Every finding on record at Liberty Commons Nursing & Rehabilitation Center of

Based on record review, and interviews with residents and staff, the facility failed to resolve repeat concerns and/or to communicate the facility's efforts to address concerns voiced during organized resident group meetings (Resident Council and Dietary Council) related to call-light response times, housekeeping services, and dietary services during 6 of 6 monthly meetings (May 2025, June 2025, July 2025, August 2025, September 2025, and October 2025).The findings included:Resident Council Meeting Minutes dated 5/28/2025 included concerns related to housekeeping services, ice, water, snacks, call light strings needing to be fixed, and a resident being told that there was no gauze in the facility. The minutes indicated that Dietary had been marked off the agenda and no dietary concerns were included in the Resident Council minutes. The Resident Council Communication Form attached to the 5/28/2025 meeting minutes indicated the concerns about strings on call lights and a lack of gauze in the building were the only issues addressed. There was no documentation showing that dietary concern or housekeeping concerns were addressed or resolved.Resident Council Meeting Minutes dated 6/30/2025 identified concerns related to call-light response times and room cleaning. The Resident Council Communication Form attached to the 6/30/2025 meeting minutes indicated that Administrator spoke with staff and encouraged them to answer call lights promptly and administrator stated several new housekeeping staff had been hired and were orienting. Resident Council Meeting Minutes dated 7/31/2025 showed repeat concerns related to call-light response times and room cleaning noted in June.The Resident Council Communication Form attached to the 7/31/2025 revealed there was no documented evidence of facility response or resolution to the repeat concerns related to call-light response times and room cleaning.Resident Council Meeting Minutes dated 8/27/2025 showed repeat concerns related to call-light response times and room cleaning.The Resident Council Communication Form attached to the 8/27/2025 meeting minutes indicated staff received routine customer service education, management would continue to monitor call lights and the Environmental Services Supervisor was to meet with housekeeping staff.Resident Council Meeting Minutes dated 9/30/2025 again included repeat concerns regarding call-light response times and room cleaning.The Resident Council Communication Form attached to the 9/30/2025 meeting minutes indicated call lights response time being monitored by camera. Resident Council Meeting Minutes dated 10/30/2025 documented resident concerns regarding menu choices, call bell response times and rooms cleaning.The Resident Council Communication Form attached to the 10/30/2025 meeting minutes stated to continue to monitor call lights via camera and a housekeeping meeting was to be held by the Environmental Services Supervisor. On 11/18/2025 at 2:30 PM interviews with Resident #18, Resident #5, Resident #37, Resident #49, Resident #61, Resident #91 and Resident #6 revealed that dietary issues, call light concerns and housekeeping concerns were ongoing and remained unresolved. Residents stated they had been expressing these same concerns for months with no resolution. Residents stated they were no longer able to voice food concerns during Resident Council because a separate Dietary Council had been created. Residents stated that they had many complaints about food and were told by the Activities Director to tell the Dietary Manager, but the residents did not feel as if he (the Dietary Manager) was approachable. The residents indicated that whenever they attempted to bring up food concerns to the Dietary Manager, he would shrug them off or dismiss their concerns. The residents could not recall the date of the last Dietary Council meeting or if the Dietary Manager attended. They stated whenever the Dietary Manager did attend, he sat quietly rolling his eyes to the point they would be hesitant to voice any concerns. The residents reported that the Dietary Manager did not attend any Resident Council meetings but if they brought up a food complaint they would be told by Activities Director to wait and discuss it at Dietary Council meeting. Residents reported they did not receive updates regarding any actions taken or resolutions for concerns voiced during the Resident Council or Dietary Council meetings. An interview conducted with the Activities Director on 11/18/2025 at 4:50 PM revealed she documented Resident Council minutes, took the concerns from the minutes to the Administrator, and the Administrator completed the Resident Council Communication Forms. The Activities Director stated she did not bring resolved or pending issues back to the next Resident Council meetings, she just verbally communicated the resolution to the resident that voiced the complaint. She verified that residents did voice repeat concerns about housekeeping and call light response times at the Resident Council meetings. The Activities Director stated she started Dietary Council meetings in May 2025 so that the Resident Council meetings were not taken over with dietary concerns. She indicated that Dietary Council meetings normally took place a few days before the Resident Council meetings, but she could not remember any dates of the Dietary Council meetings. The Activities Director explained that she did not keep formal minutes from Dietary Council meetings and could not locate the notes she kept in a notebook. The Activities Director further explained she did not submit grievances/concerns voiced during the meetings to the Administrator because the Dietary Manager attended the Dietary Council meetings. She reported she could not recall all of the concerns discussed at Dietary Council meetings, but she did recall concerns about food quality. She stated that she did not believe that residents were told that they could not bring up dietary concerns at Resident Council meetings. She added that the residents were encouraged to come to the Dietary Council meetings. The Activities Director stated that she marked Dietary off of the agenda at Resident Council meetings because those issues were already discussed at the Dietary Council meetings. An interview with the Dietary Manager on 11/18/2025 at 4:43 PM revealed he attended the Dietary Council meetings when he was able to do so. He stated that he could not recall the last Dietary Council meeting he attended but he was not receiving any complaints about the food. He reported the only food complaint he recalled receiving was about tuna casserole and he took it off the menu. The Dietary Manager stated that to his knowledge, no documentation or grievances were completed from the Dietary Council meetings. The Dietary Manager stated that he did not attend any Resident Council meetings. He indicated he was not receiving any grievances or complaints about food or dietary services from the Resident Council meetings. In an interview with the Administrator at 11/18/2025 at 4:00 PM she stated that a separate Dietary Council had been created in May 2025 because Resident Council meetings were taken over with food complaints. The Administrator stated that no meeting minutes were kept for Dietary Council meetings. The Administrator stated she expected the Activities Director to inform Resident Council members of resolutions for concerns discussed during Resident Council meetings. She revealed that she did not know how or if this occurred. The Administrator stated she addressed some concerns verbally with residents but did not document the follow-up. She reported that she felt she addressed all the issues from Resident Council meetings and she only did a grievance if she felt it was necessary. She indicated that it tended to be the same residents coming to the Resident Council meeting and some of them were difficult to appease. She stated that she felt the call light issue was an isolated issue rather than a facility issue as it was the same resident over and over voicing the concern. The Administrator acknowledged that she was aware that some of the residents found the Dietary Manager difficult to approach and stated that he (the Dietary Manager) could be passionate about his menu. The Administrator further stated that she would step in and handle any dietary issues that were not being addressed, but she was not aware that residents were not happy about the menu or the food being served. An additional interview was conducted with the Administrator on 11/19/2025 at 10:58 am. The Administrator stated residents could still bring food concerns to Resident Council, but she did not know what concerns were addressed in Dietary Council meetings. The Administrator was not aware that residents felt they could only bring food concerns up at the Dietary Council meetings.

Based on record review and staff interviews, the facility failed to accurately code a Minimum Data Set Assessment for prosthetics for 1 of 24 residents reviewed for accuracy of assessments (Resident #12).The findings included:Resident #12 was admitted to the facility on [DATE] with diagnoses which included bilateral below the knee amputations and hemiplegia (paralysis on one side of the body) and hemiparesis (partial weakness on one side of the body) following cerebral infarction. Review of Resident #12's care plan with a revision date of 6/4/25 revealed a focus for bilateral below the knee amputations and the use of bilateral prosthetic legs. Review of Resident #12's quarterly Minimum Data Assessment (MDS) dated [DATE] revealed he was not coded for limb prothesis. During an interview with the MDS Coordinator on 11/19/25 at 4:42 pm, she stated the MDS should have indicated Resident #12 had bilateral below the knee prosthetics and this had been an error. She verified that the Minimum Data Set Assessment was inaccurate and MDS should have been coded correctly. During an interview with the Administrator on 8/7/25 at 2:00 pm, she stated the MDS assessments should have been coded accurately for Resident #12's bilateral below the knee prosthetics.

Based on record review and staff interviews, the facility failed to include the use of supplemental oxygen on the baseline care plan for 1 of 2 residents reviewed for baseline care plans (Resident #54).Findings included:A review of Resident #54's hospital's Discharge summary dated [DATE] did not indicate the use of oxygen while Resident #54 was in the hospital.Resident #54 was admitted to the facility on [DATE]. Diagnoses included atherosclerotic heart disease and chronic idiopathic (unknown cause) venous hypertension with ulcers to both lower legs.Nursing documentation dated 11/10/2025 at 8:58pm by Nurse #2 recorded Resident #54 was receiving oxygen by nasal cannula oxygen.Resident # 54's baseline care plan dated 11/12/2025 included focus areas for pressure ulcers and non-pressure ulcer wound care, use of pain medications and anti-anxiety medications and the use of a peripheral inserted central catheter (PICC) for administration of intravenous antibiotics. The use of oxygen was not included as a focus area on Resident #54's baseline care plan.In an interview with MDS (Minimum Data Set) Nurse #1 on 11/20/2025 at 11:08am, she stated the MDS Coordinator would have started Resident #54's baseline care plan on admission. She stated on 11/16/2025, she completed Resident #54's MDS assessment for the use of oxygen and should have updated the baseline care plan for the use of oxygen at that time.In an interview with MDS Coordinator on 11/20/2025 at 11:14am, she explained she was not aware that Resident #54 had been receiving oxygen since admission to the facility. She explained the reason there was no focus area for the use of oxygen on Resident #54's baseline care plan was because there was no physician order on Resident #54's EMR when admitted to the facility. The MDS Coordinator further stated Resident #54's baseline care plan should have been updated after assessed by MDS Nurse #1 for the use on oxygen on 11/16/2025.In an interview with the Administrator on 11/20/2025 at 12:54pm, she stated Resident #54's admission orders were discussed the following morning in the clinical morning meeting. She explained Resident #54's discharge orders from the hospital did not include an order for oxygen therapy that led the MDS Coordinator not to include a focus for oxygen therapy on Resident #54's baseline care plan. She stated the individualized person-centered baseline care plan should be accurate and updated as needed.

Based on record review and staff interviews, the facility failed to complete quarterly smoking assessments for 1 of 1 resident reviewed for smoking (Resident #23).The findings included: Review of the facility's smoking policy dated 2/2025 revealed a smoking assessment must be completed upon admission, quarterly, and upon changes in the resident's condition. Resident #23 was admitted to the facility on [DATE] with diagnoses which included hypertension, muscle weakness, dementia, and blindness in one eye. Review of Resident #23's annual Minimum Data Set (MDS) dated [DATE] revealed the resident was coded for tobacco use. Review of Resident #23's quarterly MDS dated [DATE] revealed the resident was moderately cognitively impaired and needed assistance for most activities of daily living (ADL). The MDS indicated Resident #23's mobility device was a wheelchair. Resident #23 was coded for tobacco use. Review of Resident #23's smoking assessments revealed smoking assessments were completed on 2/28/25 and 11/13/25. Review of Resident #23's care plan dated 11/17/25 revealed the resident was a supervised smoker. The goal was for Resident #23's smoking related injuries to be minimized with intervention through next review. Interventions included smoking assessment to be completed quarterly per facility policy. Resident #23 was observed smoking on 11/19/25 at 9:18 am. Resident #23 was supervised while smoking and no concerns or issues were noted. An interview was conducted with Team Leader #1, who was a nurse, on 11/18/25 at 2:30 pm and she revealed smoking assessments were expected to be completed quarterly by the Team Leaders and/or the Assistant Director of Nursing (ADON). Team Leader #1 indicated nurses were notified by the computer what assessments were pending and needed to be completed during their shift, and they were expected to do so. Team Leader #1 indicated she was not aware Resident #23's smoking assessments had not been completed quarterly. During an interview with the Assistant Director of Nursing (ADON) on 11/20/25 at 12:30 pm, she revealed Resident #23 was the only smoker in the facility. The ADON indicated the computer system notified staff when a resident's assessment needed to be completed. The ADON explained that the Team Leaders were responsible for completing the smoking assessments quarterly; however, other members of the management staff could complete the smoking assessments if the Team Leaders were busy. The ADON further indicated she completed Resident # 23's smoking assessment on 11/13/25. The ADON stated she was not aware that Resident #23 had missing smoking assessments. The Administrator was interviewed on 11/20/2025 12:16 pm and indicated her expectations were that the smoking assessments should be completely quarterly as stated in the smoking policy.

Based on record review, observations, and staff and Physician interviews, the facility failed to perform a weekly dressing change to a resident's peripherally inserted central catheter (PICC), a long, thin tube inserted through a vein in your arm and passed through the larger veins near your heart to deliver medication and/or treatment, as ordered for 1 of 1 resident sampled for receiving antibiotics intravenously (inside the vein) through a PICC line (Resident #54). Findings included:Resident #54 was admitted to the facility on [DATE] and diagnoses included chronic idiopathic (cause unknown) venous hypertension with ulcers to both lower legs. A review of the hospital's Discharge summary dated [DATE] included an order to flush the PICC line with heparin 10 units per milliliter every 12 hours. There were no orders for PICC dressing change. Physician orders dated 11/10/2025 included an order to change PICC line dressing with sterile procedure weekly and as needed, measure the length of the exposed catheter to check for migration every day shift every Friday for line care.An incomplete in process admission Minimum Data Set (MDS) assessment indicated Resident #54 was moderately cognitively impaired, was receiving intravenous antibiotics and had an intravenous access. Resident #54's baseline care plan dated 11/12/2025 included a focus for intravenous medications via PICC with risk for complications such as infection and infiltration. Interventions included performing dressing change to site per protocol and inspecting the site for redness, inflammation, bruising or change in location and reporting to MD if noted. There was no nursing documentation that Resident #54's PICC dressing had been changed since admission.A review of the November 2025 Medication Administration Record (MAR) recorded Nurse #1 documented NA (not applicable) on Friday, 11/14/2025, for changing the PICC dressing. On 11/17/2025 at 12:43pm, Resident #54's transparent PICC dressing was observed dated 11/10/2025. The PICC site was observed with no redness, swelling or drainage underneath the transparent dressing. In an interview with Nurse #1 on 11/18/2025 at 5:54pm, she stated she did not change the PICC dressing as ordered on 11/14/2025 because she knew the PICC dressing was to be changed every 7 days and the 14th was only 4 days from the date on the PICC dressing. She explained she discussed the PICC dressing with someone (unable to recall who) on 11/14/25 and was told to record NA since the dressing was not due to be changed. Nurse #1 stated the team leaders enter admission orders into the electronic medical record (EMR) and she did not recall informing or discussing with the team leaders changing the PICC dressing order to reflect 7 days from 11/10/2025. She explained the November MAR was not prompting a PICC dressing change for 11/17/2025 and she did not work on 11/17/2025 when the PICC dressing should have been changed. On 11/19/2025 at 11:45am, Resident #54's transparent PICC dressing was observed dated 11/10/2025. The site was observed with no swelling, redness or drainage under the transparent dressing. In an interview with Nurse #1 on 11/19/2025 at 11:50 am, she stated she didn't know who was responsible for changing the PICC dressing. She stated she reported to Team Leader #1 on 11/18/2025 the PICC dressing had not been changed 11/14/2025 and the Team Leader reported the wound nurse was to change the PICC dressing. Nurse #1 stated she would add changing the PICC dressing to her list to complete on 11/19/2025 if not changed by the wound nurse, who was responsible for changing the PICC dressing. In an interview with Team Leader #1 on 11/19/2025 at 11:54am, she stated she wasn't aware who entered the PICC dressing to be changed on 11/14/2025 because the policy stated to change PICC dressing every 7 days. In a follow up interview with Team Leader #1 on 11/19/2025 at 12:24 pm, she stated Nurse #1 should have changed the PICC dressing on 11/14/2025 as ordered and clarified that the assigned nurses to Resident #54 were responsible to change the PICC dressing, not the wound nurse.On 11/19/2025 at 3:34pm, Nurse #1, assisted by the Staff Development Coordinator (SDC) Nurse, was observed using enhanced barrier precautions and sterile technique to change Resident #54's PICC dressing. The PICC insertion site was without redness, swelling or drainage. Resident #54 voiced no complaints of tenderness at the PICC site. The PICC catheter was measured at 13 centimeters and the site as cleansed, secured and dressed using a new transparent dressing. In an interview with the Assistant Director of Nursing on 11/20/2025 at 11:24am, she stated she entered the order for Resident #54's PICC dressing on 11/10/25 and chose Fridays as the day to change the PICC dressing weekly starting on 11/14/2025. She explained the MAR was set to trigger Nurse #1 to change the PICC dressing on 11/14/202, and Nurse #1 should have changed the PICC dressing on 11/14/2025. The ADON explained there was nothing wrong with changing a PICC dressing before the 7-day period. On 11/20/2025 at 10:33am in an interview with the Director of Nursing, she stated Nurse #1 did not inform her on 11/18/2025 that Resident #54's PICC line dressing had not been changed. She explained the PICC dressing should have been ordered to be changed in the first 24 hours to assess and document the site and scheduled every 7-day dressing change from that date. She explained there was an order to change the PICC dressing on 11/14/2025 and Nurse #1 should have changed Resident #54's PICC dressing on 11/14/2025 as ordered. On 11/20/2025 at 12:38 pm in a phone interview with Physician #1, he explained he was unable to observe the PICC site directly due to the net dressing covering the transparent PICC dressing when he visited Resident #54 on 11/19/2025 and observed no signs of infection in the area of the PICC dressing. He stated the PICC dressing should have been changed per the facility's policy in the 7-day period. He explained there were no clinical concerns or harm to Resident #54 because the PICC dressing was not changed due to no reports or observation of sign of infection to the PICC site. In an interview with the Administrator on 11/19/2025 at 2:03 pm, she stated Resident #54's PICC dressing was to be changed by the assigned nurse.On 11/20/2025 at 12:53pm in an interview with Administrator, she stated Nurse #1 should have followed physician order and facility's policy to change Resident #54's PICC dressing.

Based on record review, observations, and resident and staff interviews, the facility (a) failed to obtain a physician order for the use of oxygen and (b) failed to place signage outside the resident's door indicating the use of oxygen for 1 of 2 residents reviewed for oxygen use (Resident #54).Findings included:(a) Resident #54 was admitted to the facility on [DATE] and diagnoses included atherosclerotic heart disease. A review of the hospital discharge orders dated 11/10/2025 did not include orders for oxygen therapy for Resident #54. A review of the physician progress notes included no record of Resident#54 receiving oxygen.In an interview with Nurse #1 on 11/18/2025 at 4:50pm, she stated the assigned team leader on 11/10/2025 was responsible for entering the oxygen order. In a follow-up interview with Nurse #1 on 11/20/2025 at 7:50 am, she stated she was the nurse assigned to Resident #54 on 11/10/2025 and was unable to recall receiving report from the hospital that Resident #54 was receiving oxygen or that Resident #54 was wearing oxygen when arriving to the facility. Nursing documentation dated 11/10/2025 at 8:58pm by Nurse #2 recorded Resident #54 was receiving oxygen by nasal cannula oxygen and oxygen saturation was recorded at 91 percent (normal range 95-100%). There was no nursing documentation of the amount of oxygen Resident #54 was receiving. In a phone interview with Nurse #2 on 11/20/2025 at 9:10am, she stated she thought Resident #54's room was already set up for oxygen on 11/10/2025 before she started her shift at 7:00pm and could not recall if oxygen in use signage was placed outside the door. She explained she usually checked for oxygen therapy orders and didn't know why she did not check for Resident #54. There was further nursing documentation on 11/14/2025 at 11:36pm, 11/5/2025 at 11:58pm and 11/17/2025 at 12:18 am by Nurse #5 that Resident #54 was receiving oxygen via nasal cannula. There was no nursing documentation of the amount of oxygen Resident #54 was receiving. An attempt to interview Nurse #5 was unsuccessful.MDS (Minimum Data Set) Nurse #1 documented on 11/16/2025 that Resident #54 was receiving oxygen via nasal cannula. There was no documentation of the amount of oxygen Resident #54 was receiving.In an interview with MDS Nurse #1 on 11/20/2025 at 11:08am, she stated on 11/16/2025 Resident #54's MDS assessment for the use of oxygen was completed and Resident #54's MDS assessment was coded for the use of oxygen. She explained data for Resident #54's MDS assessment continued to be completed and was currently incomplete. She explained she was not aware there was no order for oxygen therapy in the EMR (Electronic Medical Record). She stated residents receiving oxygen therapy should have an order in the EMR. Nursing documentation on 11/17/2025 at 8:17pm by Nurse #4 documented Resident #54 was receiving oxygen via nasal cannula. There was no nursing documentation of the amount of oxygen Resident #54 was receiving. In a phone interview with Nurse #4 on 11/20/2025 at 8:52am, she stated she thought she had prompted the oxygen orders in the EMR for Resident #54's oxygen therapy when assigned to Resident #54 on 11/17/2025. She explained when there was no order for Resident #54's oxygen therapy, nursing staff should have told the team leader or entered an order. She stated she did not know why there was no order for oxygen in Resident #54's EMR. She stated it was an oversight by herself and the nursing staff. There was no documentation of oxygen use on the Medication Administration Record (MAR) or the Treatment Administration Record (TAR) from 11/10/2025 to 11/18/2025. On 11/17/2025 at 12:43pm, Resident #54 was observed receiving oxygen therapy at two liters per minute via nasal cannula.On 11/17/2025 at 12:44pm in an interview with Resident #54, she stated she started using oxygen while in the hospital and had been receiving oxygen since her admission to the facility. In an interview on 11/18/2025 at 5:22pm with Team Leader #2, she stated nursing staff were responsible to obtain an order for oxygen when oxygen was in use and place signage indicating no smoking, oxygen in use outside the door. She explained the central supply personnel would set up the concentrator and place the sign on the door when an oxygen order was included in the discharge orders. She stated the team leaders reviewed the admission orders and entered the orders into the EMR when residents were admitted before 5:00pm and the assigned nurse was responsible after 5:00pm. Team Leader #2 stated she did not know exactly what time Resident#54 arrived at the facility on 11/10/2025 and she did not know why there was no order for oxygen therapy for Resident #54 on the EMR. In an interview with Team Leader #1 on 11/19/2025 at 11:54am, she explained there was no order on Resident #54's chart prior to the evening hours of 11/18/2025 when she showed Nurse #1 how to activate the orders for oxygen therapy for Resident #54 who was receiving oxygen. She stated Resident #54 had been receiving oxygen therapy since admission and should have had an order. Team Leader #1 stated she was not working on 11/10/2025 when Resident #54 was admitted to the facility. A physician order transcribed on 11/18/2025 at 5:01pm by Nurse #1 included oxygen via nasal cannula at 2 liters per minute. (b) There was nursing documentation that Resident #54 was receiving oxygen on the following dates: * On 11/10/2025 at 8:58pm Nurse #2 recorded Resident #54 was receiving oxygen by nasal cannula oxygen. * On 11/14/2025 at 11:36pm, 11/5/2025 at 11:58pm and 11/17/2025 at 12:18 am Nurse #5 recorded that Resident #54 was receiving oxygen via nasal cannula.* On 11/16/2025, MDS Nurse #1 documented on 11/16/2025 that Resident #54 was receiving oxygen via nasal cannula.* On 11/17/2025 at 8:17pm, Nurse #4 documented Resident #54 was receiving oxygen via nasal cannula. In a phone interview with Nurse #2 on 11/20/2025 at 9:10am, she stated she thought Resident #54's room was already set up for oxygen on 11/10/2025 before she started her shift at 7:00pm and could not recall if oxygen in use signage was placed outside the door. She explained she usually checked that signage was posted outside the door for residents receiving oxygen therapy and didn't know why she did not check for Resident #54. An attempt to interview Nurse #5 was unsuccessful.In an interview with MDS Nurse #1 on 11/20/2025 at 11:08am, she stated on 11/16/2025 Resident #54's MDS assessment for the use of oxygen was completed and Resident #54's MDS assessment was coded for the use of oxygen. She explained she was not aware there was no signage for oxygen use outside Resident #54's door. She stated residents receiving oxygen therapy should have signage outside the resident's door indicating oxygen was in use. In a phone interview with Nurse #4 on 11/20/2025 at 8:52am, she stated there should be signage outside Resident #54's door for oxygen in use. She stated she did not know why there was no oxygen in use sign outside Resident #54's door and it was an oversight by herself and the nursing staff. On 11/17/2025 at 12:43pm, Resident #54 was observed receiving oxygen therapy at two liters per minute via nasal cannula. There was no oxygen in use signage observed outside Resident #54's door that indicated Resident #54 was using oxygen. On 11/17/2025 at 12:44pm in an interview with Resident #54, she stated she started using oxygen while in the hospital and had been receiving oxygen since her admission to the facility on [DATE]. On 11/17/2025 at 12:43pm, Resident #54 was observed receiving oxygen therapy at two liters per minute via nasal cannula and there was no signage outside Resident #54's door indicating oxygen was in use. On 11/17/2025 at 12:44pm in an interview with Resident #54, she stated she started using oxygen while in the hospital and had been receiving oxygen since her admission to the facility. There was no documentation of oxygen use on the Medication Administration Record (MAR) or the Treatment Administration Record (TAR) from 11/10/2025 to 11/18/2025. In an interview with Nurse #1 on 11/18/2025 at 4:50pm, she stated the assigned team leader on 11/10/2025 was responsible for putting the oxygen use signage on Resident #54's door. In a follow-up interview with Nurse #1 on 11/20/2025 at 7:50 am, she stated she was the nurse assigned to Resident #54 on 11/10/2025 and was unable to recall receiving report from the hospital that Resident #54 was receiving oxygen or that Resident #54 was wearing oxygen when arriving to the facility. In an interview on 11/18/2025 at 5:22pm with Team Leader #2, she stated nursing staff were responsible to place signage indicating no smoking, oxygen in use outside the door. She explained the central supply personnel would set up the concentrator and place the sign on the door when an oxygen order was included in the discharge orders. She stated the team leaders placed the oxygen use sign on the door when residents were admitted before 5:00pm and nursing staff were responsible after 5:00pm. Team Leader #2 stated she did not know exactly what time Resident#54 arrived at the facility on 11/10/2025 and she did not know why there was no signage of oxygen in use outside Resident #54's door. On 11/20/2025 at 10:33am in an interview with the Director of Nursing, she stated nursing staff needed to ensure there was an order on Resident #54's EMR for oxygen therapy and signage indicating oxygen was in use was posted outside Resident #54's door. She explained that the assigned team leaders or the admission nurse (Nurse #1) would have been responsible for clarifying with the physician and entering oxygen orders and ensuring an oxygen in use sign was posted outside Resident #54's door. She further stated all licensed nurses could enter orders into the EMR and all nursing staff could post the oxygen in use signage on the door when oxygen therapy was in use. On 11/20/2025 at 12:53pm in an interview with Administrator, she explained new admissions and their admission orders were discussed in clinical morning meetings and because Resident #54's hospital discharge orders did not include oxygen therapy, the interdisciplinary team members were not aware Resident #54 was receiving oxygen and needed an order for oxygen. She further explained the facility had a standing order for oxygen therapy and nursing staff should have transcribed the standing order into the EMR and placed signage oxygen in use outside the door when Resident #54 was admitted using oxygen and continued to use oxygen.

