 indicated Sodium Chloride Intravenous Solution 0.9 %. Use 2 liters intravenously in the morning for poor oral intake for 3 Days. Administer 2 liters intravenous fluids normal saline at 100 milliliters per hour for 3 days. (Sodium Chloride is used to replenish lost water and salt in the body.) During an interview with Nurse #1 on [DATE] at 10:20 AM, Nurse #1 stated that when she came to work on [DATE] at around 7:00 AM she was informed by the off going night shift nurse (Nurse #3) that a urine sample was still needed. She indicated the resident drank only sips of water during medication administration on [DATE]. Nurse #1 revealed that she had administered Resident #294's Lasix on [DATE], [DATE] and [DATE] at approximately 9:00 AM despite the resident's decreased oral food and fluid intake and that she did not think to hold it or ask the provider about it. She stated Resident #294 seemed more confused than the previous 2 days, and she notified Physician Assistant (PA) #1 when she came to the facility between 10:00 AM and 11:00 AM on [DATE]. She stated that she knew the PA would come to the facility that morning and she would let the PA know that they had not been able to obtain the urine specimen and the resident was not drinking much which was probably a sign of dehydration. PA #1 went to examine Resident #294 and ordered a midline and IV fluids. Nurse #1 stated she did not attempt to insert a peripheral line because Resident #294 was dehydrated and she could not find a visible vein. She stated that she did not notify the PA regarding the PIV because the PA had ordered a midline if a PIV was not obtained. She called the vascular team (a contracted entity that is specialized in inserting intravenous catheters) to come and insert a midline and also called Resident #294's family member to obtain consent for the midline insertion. The family member did not answer the phone, and she left a message for her. The family member arrived at the facility at around 3:00 PM and the Nurse informed her that the vascular team were enroute to the facility to insert the midline. The family member wanted Resident #294 to be sent to the Emergency Department (ED) due to the worsening condition and Nurse #1 stated she agreed. She informed the Unit Manager and the facility Provider and called emergency medical services (EMS) who came to transfer Resident #294 to the hospital. A Physician Assistant (PA) progress note written by PA #1dated [DATE] at 11:52 AM indicated Resident #294 was seen by PA at the request of nursing for evaluation of change in condition. The resident was minimally responsive. This was a noted change from usually being agitated and interactive per nursing/therapy. The roommate reported that he had not seen Resident #294 eat over the past 3 days. Nursing attempted to obtain UA/C&S, unable to provide adequate sample even with catheter. The progress note also indicated the resident had a change in condition, altered mental status, decreased oral intake, and was clinically dehydrated. An order was provided to obtain a PIV on [DATE] and ordered IVF 2 liters for 3 days ([DATE] to [DATE]). The progress note indicated staff were unable to obtain UA/C&S given dehydration. During an interview on [DATE] at 4:30 PM with Physician Assistant #1 (PA #1) she stated that she was notified by Nurse #1 when she came to the facility at around 10:30 AM on [DATE] that Resident #294 had a change in condition, and they had not been able to obtain a urine sample for a UA and C&S. The PA explained that when she went to assess Resident #294, he seemed dehydrated but was responsive to questions. She gave an order to insert a peripheral intravenous (PIV) line and if unable to obtain PIV access to obtain a midline so that they could administer IV fluids. The PA stated she normally put the two orders (PIV and midline) on the same order so that if they could not obtain a PIV they could go ahead and obtain the midline without needing a second order. The PA stated she did not know Resident #294's baseline since she was not the primary care provider for Resident #294. She also stated that she could not recall if the facility contacted her to let her know that they had not obtained an IV access. She indicated she would not have expected to be notified if they did not obtain the PIV since the order explicitly stated to obtain the midline if PIV access was unable to be obtained. PA #1 stated the timeline to contact a provider was a case-by-case basis based on Resident's status. She further stated that if the Resident was declining and they could not get an IV access then they would contact the Provider if they needed the Resident to be sent to the hospital. An interview was conducted with the Unit Manager (UM) on [DATE] at 10:40 AM. The UM stated that she was notified by Nurse #1 on [DATE] at approximately 3:00 PM that Resident #294's family member was in the facility to see the resident and wanted him to be sent to the hospital due to altered mental status and she told Nurse #1 to go ahead and send the Resident out to the hospital per family request. The UM verbalized she was not aware if the Provider was notified about the inability to obtain the urine sample and change in condition until [DATE] when the Provider came to the facility between 10:00 AM and 11:00 AM. An interview was conducted with Resident #294's Emergency Contact #1 (Family Member) on [DATE] at 3:02 PM. The family member stated that she received a voice message from Nurse #1 on [DATE] at approximately 1:30 PM indicating that Resident #294 was doing okay and that she wanted to give her an update. The family member decided to come to the facility to check what was going on when she tried to call back the facility and was put on hold. When she arrived at the facility around 3:00 PM she found the Resident naked and disoriented, his mouth was dry and crusty and she attempted to give him a drink and he drank it. The family member stated Nurse #1 told her she was waiting for vascular team to come and insert an intravenous line and she informed Nurse #1 that she wanted the Resident to be sent to the hospital because he was in distress and Nurse #1 called 911. An EMS report dated [DATE] indicated that EMS was contacted at 3:42 PM for a non-emergent transportation due to family choice. EMS arrived at the facility at 4:02 PM and primary impression was altered mental status and secondary impression was sepsis. The chief complaint was altered mental status with onset of [DATE]. An electrocardiogram (ECG) at 4:05 PM indicated atrial fibrillation (irregular heart rhythm characterized by rapid and irregular heartbeat). Vital signs obtained by EMS at 4:17 PM were noted as blood pressure: ,d+[DATE], pulse: 65, respirations: 8, oxygen saturation: 94 % and level of consciousness was responds to painful stimulation on the AVPU (alert, voice, pain, unresponsive scale used to measure patient's level of consciousness). EMS obtained a telephone order at 4:22 PM to administer IV fluids due to Resident #294 meeting the criteria for sepsis. IV fluids were not administered due to inability to establish an IV access. EMS departed facility at 4:39 PM with Resident #294 and notified the receiving hospital of sepsis indication at 5:00 PM. EMS assessment at 5:05 PM indicated Resident #294 was lethargic, non-verbal with minimal alertness, he had rapid mouth breathing, his skin was cold and dry, lung sounds were clear with increased respiratory rate and oxygen saturation readings were inconsistent due to the resident having cold hands. Resident #294 arrived at the ED at 5:41 PM. An ED progress note dated [DATE] indicated that Resident #294's vital signs were noted as follows: blood pressure: ,d+[DATE], heart rate: 138, and respirations 29 at 5:45 PM and oxygen saturation: 33 %, and temperature: 93.4 degrees Fahrenheit at 6:23 pm. The progress note indicated Resident #294 presented critically ill, obtunded (reduced level of alertness and consciousness), breathing on his own with cold distal extremities with dilated pupils without response bilaterally and no response to painful stimuli. Facility stated that he had not been eating or drinking anything for 3 days, and today he was found naked by his family and encouraged the nurse to take his vital signs who then emergently called for 911. Resident #294 was found to be in metabolic acidosis (a condition in which too much acid accumulates in the body). Because of his cold extremities, they were unable to reliably obtain a pulse oximeter reading. Discussion with family revealed patient had voiced wishes to have everything done to sustain his life. After discussion regarding his goals of his care, family wanted the patient to continue to be full code. They understood that he was critically ill at that moment. The ED note indicated that Resident's presentation with altered mental status, tachypnea, poor perfusion, hypothermia, severe lactic acidosis, and new vasopressor requirements, consistent with septic shock with end organ dysfunction as cause of death. Resident #294 died at 8:26 PM on [DATE]. During an interview on [DATE] at 3:07 PM with PA #2 she stated that she was the primary care provider for Resident #2 and that she had given the telephone order on [DATE] for the UA/C&S due to dysuria per nursing reports. PA #2 stated that she could not recall the facility notifying her that they had not obtained the urine sample or that the Resident's condition was declining. She also stated the timeline to contact a provider was a case-by-case basis based on Resident's status. An interview was conducted with the facility Medical Director (MD) on [DATE] at 4:37 PM. The MD stated he was aware of Resident #294's condition and the facility did what they were supposed to do to manage the Resident's condition. He indicated that when the Resident showed signs of a UTI, a UA was ordered and when they could not obtain a urine sample, they ordered an IV access for hydration, but the Resident was sent out before the IV access was obtained. The MD also stated that if the Resident had been sent out earlier the outcome would not have been any different. He also stated that if the UA had been obtained on [DATE] and was positive for a UTI they would have started the Resident on oral antibiotics and the outcome would have probably been the same. When the MD was asked if the facility staff should have notified him when they could not obtain the urine on [DATE] with the resident not drinking adequately as well as with continued Lasix administration, the MD stated the facility did everything right. When asked if the facility staff should have notified him when they didn't obtain PIV access, he stated that the vascular team had been contacted and they were on the way when the resident was sent out to the hospital. An interview was conducted on [DATE] at 4:30 PM with the Director of Nursing (DON). The DON stated that if nurses were not able to obtain the urine specimen on [DATE] at 5:00 AM, [DATE] at 9:00 PM and [DATE] at 5:30 AM with decreased oral intake nurses should have contacted the on call provider if there was no provider in the facility. She also stated nurses should have notified the PA on [DATE] when they were in the building that they had not obtained the ordered urine sample and inquired about the Lasix administration due to decreased oral intake and inability to obtain the urine specimen. The DON indicated she did not expect the staff to notify the physician/PA when the PIV access was unable to be obtained as the order specifically stated that if staff were unable to obtain PIV access that they were to obtain a midline via the vascular team. The Administrator was notified of immediate jeopardy on [DATE] at 6:04 PM. The facility provided the following credible allegation of immediate jeopardy removal: 1) Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance Resident #294 no longer resides in the facility. Resident was transferred to the local hospital on [DATE] due to altered mental status. The center recognizes that all residents have the potential to be affected from the noncompliance of notifying the physician as it relates to obtaining a urine sample for residents identified with complaints of burning urination and decreased fluid intake, including signs and symptoms of dehydration as evidenced by the inability to collect urine via an in and out catheter when the resident had a dry brief. A review of Resident #294's electronic medical record revealed an order for UA w/ reflex, Urine Culture and Sensitivity with Diagnosis of Dysuria was ordered on [DATE]. The facility staff attempted to push fluids and obtain urine sample on [DATE] at approximately 5:00 AM and 9:00 PM, [DATE] at approximately 5:30 AM and was unable to collect urine sample. A review of Resident #294 orders indicated resident was prescribed Lasix 20mg daily to be administered daily per physicians' orders. A quality review of current residents with an order for UA/C&S between [DATE] through [DATE] were audited by the Director of Clinical Services and Unit Managers on [DATE] to ensure urine sample was obtained. Nine (9) residents with orders for UA/C&S and eight (8) with no further change in condition that required notification to physician. No discrepancies were noted. Twenty-three (23) residents identified as having a physician order to administer diuretics were audited by the Director of Nursing and Unit Managers to ensure no signs and symptoms of dehydration as evidenced by the inability to collect urine. No resident was identified with signs and symptoms of dehydration as evidenced by the inability to collect urine, therefore notification to the physician was not warranted. On [DATE], a root cause analysis was completed by the Director of Clinical Services and the Executive Director regarding notifying the physician for Resident #294 when staff were unable to obtain a urine sample. It was determined through the root cause analysis that the facility failed to follow policy and procedures to notify the physician regarding change in condition as it relates to decreased fluid intake for Resident #294 receiving Lasix and unable to obtain urine sample. 2) Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete The Director of Clinical Services and Nurse Managers re-educated licensed nurses on notifying physician for residents identified as having a change in condition via Situation, Background, Assessment and Recommendation (SBAR) as it relates to assessing residents with signs and symptoms of dehydration on [DATE]. The licensed nurse is to assess the resident, including vitals, complete the SBAR and notify the attending physician when there is a change in the status or condition of the resident. The Director of Nursing and Unit Managers re-educated licensed nurses on recognizing signs and symptoms of dehydration to ensure prompt physician notification for change in condition on [DATE]. Staff (licensed nurses/ Certified Nurse Assistants) not educated on [DATE], will be educated by the Director of Nursing and or Unit Manager prior to working the floor. Newly hired staff will be educated during orientation by the Director or Nursing or Unit Manager on notifying physician for residents identified as having a change in condition via SBAR as it relates to assessing residents with signs and symptoms of dehydration. The Director of Clinical Services and Nurse Managers re-educated licensed nurses on notifying physician via change in condition (SBAR) for residents with an order for UA/C&S and unable to obtain urine sample on [DATE]. The licensed nurse is to assess the resident, including vitals, complete the SBAR and notify the attending physician when there is a change in the status or condition of the resident. The Director of Clinical Services and Nurse Managers re-educated certified nursing assistants on signs and symptoms of dehydration and immediately report the change in condition to the licensed nurse on [DATE]. Newly hired staff will be educated during orientation by the Director of Clinical Service and or Unit Managers. Staff (licensed nurses/ Certified Nurse Assistance) not educated on [DATE], will be educated by the Director of Nursing and or Unit Manager prior to working the floor. Date of Immediate Jeopardy Removal [DATE] On [DATE] the facility's immediate jeopardy removal was validated [TRUNCATED]

Based on record review, and staff, family member, Physician Assistant, and Medical Director interviews, the facility staff failed to recognize the seriousness of a significant change in condition, the importance of and identify the need for urgent medical attention to address an emergent situation. On [DATE] a sudden decrease in food and fluid intake was observed by staff. Resident #294 reported burning with urination to the night shift nurse ([DATE] at 11:00 PM through [DATE] at 7:00 AM) and an order for a urinalysis (UA) and urine culture and sensitivity (C & S) was obtained from Physician Assistant #2 on [DATE]. No attempts were made to collect the urine specimen for the UA until [DATE] at around 5:00 AM and the nurse was not successful. Another nurse attempted to obtain the urine specimen the evening of [DATE] and the morning of [DATE] but was not successful. Resident #294 was administered his diuretic daily [DATE] through [DATE] despite decreased intake. The poor intake continued and by [DATE] Resident #294 had become incontinent of urine, there was minimal urine noted when his brief was changed, and staff had to feed him. The morning of [DATE] staff requested PA #1 to evaluate Resident #294 who noted the resident had a change in condition, altered mental status, decreased oral intake, and was clinically dehydrated. PA #1 ordered intravenous (IV) fluids for 3 days, but the nurse did not attempt to insert a peripheral line because Resident #294 was dehydrated, and she could not find a visible vein. The nurse contacted the vascular team to obtain IV access. On [DATE] Resident #294's family member arrived at the facility at approximately 3:00 PM and requested the resident be sent to the hospital and the facility requested non emergent transport. The specimen for the urinalysis had still not been collected and the IV fluids had not been initiated. EMS arrived at the facility at 4:02 PM and the primary impression was altered mental status and secondary impression was sepsis. The chief complaint was altered mental status with onset of [DATE]. Resident #294 was transferred to the emergency department (ED) where the progress note indicated Resident #294 presented critically ill, obtunded (reduced level of alertness and consciousness), breathing on his own, with cold distal extremities, with dilated pupils without response bilaterally, and no response to painful stimuli. He was identified with altered mental status, tachypnea (rapid and shallow breathing), poor perfusion (occurs when there is inadequate blood circulation to organs and tissues and can be an early sign of circulatory or heart problems and can lead to life-threatening conditions), hypothermia (a medical emergency that occurs when the body's temperature drops below 95 F), severe lactic acidosis (occurs when the body produces too much lactic acid and the liver can't metabolize it fast enough), and new vasopressor requirements (vasopressors are a medication that are used to treat people with low blood pressure) most consistent with septic shock (a life-threatening condition that happens when your blood pressure drops to a dangerously low level after an infection) with end organ dysfunction. Resident #294 died at 8:26 PM on [DATE]. This deficient practice occurred for 1 of 3 residents (Resident #294) reviewed for professional standards of care. Immediate jeopardy began on [DATE] when staff failed to recognize the seriousness of Resident #294's change in condition and obtain necessary emergent medical attention. Immediate jeopardy was removed on [DATE] when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a scope and severity of D (no actual harm with potential for more than minimal harm that is immediate jeopardy) to ensure education is completed and monitoring systems put into place and are effective. The findings included: Resident #294 was initially admitted to the facility on [DATE] with the last readmission to the facility on [DATE]. His diagnoses included fracture of right femur (thigh bone between hip and knee), dementia, type 2 diabetes, adult failure to thrive, generalized muscle weakness, chronic kidney disease, and congestive heart failure. He was admitted to the facility for rehabilitation therapy services after hospitalization following the femur fracture. A hospital discharge summary dated [DATE] indicated Resident #294 was admitted to the hospital from [DATE] to [DATE] due to inability to care for himself at home after he was discharged home from SNF on [DATE] and readmitted to the hospital on [DATE]. He had an unwitnessed ground-level fall early morning on [DATE] at the hospital when he thought he smelled smoke in his room and got up to investigate. Plain films revealed right femoral neck fracture. Resident #294 underwent a right hip hemiarthroplasty on [DATE] and was discharged to SNF on [DATE] with physical and occupational therapy recommendations. A physician skilled nursing facility (SNF) admission note indicated Resident #294 was seen on [DATE] and reason for admission was debility. The symptoms had begun 11 weeks ago and the symptoms were reported as being moderate. The note indicated that the resident had a history of type 2 diabetes, coronary artery disease and suspected major neurocognitive disorder and had presented to the hospital for failure to thrive in adult. Resident #294 was admitted to the hospital on [DATE] through [DATE] for difficulty caring for self. He was discharged from the hospital on [DATE] and admitted to a skilled nursing facility and was discharged from the SNF to the community on [DATE] but he was unable to care for self at home and was readmitted to the hospital on [DATE]. He was living in a trailer without access to running water or sewer and likely not consistently taking his medications. He was known to only be able to feed and dress himself but not to perform other activities of daily living (ADL) or instrumental activities of daily living (IADLs) independently, including unable to bathe himself or use toilet, often using water jugs as commodes instead. Per review of prior records, Resident had demonstrated inability to follow-up with medical providers (was lost to Cardiology follow-up for 3 years despite significant cardiac history) and was paranoid about medications, such as self-discontinuing enalapril (medication used to treat high blood pressure) because he did not trust new pill color, demonstrating inability to make rational decisions regarding his health. The plan on the admission note indicated Resident #294 had a set of conditions, syndromes and functional impairments that would likely require frequent medication changes, other treatment changes and re-evaluations. Resident was at significant risk of worsening medical (including behavioral) status and was at significant risk for readmission to a hospital and these multiple morbidities required intensive management. Resident #294's care plan last revised on [DATE] had a care focus area that indicated Resident had potential for fluid deficit related to diuretic use with the goals for Resident to be free of symptoms of dehydration. Interventions included: monitor and document intake and output as per facility policy; monitor vital signs as ordered/per protocol and record; notify physician of significant abnormalities; monitor/document/report as needed any signs/symptoms of dehydration; obtain and monitor lab/diagnostic work as ordered and report results to physician and follow up as indicated. A physician order dated [DATE] indicated full code. A physician order dated [DATE] indicated give Lasix oral tablet 20 milligram by mouth one time a day for edema (swelling from fluid retention). Lasix is a diuretic used to treat fluid retention that can result from congestive heart failure, kidney disease or other medical conditions. Lasix increases urine output and can lead to dehydration. Resident #294's admission Minimum Data Set (MDS) assessment dated [DATE] coded Resident #294 as cognitively intact. He had no behaviors or rejection of care. He required supervision or touching assistance with toileting. He required setup or clean up assistance with eating. He was coded as frequently incontinent of bowel and bladder and was also coded as taking a diuretic. His weight was 137 pounds, and his height was 68 inches. Resident #294's overall discharge goal was to return to the community. He was not coded for hospice care. A 24-hour facility condition report completed by Nurse #5 dated [DATE] indicated Resident #294 had poor oral intake on day shift (7:00 AM to 7:00 PM). The facility's 24-hour condition report is a form that nurses document the status of all the residents during or at the end of their shift to communicate any pertinent information to the next shift and nursing management. During an interview with Nurse #5 on [DATE] at 2:45 PM, she stated that she had cared for Resident #294 on [DATE] from 7:00 AM to 7:00 PM. Nurse #5 indicated that normally Resident # 294 consumed more than 25% of his tray food and drinks but on [DATE] he had eaten and drank less than 25% during the three meals on her shift and she documented it in the 24 hour report and informed the oncoming night shift nurse (Nurse # 4). Vital signs documented on [DATE] at 1:43 PM by Nurse #5 were blood pressure (BP): ,d+[DATE], pulse:79, oxygen saturations: 96% and temperature: 98 F. Phone interviews were attempted with Nursing Assistant (NA) #3, the NA who worked with Resident #294 during the first shift (7:00 AM to 3:00 PM) on [DATE], and were unsuccessful. A 24-hour facility condition report completed by Nurse #4 dated [DATE] indicated Resident #294 was complaining of burning with urination on night shift ([DATE] 11:00 PM to [DATE] 7:00 AM shift). During an interview on [DATE] at 3:53 PM with Nurse #4, she stated that she was assigned to care for Resident #294 on [DATE] at 7:00 PM to [DATE] at 7:00 AM. Nurse #4 stated that during shift change Nurse #5 had informed her and documented in the 24-hour condition report that Resident #294 had a decreased oral intake with food and drinks. Nurse #4 verbalized that Resident #294 complained of burning with urination during her shift and she left a note for the Provider in the physician book, noted it in the 24-hour condition report and informed the oncoming day shift nurse (Nurse #1). Nurse #4 stated that Resident #294 was stable and the only concern during her shift was complaints of burning with urination which she noted in the physician's book, and she pushed fluids while Resident #294 was awake because she thought it was a sign of urinary tract infection. Resident #294's medication administration record indicated Lasix 20 mg was administered on [DATE] at 9:00 AM by Nurse #1. A Physician telephone order dated [DATE] at 11:59 AM ordered by Physician Assistant (PA) #2 indicated urinalysis (UA), urine culture and sensitivity (C & S) for a diagnosis of dysuria. During an interview on [DATE] at 10:20 AM with Nurse #1, she indicated that she had cared for Resident #294 on [DATE]. Nurse #1 stated that when she came to work on [DATE] at around 7:00 AM she was informed by the off going night shift nurse (Nurse #4) that Resident #294 had complained of pain with urination during the night shift ([DATE] at 7:00 PM to [DATE] at 7:00 AM). Nurse #1 verbalized that a UA/CS to rule out a urinary tract infection was ordered during her shift ([DATE] 7:00 AM- 7:00 PM) but she did not attempt to obtain a urine sample since it would not have been picked up until around 6:00 AM the following morning. She stated that she was pushing fluids and Resident #294's vital signs were stable. Nurse #1 stated she did not obtain urine specimen and put in the refrigerator because it was normally collected on night shift to be sent out in the morning. Vital signs documented on [DATE] at 3:13 PM by Nurse #1 were BP: ,d+[DATE], pulse:65, oxygen saturations: 94% and temperature: 97.5 F. A 24-hour facility condition report dated [DATE] on day shift (7:00 AM to 3:00 PM) completed by Nurse #1 and evening shift (3:00 PM to 11:00 PM) completed by Nurse #6 indicated the need for a UA/CS for Resident #294 in the morning ([DATE]). An interview was conducted on [DATE] at 1:40 PM with Nurse #6. He stated that he had filled in for four hours and cared for Resident #294 on [DATE] from 7:00 PM to 11:00 PM and he was aware that Resident #294 required a urine sample, but he did not obtain it because it wouldn't have been picked up until around 6:00 AM in the morning. He notified the third shift nurse (Nurse #2) to collect the urine specimen when she took over at 11:00 PM. Nurse #6 explained that the laboratory specimens were picked up by laboratory staff in the morning at approximately 6:00 AM. Nurse #2 stated that Resident #294 was stable and carried on conversation with him when he went to administer his 9:00 PM medications, he was in no pain and he took his medications with no concerns. Nurse #6 stated he did not collect the urine specimen and refrigerate it during his shift since a sample collected by third shift would have been fresher when it was sent out in the morning. A 24-hour facility condition report dated [DATE] on night shift ([DATE] 11:00 PM to [DATE] 7:00 AM) completed by Nurse #2 and day shift ([DATE] 7:00 AM to 3:00 PM) completed by Nurse #1 indicated the need for a UA and C&S for Resident #294. During an interview on [DATE] at 3:38 PM with Nurse #2, she stated that she had cared for Resident #294 on the night shift ([DATE] at 11:00 PM to [DATE] at 7:00 AM). Nurse #2 stated that when she took over the assignment that night, she was notified by the off going nurse (Nurse #6) that a urine sample was needed for Resident #294. She indicated that when she came on shift Resident # 294 was asleep and she did not recall waking him up to give him any fluids. Nurse #2 indicated that Resident #294 slept throughout her shift, and she attempted to obtain the urine specimen via an in and out catheter at around 5:00 AM on [DATE] but was unsuccessful and she notified the oncoming day shift nurse (Nurse #1). Nurse #2 indicated Resident #294's incontinence brief was wet during the in and out catheter attempt. Nurse #2 also indicated that she was not Resident #294's regular nurse and she was not familiar with his baseline. She further stated that his vital signs were obtained on day shift, but she would have obtained a set of vital signs that night if the Resident was in acute distress. An interview was conducted on [DATE] at 2:12 PM with NA #2 who had cared for Resident #294 on [DATE] and [DATE] on night shift. NA #2 stated that Resident #294 took only a few sips of water during her shifts and when she changed his incontinence brief there was very little urine. NA #2 stated she worked with Nurse #3 ([DATE] at 11:00 PM through [DATE] at 7:00 AM) and Nurse #3 was aware of Resident's condition from the beginning of her shift when she had told NA #2 to offer and encourage the Resident to drink water when she went to check on him because they needed to obtain urine. NA #2 stated she could not recall if she had reported any information about Resident #294 to Nurse #2 on [DATE] night shift. Resident #294's medication administration record indicated Lasix 20 mg was administered on [DATE] at 9:00 AM by Nurse #1. During an interview on [DATE] at 10:20 AM with Nurse #1, she stated that when she came back to work on [DATE] at around 7:00 AM she was informed by the off going night shift Nurse (Nurse #2) that a urine sample was still needed for Resident #294 since she had not been able to obtain the urine during the night shift. Nurse #1 stated that she did not attempt to obtain the urine sample on [DATE] day shift since it would wait until the following morning at around 6:00 AM to be picked up. She indicated that Resident #294 was still not at baseline; he was less talkative than usual and not eating/drinking as usual and she continued to push fluids. Nurse #1 stated that Resident #294 normally ate and drank most of what was on his tray, and he also drank most of the water she gave him during medication administration, but on [DATE] he took only sips with the medication. She further stated that Resident #294 consumed 0 out of 120 milliliters of his med pass (nutritional supplementation) on [DATE] at approximately 9:00 AM and 5:00 PM whereas previously he consumed 100 % of the supplementation. Nurse #1 stated she recognized the resident was not at his baseline and was not eating and drinking as he usually did. The UA had been ordered the day before and Nurse #2 had not been able to obtain the specimen the previous shift. Nurse #1 stated she did not think of obtaining the urine during her shift to be sent to the lab and she left it for the next shift so it could be sent out the following day because it was normally collected on night shift and sent out in the morning. Vital signs documented on [DATE] at 3:43 PM by Nurse #1 were BP: ,d+[DATE], pulse:58, oxygen saturations: 94% and temperature: 97.2 F. A 24-hour facility condition report completed by Nurse #3 dated [DATE] on night shift ([DATE] 7:00 PM to [DATE] 7:00 AM) indicated the nurse attempted twice to collect urine unsuccessfully. A late entry nursing progress note written by Nurse #3 dated [DATE] at 6:13 AM indicated report was given to the nurse that a UA/C&S was needed. The nurse attempted to push fluids, however, resident would only take small sips. The first attempt to obtain the UA/CS was around 9:00 PM on [DATE] and she was unable to collect as not enough urine came out. The writer continued to push fluids throughout the shift, again, only getting small sips. The first attempt to collect the urine was reported to the supervisor. The second attempt to obtain the UA/C&S was at 5:33 AM on [DATE] and was again unsuccessful. Oncoming nurse (Nurse #1) and the Unit Manager were made aware of the attempts and that patient is still in need of a specimen or the medical doctor may need to be called to get further orders. Nursing progress note written by Nurse #3 dated [DATE] at 6:31 AM indicated writer attempted to collect urine twice, however, was unsuccessful and Nurse #3 would report off to oncoming nurse (Nurse #1). An interview was conducted on [DATE] at 1:54 PM with the Nurse #3 who was assigned to care for Resident #294 on [DATE] at 7:00 PM through [DATE] at 7:00 AM. Nurse #3 stated she had received report from the off going day shift nurse (Nurse #1) that a urine specimen was needed for Resident #294 and she attempted to obtain the specimen at around 9:00 PM on [DATE] and at approximately 5:30 AM on [DATE] via an in and out catheter both times but was unsuccessful. She stated that there was barely any urine, and it was too thick to be processed. She stated that Resident #294's incontinence brief was dry during both attempts, and she was pushing fluids but Resident #294 was only taking small sips and could not get in much. Nurse #3 reported to the oncoming day shift nurse (Nurse #1) that she had been unsuccessful in obtaining the urine specimen via an in and out catheter. Nurse #3 stated that Resident #294's vital signs were completed on day shift on [DATE] and were stable. She stated that she could not recall if she had obtained any vital signs during her shift and if she did, she would have documented them if they were outside parameters. Nurse #3 stated that Resident #294 was verbal and did not seem to be in any acute distress otherwise she would have informed the physician to send him out. During an interview on [DATE] at 3:05 PM with Nursing Assistant (NA) #1 she stated that she had cared for Resident #294 on [DATE] through [DATE] during the 7:00 AM to 3:00 PM shift. NA #1 stated that during those 3 days she noticed that Resident #294 was eating and drinking less than usual, and he had become incontinent whereas previously he was using the urinal. She also stated that previously he could feed himself, but she had to feed him and offer drinks on [DATE] and [DATE] but he did not eat or drink as he usually did. NA #1 also stated that when she changed Resident #294's briefs there was minimal urine. NA #1 further stated that when she was giving Resident #294 a shower on [DATE] he was not as responsive as usual, he was quiet and not shouting like he would normally do during showers. She verbalized that Nurse #1 was aware that Resident #294 was not drinking and eating as he normally did and had told NA #1 to encourage Resident #294 to drink his fluids and also to give him a shower because he kept pulling off his clothes. NA #1 indicated Resident #294 was not alert and oriented when she completed her shift, and they were getting ready to transfer the Resident to the hospital. Resident #294's medication administration record indicated Lasix 20 mg was administered on [DATE] at 9:00 AM by Nurse #1. A Physician Assistant (PA) progress note written by PA #1dated [DATE] at 11:52 AM indicated Resident #294 was seen by PA at the request of nursing for evaluation of change in condition. The resident was minimally responsive. This was a noted change from usually being agitated and interactive per nursing/therapy. The roommate reported that he had not seen Resident #294 eat over the past 3 days. Nursing attempted to obtain UA/CS, unable to provide adequate sample even with catheter. The progress note also indicated the resident had a change in condition, altered mental status, decreased oral intake, and was clinically dehydrated. An order was provided to obtain a PIV on [DATE] and ordered IVF (intravenous fluids) 2 liters for 3 days ([DATE] to [DATE]). PA #1 progress note indicated she confirmed hold parameters for insulins with decreased oral intake, although blood sugar was in 300s (normal range between 70 and 100 milligrams per deciliter). The progress note also indicated unable to obtain UA/CS given dehydration. During an interview on [DATE] at 4:30 PM with Physician Assistant #1 (PA #1) she stated that she was notified by Nurse #1 when she came to the facility at around 10:30 AM on [DATE] that Resident #294 had a change in condition, and they had not been able to obtain a urine sample for a UA and CS. The PA explained that when she went to assess Resident #294, he seemed dehydrated but was responsive to questions. She gave an order to insert a peripheral intravenous (PIV) line and if unable to obtain PIV access to obtain a midline so that they could administer IV fluids. The PA stated she did not know Resident #294's baseline since she was not the primary care provider for Resident #294. She also stated that she could not recall if the facility contacted her to let her know that they had not obtained an IV (intravenous) access. A Physician order dated [DATE] at 10:15 AM ordered by PA #1 indicated to obtain peripheral intravenous (PIV) access (small catheter inserted into a superficial vein [a vein located close to the surface of the skin]). If unable to obtain, obtain a midline (a long flexible tube that is inserted into a vein in the upper arm to deliver fluids or medication into the blood stream). A Physician order dated [DATE] ordered by PA #1 indicated Sodium Chloride Intravenous Solution 0.9 %. Use 2 liters intravenously in the morning for poor oral intake for 3 Days. Administer 2 liters intravenous fluids normal saline at 100 milliliters per hour for 3 days. (Sodium Chloride is used to replenish lost water and salt in the body.) During an interview with Nurse #1 on [DATE] at 10:20 AM, Nurse #1 stated that when she came to work on [DATE] at around 7:00 AM she was informed by the off going night shift nurse (Nurse #3) that a urine sample was still needed. Nurse #1 stated she checked on Resident #294 several times that morning and she had administered his morning medications at around 9:00 AM which he took with 25% of his med pass nutritional supplementation. Nurse #1 revealed that she had administered Resident #294's Lasix on [DATE], [DATE] and [DATE] at approximately 9:00 AM despite the resident's decreased oral food and fluid intake and that she did not think to hold it or ask the provider about it. She stated Resident #294 seemed more confused than the previous 2 days, and she notified Physician Assistant (PA) #1 when she came to the facility between 10:00 AM and 11:00 AM on [DATE]. PA #1 went to examine Resident #294 and ordered a midline and IV fluids. Nurse #1 stated she did not attempt to insert a peripheral line because Resident #294 was dehydrated and she could not find a visible vein. She called the vascular team (a contracted entity that is specialized in inserting intravenous catheters) between 10:00 AM and 11:00 AM to come and insert a midline and also called Resident #294's family member to obtain consent for the midline insertion. The family member did not answer the phone, and she left a message for her. The family member arrived at the facility at around 3:00 PM and the Nurse informed her that the vascular team was enroute to the facility to insert the midline. Nurse #1 indicated Resident #249 was quieter around 3:00 PM compared to earlier in the day. The family member wanted Resident #294 to be sent to the Emergency Department (ED) due to the worsening condition and Nurse #1 stated she agreed. She informed the Unit Manager and the facility Provider and called emergency medical services (EMS) who came to transfer Resident #294 to the hospital. An interview was conducted with the Unit Manager (UM) on [DATE] at 10:40 AM. The UM stated that she was notified by Nurse #1 on [DATE] at approximately 3:00 PM that Resident #294's family member was in the facility to see the resident and wanted him to be sent to the hospital due to altered mental status and she told Nurse #1 to go ahead and send the Resident out to the hospital per family request. The UM verbalized she was not aware if the Provider was notified about the inability to obtain the urine sample and change in condition until [DATE] when the Provider came to the facility between 10:00 AM and 11:00 AM. The UM stated that Resident #294 was being provided treatment at the facility, but the family member was the one that wanted the Resident to be sent out. During the interview the UM initially told the surveyor that intravenous access had been obtained and fluids administered but when she further looked in Resident #294's medical records she stated that she thought the fluids had been administered but they were not. An interview was conducted with Resident #294's Emergency Contact #1 (Family Member) on [DATE] at 3:02 PM. The family member stated that she received a voice message from Nurse #1 on [DATE] at approximately 1:30 PM indicating that Resident #294 was doing okay and that she wanted to give her an update. The family member decided to come to the facility to check what was going on when she tried to call back the facility and was put on hold. When she arrived at the facility at around 3:00 PM she found the Resident naked and disoriented, his mouth was dry and crusty, and she attempted to give him a drink and he drank it. The family member stated Nurse #1 told her she was waiting for vascular team to come and insert an intravenous line and she informed Nurse #1 that she wanted the Resident to be sent to the hospital because he was in distress and Nurse #1 called 911. The family member also stated that Nurse #1 checked the Resident's vital signs during their conversation in the room and Nurse #1 immediately administered oxygen to the Resident after she checked the oxygen saturations. During an interview on [DATE] at 10:20 AM with Nurse #1 she stated that she had checked Resident #294's vital signs before he was transferred to the ED but she could not recall what they were, all she could remember was that oxygen saturation was below 90 % and she administered oxygen. Emergency medical services (EMS) report dated [DATE] indicated that EMS was contacted at 3:42 PM for a non-emergent transportation due to family choice. EMS arrived at the facility at 4:02 PM and primary impression was altered mental status and secondary impression was sepsis. The chief complaint was altered mental status with onset of [DATE]. An electrocardiogram (ECG) at 4:05 PM indicated atrial fibrillation (irregular heart rhythm characterized by rapid and irregular heartbeat). Vital signs obtained by EMS at 4:17 PM were noted as blood pressure: ,d+[DATE], pulse: 65, respirations: 8, oxygen saturation: 94 % and level of consciousness was responds to painful stimulation on the AVPU (alert, voice, pain, unresponsive scale used to measure patient's level of consciousness). EMS obtained a telephone order at 4:22 PM to administer IV fluids due to Resident #294 meeting the criteria for sepsis. IV fluids were not administered due to inability to establish IV access. EMS departed facility at 4:39 PM with Resident #294 and notified the receiving hospital of sepsis indication at 5:00 PM. EMS assessment at 5:05 PM indicated Resident #294 was lethargic, non-verbal with minimal alertness, he had rapid mouth breathing, his skin was cold and dry, lung sounds were clear with increased respiratory rate and oxygen saturation readings were inconsistent due to the resident having cold hands. Resident #294 arrived at the ED at 5:41 PM. Emergency department (ED) progress note dated [DATE] indicated that Resident #294's vital signs were noted as follows: blood pressure: ,d+[DATE], heart rate: 138, and respirations 29 at 5:45 PM and oxygen saturation: 33 %, and temperature: 93.4 degrees Fahrenheit at 6:23 pm. The progress note indicated Resident #294 presented critically ill, obtunded (reduced level of alertness and consciousness), breathing on his own with cold distal extremities with dilated pupils without response bilaterally and no response to painful stimuli. Facility stated that he had not been eating or drinking anything for 3 days, and today he was found naked by his family and encouraged the nurse to take his vital signs who then emergently called for 911. Resident #294 was found to be in metabolic acidosis (a condition in which too much acid accumulates in the body). Because of his cold extremities, they were unable to reliably obtain a pulse oximeter reading. Discussion with family revealed patient had voiced wishes to have everything done to sustain his life. After discussion regarding his goals of his care, family wanted the patient to continue to be full code. They understood that he was critically ill at that moment. The ED note indicated that Resident's presentation with altered mental status, tachypnea (rapid and shallow breathing), poor perfusion (occurs when there is inadequate blood circulation to organs and tissues and can be an early sign of circulatory or heart problems and can lead to life-threatening conditions), hypothermia (a medical emergency that occurs when the body's temperature drops below 95 F), severe lactic acidosis (occurs when the body produces too much lactic acid and the liver can't metabolize it fast enough), and new vasopressor requirements (vasopressors are a medication that are used to treat people with low blood pressure) most consistent with septic shock (a life-threatening condition that happens when the blood pressure drops to a dangerously low level after an infection) with end organ dysfunction as cause of death. Resident #294 died at 8:26 PM on [DATE]. An interview was conducted with the facility Medical Director (MD) on [DATE] at 4:37 PM. The MD stated he was aware of Resident #294's condition and the facility did what they were supposed to do to manage the Resident's condition. He indicated that when the Resident showed signs of a UTI, a UA was ordered and when they could not obtain a urine sample, they ordered an IV access for hydration, but the Resident was sent out before the IV access was obtained. The MD also stated that if the Resident had been sent out earlier that day on [DATE] the outcome would not have been any different. He also stated that if the UA had been obtained on [DATE] and was positive for a UTI they would have started the Res [TRUNCATED]

