Every finding on record at Lotus Village Center for Nursing and Rehabilitatio

Based on observations, record review, North Caroliana (NC) Department of Transportation (DOT) website, and resident, staff, Physician Assistant and Medical Director interviews, the facility failed to supervise a resident, who had a diagnosis of dementia with other behavioral disturbance and known exit-seeking behaviors, from exiting the facility's locked memory care unit unsupervised and without staff knowledge for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #58). Prior to her admission to the Skilled Nursing Facility (SNF), Resident #58 eloped from the previous SNF where she had resided by climbing out a window. On 01/06/26 Resident #58 was deemed incompetent by a court and appointed a guardian. On 01/08/26, Resident #58 removed the screw from the bottom of the window frame in her room and climbed out the window wearing a sweatshirt, overalls and tennis shoes with no jacket in 50-degree Fahrenheit weather. The distance from the windowsill to the ground was 5 feet 11 inches. Resident #58 walked through the back parking lot and down the hill along a public two-lane residential road with no sidewalks. There was no posted speed limit sign; however, according to the NC DOT website, NC law sets speed limits within town or city limits at 35 miles per hour unless otherwise posted. At approximately 5:05 PM, the Activity Assistant observed Resident #58 walking along a residential road approximately 1,056 feet (0.2 miles) from the facility. Resident #58 was transported back to the facility without incident and with no injuries identified. This noncompliance had a high likelihood of causing serious injury or serious bodily harm.Findings included:A hospital Medical Doctor (MD) progress note dated 11/01/25 read in part, Resident #58 arrived at the Emergency Department (ED) on 10/31/25 from the Skilled Nursing Facility (SNF) and was being seen for a mental health evaluation. The SNF staff reported Resident #58 had been making elopement attempts and no longer wanted to be there. Resident #58 was evaluated by the hospital crisis team who recommended acute, inpatient psychiatric care and involuntary commitment.A hospital MD progress note dated 11/05/25 read in part, the MD received a report from nursing around 5:00 PM yesterday evening that [Resident #58] was having severe anxiety and reported wanting to jump out a window to hurt herself. Suicide preventions were initiated and she was given Seroquel (antipsychotic) with improvement. Discussed this incident with [Resident #58] today and she said it was a transient (temporary) time that has not returned.Resident #58 was admitted to the facility's locked memory care unit on 11/12/25 with diagnoses that included dementia-moderate with other behavioral disturbance, primary progressive multiple sclerosis (chronic autoimmune disease of the central nervous system characterized by a gradual, steady worsening of neurological function), diabetes, hypertensive heart disease without heart failure, chronic obstructive pulmonary disease (difficulty breathing), anxiety disorder, and depression. A baseline care plan dated 11/12/25 indicated Resident #58 was an elopement risk with the goal that her safety would be maintained through the review date. Interventions included for staff to reorient and redirect as needed and check placement and function of safety monitoring device every shift.Review of Resident #58's comprehensive care plans initiated on 11/12/25 revealed no care plan that addressed wandering or exit-seeking behaviors.A Safe Smoking Screen assessment dated [DATE] revealed Resident #58 currently used tobacco, had no plans to stop smoking and required supervision while smoking.Review of the nursing staff progress notes for November 2025 through January 2026 revealed no entries related to exit-seeking behaviors. In addition, there was no entry related to Resident #58's elopement from the facility. A Physician's Assistant (PA) admission progress note dated 11/14/25 revealed in part, Resident #58 was admitted to the facility on [DATE] following a hospitalization. The PA noted Resident #58 was admitted to the hospital from another SNF secondary to confusion and multiple attempts to elope from the previous SNF, including an incident where she climbed out of her window. The PA noted under current medications Resident #58 had an order for Seroquel 25 milligrams (mg) every 24 hours as needed (PRN) for agitation at bedtime and no changes were made to her current medications.The admission Minimum Data Set (MDS) assessment dated [DATE] noted Resident #58 had moderate cognitive impairment. She had a height of 5 feet 7 inches, weighed 135 pounds and was independent with walking. She displayed no behaviors or wandering and received antipsychotic, antidepressant and anticonvulsant medications during the MDS assessment look-back period. A PA progress note dated 11/21/25 revealed in part, Resident #58 was seen for a follow-up visit related to her recent admission and also had a form that needed filled out for her capability to manage benefits. The PA noted Resident #58 had a diagnosis of mild cognitive disorder and he was not sure that she would be able to manage her benefits on her own at the time although she might be able to in the future.A PA progress note dated 12/08/25 revealed in part, nursing staff reported Resident #58 had been more confused and agitated that normal. She had been hovering around exits and had increased behaviors. Under the psychiatric review of symptoms, the PA noted Resident #58 had difficulty sleeping, increased confusion, agitation and exit-seeking behavior. The PA noted Resident #58's recent laboratory tests were unremarkable and he would order a urinalysis with reflux (if the initial urine test showed signs of infection or abnormality, an additional in-depth test is conducted on the same urine sample) to rule out a urinary tract infection as the possible cause of Resident #58's increased confusion and agitation.A PA progress note dated 12/10/25 revealed in part, nursing staff reported Resident #58 had increased behaviors over the past several days and as needed (PRN) Seroquel had helped with her behaviors; however, Resident #58 had been off the medication for several days with increased behaviors since then. Staff were questioning if the medication could be scheduled. An order was provided for Seroquel 25 milligrams (mg) once a day for anxiety and mood.Review of Resident #58's December 2025 Medication Administration Record (MAR) revealed a physician's order dated 12/11/25 for Seroquel 25 mg once a day for anxiety and mood. The order was initialed on the MAR daily by nursing staff as administered per physician order.Review of the State of NC Letters of Appointment Guardian of the Person document revealed Resident #58 was deemed an incompetent person and the County Department of Social Services was appointed as the Guardian of the Person by the Clerk of Superior Court effective 01/06/26.A statement written by the Activity Assistant and dated 01/08/26 revealed in part, at approximately 5:05 PM when leaving the facility, Resident #58 was observed walking down the road and had reached a point in the road between a food pantry and a thrift store. The Activity Assistant pulled her car over, asked Resident #58 what she was doing and Resident #58 asked the Activity Assistant for a ride. Resident #58 got into the car and was taken back to the facility. The Activity Assistant asked Resident #58 to go into the facility with her to figure things out, Resident #58 complied with the request and was assisted back to the memory care unit by the Activity Assistant. Nurse #3 and Nurse Aide (NA) #1 were both on the memory care unit and had just discovered Resident #58's window open with the screen pushed out.During an interview on 05/12/26 at 5:13 PM, the Activity Assistant recalled on 01/08/26 she had just gotten off work at 5:00 PM when her significant other arrived at the facility to take her home. While driving home, they almost made it to the thrift store when she noticed someone walking down the road that looked like Resident #58 and she had her significant other pull over and stop the car. She recalled it was cold outside and dusk at the time, not quite dark, and Resident #58 was wearing a sweatshirt, overalls, beret (brimless, circular soft cap), and tennis shoes with no jacket or gloves. The Activity Assistant got out of the car and went up to Resident #58. She stated Resident #58 was calm but appeared confused and seemed scared that she was going to be in trouble. The Activity Assistant asked Resident #58 what her plan was because it was cold outside and Resident #58 stated she had just gone out for a walk. She stated Resident #58 asked for a ride, she had Resident #58 get into her car and then took her back to the facility. The Activity Assistant walked with Resident #58 back into the facility and when they got to the memory care unit, Nurse #3 and NA #1 were in Resident #58's room. She recalled Resident #58's window was opened and a section of the screen was bent outward where Resident #58 climbed out of the window. The Activity Assistant stated when she found Resident #58 along the road, she called the DON to inform her of the incident. A statement written by NA #1 and dated 01/08/26 revealed in part, NA #1 observed Resident #58 in her room around 4:45 PM to 4:50 PM while completing the last round before dinner. During an interview on 05/12/26 at 5:23 PM, NA #1 confirmed she was working on the memory care unit (MCU) on 01/08/26 during the hours of 6:30 AM to 6:30 PM when Resident #58 eloped from the facility. NA #1 stated for most of the shift, Resident #58 had pretty much kept to herself in her room and she had been fine when NA #1 had checked in on her every 15 minutes. Around 4:40 PM or 4:45 PM, she and Nurse #3 walked down the unit making rounds and Resident #58 was observed in her room, calm and not displaying any exit seeking behaviors. NA #1 could not recall what Resident #58 was wearing but stated she usually wore a sweatshirt or light weight jacket all the time. NA #1 stated after rounds were completed, she then started getting all the residents to the dining room for dinner. She could not recall the exact time but thought it may have been around 4:50 PM when Nurse #3 received a call from the Activity Assistant stating Resident #58 was found outside the facility. NA #1 stated she and Nurse #3 went to Resident #58's room, Resident #58 was gone and the window was partially opened with the screen bent outward just enough for her to climb out of the window. She recalled it was starting to get dark outside and the weather was cold. NA #1 was not sure of the exact location along the road where Resident #58 was found but stated she could not believe Resident #58 had gotten out of the facility in the blink of an eye and down the road so quickly. NA #1 reported when Resident #58 was brought back to the unit, she was calm and had no injuries. She asked Resident #58 where she was going when she left the facility and Resident #58 told her she needed a cigarette and was going to find one. A statement written by Nurse #3 and dated 01/08/26 revealed Resident #58 was observed in bed at 4:30 PM when Nurse #3 was conducting a medication pass. Nurse #3 noted a skin assessment was completed and Resident #58 had no open areas or injuries.During an interview on 05/14/26 at 10:25 AM, Nurse #3 recalled she was doing her evening medication pass on 01/08/26 when she entered Resident #58's room at approximately 4:30 PM to administer her medications. Nurse #3 stated after Resident #58 took her medications, she left the room and continued down the hall. When she had completed the remainder of the medication pass, Nurse #3 stated she took the medication cart to the nurses' station and then started assisting the NAs with passing out dinner trays. Nurse #3 reported she grabbed Resident #58's meal tray from the cart and as she reached the door of Resident #58's room, she received a call from the Director of Nursing (DON) asking her if they were missing anyone. Nurse #3 stated she told the DON no one was missing, the DON asked her to go check Resident #58's room and Nurse #3 informed the DON she was at Resident #58's door about to open it to deliver Resident #58's dinner tray. Nurse #3 stated when she opened the door of Resident #58's room while still on the phone with the DON, Resident #58 was gone and the window was partially open. The DON then told her that the Activity Assistant had found Resident #58 walking down the road and was bringing her back to the facility. She indicated it was approximately 5:10 PM when she received the call from the DON. Nurse #3 stated when she walked into the room to look at the window, Resident #58 had removed the screw from the window frame, and the window was opened about a foot with the screen bent outward. When she looked out the window, Nurse #3 stated she saw footprints in the dirt and assumed they were Resident #58's. Nurse #3 stated Resident #58 could not have been gone for very long because when she asked NA #1 and NA #2 what time they had last seen Resident #58 on the unit, they both stated it was around 4:50 PM when they did rounds. Nurse #3 reported that as soon as Resident #58 was brought back to the unit, she did a head-to-toe assessment of Resident #58 with no injuries identified and Resident #58 was placed on one-to-one staff supervision. She verified she checked and all other residents on the unit were accounted for. Nurse #3 stated when she asked Resident #58 where it was she thought she was going to go, Resident #58 told her that she wanted some cigarettes and just wanted out of here. Nurse #3 stated that prior to 01/08/26, Resident #58 would pace back and forth on the unit at times but she had never attempted to elope nor had she made any attempts since. A statement written by NA #2 and dated 1/08/26 revealed in part, NA #2 and NA #1 went into Resident #58's room at approximately 4:45 PM to 4:50 PM to check on her and she was lying in the bed. NA #2 was unavailable for an interview at the time of this investigation. A Medical Director progress note dated 01/29/26 revealed in part, Resident #58 had a diagnosis of mild cognitive impairment of uncertain or unknown etiology and resided on the locked memory care unit. The Medical Director noted Resident #58 recently tried to elope but was found unharmed and brought back to the memory care unit. Following the incident, all safety measures were implemented to ensure the unit was locked and secure. Resident #58 had no further elopement attempts but was high risk and required continued care on the locked memory care unit.During an interview on 05/14/26 at 10:59 AM, the Medical Director verified that she was made aware of Resident #58's elopement on 01/08/26 and from what she recalled, Resident #58 was found outside the facility and brought back unharmed. She stated that Resident #58 obviously had a plan to go somewhere that day but then couldn't remember where it was she was wanting to go. The Medical Director explained that while Resident #58 was physically high-functioning, she had cognitive impairment and would not be safe outside unsupervised which was why she resided on the locked memory care unit. During an observation and interview on 05/13/26 at 8:48 AM, Resident #58 was lying on top of the bed with a staff member sitting in the recliner next to her providing one-to-one supervision. Resident #58 could not recall the date but did remember climbing out the window of her room stating she had just felt like going for a walk. When asked which way she went once outside, Resident #58 stated she walked down the road a bit while looking out the window and pointing to the left side (where the road led toward the funeral home next to the facility) but could not recall how far she walked. She stated the Activity Girl and her husband came by and gave her a ride back to the facility. Resident #58 expressed she didn't give them any trouble and stated, reckon I wasn't supposed to be out there. Resident #58 restated she was just going for a walk but made a bad decision and would have to deal with the consequences. When asked if she removed the screw from the window frame in order to open the window, she would not provide a direct response and just stated that the screw was in there tight but if someone wanted to, they could get the screw out.During an interview on 05/13/26 at 2:04 PM, the PA recalled he was made aware of Resident #58's elopement but was not sure if someone told him about the incident or if it was documented in the provider communication book. When asked his medical opinion regarding Resident #58 being safe outside the facility unsupervised, he stated that was hard to answer as she was rather high-functioning but she did have some cognitive impairment and might have difficulty trying to find her way back to the facility. The PA stated he felt Resident #58 would likely be safe for a short period of time, but she would not be safe outside unsupervised for a long period of time. During an interview on 05/15/26 at 12:29 PM, the DON recalled that on 01/08/26 she received a call from the Activity Assistant at 5:05 PM informing her that she had picked Resident #58 up along the side of the road near the thrift store. The DON stated the Activity Assistant reported she was driving home and saw Resident #58 walking down the road and when she asked Resident #58 where she was going, Resident #58 stated she just wanted some fresh air. She stated the Activity Assistant asked Resident #58 if she would get into the car, which she did without resistance, and the Activity Assistant brought her back to the facility. After she spoke to the Activity Assistant, the DON called Nurse #3 and asked if she was missing anyone on the unit. She had Nurse #3 go check Resident #58's room, Nurse #3 reported the door was closed and when she opened the door to the room, the window was open and Resident #58 was gone. The DON stated she was informed that Resident #58 had removed the screw from the window frame, opened the window and bent the screen enough to climb out the window. The DON headed back to the facility and by the time she arrived, the previous Maintenance Director had already fixed the window. When she spoke to Resident #58 about the incident, Resident #58 told the DON that she climbed out the window to get some fresh air. She stated that when Resident #58 returned to the facility, she was assessed by Nurse #3 with no injuries identified and placed on one-to-one staff supervision. The DON verified the facility was aware of Resident #58's elopement attempts from her previous SNF when she was admitted on [DATE] but she had not made any elopement attempts while at the facility prior to 01/08/26. The Maintenance Director at the time of this incident was no longer employed and unable to be interviewed at the time of this investigation.The Administrator at the time of this incident was no longer employed and unable to be interviewed at the time of this investigation.Observations of the window inside Resident #58's room were conducted on 05/12/26 at 4:50 PM and 05/14/26 at 4:52 PM. The back parking lot of the facility could be viewed from the window. There was one screw placed in the top and one screw placed in bottom of the window frame preventing the window from opening more than approximately 3 inches.An observation of the window outside of Resident #58's room was conducted with the Maintenance Director on 05/13/26 at 2:38 PM. The ground directly below and leading to the paved parking lot was grass covered. The Maintenance Director used a tape measure and the distance from the windowsill to the ground was 71 inches (5 feet 11 inches). An observation of the area where Resident #58 was found on 01/08/26 was conducted on 05/12/26 at 5:50 PM. A steep, grass-covered embankment extended along the right side of the facility from the rear to the front, leading down to the parking lot of a funeral home. The facility's rear parking lot connected to a driveway that exited onto a two lane road without sidewalks. This road went around the funeral home parking lot and downhill to a stop sign. Directly across from the stop sign was a residential property with sloped terrain and trees lining the rear boundary of the property. Turning left at the stop sign, the two lane road continued approximately 288 feet to a second stop sign (Google Earth was used to calculate the distance between the two stop signs). From the second stop sign, the road led straight ahead into the facility's front parking lot; to the left was an embankment; and to the right was a public two-lane road where a thrift store and food bank were located. The driving distance from the facility's rear parking lot to the area between the thrift store and food bank, where Resident #58 was found, was approximately 0.2 miles (1,056 feet). An online website named Weather Underground was used to obtain the outside weather conditions in [NAME], North Carolina on 01/08/26 which revealed at 4:55 PM: cloudy conditions, temperature of 50 degrees Fahrenheit (F) with no precipitation and South-Southeast wind speed of 8 miles per hour. The Administrator was notified of Immediate Jeopardy on 05/13/26 at 5:00 PM.The facility provided the following Corrective Action Plan of Immediate Jeopardy removal:Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 01/08/2026 at approximately 5:05 pm the Activities Assistant was driving home from the building when she saw Resident #58 walking down the side of the road in front of the facility close to a thrift store. The Activities Assistant stopped and asked Resident #58 what she was doing. Resident #58 asked the Activities Assistant for a ride. The Activities Assistant helped Resident #58 into the car and brought her back to the facility and returned her to the 400 hall. The Administrator and Director of Nursing were notified immediately. Resident #58 had removed the screw from the window and was able to open the window enough to get out. The screen was also bent and pushed outward. When Resident # 58 was asked where she was trying to go Resident #58 stated she was just going for a walk for some fresh air. Resident #58 was unable to tell us how she removed the screw. Nurse #3 assessed Resident #58 for injuries. No injuries were identified. Resident was placed on 1:1 supervision by facility staff and will remain on 1:1 supervision while residing in the facility. The Medical Director and guardian were notified of the event by the Director of Nursing on 01/08/2026. It was determined Resident #58 went out through the window due to the window being open and the screen being bent and pushed out. Resident #58 was being seen by the mental health provider prior to the incident and continues to be seen. Resident #58 was seen by the mental health provider on 01/06/2026 and there were no new orders. Resident #58's care plan was reviewed and updated by the Director of Nursing and interdisciplinary team on 01/09/2026.Address how the facility will identify other residents having the potential to be affected by the same deficient practice:Residents currently residing in the facility have the potential to be affected. On 01/08/2026 through 01/09/2026 the Director of Nursing assessed current residents for his/her ability to walk, his/her cognitive impairments, and his/her ability to reasonably remove a windowpane and climb through the window opening. This was assessed by observing the amount of assistance needed during activities of daily living care. No residents were identified at risk during the assessment. During the investigation, a review of residents who pose as a potential elopement risk based on exit seeking behaviors and their ability to exit were assessed using the elopement risk assessment on 01/08/2026 by the Director of Nursing with no additional residents identified. There are currently three residents at risk. All residents have open utilization data assessment (UDA) named elopement assessments scheduled for their Admission/ Quarterly, these assessments are completed by floor nursing and are maintained in the residents' medical record. The Maintenance Director conducted a house audit of windows to ensure that windows could not be opened greater than 3 inches (decrease from 6 inches) on 01/08/2026. Any window that had the ability to exceed the 3-inch limit was addressed and additional hardware such as additional screws were put into place. Per fire safety code and adequate alternative safety measures such as fully sprinklered building, alternative exits, and a fully fire monitored building the windows opening to 3 inches will meet National Fire Protection Agency 101 life safety code. Windows in the facility were audited and new screws added to the tops of the windows. Windows in the facility open right to left.Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur:An additional screw was added to the top of the window and the screw to the bottom of the window was replaced to allow the window to open 3 inches, previously 6 inches on 01/08/2026 by the Maintenance Director.A review was completed of the Elopement and Wandering Policy by the Administrator and Director of Nursing on 01/08/2026. No changes were needed. The education on the center's Elopement and Wandering Policy was initiated on 01/08/2026 by the Administrator and Director of Nursing. All staff in Nursing (nurses, nurse aides, medication aides), Agency staff, Therapy, Housekeeping, Administration, and Dietary have received education verbally or in-person prior to working. Education was provided face to face for individuals who were on shift, others not on-site were provided with education via phone. The education included ensuring residents that exhibit exit seeking behaviors and/or at risk for elopement receive adequate supervision to prevent accidents in the facility's control. Staff were educated on how to identify exit seeking behaviors, monitor the affected residents, and interventions. Education highlighted that alarms do not replace the necessary supervision of residents. Nor does it negate how vigilant that the staff should be in responding to alarms or actions of the residents that would indicate an elopement risk. Staff were instructed that if they were to witness a resident attempting to open a door or window, he/she should make efforts to remove the resident from the area through redirection and should never stop monitoring the resident. The Administrator and/or Director of Nursing should be notified immediately. Staff were reminded that a binder containing residents that are at risk for elopement are kept at both nurses' stations. The binders are maintained and kept current by the Director of Nursing and/or Social Worker. The Director of Nursing and Social Worker were notified of this responsibility by the Administrator on 01/09/26. When a resident is identified as high risk for elopement their name and information is added to the binders. Education will be oversighted by DON, anyone not educated on 01/08/2026 will need to be educated in-person prior to their next scheduled shift by the Director of Nursing.On 01/08/2026 the Administrator and Director of Nursing educated all Nurses either in person or via phone that a new elopement risk assessment was to be completed upon admission, quarterly, and with any significant change. The assessments are maintained in the resident's electronic medical record.Newly hired staff members will receive this education in orientation from the Director of Nursing and/or Maintenance Director on the day of orientation. In addition, newly hired nurses are educated on how to identify behaviors that trigger the need for a new elopement risk assessment to be completed.Indicate how the facility plans to monitor its performance to make sure that solutions are sustained:Effective 01/08/2026, the Maintenance Director or designee will audit all facility windows two times a week for 12 weeks to ensure that the residents' windows have a screw in place to the top of the window and the bottom so that the window does not open more than 3 inches. This will be ensured by measuring with a tape measure. Any defective item or missing screws will be corrected immediately. While the repair is being completed the window will have constant monitoring by a facility staff member.The 24-hour report will be reviewed daily by the DON/designee during the clinical meeting looking for any increased wandering and/or elopement attempts. Any areas of concern identified will be immediately assessed by the Director of Nursing/designee and interventions put into place. This will be an ongoing practice.Audits of the center's response to elopement drills will be completed 1 time a week (across all shifts/days) for 12 weeks by the Maintenance Director or designee to ensure responsiveness and demonstration of the staff to properly execute procedures outlined in the Elopement and Wandering Residents Policy.On 01/09/26 an ADHOC QAPI was initiated by the Interdisciplinary Team about the event, and the decision was made to implement the plan with monitoring. The Administrator directed the Director of Nursing and Maintenance Director on 01/09/2026 that they are responsible for forwarding the results of their audits the QAPI Committee monthly for three months. The QAPI Committee will review the audits to determine trends and/or issues that may need further interventions put into place and to determine the need for further and/or frequency of monitoring. The Medical Director was made aware of the plan on 01/09/26.IJ removal and compliance date: 01/10/2026On 05/15/26, the corrective action plan was validated onsite through observations, record review, and staff interviews. The weekly monitoring logs of the elopement drills and observations of resident windows to ensure screws were in place at the top and bottom of the window frame were reviewed with no concerns identified. Observations of windows in resident's rooms revealed screws were placed tightly in the top and bottom of the window frame preventing them from opening more than 3 inches. Elopement binders were observed at each nurses' station and reception area that contained a picture of each resident identified as high-risk along with along with a printout of their profile page that listed pertinent identification such as age, date of birth and emergency contact numbers, a document for each resident indicating whether or not they wore an elopement device, and staff search assignments in the event of a missing person. The Social Worker confirmed she was made aware of her responsibility for maintaining the elopement binders. Interviews conducted with staff on various shifts and departments revealed they received education on the facility's elopement policy and procedure and participated in elopement drills. Staff were able to verbalize where the elopement binders were located and what information they contained, what to do when a resident demonstrated exit-seeking behaviors, and what to do in the event of a missing resident. Nurses were able to verbalize the process for completing and documenting elopement risk assessments. The IJ removal and compliance date of 01/10/26 was validated.

Based on observations, record review and staff interviews, the facility failed to develop individualized, person-centered care plans that included areas of focus for smoking, exit-seeking behaviors, use of an elopement alarm device, and activities of daily living (ADL) for 3 of 28 sampled residents (Residents #58, #69 and #3). Findings included: 1. Resident #58 was admitted to the facility on [DATE] with diagnoses that included personal history of nicotine dependence, dementia with other behavioral disturbance, anxiety disorder, and depression. A Safe Smoking Screen assessment dated [DATE] revealed Resident #58 currently used tobacco, had no plans to stop smoking and required supervision while smoking. A Physician's Assistant (PA) admission progress note dated 11/14/25 revealed in part, Resident #58 was admitted to the facility on [DATE] following a hospitalization. The PA noted Resident #58 was admitted to the hospital from another skilled nursing facility (SNF) secondary to confusion and multiple attempts to elope from the previous SNF, including an incident where she climbed out of her window. Review of Resident #58's medical record revealed an active physician order dated 11/16/25 for an elopement alarm device to the right wrist due to poor safety awareness. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #58 was not coded for tobacco use or utilizing a wander/elopement alarm. A Medical Director progress note dated 01/29/26 revealed in part, Resident #58 had a diagnosis of mild cognitive impairment of uncertain or unknown etiology and resided on the locked memory care unit. The Medical Director noted Resident #58 recently tried to elope but was found unharmed and brought back to the memory care unit. Following the incident, all safety measures were implemented to ensure the unit was locked and secure. Resident #58 had no further elopement attempts but was high risk and required continued care on the locked memory care unit. The quarterly MDS assessment dated [DATE] revealed Resident #58 used a wander/elopement alarm daily. Current tobacco use was not coded on the MDS assessment. Review of Resident #58's comprehensive care plans last revised on 02/26/26 revealed no care plan that addressed smoking, exit-seeking behaviors or use of an elopement alarm device. During an observation on 05/11/26 at 11:08 AM, Resident #58 was observed sitting outside with a staff member and another resident smoking a cigarette with no concerns noted. During an interview on 05/14/26 at 3:12 PM, the MDS Coordinator reported she currently developed all the comprehensive care plans for residents at the facility. She confirmed Resident #58 used tobacco, utilized an elopement alarm device and displayed exit-seeking behaviors as evidenced by her elopement from the facility on 01/08/26. The MDS Coordinator reviewed Resident #58's care plans and stated she should have included plans that addressed smoking, use of an elopement alarm device and exit-seeking behaviors as they were all areas that she would normally care plan and it was an oversight. During an interview on 05/15/26 at 2:22 PM, the Administrator expressed she would expect care plans to be comprehensive and accurately reflect the residents' needs. 2. Resident #69 was admitted to the facility on [DATE] with diagnoses that included non-Alzheimer's dementia, depression, chronic obstructive pulmonary disease (COPD), muscle weakness, and history of falling. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #69 had severe cognitive impairment. He displayed no behavioral symptoms or rejection of care and wandered 4 to 6 days. He was occasionally incontinent of urine and always incontinent of bowel. He required substantial/maximum assistance with toileting hygiene, shower/bathing, putting on/taking off footwear and required partial/moderate assistance with lower body dressing and personal hygiene. He was independent with ambulation without the use of an assistive device and had one fall with minor injury during the MDS assessment look-back period. Review of Resident #69's comprehensive care plans last revised on 03/23/26 revealed no care plan that addressed his ADL needs. During an interview on 05/14/26 at 3:12 PM, the MDS Coordinator reported she currently developed all the comprehensive care plans for residents at the facility. She reviewed Resident #69's care plans and confirmed there was no care plan that addressed his ADL needs. The MDS Coordinator stated looking back, she should have developed a care plan that addressed the ADL areas where he needed more assistance so staff would know what level of care to provide. During an interview on 05/15/26 at 2:22 PM, the Administrator explained an ADL care plan ties into the Kardex (reference tool that contains a brief overview of a resident's daily care needs and safety precautions) which tells the nurse aides what level of care the resident required. She stated it was her expectation that ADL care plans were developed for every resident in the facility 3.Resident #3 was admitted on [DATE] with diagnoses that included dementia. A physician orders dated 2/7/25 included a wander alarm (a wearable electronic device that trigger door locks or alarms when a resident approaches an exit, allowing for freedom of movement within safe, monitored boundaries) to be placed on Resident #3's left lower leg and to monitor the wander alarm placement on the left lower leg every shift. A review of Resident #3's care plan last updated on 3/18/26 did not include a care plan for wandering or elopement risk. A review of Resident #3's quarterly Minimum Data Set (MDS) dated [DATE] coded him cognitively intact. He was not coded for having a wander/elopement alarm and had no wandering behaviors. On 5/14/26 at 3:13 PM the MDS Coordinator stated she was responsible for revising and reviewing Resident #3's care plan. She stated Resident #3 had an order for a wander alarm with a history of wandering and exit seeking and she had overlooked the order and did not care plan the resident for wandering or elopement risk. The Administrator stated on 5/15/26 at 2:30 PM Resident #3's care plan should be accurate and reflect the needs of the Resident.

Based on observations, record reviews and staff interviews, the facility failed to date medications when opened and remove expired and unlabeled medications from 4 of 4 medication carts reviewed for medication storage (Medication Carts 100/200/300/400).The findings included:Review of the facility's medication formulary dated 2025-2026 indicated to:- discard albuterol sulfate nebulization solution in 7 days after opening foil pouch,- discard fluticasone-vilanterol 42 days after opening foil tray,- discard budesonide inhalation solution 14 days after opening foil pouch.a. On 05/13/26 at 11:30 AM an observation was conducted of the 100-hall medication cart along with Nurse #2. The observation yielded one box of albuterol sulfate nebulization solution dated 04/15/26 that was available for use. The box contained one open and undated foil pouch of albuterol sulfate solution. The observation also yielded one open and undated fluticasone-vilanterol inhalation foil tray that was available for use. The dispensed date was 03/18/26.An interview was conducted with Nurse #2 on 05/13/26 at 11:30 AM. The Nurse explained that it was the third shift nurses' responsibility to clean the medication carts which meant to clean the carts and remove the expired medications and send them back to the pharmacy. She stated the nurse who opened the package should date the medication so that the nurses would know when to discard the medication.b. On 05/13/26 at 12:09 AM an observation was conducted of the 200-hall medication cart along with Nurse #2. The observation yielded one box of albuterol sulfate nebulizing solution that was available for use. The box contained an open and undated foil pouch of the albuterol sulfate solution.An interview was conducted with Nurse #2 on 05/13/26 at 12:09 AM. The Nurse explained that it was the third shift nurses' responsibility to clean the medication carts which meant to clean the carts and remove the expired medications and send them back to the pharmacy. She stated the nurse who opened the package should have dated the medication so the nurses would know when to discard the medication.c. At 10:17 AM on 05/13/26 an observation was conducted of the 300-hall medication cart along with Medication Aide (MA) #1. The observation yielded one open and unlabeled tube of oral gel pain medication.An interview was conducted with the Medication Aide on 05/13/26 at 10:17 AM. The MA explained that she normally worked on the 300-hall medication cart when she worked and she did not know who the open tube of oral gel belonged to nor did she know how long it had been on the medication cart.d. On 05/13/26 at 9:34 AM an observation was conducted of the 400-hall medication cart along with Nurse #1. The observation yielded a box of budesonide inhalation suspension dated 02/17/26 that was available for use. The box contained one open foil pouch of budesonide vials that was not dated when opened. The observation also yielded one open and undated fluticasone-vilanterol inhalation foil tray that was available for use. The dispensed date was 02/11/26.On 05/13/2026 at 9:34 AM during an interview with Nurse #1, the Nurse explained that all the nurses were responsible for keeping the medication carts clean and orderly which included removing expired medications from the carts and returning them to the pharmacy. The Nurse stated that she did not realize that the expired medications were on the medication cart. She stated the nurse who opened the package should date the package so that the nurses would know when to discard the medication.On 05/14/26 at 2:25 PM an interview was conducted with the Director of Nursing (DON) who explained that it was the third shift nurses' responsibility to check and clean the medication carts and the first shift nurses' along with herself were to check the medication carts behind them. The DON could not recall the last time she checked the medication carts. She stated the nurse who opens the package should date the package so that the nurses would know when to discard the medication.

Based on record review and interviews with staff, the Physician Assistant, and the Medical Director, the facility failed to implement an order for a urinalysis with reflex to culture (a two-step urine testing method) for 1 of 2 residents reviewed with symptoms of a urinary tract infection (Resident #27).The findings included:Resident #27 was admitted to the facility on [DATE] with cumulative diagnosis of multiple sclerosis (a chronic, progressive neurological disorder), neurogenic bladder, interstitial cystitis (a condition causing persistent pelvic pressure and bladder pain), anxiety disorder and depression.The admission Minimum Data Set (MDS) assessment dated [DATE] and the quarterly MDS assessment dated [DATE] revealed Resident #27 was cognitively intact, able to be understood and understand others and had an indwelling catheter.The care plan dated 11/05/25 indicated Resident #27 as having an indwelling catheter with nursing interventions to monitor, record and report to physician any signs and symptoms of a urinary tract infection including: pain, burning, blood tinged urine, deepening of urine color, foul smelling urine, cloudiness, no output, increased heart rate, increased temperature, altered mental status, change in behaviors, change in eating habits.A Psychiatry Nurse Practitioner (NP) note dated 04/28/26 documented concern for a possible urinary tract infection contributing to the resident's mental status changes and indicated the need to rule out infection.A physician order dated 04/28/26, created by the Director of Nursing (DON) and signed by the Psychiatry NP, directed staff to collect a urine sample on 04/29/26 and send it to the lab for a urinalysis with culture and sensitivity due to Resident #27's confusion.An interview was conducted on 05/15/26 at 9:32 AM with the nurse assigned to Resident #27 on 04/29/26. Nurse #4 stated that the assigned nurse was responsible for collecting urine samples when orders were in place. Nurse #4 did not recall collecting a urine sample on 04/29/26.An interview was conducted on 05/15/26 at 10:21 AM with the DON, who stated that on 04/28/26 she entered the physician order for a urinalysis with reflex to culture, with collection beginning at 7:00 AM on 4/29/26 and ending at 6:59 AM on 04/30/26, into Resident #27's electronic health record and did not know why it was not completed. The DON stated the nurse assigned to Resident #27 was responsible for collecting urine samples. The DON revealed the order dropped off the medication administration record (MAR) after the collection time passed and was forgotten. The DON stated she expected staff to complete the order and expressed concern that an undetected urinary tract infection could result in sepsis.An interview was conducted on 05/13/26 at 2:30PM with the Physician Assistant (PA). The PA stated that he had ordered a urinalysis on 05/12/25 at the request of Resident #27 and was unaware of the previously missed urinalysis. After being informed that the urinalysis ordered on 04/28/26 had not been completed, the PA noted that an untreated urinary tract infection could progress to sepsis within that timeframe.Initial lab results from a urinalysis collected on 5/13/26 showed a possible urinary tract infection.A physician progress note dated 05/14/26 indicated that the urinalysis obtained the previous day showed negative nitrates and positive leukocyte esterase, the patient's vital signs were stable, and the team would await culture results before starting treatment.An interview was conducted on 05/14/26 at 11:00 AM with the Medical Director, who stated staff were expected to follow all physician orders.An interview was conducted on 05/15/26 at 2:30 PM with the Administrator, who stated all physician orders must be addressed and that the facility needed a tracking process to ensure orders were completed.