Based on record review, and staff and Ombudsman interviews, the facility failed to send a copy of the notice of transfer to the Long-Term Care (LTC) Ombudsman for 1 of 2 residents transferred to the hospital (Resident #103).The findings included:Resident #103 was admitted on [DATE].A review of a progress note dated 8/23/2025 indicated Resident #103 was transferred to the hospital. Resident #103 did not return to the facility.An interview on 11/19/2025 at 11:20 am with the Social Services Director revealed the social services department notified the Ombudsman via email about discharges/transfers. The Social Services Director could not see in facility records that the Ombudsman was notified of the August discharges or transfers or any transfers regarding Resident #103. An interview with the LTC Ombudsman for facility on 11/19/2025 at 12:00 pm revealed the Ombudsman did not receive notification of any discharges/transfers for August from the facility. The Ombudsman further stated they did not receive any information regarding Resident #103's transfer or discharge.On 11/19/2025 at 2:00 pm an interview with the Administrator revealed her expectation was for staff to make certain that the Ombudsman received discharges/transfers monthly the way the Ombudsman had requested to receive the notices. The Administrator acknowledged the facility did not send the email for August but could show documentation for September and October. The Administrator did not know why the email was not sent to the Ombudsman in August.

Based on interviews with staff and record review, the facility failed to ensure 1 of 1 resident (Residents #58) who had diagnoses of schizophrenia and anxiety had a Preadmission Screening and Resident Review (PASRR) prior to admission. The findings were: The North Carolina Medicaid Uniform Screening Tool (NC MUST) record for Resident #58 revealed the resident had a Level II PASRR for serious mental illness in place from 4/02/15 through 3/29/22. On 3/30/22 Resident #58 was changed to a Level I PASRR. There was no evidence a PASRR screening was conducted since 3/30/22. Resident #58 was admitted to the facility on [DATE] with diagnoses including schizophrenia and anxiety disorder. Review of Resident #58's quarterly Minimum Data Set (MDS) dated [DATE] revealed he had severe cognitive impairment, no behaviors, had diagnoses of schizophrenia and anxiety disorder, and had not received psychotropic medication in the past 7 days. Review of Resident #58's progress notes revealed a note by the Social Worker dated 6/18/24 indicating Resident #58 was going to be moved to a long-term care hall for continued facility care. In an interview on 7/09/24 at 3:17 PM, the Administrator revealed Resident #58's PASRR dated 3/30/22 was the Level I PASRR received from the hospital prior to the resident's 4/18/24 admission. She explained, when a resident was admitted for short-term rehabilitation, the facility did not submit a new Level I PASRR to the state until they knew if a resident was going to transition to long-term care. The Administrator further explained, a new Level I PASRR was not submitted because the facility did not know if he was going to stay long term. Once that decision was made, a new PASRR request would be submitted. The Administrator said the Social Worker was going to submit a PASRR request on 7/09/24 because a decision had recently been made that he would be staying for long-term care. The Administrator was not aware residents diagnosed with a serious mental illnees required a PASRR evaluation prior to admission. In an interview on 7/10/24 at 9:05 AM, the Marketing Director said the facility accepted the PASRR that was submitted by the hospital when a resident was admitted . The policy in the facility was to accept a PASRR that was open and active, regardless of how old it was. The facility would not submit a new Level I PASRR at admission and would use the information in the state PASRR system.

Based on record review, staff interviews, and a physician interview, the facility failed to ensure a collected urine specimen was delivered to the laboratory for an analysis for 1 of 1 resident reviewed for urinary tract infections and urinary catheters. This resulted in another urine specimen having to be collected for analysis and delayed the start of treatment for a urinary tract infection (Resident #73). The findings included: Resident #73 was admitted to the facility on [DATE] with diagnoses including pneumonia. Nursing documentation dated 5/18/2024 at 6:40 pm by Nurse #1 reported Resident #73 complained of burning on urination and a urine specimen was collected. Nurse #1 further recorded the physician, and Resident #73's Representative was aware of Resident #73's complaint of burning with urination and a urine specimen was collected for analysis. A review of the laboratory patient log sheet dated 5/18/2024 recorded a urine for Resident #73 in a refrigerator near the rehabilitation nursing station for a urinalysis and culture and sensitivity test. There was no date or signature on the laboratory patient log sheet dated 5/18/2024 that laboratory personnel had picked up the urine specimen on 5/18/2024. There were no urinalysis results for the urine specimen collected on 5/18/2024 for Resident #73. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #73 was moderately cognitively impaired, frequently was incontinent of urine and required assistance with toileting. Nursing documentation dated 5/21/2024 at 2:33 am by Nurse #3 reported a urine specimen was collected for a urinalysis and culture and sensitivity test and picked up by the laboratory staff on 5/21/2024 at 2:30 am. A review of the laboratory patient log sheet dated 5/21/2024 recorded a urine for Resident #73 in a refrigerator near the rehabilitation nursing station for a urinalysis and culture and sensitivity test. The laboratory patient log sheet dated 5/21/2024 showed laboratory personnel had signed picking up the urine specimen collected on 5/21/2024. The urine specimen dated 5/21/2024 recorded the results of the urinalysis was reported at 5/21/2024 at 9:19 pm. The urinalysis report did not specify who received the urinalysis report or how resident #73's urinalysis was reported to the facility. A review of the urinalysis dated 5/21/2024 for the urine specimen collected on 5/21/2024 reported the following elements present in the urine: white blood cells, bacteria, squamous epithelial cells and moderate amount of mucous. A physician progress note dated 5/22/2024 recorded Resident #73's Representative stated Resident #73 complained of dysuria (painful or difficulty urinating) a few days ago but not on 5/22/2024, and Resident #73's urine looked like it could be infected. The culture and sensitivity test on the urine specimen dated 5/21/2024 indicated the urine specimen was obtained by conducting straight catheterization (insertion of a tube into the urinary bladder to collect urine).The culture and sensitivity test reported on 5/23/2024 at 9:14 am the microorganism, extended spectrum beta-lactamase (ESBL), was present in Resident #73's urine and had the greatest sensitivity to Sulfamethoxazole-Trimethoprim (an combination of two antibiotics used to treat urinary tract infections). On 5/23/2024, a physician order was written for Resident #73 to receive Sulfamethoxazole-Trimethoprim 800-160 milligrams (mg) tablet two times a day for a urinary tract infection for ten days. A review of the May and June 2024 Medication Administration Record (MAR) for Resident #73 recorded Sulfamethoxazole-Trimethoprim 800-160 mg tablet was administered from 5/23/2024 at 5:00 pm to 6/2/2024 at 9:00 am twice a day for ten days. Resident #73's care plan last reviewed on 6/22/2024 did not include a focus for urinary tract infection. On 7/11/2024 at 4:02 pm in an interview with Nurse #1, she stated on 5/18/2024 a urine specimen was collected from Resident #73 and was placed in the refrigerator for the laboratory personnel to pick up during the night hours. She stated due to the laboratory personnel was not reporting to the facility on weekends and the nursing staff not aware the laboratory personnel would not be picking up Resident #73's urine specimen from 5/18/2024, another urine specimen had to be recollected. She explained a urine specimen had to be discarded if in the refrigerator for more than forty-eight hours. Nurse #1 stated due to the laboratory personnel not picking up the urine specimen collected on 5/18/2024, there was a delay in obtaining results from a urine specimen to start antibiotics for resident #73's urinary tract infection. On 7/11/2024 at 4:52 pm in an interview with the Administrator, she stated she had a contract with a laboratory company that came to the facility nightly to pick up urine specimens for analyzing and was unable to recall a time receiving notification that the laboratory company would not be reporting to the facility to collect urine or blood specimens. On 7/12/2024 at 2:06 pm in an interview with the Director of Nursing, she stated a urine specimen was collected on 5/18/2024 for Resident #73 and was not aware why the laboratory personnel did not pick up the urine specimen. She explained Resident #73's urine specimen was listed on a laboratory patient log dated 5/18/2024. She further stated Nurse #1 and nursing staff need to follow up and check to ensure urine specimens have been picked up by the laboratory personnel. She stated treatment for Resident #73's urinary tract infection was delayed due to laboratory personnel not picking up the 5/18/2024 urine specimen and staff having to recollect a urine specimen for analysis for Resident #73. On 7/12/2024 at 8:39 am in an interview with the Administrator, she stated based on the review of other laboratory patient logs dated 5/18/2024, laboratory personnel were in the facility to pick up urine or blood specimens that had been collected on other residents. She explained laboratory personnel should have picked up the collected urine specimen of Resident #73 on 5/18/2024 and Nurse #1 should had checked the refrigerator the next day to ensure the urine specimen was picked up by the laboratory personnel. She said, due to having to recollect Resident #73' s urine specimen, there was a delay in diagnosing Resident #73 with a urinary tract infection and beginning antibiotic treatment. On 7/12/2024 at 12:50 pm in a phone interview with Physician #1, he explained with the antibiotic stewardship program, antibiotics were not ordered when Resident #73 complained of burning with urination on 5/18/2024. He stated he was waiting for the urinalysis to confirm Resident #73 had a urinary tract infection and the culture and sensitivity report to ensure Resident #73 would receive the correct antibiotic for the urinary tract infection. He stated he reviewed the results of the urinalysis from the specimen sent on 5/21/2024 on 5/22/2024 and did not order antibiotics until 5/23/2024 when the culture and sensitivity results were available also. He stated Resident#73 received one course of antibiotics and did not require further treatment for the urinary tract infection.

Based on record review, observations and staff interviews, the facility failed to ensure there was a physician order for the use of supplemental oxygen (Resident #197) and failed to post signage indicating the use of oxygen outside residents' rooms (Resident #197 and Resident #196) for 2 of 3 residents reviewed for oxygen use. Findings included: 1. Resident #197 was admitted to the facility on [DATE] with diagnoses including pneumonia and congestive heart failure. Resident #197's baseline care plan indicated oxygen therapy was required and a goal to not have signs or symptoms of poor oxygen absorption that was dated 7/4/2024. Interventions included observing for and reporting sign and symptoms of respiratory distress to the physician and providing extension tubing or portable oxygen equipment for ambulation as needed. The physician progress note dated 7/4/2024 recorded Resident #197 was receiving 2 liters per minute of oxygen. On 7/8/2024, there was no physician order for the use of oxygen located in Resident #197's medical record. On 7/8/2024 at 10:11 am, Resident #197 was observed lying in bed receiving oxygen at 2 1/2 liters per minute via nasal cannula. There was no oxygen signage observed outside Resident #197's door indicating oxygen was in use. On 7/9/2024 at 1:07 pm in an interview with Nurse Aide (NA) #1, she stated there was not a red (oxygen in use) sign on Resident #197's door indicating oxygen was in use. She stated it was the nurse's responsibility when Resident #197 was admitted to gather and post an oxygen in use sign outside Resident #197's door when gathering the oxygen regulator. She stated she did not know why the oxygen in use sign was not outside on Resident #197's door and said extra oxygen in use signs were stored in the nurse aide supply room. On 7/9/2024 at 1:20 pm in an interview with Nurse #2, she stated Resident #197 was receiving oxygen therapy and should have an oxygen in use sign outside the door, and she could not recall whether Resident #197 had the oxygen in use sign outside the door, She said nurses and nurse aides both had access to the oxygen in use signage and were responsible for ensuring an oxygen in use signage was posted outside Resident #197's door. On 7/9/2024 at 1:56 pm in an interview with Central Supply, she stated Nurse #1 was responsible for placing oxygen signage that communicated no smoking oxygen in use, outside residents' doors when conducting the admission and did not realize Resident #197 did not have an oxygen in use sign outside on the door. On 7/9/2024 at 1:14 pm in an interview with Nurse #1, she explained it was the assigned nurse, central supply or herself (Nurse #1) responsibility to place the oxygen in use sign outside Resident #197's door prior or on admission. She stated ensuring oxygen in use signage was outside Resident #197's door was one of her duties, and she had been too busy with other tasks to check that an oxygen in use sign was outside Resident #197's door. On 7/9/2024 at 1:27 pm in an interview with the Administrator, she explained there had not been a constant Lead Nurse, the person who was responsible on admission for placing the oxygen in use signage outside Resident #197's door. She stated Nurse #1 was acting as Lead Nurse and she had not decided who would assume the responsibility for ensuring oxygen signage was outside residents' doors at this time. The admission Minimum Data Set (MDS) assessment with an admission reference date (ARD) of 7/10/2024 was recorded as in progress and was incomplete. In a follow up interview with Nurse #1on 7/11/2024 at 3:45 pm, she stated there should have been an order entered for oxygen in Resident #197's medical record when admitted to the facility. She explained all nurses could enter physician's orders. She said the facility had standing orders for oxygen, and nurses could call the physician for an order for oxygen as needed. She explained the admitting nurse, who was usually her (Nurse #1), was responsible for ensuring Resident #197 had an order for the use of oxygen. She stated she could not recall completing Resident #197's admission assessment, and there was no order for oxygen on Resident # 196's medical record until 7/9/2024 when it was brought to her attention. On 7/12/2024 at 9:07 am in an interview with the Director of Nursing, she stated there should have been an order for the use of oxygen in Resident #197's medical record and an oxygen in use sign outside Resident#197's door. She said Nurse #1 and/or the nurses assigned to Resident #197 should have ensured there was an order on Resident #197's medical record, and a sign for oxygen in use was outside Resident #197's door to communicate no smoking oxygen was in use. 2. Resident #196 was admitted to the facility on [DATE] with diagnoses including pneumonia and chronic obstructive pulmonary disease (COPD). Resident #196's baseline care plan dated 7/2/2024 included a focus for COPD, and interventions included administering oxygen therapy as ordered by the physician. There was a physician order dated 7/5/2024 for Resident #196 to received oxygen at 3 liters per minute continuously via nasal cannula every shift for oxygen supplement. A review of Resident #196's July 2024 Medication Administration Record (MAR) recorded Resident #196 receiving oxygen at 3 liters per minute daily every shift since admission. On 7/8/2024 at 9:58 am, Resident #196 was observed wearing oxygen 3 liters per minute via nasal cannula. There was no signage communicating oxygen was in use no smoking observed outside Resident #196's door. The admission Minimum Data Set (MDS) assessment with an admission reference date (ARD) 7/9/2024 was recorded as in progress and was incomplete. On 7/9/2024 at 1:02 pm in an interview with Nurse Aide (NA) #2, she explained nurses assigned to Resident #196 were responsible for placing oxygen in use no smoking signs outside Resident #196's door. She stated the oxygen in use signs were stored in the medication room with the oxygen tanks. She said she didn't know why there was no signage for oxygen in use outside Resident #196's door. On 7/9/2024 at 1:20 pm in an interview with Nurse #2, she stated there should have been an oxygen in use no smoking sign outside Resident #196's door because she was receiving oxygen continuously. She explained she realized that morning Resident #196 did not have an oxygen in use sign outside on the door but Resident #196 was not in her room and she (Nurse#2) forgot to return to Resident #196's room with a no smoking, oxygen in use sign to place outside Resident #196's door. On 7/9/2024 at 1:56 pm in an interview with Central Supply, she stated Nurse #1 was responsible for placing the signage that communicated no smoking oxygen in use, outside residents' doors when conducting the admission and did not realize Resident #196 did not have an oxygen in use sign outside on the door. On 7/9/2024 at 1:14 pm in an interview with Nurse #1, she explained it was the assigned nurse, central supply or herself (Nurse #1) responsibility to place the oxygen in use sign outside Resident #196's door prior or on admission. She stated ensuring oxygen in use signage was outside Resident #196's door was one of her duties, and she had been too busy with other tasks to check that the oxygen in use sign was outside Resident #196's door. On 7/9/2024 at 1:31 pm in an interview with the Director of Nursing, she stated there should have been a no smoking, oxygen in use sign posted outside Resident #196's door. On 7/9/2024 at 1:27 pm in an interview with the Administrator, she explained there had not been a constant Lead Nurse, the person who was responsible on admission for placing the oxygen in use signage outside Resident #196's door. She stated Nurse #1 was acting as Lead Nurse and she had not decided who would assume the responsibility for ensuring oxygen signage was outside residents' doors at this time.

Based on record review, staff interviews, and interview with Dialysis Center Nurse, the facility failed to maintain ongoing communication with the dialysis treatment center for 1 of 1 resident reviewed for dialysis (Resident #69). The findings included: Resident #69 was admitted to the facility on [DATE] with diagnoses including end stage renal disease. An active physician order dated 6/11/2024 stated Resident #69 received dialysis on Tuesday, Thursday and Saturday at the local dialysis center. The care plan dated 6/12/2024 indicated Resident #69 was scheduled to receive hemodialysis three times per week due to renal disease with risk for complications: infection, fluid imbalances and hemorrhage from dialysis vascular access port and renal failure. Interventions included checking Resident #69 frequently after any bleeding episodes to ensure no further bleeding, observing, documenting and reporting any signs of infection to the access site and assisting Resident #69 with transfers, walking after returning from dialysis treatments. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #69 was cognitively intact and was receiving dialysis. A review of Resident #69's dialysis communication notebook on 6/9/2024 at 3:30 pm revealed 8 out of the 13 dialysis communication forms in the notebook were not completed by the facility staff prior to dialysis treatment for Resident #69 since admission to the facility (6/13/2024, 6/18/2024, 6/27/2024, 6/29/2024, 7/2/2024, 7/4/2024, 7/6/2024 and 7/9/2024.) The 8 dialysis communication forms did not have the following information recorded from the facility: pre-dialysis vital signs, weight, vascular access or information shared with dialysis center. There were blank dialysis communication forms in Resident #69's dialysis communication notebook. On 7/6/2024, the post dialysis information on the communication form from the dialysis center requested a current list of Resident #69's medications to be sent on the next dialysis day (7/9/2024). On 7/9/2024 post Resident #69's dialysis treatment, the dialysis center communicated with the facility to send a list of Resident #69's current medications on a yellow post-it note observed on the outside of Resident #69's dialysis communication notebook. On 7/9/2024 at 3:55 pm in an interview with Nurse Aide (NA) #2, she stated she was responsible for ensuing Resident #69 was dressed, received breakfast and obtain vital signs before leaving for dialysis, and she couldn't recall obtaining pre-dialysis vital signs on Resident #69 on 7/9/2024. NA #2 could not state a reason why Resident #69's vital signs were not obtained. On 7/9/2024 at 3:43 pm in an interview with Nurse #2, she stated when she went to give Resident #69's morning medications on 7/9/2024, a local transportation company had arrived and already taken Resident #69 to the dialysis center. She said she had not completed the dialysis communication form, sent a current list of medications for Resident #69's or administered Resident #69's morning medications on 7/9/2024 prior to Resident #69 going to the dialysis center. She stated she thought Resident #69's scheduled dialysis days had changed to Monday, Wednesday and Friday. When Nurse #2 checked the physician order, she stated Resident #69 was scheduled to receive dialysis on Tuesday, Thursday and Saturday. On 7/11/2024 at 11:54 pm in a phone interview with the Dialysis Center Nurse, she stated the nursing staff at the facility were not completing the dialysis communication forms that communicated vital signs and changes in Resident #69 to the dialysis center prior to Resident #69 receiving dialysis treatments. She said the dialysis center had requested twice on 7/6/2024 and 7/9/2024 for the facility to send a list of Resident #69's current medications, and the facility had not sent the medication list to the dialysis center. She stated the dialysis center had not spoken to anyone specifically at the facility about the nursing staff not completing the communication form or the medication list. On 7/9/2024 at 5:40 pm in an interview with the Director of Nursing, she stated the nurse assigned to Resident #69's was responsible for completing the dialysis communication form that included vital signs and any pertinent information prior to Resident #69's leaving the facility for a dialysis treatment, and Resident #69's dialysis pre-dialysis communication form should had been completed on 7/9/2024 and a current list of Resident #69's medications sent as requested.

Based on record review, staff interviews and a pharmacist interview, the facility failed to document the return of a discontinued medication, Hydroxyzine HCl (an antihistamine used to help control anxiety or symptoms of itching) to the pharmacy for 1 of 1 resident (Resident #73) reviewed for the provision of pharmacy services. The findings included: Resident #73 was admitted to the facility on [DATE]. A physician order for Hydroxyzine HCl 25 milligrams (mg) every six hours as needed for anxiety or itching for 14 days was written on 5/29/2024. A review of the pharmacy 's medication packing slips for proof of delivery to the facility indicated ten tablets of Hydroxyzine HCl 25mg were delivered to the facility for Resident #73 on 5/29/2024 and on 6/5/2024 for total of 20 tablets dispensed from the pharmacy. A review of the May and June 2024 Medication Administration Record (MAR) recorded Hydroxyzine HCl 25mg was administered to Resident #73 for a total of seven doses on the following dates: - 5/31/2024 at 9:36 pm. - 6/3/2024 at 10:06 pm. - 6/4/2024 at 10:59 pm. - 6/5/2024 at 9:34 pm. - 6/7/2024 at 8:54 pm. - 6/9/2024 at 9:38 pm. - 6/11/2024 at 9:14 pm. There was no documentation on a medication return to pharmacy form that accounted for the remaining 13 tablets of Hydroxyzine 25 mg when the physician order was automatically discontinued after 6/11/2024. In an interview with Nurse #4 on 7/12/2024 at 11:14 am, she stated Resident #73's Hydroxyzine HCl 25 mg tablet was discontinued after the fourteen days per physician order and stated she did not know when Resident #73's discontinued Hydroxyzine HCl medication was returned to the pharmacy. She explained discontinued medications still in bubble packs were placed in an open box labeled return to pharmacy in the locked medication room and were picked up by the pharmacy at night. She stated the night nurse, assistant Director of Nursing or the Director of Nursing completed the return to pharmacy form listing all the medications in the return to pharmacy box that were picked up by pharmacy nightly. In an interview with the Assistant Director of Nursing on 7/12/2024 at 1:06 pm, she stated the facility did not have a return to pharmacy form indicating Resident #73's Hydroxyzine HCl was returned to the pharmacy after the medication was discontinued after 6/11/2024. She explained due to unavailability of carbon copy return to pharmacy forms in the pharmacy, the facility had not been able to obtain carbon copy return to pharmacy forms and copying the original return to pharmacy form was necessary for the facility's records. She explained sometimes the original return to pharmacy form was not copied and the original copy was sent to the pharmacy. In an interview with the Director of Nursing (DON) on 7/12/2024 at 11:26 am, she stated the nursing staff were to complete the return to pharmacy form when returning discontinued medications to the pharmacy. She explained nursing staff should have removed Resident #73's discontinued medication, Hydroxyzine HCl, from the medication cart, placed the medication in the return to pharmacy box in the locked medication room and completed the return to pharmacy form for pharmacy to pick up. She stated the pharmacy and the facility did not have documentation on a return to pharmacy form that Resident #73's discontinued Hydroxyzine HCL medication had been returned to the facility. The DON was not able to explain what happened to the unaccounted 13 tablets of Resident #73's Hydroxyzine HCl tablets after the physician order was discontinued on 6/11/2024. In a phone interview with Pharmacist #1 on 7/12/2024 at 1:34 pm, he stated Hydroxyzine HCl 25 mg for Resident #73 was discontinued after the 14th day (6/11/2024) based on the physician's order, and the pharmacy had no documentation on a return to pharmacy form that Resident #73's discontinued medication, Hydroxyzine HCl 25 mg tablet, was returned to the pharmacy. He explained there was no time frame in returning discontinued medications to the pharmacy, and the facility usually kept discontinued medications until the physician made a decision not to reorder the medication. He stated discontinued medications returned to the pharmacy were listed on a return to pharmacy form and discontinued medications were picked up six days a week Monday through Saturday. He explained the return to pharmacy form was a carbon copy: one copy was sent with the medications returned to the pharmacy and one copy was maintained at the facility for documentation of the returned medications to the pharmacy. He stated it was the facility's responsibility to request the return to pharmacy forms from the pharmacy and he could not recall a period of time not having the return to pharmacy forms available for the facility. Pharmacist #1 further stated the pharmacy did not track the number of medications dispensed, administered and returned except for controlled medication, and Hydroxyzine HCl was not a controlled medication.