Based on record review, and staff, family member, Physician Assistant (PA), and Medical Director interviews the facility failed to ensure staff recognized the seriousness of signs and symptoms of dehydration for a resident receiving a diuretic (Lasix 20 mg daily) and who had decreased fluid intake. Resident #294 was first identified with decreased nutritional and fluid intake on [DATE] requiring staff to push fluids (deliberately drink beyond what thirst dictates to avoid dehydration) through [DATE]. Resident #294 exhibited signs and symptoms of dehydration on [DATE] at approximately 9:00 PM and [DATE] at approximately 5:30 AM as evidenced by the inability to collect urine via an in and out catheter (inserting a thin, hollow tube into the bladder) when the resident had no recent episodes of urination. During this time, nursing staff continued to administer the resident's Lasix (diuretic) 20 milligrams once daily at 9:00 AM despite signs and symptoms of dehydration. On [DATE] at 10:15 AM the PA ordered a peripheral intravenous (PIV) access (small catheter inserted into a superficial vein [a vein located close to the surface of the skin]) to provide intravenous fluids to the resident and staff did not attempt to insert the PIV due to the inability to find a visible vein (dehydration can cause veins to be difficult to locate). That afternoon, Resident #294's family member requested the resident be sent to the hospital. Emergency Medical Services (EMS) were contacted at 3:42 PM and Resident #294 was transferred to the emergency room where he was identified with altered mental status, tachypnea (rapid and shallow breathing), poor perfusion (occurs when there is inadequate blood circulation to organs and tissues and can be an early sign of circulatory or heart problems and can lead to life-threatening conditions), hypothermia (a medical emergency that occurs when the body's temperature drops below 95 F), severe lactic acidosis (occurs when the body produces too much lactic acid and the liver can't metabolize it fast enough), and new vasopressor requirements (vasopressors are a medication that are used to treat people with low blood pressure) most consistent with septic shock (a life-threatening condition that happens when your blood pressure drops to a dangerously low level after an infection) with end organ dysfunction. Resident #294 died at 8:26 PM on [DATE]. This deficient practice occurred for 1 of 3 residents (Resident #294) reviewed for dehydration. Immediate jeopardy began on [DATE] when staff failed to recognize the seriousness of signs and symptoms of dehydration for Resident #294 when staff were unable to collect urine via an in and out catheter when the resident had no recent episodes of urination and decreased fluid intake. Immediate jeopardy was removed on [DATE] when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a scope and severity of D (no actual harm with potential for more than minimal harm that is immediate jeopardy) to ensure education is completed and monitoring systems put into place and are effective. The findings included: Resident #294 was admitted to the facility on [DATE]. His diagnoses included fracture of right femur (thigh bone between hip and knee), dementia, type 2 diabetes, adult failure to thrive, generalized muscle weakness, chronic kidney disease, and congestive heart failure. He was admitted to the facility for rehabilitation therapy services after hospitalization following the femur fracture. Resident #294's care plan last revised on [DATE] had a care focus area that indicated Resident had potential for fluid deficit related to diuretic use with the goals for Resident to be free of symptoms of dehydration. Interventions included: monitor and document intake and output as per facility policy; monitor vital signs as ordered/per protocol and record; notify physician of significant abnormalities; monitor/document/report as needed any signs/symptoms of dehydration; obtain and monitor lab/diagnostic work as ordered and report results to physician and follow up as indicated. A physician order dated [DATE] indicated give Lasix oral tablet 20 milligram by mouth one time a day for edema (swelling from fluid retention). Lasix is a diuretic used to treat fluid retention that can result from congestive heart failure, kidney disease or other medical conditions. (Lasix increases the flow of urine and can lead to dehydration.) Resident #294's admission Minimum Data Set (MDS) assessment dated [DATE] coded Resident #294 as cognitively intact. He was coded as frequently incontinent of bowel and bladder and was also coded as taking a diuretic. Resident #294's overall discharge goal was to return to the community. He was not coded for hospice care. A facility 24-hour condition report completed by Nurse #5 dated [DATE] indicated Resident #294 had poor oral intake on day shift. The facility's 24-hour condition report is a form that nurses document the status of all the residents during or at the end of their shift to communicate any pertinent information to the next shift and nursing management. During an interview with Nurse #5 on [DATE] at 2:45 PM, she stated that she had cared for Resident #294 on [DATE] from 7:00 AM to 7:00 PM. Nurse #5 indicated that normally Resident # 294 consumed more than 25% of his tray food and drinks but on [DATE] he had eaten and drank less than 25% during breakfast, lunch and dinner and she documented it in the 24 hour report and informed the oncoming night shift nurse (Nurse # 4). During an interview on [DATE] at 3:53 PM with Nurse #4, she stated that she was assigned to care for Resident #294 on [DATE] at 7:00 PM to [DATE] at 7:00 AM. Nurse #4 stated that during shift change Nurse #5 had informed her and documented in the 24-hour condition report that Resident #294 had a decreased oral intake with food and drinks. Nurse #4 stated that Resident #294 was stable and the only concern during her shift was complaints of burning with urination which she noted in the physician's book and she pushed fluids while Resident #294 was awake because she thought it was a sign of urinary tract infection. Nurse #4 stated that Resident #294 did not drink much fluids because it was at night and he slept most of the night. A Physician telephone order dated [DATE] at 11:59 AM ordered by Physician Assistant (PA) #2 indicated urinalysis (UA), urine culture and sensitivity (C & S) for a diagnosis of dysuria. Resident #294's medication administration record indicated Lasix 20 mg was administered on [DATE] at 9:00 AM by Nurse #1. During an interview on [DATE] at 10:20 AM with Nurse #1, she indicated that she had cared for Resident #294 on [DATE]. She stated that she was pushing fluids because Resident #294 had complained of burning with urination and that could have been a sign of a urinary tract infection. Nurse #1stated that Resident #294 was less talkative than usual on [DATE]. During an interview on [DATE] at 3:38 PM with Nurse #2, she stated that she had cared for Resident #294 on night shift ([DATE] at 11:00 PM to [DATE] at 7:00 AM). Nurse #2 stated that when she took over the assignment that night, she was notified by the off going nurse (Nurse #6) that a urine sample was needed for Resident #294. She indicated that when she came on shift Resident #294 was asleep and she did not recall waking him up to give him any fluids. Nurse #2 indicated that Resident #294 slept throughout her shift, and she attempted to obtain the urine specimen via an in and out catheter at around 5:00 AM on [DATE] but was unsuccessful and she notified the oncoming day shift nurse (Nurse #1). Nurse #2 indicated Resident #294's incontinence brief was wet during the in and out catheter attempt. An interview was conducted on [DATE] at 2:12 PM with NA #2 who had cared for Resident #294 on [DATE] and [DATE] on night shift. NA #2 stated that Resident #294 took only a few sips of water during her shifts and when she changed his incontinence brief there was very little urine. NA #2 stated that Nurse #3 was aware of Resident's condition and had told her to offer and encourage the Resident to drink water when she went to check on him. Resident #294's medication administration record indicated Lasix 20 mg was administered on [DATE] at 9:00 AM by Nurse #1. During an interview with Nurse #1 on [DATE] at 10:20 AM, she stated that when she came back to work on [DATE] at around 7:00 AM she was informed by the off going night shift Nurse (Nurse #2) that a urine sample was still needed for Resident #294 since she had not been able to obtain the urine during the night shift. She indicated that Resident #294 was more like he was the previous day ([DATE]) when she had noted he was not at his baseline. He was less talkative than usual and not eating/drinking as usual and she continued to push fluids and he did not drink much. Nurse #1 stated that Resident #294 normally ate and drank most of what was on his tray, and he also drank most of the water she gave him during medication administration, but on [DATE] he took only sips with the medication. She further stated that Resident #294 consumed 0 out of 120 milliliters of his med pass (nutritional supplementation) on [DATE] at approximately 9:00 AM and 5:00 PM whereas previously he consumed 100 % of the supplementation. A facility 24-hour condition report completed by Nurse #3 dated [DATE] on night shift ([DATE] 7:00 PM to [DATE] 7:00 AM) indicated the nurse attempted twice to collect urine unsuccessfully. A late entry nursing progress note written by Nurse #3 dated [DATE] at 6:13 AM indicated report was given to the nurse that a UA/C&S was needed. The nurse attempted to push fluids, however, resident would only take small sips. The first attempt to obtain the UA/C&S was around 9:00 PM on [DATE] and she was unable to collect as not enough urine came out. The writer continued to push fluids throughout the shift, again, only getting small sips. The first attempt to collect the urine was reported to the supervisor. The second attempt to obtain the UA/C&S was at 5:33 AM on [DATE] and was again unsuccessful. Oncoming nurse (Nurse #1) and the Unit Manager were made aware of the attempts and that the resident was still in need of a specimen or the medical doctor may need to be called to get further orders. Nursing progress note written by Nurse #3 dated [DATE] at 6:31 AM indicated writer attempted to collect urine twice, however, was unsuccessful and Nurse #3 would report off to oncoming nurse (Nurse #1). An interview was conducted on [DATE] at 1:54 PM with the Nurse #3 who was assigned to care for Resident #294 on [DATE] at 7:00 PM through [DATE] at 7:00 AM. Nurse #3 stated she had received report from the off going day shift nurse (Nurse #1) that a urine specimen was needed for Resident #294 and she attempted to obtain the specimen at around 9:00 PM on [DATE] and at approximately 5:30 AM on [DATE] via an in and out catheter both times but was unsuccessful. She stated that there was barely any urine and it was too thick to be processed. She stated that Resident #294's incontinence brief was dry during both attempts, and she was pushing fluids but Resident #294 was only taking small sips and could not get in much. Nurse #3 reported to the oncoming day shift nurse (Nurse #1) that she had been unsuccessful in obtaining the urine specimen via an in and out catheter. Nurse #3 stated that Resident #294 was verbal and did not seem to be in any acute distress otherwise she would have informed the physician to send him out. She stated that when she did not obtain the urine specimen at 5:30 AM she notified the oncoming day shift nurse so that she could notify the PA that morning and they could probably get an order for an IV because he was not drinking much, they had not been able to obtain the urine sample and he was probably dehydrated. During an interview on [DATE] at 3:05 PM with Nursing Assistant (NA) #1 she stated that she had cared for Resident #294 on [DATE] through [DATE] during the 7:00 AM to 3:00 PM shift. NA #1 stated that during those 3 days she noticed that Resident #294 was eating and drinking less than usual, and he had become incontinent whereas previously he was using the urinal. She also stated that previously he could feed himself, but she had to feed him and offer drinks on [DATE] and [DATE] but he did not eat or drink as he usually did. NA #1 also stated that when she changed Resident #294's briefs there was minimal urine. NA #1 further stated that when she was giving Resident #294 a shower on [DATE] he was not as responsive as usual, he was quiet and not shouting like he would normally do during showers. She verbalized that Nurse #1 was aware of Resident #294's condition and had told NA #1 to encourage Resident #294 to drink his fluids and also to give him a shower because he kept pulling off his clothes. Resident #294's medication administration record indicated Lasix 20 mg was administered on [DATE] at 9:00 AM by Nurse #1. A Physician order dated [DATE] at 10:15 AM ordered by PA #1 indicated obtain PIV access and if unable to obtain, obtain a midline (a long flexible tube that is inserted into a vein in the upper arm to deliver fluids or medication into the blood stream). A Physician order dated [DATE] ordered by PA #1 indicated Sodium Chloride Intravenous Solution 0.9 %. Use 2 liters intravenously in the morning for poor oral intake for 3 Days. Administer 2 liters intravenous fluids normal saline at 100 milliliters per hour for 3 days. (Sodium Chloride is used to replenish lost water and salt in the body.) During an interview with Nurse #1 on [DATE] at 10:20 AM, Nurse #1 stated that when she came to work on [DATE] at around 7:00 AM she was informed by the off going night shift nurse (Nurse #3) that a urine sample was still needed. She stated that she knew the PA would come to the facility that morning and she would let the PA know that they had not been able to obtain the specimen and the resident was not drinking much which was probably a sign of dehydration. She indicated the resident drank only sips of water during medication administration on [DATE]. Nurse #1 revealed that she had administered Resident #294's Lasix on [DATE], [DATE] and [DATE] at approximately 9:00 AM despite the resident's decreased oral food and fluid intake and that she did not think to hold it or ask the provider about it. Nurse #1 stated she could not say why she had administered Lasix when they had been unable to obtain the urine specimen and the Resident was not drinking much. She stated Resident #294 seemed more confused than the previous 2 days, and she notified Physician Assistant (PA) #1 when she came to the facility between 10:00 AM and 11:00 AM on [DATE]. PA #1 went to examine Resident #294 and ordered a midline and IV fluids. Nurse #1 stated she did not attempt to insert a peripheral line because Resident #294 was dehydrated and she could not find a visible vein. She called the vascular team (a contracted entity that is specialized in inserting intravenous catheters) to come and insert a midline and also called Resident #294's family member to obtain consent for the midline insertion. The family member did not answer the phone, and she left a message for her. The family member arrived at the facility at around 3:00 PM and the Nurse informed her that the vascular team were enroute to the facility to insert the midline. The family member wanted Resident #294 to be sent to the Emergency Department (ED) due to the worsening condition and Nurse #1 stated she agreed. She informed the Unit Manager and the facility Provider and called emergency medical services (EMS) who came to transfer Resident #294 to the hospital. A PA progress note written by PA #1dated [DATE] at 11:52 AM indicated Resident #294 was seen by PA at the request of nursing for evaluation of change in condition. The resident was minimally responsive. This was a noted change from usually being agitated and interactive per nursing/therapy. The roommate reported that he had not seen Resident #294 eat over the past 3 days. Nursing attempted to obtain UA/C&S, unable to provide adequate sample even with catheter. The progress note also indicated the resident had a change in condition, altered mental status, decreased oral intake, and was clinically dehydrated. An order was provided to obtain a PIV on [DATE] and ordered IVF 2 liters for 3 days ([DATE] to [DATE]). The progress note also indicated staff were unable to obtain UA/C&S given dehydration. During an interview on [DATE] at 4:30 PM with PA #1, she stated that she was notified by Nurse #1 when she came to the facility at around 10:30 AM on [DATE] that Resident #294 had a change in condition, and they had not been able to obtain a urine sample for a UA and C&S. The PA explained that when she went to assess Resident #294, he seemed dehydrated but was responsive to questions. She gave an order to insert a peripheral intravenous (PIV) line and if unable to obtain PIV access to obtain a midline so that they could administer IV fluids. The PA stated she did not know Resident #294's baseline since she was not the primary care provider for Resident #294. She also stated that she could not recall if the facility contacted her to let her know that they had not obtained an IV access. An interview was conducted with the Unit Manager (UM) on [DATE] at 10:40 AM. The UM stated that she was notified by Nurse #1 on [DATE] at approximately 3:00 PM that Resident #294's family member was in the facility to see the resident and wanted him to be sent to the hospital due to altered mental status and she told Nurse #1 to go ahead and send the Resident out to the hospital per family request. The UM stated that Resident #294 was being provided treatment at the facility but the family member was the one that wanted the Resident to be sent out. During the interview, the UM initially told the surveyor that an intravenous access had been obtained and fluids administered but when she further looked in Resident #294's medical records she stated that she thought the fluids had been administered but they were not. An interview was conducted with Resident #294's Emergency Contact #1 (Family Member) on [DATE] at 3:02 PM. The family member stated that she received a voice message from Nurse #1 on [DATE] at approximately 1:30 PM indicating that Resident #294 was doing okay and that she wanted to give her an update. The family member decided to come to the facility to check what was going on when she tried to call back the facility and was put on hold. When she arrived at the facility around 3:00 PM she found the Resident naked and disoriented, his mouth was dry and crusty and she attempted to give him a drink and he drank it. The family member stated Nurse #1 told her she was waiting for vascular team to come and insert an intravenous line and she informed Nurse #1 that she wanted the Resident to be sent to the hospital because he was in distress and Nurse #1 called 911. The family member also stated that Nurse #1 checked the Resident's vital signs during their conversation in the room and Nurse #1 immediately administered oxygen to the Resident after she checked the oxygen saturations. EMS report dated [DATE] indicated that EMS was contacted at 3:42 PM for a non-emergent transportation due to family choice. EMS arrived at the facility at 4:02 PM and primary impression was altered mental status and secondary impression was sepsis. The chief complaint was altered mental status with onset of [DATE]. An electrocardiogram (ECG) at 4:05 PM indicated atrial fibrillation (irregular heart rhythm characterized by rapid and irregular heartbeat). Vital signs obtained by EMS at 4:17 PM were noted as blood pressure: ,d+[DATE], pulse: 65, respirations: 8, oxygen saturation: 94 % and level of consciousness was responds to painful stimulation on the AVPU (alert, voice, pain, unresponsive scale used to measure patient's level of consciousness). EMS obtained a telephone order at 4:22 PM to administer IV fluids due to Resident #294 meeting the criteria for sepsis. IV fluids were not administered due to inability to establish an IV access. EMS departed facility at 4:39 PM with Resident #294 and notified the receiving hospital of sepsis indication at 5:00 PM. EMS assessment at 5:05 PM indicated Resident #294 was lethargic, non-verbal with minimal alertness, he had rapid mouth breathing, his skin was cold and dry, lung sounds were clear with increased respiratory rate and oxygen saturation readings were inconsistent due to the resident having cold hands. Resident #294 arrived at the ED at 5:41 PM. An ED progress note dated [DATE] indicated that Resident #294's vital signs were noted as follows: blood pressure: ,d+[DATE], heart rate: 138, and respirations 29 at 5:45 PM and oxygen saturation: 33 %, and temperature: 93.4 degrees Fahrenheit at 6:23 pm. The progress note indicated Resident #294 presented critically ill, obtunded (reduced level of alertness and consciousness), breathing on his own with cold distal extremities with dilated pupils without response bilaterally and no response to painful stimuli. Facility stated that he had not been eating or drinking anything for 3 days, and today he was found naked by his family and encouraged the nurse to take his vital signs who then emergently called for 911. Resident #294 was found to be in metabolic acidosis (a condition in which too much acid accumulates in the body). Because of his cold extremities, they were unable to reliably obtain a pulse oximeter reading. Discussion with family revealed patient had voiced wishes to have everything done to sustain his life. After discussion regarding his goals of his care, family wanted the patient to continue to be full code. They understood that he was critically ill at that moment. The ED note indicated that Resident's presentation with altered mental status, tachypnea, poor perfusion, hypothermia, severe lactic acidosis, and new vasopressor requirements, consistent with septic shock with end organ dysfunction as cause of death. Resident #294 died at 8:26 PM on [DATE]. An interview was conducted with the facility Medical Director (MD) on [DATE] at 4:37 PM. The MD stated he was aware of Resident #294's condition and the facility did what they were supposed to do to manage the Resident's condition. He indicated that when they could not obtain a urine sample, they ordered an IV access for hydration, but the Resident was sent out before the IV access was obtained. The MD also stated that if the Resident had been sent out earlier the outcome would not have been any different. When the MD was asked if the staff should have continued administering Lasix with decreased oral intake and inability to obtain urine with no recent episodes of urination, the MD did not elaborate and he reiterated that the facility did everything right. An interview was conducted on [DATE] at 4:30 PM with the Director of Nursing (DON). The DON stated that if nurses were not able to obtain the urine specimen on [DATE] at 5:00 AM they should have notified the PA because PAs are normally in the building daily. She further stated that if nurses notice any signs of dehydration and the resident is not adequately drinking they should notify the on call provider if there is no provider in the building. The DON also stated that nurses should have had a discussion with the provider regarding Lasix administration if Resident #294 was not drinking adequately on [DATE] before administering the 9:00 AM Lasix since the Resident had complained of burning with urination and they had not obtained the ordered urine specimen. The Administrator was notified of immediate jeopardy on [DATE] at 6:04 PM. The facility provided the following credible allegation of immediate jeopardy removal: 1) Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance Resident #294 no longer resides in the facility. Resident was transferred to the local hospital on [DATE] due to altered mental status. The center recognizes that all residents have the potential to be affected from the noncompliance of ensuring staff recognize significant changes in condition including signs and symptoms of dehydration. A review of Resident #294's electronic medical record revealed an order for UA w/ reflux, Urine Culture and Sensitivity with Diagnosis of Dysuria was ordered on [DATE]. The facility staff attempted to push fluids and obtain urine sample on [DATE] at approximately 9:00 PM and [DATE] at approximately 5:30 AM the resident was in a dry brief and staff was unable to collect a urine sample. A review of Resident #294 orders indicated resident was prescribed Lasix 20mg daily to be administered daily per physicians' orders. A quality review of current residents with an order for UA/C&S between [DATE] through [DATE] were audited by the Director of Clinical Services and Unit Managers on [DATE] to ensure a urine sample was obtained. No residents were identified as having an issue with lab collection that would indicate dehydration. 23 residents were identified as having a physician order to administer diuretics and were audited by the Director of Nursing and Unit Managers to ensure no signs and symptoms of dehydration as evidenced by the inability to collect urine. The Director of Nursing and or Unit Manager assessed current residents to include obtaining vital signs (blood pressure, increased heart rate, oxygen saturation, temperature), observation of dry cracked lips, poor skin turgor and or altered mental status and chart review to ensure no other residents exhibited signs and symptoms of dehydration that was not addressed and communicated to the physician on [DATE]. No concerns were identified during this audit. On [DATE], a root cause analysis was completed by the Director of Clinical Services and the Executive Director regarding staff failure to recognize the signs and symptoms of dehydration and then to provide necessary medical services to address an emergent situation for Resident #294. The resident had decreased fluid intake and signs or symptoms of dehydration as evidenced by the inability to collect urine via an in out catheter. Nursing staff also continued to administer resident Lasix despite signs and symptoms of dehydration. It was determined through the root cause analysis that the facility staff failed to follow policy and procedures to recognize the seriousness of signs and symptoms of dehydration and notify the physician to obtain necessary medical services to address an emergency situation. 2) Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete The Director of Clinical Services and Nurse Managers re-educated all licensed nurses on how to recognize signs and symptoms of dehydration through assessing the resident, observation, and chart review to include medications, and notify the physician to obtain necessary medical services to address an emergent situation with emphasis on signs and symptoms of dehydration and continued administration of diuretics, on [DATE]. Staff (licensed nurses/ Certified Nurse Assistants) not educated on [DATE], will be educated by the Director of Nursing and or Unit Manager prior to working the floor. Newly hired staff will be educated during orientation by the Director of Clinical Services and or Unit Managers. The Director of Clinical Services and Nurse Managers re-educated certified nursing assistants on signs and symptoms of dehydration and immediately report the change in condition to the licensed [DATE]. Newly hired staff will be educated during orientation by the Director of Clinical Service and or Unit Managers. Date of Immediate Jeopardy Removal [DATE]. On [DATE] the facility's immediate jeopardy removal was validated by the following: The facility provided documentation to support immediate jeopardy removal that included audits completed by the Director of Nursing/Director of Clinical Services and Unit Managers. The audits included all current residents with an order for UA/C&S from [DATE] through [DATE] which was revealed nine (9) residents with orders for UA/C&S with no other residents identified as having an issue with lab collection that would indicate dehydration. The audits also included all residents with orders for diuretics and 23 residents were identified as having a physician order to administer diuretics and to ensure no signs and symptoms of dehydration as evidenced by the inability to collect urine. The audits also included assessments of all current residents to include obtaining vital signs (blood pressure, increased heart rate, oxygen saturation, temperature), observation of dry cracked lips, poor skin turgor and or altered mental status and chart review to ensure no other residents exhibited signs and symptoms of dehydration that was not addressed and communicated to the physician. The facility provided documentation on the education they provided to include sign-in sheets. The education information indicated that the Director of Clinical Services and Nurse Managers re-educated all licensed nurses on [DATE] on how to recognize signs and symptoms of dehydration through assessing the resident, observation, and chart review to include medications, and notify the physician to obtain necessary medical services to address an emergent situation with emphasis on signs and symptoms of dehydration and continued administration of diuretics. The Director of Clinical Services and Nurse Managers re-educated licensed nursing staff and nursing assistants on [DATE] on signs and symptoms of dehydration (decreased urination, dry mouth, cracked lips, low blood pressure, increased heart rate, sunken eyes, altered mental status, poor skin turgor). Interviews confirmed that newly hired staff would be educated during orientation by the Director of Clinical Service and/or Unit Managers. Interviews with nursing staff verified the staff had been educated on all information as indicated in immediate jeopardy removal plan. The immediate jeopardy removal date of [DATE] was verified.