Based on record review and staff interviews, the facility failed to complete admission Minimum Data Set (MDS) assessments no later than 14 calendar days after the residents' admission (Residents #2 and #63) and failed to complete Care Area Assessments (CAA) comprehensively that addressed the underlying causes and contributing factors of the triggered care area (Residents #58 and #9) for 4 of 28 sampled residents. Findings included: 1. Resident #2 was admitted to the facility on [DATE]. Review of Resident #2's electronic medical record revealed an admission MDS assessment dated [DATE] that was marked as completed on 01/16/26. During an interview on 05/14/26 at 3:12 PM the MDS Coordinator verified Resident #2's admission MDS assessment was not completed within the regulatory timeframe. The MDS Coordinator explained she was out of work at the time and got behind on completing assessments. During an interview on 05/15/26 at 2:22 PM the Administrator explained admission MDS assessments should be completed within 14 days of the resident's admission. She stated it was her expectation for MDS assessments to be completed and submitted within the regulatory timeframes. 2. Resident #63 was admitted to the facility on [DATE]. Review of Resident #63's electronic medical record revealed an admission MDS assessment with an Assessment Reference Date (ARD, referring to the last day of the observation period) of 03/20/26 that was marked as completed on 03/26/26. During an interview on 05/14/26 at 3:12 PM, the MDS Coordinator verified Resident #63's admission MDS assessment dated [DATE] was not completed within the regulatory timeframe. The MDS Coordinator explained she set the ARD wrong which was why the MDS assessment was completed late. During an interview on 05/15/26 at 2:22 PM, the Administrator explained admission MDS assessments should be completed within 14 days of the resident's admission. She stated it was her expectation for MDS assessments to be completed and submitted within the regulatory timeframes. 3. Resident #58 was admitted to the facility on [DATE] with diagnoses that included dementia-moderate with other behavioral disturbance, anxiety disorder, and depression. Review of the Care Area Assessment (CAA) summary from Resident #58's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the CAA for Psychotropic Drug Use triggered for Resident #58. There was no documentation in the assessment that provided any information in the analysis of findings that described the nature of Resident #58's problem, possible causes, contributing factors, and risk factors for the triggered care area. The information in the CAA noted Resident #58 is at risk for adverse drug reaction to the use of psychotropic medication and antidepressant and Psychotropic Drug Use would be addressed in the care plan. Review of the CAA summary from Resident #58's admission MDS assessment dated [DATE] revealed the CAA for Cognitive Loss/Dementia triggered for Resident #58. There was no documentation in the assessment that provided any information in the analysis of findings that described the nature of Resident #58's problem, possible causes, contributing factors, and risk factors for the triggered care area. The information in the CAA noted Resident #58 has a cognitive decline per the BIMS (Brief Interview for Mental Status, a standardized screening tool used to evaluate cognition on a scale of 0 to 15) of 11 and Cognitive Loss/Dementia would be addressed in the care plan. During an interview on 05/14/26 at 3:12 PM, the MDS Coordinator reported she currently completed all the care areas assessments of the MDS except the Activities assessment. The MDS Coordinator stated the CAAs triggered by information from the MDS to help develop the care plan. She explained that the analysis of findings puts together the story of how the triggered areas (CAAs) effects the day-to-day activities and/or functioning of the residents. The MDS Coordinator acknowledged that Resident #58's CAAs for Psychotropic Drug Use and Cognitive Loss/Dementia did not address the underlying cause or contributing factors and stated she should have written a complete CAAs for the triggered care areas. During an interview on 05/15/26 at 2:22 PM, the Administrator stated it was her expectation for the CAAs to be completed and contain a comprehensive analysis of findings for the triggered care areas. 4. Resident #9 was admitted to the facility on [DATE] with diagnoses that included vascular dementia and anxiety. Review of the Care Area Assessment (CAA) Summary from Resident #9's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the CAA for Psychotropic Drug use triggered for Resident #9. There was no documentation in the assessment that provided any information in the analysis of findings that described the nature of Resident #9's problem, possible causes, contributing factors and risk factors for the triggered care area. The information in the CAA noted Resident #9 is at risk for adverse drug reaction to the use of psychotropic med for anxiety. Proceed to CP (care plan). An interview was conducted with the MDS Coordinator on 05/14/26 at 3:15 PM. She stated she currently completed all the care areas assessments of the MDS except the Activities assessment. The MDS Coordinator stated the CAAs triggered by information from the MDS to help develop the care plan. She continued to explain that the analysis of findings puts together the story of how the triggered areas (CAAs) effects the day-to-day activities and or functioning of the residents. The MDS Coordinator acknowledged that Resident #9's CAA for Psychotropic Drug Use was lacking in that there was no underlying cause or contributing factors and stated she should have written a complete CAA for the Psychotropic Drug Use. An interview was conducted with the Administrator on 05/15/26 at 2:22 PM. The Administrator stated it was her expectation for the CAAs to be completed and contain a comprehensive analysis of findings for the triggered care areas.

Based on record review and staff interviews, the facility failed to complete a quarterly Minimum Data Set (MDS) assessment within 14 days of the Assessment Reference Date (ARD, referring to the last day of the observation period) for 1 of 28 sampled residents reviewed (Residents #2). Findings included:Resident #2 was admitted to the facility on [DATE].Review of Resident #2's electronic medical record revealed a quarterly MDS assessment with an ARD of 04/03/26 that was marked as completed on 04/20/26.During an interview on 05/14/26 at 3:12 PM, the MDS Coordinator verified Resident #2's quarterly MDS assessment dated [DATE] was not completed within the regulatory time frame. The MDS Coordinator was unsure why Resident #2's MDS assessment was completed late and stated it was an oversight.During an interview on 05/15/26 at 2:22 PM, the Administrator explained quarterly assessments should be completed within 14 days of the ARD. She stated it was her expectation for MDS assessments to be completed and submitted within the regulatory timeframes.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of Preadmission Screening and Resident Review (PASRR) (Resident #6), alarms (Resident #58 and Resident #3) and current tobacco use (Resident #58) for 3 of 28 residents reviewed for accuracy of assessments.The findings included: 1. Resident #6 electronic medical record (EMR) included a Level II PASRR Determination Notification letter issued 09/12/2025 with no expiration date. Resident #6 was admitted to the facility on [DATE] with a cumulative diagnosis which included anxiety disorder, depression and bipolar disorder. Resident #6's admission MDS assessment dated [DATE] indicated Resident #6 was not currently considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. An interview was conducted on 05/14/26 at 3:15 PM with the MDS Coordinator who completed Resident #6's admission MDS assessment. When asked about Resident #6's admission MDS assessment and Level II PASRR status the MDS Coordinator stated she had overlooked the Level II PASRR Determination Notification letter when completing the assessment. An interview was conducted on 05/15/26 at 2:30 PM with the Administrator who stated she expected all MDS assessments to be completed accurately. 2. Resident #58 was admitted to the facility 11/12/25 with diagnoses that included personal history of nicotine dependence and dementia with other behavioral disturbance. A Safe Smoking Screen assessment dated [DATE] revealed Resident #58 currently used tobacco, had no plans to stop smoking and required supervision while smoking. The Treatment Administration Record (TAR) for Resident #58 revealed a physician's order dated 11/16/25 for an elopement alarm device to the right wrist due to poor safety awareness. The order was initialed by nursing staff as completed for each 12-hour shift on 11/16/25, 11/17/25, and 11/18/25. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #58 was not coded for current tobacco use or use of a wander/elopement alarm. During an interview on 05/14/26 at 3:12 PM, the MDS Coordinator revealed her process for completing MDS assessments was to assess the resident, review the resident's medical record, write everything down, and then enter the information on the MDS assessment. The MDS Coordinator confirmed Resident #58 used tobacco and explained she usually looked at a resident's TAR when completing the MDS assessment but had overlooked nursing staff initialing the wander/elopement alarm device as being used by Resident #58 during the MDS assessment look-back period. During an interview on 05/15/26 at 2:22 PM, the Administrator stated she expected all MDS assessments to be completed accurately. 3. Resident #3 was admitted on [DATE] with diagnoses that included dementia. A physician order dated 2/7/25 included a wander alarm (a wearable electronic device that trigger door locks or alarms when a resident approaches an exit, allowing for freedom of movement within safe, monitored boundaries) to be placed on Resident #3's left lower leg and to monitor the wander alarm placement on the left lower leg every shift. A review of Resident #3's Medical Administration Record (MAR) for March 2026 noted the wander alarm was being checked every shift as ordered. A review of Resident #3's quarterly Minimum Data Set (MDS) dated [DATE] noted he was cognitively intact and he was not coded as having a wander/elopement alarm. On 5/14/26 at 3:13 PM the MDS Coordinator stated she had completed Resident # 3's MDS dated [DATE]. She confirmed Resident # 3 had an active order for a wander alarm when the MDS was completed. The MDS Coordinator stated she had overlooked the order and did not code the MDS correctly. The Administrator stated on 5/15/26 at 2:30 PM MDS assessments should be accurate and Resident #3's wander alarm should have been coded.

Based on record review and staff and resident interviews, the facility failed to revise a resident's care plan to indicate the development of a pressure ulcer for 1 of 3 residents reviewed for pressure ulcers (Resident #70).The findings included:Resident #70 was admitted to the facility on [DATE] with diagnoses that included stage III pressure ulcer to coccyx.Review of Resident #70's wound note dated 02/27/26 revealed he had a stage III pressure wound to his coccyx.Review of Resident #70's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. Resident #70 was coded for having one or more unhealed pressure ulcers/injuries and coded as having 2 stage II pressure ulcers with one that was present upon admission. Resident #70 was also coded as using a pressure reducing device for bed and was receiving pressure ulcer care.Review of Resident #70's care plan last updated on 04/10/26 revealed no care plan or interventions for pressure ulcers.During an interview with the MDS Coordinator on 05/14/26 at 3:27 PM, she reported she was familiar with Resident #70. She also reported she was responsible for updating resident care plans quarterly or when care or significant changes occurred. The MDS Coordinator verified that when she completed his quarterly MDS assessment on 03/31/26 she coded Resident #70 as having pressure ulcers/wounds and she either missed or forgot to update Resident #70's care plan at that time to reflect the development of those pressure wounds. An interview with the Director of Nursing on 05/14/26 at 4:06 PM revealed she expected pressure ulcer/wounds to be care planned. She verified that Resident #70's care plan did not currently have a pressure ulcer/wound care plan and stated it should have been updated to reflect the pressure ulcer/wounds when Resident #70's quarterly MDS assessment was completed and indicated he had pressure ulcer/wounds.An interview with the Administrator on 05/15/26 at 8:32 AM revealed Resident #70's pressure ulcer/wounds should be noted on his care plan. She reported she felt the main reason for the completion of MDS assessments was to ensure a resident's care plan was accurate and complete.

Based on observations, record review and staff interviews, the facility failed to ensure a resident's toenails were trimmed and podiatry services were arranged for 1 of 1 resident reviewed for foot care (Resident #69).Findings included:Resident #69 was admitted to the facility on [DATE] with diagnoses that included non-Alzheimer's dementia, depression, chronic obstructive pulmonary disease (COPD), muscle weakness, and history of falling.The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #69 had severe cognitive impairment. He displayed no behavioral symptoms or rejection of care and wandered 4 to 6 days. He required substantial/maximum assistance with toileting hygiene, shower/bathing, putting on/taking off footwear and required partial/moderate assistance with lower body dressing and personal hygiene. He was independent with ambulation without the use of an assistive device and had one fall with minor injury during the MDS assessment look-back period.Review of Resident #69's comprehensive care plans last revised on 03/23/26 revealed no care plan that addressed his activities of daily living (ADL) needs.Resident #69's medical record from admission through 05/11/26 revealed no consultation reports or notations in Resident #69's medical record that he had been seen by a podiatrist. During an interview on 05/14/26 at 10:25 AM, Nurse #3 reported she was first notified of the condition of Resident #69's toenails on 05/11/26. She stated she informed the Physician Assistant who evaluated Resident #69 and provided an order for a podiatry referral. Nurse #3 stated Resident #69 usually wore socks, and she hadn't noticed the condition of his toenails previously. She explained she had not noticed Resident #69 have any issues with ambulation as he often walked rapidly down the hall and he had not complained of any pain or discomfort. Nurse #3 stated that she would have thought staff would have mentioned the condition of his toenails sooner so that a podiatry referral could have been obtained for him to see the Podiatrist. Review of Resident #69's physician orders revealed an order dated 05/11/26 that read, refer to podiatry for a toenail trim.An observation of Resident #69 was conducted on 05/11/26 at 10:47 AM. Resident #69 was lying in bed, sleeping soundly, and covered with a bed sheet with his bare feet exposed. The great (big toes) toenails on both feet were thick and jagged. The toenails of the second through fifth toes on both feet were long and extended past the toenail bed. The toenails curved flat around the tip of the toes, wrapped partially around the back of the toe pad and curved inward along the mid to lower part of the toe pad.During an interview on 05/12/26 at 12:30 PM, Nurse #1 revealed she routinely provided care to Resident #69 and confirmed his toenails were thick and curved. She explained the Nurse Aides (NAs) didn't trim a resident's toenails if they were thick like Resident #69's and in those cases, an order was obtained from the provider for the resident to be seen by the Podiatrist. Nurse #1 stated she had previously put in a request with the provider for a podiatry referral (could not recall when) and was not sure why he had not been seen. Nurse #1 reviewed Resident #69's medical record and stated an order for a podiatry referral was put in yesterday (05/11/26). During an interview on 05/12/26 at 2:37 PM, NA #1 revealed she routinely provided care to Resident #69 and confirmed the toenails on both of Resident #69's feet were long and curved over the tip of the toe and around the back of the toe pads. She explained that when a resident was diabetic or had thick toenails like Resident #69, NAs did not trim the toenails. NA #1 stated the condition of Resident #69's toenails had been like that for awhile and she had informed the nurse (could not recall who) that he needed to see the Podiatrist for a trim. NA #1 expressed the condition of Resident #69's toenails did not appear to cause him discomfort or limit his walking but it was difficult for them to keep socks on his feet.During an interview on 05/14/26 at 9:36 AM, the Social Services staff member reported that she had been in her position a little over a month and had not been informed that Resident #69 needed to see the Podiatrist until she was notified of the podiatry referral on 05/11/26. The Social Services staff member explained when she received a podiatry referral, she contacted the podiatry group the facility utilized and filled out the necessary forms to get the resident enrolled for services and on the list to be seen at the next facility podiatry clinic. She stated she was currently working on getting Resident #69 enrolled with the podiatry group services so that he could be seen at the podiatry clinic scheduled on 05/26/26.An observation was conducted of Resident #69's toenails with the Director of Nursing (DON) on 05/14/26 at 11:10 AM. Resident #69 was lying in bed wearing gripper socks on both feet. The DON donned gloves and removed the gripper socks from both of Resident #69's feet. The DON acknowledged the great toenails on both of Resident #69's feet were thick and jagged and the toenails of the second through fifth toes of both feet were long, extended past the toenail bed and curved flat around the tip of the toes, wrapped partially around the back of the toe pad and curved inward along the mid to lower part of the toe pad.During an interview on 05/14/26 at 11:15 AM, the DON reported she was unaware of the condition of Resident #69's toenails prior to the observation. She expressed the condition of Resident #69's toenails appeared to have been in that condition for an extended time and needed trimmed. She stated the NAs trimmed a resident's toenails as part of routine care but if the resident had thick toenails or was diabetic, the resident was referred to the Podiatrist. She stated a podiatry referral for Resident #69 was obtained by the provider on 05/11/26. The DON stated staff should have noticed the condition of Resident #69's toenails when providing care and brought it to the provider's attention so that a podiatry referral could have been made sooner. During an interview on 05/15/26 at 2:22 PM, the Administrator stated she did not observe Resident #69's feet but was informed of the condition of his toenails by the DON yesterday (05/14/26). The Administrator explained that they had a Podiatrist who came to the facility to provide podiatry services for residents. She stated staff should have identified and notified the provider of the condition of Resident #69's toenails to obtain a podiatry referral. The Administrator stated she would have expected staff to have identified the condition of Resident #69's toenails upon his admission, during daily care or during weekly skin audits.

Based on record review and staff interviews, the facility failed to ensure code status information was accurate throughout the medical record and in locations designated by the facility for 1 of 1 resident reviewed for advance directives (Resident #63).Findings included:Resident #63 was admitted to the facility on [DATE].Review of the Code Status binder kept at the nurses' station on 05/11/26 at 3:45 PM revealed Resident #63 had a DNR form signed by the physician effective 03/27/25 with no expiration date. An advance directive care plan, revised 03/11/26, indicated Resident #63 was a full code. Interventions included: advanced directive would be honored as instructed and review the advance directive status periodically and as needed.Review of Resident #63's electronic medical record revealed an active physician's order dated 03/11/26 for full code.The admission Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #63 with severe cognitive impairment.Review of the profile page in Resident #63's electronic medical record revealed a code status of Do Not Resuscitate (DNR).Review of Resident #69's medical record revealed a Social Services progress note dated 05/12/26 revealed a second copy of the admissions agreement and a Medical Orders for Scope of Treatment (MOST, signed medical document that translates a patient's end-of-life care preferences into actionable physician orders) was sent to Resident #69's representative by certified mail on 05/07/26.During an interview on 05/12/26 at 12:30 PM, Nurse #1 explained nurses were recently informed they were now responsible for verifying a resident's code status with the resident or their representative and getting the appropriate advanced directive forms filled out. Nurse #1 stated there were two places to look for a resident's code status, the physician order in the electronic medical record and the code status binder at the nurses' station. Nurse #1 confirmed the physician order for Resident #63 indicated he was a full code but the advanced directive in the code status binder was for a DNR. Nurse #1 stated in the event of an emergency, she was instructed to go by the resident's advanced directive filed in the code status binder. During an interview on 05/12/26 at 12:50 PM, the Director of Nursing (DON) revealed the facility utilized the MOST form and nurses were responsible for completing the form with the resident or their representative upon admission or within 48 hours. The DON explained staff could view the physician order for code status in the resident's electronic medical record or check the code status binder kept at the nurses' station. She stated the physician order and code status binder should match. The DON explained that in the event of an emergency, staff should follow the resident's advanced directive filed in the code status binder.During an interview on 05/15/26 at 2:22 PM, the Administrator stated all residents should have a completed MOST form on file. The Administrator stated the physician order and MOST form filed in the code status binder should match.

Based on record review and staff and Psychiatric Nurse Practitioner (NP) interviews, the facility failed to obtain consent and inform the resident or Responsible Party in advance of the risks and benefits of psychotropic medications prior to initiation for 2 of 5 residents reviewed for unnecessary medications (Resident #9 and Resident #58).The findings included: 1. Resident #9 was admitted to the facility on [DATE] with diagnoses that included vascular dementia and anxiety. Review of Resident #9's admission physician orders dated 01/13/26 revealed buspirone (antianxiety medication) 15 milligrams (mg) one tablet by mouth twice a day. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9's cognition was moderately impaired. He displayed no behavioral symptoms and received antianxiety medications during the MDS assessment look-back period. Review of Resident #9's physician orders dated 02/08/26 indicated to increase buspirone to 15 mg one tablet by mouth three times a day. Review of the February 2026 Medication Administration Record for Resident #9 revealed buspirone was administered at 15 mg twice a day until 02/09/26 when it was increased to 15 mg three times a day through the remainder of the month of February 2026. Review of Resident #9's electronic medical record revealed no documentation that Resident #9 or the Responsible Party was informed in advance of the risks and benefits of of increasing buspirone 15 mg to three times a day on 02/09/26. On 05/14/26 at 2:30 PM an interview was conducted with the Director of Nursing (DON), who explained that Resident #9 was being followed by Psychiatry and the Psychiatry provider was responsible for obtaining informed consents from the resident or the responsible party before a psychoactive medication was initiated or increased. The DON stated Social Services was responsible for auditing the informed consents and she did not know when the last audit was completed. On 05/14/26 at 2:30 PM an interview was conducted with Social Services who explained that she had only been in her role for a few months and had never been informed that she was responsible for auditing the informed consents for the psychoactive medications. An interview was conducted with the Psychiatric NP on 05/15/26 at 8:30 AM. The Psychiatric NP explained that she did not obtain informed consents for the residents' psychoactive medications and that she had never been informed that it was her responsibility to obtain informed consents. On 05/15/26 at 2:22 PM an interview was conducted with the Administrator who had only been at the facility for seven weeks. She explained that the facility was not obtaining informed consent for the psychoactive medications, but she would have expected it to be done. 2. Resident 58 was admitted to the facility on [DATE] with diagnoses that included dementia with other behavioral disturbance, anxiety disorder, and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #58 had moderate impairment in cognition. She displayed no behavioral symptoms and received antipsychotic and antidepressant medication during the MDS assessment look-back period. Review of the April 2026 Medication Administration Record (MAR) for Resident #58 revealed the following physician orders: 03/13/26: bupropion (antidepressant medication) 150 milligrams (mg) in the morning for depression and anxiety. 03/23/26 (discontinued on 04/28/26): buspirone (antianxiety medication) 10 mg two times a day for anxiety. 03/24/26: quetiapine fumarate (antipsychotic medication) 25 mg one time a day for dementia with agitation. Continued review of the April 2026 MAR revealed the medications were initialed daily by nursing staff as administered per physician orders. Review of Resident #58's electronic medical record revealed no documentation that Resident #58 or her Responsible Party were informed in advance of the risks and benefits of initiating bupropion, buspirone or quetiapine fumarate and consented to the treatment. During an interview on 05/14/26 at 2:25 PM, the Director of Nursing (DON) explained that Resident #58 was being followed by Psychiatry, and the Psychiatry provider was responsible for obtaining informed consent from the resident or the responsible party before a psychoactive medication was initiated or increased. The DON stated Social Services was responsible for auditing the informed consents and she did not know when the last audit was completed. During an interview on 05/14/26 at 2:30 PM, the Social Services staff member explained that she had only been in her role for a few months and had never been informed that she was responsible for auditing informed consents for psychoactive medications. During a phone interview on 05/15/26 at 8:30 AM, the Psychiatric Nurse Practitioner explained that she did not obtain informed consent for residents' psychoactive medications and had never been informed that it was her responsibility to obtain informed consents. During an interview on 05/15/26 at 2:22 PM, the Administrator reported she had only been at the facility for seven weeks. The Administrator explained that the facility was not obtaining informed consents for psychoactive medications, but she would have expected it to be done.

Based on record reviews and staff interviews, the facility failed to assess residents for eligibility and ensure residents were offered the COVID-19 vaccination for 3 of 5 residents reviewed for immunizations (Resident #2, Resident #6 and Resident #9).The findings included:A review of the facility's policy entitled COVID-19 Vaccination last revised 01/01/2026 read in part that COVID-19 vaccinations will be offered to resident as per Centers for Disease Prevention and Control (CDC) guidelines unless it is medically contraindicated, the individual has already been immunized or refuses to receive the vaccine. Following assessment for potential medical contraindications, COVID-19 vaccinations for residents may be administered in accordance with physician approved standing orders.a. Resident #2 was admitted to the facility on [DATE].Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #2 was cognitively intact and was coded Yes, for COVID-19 immunization being up to date.Review of Resident #2's electronic medical record revealed the last COVID-19 immunization given to the Resident was 11/16/23 before her admission to the facility. There was no documentation in the medical record that indicated the COVID-19 vaccine had been offered to Resident #2 or education had been provided to Resident #2 regarding the benefits and potential side effects of the COVID-19 vaccine.b. Resident #6 was admitted to the facility on [DATE].Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #6 was cognitively intact and was coded No, for Covid-19 immunization being up to date.Review of Resident #6's medical record revealed no history of a Covid-19 vaccination. There was no documentation in the medical record that indicated the COVID-19 vaccine had been offered to Resident #6 or education had been provided to Resident #6 regarding the benefits and potential side effects of the COVID-19 vaccine.c. Resident #9 was admitted to the facility on [DATE].Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #9's cognition was severely impaired and was coded Yes, COVID-19 vaccine was up to date.Review of Resident #9's medical record revealed the last COVID-19 vaccine given to Resident #9 was 02/01/22 before admission to the facility. There was no documentation in the medical record that indicated the COVID-19 vaccine had been offered to Resident #9 or education had been provided to Resident #9 regarding the benefits and potential side effects of the COVID-19 vaccine.An interview was conducted with the interim Director of Nursing (DON) on 05/15/26 at 11:24 AM. The interim DON explained that the latest version of the COVID-19 vaccination should be offered on admission and annually. She reported that education on risk versus benefits should be offered to the resident or responsible party and they should be signing that they received this education and should be documented in the resident's medical record. The interim DON indicated the system failure was that no one continued to follow up on the immunization process to ensure that the vaccines were offered and given at the time of admission and annually afterwards.On 05/15/2026 at 11:34 AM during a telephone interview with the Regional Quality Assurance Nurse the Nurse explained that she was the Infection Control Preventionist which included COVID-19 immunizations. She continued to explain that the nurses were doing a good job keeping up with obtaining consent or declinations and giving the COVID-19 vaccine on admission, but when she looked at the immunization records during the survey, she could not find the information for Resident #2, Resident #6 and Resident #9, and she did not know why. The Nurse reported the expectation was that the nurses obtain the information on admission as part of the admission procedure. She stated the DON should have followed up with the residents who were already in house and made sure the COVID-19 vaccines were offered along with the benefits and potential side effects and the documentation was completed. The Regional Quality Assurance Nurse indicated that the DON knew that it was expected of her to ensure that the immunizations were done and the Regional Quality Assurance Nurse would be the final check to ensure the process was completed. The Quality Assurance Nurse added, it had been a while since she had made a final check to ensure the process was completed.

Based on record review and staff interviews, the facility failed to document that a Resident or Responsible Party (RP) were provided education regarding the benefits and potential side effects of the influenza and pneumococcal immunization or if the Resident received the influenza and pneumococcal immunization or did not receive the vaccines due to a medical contradiction or refusal. In addition, there was no documentation that the Resident was offered the influenza and pneumococcal immunization. This occurred for 1 of 5 residents reviewed for immunizations (Resident #58).The findings included:A review of the facility's policy entitled Influenza Vaccination last revised 01/01/26 read in part that Influenza vaccinations will be routinely offered from October 1st through March 31st unless such immunization is medically contraindicated, the individual has already been immunized during this time period or refuses to receive the vaccine. Following assessment for potential medical contraindications, influenza vaccinations may be administered in accordance with physician-approved standing orders.A review of the facility's policy entitled Pneumococcal Vaccine last revised 01/01/26 read in part that each resident will be assessed for pneumococcal immunization upon admission. Each resident will be offered a pneumococcal immunization unless it is medically contraindicated or the resident has already been immunized in accordance with physician-approved standing orders. Resident #58 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease.Review of Resident #58's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident's cognition was moderately impaired and did not receive the influenza vaccination because it was not offered. The MDS also indicated that Resident #58's pneumococcal vaccination was not up to date, and the vaccination was not offered.Review of Resident #58's electronic health record revealed no signed consent indicating the vaccines had been offered, no record of administration, or refusal documentation for the influenza and pneumococcal vaccines. Further review of the medical record also revealed no documentation of the benefits or potential side effects of the influenza and pneumococcal vaccines.An interview was conducted with the Interim Director of Nursing (DON) on 05/15/26 at 11:24 AM. The DON reviewed Resident #58's medical record and did not find any information regarding the influenza and pneumococcal vaccinations being offered, declined or that information about potential side effects was provided to the Resident or the Responsible Party. The DON explained that she could not find a history of Resident #58's vaccinations and that someone should have followed up on the immunizations after the Resident's admission to the facility. The DON stated the Regional Quality Assurance Nurse was responsible for the Infection Control Program which included immunizations.On 05/15/2026 at 11:34 AM during a telephone interview with the Regional Quality Assurance Nurse the Nurse explained that she was the Infection Control Preventionist which included immunizations. She continued to explain that the nurses were doing a good job keeping up with obtaining consent or declinations and giving the immunizations on admission, but when she looked at the immunization records during the survey, she could not find the information for Resident #58, and she did not know why. The Nurse reported the expectation was that the nurses obtain the information on admission as part of the admission procedure. She stated the Director of Nursing should have followed up with the residents who were already in house and made sure the immunizations were offered along with the benefits and potential side effects and the documentation was completed. The Regional Quality Assurance Nurse indicated that the DON knew that it was expected of her to ensure that the immunizations were done and the Regional Quality Assurance Nurse would be the final check to ensure the process was completed. The Regional Quality Assurance Nurse added, it had been a while since she had made a final check to ensure the process was completed.

Based on record review and staff interviews, the facility failed to maintain a complete and accurate medical record by not documenting a resident's elopement from the facility and not documenting a nurse assessment to check for injuries upon the resident's return for 1 of 3 residents reviewed for complete and accurate medical records (Resident #58). Findings included:Resident #58 was admitted to the facility's locked memory care unit on 11/12/25.A statement written as part of the facility's investigation by the Activity Assistant and dated 01/08/26 revealed in part, at approximately 5:05 PM when leaving the facility, Resident #58 was observed walking down the road and had reached a point in the road between a food pantry and a thrift store. The Activity Assistant pulled her car over, asked Resident #58 what she was doing and Resident #58 asked the Activity Assistant for a ride. Resident #58 got into the car and was taken back to the facility. The Activity Assistant asked Resident #58 to go into the facility with her to figure things out, Resident #58 complied with the request and was assisted back to the memory care unit by the Activity Assistant. A statement written as part of the facility's investigation by Nurse #3 and dated 01/08/26 revealed Resident #58 was observed in bed at 4:30 PM when Nurse #3 was conducting a medication pass. Nurse #3 noted a skin assessment was completed and Resident #58 had no open areas or injuries.Review of Resident #58's electronic medical record revealed the only nurse assessment documented on 01/08/26 was at 10:00 PM following a fall Resident #58 had while in the shower.Review of the January 2026 nursing staff progress notes for Resident #58 revealed no entry related to her elopement from the facility on 01/08/26. During an interview on 05/14/26 at 10:25 PM, Nurse #3 reported she was Resident #58's assigned nurse on 01/08/26 during the hours of 6:30 AM to 6:30 PM. Nurse #3 stated she received a call from the Director of Nursing (DON) at approximately 5:10 PM informing her that the Activity Assistant had found Resident #58 walking down the road and was bringing her back to the facility. Nurse #3 stated immediately upon Resident #53's return to the facility, she completed a head-to-toe assessment of Resident #58 with no injuries identified. She explained for any incident, per facility protocol, nurses were to document an assessment, and a progress note in the resident's electronic medical record. Nurse #3 reviewed Resident #58's electronic record and confirmed there was no assessment or progress note documented by her on 01/08/26. Nurse #3 stated she always made sure to document and thought she had for Resident #58. She could not explain what happened and stated her best guess was that it was an oversight.During an interview on 05/15/26 at 12:29 PM, the DON stated that on 01/08/26 upon Resident #58's return to the facility after her elopement, she instructed Nurse #3 to complete a head-to-toe assessment on Resident #58. She stated Nurse #3 assessed Resident #58 and no injuries were identified. The DON reviewed Resident #58's electronic medical record and verified there was no nurse assessment or progress note documented by Nurse #3 on 01/08/26. The DON stated she would have expected Nurse #3 to have documented the nurse assessment and a progress note related to Resident #58's elopement from the facility.During an interview on 05/15/26 at 2:22 PM, the Administrator stated there should have been a nurse assessment and a progress note documented in the electronic medical record related to Resident #58's elopement from the facility.

Based on record review, interviews with the resident, staff, Physician Assistant and Medical Director, the facility failed to provide pain management for a resident who reported acute, severe pain rated at a 8 out of 10 (0 meaning no pain and 10 meaning the worst pain experienced) during wound care treatment of a Stage 3 pressure ulcer. This deficient practice affected 1 of 3 residents reviewed for effective pain management (Resident #2).The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses including obstructive uropathy, cerebrovascular accident, diabetes mellitus, depression, moisture-associated skin damage (MASD) and other specified arthritis at multiple sites.A review of the admission Minimum Data Set (MDS) assessment dated [DATE] and the quarterly MDS assessment dated [DATE] revealed that Resident #2 was cognitively intact, did not display any behaviors, was able to make her needs known, received scheduled as needed (PRN) pain medication, had pain frequently and reported that pain frequently interfered with sleep, physical therapy and day-to-day activities. The quarterly MDS assessment also coded Resident #2 for having a stage 3 pressure ulcer.Resident #2 had an active medication order with a start date of 04/20/26, for hydrocodone/acetaminophen 10 milligrams/325 milligrams (MG) (opiod pain medication combined with acetaminophen used to relieve moderate to severe pain) one (1) tablet by mouth every 6 hours, as needed for break through pain.A continuous observation of wound care treatment and resident interview were conducted on 05/12/26 at 3:05 PM until 3:20PM. During the treatment, Nurse # 2 cleansed Resident #2's wound with gauze soaked in wound cleansing solution. Resident #2 gasped with a complaint of stinging pain. The wound was approximately 3 centimeters by 3 centimeters; it appeared dark pink with a moist textured open area surrounded by a larger area of scar tissue. Nurse #2 did not respond to the complaint of pain and continued with the treatment, applying calcium alginate (highly absorbent wound dressing) and silver sulfadiazine (topical antibiotic), followed by covering with a border dressing. Resident #2 again complained of pain stating, That hurts me. Nurse #2 did not reply and continued with care, providing a clean brief, cleaned up her supplies, and exited the room. At 3:20 PM Resident #2 stated her pain was 8 out of 10 and used her call light to request PRN pain medication.During an observation on 05/12/26 at 4:00 PM, Nurse #2 provided Resident #2 with one hydrocodone/acetaminophen 10/325 MG tablet.An interview was conducted on 05/12/26 at 4:20 PM with Nurse #2, who stated that she was often the assigned nurse for Resident #2 and completes the wound care treatment every day she works, except Fridays, when the wound care doctor was present. Nurse #2 stated that Resident #2 complained of pain when she performed the wound care treatment, which was why she always administered PRN pain medication after completing the treatment.An interview was conducted on 05/15/26 at 10:21 AM with Director of Nursing (DON), who stated when a resident reports pain during care the nurse must stop what they are doing, assess the pain, provide PRN pain medicine if available, notify physician if PRN pain medication is not available, and reassess the pain before continuing care.An interview was conducted on 05/13/26 at 2:30 PM with the Physician Assistant (PA), who stated that PRN pain medication could be administered before wound care treatment begins, but ordering it that way can be problematic for a nurse's workflow. The PA also stated that he would expect a nurse to pause wound care and administer PRN pain medication if a resident expressed pain.An interview was conducted on 05/14/26 at 11:00 AM with the Medical Director, who stated that if Resident #2 expressed pain during care she expected the nurse to stop the care, assess the pain and provide PRN pain medication if available.An interview was conducted on 05/15/26 at 2:30 PM with the Administrator, who stated if a resident complains of pain during care, she expects nurses to stop and assess the pain, notify MD, check for PRN orders, and provide available medication.

Based on record review, and staff and Physician Assistant (PA) interviews, the facility failed to transcribe on admission an order for surgical wound care and subsequently failed to provide care to the surgical wound as ordered by the physician for 1 of 3 residents reviewed for quality of care (Resident #1).The findings included:Review of Resident #1's hospital Discharge summary dated [DATE] revealed the following order: On the day of discharge (02/20/26) the physician opened up a small portion about 4 centimeters (cm) of the wound below the umbilicus that had some seropurulent drainage (a thin, watery, and cloudy wound exudate that appears yellowish or tan, often indicating an early or existing wound infection or inflammation) present. The discharge summary specified Resident #1 would need wet to dry dressing changes for that area of the wound with normal saline twice a day.Resident #1 was admitted to the facility on [DATE] following an exploratory laparotomy resulting in a colostomy (a surgical procedure that creates an opening (stoma) in the abdominal wall, bringing a portion of the colon to the surface to divert stool into a replaceable pouch) related to diverticulitis of the colon with perforation (occurs when an inflamed pouch in the colon wall ruptures, allowing fecal matter and bacteria to leak into the abdominal cavity, often causing severe abdominal pain, high fever, and sepsis). Review of Resident #1's progress note dated 02/20/26 at 2:42 PM written by Nurse #1 revealed the Resident was alert and oriented. The note also indicated Resident #1 did not speak English and his family was at his bedside and provided interpretation for the Resident.Review of Resident #1's physician orders dated 02/20/26 revealed no order for wet to dry dressing to the surgical wound.Review of Resident #1's Treatment Administration Record (TAR) for 02/20/26 and 02/21/26 revealed there were no orders set up to provide care for the Resident's surgical abdominal incision.Resident #1 was discharged on 02/21/26.Review of Resident #1's Discharge Minimum Data Set assessment dated [DATE] revealed he was discharged to home/community with return not anticipated.An interview was conducted with Nurse #1 via telephone on 03/18/26 at 3:55 PM who worked the day shift on 02/20/26 when Resident #1 was admitted to the facility. The Nurse explained that she remembered Resident #1 and that he was admitted because he had a new colostomy and was at the facility for rehabilitation. The Nurse reported she reviewed the Resident's discharge summary from the hospital to obtain the medication orders but did not read the entire summary to obtain the order for the care of his abdominal incision and therefore, did not transcribe the treatment order to the TAR. The Nurse continued to explain that she had a very busy day when Resident #1 was admitted and that the Director of Nursing (DON) helped with Resident #1's admission. The Nurse indicated that between herself and the DON the treatment order should have been transcribed.An interview was conducted with Nurse #2 on 03/17/26 at 3:15 PM who confirmed that she worked from 6:30 PM on 02/20/26 to 6:30 AM on 02/21/26. The Nurse explained that she remembered Resident #1 had a colostomy and did not speak English, but his family stayed with him all night on 02/20/26 to interpret for him. She stated Resident #1 slept all night. The Nurse was asked if she provided any treatment for Resident #1 and she replied that she would have to review the Resident's medical record to answer that question. When Nurse #2 was informed that there was no treatment order transcribed for the Resident's abdominal incision the Nurse repeated that she would have to review the medical record before she answered the question.An interview was conducted with Nurse #3 on 03/17/26 at 11:30 AM. The Nurse confirmed that she worked from 6:30 AM to 6:30 PM on 02/21/26. The Nurse explained that she remembered Resident #1 was admitted with a new colostomy and was to receive rehabilitation services to return home. When the Nurse was asked what the treatment was for Resident #1's abdominal incision she replied that she would have to review the medical record to answer that question. Nurse #3 indicated that she did assess Resident #1's abdominal incision but did not provide treatment for the incision.An interview was conducted with the Physician Assistant on 03/18/26 at 4:35 PM who explained that the nurses should read the entire discharge summary to obtain all discharge orders needed for the residents and not just the medication orders. The PA stated that if there were no orders for the care of the surgical incision then the facility should have called him and he would have given them orders for the incision until orders from the surgeon could have been obtained.An interview was conducted with the Director of Nursing via telephone on 03/19/26 at 10:15 AM who explained that she helped with Resident #1's admission by putting the medication orders in and she also assessed Resident #1's incision. She stated she had skimmed through the discharge summary when she noted the medication orders and when she saw the incision she realized that she did not see any orders for the incision care. The DON continued to explain that she was going to review the discharge summary again when she was stopped for something and forgot to review the discharge summary for treatment orders. The DON indicated the order for the incision care should have been put on the TAR so the other nurses could have performed the treatment.