Based on record review and staff interviews, the facility failed to implement monitoring for the side effects for a resident receiving antipsychotics (medications used to treat mental disorders) for 1 of 5 residents reviewed for unnecessary medications (Resident #197) The findings included: Resident #197 was admitted to the facility on [DATE] with diagnoses including dementia, depression and anxiety. Resident #197's baseline care plan dated reviewed on 7/4/2024 included the use of antipsychotic medications. Interventions included performing an Abnormal Involuntary Movement Scale (AIMS), a scale that measures the severity of involuntary movements caused by neuroleptic medications (medications known form their ability to attenuate hallucinations and delusions) assessment and monitoring for side effects of antipsychotics. A review of the active physician orders recorded Resident #197 was ordered the following medications: - Lorazepam (an type of antipsychotic used to treat anxiety and sleeping problems) 0.5 milligrams (mg) every four hours as needed for agitation for 14 days on 7/4/2024. - Haloperidol (an antipsychotic medication used to treat mental disorders) 0.5mg every four hours as needed for agitation until 7/16/2024 on 7/4/2024. - Risperidone (a type of antipsychotic medication that [NAME] mental health conditions) 0.5mg once a day for agitation on 7/3/2024. - Quetiapine Fumarate (antipsychotic medication that treats several kinds of mental health conditions) 25 mg 1/5 tablet every evening for agitation on 7/3/2024. A physician progress note dated 7/4/2024 recorded Resident #197's psychological history included anxiety, depression, dementia, agitation, delusions and hallucinations. A pharmacy review of Resident #197's medications was conducted on 7/4/2024. The pharmacy recommendation requested a diagnose for the medications Risperdal, Seroquel and Haldol which had not completed the recommendation process at the facility at this time. A psychoactive medication interventions consent dated 7/6/2024 listed Quetiapine Fumarate, Risperidone and Haloperidol as medications used to treat Resident #197's agitation. There was no AIMS assessment located in Resident #197's medial record. A review of the July 2024 Medication Administration Record (MAR) reported Resident #197 had received Risperidone 0.5mg daily since 7/4/2024 and Quetiapine Fumarate 25 mg 1/5 tablet every evening since 7/3/2024. There was no documentation that Resident #197 had received a dose of Lorazepam or Haloperidol. Resident #197's July 2024 MAR further reported the monitoring to indicate the number of antipsychotic side effects every shift was discontinued on 7/3/2024. There was no nursing documentation indicating Resident #197 exhibited any psychological behaviors since admission. The admission Minimum Data Set (MDS) assessment dated with an admission reference date (ARD) of 7/10/2024 was recorded in process and was incomplete. In an interview with Nurse #1 on 7/11/2024 at 3:55 pm, she explained when Resident #197 was admitted on [DATE], the order to monitor for antipsychotic medication side effects from a previous admission in May 2024 was still listed on the electronic MAR. She stated she had to discontinue the order to monitor of antipsychotic side effects from the previous admission in May 2024 before she could activate a new batch order that included the monitoring of antipsychotic side effects. She stated she did not reactivate a new batch order for Resident #197 who was receiving antipsychotic medications and could not give an explanation why she did not activate the batch order for antipsychotics for Resident #197 on the electronic MAR. Nurse #1 further stated an AIMS assessment that was usually conducted by the nursing staff had not been completed at this time for Resident #197. She explained usually in morning clinical meetings will catch when AIMS assessment had not been completed but due to Resident #197 admission prior to a holiday and the weekend, the facility had not held a morning clinical meeting to discuss Resident #197's need for an AIMS assessment. In an interview with the Director of Nursing on 7/12/2024 at 9:11 am, she stated due to Resident #197 receiving the antipsychotics, Risperidone and Quetiapine Fumarate daily, the nursing staff should complete an AIMS assessment and monitor for and document on the MAR side effects of the antipsychotics. She explained when antipsychotics were ordered by the physician, there was a batch of orders for nurses to activate that included the monitoring and documentation for antipsychotic medications that was not activated for Resident #197. She stated morning clinical meeting had not been held due to a holiday prior to the weekend to ensure AIMs assessment had been completed since Resident #197's admission on 7/3/2024.

Based on record review and staff interviews for two of ten sampled residents (Residents # 2 and # 6) the facility failed to ensure medical records were complete and accurate regarding medication administration (Resident # 2) and pressure sore assessment and care (Resident # 6). The findings included: 1. A review of Resident # 2's MARs (Medication Administration Records) from February through April 2024 revealed the following information. The MAR included a chart code. A check mark meant a medication was administered. By each dose of Resident # 2's Carvedilol there was a space for the nurse to enter Resident # 2's pulse and BP. The directions to hold the medication for a systolic BP less than 100 and a pulse less than 60 appeared on the MARs. During an interview with the DON (Director of Nursing) on 4/24/24 at 3:00 PM the DON reported that each nurse, who administers medications is assigned electronic initials which are then entered on the electronic MAR when they administer medications. (The initials at times include numbers along with a nurse's initials). On 2/16/24 at 9:00 AM, Nurse # 3's assigned electronic initials appeared with a check mark. The resident's blood pressure was 110/66 and her pulse was 56. Nurse # 3 was interviewed on 4/24/24 at 1:45 PM and reported the following. She would not have administered the medication if the resident's pulse was in the 50's. At times the NAs (Nurse Aides) will tell them of a pulse, and she does not think the pulse is accurate. She will go back and check it. Therefore, she would have gone back to check the pulse on 2/16/24, found it to be above 60, administered the medication, but not noted what the repeat pulse was in the record. On 2/16/24 at 9 PM Nurse # 4's assigned electronic initials appeared with a check mark. The resident's BP was 131/65 and her pulse was 58. On 4/24/24 at 3:52 PM Nurse # 4 was interviewed and reported the following information. She would not have administered the Carvedilol if the resident's pulse had been 58. That was the whole reason she took vitals. She did not know why the check mark indicated the medication was administered. On 2/21/24 at 9:00 AM Nurse # 4's assigned electronic initials appeared by a check mark by Carvedilol. The resident's BP was 142/71 and her pulse was 57. Nurse # 4 was interviewed on 4/24/24 at 3:26 PM and reported she was familiar with Resident # 2 and routinely cared for the resident. She (Nurse # 4) was well aware of the parameters and had held the medication on other occasions. It did not make sense to her why the check mark appeared on 2/21/24 because she would not have given it. She felt there had been some error in the computer check but did not know why. On 2/29/24 at 9:00 PM Nurse # 6's assigned electronic initials appeared by a check mark by Carvedilol. The resident's BP was 148/59 and her pulse was 59. Nurse # 6 could not be reached for interview during the survey. On 3/1/24 at 9:00 PM Nurse # 7's assigned electronic initials appeared by a check mark by Carvedilol. The resident's BP was 148/58 and pulse 53. Nurse # 7 could not be reached during the survey. On 3/7/24 at 5 PM Nurse # 8's assigned electronic initials appeared by a check mark by Carvedilol. The resident's BP was 146/74 and her pulse was 58. Nurse # 8 was interviewed on 4/24/24 at 3:50 PM and reported the following. She would not have given the Carvedilol if the resident's pulse was 58. She was aware of the parameters and it would have been held. She did not know why the check mark was on the MAR. She was aware that at times the computer with the electronic MAR would glitch at times. At times it would also lock her out and she would have to call IT (information technology) to gain access back into the system. On 3/24/24 at 5 PM Nurse #9's assigned electronic initials appeared by a check mark by Carvedilol. The resident's BP was 126/70 and the pulse was 56. Nurse # 9 was interviewed on 4/24/24 at 3:45 PM and reported the following. She would not have given the medication with a pulse of 56. She did not know why the check mark was by the initials. The nurse further reported that at times the computer with the electronic MAR would at times glitch and freeze up. She would have to wait for about five minutes before it would allow her back in, and she speculated that might have contributed to the check mark being entered inaccurately. On 3/26/24 and 3/30/24 the evening doses were blank on the MAR. According to the MAR, nurses were to code if a resident had refused the mediation or was away from the facility. Neither of these were denoted. During an interview with the Director of Nursing (DON) on 4/25/24 at 11:22 AM, the DON reported nurses should be documenting at each administration according to the chart code/legend. There should not be blanks. On 4/3/24 at 5 PM the DON's assigned electronic initials appeared by a check mark by the Carvedilol. The resident's BP was 96/60 and her pulse was 57. During an interview with the DON on 4/24/24 at 3:00 PM, the DON stated she had not even realized she had even been assigned a set of electronic initials for the MAR until the surveyor requested that she try to identify which nurses' initials corresponded to which nurse. She had called the IT department and they told her that the assigned electronic initials on 4/3/24 were hers. She reported she had not been at the facility very long and had never administered medications since being employed at the facility. It did not make sense that her initials were on the MAR and it was an error of some sort in the electronic record, but she did not know how it had occurred. On 4/14/24 at 9 AM Nurse # 3's assigned electronic initials appeared by a check mark by the Carvedilol. The resident's blood pressure was 134/69 and her pulse was 54. Nurse # 3 was interviewed on 4/24/24 at 1:45 PM and reported she would not have administered the medication with a pulse of 54. Nurses were observed as they administered medications on 4/25/24 beginning at 8:10 AM. The electronic MAR was not observed to glitch during the time of the medication pass. 2a. Resident # 6 was admitted to the facility on [DATE]. On the resident's admitted [DATE], Nurse # 10 documented Resident # 6 had a pressure sore to her sacrum and the wound nurse was notified. Nure # 10 was interviewed on 4/25/24 at 11:09 AM revealing the notation that the resident had a pressure sore on 3/26/24 was not accurate. Nurse # 10 reported the following information. The hospital had reported the resident had a sacral pressure sore when they called report to the facility on [DATE]. On 3/26/24 when she looked at the area, it was scar tissue and no longer open and in need of treatment. On the skin assessment sheet of 3/26/24, there were different areas to check if they were applicable to the resident. One of the areas was a pressure sore. She wanted to denote there had been a pressure sore at one point, and therefore she checked pressure sore. She (Nurse # 10) did not feel the other areas on the skin assessment would apply and there was no area to check scar tissue. 2b. On 4/1/24 Resident # 6 had a physician's order for wound care. There was no site specified in the order for which wound care was needed. The area was to be cleansed with wound cleanser and covered with a dry dressing every three days and PRN (as needed). On 4/10/24 this order was revised to denote the area in need of wound care was the resident's right heel. It was also revised on 4/10/24 to reflect the area should be cleaned with skin prep before the dressing was applied, and the frequency of the dressing change was to be every five days and PRN. This order stayed in effect until 4/24/24. A review of Resident # 6's April 2024 TAR (Treatment Administration Record) revealed the right heel dressing change was checked as completed on the following days: 4/2/24, 4/6/24, 4/15/24, 4/20/24. This reflected more days passed before the dressing was changed as ordered. The facility Wound Nurse was interviewed on 4/25/24 at 10:30 AM and Resident # 6's record reviewed. The facility Wound Nurse reported the following information. The electronic medical record system was new to her. She came from a different clinical background which did not utilize the system. She was continuing to learn the system. There were standing orders that could be put in place for pressure sores. On 4/1/24 Resident # 6 was first identified to have a right heel pressure blister. Standing orders included to cleanse the area with skin prep and cover the area for protection. The first order had not been entered into the computer as a complete order to reflect that it was the right heel that needed treatment or the use of the skin prep. Also, when the order was placed in the computer, the days on which the dressing should have been changed should have had an open area on the TAR so that a treatment could be recorded. The system had xed out days when the treatment was due. There was no place to chart the dressing changes on the TAR on some of the days it was due, but the dressings had been completed. The resident had another pressure sore that required more frequent checks, and every time she was in the room, she checked and applied skin prep to the heel on the correct schedule or as needed. The treatment nurse validated that the resident's record was incomplete in regards to dressing changes. The Director of Nursing was interviewed on 4/25/24 at 11:22 AM and reported that the electronic system should automatically populate the days on the TAR on which the dressings needed to be completed. She did not know why the system had not done so and reported there could be more training on the facility's electronic medical system. 2c. Review of Resident # 6's pressure sore assessments revealed the following information: 4/2/24-Sacral pressure sore 3.3 cm X 1.0 cm X 0.2 cm Stage II 4-9-24- Sacral pressure sore 2.1 cm X 1 cm X 0.1 cm Stage II 4/17/24-Sacral pressure sore 1 cm X 0.9 cm X 0.1 cm suspected deep tissue injury 4/23/24 Sacral pressure sore 1.4 cm X 1 cm X 0.1 cm Stage II pressure sore The facility wound nurse was interviewed on 4/25/24 at 10:30 AM and reported the following information. The pressure sore assessment of 4/17/24 was incorrect in the record, and the assessments were also incomplete in the electronic record. Resident # 6 had both a pressure sore to her sacral area and to her right heel. On 4/17/24 she had inadvertently entered the right heel pressure sore measurements as the sacral pressure sore measurements. She had also been measuring the right heel pressure sore every time she measured the sacrum, but she had not been entering all of the assessments in the resident's record. According to the Wound Care Nurse, the actual care of the wounds was her priority. She (the Wound Care Nurse) had the right heel measurements in her personal notes but had not yet had time to complete all the documentation in Resident # 6's record. Therefore, the record was not complete.

Based on record review and staff interview the facilities Quality Assurance/Performance Improvement (QAPI) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification survey of 2/25/22. This was for one repeat deficiency. The area of deficiency dealt with failure to maintain accurate and complete medical records. The continued failure of the facility during two federal surveys over the course of two years showed a pattern of the facility's inability to sustain an effective Quality Assurance/Performance Improvement program. The findings included: This citation is cross referred to: F 842 During the complaint investigation of 4/25/23, for two of ten sampled residents (Residents # 2 and # 6) the facility failed to ensure medical records were complete and accurate regarding medication administration (Resident # 2) and pressure sore assessment and care (Resident # 6). During the recertification survey of 2/25/22 the facility failed to maintain an accurate Medication Administration Record (MAR) for 1 of 5 residents reviewed for activities of daily living. On 4/25/24 at 11:10 AM the Administrator was interviewed revealing the following information. The Administrator was not employed at the facility when the facility was previously cited for medical records. Since her employment, they had a quality assurance program and met monthly to address identified issues and problems. The nursing staff had not brought up any issues with problems documenting accurately and completely in residents' electronic medical records so that any problems with medical records could be addressed within their quality assurance program.

Based on record review, and interviews with staff, family, and physician the facility failed to obtain an x-ray as ordered when a resident fell . This was for one (Resident # 1) of three residents reviewed for completion of diagnostic tests. The findings included: Resident # 1 was admitted to the facility on [DATE] with diagnoses of stroke, muscle weakness, dysphagia, hypertension, chronic kidney disease, chronic obstructive pulmonary disease, hyperlipidemia, and hearing loss. Resident # 1's admission Minimum Data Set assessment, dated 2/28/24, coded the resident as severely cognitively impaired. On 3/11/24 at 12:33 AM Nurse # 1 documented the following information in a nursing entry. Resident # 1 had an unwitnessed fall. The physician and the responsible party had been notified. Nurse # 1 was interviewed on 4/24/24 at 8:45 AM and reported the following. The NA (Nurse Aide) had alerted her that Resident # 1 was on the floor on 3/11/24. She had assessed the resident from head to toe. She did not appear to be in pain and had no obvious physical injuries. They checked on her frequently throughout the rest of the night, and the resident appeared to be fine. NA # 1 was interviewed on 4/24/24 at 2:14 PM and reported the following. She had been assigned to care for Resident # 1 during the night of the fall. She had been checking on Resident # 1 prior to the fall. The resident had been in bed, The resident's room had been very close to the nursing station. She (NA #1) was at the nursing station when she heard a noise. She entered the room and found Resident # 1 on the floor. She (NA # 1) alerted the nurse who checked the resident. The resident appeared to be okay when the nurse checked her. After the fall, she (NA # 1) checked on Resident # 1 frequently throughout the night and she appeared to be fine. On 3/11/24 the NP (Nurse Practitioner) noted the following. She was seeing Resident # 1 who had experienced a fall. Initially the resident had not complained of pain after the fall, but at the time of the NP's assessment, she was complaining of neck pain and limited range of motion. The resident had no further concerns. The NP noted she would order scheduled Acetaminophen and an x-ray. On 3/11/24 an order was entered into the record for a cervical and lumbar spine x-ray. According to the record, Resident # 1 was discharged from the skilled nursing facility on the following day (3/12/24) and admitted to the assisted living section of the facility. There was no record of the spine x-ray being completed prior to the resident's transfer to assisted living. A review of medical records revealed on 3/12/24, Resident # 1 had a new record which was not part of her previous skilled nursing record. Therefore, the 3/11/24 x-ray order did not show up in the assisted living record. Interview with Resident # 1's responsible party on 4/23/24 at 12:13 PM revealed that she had visited on 3/14/24. Resident # 1 was uncomfortable in her neck, and she learned the x-ray had not been completed on 3/11/24. This was mentioned to the NP, who ordered the x-ray again. On 3/14/24 the NP noted the following information in Resident # 1's assisted living record. She saw Resident # 1 again. The resident was complaining of neck pain and was unable to rotate her neck without grimacing. The NP noted she would reorder the x-ray. On 3/14/24 an order was entered into Resident # 1's assisted living record for an x-ray of the neck and lumbar spine. Review of X-ray results revealed the x-ray was completed on 3/14/24 and showed the following. The resident had subluxation (incomplete of partial dislocation) of the Cervical 3 (C3) and C4. There was also narrowing of the C4 to C5. There was moderate degenerative changes of cervical spine. There was a reversal of the cervical lordosis consistent with the presence of pain and/or muscle spasm. Clinical correlation was recommended. On 3/14/24 Resident # 1 was transferred to the hospital ED (Emergency Department) for further evaluation. Review of 3/14/24 ED records revealed the following. Under the physician's assessment of the neck, the physician noted, no cervical vertebral body tenderness. No step-off injury. No warmth erythema. A CT (computerized tomography) was completed. It revealed a Type II dens fracture without displacement, osteopenia, and degenerative changes of the spine. (The dens, which is also referred to as a the odontoid, refers to a bony element from the second cervical vertebrae). A discussion was held with the family, and they did not wish for the resident to have any type of surgery. After consulting with neurosurgery, the resident was placed in a cervical collar and transferred back to the facility's assisted living for care. On 3/18/24 the NP noted the following in the resident's assisted living record. She had seen the resident who denied neck pain at the time. Resident # 1's physician was interviewed on 4/24/24 at 9:00 AM and reported the resident had not experienced any serious issues from the delay in the x-ray being performed. The Director of Nursing (DON) was interviewed on 4/23/24 at 3:00 PM and reported the following. The facility had identified the x-ray had not been done as completed and investigated the cause. They found that the NP had entered the order into the computer on 3/11/24. Nurse # 2 had then gone into the computer and confirmed (acknowledged) the order. Nurse # 2 thought that the NP had called the mobile x-ray company and had not been aware it was his responsibility to do so when he confirmed the order. Then on 3/12/24 the resident was transferred to a different section of the facility, and the uncompleted order no longer appeared on the resident's new record. On 4/23/24 the DON presented the facility had completed a corrective action plan. The corrective action plan included the following: Corrective action for resident involved It was noted on 3/11/2024, Resident #1 experienced an unwitnessed fall. NP was notified and ordered a lumbar and spine x-ray. Nurse confirmed order in [electronic medical record], but did not contact x-ray vendor to come to facility to complete x-ray. On 3/12/2024, Resident # 1 transferred from skilled to ALF (assisted living facility). There was a delay in orders for obtaining an x-ray for Resident # 1. On 3/14/2024, it was noted by NP that initial x-ray had not been completed and 2nd x-ray was ordered and completed. Resident # 1 was sent to ER for further evaluation on 3/14/2024 following results of facility x-ray. X-ray results at the hospital indicated a cervical type ll dens fracture without displacement. Family decided against surgical intervention and resident returned to facility on 3/15/2024. Resident # 1 returned to facility with [cervical] collar for conservative treatment. Corrective action for potentially impacted residents On 3/ 15 /24 the Director of Nurses reviewed all x-ray orders received for the last 7 days to identify if x-ray orders had been obtained timely and the results reported to the physician/RP. Results: No other residents affected Systemic Changes On 3/15/2024 the DON/ADON/SDC (Director of Nursing/ Assistant Director of Nursing/ Staff Development Coordinator) met and decided to make it a part of our quality assurance program and developed a plan of correction. On 3/15/2024 SDC began in-service of all licensed nursing staff (including agency) on the x-ray order process. This training included: The x-ray order process to include contacting the x-ray company and follow through to assure the ordered x-ray is completed. Post fall review and post fall care and documentation. Notification of Dr/RP if an ordered test is not completed. The Director of Nursing will ensure that any of the above identified staff who does not complete the in-service training by 3/19/2024 will not be allowed to work until the training is completed. Quality Assurance The DON/ADON will monitor compliance with the x-ray or [NAME] process weekly for 2 weeks beginning 3/22/2024 and monthly for 3 months or until resolved for timely follow through in completing physician orders. Reports will be presented to the weekly QA committee by the Administrator or Director of Nursing to ensure corrective action initiated as appropriate. Compliance will be monitored and ongoing auditing program reviewed at the weekly QA Meeting. The weekly QA Meeting is attended by the Administrator, DON, MDS Coordinator, Therapy, HIM (Health Information Manager), and the Dietary Manager. Completion date: 3/19/24 The following was done to validate the facility's corrective action plan. On 4/23/24 beginning at 9:20 AM a tour of the facility was completed. Residents were interviewed and there were no reports of any facility failure to obtain diagnostic studies. Additionally sampled residents, who had x-rays ordered, were reviewed. The x-rays had been completed as ordered for these additionally sampled residents. The facility presented documentation of inservices and audits completed per their corrective action plan. Nurses were interviewed during the survey and reported they had attended the inservice training. On 4/25/24 the facility's plan of correction date of 3/19/24 was validated.