Based on record review, observation, and staff interview, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of hypnotics medication for 1 of 30 sampled resident reviewed (Resident # 55). Findings included: Resident #55 was admitted to the facility on [DATE] with diagnoses including dementia. The annual Minimum Data Set (MDS) dated [DATE] had Resident #55 coded as severely cognitively impaired, and hypnotics were taken during the look back period. The August and September 2024 Medication Administration Records (MAR) did not reveal an order for hypnotics. An interview with the Director of Nursing (DON) was conducted on 11/19/2024 at 2:49 PM. The DON stated she look at MARs as far back as April 2024 for Resident #55 and there had not been a hypnotic ordered. The DON also stated the MDS was coded incorrectly and expected the MDS nurse to code the assessment accurately. An interview with the MDS nurse was conducted on 11/19/2024 at 2:58 PM. The MDS Nurse stated she was the one who completed the MDS for Resident #55. There was a data entry error because Resident #55 was not receiving hypnotics during that time. An interview with the Administrator was conducted on 11/22/2024 at 1:08 PM. The Administrator stated he expected the MDS assessments to be coded correctly.

Based on observation, record review, and Resident and staff interviews, the facility failed to ensure call bells were plugged into the wall panel for a dependent resident to allow them to call for assistance if needed. The deficient practice was for 1 of 30 residents reviewed for accommodation of needs (Resident #6). Findings included: Resident #6 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] had Resident #6 coded as moderately cognitively impaired with clear speech, she makes herself understood and can understand others. Resident #6 was always incontinent with bowel and bladder. An observation and interview were conducted with Resident #6 on 11/18/2024 at 10:43 AM. Resident #6 was in her room, in her bed with head of bed elevated. One end of her call bell wire was placed over the top of the bed and the other end with the red button was tied around the bedrail. The call light panel was not visible from the door. Resident #6 was asked if she could use her call bell and if so to call for assistance. The Resident stated she does use her call bell and pushed the red button. The light outside of the Residents room did not light up. The panel behind the Resident's bed was checked to see if the light was on and it did not come on and the plug for the call light was not plugged in. The call bell was wrapped and tied around the resident's bedrail. Resident #6 stated, she used her call bell regularly. The last time she used the call bell was last evening without any issues. Nurse #7 came to Resident #6's room and found the call bell knotted up and tied to the resident's bedrail, she started to untangle the wires and then plugged the wire into the outlet. The resident was asked to push the call light, and the call light came on. An interview with Nurse #7 was conducted on 11/18/2024 at 11:11 AM. The Nurse stated all residents should have their call bells within reach and working. The Nurse also stated the last time she came in to check on the resident was an hour ago and the Nursing Assistant (NA)# 4 was giving care to Resident #6's roommate (Resident #10) and thought she would make sure the call bells were working and within reach for the residents. An interview with NA #4 was conducted on 11/18/2024 at 11:34 AM. The NA stated she usually made sure the call bells were within reach before she left the room, and she looked at the panel to make sure it was plugged in. She did not notice if the call bell was plugged in when she left the room. The NA also stated she did not know how it happened. The call bell wire could have come out when Resident #6 raised the head of her bed. An interview with the Director of Nursing (DON) was conducted 11/18/2024 at 12:32 PM. The DON stated all staff are trained to place the call bell within reach and make sure they plug into the panel prior to leaving the Residents room. She expected her staff to make sure the Residents call lights were plugged in and within the residents reach before leaving their rooms.

Based on record review and staff interview the facility failed to protect the resident's right to be free from misappropriation of controlled medication for 1 (Resident #5) of 2 residents reviewed for misappropriation of controlled medication. Findings included: Documentation on the facility abuse, neglect, exploitation and misappropriation policies and procedures, dated as last revised on 11/16/2022, revealed misappropriation of resident property included the diversion of resident's medication, including, but not limited to, controlled substances for staff use or personal gain. The same policy and procedure indicated employees were not at any time to commit misappropriation of property against any resident. Resident #5 had diagnoses of vascular dementia, hemiplegia, and osteoarthritis. Documentation in a quarterly Minimum Data Set assessment dated [DATE] coded Resident #5 as having moderately impaired cognition and received pain medication on an as needed basis. Documentation on physician orders for July 2024 revealed Resident #5 had an order renewed on 7/17/2024 for 5 milligrams (mg) Oxycodone HCL to be administered as one tablet by mouth every 8 hours as needed for moderate to severe pain. Oxycodone HCL is a controlled medication stored securely because it may be abused or cause addiction. Documentation on a pharmacy shipment summary dated 7/12/2024 revealed thirty (5 mg) tablets of Oxycodone were filled and delivered to the facility for Resident #5. There was no documentation on the July Medication Administration record for Resident #5 of her being administered Oxycodone pain medication after 7/12/2024. An interview was conducted with Nurse #1 on 10/24/2024 at 10:27 AM. Nurse #1 revealed the following information during the interview. Nurse #1 had worked from 11:00 PM beginning on 7/17/2024 to 7:00 AM on 7/18/2024 on the hallway for which Resident #5 resided. Nurse #1 knew Resident #5 had a medication card with 30 tablets of Oxycodone in the medication cart on that shift because Resident #5 rarely requested pain medication. On the morning of 7/18/2024 at 7:00 AM, Nurse #1 counted the controlled medication in the cart with Nurse #6 and confirmed it matched the amount of medication documented on the declining controlled medication inventory sheets for each resident, to include the 30 tablets of Oxycodone for Resident #5. Nurse #6 worked from 7:00 AM until 11:00 PM on 7/18/2024 repeating the reconciliation of the controlled medication on the medication cart with Nurse #1 at 11:00 PM. Nurse #1 stated she counted the controlled medication for each resident on the cart while Nurse #6 confirmed the count matched the declining controlled medication inventory sheets for each resident. Nurse #1 confirmed all the controlled medication in the drawer correctly matched the declining controlled medication count sheets for each resident that evening. Nurse #6 left the facility at the end of her shift on 7/18/2024. Nurse #1 began her nursing duties and after passing out medication to residents who needed controlled medication, she noted the full card of 30 Oxycodone for Resident #5 was missing from the medication cart along with the declining controlled medication count inventory sheet for the Oxycodone for Resident #5. Nurse #1 stated she immediately notified the evening shift supervisor, Nurse #3, and they together searched the likely places the Oxycodone for Resident #5 may have been placed along with the corresponding declining controlled medication inventory sheet. Nurse #3 called the Director of Nursing (DON). Nurse #1 stated they were instructed by the DON to tell the morning shift supervisors so the pharmacy and Nurse #6 could be contacted to locate the 30 Oxycodone. In the morning Nurse #1 and Nurse #3 informed Nurse #2 and Nurse #4 of the missing Oxycodone for Resident #5. Nurse #1 further revealed she was drug tested prior to leaving on the morning of 11/19/2024. The evening shift supervisor, Nurse #3, was interviewed on 10/24/2024 at 1:02 PM. Nurse #3 confirmed Nurse #1 let him know on the 11:00 PM to 7:00 AM shift that began on 7/18/2024 of the missing Oxycodone medication card and declining controlled medication inventory sheet for Resident #5. Nurse #3 confirmed they looked everywhere for the medication and could not find it, so they notified the Director of Nursing. Nurse #3 also stated he notified the morning shift supervisors on 7/19/2024 so the pharmacy could be contacted along with Nurse #6. Nurse #2 and Nurse #4 were simultaneously interviewed on 10/24/2024 at 1:52 PM. The following information was revealed. On the morning of 7/19/2024 Nurse #1 notified Nurse #2 of the missing 30 tablets of Oxycodone for Resident #5 and the missing corresponding declining controlled medication inventory sheet. Nurse #2 knew the 30 tablets of Oxycodone could not have been administered to Resident #5 because she very rarely complained of pain. Nurse #1 was drug tested prior to leaving at the end of her shift on 7/19/2024 and the test came back negative. Nurse #2 called the pharmacy and confirmed the Oxycodone was not sent back to the pharmacy. Nurse #2, along with Nurse #4, called Nurse #6 because she was the only nurse to have control of the medication cart prior to Nurse #1. Nurse #2 requested Nurse #6 come back to the facility to help find the missing Oxycodone for Resident #5, and Nurse #6 initially agreed she would. Nurse #6 did not call back or come to the facility and after half an hour had passed, Nurse #2 and Nurse #4 again called Nurse #6. Nurse #6 relayed to Nurse #2 and Nurse #4 she would call back later because she was talking to her family. Nurse #4 stated Nurse #6 called her back and while on the speaker phone admitted she was taking responsibility for taking the Oxycodone from the cart. Nurse #2 and Nurse #4 requested Nurse #6 bring the Oxycodone back to the facility but were told by Nurse #6 she was unable to do so. Nurse #2 and Nurse #4 relayed to Nurse #6 the consequences for her actions involved notification of the police, the board of nursing, and state officials as well as likely termination of her employment. Nurse #6 was interviewed on 10/24/2024 at 2:52 PM and provided the following information. Nurse #6 confirmed she removed the medication card with 30 Oxycodone for Resident #5 along with the corresponding declining controlled medication inventory sheet from the building. Nurse #6 called the Board of Nursing letting them know of her actions and was currently working with the Board of Nursing to seek help. Nurse #6 confirmed she was contacted by the police as well but, only on one occasion about the diversion of the medication. The DON was interviewed on 10/24/2024 at 1:02 PM. The DON confirmed she was called by Nurse #3 on 7/18/2024 after 11:00 PM letting her know a controlled medication card for Resident #5 was missing. The DON related she told Nurse #3 to have the day shift supervisors, Nurse #2 and Nurse #4, call the pharmacy in the morning and Nurse #6 to help locate the missing medication. The DON also confirmed Nurse #2 let her know in the morning on 7/19/2024 of the confession of Nurse #6 to diversion of the controlled medication. The DON said the diversion of the medication was reported to the state offices of health and human services, the board of nursing, the police, and the pharmacy. The DON said an immediate corrective action plan was started on 7/19/2024. The DON felt the diversion of the narcotic by the trusted employee was unexpected and has not happened again since that occasion in July. The facility provided the following action plan with a completion date of 7/20/2024. 1. Corrective action for resident's affected by the alleged deficient practice: On 7/19/2024 upon learning of the missing Oxycodone, the Unit Managers notified the Director of Nursing and the Facility Administrator/Executive Director. Nurse #6, who was assigned to Resident #5 and the cart for the prior 16-hour shift (7:00 AM to 11:00 PM) on 7/18/2024 was called to come into the facility. Nurse #1 who was assigned to Resident #5 for the 11:00 PM to 7:00 AM shift ending on 7/19/2024 was drug tested and the test was negative. After 30 minutes without arrival or contact from Nurse #6, the Unit Manager reached back out to her, and she stated that she would be on her way shortly but was speaking with her family. Approximately 15 minutes later, Nurse #6 confessed that she took both the card of Oxycodone and the declining controlled medication inventory sheet. The Facility Administrator notified the North Carolina Board of Nursing, local police department, and submitted an allegation of drug diversion to North Carolina Division of Health and Human Services. The facility pharmacy was contacted, and the Oxycodone for Resident #5 was replenished by the facility. It was confirmed Resident #5 had not suffered any negative outcome as a result of the missing narcotic. The Medical Director, the clinical team, and the responsible party for Resident #5 were all notified. 2. Corrective action for residents with the potential to be affected by the alleged deficient practice: A full audit of all declining controlled medication inventory sheets was reconciled with controlled medication of all residents on 7/19/2024 to ensure no other discrepancies. On 7/19/2024 a quality review was conducted by the unit managers/designee of the manifest from the pharmacy from 7/1/2024 until current to validate all controlled medications were accounted for to confirm the medication was present, sent back to the pharmacy, sent home with the resident, or administered to the resident with none remaining. Interviews and statements were obtained from all nurses that administered medication about missing controlled medications. Pain assessments were completed on 7/19/2024 on current residents to ensure pain medication was being received and pain was being controlled. 3. Measures/systematic changes to prevent reoccurrence of deficient practice: Education was provided to all staff on all shifts by the unit managers on 7/19/2024 on the abuse policy with emphasis on misappropriation of resident property. Education was provided on 7/19/2024 by the unit managers to all licensed nursing staff on the drug diversion policy, the acceptance of controlled drugs upon arrival from the pharmacy, the controlled drug count, controlled drug disposal and wasting, and managing a drug diversion. All the licensed nurses signed the zero-tolerance policy of misappropriation of medications on 7/19/2024 which detailed the expectation and the consequences for non-compliance. Staff and Licensed Nursing staff were not allowed to work until education about misappropriation of resident property and/or drug diversion was provided. On 7/19/2024 the Executive Director presented the allegation of diversion of medication, plan, education, and findings to Quality Assurance Performance Improvement (QAPI) committee members in an ad hoc meeting. The Executive Director and the Director of Nursing and/or Nursing Supervisor oversee the Quality Improvement Monitoring. The Director of Nursing or Nursing Supervisor will complete Quality Improvement monitoring on medication carts 2 times weekly for 4 weeks then weekly for 12 weeks to ensure all medications are accounted for with count correct with nurses counting and documenting total cards and total count sheets. The Quality Improvement Monitoring was started on 7/19/2024. The results of the Quality Improvement Monitoring were reported to the QAPI committee by the Executive Director and/or Director of Nursing to ensure compliance was achieved and maintained monthly for three months and then quarterly for two quarters. The QAPI committee members consisted of but were not limited to the following members of the Interdisciplinary team: Executive Director/Administrator, Director of Nursing, Nursing Supervisor, Medical Director, Social Services Director, Activities Director, Maintenance Director, and Minimum Data Set Assessment Nurse and at least one direct care staff member. The correction date was 7/20/2024. The facility corrective action plan was reviewed on 10/24/2024. Interviews with nursing staff confirmed all staff were provided with training on abuse policies and procedures for misappropriation of resident property. Interviews with the licensed nursing staff confirmed re-education was provided on entire process of documentation and handling of controlled medication from the receipt of medication from the pharmacy to the storage, disposal, administration, or return of medication to the pharmacy. Licensed nursing staff interviews also confirmed each was required to sign a copy of the diversion of drugs zero-tolerance policy. Monitoring tools, staff education, and performance improvement plan were reviewed. The corrective action plan was verified as completed on 7/20/2024.

Based on record review, staff, and resident interviews, the facility failed to treat residents (Resident #1, and Resident #2) with dignity and respect when staff failed to provide the resident with a bed bath or shower. The residents expressed anger, frustration, and embarrassment. This was for 2 of 8 residents reviewed for dignity. The findings included: 1.Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included diabetes, atherosclerotic heart disease, and muscle weakness. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #3 was cognitively intact, dependent on staff for toileting, and required substantial maximum assistance with bathing. Review of Care Plan dated 4/15/24 revealed Resident #1 required assistance with activities of daily living (ADL) care to include bathing. An interview with Resident #1 on 6/26/24 at 11:48 am revealed that the facility frequently ran out of briefs, wash cloths, and towels. She stated yesterday (6/25/24) that she no washcloth and she had to wash herself off with disposable wipes. She further indicated that she did not get a bath today (6/26/24) because the facility ran out of wash cloths and towels. Resident #1 stated this made her feel angry and frustrated. In an interview with NA #5 on 6/26/24 at 12:15 pm she stated that she had been employed for the facility since December 2023 and that they had been short of towels and wash cloths for the past 2 to 3 months. NA #5 further indicated that Resident #1 did not get a bath today (6/26/24) because she did not have clean washcloths available. NA#5 stated that when washcloths and towels became available that she did go back and bath residents that had not had their bath that morning because many were already up and she would not have time to complete her assignment if she did. She stated she told the Director of Nursing (DON) about a month ago and was told the facility was trying to order more washcloths and towels. 2.Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included hemiplegia, hemiparesis, cerebral infarction (stroke), chronic obstructive pulmonary disease, and diabetes. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #2 was cognitively intact and required substantial maximum assistance with bathing and toileting. Review of Care Plan dated 5/13/24 revealed Resident #2 required extensive assistance with one staff member for activities of daily living (ADL) care to include bathing. During an interview with Resident #2 on 6/27/24 at 8:10 am she stated that she did not get a shower on her shower day 6/25/24 and did not get a bed bath on 6/26/24 because the facility did not have any towels or wash cloths. She further indicated the facility did not have disposable wipes. She stated this was an ongoing issue and she was not sure how long it had occurred. She stated that it made her feel uncomfortable and dirty when she could not get a bath or shower and that embarrassed her. In an interview with NA #5 on 6/26/24 at 12:15 pm she stated that she had been employed for the facility since December 2023 and that they had been short of towels and wash cloths for the past 2 to 3 months. NA #5 further indicated that Resident #2 did not get a bath yesterday (6/25/24) or today (6/26/24) because she did not have clean towels or washcloths available. NA#5 stated that when washcloths and towels became available that she did go back and bath residents that had not had their bath that morning because many were already up and she would not have time to complete her assignment if she did. She stated she told the Director of Nursing (DON) about a month ago and was told the facility was trying to order more washcloths and towels. In an interview with Nurse #3 on 6/26/24 at 11:03 am she stated that if her unit ran out of supplies that she had to find someone with a key to central supply to access supplies. She stated staff had to wait for towels and wash cloths today (6/26/24) and residents could not get a bath, shower or incontinence care completed until they found wash cloths and that it could take an hour and a half before they found washcloths and towels. In an interview with NA #7 on 6/26/24 at 2:26 pm revealed that she could not give baths to the residents in her assignment in the mornings when she arrived to work because she did not have access to clean wash cloths and towels and this upset the residents and some got angry. An interview with NA #8 on 6/27/24 revealed that she had been employed by the facility for 2 weeks. She stated that she had not had clean wash cloths and towels for morning care for the past 2 weeks so the care did not get done and that the residents would get angry and upset with the NAs. An interview with the Director of Nursing (DON) on 6/27/24 at 10:15 am She stated that residents should be getting their daily bath or shower unless they refused. She stated she was unaware that residents did not get a bath. In an interview with the Administrator on 6/27/24 at 11:45 am it was revealed that he was aware of an issue with a shortage of wash cloths and towels but was not aware residents did not get a bath.