Based on record review, staff and Physician Assistant interviews, the facility failed to maintain a complete and accurate medical record related to a resident's abdominal incision and colostomy for 1 of 3 residents reviewed for complete and accurate medical records (Resident #1). The findings included:Resident #1 was admitted to the facility on [DATE] following an exploratory laparotomy resulting in a colostomy (a surgical procedure that creates an opening (stoma) in the abdominal wall, bringing a portion of the colon to the surface to divert stool into a replaceable pouch).Review of Resident #1's medical record from admission on [DATE] to discharge on [DATE] revealed there were no assessments of the Resident's abdominal incision or the new colostomy documented in the medical record.Resident #1 was discharged on 02/21/26.An interview was conducted with Nurse #1 via telephone on 03/18/26 at 3:55 PM who worked the day shift on 02/20/26 when Resident #1 was admitted to the facility. The Nurse explained that she remembered Resident #1, and he was admitted because he had a new colostomy. The Nurse reported that she assessed the Resident's new colostomy and abdominal incision that had a damp gauze packed in the bottom of the incision with a dry gauze over it, but she did not document her assessment in the medical record because it was late and she had intended to document the assessment the following morning. Nurse #1 continued to explain that she was notified that Resident #1 was discharged the following day and forgot to document the assessment when she returned to duty. An interview was conducted with Nurse #2 on 03/17/26 at 3:15 PM who confirmed that she worked from 6:30 PM on 02/20/26 to 6:30 AM on 02/21/26. The Nurse explained that she remembered Resident #1 he had a colostomy. Nurse #2 indicated assessments should be documented in the medical record on the residents every shift when they were admitted . The Nurse stated she did assess Resident #1 during the night by listening to his chest while he was sleeping. When asked about his colostomy and abdominal incision the Nurse remarked that she would have to refer to the Resident's medical record to answer that question. The Nurse was informed that there was no assessment documented in the medical record by Nurse #2 and she again stated she would have to refer to Resident #1's medical record before she could answer that question.An interview was conducted with Nurse #3 on 03/17/26 at 11:30 AM. The Nurse confirmed that she worked from 6:30 AM to 6:30 PM on 02/21/26. The Nurse explained that she remembered Resident #1 was admitted with a new colostomy and was to receive rehabilitation services to return home. Nurse #3 continued to explain that the facility staff documented in the medical record on the newly admitted residents once a shift which included an assessment for their reason for admission. She stated she assessed Resident #1's colostomy which was almost full and had a good seal. Nurse #3 further stated she also assessed his abdominal incision but could not describe the incision and stated to refer to her documentation. When the Nurse was shown that there was no documentation she stated she must have forgotten to document her assessment.An interview was conducted with the Regional Nurse Consultant on 03/17/26 at 1:35 PM, who explained that the new admissions should have documentation of assessments every shift until it was determined that they no longer required the documentation. The Regional Nurse Consultant stated she had already reviewed Resident #1's medical record and acknowledged there were no documented assessments about his new colostomy or his abdominal incision in the medical record. She stated she knew the nurses were educated to document their assessments in the medical record when they were done.An interview was conducted with the Director of Nursing (DON) on 03/17/26 at 1:40 PM who explained that she remembered Resident #1 being admitted because she looked at his colostomy, but she could not remember where it was positioned. He also had an abdominal incision, but she could not remember if it had a dressing on it. When asked where the documentation of her assessment was, she remarked that she did not document it, but she should have. The DON explained that she tried to review the residents' medical record the following morning after they were admitted for documentation and when she realized Resident #1 did not have any documentation of assessments while he was in the facility she did not follow up with the nurses to document their assessments.An interview was conducted with the Physician Assistant on 03/18/26 at 4:35 PM who indicated that he often reviewed the nurses' assessments in order to obtain information about the residents that would be beneficial for his treatment plan therefore, it was important for the nurses to document their assessments of the residents in the medical record.

Based on observations, record reviews and staff and Consultant Pharmacist interviews, the facility failed to remove loose and unsecure pills of various shapes, sizes and colors, failed to remove expired and unlabeled medications, failed to remove discharged residents' medications from a medication cart and failed to secure medications in locked medication carts. These failures occurred on 4 of 4 medication carts (100 Hall, 200 Hall, 300 Hall and 400 Hall medication carts) and 1 of 1 medication room (the main medication room) reviewed for medication storage. The findings included: 1a. An observation of the 100-hall medication cart was made on 05/21/25 at 3:30 PM accompanied by Nurse #3. The cart yielded 14 loose pills of various shapes, colors and sizes in the bottom of the drawers. An interview conducted with Nurse #3 on 05/21/25 at 3:30 PM. The Nurse explained that it was the responsibility of the nurse on the cart to keep the medication carts clean and orderly. b. An observation of the 300-hall medication cart was made on 05/21/25 at 2:04 PM accompanied by Nurse #1. The cart yielded 23 loose pills of various shapes, colors and sizes in the bottom of the drawers. An interview was conducted with Nurse #1 on 05/21/25 at 2:04 PM. The Nurse explained that it was the responsibility of the third shift nurses to keep the medication carts clean and orderly, but every nurse should do their part in keeping them clean. c. An observation of the 400-hall medication cart was made on 05/21/25 at 3:02 PM accompanied by Nurse #4. The cart yielded 4 loose pills of various shapes, colors and sizes in the bottom of the drawers. An interview was conducted with Nurse #4 on 05/21/25 at 3:02 PM. The Nurse explained that it was the responsibility of the third shift nurses to keep the medication carts clean and orderly because they had the most time to do it. An interview was conducted with the Director of Nursing (DON) on 05/21/25 at 3:40 PM. The DON explained that it was the nurses' responsibility to keep the medication carts clean and orderly which included checking for undated and expired medications. She stated the Unit Manager audited the medication carts once a week, but she was on vacation this week. The DON stated she looked at the medication carts last week. 2. An observation was conducted of the 200-hall medication cart on 05/21/25 at 3:15 PM accompanied by Nurse #3. The cart yielded 5 insulin pens of discharged residents. An interview was conducted with Nurse #3 on 05/21/25 at 3:15 PM. The Nurse explained that the insulin pens should have been removed from the medication cart and sent back to the pharmacy when the residents were discharged from the facility and not left stored on the medication cart. An interview was conducted with the Director of Nursing (DON) on 05/21/25 at 3:40 PM. The DON indicated that the insulin pens should have been removed by the Unit Manager who audited the medication carts once a week. The DON stated the insulin pens should have been returned to the pharmacy when the resident was discharged from the facility. An interview was conducted with the Consultant Pharmacist on 05/22/25 at 12:40 PM. The Consultant Pharmacist explained that when a resident was discharged from the facility their medications should be removed from the medication cart. Therefore, the insulin pens should have been removed from the medication cart and returned to the pharmacy. 3. Review of the facility's pharmacy guide information for: *DuoNeb Inhalation solution indicated the vial of solution left in an open pouch has an expiration date of 14 days. *Open Lantus insulin pen expires in 28 days. *Unopen Lantus insulin pen refrigerate until used. *Open latanoprost eye drops expiration date 42 days. *Open vials of PPD solution expired in 30 days. Review of the manufacturer's Guidelines for Lantus Insulin Pens indicated: *Unused Lantus pens should be stored in the refrigerator at 36? to 46?. When stored this way, they will last until their expiration date. If you store them at room temperature (up to 86?), they'll last for up to 28 days. a. An observation was conducted of the 300-hall medication cart on 05/21/25 at 2:04 PM accompanied by Nurse #1. The cart yielded one open and undated vial of lidocaine (a local anesthetic), an open and undated DuoNeb inhalation solution (nebulizing solution) foil pouch, an open and undated Lantus insulin pen and an unopen Lantus insulin pen with the dispensed date of 04/04/25. An interview was conducted with Nurse #1 on 05/21/25 at 2:04 PM. The Nurse explained that she did not know how long a vial of open lidocaine could be used but stated she would discard it because it had been a long time since a resident had been on the antibiotic the lidocaine was used with. She stated she did not know how long the DuoNebs could be used after the pouch has been opened but the pouch should have been dated when it was opened. Nurse #1 stated she did not know how long the Lantus insulin pen could be used after it was open, but she did know that the unopen Lantus insulin pen should be refrigerated until it was opened. An interview was conducted with the Director of Nursing (DON) on 05/21/25 at 3:40 PM. The DON explained that it was the nurses' responsibility to keep the medication carts clean and orderly which included checking for undated and expired medications. She stated the Unit Manager audited the medication carts once a week, but she was on vacation this week. The DON stated she looked at the medication carts last week. The DON indicated that the vial of lidocaine should have been discarded when it was used on the resident it was needed for, the DuoNeb pouch should have been dated when opened, the insulin pen should have been dated when it was open, and the unopen insulin pen should have been refrigerated until it was needed for the resident. The DON was unclear as to the expiration dates of these medications. An interview was conducted with the Consultant Pharmacist on 05/22/25 at 12:40 PM. The Consultant Pharmacist reported the lidocaine should have been discarded after it was used for the resident and not left in the medication cart. She stated the DuoNebs were good for 14 days after opening and since the DuoNebs were not dated they should be discarded. The Consultant Pharmacist reported the open Lantus insulin pen was good for 28 days and the unopen Lantus insulin pen should have been refrigerated until it was needed for the resident. b. An observation was conducted of the 400-hall medication cart on 05/21/25 at 3:02 PM accompanied by Nurse #4. The cart yielded 2 bottles of open latanoprost eye drops with open dates of 03/20/25 and 03/31/25. An interview was conducted with Nurse #4 on 05/21/25 at 3:02 PM. The Nurse stated she did not know how long the latanoprost eye drops could be open before they should be discarded. An interview was conducted with the Director of Nursing (DON) on 05/21/25 at 3:40 PM. The DON explained that it was the nurses' responsibility to keep the medication carts clean and orderly which included checking for undated and expired medications. She stated the Unit Manager audited the medication carts once a week. The DON stated she looked at the medication carts last week. The DON was unclear as to how long the open latanoprost eye drops could be open before the expiration date. An interview was conducted with the Consultant Pharmacist on 05/22/25 at 12:40 PM. The Consultant Pharmacist reported that the latanoprost eye drops should have been discarded 42 days after being opened. c. An observation was conducted of the main Medication room on 05/21/25 at 2:50 PM accompanied by Nurse #1. The medication room yielded 2 open and undated vials of PPD (purified protein derivative) solution (used for tuberculosis skin tests) in the refrigerator dispensed on 02/24/25. An interview was conducted with Nurse #4 on 05/21/25 at 2:50 PM. The Nurse explained that she did not know how long the PPD solution could be used after it was open and she did not know how long the 2 vials had been in the refrigerator. An interview was conducted with the Director of Nursing (DON) on 05/21/25 at 3:40 PM. The DON explained that it was the Unit Manager responsibility to audit the Medication room once a week. The DON stated the open PPD solution vials should have been discarded in 30 days after being opened. An interview was conducted with the Consultant Pharmacist on 05/22/25 at 12:40 PM. The Consultant Pharmacist explained that the opened PPD solution was good for 28 days and it should have been dated when it was open so that it would not be used past the expiration date so therefore, the PPD vials should be discarded. 4. An observation was conducted of the 300-hall medication cart which was left unattended and unlocked (lock button out) parked outside the nursing station in the hallway on 05/21/25 from 4:18 PM to 4:25 PM. The observation yielded 17 staff and 2 residents walking directly in front of the unlocked medication cart. An interview was conducted with Nurse #1 on 05/21/25 at 4:25 PM. The Nurse explained that she had to look for some missing hearing aids in the medication room and when she could not find them in the medication room, she had to look for them down 100 hall. Nurse #1 stated the medication carts should always be locked when not in use. An interview was conducted with the Director of Nursing (DON) on 05/22/25 at 11:20 AM. The DON explained that the nurses were educated to lock the medication carts when they were out of sight of the medication carts and Nurse #1 and Nurse #4 should have locked their medication carts before they left the carts unattended. During an interview with the Administrator on 05/22/25 at 4:15 PM the Administrator indicated that she expected the nurses to keep the Medication room and medication carts clean and orderly which included discarding the expired medications, dating open medications and keeping the medication carts locked when they were not in use no matter where the medication carts were parked.

Based on record reviews and staff interviews, the facility failed to complete Care Area Assessments (CAA) comprehensively to address the underlying causes and contributing factors of the triggered areas for 1 of 2 residents reviewed for Activities of Daily Living and Indwelling Urinary Catheters (Resident #82). The findings included: Resident #82 was admitted to the facility on [DATE] with diagnoses that included spastic quadriplegic, cerebral palsy and neurogenic bladder. Review of Resident #82's 10/13/24 Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident's cognition was moderately impaired and he required substantial to maximal assistance with his activities of daily living. The MDS also indicated Resident #82 had an indwelling urinary catheter. Review of Section V (CAA Summary) from the admission MDS dated [DATE] revealed the care area for activities of daily living for Resident #82. The MDS Coordinator who completed the assessment did not provide any information in the analysis of findings that described the nature of Resident #82's problem, possible causes, contributing factors, and risk factors for the triggered care area. It was noted on the CAA summary that activities of daily living would be addressed in the care plan due to Resident #82's admission MDS assessment. Review of Section V (CAA Summary) from the admission MDS dated [DATE] revealed the care area for indwelling urinary catheter for Resident #82. The MDS Coordinator who completed the assessment did not provide any information in the analysis of findings that described the nature of Resident #82's problem, possible causes, contributing factors, and risk factors for the triggered care area. It was noted on the CAA summary that urinary catheter would be addressed in the care plan due to Resident #82's admission MDS assessment. An interview was conducted with the former Minimum Data Set (MDS) Nurse on 05/21/25 at 8:39 AM. The former MDS Nurse confirmed that she completed the CAA assessments of Activities of Daily Living and Indwelling Urinary Catheter for Resident #82. She explained that she had been completing MDS assessments for over 17 years and the only verbiage she documented on the CAAs was care plan as indicated ARD (Assessment Reference Date) 10/20/24 with lookback per RAI (Resident Assessment Instrument) and no one has had a problem with it. The former MDS Nurse stated she understood that the verbiage she used did not provide an appropriate description of the triggered areas. During an interview with the Director of Nursing (DON) on 05/22/25 at 11:20 AM the DON stated she used to be the MDS Nurse for the facility and explained that the reason for the CAAs was to explain the underlying causes and contributing factors for the Residents' triggered care areas in order to paint a picture of the Resident so that an informed decision could be made whether to proceed to the care plan and that was what she expected to be done when completing the resident assessment process. An interview was conducted with the Administrator on 05/22/25 at 4:15 PM. The Administrator indicated she expected the MDS process to be completed as it was intended.

Based on observation, staff interviews and record reviews, the facility failed to complete a significant change in status Minimum Data Set (MDS) assessment following hospice election for 1 of 1 resident reviewed for hospice (Resident #44). The findings included: Resident #44 was admitted to the facility on [DATE]. A medical record review revealed Resident #44 was admitted to hospice on 04/23/2025 with hospice admission diagnoses of dementia and failure to thrive. A review of Resident #44's MDS assessments revealed no significant change MDS assessment was completed after the resident was admitted to hospice services. A phone interview with the Remote MDS Nurse, who was responsible for the MDS assessments at the facility, at 9:17 AM on 05/22/2025 revealed if a resident went to hospice, then the resident should have a significant change MDS assessment completed. She further stated no significant change MDS assessment had been completed for Resident #44 and according to Resident Assessment Instrument (RAI) manual (a manual utilized completing MDS assessments), Resident #44 should have had a significant change MDS assessment completed after she was admitted to hospice services on 04/23/2025. An interview was conducted with the Director of Nursing (DON) on 05/22/2025 at 3:34 PM and she stated a resident being placed on hospice is a significant change and a significant change MDS assessment should have been completed within 14 days. At 3:38 PM on 05/22/2025 an interview was conducted with the Interim Administrator, and it was revealed during the interview by the Interim Administrator that a significant change MDS should have been triggered and completed when Resident #44 was admitted to hospice.

Based on record review and interviews with the Nurse Practitioner, resident and staff, the facility failed to notify the physician when a one-time dose of methyl prednisolone (a steroid medication used to treat inflammatory conditions) was not administered as ordered for the treatment of an allergic reaction. The administration of methyl prednisolone was delayed five days for treatment of a rash that had worsened causing increased redness and hives, increased itching, and a low-grade fever for 1 of 1 resident reviewed for significant medication errors (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses including heart failure, hypertension, and chronic pain. A review of the Nurse Practitioner (NP) progress note dated 3/5/25 revealed nursing reported Resident #1's rash had worsened, he had a low-grade fever, was very itchy and requested something stronger for a rash. The NP ordered a one-time dose of methyl prednisolone 40 mg intramuscular (IM) injection. A review of the Medication Administration Record (MAR) revealed the physician's order for methyl prednisolone 40 mg intramuscular injection was scheduled as a one-time dose on 3/5/25. On 3/5/25 at 4:38 PM Nurse #1 initialed and documented NN (see nurse note) on the MAR for the administration of methyl prednisolone. A review of the nurse note dated 3/5/25 at 4:38 PM revealed Nurse #1 documented the methyl prednisolone was on order. During a phone interview on 4/8/25 at 6:41 PM, Nurse #1 revealed she initialed the MAR for Resident #1's methyl prednisolone on 3/5/25 and added the code NN (see nurse note) to document the medication was on order. Nurse #1 revealed she did not notify the physician on 3/5/25 she had not administered the scheduled one-time dose of methyl prednisolone as ordered. Nurse #1 revealed on 3/10/25 when the NP saw Resident #1 and was made aware the injection was not given, she was instructed to administer and did. An interview was conducted on 4/8/25 at 4:53 PM with Resident #1. Resident #1 revealed he was started on clindamycin (antibiotic) and after about five days his skin broke out with red dots. Resident #1 revealed at first the rash appeared as small dots on his chest and arms then spread everywhere all over his body and his skin was bright red like a sunburn and itched and started peeling. Resident #1 revealed the rash was very itchy and he continuously scratched himself. A review of the NP progress note revealed on 3/10/25 Resident #1 was reevaluated for itching, an allergic reaction, and a rash nursing reported had not improved. The note revealed nursing reported the methyl prednisolone injection was still on order from pharmacy and Resident #1 had not received the medication. The NP directed nursing to call the pharmacy and ensure they delivered the injection and for nursing to give the medication when it arrived. During a phone interview on 4/8/25 at 3:29 PM and 5:33 PM, the NP revealed on 3/5/25 she saw Resident #1's rash was worse, he had low-grade fever, and she order a one-time dose of methyl prednisolone injection and wanted the medication administered the day she ordered it. The NP revealed she expected Nurse #1 to administer the methyl prednisolone IM injection and if not administered she expected to be notified within 24 hours. A phone interview was conducted on 4/10/25 at 10:00 AM with the Director of Nursing (DON). The DON revealed if methyl prednisolone was not administered as ordered on 3/5/25 she expected Nurse #1 to call the physician and request a new order to hold the medication until it arrived from the pharmacy.

Based on record review and interviews with the Nurse Practitioner, Director of Pharmacy Operations, resident and staff, the facility failed to have effective systems in place to ensure a one-time dose of an intramuscular injection of methylprednisolone (steroid) prescribed for the treatment of an allergic reaction was administered resulting in a five-day delay of it being administered. Resident #1 had an itchy rash which worsened and spread over his entire body, hives, and a low-grade fever. Resident #1 stated the rash was very itchy and he continuously scratched himself. This occurred for 1 of 1 resident reviewed for significant medication error (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses including heart failure and chronic pain. A review of the nurse progress note revealed on 2/24/25 Resident #1 was evaluated by the Nurse Practitioner (NP) for an abscess. The NP's treatment plan included a new order for clindamycin (antibiotic) 300 milligrams (mg) every 6 hours for seven days for a gum abscess. A review of the NP progress note dated 2/28/25 revealed Resident #1 continued to receive clindamycin for a gum abscess and denied any side effects, was doing a little better, and had no new concerns. The NP made no changes and continued Resident #1's medications as ordered. A review of the NP progress note dated 3/4/25 revealed nursing reported Resident #1 now had an itchy rash. The NP's physical exam noted Resident #1 had an erythematous (redness and inflammation of the skin) rash, hives and was itchy. Resident #1 denied shortness of breath, chest pain, trouble swallowing, or palpitations and the NP ordered to discontinue clindamycin. The NP's treatment plan included sulfamethoxazole-trimethoprim (antibiotic) DS (double strength) give one tablet twice a day for 10 days (20 doses), germicidal mouthwash 15 milliliters swish and spit twice a day, and diphenhydramine (antihistamine) 25 mg give one dose now. A review of the physician orders dated 3/4/25 included sulfamethoxazole-trimethoprim DS 800-100 mg give one tablet twice a day for abscess for 10 days, germicidal mouthwash 15 ml swish and spit two times a day for oral abscess with no end date, and diphenhydramine 25 mg give 1 tablet one time only for allergies. A review of the Medication Administration Record (MAR) revealed sulfamethoxazole-trimethoprim DS was initialed by nurses with the first dose administered on 3/4/25 at 9:00 PM and continued through 3/12/25 at 9:00 AM (20 doses), germicidal mouthwash 15 milliliters swish and spit twice a day was started on 3/4/25 and initialed by nurses it was administered twice a day with no end date, diphenhydramine 25 mg give one time only for allergies was initialed by the nurse as given on 3/4/25 at 10:00 AM. A review of the physician orders started on 3/5/25 revealed prednisone (a steroid) 20 mg give one tablet daily for 3 days for rash, hydroxyzine (antihistamine) 25 mg give one tablet twice a day for 3 days and as needed every eight hours for 7 days for itching, clobetasol propionate external cream (steroid cream) apply to body topically twice a day for 14 days for rash. A review of the MAR revealed prednisone 20 mg was initialed as administered by the nurses on 3/5/25 through 3/7/25, hydroxyzine 25 mg give one tablet twice a day for 3 days initialed as administered by the nurses on 3/6/25 through 3/8/25 with one as needed dose given on 3/9/25 that was effective, and clobetasol propionate external cream apply to body topically twice a day for 14 days for rash started on 3/5/25. A review of the NP progress note dated 3/5/25 revealed nursing reported Resident #1's rash was worse, he had a low-grade fever of 100.7, was very itchy and requesting something stronger for the rash. The physical exam noted the erythematous rash had spread all over, hives, and mild skin peeling on the upper chest. The NP ordered a one-time dose of methyl prednisolone 40 mg intramuscular injection. The physician's order for methyl prednisolone inject 40 mg intramuscular one time only for rash started on 3/5/25 with an end date of 3/5/25. A review of the MAR revealed Nurse #1 initialed and documented NN (see nurse note) on 3/5/25 at 4:38 PM for methyl prednisolone inject 40 mg intramuscular one time only for rash. A review of the nurse note dated 3/5/25 revealed Nurse #1 documented the methyl prednisolone was on order. A review of the facility's backup medication supply list revealed three doses of 40 mg methyl prednisolone intramuscular injections were available on 3/5/25. A review of the physician's order dated 3/9/25 for methyl prednisolone inject 40 mg intramuscularly one time for rash was restarted on 3/9/25. During a phone interview on 4/8/25 at 6:41 PM Nurse #1 revealed she worked the day shift on 3/5/25 and her initials on the MAR meant she was supposed to administer Resident #1's intramuscular injection of methyl prednisolone. She revealed the medication was not on the medication cart and she asked a nurse she did not recall and was told methyl prednisolone was not in the backup medication storage supply. She informed the oncoming nurse the methyl prednisolone injection was not administered and thought after it was delivered by pharmacy that nurse would give the injection. Nurse #1 revealed she did not hear anything about the injection until 3/9/25 when the Unit Manager told her to call the pharmacy and have them deliver the medication. Nurse #1 revealed if the methyl prednisolone was delivered on 3/9/25 she thought the nurse would administer it after delivery. Nurse #1 stated she administered methyl prednisolone to Resident #1 on 3/10/25 as directed by the NP. A review of the NP progress note dated 3/10/25 revealed nursing reported Resident #1's rash had not improved, and he was still very itchy. The NP directed nursing to call pharmacy and ensure they delivered the steroid (methyl prednisolone) injection and directed nursing to give the medication when it arrived. A review of the MAR revealed on 3/10/25 Nurse #1 initialed methyl prednisolone inject 40 mg intramuscularly to indicate the medication was administered. A phone interview was conducted on 4/8/25 at 3:29 PM and 5:33 PM with the NP. The NP revealed Resident #1 was started on oral prednisone on 3/5/25 for a rash she attributed as an allergic reaction to clindamycin. The oral prednisone was not as effective and when the NP saw Resident #1 on 3/5/25 the rash was worse and he had a low-grade fever and wanted something stronger, so she ordered a one-time dose of methyl prednisolone intramuscular injection. On 3/10/25 she was at the facility and made aware the injection was not administered and she still wanted Resident #1 to receive it. The NP revealed she expected methyl prednisolone was administered on 3/5/25 when she ordered it and considered it as a medication error if not. She revealed a 40 mg of methyl prednisolone was a standard dose and Resident #1 had received oral and topical medications to help relieve his symptoms and did not have shortness of breath or chest pain and she did not think there was a negative outcome it was delayed for five days. A phone interview was conducted on 4/9/25 at 10:16 AM with the Director of Pharmacy Operations. After review of methyl prednisolone ordered on 3/5/25, the Director stated the order was received after the cutoff time and the expectation for a one-time dose the nurse would need to access the medication from the backup storage system. The Director revealed a second order was received and delivered by pharmacy on 3/9/25. After reviewing the transactions made from the backup medication storage system the Director revealed methyl prednisolone was not removed and the quantity on hand remained at three doses and no transactions were made for March 2025. An interview was conducted on 4/8/25 at 4:53 PM with Resident #1. Resident #1 revealed he had an infected tooth and was started on clindamycin and after about five days his skin broke out with red dots. Resident #1 revealed at first the rash appeared as small dots on his chest and arms then spread everywhere all over his body and his skin was bright red like a sunburn and itched and started peeling. Resident #1 revealed the rash was very itchy and he continuously scratched himself. A joint phone interview was conducted on 4/10/25 at 10:00 AM with the Director of Nursing (DON) and Administrator. The DON and Administrator were asked if methyl prednisolone was available in the backup storage medication supply did they expect Nurse #1 to administer the medication as ordered on 3/5/25. The DON revealed she expected Nurse #1 to check the backup medication supply and administer methyl prednisolone injection as ordered and if the medication was not administered provide that information to the oncoming nurse to ensure it was. The Administrator and DON revealed Resident #1 was getting oral prednisone and other medications to help relieve his allergic reaction symptoms. The DON revealed not administering methyl prednisolone was a medication error and the NP was closely monitoring Resident #1 and with other medication treatments in place she did not feel the delay in administration was a significant medication error.