Based on observation, record review, resident, staff, paramedic, and physician interview the facility failed to notify the physician regarding a significant change in condition for one (Resident # 3) of two sampled residents. On the morning of 9/27/23 Nurse Aide #1 and Nurse #3 observed signs Resident # 3 was experiencing a significant change in condition including a low blood pressure, slurred speech, sluggishness, inability to carry on a conversation per his norm, inability to help in his care per his norm, and bloody urine in his catheter. The physician was not notified when staff noted the change in condition. Resident # 3 was found in the afternoon on 9/27/23 unresponsive, with a temperature reading of 102 Fahrenheit, and using accessory respiratory muscles to breathe (muscles other than the diaphragm and muscles within the rib cage which are used in labored breathing.) Resident #3's condition had declined to the point where Emergency Medical Services (EMS) was called, and Resident # 3 was transferred to the hospital where he was admitted to the hospital Intensive Care Unit (ICU) with severe sepsis with septic shock (when a person is not getting enough blood flow through their body). Immediate Jeopardy began on 9/27/23 when staff members observed but failed to notify the physician that Resident # 3 was experiencing a change in condition which resulted in the resident's admission to the hospital ICU with sepsis and septic shock. Immediate Jeopardy was removed on 12/7/23 when the facility provided an acceptable credible allegation for immediate jeopardy removal. The facility will remain out of compliance at a scope and severity level of D (not actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put in place are effective. The findings included: Resident # 3 was admitted to the facility on [DATE] with diagnoses which in part included spinal stenosis and functional mobility problems, and neurogenic bladder with a chronic indwelling catheter. A review of hospital records revealed Resident # 3 was hospitalized from 7/12/23 to 7/18/23 with sepsis due to a urinary tract infection caused by obstructive nephrolithiasis (kidney stones). A stent was placed at that time. Resident # 3's quarterly MDS (Minimum Data Set) assessment, dated 7/21/23 coded Resident # 3 as cognitively intact and as having an indwelling catheter. According to hospital records, Resident # 3 was hospitalized again from 7/29/23 until 8/2/23 with a urinary tract infection and sepsis. On 9/27/23 at 7:10 AM Resident # 3's vital signs were documented as the following by Nurse # 2. Temperature 98; pulse 76; respirations 18; blood pressure 128/62. NA (Nurse Aide) # 1 was the NA who had cared for Resident # 3 on 9/27/23. NA # 1 was interviewed on 11/29/23 at 9:05 AM and reported the following. She had taken his vital signs that morning and they were low. His systolic blood pressure was below 100 and his diastolic was also low. She took them twice to make sure they were registering. She did not enter them into the record. She told Nurse # 2, Resident #3's assigned nurse, about them. Usually, Resident # 3 did not eat breakfast, but he always asked for coffee and would drink it. That morning he did not ask for or drink coffee. He seemed off. Around 10 AM, she bathed him. Normally he was very alert and would carry on a full conversation during his care. He normally would also assist to turn in the bed and hold onto the rail. That morning, he was not doing nothing. His eyes would open a little bit and then close. He would mumble but not carry on a full conversation. He also had blood in his catheter bag. She told Nurse # 2 how he was acting and that he had blood in his catheter bag. That morning the treatment nurse also went into Resident # 3's room to do wound treatments for him. She told the treatment nurse also that Resident # 3 was not acting right. This was before lunch. Nurse # 3 said she would tell Nurse # 1. At lunch time Resident # 3 did not eat anything and she was still concerned. She was hoping they would send him to the hospital. Nurse # 1 did come to check him in the afternoon, and he was sent out. Nurse # 1 asked her (NA # 1) why she had not let her know sooner about his condition, and she informed her that she had been alerting Nurse # 2 throughout the day. Nurse # 3 was interviewed on 11/29/23 at 10:15 AM and reported the following. She went to provide wound treatments to Resident # 3 sometime between 10 AM and lunch on 9/27/23. Usually, Resident # 3 would initiate conversation on his own when you entered his room. That morning he did not do so. She could not engage him in conversation. If she would say, Hey (Resident # 3), he would just say, ah . in a slurred way. His speech was slurred, and he was sluggish. Normally he would help them turn, but he did not help that AM turn for treatments. She knew something was not right with him. NA # 1 also told her he had not been acting right. After she left the room, she went to Nurse # 2 and told her, You better check on (Resident # 3). He's not acting right. Nurse # 2 told her that it had taken her awhile to get him to take his morning medications, but he took them, and he was on an antibiotic. She had also said she would check on him. According to Nurse # 3, if Resident # 3 had been assigned to her then she would have called the provider at that point in the morning given the change she had seen in Resident # 3 and alerted the provider about the change. The treatment nurse stated she would have asked the physician if he wanted to do labs or send the resident out for evaluation. She thought that was what Nurse # 2 was going to do after she spoke to Nurse # 2 in the morning. Therefore, she went on to do her treatments. Later after lunch she returned, and NA # 1 again told her Resident # 3 still was not right and Nurse # 2 had not done anything. At that point, Nurse # 3 stated she went to Nurse # 1 and Nurse # 1 immediately went to check on Resident # 3. Nurse # 1 was interviewed on 11/29/23 at 4:30 PM and reported the following. Nurse # 1 stated she was the rehabilitation nurse manager, but also served as the point of contact for the unit where Resident # 3 resided. On 9/27/23 she had been in her office when Nurse # 3 alerted her Resident # 3 was not acting right. She went right away to check on him. It was around 3:00 or 4:00 PM when she was alerted. When she assessed him, she found he could not talk and would not follow commands, but he did respond to a sternal rub a little. She immediately had him sent to the hospital. Nurse # 2 was interviewed on 11/28/23 at 3:00 PM and again on 11/29/23 at 5:30 PM and reported the following. It was not unusual for Resident # 3 to be groggy or sleepy in the AM. She did not recall all the specific details of 9/27/23. She just recalled Resident # 3 took his medications that morning, throughout the day she was in and out to check on him, and he was eventually sent out because he was not responding. She did not recall if she took his vital signs as she was in and out checking on him. There was no documentation the physician was notified of Resident # 3's change in condition which Nurse # 3 and NA # 1 had observed before lunch on 9/27/23. On 9/27/23 at 5:03 PM, Nurse # 1 entered the following entry into the record. Resident was found in his bed in the supine position [on his back] with mouth agape [open] and using his accessory muscles to breathe. He had blood tinge urine as well. Resident would not respond to his name or sternum rub. Writer [Nurse #1] immediately called 911 and went to grab the AED [automated external defibrillator]. Writer [Nurse #1] held pt [patient] airway opened until EMS [Emergency Medical Services] arrived. Resident BP [blood pressure] was very low and he was clammy and hot. He had a fever of 102 and BP was 82/46. NP [Nurse Practitioner] [Name of Nurse Practitioner] was notified of the emergency transfer out to the ER [emergency room ]. Resident # 3's 9/27/23 EMS records revealed EMS received the facility's call at 2:53 PM and arrived on the scene at 3:02 PM. They noted the following in their EMS assessment. At 3:05 PM Resident #3's vital signs were BP 84/53; pulse 94; respirations 19 and oxygen level 93%. The resident's temperature was 102.1 degrees Fahrenheit. There was visible blood in Resident # 3's catheter. Upon initial EMS arrival, Resident # 3 was unresponsive, and his skin was hot. He was moved to the stretcher, and once on the stretcher, he opened his eyes briefly. Several IV (intravenous attempts) were made, and a successful IV was established. The resident began to respond to voice, but only with one- word answers. The Lead Paramedic that had responded on 9/27/23 was interviewed on 12/4/23 at 4:30 PM and reported the following. She had been concerned he might not live given his condition. Review of Resident # 3's emergency room notes revealed the physician documented EMS reported, they [EMS] state staff at facility was unable to answer most of her [the paramedic's] questions about what baseline is. Resident # 3's hospital admission history and physical revealed the physician noted the following information on 9/27/23. In the emergency room Resident # 3's blood pressure was 64/36; heart rate 118, respirations 23 and temperature 39.6 degrees Celsius. (103.28 Fahrenheit). His WBC (white blood count) was high at 28 (normal range 4.2 to 10.9). The physician noted Resident # 3 was obtunded and met the criteria for septic shock. The physician also noted his hypotension did not respond to fluid resuscitation and he was given Levophed (a medication that can raise the blood pressure in septic shock). A central line (a catheter line placed in the large vein above the heart for fluids and medications) was placed and the resident was given antibiotics. Resident # 3 was hospitalized for treatment in the Intensive Care Unit. He remained In ICU until 10/1/23. He remained hospitalized until 10/4/23. Resident # 3's 10/4/23 hospital discharge summary listed Resident # 3's first two discharge diagnoses as septic shock and urinary catheter associated urinary tract infection. The discharge summary also noted, His AMS [altered mental status] was resolved after receiving antimicrobials, etiology due to sepsis. (The reason for the altered mental status was due to sepsis.) On 10/4/23, Resident # 3 was transferred back to the facility for care. Resident # 3's physician was interviewed on 12/4/23 at 11:11 AM. NA # 1 and Nurse # 3's 9/27/23 observations were shared with the physician. The physician reported the following. Based on the observations of NA # 1 and Nurse # 3, it did appear Resident # 3 experienced a change in condition on the AM of 9/27/23 and he should have been notified in the morning of 9/27/23. Resident # 3's physician was interviewed regarding possible danger if the facility staff delayed in notifying the provider about changes in condition in residents. According to the physician the outcome of a delay in physician notification could be different on a case-by-case scenario. On 12/5/23 at 2:56 PM the Administrator was informed of Immediate Jeopardy and subsequently provided the following Immediate Jeopardy removal plan. Removal Plan F580 Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Resident #3 was found nonresponsive by the lead nurse on the afternoon of 9/27/23. Resident was discharged to the hospital via Emergency Medical Services at 2:53 p.m. Resident #3 is currently a resident of the facility and had no noted change of condition when assessed by the Director of Nurses when readmitted to the facility on [DATE] or on 12/05/2023. Current residents are at risk of experiencing a change in condition that requires assessment and notification of the physician. On 12/5/2023, the Director of Nurses met with all floor nurses and initiated assessment of all current residents to identify any resident with any change in condition to include: Any symptom, sign or apparent discomfort that is: acute or sudden in onset, and is a marked change (i.e., more severe) in relation to usual symptoms and signs, or unrelieved by measures already prescribed and where physician notification of the resident change in condition was delayed. 4 of 86 current residents were assessed by the assigned nurse or Director of Nurses and identified as having a new change in condition and the physician was notified on 12/5/23 by the assigned nurse or Director of Nurses. On 12/06/2023 the Regional Nurse Consultant audited all residents transferred to the hospital in the last 30 days (11/01/2023- 12/06/2023) for timely notification of the physician. The physician of all 13 residents who were transferred to the hospital was notified when the change in condition was observed by the attending nurse. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 12/05/2023 the Director of Nurses/Nurse Consultant and Staff Development Coordinator began in servicing all licensed nurses, Registered Nurses (RN) and Licensed Practical Nurses (LPN), certified nursing assistants and medication aides (full time, part time, and as needed, including agency) on any change in condition to include: Any symptom, sign or apparent discomfort that is: acute or sudden in onset, and is a marked change (i.e., more severe) in relation to usual symptoms and signs, or unrelieved by measures already prescribed. Additional education included, if resident's condition worsened and nurse's assessment warrants, the nurse is to activate emergency medical services. At the time the change is observed, the Physician and family/responsible party are to be notified to ensure the resident receives the care needed to address the change. The Director of Nurses will ensure that all licensed nurses, RN's, LPN's, and CNA's, Med Aides (full time, part time, and as needed including agency) who do not complete the in-service training by 12/06/2023 will not be allowed to work until the training is completed. This in-service was incorporated into the new employee facility and agency orientation for all licensed nurses and certified nursing assistants (full time, part time, and as needed including agency.) Alleged date of IJ removal 12/07/2023 Onsite validation of the immediate jeopardy removal plan was completed on 12/8/23. Documentation of all the residents' assessments for change in condition on 12/5/23 were reviewed and verified the physician was notified for the four residents identified with changes in condition and verbal orders were received and implemented as determined necessary by the physician. Nursing staff (licensed practical nurses, registered nurses, nurse aides, medication aides) who worked different shifts were interviewed and verified they had received training on what constituted a change in condition, the steps to take when a change in condition is first identified, and steps to take if a change in condition worsened to include activation of emergency medical services. Inservice sign-in logs verified the education was provided as indicated. This education was confirmed to be added to the new employee facility and agency orientation for licensed and unlicensed nursing staff. The facility's immediate jeopardy removal date of 12/7/23 was validated.

Based on observation, record review, resident, staff, paramedic, and physician interview the facility failed to effectively assess and address a significant change in condition for one (Resident # 3) of two sampled residents whose condition necessitated Emergency Medical Services (EMS) to be called. Resident # 3 had a history of sepsis (when an infection triggers widespread inflammation in a person's body which can lead to organ damage) and on the morning of 9/27/23 Nurse Aide #1 and Nurse #3 observed Resident # 3 was experiencing a change in condition prior to the lunch meal that included: a low blood pressure, slurred speech, sluggishness, inability to carry on a conversation per his norm, inability to help in his care per his norm, and bloody urine in his catheter. Resident # 3 was found in the afternoon on 9/27/23 unresponsive, with a temperature reading of 102 degrees Fahrenheit, and using accessory respiratory muscles to breathe (muscles other than the diaphragm and muscles within the rib cage which are used in labored breathing). EMS was called at 2:53 PM. Upon their arrival, EMS also found Resident # 3 to be unresponsive and with what appeared as an undissolved pill in the resident's mouth. Resident # 3 was transferred by EMS to the hospital where he was admitted to the hospital Intensive Care Unit (ICU) with severe sepsis with septic shock (when a person is not getting enough blood flow through their body). Immediate Jeopardy began on 9/27/23 when staff failed to comprehensively assess Resident # 3 after a significant change in condition was noted to determine if medical interventions were necessary. Immediate Jeopardy was removed on 12/7/23 when the facility provided an acceptable credible allegation for immediate jeopardy removal. The facility will remain out of compliance at a scope and severity level of D (not actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete staff training and to ensure monitoring systems put in place are effective. The findings included: Resident # 3 was admitted to the facility on [DATE] with diagnoses which in part included spinal stenosis and functional mobility problems. Additionally, the resident had a diagnosis of neurogenic bladder with a chronic indwelling catheter. A review of hospital records revealed Resident # 3 was hospitalized from 7/12/23 to 7/18/23 with sepsis due to a urinary tract infection caused by obstructive nephrolithiasis (kidney stones). A stent (a tube used to hold open a bodily passage) was placed at that time. Resident # 3's quarterly MDS (Minimum Data Set) assessment, dated 7/21/23 coded Resident # 3 as cognitively intact and as having an indwelling catheter. Resident # 3 was also coded as having clear speech, able to feed himself after set up, able to perform his oral care with supervision, and required substantial/maximum assistance with bathing and bed mobility. According to hospital records, Resident # 3 was hospitalized again from 7/29/23 until 8/2/23 with a urinary tract infection and sepsis. On 8/2/23 Resident # 3 was ordered to receive Methenamine Hippurate 1 gram two times per day. (A medication used to prevent returning urinary tract infections). This remained as an active order through 9/27/23. Resident # 3's care plan, updated on 8/10/23, revealed staff had noted Resident # 3 had recurrent urinary tract infections and included this on the care plan update of 8/10/23. One of the interventions was to monitor the resident for symptoms of altered mental status, behavioral changes, and hematuria (bloody urine). On 9/27/23 at 7:10 AM Resident # 3's vital signs were documented as the following by Nurse # 2. Temperature 98; pulse 76; respirations 18; blood pressure 128/62. NA (Nurse Aide) # 1 was the NA who had cared for Resident # 3 on 9/27/23. NA # 1 was interviewed on 11/29/23 at 9:05 AM and reported the following. She had taken his vital signs that morning and they were low. His systolic blood pressure was below 100 and his diastolic was also low. She took them twice to make sure they were registering. She did not enter them into the record and instead reported them to Nurse # 2 as this was the normal protocol. Usually, Resident # 3 did not eat breakfast, but he always asked for coffee and would drink it. That morning he did not ask for or drink coffee. He seemed off. Around 10 AM, she bathed him. Normally he was very alert and would carry on a full conversation during his care. He normally would also assist to turn in the bed and hold onto the rail. That morning, he was not doing nothing. His eyes would open a little bit and then close. He would mumble but not carry on a full conversation. He also had blood in his catheter bag. She told Nurse # 2, Resident # 3's assigned nurse, how he was acting and that he had blood in his catheter bag. That morning the treatment nurse, Nurse #3, also went into Resident # 3's room to do wound treatments for him. She also told Nurse # 3 that Resident # 3 was not acting right. This was before lunch. Nurse # 3 said she would tell Nurse # 1. At lunch time Resident # 3 did not eat anything and she was still concerned. She was hoping they would send him to the hospital. Nurse # 1 did come check him in the afternoon and he was sent out. Nurse # 1, a nurse manager, asked her (NA # 1) why she had not let her know sooner about his condition, and she informed her that she had been alerting Nurse # 2 throughout the day. Nurse # 3 was interviewed on 11/29/23 at 10:15 AM and reported the following. She went to provide wound treatments to Resident # 3 sometime between 10 AM and lunch on 9/27/23. Usually, Resident # 3 would initiate conversation on his own when you entered his room. That morning he did not do so. She could not engage him in conversation. If she would say, Hey [Resident # 3], he would just say, ah . in a slurred way. His speech was slurred, and he was sluggish. Normally he would help them turn, but he did not help that morning with turning for treatments. She knew something was not right with him. NA # 1 also told her he had not been acting right. After she left the room, she went to Nurse # 2 (Resident # 3's assigned nurse) and told her, You better check on [Resident # 3]. He's not acting right. Nurse # 2 told her that it had taken her awhile to get him to take his morning medications, but he took them and he was on an antibiotic. She (Nurse # 2) had also said she would check on him. According to Nurse # 3, if Resident # 3 had been assigned to her then she would have called the provider at that point in the morning given the change she had seen in Resident # 3 and alerted the provider about the change. She thought that was what Nurse # 2 was going to do after she spoke to Nurse # 2 in the morning. Therefore, she went on to do her treatments. Later after lunch she returned to Resident #3's unit and NA # 1 again told her Resident # 3 still was not right and Nurse # 2 had not done anything. At that point, Nurse # 3 stated she went to Nurse # 1 and Nurse # 1 immediately went to check on Resident # 3. Nurse # 1 was interviewed on 11/29/23 at 4:30 PM and reported the following. Nurse # 1 stated she was the rehabilitation nurse manager, but also served as point of contact for the unit where Resident # 3 resided. On 9/27/23 she had been in her office when Nurse # 3 alerted her Resident # 3 was not acting right. She went right away to check on him. It was around 3:00 or 4:00 PM when she was alerted. When she assessed him, she found he could not talk and would not follow commands but he did respond to a sternal rub a little. She immediately had him sent out to the emergency room (ER). Nurse # 2 was interviewed on 11/28/23 at 3:00 PM and again on 11/29/23 at 5:30 PM and reported the following about 9/27/23. It was not unusual for Resident # 3 to be groggy or sleepy in the morning. She just recalled Resident # 3 took his medications that morning, throughout the day she was in and out to check on him, and he was eventually sent out because he was not responding. She did not recall if she took his vital signs as she was in and out checking on him and did not recall the actions she took while checking in on him. There was no further nursing assessment, progress note, or vital signs noted in Resident # 3's record after 7:10 AM on 9/27/23 until the following note was documented at 5:03 PM by Nurse # 1. On 9/27/23 at 5:03 PM, Nurse # 1 entered the following entry into Resident #3's record. Resident was found in his bed in the supine [on his back] position with mouth agape [open] and using his accessory muscles to breathe. He had blood tinge urine as well. Resident would not respond to his name or sternum rub. Writer immediately called 911 and went to grab the AED (automated external defibrillator). Writer held pt [patient] airway opened until EMS (emergency medical services) arrived. Resident BP (blood pressure) was very low and he was clammy and hot. He had a fever of 102 and bp (blood pressure) was 82/46. NP [Name of Nurse Practitioner] was notified of the emergency transfer out to the ER. Resident # 3's 9/27/23 EMS records revealed EMS received the facility's call at 2:53 PM and arrived on the scene at 3:02 PM. They noted the following in their EMS assessment. At 3:05 PM Resident #3's vital signs were BP 84/53; pulse 94; respirations 19 and oxygen level 93%. The resident's temperature was 102.1. There was visible blood in Resident # 3's catheter. Upon initial EMS arrival, Resident # 3 was unresponsive and his skin was hot. He was moved to the stretcher, and once on the stretcher, he opened his eyes briefly. Several IV (intravenous attempts) were made, and a successful IV was established. The resident began to respond to voice, but only with one- word answers. The Paramedic further noted, while assessing the resident, EMS noticed, what looked like an undissolved pill in the patient's mouth. The hospital was made aware of this when transferring patient care. The Lead Paramedic that had responded on 9/27/23 was interviewed on 12/4/23 at 4:30 PM and reported the following. From her assessment at arrival to the facility, she had thought Resident # 3 could be septic. In route to the hospital, they had noticed what appeared to be a pill in his mouth that had not completely dissolved. She had been concerned he might not live given his condition. Review of Resident # 3's hospital record revealed on 9/27/23 the physician documented EMS reported, they [EMS] state staff at facility was unable to answer most of her [the paramedic's] questions about what baseline is. Resident # 3's hospital admission history and physical revealed the physician noted the following information on 9/27/23. In the emergency room Resident # 3's blood pressure was 64/36; heart rate 118, respirations 23 and temperature 39.6 degrees Celsius (103.28 Fahrenheit). His WBC (white blood count) was 28 (normal range 4.2 to 10.9) . The physician noted Resident # 3 was obtunded (decreased level of consciousness) and met the criteria for septic shock. The physician also noted his hypotension did not respond to fluid resuscitation and he was given Levophed (a medication that can raise the blood pressure in septic shock). A central line (a catheter line placed in the large vein above the heart for fluids and medications) was placed, and Resident # 3 was given antibiotics. Resident # 3 was hospitalized for treatment in the Intensive Care Unit. He remained In ICU until 10/1/23. He remained hospitalized until 10/4/23. Resident # 3's 10/4/23 hospital discharge summary listed Resident # 3's first two discharge diagnoses as septic shock and indwelling catheter associated urinary tract infection. The discharge summary also noted His AMS [altered mental status] was resolved after receiving antimicrobials, etiology due to sepsis. He was directed to follow up with a urologist following discharge and placed on a medication to help with hypotension (Midodrine). On 10/4/23, Resident # 3 was transferred back to the facility for care. Resident # 3 was interviewed on 11/28/23 at 2:10 PM. During the interview, Resident # 3 was observed to be very alert, articulate in his conversation, and capable of using his hands and arms to use his cell phone and access information during the interview. Resident # 4 reported the following. He had been concerned that the facility staff did not send him to the hospital earlier on 9/27/23. He had already had other urinary tract infections that had made him very sick. Nurse # 2 had given him his morning medications that day and he did not recall anything after that. After he recovered, NA # 1 had later told him that she could not get him to wake up during the morning on 9/27/23 and had alerted Nurse # 2 about this. He was concerned that when NA # 1 could not arouse him that nothing had been done at that point. The DON (Director of Nursing) was interviewed on 11/29/23 at 11:00 AM and reported the following. She had reviewed Resident # 3's record and found no evidence of an assessment or vital signs being taken after the vital signs at 7:10 AM on 9/27/23. It would be her expectation that the resident would have been assessed when a change was observed, and she wished he had been sent out sooner. Resident # 3's physician was interviewed on 12/4/23 at 11:11 AM. NA # 1 and Nurse # 3's 9/27/23 observations were shared with the physician. The physician reported it was the expectation that an assessment needed to be done when a change in condition was noted, and from NA #1's and Nurse # 3's observations it appeared Resident # 3 had experienced a change prior to lunch on 9/27/23. On 12/5/23 at 2:56 PM the Administrator was informed of Immediate Jeopardy. The facility provided the following Immediate Jeopardy (IJ) removal plan. Removal Plan F684 Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Resident #3 was found nonresponsive by the lead nurse on the afternoon of 9/27/23. Resident was discharged to the hospital via Emergency Medical Services at 2:53 p.m. Resident #3 is currently a resident of the facility and had no noted change of condition when assessed by the Director of Nurses when readmitted to the facility on [DATE] and on 12/05/2023. Current residents are at risk of experiencing a change in condition that requires assessment and notification of the physician. On 12/5/2023, the Director of Nurses met with all floor nurses and initiated assessment of all current residents to identify any resident with any acute change in condition to include: Any symptom, sign or apparent discomfort that is: acute or sudden in onset, and is a marked change (i.e., more severe) in relation to usual symptoms and signs, or unrelieved by measures already prescribed. 4 of 86 current residents were identified by the assigned nurse or Director of Nurses as having a new change in condition. Notification of the Physician was conducted at the time the change was observed. The attending Physician gave verbal orders related the individual resident's change as he determined necessary on 12/5/23. The responsible party/family was notified of this change and new orders prescribed after speaking with the Physician. The orders were carried out as prescribed on 12/5/23. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 12/05/2023 the Director of Nurses/Nurse Consultant and Staff Development Coordinator began in servicing all licensed nurses, Registered Nurses (RN) and Licensed Practical Nurses (LPN), certified nursing assistants and medication aides (full time, part time, and prn including agency) on any change in condition to include: Any symptom, sign or apparent discomfort that is: acute or sudden in onset, and is a marked change (i.e., more severe) in relation to usual symptoms and signs, or unrelieved by measures already prescribed. Additional education included, if resident's condition worsened and nurse's assessment warrants, the nurse is to activate emergency medical services. At the time the change is observed, the Physician and family/responsible party are to be notified to ensure the resident receives the care needed to address the change. The Director of Nurses will ensure that all licensed nurses, RN's, LPN's, and CNA's, Med Aides (full time, part time, and prn including agency) who do not complete the in-service training by 12/06/2023 will not be allowed to work until the training is completed. This in-service was incorporated into the new employee facility and agency orientation for all licensed nurses and certified nursing assistants (full time, part time, and prn including agency.) Alleged date of IJ removal 12/07/2023 Onsite validation of the immediate jeopardy removal plan was completed on 12/8/23. Documentation of all the residents' assessments for change in condition on 12/5/23 were reviewed and verified the physician was notified for the four residents identified with changes in condition and verbal orders were received and implemented as determined necessary by the physician. Nursing staff (licensed practical nurses, registered nurses, nurse aides, medication aides) who worked different shifts were interviewed and verified they had received training on what constituted a change in condition, the steps to take when a change in condition is first identified, and steps to take if a change in condition worsened to include activation of emergency medical services. Inservice sign-in logs verified the education was provided as indicated. This education was confirmed to be added to the new employee facility and agency orientation for licensed and unlicensed nursing staff. The facility's immediate jeopardy removal date of 12/7/23 was validated.