Based on record review, observation, and staff and resident interviews, the facility failed to provide a bed bath or shower for 3 of 7 dependent residents (Resident #1, Resident #2, and Resident #12) reviewed for activities of daily living (ADL) care. The findings included: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses including diabetes, atherosclerotic heart disease, and muscle weakness. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #1 was cognitively intact, dependent on staff for toileting, and required substantial maximum assistance with bathing. Review of Care Plan dated 4/15/24 revealed Resident #1 required assistance with ADL care to include bathing. An interview with Resident #1 on 6/26/24 at 11:48 am revealed yesterday (6/25/24) she only had one towel, no washcloth and she had to wash herself off with disposable wipes. She further indicated that she did not get a bath today (6/26/24) because the facility ran out of wash cloths and towels. In an interview with Nurse Aide (NA) #5 on 6/26/24 at 12:15 pm she revealed that she could not bathe Resident #1 today (6/26/24) because she did not have clean towels or washcloths. She indicated that she had to work without washcloths or towels every day until around 11:00 am, when they became available from the laundry. She stated that on average Resident #1 did not get a bath 3 to 4 days a week because of no available towels or washcloths. In an interview with Nurse #3 on 6/26/24 at 11:03 am she stated staff had to wait for towels and washcloths today (6/26/24) and residents, such as, Resident #1 and Resident #12 could not get a bath or shower completed until they found washcloths and that it could take an hour and a half before they found washcloths and towels. 2. Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included hemiplegia, hemiparesis, cerebral infarction (stroke), chronic obstructive pulmonary disease, and diabetes. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #2 was cognitively intact and required substantial maximum assistance with bathing and toileting. Review of Care Plan dated 5/13/24 revealed Resident #2 required extensive assistance with one staff member for ADL care to include bathing. During an interview with Resident #2 on 6/27/24 at 8:10 am she stated that she did not get a shower on her shower day 6/25/24 and did not get a bed bath on 6/26/24 because the facility did not have any towels or washcloths. She stated this was an ongoing issue and she was not sure how long it had occurred. In an interview with NA #5 on 6/26/24 at 12:15 pm she stated that Resident #2 did not get a shower yesterday (6/25/24) and did not get a bath today (6/26/24) because she did not have clean towels or washcloths available. She indicated that she had to work without washcloths or towels every day until around 11:00 am, when they became available from the laundry. 3. Resident #12 was admitted to the facility on [DATE] with diagnoses which included myocardial infarction (heart attack), diabetes, chronic kidney disease, and hypertension (high blood pressure). The annual Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #12 was severely cognitively impaired and required partial to moderate assistance with bathing and supervision for toileting. Review of Care Plan dated 5/8/24 revealed Resident #12 required one person assistance for ADL care to include bathing and toileting. During an interview with Resident #12 on 6/26/24 at 11:50 am Resident #12 stated that she did not get a bath this morning (6/26/24) because they did not have washcloths and towels when she got up. In an interview with NA #5 on 6/26/24 at 12:15 pm she revealed that she could not bathe Resident #12 today because she did not have washcloths or towels, so instead she assisted Resident #12 to wipe off with wipes. She indicated that she had to work without washcloths or towels every day until around 11:00 am, when they became available from the laundry. She stated that on average Resident #12 did not get a bath 3 to 4 days a week because of no available towels or washcloths. In an interview with Nurse #3 on 6/26/24 at 11:03 am she stated staff had to wait for towels and washcloths today (6/26/24) and residents, such as, Resident #1 and Resident #12 could not get a bath or shower completed until they found washcloths and that it could take an hour and a half before they found washcloths and towels. An interview with the Director of Nursing (DON) on 6/27/24 at 10:15 am she was not aware that the facility had been low on towels and washcloths or that residents did not get baths and showers. She stated that residents should be getting their daily bath or shower unless they refuse. In an interview with the Administrator on 6/27/24 at 11:45 am he stated that residents should get a bath or shower each day unless they refuse. He stated that he felt that this concern was related to a shortage of washcloths and towels and that he would address that.

Based on record reviews, resident and staff interviews, the facility failed to provide effective leadership and implement effective systems to ensure there was an adequate number of washcloths and towels for the provision of resident care. This failure had the potential to affect all the residents in the facility. The findings included: 1a. Resident #1 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #1 was cognitively intact. An interview with Resident #1 on 6/26/24 at 11:48 am revealed that the facility frequently would run out of washcloths and towels. She stated yesterday (6/25/24) that she only had one towel, no washcloth and she had to wash herself off with disposable wipes. She further indicated that she did not get a bath today (6/26/24) because the facility ran out of washcloths and towels 1b. Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #2 was cognitively intact. During an interview with Resident #2 on 6/27/24 at 8:10 am she stated that she did not get a shower on her shower day 6/25/24 and did not get a bed bath on 6/26/24 because the facility did not have any towels or washcloths. She stated not having washcloths and towels was an ongoing issue and she was not sure how long it had occurred. 1c. Resident #12 was admitted to the facility on [DATE]. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #12 was severely cognitively impaired. During an interview with Resident #12 on 6/26/24 at 11:50 am she stated that she did not get a bath this morning (6/26/24) because they did not have wash cloths and towels when she got up. In an interview with Nurse Aide (NA) #5 on 6/26/24 at 12:15 pm she indicated that Resident #1 did not get a bath today (6/26/24) because she did not have clean towels or washcloths. She stated that on average Resident #1 did not get a bath 3 to 4 days a week because of no available towels or washcloths. She stated that Resident #2 did not get a bath yesterday (6/25/24) or today (6/26/24) because she did not have clean towels or washcloths available. She further indicated that she could not bathe Resident #12 today because she did not have washcloths or towels, so instead she assisted Resident #12 to wipe off with wipes. She stated that on average Resident #12 did not get a bath 3 to 4 days a week because of no available towels or washcloths. She indicated that she had to work without washcloths or towels every day until around 11:00 am, when they became available from the laundry. She stated that she had made her own wipes/cloths by wetting paper towels and that she had bought her own wipes to use for resident care. She stated that she did what she had to do to ensure the resident was cared for. She stated that she reported this concern through the chain of command and reported it to the unit manager who told her she had to wait for the washcloths and towels to be washed. She stated she told the Director of Nursing (DON) about the lack of washcloths and towels a month ago and was told the facility was trying to order more washcloths and towels. NA #5 stated that she had been employed by the facility since December 2023 and that they had been short of towels and washcloths for the past 2 to 3 months. In an interview with NA #2 on 6/25/24 at 1:36 pm she stated that she worked short of clean towels and washcloths every day. She stated that she told the nurses, but they often could not find clean towels or wash cloths. She stated the facility had some washcloths but not enough to provide care to all residents. She stated that it was after lunch some days before clean towels and washcloths were received on the hall. In an interview with NA #6 on 6/26/24 at 12:30 pm she indicated she had worked for the facility since March 2024 and that she had worked short of towels and washcloths on most days. She stated she felt she could not provide proper care to the residents without clean towels and washcloths. She stated the facility stopped providing wipes so she bought her own so she could, at minimum, wipe the residents arm pits and private areas when the facility did not have wash cloths and towels available. She stated this occurred mostly on weekdays and was not an issue on the weekend. In an interview with NA #7 on 6/26/24 at 2:26 pm revealed that she could not give baths in the mornings when she arrived to work because she did not have access to clean washcloths and towels. She indicated that residents did not get a bath or showers when they did not have available washcloths and towels because some residents were already up for the day, and she would not have time to complete her assignments. She stated this happened about 3 to 4 times a week. In an interview with NA #1 on 6/27/24 at 8:15 am she indicated that she could not clean resident's hands prior to meals or provide morning care because she did not have access to clean towels and washcloths and she had to wait for clean towels and wash cloths to become available. By the time they arrived from the laundry many of the residents had gotten up for the day. An interview with NA #8 on 6/27/24 revealed that she had been employed by the facility for 2 weeks. She stated that she had not had clean washcloths and towels for the past 2 weeks so the residents on her assignment did not get a bath and that the residents would get angry with the NAs. An interview with Nurse #1 on 6/25/24 at 4:21 pm revealed that NAs complained to her that they did not have clean washcloths and that laundry had ordered more washcloths, but they had not arrived. In an interview with Nurse #2 on 6/25/24 at 4:53 pm he stated that he worked 3:00 PM to 11:00 PM shift on a regular basis, and the NAs often ran out of washcloths, so they tore up clean briefs and used them as wipes for incontinence care. He further indicated that they were out of washcloths last night. He stated that on days that the facility was short on washcloths that he had passed the concern on in shift report and that administration had been aware of the problem. In an interview with Nurse #3 on 6/26/24 at 11:03 am she stated staff had to wait for towels and washcloths today (6/26/24) and residents could not get a bath, shower or incontinence care completed until they found washcloths and that it could take an hour and a half before they found washcloths and towels. She further indicated that towels and washcloths were not washed during the night, so they had to wait for linen to be washed in the mornings before they had clean washcloths and towels. In an interview with Nurse #5 on 6/26/24 at 2:11 pm she stated that she worked part time for the facility as needed and did not work every day. She stated when staff told her they were short on towels and washcloths she checked with laundry and was told towels and washcloths would be available after they had been washed and dried. She stated that it would take until 10:00 am or 11:00 am before clean towels and wash cloths were available. During an interview with the Housekeeping Director on 6/27/24 at 9:15 am it was revealed that he was an outside contractor, and he oversaw the laundry department as well as other housekeeping duties. He stated that when he arrived at the job just over a month ago (exact date unknown) that the facility hardly had any washcloths (he had not done a count) so he borrowed washcloths from another facility that also contracted with his company. He stated a week and a half after he borrowed washcloths there was still a shortage. He stated that staff told him they were not permitted to use disposable wipes and threw away washcloths that were soiled with bowel movement. He further indicated that housekeeping staff had reported to him that they saw soiled washcloths in the trash when they disposed of trash in the dumpster. The Housekeeping Director stated that a Periodic Automatic Replacement (PAR) level (an inventory control system that tells you what levels of inventory you should have in stock to fulfil a demand) for washcloths should be eight washcloths' times the number of residents on the census. He stated that with a census of one hundred residents that the facility should have 800 washcloths in stock and that the facility only had approximately 100 washcloths available. He stated the facility did not have any washcloths in storage. He stated the facility was low on towels, but not as low as washcloths, and he did not know how many towels were on hand, because he had not counted. He stated he ordered a large order of towels and washcloths yesterday that should arrive Monday, 7/1/24. He indicated the process to prep soiled linens, towels, and washcloths for the next morning was laundry staff picked up by the soiled linens each evening, washed and dried, and prepped the clean linen cart for the next day before their shift ended at 10:00 pm so clean linen was ready to be rolled out to the units first thing the next morning, but that system did not work at the facility because they did not have enough towels and washcloths. He further stated that laundry staff picked up the soiled laundry from the units when they arrived to work at 7:00 am each morning and washed, dried, and folded the laundry and that it took them from 7 am to about 9:30 to get the some linen ready to deliver to the units each day. He stated that he had noticed that staff used pillowcases for incontinence care because they did not have washcloths. The Housekeeping Director explained that since he had been in the position he had been working with the Administrator to resolve the issue of the shortage of washcloths and towels and they were working on establishing a PAR level. An interview with the Director of Nursing (DON) on 6/27/24 at 10:15 am she was not aware that the facility had been low on towels and wash cloths. She stated the facility was currently in the process of establishing a PAR level with the new Housekeeping Director for towels and washcloths. She stated that when she was hired as the DON on 3/13/24 that staff used disposable wipes for all resident care and did not use washcloths. She stated that the wipes clogged toilets because staff flushed them, so wipes were no longer used. She stated that she educated staff to use washcloths for resident care, and to use the soiled diaper and toilet paper to wipe bowel movement from resident's during incontinence care, but they used the washcloths instead and threw them away. She stated that the facility had an emergency supply of washcloths and staff could ask for them and they would be provided to staff for use for resident care, but they had not asked. The interview further revealed that staff were hoarding and hiding washcloths and that decreased the number of washcloths available for use by all staff. In an interview with the Administrator on 6/27/24 at 11:45 am it was revealed that he was aware of an issue with a shortage of washcloths and towels, and he had been working with the Housekeeping Director to establish a PAR level. He further indicated that the facility had used wipes in the past but had stopped because staff and residents had flushed them, and it clogged the toilets. Staff then used washcloths and towels for incontinence care and threw away washcloths soiled with bowel movement and that caused a shortage of washcloths and reduced the number of washcloths and towels available for morning care. The Administrator stated that he would transition back to providing wipes today( 6/27/24) for incontinence care.

Based on observation and staff interviews, the facility failed to safeguard protected health information (PHI) for 1 of 100 residents residing in the facility by leaving confidential PHI unattended and exposed in an area accessible to the public (Resident #11). The findings included: Resident #11 was admitted to the facility on [DATE]. An observation was made of an unattended medication cart on the 200 Hall on 06/26/24 11:05 am. Nurse #4 left the medication cart with the Medication Administration Record (MAR) in the computer exposed when he walked away from the medication cart and went down the hall. The computer screen showed the name, picture, and other PHI of Resident #11. Staff and family passed by the exposed computer screen that displayed the PHI of Resident #11. Nurse #3 returned to the medication cart approximately 2 minutes later at 11:07 am. A second observation was made of the medication cart on 200 hall on 6/26/24 at 11:14 am. Nurse #4 left the medication cart with the Medication Administration Record (MAR) in the computer exposed when he walked to the opposite side of the nurse's station to talk to another staff member. The computer screen showed the name, picture, and other PHI of Resident #11. Nurse #3 returned to the medication cart approximately 1 minute later at 11:15 am. During an interview conducted on 06/26/24 at 11:16 am, Nurse #4 stated residents' PHI should not be exposed or left unattended and acknowledged that it was his oversight. He stated had been trained to not leave resident PHI visible to others and that he should have closed his computer before he walked away. During an interview with the Administrator on 06/27/24 at 11:45 am he stated all residents' confidential PHI should be protected. He indicated that he would not have expected resident PHI to be accessible in plain view.

Based on record review, resident and staff interviews, the facility failed to report an allegation of abuse to the Administrator immediately for 1 of 1 resident (Resident #4) reviewed for Abuse. The facility further failed to implement their policy and procedures in the area of resident protection. Findings included: Review of facility policy entitled Abuse, Neglect, Exploitation, & Misappropriation read in part Protection- any suspect(s), who is an employee or contract service provider, once he/she have been identified, will be suspended pending the investigation and Reporting/Response- any employee or contracted service provider who witness or has knowledge of an act of abuse or an allegation of abuse, to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made if the events that cause the allegation involve abuse, to the Administrator and to other officials in accordance with State law. Resident #4 was admitted to the facility on [DATE]. The Annual Minimum Data Set (MDS) dated [DATE] revealed Resident #4 was moderately cognitively impaired and was dependent on staff for bathing, and toileting. In an interview with Resident #4 on 6/25/24 at 12:10 pm she stated that she was touched inappropriately by a male NA when incontinence care was provided a few weeks ago, she could not recall the date or his name. She stated that she reported her concern to two women that worked that day but could not recall their names or what time the event occurred. In an interview with Nurse #2 on 6/25/24 at 4:42 pm he stated that NA #11 reported to him that Resident #4 had made a complaint that she had been inappropriately touched by NA #11 when incontinence care was provided. He stated that this was reported to him soon after he came on duty after 3:00 pm (he did not recall the exact time) on 6/15/24. He stated that he spoke to Resident #4 around 4:00 pm on 6/15/24 during medication pass and she told him that NA # 11 had touched her private area. Nurse #2 stated that he did not report this to anyone because he did not think it was abuse, because he told Resident #4 that NA #11 had to touch her in her private area to provide incontinence care and she had responded oh, ok. He further stated that at 8:00 pm on 6/15/24 that Resident #4 asked him if she should apologize to NA #11 for accusing him of touching her inappropriately. He indicated that Resident #4 was alert with confusion and often needed to be reoriented (reacquaint someone with a situation or environment). He further stated that he did not feel like this was abuse or that it was reportable so he did not report it. He stated that he did not receive any concerns on shift report from the off-going day shift nurse (Nurse #6). Attempts to contact Nurse #6 by phone were unsuccessful during the survey. It was learned from the Administrator that Nurse #6 only worked for the facility on the weekend and worked elsewhere during the weekdays. In an interview with NA #11 on 6/26/24 at 5:19 pm he stated that on the morning of 6/15/24 (unsure of exact time) when he provided incontinence care to Resident #4 that she accused him of touching her private areas. He further stated that because of the seriousness of the allegation that he immediately reported the concern to Nurse #6, and she did not take it seriously and told him to that she would get another staff member to provide care for Resident #4 for the remainder of the shift. NA #11 stated that he worked a double shift that day and remained concerned about the allegation against him, so he again reported the concern to the evening shift Nurse #2, and he told him that he was the best NA and to just do the best he could. NA#11 stated he did not feel that Nurse #2 took him seriously and that no one cared what he reported to them. He stated he reported the concern to the Central Supply Manager on the morning of 6/17/24 because the Director of Nursing (DON) and the Administrator were not in the facility and that she directed him to report to the Social Worker (SW). The interview further revealed that NA #11 reported the allegation to the SW on the afternoon of 6/17/24 and she told him to not to worry about it because the resident had dementia, and that she would report it to the Administrator. He stated that on 6/18/24 when he arrived at work, he went to the DON office so he could report the concern, but she was not available, so he returned to his hall to begin work. Later that afternoon he stated he went to the Administrator's office to report the concern and at that time he was suspended pending an investigation into the concern. In an interview with the SW on 6/26/24 at 2:56 pm she stated that on 6/17/24 around 3:40 pm NA #11 reported to her that Resident #4 had made an allegation of abuse against him and afterwards she finished her work left the facility for the day without reporting it to the Administrator. She indicated that Adult Protective Services (APS) came into the facility on [DATE] and that is when she reported what NA #11 reported to her on 6/17/24. In review of staffing schedules for 6/15/24 NA #11 was on the schedule assigned to care for Resident #4 for a double shift that included hours from 7:00 am to 11:00 pm. In review of staffing schedules for 6/16/24 NA #11 was on the schedule assigned to care for Resident #4 for a double shift that included hours from 7:00 am to 11:00 pm. In review of staff schedules for 6/17/24 3-11 shift NA #11 was assigned to work as medication aide on the 100 hall where Resident #4 resided. In review of staff schedules for 6/18/24 3-11 shift NA #11 was assigned to work as medication aide on the 100 hall where Resident #4 resided. In an interview with the Administrator on 6/26/24 at 4:13 pm he stated he had not been made aware of the alleged abuse until 6/18/24 when APS arrived at the facility and informed him, they had received a report of abuse for Resident #4. He stated that on 6/18/24 he learned that the SW had knowledge of the alleged abuse on 6/17/24 and failed to report the allegation to the Administrator. He indicated that staff who worked on 6/15/24 should have called him at home to report the allegation immediately but did not and stated that staff did not follow the facility's own policy for 2-hour reporting. The interview further revealed that the Administrator was made aware of the alleged abuse on 6/18/24 at 4:15 pm and that he reported it to the local police department on 6/18/24 at 4:30 pm and to the Division of Health Service Regulation (DHSR) on 6/18/24 at 5:10 pm. He further stated that he filed the 5-day report with DHSR on 6/25/24 at 4:15 pm. The facility provided the following Corrective action plan Abuse Reporting Allegation Reported to Facility Administration 06/18/2024 Event occurred on 06/15/2024 On 06/18/2024, at approximately 4:00 pm an Adult Protective Services Supervisor spoke with Facility Administrator regarding an intake they had received on 06/17/2024. The APS worker was escorted to the resident room for interview and upon completion of their discussion, the accused Certified Nursing Assistant was suspended pending investigation following an allegation of inappropriate touching. The initial allegation report was submitted to North Carolina Department of Health and Human Services within an hour of notification to facility administrator. Police were contacted. The physician and resident responsible party were notified. Education of staff started immediately by facility administrator for all on-site staff at that time. Staff scheduler submitted notification to all off-shift staff they were not allowed to return to work until education had been completed. Scheduler and Social Worker were suspended for failure to report potential abuse timely. On 06/19/2024, Resident #4 was interviewed, physician team provided a clinical evaluation and a head-to-toe assessment was completed. Resident #4's roommate was interviewed. An ad hoc Quality Assurance Performance Improvement (QAPI) program was completed and discussed regarding facility plan and monitoring to include education of department heads. Interviews for inter-viewable residents were conducted by Director of Nursing, Regional RN Nurse Consultant, Unit Manager, RN Day Supervisor and RN Evening Supervisor on 06/20/2024 regarding definition of abuse and neglect and if they witnessed it on someone else or personally experienced it. In addition, Unit Manager and RN Evening Supervisor also conducted Skin Integrity tool (skin sweeps) on 06/20/2024 for non-inter-viewable residents to assess for any signs of abuse. All current staff were interviewed for knowledge of known abuse and neglect, abuse policy and mandatory abuse reporting criteria. Director of Nursing interviewed all staff who worked with the resident on date of allegation and statements were obtained. The Director of Nursing, Facility Administrator and Unit Manager educated all staff including all shifts, part-time and PRN on the abuse policy which included a test for abuse and abuse questions to validate any known awareness of abuse and validation of who to report abuse to. Education began on 06/18/2024 and staff were not allowed to return to work until education, test and abuse question responses were completed. Facility abuse policy and direct test questions included requirements for whom to report to (mandatory reporting immediately to Administrator and/or Director of Nursing). Abuse policy and employee handbook state that the accused employee will be suspended immediately pending investigation and a failure of staff to report immediately, result in disciplinary action including suspension and potential termination of employment. Facility administration determined on 06/19/2024 to develop a Quality Assurance and Performance Improvement (QAPI) program to ensure resident safety and compliance with our abuse policy including immediate reporting by all staff of any allegations or actual resident abuse. The Director of Nursing and/or Designee will complete quality monitoring of 5 inter-viewable residents using the resident abuse questions and will be completed weekly for 12 weeks and then monthly for 3 months to ensure residents are free from abuse. The DON and/or Designee will complete quality monitoring on 5 non-inter-viewable residents using the facility Weekly Skin Integrity tool on a weekly review for 12 weeks and then monthly for 3 months to ensure residents are free from abuse. Any abuse allegation cases will be reviewed to ensure the event was reported immediately to the Administrator and/or Director of Nursing and the accused was immediately suspended pending investigation. This will be discussed during QAPI for any incidents where the employee did not immediately report and will include targeted education for all staff. The Director of Nursing and/or Designee will conduct random interviews of 5 staff members per week for 12 weeks and then monthly for 3 months to ensure clear understanding of abuse policy and immediate mandatory reporting. The DON will report on the results of the quality monitoring (audit) and report to the QAPI IDT Committee. Findings will be reviewed by the QAPI Committee monthly and the quality monitoring report (audit) will be updated as indicated. Date of Compliance = 06/20/2024 The facility's Past Non-Compliance date of 6/20/24 was validated. The corrective action plan was verified on 6/27/24. Interviews were conducted with a sample of Nursing Assistants, Nurses, and administrative and ancillary staff to verify education was conducted regarding reporting allegations of abuse and reporting timeline requirements. Documentation of in-service records was reviewed. In an interview with the Director of Nursing on 6/27/24 at 4:05 pm, she stated that all Nurses, Nursing Assistants, therapists, housekeeping, dietary, and administrative personnel had been educated on abuse types, abuse reporting, abuse reporting timelines and that return demonstration of the training was verified through a written test. She stated that PRN (as needed staff), part-time staff and staff that had not reported to work since the onset of the education would be educated prior to being given an assignment. She further stated that the new hire orientation had been reviewed and included abuse, what to report, when to report, how to report and who to notify.

Based on record review, resident interview, and staff interview the facility failed to create a baseline care plan with the resident or responsible party for one (Resident #7) of three residents reviewed for creation of a baseline care plan upon admission. Findings included: Resident #7 was admitted to the facility on [DATE] and discharged from the facility on 2/11/2024. Resident #7 had multiple diagnoses some of which included acquired absence of right leg below the knee, type 2 diabetes mellitus, peripheral vascular disease, rheumatoid arthritis, and lymphedema. There was no documentation in the electronic medical record of a baseline care plan for Resident #7. Documentation on a paper copy of a Baseline Care Plan and Summary dated 2/7/2024 for Resident #7 revealed the form was filled out with the resident care needs but was unsigned by facility staff, Resident #7, or a resident representative. An interview was conducted with Resident #7 on 6/26/2024 at 12:54 PM. Resident #7 stated he had just had surgery to remove his leg and while he was at the facility nobody went over his plan of care with him or his wife. An interview was conducted with the Director of Nursing (DON) on 6/27/2024 at 9:39 AM. The DON explained that she became the full time DON at the facility in March of 2024 and up until that time the facility did not have a consistent system in place for the preparation of baseline care plans. The DON explained in February, it was hit or miss if the baseline care plans were completed and the paper documents were not being uploaded into the electronic record system. The DON stated she currently had a system in place for the completion of baseline care plans, but she did not have a performance improvement plan or monitoring to confirm compliance.

Based on record review, resident and staff interviews, the facility failed to update the care plan after the quarterly assessment for 1 of 4 residents reviewed for care plans (Residents #3). Findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses which included diabetes, muscle weakness, and right below the knee amputation. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #3 was cognitively intact. Review of care plan history revealed that the last care plan for Resident #3 was dated 1/25/24. Review of the electronic medical record (EMR) for Resident #3 revealed that there was no documentation of a care plan meeting being held since 1/25/24. An interview with Resident #3 on 6/27/24 at 9:09 am revealed that he did not know if a care plan review meeting had been held since 1/25/24. In an interview with MDS Nurse #1 on 6/26/24 at 2:34 pm it was revealed that care plan meetings were triggered after the completion of each MDS assessment update. She stated that Resident #3's MDS assessment was last updated 4/28/24 and a care plan review meeting should have followed. The interview further revealed that the care plan review should have been held quarterly, and the Social Worker (SW) planned the care plan review meetings. In a phone interview with SW on 6/26/24 at 2:56 pm it was revealed that she was aware that Resident #3's care plan had not been reviewed on time. She stated that she had not held care plan review meetings regularly in the past few months because she did not have an assistant and she was behind. She stated that she addressed more urgent matters by prioritization until she could get caught up. The SW added that care plan review meetings should be held on admission, quarterly, annually, and as needed. An interview with the Director of Nursing on 6/26/24 at 3:50 pm revealed that a care plan review meeting should be held regularly to review the resident's plan of care. She stated that Resident #3's care plan review had not been done on time because the SW did not have an assistant. She stated the facility was aware the care plan reviews were behind. In an interview with the Administrator on 6/26/24 at 4:13 pm he stated that he was aware that care plan meetings were not being held on time. He further indicated that care plan meetings were not on time because the SW did not have an assistant and was behind in her work. He stated he felt care plan reviews were behind related to a changeover in the SW position. He stated Resident #3's care plan review should have been up to date.