Based on observations, record review, and staff, Law Enforcement Officer and Medical Director (MD) interviews, the facility failed to supervise a cognitively impaired resident from exiting the locked memory care unit of the facility unsupervised without staff knowledge for 1 of 2 residents reviewed for accidents (Resident #1). Resident #1 went through the adjoining bathroom to the neighboring room and removed a windowpane and exited through the window. Resident #1 walked approximately 2/10 mile after dark on a two-lane street with streetlights and no sidewalk. He was wearing pants, shirt, jacket, and shoes. Resident #1 was found across the three-lane road from the gas station/convenience store by a staff member. He was transported back to the facility by a law enforcement officer. There was the high likelihood of a serious adverse outcome for Resident #1 when he removed the heavy glass windowpane, exited through the window which was 79 inches from the ground, and walked unsupervised to the gas station/convenience store. Findings included: Resident #1, a [AGE] year-old male, was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, dementia, aphasia, anxiety, tobacco use and history of stroke. Resident #1's annual Minimum Data Set (MDS) dated [DATE] revealed he had moderately impaired cognition and his speech was unclear. Resident #1 was usually understood and usually understood by others. He exhibited no wandering behaviors during the lookback period (7 days prior to the MDS date). He was independent for walking at least 150 feet. Resident #1 did not utilize a mobility device and did not use a wander/elopement alarm. He was 74 inches tall and weighed 200 pounds. Resident #1 had verbal behavioral symptoms directed toward others 1-3 days during the lookback period (7 days prior to MDS date). Resident #1 had no range of motion impairment in his upper or lower extremities and was independent with transfers. Resident #1's elopement assessment dated [DATE] revealed he had no history of attempted elopement or actual elopement. Resident #1's care plan last revised on 8/02/24 had a focus which read in part the resident is at risk for elopement related to confusion. Interventions included to encourage resident's participation in activity preferences, divert resident by giving alternative objects or activities, and listen to resident and try to calm. Resident #1's care plan had another focus related to impaired communication with resident usually understood and usually understands and does have diagnosis of aphasia (Aphasia is a brain disorder where a person has trouble speaking or understanding other people speaking). Interventions included that resident does use gestures and nods yes or no, repeat answers to verify what you understood was correct, and allow sufficient time for resident to process and respond. The Weather Underground website revealed the outdoor air temperature where the facility was located on 9/18/24 at 11:54 PM was 69 degrees F with no precipitation. Nurse's progress note dated 9/19/24 at 1:00 AM written by Nurse #1 read in part that the resident had an event that warranted the MD notification. The Resident was ordered Ativan (an antianxiety medication) 1 milligram by mouth immediately. He was agitated, cursing, but calmed down and took the medication. Resident placed on 1:1 with a Nursing Assistant. An interview on 9/24/24 at 3:02 PM with Nurse #1 revealed she was the nurse assigned to Resident #1 on the night shift of 9/18/24. She stated she saw the resident between 10:00 PM and 10:17 PM when he was gesturing to go outside to smoke. Nurse #1 stated the resident was told they were in the middle of putting some other residents to bed and she was completing her medication pass and they were unable to take him outside at that time. Nurse #1 indicated Resident #1 went to his room and she and the other staff continued to provide care for other residents. Nurse #1 observed the resident wearing pajama pants, t-shirt, and was barefoot when she saw him on the unit between 10:00 PM and 10:17 PM. Then Nursing Assistant (NA) #1 informed her around 11:30 PM that Resident #1 was not in his room or his bathroom. Nurse #1 went to Resident #1's room (room [ROOM NUMBER]), and the resident was not in his room or bathroom. Nurse #1 indicated she went to the next room (room [ROOM NUMBER]) and saw a windowpane leaning up against the empty bed by the window. She directed staff to continue searching the facility and outside around the facility. Nurse #1 initiated the facility's missing resident/elopement procedure and called the police to notify them of the resident's elopement and then notified the facility Administrator and the on-call Department of Social Services employee. Resident #1 was located at a convenience store/gas station 2/10 mile from the facility by a staff member. The police went to the gas station and transported Resident #1 back to the facility around midnight. Nurse #1 explained Resident #1 was agitated when he returned, and she contacted the on-call physician for an order for medication to help with his agitation. Resident #1 was also placed on 1:1 observation. Resident #1 initially refused a skin check but later let her complete a skin check and vital signs where she noted no injuries or abnormalities. An interview on 9/24/24 at 4:05 PM with Nurse #2 revealed she was in the facility on night shift on 9/18/24 when Resident #1 eloped out the locked memory care unit window. Nurse #2 stated she was assigned to another unit at the facility, but when she became aware of the resident's elopement, she got into her personal vehicle and drove around the neighborhood to look for the resident. Nurse #2 further stated she went to the closest convenience gas station and asked the store clerk if they had seen anyone with Resident #1's description. The clerk indicated that someone matching Resident #1's description had been in the store twice, once to buy cigarettes and once to buy a drink. Nurse #2 stated she walked back out of the store and observed Resident #1 across the street. She called out to Resident #1, and he walked over to her. Resident #1 refused to get in her car, but the police were able to get him to ride in their car back to the facility. Nurse #2 stated Resident #1 was wearing pajama pants, white t-shirt, light jacket and shoes. An interview on 9/24/244 at 8:02 PM with Law Enforcement Officer #1 revealed he responded to Resident #1's elopement from the facility. He stated Resident #1 was located at a convenience store/gas station and was transported back to the facility. The interview further revealed Law Enforcement Officer #1 along with 2 other officers, put the windowpane back into the frame. An interview on 9/24/24 at 3:37 PM with Nursing Assistant (NA) #1 revealed he was working on the memory care unit the night shift of 9/18/24 when Resident #1 eloped. He stated that around 10:00 PM, Resident #1 wanted to go outside to smoke, but was told a staff member would take him out after they made rounds to provide care for some other residents. NA #1 went to check on Resident #1 around 11:30 PM and couldn't find him in his room or bathroom. NA #1 notified Nurse #1, and they started looking for the resident. NA #1 stated he did not remember what Resident #1 was wearing but noted he was wearing shoes when the officer brought him back to the unit. He stated after the resident was returned to the unit; he was assigned to provide 1:1 care for him the rest of his shift. Review of the [NAME] Police Department incident report dated 9/18/24 at 11:37 PM read in part that Law Enforcement Officer #1 was dispatched to the facility at approximately 11:40 PM and arrived at the facility at 11:41 PM. Resident #1 was found by Nurse #2 at approximately 11:57 PM and Law Enforcement Officer #1 went to the convenience store and transported the resident back to the facility. Several officers assisted with putting the window back in place and then left the scene. An interview on 9/24/24 at 1:20 PM with the Administrator revealed she was notified of Resident #1's elopement on 9/18/24 at 11:40 PM. She arrived at the facility around midnight and the police had already brought Resident #1 back. The Administrator stated they were already in the process of transferring the resident to another facility to be closer to his guardian and family and he was transferred to another facility on 9/20/24 which had an interior courtyard where the resident could smoke. Resident #1 was placed on 1:1 observation from the time he returned to the facility until he was transported to his new facility. The Administrator indicated all staff were in-serviced on the resident elopement policy and process. All residents were evaluated for their physical capabilities, behaviors, and wandering to assess whether they could remove a windowpane. The Administrator further stated all new admissions would be evaluated for their ability to remove the windowpanes. An interview on 9/25/24 at 8:40 AM with the Medical Director revealed he was notified of Resident #1's elopement 9/19/24. The Medical Director stated that he did not see how anyone could have anticipated that the resident would be able to remove a windowpane, and he had never heard of that happening before. The interview further revealed given Resident #1's diagnoses and the fact that he was in a locked memory care unit, it was not safe for him to be out of the facility unsupervised. An observation and interview on 9/24/24 at 11:43 AM with the Maintenance Director revealed that the window had 2 panes and measured 70 x 45 inches total. The right side of the window slid to the left side on a track. The left side of the track had a screw affixed to the bottom of the track to prevent the window from opening more than 6 and 5/8 inches. There was no screen in the window. The window in room [ROOM NUMBER] was 79 inches from the grass/ground outside. The Maintenance Director stated that he had been employed at the facility about 4 months and had completed a window audit in July to ensure that all the windows had a screw in the bottom track to prevent it from opening more than 7 inches. He also stated that the right windowpane was physically removed from the track by Resident #1. He did not know how Resident #1 was able to remove the windowpane. The Maintenance Director noted he had completed another window audit on 9/19/24 to ensure all the windows had a screw in the bottom track. An interview on 9/25/24 at 11:17 AM with the Director of Plant Operations revealed he had been the Maintenance Director at the facility for several years. The Director of Plant Operations stated he had looked at the window in room [ROOM NUMBER] where Resident #1 removed the windowpane on 9/19/24 and did not know how the resident got the windowpane out. An observation on 9/24/24 at 5:00 PM with the Administrator revealed from the facility to the convenience gas station was about 2/10 mile through the back parking lot, service area, and two neighborhood roads. There were streetlights observed on the two neighborhood roads. These roads were wide enough for 2 cars but had no painted lines or sidewalks. There were no posted speed limit signs. The convenience store/gas station was across the street at the end of the neighborhood road. The street the convenience gas station was located on was three lanes (middle turn lane) with painted lanes and streetlights. The posted speed limit sign was 20 miles per hour. An additional observation on 9/25/24 at 11:00 AM of the window in room [ROOM NUMBER] revealed there were four 2-inch scratch marks about 1/4 inch deep on the window casement as well as a black scuff mark. The caulking was in place around the window frame. The Maintenance Director and the Administrator were present during the observation and reiterated they had no idea how Resident #1 was able to remove the windowpane to exit the facility. The Administrator was notified of the immediate jeopardy on 9/25/24 at 12:53 PM. The facility provided the following corrective action plan with a completion date of 9/20/24. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident #1 is a [AGE] year-old male admitted to the facility on [DATE]. Resident #1 was admitted with a diagnosis of but not limited to unspecified injury of the head, aphasia, unspecified mood disorder and unspecified dementia. Resident does not have history of previous elopements Resident #1 is a smoker. Resident was admitted on the secured unit secondary to having diagnosis of unspecified dementia and ability to ambulate. On 9/18/24 approximately at 10:30 PM Resident #1 requested facility staff to have a smoke break. Facility staff addressed Resident #1 letting him know that it would be a little bit as he had just had a smoke, and staff were providing resident care. Resident #1 returned to his room and closed the door as he normally would. Resident #1 showed no signs of being upset or agitated and returned to his room as he normally would, closing the door behind him. This was normal behavior for Resident #1. While conducting rounds at approximately 11:40 PM staff identified that Resident #1 was not in his room. This alerted the staff to begin looking in other rooms and do a general sweep of the area. It was also identified that the windowpane in the adjoining room had been removed and placed on the floor. Facility staff immediately began systematic procedures for missing resident and notifying the Administrator, and Police Department. Nurse Aides and Nurse #1 began facility sweep while Nurse #2 went to her vehicle and began driving around surrounding areas in search of Resident #1. Nurse #2 drove to the only 24-hour business in the area which was a nearby gas station. Nurse #2 entered the gas station and provided the clerk with a description of Resident #1. The clerk stated that the resident had been in the gas station and purchased a soda and pack of cigarettes. Nurse #2 exited the gas station and began looking in the area when she saw Resident #1 on the sidewalk in front of the store and called his name. Resident #1 began walking towards Nurse #2. At this time the police arrived on the scene and Resident #1 agreed to return to the facility and chose to ride with the police officer. Upon arrival back at the facility a skin assessment was completed on Resident #1 and no issues were identified. Vital signs were also recorded for the resident by Nurse #1. Resident #1 was placed on 1:1 supervision. Three of the responding police officers were able to work together and put the windowpane back into place. The on-call provider and guardian were notified of the event. The center had previously been seeking alternative placement for the resident months prior to the event. Requirements for that location were that the new facility needed to be more proximal to the guardian's location and offer smoking. Arrangements were finalized earlier that evening prior to the event and communicated by the Administrator to the guardian. Arrangements were agreed upon and discharge was set for 9/20/2024. Post the event there was a discussion with the guardian and a new location was proposed. This facility differed from the original proposal because the structure of the center was a single level facility with an interior smoking area. Once discussed with the guardian, arrangements were made for the resident to be discharged there on 9/20/2024. Resident discharge as planned on 9/20/2024 with no adversity. The Director of Nursing, Administrator, and the attending nurse discussed the root cause and determined Resident #1's request to smoke was declined, and he went to his room while unsupervised. Resident #1 then went through an adjoining bathroom and removed a windowpane in the neighboring room and exited through the window. Address how the facility will identify other residents having the potential to be affected by the same deficient practice Residents currently residing in the facility have the potential to be affected. On 9/19/24 the Director of Nursing assessed current residents for ability to walk, cognitive impairment, ability to reasonably remove a windowpane and climb through the window opening. No residents were identified at risk during the assessment. During the investigation, a review of residents who pose as a potential elopement based on exit seeking behaviors and abilities to exit were assessed with no additional residents identified. All residents have open utilization data assessment (UDA) named elopement assessments scheduled for their Admission/ Quarterly, these assessments are completed by floor nursing. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: The Maintenance Director conducted a house audit of windows to ensure that windows could not open greater than 7 inches on 9/19/24. Any window that indicated the ability to exceed the limit, or seemed defective was addressed and additional hardware such as additional screws were put into place. Center utilizes a keypad system on each of the exit doors. Each door has a different code and are frequently changes to prevent residents from exiting. On 9/19/24 the Maintenance Director reviewed the affected window and was unable to identify any deficits of the window, causing it to be easily removed. Screw was in place and there was no damage sustained to the glass or the tracks of the window. Maintenance Supervisor did replace a weather type seal of the window, but this was not part of the operations of the window. Window was found to not be defective. An interview with the Regional Maintenance Director took place on 9/19/24 at 10:31PM. Results from that indicated that the frames of the windows were not removeable and was part of the structure of the building, which is composited of brick and mortar. The windowpanes do have less than a 1/4 inch space around them for expansion. The windows will continue to be assessed for any malfunction or age-related faults. The facility is equipped with door locks/alarms, keypad systems and wanderguards to help avoid elopements. These mechanisms were checked by the center's Maintenance Director on 9/19/24. The Wanderguard system and door monitoring system were also audited by the Maintenance Director on 9/19/24. Results from the audits indicated that all systems were operable. The education on the center's Elopement and Wandering Policy was initiated on 9/19/24 by the Administrator and carried on by the Unit Manager. All staff in Nursing, Agency, Therapy, Housekeeping, Administration, and Dietary have received education verbally or in-person prior to working. Education was provided face to face for individuals who were on shift, others not on-site were provided with education via phone. Those who received education via phone will be expected to sign the education prior to working next shift. The education included ensuring residents that exhibit exit seeking behaviors and/or at risk for elopement receive adequate supervision to prevent accidents in the facility's control. Staff were educated on how to identify exit seeking behaviors, monitor the affected resident, and interventions. Education highlighted that alarms doesn't replace the necessary supervision of a resident. Nor does it negate how vigilant that the staff should be in responding to alarms or actions of the resident that would indicate an elopement risk. Staff were instructed that if they were to witness a resident attempting to open a door or window, he / she should make efforts to remove the resident from the area through redirection and should never stop monitoring the resident. Once resident is safe the attending nurse should immediately notify the Nurse Leadership for interventions and make sure that a new elopement assessment is completed. Behaviors that indicate a risk for elopement of a resident should be communicated in report between staff and added to the elopement binder, which will be maintained by the Social Worker. The elopement binder was updated by the DON on 9/19/24. The elopement binder will be maintained moving forward by the Social Worker. The Social Worker was notified of this responsibility on 9/19/24. Staff were reminded that elopement binders are located at each Nurses Station and in the Social Worker's office. Education will be oversighted by DON, anyone not educated on 9/19/24 will need to be educated in- person prior to shift by the Unit Manger / DON. Both the Unit Manager and DON have been educated on their responsibilities effective 9/19/24 Newly hired staff members will receive education in orientation from the Director of Nursing and/or Maintenance Director on the day of orientation it is also during that time that staff will be educated on how to identify behaviors that will trigger a new elopement risk assessment to be completed. On 9/19/24 the Administrator implemented the Director of Nursing or Unit Manager would be responsible for conducting the elopement assessments on new admissions. Residents will be assessed for risk of elopement and unsafe wandering throughout their stay by the interdisciplinary care plan team. The Director of Nursing and Unit Manager have been educated by the Therapy Director on how to assess residents who are at risk exiting through a window and via the door. Assessments will take into consideration a resident; mobility, cognition, dexterity, and ability to balance bi-laterally. Both DON and Unit Manger have been made aware of the responsibility and comprehensively assess and complete the elopement risk UDA for each resident. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: Audits were put into place on 9/19/24, the Maintenance Director will audit two times a week for 12 weeks to ensure that the residents' windows do not have any defective or bent areas that keeps them secured. Any defective item will be corrected immediately. While repair is being completed the window will have constant monitoring by a facility staff member. Audits will also consist of the responsiveness and demonstration from the staff to properly execute procedures outlined in the Elopement and Wandering Residents Policy. Random audits of the center's response to elopement drills will be completed 1 time a week for 12 weeks by the Maintenance Director or Administrator. Weekly assessment of the wanderguard system by the Maintenance Director will continue regularly thereafter. ADHOC QAPI was initiated by the IDT team about the event on 9/19/24. The Administrator directed the Director of Nursing and Maintenance Director on 9/19/24 that they are responsible for forwarding the results of their audits the QAPI Committee monthly for three months. The QAPI Committee will review the audit to determine trends and/or issues that may need further interventions put into place and to determine the need for further and/or frequency of monitoring. Completion date: 9/20/24 The corrective action plan of immediate jeopardy removal was validated on 9/25/24. Interviews were conducted with a sample of Nursing Assistants, Nurses, Director of Nursing, Unit Manager, and the Maintenance Director to verify education was conducted for elopement and wandering residents. Review of sign-in sheets confirmed all staff in departments received education regarding elopement and wandering residents. Review of audits revealed the twice weekly window audits were completed (9/19/24 and 9/24/24). Further review of audits revealed weekly wander guard assessments including doors, locks and alarm systems were completed on 9/19/24 and 9/23/24. An interview with the Unit Manager on 9/24/24 at 9:00 AM revealed she had received education about resident elopement and assessment of current and new residents for elopement risks. She will assess new admission for elopement risks. An interview with the Director of Nursing on 9/25/24 at 8:51 AM revealed she had assessed the current residents for elopement risks. She also will assess new admissions for elopement risks. An interview with the Maintenance Director on 9/24/24 at 11:43 AM revealed he had received education about resident elopement and wandering residents. He stated he will be conducting twice weekly window audits and weekly elopement drills. The facility's completion date for the corrective action plan of 9/20/24 was validated.

Based on record reviews and staff, family member, Nurse Practitioner, Urology Surgeon, Wound Physician and Medical Doctor interviews the facility failed to protect a Resident's right to be free from neglect when the facility failed to identify the seriousness of a left swollen testicle, complete thorough and ongoing nursing assessments, schedule a urology appointment per the Nurse Practitioner's order which led to a delay in care and treatment for a serious medical emergency for 1 of 3 residents (Resident #1) reviewed for neglect. Resident #1 experienced a serious adverse outcome when an acute change in condition was noted on 03/11/24 with a blood pressure of 86/42 and weakness. The Resident was sent to the local emergency department where he was transferred to a hospital for a higher level of care and diagnosed with severe septic shock and urinary tract infection. An ultrasound showed no blood flow with necrotic changes to the left testicle and an orchiectomy (removal of the testicle) had to be performed. This practice affected 1 of 3 residents (Resident #1) reviewed for neglect. Immediate Jeopardy began on 02/23/24 when the facility failed to protect a Resident's right to be free from neglect when they failed to identify the seriousness of a left swollen testicle, complete thorough and ongoing assessments and schedule a urology appointment per the Nurse Practitioner's order which led to a delay in care and treatment for a serious medical emergency. Immediate jeopardy was removed on 04/05/24 when the facility provided and implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure the completion of education and monitoring system are in place. The findings included: This tag is crossed referenced to: F 684: Based on record reviews and staff, family member, Nurse Practitioner, Urologist and Wound Physician's interviews the facility failed to identify the seriousness of decreased vascular flow to Resident #1's left testicle and complete and document thorough and ongoing nursing assessments of left testicle after 03/23/24 to determine the need for further medical attention. In addition, a Urology Consultation for evaluation of the Resident's left testicle was scheduled for after 3/23/24 not as ordered by the NP which further delayed the determination of what medical interventions were necessary. The Resident experienced an acute change in condition on 03/11/24 with a blood pressure of 86/42 (normal blood pressure range 120/80) and weakness. The Resident was sent to the local hospital emergency department (ED) and was then life flighted to a second hospital due to the need for a higher level of care and capabilities. The Resident was diagnosed with severe septic shock and urinary tract infection. A renal ultrasound showed an obstructing stone in the right ureter with hydronephrosis (excessive fluid in the kidney due to a backup of urine) and a testicular ultrasound showed no blood flow with necrotic (death of cells or tissue due to disease or injury) changes to the left testicle. On 03/12/24 an emergency stent was placed in the right ureter and the left testicle was removed. This practice affected 1 of 3 residents reviewed for providing care according to professional standards of practice (Resident #1). F 580: Based on record reviews, and staff, Nurse Practitioner, and Medical Doctor's interviews the facility failed to notify the Nurse Practitioner or the Medical Doctor when a Urology Consult was not able to be scheduled per the Nurse Practitioner's order after a CT (computed tomography) scan noted decreased vascular flow to Resident #1's left testicle. Resident #1 experienced serious adverse outcome after an acute change in condition was noted on 03/11/24 and was transferred to the hospital emergency department (ED), diagnosed with severe sepsis and underwent a left orchiectomy (removal of the testicle) on 3/12/24. This practice affected 1 of 3 residents (Resident #1) reviewed for notification. The Administrator was notified of Immediate Jeopardy on 04/03/24 at 3:55 PM. The facility provided the following Immediate Jeopardy removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. The facility failed to identify the seriousness of a swollen left testicle, complete thorough and ongoing assessments, schedule a urology appointment per the Nurse Practitioner's order which led to a delay in care and treatment for a serious medical emergency. On 12/21/23 Resident #1 was admitted to Lotus Village Center for Nursing and Rehabilitation with diagnosis of brain damage, dysphagia, hypertension and gastrostomy. On 2/19/24 the physician ordered Resident #1 to have urology appointment as soon as possible due to ultrasound showing possible decreased vascular flow to the left testicle. The facility scheduled the appointment for 3/27/24 and did not notify the ordering nurse practitioner of the delay between order and available appointment. Nursing staff did not complete ongoing and thorough assessments of the scrotal area to identify changes. On 3/11/24 Resident #1 had an acute change of condition noted with a blood pressure of 86/42 and weakness. Resident #1 was sent to the emergency room and was diagnosed with severe septic shock, urinary tract infection and aspiration pneumonia. Necrotic changes were found to the left testicle and removal of the testicle was performed. Current residents residing in the facility have the potential to be affected by the deficient practice. On 4/4/24 all alert and oriented residents with a BIMS of 12 or greater were interviewed by the Social Worker regarding care and questioned if they felt they were neglected of care and services. There were no issues reported. All residents with cognitive impairment, a BIMS of 11 or less had total body skin assessments completed by the MDS Coordinator. There were no signs of neglect identified. 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: Beginning on 4/3/24 the Director of Nursing and Regional Nurse Consultant educated the staff in all departments including agency staff on the definition of neglect: the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Some examples of neglect include lack of sufficient staffing to be able to provide services, lack of knowledge of the needs of the resident, lack of supplies to provide care, or indifference or disregard for resident care and safety. The Director of Nursing and Administrator will ensure that staff members, to include agency staff, that have not received the education will not be able to work until they have received this education. The Director of Nursing and Administrator are responsible for tracking who has received the education and who still needs to receive it prior to working their next shift. Both the Director of Nursing and the Administrator were made aware of this responsibility on 4/3/24. The Director of Nursing will provide this education to newly hired staff, including agency, during orientation. Education was given verbally either in person or via phone and/or written format and the staff were asked to restate the information to confirm understanding of the education. Staff will not be able to work their next scheduled shift until education has been completed. Effective 4/3/2024, the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: 4/5/23 On 04/08/24 an onsite validation of the immediate jeopardy removal plan was conducted. The facility assessed all residents either through interviews or skin assessments for signs and symptoms of neglect and there were no issues noted. The entire staff was educated on the definition of neglect and different examples of neglect and will ensure that no staff will be allowed to work without receiving the education. Newly hired staff as well as agency staff will be educated on neglect. Return understanding of neglect was demonstrated verbally after the education was completed. The immediate jeopardy removal date of 04/05/24 was validated.

Based on record reviews and staff, family member, Nurse Practitioner (NP), Urology Surgeon and Wound Physician interviews the facility failed to identify the seriousness of decreased vascular flow to Resident #1's left testicle and complete and document thorough and ongoing nursing assessments of left testicle after [DATE] to determine the need for further medical attention. In addition, the Urology Consultation for evaluation of the Resident's left testicle was scheduled for [DATE] which further delayed the determination of what medical interventions were necessary. The Resident experienced an acute change in condition on [DATE] with a blood pressure of ,d+[DATE] (normal blood pressure range ,d+[DATE]) and weakness. The Resident was sent to the local hospital emergency department (ED) and was then life flighted to a second hospital due to the need for a higher level of care and capabilities. The Resident was diagnosed with severe septic shock and urinary tract infection. A renal ultrasound showed an obstructing stone in the right ureter with hydronephrosis (excessive fluid in the kidney due to a backup of urine) and a testicular ultrasound showed no blood flow with necrotic (death of cells or tissue due to disease or injury) changes to the left testicle. On [DATE] an emergency stent was placed in the right ureter and the left testicle was removed. This practice affected 1 of 3 residents reviewed for providing care according to professional standards of practice (Resident #1). Immediate Jeopardy began on [DATE] when the facility failed to complete and document thorough and ongoing nursing assessments of Resident #1's left testicle. Immediate jeopardy was removed on [DATE] when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure the completion of education and monitoring system are in place. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included anoxic brain injury, persistent vegetative state and neurogenic bladder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had long and short-term memory problems, functional impairment of upper and lower extremities for range of motion, totally dependent on staff for all activities of daily living and had an indwelling urinary catheter. A review of Resident #1's medical record from [DATE] through discharge on [DATE] revealed there were no documented nursing assessments of the Resident's scrotum. An interview was conducted with the Nurse Practitioner (NP) on [DATE] at 5:00 PM, [DATE] at 1:00 PM and [DATE] at 2:05 PM. The NP explained that she was notified of Resident #1's scrotal swelling on [DATE] and assessed his scrotum to be swollen to approximately the size of a softball with a little redness. The NP stated she offered to the family member to send the Resident to the local ED, but the family member did not want the Resident to go to the ED but wanted him treated at the facility. The NP stated she ordered an ultrasound to be performed on the scrotum immediately and antibiotics to be administered twice a day for 10 days. She reported the ultrasound was completed on [DATE] and she learned the results of the ultrasound on [DATE] when she went to the facility for rounds. The ultrasound showed decreased vascular flow to the left testicle, and she felt that Resident #1 needed a urology consult as soon as possible because anytime you have decreased vascular flow you need to get scooting, so she wrote the ordered for the urology consult as soon as possible that day on [DATE]. She stated she assessed the Resident's scrotum on [DATE] and [DATE] and there was no change in the scrotum since the first time she assessed the scrotum on [DATE]. She stated the facility needed to monitor the scrotum closely for changes and they could send him to the ED for any changes if need be. At the time of the interview the NP stated that she was not aware that the facility was having a difficult time getting a urology consult scheduled for Resident #1 and assumed the appointment had been made. She also stated she was not aware that Resident #1's urology consult was scheduled for [DATE] and explained that was too long away. She stated she could see maybe being scheduled for 2 weeks out from when it was ordered but 5 to 6 weeks away was too long. During an interview with the Wound Physician (who was also a Surgeon) on [DATE] at 11:35 AM the Physician explained that he consulted weekly on Resident #1's pressure ulcers and when he made rounds on [DATE] it was brought to his attention by Resident #1's family member that his scrotum was swollen and appeared to be tender. He continued that he noticed that Resident #1's scrotum was swollen and tender and he would recommend a scrotal ultrasound to determine whether it was a cystocele (a bulge of the bladder) or a torsion. He indicated he spoke with the Nurse Practitioner about it on [DATE] who was already aware of the Resident's swollen scrotum and was going to order an ultrasound. The Wound Physician stated he made note of the assessment in his [DATE] notes but not after that because the NP was aware of the issue and that was not the area of his consultation. He continued to explain that when he made rounds on Resident #1 the following weeks, he noticed his scrotum was still swollen and he was told by the Resident's family member that he had a urology appointment scheduled. The Physician stated he informed the family member that Resident #1 would probably have to have the testicle removed. The Physician explained that the amount of time it took for the testicle to die depended on what the cause was, for example if the cause was torsion, then it would be faster. He stated the last two times ([DATE] and [DATE]) he looked at the Resident's scrotum it looked about the same as it did on [DATE] and he did not feel like it needed to be an emergency urology consultation, but it needed to be evaluated. He explained that according to the ultrasound where it showed decreased vascular blood flow Resident #1 may not have needed an orchiectomy but only more or a different antibiotic. He stated Resident #1 did not seem to have the pain the second and third time he saw him and the last time he rounded on Resident #1 ([DATE]) his scrotum did not seem painful or tender. The Physician stated it was possible the testicle could have twisted and untwisted and if so, the pain would have come and gone. On [DATE] at 11:40 AM an interview was conducted with the Scheduler who explained that she was working on the hall as a nurse aide on [DATE] when she was given the order for Resident #1 to have a urology consult as soon as possible from the Staff Development Coordinator. She explained that as soon as possible meant it needed to schedule with high priority like then and there, but she was on the hall and knew she would have to follow up the next day. When she was able to follow up, she called a urology office that told her to fax over the information on Resident #1 and they would get back to her. She stated she waited several days, and they never followed up with her so when she was able to get back in touch with the urology office, they told her there was a mix-up in their records and they needed more information. The Scheduler stated that by that time it was about [DATE] or [DATE] so she decided to try to get Resident #1 a urology appointment at a local urology clinic and on [DATE] she was able to schedule a urology appointment for the Resident for [DATE]. The Scheduler stated she kept that appointment and tried another clinic [DATE] and was able to schedule a urology appointment for the Resident for [DATE]. The Scheduler stated she did not inform anyone that she was having difficulties with scheduling Resident #1 for a urology appointment because she thought she could manage it but now she knew different. An interview was conducted with the Social Worker (SW) on [DATE] at 10:25 AM who explained that she had heard from the Scheduler (she could not remember when) that she was having trouble getting a urology appointment scheduled for Resident #1 and the family member did not agree with the first appointment that was made for him. The SW thought they worked it out because the final urology appointment was in the books for a urology clinic out of town but did not know when it was scheduled for. The SW stated she was made aware of the difficulty that the Scheduler was having making the urology appointment through the family member. During an interview with Nurse #7 on [DATE] at 2:00 PM the Nurse stated she had only worked with Resident #1 one time (Medication Administration Record indicated she worked with the Resident on [DATE] and [DATE]) and the Resident's family member brought the Resident's swollen scrotum to her attention. The Nurse explained that the scrotum appeared to be swollen and the scrotum was elevated using a pillow. There was no documentation in the Resident's medical record of the assessment. On [DATE] at 3:05 PM an interview was conducted with Nurse Aide (NA) #1 who stated that she mostly worked the hall where Resident #1 resided. The NA explained that she knew of the Resident's scrotum being swollen and hard and reported it to several nurses but could not remember which nurses she reported it to. She stated she did not know what was being done about the swelling other than keeping his scrotum elevated which they always did, and his family member did as well. The NA explained that Resident #1 flinched when you touched his scrotum but he flinched every time you touched him so she could not be sure it was painful. She stated the swelling eventually subsided. During an interview with Nurse Aide (NA) #2 on [DATE] at 3:06 PM the Nurse Aide explained that she worked on all the halls including the hall that Resident #1 resided. The NA continued to explain that she noticed Resident #1's scrotum to be slightly larger than the normal scrotum and it was fleshy looking. She stated the family member was very particular with his care and always kept his scrotum elevated on pillows. The NA stated she did not notice his scrotum being painful when touched because the Resident always yelled and screamed when he was touched even before his scrotum was swollen. She stated she would not have identified the scrotum to be swollen but maybe slightly enlarged therefore she did not report the swollen scrotum to the nurses. An interview was conducted with Nurse Aide #3 on [DATE] at 3:15 PM. The NA explained that she often worked the hall where Resident #1 resided and took him to the shower room for his showers. The NA continued to explain that she noticed that Resident #1's scrotum was swollen and red like it was irritated and she knew that nursing was aware of it but did not know what was being done. She stated the family member was particular about his care and kept his scrotum elevated all the time. The NA reported she did not notice his scrotum being painful because he hollered every time he was touched not just when you touched his scrotum. A review of Resident #1's progress notes dated [DATE] at 5:33 AM and written by the Director of Nursing (DON) revealed cleaned scant amount of blood from around catheter when providing resident care. Catheter patent and draining and not leaking at this time. Flushed catheter. Resident slept very soundly this shift. Tried not to disturb the resident too much because he does not sleep well usually. An interview was conducted with Nurse #3 on [DATE] at 12:00 PM and [DATE] at 8:50 AM who confirmed that she worked from 7:00 AM to 7:00 PM on [DATE] with Resident #1. Nurse #3 stated she never knew anything about Resident #1 having scrotal swelling and she even worked on [DATE] and flushed his catheter and did not notice any scrotal swelling. She stated she felt like if he had scrotal swelling, she would have seen it when she flushed his catheter on [DATE] and if so, she would have notified the Physician. On [DATE] at 11:45 AM an interview was conducted with Nurse #2 who confirmed she worked with Resident #1 on [DATE] from 7:00 PM to 7:00 AM on [DATE]. The Nurse reported she had never noticed any scrotal swelling on Resident #1 at that time nor had she ever noticed any scrotum swelling on the Resident nor was she aware that he had a scrotal ultrasound or what the results were. A review of Resident #1's progress note dated [DATE] at 4:05 PM and written by Nurse #1 revealed Resident was just not himself and appeared to be weaker than usual. Blood pressure ,d+[DATE] and heart rate was 80. His pupils were not as reactive as his baseline and the urinary catheter was draining adequate urine output. The feeding tube was intact. The Resident's family insisted that something was wrong and wanted the physician to send him to the hospital. Nurse Practitioner contacted and received an order to send him to the emergency department for further evaluation. An interview was conducted with Nurse #1 on [DATE] at 3:00 PM and [DATE] at 10:10 AM who stated she had recently worked with Resident #1 more often and confirmed she was the Nurse on duty on [DATE] from 7:00 AM to 7:00 PM and sent Resident #1 to the ED. Nurse #1 continued to explain that Resident #1 seemed quieter than normal during her shift. She did not have any trouble flushing his catheter and his feeding tube was patent and she took the Resident's blood pressure several times throughout the shift which fluctuated. She stated the third time she took his blood pressure it was ,d+[DATE] and that was lower than it had been all day and he seemed weaker, and she felt at that time that he was septic. The Nurse explained that she called the Nurse Practitioner and got an order to send Resident #1 to the ED. Nurse #1 reported that she did not know about Resident #1's scrotal swelling but she did know that he had an ultrasound ordered because she noted the order for the ultrasound of the scrotum on [DATE] the day it was written. She explained that she only occasionally worked with Resident #1, and she did not have to assess his scrotal swelling but that if he had scrotal swelling, she would have noticed it when she flushed his catheter. Nurse #1 stated that when she worked with Resident #1, she never noticed any swelling of his scrotum. When asked how she would know to assess for scrotal swelling the Nurse responded that would be considered an acute episode or a change in condition and when the issue was first identified the nurse who discovered the issue should set up a user defined assessment (UDA) that would automatically populate to be done once a shift for 72 hours or until it was resolved. Review of Resident #1 progress notes from the local hospital ED dated [DATE] at 4:15 PM revealed the Resident presented with an oxygenation saturation of 89% and blood pressure of ,d+[DATE] with an additional reading of ,d+[DATE] during his limited stay at the local hospital. Abnormal labs included an elevated white blood cell (WBC) of 11.08 (normal range 4XXX,d+[DATE].80) and a blood urea nitrogen (BUN) of 107 (normal range ,d+[DATE]) and Urine culture with greater than 100,000 CFU/ML (greater than 100,000 CFU/ML would indicate infection) gram negative bacilli (bacteria). Resident #1 was administered three liters of intravenous fluids and started on two different intravenous antibiotics. After consultation with internal and external providers it was decided Resident #1 would need to be transferred to a hospital with a higher level of care capabilities due to Resident #1's condition, the need for a bed in the intensive care unit and the specialty of an intensivist (physician who provides special care for critically ill patients) and infectious disease. The progress note described Resident #1's specific medical risks of worsening pneumonia, sepsis or death. Resident #1 had to be air lifted to the secondary hospital. There was no documentation in the ED progress notes about Resident #1's scrotum. discharge date and time was [DATE] at 11:14 PM with discharge diagnoses of dehydration, facility acquired pneumonia and kidney stone in the right ureter. Attempts to interview the local emergency department physician were unsuccessful. A review of Resident #1's progress notes dated [DATE] at 2:18 AM from the second hospital revealed he had a continuous medication infusing via intravenous access to improve his blood pressure which was effective. It was noted that he had received 3 liters of intravenous and the two antibiotics ordered at the previous hospital would be continued. The Resident was admitted with diagnosis of severe septic shock secondary to urinary tract infection, dehydration, aspiration pneumonia and right stone in ureter with hydronephrosis. A urology consultation was obtained on the morning [DATE] and orders were received for ultrasounds of the kidneys and testicles to be completed. The urology consultation revealed Resident #1 had a history of left testicular swelling and pain for one month with a previous ultrasound demonstration of decreased vascular flow to the left testicle. The ultrasound of the left testicle completed on [DATE] demonstrated no blood flow with surrounding necrotic changes consistent with the left testicle. On [DATE] an emergency stent was placed in the right ureter and a left orchiectomy (removal of the left testicle) was performed. An interview was conducted with the Urology Surgeon on [DATE] at 4:35 PM. The Surgeon explained that he received a call from the hospital emergency department for a consultation for Resident #1 on the early morning of [DATE] and was informed that he was an air transfer from another hospital. The Physician Assistant (PA) reported that Resident #1 had tests from the previous hospital that showed an obstructing stone in the right ureter and was showing signs of sepsis, and the Surgeon's initial thought was that if it was a stone or stones then it was reason for urgent intervention and a stent needed to be placed to allow the infected urine to pass through which was a common procedure. The Surgeon continued to explain that the PA informed him that Resident #1's family member reported that the Resident had endured scrotal swelling and pain for about one month with a previous ultrasound that showed decreased vascular flow in the left testicle therefore, the Surgeon wanted a stat (immediate) ultrasound on the kidneys and testicles before the Surgeon arrived at the hospital so he would know what he was dealing with and what needed to be done. The Surgeon explained that when he read the results of the ultrasounds, he knew he needed to remove the stone in the right ureter and place a stent to relieve the hydronephroses in the right ureter and he needed to remove the left testicle because the repeat ultrasound showed no blood flow to the left testicle at all. He stated the ultrasound completed [DATE] showed missed to late torsion (twisting) and also showed the left testicle had been dead for a long time. He reported his belief was that the reason for the sepsis was the dead testicle. When asked if Resident #1's dead testicle was painful the Surgeon informed that during the process of dying (decreased blood flow) the testicle would be painful but after the testicle died there would be no pain and when the testicle died it was necessary to be removed. He stated there was no way to tell how long the testicle had been dead. The Surgeon indicated that he could tell that the testicle did not die from torsion that more than likely it died from orchitis (an inflammation of one or both testicles mainly caused by a bacterial or viral infection) that was not treated appropriately. The Surgeon was asked if the orchiectomy could have been prevented if Resident #1 had been sent for a urology consult when it was ordered on [DATE] the Surgeon stated that it was hard to say but that initially an antibiotic would be necessary to treat the infection (orchitis) but if after a few days of no improvement then he would have switched the antibiotic and obtained a repeat ultrasound. On [DATE] at 10:37 AM during an interview with Resident #1's family member she explained that the Resident had a history of recurrent urinary tract infections and had several trips to the emergency department for catheter changes due to blockages related to thick sediment in his urine that was treated with a medication used to flush the catheter. She informed Resident #1 had a 5 day stay at the hospital in [DATE] due to a severe urinary tract infection. The family member continued to explain that in mid-February she noticed his scrotum was swollen to the size of an orange and asked for him to be evaluated by the Nurse Practitioner (NP) which she did, and the NP ordered an ultrasound to be done. The ultrasound was done which showed a decreased vascular flow of his left testicle and on [DATE] the NP ordered an antibiotic and a urology consult as soon as possible due to decreased vascular flow to his left testicle. The family member stated she approached the Scheduler and Social Worker several times with her concerns about not getting a urology consult for the Resident and even helped with obtaining an appointment herself before one was eventually made on [DATE] for [DATE] at a urology clinic in a nearby town. The family member continued to inform that on the afternoon of [DATE] she went to the facility and found Resident #1 appearing white as a ghost, his gums were white, and he was clammy and barely breathing. She called for Nurse #1 to assess him, and the Nurse got a blood pressure of ,d+[DATE], then she told the Nurse to call 911. The family member reported that while at the local ED the doctor informed her that they were going to airlift him to another hospital when he was stable because he was severely dehydrated, malnourished and possible renal failure or septic shock. She stated they did a CT scan of his kidneys to verify the need to send him to the other hospital to see a kidney specialist. The family member stated Resident #1 was sent by helicopter to the other hospital late that same night on [DATE]. She informed that when she got to the hospital she informed the doctors of everything the Resident had been through and around 5:30 AM on [DATE] the Urology Surgeon told her that he was going to do emergency surgery because Resident #1 had a blockage related to a kidney stone in his right ureter and he had to place a stent (a tubular support placed temporarily inside a blood vessel, canal or duct to aid healing or relieve an obstruction). The Surgeon also informed that Resident #1's left testicle was dead, and he would have to remove it while he was placing the stent. The family member stated the surgery was successful and Resident #1 was due to be discharged on [DATE] to her home for her to provide his care. During an interview with the Director of Nursing (DON) on [DATE] at 9:00 AM and [DATE] at 5:30 PM the DON stated that she vaguely remembered Resident #1 having scrotal swelling, but she was not involved with it. She stated she saw his scrotum a couple of days after the reported swelling, but she did not think it looked swollen. The DON continued to explain that she assisted the nurse aide in turning and repositioning the Resident a couple nights before he was sent out and even changed and flushed his catheter and she did not see any signs of a swollen scrotum. The DON was asked how the facility managed the documentation on acute changes or changes in condition to ensure they were being monitored and documented correctly and she indicated the documentation was subject to the nurses' judgement as to whether the acute change warranted documentation. If so, the nurse would set up UDA documentation or at the very least she should document the assessment in the Resident's progress notes until the issue resolved. The DON was asked if Resident #1's scrotal swelling and decreased vascular blood flow to his left testicle should be considered an acute episode or a change in condition and the DON replied yes. When asked what the facility's policy stated about documentation on acute episodes or changes in conditions the DON informed, they did not have a policy on documentation of acute episodes or changes in the residents' conditions. The Administrator was notified of Immediate Jeopardy on [DATE] at 3:55 PM. The facility provided the following Immediate Jeopardy removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Resident #1 was admitted to the facility on [DATE] with diagnosis brain damage, dysphagia, hypertension, and gastrostomy. On [DATE] the physician ordered Resident #1 to have a urology appointment as soon as possible due to ultrasound of scrotum showing possible decreased vascular flow to the left testicle. A urology appointment was scheduled for [DATE]. Nursing staff failed to document on-going thorough assessments to include Resident #1's scrotum once the swelling was identified. On [DATE] Resident #1 had a change of condition noted with a blood pressure of ,d+[DATE] and weakness. Resident #1 was sent to the emergency room and was diagnosed with severe septic shock, urinary tract infection and aspiration pneumonia. Necrotic changes were found to the left testicle and removal of the testicle was performed. All residents residing in the facility have the potential to be affected by the deficient practice. On [DATE] the Director of Nursing and MDS Nurse Coordinator reviewed 30 days of vital signs and progress notes for all current residents to identify if there was a change in condition. If acute changes were identified, monitoring and assessments were reviewed for proper documentation. Physician and Nurse Practitioner orders including consultations, laboratory tests and x-rays were reviewed. Any issues were addressed upon identification by the Director of Nursing, MDS Nurse Coordinator and Regional Nurse Consultant. 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 [DATE] the Director of Nursing and Regional Nurse Consultant educated both in person and via phone the nursing staff to include nurses and nurse aides including agency staff. Verbal understanding was demonstrated by conversation and return of information. Education included when they recognize a resident with a change of condition nurse aides are to notify the nurse immediately. This is to include the definition of change in conditions. A change of condition was explained as changes from the resident's baseline, lethargy, confusion, increase/decrease vital signs, behaviors, skin issues, shortness of breath, swelling. Nurses were educated on completing and documenting their thorough assessment after a change has been noted. The MDS Coordinator will open a user defined assessment (UDA) which will flag in the resident's electronic medical record for the nurses to complete every shift on residents requiring on-going monitoring. The MDS Coordinator will be made aware of the need to open the UDA during daily stand-up and stand-down meetings. The Interdisciplinary Team will determine who needs the UDA opened based on the change of condition. The MDS Coordinator was made aware of this responsibility on [DATE]. This assessment will be left open until the IDT team resolves the issue. The need for monitoring will remain on the 24-hour report until resolved by the IDT team during the daily stand up and stand down meeting. Residents who are identified with changes in condition requiring on-going thorough assessments will be documented on every shift until resolved. The 24-hour summary will continue to be used for nurses to pass along information to the oncoming shift. Nurses were educated on changes in condition needing continuous monitoring to be reported to the oncoming nurse at shift change and placed on the 24-hour report. The 24-hour report communication will also be used for nurses to be aware of residents that require more than routine assessments. Nurses will notify their nurse aides at the beginning of the shift of the need to monitor said residents for changes and the frequency of the monitoring. Any change in condition needs to be documented in the medical record as well as physician notification and any new orders. On [DATE] the Director of Nursing was made aware that it was her responsibility to ensure staff members have the education prior to working their next scheduled shift and that she is to track this education. The Director of Nursing is responsible for ensuring any staff that have not been educated will be prior to their next shift. The Director of Nursing was notified of this responsibility on [DATE]. Effective immediately this education will be added to the new hire orientation and the Director of Nursing will educate newly hired staff. Education completed [DATE]. On [DATE] the Regional Nurse Consultant educated the Director of Nursing on completing a comprehensive clinical meeting. This meeting is attended by the Director of Nursing, Wound Nurse, Director of Therapy and Social Worker daily Monday through Friday immediately following 9 a.m. stand up meeting. This meeting will consist of reviewing physician orders, labs, x-rays and consultations to ensure that these items are followed up as needed. The DON is responsible for the gathering of this information. The Director of Nursing, Wound Nurse, Director of Therapy and Social Worker were made aware of these responsibilities on [DATE]. Effective [DATE] the Administrator will be ultimately responsible for ensuring implementation of this immediate jeopardy removal. Alleged Date of IJ Removal: [DATE] An onsite validation of the immediate jeopardy removal plan was conducted on [DATE]. Thirty days of residents' vital signs and progress notes were reviewed to identify if there were changes in conditions and if the changes were identified, monitoring and assessments were reviewed for proper documentation. Physician and Nurse Practitioner's orders such as lab tests and x-ray orders were reviewed as well, and any issues were addressed. All nursing staff including nurse aides were educated about reporting any changes in the residents' conditions related to anything from their baseline and informed to report changes. The Administrative staff will be responsible for setting up the assessments and responsible for monitoring the documentation until resolution. The changes will be discussed and monitored in the morning clinical meetings. The nursing staff will not be allowed to work until they have been educated on the new procedures and were expected to voice their understanding of the new procedures. The immediate jeopardy removal date of [DATE] was validated.