Based on record review and staff interview the facility failed to assure they had provided training for all their staff on the facility's QAPI (Quality Assurance Performance Improvement) program. The findings included: During a review of facility records on 12/8/23, there was no documentation that the facility had incorporated training for all their staff on the facility's QAPI. The Administrator was interviewed on 12/8/23 at 5:30 PM and reported the following. She began her employment as facility Administrator in June 2023. She had been working on the facility's quality improvement program since she began as the Administrator and tried to include her line staff in the quality improvement program, but she had not educated or included 100% of her staff. She had also looked through previous records from the prior Administrator's files and had found no evidence that the facility had included training and involvement from 100% of their staff regarding QAPI.

Based on record review, resident interview, and staff interview the facility failed to ensure a resident's personal possessions were retained when her belongings were packed by staff when she was moved to a different room. This was for one (Resident # 4) of one sampled resident who had personal items packed away without the resident being present. The findings included: Resident # 4 was admitted to the facility on [DATE]. Review of the record revealed Resident # 4 was moved to another room within the facility on 7/19/23 from a room in which she had resided since her admitted [DATE]. Review of a grievance form, dated 7/25/23, revealed a grievance was filed by a family member on Resident # 4's behalf. The form included information that multiple personal items had not been returned to Resident # 4 following her move. These included her phone, television, clothing, refrigerator, and hygiene items. There were documented facility efforts to return items and resolve issues on the form. On 8/16/23 another grievance was filed by Resident # 4 when she reported that her phone chargers and remote were missing. The grievance form included facility documentation the items were returned. On 11/2/23 another grievance form was completed for Resident # 4 during a care plan meeting. The grievance form noted Resident # 4 reported she was still missing bras, clothing, and a clock. The grievance form noted Resident # 4 was stating the items had been missing since her room change. The grievance form included facility documentation the facility had made efforts to replace items and resolve the issue. Resident # 4's Minimum Data Set assessment, dated 11/3/23, coded Resident # 4 as cognitively intact. On 11/5/23 another grievance form included the information that Resident # 4 voiced during a resident council meeting that her photo albums had been missing since the room change. Resident # 4 was interviewed on 11/28/23 at 4:10 PM and reported the following. She had been moved on a date in July to a temporary room. She had not been present when her things were packed. She had been told by staff they needed to clear her initial room of everything, and her things would be returned to her after the temporary move was complete. After the temporary move was over, some of her things had been returned to her and others had not been returned to her. According to Resident # 4 she was still missing the bras and photo albums which had been mentioned in the grievances. A Maintenance Employee was interviewed on 11/18/23 at 1:40 PM and reported the following. In July, 2023, he had packed Resident # 4's belongings in a box and put them away in storage. He did not know anything about missing items for Resident # 4. The Administrator and the facility Social Worker were interviewed on 11/29/23 at 12:00 PM. The Social Worker reported the following. There had been an environmental issue identified in Resident # 4's room on 7/19/23. It had been explained to Resident # 4 the nature of the issue, her things would need to be packed and stored for an interim, and she would need to be moved temporarily while the issue was addressed. Because of the nature of the issue, it had been best that Resident # 4 not go back in the room after the issue was identified. Resident # 4 understood this and was in the hallway as her things were packed. The Administrator reported the following. Resident # 4's personal items had been placed in an empty storage room after being packed by the maintenance employee for her. There had never been any accounting system of Resident # 4's personal belongings and exactly what was packed away into the box prior to the move. The Administrator had just begun her position at the facility on 7/7/23, which was a few days prior to Resident # 4's issue needing to be addressed. At the time, it was a priority issue to get the environmental issue addressed. After the move, Resident # 4 and her family member repeatedly came to her to voice that personal items were missing. They stated the items had been missing since the temporary move in July, 2023. She filled out grievance forms each time and tried to address all the items. She replaced what she could by going upon what the resident reportedly said she had before the move. On 11/2/23 when yet another grievance was filed regarding missing items by Resident #4 going back to July, 2023, the Administrator recognized that there was a problem in that the facility did not have an inventory sheet to account for personal items packed away if the need arose. Therefore, she initiated a plan of correction with her management team. The Administrator presented the following plan of correction she had completed. 1. Resident # 4 had a necessary room change on 7/19/23. Post room change resident stated she was missing several items. The items that were in storage were returned to her and/or purchased by the facility. On 11/2/23 the Administrator identified the facility was not keeping an inventory list of resident's personal belongings if a resident was transferred in the facility or if for any reason the facility was storing personal belongings. This was discovered due to resident # 4 stating she had photo albums that were not returned to her during a room change in July 2023. A grievance form was written and staff checked the facility and photo albums were not found at this time. This will be an on-going investigation. 2. Other residents who change rooms in the facility or who need personal belongings put into storage are determined to be at risk for lost personal belongings. Residents or responsible parties of residents who were relocated within the facility in July, when the facility had an environmental challenge, were interviewed by the Social Worker to ensure all property was returned. There were no negative findings. 3. Systemic Measures: Residents who are being discharged from the facility will have the family pack their belongings. Those residents whose belongings cannot be removed by the family or those who are transferred within the facility will have an inventory of the items packed up to be relocated to storage and/or the new room. This inventory will be documented along with the exact location of where belongings will be stored by the person packing the belongings. A copy of the inventory will be placed with the items and/or given to the resident as well as a copy being maintained in the housekeeping office if needed for future reference to ensure all of the personal property is returned per the inventory sheet. If there is a discrepancy when the items are returned, the discrepancy will be reported to the Administrator and the grievance policy related to lost items will be followed. 4. The implementation of this plan was discussed and agreed upon on 11/3/23 by the interdisciplinary team which includes the Administrator, Director of Nursing, Social Workers, Maintenance/Housekeeping Director, Rehabilitation Director, Admission and Marketing Team, Dietary Supervisor and Activity Director. The maintenance/housekeeping supervisor, as of 11/3/23 is monitoring this process for effectiveness for residents whose personal belongings are to be transferred to a different room or stored within the facility. The results of the monitoring of personal belongings will be presented to the quality assurance performance improvement committee for 3 months to determine effectiveness. Additional interventions will be developed and implemented by the committee as determined necessary. The facility alleged this plan of correction was completed on 11/3/23. The facility's corrective action plan was validated on 12/1/23 by the following. Multiple residents were interviewed during an initial tour of the facility which took place on 11/27/23. The residents who were interviewed had no complaints regarding the safe- guarding of their items. The Administrator presented documentation of efforts to resolve Resident # 4's grievances, which led her to recognize the need for and develop a plan of correction to safeguard personal items. The Administrator presented a signed in-service sheet noting the interdisciplinary team members had attended the in-service meeting on 11/3/23 as noted in their plan of correction. The Administrator also provided an inventory sheet the facility had adopted to use to ensure the tracking and safe- guarding of personal items when they were packed. Per the Administrator, the facility was monitoring their system and as of the date of the survey, no other residents' belongings had been packed away for storage since their new plan was initiated. The facility's plan of correction with a completion date of 11/3/23 was validated.

Based on observation, record review, resident interviews, and staff interviews the facility failed to protect the rights of two residents (Resident # 5 and Resident # 6) to be free of abuse. Following a verbal altercation, Resident # 6, who was cognitively intact, reported feeling threatened by Resident # 5, who was cognitively impaired. Resident # 6 and Resident # 5 then became involved in a physical fight during which Resident # 6 held Resident # 5 down on his bed by Resident # 5's neck and hit him multiple times in the face. Resident # 5 sustained scratches to his neck and finger. This was for two of three sampled residents reviewed for abuse. The findings included: Record review revealed Resident # 5 was admitted to the facility on [DATE]. Resident # 5's diagnoses in part included dementia, depression, diabetes, and history of right lower leg amputation and history of left foot amputation for which he used prosthetic devices. Resident # 5's annual Minimum Data Set assessment, dated 3/8/23, revealed Resident # 5 was severely cognitively impaired. He was coded as being independent in his locomotion around the unit on which he resided. Resident # 5 was not coded as having behavioral problems. Record review revealed Resident # 6 was admitted to the facility on [DATE]. Resident # 6's diagnoses in part included cancer, chronic obstructive pulmonary disease, and a history of heart attack. Resident # 6's quarterly Minimum Data Set assessment, dated 5/17/23, coded Resident # 6 as cognitively intact. He was assessed to need oversight supervision for locomotion around the unit on which he resided. He was not assessed to have behavioral problems. Review of Resident # 6 and Resident # 5's records revealed they shared a room together up until the date of 5/18/23. On 5/18/23 at 10:19 PM Nurse # 1 made the following entry into Resident # 5's record. Writer was attempting to give insulin. Resident stated 'No, I'm not taking that I just received that, get the (expletive) on.' Writer attempted to explain the type of insulin being given. Resident stated 'dumb (expletive) I'm not taking it.' Writer exited. Writer heard roommate state 'Stop talking to the nurses like that.' (Resident # 5) stated 'well if you don't like it come on over and do something about it.' (Resident # 5) then stated 'I'm sick of your mouth and theirs.' After that statement residents connected physically. Review of the facility's investigative file regarding the 5/18/23 incident revealed the following written statement by Nurse # 1. At around 8 PM writer was passing medication. Once I got to (Resident # 5's room) he allowed me to take his blood sugar. Insulin offered. Resident stated 'What the (expletive) are you giving me?' Writer explained what insulin it was, he then proceeded to say 'No I'm not taking that get the (expletive) on.' He again stated 'dumb (expletive) nurses I'm not taking that.' I then exited the room. I then started giving medication to (Resident #6). Once his medication was given, they proceeded to talk. Writer overheard (Resident # 6) state 'Stop talking to the nurses like that.' (Resident # 5) stated 'well if you don't like it come over and do something about it.' A few minutes later I could hear what sounded like hits landed. I walked in and noticed (Resident # 6) on top of (Resident # 5) with his left hand around his neck and the right hand punching him. (Resident # 5) did hit back. After a few minutes I was able to separate the two. (Resident # 5) was placed in TV room until police came into the facility. According to Resident # 5's record and the facility's investigative file, Resident # 5 was moved to a private room and did not reside with Resident # 6 following the altercation. On 5/18/23 at 10:16 AM Nurse # 3, who worked as the facility social worker, noted the following. On 5/18/23, she had talked to Resident # 5, who stated he did not recall anything about the altercation and did not know who Resident # 6 was. Resident # 5 also reported he did not recall talking to the police. He further reported to Nurse # 3 that if everyone just leaves me alone everything will be fine. Nurse # 3 noted a referral was sent to for psychological services. Nurse # 3 noted she visited to check on Resident # 5 again on 5/22/23, 5/24/23, and 5/25/23. In Nurse # 3's 5/25/23 notation, she documented that Resident # 5 was sick of being asked questions about the incident. He continued to deny he knew Resident # 6. On 5/25/23 Resident # 5 was seen for a comprehensive psychotherapy assessment. Review of the therapist's report revealed Resident # 5 reported he did not recall any memory of an altercation. The psychotherapist further noted the following. He was alert to person and place, but not fully oriented to time or situation. He had cognitive decline. During the conversation with the therapist he would at times rock back and forth while sitting on his bed and crying. He answered some of the therapist's questions and then concluded with her by saying, 'I am through talking with you.' The therapist noted that his loss of independence and his environment were contributing to depression. On 5/18/23 at 10:22 AM Nurse # 3 noted she also visited with Resident # 6 and spoke to him about the incident. Nurse # 3 documented that Resident # 6 reported the following to her. Resident # 5 was cursing at the staff, and he asked Resident # 5 to stop being ugly to the staff. Resident # 5 then told Resident # 6 to come over and make him stop. Words were exchanged between the two of them. Then Resident # 5 walked towards his (Resident #6's) bed and he (Resident # 6) felt endangered and stood up himself. Resident # 6 did not recall much following that. Nurse # 3 further noted that Resident # 6 was very soft spoken and appeared upset about the incident while stating, 'I don't want to get in trouble. He's (Resident # 5) mean to the staff.' Nurse # 3 concluded her notation by documenting that an emergency psychiatric referral was made for Resident # 6. According to the facility's investigative file, Resident # 5 had sustained the following injuries: a small scratch to his neck, redness to both lateral sides of his neck , 3 small scratches to his left ring finger with some swelling. Resident # 6 had not sustained injuries. Review of a police report noting the incident revealed the following information. The police officer had responded on 5/18/23 at 8:10 PM. The police officer noted he had spoken to Resident # 5 who stated he had gotten into a fight with Resident # 6 because he was tired of hearing his mouth. The police officer also spoke to Resident # 6 and noted Resident # 6 reported Resident # 5 was being disrespectful to the nurses and he had told him to relax and let the nurses help him. Then Resident # 6 stated he had enough of Resident # 5's mouth and got into a fight with him. The officer noted Resident # 5 was bleeding from his neck and left pinky finger due to a scratch. Nurse # 1 was interviewed on 5/31/23 at 4:25 PM and reported the following about the incident. Resident # 5 and Resident # 6 had no history of prior altercations of which she was aware. Resident # 5 could at times curse at staff, but not at residents. Resident # 6 had no history of aggressive behavior. Both the residents had been sitting on their own beds when she left the room on the night of the incident. After she left the room, she did hear them continue to talk from the hallway, but Resident # 6 used a rollator walker to move around and at times needed oxygen. Resident # 5 used prosthetic devices. She thought it was just talk between them. Then she heard a noise as if someone was hitting someone. She went immediately into the room. When she entered Resident # 6 was not physically on top of Resident # 5. Rather, Resident # 6 was standing over the top of Resident # 5 while Resident # 5 was in his bed. Resident # 6 was holding Resident # 5 down with his left hand. Resident # 6 had done this by cupping his left hand around Resident # 5's neck. It was clear to Nurse # 1 that Resident # 6 was not trying to strangle Resident # 5 but had positioned his left hand to hold him down. She (Nurse # 1) witnessed Resident # 6 use his right hand to punch Resident # 5 on the left side of Resident # 5's face. Resident # 6 did this about four times. Resident # 5 was also hitting back. She (Nurse # 1) witnessed Resident # 5 hitting Resident # 6 in the torso about two times. She yelled at them to stop, and it took about one minute and she was able to get them to stop. They were separated and the police were called. The police tried to ascertain who had hit who first, but could not determine that. At the time of the police arrival, Resident # 5 wanted to continue fighting. Following the altercation, Resident # 5 had some scratches to his finger and neck, with a little blood from his finger scratch. Resident # 6 had no injuries. According to the nurse, there was nothing that signified to her that the incident would have occurred before it actually did. Nurse # 2 was interviewed on 5/31/23 at 12:30 PM. Nurse # 2 had routinely cared for both Resident # 5 and Resident # 6 prior to the incident and was familiar with them. She reported the two residents had no history of altercations prior to the incident of 5/18/23. Resident # 6 was interviewed on 5/31/23 at 1:00 PM and again at 4:15 PM. Resident # 6 reported the following. On the night of the incident, Resident # 5 was cursing the nurses and he (Resident # 6) asked him to stop. Then Resident # 5 came over to his (Resident # 6's) side of the room and threatened him. Resident # 5 hit him first. He (Resident # 6) then went to Resident # 5's side of the room and held him on the bed and hit him. They had never had an altercation before that date. Nurse # 3 was interviewed on 5/31/23 at 1:15 PM and reported the following. She was employed as the facility social worker. There had been no altercations between Resident # 5 and Resident # 6 prior to the incident. They were immediately separated, and psychological referrals were placed for both residents. Resident # 5 reported he had had no recall of the incident. On 5/31/23 at 3:45 PM the Administrator, Director of Nursing (DON) and facility corporate Nurse Consultant were interviewed. They reported the following. They had investigated the incident and found no evidence the altercation could have been anticipated by their staff. Immediately following the incident, the police and Director of Nursing were called. The DON came to the facility the night of the incident to assure safety for Residents # 5, Resident # 6, and other residents. Resident # 5 was placed in a private room where he currently remained. The facility completed a review of incident reports to assure there were no other residents at risk for altercations that could lead to abuse. They talked to residents to assure compatibility between roommates. They also completed education training for their staff regarding abuse and dealing with challenging behaviors in residents. They had a system in place to monitor for future occurrences by discussing clinical needs in daily meetings, reviewing grievance reports, and monitoring clinical records for behavioral issues. They had reviewed the care plans and updated as needed. On 5/31/23 at 5:55 PM the Administrator was notified of immediate jeopardy. The Administrator presented the following corrective action plan. Date of Incident was 5/18/2023. Residents involved were Resident #5 in A Bed and Resident #6 in B Bed. Resident #5 has a Brief Interview for Mental Status (BIMS) of 7 and Resident #6 has a BIMs of 15. There were no staff involved. Initial Report Why Investigation Was Needed: Resident on Resident Altercation reported by staff. Resident 5 obtained scratches from altercation with roommate Resident #6. A 24 hour report was submitted. The police were notified on 5/18/2023 and came out to interview Residents #5 and #6. There were no employees involved. Notifications to family and physician were made for both Residents #5 and #6. Skin assessments by assigned nurse were completed for Residents #5 and #6 on 5/18/2023. First aide was rendered as follows: assigned nurse cleansed scratches for Resident #5 with normal saline, applied with an antibiotic ointment and left opened to air. Head to toe assessments were completed for Residents #5 and #6. Both residents were assessed for pain and signs/symptoms of injuries with no other signs or symptoms of injuries noted. Final Investigation The following documents were completed: Witness statements, audits education, quality assurance. The timeline of events is as follows: At 8:50pm Residents #5 and #6 were separated immediately and Resident #5 was moved to another hall. Body audits were completed on Residents #5 and #6 and both residents were assessed for injuries. Police were called and interviewed Residents #5 and #6. Physician and Responsible Parties were notified for both Residents #5 and #6. Adult Protective Services was notified of incident. The root cause of the event was: Resident to resident altercation due to both residents having poor impulse control. The root cause analysis statement is as follows: Resident to resident altercation is related to unanticipated poor impulse control. Plan for Correcting specific area of concern identified, including the process that led to the concern: Corrective action for resident involved: On 5/18/2023 the assigned nurses assessed the residents for any noted change in condition or signs/symptoms of injuries. Residents were immediately separated and Resident #5 was moved to another room on another hallway. Both residents were monitored by floor nurses and nurse aides assigned to respective halls (200 and 500) for any further behaviors or signs/symptoms of injuries. Resident #5 sustained some scratches on his left hand. Root cause of injury was resident to resident altercation related to poor impulse control. Resident #5 does not currently have a roommate. Resident #6 does have a roommate. Interventions to address root cause of poor impulse control and to prevent further incidents are as follows: Both Resident #5 and Resident #6 were referred for psychological evaluations. Evaluation has been completed on Resident #5 on 5/ 25 /2023. Resident #6 has been referred for psych services but was out of the building at the time psych services visited on 5/25/23 and will be seen on their next visit. Corrective action for potentially impacted residents: On 5/19/2023 the Director of Nursing audited incident reports for the last 14 days for any incidents of resident altercations with none found. On 5/19/2023 the social worker interviewed alert and oriented residents on the 200 Hall with no room compatibility issues identified. Systemic changes: On 5/18/2023 the Director of Nursing and Assistant Director of Nursing began an in-service of all staff (including agency) on Resident to Resident Abuse and Handling Challenging Behaviors. As of 5/26/2023, 100% of staff have attended the in-service. The Director of Nursing will ensure that any of the above mentioned staff who do not complete the in-service by 5/26/2023 will not be allowed to work until the training is completed. Quality Assurance: Quality assurance monitoring will be completed by the Administrator/Director of Nursing on an ongoing basis utilizing facility processes related to the Daily Clinical Review Process for change in condition, the Daily Standup Meeting with the interdisciplinary team, which includes a review of incident reports and applicable interventions; an ongoing review of grievances and a monthly review of Resident Council Minutes. The Daily Clinical Review is separate and distinct from the Daily Standup Meeting. Daily Clinical Review process for a change in condition is: Review of the Real Time Report, the 24 hour report from the electronic health record system, search of key words by clinical staff, and review of staff 24 hour reports collected from clinical floor staff. (Key word search is the process of looking for words anywhere in the record utilizing the search engine). The interdisciplinary team members include: Administrator, Director of Nursing, Minimum Data Set Coordinator, Activities Director, Assistant Director of Nursing, Social Worker, Dietary Manager, and Rehab Director. The Social worker will complete ongoing monitoring through interviews of 25 alert and oriented residents on various halls weekly x 2 for any concerns with roommate compatibility. Reports will be presented to the weekly QA Committee by the Administrator or Director of Nursing to ensure corrective action is initiated as appropriate. The Administrator and Director of Nursing are responsible for this plan of correction. Compliance will be monitored and ongoing auditing reviewed at the weekly QA meeting. The weekly QA meeting is attended by the Administrator, Director of Nursing, MDS Coordinator, Rehab Director, Health Information Manager, and Dietary Manager. Corrective Action Completion Date: 5/26/2023 On 5/31/23 the facility's plan of correction was validated by the following. Resident # 5 was observed residing in a private room on 5/30/23 at 11:05 AM. The resident appeared without any signs of injury and was able to report he had no complaints about care and treatment. Resident # 6's care plan was updated on 5/19/23 to reflect he had the potential for physical behaviors related to poor impulse control. Multiple interventions were listed on Resident # 6's care plan which included but were not limited to monitoring his behavior and if he became agitated then staff were to intervene before things escalated. The facility presented documented evidence of education for their staff regarding abuse and dealing with residents who displayed challenging behavior. Staff interviews were conducted on 5/31/23 on multiple units which validated education had been provided for staff. Staff also reported in the interviews that they were no residents they felt displayed behaviors that might endanger other residents or place other residents at risk for abuse. On 5/31/23 the facility presented evidence they had audited their incident reports to assure other residents were not in altercations that could lead to abuse. This had been done on 5/19/23. On 5/31/23, the facility's correction date of 5/26/23 was validated.