Based on records reviews and staff interviews, the facility failed to have Advance Directives (AD) in the residents' records for 7 of 9 sampled residents. (Resident #16, Resident #76, Resident #132, Resident #33, Resident #44, Resident #47, and Resident #52). The findings included: 1. Resident #16 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident ' s cognition was cognitively impaired. Review of the computerized clinical record for Resident # 16 revealed no advanced directive noted in the resident's medical record. An interview with the Administrator was conducted on 11/07/2023 at 02:04 PM, He stated he could not find the advance directive in the medical records and there was no documentation found that stated the resident refused to sign the advance directives. He indicated advance directives were not completed due to a shift in key personnel and admission process. He indicated that currently the Social Worker (SW) will complete the advance directives during admissions and the advance directive documentations will be scanned into the residents' electronic medical records. An interview with the Social Worker (SW) was conducted on 11/07/23 02:10 PM. The SW stated the advanced directives were being completed by the Admissions Coordinator . They currently do not have an Admission Coodinator, and she had recently been trained in Advanced Directives and code status. The task of completing new admissions packets was shared among the staff. The SW also stated she was not aware the advanced directives were not signed in the admission packet and in the future, she will be discussing it in the scheduled admission meeting and documenting it on the Advanced Directive Discussion Document in the admission packet and in her notes. An interview with the Director of Nursing (DON) was conducted on 11/07/23 03:10 PM. The DON stated the advanced directives are completed by the admissions Coordinator. She indicated they did not have an Admission Coodinator at the time of the survey, but a new Admission Coodinator would be starting on Monday 11/13/2023. DON indicated that currently the task of completing new admissions packets is shared among the staff. She stated she was not aware the advanced directives were not being signed in the admission packet and in the future, it will be discussed during the initial 72 hours care plan meetings. 2. Resident #76 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident ' s cognition was intact. Review of the computerized clinical record for Resident # 76 revealed no advanced directive noted in the resident's medical record. An interview with the Administrator was conducted on 11/07/2023 at 02:04 PM, He stated he could not find the advance directive in the medical records and there was no documentation found that stated the resident refused to sign the advance directives. He indicated advance directives were not completed due to a shift in key personnel and admission process. He indicated that currently the Social Worker (SW) will complete the advance directives during admissions and the advance directive documentations will be scanned into the residents' electronic medical records. An interview with the Social Worker (SW) was conducted on 11/07/23 02:10 PM. The SW stated the advanced directives were being completed by the Admissions Coordinator . They currently do not have an A, and she had recently been trained in Advanced Directives and code status. The task of completing new admissions packets was shared among the staff. The SW also stated she was not aware the advanced directives were not signed in the admission packet and in the future, she will be discussing it in the scheduled admission meeting and documenting it on the Advanced Directive Discussion Document in the admission packet and in her notes. An interview with the Director of Nursing (DON) was conducted on 11/07/23 03:10 PM. The DON stated the advanced directives are completed by the Admissions Coordinator . She indicated they did not have an Admissions Coordinator at the time of the survey, but a new Admission Coordinator would be starting on Monday 11/13/2023. DON indicated that currently the task of completing new admissions packets is shared among the staff. She stated she was not aware the advanced directives were not being signed in the admission packet and in the future, it will be discussed during the initial 72 hours care plan meetings. 3. Resident #132 was admitted to the facility on [DATE]. Review of the computerized clinical record for Resident #132 revealed no advanced directive noted in the resident's medical record. An interview with the Administrator was conducted on 11/07/2023 at 02:04 PM, He stated he could not find the advance directive in the medical records and there was no documentation found that stated the resident refused to sign the advance directives. He indicated advance directives were not completed due to a shift in key personnel and admission process. He indicated that currently the Social Worker (SW) will complete the advance directives during admissions and the advance directive documentations will be scanned into the residents' electronic medical records. An interview with the Social Worker (SW) was conducted on 11/07/23 02:10 PM. The SW stated the advanced directives were being completed by the Admissions Coordinator. They currently do not have an Admission Coordinator, and she had recently been trained in Advanced Directives and code status. The task of completing new admissions packets was shared among the staff. The SW also stated she was not aware the advanced directives were not signed in the admission packet and in the future, she will be discussing it in the scheduled admission meeting and documenting it on the Advanced Directive Discussion Document in the admission packet and in her notes. An interview with the Director of Nursing (DON) was conducted on 11/07/23 03:10 PM. The DON stated the advanced directives are completed by the Admissions Coordinator. She indicated they did not have an Admission Coordinator at the time of the survey, but a new Admission Coordinator would be starting on Monday 11/13/2023. DON indicated that currently the task of completing new admissions packets is shared among the staff. She stated she was not aware the advanced directives were not being signed in the admission packet and in the future, it will be discussed during the initial 72 hours care plan meetings. 38702 4. Resident #33 was admitted to the facility on [DATE]. The quarterly MDS dated [DATE] had resident coded as moderately cognitively impaired. A review of the computerized medical record for Resident #33 did not reveal a advanced directive noted in the resident's medical record. An interview with the Administrator was conducted on 11/07/2023 at 2:04 PM. He stated he could not find the advance directive in the medical records and there was no documentation found that stated the resident refused to sign the advance directives. He indicated advance directives were not completed due to a shift in key personnel and admission process. He indicated that currently the Social Worker (SW) will complete the advance directives during the admission process and the advance directive information will be scanned into the resident's electronic medical record. An interview with the Social Service Worker (SW) was conducted on 11/07/2023 at 2:10 PM. The SW stated the advanced directives were being completed by the Admissions Coordinator . They currently do not have an Admission Coordinator and she had recently been trained in Advanced Directives and code status. The task of completing new admissions packets was shared among the staff. The SW also stated she was not aware the advanced directives were not signed in the admission packet and in the future, she will be discussing it in the scheduled admission meeting and documenting it on the Advanced Directive Discussion document in the admission packet and in her notes. 35930 5. Resident #44 was admitted to the facility on [DATE]. A review of Resident #44's annual Minimum Data Set (MDS), dated [DATE], indicated resident was cognitively intact. A review of Resident #44's electronic health record (EHR) revealed no advance directives noted in the resident's medical record. An interview with the Administrator was conducted on 11/07/2023 at 2:04 p.m. The Administrator he could not find the advance directive in the medical records and there was no documentation found that stated the resident refused to sign the advance directives. He indicated advance directives were not completed due to a shift in key personnel and admission process. He indicated that currently the Social Worker (SW) will complete the advance directives during admissions and the advance directive documentation will be scanned into the residents' EHR. An interview with the SW was conducted on 11/07/23 at 2:10 p.m. The SW stated the advanced directives were being completed by the Admissions Coordinator and explained they currently do not have an Admission Coordinator. The SW stated she had recently been trained in Advanced Directives and code status. The SW further explained the task of completing new admissions packets was shared among the staff. The SW also stated she was not aware the advanced directives were not signed in the admission packet and in the future, she will be discussing it in the scheduled admission meeting and documenting it on the Advanced Directive Discussion Document in the admission packet and in her notes. 48007 6. Resident #47 was admitted into the facility on [DATE]. A review of Resident #47 Prospective Payment System Part A discharge Minimum Data Set, dated dated dated [DATE] revealed the Resident #46 was moderately cognitively impaired. A review of the computerized clinical record for Resident #47 revealed no advanced directive noted in the resident's medical record. An interview with the Administrator was conducted on 11/07/2023 at 2:04 PM. He stated he could not find the advance directive in the medical records and there was no documentation found that stated the resident refused to sign the advance directives. He indicated advance directives were not completed due to a shift in key personnel and admission process. He indicated that currently the Social Worker (SW) will complete the advance directives during the admission process and the advance directive information will be scanned into the resident's electronic medical record. An interview with the Social Service Worker (SW) was conducted on 11/07/2023 at 2:10 PM. The SW stated the advanced directives were being completed by the Admissions Coordinator . They currently do not have an Admission Coordinator and she had recently been trained in Advanced Directives and code status. The task of completing new admissions packets was shared among the staff. The SW also stated she was not aware the advanced directives were not signed in the admission packet and in the future, she will be discussing it in the scheduled admission meeting and documenting it on the Advanced Directive Discussion document in the admission packet and in her notes. 7. Resident #52 was admitted into the facility on [DATE]. A review of Resident #52's quarterly Minimum Data Set, dated dated dated [DATE] revealed that Resident #52 was severely cognitively impaired. A review of the computerized clinical record for Resident #52 revealed no advanced directive noted in the resident's medical record. An interview with the Administrator was conducted on 11/07/2023 at 2:04 PM. He stated he could not find the advance directive in the medical records and there was no documentation found that stated the resident refused to sign the advance directives. He indicated advance directives were not completed due to a shift in key personnel and admission process. He indicated that currently the Social Worker (SW) will complete the advance directives during the admission process and the advance directive information will be scanned into the resident's electronic medical record. An interview with the Social Service Worker (SW) was conducted on 11/07/2023 at 2:10 PM. The SW stated the advanced directives were being completed by the Admissions Coordinator . They currently do not have an Admission Coordinator and she had recently been trained in Advanced Directives and code status. The task of completing new admissions packets was shared among the staff. The SW also stated she was not aware the advanced directives were not signed in the admission packet and in the future, she will be discussing it in the scheduled admission meeting and documenting it on the Advanced Directive Discussion document in the admission packet and in her notes. An interview with the Director of Nursing (DON) was conducted on 11/07/2023 at 3:10 PM. The DON stated the advanced directives were completed by the Admissions Coordinator. She indicated they did not have an Admission Admission Coordinator at the time of survey but, a new Admission Coordinator would be starting on Monday 11/13/2023. The DON indicated that currently the task of completing new admission packets was shared among the staff. She stated she was not aware the advanced directives were not being signed in the admission packet and in the future, it will be discussed during the initial 72-hour care plan meeting.

Based on observations, record review, and staff interviews the facility staff failed to disinfect a shared blood glucose meter between residents in accordance with the instructions provided by the manufacturer of the blood glucose meter and the disinfectant wipes used for 3 of 3 residents whose blood glucose levels were checked (Resident #6, Resident #7, and Resident #8) by 3 of 3 nurses (Nurse #1, Nurse #2, and Nurse #3). This occurred while there was a resident (Resident #9) with a known bloodborne pathogen in the facility. This deficient practice had a high likelihood of transmitting bloodborne pathogens within the facility. Immediate Jeopardy began on 6/20/2023 when Nurse #1 was observed performing a blood glucose test on Resident #6 using a shared blood glucose meter put the in the medication cart without cleaning or disinfecting per the manufacturer's instructions. Immediate Jeopardy was removed on 6/22/2023 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 E (no actual harm with more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put in place are effective. The findings included: A review of the facility's policy entitled Blood Glucose Monitoring and Disinfecting (Revised in April 2022) read in part Clean and disinfect the meter with disinfecting wipes (per manufacture guidelines). The manufacturer's guidelines for cleaning the blood glucose meter used at the facility included: a) wear appropriate protective gear such as disposable gloves. b) Open the cap of the disinfectant container and pull out 1 towelette and close the cap. c) Wipe the entire surface of the meter 3 times horizontally and 3 times vertically using one towelette to clean blood and other body fluids. d) dispose of the used towelette in a trash bin. She meter should be cleaned prior to each disinfection step. The manufacturer's guidelines for disinfecting the blood glucose meter used at the facility included: a) Pull out 1 new towelette and wipe the entire surface of the meter 3 times horizontally and 3 times vertically using a new towelette to remove blood borne pathogens. b) Dispose of the used towelette in a trash bin c) Allow exteriors to remain wet for the corresponding contact time for each disinfectant. d) After disinfection the user's gloves should be removed to be thrown away and hands washed before proceeding to the next patient. The disinfectant wipes used at the facility for blood glucose meter disinfection were approved by the EPA (Environmental Protection Agency) for cleaning and disinfecting their (brand name) blood glucose meter. The instructions on the label of the disinfection wipes stated may be used on blood glucose meters and indicated to allow surfaces to remain wet for two minutes and let air dry. The medication cart assignments on 6/20/23 during the first shift indicated 3 nurses (Nurse #1, Nurse #2, and Nurse #3) were assigned to medication carts. On 6/20/2023 at 11:24 AM an observation and interview were conducted with Nurse #1 who was a facility employee. Nurse #1 performed a glucose check on Resident #6 and when she completed the task, she disposed of the test strip and lancet, performed hand hygiene, and placed the blood glucose meter in the right top drawer of the medication cart without cleaning or disinfecting it. She revealed that to clean the blood glucose meter I just wipe it like this and she removed the blood glucose meter from the medication cart demonstrated wiping it with an unopen alcohol swab and replaced it back into the top right top drawer of the medication cart. She indicated this was her normal practice for cleaning and disinfecting the blood glucose meter. No observation was made of her cleaning and disinfecting the blood glucose meter. She further stated that the same blood glucose meter was used for all the residents requiring blood glucose monitoring on her assignment. She stated that there were residents on her assignment that required blood glucose checks, but they were not due until later in the day. No other blood glucose meters were noted in the medication cart at this time. Nurse #1 stated that she had received training on how to clean the blood glucose meters when she hired, she thought by the Director of Nursing but was not sure. On 6/20/2023 at 11:42 AM an observation and interview were conducted with Nurse #2 who was a facility employee. Nurse #2 performed a blood glucose check on Resident #7 and when she completed the task, she disposed of the test strip and lancet, stated she needed to clean the blood glucose meter, took a disinfectant wipe from the container, and wiped down the blood glucose meter one time then removed her gloves, and performed hand hygiene. She then stated she needed to let the blood glucose meter dry, and 5-10 seconds later placed the blood glucose meter in the top right-hand drawer of the medication cart. No other blood glucose meters were observed in the medication cart. Nurse #2 indicated that this was her normal practice for cleaning and disinfecting the blood glucose meter. She revealed that the same blood glucose meter was used for all the residents requiring blood glucose monitoring on her assignment. She stated that she received training when she was hired by the facility on using the blood glucose meter but could not remember if it was the Director of Nursing or the Infection Control Nurse who completed the training. On 6/20/2023 at 11:55 AM observed Nurse #3 who was a facility employee, perform a blood glucose check on Resident #8 and when she completed the task, she disposed of the test strip and lancet a, placed the blood glucose meter on the medication cart, removed her gloves, performed hand hygiene, and left the medication cart to assist a nursing assistant with patient care. Continuous observation of the medication cart for 10 minutes was conducted, and Nurse #3 did not return to the medication cart during this time. An interview with the Minimum Data Set Nurse on 6/20/23 at 1:22 PM revealed there was one current resident (Resident #9) who had a diagnosis of a blood borne pathogen. The current Director of Nursing was interviewed on 06/20/23 at 3:17 PM and stated that she had started two weeks ago. She indicated she was unable to answer any questions related to blood glucose cleaning and disinfecting. An interview was conducted with the Infection Preventionist on 6/21/23 at 9:27 AM revealed that she had recently been recently hired and could not answer questions on past training of cleaning and disinfecting the blood glucose meters. She indicated that staff were to follow the blood glucose manufacturer's instructions for cleaning and disinfection. The Administrator stated that the blood glucose meters should be cleaned and disinfected per manufacturer instructions after each resident's blood glucose was checked. She stated that she could not explain why Nurse #1, Nurse #2, and Nurse #3 did not clean and disinfect the blood glucose meters per manufacturer instructions. The facility's Administrator was informed of the immediate jeopardy on 6/20/2023 at 2:47 PM. The facility provided the following credible allegation of immediate jeopardy removal. o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and On 6/20/23 Nurse #1, Nurse #2 and Nurse #3 failed to clean shared blood glucose meters which were used during medication administration. Nurse #1, #2 and #3 were immediately educated by the Director of Nursing on F880 following manufacturer's guidelines for cleaning and disinfection of blood glucose monitoring. Including the following education: Skills Competency Assessment of Glucometer cleaning to include direct observation and return demonstration and Storage individual resident's Glucometer in medication cart in individual bag. On 6/20/23, 89 residents have been reviewed by the Director of Nursing for use of blood glucose meters. Residents identified with orders for glucose monitoring were given individualized glucose meters, labeled and placed in bag in medication administration cart by Director of Nursing. On 6/20/23 21 residents identified to receive blood glucose monitoring were assessed by the charge nurse and no negative outcomes as related to Infection Control during medication pass glucometer cleaning were observed. On 6/20/23 all current glucometers were cleaned and placed in bag, labeled, and placed in medication cart. The local public health authority will be notified on 6/21/2023 on the improper cleaning of the shared glucometer with corrective actions taken and inquire about any immediate monitoring of residents potentially affected by the Director of Nursing. o Ths facility currently does not have any contact nursing staff however will add to the contract nursing staff orientation should we have any in the future. On 6/20/23, the Director of Nursing initiated education to the Licensed Nurses on F880 following manufacturer's guidelines for cleaning and disinfection of blood glucose monitoring. Including the following education: Skills Competency Assessment of Glucometer cleaning to include direct observation and return demonstration Storage individual resident's Glucometer in medication cart in individual bag After 6/20/23 Licensed Nurses not previously educated on glucometer cleaning with skills competency and storage of glucometer will be educated prior to working their next scheduled shift. Newly Hired Licensed Nurses will be educated during the Orientation process going forward. The Director of Nursing has been notified by the Regional Director of Clinical Services of this responsibility on 6/20/2023. Education is being provided in person and via phone. Prior to next shift nurse will complete skills competency assessment. The Executive Director is tracking who has received education. Validation of understanding has been documented on Skills Competency Assessment: Glucometer. Date of IJ Removal: 6/22/2023 The facility's credible allegation of immediate jeopardy removal was validated on 6/22/2023. The validation was evidenced by observations and interviews conducted with regards to the required infection control practices for the use of blood glucose meters. All nurses who were interviewed reported they had received the required in-service training and were made aware of the facility's policy to use individually assigned blood glucose meters for each resident requiring blood glucose monitoring. The education included review of the facility's infection control policy, manufacturer instructions related to blood glucose meter disinfection, and a return demonstration. The nurses reported each resident's individual blood glucose meter was now stored in the medication cart. Multiple observations confirmed the glucometers were stored inside a non-porous container and located in the medication carts. Multiple observations were made of nursing staff cleaning and disinfection the blood glucose meters per manufacturer's instructions. The credible allegation was validated, and the immediate jeopardy was removed on 6/22/2023.