Based on record reviews, and staff, Nurse Practitioner, and Medical Doctor interviews the facility failed to notify the Nurse Practitioner or the Medical Doctor when a Urology Consult was not able to be scheduled per the Nurse Practitioner's order after a CT (computed tomography) scan noted decreased vascular flow to Resident #1's left testicle. Resident #1 experienced serious adverse outcome after an acute change in condition was noted on 03/11/24 and was transferred to the hospital emergency department (ED), diagnosed with severe sepsis and underwent a left orchiectomy (removal of the testicle) on 3/12/24. This practice affected 1 of 3 residents (Resident #1) reviewed for notification. Immediate Jeopardy began on 02/23/24 when the facility failed to notify a medical provider that they were not able to schedule a urology consultation per the Nurse Practitioner's order for as soon as possible. Immediate jeopardy was removed on 04/05/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure the completion of education and monitoring system are in place. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included anoxic brain injury, persistent vegetative state and neurogenic bladder. An interview was conducted with the Nurse Practitioner (NP) on 04/01/24 at 5:00 PM, 04/02/24 at 1:00 PM and 04/04/24 at 2:05 PM. The NP explained that she was notified of Resident #1's scrotal swelling on 02/14/24 and assessed his scrotum to be swollen to approximately the size of a softball with a little redness. The NP stated she offered to the family member to send the Resident to the local ED, but the family member did not want the Resident to go to the ED but wanted him treated at the facility. The NP stated she ordered an ultrasound to be performed on the scrotum immediately and antibiotics to be administered twice a day for 10 days. She reported the ultrasound was completed on 02/15/24 and she learned the results of the ultrasound on 02/19/24 when she went to the facility for rounds. The ultrasound showed decreased vascular flow to the left testicle, and she felt that Resident #1 needed a urology consult as soon as possible because anytime you have decreased vascular flow you need to get scooting, so she wrote the ordered for the urology consult as soon as possible that day on 02/19/24. She stated she assessed the Resident's scrotum on 02/19/24 and 02/28/24 and there was no change in the scrotum since the first time she assessed the scrotum on 02/14/24. She stated the facility needed to monitor the scrotum closely for changes and they could send him to the ED for any changes if need be. At the time of the interview the NP stated that she was not aware that the facility was having a difficult time getting a urology consult scheduled for Resident #1 and assumed the appointment had been made. She also stated she was not aware that Resident #1's urology consult was scheduled for 03/27/24 and explained that was too long away. She stated she could see maybe being scheduled for 2 weeks out from when it was ordered but 5 to 6 weeks away was too long. On 04/01/24 at 11:40 AM an interview was conducted with the Scheduler who explained that she was working on the hall as a nurse aide on 02/19/24 when she was given the order for Resident #1 to have a urology consult as soon as possible from the Staff Development Coordinator. She explained that as soon as possible meant it needed to schedule with high priority like then and there, but she was on the hall and knew she would have to follow up the next day. When she was able to follow up, she called a urology office that told her to fax over the information on Resident #1 and they would get back to her. She stated she waited several days, and they never followed up with her so when she was able to get back in touch with the urology office, they told her there was a mix-up in their records and they needed more information. The Scheduler stated that by that time it was about 03/03/24 or 03/04/24 so she decided to try to get Resident #1 a urology appointment at a local urology clinic and on 03/08/24 she was able to schedule a urology appointment for the Resident for 05/22/24. The Scheduler stated she kept that appointment and tried another clinic 03/08/24 and was able to schedule a urology appointment for the Resident for 03/27/24. The Scheduler stated she did not inform anyone that she was having difficulties with scheduling Resident #1 for a urology appointment because she thought she could manage it but now she knew different. During an interview with the Staff Development Coordinator (SDC) on 04/02/24 at 10:35 AM revealed that on 02/19/24 she put the order in Resident #1's electronic medical record for a urology consultation as soon as possible that was written by the NP on 02/19/24. She stated her routine was to make 2 copies of the orders and she kept one for herself and gave the other order to the Scheduler on 02/19/24 to make an appointment for the Resident. The SDC explained that she always highlighted the area of the order for the consultation and pointed it out to the Scheduler when she gave it to her on 02/19/24. If the Scheduler had any questions about the order, then she would get back to her, but the SDC stated she did not recall that the Scheduler had any questions about the order. The SDC stated that she did not know if the urology consultation was ever made because she did not follow up with the order. An interview was conducted with Nurse #1 on 04/01/24 at 3:00 PM who confirmed she was the Nurse on duty on 03/11/24 and sent Resident #1 to the emergency department. Nurse #1 continued to explain that Resident #1 seemed quieter than normal during her shift, and she did not have any trouble flushing his catheter and his feeding tube was patent and she took the Resident's blood pressure several times throughout the shift that fluctuated. She stated the third time she took his blood pressure it was 86/42 and that was lower than it had been all day and he seemed weaker, and she felt at that time that he was septic. The Nurse explained that she called the Nurse Practitioner and got an order to send Resident #1 to the emergency department. Review of Resident #1 progress notes from the local hospital ED dated 03/11/24 at 4:15 PM revealed the Resident presented with an oxygenation saturation of 89% and blood pressure of 73/46 with an additional reading of 70/39 during his limited stay at the local hospital. Abnormal labs included an elevated white blood cell (WBC) of 11.08 (normal range 4.80-10.80) and a blood urea nitrogen (BUN) of 107 (normal range 7-10) and Urine culture with greater than 100,000 CFU/ML (greater than 100,000 CFU/ML would indicate infection) gram negative bacilli (bacteria). Resident #1 was administered three liters of intravenous fluids and started on two different intravenous antibiotics. After consultation with internal and external providers it was decided Resident #1 would need to be transferred to a hospital with a higher level of care capabilities due to Resident #1's condition, the need for a bed in the intensive care unit and the specialty of an intensivist (physician who provides special care for critically ill patients) and infectious disease. The progress note described Resident #1's specific medical risks of worsening pneumonia, sepsis or death. Resident #1 had to be air lifted to the secondary hospital. There was no documentation in the ED progress notes about Resident #1's scrotum. discharge date and time was 03/11/23 at 11:14 PM with discharge diagnoses of dehydration, facility acquired pneumonia and kidney stone in the right ureter. Attempts to interview the local emergency department physician were unsuccessful. A review of Resident #1's progress notes dated 03/12/24 at 2:18 AM from the second hospital revealed he had a continuous medication infusing via intravenous access to improve his blood pressure which was effective. It was noted that he had received 3 liters of intravenous and the two antibiotics ordered at the previous hospital would be continued. The Resident was admitted with diagnosis of severe septic shock secondary to urinary tract infection, dehydration, aspiration pneumonia and right stone in ureter with hydronephrosis. A urology consultation was obtained on the morning 03/12/24 and orders were received for ultrasounds of the kidneys and testicles to be completed. The urology consultation revealed Resident #1 had a history of left testicular swelling and pain for one month with a previous ultrasound demonstration of decreased vascular flow to the left testicle. The ultrasound of the left testicle completed on 03/12/24 demonstrated no blood flow with surrounding necrotic changes consistent with the left testicle. On 03/12/24 an emergency stent was placed in the right ureter and a left orchiectomy (removal of the left testicle) was performed. An interview was conducted with the Medical Doctor (MD) on 04/01/24 at 4:30 PM. The MD explained he reviewed Resident #1's ultrasound done on 02/15/24 and noted that the Nurse Practitioner wrote an order to have a urology consultation as soon as possible, so it should have been done right away. He stated the facility should have let them know if they were having difficulty obtaining a urology consult because it was possible that he could have intervened and arranged for the Resident to be seen sooner to avoid the outcome of the orchiectomy. During an interview with the Director of Nursing (DON) on 04/02/24 at 9:00 AM the DON stated the Staff Development Coordinator at the time was the one who wrote the order for the urology consultation for Resident #1 so it would have been her responsibility to follow up with the Scheduler to make sure she made the appointment. She stated they normally discussed the new orders in the morning clinical meeting but the morning they would have discussed the order was when the state was in the building, and they did not have the morning meeting. The DON stated she did not know who the Scheduler's contact person was in house to go to if she was having scheduling problems but regardless the DON stated the Scheduler should have let someone in management know that she was having difficulty scheduling the urology appointment. An interview was conducted with the Administrator on 04/02/24 at 10:40 AM and 04/03/24 at 2:00 PM who explained that that the facility discussed physician orders in the clinical meeting which was held in the morning after a general meeting with all the managers. The Administrator stated she knew Resident #1 had an order for a urology consult but she did not know that he had a problem with his testicle. She reported the Scheduler received training from the previous Scheduler, but she could not say what the training entailed just that it was completed. She indicated, if need be, the Scheduler could have reached out to the previous Scheduler for instruction and at the least she could have notified the DON of difficulties in making the urology appointment for Resident #1. The Administrator indicated that the Physician should have been notified if they were having difficulty in scheduling a urology appointment. The Administrator was notified of Immediate Jeopardy on 04/03/24 at 3:55 PM. The facility provided the following Immediate Jeopardy removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as the result of noncompliance. On 2/19/21 the Nurse Practitioner wrote an order for Resident #1 to have a urology appointment as soon as possible due to ultrasound of scrotum showing possible decreased vascular flow to left testicle. The facility transport scheduler scheduled the urology appointment for 3/27/24. The facility did not contact the nurse practitioner to notify her of the date of the appointment. On 3/11/24 Resident #1 experienced an acute change in condition with a blood pressure of 86/42 and weakness. Resident #1 was sent to the emergency department where he was diagnosed with severe septic shock, urinary tract infection and aspiration pneumonia. The left testicle was found to have no blood flow with necrotic changes to the left testicle and removal of the testicle had to be performed. On 4/3/24 and 4/4/24 the Nurse Managers reviewed residents who have change of condition during the last 30 days using 24-hour reports, x-rays, lab tests and vital signs. These items were reviewed for indicators of a change such as not at baseline, not normal for resident, lethargic, shortness of breath, new onset pain, out of range results, etc. Falls with major injuries for the last 30 days were reviewed. This audit included notification to the physician or nurse practitioner. Any opportunities identified during this audit will be corrected by the Nurse Managers by 4/4/24. On 4/3/24 the Administrator did an audit of all consult orders for all residents in the last 90 days. This information was pulled from the orders in the electronic health record. Any issues identified were addressed immediately by the Interdisciplinary Team. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: The Director of Nursing and The Regional Nurse Consultant educated all nurses, including agency, regarding the requirements for notification to the Physician or Nurse Practitioner following a change of condition. Verbal education was given on a change of condition is noted when a resident presents different than known baseline, lethargic, restless or short of breath. Furthermore, education was provided on how to use the on-call MD system after hours and on weekends. Hall nurses are responsible for retrieving faxed x-ray and lab results from the fax machine which is located at the nurse's station. Critical lab and x-ray results are called to the on-call provider at that time they are received. All other lab and x-ray results are to be placed in the communication book for physician/nurse practitioner follow up. The Director of Nursing will ensure no staff will work without receiving this education. Any new hires, including agency staff, will receive education prior to the start of their shift. This education was provided both in person and via telephone. Verbal understanding was demonstrated by conversation and return of information. Education will be completed by 4/4/24. On 4/3/24 the Director of Nursing was made aware that it was her responsibility to educate staff members prior to working their next scheduled shift and that she is to track this education. On 4/4/24 the Administrator educated the resident transport scheduler on notifying the Director of Nursing so that she can notify the physician and nurse practitioner when orders for consultation appointments cannot be scheduled per the physician or nurse practitioner orders. The Director of Nursing (DON) was notified of this responsibility on 4/4/24. In the event the DON is not in the building, the transport scheduler will notify the MDS Coordinator who will notify the physician or nurse practitioner. The MDS Coordinator was made aware of this responsibility 4/4/24. Newly hired transport schedulers will be educated in orientation. Effective 4/3/24 the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: 4/5/24 An onsite validation of the immediate jeopardy removal plan was conducted on 04/8/24. Residents' information including vital signs, orders, assessments and incidences for the last 30 days were reviewed to identify if the providers had been notified of changes in condition. Specific orders for consultations were reviewed and all issues were corrected when identified. All nursing staff were educated on the new system of notification and ensured the nurses knew how to contact the on call provider when necessary. Return demonstration of understanding the system was ensured. All new nurses will be educated on the system upon hire. The Scheduler was educated to inform the DON when she was having trouble making appointments for consultations ordered by the providers. The immediate jeopardy removal date of 04/05/24 was validated.

Based on observations, record review, resident, staff, and Psychiatric Nurse Practitioner interviews the facility failed to protect a resident's right to be free from abuse or mistreatment when Resident #11's arms were pinned between Nurse Aide (NA) #10 and the resident during incontinence care when Resident #11 became combative. On [DATE] during incontinence care Resident #11 became combative with staff and attempted to pinch, scratch, and bite the staff. When Resident #11 was turned on her side facing NA #10, NA #10 pinned Resident #11's arms and hands between the NA and Resident to prevent Resident #11 from pinching and scratching the staff and so they could finish the incontinence care. Resident #11 was noted to have bruises to bilateral hands and lower arms. This was for 1 of 1 resident reviewed for resident to staff abuse. The facility also failed to protect a female resident (Resident #1) from sexual abuse from a male resident (Resident #2) on [DATE] when Resident #2 entered Resident #1's room and touched her breast and vaginal area (outside of her clothes). NA #1 asked Resident #2 to stop touching Resident #1 and then left Resident #1 alone and unsupervised with Resident #2 while she went to report the sexual abuse to Nurse #1. Nurse #1 failed to notify the Administrator of the sexual abuse. Then on [DATE] Resident #2 again entered Resident #1's room and tried to touch and kiss her. Resident #1 did not want Resident #2 touching or kissing her. This affected 1 of 3 residents reviewed for resident-to-resident abuse. The facility further failed to prevent a resident (Resident #9) from being neglected on [DATE] when he experienced an acute change in condition. NA #3 described the change in condition as restless, pale in color, struggling to breathe, and a change in urinary continence. NA #4 described the change as restless and up and down all night. Resident #9 requested and attempted to call Emergency Medical Services (EMS) and Nurse #2 removed the phone from Resident #9 and took it off the wall. Nurse #2 neglected to call or seek medical assistance for 1 of 1 resident reviewed for neglect (Resident #9). Resident #9 was found slumped over in his wheelchair in cardiac arrest. Resident #9 expired in the facility on [DATE]. Immediate jeopardy began on [DATE] when Resident #11's arms were pinned down by NA #10 during incontinent care. Immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity E (no actual harm with more than minimal harm that is not immediate jeopardy to ensuring monitoring systems are in place and the completion of staff education. The findings included: 1. Resident #11 was admitted to the facility on [DATE] with diagnoses that included cerebral vascular accident, diabetes mellitus and dementia. A review of Resident #11's care plan initiated [DATE] revealed the Resident required assistance with her activities of daily living (ADL) related to left hemiparesis and mood symptoms. The goal indicated her needs would be anticipated and met through encouraging her to participate in the activity to her fullest capacity, provide the amount of assistance required to complete the task and promptly answering call light. Further review of the Resident's care plan dated [DATE] revealed Resident #11 exhibited verbal/manipulative behaviors by making false accusations about staff, continuously ringing call light for attention and conversation, periods of refusing care and being combative with staff, behaviors of pinching her arms causing abrasions and skin tears and will call staff names and hit staff while providing care. The goal that the Resident will seek care giver support when feeling frustrated would be attained by encouraging her to be changed and if refused report to nurse and return to provide care later, explain the procedure for care task before starting and allowing the Resident to express her feelings. A review of Resident #11's skin assessment dated [DATE] revealed there were no skin issues documented. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #11 was severely cognitively impaired and had no behaviors during the assessment reference period. Review of the Initial Allegation Report for resident abuse dated [DATE] revealed the Administrator was notified during the morning meeting that Resident #11 had new discolorations to her right and left arms. Nurse Aide (NA) #9 was listed as the accused individual. The report was signed by the Administrator. A review of the Investigation Report for resident abuse dated [DATE] revealed the accused individual was NA #9 with NA #10 and NA #11 witnessing the incident. The report summary read the Administrator interviewed staff and statements indicated that 3 staff members, NA #9, NA #10 and NA #11, were attending to Resident #11 while the Resident was attempting to hit, bite and scratch the staff while they were attempting to change her. NA #9 indicated that she did not hold the Resident's hands or arms during her interaction with the Resident. NA #10 indicated that she did hold the Resident's hands together so that the staff could finish changing the Resident without being injured. All the staff's statements were consistent indicating that Resident #11 was being combative with staff and swinging her bed remote. The incident resulted in physical injury of discolorations to the Resident's left and right forearms. The incident was substantiated. The summary of the investigation found that staff did hold down the Resident's arms to keep her from hitting and scratching them. During an observation and interview with Resident #11 on [DATE] at 10:10 AM the Resident was alert and talkative while lying in bed, well-groomed and without body odors. The Resident held the bed remote in her right hand which was resting next to her on the bed as was the call light and her cell phone. Resident #11 explained that she vaguely remembered the incident when two girls, she could not remember who they were, held her hands down and caused bruises on her hands but could not remember when it was or any details about it. She stated she thought it was just a big misunderstanding. There were no bruises or skin tears noted on the Resident's arms or hands. During an interview with NA #9 on [DATE] at 9:40 PM the NA explained that during that night in question she was asked to assist NA #11 with Resident #11 because the Resident can be combative so they must have 2 staff members to go into the Resident's room to render care. The NA stated Resident #11 was soiled from top to bottom and desperately needed to be changed and she agreed to let them change her. When NA #11 started to pull her covers down Resident #11 picked up her bed remote and hit NA #11 on her hand which made a loud thud. She stated they stopped and called Nurse #7 into the Resident's room and the Nurse tried to talk her into letting the NAs change her, but the Resident still refused care. They ended up not being able to provide care. The NA stated, later the Resident reported that staff hit her, even though the Resident #11 already had bruising on her left hand that was verified by Nurse #7. An interview was conducted with NA #10 on [DATE] at 7:52 PM revealed the NA assisted NA #11 who was assigned to Resident 11 during the night of [DATE] to [DATE], when the Resident refused to be changed for hours and was soaked and soiled with urine and stool. NA #10 stated that by the time Resident #11 allowed them to change her she required a full bed change along with her soiled brief and gown. The NA explained that when they were halfway finished with the task Resident #11 started pinching, scratching, and attempting to bite them. When they rolled Resident #11 onto her side facing NA #10, NA #10 indicated that she had to pin Resident #11's arms between their (Resident #11 and NA #10) bodies so they could finish care and prevent her from scratching. The NA was insistent that she did not touch the Resident's hands that if the Resident was bruised then the bruising was present before they went into her room to provide care. The NA stated that she positioned Resident #11 the way that she had been taught by the Nurse Educator when the staff had to care for combative residents. On [DATE] at 8:15 AM during an interview with NA #11 the NA explained that she was assigned to Resident #11 on [DATE] and that they attempted to change Resident #11 multiple times during the 12-hour shift, and multiple times she refused. She stated by the early morning you could literally smell the strong urine and bowel movement odor in the hallway and when she did allow them to change her the Resident required a brief change complete with her gown and bed sheets. NA #11 reported that Nurse #7 came into the Resident's room and asked the Resident not to pick at a sore on her hand because she had it bleeding but the Resident continued to pick at the sore. NA #11 explained NA #10 assisted her with the Resident's incontinence care and halfway through the process the Resident began to scratch, pinch and attempted to bite them while swinging the bed remote at them. She continued to explain when they turned the Resident towards NA #10 the NA had to lay the Resident's arms down and lean over her to prevent the Resident from scratching them and to finish changing her, but NA #10 never held the Resident's hands down. The NA stated she did not notice any bruising on Resident #11's hands or arms because if she had, she would have reported it. An interview was conducted with Nurse #7 on [DATE] at 8:40 PM who explained that she worked with Resident #11 often during the evening shifts and was on duty on [DATE] to the morning of [DATE]. The Nurse reported that Resident #11 already had bruises to her arms and hands before that evening shift because the Resident had pulled a band aid off her left arm earlier in the shift and was picking at the skin tear and had it bleeding with blood on her bed and I asked her several times that night not to pick at the skin tear that she was making it worse, but she continued to pick at the skin tear. She stated the Resident had bruise's on her arms as well, but she did not report the bruising, nor did she document the bruising because she always had bruising. That night Resident #11 had refused to be changed multiple times but at one point she agreed to be changed so all three NAs went in there to change her because they did not allow one aide to provide care for Resident #11 because of her behaviors. During an interview with Nurse #6 on [DATE] at 8:56 PM the Nurse confirmed she was on duty the night of [DATE] to [DATE] and assisted Nurse #7 in attending to Resident #11. Nurse #6 stated she did not remember or know about any bruising on Resident #11, but she knew that Nurse #7 had walked in on the Resident picking at a sore on her arm and had it bleeding. The Nurse reported that Resident #11 had refused care multiple times even after calling out for it several times that night. She stated she had instructed the NAs not to go into the Resident's room by themselves to provide care because of Resident #11's combative behaviors and false accusations toward the staff and she felt that was best for everyone's protection. Nurse #6 stated that she was not aware of any accusations made by Resident #11 against any of the NAs that worked that night until she came back on duty and learned that NA #10 was suspended because she crossed the Resident's arms in order to roll her over to provide care and NA #9 and Nurse #7 were in the room at the time. An interview was conducted with the Unit Manager (UM) on [DATE] at 1:50 PM who explained that she did not know any details about an incident with Resident #11 and NAs #9, #10 and #11 on the night of [DATE] to [DATE] except that she was asked by the Administrator on [DATE] to complete a skin assessment on Resident #11 that showed bruising on one of her hands, but she couldn't remember which hand. The UM stated Resident #11 told her that they held her hands down to change her but did not explain who they were. During an interview with NA #7 on [DATE] at 2:25 PM the NA explained that on the morning of [DATE] she overheard some aides talking about how Resident #11 had hit NA #9 with her bed remote and they took it from her. She stated when she went to see the Resident right after she overheard the conversation, the Resident had bruising on both hands, near her elbow and a skin tear which had steri strips on her hand that had dried blood on it that looked like it had already been tended to it. The NA stated the bruising was not there the Tuesday prior because she dried her hair, and it wasn't there. On [DATE] at 8:00PM during an interview with the Activity Assistant she explained that she visited Resident #11 on the morning of [DATE] and noticed the bruising and skin tears on the Resident's arms and hands. She stated the Resident told her that they held her hands down when they were changing her last night. The Activity Assistant continued to explain that she asked the NA (don't remember who it was) on the hall what happened, the NA told her that Resident #11 was trying to hit and bite the NAs on the night shift while they were changing her and they had to hold her hands down, with their hands flat on top of her hands to prevent the Resident from being combative while they changed her. An interview was conducted with the Nurse Educator on [DATE] at 9:00 PM who explained that she only educated the staff after the events that occurred, and she had educated the staff not to provide care for Resident #11 alone, always have at least 2 staff when providing her care because of the Resident's potential to be combative. During an interview with the former Director of Nursing (DON) on [DATE] at 2:55 PM the DON reported he was the acting DON from January through most of February 2023. The DON explained that he remembered Resident #11 in that she frequently accused the staff of being abusive to her and they were afraid to go into her room to provide care for her, so I had them go in with at least 2 people and to document the care provided. The Resident liked to use her call light and bed remote as a [NAME] and swing at them, threatening to hit them. An interview was conducted with the Administrator on [DATE] at 10:45 AM who explained that the staff (he could not remember who) informed him in the morning meeting on [DATE] that Resident #11 had bruise's on her arms and to his knowledge there had been no reports of bruising reported on the Resident before that day. The Administrator stated the Nurse Educator informed him that she had taught the staff to cross the residents' arms in front of them in order to make turning and repositioning easier for the residents but not intending to hurt them. The Administrator continued to explain that he interviewed Resident #11 on [DATE] and did not see any bruising nor did he document it in his statement that he did or did not observe any bruising. He stated the Resident reported to him that a large aide, NA #9 held her hands down during care which caused the bruising on her hands and NA #11 was present at the time. He reported that they collected written statements from the NAs involved which were NA #9 who denied holding the Resident's hands down, NA #10 who admitted to holding the Resident's hands down and NA #11 who denied holding the Resident's hands down. The Administrator was notified of the immediate jeopardy on [DATE] at 4:49 PM. The facility provide the following IJ removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. At approximately 9:00 am on [DATE] the Administrator was notified that Resident #11 had new discolorations to her right and left arms. The Administrator and Infection Preventionist entered the room to interview Resident #11 to gather information on the new discolorations to her arms. Resident #11 stated that a large black woman held her down last night causing the discolorations. The Administrator asked what led up to the event, Resident #11 stated she could not recall. The Administrator asked when the event occurred, Resident #11 stated last night. The Administrator asked Resident #11 to describe the event, Resident #11 stated it happened during the time the nursing aides attempted to change me and the nurse aide put her hands together. Resident #11 then stated it was a large nurse aide who held her down. Facility staff interviewed the staff working the hall from the previous night shift, interviews indicate that Resident #11 was combative with staff who attempted to change her clothing and bedding that were soiled. The Administrator collected written statements from the NAs that were involved in the allegation. NA #11 was present during the care and denied holding the residents' hands down. NA #9 denied holding the residents' hands down while providing care. NA #10 stated the resident was combative while providing care and she held the residents' hands together to avoid being injured. On [DATE] Nurse Aide #1 entered Resident #1 room and witnessed Resident #2 touching Resident #1 breast and vagina through her clothing. Nurse Aide #1 asked Resident #2 to stop touching Resident #1 and he did immediately. Nurse Aide #1 went and reported to Nurse #1. Resident #1 reported that Resident #2 entered Resident #1's room again on [DATE] and tried to touch and kiss her. Resident #1 was sent to the Emergency Department on [DATE] for evaluation and returned to the facility. Resident #1 was seen and will continue to be seen by psych services. Resident #2 no longer resides in the facility. All residents have the potential to be involved in resident-to-resident abuse but residents with cognitive impairment, dependent transfer statuses and such are more vulnerable to such situations. On [DATE] the Social Worker and Administrator conducted interviews with alert and oriented residents having a BIMs of 12 or greater to ensure there were no other reportable incidents. On [DATE] the Director of Nursing, Assistant Director of Nursing and Unit Manager completed skin assessments on residents that are not alert and oriented. There were no concerns identified. 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: Initial education was completed on [DATE] with staff regarding identifying abuse. On [DATE] the Director of Nursing and Assistant Director of Nursing educated current staff in all departments on Abuse. Education included verbal abuse, sexual abuse, physical abuse, mental abuse, neglect, involuntary seclusion, exploitation, misappropriation of resident property, resident to resident abuse and mistreatment. Staff were educated on identifying any changes in behavior or patterns that may be indicative of resident-to-resident abuse. Staff in all departments were educated that if they identify changes in behavior, they should monitor the resident while reporting the concern to their supervisor and additional monitoring will be put into place. The staff and residents with Bims of 12 and greater were informed by the Director of Nursing, Assistant Director of Nursing or the Regional Nurse Consultant on [DATE] in one-to-one verbal communication that abuse of any type would not be tolerated in this facility. For the residents with a BIMs of 11 or less the RP was contacted with the same education. The Director of Nursing and Administrator will ensure that staff members, to include agency staff, that have not received the education will not be able to work until they have received this education. In the event abuse is witnessed the staff member should stay with the resident providing protection from the abuse. Furthermore, staff were educated to remain with the resident when they are alleging abuse on someone present. The Director of Nursing will provide education to newly hired staff, including agency during orientation. Education was given in a verbal and/or written format and the staff were asked to give feedback to confirm understanding of the education. Education was given in verbal format with written key points to include types of abuse provided. Effective [DATE], the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: [DATE] Validation of the immediate jeopardy removal plan was conducted in the facility on [DATE]. The interviews with alert and oriented residents were reviewed with no additional concerns noted. The skin assessment of non-alert and oriented residents were reviewed with no additional concerns noted. The initial education from [DATE] was reviewed along with the education completed on [DATE] along with staff signature sheets to verify completion and understanding of the education. The education included the different types of abuse, how to stop the abuse, how/when to report abuse or suspected abuse, and the importance of immediately notifying the Administrator of any suspected or witnessed abuse. The abuse education was verified to be included in the new hire orientation information for any newly hired staff. Interviews with staff across all departments in the facility revealed they were able to verbalize the abuse policy and procedure. They were able to verbalize the education points of stopping the abuse and immediately protecting the residents and reporting the suspected or witnessed abuse to the facility Administrator. The facility's IJ removal date of [DATE] was validated. 2. Resident #1 was admitted to the facility on [DATE]. Review of the significant change Minimum Data Set (MDS) dated [DATE] revealed that Resident #1 had clear speech and was able to make her needs known and was able to understand others. Resident #1 was moderately cognitively impaired and required limited to extensive assistance with activities of daily living. Resident #2 was admitted to the facility on [DATE] with diagnoses that included anxiety, major depressive disorder, vascular dementia, and others. Review of a care plan for Resident #2 initiated on [DATE] read Resident #2 tends to exhibit sexually inappropriate behavior towards staff members. The goal read, Resident #2 will verbalize an increased understanding and demonstration of control of sexually inappropriate behaviors. The interventions included: monitor medications for potential contribution to sexually inappropriate behaviors, monitor laboratory test results and report abnormal results to physician, evaluate need for behavioral health consult, when sexually inappropriate behaviors occur, approach Resident #2 in a calm, unhurried manner, reassure as necessary, if Resident #2 becomes combative or resistive postpone care/activity and allow time for him to regain composure, provide privacy as needed, allow time for expression of feelings, divert Resident #2 by giving alternate objects or activities, listen and try to calm resident, and remove Resident #2 from environment. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #2 was moderately cognitively impaired, had no delirium, no behaviors, rejection of care, or wandering during the assessment reference period. Resident #2 required limited to extensive assistance with activities of daily living and used a wheelchair for mobility. Review of a facility incident report dated [DATE] read, Resident #1 reported that Resident #2 came into her room and started holding her hand and kissing her hand, then proceeded to touch her breast on top of her clothing and under her clothing, then tried to touch her vaginal area. Resident #1 stated that she asked Resident #2 to stop, and he did. Resident #1 was not sure of the exact date and time the incident occurred. Resident #1 was assessed for injuries, and none were noted. An investigation was initiated. Resident #2 was placed on one-on-one supervision. Resident #1 was sent to the Emergency Department (ED) for evaluation. The report was completed by the Director of Nursing (DON). Resident #2 was discharged home from the facility on [DATE]. Review of the facility's schedule for [DATE] revealed that Nurse Aide (NA) #1 was caring for Resident #1 and Nurse #1 was on the unit where Resident #1 resided. An observation and interview were conducted with Resident #1 on [DATE] at 10:23 AM. Resident #1 was resting in bed and was well groomed. She stated that she recalled the incident with Resident #2. She stated she did not know the date or time but stated she was in her room but could not recall if she was in bed or in her wheelchair and Resident #2 came in her room and touched me on my breast and tried to touch my vagina but I pushed his hand away. She explained that he touched her on top of her clothes, but she did not like to talk about it and stated she tried to block it from her memory because she did not like to think about what had happened to her. Resident #1 explained her spouse had recently passed away and she did not want another man touching her. She added that Resident #2 had never made an inappropriate gesture or passes toward her before but again she did not wish to talk about the incident anymore. Nurse Aide (NA) #1 was interviewed via phone on [DATE] at 2:33 PM who confirmed that she was caring for Resident #1 on [DATE]. She stated that evening Resident #1 was in her wheelchair in her room and Resident #2 who had been outside smoking entered Resident #1's room in his wheelchair. NA #1 stated that when she entered Resident #1's room, they were both in their wheelchair's facing each other and Resident #1 stated to her, please tell him to remove his hand from my twat, NA #1 stated that Resident #2's hand was on top of Resident #1's clothes in her vaginal area. NA #1 stated she very sternly asked Resident #2 to stop touching Resident #1 and he did. NA #1 stated that she then left the room with Resident #1 and Resident #2 still in their wheelchairs alone facing each other to go and alert Nurse #1 of what had occurred. As NA #1 was returning to Resident #1's room she passed Resident #2 in the hallway in his wheelchair returning to his room on the same unit. NA #1 stated that both Resident #1 and Resident #2 were alert and oriented and aware of what was going on, and Resident #1 was very clear that she did not want Resident #2 touching her, she further explained Resident #1 was not sad or tearful but appeared like her usual self. NA #1 stated that at the end of her shift she had reported what had occurred to NA #7 and followed up with Nurse #1 about if she had documented what had occurred. NA #1 stated that Nurse #1 stated she had not documented anything regarding the incident because she felt it was consensual. NA #1 stated that she did not think anything about leaving Resident #1 and Resident #2 in the room together while she went to report to Nurse #1 because he instantly removed his hand from her when I asked him to. She added that she assumed Nurse #1 had taken care of what she needed to regarding the incident. Attempts to speak to Nurse #1 were made on [DATE] at 11:12 AM and were unsuccessful. A statement provided by Nurse #1 dated [DATE] at 5:00 AM read on Sunday night [DATE] during medication pass, staff reported to this writer of witnessing Resident #2 in Resident #1's room and had his hand in Resident #1's brief while both residents were sitting in wheelchairs in the room. This Nurse asked Resident #1 about the incident, and she replied, so this is my p***y, and I can do what I want. Resident #1 used other foul language and reported to this writer that the incident was consensual between the two parties involved. NA #7 was interviewed via phone on [DATE] at 3:20 PM who confirmed that she cared for Resident #1 on [DATE] during the day shift. She stated that during report that morning NA #1 had told her about the incident that had occurred between Resident #1 and Resident #2 during the night. She reported that Resident #2 touched Resident #1 on the outside of her pants in her vaginal area and touched her breast and that she had reported the incident to Nurse #1. NA #7 stated that Resident #1 did not mention anything to her about the incident with Resident #2 during that shift and was her usual self. NA #7 stated that Resident #2 never had sexual behaviors toward other residents that she was aware of, but he did at times grab staff inappropriately. NA #5 was interviewed on [DATE] at 2:07 PM and confirmed that she was caring for Resident #1 on [DATE]. She stated that Resident #1 had turned her call light on and requested to get out of bed, she stated that she and NA #6 were going to assist Resident #1 with getting up. During the transfer NA #5 stated that Resident #1 had tears in her eyes and told her that Resident #2 had his hands down Resident #1's pants and had touched her breasts. NA #5 stated she left the room while NA #6 stayed with Resident #1 and went and told Nurse #4 what Resident #1 had reported. NA #5 was certain that Resident #1 was sad and had tears in her eyes when she told her what had happened, and it was very clear that Resident #1 did not want Resident #2 touching her. NA #5 stated that after they reported to Nurse #4, she, reported to the DON and Administrator, and they immediately began an investigation. She added that she had not seen Resident #2 touch another resident inappropriately, but he did have a foul mouth and would grab staff inappropriately from time to time. NA #5 stated that Resident #2 stayed in the building for a bit after this incident, but he was on one-to-one supervision until he discharged home. NA #6 was interviewed on [DATE] at 1:04 PM who confirmed that she was caring for Resident #1 on [DATE] during the day shift. She stated that Resident #1 had requested to get out of bed and she and NA #5 were assisting with the transfer. During the transfer Resident #1 stated that Resident #2 had touched her in places that he should not be touching her and Resident #1 was very clear she did not want Resident #2 touching her at all. NA #6 stated that Resident #1 stated that Resident #2 had touched her inside her pants and her breast area, and that NA #1 had gotten Resident #1 to stop and reported it to Nurse #1. NA #6 stated that when Resident #1 told her and NA #5 what had happened, they immediately reported it to Nurse #4 who told the DON and Administrator and they began an investigation. NA #6 stated she did not recall Resident #1 being tearful or sad, but she was very clear she did not want Resident #2 touching her. NA #6 stated that Resident #2 stayed in the building for a few weeks and was on one-to-one supervision until he discharged home. Nurse #4 was interviewed via phone on [DATE] at 11:52 AM who confirmed that she was caring for Resident #1 on [DATE]. She stated she had gotten report that morning from a nurse she could not recall but stated that there was nothing in report about the incident with Resident #1 and Resident #2. She stated that Resident #1 had requested to get out of bed by NA #5 and NA #6 and during the transfer Resident #1 was not acting like her usual self, she was very upset and not joking with them like she normally did. Resident #1 reported that Resident #2 had stuck his hands down her pants and touched her breast and NA #5 and #6 immediately came and reported to Nurse #4. Nurse #4 confirmed that she went and reported to the DON who asked that Resident #1 be sent to the ED for evaluation which she was and returned with no new orders. Nurse #4 explained that she had worked at the facility since [DATE] but was not familiar with Resident #2 or his history but the time she had worked with Resident #2 this type of inappropriate behavior was not his normal. Review of an ED note dated [DATE] read in part, patient presents to the emergency room after being referred from the nur [TRUNCATED]