Based on record review, physician, and staff interviews, the facility failed to prevent an accident when Nurse Aide #2 performed a standing pivot transfer with Resident #11 instead of the care planned slide board transfer which caused her left leg to twist and resulted in a nondisplaced (not out of place) medial malleolus fracture (fracture of the inner bone of the ankle) and transversely oriented (bone broken perpendicular to its length). This was for 1 of 6 residents reviewed for accidents (Resident #11). The findings included: Resident #11 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, coronary artery disease, and heart failure. Review of the care plan dated 11/18/21 for Resident #11 revealed she had an activities of daily living (ADL) self-care performance deficit related to activity intolerance and fatigue. Interventions included: staff assistance with slide board for transfers and use slide board assistive device to transfer. The quarterly Minimum Data Set (MDS) completed on 8/19/22 indicated Resident #11 had moderately impaired cognition and required extensive assistance of one person for bed mobility. The MDS noted transfers and walking did not occur. Review of physician orders for Resident #11 revealed 1000mg (milligrams) of Tylenol was ordered on 8/22/22 three times daily osteoarthritis. Review of the Investigation Report dated 10/4/22 revealed the incident involving Resident #11 occurred on 9/25/22, and the facility became aware of the incident on 9/27/22 at 7:18 PM. It stated Resident #11 reported that her foot got caught under the bed when nurse aide (NA #2) transferred her. The investigation summary included NA #2's statement that on 9/25/22 after lunch meal she transferred Resident #11 from the wheelchair to the bed, and she placed Resident #11's feet in between her legs to perform a standing pivot. NA #2 stated that during the transfer, Resident #11's leg got caught on her leg, and once she was in bed, Resident #11 told her that her leg hurt. Review of a health status note dated 9/25/22 at 2:08 AM written by Medication Aide (MA) #1 revealed she was told by Resident #11 during medication pass that she had pain in her ankle area. Resident #11 told her that NA #2 was helping her get back to bed when her foot twisted during the pivot movement. MA #1 assessed Resident #11's ankle and no swelling/restriction of movement. She provided her with 750 milligrams (mg) of Tylenol and elevated her leg. Interview with MA #1 on 4/20/23 at 11:46 AM revealed she had worked from 7:00 PM on 9/25/22 through 9/26/22 at 7:00 AM. MA #1 stated she could not recall if Resident #11 complained of pain during the shift or not. She further stated Resident #11 kept trying to get out of bed and the NA on duty was assigned to make frequent checks on her throughout the night. MA #1 did not indicate if she had reported this to Nurse #2 or the oncoming day shift staff. NA #3, who worked the evening shift on 9/25/22, was interviewed on 4/20/23 at 12:13 PM. She revealed that around 4:30 PM on 9/25/22, Resident #11 did not complain of pain. NA #3 indicated Resident #11 screamed of pain in the left shin/ankle area when she was changing her after supper meal. She stated she told MA #1 immediately of the change and new onset of pain. MA #1 assessed Resident #11 and told NA #3 that she would address the issue. NA #3 indicated she was more careful with Resident #11 for the rest of her shift. When she asked Resident #11 what happened, Resident #11 told her that NA #2 was transferring her back to bed on first shift, and her foot got caught under the bed or chair. Resident #11 did not complain of pain for the remainder of the night. An interview was attempted with NA #2, but she was not available during the investigation. Review of the September 2022 medication administration record (MAR) for Resident #11 revealed MA #1 administered scheduled Tylenol on 9/25/22 at 9:00 PM with a 1/10 pain scale assessment. Nurse #2 was interviewed on 4/20/23 at 10:44 AM. She revealed she discovered new onset of pain in Resident #11's left leg during her morning shift. She then verbally notified NP #1, who happened to be in the facility, of Resident #11's pain on the morning of 9/26/22. The following orders were created on 9/26/22: oxycodone 5mg every 4 hours as needed (PRN) for pain for 14 days and a portable left hip x-ray for pain and decreased range of motion (ROM). Nurse #2 noted a pain scale of 3/10 at 9:00 AM and 2:00 PM when the scheduled Tylenol was administered on 9/26/22. Review of Nurse Practitioner (NP) #1's assessment of Resident #11 on 9/26/22 revealed she complained of severe left hip pain. Resident #11 told her the hip area hurt constantly but was worse with any movement. Resident #11 reported it started to hurt when she was assisted back to bed from the wheelchair by a staff member. NP #1 ordered an x-ray of the left hip and prescribed oxycodone 5 mg every 4 hours PRN (as needed) for pain. An interview with NP #1 was conducted on 4/18/23 at 2:36 PM, and she revealed she had assessed Resident #11 on 9/26/22 in the morning when she was first notified by Resident #11 of the incident. NP #1 stated she told Nurse #2 on 9/26/22 before noon to order the x-ray, and the x-ray order was placed at 10:09 AM, and it was not uncommon for a 24-hour turnaround for the mobile x-ray company. NP #1 indicated if she had suspected a femur fracture, she would have sent Resident #11 to the emergency room (ER). During the 9/26/22 assessment, Resident did not express exacerbating pain for an urgent response. She stated she had never seen Resident #11 in what appeared to be excruciating pain, and she was treated with Tylenol as ordered for osteoarthritis and pain medication before she was sent to hospital on 9/27/22. Resident #11 was normally bed bound. Continued review of Resident #11's MAR revealed the pain scale was also noted as a 4/10 for both Tylenol administrations at 9:00 AM and 2:00 PM on 9/27/22. Oxycodone was not administered to Resident #11 on 9/26/22. Review of the 9/27/22 mobile x-ray results performed at the facility prior to Resident #11's discharge to the hospital revealed an osteochondral (damage to cartilage and underlying bone) fracture of the medial femoral condyle (the inner rounded prominence at the end of the leg bone) of unknown age. Review of a provider note dated 9/27/22 revealed they had received a call from Nurse #2 with x-ray results of an osteochondral fracture of the medial femoral condyle of indeterminate age. There was significant swelling to Resident #11's left lower leg, and an order was created to send her to hospital. Resident #11 received a dose oxycodone 5 mg on 9/27/22 at 3:44 PM due to a 4/10 pain scale assessment. Resident #11 was sent to hospital emergency room (ER) on 9/27/22 at 7:18 PM. Review of the ER notes from 9/27/23 revealed Resident #11's x-ray results showed a medial malleolus fracture transversely oriented, nondisplaced. Orthopedics was consulted and recommended Resident #11's left leg be placed in a posterior splint with a stirrup, remain non-weight bearing, and follow up with orthopedics. Pain medication was prescribed as needed, and Resident #11 was discharged back to the facility on [DATE]. During an interview with the Director of Nursing (DON) on 4/20/23 at 12:28 PM, she revealed she was not the DON at the time of the incident on 9/25/22. The DON stated NA #2 should have followed the care plan for Resident #11 and used the slide board during all transfers. The interim Administrator was interviewed on 4/20/23 at 1:37 PM, and he revealed NA #2 should have used the slide board for all transfers as it was stated in Resident #11's care plan. The facility provided the corrective action plan with a compliance date of 10/24/22. On 9/27/2022 the resident was sent to emergency room for eval and treatment. Follow up appointments in place for 10/05/2022. Referred to therapy for eval of transfer safety on 9/29/22. On 9/30/22 the Nurse Consultant audited change in condition and the 24-hour report for the past 7 days, reviewing residents that flagged for high to moderate risk for changes in condition and notification. This was completed on 10/1/22. The results included: 0 of 32 residents noted with change in condition that had not been identified and reported per policy. On 9/29/22 the Nurse Consultant identified all residents that were potentially impacted by this practice. On 9/29/2022 the therapy director began an audit of the most recent Functional Mobility Program on all current residents. The information was provided to the Minimum Data Set Coordinator and the Director of Nursing for review of all care plans to ensure they contain the current recommendations. This was completed on 10/14/2022. The results included: 18 of 111 were not in compliance. As of 10/24/2022 all identified residents were in compliance for care plan and kardex accuracy with transfer status. On 9/30/22, the Staff Development Coordinator and Director of Nursing began inservice of all nursing staff (including agency) on Transfer Safety and Kardex Utilization policy. This training will include all current staff including agency. The training included: accessing the Kardex prior to the initiation of care and following the Kardex plan of care. As of 10/5/2022, 23 staff members have not attended the in-service. The Director of Nursing will ensure that any of the above-identified staff who did not complete the in-service training by 10/ 5/ 2022 will not be allowed to work until the training is completed. All new employees, including agency, will be educated on accessing the Kardex prior to the initiation of care and following the Kardex plan of care. The Director of Nursing will monitor residents transfer status and Kardex utilization weekly for 2 weeks and monthly for 3 months or until resolved for compliance with the process. Reports will be presented to the weekly QA committee by the Administrator or Director of Nursing to ensure corrective action is initiated as appropriate. Compliance will be monitored, and the ongoing auditing program reviewed at the weekly QA Meeting. The weekly QA Meeting is attended by the Administrator, Director of Nurses, Minimum Data Set Coordinator, Therapy Manager, Health Information Manager, and the Dietary Manager.

Based on record review, resident, and staff interview, the facility failed to protect 1 of 1 resident (Resident #65) from employee to resident physical abuse. On 12-24-21 while providing care to Resident #65 Nursing Assistant (NA) #1 grabbed onto his right arm, jerked his arm and slapped his face resulting in the bridge of Resident #65's nose bleeding and bruising to his right upper and lower arm. Immediate Jeopardy began on 12-24-21 when the facility failed to protect Resident #65 from employee to resident physical abuse. Immediate Jeopardy was removed on 2-25-22 when the facility implemented an acceptable credible allegation on Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D no actual harm with potential for more than minimal harm that is not Immediate Jeopardy to ensure education is completed and monitoring systems put in place are effective. Findings included: Resident #65 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #65 was cognitively intact. Resident #65 was not coded for any behaviors or refusal of care and had not received any anticoagulant (blood thinner) medications during the look back period. Resident #65's care plan was reviewed and revealed no care plans related to behaviors or refusals of care. A nursing note completed by Nurse #1 dated 12-24-21 at 5:35am documented Resident #65 was combative with NA #1 during incontinence care and when the NA attempted to reposition the resident in bed, Resident #65 hit himself in the face. A nursing note completed by Nurse #1 dated 12-24-21 at 6:20am documented an assessment of Resident #65's face showing a scratch to the bridge of Resident #65's nose. Another note completed by Nurse #1 on 12-24-21 at 7:10am revealed an assessment of Resident #65 was completed showing bruising to the resident's right upper arm and right forearm with Resident #65 informing Nurse #1 that NA #1 grabbed him and yanked him. Resident #65 was interviewed on 2-21-22 at 2:15pm. The resident stated on Christmas Eve (12-24-21) a NA came into his room, held his arms down and hit him on his forehead leaving a bruise and broke his skin on his thumb with her fingernail. He explained he had informed the Administrator, nurse and that the police were notified. Resident #65 stated he was concerned that the NA still worked at the facility. During a telephone interview with NA #1 on 2-23-22 at 3:58pm. NA #1 explained she was unfamiliar with Resident #65 because it was her first day (12-24-21) working at the facility and when she had entered Resident #65's room around 5:30am on 12-24-21, the resident had requested to be repositioned in the bed. She reported when she grabbed Resident #65's draw sheet, the resident swung at her, so she grabbed his arm, but the resident continued to try and hit her. NA #1 stated she then left the room and reported the incident to Nurse #1. She said she had not hit Resident #65. She explained she had education on abuse over the years and would not hurt a resident. NA #1 stated Resident #65 had hurt himself to get her into trouble. The NA said she had not encountered an aggressive resident before but now thought she should have just left the room instead of grabbing his arm. She also explained she had not been back to the facility since 12-24-21. Nurse #1 was interviewed by telephone on 2-23-22 at 4:45pm. Nurse #1 confirmed she was the nurse on duty caring for Resident #65 on 12-24-21 from 11:00pm to 7:00am. She stated she entered Resident #65's room for medication pass around 5:45am and found Resident #65 upset and crying. Nurse #1 reported Resident #65 informed her NA #1 had held his arms down and hit him in his face. She stated she assessed Resident #65 briefly and saw his right arm was red and then went and discussed the allegation with NA #1. The nurse said NA #1 told her Resident #65 had hit her and she held his arms down but had not hit him in his face. NA #1 informed her that the resident hit himself in his face while she (NA #1) was trying to reposition him in the bed. She stated she informed the Director of Nursing and the Nursing Supervisor of the allegation of employee abuse and instructed NA #1 to not enter Resident #65's room for the rest of the shift. Nurse #1 stated she continued her medication pass entering another resident room and the resident had informed her NA #1 had been rough with her while providing incontinence care. The nurse stated she did not ask the resident any questions or examine the resident. She further stated, I just did not think about it. I was concerned with Resident #65. She also said she could not remember who the other resident was. Nurse #1 spoke about Resident #65 and explained that he sometimes had agitation expressed through verbal behaviors, but he had never been combative or stated anything to indicate that a staff member had physically abused him before. A nursing note by Nurse #2 dated 12-24-21 at 10:15am documented she saw bruises on Resident #65's right forearm and a small laceration on his nose with dried blood. The nurse documented that Resident #65 told her he was beat up and that he had his arms held down and hit in the nose. Nurse #2's note indicated she had worked the day before (12-23-21) and Resident #65 did not have any bruises or laceration to his nose. Nurse #2 was interviewed by telephone on 2-23-22 at 1:55pm. Nurse #2 confirmed she worked 7:00am to 3:00pm on 12-24-21 and was assigned to care for Resident #65. She explained Nurse #1 had informed her of the incident with Resident #65 and NA #1 that occurred during the 11:00pm to 7:00am shift. Nurse #2 stated when she saw Resident #65 around 8:00am on 12-24-21, the resident told her he had been beat up with his arms held down and hit in the nose. She observed bruising to his right arm and a laceration to his nose that had dried blood. Nurse #2 also explained when she worked on 12-23-21 during the 7:00am to 3:00pm shift, Resident #65 did not have any bruising on his arms or laceration to his nose. Nurse #2 stated Resident #65 had always been pleasant with her and had never been combative. She also said Resident #65 had not made allegations of physical abuse before and that she trusted that what he told her was the truth. Review of the initial allegation report completed by the former Director of Nursing (DON) dated 12-24-21 revealed the following: Resident #65 reported NA #1 came into his room at approximately at 5:30am on 12-24-21 and snatched the covers off of me. He stated the NA told him I have been a NA for [AGE] years and I am going to show you to pull [yourself] up. The resident stated in the report the next thing he knew the NA was grabbing onto his right arm and jerking him. He reported he began shaking his arm trying to get the NA to let him go and the next thing he knew NA #1 slapped him in the face causing the bridge of his nose to bleed. The report indicated on assessment of Resident #65 he had fresh reddish-purple bruising on his entire right forearm down to the top of his wrist and a bruise to the base of his right thumb. Resident #65 also had a fresh abrasion to the bridge of his nose that was no longer bleeding. Report documentation revealed the police were notified on 12-24-21 at 2:10pm. Review of the police report dated 12-24-21 at 4:00pm revealed documentation of minor injuries to Resident #65 to include bruising to his right arm and a cut to the bridge of his nose. The Administrator was interviewed on 2-25-22 at 11:30am. The Administrator stated Resident #65 never displayed any type of aggressive behaviors towards the staff or refused care prior to the incident on 12-24-21. He also stated Resident #65 had not made previous allegations of physical abuse. He revealed that due to the resident's injuries and recollection of the events the allegation was substantiated. The Administrator was notified of immediate Jeopardy on 2-23-22 at 1:38pm. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and On 12/24/2021, Resident #65 reported to his nurse that his assigned nursing assistant had hit him. At approximately 5:30am on 12-24-21 a Nursing Assistant (NA #1) came into Resident #65's room and snatched the covers off and when the resident asked the NA not to snatch his covers off the NA told him that she was going to show him how to reposition himself and grabbed his right arm. Resident #65 stated that he tried to get loose from the NA's grasp and that was when the NA slapped Resident #65 on his face causing the bridge of his nose to bleed. The Director of Nursing was notified by the staff nurse on 12/24/2021. Resident #65 was assessed immediately on 12/24/2021 by the staff nurse. The nurse noted that the resident had a fresh reddish-purple bruise on his right forearm down to his wrist, top of right thumb. Also has a fresh abrasion/scab with no bleeding on bridge of nose. No other injuries noted The Physician and resident responsible party were notified on 12/24/2021 by staff nurse. No new orders were received. The involved agency staff member was suspended, and the agency was notified that the staff member would not be allowed to return. On 12/24/2021 the police were notified, and they obtained a statement from the resident. A 24-hour report was also submitted on 12/24/2021 by the facility and an investigation report was submitted on 12/29/2021. The facilities investigation concluded that it is likely that the resident was hit by the nursing assistant. After interviews and chart reviews the Director of Nursing identified that the root cause was that the aide did not follow policies and did not ensure resident safety by exiting the room to de-escalate the situation related to an agitated or aggressive resident. All residents have the potential to be affected by this deficient practice. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 02/23/2022, current residents that were able to be interviewed, were asked if they had been abused or mistreated by staff. This was completed by the activity director and the health information director. No new allegations of abuse were identified. Also, on 02/23/2022, skin assessments were completed on current residents that were not interviewed. This was completed by the staff nurses. These residents were assessed to identify if there were any sign of abuse such as bruises or scratches of unknown origin. No additional residents were identified. On 12/24/2021, the staff development coordinator in-serviced all nursing staff on the abuse and prohibition policy. This training was completed for all staff and has been ongoing since 12/24/2021 for new hires. Additional training began on 02/23/2022. This training will include all current staff including agency. This training included how to manage behaviorally difficult residents. Training was completed by the Nurse Clinical Consultant and Staff RN. Areas discussed include: attempting to identify the cause of the resident behavior and eliminate it if possible, respect the resident's need for personal space, taking threats seriously and keeping distance, remaining calm, speaking in soft, low, calm voice, not making the resident feel trapped or cornered, not turning your back on the resident, avoid touching the resident, show interest in what they are saying, empathize with the resident, reassure the resident, praise self-control, do not argue with the resident and make sure that your body language is not threatening. The Director of Nursing and Nurse Clinical Consultant as well as Facility Administrator will ensure that any staff who does not complete the in-service training by 2/24/2022 will not be allowed to work until the training is completed. Alleged IJ Removal Date: 2/25/22 The facility's credible allegation of Immediate Jeopardy was validated on 2-25-22 with interviews with facility staff including nursing staff, dietary and housekeeping. The staff verbalized receipt of education on types of abuse, reporting abuse and how to interact with behaviorally challenged residents. A sample of residents were interviewed and stated they were questioned about abuse and educated on reporting abuse. Staff education documentation, audits and monitoring were reviewed. The facility's date of Immediate Jeopardy removal of 2-25-22 was validated.

Based on record review, staff and Physician interview, the facility failed to follow their abuse policy to implement interventions to protect residents from physical abuse. On 12-24-21 at approximately 5:30am Nursing Assistant (NA) #1 grabbed Resident #65's right arm, jerked his arm and slapped his face resulting in the bridge of Resident #65's nose bleeding and bruising to his right upper and lower arm. NA #1 was allowed to complete her shift and continue to provide care to other residents following the incident. The facility also failed to implement their abuse policy in the areas of reporting and investigating abuse. This was for 1 of 1 resident (Resident #65) reviewed for abuse. Immediate Jeopardy began on 12-24-21 when NA #1 physically abused Resident #65 and the facility failed to implement interventions to protect other facility residents from NA #1. Immediate Jeopardy was removed on 2-25-22 when the facility implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D no actual harm with potential for more than minimal harm that is not Immediate Jeopardy to ensure education is completed and monitoring systems put in place are effective. Example 1b was cited at scope and severity level of D. Findings included: Review of the facility's Abuse Prohibition policy and procedure dated January 2021 revealed in part, the individual conducting the investigation will interview/review resident abuse report, interview person reporting the incident, resident, witnesses, resident's physician, roommate, other residents the employee had contact with, staff members and review events leading up to the incident. All potentials for harm must be removed during the investigation, this may constitute suspending an employee of suspected activity. The report must be submitted to the state agency immediately but not later than 2 hours following the allegation of abuse. 1. Resident #65 was admitted to the facility on [DATE]. Review of the census report for hall 200 on 12-24-21 revealed 20 residents resided on the hall. A nursing note completed by Nurse #1 dated 12-24-21 at 5:35am documented Resident #65 was combative with NA #1 during incontinence care and when the NA attempted to reposition the resident in bed, Resident #65 hit himself in the face. Nurse #1 documented on 12-24-21 at 5:58am that the facility's Director of Nursing was notified of the allegation of employee to resident physical abuse. A nursing note completed by Nurse #1 dated 12-24-21 at 6:20am documented an assessment of Resident #65's face showing a scratch to the bridge of Resident #65's nose. Another note completed by Nurse #1 on 12-24-21 at 7:10am revealed an assessment of Resident #65 was completed showing bruising to the resident's right upper arm and right forearm with Resident #65 informing Nurse #1 that NA #1 grabbed him and yanked him. Review of the initial allegation report completed by the former Director of Nursing dated 12-24-21 revealed the following: Resident #65 reported NA #1 came into his room at approximately 5:30am on 12-24-21 and snatched the covers off of me. He stated the NA told him I have been a NA for [AGE] years and I am going to show you to pull [yourself] up. The resident stated in the report the next thing he knew the NA was grabbing onto his right arm and jerking him. He reported he began shaking his arm trying to get the NA to let him go and the next thing he knew NA #1 slapped him in the face causing the bridge of his nose to bleed. The report indicated on assessment of Resident #65 he had fresh reddish-purple bruising on his right forearm down to the top of his wrist and a bruise to the base of his right thumb. Resident #65 also had a fresh abrasion to the bridge of his nose that was no longer bleeding. Report documentation revealed the police were notified on 12-24-21 at 2:10pm. 1a. NA #1 was interviewed by telephone on 2-23-22 at 3:58pm. NA #1 confirmed she was the NA for all of 200 hall including Resident #65 on 12-24-21 during the 11:00pm to 7:00am shift. The NA discussed Resident #65 being agitated most of her shift and around 5:30am she entered Resident #65's room to reposition him in the bed. She explained when she grabbed his draw sheet to reposition him, the resident swung at her, so she grabbed his arms, but the resident continued to swing hitting himself in the face. NA #1 stated she reported the incident to Nurse #1 and Nurse #1 instructed her to stay out of Resident #65's room. She said after she reported the incident, she still had 17 other residents to care for, so she continued her care of the other residents. Review of NA #1's time sheet for 12-24-21 confirmed NA #1's interview revealing she clocked out of work at 7:00am. A telephone interview occurred with Nurse #1 on 2-23-22 at 4:45pm. Nurse #1 confirmed she was the nurse for Resident #65 on 12-24-21 during the 11:00pm to 7:00am shift. She explained she entered Resident #65's room at approximately 5:45am (12-24-21), she found Resident #65 upset and crying. She stated the resident informed her that NA #1 had slapped him in his face and held his arms down. Nurse #1 said she spoke with NA #1 of the physical abuse allegation then reported the allegation to the DON. She discussed not remembering what the DON told her to do with NA #1 but stated NA #1 continued with her resident assignment and rounds until the end of the shift at 7:00am. Nurse #1 stated she did not think about removing the NA from the floor and said she thought NA #1 only had 1-2 more residents to provide care to. Nurse #1 stated she continued her medication pass entering another resident room and the resident had informed her NA #1 had been rough with her while providing incontinence care. The nurse stated she did not ask the resident any questions, examine the resident or report the information to management and she stated, I just did not think about it. I was concerned with Resident #65. She also said she could not remember who the other resident was. The former Director of Nursing (DON) was interviewed by telephone on 2-23-22 at 3:37pm. The DON confirmed she was the DON for the facility on 12-24-21. She discussed receiving a call from Nurse #1 who told her Resident #65 had made an allegation of physical abuse by NA #1. She further discussed the allegation involved NA #1 slapping Resident #65 in the face causing an abrasion to the bridge of his nose and holding Resident #65's arms down causing bruising to his right arm. The DON stated she instructed Nurse #1 to remove NA #1 from the hall but not to let the NA leave the building before she arrived. She explained that she had not wanted the NA to have any further resident contact after the allegation was made because it could put other residents at risk for harm. She stated she arrived at the facility around 7:45am and observed NA #1 sitting at the nurse's station writing out her recall of events leading to the allegation of physical abuse. The DON stated she allowed the NA to stay at the nursing station while she went to assess and interview Resident #65. She revealed she had not known that NA #1 continued to provide resident care after the allegation was reported. The Administrator was interviewed on 2-24-22 at 11:48am. The Administrator stated he was not aware NA #1 continued with her assignment after the allegation of physical abuse was made and did not know why Nurse #1 did not remove her immediately. He stated Nurse #1 knew the abuse policy which indicated an employee was to be removed immediately from the floor and placed in a non-resident area if an allegation of abuse was made. The facility's Medical Director was interviewed by telephone on 2-24-22 at 2:48pm. The Medical Director stated he would have expected NA #1 to be suspended immediately and escorted out the door. The Administrator was notified of Immediate Jeopardy on 2-24-22 at 1:46pm. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and On 12/24/2021, Resident #65 reported to his nurse that his assigned nursing assistant had hit him. At approximately 5:30am on 12-24-21 a Nursing Assistant (NA #1) came into Resident #65's room and snatched the covers off and when the resident asked the NA not to snatch his covers off the NA told him that she was going to show him how to reposition himself and grabbed his right arm. Resident #65 stated that he tried to get loose from the NA's grasp and that was when the NA slapped Resident #65 on his face causing the bridge of his nose to bleed. The Director of Nursing was notified by the staff nurse on 12/24/2021. Resident #65 was assessed immediately on 12/24/2021 by the staff nurse. The nurse noted that the resident had a fresh reddish-purple bruise on his right forearm down to his wrist, top of right thumb. Also has a fresh abrasion/scab with no bleeding on bridge of nose. No other injuries noted The Physician and resident responsible party were notified on 12/24/2021 by staff nurse. No new orders were received. The DON instructed Nurse #1 to remove the NA from the floor and have her wait until she arrived at the facility to leave. Nurse #1 stated she could not remember what the DON instructed her to do with the accused NA. Nurse #1 allowed the NA to finish her rounds. The NA clocked out at 7AM on 12/24/2021. The accused NA was suspended, and the agency was notified on 12/24/2021 that the staff member would not be allowed to return. All residents have the potential to be affected by this deficient practice. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 02/23/2022, all current residents that were able to be interviewed, were asked if they had been abused or mistreated by staff. This was completed by the activity director and the health information director. No new allegations of abuse were identified. Also, on 02/23/2022, skin assessments were completed on current residents that were not interviewed. This was completed by the staff nurses. These residents were assessed to identify if there were any sign of abuse such as bruises or scratches of unknown origin. No additional residents were identified. On 12/24/2021, the staff development coordinator in-serviced all nursing staff on the abuse and prohibition policy. This training was completed for all staff and has been ongoing since 12/24/2021 for new hires. Additional training began on 02/24/2022 by the Nurse Consultant and Nurse Administration Team. This training will include all contracted, full time, part time, prn - all staff. This training included: When abuse is suspected or reported, staff must immediately report the suspicion or allegation to the nurse, Administrator, or Director of Nursing. Facility investigation beginning steps (Take whatever steps are necessary to protect the residents and to prevent further acts of abuse, neglect, misappropriation of property, drug diversion, or fraud while the investigation is in progress. This includes immediate suspension of the accused employee or employees.) It is imperative that all staff understand that when an allegation of staff to resident abuse is made that the accused staff member must immediately be removed from the floor with no resident contact until the investigation is completed to protect the facility residents. The Director of Nursing and Nurse Clinical Consultant as well as Facility Administrator will ensure that any staff who does not complete the in-service training by 2/24/2022 will not be allowed to work until the training is completed. Alleged IJ Removal Date: 2/25/2022 The facility's credible allegation of Immediate Jeopardy was validated on 2-25-22 with interviews with facility staff including nursing staff, dietary and housekeeping. The staff verbalized receipt of education on types of abuse, reporting abuse and removing the accused staff member from any further resident interactions. A sample of residents were interviewed and stated they were questioned about abuse and educated on reporting abuse. Staff education documentation, audits and monitoring were reviewed. The facility's date of Immediate Jeopardy removal of 2-25-22 was validated. 1b. The facility's initial allegation report for the staff (NA #1) to resident (Resident #65) physical abuse allegation that occurred on 12-24-21 at approximately 5:30 AM revealed it was reported to the state by the Director of Nursing on 12-24-21 at 4:50pm. Review of the facility's investigation report dated 12-29-21 revealed no documentation that other residents, who had contact with Nursing Assistant (NA) #1 after the alleged physical abuse of Resident #65 were interviewed or assessed for injuries. During a telephone interview with the former DON on 2-23-22 at 3:37pm, the DON indicated she arrived at the facility around 7:45am on 12-24-21 and began completing the initial allegation and investigation of employee to resident physical abuse by NA #1 to Resident #65. She stated she was aware allegations of physical abuse needed to be reported to the state agency within 2 hours. The DON said she believed the Administrator was going to send the initial allegation to the state and did not realize it was not sent until 4:30pm on 12-24-21. She verified there were no interviews conducted with other residents because she believed NA #1 did not have any further contact with the residents after she was made aware of the allegation of physical abuse. The Administrator was interviewed on 2-23-22 at 9:15am. The Administrator stated he was unaware the initial report of employee to resident physical abuse on 12-24-21 was not faxed to the state agency within the 2 hour requirement. He stated the facility policy was for abuse allegations to be reported to the state agency within 1 hour. The Administrator verified there were no interviews or assessments of the other residents who had contact with NA #1 after the allegation of physical abuse was reported. The facility's Medical Director was interviewed by telephone on 2-24-22 at 2:48pm. The Medical Director stated he would have expected the DON to assess and conduct interviews with the other residents that NA #1 had contact with to ensure no other residents were physically abused.