Based on record review and interviews with family, fireman, home healthcare nurse, and staff, the facility failed to assess the resident's home environment to identify and evaluate barriers of the discharge location and failed to verify the assessed level of caregiver support was in place for the resident's safe discharge home. The facility also failed to include monitoring for exhaustion of benefits and notification to the resident and/or involved family of benefit exhaustion in their discharge planning process. This was for 1 of 3 residents (Resident #1) reviewed for discharge. Immediate Jeopardy began on 8/2/21 when Resident #1 was discharged from the facility and transported to his home in the community via a private transportation ambulette (a specially equipped van for non-emergent transportation). Upon arrival home the transport driver assisted Resident #1, who was in a bariatric wheelchair (a wheelchair for larger adults weighing 300 pounds or more), off of the vehicle and onto the sidewalk in front of his home. The home had 2 stairs leading to the front door and no wheelchair ramp. Family Members #1 and #3 were present at the home, but they were unable to get Resident #1 into the home on their own due to his size and his need for extensive assistance with transfers. Family Member #3 contacted their local Volunteer Fire Department as well as additional family members to assist with getting Resident #1 from the sidewalk into the home. The family built a makeshift wheelchair ramp using wood 2 by 6s and concrete blocks in order to get Resident #1 up the stairs. It took approximately 2 hours and 6 people to get Resident #1 into the home. The Immediate Jeopardy was removed on 8/5/21 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems put into place related to the discharge planning process are effective and to complete staff training. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's care plan, initiated on 5/25/21, included the focus area of his wish to return home. The goal was for Resident #1 to verbalize/communicate an understanding of the discharge plan and describe the desired outcome by the target date of 8/23/21. The interventions, all initiated on 5/25/21 included: - Encourage Resident #1 to discuss feelings and concerns with impending discharge. Monitor for and address episodes of anxiety, fear, and distress. - Establish a pre-discharge plan with Resident #1 and his family upon admission in the care navigation meeting and evaluate progress and revise plan as needed - Evaluate/record Resident #1's abilities and strengths, with resident's representative/caregivers/Interdisciplinary Team (IDT). Determine gaps in abilities which would affect discharge. - Make arrangements with required community resources to support independence post-discharge. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1's cognition was intact. He had no behaviors and no rejection of care. He required the extensive assistance of 2 or more for bed mobility, dressing, toileting, and personal hygiene. Resident #1 was dependent on 2 or more for transfers and bathing. Locomotion on/off unit had occurred only once or twice with 1 assist. He had no functional impairment with range of motion and he utilized a wheelchair. Resident #1 had an indwelling catheter, he was always incontinent of bowel, and he had 3 stage 2 pressure ulcers. He had a fall in the last month prior to admission and a fall with fracture in the last 6 months prior to admission. Resident #1 received antidepressant medication and anticoagulant medication on 7 of 7 days. He was receiving Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST). A nursing note dated 6/3/21 indicated Resident #1's indwelling urinary catheter was discontinued as ordered by the physician. Resident #1's care plan was updated on 6/4/21 with a focus area for an Activities of Daily Living (ADL) self-care performance deficit related to impaired balance, limited mobility, and status post [MEDICAL RECORD OR PHYSICIAN ORDER] . The interventions (all initiated on 6/4/21) indicated he was totally dependent on 1 to 2 staff for bathing/showering and required the extensive assistance of 2 staff for transfers. Resident #1 required the extensive assistance of 1 to 2 staff for bed mobility and dressing and the extensive assistance of 1 staff for toileting and personal hygiene. A hard copy typed document completed by the Social Worker (SW) revealed the following information: - On 7/27/21 the SW met with Resident #1 to inform him of his upcoming 100th day of his Medicare benefit. The SW wrote that Resident #1 had expressed his desire to stay at the facility, but felt he had not wanted to apply for Medicaid and could not afford the private rate. The SW told him that she would assist him with the discharge process and would make referrals for home healthcare nursing, PT, OT, and Nursing Assistant (NA). Resident #1 stated that he had all the equipment he needed at home. - On 7/28/21 the SW met with Resident #1 to discuss discharge planning. His spouse was noted to be listening in by way of speaker phone. The SW explained that his last covered day at the facility was 8/1/21 so he had to be discharged on [DATE]. They discussed home healthcare services and equipment that was needed. Resident #1 indicated he had all of the necessary equipment at his home already and his spouse requested a bariatric commode (designed for the toileting, showering, and hygiene routines of larger adults weighing 300 pounds or more) for the resident. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A hard copy typed document completed by the SW revealed the following information: - On 7/30/21 the SW met with Resident #1 to sign his Notice of Medicare Non-Coverage (NOMNC) and reiterated that his last covered day would be 8/1/21. Resident #1 asked questions about how his 100 days were already exhausted and the SW explained to him the days he spent in another facility prior to coming to this facility counted in his total days. The SW wrote that she talked with Resident #1 about getting ready for discharge. His family was to come to the facility over the weekend (7/31/21 - 8/1/21) to pick up the majority of his belongings and to bring in his personal wheelchair. The SW indicated that she explained the transportation cost of an ambulette and he stated that he would not pay for that and he would go by car. SW stated to Resident #1 that he was not able to transfer independently and asked Resident #1 how was he going to get out of the car when he arrived at his home. He stated that he would do it with Family Member #3 and a family friend. Resident #1 also spoke about the stairs that he had at the house and he reported that they had no wheelchair ramp yet. The SW gave him information on a ramp that could be purchased online and delivered to his home. - On 7/30/21 the SW, Director of Therapy (DOT), and the Business Office Manager (BOM) had a phone conference with Resident #1's Family Member #1 who was expressing great concern about his returning home. The SW wrote that they (SW and DOT) also expressed that they felt this discharge was premature. The SW noted that she expressed concerns about the stairs with no wheelchair ramp and the car ride. The DOT spoke about Resident #1's lack of progress in therapy and what his short [NAME] and safety issues were. Family member #1 indicated she would talk with her family and call back. - On 7/30/21 the SW spoke with Family Member #1 after the phone conference and she decided that Resident #1 would be transported by ambulette. She also told the SW that a community organization was going to build a wheelchair ramp at the home on the morning of 8/2/21 so his discharge time would be set for after 3:00 PM. The SW completed referrals for home healthcare and medical equipment (bariatric commode). A DOT hard copy note dated 7/30/21 indicated she attended a conference call meeting for Resident #1 with the SW present and Family Member #1 on the phone. She wrote that during the conversation they discussed concerns for Resident #1 returning home as he would require extensive assistance from the family. Family Member #1 was informed he required maximum assistance to perform a sit to stand from any surface and that once he was standing he was able to walk short distances. Family Member #1 expressed concerns regarding the living environment, in particular the doorways that may not accommodate his bariatric wheelchair. The DOT indicated she explained to the family that it may not be feasible to have Resident #1 walk through doorways as he needed extensive assistance just to stand up from a chair. The DOT wrote, [Family Member #1] also stated she didn't think [Resident #1] was ready to come home yet and we agreed with her. Family Member #1 was informed that Resident #1 could be treated at the facility for therapy after his Medicare benefit was exhausted. Family Member #1 was also informed that they (the SW and DOT) had not believed it was reasonable to attempt to transport Resident #1 home by personal vehicle for his safety and theirs. A SW note in the Electronic Medical Record (EMR) dated 7/30/21 (entered as a late entry note on 8/3/21) indicated the SW and DOT had a phone conference with Resident #1's Family Member #1 to discuss his upcoming discharge on 8/2/21. Family Member #1 expressed her concerns about his not being ready to come home. SW wrote that she discussed with Resident #1 and his spouse their options of a Medicaid application or private pay to remain at the facility and neither option worked for them. The SW indicated she told Family Member #1 that she was very concerned that Resident #1 wanted to go home in a car as he was not able to transfer and would really struggle getting in the house. The SW further wrote that Resident #1 informed her he had no wheelchair ramp at his home to get up the 2 stairs to his front door. Family Member #1 informed the SW that a community organization was going to build the ramp on 8/2/21 so the SW pushed his discharge to 3:00 PM. Family Member #1 reported that she was able to convince Resident #1 and his spouse to let the SW arrange for an ambulette to take him home rather than being transported by car. The SW wrote, [DOT] told [Family Member #1] she felt this was an unsafe discharge and we felt [Resident #1's spouse] would not be able to provide him with the assistance he needs. Resident told SW he felt sure they would handle it. An OT discharge summary for services from 5/25/21 through 7/30/21 indicated Resident #1 required substantial help with bathing, dressing, and toileting and moderate help with transfers. A PT discharge summary for services from 5/26/21 through 7/31/21 indicated Resident #1 needed assistance for bed mobility, transfers, and ambulation. The Discharge Plan and Instructions form dated 8/2/21 indicated Resident #1 was to be discharged home to a private house with his spouse due to his 100 days of Medicare being exhausted and declining to pay privately. He was noted to be admitted to the facility after being hospitalized from a previous facility for altered mental status. He had suffered a fractured fibula weeks earlier. Resident #1 was admitted for rehabilitation, strengthening, and mobility. His insurance days were up so he was being discharged to his home. His functional mobility/self-care skills revealed the following questions and answers: - You can get up and down from a seated position: With a great deal of help - You can go up and downstairs with handrails: Not recommended - You can move around: With a little help - You can wash and bathe: With a great deal of help - You can dress: With a great deal of help - You can prepare your own meals: Total help is recommended - Toilet use: Total help is recommended The social service discharge summary on his form indicated that the SW made referrals for home healthcare nursing, PT, OT, and NA services and ordered a bariatric commode. SW gave Resident #1 information on a wheelchair ramp he could order from an online site if he was not able to have a ramp built. The SW arranged for an ambulette. The discharge body audit indicated Resident #1 had a blister to his left thigh and buttocks, but had no open wounds. The nursing discharge summary on this form indicated that Resident #1 left the facility around 4:00 PM via ambulette. His discharge instructions/information were given to him and he voiced understanding of the instructions. He took all belongings, medications, and prescriptions. A home healthcare discharge summary completed by the Home Healthcare Nurse dated 8/3/21 revealed the following: [Resident #1] was not accepted for care due to safety concerns. [Resident] is morbidly obese, weighing in excess of 400 [pounds]. According to [Resident #1] and family [he] is unable to get up out of the recliner without aide of at least 3 people, and if an emergency takes place requiring [Resident #1] to exit the [home] he would be unable to do so safely. [Resident #1's] needs are also unable to be met [due to] the amount of assistance he needs and family unable to provide. [Adult Protective Services] referral was made . A SW note dated 8/4/21 indicated Resident #1's discharge home was very difficult for him and his family. Volunteer firemen needed to get him in the home. His family felt that they couldn't meet his needs at home and had him readmitted on [DATE]. The Business Office staff spoke with them about applying for Medicaid and the facility would assist them with the process. The SW wrote that the family stated they were not given any other options besides discharge home or private pay but that she spoke with Resident #1 and his spouse on the speaker phone about the option of Medicaid. A phone interview was conducted on 8/4/21 at 7:10 PM with Resident #1's Family Member #1. She stated that on 7/28/21 Resident #1's spouse phoned her to let her know that she and Resident #1 spoke with the SW and they were informed his last Medicare covered day at the facility was 8/1/21 due to him exhausting his 100 day benefit. The spouse reported that the SW said he would either have to be discharged home or they would need to pay privately. Family Member #1 stated that this was the first time she heard any mention of his discharge and she was unable to understand why the facility wouldn't have let them know that his 100 days was approaching rather than waiting until he had less than a week out from his last covered day (8/1/21). Family Member #1 stated that the facility staff had not informed Resident #1 or any of his other involved family members (Family Members #2 and #3) that they could complete a Medicaid application and Resident #1 could stay at the facility while waiting for the Medicaid application to be approved. She revealed that she spoke with the SW and DOT by phone on 7/30/21 and both of these staff expressed concerns with him returning home. She explained that they spoke of his need for extensive assistance with his ADL care and the need for maximum assistance for transfers. Family Member #1 reported that she expressed concerns about the home environment to the SW and DOT. She indicated that Resident #1's home had 2 stairs going into the house and the doorways were all very narrow and would most likely not accommodate his bariatric wheelchair. She explained that when he lived at home previously he was able to ambulate with the use of a cane or walker, but he was no longer able to do so. Family Member #1 revealed she asked the SW if they had any options other than private pay or discharge home and no other options were provided. She added that Family Member #2 also spoke with the SW on 7/30/21 and no mention of a Medicaid application was made to her either. She stated that she felt like they said, time is up and he has to get out or pay so she proceeded with the plans for him to discharge home with his spouse as she thought she had no other choice. She added that Resident #1's spouse was elderly and she was unable to provide the assistance he needed for ADL care. Family Member #1 revealed that there was no home assessment completed prior to Resident #1's discharge from the facility. This phone interview with Family Member #1 continued (8/4/21 at 7:10 PM). She stated that Family Member #2 spoke with the SW on 7/30/21 about arranging the transportation home on the discharge date via an ambulette. She indicated that the SW scheduled the ambulette transfer. Family Member #1 reported that she got in touch with the local Department of Aging and they reported that they would install a wheelchair ramp on 8/2/21 for Resident #1 to be able to get into his home. She stated that at the time of discharge home on 8/2/21 the ramp had not been completed as scheduled so it was not installed at the time he arrived home. She was asked if she notified the facility that the ramp was not completed as scheduled and she stated that she had not. She explained that from her communication with the facility staff that she believed there was no other option than for him to be discharged on [DATE] so she thought the notification wouldn't have changed anything with his discharge date . Family Member #1 reported that she and Family Member #3 were at Resident #1's home when he was dropped off by the ambulette company. She stated that the ambulette driver got Resident #1 out of the vehicle and onto the sidewalk, but had not assisted them with getting Resident #1 inside of the house. Family Member #1 revealed that the family built a makeshift wheelchair ramp out of wood 2 by 6s and concrete blocks so they could get his wheelchair up the stairs that led to the front door of the house. She reported that she and Family Member #3 were unable to push Resident #1 up the ramp by themselves so they had to call in assistance from other family members and the volunteer fire department. She further revealed that once up this ramp they realized that his bariatric wheelchair would not fit through the front door as it was too wide for the narrow doorway. She indicated that about 2 hours after Resident #1's arrival home and with the assistance of 6 people they were able to transfer Resident #1 into his spouse's wheelchair, which had a smaller frame, and they were then able to get him inside the house and transferred him to his electric lift recliner. She indicated that during that time period (2 hours) Resident #1 had a bladder movement and he had to remain in his wet brief. She stated that once Resident #1 was in this electric lift recliner he remained there for the rest of the day and overnight as he was not even able to transfer out of the electric lift wheelchair without maximum assistance of multiple people. Family Member #1 stated that she stayed at Resident #1's home with he and his spouse until around 11:00 PM when she returned to her own house. She indicated that during that time she was able to pull Resident #1's wet brief off of him and replace it with a clean one by sliding it under him. Family Member #1 indicated that she returned to Resident #1's house the following morning when home healthcare was scheduled for their initial visit. She stated that during the initial assessment by the Home Healthcare Nurse, Resident #1 was asked if he could get up and out of the house if there was an emergency and he reported that he would not have been able to do so. The Home Healthcare Nurse stated that they were unable to provide services to Resident #1 due to liability reasons as he was not able to escape in an emergency. Family Member #1 revealed that the Home Healthcare Nurse further stated that he was going to have to notify Adult Protective Services (APS) to file a report for Resident #1 residing in an unsafe environment. Family Member #1 stated that she and Resident #1's spouse were very overwhelmed and she reached out to the facility and spoke with the Administrator by phone on 8/3/21. She reported that the Administrator said she would talk to the Business Office and see if they could assist with a Medicaid application. Family Member #1 stated that this was the first time anyone had mentioned a Medicaid application to her. She indicated she was agreeable to completing a Medicaid application for Resident #1. She further indicated that during the morning of 8/3/21 she and Family Member #3 phoned the State Agency seeking assistance and the State Agency spoke with the facility Administrator. Family Member #1 revealed that the Administrator informed her by phone that Resident #1 could be readmitted to the facility that day (8/3/21). She reported he was readmitted to the facility in the early evening on 8/3/21. She stated that although their problem was resolved by Resident #1 being readmitted , the discharge planning was non-existent and he was sent home to an environment where his care needs could not be met. She indicated that this was very scary and she feared that if it happened to someone else who had no family support that it could have very dangerous results. During a phone interview with Resident #1 on 8/4/21 at 3:30 PM he stated that 7/27/21 was the first time he met with the SW to discuss discharge planning. He revealed he had no idea his Medicare benefit days were almost up at that time. He stated that the SW had not mentioned anything about applying for Medicaid. He reported he was told that he would have to discharge home on 8/2/21 or pay privately. Resident #1 stated that he shared this information with his spouse and his spouse informed Family Member #1. The events that occurred on his day of discharge (8/2/21) were reviewed with Resident #1. He confirmed Family Member #1's interview that indicated the family had to build a makeshift ramp and that it took 2 hours and 6 people to get him into the home and into his electric lift reclining chair where he remained until the following day. A phone interview was conducted with Family Member #3 on 8/5/21 at 1:49 PM. He verified Resident #1 and Family Member #1's interviews stating that it took 6 people and approximately 2 hours to get Resident #1 up the makeshift ramp, into the house, and into his electric recliner. He further stated that he thought the makeshift ramp was dangerous to use, but that they had no other way to get Resident #1 up the stairs to the house. A phone interview was conducted with Fireman #1 on 8/5/21 at 4:25 PM. He confirmed that he provided assistance with getting Resident #1 into his home after being discharged from the facility on 8/2/21. He indicated that Resident #1 appeared to be very weak and he was unable to actually support any of his own bodyweight when transferring him from the wheelchair to his electric reclining chair. He stated that this made it very difficult to transfer him and that it required 6 people to complete the transfer. Fireman #1 added that the makeshift ramp that was used to get Resident #1 up the front stairs to the house had not appeared very safe or sturdy. A phone interview was conducted with the Home Healthcare Nurse on 8/5/22 at 4:22 PM. He stated that when he arrived at Resident #1's home on 8/3/21 there were building materials for a ramp outside of the home, but no ramp was in place. He indicated when he entered the home Resident #1 was seated in a recliner and he said that he had not been out of the recliner since he got home on 8/2/21. His spouse and Family Member #1 were present. Resident #1 and Family Member #1 explained that it took 6 people, to include family and firemen, to get him into the house and into the recliner. He indicated that Resident #1's spouse was elderly and about 100 pounds so she was not able to provide him with assistance. When Resident #1 was asked if he would be able to get out of the house if there was an emergency he indicated he would not have been able to do so. The Home Healthcare Nurse revealed that because of that safety concern, they were unable to admit him to home healthcare services. He further revealed that he notified APS due to the unsafe home environment for Resident #1. He indicated it was clear that Resident #1's ADL care needs were unable to be met by the family. During a phone interview with Family Member #2 on 8/4/21 at 2:37 PM she stated that on 7/30/21 she spoke with the SW regarding transportation options for Resident #1's discharge from the facility. She revealed that during this phone call she asked if there were any options other than private pay or discharge and she was informed that these were the only options. During an interview with the DOT on 8/4/21 at 3:08 PM she revealed that in her opinion Resident #1 was not ready to discharge on 8/2/21 as he could have benefited with a continuance of therapy to improve his ADL ability. She indicated that the SW was aware that she thought Resident #1 was not ready for discharge. She explained that at the time of his discharge on 8/2/21 he required maximum assistance for transfers and extensive assistance for most ADLs. She further explained that he was able to ambulate short distances with a rolling walker, but that this required maximum assistance to transfer him from a seated to standing position in order to get up to the rolling walker. The DOT revealed that the therapy department had not completed a home assessment for Resident #1 as they had ceased doing these since COVID-19 began. She stated that in place of an onsite home assessment she asked some general questions about the home during a conference call with one of the family members (Family Member #1) on 7/30/21. She stated that the family spoke about the stairs to the front entrance and the narrow doorways in the home. She stated that from her understanding a wheelchair ramp was going to be installed at the front of the house and that his family was going to be available to provide assistance with his ADL needs. She revealed she had not known that the ramp was not installed at the time of his discharge and she had not verified that the family was going to be available to provide the amount of assistance Resident #1 required to meet his care needs. An interview was conducted with the SW on 8/4/21 at 4:02 PM. She stated that she began working at the facility about 5 weeks ago. She indicated she was not very familiar with Resident #1 until he was discussed in the morning clinical meeting on 7/26/21. She revealed that during that meeting she first learned that Resident #1's Medicare coverage benefits would be exhausted on 8/1/21. She further revealed that 7/27/21 was the first time that Resident #1 was informed of the upcoming exhaustion. She explained that on 7/27/21 she spoke with Resident #1 in his room and let him know that his last Medicare covered day in the facility would be 8/1/21. She indicated that Resident #1 was surprised and had not known this benefit exhaustion was coming up so soon. The SW stated that she told Resident #1 that he could stay at the facility and pay privately, apply for Medicaid, or discharge home. She reported that he said he had not wanted to apply for Medicaid and that he would talk with his spouse. She stated that on 7/28/21 she met with Resident #1 again and during this meeting his spouse was on the phone via speaker. They indicated that they were not going to pay privately so she began to discuss discharge planning for him to go back to his private home where he resided with his spouse. The SW stated that was when she informed Resident #1 and his spouse she would made a referral for home healthcare services and order any medical equipment he required. She indicated she had not brought Medicaid up again as she assumed that Resident #1 had discussed this option with his spouse and family members and that this was not an interest to them. She revealed she had never discussed the option of a Medicaid application with Resident #1's family members who were involved with his care (Family Members #1, #2, and #3). The SW spoke about the phone conference she had with the DOT and Family Member #1 on 7/30/21. She stated that this conference included a discussion about his transportation home. She explained that Resident #1 wanted to travel by car, but she and the DOT felt that this was not feasible due to his inability to transfer out of the car once at home. She further explained that it seemed as if Resident #1 and the family had not realized what his functional limitations were. She stated that it was obvious that Resident #1 overestimated his ability to do things on his own which was why he thought he could be transported home by car. This interview with the SW continued (8/4/21 at 4:02 PM). She was asked if a home assessment was completed prior to Resident #1's discharge and she stated that because she was new to the facility she was not sure what the normal protocol was for a home assessment, but that she believed this would have been the therapy department's responsibility. She indicated she thought therapy was not completing home assessments in person due to COVID-19 protocols. She was asked what the plan was for Resident #1's care needs to be met at home where he resided with his elderly spouse and no other live in family members. SW #1 stated that Resident #1 made it seem like his family would be there to help him with everything and he said they would make it work. She acknowledged that Resident #1 overestimated his own functional abilities and that he may not have realized how much assistance he actually needed. The SW was asked if she verified the timeframes that his family would be with him in the home to provide care and she revealed that she had not. She was asked if his spouse would have been able to assist him with his care needs and she indicated that she had never seen Resident #1's spouse in person to assess her abilities, but due to the fact that she was also elderly and that he required maximum assistance and was a large man that it was doubtful. She indicated that she asked Resident #1 how he was going to get into the house when he got home and he stated that 2 of his family members would be there to help him. The SW revealed that at the time of discharge on 8/2/21 she had not verified the wheelchair ramp was installed. She explained that she assumed this had been completed as scheduled. She revealed that it was not until today (8/4/21) that she learned that the ramp had not been installed at the time of discharge and that it took 6 people to assist him to get into the home. She further revealed that she also learned today that home healthcare refused to provide services due to an unsafe living environment and that they had notified APS. The SW stated that this was an unfortunate situation as she was not familiar with the facility's normal discharge planning process due to being so new to the facility so she had completed no discharge planning with Resident #1 prior to 7/27/21. She further stated that she had not verified the family assistance that Resident #1 would have at home as she took him for his word that his family would be there to assist him and that they would make it work. She revealed that in hindsight, she absolutely would have done things differently with Resident #1's discharge. She explained that she should have asked many more questions about the plan for getting Resident #1 into the home, for how his care needs would be met, and for his family members' availability to provide assistance to meet his care needs. She revealed that if she knew the wheelchair ramp was not installed, that home healthcare [TRUNCATED]

Based on record review, staff and family interview, physician and Physician Assistant (PA) interviews the facility failed to supervise and provide limited assistance to Resident #5 after toileting and redressing while the resident performed hand hygiene in the bathroom. While unsupervised, the resident fell in the bathroom and hit her head. She was sent to the emergency room and diagnosed with [REDACTED]. The deficient practice affected 1 of 4 residents who were sampled for supervision to prevent accidents (Resident #5). Immediate jeopardy began on [DATE] when Resident #5 was left in the bathroom to wash her hands after toileting. She fell and hit her head. She was sent to the emergency room for evaluation. Immediate jeopardy was removed on [DATE] when the facility provided a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of level of D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee education and ensure monitoring systems in place are effective. Findings included: According to the hospital discharge summary dated [DATE], Resident #5 was admitted to the hospital for weakness and falls. She was subsequently admitted to the nursing home on [DATE]. A baseline care plan dated [DATE] was established for Falls/Safety/Elopement with a goal that said, Will remain free of injury. Interventions included evaluate cognitive status and gait steadiness and maintain safe environment. A physical therapy (PT) evaluation dated [DATE] identified fall predictors for Resident #5 : These included: Age greater than 80, female gender, gait impairment, history of falls, impaired activities of daily living (ADL), impaired cognition, impaired strength, visual impairment and five or more medications. She had more than two falls in the last year without injury and had, no fear of falling. Contact guard was noted. Her prior level of function was independent. She used a rolling walker 16 -20 feet. Cues were required for walker body orientation and distances were limited due to fatigue. A care plan dated [DATE] for ADLs indicated limited assist of one for transfer, dressing, toilet use and personal hygiene. The resident was assessed using the Minimum Data Set with assessment reference date of [DATE]. The assessment indicated she understood and could understand. She had moderate impairment in cognition. She required limited assistance from one staff person for transfer, personal hygiene and walking in the room. She required extensive assistance for dressing and toilet use. Her balance was assessed as not steady. She was occasionally incontinent of bowel and bladder. Her [DIAGNOSES REDACTED]. She had a history of [REDACTED]. She received an anticoagulant and diuretic. According to PT Treatment Encounter Notes, Physical Therapy Assistant (PTA) #1 had worked with Resident #5 throughout the course of her stay. PTA #1 was interviewed on [DATE] at 10:40 AM. He said the need for assistance typically varied with Resident #5 . It would depend on what activity she had prior to therapy. She had a rolling walker. She required supervision. He said supervising meant eyeballs on person. She would walk to the bathroom. They practiced pivoting and foot position. They would ambulate from her room to the gym. He usually provided stand by assistance (SBA) to supervision. SBA meant being really close. If she lost balance he would be close enough to prevent a fall. He was not sure if she had therapy on the day of the incident. He stated [DATE] was the last day he saw her. She needed supervision and verbal cues for ADLs. September (YEAR) Physician Monthly Orders included the following medications: [REDACTED]. Nurse #2 was interviewed on [DATE] at 9:51AM regarding the level of ADL assistance Resident #5 needed prior to her fall on [DATE]. He said she was steady on feet. She was taught how to use the call bell and would use it. She required minimal assistance with most ADLs, but for walking she was strictly supervision. He clarified supervision meant watching. He said she had been discharged from therapy and was preparing to move to an assisted living facility. Nurse #1 was interviewed on[DATE] at 3:27 PM about the day of the incident. She said she had worked with Resident #5 on [DATE]. She said a family member was in the room at the time of the fall and was present often during the resident's stay. She said Nurse Aide (NA) #9 had just provided Resident #5 with incontinence care. NA#9 then left work for the day. She said Resident #5 wanted to go to the bathroom again. Nurse #1 said she was not sure if the family member put Resident #5 on the toilet or if she (Nurse #1) put her on the toilet. Nurse #1 said the resident's toileting was taking a long time and when she was finished, NA #1 came in the bathroom and cleaned the resident. Nurse #1 said a short time later she heard a thump. Nurse #1 said four to five staff ran into the resident's room. Nurse #1 saw the resident's walker at the sink. The resident's family member was up against wall, but standing. Resident #5's head was up against bathroom door and there was blood. Nurse #1 said she assessed the resident. Resident #5 said her head hurt. Nurse #1 found a small laceration on the resident's head. Resident #5 was sent to the emergency room . Nurse #1 notified the supervisor and the nurse practitioner and called the power of attorney. She said no staff was in the room at the time of the fall. NA #1 was interviewed on [DATE] at 3:48 PM about the period of time immediately before the resident's fall. She said on [DATE] at 2:00 PM she relieved NA#9. She said she made a round. She asked Nurse #1 what to do. The nurse said Resident #5 was on the toilet. She said, Go in and clean her up. NA #1 said she cleaned her up. She said the family member was sitting on edge of bed. NA #1 stated, I asked (family member) if she needed assistance and (family member) said No, I can help her. NA #1 said we use a Kardex to know resident needs. NA #1 specified that Resident #5 was stand and pivot with transfers and could feed herself. She said she went to the toilet, but wore diapers for protection. She said, I was in the bathroom. {Family member) said Mama needs to wash her hands. She said, I have it. When she got to door, I walked out. I got half way down the hall and I heard boom. Everyone ran. She was on the floor. She had gash and was bleeding. They evaluated her. We got her into chair and then bed. Emergency Medical services got her. A telephone interview was conducted on [DATE] at 5:43 PM with the family member who was in the room at the time of the incident and was the sole witness. The family member said, I was in the room. The door to the bathroom was open. She went into the bathroom. She said two [MEDICATION NAME] had been given. Someone took her to the bathroom. They stood her up. Pulled her pants up and walked out. She had her walker. Put walker along wall by paper towel holder. She washed her hands. Put paper towels in trash can. She turned right instead of turning left toward her walker. Her legs tangled up and she hit her head on other door which was closed. Her head was toward door. I was on the bed. I jumped up and screamed. I looked in the hall and saw no one. I ran back. I stepped over her. Blood was under her head. Three to five people appeared. The Physician's Assistant came in for brief second. One of the responders said, Let's pick her up and they got a towel under her head. The pulled diaper and pants up. They told me she was on falls protocol. They were supposed to help her. I did not tell the aide she could go. She was on [MEDICATION NAME]. They could have guided her fall. A nurse's note recorded after the incident was dated [DATE] at 3:45PM. It said, Resident had large bowel movement and had been cleaned, dried and barrier cream applied. (Family member) was in room as well. CNA asked (Family member) if further assistance was needed to help resident wash hands. (Family member) stated I got it. CNA left room. Staff heard loud noise and help. Resident found on bathroom floor with head resting up against bathroom door with (Family member) standing over resident. (Family member) stated she was washing her hands and she fell . Resident had a small laceration on the back of her head. Followed by profuse bleeding. Cleaned site with sterile water, cleaned area and applied gentile pressure. Bleeding stopped. NP and manager notified and present in room as well. Sent resident out via EMT (emergency medical transport), Fall at 2:45 PM. Notified (responsible party (RP)) of fall. Had been notified by (family member) of fall. (RP) asked if she was alone. Notified {RP) that (family member) was in the bathroom at the time and no staff witnessed the fall. (RP) made staff aware that resident will be headed to (hospital). A Situation Background Assessment Report dated [DATE] indicated Fall with head injury. Rehab, weakness, status [REDACTED]. Pain yes, ,[DATE], Found resident on bathroom floor. Family present. New pain, [DATE] at 2:25 PM Send to ER. Excerpts from the hospital emergency room (ER) record dated [DATE] indicated Resident #5 arrived at 2:54PM. Her [DIAGNOSES REDACTED]. The chief complaint was patient had a witnessed lost balance and fall hitting head prior to admission. Patient (Pt) was assisted to wheelchair then to bed by skilled nursing facility staff. Emergency Medical Services (EMS) states that the bystander reported she was walking backwards, slipped, fell and hit the right side of her head. She complained of headache. Upon arrival to the ED, a small laceration of the patient's occipital region was noted. Bleeding was controlled when they arrived. Of note, the patient's [MEDICATION NAME] was recently increased. Pt's medications were listed including [MEDICATION NAME]. At 4:19 PM the INR was 4.39. At 5:36 PM Kcentra, (a product used for the urgent reversal of acquired coagulation factor deficiency induced by a medication like [MEDICATION NAME]) was ordered. Resident #5 expired on [DATE]. The Regional Director of Clinical Services entered an incident report on [DATE]. It included the following information. Event Date [DATE] at 2:24PM. Upon entering the resident's bathroom she was sitting on the floor with her head up against the bathroom door her (family member) was standing with her back up against the wall that the toilet rail sits on and her walker was at the bathroom sink. Fall to floor unwitnessed. Was the resident who fell attended by an employee? No. Location Restroom: Resident. Was the resident found on the floor? Yes. Prior to using the bathroom the resident was sitting in her wheelchair in her room. What footwear was in use at the time of the event? Shoes. Resident's history of Condition: cardiovascular disease and falls. Was the resident assessed for fall prior to event? No. Did the resident's plan of care include fall prevention? Yes. Were safety measures to prevent a fall in place prior to event? Yes. Preventive measures: Assistive devices: Instructed resident on and end encouraged use of; call light, encouraged and taught use of, grab bar in bath room, therapy, call light within reach. Room well lit, Toileted at least every two hours. What assistive devices .? Walker. Was the resident injured? Yes. What was the level of injury? Minor injury. 1 laceration. Current medications? Diuretics, laxatives, anti-hypertensives, cardiovascular meds, anticoagulant. Initial disposition. ER. The resident's disposition was documented in the medical record. Possible causative factors - other Unknown all safety measures were in place. During interview on [DATE] at 11:44 AM the Regional Director of Clinical Services said I was there that day, but just in the executive director's office. She said there was no investigation of the accident found. On [DATE] at 10:10 AM the physician assistant was interviewed. She said Resident #5 was our rehab patient. She was very medically complex. She had an extensive hospital stay prior to entry. [MEDICAL CONDITION] continued to be an issue. We followed Resident #5 closely with several medication adjustments. She was followed by nephrology. She was doing well in rehab. She was planned to discharge to and assisted living facility later that week. She said she had spoken to the family member that day about discharge paperwork. She said she had not assessed her ADLs, but said Resident #5 was able to get up probably with standby and minimal assist. She could do some ADLs. We always had someone by her. She said the family member was in the room. After the fall she said the family member was in the room. She repeated NA #1's account of leaving the room and why she left. She said she understood the family member was in the resident's room, but not in the bathroom. She said the aide was not in room because the family member was there. She said the resident was in the bathroom by herself. She fell . She hit back of head. The family member called in hallway. Staff came to assess. Small laceration was found and it was no longer actively bleeding. She arranged to send her to the emergency room . The PA said the subdural hematoma was likely result of the fall. On [DATE] at 9:58 AM the resident's physician was interviewed. He said Resident #5 was quite sick. She had bad [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. He said Resident #5 was on [MEDICATION NAME] that was difficult to adjust and on high end meds. He said she was followed by nephrology. He was asked if it was possible she had a brain bleed before the fall or if the fall resulted in the bleed. He said it would be difficult to know if the fall came before or after the bleed. He said with [MEDICAL CONDITION] and low sodium, balance is a problem. He mentioned she had two to three complicating factors that could contribute to falls and was on [MEDICATION NAME]. He said four to five people responded. He said his expectation would be everything the nursing home staff did. He added there was an attempt to provide assistance and the implementation of the care plan was sort of a gray area. On [DATE] at 12:00 PM, the Regional Director of Clinical Services stated her expectation is to provide the assistance the resident needs. At 12:03 PM, the Administrator stated the same expectation. On [DATE] at 3:11 PM the Interim Director of Nurse said she started last Monday, (MONTH) 17, (YEAR). She said, Typically there is a root cause analysis done after a fall. There is an intervention put in place. It's talked about in stand up. We make sure everything is in place and functioning. We meet for three days and monitor for three days. On [DATE] at 11:43 AM the administrator was notified of immediate jeopardy. An acceptable credible allegation of immediate jeopardy removal was received on [DATE] at 12:20 PM. It included the following. 1. Root Cause Analysis was completed regarding care and services provided to Resident #5 on [DATE]: Root Cause determined to be the CNA assumed her responsibility ended and she left the resident unsupervised. Resident #5 ambulates using a rolling walker and on [DATE], was assisted times 1 with transfer to toilet by licensed nurse at approximately 2:15pm. Resident is care planned for 1 staff assistance with transfer. According to the Certified Nursing Assistant (CNA) statement and interview, CNA completed peri-care, and assisted resident to be seated on rolling walker in resident room bathroom. Family member reminded resident to wash her hands. After resident completed toileting, CNA assumed that her responsibility ended and she left the resident unsupervised. According to CNA statement from her interview, when CNA left resident room resident and family member were in bathroom, at sink washing hands and resident was seated on rolling walker. At approximately 2:25pm nurse and CNA's heard loud noise and responded to room and noted resident on floor in bathroom up against bathroom door. Resident #5 assessed by nurse and physician assistant and sent to ER for evaluation. The Center is unable to locate evidence of a thorough investigation. Director of Nursing (DON) and Unit Manager who were employed during the time of the event are no longer employed at center. CNA involved was suspended [DATE], pending investigation of event regarding Resident #5 to ensure CNA receives appropriate re-education and training to prevent future incidents. 2. On [DATE], 2:55pm Center Administration including Regional Director of Clinical Services (DCS), Interim DON, Interim Divisional Executive Director (ED), Consulate sister center ED's and Regional Vice President of Operations (RVPO) immediately began education to licensed nurses and CNAs on: Staff to provide the supervision and or assistance as indicated per plan of care (Kardex) for transfers and ambulation for all residents. Staff aware location of plan of care (Kardex). Staff are responsible for transfers and ambulation regardless of who else may be present. All current Licensed Nurses and Certified Nursing Assistants educated on [DATE] or prior to working next scheduled shift. Temporary staff will be educated via telephone and/or in person prior to their next scheduled shift. 3. Center Executive Director convened an Ad Hoc Quality Assurance Performance Improvement Meeting [DATE] 6:00PM regarding Plan of Removal of Immediacy. Director of Nursing and Regional Director of Clinical Services to conduct random quality improvement monitoring using a sample size of 5 residents 3 times weekly X 4 weeks, 2 times weekly X 4 weeks, then weekly X 4 weeks then monthly as needed. Results of the quality monitoring to be brought to the monthly Quality Assurance Process Improvement. Quality Improvement Monitoring schedule modified based on findings of monitoring. 4. Center Divisional Interim Executive Director alleges abatement of Immediate Jeopardy on [DATE] at 11:00 a.m. The immediate jeopardy was removed on [DATE] at 1:04 PM. Staff had been trained on following the care plan, the responsibility of the staff to deliver care as it is determined on the care plan and how to respond to family members who insist on providing assistance.