Based on observations, record reviews, staff and resident interviews the facility failed to identify abuse, protect all residents from abuse, and report abuse to the state agency and local law enforcement and complete a thorough investigation that included staff interviews of bruising that was reported to have occurred during incontinence care for 1 of 3 residents (Resident #11) reviewed for abuse. On 02/16/23 Nurse Aide (NA) #10 pinned Resident #11's arms between their bodies when Resident #11 became combative during incontinent care. After the care Resident #11 was noted to have bruising to her bilateral lower arms. At the conclusion of the investigation the facility substantiated abuse but allowed NA #10 to return to work to care for other residents in the facility. The facility further failed to protect Resident #1 on 03/19/23 when Resident #2 entered Resident #1's room and touched her on her breast and vaginal area, the incident was witnessed by NA #1 who asked Resident #2 to stop touching Resident #1 then left Resident #1 and Resident #2 alone and unsupervised in the room while she went to report the sexual abuse to Nurse #1. Nurse #1 failed to report the sexual abuse to the Administrator on 03/19/23 which allowed a second incident of sexual abuse on 3/20/23 to occur. On 03/21/23 Resident #1 reported the sexual abuse that occurred on 03/19/23 to NA #5 and NA #6 who then reported the sexual abuse to the Director of Nursing (DON) and Administrator. The facility failed to thoroughly investigate the allegation of abuse to ensure all residents were assessed for sexual abuse. This affected 1 of 3 residents reviewed for resident-to-resident abuse (Resident #1). Immediate jeopardy began on 02/16/23 when the facility failed to identify, thoroughly investigate, report, and protect all residents from abuse after an allegation of staff to resident abuse. Immediate jeopardy was removed on 06/23/23 when the facility provided and implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity E (no actual harm with potential for harm) to ensure monitoring systems are in place and the completion of staff education. The finding included: A review of the facility's policy titled Abuse Prohibition revised 10/24/22 revealed: Centers prohibit abuse, mistreatment, misappropriation of property, exploitation and neglect. The Center will implement an abuse prohibition program through the following: investigation of incidences and allegations. 7. Immediately upon receiving information concerning a report of suspected or alleged abuse the administrator will perform the following: 7.7 Initiate an investigation within 24 hours of an allegation of abuse that focuses on: 7.7.1 whether abuse occurred and to what extent; 7.7.2 clinical examination of injuries; 7.7.3 causative factors. 7.8 The investigation will be thoroughly documented in Risk Management Portal. Ensure that documentation of witnessed interviews is included. Further review of the facility's policy read: a. A review of the facility's policy titled Abuse Prohibition revised 10/24/22 revealed: Centers prohibit abuse, mistreatment, misappropriation of property, exploitation, and neglect. 7. Immediately upon receiving information concerning a report of suspected or alleged abuse the administrator will perform the following: 7.2 report allegations to state and local authorities involving abuse (verbal, mental, physical, and sexual) no later than 2 hours after the allegation is made. 1. Resident #11 was admitted to the facility on [DATE] with diagnoses that included cerebral vascular accident, diabetes mellitus and dementia. A review of the Initial Allegation Report dated 02/16/23 indicated the facility became aware of the abuse incident of new discolorations on Resident #11's right and left arms at 9:00 AM on 02/16/23. The Report indicated local law enforcement was notified on 02/16/23 at 3:00 PM. A review of the facility Investigation Report dated 02/20/23 for Resident #11 abuse that occurred on 2/16/23 revealed the accused individual was Nurse Aide (NA) #9 with NA #10 and NA #11 witnessing the incident. The report summary read the Administrator interviewed staff and statements indicated that 3 staff members, NA #9, NA #10, and NA #11, were attending to Resident #11 and the Resident was attempting to hit, bite and scratch the staff while they were attempting to change her. NA #9 indicated that she did not hold the Resident's hands or arms during her interaction with Resident #11. NA #10 indicated that she did hold Resident #11's hands together so that the staff could finish changing the Resident without being injured. All the staff's statements were consistent indicating that Resident #11 was being combative with staff and swinging her bed remote. The incident resulted in physical injury of discolorations to the Resident 11's left and right forearms. The summary of the investigation found that NA #10 did hold down Resident 11's arms to keep her from hitting and scratching the staff and the incident was substantiated but NA #10 continued to work and provide care to the other residents. During an observation and interview with Resident #11 on 06/20/23 at 10:10 AM the Resident was alert and talkative while lying in bed. Resident #11 explained that she vaguely remembered the incident when two girls, she could not remember who they were, held her hands down and caused bruises on her hands but could not remember when it was or any details about it. She stated she thought it was just a big misunderstanding. During an interview with NA #9 on 06/20/23 at 9:40 PM the NA explained that she was still worked at the facility and worked a few nights a week. She continued to explain that on 2/16/23 she was asked to assist NA #11 with Resident #11 because the Resident could be combative so they must have 2 staff members to go into the Resident's room to provide care. NA #9 stated Resident #11 was soiled from top to bottom and needed to be changed and she agreed to let them change her. When NA #11 started to pull the Resident's sheet down Resident #11 picked up her bed remote and hit NA #11 on her hand which made a loud thud. She stated they stopped and called Nurse #7 into the Resident's room and the Nurse tried to talk the Resident into letting the NAs change her, but the Resident still refused care. They ended up not being able to provide care. The NA stated, later Resident #11 told other staff members (she could not recall who) that they hit her, but the Resident already had a bruise on her left hand. When NA #9 was asked if she was interviewed by anyone about the situation the NA stated that she had not been interviewed about the incident, but Nurse #6 asked her to write a statement about the events of 2/15/23 before she left the faciity on [DATE]. An interview conducted with NA #10 on 06/20/23 at 7:52 PM revealed she assisted NA #11 who was assigned to Resident #11 during the night of 02/15/23 to 02/16/23. NA #10 stated that by the time Resident #11 agreed to allow them to change her she required a full bed change along with her soiled brief and gown. NA #10 explained when they were halfway finished with providing care, Resident #11 started pinching and scratching them so when they rolled the Resident over to facing her, she crossed the Resident arms and extended them downward between her body and the Resident's body to prevent the Resident from scratching and biting. NA #10 was insistent that she did not touch Resident 11's hands and if the Resident was bruised then the bruising was present before they went into her room to provide care. NA #10 was asked if she was interviewed by anyone from the facility about the incident and she indicated, no one had spoken with her about the events of the night of 2/16/23 with Resident #11 or she would have demonstrated to them how she crossed the Resident's arms. She stated she was only asked by Nurse #6 to write a statement about the night of 2/16/23 before she left that morning. NA #10 reported she was suspended pending investigation then was allowed to go back to work but has not been assigned to Resident #11. The NA stated the last night she worked at the facility was Friday 06/16/23. On 06/22/23 at 8:15 AM during an interview with NA #11 she explained she still worked at the facility and the last night she worked was 06/21/23. The NA stated she was assigned to Resident #11 on 02/16/23 and that they attempted to change Resident #11 multiple times during the 12-hour shift, and multiple times she refused. She stated by the early morning you could literally smell the strong urine and fecal odor in the hallway and when the Resident did allow them to change her, Resident #11 required a brief change including her gown and bed sheets. NA #11 explained NA #10 assisted her with Resident 11's incontinence care and halfway during the process the Resident began to scratch, pinch and attempted to bite them while swinging the bed remote at them. She continued to explain when they turned Resident #11 toward NA #10 the NA had to lay the Resident's arms down and lean over her to prevent the Resident from scratching them and to finish changing her, but NA #10 never held the Resident's hands down. NA #11 stated she did not notice any bruising on Resident #11's hands or arms because if she had, she would have reported it. The NA stated no one from administration had interviewed her about the situation but she did write a statement as requested by Nurse #6 for her protection because it was common for Resident #11 to accuse the staff of doing things that they did not do. An interview was conducted with Nurse #7 on 06/20/23 at 8:40 PM who explained that she worked with Resident #11 often during the evening shifts and was on duty the night of 02/15/23 to the morning of 02/16/23. The Nurse reported that Resident #11 already had bruising to her arms and hands before that evening shift because the Resident had pulled a band aid off her left arm earlier in the shift and was picking at the skin tear and had it bleeding with blood on her bed and I asked her several times that night not to pick at the skin tear that she was making it worse, but she continued to pick at the skin tear. She stated the Resident had bruising on her arms as well, but she did not report the bruising because she always had bruising. The Nurse explained that night Resident #11 had refused to be changed multiple times but at one point she agreed to be changed so all three NAs went in there to change her mainly because they did not allow one aide to provide care for Resident #11 because of her behaviors. The Nurse stated she did not know anything about Resident #11's accusations toward the nurse aides during that shift until she came back to work her next scheduled shift and learned that NA #10 had been let off for several days. The Nurse stated no one from administration interviewed her about the nights events or she would have told them how Resident #11 acted and that the bruising on the Resident's arms and the skin tear was there when she started her shift the evening of 02/15/23. During an interview with Nurse #6 on 06/20/23 at 8:56 PM the Nurse confirmed she was on duty the night of 02/15/23 to 02/16/23 and assisted Nurse #7 in attending to Resident #11. Nurse #6 stated she did not remember or know about any bruising on Resident #11, but she knew that Nurse #7 had walked in on the Resident picking at a sore on her arm and had it bleeding. The Nurse reported that Resident #11 had refused care multiple times even after calling out to be changed several times that night. Nurse #6 stated she had instructed the NAs not to go into the Resident's room by themselves to provide care because of Resident #11's combative behaviors and false accusations toward the staff and she felt that was best for everyone's protection. Nurse #6 stated that she was not aware of any accusations made by Resident #11 against any of the NAs that worked that night until she came back on duty and learned that NA #10 was suspended because she crossed the Resident's arms in order to roll her over to provide care and NA #9 and Nurse #7 were in the room at the time. The Nurse stated she had the staff write statements about the night's events and gave them to the Nurse Educator but was never interviewed by administration about the events or she would have explained what happened during the shift. An interview was conducted with the Unit Manager (UM) on 06/20/23 at 1:50 PM who explained that she did not know any details about an incident with Resident #11 and NAs #9, #10 and #11 on the night of 02/15/23 to 02/16/23 except that she was asked by the Administrator on 02/16/23 to complete a skin assessment on Resident #11 that showed bruising on one of her hands, but she couldn't remember which hand. The UM stated Resident #11 told her that they held her hands down to change her but did not explain who they were. The UM explained that she did not report what Resident #11 told her about how the bruising occurred because the Administrator was already aware of the bruising and had interviewed the Resident during her presence. The UM stated she was not asked to investigate the incident, nor did she interview any staff about the incident because that was not her job to do so. An interview was conducted with the Nurse Educator on 06/20/23 at 9:00 PM who explained that she was no longer employed at the facility but stated she only educated the staff after the incidents of abuse had occurred. The Nurse continued to explain that she educated the staff on abuse from 02/17/23 to 02/20/23 which included identifying and reporting abuse as well as dealing with the abusive resident which included not providing care for Resident #11 alone and to always have a least two staff when providing care for her. The Nurse insisted that she did not investigate the accusation of bruising on Resident #11 that happened back in February because that was not her job to do that. She indicated the investigation would have been done by the Director of Nursing at the time of the incident. During an interview with the former Director of Nursing (DON) on 06/22/23 at 2:55 PM the DON reported he was the acting DON from January through most of February 2023. The DON explained that he remembered Resident #11 in that she frequently accused the staff of being abusive to her and they were afraid to go into her room to provide care for her, so he had them go in with at least 2 people and to document the care provided. He stated Resident #11 liked to use her call light and bed remote as a [NAME] and swing at them, threatening to hit them. The DON stated he investigated several incidences involving Resident #11 that happened with the daytime staff but not the nighttime staff and he did not remember investigating anything pertaining to bruising on Resident #11 before he left. The DON stated if he had there would have been documentation of his investigation and he would have assessed the Resident and documented it in Resident 11's chart. An interview was conducted with the Administrator on 06/21/23 at 10:45 AM who explained that the staff (he could not remember who) informed him in the morning meeting on 02/16/23 that Resident #11 had bruising on her arms and to his knowledge there had been no reports of bruising reported on the Resident before that day. The Administrator stated the Nurse Educator informed him that she had taught the staff to cross the residents' arms in front of them in order to make turning and repositioning easier for the residents but not intending to hurt them. The Administrator continued to explain that he interviewed Resident #11 on 02/16/23 and did not see any bruising nor did he document it in his statement that he wrote. He stated Resident #11 reported to him that a large aide, NA #9 held her hands down during care and that caused the bruising and NA #11 was present at the time. He reported they collected written statements from NAs #9, #10, and #11, who were involved, and NA #9 denied holding the Resident's hands down, NA #10 admitted to holding Resident 11's hands down and NA #11 denied holding the Resident's hands down. The Administrator stated they suspended NA #10 pending the outcome of the investigation because she admitted to holding the Resident 11's hands down during care even though Resident #11 stated it was NA #9. The Administrator stated he did not personally interview the named staff about the incident or get a verbal explanation of their written statements because the verbal investigation was done by the Unit Manager and the Nurse Educator. The Administrator stated he only reviewed the NAs written statements, which were all consistent in that Resident #11 was combative during care which made himself and the upper management question whether it was abuse. He stated they did not feel it was abuse and therefore, they did not terminate the employee and explained he must have marked the investigation report as substantiated by mistake. The Administrator stated NA #10 returned to work after the investigation and continued to work at the facility as were NA #9 and #11. During the interview the Administrator was asked how the facility protected the other residents who were under the care of accused NA #10 and the Administrator was unable to explain nor was he able to provide demonstration of the other residents' protection from NA #10 since she continued to work in the facility since the incident on 2/26/23. The Administrator indicated he should have been more thorough with investigating the incident and remarked that he was unfamiliar how things were done in this state coming from another state, but he had learned that he needed to be more detailed and thorough when he investigated abuse and report abuse to local law enforcement and state agencies within the 2-hour timeframe. The Administrator added he did not report the incident to the local law enforcement or the state agency in the two-hour time frame because he was waiting for direction from upper management to do so but he never received permission. The Administrator was notified of the immediate jeopardy on 07/12/23 at 4:49 PM. The facility provided the following IJ removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. At approximately 9:00 AM on 2/16/2023 the Administrator was notified that Resident #11 had new discolorations to her right and left arms. The Administrator and Infection Preventionist entered the room to interview Resident #11 to gather information on the new discolorations to her arms. Resident #11 stated that a large black woman held her down last night causing the discolorations. The Administrator asked what led up to the event, Resident #11 stated she could not recall. The Administrator asked when the event occurred, Resident #11 stated last night. The Administrator asked Resident #11 to describe the event, Resident #11 stated it happened during the time the nursing aides attempted to change me and the nursing aide put her hands together. Resident #11 then stated it was a nurse aide who held her down. Facility staff interviewed the staff working the hall from the previous night shift, interviews indicate that Resident #11 was combative with staff who attempted to change her clothing and bedding that were soiled. The incident happened approximately 1:30 AM 2/16/2023. The employees did not inform the supervisor nor the Administrator at the time the incident happened. The Administrator was notified approximately at 9:00AM on 2/16/2023 and the incident was reported on 2/16/2023 at 5:24PM. NA #9, NA #10, and NA #11 were suspended pending an investigation. The Administrator failed to report and failed to investigate the allegation per the facility policy which led to further abuse allegations. On 3/19/23 Nurse Aide #1 entered Resident #1 room and witnessed Resident #2 touching Resident #1 breast and vagina through her clothing. Nurse Aide #1 asked Resident #2 to stop touching Resident #1 and he did immediately. Nurse Aide #1 left the room with the perpetrator present and reported to Nurse #1. Nurse #1 failed to immediately report the incident to her supervisor as directed by the facility's policy. The failure of Nurse #1 to report to the Administrator led to not reporting to law enforcement, Adult Protective Services, not starting an investigation, lack of protection, and then the perpetrator approached the resident again on 3/20/23 attempting to touch her. All facility staff have the potential to repeat the same deficient practice. On 6/21/23 the Administrator reviewed 24 hour/5 days for the last 30 days to identify if reporting was completed per policy. There was one issue identified and corrected. 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: Initial education was completed on 3/22/23 with current staff including agency regarding identifying and reporting abuse. On 6/21/23 the Director of Nursing and Assistant Director of Nursing educated current staff on Abuse. Education included verbal abuse, sexual abuse, physical abuse, mental abuse, neglect, involuntary seclusion, exploitation, misappropriation of resident property and mistreatment. The staff members, to include agency staff, that have not received the education will not be able to work until they have received this education. The Director of Nursing is responsible for ensuring this is enforced. In the event abuse is witnessed the staff member should stay with the resident providing protection from the abuse. Immediately after removing the abuse the abuse must be reported to the Administrator. The Administrator was educated by the Chief Nursing Officer on 6/21/23 on how he should confirm the abuse and potential has been removed, the perpetrator is monitored, submit an initial investigation to the State, contact the police department and Adult Protective Services and complete a thorough investigation prior to submitting the five-day report to the State. Staff were asked to return information verbally to confirm understanding of education. The Director of Nursing will educate in orientation for newly hired staff, to include agency staff. Education completed 6/21/23. In the event of resident-to-resident abuse the perpetrator will be placed on a 1:1 monitoring until a medical/psychiatric evaluation can be completed to protect the victim and all other residents. The charge nurse on duty is responsible for assigning the 1:1 monitor. Charge nurses were notified of this responsibility on 6/22/23 by the Director of Nursing. Effective 6/21/2023/2022 the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance. On 06/28/23 a credible allegation of Immediate Jeopardy removal was conducted in the facility. The facility's current Abuse policy and procedure was reviewed, along with facility reported incidents in the last thirty days to ensure timely reporting. No additional concerns were noted. The education used to re-educate the facility staff on abuse was reviewed along with staff sign in sheets to confirm receipt of the education. Interviews with staff across the disciplines were conducted and staff were able to verbalize the steps they should take if they witness or suspect any type of abuse. The staff were able to verbalize that they must stop the abuse and stay with the resident providing protection from the abuse and then immediately report the abuse to the Administrator. The perpetrator is to be placed on one-on-one supervision immediately for the protection of other residents. The education was verified to be a part of the orientation program for all newly hired staff. The Administrator was able to verbalize his reporting requirements and time frames after becoming aware of any witness or suspected abuse in the facility. The facility's removal date of 06/23/23 was validated. 2. Review of the facility's abuse policy dated 07/01/13 and revised on 10/24/22 read in part, if the suspected abuse is patient to patient, the patient who has in any way threatened or attacked another will be removed from the setting or situation and an investigation will be completed. The Center will protect the patient from further harm during an investigation. Anyone who witnesses an incident of suspected abuse, neglect, or involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately, regardless of shift worked. The notified supervisor will report the suspected abuse immediately to the Administrator or designee and other officials in accordance with state law. Resident #1 was admitted to the facility on [DATE]. Review of the significant change Minimum Data Set (MDS) dated [DATE] revealed that Resident #1 had clear speech and was able make her needs known and was able to understand others. Resident #1 was moderately cognitively impaired and required limited to extensive assistance with activities of daily living. Resident #2 was admitted to the facility on [DATE] with diagnoses that included anxiety, major depressive disorder, vascular dementia, and others. Review of the quarterly MDS dated [DATE] revealed that Resident #2 was moderately cognitively impaired, had no delirium, no behaviors, rejection of care, or wandering during the assessment reference period. Resident #2 required limited to extensive assistance with activities of daily living and used a wheelchair for mobility. Review of a facility incident report dated 03/21/23 read, Resident #1 reported that Resident #2 came into her room and started holding her hand and kissing her hand, then proceeded to touch her breast on top of clothing and under clothing then tried to touch her vaginal area. Resident #1 stated that she asked Resident #2 to stop, and he did. Resident #1 was not sure of the exact date and time the incident occurred. Resident #1 was assessed for injuries, and none were noted. Investigation initiated. Resident #2 placed on one-on-one supervision. Resident #1 was sent to the Emergency Department (ED) for evaluation. The report was completed by the Director of Nursing (DON). Resident #2 was discharged home from the facility on 03/29/23. Review of the facility's schedule for 03/19/23 revealed that Nurse Aide (NA) #1 was caring for Resident #1 and Nurse #1 was on the unit where Resident #1 resided. Nurse Aide (NA) #1 was interviewed via phone on 06/20/23 at 2:33 PM who confirmed that she was caring for Resident #1 on 03/19/23. She stated that evening Resident #1 was in her wheelchair in her room and Resident #2 who had been outside smoking entered Resident #1's room in his wheelchair. NA #1 stated that when she entered Resident #1's room, they were both in their wheelchair's facing each other and Resident #1 stated to her, please tell him to remove his hand from my twat, NA #1 stated that Resident #2's hand was on top of Resident #1's clothes in her vaginal area. NA #1 stated she very sternly asked Resident #2 to stop touching Resident #1 and he did. NA #1 stated that she then left the room with Resident #1 and Resident #2 still in their wheelchairs alone facing each other to go and alert Nurse #1 of what had occurred. As NA #1 was returning to Resident #1's room she passed Resident #2 in the hallway in his wheelchair returning to his room on the same unit. NA #1 stated that at the end of her shift she had followed up with Nurse #1 about if she had documented what had occurred. NA #1 stated that Nurse #1 stated she had not documented anything regarding the incident because she felt it was consensual. NA #1 stated that she did not think anything about leaving Resident #1 and Resident #2 in the room together while she went to report to Nurse #1 because he instantly removed his hand from her when I asked him to. She added that she assumed Nurse #1 had taken care of what she needed to regarding the incident. Attempted phone interview to Nurse #1 were made on 06/20/23 at 11:12 AM and were unsuccessful. A statement provided by Nurse #1 dated 03/22/23 at 5:00 AM read on Sunday night 03/19/23 during med pass, staff reported to this writer of witnessing Resident #2 in Resident #1's room and had his hand in Resident #1's brief while both residents were sitting in wheelchairs in the room. This Nurse asked Resident #1 about the incident, and she replied, so this is my p***y, and I can do what I want. Resident #1 used other foul language and reported to this writer that the incident was consensual between the two parties involved. An observation and interview were conducted with Resident #1 on 06/20/23 at 10:23 AM. Resident #1 was resting in bed and was well groomed. She stated that she recalled the incident with Resident #2. She stated she did not know the date or time but stated she was in her room but could not recall if she was in bed or in her wheelchair and Resident #2 came in her room and touched me on my breast and tried to touch my vagina but I pushed his hand away. She explained that he touched her on top of her clothes, but she did not like to talk about it and stated she tried to block it from her memory because she did not like to think about what had happened to her. Resident #1 explained her spouse had recently passed away and she did not want another man touching her. She added that Resident #2 had never made an inappropriate gesture or passes toward her before but again she did not wish to talk about the incident anymore. NA #5 was interviewed on 06/20/23 at 2:07 PM who confirmed that she was caring for Resident #1 on 03/21/23. During care and transfer of Resident #1, NA #5 stated that Resident #1 had tears in her eyes and told her that Resident #2 had his hands down Resident #1's pants and had touched her breasts. NA #5 stated she left the room while NA #6 stayed with Resident #1 and went and told Nurse #4 what Resident #1 had reported. NA #5 was certain that Resident #1 was sad and had tears in her eyes when she told her what had happened, and Resident #1 made it very clear she did not want Resident #2 touching her. NA #5 stated that after they reported to Nurse #4, she reported to the DON and Administrator, and they immediately began an investigation. NA #6 was interviewed on 06/20/23 at 1:04 PM who confirmed that she was caring for Resident #1 on 03/21/23 during the day shift. She stated while transferring Resident #1 out of bed she stated that Resident #2 had touched her in places that he should not be touching her, and Resident #1 was very clear she did not want Resident #2 touching her at all. NA #6 stated that Resident #1 stated that Resident #2 had touched her inside her pants and her breast area, and that NA #1 had gotten Resident #1 to stop and reported it to Nurse #1. NA #6 stated that when Resident #1 told her and NA #5 what had happened, they immediately reported it to Nurse #4 who told the DON and Administrator and they began an investigation. Nurse #4 was interviewed via phone on 06/20/23 at 11:52 AM who confirmed that she was caring for Resident #1 on 03/21/23. She stated that Resident #1 had requested to get out of bed by NA #5 and NA #6 and during the transfer Resident #1 was not acting like her usual self, she was very upset and not joking with them like she normally did. Resident #1 reported that Resident #2 had stuck his hands down her pants and touched her breast and NA #5 and #6 immediately came and reported to Nurse #4 who confirmed that she went and reported to the DON who asked that Resident #1 be sent to the ED for evaluation which she was and returned with no new orders. Review of a statement recorded by the SW dated 03/21/23 read, the questions were asked by the Administrator to Resident #1: Resident #1 reported that Resident #2 came into her room and tried to play with my titties and Resident #1 reported, I do not like that. He also tried to play with my twat. He tried to kiss on me, and I don't want him kissing on me. I told him to stop. The Administrator asked [TRUNCATED]

Based on record reviews and staff and Physician interviews the facility failed to notify the Medical Director when a resident (Resident #9) experienced an acute change in condition on [DATE] as described by Nurse Aide (NA) #3 as restless, pale in color, struggling to breathe, and a change in urinary continence and as described by NA #4 as restless and up and down all night for 1 of 1 resident reviewed for notification of change. A few hours later Resident #9 was found slumped over in his wheelchair in cardiac arrest. Resident #9 expired in the facility on [DATE]. Immediate jeopardy began on [DATE] when Resident #9 experienced an acute change in condition and Nurse #2 failed to notify the physician. Immediate jeopardy was removed on [DATE] when the facility provided and implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity D (no actual harm with more than minimal harm that is not immediate jeopardy) to ensuring monitoring systems are in place and the completion of staff education. The finding included: Resident #9 was readmitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, congestive heart failure, coronary artery disease, atrial fibrillation and heart failure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 was cognitively intact. A review of Resident #9's medical record revealed the following medication and treatment orders: *[DATE] Ventolin HFA (Albuterol) Inhalation Aerosol Solution 108 micrograms (mcg) (90 Base) 2 puffs inhale orally four times a day for wheezing/dyspnea, give with spacer. A review of Resident #9's progress note dated [DATE] at 5:07 AM revealed, Resident #9 was up and down from his bed to his wheelchair and vice versa most of the night. He was constantly complaining of pain to bilateral lower extremities but would not take any physician ordered pain meds. His bilateral lower extremities were draining serous sanguineous, both blood and the liquid part of blood (serum), fluid in moderate amounts. Resident #9 had previously cut off his Unna boots (medicated dressings/wraps applied to his legs used to control swelling) and refused to allow staff to replace them. He was non-compliant with all meds and care. Would not allow staff to assist with any care at this time. Will continue to offer pain med and or treatment to bilateral lower extremities. The note was written by Nurse #2. A review of Resident #9's progress note dated [DATE] at 5:59 AM revealed, Ventolin HFA Inhalation Aerosol Solution 108 mcg (90 Base) 2 puffs inhale orally four times a day for Wheezing/Dyspnea give with spacer inhaler. Refused med. The note was written by Nurse #2. A review of Resident #9's Medication Administration Record for ,d+[DATE] indicated Resident #9 refused his Ventolin Inhaler on [DATE] for 6:00 AM. A review of Resident #9's progress note dated [DATE] at 6:40 AM revealed, the nurse was called to room via staff, and upon arrival Resident #9 was noted to be slumped over in his wheelchair, non-responsive to verbal stimuli, blue in color with no respirations. Resident #9 was placed on floor and Cardiopulmonary Resuscitation (CPR)was initiated. 911 was called. CPR continued until 911 arrived. Pronounced deceased at 7:00 AM. MD was notified. The note was written by Nurse #2. On [DATE] at 9:10 PM during an interview with Nurse #2 the Nurse confirmed that she took care of Resident #9 about 3 nights a week and on the night of [DATE] until the morning of [DATE]. The Nurse reported the Resident was alert and oriented and was non-compliant with his medications mainly his heart medications and the medicated dressing to his legs. She explained that his legs were edematous and had draining sores and he would cut the medicated dressings off after the nurses applied them. The Nurse explained that Resident #9 acted no different that night of [DATE] to [DATE] as he did on any other night, she had taken care of him. She stated he was restless in that he was up and down from his bed to the chair and at one time they found him lying in the floor but that was not anything unusual about him either because he would often put himself on the floor. She stated the Resident complained of pain in his legs but refused to take pain medication for the pain. Nurse #2 continued to explain that around 4:00 AM she found the Resident using the telephone on the wall in the hall saying he wanted to call 911. She stated she took the phone from him and off the wall because he called 911 all the time and that was no change in his behavior. The Nurse reported if she thought he warranted being sent to the hospital she would have called 911 herself. Nurse explained that she last spoke with Resident #9 between 6:00 AM to 6:20 AM when he was sitting in his wheelchair in the hallway, and she gave him his Ventolin inhaler which was due at 6:00 AM. Nurse #2 continued to explain that during shift change she was giving report to the oncoming nurse when nurse aides yelled for the nurses to come down to Resident #9's room where they found him sitting in his wheelchair at the foot of his roommate's bed. He was slumped over and nonresponsive. The Nurse continued to explain that she and the Nurse Educator initiated CPR with the Nurse Educator starting the chest compressions first. Nurse #2 stated someone had called 911 and when the EMS arrived, the Nurse Educator had already stopped CPR due to Resident #9 not responding to the CPR. The Nurse again confirmed that she had not called the on-call provider services or the physician regarding a change in condition for Resident #9 because she did not think he had experienced any change in condition. The Nurse stated if she thought Resident #9 experienced a change in condition, she would have called EMS herself. Resident #9 expired in the facility on [DATE]. An interview was conducted with NA #4 on [DATE] at 4:25 PM. The NA stated he routinely worked with Resident #9 about ,d+[DATE] nights a week and had taken care of the Resident the Saturday and Sunday night prior to the morning of Monday [DATE]. The NA explained that Resident #9 was not his usual self throughout the shift in that he was restless, he was going from his chair then back to his bed like he was restless. He continued to explain that earlier in the night he found Resident #9 lying on the floor and went to get Nurse #2 and NA #3 to help him get the Resident out of the floor and back into his chair where he always stayed. He reported he had never known of the Resident to lie in the floor before. The NA explained that the Nurse asked the Resident if he was in pain and the Resident denied being in pain and wanted to stay in the floor where he said was more comfortable for him. After some encouragement the Resident agreed to get into his wheelchair. The NA stated he and NA #3 left the room to continue their rounds. Then later in the night Resident #9 turned his call light on and when the NA answered it the Resident wanted him to call an ambulance for him but did not say why he wanted the ambulance. The NA stated Resident #9 had never asked him to call an ambulance before that night and he went and got Nurse #2 for the Resident before the NA left the room to continue his rounds. The NA stated that he did not know what transpired between Resident #9 and Nurse #2 after he left the room, but the NA knew the Nurse did not call an ambulance for Resident #9 before he left off shift because the Resident was still at the facility. The NA continued to explain that after he got home that morning someone from the facility called and asked him if Resident #9 had asked him to call an ambulance and he told the person that he did, and the NA reported to Nurse #2 that the Resident wanted an ambulance called but did not say why. The NA stated he had never known of Resident #9 requesting an ambulance or calling for an ambulance himself nor did he observe the Resident trying to use the hall phone to call an ambulance himself. During an interview with NA #3 on [DATE] at 4:59 PM the NA reported that she was one of the two NAs that took care of Resident #9 on a routine basis but the night of [DATE] to [DATE] NA #4 was the Resident's aide and he helped with his care. NA #3 explained that earlier in the night NA #4 found him lying on the floor and came and got her and Nurse #2 to get Resident #9 up out of the floor. The Resident stated he wanted to stay in the floor, but they put him back into his chair and NA #3 left the room to continue her rounds. NA #3 continued to explain that around 4:30 AM she noticed Resident #9 trying to call 911 using the phone on the wall in the hallway. When the NA asked him what he was doing the Resident told her that he was having trouble breathing and wanted to go to the hospital. The NA stated Resident #9 seemed to be struggling to breathe and was pale, so she immediately went to Nurse #2 who was at the nurses' desk and told her that Resident #9 was trying to call 911 using the hall phone and he stated he was having trouble breathing and was pale. The NA stated the Nurse asked her why she didn't just take the phone from Resident #9 and the NA told the Nurse because he didn't look right and wanted to go to the hospital. The NA reported Nurse #2 went to Resident #9 who was still trying to call 911 from the hall phone and took the phone from the Resident and told him that he was asking to go to the hospital but he won't take his medications here so what was the hospital going to do for him then proceeded to remove the phone from the wall. Resident #9 sat back down in his wheelchair still looking pale and struggling to breath. NA #3 stated Nurse #2 walked back to the nurses' desk and did not come back to the hall until she started her med pass around 5:45 AM to 6:00 AM. The NA stated she knew Resident #9 was not his usual self that night because he would normally do what he wanted to like go smoke when he wanted then to go to his room, and he was normally continent but that night he was incontinent and had to be changed. The NA stated she was certain she reported his change in behavior to Nurse #2 because she and NA #4 discussed how Resident #9 was acting different that night. During an interview with the Director of Nursing (DON) on [DATE] at 1:15 PM the DON explained that after the morning meeting on [DATE] NA #5 informed her that third shift NA #3 reported that Resident #9 had fallen during the shift and had tried to call 911 himself by using the phone in the hall but Nurse #2 took the phone from him and did not assess him for a change in condition. She continued to explain that they found the Resident slumped over in his wheelchair and CPR was initiated but the Resident expired. The DON stated that based on the information she was given and the fact that there was no incident report about Resident #9's fall she reported the situation to the Administrator and an investigation was started because they felt Nurse #2 should have assessed the Resident's change in condition and notified the Medical Director for further orders. On [DATE] at 10:45 AM during an interview with the Administrator he reported that when he learned of the situation with Resident #9 on the morning of [DATE] he immediately started an investigation of the situation and found that the Resident was complaining of pain and had even requested to go to the emergency room and tried to call 911 himself until Nurse #2 took the phone from him and from the wall so that he couldn't call 911 himself. The Nurse should have assessed the Resident and called the Medical Director and the Nurse on Duty to report the Resident's change in condition, but she didn't and ultimately Resident #9 coded and expired. The Administrator stated he felt the Nurse was negligent in not assessing the Resident's change in condition and notifying the physician to obtain further guidance in the situation. An interview conducted with the resident's Physician on [DATE] at 2:20 PM revealed he was not surprised when he was notified that Resident #9 had expired because of his history of refusing his medications and treatments that were necessary to prevent swelling and fluid overload which were related to his significant heart failure. While reviewing Resident #9's death certificate the MD explained that the Resident went into biventricular dysrhythmia (arrhythmias that cause the heart to beat too fast, which prevents oxygen rich blood from circulating to the brain and body and may result in cardiac arrest) heart failure related to his coronary heart disease. He continued to explain that Resident #9's heart was beating so fast that even if he was in the emergency room there was a slight chance of survival but regardless, the MD indicated a medical provider should have been notified of Resident #9's change in condition status so that he could be evaluated and treated accordingly. On [DATE] at 2:30 PM the Administrator was notified of Immediate Jeopardy at F 580. The facility provided a Credible Allegation of Immediate Jeopardy Removal on [DATE]. On [DATE] at approximately 4:30 am Nurse Aide #3 identified Resident #9 as restless, pale in color, struggling to breathe, and a change in urinary continence. Nurse Aide #4 described Resident #9 as being restless and up and down all night long requesting to go to the hospital. There was no notification made to the MD regarding the change in condition for Resident #9. At approximately 6:40 am CNA #5 and CNA #6 started their round and discovered resident to be slumped over in wheelchair. At that time, they called for help. The Nurse Practice Educator responded. Upon assessment the Nurse Practice Educator determined resident was not breathing and did not have a pulse. Resident was placed on the floor by the Nurse Practice Educator, CNA #5, and CNA #6. Chest compressions were started by the Nurse Practice Educator after confirming resident was a full code. Resident #9 expired in the facility. On [DATE] the Nurse managers reviewed residents who have change of condition during the last 30 days using the 24-hour report. The 24-hour report was reviewed for indicators of a change such as not at baseline, not normal for resident, lethargic, shortness of breath, new onset pain, etc. Any opportunities identified during this audit will be corrected by the Nurse Managers by [DATE]. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: The Director of Nursing and Assistant Director of Nursing educated Licensed Nurses regarding the requirements for notification of the Physician following a change of condition. The Director of Nursing and Assistant Director of Nursing educated Nursing Assistants on identifying a change in resident condition and reporting to the Licensed Nurse immediately. Verbal education was given on a change of condition is noting when a resident presents different than known baseline, lethargic, restless or short of breath. Furthermore, education was provided on how to use the on-call MD system after hours and on weekends. The Director of Nursing will ensure no staff will work without receiving this education. Any new hires, including agency staff will receive education prior to the start of their shift. It will be the responsibility of the Director of Nursing to ensure this is completed. Education will be completed by [DATE]. Effective [DATE] the Administrator will be responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: [DATE] On [DATE] the facility's Credible Allegation for removal of Immediate Jeopardy on [DATE] was validated by verifying the nurse managers reviewed the 24-hour report sheets to identify residents that had any change in condition within the last 30 days and followed up on the changes by [DATE]. The nurse managers also educated the licensed nurses on the requirements for notifying the providers in the changes in conditions. Nurse aides were educated on identifying a resident's change in condition to be anything different from the resident's baseline and should be reported immediately to the licensed nurse. The Director of Nursing will be responsible to ensure no staff, facility or agency will work before being educated on the new procedure. The facility's removal date of [DATE] was validated.