Based on record review, staff and physician interviews, the facility failed to notify the physician of a change in mental status of Resident #2 after returning from the hospital with [DIAGNOSES REDACTED]. This was evident in 1 of 7 residents in the survey sample that had a change in status. Immediate jeopardy began on [DATE] when she returned to the facility from the hospital with [DIAGNOSES REDACTED]. The jeopardy was removed on [DATE]. The facility remains out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems put in place and completion of employee training. Findings included: Resident #2 was readmitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Review of the quarterly MDS (minimum data set) assessment dated [DATE] revealed Resident #2 was alert to person and time, able to make her needs known and required extensive assistance from the staff for ADLs (activities of daily living). Review of the Nurses' Notes (NN) dated [DATE] at 6:45 am revealed the resident was observed on the floor with bleeding from a wound to the forehead. A medical emergency service of 911 was summoned and transferred the resident to the hospital. Review of the NN dated [DATE] at 12:05 pm completed by Nurse #1 revealed the resident returned to the facility. During a telephone interview on [DATE] at 7:45 am with Nurse #1, who admitted resident back from ER (emergency room ), she stated "I readmitted the resident but I do not remember how she looked, (regarding her mental status) or any other bruises than what I documented in my notes, she looked tired." Nurse #1 stated Resident #2 was sleeping the whole time when she returned from the hospital. Her face had a large bump on her forehead, stitches with no dressing on it. The nurse stated "I thought it was odd that she was sent back so soon after sustaining a head injury. I know in the hospital they gave her a dose of Tylenol #3, and I am not sure if that had anything to do with her being sleepy." She continued "I only work every other weekend, so I really did not know this resident's normal behavior or alertness." Continued interview with Nurse #1 indicated Resident #2 did not follow commands upon return from the hospital as she did prior to the fall. Nurse #1 indicated that, after her return from the ER, the resident would respond by smiling. This nurse indicated she did not feel it was necessary to contact the physician because the resident had just returned from the hospital, so Nurse #1 expected the resident to be tired. During an interview with NA #5 on [DATE] at 3:15 pm, who worked Saturday ([DATE]), Sunday ([DATE]) and Monday ([DATE]) during the day shift and cared for Resident #2, she stated "she (Resident #2) was very different when she came back from the ER, she stayed in the bed and slept more. Her appetite was poor. The resident's family had to assist her and encourage her to eat. She did not eat Sunday breakfast or lunch, and I told the nurses." (Nurse #1 on Saturday and Sunday and Nurse # 5 on Monday"). NA #5 indicated on interview that the decreased eating or needing assistance with meals was unusual. Review of NN dated [DATE] at 9:00 PM completed by Nurse #2 revealed Resident #2 had no signs and symptoms of acute distress or shortness of breath. Resident #2 complained of pain at 7:00 PM, an as needed pain medication, Tylenol #3, was administered and was effective. She was resting in bed with respirations even and unlabored. Vital signs at 6:00 PM were documented as blood pressure (BP) ,[DATE], pulse (P) 97, respirations (R) 19, and oxygen saturation 92%. During an interview on [DATE] at 2:55 PM with Nurse #2, who worked [DATE] (,[DATE] PM) she stated "she (Resident #2) appeared to be tired and sleepy. She ate about 50% of her dinner, but the NA informed me she had a poor appetite even with a lot of encouragement, and her family fed her. She was moaning about 8:30 pm, I think because she had pain in her head. She took her meds, but was unable to describe where the pain actually was. She did shake her head to indicate her head hurt. It was obvious there was something different about the way she acted and responded, I just thought it was from the bump on her head. I told the oncoming nurse (Nurse # 3) about her behavior during report. I did the neuro checks and documented them. I did not notice any difference (in her vitals signs)." She indicated even though she had a poor appetite, needed encouragement from her family to eat, complained of discomfort that she was unable to describe and slept a lot during the shift,) "I did not think it was necessary to call the doctor." During an interview with NA #3 on [DATE] at 3:10 pm; who worked with Resident #2 on Saturday and Sunday; 3:00pm-11:00 pm shift. NA #3 stated "the resident did not eat and I tried to encourage her to eat. She slept a lot and she was more sedated than usual. Before she went to the hospital she was usually out of bed in her wheelchair and ate her meals in the dinning room. I told the Nurse (Nurse # 6), that she was sleeping more and not as hungry or eating like she usually did." During an interview with NA #4 on [DATE] at 3:12 pm who also worked on Saturday and Sunday from 3:00 pm-11:00 pm NA #4 stated "The resident was very sleepy and did not respond to me like she did before she fell . Usually she would smile at me and assisted me when it was time to change her clothes. That weekend she did not assist with any of her care. I told the Nurse (Nurse #6) and she told me she had a head injury and was taking pain medication, it was to be expected." Review of NN dated [DATE] at 2:32 am completed by Nurse #3 revealed Resident #2 was easily aroused but did not follow commands; she was sleepy. She moaned and groaned when she was moved or was encouraged taking fluids or waking up. She did not answer the nurse's questions because she was too sedated. Nurse #3 gave the resident pain medications per PRN (when necessary) order due to moaning and crying out. The nurse continued to monitor the resident. Her vital signs at 6:00 am were: T (temperature) 98.7, P109, R 16 BP ,[DATE]. Review of NN dated [DATE] at 5:00 am completed by Nurse #3 revealed Resident #2 in bed resting quietly. NAD (no acute distress) noted. She was easily aroused but drowsy, and did not follow commands because she was too sedated. She was not moaning and crying out as much as before the pain medication was administered. Resident #2 would not squeeze the nurse's hands when asked but she had some strength in upper extremities as evident by pulling arms back when "we were trying to get her vital signs. No apparent distress noted from previous fall. Will con't (continue) to monitor." Vital signs were T 97.4, R 16, P 108, BP ,[DATE]. During an interview with Nurse #3 on [DATE] at 9:32 am she indicated she (Resident #2) slept most of the shift. Pain medication was administered. She stated "she (Resident #2) would not respond, and I was not sure how far out of "norm" that was for her, anytime I cared for her she usually slept the whole time. I did the neuro checks, I think they were done every 2 hours, from what I was told by the NAs she was usually coherent at times and was able to follow commands and express her needs." Nurse #3 continued "this was the first time I cared for her when she required medication. She did moan and cry out at times and made facial grimacing; it appeared to me (nurse) that she was in pain. The resident was hard too arouse, I thought it was from medication." Review of NN dated [DATE] at 10:34 am completed by Nurse #1 revealed that Resident #2 was resting in bed and appeared disoriented. Her speech was somewhat clear with rambling comments. Pt (patient) will hold the nurse's hand when asked but when asked to squeeze the nurse's hand; Resident #2 would "pet" the nurse's hand. Pt. ate approximately 25% of am meal. Her vital signs ,[DATE], 92, 18, 98.3. Review of NN dated [DATE] at 2:35 pm completed by Nurse #1 revealed the neuro checks continued and she (Resident #2) would respond to verbal stimuli by opening her eyes and attempted to verbally respond. She continued to ramble "row, row, row ". She did not eat her lunch even with the staff's encouragement. During a telephone interview with Nurse #1 [DATE] at 7:45 am revealed Resident #2 was very sleepy and stated her family member kept trying to wake her up and get her to drink and eat. Nurse #1 stated "I just thought it was because she had been through a lot from the fall. I did not think it was necessary to notify the doctor. I continued the neuro checks like ordered. Her vital signs were okay, I did not realize her pulse was elevated since her return from the hospital. " Interview with Nurse #3 (who worked on [DATE] from 11:00 pm to 7:00 am and [DATE] from 11:00 pm to 7:00 am) on [DATE] at 9:32 am revealed "I did not continue to do the neuro checks on Sunday evening. I was told in report by the reporting nurse (Nurse #6) that it was no longer necessary." Nurse #3 concluded the interview by stating "All my documentation was from the resident's reactions on Saturday and Sunday at night, I usually only saw her when she was sleeping. All her vital signs seemed normal; I did not realize her pulse rate was fast. I spoke with the NAs and they said she was not acting like she usually did. I am not sure what her baseline was. She had a head injury, I expected her to be groggy from head injury. I did not notify the doctor, but told the oncoming nurse of her condition." During an interview at 7:07 am [DATE] with Nurse #5 who cared for resident on [DATE] 7:00 am -3:00 pm, she stated "the resident was not acting herself; I told the DON (Director of Nursing) and thought she (the DON) was going to speak to the doctor. She revealed the resident was lethargic and not really herself, she did not want to drink or eat and refused her breakfast and lunch. She (Nurse #5) stated "I should have put more information in my nursing note about her change in condition; I thought the DON was going to contact the doctor after I spoke to her that morning. " Review of the NN dated [DATE] completed by Nurse #4 revealed the resident was found at 7:00 pm while the nurse was making rounds to be unresponsive and wheezing. The nurse applied oxygen and tried to suction the resident. She contacted the doctor and sent her to the ER for evaluation. During a telephone interview with Nurse #4 on [DATE] at 5:20 pm (worked 3:00 pm -11:00pm on [DATE] and sent Resident #2 to ER) she stated "she was not familiar with this resident." She indicated Resident #2 seemed to be doing ok, when she initially saw her at 4:00 pm, she was alert, she was talking incoherently like a mumble. According to the NAs she was not acting like she did before she fell . Nurse #4 indicated during her medication pass at about 7:00 pm, she could hear Resident #2 wheezing from her room door. She went and got O2, and put it on the resident. She stated "I was concerned that she was fed dinner that evening by her family. My thought was that she could have aspirated." She continued she called the doctor and the resident was sent to the hospital. Resident #2 was sent to theER on [DATE] for evaluation of unresponsiveness. Review of the Hospital Records for treatment of [REDACTED]. "admitted for altered mental status. She underwent an x-ray confirming [MEDICAL CONDITION] and a urinalysis showing evidence of a urinary tract infection." Resident #2 expired on [DATE] in the hospital. Interview with the Administrator on [DATE] at 3:45 pm revealed her expectation of the nursing staff was that when a resident was readmitted from the hospital; the nurse would complete a head to toe assessment of the resident and also if necessary start neuro checks to be done per facility policy for 48 hours. Most importantly, the nurse or staff are to notify the physician, the on call nurse, DON or myself if they have any concerns about the residents status and /or orders. The neuro checks were stopped on Sunday evening. The facility policy is that the neuro checks are done for 48 hours and changes were to be reported to the doctor and the supervisor." During an interview with Administrator on [DATE] at 6:10 am revealed it was her understanding that the physician was not notified of any changes because she was told by the DON that Resident #2 was assessed by the admitting nurse to be at her baseline for mentation when she returned from the hospital. After reviewing the records, there was no indication of that assessment or documentation and she would have expected the staff to have notified the doctor of the change in Resident #2's mental status changes or changes in her behavior. During an interview with the director of nursing (DON) on [DATE] at 9:04 am the DON stated "I was made aware during the Monday morning meeting (administrative staff meeting) that the resident had a head injury and went to the hospital and got stitches and was returned to the facility on the same day." The DON stated "It is actually the nurse who admitted the resident from the hospital who is responsible to assess the resident, transcribe the orders from the hospital to the appropriate places in the chart and notify the physician the resident had returned to the facility. That nurse is also responsible to make sure she informs the on-call nurse if she had any concerns about the resident's condition or orders the resident returned from the hospital with, so the on-call nurse can clarify these things and contact the physician if necessary. She further indicated it was ultimately the DON's responsibility to make sure changes in resident condition were reflected in the chart, to make sure the orders were clear and all staff was aware of any changes or new needs of the resident and contact the physician to inform him of any changes. The nurses were also to notify the physician if they feel there were any changes in the resident's condition. She stated "as I reviewed the chart after the resident was sent to the hospital on Monday, there was no assessment of the resident when she returned from the hospital and there was a change in resident, but the staff did not notify the doctor." She continued "the assessment should have been written, so we (the nurses) had a picture of what the resident was like when she returned from the hospital. According to the NN she was definitely acting differently from before she went to the hospital. The nurses should have called the doctor or the on-call nurse if they had a question or concern. No one told me they had a concern about her behavior or mental status changes until after she went to the hospital." During an interview with UM #2 at 8:48 am on [DATE], UM #2 indicated her responsibilities as a unit manager was to help the nurses, she reviewed the charts whenever there was an admission, re-admission or new orders to make sure all the orders were clarified. The chart (referring to resident #2) was reviewed during the critical care meeting on Monday ([DATE]) morning after the DON had reviewed the chart first. She stated "the DON usually looks through the charts to make sure everything was in place; like orders, referrals, treatments and physician notifications. As they reviewed the chart in the critical care meeting they realized the neuro checks were not completed properly and the orders for the [MEDICAL CONDITION] were not clear or transcribed to the TAR (Treatment Administration Record), there was no assessment of the resident's change in status from the nurses and the doctor was never notified." Interview with the Physician on [DATE] at 11:45 am revealed he was unaware Resident #2 had a fall or was returned back to the facility. He stated "the staff should have contacted me if there was a change in the resident's condition (example: change in vital signs, pain, sleepiness, lethargy, poor appetite, difficult to arouse, anything that was different from her baseline behavior). They (the nurses) received discharge orders/instructions from the hospital and they stated to contact the physician immediately if there was a change. She was diagnosed with [REDACTED]." The Administrator was notified of the Immediate Jeopardy on [DATE] at 12:45 pm. The facility presented a credible allegation of compliance on [DATE] at 3:41 pm which included: "Resident # 2 was discharged to the hospital on [DATE]. On [DATE], she sustained a fall and was treated at the emergency room . She returned to the facility on [DATE] with orders for the staff nurses to complete neurological checks per facility protocol for 48 hours and a [DIAGNOSES REDACTED]. On [DATE] in-service training was completed by the Director of Nursing and staff development. All staff nurses attended this in-service. The exact in-service included: "In-service [DATE] Neurochecks are done as ordered. If you have a resident with a head injury there must be done using the flow sheet that is attached. Any changes in neuro status, the MD, must be notified. Checks are q 15 mins x1 hour, q30 mins x 1 hour q hour x 4 hours, q4 hour x 24 hours. When orders are received, the nurse transcribing should initial and date on the MAR. If received at the end of month, it should be transcribed on new month MARS's as well. Weekly charting and vital signs is to be done on every resident. Documentation is to be done on any change in condition, medication, or education. This is to be done prior to leaving your shift. Any change of condition, or medication that is reported, should be written on 24 hour acute charting sheet as well. Third checks should be completed on all orders. Falls witnessed and unwitnessed, neuro checks must be done. Any change in mental status must be followed up with Physician and RP Notified. Family R/P must be notified on all incidents. Medication changes or change in condition When notifying the residents RP, you are to only use the facility phone. Cell Phone use during work hours is prohibited. (Please refer to policy). Nurses are to do walking rounds with your report sheet and if there is an incident or if it is reported to the oncoming nurse, it must be placed on the 24 hour report sheet. Documentation must be done in the residents chart. " All residents are potentially affected by this practice. On [DATE], the charge nurses with the supervision of unit manager, MDS nurse and staff development coordinator assessed all current residents for changes in conditions and the attending physician was notified immediately of any identified changes. 92 out of 92 residents were assessed and 4 were noted to have change in conditions. The attending physicians were contacted by the staff nurses and orders were received and implemented. This included a 1. Resident who was experiencing nausea, vomiting and loose stools and received orders for [MEDICATION NAME], immodium, clear liquid diet, intravenous fluids and [MEDICATION NAME]. 2. Resident who complained of pain and received orders for a urine analysis and culture, 3. Resident who developed rash and received orders for [MEDICATION NAME], benedryl, [MEDICATION NAME], to hold [MEDICATION NAME], and foley catheter 4. resident who was experiencing some hallucinations and received an order to be evaluated by physician elder care on [DATE]. Order obtained have been implemented by the staff nurses. These resident will remain on the acute charting list and will be assessed every shift for 72 hours after treatment has stopped. If improvement is not noted within 24 hours the physician will be contacted by the staff nurse assigned to the resident for follow up instructions/orders. This assessment includes the following: ? Observing for lacerations; if present, clean and apply dry, sterile dressing. Note size, depth and amount of bleeding or drainage. ? Observing for swelling and discoloration; if present, chart size, site, amount and color. ? Observing for convulsions; chart time began, precipitating factors, duration, vital signs and time ended. Also chart whether or not resident had difficulty breathing. ? Observing and inquire if resident has headache or pain. ? Observing for personality changes. ? Observing for alterations in consciousness. ? Observing for incontinence. ? Observing for sensory weakness. ? Observing for generalized weakness. ? Observing for speech disorder. ? Observing for gait, posture or balance disorder. ? Observing for stiff neck. ? Observing for proper reflexes (response to painful stimuli). ? Observing for abdominal spasm or pain. ? Observing for bleeding from ears, nose, throat. ? Observing for unequal pupils. ? Observing for dyspnea or variations in respirations (irregular). ? Observing for flushing or cyanosis. ? Observing for pain. ? Observing for abduction, adduction, shortening or improper position of extremities. ? Taking vital signs by the nursing assistant ? ? ? On [DATE] and [DATE], all staff nurses were in-serviced by staff development coordinator, unit manager, the nurse consultant and the administrator how to contact the physician and how to document significant changes. 24 out of 30 staff nurses have received this education. The exact in-service content is as follows: ? Credible Allegation In-service ? After all resident falls, injuries or changes in physical or mental function, the charge nurse will monitor the following every shift for 72 hours: ? Observe for lacerations; if present, clean and apply dry, sterile dressing. Note size, depth and amount of bleeding or drainage. ? Observe for swelling and discoloration; if present, chart size, site, amount and color. ? Observe for convulsions; chart time began, precipitating factors, duration, vital signs and time ended. Also chart whether or not resident had difficulty breathing. ? Observe and inquire if resident has headache or pain. ? Observe for personality changes. ? Observe for alterations in consciousness. ? Observe for incontinence. ? Observe for sensory weakness. ? Observe for generalized weakness. ? Observe for speech disorder. ? Observe for gait, posture or balance disorder. ? Observe for stiff neck. ? Observe for proper reflexes (response to painful stimuli). ? Take vital signs and include temperature. ? Observe for abdominal spasm or pain. ? Observe for bleeding from ears, nose, throat. ? Observe for unequal pupils. ? Observe for dyspnea or variations in respirations (irregular). ? Observe for flushing or cyanosis. ? Observe for pain. ? Observe for abduction, adduction, shortening or improper position of extremities. ? Have someone stay with the resident while the nurse is calling the attending physician, if necessary. The physician should be called promptly (within 15 minutes) after completion of an assessment that determines that a change of condition as outlined above has occurred. The phone numbers for the physicians are in the rolodexes located at each nurses station. The physician should be called for any change of condition as outlined above 24 hours a day and 7 days a week. This process does not change due to time or day of the week. ? If you are unable to reach the attending physician or the physician on call, call the RN on call within 30 minutes of contacting the primary physician for further instructions. The RN on call phone number is [PHONE NUMBER]. ? This assessment should be documented in the nursing notes. ? The nurse will note any concerns or changes noted by other staff or family ? Additionally, neurological assessments should be completed any time there is an physician order, when a fall causes an impact to the head, when there is an un-witnessed fall or any other time the nurses deems necessary. The nurse should document using the form for neurological checks. Neurological checks should be completed every hour times 4 hours and then every shift for a total of 48 hours. A neurological assessments includes the following: ? Date and time the assessment was completed ? Level of Consciousness: Is resident alert, drowsy, stuporous or comatose ? Pupil response: Is the resident's pupil equal and reactive to light. Also document the pupil response in each eye as either brisk, sluggish, non-reactive, pinpoint, dilated or fixed. ? Motor functions: Document the hand grasp as either equal, the right greater than left, left greater than right, if the resident is unable to participate or if hand grasp is absent. Also document whether the resident is able to to move all extremities. If unable to move all extremities then document which extremities they are able to move. Complete this for the right arm, left arm, right leg and left leg, checking all that apply. If the resident is unable to follow commands or if they are absent any extremities indicate that as well. ? Pain response: Document if the resident has an appropriate pain response, inappropriate pain response or no pain response. ? Vital Signs: Document blood pressure, pulse, respirations and temperature ? Observations: Document any additional observations such as [MEDICAL CONDITION], headache, vomiting or paralysis ? Sign you name in the box indicated on the form. ? Complete an incident, accident or risk management report per facility policy. ? Notify resident's responsible party. ? If a new order is received by the physician then the order should be documented by the nurse who received the order on the telephone order sheet. Then the order should be transcribed to Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Other non-medication/treatment orders should be initiated based on order type. This transcription should be completed by the staff nurse receiving the order. The ,[DATE] nurse is to complete a chart check every night where every chart is reviewed for new orders. If new orders (within the last 24 hours) are identified the night shift nurse is to verify that the order was transcribed appropriately to the medication/treatment record or implemented appropriately. If a problem or concern is identified then the night shift nurse must notify the Director of Nursing that morning by either phone or note placed in the Director of Nursing's box at the nursing station. ? Any concerns identified by this audit will be corrected or addressed by the Director of Nursing and will be reviewed weekly at the Quality Assurance Committee Meeting describe in this document. The staff development coordinator will ensure that any staff nurse who does not complete the in-service training by [DATE] will not be allowed to work until the training is completed. This in-service was incorporated into the new employee facility orientation. An in service on [DATE] has been provided to the Nursing Assistants by the Staff Development Coordinator, Nurse Consultant, Nurse manager and MDS Coordinator to report any changes to the resident to the nurse on the unit as soon as identified. The staff development coordinator will ensure that any nursing assistant who does not complete the in-service training by [DATE] will not be allowed to work until the training is completed. 32 out of 69 have completed this training. This in-service was incorporated into the new employee facility orientation. A quality assurance monitor will be completed five times a week for two weeks by the Administrator or Director of Nursing and then will continue weekly for three months and then monthly until resolved by the Quality Assurance Committee. Reports of the MD notification audit will be given by the director of nursing to the weekly Quality of Life- QA committee and corrective action initiated as appropriate. The Quality of Life committee consists of the Director of Nursing, Administrator, Staff Development Coordinator, Dietary Manager, Wound Nurse, Minimal Data Assessments Nurse and Support Nurse and Health Information Management and meets weekly. This monitor will include reviewing all residents who went to the emergency room or hospital charts to ensure that the physician was notified of any changes in condition when they were first documented by staff, if the physician responded and if the staff notified the medical director and RN on call if needed. This review will be completed on 100 % of residents who go to the emergency room or hospital. Completion Date: [DATE] Validation of the credible allegation of compliance was done on [DATE] from 3:58 pm to 5:15 pm. Validation of the credible allegation of compliance was done on [DATE] from 3:58 pm to 5:15 pm. Interviews with nurses and nursing assistants and licensed nursing staff confirmed they had received training on [DATE] on nursing assessment, use of the new neuro check policy for assessment and when/ whom to notify for acute changes in resident condition. Documentation of training, auditing and new protocols was reviewed. Immediate Jeopardy was removed on [DATE] at 6:39 pm.