Based on record review, staff and resident interviews, the facility failed to have prescribed medications available on the day of admission to manage the pain of 1 of 1 residents reviewed for pain. The resident returned to the emergency room to be treated for [REDACTED].#11). Findings included: Review Resident #11's medical record revealed he was admitted to the nursing home on 8/31/18 at 5:35 PM from the hospital. According to the admission physician's orders [REDACTED]. Resident #11 had several medications ordered upon admission to the facility on [DATE] including [MEDICATION NAME] 10 milligrams per oral two times a day at 8:00 AM and 8:00 PM. A telephone order dated 8/31/18 was obtained for [MEDICATION NAME] APAP 5/325 1 tab by mouth every 6 hours as needed for pain. Review of Resident #11's medical record revealed the monthly (MONTH) (YEAR) Medication Administration Record [REDACTED]. Nurse #5 confirmed on 9/23/18 at 8:26 AM that she never found the (MONTH) MAR. According to the admission nursing note dated 8/31/18 and written by Nurse #4, Resident #11 arrived at the facility at 5:35 PM from the hospital. He was alert, oriented and anxious. Resident #11 was increasingly agitated and reported pain. He refused to allow the nurse to assess him due to pain. The physician assistant was notified that his antibiotic and [MEDICATION NAME] were not available because the medications had not been delivered from the pharmacy and were not available in the facility's emergency medications box. The 8/31/18 nursing note indicated that [MEDICATION NAME] - APAP 5/325mg 1 every 6 hours was ordered until medications arrived from pharmacy. Resident #11 was medicated, but remained agitated. Resident #11 refused a body assessment a second time, stating if you come back in an hour with another pill then we can do it. Nurse #4 explained to Resident #11 that [MEDICATION NAME] /APAP was available until other medications were delivered from pharmacy. Resident #11 expressed dissatisfaction with that answer. An attempt to interview Nurse #4 was made on 9/22/18 at 3:29 PM. The voice mail box was full. Interview with Nurse #2 on 9/22/18 at 2:45 PM revealed he was assigned to care for Resident #11 after Nurse #4 on 9/1/2018. He said Nurse #4 had not had a lot of experience with admissions in the evening and she had two to three admissions that day. He said the resident's intravenous antibiotic and the [MEDICATION NAME] did not come from the pharmacy that night. He said the antibiotic was not a concern because the next dose was not due until the morning. He said Resident #11 received [MEDICATION NAME] /APAP in between, but his pain was through the roof. The pharmacy was called and said they were unable to deliver the medications to the facility that night. Nurse #2 called again and the pharmacy was unable to give him an estimated time of arrival for the delivery and the resident was declining. He said Resident #11 was at the facility for fourteen hours before he obtained orders to send him back to the hospital. On 9/1/18 a physician's orders [REDACTED].#11 to send to the emergency room related to [MEDICATION NAME] withdrawal. Resident #11 was admitted to the emergency roiagnom on [DATE] at 11:12 AM for complaint of pain. The emergency triage note indicated patient has chronic pain and is seen at (__) pain clinic for L4-5 pain and abscess on spine. Patient states pain is 12/10. Resident #11 was administered [MEDICATION NAME] intravenously. The final impression was L 5 -S1 paraspinal abscess, back pain, chronic back pain, spinal cord stimulator and recent abscess. Resident #11 was discharged from the emergency room and readmitted to the nursing home on 9/1/2018. An interview was conducted on 9/23/18 at 9:44 AM with a pharmacy technician at the facility's pharmacy. She pulled communications the pharmacy received from the nursing home on 8/31/18. She said the nursing home sent a fax for [MEDICATION NAME] on 8/31/18 at 11:30 PM. She said the pharmacy closed at midnight. On 9/1/18 at 3:34 AM a hand written MAR indicated [REDACTED]. She said the pharmacy has a helpline the nursing home can call to get meds after hours. Resident#11 was interviewed on 9/23/18 at 8:15 AM regarding his recollection of his admission at the nursing home on 8/31/18. He said on the night of admission, the nursing home did not have all medications on arrival. He said he had to go back to hospital. He said it was a late discharge from the hospital. He said they brought him to the room and put him in bed. He said he got his medications at the hospital at 4:00 PM and the next dose of pain medication was scheduled at 8:00 PM. He was told the medications were on order. He asked again around 9:00 PM. Still not there. Around 11:00 PM, he received [MEDICATION NAME] /APAP. He said he had whole body pain. Around 11:00 - 11:30 PM, he said, I went into cold turkey. I didn't sleep. I was in pain. Nurse #2 saw what was going on and gave me medications he had available. He called the pharmacy. I was hurting to high heaven. He told Nurse #2 to call 911. On 9/23/18 at 10:06 AM NA #3 was interviewed. She said Resident #11 rings for pain pills. She recalled his admission, I remember the first or second night he was here. His meds did not come. I observed him being in pain. That night he didn't get pain meds.

Based on record review, pharmacy interview, staff and resident interview, the facility failed to acquire a prescribed pain medication to treat 1 of 1 resident's pain. The resident returned to the emergency room to be treated for [REDACTED].#11). Findings included: Review Resident #11's medical record revealed he was admitted to the nursing home on 8/31/18 at 5:35 PM from the hospital. According to the admission physician's orders [REDACTED]. Resident #11 had several medications ordered upon admission to the facility on [DATE] including [MEDICATION NAME] 10 milligrams per oral two times a day at 8:00 AM and 8:00 PM. A telephone order dated 8/31/18 was obtained for [MEDICATION NAME] APAP 5/325 1 tab by mouth every 6 hours as needed for pain. Review of Resident #11's medical record revealed the monthly (MONTH) (YEAR) Medication Administration Record [REDACTED]. Nurse #5 confirmed on 9/23/18 at 8:26 AM that she never found the (MONTH) MAR. According to the admission nursing note dated 8/31/18 and written by Nurse #4, Resident #11 arrived at the facility at 5:35 PM from the hospital. He was alert, oriented and anxious. Resident #11 was increasingly agitated and reported pain. He refused to allow the nurse to assess him due to pain. The physician assistant was notified that his antibiotic and [MEDICATION NAME] were not available because the medications had not been delivered from the pharmacy and were not available in the facility's emergency medications box. The note indicated that [MEDICATION NAME] - APAP 5/325mg 1 every 6 hours was ordered until medications arrived from pharmacy. Resident #11 was medicated, but remained agitated. Resident #11 refused a body assessment a second time, stating if you come back in an hour with another pill then we can do it. Nurse #4 explained to Resident #11 that [MEDICATION NAME] /APAP was available until other medications were delivered from pharmacy. Resident #11 expressed dissatisfaction with that answer. An attempt to interview Nurse #4 was made on 9/22/18 at 3:29 PM. The voice mail box was full. Interview with Nurse #2 on 9/22/18 at 2:45 PM revealed he was assigned to care for Resident #11 after Nurse #4 on 9/1/2018. He said Nurse #4 had not had a lot of experience with admissions in the evening and she had two to three admissions that day. He said the resident's intravenous antibiotic and the [MEDICATION NAME] did not come from the pharmacy that night. He said the antibiotic was not a concern because the next dose was not due until the morning. He said Resident #11 received [MEDICATION NAME] /APAP in between, but his pain was through the roof. The pharmacy was called and said they were unable to deliver the medications to the facility that night. Nurse #2 called again and the pharmacy was unable to give him an estimated time of arrival for the delivery and the resident was declining. He said Resident #11 was at the facility for fourteen hours before he obtained orders to send him back to the hospital. On 9/1/18 a physician's orders [REDACTED].#11 to send to the emergency room related to [MEDICATION NAME] withdrawal. Resident #11 was admitted to the emergency roiagnom on [DATE] at 11:12 AM for complaint of pain. The emergency triage note indicated patient has chronic pain and is seen at (__) pain clinic for L4-5 pain and abscess on spine. Patient states pain is 12/10. Resident #11 was administered [MEDICATION NAME] intravenously. The final impression was L 5 -S1 paraspinal abscess, back pain, chronic back pain, spinal cord stimulator and recent abscess. Resident #11 was discharged from the emergency room and readmitted to the nursing home on 9/1/2018. An interview was conducted on 9/23/18 at 9:44 AM with a pharmacy technician at the facility's pharmacy. She pulled communications the pharmacy received from the nursing home on 8/31/18. She said the nursing home sent a fax for [MEDICATION NAME] on 8/31/18 at 11:30 PM. She said the pharmacy closed at midnight. On 9/1/18 at 3:34 AM a hand written MAR indicated [REDACTED]. She said the pharmacy has a helpline the nursing home can call to get meds after hours. Resident#11 was interviewed on 9/23/18 at 8:15 AM regarding his recollection of his admission at the nursing home on 8/31/18. He said on the night of admission, the nursing home did not have all medications on arrival. He said he had to go back to hospital. He said it was a late discharge from the hospital. He said they brought him to the room and put him in bed. He said he got his medications at the hospital at 4:00 PM and the next dose of pain medication was scheduled at 8:00 PM. He was told the medications were on order. He asked again around 9:00 PM. Still not there. Around 11:00 PM, he received [MEDICATION NAME] /APAP. He said he had whole body pain. Around 11:00 - 11:30 PM, he said, I went into cold turkey. I didn't sleep. I was in pain. Nurse #2 saw what was going on and gave me medications he had available. He called the pharmacy. I was hurting to high heaven. He told Nurse #2 to call 911. On 9/23/18 at 10:06 AM NA #3 was interviewed. She said Resident #11 rings for pain pills. She recalled his admission, I remember the first or second night he was here. His meds did not come. I observed him being in pain. That night he didn't get pain meds.

Based on staff and Nurse Practitioner interviews and record review, the facility staff let go of a resident while giving care to one of three residents reviewed for accidents (Resident #3) resulting in a fall causing the re-opening of a wound and being transported to the hospital. Findings included: A review of medical records revealed Resident #3 was readmitted on [DATE] with [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set ((MDS) dated [DATE] noted Resident #3 to be moderately impaired for cognition and needed extensive to total assistance for all Activities of Daily Living (ADLs). The MDS indicated Resident #3 was totally dependent for bathing and required the assistance of two persons. Resident #3 needed extensive assistance for bed mobility with the physical assistance of two persons. The MDS noted impairment on both sides of the lower extremities. The Care Area Assessment (CAA) focused on ADL function and this went to care planning. The CAA also noted a focus of risk for falls related to antidepressant use, need for assistance with mobility and functional limitations, and this was care planned also. No recent falls noted. The care plan dated 5/29/2018 noted Resident #3 had an ADL self-care deficit related to limited mobility and [MEDICAL CONDITION]. The goal was Resident #3 would receive appropriate staff support for personal hygiene. Interventions included: Resident #3 was dependent on two staff regarding bathing. Resident #3 was on Hospice care. A review of the wound rounds progress notes revealed an assessment on 7/17/2018 stated Resident #3 was seen for chronic post-operative wound to the left abdomen. The wound measured 2 x 0.8 x 0.1. The wound had unhealthy/inadequate granulation tissue to the wound bed and mild serous drainage. No signs or symptoms of infection. The nurse progress note for 7/20/2018 indicated the writer was notified Resident #3 had slid out of bed during a bed bath. Upon entering the room, the writer found Resident #3 on her knees on the floor beside the bed. Resident #3 was assisted back to bed and the writer noted the abdominal wound had reopened and was bleeding. The treatment nurse was notified to assess the wound. Resident #3 denied pain or discomfort at that time and attempts were made to administer pain medication that were refused by Resident #3. The Physician Assistant (PA) was notified and an order was given to transport Resident #3 to the hospital. A review of the Situation, Background, Appearance, Review (SBAR) communication form revealed on 7/20/2018 the abdominal wound for Resident #3 re-opened. No pain or neurological changes noted. Vital signs were documented. Noted the clinician was notified. A review of the hospital record dated 7/20/2018 revealed Resident #3 had a past medical history that included a non-healing abdominal wound since a surgery in (YEAR). Resident #3 was assessed in the Emergency Department (ED) and the ED physician noted the case was discussed with surgery. Further review of notes from the surgery indicated the abdominal wound was repaired with a surgical mesh. On 8/16/2018 at 11:25 AM, NA #4 was interviewed and stated he and NA #5 were giving Resident #3 a bed bath on 7/20/2018. NA #4 noted he had given her a bed bath in the past and she was always able to hold on to the side rail. NA #4 said her hands were shaky and he had not noticed that before. NA #4 stated he turned to get a towel or toward the wash basin, let go of Resident #3 and she slid off the mattress and onto the floor on her knees. NA #4 stated it happened so fast and he could not grab her or keep her from falling. NA #4 noted there was a chair at the bedside and Resident #3 held onto it and NA #5 stayed with the Resident while he went for the nurse. NA #4 stated at no time was only one NA in the room and he had never given Resident #3 a bed bath without another NA with him, she was a two person assist for a bath. In an interview on 8/16/2018 at 12:15 PM, the Unit Manager for Resident #3's hall stated NA #4 came to her and she entered the room and Resident #3 was on the floor, on her knees, holding on to a chair. The Unit Manager indicated she asked Resident #3 if she was hurt and the Resident stated no, she just wanted to get up. The Unit Manager noted the treatment nurse was called and, by that time, other staff were in the room and got the lift and got her into bed. The Unit Manager stated Resident #3 said she was not in pain, but the open wound could be seen. On 8/16/2018 at 3:00 PM Nurse #1 was interviewed and stated she was told Resident #3 had fallen, she went into the room and the Resident was on the floor, on her knees, holding onto a chair. Nurse #1 stated there was some blood on the floor. Nurse #1 indicated she took Resident #3's vital signs and staff used the mechanical lift to put Resident #3 back into the bed. Nurse #1 noted the treatment nurse assessed the open wound and said Resident #3 had to be sent to the hospital. In describing the wound, Nurse #1 stated it looked like a skin tear, like the flap of skin could be picked up and laid back over the wound. Nurse #1 stated the Resident did not complain of pain. On 8/16/2018 at 3:15 PM NA #5 was interviewed and stated he was in the room the entire time of the bed bath for Resident #3. NA #5 stated she was on one side of the bed with the side rail up and NA #4 was on the other side of the bed with the side rail up. NA #5 indicated the two NAs had rolled Resident #3 over toward NA #4 and NA #5 had finished washing and rinsing Resident #3's back and bottom and she asked NA #4 for a towel and when he turned to get it, he let go of Resident #3 and the Resident let go of the side rail and she went sliding out of the bed. NA #5 said it happened so fast, I could not hold onto her. NA #5 stated the other NA went to get the nurse and I stayed with Resident #3 and she told me she was not hurt, she wanted to get up. In an interview on 8/16/2018 at 4:36 PM, the Nurse Practitioner (NP) stated she was in the building and was called to look at Resident #3 who she did not know. The NP stated she looked at the wound and told staff to call the physician and 911. The NP stated the wound looked red. The treatment nurse was interviewed on 8/17/2018 at 10:45 AM, and stated she was familiar with the wound because she made weekly rounds with the wound care specialist who came to the facility. The treatment nurse stated when she got to the room, Resident #3 was in bed. The treatment nurse described it as the skin was torn away, like a skin tear. The treatment nurse stated she did not see bleeding and the Resident did not complain of pain. The Director of Nursing stated on 8/17/2018 at 11:30 AM that her expectation was that NAs needed to make sure residents were safe while care was being given.