Based on observations, record review, staff, Nurse Practitioner, and Medical Director interviews the facility failed to follow the Center for Disease Control and Prevention (CDC) guidelines and facility policy when they did not identify Covid 19 positive residents and failed to place them on transmission-based precautions, therefore the staff (Nurse Aide (NA) #3, NA #4, and Housekeeper #1) failed to don/doff personal protective equipment (PPE) when entering and exiting a Covid 19 positive room and before interacting with other residents (Resident#35, Resident #41, and Resident #44) this affected 3 of 24 residents on 1 of 4 units (memory care unit.) The facility failed to have personal protective equipment available for the staff to use when caring for Covid 19 positive residents that resided on the memory care unit. The facility was in outbreak status that started on 08/26/22 and affected 10 of 24 residents on the memory care unit. There were 5 residents that had not had Covid 19 in the last 90 days and of those 5 residents 1 was unvaccinated against Covid 19. The facility further failed to identify and prevent the spread of scabies (a very contagious skin condition caused by a tiny burrowing mite). This affected 3 of 4 residents (Resident #21, Resident #17, and Resident #61 that resided on 2 of 4 units in the facility (100 and 300 units). Immediate jeopardy began on 09/11/22 when the facility direct care staff and housekeeping staff were unable to identify the Covid 19 positive residents or rooms on the memory care unit. The staff were observed caring for Covid 19 positive residents without personal protective equipment and then caring for and/or interacting with Covid 19 negative residents. The immediate jeopardy was removed on 09/13/22 when the facility provided and implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity Level G (actual harm that is not immediate jeopardy) to implement a plan of correction for the second example. The findings included: Review of a facility document titled, Hand Hygiene dated 12/01/06 read in part, wash hand with soap and water in the following situations: when visibly soiled or contaminated, before any direct contact with residents, before putting on gloves, after contact with residents ' intact skin, after contact with inanimate objects in the immediate vicinity of the resident and after removing gloves. Review of a facility document titled, Suspected Covid 19 Facility Checklist revised on 07/30/21 read; for all suspected or confirmed patients: close door to affected patients' room and wear appropriate PPE when entering the room(s) of affected patients (gown, gloves, full face shield, N95 respirator). Review of the Center for Disease Control and Prevention (CDC) guidelines dated 02/02/22 read in part, Manage Residents with Suspected or confirmed [CONDITION(S)]-CoV-2 (Covid 19) infection: Healthcare personnel caring for residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection should use full personal protective equipment (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator). 1a. Upon entrance to the facility on [DATE] at 10:32 AM the Nurse Supervisor stated that the facility had 5 of 24 residents that were Covid positive, and all resided on the 400 hall that was the facility's memory care unit. An observation of the door to the memory care unit was made on 09/11/22 at 10:44 AM, the door contained a sign that read: Patient Specific: Contact Plus Airborne Precautions: STOP: Perform hand hygiene before and after patient contact with environment and after removal of PPE, Wear a N95 respirator, Gown, Face shield and gloves upon entering the room. Change gown after each patient contact, keep room door closed. There was no PPE available at the entrance to the unit. Nurse #6 was interviewed on 09/11/22 at 11:15 AM and confirmed that he was working on the memory care unit of the facility, and he was unable to confirm who the Covid 19 positive residents were but stated he had a list at the station. After Nurse #6 retrieved his list, he was able to report that the follow rooms were Covid positive rooms: room [ROOM NUMBER] A and B, room [ROOM NUMBER] B, room [ROOM NUMBER] A, room [ROOM NUMBER] A, room [ROOM NUMBER] B, and room [ROOM NUMBER] B. Observation of the memory care unit was made on 09/11/22 at 11:45 AM and revealed that room [ROOM NUMBER] room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] contained no sign on the door indicating that either resident in the room were Covid positive. The observation further revealed that there were 2 PPE containers sitting on the hallway of the unit. One at the far end of the hallway and one near the upper end of the hallway. Neither PPE cart contained any gowns for the staff to wear. Each PPE cart contained a box of gloves and a few N95 mask but no other PPE. The residents in room [ROOM NUMBER], 405, 406, 408, and 409 were all in their rooms in their bed. The resident in room [ROOM NUMBER] which had a transmission-based precaution sign on their door was ambulating and wandering in/out of other resident rooms on the unit. A follow up interview was conducted with Nurse #6 on 09/11/22 at 3:03 PM who confirmed he only worked the memory care unit when he worked at the facility through an agency and had worked on 09/10/22 and 09/11/22 twelve-hour shifts. Nurse #6 stated that they kept a list of the Covid positive residents and room numbers at the nurse's station and he would always verify the information with the off going nurse in report. He stated that the Nurse Aides (NAs) would get report from the off going NAs about which residents who were Covid positive and if they did not get that information, they could always ask the nurse on the unit. Nurse #6 stated I treat the whole hall as a Covid unit. He stated we are supposed to have gowns, gloves masks and goggles on the unit but he could not say why they did not have personal protective equipment on both 09/10/22 and 09/11/22. Nurse #6 stated they were not supposed to leave the hall to get supplies and was not aware if the facility had supplies in other areas of the facility or not. He indicated that he wore his N95 mask for the duration of his 12-hour shift and was not aware of what the protocol was for changing his N95 mask. Nurse #6 confirmed that during the weekend of 09/10/22 and 09/11/22 he had not called the other side of the facility or the Director of Nursing (DON) to obtain the personal protective equipment and stated, in the past they have brought it to us. He further added that when a resident tested positive for Covid the PPE container did not always get put out for use by the staff on the unit. 1b. Resident #13 admitted to the facility on [DATE] and resided in room [ROOM NUMBER] B and tested positive for Covid 19 on 09/05/22. Resident #24 was readmitted to the facility on [DATE] and resided in room [ROOM NUMBER] A and tested positive for Covid 19 on 09/08/22. NA #3 and NA #4 were observed to enter room [ROOM NUMBER] (both Covid positive) on 09/11/22 at 11:45 AM wearing a N95 mask and eye protection. They were observed to interact with both residents and their environment. They adjusted covers on bed, moved bedside tables and touched Resident #13's hand. NA #3 and NA #4 exited the room and neither changed their N95 mask or cleaned or disinfected their eye protection and did not perform hand hygiene. They exited into the hallway and entered the common area on the unit where other residents were located. NA #3 and NA #4 were interviewed on 09/11/22 at 11:48 AM. Neither NA #3 nor NA #4 could verbalize who the Covid positive residents were on the unit. They both confirmed that this was their weekend to work and during report no one gave them the names or room numbers of the Covid positive residents. Both NAs stated that sometimes they had a Covid positive and Covid negative in the same room and it was so confusing on what they should do with their PPE. NA #3 stated that if she was aware that a resident was Covid positive then she would put on a gown before entering the room but stated we don't have any right now and we did not have any yesterday either and of course we already have on goggles and N95 mask. NA #3 stated that when they came out of a Covid positive room they would remove their gown and gloves but did not change their N95 mask or clean/disinfect their goggles. NA #4 confirmed that they wore their N95 mask for the duration of their 12-hour shift on the memory care unit. Both NAs stated that none of the residents had any symptoms of Covid 19 and added we treat everyone like their positive. NA #3 stated that they had not received any education since their Nurse Educator that was here temporarily left a few weeks ago but added that they used to get education on Covid and PPE pretty often. A subsequent observation of NA #3 was made on 09/11/22 at 3:14 PM. There was a sign on the door of room [ROOM NUMBER] that read; Contact Plus Airborne Precautions: STOP Perform hand hygiene before and after patient contact with environment and after removal of PPE, Wear a N95 respirator, Gown, Face shield and gloves upon entering the room. Change gown after each patient contact, keep room door closed. NA #3 entered room [ROOM NUMBER] (both resident Covid positive) wearing a N95 mask and goggles. She reapplied Resident #24 ' s oxygen cannula in his nose and moved his bedside table back within his reach. She exited the room without performing hand hygiene or changing her N95 mask and she did not clean/disinfect her eye protection. Once in the hallway NA #3 was observed to approach two wandering residents (Resident #35 (who was currently Covid negative but had Covid 07/19/22) and Resident #41 (who was currently Covid negative but had Covid 08/03/22) and grab their hand and walk them down the hallway to the common area again without performing hand hygiene. NA #3 was interviewed on 09/11/22 at 3:16 PM. NA #3 stated that if she was aware that a resident was Covid positive then she would put on a gown before entering the room but stated we don't have any right now and we did not have any yesterday either and of course I already have on goggles and N95 mask. NA #3 stated that when she came out of a Covid positive room she would remove her gown and gloves but did not change her N95 mask or clean/disinfect her goggles. She stated she had not noticed the sign on the door when she entered room [ROOM NUMBER] but also there was no gowns for her to apply anyway when she entered the room. NA #3 also stated that she forgot about using hand sanitizer because when she walked out of room [ROOM NUMBER] there were 2 residents in the hallway that she needed to redirect. 1c. Resident #36 was admitted to the facility on [DATE] and resided in room [ROOM NUMBER] B and tested positive for Covid 19 on 09/06/22. An observation of Resident #36 was made on 09/11/22 at 11:59 AM. Resident #36 was observed wandering on the memory care unit. She was observed to enter room [ROOM NUMBER] (Resident#44 who resided in 408 B was Covid Negative) and shut the door behind her. Nurse Aide (NA) #3 was notified that Resident #36 had gone into room [ROOM NUMBER] and shut the door on 09/11/22 at 12:03 PM. NA #3 replied she is hiding in that room she will be ok and continued up with the hallway without redirecting Resident #36 out of the room. An observation of Housekeeper #1 was made on 09/11/22 at 3:17 PM. Housekeeper #1 was observed in the hallway wearing a N95 mask and a face shield he was observed to enter Resident #36's room that had a sign on the door that read: Contact Plus Airborne Precautions: STOP Perform hand hygiene before and after patient contact with environment and after removal of PPE, Wear a N95 respirator, Gown, Face shield and gloves upon entering the room. Change gown after each patient contact, keep room door closed. Housekeeper #1 was observed to enter the room and place a trash bag in the trash can and then enter the bathroom and exit out of the adjoining room which was room [ROOM NUMBER] (Covid negative) room. He returned to the housekeeping cart in the hallway and proceed to empty the trash and clean the trash can. Housekeeper #1 did not change his N95 mask, clean/disinfect his eye protection or perform hand hygiene in between a Covid positive room and a Covid negative room. Housekeeper #1 was interviewed on 09/11/22 at 4:36 PM. He stated that he did not see the sign on the door of room [ROOM NUMBER], so he did not apply his gown or gloves and did not change his N95 mask when he exited the room. Housekeeper #1 stated that generally if he was entering a Covid positive room he would follow the instructions on the door as to what personal protective equipment he needed to apply but because he had not seen the sign posted on the door, he had not done that earlier in the day. An observation of NA #4 was made on 09/12/22 at 8:32 PM. NA #4 was observed to enter Resident #36's room wearing gown, gloves, N95 mask and eye protection and provided morning care to Resident #36 and assisted her with meal set up. Prior to exiting Resident #36's room NA #4 removed her gown and gloves and bagged them in a trash bag and exited the room she did not clean/disinfect her eye protection and did not change her N95 mask. NA #4 was interviewed on 09/12/22 at 8:33 AM and confirmed that she had removed her gown and gloves but had not changed her N95 mask or clean/disinfected her goggles and she should have. NA #4 could not provide a reason why she did not change her N95 mask or clean/disinfect her goggles. The former Nurse Practice Educator was interviewed via phone on 09/13/22 at 2:52 PM via phone. The former Nurse Practice Educator stated that she had worked at the facility through an agency and a couple of weeks into her contract the Director of Nursing (DON) informed her that she would also be responsible for maintaining the infection control program at the facility. She stated she was responsible for ensuring appropriate signage was on the door if we had Covid 19 positive resident in the facility, ensuring PPE was available, ensure staff were wearing the PPE correctly, provide education on donning/doffing PPE, hand washing, Covid testing, keeping line listing of infections and tracking resident quarantine days. The Nurse Practice Educator stated the biggest issue she had was the staff was not compliant at all no one wanted to apply the PPE correctly. The Nurse Practice Educator explained that she was on vacation when the memory care unit had its first initial outbreak on 08/05/22, she stated when she returned to work on Monday 08/08/22 and found out that they had 7 residents that tested positive on 08/05/22 and nothing had been done. She stated that on 08/08/22 in the afternoon the former Administrator had asked her to round with him to ensure that all the pieces had been implemented for the outbreak on the memory care unit, she stated when they rounded, she discovered that there was no signage posted on door, no PPE on the unit, and staff were not wearing the appropriate PPE to be caring for Covid positive residents. The former Nurse Practice Educator stated that she immediately began implementing the appropriate measures, she placed signs on the doors, obtained PPE carts and filled them and put them outside of the resident rooms and she educated the staff on appropriate PPE use. She stated that when she would say to the staff in the facility pull your mask up, they would respond we have already had covid and would not follow directions. She stated that she made the DON aware of the issues and questioned her why the measures were not implemented when the residents tested positive but received no answer. When a resident tested positive for Covid the staff were taught and expected to wear full PPE including N95 mask, eye protection, gown, and gloves. They were also taught and expected to remove the PPE when they exited the Covid positive room perform hand hygiene and reapply a new N95 mask and new face shield. Again, compliance was always the biggest issue with infection control in the facility. The Nurse Practice Educator stated she had specific concerns with NA #3 and NA #4 that she had spoken to them several times and educated them several times during the first outbreak on the memory care unit and they just would not wear the PPE correctly. She added the DON was informed numerous times of my concerns with the staff noncompliance and the only response she would get if any at all was that we have to cover the building. The former Administrator was interviewed via phone on 09/13/22 at 5:14 PM and confirmed that his last day at the facility was 08/26/22. He stated that at the time the Nurse Practice Educator was handling infection control and reporting to the health department as needed. He stated that when he left the faciity on [DATE] there was no positive cases of Covid 19. When asked if he had any issue with infection control the former Administrator replied, we had error of opportunity and I constantly harped on staff to put goggles on and pull your mask up. He further stated he had the department managers responsible for stocking PPE carts each day and the biggest issue was the off-hour times like early morning, late evening, and weekends when management staff was not always present. The former Administrator stated that they did a lot of coaching in the moment to ensure mask were properly worn but to his knowledge he had no egregious issues with compliance. The Nurse Supervisor was interviewed on 09/14/22 at 10:16 AM and confirmed that she had seen staff not being compliant with PPE all the time. She stated she believed staff noncompliance with PPE contributed to the facility's Covid outbreaks. The Nurse Supervisor stated that when the residents that resided on the memory care unit test positive everyone should have been isolated but the staff noncompliance contributed to the continued outbreak. She stated night shift on the memory care unit was the worst for compliance with PPE but added NA #3 and NA #4 were also very non-compliant more so than the other staff. The Nurse Supervisor stated she would address her immediate concerns with the staff member at the time but could not say if the DON was aware of the staff noncompliance or not as she just assumed the Nurse Supervisor role and was not sure what previous conversations had been had. The Nurse Practitioner (NP) was interviewed via phone on 09/14/22 at 6:29 PM who stated she worked at the facility from January 2022 to August 2022 and treated the residents as they tested positive for Covid. She stated if staff were not wearing PPE as they were supposed to then it would have caught her attention. She stated she had no infection control concerns that she could recall. The DON was interviewed on 09/11/22 at 12:54 PM who confirmed she was the acting infection preventionist because the former Nurse Practice Educator who was responsible for infection control left 2 weeks ago. The DON stated she had been at the facility since January 2022 and the facility had been in outbreak status the entire time except for one week. The DON explained that the outbreak on the 400 hall or memory care unit started in August 2022 and currently all but 5 of the residents have had Covid in the last 90 days. The DON stated that of the 5 residents who had not had Covid in the last 90 days two were fully vaccinated and boosted/ up to date, one was only partially vaccinated, one was vaccinated without booster and one resident vaccination status was unknown. The DON stated that she worked Friday 09/09/22 until 11:00 PM and when she left the facility the memory care unit had a good supply of PPE, in addition there was more PPE on the other side of the building and even more in storage building outback that was not locked so it was accessible by all staff. She confirmed that she had not received any calls from the facility on 09/10/22 or 09/11/22 stating they needed or did not have PPE. The DON stated that each resident room that had a Covid 19 positive resident in it should have a sign on the door indicating Contact/Airborne precautions and tell staff to don eye protection, gloves, gown, and N95 mask before entering the room. There should be PPE carts outside of each of the resident rooms that were fully stocked with PPE for staff to use. She continued to say that education on Covid 19 and PPE use had been a constant revolving door and indicated the facility had done full PPE and hand hygiene competencies twice recently but could not recall the exact dates. Periodic emails were sent out to staff updating them on any changes with guidance and they also continued to have staff meetings to keep staff aware of the Covid status and changes. The DON stated that the local health department had made a visit less than a month ago and had no recommendations related to Covid 19. The Administrator was interviewed on 09/14/22 at 3:45 PM and stated that he expected the staff to follow the CDC guidance on infection control and for all staff to be compliant with PPE use to prevent the spread of infection. The Medical Director (MD) was interviewed on 09/14/22 at 4:10 PM and confirmed that he had been the MD at the facility since the summer of 2022. He stated that when he came to the facility, they were in the middle of a Covid outbreak. He also confirmed that staff made him aware of the recent outbreak on the memory care unit. The MD stated that he expected the staff to wear PPE appropriately, they should be performing frequent hand hygiene, and they should certainly be aware of who the Covid positive residents were all in attempt to prevent the spread of the Covid 19 within the facility. The DON was notified of the immediate jeopardy on 09/11/22 at 8:02 PM via phone. The facility provided the following immediate jeopardy removal plan: Identify those residents who have suffered, or are likely to suffer a serious adverse outcome as a result of the noncompliance: Facility failed to follow transmission-based precautions and use of personal protective equipment (PPE) per CDC Guidance on the Memory Support Unit on 9/11/22. All residents on the Memory Support Unit have potential to be affected. As of 9/11/22 there were 24 residents on the Memory Support Unit, with 7 of them being Covid Positive, 12 Covid Recovered in the last 90 days, leaving 5 residents at risk for exposure to Covid due to this deficient practice. Testing was completed in the morning of 9/12/22 by 8:30 a.m., with no new positive residents. The 5 residents at risk have the following vaccination status: two fully vaccinated and boosted/ up to date, one with only initial dose of a 2 dose vaccination (partially vaccinated), refused the second dose/ partially vaccinated, one vaccinated without booster- booster declined/ fully vaccinated, and one status unknown. On 9/11/22 at approximately 7 p.m. the Director of Nursing responded to the Memory Support Unit and provided education for NA # 1 and # 2. The Director of Nursing assigned the RN Supervisor to the unit to monitor for compliance with immediate action taken for any discrepancies noted. Director of Nursing stayed at center and educated night shift staff on the Memory Support/Covid Positive unit on 9/11/22. Director of Nursing restocked the PPE supplies on the Memory Support Unit/Covid Positive Unit, on day shift on 9/11/22 and again on evening shift on 9/11/22. Specify action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when action will be complete: Director of Nursing began education for all staff in all departments on 9/11/22 and continues on 9/12/22, regarding CDC Guidance for use of PPE/ Transmission Based precautions during an outbreak and hand hygiene. Education also included the location of PPE Supplies in the event that they are needed during off shifts/weekends to restock units, located in the Biohazard Room and in the storage building in back parking lot, this is unlocked and available to all staff. Education included that staff should monitor each other, peer to peer for PPE compliance and report noncompliance to management. Education included disinfecting of eye protection and changing of N95s between Covid positive and Covid negative residents and the use of gloves and gowns (don and doff gloves and gowns on entry to a room with a resident on Transmission Based Precautions and to change gloves and gowns between roommates). Education included following the precaution signage on resident rooms and the location of a list of residents on precautions maintained at the nurse's station. Signage will designate if precautions are indicated for Bed A, Bed B or both, this was initiated on 9/12/22. This education included Full Time, Part Time, PRN (as needed) and Agency Staff. Across all departments. Education will continue for all new hires and new agency staff, and no staff shall work until education completed. The Director of Nursing is responsible for tracking who still needs education and providing the education. Part-time and prn staff being educated via phone, and then in person upon next scheduled shift. On 9/11/22 signage was replaced on all resident's rooms who were Covid positive and required transmission-based precautions, and a list updated and kept at nurse's station in the event that the cognitively impaired residents remove the signage by the Director of Nursing. Nursing Management (Director of Nursing and Nursing Supervisor) responsible for monitoring that signage is in place and replaced as needed. The Nursing Supervisor is responsible for keeping the list updated daily as of 9/12/22. Nursing Supervisor and Director of Nursing educated by the Regional Nurse regarding this responsibility to include keeping the list and signage up to date for all residents that require Transmission Based Precautions and those that are coming off precautions on 9/12/22. Current signage follows CDC Guidance. Immediate plan of correction initiated on 9/12/22 which included management assigned to complete surveillance on all shifts and weekends on appropriate PPE use, PPE supplies and Hand hygiene. This surveillance will be documented on the Covid- 19 Walking Infection Control Rounding Tool. The Management Team consisting of the Administrator, Director of Nursing, Nursing Supervisor, Social Service Director, Activities Director, Central Supply, Business Office Manager, and Manager on Duty, were educated by the Regional Nurse on 9/12/22 regarding how to complete the Covid 19 Walking Infection Control Rounds and ensuring that there is an adequate PPE supplies stocked on the units. PPE is routinely stocked during the week by the Central Supply Clerk, Weekends will be covered by Nursing Supervisor and/or the Manager on Duty. The surveillance for Infection Control Rounds and PPE supplies will be monitored by the Administrator through daily review of the Covid 19 Walking Infection Control Rounds tool, which monitors the following: 1) rooms on transmission based precautions are clearly marked with signage 2) these rooms have the doors closed as residents will allow 3) staff perform hand hygiene before and after resident care and/or contact with resident/resident's environment 4) PPE is readily available 5) PPE is donned per CDC guidance- gloves, gowns, N95s and eye protection. 6) PPE is removed and discarded per CDC guidance. 7) staff follow procedures for cleaning/disinfecting eye protection 8) staff change gloves and perform hand hygiene after each patient. Management team (as outlined above and Manager on duty) will be assigned Covid-19 Walking Infection Control Rounds by the Administrator on a schedule that will cover both shifts 7 days per week. Administrator held an ADHOC QAPI Meeting to address this plan as well as the facility's current policy for transmission-based precautions during outbreak was reviewed and current with CDC guidelines on 9/12/22. Alleged date Immediate Jeopardy was removed, 9/13/22. The Administrator is responsible for the implementation of this plan. A credible allegation of infection control was conducted in the facility on 09/14/22. Observations of the memory care unit on 09/14/22 revealed that all Covid positive rooms had a sign on the door indicating which resident was positive. Each Covid 19 positive resident room was observed to have a PPE cart outside of the room that was fully stocked with gowns, gloves, N95, and face shields. Each staff member was observed to have disinfecting wipes available to clean/disinfect their eye protection. The Nurse Supervisor was observed on the unit monitoring the infection control practices of the staff on the unit. Further observations revealed supplies of additional PPE to be located across from the main nurse ' s station, in the facility break room, and in a unlocked storage container out back of the facility. Interviews were conducted with staff members that worked in administration, nursing department, dietary department, maintenance department revealed that they had all received recent education on Covid 19, and appropriate PPE use along with hand hygiene. The managers at the facility verbalized understanding of their walking infection control rounds that they were to complete, and the supporting documentation required on the Covid 19 Walking Infection Control Round audit form. The facility's IJ removal date of 09/13/22 was validated. 2. Review of the facility policy and procedure for scabies with an effective date of 9/1/2004 and review on 11/15/2021 revealed: Definition: Crusted (Norwegian) Scabies- single or multiple cases: an infestation characterized by thick crusts of skin that contain large numbers of scabies mites and eggs. It is a severe form of scabies. 1.Identify signs and symptoms of scabies: 1.1: intense itching, especially at night, 1.2: maculopapular rash, 1.3: tiny, irregular reddish lines (burrows), 2.1 Document daily patient skin checks for 8 weeks, 2.2 Maintain a high index of suspicion that scabies may be the cause of undiagnosed skin rash; suspected cases should be evaluated and confirmed by obtaining skin scrapings. 2.5 Maintain accurate line listings with patient name, age, sex, room number, roommate name, skin scraping status and result and name of all staff who provided hands on care to the patient before implementation of infection control measures. 2.10 Follow contact precautions until 24 hours after treatment. 2.13 Ensure bedding and clothing used by a person with scabies is collected and transported in a plastic bag and emptied directly into washer to avoid contaminating other surfaces and items. Machine wash and dry all items using the hot water and high heat cycles (temperature in excess of 50 degrees Celsius or 122 degrees Fahrenheit for 10 minutes will kill mites and eggs). Ensure laundry personnel use protective garments and gloves when handling contaminated items. 2.15 Store items that cannot be washed (shoes, slippers, pillows, stuffed animals, etc.,) in a sealed plastic bag for at least 72 hours. a. Resident #21 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #21 was cognitively intact and required extensive to total assistance with activities of daily living (ADLs). Review of Resident #21's care plan initiated on 7/8/2022 revealed a care plan in place for rash on admission to upper, inner and posterior thighs, bilateral buttocks, abdominal folds and bilateral groin with interventions of redirect from scratching, administer as needed anti-itch medication initiated 8/18/2022 and was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of physician's orders for July 2022 revealed an order on 7/20/2022 of apply [MEDICATION(S)] Cream 5% (medication used to treat scabies, a condition caused by tiny insects called mites that infest and irritate the skin) apply cream to entire body topically one time for scabies to include scalp and skin scrapping and send samples to lab one time only for screening for scabies. Both orders documented as completed by Nurse Supervisor on the Medication Administration Record. Review

Based on observation, record review, resident, staff, and Nurse Practitioner interview the facility failed to perform a skin assessment upon admission and failed to initiate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #21 was admitted on [DATE] with a rash that was very itchy. The rash was not treated until 07/21/22. The finding included: Resident #21 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #21's care plan initiated on 7/8/2022 revealed a care plan in place for rash on admission to upper, inner and posterior thighs, bilateral buttocks, abdominal folds and bilateral groin with interventions of redirect from scratching, administer as needed anti-itch medication initiated 8/18/2022 and was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #21's medical record revealed no skin assessment completed on admission. Review of an admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #21 was cognitively intact and required extensive assistance with activities of daily living and no behaviors or rejection of care was noted during the assessment reference period. The MDS did not identify any open lesion other then ulcers, rashes, cuts. Review of a skin assessment dated [DATE] revealed that Resident #21 had a rash on her bilateral arms. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration dated July 2022 revealed that Resident #21 received the [MEDICATION(S)] cream as ordered on 07/21/22, 07/23/22, 07/24/22, 07/25/22, 07/26/22, and 07/27/22. An observation and interview were conducted with Resident #21 on 9/11/2022 at 3:47 PM. Resident #21 stated she was admitted to the facility on [DATE] with skin sores on her bilateral arms, legs, chest, bilateral legs, back and buttocks. She revealed she had scabies before but could not remember the date. Resident #21 stated she just thought she might have come in contact with something she was allergic to at the hospital, since her Cardiologist told her it was not scabies, but an allergic reaction to something. She indicated it was very itchy and she kept scratching the sores. An interview was conducted with Nurse Aide (NA) #5 on 9/13/2022 at 4:21 pm. NA #5 stated she was assigned to 100 hall and took care of Resident #21 upon her admission on 07/08/22. She revealed Resident #21 was admitted to the facility with a rash all over her. She stated the Nurse Practitioner was here when Resident #21 was admitted and came to assess Resident #21's rash. NA #5 revealed Resident #21 was on contact precautions because we were told she had a bad bug in her urine, so we were only wearing personal protective equipment (PPE) to empty her urinary catheter. NA #5 stated that the first time she was aware that Resident #21 was ordered a cream for her rash was on 07/23/22. The Nurse applied cream to Resident #21's entire body on Saturday, 7/23/2022, and the Nurse told me that it would need to be washed off after 24 hours. NA #5 stated she gave Resident #21 a bath on Sunday, 7/24/2022. An observation and interview of Resident #21 was made on 09/13/22 at 5:27 PM. Resident #21 was up in chair at the nursing station. She stated that this was her first time up and out of her room since admission. She was dressed in long pants and short sleeve shirt. Resident #21's bilateral arms were covered with small irregular scabs that were approximately the size of pencil eraser. They were well defined, and each area was scabbed over. There was no redness or [CONDITION(S)] or drainage and were not crusted. Resident #21 indicated that her arms looked better than they have in a long time. The Nurse Supervisor was interviewed on 9/14/2022 at 10:16 AM. The Nurse Supervisor stated that each resident upon admission was supposed to have a head-to-toe assessment including their skin. Once the admission nurse completed the assessment then the night shift nurse was supposed to check and ensure all the components of the admission were completed then the Director of Nursing (DON) would do the final check to ensure all components of the admission were completed. The Nurse Supervisor stated she did not know who was supposed to completed Resident #21's admission assessment and could not speak to how the checks and balances were not done to ensure the admission skin assessment was completed and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] An interview was conducted with Medication Aide (MA) #2 on 09/14/22 at 2:00 PM who confirmed she was working on the hall when Resident #21 was admitted to the facility. She confirmed that she did not do treatments or any form of skin assessment that would be up the Nurse Supervisor and she could not recall who was the nurse was that day. MA #2 stated that she assisted Resident #21 on the bed pan on 07/08/22 and noted that she had open [CONDITION(S)] all over her body that looked like bites or bug bites. MA #2 stated that she told a nurse but could not recall who that was but recalled being told it looked like something she was allergic to probably from the hospital. She stated she did not think that was right and couple of week later learned that it was scabies. The DON was interviewed on 9/14/2022 at 2:24 PM. DON stated she was on vacation when Resident #21 was admitted to the facility, from 7/8/2022 through 7/16/2022, so she was unaware that Resident #21's admission assessments, to include a skin assessment, had not been completed or why treatment to identified areas had not been initiated sooner. DON revealed she was supposed to have daily clinical meetings to talk about resident findings and concerns, this team is supposed to made up of the DON, Social Worker, MDS, Nurse Supervisor, Assistant Director of Nursing and Therapy, but right now the clinical team consisted of the DON and Nurse Supervisor and at lot of time the Nurse Supervisor was being pulled to the hall due to staffing challenges. The Nurse Practitioner was interviewed on 06/14/22 at 6:29 PM. The NP confirmed that she had seen and evaluated Resident #21 upon her admission to the facility on [DATE] and suspected scabies by the crusted lesion she had on her arms and legs. The Nurse Practitioner stated that she had ordered Triamcinolone cream for the itching and [MEDICATION(S)] cream for the scabies but later learned that she did not enter a date and time on the order, so the order never got carried out and the medication never got applied until it was again ordered on 07/20/22. The Nurse Practitioner also stated she was unaware until 07/20/22 that her initial order never got carried out by staff.

Based on record review, facility staff interviews, the facility failed to provide care in a safe manner for 1 of 4 residents reviewed for accidents. The resident rolled out of bed during care and sustained a laceration above his eye along with contusions to his head, skin tear to left elbow and a skin tear just above the left wrist (Resident #33). The findings included: Resident #33 was admitted to the facility on [DATE] with diagnoses that included contracture and poly-[CONDITION(S)]. Review of Resident #33's most recent annual Minimum Data Set assessment dated [DATE] revealed him to be severely impaired with no behaviors or rejection of care. He required total assistance of 2 or more with bed mobility, transfer, dressing, personal hygiene, and bathing. He required extensive assistance of 2 or more with toilet use. A review of Resident #33's progress notes revealed a progress note dated 6/18/22 at 4:47 AM and was written by Nurse #3. The note documented at approximately 12:45 AM, the nurse was called to Resident #33's room by the Nursing Assistant (NA). Upon entering the room, the nurse observed the resident lying on the floor, face down. The resident's mouth, nose, and face were found to be actively bleeding. After checking for injuries, the resident was rolled over onto side to and the resident had an approximate 1.5 centimeter (cm) laceration just above his left eye. There was also a skin tear to left elbow and a skin tear just above his left wrist. The nurse applied pressure to left eye to control the bleeding while another nurse called 911 for emergency transport. The resident was sent to emergency room (ER) and received stitches above the left eye and steri-strips to the left elbow. The resident returned was documented as having returned to the facility in stable condition. Review of Resident #33's hospital notes dated 6/18/22 from his visit post fall revealed he was treated for a 1.5 cm laceration above the left eye between the eyebrow and eyelid. The notes indicated 3 sutures (stitches) were completed with no complications. Other injuries noted in the hospital report included a contusion (bruise) to Resident #33's left knee and shoulder, a contusion on his head, a cervical strain, and abrasions and skin tears. An interview with Nurse Aide (NA) #6 on 9/13/22 at 4:00 PM, she reported she remembered the night Resident #33 fell out of bed on 6/18/22. She stated it was her first night working and on her 2nd round, she went into Resident #33's room and noticed he had vomited on himself and had some diarrhea. She reported after she changed him and had removed his dirty sheets, she rolled him on his side to put on clean sheets and when she went to apply the corner of the fitted sheet over the corner of his mattress, Resident #33 rolled out of bed towards her and face down onto the floor. She reported she believed he hit his head, elbow, and side. NA #6 verified it was just her in the room during care and that she was under the impression from the NA she received report from that Resident #33 was a one person assist. She stated she did not verify his care status with the nurse or in the electronic system. NA #6 detailed that Resident #33 was bleeding from his head, so she went and got the hall nurse immediately who assessed the resident and began first aid while another staff member contacted 911. During an interview with Nurse #3 on 9/14/22 at 4:45 PM, she reported she remembered the night Resident #33 fell on [DATE]. She stated she was on the hall when NA #6 came and got her and stated Resident #33 had fallen from the bed while she was providing care. Nurse #3 stated she went to the room and noticed he was bleeding from his head and was face down on the floor. After she assessed him, they rolled him over and she noted a laceration above Resident #33's eye that looked like it would need stitches. 911 was called and resident was sent to the emergency room for treatment and evaluation. She reported she believed he returned shortly after with stitches and other bandages from various skin tears. A review of the facility ' s fall investigation dated 6/18/22 and completed by Nurse #3, revealed Resident #33 was being cleaned up from vomiting just before incident occurred, was turned to his side to prevent aspiration if vomiting should occur again, NA (Nurse Aide) #6 was reaching for a clean sheet when resident rolled onto the floor. Per the investigation, there was only one staff member in the room at the time and attempted to change the bed sheets when Resident #33 fell from the bed. During an interview with the Director of Nursing on 09/14/22 at 5:54 PM, she reported she was aware of the incident and reported staff should verify care needs by looking at the electronic system. The DON indicated NA #6 received training to verify care status before providing care to all residents on her assignment. She stated all staff should verify care needs daily before their shift to ensure they knew how many staff members would be needed to safely provide care. She reported if Resident #33 was coded as requiring 2 or more persons to assist with bathing, dressing, toilet use, and personal hygiene, then there should have been at least two staff members in the room the night he fell out of the bed.