Based on record review, staff and physician interviews, the facility failed to identify a change in mental status and notify the physician of one resident (Resident #2) when Resident #2 exhibited sleepy, lethargic and inappropriate responses after returning from the hospital post fall which resulted in a concussion and a 3 centimeter laceration to the forehead. This was evident in 1 of 7 residents in the survey sample that had a change in status. Immediate jeopardy began on [DATE] when she returned to the facility from the hospital with [DIAGNOSES REDACTED]. The jeopardy was removed on [DATE]. The facility remains out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems put in place and completion of employee training. Findings included: Review of the Facility Policy for Neuro Checks for nursing dated [DATE] revealed the purpose of the policy is to assess the patient's condition and stability and to provide pertinent information to the physician. Observations should note the presence or absence of specific resident conditions. These specific conditions were not identified in the policy. Resident #2 was readmitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Review of the quarterly MDS (minimum data set) assessment dated [DATE] revealed Resident #2 was alert to person and time, able to make her needs known and required extensive assistance from the staff for ADLs (activities of daily living). Review of the Nurses' Notes (NN) dated [DATE] at 6:45 am revealed the resident was observed on the floor, positioned on her left side in front of the wheelchair. A pool of bright red blood was observed from a wound to the forehead. This nurse's note indicated pressure and ice was applied to stop the bleeding. A 3 centimeter (cm) open area was noted to the forehead. Resident #2's vital signs were temperature at 98.7 degrees Fahrenheit, pulse rate at 54 beats per minute, respirations at 22 breaths per minute and blood pressure reading of ,[DATE]. A medical emergency service of 911 was summoned and transferred the resident to the hospital. An interview on [DATE] at 6:30 am with nurse #7 who responded to Resident #2 on [DATE] indicated he heard the nursing assistant (NA) call for help. He looked at the nurses' station and saw Resident #2 on the floor, with her head facing down, and he saw red blood on the floor. He applied pressure and ice to her forehead. He stated she was moaning and "I explained to her that she fell and hit her head." The NA (nursing assistant) stayed with the resident and another NA came and helped keep her still. He stated "I was surprised that she fell because she never tried to get up or move out of her wheelchair." He continued "the wheelchair was sitting upright against the wall to the nurses' station and the brakes were locked. I do not understand how she fell . When she was lying on the floor she was lying towards her left side, which is her weak side from her previous stroke." Review of the NN dated [DATE] at 12:05 pm completed by Nurse #1 revealed the resident returned to the facility. Review of the Hospital Discharge Orders/Instructions revealed the resident sustained [REDACTED]. Review of NN dated [DATE] at 12:45 pm completed by Nurse #1 revealed the resident was asleep, Stitches intact, no active bleeding with discoloration and swelling to the forehead. During a telephone interview on [DATE] at 7:45 am with Nurse #1, who admitted resident back from ER (emergency room ), she stated "I readmitted the resident but I do not remember how she looked, (regarding her mental status) or any other bruises than what I documented in my notes, she looked tired." Nurse #1 stated Resident #2 was sleeping the whole time when she returned from the hospital. Her face had a large bump on her forehead, stitches with no dressing on it. She indicated she reviewed the short synopsis narrative discharge orders/instructions from the ER. She stated "I did not get a report (referring to a verbal report) from the hospital, no one called to tell us she was returning." The papers she (the resident) brought back from the ER indicated what to look for with a concussion, how to clean the laceration, they were very generic directions. I thought it was odd that she was sent back so soon after sustaining a head injury. I know in the hospital they gave her a dose of Tylenol #3, and I am not sure if that had anything to do with her being sleepy." Nurse #1 indicated the nursing assistant (NA) got her vital signs, and after the unit manager came in "I started to do the neuro checks." "I think I did them every 15 minutes for the first hour then every 30 minutes for the next 2 hours then every hour for the rest of my shift. I documented on the neuro check sheet." She continued "I only work every other weekend, so I really did not know this residents normal behavior or alertness." Continued interview with Nurse #1 indicated Resident #2 did not follow commands upon return from the hospital as she did prior to the fall. Nurse #1 indicated that, after her return from the ER, the resident would respond by smiling. Nurse #1 indicated that she did not perform a body check or assessment on the resident when she returned from the hospital. This nurse indicated she did not feel it was necessary to contact the physician because the resident had just returned from the hospital, so Nurse #1 expected the resident to be tired. During an interview with NA #5 on [DATE] at 3:15 pm, who worked Saturday ([DATE]), Sunday ([DATE]) and Monday ([DATE]) during the day shift and cared for Resident #2, she stated "she (Resident #2) was very different when she came back from the ER, she stayed in the bed and slept more. Her appetite was poor. The resident's family had to assist her and encourage her to eat. She did not eat Sunday breakfast or lunch, and I told the nurses." (Nurse #1 on Saturday and Sunday and Nurse # 5 on Monday "). NA #5 indicated on interview that the decreased eating or needing assistance with meals was unusual. Review of NN dated [DATE] at 9:00 PM completed by Nurse #2 revealed Resident #2 had no signs and symptoms of acute distress or shortness of breath. Resident #2 complained of pain at 7:00 PM, an as needed pain medication, Tylenol #3, was administered and was effective. She was resting in bed with respirations even and unlabored. Neuro-checks continued. No falls this far during shift. Vital signs at 6:00 PM were documented as blood pressure (BP) ,[DATE], pulse (P) 97, respirations (R) 19, and oxygen saturation 92%. During an interview on [DATE] at 2:55 PM with Nurse #2, who worked [DATE] (,[DATE] PM) she stated "she (Resident #2) appeared to be tired and sleepy. She ate about 50% of her dinner, but the NA informed me she had a poor appetite even with a lot of encouragement, and her family fed her. She was moaning about 8:30 pm, I think because she had pain in her head. She took her meds, but was unable to describe where the pain actually was. She did shake her head to indicate her head hurt. It was obvious there was something different about the way she acted and responded, I just thought it was from the bump on her head. I told the oncoming nurse (Nurse # 3) about her behavior during report. I did the neuro checks and documented them. I did not notice any difference (in her vitals signs)." She indicated even though she had a poor appetite, needed encouragement from her family to eat, complained of discomfort that she was unable to describe and slept a lot during the shift,) "I did not think it was necessary to call the doctor. " During an interview with NA #3 on [DATE] at 3:10 pm; who worked with Resident #2 on Saturday and Sunday; 3:00pm-11:00 pm shift. NA #3 stated "the resident did not eat and I tried to encourage her to eat. She slept a lot and she was more sedated than usual. Before she went to the hospital she was usually out of bed in her wheelchair and ate her meals in the dinning room. I told the Nurse (Nurse # 6), that she was sleeping more and not as hungry or eating like she usually did." During an interview with NA #4 on [DATE] at 3:12 pm who also worked on Saturday and Sunday from 3:00 pm-11:00 pm NA #4 stated "The resident was very sleepy and did not respond to me like she did before she fell . Usually she would smile at me and assisted me when it was time to change her clothes. That weekend she did not assist with any of her care. I told the Nurse (Nurse #6) and she told me she had a head injury and was taking pain medication, it was to be expected." Review of NN dated [DATE] at 2:32 am completed by Nurse #3 revealed Resident #2 was easily aroused but did not follow commands; she was sleepy. She moaned and groaned when she was moved or was encouraged taking fluids or waking up. She did not answer the nurse's questions because she was too sedated. Eyes PERRLA (pupils equal round and reactive to light, accommodation). VS (vital signs) stable. Nurse #3 gave the resident pain medications per PRN (when necessary) order due to moaning and crying out. The nurse continued to monitor the resident. Her vital signs at 6:00 am were: T (temperature) 98.7, P109, R 16 BP ,[DATE]. Review of NN dated [DATE] at 5:00 am completed by Nurse #3 revealed Resident #2 in bed resting quietly. NAD (no acute distress) noted. She was easily aroused but drowsy, and did not follow commands because she was too sedated. She was not moaning and crying out as much as before the pain medication was administered. Resident #2 would not squeeze the nurse's hands when asked but she had some strength in upper extremities as evident by pulling arms back when "we were trying to get her vital signs. No apparent distress noted from previous fall. Will con't (continue) to monitor." Vital signs were T 97.4, R 16, P 108, BP ,[DATE]. During an interview with Nurse #3 on [DATE] at 9:32 am she indicated she (Resident #2) slept most of the shift. Pain medication was administered. She stated "she (Resident #2) would not respond, and I was not sure how far out of "norm" that was for her, anytime I cared for her she usually slept the whole time. I did the neuro checks, I think they were done every 2 hours, from what I was told by the NAs she was usually coherent at times and was able to follow commands and express her needs." Nurse #3 continued "this was the first time I cared for her when she required medication. She did moan and cry out at times and made facial grimacing; it appeared to me (nurse) that she was in pain. The resident was hard too arouse, I thought it was from medication." Review of NN dated [DATE] at 10:34 am completed by Nurse #1 revealed that Resident #2 was resting in bed and appeared disoriented. Her speech was somewhat clear with rambling comments. Pt (patient) will hold the nurse's hand when asked but when asked to squeeze the nurse's hand; Resident #2 would "pet" the nurse's hand. Pt. ate approximately 25% of am meal. Her vital signs ,[DATE], 92, 18, 98.3. Review of NN dated [DATE] at 2:35 pm completed by Nurse #1 revealed the neuro checks continued and she (Resident #2) would respond to verbal stimuli by opening her eyes and attempted to verbally respond. She continued to ramble "row, row, row ". She did not eat her lunch even with the staff's encouragement. During a telephone interview with Nurse #1 [DATE] at 7:45 am revealed Resident #2 was very sleepy and stated her family member kept trying to wake her up and get her to drink and eat. Nurse #1 stated "I just thought it was because she had been through a lot from the fall. I did not think it was necessary to notify the doctor. I continued the neuro checks like ordered. Her vital signs were okay, I did not realize her pulse was elevated since her return from the hospital. " During an interview with NA #6 on [DATE] at 3:30 pm (who was familiar with Resident #2) indicated Resident #2 was able to independently feed herself meals in the dining room (before the fall). Interview with Nurse #3 (who worked on [DATE] from 11:00 pm to 7:00 am and [DATE] from 11:00 pm to 7:00 am) on [DATE] at 9:32 am revealed "I did not continue to do the neuro checks on Sunday evening. I was told in report by the reporting nurse (Nurse #6) that it was no longer necessary. " Nurse #3 concluded the interview by stating "All my documentation was from the resident's reactions on Saturday and Sunday at night, I usually only saw her when she was sleeping. All her vital signs seemed normal; I did not realize her pulse rate was fast. I spoke with the NAs and they said she was not acting like she usually did. I am not sure what her baseline was. She had a head injury, I expected her to be groggy from head injury. I did not notify the doctor, but told the oncoming nurse of her condition. " During an interview at 7:07 am [DATE] with Nurse #5 who cared for resident on [DATE] 7:00 am -3:00 pm, she stated "the resident was not acting herself; I told the DON (Director of Nursing) and thought she (the DON) was going to speak to the doctor. She revealed the resident was lethargic and not really herself, she did not want to drink or eat and refused her breakfast and lunch. She (Nurse #5) stated "I should have put more information in my nursing note about her change in condition; I thought the DON was going to contact the doctor after I spoke to her that morning. " Review of the NN dated [DATE] completed by Nurse #4 revealed the resident was found at 7:00 pm while the nurse was making rounds to be unresponsive and wheezing. The nurse applied oxygen and tried to suction the resident. She contacted the doctor and sent her to the ER for evaluation. During a telephone interview with Nurse #4 on [DATE] at 5:20 pm (worked 3:00 pm -11:00pm on [DATE] and sent Resident #2 to ER) she stated "she was not familiar with this resident. " She indicated Resident #2 seemed to be doing ok, when she initially saw her at 4:00 pm, she was alert, she was talking incoherently like a mumble. According to the NAs she was not acting like she did before she fell . Nurse #4 indicated during her medication pass at about 7:00 pm, she could hear Resident #2 wheezing from her room door. She went and got O2, and put it on the resident. She stated "I was concerned that she was fed dinner that evening by her family. My thought was that she could have aspirated. " She continued she called the doctor and the resident was sent to the hospital. There were no completed neuro Check sheets for review for Resident #2. Resident #2 was sent to theER on [DATE] for evaluation of unresponsiveness. Review of the Hospital Records for treatment of [REDACTED]. "admitted for altered mental status. The patient sustained a fall last Saturday ([DATE]), after which she was assessed, underwent a CT scan, which turned out to be negative. She was sent back to the facility awake, alert and oriented; however today (Monday) she was found to be unresponsive, where she is [MEDICAL CONDITION]. She was found to be in moderate respiratory distress, she underwent an x-ray confirming [MEDICAL CONDITION] and a urinalysis showing evidence of a urinary tract infection. " Review of Consultation for Mental Status Changes completed on [DATE] read: "she fell off the wheelchair and suffered a laceration on the forehead. discharged but not doing well. She was poorly responding, she barely opened her eyes on verbal commands. She was brought into the hospital for history of mental status changes. " Resident #2 expired on [DATE] in the hospital. Interview with the DON (director of Nursing) on [DATE] at 3:30 pm, She stated "we (the administrative staff) are unable to locate the neuro check sheet used for this resident, this chart has been reviewed by a lot of people, we are checking to make sure it was not left with one of the consultants who reviewed the chart. " Interview with the Administrator on [DATE] at 3:45 pm revealed her expectation of the nursing staff was that when a resident was readmitted from the hospital; the nurse would complete a head to toe assessment of the resident and also if necessary start neuro checks to be done per facility policy for 48 hours. Most importantly, the nurse or staff are to notify the physician, the on call nurse, DON or myself if they have any concerns about the residents status and /or orders. The neuro checks were stopped on Sunday evening. The facility policy is that the neuro checks are done for 48 hours and changes were to be reported to the doctor and the supervisor. We did an inservice about that issue, so the staff is aware of the facility policy for neuro checks and to document the resident condition clearly in their nurse's notes " During an interview with Administrator on [DATE] at 6:10 am revealed it was her understanding that the physician was not notified of any changes because she was told by the DON that Resident #2 was assessed by the admitting nurse to be at her baseline for mentation when she returned from the hospital. After reviewing the records, there was no indication of that assessment or documentation and she would have expected the staff to have notified the doctor of the change in Resident #2's mental status changes or changes in her behavior. During an interview with the director of nursing (DON) on [DATE] at 9:04 am the DON stated "I was made aware during the Monday morning meeting (administrative staff meeting) that the resident had a head injury and went to the hospital and got stitches and was returned to the facility on the same day. " The DON indicated the resident's care (Resident #2) was discussed during the critical care meeting with the unit managers. In this meeting we (administrative staff) reviewed the chart, and noticed the UM (Unit Manager) #1, who was on-call, came to the facility on [DATE] and wrote orders for neuro checks, "pt eval, use geri chair until pt eval, add chair alarm and fall mats ", and I assumed the unit manager did an assessment of the resident. The DON stated "It is actually the nurse who admitted the resident from the hospital who is responsible to assess the resident, transcribe the orders from the hospital to the appropriate places in the chart and notify the physician the resident had returned to the facility. That nurse is also responsible to make sure she informs the on-call nurse if she had any concerns about the resident's condition or orders the resident returned from the hospital with, so the on-call nurse can clarify these things and contact the physician if necessary. She further indicated it was ultimately the DON's responsibility to make sure changes in resident condition were reflected in the chart, to make sure the orders were clear and all staff was aware of any changes or new needs of the resident and contact the physician to inform him of any changes. The nurses were also to notify the physician if they feel there were any changes in the resident's condition. She stated "as I reviewed the chart after the resident was sent to the hospital on Monday, there was no assessment of the resident when she returned from the hospital and there was a change in resident, but the staff did not notify the doctor. " She continued "the assessment should have been written, so we (the nurses) had a picture of what the resident was like when she returned from the hospital. According to the NN she was definitely acting differently from before she went to the hospital. The nurses should have called the doctor or the on-call nurse if they had a question or concern. No one told me they had a concern about her behavior or mental status changes until after she went to the hospital. " During an interview with UM #2 at 8:48 am on [DATE], UM #2 indicated her responsibilities as a unit manager was to help the nurses, she reviewed the charts whenever there was an admission, re-admission or new orders to make sure all the orders were clarified. The chart (referring to resident #2) was reviewed during the critical care meeting on Monday ([DATE]) morning after the DON had reviewed the chart first. She stated "the DON usually looks through the charts to make sure everything was in place; like orders, referrals, treatments and physician notifications. As they reviewed the chart in the critical care meeting they realized the neuro checks were not completed properly and the orders for the [MEDICAL CONDITION] were not clear or transcribed to the TAR (Treatment Administration Record), there was no assessment of the resident's change in status from the nurses and the doctor was never notified. " Interview with the Physician on [DATE] at 11:45 am revealed he was unaware Resident #2 had a fall or was returned back to the facility. He stated "the staff should have contacted me if there was a change in the resident's condition (example: change in vital signs, pain, sleepiness, lethargy, poor appetite, difficult to arouse, anything that was different from her baseline behavior). They (the nurses) received discharge orders/instructions from the hospital and they stated to contact the physician immediately if there was a change. She was diagnosed with [REDACTED]. " The Administrator was notified of the Immediate Jeopardy on [DATE] at 12:45 pm. The facility presented a credible allegation of compliance on [DATE] at 3:41 pm which included: Resident # 2 was discharged to the hospital on [DATE]. On [DATE], she sustained a fall and was treated at the emergency room . She returned to the facility on [DATE] with orders for the staff nurses to complete neurological checks per facility protocol and a [DIAGNOSES REDACTED]. On [DATE] in-service training was completed by the Director of Nursing and staff development. All staff nurses attended this in-service. The exact in-service included: "In-service [DATE] Neurochecks are done as ordered. If you have a resident with a head injury there must be done using the flow sheet that is attached. Any changes in neuro status, the MD, must be notified. Checks are q 15 mins x1 hour, q30 mins x 1 hour q hour x 4 hours, q4 hour x 24 hours. When orders are received, the nurse transcribing should initial and date on the MAR. If received at the end of month, it should be transcribed on new month MARS's as well. Weekly charting and vital sings is to be done on every resident. Documentation is to be done on any change in condition, medication, education. This is to be done prior to leaving your shift. Any change of condition, or medication that is reported, should be written on 24 hour acute charting sheet as well. Third checks should be completed on all orders. Falls witnessed and unwitnessed, neuro checks must be done. Any change in mental status must be followed up with Physician and RP Notified. Family R/P must be notified on all incidents. Medication changes or change in condition When notifying the residents RP, you are to only use the facility phone. Cell Phone use during work hours is prohibited. (Please refer to policy). Nurses are to do walking rounds with your report sheet and if there is an incident or if it is reported to the oncoming nurse, it must be placed on the 24 hour report sheet. Documentation must be done in the residents chart. " All residents are potentially affected by this practice. On [DATE], the charge nurses with the supervision of unit manager, MDS nurse and staff development coordinator assessed all current residents for changes in conditions and the attending physician was notified immediately of any identified changes. 92 out of 92 residents were assessed and 4 were noted to have change in conditions. The attending physicians were contacted by the staff nurses and orders were received and implemented. This included a 1. resident who was experiencing nausea, vomiting and loose stools and received orders for [MEDICATION NAME], immodium, clear liquid diet, intravenous fluids and [MEDICATION NAME] 2. Resident who complained of pain and received orders for a urine analysis and culture, 3. Resident who developed rash and received orders for [MEDICATION NAME], benedryl, [MEDICATION NAME], to hold [MEDICATION NAME], and foley catheter 4. resident who was experiencing some hallucinations and received an order to be evaluated by physician elder care on [DATE]. Order obtained have been implemented by the staff nurses . These resident will remain on the acute charting list and will be assessed every shift for 72 hours after treatment has stopped. If improvement is not noted within 24 hours the physician will be contact by the staff nurse assigned to the resident for follow up instructions/orders. This assessment includes the following: ? Observing for lacerations; if present, clean and apply dry, sterile dressing. Note size, depth and amount of bleeding or drainage. ? Observing for swelling and discoloration; if present, chart size, site, amount and color. ? Observing for convulsions; chart time began, precipitating factors, duration, vital signs and time ended. Also chart whether or not resident had difficulty breathing. ? Observing and inquire if resident has headache or pain. ? Observing for personality changes. ? Observing for alterations in consciousness. ? Observing for incontinence. ? Observing for sensory weakness. ? Observing for generalized weakness. ? Observing for speech disorder. ? Observing for gait, posture or balance disorder. ? Observing for stiff neck. ? Observing for proper reflexes (response to painful stimuli). ? Observing for abdominal spasm or pain. ? Observing for bleeding from ears, nose, throat. ? Observing for unequal pupils. ? Observing for dyspnea or variations in respirations (irregular). ? Observing for flushing or cyanosis. ? Observing for pain. ? Observing for abduction, adduction, shortening or improper position of extremities. ? Taking vital signs by the nursing assistant ? ? ? On [DATE] and [DATE], all staff nurses were in-serviced by staff development coordinator, unit manager, the nurse consultant and the administrator how to contact the physician and how to document significant changes. 24 out of 30 staff nurses have received this education. The exact in-service content is as follows: ? Credible Allegation In-service ? After all resident falls, injuries or changes in physical or mental function, the charge nurse will monitor the following every shift for 72 hours: ? Observe for lacerations; if present, clean and apply dry, sterile dressing. Note size, depth and amount of bleeding or drainage. ? Observe for swelling and discoloration; if present, chart size, site, amount and color. ? Observe for convulsions; chart time began, precipitating factors, duration, vital signs and time ended. Also chart whether or not resident had difficulty breathing. ? Observe and inquire if resident has headache or pain. ? Observe for personality changes. ? Observe for alterations in consciousness. ? Observe for incontinence. ? Observe for sensory weakness. ? Observe for generalized weakness. ? Observe for speech disorder. ? Observe for gait, posture or balance disorder. ? Observe for stiff neck. ? Observe for proper reflexes (response to painful stimuli). ? Take vital signs and include temperature. ? Observe for abdominal spasm or pain. ? Observe for bleeding from ears, nose, throat. ? Observe for unequal pupils. ? Observe for dyspnea or variations in respirations (irregular). ? Observe for flushing or cyanosis. ? Observe for pain. ? Observe for abduction, adduction, shortening or improper position of extremities. ? Have someone stay with the resident while the nurse is calling the attending physician, if necessary. The physician should be called promptly (within 15 minutes) after completion of an assessment that determines that a change of condition has occurred. The phone numbers for the physicians are in the rolodexes located at each nurses station. The physician should be called for any change of condition as outlined above 24 hours a day and 7 days a week. This process does not change due to time or day of the week. ? If you are unable to reach the attending physician or the physician on call, on call RN within 30 minutes of contacting the primary physician for further instructions. The RN on call phone number is [PHONE NUMBER]. ? This assessment should be documented in the nursing notes. ? The nurse will note any concerns or changes noted by other staff or family. ? Additionally, neurological assessments should be completed any time there is an physician order, when a fall causes an impact to the head, when there is an un-witnessed fall or any other time the nurses deems necessary. The nurse should document using the form for neurological checks. Neurological checks should be completed every hour times 4 hours and then every shift for a total of 48 hours. A neurological assessments includes the following: ? Date and time the assessment was completed ? Level of Consciousness: Is resident alert, drowsy, stuporous or comatose ? Pupil response: Is the resident's pupil equal and reactive to light. Also document the pupil response in each eye as either brisk, sluggish, non-reactive, pinpoint, dilated or fixed. ? Motor functions: Document the hand grasp as either equal, the right greater than left, left greater than right, if the resident is unable to participate or if hand grasp is absent. Also document whether the resident is able to to move all extremities. If unable to move all extremities then document which extremities they are able to move. Complete this for the right arm, left arm, right leg and left leg, checking all that apply. If the resident is unable to follow commands or if they are absent any extremities indicate that as well. ? Pain response: Document if the resident has an appropriate pain response, inappropriate pain response or no pain response. ? Vital Signs: Document blood pressure, pulse, respirations and temperature ? Observations: Document any additional observations such as [MEDICAL CONDITION], headache, vomiting or paralysis ? Sign you name in the box indicated on the form. ? Complete an incident, accident or risk management report per facility policy. ? Notify resident's responsible party. ? If a new order is received by the physician then the order should be documented by the nurse who received the order on the telephone order sheet. Then the order should be transcribed to Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Other non-medication/treatment orders should be initiated based on order type. This transcription should be completed by the staff nurse receiving the order. The ,[DATE] nurse is to complete a chart check every night where every chart is reviewed for new orders. If new orders (within the last 24 hours) are identified the night shift nurse is to verify that the order was transcribed appropriately to the medication/treatment record or implemented appropriately. If a problem or concern is identified then the night shift nurse must notify the Director of Nursing that morning by either phone or note placed in the Director of Nursing's box at the nursing station. ? Any concerns identified by this audit will be corrected or addressed by the Director of Nursing and will be reviewed weekly at the Quality Assurance Committee Meeting describe in this document. The staff development coordinator will ensure that any staff nurse who does not complete the in-service training by [DATE] will not be allowed to work until the training is completed. This in-service was incorporated into the new employee facility orientation. An in service on [DATE] has been provided to the Nursing Assistants by the Staff Development Coordinator, Nurse Consultant, Nurse Manager and MDS Coordinator to report any changes to the resident to the nurse on the unit as soon as identified. The staff development coordinator will ensure that any nursing assistant who does not complete the in-service training by [DATE] will no