Based on observations, resident, staff and police interviews, record review and police report review, the facility failed to prevent a resident from exiting the facility's building. This was evident in 1 of 3 sampled residents at risk for elopement (Resident #1). Immediate Jeopardy began on 10/24/13 and was identified on 10/30/13 at 4:30 PM. Immediate Jeopardy was removed on 11/1/13 at 11:30 AM, 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). The facility was in the process of full implementation and monitoring their corrective action. Findings include: Review of the facility 's Policy dated 1/1/2007 and revised on 9/1/2011 revealed, " POLICY It is policy of The Company that on admission and quarterly, all residents will be assessed for elopement risk. " " PROCEDURE 1. An elopement risk assessment will be completed on admission and quarterly by nursing. 2. If the resident is identified as an elopement risk based on assessment, the care plan will reflect the intervention (i.e. Wander Guard or Code Alert) and desired outcomes. Review and/or revised care plan following attempt to leave the facility. 3. Resident identified as at risk for elopement will require nursing to check resident regularly and document on Safety Checks (N-1275A). " Guide to the Elopement Risk Assessment (no date) revealed in part, 3. Interventions will be developed and entered on the interim plan of care for all residents identified as being an elopement risk. 4. Communication of residents ' risk and interventions will be completed daily at the morning meeting. 6. In-service education and elopement drill will be conducted quarterly on each shift to strive to assure that all staff is aware of what steps to take to prevent or interrupt elopement attempt. Resident #1 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Review of nursing notes from 1/14/13 -8/25/13, indicated Resident #1 had no wandering behaviors. Review of the form titled " Elopement Risk Evaluation " , dated 8/25/13, indicated the resident was at risk for elopement. Review of Resident #1 care plan dated 8/25/13 and last revised on 8/26/13 revealed a plan of care for elopement prevention. The problem was exit seeking behavior. The goal was to minimize the risk of the resident's elopement (no goal date). The interventions included: ? Initiate wander alert system Describe system used : no system described ? Photograph resident /patient; Place on protected list for at risk resident/patient ? Allow for safe wandering ? Encourage movement and exercise ? Enhance recreation exercises ? Provide evening activities ? Redirect resident/patient ? Encourage family participation & support ? Remove objects that are reminders of leaving ( i.e. coat hat etc) ? Offer reassurance if resident feels lost or abandoned ? Encourage conversation about past experiences (i.e. children pets occupation) ? Attempt to identify a need that the exit seeking behavior may be a result of( need to get home for children spouses etc). Provide activities at these times ? Encourage involvement in productive daily activities (i.e. folding clothes cooking etc.) Review of the nursing notes dated 8/25/13 at 9:00 AM revealed in part, " Resident was brought back into the building by a member of staff. He was spotted outside the building heading towards Tryron Rd. " SBAR (Situation, Background, Assessment, and Request), dated 8/25/13, revealed: S: Resident elopement due to loneliness, desire spouse to visit B: Dementia A: Loneliness R: Wander guard placement A Physician Order, dated 8/25/13, read " place wanderguard to left ankle. Check place q (every) shift. Visual check q 30 min x 3 days. " Review of the visual check list , revealed checks were done every 15 minutes from 8:45 AM until 2:45 PM on 8/25/13. Then checks were done every 15 minutes from 3:00 PM until 3:00 PM on 8/26/13. Checks were done every 15 minutes from 3:30 PM until 10:30 PM. No checks were documented for 8/27/13. An " Elopement Risk Care Plan " was initiated on 8/26/13. The " Problem " was the resident was at risk for elopement R/T (related to) exit seeking behaviors The " Goal " was not indicated, and there was no target date. The Approaches and Interventions included the following: Elopement Risk assessment per Protocol Re-direct resident from doors and exit PRN (as needed) Observe for exit seeking behaviors/Patterns Encourage and assist to activities when exit seeking Use Diversion when exit seeking Personal wander prevention device Check bracelet for placement each shift Check function of bracelet daily Picture ID and face sheet in wander book Assess for wander/elopement patterns Assess for pain. The most current Minimum Data Set ((MDS) dated [DATE], revealed he had intact long and short term memory. He was able to make his needs known and had no problems with hearing, speech or vision. He had no behaviors and was depressed. He was able to walk the corridor independently; his balance while walking was unsteady. Wandering behavior was not exhibited the previous seven days. He had no impairments to his upper or lower extremities. He received antidepressant and antipsychotic medications daily. Review of the nursing notes dated 9/23/13 at 1:55 PM, revealed in part, " Resident's window was opened all the way. Safety screw not in place, screw removed, maintenance fixed both screen and screw. " Review of nursing notes dated 9/23/13 at 7:10 PM revealed, " Resident tried to go out the back door of the 300 hall, asked resident why he was leaving and stated he wanted to go home. Advised C N A to monitor due to exit seeking behaviors. " Review of nursing notes dated 9/23/13 at 7:40 PM, read in part, " Resident tried to exit again through the door by nurses station on 300 hall. Also walke (sic) up 400 hall and tried to leave out door by MDS office but was redirected. " A Physician order [REDACTED]. Review of the " Alarm response and elopement protocol " (no date) revealed In part: ? When a door alarm is sounding and the source for the alarm is not identifiable. The expectation is to exit the facility to search the surrounding areas. Behind bushes, between cars, etc .... Review of the weather for 10/24/13 revealed the temperature at Raleigh Durham Airport between 9 and 10 PM was 47 degrees with a wind at 4 miles per hour west to North West. Review of Cary police report dated 10/24/13 at 9:05 PM revealed, an officer was called to the facility for a missing person. A canine officer was deployed at 9:06 PM and arrived to the scene at 9:27 PM, the deployment time of the canine officer was 9:35 PM. Clear time ( the time the officer left the facility) was 10:19 PM. The woods were slightly illuminated from the parking lot lights. A flashlight was required to see. The canine officer went to the end of a split rail fence (off from the parking lot) and walked through 25-30 yards of woods. On the other side of the woods was an embankment that sloped down onto Tryon Road. The embankment had numerous small pine trees growing on the slope. Once at the top of the slope the canine officer turned East and in a few feet the resident was laying face down on the slope with his head towards the top of the slope. Only his head and face were observed. Blood was noted on the right side of his face. " The area where the subject (Resident #1) was located was on a slope. The slope was covered with pine straw, which made it very slippery, even for me (the officer) to walk on. The pine straw under the subject (Resident#1) had been pushed away, which indicated to me (the officer) that he (Resident#1) was trying to climb up the embankment but could not. I (the officer ) also located both of his (Resident #1) sneakers were on top of the embankment about 15 feet from where he was located. " Hospital discharge record dated 10/25/13, (time seen was 10:15 PM and discharge time was 12:05 AM), revealed a [DIAGNOSES REDACTED]. During an interview on 10/28/13 at 3:33 PM, Resident #1 indicated he got the abrasion above his right eye when he had " escaped " out of the door at the end of 300 hall. He said the alarm made a sound and he kept going. He said it was dark and he fell and laid in the dark for about an hour. He said he didn ' t want to talk any more. Observation revealed Resident #1 was standing in his doorway wearing slippers socks, sweat pants and a t-shirt and a wander guard on the left ankle. During an interview on 10/28/13 at 3:38 PM, the Maintenance Director indicated when the alarm is activated at the door, the panel at each of the nurses stations will light up. The wander guard device worked at the front door only. The other five doors can be exited after 15 seconds of pushing on the exit bar. The locking magnet would release. He indicated all doors were checked daily. To track the doors were checked the Maintenance Director logged into the computer system at 3:58 PM and demonstrated once the task was acknowledge it was completed it was removed from the screen. To ensure compliance any weekly maintenance tasks was not completed were automatically send via email to the Administrator. He indicated residents can leave the building, by " pushing the door until the door alarm sounds and the door can be open in 15 seconds " . Usually when a resident does get out the staff are able to get the resident before they leave the building. Review of " Check Operation of magnetic door locks " printed 10/28/13 revealed In part, 1. Inspect door lock mounting and operation and panic hardware on egress doors 5. Check patient transmitter to make sure the door stays locked and alarm sounds Check delayed egress operation 1. Push door release hard for a fraction of a second-door should not open and alarm should not sound 2. Apply pressure to the door release for the pre-determined nuisance period setting ( normally 1-3 seconds) 3. Door should go into irreversible unlocking sequence ? Door alarm will sound ? Door will automatically open within (15-30 Seconds) 4. Close door and reset the alarm 5. Ensure signs are place on doors adjacent to the release device that read ' Keep pushing. Door will unlock after 15 seconds. ' Test doors and hard ware for proper operation and condition Document results of inspection in log book 1. Note any discrepancies 2. Contact manufacturer with any questions During an interview on 10/28/13 at 4:00 PM, Aide #5 indicted she was not aware of a resident who had eloped recently from her assigned hall. To her knowledge all the doors were equipped with the wander guard alarm system. During an interview on 10/28/13 at 4:20 PM, Nurse #1 indicated she was working the upper hall and assisted living with Aides #1 and #2 on 10/24/13 Aide #1 came at 8:30 PM, and told her Resident #1 was missing. Nurse #2 called the Director of Nurses, the Administrator, family and police. During an interview on 10/28/13 at 4:30 PM, Aide #1 indicated he was working on 10/24/13. He was working with Aide #2 on the upper 300 hall. He indicated he told Nurse #1 he was going on break with Aide #2. He heard the 300 door alarm went off. Aide #2 said to him she saw laundry aide #2 turn off the alarm. Break ended between 8:30 PM and 8:45 PM. Three call lights were going off on the lower hall 300 hall He indicated he went into Resident #6 room, who said he saw Resident #1 go down the hall and heard the 300 hall door alarm and didn ' t see him return. Aide # 1 revealed that " (Aide #2) and I both went out to check outside. We didn ' t see (Resident #1). We got into my car and drove Tryon Road looking for him. We called (Nurse #1) and returned to the facility. An observation on 10/28/13 at 4:56 PM, was conducted with Aide #1 of the route taken to look for Resident #1. Exiting the 300 hall door looking to the right was the corner of the building. There was a dumpster, a generator and an out building. To the left was a picnic table. Straight ahead was the parking lot, with lighting. No lighting was in any other areas. A split rail fence was noted along the edge of the tree line and the woods, which ended at the end of the parking lot. Aide #1 indicated he used his cell phone for light in the dark areas. He was unable to see past the tree line into the woods. The route continued to around the front of the building where there was a long driveway which led to Tryon Road. He indicated he entered the building through the 200 hall door and reported to Nurse #1 he had not located Resident #1. During an interview on 10/28/13 at 5:55 PM, laundry aide #1 indicated 300 door alarm can be heard in the laundry room. It will continue until the code was put into the box to silence the alarm. He said the front door was the only door the wander guards worked. All other doors have the alarm that required a code to silence. He indicated he had turned off the alarm when he had seen a staff member sitting outside in the past. During an interview on 10/28/13 at 6:10 PM, Aide #2 indicated she was aware Resident #1 had made previous elopement attempts. On the evening of 10/24/13 between 8:20 -8:25 PM she and Aide #1 were coming off of break from the break room behind the nursing station, and Aide #3 was going on break. She indicated she heard the 300 hall alarm go off, she looked down the hall and saw laundry aide #2 come out of the laundry room and go to the door and turn off the alarm. Aide #2 said " I assumed he had looked to see who had gone outside. Aid #1 and I continued to work on the upper hall between 8:35 PM and 8:40 PM. We observed 3 call lights on the lower hall. (Aide #1) went into (Resident #6 room). He reported he had seen (Resident #1) go toward the exit and the alarm had gone off. (Aide #1) and I put it together and checked (Resident #1) room. We both went outside to check and reported it to (Nurse #1 and Nurse #2) and started to look for (Resident #1). We continued to look until the police took over about 9:20 PM. " During a telephone interview on 10/29/13 at 10:06 PM, laundry aide #2 indicated on 10/24/13 he was working for laundry aide #1 who was on vacation. The laundry room was divided into two areas the washer and dryer area and the folding area. The alarm was audible in the folding area. He indicated he came from the washing area to the folding area and heard the alarm. He came out of the laundry room, looked down the hall and saw two nurses sitting at the nursing station. He looked outside to see if he saw anyone. It was dark and he didn ' t see anyone. He disengaged the alarm and went back to work. He indicated the door was used heavily by staff to go out to smoke, for deliveries, and by housekeeping. He said he left at approximately 9:15 PM and was not aware a resident was missing until he was called by the administrator at 10:00 PM. He had no in-service on elopement with the facility until after the elopement. During an interview 10/29/13 at 10:54 AM, the Administrator indicated he had worked the evening of 10/24/13 as the customer care liaison which entailed the 7:00 PM smoke break. Resident #1 was at the smoke break. He indicated 5 of the doors required staff to enter a code to silence the alarm once activated upon opening the door . If the door did not latch completely it would begin to alarm after 30 seconds, until the code was entered again. He indicated he had called laundry aide #2 and asked him if he had silenced the door alarm that night. The laundry aide said yes he had silenced the alarm and had looked outside to see if anyone had left. Resident # 6 was identified by the facility as reliable and interviewable. Review of the MDS dated [DATE] revealed some long or short term memory deficit. During an interview on 10/29/13 at 11:29 AM, Resident #6 was sitting in his bed at 7:00 PM watching television. He observed, Resident #1 shuffling past his room toward the 300 exit. He heard the door alarm go off and the resident didn ' t return. The alarm continued to sound for at least 30 minutes, which was not uncommon. Unsure of the time, he rang his call bell. Aide #1 answered the call bell, he told the aide what he saw and he gave a description of the resident he saw go toward the door. During an interview on 10/29/13 at 12:04 PM, Director of Nursing (DON) indicated she did not know if everyone knew Resident #1 was at risk for elopement. The DON indicated to prevent Resident #1 from elopement he had placed a wander guard on him. It does not work at the door nearest his room where he had eloped. She indicated Resident #6 was reliable to interview. She had not interviewed him as part of her investigation. During an interview on 10/29/13 at 2:24 PM, Nurse #3 indicated she was aware of Resident #1 previous elopement attempts. Resident #1 was a smoker and indicated he wanted to go home. His gait some days was steady and other days he used the hand rail. Smoke breaks lasted approximately 15 minutes. During an observation on 10/29/13 at 2:25 PM of the 300 hall door, the activity intern entered the code to the door and entered into the building and continued down the hall. The door did not latch completely and the alarm sounded. Nurse #3 indicated this was normal she shut the door entered the security code and the door became silent. She indicated the 300 door was used by the housekeepers, and staff who smoked. There was 194 feet from the nurse ' s station down a hall, then a left turn at the corner and 20 more feet to the 300 hall exit door. The exit was not visible from the nursing station. During an interview on 10/29/13 at 3:02 PM, Aide #3 indicated on 10/24/13 he was assigned to Resident #1. He indicated Resident #1 wasn ' t exit seeking. He was standing at his doorway as usual. Aide #3 stated that night the resident had asked him a couple of times to help his room mate. He indicated the last time he saw resident #1 was at 8:20 PM standing in his room. During an interview on 10/29/13 at 4:39 PM, Nurse #2 she saw Resident #1 at 7:45 PM at his doorway. Aide #3 was in the shower room giving a shower. She indicated she (Nurse #2) was sitting at the nursing station and did not hear the door alarm. On the night of 10/24/13 at 7:55 PM, Aide #1 came and told her Resident #1 was missing. Staff searched for Resident #1 for 10 minutes, and then she called the DON and Administrator, family and the police. It took 2 hours for Resident #1 to be found. During an interview on 10/30/13 at 8:57 AM, Aide #4 indicated she worked on the evening of 10/24/13 on the same hall Resident #1 resided the last time she saw Resident #1 was at 7:00 PM. She was made aware Resident #1 was missing at 8:30 PM. During an interview on 10/31/13 at 10:39 AM, social worker indicated Resident #1 was very depressed that his roommate went out on pass often. He has stated he wanted to go home and he missed his dogs. He had a computer that got a virus from a website and the family elected not to have it fixed. During a telephone interview on 11/6/13 at 12:54 PM, police (canine) officer who located Resident #1 indicated the area was very dark where Resident #1 was found. It was very slippery and he had difficulty navigating the area. Resident #1 was lying on the ground and it looked as though he were making a snow angel in the pine needles. All the pine needles had been removed completely and the dirt was exposed. The temperature was in the 40 degree Fahrenheit range. Resident#1 was not dressed for the weather. He was bleeding and disoriented. Once the search was started it took approximately 20 minutes to locate the resident. The EMS and Rescue had to assist to get him (Resident #1) out of the wooded area. The facility was notified of the Immediate Jeopardy on 10/30/2013. The credible allegation was accepted on 10/31/2013. Credible Allegation of Compliance for Cary Health and Rehabilitation 1.Resident #1 admitted on [DATE] with [DIAGNOSES REDACTED]. Elopement risk assessment completed on 1/15/2013 determined resident was not at risk for elopement. Resident #1 has a BIMS of 14 according to the MDS with an ARD of 7/3/2013 and 9/22/2013. Resident #1 has a BIMS of 15 as of 10/31/2013. On, 8/25/2013 at approximately 9:00 AM, Resident #1 was spotted outside of the building by a Certified Nursing Assistant and was brought back into the building by the staff member. Resident #1 suffered no injuries and his vital signs were stable at that time. Resident had last been visually placed at 0830 at the nurses ' station by a staff nurse. Nurse notified Resident #1 ' s second contact who translated the information to the Responsible Party. Nurse Supervisor notified the Director of Clinical Services. MD was notified of event on 8/25/2013 and a new order was written to place Wanderguard on Resident #1. The Wanderguard was placed on Resident #1 ' s left ankle by Nurse Supervisor. At that time, there was no further exit seeking attempts noted. Visual checks every 30 minutes maintained. Resident #1 's Elopement Risk Assessment was updated along with Resident #1 ' s Plan of Care on 8/25/2013 by the Nurse Supervisor. On 10/24/2013, at approximately 8:45 pm, the alarm on the exit door alarmed at the end of 300 hall, per one Staff Nurse #1 and two Certified Nursing Assistants #1 and #2 scheduled on the unit at that time. Staff Certified Nursing Assistant witnessed the Housekeeping Supervisor walk from the laundry room toward the door on 300 hall and silence the alarm. At approximately 8:50 pm, per Certified Nursing Assistant #2 stated that the Resident in room 320 stated that a resident had shuffled past his door toward the door on 300 hall just before the alarm sounded. Certified Nursing Assistant #2 said that Resident #1 immediately came to mind and notification was made to Resident #1 ' s assigned Nurse #1, and a search for Resident #1 began at approximately 8:55 PM. Nurse #2 on unit got the elopement kit which contains flash lights, floor plan of the building for systematic checks, walkie talkie for each of the four leaders of the teams, whistles, magnetic check marks for placing on the doors of rooms to indicate areas already checked during the search process. Staff members on duty searched the interior and the exterior of the facility. Per Nurse #1, at approximately 9:02pm, notification was made to the Director of Clinical Services, local police and Resident #1 ' s Responsible Party. The Director of Clinical Services notified the Executive Director of the facility at approximately 9:03 PM. Both the Director of Clinical Services and the Executive Director immediately made their way to the building upon notification. At approximately 9:10 PM and Nurse #1 provided a description of Resident #1 as well as a picture from the elopement book. Facility staff continued their searching of the building. Then the police brought in K-9 dogs to aide in the search for the resident. At 9:23 PM the Director of Clinical Services notified the Regional Director of Clinical Services of the events surrounding Resident #1. At approximately 10:05 PM, Resident #1 was found by the police about 135 feet from the 300 hall exit door in the wooded area behind the parking lot. Resident #1 had fallen down in the wooded area. Upon assessment by the EMS, there was a noted abrasion to Resident #1 ' s head, but there were no complaints of pain and vital signs were within normal limits. First aide was provided to the abrasion by EMS. Resident #1 was taken to the emergency room for further evaluation and treatment. At approximately 9:00 PM a whole house check to account for all residents was begun. ? The residents at risk for elopement were checked for the placement of the wanderguard. ? All residents were accounted for. ? All wander guard devices were present for the residents assessed as at risk for elopement. All were checked for function on 10/24/2013. ? The elopement books that are located at each nurse ' s station and the front desk were checked for complete information on all residents at risk for elopement. ? All exit door alarms were assessed for function. All alarms were functioning properly. At approximately 1:15am on 10/25/2013, Resident #1 returned to the facility from the ER with no new orders. The resident denied any pain. Resident #1 was settled into bed with every 15 minute checks that began at that time. At approximately 3:30 pm on 10/31/2013, the MD gave a verbal order to have the wanderguard removed from Resident #1. Resident #1 will have a 1:1 staff member assigned to him until the time of his discharge to ensure that he understands the need to sign out of the building if he chooses to leave and to accompany him if he exits the building to ensure his safety. The Director of Clinical Services and/or Executive Director will ensure that the 1:1 is assigned every shift by approving the schedule the day before the assignment. The staff members assigned will be listed on the assignment sheet as dedicated to Resident #1 each shift. 2.On 10/30/2013 all other residents who have been assessed as at risk for elopement were reviewed for the appropriateness of wanderguard placement as related to cognition using the Brief Interview for Mental Status (BIMS). This criterion is a BIMS score of 12 or less as indicated by the MDS scale in order to be considered cognitively impaired. On 10/30/2013 all current residents were re-evaluated using the elopement risk assessment form to identify any other resident at risk for elopement. This will be done on admission/re admission, quarterly and with significant change. The assessment will be completed by a licensed staff nurse. The form consists of 7 yes or no questions with an answer to questions 4, 5, or 6 automatically placing the resident at risk. 1. Is the resident cognitively impaired? 2. Is the resident independently mobile (ambulatory or wheel chair)? 3. Does the resident have poor decision-making skills? 4. Has the resident demonstrated exit seeking behavior? 5. Does the resident wander oblivious to safety needs? 6. Does the resident have a history of elopement? If yes, # of times, if known:____ 7. Does the resident have the ability to exit the facility? The re-education of the staff for the elopement process was begun by the Director of Clinical Services and Executive Director for all individuals who work in the building as soon as the resident was secured. The re-education was continued by the Executive Director, Director of Clinical Services, Assistant Director of Clinical Services, Unit Managers, Regional Director of Human Resources, and Regional Director of Clinical Services. The education included: ? When a door alarm is sounding and the cause of the alarm is not identifiable, the expectations are to exit the facility to search to identify the cause of the alarm in the surrounding. ? If the source of the alarm is not identified, immediate head count of the residents is to be done. ? If a resident is determined to be missing, the elopement protocol begins. An over head announcement is made " (resident) is looking for room (resident room number) three times over head. ? At that time the building is divided into 4 teams. Each team is provided with a whistle and a walkie talkie. 1 team is assigned the outside search of the property; the other teams are searching the interior of the building. The floor plan of the building is used to assign the teams areas of the building to search. A check mark magnet is placed outside of any are that has been completely searched. ? If the resident has not been located within 10 minutes of the initial page, the Executive Director, Director of Clinical Services, police, and responsible party are to be notified while the searching continues. 100% of all current employees were re-educated by 10:00 pm on 10/25/2013, including contracted employees. Those not educated by that time were removed from the schedule until they could be re-educated prior to the start of their next scheduled shift. Per facility policy, all new employees receive elopement training during orientation prior to working an assignment. All contracted employees will also have this done prior to their first assignment. On 10/30/13 the Executive Director and Director of Clinical Services were re- educated by the Vice President of Clinical Services concerning the expectations when an elopement occurs. This includes the reporting requirements within the corporation, the investigation scope, and the interventions to be implemented. On 10/30/3013 the incident log was reviewed to ensure that no other elopement occurred that was not investigated. There were no other elopements listed. On 10/30/13, the Social Worker for Resident # 1 called for a Care Plan meeting with the resident ' s family, the interdisciplinary team, the MD, and the Ombudsman. The invitations were extended at 5pm on 10/30/2013 to have a meeting on 10/31/2013 at a time convenient to the attendees. On 10/31/2013, the family of Resident #1 arrived to attend a care plan meeting with the resident. The root cause of Resident #1 exit seeking behavior is his expectation and desire to be living at home with his family. The family was informed of the resident ' s BIMS indicating that he is cognitively intact. The meeting focused on the need to find a setting that he found acceptable with specific goals to be set leading to more time spent at home. The decision was made during the meeting to present options for an appropriate setting at an appropriate level of care per the most recent FL2 closer to home to act as a bridge to home. The BIMS was repeated today with a score of 15. The MD has given a verbal order for the cessation of wanderguard placement. Resident #1 has been evaluated and treated by psychiatric services since admission and will continue under psychiatric care. Resident#1 will be on 1:1 while in the building to ensure the resident ' s safety. This will continue until discharge. On 10/31/2013 a lap top which had been ordered for activities has arrived and been connected to the internet which will be available to Resident #1 to check out as he wishes for his entertainment. Resident #1 has also been showed where the piano is located and he has been playing the piano. 3.Beginning 10/25/2013, the facility conducted elopement drills by the Executive Director/Director of Clinical Services/Assistant Director of Nursing/ Maintenance Director every shift for 10/25/2013, 10/26/2013, and 10/27/2013, then daily x 7 days beginning 10/28/2013, y2 x week for 3 weeks, then weekly for y4 weeks to ensure staff response is appropriate. Appropriate response will be demonstrated by all alarms being responded to by staff upon sounding and determining the cause of the alarm. This will be documented on the Quality Improvement (QI) monitoring tool for Elopement Drills. Elopement drills will be conducted quarterly each shift pattern as scheduled according to the facility policy and procedure. All wanderguard devices will be checked for placement of the device on the resident at risk every shift and will have function of the device checked every day. This will be the responsibility of the staff nurse assigned to the resident. This will be documented on the MAR. All residents identified as at risk for elopement have behavior monitoring sheets that include target behavior identification of exit seeking and verbalization of exiting the facility. The behavior monitoring tool has non pharmacological interventions that are listed to be used if behavior arises. 4.An Ad-Hoc Quality Assurance Performance Improvement (QAPI) meeting was held at 3:30 pm on 10/25/13, by the Executive Director with members of the Interdisciplinary Team. At that time, the interventions and plan for correction from the elopement on 10/24/2013 were reviewed. The Interdisciplinary Team members accepted the plan that included the re-education of all employees, ongoing drill

Based on record review, facility staff, Laboratory Manager, Physician, Physician Assistant, Nurse Practioner and Medical Director interviews the facility failed to conduct [MEDICATION NAME] time (PT) and International Normalization Ratio (INR) tests as ordered to monitor [MEDICATION NAME] levels for 1 of 3 residents receiving [MEDICATION NAME] resulting in hospitalization for decreased appetite, lethargy, increased temperature, swollen and purple colored tongue, reddened chin and elevated PT/INR (Resident #2). Immediate Jeopardy (IJ) began on 12/26/11. The facility was notified of immediate jeopardy on 3/1/12 at 11:47 AM. The facility was not able to provide evidence of a system for implementing laboratory testing in the time frame ordered and how this system was monitored. The jeopardy remains present and ongoing. Findings included: Lexi-Comp's Geriatric Dosage Handbook, 12th edition, stated: [MEDICATION NAME] ([MEDICATION NAME]) is an anticoagulant medication used in [MEDICATION NAME] and treatment of [REDACTED]." Under Warnings/Precautions, the reference stated " bleeding is the major adverse effect of [MEDICATION NAME] ([MEDICATION NAME]). Hemorrhage may occur at virtually any site. " Under Adverse Reactions, the reference stated: Gastrointestinal: [MEDICAL CONDITION], anorexia, nausea, vomiting, stomach cramps, and abdominal pain. Under Monitoring Parameters: " [MEDICATION NAME] time (PT) ratio, INR (international; normalization ratio); stool guaiac (check stool for occult blood), hemoglobin, hematocrit." Lexi-Comp's Geriatric Dosage Handbook, 12th edition, stated that [MEDICATION NAME] ([MEDICATION NAME]) is a low molecular weight [MEDICATION NAME] used in the treatment of [REDACTED]. Under Adverse Reactions: " As with all anticoagulants, bleeding is the major adverse effect of [MEDICATION NAME]. Hemorrhage may occur at virtually any site. " Resident #2 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #2 ' s minimum data set admission assessment dated [DATE] revealed the resident had short and long term memory problems, was impaired for decision making and had [MEDICAL CONDITION] behaviors. The resident was totally dependent on staff for bed mobility, transfers, dressing, eating, hygiene and bathing. Brief Interview of Mental status score was 3 indicating severe cognitive impairment. Admission medications dated 12/13/11 included but not limited to: [MEDICATION NAME] 40 mg. (milligrams) subcutaneous for 5 days, (12/14/11 - 12/18/11), [MEDICATION NAME] 5 mg. for 2 days (12/13/11 and 12/14/11) " PT/INR as ordered by physician. " Record review of lab results for PT/INR dated 12/14 11 revealed PT 12.1 (normal values 11.6 - 15.2 seconds) INR 1.05 (normal values <1.50). Review of Lab result dated 12/15/11 revealed PT 12.5 and INR 1.1 A review of the physician orders [REDACTED]. for 2 days (12/15/11 and 12/16/11) then 6 mg. daily (12/17/11 on going) and PT/INR in 10 days (12/25/11). A review of the physician orders [REDACTED]. daily. Record review of the physician orders [REDACTED]. A review of the lab records indicated there was no record of the lab drawn on 12/26/11. Record review indicated the PA (Physician Assistant) came in on 1/9/12 and found the 12/26/11 lab was not done and ordered PT/INR STAT. The PT/INR dated 1/9/12 revealed PT 40.8 and INR 8.39 (HIGH). The PA ordered Vitamin K 10 mg subcutaneous, discontinue [MEDICATION NAME] and PT/INR in the am (1/10/12). Review of the lab results dated 1/10/12 revealed the PT was 46.5 and the INR was 10.50 (HIGH). The PA ordered Vitamin K 10 mg. subcutaneous now/stat and send to ER for evaluation. A phone interview with the PA on 3/1/12 at 2:00 pm revealed that she wrote the order on 12/23/11 to discontinue PT/INRs and draw a PT/INR on 12/26/11. She further stated it is her responsibility as well as the nurses to monitor [MEDICATION NAME] levels and associated labs. She further stated Resident #2 was typically seen on Mondays and Thursdays and it was during the holidays when the lab was due. The PA stated when she came in on 1/9/12 she discovered Resident #2 did not have a recent PT/INR and ordered one " STAT " and was to be called with the results. She further stated the order was written at 10:00 am and she expected the results sometime in the afternoon. When the results were known to her (telephone order received at 6:03 pm) she ordered vitamin K 10 mg. subcutaneous, discontinue [MEDICATION NAME] and to repeat the PT/INR in the AM. (1/10/12). When she received the results the next day she ordered Vitamin K 10 mg. subcutaneous and sent the resident to the hospital on [DATE]. Review of the MAR indicated [REDACTED]. at 6:00 PM on 1/9/12 Interview on 2/29/12 at 4:00 PM with the DON (Director of Nurses) revealed the nurse that took the order off the chart written on 12/23/11 which read " D/C PT/INRs, PT/INR on 12/26/11 AM " was Nurse #1 who was no longer employed. A review of the " Blood Draw Logs " for December 26, 2011 through 12/29/11 did not indicate the resident's name for a blood draw on 12/26/11. The DON continued that Nurse #2 was the weekend Supervisor, who was no longer employed, probably attempted the blood draw, and did not record it. She continued that the next blood draw was noted on January 9th and 10th, 2012, and the resident was sent to the hospital on [DATE]. When asked for the policy on [MEDICATION NAME] therapy prior to January 9, 2012 the DON stated they did not have a policy. On 2/29/12 a Phone Interview was attempted for Nurse #2. The telephone number was not valid and no other phone number was available. On 3/2/12 at 3:30 PM a phone interview was conducted with the former ADON (Assistant Director of Nurses) which revealed that the Unit Manager was responsible for medication monitoring. On 3/3/12 at 8:00 PM a phone interview with Nurse #1 revealed she transcribed the physician order [REDACTED]. She stated the policy was to fill out a lab requisition form and attach the Resident ' s face sheet to it and put it in the lab folder on the unit. She continued she did the paper work for Resident #2 and told the night nurse (not sure of her name). She continued that the next day she checked the lab folder and found the requsition was not there. When she questioned Nurse #3, Unit Manager and the ADON she was told that the lab was not necessary and Nurse #3 threw out the requisition Interview on 3/1/12 at 9:30 am with the DON and Administrator revealed that the physician order [REDACTED]. 12/26/11. On 3/2/11 at 2:31 PM an interview with the DON stated she did not have a policy on transcribing physician orders. She stated it is her expectation when you get a nursing liscense you are trained in Nursing School how to take off physician orders. She also stated they (referring to nurses) would get the hands-on experience during orientation. She further stated that she called Resident #2 ' s physician today and he agreed with her interpretation of the order not to do a PT/INR on 12/26/11. Interview with Nurse #3, Unit Manager, on 2/29/12 at 3:15 PM revealed that as the Unit Manager as well as all the nurses were responsible for monitoring residents on [MEDICATION NAME]. She continued that she was not there when this happened (referring to holiday weekend). She continued that the blood draw on 12/26/11 (Sunday) was attempted but the nurse (did not know name) was unable to draw the blood. She stated that this would be indicated on the " Laboratory Draw Log " (pointing to the binder.) The nurse taking the orders off the chart will put the blood draw in the binder on the date it is due. She continued that all the nurses check the book daily and the phlebotomist comes in the morning and checks the book. She continued that the lab person came in on Monday, December 27, 2011 and could not draw the blood and supposedly told the nurse. (She did not know the name). She continued that she did not observe any changes in Resident #2 however she did have a cough when she was admitted and this was on-going. She continued that Resident #2 had a blood draw due on January 8 or 9, 2012. She stated that she did not have an answer as to why the blood draw was not followed up on (referring to 12/26/11). She continued that if there were any changes in Resident #2 ' s condition the NAs (Nursing Assistants) would have told her or the PA as she (PA) is in the facility Monday through Thursday. She continued that the PA was in the facility on 1/10/12 and felt the resident didn ' t look right and she (PA) and the DON decided to send Resident #2 to the hospital. On 3/2/12 at 3:05 pm a phone call to Nurse #5 (Nurse who gave [MEDICATION NAME] on 1/9/12) was attempted. The 3 phone numbers were not in service. Interview with Nurse #4 on 3/2/12 at 2:17 PM revealed she noted the change in Resident #2 at approximately 2:30 pm on 1/10 12. She continued that she noticed redness around her chin. She further stated that when she asked Resident #2 to speak she noticed her tongue was swollen and dark purple and her breathing sounded like " snoring " . She continued that Resident #2 ' s O2 stat was 95% and her appetite had decreased in the past couple of days. She stated that she called the PA at 3:00 PM and the PA sent Resident #2 to the ER (emergency room ) for an evaluation. The resident left at 3:30 pm. She further stated that Nurse #3 would have been the Manger of Resident #2 ' s [MEDICATION NAME]. An interview with the DON on 3/1/12 at 9:30 am stated she checked Resident #2 ' s record and found that the resident was not acute on 1/9/12. She continued that on 1/10/12 she was not comfortable with her status and Resident #2 had a cough, an increase in the PT/INR and she was given Vitamin K on 1/9/12. She continued that there was no bleeding, no bruising and no blood in the urine or stool and no clinical indication of [MEDICATION NAME] toxicity. She continued that on 1/9/12 when the PT/INR was drawn there was no history or indication that her INR would be high because she had been stable previously. She continued that the facility staff discontinued the PT/INRs because of the order written on 12/23/11. The DON further stated when the order was written on 1/9/12 for the STAT PT/INR it was done because the PA ordered it. She further stated that she spoke with the Resident #2 ' s doctor today and asked him about the order on 12/23/11, and he stated he wanted the PT/INRs discontinued on 12/26/11. When the DON was asked about a policy and procedure for PT/INRs ' monitoring she stated it was just done on February 1, 2012. She continued that the facility did not have a policy in place prior to February 1, 2012. She continued that the nurses have the lab logs and the anticoagulation logs and when the lab is drawn the PT/INR and the dosage and the next lab draw date is put on the sheet. She further stated that the nurse would notify the physician and he will indicate if there is a new order. She continued that the new management company, (name of company) took over January 1, 2012 and everything should be implemented by March 1, 2012. The DON produced an anticoagulant flow sheet for Resident #2 which she stated was kept in the anticoagulation log which is kept at the nurses ' station. On 3/1/12 at 9:45 am an interview with Resident #2 ' s physician, revealed the order written on 12/23/11 to discontinue PT/INRs and PT/INR on 12/26/11 meant to draw a PT/INR on 12/26/11. He further stated that he was out of town for the week and his partner or PA should have been notified that it was not done. He continued that the next time he knew of anything was on 1/9/12 when the PT/INR was elevated, and on 1/10/12 when it was still elevated Resident #2 was sent to the Hospital. On 3/1/12 at 1:30 pm an interview with the Medical Director, indicated the order on 12/23/11 was to be interpreted to do the PT/INR on 12/26/11. On 3/2/12 at 2:20 PM interview with the FNP (Family Nurse Practioner) revealed it is the NP/MD responsibility to monitor the PT/INR of the residents ' and expected the nurses to also make sure there is monitoring of a resident on [MEDICATION NAME]. She stated she expects the nurses to know when the labs are due to be drawn and she also stated she expects the nurses to be aware of the lab values before giving this medication. She continued that a drug like [MEDICATION NAME] should be monitored every 10 days or 2 weeks if long term, but initially it should be done more frequently. She stated if a dose is bumped up the resident should be monitored in 2-3 days unless specifically documented and if there is a STAT lab ordered, the medication should not be given until the stat lab result is obtained, then call the MD for further orders. A review of the nurses notes dated 1/10/12 " 7-3:30 pm " revealed the resident ' s condition changed, evaluation revealed the resident had decreased level of consciousness, tongue and face color change from pale to red at chin and neck bilaterally and tongue dark purple with swelling. At 3:00 pm a call was placed to the PA and a new order was received to send the resident to the hospital. The resident left at 3:30 PM via Emergency Medical Services. A review of the Hospital records dated 1/11/12 revealed: " The patient was admitted to the hospital with [REDACTED]. She was noted to have a purplish-blue tongue on admission as well as lethargy " and had an elevated INR greater than 11 on admission. The resident was given 4 units of fresh frozen plasma and 10 mg. of Vitamin K subcutaneously. The resident was intubated as a precautionary measure. The resident was discharged back to the facility on [DATE] and discharged home on[DATE].

Based on record review, interviews with facility staff, laboratory manager, physician, physician assistant, nurse practioner and the medical director, the facility failed to conduct [MEDICATION NAME] time (PT) and International Normalization Ratio (INR) tests as ordered to monitor coagulation status for 1 of 3 residents receiving [MEDICATION NAME] resulting in hospitalization for decreased appetite, lethargy, increased temperature, swollen and purple colored tongue, reddened chin and elevated PT/INR (Resident #2). Immediate Jeopardy (IJ) began on 12/26/11. The facility was notified of immediate jeopardy on 03/01/12 at 11:47 AM. The facility provided a credible allegation of compliance on 03/15/12. The immediate jeopardy was removed effective 03/13/12 during a survey on 03/20/12. The credible allegation of compliance was validated on 03/20/12. Validation of the Credible Allegation of Compliance was accomplished through record reviews and interviews with nursing staff, unit managers, director of nursing, and administrator. The facility provided evidence of the audits that were conducted to ensure that the laboratory tests were done as ordered by residents' physicians. The facility provided evidence of policy and procedures for ordering and monitoring laboratory tests. The facility provided evidence of in-services of all nursing staff regarding the process of handling laboratory tests for anticoagulation monitoring. The validation process included record review of sampled residents that had orders for anticoagulation monitoring to make sure laboratory tests were done as ordered. The validation process included review of the facility's monitoring tools, which demonstrated active and ongoing monitoring of laboratory tests for anticoagulation therapy Based on staff interviews and record review, the immediate jeopardy was removed during the survey dated 03/20/12. The facility remained out of compliance at a Scope and Severity level "D"- an isolated deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility will remain out of compliance until it provides an acceptable plan of correction and the facility's corrective measures could be reviewed and evaluated by the Quality Assurance committee.