Based on observations, record review, resident, and staff interview the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification survey completed on [DATE] and the complaint investigation completed on [DATE], [DATE], and [DATE]. This was for three repeat deficiencies in the area of respiratory care, supervision to prevent accidents, and prepare and serve food under sanitary conditions that were originally cited on [DATE] during a recertification survey and complaint survey for four repeat citation in the area of notification, supervision to prevent accidents, significant medication errors, serve food under sanitary conditions, and infection control that was cited on [DATE], [DATE], and/or [DATE] during a complaint investigation. The continued failure of the facility during three federal surveys showed a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program. The finding included: This citation is cross referred to: F580: During the recertification of [DATE] the facility failed to notify the Physician of a medication unavailability for 1 of 1 resident (Resident #38) reviewed for pain. During the complaint investigation of [DATE] the facility failed to notify the medical provider of a delay in administering an antibiotic and steroid for 1 of 4 sampled residents. F689: During the recertification of [DATE] the facility failed to provide care in a safe manner for 1 of 4 residents reviewed for accidents. The resident rolled out of bed during care and sustained a laceration above his eye along with contusions to his head, skin tear to left elbow and a skin tear just above the left wrist (Resident #33). During the recertification of [DATE] the facility failed to determine the root cause analysis of a Resident's fall with no injury, in order to implement effective interventions to prevent further falls for 1 of 5 residents reviewed for accidents. During the complaint investigation of [DATE] the facility failed to provide supervision to prevent accidents by leaving a resident unassisted on the toilet while summoning assistance which resulted in a resident being lowered to the floor. Once the resident was lowered to the floor the facility failed to assess the resident and subsequently failed to notify the medical provider. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected 1 of 3 residents (Resident #1) investigated for providing care according to professional standards. F695: During the recertification survey of [DATE] the facility failed to keep air filters on oxygen concentrators clean and free from dust buildup for 1 of 3 residents reviewed for respiratory care (Resident #24). During the recertification survey of [DATE] the facility failed to administer oxygen as ordered and failed to replace oxygen cannula that had been placed on the floor for 2 of 3 residents reviewed for respiratory management. F760: During the recertification of [DATE] the facility failed to prevent a signification medication error when they failed to obtain and administer a steroid medication as ordered by the Physician for 1 of 2 residents reviewed for pain (Resident #38). During the complaint investigation of [DATE] the facility failed to administer an antibiotic and steroid per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] F812: During the recertification survey of [DATE] the facility failed to remove expired refrigerated food items and food items with signs of spoilage stored ready for use, failed to date opened containers of food stored in the reach-in cooler and failed to ensure 1 of 1 refrigerator was free from dust and black slimy. These practices had the potential to affect food served to residents. During the complaint survey of [DATE] the facility failed to follow their recipe for pureed egg salad and failed to serve pureed egg salad, a potentially hazardous food at 41 degree or below per the recipe on the lunch tray line for 1 of 1 observed meal. This had the potential to affect 2 of 12 residents on the 100 hall. The facility also failed to remove expired food items and unlabeled food items from 1 of 1 refrigerator, 1 of 1 freezer, 1 of 1 dry storage areas, and 1 of 2 (200 hall) nourishments rooms reviewed. During the recertification survey of [DATE] the facility failed to label, and date opened food items in one of two kitchen refrigerators and one of one nourishment room refrigerators and failed to remove expired items from one of one nourishment room refrigerators. F880: During the recertification survey of [DATE] the facility failed follow the Center for Disease Control and Prevention (CDC) guidelines and facility policy when they did not identify Covid 19 positive residents and failed to place them on transmission-based precautions, therefore the staff (Nurse Aide (NA) #3, NA #4, and Housekeeper #1) failed to don/doff personal protective equipment (PPE) when entering and exiting a Covid 19 positive room and before interacting with other residents (Resident#35, Resident #41, and Resident #44) this affected 3 of 24 residents on 1 of 4 units (memory care unit.) The facility failed to have personal protective equipment available for the staff to use when caring for Covid 19 positive residents that resided on the memory care unit. The facility was in outbreak status that started on [DATE] and affected 10 of 24 residents on the memory care unit. There were 5 residents that had not had Covid 19 in the last 90 days and of those 5 residents 1 was unvaccinated against Covid 19. The facility further failed to identify and prevent the spread of scabies (a very contagious skin condition caused by a tiny burrowing mite). This affected 2 of 4 units in the facility (100 and 200 units). During the complaint investigation of [DATE] the facility failed to follow the facility hand washing policy when 1 of 3 staff members (Nurse Aide #2 ) failed to wash her hands and change her gloves between contact between 2 residents (Resident #2 and Resident #3) on 1 of 4 halls (300 hall) and also failed to follow Center for Disease Control and Prevention (CDC) guidelines regarding appropriate Personal Protective Equipment (PPE) for counties of high transmission rate when 1 of 1 Hospice Staff failed to wear eye protection when providing care to 1 of 1 resident (Resident #1). The failure occurred during a COVID-19 pandemic. The Administrator was interviewed on [DATE] at 6:15 PM. The Administrator stated he has not had the opportunity to have a QA meeting since he came to the facility a few weeks ago. He stated the QA members were made up of the Administrator, the Director of Nursing, Dietary Manager, Business office manager, Maintenance Director, Social Worker, Activities Director, Housekeeping director, Nurse Supervisor and the Medical Director was always invited. The Administrator stated that he currently had 5 areas that the facility was currently working on improving and obviously we will look at the things identified during the survey. He stated he was made aware of the issues as they were identified during the survey but did not realize how significant they were. The Administrator stated he had to have consistent staff especially with infection control to make progress and maintain that progress. He added he would be holding staff members accountable and especially the department managers and he believed through consistency and accountability the facility can achieve substantial compliance.

Based on observation, record review, staff, Nurse Practitioner, Medical Director, and Radiologist interviews the facility failed to provide supervision to prevent accidents by leaving a resident unassisted on the toilet while summoning assistance which resulted in a resident being lowered to the floor. Once the resident was lowered to the floor the facility failed to assess the resident and subsequently failed to notify the medical provider. The resident sustained [REDACTED]. This affected 1 of 3 residents (Resident #1) investigated for providing care according to professional standards. The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was moderately impaired for daily decision making and required total assistance of 2 staff members with transfers and toileting. The MDS further indicated that Resident #1 had one fall with injury (except major) since the previous assessment. Review of a care plan last updated on 03/18/20 read in part, Resident #1 was at risk for falls related to impaired mobility, unsteady gait, pain, [MEDICAL CONDITION], dementia, non-complaint with calling for assistance of staff for transfers, history of falls, and demanding behavior with history of placing self in the floor. The goal read, Resident #1 has had a change in wheelchair due to brakes and brakes stopped being faulty. The interventions included: continue to remind resident to call for assistance, encourage and remind resident to lock wheelchair brakes prior to transfer, encourage resident to use bathroom light prior to attempting to transfer to toilet, encourage resident to use grab bar in bathroom if she is going to transfer herself to toilet unassisted, and offer and assist with commode as requested/needed. Review of a late entry Change in Condition created on 05/03/20 read in part: on 05/02/20 at 3:40 PM a change in condition had been noted. The symptoms included: fall on 05/02/20 in the afternoon. Change reported to primary care clinician, order obtained, and name of family/healthcare agent notified were all blank. The change in condition indicated that no changes were noted, and no pain was reported. The summary read, Nurse Aide (NA) reported resident lowered to floor in bathroom. The change in condition was signed by Nurse #1. Review of the on-call log (which was used to document phone calls made to the on-call Medical Director or Nurse Practitioner) indicated Nurse Practitioner (NP) #2 had been on call 5/02/20 and 5/03/20. A call had been placed on 5/02/20 at 7 PM (unrelated to Resident #1.) and another on 5/03/20 at 1:34 AM by Nurse #3 related to Resident #1. An interview was conducted with NA #1 on 06/25/20 at 2:06 PM. NA #1 stated that on 05/02/20 she was caring for Resident #1 and was familiar with her care. At approximately 3:00 PM Resident #1's call light came on and she responded to find Resident #1 in the bathroom on the commode. NA #1 stated she was not sure how Resident #1 got on the commode but stated she assumed her partner on the unit that day NA #3, placed her on the commode. She instructed Resident #1 to sit still while she went to find some help in getting her off the commode because Resident #1 usually required 2 person assistance with transfers with the use of a gait belt. NA #1 added Resident #1 had a history of [REDACTED]. NA #1 stated she went to the doorway and could not find any other staff, so she returned to the bathroom and Resident #1 was standing between the toilet and sink. Resident #1 reached out for her and said she was going to fall. NA #1 stated she did what she was trained to do. NA #1 stated that Resident #1's wheelchair was sitting outside the door out of her reach, so she pulled Resident #1 to her own thigh and slid her down her leg to the floor as gently as possible. She indicated she sat Resident #1 on the floor on her buttocks with her feet straight out in front of her. Once Resident #1 was on the floor NA #1 again went to the door to find some help and saw Nurse #1 coming down the hallway. She summoned her to Resident #1's room. NA #1 stated that she and Nurse #1 got on each side of Resident #1 and lifted her off the floor and stood her up so they could clean her bottom. While Resident #1 was standing with her pants down she and Nurse #1 visually checked Resident #1 and asked her if she was ok and she replied yes she was fine. Once they had her cleaned up, they placed her back in the wheelchair. NA #1 stated that Resident #1 did not voice any complaints and was not showing any non-verbal signs of pain or discomfort. An interview with Nurse #1 was conducted on 06/25/20 at 12:13 PM. Nurse #1 stated that on 05/02/20 (she could not recall the time) she was walking down the hall and saw NA #1 in the hall summoning her to Resident #1's room. Nurse #1 stated she went into Resident #1's bathroom and observed Resident #1 sitting on the floor on her bottom with her legs out in front of her. She stated that they lifted Resident #1 off the floor by grabbing Resident #1 under her arms and stood her up. Nurse #1 stated that once Resident #1 was standing up with their assistance she looked at her legs and her arms and did not see anything and they placed Resident #1 in her wheelchair. Nurse #1 again confirmed that it was a visual check and no range of motion was completed and stated she could not answer if Resident #1 was able to bear weight because she and NA #1 had a hold of Resident #1. Nurse #1 stated that she did not recall any inward rotation of the leg or foot and observed no bruising. She added that Resident #1 also had no indication of pain. Nurse #1 stated that shortly after the incident Resident #1 did complain of pain in her right leg and she gave her some Tylenol and that was effective. Nurse #1 stated she did not consider this a fall because NA #1 said she sat her in the floor. She further stated she does not recall obtaining vital signs. Nurse #1 added that if someone was lowered to the floor then it was considered a fall, but NA #1 stated she lowered Resident #1 to the floor, so she initially did not consider this a fall. Nurse #1 stated that it was her responsibility to determine if Resident #1 had any injury but NA #1 kept saying she did not fall she was lowered to the floor. Nurse #1 confirmed that for the remainder of her shift, she did no further assessment, inspection, range of motion, or vital signs of Resident #1. Nurse #1 stated that she did not call the Medical Director (MD) because she was lowered to the floor, she did not consider this a fall at the time. She also confirmed that she did not notify the MD when Resident #1 began complaining of pain in her right leg after being lowered to the floor. An interview was conducted with NA #2 on 06/25/20 at 11:26 AM. NA #2 confirmed she was the night shift staff that cared for Resident #1 on 05/02/20-05/03/20. NA #2 stated that during report NA #3 reported that Resident #1 had fallen in the bathroom earlier in the day. NA #2 stated they rounded with Resident #1 at approximately 6:50 PM and during that round they provided incontinent care and she complained of her right leg hurting and she reported that to Nurse #2 and Nurse #3 but she did not notice any visible injuries to her leg. NA #2 stated that she again rounded at 10:00 PM to again provide incontinent care and Resident #1 was still complaining of right leg pain but she stated she did not notice anything wrong with the leg but again reported it to the nurse who she believed gave Resident #1 some Tylenol. NA #2 stated at 1:00 AM when they rounded with Resident #1 and pulled the covers back the knee was swollen, and the leg was turned inwards and was badly bruised and had a blister. NA #2 stated she immediately went and got Nurse #2 and Nurse #3 and they came to Resident #1's room. An interview was attempted with NA #3 on 06/25/20 at 2:36 PM and was unsuccessful. An interview was conducted with Nurse #3 on 06/25/20 at 3:05 PM. Nurse #3 stated that the first time he encountered Resident #1 on 05/02/20 was when he took her medications at 8:30 PM. He stated she was resting in bed and did not have any complaints at the time, and he did not perform any assessment at that time. Nurse #3 stated that Nurse #1 had reported Resident #1 was lowered to the floor earlier in the day and had no injury. Sometime after midnight NA #2 reported that Resident #1 was guarding her right leg and would not let them move her. Nurse #3 stated he went to the room and as soon as he touched her leg she cried out in pain, the leg was shorter than the left leg and was rotated inwards. Nurse #3 stated he knew that it was broken or dislocated. He stated he notified the on-call provider and obtained an order for [REDACTED].#3 stated Resident #1 was discharged to theER on [DATE] at 3:15 AM. He stated that he was unsure if Nurse #1 notified the medical provider but stated there was no change in condition note completed and no 72-hour monitoring (which was standard procedure after a fall) initiated until he completed them. An interview was conducted with Nurse #2 on 06/25/20 at 2:29 PM. Nurse #2 stated she was in training with Nurse #3 on night shift on 05/02/20-05/03/20. She stated that sometime after midnight NA #2 came to her and stated that Resident #1 did not want to be moved and was hurting really bad. Nurse #2 stated that she went to Resident #1's room and her right leg was red, swollen, and had a blister. Nurse #2 stated she really did not complain of pain unless they were moving her. She stated since she was in training Nurse #3 did the majority of the paperwork, but she did assess the leg for a pulse and was able to find one. Review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. An x-ray report from the local ER read: Right Tibia (shin bone)/Fibula (lower leg bone): obtained 05/03/2020 at 4:25 AM read in part, Acute tibial (shin bone) fracture and acute fibula (lower leg bone) fracture, and osteopenia (low bone mass). Resident #1 was readmitted to the facility on [DATE] after surgical repair of her acute tibial and fibular neck fracture. An observation of Resident #1 was made on 06/25/20 at 10:35 AM. Resident #1 was up in her wheelchair dressed in pants and a sweater and had on slippers. She was leaning to the left side of her wheelchair and was propelling herself in short distances. An observation and interview were conducted with Resident #1 on 06/25/20 at 3:46 PM. Resident #1 was up in her wheelchair in her room sucking on a sucker. Resident #1 stated she did not recall falling and breaking her leg. When asked if her leg hurt, she pointed to her right knee area. Resident #1 stated she took a pill for her pain and that it helped ease the pain most of the time. Resident #1 was asked if she recently had surgery on her right leg and she replied, did I? Resident #1 had no recollection of the fall, fracture or subsequent surgery. An interview was conducted with the Director of Nursing (DON) on 06/25/20 at 5:05 PM. The DON stated she started with the company on 05/18/20. The DON stated that when an incident occurred whether it be a fall, or a resident being lowered to the floor the staff were expected to immediately let the nurse know. The nurse was expected to immediately conduct a head to toe assessment and from that assessment determine what the next action was. They should obtain a set of vital signs and initiate neurological checks if needed. They need to determine if the resident needs to go the ER or if they can be treated in the facility. The DON stated that anytime a resident went from a higher plane to a lower plan that was considered a fall whether it was assisted or unassisted. The DON stated that she expected the Nurse to complete a head to toe assessment including range of motion moving the arms/legs and a set of vital signs despite what the NA told them. In addition, the DON stated the MD should be notified as soon as possible following the incident. If the resident began complaining of pain, she would expect another assessment to be completed and the MD provider to be notified of the new onset of complaints. An interview was conducted with the MD on 06/26/20 at 12:43 PM. The MD stated that he was aware of the fall and fracture with Resident #1 via the on-call system. The MD stated that it would be very coincidental to have a fracture after a fall or being lowered to the floor coupled with osteopenia. He stated he was not able to discern if the fracture occurred at the time of the incident or if it was spontaneous, but it would be very coincidental if it occurred spontaneously after having a fall. The MD stated that after any type of incident whether it be a fall or being lowered to the floor, he expected the nursing staff to conduct a complete head to toe assessment including range of motion and a set of vital signs and subsequently notify the medical provider. He further stated that if a resident began complaining of pain after the incident, he would expect another assessment to be completed and the medical provider to again be notified. An interview was conducted with NP #2 on 06/26/20 at 2:11 PM. NP #2 confirmed that she was on call the weekend of 05/02/20 -05/03/20. She stated that she received a call in the early hours of 05/03/20 reporting that Resident #1 was having pain and swelling to her leg after being lowered to the floor. An x-ray was ordered but when the x-ray company could not come for an extended period of the time a decision was made to send Resident #1 to the local ER for evaluation. NP #2 stated she did not recall the specific details about the call at 7:00 PM from the facility but stated the call on 05/03/20 in the early morning hours was the first time she had been notified about Resident #1 falling or her complaints of pain. An interview was conducted with the Radiologist on 06/29/20 at 10:01 AM. The Radiologist confirmed he read Resident #1's x-ray report at the local ER. He stated that her tibial plateau fracture was most likely a result of her recent trauma. The type of fracture that Resident #1 sustained does not typically occur spontaneously as a result of osteopenia. The fractures seen on the x-ray report are going to be the result of some type of trauma 99% of the time. The Radiologist stated that Resident #1 was certainly at risk for other types of fracture due to her osteopenia but there was some type of trauma to bust her tibia in this way in my professional opinion.

Based on observations, record review and resident, Physician and staff interviews the facility neglected to protect a cognitively impaired and dependent resident who was left unattended in the facility's outside courtyard for at least 3 hours in the sun with an outside temperature of 86 degrees Fahrenheit for 1 of 4 residents reviewed for neglect. Resident #1 was found outside in the courtyard lethargic and sluggish and received second [MEDICAL CONDITION] blisters on both of his thighs. Resident #1 was sent to the hospital for evaluation and treatment and returned to the facility. Immediate jeopardy began on 09/15/19 when Resident #1, who was moderately impaired in cognition, was left outside in a courtyard smoking area in the sun for at least 3 hours and had second [MEDICAL CONDITION] both of his thighs. Immediate jeopardy was removed on 10/03/19 when the facility provided and implemented a Credible Allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place are effective. Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A current care plan most recently reviewed by staff on 05/22/19 revealed Resident #1 could smoke with supervision and the goal indicated Resident #1 would smoke safely every shift. The interventions were listed in part to supervise Resident #1 with smoking in accordance with his assessed needs. A Quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was moderately impaired in cognition for daily decision making and was totally dependent on staff for bed mobility, transfers and locomotion on and off the unit in a wheelchair. A Smoking Evaluation dated 07/02/19 indicated in part Resident #1 required supervised smoking because he could not hold a cigarette safely. During a telephone interview on 10/04/19 at 10:18 AM, Nurse Aide (NA) #4 explained on 09/15/19 she was told to take residents out to smoke at 1:00 PM to a courtyard smoking area. She stated she left her assigned unit and went to the courtyard but Resident #1 was already there with other residents. She further stated she did not know who had transported Resident #1 outside. She explained she recalled Resident #1 smoked 1 cigarette and when residents had finished smoking, she asked Resident #1 if he wanted help to get back inside the facility, but he said no. She stated she told a Nurse, but could not recall who it was, the alarm needed to be turned off and she assisted all the residents except Resident #1 inside the facility. She confirmed she did not tell the Nurse she had left Resident #1 outside in the courtyard. She explained she did not realize Resident #1 could not get back inside the facility by himself. She stated she put the resident's smoking materials away and went back to her assignment because it was a busy day and she was behind on getting work done. She further stated she should have gone back to check on Resident #1 but she did not. She explained she recalled Resident #1 was dressed in a shirt with sleeves down to his elbows, he had on long pants and was wearing a toboggan on his head and was sitting in his wheelchair half way under the canopy and half way in the sun. During an interview on 10/01/19 at 4:07 PM, the Social Worker explained she was the manager on duty on Sunday 09/15/19 from 8:00 AM until 12:00 PM. She stated there were no concerns reported to her regarding Resident #1 while she was at the facility and after she left the facility she did not receive any calls about Resident #1. A review of a Nurse's note dated 09/15/19 at 4:31 PM documented by Nurse #1 revealed NA #1 called for Nurse #1 to come to the smoking area. The note indicated Resident #1 was found sitting in a wheelchair outside in the smoking area and Nurse #1 found Resident #1 was lethargic (sluggish) and would not respond verbally to Nurse #1. The note further indicated Resident #1 was immediately brought inside, and his vital signs were obtained and his blood pressure was 146/77, pulse 129, oxygen saturation percentage 94, respirations 18 and his temperature was 101.2 degrees Fahrenheit (F). The note revealed Resident #1 was transported to the emergency room (ER) for evaluation and treatment. During an interview on 10/03/19 at 9:03 AM, Nurse #1 explained she was assigned to Resident #1 on 09/15/19 during the 6:30 AM to 6:30 PM shift and remembered it was a very busy day. She stated she recalled Resident #1 ate lunch in his room and she gave him medications around 12:30 PM. She further stated she saw Resident #1 after lunch in the hallway in his wheelchair but she did not recall what time that was. She explained Nurse Aides (NAs) assigned to the 400 hall were responsible to take resident's out for the 1:00 PM smoke break and they were supposed to stay with residents until they finished smoking. She stated if a resident stayed outside after the smoke break the NAs were supposed to let the Nurse or the NA assigned to the resident know that the resident so they could check on them frequently. She explained later that afternoon, NA #1 came to her around 4:00 PM and told her she needed to go to the smoking area right away. Nurse #1 stated she went outside to the courtyard and Resident #1 was sitting in a wheelchair in the sun on the concrete patio and he was slumped to one side and did not speak her. She further stated she took Resident #1 inside to the nurse's station to check his vital signs and she asked Resident #1 if he could speak and he said yes but Resident #1 said nothing else. She confirmed Resident #1 had on a toboggan and sweatshirt and long pants. She stated and it was a hot day and her first concern was Resident #1 had gotten too hot. She explained she remembered Resident #1's temperature was over a 100 degrees F and they took him to his room and put him on his bed because she was trying to hurry to get him ready to send to the hospital. She stated when she saw Resident #1's legs her first instinct was he had been sunburned. She confirmed she had not seen Resident #1 in the courtyard smoking area until NA #1 called her to go out there around 4:00 PM. She confirmed it was a hot day and there was no water station or fluids for residents to drink in the smoking area. She explained she notified the Administrator about the incident after Resident #1 had been sent to the hospital. During a telephone interview on 10/01/19 at 2:25 PM, NA #1 stated she was assigned to Resident #1 on 09/15/19 during the 6:30 AM to 6:30 PM shift and confirmed he ate lunch in his room. She explained after Resident #1 ate lunch he got his wheelchair stuck between the overbed table and the door of his room and she assisted him to propel into the hallway. She further explained Resident #1 was unable to propel himself through both doors at the courtyard and needed staff assistance to go outside. She confirmed NA #4 was assigned to go outside with residents in the smoking area at 1:00 PM but NA #4 did not report off to her that Resident #1 stayed outside after the smoke break was finished. NA #1 stated it was their usual routine to make rounds every 2 hours to check and change residents but Resident #1 usually stayed out of his room and she did not realize he was still outside in the courtyard. NA #1 further stated she was assigned to take residents outside for the 4:00 PM smoke break and when she went to the courtyard she found Resident #1 was sitting in a wheelchair in the sun and he was unresponsive. She explained she called for Nurse #1 and they brought Resident #1 inside the facility and transferred him to bed. She explained when they took his pants off she saw blisters on the upper part of his thighs and one leg had more blisters than the other. She stated she recalled Resident #1 had on long pants that were a light and dark color. During an interview on 10/01/19 at 11:06 AM, Nurse #2 explained the facility had designated smoking times at 9:00 AM, 11:00 AM, 1:00 PM, 4:00 PM and 8:00 PM and NAs from each hall rotated to take residents out to smoke on weekends. She explained she recalled on 09/15/19 Resident #1 was sitting across from the nurses station before the 1:00 PM smoke break and when it was time to go out to smoke he propelled himself to the first door of the courtyard. She stated Resident #1 could not get himself through the door but she did not recall who took Resident #1 out to the courtyard. She explained it usually took residents about 30 minutes to finish smoking and she was told all of the residents came back in after the smoke break except Resident #1 did not come back insided. She further explained NA #4 who was in the courtyard during the 1:00 PM smoke break did not report that Resident #1 had been left outside. She stated it was a hot and sunny day and around 4:00 PM she heard NA #1 call for Nurse #1 to come to the courtyard. Nurse #2 stated she ran out to the courtyard and Resident #1 was sitting in a wheelchair in the sun approximately half way between a covered canopy and the courtyard door and he was slumped to his right side with saliva running from his mouth and down onto his shirt. She explained Resident #1 was unresponsvide and they took him inside to his room and transferred him to his bed. She stated when NAs removed Resident #1's pants there were multiple areas with bilsters on the top of both of his thighs approximately 1-2 inches in length and they were raised approximately one-half inch and it looked like his legs had been sunburned. She further stated she recalled Resident #1 had on long pants but did not recall any specifics about them or his other clothing. During a telephone interview on 10/01/19 at 2:40 PM, NA #3 stated on 09/15/19 she fed Resident #1's roommate lunch while Resident #1 ate lunch in his room. She explained Resident #1 could propel himself in his wheelchair but only for short distances of about 5 feet. She stated she was not sure who took Resident #1 out to the courtyard at 1:00 PM but at approximately 4:00 PM the 300 hall NAs were taking residents out to smoke and found Resident #1 outside. She explained when she got to the courtyard Resident #1 was slumped over and had saliva running out of his mouth. She stated she recalled his shirt was wet from sweat and he had on long pants that had a light and dark print. She explained when NAs removed Resident #1's pants, she saw his thighs were red and blistered. During a telephone interview on 10/01/19 at 3:30 PM, NA #2 explained on 09/15/19 she went to Resident #1's room to help out after staff had brought him inside. She stated she recalled he had on long black pants that were thin but she was not sure what the fabric was made of. She also stated he had on a long sleeve shirt that was wet with sweat. She explained when they removed his pants the skin on his thighs were bright red with blisters. She also confirmed Resident #1 could not propel himself without staff assistance through the doors at the courtyard. An Emergency Department note dated 09/15/19 at 4:34 PM revealed in part Resident #1 was taken outside to smoke and he was left alone and was found to have blisters on his legs. The note also indicated a large water type blister was on his inner thigh of his left leg and both legs were red. The note further indicated Resident #1 was nonverbal on arrival to the ER, his temperature was 99.9 degrees F and his vital signs were monitored. A section of the Emergency Department note titled physical exam dated 09/15/19 at 5:59 PM indicated Resident #1 was awake but lethargic and [MEDICAL CONDITION] debrided and his condition had improved. An attempt on 10/03/19 at 10:39 AM to interview the ER Physician who had treated Resident #1 was unsuccessful. A Nurse's progress note dated 09/16/19 at 3:29 AM indicated a call was received from the hospital that the ER Physician had debrided Resident #1's left upper leg and the dressing on the area was to be changed twice a day and [MEDICATION NAME] applied with an abdominal pad (thick dressing) and wrapped loosely with kling (gauze wrap). The note also revealed Resident #1 was to follow up with a Physician and start Keflex (antibiotic) 500 milligrams by mouth 3 times a day for 7 days. The note further revealed Resident #1 returned to facility on 09/16/19 at 3:29 AM by Emergency Medical Services with a dressing to his left upper leg and redness with multiple blisters was observed above the top of the dressing on his left leg and redness was throughout the top of his right leg. A skin integrity report dated 09/18/19 documented by Nurse #4 revealed in part Resident #1's right upper thigh burn measured 9.7 centimeters (cm) x 2.3 cm and a right lower thigh burn measured 18.3 cm x 5.6 cm. The note also indicated a left lower thigh burn measured 27.9 cm x 18.6 cm. A Physician's progress note dated 09/24/19 revealed Resident #1 was placed on rounds today [MEDICAL CONDITION] were acquired earlier this week and he was seen in the ER and was given topical (on the skin) [MEDICATION NAME]. The note further revealed Resident #1 stated he was outside and it was caused by the sun. The note also revealed Resident #1'[MEDICAL CONDITION] along the proximal (close to the center) thigh but no where else. The note indicated Resident #1 was slow to self-propel a wheelchair and moved slowly along the hand rail. A section labeled plan indicated to continue topical [MEDICATION NAME] as ordered with dressings and monitor for secondary infection. The note also revealed there was no infection present and Resident #1's pain was controlled with [MEDICATION NAME] (narcotic pain medication) and continue to monitor closely. During an interview on 10/01/19 at 1:30 PM, Resident #1's Physician who was also the facility Medical Director explained she was notified Resident #1 had been sent to the hospital with burns. She stated she was asked to see Resident #1 last week on rounds and when she asked him what happened, he told her in the sun. She explained [MEDICAL CONDITION] distributed on both thighs and down in his medial (middle) thighs and thought it could have been caused by the sun. She confirmed Resident #1 had second [MEDICAL CONDITION] both thighs and they were extensive. She stated Resident #1 had not had any secondary infections from [MEDICAL CONDITIONS] heal but she expected there would be scarring. She explained due to Resident #1's medical conditions he could not defend himself or get himself out of that type of situation and she felt the incident was avoidable. During a follow up telephone interview on 10/03/19 at 3:32 PM with Resident #1's Physician she stated in her professional opinion Resident #1's rise in temperature to 101.2 degrees F. could have been related to him sitting in the heat for approximately 3 hours. She further stated she did not know what the temperature was that day but recently they had heat indexes in the 90's. She also stated Resident #1's unresponsiveness could have been due to the heat from sitting in the sun and she was concerned because he was also an insulin dependent diabetic. During an observation and interview on 10/01/19 at 10:10 AM, Resident #1 was seated in a broda chair in the hallway dressed in sweat pants, a long sleeve shirt and he had a toboggan on his head. When asked what had caused [MEDICAL CONDITION] his legs, he stated the sun but did not offer any other explanation. During an interview and observation on 10/01/19 at 10:48 AM, Nurse #4 confirmed she had already provided treatments to Resident #1'[MEDICAL CONDITION] that morning but the dressings could be observed. Resident #1 was observed in bed and when his pants were removed the gauze wrap had rolled down at the top of the dressings on both thighs and both thighs had areas of open skin with [MEDICATION NAME] ointment in place. During a follow up interview on 10/03/19 at 1:07 PM, Resident #1 stated when asked what had happened to his legs I burnt them up but they are getting better. When asked how he did that he said in the hot sun and he verified he had on a long sleeve shirt and long pants and his toboggan because that was what he liked to wear everyday. A review of local weather data revealed a high temperature of 86 degrees on 09/15/19. Observations of the courtyard smoking area revealed a large concrete pad with no covering or shade at the front. Near the back of the courtyard there was a large canopy with a table and chairs underneath. During an interview with the Administrator on 10/02/19 at 11:26 AM she confirmed Nurse #1 called her around 5:45 PM on 09/15/19 and told her an event had taken place with Resident #1. She explained Nurse #1 told her Resident #1 was left outside unattended and she thought he had sustained sunburns. She stated Nurse #1 also said Resident #1 was unresponsive to verbal stimuli and he was brought inside and was sent to the hospital. She confirmed NA #4 was in the courtyard for the 1:00 PM smoke break but did not do a clear all to ensure all residents had been brought back inside after the smoke break. She explained NA #4 did not go back outside later to check to see if any residents were still outside. The Administrator was informed of immediate jeopardy on 10/02/19 at 3:43 PM. The facility provided an Acceptable Allegation of Immediate Jeopardy removal on 10/03/19 at 12:32 PM as follows: Identify those residents who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Resident #1 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. On 9/15/2019 at approximately 4:00 pm the resident was found outside in courtyard/smoking area unresponsive. Resident # 1 was noted to be in the sun without shade or fluids available. He was taken into the center and assessed by the nurse on duty. Temperature was 101.2, BP 146/77 and Pulse 129. Difficult to arouse. Upon assessment resident was noted to have burns/blisters to both thighs. Resident was sent to the emergency room for evaluation where he had 2nd [MEDICAL CONDITION] and returned to the center with treatment orders and an antibiotic. On Monday (MONTH) 16, 2019 a full investigation was initiated and a self-report was sent to DHHS. Through the investigation it was determined that resident had been outside in the courtyard/smoking area since approximately 1:00 pm for the scheduled smoking time. Resident estimated to have been outside in high temperatures (between 85 and 90 degrees) for approximately 3 hours unattended. Staff failed to check on residents that had been out on the 1:00 p.m. smoke break. No other residents have been affected by this deficient practice as evidenced by [MEDICAL CONDITION] on Skin Assessments completed since 9/15/19, and no residents with signs and symptoms of exposure. As evidenced by skin assessments completed on 100% current residents week of 9/16-9/21/19. Specify action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when action will be complete: Center Executive Director notified the Regional Nurse of this event on 9/16/19 and a plan of correction was drafted to address and prevent future occurrences. Part of this plan included education for the staff and ongoing monitoring. Education was conducted, however did not include 100% of current staff. This education included importance of checking on residents frequently and not leaving dependent residents unattended in courtyard and rounding on residents more frequently. An ADH[NAME] QAPI was held with IDT however it did not include the Medical Director. Ongoing audits were conducted according to the plan, however did not include off shifts and weekends. On 10/02/19 Education was initiated to include review of Center Neglect Policy and re-education on not leaving dependent residents unattended in the Courtyard/Smoking area. Education also addressed ensuring residents are free from Sun Exposure/ heat to include ensuring that residents that wish to be outside on days of extreme heat have access to shade and sufficient fluids, and monitoring residents that choose to sit outside. Residents who are dependent and /or cognitively impaired that wish to sit outside will either have staff member present with them or be checked every 15 minutes. Education included Full time/Part time/PRN and Agency staff members, as well as contract staff members for Dietary, Laundry and Housekeeping. Education is at 80 % for all Nursing Employees, any staff that have not received this training will not work until they have completed the education. This education will be added to the orientation/onboarding process for all new hires and new agency staff. Center Executive Director will draft a memo to family members, which will be sent out today, addressing concerns with heat exposure and what steps have been taken by the center to ensure residents have shade, fluids, sun screen and monitoring while they enjoy the outdoors. The Center Executive Director and/or the Social Service Director will personally discuss these actions with each alert and oriented resident today and provide a copy of the memo. Any visitors today will receive this education in person by the Center Executive Director or the Director of Social Services. Social Services Director will be responsible tracking what family members have received in person education or mailed the information. On 10/03/19 at approximately 9:00 a.m. an electronic, self-serve water cooler and disposable cups were placed outside in the courtyard/smoking area for residents to have access to fluids while outside. The water cooler will be maintained by the Maintenance Director. Residents requiring assistance with fluids and/or on thickened liquids will be offered hydration by staff through the monitoring process established in this plan. Alleged date Immediate Jeopardy was removed, 10/03/19. Administrator is responsible for the implementation of this plan. The facility's Credible Allegation of Immediate Jeopardy removal was verified on 10/03/19 at 6:08 PM. Administrative, nursing, housekeeping, dietary, social work and therapy staff all verified they had received training regarding neglect and the importance of checking on residents frequently when they were outside. They also verified they had been educated about not leaving dependent residents unattended in the courtyard and they were expected to round on residents more frequently when residents were outside. Verification also revealed letters had been mailed to family members regarding heat exposure and the facility had a canopy in the courtyard and encouraged residents to sit in shady areas. There was also verification of sunscreen and a water station was in the courtyard for residents. Interviews with residents who smoked revealed they were aware of the water station, shade and sunscreen. Reviews of the training and education materials revealed they had been provided to all departments.